RESUMEN
Objectives: The primary aims of this study were to determine if any correlation exists in cases of fracture fixation among: (1) bacterial profiles recovered from the instrumentation and adjacent tissues; (2) the type of orthopedic injury; and (3) the clinical outcome-union versus nonunion. A secondary goal was to compare culture and molecular diagnostics for identifying the bacterial species present following fracture fixation. Design: Single-institution, prospective case-control cohort study. Setting: Single level 1 trauma center. Patients: Forty-nine bony nonunion cases undergoing revision internal fixation and 45 healed fracture controls undergoing removal of hardware. Intervention: Bacterial infection was detected by standard microbial culture methods and by a pan-eubacterial domain, molecular diagnostic (MDx) assay. Confirmation of culture and MDx results was achieved with bacterial ribosomal 16S rRNA fluorescence in situ hybridization (FISH) to visualize bacterial biofilms. Main Outcome Measurements: MDx and microbial culture methods results were the primary study outcomes. Results: Ninety-four percent of the nonunion cohort and 93% of the union cohort had bacteria detected by the MDx. Seventy-eight percent of the nonunion cases and 69% of the controls were culture negative, but MDx positive. Although no significant differences in bacterial composition were observed between the cases and controls, differences were observed when cases were divided by comorbidities. Conclusion: The MDx is more sensitive than microbial culture in detecting bacterial presence. The lack of significantly different findings with regard to bacterial profile identified between the cases and controls suggests that host factors and environmental conditions are largely responsible for determining if bony union will occur. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Asunto(s)
Fracturas no Consolidadas , Bacterias/genética , Biopelículas , Estudios de Casos y Controles , Fracturas no Consolidadas/diagnóstico , Fracturas no Consolidadas/microbiología , Fracturas no Consolidadas/cirugía , Humanos , Hibridación Fluorescente in Situ , ARN Ribosómico 16S/genética , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
INTRODUCTION: Segmental bone loss in the distal femur presents a challenge for reconstruction regardless of etiology. Use of tantalum trabecular metal cones with intramedullary fixation and autologous bone graft may be used as a salvage technique in difficult situations where other options have either been exhausted or are unavailable. CASE REPORT: Surgical planning and technique for this approach to reconstruction are described. A retrospective review of five cases with >1 year of follow-up was performed to provide radiographic and clinical outcomes. All five patients had satisfactory outcomes with clinical union and retention of implants at final follow-up (average >4 years). CONCLUSIONS: Use of tantalum metal cones for reconstruction of distal femur nonunion with segmental bone defects can be a successful technique in a complex group of patients.
RESUMEN
BACKGROUND: Currently, no consensus exists for selection criteria of appropriate candidates for outpatient total hip arthroplasty (THA). This study evaluates patient characteristics associated with same-day discharge, examined surgical start time's effect on rates of same-day discharge, and compares readmission and reoperation rates between groups. METHODS: All patients who underwent a THA by one surgeon at a single quaternary care hospital between February 2016 and May 2018 were captured. All patients were given the option for same-day discharge. Patient characteristics and perioperative variables were analyzed. RESULTS: A total of 429 patients met inclusion criteria, 153 (36%) were discharged on the day of surgery. In a multivariate analysis, age (P = .000), multiple comorbidities (P = .004), and start time remained statistically significant (P = .000). Patients with start times prior to 9 AM had odds ratio of 11.56 of being discharged same day when compared to those with start times after 12 PM. Patients discharged the day of surgery were less likely to have a 90-day emergency room visit (P = .010), a readmission within 30 days (P = .001) or 90 days (P = .000), or a reoperation (0 vs 14, P = .003). CONCLUSION: Same-day discharge following THA is safe and feasible. Patient's age and number of comorbidities should be considered when developing selection criteria for same-day discharge programs. Patients selected for same-day discharge should receive earlier operating room start times.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Humanos , Tiempo de Internación , Alta del Paciente , Readmisión del Paciente , Complicaciones Posoperatorias , Factores de RiesgoRESUMEN
CASE: A 67-year-old woman who underwent a re-revision of a total hip arthroplasty with a cemented polyethylene liner fell 14 months after surgery. The patient had symptoms of pain and weakness; however, clinical, laboratory, and radiographic evaluation did not disclose fracture, infection, osteolysis, or component migration. Liner dissociation was suspected, and a double-contrast computed tomography (CT) arthrogram confirmed failure at the cement-liner interface. She underwent additional revision surgery and was doing well at the 3-year follow-up. CONCLUSION: Double-contrast CT arthrography confirmed failure at the cement-liner interface and is an effective diagnostic tool in identifying suspected dissociations of cemented polyethylene liners.
