Over 50% of self-reported burnout among Latin American orthopaedic surgeons: A cross-sectional survey on prevalence and risk factors.

OBJECTIVE: Assess the prevalence of self-reported burnout and identify risk and protective factors based on demographic and life quality aspects, among Latin American orthopaedic surgeons. METHODS: This study employed a cross-sectional analytical design. An original design survey was developed using multiple-choice and Likert-scale questions to gather self-reported burnout, demographic, work-related, social, personal, and mood-related data. The survey was electronically distributed to the Chilean Orthopaedic Surgery Society and the Latin American Society of Arthroscopy, Knee Surgery, and Sports Medicine members. Statistical analysis included Chi-square and Fisher's exact tests to determine associations between self-reported burnout and other variables. Subsequently, a multivariate logistic regression was carried out to identify key risk and protective factors (p â€‹< â€‹0.05). RESULTS: The survey's response rate was 20 â€‹% (n â€‹= â€‹358) out of the 1779 invitations that were sent. The most representative age range was 41-60 years (50 â€‹%) and 94 â€‹% were men. Of those surveyed, 50 â€‹% reported a burnout episode more than once per year, 60 â€‹% depersonalization when treating patients at least yearly, 13 â€‹% anhedonia, 11 â€‹% a depressive mood more than half of the month or almost every day, and 61 â€‹% weariness at the end of a working day. Burnout was statistically associated with age under 40 years old (p â€‹= â€‹0.012), fewer years as a specialist (p â€‹= â€‹0.037), fear of lawsuits (p â€‹< â€‹0.001), a non-healthy diet (p â€‹= â€‹0.003), non-doing recreational activities (p â€‹= â€‹0.004), depersonalization when treating their patients (p â€‹< â€‹0.001), weariness (p â€‹< â€‹0.001), anhedonia (p â€‹< â€‹0.001), depressive mood (p â€‹< â€‹0.001), and career dissatisfaction (p â€‹< â€‹0.001). The logistic regression demonstrated that fear of lawsuits (p â€‹< â€‹0.001), weariness at the end of a workday (p â€‹= â€‹0.016), and anhedonia (p â€‹= â€‹0.019) were those variables with stronger direct associations with self-reported burnout. A healthy diet was the strongest protective variable (p â€‹< â€‹0.001). CONCLUSION: Over 50 â€‹% of the Latin American orthopaedic surgeons who participated in the survey reported experiencing burnout episodes more than once a year, along with depersonalization when treating their patients at least once a year. Additionally, nearly 10 â€‹% of respondents experienced weekly depressive symptoms. Among the noteworthy risk factors for self-reported burnout were fear of lawsuits, weariness at the end of the workday, and anhedonia. Conversely, maintaining a healthy diet emerged as the most potent protective factor. LEVEL OF EVIDENCE: Level III.

Early Postoperative Results in Robotic-Arm-Assisted Total Knee Replacement versus Conventional Technique: First Latin American Experience.

Early results with robotic-arm-assisted total knee arthroplasty (TKA) are encouraging; nevertheless, literature might be unrepresentative, as it comes mostly from American, European, and Asian countries. There is limited experience and no comparative clinical reports in Latin America, a region of mainly low- and middle-income countries with limited access to these promising technologies. This study aims to compare the early postoperative results of the first Latin American experience with robotic-arm-assisted TKA versus conventional TKA. A cohort study was performed, including 181 consecutive patients (195 knees) with advanced symptomatic knee osteoarthritis (OA) undergoing primary TKA between March 2016 and October 2019. The cohort included 111 consecutive patients (123 knees) undergoing conventional TKA, followed by 70 consecutive patients (72 knees) undergoing robotic-arm-assisted TKA. The same surgical team (surgeon 1 and surgeon 2) performed all procedures. Patients with previous osteotomy, posttraumatic OA, and revision components were not considered. The same anesthetic and rehabilitation protocol was followed. The investigated clinical outcomes (for the first 60 postoperative days) were: surgical tourniquet time, time to home discharge, time to ambulation, postoperative daily pain (Visual Analog Scale), opioid use, range of motion, blood loss, complications, and postoperative mechanical axis. The early clinical postoperative results of this first Latin American comparative experience of robotic-arm-assisted TKA versus conventional technique showed lower opioids requirements and faster functional recovery of ambulation in those patients operated with the robotic system; nevertheless, surgical times were higher, without differences in total postoperative complications and other clinical outcomes.

Knee Iliotibial Band Z-Plasty Lengthening and Bursectomy Technique.

Multiple surgical techniques have been described to treat refractory iliotibial band syndrome. However, there is lacking evidence demonstrating superiority of one technique over the other and limited audiovisual resources. Most surgical procedures aim to release the iliotibial band; nevertheless, few focus on reducing concomitant inflammation. The present article illustrates a Z-plasty lengthening technique associated with local bursectomy for treating iliotibial band syndrome refractory to conservative treatment.

Infecciones periprotésicas en artroplastia total de rodilla: ¿cuál es nuestra realidad? / Periprosthetic infections in total knee arthroplasty: what is our reality?

