Comparison between functionality and quality of reduction between suprapatellar vs infrapatellar approaches in the treatment of diaphyseal and distal tibial fractures.

INTRODUCTION: Intramedullary nailing is the most frequent procedure used for the treatment of tibial fractures that do not involve the articular surfaces. The goal of this study is to analyse the clinical outcomes, time of surgery and use of fluoroscopy in patients with midshaft and distal tibial fractures treated with suprapatellar and infrapatellar nailing and compare the results between these different groups. METHODS: A retrospective study was conducted, and patients were selected between the period of March 2018 and October 2019. The following variables were studied: age, gender, AO classification, time of surgery (minutes), time of fluoroscopy (seconds), quality of reduction in postoperative controls and 1 year follow-up (using the angles MPTA, LDTA, PPTA, ADTA). Functional outcomes were studied at 1 month and 1 year follow-up. The visual analogue scale was used to study and compare the postoperative pain of the patients. The Lysholm Knee Score was used to evaluate the functional outcomes of the patients. RESULTS: A total of 80 patients meeting the inclusion criteria were included in this study. The suprapatellar approach was used in 44 patients and the infrapatellar in 36 patients. The time of surgery (p=0.008) and the mean time of use of fluoroscopy (p <0.001) difference were significant in favour of the suprapatellar approach. In the quality of reduction analysis, we have statistically significant results in the LDTA and ADTA angles. Also, in the evaluation of postoperative pain, significant difference was found in favour of the suprapatellar approach. CONCLUSION: In conclusion, our study compared the suprapatellar approach and the infrapatellar approach for the treatment of midshaft and distal tibia fractures with intramedullary nailing. The results showed lesser time of surgery and use of fluoroscopy, lower knee pain, and lower rate of malalignment with the suprapatellar approach than with the infrapatellar approach.

Prolonged social lockdown during COVID-19 pandemic and hip fracture epidemiology.

PURPOSE: To analyse the impact of prolonged mandatory lockdown due to COVID-19 on hip fracture epidemiology. METHODS: Retrospective case-control study of 160 hip fractures operated upon between December 2019 and May 2020. Based on the date of declaration of national lockdown, the cohort was separated into two groups: 'pre-COVID time' (PCT), including 86 patients, and 'COVID time' (CT), consisting of 74 patients. All CT patients tested negative for SARS-CoV-2. Patients were stratified based on demographic characteristics. Outcome measures were 30-day complications, readmissions and mortality. A logistic regression model was run to evaluate factors associated with mortality. RESULTS: Age, female/male ratio, body mass index and American Society of Anaesthesia score were similar between both groups (p > 0.05). CT patients had a higher percentage of Charlson ≥ 5 and Rockwood Frailty Index ≥ 5 scores (p < 0.05) as well as lower UCLA and Instrumental Activities of Daily Living scores (p < 0.05). This translated into a higher hemiarthroplasty/total hip arthroplasty ratio during CT (p = 0.04). Thromboembolic disease was higher during CT (p = 0.02). Readmissions (all negative for SARS-CoV-2) were similar between both groups (p = 0.34). Eight (10.8%) casualties were detected in the CT group, whereas no deaths were seen in the control group. Logistic regression showed that frailer (p = 0.006, OR 10.46, 95%CI 8.95-16.1), less active (p = 0.018, OR 2.45, 95%CI 1.45-2.72) and those with a thromboembolic event (p = 0.005, OR 30, 95%CI 11-42) had a higher risk of mortality. CONCLUSION: Despite testing negative for SARS-CoV-2, CT patients were less active and frailer than PCT patients, depicting an epidemiological shift that was associated with higher mortality rate.

Analysis of sacro-iliac joint screw fixation: does quality of reduction and screw orientation influence joint stability? A biomechanical study.

