WALANT Technique versus Local Anesthesia with a Tourniquet in Carpal Tunnel Syndrome.

Objectives: Obtaining a blood-free surgical field is critical during carpal tunnel decompression (CTD) to identify anatomic structures and avoid iatrogenic injury. A tourniquet is often used to minimize bleeding and improve visualization. However, it may be associated with discomfort and intolerance when sedation is not employed. WALANT ("Wide awake local anesthesia no tourniquet") technique surgeries have become very popular and enable the patient to be involved in the procedure; in addition, the adrenaline avoids the use of the tourniquet and the discomfort it produces. We hypothesized that there is no difference in postoperative pain after CTD between local anesthetic with a tourniquet (LA-T) and WALANT technique. The objective of this paper is to report the results of CTD, comparing those performed with local anesthesia and those performed with the WALANT. Methods: In this prospective study, 60 CTS were operated in two different institutions. Patients in group 1 (30 patients) were operated under LA-T, while patients in group 2 (30patients) were operated on using lidocaine with epinephrine (WALANT). Statistical analysis was performed. Results: Postoperative pain immediately after surgery, at 4 and 24 hours, and 15, and 30 days after surgery; and degree of satisfaction did not show a significant difference between the two groups. Moreover, surgical time was slightly shorter in the LA-T group, but the difference was not significant. Conclusion: In our study, CTD performed with LA-T, and WALANT technique resulted in similar results. In cases of experienced surgeons, LA-T may be enough to perform the procedure, avoiding epinephrine's low but complex complications. In less experienced surgeons who require more surgical time, the use of WALANT may increase the intraoperative comfort of the patient.

Fibula flap in upper extremity segmental/critical size bone defects fixed with locking plates. Single-institution observational cohort.

INTRODUCTION: Management of bone defects in the upper extremity can vary depending on the size and location of the defect. Large defects may require complex reconstruction techniques. Vascularized bone grafts, mainly free vascularized fibula flap (FVFF), have many advantages in the treatment of bone or osteocutaneous defects. However, complications such as graft fracture are the most common, with a free fibula flap for bone defects in the upper extremity. This study aimed to describe the results and complications associated with the treatment of posttraumatic bone defects in the upper extremity using FVFF. We hypothesized that performing osteosynthesis using locking plates would prevent or reduce the fracture of the fibula flap MATERIALS AND METHODS: This was a retrospective single-centre cohort study. Patients with segmental bone defects caused by trauma who underwent reconstructive surgery with FVFF fixed with locking compression plates (LCP) between January 2014 and 2022 were included. Demographic variables and preoperative data, such as bone defect, location, and time until reconstruction, were collected. Bone defects were classified according to the Testworth classification. Intraoperative variables included the length of the FVFF, type of graft (osteocutaneous or not), type and technique of arterial and venous sutures, number of veins used as output flow, and the osteosynthesis technique used. RESULTS: Ten patients were included (six humerus, three ulna, and one radius). All patients had critical-size bone defects, and nine patients had a history of infection. In 9 of 10 patients, bone fixation was performed with a bridge LCP and in one patient with two LCP plates. In eight cases, the FVFF was osteocutaneous. All the patients showed bone healing at the end of the follow-up period. There was one early complication, donor site wound dehiscence, and two long-term complications (proximal radioulnar synostosis and soft-tissue defect). CONCLUSION: A high rate of bone union with a low rate of complications can be obtained with an FVFF in upper extremity segmental/critical-size bone defects. Rigid fixation with locking plates avoids stress fractures of the grafts, mainly in humeral reconstruction. However, in these cases, a bridge plate should be used.

Lunate Revascularization With Temporary Internal Radiocarpal Spanning Fixation for Kienböck Disease.

BACKGROUND: The goal in the treatment of stages II and III Kienböck disease is to restore lunate vascularity and halt the progression of avascular necrosis. METHODS: We report the outcomes for patients with stages II and III Kienböck disease treated with fourth extensor compartment artery vascularized bone grafting and temporary radiocarpal spanning internal fixation. Nine patients with a mean age of 28.8 years were included. Mean clinical and radiographic follow-up were 4.9 and 1.9 years, respectively. RESULTS: Six patients had no change in Lichtman stage, 2 patients regressed 1 stage, and 1 patient progressed 1 stage. Mean postoperative quick disabilities of the arm, shoulder, and hand (QuickDASH) was 17.4. Mean postoperative visual analogue pain scale (VAS) was 1.8. Patients under age 25 trended toward improved clinical outcomes compared with patients over age 25. Two patients, aged 33 and 65, underwent proximal row carpectomy at a mean 30.5 months postoperatively. CONCLUSIONS: In conclusion, the use of local vascularized bone graft with temporary internal radiocarpal spanning fixation provides a treatment option with outcomes comparable to existing literature with benefits inherent to internal immobilization.

