Ligadura del trayecto fistuloso interesfinteriano. Nuestros resultados / Ligation of the intersphincteric fistulatract. Our results

Introducción: existen varias técnicas para el tratamiento quirúrgico de las fístulas anales, con variables resultados. La técnica de ligadura del trayecto fistuloso interesfinteriano (LIFT) consiste en la disección del espacio entre ambos esfínteres para localizar el trayecto fistuloso y proceder a su ligadura y sección. Objetivo: evaluar nuestros resultados con la técnica de LIFT para del tratamiento de las fístulas anales transesfinterianas. Diseño: retrospectivo, observacional de corte transversal. Materiales y métodos: Se incluyeron todos los pacientes con fístulas transesfinterianas tratados con LIFT desde enero de 2013 a diciembre 2020. El seguimiento postoperatorio se realizó hasta los 2 años. Resultados: se operaron 62 pacientes. El sexo predominante fue masculino. Hubo 47 pacientes con fístulas transesfinterianas bajas y 15 con fístulas transesfinterianas altas. En todos se identificó el trayecto fistuloso realizándose ligadura de ambos cabos del trayecto interesfinteriano y se procedió a un curetaje del trayecto a través del orificio externo. Cinco pacientes (8%) presentaron dehiscencia de piel a nivel de la incisión del espacio interesfinteriano, manejado en forma conservadora. Este grupo tuvo una cicatrización mas retardada de 4 semanas. Ocurrió recidiva en 22 (35,5%) pacientes. Conclusión: La técnica de LIFT parece una alternativa eficaz y segura para el tratamiento de las fístulas transesfinterianas bajas y altas ya que no altera la anatomía ni la continencia. (AU)

Introduction: there are various techniques for the surgical treatment of anal fistulas, with variable results. The ligation procedure of the intersphincteric fistulous tract (LIFT) consists of dissecting the space between both sphincters to locate the fistulous tract and proceed to its ligation and section. Objective: to evaluate our results with the LIFT procedure for the treatment of transsphincteric anal fistulas. Design: retrospective, cross-sectional observational study. Material and methods: all patients with transsphincteric fistulas treated with LIFT from January 2013 to December 2020 were included. Postoperative follow-up was carried out for up to 2 years. Results: sixty-two patients underwent surgery. The predominant sex was male. There were 47 patients with low transsphincteric fistulas and 15 with high transsphincteric fistulas. After identifying the fistulous tract in the intersphincteric groove, both ends were ligated and the tract was cut. Finally, curettage of the tract through the external orifice was performed. Five patients (8%) presented skin dehiscence at the level of the intersphincteric groove incision, managed conservatively. This group had a longer healing time of four weeks. Recurrence occurred in 22 (35.5%) patients. Conclusion: the LIFT procedure appears to be an effective and safe alternative for the treatment of low and high transsphincteric fistulas, since it does not alter the anatomy or continence. (AU)

Vigilancia activa en cáncer de próstata en un grupo de pacientes asistidos en el Centro Docente Asociado de Oncología Médica Rivera: Cooperativa Médica de Rivera (COMERI) / Active surveillance in prostate cancer in a group of patients assisted at the Rivera Associated Teaching Center for Medical Oncology: Rivera Medical Cooperative (COMERI) / Vigilância ativa do câncer de próstata em um grupo de pacientes atendidos no Rivera Associated Teaching Center for Medical Oncology: Rivera Medical Cooperative (COMERI)

Introducción: En Uruguay el cáncer de próstata ocupa el primer lugar en incidencia y el tercer lugar en mortalidad en el hombre. La mayoría de estos cánceres se diagnostican en estadios precoces. Hoy en día, para pacientes con adenocarcinoma de muy bajo riesgo, bajo riesgo o riesgo intermedio favorable, la vigilancia activa es una opción adecuada. Objetivos: Describir una población de pacientes con cáncer de próstata de muy bajo riesgo, bajo riesgo o riesgo intermedio favorable, en vigilancia activa en COMERI. Material y métodos: Estudio descriptivo, observacional, retrospectivo. Se incluyeron pacientes con cáncer de próstata de muy bajo riesgo, bajo riesgo o riesgo intermedio favorable, tratados entre 2010 y 2018 en COMERI. Se recopilaron datos en el sistema de registro clínico electrónico. Resultados: Se incluyeron 33 pacientes, la mediana de edad al diagnóstico fue de 74 años. Todos los pacientes fueron sometidos a controles clínicos y determinación de PSA cada 3 meses. El tacto rectal se realizó en forma anual. El tiempo mediano de vigilancia activa fue de 33 meses. Durante el seguimiento, se observaron pocas variaciones en los valores de PSA. El 21% de los pacientes fue sometido a una nueva biopsia durante el seguimiento activo, y en todos los casos, el Gleason se mantuvo incambiado. Ningún paciente abandonó la modalidad de vigilancia activa. Conclusión: En nuestro entorno, la vigilancia activa se considera una opción terapéutica válida para pacientes altamente seleccionados con cáncer de próstata de muy bajo riesgo, bajo riesgo o riesgo intermedio favorable, y es bien aceptada por ellos.

Introduction: In Uruguay, prostate cancer ranks first in incidence and third in mortality among men. The majority of these cancers are diagnosed at early stages. Nowadays, active surveillance is an appropriate option for patients with adenocarcinoma of very low risk, low risk, or favorable intermediate risk. Objectives: To describe a population of patients with prostate cancer of very low risk, low risk, or favorable intermediate risk under active surveillance at COMERI. Materials and Methods: Descriptive, observational, retrospective study. Patients with prostate cancer of very low risk, low risk, or favorable intermediate risk treated between 2010 and 2018 at COMERI were included. Data were collected from the electronic clinical registry system. Results: Thirty-three patients were included, with a median age at diagnosis of 74 years. All patients underwent clinical monitoring and PSA determination every 3 months. Digital rectal examination was performed annually. The median time of active surveillance was 33 months. During follow-up, there were few variations in PSA values. 21% of patients underwent a repeat biopsy during active surveillance, and in all cases, the Gleason score remained unchanged. No patient discontinued active surveillance. Conclusion: In our setting, active surveillance is considered a valid therapeutic option for highly selected patients with prostate cancer of very low risk, low risk, or favorable intermediate risk, and it is well accepted by them.

