Reconstruction of bone defects around the ankle with retrograde gentamicin-coated tibial intramedullary nail (ETN PROtect™) for tibiotalocalcaneal arthrodesis: a case series.

PURPOSE: The objective of this study was to describe the use of retrograde gentamicin-coated tibial intramedullary nail (ETN PROtect™) in patients with tibial defects who required a tibiotalocalcaneal arthrodesis (TTC). METHODS: Consecutive series case review of seven men treated with TTC using retrograde PROtect™ between January 2018 and December 2023. The main outcomes evaluated were fracture union, complications, and the health-related quality of life using the EuroQol five-dimension three-level questionnaire (EQ-5D-3L). RESULTS: The mean age was 45.3 ± 8.0 years. Six patients had a clinical history of chronic osteomyelitis, and one case underwent TTC for congenital pseudoarthrosis. Fracture union was achieved in 5 of 7 patients between 4 and 11 months after surgery. Three patients developed complications; two patients had fistulas, and one had persistent pain. At the end of the follow-up, a median of 70 points (interquartile range: 60 to 90) on the EQ-5D-3L was reported. No complications directly attributed to the use of the PROtect™ were reported. CONCLUSION: TTC with retrograde PROtect™ is a prophylactic treatment option in patients with tibial defects treated with external fixation requiring a tibiotalar and subtalar arthrodesis. This novel use of PROtect™ allows simultaneous fixation of the tibiotalocalcaneal joint and protection of the regenerated bone, facilitating earlier rehabilitation in patients at high risk for postoperative infections.

[Functional evaluation and quality of life in the follow-up of patients with Charcot arthropathy treated by ankle arthrodesis with a locked retrograde nail]. / Evaluación funcional y de calidad de vida en el seguimiento de pacientes con artropatía de Charcot tratados mediante artrodesis de tobillo con clavo centromedular retrógrado bloqueado.

INTRODUCTION: Charcot's arthropathy is a disabling non-infectious, progressive condition characterized by bony and articular destruction in patients with sensory neuropathy. In advanced cases with deformities and ankle instability, it requires a more invasive treatment as an ankle fusion with a retrograde locked intramedullary nail. It is unknown if, in these patients, the functional results of AOFAS (American Orthopaedic Foot and Ankle Society) correlate with the quality of life ones from the EuroQol-5D test and the possible postoperative complications. MATERIAL AND METHODS: the design is experimental, longitudinal prospective with ambispective data analysis (retrospective and prospective) to evaluate the functional results and life quality with a year of following patients with Charcot's arthropathy diagnosis treated with a retrograde locked nail from January 1, 2010, to November 1, 2018. RESULTS: this study resulted in complete consolidation from nine out of 11 cases, with a success rate of 81.2%, and only two cases (18.2%) developed nonunion. AOFAS and EuroQol-5D tests correlate positively in agreement with the Pearson correlation. CONCLUSIONS: AOFAS and EuroQol-5D correlate positively, having a 45 and 63% of acceptable and satisfactory results, respectively, for both tests.

INTRODUCCIÓN: la artropatía de Charcot es una condición incapacitante, no infecciosa, progresiva, que se caracteriza por destrucción ósea y articular en pacientes con neuropatía sensorial. En casos avanzados, en los que se tiene deformidad severa e inestabilidad de tobillo, se requieren procedimientos más invasivos como la artrodesis de tobillo con clavo centromedular retrógrado bloqueado. Se desconoce si en estos pacientes las puntuaciones de la valoración funcional postquirúrgica con la escala de AOFAS (American Orthopaedic Foot and Ankle Society) correlaciona con las puntuaciones de la escala de calidad de vida medida con el test EuroQol-5D y las posibles complicaciones postquirúrgicas. MATERIAL Y MÉTODOS: se trata de un ensayo autocontrolado de práctica clínica habitual, cuasiexperimental, longitudinal y prospectivo con recolección ambispectiva (retrospectiva y prospectiva) de datos para evaluar los resultados funcionales y de calidad de vida a un año de seguimiento de los pacientes con artropatía de Charcot tratados mediante artrodesis de tobillo con clavo centromedular retrógrado bloqueado del 1 de Enero de 2010 al 1 de Noviembre de 2018. RESULTADOS: la consolidación se logró en nueve casos de un total de 11 pacientes para una tasa de éxitos de 81.8% y únicamente dos casos (18.2%) en los cuales no se observó consolidación. Las escalas de AOFAS y EuroQol-5D se correlacionaron positivamente de acuerdo con la correlación de Pearson. CONCLUSIONES: las escalas de AOFAS y EuroQol-5D se correlacionan positivamente, obteniéndose 45 y 63% con resultados aceptables y satisfactorios respectivamente en ambas escalas.

Tibiotalocalcaneal Arthrodesis: A Retrospective Comparison Between Nails and Lateral Locking Plate Complications.

Background: Tibiotalocalcaneal arthrodesis is a well-established procedure to treat some hindfoot diseases. Currently, the most used implants are retrograde intramedullary nails and locking plates combined with lag screws, but there are few articles comparing differences regarding the complications. Methods: We have retrospectively analyzed the medical records and the radiographs of patients older than 18 years who underwent this procedure in our service between 2005 and 2019 through retrograde intramedullary nails or lateral locking plates and compression screws with at least 12 months of follow-up and with no history of osteomyelitis in these bones. Results: We evaluated a total of 67 patients; of these, 48 received retrograde intramedullary nail implants and 19 received locking plates and compression screws. The overall mean age was 48 years; the median follow-up time was 64.3 months. The complication rate was 60.4% for the intramedullary nail procedure and 52.6% for the locking plate combined with compression screws procedure. Conclusion: No significant differences were found in the complication rates between the 2 implants. Level of Evidence: Level V, Case series.

