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INTRODUCTION: Ceramic-on-ceramic bearings have been widely used since their introduction in the 1970s. First-generation ceramics have very high fracture (breakage) rates. To overcome this, in the 1990s, modular cotyloid insert designs were developed, consisting of a ceramic and polyethylene composite (sandwich-type) liner; however, high implant fracture rates were observed in the medium term. We aimed to estimate the cumulative incidences of revision surgery (implant failure) and implant failure due to fractures, survival rates (time-to-revision surgery and time-to-fracture), and the long-term clinical and radiological outcomes in our series. METHODS: This was an observational, longitudinal, ambispective, single-centre study based on patients who underwent primary total hip arthroplasty (THA) using a sandwich-type liner (Cerasul), only available in our tertiary hospital between January 1999 and December 2002. Cumulative incidences were estimated and the 95% confidence interval (95% CI) was calculated. The Kaplan-Meier method was used to assess the time-to-revision surgery and time-to-fracture. RESULTS: 54 patients (49 men) were included, accounting for 59 sandwich-type linear implants. The mean (range) age was 47.4 (22-57) years. The primary THA indications were osteoarthritis (28 patients), osteonecrosis (14), childhood pathology sequelae (11), and inflammatory arthritis (6). The cumulative incidence of revision surgery by implants was 8.5% (5/59, 95% CI, 3.5-19.2%), 9.3% by patients (5/54, 95% CI, 4.0-19.9%), and 5.1% by implant fractures (3/59, 95%CI, 1.7-13.9%). The median (Interquartile Range, IQR) time-to-revision surgery was 158 (72.5-161) months, and the time to fracture was 182 (138-215) months. All primary THAs had good clinical and long-term survival outcomes. All implants had signs of solid fixation. CONCLUSIONS: After a 20-year follow-up period, the polyethylene-ceramic sandwich-type liner showed a long survival rate and low cumulative incidence of implant fracture; however, implant fractures remain the main complication. Orthopaedic surgeons should be aware that some patients still have this type of prosthesis and must be capable of responding quickly if a fracture occurs.

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CASE: A 67-year-old patient sustained a medial clavicle fracture (MCF) treated with open reduction and fixation with cerclage sutures. A year later, he presented with symptomatic nonunion and skin prominence, which was revised with an intramedullary tendon allograft fixation including the sternoclavicular joint. At 31 months after the procedure, the patient showed no pain or clinical instability. CONCLUSION: MCF is an uncommon injury. Symptomatic nonunion after the failure of fixation is rarely described. Although the best way to treat this complication is debatable, revision fixation using an intramedullary tendon allograft can be a viable option in elderly patients.

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Recurrent posterior glenohumeral instability is an entity that demands a high clinical suspicion and a detailed study for a correct approach and treatment. Its classification must consider its biomechanics, whether it is due to functional muscular imbalance or to structural changes, volition, and intentionality. Due to its varied clinical presentations and different structural alterations, ranging from capsule-labral lesions and bone defects to glenoid dysplasia and retroversion, the different treatment alternatives available have historically had a high incidence of failure. A detailed radiographic assessment, with both CT and MRI, with a precise assessment of glenoid and humeral bone defects and of glenoid morphology, is mandatory. Physiotherapy focused on periscapular muscle reeducation and external rotator strengthening is always the first line of treatment. When conservative treatment fails, surgical treatment must be guided by the structural lesions present, ranging from soft tissue repair to posterior bone block techniques to restore or increase the articular surface. Bone block procedures are indicated in cases of recurrent posterior instability after the failure of conservative treatment or soft tissue techniques, as well as symptomatic demonstrable nonintentional instability, presence of a posterior glenoid defect >10%, increased glenoid retroversion between 10 and 25°, and posterior rim dysplasia. Bone block fixation techniques that avoid screws and metal allow for satisfactory initial clinical results in a safe and reproducible way. An algorithm for the approach and treatment of recurrent posterior glenohumeral instability is presented, as well as the author's preferred surgical technique for arthroscopic posterior bone block.

