Two-Stage Treatment of Chronic Periprosthetic Knee Infections With the Use of Gentamicin-Articulated Spacers: Success Rate and Predictors of Failure at the Minimum Seven-Year Follow-Up.

Background: The purpose of this study was to assess the survivorship rates of 2-stage treatment with gentamicin-impregnated polymethylmethacrylate articulated knee spacer in patients with chronic periprosthetic joint infection and to identify risk factors associated with failure. Methods: We conducted a retrospective study among 73 patients with chronic periprosthetic joint infection after primary total knee replacement with articulated polymethylmethacrylate gentamicin-impregnated spacers (Subiton, Medical Labs, Ind Argentina), performed in a single institution with a minimum follow-up of 7 years. Clinical and functional assessment was performed with Knee Society Score and Western and Ontario McMaster Universities Osteoarthritis Index. A univariate and multivariate analysis was performed to identify the variables that influenced the success and failure rates. Results: We included 73 patients. There were 53 (71.3%) monomicrobial, 11 (15%) polymicrobial, and 10 (13.7%) negative cultures infections. The success and failure rates were 90.5% (n = 66) and 9.5% (n = 7), respectively. Multivariate analysis identified that age (odds ratio = 1.77; P = .039), greater erythrocyte sedimentation rate values prior to the first stage (odds ratio = 1.04; P = .006), and polymicrobial infections (odds ratio = 7.32; P = .0003) were independent variables associated with failure. Conclusions: Two-stage revision with polymethylmethacrylate gentamicin-impregnated knee spacers is an effective strategy for the treatment of chronic periprosthetic joint infection after total knee arthroplasty. Age, higher erythrocyte sedimentation rate values prior first stage, and polymicrobial infections were independent risk factors for treatment failure.

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.

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.

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.

Infectious disease specialists and teamwork strategies worldwide: the World Association against Infection in Orthopedics and Trauma (WAIOT) and SICOT continue to cooperate in fighting musculoskeletal infections.

Bone and joint infections are associated with a devastating global burden. The successful treatment of these infections requires a multidisciplinary approach between orthopedic surgeons and experts of different disciplines. This multidisciplinary approach has gained ground over the past decades in modern infection units as a more effective treatment strategy, yielding better outcomes regarding infection eradication rates, length of hospital stay, and overall cost of treatments. Additionally, preventing and managing musculoskeletal infections requires strong connections between medical associations, biological laboratories, and the pharmaceutical industry worldwide. In this context, SICOT and World Association against Infection in Orthopaedics and Trauma (WAIOT) relationships have been increasing. The present editorial article discusses the multidisciplinary approach for managing bone and joint infections worldwide, explores the controversies in practices in terms of training, area of expertise, and extent of clinical involvement, and emphasizes the role of societies in research, prevention and management of musculoskeletal infections. The purpose is to acknowledge what orthopedics can obtain from specialists dealing with bone and joint infections and to consolidate their practice to provide the best care for orthopedic patients.

Total Knee Replacement in Alkaptonuric Ochronosis.

BACKGROUND AND OBJECTIVE: Alkaptonuria is a rare disease characterized by the accumulation of homogentisic acid (HGA). Over time, these patients may develop disabling ochronotic arthropathy. We present 2 cases of patients with end-stage arthropathy treated with total knee arthroplasty (TKA). METHODS: Both patients complained of disabling knee pain and reported limited walking distance (200-300 m). One had a history of osteotomy for medial knee arthtritis and ignored his underlying condition. The other presented with valgus gonoarthrosis and diagnosis of alkaptonuria. RESULTS: Intraoperatively, the characteristic dark-blue color in the joint was observed. Both patients evolved favorably after TKA with excellent results according to the Knee Society Scores (KSS) at three years of follow-up. CONCLUSION: We believe TKA is the right treatment for patients with end-stage disease because it offers considerable relief from pain and allows patients to recover function.

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.

Metal Hypersensitivity or Missed Periprosthetic Joint Infection? A Critical Review.