Tratamiento de la fractura diafisaria de húmero con clavo intramedular "Telegraph®"

Introducción: El enclavado intramedular acerrojado por vía anterógrada es uno de los métodos quirúrgicos para el tratamiento de la fractura diafisaria de húmero y tiene como ventaja ser una técnica por mínimo acceso. Objetivo: Evaluar los resultados del tratamiento de la fractura diafisaria de húmero con el clavo intramedular acerrojado anterógrado "Telegraph®". Métodos: Se realizó un estudio prospectivo, longitudinal y descriptivo en 16 pacientes con fractura diafisaria de húmero; intervenidos quirúrgicamente con el sistema intramedular "Telegraph®" en el Hospital Ortopédico Docente "Fructuoso Rodríguez". Se evaluaron los resultados según la escala QuickDASH. Resultados: Predominaron los pacientes entre 40 y 60 años y del sexo femenino. El tiempo medio de seguimiento estuvo entre 27,25 ± 4,5 meses. El tipo de fractura A2a (trazo simple, oblicuo, del tercio medio) fue la más frecuente. Hubo pocas complicaciones y no afectaron el resultado final. A los 6 meses de la operación, el 75 % de los pacientes presentó un grado de dificultad nulo o incipiente. Conclusiones: Con el uso del clavo intramedular acerrojado "Telegraph®" se obtienen resultados funcionales satisfactorios por lo que constituye una opción válida de tratamiento.

Introduction: Locked intramedullary nailing by antegrade approach is one of the surgical methods for the treatment of humeral diaphyseal fracture and has the advantage of being a minimal access technique. Objective: To evaluate the results of the treatment of the diaphyseal fracture of the humerus with the Telegraph® antegrade locked intramedullary nail. Methods: A prospective, longitudinal, descriptive study was carried out in 16 patients with diaphyseal fracture of the humerus; underwent surgery with the Telegraph® intramedullary system at Fructuoso Rodríguez Orthopedic Hospital. The results were evaluated according to the QuickDASH scale. Results: There was a predominance of patients between 40 and 60 years of age and of the female sex. The mean follow-up time was 27.25 ± 4.5 months. The type of A2a fracture (simple, oblique line, of the middle third) was the most frequent. There were few complications and they did not affect the final result. Six months after the operation, 75% of the patients had no or incipient degree of difficulty. Conclusions: The use of Telegraph® locked intramedullary nail, satisfactory functional results are obtained, establishing a valid treatment option.

Evaluación funcional y de calidad de vida en el seguimiento de pacientes con artropatía de Charcot tratados mediante artrodesis de tobillo con clavo centromedular retrógrado bloqueado / Functional evaluation and quality of life in the follow-up of patients with Charcot arthropathy treated by ankle arthrodesis with a locked retrograde nail

Resumen: Introducción: la artropatía de Charcot es una condición incapacitante, no infecciosa, progresiva, que se caracteriza por destrucción ósea y articular en pacientes con neuropatía sensorial. En casos avanzados, en los que se tiene deformidad severa e inestabilidad de tobillo, se requieren procedimientos más invasivos como la artrodesis de tobillo con clavo centromedular retrógrado bloqueado. Se desconoce si en estos pacientes las puntuaciones de la valoración funcional postquirúrgica con la escala de AOFAS (American Orthopaedic Foot and Ankle Society) correlaciona con las puntuaciones de la escala de calidad de vida medida con el test EuroQol-5D y las posibles complicaciones postquirúrgicas. Material y métodos: se trata de un ensayo autocontrolado de práctica clínica habitual, cuasiexperimental, longitudinal y prospectivo con recolección ambispectiva (retrospectiva y prospectiva) de datos para evaluar los resultados funcionales y de calidad de vida a un año de seguimiento de los pacientes con artropatía de Charcot tratados mediante artrodesis de tobillo con clavo centromedular retrógrado bloqueado del 1 de Enero de 2010 al 1 de Noviembre de 2018. Resultados: la consolidación se logró en nueve casos de un total de 11 pacientes para una tasa de éxitos de 81.8% y únicamente dos casos (18.2%) en los cuales no se observó consolidación. Las escalas de AOFAS y EuroQol-5D se correlacionaron positivamente de acuerdo con la correlación de Pearson. Conclusiones: las escalas de AOFAS y EuroQol-5D se correlacionan positivamente, obteniéndose 45 y 63% con resultados aceptables y satisfactorios respectivamente en ambas escalas.

Abstract: Introduction: Charcot's arthropathy is a disabling non-infectious, progressive condition characterized by bony and articular destruction in patients with sensory neuropathy. In advanced cases with deformities and ankle instability, it requires a more invasive treatment as an ankle fusion with a retrograde locked intramedullary nail. It is unknown if, in these patients, the functional results of AOFAS (American Orthopaedic Foot and Ankle Society) correlate with the quality of life ones from the EuroQol-5D test and the possible postoperative complications. Material and methods: the design is experimental, longitudinal prospective with ambispective data analysis (retrospective and prospective) to evaluate the functional results and life quality with a year of following patients with Charcot's arthropathy diagnosis treated with a retrograde locked nail from January 1, 2010, to November 1, 2018. Results: this study resulted in complete consolidation from nine out of 11 cases, with a success rate of 81.2%, and only two cases (18.2%) developed nonunion. AOFAS and EuroQol-5D tests correlate positively in agreement with the Pearson correlation. Conclusions: AOFAS and EuroQol-5D correlate positively, having a 45 and 63% of acceptable and satisfactory results, respectively, for both tests.

[First case series of femoral lengthening using a Precice® intramedullary nail in our center]. / Primera serie de casos de alargamiento femoral mediante clavo intramedular Precice® en nuestro centro.

