Measuring Outcomes: Pain and Quality of Life 48 Months After Acute Postoperative Total Knee Prosthetic Joint Infection.

BACKGROUND: Measuring HRQOL is simple, inexpensive, permits the health status to be measured over time, and is useful to compare or initiate treatments and evaluate results, facilitating homogenization in patient inclusion. OBJECTIVES: To evaluate disease-specific and generic HRQOL and influence of associated factors in patients undergoing open debridement for acute postsurgical knee prosthetic joint infection after TKR at 12 and 48 months after completing antibiotic treatment and considered cured of infection. METHODS: Health-related quality-of-life measures were administered at baseline (WOMAC) and 12 and 48 months (WOMAC and SF-36) in patients with prosthesis retention, no symptoms of infection, and CRP (≤ 1 mg/dL). RESULTS: Thirty patients were included, and 24 were evaluated at 48 months. WOMAC scores improved significantly (P < 0.01) at 12 and 48 months. The effect size was 0.72 for stiffness, 2.01 for pain, and 2.15 for function. At 48 months, improvements were greater (P < 0.02) except for stiffness. The most frequently isolated microorganisms were Staphylococcus aureus (14 patients) and coagulase-negative staphylococci (9 patients). SF-36 physical role, bodily pain, emotional role, and mental health dimension scores at 12 and 48 months were significantly worse in patients with isolates of Staphylococcus aureus (P < 0.05). CONCLUSIONS: Health-related quality-of-life measures detected significant differences in outcomes in patients infected by S. aureus compared with patients infected by other microorganisms. HRQOL measures may provide useful complementary information on outcomes after acute postoperative infection.

Tibial tubercle osteotomy in septic revision total knee arthroplasty.

PURPOSE: The incidence of revision knee arthroplasty for infection is increasing and the required surgical approach for the revision is a challenge for surgeons. Extensile approaches are frequently used when it is impossible to evert the extensor mechanism. The aim of this paper is to report our experience with tibial tubercle osteotomy (TTO) and the functional results in patients who underwent a two-stage revision due to prosthesis infection. METHODS: Twenty-six patients underwent a TTO as a surgical approach in the second stage of revision for infection. The patients were clinically assessed by means of functional scales (the Knee Society Score and WOMAC) and X-rays. RESULTS: The TTO healed without complications in 22 patients (84.6%) and the average length of follow-up was 3.4 years. Non-union was observed in two patients. One patient presented an extension lag of 5°. A total of 23 patients (88.4%) were free from infection. Twenty-five patients (96.1%) had better scores on the Knee Society Score and WOMAC after the procedure. CONCLUSIONS: In patients undergoing the second stage of revision total knee arthroplasty for infection, the TTO approach provides a large operating field. This enables surgeons to withdraw spacers and position new implants without damaging the extensor mechanism of the knee or altering the postoperative rehabilitation process. The complications that have been reported as a result of this procedure could be reduced by performing a meticulous surgical technique. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

[Secondary prevention in osteoporotic fractures. The GIOS project]. / Prevención secundaria en fracturas osteoporóticas. Resultados del proyecto GIOS.

BACKGROUND AND OBJECTIVE: The aim of this report is to describe and evaluate the results of a secondary prevention program in osteoporotic fractures in 70 Spanish hospitals. This project was started to improve the treatment of these fractures, with the inhospital implementation of software collecting epidemiological data on patients with osteoporotic fractures. PATIENTS AND METHODS: A prospective case study was conducted between March 2003 and March 2006 involving a consecutive sample of 24,534 patients with established fragility fracture seen in 70 hospitals. The study exclusion criterion was secondary osteoporotic fracture. The project consists of implementing software in hospitals, designed to collect such epidemiological data among these patients. Based on this information and on the published scientific evidence, the software automatically generates drug therapy recommendations and non pharmacologic measures of prevention to be included in the discharge report. RESULTS: The number of patients with osteoporotic fractures included in the program totalled 24,534 subjects. Of these patients, only 22.7% were receiving treatment for osteoporosis. Implementation of the program made it possible to discharge 19,033 patients (77.6%) with prescribed treatment, but in only 15,153 patients (61.8%) the treatment was correct. CONCLUSIONS: The GIOS project has proved effective in increasing the identification of fragility fractures and improve the percentage of secondary prevention measures, both pharmacological and non pharmacological, for patients with these fractures.

Timing of antibiotic prophylaxis for primary total knee arthroplasty performed during ischemia.

