Maintenance of joint reduction and allograft incorporation in treating tibial plateau fractures. Retrospective case series using cortico-cancellous, non-irradiated, bone allograft.

Background: Restoring joint congruence and maintaining reduction until healing is imperative in treating tibial plateau fractures (TPF). The main objective of this study was to evaluate the feasibility of augmentation with impacted bone allograft (IBA) to prevent loss of reduction in tibial plateau fractures during healing and to evaluate its incorporation. Methods: We retrospectively analyzed all patients with an acute, closed tibial plateau fracture (Schatzker II, III, IV) treated between 2010 and 2019 with open reduction and internal fixation (ORIF) and impacted bone allograft (IBA), with a minimum follow-up of 24 months. We evaluated the postoperative radiographs by drawing a line along the tibial axis and another perpendicular to the healthy plateau to measure the reduction and subsequent behavior. The incorporation of the allograft was evaluated by radiological analysis assessing its integration, non-union, resorption, or sclerosis. We used the clinical-radiological Rasmussen system and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) to objectify the outcomes. Results: 78 TPFs were included, with a median age of 51.5 (40.7-62.2) years and a median follow-up of 66 (24-89) months. Two (2.5 %) patients presented loss of joint reduction (subsidence) during the follow-up regarding the achieved in the surgery. Seventy-six (94.7 %) patients presented integration, two (2.5 %) resorption, and one (1.3 %) sclerosis. Seventy-two (92.3 %) patients presented excellent and good results in the Rasmussen radiological score, and 72 (92.3 %) patients presented excellent or good clinical scores. The mean WOMAC at two years postoperatively was 15 ± 6.5. Conclusion: Our results demonstrate that allograft is an adjuvant in maintaining a reduction in type II, III, and IV Schatzker's tibial plateau fractures. Low rates of loss of reduction during follow-up can be expected with its use.

Distal femur fractures in elderly treated with internal fixation or distal femoral replacement - retrospective cohort study on 75 patients assessing functional outcomes, reoperations, and mortality.

PURPOSE: This cohort study aimed to describe the functional outcomes, complications, and mortality of patients over 65 with acute distal femur fractures treated with open reduction and internal fixation (ORIF) or distal femoral replacement (DFR). METHODS: We retrospectively analyzed all patients older than 65, operated consecutively for a distal femur fracture treated with ORIF or DFR. We included 75 patients (9 33A, 5 33B, and 61 33C AO/OTA fractures), 55 treated with ORIF, and 20 with DFR. We used Parker's mobility index (PMI) to assess functional outcomes at 1, 3, and 12 months and study closure. We analyzed complications, reoperations, and mortality at 30 days, one year, and at the end of the study. RESULTS: The PMI was significantly higher in the DFR group at months 1 (p = 0.023) and 3 (p = 0.032). We found no significant differences between cohorts at one year and the end of follow-up. Postoperative complications were significantly more frequent in the ORIF group (38.10% vs. 10%, p = 0.022). Reoperations were similar in both cohorts (p = 0.98). Mortality at one month was 4% and 20% at one year, and at the end of follow-up, there were no significant differences between groups. CONCLUSION: The outcomes of this study suggest that DFR offers a faster functional recovery with lower complication rates than those treated with ORIF. Additionally, both options have similar reoperation and mortality rates. Appropriately designed studies are needed to define the best treatment strategy for this type of patient.

Bilateral simultaneous total knee arthroplasty with and without patellar resurfacing. A prospective single surgeon series with a minimum follow-up of 7 years.

