Accuracy of intraoperative cultures in primary total hip arthroplasty

The aim of this investigation was to assess the diagnostic accuracy of intraoperative cultures for the early identification of patients who are at risk of infection after primary total hip arthroplasty. Four or six swabs were obtained immediately before the wound closure in 263 primary total hip replacements. Patients with a maximum of one positive culture were denoted as patients with a normal profile and did not receive any treatment. Patients with two or more positive cultures, with the same organism identified, were denoted as patients with a risk profile and received treatment with a specific antibiotic as determined by the antibiogram for six weeks. The follow-up ranged from a minimum of one year to five years and eleven months, concentrating on the presence or absence of infection, which was defined as discharge of pus through the surgical wound or as a fistula at any time after surgery. The accuracy of this procedure ( number of cases correctly identified in relation to the total number of cases) in the group of 152 arthroplasties in which 4 swabs per patient were collected was 96%. In the group of 111 arthroplasties in which 6 swabs per patient were collected the accuracy was 95.5%. We conclude that the collection of swabs under the conditions described is a method of high accuracy ( above 95%) for the evaluation of risk of infection after primary total hip arthroplasty.

Intervenção em fisioterapia numa prótese total do ombro

Introdução: A artroplastia total do ombro é largamente aceite como tratamento para uma variedade de patologias do ombro com dor persistente e perda acentuada da funcionalidade. Em termos globais, os resultados obtidos após a intervenção cirúrgica são bastante bons, parecendo estar, no entanto, condicionados com a patologia subjacente e a qualidade da coifa dos rotadores. Objectivo: Pretende-se com este trabalho descrever e avaliar a eficácia de um plano de intervenção numa prótese total do ombro com integridade da coifa dos rotadores. Metodologia: Paciente sexo feminino, 61 anos, reformada, com dor acentuada no ombro esquerdo desde há três anos, submetida a uma cirurgia de colocação de prótese total do ombro. Apresentava limitação da amplitude articular, diminuição da força, alteração do ritmo escapulo-umeral e ligeira incapacidade funcional. Cinco semanas após a cirurgia, iniciou sessões diárias de fisioterapia durante 12 semanas. A intervenção incluiu a aplicação de modalidades anti-álgicas, mobilização articular, fortalecimento muscular e reeducação neuromuscular. Foi avaliada em quatro momentos: antes da intervenção (M1), 4 (M2), 7 (M3) e 12 (M4) semanas após. Resultados: A dor diminuiu de 4 para 0 (END) no final de 7 semanas e as amplitudes articulares passivas aproximaram-se dos valores definidos pelo protocolo com a flexão/elevação anterior a evoluir de 90º para 130º; a abdução/elevação lateral de 80º para 110º e a rotação medial de 35º para 70º. A força muscular inicial era de 3 nos grupos musculares flexores, extensores e rotadores do ombro atingindo no final grau 4. O ritmo escapulo-umeral demonstrou assincronia durante a elevação do ombro na primeira avaliação, ficando quase normalizado no final das sessões. Quanto à funcionalidade, antes da intervenção o score obtido foi de 30.8 atingindo um valor de 11.6 no final das sessões de tratamento. Conclusão: Após 12 semanas de tratamento, os objectivos delineados foram praticamente atingidos, uma vez que a utente já não refere dor no ombro e apresenta uma boa capacidade funcional, apesar de apresentar ligeiras diferenças nas amplitudes articulares e força muscular esperadas, apontando para o sucesso do protocolo de tratamento aplicado.

Visual loss after orthopedic procedures.

Perioperative visual loss (PVL) is a very rare and unpredictable complication of surgery performed at distance from the visual pathways, mostly after spine or cardiac procedures. We report 6 consecutive patients with PVL after routine orthopedic procedures (osteosynthesis for complex fracture of the femur [2], total hip arthroplasty [2], hip prosthesis arthroplasty [1], bilateral simultaneous total knee arthroplasty [1]) and reviewed the literature on the subject. An ischemic optic neuropathy was diagnosed in all cases, and visual loss was bilateral in 5 of 6 patients. Partial visual improvement occurred in only 3 of 11 eyes. No specific therapy is available for PVL. Postoperative visual disturbances should prompt without delay an ophthalmic evaluation because emergent correction of anemia, systemic hypotension, or hypovolemia might improve visual prognosis of PVL.

