Retrospective survival analysis of the use of uncemented modular tapered stems for revision in periprosthetic Vancouver B-type fractures. Is instability a threat to survival?

INTRODUCTION AND OBJECTIVES

Periprosthetic hip fractures show increasing incidence and complexity, representing a challenge for the surgeon. We aimed to evaluate the survival of uncemented modular tapered stems in the treatment of periprosthetic Vancouver B2 and B3 type fractures and review the main complications and factors associated with decreased survival.

MATERIALS AND METHODS

We performed a retrospective study of patients submitted to revision arthroplasty for treatment of periprosthetic femoral stem Vancouver B2 and B3 type fractures with an uncemented modular fluted tapered stem (MRP-Titan). Demographic and radiographic parameters were analyzed. The survival rate (free of reoperation) was calculated at 2- and 5-years using the Kaplan-Meier survivorship analysis.

RESULTS

Thirty-nine patients were included with a mean age of 73.5 years and a mean follow-up of 5 years. Arthroplasty survivorship at 2 years was 73.7% and at 5 years was 67.5% (mean 8.4 years; range 6.7-10.2). Survivorship was inferior in the patients with episodes of instability (mean 2.5 years; range 0-5.42) (p<0.001). At least one episode of instability occurred in 26.3% of patients and 60% of these patients had a femoral head size 32mm or lower. At least one episode of instability occurred in 71.4% of patients with a greater trochanter fracture (p=0.008). The consolidation rate was 90.6% and the mortality rate was 23.7%. In the group of patients that died, 55.6% were submitted to at least one revision surgery (p=0.044).

CONCLUSION

Survivorship of an uncemented modular stem (MRP-Titan) in revision for PHF is significantly reduced by episodes of instability.

[Translated article] Latarjet procedure for shoulder instability: Implications in the innervation of the subscapularis muscle

INTRODUCTION

Our aim was to describe whether Latarjet's technique affects subscapularis muscle innervation.

MATERIALS AND METHODS

We studied 12 embalmed shoulders. Subscapularis muscle innervation pattern was registered. Dimensions of the subscapularis at the glenohumeral joint line and the nerves entry point were measured. Horizontal distances from the nerves to the glenohumeral joint line as well as vertical ones to the split were measured before and after Latarjet procedure. A safe zone for the split was designed to avoid damage to subscapularis innervation.

RESULTS

Subscapularis muscle is innervated by three principal branches: upper, middle, and inferior subscapularis nerves. No statistical differences were found between innervation distances before and after Latarjet procedure. To perform subscapularis split along the muscle safe zone, two thirds' proportions throughout all the split must be maintained.

CONCLUSIONS

Subscapularis muscle has a triple innervation and was not altered after Latarjet procedure. Therefore, Latarjet technique seems to respect subscapularis muscle innervation if its split is placed through the subscapularis muscle safe zone.

Latarjet procedure for shoulder instability: Implications in the innervation of the subscapularis muscle

INTRODUCTION

Our aim was to describe whether Latarjet's technique affects subscapularis muscle innervation.

MATERIALS AND METHODS

We studied 12 embalmed shoulders. Subscapularis muscle innervation pattern was registered. Dimensions of the subscapularis at the glenohumeral joint line and the nerves entry point were measured. Horizontal distances from the nerves to the glenohumeral joint line as well as vertical ones to the split were measured before and after Latarjet procedure. A safe zone for the split was designed to avoid damage to subscapularis innervation.

RESULTS

Subscapularis muscle is innervated by three principal branches: upper, middle, and inferior subscapularis nerves. No statistical differences were found between innervation distances before and after Latarjet procedure. To perform subscapularis split along the muscle safe zone, two thirds' proportions throughout all the split must be maintained.

CONCLUSIONS

Subscapularis muscle has a triple innervation and was not altered after Latarjet procedure. Therefore, Latarjet technique seems to respect subscapularis muscle innervation if its split is placed through the subscapularis muscle safe zone.

