Osteosarcoma After Total Knee Arthroplasty: A Case Report.

CASE: A 79-year-old woman presented with a periprosthetic fracture 8 years after a total knee arthroplasty (TKA). Radiographs demonstrated tibial implant loosening with severe osteolysis. A high-grade osteosarcoma around the prosthesis was diagnosed, and a supracondylar femoral amputation was performed. After 2 years, no complications have occurred. CONCLUSIONS: A malignant tumor around a TKA is extremely rare. Surgeons should remain vigilant with patients who present with rapidly progressive or very aggressive implant loosening with osteolysis. Owing to its complexity and potentially devastating prognosis, treatment should be guided by a specialist multidisciplinary team. Complex limb salvage procedures or amputation is usually required.

Temporary immobilization methods for closed low-energy ankle fracture-dislocations: comparative analysis of a retrospective cohort.

PURPOSE: Ankle fracture-dislocations (AFD) often necessitate staged management involving temporary external fixation (EF) due to mechanical instability or blistering. However, limited literature exists on the optimal temporary immobilization method for low-energy closed AFD. This study compared baseline patient and fracture characteristics, along with clinical and radiological outcomes between AFD initially immobilized with EF versus splinting. METHODS: A retrospective cohort study was conducted involving patients with AFD temporarily immobilized using EF or splinting, followed by definitive open reduction and internal fixation. Quality of reduction (QOR) was assessed for each patient post-initial immobilization and after the definitive surgery. RESULTS: The study encompassed 194 patients: 138 treated with a splint (71.1%) and 56 (28.9%) with EF. Secondary loss of reduction had occurred in three patients who were splinted (2.2%). The mean ages in the EF and splint groups were 63.2 and 56.1 years, respectively (p = 0.01). Posterior malleolus fracture (PMF) and blisters were more prevalent in EF patients (69.6% vs. 43.5% for PMF and 76.8% vs. 20.3% for blisters, respectively; p = 0.05 and p < 0.01). Postoperative complication rates were 8.9% for EF versus 10.9% for splinting (p = 0.69). Satisfactory final QOR was attained in 79.8% of patients treated with a splint versus 64.3% with EF (p = 0.02). CONCLUSION: Patients immobilized by EF presented with poorer baseline characteristics and had more unstable injuries. Nevertheless, postoperative complication rates were comparable. Thus, EF appears to be a valuable tool for standardizing outcomes in AFD patients with a less favorable prognosis.

Economic evaluation of high tibial osteotomy: Closing wedge is more cost-effective than open wedge technique when analysing the KOOS-12 improvement.

PURPOSE: The purpose of this study was to compare the cost-effectiveness of two techniques for performing a knee valgus osteotomy: opening wedge high tibial osteotomy (OW-HTO) vs closing wedge high tibial osteotomy (CW-HTO). METHODS: In this economic evaluation study, a cost-effectiveness analysis from the perspective of the Spanish public healthcare system was performed, comparing OW-HTO with CW-HTO. All patients with medial knee osteoarthritis who underwent one of these procedures between 2018 and 2020 in our institution were included. The cost analysis included operating room, implant, graft and hospital admission costs. Functional outcomes (KOOS-12, Tegner activity scale, pain and satisfaction) and radiological outcomes (hip-knee-ankle angle, medial proximal tibial angle, tibial slope and patellar height) were analysed. The cost-effectiveness ratio was obtained by calculating the cost of improving the minimal clinically important difference (MCID) of KOOS-12 for each procedure. All costs are expressed in 2020 euros. RESULTS: Fifty-one patients met the inclusion criteria (27 OW-HTO and 24 CW-HTO). Good to excellent functional outcomes, significant pain reduction (>6 points) and high patient satisfaction (>9/10) were observed in both groups. Both techniques yielded excellent radiological outcomes. N.s. differences in functional or radiological outcomes improvements between both procedures were found. However, the OW-HTO group presented a higher total cost than the CW-HTO group (4612.1 ± 765.6€ vs. 1827.1 ± 701.9€; p < 0.001). The cost-effectiveness ratio was 818.1 ± 46.8 €/MCID for the CW-HTO procedure and 2414.3 ± 115.2 €/MCID for the OW-HTO procedure (p = 0.025). CONCLUSION: The CW-HTO procedure presented a cost-effectiveness ratio almost three times lower than the OW-HTO procedure. Both techniques allowed to achieve of good to excellent functional outcomes, significant pain reduction and high patient satisfaction while correcting the varus limb malalignment and the metaphyseal tibial varus in patients with medial compartment osteoarthritis. LEVEL OF EVIDENCE: Level III; economic study.