INTRODUCTION: Treatment of posterior pelvic ring injuries is frequently associated with pain or/and high mortality rates. Percutaneous sacro-iliac (SI) screw fixation has proved to be one of the methods of choice, providing minimal operative time, blood loss and wound-related morbidity. However, fixation failures due to secondary fracture dislocation or screw backing out have been reported. There is a little knowledge regarding the impact of varying screw orientation and quality of reduction on the fixation strength. PURPOSE: The purpose of the present study was biomechanical investigation of joint stability after SI screw fixation and its dependence on quality of reduction and screw orientation. METHODS: Thirty-two artificial hemi-pelvices were assigned to four study groups and simulated SI dislocations were fixed with two SI screws in oblique or transverse screw orientation and anatomical or non-anatomical reduction in group A (oblique/anatomical), B (transverse/anatomical), C (oblique/non-anatomical) and D (transverse/non-anatomical). Mechanical testing was performed under progressively increasing cyclic axial loading until fixation failure. SI joint movements were captured via optical motion tracking. Fixation performance was statistically evaluated at a level of significance p = 0.05. RESULTS: The highest cycles to failure were observed in group A (14038 ± 1057), followed by B (13909 ± 1217), D (6936 ± 1654) and C (6706 ± 1295). Groups A and B revealed significantly longer endurance than C and D (p ≤ 0.01). CONCLUSIONS: Different screw orientations in the presented model do not influence substantially SI joint stability. However, anatomical reduction is not only mandatory to restore a malalignment, but also to increase the SI screw fixation strength and prevent fixation failures.

Outcomes, risk factors, and conversion rate in acetabular fractures in patients over 65 years of age. Analysis at a mean follow-up of 6 years.

INTRODUCTION: Acetabular fractures are devastating injuries that can affect patients of different ages, as well as being associated with high or low energy trauma. Conversion to total hip arthroplasty (THA) results in increased complication rates, resource use and costs compared to primary THA due to osteoarthritis. The aim of this paper is to describe a retrospective cohort of patients over 65 years of age who presented with an acetabular fracture and were treated with open reduction and internal fixation (ORIF). METHODS: A retrospective cohort study was conducted from January 2002 to December 2017. The study identified all patients over 65 years of age who suffered an acetabular fracture and were treated primarily with ORIF. The quality of reduction, fracture pattern and associated poor prognostic factors for fracture were analyzed. RESULTS: A total of 50 cases of acetabular fractures in patients over 65 years of age were included. Six of them required conversion to THA (12%). In 3 of these cases conversion surgery was performed because of pre-existing osteoarthritis, pain, and postoperative progression of osteoarthritis. The main factors involved in the conversion cases were intra-articular fragments, femoral head protrusion and posterior wall comminution. Postoperative intra-articular gap had a p = 0.01 in linear regression analysis for conversion to arthroplasty. CONCLUSION: The conversion rate reported in our cohort of elderly patients is similar to that reported in the literature in patients of all age ranges. The quality of reduction was a significant factor in predicting progression to conversion to THA.

Bisphosphonates and atypical femoral fractures: Is the location of the fracture associated with the time of consolidation?

INTRODUCTION: Bisphosphonates are commonly prescribed to mitigate the effects of osteoporosis, a condition associated with an increased risk of fracture. However, despite their success, there has been growing concern regarding the long-term use of bisphosphonates because of the increased risk of atypical subtrochanteric fractures of the femur (AFFs). The objective of this study was to describe a cohort of patients with AFFs and evaluate the risk of evolving to non-union, the time of consolidation associated with the location of the fracture, the time of use of the drug, and the implant involved in its treatment. METHODS: This retrospective study recruited patients between June 2008 and May 2018. We identified patients with AFFs according to the task force criteria and a history of bisphosphonate use. We included all patients older than 65 years, with long-term use of bisphosphonates, AFF criteria according to the task force, and a follow-up of 12 months or longer. We studied the following variables: the time of use of bisphosphonates, localization of the fracture according to Hyodo et al., implant use, and fracture healing time, considering the presence of bone callus observed in two radiologic projections, which were measured in weeks. RESULTS: Between June 2008 and May 2018, 72 patients met the task force criteria for AFFs. A total of 67 patients were included in this study. From this total, 37 were in the proximal region of the femur and 31 corresponded to the diaphyseal region. Univariate and multivariate analyses showed statistical significance in the time of bone healing compared with the different locations of the fracture along the femur. CONCLUSION: According to our study, the localization of AFFs in patients with a history of bisphosphonate use influences the duration of bone healing.