Asunto(s)
Artrografía/métodos , Artroplastia de Reemplazo de Cadera , Prótesis de Cadera/efectos adversos , Falla de Prótesis , Anciano , Femenino , Humanos , ReoperaciónRESUMEN
Systemic cobalt toxicity is a rare complication after metal-on-metal (MOM) total hip arthroplasty. Here we present a case of progressive cardiomyopathy, as evidenced by biopsy and cardiac magnetic resonance imaging (MRI), in a patient with bilateral MOM total hip arthroplasties. To our knowledge, it is one of the first cases in which cardiomyopathy resulting from systemic cobalt disease has been shown on MRI. While there is no guideline to unequivocally diagnose cobalt cardiomyopathy, the constellation of findings, including pathologic, biologic, blood levels, imaging, and surgical, all uniformly indicate a unifying diagnosis. The lack of improvement after removal of the prosthetic device supports a diagnosis of permanent myocardial damage, which is consistent with cardiomyopathy of advanced toxic etiology.
Asunto(s)
Artroplastia de Reemplazo de Cadera/efectos adversos , Cardiomiopatías/inducido químicamente , Cobalto/envenenamiento , Prótesis de Cadera/efectos adversos , Prótesis Articulares de Metal sobre Metal/efectos adversos , Cardiomiopatías/sangre , Cardiomiopatías/patología , Cobalto/sangre , Humanos , Intoxicación/etiología , Falla de PrótesisRESUMEN
The purpose of the present study is to retrospectively analyze clinical and radiographic outcomes in primary constrained condylar knee arthroplasty at a minimum follow-up of 7 years. Given the concern for early aseptic loosening in constrained implants, we focused on this outcome. Our cohort consists of 127 constrained condylar knees. The mean age of patients in the study was 68.3 years, with a mean follow-up of 110.7 months. The diagnosis was primary osteoarthritis in 92%. There were four periprosthetic distal femur fractures, with a rate of revision of 0.8%. No implants were revised for aseptic loosening. Kaplan-Meier survivorship analysis with removal of any component as the end point revealed that the 10-year rate of survival of the primary CCK was 97.6% (95% CI, 94%-100%).
Asunto(s)
Artroplastia de Reemplazo de Rodilla/métodos , Prótesis de la Rodilla , Osteoartritis de la Rodilla/cirugía , Anciano , Artroplastia de Reemplazo de Rodilla/efectos adversos , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Fracturas Periprotésicas/etiología , Diseño de Prótesis , Falla de Prótesis , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVES: To identify the presence of bacterial biofilms in nonunions comparing molecular techniques (multiplex polymerase chain reaction and mass spectrometry, fluorescent in situ hybridization) with routine intraoperative cultures. METHODS: Thirty-four patients with nonunions were scheduled for surgery and enrolled in this ongoing prospective study. Intraoperative specimens were collected from removed implants, surrounding tissue membrane, and local soft tissue followed by standard culture analysis, Ibis's second generation molecular diagnostics (Ibis Biosystems), and bacterial 16S rRNA-based fluorescence in situ hybridization (FISH). Confocal microscopy was used to visualize the tissue specimens reacted with the FISH probes, which were chosen based on the Ibis analysis. RESULTS: Thirty-four patient encounters were analyzed. Eight were diagnosed as infected nonunions by positive intraoperative culture results. Ibis confirmed the presence of bacteria in all 8 samples. Ibis identified bacteria in a total of 30 of 34 encounters, and these data were confirmed by FISH. Twenty-two of 30 Ibis-positive samples were culture-negative. Four samples were negative by all methods of analysis. No samples were positive by culture, but negative by molecular techniques. CONCLUSIONS: Our preliminary data indicate that molecular diagnostics are more sensitive for identifying bacteria than cultures in cases of bony nonunion. This is likely because of the inability of cultures to detect biofilms and bacteria previously exposed to antibiotic therapy. LEVEL OF EVIDENCE: Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.