BACKGROUND: There is no clinical trial analyzing the best moment to infuse an antibiotic during knee arthroplasty performed during ischemia. We designed a single-center, randomized, double-blind, placebo-controlled trial to evaluate whether antibiotic therapy should be administered before tourniquet inflation or just before tourniquet deflation. MATERIAL AND METHODS: Patients who underwent a primary knee arthroplasty were randomized to receive (1) 1.5 g of cefuroxime 10-30 min before inflation of the tourniquet and placebo 10 min before release of the tourniquet (standard arm) or (2) placebo 10-30 min before inflation of the tourniquet and 1.5 g of cefuroxime 10 min before release of the tourniquet (experimental arm). In both arms, a postoperative dose of 1.5 g of cefuroxime was given 6 h after the surgical procedure. The main variables associated with the rate of deep-tissue infection after 3 and 12 months of follow-up were gathered. Continuous variables were compared using Student's t test, and categorical variables were compared using the chi(2) test or Fisher's exact test. RESULTS: From September 2004 through December 2005, a total of 908 patients were randomized, 442 and 466 of whom were allocated to the standard and experimental arms, respectively. There were no differences between treatment arms in terms of age, sex, comorbidity, American Society of Anaesthesiologists score, duration of surgery, need of blood transfusion, or fourth-day hematocrit. The rates of deep-tissue infection among the standard and experimental groups were 3.4% and 1.9%, respectively, at 3 months of follow-up (P = .21) and 3.6% and 2.6%, respectively, at 12 months of follow-up (P = .44). CONCLUSION: The administration of prophylactic antibiotics just before tourniquet release was not inferior to standard antibiotic prophylaxis.

Good quality of life in severely obese total knee replacement patients: a case-control study.

BACKGROUND: The impact of obesity on total knee replacement (TKR) outcomes is unclear. Studies use different classifications of obesity and heterogeneous methods, making comparisons difficult. The aim of this study was to evaluate health-related quality of life (HRQL) preoperatively and at 12 months of follow-up in severe and morbidly obese patients with knee osteoarthritis and a control group of nonobese patients undergoing TKR. METHODS: Case-control study with 12 months follow-up. HRQL was measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire. Sociodemographic variables, comorbidity, body mass index (BMI), degree of intra-operative difficulty (IOD), in-patient data, and postoperative medical data were collected. The effect size (ES) was measured for the different outcome measures. Comparison of the two groups after 12 months of follow-up was made using the t test. STUDY GROUP: sixty patients (88% women) with a mean age of 70.2 years (SD 6.7) and mean total WOMAC dimension score 61.4 (SD 16.7). CONTROL GROUP: 60 matched controls. There were 88% women, with a mean age of 71.7 years (SD 6.7), and a mean WOMAC score of 58.2 (SD 13.4). There were significant improvements in all WOMAC dimensions compared to baseline (p < 0.001) in both groups. There were no differences in WOMAC dimension scores between the two groups at 12 months. The study group had more IOD (p = 0.014) and more-severe complications in the follow up. CONCLUSIONS: Severe and morbidly obese and nonobese patients had similar change scores and TKR outcomes in terms of HRQL at 12 months after TKR. Obese patients had more intraoperative difficulties and more-severe postoperative complications.

Hospital at home in elective total hip arthroplasty.

With the recent trend towards reducing hospital stay, it has become increasingly important to ensure that early patient discharge after total hip replacement is a safe practice. We evaluated complications and length of hospital stay associated with primary unilateral hip arthroplasty in 47 patients undergoing a new early discharge protocol consisting of at home based specialized care after hospital discharge. The mean length of stay (and standard deviation) in hospital was 4.59 ± 0.68. The mean length of stay of home-based hospitalization was 3.7 ± 1. The prevalence of postoperative complications was 12.8% and the readmission rate was 6.4%. We saw a reduction of hospital stay with no difference in outcomes in comparison with previous data. On the basis of our findings we recommend the use of the early discharge protocol following elective primary total hip replacement and ongoing evaluation of the process.

Total knee replacement and health-related quality of life: factors influencing long-term outcomes.