Patients with trochanteric hip fractures and pre-existing osteoarthritis can be treated with nailing osteosynthesis without significant decrease in functional status.

PURPOSE: Functional outcome in patients after trochanteric fracture fixation with pre-existing radiographic osteoarthritis (OA) is unclear. Analyzing their function and independence, before and after fracture, could optimize their treatment and decrease the socioeconomic burden in this particular group. METHODS: The influence of pre-existing radiographic hip OA on functional outcome was retrospectively analyzed with a cohort of patients undergoing proximal femoral nailing for trochanteric fracture. OA was graded according to the Tonnis classification. Functional outcome was assessed preoperatively and 12 months after surgery by the Parker Mobility Score (PMS). We consider a meaningful reduction a difference between preoperatively PMS and 12 months after surgery ≥ 2. In order to evaluate if OA is related to PMS reduction ≥ 2, we calculate the SubHazard ratio (SHR) performing a competing risk regression model considering death as a competing risk event, adjusting by confounders. Death, reoperations, readmissions, surgical time, and fracture reduction quality in patients with and without osteoarthritis were recorded. RESULTS: 375 trochanteric hip fractures treated with cephalomedullary nails were included, from which 80 (21% CI95% 17%-21%) were classified as Tonnis 2 or 3. This group of patients with pre-existing OA was significantly older (mean age of 88.6 [SD 5.65] vs 85.5 years [SD 6.95]) than the group without OA. The preoperatively PMS score was 6.28 (2.71) in non-OA patients and 5.69 (2.67) in OA patients. The mean PMS reduction 12 months after surgery was 1.3 (SD 2.05) in OA patients and 1.07 (SD 2.2) in non-OA patients (p = 0.43). Competing risks analysis, adjusted by confounders had an SHR of 1.15 (IC95% 0.77 - 1.69). Death, readmission, reoperations, surgical time, and fracture reduction quality did not differ in both groups. CONCLUSIONS: Patients with pre-existing radiographic OA treated with femoral nailing have a similar reduction in functional outcomes compared to the non-OA group at one-year follow-up. Further studies will be needed to compare the results of the functional outcome in arthroplasty with those of femoral nailing for the treatment of trochanteric femur fractures in patients with OA.

Very early prescription of range of motion exercises in ankle fractures treated with ORIF does not increase the rate of complications and reoperations: A survival risk analysis.

BACKGROUND: Ankle fractures are commonly treated with non-surgical or surgical (preferably ORIF) approaches based on fracture characteristics. The postoperative care regimens vary widely, and the impact of very early mobilization on complications and reoperation rates in ankle fractures treated with ORIF remains unclear. METHODS: A retrospective analysis was conducted on ankle fractures treated between January 2014 and November 2020. Demographic and fracture characteristic data were collected. Very early prescription of range of motion exercises was defined as initiation within the first week after surgery, typically between the second and seventh postoperative day. Complications, reoperations, and time to these events were analyzed. Kaplan Meier survival analysis was performed to assess the risk of complications with very early mobilization. RESULTS: A total of 299 patients met the inclusion criteria. The cohort included 83 unimalleolar, 77 bimalleolar, and 138 trimalleolar fractures. Of the patients, 116 (38.8%) underwent very early range of motion. Complications occurred in 45 events among 39 patients (13%), with 16 events (41%) in the very early range of motion group. Reoperations were required for 23 patients (3.67% of the cohort). No statistically significant differences were found in the analysis of complications, with a hazard ratio (HR) of 1.17, and in the adjusted analysis with an HR of 1.12. Similarly, the reoperation analysis showed no significant differences, with an HR of 0.85 and 0.68 in the adjusted analysis. CONCLUSION: Very early prescription of range of motion exercises in ankle fractures treated with ORIF is a safe approach, as it does not increase the rates of complications or reoperations compared to early or late mobilization. This study supports the use of very early mobilization as a rehabilitation method for ankle fractures.