Volar Capsulodesis With Early Active Motion for the Treatment of Chronic Proximal Interphalangeal Joint Hyperextension Deformity.

PURPOSE: We evaluated the clinical outcomes of a series of patients with hyperextension deformity of the proximal interphalangeal joint treated with volar capsulodesis. METHODS: This retrospective study included 16 patients with symptomatic locking of the proximal interphalangeal joint who underwent volar capsulodesis and were followed for at least 2 years. We excluded patients with severe, degenerative changes on plain radiographs. Clinical evaluation included the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire; Catalano's scale for proximal interphalangeal joint hyperextension deformity correction; a visual analog scale for pain; range of motion; and grip strength. Hyperextension recurrence and residual flexion contracture were also recorded. RESULTS: There were 2 women and 14 men, with a mean age of 36 years (range, 22-60 years). The mean preoperative pain scores according to the visual analog scale were 3.6 (range,1-8) and 0.5 (range, 0-3) at the final follow-up. No patient had a recurrence of the hyperextension deformity. The average Quick Disabilities of the Arm, Shoulder, and Hand score was 5, and the mean grip strength was 87% of the contralateral side. Five patients were rated as having excellent results, 9 patients as having good results, and 2 patients as having fair results. Residual flexion contracture was less than 10° in 13 patients and more than 10° in 3 cases. All patients returned to unrestricted activities. CONCLUSION: Volar capsulodesis with early active motion demonstrated favorable results and could be considered as a surgical option for the treatment of chronic hyperextension deformity of the proximal interphalangeal joint. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

What Is the Infection Rate of Carpal Tunnel Syndrome and Trigger Finger Release Performed Under Wide-Awake Anesthesia?

BACKGROUND: High infection rates have been reported in hand procedures using the wide-awake local anesthesia no tourniquet (WALANT) method, causing some to question the validity of this approach. However, little evidence exists surrounding the direct use of WALANT compared with monitored anesthetic care (MAC). This study was conducted to directly compare the postoperative infection rates of carpal tunnel syndrome (CTS) and trigger finger (TF) release surgeries performed under WALANT and MAC. METHODS: A retrospective study comparing postoperative infection rates between patients undergoing CTS and TR releases was conducted. Our primary outcome measure was postoperative infection. Our secondary outcome was postoperative complications. Comparative statistics were used to compare means of infection between the groups. RESULTS: A total of 526 patients underwent CTS release (255 with WALANT and 271 with MAC), and 129 patients underwent TF release (64 with WALANT and 65 with MAC). Patients undergoing WALANT and MAC were statistically comparable in terms of sex, smoking status, diabetes, and American Society of Anesthesiologists physical status classification. In patients undergoing CTS release, there were no infections with WALANT and 6 infections (2.2%) with MAC. In patients undergoing TF release, there were no infections in either group. There were similar rates of complications in patients undergoing WALANT and MAC for CTS and TF releases. CONCLUSION: There was no increased risk of infection with WALANT compared with MAC in CTS or TR surgeries. These surgeries can be safely conducted with lidocaine and epinephrine without a concern for increased risk of infections or complications.

Transferencia tendinosa del primer radial externo al cubital posterior: ¿mejora significativamente la corrección de la desviación radial en la muñeca reumática? / Extensor carpi radialis longus tendon transfer to extensor carpi ulnaris: Does it significantly improve the correction of radial deviation in the rheumatoid wrist?

Introducción: La artritis inflamatoria puede conducir al síndrome de caput ulnae con desviación radial de la muñeca y los meta-carpianos. El tratamiento es la artroplastia de rescate de la articulación radiocubital distal y la reubicación del tendón del extensor cubital del carpo (ECC). Sin embargo, puede ser débil para corregir la desviación. Clayton describió la transferencia del tendón del extensor radial largo del carpo (ERLC) al ECC. El objetivo de este estudio fue comparar la corrección de la desviación radial de los metacarpianos en pacientes operados con transferencia del ERLC al ECC o sin ella. Materiales y Métodos: Estudio de cohorte retrospectiva en pacientes con artritis reumatoide y síndrome de caput ulnae, sometidos a tenoplastia del ECC con ERLC o sin este procedimiento. Se formaron dos grupos: pacientes con transferencia (grupo A) y sin transferencia (grupo B). Se calculó la corrección del ángulo de Clayton comparando las medidas preoperatoria y del último control, y se compararon los resultados. Resultados: El seguimiento promedio fue de 28 meses. El ángulo de Clayton preoperatorio promedio era de 44,54° (DE ± 7,52) en el grupo A y 60,24° (DE ± 12,28) en el grupo B (p = 0,001). El promedio de corrección fue de 6,57° (DE ± 4,11) y 0,95° (DE ± 9,17), respectivamente (p = 0,026). Conclusiones: El nivel de corrección fue mayor en el grupo A. No obstante, si bien ambas técnicas lograron mejorar el ángulo, el grado de corrección podría estar supeditado a la magnitud del ángulo preoperatorio. Nivel de Evidencia: IV