INTRODUCCIÓN La infección periprotésica (IPP) es una de las complicaciones más serias en una artroplastia total de rodilla (ATR). Pese a esto, existe poca literatura chilena respecto de esta patología. OBJETIVOS Determinar la incidencia, las comorbilidades, los microorganismos aislados y su susceptibilidad antibiótica, y la morbimortalidad en pacientes con IPP. MATERIALES Y MÉTODOS Estudio descriptivo y retrospectivo en pacientes operados entre 2001 y 2020 por gonartrosis, con una ATR primaria, en un mismo centro de salud, con al menos 1 año de seguimiento. Se excluyeron pacientes operados en otros centros o con registros clínicos incompletos. Se registraron las comorbilidades, los microorganismos aislados, la susceptibilidad antibiótica, y la sobrevida por medio de una búsqueda sistemática de las fichas clínicas de los pacientes con IPP. Se utilizó estadística descriptiva para presentar los datos. RESULTADOS Se incluyeron 544 ATRs, de las cuales 8 (1,47%) presentaron IPP, y los pacientes tenían una edad promedio de presentación de 66 (±5,7) años, e índice de masa corporal (IMC) promedio de 30,3 (±4,5) kg/m2. La mediana de tiempo de presentación de la IPP fue de 411 (±1.034) días. Las principales comorbilidades registradas fueron hipertensión arterial en 5 (62,5%), tabaquismo en 4 (50%) casos, y dislipidemia in 4 (50%) casos. En total, 5 (62,5%) pacientes presentaron etiología polimicrobiana, y en 3 (37,5%) se aisló un solo microorganismo. Los principales agentes aislados fueron Staphylococcus aureus y Staphylococcus coagulasa negativo, ambos multirresistentes, en 6 (75%) y 3 (37,5%) pacientes respectivamente. Todos los pacientes recibieron tres dosis de cefazolina como profilaxis quirúrgica. Se describe una sensibilidad del 100% frente a vancomicina y rifampicina (12/12 cultivos), y una resistencia del 83,4% al ciprofloxacino (4/9 cultivos). Un total de 2 (25%) pacientes fallecieron después de 3 años de la ATR por causas no relacionadas con la IPP. No hubo casos de recidiva infecciosa tras la revisión. CONCLUSIÓN Se encontró una incidencia de 1,47% (8 casos) de IPP. Todos los pacientes con IPP presentaron alguna comorbilidad prequirúrgica. Los principales agentes microbiológicos identificados fueron multirresistentes y susceptibles a vancomicina y rifampicina.

INTRODUCTION Periprosthetic infection (PPI) is one of the most serious complications in total knee arthroplasty (TKA). Despite this, there is little Chilean literature regarding this pathology. OBJETIVES To determine the incidence, comorbidities, isolated microorganisms and their antibiotic susceptibility, morbidity, and mortality in patients with PPI. MATERIALS AND METHODS A descriptive and retrospective study in patients operated between 2001 and 2020 for gonarthrosis, with a primary TKA, in the same health center, with at least 1 year of follow-up. Patients operated on in other centers or with incomplete clinical records were excluded. Comorbidities, isolated microorganisms, antibiotic susceptibility, and survival were recorded through a systematic search of the clinical records of patients with PPI. Descriptive statistics were used to present the data. RESULTS We included 544 TKAs, 8 (1.47%) of which presented PPI, and the patients had an average age at presentation of 66 years ( 5.7 years) and an average body mass index (BMI) of 30.3 ( 4, 5) kg/m2 . The median time of presentation of the PPI was of 411 ( 1,034) days. The main comorbidities recorded were arterial hypertension in 5 (62.5%), smoking in 4 (50%) cases, and dyslipidemia in 4 (50%) cases. In total, 5 (62.5%) patients presented polymicrobial etiology, and in 3 (37.5%), a single microorganism was isolated. The main isolated agents were Staphylococcus aureus and coagulasenegative Staphylococcus, both multidrug-resistant, in 6 (75%) and 3 (37.5%) patients respectively. All patients received three doses of cefazolin as surgical prophylaxis. A sensitivity of 100% to vancomycin and rifampicin (12/12 cultures), and a resistance of 83.4% to ciprofloxacin (4/9 cultures) were described. Overall, 2 (25%) patients died 3 years after the TKA, due to causes unrelated to PPI. There were no cases of infectious relapse after the review. CONCLUSION An incidence of 1.47% (8 cases) of PPI was found. All patients with PPI presented some presurgical comorbidity. The main microbiological agents identified were multidrug-resistant and susceptible to vancomycin and rifampicin

La fijación con tornillo de interferencia tibial cuadrante específico permite un constante desplazamiento de los injertos de tejido dentro de tuneles tibiales mal poscionados: análisis cuantitativo de ligamento cruzado anterior en porcinos / Quadrant specific tibial interference screw fixation allows constant displacement of soft tissue grafts inside misplaced tibial tunnels: a porcine anterior cruciate ligament quantitative assessment study

INTRODUCCIÓN El error técnico más común durante la reconstrucción del ligamento cruzado anterior (LCA) es la ubicación incorrecta del túnel. Es incierto si un túnel tibial mal ubicado puede corregirse en el intraoperatorio. OBJETIVO Medir el desplazamiento del injerto de tejido blando con tornillos de interferencia tibial.MATERIALES Y MÉTODOS Estudio experimental ex vivo en 28 rodillas porcinas. Se cosechó el tendón flexor de la extremidad posterior, que fue duplicado y dimensionado para que pasara a través de un túnel tibial mal posicionado. Las muestras se dividieron en 4 grupos según el cuadrante de entrada (anterior [A], posterior [P], medial [M], o lateral [L]) de un tornillo de interferencia tibial de 9 mm con relación al injerto. Se ubicó una regla milimétrica en la meseta tibial, la cual fue fotografiada con una cámara EOS T6 (Canon Inc., Ota, Tokio, Japón), y la imagen fue digitalizada, y puesta en escala a tamaño. La distancia y dirección de los desplazamientos del injerto se midieron con Adobe Photoshop CC 2019 (San José, CA, EEUU). Se analizaron las diferencias medias entre los grupos por análisis de la varianza (analysis of variance, ANOVA, en inglés) unidireccional. El análisis estadístico se realizó con el programa Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Armonk, NY, EEUU), versión 25.0 (p ≤ 0,05)).RESULTADOS La distancias medias de los desplazamientos del injerto fueron similares en todos los grupos: A ­ 4,4 mm; P ­ 4,6 mm; M ­ 4,5 mm; y L ­ 4,3 mm, sin diferencias estadísticamente significativas (p = 0,894). Las direcciones medias de los desplazamientos del injerto también fueron similares entre los 4 grupos: A ­ 176° (desviación estándar [DE]: ± 15,4°); P ­ 165° (DE: ± 16,6°); M ­ 166° (DE: ± 12,1°); y L ­ 169° (DE: ± 10,6°). No se encontraron diferencias estadísticamente significativas (p = 0.42).CONCLUSIONES Independientemente del cuadrante de entrada, se observó un desplazamiento constante del injerto hacia el lado opuesto cuando el tornillo tibial alcanzaba la superficie articular. Relevancia clínica: el tornillo tibial mal posicionado puede corregirse en el intraoperatorio con fijación proximal en cuadrante específico, y debe alcanzar la superficie articular para generar un desplazamiento efectivo del injerto. Sin embargo, no podemos predecir la magnitud de error en todos los túneles mal brocados, que debe ser evaluada caso a caso.

