Peri-implant femoral fractures: Challenges, outcomes, and proposal of a treatment algorithm.

PURPOSE: Non-prosthetic peri-implant fractures are challenging injuries. Multiple factors must be carefully evaluated for an adequate therapeutic strategy, such as the state of bone healing, the type of implant, the time and performed personnel of previous surgery, and the stability of fixation. The aim of this study is to propose a rationale for the treatment. METHODS: The peri-implant femoral fractures (PIFFs) system, a therapeutic algorithm was developed for the management of all patients presenting a subtype A PIFF, based on the type of the original implant (extra- vs. intra-medullary), implant length and fracture location. The adequacy and reliability of the proposed algorithm and the fracture healing process were assessed at the last clinical follow-up using the Parker mobility score and radiological assessment, respectively. In addition, all complications were noticed. Continuous variables were expressed as mean and standard deviation, or median and range according to their distribution. Categorical variables were expressed as frequency and percentages. RESULTS: This is a retrospective case series of 33 PIFFs, and the mean post-operative Parker mobility score was (5.60 ± 2.54) points. Five patients (15.1%) achieved complete mobility without aids (9 points) and 1 (3.0%) patient was not able to walk. Two other patients (6.1%) were non-ambulatory prior to PPIF. The mean follow-up was (21.51 ± 9.12) months (range 6 - 48 months). There were 7 (21.2%) complications equally distributed between patients managed either with nailing or plating. There were no cases of nonunion or mechanical failure of the original implant. CONCLUSION: The proposed treatment algorithm shows adequate, reliable and straightforward to assist the orthopaedic trauma surgeon on the difficult decision-making process regarding the management of PIFF occurring in previously healed fractures. In addition, it may become a useful tool to optimize the use of the classification, thus potentially improving the outcomes and minimizing complications.

Fragility fracture systems, Latin America perspective.

Osteoporosis is a worldwide epidemic, affecting an average of 30% to 50% of those over 50 years of age in Latin America. Resulting from it is another epidemic, that of fragility fractures, which adversely affects morbidity and mortality of this population. Increasing in their incidence, fragility fractures are expected to occur in 1 in 3 women and 1 in 5 men over 50years of age during their lifetimes. Currently, there are diagnostic and management guidelines for fragility fractures in Latin American countries, especially those for hip and spine fractures. In general, in Latin America, the quality indicators and standards for the care of these fractures vary greatly according to the health system, being suboptimal in many situations. The organization of health services is different in the different countries throughout Latin America. Common underlying characteristics, however, include the distinctions that exist in care between public and private medicine and the lack of economic resources directed to public healthcare systems from the national levels. Several important changes have been implemented in recent years, with the collaboration between national organizations and international associations such as the Fragility Fracture Network and the International Osteoporosis Foundation, aimed at improving quality standards in care and rates of morbidity and mortality in patients treated thorough fragility fracture programs. The underregistration in these programs and absence of formal national registries also contribute to a lack of recognition of the size, scope, and severity of the problem.

Open Tibial Fracture Treatment in Argentina: Reoperation Rates Following Surgical Management.

The purposes of the present study were (1) to characterize open tibial fractures and their treatment in trauma centers located across different regions of Argentina and (2) to evaluate the rates of and indications for reoperation after the surgical treatment of such fractures. Methods: This retrospective multicenter study evaluated open tibial fractures in Argentina that were operatively treated by experienced orthopaedic trauma surgeon-members of the Argentine Association of Orthopedic Trauma (AATO) between January 2015 and June 2020. Data were collected from 13 hospital databases; 8 hospitals were designated as "interior," and 5 hospitals were designated as "exterior." The study included 701 skeletally mature patients, all of whom had a minimum of 12 months of follow-up. Information was collected on patient demographics, injury pattern and mechanism, fracture classification, treatment modality, reoperation rates, time between definitive fixation and reoperation, and indications for reoperation. Results: Seventy-six percent of presenting injuries were the result of a high-energy mechanism. Intramedullary nailing represented the most common type of fixation (88%). One hundred and fifty patients (21%) required reoperation. Delayed union/nonunion was the most common indication for reoperation in patients who had been previously treated with intramedullary nail fixation (31%; 39 of 126), and infection was the most common indication for reoperation in patients who had been treated with plate fixation (43%; 3 of 7). The time between the injury and definitive fixation was significantly different between the interior and exterior trauma centers (13.8 versus 4.7 days; p < 0.001), as was the time between definitive fixation and reoperation (69.3 versus 25.2 days; p = 0.004). The reoperation rates for the interior and exterior trauma centers were similar (20% versus 24%; p = 0.2). Infection, delayed union/nonunion, and implant removal were the most common indications for reoperation across groups. Conclusions: An improved understanding of the factors that influence treatment may help to guide future areas for improvement, establish educational goals, and create additional nationwide guidelines for open tibial fracture treatment. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Orthopaedic trauma care during the COVID-19 Pandemic: the Latin American perspective.