Introduction: Inflammatory arthritis can lead to caput ulnae syndrome with radial deviation of the wrist and metacarpals. Treatment includes salvage arthroplasty of the distal radioulnar joint and relocation of the extensor carpi ulnaris (ECU) tendon. However, the ECU may be too weak to correct the deviation. To strengthen the ECU, Clayton described the transfer of the extensor carpi radialis longus (ECRL) tendon to the ECU. The aim of this work is to compare the correction of the radial deviation of the metacarpals in patients with and without transfer of the ECRL to the ECU. Materials and Methods: Retrospective cohort study. Patients with rheumatoid arthritis and caput ulnae syndrome, treated with ECU tenoplasty with or without ECRL, were included. The patients were divided into two groups: ECRL to ECU transfer (group A) and no transfer (Group B). The correction of the metacarpal-radial angle (Clayton's angle) was calculated by comparing the measurements before surgery and at end of follow-up, and the results obtained were compared. Results: The average follow-up was 28 months. The preoperative Clayton angle was on average 44.54° (SD ± 7.52) in group A and 60.24° (SD ± 12.28) in group B (p = 0.001). The correction average was 6.57° (SD ± 4.11) and 0.95° (SD ± 9.17) for group A and B respectively (p=0.026). Conclusions: The level of correction obtained was higher in group A. However, although both techniques managed to improve the angle, the degree of correction could be subject to the magnitude of the preoperative angle. Level of Evidence: IV

Resultados de la neurólisis como tratamiento del dolor neuropático en pacientes con lesión del nervio ciático. Reporte de casos / Results of neurolysis for the treatment of neuropathic pain in patients with sciatic nerve Injury. Case report

Introducción: La lesión del nervio ciático puede ocasionar desde parestesias e hipoestesias, hasta dolor neuropático severo y parálisis. La neurólisis suele mejorar la función, el dolor y la calidad de vida de los pacientes. El objetivo de este estudio fue evaluar los resultados clínico-funcionales de una serie de pacientes con dolor neuropático por lesión del nervio ciático que no respondieron al tratamiento conservador y fueron sometidos a neurólisis. Materiales y métodos: Se analizó retrospectivamente una serie de pacientes sometidos a neurólisis del nervio ciático mayor entre marzo de 2009 y junio de 2018. El dolor pre- y posoperatorio se evaluó mediante la escala analógica visual y la escala de Likert. El tipo de dolor posoperatorio se evaluó con el cuestionario DN4 y la calidad de vida relacionada con la salud, con el cuestionario SF-36.Resultados:Se incluyó a 8 pacientes. A los 32 meses de seguimiento promedio (rango 14-66), el dolor había mejorado notablemente (promedio de 3 y 1,88 puntos en las escalas analógica visual y de Likert, respectivamente). El cuestionario DN4 arrojó un promedio de 3,75 puntos (rango 2-7). Según el SF-36, la "salud física" fue la variable con peores resultados (promedio 30,15).Conclusiones: La neurólisis, cuando se indica a pacientes con mala respuesta al tratamiento conservador, es un método que alivia el dolor y mejora la calidad de vida de los pacientes con dolor neuropático secundario a una lesión del nervio ciático. Nivel de Evidencia: IV

Introduction: Sciatic nerve injury may cause paresthesias and hypoesthesias, severe neuropathic pain, and paralysis. Neurolysis can improve function, pain, and quality of life for these patients. The objective of this paper is to evaluate the clinical-functional outcomes of a series of patients with neuropathic pain due to sciatic nerve injury that was refractory to conservative treatment in whom neurolysis was performed. materials and methods:A retrospective case series of patients operated on for neurolysis of the greater sciatic nerve between March 2009 and June 2018 was analyzed. Preoperative and postoperative pain were evaluated using the visual analog scale (VAS) and the Likert scale. The type of postoperative pain was evaluated using the DN4 questionnaire, and the health-related quality of life was measured with the SF-36 questionnaire. Results: Eight patients were included. All patients evolved with a notable improvement in pain, with an average of 3 and 1.88 points on the VAS and Likert scales, respectively. The mean follow-up was 32 months (range 14­66). The DN4 questionnaire showed an average of 3.75 points (range 2­7). According to the SF-36, "Physical Health" was the variable with the worst results, with an average of 30.15. Conclusions: Sciatic nerve neurolysis in patients with neuropathic pain due to sciatic nerve injury and poor response to conservative treatment may improve pain and quality of life. Level of Evidence: IV

Total Elbow Arthroplasty in the Context of an Olecranon Nonunion: A Surgical Technique and Report of Three Cases.

