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.

Antibiotic cement-coated rigid locked nails in infected femoral and tibial nonunion. Reoperation rates of commercial versus custom-made nails.

INTRODUCTION: The objective of this study is to assess bone union, infection control, and reoperation rates in a series of patients with infected femoral or tibial nonunion treated with antibiotic-cement-coated rigid nails and to compare the results obtained with custom-made nails versus commercial nails. METHODS: We retrospectively analyzed a series of consecutive patients with infected nonunion of the femur or the tibia treated with antibiotic-cement-coated rigid nails between January 2010 and 2020. We assessed patients' distinctive characteristics, initial injury, type of nail used (custom-made nail with vancomycin or commercial nail with gentamicin), success rate (bone union + infection control), reoperation rate, and failure rate. Comparative analyses were conducted between reoperated and non-reoperated patients regarding the type of nail used. A multivariate regression analysis was performed to assess the risk variables that impacted reoperation rates. RESULTS: We included 54 patients with 22 (40.74%) infected femoral nonunions and 32 (59.25%) tibial nonunions, who were treated with 38 (70.37%) custom-made antibiotic-cement coated nails and 16 (29.62%) commercial nails. Bone union and infection control were achieved in 51 (94.44%) cases. The reoperation rate was 40.74% (n = 22), and the failure rate was 5.55% (n = 3). The use of custom-made nails was associated with a higher risk of reoperation (Odds Ratio 4.71; 95% Confidence Interval 1.10 - 20.17; p = 0.036). CONCLUSION: Antibiotic-cement-coated nails reached a 94.44% success rate. Nails manufactured in the OR coated with vancomycin cement were associated with a higher risk of reoperation than commercial nails loaded with gentamicin cement. LEVEL OF EVIDENCE: III comparative, observational, non-randomized.

Antibiotic cement-coated plate is a viable and efficient technique for the definitive management of metaphyseal septic nonunions of the femur and tibia.

OBJECTIVE: the management of septic metaphyseal nonunions is challenging, with inconsistent outcomes. Antibiotic cement-coated implants have been demonstrated good outcome for diaphyseal infected nonunions, however there is no data in metaphyseal infected nonunions. METHODS: fifteen adult patients with septic metaphyseal nonunions of the femur or tibia were treated with antibiotic cement-coated plates. The antibiotic cement-coated plate was prepared with either gentamicin or vancomycin. Outcome measures were infection control, bone healing, return to pre-injury level on daily activities, and quality of life at the last follow-up visit. A p value of <5% was considered significant. RESULTS: Methicillin-susceptible S. aureus was isolated in 53.3% cases. Average postoperative follow-up time was 18 months. Local infection control and radiographic bone healing were adequately achieved in 93.3% patients. No patient presented recurrent symptoms of surgical site infection. Fourteen patients reported to be either able, or on the same level as before injury, with 73.3% reporting no problems in all five dimensions of the EQ-5D-3L. Persistent infection was the only variable associated with a reduced long-term quality of life. CONCLUSION: antibiotic cement-coated plate is a viable and efficient surgical technique for the definitive management of juxta-articular metaphyseal septic nonunions of the femur and tibia.

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.

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.

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.

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.

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.

Safety and efficacy of a novel retrograde route for femoral bone graft harvesting by Reamer-Irrigator-Aspirator: a pilot study on 24 patients.

