Pelvis: menos complicado el injerto autólogo extraído mediante RIA

Complications following autologous bone graft harvesting from the iliac crest and using the RIA [Reamer-Irrigator-Aspirator]: a systematic review.

Dimitriou RMataliotakis GIAngoules AGKanakaris NKGiannoudis PV

Injury 2011 Sep.:S3-15.

Abstract

Bone grafting is a commonly performed surgical procedure to augment bone regeneration in a variety of cases in orthopaedic and maxillofacial surgery. Autologous bone graft remains to be the 'gold standard' and the iliac crest to be the most common harvesting site. The intramedullary canal of long bones represents another potential site for large volume of autologous bone graft harvesting and is recently being used as an alternative donor site. However, harvesting of autologous bone graft is associated with morbidity and a number of complications. The aim of this systematic review was to collect and summarise the existing data on reported complications after harvesting autologous bone from the iliac crest (anterior and posterior) and the long bone intramedullary canal using the RIA device.

We searched the PubMed Medline and Ovid Medline databases, from January 1990 to October 2010, to retrieve all relevant articles. A total of 92 articles (6682 patients) were included in the analysis.

Overall, the complication rate following RIA was 6% (14 complications in 233 patients) and 19.37% after iliac crest bone graft harvesting (1249 complications in 6449 patients). The rate of each of the reported complications was assessed and, when the donor site was properly documented, comparison within the anterior and posterior iliac crest donor sites was performed. Although the difference of the overall morbidity rates between the two harvesting sites was not statistically significant (p=0.71); the rates of certain complications were found to significantly differ when anterior or posterior iliac crest was used. The rates of infection (p=0.016), haematoma formation (p=0.002), fracture (p=0.017), and hyperthrophic scar (p=0.017) were significantly higher when the donor site was the anterior iliac crest compared to the posterior iliac crest; whereas the rates of chronic donor site pain (p=0.004) and sensory disturbances (p=0.003) were significantly lower.

The incidence of bone graft harvesting related complications can be reduced further if certain principles are followed depending on the performed harvesting methods; but overall the use of RIA device as harvesting method seems a promising alternative with a low complication rate.

Rodilla / Knee: difícil aloinjerto para la rotura del mecanismo extensor

Extensor mechanism allograft reconstruction for extensor mechanism failure following total knee arthroplasty.

Brown NM, Murray T, Sporer SM, Wetters N, Berger RA, Della Valle CJ.

J Bone Joint Surg Am. 2015 Feb 18;97(4):279-83. doi: 10.2106/JBJS.N.00759.

Abstract

BACKGROUND: Extensor mechanism disruption following total knee arthroplasty is a rare but devastating complication. The purpose of this study was to report our experience with extensor mechanism allograft reconstruction for chronic extensor mechanism failure.

METHODS: Fifty consecutive extensor mechanism allograft reconstructions were performed in forty-seven patients with a mean age of 67.6 years who were followed for a mean time of 57.6 months (range, twenty-four to 125 months). The operative technique included the use of a fresh-frozen, correctly sized full extensor mechanism allograft that was tensioned tightly in full extension. Patients were evaluated clinically with use of the Knee Society score, and reconstructions were considered failures if the patient had a score of <60 points or a recurrent extensor lag of >30° or if they required revision or removal of the allograft.

RESULTS: Nineteen reconstructions (38%) were considered failures, including four revised to a second extensor mechanism allograft due to failure of the allograft, five for deep infection, and ten considered clinical failures secondary to a Knee Society score of <60 points or an extensor lag of >30°. The mean Knee Society score improved from 33.9 to 75.9 points (p < 0.0001). The estimated Kaplan-Meier survivorship with failure for any reason as the end point was 56.2% (95% confidence interval, 39.4% to 70.1%) at ten years.