The deficiency of the triceps tendon has been considered a relative contraindication to performing a total elbow arthroplasty. One of the conditions that may compromise triceps integrity is the presence of an olecranon non-union (ON). In this scenario, the placement of a total elbow arthroplasty in a patient with end-stage elbow arthritis is a complex problem to be solved. The aim of this study is to describe the surgical technique for the placement of a TEA in the context of a previous ON and to report the results of three cases. Surgical technique: the focus of the nonunion is identified, and the olecranon fragment is proximally reflected with the triceps tendon to allow accurate exposure of the medullary canal of the ulna and easy access to the joint. With the elbow in a fully flexed position, the previously assembled test prosthesis is placed and the proximal ulna fragment should then be reduced to match the distal ulna. Osteosynthesis with a tension band technique was performed at 45° of elbow extension. A non-absorbable Krackow suture (Ti-Cron 2-0) from the triceps's tendon to the hole of the wire in the distal ulna is applied to decrease the triceps tension traction. Bone grafting is performed when a persistent gap is present at the fracture site following reduction. This technique enables us to achieve a stable elbow with little pain and maintains the extensor apparatus's continuity.

Time until union in absolute vs. relative stability MIPO plating in simple humeral shaft fractures.

PURPOSE: The objective of this study is to evaluate the effect of absolute stability (AS) versus relative stability (RS) performed through a minimally invasive plate osteosynthesis (MIPO) in AO/OTA 12A1 and 12A2 fractures on healing and the time to radiographic union. METHODS: This was a retrospective cohort study of all patients treated with plate fixation for AO/OTA type 12A1-A2 fractures at a single institution. Patients were grouped according to the type of stability used in their surgery. Time until radiographic union was estimated using the Kaplan-Meier method, which was compared by long-rank test between both types of surgical techniques. RESULTS: A total of 70 patients were included in this study with 35 patients in each group. The median follow-up was 9 (IQR 6-14) months. The median time to radiographic union was significantly lower in the AS group than in the RS group: 12 (interquartile range (IQR) 10-14) weeks versus 18 (IQR 16-19) weeks, respectively (p < 0.001). Non-union was seen in two cases (7%) in the relative stability group. Three patients in the RS group developed a post-operative radial nerve palsy. CONCLUSION: The main finding of this study is that the median time to radiographic union was significantly shorter in the patients treated with AS compared to those with a RS technique. These findings support the recommendations of the AO foundation in that simple metaphyseal fractures (type A) that require surgical treatment should be treated with an AS construct. RS techniques should be reserved to multifragmentary fractures where fragment preservation of blood supply is paramount.

Trapeziometacarpal osteoarthritis: Arthroscopic hemitrapeziectomy using the Thenar Portal.

BACKGROUND: Although the standard 1Radial and 1Ulnar portals allow for visualisation of most of the trapezium articular surface, the proximity of these two portals can often make arthroscopic triangulation and visualisation of the most lateral capsule and joint surface challenging. Despite its already reported advantages in improving visualisation, there is little literature reporting the clinical experience with the Thenar Portal. The purpose of this study is to describe potential complications and the short-term clinical-radiographic outcomes of arthroscopic hemitrapeziectomy using the Thenar Portal in order to determine its safety and efficacy as a standard working portal. PATIENTS AND METHODS: A retrospective chart review was conducted for all patients diagnosed with first carpometacarpal (CMC) osteoarthritis who were treated surgically with an arthroscopic hemitrapeziectomy. Only patients with stage II or III osteoarthritis and a minimum of 1-year follow-up were included. Twenty-two patients (24 thumbs) with an average age of 62 years met the inclusion criteria. The average follow-up was 52 months. Intra-operative and post-surgical complications were recorded. Objective evaluation consisted of an assessment of range of motion (ROM), grip and pinch strength. Subjective evaluation consisted of a DASH questionnaire and the visual analog scale to score pain at rest, during activities, and function. RESULTS: There were no intra- or post-surgical complications. In one case, pain persisted with a poor functional result, requiring a revision surgery. Average range of motion (compared with the contralateral) showed a statistically significant improvement in palmar abduction and radial abduction of the CMC joint: 50° vs. 55° (p=0.01235), and 50° vs. 55° (p=0.06009), respectively. There was no statistically significant improvement in thumb adduction, grip strength, or lateral and tip-pinch. All patients achieved retropulsion with their affected thumb. According to the VAS, average rest pain improved from 7.5 to 0 (p<0.001) and from 9 to 0 (p<0.001) during activity. The average final function and QuickDASH were 9 (VAS) and 8, respectively (p<0.001). The average radiographic proximal migration of the first metacarpal was 2.9mm (range: 0.7-5.8mm). DISCUSSION: Arthroscopic hemitrapeziectomy using the Thenar portal: 1) improved visualisation of the trapeziometacarpal joint, 2) facilitated arthroscopic triangulation, and 3) represents a safe and effective alternative for the treatment of thumb osteoarthritis, with pain relief and function improvement in most patients without a higher risk of complications. LEVEL OF EVIDENCE: IV.

