Resultados clínicos de la artroplastia radial en la tríada terrible de Hotchkiss, a propósito de 47 casos / Clinical results of radial arthroplasty in Hotchkiss' terrible triad, a case series of 47

INTRODUCCIÓN: Las fracturas de cabeza radial representan el 33-75% de las fracturas del codo (30 casos/100.000 habitantes/año). La «tríada terrible de Hotchkiss» se caracteriza por fractura de cúpula radial, coronoides y luxación del codo. Nuestro objetivo principal es comparar los resultados según el tipo de prótesis utilizada en el contexto de la tríada. MATERIAL Y MÉTODOS: Estudio observacional, descriptivo y retrospectivo. Tamaño muestral de 47 pacientes. Variables analizadas: filiación, clasificación de Mason, aspectos quirúrgicos (demora, tiempo quirúrgico, tipo de prótesis, reintervenciones), tiempo rehabilitador, causas de fracaso protésico, complicaciones, hallazgos radiológicos (según Van-Riet), zonas de aflojamiento (Popovic), escalas MEPS y Cassebaum. Se realizó un estudio intergrupal entre los tipos protésicos monopolar y bipolar, para ver los resultados obtenidos. RESULTADOS: Edad media: 43,5+/-8,9 años. El 72,7% de profesionales de grandes esfuerzos. La fractura Mason IV apareció en todos los casos y la tipo I de Regan y Morrey para coronoides (42,6%); 22 prótesis bipolares y 25 prótesis monopolares. Tiempo de intervención: 112,3+/-59,1 min. Fijación externa en el 6,4%. MEPS final: 85,9+/-15 puntos. Tiempo rehabilitador: 4,7+/-2,5 meses. Alta por mejoría: 76,6%. Cassebaum bueno-excelente en el 74,5%. Hubo 3 casos de movilización protésica, 29,8% de osificaciones heterotópicas y sobredimensionado en el 15,2%. En el estudio intergrupal, objetivamos que con prótesis monopolares hubo menor tiempo quirúrgico (p = 0,006), menores reintervenciones (p = 0,05), menor rigidez (p = 0,04), osificación heterotópica (p = 0,004) o aflojamiento protésico (p = 0,005), sin influir en escala MEPS (p = 0,44). CONCLUSIONES: Los resultados obtenidos en tríadas terribles con prótesis en nuestra experiencia son favorables. El tipo protésico sí influye, ya que el tiempo quirúrgico para la implantación de una prótesis monopolar fue menor, aunque el tiempo de rehabilitación fue algo mayor. Con las prótesis bipolares se requirió más la fijación externa, siendo también mayor la tasa de reintervenciones, rigidez, movilización protésica, osificación heterotópica y aflojamiento protésico. Sin embargo, no hubo diferencias entre ambos tipos protésicos en cuanto a resultados clínicos, ya fuera MEPS o Cassebaum

INTRODUCTION: Radial head fractures represent 33-75% of elbow fractures (30 cases/100,000 population/year). "Terrible triad's Hotchkiss" is characterized by radial head fracture, coronoid fracture and elbow dislocation. Our principal goal is to compare our results on each type of prosthesis in the context of the triad. MATERIAL AND METHODS: We conducted an observational, descriptive and retrospective study. Sample size was 47 patients. Variables analyzed were affiliation, Mason's classification, surgical aspects (moment of surgery, surgical time, prosthesis type, re-surgery), rehabilitation time, causes of prosthetic failure, complications, radiographic findings (according to van Riet), Popovic's loosening areas, MEPS and Cassebaum's scales. We performed an inter-group study, on patients treated with monopolar or bipolar prosthesis, in order to see results. RESULTS: Average age was 43.5+/-8.9 years. 72.7% were in highly demanding jobs. Mason's fracture type IV appeared in all the cases and Regan-Morrey's type I was the most frequent coronoid fracture (42.6%). There were 22 bipolar prosthesis and 25 monopolar prosthesis. Surgery time was about 112.3+/-59.1minutes. External fixation was used in 6.4%. MEPS final: 85.9+/-15 points. Rehabilitation time was about 4.7+/-2.5 months. Of the patients, 76.6% returned to work. Cassebaum's results were good-excellent in 74.5% of patients. There were 3 cases of prosthetic mobilization. Heterotopic ossification appeared in 29.8% of cases and 15.2% presented overstuffing. With regard to the inter-group study, we observed that there was less surgical time with monopolar prosthesis (P=.006), fewer second look surgeries (P=.05), less stiffness (P=.04), less heterotopic ossification (P=.004) and septic loosening (P=.005), without any influence on MEPS (P=.44). CONCLUSIONS: Results obtained in terrible triads with prostheses in our experience are good. Prosthetic type influences results, because surgical time for implantation of a monopolar prosthesis was less than for a bipolar one, although rehabilitation time was longer. With bipolar prostheses, external fixation was required, with a higher rate of reinterventions, stiffness, prosthetic mobilization, heterotopic ossification and prosthetic loosening. However, there were no differences between the 2prosthetic types in terms of clinical results, like MEPS or Cassebaum scores