Introdução: No Uruguai, o câncer de próstata ocupa o primeiro lugar em incidência e o terceiro lugar em mortalidade entre os homens. A maioria desses cânceres é diagnosticada em estágios precoces. Atualmente, para pacientes com adenocarcinoma de risco muito baixo, baixo risco ou risco intermediário favorável, a vigilância ativa é uma opção adequada. Objetivos: Descrever uma população de pacientes com câncer de próstata de risco muito baixo, baixo risco ou risco intermediário favorável sob vigilância ativa em COMERI. Material e métodos: Estudo descritivo, observacional, retrospectivo. Foram incluídos pacientes com câncer de próstata de risco muito baixo, baixo risco ou risco intermediário favorável, tratados entre 2010 e 2018 em COMERI. Os dados foram coletados no sistema de registro clínico eletrônico. Resultados: Foram incluídos 33 pacientes, com mediana de idade no diagnóstico de 74 anos. Todos os pacientes foram submetidos a controles clínicos e determinação de PSA a cada 3 meses. O toque retal foi realizado anualmente. O tempo médio de vigilância ativa foi de 33 meses. Durante o acompanhamento, houve poucas variações nos valores de PSA. 21% dos pacientes foram submetidos a uma nova biópsia durante a vigilância ativa, e em todos os casos, o Gleason permaneceu inalterado. Nenhum paciente abandonou a modalidade de vigilância ativa. Conclusão: Em nosso ambiente, a vigilância ativa é considerada uma opção terapêutica válida para pacientes altamente selecionados com câncer de próstata de risco muito baixo, baixo risco ou risco intermediário favorável, e é bem aceita por eles.

The efficacy of porcine dermal collagen to treat complex anal fistulae: results of a multicenter cohort

Introduction: The management of complex anal fistulae remains a topical surgical problem. The choice and success of surgical management are based on the balance between healing and continence. Although porcine dermal collagen (Permacol Collagen Paste [PCP]- Covidien plc, Gosport, Hampshire, UK) represents a new generation of non-solid biomaterials, its results in anal fistulae are mixed. Methods: A multicenter observational retrospective analysis of consecutive patients with cryptoglandular anal fistula treated in four colorectal surgery units was performed between 2015 and 2020. Clinical cure of the fistula was the main outcome measure. Adverse events and alterations in anal continence were secondary outcomes. Results: The study included 119 patients (87 males, 71.1%), with a mean age of 53 years (IR 44-65). Most patients had complex (80.6%) and recurrent (91.6%) fistulae. With the first PCP treatment, the overall cure rate was 41.2% (49 patients) and 45.4% with the second treatment (5 out of 17 patients). The mean follow-up period was 17 months (IR 5-25). Healing was not affected by the location and type of fistula, the existence or not of a cavity, the number of tracts, or the administration of prophylactic antibiotics. After the PCP treatment, no patient in the series had worsening of continence. Morbidity affected 22.7% of the patients (27), with postoperative abscesses being the most frequent adverse event. There were no statistical differences between the four hospitals studied. Conclusions: Permacol collagen paste is a safe and easily reproducible therapy for complicated anal fistulae that has moderate efficacy. The overall success rate is slightly over 40%, with no detriment to fecal continence. (AU)

Functional outcomes and satisfaction rates of sacral nerve stimulation in the treatment of one and multiples pelvic floor dysfunctions

Objective: Few studies have addressed the use of sacral nerve stimulation (SNS) in the treatment of patients with multiple pelvic floor dysfunctions (PFD). So, we evaluated the functional outcomes and level of satisfaction with SNS in selected patients with one or multiples PFD. Methods: A prospective database was used to collect information on eligible patients treated for PFD with SNS, and severity of symptoms was assessed with scores and satisfaction rates by visual analogue scale (VAS) at baseline and by the end of follow-up. Results: We recruited 70 patients, 98.6% of whom responded positively during the evaluation period (Global Response Assessment ≥ 50% for at least one type of PFD), resulting in the implantation of a permanent SNS device. Additionally, 49 of the patients (71%) had a single PFD (fecal incontinence [FI] = 38; constipation/obstructed defecation syndrome [C/ODS] = 11), while 20 (29%) had more than one PFD (double incontinence/n = 12; double incontinence + C/ODS/n = 8). All scores improved significantly between baseline (pre-SNS) and the end of follow-up (post-SNS), as did VAS in all groups (single and multiple PFD). The pre-SNS scores were higher in patients with a single PFD, including FI (Cleveland clinic Florida incontinence score [CCF-FI]) and C/ODS (Cleveland clinic constipation score [C-CCF] and the Renzi ODS score). The pre-SNS impact of VAS scores was similar in all groups (single and multiple PFD), but the VAS (post-SNS) was significantly lower (better response) for FI alone compared with multiple PFD. Conclusion: The SNS technique is an effective and safe option for patients with one or more PFD refractory to conservative measures. Response was positive for at least two PFD, based on reduced correspondent scores and satisfaction rate. (AU)

Cirugía de revascularización miocárdica: comparación de supervivencia a 10 años de la cirugía coronaria con y sin circulación extracorpórea mediante Propensity Score Matching / Ten-year survival after off-pump coronary artery bypass grafting compared with traditional bypass grafting

