Intramedullary nail for the surgical treatment of unstable fractures of the femur in previously amputated patients / [Clavo endomedular para el tratamiento quirúrgico de fracturas inestables de fémur en pacientes previamente amputados]

Introduction: Femoral fractures in previously amputated patients (PAP) have been poorly reported in international literature, however it is worth mentioning that advances in the manufacture of orthotics for lower limbs have allowed these patients to remain functionally active. Surgery is then an option but difficulties may appear in positioning the patient for surgery due to the absence of the foot or ankle from where to pull and optimize the fracture reduction. Objective: We report 3 cases of PAP with ipsilateral unstable femur fractures, treated surgically with cervicodiaphyseal endomedular nail. The surgical technique used in each case is described. Results: Good long-term results were obtained demonstrating the effectiveness of surgical treatment and the reduction technique used. Conclusion: Surgical treatment of unstable fractures of the proximal femur with an endomedullary nail should be considered a valid therapeutic option.

Introducción: Las fracturas de fémur en pacientes previamente amputados (PPA) han sido escasamente reportadas en la literatura internacional, sin embargo, cabe mencionar que los avances en la fabricación de ortesis para miembros inferiores han permitido que estos pacientes, se mantengan funcionalmente activos. La cirugía entonces es una opción, pero representa una dificultad en el posicionamiento del paciente a la hora de planificar su cirugía debido a la ausencia del pie o tobillo del cual traccionar y optimizar la reducción de la fractura. Objetivo: Reportamos a continuación 3 casos de PPA con fracturas inestables ipsilaterales de fémur, tratadas mediante reducción y osteosíntesis con clavo endomedular cervicodiafisario. Se describe la técnica quirúrgica utilizada en cada caso. Resultados: Se obtuvieron buenos resultados a largo plazo demostrando la efectividad del tratamiento quirúrgico y la técnica de reducción utilizada. Conclusión: El tratamiento quirúrgico de fracturas inestables de fémur proximal con clavo endomedular, ha de ser considerado una opción terapéutica válida.

Preliminary outcomes of proximal femur megaspacers.

There are very few therapeutic alternatives for patients with proximal femoral epiphyseal bone deficit combined with a fracture at another level and signs of infection. This combination can be successfully managed with a proximal femur megaspacer. This article is intended to review our variation of this technique and to show the initial results obtained from 11 cases. Of these 11 cases, there were 6 women and 5 men. The mean age was 66 years. The average number of previous surgeries was 3. Definitive prosthetic reconstructive treatment was achieved in 7 of these 11 subjects. The average time to reimplantation was 11.7 months. Fractures or nonunion healed uneventfully. Bone union and infection control were achieved in 10 of the 11 patients.

Nutrition and Inflammation Influence 1-Year Mortality of Surgically Treated Elderly Intertrochanteric Fractures: A Prospective International Multicenter Case Series.

INTRODUCTION: Hip fracture is a common and devastating event in older adults causing increased dependence, comorbidity, and mortality. Since new surgical techniques have not significantly improved the mortality rate, a better understanding of patient risk factors could improve the treatment algorithm and outcomes. This prospective study aimed to document the 1-year survival rate of patients with intertrochanteric fracture treated surgically in Latin America and to investigate risk factors associated with 1-year mortality. PATIENTS AND METHODS: Between January 2013 and March 2015, 199 patients were prospectively enrolled. Inclusion criteria were aged 60 years or older, isolated intertrochanteric fracture (AO/OTA 31-A), and time to surgery within 10 days after injury. The follow-up period was 1 year. The association between mortality and patient demographics, comorbidity, surgical details, and preoperative laboratory parameters was assessed using log-rank tests. RESULTS: Twenty patients died by 365 days after surgery (including 5 that died within 30 days of surgery) resulting in a 1-year survival rate of 89.8% (95% confidence interval = 84.6-93.3). The 1-year mortality was significantly associated with age (≥85 years old, P = .032), existing comorbidity (P = .002), preinjury mobility level (P = .026), mental state (Mini-Mental State Examination > 23, P = .040), low preoperative plasma albumin level (P = .007), and high preoperative blood C-reactive protein level (CRP; P = .012). At the 1-year follow-up, patients on average did not regain their preinjury hip function and mobility, although the self-assessed quality of life was equal or better than before the injury. DISCUSSION: As a prospective study, the current patient population had clear inclusion and exclusion criteria and was relatively homogeneous. The resulting associations between 1-year postoperative mortality and preoperative hypoalbuminemia and preoperative elevated CRP level are therefore especially notable. Previously identified risk factors such as male gender and time to surgery showed no significant association with 1-year mortality-the overall favorable condition of the current population or the lack of statistical power maybe responsible for this observation. CONCLUSION: The current results showed that under the condition of optimal surgical treatment and low surgery-related complication, preinjury health status as indicated by the blood level of albumin and CRP has a direct and significant impact on 1-year mortality rate.

Treatment of long bone osteomyelitis with a mechanically stable intramedullar antibiotic dispenser: nineteen consecutive cases with a minimum of 12 months follow-up.