Acute total hip arthroplasty for acetabular fractures in the elderly: 11 patients followed for 2 years.

We describe the use of cable fixation and acute total hip replacement for acetabular fracture in the elderly. 12 patients with acetabular fractures, having a mean age of 79 (65-93) years, were treated with cable fixation and acute total hip arthroplasty. 8 were T-shaped fractures and 4 associated fractures of the posterior column and posterior wall. 1 patient died 5 months after surgery and the remaining 11 were followed for 2 years. All patients had a good clinical outcome. Radiographic assessment showed healing of the fracture and a satisfactory alignment of the cup without loosening. This surgical technique provides good primary fixation, stabilizes complex acetabular fractures in elderly patients with osteoporotic bone and permits early postoperative mobilization.

Extra-articular knee resection for a secondary chondrosarcoma evolving from an isolated enchondroma of the distal femur: A case report.

Introduction: Enchondromas are among the most current benign bone tumours. Malignant degeneration is extremely rare (<1%) and generally presents as a low grade chondrosarcoma. For localized grade 1 lesions, the treatment of choice is curettage. Wide excision and reconstruction is generally not necessary, unless locally advanced or more aggressive behaviour is suspected at presentation. Case report: A healthy 72 yo male presented with pain and recurrent knee joint effusion. X-rays show a classical central distal metaphyseal enchondroma of the femur associated with subtle osteolysis of the lateral condyle. MRI confirms the presence of a locally aggressive chondromatous lesion based in a classical enchondroma. Core needle biopsy revealed a grade 1 chondrosarcoma, which was in contrast to the radiological aggressiveness of the lesion. Total body CT-scan did not reveal metastatic disease. A wide resection was planned, as a high-grade lesion and joint contamination was suspected. We performed an extra-articular knee resection and reconstruction with a hinged modular total knee megaprosthesis. The definitive histology was grade 1 chondrosarcoma, the surgical margins were wide. The evolution was favourable and the patient was able to perform all his activities of daily living independently without pain at 6 weeks postop. Knee flexion reached 90°. The oncologic screening at 18 months did not show local or distant recurrence. Conclusion: Joints near a benign tumour that suddenly become symptomatic or present an effusion might indicate a malignant transformation. Wide resection and prosthetic reconstruction remains an effective treatment option even in low grade cartilaginous lesions if (1) the adjacent joint is contaminated, or (2) joint-sparing surgery would result in a severe functional impairment of the limb.

Prothèse totale de la hanche par voie antérieure "mini-invasive" [Total hip arthroplasty through anterior "minimal invasive" approach].

Total hip replacement has seen a tremendous development and has become one of the most successful surgical interventions in orthopaedics. While during the first decades of development of total hip arthroplasty the fixation of the implant into the bone was the main concern, the focus has shifted towards surgical technique and soft tissue handling. In order to avoid permanent soft tissue damage, muscular dysfunction and concerns in regards to cosmetics, minimal invasive and anatomic approaches have been developed. We here provide a short overview on various methods of total hip replacements and we describe our technique through a minimal invasive direct anterior approach. While muscle and nerve damage is minimal, this technique allows for a rapid rehabilitation and is associated with an excellent functional outcome and a minimal risk for dislocation.