BACKGROUND: Long-term outcomes of Off-Pump Coronary Artery Bypass Grafting (OPCAB) as an alternative to the traditional Coronary Artery Bypass Grafting (CABG) technique with cardiopulmonary bypass (CPB) are not well defined. AIM: To compare 10-year survival of isolated OPCAB versus CABG with CPB. MATERIAL AND METHODS: Analysis of information obtained from databases, clinical records and surgical protocols of patients treated with isolated CABG between January 2006 and November 2008 at a Regional Hospital. Of 658 isolated CABG, 192 (29.2%) were OPCAB and 466 (79.9%) CPB. Propensity Score Matching (PSM) was performed to compare both groups. After PSM, two groups of 192 cases were obtained. Mortality data was obtained from the Chilean public identification service. Ten-year survival was calculated and compared with Kaplan-Meier and log-rank methods. RESULTS: Follow-up data was obtained in all cases. No statistically significant differences were found when comparing 10-year survival between OPCAB versus CPB (78.6% and 80.2% respectively, p 0.720). There was also no statistical difference in cardiovascular death free survival (90.1% with CPB versus 89.1% OPCAB, p 0.737). Survival was comparable when analyzing subgroups with diabetes mellitus, left ventricular dysfunction or chronic kidney disease, among others. CONCLUSIONS: In our series, OPBAB has a comparable 10-year survival with CABG with CPB.

Primer caso de escisión mesorrectal total transanal (TaTME) para el tratamiento del cáncer de recto medio en un centro docente universitario: descripción de la técnica / First case of transanal total mesorectal excision (TaTME) for middle rectal cancer in a teaching tertiary center: technical aspects / Primeiro caso de excisão total do mesorreto transanal (TaTME) para tratamento de câncer de reto meio em um centro universitário de ensino: aspectos tecnicos

La escisión mesorrectal transanal (TaTME: transanal total mesorectal escision) es la última de una larga lista de desarrollos técnicos y tecnológicos para el tratamiento del cáncer de recto medio y bajo. Incluso para los cirujanos colorrectales experimentados, lograr una escisión mesorrectal total (emt) de calidad en cirugía oncológica no siempre es sencillo, por la dificultad de obtener un adecuado acceso a la pelvis. Los estudios realizados han mostrado resultados comparables al abordaje laparoscópico, con tasas elevadas de escisiones mesorrectales completas y bajo porcentaje de margen circunferencial radial (CRM: circumferential radial margin) y distal positivos, con un adecuado número de ganglios resecados. Como toda técnica nueva, su implementación puede traer consecuencias no intencionales. La complejidad del abordaje, la dificultad en la identificación de nuevos repères y planos anatómicos, ha llevado a complicaciones graves como la lesión uretral o la siembra tumoral pelviana. Por ello, la comunidad quirúrgica ha retrasado la implementación masiva de la técnica y desarrollado estrategias de enseñanza y monitorización de este procedimiento para su realización en centros de alto volumen. El objetivo de esta publicación es presentar el primer caso de TaTME en un centro docente universitario y difundir en nuestra comunidad científica el fundamento de la técnica, sus indicaciones, describir los principales pasos técnicos, complicaciones, resultados oncológicos y funcionales.

Transanal total mesorectal excision (TaTME) is the last of a long list of technical and technological developments for treatment of middle and low rectal cancer. Even for skilled colorectal surgeons, achieving a good quality total mesorectal excision (TME) in oncology surgery is not always simple, due to the difficulty of obtaining optimal access to the pelvis. So far, studies have shown similar results to laparoscopic surgery, with high rates of complete mesorectal excisions and low rate of circumferential radial margin (CRM) and distal margin with an appropriate number of resected lymph nodes. Like every new technique, its implementation can bring unwanted consequences. The complexity of the approach, the difficulty in the identification of new landmarks and anatomic planes, has led to serious complications such as urethral injury or tumoral seeding. This has made slowdown the massive implementation of the technique among the surgical community, addressing the need of developing training programs and mentoring of this procedure that belongs to high volume centers. The aim of this publication is to present the first case of TaTME in a teaching tertiary center and spread, in our scientific community, the principles of the technique, its indications, main technical steps, complications and functional and oncologic results.

A excisão mesorretal transanal (TaTME: transanal total mesorectal escision) é o mais recente de uma longa linha de desenvolvimentos técnicos e tecnológicos para o tratamento do câncer retal inferior e médio. Mesmo para cirurgiões colorretais experientes, nem sempre é fácil obter uma excisão total do mesorreto (EMT) de qualidade em cirurgia de câncer, devido à dificuldade de obter acesso adequado à pelve. Os estudos realizados mostraram resultados comparáveis ​​à abordagem laparoscópica, com altas taxas de excisões completas do mesorreto e baixo percentual de margem radial circunferencial positiva (CRM: circumferential radial margin) e distal, com número adequado de linfonodos ressecados. Como qualquer nova técnica, sua implementação pode ter consequências não intencionais. A complexidade da abordagem, a dificuldade em identificar novos repères e planos anatômicos, levou a complicações graves, como lesão uretral ou semeadura de tumor pélvico. Por esse motivo, a comunidade cirúrgica atrasou a implementação massiva da técnica e desenvolveu estratégias de ensino e acompanhamento desse procedimento para sua realização em centros de alto volume. O objetivo desta publicação é apresentar o primeiro caso de TaTME em um centro de ensino universitário e divulgar em nossa comunidade científica as bases da técnica, suas indicações, descrever as principais etapas técnicas, complicações, resultados oncológicos e funcionais.

Colonoscopic laxative instillation for the fecal-loaded colon: a case series

Context: Postoperative, critically ill, and elderly patients often have fecal loading or impaction. In a few such patients, disimpaction of fecalomas and colon cleansing are difficult. Bowel obstruction, megacolon, lower gastrointestinal bleeding, and gut perforation are complications that may ensue. Oral laxatives or enemas may only be partially effective. Surgical intervention may be needed for salvage or to treat complications. Series and Design: Fourteen hospitalized cases with defecation disorder due to fecal loading of the colon were enrolled for retrospective analysis. Colonoscopic instillation of mannitol and/or lactulose was undertaken as an intervention when the use of oral laxatives was either ineffective or unfeasible, and enema had yielded poor results. Results: Ten patients had satisfactory outcomes for fecal clearance, whereas four patients with poor or incomplete responses underwent repeat interventions or surgery. No significant complications were encountered due to this therapy. Conclusion: Colonoscopic instillation of mannitol or lactulose in fecal-loaded critically ill patients results in a safe and satisfactory fecal clearance. (AU)

