SERPINA9 and SERPINB2: Novel Cartilage Lineage Differentiation Markers of Human Mesenchymal Stem Cells with Kartogenin.

OBJECTIVE: Human mesenchymal stem cells (hMSCs) are a promising source for regenerative medicine, especially mesodermal lineages. Clinical applications require an understanding of the mechanisms for transcriptional control to maintain the desired cell type. The aim of this study was to identify novel markers for differentiation of hMSCs into bone or cartilage with the use of Kartogenin, by RNA analysis using microarray technology, and explore the role of RhoA-Rho associated protein kinase (ROCK) inhibition in these. METHODS: Commercial human bone marrow derived primary mesenchymal stem cells were purchased from ATCC. Cells were differentiated in vitro in 2-dimensional cultures using Kartogenin as the main cartilage inducer and bone morphogenetic protein 2 for bone differentiation; cells were cultured with and without ROCK inhibitor Y-27632. After 21 days of culture, whole RNA was extracted and analyzed via Affimetrix microarrays. The most significant hits were validated by quantitative polymerase chain reaction. RESULTS: We found a total of 1,757 genes that were either up- or downregulated on differentiation, when compared to P1 hMSC (control) at day 0 of differentiation. Two members of the Serpin superfamily, SERPINA9 and SERPINB2, were significantly upregulated in the cartilage groups, whereas they were unchanged in the bone groups with and without ROCK inhibition. CONCLUSIONS: SERPINA9 and SERPINB2 are novel differentiation markers, and molecular regulator candidates for hMSC lineage commitment toward bone and cartilage, providing a new tool for regenerative medicine. Our study highlights the roles of these 2 genes, with significant upregulation of both in cell cultures stimulated with Kartogenin.

Quiste de inclusión epidérmica intraóseo con osteólisis de la falange distal / Kyste épidermoïde intra-osseux s'associant à une ostéolyse de la phalange distale / Intraosseous Epidermoid Inclusion Cyst with Osteolysis of the Distal Phalanx

Un motivo común de consulta en la práctica de la cirugía de mano es la aparición de algún tipo de tumoración. Afortunadamente la mayoría de dichas lesiones son benignas, sin embargo no deben subestimarse ya que existen lesiones malignas que pueden en apariencia y comportamiento imitar lesiones benignas, lo que puede retardar el diagnóstico o causar errores en el tratamiento inicial con consecuencias desastrosas para la función e incluso para la vida del paciente. El abordaje debe realizarse de acuerdo con los protocolos y lineamientos establecidos para las tumoraciones del sistema musculoesquelético, y los procedimientos quirúrgicos se deben planificarse de manera cuidadosa contando con los recursos técnicos necesarios para la resección adecuada y la reconstrucción funcional en caso necesario(AU)

A common cause of care in hand surgery practice is the appearance of a tumor or tumor like lesion. Fortunately, the majority of them are benign. Nevertheless, malignant lesions with benign-like appearance or behavior should not be underestimate since it may cause delayed diagnosis or inappropriate initial treatment with catastrophic functional consequences or even life threatening. Approach must be done in accordance to musculoskeletal tumor guidelines and surgical procedures carefully planned and executed by a surgeon with the experience to effectively resect and reconstruct if needed(AU)

La survenue de quelque sorte de tumeur au niveau de la main conduit souvent à une consultation de chirurgie. Heureusement, la plupart de ce dites lésions sont bénignes, mais elles ne doivent pas être négligées, car il y a des lésions malignes pouvant faire évoquer des lésions bénignes du fait de leur aspect et comportement, en retardant ainsi le diagnostic et en provoquant des erreurs dans le traitement initial avec des conséquences néfastes pour la fonction, et même pour la vie du patient. L'approche doit suivre les règles et protocoles établis pour les tumeurs du système musculo-squelettique, et les procédés chirurgicaux doivent être planifiés soigneusement au moyen des ressources techniques nécessaires pour une adéquate résection et une reconstruction fonctionnelle en cas nécessaire(AU)

[Ultrasound-guided continuous infraclavicular block for hand surgery: technical report arm position for perineural catheter placement]. / Bloqueo infraclavicular continuo guiado por ultrasonido para cirugía de mano. Reporte técnico de la posición del brazo para la colocación del catéter perineural.