Multiligament knee injuries. Ten years' experience at a public university, level I Trauma Center.

PURPOSE: To describe our institutional experience and results in the surgical management of multiligament knee injuries (MLKI). MATERIALS AND METHODS: Retrospective series of MLKI consecutively operated on at a single, level I Trauma Center. Data on patients' baseline characteristics, injuries, treatments, and outcomes were recorded up to one-year follow-up. Recorded outcomes included the Tegner-Lysholm Knee Scoring Scale (TLKSS), return to work, and patient satisfaction. RESULTS: MLKI incidence was 0.03% among 9897 orthopedic trauma admissions. Twenty-four patients of mean age 43.6 years were included in analysis. The mean Injury Severity Score was 12.6. Five patients presented with knee dislocations and six had fracture-dislocations, two of them open fractures. There was one popliteal artery injury requiring a bypass and four common peroneal nerve palsies. Staged ligamental reconstruction was performed in all cases. There were seven postoperative complications. The median TLKSS was 80 and, though patient satisfaction was high, and dissatisfaction was largely restricted to recreational activities (only 58.3% satisfied). Seventeen patients returned to their previous employment. CONCLUSIONS: We found a high aggregation of fracture-dislocations secondary to road traffic accidents. One in four patients experienced complications, particularly stiffness. Complications were more common in cases involving knee dislocation. Most patients had good functional results, but 25% were unable to return to their previous work, which demonstrates the long-lasting sequelae of this injury.

Single-injection nerve blocks for total knee arthroplasty: femoral nerve block versus femoral triangle block versus adductor canal block-a randomized controlled double-blinded trial.

INTRODUCTION: Femoral nerve block (FNB) is a well-established analgesic technique for TKA. However, it associates quadriceps weakness. Therefore, femoral triangle block (FTB) and adductor canal block (ACB) were proposed as effective alternative motor-spearing techniques. The primary objective was to compare quadriceps muscle strength preservation between FNB, FTB and ACB in TKA. The secondary objective was to analyze pain control and functional outcomes. METHODS: This is a prospective, double-blinded RCT. From April 2018 to April 2019, patients who undergo a primary TKA were randomized into three experimental groups: FNB-G1/FTB-G2/ACB-G3. Quadriceps strength preservation was measured as the difference in maximum voluntary isometric contraction (MVIC) preoperatively and postoperatively. RESULTS: Seventy-eight patients (G1, n = 22; G2, n = 26; G3, n = 30) met our inclusion/exclusion criteria. Patients with FNB retained significantly lower baseline MVIC at 6 h postoperatively (p = 0.001), but there were no differences at 24 and 48 h. There were no differences between the groups in functional outcomes at any time point. Patients in the FNB-G1 presented significant lower pain scores at 6 h (p = 0.01), 24 h (p = 0.005) and 48 h (p = 0.01). The highest cumulative opioid requirement was reported in ACB-G3. CONCLUSION: For patients undergoing TKA, FTB and ACB preserve quadriceps strength better than FNB at 6 h postoperatively, but there are no differences at 24 and 48 h. Moreover, this early inferiority does not translate to worse functional outcomes at any time point. FNB is associated with better pain control at 6, 24 and 48 h after surgery, while ACB presents the highest cumulative opioid requirement. CLINICAL TRIAL REGISTRATION: This study was registered in clinicaltrials.gov (NCT03518450; https://clinicaltrials.gov/ct2/show/NCT03518450 ; submitted March 17, 2018).

Sequential repeated tibial tubercle osteotomy in a two-stage exchange strategy: a superior approach to treating a chronically infected knee arthroplasty?

