Encarnacion Cruz

Fractures of the acetabulum in elderly patients: An update

The incidence of acetabular fractures in elderly patients is increasing. Poor bone quality and concomitant diseases are the main features of these patients. Fracture patterns are marked by a high degree of variability in terms of patient and fracture characteristics. Preoperative planning with plain radiographs and computed tomography, including 3-dimensional reconstructions, is recommended. Treatment remains challenging because of precarious general health, severe osteopenia, comminution, and associated femoral head damage. Treatment options available include closed management, open reduction with internal fixation, percutaneous fixation in situ, and acute or staged total hip arthroplasty (THA) whether alone or combined with osteosynthesis. In the case of significant destruction of the articular cartilage, primary THA may provide the best solution. Whichever surgical method is chosen, the objective is rapid mobilisation of the patient on a walker or crutches. Late local complications that may occur after nonoperative or operative treatment include posttraumatic arthritis, nonunion, malunion, wound infection, dislocation, intrusive hardware, nerve palsy, and heterotopic bone formation. In this article an overview of the current trends in the management of acetabulum fractures in the elderly is presented.

Characterization of Adult Stem/Progenitor Cell Populations From Bone Marrow in a Three-Dimensional Collagen Gel Culture System

Stem cell transplantation therapy using mesenchymal stem cells (MSCs) is considered a useful strategy. Although MSCs are commonly isolated by exploiting their plastic adherence, several studies have suggested that there are other populations of stem and/or osteoprogenitor cells that are removed from primary culture during media replacement. Therefore, we developed a three-dimensional (3D) culture system in which adherent and nonadherent stem cells are selected and expanded. Here, we described the characterization of 3D culture-derived cell populations in vitro and the capacity of these cells to differentiate into bone and/or cartilage tissue when placed inside of demineralized bone matrix (DBM) cylinders, implanted subcutaneously into the backs of rat for 2, 4, and 8 weeks. Our results demonstrates that 3D culture cells were a heterogeneous population of uncommitted cells that express pluripotent-, hematopoietic-, mesenchymal-, and endothelial-specific markers in vitro and can undergo osteogenic differentiation in vivo.

Surgical technique: Intraacetabular osteosynthesis with arthroplasty for acetabular fracture in the octogenarian

Acetabular fractures in elderly patients need prompt and proper diagnosis and treatment, as delay for management and early failures with subsequent salvage surgery can be accompanied by significant morbidity. Treatment options available include closed management, open reduction with internal fixation (ORIF), and acute or staged total hip arthroplasty (THA) whether alone or combined with osteosynthesis by a wire cerclage. In the case of octogenarian patients, since there is significant destruction of the articular cartilage, primary THA may provide the best solution. Removal of the femoral head allows for excellent exposure of the acetabulum, making it possible to stabilize most fractures without the need for extensile approaches. In older individuals with severe osteoporosis as octogenarians, a typical fracture pattern results in intrapelvic dislocation of the femoral head with a blowout fracture of the anterior column and medial wall. In this paper we present a simple, minimal, and cost-effective osteosynthesis technique performed in the course of a straightforward THA for the treatment of acetabular fractures in octogenarian patients.

Simultaneous ilioinguinal and Kocher-Langenbeck approaches for the treatment of complex acetabular fractures

Complex acetabular fractures are best treated by a surgical approach. Although some other variables such as comminution or cartilage lesion of the femoral head are related to the final outcome, early anatomic reduction is the only way to get good results; this has made the appropriate type of surgical approach of overwhelming importance. Seeing the fracture and also having the possibility of manoeuvring its fragments as much as required are the keys for reduction of these sort of fractures. In this paper we have studied the results of the treatment of complex acetabular fractures by simultaneous ilioinguinal and Kocher-Langenbeck approaches. Ten cases of complex fractures out of 260 surgically treated acetabular fractures were chosen for simultaneous combined approaches. In cases of comminution of both the anterior and the posterior columns together with circumferential shortening of the pelvic ring, reduction and stable internal fixation could be accomplished only by simultaneous combined accesses.

