Treatment of intertrochanteric fractures using cephalomedullary nail: One or two cephalic screws?

OBJECTIVES: To determine the incidence of cut-out, cut-in, cut-through, Z-effect, and reverse Z-effect in two cephalomedullary nail (CMN) systems: one with single cephalic screw fixation and the other with dual-screw fixation using a lag screw and an anti-rotation screw. METHODS: A retrospective study from a cohort of patients was conducted between January 2017 and August 2019 in patients with intertrochanteric fractures treated with osteosynthesis using CMN. RESULTS: One hundred ninety-six patients with intertrochanteric fractures who met the inclusion criteria were recruited. The median age was 81 years [interquartile range (IQR) 12]. Seventy-six percent had fractures classified as Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen (OTA/AO) 31A2. Twenty-one mechanical complications occurred, 8.7% (17) was cut-out with a single cephalic screw CMN and 2% (4) was Z-effect with a dual-screw CMN non-integrated. The median tip-apex distance (TAD) was 19.4 mm (IQR 10.8) in patients who experienced cut-out and 19 mm (IQR 10) in those who experienced Z-effect. The median time to cut-out occurrence was 39,5 days (IQR 47,5), while the median time to Z-effect was 90 days (IQR 86). CONCLUSIONS: The incidence of osteosynthesis failure using CMN is more frequent in patients treated with a single cephalic screw CMN. LEVEL OF EVIDENCE: Therapeutic, Level III.

Morbidity and mortality in hip surgery patients due to fracture during the COVID-19 pandemic.

BACKGROUND: The COVID-19 epidemic generated major changes in general surgical management protocols. The literature has reported high mortality rates for hip fracture surgery in patients with COVID-19. This study describes the morbidity and mortality in patients undergoing surgery due to hip fractures in 12 Colombian institutions between March and September 2020. METHODOLOGY: This was a retrospective observational descriptive study. Medical records of 12 hospitals were reviewed. Consecutive patients who underwent hip fracture surgery from March 6 to September 6, 2020, were included. Data collected were sociodemographic profile, type of fracture, surgical treatment, complications, and early (1 month) or mid-term (1-6 months) mortality associated or not with COVID-19. RESULTS: Five hundred twenty patients with hip fractures requiring surgery in the 12 institutions were included. 364 (70%) were women; mean age was 77.7 years (SD: 13.8), mean BMI was 25.1, 91.73% of patients had at least one comorbidity, 60.38% were classified as ASA II and 25.77% as ASA III. There were 267 (51.34%) pertrochanteric fractures, 227 (43.65%) femoral neck fractures, and 26 (5.0%) subtrochanteric fractures. 274 (52.69%) patients were treated with osteosynthesis, 244 (46.92%) with arthroplasty, and 2 (0.38%) with girdlestone. Surgery was performed less than 24 h after the fracture for 115 (22.11%) patients, between 24 and 72 h for 208 (40.0%) patients, and more than 72 h for 197 (37.88%) patients. One hundred six patients in total suffered a medical or surgical complication throughout the different follow-up stages, amongst the most frequent were respiratory failure, coronary events, surgical site infection, cutting-out and peri­implant fracture. 25 (4.8%) patients required attention in the Intensive Care Unit (ICU). 13 patients had COVID-19 throughout the follow-up period. 27 patients died due to any cause, and 3 of them had reported a positive COVID-19 test any time during follow-up period, of which one died during the first month, and two died between 1 and 6 months. Statistically significant associations were found between age older than 75 years old, ASA classification, ICU requirement, and death. CONCLUSION: 520 patients received surgical treatment for hip fracture during the first six months of the COVID-19 pandemic in 12 medical centers in Colombia. 21.10% suffered a complication during the early stage (30 days) and 4.77% during the midterm stage (1-6 months). 4.8% were admitted in the ICU during the early stage. All-cause death was 27 patients, early death was 11 (40.74%) and midterm death was 16 (59.25%). 13 patients were positive for COVID-19, 3 died, one (1/5=20%) on the first 30 days and the other two (2/8=25%) from month 1 to 6.

