RESUMEN
Despite the need for effective and safe thromboprophylactic drugs for patients with renal impairment, clinical trial data on anticoagulant agents are limited in this population. The study aim was to assess in the real-world setting the use of the once-daily 1.5 mg reduced dosage regimen of fondaparinux available for this context. In this prospective cohort study, patients with a creatinine clearance (CrCl) of 20-50 ml/minute, undergoing total hip (THR) or knee (TKR) replacement or hip fracture surgery (HFS) received fondaparinux thromboprophylaxis. Main clinical outcomes were bleeding (major/clinically relevant non-major), symptomatic venous thromboembolism (VTE) and death. Overall, 442 patients (353 women; median age: 82 years; 39.4% in ASA class ≥3; mean ± SD CrCl: 39.0 ± 8.0 ml/minute; 78% with additional risk factors for bleeding), undergoing THR (43.7%), TKR (27.6%), or HFS (28.7%) received fondaparinux 1.5 mg for a mean ± SD duration of 16.0 ± 12.5 days. At postoperative day 10, the rates (95% confidence interval) of major bleeding, clinically relevant bleeding and symptomatic VTE were 4.5% (2.8-6.9), 0.5% (0.1-1.6) and 0.5% (0.05-1.62), respectively; no fatal bleeding, bleeding into a critical organ, pulmonary embolism or proximal deep-vein thrombosis occurred. Corresponding rates at one month were 5.2%, 0.7% and 0.7%. One-month mortality was 2.3% (0.9-3.6). This large clinical prospective study provides for the first time, under conditions reflecting "real-world" routine clinical practice, data on the bleeding and VTE risks of thromboprophylaxis with fondaparinux 1.5 mg after major orthopaedic surgery in renally impaired patients. It shows that these patients constitute a very elderly and fragile population.
Asunto(s)
Anticoagulantes/administración & dosificación , Riñón/fisiopatología , Procedimientos Ortopédicos/efectos adversos , Polisacáridos/administración & dosificación , Insuficiencia Renal/complicaciones , Tromboembolia Venosa/prevención & control , Factores de Edad , Anciano , Anciano de 80 o más Años , Anticoagulantes/efectos adversos , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Biomarcadores/sangre , Creatinina/sangre , Femenino , Fondaparinux , Fijación de Fractura/efectos adversos , Francia , Hemorragia/inducido químicamente , Fracturas de Cadera/complicaciones , Fracturas de Cadera/cirugía , Humanos , Riñón/metabolismo , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Procedimientos Ortopédicos/mortalidad , Polisacáridos/efectos adversos , Estudios Prospectivos , Insuficiencia Renal/sangre , Insuficiencia Renal/mortalidad , Insuficiencia Renal/fisiopatología , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Tromboembolia Venosa/etiología , Tromboembolia Venosa/mortalidadRESUMEN
OBJECTIVE: To assess the feasibility of ultrasound-guided surgery for carpal tunnel syndrome. METHOD: We first studied the ultrasound and anatomic findings in 30 cadaver wrists to determine the best surgical approach and the best plane for releasing the flexor retinaculum. We then used 104 cadaver wrists to assess the feasibility of our technique by performing the surgical procedure then extensively dissecting each wrist and hand. Our evaluation criteria were full release of the transverse carpal ligament and absence of injury to the vessels, nerves, and tendons. RESULTS: The transverse carpal ligament was fully released in all 104 forearms. Full release required a single pass in 61 forearms, two passes in 27 forearms, and three passes in 16 forearms. No injuries to adjacent structures were identified. CONCLUSIONS: Our cadaver study supports the feasibility of percutaneous surgery under ultrasound-guidance for carpal tunnel syndrome.