Outcome evaluation of ankle osteoarthritis treatments using spatio-temporal gait parameters and plantar pressure during unconstrained long distance walking : P25

Introduction: Ankle arthrodesis (AD) and total ankle replacement (TAR) are typical treatments for ankle osteoarthritis (AO). Despite clinical interest, there is a lack of their outcome evaluation using objective criteria. Gait analysis and plantar pressure assessment are appropriate to detect pathologies in orthopaedics but they are mostly used in lab with few gait cycles. In this study, we propose an ambulatory device based on inertial and plantar pressure sensors to compare the gait during long-distance trials between healthy subjects (H) and patients with AO or treated by AD and TAR. Methods: Our study included four groups: 11 patients with AO, 9 treated by TAR, 7 treated by AD and 6 control subjects. An ambulatory system (Physilog®, CH) was used for gait analysis; plantar pressure measurements were done using a portable insole (Pedar®-X, DE). The subjects were asked to walk 50 meters in two trials. Mean value and coefficient of variation of spatio-temporal gait parameters were calculated for each trial. Pressure distribution was analyzed in ten subregions of foot. All parameters were compared among the four groups using multi-level model-based statistical analysis. Results: Significant difference (p <0.05) with control was noticed for AO patients in maximum force in medial hindfoot and forefoot and in central forefoot. These differences were no longer significant in TAR and AD groups. Cadence and speed of all pathologic groups showed significant difference with control. Both treatments showed a significant improvement in double support and stance. TAR decreased variability in speed, stride length and knee ROM. Conclusions: In spite of a small sample size, this study showed that ankle function after AO treatments can be evaluated objectively based on plantar pressure and spatio-temporal gait parameters measured during unconstrained walking outside the lab. The combination of these two ambulatory techniques provides a promising way to evaluate foot function in clinics.

Lack of extended venous thromboembolism prophylaxis in high-risk patients undergoing major orthopaedic or major cancer surgery. Electronic Assessment of VTE Prophylaxis in High-Risk Surgical Patients at Discharge from Swiss Hospitals (ESSENTIAL).

Extended pharmacological venous thromboembolism (VTE) prophylaxis beyond discharge is recommended for patients undergoing high-risk surgery. We prospectively investigated prophylaxis in 1,046 consecutive patients undergoing major orthopaedic (70%) or major cancer surgery (30%) in 14 Swiss hospitals. Appropriate in-hospital prophylaxis was used in 1,003 (96%) patients. At discharge, 638 (61%) patients received prescription for extended pharmacological prophylaxis: 564 (77%) after orthopaedic surgery, and 74 (23%) after cancer surgery (p < 0.001). Patients with knee replacement (94%), hip replacement (81%), major trauma (80%), and curative arthroscopy (73%) had the highest prescription rates for extended VTE prophylaxis; the lowest rates were found in patients undergoing major surgery for thoracic (7%), gastrointestinal (19%), and hepatobiliary (33%) cancer. The median duration of prescribed extended prophylaxis was longer in patients with orthopaedic surgery (32 days, interquartile range 14-40 days) than in patients with cancer surgery (23 days, interquartile range 11-30 days; p<0.001). Among the 278 patients with an extended prophylaxis order after hip replacement, knee replacement, or hip fracture surgery, 120 (43%) received a prescription for at least 35 days, and among the 74 patients with an extended prophylaxis order after major cancer surgery, 20 (27%) received a prescription for at least 28 days. In conclusion, approximately one quarter of the patients with major orthopaedic surgery and more than three quarters of the patients with major cancer surgery did not receive prescription for extended VTE prophylaxis. Future effort should focus on the improvement of extended VTE prophylaxis, particularly in patients undergoing major cancer surgery.

Indirect comparison meta-analysis of two enoxaparin regimens in patients undergoing major orthopaedic surgery. Impact on the interpretation of thromboprophylactic effects of new anticoagulant drugs.

