Revisiones bibliográficas. Documentación científica en Ortopedia y Traumatología, medicina deportiva, artroscopia, artroplastia y de todas las patologías del sistema Músculo-Esquelético
2017 May 1;40(3):e387-e394. doi: 10.3928/01477447-20170117-07. Epub 2017 Jan 23.
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Copyright 2017, SLACK Incorporated.
Abstract
With increases in both life expectancy and the number of patients with endoprosthetic replacements, more periprosthetic fractures are expected to occur. Periprosthetic fractures related to megaprostheses present a treatment challenge, with a high incidence (one-third of affected patients) of secondary revision as a result of prosthetic loosening, infection, nonunion, refracture, or even amputation. Efforts to improve endoprosthetic reconstruction should focus on preventing postoperative complications. Understanding the causes of complications and strategies to avoid them could lead to significant improvements in implant survival, limb function, and patient outcomes. This article presents a concise review of the current literature and an algorithmic approach to reconstruction of these complex injuries. [Orthopedics. 2017; 40(3):e387-e394.].
Resumen
Con aumentos en la esperanza de vida y el número de pacientes con reemplazos endoprotésicos, se esperan más fracturas periprotésicas. Las fracturas periprotésicas relacionadas con las megaprotesis presentan un reto de tratamiento, con una alta incidencia (un tercio de los pacientes afectados) de revisión secundaria como resultado del aflojamiento protésico, infección, no unión, refracción o incluso amputación. Los esfuerzos para mejorar la reconstrucción endoprótesis deben centrarse en la prevención de complicaciones postoperatorias. Entender las causas de las complicaciones y las estrategias para evitarlas podría conducir a mejoras significativas en la supervivencia del implante, la función de la extremidad y los resultados del paciente. Este artículo presenta una revisión concisa de la literatura actual y un abordaje algorítmico para la reconstrucción de estas lesiones complejas. [Ortopedía. 2017; 40 (3): e387 – e394.].
Courtesy: Prof Nabil Ebraheim, University of Toledo, Ohio, USA
Courtesy: Prof Nabil Ebraheim, University of Toledo, Ohio, USA
Publicado el 5 may. 2017
Dr. Ebraheim’s educational animated video describes classifications of femoral neck fractures.
Femoral neck fractures can occur as a result of low energy trauma in the elderly. In this case you will need to get a medical consultation! Femoral neck fractures can also occur due to high energy trauma, such as with falls or motor vehicle accidents. Femoral neck fractures can occur in older as well as younger patients, and in these cases you need to apply the ATLS protocol. Femoral neck fractures can also occur due to insufficiency fractures. This occurs due to weak bones, because of osteoporosis or osteopenia. The patient will have groin pain, pain with axial compression and the x-ray may be normal (helpful in diagnosing insufficiency fracture). There may also be a stress fracture due to overuse and more loading on the hips. Stress fractures may occur in athletes, ballet dancers, or military recruits. Anatomic classification 1. Subcapital – common 2. Transcervical 3. Basicervical The subcapital fracture has two classifications: the garden classification and Pauwel’s classification. The garden classification system classifies the fracture according to the amount or degree of displacement. It relates the amount of displacement to the risk of vascular disruption. This classification applies to the geriatric and insufficiency fractures. It can then be classified into two groups: the nondisplaced and the displaced. Types I and II are nondisplaced, while types III and IV are displaced. Type I is incomplete and impacted in valgus. Type II is a complete fracture and nondisplaced on at least two planes (anteroposterior & lateral). Type III is a complete fracture and partially displaced. The trabecular pattern of the femoral head does not line up with the acetabular trabecular pattern. A type IV fracture is completely displaced with no