Cadera/Hip: No siempre la evidencia pasa a la clínica

Surgical Treatment of Trochanteric and Cervical Hip Fractures in the United States: 2000–2009

Sunny H. Kim, John P. Meehan,  Mark A. Lee

The Journal of Arthroplasty 28 (2013) 1386–1390

The objective of this study was to evaluate the most common treatments performed for hip fractures over the last decade in the United States. The leading treatment for trochanteric fractures was internal fixation, accounting for 96%–98% of surgical treatments each year. For cervical fractures, hemiarthroplasty (HA), total hip arthroplasty (THA), and internal fixation were performed nearly 61%, 5%, and 33% of the time, respectively, each year without any sign of change during the period assessed. The surgical choice for cervical fractures varied greatly by patient age. In 2009, two-thirds of patients younger than 60 years underwent internal fixation while two-thirds of patients 60 years or older underwent HA. Regardless of patient age, HA was performed more often than THA for cervical hip fractures.

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El objetivo de este estudio fue evaluar los tratamientos más comunes realizados para las fracturas de cadera en la última década en los Estados Unidos. El principal tratamiento para las fracturas trocantéricas fue la fijación interna, que representó el 96% -98% de los tratamientos quirúrgicos cada año. Para las fracturas cervicales, la hemiartroplastia (HA), la artroplastia total de cadera (THA) y la fijación interna se realizaron casi el 61%, 5% y 33% de las veces respectivamente, anualmente sin ningún signo de cambio durante el período evaluado. La elección quirúrgica para las fracturas cervicales varió mucho dependiendo de la edad del paciente. En 2009, dos tercios de los pacientes menores de 60 años se sometieron a fijación interna, mientras que dos tercios de los pacientes de 60 años o más se sometió a HA. Independientemente de la edad del paciente, la HA se realizó con más frecuencia que THA para las fracturas cervicales de cadera.

Hombro/Shoulder: reducir la muesca escapular está a mano

¿La lateralización del centro de rotación en la prótesis total invertida de hombro  (PTHI) evita la muesca escapular? Revisión clínica y radiológica de ciento cuarenta casos con cuarenta y cinco meses de seguimiento

Denis Katz, Philippe Valenti, Jean Kany, Kamil Elkholti, Jean-David Werthel

International Orthopaedics 2016, 40 (1): 99-108

OBJETIVO: Evaluar la influencia de la lateralización metálica del centro de rotación (CR) en la PTHI sobre la incidencia de la muesca escapular y sus eventuales consecuencias clínicas y radiológicas.

MÉTODOS: Se analizaron 140 PTHI con un modelo lateralizado (Arrow, FH Orthopedics, Mulhouse, Francia) implantado para tratar el desgarro masivo del manguito rotador con o sin artritis. La media de seguimiento fue de 45 meses (rango 24-120, desviación estándar 20). Los pacientes fueron evaluados clínicamente usando la puntuación de Constant y Murley (Clin Orthop Relat Res 214: 160-164, 1987) y el rango de movimiento activo (ROM) y radiológicamente usando las proyecciones anteroposterior estándar y axilar. La muesca escapular se evaluó según la clasificación de Sirveaux Simovitch et al. (J Bone Joint Surg Am, 89: 588-600, 2007), y los pacientes se separaron en dos grupos (con escotadura escapular / sin escotadura escapular) y se compararon.

RESULTADOS: Se encontraron cuarenta y una muescas (29%): 20 grado 1, 18 grado 2 y 3 grado 3. Los tres últimos pacientes tuvieron un seguimiento de 44, 70 y 84 meses, respectivamente, y la muesca escapular no evolucionón en los últimos dos años. Una mejor función preoperatoria se asoció significativamente con la presentación de muesca escapular (p <0,05 para la flexión y la abducción), pero no se encontraron diferencias clínicas finales en la ROM y la puntuación de Constant entre los grupos. Un índice de masa corporal (IMC) <30 aumentó el riesgo de muesca escapular, lo que se observó en el 43% de los pacientes con IMC <30 y en el 30% de los pacientes con IMC> 30 (p = 0,048). El pinzamiento preoperatorio del espacio subacromial aumentó el riesgo de muescas escapulares, pero la edad o el sexo no mostraron influencia. Sin embargo, hubo un número significativamente mayor de muescas escapulares en pacientes operados en el lado dominante (p = 0,04). No se encontró diferencia significativa en el desplazamiento lateral entre los grupos (p = 0,99). La implantación glenoidea en una posición excesivamente alta (p = 0,033) y la ausencia de inclinación inferior (p = 0,0029) se asociaron significativamente con la muesca escapular.

CONCLUSIONES: En esta serie, la lateralización metálica del CR en la PTHI no perjudicó los resultados clínicos. Los pacientes lograron un buen aumento de la flexión y las rotaciones. La lateralización metálica del CR en la PTHI conduce a una menor incidencia de muesca escapular (29%) en comparación con los resultados reportados anteriormente utilizando otros sistemas artroplásticos con un COR más medializado. Sin embargo, aunque la escotadura escapular no se eliminó totalmente, las que se encontraron no evolucionaron con el tiempo. Varios factores aumentaron la incidencia de muesca escapular: IMC <30, mejor ROM preoperatoria, implante glenoideo excesivamente alto y la ausencia de su inclinación inferior.

Hombro / Shoulder: En la PTH escoge cerrar bien la osteotomía del troquín

How should I fixate the subscapularis in total shoulder arthroplasty? A systematic review of pertinent subscapularis repair biomechanics
 
John B. Schrock, Matthew J. Kraeutler, Charles T. Crellin, Eric C. McCarty, Jonathan T. Bravman
First Published April 5, 2017

Shoulder & Elbow
Article first published online: April 5, 2017
DOI: https://doi.org/10.1177/1758573217700833

Abstract

Background

The present study aimed to review the biomechanical outcomes of subscapularis repair techniques during total shoulder arthroplasty (TSA) to assist in clinical decision making.