Esofagitis necrotizante aguda / Acute necrotizing esophagitis / Esofagite necrotizante aguda

La esofagitis necrotizante aguda es un trastorno poco común que puede ser causa de hemorragia digestiva alta. Predomina en el sexo masculino en la sexta década de la vida. El diagnóstico es endoscópico y muestra una mucosa esofágica de apariencia negra que afecta al esófago distal en toda su circunferencia y se detiene abruptamente en la unión gastroesofágica. Clínicamente suele presentarse con hematemesis y melenas, shock hipovolémico por sangrado masivo, siendo otras manifestaciones el dolor epigástrico, molestia retroesternal y disfagia. Se vincula a pacientes con antecedentes de enfermedad cardiovascular, alcoholismo, diabetes mellitus, desnutrición, hernia hiatal, estenosis gastroduodenal, cáncer, así como pacientes en shock, traumatizados, sometidos a cirugía mayor e inmunosuprimidos. El tratamiento se basa en fluidoterapia, inhibidores de la bomba de protones y suspensión de la vía oral, siendo controvertido el uso de antibioticoterapia. Su pronóstico es malo y dependerá de la gravedad de la enfermedad esofágica y del terreno del paciente, con una mortalidad de hasta el 36 %. Presentamos el caso clínico de un paciente de 81 años, hipertenso, que presenta hematemesis, confirmándose en la endoscopía una esofagitis necrotizante aguda, que evoluciona favorablemente con tratamiento médico.

Acute necrotizing esophagitis is a rare disorder that can cause upper gastrointestinal bleeding. It predominates in males in the sixth decade of life. The diagnosis is endoscopic and shows a black-appearing esophageal mucosa that affects the entire circumference of the distal esophagus and stops abruptly at the gastroesophageal junction. Usually, patients present with hematemesis and melena, with other manifestations such as epigastric pain, retrosternal discomfort, dysphagia, and hypovolemic shock. Almost all patients reported comorbidities: cardiovascular disease, alcoholism, diabetes mellitus, malnutrition, hiatal hernia, gastroduodenal stenosis, and malignant neoplasia; is related as well to patients with shock, trauma, undergoing major surgery, and immunosuppression. The treatment is based on fluid reposition, proton pump inhibitors and suspension of the oral route, the use of antibiotic therapy being controversial. Its prognosis is poor and will depend on the severity of the esophageal disease and the patient comorbidities, with a mortality rate up to 36 %. Case: A 81-year-old male patient with hypertension, who presented hematemesis, confirmed by endoscopy as acute necrotizing esophagitis, whose evolution was favorable with medical treatment.

A esofagite necrosante aguda é uma doença rara que pode causar hemorragia digestiva alta. Predomina no sexo masculino na sexta década de vida. O diagnóstico é endoscópico e mostra uma mucosa esofágica circunferencial difusa com aspecto preto que envolve quase universalmente o esôfago distal e para abruptamente na junção gastroesofágica. Clinicamente, geralmente se apresenta com hematêmese e melena, com outras manifestações sendo dor epigástrica, desconforto retroesternal, disfagia e choque hipovolêmico. Está relacionado a pacientes com histórico de doenças cardiovasculares, alcoolismo, diabetes mellitus, desnutrição, hérnia hiatal, estenose gastroduodenal e neoplasia maligna, bem como pacientes em choque, trauma, cirurgia de grande porte e imunossupressão. O tratamento é a medicação dietética higiênica baseada em fluidoterapia, inibidores da bomba de prótons e suspensão da via oral, sendo o uso de antibioticoterapia controverso. Seu prognóstico é ruim e dependerá da gravidade da doença esofágica e do terreno do paciente, com mortalidade de até 36 %. Apresentamos o caso clínico de um paciente hipertenso de 81 anos que apresentou hematêmese, confirmada por endoscopia como esofagite necrosante aguda, que evoluiu favoravelmente com tratamento higiênico-dietético e medicamentoso.

Uso de endoprótesis para el tratamiento de enfermedades no neoplásicas de la rodilla / Use of endoprosthesis for the treatment of non-neoplastic pathologies of the knee

Introducción: Las endoprótesis son el método de elección para la reconstrucción luego de las resecciones oncológicas. Los avances en los materiales y diseños permitieron expandir las indicaciones a enfermedades no neoplásicas. Su montaje intraoperatorio simple y rápido, y su estabilidad mecánica inmediata permiten una rehabilitación y una recuperación funcional tempranas. Sin embargo, la tasa de fallas es elevada, aunque distinta de la de las enfermedades oncológicas. Las causas predominantes son diferentes. Objetivos: Analizar nuestra experiencia con el uso de endoprótesis de rodilla y compararla con los estudios publicados, evaluando los resultados funcional y radiográfico, la supervivencia del implante y las causas de su eventual falla. Materiales y Métodos: Se seleccionaron pacientes con enfermedad no neoplásica compleja de rodilla que requirieran una reconstrucción con endoprótesis. Para el examen clínico y la evaluación funcional se utilizó el puntaje de la Musculoskeletal Tumor Society, y para las fallas de los implantes, la clasificación de Henderson y cols. modificada. Resultados:Se estudiaron 12 endoprótesis, con un seguimiento promedio de 3.8 años. Se registraron 2 fallas (18%), con un tiempo promedio hasta la falla de 47.5 meses. Una fue tipo 2 (aflojamiento aséptico) y la otra, tipo 4 (infección). No hubo otras complicaciones. En la evaluación funcional, el puntaje final medio fue del 76,6%. Conclusión: Nuestros resultados respaldan el uso de endoprótesis para enfermedades complejas no neoplásicas de rodilla en pacientes cuidadosamente seleccionados, pese a ser un procedimiento quirúrgico complejo y con muchas complicaciones. Nivel de Evidencia: IV