BACKGROUND: Continuous perineural infusion of local anesthetic provides better postoperative analgesia than intravenous administration of opioids or NSAIDs in upper limb surgery. The infraclavicular approach is a good option due to the muscular stability to catheter; the abduction of the arm apparently makes more superficial the brachial plexus and which elevates clavicle cephalad. AIM: The aim of this study was to identify whether the abduction of the arm for to decreases the skin-plexus distance, facilitating it catheter insertion in a perineural way for a better analgesia. This relation between the arm and the colocation of catheter has not yet been established. MATERIAL AND METHODS: We included 58 adult patients, undergoing forearm and hand surgery, initially divided into two groups, adduction and abduction. It was placed continuous infraclavicular block guided by ultrasound, it allow the catheter tip was adjacent to the posterior cord. In the group patients with high technical difficulties were allowed to reposition the arm abduction, recording number of punctures, redirects, ease of insertion of the catheter and skin-plexus distance. RESULTS: The abduction of the arm moved the clavicle toward cephalad and separated it from the linear transducer, this allowed to maneuver the needle right angle and redirect it, the distance skin-plexus did not decrease significantly with arm position. CONCLUSIONS: Arm abduction allows better scanning facilitates the infraclavicular puncture and catheter introduction.

[Design of an electronic leech]. / Diseno de una sanguijuela electronica.

This research presents the development of a continual suction electromechanical device (CSED) which emulates the feeding characteristics of a medicinal leech to drain body fluids. After the research, design and building of the device, its performance in normal conditions with fluids of different viscosity was evaluated. Finally, the device was submitted to a test of blood draining in three adult male rabbits NZW with a weight of three kilograms, obtaining drain.

[Semiconstrained bipolar implant arthroplasty of the distal radioulnar joint. Case report]. / Artroplastía de la articulación radiocubital distal con prótesis bipolar semiconstreñida. Reporte de caso.

INTRODUCTION: The distal radioulnar joint is of paramount importance for the proper function of the upper extremity. There is a wide variety of procedures for the treatment of its advanced pathology but none of them is capable of providing a stable load-bearing joint. CLINICAL CASE: We present the case of a 54 year old man who was treated by a semiconstrained bipolar distal radioulnar joint arthroplasty (Aptis) who had a distal radioulnar impingement secondary to a distal ulnar resection (Darrach) previously performed to treat a fracture-dislocation of the distal radioulnar joint. CONCLUSION: This case was the first semiconstrained bipolar distal radioulnar joint arthroplasty (Aptis) performed in México. This treatment is capable of providing provides a stable load-bearing joint.

[Bacteriological study of oral cavity of people of Mexican origin to determine etiology agents of human infections in hand bite]. / Estudio bacteriológico de la cavidad oral de personas de origen Mexicano para determinar agentes causales de infecciones por mordedura humana en la mano.

INTRODUCTION: Hand infections secondary to human bites often leave serious consequences on the functioning of the hand. Such infections are caused by different bacteria. Most bacteriological studies have been made to people of Anglo-Saxon origin or descent, and based on these findings; provide treatment to patients of different origins which may not always be as effective. METHODS: Descriptive, internal stratified 17 patients were isolated samples of oral cavity and dental plaque bacterial species to identify and define the possible treatment according to the species identified. RESULTS: Microorganisms were isolated Gram (+) and Gram (-) belonging to the normal flora of the oral cavity and dental plaque in all the cases studied, presenting a variable number of microorganisms according to age but not by sex. The group of Gram-positive bacteria isolated showed sensitivity to: erythromycin, chloramphenicol and ciprofloxacin. In the group of Gram negative: kanamycin, amoxicillin + clavulanic acid, ciprofloxacin and norfloxacin, E. Corrodens sensitive to the group of quinolones as ciprofloxacin, norfloxacin as well as ceftriaxone and cefoperazone sulbactam. CONCLUSIONS: The bacterial species that are commonly found in normal flora of the oral cavity and dental plaque may be potential pathogens in a hand injury where to find the appropriate conditions for their development.

