Clinical assessment of patients with isolated hip fractures associated with an upper limb fracture. / Evaluación clínica de pacientes con fractura de cadera aislada y asociada a fractura de miembro superior.

INTRODUCTION: Some patients with a hip fracture also present a concomitant upper limb fracture. We want to know whether these patients have a worse functional level and whether they have any differences in various clinical parameters compared with patients with an isolated hip fracture. MATERIAL AND METHODS: We retrospectively reviewed 1061 discharge reports from the Orthogeriatrics Unit. We collected information on several clinical parameters of the fractures. Subsequently, we performed a statistical analysis of the data by comparing the associated fracture group with the isolated fracture group. RESULTS: We detected 44 patients with associated upper limb fracture, 90.9% were women (40) and the average age was 84.45years. Eighty-one point eight percent of the upper limb fractures were distal radius or proximal humerus. Pertrochanteric fractures were the most common (none of them were subtrochanteric fractures). Surgical delay was 2.60days and the average hospital stay was 12.30days. Sixty-four point three percent were nail surgery and 31% arthroplasty. The mean Barthel index score was 84.88 (P=.021). Fifty-two point 5 percent of the patients in the study group were referred to a functional support unit (P=.03). The in-hospital mortality rate was 4.2%, with no differences between groups. CONCLUSIONS: Patients with an associated fracture have a higher previous functional capacity and they are more independent. Nevertheless, after the fracture they need more help from the healthcare system for optimal functional recovery.

SECOT-GEDOS consensus on pre-surgical pain management in knee and hip arthrosis.

OBJECTIVE: To develop recommendations, based on best evidence and experience, on pain management in patients undertaking total knee or hip replacement. METHODS: Nominal group methodology was followed. A group of experts was selected (5 orthopedics, 1 anesthesiologist), who defined the scope, users, topics, preliminary recommendations, and 3 systematic reviews: efficacy and safety of pre-surgical analgesia regarding to post-surgical pain, efficacy and safety of pre-emptive analgesia and pre-operative factors of post-operative pain. The level of evidence and grade of recommendation was established using the Oxford Centre for Evidence Based Medicine, and the level of agreement with the Delphi technique (2 rounds). The Delphi was extended to 39 orthopedics and anesthesiologists. The whole document was reviewed by all the experts. RESULTS: A total of 21 recommendations were produced. They include specific pharmacological treatment, as well as the evaluation and monitoring of patients on this treatment, and post-operative pre-emptive treatment. Agreement above 70% was reached in 19 recommendations. CONCLUSIONS: In patients undergoing total knee or hip replacement, a proper evaluation, follow-up, pharmacological and non-pharmacological treatment of predictors of poor surgical outcomes should be performed, especially those related to pre-operative pain. This can improve post-operative pain and surgery outcomes.

[Medial versus lateral plating in distal tibial fractures: a prospective study of 40 fractures]. / Placas mediales versus laterales para las fracturas de pilón tibial: estudio prospectivo de 40 fracturas.

OBJECTIVE: Tibial plafond fractures are one of the most challenging injuries in orthopaedic surgery. Their results could be improved by following the new guidelines for the management, and modern plating techniques. The results and complication rate between anteromedial and anterolateral approach for open reduction and internal fixation of these fractures were compared. MATERIAL AND METHODS: A study was conducted on 40 patients treated by open reduction an internal fixation between 2007 and 2008. The surgical approach was selected by the surgeon in charge, depending on fracture pattern and skin situation. Patients were evaluated clinically and radiographically by an independent orthopaedic surgeon, not involved in the surgical procedure, using clinical (American Orthopaedic Foot and Ankle Society score) and radiological criteria at a minimum of two years. The appearance of complications after both approaches was recorded. RESULTS: Forty patients were included. The mean age was 53 years, with 24 males and 16 females. Seventeen of the injuries were of high energy, and there were 8 open fractures (3 of type i, 4 type ii and one type iii), and 12 of the closed injuries were grade ii or iii in the Tscherne classification. Six patients (15%) had associated injuries. At final follow-up there were 33 (82%) excellent or good results. No statistical differences were found between either surgical approach regarding time to bone union, rate of delayed union and infection rate. Three plates of the anteromedial group and none of the anterolateral group needed to be removed. CONCLUSION: Open reduction and internal fixation of distal tibia fractures produced reliable results, with no statistical differences found between anteromedial and anterolateral surgical approaches. Clinical and radiological results and complication rate were mainly related to the fracture type.