BACKGROUND: Total knee arthroplasty (TKA) is the most effective treatment for end-stage adult knee osteoarthritis, but it has been reported that patient satisfaction may vary. A malfunction of the patellofemoral joint may produce anterior knee pain (AKP) for several reasons. While some surgeons systematically resurface the patella despite the risk of potential complications such as fracture, loosening, or wear of the patella, others prefer to preserve it to reduce AKP and revision rates. This study aimed to evaluate whether patellar resurfacing had better clinical and functional outcomes, complications, and revision rates in patients undergoing simultaneous bilateral total knee arthroplasty. METHODS: We conducted a prospective cohort study, including patients who underwent bilateral simultaneous TKA in which the patella was replaced in one knee and preserved in the other, with a minimum follow-up of 7 years. We assessed clinical and functional outcomes with the Knee Society Score (KSS) and Visual Analogue Scale (VAS); complications and revision rates were also registered. RESULTS: The final series consisted of 43 patients with 86 knee arthroplasties. After a mean of 7.6 years of follow-up, no significant differences were found regarding KSS (clinical: 82.8 ± 7.4 versus 83.2 ± 3.4, p = 0.92; functional 89.1 ± 8.2: versus 90.4 ± 6.8; p = 0.99), VAS (2.0 ± 0.9 versus 1.8 ± 1.0; p = 0.84), complications (10.5% versus 8.1%; p = 0.57), or revision rates (2.3% versus 2.3%; p = 0.99) when comparing patellar resurfacing versus retention. CONCLUSION: In the context of total knee arthroplasty, patellar replacement did not demonstrate statistically significant differences concerning patellar retention in clinical nor functional outcomes, AKP, complications, or revision rates after a minimum of 7 years of follow-up.

The polymicrobial infection affects the infection recurrence rate (not failure) in treating femoral and tibial bone defects with the Masquelet technique-a comparative retrospective analysis of 54 patients with mono- and polymicrobial infections.

INTRODUCTION: This study evaluated whether polymicrobial infection affects reoperation rates due to infection recurrence and treatment failure with the Masquelet technique in infected posttraumatic segmental bone defects of the femur and tibia. METHODS:  We retrospectively analyzed patients treated between 2012 and 2021 in two trauma referral centers. We evaluated demographic data, injury, treatment, infection recurrence, failures, and bone healing rates according to whether the infection was mono- or polymicrobial. After uni-bivariate analysis between patients with polymicrobial and monomicrobial infection, we identified the variables associated with infection recurrence and failure through multivariate analysis. RESULTS:  We analyzed 54 patients, 30 (55.55%) with tibial and 24 (44.44%) femoral segmental bone defects, with a mean follow-up of 41.7 ± 15.0 months. Forty-four (81.48%) presented monomicrobial, and 10 (18.51%) polymicrobial infections. Comparatively, the need for soft tissue reconstruction and the infection recurrence rate was significantly higher in patients with polymicrobial infections. There was no significant difference in the failure rate (20 vs. 6.81% p = 0.23). Multivariable logistic regression analysis identified the polymicrobial infection as the only independent variable associated with infection recurrence (Odds Ratio = 11.07; p = 0.0017). CONCLUSION:  Our analysis suggests that polymicrobial infection is associated with a higher risk of infection recurrence in treating the femur and tibia segmental bone defects with the Masquelet technique. This information can help surgeons to inform patients about this and give them a realistic expectation of the outcome and the possibility of reoperation.

Does the type of medial plate fixation matter for supplemental fixation of distal femur fractures manage with a lateral pre-contoured locked plate? A Biomechanical study.

INTRODUCTION: Fixation of distal femur fractures with a lateral pre-contoured locking plate provides stable fixation and is the standard treatment in most cases, allowing early range of motion with a high rate of union. However, in situations, the stability achieved with the lateral plate alone may be insufficient, predisposing to fixation failure. The objective of the study was to compare, in synthetic bone models, the biomechanical behaviour of the fixation with a distal femur lateral pre-contoured locking plate solely and associated with a 3.5 mm proximal humeral locking plate applied upside down or a 4.5 mm helical locking compression plate on the medial side. MATERIAL AND METHODS: A total of 15 solid synthetic left femur samples were used. A metaphysical defect at the level of the medial cortex was simulated. The samples were randomly distributed into three groups equally. All groups received a 4.5/5.0 mm single lateral 9-hole distal femur lateral pre-contoured locking plate. Group 1 had no supplementary plate. Group 2 received a supplementary 6-hole 3.5 mm proximal humeral locking plate and Group 3 received a supplementary 4.5/5.0 mm helical 14-hole narrow locking compression plate. RESULTS: Both supplementary plate types used in groups 2 and 3 contributed to increase the apparent stiffness of the construct, but pairwise comparison showed statically significant difference only between group 1 and 3. No significant difference was observed between groups 2 and 3. CONCLUSION: Both supplementary plates might be considered for improving the fixation in distal femur fracture in selected cases.