BACKGROUND: The Reamer-Irrigator-Aspirator system was initially developed to reduce fat embolism and thermic necrosis during reamed intramedullary nail fixation of femoral shaft fractures. Currently, this system is used in extended applications including accessing large volume of autologous bone graft, as alternative for iliac crest harvesting. Antegrade femoral bone graft harvesting using the Reamer-Irrigator-Aspirator system is considered the standard technique. The aim of our study is to evaluate the efficacy (bone graft volume) and the complications (blood loss, postoperative pain, and incidence of iatrogenic fractures) of the Reamer-Irrigator-Aspirator system through the retrograde femoral route in a series of patients with post-traumatic bone defects or nonunions. METHODS: A non-controlled single center retrospective observational cohort study was conducted in a level1 trauma center to evaluate all patients who were treated using the RIA system. Between November 2015 and May 2019, 24 patients (8 women and 16 men; mean age: 41 years [range 27-55 years]) with bone defects or nonunions underwent bone graft harvesting using the Reamer-Irrigator-Aspirator system through retrograde femoral route. Postoperative pain, complications, and bone graft volume were analyzed. Inclusion criteria was patients older than 18 years with a diagnosis of post-traumatic bone defect or associated tibial or femoral nonunion, with minimum 6-months follow, treated using the RIA. We hypothesized that the retrograde route of the RIA system is a safe and efficacious method for bone harvesting. RESULTS: The average volume of collected graft was 45 cc (range 30-60 cc). In 83% of the cases, bone grafting was sufficient, while in 17% it was necessary to add iliac crest bone graft to completely fill the bone defect. A mean drop in postoperative hemoglobin of 4.1 g / dL (range 0.5-6.0 g / dL) was evidenced. In 4 cases (33%), a unit of packed red blood cells was required. Regarding postoperative pain, visual analogue scale after 3 months postoperatively was 1.6 in average. After 6 months, the value has decreased to 0.4. There were no perioperative or postoperative complications at 6-month follow-up. CONCLUSION: In this limited case series, large volumes of bone graft were harvested using the retrograde route of the RIA system and there were no intra-/ postoperative complications observed at 6-month follow-up. Therefore this novel technique appears safe and efficacious. However, it's important to highlight that future prospective controlled studies are necessary to validate the insights from this pilot study.

Medial Hoffa Fracture: Description of a Novel Classification System and Rationale for Treatment Based on Fragment-Specific Fixation Strategy.

PURPOSE: This study aims to present a novel classification system and a rationale for treatment of medial Hoffa fractures. METHODS: We developed a simple comprehensive classification system for medial Hoffa fractures based on the fragment size and presence of fracture comminution. Furthermore, we propose a treatment algorithm based on two pillars: our case series of nine patients presenting medial Hoffa fractures and the best evidence-based pertinent literature. Fracture healing, range of motion, function, and complications were evaluated after a minimum of 6 months follow-up. RESULTS: All fractures healed with no loss of reduction. Knee flexion ranged from 90 - 130° (mean 110°, standard deviation 15.2). Knee extension ranged from 0 - 10° (mean 1°, standard deviation 3.3). Knee function according to the Lysholm score ranged from 74 - 96 points (mean 85, standard deviation 6.3). There were no complications such as infection, fixation failure, or medial femoral condyle osteonecrosis. One patient required hardware removal due to soft tissue irritation and one patient underwent knee mobilization under anesthesia after 8 weeks of fracture fixation due to knee stiffness. CONCLUSION: The presented rationale for treatment based on the new classification system is a simple and effective strategy on the decision-making process for adequate management of medial Hoffa fractures.

Osteosíntesis en fracturas femorales periprotésicas de cadera Vancouver tipos B1 y C. Análisis multicéntrico / Osteosynthesis in Vancouver type B1 and C periprosthetic hip fractures of the femur. A multicenter analysis

Introducción: Nuestro objetivo fue analizar los resultados del tratamiento con osteosíntesis en pacientes con fracturas Vancouver tipos B1 y C, evaluar las complicaciones, las reintervenciones y la tasa de mortalidad en este grupo. Materiales y métodos: Estudio multicéntrico, retrospectivo. Se estableció una base de datos que incluía a 53 pacientes con fracturas periprotésicas de fémur Vancouver tipos B1 y C tratadas con osteosíntesis, desde 2008 hasta 2021, en dos centros hospitalarios de alta complejidad. Resultados: La fijación proximal más utilizada fue con tornillos bicorticales más lazadas de alambre. El tipo de fractura según la clasificación de Vancouver se correlacionó con un valor significativo en el uso de tornillos de compresión interfragmentaria (p 0,001), con un total de 13 pacientes (24,52%), 9 en fracturas Vancouver tipo C. El tiempo de consolidación promedio fue de 4 meses, con un puntaje promedio del Harris Hip Score de 68. Doce pacientes (22,64%) tuvieron complicaciones: retraso de la consolidación (7 casos; 13,2%), falla de la osteosíntesis con trazo de fractura a nivel distal del tallo (un caso; 1,88%), una nueva osteosíntesis por falla a nivel del material de osteosíntesis (un caso; 1,88%) y tres fallecieron (5,66%). Conclusiones: El manejo de las fracturas femorales periprotésicas es un tema complejo y desafiante. El tratamiento con osteosíntesis constituye un método exitoso que requiere de la aplicación de principios actuales de técnicas mínimamente invasivas que, junto con una fijación proxi-mal estable, mejoran las posibilidades de éxito. Nivel de Evidencia: IV

