Complications in simultaneous bilateral total knee arthroplasty, is it a safe procedure?

BACKGROUND: There is controversy regarding various aspects of simultaneous bilateral total knee replacement (SBTKR). We found disparity in the postoperative outcomes and complications associated with the procedure in the literature linked with the topic. OBJECTIVE: To retrospectively analyze the need for blood transfusion after surgery and complications associated with total knee replacement according to the type of procedure (SBTKR or unilateral). METHODS: Retrospective cohort analytical study. We included 251 patients with severe knee osteoarthritis that were divided into two groups. 124 (49%) who underwent SBTKR and 127 upon whom unilateral total knee replacement (UTKR) was performed. Demographic data, days of hospitalization, complications within the first 90 days after surgery (thromboembolic events, superficial and deep infection, stiffness, death); and percentages of patients transfused with blood products during hospitalization were evaluated. RESULTS: There were no statistical differences in the analysis of postoperative complications in the first 90 days after surgery. In the SBTKR group, 8 patients (6.5%) presented some thromboembolic complication during the postoperative period, while this event was observed in only 2 patients (1.5%) from the other group. The analysis showed a statistically significant drop in postoperative hemoglobin, on average that of 0.8 â€‹g/dl, in the SBTKR patient group compared to the UTKR group (95% CI 0.44-1.13; p â€‹< â€‹0.001). A higher proportion of patients who required transfusion were observed in the SBTKR group (40%) (OR â€‹= â€‹7.12; 95% CI 3.3-16; p â€‹< â€‹0.001). We analyzed the cause of postoperative transfusion in the patients who required transfusion taking into account two parameters: hemoglobin less than 8 â€‹g/dl and the clinical needs of the patients (symptoms of hypotension, decay, difficulty to rehabilitate without pain, dyspnea). 59 patients received transfusion (50 in the SBTKR group and 9 in the other group). Of these, 19 patients (32.2%) did not meet any transfusion criteria. CONCLUSION: We consider SBTKR a safe procedure, which does not increase postoperative complications compared to UTKR. Although there is an increase in blood loss in SBTKR, it does not generate clinical symptoms of relevance. LEVEL OF EVIDENCE: Level III.

Total knee replacement in octogenarians, Is age a determining factor in predicting complications? a retrospective cohort study.

INTRODUCTION: Given the increase in life expectancy in the general population of our country, there is an exponential increase since the last decades of functional older adults who undergo total knee replacement (TKR). There is a direct relationship between the increase in age and the prevalence of both functional and cognitive disabling chronic diseases, however, little we know about whether age is an independent factor in predicting worse functional outcomes and readmissions after TKR. The objective of this study was to evaluate the clinical-functional results and unplanned readmissions within the first 90 postoperative days in patients older than 80 years compared with a control group of patients younger than 80 years. METHODS: From our institutional patient database, 450 patients who underwent TKR between 2016 and 2019 were retrospectively analyzed. All patients had the medical assurance of Hospital Italiano (Plan de Salud), for which none of these was lost on the follow-up nor were treated in another hospital. Patients were divided in two groups: Group A with 186 patients over 80 years and a control group B with 264 patients between 70 and 80 years. The fragility of these was defined according to the Charlson Comorbidity Index and the Simple Frail Score. Comorbidities were divided in eight groups to define which were the most influential in the final results. RESULTS: No significant differences were observed in terms of unplanned readmissions, pain or in functional scores within 90 days between both groups. There was a significant difference in the length of postoperative hospital stay in favor of group A (A: 2.56 SD + - 0.76, B: 4.08 SD = - 2.23; p = 0.00001). The Charlson score was higher in the group of patients older than 80 years (p = 0.02) as well as the Simple Frail Score (p = 0.004). The ASA score did not show significant differences between both groups. CONCLUSION: Age as an independent factor proved not to be a predictor by itself of unplanned readmissions or worse clinical-functional results in a period of 90 postoperative days between both groups. We believe that the preoperative evaluation of octogenarian patients should be multidisciplinary, with special attention to the identification of comorbidities that can influence the fragility of a patient and the optimization of the pathology.

¿Es seguro el ácido tranexámico en la cirugía de reemplazo total de rodilla de pacientes con enfermedad coronaria? / Is tranexamic acid safe in total knee replacement surgery in patients with coronary artery disease?