[Cost-benefit of various treatments for patients with distal radius fracture]. / Costo-beneficio de diferentes tratamientos en pacientes con fractura distal de radio.

UNLABELLED: Fractures of the distal third of the radius seriously impair quality of life and have high economic and social costs, and families face the high costs of care in our country. There are only a few studies evaluating the direct medical and non-medical costs resulting from distal radius fractures, from the patient perspective. OBJECTIVE: Determine the treatment-related costs and their relation with the benefits provided by the treatment. MATERIAL AND METHODS: A total of 120 patients with distal radius fracture were enrolled; they were divided into two groups based on their treatment, which included a cast and surgery with an angular stability plate, both provided by the hand surgery and microsurgery services; treatment-related costs were analyzed: Bed days, surgery, implant, cast, visit to the doctor, disability days and rehabilitation. RESULTS: 80% were females, mean age was 50 years, the patients' disability cost time was estimated using the 2007 minimum wage for geographic area "A". The mean surgical treatment-related expenses amounted to $ 9,850, with a mean cost for disability days of $8,462. In the case of conservative treatment, mean expenses were $1,075, with a mean cost for disability days of $16,004; however, the return to the family economy took longer and involved delayed wrist mobility.

[Description of a novel arthroscopic surgical technique for radio-ulnar instability in a cadaveric model]. / Descripción de una nueva técnica artroscópica para la inestabilidad radiocubital distal en modelos de cadáveres humanos.

INTRODUCTION: The distal radioulnar joint is subjected to two resultant loads. Axial load caused by grip and the transversal load due to the possibility of lifting weight against gravity. Therefore, instability of this joint leaves as a consequence a great functional incapacity. For this reason, numerous techniques have been described for its treatment such as Dr. Scheker's technique, a reconstruction technique based on a logical, anatomical, biological, mechanical, and functional solution. METHODS: We performed a descriptive study based in seven cadaveric models and fourteen wrists using a normal minimally invasive arthroscopic technique. The first step of the technique consisted in reproducing instability of the joint by means of a direct lesion of the dorsal fascicle of the triangular fibrocartilage complex. After this procedure, the reconstruction of the distal dorsal radioulnar ligament was carried out with a graft of palmaris longus tendon passed through the drilled tunnels in the distal methaphysis of the radio and ulna. Tunnels were performed under arthroscopic direct vision. The graft was inserted through the tunnels and then, fixed with a 2 mm. Endo-button system and a biodegradable screw of 5 mm. We measured range of motion before and after the surgery. The anterior-posterior translation test was applied on the models to measure instability of distal dorsal radioulnar joint, before, and after the surgical procedure. We performed descriptive statistics with SPPS 10.0 software. RESULTS: The technique was performed in fourteen wrists, with a mean surgical time of 104 minutes (80-164 min). The mean range of motion in flexion was 90.1 degrees before surgery and 90 degrees after surgery. Mean range of motion in extension was 86 degrees before and 88 degrees after the procedure. This finding was significant statistically with a value of p 0.008; the rest of measurements did not reach statistic significance. Stability was achieved in 12 models and 2 had a doubtful anterior-posterior translation test. DISCUSSION: The post-surgery extension was modified by the position and traction of the extremity in the cadaveric models. Two wrists remain unstable, by a technical defect while tensioning the graft at moment of fixation. CONCLUSION: Arthroscopic reconstruction for the distal dorsal radioulnar instability with a tendon graft is a technically reproducible technique. We recovered stability of the joint, and conserved range of motion in a cadaveric study.

[Results of anchor fixation in ligament and tendon injuries of hand and wrist]. / Resultados de la fijación con anclas en lesiones de ligamentos y tendones de la mano y la muñeca.