PURPOSE: Surgical approach can impact the reliability of the debridement after a chronic total knee periprosthetic joint infection (PJI), a factor of utmost importance to eradicate the infection. The most adequate knee surgical approach in cases of PJI is a matter of debate. The purpose of this study was to determine the influence of performing a tibial tubercle osteotomy (TTO) in a two-stage exchange protocol for knee PJI treatment. METHODS: Retrospective cohort study examining patients managed with two-stage arthroplasty due to chronic knee PJI (2010-2019). Performance and timing of the TTO were collected. Primary end-point was infection control with a minimum FU of 12 months and according to internationally accepted criteria. Correlation between TTO timing and reinfection rate was reviewed. RESULTS: Fifty-two cases were finally included. Overall success (average follow-up: 46.2 months) was 90.4%. Treatment success was significantly higher among cases addressed using TTO during the second stage (97.1% vs. 76.5%, p value 0.03). Only 4.8% of the patients relapsed after performing a sequential repeated TTO, that is, during both first and second stages, compared to 23.1% cases in which TTO was not done (p value 0.28). No complications were observed among patients in the TTO group with a significant decrease in soft tissue necrosis (p: 0.052). CONCLUSION: Sequential repeated tibial tubercle osteotomy during a two-stage strategy is a reasonable option and offers high rates of infection control in complex cases of knee PJI with a low rate of complications.

High reoperation and mortality rate after distal femoral replacement for periprosthetic knee fracture in the elderly.

PURPOSE: To analyze the outcomes of elderly patients with periprosthetic fractures around the knee operated on with a distal femur replacement (DFR). METHODS: We performed a retrospective case series study of eleven elderly patients who underwent DFR due to a periprosthetic fracture. Mean follow-up was 30.1 months (SD 28.1). Demographic, clinical and radiological data were reviewed. A descriptive analysis and a study of survival were conducted. Then, a comparative analysis between the patients who needed reoperation and did not need reoperation, and the patients who died and the patients who were alive during the follow-up was performed. RESULTS: Mean age was 77.1 years (SD 13.9). Reoperation rate was 36%, being infection the most common complication (27%). The risk of reoperation increased with a longer time between fracture and surgery. The 36.4% of patients died during the follow-up. Older age, need of blood transfusion and need of early reoperation were related to a higher risk of mortality. CONCLUSION: DFR could be a valuable option for knee periprosthetic fractures in elderly patients. However, surgeons should be aware of the high reoperation and mortality rate.

Preoperative mechanical axis has no influence on reoperation rate in primary rotating-hinge knee arthroplasty.

Background: The purpose of the study is to evaluate reoperation rate and its relationship to preoperative mechanical axis of rotating-hinge TKA used as the primary implant in complex knees. Methods: Patients subjected to primary TKA with a rotating-hinge knee prosthesis due to primary osteoarthritis between 2010 and 2019 were retrospectively reviewed. Preoperative mechanical axis was measured using the last preoperative telemetry x-ray image. Preoperative axis was classified according to the type of deformity (varus or valgus) and its magnitude (0-15°, 16-25° or >25°). Reoperation rate (with or without implant removal) was the primary outcome of the current study. We studied if the preoperative mechanical axis (either varus-valgus, or magnitude of malalignment) was related to implant survival rate. Results: Forty-two patients were included in the study. Mean follow-up was 51.42 ± 31.88 months. The 83.3% of patients presented a valgus axis while the 16.7% presented a varus axis. Need of reoperation occurred in eight patients (19.0%). However, no patients (0%) required implant removal with revision TKA. No association was seen between the preoperative mechanical axis and risk of reoperation (p = 0.16). Conclusion: In selected situations that do not permit less constrained implants, primary rotating-hinge arthroplasty could be a good alternative. Risk of reoperation does not seem to depend upon the preoperative mechanical axis when using a rotating-hinge knee prosthesis for primary arthroplasty in non-tumoral complex knees.

Iliopsoas impingement after total hip arthroplasty: Does the CT-scan have any role? Our Algorithm proposal.