Introducción: El ácido tranexámico reduce la pérdida sanguínea y los requerimientos de transfusiones luego de un reemplazo total de rodilla. Una de sus contraindicaciones relativas son los antecedentes de colocación de prótesis intravasculares coronarias, por un supuesto aumento de eventos tromboembólicos. materiales y métodos:Análisis retrospectivo de pacientes sometidos a un reemplazo total de rodilla primario y de revisión que recibieron ácido tranexámico y tenían antecedente de colocación de prótesis intravascular coronaria. Se los comparó con un grupo sin estas prótesis. Se analizó la presencia de cualquier cambio clínico o electrocardiográfico de oclusión coronaria aguda, eventos tromboembólicos, el requerimiento de transfusión sanguínea y el nivel de hemoglobina pre y posoperatorio. Resultados: 57 pacientes (59 cirugías, 56 reemplazos primarios y 3 revisiones) con colocación de prótesis intravascular coronaria, al menos, un año antes de la artroplastia. Un paciente tuvo síntomas de síndrome coronario agudo y cambios en el electrocardiograma. No hubo diferencias en la cantidad de eventos tromboembólicos. Solo un paciente del grupo de control recibió una transfusión de glóbulos rojos. El sangrado relativo fue menor en el grupo coronario independientemente del uso crónico de aspirina y clopidogrel antes de la cirugía (2,09 vs. 3,06 grupo de control; p = 0,01). En pacientes del alto riesgo, el ácido tranexámico no se asoció con más eventos tromboembólicos. Conclusiones: El ácido tranexámico impresionó ser seguro y efectivo en nuestro grupo de pacientes con prótesis intravasculares coronarias; sin embargo, se necesita un estudio prospectivo con más casos para confirmar estos resultados. Nivel de Evidencia: IV

Introduction: Tranexamic acid (TXA) reduces blood loss and need for a transfusion after total knee arthroplasty (TKA). However, patients with a history of coronary artery (CA) stent placement might be at increased risk for thromboembolic complications. Materials and methods: We performed a retrospective analysis of patients with a history of coronary stenting who had undergone primary and revision TKA and received preoperative TXA. A comparison was made with a group of patients without coronary stenting. The presence of any clinical or electrocardiographic changes of acute coronary occlusion, thromboembolic events (TEE), blood transfusion, and pre- and postoperative hemoglobin levels were analyzed. Results: 57 patients underwent 59 TKA surgeries (56 primary and 3 revisions) with a history of coronary stenting at least 1 year before arthroplasty. One patient presented symptoms of acute coronary syndrome and electrocardiogram (ECG) changes. There were no differences in the number of thromboembolic events. Only 1 patient received red blood cell transfusion in the control group. Relative bleeding was lower in the coronary group regardless of chronic use of aspirin and clopidogrel before surgery (2.09 vs 3.06 in the control group; p=0.01). In high-risk patients, TXA was not associated with higher TEEs. Conclusions: Although TXA seemed safe and effective in this database review of patients with previous placement of CAS; a larger prospective trial is warranted to confirm these results. Level of Evidence: IV

Trombosis arterial de diagnóstico tardío que simula un síndrome de Südeck luego de un reemplazo total de rodilla / Late-diagnosed arterial thrombosis mimicking Complex regional pain syndrome after total knee arthroplasty in a patient with CREST syndrome

La trombosis arterial luego de una artroplastia total de rodilla es una complicación poco frecuente; sin embargo, puede tener consecuencias devastadoras. Describimos un caso de una oclusión arterial después de una artroplastia total de rodilla en una mujer de 85 años. Inicialmente, la presentación clínica nos hizo pensar en una manifestación de la enfermedad de Raynaud (la paciente tenía antecedente de síndrome de CREST). Entre los diagnósticos diferenciales también se planteó un síndrome de dolor regional complejo, que retrasó el diagnóstico durante dos semanas. Finalmente, el diagnóstico y el tratamiento se realizaron mediante angiografía. La recuperación funcional fue completa. La baja frecuencia de esta lesión puede determinar que el diagnóstico sea un desafío para el cirujano. En este caso, la oclusión parcial de las arterias evitó complicaciones más graves. Nivel de Evidencia: IV

Arterial thrombosis after total knee replacement (TKR) is a rare complication; however, it can lead to disastrous consequences. We describe a case of an arterial occlusion after TKR in an 85-year-old female patient. Initially, the clinical presentation made us con-sider Raynaud (she had a history of CREST) and complex regional pain syndrome, which delayed the diagnosis for 2 weeks. Diagnosis and treatment were accomplished with angiography and the patient achieved a full recovery. The low frequency of this injury may make diagnosis a challenge for the surgeon. In this case, partial occlusion of the arteries avoided more serious complications. Level of evidence: IV

Mucormycosis osteomyelitis after anterior cruciate ligament reconstruction: treatment and outcomes of 21 reported cases.

