One- and two-stage surgical revision of peri-prosthetic joint infection of the hip: a pooled individual participant data analysis of 44 cohort studies.

One-stage and two-stage revision strategies are the two main options for treating established chronic peri-prosthetic joint infection (PJI) of the hip; however, there is uncertainty regarding which is the best treatment option. We aimed to compare the risk of re-infection between the two revision strategies using pooled individual participant data (IPD). Observational cohort studies with PJI of the hip treated exclusively by one- or two-stage revision and reporting re-infection outcomes were retrieved by searching MEDLINE, EMBASE, Web of Science, The Cochrane Library, and the WHO International Clinical Trials Registry Platform; as well as email contact with investigators. We analysed IPD of 1856 participants with PJI of the hip from 44 cohorts across four continents. The primary outcome was re-infection (recurrence of infection by the same organism(s) and/or re-infection with a new organism(s)). Hazard ratios (HRs) for re-infection were calculated using Cox proportional frailty hazards models. After a median follow-up of 3.7 years, 222 re-infections were recorded. Re-infection rates per 1000 person-years of follow-up were 16.8 (95% CI 13.6-20.7) and 32.3 (95% CI 27.3-38.3) for one-stage and two-stage strategies respectively. The age- and sex-adjusted HR of re-infection for two-stage revision was 1.70 (0.58-5.00) when compared with one-stage revision. The association remained consistently absent after further adjustment for potential confounders. The HRs did not vary importantly in clinically relevant subgroups. Analysis of pooled individual patient data suggest that a one-stage revision strategy may be as effective as a two-stage revision strategy in treating PJI of the hip.

Analysis of potential contamination factors in musculoskeletal tissues.

Tissue Banks have become the main source for bone grafts, due to preference for homologous tissues. Notwithstanding the use of aseptic techniques for procurement of tissues and judicious selection of donors, microorganisms are frequently found in procured bones. Purpose of this study is to evaluate the factors that increase safety of procurement and minimize discard of procured tissues. Microbiological contamination was analyzed in 1271 musculoskeletal tissues removed from 138 multi-organ donors over a period extending from 2006 to 2016. Effects of various risk factors related with contamination were estimated using a logistic regression model. Microbiological contamination rate in the tissues was 17.1%; low pathogenic microorganisms were cultivated in 12.9% of the tissues, while highly pathogenic ones were cultivated in 4.2% of the tissues. Evolution of one single team was monitored during that period, verifying a fall in the general contamination level from 22.5 to 9.2%. Absence of antibiotics increased low pathogenic contamination risk. Every additional day in intensive care unit (ICU) increased the risk of highly pathogenic contamination. Time elapsed between death and the beginning of removal procedures was found to be relevant for both low pathogenic and highly pathogenic microorganisms. Among the studied factors, the following contributed for a significant increase in contamination by microorganisms in removed tissues: lack of use of prophylactic antibiotic therapy in donors, quantity of removed tissues, length of admission in ICU and the time elapsed between aortic clamping and beginning of the removal procedure.

Prevalence and risk factors for intra-operative periprosthetic fractures in one thousand eight hundred and seventy two patients undergoing total hip arthroplasty: a cross-sectional study.

PURPOSE: The purpose of this study was to identify the frequency and type of intra-operative periprosthetic fractures and to describe risk factors in a single tertiary, public hospital, so that these events could be prevented, even among less experienced surgeons. METHODS: This is a cross-sectional study, based on medical records and imaging exams from the archives of a public, tertiary hospital, from April 1998 to October 2013. All consecutive patients submitted to total hip arthroplasty (THA) in the study period were evaluated, excluding unipolar or bipolar arthroplasty, surgery for the osteosynthesis of periprosthetic fractures, surgical procedure to clean infection site without component substitution and not arthroplastic surgery. Data were analyzed with chi-squared test and multivariate Cox regression. RESULTS: In the study period, 1,872 THA (1,728 patients) were performed and analyzed, with 144 bilateral cases. In 173 cases, patients had undergone surgical procedures other than THA previously, and in only 260 the surgery consisted of revision THA. There were only two cases of resection THA. Among all patients 101 intra-operative periprosthetic fractures occurred. The univariate analysis revealed a significantly higher risk of intra-operative fractures in female patients, aged more than 65 years, with indication of primary THA and the presence of a previous hip surgery. It indicated also that revision surgeries were associated with a 2.8-fold higher risk of intra-operative fracture, 2.18-fold risk in a previously operated hip and 3.9-fold in cases of resection THA or revision surgery in two stages. CONCLUSIONS: Intraoperative periprosthetic fracture is a rare event, and it is associated with revision type surgery and THA in a previously operated hip.