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BACKGROUND: Cemented hip arthroplasty requires applying a layer of polymethylmethacrylate (cement) in the space between the bone and the prosthetic stem. This can be achieved using 2 techniques: the thick-layer technique (requires a layer of at least 2 mm to surround an undersized prosthetic stem), and the thin-layer technique (requires a thin layer of cement, so that the prosthetic stem fills the femoral medullary canal). Both approaches have excellent long-term clinical and radiological outcomes, although an implant's insertion into the bone generates inevitable bone mass and bone metabolic changes around it. Combination of single photon emission computed tomography and computed tomography scan (SPECT-CT) imaging combines the single photon emission computed tomography's ability to provide detailed bone metabolism assessment with the computed tomography scan's capacity to provide a meticulous anatomical study. METHODS: This is a single center, open label, randomized clinical trial, performed in the premises of the Bellvitge University Hospital. Participants will be randomly assigned to the Thick-layer technique group (Exeter V40 Cemented Femoral Stem) or to the French paradox technique group (Müller Straight Stem). All participants will have a SPECT-CT scan study at 3, 6, 12, and 24 months after the surgery. DISCUSSION: Surgical distress itself and the implant's insertion into the bone may cause microvascular changes that alter periprosthetic bone mass and bone metabolism. To the best of our knowledge, there are no studies using SPECT-CT to compare bone metabolism evolution in the postoperative period between these 2 surgical cementation techniques. We aim to provide information in this regard that could help decision making in complicated implant cases and, maybe, pave the way for larger, and methodologically improved studies. TRIAL REGISTRATION: NCT05010733 (August 18, 2021).

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Los pacientes con mieloma múltiple (MM) no tienen mayor incidencia de pancreatitis aguda ni diferente etiología de ésta que la población general. Sin embargo, pueden presentar pancreatitis aguda, o hiperamilasemia o hiperlipasemia aisladas, por causas que son poco habituales sin la presencia de la enfermedad hematológica. En los pacientes con MM, la afectación hepática aparece en el 30 al 50% de los casos. Fundamentalmente se produce como infiltración difusa de predominio sinusoidal, y la aparición en forma de nódulos es menos frecuente. Se presenta el caso de un paciente que recibió un trasplante de médula ósea por MM y que presentó un cuadro compatible clínica y analíticamente con pancreatitis aguda de etiología no filiada, durante el que se identificó la presencia de múltiples lesiones hepáticas ocupantes de espacio que se diagnosticaron mediante biopsia como recidiva extramedular de mieloma (AU)

Patients with multiple myeloma (MM) do not have a higher incidence of acute pancreatitis or pancreatitis of other etiologies than the general population. However, these patients may develop acute pancreatitis, or hyperamylasemia or isolated hyperlipasemia, due to etiologies that are highly infrequent in the absence of hematological disease. Liver involvement is found in 30 50% of patients with MM and mainly manifests as diffuse sinusoidal infiltration and less frequently in the form of nodules. We report the case of a patient who underwent bone marrow transplantation due to MM who showed clinical and laboratory findings compatible with acute pancreatitis of unknown origin, during which the presence of multiple space-occupying hepatic lesions was identified. Based on the results of biopsy, a diagnosis of extramedullary recurrence of MM was established (AU)

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Patients with multiple myeloma (MM) do not have a higher incidence of acute pancreatitis or pancreatitis of other etiologies than the general population. However, these patients may develop acute pancreatitis, or hyperamylasemia or isolated hyperlipasemia, due to etiologies that are highly infrequent in the absence of hematological disease. Liver involvement is found in 30-50% of patients with MM and mainly manifests as diffuse sinusoidal infiltration and less frequently in the form of nodules. We report the case of a patient who underwent bone marrow transplantation due to MM who showed clinical and laboratory findings compatible with acute pancreatitis of unknown origin, during which the presence of multiple space-occupying hepatic lesions was identified. Based on the results of biopsy, a diagnosis of extramedullary recurrence of MM was established.

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Inflammatory cloacogenic polyps are infrequent lesions that usually arise in the anorectal zone. The most common clinical presentation is rectal bleeding. Two cases of rectal bleeding related to cloacogenic polyps with different endoscopic appearance are reported. Endoscopists should be familiar with this entity, which should be considered in the differential diagnosis with other polypoid lesions observed in colonoscopy.

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Los pólipos inflamatorios cloacogénicos son lesiones poco frecuentes, que suelen surgir en la zona anorrectal. La presentación clínica más frecuente es en forma de sangrado rectal. Se presentan 2 casos de pólipos cloacogénicos con distinto aspecto endoscópico y clínica de rectorragia. El endoscopista debe tener en cuenta la existencia de esta entidad y considerarla en el diagnóstico diferencial con otras lesiones polipoideas que se pueden observar en la colonoscopia

Inflammatory cloacogenic polyps are infrequent lesions that usually arise in the anorectal zone. The most common clinical presentation is rectal bleeding. Two cases of rectal bleeding related to cloacogenic polyps with different endoscopic appearance are reported. Endoscopists should be familiar with this entity, which should be considered in the differential diagnosis with other polypoid lesions observed in colonoscopy

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