[Thromboprophylaxis with enoxaparin for total knee replacement: an observational, retrospective and multicentre study comparing starting the treatment before and after the operation]. / Tromboprofilaxis con enoxaparina para artroplastia total de rodilla: estudio observacional, retrospectivo y multicéntrico comparando el inicio del tratamiento preoperatorio con el postoperatorio.

OBJECTIVE: The low molecular weight heparins are the first option for the prophylaxis of venous thromboembolic disease in major orthopaedic surgery. The time of starting their administration is controversial. The aim of this study was to evaluate the efficacy and safety of enoxaparin in patients subjected to total knee replacement comparing the starting of it before and after the surgery. METHODS: An observational, retrospective and multicentre study of normal clinical practice to determine the incidence of symptomatic deep venous thrombosis and/or pulmonary thromboembolism in total knee replacement surgery. Thromboprophylaxis was normal practice in each centre. Patients were included if they received the first dose of 40 mg/24 h of enoxaparin either 12 h (± 2 h) before the surgery (G-PRE) or between 6 and 12 hours after the surgery (G-POST). The main safety objective was haemorrhage. A multivariate logistic regression analysis was performed to determine the real influence of each variable. RESULTS: Data was collected from 2014 patients, of whom 1440 were included for the analysis of efficacy (782/1440, 54% of the G-PRE and 658/1440, 46% of the G-POST). The mean incidence of symptomatic thrombotic events was 1.67% (24/1440). The incidence of deep venous thrombosis in the G-PRE was 1.15% compared to 1.22% in the G-POST (P=.569 after multivariate analysis) and the incidence of pulmonary thromboembolism was 0.51 compared to 0.76%, respectively (P=.582 after multivariate analysis). A total of 1422 patients were included for the safety analysis. There was significant bleeding in 59/788 of the G-PRE and in 35/634 of the G-POST (7.49% compared to 5.52%, respectively, P=.138). CONCLUSIONS: These results suggest that thromboprophylaxis with enoxaparin (40 mg/24 h sc) in patients subjected to total knee replacement surgery has a similar safety and effective profile when it is given 12 hours before the surgery or between 6 and 12 hours afterwards.

Comparative study of the Weil osteotomy with and without fixation.

BACKGROUND: Weil osteotomy is a technique widely used in patients with metatarsalgia which shortens the metatarsal and reduces the load under the metatarsal head. METHODS: The aim of this paper is to compare the results of the Weil osteotomy with and without any fixation system. We present a retrospective study of 92 patients (97 feet) who underwent treatment for metatarsalgia between 1999 and 2005. One hundred and six osteotomies were vixed using a screw amd no fixation was used in 92. The mean follow-up was 51.2 and 46.6 months respectively. RESULTS: All the patients were evaluated following the AOFAS LMIS scale, obtaining a mean score of 69.8 points (ranged 15-100) and 75.3 points (from 47 to 100) in each group (P=0.11). CONCLUSIONS: The results of fixed and unfixed Weil osteotomies were not significantly different. Our study could not find a significant relationship between metatarsal shortening and main complications (recurrent metatarsalgia, transfer metatarsalgia and stiffness of the metatarsophalangeal joint).

Identification of differentially expressed genes in trabecular bone from the iliac crest of osteoarthritic patients.