Introduction: Endoprosthesis is the gold standard for reconstruction after oncological resections. The advances regarding its materials and designs allowed for the expansion of the indications to non-neoplastic pathologies. Its simple and fast intraoperative assembly and its immediate mechanical stability allow for early rehabilitation and functional recovery. However, the failure rate is high, although it is different from oncological pathologies. The predominant causes are varied. Objectives: To analyze our experience in the use of knee endoprosthesis and compare it with the literature, evaluating functional outcomes, radiographic outcomes, implant survival and causes of eventual failure. Materials and Methods: Patients with complex non-neoplastic knee pathology that required reconstruction with endoprosthesis were selected. Clinical history, anamnesis, physical examination, and radiographs were reviewed. For clinical examination and functional evaluation, the MusculoSkeletal Tumor Society Score (MSTS Score) was used. For implant failures, the modified Henderson et al. classification was used. Results: 12 endoprostheses were studied, with an average follow-up of 3.8 years. Failures were recorded in 2 (18%), with a mean time to failure of 47.5 months. One type 2 failure (aseptic loosening) and one type 4 failure (infection) were recorded. No other complications were noted. For the functional evaluation, the mean final score was 76.6%. Conclusion: Our results support the use of endoprostheses for complex non-neoplastic knee diseases in carefully selected patients, despite being a complex surgical procedure with many complications.Keywords: Endoprosthesis; knee; infection; complications. Level of Evidence: IV

Artroplastia total de rodilla con implante semiconstreñido. Análisis de serie de casos / Semi-constrained knee prosthesis

Introducción: Los implantes semiconstreñidos en la artroplastia total de rodilla están indicados cuando hay compromiso de la estabilidad de la rodilla, ya sea en cirugías primarias o de revisión. materiales y métodos:Se evaluó a 43 pacientes tratados con implantes de constricción condilar varo-valgo, en una misma institución, por el mismo equipo quirúrgico, entre 2015 y 2022. Resultados:Los resultados en las escalas de función WOMAC, KSS y Oxford fueron buenos/muy buenos. Los puntajes fueron menores en pacientes >75 años, si utilizaban asistencia para caminar y si tenían enfermedades previas (estadísticamente significativo). El 86% no tuvo dolor, el 91% estaba satisfecho y el 11% sufrió complicaciones. No hubo infecciones, ni cirugías de revisión. Conclusiones: Respetando las indicaciones y la técnica quirúrgica, las artroplastias totales de rodilla semiconstreñidas con constricción condilar varo-valgo logran buenos resultados a corto y mediano plazo, con una tasa baja de complicaciones, sin diferencias estadísticas en la función entre las cirugías primarias y de revisión. Nivel de Evidencia: III

Introduction: Semi-constrained implants in TKA are indicated in cases where knee stability is compromised, either in primary or revision surgeries. materials and methods:43 patients were evaluated at the same institution, treated by the same surgical team between 2015-2022, with Sigma TC3 (Johnson & JohnsonTM) implants. Results: the WOMAC, KSS function and Oxford functiona-lity scales had good/very good results. The scores were lower in patients over 75 years of age if they used gait assistance and if they had previous pathologies (statistically significant). 86% had no pain, 91% were satisfied, 11% had complications. There were no infections or revision surgeries. Conclusions: TKAs with Sigma TC3 present good outcomes in the short and medium term with a low rate of complications in this series, with no statistical differences in function between primary and revision surgeries. Level of Evidence: III

Fracturas basicervicales tratadas con clavo intramedular con tornillo cefálico único. Serie de casos y revisión bibliográfica / Basicervical fractures treated with single-screw cephalomedullary nail. Case series and review of the literature

Introducción: Debido a la inestabilidad rotatoria de las fracturas basicervicales, en estudios recientes, se sugiere el uso de una hoja espiral, doble tornillo o tornillos de compresión en lugar del tornillo cefálico único. Objetivo: Analizar los resultados de las fracturas basicervicales tratadas con tornillo cefálico único en nuestro centro. Materiales y Métodos: Estudio retrospectivo de una serie de casos formada a partir de la revisión de todas las fracturas extracapsulares de fémur proximal tratadas con clavo intramedular con tornillo cefálico único entre 2016 y 2020. Se revisaron las historias clínicas y las radiografías de 269 pacientes, y solo 12 (6,4%) de ellos cumplieron los criterios de inclusión (fracturas en dos fragmentos no patológicas y con seguimiento mínimo de 9 meses). Se evaluaron diferentes factores, como distancia punta-ápex, posición del tornillo cefálico, calidad de la reducción, tiempo quirúrgico, complicaciones y reintervención, y se analizaron las posibles diferencias entre los pacientes que sufrieron complicaciones y los que no. Resultados: Cuatro de los 12 pacientes tuvieron una falla de la fijación que evolucionó a cut-out (única complicación identificada en la muestra). No hubo diferencias estadísticamente significativas entre pacientes con cut-outo sin cut-out respecto al resto de las variables analizadas. Conclusiones: La elevada proporción de pacientes que desarrollaroncut-out sugiere considerar la hipótesis de que debería evitarse fijar las fracturas basicervicales con tornillo cefálico único. Dada su alta tasa de inestabilidad rotatoria, podría ser más apropiado el uso de implantes que la contrarresten. Nivel de Evidencia: IV

Background: Given the rotational instability of basicervical fractures, recent studies suggest using a spiral blade, a second screw or compression screws instead of single-screw cephalomedullary nail fixation. Objective: The aim of our study is to analyze the outcomes of basicervical fractures treated with single-screw cephalomedullary nails. Materials and Methods: This is a retrospective study based on a case series identified from all extracapsular femoral fractures treated with single-screw cephalomedullary nails in our hospital from 2016 to 2020. Clinical records and radiographs from 269 patients were reviewed; only 12 (6.4%) subjects met inclusion criteria (two-part non-pathologic fractures with at least a 9-month follow-up). Different factors were evaluated, including: tip-apex distance, cephalic screw position, reduction quality, surgical time, complications and re-operations; differences between patients who experienced complications and those who did not were also assessed. Results: Four subjects out of the 12 included patients experienced fixation failure and implant cut-out. There were no statistically significant differences between subjects with and without cut-out regarding the analyzed variables. Conclusions: The high cut-out rate observed in our sample suggests considering the hypothesis that single-screw cephalomedullary nail fixation should not be used in basicervical fractures. Alternative fixation devices capable of controlling the high rotational instability of these fractures may be preferable. Level of Evidence: IV

