Modified extensile calcaneal exposure is safe.

OBJECTIVE: The objective of this study was to evaluate the effect of open reduction and internal fixation for displaced intra-articular calcaneal fractures through a modified tarsal sinus incision. METHODS: A retrospective review over 3 years of the clinical data of patients with intra-articular calcaneal fractures treated with open reduction and internal fixation through lateral hook curvy incisions. The efficacy of the 25 lateral hook curvy incisions was analyzed. RESULTS: According to the AOFAS hindfoot function scoring criteria, there were 20 excellent (80%), 2 good (8%), 2 fair (8%), and 1 poor patient outcome. The average pre-operative Bohler's angle was 6.8 ± 8.9°, and the average angle at follow-up was 33.6 ± 5.7°. The average pre-operative Gissane angle was 89.2 ± 20.0°, and the average angle at follow-up was 115.5 ± 5.5°. CONCLUSIONS: A lateral hook curvy incision can expose the posterior articular surface of the calcaneus and the calcaneocuboid joint, reduce stripping and pulling of the soft tissue, and avoid calcaneus valgus caused by the pulling of the peroneus tendon.

OBJETIVO: Evaluar el efecto de la reducción abierta y la fijación interna de las fracturas de calcáneo intraarticulares desplazadas a través de una incisión del seno tarsiano modificada. MÉTODO: Revisión retrospectiva de 3 años de los datos clínicos de pacientes con fracturas intraarticulares de calcáneo tratadas con reducción abierta y fijación interna a través de incisiones laterales curvadas en gancho. Se analizó la eficacia de la incisión curvada con 25 ganchos laterales. RESULTADOS: Según los criterios de puntuación de la función del retropié de la AOFAS, hubo 20 resultados excelentes (80%), 2 buenos (8%), 2 regulares (8%) y 1 pobre. El ángulo de Bohler preoperatorio promedio fue de 6.8 ± 8.9° y el ángulo promedio en el seguimiento fue de 33.6 ± 5.7°. El ángulo de Gissane preoperatorio promedio fue de 89.2 ± 20.0° y el ángulo promedio en el seguimiento fue de 115.5 ± 5.5°. CONCLUSIONES: Una incisión curvada en gancho lateral puede exponer la superficie articular posterior del calcáneo y la articulación calcaneocuboidea, reducir el desprendimiento y la tracción del tejido blando, y evitar el calcáneo valgo causado por tracción del tendón peroneo.

Metaphyseal Fracture Displacement is Predictive of Intra-articular Diastasis in Adolescent Triplane Ankle Fractures.

BACKGROUND: Triplane fractures are rare enough that large homogeneous series to support management decisions are lacking. During initial evaluation, the addition of computed tomography (CT) to conventional X-rays (XR) does not always alter the patient's clinical course. Therefore, routine use of CT is controversial. This study aims to: (1) clarify quantitative relationships between articular displacement measured on XR versus CT and (2) identify whether metaphyseal displacement on the lateral XR predicts clinically relevant articular displacement on a CT scan. METHODS: A 10-year retrospective review of consecutive triplane fractures was performed at a level 1 pediatric trauma center. Maximum articular and metaphyseal displacement were recorded from XR and CT. Quantitative relationships between XR and CT measurements were compared among imaging modalities and radiographically operative versus nonoperative fractures. RESULTS: Eighty-seven patients met the inclusion criteria. XR underestimated articular displacement by 229% in the sagittal plane (1 mm on XR vs 3.3 mm on CT; P < 0.05) and 17% in the coronal plane (2.3 mm on XR vs 2.7 mm on CT; P < 0.05). XR underestimated articular step-off by 184% in the coronal plane and 177% in the sagittal plane ( P < 0.05). CT measurements more often differentiated patients who did or did not undergo surgery at our institution. Metaphyseal displacement was significantly higher in patients with traditionally operative articular displacement (≥2.5 mm on CT) versus those with articular displacement below traditionally operative thresholds (2.4 vs 0.9 mm, P = 0.001). Sixty patients had metaphyseal displacement >1 mm on the lateral XR, of whom 56 had surgical-magnitude articular displacement (≥2.5 mm) on CT (positive predictive value = 94%). CONCLUSIONS: Conventional radiographs underestimate the true articular displacement of triplane fractures. Surgical-magnitude articular step-off is rare, and the largest articular gap is usually visualized on the axial CT image. Metaphyseal displacement >1 mm, which is easily measured on a lateral XR, is strongly predictive of clinically relevant articular displacement on CT. This radiographic finding should prompt advanced imaging before proceeding with nonoperative management. LEVEL OF EVIDENCE: Level III.

Arthroscopic Assisted Treatment of Combined Trapezium and Bennett Fracture-Dislocation.