Effectiveness of two-stage revision with commercial polymethylmethacrylate articulated hip spacer: similar outcomes against monomicrobial and polymicrobial hip periprosthetic joint infections.

Background: orthopaedic surgeons still struggle against a devastating complication - periprosthetic joint infection (PJI). A two-stage revision is considered the gold standard for chronic PJI for several authors, with success rates over 90 %. This strategy implies the remotion of the prosthesis and the implantation of an antibiotic-impregnated cement spacer in the joint. The primary objective of this study was to assess the effectiveness of a two-stage revision approach using a commercial prefabricated antibiotic-impregnated cement hip spacer for the treatment of hip PJI regarding monomicrobial and polymicrobial infections. Secondly, to assess risk factors for failure of two-stage revision. Material and methods: we conducted a retrospective study on patients that underwent revision of total hip arthroplasty (THA) between January 2002 and January 20218. We included adult patients with a diagnosis of chronic hip PJI that underwent two-stage revision using a prefabricated gentamicin-impregnated cement of polymethylmethacrylate (PMMA) hip spacer. We assessed whether it was monomicrobial or polymicrobial infections and comorbidities. Treatment success was defined when eradication of the infection was observed and no further procedures or mortality were registered after the second stage. Persistence or recurrence of infection was considered a failure of treatment. Results: the final series consisted of 84 patients treated with the same hip spacer: 60 (71.4 %) monomicrobial and 24 (28.6 %) polymicrobial joint infections with an overall follow-up of 59.0 (36.0-84.0) months. The overall success rate was 90.5 %. Eight (9.5 %) patients failed. Smoking and BMI greater than 30 m kg-2 were identified independent risk factors for failure in multivariate analysis. Conclusion: our study suggests that prefabricated gentamicin-impregnated PMMA spacer is an effective tool for the treatment of PJI, achieving similar outcomes whether it is monomicrobial or polymicrobial infections. Randomized prospective studies are needed to obtain more reliable conclusions.

Does the distal nail position impact the rates of misalignment and bone union in distal tibial fractures?

PURPOSE: This retrospective study aimed to assess the impact of distal nail placement on misalignment and healing rates in distal tibial fractures. METHODS: We reviewed all patients with distal tibial fracture treated with intramedullary nailing between 2015 and 2021, and a minimum follow-up of 12 months. Distal nail positioning was determined according to the Triantafillou zones. We related these positioning zones to misalignments (alignment ≥ 3°) and too bony union disorders (delayed union, non-union). RESULTS: Out of the 62 patients included, 56 (90.3%) show bone union without additional procedure, 3 (4.8%) with dynamization, and 3 (4.8%) showed non-union. Twenty-one (33.8%) presented misalignment, with valgus in the coronal plane being the most frequent (76.19%). In patients with and without misalignment, the most frequent distal nail position was 2-2 in 47.6% and 80.5%, respectively (p = 0.01). In multivariate analysis, distal nail positioning in the 2-2 zone showed a significant protective effect against misalignment (OR 0.18; p = 0.018), while nail positioning in the 3-2 zone generated a significant risk of misalignment (OR 18.55; p = 0.009). CONCLUSION: In intramedullary nailing of distal tibial fractures, distal positioning of the nail slightly lateral to the center of the talus in the coronal plane and slightly posterior in the sagittal plane (zone 2-2) allows high alignment percentages to be obtained. Positioning medial to this point in the coronal plane (zone 3) is associated with more significant misalignment and should be avoided.

Pre-fracture ambulation capacity, Charlson comorbidity index, and dementia as predictors of functional impairment after bipolar hemiarthroplasty for unstable intertrochanteric fracture. A retrospective analysis in 158 octogenarian patients.