Complicaciones tempranas de la artroplastia total de cadera por vía anterolateral transglútea directa: estudio comparativo / Early complications in direct transgluteal anterolateral total hip arthroplasty. A comparative study

Introducción: En los últimos años, la introducción de diversas técnicas, el instrumental quirúrgico y las competencias del cirujano han contribuido a disminuir las complicaciones tempranas que pueden sobrevenir luego de una artroplastia de cadera. Las complicaciones más frecuentes son: el aflojamiento femoral, la trombosis venosa profunda y la luxación. Objetivos: Evaluar la tasa de complicaciones intraoperatorias y durante los primeros 12 meses luego de una artroplastia de cadera por vía anterolateral directa; y comparar los resultados con la serie publicada en 2007. Materiales y métodos: Estudio de cohorte retrospectivo que incluyó a pacientes operados por artrosis primaria de cadera en 2 instituciones, divididos en: grupo I (468 pacientes operados entre junio de 1999 y junio de 2003) y grupo II (344 pacientes operados entre enero de 2018 y enero de 2020). Resultados:La tasa global de complicaciones en la nueva serie fue del 4,7%. La trombosis venosa profunda fue la complicación que más se repitió, no hubo episodios de luxación. El empleo de cabezas de 22 mm de diámetro se asoció con un riesgo de luxación más alto que con cabezas más grandes (OR = 6,7; IC95% 1,2-78,2). Conclusiones: La artroplastia total de cadera con abordaje anterolateral transglúteo directo causó una baja tasa global de complicaciones dentro del primer año de la cirugía. Las complicaciones se redujeron casi a la mitad en las cirugías realizadas entre 2018 y 2020, con respecto a la serie anterior, fundamentalmente a expensas de la luxación. Nivel de Evidencia: IV

Introduction: In recent years, the advent of new procedures, surgical instruments, and surgeon skills has contributed to a reduction in the number of early complications that can arise after hip arthroplasty. Among the most frequent are femoral loosening, deep vein thrombosis, and dislocation. Objective: To evaluate the rate of intraoperative complications and complications within the first 12 months after a hip arthroplasty performed utilizing the direct anterolateral approach; and to compare the results to a series published in 2007. materials and methods: Retrospective cohort study, which included patients who underwent surgery for primary hip osteoarthritis at two institutions, divided into: group I (468 patients who were operated between June 1999 and June 2003) and group II (344 patients who were operated between January 2018 and January 2020). Results: The global rate of complications in group II was 4.7%. Deep vein thrombosis was the most frequent event, and there were no episodes of dislocation. The use of 22 mm diameter heads was associated with a higher risk of dislocation compared to surgeries in which larger heads were used (OR= 6.7 - 95% CI 1.2 - 78.2). Conclusions: Total hip replacement through a direct transgluteal anterolateral approach had a low global rate of complications within the first postoperative year. Complications were reduced by almost half in surgeries performed between 2018 and 2020, compared to the previous series, mainly in regards to dislocation. Level of Evidence: IV

Tratamiento de defectos acetabulares tipo IIIA-B de Paprosky y discontinuidad pélvica con implantes 3D a medida: resultados a mediano plazo / Treatment of Paprosky type IIIA-B acetabular defects and pelvic discontinuity with custom 3D implants. Medium-term results

Introducción: La revisión acetabular es una cirugía particularmente desafiante cuando hay pérdida de stock óseo y defectos acetabulares extensos. Los implantes 3D pueden suplir estos defectos y adaptarse a cada circunstancia. El objetivo de este estudio fue evaluar los resultados clínicos y radiográficos en pacientes con defectos acetabulares severos tratados con implantes impresos en 3D y determinar la constricción adecuada del cotilo para cada paciente. Materiales y métodos: Se realizó un estudio retrospectivo de 10 pacientes con defectos acetabulares severos clasificados como tipo IIIA-B de Paprosky y discontinuidad pélvica que se sometieron a una cirugía con prótesis acetabular a medida impresa en 3D, a cargo del mismo equipo quirúrgico, entre 2016 y 2022. Resultados: El seguimiento medio fue de 40.5 meses. El puntaje de cadera de Harris mejoró significativamente de un promedio de 24,2 a 63,5 en el último control. No se observaron signos de aflojamiento ni migración del cotilo 3D en cuanto a la inclinación y anteversión en ningún caso, en el último control. Conclusión: Los implantes acetabulares a medida representan una solución válida para tratar defectos óseos acetabulares severos y la discontinuidad pélvica. Nivel de Evidencia: IV

Introduction: Acetabular revision is a particularly challenging surgery when there is loss of bone stock and extensive acetabular defects. 3D implants can make up for these defects and adapt to each circumstance. The objective of this study was to evaluate clinical and radiographic outcomes in patients with severe acetabular defects treated with 3D-printed implants and determine the appropriate cup constraint for each patient. Materials and methods: A retrospective study was carried out on 10 patients with severe acetabular defects classified as Paprosky type IIIA-B and pelvic discontinuity who underwent surgery with a custom 3D-printed acetabular prosthesis, carried out by the same surgery team between 2016 and 2022. Results: The average follow-up was 40.5 months. The Harris hip score improved significantly from an average of 24.2 to 63.5 at the last follow-up. No signs of loosening or migration of the 3D cup in terms of inclination and anteversion were observed in any case, at the last control. Conclusion: Custom-made acetabular implants represent a valid solution to treat severe acetabular bone defects and pelvic discontinuity. Level of Evidence: IV