AIMS: Our purpose was to describe an unusual series of 21 patients with fungal osteomyelitis after an anterior cruciate ligament reconstruction (ACL-R). METHODS: We present a case-series of consecutive patients treated at our institution due to a severe fungal osteomyelitis after an arthroscopic ACL-R from November 2005 to March 2015. Patients were referred to our institution from different areas of our country. We evaluated the amount of bone resection required, type of final reconstructive procedure performed, and Musculoskeletal Tumor Society (MSTS) functional score. RESULTS: A total of 21 consecutive patients were included in the study; 19 were male with median age of 28 years (IQR 25 to 32). All ACL-R were performed with hamstrings autografts with different fixation techniques. An oncological-type debridement was needed to control persistent infection symptoms. There were no recurrences of fungal infection after median of four surgical debridements (IQR 3 to 6). Five patients underwent an extensive curettage due to the presence of large cavitary lesions and were reconstructed with hemicylindrical intercalary allografts (HIAs), preserving the epiphysis. An open surgical debridement was performed resecting the affected epiphysis in 15 patients, with a median bone loss of 11 cm (IQR 11.5 to 15.6). From these 15 cases, eight patients were reconstructed with allograft prosthesis composites (APC); six with tumour-type prosthesis (TTP) and one required a femoral TTP in combination with a tibial APC. One underwent an above-the-knee amputation. The median MSTS functional score was 20 points at a median of seven years (IQR 5 to 9) of follow-up. CONCLUSION: This study suggests that mucormycosis infection after an ACL-R is a serious complication. Diagnosis is usually delayed until major bone destructive lesions are present. This may originate additional massive reconstructive surgeries with severe functional limitations for the patients.Level of evidence: IVCite this article: Bone Joint Open 2020;2(1):3-8.

International Organism Profile of Periprosthetic Total Hip and Knee Infections.

BACKGROUND: There is scarce literature describing pathogens responsible for periprosthetic joint infections (PJIs) around the world. Therefore, we sought to describe periprosthetic joint infection causative organisms, rates of resistant organisms, and polymicrobial infections at 7 large institutions located in North/South America and Europe. METHODS: We performed a retrospective study of 654 periprosthetic hip (n = 361) and knee (n = 293) infections (January 2006 to October 2019) identified at Cleveland Clinic Ohio/Florida in the United States (US) (n = 159), Hospital Italiano de Buenos Aires in Argentina (n = 99), Hospital Asociación Española in Uruguay (n = 130), Guy's and St Thomas' Hospital in the United Kingdom (UK) (n = 103), HELIOS Klinikum in Germany (n = 59), and Vreden Institute for Orthopedics in St. Petersburg, Russia (n = 104). Analyses were performed for the entire cohort, knees, and hips. Alpha was set at 0.05. RESULTS: Overall, the most frequent organisms identified were Staphylococcus aureus (24.8%) and Staphylococcus epidermidis (21.7%). The incidence of organisms resistant to at least one antibiotic was 58% and there was a significant difference between hips (62.3%) and knees (52.6%) (P = .014). Rates of resistant organisms among countries were 37.7% (US), 66.7% (Argentina), 71.5% (Uruguay), 40.8% (UK), 62.7% (Germany), and 77.9% (Russia) (P < .001). The overall incidence of polymicrobial infections was 9.3% and the rates across nations were 9.4% in the US, 11.1% in Argentina, 4.6% in Uruguay, 4.9% in UK, 11.9% in Germany, and 16.3% in Russia (P = .026). CONCLUSION: In the evaluated institutions, S aureus and S epidermidis accounted for almost 50% of all infections. The US and the UK had the lowest incidence of resistant organisms while Germany and Russia had the highest. The UK and Uruguay had the lowest rates of polymicrobial infections.

Uso de conos de metal trabecular para defectos óseos severos en cirugía de revisión de reemplazo total de rodilla / The use of trabecular metal cones for the management of severe bone defects in revision total knee replacement

