Long-term recurrence of Dupuytren's disease treated with clostridium histolitycum collagenase. Surgical treatment and anatomopathological study.

OBJECTIVE: To present the functional results obtained and the possible surgical difficulties after the surgical treatment of Dupuytren's disease (DD) recurrence in patients previously treated with Clostridium histolyticum (CCH) collagenase. MATERIALS AND METHODS: In this prospective study, 178 patients with DD were treated with CCH from 2011 to 2018; During long-term postoperative follow-up, 34 patients (19.1%) had recurrence of DD. In all patients injected in the IFP the disease recurred; In patients injected in the MCP, recurrence was highest in grade III and IV of the Tubiana classification, with involvement of the 5th finger and the two-finger Y-chord. Fourteen patients (7,8%) required surgery by partial selective fasciectomy due to recurrence of cord DD infiltration. The clinical and functional results of the patients, the difficulty of the surgical technique and the anatomopathological analysis of the infiltrated cords were evaluated in comparison with those of cords and patients who had had no previous CCH treatment. RESULTS: In all patients, cord rupture was achieved after injection, reducing joint contracture. In 14 patients, we observed during the follow-up the existence of DD recurrence that required surgical treatment by selective partial fasciectomy. There were no major difficulties in surgery and good clinical and functional results at 6 months of follow-up. The anatomopathological study of the resected tissue did not present histological alterations with respect to the samples obtained from patients initially treated by selective partial fasciectomy. CONCLUSIONS: Selective fasciectomy after CCH injection does not lead to important operative difficulties, as long as the CCH injection is performed according to the recommendations. There were no histological changes in the tissue after CCH injection. LEVEL OF EVIDENCE: III.

Functional survival of cementless trapeziometacarpal total joint arthroplasty after upper extremity trauma.

INTRODUCTION: Our purpose with this publication is to document the survival of uncemented and unconstrained total trapeziometacarpal arthroplasty after energy trauma to the upper extremity. MATERIAL AND METHODS: From 1999 to the present, ten patients carrying total TMC arthroplasty suffered major traumatic injuries on the hand. Eight patients had fractures of the distal radius, one patient had scapho-lunate dissociation and one patient had a dorsal pullout of the triquetrum. A clinical and radiological examination of the patients after the trauma was carried out and compared with the pre-traumatic prosthesis status. RESULTS: Three patients required surgical intervention for the associated traumatic injury. The postraumatic clinical and functional follow-up of the patients was good, and no differences were documented with respect to mobility, strength and pain at the level of the thumb with respect to the prior to the trauma. No signs of loosening, instability or alteration in the alignment of the components of the protheses were observed in the radiological examinations following the trauma. CONCLUSIONS: There is a high survival rate of uncemented total trapeziometacarpal arthroplasty in the long term, even in the face of energy trauma. It is then a safe implant. Despite of being non-constrained, a good alignment of the prosthetic components is the key to avoid dislocation of the prosthesis.

Efficacy comparison of intraperitoneal anaesthesia and post-operative analgesia regimens in laboratory rats.

INTRODUCTION: Effective and safe anesthesia for rodents has long been a leading concern among biomedical researchers. Intraperitoneal injection constitutes an alternative to inhalant anesthesia. PURPOSE: The aim of this study was to identify a safe, reliable, and effective anesthesia and postoperative analgesia protocol for laboratory rats exposed to painful procedures. MATERIAL AND METHODS: Twenty-seven female Wistar rats in an ongoing study that required surgery were randomized into groups for three different intraperitoneal anesthesia protocols and three different analgesia regimens. The anesthesia groups were (1) medetomidine + ketamine (MK), (2) ketamine + xylacine (KX), and (3) fentanyl + medetomidine (FM). Three analgesia groups were equally distributed among the anesthesia groups: (1) local mepivacaine + oral ibuprofen (MI), (2) oral tramadol + oral ibuprofen (TI), and (3) local tramadol + oral tramadol + + oral ibuprofen (TTI). A core was assigned to measure anesthesia (0-3) and analgesia (0-2) effectiveness; the lower the score, the more effective the treatment. RESULTS: The mean MK score was 0.44 versus 2.00 for FM and 2.33 for KX. Mean score for analgesia on the first postoperative day was TTI (4.66) TI (9.13), and MI (10.14). Mean score 48 hours after surgery was TTI (3.4), TI (6.71), and MI (9.5). These differences were statistically significant. CONCLUSION: MK was shown to be a reliable, safe, and effective method of anesthesia. The TTI analgesia regimen is strongly recommended in light of these results.