OBJECTIVE: To evaluate health-related quality of life (HRQOL) in patients with osteoarthritis undergoing total knee replacement (TKR); identify the influence of sociodemographic, clinical, intraoperative, and postoperative variables on HRQOL; and determine patient perceptions at 7 years. METHODS: We conducted a prospective study with 7 years of followup. HRQOL measures (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] and Short Form 36 [SF-36]); sociodemographic, clinical, intraoperative, inpatient, and postoperative data; patient perceptions of TKR outcomes; and physical activity at 7 years were determined. Associations were analyzed using linear regression models. RESULTS: Of 146 eligible patients, 112 (86 women, mean age 67.3 years) completed followup data. There were significant differences between pre- and postoperative WOMAC pain, stiffness, and function scores (P < 0.001). Variables retained in each of the models explained 14-32% (adjusted R(2)) of variability of the WOMAC dimensions. Obesity and postdischarge complications were associated with worse scores in all WOMAC dimensions (P < 0.05). Eighty-six percent of patients were satisfied with TKR, 80% would undergo the operation again, and 56% did regular physical activity and had better WOMAC scores (P < 0.05, except for stiffness [not significant]). Mean +/- SD SF-36 scores for men and women at 7 years were 55.1 +/- 27.1 and 39.5 +/- 22.9 for physical function, 71.2 +/- 36.5 and 51.5 +/- 42.7 for physical role, 66.2 +/- 26 and 55.6 +/- 28.9 for bodily pain, and 60.7 +/- 17.1 and 50.7 +/- 21.2 for general health, respectively. CONCLUSION: WOMAC dimension scores, especially pain, significantly improved at 7 years and were negatively influenced by obesity and postdischarge complications. HRQOL measures may help identify an increased risk of negative outcomes after TKR.

[Meniscal harvesting, processing and preservation for allogeneic transplantation]. / Obtención, procesamiento y conservación de menisco para trasplante alógeno.

INTRODUCTION: The allogeneic meniscal transplantation (AMT) has received much attention lately for the treatment of young, active patients with painful knees previously subjected to meniscectomy. OBJECTIVE: Show the current concepts on AMT as well as the methods for meniscal harvesting, processing and preservation that the Tissue Bank must implement. CONCLUSIONS: Based on the results of the short- and medium-term studies, the AMT has proven to relieve pain and improve function in patients with symptomatic knees and a history of meniscectomy. To respond to the requests from surgeons, the Tissue Bank should supply grafts that assure the appropriate processing and quality of the meniscus.

Anterior Dislocation of the Hip Associated with an Actebular Fracture: Case Report.

Anterior hip joint dislocation is less common than posterior dislocation. Although fractures of the acetabulum can occur in anterior hip dislocations, they are infrequently. In this article, we report an uncommon lesion in a woman who sustained an anterior dislocation of the hip associated with a fracture of the acetabular wall. Close reduction was performed immediately the initial injury. The patient underwent open reduction and internal fixation since the hip joint was result unstable and the CT scan showed the presence of a bone fragment of the anterior acetabular wall. At 2-year follow-up, the clinical and radiological results are excellent.

Cryopreserved and frozen hyaline cartilage imaged by environmental scanning electron microscope. An experimental and prospective study.

OBJECTIVE: To obtain images of the articular surface of osteochondral grafts (fresh, frozen, and cryopreserved in RPMI) using an environmental scanning electron microscope (ESEM). To evaluate and compare the main morphological aspects of the chondral surface of the fresh, frozen, and cryopreserved grafts as visualized via ESEM. METHODS: The study was based on osteochondral fragments from the internal condyle of the knee joint of New Zealand rabbits, corresponding to the chondral surface from fresh, frozen, and cryopreserved samples. One hundred ESEM images were obtained from each group and then classified according to a validated system. The kappa index and the corresponding concordance index were calculated, and the groups were compared by Pearson's chi-squared test (p < 0.05). RESULTS: The articular surface of cryopreserved osteochondral grafts had fewer even surfaces and filled lacunae and a higher number of empty lacunae as compared to fresh samples; these differences correspond to images of cell membrane lesions that lead to destruction of the chondrocyte. Frozen grafts showed more hillocky and knobby surfaces than did fresh grafts; they also had a greater number of empty chondrocyte lacunae. CONCLUSION: ESEM is useful for obtaining images of the surface of osteochondral grafts. When compared to fresh samples, cryopreservation in RPMI medium produces changes in the surface of hyaline cartilage, but to a lesser extent than those produced by freezing.

Prevención secundaria en fracturas osteoporóticas. Resultados del proyecto GIOS / Secondary prevention in osteoporotic fractures. The GIOS project