The internal rotation traction radiograph does not improve the reliability in the AO classification system for pertrochanteric fractures. An inter- and intra-observer reliability assessment.

INTRODUCTION: The most universal method for classifying pertrochanteric fractures is the AO/OTA classification. These fractures are classified into different categories according to the features found in the anteroposterior radiograph of the hip. Anteroposterior radiograph of the hip with internal rotation traction can improve the characterization of the fracture. Inter- and intra-observer reliability in any classification is essential to achieve a homogeneous agreement for decision making. Our objective is assessing the overall reliability and by level of experience of the new AO/OTA classification of pertrochanteric fractures. MATERIALS AND METHODS: A hospital registry was used to collect patients with pertrochanteric hip fracture who had anteroposterior radiograph of the hip with and without internal rotation traction. We selected six evaluators stratified by levels of expertise in orthopedic trauma, leaving three groups: advanced, intermediate and beginner. Radiographs were sent through electronic forms and inter- and intra-observer reliability was calculated using the kappa (K) statistic. RESULTS: 115 (one hundred fifteen) patients were included, each with their corresponding anteroposterior radiograph of the hip with and without internal rotation traction. Overall inter- and intra-observer reliability was moderate on both anteroposterior radiographs of the hip with and without internal rotation traction. Regarding the different levels of experience, the advanced level group reached a substantial inter- and intra-observer reliability in both anteroposterior radiographs with and without traction, while the rest of the groups with lower level of experience obtained a lesser reliability. CONCLUSION: Our study found that the internal rotation traction x-ray did not improve the reliability of the new AO/OTA classification for pertrochanteric fractures, as assessed by inter- and intra-observer agreement, in either the overall group or in groups divided by experience level.

[Conservation surgery and early rehabilitation in massive necrotizing fasciitis of the lower limbs] / Cirugía de conservación y rehabilitación temprana en fascitis necrotizante masiva de miembros inferiores.

Necrotizing fasciitis is a life-threatening infection. Early diagnosis and treatment are essential. Reconstruction techniques and rehabilitation protocols have been poorly described. The objective of this work is to describe the results of timely treatment for limb preservation and early rehabilitation in a case of massive necrotizing fasciitis of the lower limbs. We present a case of necrotizing fasciitis in the lower limbs, treated surgically with a negative aspiration system, muscle flaps, and skin graft. We describe his rehabilitation protocol and the results at one year of follow-up.

La fascitis necrotizante es una infección potencialmente letal. Es esencial un diagnóstico y tratamiento temprano. Las técnicas de reconstrucción y los protocolos de rehabilitación han sido escasamente descritos. El objetivo de este trabajo es describir los resultados del tratamiento oportuno para la conservación de miembros y la rehabilitación temprana en un caso de fascitis necrotizante masiva de miembros inferiores. Presentamos un caso de fascitis necrotizante en miembros inferiores, tratado quirúrgicamente mediante sistema de aspiración negativa, colgajos musculares e injerto cutáneo. Describimos su protocolo de rehabilitación y los resultados al año de seguimiento.

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.

A novel radiological projection of the pelvis to evaluate the sitting imbalance in pelvis nonunions and malunions.