Methods

A systematic review of multiple databases was performed by searching PubMed, Scopus, Cochrane Library, Google Scholar, and all databases within EBSCOhost to find biomechanical studies of subscapularis repair techniques in cadaveric models of TSA.

Results

Nine studies met the inclusion criteria. In the majority of studies, lesser tuberosity osteotomy (LTO) techniques had greater load to failure and less cyclic displacement compared to subscapularis tenotomy or peel methods. LTO repairs with sutures wrapped around the humeral stem demonstrated superior biomechanical outcomes compared to techniques using only a tension band. In terms of load to failure, the strongest repair of any study was a dual-row  LTO using four sutures wrapped around the stem.

Conclusions

Several cadaveric studies have shown superior biomechanical outcomes with LTO techniques compared to tenotomy. In the majority of studies, the strongest subscapularis repair technique in terms of biomechanical outcomes is a compression LTO. Using three or more sutures wrapped around the implant and the addition of a tension suture may increase the biomechanical strength of the LTO repair.

Cadera / Hip: cadera de anciano fracturada operada cementando

Cemented versus cementless hemiarthroplasty for a displaced fracture of the femoral neck

a systematic review and meta-analysis of current generation hip stems

H. D. Veldman, I. C. Heyligers, B. Grimm, T. A. E. J. Boymans

Bone Joint J 2017;99-B:421–31

DOI: 10.1302/0301-620X.99B4.BJJ-2016-0758.R1 Published 6 April 2017

Abstract

Aims 

Our aim was to prepare a systematic review and meta-analysis to compare the outcomes of cemented and cementless hemiarthroplasty of the hip, in elderly patients with a fracture of the femoral neck, to investigate the mortality, complications, length of stay in hospital, blood loss, operating time and functional results.

Materials and Methods 

A systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines on randomised controlled trials (RCTs), studying current generation designs of stem only. The synthesis of results was done of pooled data, with a fixed effects or random effects model, based on heterogeneity.

Results 

A total of five RCTs including 950 patients (950 hips) were included. Cementless stems were found to be associated with more complications compared with cemented stems (odds ratio (OR) 1.61, 95% confidence interval (CI) 1.12 to 2.31, p = 0.01), especially implant-related complications (OR 3.15, 95% CI 1.55 to 6.41, p = 0.002). The operating time was shorter for cementless stems (weighted mean difference -9.96 mins, 95%CI -12.93 to -6.98, p < 0.001). The data on functional outcomes could not be pooled. There was no statistically significant difference for any other outcome between the two methods of fixation.

Conclusion 

In hemiarthroplasty of the hip using current generation stems, cemented stems result in fewer implant-related complications and similar mortality compared with cementless stems.

Cadera/Hip: El abordaje posterior mejor, suturar la cápsula no influye

The stability of the hip after the use of a proximal femoral endoprosthesis for oncological indications
analysis of variables relating to the patient and the surgical technique

E. R. Henderson, B. J. Keeney, E. Pala, P. T. Funovics, W. C. Eward, J. S. Groundland, L. K. Ehrlichman, S. S. E. Puchner, B. E. Brigman, J. E. Ready, H. T. Temple, P. Ruggieri, R. Windhager, G. D. Letson, F. J. Hornicek

Bone Joint J 2017;99-B:531–7
DOI: 10.1302/0301-620X.99B4.BJJ-2016-0960.R1 Published 6 April 2017

 
Abstract

Aims

Instability of the hip is the most common mode of failure after reconstruction with a proximal femoral arthroplasty (PFA) using an endoprosthesis after excision of a tumour. Small studies report improved stability with capsular repair of the hip and other techniques, but these have not been investigated in a large series of patients. The aim of this study was to evaluate variables associated with the patient and the operation that affect post-operative stability. We hypothesised an association between capsular repair and stability.

Patients and Methods

In a retrospective cohort study, we identified 527 adult patients who were treated with a PFA for tumours. Our data included demographics, the pathological diagnosis, the amount of resection of the abductor muscles, the techniques of reconstruction and the characteristics of the implant. We used regression analysis to compare patients with and without post-operative instability.

Results

A total of 20 patients out of 527 (4%) had instability which presented at a mean of 35 days (3 to 131) post-operatively. Capsular repair was not associated with a reduced rate of instability. Bivariate analysis showed that a posterolateral surgical approach (odds ratio (OR) 0.11, 95% confidence interval (CI) 0.02 to 0.86) and the type of implant (p = 0.046) had a significant association with reduced instability; age > 60 years predicted instability (OR 3.17, 95% CI 1.00 to 9.98). Multivariate analysis showed age > 60 years (OR 5.09, 95% CI 1.23 to 21.07), female gender (OR 1.73, 95% CI 1.04 to 2.89), a malignant primary bone tumour (OR 2.04, 95% CI 1.06 to 3.95), and benign condition (OR 5.56, 95% CI 1.35 to 22.90), but not metastatic disease or soft-tissue tumours, predicted instability, while a posterolateral approach (OR 0.09, 95% CI 0.01 to 0.53) was protective against instability. No instability occurred when a synthetic graft was used in 70 patients.

Conclusion

Stability of the hip after PFA is influenced by variables associated with the patient, the pathology, the surgical technique and the implant. We did not find an association between capsular repair and improved stability. Extension of the tumour often dictates surgical technique; however, our results indicate that PFA using a posterolateral approach with a hemiarthroplasty and synthetic augment for soft-tissue repair confers the lowest risk of instability. Patients who are elderly, female, or with a primary benign or malignant bone tumour should be counselled about an increased risk of instability.