Trapezium fractures are unusual; however, they represent the third most frequent fracture of the carpal bones. As they usually follow a high-energy trauma, they are associated with distal radius, Bennett, or Rolando fractures in 80% of cases. Traditional treatment options include, closed reduction and percutaneous pinning, or open reduction and internal fixation. To minimize the additional surgical trauma, an arthroscopic technique has been developed for safe, minimally invasive management of complex injuries of the first carpo-metacarpal joint. Intra-articular dislocated fracture fragments are reduced under direct visualization and fixed through small incisions. Limiting additional surgical damage on the carpo-metacarpal joint ligaments, capsule, and other soft tissues around the fracture preserves the blood supply to fracture fragments and also the proprioceptive system, which is key for the dynamic stability of such a hypermobile joint. This report confirms that the procedure is feasible, and a complete functional recovery can be expected with reduced postoperative rehabilitation.

Distal articular involvement in tibial shaft fractures: an evaluation of 125 consecutive cases.

PURPOSE: To report the incidence and morphology of ipsilateral distal articular involvement (DAI) in a consecutive series of tibial shaft fractures. METHOD: A retrospective review was performed on 115 patients who underwent intramedullary nailing for tibia shaft fractures. Ankle evaluations included preoperative radiographs and computed tomography (CT) scans in all patients. RESULTS: Thirty-two patients (27.8%) in our series presented with tibial shaft fractures associated with DAI. Tibial spiral fractures (42A1) were significantly related to DAI (RR: 1788). In 28 (87.5%; 28/32) articular fractures, posterior malleolus fractures (PMF) were present; 22 were isolated, and six (18.8%) occurred in combination with medial malleolus or anterolateral fractures. The remaining (12.5%; 4/32) were isolated medial malleolus fractures. Ten (31.2%; 10/32) articular fractures were occult on the radiographs and only detected on CT scan. CONCLUSION: DAI is common in tibial shaft fractures. CT evaluation is mandatory due to the high number of occult fractures. Although isolated PMF is the most frequent pattern of DAI involvement, 31.3% of the cases exhibited different patterns.

Quality and Variability of Physical Therapy Protocols Varies Widely for Osteochondral Allograft Transplantation of the Femoral Condyles.

OBJECTIVE: To assess the quality and variability of osteochondral allograft (OCA) transplantation rehabilitation protocols associated with academic orthopedic programs in the United States. DESIGN: A systematic review was performed to collect all publicly available online rehabilitation protocols for femoral condyle OCA transplant from US academic orthopedic programs participating in the Electronic Residency Application Service. These protocols were evaluated for inclusion of different rehabilitation components as well as timing of suggested initiation of these activities. RESULTS: A total of 22 protocols were included. Although 91% of protocols recommended bracing, wide variation exists in total time of utilization. Median time for full weight bearing (FWB) was 7 weeks (range 4-8). On average, each protocol mentioned 9 (range 2-18) different strengthening exercises. The median time suggested to return to high-impact activities was 9 months (range 8-12). Only 3 protocols (14%) offered criteria of advancement for each phase as well as criteria for discharge. CONCLUSION: Very few of the academic orthopedic programs have published online rehabilitation protocols following OCA transplantation. Although there is wide variation between the protocols, it allowed the identification of trends or patterns that are more common. However, there is need for more standardized evidence-based rehabilitation protocols which are easy to understand and follow by patients.

Células-tronco mesenquimais para tratamento de displasia coxofemoral em cão / Mesenchymal stem cells for treatment of coxofemoral dysplasia in a dog

Background: Coxofemoral dysplasia (CFD) is the abnormal development of the hip joint, mostly affecting large breeds, and is characterized by subluxation or complete luxation of the femoral head. Among the conservative therapeutic options, cell therapies with stem cells for CFD provides potential by the countless possibilities of therapeutic application, especially those related to the chronic and/or degenerative diseases treatment, which could be a key point for the bone and joint repair. The objective was to report a bilateral CFD case in a dog, treated with intra-articular application of mesenchymal stem cells (MSC), with 0, 30, 60 and 90 days, and further evaluations. Case: A 2-year-old male Akita dog was referred to the Veterinary Hospital Harmonia (HVH) located in the city of Recife, Pernambuco, presenting clinical signs of hip pain, lameness and pelvic limbs hopping. By orthopedic examination, pain was observed at the cranial and caudal extension of the pelvic limb, and at flexion, abduction and adduction of the limb, as well as moderate muscle atrophy and presence of joint crackling. By coxofemoral radiography performed in ventrodorsal projection, it were detected bilateral femoral head subluxation, thickening of the femoral neck and the presence of intraarticular osteophytes. These findings are compatible with the degeneration caused by the presence of CFD. Laboratory tests performed such as hemogram and biochemical had no changes. Thus, the patient had intra-articular application of allogeneic MSC, derived from adipose tissue, obtained by private company. For stem cell applications, arthrocentesis of the hip joints was performed one at a time, using a 5 mL syringe and 16G needle for aspiration of 2 mL synovial fluid, for discard and application of stem cells. After aspiration, the syringe containing the MSC were fitted to the 16G needle for the implant. After the...