INTRODUCTION: femoral lengthening using an intramedullary nail is one of the surgical options in the treatment of severe lower limb dysmetria in routine clinical practice. MATERIAL AND METHODS: a retrospective descriptive study was carried out on a series of five patients with a mean age of 15.4 years, who underwent femoral lengthening surgery using a Precice® intramedullary nail. The etiology in all cases was idiopathic. Preoperative and definitive postoperative theoretical lengthening or dysmetry was measured, as well as lengthening accuracy, distraction rate and index (mm/day and days/cm, respectively) and consolidation index (days/cm). Intraoperative and postoperative complications were identified in all cases. RESULTS: mean follow-up was 21 months (12-42), with no loss to follow-up. The mean duration of the surgical procedure was 126 minutes (105-160). The preoperative theoretical dysmetry was 38 ± 2.7 mm. The final mean lengthening was 41 ± 7.5 mm. The mean accuracy was 108% (91-125) and the distraction rate was 0.9 ± 0.4 mm/day. The distraction rate was 13.9 ± 5.1 days/cm and the consolidation rate was 26.6 ± 9.1 days/cm. Bone consolidation was observed in all patients with a mean of 113 ± 58 days. Regarding complications, a total of four minor muscular complications were found. CONCLUSION: the Precice® intramedullary nail is a good treatment option for cases of severe femoral shortening, providing good clinical and radiological results with a low rate of complications and implant failure.

INTRODUCCIÓN: el alargamiento femoral mediante clavo intramedular es una de las opciones quirúrgicas en el tratamiento de las dismetrías severas de miembros inferiores en la práctica clínica habitual. MATERIAL Y MÉTODOS: se realizó un estudio descriptivo retrospectivo de una serie de cinco pacientes con una media de edad de 15.4 años, intervenidos de alargamiento femoral mediante clavo intramedular Precice®. La etiología en todos los casos fue idiopática. Se midió la dismetría o alargamiento teórico prequirúrgico y el definitivo postquirúrgico, así como la precisión del alargamiento, la tasa y el índice de distracción (mm/día y días/cm respectivamente) y el índice de consolidación (días/cm). Se identificaron las complicaciones intra y postoperatorias en todos los casos. RESULTADOS: la media de seguimiento fue de 21 meses (12-42), sin pérdidas en el seguimiento. La duración media del procedimiento quirúrgico fue de 126 minutos (105-160). La dismetría teórica prequirúrgica fue de 38 ± 2.7 mm. El alargamiento medio final fue de 41 ± 7.5 mm. La precisión media fue de 108% (91-125) y la tasa de distracción de 0.9 ± 0.4 mm/día. El índice de distracción fue de 13.9 ± 5.1 días/cm y el índice de consolidación, de 26.6 ± 9.1 días/cm. La consolidación ósea se observó en la totalidad de los pacientes con una media de 113 ± 58 días. Con respecto a las complicaciones, se encontraron un total de cuatro complicaciones menores de índole muscular. CONCLUSIÓN: el clavo intramedular Precice® es una buena opción de tratamiento para casos de acortamiento femoral severo aportando buenos resultados clínicos y radiológicos con una baja tasa de complicaciones y fallo del implante.

Conceptos actuales: ventajas del clavo endomedular para fracturas del húmero proximal / Current concepts: advantages of intramedullary nail for proximal humerus fractures

Las fracturas de húmero proximal (FHP) son una de las fracturas más frecuentes en la población anciana. La reducción abierta y fijación interna (RAFI) generalmente está indicada para pacientes con una FHP desplazada en jóvenes o pacientes mayores con alta demanda funcional y buena calidad ósea. No se ha llegado a un consenso sobre la técnica de fijación ideal. La RAFI con placas ha sido la más utilizada, pero se han reportado altas tasas de reintervenciones y complicaciones globales en la literatura. La necesidad de agregar técnicas de aumentación a la RAFI con placas bloqueadas en fracturas complejas puede resultar en un tiempo quirúrgico más largo, abordajes extensos y mayores costos. Debido a esto, se hace necesario considerar otras opciones para la osteosíntesis de FHP. Con una mayor comprensión de los mecanismos de falla de la osteosíntesis, la fijación intramedular se ha convertido en una opción de tratamiento aceptada para las FHP con ventajas biomecánicas y biológicas. La fijación intramedular para las FHP ha demostrado menor tiempo quirúrgico, sangrado intraoperatorio, tiempo hasta la unión ósea y menores tasas de infecciones, que las placas bloqueadas. La fijación intramedular es una opción válida para que las fracturas complejas se resuelvan con un implante que por sí solo puede satisfacer en gran medida todas las necesidades de aumento requeridas por una placa bloqueada

Proximal humeral fractures are one of the most frequent fractures in the elderly population. Open reduction and internal fixation (ORIF) is generally indicated for young patients and older patients with high functional demands and good bone quality. No consensus has been reached regarding the ideal fixation technique. Although ORIF with plates is the most widely used technique, high re-intervention rates and global complications with locked plate fixation have been reported in the literature. Addition of augmentation techniques to locked plate fixation in complex fractures may result in longer surgical times, extensive approaches, and higher costs. Therefore, considering other options for ORIF is necessary. With a greater understanding of the mechanisms of fixation failure, intramedullary fixation has become the accepted treatment option for proximal humeral fractures considering the specific biomechanical and biological advantages. Compared with ORIF with locked plates, intramedullary fixation for proximal humeral fractures has low surgical time, intraoperative bleeding, time to bone union, and rate of infections. Intramedullary fixation is a valid option to resolve complex fractures with an implant that may largely supply all the augmentation requirements of a locked plate.