Background: the primary purpose of this study was to assess the ambulatory capacity 12 months after surgery in patients that underwent bipolar hemiarthroplasty (BH) due to unstable intertrochanteric fractures (UITF). Secondly, to identify which preoperative variables influenced these modifications. Methods: We retrospectively analyzed a consecutive series of patients older than 80 years with UITF treated with BH between 2010 and 2019. Ambulatory capacity was assessed before surgery, at 3 and 12 months postoperatively, using Koval's classification and the modified Harris Hip Score (mHHS). The registered variables were: gender, age, osteoporosis, Charlson comorbidity index (CCI), ASA classification, body mass index (BMI), and dementia. The identification of variables that impaired postoperative functionality was performed by uni- and multivariate analysis. Results: 158 patients were included with a median age of 87 (range 80-102) years and a follow-up of 29.2 (range 12-56) months. The 1-year overall ambulatory capacity impairment was 28.5% and significantly affected pre-fracture community walkers (p = 0.001). A CCI >4 (OR 2.72; p = 0.044), dementia (OR 14.13; p = 0.0001), and a Koval 2-3 (OR 12.84; p = 0.001) were identified as risk factors for this impairment. Conclusion: Ambulation impairment at one year was 28.5%. The predictive characteristics found in this study help to identify patients with a greater risk of ambulation impairment and to focus rehabilitation plans to reduce this impact.

Definitive fixation in the first stage of the induced membrane technique for septic segmental bone defects. Why not?

Background: Infected segmental bone defects (I-SBD) are challenging and complex to manage. This study aimed to show the outcomes achieved in I-SBD of the femur and tibia, treated with the induced membrane technique performing a definitive bone stabilization in the first stage. Methods: We retrospectively reviewed 30 patients with infected non-articular segmental bone defects of the femur (n = 11) and tibia (n = 19), operated consecutively between January 2015 and May 2021. The need for fixation exchange, bone defect length, allo/autograft ratio used, bone healing, reoperation (discriminating between mechanical and infection-related causes), and failure rates (graft resorption or nonunion) were recorded. Results: Fixation in the first stage was performed with 28 (93.33%) intramedullary nails, ten coated with antibiotic cement, and 2 (6.67%) locked plates. None were removed during the second stage of the technique. The mean length of the bone defects was 5cm (range 3.5-12). The most commonly used allo-/autograft ratio was 50-50. The bone healing rate was 93.33% (n = 28), with a median follow-up of 7 months (range 3-12). The reoperation rate due to mechanical instability was 3.33% (n = 1) and for recurrence of infection was 10.0% (n = 3). The overall failure rate was 6.67% (n = 2). The median follow-up was 42 months (range 12-85). Conclusion: Masquelet technique appears feasible and effective in treating infected segmental bone defects of the femur and tibia. Definitive fixation at the first stage showed a success rate of 93.33%, with a re-operation rate of 10.0% related to infection.

The relevance of the number of distal locking planes and nail to canal ratio in bone healing after intramedullary nailing in tibial shaft fractures.

INTRODUCTION: The objective of this retrospective study was to assess the effect of the nail to canal ratio and the number and configuration of distal locking screws in bone healing in tibial shaft fractures. METHODS: We analyzed 223 consecutive tibial shaft fractures treated with reamed intramedullary nailing between January 2014 and December 2020. We recorded and evaluated the nail to canal ratio (NCR) and the number and configuration of distal locking screws. Median NCR was 0.87 (IQR 0.82-0.94). Ten (4.48%) fractures were treated with one distal locking screw, 173 (77.57%) with two, and 40 (17.93%) with three. Uniplanar fixation was used in 63 (28.25%), biplanar in 150 (67.26%), and triplanar in 10 (4.48%) cases. Uni-, bi-, and multivariate analyses were performed to compare patients who achieved bone union with those who did not. RESULTS: Bone union was achieved in 195 (87.44%) patients. Uni- and bivariate analyses showed that bone union increased significantly with larger NCR (p = 0.0001) and a greater number of locking planes (p = 0.001) and distal screws (p = 0.046). NCR > 0.78 (OR 48.77 CI 95% 15.39-154.56; p = < 0.0001) and distal locking screw configuration (OR 2.91 CI 95% 1.12-9.91; p = 0.046) were identified as independent variables for union. CONCLUSION: Our findings suggest that in tibial shaft fractures treated with intramedullary nailing, NCR should be equal to or greater than 0.79. Additionally, distal locking screws should be used with a biplanar or triplanar configuration.

Distal articular involvement in tibial shaft fractures: an evaluation of 125 consecutive cases.