Osteotomía en cuña sustractiva supracondílea para el tratamiento del codo valgo del adulto / Supracondylar subtraction wedge osteotomy for the treatment of adult cubitus valgus

Objetivo: Comunicar los resultados de una serie de adultos con consolidaciones en valgo del codo tratados con una osteotomía en cuña sustractiva monoplanar. materiales y métodos: Se incluyeron 5 pacientes. Se describe la técnica quirúrgica que consistió en un abordaje posterior paratricipital, resección en cuña sustractiva y transposición anterior del nervio cubital. El seguimiento promedio fue de 17 meses. Resultados: Se trató a 4 hombres y una mujer, con una edad promedio de 27 años. La movilidad preoperatoria promedio fue de 138-7° y la posoperatoria, de 138-6°, el puntaje de dolor en la EAV fue de 4 y 1, el MEPS de 71 y 97, y el DASH de 26 y 8, respectivamente. La evaluación radiográfica preoperatoria arrojó un valgo promedio de 30° con un valgo contralateral de 11°. La corrección radiográfica demostró un valgo de 13°. Se obtuvo una corrección promedio de 2° menos que del otro lado. Todas las osteotomías consolidaron, y la medición de la prominencia medial fue, en promedio, un 32% mayor que en el preoperatorio. Según la escala de Oppenheim, el resultado fue excelente en 4 pacientes y bueno en uno. La satisfacción personal fue, en promedio, de 8,6. Conclusiones: La osteotomía en cuña sustractiva para tratar un codo valgo es una buena opción terapéutica, con recuperación de valores angulares comparables con el lado contralateral, y alta tasa de satisfacción de los pacientes. Como es una técnica menos compleja que las osteotomías multiplanares, es nuestra elección ante una consolidación viciosa en valgo del codo del adulto. Nivel de Evidencia: IV

Objective: To report the results of a series of adult patients with a valgus malunion of the elbow treated with a supracondylar subtractive monoplanar wedge osteotomy, materials and methods: 5 patients were included. The surgical technique consisted of a posterior paratricipital approach, with resection of a subtractive wedge and the anterior transposition of the ulnar nerve. The average follow-up was 17 months.Results: 4 patients were men and 1 woman with an average age of 27 years. The preoperative range of motion was 138°-7° and the postoperative range of motion was 138-6°. Pain according to VAS was 4 and 1, MEPS was 71 and 97, and DASH was 26 and 8, respectively. The preoperative radiological evaluation showed an average valgus of 30° with a contralateral valgus of 11º. The final valgus obtained was 13°. The final correction was, on average, 2° less than the contralateral side. All osteotomies healed and the medial prominence was on average 32%, more than before surgery. According to Oppenheim scale, the results were excellent in 4 patients and good in 1. Personal satisfaction was, on average, 8.6. Conclusions: Supracondylar subtractive wedge osteotomy is a good option for the treatment of adult cubitus valgus with a recovery of angular values similar to the contralateral side and a high satisfaction rate. As it is a simpler technique, compared to the multiplanar osteotomies, it is our treatment of choice for adult cubitus valgus. Level of Evidence: IV

Prótesis total de codo en el contexto de una seudoartrosis de olécranon. Técnica quirúrgica y reporte de tres casos / Total elbow arthroplasty in the context of a nonunion of the olecranon. Surgical technique and report of 3 cases

La indemnidad del aparato extensor es fundamental para un correcto funcionamiento de una prótesis de codo. Se ha considerado que la deficiencia del tríceps es una contraindicación relativa para la artroplastia, porque produce una contractura en flexión y un déficit de extensión activa. Estas limitaciones pueden afectar significativamente la mejora funcional que la artroplastia total de codo produce. Ante una seudoartrosis de olécranon, la colocación de una prótesis total de codo se presenta como un problema complejo que resolver. El objetivo de este artículo es describir la técnica quirúrgica para la colocación de una prótesis total de codo en el contexto de una seudoartrosis de olécranon, y comunicar tres casos. Nivel de Evidencia: IV

The integrity of the extensor apparatus is essential for the correct functioning of an elbow prosthesis. Triceps deficiency has been considered a relative contraindication for arthroplasty, because it produces a flexion contracture and an active extension deficit. These limitations can significantly affect the functional improvement that total elbow arthroplasty produces. Faced with an olec-ranon nonunion, the placement of a total elbow prosthesis is presented as a complex problem to be solved. The objective of this article is to describe the surgical technique for the placement of a total elbow prosthesis in the context of an olecranon nonunion, and to report three cases. Level of Evidence: IV