Surgical technique: Endoscopic gluteus maximus tendon release for external snapping hip syndrome.

BACKGROUND: While many authors have recommended surgery for patients with persistent symptoms of external snapping hip, it is unclear which one best relieves symptoms. Concerns with iliotibial band (ITB)-modifying techniques include altering the shape of the lateral thigh and overload of the contralateral abduction mechanism. We describe a new endoscopic technique that decreases the tension of the ITB complex by releasing the femoral insertion of the gluteus maximus tendon (GMT). DESCRIPTION OF TECHNIQUE: Via an endoscopic approach, we tenotomize the GMT near its insertion at the linea aspera through two trochanteric portals, developing a space beneath the ITB. METHODS: We reviewed eight patients (nine hips) with external snapping hip nonresponsive to nonoperative treatment treated by endoscopic GMT release. There were seven women (one bilateral) and one man, with a mean ± SD age of 35 ± 13.1 years (range, 18-55 years). Mean symptom duration was 36 ± 20.3 months (range, 16-84 months). Minimum followup was 22 months (mean, 32 ± 9.3 months; range, 22-45 months). RESULTS: Snapping and pain resolved in seven patients after the initial procedure. We performed one revision procedure with complete relief of symptoms. All eight patients returned to their previous level of activity. Average modified Harris hip score was 61 points (range, 45-70 points) preoperatively and 78 points (range, 62-93 points) at latest followup. We observed no neurovascular complications. CONCLUSIONS: Our small series suggests endoscopic release of the GMT resolves pain and snapping symptoms in most patients.

Is There Any Difference Between a Spherical Marker and a Simple Coin for Hip Replacement Digital Planning?

Objective To evaluate the accuracy and differences between 2 types of metallic markers, sphere, and coin, for radiographic calibration in the preoperative planning of hip arthroplasty. Methods Four spherical metallic markers and four coins, both 25 mm in diameter, were placed on the greater trochanter, pubic symphysis, between the thighs, and on the table of the exam, for radiographic examination of the hip in 33 patients with hip prosthesis. The prosthesis head was used for calibration and two examiners measured the markers' image diameters, and the results were analyzed statistically. Results In the greater trochanter, the sphere and the coin were not visualized in 19 radiographs (57.6%). Between the thighs, the coin marker was not visualized in 13 radiographs (39.4%). In the greater trochanter, the 25-mm accuracy of the coin and the sphere was, respectively, between 57.1 and 63.3% and between 64.3 and 92.9%. The coin between the thighs reached 25-mm accuracy in between 50 and 60% of cases. Over the exam table, the coin and sphere markers reached, respectively, the mean diameters of 22.91 mm and 23 mm, the lowest coefficient of variation, the lowest confidence interval, and the easiest positioning. There was statistical difference between the evaluations of the markers (coin vs. sphere) in all positions ( p < 0.032), except for the exam table position ( p = 0.083). Conclusions The coin between the thighs is the best marker for radiographic calibration in the preoperative planning of hip arthroplasty, and we suggest the use of another coin on the exam table for comparison, considering the 8% reduction in relation to its real size.

The impact of sonication cultures when the diagnosis of prosthetic joint infection is inconclusive.