Impacto del diámetro del clavo endomedular en la consolidación de fracturas diafisarias de tibia. Análisis retrospectivo sobre 96 pacientes / Impact of the nail diameter on consolidation of tibial diaphyseal fractures. Retrospective analysis of 96 patients

Resumen: Introducción: el estándar de oro de tratamiento para la mayoría de las fracturas diafisarias de tibia está representado por el clavo endomedular (CEM). El objetivo de este estudio fue analizar la importancia del diámetro del CEM sobre la consolidación de fracturas diafisarias de tibia. Material y métodos: se realizó un estudio retrospectivo en pacientes con fracturas cerradas de tibia 42 OTA/AO, tratados con un CEM fresado y acerrojado, entre Enero de 2014 y Diciembre de 2020. Las variables analizadas fueron género, edad, comorbilidades, cantidad de cerrojos utilizados, relación clavo/canal (diferencia entre el diámetro del canal medular y clavo), el índice clavo/canal (razón entre diámetro del clavo y el canal medular), en relación con la tasa de consolidación y falla (retardo de consolidación y seudoartrosis). Resultados: la serie final se conformó por 96 pacientes y la tasa de consolidación fue de 91.7% (n = 88). Se observó un diámetro de clavo significativamente mayor en los pacientes que consolidaron respecto a los que fallaron (p = 0.0014), incrementando la posibilidad de consolidación 5.30 (p = 0.04) veces, por cada milímetro que el clavo aumentó su diámetro. Se observó un incremento de probabilidad de consolidación de 13.56 (p = 0.018) veces utilizando un clavo > 10 mm de diámetro. El índice clavo/canal ≥ 0.80 aumentó la posibilidad de consolidación 23.33 veces (p = 0.005). Conclusión: nuestros hallazgos sugieren que los CEM fresados y acerrojados en fracturas diafisarias de tibia deben colocarse del mayor diámetro posible (> 10 mm y con un índice clavo/canal ≥ 0.80) para favorecer la consolidación.

Abstract: Introduction: the gold standard for tibial diaphyseal fracture treatment is represented by the intramedullary nail (IMN). This study aimed to assess the relevance of nail diameter in bone healing of tibial diaphyseal fractures. Material and methods: a retrospective study was conducted analyzing patients with closed 42 OTA/AO tibial fractures, treated with a reamed and locked IMN between January 2014 and December 2020. The variables assessed were gender, age, comorbidities, number of bolts used, canal/nail index (difference between the diameter of the medullary canal and nail), nail/canal ratio (ratio between nail diameter and medullary canal), related to consolidation and failure rates (delay - and non-union). Results: 96 patients were included. The consolidation rate was 91.7% (n = 88). Patients with consolidation had a significantly larger nail diameter than those who failed (p = 0.0014), increasing the chance of consolidation 5.30 (p = 0.04) times for each millimeter that the nail increased its diameter. Using a nail > 10 mm increased the chance of consolidation 13.56 times (p = 0.018). A nail/canal ratio ≥ 0.80 increased the chance of consolidation 23.33 times (p = 0.005). Conclusion: our findings suggested that reamed and locked IMN in tibial diaphyseal fractures should be implanted with the largest possible diameter (> 10 mm and with a nail-to-canal ratio ≥ 0.80) to promote bone healing.

Primera serie de casos de alargamiento femoral mediante clavo intramedular Precice® en nuestro centro / First case series of femoral lengthening using a Precice® intramedullary nail in our center

Resumen: Introducción: el alargamiento femoral mediante clavo intramedular es una de las opciones quirúrgicas en el tratamiento de las dismetrías severas de miembros inferiores en la práctica clínica habitual. Material y métodos: se realizó un estudio descriptivo retrospectivo de una serie de cinco pacientes con una media de edad de 15.4 años, intervenidos de alargamiento femoral mediante clavo intramedular Precice®. La etiología en todos los casos fue idiopática. Se midió la dismetría o alargamiento teórico prequirúrgico y el definitivo postquirúrgico, así como la precisión del alargamiento, la tasa y el índice de distracción (mm/día y días/cm respectivamente) y el índice de consolidación (días/cm). Se identificaron las complicaciones intra y postoperatorias en todos los casos. Resultados: la media de seguimiento fue de 21 meses (12-42), sin pérdidas en el seguimiento. La duración media del procedimiento quirúrgico fue de 126 minutos (105-160). La dismetría teórica prequirúrgica fue de 38 ± 2.7 mm. El alargamiento medio final fue de 41 ± 7.5 mm. La precisión media fue de 108% (91-125) y la tasa de distracción de 0.9 ± 0.4 mm/día. El índice de distracción fue de 13.9 ± 5.1 días/cm y el índice de consolidación, de 26.6 ± 9.1 días/cm. La consolidación ósea se observó en la totalidad de los pacientes con una media de 113 ± 58 días. Con respecto a las complicaciones, se encontraron un total de cuatro complicaciones menores de índole muscular. Conclusión: el clavo intramedular Precice® es una buena opción de tratamiento para casos de acortamiento femoral severo aportando buenos resultados clínicos y radiológicos con una baja tasa de complicaciones y fallo del implante.

Abstract: Introduction: femoral lengthening using an intramedullary nail is one of the surgical options in the treatment of severe lower limb dysmetria in routine clinical practice. Material and methods: a retrospective descriptive study was carried out on a series of five patients with a mean age of 15.4 years, who underwent femoral lengthening surgery using a Precice® intramedullary nail. The etiology in all cases was idiopathic. Preoperative and definitive postoperative theoretical lengthening or dysmetry was measured, as well as lengthening accuracy, distraction rate and index (mm/day and days/cm, respectively) and consolidation index (days/cm). Intraoperative and postoperative complications were identified in all cases. Results: mean follow-up was 21 months (12-42), with no loss to follow-up. The mean duration of the surgical procedure was 126 minutes (105-160). The preoperative theoretical dysmetry was 38 ± 2.7 mm. The final mean lengthening was 41 ± 7.5 mm. The mean accuracy was 108% (91-125) and the distraction rate was 0.9 ± 0.4 mm/day. The distraction rate was 13.9 ± 5.1 days/cm and the consolidation rate was 26.6 ± 9.1 days/cm. Bone consolidation was observed in all patients with a mean of 113 ± 58 days. Regarding complications, a total of four minor muscular complications were found. Conclusion: the Precice® intramedullary nail is a good treatment option for cases of severe femoral shortening, providing good clinical and radiological results with a low rate of complications and implant failure.