PURPOSE: To report the incidence and morphology of ipsilateral distal articular involvement (DAI) in a consecutive series of tibial shaft fractures. METHOD: A retrospective review was performed on 115 patients who underwent intramedullary nailing for tibia shaft fractures. Ankle evaluations included preoperative radiographs and computed tomography (CT) scans in all patients. RESULTS: Thirty-two patients (27.8%) in our series presented with tibial shaft fractures associated with DAI. Tibial spiral fractures (42A1) were significantly related to DAI (RR: 1788). In 28 (87.5%; 28/32) articular fractures, posterior malleolus fractures (PMF) were present; 22 were isolated, and six (18.8%) occurred in combination with medial malleolus or anterolateral fractures. The remaining (12.5%; 4/32) were isolated medial malleolus fractures. Ten (31.2%; 10/32) articular fractures were occult on the radiographs and only detected on CT scan. CONCLUSION: DAI is common in tibial shaft fractures. CT evaluation is mandatory due to the high number of occult fractures. Although isolated PMF is the most frequent pattern of DAI involvement, 31.3% of the cases exhibited different patterns.

Peri-implant femoral fractures: Challenges, outcomes, and proposal of a treatment algorithm.

PURPOSE: Non-prosthetic peri-implant fractures are challenging injuries. Multiple factors must be carefully evaluated for an adequate therapeutic strategy, such as the state of bone healing, the type of implant, the time and performed personnel of previous surgery, and the stability of fixation. The aim of this study is to propose a rationale for the treatment. METHODS: The peri-implant femoral fractures (PIFFs) system, a therapeutic algorithm was developed for the management of all patients presenting a subtype A PIFF, based on the type of the original implant (extra- vs. intra-medullary), implant length and fracture location. The adequacy and reliability of the proposed algorithm and the fracture healing process were assessed at the last clinical follow-up using the Parker mobility score and radiological assessment, respectively. In addition, all complications were noticed. Continuous variables were expressed as mean and standard deviation, or median and range according to their distribution. Categorical variables were expressed as frequency and percentages. RESULTS: This is a retrospective case series of 33 PIFFs, and the mean post-operative Parker mobility score was (5.60 ± 2.54) points. Five patients (15.1%) achieved complete mobility without aids (9 points) and 1 (3.0%) patient was not able to walk. Two other patients (6.1%) were non-ambulatory prior to PPIF. The mean follow-up was (21.51 ± 9.12) months (range 6 - 48 months). There were 7 (21.2%) complications equally distributed between patients managed either with nailing or plating. There were no cases of nonunion or mechanical failure of the original implant. CONCLUSION: The proposed treatment algorithm shows adequate, reliable and straightforward to assist the orthopaedic trauma surgeon on the difficult decision-making process regarding the management of PIFF occurring in previously healed fractures. In addition, it may become a useful tool to optimize the use of the classification, thus potentially improving the outcomes and minimizing complications.

Morbimortalidad en pacientes con fracturas intertrocantéricas de cadera tratadas con clavos cefalomedulares. Valor predictivo del Índice de Movilidad de Parker / Morbidity and mortality in intertrochanteric hip fractures treated with cephalo-medullary nailing. Predictive value of the Parker mobility score

Introducción: La fractura de cadera es un factor independiente que aumenta la morbimortalidad. El objetivo de este estudio retrospectivo fue determinar la morbimortalidad en ancianos con fracturas intertrocantéricas de cadera tratadas con clavos cefalomedulares. Materiales y métodos: Se analizó a pacientes tratados con clavo cefalomedular por fractura intertrocantérica de cadera, entre 2018 y 2021, y un seguimiento mínimo de 12 meses. Se registraron: datos demográficos, comorbilidades, capacidad funcional con el Índice de Movilidad de Parker, complicaciones y tasa de mortalidad a los 12 meses y al final del seguimiento. Se identificaron las variables independientes relacionadas con complicaciones o muerte. Resultados: Se incluyó a 68 pacientes (seguimiento medio 23 meses). La tasa de complicaciones fue del 8,8%: infección urinaria, neumonía, trombosis venosa profunda y tres pérdidas de fijación del tornillo cefálico. Al comparar pacientes con complicaciones o sin ellas, hubo diferencias significativas en la edad cuando se produjo la fractura. Las tasas de mortalidad anual y al concluir el estudio fueron del 2,9% y 29,4%, respectivamente. Las diferencias fueron significativas en la incidencia de comorbilidades renales, demencia, el Índice de Comorbilidad de Charlson >4 y el puntaje de Parker <5 en quienes fallecieron. El puntaje de Parker <5 fue la variable independiente relacionada con muerte. Conclusiones: Las tasas de complicaciones y de mortalidad a los 12 meses del tratamiento de las fracturas intertrocantéricas inestables de cadera con clavos cefalomedulares es aceptable en ancianos. El riesgo de muerte aumenta significativamente si el puntaje de Parker es <5 antes de la fractura. Nivel de Evidencia: IV

