Optimal posterior screw placement configuration in Sanders 2B calcaneal fractures: A biomechanical study.

BACKGROUND: Calcaneal fractures can be high energy intra-articular injuries associated with joint depression. Challenges to fracture reduction include lateral wall blow out, medial wall overlap, comminution and central bone loss. Secondary deformity such as hindfoot varus alters foot biomechanics. Minimally invasive approaches with indirect reduction of the calcaneal tuberosity to maintain the reduction using posterior screws is routinely being used in the treatment of joint depression fractures. Biomechanically, optimum screw numbers and configuration is not known. Biomechanical studies have evaluated and proposed different screw configurations, however, it is not clear which configuration best controls varus deformity. This study aims to determine the optimum screw configuration to control varus deformity in Sanders 2B calcaneal fractures. METHODS: Sawbone models were prepared to replicate Sanders type 2-B fracture, with central bone loss and comminution. 0.5cm medial wedge of the calcaneal tuberosity was removed to create varus instability. After stabilising posterior facet with a single 4mm partial threaded screw, and applied an 8 hole contoured plate to stabilise the angle of Gissane, inserted one or two 7mm cannulated partially threaded Charlotte™ (Wright Medical Technology, Inc. 5677 Airline Road Arlington, TN) Headless Multi-use Compression (under image guidance) extra screws to control varus and subsidence deformity of the fracture. Coronal plane displacement of the dissociated calcaneal tuberosity fragment relative to the body when applying 5N, 10N and 20N force was measured in millimetres (mm). RESULTS: 2 screws inserted (one medial screw into the sustentaculum talus from inferior to superior and, one lateral screw into the long axis anterior process) provides the least displacement (0.88±0.390 at 5N and 1.7±1.251 at 20N) and the most stable construct (p<0.05) when compared to other configurations. A single medial screw into the sustentaculum tali (conf. 3) resulted in the least stable construct and most displacement (4.04±0.971 at 5N and 11.24±7.590 at 20N) (p<0.05). CONCLUSION: This study demonstrates the optimal screw configuration to resist varus in calcaneal fractures using minimally invasive techniques. Optimal stability is achieved using 2 screws; one located along the long axis of the calcaneus (varus control) and the other placed in the short axis directed towards the posterior facet of the calcaneus (control varus and subsidence). Further cadaver research would help evaluate optimal screw placement in simulated fractures to further assess reproducibility.

Optimal posterior screw placement configuration in Sanders 2B calcaneal fractures: A biomechanical study. / [Artículo traducido] Configuración y localización óptima de los tornillos posteriores en las fracturas de calcáneo Sanders 2B: estudio biomecánico.

BACKGROUND: Calcaneal fractures can be high energy intra-articular injuries associated with joint depression. Challenges to fracture reduction include lateral wall blow out, medial wall overlap, comminution and central bone loss. Secondary deformity such as hindfoot varus alters foot biomechanics. Minimally invasive approaches with indirect reduction of the calcaneal tuberosity to maintain the reduction using posterior screws is routinely being used in the treatment of joint depression fractures. Biomechanically, optimum screw numbers and configuration is not known. Biomechanical studies have evaluated and proposed different screw configurations, however, it is not clear which configuration best controls varus deformity. This study aims to determine the optimum screw configuration to control varus deformity in Sanders 2B calcaneal fractures. METHODS: Sawbone models were prepared to replicate Sanders type 2-B fracture, with central bone loss and comminution. 0.5 cm medial wedge of the calcaneal tuberosity was removed to create varus instability. After stabilising posterior facet with a single 4 mm partial threaded screw, and applied an 8 hole contoured plate to stabilise the angle of Gissane, inserted one or two 7 mm cannulated partially threaded CharlotteTM (Wright Medical Technology, Memphis, USA) Headless Multi-use Compression (under image guidance) extra screws to control varus and subsidence deformity of the fracture. Coronal plane displacement of the dissociated calcaneal tuberosity fragment relative to the body when applying 5 N, 10 N and 20 N force was measured in millimetres (mm). RESULTS: 2 screws inserted (one medial screw into the sustentaculum talus from inferior to superior and, one lateral screw into the long axis anterior process) provides the least displacement (0.88 ± 0.390 at 5 N and 1.7 ± 1.251 at 20 N) and the most stable construct (p < 0.05) when compared to other configurations. A single medial screw into the sustentaculum tali (conf. 3) resulted in the least stable construct and most displacement (4.04 ± 0.971 at 5 N and 11.24 ± 7.590 at 20 N) (p < 0.05). CONCLUSION: This study demonstrates the optimal screw configuration to resist varus in calcaneal fractures using minimally invasive techniques. Optimal stability is achieved using 2 screws; one located along the long axis of the calcaneus (varus control) and the other placed in the short axis directed towards the posterior facet of the calcaneus (control varus and subsidence). Further cadaver research would help evaluate optimal screw placement in simulated fractures to further assess reproducibility.