Resultados iniciales del uso de cotilos de doble movilidad en pacientes >65 años con fractura de cadera. Análisis retrospectivo de 102 casos / Preliminary outcomes with dual mobility cups in patients older than 65 with hip fractures. A retrospective analysis of 102 patients

Objetivo: El objetivo de este estudio retrospectivo fue evaluar los resultados funcionales y la tasa de luxación en pacientes >65 años con fractura de cadera operados con prótesis de doble movilidad. materiales y métodos: Se analizó a los pacientes tratados por una fractura de cadera entre 2017 y 2021. Se incluyó a pacientes >65 años, tratados con copas de doble movilidad y un seguimiento mínimo de 24 meses. Se analizaron los datos demográficos, las comorbilidades, los resultados funcionales (Parker y puntaje de Harris), las complicaciones (infección, luxación, aflojamiento), las reoperaciones y revisiones. Resultados: Se trataron 102 fracturas de cadera (75 mediales y 27 intertrocantéricas) en 102 pacientes. El 72,5% eran mujeres (media de la edad 80.59 ± 6.92 años), el Índice de Comorbilidad de Charlson promedio fue de 4,71 y el puntaje ASA, 2,47. El 93,1% comenzó a caminar al segundo día de la cirugía. Según el puntaje de Harris, los resultados fueron excelentes o muy buenos en el 94,1%; los puntajes de Parker preoperatorio y posoperatorio no difirieron significativamente (p <0,05). El seguimiento promedio fue de 30 meses. Hubo 8 (7,84%) complicaciones: 2 (1,9%) casos de trombosis venosa profunda, 4 (3,9%) de tromboembolismo pulmonar, tres infecciones (2,9%) y una (0,9%) luxación. La tasa de reoperaciones fue del 2,9%. Conclusiones: Con el empleo de copas de doble movilidad se obtuvieron resultados funcionales aceptables y una tasa de luxación relativamente baja (0,9%). Esto sugiere que estos implantes representan una opción en el tratamiento de estas lesiones. Nivel de Evidencia: IV

Objective: This retrospective study aimed to assess the functional outcomes and dislocation rate in the treatment with dual mobility prostheses in patients older than 65 with hip fractures. materials and methods: We analyzed all patients treated between 2017 and 2021 for hip fractures in our service. We included patients older than 65 years, treated with dual mobility cups, and a minimum follow-up of 24 months. We analyzed demographic data, comorbidities, functional outcomes (Parker score and Harris Hip Score, HHS), complications (infection, dislocation, loosening), reoperations, and revisions. Results: We included 102 hip fractures (75 medial and 27 intertrochanteric) in 102 patients. Seventy-four (72.5%) were women, the mean age was 80.59 ± 6.92 years, the mean Charlson index was 4.71 (range 3-10), and ASA was 2.47 (1-4). 93.1% started walking on the second postoperative day. 94.1% presented excellent or very good outcomes according to the HHS, the postoperative Parker index did not show significant differences in comparison to the preoperative one (p < 0.05). The average follow-up was 30 months (range 24-60). There were 8 (7.84%) complications: 2 (1.9%) deep vein thrombosis, 4 (3.9%) pulmonary thromboembolism, 3 infections (2.9%), and 1 (0.9%) dislocation. The reoperation rate was 2.9%. Conclusions: We obtained acceptable functional outcomes using dual mobility cups with a relatively low dislocation rate (0.9%). This suggests that these implants are an option to consider in treating these lesions. Level of Evidence: IV

Profilaxis antibiótica extendida para pacientes sometidos a una artroplastia de cadera primaria: ¿disminuye el riesgo de infecciones periprotésicas? / Extended oral antibiotic prophylaxis in primary hip arthroplasty: Does it decrease periprosthetic joint Infections?

Introducción: La prevalencia de infecciones periprotésicas luego de una artroplastia total de cadera primaria es aproximadamente del 2%. El objetivo de este estudio fue determinar si existen diferencias estadísticamente significativas entre la tasa de infeccio-nes periprotésicas agudas ante una profilaxis antibiótica extendida (7 días) y una profilaxis antibiótica estándar (24 h). Materiales y Métodos: Se realizó un estudio clínico prospectivo, entre julio de 2021 y mayo de 2022, que incluyó a 28 adultos con fractura de cadera sometidos a una artroplastia primaria que recibieron profilaxis antibiótica con cefalosporinas de primera generación durante 7 días a quienes se comparó con 95 adultos con fracturas de cadera con una artroplastia primaria y profilaxis antibiótica de 24 h, extraídos de una base de datos secundaria del registro del hospital. Resultados: La tasa de infecciones periprotésicas agudas fue del 10,71% en el grupo con profilaxis extendida y del 17,89% en quienes recibieron profilaxis estándar, sin diferencias estadísticamente significativas (p = 0,36). Conclusiones: Si bien, según la bibliografía disponible, la prolongación de la profilaxis antibiótica puede ser una medida simple, segura y rentable para contrarrestar los factores no modificables del paciente y así reducir las infecciones periprotésicas; en este estudio, no se demostró que la profilaxis antibiótica extendida disminuya la tasa de infecciones periprotésicas agudas a los 30 días en pacientes con artroplastias de cadera primarias. Nivel de Evidencia: II

Introduction: The prevalence of periprosthetic infections (PPIs) after primary total hip arthroplasty (THA) is approximately 2%. The objective of this study is to determine if there are statistically significant differences between the proportion of acute PPIs with extended oral antibiotic prophylaxis (7 days) vs standard oral antibiotic prophylaxis (24 hours). Materials and Methods: A prospective clinical trial was conducted between July 2021 and May 2022. A total of 28 adult patients with hip fracture underwent a primary arthroplasty and received extended oral antibiotic (EOA) prophylaxis for 7 days with first-generation cephalosporins. They were compared to a secondary database of the hospital registry, which included a total of 95 adult patients with hip fractures who underwent primary arthroplasty and received a standard oral antibiotic (SOA) prophylaxis for 24 hs. Results: In the EOA group, the rate of acute PPI was 10.71%, while in the SOA group it was 17.89%. When comparing the rate in both groups, no statistically significant differences were found (p=0.36). Conclusions: Although the available literature suggests that extended antibiotic prophylaxis can be a simple, safe, and cost-effective measure to counteract the patient's non-modifiable factors and thus reduce periprosthetic infections, our study found no evidence that it reduces the proportion of acute PPI at 30 days in primary hip arthroplasties. Level of Evidence: II