Introduction: Hip fracture represents an independent predictor of morbidity and mortality. The aim of this retrospective study was to assess the morbidity and mortality associated with intertrochanteric hip fractures fixed with cephalomedullary nails. materials and methods: We analyzed all patients treated between 2018 and 2021 with a cephalomedullary nail for an intertrochanteric hip fracture, with a minimum follow-up of 12 months. We evaluated the demographic data, comorbidities, functional level through the Parker Mobility Score (PMS), complications, and mortality (12 months and at the end of follow-up). Variables related to postoperative complications or death were identified by bivariate and multivariate regression analyses. Results: 68 patients were included. The mean follow-up was 23 (range 12-40) months. The rate of complications was 8.8% (n=6), 1 urinary tract infection, 1 pneumonia, 1 deep vein thrombosis, and 3 (4.4%) cephalic screw fixation losses. Patients who had complications presented significant differences in age at the time of fracture. Mortality at 12 months and at the end of the study was 2.9% (n=2) and 29.4% (n=20) respectively. Those patients who died presented significant differences in the incidence of kidney comorbidities, dementia, a Charlson Comorbidity Index > 4, and a PMS < 5. PMS < 5 was the only independent variable related to mortality. Conclusions: Cephalomedullary nailing in unstable intertrochanteric hip fractures in elderly patients represents a treatment option that offers an acceptable complication rate and a low 12-month mortality rate. The risk of death is significantly increased in patients with low functional scores (Parker < 5) pre-fracture. Level of Evidence: IV

Resultados iniciales del uso de cotilos de doble movilidad en pacientes >65 años con fractura de cadera. Análisis retrospectivo de 102 casos / Preliminary outcomes with dual mobility cups in patients older than 65 with hip fractures. A retrospective analysis of 102 patients

Objetivo: El objetivo de este estudio retrospectivo fue evaluar los resultados funcionales y la tasa de luxación en pacientes >65 años con fractura de cadera operados con prótesis de doble movilidad. materiales y métodos: Se analizó a los pacientes tratados por una fractura de cadera entre 2017 y 2021. Se incluyó a pacientes >65 años, tratados con copas de doble movilidad y un seguimiento mínimo de 24 meses. Se analizaron los datos demográficos, las comorbilidades, los resultados funcionales (Parker y puntaje de Harris), las complicaciones (infección, luxación, aflojamiento), las reoperaciones y revisiones. Resultados: Se trataron 102 fracturas de cadera (75 mediales y 27 intertrocantéricas) en 102 pacientes. El 72,5% eran mujeres (media de la edad 80.59 ± 6.92 años), el Índice de Comorbilidad de Charlson promedio fue de 4,71 y el puntaje ASA, 2,47. El 93,1% comenzó a caminar al segundo día de la cirugía. Según el puntaje de Harris, los resultados fueron excelentes o muy buenos en el 94,1%; los puntajes de Parker preoperatorio y posoperatorio no difirieron significativamente (p <0,05). El seguimiento promedio fue de 30 meses. Hubo 8 (7,84%) complicaciones: 2 (1,9%) casos de trombosis venosa profunda, 4 (3,9%) de tromboembolismo pulmonar, tres infecciones (2,9%) y una (0,9%) luxación. La tasa de reoperaciones fue del 2,9%. Conclusiones: Con el empleo de copas de doble movilidad se obtuvieron resultados funcionales aceptables y una tasa de luxación relativamente baja (0,9%). Esto sugiere que estos implantes representan una opción en el tratamiento de estas lesiones. Nivel de Evidencia: IV