Introducción: Las alternativas reconstructivas para defectos óseos severos en la cirugía de revisión de prótesis son las camisas metafisarias, los conos de metal trabecular y el injerto óseo impactado o estructural. El objetivo del estudio fue analizar la tasa de osteointegración de los conos de metal trabecular en pacientes con cirugía de revisión de prótesis total de rodilla. El objetivo secundario fue analizar los resultados funcionales, las tasas de complicaciones y reoperaciones. Materiales y Métodos: Cohorte retrospectiva de pacientes con conos de metal trabecular colocados en la cirugía de revisión de prótesis y un seguimiento mínimo de 2 años. Se evaluaron las causas de la revisión, cirugías previas, tipo de defecto óseo, cantidad y tipo de conos utilizados, y los diseños de las prótesis. Se realizó una evaluación clínico-radiográfica, se registraron las complicaciones y las revisiones ulteriores. Resultados: Se evaluó a 35 pacientes (49 conos de metal trabecular) en forma retrospectiva, con un seguimiento promedio de 32.1 meses. La mayoría de los defectos eran tibiales AORI 3, seguidos de los femorales tipo 3. La tasa de osteointegración de los conos fue del 94%; la de complicaciones, del 20% y la de reoperaciones, del 8,5%. El KSS objetivo promedio aumentó de 39 en el preoperatorio a 71 en el último control y el puntaje de la EAV promedio fue 8 y 2,5, respectivamente. Conclusión: La excelente tasa de osteointegración (94%) y los buenos resultados clínicos posicionan a los conos de metal trabecular como una alternativa para los defectos óseos severos. Nivel de Evidencia: IV

Introduction: Major bone defects represent a challenge during revision total knee arthroplasty (TKA) and there is still considerable debate about the best therapeutic option. The purpose of this study was to retrospectively assess the osseointegration rate of trabecular metal cones in revision TKA with severe bone defects. The secondary purpose was to evaluate the functional outcomes and complication and reoperation rates. Materials and Methods: A single-center, retrospective cohort including all consecutive cases of revision TKA using trabecular metal cones. All patients with a minimum 2-year follow-up were included in the study. Reasons for revision, number of previous surgeries, type of bone defect, and number and type of trabecular cones used were evaluated. Clinical and radiological outcomes were also analyzed as well as complications rates. Results: 35 patients (49 cones) were evaluated with a mean follow-up of 32.1 months (24-62). Most defects were localized in the tibia and were classified as AORI type 3. The rate of osseointegration of the cones was 94%; the complication rate, 20%; and the reoperation rate, 8.5%. The mean KSS increased from 39 preoperatively to 71 at the last follow-up, and the mean VAS from 8 to 2.5. Conclusion: The excellent osseointegration rate (94%), added to the good clinical outcomes, position the trabecular metal cones as an alternative to treat severe bone defects. Level of Evidence: IV

Comparación de los espaciadores articulados vs. fijos en la revisión de la infección periprotésica de rodilla / Comparison between articulating vs. fixed spacers in revision for periprosthetic knee infection

Introducción: Los espaciadores de cemento con antibiótico pueden ser fijos o articulados y se logra un resultado similar con ambos para erradicar una infección. Nuestro objetivo fue comparar el rango de movilidad articular y los resultados funcionales después del reimplante. Materiales y Métodos: Estudio de cohorte retrospectiva de pacientes sometidos a una revisión de la prótesis de rodilla por infección, en dos tiempos quirúrgicos. Se analizó la funcionalidad según el Knee Society Score (KSS) al año de la cirugía y se registró el rango de movilidad a los 45 días. Se registraron el grado de defecto óseo, dolor, satisfacción, las complicaciones y la recidiva de la infección. Resultados:Se incluyeron 103 pacientes (40 con espaciador articulado, 63 con espaciador fijo). El grupo con espaciador articulado tuvo una mediana 2,5° mayor en la movilidad final (102,5; RIC 95-110 vs. 100; RIC 90-105, p 0,01). Según el KSS funcional y el KSS de rodilla, no hubo diferencias entre ambos grupos. No hubo diferencias en el grado de satisfacción, dolor y el tiempo hasta el reimplante. Las complicaciones fueron similares en ambos grupos, con una tasa de reinfección sin diferencias estadísticamente significativas. Conclusión: Los espaciadores articulados proporcionaron un beneficio en el rango de movilidad después del reimplante de la prótesis. Nivel de Evidencia: III

Introduction: Cement spacers with antibiotics can be fixed or articulating, with similar results in eradicating infection. Our objective was to compare joint range of motion (ROM) and functional outcomes after reimplantation. Materials and Methods: A retrospective cohort study of patients who had undergone a knee prosthetic revision due to infection in two surgical stages. Functionality was analyzed according to the Knee Society Score (KSS) one year after surgery and ROM was recorded 45 days after surgery. Bone defect, pain, satisfaction, complications, and recurrence of infection were recorded. Results:A total of 103 patients were included. 40 with articulating spacers and 63 with fixed spacers. The articulating spacer group presents a median of 2.5 degrees greater in final mobility (102.5 IQR 95-110 vs 100 IQR 90-105, p 0.01). The KSS functional scale and KSS of the knee did not show differences between two groups. There were no differences concerning satisfaction, pain, and time until reimplantation. Complications were similar in both groups, with a reinfection rate without statistically significant differences. Conclusion: Articulating spacers have shown a benefit in ROM after prosthetic reimplantation. Level of Evidence: III