[Impact of the nail diameter on consolidation of tibial diaphyseal fractures. Retrospective analysis of 96 patients]. / Impacto del diámetro del clavo endomedular en la consolidación de fracturas diafisarias de tibia. Análisis retrospectivo sobre 96 pacientes.

INTRODUCTION: the gold standard for tibial diaphyseal fracture treatment is represented by the intramedullary nail (IMN). This study aimed to assess the relevance of nail diameter in bone healing of tibial diaphyseal fractures. MATERIAL AND METHODS: a retrospective study was conducted analyzing patients with closed 42 OTA/AO tibial fractures, treated with a reamed and locked IMN between January 2014 and December 2020. The variables assessed were gender, age, comorbidities, number of bolts used, canal/nail index (difference between the diameter of the medullary canal and nail), nail/canal ratio (ratio between nail diameter and medullary canal), related to consolidation and failure rates (delay and non-union). RESULTS: 96 patients were included. The consolidation rate was 91.7% (n = 88). Patients with consolidation had a significantly larger nail diameter than those who failed (p = 0.0014), increasing the chance of consolidation 5.30 (p = 0.04) times for each millimeter that the nail increased its diameter. Using a nail > 10 mm increased the chance of consolidation 13.56 times (p = 0.018). A nail/canal ratio 0.80 increased the chance of consolidation 23.33 times (p = 0.005). CONCLUSION: our findings suggested that reamed and locked IMN in tibial diaphyseal fractures should be implanted with the largest possible diameter (> 10 mm and with a nail-to-canal ratio 0.80) to promote bone healing.

INTRODUCCIÓN: el estándar de oro de tratamiento para la mayoría de las fracturas diafisarias de tibia está representado por el clavo endomedular (CEM). El objetivo de este estudio fue analizar la importancia del diámetro del CEM sobre la consolidación de fracturas diafisarias de tibia. MATERIAL Y MÉTODOS: se realizó un estudio retrospectivo en pacientes con fracturas cerradas de tibia 42 OTA/AO, tratados con un CEM fresado y acerrojado, entre Enero de 2014 y Diciembre de 2020. Las variables analizadas fueron género, edad, comorbilidades, cantidad de cerrojos utilizados, relación clavo/canal (diferencia entre el diámetro del canal medular y clavo), el índice clavo/canal (razón entre diámetro del clavo y el canal medular), en relación con la tasa de consolidación y falla (retardo de consolidación y seudoartrosis). RESULTADOS: la serie final se conformó por 96 pacientes y la tasa de consolidación fue de 91.7% (n = 88). Se observó un diámetro de clavo significativamente mayor en los pacientes que consolidaron respecto a los que fallaron (p = 0.0014), incrementando la posibilidad de consolidación 5.30 (p = 0.04) veces, por cada milímetro que el clavo aumentó su diámetro. Se observó un incremento de probabilidad de consolidación de 13.56 (p = 0.018) veces utilizando un clavo > 10 mm de diámetro. El índice clavo/canal 0.80 aumentó la posibilidad de consolidación 23.33 veces (p = 0.005). CONCLUSIÓN: nuestros hallazgos sugieren que los CEM fresados y acerrojados en fracturas diafisarias de tibia deben colocarse del mayor diámetro posible (> 10 mm y con un índice clavo/canal 0.80) para favorecer la consolidación.

Nailing the fibula: alternative or standard treatment for lateral malleolar fracture fixation? A broken paradigm.

PURPOSE: Despite the fact that open reduction and internal fixation with a plate, either non-locked or locked, is the standard of care for managing lateral malleolus fractures, intramedullary (IM) fixation of the fibula has been recently introduced as an alternative, mainly for some potential complicated situations. We hypothesized that almost all patterns of distal fibula fracture can be safely fixed with an IM device, with the potential benefit of providing biomechanical efficiency, but using a soft-tissue friendly implant. Here, we present a multicenter case series based on a proposed algorithm. PATIENTS AND METHODS: Sixty-nine consecutive patients were managed with fibular IM fixation for closed malleolar fractures. Twenty patients were managed by IM screw fixation and 49 by fibular nailing. Outcome was measured both according to the American Orthopaedic Foot and Ankle Society (AOFAS) score for ankle and hindfoot, and the time to bone union. RESULTS: The mean AOFAS for Group I was 99.35 ± 1.95 points and that for Group II was 89.30 ± 16.98 points. There were no significant differences between the fracture pattern, according to the Lauge-Hansen classification, and post-operative levels of pain and functional activity among patients in both groups (p > 0.05). All fractures healed uneventfully in both groups. The mean time to union for Group I was 8.15 weeks and for Group II was 8.25 weeks (p > 0.05). CONCLUSION: In this multicenter case series, intramedullary fixation for the lateral malleolus fracture presented itself as a viable and safe option for the treatment of almost all patterns of fibula fracture in adults. Overall, we were able to demonstrate the potential indications of the proposed algorithm for the choice of IM implant for the lateral malleolus fracture in terms of the Lauge-Hansen staged classification.

Microbiological diagnosis of intramedullary nailing infection: comparison of bacterial growth between tissue sampling and sonication fluid cultures.

BACKGROUND: Intramedullary nailing (IMN) has been frequently indicated to treat long bone open and closed fractures, but IMN infection (IMNI) may have devastating consequences. Sonication has been regarded as an important add-on for microbial identification on a variety of orthopaedic implant-associated infections, but its role in the IMNI is poorly studied. We aim at evaluating the accuracy obtained by conventional peri-implant tissue culture (TC) samples with sonication fluid cultures (SCs) of IMNI. METHODS: Longitudinal prospective cohort study ongoing since June 2014, which included patients with indication for IMN removal due to any reason. Clinical diagnosis of INMI was defined according to publication addressing fracture-related infections. Minimal of two samples from TC were cultured. SCs followed the protocol previously published. Statistical analysis was performed using McNemar's test for related proportions. RESULTS: We included 54 patients submitted to IMN retrieval, of whom 47 presenting clinical signs of IMNI. Sensitivity for detecting microorganisms using TC and SC was 89.4% (42/47) and 97.6% (40/41), and specificity was 71.4% (5/7) for both TC and SC (p = 1.00). Positive and negative predictive values for TC and SC were 95.5% (42/44), 95.2% (40/42), 50% (5/10), and 83.3% (5/6), respectively. The most frequent organisms isolated in both TC and SC were Staphylococcus aureus, S. epidermidis, and Enterococcus sp. Polymicrobial infection was diagnosed in 14.8% (8/54) and 25% (12/48) by TC and SC, respectively (p = 0.19). CONCLUSION: Sonication fluid and tissue samples presented similar accuracy on the diagnosis of IMNI, but SC was advantageous of detecting polymicrobial infection.