Two enoxaparin dosage regimens are used as comparators to evaluate new anticoagulants for thromboprophylaxis in patients undergoing major orthopaedic surgery, but so far no satisfactory direct comparison between them has been published. Our objective was to compare the efficacy and safety of enoxaparin 3,000 anti-Xa IU twice daily and enoxaparin 4,000 anti-Xa IU once daily in this clinical setting by indirect comparison meta-analysis, using Bucher's method. We selected randomised controlled trials comparing another anticoagulant, placebo (or no treatment) with either enoxaparin regimen for venous thromboembolism prophylaxis after hip or knee replacement or hip fracture surgery, provided that the second regimen was assessed elsewhere versus the same comparator. Two authors independently evaluated study eligibility, extracted the data, and assessed the risk of bias. The primary efficacy outcome was the incidence of venous thomboembolism. The main safety outcome was the incidence of major bleeding. Overall, 44 randomised comparisons in 56,423 patients were selected, 35 being double-blind (54,117 patients). Compared with enoxaparin 4,000 anti-Xa IU once daily, enoxaparin 3,000 anti-Xa IU twice daily was associated with a reduced risk of venous thromboembolism (relative risk [RR]: 0.53, 95% confidence interval [CI]: 0.40 to 0.69), but an increased risk of major bleeding (RR: 2.01, 95% CI: 1.23 to 3.29). In conclusion, when interpreting the benefit-risk ratio of new anticoagulant drugs versus enoxaparin for thromboprophylaxis after major orthopaedic surgery, the apparently greater efficacy but higher bleeding risk of the twice-daily 3,000 anti-Xa IU enoxaparin regimen compared to the once-daily 4,000 anti-Xa IU regimen should be taken into account.

Tratamiento quirúrgico de las fracturas intertrocantéricas del fémur con placa tornillo dinámico convencional comparado con tornillo dinámico helicoidal

Introducción: Las fracturas intertrocantéricas han llegado a nuestros días con una mayor incidencia dado el envejecimiento de la población, con fracturas más complejas, menos estables y asociadas a osteoporosis, se estima que representan aproximadamente 1,75 millones de años de vida perdidos ajustados a discapacidad es decir 0,1% de la carga de morbilidad a nivel mundial. Existe consenso en el tratamiento quirúrgico de este tipo de fracturas, presentando una incidencia variable de fallos, principalmente cuando son inestables, entre estos el denominado “cuto ut”. La utilización de un método de fijación con placa y tornillo helicoidal (DHHS) aparentemente disminuye la incidencia de dichos fallos con respecto a otras técnicas. Metodología: Por medio de una muestra calculada en 128 de pacientes con fracturas intertrocantéricas operados con DHS y DHHS entre el 2007 y el 2012 en La Clínica San Rafael de la ciudad de Bogotá, Colombia, se realizó un análisis multivariado para determinar si existe o no diferencias significativas en los índices de fallo entre estas dos técnicas. Resultados: Los pacientes incluidos en el estudio 54 (42,1%) fueron hombres y 74 (57,8%) fueron mujeres. 75 fueron operados con DHHS y 53 con DHS; en cuanto a las comorbilidades las principales fueron Hipertensión con 40 pacientes para DHS y 30 para DHHS, para el caso de Diabetes Mellitus fueron 13 y 9 para DHS y DHHS, respectivamente; en cuanto al tipo de fractura más común la principal fue la clasificación Tronzo II con 9 pacientes para DHS y 13 para DHHS. Conclusión. Para el estudios se evidencia que para los 3 desenlaces principales evaluados, 1. El porcentaje de re intervención (p=0,282), 2. La supervivencia en el primer año (p=0,499) y 3. El desempeño funcional con la escala de Oxford (p=0,06); no hubo diferencias estadísticamente significativas entre los grupos.

Resultados tratamiento de las fracturas intertrocantéricas en el Hospital Universitario Mayor MEREDÍ