Reemplazo total de rodilla en pacientes con anquilosis. Reporte de tres casos y revisión bibliográfica / Total knee replacement in patients with ankylosis. Report of three cases and literature review

Introducción: El reemplazo total de rodilla en pacientes con anquilosis representa un desafío para el cirujano, tanto por la alta demanda técnica de la cirugía como por la elevada tasa de complicaciones comunicada. El objetivo de este artículo es presentar tres pacientes con anquilosis tratados con un reemplazo total de rodilla y una revisión bibliográfica actualizada. materiales y métodos: Se evaluaron las distintas etiologías, la movilidad preoperatoria, la técnica quirúrgica y el tipo de implante utilizado en cada caso. En el seguimiento, se evaluaron la tasa de complicaciones, el rango de movilidad y la supervivencia del implante. Por último, se realizó una revisión actualizada de la bibliografía. Resultados: Dos pacientes tenían artritis reumatoide juvenil y uno, una secuela de osteomielitis crónica de rodilla. Los pacientes no tenían movilidad articular y sufrían un severo compromiso para realizar las actividades de la vida cotidiana. En los tres pacientes, se efectuó un abordaje pararrotuliano medial seguido de una amplia liberación de partes blandas. En dos casos, se utilizaron prótesis primarias con vástagos y, en el restante, una prótesis de bisagra rotacional. El rango de movilidad alcanzado fue de 90° en promedio y los pacientes refirieron una tasa alta de satisfacción. No se registraron complicaciones. Conclusiones: El reemplazo total de rodilla en pacientes con anquilosis es una opción terapéutica por considerar, y tiene un impacto beneficioso en la calidad de vida. Por la complejidad que representa debe afrontarse como una cirugía de revisión, con una detenida planificación preoperatoria. Nivel de Evidencia: IV

Introduction: Performing a Total Knee Replacement (TKR) in patients with ankylosed knees is technically demanding and associated with considerable complications. The purpose of this study is to report three cases of patients with ankylosed knees treated with TKR and present an updated literature review. Materials and methods: We evaluated etiologies, preoperative range of motion, surgical technique and type of implant utilized in each case. Complications and postoperative range of motion were also analyzed. Radiographs were used to evaluate loosening or osteolysis. Lastly, we performed an updated literature review. Results: The etiologies were juvenile rheumatoid arthritis in two cases and chronic osteomyelitis in one. The patients did not have range of motion at all and the ability to perform daily life activities was severely affected. A medial parapatellar approach was used in all cases followed by an extensive soft tissue release. A primary posterior-stabilized design was used in two cases and a rotating-hinge in one case. The mean postoperative range of motion was 90° and all three patients reported a high satisfaction rate. No complications were reported. Conclusions: TKR in patients with ankylosed knees has substantially improved the clinical outcome and the arc of movement. Due to its complexity, it must be approached as a revision surgery, with careful preoperative planning. Level of Evidence: IV

Complementary Saphenous Nerve Block to Intra-Articular Analgesia Reduces Pain After Total Knee Arthroplasty: A Prospective Randomized Controlled Trial.

BACKGROUND: Numerous strategies exist for pain management after total knee arthroplasty (TKA), with a fast recovery and early ambulation required for full function. Currently, there is no universal standard of care to facilitate this management. We assessed pain management safety and efficacy after TKA, using intra-articular infiltration associated with peripheral saphenous nerve block (SNB) vs intra-articular infiltration alone. METHODS: We performed a controlled, double-blinded, and randomized trial to evaluate postoperative pain in TKA. One group was treated with intra-articular analgesia associated with SNB, whereas a second group received the same intra-articular cocktail, associated with placebo. Efficacy was evaluated according to average pain, pain-free time, and morphine rescue indices. Safety was assessed by intervention complications and surgery. RESULTS: About 70 patients were recruited. At time 0 (immediately postoperative), 51.43% of the intra-articular analgesia + placebo group presented pain <3, whereas in the intra-articular analgesia + SNB group, 8.82% (P = .001) presented with pain. This difference was maintained at 6, 12, and 24 hours, postoperatively. After 24 hours, the placebo group received an average 0.66 morphine rescues (standard deviation, 0.86), when compared with the SNB group that received 0.14 rescues (standard deviation, 0.43), (P = .002). We recorded a paresis of the external popliteal sciatic nerve, with spontaneous recovery without other complications. CONCLUSION: Complementary SNB to intra-articular analgesia was more effective in reducing average pain and the amount of pain-free time in the first 24 hours after TKA, with fewer requests for morphine rescue analgesia.