Efficacy and safety of the topical application of tranexamic acid in primary cementless hip arthroplasty: prospective, randomised, double-blind and controlled study. / Eficacia y seguridad de la aplicación del ácido tranexámico tópico en la artroplastia primaria no cementada de cadera: estudio prospectivo, aleatorizado, doble ciego y controlado.

OBJECTIVE: To evaluate the efficacy of topical tranexamic acid topical in cementless total hip arthroplasty from the point of view of bleeding, transfusion requirements and length of stay, and describe the complications of use compared to a control group. MATERIAL AND METHODS: A prospective, randomised, double-blinded and controlled study including all patients undergoing cementless total hip arthroplasty in our centre between June 2014 and July 2015. Blood loss was estimated using the formula described by Nadler and Good. RESULTS: The final analysis included 119 patients. The decrease in haemoglobin after surgery was lower in the tranexamic acid group (3.28±1.13g/dL) than in the controls (4.03±1.27g/dL, P=.001) and estimated blood loss (1,216.75±410.46mL vs. 1,542.12±498.97mL, P<.001), the percentage of transfused patients (35.9% vs. 19.3%, P<.05) and the number of transfused red blood cell units per patient (0.37±0.77 vs. 0.98±1.77; P<.05). There were no differences between groups in the occurrence of complications or length of stay. CONCLUSIONS: The use of topical tranexamic acid in cementless total hip arthroplasty results in a decrease in bleeding and transfusion requirements without increasing the incidence of complications.

Isolated scaphotrapeziotrapezoid osteoarthritis treatment using resurfacing arthroplasty with scaphoid anchorage. / Tratamiento de la artrosis escafotrapeciotrapezoidea aislada con artroplastia de recubrimiento con anclaje escafoideo.

OBJECTIVE: The aim of this study is to show the results of scaphotrapeziotrapezoid (STT) joint osteoarthritis treatment performing resurfacing arthroplasty with scaphoid anchorage. MATERIAL AND METHOD: An observational, descriptive and retrospective study was performed. Ten patients with isolated STT joint osteoarthritis were studied between 2013 and 2015. The mean follow-up time was 26months. Clinical results, functional and subjective scores were reviewed. RESULTS: The patients were satisfied, achieving an average of 2.1 (0-3) on the VAS score and 16 (2 to 28) in the DASH questionnaire, and returning to work in the first three months post-surgery. Recovery of range of motion compared to the contralateral wrist was 96% in extension, 95% in flexion, 87% in ulnar deviation and 91% in radial deviation. The average handgrip strength of the wrist was 95% and pinch strength was 95% compared to the contralateral side. There were no intraoperative complications or alterations in postoperative carpal alignment. CONCLUSION: Resurfacing arthroplasty is proposed as a good and novel alternative in treating isolated SST joint arthritis. Achieving the correct balance between the strength and mobility of the wrist, without causing carpal destabilisation, is important to obtain satisfactory clinical and functional results.

Repair of nerve injury by implanting prostheses obtained from isogenic acellular nerve segments. / Reparación de lesiones en nervios mediante el implante de prótesis obtenidas de segmentos acelulares de nervio isogénico.

