Damage control orthopaedics: State of the art.

Damage control orthopaedics (DCO) originally consisted of the provisional immobilisation of long bone - mainly femur - fractures in order to achieve the advantages of early treatment and to minimise the risk of complications, such as major pain, fat embolism, clotting, pathological inflammatory response, severe haemorrhage triggering the lethal triad, and the traumatic effects of major surgery on a patient who is already traumatised (the "second hit" effect). In recent years, new locations have been added to the DCO concept, such as injuries to the pelvis, spine and upper limbs. Nonetheless, this concept has not yet been validated in well-designed prospective studies, and much controversy remains. Indeed, some researchers believe the indiscriminate application of DCO might be harmful and produce substantial and unnecessary expense. In this respect, too, normalised parameters associated with the acid-base system have been proposed, under a concept termed early appropriate care, in the view that this would enable patients to receive major surgical procedures in an approach offering the advantages of early total care together with the apparent safety of DCO. This paper discusses the diagnosis and treatment of severely traumatised patients managed in accordance with DCO and highlights the possible drawbacks of this treatment principle.

Trapezio-metacarpal arthrodesis: procedure and results.

The high prevalence of trapezio-metacarpal joint (TMJ) osteoarthritis leads to develop techniques to improve surgical outcomes when conservative treatment has failed. We have evaluated 18 patients with Eaton III TMJ osteoarthritis, who underwent an arthrodesis. Using a dorsal-radial curved shaped skin incision the TMJ was exposed through the space between the abductor pollicis longus and the extensor pollicis brevis muscles. The articular capsule was divided and the TMJ was opened. Neat curettage was then performed in both joint surfaces by removing all the articular cartilage until some cancellous bone hints appeared underneath. The joint was then fixed in the optimal position by a 1.6 mm Kirschner wire and a 1.1 mm guide wire. A cannulated drill for the guide wire was used and matched to a cannulated lag screw. Then, a cylinder-shaped cancellous bone autograft harvested from the distal radius by a percutaneous approach was applied in the hole by drilling backwards in order to spread the bone about onto the hole walls. The joint was then definitively fixed by the cannulated lag screw. The K wires were removed by that time. DASH score changed from an average of 68 in the preoperative assessment to 39.4 at the end of the evolution time. The evolution of pain has decreased from 9.2 points preoperatively to 3.9 points in the postoperative using the visual analogue scale. In terms of mobility, it has decreased from 4 points preoperatively to 3.9 postoperatively, 14 patients got opposition of the thumb to the fifth finger, two of them to the head of the fifth metacarpal bone, one patient to the fourth finger, and one to the third. This slight decrease of mobility had no effect on performing activities of daily life, as expressed by the patients. The grip strength increased from 17 to 21.7 kg and the thumb opposition from 7.8 to 11.2 kg. All patients, except one, would have the operation again after knowing the final results. This patient said that results did not meet previous expectations. On the radiographic evaluation, consolidation has been achieved in 17 patients. When thumb carpo-metacarpal arthrodesis is indicated, the procedure provides a reliable and lasting treatment with satisfactory results. The development of new implants and the possibility of introducing autologous graft percutaneously as is described using this technique leads to improve the results.

Result of a pyrocarbon prosthesis after comminuted and unreconstructable radial head fractures.

BACKGROUND: The purpose of this study is to analyze the results of treating unreconstructable acute radial head fractures associated with other elbow fractures and soft-tissue injuries with a pyrocarbon radial head prosthesis replacement, as well as repair of the associated injuries. MATERIALS AND METHODS: Twenty-eight patients with Mason type III unreconstructable and unstable radial head fractures and with associated injuries (according to Hotchkiss classification modified by van Riet) were treated with a pyrocarbon radial head prosthesis replacement; repair of collateral ligaments and associated elbow fractures was also carried out. Patients were evaluated in accordance with the Mayo Elbow Performance Score, measuring pain, grip strength, range of motion, and stability, as well as radiographic images. RESULTS: After a mean of 32 months postoperatively (range, 12-62 months), the mean Mayo Elbow Performance Score was 92 points. The result was considered excellent or good in 25 patients, with a high degree of satisfaction and functional restoration. CONCLUSION: The results of treating Mason type III radial head fractures with additional elbow fractures and soft-tissue injuries with pyrocarbon radial head prostheses are satisfactory; nevertheless, long-term follow-up is still necessary.