Surgical repair of hand and wrist tendons and ligaments usually require stability and secure fixation to bone. The stability obtained by anchors have been proved to be effective, safe, easy to use and with less difficulties compared to traditional systems. We retrospectively reviewed 19 patients treated with this system in our service between June, 2002 and September, 2004. All of them with a diagnosis of capsular, ligament or tendon injuries of the hand and/or wrist. Our main objective was to evaluate satisfaction and clinical evolution using anchors. Each patient was evaluated clinically and radiografically. Mean follow-up was 17.63 months (range 6-31). The mean age was 42.7 years (range 23-70). We found 4 scapholunate instabilities, 8 metacarpophalangeal (MCP) and interphalangeal (IP) capsular-ligament instabilities, 1 triquetral-metacarpal instability, 3 rheumatic hands, 2 interposition arthroplasties (IFP) and 1 tendon transfer. Two complications were found related to articular stiffness, 16 patients reported significant improvement, 2 reported mild improvement and 1 showed poor improvement. Residual instability was found in 2 patients after the procedure at the evaluation time, complete range of motion was found in 15 patients, mild decrease in the range of motion appeared in 2 patients and complete loss of motion in 2. The DASH questionnaire was applicated to all patients. The radiographic evaluation didn't show failure in the fixation procedure. We conclude that the anchor the fixation system is highly successful, safet and useful in any capsular ligament and tendon reinsertion to bone in hand surgery.

[Wrist arthroscopy for fractures of the distal end of the radius]. / Artroscopía de muñieca en fracturas del extremo distal del radio.

INTRODUCTION: Fractures of the distal end of the radius are very frequent in the orthopedist's practice. The anatomical reduction of the articular surface and the extra-articular alignment of the radius are extremely important to minimize complications. The purpose of the study is to make an arthroscopic diagnosis of the lesions associated to the distal radius and assist in the reduction of the distal radius fracture. MATERIAL AND METHODS: The study was conducted from March 2007 to February 2008. We performed 20 wrist arthroscopies in 20 patients with an intraarticular fracture of the distal end of the radius. They were classified according to Frykman's criteria. Patient age ranged from 17 to 67, with a mean of 38.7 +/- 15.9 years. 60% were males and 40% females; mean follow-up was 12 months; the chondral lesions were classified according to Outerbridge, the interosseous ligament lesions and the triangular fibrocartilage lesions, according to Palmer's criteria. We did articular debridement, radiofrequency chondroplasty, and assisted the fracture reduction. We used Henry's palmar approach and did open reduction and internal fixation with a T-shaped palmar plate and finally performed an arthroscopy to check the reduction. RESULTS: 8 cases had chondral lesions (grades II to IV); 7 cases had lesion of the triangular fibrocartilage (central isolated ruptures, radial detachment of the triangular fibrocartilage from the sigmoid notch), 5 cases had lesion of the scapholunate ligament; one case had a lesion of the luno-pyramidal ligament, and in 6 cases no associated lesions were found; 8 cases had a single lesion and 6 cases had 2 to 3 concomitant lesions. Two patients had been lost at the 3- and 6-month follow-up visits; 35% of those that were followed-up had pain at 3 months (7 patients) and 15% at 6 months. Only 2 cases had scapholunate instability and only one case had distal radioulnar instability. CONCLUSIONS: Arthroscopy has proven useful in identifying hidden lesions, assisting in fracture reduction and even treating the lesions found at the time of the diagnosis. Chondral lesions were the most frequent ones, followed by lesions of the triangular fibrocartilage; a close relation was found between the type of Frykman fracture and the associated lesion. Type 7 and 8 lesions were more frequently associated with chondral lesions and with a higher mean age. At the end of the follow-up period the scapholunate ligament lesions remained unstable. Chondral lesions were related with persistent pain at 3 months.

[Analysis of histological changes of tendinous grafts in reconstruction of the dorsal wrist ligament]. / Análisis de cambios histológicos de injertos tendinosos para la reconstrucción del ligamento dorsal de la muñeca.