Introduction: Our objective was to analyze the results of osteosynthesis treatment in patients with Vancouver type B1 and C fractures, evaluate complications, reinterventions and the mortality rate in this group. Materials and methods: Multicenter, retrospective study. A database was established that included 53 patients with Vancouver type B1 and C periprosthetic femoral fractures treated with osteosynthesis, from 2008 to 2021, who were evaluated in two high-complexity hospital centers. Results: The most used proximal fixation was bicortical screws and wire loops. The type of fracture according to the Vancouver classification correlated with a significant value in the use of interfragmentary compression screws (p 0.001), with a total of 13 patients (24.52%), 9 in Vancouver type C fractures. Mean consolidation was 4 months, with a mean Harris Hip Score of 68. Twelve patients (22.64%) had complications: delayed union (7 cases; 13.2%), failed osteosynthesis with fracture at the distal level of the stem (one case; 1.88%), one new osteosynthesis due to failure at the level of the osteosynthesis material (one case; 1.88%) and three patients died (5.66%). Conclusions: The management of periprosthetic femoral fractures is a complex and challenging issue. Osteosynthesis treatment is a successful method that requires the application of current principles of minimally invasive techniques that, together with stable proximal fixation, improve the chances of success. Level of Evidence: IV

Estudio comparativo de la función y el dolor de la rodilla entre el abordaje suprarrotuliano y pararrotuliano medial luego del enclavado endomedular de una fractura de tibia / Comparative study of knee function and pain between the suprapatellar and medial parapatellar approaches after intramedullary nailing of a tibial fracture

Introducción: El dolor anterior de rodilla es la causa más frecuente de reoperaciones luego del enclavado endomedular de una fractura de tibia. En los últimos años, los abordajes en semiextensión han facilitado la técnica quirúrgica; sin embargo, el dolor posoperatorio sigue siendo la complicación más frecuente. El objetivo de este estudio fue comparar el abordaje pararrotuliano medial con el suprarrotuliano en cuanto al dolor de rodilla y la función posoperatoria luego del enclavado endomedular de tibia. materiales y métodos: Se conformaron retrospectivamente 2 grupos de pacientes con fracturas de tibia tratados con clavo endomedular a través del abordaje pararrotuliano medial (n = 33) y suprarrotuliano (n = 17). Se evaluaron el dolor de rodilla posoperatorio con las escalas analógica visual y de Lysholm, y la función con el SF-12, al mes 1, 3, 6 y 12. Resultados: La edad promedio era de 41.5 años (rango 29-76) para el grupo con abordaje pararrotuliano y de 40.4 años (rango 23-90) para el otro grupo. Los resultados respecto del dolor y la función de la rodilla fueron significativamente mejores en el grupo operado con el abordaje suprarrotuliano. Conclusiones: El abordaje suprarrotuliano se asocia con menor dolor de rodilla y mejor función posoperatoria luego del enclavado endomedular de una fractura de tibia. Sin embargo, estudios prospectivos deberán validar estos resultados. Nivel de Evidencia: III

Anterior knee pain is the most frequent cause of reoperation after intramedullary nailing of a tibial fracture. In recent years, semi-extension approaches have simplified the surgical technique, but postoperative pain continues to be the most frequent complica-tion. The aim of this study is to compare the medial parapatellar approach (PPM) vs the suprapatellar approach (SP) with respect to knee pain and postoperative function after intramedullary tibial nailing. materials and methods: We retrospectively formed 2 groups of patients with tibial fractures treated with intramedullary nailing through the PPM (n:33) and SP (n:17) approaches. We evaluated postoperative knee pain with the VAS and Lysholm score; and function with the SF-12. They were clinically evaluated at 1, 3, 6 and 12 months. Results: The mean age of the groups was 41.5 years (29-76) for the PPM group and 40.4 years (23-90) for the SP group. Pain and knee function were significantly better in the group of patients operated through the SP approach. Conclu-sion: The suprapatellar approach is associated with less knee pain and better postoperative function after intramedullary nailing of a tibial fracture. However, prospective studies should validate these results. Level of Evidence: III