Alargamiento óseo con clavo intramedular magnético experiencia preliminar y lecciones aprendidas / Bone lengthening with magnetic intramedullary nail preliminary experience and learned lessons

OBJETIVOS: Mostrar resultados, complicaciones y lecciones aprendidas utilizando el clavo intramedular magnético (IML, Intramedullary Magnetic Lengthener) en un grupo de pacientes sometidos a alargamiento óseo. PACIENTES Y MÉTODOS: Entre enero 2017 y diciembre 2019, 9 pacientes (15 segmentos), edad entre 15 y 39 años, fueron sometidos a alargamiento óseo con IML: 5 pacientes tuvieron alargamiento femoral bilateral por talla baja, 1 paciente se sometió a alargamiento de Piernas bilateral por Tibia vara y acortamiento mesomélico y 3 recibieron alargamientos femorales unilaterales por discrepancia de longitud de extremidades. Todos fueron operados por el mismo cirujano, con técnica standard. Se indicó kinesiterapia al menos 5 veces por semana durante la fase de distracción. RESULTADOS: En todos se logró el objetivo de alargamiento planteado. No hubo complicaciones intra ni postoperatorias graves (TVP, TEP, Embolia grasa), ni fallas del sistema distractor. Un paciente desarrolló contracturas articulares de ambas rodillas por no adhesión a Kinesiterapia. Ninguno requirió aporte de injerto óseo, sin embargo en 2 pacientes de alargamiento de Fémur bilateral, se presentó deformidad en varo, que hizo necesario recambio a clavo convencional y un paciente desarrolló una parálisis transitoria del Nervio Peroneo común. CONCLUSIONES: El advenimiento de los IML significó un gran avance en el campo de la osteogénesis por distracción, sin embargo, aún se trata de un procedimiento complejo, que debe ser planificado cuidadosamente para minimizar los riesgos y complicaciones. Una selección meticulosa del paciente y la evaluación física y psicológica previa, son fundamentales para el éxito del procedimiento. Los casos bilaterales requieren de un seguimiento cercano, por el riesgo de falla del implante.

objective: We show our results, complications and lessons learned using the Intramedullary Magnetic Lengthener (IML) in a group of patients who were subjected to bone lengthening. PATIENTS AND METHODS: Between January 2017 and December 2019, 9 patients (15 segments), aged between 15 and 39 years, underwent bone lengthening with IML: 5 patients had bilateral femoral lengthening due to short stature, 1 patient had bilateral leg lengthening due to Tibia vara and mesomelic shortening and 3 had unilateral femoral lengthening for limb length discrepancy. All were operated by the same surgeon, with standard technique. Physical therapy was indicated at least 5 times per week during the distraction phase. RESULTS: In every case, the proposed lengthening amount was achieved. There were no serious intraoperative or postoperative complications (DVT, Pulmonary Embolism, Fat Embolism), nor failures of the distractor system. One patient developed knee joint contracture due to non-adherence to Physical therapy. None required bone grafting, however, in 2 patients with bilateral Femur, a varus deformity appeared, which required nail exchange with a conventional trauma nail. One case developed a transit common Peroneal Nerve palsy. CONCLUSIONS: IMLs represent a great advance in the bone lengthening realm, however, it is still a complex procedure, which must be carefully planned to minimize risks and complications. Meticulous patient selection and prior physical and psychological evaluation are essential to the success of the procedure. Bilateral cases need a closer follow up, because implant failure is a potential risk.

Análise clínica e radiológica de pacientes em pós-operatório de fratura de terço distal da tíbia: haste intramedular x placa / Clinical and radiological analysis of post-operative patients with distal tibia fractures: intramedullary nail versus plate

Objetivo: Avaliar e comparar os resultados clínicos e radiológicos de pacientes com fratura de tíbia distal, sem acometimento articular, tratados com haste intramedular ou placa e parafusos. Métodos: Foram analisados 27 pacientes, sendo 15 tratados com placa e 12 com haste intramedular, após 6 meses completos de pós operatório. Foram aplicados os escores de EVA e de Olerud-Molander, além de análise radiográfica. A análise estatística foi realizada utilizando os testes de qui quadrado e o teste de Mann-Whitney. Resultados: A média de idade foi de 45 anos e o sexo masculino foi prevalente. Foi observada alta prevalência da fratura de fíbula associada (92,6%) sendo 25,9% fixadas. A media angular de desvio foi de 2,60o nos pacientes tratados com placa e 2,42o nos tratados com haste intramedular (p=0,829). A média do escore da EVA e Escore de Olerud-Molander não mostrou diferença estatisticamente significativa entre os dois grupos. Três pacientes apresentaram pseudoartrose, sendo dois deles tratados com haste. Conclusão: Não houve consenso da superioridade de um método em relação ao outro em nossa análise. A fixação da fibula pode ser um fator determinante no alinhamento das fraturas. Cada um dos métodos apresenta vantagens e desvantagens, porém ambos mostraram resultados bons e semelhantes. A escolha do tratamento deve ser atribuida ao perfil do trauma, a condições clinicas do paciente e a experiencia do profissional.