At first glance, the COVID-19 pandemic and the field of orthopaedics and traumatology do not appear to be related. Although orthopaedists are not considered front-line personnel in the fight against the pandemic, the role of the surgeon as part of the overall health care team is crucial. The specialty of orthopaedics and orthopaedic trauma, due to its extraordinary scope, affects individuals of all ages and timely care affects patients' long-term function and quality of life. Therefore, positioning the type and timing of care for musculoskeletal injuries and conditions, while maintaining the safety of the patient and healthcare providers, is essential. This article reviews the initial approaches to orthopaedic trauma care during the COVID-19 pandemic as established by 4 representative countries in Latin America: Mexico, Argentina, Colombia, and Brazil.

Luxación de una prótesis abisagrada de rodilla: Reporte de un caso / Posterior dislocation of a hinged knee prosthesis. Case report

Las prótesis abisagradas de rodilla tienen índices de complicaciones que pueden llegar al 44% en 15 años. La luxación protésica secundaria a una ruptura del mecanismo abisagrado resulta ser la complicación alejada más frecuente luego del aflojamiento mecánico. Presentamos un caso de luxación protésica posterior, en un implante abisagrado rotatorio de tercera generación (Rotax, FII SA®, Saint Just Malmont, Francia), implantado originalmente en una paciente de 69 años, con artritis reumatoide y en terapia prolongada con metilprednisona y metotrexato a altas dosis. El tratamiento se realizó en ambas rodillas, en dos tiempos para corregir una deformidad en ráfaga altamente invalidante. Nuestra hipótesis postula que la luxación se debió a la ruptura del buje de polietileno del implante, este es el eslabón más débil del mecanismo abisagrado. Existen escasos reportes bibliográficos sobre esta particular complicación. Sin embargo, encontramos homogeneidad en las conclusiones, que consideran el ensamble entre el componente tibial y femoral, como el punto más frágil del sistema. Recomendamos, en estos complejos escenarios, efectuar la revisión protésica solo ante la presencia de episodios clínicos evidenciables, como luxaciones o inestabilidad persistente. Nivel de Evidencia: IV

Hinged knee prosthesis has a complication rate up to 44% at 15 years. Prosthetic dislocation secondary to a breakage of the hinged mechanism turns to be the second most frequent late complication after mechanical loosening. We present a patient with a posterior dislocation of a third generation rotating hinged total knee replacement (Rotax, FII SA®, Saint Just Malmont, France), implanted originally in a 69-year-old woman with rheumatoid arthritis and history of treatment with metilprednisone and methotrexate at high doses. The bilateral arthroplasty was performed in two times to correct a highly disabling deformity. We hypothesize the dislocation is due to the breakage of the polyethylene yoke of the prosthesis, being the weakest link of the hinged mechanism. There are rare bibliographic reports about this complication. However, we found similar conclusions, considering the engage of the tibial and femoral components as the weakest link of the system. We recommend in these complex scenarios to perform revision surgery only in cases with high repercussion in daily life presenting persistent instability or multiple dislocations. Level of Evidence: IV

Artroplastia total de rodilla en genu valgo severo: Seguimiento de 5 a 14 años / Total knee arthroplasty in severe genu valgum. Five to 14 years follow-up

Introducción: El deseje en valgo es una deformidad compleja, con alteracion osea y de partes blandas. Se han descrito numerosas tecnicas quirurgicas que detallan la secuencia de liberacion de las estructuras posterolaterales y la necesidad de utilizar implantes constrenidos. El reemplazo total de rodilla para el genu valgo es un desafio para el ortopedista. Los objetivos fueron evaluar nuestros resultados en el tratamiento quirurgico del genu valgo severo y detallar la tecnica quirurgica empleada. Materiales y Métodos: Se establecio una clasificacion clinico-radiologica y se discriminaron los casos con genu valgo severo. Se evaluaron 42 reemplazos totales de rodilla en 39 pacientes (seguimiento promedio 9.2 anos). Se utilizo el Knee Society Score como parametro de evaluacion clinica. Para la evaluacion radiografica, se conto con la radiografia de mejor calidad del ultimo control. El analisis de supervivencia contemplo la necesidad de revision por cualquier causa y por falla mecanica. Resultados: El Knee Society Score fue, en promedio, de 83,3, con franca mejoria en los parametros dolor y rango de movilidad. Se utilizaron implantes constrenidos en el 16,7% de los casos. El angulo posoperatorio promedio fue de 5,9°. Hubo dos revisiones, con una supervivencia protesica por falla mecanica del 97,6%. No hubo revisiones por causa infecciosa. Conclusiones: Se requiere de un minucioso examen fisico y radiografias preoperatorias. La decision de utilizar implante constrenido se toma durante la cirugia. Es importante la apropiada liberacion de partes blandas. Al margen de la tecnica quirurgica empleada, el requerimiento de protesis constrenida es bajo. Recomendamos nuestra tecnica, pues se trata de un procedimiento poco demandante con resultados alentadores a mediano y largo plazo. Nivel de Evidencia: IV