Fractura de fémur distal asociada con una lesión del tendón cuadricipital: reporte de dos casos / Fractures of the distal femur associated with a complete quadricipital tendon injury: report of two cases

Las fracturas de fémur distal, especialmente las abiertas, se asocian con traumas de alta energía. Las lesiones asociadas al-rededor de la rodilla son frecuentes; sin embargo, la asociación con una lesión completa del tendón cuadricipital ha sido poco documentada. El diagnóstico temprano y un adecuado tratamiento de ambas lesiones son fundamentales para conseguir buenos resultados posoperatorios. Presentamos dos casos de fracturas intrarticulares de fémur distal expuestas asociadas con lesiones completas del tendón cuadricipital. La reparación de la lesión tendinosa asociada mediante túneles transóseos luego de la fijación de la fractura permite comenzar un protocolo de rehabilitación temprano, esencial para obtener buenos resultados funcionales.Palabras clave: Fractura; fémur distal; lesión; tendón cuadricipital; aparato extensor. Nivel de Evidencia: V

Fractures of the distal femur, especially open fractures, occur in association with high-energy trauma. The presence of associated injuries around the knee is common; however, the association with a complete quadricipital tendon injury has been poorly documented. Early diagnosis and adequate treatment of both injuries is essential to achieve good postoperative outcomes. We present two cases of exposed intra-articular distal femoral fractures associated with complete quadricipital tendon injuries. The repair of the associated tendon injury with transosseous tunnels after fracture fixation allows an early rehabilitation protocol, essential to obtain good functional outcomes.Key words:Fracture; distal femur; injury; quadricipital tendon; extensor mechanism. Level of Evidence: V

Antibiotic cement-coated plate is a viable and efficient technique for the definitive management of metaphyseal septic nonunions of the femur and tibia / O uso de placas revestidas de cimentado com antibiótico é uma técnica viável e eficiente para o tratamento da pseudoartrose infectada da metáfise do fêmur e da tíbia

ABSTRACT Objective: the management of septic metaphyseal nonunions is challenging, with inconsistent outcomes. Antibiotic cement-coated implants have been demonstrated good outcome for diaphyseal infected nonunions, however there is no data in metaphyseal infected nonunions. Methods: fifteen adult patients with septic metaphyseal nonunions of the femur or tibia were treated with antibiotic cement-coated plates. The antibiotic cement-coated plate was prepared with either gentamicin or vancomycin. Outcome measures were infection control, bone healing, return to pre-injury level on daily activities, and quality of life at the last follow-up visit. A p value of <5% was considered significant. Results: Methicillin-susceptible S. aureus was isolated in 53.3% cases. Average postoperative follow-up time was 18 months. Local infection control and radiographic bone healing were adequately achieved in 93.3% patients. No patient presented recurrent symptoms of surgical site infection. Fourteen patients reported to be either able, or on the same level as before injury, with 73.3% reporting no problems in all five dimensions of the EQ-5D-3L. Persistent infection was the only variable associated with a reduced long-term quality of life. Conclusion: antibiotic cement-coated plate is a viable and efficient surgical technique for the definitive management of juxta-articular metaphyseal septic nonunions of the femur and tibia.