OBJECTIVE: Osteoarthritis (OA) is clinically characterized by degeneration of the joints and has been traditionally considered a primary disorder of articular cartilage, with secondary changes in the subchondral bone. The increased bone mass and generalized changes in bone quality observed in osteoarthritic patients suggest that OA may be a primary systemic bone disorder with secondary articular cartilage damage. The iliac crest is a skeletal site distant from the affected joint, with a minimal load-bearing function. To provide evidence that OA is a systemic disorder, we searched for differentially expressed genes in the iliac crest bone of patients suffering from hip OA. MATERIAL AND METHODS: Gene expression levels between bone samples collected at surgery from the iliac crest of patients undergoing total hip arthroplasty for primary OA and younger donors, who were undergoing spinal arthrodesis, were investigated by means of oligonucleotide microarrays. To verify data detected by microarrays technology, Real Time Reverse Transcription-Polymerase Chain Reaction (RT-PCR) assays were performed with specimens from osteoarthritic patients and donors, as well as from elderly donors who were undergoing arthroplasty for subcapital femoral neck fracture. RESULTS: The microarray analysis surveyed 8327 genes and identified 83 whose expression levels differed at least 1.5-fold in the OA group (P<0.005). Comparisons between Real Time RT-PCR data from OA and the two donor groups indicated differential expression of genes involved in bone cell functions in the group of OA patients. The genes identified, including CCL2, FOS, PRSS11, DVL2, AKT1, CA2, BMP6, OMD, MMP2, TGFBR3, FLT1, BMP1 and TNFRS11B, have known roles in osteoblast or osteoclast activities. CONCLUSIONS: The data from this study identify a set of genes, closely related to bone cell functions, in which differential regulation in osteoarthritic bone distant from the diseased subchondral bone might underlie the etiopathogenesis of OA as a generalized bone disease.

Insufficient duration of venous thromboembolism prophylaxis after total hip or knee replacement when compared with the time course of thromboembolic events: findings from the Global Orthopaedic Registry.

Patients who have undergone total hip or knee replacement (THR and TKR, respectively) are at high risk of venous thromboembolism. We aimed to determine the time courses of both the incidence of venous thromboembolism and effective prophylaxis. Patients with elective primary THR and TKR were enrolled in the multi-national Global Orthopaedic Registry. Data on the incidence of venous thromboembolism and prophylaxis were collected from 6639 THR and 8326 TKR patients. The cumulative incidence of venous thromboembolism within three months of surgery was 1.7% in the THR and 2.3% in the TKR patients. The mean times to venous thromboembolism were 21.5 days (sd 22.5) for THR, and 9.7 days (sd 14.1) for TKR. It occurred after the median time to discharge in 75% of the THR and 57% of the TKA patients who developed venous thromboembolism. Of those who received recommended forms of prophylaxis, approximately one-quarter (26% of THR and 27% of TKR patients) were not receiving it seven days after surgery, the minimum duration recommended at the time of the study. The risk of venous thromboembolism extends beyond the usual period of hospitalisation, while the duration of prophylaxis is often shorter than this. Practices should be re-assessed to ensure that patients receive appropriate durations of prophylaxis.

Femoral shaft fractures after cemented total hip arthroplasty.

Thirty-seven femoral shaft fractures occurred in 2360 cemented hip arthroplasties carried out between 1971 and 1989 at varying intervals after operation (average 3.7 years). Three types of fracture were recognised and treatment depended on the type, as did the prognosis. Good results were obtained in 70% of the cases.

Acetabular dysplasia in the rat induced by injury to the triradiate growth cartilage.

An extraarticular lesion of the physeal component of the acetabular roof was performed by thermal cautery in young Wistar rats. Seventy-four animals were studied. The effects of the lesion on the pelvis, the hip joint, and the femur were analyzed during a 14-week period by radiographic, gross morphologic, morphometric, and histologic methods. Most hips developed dysplasia with a shallow and deformed acetabulum and a deformed and underdeveloped femoral head.

Experimental acetabular dysplasia associated with a lesion of iliopubic limb of the triradiate cartilage.

An experimental lesion was created in the iliopubic limb of the triradiate cartilage in young Wistar rats with the object of studying the role of this structure in the development of hip joint disorders. Roentgenographic, functional, morphologic, and morphometric results were evaluated during the following 12 weeks. Acetabular dysplasia, dislocation, or subluxation of the hip, deformities of the acetabulum and the femoral head, and bending and hypoplasia of the innominate bone were the most significant findings. It is concluded that a lesion of the iliopubic limb of the triradiate cartilage may be a cause of severe hip joint disorders such as acetabular dysplasia, subluxation, and dislocation.