The World Association Against Infection in Orthopedics And Trauma (W.A.I.O.T.) Study Group on Bone And Joint Infection Definitions Metal hypersensitivity (MHS) has been investigated by several authors as a possible reason for painful total joint arthroplasty, with controversial results. Periprosthetic joint infection (PJI) is another possible source of unexplained pain and implant failure that may be difficult to diagnose if not properly investigated. We performed this critical review to assess whether the current literature on MHS includes an adequate diagnostic workup to discern metal allergy from PJI. The results of this review highlight the importance of assessing patients for PJI before making a diagnosis of MHS and emphasize that the methods currently used to exclude PJI are substantially inadequate. Therefore, well-designed clinical trials with adequate diagnostic protocols and definitions of PJI that can differentiate MHS from low-grade PJI are needed. [Orthopedics. 2022;45(2):e73-e78.].

Bipolar hemiarthroplasty in unstable intertrochanteric fractures in elderly patients. The predictive value of the Charlson Comorbidity Index in 1-year mortality.

BACKGROUND: Hip fractures have a significant impact on morbidity and mortality in the elderly. Aims: We retrospectively evaluated the predictive role of the Charlson Comorbidity Index (CCI) for 1-year mortality in elderly patients with unstable intertrochanteric hip fractures (ITHF) treated with bipolar hemiarthroplasty. The secondary objective was to identify other relationships, if any, between the variables recorded and mortality. METHODS: We included ≥75-year-old patients with unstable ITHF treated with bipolar hemiarthroplasty. We recorded patient gender, age, Body Mass Index, pre-fracture walking ability (Parker Mobility score, modified Harris Hip Score), America Society of Anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI), time to surgery, time to mobilization, hospital stay, and postoperative complications. Uni- and multivariate logistic regression analysis were performed. Sensitivity and specificity were calculated using a ROC curve. RESULTS: A total of 135 patients with a mean age of 87.34 ± 5.5 years were included. The overall 1-year mortality rate was 18.5%. The CCI (OR 1.64 CI 95% 1.21-2.23; p 0.00821) and postoperative complications (OR 3.5 CI 95% 1.19-10.23 p 0.0202) were identified as independent predictors of 1-year mortality in the univariate regression and confirmed in the multivariate regression. CCI sensitivity to predict 1-year mortality was 80%. CONCLUSION: CCI has shown acceptable sensitivity in the prediction of 1-year mortality in elderly patients with unstable ITHF treated with bipolar hemiarthroplasty. It is of utmost importance to prevent postoperative complications due to their significant impact on 1-year mortality.

Cerclaje con alambre en fracturas subtrocantéricas de cadera. Análisis de beneficios y complicaciones / Cerclage wiring in subtrochanteric hip fractures. Analysis of benefits and complications

Introducción: El objetivo de este estudio retrospectivo fue evaluar si la reducción abierta con cerclaje de alambre afectó la consolidación, la tasa de complicaciones y de reoperaciones en pacientes con fracturas subtrocantéricas de cadera, tratadas con clavos cefalomedulares. materiales y métodos:Se evaluó a todos los pacientes operados consecutivamente entre enero de 2010 y diciembre de 2017. Se comparó a los tratados con cerclaje (Grupo A) o sin cerclaje (Grupo B) de alambre en términos de tipo de fractura, estancia hospitalaria, tiempo quirúrgico, necesidad de transfusiones, calidad de la reducción, consolidación y complicaciones (infección, seudoartrosis, reoperaciones). Resultados:Se incluyó a 58 pacientes. El grupo A estaba conformado por 20 pacientes y el grupo B, por 38. El tipo de fractura más frecuente fue 3A (p = 0,0004). La estancia hospitalaria fue similar (9.0 vs. 10.6 días; p = 0,81), el tiempo quirúrgico y la necesidad de transfusiones fue mayor en el grupo A (p<0,0001 y p = 0,58, respectivamente). La tasa de consolidación fue similar en ambos grupos (90 vs. 92,1%, respectivamente; p = 0,09). Los desejes se observaron solo en el grupo tratado sin lazadas (5-13,5%; p = 0,01). Las tasas de complicaciones (15 vs. 18,4%) y de reopera-ciones (15 vs. 15,8%) fueron similares (p = 0,99). Conclusiones: El uso de lazadas de alambre en fracturas subtrocantéricas de cadera tratadas con clavos cefalomedulares generó un aumento significativo del tiempo quirúrgico, y disminuyó significativamente la incidencia de desejes. La incidencia de reoperaciones fue menor, aunque no significativamente. Nivel de Evidencia: III