RESUMO Introdução: implantes revestidos de cimento com antibiótico vêm demonstrando bons resultados no tratamento da pseudoartrose infectada da diáfise, no entanto seu uso na metáfise dos ossos longos ainda é pouco explorado. Neste estudo relatamos uma série de casos de pseudoartrose infectada da metáfise do fêmur e da tíbia tratados com o uso de placas revestidas de cimento com antibiótico. Métodos: Os antibióticos usados foram gentamicina e/ou vancomicina. Os desfechos analisados na última visita ambulatorial foram controle de infecção, consolidação óssea, retorno às atividades diárias e qualidade de vida. Regressão linear bivariada foi usada para avaliar fatores individuais que afetaram a qualidade de vida dos pacientes. Um valor p<5% foi considerado estatisticamente significativo. Resultados: quinze pacientes adultos foram incluídos no estudo. S. aureus suscetível à meticilina foi isolado em 53,3% dos casos. O tempo médio de acompanhamento pós-operatório foi de 18 meses. Controle local da infecção e consolidação óssea radiográfica foram alcançados em 93,3% dos pacientes. Nenhum paciente apresentou sintomas recorrentes de infecção de sítio cirúrgico. Quatorze pacientes relataram ser capazes, mas não no nível pré-lesional ou no mesmo nível de antes da lesão, com 73,3% relatando nenhum problema em todas as cinco dimensões do EQ-5D-3L. Infecção persistente foi a única variável associada à redução da qualidade de vida a longo prazo. Conclusão: A placa revestida de cimento com antibiótico mostrou-se uma técnica cirúrgica viável e eficiente para o tratamento da pseudoartrose infectada da metáfise do fêmur e da tíbia.

Safety and efficacy of the modified Judet quadricepsplasty in patients with post-traumatic knee stiffness.

BACKGROUND: Knee stiffness is a challenging complication following complex fractures around the knee. Several treatment strategies have been described in the last decades, but clinical results and complication rates still remain as potential drawbacks. The aim of this study was to access the clinical outcomes and complications of the modified Judet quadricepsplasty following knee stiffness secondary to complex fractures around the knee. METHODS: A total of 11 patients presenting post-traumatic knee stiffness underwent modified Judet quadricepsplasty from 2014 to 2017. All procedures were performed by the same surgical team, and all patients followed the same postoperative pain control and rehabilitation protocols. No patients underwent medial approach for medial release. When necessary, medial release was performed through the lateral approach. Patients were evaluated using the Judet criteria for final range of motion after 1-year minimum follow-up. RESULTS: According to the Judet criteria, 4 patients (36.4%) presented excellent, 6 (54.5%) good, and 1 (9.1%) poor clinical outcomes. Blood transfusion was required in 5 patients (45.4%). No patients presented infection or wound dehiscence. CONCLUSIONS: Although quadricepsplasty is considered a high morbidity surgical procedure, our favorable functional outcomes with very low complication rates using this modified Judet quadricepsplasty confirmed safety and efficacy of this helpful surgical procedure for the challenge of post-traumatic knee stiffness. LEVEL OF EVIDENCE: Level 4 retrospective case series.

Lesiones tendinosas del aparato extensor de la rodilla: Protocolo de tratamiento y rehabilitación / Tendon injuries of the knee extensor mechanism: Treatment and rehabilitation protocol

Introducción: La rotura del aparato extensor puede ocurrir a nivel óseo o tendinoso; la principal causa es la fractura de rótula, seguida de la rotura del tendón cuadricipital y la rotura del tendón rotuliano. Estas lesiones pueden deberse a traumas directos o indirectos. La rotura tendinosa del aparato extensor es poco frecuente: representa el 3% de todas las lesiones tendinosas. Se presenta con traumatismos relacionados con la actividad diaria, deportiva o asociada a enfermedades sistémicas. materiales y métodos: Presentamos una serie de 22 roturas tendinosas del aparato extensor de la rodilla (8 del tendón cuadricipital [2 bilaterales] y 14 del tendón rotuliano [1 bilateral]), tratadas mediante cirugía, entre junio de 2015 y enero de 2019. Todos los pacientes fueron evaluados inicialmente con radiografías y resonancia magnética. Se empleó la escala de Lysholm para la evaluación funcional posquirúrgica. Resultados: El seguimiento posquirúrgico fue mínimo de un año (rango 12-24); los resultados fueron excelentes en 13 casos, buenos en 7 casos y regulares en 2 casos. Conclusión: La reparación primaria, con sutura transósea de las roturas tendinosas del aparato extensor más cerclaje en 8 como aumento en las lesiones del tendón rotuliano brinda una reconstrucción estable, permite implementar un protocolo posquirúrgico de movilización temprana, y así lograr excelentes resultados funcionales con una tasa baja de complicaciones. Nivel de Evidencia: IV

