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.

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.

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.

Allografts and lateral extra-articular tenodesis for revision anterior cruciate ligament reconstruction: enhanced rotational stability and improved functional outcomes.

PURPOSE: Multiple studies have shown higher failure rate and patient-reported outcomes to be significantly worse following revision anterior cruciate ligament reconstructive (ACLR) surgery, especially using allografts. One of the reasons being rotational instability. Because of this, augmentation with lateral extra-articular tenodesis (LET) is often considered. Good short-term results in regards to functional and perceived scores and low complication rate can be expected in revision ACLR using allografts in combination with LET. METHODS: Between 2014 and 2021, 46 patients were registered for revision ACLR using allografts and extra-articular augmentation (modified Lemaire) and included in this prospective study. Patients' demographic and clinical data were collected preoperatively, postoperatively, and during the follow-up period of 12 months. RESULTS: Patient-reported functional outcomes were statistically significant for IKDC, Lysholm, and SF-12 physical scale (p < 0.05). Tegner score showed a decreased number of patients who were able to return to sport at their previous level (p = 0.001). Stability examination tests (Lachman and pivot-shift) showed significant improvements. Concomitant lesions were present in 76.1% of patients. Ten patients (21.7%) presented major complications, including six cases of anteroposterior instability, three cases of knee pain and one graft re-rupture. CONCLUSION: Revision procedures are inherently challenging with a high number of associated chondral and meniscus lesions. However, good short-term functional outcomes and enhanced rotational stability with an acceptable complication rate can be expected in most cases where revision ACLR using allografts is augmented with LET. STUDY DESIGN: Prospective; Case series; Level of evidence IV.

Predictors of outcomes after internal fixation of periprosthetic femoral hip fractures Subgroup analysis of the peri-implant and peri-prosthetic fractures Spanish registry (PIPPAS).

PURPOSE: To identify risk factors predisposing patients to poor outcomes after fixation of periprosthetic hip fractures around femoral stems. METHODS: Prospective multicentre cohort study of fractures around a hip replacement stem managed by internal fixation. The primary outcome was one-year mortality, while secondary outcomes were local complications and healthcare burden-related outcomes (nursing facility utilization and hospital length of stay). RESULTS: One-year mortality was 16.2%. Age-adjusted Charlson Comorbidity Index score (OR=1.17; 95%CI=1.03-1.33)), Pfeiffer Short Portable Mental Status Questionnaire (SPMSQ) score (OR=1.16; 1.06-1.28), prosthetic dysfunction (OR=1.90; 1.00-3.61), and postoperative medical complications (OR=1.97; 1.06-3.68) were predictors of mortality. Patients with prior prosthetic dysfunction, lower Pfeiffer SPMSQ scores, Vancouver A fractures, and fractures fixed only using cerclages were at higher risk of local complications, which occurred in 9.3% of cases. Medical (OR=1.81; 1.05-3.13) and local complications (OR=5.56; 2.42-3.13) emerged as consistent risk factors for new institutionalization. Average hospitalization time was 13.9±9.2 days. Each day of fixation delay led to an average 1.4-day increase in total hospitalization. CONCLUSION: Frail periprosthetic hip-fracture patients with poorer functional status, dysfunctional replacements, and postoperative complications are at increased risk of mortality. Postoperative complications are more common in patients with dysfunctional arthroplasties, Vancouver A fractures, and fixation using cerclages alone. Postoperative complications were the most consistent predictor of higher healthcare resource utilization.

Preliminary Outcomes of a Staged Percutaneous Retrograde Prefabricated Gentamicin-coated Intramedullary Nail to Manage Complications after Ankle Fusion through Tibial Bone Transport.

Aim: Distal tibial injuries combining bone loss, articular destruction and infection can be treated through distraction osteogenesis combined with ankle fusion. Bone transport is not without complications. This study investigates our preliminary results using a retrograde prefabricated gentamicin-coated nail (ETN PROtect®) to treat complications after infected bone defects of the distal tibial were managed by ankle arthrodesis and distraction osteogenesis. Materials and methods: This is a retrospective case series study. All consecutive patients with bone transport complications after ankle arthrodesis and distraction osteogenesis who were subsequently operated on using a retrograde ETN PROtect® nail were analysed. The cases occurred between 2017 and 2020. The primary objective was to report on the resolution of the clinical problem and the risk of deep infection after nail implantation. Results: Five patients have included: two docking site non-unions, two regenerated bone fractures and one hypotrophic regenerated bone. These complications were resolved in all patients (5/5, 100%). A painless, stable and plantigrade ankle arthrodesis was achieved in all cases. No patient developed a local infection or required nail removal (mean follow-up: 35.2 months). The mean LEFS score was 46.8 ± 13.8 and the mean knee ROM was 112 ± 12.7°. All patients tolerated full weight-bearing. All patients were very satisfied with the procedure (mean SAPS score was 93.8 points). Conclusion: The staged retrograde nailing technique using the ETN PROtect® nail may represent an effective and safe treatment for bone transport complications in high-infection-risk patients. Furthermore, the technique allows simultaneous achievement of ankle arthrodesis. The patients had good functional outcomes and were satisfied with the procedure. Clinical significance: This strategy of using retrograde gentamicin-coated tibial nails offers a solution to resolve bone transport complications while simultaneously achieving functional ankle arthrodesis. How to cite this article: Pujol O, Vicente M, Castellanos S, et al. Preliminary Outcomes of a Staged Percutaneous Retrograde Prefabricated Gentamicin-coated Intramedullary Nail to Manage Complications after Ankle Fusion through Tibial Bone Transport. Strategies Trauma Limb Reconstr 2023;18(3):155-162.

