Pararectus Approach in Acetabular Fractures in Patients Older Than 65 years. Is it Possible to Improve the Technique?

OBJECTIVES: Review clinical results of the treatment for acetabular fractures using the pararectus approach and analyze surgical variations of the traditional approach. DESIGN: Retrospective. SETTING: Tertiary referral hospital. PATIENTS: 46 patients over 65 years of age who sustained an acetabular fracture and underwent surgery using the pararectus approach. INTERVENTION: Fractures were treated using a pararectus approach. Three variations of the original technique were performed: (1) Ligature of the deep iliac circumflex artery and vein, (2) separation of the psoas and iliacus muscles, and (3) isolation of the spermatic cord in men and round ligament in women together with the iliac and epigastric vessels. MAIN OUTCOME MEASUREMENTS: Outcomes measures included surgical, demographic, and clinical data, and information related to follow-up. RESULTS: Duration of surgery, 125 minutes (95-210). Quality of reduction on postoperative computed tomography (CT) scan; anatomic in 22 patients (47.8%), incomplete in 16 (34.8%), and poor in 8 (17.4%). In patients in whom the hip was preserved (n = 41), functional status was excellent in 15 patients (36.5%), good in 17 (41.4%), fair in 6 (14.7%), and poor in 3 (7.4%), with mean functional score of 16 points (7-18). Seven patients (15.2%) developed posttraumatic osteoarthritis and 4 of these patients underwent total hip replacement. CONCLUSIONS: This study reports positive outcomes in fracture reduction and clinical outcomes with low complications in older patients who suffered acetabular fractures and were treated using a pararectus approach. Small variations in the technique, such as those proposed in this study, may help to widen access to the surgical site and simplify the technique. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Estrategia de reducción de costes en la artroplastia total de rodilla / Strategies to lower the costs related to total knee arthroplasty

Objetivo: Valoración de la utilidad clínica de la radiografía en la primera visita postoperatoria tras una artroplastia total de rodilla Material y Método: Se analizaron 200 pacientes de forma retrospectiva a los que se le practicó una artroplastia total de rodilla (ATR) de enero a mayo del año 2012, realizándoles dos proyecciones radiográficas de control previa al alta hospitalaria y otras dos a las 4-6 semanas en la primera visita en consultas, las cuales se compararon en busca de cambios imaginológicos que indujesen una modificación terapéutica en el curso clínico del paciente. Resultados: En ninguno de los casos estudiados se objetivó ningún cambio radiológico en la primera visita postoperatoria al mes de la intervención, consecuentemente no se modificó el plan terapéutico del paciente. Discusión: Nuestros resultados apoyan los de otros autores que han reconocido los beneficios de la reducción del número de las radiografías postoperatorias tanto en costes económicos por el ahorro generado como por la propia salud del paciente. Creemos que la utilización repetida de radiografías seriadas en consultas externas no es más que una costumbre que se ha convertido en ley, que tranquiliza al paciente, tranquiliza a su cirujano, sin evidencia científica que la apoye. Conclusiones: Creemos que la proyección radiográfica de control AP y L en la primera visita ambulatoria tras una ATR no aportan información alguna, encarecen el sistema sanitario y perjudican innecesariamente al paciente

Aim: Assess the clinical utility of plain radiography in the first postoperative outpatient visit after total knee arthroplasty Patients and Methods: 200 patients which underwent a total knee arthroplasty from January to May 2012 were analyzed retrospectively, they had two previous control radiographs at hospital discharge and two more at 4-6 weeks after surgery, which were compared, seeking for radiographics signs that would induce a therapeutic changes in the patient’s clinical course. Results: No radiographics signs were observed in the cases studied in the first postoperative visit one month after the surgery, consequently the patient’s treatment plan had no change. Discussion: Our results support those of other authors who have recognized the benefits of reducing the number of postoperative radiographs, improve the cost effectiveness of outpatients care and avoid an extra damage to the patient’s health. We believe that repeated use of serial radiographs in outpatient is simply a custom that has become law, to calm down the patient, and his surgeon, with no scientific evidence to support it use. Conclusions: Our results suggest that the plain AP and L radiographic projection at the first visit, one month later after a TKA, does not provide any clinic information, adds substantial cost to the heath-care system and unnecessary harms the patient