Objective: This retrospective study aimed to assess the functional outcomes and dislocation rate in the treatment with dual mobility prostheses in patients older than 65 with hip fractures. materials and methods: We analyzed all patients treated between 2017 and 2021 for hip fractures in our service. We included patients older than 65 years, treated with dual mobility cups, and a minimum follow-up of 24 months. We analyzed demographic data, comorbidities, functional outcomes (Parker score and Harris Hip Score, HHS), complications (infection, dislocation, loosening), reoperations, and revisions. Results: We included 102 hip fractures (75 medial and 27 intertrochanteric) in 102 patients. Seventy-four (72.5%) were women, the mean age was 80.59 ± 6.92 years, the mean Charlson index was 4.71 (range 3-10), and ASA was 2.47 (1-4). 93.1% started walking on the second postoperative day. 94.1% presented excellent or very good outcomes according to the HHS, the postoperative Parker index did not show significant differences in comparison to the preoperative one (p < 0.05). The average follow-up was 30 months (range 24-60). There were 8 (7.84%) complications: 2 (1.9%) deep vein thrombosis, 4 (3.9%) pulmonary thromboembolism, 3 infections (2.9%), and 1 (0.9%) dislocation. The reoperation rate was 2.9%. Conclusions: We obtained acceptable functional outcomes using dual mobility cups with a relatively low dislocation rate (0.9%). This suggests that these implants are an option to consider in treating these lesions. Level of Evidence: IV

Open tibial shaft fracture management in Argentina: an evaluation of treatment standards in diverse resource settings.

Background: Argentina is a country with varying access to orthopedic surgical care. The Argentine Association of Trauma and Orthopedics (AATO) "Interior Committee" was developed to address potential regional differences and promote standardization of orthopedic trauma care. The paper assesses the level of national standardization of the management of open tibia fractures across 9 provinces in Argentina. Methods: Utilizing a matched-comparison group design, management of these injuries were assessed and compared between 3 groups: an "AATO Exterior Committee" consisting of surgeons that practice in Buenos Aires, and 2 "Interior Committees," comprising surgeons that practice in outlying provinces, 1 of which is affiliated with the AATO, and 1 that is not affiliated with the AATO. The study was conducted in 2 phases: phase 1 assessed open tibia fracture management characteristics, and phase 2 evaluated the management of soft-tissue wound coverage following open fractures. Results: Soft-tissue coverage procedures for Gustilo Anderson Type IIIB fractures were more commonly performed by orthopedic surgeons in Interior Committees than the AATO Exterior Committee. Greater rates of definitive wound coverage within 7 days post-injury were reported in both Interior Committees compared to the Exterior Committee. Plastic surgeons were reported as more available to those in the AATO Exterior Committee group than in the AATO Interior Committees. Conclusion: While treatment patterns were evident among groups, differences were identified in the management and timing of soft-tissue coverage in Gustilo Anderson Type IIIB fractures between the Exterior Committee and both Interior Committees. Future targeted educational and surgical hands-on training opportunities that emphasize challenges faced in resource-limited settings may improve the management of open tibia fractures in Argentina.

Culture-negative Peri-prosthetic Joint Infection after Total Hip Arthroplasty Treatment Protocol and Outcomes in Acute and Chronic Cases.

The treatment of culture-negative periprosthetic joint infections (CN PJI) of the hip represents complex entities. We, as a result of this, report on 12 cases. Irrigation and debridement (I&D) with implant retention were performed in acute cases and two-stage revisions in chronic infections. Combined antibiotic therapy was administered in all cases for 12 weeks. Infection control was achieved in all patients with an infection-free rate of 100% at 7.5 years of average follow-up.

Stress shielding in total knee replacements: Comparative analysis between titanium and all-polyethylene bases at 10 years follow-up.

Objective: The aim of this retrospective study was to assess bone resorption due to stress shielding in total knee replacement (TKR), comparing titanium bases (TiB) versus all polyethylene bases (APB), analyzing its incidence, progression and mechanical consequences after 10 years of follow-up. Methods: We evaluated two groups of patients undergoing TKR, one treated with TiB and the other with APB, operated consecutively between 2004 and 2009 with a diagnosis of idiopathic gonarthrosis and a minimum of 10 years of follow-up. Deen's radiographical method was used to assess tibial bone resorption. We assessed its incidence, progression, relationship with the femoro-tibial and prosthetic alignment, clinical outcomes and mechanical loosening. Results: Eighty-six patients were treated with TiB and 80 with APB with a median follow-up of 11 (range 10-15) years. The bone resorption rate in TiB was 24.41% and in APB was 1.25% (p < 0.0001). The type 2 of Deen's classification was the most frequently observed. Bone resorption was strongly correlated with preoperative varus femoro-tibial alignment and varus placement of the tibial component, also showing a significant association with postoperative femoro-tibial alignment correction (p 0.009). We observed no significant differences in functional scores or revision rates due to mechanical loosening after 10 years of follow-up between the groups. Conclusion: Titanium tibial bases in TKR showed a significantly higher incidence of medial tibia resorption compared to all-polyethylene bases. Our results suggest that bone resorption does not influence long-term mechanical loosening.