Management of vertebral metastases in the cervico-occipital junction

Occipito-cervical metastases correspond to 0.5% of spinal metastases. The management of these lesions is complex and involves multiple radiological studies, such as simple radiology, computed tomography (CT), magnetic resonance imaging (MRI). Is vascular involvement is suspected, tests to assess vascular permeability are also recommended (angioCT). This type of lesion, due to its complex location, may require different types of approaches, commonly it will be the posterior approach, but sometimes anterior or anterolateral approaches will be needed assisted by maxillofacial surgeons or otorhinolaryngologists for correct excision of the tumor. Pain with head turning can guide us to the diagnosis in an unstable spine. Magnetic resonance is the test of choice to diagnose and study these lesions. The presence of instability or progressive neurological symptoms are an indication for surgery.

[Translated article] Management of vertebral metastases in the cervico-occipital junction

Occipito-cervical metastases correspond to 0.5% of spinal metastases. The management of these lesions is complex and involves multiple radiological studies, such as simple radiology, computed tomography (CT), magnetic resonance imaging (MRI). Is vascular involvement is suspected, tests to assess vascular permeability are also recommended (angioCT). This type of lesion, due to its complex location, may require different types of approaches, commonly it will be the posterior approach, but sometimes anterior or antero-lateral approaches will be needed assisted by maxillofacial surgeons or otorhinolaryngologists for correct excision of the tumour. Pain with head turning can guide us to the diagnosis in an unstable spine. Magnetic resonance is the test of choice to diagnose and study these lesions. The presence of instability or progressive neurological symptoms is an indication for surgery.

[Childhood Lunatomalacia Or Kienböck Disease With VISI Conformation In A Child: A Case Report And Literature Review]

Semilunar osteonecrosis or Kienböck's disease has a low prevalence, usually occurring in young men aged between 20 and 40 years. This disease is even less common in childhood. The aetiology varies, with postulation of the vascular trauma theory and the non-traumatic theory, in which the disease is caused by various other mechanisms. Semilunar involvement can occur with bone oedema, fragmentation, and scapholunate misalignment and progresses towards collapse. We present the case of an adolescent boy with Kienböck's disease, with no attributable traumatic antecedent, who developed a complex classification injury on the Litchman scale. Partial improvement of symptoms was achieved with conservative treatment but without definitive pain elimination. Future surgery for this patient is currently being discussed, bearing in mind his skeletal maturity and the pathophysiological progression of the injury.

Arthroscopic bone block metal-free fixation for anterior shoulder instability. Short-term functional and radiological outcomes

INTRODUCTION

Anterior glenohumeral bone loss reconstruction reduces failure rates after soft tissue surgery in patients with large glenoid bone defects. Multiple bone block techniques have been described, most with metal hardware fixation. The objective of this study is to evaluate the safety, as well as the short-term functional and radiological results of an arthroscopic bone block metal-free fixation or bone block cerclage.

MATERIAL AND METHODS

Retrospective study of patients with glenohumeral instability and>15% glenoid bone loss operated during 2019 with follow-up of at least 12 months. Radiography and computerized tomography studies were performed. Functional outcomes were evaluated before and after surgery with the Western Ontario Shoulder Instability Index and Rowe score.

RESULTS

A total of 21 patients with a median age of 30.6 (SD 7.1) were included. All showed radiographic consolidation at 3 months follow-up. A percentage of 90.4 of bone grafts presented osteolysis at peripherical areas and 95.2% revealed consolidation in the areas with contact to the glenoid. The median glenoid estimated surface went from 79.3% before surgery to 98.4% at 12 months. Functional scores were statically significant (P<.001) for Western Ontario Shoulder Instability Index (35.6-86.9) and Rowe score (25.2 to 96.4). No serious complications were reported.

CONCLUSION

The bone block cerclage is a safe, metal-free technique that achieves total consolidation of the bone graft and favorable functional and radiological outcomes at 12 months follow-up.