INTRODUCTION: When a nerve section with a significant gap occurs, it is necessary to use a prosthesis to suture it. To date an autologous nerve segment graft appears to be the best treatment; but it has several important disadvantages. Our goal is to study the effectiveness of an isogenic acellular nerve prosthesis comparing a simple suture with tubulisation. MATERIAL AND METHOD: Four groups of Wistar rats were used. The animals in Group 0 served as donors of nerve segments to graft. Group 1 received the implant with an end-to-end suture. In group 2, the implant was sutured inside an ɛ-caprolactone tube. Group 3 received it in a polylactic-co-glycolic acid tube. We evaluated the motor function (sciatic index and step test in motion), and the regeneration length by histological study of regeneration, after a maximum of 3 weeks. RESULTS: Regeneration was uneven in the three groups. In all groups, there were implants with regenerated nerve fibres at the maximum studied length (15mm) and others where regeneration was scarce. The mean regeneration length was greater in the direct end-to-end suture group (G1), although the regeneration speed was similar in the three groups. Group 1 showed the highest percentage of regeneration, but the variability of results prevents this difference reaching statistical significance. We found no significant differences between the two groups with polymer tubes. CONCLUSION: For the implantation of isogenic acellular nerve prosthesis, under our experimental conditions, the direct end-to-end suture was more effective than when it isprotected with biopolymer tubes.

[Comparative clinical study of 2 surgical techniques for trapeziometacarpal osteoarthritis]. / Estudio clínico comparativo de 2 técnicas quirúrgicas de rizartrosis del pulgar.

OBJECTIVE: In trapeziometacarpal osteoarthritis (or rhizarthrosis), there is great controversy over the surgical technique to choose: simple trapeziectomy, resection-interposition arthroplasty, interposition arthroplasty suspension-or arthroplasty with implant or prosthesis. These latter 2 are the most used without consensus in the literature on the technique to choose and without sufficient comparative studies. The objective is to compare the 2 techniques most used today: suspension-interposition arthroplasty and arthroplasty with prosthesis. MATERIAL AND METHOD: A prospective study was conducted on 15 patients diagnosed with grade 2-3 rhizarthrosis treated with interposition arthroplasty-suspension (group 1) and 15 with prosthesis (group 2) showing clinical outcomes, advantages and disadvantages of each. The study variables were the visual analogue scale (VAS), the DASH questionnaire, the grip strength, the strength of end to end and end-lateral clamp, the joint balance adduction-abduction and preemption-retropositioning, and the opposition. The 2 groups are from 2 different hospitals operated on by a hand surgeon from the Hand Unit. The follow-up time for all patients included in the study was 12 months. RESULTS: The VAS, DASH and grip strength at 12 months did not show significant differences. As regards the strength of end to end and end-lateral clamp, group 2 showed the highest values in all follow-up periods with statistically significant differences. CONCLUSIONS: Patient selection and surgical experience is essential, given the satisfactory results of both techniques. Arthroplasty prosthesis is reserved for grades 2 and 3, middle-aged patients, good trapezium architecture, and experienced surgeons.

[Results of surgical treatment of carpal scaphoid pseudarthrosis using the Fisk-Fernández technique]. / Resultados del tratamiento quirúrgico de la seudoartrosis de escafoides carpiano con la técnica de Fisk-Fernández.