Age as a risk factor of nosocomial infection after hip fracture surgery

Surgery for the treatment of hip fractures is considered the gold standard even among nonagerians with a heavy comorbidity burden. Therefore, a study of an association between surgical complications and some variables in elderly individuals appears to be very important. We designed a transverse study in which we determined patient age at the time of development of a nosocomial infection (NI) in patients who underwent surgery to treat a hip fracture. Univariate and multivariate analyses were performed by simple and multiple logistic regression. We found that age was a determinant in NI after surgical treatment for hip fracture. The older the patient was, the higher the risk of development of an NI after surgical treatment for hip fracture (operative hypothesis). However, the risk of infection changed depending on the treatment. No association with other variables was found.

Bone mineral density aspects in the femoral neck of hip fracture patients

Elderly people, due to neurological conditions and muscular atrophy, present a greater propensity to falls and thus are very susceptible to hip fractures. Other variables, such as osteoporosis, may also be related to the etiopathogenesis of hip fractures, although osteoporosis is in fact a concurrent disease, and merely a coadjutant cause. Nonetheless, osteoporosis can make fracture patterns more severe and interfere with osteosynthesis. Osteoporosis is the radiological image of osteopenia, a pathological concept meaning a smaller quantity of bone per unit of volume. The radiological expression of osteopenia is therefore that of bone tissue with a lower radiological density than normal. In the context of hip fractures, bone mineral density and bone architecture of the femoral neck together with protein expression profiles and cross-links of this anatomical area are of special interest which is reviewed in the current paper. Spatial variations in bone mineral density in the femoral neck were found in the literature with increased porosity from the periosteal to the endosteal region and also from the distal to the proximal part of the femoral neck. Furthermore, increased crystal size, increased cortical porosity, reduced osteocyte lacunar density and an increased Ca/P ratio associated with higher concentrations of Ca and P were described in hip fracture patients compared to control patients. Osteocalcin/collagen type 1 expression ratio and enzymatic cross-link content in high-density bone was found to be significantly lower in hip fractures compared to controls. In conclusion, further research in bone mineral density and associated parameters are of interest to deepen the understanding of osteoporotic hip fractures.

Resuscitation of Polytrauma Patients: The Management of Massive Skeletal Bleeding.

The term ‘severely injured patient’ is often synonymous of polytrauma patient, multiply-injured patient or, in some settings, polyfractured patient. Together with brain trauma, copious bleeding is the most severe complication of polytrauma. Consequently hypotension develop. Then, the perfusion of organs may be compromised, with the risk of organ failure. Treatment of chest bleeding after trauma is essential and is mainly addressed via surgical manoeuvres. As in the case of lesions to the pelvis, abdomen or extremities, this approach demonstrates the application of damage control (DC). The introduction of sonography has dramatically changed the diagnosis and prognosis of abdominal bleeding. In stable patients, a contrast CT-scan should be performed before any x-ray projection, because, in an emergency situation, spinal or pelvic fractures be missed by conventional radiological studies. Fractures or dislocation of the pelvis causing enlargement of the pelvic cavity, provoked by an anteroposterior trauma, and in particular cases presenting vertical instability, are the most severe types and require fast stabilisation by closing the pelvic ring diameter to normal dimensions and by stabilising the vertical shear. Controversy still exists about whether angiography or packing should be used as the first choice to address active bleeding after pelvic ring closure. Pelvic angiography plays a significant complementary role to pelvic packing for final haemorrhage control. Apart from pelvic trauma, fracture of the femur is the only fracture provoking acute life-threatening bleeding. If possible, femur fractures should be immobilised immediately, either by external fixation or by a sheet wrap around both extremities.