INTRODUCTION: Inadequate initial management of unstable pelvic injuries is usually associated with a fracture non-union and/or mal-union. Complete clinical and imaging evaluation is mandatory for a correct preoperative planning. Among other symptoms, sitting discomfort may arise from asymmetry of the ischial tuberosities or pressure from a prominent bony projection. Conventional radiographs are usually taken with the individual in a supine position and not in position where the symptoms are referred. We attempted to define a new radiological projection different than the regular pelvis views to study the position of pelvis of a normal person in sitting position. The second objective was to demonstrate its utility in the evaluation of a pelvic deformity. MATERIAL AND METHODS: Fifteen healthy individuals were evaluated with a radiological projection in a sitting position. One patient with a vertically migrated pelvis nonunion was also evaluated with the same radiological protocol. RESULTS: In each volunteer's radiological study, a parallel line could be drawn between the sitting table and both distal aspects of the ischial tuberosities, sacral alas and superior aspect of the iliac wings. A plumb line perpendicular to the above mentioned ones could be drawn uniting the vertebras' spinous processes. A 90° line intersection confirms the absence of deformity. In the pathological case, a pseudo scoliosis of the thoracolumbar spine is detected trying to compensate the pelvis obliquity and maintain equilibrium. CONCLUSIONS: We determined normal and pathological radiological features in the sitting imbalance of the pelvic in the anteroposterior plane of the pelvis. The study helps to understand the biomechanics and compensation of the pelvis to define surgical indications and predict post correction anatomy.

Treatment of Infected Pseudoarthrosis in a Subtrochanteric Fracture in a Patient with Osteopetrosis.

Osteopetrosis is a disease of osteoclasts that results in failure of bone remodeling. Despite the sclerotic radiographic appearance of the thickened cortices and its material hardness, osteopetrotic bone is weak and prone to fracture by minor trauma. We report a case of a subtrochanteric fracture in an osteopetrotic patient, with further pseudoarthrosis and infection. Several surgical procedures were required, with further complications. The outcome of each procedure and the final result are also described.

Cement leakage into the hip joint during TFN-A cement augmentation in a revision surgery of an extra-capsular hip fracture.

INTRODUCTION: The intra-articular migration of the spiral lamina or screw, after close reduction and internal fixation (CRIF) with an intramedullary cervicodiaphyseal nail (cut-through), is one of the most frequent postoperative complications. We present a patient with a cut-through and cement leakage into the hip joint after TFN-A cement augmentation and spiral lamina replacement. METHODS: A 83-year-old man, suffered a cut-through after CRIF of his left extracapsular hip fracture during the third postoperative month. A revision surgery was planned, including spiral lamina replacement and cement augmentation. Cement leakage into the hip joint was confirmed in the immediate postoperative radiograph and a new intervention was indicated with the removal of the third bodies. RESULTS: The patient presented good clinical evolution, without functional limitation or pain. In routinely postoperative radiographic controls, no differences were observed respect to the immediate postoperative one. DISCUSSION: Current literature dealing with implant revision surgery and associated cement augmentation are scarce. CONCLUSION: As far as we are concerned, this is the first case in the literature of a re-revision surgery of an extracapsular hip fracture due to a three months postoperative cut-through and a posterior cement leakage into the hip joint after TFN-A cement augmentation and spiral lamina replacement with the need of a posterolateral approach for removal.

Biomechanical comparison between standard and inclined screw orientation in dynamic hip screw side-plate fixation: The lift-off phenomenon.