Missed Tillaux Fracture and Syndesmosis Injury in Adult: Arthroscopic Assisted Reduction and Fixation / Fratura de Tillaux não percebida e lesão por sindesmose em adultos: Redução e fixação artroscópica assistida

Abstract Tillaux fractures are fractures of the lateral margin of the distal tibia, usually reported in children between 12 and 14 years old. As intraarticular fractures, they require anatomic reduction and fixation to avoid posttraumatic complications. Since the injury mechanism is external rotation of the foot on the leg, these injuries are commonly associated with other fractures or ligamentous lesions. Currently, arthroscopy is being increasingly used to assist and improve surgical treatment of ankle fractures. The authors describe a 12-month follow-up of a rare case of a missed Tillaux fracture associated with syndesmosis injury in a 76-year-old polytrauma patient, successfully treated by arthroscopically-assisted reduction and internal fixation.

Resumo As fraturas de Tillaux são fraturas da margem lateral da tíbia distal, geralmente relatadas em crianças entre 12 e 14 anos. Como fraturas intra-articulares, requerem redução e fixação anatômica para evitar complicações pós-traumáticas. Como o mecanismo de lesão é a rotação externa do pé na perna, essas lesões são comumente associadas a outras fraturas ou lesões ligamentares. Atualmente, a artroscopia está sendo cada vez mais utilizada para auxiliar e melhorar o tratamento cirúrgico das fraturas do tornozelo. Os autores descrevem um acompanhamento de 12 meses de um caso raro de uma fratura não percebida de Tillaux associada a lesão por sindesmose em um paciente de politrauma com 76 anos de idade, tratado com sucesso por redução e fixação interna assistida por artroscopia.

[Intra-articular fracture of the calcaneus associated with injury to lateral collateral ligaments of the ankle]. / Fractura intraarticular de calcáneo asociada a lesión de ligamentos colaterales laterales del tobillo.

Calcaneal fractures are the most frequent of the tarsus (3.5% of all fractures). Young adults are mainly affected, being more frequent in men (5.9:1). On the other hand, ligament injuries associated with fracture of the calcaneus are very infrequent. We describe a case of a 39 year old patient who suffered ankle trauma. He presented instability in plantar flexion and inversion. A fracture of the calcaneus was diagnosed. During surgery, a complete lesion of the lateral ligament complex was found. The reduction and osteosynthesis associated with ligament reconstruction was performed. We consider important to confirm the stability of the ankle after a calcaneus fracture. Lack of diagnosis in this type of injuries can evolve into chronic instability.

Las fracturas de calcáneo son las más frecuentes del tarso (3.5% de todas las fracturas). Afectan a adultos jóvenes, siendo más frecuentes en hombres (5.9:1). Por otro lado, las lesiones ligamentarias asociadas a fractura de calcáneo no son muy frecuentes. Presentamos un caso de un paciente de 39 años que sufrió entorsis de tobillo. Mostraba inestabilidad en flexión plantar e inversión. Radiografías mostraron una fractura de calcáneo. Durante la cirugía se evidenció una lesión completa del complejo ligamentario lateral. Se realizó la reducción y osteosíntesis asociada a la reconstrucción ligamentaria. Ante fracturas de calcáneo es importante corroborar la estabilidad del tobillo. La falta de diagnóstico en este tipo de lesiones puede generar inestabilidades crónicas.

Treatment of pelvic fractures in cats with patellar fracture and dental anomaly syndrome.

OBJECTIVES: The aim of this study was to describe the treatment and outcome of acetabular and other pelvic fractures in cats with patellar fracture and dental anomaly syndrome (PADS) and to provide advice on how to manage these cases in practice. METHODS: Data were collated on cats with PADS that were reported to have sustained pelvic fractures or had fractures or fissures of the pelvis identified on submitted radiographs. The details of the fractures were recorded, in addition to any treatment and outcome information. RESULTS: Of the 215 cases reported with PADS, 58 cats (27%) were found to have pelvic fractures, none of which were known to have resulted from significant trauma. There were 101 fractures in total and of these 15 were treated with surgery, including 10 acetabular fractures, two ilial, two pubic and one ischial fracture. Screw loosening and loss of fracture reduction was seen in four of the surgically treated fractures (two pubic fractures, one ilial and one acetabular fracture). Fourteen cats were euthanased as a direct result of a fracture occurring. While most pelvic fractures healed uneventfully, some cats remained intermittently lame, but it was not always possible to determine the cause of the lameness from the information available and because all cats had concurrent patellar fractures. CONCLUSIONS AND RELEVANCE: Many of the pelvic fractures healed with conservative management. Fractures involving articular surfaces such as acetabular fractures may benefit from surgical stabilisation as surgery may offer the benefits of articular fracture repair with improved joint congruency and a faster return to normal activity.