Uso de la matriz dérmica acelular para el tratamiento de zonas críticas en defectos de cobertura. Serie de casos / The role of dermal regeneration templates in severe soft tissue defects. Management of "critical zones". Case series

Introducción: El objetivo de esta serie de casos es describir los resultados y las complicaciones de pacientes con heridas gra-ves con defecto de cobertura en zonas críticas tratadas con una matriz dérmica acelular. materiales y métodos: Se realizó una revisión retrospectiva de los pacientes con déficit de cobertura en zonas críticas tratados con matriz dérmica acelular en nuestro centro. Definimos como zona crítica al déficit de cobertura que no pueda ser tratado solo con injerto de piel. Evaluamos variables preoperatorias, intraoperatorias y posoperatorias. Resultados: Los diagnósticos iniciales fueron tumor (3 pacientes), trauma agu-do (3 pacientes) y secuela de síndrome compartimental (2 pacientes). El defecto de cobertura estaba localizado en la pierna (3 casos), en la mano (2 casos), en el muslo (1 caso), en el antebrazo (1 caso) y en el pie (1 caso). La zona crítica se caracterizó por exposición tendinosa con pérdida de peritenon (5 casos), exposición ósea y pérdida de periostio (1 caso), exposición de injerto de nervio (1 caso) y exposición de osteosíntesis (1 caso). Se registraron tres complicaciones. Dos pacientes requirieron una nueva colocación de matriz y, en otro paciente, se realizó un colgajo neurocutáneo de safeno interno por fracaso de la cobertura con membrana. Conclusiones: Los sustitutos dérmicos se caracterizan por su fácil uso y versatilidad. Esta técnica otorga protección en situaciones de exposición ósea, además de proveer un plano de deslizamiento en caso de exposición tendinosa. El uso de matriz dérmica permite, además, ahorrar el empleo de colgajos. Nivel de Evidencia: IV

Introduction: The aim of this study is to report outcomes and complications in a series of patients suffering soft tissue defects in critical areas treated using an acellular dermal matrix. Materials and Method: A retrospective review of patients with soft tissue coverage deficits in critical areas treated with acellular dermal matrix in our center over a five-year period was conducted. The preoperative variables analyzed were: age, sex, comorbidities, number of previous surgeries, size and characteristics of the critical area and cause of the coverage defect. The intraoperative variables analyzed were: size of the dermal substitute used, surgical time and complications. The postoperative variables were: incorporation of the dermal substitute, time elapsed until the placement of the skin graft, and postoperative complications. Results: The initial diagnoses were tumor (3 patients), acute trauma (3 patients) and sequelae of compartment syndrome (2 patients). The soft tissue defect was located in the leg (3 cases), in the hand (2 cases), in the thigh (1 case), in the forearm (1 case) and in the foot (1 case). In 5 cases the critical zone was characterized by tendon exposure with loss of peritenon; in one case bone exposure and loss of periosteum; in one case exposure of nerve graft and in one case exposure of osteosynthesis material. Three complications were recorded. Conclusion: Dermal substitutes are characterized by their versatility. This technique can provide protection in situations of bone exposure, in addition to providing a gliding plane in case of tendon exposure. In situations of failure or impossibility of performing a biological reconstruction, dermal substitutes havea role within reconstructive options. Level of Evidence: IV

Artroplastia total de codo después de un proceso infeccioso. Cirugía en dos tiempos / Total elbow arthroplasty after an infection process. Two-stage surgery

Objetivo: Comunicar los resultados en pacientes con un proceso infeccioso del codo, tratados en 2 etapas quirúrgicas: la primera con un espaciador de cemento con antibiótico y la segunda con una artroplastia total de codo. materiales y métodos: Se descri-ben los criterios de inclusión, el diagnóstico de infección y las 2 etapas quirúrgicas. Resultados: Se incluyeron 10 pacientes (4 hombres y 6 mujeres, edad promedio 62 años). Causas iniciales: degenerativas (2 casos) y traumáticas (8 casos). Se realizaron 4 aloprótesis y 2 colgajos de dorsal ancho. Se identificaron 2 grupos: A (defectos óseos <4 cm) y B (>4 cm). El seguimiento fue de 5 años. La flexo-extensión fue de 117°/29° en el preoperatorio y 130°/29° en el posoperatorio; los puntajes de dolor fueron 6,5 y 2,5 (EAV); 40 y 80 (MEPS); y 56 y 30 (DASH), respectivamente. La fuerza de extensión fue de M5 (4 casos), M4 (2 casos), M3 (1 caso), M1 (2 casos) y M0 (1 caso). Un paciente tuvo una necrosis del colgajo que evolucionó con infección y 9 no tenían infección al final del seguimiento. Los pacientes del grupo A tenían menos cirugías previas y mejores resultados funcionales. Conclusiones: El tratamiento de un proceso infeccioso de codo mediante un espaciador de cemento con antibiótico permite controlar la infección en un alto porcentaje de los casos. La reconstrucción protésica secundaria es demandante y se asocia a complicaciones. Cabe esperar que, cuanto más grande sea el defecto óseo y mayor la cantidad de procedimientos previos, los resultados funcionales sean peores. Nivel de Evidencia: IV