BACKGROUND: In the absence of a gold standard criterion for diagnosing prosthetic joint infections (PJI), sonication of the removed implant may provide superior microbiological identification to synovial fluid and peri-implant tissue cultures. The aim of this retrospective study was to assess the role of sonication culture compared to tissue cultures for diagnosing PJI, using different consensus and international guidelines for PJI definition. METHODS: Data of 146 patients undergoing removal of hip or knee arthroplasties between 2010 and 2018 were retrospectively reviewed. The International Consensus Meeting (ICM-2018), Musculoskeletal Infection Society (MSIS), Infectious Diseases Society of America (IDSA), the European Bone and Joint Infection Society (EBJIS), and a modified clinical criterion, were used to compare the performance of microbiological tests. McNemar´s test and proportion comparison were employed to calculate p-value. RESULTS: Overall, 56% (82/146) were diagnosed with PJI using the clinical criteria. Out of these cases, 57% (47/82) tested positive on tissue culture and 93% (76/82) on sonication culture. Applying this clinical criterion, the sensitivity of sonication fluid and tissue cultures was 92.7% (95% CI: 87.1%- 98.3%) and 57.3% (95% CI: 46.6%-68.0%) (p<0.001), respectively. When both methods were combined for diagnosis (sonication and tissue cultures) sensitivity reached 96.3% (95% CI: 91.5%-100%). Sonication culture and the combination of sonication with tissue cultures, showed higher sensitivity rates than tissue cultures alone for all diagnostic criteria (ICM-18, MSIS, IDSA and EBJIS) applied. Conversely, tissue culture provided greater specificity than sonication culture for all the criteria assessed, except for the EBJIS criteria, in which sonication and tissue cultures specificity was 100% and 95.3% (95% CI: 87.8-100%), respectively (p = 0.024). CONCLUSIONS: In a context where diagnostic criteria available have shortcomings and tissue cultures remain the gold standard, sonication cultures can aid PJI diagnosis, especially when diagnostic criteria are inconclusive due to some important missing data (joint puncture, histology).

Do complications in hip arthroscopy change with experience?

PURPOSE: The aim of this study was to evaluate the type and incidence of complications during the development of hip arthroscopic techniques. METHODS: A retrospective series of 194 files of patients treated with hip arthroscopy in a tertiary hospital from December 1999 to March 2008 was reviewed for complications. The incidence of complications was recorded consecutively for each group of 30 patients and in intervals of 2 years. A comparison between the complication rates was performed within the time frames and the set of cases. The type and severity of complications were also recorded. RESULTS: There were 12 complications (6.1%) in this series. Of these, 5 were neurologic (2.6%), 4 were musculoskeletal (2%), and 3 were vascular/ischemic (1.5%). According to severity, 2 were considered major complications (1%), 8 were intermediate (4.1%), and 2 were minor (1%). The incidence of complications did not change with time (P = .959) or with the number of cases performed (P = .771), but different types of complications occurred along the learning curve. CONCLUSIONS: The nature of complications changed with experience, but no significant variation in the incidence was observed over the 9-year period of experience with hip arthroscopy. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Acetabular revision with bone graft and cementless cup.

Cementless acetabular components are routinely used in revision hip surgery. Nevertheless, few investigators have assessed their retention and efficacy over the long term. This occurs mainly in cases which originate from moderate to severe bone losses (cavitary and or segmental) requiring the use of morselized and or bulk bone graft. Our objective in the present study is to report the outcome of 42 patients with 43 cementless acetabular revisions with bone graft who were operated by the same surgeon. The report is based on the clinical and radiographic evaluation of the patients alive at 167 months of follow-up.

Comparative Study of the Osteointegration of Irradiated and Non-irradiated Bone Grafts Used in Patients with Revision Hip Arthroplasty.

Objective To evaluate and compare the osteointegration of irradiated and non-irradiated frozen bone grafts used in 21 patients undergoing revision hip arthroplasty procedures with the Exeter technique. Methods A retrospective study of 21 patients undergoing revision hip arthroplasty with the Exeter technique using bone tissues treated or not with gamma radiation between 2013 and 2014. The patients were divided into two groups according to the use of grafts treated or not with ionizing radiation (gamma rays); as such, these groups were classified as irradiated or non-irradiated. The osteointegration results determined by radiographic analysis of these grafts were compared in the postoperative period of 6 and 12 months. Results Comparing the graft osteointegration in all patients at 6 and 12 months postoperatively, we noticed a significant difference in the radiographic evaluations in this period ( p = 0.031). Out of the patients studied, 7 were from the irradiated group, and 14 belonged to the non-irradiated group. No statistically significant differences were observed ( p = 0.804) regarding osteointegration when we compared the irradiated and non-irradiated groups. Conclusion There was no significant difference in the use of irradiated or non-irradiated grafts in revision hip arthroplasty procedures with the Exeter technique.

One-stage revision of infected total hip arthroplasty with bone graft.