Background: The aim of this retrospective study was to assess whether open reduction with cerclage wire affected the union and/or complication rate in subtrochanteric hip fractures treated with cephalomedullary nails. materials and methods: We analyzed all patients who had undergone surgery in our center between January 2010 and December 2017. We comparatively analyzed those treated with (Group A) and without (Group B) cerclage wire in terms of fracture type, hospital stay, surgical time, blood transfusions, malalignment, union, and complications (infection rates, non-union, and reoperations). Results: Fifty-eight patients were included. Group A consisted of 20 patients and Group B of 38. The most frequent type of fracture was 3A (p 0.0004). The mean hospital stay was similar (9 vs 10.6 days p 0.81), the surgical time and transfusions were higher in group A (p<0.0001 and p 0.58 respectively). The union rate was similar (90 vs 92.1%; p 0.09, respectively). Malalignment was only observed in group B (5 - 13.5%; p 0.01). The complication (15 vs 18.4%) and reoperation (15 vs 15.8%) rates were similar (p 0.99). Conclusions: The use of cerclage wire in subtrochanteric hip fractures treated with cephalomedullary nails generated a significant increase in surgical time and a lower rate of malalignment. It allowed a lower rate of re-operation, although it was not significant. Level of Evidence: III

Genu valgo artrósico severo: Prótesis de estabilidad aumentada en artroplastia primaria / The severe valgus knee: Total knee arthroplasty with a constrained prosthesis

Objetivo El genu valgo artrósico severo (> 20°) puede presentar distintos grados de insuficiencia del ligamento colateral medial e inestabilidad articular. El objetivo de este trabajo retrospectivo evalúa nuestra experiencia en el tratamiento del genu valgo severo con prótesis de estabilidad aumentada y propone un método para la evaluación y clasificación del genu valgo artrósico. Material y métodos A 27 pacientes (28 rodillas) con genu valgo artrósico severo se les realizó una artroplastia total de rodilla primaria con un implante de estabilidad aumentada, y un seguimiento promedio de 6.2 años. Se confeccionó una nueva clasificación del genu valgo artrósico que contempla la suficiencia ligamentaria y por lo tanto relaciona el tipo de rodilla con el tipo de implante necesario. Resultados Se utilizó una prótesis constreñida en 17 pacientes con un eje promedio de 22,7° y el ligamento colateral medial atenuado. En 11 casos con un eje promedio de 28,1°, LCM incompetente y/o recurvatum, se optó por bisagras rotatorias. Se confeccionó una nueva clasificación del genu valgo artrósico que considera el desgaste y estabilidad articular, el grado de deformidad de la rodilla y la suficiencia ligamentaria. Discusión Las prótesis constreñidas deben utilizarse en pacientes que presenten inestabilidad exclusivamente en el plano coronal, aún en genu valgo severo, con LCM atenuado. Debe reservarse el uso de bisagras rotatorias a aquellos pacientes que presentan incompetencia ligamentaria, inestabilidad combinada (recurvatum) y/o déficit neuro-muscular severo.

Purpose This retrospective level 2 analysis evaluates the prosthesis type selected in our department for the treatment of the severe valgus knee and proposes a new classification for the valgus knee osteoarthritis. Material and methods A total knee arthroplasty with a constrained or hinged knee prosthesis was performed in 28 valgus knees. The average follow-up was 6.2 years. A new classification that considerates the ligament sufficiency status was developed in order to relate the different knee types with the different type of eventually needed implants. Results Constrained prosthesis was used in 17 patients with an attenuated medial collateral ligament, and a rotating hinge in 11 patients with incompetent medial collateral ligament and/or recurvatum. The postoperatory Knee Society Score was of 85 points. The valgus knee was classified in 5 types considering the knee valgus deformity, the ligament sufficiency and joint stability and wear. Discussion The classification proposed clearly defines the ligament status and valgus knee types, and it seems to be a comprehensive tool to select the appropriate prosthesis. Constrained prosthesis must be used on patients who present coronal instability with attenuated medial collateral ligament. Rotating hinges must be reserved for those patients who have medial collateral ligament incompetence, recurvatum, combined instability and/or severe muscular deficiency.