Trend in Spain in the use of total ankle arthroplasty versus arthrodesis in the period 1997-2017. / Tendencia en España en el uso de artroplastia total de tobillo frente a artrodesis en el periodo 1997-2017.

OBJECTIVE: The main objective of this study is to compare proportionally the incidence of total ankle arthroplasty (TAA) versus ankle arthrodesis and to determine the variables that may have influenced its indication. The secondary objective is to analyse the trend in the use of TAA using a population-based analysis and to compare our results with those reported by national registries in other countries. MATERIAL AND METHOD: A retrospective review of the Minimum Basic Data Set from 1997-2017 was performed. Subjects were categorised according to surgical procedure. Their temporal evolution was analysed and hospital variables associated with the indication (age, sex, hospital complexity) were identified. In order to compare the trend in Spain with respect to other countries, the information was standardised as number of procedures per 100,000 inhabitants/year and a projection was made for the five-year period 2020-2025. RESULTS: In the period 1997-2017, 11,669 ankle arthrodesis and 1,049 TAAs were performed. The trend was increasing and significant for both procedures, however, in the last 10 years analysed the proportional trend of TAA decreased significantly. Being female (OR 1.32), being 65 years or older (OR 1.50) and being operated in a complex hospital (OR 1.31) were associated with the indication for a TAA. Compared to other countries, Spain has much lower rates of TAA utilisation, with minimal growth estimated for the year 2025. CONCLUSION: Although the use of TAA has increased, its growth has been lower than that of ankle arthrodesis and its current trend is proportionally decreasing, with female sex, age≥65 years and the patient being operated in a medium/high complexity hospital being associated with the indication for TAA. Compared with other countries, Spain has much lower rates of use and its projection over the next five years, although increasing, is expected to be minimal.

Matrix-induced autologous chondrocyte implantation grafting in osteochondral lesions of the talus: Evaluation of cartilage repair using T2 mapping.

Osteochondral lesions of the talus may be treated with different autologous biological approaches. These include platelet-rich plasma, stem cells or MACI and ACI. MACI implants are used to cover cartilage lining defects in the ankle. A total of 18 patients were treated with MACI implants. NMR images were taken before and after the procedure. T2 mapping was used to quantify the changes in cartilage collagen after a 6 12-month postoperative period. Increase in collagen was recorded on all patients. Both open and arthroscopic procedures were performed depending on the technical difficulties encountered during the repair.

[Randomized prospective study on the influence distal block and Gamma 3 nail on the treatment of intertrochanteric fractures of femur]. / Estudio prospectivo aleatorizado sobre la influencia del bloqueo distal del clavo Gamma 3 en el tratamiento de las fracturas pertrocantéreas de fémur.

OBJECTIVE: The purpose of this study is to assess the need to lock the Gamma 3 nail (Stryker, Mahwah New Jersey USA) distally for intertrochanteric fractures of femur 31-A1 and 31-A2 of the AO. MATERIAL AND METHODS: Details were recorded on a sample of 177 patients with intertrochanteric femoral fractures treated in our hospital by a standard Gamma nail between June 2011 and January 2013. A prospective study was conducted by randomizing patients by year of birth, even numbers with, or odd number without, distal locking, forming two groups of 90 and 87 fractures, respectively. RESULTS: The patients treated with a distal locking nail had an increased incidence of medical complications, a lower incidence of biomechanical complications, and an increase in the fracture collapse compared with the control group, with statistical significance (p < 0.05). It is also observed in the group with distal locking increased transfusion requirement and a higher death rate, with statistically significant differences (p < 0.05), but this significance disappears when adjusting for other patient-related characteristics. CONCLUSIONS: Based on the results found in this work, the use of distal locking screw in the Gamma 3 nails should be restricted to unstable trochanteric fractures after reduction where additional stability to the intramedullary nail is required, and may decrease the risk of complications from use.