There are many different opinions in the literature regarding the best procedure for revision of infected hip arthroplasty and hence in achieving long-term stabilization of a new implant. Thirty-two patients with 32 loose and infected total hip arthroplasties underwent revision with a bone graft in a 1-stage procedure. The bone graft was used in the acetabulum and femur in 25 patients, in the acetabulum alone in 4 patients and in the femur alone in 3 patients. A metal mesh was necessary in 15 patients to contain the morselized bone graft. At the time of surgical revision, 9 patients had a draining sinus, 6 had a closed sinus, and 17 had never had sinuses in the surgical wound. Antibiotic therapy was administered intravenously and orally for 6 months. Mean follow-up was 103 months (range, 63-183 months), and infection recurred in 2 (6.2%) cases. Further studies are necessary, and continuation of this method is justified.

Is There Any Difference Between a Spherical Marker and a Simple Coin for Hip Replacement Digital Planning? / Existe alguma diferença entre um marcador esférico e uma moeda simples para planejamento digital de substituição de quadril?

Abstract Objective To evaluate the accuracy and differences between 2 types of metallic markers, sphere, and coin, for radiographic calibration in the preoperative planning of hip arthroplasty. Methods Four spherical metallic markers and four coins, both 25 mm in diameter, were placed on the greater trochanter, pubic symphysis, between the thighs, and on the table of the exam, for radiographic examination of the hip in 33 patients with hip prosthesis. The prosthesis head was used for calibration and two examiners measured the markers' image diameters, and the results were analyzed statistically. Results In the greater trochanter, the sphere and the coin were not visualized in 19 radiographs (57.6%). Between the thighs, the coin marker was not visualized in 13 radiographs (39.4%). In the greater trochanter, the 25-mm accuracy of the coin and the sphere was, respectively, between 57.1 and 63.3% and between 64.3 and 92.9%. The coin between the thighs reached 25-mm accuracy in between 50 and 60% of cases. Over the exam table, the coin and sphere markers reached, respectively, the mean diameters of 22.91 mm and 23 mm, the lowest coefficient of variation, the lowest confidence interval, and the easiest positioning. There was statistical difference between the evaluations of the markers (coin vs. sphere) in all positions (p< 0.032), except for the exam table position (p= 0.083). Conclusions The coin between the thighs is the best marker for radiographic calibration in the preoperative planning of hip arthroplasty, and we suggest the use of another coin on the exam table for comparison, considering the 8% reduction in relation to its real size.

Resumo Objetivo Avaliar a precisão e as diferenças entre 2 tipos de marcadores metálicos, esfera e moeda, para calibração radiográfica no planejamento pré-operatório da artroplastia de quadril. Métodos Quatro marcadores metálicos esféricos e quatro moedas, ambas de 25 mm de diâmetro, foram colocadas em trocânter maior, sínfise púbica, entre as coxas e a mesa do exame, para exame radiográfico do quadril em 33 pacientes com prótese de quadril. A cabeça da prótese foi utilizada para calibração e dois examinadores mediram os diâmetros da imagem dos marcadores, e os resultados foram analisados estatisticamente. Resultados No trocânter maior, a esfera e a moeda não foram visualizadas em 19 radiografias (57,6%). Entre as coxas, o marcador de moeda não foi visualizado em 13 radiografias (39,4%). No trocânter maior, a precisão de 25 mm da moeda e da esfera foi, respectivamente, entre 57,1 e 63,3% e entre 64,3 e 92,9%. A moeda entre as coxas atingiu 25 mm de precisão entre 50 e 60%. Sobre a mesa de exame, os marcadores de moeda e esfera atingiram, respectivamente, diâmetros médios de 22,91 mm e 23 mm, o menor coeficiente de variação, o menor intervalo de confiança e o posicionamento mais fácil. Houve diferença estatística entre as avaliações dos marcadores (moeda vs. esfera) em todas as posições (p< 0,032), com exceção da posição na mesa de exame (p= 0,083). Conclusões A moeda entre as coxas é o melhor marcador para calibração radiográfica no planejamento pré-operatório da artroplastia de quadril, e sugerimos o uso de outra moeda na mesa de exame para comparação, considerando os 8% de redução em relação ao seu tamanho real.

Effects of ionizing radiation on proteins in lyophilized or frozen demineralized human bone.