Does the fracture of the lateral wall affect the degree of collapse and the degree of sliding of the cephalic plate, in pertrochanteric fractures treated by intramedullary interlocking? Radiological study and review of the literature

BACKGROUND

Lateral wall fracture has been recognized as an important sign of instability of pertrochanteric fractures. The aim of the present study is to assess the relationship between lateral wall fractures, helical blade telescoping and neck shortening in fractures treated with intramedullary nailing.

MATERIAL AND METHOD

A descriptive radiological study was performed at our institution. Patients who suffered a pertrochanteric fracture, treated at Hospital 12 de Octubre by intramedullary nailing were included. All fractures were classified according to Evans and AO systems. Preoperative and postoperative radiological assessment was carried out including a lateral wall fracture classification, helical blade telescoping and femoral neck shortening.

RESULTS

210 patients were included, 48% had a fracture of the femoral lateral wall. Helical blade telescoping was higher in lower lateral wall fractures with respect to higher fractures. Difference was statistically significant (p<0.05). Neck shortening was higher in fractures with femoral lateral wall disruption; despite not have found any significant differences comparing to fractures with intact lateral wall (P=.39). Multivariate analysis showed statistically significant association between helical blade telescoping, neck shortening and lateral wall fracture.

CONCLUSIONS

There is evidence of a higher helical blade telescoping and neck shortening in pertrochanteric fractures with lateral wall fracture treated with intramedullary nails, especially in those with most unstable patterns such us fractures of the lateral wall distal to the vastus ridge.

Unclear origin vertigo protocol

BACKGROUND AND OBJECTIVE

Differential diagnosis of vertigo is a diagnostic challenge in the emergency setting. In our centre we have created a vertigo protocol to distinguish the different pathologies and their management in the emergency department. Our goal is to determine the efficacy of our hospital protocol in the diagnostic and therapeutic approach to acute vestibular syndrome.

PATIENTS AND METHODS

It is a retrospective descriptive observational study on patients with a diagnosis of acute vestibular syndrome in the emergency department using our unclear origin vertigo protocol. All patients underwent an examination that included the HINTS protocol and had a minimum follow-up of 6 months. The results of the clinical assessments by the specialists were compared, as well as the physical examination with the different final diagnoses classified as peripheral, central and other-origin.

RESULTS

We obtained 97 patients, with a mean age of 61.46 years. The final diagnoses were 26 patients for the peripheral group (26.8%), 38 for the other-origin group (39.2%) and 33 for the central group (34%). Stroke was found in 18 of the latter group, clinical-exploratory disagreement being the most frequent reason for activation of the protocol.

CONCLUSIONS

Our protocol has proven to be a useful tool to differentiate a possible acute vestibular syndrome of central origin from a peripheral one, avoiding unnecessary imaging tests. The most frequent cause of activation of the protocol was clinical-exploratory disagreement seen by the ENT doctor.

Dual mobility system. The French solution in elderly patients with intracapsular hip fracture and high risk of dislocation

OBJECTIVE

Actually there is a controversy about the treatment of hip fractures on older patients with high risk of dislocation. Our study is focused on report clinico-functional and radiographic results in this population treated with total hip replacement using a dual mobility system after a minimum follow up of 2 years.

MATERIALS AND METHODS

In the period from January 2015 to January 2016 patients assisted at the Emergency Unit at the participant hospital were recluted for participation. A total of 137 patients were assisted and 41 fulfilled the inclusion criteria and accepted to participate. All patients received a total hip replacement with a dual mobility system (cemented or uncemented). The patients were evaluated with the Mini-Mental State Examination, walking distance test, preop and postop at 3 and 6 weeks, 3 months, 6 months, one year and subsequent years. Radiographic evaluation was scheduled with clinico-functional review.

RESULTS

Forty-one patients included, follow up average 2.4 years (range 2 to 3.2 years). Mean age 85.2 (range 80 to 96 years). Four patients died during follow up due to causes not related to the total hip replacement and the implant was functioning. One case have an infection and was revised in one stage procedure. One case have an infection at 8 months follow-up and was revised in one stage procedure. There were no dislocations.