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Artroscopía/métodos , Síndrome del Túnel Carpiano/cirugía , Procedimientos Ortopédicos/métodos , Ultrasonografía Intervencional/métodos , Artroscopía/instrumentación , Cadáver , Antebrazo , Humanos , Procedimientos Ortopédicos/instrumentación , Técnicas de Sutura , Articulación de la Muñeca/diagnóstico por imagen , Articulación de la Muñeca/cirugíaRESUMEN
Long-term results of a retrospective series of primary arthroplasty with the original cementless dual mobility socket (A) and the midterm results with the second generation (B) are reported. In series A (follow-up 16.5 years) 437 total hip arthroplasties (THA) were included and in series B (follow-up five years) 231 hips. The 15-year survival rate was 84.4 ± 4.5% (revision for any reason as endpoint); 30 hips (6.8%) were revised for aseptic loosening. Five THA were revised for dislocation: two early and three after ten years or more. With the second generation socket neither dislocation nor revision for mechanical reasons were observed. The survival rate was 99.6 ± 0.4% (revision for any reason). The prevalence of revision for dislocation was very low in our series. This concept does not avoid wear and aseptic loosening, especially in young active patients, but the long-term stability has been confirmed. Dual mobility can be recommended for patients over 70 years of age and for younger patients with high risk of dislocation.
Asunto(s)
Artroplastia de Reemplazo de Cadera/instrumentación , Prótesis de Cadera , Diseño de Prótesis , Falla de Prótesis , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Artroplastia de Reemplazo de Cadera/métodos , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Osteoartritis de la Cadera/cirugía , Reoperación , Estudios RetrospectivosRESUMEN
INTRODUCTION: The optimal duration of thromboprophylaxis after total knee arthroplasty remains uncertain. MATERIAL AND METHODS: We performed a randomized, open trial to determine whether to stop thromboprophylactic therapy at Day 10±2 ('short thromboprophylaxis') was non-inferior to continue thromboprophylactic therapy up to Day 35±5 ('extended thromboprophylaxis') after total knee arthroplasty. At Day 7±2, subjects were screened by ultrasonography for asymptomatic deep-vein thrombosis and randomized. The primary outcome was a composite of proximal deep-vein thrombosis, any symptomatic deep-vein thrombosis, non-fatal symptomatic pulmonary embolism, major bleeding, heparin-induced thrombocytopenia, or all-cause death up to Day 35±5. The secondary outcome was ultrasonographic (extension or new onset) distal deep-vein thrombosis at Day 35±5. RESULTS: Twenty-one patients (2.4%) were not randomized, because of asymptomatic proximal deep-vein thrombosis on systematic ultrasonography at Day 7±2. Among the 857 randomized patients, mean (SD) duration of anticoagulant treatment was 11.2 (6.7) and 33.9 (3.7) days in the short and extended thromboprophylaxis groups, respectively. The respective rates of the primary outcome were 4.0% (17/420) and 2.4% (10/422), with an absolute difference of 1.7% (90% confidence interval, -0.3 to 3.7). In 285 patients with asymptomatic distal deep-vein thrombosis at Day 7±2, the respective rates of the primary outcome were 7.8% and 2.8% (p=0.067). The rates of the secondary outcome were 14.8% (62/420) and 4.5% (19/422), respectively (p<0.001). CONCLUSIONS: Short thromboprophylaxis was not non-inferior to extended thromboprophylaxis after total knee arthroplasty. In this setting, the thromboembolic risk persisted longer than seven days, notably in patients with asymptomatic distal deep-vein thrombosis at discharge. ClinicalTrials.gov number: NCT00362492.