Copas de doble movilidad cementadas: sobrevida, indicaciones y medición de la calidad de vida / Cemented double mobility cups: Survival, indications and measurement of quality of life

Introducción Las copas de doble movilidad son implantes en que se introduce una cabeza protésica en un núcleo de polietileno, el cual posteriormente se articula con una copa metálica implantada en el acetábulo. Este tipo de diseño desarrollado en Francia desde la década de 1970ha demostrado disminuir el riesgo de luxación en un remplazo total de cadera. Estas copas han sido utilizadas históricamente de forma no cementada. No obstante, actualmente se pueden utilizar copas cementadas. Los objetivos de este estudio son determinar la sobrevida de las copas de doble movilidad cementadas y medir la calidad de vida de los pacientes. Materiales y métodos Se realiza un estudio multicéntrico retrospectivo, cuya indicación para la cirugía sea fracturas (61,5%), artrosis (34,6%) o tumores (3,8%). El análisis se realizó con los pacientes operados entre los años 2011-2013 y se encontraron 82 caderas operadas con copas de doble movilidad cementadas con un promedio de edad de 76 años. Resultados Se revisó una copa de doble movilidad por infección; por tanto, se obtuvo una sobrevida del 97,6% con un promedio de tiempo de seguimiento de 33,7 (29,7-37,7) meses con un IC 95%, y un promedio en la escala de Oxford de 38,2 (34,8-41,7) con un IC 95%. Discusión Se pudo concluir que la tasa de sobrevida es óptima para el tiempo de seguimiento y el puntaje promedio en la escala de Oxford es bueno si se tienen en cuenta las comorbilidades y la media de edad de los pacientes. Nivel de evidencia clínica. Nivel IV.

Background The dual mobility cups are implants where a prosthetic head is introduced into a polyethylene core, which is subsequently articulated with a metal cup to be implanted in the acetabulum. This type of design developed in France since the seventies has shown to decrease the risk of dislocation in total hip replacement. These cups have been used historically cementless, however now can be use cemented. The objectives are to determine the survival of double cemented mobility cups and to measure the quality of life of patients. Materials and methods A retrospective multicenter study was made. Patients who underwent primary surgery and whose indication for surgery is fractures (61.5%), osteoarthritis (34.6%) or tumors (3.8%) were included. The analysis was performed with patients operated between 2011 and 2013. Results The study was based in 82 hips operated with dual mobility cemented cups with a patient's average age of 76 (13.4) years old. A dual mobility cup was checked for infection therefore obtaining a survival rate of 97.6% and an average follow up of 33.7 months with 95% CI (29,7-37,7) and an average in the Oxford scale of 38.2 with 95% CI (34,8-41,7) Discussion It was concluded that the survival rate is optimal taking into account the follow up time and the average score on Oxford scale were good considering comorbidities and the average age of patients. Evidence level. IV.

Biopsia por congelación para el diagnóstico de infección en revisión de reemplazo total de cadera / Frozen biopsy in diagnosing infections in hip arthroplasty

Introducción: en Estados Unidos se realizaron 200 000 reemplazos de cadera en el 2001, de los cuales 36 000 fueron cirugías de revisión. Es determinante detectar la presencia o no de infección en una cirugía de revisión para seleccionar el procedimiento quirúrgico más conveniente para el paciente. El cultivo intraoperatorio es el patrón de oro, pero es inoportuno para tomar decisiones intraoperatorias. La biopsia por congelación es un estudio histopatológico que ayuda a determinar infección durante el procedimiento quirúrgico. El objetivo fue determinar la sensibilidad, la especificidad, el valor predictivo positivo (VPP) y el valor predictivo negativo (VPN) de la biopsia por congelación frente al cultivo, en pacientes sometidos a cirugía de revisión de reemplazo total de cadera. Materiales y métodos: se realizó un estudio transversal de prueba diagnóstica. Se revisaron 61 historias clínicas de pacientes que requirieron cirugía de revisión de reemplazo total de cadera, realizada en la Clínica Reina Sofía entre los años 2004 y 2007. 58 cumplieron los criterios de inclusión. Se verificaron los resultados de la biopsia por congelación y gram y se compararon con el cultivo. Resultados: se encontró una sensibilidad de 64,2% (IC 95% 35-92), una especificidad de 65,9% (IC 95% 50,7-81,1), un VPP de 37,5% y un VPN de 85,2% para el diagnóstico de infección con la biopsia por congelación positiva mayor a 5 polimorfonucleares. Discusión: la biopsia por congelación debe ser tomada como uno de los criterios intraoperatorios en el diagnóstico de infección en la cirugía de revisión de reemplazo total de cadera.