Background: The rupture of the extensor mechanism can have its origin at bone or tendon level. Its main cause is patellar fracture, followed by quadriceps tendon rupture, and, finally, patellar tendon rupture. These ruptures can be due to direct or indirect trauma. Tendon ruptures of the extensor mechanism are rare, developing with trauma related to the daily routine, sports, or associated systemic diseases. They represent 3% of all tendon injuries. materials and methods: We presented 22 tendon ruptures of the knee extensor mechanism, surgically treated between June 2015 and January 2019, from which eight (8) ruptures were of the quadriceps tendon (2 bilateral) and fourteen (14) of the patellar tendon (1 bilateral). The cases were evaluated using the Lysholm score, radiographs, and MRI. Results: The minimum follow-up was one (1) year. According to the results of those twenty-two (22) surgeries, thirteen (13) cases had excellent results, seven (7) cases were good and two (2) of them were fair. Conclusion: In cases of patellar tendon injury, the primary repair with transosseous suture plus figure-of-eight cerclage as augmentation provides a stable reconstruction, allowing the implementation of an early mobilization post-surgery protocol, thus achieving excellent functional outcomes with low complication levels. Level of Evidence: IV

Técnicas de extracción de clavos endomedulares retrógrados de fémur rotos. Presentación de tres casos / Retrograde femoral intramedullary nail extraction techniques. Report of three cases

Introducción: La indicación de realizar una osteosíntesis con un clavo endomedular retrógrado en las fracturas de fémur se ha incrementado en los últimos años y, con ello, la cantidad de complicaciones. Se describen tres técnicas quirúrgicas para el manejo del fragmento proximal de la osteosíntesis endomedular rota. Desde marzo de 2001 hasta enero de 2019, se realizaron 321 osteosíntesis con clavos endomedulares retrógrados de fémur en nuestra institución. La tasa de rotura del implante asociada a una seudoartrosis fue del 0,9%. Se realizaron técnicas mínimamente invasivas para la extracción del implante, preservando las partes blandas. Se logró la reosteosíntesis definitiva con la consiguiente consolidación en un tiempo medio de 140 días. Conclusiones: Las técnicas utilizadas fueron simples, seguras, mínimamente invasivas y muy reproducibles. Nivel de Evidencia: IV

background: The indication for osteosynthesis with a retrograde intramedullary nail in femur fractures has increased in recent years and with it, the number of complications. Three surgical techniques are described for the management of the proximal fragment of the broken intramedullary osteosynthesis. From March 2001 to January 2019, 321 osteosyntheses with retrograde femoral intramedullary nails were performed at our institution. The implant rupture rate associated with nonunion was 0.9%. Minimally invasive techniques were performed to remove the implant, preserving the soft tissues. Definitive reosteosynthesis was achieved with the consequent consolidation in an average time of 140 days. Conclusions: The techniques used were simple, safe, minimally invasive, and reproducible. Level of Evidence: IV

Actualización del tratamiento de las fracturas intertrocantéricas / Treatment update for intertrochanteric fractures

Las fracturas intertrocantéricas representan el 50% de todas las fracturas del fémur proximal y su incidencia aumenta debido a la mayor expectativa de vida de la población. La reducción y fijación con un clavo de fémur proximal es el tratamiento de elección. Sin embargo, la falla de la osteosíntesis genera un aumento en la morbilidad y mortalidad, especialmente en el grupo de pacientes más añosos. Numerosos estudios señalan que los principales factores predictivos de falla están relacionados con errores de reducción de la fractura o con una incorrecta colocación del implante. Estos errores pueden ocurrir en distintas etapas de la técnica quirúrgica, como la planificación preoperatoria, la ubicación del paciente, la visualización y la reducción de la fractura, la ubicación del punto de ingreso y la colocación del clavo, y el posicionamiento del elemento (tornillo o lámina) cefálico. Por lo tanto, sobre la base de la bibliografía disponible y las más de 1000 fracturas intertrocantéricas tratadas con clavos de fémur proximal desde abril de 2002 hasta mayo de 2020, nos proponemos describir los posibles errores durante la técnica quirúrgica y ofrecer una guía sistematizada para evitarlos. Conclusiones:A pesar del gran avance y desarrollo de implantes en los últimos años, los principales factores determinantes del resultado final de la fijación de las fracturas intertrocantéricas siguen siendo la calidad de la reducción y el correcto posicionamiento del implante. Conocer los diferentes errores que se pueden producir durante cada uno de los pasos de la técnica quirúrgica resulta indispensable para poder evitarlos. Nivel de Evidencia: V