Las fracturas intertrocantericas son una importante causa de la morbimortalidad en los adultos mayores. Requieren la mayoria manejo quirurgico. No se ha logrado definir si es mejor el tratamiento con osteosintesis o artoplastia de cadera. Por esta razon decidimos realizar un estudio identificando los resultados en cada uno de los tratamientos con poblacion colombiana en el Hospital Universitario Mayor Mederi. Metodos: Estudio de serie de casos. Se analizó una cohorte retrospectiva de pacientes mayores de 59 años con fractura intertrocantérica en el Hospital Universitario Mayor Méderi. Resultados: Se reportaron un total de 179 pacientes con diagnóstico de fractura intertrocantérica. De los cuales se realizaron 100 osteosíntesis , 20 reemplazos totales de cadera y 59 hemiartroplastias. La mortalidad fueron 11 pacientes que corresponde al 6.1%, 3 fueron hombres y 8 mujeres, en cuanto al procedimiento realizado a 7 pacientes se les realizo osteosíntesis y a los 4 restantes se les realizo hemiartroplastia. En total 7 infecciones las cuales se presentaron respectivamente en 6 osteosíntesis y 1 hemiartroplastia. Discusión: La mortalidad fue mayor en la osteosíntesis con 7 pacientes que equivale al 63,6 % de la mortalidad total del estudio. Los porcentajes de infección postoperatoria fueron mayores en la osteosíntesis , encontrándose que del total de pacientes intervenidos 3,9% se infectaron y de estos el 85,7 % corresponden a osteosíntesis versus 14,3% de hemiartroplastia. El sangrado postoperatorio fue mayor a 500 cc en un 39% de las osteosíntesis y en un 44% en las hemiartroplastias. Conclusión: el tratamiento de las fracturas intertrocantéricas tuvo menor mortalidad y menor porcentaje de infección cuando los pacientes fueron tratados con hemiartroplastia y reemplazo total de cadera.

Total Endovascular Debranching of the Aortic Arch

Background: Significant morbidity and mortality are related to conventional aortic replacement surgery. Endovascular debranching techniques, fenestrated or branched endografts are time consuming and costly.Objective: We alternatively propose to use endovascular approach with parallel grafts for debranching of aortic arch.Methods: Under general anesthesia, 12 F sheaths were inserted in the femoral, axillary and common carotid arteries for vascular accesses. ViaBahn grafts 10 - 15 cm in length were placed into the aortic arch from right common carotid, left common carotid and left axillary arteries, until the tip of each graft reached into the ascending aorta. Through one femoral artery, the aortic stent-graft was positioned and delivered. Soon after, the parallel grafts were sequentially delivered. Self-spanding Wallstents(R) were used for parallel grafts reinforcement. Ballooning was routinely used for parallel grafts and rarely for aortic graft.Results: This technique was used in 2 cases. The first one was a lady with 72 years old, with an aortic retrograde dissection from left subclavian artery and involving remaining arch branches. Through right common carotid artery a stent-graft was placed in the ascending aorta and through the left common carotid artery a ViaBahn was inserted parallel to the former. A thoracic endograft then covered all the aortic arch dissection extending into the ascending aorta close to the sinu-tubular junction. The second case was a 82 year old male patient with a 7 cm aortic arch aneurysm. Through both common carotid arteries ViaBahn grafts were introduced and positioned into the ascending aorta. Soon after, the deployment of the thoracic stent graft covered all parallel grafts of the aortic arch, excluding the aneurysm. Both cases did not have neurologic or cardiac complications and were discharged 10 days after the procedure.Conclusions: This technique may be a good minimal invasive off-the-shelf technical option for aortic arch "debranching". More data and further improvements are required before this promising technique can be widely advocated. (C) 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Plasma rico e plaquetas (PRP) aplicado na artroplastia total do joelho

Pós-graduação em Pesquisa e Desenvolvimento (Biotecnologia Médica) - FMB

Simulação numérica através do método dos elementos finitos e comparação experimental para obtenção de tensões e deformações específicas em fêmur com prótese total de quadril

Pós-graduação em Engenharia Mecânica - FEG

Obesity, age, sex, diagnosis, and fixation mode differently affect early cup failure in total hip arthroplasty: a matched case-control study of 4420 patients

Studies about the influence of patient characteristics on mechanical failure of cups in total hip replacement have applied different methodologies and revealed inconclusive results. The fixation mode has rarely been investigated. Therefore, we conducted a detailed analysis of the influence of patient characteristics and fixation mode on cup failure risks.