Treatment of a post-traumatic stiff knee after an open extensor apparatus injury by arthroscopic arthrolysis through a free flap

Extensor apparatus injury; Open patella fracture; Stiff kneeLesión del aparato extensor; Fractura de rótula abierta; Rodilla rígidaLesió de l'aparell extensor; Fractura de ròtula oberta; Genoll rígidOpen patella fractures have high complication rates. Post-traumatic joint stiffness is particularly common. The management of this complication is even more difficult if free flap was used to cover a soft tissue defect. Late surgical manipulation of free flaps can lead to their failure, with catastrophic consequences. The use of minimally invasive techniques could reduce the associated risks. We present a case of knee stiffness after the fix and flap treatment of a grade IIIB open patella fracture. We performed an arthroscopic arthrolysis with portals through the flap. The pedicle was preoperatively located and avoided. Joint range of motion remarkably improved without records of flap complications. We consider that the technique is feasible. Its success was based on the multidisciplinary collaboration between orthopaedic and plastic surgeons and rehabilitation medicine specialists

Rationale and design of the HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) Trial: a protocol for an international randomised controlled trial evaluating early surgery for hip fracture patients

Accelerated surgery; Hip fracture; Randomised control trialCirurgia accelerada; Fractura de maluc; Prova controlada aleatòriaCirugía acelerada; Fractura de cadera; Prueba controlada aleatorizadaINTRODUCTION: Annually, millions of adults suffer hip fractures. The mortality rate post a hip fracture is 7%-10% at 30 days and 10%-20% at 90 days. Observational data suggest that early surgery can improve these outcomes in hip fracture patients. We designed a clinical trial-HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) to determine the effect of accelerated surgery compared with standard care on the 90-day risk of all-cause mortality and major perioperative complications. METHODS AND ANALYSIS: HIP ATTACK is a multicentre, international, parallel group randomised controlled trial (RCT) that will include patients ≥45 years of age and diagnosed with a hip fracture from a low-energy mechanism requiring surgery. Patients are randomised to accelerated medical assessment and surgical repair (goal within 6 h) or standard care. The co-primary outcomes are (1) all-cause mortality and (2) a composite of major perioperative complications (ie, mortality and non-fatal myocardial infarction, pulmonary embolism, pneumonia, sepsis, stroke, and life-threatening and major bleeding) at 90 days after randomisation. All patients will be followed up for a period of 1 year. We will enrol 3000 patients. ETHICS AND DISSEMINATION: All centres had ethics approval before randomising patients. Written informed consent is required for all patients before randomisation. HIP ATTACK is the first large international trial designed to examine whether accelerated surgery can improve outcomes in patients with a hip fracture. The dissemination plan includes publishing the results in a policy-influencing journal, conference presentations, engagement of influential medical organisations, and providing public awareness through multimedia resources. TRIAL REGISTRATION NUMBER: NCT02027896; Pre-results

Enclavado endomedular tibial : ¿Logra la vía de abordaje suprapatelar la misma reducción radiológica?

El tractament definitiu de les fractures tibials motiva diversos punts de controvèrsia. La via d'abordatge suprapatelar en posició de semiextensió, per al enclavat endomedul·lar tibial anterógrad, es va dissenyar amb l'objectiu principal d'evitar complicacions de l'abordatge tradicional trans o paratendó rotulià, com són la reducció de les fractures diafisàries proximals tibials i reduir el dolor anterior de genoll. Aquest nou abordatge quirúrgic, descrit al 2009, a més ha d'oferir uns resultats postoperatoris radiològics iguals o millors a la via d'abordatge tradicional. En aquest treball, s'ha descrit l'alineació radiològica postoperatòria, d'una sèrie de pacients afectes de fractura diafisaria tibial, tractats mitjançant abordatge suprapatelar i enclavat endomedul·lar a l'Hospital Vall d'Hebron.El tratamiento definitivo de las fracturas tibiales motiva diversos puntos de controversia. La vía de abordaje suprapatelar en posición de semiextensión, para el enclavado endomedular tibial anterógrado, se diseñó con el objetivo principal de evitar complicaciones del abordaje tradicional trans o paratendón rotuliano, como son la reducción de las fracturas diafisarias proximales tibiales y reducir el dolor anterior de rodilla. Este nuevo abordaje quirúrgico, descrito en 2009, además debe ofrecer unos resultados postoperatorios radiológicos iguales o mejores a la vía de abordaje tradicional. En este trabajo, se ha descrito la alineación radiológica postoperatoria, de una serie de pacientes afectos de fractura diafisaria tibial, tratados mediante abordaje suprapatelar y enclavado endomedular en el Hospital Vall d'Hebrón

Fractures pèlviques: quina classificació prediu millor la inestabilitat hemodinàmica