Intertrochanteric fractures represent 50% of all proximal femur fractures and their incidence is increasing due to the greater life expectancy of the population. Reduction and fixation with a proximal femoral nail is the treatment of choice. However, the failure of osteosynthesis generates an increase in morbidity and mortality, especially in elderly patients. Numerous studies indicate that the main factors of failure are related to errors in fracture reduction and incorrect implant placement. These errors can occur at different stages of the surgical technique: preoperative planning; patient positioning; visualization and reduction of the fracture; location of the entry point and positioning of the cephalic element (screw or blade). Therefore, based on the existing literature and the experience of more than 1000 intertrochanteric fractures treated with proximal femoral nails from April 2002 to May 2020, we set to describe possible errors during the surgical technique and provide a systematic guide to avoid them. Conclusion: In spite of the improvements in implant design in recent years, the main factors determining the final outcome of the fixation of intertrochanteric fractures are the quality of reduction and the correct positioning of the implant. Awareness of the different errors that may occur at each stage of the surgical technique is essential to avoid them. Level of Evidence: V

Implicancia de la radiografía con tracción y rotación interna en la evaluación de las fracturas de fémur proximal / Implication of internal rotation traction radiography in proximal femoral fracture evaluation

Introducción: La correcta valoración de las radiografías cuando ingresa un paciente con una fractura de fémur proximal tiene una implicancia directa en el tratamiento propuesto. Materiales y Métodos: Se evaluó consecutivamente a 100 pacientes con diagnóstico de fractura de fémur proximal. Se tomaron radiografías de pelvis de frente, de la cadera afectada de frente y de la cadera afectada de frente con tracción y rotación interna. Se comparó la clasificación realizada por residentes con la clasificación de los médicos senior, todos utilizaron las tres radiografías para evaluar las fracturas. Resultados: El resultado global de concordancia entre la clasificación inicial de los residentes con la de los médicos senior fue del 68,9%. Cuando los médicos residentes utilizaron la radiografía con tracción y rotación interna, la concordancia aumentó al 81,5%. Cincuenta y una respuestas cambiaron con respecto a la clasificación inicial. De estas, en 42 (82,4%) casos, la clasificación inicial era incorrecta y cambió a una correcta. En 9 (17,6%) casos, la clasificación inicial era correcta y cambió a una incorrecta. Conclusiones: La radiografía con tracción y rotación interna es un estudio simple, de bajo costo y bien tolerado por el paciente que facilita la correcta interpretación de las fracturas de fémur proximal, lo que tiene un impacto directo en la indicación del tratamiento y su resultado final. Nivel de Evidencia: IV

Introduction: The correct assessment of radiographs at the time of admission of a patient with proximal femoral fracture has a direct effect on the choice of treatment. Materials and Method: We consecutively evaluated 100 patients with a diagnosis of proximal femoral fracture. Antero-posterior pelvic radiographs (A-P), A-P radiographs of the affected hip, and internal rotation traction radiographs of the affected hip were taken. A comparison was made between the classifications made by residents and the classification of senior doctors, who used the 3 radiographs to classify all fractures. Results: The overall agreement score between the initial classification of residents and that of senior doctors was 68.9%. When the resident physicians used internal rotation traction radiography, agreement increased to 78.75%. 51 responses changed with respect to the initial classification. Of these, in 42 (82.4%) cases the initial classification was incorrect and changed to a correct classification. While in 9 (17.6%) cases the initial classification was correct and changed to an incorrect one. Conclusion: Internal rotation traction radiography is a simple, low-cost study that is well-tolerated by the patient and facilitates correct interpretation of proximal femoral fractures with a direct impact on the choice of treatment and its outcome. Level of Evidence: IV