Fracturas intraarticulares de radio distal: reducción bajo fluoroscopía versus asistencia artroscópica. Revisión sistemática / Distal radius intraarticular fractures: fluoroscopy reduction versus arthroscopic assistance. Systematic review

Resumen: Introducción: Las fracturas intraarticulares de radio distal son un desafío terapéutico para el cirujano ortopedista. Hay estudios que avalan el uso de la fluoroscopía y otros promueven la artroscopia. Con este trabajo intentamos resumir la evidencia, para determinar si la asistencia artroscópica aporta beneficios adicionales para evitar incongruencias articulares en comparación con los resultados obtenidos bajo asistencia fluoroscópica. Material y métodos: Búsqueda sistemática de estudios prospectivos, retrospectivos, de cohortes, seguimiento, ensayos clínicos en PubMed, MEDLINE, Scopus, Scielo, Embase, Google Scholar y otras fuentes nacionales, incluyendo como palabras clave los términos: intraarticular distal radius fracture, wrist arthroscopy, arthroscopy, fluoroscopy. Los valores medios y desvíos estándar para cada característica, obtenidos de los trabajos seleccionados fueron analizados usando estadística descriptiva y gráficos ilustrativos. Resultados: Fueron evaluados 463 pacientes (256 mujeres y 207 hombres), con una edad promedio de 48.29 años y rango de 39 a 64 años. Los dos tratamientos (A y F) fueron homogéneos en cuanto a la edad de los pacientes que reportan (p = 0.5820) y el tiempo de seguimiento promedio (p = 0.9597). Sólo la desviación cubital y el DASH, para las cuales el grupo de artroscopía tuvo mejor desempeño, en las variables restantes las diferencias no fueron significativas. Conclusión: La evidencia disponible hasta la fecha es controvertida y no permite hacer recomendaciones a favor o en contra de estas intervenciones, encontrando otros factores que podrían influir en la toma de decisiones.

Abstract: Introduction: Intraarticular distal radius fractures are a therapeutic challenge for the orthopedist surgeon there are studies that support the use of fluoroscopy, and others promote arthroscopy, with this work we try to summarize the evidence, to determine whether arthroscopic assistance provides additional benefits to avoid joint incongruities compared to results obtained under fluoroscopic assistance. Material and methods: Systematic search for prospective, retrospective, cohort, follow-up, clinical trials on PubMed, MEDLINE, Scopus, Scielo, Embase, Google Scholar and other national sources, including as keywords the terms: «intra-articular distal radius fracture¼, «wrist arthroscopy¼, «arthroscopy¼, «fluoroscopy¼. The average values and standard offsets for each characteristic, obtained from the selected works, were analyzed using descriptive statistics and illustrative graphs. Results: 463 patients (256 women and 207 men) were evaluated, with an average age of 48.29 years and range from 39 to 64 years. The two treatments (A and F) were homogeneous in terms of the age of the patients reporting (p = 0.5820) and the average follow-up time (p = 0.9597). Only the ulnar deviation and DASH score, for which the arthroscopy group performed best, in the remaining variables the differences were not significant. Conclusion: The evidence available to date is conflicting, and does not allow recommendations to be made for or against these interventions, finding other factors that could influence decision-making.

Intra-articular Transcalcaneal Fracture-Dislocation Associated With Ipsilateral Transtalar Fracture: A Report of a Rare Combination.

The association of ipsilateral talar and calcaneal fractures is an uncommon combination and is typically the result of a high-energy trauma. It is often associated with comminution, marked fracture displacement, and soft-tissue compromise. Obtaining satisfactory clinical and radiographic results is very challenging. Residual deformities, multiple procedures, and limitations are usually the norm. Therefore, studies have suggested that primary arthrodesis may represent the best option of surgical treatment. In this study, we report a case of a 30-year-old male patient with a rare combination of a highly comminuted transcalcaneal fracture-dislocation associated with a talar neck fracture successfully treated with open reduction and internal fixation (ORIF) with an 18-month follow-up. This case demonstrates that even when there are associated fractures of the talus and calcaneus with severe bone loss, ORIF may provide satisfactory outcomes in the short-term postoperative period.Levels of Evidence: Level V: Case report.