Conservación de tallos femorales no cementados fijos en pacientes con infección periprotésica crónica de cadera / Preservation of fixed cementless femoral stems in patients with chronic periprosthetic hip Infection

Introducción: La revisión en dos tiempos se considera el método de referencia para tratar a pacientes con artroplastia de cadera e infección crónica. Sin embargo, durante el retiro de un vástago femoral no cementado fijo, se puede dañar el fémur proximal, lo que puede plantear dificultades en el reimplante. Objetivo: Determinar si la infección periprotésica crónica de cadera se puede tratar con un intercambio parcial de sus componentes, conservando un vástago femoral no cementado fijo. materiales y métodos:Estudio de serie de casos retrospectivo, multicéntrico que incluyó a 9 pacientes con artroplastia de cadera e infección crónica, programados para el recambio parcial en uno o dos tiempos con retención del tallo femoral fijo, entre enero de 2014 y noviembre de 2019. Se evaluó la evolución mediante el examen clínico, el puntaje de cadera de Harris, y estudios de laboratorio y radiológicos. Resultados: En un seguimiento medio de 5.8 años de 9 pacientes con artroplastia de cadera no cementada, después del reimplante de la prótesis, la infección remitió en 8 pacientes (88,9%), y el puntaje medio de cadera de Harris fue de 81 en el último control. No hubo aflojamiento de componentes acetabulares ni femorales. Conclusiones: La conservación de vástagos femorales no cementados puede representar una opción aceptable para los pacientes con infección periprotésica crónica de cadera cuando la extracción del componente femoral daría como resultado una pérdida significativa de hueso y un compromiso de la reconstrucción. Sin embargo, se requieren más estudios sobre esta técnica. Nivel de Evidencia: IV

Introduction: Two-stage revision is considered the gold standard for the treatment of chronically infected hip arthroplasty. However, during the removal of a fixed cementless femoral stem, the proximal femur can be damaged, which can lead to difficulties in reimplantation. Objective: We intend to determine if chronic periprosthetic hip infection can be treated with a partial exchange of its components, in two stages, keeping a fixed cementless femoral stem. materials and methods: This retrospective, multicenter case series study included 9 patients with chronic infection following hip arthroplasty, scheduled for single- or two-stage partial exchange with retention of the fixed femoral stem between January 2014 and November 2019. We assessed the patients' progress through clinical examination, Harris Hip Score evaluation, and laboratory and radiological studies. Results: In a mean follow-up of 5.8 years in 9 patients with cementless hip arthroplasty, 8 patients achieved infection remission (88.9%) after prosthetic reimplantation, and the mean Harris Hip Score reached 81 points at the last follow-up evaluation. There was no loosening of acetabular or femoral components. Conclusions: Uncemented femoral stem retention may represent an acceptable option for patients with chronic periprosthetic hip infection when removal of the femoral component would result in significant bone loss and compromise of the reconstruction. However, more studies are required on this treatment. Level of Evidence: IV

Método simple para minimizar la discrepancia en la longitud de las extremidades y restaurar el offset en la artroplastia total de cadera / A Simple method to minimize limb length discrepancy and restore offset in total hip arthroplasty

Introducción: Existen más de 20 técnicas diferentes para corregir la discrepancia de miembros inferiores. El método que aquí se evalúa se basa en una clavija fija posicionada en el ala ilíaca asociada a un "calibre" móvil, con otra clavija con la que se marca la referencia en el trocánter mayor. Objetivo: Evaluar la confiabilidad de este dispositivo de medición usado durante la artroplastia total de cadera para restaurar la longitud del miembro inferior y el offset femoral. Materiales y Métodos: Se formaron dos grupos: grupo A con pacientes en quienes no se había usado el dispositivo y grupo B con pacientes en quienes sí se había usado el dispositivo. Se realizaron las mediciones en la radiografía panorámica de pelvis obtenida con el paciente de pie, antes de la cirugía y 3 meses después. Resultados: Se obtuvo una muestra de 80 pacientes (40 por grupo). Se logró corregir la discrepancia de la longitud de los miembros, pero no se hallaron diferencias estadísticamente significativas en la corrección promedio, entre ambos grupos (p = 0,07). Sin embargo, al analizar la varianza en la corrección de la discrepancia de la longitud de cada grupo se obtuvo una diferencia estadísticamente significativa (p <0,001). Conclusiones: Este dispositivo que permite una medición cuantificable más objetiva no asegura una corrección de la discrepancia de la longitud exacta a 0 mm, pero sí permite trabajar dentro de un rango más confiable y seguro. Nivel de Evidencia: III

Introduction: There are more than 20 different techniques to correct lower limb length discrepancy. The method evaluated in this study is based on a fixed pin in the iliac wing connected to a mobile gauge and another pin in the greater trochanter with which the reference is marked. The objective is to evaluate the reliability of this measurement device used during THA to restore lower limb length and femoral offset. Materials and Methods: Two groups were formed: Group A (patients who did not use the device) and Group B (patients who did use the device). Measurements were taken in the pre-surgery panoramic pelvic radiograph with the patient standing and three months later. Results: A sample of 80 patients was obtained, with 40 in each group. The difference in limb length could be corrected in each group, however the average correction achieved by both groups did not result in a statistically significant difference (p=0.07). However, when the variance in the correction of the difference in length of each group was examined, a statistically significant difference (p<0.001) was obtained. Conclusions: We can conclude that while this device, which serves as a more objective quantifiable measurement technique, does not guarantee a correction of the exact length discrepancy to 0 mm, it does allow us to work within a more dependable and safe range. Level of Evidence: III