Role of Mental Disorders in Nosocomial Infections after Hip Fracture Treatment

The association between mental disorders (MDs) and iatrogenic complications after hip fracture surgery has been poorly studied. Among iatrogenic complications, nosocomial infections (NIs) are a major factor in hip fracture surgery. The aim of this paper was to determine whether patients with a MD and a hip fracture develop more NIs after hip surgery than patients with no MD. We studied 912 patients who underwent surgery for a hip fracture (223 patients with a MD who underwent surgery for a hip fracture and 689 control patients without a MD who also underwent surgery for a hip fracture) and followed them after surgery. Univariable and multivariable analyses were performed using simple and multiple logistic regression analysis (confidence interval, crude and adjusted odds ratios, and P value). We found that MDs, gender, and comorbidities were not associated with a higher risk of developing a NI after surgery for a hip fracture. Only age increases the risk of a NI.

Occult Acetabular Fracture in Elderly Patients

Acetabular fractures in the elderly are increasingly common; however, an antecedent of trauma may not be known, and the diagnosis easily missed. Early identification and prompt management are needed in order to minimise morbidity rates, but little has been published on occult acetabular fracture. In this paper we present three cases of occult acetabular fracture in patients older than 75 years. All three are females and had previously been operated on the ipsilateral hip with an implant (two proximal femur fractures treated with a proximal intramedullary femoral nail, and one case of total joint replacement); these acetabular fractures could be related to the existence of a stress shielding mechanism. We believe that whenever an elderly patient feels groin pain, and anteroposterior pelvis X-rays are normal, oblique Judet projections (obturator and iliac) should be obtained. In any case, displacement will make any fracture evident within a few weeks.

Reply to comments by Li et al.: “Do the specialist hip unit surgeons have no significant influence on reducing rates of surgical site infection?”

1. The surgical techniques were classified into osteosynthesis and arthroplasties. Dr. Li et al. consider that, in general, hemiarthroplasty and total hip arthroplasty may obtain differences in infection rates. We concur with this view, but what is important in our paper is whether there were significant differences in surgical procedures between the two groups of surgeons. If so, this could have introduced a bias in our study. Table 1 clearly shows that there were no differences between the groups (p=0.146). The same conclusion is drawn regarding possible differences between hemiarthroplasty and total hip replacement in proclivity to infection according to co-morbidities. In this variable, too, there were no differences between the two groups of surgeons (p=0.588). Therefore, we believe that as there were no differences according to type of operation and co-morbidities, the chance of the patient developing an infection is, a priori, the same for both groups of surgeons. 2. We also believe, like Dr. Li et al., that some other variables, such as the duration of surgery or the preoperative haemoglobin level, might affect infection rates. Indeed, many other variables, including cementation, antibiotics and residency, might be considered. We have many such variables recorded in our database but in this study the number of variables was limited in order to conform with the aim of this paper (and also to prevent it from becoming too long for publication). In any case, although interesting, extending the list of variables discussed in this paper could be justified if the conclusions reached led us to support either the operative or the alternative hypothesis, but not the null one (i.e. that the rate of infection is not significant for both groups). On the other hand, the paper of Rasouli et al. [2] cited by Dr. Li et al. concerns revision surgery and includes both hip and knee surgery; in other words, it does not concentrate on the primary treatment of hip fractures, as ours does. This is also the case of another paper cited by Dr. Li et al., that of Dale et al. [3], which discusses the situation of already-infected patients in revision surgery, not that of non-infected hip fractures treated by primary osteosynthesis or arthroplasty, which is the core concern of our paper. As we observe in the “Material and methods” section, patients undergoing reinterventions were excluded unless an infection had developed as a result of the first surgery. 3. In the last paragraph, Dr. Li et al. pose two interesting questions: on the one hand, the possibility that the sample size of 814 patients might not be large enough for statistical analysis; and on the other, the fact that in a paper by Harrison et al. [4] (also cited by Dr. Li et al.), it was found that differences between surgeons were significant. In relation to the first question: unlike the papers cited above, we stratified to a very E. Guerado (*) : J. Cano : E. Cruz :M. Bertrand :M. Hirschfeld Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, 29603 Marbella, Malaga, Spain e-mail: eguerado@hcs.es