Total Elbow Arthroplasty and Antegrade Posterior Interosseous Flap for Infected Posttraumatic Arthritis with an Active Fistula. A Rationale for Comprehensive Treatment. Case Report.

The indication for total elbow arthroplasty (TEA) for primary and posttraumatic elbow arthritis has increased, however, its indication after infection remains elusive. Wound closure about the elbow increases the challenge of treating a previously infected elbow, often necessitating soft tissue coverage with local or regional flaps. We present a 75-year-old male patient with an elbow infection following a failed complex intraarticular fracture open reduction and internal fixation of the distal humerus. Initially, he presented with severe functional impairment and pain, also with an active fistula with serous exudate, whose culture was positive for Cutinebacterium acnes. Septic hardware loosening, and septic nonunion with intraarticular involvement of the left elbow was diagnosed. The patient underwent hardware removal, fistulectomy, serial irrigation and debridement and a pedicled antegrade posterior interosseous artery (PIA) flap on staged surgical treatment. Finally, after ruling out infection persistence, a TEA was performed. We aim to report the outcome of a patient treated with a TEA in the context of a previously infected elbow with soft tissue coverage with an antegrade PIA flap. Comprehensive treatment must be done in an appropriate manner, to obtain an expedited and desirable outcome.

Surgical Solution for Total Carpectomy due to Destructive Wrist Pan-Osteomyelitis Using a Free Femoral Condyle Osteocutaneous Flap for Wrist Arthrodesis.

Osteomyelitis of the hand is rare, even more so in the carpal bones. Patients with rheumatoid arthritis (RA) have a higher infection rate overall, and up to a 14-fold increase in the incidence of septic arthritis of the hand. The destruction of immunologic barriers, such as cartilage and joint capsules, as well as the use of immunosuppressive medications will have an impact on the higher incidence of articular infections and osteomyelitis in these patients. Infection in these cases is often overlooked because of the similarity of presentation to an acute event of RA. When osteomyelitis is present, rapid and aggressive treatment should be given. Surgical debridement, lavage, and excision of necrotic bone is the best choice, followed by cemented antibiotic impregnated spacer to resolve the acute scenario. Vascularized bone grafts (VBG) can then be used for a definitive solution, as these have great biologic properties that increase the possibility of a good outcome. We hereby present a report of a wrist arthrodesis, using a free medial femoral condyle VBG for the treatment of destructive osteomyelitis of the carpal bones in a female patient with RA.

[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.

[Fracture dislocation of the proximal interphalangeal joint]. / Fractura-luxación de la articulación interfaláingica proximal.

INTRODUCTION: The proximal interphalangeal (PIP) joint is the most commonly dislocated joint in the body and the hand. We did a review of the literature and report herein our experience treating this condition at the ABC Medical Center from 1991 to 2007. MATERIAL AND METHODS: Systematic review of the literature. Retrospective and descriptive study. RESULTS: A total of 13 patients were included between 1991 and 2007. Three of them were managed with ORIF with Kirschner nails, 3 with OR and Kirschner nails blocking extension, 2 with plasty with volar plate interposition, and one with CRIF with a Kirschner nail. Mean follow-up was 4.8 months in 8 patients, the ranges of motion were recorded. The following factors were negatively correlated with the range of motion: age, time elapsed between the injury and the treatment, the combined approaches, and the pins blocking extension. Those treated with interposition arthroplasty had a better range of motion. CONCLUSION: The fracture dislocation of the PIP joint is a rare pathology with multiple treatments and variable outcomes that usually result in the limitation of flexion and extension.

[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.

[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.