CONCLUSION

The use of dual mobility system in this high dislocation risk population has shown good clinical and functional results, and support the sistematic indication in our services.

Protocolised surgical treatment of terrible triad of elbow. Results and complications

BACKGROUND

Terrible triad of elbow is a complex lesion with a high rate of complications. Our goal is to analyse both clinical results and complications after performing protocolised surgery.

MATERIAL AND METHODS

The database of our hospital was used during 2005-2015, collecting characteristics of the patient, the fracture, the surgery and the associated complications, as well as functional results and range of mobility.

RESULTS

A total of 62 triads were obtained, of which 27 (43%) were women and 35 (56%) were men. All had a Kaplan lateral approach and those who needed it were complemented with a medial approach to repair the LCM. The radial head was synthesized in 14 (22%) cases, a prosthesis was placed in 45 (74%) cases and other actions in 3 (5%) cases. Osteosynthesis of the choroid process was performed by transosseous harpoon±suture in 41 (62%) patients and by synthesis in 12 (19%) cases. In 9 (14%) cases, no action was taken. In 100% of the cases the LCL was repaired and in 9 (14%) the LCM also had to be repaired. Twenty-two percent of the patients required ESA due to instability after the surgical technique. With respect to results, a range of mobility was obtained between 120°/-20° of flexoextension and 98°/85° of pronosupination. In terms of complications, we obtained a total of 17 (27%).

CONCLUSIONS

Elbow triads are complex lesions where protocolised surgery is necessary, nevertheless the complication rate was 27% in our series.

Lumbar synovial cysts: presentation of a series of 10 cases and literature review

INTRODUCTION

Although they are freqqently described in the literature, lumbar synovial cysts are a relative uncommon cause of low back and radicular leg pain.

OBJECTIVE

To evaluate the treatment and surgical outcomes of the lumbar synovial cysts operated on in our hospital during a 5 year period.

MATERIAL AND METHODS

A retrospective study was conducted on patients surgically treated in our department from August 2009 to September 2014, using a visual analogue scale for the clinical follow-up in the first year after surgery.

RESULTS

After the surgical treatment (surgical removal of the synovial cyst with or without instrumented arthrodesis with transpedicular screws) of 10 patients (5 female and 5 male) with a mean age of 70.2 years (range 50-80), the clinical outcome was satisfactory in 80% of the patients, with the resolving of their symptoms.

CONCLUSIONS

Lumbar synovial cysts have to be considered in the differential diagnosis in patients with low back and radicular leg pain. The majority of the patients are in their sixties and have lumbar degenerative spondylopathy. Nowadays, surgical resection of the lumbar synovial cysts and spinal fusion are the recommended treatment, because it is thought that the increased movement of the spine is one to the causes of the cyst formation. More studies are still needed, hence the relevance of this article.

Causes for revision surgery in total hip replacement. A retrospective epidemiological analysis

OBJECTIVE

To determine the impact of each cause of revision surgery in total hip arthroplasty during the period 2009-2013. To analyse the relationship between these causes with different variables.

MATERIALS AND METHODS

A study was conducted on 127 patients who had hip replacement revision surgery in our hospital during this period. Parameters, such as age, sex, date of primary arthroplasty, prosthetic replacement date, and main cause of the revision were recorded. Those revisions performed within 5 years after the primary arthroplasty were considered as early rescue.

RESULTS

The most common cause of rescue was aseptic loosening in 38 (30%) followed by instability in 30 (24%). In terms of age at the time of rescue, statistically significant differences were found, with it being significantly higher in patients re-operated for a fracture. Differences in age at first surgery were found to be 7 years younger than those with late rescue (63.40) with respect to early (70.21).

DISCUSSION

Similar results to ours have been observed in other published series, except for the higher incidence of instability in early rescue.