BACKGROUND: Antibiotic cement beads are the most common system of local antibiotic delivery. Unfortunately, bead strings do not give mechanical support to the fracture site, stability being fundamental in osteomyelitis treatment. Local treatment associated with bone stability should improve the results in posttraumatic osteomyelitis. The objective of this article is to present our experience in the treatment of long bone osteomyelitis using an intramedullary, mechanically stable antibiotic dispenser. METHOD: We present a retrospective review of a consecutive series of patients with a long bone osteomyelitis treated using an intramedullary, mechanically stable antibiotic dispenser. The dispenser used with a T-95 chest tube filled with poly(methyl methacrylate) + antibiotic (vancomycin, gentamycin, or both, tobramycin or imipenem; depending on culture results) and with a metal center (Ender nail). RESULTS: Fifteen patients were men and three were women, with an average age of 37 years (range, 18-52 years). In four cases, treatment involved the femur and in 15 the tibia. Positive cultures were obtained from each patient. Methicillin-resistant Staphylococcus aureus was isolated in 17 cases. The intramedullary dispenser was removed between 6 and 76 weeks after surgery. Success was defined as negative cultures after dispenser removal. Follow-up period was between 10 and 54 months. Negative cultures were obtained from intramedullary reaming after dispenser removal in all but one patient who could not finish treatment because of local intolerance to antibiotic treatment. None of the 17 patients presented an infection recurrence. CONCLUSION: The combination of local antibiotic treatment with bone segment stability showed acceptable results in our short series of patients. Further investigation on locked intramedullary antibiotic dispensers providing improved stability will help us learn about this difficult clinical scenario.

Tasa de reinternaciones y factores asociados en ancianos luego de una internación por fractura de cadera / Rate of re-experiences and associated factors in the elderly after hospitalization due to hip fracture

INTRODUCCIÓN: El anciano con fractura de cadera tiene alto riesgo de complicaciones y mortalidad hospitalaria. Las estadías hospitalarias cortas y el alta temprana con problemas clínicos activos pueden llevar a reinternaciones. OBJETIVOS: conocer la tasa de reinternaciones, los motivos y las variables predictoras de las mismas en los sujetos que tuvieron fracturas de cadera. MÉTODOS: Se trabajó una cohorte retrospectiva. Se incluyó a todos los pacientes ingresados en el Registro Institucional de Ancianos con Fractura de Cadera entre julio de 2014 y julio de 2017. Se describió la tasa de reinternación y su IC95%. Se utilizó un modelo de riesgo proporcional de Cox para describir factores de riesgo y el tiempo a la reinternación. RESULTADOS: Se incluyó a 858 pacientes. La mediana de días de internación fue de 6 (rango intercuartil [RIC 5-9]). El 86% (737) de los pacientes era de sexo femenino, con una mediana de edad de 86 años (RIC 81-89). La tasa de reinternación a los 30 días fue de 10% (IC95%: 8,3-12,5) y al año, de 39% (IC95%: 34,8-42,6). La principal causa fue la infección (30%). Los factores asociados fueron: edad (>85 años) Razón de Hazard o Hazard ratio (HR)1,3 (IC95%: 1-1,7; p 0,03), sexo femenino HR 0,5 (IC95%: 0,4-0,7; p<0,01), fragilidad HR 1,4 (IC95%: 1,1-1,8; p<0,01), score de Charlson (≥2) HR 1,6 (IC95%: 1,3-2,1; p<0,01), días de internación (>7 días) HR 1,4 (IC95%: 1,2-1,9; p<0,01). CONCLUSIONES: La reinternación después de una fractura de cadera tiene alta incidencia. El cuidado perioperatorio de los pacientes con fractura de cadera es esencial para reducir las complicaciones.

INTRODUCTION: Elderly patients with hip fracture are at high risk for complications and in-hospital mortality. Short hospital stay and early discharge with still active clinical problems may lead to readmissions. OBJECTIVES: to know the rate of readmissions, the reasons and the predictive variables in patients who had hip fractures. METHODS: A retrospective cohort study was performed, with all patients included in the institutional registry of elderly patients with hip fracture between July 2014 and July 2017. Readmission rates and their CI95% were described. A proportional risk Cox model was used to describe risk factors and time-toreadmission. RESULTS: A total of 858 patients were included with a median hospital stay of 6 days (interquartile range [IQR] 5-9), 86% (737) of female patients and a median age of 86 years (IQR 81-89). Readmission rates were 10% (CI95%: 8.3-12.5) at 30 days and 39% (CI95%: 34.8-42.6) at 12 months. The main cause was infection (30%). Associated factors were: age (>85 years) HR 1.3 (CI95%: 1-1.7; p 0.03), female gender HR 0.5 (CI95%: 0.4-0.7; p<0.01), fragility HR 1.4 (CI95%: 1.1-1.8; p<0.01), Charlson score (≥2) HR 1.6 (CI95%: 1.3-2.1; p<0.01), hospital stay (>7 days) HR 1.4 (CI95%: 1.2- 1.9, p<0.01). CONCLUSIONS: Readmission after hip fracture has a high incidence. Perioperative care of patients with hip fracture is essential to reduce complications.