Radiographic Analysis of Intra-articular Fractures of the Calcaneus in patients undergoing Minimally Invasive Surgical Treatment in a Tertiary Hospital / Análise radiográfica de fraturas intra-articulares de calcâneo em pacientes submetidos a tratamento cirúrgico minimamente invasivo em hospital terciário

Abstract Objective This paper aims to evaluate patients with articular calcaneal fractures treated with a minimally invasive surgical technique between January 2015 and August 2016, with emphasis on radiographic results. Methods Retrospective study of 49 patients with 64 displaced calcaneal fractures treated with open reduction by minimal lateral access to the subtalar joint and minimal fixation. Pre- and postoperative radiographic studies were performed to measure the angles of Böhler and Gissane. Results The average angle of Böhler before surgery was 2.5º, increasing to an average value of 25.3º after the minimally invasive surgical treatment. The average angle of Gissane before surgery was 136.3º, decreasing to an average value of 114.3º after the procedure. Conclusion The minimally invasive surgical technique improves the radiographic parameters of intra-articular calcaneal fractures, with appropriate anatomical restoration of anatomical shape.

Resumo Objetivo Avaliar pacientes com fraturas intra-articulares de calcâneo tratados entre janeiro de 2015 e agosto de 2016 com técnica cirúrgica minimamente invasiva, com ênfase no resultado radiológico. Métodos Estudo retrospectivo de 49 pacientes com 64 fraturas intra-articulares de calcâneo, submetidos a tratamento cirúrgico minimamente invasivo. As lesões foram tratadas com redução aberta por acesso mínimo lateral à articulação subtalar e fixação mínima. Foi realizado estudo radiográfico no pré- e no pós-operatório para aferição dos ângulos de Böhler e de Gissane. Resultados O ângulo de Böhler médio dos casos antes da cirurgia foi de 2,5º, apresentando aumento da média dos ângulos para 25,3º após o tratamento cirúrgico minimamente invasivo. O ângulo de Gissane médio dos casos antes da cirurgia foi de 136,3º, apresentando diminuição da média dos ângulos para 114,3º na análise após a cirurgia. Conclusão A técnica cirúrgica minimamente invasiva permite melhora dos parâmetros radiográficos (ângulos de Böhler e Gissane) nas fraturas intra-articulares de calcâneo, com sua adequada recuperação da forma anatômica.

Radiological Evaluation of Juvenile osteochondral Conditions in Brazilian Warmblood Horse.

The term juvenile osteochondral condition (JOCC) has been used to identify developmental changes in the growth plates. The condition is characterized by a set of changes with similar pathogenesis that affect the immature skeleton and joints of growing foals. The aim of the current study is to investigate the prevalence and degree of severity of osteochondral changes in Brazilian warmblood (BW) foals in two farms in the south of Brazil. Radiological evaluation was applied to the metacarpophalangeal (MCP), carpal (C), metatarsophalangeal (MTP), tarsal (T), and femorotibiopatellar (FTP) joints of 90 foals (47 females and 43 males) in the age group 16-36 months. The evaluation was made before the animals started their athlete performance. Changes were classified as a degree of severity 0 to 4. Changes were diagnosed in 56 foals (58%) that had 105 affected joints. Thirty-three (59%) out of the 56 animals had changes in more than one joint; 57% (19/33) of them had bilateral changes. MTP and MCP were the joints with the most severe changes, respectively (severity 2 and 3), followed by FTP, T, and C. Osteochondral fragments (59%), tarsal arthropathies (48%), irregularities and radiolucency in the FTP joint (7%), and subchondral cystic lesion in the FTP joint (1%), were the most observed changes. BW foals recorded the high prevalence of osteochondral alterations; although MTP and T were the most affected joints, MTP and MCP presented the most severe changes. The present study confirmed significant JOCC prevalence in BW. Further studies should be carried out in different properties.

[Distal radius intraarticular fractures: fluoroscopy reduction versus arthroscopic assistance. Systematic review]. / Fracturas intraarticulares de radio distal: reducción bajo fluoroscopía versus asistencia artroscópica. Revisión sistemática.

INTRODUCTION: Intraarticular distal radius fractures are a therapeutic challenge for the orthopedist surgeon there are studies that support the use of fluoroscopy, and others promote arthroscopy, with this work we try to summarize the evidence, to determine whether arthroscopic assistance provides additional benefits to avoid joint incongruities compared to results obtained under fluoroscopic assistance. MATERIAL AND METHODS: Systematic search for prospective, retrospective, cohort, follow-up, clinical trials on PubMed, MEDLINE, Scopus, Scielo, Embase, Google Scholar and other national sources, including as keywords the terms: "intra-articular distal radius fracture", "wrist arthroscopy", "arthroscopy", "fluoroscopy". The average values and standard offsets for each characteristic, obtained from the selected works, were analyzed using descriptive statistics and illustrative graphs. RESULTS: 463 patients (256 women and 207 men) were evaluated, with an average age of 48.29 years and range from 39 to 64 years. The two treatments (A and F) were homogeneous in terms of the age of the patients reporting (p = 0.5820) and the average follow-up time (p = 0.9597). Only the ulnar deviation and DASH score, for which the arthroscopy group performed best, in the remaining variables the differences were not significant. CONCLUSION: The evidence available to date is conflicting, and does not allow recommendations to be made for or against these interventions, finding other factors that could influence decision-making.