continuity between the proximal and distal fragments. The trabecular pattern of the femoral head remains parallel with the acetabulum trabecular pattern. The Pauwel’s Classification is classified into three fracture types. It classifies the fracture according to the orientation and direction of the fracture line across the femoral line. It related to the biomechanical stability. The more vertical the fracture, the more sheer forces and the more the complication rate. Type I is stable and has an obliquity ranging from 0-30 degrees. Type II is less stable and have an obliquity ranging from 30-50 degrees. Lastly, type III is unstable and has an obliquity between 50-70 degrees or more. As the fracture progresses from Type I – Type III, the obliquity of the fracture line increases. As the fracture line becomes more vertical, the sheer forces increase and the instability increases. A horizontal fracture is good and stable while a vertical fracture is bad and unstable. The more displaced the fracture, the more disruption of the blood supply and the chance of avascular necrosis and nonunion (can occur in about 25% of displaced fractures). In nonunion occurs in a younger patient, you may help the patient by doing a subtrochanteric osteotomy to reorient the fracture line from vertical to horizontal (will help the fracture healing). Femoral Neck Fractures Associated with Femoral Shaft Fractures The typical neck fracture is vertical and nondisplaced. It may require internal rotation view x-rays to see this hip fracture (fracture could be missed). Treatment of this fracture is to fix the femoral neck fracture first, followed by the femoral shaft fracture. The usual combination is parallel screws in the femoral neck and a retrograde femoral rod for the fractured femur. Stress fractures are more common in females due to the female athletic triad. It can be a tension fracture. The fracture or callus is present on the superior aspect of the femoral neck. Adult bone is weak in tension, so stress fracture of the femoral neck needs to be fixed! This should be an emergency operation before the fracture displaces. With compression fractures, the compression or callus is present on the inferior aspect of the femoral neck. It is believed that if the compression fracture is less than 50% across the neck, then the fracture could be stable and you can do protected crutch ambulation. If the fracture is more than 50% across the neck, then the fracture is unstable and you will do an ORIF. Some surgeons fix all stress fractures of the femoral neck. A female runner with groin pain can indicated a stress fracture. Get an MRI, the fracture will probably need to be fixed.
van Oostveen DP, Temmerman OP, Burger BJ, van Noort A, Robinson M.
Acta Orthop Belg. 2014 Mar;80(1):88-98.
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Acta Orthopædica Belgica, Vol. 80 – 1 – 2014
Abstract
Glenoid fractures are rare, and relatively little is known about their mechanism, fracture pattern and optimal treatment strategies. The avulsions and rim fractures are strongly associated with anterior shoulder dislocations. Fossa fractures are mostly seen in high energy trauma patients as direct impact of the humeral head against the glenoid fossa. CT-scanning can be very useful in diagnosing the extend of injury and relation of humeral head with the main fragment of the glenoid. Fracture classification systems, have been designed mainly based on trauma mechanism, location and severity of fracture pattern. Treatment depends on instability, the degree of displacement and the articular surface fragment size, but is conservative in most cases. Due to the increase of arthroscopic fixation possibilities, operative treatment may increase. In this review, we have tried to summarize the available evidence into a treatment algorithm for different types of glenoid fractures. With regard to best functional outcome, an anatomical and concentric joint restoration should be the goal of treatment. Outcome is generally good in conservative and operative treatment, but exact data is difficult to appreciate, due to heterogeneity and comorbidities in different studies.
