Arthroscopic-Assisted Treatment of Bennett Fractures: A Potentially Advantageous Operative Procedure?

BACKGROUND: Articular fractures of the base of the first metacarpal (Bennett fractures) have been studied for years to determine the best method of reduction and fixation. This study aims to show the application of the percutaneous reduction and internal fixation technique with cannulated screws and arthroscopic assistance in articular fractures of the base of the first metacarpal. METHODS: Descriptive cohort study in a series of 30 patients, the first cohort in our country and the largest series published so far, in which 8 patients presented with type 2A fracture and 19 patients with type 2B of the Torres-Becerra classification underwent the mentioned technique under direct vision and control of the articular reduction by arthroscopy evaluating the intraoperative characteristics of the articular surface, stability of de reduction and fixation. Assessment of functional and rehabilitation results with a minimum postoperative follow-up of 6 to 12 months. RESULTS: The senior author has used this technique with consistent clinical outcomes to improve reduction and fixation of intra-articular base fractures of first metacarpal bone (Bennett), reducing the articular step-off and gapping permitting an early rehabilitation progress with satisfactory functional results. CONCLUSIONS: We can suggest that this surgical method for the treatment of Bennett fractures may offer multiple advantages: adequate debridement of the trapeziometacarpal joint, direct visualization of the articular surface during reduction, achieving greater precision in fixation with minimum morbidity, imperceptible incisions and scars, shorter surgical time, and fewer associated complications.

Angiolymphoid Hyperplasia of the External Auditory Canal; Reconstruction of a Complex Defect.

Angiolymphoid hyperplasia (AH) was first described by Wells and Whimster in 1969 as a benign vasoproliferative pathology with a varied infiltrate of eosinophils, lymphocytes, and plasmatic cells. Clinical presentation has been described in the literature as small red-bluish nodules, less than 3 cm in diameter that can bleed in 25% of the cases and be pruritic and painful in 37% and 20% of the cases, respectively. Particularly, AH can appear in the ear; nevertheless, other regions have been affected, including the scalp, lips, tongue, orbit, muscle, and bone. Most of these cases have occurred in adults with an unknown etiology; however, an inflammatory process has been associated in approximately 20% with eosinophilia. No malignancy has been reported.

Neuromonitoreo intraoperatorio en reconstrucción del plexo braquial. Serie de casos / Intraoperative electrophysiological monitoring in brachial plexus reconstructive surgery

Introducción y objetivo: Introducción y objetivo. Las lesiones del plexo braquial tienen alto impacto en la persona y su entorno, con gran pérdida funcional. Estos pacientes requieren un manejo multidisciplinario, evaluación clínica completa, que se complementa con estudios de neurofisiología, imagenología o ambos. En las últimas décadas se han logrado avances en el tratamiento quirúrgico del plexo braquial, se ha propuesto el uso del neumoronitoreo intraoperatorio (NMIO) como herramienta útil en la exploración y toma de decisiones individualizadas en su reconstrucción primaria. Nuestro objetivo es describir la experiencia del uso de diferentes modalidades de NMIO en pacientes adultos con lesiones del plexo braquial en el Hospital Universitario San José y Hospital Universitario San José Infantil de Bogotá, Colombia. Material y método: Serie de casos, revisión de los registros del Servicio de Cirugía de la Mano y Microcirugía, videos e imágenes preoperatorias tomados por el cirujano, y hallazgos descritos en el informe del NMIO de pacientes adultos con lesiones de plexo braquial operados en el periodo de estudio. Resultados: Catorce pacientes sometidos a reconstrucción de plexo braquial con NMIO durante el periodo de estudio: 11 hombres (78%) y 3 mujeres (22%); lateralidad derecha 9 (65%) e izquierda 5 (35%). Rango de edad de 19 a los 62 años (media 33 años). La principal etiología fue accidente de tránsito (motocicleta). Respecto a las modalidades usadas, en todos los pacientes se utilizó estimulación eléctrica directa y electromiografía estimulada; en 9 pacientes (64%) se midió potenciales evocados somatosensoriales y en 8 (57%) se midió potenciales evocados motores transcraneales. Conclusiones: En las lesiones del plexo braquial, los estudios electrofisiológicos en el intraoperatorio permiten clasificar el estado de los nervios afectados y definir el mejor procedimiento quirúrgico reconstructivo, sin un aumento en el tiempo operatorio. (AU)