INTRODUCCIÓN: Las fracturas intraarticulares de radio distal son un desafío terapéutico para el cirujano ortopedista. Hay estudios que avalan el uso de la fluoroscopía y otros promueven la artroscopia. Con este trabajo intentamos resumir la evidencia, para determinar si la asistencia artroscópica aporta beneficios adicionales para evitar incongruencias articulares en comparación con los resultados obtenidos bajo asistencia fluoroscópica. MATERIAL Y MÉTODOS: Búsqueda sistemática de estudios prospectivos, retrospectivos, de cohortes, seguimiento, ensayos clínicos en PubMed, MEDLINE, Scopus, Scielo, Embase, Google Scholar y otras fuentes nacionales, incluyendo como palabras clave los términos. RESULTADOS: intraarticular distal radius fracture, wrist arthroscopy, arthroscopy, fluoroscopy. Los valores medios y desvíos estándar para cada característica, obtenidos de los trabajos seleccionados fueron analizados usando estadística descriptiva y gráficos ilustrativos. Fueron evaluados 463 pacientes (256 mujeres y 207 hombres), con una edad promedio de 48.29 años y rango de 39 a 64 años. Los dos tratamientos (A y F) fueron homogéneos en cuanto a la edad de los pacientes que reportan (p = 0.5820) y el tiempo de seguimiento promedio (p = 0.9597). Sólo la desviación cubital y el DASH, para las cuales el grupo de artroscopía tuvo mejor desempeño, en las variables restantes las diferencias no fueron significativas. CONCLUSIÓN: La evidencia disponible hasta la fecha es controvertida y no permite hacer recomendaciones a favor o en contra de estas intervenciones, encontrando otros factores que podrían influir en la toma de decisiones.

Fracturas inestables de radio distal intra y extraarticulares: análisis comparativo de resultados a mediano plazo del tratamiento quirúrgico con placas volares / Intra- and extra-articular distal radius unstable fractures: comparative analysis of the medium-term results of volar plate surgical treatment

Introducción Comparar los resultados radiológicos y recuperación postoperatoria de la función de la muñeca a mediano plazo en las fracturas inestables extra e intra articulares de radio distal, después de la reducción abierta con abordaje palmar y osteosíntesis con placa volar. Materiales y métodos Estudio de casos y controles en 52 pacientes divididos en los grupos de fracturas extra o intra articulares de acuerdo a la clasificación AO. Las radiografías preoperatorias y postoperatorias fueron evaluadas para determinar la restauración anatómica de la longitud radial, ángulo radial e inclinación palmar del radio. Se evaluó además el resultado, seis meses después de la cirugía, del rango activo de movimiento y la fuerza de agarre, a la vez, que se hizo evaluación del puntaje de QuickDASH. Resultados La edad promedio fue 53,7±16,8 (DE) años; el 63% mujeres. Las fracturas extra articulares fueron más frecuentes en las mujeres, pero las intra articulares presentaron distribución similar por sexo (p=0.023). La fuerza de agarre de la mano operada fue 73.7% y 67.5% de la mano opuesta en las fracturas extra e intra articulares, respectivamente. El puntaje QuickDASH promedio fue 2.36 (DE 2.01) y 4.16 (DE 3.82) en fracturas extra e intra articulares respectivamente (p=0.111). Discusión Para fracturas de radio distal la reducción abierta con abordaje palmar y estabilización con placa volar ofrece resultados funcionales satisfactorios tanto para las fracturas extra articulares como para las intra articulares, con una leve, aunque esperada, ventaja en las primeras debido a su menor complejidad.

Background To examine and compare the radiological results and postoperative recovery of the medium-term wrist function in unstable extra- and intra-articular fractures of distal radius, after open reduction with a palmar approach and osteosynthesis with a volar plate. Materials and methods Retrospective case control study in 52 patients, divided into groups according to the Orthopaedic Association (AO) classification as extra- or intra-articular fractures. The pre-operative and post-operative radiographs were evaluated to determine the anatomical restoration of the radial length, radial angle, and palmar inclination of the radius. The medium-term results of the active range of motion and the grip strength, as well as the Quick DASH score, were evaluated six months after surgery. Results The mean age was 53.7±16.8 (SD) years and 63% were women. Extra-articular fractures were more frequent in women, but intra-articular fractures had a similar distribution by gender (P=.023). The grip strength of the operated hand was 73.7% and 67.5% of the opposite hand in the extra- and intra-articular fractures, respectively. The mean Quick DASH score was 2.36 (SD 2.01) and 4.16 (SD 3.82) in extra- and intra-articular fractures, respectively (P=.111). Discussion For unstable distal radius fractures, open reduction with palmar approach and volar plate stabilisation offers satisfactory functional results for both extra-articular and intra-articular fractures, with a slight, but expected, advantage in the former due to its lesser complexity.