CONCLUSIONS: Extensor mechanism disruption following total knee arthroplasty is a difficult complication to treat, with modest outcomes. Extensor mechanism allograft reconstruction is a reasonable option; however, patients must be informed regarding the substantial risk of complications, and although initial extensor mechanism function may be restored, expectations regarding longer-term outcomes are more guarded.

LEVEL OF EVIDENCE: Therapeutic Level IV

Rodilla/Knee: Ojo con la gonartritis séptica posoperatoria

Joint infection after knee arthroscopy: Medicolegal aspects
S. Marmora, T. Farmanb, A. Lortat-Jacobc
Orthopaedics & Traumatology: Surgery & Research (2009) 95, 278—283

Summary

Introduction:
Septic knee arthritis following arthroscopy is a rare but dreaded complication: it might compromise patients’ functional prognosis and engage surgeon’s liability. This study ana- lyzes the context of such infection occurrences, their management as well as their medicolegal consequences.

Patients and methods:
Twenty-two cases of knee septic arthritis following arthroscopy were examined during the medicolegal litigation process and collected for assessment from a medi- cal liability specialised insurer. Half of the patients were manual workers who worked on their knees, and seven knees had a previous surgical history. The procedures performed at arthroscopy included seven ligamentoplasties, nine meniscotomies, three arthroscopic lavages, one arthrol- ysis, one chondroma removal and one plica resection. Seven patients, to some point, received corticosteroids: three preoperative joint injections, three intraoperative injections, and one oral corticotherapy.

Results:
Clinical signs of septic arthritis appeared after a median interval of 8 days (0—37), twice after a hemarthrosis and once after an articular burn. The median delay before treatment initiation was 4.2 days, and in 10 cases this therapeutic delay exceeded 3 days. On average, 3.5 additional procedures (1—9) were required to treat the infection and its residual sequels. Two total knee prostheses were implanted. Only two patients were free of disabling sequellae, and in five patients these sequels affected their livelihood. The medicolegal consequences were a partially permanent disability averaging 5% (0—20), a total temporary work incapacity of 120 days (40—790), a suffering burden averaging 3 out of 7 (0—4,5) points on the scale conventionally used in France. Twelve of these legal claims led to court ordered patient compensation.

Discussion:
Some risk factors of articular infection are known and well-identified. They can be linked to the patient’s condition (addiction to smoking, surgical history, professional activity)
or to medical management (intra-articular corticoid injections, interventions under oral anti- coagulants, inadvertently overheated irrigation fluid). When infection is suspected, it is often the needle-aspirated fluid’s inappropriate handling (such as absence of bacteriological testing or defective waiting time for the results), which delays the diagnostic or therapeutic manage- ment of this complication. All failures of infection diagnosis or treatment heavily contribute to malpractice claims against the surgeon. Early and appropriate management of postoperative infections helps limiting the risk of functional sequellae for the patient and reduces the risk of malpractice litigation for the practitioner.

Level of evidence: Level IV; economic and decision analysis, retrospective study

Rodilla/Knee/Knie/Genou:¿Con menos complicaciones de lo imaginado?

The John Insall Award: Morbid Obesity Independently Impacts Complications, Mortality, and Resource Use After TKA
Michele R D'Apuzzo, Wendy M Novicoff, James A Browne
Clinical Orthopaedics and related Research 2015, 473 (1): 57-63

BACKGROUND: The importance of morbid obesity as a risk factor for complications after total knee arthroplasty (TKA) continues to be debated. Obesity is rarely an isolated diagnosis and tends to cluster with other comorbidities that may independently lead to increased risk and confound outcomes. It is unknown whether morbid obesity independently affects postoperative complications and resource use after TKA.

QUESTIONS/PURPOSES: The purpose of this study was to determine whether morbid obesity is an independent risk factor for inpatient postoperative complications, mortality, and increased resource use in patients undergoing primary TKA.