The reconstruction of the dorsal aspect of the triangular fibrocartilage complex in the distal radioulnar joint with an autologous ligament graft has been an optimal treatment for instability of this joint. Tendinous grafts for ligament reconstruction have been studied in ACL reconstruction finding a metaplasia of the tendinous tissue into ligament like tissue. These studies have been performed in humans without making an important lesion to the reconstructed ligament. The purpose of this study is to evaluate the integration and adaptation of a tendon graft into an intraarticular environment with a different mechanical demand. We enrolled 3 patients that underwent reconstruction of the dorsal aspect of the triangular fibrocartilaginous complex in the distal radio ulnar joint, with an evolution between 6 to 48 months, and studied specimens with electronic microscope. In all specimens we found revascularization, reorientation of collagen fibers into a longitudinal pattern at 6 months after surgery, very similar to ligament. Patients did not require further immobilization after biopsy, rehabilitation of range of movement at home, returning to their normal daily activities. We conclude that tendinous grafts for ligamentous instability of distal radioulnar joint undergo histologic changes that make them similar to original ligaments.

[Dynamic suspension arthroplasty in trapeziometacarpal joint osteoarthritis. A case series]. / Artroplastía de suspensión dinámica en la osteoartritis trapecio-metacarpiana. Revisión de los años 2001 al 2006.

UNLABELLED: Osteoarthritis describes the degeneration of articular cartilage. Trapeziometacarpal joint is the second most commonly affected place in the hand. OBJECTIVE: To evaluate the clinical-functional results and the degree of personal satisfaction after dynamic suspension arthroplasty in patients diagnosed with severe osteoarthritis of the trapeziometacarpal joint. MATERIALS AND METHODS: Prospective, longitudinal and descriptive study. Twenty five patients diagnosed with osteoarthritis of the trapeziometacarpal joint and treated with dynamic suspension arthroplasty were studied. The clinical-functional state of the thumb was evaluated by means of the DASH questionnaire. RESULTS: Females were highly predominant (92%), mean age: 62.9 +/- 10.7, housewifes (44%), most affected right thumb (40%), operated right thumbs (56%), left thumbs (44%). Follow-up period: 3 years. Preoperative DASH average 61.7 points +/- 14.0 and postoperative DASH average 31.9 +/- 13.8. The surgery reduced grip and pinch strength for the operated hand but this difference was not statistically significant. CONCLUSION: Dynamic suspension arthroplasty constitutes an excellent surgical alternative for trapeziometacarpal osteoarthritis due it eliminates pain, preserves mobility, stability and offers a high degree of personal satisfaction.

[Arthroscopy of the trapeziometacarpal joint: anatomical study on cadavers]. / Artroscopía de la articulación trapeciometacarpiana: estudio anatómico en cadáver.

INTRODUCTION: Osteoarthritis of the trapeziometacarpal joint is one of the most common degenerative diseases of the hand for which a variety of surgical procedures have been developed. Arthroscopic techniques offer good results, although they have not been standardized. OBJECTIVE: To identify the main anatomical structures in relation to arthroscopy portals from the trapeziometacarpal joint and to determine their security area. MATERIAL AND METHODS: We conducted a transversal and descriptive study in which the anatomy was analyzed in seven cadaveric specimens. Fourteen thumbs were dissected after the arthroscopic portals were made. In all of the specimens the distance between the radial artery, the articular line and the arthroscopy portals was measured. RESULTS: The radial artery was found dorsal to the Extensor Pollicis Longus (EPL), 4-5 mm proximal to the dorsal arthroscopic portal, 4-8 mm to the articular line and 8-11 mm to the Extensor Pollicis Brevis (EPB). In two cases sensitive branches of the radial nerve were found through the dorsal portal. CONCLUSION: The anatomical evaluation defined a secure area for the dorsal portal between the EPL and the EPB. The proximal radial zone to the EPL must be avoided so that the dorsal branch of the radial nerve is not damaged.

Reconstrucción del ligamento radio-cubital distal mediante la plastía de Scheker / Radio ulnar ligament reconstruction by shecker plasty

Objetivo. Determinar los resultados de la técnica de Scheker para la reconstrucción de la estabilidad radiocubital distal crónica. Material y métodos. Se operaron 16 adultos con edad promedio de 36.5 años (18 a 61) mediante el reforzamiento del ligamento radio-cubital distal a nivel del cartílago triangular, con tendón obtenido del palmar mayor o del plantar delgado. Resultados. Los resultados fueron buenos en 14 casos (87 por ciento), mientras que en los dos restantes fueron regular en uno y malo en otro, por limitación de la prono-supinación y por dolor residual. Conclusión. Se concluye que es una técnica útil y de fácil aplicación para recuperar la estabilidad articular.