Böhler's Angle-Comparison Between the pre- and Postoperative in Displaced Intra-Articular Calcaneal Fractures / Ângulo de Böhler-comparação entre o pré e pós-operatório nas fraturas intra-articulares desviadas do calcanhar

Abstract Objective To compare pre- and postoperative variation of radiographicmeasurements of the Böhler angle (BA) in fractures with two types of deviations: severe and moderate. Methods Pre- and postoperative BAs in 31 calcaneal fracture radiographs were retrospectively analyzed. A total of 4 patients were female (6.5%) and 26 were male (83.9%), with age ranging from 23 to 72 years old, and a mean age of 44.5 years old. Results The results show that the postoperative BA was significantly larger than the preoperative BA (p = 0.000). At the intraevaluator and overall assessments, the postoperative BA was, on average, 10.6° higher than the preoperative measure. The postoperative angle was, on average, 108% higher than the preoperative angle. In the global assessment, the agreement between evaluatorswas excellent, bothregarding the estimated point value (0.98) and the intraclass correlation (ICC) confidence interval (CI). Conclusion In the global analysis, the postoperative BAs were, on average, significantly higher than the preoperativemeasurements. The farther from the normal range (20° to 40°) the preoperative angle is, the greater the difference after the surgery. When the preoperative angle was normal, the postoperative angle was, on average, 1.28 times the preoperative measurement. If the preoperative BA was abnormal, the postoperative angle was, on average, 17.3 times the preoperativemeasurement. It was demonstrated that more severe fractures present better anatomic results when compared with moderate fractures. The present study also confirms a good interobserver correlation for the BA.

Resumo Objetivo Comparar a variação dos resultados dasmedidas radiográficas do ângulo de Böhler, no pré e pós-operatório, em fraturas com dois tipos de desvio: graves e moderadas. Métodos: O ângulo de Böhler foi analisado retrospectivamente em 31 radiografias pré e pós-operatórias de fraturas do calcâneo. Quatro pacientes eram do sexo feminino (6,5%) e 26 do masculino (83,9%), entre 23 e 72 anos, média de 44,5. Resultados As medidas pré e pós-operatória demonstraram que o ângulo de Böhler após a cirurgia foi significativamente maior do que o ângulo de Böhler pré-operatório (p-valor = 0,000). Nas análises intraobservador e global, o ângulo de Böhler pósoperatório foi, em média, 10,6 graus maior do que no pré-operatório. O ângulo pósoperatório foi, em média, 108% maior do que o ângulo pré-operatório. No global, a concordância entre os avaliadores é excelente, tanto em relação ao valor pontual estimado (0,98) quanto em relação ao intervalo de confiança do ICC. Conclusão Na análise global, verificou-se que asmedidas do ângulo de Böhler no pósoperatório são, em média, significativamente maiores do que as do ângulo préoperatório. Quanto mais distante da faixa de normalidade (20 a 40 graus) estiver o ângulo pré-operatório, maior a diferença no ângulo após a cirurgia. Quando o ângulo pré-operatório está na faixa de normalidade, o ângulo pós-operatório será, em média, 1,28 vez o ângulo pré-operatório; se o ângulo de Böhler pré-operatório estiver fora da

Irreducible Acute Patellar Dislocation due to a New Anatomical Variant - the Notched Patella / Dislocação patelar aguda irredutível devido a uma nova variante anatômica - a patela entalhada

Abstract Irreducible patella dislocations are rare and are usually associated with complex mechanisms. Theauthors report the clinical case of an irreducible lateral patellardislocationdueto an anatomical variant. The authors assisted a 16-year-old patient who presented with a lateral patella dislocation that was impossible to reduceby closedmanipulation, even under general anesthesia. During the imaging study, the computed tomography (CT) exam showed a notch in the medial facet of the patella, impacted in the lateral condyle, which prevented the reduction. This anatomical variant was later confirmed during surgery. In a bilateral follow-up CT, this variant was also present in the contralateral, normal knee, excluding traumatic reshaping as the reason for this patellar notch. The authors used a medial parapatellar approach for open reduction of the dislocation and to repair themedial retinaculum. According to Wiberg, there are three different patella types. The authors describe a variation of type III patellawith a notch inthemedial border that is not included in the previous classification. They emphasize the importance of a CTstudy in the presence of an irreducible dislocation and the recognition of this anatomical variant of the patella, as further aggressive maneuvers have proven to be unsuccessful. Open reduction appears to be the best option in this scenario.