Congenital Fibular Deficiency: Total Knee Arthroplasty with Extraarticular Deformity: A Case Report.

CASE: A total knee arthroplasty (TKA) was performed on a 35-year-old man with congenital fibular deficiency and a 20° varus and 28° antecurvatum tibial deformity of the left lower limb. CONCLUSION: One-stage TKA and correction of the extraarticular deformity by means of intraarticular bone resections and a standard soft tissue release were performed to restore the limb's mechanical axis. Patients with congenital fibular deficiency present a wide range of limb deformities because of bone deficiencies or treatment sequels, which might require a specific surgical technique and small-sized implants to obtain good results during a TKA.

Distal fixation stems for revision of total hip replacement.

The purpose of this study was to retrospectively assess patients treated with modular, non-cemented, tapered, fluted, distal fixation stems. We included patients with 24 months mínimum follow-up. Diagnosis that led to revisions were described. The radiographic analysis was made with preoperative, immediate postoperative and last control postoperative X-rays. Sixty-seven patients met inclusion criteria. We observed 59,7% (n=40) Osteointegration, 34,3% of Stable Fibrosis and 5,97% Unstable fibrosis. Stress Shielding was registered with 10,44% and Subsidence was observed in 34,3% of the patients. Modular, fluted, tapered, distal fixation stems have an excellent survival rates.

Extended trochanteric osteotomy (ETO) and fluted tapered modular stems in revision hip arthroplasty. Does ETO integrity or consolidation, really matter?

INTRODUCTION: The objective of this study was to assess if the fracture and/or non-union of extended trochanteric osteotomy (ETO) affected the behavior and survival of modular fluted and tapered distal fixation stems in revision total hip arthroplasties (rTHA). METHODS: We retrospectively analyzed 52 rTHA in 52 patients. Preoperative diagnoses were mechanical loosening (42 cases), septic loosening (8), periprosthetic fracture (1), and femoral stem fracture (1). According to the Paprosky classification, femoral bone stock deficiencies were 19 type-II, 26 type IIIA, and 7 type IIIB. We assessed the behavior of the osteotomy (union, fracture, migration) and the survival and behavior (integration and subsidence) of prosthetic femoral stems. RESULTS: ETO union and non-union rates were 84.61% (44 patients) and 15.38% (8 cases) respectively. There were twelve (23%) intra-operative fractures of the osteotomy fragment and 11 (21.15%) migrations (4.5 mm on average). We observed bone union in 39 (75%) stems and 13 (25%) stable fibrous unions. Nine (17.3%) stems subsided 7 mm (2-15 mm) on average before becoming stable. Stem subsidence and integration was not significantly affected by ETO fracture/no fracture or union/non-union. The postoperative Harris Hip Score (HHS) improved significantly as compared to the pre-operative HHS (38.41 ± 3.54 vs 85.29 ± 3.36; p < 0.01). Patients were followed up for 55 (24-100) months. The overall implant survival at the end of follow-up was 100%. CONCLUSIONS: In this series, neither the non-union nor the intra-operative fracture of the ETO segment affected the behavior or medium-term survival of femoral stems.

The effectiveness of antibiotic cement-coated nails in post-traumatic femoral and tibial osteomyelitis - comparative analysis of custom-made versus commercially available nails.

Background: The first objective of this retrospective study was to assess infection control rates in patients with chronic post-traumatic osteomyelitis (CPTO) of the femur or tibia treated with antibiotic cement-coated nails. The second objective was to compare the efficacy of custom-made nails versus commercially available antibiotic-coated nails in terms of infection control and need for reoperation. Methods: We reviewed a consecutive series of CPTO patients treated with antibiotic-coated nails who had a minimum follow-up of 24 months. We recorded the characteristics of the initial injury, the type of nail used, cement-nail debonding, infecting microorganisms, operating time, infection control, need for reoperation, and failure rate. We performed a comparative analysis between nails manufactured in the operating room (i.e., custom-made) and those commercially available. Results: Thirty patients were included. The affected bones were the femur ( n = 15 ) and the tibia ( n = 15 ). Twenty-one of the 30 initial injuries were open fractures. Staphylococcus aureus was the most frequently isolated microorganism (50 %). Sixteen patients were treated with custom-made nails and 14 with commercially available antibiotic-coated nails. At the time of extraction, four out of five custom-made antibiotic-coated nails experienced cement-bone debonding. Commercial nails were associated with shorter operating times ( p < 0.0001 ). The overall infection control rate was 96.66 %. Eight (26.66 %) patients needed reoperation. There was one failure (3.33 %) in the group treated with custom-made antibiotic-coated nails. We did not find significant differences between nail types in terms of reoperation, infection control, and failure rate. Conclusions: The use of antibiotic cement-coated nails proved useful in CPTO treatment. Commercially available nails had significantly shorter operating times and did not present cement-bone debonding during removal. Our results seem to indicate that both nail types are similar in terms of infection control and reoperation rates.