Objective: To evaluate and compare clinical and radiological outcomes of patients with distal tibial fractures, without joint involvement, treated with intramedularry nail or plate and screws. Methods: twenty seven patiens were analyzed, 15 treated with plates and 12 treated with intramedullary nail, after 6 complete months of postoperative period. The Olerud-Molander Ankle Score and the Visual Analogue Scale for Pain, as well as radiographic analysis. Statistical analysis was performed using the chi-squared and Mann-Whitney tests. Results: The mean age was 45 years and males were more prevalent. A high prevalence of associated fíbula fracture was observed (92,6%), with 25,9% being fixed. The mean angular deviation was 2,6 degreees in patients treated with plate and 2,42 degrees in those treated with nails. (p=0,829). The Olerud-Molander Ankle Scores and the EVA did not show statistically siginifcance difference between the two groups. Three patients evolved with nonunion, two of them being treated with intramedullary nail. Conclusions: There was no consensus of the superiority of one method over the other. Fíbula fixation can be a determining factor int the fracture alingnment. Both methods has advantages and disadvantages, but both shows good and similar results. Treatment's choice shoud be attributed to trauma profile, patient's clinical conditions and surgeon's experience.

"Clothesline technique" for proximal tibial shaft fracture fixation using conventional intramedullary nail: a simple, useful, and inexpensive technique to prevent fracture malalignment.

Treatment of proximal tibial shaft fractures is always challenging. Despite the development of modern techniques, the literature still shows high complication rates, especially regarding proximal fragment malalignment. It is well known that knee position in flexion during tibial nailing is responsible for extension and valgus deformities of the proximal fragment. Unlike in tibial shaft fractures, nails do not reduce proximal tibial fractures due to the medullary canal width. This study aims to describe a simple, useful, and inexpensive technique to prevent valgus and extension deformities when treating proximal tibial fractures using conventional nails: the so-called clothesline technique.

Zona de seguridad para tornillo de bloqueo cefálico posterior-anterior durante enclavijado endomedular retrógrado del húmero: estudio ex vivo en muestras óseas / Safe zone for anterior-posterior cranial blocking screw during retrograde intramedullary nailing of the humerus: ex-vivo study in bone specimens

OBJETIVO: Definir una zona segura, usando como referencia la línea intercondílea anterior (LCA) del codo para realizar los bloqueos anteroposteriores durante el enclavijado endomedular retrógrado humeral (CEMR). MÉTODOS: Estudio experimental ex-vivo. Trece húmeros humanos fueron analizados. Se tomaron fotografías registrando la porción distal de los húmeros paralelos a la LCA, elevando el húmero distal 10cm. Tres evaluadores independientes realizaron las siguientes mediciones: ángulo del surco bicipital (SB) a la altura del cuello quirúrgico humeral (S, formado por las paredes medial y lateral del SB; zona de peligro) y el ángulo complementario lateral (formado por el límite lateral de la tróclea y la pared lateral del SB a la altura del cuello quirúrgico humeral; zona segura). RESULTADOS: Valor promedio de S: 3,1±0,5° (3,3-4), coeficiente de correlación intraclase: 0,057 (p=0,057). Valor promedio del ángulo complementario lateral: 87,5±3,3° (81,3-92,5), coeficiente de correlación intraclase: 0,304 (p=0,217). Considerando 3 desviaciones estándar del promedio de los ángulos medidos (para aumentar los parámetros de seguridad) la zona segura se enmarcó entre los 0° y los 80° con relación a la LCA. CONCLUSIÓN: En este estudio la zona de seguridad del bloqueo cefálico anteroposterior para evitar el daño del tendón bicipital durante el enclavijado endomedular retrógrado humeral se localizó entre los 0° y 80° con relación a la LCA.

OBJECTIVE: To define a safe zone, using the anterior intercondylar line (AIL) of the elbow as a reference to perform anterior-posterior (AP) cranial blocks during retrograde intramedullary humeral nailing (RIHN). METHODS: An ex-vivo experimental study was performed by analysing 13 human humeri. Photographs were taken, recording the distal portion of the humeri parallel to the AIL, elevating the distal humerus 10cm. Three independent evaluators made the following measurements: Bicipital groove (BG) angle at the level of the surgical neck of the humerus (S, formed by the medial and lateral walls of the BG; danger zone) and the Lateral Complementary Angle (LCA, formed by t5he lateral trochlear limit and the lateral wall of the BG at the level of the surgical neck of the humerus; safe zone). RESULTS: The mean value of S: 3.1±0.5° (3.3-4), intraclass correlation coefficient (ICC): 0.057 (P=.057). The mean value of the AIL: 87.5±3.3° (81.3-92.5), ICC: 0.304 (P=.217). Using 3 standard deviations from the mean of the angles measured (in order to increase the safety parameters), the safety zone is located between 0° and 80° in relation to the AIL. CONCLUSION: In this study, the safety zone of the AP cranial block, in order to avoid damage to bicipital tendon during RIHN, is situated between 0° and 80° in relation to the AIL.

Is Subtalar Joint Cartilage Resection Necessary for Tibiotalocalcaneal Arthrodesis via Intramedullary Nail? A Multicenter Evaluation.

Tibiotalocalcaneal arthrodesis with intramedullary nailing is traditionally performed with formal preparation of both the subtalar and ankle joints. However, we believe that subtalar joint preparation is not necessary to achieve satisfactory outcomes in patients undergoing tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail. The primary aim of the present retrospective study was to evaluate the outcomes of patients who had undergone tibiotalocalcaneal arthrodesis with an intramedullary nail without formal subtalar joint cartilage resection. A multicenter medical record review was performed to identify consecutive patients. Pain was assessed using a visual analog scale, and osseous union at the tibiotalar joint was defined as bony trabeculation across the arthrodesis site on all 3 radiographic views. Progression of joint deterioration was evaluated across time at the subtalar joint, using a modified grading system developed by Takakura et al. Forty consecutive patients (aged 61.9 ± 12.9 years; 17 men) met the inclusion and exclusion criteria. Compared with the pain reported preoperatively (6.4 ± 2.7), a statistically significant decline was seen in the pain experienced after surgery (1.2 ± 1.8; p < .001). The mean time to consolidated arthrodesis at the ankle joint was 3.8 ± 1.5 months. A statistically significant increase in deterioration at the subtalar joint was observed across time [t(36) = -6.200, p < .001]. Compared with previously published data of subtalar joint cartilage resection, the present study has demonstrated a similar decline in pain, with a high rate of union, and also a decrease in operative time when preparation of the subtalar joint was not performed.