Abstracto
Las fracturas glenoides son raras y se sabe relativamente poco sobre su mecanismo, su patrón de fractura y estrategias de tratamiento óptimas. Las avulsiones y las fracturas del borde están fuertemente asociadas con dislocaciones anteriores del hombro. Las fracturas de la fosa se observan principalmente en pacientes con traumatismos de alta energía como impacto directo de la cabeza del húmero contra la fosa glenoidea. La exploración por TC puede ser muy útil para diagnosticar la extensión de la lesión y la relación de la cabeza del húmero con el fragmento principal de la glenoidea. Los sistemas de clasificación de fractura, han sido diseñados principalmente basados en el mecanismo de traumatismo, localización y gravedad del patrón de fractura. El tratamiento depende de la inestabilidad, el grado de desplazamiento y el tamaño del fragmento de la superficie articular, pero es conservador en la mayoría de los casos. Debido al aumento de las posibilidades de fijación artroscópica, el tratamiento quirúrgico puede aumentar. En esta revisión, hemos tratado de resumir la evidencia disponible en un algoritmo de tratamiento para diferentes tipos de fracturas glenoides. Con respecto al mejor resultado funcional, una restauración anatómica y concéntrica de la articulación debe ser la meta del tratamiento. El resultado es generalmente bueno en el tratamiento conservador y operativo, pero los datos exactos son difíciles de apreciar, debido a la heterogeneidad y las comorbilidades en diferentes estudios.
Un componente femoral sin cemento puede permitir una incisión quirúrgica más pequeña cuando se utiliza un abordaje mínimamente invasivo durante la artroplastia total primaria de rodilla. La fijación por cemento es el estándar de oro para la artroplastia total de rodilla. Los resultados de la artroplastia total de rodilla no cementada se mezclan. Los componentes femorales sin cemento lo han hecho bien. Aunque algunos componentes tibiales han tenido un buen desempeño en el seguimiento a largo plazo, otros han sido plagados por altas tasas de aflojamiento y revisión. La cuestión sigue siendo si los resultados de la artroplastia total híbrida de rodilla, consistente en un componente femoral no cementado y un componente tibial cementado, serán iguales a los del reemplazo total de rodilla fijado con cemento en el seguimiento a largo plazo. Los autores revisaron 148 artroplastias totales de rodilla híbridas realizadas por un solo cirujano entre 1993 y 1995. Con un seguimiento medio de 14 años (rango, 10-16) 5 rodillas (4%) habían sido sometidas a revisión de los componentes femoral y tibial . Sólo se requirió una revisión de rodilla para el aflojamiento aséptico. Se revisaron dos rodillas para la sepsis; 1 rodilla se había revisado para la fractura y 1 para la inestabilidad. No hubo componentes femorales o tibiales adicionales por criterios radiográficos. Se identificó osteólisis femoral focal leve en 3 rodillas (2%), y osteólisis tibial menor estuvo presente en 2 rodillas (1%). La tasa de supervivencia con revisión para el aflojamiento aséptico como punto final fue de 99% (intervalo de confianza del 95%, 0,97-100) a los 16 años para los componentes femoral y tibial. En esta serie, la artroplastia total híbrida de rodilla demostró una excelente fijación a los 16 años.
Abstract
A cementless femoral component may allow for a smaller surgical incision when a minimally invasive approach is used during primary total knee arthroplasty. Fixation by cement is the gold standard for total knee arthroplasty. The results of cementless total knee arthroplasty are mixed. Cementless femoral components have done well. Although some tibial components have performed well at long-term follow-up, others have been plagued by high rates of loosening and revision. The question remains whether the results of hybrid total knee arthroplasty, consisting of an uncemented femoral component and a cemented tibial component, will equal those of total knee replacement fixed with cement at long-term follow-up. The authors reviewed 148 hybrid total knee arthroplasties performed by a single surgeon between 1993 and 1995. At a mean follow-up of 14 years (range, 10-16) 5 knees (4%) had undergone revision of both the femoral and tibial components. Only 1 knee required revision for aseptic loosening. Two knees were revised for sepsis; 1 knee had been revised for fracture and 1 for instability. No additional femoral or tibial components were loose by radiographic criteria. Mild focal femoral osteolysis was identified in 3 knees (2%), and minor tibial osteolysis was present in 2 knees (1%). The rate of survivorship with revision for aseptic loosening as the end point was 99% (95% confidence interval, 0.97-100) at 16 years for both the femoral and tibial components. In this series, hybrid total knee arthroplastyshowed excellent fixation at 16 years.