[Combined sciatic and inguinal paravascular nerve block: a valid alternative for arthroscopic knee surgery]. / Bloqueo ciático y paravascular inguinal para cirugía artroscópica de rodilla, una alternativa válida.

OBJECTIVE: To assess the effectiveness of a combined transgluteal sciatic and inguinal paravascular nerve block for arthroscopic knee surgery. MATERIAL AND METHODS: Prospective descriptive study of 88 patients scheduled for arthroscopic knee surgery. Using a nerve stimulator and a transgluteal approach, we infiltrated the sciatic nerve with 20 mL of 1.5% mepivacaine. Then, with the patient in supine position, we located the femoral nerve and inserted a plastic catheter into the descending inguinal canal, applying pressure near the tip, to inject 20 mL of 1% mepivacaine. We evaluated a) anesthetic effectiveness, b) tolerance of the pressure cuff, c) time in the intensive care recovery unit, and d) time until reversal of the block. RESULTS: Anesthesia was efficacious for 89.77% of the patients: excellent for 54 patients (61.36%), good for 25 (28.41%), and insufficient for 9 (10.23%). The pressure cuff was well tolerated by 70 patients (79.54%) and caused discomfort for 18 (20.45%). Mean postoperative stay in the intensive care recovery unit was 19.05 (SD 8.11) minutes. Reversal took place at a mean 204.09 (SD 22.59) minutes for the sensory nerve block and at 223.45 (SD 20) minutes for the motor block. CONCLUSIONS: The combined sciatic and inguinal paravascular block is effective for arthroscopic knee surgery and offers an alternative when other anesthetic techniques cannot be used. Use of a pressure cuff may require complementary sedation.

[Continuous parascalene block for shoulder surgery]. / Bloqueo paraescalénico continuo en la cirugía del hombro.

OBJECTIVE: To evaluate the efficacy and incidence of side effects of parascalene brachial plexus block for shoulder surgery and for postoperative analgesia. PATIENTS AND METHODS: This prospective descriptive study enrolled 186 patients scheduled for conventional (open) and arthroscopic shoulder operations. The parascalene approach to the brachial plexus was used, with an 18-G x 4.5 cm cannula (30 degrees bevel), applying the technique of detecting perforation of the prevertebral fascia. Mepivacaine 1.5% was administered for anesthesia, beginning with a test dose of 5 ml followed by doses of 25 ml. Bupivacaine 0.125% with 1/400,000 adrenaline was given for postoperative analgesia. Two groups were established according to type of surgery. In group A were patients undergoing open surgery and those with articular stiffness undergoing arthroscopic surgery; analgesics were delivered in continuous perfusion of 5 to 8 ml/h. Group B patients, who underwent arthroscopic surgery, received the analgesic in boluses of 10 to 14 ml every 4 to 6 hours. We assessed perception of perforation of the fascia, provocation of paresthesia, number of puncture attempts, anesthetic efficacy, postsurgical analgesia (visual analogue scale from 0 to 10) and complications. RESULTS: Blockade was effective for 155 of the 186 patients (83.33%). In 118 (63.44%) the perception of perforation of the prevertebral fascia was ostensible, in 52 (27.95%) it was slight and in 16 (8.6%) it was undetectable. Paresthesia was triggered by the cannula in 18 cases (9.13%) and by the test dose in 181 cases (97.31%). The mean number of puncture attempts was 1.2 +/- 0.09 per patient. During the early postoperative period analgesia was adequate for 92 (84.40%) of the 109 patients in group A. In group B, 45 patients (97.82%) required 1 to 2 analgesic doses (mean 1.4 +/- 2 doses) and one patient (2.17%) needed 6 doses within the first 24 hours. Catheters remained inserted as long as 36 hours to 10 days (mean 3.5 days) in group A. In group B they had been removed by 24 hours. Complications were transitory and slight. No cases of pneumothorax, no intra- or epidural anesthesia was required and no instances of vascular puncture occurred. CONCLUSIONS: The parascalene approach is easy to use and entails few risks while providing excellent anesthetic conditions for open and arthroscopic shoulder operations. It is useful for ambulatory analgesia to facilitate early rehabilitation after surgery.