BACKGROUND The most common technical error during anterior cruciate ligament (ACL) reconstruction is incorrect tunnel placement. It remains unclear if a misplaced tibial tunnel may be corrected intraoperatively. AIM To measure the displacement of soft-tissue grafts with tibial interference screws. MATERIALS AND METHODS Ex-vivo experimental study in 28 porcine knees. The flexor tendon of the posterior limb was harvested, doubled and sized to fit through a 9-mm misplaced tibial tunnel. The specimens were divided into 4 groups according to the quadrant of entry (anterior [A], posterior [P], medial [M], or lateral [L]) of a 9-mm tibial interference screw in relation to the graft. A millimetric ruler was placed at the tibial plateau, which was photographed with a an EOS T6 (Canon Inc., Ota, Tokio, Japan) camera, and the image was digitalized and scaled to size. The length and direction of the graft displacements were measured with Adobe Photoshop CC 2019 (San José, CA, US). The mean differences among the groups were analyzed through one-way analysis of variance (ANOVA). The statistical analysis was performed using the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Armonk, NY, US) software, version 25.0 (p 0.05) RESULTS The mean lengths of the graft displacements were similar among the groups: A ­ 4.4 mm; P ­4.6 mm; M ­ 4.5 mm; and L ­ 4.3 mm, without statistically significant differences (p » 0.894). The mean directions of the graft displacements were also similar among the groups: A ­ 176° (standard deviation [SD]: 15.4°); P ­ 165° (SD: 16.6°); M ­ 166° (SD: 12.1°); and L ­ 169° (SD: 10.6°). No statistically significant differences were found (p » 0.42). CONCLUSIONS Regardless of the entry quadrant, constant graft displacement to the opposite side was observed when the tibial screw reached the articular surface. Clinical relevance: a misplaced tibial tunnel may be corrected intraoperatively with a quadrantspecific screw, which must reach the articular surface to produce an effective graft displacement. Nevertheless, we cannot predict the magnitude of this error in every poorly-drilled tibial tunnel; it should be assessed case by case.

Vancomycin Presoaking of the Graft Appears to Prevent Infection After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis.

Background: Vancomycin presoaking of the graft has been shown to decrease infection rates in some case series of anterior cruciate ligament (ACL) reconstruction. Purpose: We sought to substantiate the efficacy of vancomycin presoaked grafts for the prevention of infection after ACL reconstruction. Methods: We performed a systematic review of Medline and OVID to assess the incidence of postoperative infection in studies comparing patients undergoing ACL reconstruction with the use of vancomycin presoaked ACL grafts and a control group of patients undergoing ACL reconstruction without the use of presoaked grafts. The efficacy of vancomycin presoaking was calculated using the Agresti-Coull confidence interval. Relative risk (RR) was calculated for every study and the total sample. Results: The 11 studies that met inclusion criteria comprised 24,298 patients. In patients with vancomycin presoaking of the graft, 1 infection was reported in 8764 cases (0.01% rate). In the studies with control groups that did not have vancomycin presoaked grafts, there were 125 infections in 15,534 ACL reconstructions (0.8% rate). The efficacy of vancomycin presoaking in preventing infection after ACL reconstruction was 99.9% (0.999%-1.000% CI). The overall RR obtained was 0.07 (0.03-0.16 CI). All included studies were retrospective cohort studies (level III). Conclusions: Vancomycin presoaking of the graft has been shown to decrease infection rates after ACL reconstruction in studies of low evidence level. This suggests the need for prospective randomized controlled trials addressing this issue so that recommendations on the routine use of vancomycin presoaking of ACL grafts can be made with confidence.

Manejo no quirúrgico de la artrosis de rodilla: ¿Son efectivos los medicamentos orales complementarios? / Non-surgical management of knee osteoarthritis: are complementary oral medications effective?

La artrosis es una enfermedad progresiva de las articulaciones sinoviales que causa dolor, impotencia funcional, discapacidad, y degeneración progresiva de la articulación. En sus tratamientos, sobre todo en etapas tempranas, existen distintas intervenciones para evitar tanto su desarrollo y progresión como también para lograr un adecuado manejo de los síntomas, y hay tratamientos médicos orales no convencionales con evidencia controvertida. El objetivo de este trabajo es proporcionar una actualización, dirigida a especialistas en Ortopedia y Traumatología, respecto a la evidencia actual sobre las terapias complementarias orales en el tratamiento de la artrosis de rodilla. Se hace referencia a los métodos fármacológicos complementarios más usados y estudiados, mencionando el método de acción y las consecuencias estudiadas sobre la artrosis de rodilla. Se finaliza con una tabla de recomendaciones basada en evidencia actual.