OBJECTIVE: The aim was to study the effects of application of ionizing radiation (gamma and electrons) as sterilizing agents at doses of 15 kGy, 25 kGy and 50 kGy, on lyophilized or frozen demineralized bone tissue for use in transplants. METHODS: Five human femoral diaphyses from different donors of musculoskeletal tissue were demineralized and preserved as lyophilized or frozen at -80 °C. The samples were divided into two groups: non-irradiated (control) and irradiated by means of gamma rays or an electron beam. The bone proteins were extracted and used to determine the concentrations of total protein and BMP 2 and 7. RESULTS: Decreases in total protein and BMP 2 and 7 concentrations were observed. The decreases in total protein concentrations, in comparison with the respective control groups, were significant in the lyophilized and frozen samples that were irradiated at a dose of 50 kGy of gamma radiation and electron beam, with reductions of more than 30%. Significant decreases in the levels of BMP 2 and 7 were also observed at higher doses and especially through use of the electron beam. CONCLUSION: The reductions in the concentrations of total proteins and osteoinductive proteins (BMP 2 and 7) were related to the radiation dose, i.e. they increased with higher doses of ionizing radiation type and the type of bone preservation. The largest reductions in concentrations were observed in the bones irradiated by means of an electron beam and at a dose of 50 kGy. However, this type of radiation and this high dose are not usual practices for sterilization of bone tissue.

OBJETIVO: Estudar os efeitos da aplicação das radiações ionizantes (gama e elétrons) como agentes esterilizantes, nas doses de 15 kGy, 25 kGy e 50 kGy, nos tecidos ósseos desmineralizados congelados e liofilizados para uso em transplantes. MÉTODOS: Cinco diáfises femorais humanas de doadores distintos de tecidos musculoesqueléticos foram desmineralizadas e preservadas como liofilizadas ou congeladas a −80 °C. As amostras foram divididas em grupos não irradiados (controle) e irradiados por raios gama ou feixe de elétrons. As proteínas ósseas foram extraídas e dosadas as concentrações de proteínas totais, BMP 2 e 7. RESULTADOS: Foi observada diminuição das concentrações de proteínas totais e BMP 2 e 7. A diminuição das concentrações de proteínas totais, quando comparada com o respectivo controle, foi significativa nos grupos de amostras liofilizadas e congeladas e irradiadas na dose de 50 kGy por radiação gama e feixe de elétrons com redução superiores a 30%. A diminuição significativa nas concentrações das BMP 2 e 7 também foi observada nas maiores doses e principalmente por feixe de elétrons. CONCLUSÃO: As reduções nas concentrações das proteínas totais e em proteínas osteoindutoras (BMP 2 e 7) foram relacionadas à dose de radiação, ou seja, aumentam com maiores doses, tipo de radiação ionizante e ao tipo de preservação dos ossos. As maiores reduções das concentrações foram observadas nos ossos irradiados por feixe de elétrons e na dose de 50 kGy. Porém esse tipo de radiação e essa alta dose não são práticas usuais para a esterilização dos tecidos ósseos.

TREATMENT OF INFECTION AFTER TOTAL KNEE ARTHROPLASTY.

OBJECTIVES: To identify and compare the rate of success of therapeutic modalities applied in surgeries for the treatment of infections associated with total knee arthroplasty (TKA), and to evaluate the functional outcome and pain in different therapeutic modalities by means of quality of life scores. METHODS: We evaluated all patients who developed periprosthetic infection after TKA for primary or secondary osteoarthritis, in the period from January 1(st), 2008 to December 31(st), 2010. RESULTS: In the study period, 29 patients with TKA had infection, and 12 of these underwent debridement and retention of the prosthesis (D+R), seven received two-stage and six one-stage exchange arthroplasties, and four patients were treated with suppressive antibiotic therapy because they could not undergo another surgical procedure. CONCLUSION: The D+R, one-stage revision and two-stage revision success rates were 75%, 83.3%, and 100%, respectively. The best results of quality of life (QoL) and function occur in patients undergoing D+R. In contrast, the worst QoL and functional results were obtained in patients treated with two-stage revision arthroplasty. Level of Evidence II, Prognostic Studies - Investigating the Effect of a Patient Characteristic on the Outcome of Disease.

Epidemiology of fractures of the proximal third of the femur in elderly patients.