AIM: The aim of the study was to evaluate the clinical and radiological results obtained in the treatment of carpal scaphoid non-union treated at the University Hospital of Valladolid using the Fisk Fernandez technique. MATERIAL AND METHODS: A review was performed on 43 cases of surgically treated non-union using Fisk Fernandez technique with a minimum of 6 months follow-up. The time until surgery, previous treatment, the mechanism of injury, type of non-union, and the existence of radio-carpal arthrosis were evaluated. A subjective evaluation was performed using the "Scaphoid Score" and the DASH, plus an objective assessment with the modified Green & O'Brien, together with the measurement of the intra-scaphoid, radioulnar, scapholunate angles, and carpal height. RESULTS: The median time to healing in the series was between 16 to 24 weeks, except in 3 patients who failed to heal and required salvage surgery. There was a statistically significant variation between the preoperative and postoperative angles and carpal height measured in the X-rays. DISCUSSION: There are different osteosynthesis techniques and materials for the treatment of non-union. The evaluation of results performed using objective and subjective scales showed variable results between studies. Different techniques are aimed at preventing the progression of the disease. CONCLUSION: The Fisk Fernandez technique enables the deformity of the scaphoid to be corrected by wedge grafting and internal fixation with Kirschner wires or screws.

Ambulatory surgery in orthopedics: experience of over 10,000 patients.

PURPOSE: The concept of day surgery is becoming an increasingly important part of elective surgery worldwide. Relentless pressure to cut costs may constrain clinical judgment regarding the most appropriate location for a patient's surgical care. The aim of this study was to determine clinical and quality indicators relating to our experience in orthopedic day durgery, mainly in relation to unplanned overnight admission and readmission rates. Additionally, we focused on describing the main characteristics of the patients that experienced complications, and compared the patient satisfaction rates following ambulatory and non-ambulatory procedures. METHODS: We evaluated 10,032 patients who underwent surgical orthopedic procedures according to the protocols of our Ambulatory Surgery Unit. All complications that occurred were noted. A quality-of-life assessment (SF-36 test) was carried out both pre- and postoperatively. Ambulatory substitution rates and quality indicators for orthopedic procedures were also determined. RESULTS: The major complication rate was minimal, with no mortal cases, and there was a high rate of ambulatory substitution for the procedures studied. Outcomes of the SF-36 questionnaire showed significant improvement postoperatively. An unplanned overnight admission rate of 0.14 % was achieved. CONCLUSIONS: Our institution has shown that it is possible to provide good-quality ambulatory orthopedic surgery. There still appears to be the potential to increase the proportion of these procedures. Surgeons and anesthesiologists must strongly adhere to strict patient selection criteria for ambulatory orthopedic surgery in order to reduce complications in the immediate postoperative term.

[Treatment of Dupuytren's disease using collagenase from Clostridium histolyticum]. / Tratamiento de la enfermedad de Dupuytren mediante la colagenasa del Clostridium histolyticum.

OBJECTIVE: The collagenase from Clostridium histolyticum is a new therapeutic option, and the first pharmacological one, in the treatment of Dupuytren's disease. MATERIAL AND METHODS: A prospective study was conducted on 35 patients with Dupuytren's disease. The clinical and functional variables, as well as patient satisfaction and drug safety were evaluated. RESULTS: The functional and clinical results after its administration were good, with a rapid recovery, especially at the metacarpophalangeal (MCP) joint. The index finger contracture prior to MCP puncture was 64 degrees and after puncture it was 4 degrees. In the proximal interphalangeal (PIP) prior to puncture it was 83.3 degrees and after puncture it was 15 degrees; In the MCP/PIP prior to puncture it was 140 degrees, and after puncture it 25 degrees. CONCLUSIONS: Collagenase from Clostridium histolyticum an alternative of treatment of Dupuytren's disease, mainly in the elderly. More research is required in order to clarify the rate of recurrence of the disease, the possible adverse reactions, and to compare the efficiency and permanence with other treatment options.

[Regeneration of critical injuries of the peripheral nerve with growth factors]. / Regeneración de las lesiones críticas del nervio periférico con factores de crecimiento. Estudio experimental.

