Insertion of S1 iliosacral screws in the computed tomography room: An alternative to improve safety in the percutaneous management of posterior pelvic ring injuries

Pelvis; Iliosacral screw; Computed tomographyPelvis; Tornillo iliosacro; Tomografía computarizadaPelvis; Cargol iliosacre; Tomografia computaritzadaIntroducción La principal complicación de la osteosíntesis percutánea con tornillos iliosacros es la malposición del implante, que puede ocasionar lesiones vasculares y nerviosas. La variabilidad anatómica del sacro puede dificultar la inserción del tornillo bajo control fluoroscópico. De entre los métodos descritos para mejorar la precisión de esta técnica, destaca el uso de la tomografía computarizada (TC). El objetivo del estudio es comparar los resultados de la implantación de tornillos iliosacros con fluoroscopia y TC. Metodología Estudio de cohortes retrospectivo sobre 66 tornillos iliosacros implantados en 56 pacientes durante 11 años. Los tornillos fueron introducidos con fluoroscopia en el quirófano o con TC en el área de radiodiagnóstico. Recogimos datos sobre las características de los pacientes, sus lesiones, el tratamiento y los resultados clínicos y radiológicos. Resultados Cuarenta y siete tornillos fueron implantados con fluoroscopia y 19 con TC. El 18,2% de los tornillos perforaba el corredor S1. Todos ellos se intervinieron con fluoroscopia (0 vs. 34%; p < 0,01). Pese a ello, los intervenidos en TC acumulaban más criterios de dismorfismo sacro que los intervenidos con fluoroscopia (2,2 vs. 1,6; p = 0,02). El corredor S1 en la TC axial era más estrecho en aquellos en que se había producido una perforación (18,8 vs. 21,0 mm; p = 0,02). Dos casos con perforación desarrollaron una radiculalgia S1. Fue necesario retirar 2 tornillos endopélvicos. Conclusión Aconsejamos el uso de la guía por TC para la inserción de tornillos iliosacros en pacientes con sacros displásicos o corredores estrechos en S1 en instalaciones que no dispongan de otros métodos de navegación.Introduction The main complication of percutaneous iliosacral screw fixation is implant malposition, which can lead to vascular and nerve damage. The anatomical variability of the sacrum can make screw insertion difficult under fluoroscopic guidance. Among the methods described to improve the accuracy of this technique, stands out the use of computed tomography (CT). The aim of this study is to compare the results of iliosacral screw insertion with fluoroscopy or CT navigation. Methodology Retrospective cohort study of 66 iliosacral screws in 56 patients during 11 years. The screws were inserted with fluoroscopy in the operating room or with CT in the radiodiagnosis area. We collected data on patient characteristics, lesions, treatment, and clinical and radiological results. Results Forty-seven screws were inserted with fluoroscopy and 19 with CT. A percentage of 18.2 of screws perforated the S1 osseous corridor. All of them were inserted with fluoroscopy guidance (0 vs. 34%; p < 0.01). Those operated with CT accumulated more sacral dysmorphism criteria than those operated with fluoroscopy (2.2 vs. 1.6; p = 0.02). The S1 corridor on the axial CT view was narrower in those in whom perforation had occurred (18.8 vs. 21.0 mm; p = 0.02). Two cases with perforation developed S1 radiculalgia. Two endopelvic screws had to be removed. Conclusion We advise the use of CT guidance for iliosacral screw insertion in patients with sacral dysmorphism or narrow S1 corridors in facilities where other navigation methods are not available

Letter to the Editor: «Suprapatellar tibial nailing, why have we changed?»

Tibia suprapatelar; Fracturas tibiales; Abordaje infrapatelarSuprapatellar tibial; Tibial fractures; Infrapatellar approachTíbia suprapatel·lar; Fractures tibials; Abordatge infrapatela

Open reduction and polyaxial plating for stemmed knee periprosthetic fractures: A case series

Introduction: Stemmed total knee arthroplasty (STKA) periprosthetic fractures (PPFs) are an emerging problem affecting frail patients. Their surgical fixation is challenging, due to intramedullary involvement and poor bone stock. Polyaxial locking plating has yielded good results in implant-related femur fractures. We hypothesized that this treatment would provide similar results for STKA PPFs. Methods: Retrospective analysis of consecutive patients with a femoral PPF or inter-implant fracture around a knee revision stem who had undergone open reduction and periprosthetic-specific polyaxial plate fixation. Results: We found 14 cases of mean age 85.4 years. Cerclages were used in 80% of cases. Fixation of a mean 8.6 cortices around the revision stem was achieved, with an overall screw density of 1:2 or 1:3. Four patients lost their ability to walk, while four experienced postoperative local complications. Bone healing was achieved in all except one who died during hospitalization. The 13 remaining survived the first year of follow-up. Conclusion: STKA PPFs are an emerging and challenging problem affecting frail patients. Treatment using polyaxial locking plates provides stable fixation allowing early mobilization despite high complication rates

Implementing stakeholder engagement to explore alternative models of consent: An example from the PREP-IT trials

Introduction: Cluster randomized crossover trials are often faced with a dilemma when selecting an optimal model of consent, as the traditional model of obtaining informed consent from participant's before initiating any trial related activities may not be suitable. We describe our experience of engaging patient advisors to identify an optimal model of consent for the PREP-IT trials. This paper also examines surrogate measures of success for the selected model of consent. Methods: The PREP-IT program consists of two multi-center cluster randomized crossover trials that engaged patient advisors to determine an optimal model of consent. Patient advisors and stakeholders met regularly and reached consensus on decisions related to the trial design including the model for consent. Patient advisors provided valuable insight on how key decisions on trial design and conduct would be received by participants and the impact these decisions will have. Results: Patient advisors, together with stakeholders, reviewed the pros and cons and the requirements for the traditional model of consent, deferred consent, and waiver of consent. Collectively, they agreed upon a deferred consent model, in which patients may be approached for consent after their fracture surgery and prior to data collection. The consent rate in PREP-IT is 80.7%, and 0.67% of participants have withdrawn consent for participation. Discussion: Involvement of patient advisors in the development of an optimal model of consent has been successful. Engagement of patient advisors is recommended for other large trials where the traditional model of consent may not be optimal