Osteoarthritis (OA) is a progressive disease of the synovial joints that causes pain, functional impairment, disability, and progressive degeneration of the joint. Regarding its treatments, especially in early stages, there are different interventions to avoid its development and progression and also to achieve an adequate management of symptoms, and there are unconventional oral medical treatments with controversial evidence. The objective of the present paper is to provide an update, to specialists in Orthopedics and Traumatology, regarding the current evidence on complementary oral therapies in the treatment of knee osteoarthritis. References are made to the most widely used and studied complementary pharmacological methods, mentioning the method of action and the consequences studied on knee osteoarthritis. The article ends with a table of recommendations based on current evidence.

¿Es segura la cirugía ambulatoria de reconstrucción de ligamento cruzado anterior? experiencia a dos años de seguimiento clínico / Is outpatient reconstruction of the anterior cruciate ligament a safe procedure? experience with two years of follow up

INTRODUCIÓN: La cirugía ambulatoria permite una reducción importante del costo en procedimientos de alta prevalencia; no obstante, siempre debe resguardarse la seguridad del paciente. OBJETIVO: Evaluar las complicaciones operatorias tempranas y resultados funcionales en pacientes sometidos a reconstrucción de ligamento cruzado anterior (R-LCA) en cirugía ambulatoria. Se analiza además una estimación en la reducción de costos por programa ambulatorio. MATERIAL Y MÉTODOS: Estudio retrospectivo de pacientes sometidos a R-LCA con técnica hueso-tendón-hueso (HTH) en pabellón ambulatorio en un mismo centro, entre 2016 y 2018. Se excluyeron pacientes con menos de un año de seguimiento. Se utilizó el mismo protocolo anestésico: anestesia espinal y bloqueo sensitivo único, asociado a analgesia postoperatoria por vía oral. Se entregó a pacientes instructivo de cuidados postoperatorios, síntomas de alarma, y ejercicios de fisioterapia al alta. Se realizó encuesta telefónica al tercer día para evaluar el estado general y las complicaciones, y, al final del seguimiento, para evaluación funcional mediante las escalas de Tegner y Lysholm pre- y postquirúrgicos. Se identificaronó a pacientes no dados de alta el mismo día, consulta precoz no programada, y reintervenciones. Se realizó un análisis de costo para evaluar el ahorro por procedimiento ambulatorio versus hospitalizado. RESULTADOS: Se operaron 36 pacientes de forma ambulatoria. En 4 (11,1%) se asoció a sutura meniscal con técnica dentro-fuera. La encuesta postoperatoria inicial fue respondida por 23 pacientes (63,8%); todos presentaron buen estado general: 43% sin dolor y 57% con molestias tolerables. No hubo sangrados. La encuesta al final del seguimiento (promedio: 22,5 7,9meses) fue respondida por 20 pacientes (55,5%): la puntación en las escalas de Tegner y Lysholm aumentó significativamente, de 3 (rango: 1 a 6) a 6 (rango: 3 a 8) (p » 0,0001) y de 44 (rango: 12 a 81) a 91 (rango: 61 a 100) (p » 0,0001), respectivamente. Todos fueron dados de alta el mismo día de la operación. Hubo 2 (5,5%) consultas precoces, una por caída en domicilio con dehiscencia de herida operatoria, y otra por hematoma no complicado. Se registraron dos reintervenciones: una dehiscencia de herida operatoria y una fractura de patela. La reducción de costos por realizar el procedimiento de forma ambulatoria fue de 203.205 pesos/paciente. CONCLUSIÓN: La cirugía ambulatoria de R-LCA mediante la técnica HTH fue un procedimiento seguro en esta serie, con un manejo adecuado del dolor y resultados funcionales satisfactorios al mediano plazo. Se asoció además a una reducción en estimación de costos.

INTRODUCTION: Outpatient procedures allow for an important cost reduction in highprevalence procedures; however, patient safety must always be ensured. OBJECTIVE: To evaluate the early complications and functional scores of patients undergoing an anterior cruciate ligament reconstruction (ACLR) as an outpatient procedure. An estimated cost reduction is also analyzed. MATERIALS AND METHODS: A retrospective study of patients undergoing outpatient ACLR with a bone-patellar tendon-bone (BPTB) technique in one center between 2016 and 2018. Patients with less than one year of follow-up were excluded. All patients were submitted to the same anesthetic protocol: spinal anesthesia, a one-shot echo-guided adductor canal nerve block, and outpatient analgesics. Upon discharge, all patients received instructions regarding postoperative care, physical therapy exercises, and red flags. A telephone survey was conducted on the third day to evaluate the general conditions and complications, as well at the final follow-up, to collect pre- and postoperative Tegner and Lysholm functional scores. Patients who were not discharged on the same day, early non-scheduled visits, and re-interventions were recorded. A cost-reduction analysis was performed for the inpatient versus outpatient procedures. RESULTS: In total, 36 patients were submitted to an outpatient procedure, and 4 (11.1%) had an outside-in meniscal suture. The survey was filled out by 23 patients (63.8%); all were in good general condition: 43% reported no pain and 57%, tolerable pain. No bleeding was observed. The survey at the end of the follow-up (average: 22.5 7.9 months) was filled out by 20 patients (55.5%); the scores on the Tegner and Lysholm scales improved significantly, from 3 (range: 1 to 6) to 6 (range: 3 to 8) (p » 0.0001), and from 44 (range: 12 to 81) to 91 (61 to 100) (p » 0.0001) respectively. All patients were discharged on the same day of surgery. There were 2 (5.5%) early visits, one due to a fall at home withdehiscence of the surgical wound, and one due to a non-complicated hematoma. Two re-interventions at the end of the follow-up were recorded: traumatic surgical-wound dehiscence and a patellar fracture. The cost reduction for the outpatient procedure was of 203, 205 pesos per patient CONCLUSION: The outpatient ACLR with the BPTB technique was a safe procedure in the present series, with adequate pain management and satisfactory functional scores at the medium-term follow-up. It was also associated with a reduction in cost estimates.