[Local anesthesia of the knee for arthroscopic surgery. Our experience in 1,000 cases]. / Anestesia local de la rodilla para cirugía artroscópica. Nuestra experiencia en 1.000 casos.

We performed local anesthesia of the knee for arthroscopic surgery in 1,000 patients who were diagnosed of meniscopathy, chondropathy, or block of the knee. We established two anesthetic times. The first consisted of an intraarticular administration of 40 ml of a mixture containing bupivacaine 0.5%, lidocaine 0.5% or prilocaine 1%, and adrenaline 1:200,000. The second was extraarticular and consisted of a local infiltration at the sites of entrance of the arthroscope or instrumental material with lidocaine 0.5% or prilocaine 1%, with adrenaline 1:100,000. We kept a latency period of 10 to 15 min, time required for setting up the arthroscopic procedure. Ischemia was systematically avoided. With this technique the following surgical treatments were performed: meniscectomy, curettage of articular cartilage, synovectomy, plica sections, and extraction of free bodies. Tolerance to surgery was excellent in 32.3% cases, good in 46.5%, regular in 16%, and bad in 5.2%. In no cases more complex anesthetic techniques were undertaken. We conclude that the anesthetic technique used in this study is appropriate for arthroscopic surgery of the knee and allows to perform ambulatory surgery. The procedure is not useful in cases of ligament reconstruction, regional infection, and rupture of the articular capsula. Although the anesthetic technique is easy some factors should be considered before indication of the procedure such as a careful selection of the patient, skillfulness of the surgeon in performing the arthroscopy, and the accuracy of the preoperative diagnosis.

[Progression to AIDS among HIV-seropositive hemophiliacs]. / Progresión a SIDA en hemofílicos seropositivos frente al VIH.

PURPOSE: To assess the incidence of AIDS, along with its origin and mortality rate, in a group of sero-positive haemophiliacs with long follow-up. MATERIAL AND METHODS: The progression into AIDS in 94 HIV-seropositive haemophiliacs (88 with haemophilia A and 6 with haemophilia B) followed since 1986 has been analyzed. The mean age was 19 years and 64% of the patients had severe haemophilia. All of them had been previously treated with non virus-inactivated factor concentrates. Was detected HIV antigen in 13 of them and 32 were treated with zidovudine. Actuarial analysis started from seroconversion date or from the first positive result and the average observation time was 90 months (5-97). RESULTS: Sixteen patients developed AIDS, resulting in an eight-years accumulative actuarial indice of about 24%. AIDS incidence was lower (p less than 0.0001) in haemophilia A (21%) than in haemophilia B (67%). The eight-years progression rate to AIDS showed a significant dependence on patient age, it being higher in patients aged greater than 30 (77%) than in those aged 15-30 (30%) and less than 15 (9%). Patients who presented CD4+ counts lower than 0.5 x 10(9)/L or CD4/CD8 ratios lower than 0.5 at the beginning of the observation period had a greater 8-year AIDS incidence (63% and 57% respectively) than the remaining patients (16% and 12%). At AIDS diagnosis, all patients had CD4+ lymphocyte counts lower than 0.2 x 10(9)/L, two had detectable HIV antigenaemia and six had been previously treated with zidovudine. The cause of AIDS was an opportunistic infection in all the cases namely, P. carinii pneumonia and candidiasis, but no secondary neoplasia was registered. Nineteen patients died during the follow-up, 12 because of AIDS and 7 because of other reasons unrelated to HIV-infection. CONCLUSION: Our results suggest that 25% of the haemophiliacs will develop AIDS eight years after seroconversion, and a decreasing incidence is not observed. Lower progression rate to AIDS in children than in adults is confirmed.

[Primary Sjogren's syndrome in men: evolution to acute lymphoblastic leukemia]. / Síndrome de Sjögren primario en varón: evolución a leucemia linfoblástica aguda.

A clinical case of a 55-year-old man with syndrome of primary Sjögren, seronegative, normoglobulinemic and normocomplementary with 7 years of evolution, which developed acute lymphoblastic leukemia, having suffered recurrent lympho-adenopathy and paresthetic meralgia as previous clinical signs, is presented. Clinical, serological and immunologic characteristics of this syndrome are reviewed, highlighting its rare appearance among men. While appearance of malignant lymphoproliferation disorders is well known, evolution to acute or chronic myeloid leukemia is very rare and so far, an acute lymphoblastic leukemia as the one presented in this study has never been described.