Les fractures de pelvis en el context del pacient politraumàtic amb freqüència s'acompanyen d'altres lesions, que en conjunt poden generar una situació de inestabilitat hemodinàmica. En el nostre estudi, retrospectiu sobre 100 fractures de pelvis en pacients politraumàtics atesos al Hospital Vall d'Hebron en un període de tres anys, hem volgut valorar quina classificació de fractures de pelvis (Tile/Young-Burgess) ens prediu millor la inestabilitat hemodinàmica. No s'han observat diferències estadísticament significatives entre les dues classificacions, en relació a la inestabilitat hemodinàmica. Per tant, el patró de fractura no ens útil per a predir la inestabilitat hemodinàmica

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

Rationale and design of the hip fracture accelerated surgical treatment and care track (hip attack) trial : A protocol for an international randomised controlled trial evaluating early surgery for hip fracture patients

Introduction Annually, millions of adults suffer hip fractures. The mortality rate post a hip fracture is 7%-10% at 30 days and 10%-20% at 90 days. Observational data suggest that early surgery can improve these outcomes in hip fracture patients. We designed a clinical trial - HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) to determine the effect of accelerated surgery compared with standard care on the 90-day risk of all-cause mortality and major perioperative complications. Methods and analysis HIP ATTACK is a multicentre, international, parallel group randomised controlled trial (RCT) that will include patients ≥45 years of age and diagnosed with a hip fracture from a low-energy mechanism requiring surgery. Patients are randomised to accelerated medical assessment and surgical repair (goal within 6 h) or standard care. The co-primary outcomes are (1) all-cause mortality and (2) a composite of major perioperative complications (ie, mortality and non-fatal myocardial infarction, pulmonary embolism, pneumonia, sepsis, stroke, and life-threatening and major bleeding) at 90 days after randomisation. All patients will be followed up for a period of 1 year. We will enrol 3000 patients. Ethics and dissemination All centres had ethics approval before randomising patients. Written informed consent is required for all patients before randomisation. HIP ATTACK is the first large international trial designed to examine whether accelerated surgery can improve outcomes in patients with a hip fracture. The dissemination plan includes publishing the results in a policy-influencing journal, conference presentations, engagement of influential medical organisations, and providing public awareness through multimedia resources. Trial registration number NCT02027896; Pre-results

Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial

© 2020 Elsevier Ltd Background: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. Methods: HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896). Findings: Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4–9) in the accelerated-surgery group and 24 h (10–42) in the standard-care group (p\u3c0·0001). 140 (9%) patients assigned to accelerated surgery and 154 (10%) assigned to standard care died, with a hazard ratio (HR) of 0·91 (95% CI 0·72 to 1·14) and absolute risk reduction (ARR) of 1% (−1 to 3; p=0·40). Major complications occurred in 321 (22%) patients assigned to accelerated surgery and 331 (22%) assigned to standard care, with an HR of 0·97 (0·83 to 1·13) and an ARR of 1% (−2 to 4; p=0·71). Interpretation: Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared with standard care. Funding: Canadian Institutes of Health Research

Rationale and design of the HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) Trial : a protocol for an international randomised controlled trial evaluating early surgery for hip fracture patients

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.Peer reviewedPublisher PD

Is it really advantageous to operate proximal femoral fractures within 48 h from diagnosis? – A multicentric retrospective study exploiting COVID pandemic-related delays in time to surgery

Objectives: Hip fractures in the elderly are common injuries that need timely surgical management. Since the beginning of the pandemic, patients with a proximal femoral fracture (PFF) experienced a delay in time to surgery. The primary aim of this study was to evaluate a possible variation in mortality in patients with PFF when comparing COVID-19 negative versus positive. Methods: This is a multicentric and retrospective study including 3232 patients with PFF who underwent surgical management. The variables taken into account were age, gender, the time elapsed between arrival at the emergency room and intervention, pre-operative American Society of Anesthesiology score, pre-operative cardiovascular and respiratory disease, and 10-day/1-month/6-month mortality. For 2020, we had an additional column, “COVID-19 swab positivity.” Results: COVID-19 infection represents an independent mortality risk factor in patients with PFFs. Despite the delay in time-to-surgery occurring in 2020, no statistically significant variation in terms of mortality was detected. Within our sample, a statistically significant difference was not detected in terms of mortality at 6 months, in patients operated within and beyond 48 h, as well as no difference between those operated within or after 12/24/72 h. The mortality rate among subjects with PFF who tested positive for COVID-19 was statistically significantly higher than in patients with PFF who tested. COVID-19 positivity resulted in an independent factor for mortality after PFF. Conclusion: Despite the most recent literature recommending operating PFF patients as soon as possible, no significant difference in mortality was found among patients operated before or after 48 h from diagnosis