Introduction: The first surgical option considered in managing iliopsoas impingement following THA is endoscopic/arthroscopic iliopsoas tenotomy, because of its low risk and minimal invasiveness. Acetabular revision is a much more aggressive surgery, recommended only in cases of substantial cup malposition. However, there are no clear indications for this procedure. The purpose of this article is to analyse the role of CT-scan measurement of acetabular cup positioning in a therapeutic algorithm for iliopsoas impingement. Methods: In this retrospective observational study, we reviewed 25 patients treated for iliopsoas impingement following THA between 2011 and 2019. We studied acetabular cup positioning using CT-scan. We compared radiological parameters of patients who presented with significant clinical improvement with conservative treatment and with tenotomy against those who did not. Finally, we developed a proposed therapeutic algorithm. Results: Forty-eight percent of patients presented a significant clinical improvement following conservative treatment. Patients who did not improve were found to have greater acetabular cup axial and sagittal overhang (p-values 0.016 and 0.003). These patients were considered for tenotomy. Of this group, those who did not improve with surgery (38%) showed greater axial overhang (p-value 0.005). Conclusions: Conservative management should be the first line of treatment. In cases of non-operative treatment failure, axial acetabular cup overhang measured by CT-scan can be a useful tool in choosing between iliopsoas tenotomy or cup-revision surgery in selected cases of very severe acetabular malposition. A cut-off point of 10 mm of axial overhang is a reliable predictor of higher failure risk with iliopsoas tenotomy.

Considerations of the Posterior Tibial Slope in Anterior Cruciate Ligament Reconstruction: a Scoping Review.

PURPOSE OF REVIEW: The significance of posterior tibial slope (PTS) in the setting of anterior cruciate ligament (ACL) injury and reconstruction has been increasingly recognized in recent years. The purpose of this article is to review the biomechanical and clinical studies of PTS in conjunction with ACL injuries, providing an evidence-based approach for the evaluation and management of this patient population. RECENT FINDINGS: Several biomechanical and clinical studies suggest that PTS > 12° may be considered with increased strain on the native ACL fibers (or reconstructed graft) and greater anterior tibial translation, predisposing patients to a recurrent ACL injury. The increased rates of ACL injury and graft failure seen in those with increased PTS have garnered attention to diagnose and surgically address increased PTS in the revision ACL setting; however, the role of a slope-reducing high tibial osteotomy (HTO) in primary ACL reconstruction (ACL-R) has yet to be defined. Various HTO techniques to decrease PTS during revision ACL-R have demonstrated promising outcomes, though conclusions are limited by the multifactorial nature of revision surgery and concomitant procedures performed. Recent evidence suggests that increased PTS is a risk factor for failure following ACL-R, which may be mitigated by a slope-reducing HTO. Further investigation is needed to elucidate abnormal PTS values and to determine appropriate indications for a slope-reducing HTO in primary ACL-R.

Machine Learning-Based Surrogate Model for Press Hardening Process of 22MnB5 Sheet Steel Simulation in Industry 4.0.

The digitalization of manufacturing processes offers great potential in quality control, traceability, and the planning and setup of production. In this regard, process simulation is a well-known technology and a key step in the design of manufacturing processes. However, process simulations are computationally and time-expensive, typically beyond the manufacturing-cycle time, severely limiting their usefulness in real-time process control. Machine Learning-based surrogate models can overcome these drawbacks, and offer the possibility to achieve a soft real-time response, which can be potentially developed into full close-loop manufacturing systems, at a computational cost that can be realistically implemented in an industrial setting. This paper explores the novel concept of using a surrogate model to analyze the case of the press hardening of a steel sheet of 22MnB5. This hot sheet metal forming process involves a crucial heat treatment step, directly related to the final part quality. Given its common use in high-responsibility automobile parts, this process is an interesting candidate for digitalization in order to ensure production quality and traceability. A comparison of different data and model training strategies is presented. Finite element simulations for a transient heat transfer analysis are performed with ABAQUS software and they are used for the training data generation to effectively implement a ML-based surrogate model capable of predicting key process outputs for entire batch productions. The resulting final surrogate predicts the behavior and evolution of the most important temperature variables of the process in a wide range of scenarios, with a mean absolute error around 3 °C, but reducing the time four orders of magnitude with respect to the simulations. Moreover, the methodology presented is not only relevant for manufacturing purposes, but can be a technology enabler for advanced systems, such as digital twins and autonomous process control.

Should we employ preoperative templating in hip hemiarthroplasty after femoral neck fracture? A nested case-control study.