Clinical results of radial arthroplasty in Hotchkiss' terrible triad, a case series of 47. / Resultados clínicos de la artroplastia radial en la tríada terrible de Hotchkiss, a propósito de 47 casos.

INTRODUCTION: Radial head fractures represent 33-75% of elbow fractures (30 cases/100,000 population/year). "Terrible triad's Hotchkiss" is characterized by radial head fracture, coronoid fracture and elbow dislocation. Our principal goal is to compare our results on each type of prosthesis in the context of the triad. MATERIAL AND METHODS: We conducted an observational, descriptive and retrospective study. Sample size was 47 patients. Variables analyzed were affiliation, Mason's classification, surgical aspects (moment of surgery, surgical time, prosthesis type, re-surgery), rehabilitation time, causes of prosthetic failure, complications, radiographic findings (according to van Riet), Popovic's loosening areas, MEPS and Cassebaum's scales. We performed an inter-group study, on patients treated with monopolar or bipolar prosthesis, in order to see results. RESULTS: Average age was 43.5±8.9 years. 72.7% were in highly demanding jobs. Mason's fracture type iv appeared in all the cases and Regan-Morrey's type I was the most frequent coronoid fracture (42.6%). There were 22 bipolar prosthesis and 25 monopolar prosthesis. Surgery time was about 112.3±59.1minutes. External fixation was used in 6.4%. MEPS final: 85.9±15 points. Rehabilitation time was about 4.7±2.5 months. Of the patients, 76.6% returned to work. Cassebaum's results were good-excellent in 74.5% of patients. There were 3 cases of prosthetic mobilization. Heterotopic ossification appeared in 29.8% of cases and 15.2% presented overstuffing. With regard to the inter-group study, we observed that there was less surgical time with monopolar prosthesis (P=.006), fewer second look surgeries (P=.05), less stiffness (P=.04), less heterotopic ossification (P=.004) and septic loosening (P=.005), without any influence on MEPS (P=.44). CONCLUSIONS: Results obtained in terrible triads with prostheses in our experience are good. Prosthetic type influences results, because surgical time for implantation of a monopolar prosthesis was less than for a bipolar one, although rehabilitation time was longer. With bipolar prostheses, external fixation was required, with a higher rate of reinterventions, stiffness, prosthetic mobilization, heterotopic ossification and prosthetic loosening. However, there were no differences between the 2prosthetic types in terms of clinical results, like MEPS or Cassebaum scores.

Artroplastia de cúpula radial, experiencia de 11 años. Estudio sobre 82 pacientes / Radial head arthroplasty, 11 years experience: a series of 82 patients