Linfangiohemangiona del músculo pronador cuadrado: presentación de un caso clinicopatológico / Lymphangi-hemangioma of the quadratus pronator muscle: a clinico pathological case

Los linfangiomas son tumores poco frecuentes de los tejidos blandos, piel y órganos internos; son neoplasias generalmente benignas, los raros casos malignos están asociados a radioterapia o aplicaciones de soluciones esclerosantes. Las manifestaciones clínicas de los linfangiomas son tardías y dependen de las dimensiones del tumor y la región anatómica afectada. Se presenta el caso clínico-patológico de una paciente de 43 años de edad, con un linfangiohemangioma que afectó el músculo pronador cuadrado en antebrazo derecho, en quien no se estableció el diagnóstico y la evolución fue tórpida hasta que se logró la resección total de la neoplasia, seguida de rehabilitación y se dio de alta por curación. La importancia de este caso radica en las dificultades diagnósticas presentes en la paciente.

Seudoartrosis congénita de tibia. Reconstrucción con transplante de peroné vascularizado. Informe de 5 casos / Congenital pesuarthrosis of the tibia. reconstruction with fibular free flap. Report of five cases

Los tres principales retos que se plantean en la reconstrucción de una Seudoartrosis Congénita de Tibia (SCT) son: 1) lograr la unión ósea, 2) Corregir la discrepancia de longitud y 3) Minimizar la hiportrofia de la extremidad. Presentamos una serie de 5 pacientes con diagnóstico de SCT tipo II de Boyd, intervenidos entre los 18 meses y los 7 años meses (m;4a 2m) 4 pacientes con un total de 9 cirugías previas y uno solo sin antecedentes quirúrgicos. El acortamiento previo varió entre 3 y 7 cm. A todos los pacientes se les transfirió un peroné vascularizado con una longitud entre 8.7 y 14 cm, utilizando fijación externa en 3 y clavo centromedular en 2 casos. En todos los casos se obtuvo consolidación ósea: la unión proximal entre las 6 y 24 semanas y la distal entre las 6 y 16 semanas. En cuatro pacientes se retiró la osteosíntesis y se inició el apoyo gradual a partir de las 16 semanas. Se dio el índice de hipertrofia del peroné transplantado según de Boer y Wood, encontrando hipertrofia mayor del 20 por ciento a partir de la 4ª semana e hipertrofia endóstica entre la 8ª y 10ª semanas. Las complicaciones fueron: neuropraxia bilateral del sural externo que revirtió rápidamente (un caso), contractura del flexor hallucis longus manejada con servadoramante (un caso), infección del tracto de los clavos en un fijador que requirió de su retiro precozmente (un caso) y consolidación en valgo de tobillo que requirió de osteotomía correctora (un caso), El acortamiento residual al máximo seguimiento fue de entre 0 a 2.5 cm. La transferencia microvascular de peroné es el método más efectivo en el manejo actual de SCT tipo II de Boyd o multioperadas. Su morbilidad es menor que la reportada para otros métodos convencionales más reconocidos

Pseudoartrosis congénita de la tibia. Reconstrucción con transplante de peroné vascularizado. Informe de 5 casos / Congenital pseudoarthrosis of the tibia. Reconstruction by micro-vascular fibular graft. report o five cases