There is direct relationship between bone bridge length and coracoclavicular fixation resistance to failure: Biomechanical study in a porcine model.

BACKGROUND: This study aims to evaluate the relation between coracoclavicular resistance to failure and the distance between clavicular tunnels. The hypothesis is that a greater clavicular bone bridge between tunnels achieves a stronger coracoclavicular fixation. METHODS: Descriptive Laboratory Study. Thirty-six (36) coracoclavicular models were constructed utilizing porcine metatarsals. Coracoclavicular stabilizations were performed using a subcoracoid loop fixation configuration through two clavicular tunnels, tied at the clavicle's superior cortex using a locking knot. Models were randomly assigned to 1 of 3 experimental groups of variable bone bridge length between clavicular tunnels: 5 mm, 10 mm, and 15 mm. Each group had 12 models. Fixation resistance was assessed through the ultimate failure point under an axial load to failure trial. Failure patterns were documented. A one-way ANOVA test was used, and a Tukey post hoc as needed (P < 0.05). FINDINGS: Mean strength per bone bridge length: 5 mm = 312 N (Range: 182-442 N); 10 mm = 430 N (Range: 368-595 N); 15 mm = 595 N (Range: 441-978 N). The 15 mm group had a significantly higher ultimate failure point than the other two groups: 5 mm (P < 0.001) and 10 mm (P < 0.001). All fixations systematically failed by a superior cortex clavicle fracture at the midpoint between tunnels. INTERPRETATION: A direct relationship between bone bridge length and coracoclavicular resistance to failure was demonstrated, being the 15 mm length a significantly higher strength construct in a tied loop model.

Vancomycin presoaking of hamstring autografts to prevent infection in anterior cruciate ligament reconstruction: a narrative review.

Hamstring autograft use has been linked to an increased risk of infection after anterior cruciate (ACL) reconstruction compared to other grafts. The absolute reason for this remains unclear, with contamination after harvesting and preparation of the graft being the most accepted hypothesis.Using the rationale that a contaminated graft could be the main factor in postoperative septic arthritis and in an effort to maximize the antibiotic efficacy of the graft, the Vancomycin presoaking technique was developed. It has shown success in decreasing the infection rate in ACL reconstruction. In recent years, an important number of research articles using this protocol have appeared, but the technique is still not widely implemented.Recent literature shows that Vancomycin presoaking of the graft has shown a successful decrease in the infection rate after hamstring autograft ACL reconstruction. It has also shown efficacy decreasing the infection rate in other types of grafts (patellar tendon, quadriceps tendon, allograft) and also in patients with concomitant ligament procedures or open surgeries.Despite the positive effects of Vancomycin presoaking reducing the infection rate after ACL reconstruction, the lack of prospective randomized control trials and the heterogeneity of the different studies mean it is not feasible to recommend Vancomycin presoaking of the graft universally for every ACL reconstruction patient. Cite this article: EFORT Open Rev 2021;6:211-216. DOI: 10.1302/2058-5241.6.200059.

Meniscal polyurethane scaffold plus cartilage repair in post meniscectomy syndrome patients without malalignment improves clinical outcomes at mid-term follow-up.

BACKGROUND: The aim of this study is to report the mid-term follow-up results of a prospective cohort of patients who underwent a polyurethane (PU) meniscal scaffold implantation for post meniscectomy syndrome (PMS), without limb realignment procedures. METHODS: Prospective study in patients with PU meniscal scaffolds implanted during 2014-2016. Limb realignment procedures excluded. Clinical outcomes were prospectively evaluated pre-operatively and every year post-operatively using patient-reported outcome scores (KOOS, VAS, Lysholm and IKDC). Post-operative radiologic evaluation was done using 3.0 T magnetic resonance imaging (MRI). Meniscal scaffold extrusion, signal intensity, tibio-femoral cartilage degeneration progression and complications were analyzed. RESULTS: Fourteen patients with an average age of 25.8 years (range: 17-47) received a PU scaffold (8 lateral and 6 medial). Associated procedures were done in all patients, with an osteochondral allograft transplantation (OAT) being the most common. Mean follow up was 51.6 (range: 39-66) months. Post-operative mean clinical outcomes scores showed significantly improved results compared to the pre-operative scores. Lysholm scores increased from 62.4 to 80.2 (P = 0.0023), KOOS from 68.9 to 80 (P = 0.0083) and VAS for pain decreased from 5.3 to 3.1 (P = 0.0024). Average post-operative IKDC score was 67.7. There were 8 cases of complete extrusion (>3 mm). The mean extrusion value was 4.0 mm (range: 3-6 mm). Three patients showed signs of a ruptured meniscal scaffold. One patient showed progression of the cartilage degenerative process. CONCLUSION: The use of a PU scaffold, associated with other surgical procedures in the knee, especially chondral repair, had a significant improvement in clinical outcomes compared to the baseline status, at an average of 51.6 months follow-up in patients suffering from PMS. Although imaging results show a high proportion of implant extrusion, this does not appear to imply a worsening in clinical outcomes in the short term. LEVEL OF EVIDENCE: IV. Case series.