Resumo As luxações irredutíveis da patela são raras e são geralmente associadas a mecanismos complexos. Os autores relatam o caso clínico de uma luxação patelar lateral irredutível devido a uma variante anatômica. Os autores atenderam um paciente de 16 anos que apresentou uma luxação lateral da patela de redução impossível por manipulação fechada, mesmo sob anestesia geral. Durante o estudo de imagem, a tomografia computadorizada (TC) mostrou um entalhe na faceta medial da patela, impactada no côndilo lateral, o que impediu a redução. Esta variante anatômica foi posteriormente confirmada durante a cirurgia. Em uma TC bilateral de acompanhamento, esta variante anatômica também estava presente no joelho contralateral, normal, excluindo o remodelamento traumático como o motivo deste entalhe patelar. Os autores utilizaramuma abordagem parapatelar medial para a redução aberta do deslocamento e para o reparo do retináculo medial. De acordo comWiberg, existem três tipos diferentes de patela. Os autores descrevem uma variação da patela de tipo III com um entalhe na margem medial que não está incluída na classificação anterior. Ressalta-se a importância de um estudo de TC na presença de luxação irredutível e o reconhecimento desta variante anatômica da patela, já quemanobras agressivas foram testadas sem sucesso. A redução aberta parece ser a melhor opção neste cenário. Abstract Irreducible patella dislocations are rare and are usually associated with complex mechanisms. The authors report the clinical case of an irreducible lateral patellar dislocation due to an anatomical variant. The authors assisted a 16-year-old patient

Dual Radial Styloid and Volar Plating for Unstable Fractures of the Distal Radius.

As the operative management of displaced distal radius fractures evolves, intraoperative techniques and fixation strategies evolve as well. Achieving and maintaining an acceptable reduction is paramount but can be difficult with particular fracture patterns. In this article, we describe the use of a radial column plate as a reduction tool in the management of unstable distal radius fractures, along with clinical and radiographic clinical outcomes. This technique can be useful in situations where multiplanar instability exists, or simply when intraoperative assistance is limited. Surgeons can expect acceptable radiographic and clinical outcomes when using this technique, although effects on scar formation and wrist range of motion are currently not known.

Subtalar Dislocations: Case Series Inclusive of the Rare Anterior Subtalar Dislocation and Review of the Literature / Dislocaciones subtalares: serie de casos con inclusión de la rara dislocación subtalar anterior y revisión de la literatura

ABSTRACT Subtalar dislocations were first described by Judey and Dufaurest in 1811. These dislocations represent only 1-2% of all joint dislocations, making them a rare injury. In this rare injury, there are four variations with differing clinical presentations. The clinical picture may vary from a dramatic deformity (as in medial and lateral dislocations) to a more subtle presentation (as in anterior and posterior dislocations). This case series highlights the variations in clinical presentations and the management difficulties associated with each subtype.

RESUMEN Las dislocaciones subtalares fueron por primera vez descritas por Judey y Dufaurest en 1811. Estas dislocaciones representan solamente el 1-2% de todas las dislocaciones de las articulaciones, por lo que constituye una lesión poco frecuente. Esta rara lesión se caracteriza por cuatro variaciones con presentaciones clínicas que difieren. El cuadro clínico puede variar desde una deformidad dramática (tal cual ocurre en las dislocaciones intermedias y laterales) hasta una presentación más sutil (como en el caso de las dislocaciones anteriores y posteriores). Esta serie de casos destaca las variaciones en las presentaciones clínicas y las dificultades en el tratamiento asociado con cada subtipo.

Incidence of Meniscal Entrapment and Associated Knee Injuries in Tibial Spine Avulsions.

BACKGROUND: Tibial spine avulsions (TSA) have historically been treated as isolated injuries. Data on associated injuries are limited with existing literature reporting wide ranging incidences. The purpose of this multicenter study was to (1) describe the incidence of meniscal entrapment and associated knee injuries in TSA and to (2) compare surgical and magnetic resonance image (MRI) findings for these injuries. Our hypothesis is that tibial spine injuries are not usually isolated injuries, and other meniscal, ligament, and cartilage injuries may be present. METHODS: MRI and surgical reports for patients with a diagnosis of a tibial spine fracture were retrospectively reviewed. Type of fracture was recorded as noted in the reports along with concomitant meniscal entrapment and osteochondral, ligamentous, and meniscal injury. Images and reports were reviewed by an orthopaedic surgeon at each respective institution. RESULTS: A total of 163 patients were included in this study. MRI was done for 77 patients and surgery was performed in 144 cases. Meniscal entrapment was found in 39.9% of all patients. MRI diagnosed meniscus, osteochondral, and non-anterior cruciate ligament ligamentous injury was found in 31.2%, 68.8%, and 32.4% of cases, respectively. Surgically diagnosed meniscus, chondral, and non-anterior cruciate ligament ligamentous injury was found in 34.7%, 33.3%, and 5.6% of patients, respectively. CONCLUSIONS: TSA fractures are associated with significant risk for concomitant knee injuries including meniscal tear, bone contusion, and chondral injury. Incidence of meniscal entrapment found during surgery was high, in spite of low incidence of positive findings by MRI. LEVEL OF EVIDENCE: Level IV-retrospective case series.