Artroplastia total de rodilla posterior a osteotomía tibial alta. Estudio retrospectivo comparativo entre osteotomías sustractivas y aditivas / Total knee replacement after high tibial osteotomy. Retrospective comparative study between subtractive and additive osteotomies

Introducción: El reemplazo total de rodilla luego de una osteotomía tibial alta plantea dificultades técnicas adicionales. El objetivo de este estudio fue analizar los resultados clínicos y radiográficos de la conversión a reemplazo total de rodilla luego de una osteotomía tibial alta y comparar la evolución de los pacientes con una osteotomía de cierre (sustractiva) o de apertura (aditiva) previa. Materiales y Métodos: Se analizó retrospectivamente una serie de 46 artroplastias de rodilla realizadas entre 1997 y 2019, en 39 pacientes con antecedente de osteotomía tibial alta. Se evaluaron los parámetros clínicos y radiográficos antes de la artroplastia y después, determinando el eje femorotibial, la caída tibial posterior, el valor de Insall-Salvati y el Knee Society Score. También se compararon los resultados en pacientes con antecedente de osteotomía tibial sustractiva vs. aditiva. Resultados:El seguimiento promedio fue de 5.72 años (mín. 1, máx. 19). El Knee Society Score de la serie tuvo una mejoría promedio de 42,3 a 79,8. La caída tibial posterior y el índice de Insall-Salvati no sufrieron grandes modificaciones luego de la cirugía. La supervivencia promedio de la osteotomía aditiva hasta la conversión a reemplazo total de rodilla fue de 5.5 años, mientras que la de la sustractiva, de 13.5 años.Conclusiones:Pese a la dificultad técnica que puede plantear, el reemplazo total de rodilla luego de una osteotomía tibial alta valguizante tuvo una buena evolución clínico-radiográfica a corto y mediano plazo, y el tipo de osteotomía no repercutió en los resultados luego de la artroplastia. Nivel de Evidencia: IV

Introduction: Total knee replacement after a high tibial osteotomy presents additional technical difficulties. The objective of this study was to analyze the clinical and radiological outcomes of conversion to total knee replacement after a high tibial osteotomy and to compare the evolution of patients with a history of a closing (subtractive) versus opening (additive) osteotomy. Materials and Methods: A series of 46 knee arthroplasties performed between 1997 and 2019 in 39 patients with a history of a high tibial osteotomy was retrospectively analyzed. The clinical and radiographic parameters were evaluated before and after the arthroplasty by measuring the femorotibial axis, the posterior tibial slope, the Insall Salvati value, and the Knee Society Score. At the same time, the results were compared in patients with a history of subtractive versus additive tibial osteotomy. Results:In the series of 46 patients, an average follow-up of 5.72 years was achieved (minimum 1, maximum 19). The Knee Society Score for the entire series had an average improvement from 42.3 to 79.8 points. The posterior tibial slope and the IS value did not show great modifications after surgery. In this series, the average survival of additive osteotomy until conversion to total knee replacement was 5.5 years, while for the subtractive one it was 13.5 years. Conclusions:Despite the technical difficulty that it may present, total knee replacement after a valgus high tibial osteotomy presented a good clinical-radiological evolution in the short and medium term and the type of osteotomy did not affect the results obtained after arthroplasty. Level of Evidence: IV