INTRODUCTION: Dislocation following hip hemiarthroplasty is a serious complication. It remains unclear if acetabular morphology is associated with a higher risk of dislocation. The aim of our study was to investigate whether there are differences in hip morphology radiological parameters between patients who have suffered a dislocation episode, and those who have not suffered a dislocation. MATERIAL AND METHODS: Between January 2015 and December 2018, a nested case-control study was performed. From 707 patients who underwent hip hemiarthroplasty because of femoral neck fracture, 50 patients (50 hips) suffered an episode of dislocation. They were randomly matched with 94 patients (100 hips) without dislocation (ratio 1:2). Clinical data regarding demographics, medical comorbidities and surgical and radiological parameters were studied. RESULTS: Statistically significantly smaller lateral centre-edge angle (LCEA) and femoral offset (FO) and greater Tönnis angle were found in the dislocation group. No differences in acetabular angle were seen. Neurological impairment prevalence was statistically significantly higher in patients who suffered a dislocation (60% vs. 44%, p = 0.011). CONCLUSIONS: The current study suggests that a smaller LCEA and FO, a greater TA, and neurological impairment could be related to a higher risk of hip hemiarthroplasty dislocation after femoral neck fracture in the elderly. We consider that preoperative templating could be helpful in identifying abnormal parameters and carefully planning surgery could lead to changes in treatment strategy, such as choosing a dual-mobility total hip arthroplasty.

A comparative of a single novice surgeon's direct anterior approach and posterior approach learning curves in total hip arthroplasty: a retrospective cohort study.

INTRODUCTION: The purpose of the present study was to compare a novice surgeon's learning curves with the direct anterior approach and posterior approach in total hip arthroplasty. METHODS: A consecutive series of 376 total hip arthroplasties performed from November 2014 to September 2019 in a level-one healthcare center by a single surgeon (V.B) were retrospectively studied. Demographic data, functional outcomes, and complications were collected and compared. RESULTS: Within the ranks of the patients studied, we found differences between groups with respect to dislocation rate and length of stay; these were lower in the direct anterior approach (DAA) group. The approach was not associated with an increase in complications, but rather with a decrease in the rate of dislocations and better functional outcomes at 1-year follow-up. Operative time was initially higher with this approach, but equalized during the learning curve. CONCLUSION: The DAA can be safe even in the early stages of a novice surgeon's learning curve. It does not present a higher complication rate than the posterior approach, either in infection rate or in periprosthetic fractures. However, the DAA may provide greater functionality, lower dislocation rate and a shorter hospital stay. It can also be concluded that after having performed a certain number of interventions, operative time for the DAA can be comparable to that of other approaches.

Pulmonary Embolism after Core Decompression of the Femoral Head Using Injectable Bone Graft Substitute: A Case Report.

The authors report a rare complication regarding the case of an 18-year-old female with bilateral osteonecrosis of the femoral head (ONFH) secondary to the treatment and hematopoietic stem cell transplant (HSCT) of an acute lymphoblastic leukemia (ALL). The patient underwent a bilateral necrotic bone debridement and core decompression (CD) surgery with injectable synthetic bone graft, which unfortunately caused a pulmonary injectable bone graft substitute embolism.

Restoring hip biomechanics during the learning curve of a novice surgeon: Direct anterior approach vs posterior approach.

INTRODUCTION: It remains controversial whether the direct anterior approach (DAA) or the posterior approach (PA) allows better restoration of hip biomechanics after total hip arthroplasty (THA). Besides, it is not certain which approach is best for a novice surgeon to avoid implant malposition, neither during the learning curve nor once the curve plateau has been reached. METHODS: We performed a retrospective cohort study of THAs operated on between 2014 and 2019 by a single novice surgeon (DAA, n = 187; PA, n = 184). The surgeon used both approaches, and thus went through parallel learning curves. RESULTS: While the DAA presented a greater number of acetabular cup implantations within Lewinnek's "safe zone" for inclination (84.5% vs. 79.3%; p = 0.003), the PA returned superior results for anteversion (77.7% vs. 68.4%; p = 0.000). The PA showed a tendency to verticalize acetabular cups, while the DAA tended to antevert them. The DAA resulted in fewer patients with leg length discrepancy (3.2% vs. 8.2%, p = 0.041). No differences were found in stem coronal alignment or femoral offset. CONCLUSION: Both approaches are safe and reliable for restoring hip biomechanics through THA surgery during the learning curve of a novice hip surgeon. Similar radiological outcomes are also seen once the surgeon has reached the learning curve plateau.