Asunto(s)
Anticoagulantes/uso terapéutico , Artroplastia de Reemplazo de Rodilla/efectos adversos , Terapia Trombolítica/métodos , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/tratamiento farmacológico , Anciano , Femenino , Humanos , Pierna/diagnóstico por imagen , Pierna/cirugía , Masculino , Persona de Mediana Edad , Factores de Tiempo , Ultrasonografía , Trombosis de la Vena/etiologíaRESUMEN
BACKGROUND: Anterior cruciate ligament reconstruction surgery and technique have changed over the past decade. HYPOTHESIS: Modern arthroscopic management of an anterior cruciate ligament tear using patellar tendon autograft offers a high patient satisfaction rate and good clinical results over the long term. However, it may be associated with osteoarthritis changes over time. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: In 1992, a prospective computerized database of anterior cruciate ligament reconstruction was established. Since that time, 101 anterior cruciate ligament arthroscopic reconstructions performed at our institution have been observed. Inclusion criteria were as follows: reconstruction with bone-patellar tendon-bone graft, a minimum 10-year follow-up, a standardized operative procedure, and no previous anterior cruciate ligament repair or associated ligament lesions. Before surgery, the mean age of the patients was 28.8 years +/- 8.3 (mean +/- SD). The follow-up assessment was established using the International Knee Documentation Committee (IKDC) 2000 form and quantitative laxity testing with a KT-1000 arthrometer. The joint space narrowing assessment used the IKDC score with a 30 degrees posteroanterior weightbearing view. RESULTS: Mean follow-up was 11.6 +/- 0.8 years. Nine graft ruptures occurred. The satisfaction rate was excellent (90%). Seventy patients (74%) were still actively participating in sports. The mean subjective IKDC 2000 score was 90.5 +/- 8.8 points. The IKDC score was statistically correlated to laxity, time from injury, and osteoarthritis development at final follow-up. Ninety-one percent of patients were graded A or B according to the overall IKDC score. The radiological assessment reported osteoarthritis development in 17.8% of patients, and 39% showed radiological changes. Osteoarthritis was correlated with body mass index (P = .01) and age at follow-up (P = .006). In a selected population without meniscus and articular cartilage injury, an osteoarthritis rate of only 8% was found. Conclusion Arthroscopic anterior cruciate ligament reconstruction using bone-patellar tendon-bone autograft resulted in high patient satisfaction levels and good clinical results after 10 years. Moreover, a high percentage of patients remained involved in sports activities, and anterior cruciate ligament reconstruction protected their meniscus from a secondary tear. However, knee osteoarthritis developed in 17.8% of patients so treated.
Asunto(s)
Lesiones del Ligamento Cruzado Anterior , Ligamento Cruzado Anterior/cirugía , Artroscopía , Plastía con Hueso-Tendón Rotuliano-Hueso/efectos adversos , Plastía con Hueso-Tendón Rotuliano-Hueso/métodos , Osteoartritis/etiología , Ligamento Cruzado Anterior/fisiopatología , Artroscopía/efectos adversos , Artroscopía/métodos , Traumatismos en Atletas/diagnóstico por imagen , Traumatismos en Atletas/fisiopatología , Traumatismos en Atletas/cirugía , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Estudios Prospectivos , RadiografíaRESUMEN
OBJECTIVE: To develop a cost-effective strategy for improving osteoporosis management in patients admitted to an orthopedic surgery department for low-energy fractures. METHODS: From November 2003 to July 2004, all patients over 50 years admitted to the orthopedics department of the Caen Teaching Hospital (France) for low-energy fractures were identified and evaluated by rheumatology department physicians in the same hospital. RESULTS: During the study period, 313 patients were identified, 257 women (mean age, 79.5+/-10.2 years) and 56 men (mean age, 74.6+/-10.8 years), each with one fracture (proximal femur, 58.9%; wrist, 13%). Among them, 91 (29%) had a previous history of osteoporotic fractures. Mean bone mineral density (BMD) values were lower at the femoral neck than at the total hip or lumbar spine (e.g. in women, -2.3+/-0.9 versus -1.8+/-1.0 and -1.4+/-1.7, respectively). Osteoporosis treatment was given to 88 (28%) patients and consisted of calcium and vitamin D supplements, combined with alendronate in 32 patients. Complete loss of self-sufficiency occurred in 73 patients. Thus, 161 patients (88 with osteoporosis treatment and 73 with loss of self-sufficiency) received optimal treatment. CONCLUSION: Cooperation between the orthopedics and rheumatology departments improved the management of osteoporosis in patients with low-energy fractures. However, appropriate investigation and treatment of osteoporosis proved difficult in the oldest old and in patients with cognitive impairments.