Background and objective: Brachial plexus injuries are devastating lesions for the patient and their environment, with great functional loss. They require multidisciplinary management, complete clinical evaluation and complementary neurophysiological studies, imaging studies or both. In recent decades, the use of intraoperative neuromonitoring has been proposed as a useful tool for brachial plexus surgery, and helps to individualize decision-making in primary reconstruction of brachial plexus injuries. We describe the experience using different modalities of intraoperative neuromonitoring in patients with brachial plexus injuries in Hospital Universitario San José y Hospital Universitario San José Infantil de Bogotá, Colombia. Methods: Retrospective case series, conducted using electronic medical data from Hand Surgery and Microsurgery services, videos and preoperative images taken by the surgeon, and findings described in the report of intraoperative neurophysiological monitoring, of patients with brachial plexus injuries operated in the study period. Results: Fourteen patients underwent brachial plexus reconstruction using intraoperative neuromonitoring during the study period: 11 male (78%) and 3 female (22%); 9 (65%) right upper extremity injuries and 5 (35%) left. Age ranged from 19 to 62 years old (average of 33 years). Main etiology was motorcyclist accident. Direct electrical stimulation and stimulated electromyography were used in all patients. Somatosensory evoked potentials were measured in 9 (64%) patients, and transcranial motor evoked potentials were measured in 8 (57%) patients. Conclusions: In brachial plexus injuries, intraoperative electrophysiological studies allow better classification of nerve injuries and provide an optimal individualized surgical management, without increasing operative time. (AU)

Helical 6-Strand Cruciate Tenorrhaphy: Description of a New Technique and Biomechanical Comparative Analysis With 2 Standard Techniques.

Background: Multiple flexor tendon repair techniques have been developed over the last years. Despite all this, there is no standard technique that has proven to be superior to others, leading to great variability in the use of techniques in surgical practice. We describe a novel tendon repair technique and compare its biomechanical characteristics with 2 conventional techniques. Methods: Comparative experimental biomechanical study in ex vivo animal models. In all, 66 deep flexor tendons of the pig's front legs were taken and it's repair was performed by 1 of 3 techniques (helical 6-strand cruciate tendon repair, Adelaide tendon repair, or modified Kessler). These repairs were subjected to biomechanical study, measuring, and registering the ultimate tensile strength, load to 2-mm gap force, and stiffness. Results: The helical 6-strand cruciate tenorrhaphy compared with the Adelaide and modified Kessler techniques carries statistically significant greater ultimate tensile strength before failure (65.5, 46, and 36 N, respectively, P < .001). It also required a greater load to 2-mm gap force and is less stiff, allowing greater strain before failure. This technique does not generate significant changes in the dimensions of the tendons compared to the others, and there was no significant difference in the strength of repair between surgeons. Conclusions: The helical 6-strand cruciate tenorrhaphy is a novel technique, useful for the repair of flexor tendons in the hand that holds up the necessary forces to initiate early mobilization in the postoperative period and has better biomechanical properties than 2 standard techniques.

Red Blood Cell Transfusion and its Relationship with Pedicle Thrombosis in Microvascular Free Flaps.

BACKGROUND: Free flaps have become a highly valuable tool for complex reconstructive surgeries. The requirement of red blood cell transfusion (RBCT) during the perioperative period is common and its effect on the free flap survival is debatable. The aim of this study was to determine the relationship between perioperative RBCT and vascular pedicle thrombosis (VPT). METHODS: For this study 302 free flaps performed between January 2006 and December 2019 were retrospectively analyzed. It included their characteristics from before, during, and after the surgical procedure. The incidence of VPT and flap survival were calculated based on Kaplan Meier's method and the relationship between VPT and perioperative variables were analyzed by Cox regression models. RESULTS: The transfusion group was represented by 62 flaps (20.5%) and no transfusion by 240 flaps. The overall transfusion requirement was 20.5% and the cumulative incidence of VPT was 9.11%. A statistically significant relationship was not demonstrated between flap survival and transfusion status (HR = 1.73 IC 95%: 0.5 to 3.96; p = 0.192) (p = 0.192) independently from the number of units transfused, the preoperative diagnosis of anemia, and the type of flap used and did not establish an increased risk of VPT. CONCLUSION: This study did not demonstrate an association between RBCT during preoperative period and the risk for VPT or microvascular free flap survival rate on postoperative follow up.

