ABSTRACT
Periprosthetic fractures around total knee arthroplasty in elderly represent an emerging cause of implant revision and their incidence seems destined to further increase in the upcoming years, considering the ever-increasing number of implanted prostheses. These are complex injuries with very high complication rates. It has been estimated that the incidence of femoral periprosthetic fractures after T.K.A. ranged between 0,3 to 2,5%, but increases up to 38% when considering revision T.K.A. Patient-related risk factors for T.K.A. periprosthetic fracture (T.K.A.P.F.) include osteoporosis, age, female sex, revision arthroplasty and peri-implant osteolysis. The grate debate concerns the choice of the most appropriate fixation device for T.K.A.P.F.: closed or open reduction with internal fixation with either locked plate or intramedullary nail is the most commonly used for treating these fractures. Success of these methods depends on the fracture pattern, the stability of implants, and the patient's bone quality which is often poor in elderly, thus resulting in high complication rates. Conversely, a revision of T.K.A. (R.T.K.A.) should be considered in case of prosthetic component instability, severe comminution or metaphyseal extension of the fracture (that precludes a good fixation), previous treatments failure and severe malalignment of T.K.A. Instead megaprosthesis and allograft-prosthesis composite are necessary in case of sever bone loss. Considering the variability of the clinical scenario of T.K.A.P.F., this complex injury requires and experienced and comprehensive approach based on both facture fixation and/or revision arthroplasty.
ABSTRACT
INTRODUCTION: The fractures that occurred around trochanteric nails (perinail fractures, PNFs) are becoming a huge challenge for the orthopaedic surgeon. Although presenting some specific critical issues (i.e., patients' outcomes and treatment strategies), these fractures are commonly described within peri-implant ones and their treatment was based on periprosthetic fracture recommendations. The knowledge gap about PNFs leads us to convene a research group with the aim to propose a specific classification system to guide the orthopaedic surgeon in the management of these fractures. MATERIALS AND METHODS: A steering committee, identified by two Italian associations of orthopaedic surgeons, conducted a comprehensive literature review on PNFs to identify the unmet needs about this topic. Subsequently, a panel of experts was involved in a consensus meeting proposing a specific classification system and formulated treatment statements for PNFs. Results and Discussion. The research group considered four PNF main characteristics for the classification proposal: (1) fracture localization, (2) fracture morphology, (3) fracture fragmentation, and (3) healing status of the previous fracture. An alphanumeric code was included to identify each characteristic, allowing to describe up to 54 categories of PNFs, using a 3- to 4-digit code. The proposal of the consensus-based classification reporting the most relevant aspects for PNF treatment might be a useful tool to guide the orthopaedic surgeon in the appropriate management of these fractures.
ABSTRACT
BACKGROUND: Arthroscopic partial meniscectomy is a common procedure in orthopedic practice. Infections are uncommon complications of this procedure with an incidence rate of 0,01% - 3,4%. Staphylococcus spp are the predominant causative agents in such cases. We present a case of knee septic arthritis caused by α-hemolytic Streptococcus. CASE PRESENTATION: A 22-year-old woman diagnosed with obesity (body mass index [BMI] 35 kg/m2) but with no other major comorbidities underwent an arthroscopic selective meniscectomy with administration of intravenous cefazolin for antibiotic prophylaxis. After an uneventful period of 2 months, the patient returned with pain, fever and a discharging sinus at the site of anterolateral arthroscopic portal. Blood tests and magnetic resonance imaging revealed osteomyelitis involving the tibial plate. Cultures of synovial fluid obtained from the knee and a pharyngeal swab yielded α-hemolytic Streptococcus. Five days later, the patient underwent arthroscopic debridement with partial synovectomy. Intraoperative specimens yielded α-hemolytic Streptococcus. The patient received intravenous piperacillin/tazobactam, followed by an associative regimen of amoxicillin and clindamycin with clinical, laboratory and instrumental evidence of symptom resolution. CONCLUSION: The incidence of knee septic arthritis after arthroscopic partial meniscectomy is 0.01-3.4%. This infection is usually caused by Staphylococcus spp. and in rare cases by commensal bacteria, such as α-hemolytic streptococci, secondary to transient bacteremia. Screening of the colonized area is important to prevent possible transient bacteremia. Diagnosis is based on isolation of the causative organisms from synovial fluid cultures, and treatment comprises arthroscopic debridement with individualized systemic antibiotic therapy based on the results of an antibiogram.