Estudio retrospectivo comparativo entre aspirina y dabigatrán en la incidencia de efectos tromboembólicos en pacientes con artroplastia de cadera y rodilla / Comparative retrospective study between aspirin and dabigatran in the incidence of thromboembolic events in hip and knee arthroplasty

Objetivo: Analizar la incidencia de eventos tromboembólicos extrahospitalarios luego de un reemplazo total de rodilla o cadera primario en los primeros 90 días posoperatorios, utilizando como tromboprofilaxis ácido acetilsalicílico o dabigatrán. El objetivo secundario fue evaluar el costo de la terapia antiagregante y de la anticoagulante. Materiales y Métodos: Se realizó un estudio observacional retrospectivo en el posoperatorio de reemplazos totales de cadera y rodilla primarios sobre la incidencia de eventos tromboembólicos extrahospitalarios, durante los primeros 90 días posteriores a la cirugía, en dos grupos. Se administró ácido acetilsalicílico (325 mg/día) o dabigatrán (150-220 mg/día) por 35 días. Resultados: La serie incluyó a 224 pacientes (media de la edad 68.5 años), el 44,2% eran hombres. El 51,3% era un reemplazo total de cadera. El 64,3% continuó la tromboprofilaxis con dabigatrán y el 35,7%, con aspirina. La incidencia total de eventos tromboembólicos fue del 1,3%; 1,4% con dabigatrán y 1,3% con aspirina (p = 0,9). El costo de la tromboprofilaxis fue de USD 3,6 con aspirina 325 mg y USD 130 o 175 con dabigatrán, según la presentación de 75 y 110 mg. Conclusiones:La aspirina como tromboprofilaxis tras un reemplazo total de cadera o rodilla en pacientes con bajo riesgo de sufrir eventos tromboembólicos ha logrado resultados clínicos similares a los del dabigatrán. Se puede recomendar un protocolo multimodal basado en el uso de aspirina. Este mejora el cumplimiento de la terapia antitrombótica por parte de los pacientes, debido al bajo costo de la profilaxis con aspirina. Nivel de Evidencia: III

Objective: To analyze the incidence of out-of-hospital thromboembolic events after a primary total knee or hip replacement in the first 90 postoperative days, using acetylsalicylic acid or dabigatran as thromboprophylaxis. As a secondary objective, to evaluate the cost of antiplatelet therapy compared to anticoagulants. Materials and Methods: A retrospective observational study was carried out in the postoperative period of primary total hip and knee replacement on the incidence of out-of-hospital thromboembolic events during the first 90 postoperative days in two groups of patients. Acetylsalicylic acid (325 mg per day) or dabigatran (150 to 220 mg per day) were used as thromboprophylaxis for 35 days. Results: The series consisted of 224 patients aged 68.5 years (38-95 years), 44.2% male. 51.3% corresponded to total hip replacement. 64.3% continued thromboprophylaxis with dabigatran and 35.7% with aspirin. The total incidence of thromboembolic events was 1.3%. In the patients who received dabigatran it was 1.4% and in those who received aspirin, 1.3% (p = 0.9). The cost of thromboprophylaxis with aspirin 325 mg was US $ 3.6 while with dabigatran it was US $ 130 or $ 175, according to its presentation, 75 and 110 mg. Conclusion: Aspirin as thromboprophylaxis after total hip or knee replacement in individuals at low risk of thromboembolic events has shown similar clinical outcomes as dabigatran, and a multimodal protocol based on the use of aspirin can be recommended. This improves patient adherence to antithrombotic therapy, due to the low cost of aspirin prophylaxis. Level of Evidence: III

Comportamiento de los tallos no cementados recubiertos con hidroxiapatita colocados con alineación coronal inadecuada en la artroplastia primaria de cadera. Resultados del seguimiento a largo plazo / Behavior of hydroxyapatite-coated cementless stems placed with coronal malalignment in primary hip arthroplasty. Long-term follow-up results