Objective: to report the results of patients with an infectious elbow process, treated in 2 surgical stages: the first with an antibiotic cement spacer (ACE) and the second with a total elbow arthroplasty. Material and methods: the inclusion criteria, the diagnosis of infection and the 2 surgical stages are described. Results: 10 patients were included (7 men and 3 women), average age: 62 years old. Initial causes: degenerative in 2 cases and traumatic in 8. 4 alloprostheses and 2 latissimus dorsi flaps were performed.Follow-up was 5 years. Flexo-extension was 117°/29° in preoperative and 130°/29° in postoperative; pain according to EVA: 6.5 and 2.5; MEPS: 40 and 80; DASH 56 and 30 respectively. The extension force was M5 (4 cases), M4 (2), M3 (1), M1 (2) and M0 (1). One patient presented a necrosis of the flap that evolved with infection. In 9 of the 10 cases the patients were free of infection at the end of the follow-up. Two groups of patients were identified: Group A (bone defects less than 4 cm) and B (more than 4 cm). Group A patients had fewer previous surgeries and better functional outcomes. Conclusion: the treatment of an infectious elbow process through the placement of antibiotic cement spacer, allows a control of the infection in a high percentage of cases. Secondary prosthetic reconstruction is demanding and associated with complications. It is to be expected that the greater the bone defect and the greater the number of previous procedures, result in the worse the functional results. Level of Evidence: IV

Bipolar Disruption of the Lateral Ulnar Collateral Ligament of the Elbow: A Case Report.

CASE: The lateral ulnar collateral ligament (LUCL) is one of the primary stabilizers of the elbow. Disruption typically occurs from the humeral origin and may be because of an elbow dislocation or fracture/dislocation. If not identified and properly managed, posterolateral rotatory instability may result from LUCL insufficiency. We describe the case of a patient with bipolar LUCL disruption consisting of an avulsion fracture of the crista supinatoris and a soft-tissue avulsion from the lateral epicondyle. CONCLUSION: Bipolar disruption of the LUCL is a previously unreported injury pattern that may lead to posterolateral instability if not identified and treated.

Resultados de la osteotomía y la osteosíntesis rígida en la consolidación viciosa de falange / Outcomes of osteotomy and rigid internal fixation treatment for the correction of phalangeal malunions

Objetivo: Evaluar los resultados y las complicaciones de una serie de pacientes con consolidación viciosa de falange. Materiales y Métodos: Se realizó un estudio retrospectivo que incluyó a pacientes con consolidación viciosa de falange tratados mediante osteotomía en el sitio de la deformidad, estabilizados con osteosíntesis rígida. Se registró la movilidad de los dedos. La valoración subjetiva consistió en el puntaje DASH y una escala analógica visual para el dolor en reposo, en actividad y la función. Resultados: Doce pacientes (13 falanges) cumplieron los criterios de inclusión. El tiempo promedio entre la lesión inicial y la osteotomía fue 14 meses y el seguimiento promedio, 34 meses. La movilidad final promedio en flexo-extensión fue 89° metacarpofalángica, 74° interfalángica proximal, 54° interfalángica distal y la distancia pulpejo-palma, 3 mm. El puntaje promedio de la escala analógica visual en reposo fue 0; en actividad, 1 y la función promedio fue de 7 puntos; el puntaje DASH promedio fue 6. No hubo casos de seudoartrosis. Cinco pacientes requirieron el retiro de la placa. Los pacientes con osteotomía articular no presentaron signos de artrosis. Conclusiones: La osteotomía de falange en el sitio de la deformidad es un procedimiento eficaz con un buen resultado objetivo y subjetivo a corto plazo. La utilización de placas y tornillos conlleva una tasa más alta de complicaciones; por lo tanto, los pacientes deben ser advertidos sobre la posibilidad de una segunda intervención quirúrgica. Nivel de Evidencia: IV