Asunto(s)
Biopelículas , Fracturas no Consolidadas/microbiología , Prótesis e Implantes/microbiología , Infecciones Relacionadas con Prótesis/diagnóstico , Infecciones Relacionadas con Prótesis/microbiología , Adolescente , Adulto , Anciano , Técnicas Bacteriológicas , Remoción de Dispositivos , Femenino , Humanos , Hibridación Fluorescente in Situ , Periodo Intraoperatorio , Masculino , Espectrometría de Masas , Persona de Mediana Edad , Reacción en Cadena de la Polimerasa Multiplex , Adulto JovenAsunto(s)
Artroplastia de Reemplazo de Cadera/métodos , Bacillus cereus/aislamiento & purificación , Necrosis de la Cabeza Femoral/cirugía , Fijación Interna de Fracturas/métodos , Fracturas de Cadera/cirugía , Prótesis de Cadera , Reacción en Cadena de la Polimerasa/métodos , Infecciones Relacionadas con Prótesis/microbiología , Adulto , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Espectrometría de Masas , ReoperaciónRESUMEN
BACKGROUND: Knee arthrodesis can be an effective treatment option for relieving pain and restoring some function after the failure of a total knee arthroplasty as the result of infection. The purpose of the present study was to review the outcome of a staged approach for arthrodesis of the knee with a long intramedullary nail after the failure of a total knee arthroplasty as the result of infection. METHODS: We reviewed the results for twelve patients who underwent knee arthrodesis after the removal of a prosthesis because of infection. The study group included seven women and five men who had an average age of sixty-eight years at the time of the arthrodesis. All patients were managed with a staged protocol. Implant removal, débridement, and insertion of antibiotic cement spacers was followed by the administration of systemic antibiotics. Provided that clinical and laboratory data suggested eradication of the infection, arthrodesis of the affected knee with use of a long intramedullary nail was carried out. Clinical and laboratory evaluation and radiographic analysis were performed after an average duration of follow-up of 4.1 years. RESULTS: Solid union was achieved in ten of the twelve knees. The average time to union was 5.5 months. One patient had an above-the-knee amputation because of recurrence of infection. In another patient, nail breakage occurred three years following implantation. The average limb-length discrepancy was 5.5 cm. The mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score improved from 41 to 64 points. None of the seven patients who underwent arthrodesis with a technique involving convex-to-concave reamers had a complication, and the average time to union for these seven patients was shorter than that for the remaining five patients (4.3 compared with 7.4 months). CONCLUSIONS: We believe that obtaining large surfaces of bleeding contact bone during arthrodesis following staged treatment of an infection at the site of a failed total knee arthroplasty contributes to stability and enhances bone-healing. Staged arthrodesis with use of a long intramedullary nail and convex-to-concave preparation of bone ends provided a painless functional gait with low complication and reoperation rates in this challenging group of patients.
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Artrodesis/métodos , Artroplastia de Reemplazo de Rodilla , Articulación de la Rodilla/cirugía , Infección de la Herida Quirúrgica/cirugía , Anciano , Amputación Quirúrgica , Antibacterianos/administración & dosificación , Clavos Ortopédicos , Desbridamiento , Remoción de Dispositivos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Reoperación , Resultado del TratamientoRESUMEN
OBJECTIVE: The purpose of this study was to describe the technique of and experience in using CT guidance for percutaneous iliosacral screw placement in patients with unstable pelvic fractures. CONCLUSION: CT-guided iliosacral screw placement is a safe and accurate procedure that can be performed by radiologists in a radiology suite.