Factores determinantes del rango de movimiento postoperatorio en artroplastia total de rodilla primaria / Identify determinants for postoperative range of motion after primary total knee arthroplasty

Introducción: El objetivo de este trabajo es describir e identificar variables determinantes de la progresión del rango de movilidad articular (RMA) postoperatorio en artroplastia total de rodilla primaria (ATRp). Materiales y métodos: estudio prospectivo de pacientes con gonartrosis, operados de ATRp por un mismo equipo quirúrgico, implante y protocolo de rehabilitación. Se excluyeron pacientes con seguimiento menor a seis meses. Se midió el RMA (extensión-flexión) preoperatorio, durante la hospitalización y al primer, tercer y sexto mes postoperatorio. Se definió RMA funcional y satisfactorio como 5-95º y 0-120º, respectivamente. El análisis estadístico incluyó modelos mixtos, buscando relación entre la progresión del RMA postoperatorio y variables demográficas, pre, intra y postoperatorias externas a la técnica quirúrgica (p < 0.05).Resultados: cincuenta pacientes (53 ATRp), edad mediana 68 (49-91), 75.5% mujeres. Al sexto mes, el 100% presentó un RMA funcional y un 72.2% un RMA satisfactorio. Un umbral de 105º de flexión al tercer mes fue significativo para discriminar aquellos pacientes que alcanzaron un RMA favorable al sexto mes (sensibilidad = 97.1%; especificidad = 75%). Conclusión: la progresión del RMA postoperatorio de ATRp fue determinante del RMA satisfactorio (0-120º) a los seis meses. Un umbral de 105º de flexión al tercer mes postoperatorio posee una excelente capacidad de identificar aquellos pacientes que no lograrán el RMA apropiado. Nivel de Evidencia: Estudio pronóstico Nivel I

Introduction: This study aims to describe and identify determinants for the postoperative RMA progression after a primary total knee arthroplasty (pTKA).Materials and methods: prospective study in patients with knee osteoarthritis who underwent pTKA. Patients were operated by the same surgical team, implant, and followed the same rehabilitation protocol. Exclusion criteria included a follow-up of less than six months. The RMA (extension-flexion) was evaluated preoperatively, during the hospital stay, and postoperatively (first, third and sixth months). Functional and satisfactory RMA were established as 5-95º and 0-120º, respectively. Statistical analysis included mixed models for association between postoperative RMA and demographic, pre, intra, and postoperative non-related surgical technique variables (p < 0.05).Results: fifty patients (53 pTKA), median age 68 (49-91), 75.5% females. At six months, 100% of patients presented with functional RMA, and 72.2% with satisfactory RMA. A threshold of 105º of flexion at the third postoperative month, was statistically significant for identifying patients who achieved an acceptable RMA at six months (sensitivity = 97.1%; specificity = 75%).Conclusions: the postoperative RMA progression was determinant for a satisfactory RMA at six months after pTKA. A threshold of 105º of flexion at the third postoperative month has an excellent accuracy to identify patients who will not achieve an acceptable RMA. Level of Evidence: Prognostic study Level I

Is the Clinician's Eye a Valid and Reproducible Tool for Diagnosing Patella Alta on a Lateral Knee Radiography?

INTRODUCTION: Validity and reproducibility of the clinician's eye (CE) to diagnose patella alta (PA) on a lateral knee radiography (radiograph) is unknown. METHODS: Cross-sectional study of 46 lateral knee x-rays. Three blind observers used CE, Insall-Salvati (IS), modified Insall-Salvati (mIS), and Caton-Deschamps (C-D) to determine patellar height. Sensitivity and specificity of each observer was compared with the musculoskeletal radiologist's C-D measurements. Intraobserver and interobserver agreement were assessed with intraclass correlation coefficient and Fleiss κ, respectively. Time needed to estimate patellar height for every method was recorded in seconds. Statistical differences between observers were calculated with a generalized estimating equation. Analysis of variance and post hoc Bonferroni test compared duration of each method (P < 0.05). Data were analyzed using Stata 15 (StataCorp). RESULTS: CE, IS, mIS, and C-D's sensitivity and specificity values are as follows: 77%, 92%; 94%, 52%; 67%, 58%; and 53%, 89%, respectively. Intraclass correlation coefficient and Fleiss κ of CE, IS, mIS, and C-D values are as follows: 0.66 and 0.43, 0.88 and 0.68, 0.54 and 0.09, and 0.68 and 0.59, respectively. CE was the second most sensitive and most specific method for diagnosis of PA, with moderate intraobserver and interobserver agreement. IS was the most sensitive method with good intraobserver and interobserver agreement. CE was significantly faster (P < 0.05) than all other conventional radiographic ratios. CONCLUSION: CE's sensitivity increases with observer's experience and is highly specific. If normal patellar height is diagnosed, no other ratios are necessary, even in the less experienced clinician. Intraobserver and interobserver reproducibilities were moderate and only inferior to the IS ratio. In case patellar height is uncertain with the CE, the IS ratio is the most sensitive and reproducible method to confirm the diagnosis of PA.

High-Grade Patellar Chondral Defects: Promising Results From Management With Osteochondral Autografts.

BACKGROUND: Patellar chondral defects represent up to 34.6% of defects found during routine arthroscopy. Surgical management has evolved during the past 20 years in an effort to develop techniques to replace hyaline cartilage. Currently, the only technique that achieves this is osteochondral autologous transfer (OAT). Although good and excellent results have often been reported at midterm and long-term follow-up for femoral lesions, little is known about isolated patellar defects. PURPOSE: To assess clinical and imaging results of patients treated with OAT for high-grade patellar defects. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This was a retrospective study on all patients who received OAT for high-grade symptomatic patellar chondral defects between 2010 and 2018 at our institution. The study included patients younger than 40 years of age with anterior knee pain and a grade 4 International Cartilage Repair Society patellar chondral defect between 1 and 2.5 cm2. Patients with surgery in other knee compartments, concomitant anterior cruciate ligament ruptures, infection, rheumatoid arthritis, and degenerative lesions were excluded. Six months postoperatively, all patients underwent magnetic resonance imaging (MRI) to allow assessment of graft integrity via the MOCART (Magnetic Resonance Observation of Cartilage Repair Tissue) score to evaluate morphologic features and integration. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Kujala scores were used to assess functional outcomes at final follow-up. RESULTS: A total of 26 patients who received a patellar OAT were included. Most patients were male (88.4%), and the mean ± SD age was 28.5 ± 9.7 years. Patellar chondral defects had a median size of 180 mm2 (range, 64-250 mm2), and patients received a median of 1 autograft (range, 1-3). Functional outcomes assessed at a minimum of 1 year after surgery showed a mean Kujala score of 90.42 ± 6.7 and a mean WOMAC score of 95 ± 3.6. MRI revealed a median MOCART score of 75 points (range, 20-90 points). CONCLUSION: To our knowledge, this is the largest series to date regarding isolated patellar OAT. At midterm follow-up, most patients reported good and excellent results regarding symptoms and activity levels. Most autografts showed good osseous integration and excellent filling of the chondral surface, as evidenced on MRI. OAT is a good alternative to treat high-grade patellar chondral defects, especially among young patients.