Simultaneous bilateral dual mobility total hip arthroplasty dislocation in a patient with hepatic encephalopathy: A case report.

INTRODUCTION AND IMPORTANCE: Dislocation is a severe complication after total hip arthroplasty (THA). It is one of the most common reasons for failure and revision surgery. This is the first case of a documented simultaneous bilateral dual mobility (DM) THA dislocation. CASE PRESENTATION: A forty-nine-year-old man presented with bilateral hip pain, immobility and deformity. X-ray images demonstrated simultaneous bilateral posterior THA dislocation. Previously, the patient had presented atraumatic dislocations recurrently. When he was thoroughly re-interrogated, he complained of uncontrolled and generalized muscle contractions, which were compatible with myoclonus due to hepatic encephalopathy (HE). Multidisciplinary treatment was performed satisfactorily to control myoclonus symptomatology and to prevent dislocation. CLINICAL DISCUSSION: Patient's most important risk factor was a neuromuscular disorder, which we initially gave little notice and undervalued. HE is a serious but reversible syndrome, observed in patients with liver dysfunction. It leads to a wide spectrum of neuropsychiatric abnormalities. Management is based on prevention of episodes, avoiding the underlying triggers. Due to the high risk for dislocation of our patient, we decided to use DM cups bilaterally. This system has demonstrated lower rates of dislocation. CONCLUSION: This case report reminds us that a careful evaluation through meticulous history and physical examination are mandatory when faced with recurrent instability. Furthermore, prevention of dislocation is vastly preferable to treating this challenging complication. High-risk patients should be identified, and appropriate surgical approach, technique and implants have to be collectively used to reach a strategy that mitigates and ideally prevents dislocation.

Major trauma and severe burn: a synergistic mortality: case report and literature review / Traumatismo grave y quemadura severa: una mortalidad sinérgica: reporte de un caso y revisión bibliográfica

CASE PRESENTATION: A 42-year-old man was transferred to our institution after a highenergy accident (an explosion). He presented second-degree burns on 20% of the total body surface area (TBSA), affecting the lower hemiabdomen and the lower right limb. He also presented a supraintercondylar open fracture of the right femur (Gustilo I). The burns were treated with debridement and coverage withmesh graft, while the fracture required an early transitory transarticular external fixation with delayed definitive osteosynthesis. Our patient presented good local and systemic evolution. We can offer a eleven-month follow-up. DISCUSSION: The literature supports that the combination of trauma and burn injuries is a relatively rare pattern, which may explain the lack of knowledge and studies on this subject. This double injury has demonstrated a synergistic effect on mortality. The management of soft tissues in the coexistence of an open fracture and a burn in the same limb is a challenge. The method and timing of the treatment of the fracture directly impacts the treatment of the burn (and vice versa), and most authors tend to treat the fracture first. All of the studies reviewed emphasized the importance of the multidisciplinary approach. CONCLUSIONS: We have presented a complex case combining major trauma and severe burns. Although there is a lack of studies in the literature on this subject, the papers state that this is an unusual pattern with a synergistic effect on mortality. In our experience, the management of soft tissues and the multidisciplinary approach play a central role, as it is also stated in the literature. The management of these patients is still controversial, and more studies are needed.