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Fracturas Espontáneas/terapia , Hospitalización/estadística & datos numéricos , Ortopedia/estadística & datos numéricos , Osteoporosis/diagnóstico , Derivación y Consulta/organización & administración , Reumatología/organización & administración , Absorciometría de Fotón , Anciano , Conservadores de la Densidad Ósea/uso terapéutico , Calcio de la Dieta/administración & dosificación , Suplementos Dietéticos , Femenino , Fracturas Espontáneas/etiología , Francia , Humanos , Masculino , Ortopedia/organización & administración , Osteoporosis/complicaciones , Osteoporosis/terapia , Vitamina D/administración & dosificaciónRESUMEN
In the 20-50-year age group, hip pain usually indicates dysplasia. Chronic mechanical pain is the usual pattern, although acute pain caused by avulsion or degeneration of the labrum may occur. The morphological characteristics of the dysplastic hip should be evaluated, and the link between the dysplasia and the osteoarthritis should be confirmed. Three factors indicate a favorable prognosis: joint space preservation, age younger than 40 years, and correctable femoral and acetabular abnormalities. Reconstruction is highly desirable, as it delays the need for joint replacement by 20 years. After 15 years, good outcomes are seen in 87% of patients after shelf arthroplasty and 85% after femoral varus osteotomy with or without shelf arthroplasty. Chiari acetabular osteotomy can be performed in patients with osteoarthritis but is followed by prolonged limping. Periacetabular osteotomy should be reserved for patients with moderate dysplasia and no evidence of osteoarthritis. Shelf arthroplasty and femoral osteotomy require 5-8 months off work (compared to 5 months after hip replacement surgery) but subsequently permits a far more active lifestyle. Hip replacement, which is required 20 years or more after biologic reconstruction, carries the same prognosis as first-line hip replacement (good results in 80% of patients after 15 years). Acute sharp pain related to anterior hip derangement also occurs in primary femoroacetabular impingement (FAI). The most common pattern is cam impingement, which is due to a decrease in head-neck offset and manifests as pain during flexion and adduction of the hip. Cam impingement can be corrected by anterolateral osteoplasty, which is often performed arthroscopically. Pincer-type impingement is contact between the anterior acetabular rim and the femoral neck due to retroversion of the proximal acetabulum. The imaging study strategy is discussed. Coxometry, computed tomography, and arthrography can be used. Primary FAI, which occurs as a result of geometric abnormalities, should be distinguished from secondary impingement. Causes of secondary impingement include exaggerated lumbar lordosis with pelvic tilt and to hip osteophytosis (sports or posterior hip osteoarthritis). Osteoplasty is rarely appropriate in patients with secondary impingement. The features of acute anterior hip derangement are now better defined. They can be used to guide palliative treatment, which is effective, in the medium term at least. Experience acquired over the last two decades has established the efficacy of surgery for hip dysplasia.
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Artralgia/cirugía , Luxación Congénita de la Cadera/cirugía , Procedimientos Ortopédicos , Procedimientos de Cirugía Plástica , Adulto , Factores de Edad , Artralgia/diagnóstico por imagen , Artralgia/etiología , Luxación Congénita de la Cadera/diagnóstico por imagen , Luxación Congénita de la Cadera/etiología , Humanos , Persona de Mediana Edad , RadiografíaRESUMEN
PURPOSE: To evaluate meniscal damage and the midterm clinical outcome, we performed a retrospective review of 105 lateral meniscal cysts that were treated arthroscopically at our institution. TYPE OF STUDY: Retrospective review. METHODS: From a series of 8,100 knee arthroscopies, 122 patients (1.5%) with 124 lateral meniscal cysts were selected. Eight of the patients were lost to follow-up and 11 patients had associated pathology; therefore, 105 lateral meniscal cysts on stable knees were included in this study. Average follow-up was 5 years (range, 1 to 12.5 years). The mean age was 33 years (range, 12 to 69 years). All patients had presented with tenderness over the joint line with a palpable mass. All cases were treated arthroscopically and all patients underwent a complete physical examination before surgery and at last follow-up. Radiographic evaluation was available at final follow-up for 68 cases. RESULTS: All patients had a meniscal tear at the time of surgery and 60 (57%) had a horizontal cleavage component. For meniscal tears, arthroscopic partial lateral meniscectomy was performed in 104 cases and meniscal repair in 1 case. For cysts, intra-articular debridement was performed in 91 cases and open cystectomy in 14. Eleven cysts recurred and a second arthroscopy was required. The clinical results, including those cases with recurrent cysts, were excellent or good in 87% of cases. Osteoarthritis following treatment for meniscal cysts occurred in 9% of cases. CONCLUSIONS: When there was a cyst and no other intra-articular damage, the prognosis was excellent. For lateral meniscal cysts, arthroscopic partial meniscectomy with intra-articular debridement yields predictable results. LEVEL OF EVIDENCE: Level IV.