OBJECTIVE: This was an epidemiological study on fractures of the proximal third of the femur in elderly patients who were treated at a teaching hospital in the central region of São Paulo. METHODS: The subjects were patients over the age of 60 years who were attended over a 1-year period. A questionnaire seeking basic sociodemographic data and information on comorbidities presented and medications used was drawn up. The circumstances of the fractures and their characteristics, the treatment instituted and the intra-hospital mortality rate were evaluated. RESULTS: The 113 patients included in the study presented a mean age of 79 years. The ratio between the sexes was three women to each man. Only 30.4% of the patients reported having osteoporosis and only 0.9% had had treatment for the disease. Low-energy trauma was the cause of 92.9% of the fractures. Femoral neck fractures accounted for 42.5% of the fractures and trochanteric fractures, 57.5%. Five patients did not undergo operations; 39 underwent joint replacement; and 69 underwent osteosynthesis. The mean length of hospital stay was 13.5 days and the mean length of waiting time until surgery was 7 days. The intra-hospital mortality rate was 7.1%. CONCLUSION: The patients attended at this institution presented an epidemiological profile similar to what is found in the Brazilian literature. Chronic kidney failure is a significant factor with regard to intra-hospital mortality. Preventive measures such as early diagnosis and treatment of osteoporosis and regular physical activity practices were not implemented.

OBJETIVO: Estudo epidemiológico das fraturas do terço proximal do fêmur em pacientes idosos, tratados em hospital-escola na região central de São Paulo. MÉTODOS: Pacientes a partir 60 anos atendidos no período de um ano. Questionário foi elaborado com informações sociodemográficas básicas, comorbidades apresentadas e medicações em uso. Foram avaliadas circunstâncias da fratura e suas características, tratamento instituído e taxa de mortalidade intra-hospitalar. RESULTADOS: Os 113 pacientes incluídos no estudo apresentavam 79 anos em média. A proporção entre os sexos foi de três mulheres para cada homem. Somente 30.4% dos pacientes relataram osteoporose e somente 0.9% tratavam a doença. Trauma de baixa energia foi a causa de 92,9% das fraturas. Fraturas do colo do fêmur representaram 42,5% das fraturas e trocantéricas 57,5%. Cinco pacientes não foram operados, 39 foram submetidos a substituição articular e 69 foram submetidos a osteossíntese. O tempo médio de internação foi de 13,5 dias e de espera até a cirurgia sete dias. A taxa de mortalidade intra-hospitalar foi de 7,1%. CONCLUSÃO: Pacientes atendidos na instituição apresentam perfil epidemiológico semelhante àqueles encontrados em literatura nacional. Insuficiência renal crônica é um fator significativo para mortalidade intra-hospitalar. Medidas preventivas como diagnóstico precoce e tratamento da osteoporose e prática regular de atividades físicas não são adotadas.

Comparative Study of the Osteointegration of Irradiated and Non-irradiated Bone Grafts Used in Patients with Revision Hip Arthroplasty / Estudo comparativo da osteointegração de enxertos ósseos irradiados e não irradiados utilizados em pacientes com revisão de artroplastia do quadril

Abstract Objective To evaluate and compare the osteointegration of irradiated and nonirradiated frozen bone grafts used in 21 patients undergoing revision hip arthroplasty procedures with the Exeter technique. Methods A retrospective study of 21 patients undergoing revision hip arthroplasty with the Exeter technique using bone tissues treated or not with gamma radiation between 2013 and 2014. The patients were divided into two groups according to the use of grafts treated or not with ionizing radiation (gamma rays); as such, these groups were classified as irradiated or non-irradiated. The osteointegration results determined by radiographic analysis of these grafts were compared in the postoperative period of 6 and 12months. Results Comparing the graft osteointegration in all patients at 6 and 12months postoperatively, we noticed a significant difference in the radiographic evaluations in this period (p = 0.031). Out of the patients studied, 7 were from the irradiated group, and 14 belonged to the non-irradiated group. No statistically significant differences were observed (p = 0.804) regarding osteointegration when we compared the irradiated and non-irradiated groups. Conclusion There was no significant difference in the use of irradiated or nonirradiated grafts in revision hip arthroplasty procedures with the Exeter technique.