Atraumatic Fracture of the Femoral Component of a Cemented Total Knee Arthroplasty: A Case Report.

CASE: An 81-year-old man presented with severe atraumatic knee pain. Sixteen years before, he had undergone a primary cemented total knee arthroplasty (TKA). A radiological study showed osteolysis and loosening of the femoral component. Intraoperatively, a medial femoral condyle fracture was found. A rotating-hinge revision TKA with cemented stems was implanted. CONCLUSION: Femoral component fracture is extremely rare. Surgeons should remain vigilant with younger and heavier patients with severe unexplained pain. Early revision TKA using cemented, stemmed, and more constrained implants is usually necessary. Full and stable metal-to-bone contact through perfect cuts and a careful cementing technique avoiding debonded areas are recommended to prevent this complication.

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.

Outcome of Arthroscopic Treatment of Mucoid Degeneration of the Anterior Cruciate Ligament.

BACKGROUND: Mucoid degeneration of the anterior cruciate ligament is a rare pathological entity. Several authors have identified this condition, described their experiences, and suggested their own guidelines for management. The aim of this study was to detail the clinical, radiological, arthroscopic, and pathological findings of mucoid degeneration of the anterior cruciate ligament and report the clinical outcomes following arthroscopic treatment. METHODS: A historical cohort of patients who underwent arthroscopic total or partial excision of the anterior cruciate ligament due to mucoid degeneration between 2011 and 2014 were reviewed. The minimum follow-up was 3 years. Demographic, radiological, and histological findings, type of surgery, and clinical pre- and postoperative data were analyzed. The visual analogue scale score, the International Knee Documentation Committee score, and the Tegner Lysholm Knee Score were collected preoperatively, postoperatively, and during the follow-up period. RESULTS: Seventeen females (67%) and eight males (33%) were included in the final analysis. The mean age at the time of surgery was 57 years (range, 31 to 78 years). Partial resection of the anterior cruciate ligament was done in seven cases and a complete resection in 18 cases. No reconstruction was performed at the same time. A positive Lachman test and a negative pivot shift were noted after surgery in all cases. Anterior cruciate ligament reconstruction was required in only one young patient due to disabling instability. At last follow-up, the mean visual analogue scale score, International Knee Documentation Committee score, and Tegner Lysholm Knee score improved (p < 0.01). CONCLUSIONS: Our study provides further evidence that arthroscopic total or partial excision of anterior cruciate ligament is a safe and effective treatment for mucoid degeneration of the anterior cruciate ligament, improving patient satisfaction and function without causing clinical instability in daily activities. However, young patients should be forewarned about the risk of instability, and an anterior cruciate ligament reconstruction could be necessary.

Platelet-Rich Plasma Injections for Advanced Knee Osteoarthritis: A Prospective, Randomized, Double-Blinded Clinical Trial.

BACKGROUND: Intra-articular injections of platelet-rich plasma (PRP) to treat symptoms of knee osteoarthritis (OA) have been successfully used in young patients and in the early stages of disease. No previous studies have analyzed outcomes of PRP injections during the late stages. HYPOTHESIS: PRP reduces pain and leads to a more effective and lasting functional recovery than corticosteroid with local anesthetic. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: A total of 75 patients with symptomatic knee OA (Kellgren-Lawrence grade 3 to 4) were enrolled in this study between August 2013 and July 2014. Patients were randomized to treatment either with a single leukocyte-reduced PRP or corticosteroid intra-articular injection. The primary variable was visual analog scale assessment at 1 month. Secondary outcomes were the Knee injury and Osteoarthritis Outcome Score (KOOS) and Short Form-36 (SF-36) at 1, 3, and 6 months after treatment. Patient satisfaction at final follow-up was assessed. Both groups were homogeneous and comparable in baseline characteristics. RESULTS: All variables improved in both groups. Statistical differences between groups were not found for the majority of the outcome variables, although the magnitude of improvements tended to be greater in the PRP group. Quality-of-life differences between values at 3 and 6 months versus baseline increased significantly more in the study group (P = .05 and .03, respectively), and so did general health perception differences at 6 months (P = .018). CONCLUSION: A single PRP intra-articular injection is effective for relieving pain and improving activities of daily living and quality of life in late-stage knee OA. For patients with late-stage knee OA who are 67 years or older, 1 intra-articular injection of PRP has similar results to 1 shot of corticosteroid.