Open Tibial Fracture Treatment in Argentina: Reoperation Rates Following Surgical Management.

The purposes of the present study were (1) to characterize open tibial fractures and their treatment in trauma centers located across different regions of Argentina and (2) to evaluate the rates of and indications for reoperation after the surgical treatment of such fractures. Methods: This retrospective multicenter study evaluated open tibial fractures in Argentina that were operatively treated by experienced orthopaedic trauma surgeon-members of the Argentine Association of Orthopedic Trauma (AATO) between January 2015 and June 2020. Data were collected from 13 hospital databases; 8 hospitals were designated as "interior," and 5 hospitals were designated as "exterior." The study included 701 skeletally mature patients, all of whom had a minimum of 12 months of follow-up. Information was collected on patient demographics, injury pattern and mechanism, fracture classification, treatment modality, reoperation rates, time between definitive fixation and reoperation, and indications for reoperation. Results: Seventy-six percent of presenting injuries were the result of a high-energy mechanism. Intramedullary nailing represented the most common type of fixation (88%). One hundred and fifty patients (21%) required reoperation. Delayed union/nonunion was the most common indication for reoperation in patients who had been previously treated with intramedullary nail fixation (31%; 39 of 126), and infection was the most common indication for reoperation in patients who had been treated with plate fixation (43%; 3 of 7). The time between the injury and definitive fixation was significantly different between the interior and exterior trauma centers (13.8 versus 4.7 days; p < 0.001), as was the time between definitive fixation and reoperation (69.3 versus 25.2 days; p = 0.004). The reoperation rates for the interior and exterior trauma centers were similar (20% versus 24%; p = 0.2). Infection, delayed union/nonunion, and implant removal were the most common indications for reoperation across groups. Conclusions: An improved understanding of the factors that influence treatment may help to guide future areas for improvement, establish educational goals, and create additional nationwide guidelines for open tibial fracture treatment. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effectiveness of Nail Dynamization in Delayed Union of Tibial Shaft Fractures: Relationship Between Fracture Morphology, Callus Diameter, and Union Rates.

OBJECTIVE: Dynamization has already been described as a secondary intervention for delay unions of tibial shaft fractures treated with intramedullary nailing. Although it's a common procedure, it is not widely supported in the literature. The purpose of this study was to determine the union rate of nail dynamization in cases of delayed union of diaphyseal tibial fractures, and assess the effect of fracture morphology on union rates. MATERIALS AND METHODS: We retrospectively analyzed a series of 199 consecutive tibial shaft fractures. We recorded the dynamization rate, period from nailing to dynamization, nailing to the union, the fracture pattern (according to AO/ASIF and whether it was closed or open), the callus diameter before dynamization (fracture healing index; FHI) and union/failure rates. RESULTS: Out of a total of 199 fractures treated during the study period, 41 (20.6%) were dynamized. After applying inclusion and exclusion criteria, 39 patients with 39 fractures were included in the study. The mean time from nailing to dynamization was 18.4 ± 7.2 weeks. The union rate was 92.3% (n = 36) over a mean time of 14.1 ± 5.6 weeks as from dynamization. The overall failure rate was 6.7% (n = 3). There was no significant association between failure and AO/ASIF classification (p > 0.05) or fracture exposure (X 2 = 0.19; p = 0.66). The pre-dynamization FHI of ≥ 1.17 was significantly associated with consolidation (p < 0.05). CONCLUSION: In cases of delayed union of tibial fractures, dynamization offered a high union rate associated with pre-dynamization FHI, while fracture morphology did not affect the failure rate.