BACKGROUND: Common failure modes of dynamic hip screw are cut-out and lift-off. To minimize the latter, distal screws can be inserted in different orientations. However, the effectiveness remains controversial. The aim of this study was to biomechanically investigate the influence of distal screw orientation on construct stability. METHODS: Thirty artificial generic long bones were assigned to three groups (n = 10) and fixed with two-hole dynamic hip screw-plates, inserting distal cortical screws with neutral parallel screw orientation (A), divergent screw orientation (B) or convergent screw orientation (C). Starting at 60 N, cyclic loading was applied to the implant tip perpendicular to the lag screw axis with progressive peak load increase at a rate of 0.002 N/cycle until failure. Parameters of interest were construct stiffness and machine actuator displacement after 250, 1000 and 5000 cycles, as well as cycles to failure. RESULTS: Displacement after 250, 1000 and 5000 cycles was significantly higher in Group C than in Groups A and B, p < 0.01, whereas no significant differences were observed between Groups A and B, p = 0.20. Specimens in Group C failed after 11,584 [standard deviation (SD), 5924] cycles, significantly earlier than those in Groups A and B [A: 27,351 (SD, 12,509); B: 28,793 (SD, 14,764)], p ≤ 0.02. Cycles to failure were not significantly different between Groups A and B, p > 0.99. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE: Parallel or divergent distal screw insertion provides similar construct stability in terms of resistance to plate lift-off. In contrast, converging screw insertion leads to inferior stability and is not advisable from a biomechanical point of view.

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.

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.

Fasciitis and Streptococcal Toxic-shock Syndrome: The Importance of Early Diagnosis and Surgical Management.

INTRODUCTION: Fasciitis of the limb and toxic-shock syndrome due to Streptococcus Pyogenes infection is considered a surgical emergency. This condition may occur in previously healthy patients. It is a life-threatening condition with high morbidity rates when treatment is delayed due to poor diagnosis and non-surgical intervention. CASE REPORT: 17-year-old male patient sustained a minor ankle trauma while skating. Initials findings were a 1cm wound in relation with his left lateral malleolus and moderate swelling. About 6 h later, the patient was admitted at the emergency room with disproportionate limb pain, increased swelling, persistent fever, paleness, tachycardia, and hypotension. The patient was intubated due to his unstable hemodynamic condition and underwent fasciotomy of the limb. A vacuum-assisted closure device was used. After the first surgical procedure, patient's condition radically improved. He was extubated with good clinical prognosis. He underwent several surgical procedures in a 3-weeks lapse until the wound finally healed. CONCLUSION: Streptococcal toxic-shock syndrome and limb fasciitis have no specific early signs or symptoms. It seems that clinical dissociation (disproportionate pain together with a minor wound) should become an alarm sign to trauma surgeons. It is important to contemplate this serious condition as differential diagnosis in every patient undergoing trauma with torpid evolution. Aggressive surgical management is the gold standard treatment and should not be delayed.

Fractura de Tillaux en adultos. Reporte de un caso y revisión de la bibliografía / Tillaux fracture in adults. Case report and literature review

Introducción: La fractura de la región anterolateral de la epífisis distal de la tibia, o tubérculo de Tillaux-Chaput, es conocida como fractura de Tillaux. Se trata de una fractura extremadamente rara en los adultos, pero tiene una importancia fundamental, porque compromete la superficie articular tibio-astragalina, la estabilidad de la sindesmosis y, en algunos casos, la incisura peronea. Se presenta el caso de una mujer de 45 años con un traumatismo rotatorio del tobillo izquierdo e impotencia funcional y dolor en la región anterolateral del tobillo. Las radiografías generaron la sospecha de un trazo de fractura correspondiente al tubérculo de Tillaux-Chaput. Por lo tanto, se realizó una tomografía computarizada que confirmó una fractura de Tillaux, que tenía un desplazamiento >2 mm y compromiso de la incisura peronea. La paciente fue sometida a reducción abierta y fijación interna. La fractura consolidó a los 3 meses. Al año de la cirugía, su estado clínico y funcional es excelente. Conclusión: La sospecha diagnóstica que surge de una completa anamnesis y un meticuloso examen físico, y la confirmación mediante estudios por imágenes son esenciales para abordar correctamente patrones de fracturas raros, como la fractura de Tillaux. Nivel de Evidencia: IV