Unusual Listeria monocytogenes hematogenous infection in total knee replacement treated with one-stage revision surgery.

Septic arthritis due to Listeria monocytogenes (LM) is extremely rare and most infections due to this organism are seen in immunocompromised patients. We describe a patient without immunological compromise, with a late total knee arthroplasty infection caused by LM treated with one-stage revision surgery. She had an elevated erythrocyte sedimentation rate (79 mm/h) and C-reactive protein (13 mg/dL). Aspiration of the knee joint yielded purulent fluid; cultures showed LM. The patient was given 6 weeks of intravenous ampicillin, followed by trimethoprim/sulfamethoxazole, and finally amoxicillin orally for 7 months. Two years after revision surgery, radiographs showed no evidence of implant loosening. This is a single case and although one-stage approach seemed to have worked, it should not be recommended on the basis of a single report.

Soft-Tissue Expansion beforeTotal Knee Arthroplasty:A Report of Two Cases.

INTRODUCTION: Wound complications are a feared complication following total knee arthroplasty (TKA). Furthermore, it is important to avoid underestimation in the pre-operative planning as it may lead to catastrophic TKA failure. Soft-tissue expansion (STE) has been indicated when insufficient or inadequate soft-tissue coverage is present before TKA as an alternative to optimize soft-tissue management. CASE REPORT: We report two cases in which we performed, previous to TKA, a prophylactic skin expansion around the knee. CONCLUSION: STE technique to expand the available tissue for closure and healing after TKA is a valuable tool in the treatment arsenal, which can be implemented by orthopedic surgeons.

Patellofemoral arthritis treated with resurfacing implant: Clinical outcome and complications at a minimum two-year follow-up.

BACKGROUND: This study evaluated the clinical and radiographic outcomes of a series of patients treated with an anatomic inlay resurfacing implant, with a minimum two-year follow-up. METHODS: Fifteen patients underwent patellofemoral-resurfacing procedures using a HemiCAP Wave Patellofemoral Inlay Resurfacing implant from 2010 to 2013. Clinical outcomes included: Visual Analog Scale (VAS), Lysholm score, Knee Society Score (KSS), and evaluation of Kujala, and Hospital for Special Surgery Patellofemoral score (HSS-PF). The postoperative complications were analyzed. RESULTS: Nineteen knees were evaluated; the average follow-up was 35.2months. Fourteen were women, with an average age of 54years. The pre-operative/postoperative clinical results presented a significant improvement: VAS 8/2.5, Lysholm 31.9/85.8, KSS 39.8/82.5, Kujala 32.1/79.3 and Hospital for Special Surgery Patellofemoral score (HSS-PF) 15.9/90.6. A total of 87% of patients were either satisfied or very satisfied with the overall outcome. There were no radiographic signs of loosening. Seven postoperative complications were recorded: two presented ongoing knee pain, one postoperative stiffness, one patellar bounce due to maltracking, two ilio-tibial band syndrome, and one tibial anterior tuberosity osteotomy nonunion. Two patients underwent a total knee arthroplasty conversion and were considered a failure. None of these complications were implant related. CONCLUSIONS: Patellofemoral inlay resurfacing for isolated patellofemoral arthritis was an effective and safe procedure with high levels of patient satisfaction. No mechanical implant failure was seen at a minimum two-year follow-up. This implant design appeared to be an alternative to the traditional patellofemoral prostheses. Concomitant osteochondral lesions, patellofemoral dysplasia or patellar maltracking might be poor prognostic factors for this type of implant.

