Browsing by Author "Fonseca, R"
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- Bilateral Distal Femoral Nailing in a Rare Symmetrical Periprosthetic Knee FracturePublication . Carvalho, M; Fonseca, R; Simões, P; Bahute, A; Mendonça, AThe authors report a case of a 78-year-old polytrauma patient, with severe thoracic trauma and bilateral symmetrical periprosthetic femoral fractures after a violent car accident. After the primary survey, with the thoracic trauma stabilized, neurovascular lesions excluded, and provisional immobilization applied, both fractures were classified as OTA: 33-A3, Rorabeck Type II, and closed reduction and internal fixation with distal femoral nails were performed. At 5 months of follow-up, the patient was able to walk with crutches and clear radiologic signs of fracture consolidation could be seen. At 24 months, the patient walked without any walking aid and had recovered her previous functional status. This surgical option allowed the authors to achieve relative stability using an intramedullary technique, preserving fracture hematoma in an osteopenic patient, and was found to be successful in recovering the patient’s previous functional status and satisfaction after major trauma.
- Favorable outcome of total hip arthroplasty with insufficient bone coverage of the roof reinforcement ring: a case reportPublication . Judas, F; Nascimento, M; Caetano, M; Carvalho, M; Lucas, F; Fonseca, RA 59-year-old male patient underwent a total hip arthroplasty for the treatment of end-stage dysplastic osteoarthritis. A roof reinforcement ring, a cemented polyethylene cup, and a cementless stem were used. Extensive superolateral portion of the ring was uncovered by host bone. Morsellized autogenous femoral-head graft was impacted to fill the space between superolateral border of the ring and superior part of the dysplastic acetabulum. At the follow-up after 4-years, the patient had no complaints and was very satisfied with the operation result. The hip radiograph revealed no signs of instability of the acetabular component, and no bone graft resorption. Despite the suboptimal implantation of the ring compromising, apparently, mechanical stability of the prosthesis, the outcome was favorable. This result can be supported by the fixation of the metal ring with screws, the adequate orientation of the prosthesis, the position of hip´s center of rotation, and bone graft incorporation.
- Fractura periprotética da anca em osso muito osteoporótico – Um caso perdido?Publication . Bento-Rodrigues, J; Simões, P; Caetano, M; Brandão, A; Fonseca, R; Lucas, F
- Limb salvage surgery in extreme situations of prosthetic complicationsPublication . Freitas, J; Moura, DL; Fonseca, R; Ferreira, R; Casanova, J; Judas, F; Fonseca, FThe treatment of periprosthetic hip and knee infection associated with loss of bone substance, as well as the treatment of the infection of large structural allografts used in tumoral reconstructive surgery, are a major challenge to the orthopaedic surgeon. Indeed, these are chronic conditions which are submitted to multiple surgeries and prolonged antibiotic therapy in socially and professionally vulnerable patients. Many of these cases receive proposals for limb amputation/disarticulation or extraction of the prosthesis without structural reconstruction aggravating, even more, their suffering and functional disability. The aim of this study is to show the results of a treatment of complex hip and knee periprosthetic infections and of a structural allograft, in the context of limb salvage surgery. 9 patients were treated, minimum age of 22 years and maximum of 76 years with multiple surgeries and from different national hospitals. Six of these patients had periprosthetic infection of the hip and knee (primary, revision and tumoral prostheses) and two of the patients showed an apparent allergic reaction to metal/iodine. The remaining case, an infection of a large femoral structural allograft, used in tumoral surgery. The main cause of the infection was the St. aureus multiresistant. One of the patients showed multimicrobial multiresistant flora. Treatment consisted in 2 different operative stages. First stage (7 to 9h): Extraction of the prosthesis or allograft; debridement and extensive excision of the periprothetic infected and devitalized bone and soft tissue, a minimum thickness of 4 mm; pulsatile lavage of the bleeding “surgical bed” with betadine / H2O2 and saline; implantation of large methyl methacrylate with gentamicin spacer. Triple intravenous antibiotic therapy was made for 8 to 9 weeks, with rigorous analytical control, and some of the patients were able to walk with the support of axillary support crutches. The second surgical stage (5 to 7h) takes place after normal levels of PCR: spacer excision with prosthetic joint reconstruction in 8 cases and in one case a silver coated knee arthrodesis prosthetic implant (bactericidal effect). So, 3 silver coated total femoral prostheses and 5 silver coated total hip prostheses, with the reconstruction of the proximal half of the femur, were applied. The interventions took place between July 2014 and April 2016. Patients were discharged after being able to walk with the help pf crutches and kept taking oral antibiotics until the normalization of PCR in 3 consecutive analytical assessments spaced by 15 days. After a clinical/ analytical evaluation, all patients showed a normal PCR, without pain and without signs of infection and/or active fistulas. Currently 5 patients walk without external support. The oldest case has 28 months of follow-up and all have a minimum follow-up of 7 months, average of 17,5 months. All patients expressed great satisfaction with the outcome of the surgical procedures for the preservation of their lower limbs. Chronic relapsing, multidrug-resistant, periprosthetic infection should be treated aggressively in a combination of surgical techniques of prosthetic revision and tumoral surgery, first through an extended debridement of devitalized tissue and the extraction of the prosthesis with the appropriate antibiotic therapy; second, with the reconstruction of the bone loss with silver coated modular prostheses, which are indicated in order to prevent the mutilating surgery and provide the restoration, as much as possible, of the functional capacity. The results obtained have been very satisfactory, although the follow-up time is insufficient to draw definitive conclusions about the infectious relapse. Such limb salvage surgery is indicated for the treatment of complex clinical situations as an alternative to the disarticulation / limb amputation, i.e. supports the hope of curing clinical and surgical situations that many surgeons designate by horrendoplasties.
- Treatment of Pathological Humerus-Shaft Tumoral Fractures with Rigid Static Interlocking Intramedullary Nail-22 Years of ExperiencePublication . Moura, DL; Alves, F; Fonseca, R; Freitas, J; Casanova, JObjective This was a retrospective observational study in patients submitted to intramedullary nail fixation after established or impeding pathological humerus-shaft tumoral fracture in the context of disseminated tumoral disease along 22 years of experience at the same institution. Methods Sample with 82 patients and 86 humeral fixations with unreamed rigid interlocking static intramedullary nail by the antegrade or retrograde approaches. Results The most prevalent primary tumors were breast carcinoma (30.49%), multiple myeloma (24.39%), lung adenocarcinoma (8.54%), and renal cell carcinoma (6.10%). The average surgical time was 90.16 ± 42.98 minutes (40-135 minutes). All of the patients reported improvement in arm pain and the mean Musculoskeletal Tumor Society (MSTS) score rose from 26% in the preoperative period to 72.6% in the evaluation performed in patients still alive 3 months after the surgery. The overall survival was 69.50% 3 months after the surgery, 56.10% at 6 months, 26.70% at 1 year, and 11.90% at 2 years. No death was related to the surgery or its complications. There were only 4 surgery-related complications, 1 intraoperative and 3 late, corresponding to a 4.65% complication risk. Conclusion Closed unreamed static interlocking intramedullary nailing (both in the antegrade or retrograde approaches) of the humerus is a fast, safe, effective, and low morbidity procedure to treat pathological fractures of the humerus shaft, assuring a stable arm fixation and consequently improving function and quality of life in these patients during their short life expectation.