CONCLUSIONS

This study demonstrates aseptic loosening and instability as the most frequent causes of revision surgery in our hospital. Age is a very influential factor in relation to longevity of primary arthroplasty. Complications were higher in when the primary hip replacement is implanted in older patients.

Instability of total hip replacement: A clinical study and determination of its risk factors

OBJECTIVES

To determine the risk factors associated with prosthetic dislocation and simulate a finite element model to determine the safe range of movement of various inclination and anteversion cup positions.

MATERIAL AND METHODS

Retrospective Case Control study with 46 dislocated patients from 1994 to 2011.

CONTROL GROUP

83 randomly selected patients. Dislocation risk factors described in the literature were collected. A prosthetic model was simulated using finite elements with 28, 32, 36 mm heads, and a 52 mm cup. Acetabular position was 25°, 40°, and 60° tilt and with 0°, 15° and 25° anteversion. In extension of 0° and flexion of 90°, internal and external rotation was applied to analyze the range of movement, maximum resisting moment, and stress distribution in the acetabulum to impingement and dislocation.

RESULTS

There was greater dislocation in older patients (p=0.002). Higher dislocation in fractures than in osteoarthritis (p=0.001). Less anteversion in dislocated patients (p=0.043). Longer femoral neck in dislocated patients (p=0.002). Finite element model: lower dislocation when there is more anteversion, tilt and bigger femoral heads.

DISCUSSION-CONCLUSIONS

Advanced age and fractures are the major risk factors for dislocation. "Safe zone" of movement for dislocation avoidance is 40°-60° tilt and 15°-25° anteversion. Both the defect and excess of soft tissue tension predispose to dislocation. Bigger femoral heads are more stable.

Audio-vestibular signs and symptoms in Chiari malformation type i. Case series and literature review

INTRODUCTION

Chiari malformation is an alteration of the base of the skull with herniation through the foramen magnum of the brain stem and cerebellum. Although the most common presentation is occipital headache, the association of audio-vestibular symptoms is not rare. The aim of our study was to describe audio-vestibular signs and symptoms in Chiari malformation type i (CM-I).

MATERIALS AND METHODS

We performed a retrospective observational study of patients referred to our unit during the last 5 years. We also carried out a literature review of audio-vestibular signs and symptoms in this disease.

RESULTS

There were 9 patients (2 males and 7 females), with an average age of 42.8 years. Five patients presented a Ménière-like syndrome; 2 cases, a recurrent vertigo with peripheral features; one patient showed a sudden hearing loss; and one case suffered a sensorineural hearing loss with early childhood onset. The most common audio-vestibular symptom indicated in the literature in patients with CM-I is unsteadiness (49%), followed by dizziness (18%), nystagmus (15%) and hearing loss (15%). Nystagmus is frequently horizontal (74%) or down-beating (18%). Other audio-vestibular signs and symptoms are tinnitus (11%), aural fullness (10%) and hyperacusis (1%). Occipital headache that increases with Valsalva manoeuvres and hand paresthesias are very suggestive symptoms.

CONCLUSIONS

The appearance of audio-vestibular manifestations in CM-I makes it common to refer these patients to neurotologists. Unsteadiness, vertiginous syndromes and sensorineural hearing loss are frequent. Nystagmus, especially horizontal and down-beating, is not rare. It is important for neurotologists to familiarise themselves with CM-I symptoms to be able to consider it in differential diagnosis.

[Cervical spine instability: point of view of the anesthesiologist]

The experience in airway management permits the anesthesiologist to participate in cases of cervical spine instability in the operating room when the patient is subjected to surgical procedures, or in cases of difficulty to access or keep the airway open in emergencies. This article reviews the epidemiology, definition, etiology, diagnostic criteria, methods of approach to airway management, and current recommendations on handling cervical instability in different scenarios. There is no approach to the airway that ensures complete immobility of the cervical spine, but there are methods that are better adapted to specific contexts; at the end, the reader will be able to identify the virtues and defects of the various options that the anesthesiologists have to address the airway in cases of cervical instability.