Fundamento y objetivo: El propósito de este trabajo es presentar y evaluar el resultado de un programa de prevención secundaria de fracturas osteoporóticas en 70 hospitales españoles. El proyecto se puso en marcha para mejorar el tratamiento de dichas fracturas, con la introducción de un programa que recopila datos epidemiológicos de pacientes con fracturas osteoporóticas.Pacientes y método: Se realizó un estudio prospectivo entre marzo de 2003 y marzo de 2006 que recogió una muestra consecutiva de 24.534 pacientes con fractura por fragilidad ósea atendidos en 70 hospitales. Se excluyeron las fracturas por osteoporosis secundaria. El proyecto consistió en instalar el programa en los hospitales con el objeto de recopilar datos epidemiológicos de estos pacientes. Basados en la información obtenida y en las evidencias científicas publicadas, el programa genera automáticamente unas recomendaciones terapéuticas de prevención farmacológicas y no farmacológicas que son incluidas en el informe de alta.Resultados: El número de pacientes con fractura osteoporótica incluidos en el programa fue 24.534. De estos pacientes, sólo el 22,7% estában recibiendo tratamiento para la osteoporosis. La utilización del programa hizo posible que 19.033 pacientes (77,6%) recibieran tratamiento al alta, pero sólo 15.153 pacientes (61,8%) recibieron un tratamiento correcto. Conclusiones: El proyecto GIOS ha demostrado ser efectivo para incrementar la identificación de fracturas por fragilidad y mejorar el porcentaje de medidas de prevención secundaria, farmacológicas y no farmacológicas, en pacientes con estas fracturas (AU)

Background and objective: The aim of this report is to describe and evaluate the results of a secondary prevention program in osteoporotic fractures in 70 Spanish hospitals. This project was started to improve the treatment of these fractures, with the inhospital implementation of software collecting epidemiological data on patients with osteoporotic fractures. Patients and methods: A prospective case study was conducted between March 2003 and March 2006 involving a consecutive sample of 24,534 patients with established fragility fracture seen in 70 hospitals. The study exclusion criterion was secondary osteoporotic fracture. The project consists of implementing software in hospitals, designed to collect such epidemiological data among these patients. Based on this information and on the published scientific evidence, the software automatically generates drug therapy recommendations and non pharmacologic measures of prevention to be included in the discharge report.Results: The number of patients with osteoporotic fractures included in the program totalled 24,534 subjects. Of these patients, only 22.7% were receiving treatment for osteoporosis. Implementation of the program made it possible to discharge 19,033 patients (77.6%) with prescribed treatment, but in only 15,153 patients (61.8%) the treatment was correct. Conclusions: The GIOS project has proved effective in increasing the identification of fragility fractures and improve the percentage of secondary prevention measures, both pharmacological and non pharmacological, for patients with these fractures (AU)

Rupturas meniscales en pacientes mayores de 50 años / Menisci rupture in patients greatest fifty years

A 30 pacientes de edad superior a los 50 años que presentaban un dolor en compartimiento interno de rodilla de origen degenerativo, se les diagnosticó de una lesión meniscal, practicándoseles una meniscectomía artroscópica. Se valoraron los resultados en relación con la presencia o no de signos artrósicos previos a la meniscectomía. Se constató la mejoría sintomática, consiguiendo los mejores resultados en las lesiones traumáticas y degenerativas tipo IV. En los pacientes sin signos artrósicos, la edad no fue un factor adverso al resultado de la meniscectomía

Tuberculosis espinal: tratamiento quirúrgico temprano coadyuvante al tratamiento médico / Spinal tuberculosis: early surgical treatment combined with medical treatment

FUNDAMENTO: La tuberculosis vertebral puede producir cifosis con déficit neurológico a pesar del tratamiento antibiótico. En ausencia de respuesta a la medicación debe efectuarse curetaje del foco, desbridamiento y fusión. Las características biológicas de Mycobacterium tuberculosis no impiden la osteosíntesis sobre el hueso infectado. PACIENTES Y MÉTODO: Cinco pacientes con tuberculosis vertebral y déficit neurológico fueron tratados mediante curetaje, desbridamiento, fusión intersomática y osteosíntesis anterior además del tratamiento médico. En tres pacientes se añadió fusión posterior para asegurar la estabilidad de la osteosíntesis. Todos presentaban astenia y paresia de extremidades inferiores, dos pacientes sufrían una radiculopatía de L4 y otro paciente presentó una paraparesia. El valor medio de la cifosis vertebral fue de 22,8°. El seguimiento ha sido de 3,1 años, y se descartó a un paciente por seguimiento insuficiente. RESULTADOS: No se ha producido ningún aflojamiento séptico del material de osteosíntesis ni progresión de la enfermedad. La corrección de la cifosis ha sido del 104,5 por ciento postoperatoria y del 80,5 por ciento al final del seguimiento. Se ha recuperado el déficit neurológico en todos los pacientes, excepto en uno con dolor metamérico L4. CONCLUSIONES: La instrumentación anterior permite la descompresión espinal, la limpieza del foco séptico, la corrección de la deformidad y el aporte de hueso autólogo. En aplastamientos cifóticos graves es aconsejable asociar una artrodesis posterior economizando el número de niveles. La asociación de los tratamientos médico y quirúrgico mejora la evolución de los pacientes cuando aparecen fracturas patológicas o en ausencia de respuesta al tratamiento antibiótico (AU)