Graft choice in combined anterior cruciate ligament and medial collateral ligament reconstruction.

There is a concern regarding which grafts should be used in combined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) reconstructions, with a paucity of recommendations focused on this specific topic.Expert opinions suggest the use of allograft-only reconstructions to limit donor-site morbidity or using at least one allograft and one autograft.When a hamstring tendon autograft is harvested, techniques that maintain both the integrity of the sartorius fascia and the gracilis are recommended because of the role that the ST-G-S (semitendinosus-gracilis-sartorius) complex plays in valgus stability in the setting of an MCL-deficient knee. Cite this article: EFORT Open Rev 2020;5:221-225. DOI: 10.1302/2058-5241.5.190049.

Trends in Total Knee Arthroplasty in a Developing Region: A Survey of Latin American Orthopaedic Surgeons.

INTRODUCTION: A number of different total knee arthroplasty techniques are available. There is also a degree of surgeon preference for these, and the variation across orthopaedic surgeons in Latin America is currently unknown. METHODS: A survey on members of Sociedad Latinoamericana de Artroscopia, Rodilla y Deporte was performed, with questions based on categories within worldwide national joint registries. In total, 315 Sociedad Latinoamericana de Artroscopia, Rodilla y Deporte members received the survey via e-mail, and the return answers were compared with the latest worldwide national joint registry annual reports. RESULTS: The survey was completed in full by 262 surgeons (83%). It was answered that 19% of surgeons perform less than 10 total knee arthroplasties per year, 54% perform less than 30, and only 9% perform more than 100. Seventy-three percent of surgeons use a posterior stabilized total knee replacement, 18% use a cruciate retaining total knee replacement, and 9% use a medial pivot design. Forty-nine percent of surgeons resurface the patella, 27% never resurface it, and 24% choose to resurface it based on an individual case scenario. Ninety-eight percent of surgeons use cemented fixation in the femur and tibia, with the remaining 2% choosing hybrid fixation and 1% using fully noncemented fixation. CONCLUSION: This survey among Latin American surgeons has demonstrated important differences in surgical technique and implants choice compared with worldwide national registries.

Medial side knee injuries: simplifying the controversies: current concepts.

Injuries to the medial side of the knee (MSK) are the most common knee ligament lesions. Historically, these injuries have been treated conservatively; however, a better understanding of the anatomy and biomechanics of the different structures of the MSK have resulted in diverse and controversial opinions about the ideal management of these lesions. A cautious analysis should be done in nomenclature because the same surgical technique principles have been differently named in the literature. The diagnostic process of MSK injuries must involve a critical thinking process to precise those lesions that imply an imminent risk of healing failure. This review article provides an evidence and clinical-based clarification of the controversies regarding injuries to the MSK and proposes an evidence-based algorithm for their management.

Burnout y calidad de vida en traumatólogos chilenos: ¿Estamos realmente bien? / Burnout and Quality of Life in Chilean Orthopaedic Surgeons: Are we doing ok?

INTRODUCCIÓN No existen reportes sobre el índice de burnout en traumatólogos que ejercen en Chile. OBJETIVO Evaluar la presencia de burnout y otros aspectos de calidad de vida en esa población. MATERIAL Y MÉTODO Estudio transversal analítico. Encuesta diseñada para conocer el auto-reporte de burnout y síntomas depresivos entre otros factores. Se incluyeron variables demográficas, laborales, sociales, hábitos personales y anímicas. La encuesta fue compartida vía online a miembros de la Sociedad Chilena de Ortopedia y Traumatología. Se realizó análisis estadístico para buscar asociación entre variables, utilizando pruebas de Chi-cuadrado, test exacto de Fisher y regresión logística (p < 0,05). RESULTADOS Encuesta respondida por 136 especialistas. Rango etario modal menor de 40 años (46,3%), 94,1% hombres. Un 53,7% reportó burnout más de una vez al año, 11% anhedonia, 9,6% ánimo depresivo más de la mitad del mes o casi todos los días y 59,6% cansancio diario. Se encontró asociación significativa entre burnout y edad menor de 40 años (p = 0,004), ausencia de hijos (p = 0,007), dieta no saludable (p = 0,001), anhedonia (p = 0,007), temor a demandas (p < 0,001) y cansancio (p < 0,003). CONCLUSIÓN Más de la mitad de los traumatólogos encuestados reportaron burnout más de una vez al año y cerca del 10% presentan síntomas depresivos semanalmente. Una edad menor a 40 años, anhedonia, el temor a demandas laborales y el cansancio al final de la jornada, fueron las variables de mayor impacto en la manifestación del burnout. La presencia de hijos y una dieta saludable fueron factores protectores.