Presentamos una serie de 5 pacientes con diagnóstico de SCT tipo II de Boyd, intervenidos entre los 18 meses y los 7 años 2 meses (m: 4a 2m) 4 pacientes con un total de 9 cirugías previas y uno solo sin antecedentes quirúrgicos. El acortamiento previo varió entre 3 y 7 cm (m: 4.98 cm). A todos los pacientes se les transfirió un peroné vascularizado con una longitud entre 8.7 y 14 cm (m: 11.14 cm), utilizando fijación externa en 3 y clavo centromedular en 2 casos. En todos los casos se obtuvo consolidación ósea: la unión proximal entre las 6 y 24 semanas y la distal entre las 6 y 16 semanas. En cuatro pacientes se retiró la osteosíntesis y se inició el apoyo gradual a partir de las 16 semanas. Se midió el índice de hipertrofia del peroné transplantado según de Boer y Wood, encontrando hipertrofia mayor del 20 por ciento a partir de la cuarta semana e hipertrofia endóstica entre la octava y décima semanas. Las complicaciones fueron: neuropraxia bilateral del sural externo que revirtió rápidamente (un caso), contractura del flexor propio del dedo grueso manejada conservadoramente (un caso), infección del tracto de los clavos en un fijador que requirió de su retiro precozmente (un caso) y consolidación en valgo de tobillo que requirió de osteotomía correctora (un caso). El acortamiento residual al máximo seguimiento fue de entre 0 a 2.5 cm (m: 1.12 cm). La transferencia microvascular de peroné es el método más efectivo en el menejo actual de SCT tipo II de Boyd o multioperadas. Su morbilidad es menor que la reportada para otros métodos convencionales más reconocidos

Transplante de peroné vascularizado. Reconstrucción de pérdidas óseas segmentarias mayores de 6 cm. Informe de 11 casos / Microvascular fibular graft transplantation. Reconstruction for segmental bone loss greater than six centimeters: report of 11 cases

Uno de los problemas más difíciles de resolver a los que se enfrenta el ortopedista es la reconstrucción de grandes pérdidas óseas segmentarias secundarias a traumatismos, malformaciones congénitas, infecciones óseas o a resecciones en bloque por tumores óseos. La reconstrucción con aportes osteogénicos convencionales es impredecible en defectos mayores de 6 cm. El transplante microvascular de hueso vascularizado ha probado ser una técnica efectiva, ya que no tiene que existir sustitución celular, sino que se integra consolidando en sus extremos como una fractura. En este trabajo se presentan 11 casos con pérdidas óseas segmentarias mayores de 6 cm, tratados con transplante de peroné microvascular en el Instituto Nacional de Ortopedia durante el periodo comprendido de marzo de 1993 a julio de 1995. De los 11 pacientes, seis correspondieron al sexo masculino (54.5 por ciento). Las edades oscilaron entre cinco y 33 años (promedio de 19.9 años). La etiología fue multifactorial: pseudoartrosis postraumática en cinco casos, osteomielitis hematógena en uno, pseudoartrosis congénita de tibia en dos, resecciones en bloque por tumores óseos en dos y pérdida segmentaria debido a herida por proyectil de arma de fuego en un caso. Diferentes huesos largos fueron afectados: radio (tres casos), tibia (tres), húmero (dos) y fémur (dos); uno de los pacientes presentó afección de cúbito y radio. El tiempo de evolución en los casos crónicos osciló de seis meses a 13 años (promedio de 4.2 años); sólo un paciente fue tratado en estado agudo. Nueve sujetos ya habían sido intervenidos quirúrgicamante en varias ocasiones. Las pérdidas óseas variaron desde 8 hasta 26 cm (promedio de 13.4 cm). La longitud del injerto fue de 9 a 30 cm (promedio de 17.5 cm). El tipo de osteosínteis que utilizamos varió en cada caso en particular; en seis casos se utilizó clavo centromedular más inmovilización externa con fibra de vidrio o yeso, en cuatro se empleó fijador externo y en un caso tornillos de cortical. Se utilizó isla de piel en nueve pacientes. Los tiempos quirúrgicos variaron de 6 a 12 horas (promedio de 7.57 horas). En todos los casos se presentó hipertrofia del peroné. Los tiempos de consolidación oscilaron entre nueve y 16 semanas. Las complicaciones que se presentaron no difieren de las consignadas en otras series. Los resultados obtenidos son alentadores, ya que en todos los casos existió integración del peroné transplantado con tiempos de consolidación similares a los de...