Subtrochanteric and Distal Femur Fractures in a Patient with Femoral Shaft Fracture Malunion and Knee Disarticulation: A Rare and Challenging Case Report.

This study aims to describe a rare and challenging case of a patient who presented ipsilateral subtrochanteric and distal femur fractures due to low-energy trauma. The peculiarity of this case is the presence of femoral shaft fracture malunion and knee disarticulation in the same limb resulting from an accident suffered 30 years ago. The patient underwent femoral diaphyseal osteotomy and fixation of the subtrochanteric and distal femur fractures with a long cephalomedullary nail and distal femur locking plate, respectively. Despite the magnitude of the surgical procedure, all fractures healed, preserving the femoral length with the absence of infection and clinical complications. There was an improvement of the preinjury function attributed to the osteotomy of the femoral diaphyseal, which alleviated the anterior thigh discomfort.

Empleo del clavo intramedular de Küntscher en pacientes con fracturas diafisarias de tibia / Use of Küntscher intramedullary nail in patients with tibial diaphyseal fractures

Se realizó un estudio descriptivo, longitudinal y retrospectivo de 123 pacientes con fractura diafisaria de tibia, quienes fueron intervenidos mediante la técnica quirúrgica de fijación con clavo intramedular de Küntscher sin fresado del canal, desde agosto del 2012 hasta diciembre del 2013, en el Hospital Especial de Tumbi, de Kibaha, Tanzania, con vistas a evaluar los resultados de dicho procedimiento. En la serie predominaron el sexo masculino (74,0 %), el grupo etario de 26-35 años (37,4 %), los accidentes de tránsito como causa principal de las lesiones (74,0 %) y la reducción de la fractura de forma abierta (90,2 %); asimismo, 29,4 % de los pacientes presentó complicaciones y 80,5 % mostró buenos resultados en la evaluación final. Finalmente, se pudo concluir que el uso del clavo intramedular de Küntscher sin fresado del canal, es una técnica quirúrgica viable para solucionar las fracturas diafisarias de tibia.

A descriptive, longitudinal and retrospective study of 123 patients with tibial diaphyseal fracture who were surgically treated by means of the surgical technique of fixation with Küntscher intramedullary nail without reaming of channels was carried out from August, 2012 to December, 2013, in Tumbi Special Hospital, Kibaha, Tanzania, with the aim of evaluating the results of this procedure. The male sex (74.0%), the age group 26-35 years (37.4%), the traffic accidents as main cause of the lesions (74.0%) and the reduction of the fracture in an open way (90.2%) prevailed in the series; also, 29.4% of the patients presented complications and 80.5% showed good results in the final evaluation. Finally, it could be concluded that the use of Küntscher intramedullary nail without reaming channels, is a viable surgical technique to solve the tibial diaphyseal fractures.

Tratamiento de las fracturas de antebrazo en niños y adolescentes con clavo endomedular flexible en el Hospital Universitario de los Andes 2006-2010 / Treatment of forearm fractures in children and adolescents with Flexible Intramedullary Nail in the Andes University hospital 2006-2010

Las fracturas del antebrazo en el niño son muy frecuentes y suponen el 45% de todas las fracturas pediátricas con predominio de varones de 3 a 1 y una mayor incidencia en mayores de 5 años , el manejo de estas fracturas tienen como objetivo, la curación consiguiendo: 1-. Reducción anatómica de los fragmentos con restableciendo de la longitud y rotación ósea, que permitan la prono supinación completa; 2-. Fijación estable que permita movilización inmediata de las articulaciones adyacente. 3-. La restitución de la curvatura radial que influye no solo en resultado funcional de la movilidad si no también en la fuerza de la aprehensión. En este trabajo se realizo una revisión clínica prospectiva en el Hospital Universitario de los Andes de Mérida, durante un lapso de 4 años, desde 2006 al 2010, estudiándose 2.869 casos de fracturas del antebrazos en niños de 2 a 16 años de los cuales 815 casos correspondieron a fracturas diafisarias. El tratamiento aplicado fue de la siguiente manera: Conservador 64%(520/815 casos) con yeso braquio palmar por 6 semanas. Quirúrgico: 36%(295/815 casos), Enclavijado 210/295 casos representando el 71.2%, Placas: 72/295 casos representando el 24.4%, Fijador Externo: 13/295 casos representando el 4.4%(AU)

Forearm fractures in children are very common and account for 45% of all pediatric fractures with a male predominance of 3-1 and an increased incidence in over 5 years, the management of these fractures aim, getting healing : 1 -. Anatomic reduction of the fragments with restoring bone length and rotation, permitting full supination prone; 2 -. Stable fixation that allows early mobilization of the adjacent joints. 3 -. The return of the radial curvature influences not only functional outcome of mobility but also on the strength of apprehension. In this paper a prospective clinical review at the University Hospital of the Andes in Mérida was conducted over a period of 4 years from 2006 to 2010, studying 2,869 cases of forearm fractures in children 2-16 years of which 815 cases corresponded to diaphyseal fractures. The treatment was applied as follows: Conservative 64% (520 cases) with brachial palmar plaster for 6 weeks. Surgical: 36% (295 cases), 210 cases Pegged representing 71.2%, Blocks: 72 cases representing 24.4%, External fixator: 13 cases representing 4.4%(AU)