INTRODUCTION There are no reports regarding the burnout index in Orthopaedic Surgeons in Chile. OBJECTIVE Assess the presence of burnout and other life quality aspects of this population. MATERIAL AND METHODS Cross-Sectional analytical study. An originally designed survey was used to identify the self-report on burnout and depressive symptoms, amongst other factors. Demographic, work-related, social, personal habits, and mood-related variables were included. The survey was distributed by email to members of the Chilean Orthopaedic Surgery Society. Statistical analysis was conducted to determine the association between variables through the Chi-square test, Fisher's exact test, and logistic regressions (p < 0.05). RESULTS The survey was answered by 136 orthopaedic surgeons. The modal age range was less than 40 years (46.3%), and 94.1% were men. Of those surveyed, 53.7% reported a burnout episode more than once per year, 11% anhedonia, 9.6% a depressive mood more than half of the month or almost every day, and 59.6% of chronic fatigue. Statistical analysis showed a significant association between burnout and age under 40 years old (p = 0.004), not having children (p = 0.007), a non-healthy diet (p = 0.001), anhedonia (p = 0.007), fear of lawsuits (p < 0.001) and fatigue (p < 0.003). CONCLUSION More than half of the surveyed orthopaedic surgeons reported episodes of burnout more than once per year, and near 10% referred to have experienced weekly depressive symptoms. Age under 40 years, anhedonia, fear of lawsuits, and fatigue were the variables of more significant impact over the self-report of burnout. Having children and a healthy diet resulted in protective factors.

Artroplastía total de rodilla con asistencia de brazo-robótico: resultados clínicos postoperatorios tempranos / Robotic arm-assisted total knee arthroplasty: early postoperative results

OBJETIVO: Describir los resultados clínicos postoperatorios tempranos de la primera serie de pacientes operados de artroplastía total de rodilla (ATR) con asistencia de brazo-robótico en Latinoamérica. MATERIALES Y MÉTODOS: Estudio prospectivo de 52 pacientes (53 rodillas) con gonartoris tricompartimental sintomática operados de ATR primaria con asistencia de brazo-robótico (RIO-MAKO) de manera consecutiva, con seguimiento a 2 meses postoperados. No se excluyeron pacientes. Se utilizó el mismo protocolo anestésico y de rehabilitación. Se realizó revisión de fichas clínicas para recolectar los siguientes resultados: tiempo de isquemia quirúrgica, estadía hospitalaria, tiempo a marcha, dolor postoperatorio diario [Escala visual análoga (EVA)], uso de opioides, rangos de movilidad articular (ROM), pérdida sanguínea, complicaciones y eje mecánico postoperatorio. RESULTADOS: Tiempos de Isquemia: 82 minutos (60­120). Estadía Hospitalaria: 4 días (2­12). Dolor postoperatorio: EVA el mismo día operatorio de 0 (0­10) y previa al alta de 0 (rango 0­4), con 0,3 purgas (0­6,5) de opioides por paciente. Tiempo a marcha (día logrado): 1 día (1­3), cuarenta y cinco pacientes (84,9%) iniciaron la marcha el primer día postoperatorio. ROM (Extensión-Flexión): Aumento progresivo durante el seguimiento. En el control ambulatorio de los dos primeros meses [23 días (13­50)], veintiún pacientes (40%) alcanzaron un ROM mayor o igual a 0­90° y once (20%) presentaron un ROM funcional máximo (0­120°). Pérdida sanguínea: Siete pacientes (13,2%) requirieron transfusión. Complicaciones: un paciente (1,89%) presentó una dehiscencia del cierre de la artrotomía. No hubo otras complicaciones. Eje mecánico postoperatorio: 179,1° (178,2­180). DISCUSIÓN: Los resultados concuerdan con la evidencia descrita en otras regiones, sugiriendo que la asistencia de brazo-robótico permite resultados postquirúrgicos reproducibles. CONCLUSIÓN: Los resultados clínicos postoperatorios tempranos de esta serie de pacientes operados de ATR con asistencia de brazo-robótico, muestran una baja percepción del dolor, con bajo consumo de opioides, una rápida recuperación funcional de la marcha y ROM, y excelentes resultados desde el punto de vista del eje mecánico postoperatorio. NIVEL DE EVIDENCIA: IV.

OBJECTIVE: Describe the early clinical postoperative outcomes, of the first series of patients operated on Robotic Arm-Assisted Total Knee Arthroplasty (TKA) in Latin America. MATERIAL AND METHOD: Retrospective study including 52 patients (53 knees) with advanced symptomatic knee osteoarthritis, consecutively operated on Robotic ArmAssisted TKA (RIO-MAKO) during October 2018 and May 2019 with two months of follow-up. No patients were excluded from the study. The same anesthetic and rehabilitation protocol was followed for all patients. Data were obtained from the clinical files for the following outcomes: Surgical tourniquet time, hospital stay, time to walk, postoperative daily pain [Visual Analog Scale (VAS)], opioid consumption, range of motion (ROM), blood loss, complications, and the attained postoperative mechanical axis. RESULTS: Tourniquet Time: 82 minutes (60­120). Hospital Stay: 4 days (2­12). Postoperative Pain: VAS of 0 (0­10) the same day of surgery, and 0 (0­4) before discharge. The opioid consumption was 0,3 purge (0­6,5) per patient. Time to Walk (Day achieved): 1st day (1­3), forty-five patients (84,9%) walked on their first postoperative day. ROM (Extension-Flexion): progressively increases during the follow up. On the first two-month visits [23 days (13­50)], twenty-one patients (40%) reached a ROM equal or superior to 0­90°, and eleven (20%) presented a maximal functional ROM (0­120°). Blood Loss: Seven patients (13.2%) required a blood transfusion. Complications: one patient (1.89%) presented dehiscence of the arthrotomy closure. No other complications were registered. Postoperative Mechanical Axis: 179.1° (178.2­180). DISCUSSION: The results coincide with the reported evidence from other regions. Robotic-arm assistance may generate reproducible postoperative results. CONCLUSIONS: The early postoperative clinical results of this series of patients operated on Robotic Arm-Assisted TKA show a low pain perception and opioid use, a rapid functional rehabilitation in terms of gait and ROM, and excellent postoperative mechanical alignment. LEVEL OF EVIDENCE: IV.