Introducción: La mala alineación de los tallos femorales no cementados sigue siendo un tema controvertido. Algunos autores han comunicado una inadecuada osteointegración y hundimiento en los tallos en varo y otros no encontraron dichos efectos adversos, pese a la incorrecta alineación. Los objetivos de este estudio fueron determinar la prevalencia de tallos no cementados con cobertura total de hidroxiapatita en deseje coronal y mostrar los resultados clínico-radiográficos a largo plazo. materiales y métodos: Estudio retrospectivo entre 2006 y 2009. Se analizaron 220 reemplazos totales de cadera primarios con tallos no cementados con cobertura completa de hidroxiapatita. La alineación coronal fue analizada con radiografías anteroposteriores de ambas caderas en 10° de rotación interna. Se registraron datos, como osteointegración, hundimiento, osteólisis femoral proximal e hipertrofia cortical. Para el análisis clínico se utilizó el Harris Hip Score. El análisis de supervivencia contempló la necesidad de revisión por cualquier causa. Resultados: La prevalencia de tallos en deseje fue del 32,3%, con mayoría de implantes en varo (73,3%). El Harris Hip Score tuvo un incremento estadísticamente significativo (41,05 ± 6,5 vs. 90,05 ± 2,5; p <0,01). El 73,1% de los tallos desarrollaron una fijación ósea estable. Se observó osteólisis femoral proximal en el 3% de los casos. Hubo un 3% de fracturas periprotésicas femorales. La supervivencia de la prótesis fue del 100% a los 10.9 años. Conclusión: Los tallos no cementados con cobertura total de hidroxiapatita toleran adecuadamente la alineación coronal en varo/valgo a largo plazo. Nivel de Evidencia: IV

Introduction: Coronal malalignment of non-cemented stems remains controversial. It's been reported that femoral stems implanted with varus or valgus developed subsidence and lack of integration with femoral bone. The purpose of this study was to calculate prevalence of coronal malalignment in cementless, fully coated with hydroxialapatyte (HA) femoral stems focusing in their long-term clinical and radiographic outcomes. Materials and methods: A retrospective study was performed, assessing 220 primaries total hip replacements with non-cemented, fully coated with HA, femoral stems between 2006 and 2009. Coronal alignment was assessed with hips antero-posterior views with 10º of internal rotation of lower limbs. We registered data about subsidence, proximal femoral osteolysis and cortical hipertrophy. Functional outcomes were assessed with Harris Hip Score (HHS). Free revision rate implant survival was calculated. Results: Prevalence of femoral stems with malalignment was 32.3%. HHS showed an statistically significant increase after surgery (41.05 ± 6.5 versus 90.05 ± 2.5; p <0.01). There were 73.1% of femoral stems that achieved a bone stable fixation. We observed proximal femoral osteolysis in 3.0% of the patients and there were 3% of periprosthetic fractures. Free-revision survival rate was 100% at 10.9 years of follow-up. Conclusion: Cementless, fully coated with HA femoral stems with varus/valgus malalignment achieves good long-term clinical and radiographic outcomes. Level of Evidence: IV

Colgajo neurocutáneo safeno y recambio de espaciador de cemento en el manejo de una artroplastia de rodilla infectada con defecto de cobertura cutánea. Reporte de un caso / Saphenous neurocutaneous flap and cement spacer replacement in the management of arthroplasty of an infected knee with a soft tissue coverage defect. Case report

Los defectos de cobertura asociados a una infección de la prótesis son un desafío al cual nos enfrentamos los cirujanos ortopédicos en el posoperatorio de un reemplazo articular. El objetivo de este artículo es comunicar un caso de defecto de cobertura tratado con un colgajo neurocutáneo safeno por una artroplastia de rodilla infectada. Se recambió el espaciador y se cubrió el defecto tegumentario con colgajo neurocutáneo safeno en un mismo tiempo. Conclusiones:El colgajo neurocutáneo safeno proporciona una adecuada cobertura en la cara anterior de la rodilla y permite tratar defectos tegumentarios asociados a una infección de la prótesis. Nivel de Evidencia: IV

Soft tissue defects in the setting of periprosthetic joint infection represent serious problems for orthopaedic surgeons following total joint replacement. This report aims is to show our experience using the proximal-based saphenous neurocutaneous flap for the reconstruction of a wound defect in the treatment of a periprosthetic knee infection. A new cement spacer was placed and a neurocutaneous saphenous flap was performed in the same stage. Conclusions: Soft tissue defects around the knee can be effectively solved with the neurocutaneous saphenous flap, which provides an adequate coverage to this joint within the context of infected arthroplasty. Level of Evidence: IV