Complication After Mandibular Reconstruction With Fibula Free Flap in a Patient With Hemifacial Microsomia.

ABSTRACT: Hemifacial microsomia is the second most frequent pathology in craniofacial malformations. Clinical findings are broad, mainly affecting the mandible. Several classifications of mandibular compromise exist that guide the best treatment option in each patient. The authors present a case of an unusual complication following fibular free flap mandibular reconstruction in a patient with hemifacial microsomia prada type IV, who presented with ankylosis at the skull base and simultaneous fibula pseudoarthrosis at the union with the residual mandible. These dual findings allowed the patient to have a functional mouth aperture, which give us time to let him grow and wait for final management. Treatment options and follow up are discussed, knowing that there is no literature to support any protocol with this patient, so we present his evolution.

Manejo inicial de las lesiones de punta de dedo: guía de tratamiento basado en la experiencia en el Hospital San José / Initial management of fingertip injuries: a treatment guide based on experience in the San Jose hospital (involving 91 cases)

Antecedentes. Las lesiones de punta de dedo son las más frecuentes del miembro superior y constituyen una causa importante de atención en urgencias en los hospitales de Colombia, pues generan incapacidad laboral y funcional por amputaciones de la falange distal. El tratamiento de este tipo de lesiones tiene como objetivo restablecer la función de la punta de dedo, mejorando la calidad de vida del paciente. Objetivo. Plantear un protocolo de manejo aplicable en este tipo de lesiones. Materiales y métodos. Se presentan 91 casos de pacientes con lesión en punta de dedo como diagnóstico de ingreso. Se determinó el mecanismo de lesión, sexo, dominancia manual, si hubo lesión del lecho ungueal y si se presentaron fracturas asociadas. En los casos de amputación se intentó aplicar la clasificación de Allen, pero no fue útil, ya que la mayoría de lesiones fueron producidas por objetos cortocontundentes que generaron lesiones irregulares en tejidos blandos y pérdida de la uña. Por ello, se estableció una clasificación que permite ejecutar las diferentes alternativas de manejo. Resultados. Se evidenció una mayor incidencia en hombres. La mano más afectada fue la derecha; en la mayoría de los casos era la mano dominante. Asimismo, los dedos más afectados fueron el segundo y el tercero. El mecanismo de lesión más frecuentemente reportado fue el trauma por aplastamiento con objeto cortocontundente. Conclusión. La clasificación de Allen no fue útil en ningún caso, por lo cual se aplicó la clasificación y protocolo de manejo sugerido por los autores.

Background. Fingertip injuries are the commonest upper limb injury and represent a major cause for emergency care in Colombia, leading to disability regarding employment and function due to amputation of the distal phalanx. Treatment of these injuries aims to restore fingertip function, thereby improving patients' quality of life. Objective. Proposing an effective management protocol for this type of injury. Materials and methods. This document presents 91 cases of patients having an admission diagnosis of fingertip injury. The research determined injury mechanism, gender, handedness and whether there was an injury or nail bed and associated fractures. An initial attempt was made at determining both clinical and surgical treatment according to Allen's classification; however, most injuries were unrelated and thus treatment options were described instead. Cutting tools caused most injuries, resulting in irregular lesions of soft tissue and nail loss. Repositioning the nail bed as well as a nail equivalency was paramount; this served as a splint in cases of associated fracture and a guide for the forthcoming tissue. Results. There was higher incidence in men than in women; the right hand (in most cases the dominant hand) was affected more and the second and third fingers were the most affected. The most frequently reported mechanism of injury was trauma resulting from being crushed with a short, blunt object. Conclusion. Allen's classification was not useful in any of the cases; the classification and management protocol suggested by the authors was thus followed.