INTRODUCTION: This project aims to study the regeneration of non-repairable lesions of peripheral nerve by muscle grafts enhanced with growth factors. MATERIAL AND METHODS: The experiment was carried out in two phases. The first one compared direct suture of a critical defect in the sciatic nerve of ten rats, with the interposition of autologous muscle graft, denatured by heat, in another ten. The second phase compared ten rats with nerve repair using an acellular muscle graft, with injection of 2cc of IGF-1 (10mg/ml mecasermin, Injectable solution) into the acellular graft of another ten. A clinical and functional follow-up was carried out including, ambulation, footprint measurement, and "grasping test". . The animals were sacrificed at 90-100 days, and samples obtained for macro- and microscopic studies with toluidine blue, haematoxylin-eosin and Masson's trichrome staining. RESULTS: The first experiment showed the characteristic findings of nerve tissue in muscle graft level sections. The second was an enhancement of the results: post-surgical clinical improvement, early ambulation, decrease in the rate of pressure ulcers in toes, recovery of the footprint, and increasing the percentage of nerve endings in distal sciatic regeneration (47-62%). CONCLUSIONS: In this study the experimental and clinical possibilities of nerve defect repair by denatured muscle are demonstrated, confirming the suitability of the technique. Furthermore, it confirms our hypothesis with clinical and cellular determinations enriched by the addition of growth factors that promote nerve regeneration.

The long-term post-operative electromyographic evaluation of patients who have undergone carpal tunnel decompression.

We present the electromyographic (EMG) results ten years after open decompression of the median nerve at the wrist and compare them with the clinical and functional outcomes as judged by Levine's Questionnaire. This retrospective study evaluated 115 patients who had undergone carpal tunnel decompression at a mean of 10.47 years (9.24 to 11.36) previously. A positive EMG diagnosis was found in 77 patients (67%), including those who were asymptomatic at ten years. It is necessary to include both clinical and functional results as well as electromyographic testing in the long-term evaluation of patients who have undergone carpal tunnel decompression particularly in those in whom revision surgery is being considered. In doubtful cases or when there are differing outcomes, self-administered scales such as Levine's Questionnaire should prevail over EMG results when deciding on the need for revision surgery.

Prediction of overgrowth in femoral shaft fractures in children.

A prospective study of femoral shaft fractures in children under the age of 14 years has been carried out in 71 patients who were reviewed both clinically and radiographically at yearly intervals. The processing of data has been carried out by univariate and multivariate analysis. Femoral overgrowth (F.O.) averaged 8.63 mm (range 1-21 mm), and was found to be influenced by age (greater overgrowth in children between 3 and 9 years), the initial displacement of the fracture (greater overgrowth in severely displaced fractures), and overriding of the fragments at the time of healing (the greater the overriding the lesser the overgrowth). Consideration of these factors allowed overgrowth to be predicted from the time of fracture. Overgrowth occurred in all children over 2 years of age, and took place mainly during the first year after the fracture. It continued, although to a lesser extent, during the second year, and for as long as the fifth year in 27%. After this time the growth rate of both femurs was equal in all the children. Ipsilateral tibial overgrowth was present in only 60% of the children and averaged 1.05 mm (1-5 mm).

Prediction of overgrowth in femoral shaft fractures in children.

A prospective study of femoral shaft fractures in children under the age of 14 years has been carried out in 71 patients who were reviewed both clinically and radiographically at yearly intervals. The processing of data has been carried out by univariate and multivariate analysis.Femoral overgrowth (F.O.) averaged 8.63 mm (range 1-21 mm), and was found to be influenced by age (greater overgrowth in children between 3 and 9 years), the initial displacement of the fracture (greater overgrowth in severely displaced fractures), and overriding of the fragments at the time of healing (the greater the overriding the lesser the overgrowth). Consideration of these factors allowed overgrowth to be predicted from the time of fracture. Overgrowth occurred in all children over 2 years of age, and took place mainly during the first year after the fracture. It continued, although to a lesser extent, during the second year, and for as long as the fifth year in 27%. After this time the growth rate of both femurs was equal in all the children. Ipsilateral tibial overgrowth was present in only 60% of the children and averaged 1.05 mm (1-5 mm).