Asunto(s)
Tornillos Óseos , Fijación Interna de Fracturas/instrumentación , Fracturas Óseas/diagnóstico por imagen , Fracturas Óseas/cirugía , Huesos Pélvicos/lesiones , Huesos Pélvicos/cirugía , Cirugía Asistida por Computador/métodos , Adolescente , Adulto , Anciano , Femenino , Fijación Interna de Fracturas/métodos , Humanos , Ilion/diagnóstico por imagen , Ilion/cirugía , Inestabilidad de la Articulación/diagnóstico por imagen , Inestabilidad de la Articulación/cirugía , Masculino , Persona de Mediana Edad , Huesos Pélvicos/diagnóstico por imagen , Implantación de Prótesis/métodos , Sacro/diagnóstico por imagen , Sacro/cirugía , Tomografía Computarizada por Rayos X/métodos , Resultado del TratamientoRESUMEN
Dislocation after total hip arthroplasty is frequently due to acetabular malpositioning. Positioning of the acetabular component using anatomical landmarks may reduce the incidence of dislocation from improper acetabular orientation. The pelvis provides 3 bony landmarks (ilium, superior pubic ramus, and superior acetabulum), which, when used to define a plane, allows cup orientation in abduction and version. Landmarks evaluated in 24 cadaveric acetabuli allowed slightly increased abduction and anteversion of the cup, compared with native acetabuli. Six hundred seventeen primary total hip arthroplasties were performed between 1996 and 2003 using this technique. Mean cup abduction was 44.4 degrees with 13.2 degrees of anteversion. This technique allows satisfactory reproducible cup orientation based on individual pelvic morphology. Review of patient outcome data suggest high patient satisfaction and lower dislocation rate without additional equipment, time, or cost.
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Acetábulo/anatomía & histología , Artroplastia de Reemplazo de Cadera/métodos , Luxación de la Cadera/prevención & control , Prótesis de Cadera , Pelvis/anatomía & histología , Complicaciones Posoperatorias/prevención & control , Acetábulo/cirugía , Artroplastia de Reemplazo de Cadera/efectos adversos , Femenino , Luxación de la Cadera/etiología , Humanos , Masculino , Falla de Prótesis , Factores de RiesgoAsunto(s)
Tornillos Óseos/efectos adversos , Fijación Interna de Fracturas , Fracturas por Estrés/etiología , Fracturas de la Tibia/etiología , Anciano , Traumatismos del Tobillo/cirugía , Remoción de Dispositivos , Femenino , Fracturas Óseas/cirugía , Fracturas por Estrés/cirugía , Humanos , Luxaciones Articulares/cirugía , Fracturas de la Tibia/cirugíaRESUMEN
BACKGROUND: Knee arthrodesis can be an effective treatment option for relieving pain and restoring some function after the failure of a total knee arthroplasty as the result of infection. The purpose of the present study was to review the outcome of a staged approach for arthrodesis of the knee with a long intramedullary nail after the failure of a total knee arthroplasty as the result of infection. METHODS: We reviewed the results for twelve patients who underwent knee arthrodesis after the removal of a prosthesis because of infection. The study group included seven women and five men who had an average age of sixty-eight years at the time of the arthrodesis. All patients were managed with a staged protocol. Implant removal, débridement, and insertion of antibiotic cement spacers was followed by the administration of systemic antibiotics. Provided that clinical and laboratory data suggested eradication of the infection, arthrodesis of the affected knee with use of a long intramedullary nail was carried out. Clinical and laboratory evaluation and radiographic analysis were performed after an average duration of follow-up of 4.1 years. RESULTS: Solid union was achieved in ten of the twelve knees. The average time to union was 5.5 months. One patient had an above-the-knee amputation because of recurrence of infection. In another patient, nail breakage occurred three years following implantation. The average limb-length discrepancy was 5.5 cm. The mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score improved from 41 to 64 points. None of the seven patients who underwent arthrodesis with a technique involving convex-to-concave reamers had a complication, and the average time to union for these seven patients was shorter than that for the remaining five patients (4.3 compared with 7.4 months). CONCLUSIONS: We believe that obtaining large surfaces of bleeding contact bone during arthrodesis following staged treatment of an infection at the site of a failed total knee arthroplasty contributes to stability and enhances bone-healing. Staged arthrodesis with use of a long intramedullary nail and convex-to-concave preparation of bone ends provided a painless functional gait with low complication and reoperation rates in this challenging group of patients.