Resumo Objetivo Avaliar e comparar a osteointegração dos enxertos ósseos congelados irradiados e não irradiados utilizados em 21 pacientes submetidos a revisão de prótese do quadril pela técnica Exeter. Métodos Foi realizado estudo retrospectivo de 21 pacientes submetidos a revisão de artroplastia do quadril pela técnica Exeter comutilização de tecidos ósseos tratados ou não com radiação gama no período entre 2013 e 2014. Dividimos os pacientes em dois grupos, de acordo com o uso do enxerto tratado ou não com radiação ionizante (raios gama), que foram, portanto, classificados como: grupo irradiado e não irradiado. Os resultados da osteointegração por análise radiográfica destes enxertos foram comparados no pós-cirúrgico de 6 e 12 meses. Resultados Quando comparamos a osteointegração dos enxertos no pós-cirúrgico de 6 e 12 meses de todos os pacientes, notamos que houve diferença significativa entre as avaliações radiográficas neste período (p= 0,031). Dos pacientes estudados, 7 pertenciam ao grupo irradiado, e 14, ao grupo não irradiado. Não foram observadas diferenças estatisticamente significativas (p= 0,804) quando a osteointegração entre os grupos irradiados e não irradiados foi comparada. Conclusão Não houve diferença significativa no uso de enxerto irradiado e não irradiado nas revisões de artroplastias do quadril pela técnica Exeter.

Current possibilities for hip arthroplasty.

Hip arthroscopy has been popularized over the last decade and, with technical advances regarding imaging diagnostics, understanding of the physiopathology or surgical techniques, several applications have been described. Both arthroscopy for intra-articular conditions and endoscopy for extra-articular procedures can be used in diagnosing or treating different conditions. This updated article has the objective of presenting the various current possibilities for hip arthroscopy.

A artroscopia de quadril tem sido popularizada na última década e com o avanço técnico, seja no diagnóstico por imagem, no entendimento da fisiopatologia ou na técnica cirúrgica, diversas aplicações foram descritas. Tanto a artroscopia, para afecções intra-articulares, como a endoscopia, para procedimentos extra-articulares, podem ser usadas no diagnóstico ou no tratamento de diferentes afecções. Este artigo de atualização tem como objetivo apresentar diversas possibilidades atuais da artroscopia de quadril.

There have been changes in the incidence and epidemiology of pelvic ring fractures in recent decades?

The pelvic ring fractures comprise 2-8% of all skeletal injuries. As the incidence rises to 25% in polytrauma and represents a negative prognostic factor with regard to morbidity and mortality of patients, we sought with this work to establish the profile of these, compared to an alteration in the profile of patients with pelvic ring fractures in recent decades. To this end, we evaluated the epidemiological profile, mechanism of injury and types of fractures. By reviewing the literature indexed in the databases related to the theme, 20 papers were selected that contained the requirements for the study. For the period between January 1987 and December 1999 (first decade), and another period in January 2000 and December 2010 (second decade), data were analyzed by Mann-Whitney test. The ratings Tile, Young and Burgess AO were adequate to permit their categorization. The research in each decade was homogeneous. At first the lesions were more prevalent in men with 62.5% with a tendency to reverse this pattern given the increase of women in the second decade (p = 0.286). The average age in the first decade was 39.3 years, an increase in the second (p = 0.068). The most prevalent mechanisms of trauma were related to traffic in both periods as well as fractures classified as type A (p = 0.203 and p = 0.457, respectively), having mortality rates decreased (p = 0.396). We conclude that there was a tendency to increase in the average age of patients (p = 0.068); however the increasing involvement of women (p = 0.286) and decreased mortality (p = 0.396) were not significant.