PRESENTACIÓN DEL CASO: Hombre de 42 años trasladado a nuestra institución tras un accidente de alta energía (explosión). Presentaba quemaduras de segundo grado del 20% de la superficie corporal total (SCT), afectando el hemiabdomen inferior y la extremidad inferior derecha. También presentaba una fractura abierta supraintercondílea de fémur derecho (Gustilo I). Las quemaduras fueron tratadas mediante desbridamiento y cobertura mediante injerto mallado, mientras que la fractura requirió un fijador externo transarticular precoz de forma transitoria con una osteosíntesis definitiva diferida. Nuestro paciente presentó buena evolución local y sistémica. Podemos ofrecer un seguimiento a 11 meses. DISCUSIÓN: La bibliografía defiende que la lesión combinada de traumatismo y quemadura es un patrón relativamente raro, pudiendo explicar la falta de conocimiento y publicaciones al respecto. Este doble insulto ha demostrado un efecto sinérgico en la mortalidad. El manejo de las partes blandas cuando coexisten una fractura abierta y una quemadura en la misma extremidad es un desafío. El método y el momento de tratamiento de la fractura impactan de forma directa en el tratamiento de la quemadura (y viceversa); y la mayoría de los autores tienden a tratar en primer lugar la fractura. Todos los estudios analizados enfatizan la importancia del abordaje multidisciplinario. CONCLUSIONES: Hemos presentado un caso complejo combinando traumatismo grave y quemaduras severas. Aunque haya una falta de bibliografía, los estudios afirman que se trata de un patrón inusual con un efecto sinérgico sobre la mortalidad. En nuestra experiencia, el manejo de las partes blandas y el abordaje multidisciplinario tienen un rol central, tal y como defienden también los artículos publicados. El manejo de estos pacientes sigue siendo controvertido, y son necesarios más estudios.

Results of a fast-track knee arthroplasty according to the experience of a multidisciplinary team.

INTRODUCTION: Fast-Track is a multidisciplinary system that has changed the perception of total knee arthroplasty surgery. It's based on the education of the patient, an increased autonomy, adequate pain control and early mobilization. In the bibliography, there are no articles that refer to the evolution of the protocol once established, and most of them are comparatives with the previously existing conventional system. For this reason, the objective of our work is to study the evolution of the clinical results obtained through a Fast-Track system according to the experience acquired by the multidisciplinary team in this protocol. MATERIAL AND METHODS: It's a prospective observational study. We have analyzed the results obtained in our center from its implementation in 2013 (n = 65) to the end of the study in 2016 (n = 60). We evaluated the pain at 24 and 48 h after surgery, the time until the first ambulation, the range of flexion and extension at discharge, and length of hospital stay. RESULTS: The results obtained at the beginning of the implantation of the Fast-Track protocol in our center and the present ones do not present statistically significant differences. Mean pain at 24 h was 1,65/10 in 2013 and 1,5/10 in 2016, and at 48 h 1,61/10 and 1,58/10 respectively. Most of the patients in both years scored a pain below 4/10 at 24 h and 48 h. Mean time of the first ambulation was 260 min in 2013 and 254 min in 2016 (most of the patients started walking in ≤5 h). Mean flexion at discharge was 90,3° in 2013 and 87,92° in 2016 (most of the patients presented a flexion between 80 and 100°). Mean extension at discharge was 6,95° in 2013 and 8,1° in 2016 (most of the patients presented an extension between 0 and 10°). Mean length of stay was 2,46 days in 2013 and 2,43 days in 2016 (most of the patients had a stay of fewer than 4 days). CONCLUSIONS: When applying the Fast-Track protocol by a multidisciplinary team in primary knee prosthetic surgery, the clinical results obtained are independent of the experience of this team in the protocol. So, from our experience, we can affirm that the protocol has enough solidity since its beginning and it maintains similar results despite the years of execution.

Fusing in-vitro and in-vivo intravascular ultrasound data for plaque characterization.

Accurate detection of in-vivo vulnerable plaque in coronary arteries is still an open problem. Recent studies show that it is highly related to tissue structure and composition. Intravascular Ultrasound (IVUS) is a powerful imaging technique that gives a detailed cross-sectional image of the vessel, allowing to explore arteries morphology. IVUS data validation is usually performed by comparing post-mortem (in-vitro) IVUS data and corresponding histological analysis of the tissue. The main drawback of this method is the few number of available case studies and validated data due to the complex procedure of histological analysis of the tissue. On the other hand, IVUS data from in-vivo cases is easy to obtain but it can not be histologically validated. In this work, we propose to enhance the in-vitro training data set by selectively including examples from in-vivo plaques. For this purpose, a Sequential Floating Forward Selection method is reformulated in the context of plaque characterization. The enhanced classifier performance is validated on in-vitro data set, yielding an overall accuracy of 91.59% in discriminating among fibrotic, lipidic and calcified plaques, while reducing the gap between in-vivo and in-vitro data analysis. Experimental results suggest that the obtained classifier could be properly applied on in-vivo plaque characterization and also demonstrate that the common hypothesis of assuming the difference between in-vivo and in-vitro as negligible is incorrect.