Introduction: The fracture of the anterolateral region of the distal tibial epiphysis, or Tillaux-Chaput tubercle, is known as Tillaux fracture. It is an exceptional entity in adults, but it has significant importance because it affects the tibiotalar joint surface, the stability of the syndesmosis, and, in some cases, the fibular notch. We present the case of a 45-year-old woman treated in the Emergency Service due to rotational trauma to the left ankle and functional impairment and pain in the anterolateral region of the ankle. The radiographs led to the suspicion of a fracture line corresponding to the Tillaux-Chaput tubercle. Therefore, a CT scan was performed, which confirmed a Tillaux fracture with a >2 mm displacement and involvement of the fibular notch. The patient underwent open reduction and internal fixation. The fracture consolidated after 3 months. One year after surgery, her clinical and functional status was excellent. Conclusion:Diagnostic suspicion through meticulous physical examination and anamnesis and confirmation by imaging studies are essential for the proper management of rare fracture patterns, such as Tillaux fractures. Level of Evidence: IV

Enclavado endomedular suprarrotuliano vs. infrarrotuliano en el tratamiento de fracturas diafisarias y distales de tibia: análisis comparativo y técnica quirúrgica / Suprapatellar vs. infrapatellar intramedullary nailing for the treatment of distal and diaphyseal tibial fractures: Comparative analysis and surgical technique

Introducción: Las fracturas diafisarias y distales de tibia son lesiones frecuentes en personas jóvenes que sufren un trauma de alta energía y en ancianos por un trauma de baja energía. El objetivo de este estudio fue comparar el tiempo quirúrgico, el uso de radioscopia, la evaluación funcional y el dolor en el tratamiento de fracturas diafisarias y distales de tibia mediante una técnica suprarrotuliana y una infrarrotuliana. Materiales y métodos: Se realizó un estudio retrospectivo entre marzo de 2018 y octubre de 2019. La información de los pacientes se obtuvo de la historia clínica electrónica. Se incluyó a pacientes con fracturas diafisarias y distales de tibia. Se estudiaron y compararon los tiempos de radioscopia y de cirugía. El dolor posoperatorio se evaluó mediante la escala analógica visual y la función, con el puntaje de Lysholm. Resultados:Ochenta pacientes cumplían con los criterios de inclusión. Sus datos sociodemográficos fueron pareados en dos grupos similares. Treinta y seis pacientes fueron tratados con la técnica infrarrotuliana y 44, con la técnica suprarrotuliana. Se obtuvieron diferencias estadísticamente significativas en el tiempo de cirugía, el tiempo de radioscopia y en el puntaje de la escala analógica visual para dolor al año. Conclusiones: Los resultados mostraron un menor tiempo de cirugía y de radioscopia, y mejores resultados en la escala analógica visual para dolor con la técnica suprarrotuliana para el tratamiento de las fracturas mediodiafisarias y distales de tibia. Nivel de Evidencia: III

Introduction: Fractures of the medial and distal tibial segment often occur in young patients with high-energy trauma and older patients with low-energy trauma. The objective of this study is to compare the time of surgery, time of use of fluoroscopy, functional outcomes, and postoperative pain in patients treated with the suprapatellar vs. infrapatellar technique for tibial nailing. materials and methods: We carried out a retrospective study between March 2018 and October 2019. All the data was collected from the electronic clinical record (ECR). We included patients with diaphyseal and distal tibial fractures. The variables analyzed were: fluoroscopy and surgery time, pain evaluation, and functional outcomes of the patients using the Lysholm score. Results: 80 patients met all the inclusion criteria. Sociodemographic data were divided into 2 similar groups. The suprapatellar approach was used in 44 patients and the infrapatellar in 36 of them. A statistical difference was obtained in the analysis for the time of surgery, use of fluoroscopy, and pain evaluation in favor of the suprapatellar technique. Conclusions: The results of our study showed shorter surgery and fluoroscopy times with the use of the suprapatellar technique compared with the infrapatellar technique. The suprapatellar technique also yielded better pain results in the visual analog scale. Level of Evidence: III