METHODS: The Healthcare Cost and Utilization Project Nationwide Inpatient Sample (NIS) database was used to identify patients undergoing primary TKA from October 2005 to December 2008. Morbid obesity (body mass index ≥ 40 kg/m(2)) was determined using International Classification of Diseases, 9(th) Revision, Clinical Modification codes. In-hospital postoperative complications, mortality, costs, and disposition for morbidly obese patients were compared with nonobese patients. To control for potential confounders and comorbid conditions, each morbidly obese patient was matched to a nonobese patient using age, sex, and all 28 comorbid-defined elements in the NIS database based on the Elixhauser Comorbidity Index. Of 1,777,068 primary TKAs, 98,410 (5.5%) patients were categorized as morbidly obese. Of these, 90,045 patients (91%) were able to be matched one-to-one to a nonobese patient for the adjusted analysis.

RESULTS: Morbidly obese patients had a higher risk of postoperative in-hospital infection (0.24% versus 0.17%; odds ratio [OR], 1.3; 95% confidence interval [CI], 1.1-1.7; p = 0.001), wound dehiscence (0.11% versus 0.08%; OR, 1.3; 95% CI, 1.0-1.7; p = 0.28), and genitourinary-related complications (0.60% versus 0.44%; OR, 1.3; 95% CI, 1.1-1.5; p < 0.001). There was no increase in the prevalence of cardiovascular or thromboembolic-related complications. Morbidly obese patients were at higher risk of in-hospital death after primary TKA compared with nonobese patients (0.08% versus 0.02%; OR, 3.2; 95% CI, 2.0-5.2; p < 0.001). Total hospital costs (USD 15,174 versus USD 14,715, p < 0.001), length of stay (3.6 days versus 3.5 days, p < 0.001), and rate of discharge to a facility (40% versus 30%, p < 0.001) were all higher in morbidly obese patients.

CONCLUSIONS: Morbid obesity appears to be independently associated with a higher risk for a small number of select in-hospital postoperative complications and mortality after matching for comorbid medical conditions linked to obesity. However, the independent impact of morbid obesity appears to be fairly modest, and morbid obesity did not appear to be an independent risk factor for many systemic complications. Continued research is necessary to identify the influence of associated comorbidities on early postoperative complications in morbidly obese patients after TKA.

LEVEL OF EVIDENCE: Level II, prognostic study.

Cadera/Hip/Hüfte/Hanche: Qué le espera el paciente joven tras una prótesis total de cadera

Mid-to long-term results of revision total hip replacement in patients aged 50 years or younger 
Lee, P. T. H., Lakstein, D. L., Lozano, B., Safir, O., Backstein, J., Gross, A. E.
Bone Joint J 2014;96-B:1047–51.

Revision total hip replacement (THR) for young patients is challenging because of technical complexity and the potential need for subsequent further revisions.

We have assessed the survivorship, functional outcome and complications of this procedure in patients aged < 50 years through a large longitudinal series with consistent treatment algorithms.
Of 132 consecutive patients (181 hips) who underwent revision THR, 102 patients (151 hips) with a mean age of 43 years (22 to 50) were reviewed at a mean follow-up of 11 years (2 to 26) post-operatively. We attempted to restore bone stock with allograft where indicated.

Using further revision for any reason as an end point, the survival of the acetabular component was 71% (sd 4) and 54% (sd 7) at ten- and 20 years. The survival of the femoral component was 80% (sd 4) and 62% (sd 6) at ten- and 20 years. Complications included 11 dislocations (6.1%), ten periprosthetic fractures (5.5%), two deep infections (1.1%), four sciatic nerve palsies (2.2%; three resolved without intervention, one improved after exploration and freeing from adhesions) and one vascular injury (0.6%). The mean modified Harris Hip Score was 41 (10 to 82) pre-operatively, 77 (39 to 93) one year post-operatively and 77 (38 to 93) at the latest review.

This overall perspective on the mid- to long-term results is valuable when advising young patients on the prospects of revision surgery at the time of primary replacement.