As fraturas do anel pélvico compõem de 2% a 8% de todas as lesões do esqueleto, incidência que sobe para 25% nos politraumatizados e representa fator prognóstico negativo no que diz respeito à morbidade e à mortalidade. Buscou-se com este trabalho estabelecer se houve mudança do perfil desses pacientes nas últimas décadas e por que ela ocorreu. Para tanto, avaliaram-se epidemiologia, mecanismo de trauma e tipos de fratura, por revisão bibliográfica nas bases de dados indexadas relacionadas ao tema, selecionados 20 trabalhos que continham os requisitos para o estudo. O período entre janeiro de 1987 e dezembro de 1999 (primeira década) e outro de janeiro de 2000 a dezembro de 2010 (segunda década) foram analisados e comparados estatisticamente pelo Teste de Mann­Whitney. As classificações de Tile, Young Burgess e AO foram adequadas para permitir sua categorização. As pesquisas em cada uma das décadas foram homogêneas. Na primeira, as lesões foram mais prevalentes em homens, com 62,5%, com tendência a inversão desse padrão, dado o aumento de mulheres acometidas na segunda década (p = 0,286). A média de idade na primeira década era de 39,3 anos e revelou um aumento na segunda (p = 0,068). Os mecanismos de trauma mais prevalentes foram aqueles relacionados ao tráfego nos períodos, assim como as fraturas classificadas como do tipo A (p = 0,203 e p = 0,457, respectivamente). Os índices de mortalidade diminuíram (p = 0,396). Conclui-se que houve tendência ao aumento na média de idade dos pacientes (p = 0,068). Já o crescente acometimento das mulheres (p = 0,286) e a diminuição da mortalidade (p = 0,396) não foram significantes.

Comprehension and reproducibility of the Judet and Letournel classification.

OBJECTIVE: To evaluate the effectiveness of the method of radiographic interpretation of acetabular fractures, according to the classification of Judet and Letournel, used by a group of residents of Orthopedics at a university hospital. METHODS: We selected ten orthopedic residents, who were divided into two groups; one group received training in a methodology for the classification of acetabular fractures, which involves transposing the radiographic images to a graphic two-dimensional representation. We classified fifty cases of acetabular fracture on two separate occasions, and determined the intraobserver and interobserver agreement. RESULT: The success rate was 16.2% (10-26%) for the trained group and 22.8% (10-36%) for the untrained group. The mean kappa coefficients for interobserver and intraobserver agreement in the trained group were 0.08 and 0.12, respectively, and for the untrained group, 0.14 and 0.29. CONCLUSION: Training in the method of radiographic interpretation of acetabular fractures was not effective for assisting in the classification of acetabular fractures. Level of evidence I, Testing of previously developed diagnostic criteria on consecutive patients (with universally applied reference "gold" standard).

Translation and cross-cultural adaptation of the International Hip Outcome Tool (iHOT) into Portuguese.

OBJECTIVE: iHOT12/33 is an outcome tool designed for young patients with hip problems. The objective of this study is to translate and establish a cross-cultural adaptation of this questionnaire to Portuguese. METHOD: The Guillemin guidelines were followed for the translation and cross-cultural adaptation consisting on: translation, back-translation, prefinal version, administration of the Questionnaire, and editing of the final version. RESULTS: The prefinal version was applied to 30 young patients with hip problems. Some difficulties in understanding some of the words and expressions were noted, and these were replaced with simpler ones, achieving the patient's full acceptability in the final version of the Questionnaire. CONCLUSION: The creation of the Brazilian version of the International Hip Outocome Tool (iHOT) 12/33 enables this questionnaire to be used in the evaluation of patients with hip problems in Brazil, and was clearly understood, with good acceptance by the patients tested. Level of evidence II - Development of diagnostic criteria on consecutive patients (with universally applied reference "gold" standard).

Evaluation of the reliability of the modified Merle d'Aubigné and Postel Method.

OBJECTIVE: To assess the inter-evaluator reproducibility of the Modified Merle d'Aubigné and Postel Method. METHOD: Forty-five patients took part in the study, with a mean age of 57.93 (±13.35) who underwent total hip arthroplasty. All were evaluated by three researchers, who received training to standardize their criteria. The evaluation was held by the Modified Merle d'Aubigné and Postel Method (association of prefixes A, B and C) the same day at random, and the researchers did not report to one another throughout the evaluations. For mobility assessment, passive hip movements were performed and measured with the universal goniometer. The statistical analysis was carried out by the Cronbach Test (p≤0.05 and 0.7≤ α<1.0). RESULTS: The statistical analysis showed significantly high inter-evaluators reliability for the items: prefix (p<0.001; α = 0.961), pain (p<0.001; α= 0.892), gait (p<0.001; α= 0.898), mobility (p<0.001; α=0.810) and total score (p<0.001; α=0.917). CONCLUSION: There was high significance and reliability among the three evaluators for all items of the Modified Merle d'Aubigné and Postel Method, suggesting that this method is reliable, provided its items are parameterized and previous training of evaluators is carried out. Level of Evidence II, Diagnostic Study.