Rango de movilidad y resultados funcionales en tres disenos diferentes de artroplastia de rodilla primaria. estudio comparativo / Range of motion and functional results in three different designs of total knee arthroplasty. comparative study

Introducción: El objetivo de este trabajo fue analizar los resultados funcionales y el rango de movilidad entre tres grupos de pacientes con artroplastia total de rodilla: dos con prótesis de alta flexión y otro con un diseño convencional. Materiales y Métodos: Sesenta y cuatro pacientes fueron operados con una prótesis total de rodilla Zimmer® NexGen® y 34, con una Optetrack® de alta flexión. Luego de la exclusión de pacientes, 22 (grupo A) fueron tratados con un diseño Zimmer® de alta flexión; 21 (grupo B), con una prótesis Zimmer® convencional y 25 (grupo C), con una prótesis Optetrack ® PS. La evaluación funcional se realizó con el Knee Society Score, el Western Ontario and McMaster Universities Osteoarthritis index y la escala analógica visual. Resultados: En el posoperatorio, el promedio de flexión máxima subió de 99° a 113º en el grupo A, con un aumento promedio de 14º; de 106° a 118º en el grupo B, con una ganancia promedio de 12º y de 110° a 111° en el grupo C, con una ganancia de 1°. Los resultados funcionales evaluados con los dos puntajes mejoraron en los tres grupos. Conclusiones: Las evaluaciones clínicas funcionales son favorables en los tres diseños evaluados. Este estudio muestra que no hay diferencias significativas en la flexión final lograda y los resultados funcionales entre los dos primeros diseños; sin embargo, estos son significativamente superiores al diseño del tercer grupo luego de un año de seguimiento.

Introduction: The purpose of this comparative study was to analyze functional results and the range of motion of the knee among three groups of patients with total knee arthroplasty using high-flex prosthesis (in two groups) and a conventional design (one group). Methods: Sixty-four patients were surgically treated with total knee arthroplasty using a Zimmer® NexGen® prosthesis, and 34 patients received a high-flex Optetrack® design. After exclusion of patients, 22 patients (group A) were treated with a high-flex Zimmer® NexGen® design, 21 patients (group B) were treated with a conventional implant, and 25 patients (group C) received a high-flex PS Optetrack® prosthesis. Functional evaluation was performed with the Knee Society Score, the Western Ontario and McMaster Universities Osteoarthritis index, and a visual analogue scale. Results: Mean post-surgical maximum flexion increased from 99° to 113º in group A, with an average increase of 14º, from 106° to 118º in group B, with an average gain of 12º, and from 110 to 111° in group C, with an average increase of 1°. Functional results assessed with both scores showed improvements in all three groups. Conclusions: The functional and radiographic outcomes were favorable in the three designs. This study suggests that there are no significant differences in the final flexion and functional outcomes between the first two designs; however together they are significantly superior to the third group after one year of follow-up.

Traumatic Dislodgement of Tibial Polyethylene Insert after a High-Flex Posterior-Stabilized Total Knee Replacement.

Many pathologic entities can produce a painful total knee replacement (TKR) that may lead to potential prosthetic failure. Polyethylene insert dissociation from the tibial baseplate has been described most frequently after mobile-bearing and cruciate-retaining TKRs. However, only 3 tibial insert dislocations in primary fixed-bearing High-Flex posterior-stabilized TKRs have been reported. We present a new case of tibial insert dislocation in a High-Flex model that shares similarities and differences with the cases reported, facilitating the analysis of the potential causes, which still remain undefined.

Estudio prospectivo aleatorizado sobre el uso o no de drenaje en la artroplastia total de rodilla / Prospective randomized study on the use of drainage in total knee arthroplasty

Introducción: La utilización de drenaje en la artroplastia total de rodilla es una práctica ampliamente aceptada en la comunidad ortopédica; sin embargo, en la bibliografía, no se encuentra evidencia concluyente sobre su beneficio. El propósito de este estudio fue comparar dos grupos de pacientes sometidos a artroplastia total de rodilla primaria con drenaje y sin él. Materiales y Métodos: Se llevó a cabo un estudio prospectivo aleatorizado en el que se realizaron 76 artroplastias totales de rodilla primarias; se dividió a los pacientes en dos grupos: grupo A, con drenaje y grupo B, sin drenaje. Se evaluaron el número de unidades de sangre transfundidas, el débito de sangre en los pacientes con drenaje, las complicaciones posoperatorias y el tiempo de hospitalización. Antes de la cirugía y después de ella, se registró el diámetro del muslo, el rango de movilidad, el hematocrito y la hemoglobina en ambos grupos. Resultados: No se hallaron diferencias estadísticamente significativas en el diámetro del muslo, el rango de movilidad, el hematocrito, la hemoglobina, el número de transfusiones y la estadía hospitalaria. El número de complicaciones en el grupo B (sin drenaje) fue mayor (p = 0,019): dos infecciones profundas, dos casos de celulitis, uno de flictena, una fractura de cadera, una trombosis venosa superficial, una trombosis venosa profunda y un tromboembolismo pulmonar. Conclusión: Los pacientes sin drenaje posoperatorio sufrieron más complicaciones. Nivel de evidencia: II.