Hombro / Shoulder / Schulter: Un repaso de las complicaciones de las PTHi

Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: A systematic review

Matthias A. Zumstein, Miguel Pinedo, Jason Old, Pascal Boileau

The use of hemiarthroplasty in patients with an arthritic rotator cuff deficient shoulder has been shown to provide limited function and inconsistent pain relief.

The semiconstrained reverse shoulder prosthesis, designed by Grammont in the late 1980s, was invented based on 2 biomechanical concepts: lowering the humerus and medialization of the center of rotation at the glenoid component. This design has the dual advantage of tensioning the deltoid muscle to increase its functional strength, and decreasing mechanical torque at the glenoid component, thus avoiding glenoid loosening. The first series of reverse shoulder arthroplasty (RSA) with at least 2 years of follow-up confirmed the preliminary results, with excellent functional outcome and stable glenoid fixation. However, these series had a small numbers of patients and reported variable compli-cation and revision rates of 15% to 50% and reoperation rates of 4% to 40%. One reason for the high variability was unclear definitions of complications and revisions, which varied markedly between the series. Furthermore, it is difficult to draw conclusions from small numbers of patients.

The purpose of the present study was to determine the incidence and functional significance of adverse events after RSA, including problems, complications, reopera-tions, and revisions. We established a study design and specific objectives before commencing the literature research. These objectives were (1) to perform a systematic review of the published literature to determine the overall rates of problems, complications, reoperations, and revi-sions after RSA; (2) to compare their influence on the final functional outcome; and, (3) to analyze the different problems, complications, reoperations, and revisions based on the etiology of the RSA

Rodilla / Knee: La artroscopia de rodilla, frecuente pero con peligros

Complications after arthroscopic knee surgery.

Salzler MJ, et al

Am J Sports Med. 2014 Feb;42(2):292-6

Abstract

BACKGROUND: Knee arthroscopies are among the most common procedures performed by orthopaedic surgeons, yet little is known about the associated complications and complication rates.

PURPOSE: To examine the nature and frequency of complications after the most common arthroscopic knee procedures, with particular attention to fellowship training, geographic location of practice, and age and sex of the patient.

STUDY DESIGN: Cross-sectional study; Level of evidence, 3.

METHODS: Data were obtained from the American Board of Orthopaedic Surgery database for orthopaedic surgeons who sat for the part II examination from 2003 to 2009. The database was queried to determine the type and frequency of complications for patients who underwent knee arthroscopy and for those who underwent sports medicine knee arthroscopy, including arthroscopic partial meniscectomy, meniscal repair, chondroplasty, microfracture, anterior cruciate ligament reconstruction, or posterior cruciate ligament reconstruction. Factors affecting complication rates that were investigated included type of procedure, fellowship training status, geographic location of practice, and age and sex of the patient.

RESULTS: There were 4305 complications out of 92,565 knee arthroscopic procedures obtained from the American Board of Orthopaedic Surgery database for an overall candidate-reported complication rate of 4.7%. The complication rates were highest for posterior cruciate ligament reconstruction (20.1%) and anterior cruciate ligament reconstruction (9.0%); complication rates for meniscectomy, meniscal repair, and chondroplasty were 2.8%, 7.6%, and 3.6%, respectively. The complication rate for sports fellowship-trained candidates was higher than for non-sports trained candidates (5.1% sports, 4.1% no sports; P < .0001) and for male patients (4.9% male vs 4.3% female; P < .0001). Younger patients (<40 years; 6.2%) had a higher complication rate than older patients (≥40 years; 3.58%) (P < .0001). Procedure complexity is a likely confounding factor affecting sports-trained candidates and younger patients. There were no geographic differences (P = .125). The overall rate of pulmonary embolus was 0.11%. Surgical complications (3.68%) were more common than medical (0.77%) or anesthetic complications (0.22%), and infection was the most common complication overall (0.84%).

CONCLUSION: The overall self-reported complication rate for arthroscopic knee procedures was 4.7%. Knee arthroscopy is not a benign procedure, and patients should be aware of the risk of complications.