Objective: To present the results and complications of a series of phalangeal malunion patients. Materials and Methods: A retrospective study was conducted on phalangeal malunion patients treated with an osteotomy at the deformity site and stabilized with rigid internal fixation. Postoperative mobility of the digit was recorded. The subjective assessment used the Disabilities of the Arm, Shoulder and Hand (DASH) score and a Visual Analogue Scale (VAS) to rate their function and pain at rest and during activity. Results: Twelve patients (13 phalanges) met the inclusion criteria. The average time between fracture and osteotomy was 14 months and the mean follow-up was 34 months. Final mobility in flexo-extension was: 89 degrees for metacarpophalangeal joint, 74 degrees proximal interphalangeal joint, 54 degrees distal interphalangeal joint. The average VAS pain score was 0 at rest and 1 during activity, and the average function was 7 points. The average DASH score was 6. There were no cases of nonunion. Five patients required plate removal. No patients with articular osteotomy presented signs of Osteoarthritis. Conclusions: Phalangeal osteotomy at the deformity site is an effective procedure with good objective and subjective short-term outcomes. Patients should be warned about the possibility of a second procedure in cases of plate fixation due to a higher complication rate associated with plate and screw fixations. Level of Evidence: IV

Ulnohumeral Bridge Plating for Massive Distal Humerus Bone Loss: A Case Report.

CASE: Massive bone loss around the elbow is a challenging clinical condition. Short periarticular osseous segments present few reconstructive options in the setting of distal humerus bone loss. We report the case of a 20-year-old man who sustained an open, intra-articular distal humerus fracture with a massive metaphyseal defect of 15 cm after a motorcycle accident. The defect was reconstructed using an induced membrane technique with temporary ulnohumeral bridge plate stabilization. CONCLUSION: Temporary ulnohumeral spanning plate fixation is a reliable method for periarticular reconstruction in the setting of massive distal humerus bone loss.

Doble compresión del nervio mediano en el brazo: Revisión crítica de la bibliografía / Double crush syndrome of the median nerve in the arm: A critical review of the literature

La compresión mecánica de un nervio periférico en dos sitios diferentes a lo largo de su trayecto se define como síndrome de doble compresión. Esta enfermedad se basa en la teoría de la mayor susceptibilidad que tendría un nervio a nivel distal cuando este también se encuentra comprimido, en forma asintomática, a nivel proximal, debido a una alteración en el flujo axonal. Si bien la descompresión del túnel carpiano es una cirugía con resultados previsibles, hay pacientes operados por síndrome del túnel carpiano que no mejoran después de una cirugía, como cabría esperar. Si se excluye de este análisis a las comorbilidades, como diabetes, casos avanzados con atrofia muscular o descompresiones insuficientes, muchos de estos fracasos terapéuticos podrían estar fundamentados por el escaso diagnóstico de un segundo sitio de compresión concomitante. No obstante, existe gran controversia alrededor del síndrome de doble compresión que involucra no solo a su existencia, sino también a su incidencia y fisiopatología. El objetivo de esta publicación es presentar una revisión bibliográfica crítica del síndrome de doble compresión centrada en el compromiso del nervio mediano tanto en la muñeca como en el codo.

Double crush syndrome is the mechanical compression of a peripheral nerve at two different sites and is based on the hypothesis that a nerve that has been compressed at a distal site is especially susceptible to also be compressed, asymptomatically, at a more proximal site. While carpal tunnel release is a surgical procedure with predictable results, some patients do not improve as expected after surgery. If comorbidities such as diabetes, advanced cases presenting with muscle atrophy or incomplete decompressions are excluded from the analysis, many of these treatment failures could be explained by a second concomitant compression site, which is often underdiagnosed. The very existence of double crush syndrome is highly questioned, but also its incidence and pathophysiology. The objective of our paper is to perform a critical review of the literature available on double crush syndrome involving mainly the median nerve in the wrist and the elbow.

Metaphyseal Core Decompression and Anterograde Fixation for Scaphoid Proximal Pole Fracture Nonunion without Avascular Necrosis.

Objective To report the consolidation rate and the results of a series of 22 patients with metaphyseal core decompression of the distal radius and an antegrade compression screw. Methods We present a prospective series of patients with scaphoid proximal pole nonunion in whom the presence of intraoperative bleeding was confirmed in both fragments. Patients with displacement, degenerative changes, fragmentation of the proximal pole, cavitation of the focus, loss of height, and necrosis, as well as those with carpal instability, were excluded. The patients were evaluated with X-rays and computed tomography to evaluate their consolidation; their mobility and fist strength were recorded and an analog visual scale (VAS) of pain at rest, pain in activity, subjective functional status, and DASH questionnaire were completed. Results Of the 23 patients, 21 accomplished union. The average follow-up was 19 months and the average final range of motion was flexion 86%, extension 85%, radial deviation 79%, ulnar deviation 84%, and grip strength 84%. The average VAS for pain at rest was 1 point, the average VAS for activity pain was 2 points, the average VAS for function was 9 points, and the average DASH score was 8. Conclusions Using this simple and reliable technique, we obtained 91% union and very good functional results. Metaphyseal core decompression of the distal radius associated with an antegrade scaphoid screw is a reasonable and effective option for the treatment of proximal pole scaphoid nonunions without avascular necrosis in carefully selected patients. Level of Evidence This is Level IV study.