Introduction: Valgus malalignment is a complex, multiplanar deformity characterized by bone alterations and soft-tissue abnormalities. Several surgical techniques have been described for valgus knee, and the sequence of tight lateral structure release and the need of constrained prosthesis were addressed. Total knee arthroplasty in valgus deformity remains a surgical challenge for orthopaedic surgeons. The objectives of the study were to evaluate our mid- and long-term results in the surgical treatment of severe valgus disease, and to describe the applied surgical technique. Methods: A clinical-radiological classification was developed, and patients treated for severe genu valgum were discriminated. We retrospectively evaluated 42 total knee arthroplasties in 39 patients, with an average follow-up of 9.2 years. Knee Society Score was used for clinical evaluation, and the last control best quality radiograph was considered for radiographic evaluation. Survival analysis contemplated the need for revision for any reason and for mechanical failure. Results: Postoperative average Knee Society Score was 83.3, with marked improvement in pain and range of motion parameters. Constrained implants were used in 16.7% of cases. Postoperative alignment was on average 5.9°. Two patients underwent revision surgery, having achieved a prosthetic survival for mechanical failure of 97.6%. We did not have any revision due to infection. Conclusions: A meticulous physical examination and proper preoperative radiographs are mandatory. The decision to use a constrained device is taken during surgery. Appropriate soft-tissue release is extremely important. Despite the surgical technique, the use of a constrained prosthesis is limited. We recommend our technique as a low-demanding procedure, with encouraging mid- and long-term results. Level of Evidence: IV

Espaciadores estáticos de cemento con antibiótico en la infección protésica de rodilla: Técnica de elaboración y movilidad posoperatoria

Introducción: A pesar de las mejoras en la técnica quirúrgica en reemplazos totales de rodilla, el número de infecciones posquirúrgicas continúa en aumento. En la bibliografía mundial, está demostrado que las revisiones en dos tiempos logran mayores porcentajes de curación que las de un solo tiempo. El objetivo de este trabajo es mostrar nuestra técnica de elaboración de los espaciadores estáticos y los resultados obtenidos con estos espaciadores en revisiones de reemplazos totales de rodillas infectadas, tratadas en dos tiempos y, además, evaluar la movilidad obtenida. Materiales y Métodos: De 1997 y 2010, en nuestro Centro, se efectuaron 153 revisiones de reemplazos totales de rodilla, 33 (21%) fueron a causa de una infección periprotésica crónica, tratada en dos tiempos, con el uso de un espaciador estático de cemento con antibiótico. La serie estaba conformada por 33 rodillas en 32 pacientes, con un promedio de edad de 69 años y un seguimiento de 3.5 años. Resultados: Treinta (91%) de las 33 rodillas se curaron. Veintiocho fueron reimplantadas exitosamente, 2 rodillas con infección curada no fueron reimplantadas por distintos motivos y permanecieron con el espaciador en forma definitiva y la infección persistió en 3 casos. Las 28 rodillas reimplantadas evolucionaron favorablemente, con una movilidad de 90° a los 3.15 meses de posoperatorio promedio. Conclusiones: Con el empleo de espaciadores estáticos de rodilla, obtuvimos un porcentaje de curación similar al publicado con espaciadores articulados. La ventaja de los primeros es su fácil fabricación y colocación, le otorgan a la articulación una adecuada estabilidad y un aceptable rango de movilidad posoperatoria.(AU)

Background: Despite improvements in surgical technique, the number of infections after total knee arthroplasty continues to rise. According to bibliographic reviews, the two-stage exchange procedure has obtained higher percentages of cure than that performed in a single stage. The purpose of this paper was to show our technique for preparing the static spacer, the results and the range of motion achieved with two-stage revision of infected total knee arthroplasty using those spacers. Methods: We performed 153 total knee arthroplasty revisions between 1997 and 2010, 33 (21%) of them due to a prosthetic chronic infection, treated with a two-stage procedure with cement static spacer with antibiotic. We evaluated 33 total knee arthroplasties in 32 patients, with an average age of 69 years and an average postoperative follow-up of 3.5 years. Results: Healing was achieved in 30 (91%) of the 33 knees. Twenty-eight knees were successfully reimplanted, two with healing infection were not reimplanted for different reasons and 3 had persistent infection. The 28 reimplanted knees evolved favorably, achieving a range of motion of 90º in an average of 3 months after surgery. Conclusions: The static knee spacer achieved a similar healing rate to that obtained with articulated spacers. The advantage of static spacers is its easy manufacture and placement, giving greater stability and an acceptable range of motion.(AU)