Introduction: The use of drainage in total knee arthroplasty is a widely accepted practice in Orthopedics; however, there is not conclusive evidence about its benefit in the literature. The purpose of this study was to compare two groups of patients in whom primary total knee arthroplasty with and without drainage was performed. Methods: Prospective randomized study in which 76 primary total knee arthroplasties were performed; patients were divided into two groups: group A, with drainage, and group B, without drainage. The number of transfusions, the drainage debit, postoperative complications and length of hospital stay were evaluated. Diameter of the thigh, range of motion, hematocrit and hemoglobin were also recorded before and after surgery in both groups. Results: No statistically significant differences were found in thigh diameter, range of motion, hematocrit, hemoglobin, number of transfusions, and hospital stay. The number of complications in group B (without drainage) was higher (P = 0.019): two deep infections, two cases of cellulitis, one case of blebs, a hip fracture, a superficial vein thrombosis, a deep venous thrombosis, and one pulmonary thromboembolism. Conclusion: Patients without postoperative drainage presented a higher number of complications. Level of evidence: II.

Osteotomía varizante distal de fémur para genu valgo / Distal femoral varus osteotomy for genu valgum

Objetivo: Analizar una serie de pacientes con osteotomías varizante de fémur distal y evaluar los resultados, tanto clínicos como radiográficos. Material y Métodos: Se analizaron retrospectivamente 11 pacientes con osteotomía varizante de fémur realizada en nuestra institución, entre los años 2005 y 2013. En 7 casos se realizó una osteotomía aditiva externa y en 4 sustractiva interna. Como procedimientos asociados se realizaron: 1 trasplante meniscal, 4 mosaicoplastias, 1 reconstrucción del LCP y en 1 caso microperforaciones. El promedio de seguimiento fue de 39 meses (rango de 12-102 meses). Se midieron el eje, la consolidación ósea y la progresión de la artrosis del compartimento lateral (Score de Kellgren-Lawrence). Se realizaron las siguientes evaluaciones funcionales: IKDC subjetivo, Lysholm y Tegner. Resultados: El Promedio de corrección del eje fue de 12,6°, no se observó modificación del mismo durante el seguimiento. Todas las osteotomías consolidaron y no se observó progresión de la artrosis en el compartimento externo. El IKDC subjetivo promedio fue de 70,5, el Lysholm promedio de 83,1 y el Tegner de 4. Dos pacientes evolucionaron con rigidez articular y 1 presento molestias a nivel de la placa, por lo que se realizaron 2 movilizaciones bajo anestesia y 1 retiro de material de osteosintesis. Ninguno de los pacientes fue sometido a una artroplastia hasta la fecha. Conclusión: Se logró corregir la mala alineación en valgo que presentaban los pacientes, con buenos escores funcionales y baja tasa de complicaciones, ubicando la osteotomía de fémur distal para genu valgo como una alternativa válida en casos bien seleccionados. Nivel de Evidencia: IV. Tipo de Estudio: Serie de Casos.

Objective: To analyze a series of patients who underwent varus osteotomy of distal femur and evaluate both clinical and radiographic results. Method: We retrospectively analyzed 11 patients with distal femoral varus osteotomy performed at our institution between 2005 and 2013. 7 of these were open wedge osteotomies, whereas the remaining 4 were closing wedge ones. Associated procedures were performed as follows: 1 meniscal transplant, 4 mosaicplasties, 1 LCP reconstruction and in 1 case microfractures. The mean follow-up was 39 months (range 12 to 102 months). Pre- and postoperative radiographs were evaluated for tibiofemoral angle, bone healing and progression of lateral compartment osereoarthritis (Kellgren-Lawrence Score). The IKDC, Lysholm and Tegner scores assessed clinical outcomes. Results: The average correction of the femorotibial angle was of 12.6°, there were no changes evidenced along the follow up. Union of the osteotomy site was achieved in all cases. Osteoarthritis of the lateral compartment did not show progression. The mean results of the clinical scores were: IKDC 70.5, Lysholm 83.1, and Tegner 4. Two patients revealed joint stiffness and 1 complained about discomfort at the plate site. For these reasons, two mobilizations under anesthesia and 1 material removal were performed. To the date, none of the patients required an arthroplasty. Conclusion: We were able to correct the valgus malalignment in all patients, with good functional outcomes and low complication rate, placing the distal femoral osteotomy for valgus arthritic knees as a valid alternative in well-selected cases. Level of Evidence: IV. Type of study: Case Series.