Objetivos. Las indicaciones de artroplastia de cúpula radial son esencialmente fracturas complejas con daño ligamentoso (medial, lateral o Essex-Lopresti), y/o asoaciadas a daños óseos (coronoides u olécranon). Nuestro objetivo es revisar nuestra experiencia con la utilización de prótesis de cabeza del radio en un contexto traumático. Material y método. Estudio observacional, descriptivo y retrospectivo, con seguimiento de 1-11 años. El grupo de estudio tuvo un tamaño muestral de 82 pacientes, con una edad media de 41,6 años (± 9,2). Los criterios de inclusión fueron: pacientes en edad laboral (25-64 años) con fracturas de cúpula radial complejas (II, III, IV de Mason), con lesiones de partes blandas u óseas, que conllevarán inestabilidad, no reconstruibles mediante osteosíntesis y tratadas mediante artroplastia. Las principales variables analizadas fueron datos de filiación, clasificación de Mason o aspectos quirúrgicos, como demora, tiempo quirúrgico, tipo protésico (donde la prótesis bipolar fue la más utilizada, 88,6%), necesidad de cementación o reintervenciones. También se analizó el tiempo rehabilitador, las causas de fracaso protésico, complicaciones, hallazgos radiológicos (según Van-Riet), zonas de aflojamiento (según Popovic), así como las escalas MEPS y de Cassebaum. Se apreciaron diversas lesiones asociadas, como el daño en el ligamento colateral lateral cubital en el 39% de los casos, la fractura de coronoides, en el 25,6% y la fractura de olécranon, en el 15,9% de la serie. Hubo un caso de lesión de Essex Lopresti. Los test estadísticos utilizados fueron: para variables categóricas, las tablas de contingencia, Chi Cuadrado y test de Fisher. Para las variables numéricas, la U de Mann Whitney o el test de Kruskall Wallis. Nivel de evidencia IV. Resultados. El tiempo quirúrgico fue de 100 minutos (± 56,8). Se cementaron el 53,8% de las prótesis. El resultado de la escala MEPS: 80,4 puntos (± 19,3), siendo excelentes-buenos en el 71,6%. El codo era estable en el 93,7% de los casos, presentaba una moderada inestabilidad, inferior a 10° en varo-valgo, en el 4,9% de los casos y una franca inestabilidad, con 10° o más de inestabilidad en varo o en valgo, en el 1,3% restante de la serie. El tiempo de rehabilitación fue menor en las cementadas (p = 0,03), hubo mayor rigidez (p = 0,03) y más secuelas (limitaciones de movilidad, dolor residual), (p < 0,05) en los casos en los que hubo que reparar el ligamento colateral lateral cubital (dada la coexistencia de otras lesiones graves en estos casos). Se obtuvieron mejores resultados en la escala de Cassebaum (p = 0,02) y más resultados excelentes en la escala MEPS (p = 0,02), cuando la cirugía fue antes de una semana. Se retiró la prótesis en 11 casos (13,4%), donde la principal causa de retirada fue el dolor en la pronosupinación en 5 casos, las lesiones capitelares en 4 casos, una luxación y una infección. La complicación más frecuente fue la rigidez (30,5%)... (AU)

Objectives. The indications for radial head arthroplasty are essentially complex fractures with ligament damage (medial, lateral or Essex-Lopresti), and/or associated with bone damage (coronoids or olecranon). The aim of this study is to review our experience with the use of a radial head prosthesis in the context of a trauma. Material and method. An observational, descriptive and retrospective study, with a follow-up of 1- 11 years, was performed on a study group of 82 patients with a mean age of 41.6 (± 9.2) years. The inclusion criteria were: patients of working age (25-64 years) with complex radial head fractures (Mason II, III, IV), with soft tissue and bone injuries that caused instability, non-reconstructable by osteosynthesis and treated using arthroplasty. he primary variables analysed were social demographics, Mason classification, or surgical aspects such as delay, surgical time, type of prosthesis (where the bipolar prosthesis was most used, 88.6%), need of fixation or further surgery. Rehabilitation time, causes of prosthesis failure, radiological findings (according to Van-Riet), areas of loosening (according to Popovic), as well as the Mayo Elbow Performance Score (MEPS) and the Cassebaum scale. Various associated injuries were observed, such as injuries in the lateral collateral ligament of the elbow in 39% of cases, coronoid fractures in 25.6%, and an olecranon fracture in 15.9% of the series. There was one case of an Essex- Lopresti injury. The tests used for the statistical analysis were Chi squared and Fisher test for categorical variables and contingency tables. The Mann Whitney U or Kruskall Wallis tests were used for the numerical variables. Evidence level: IV. Results. The mean surgical time was 100 (± 56.8) minutes. The prosthesis was fixed in 53.8% of cases. The mean score on the MEPS scale was 80.4 (± 19.3) points, being good-excellent in 71.6%. The elbow was stable in 93.7% of cases. There was moderate instability, with 10° or more in varus or valgus, and in 1.3% in the rest of the series. The rehabilitation time was lower in the fixed cases (P=.03), and there was greater rigidity (P=.03) and more sequelae (limitations in mobility, residual pain), (P < 0.05) in the cases where the LCL had to be repaired (given that there were other serious injuries in these cases). When the surgical delay was less than one week, better results were obtained on the Cassebaum scale (P=.02), as well as more excellent results on the MEPS scale MEPS (P=.02). The prosthesis was removed in 11 cases (13.4%), with the main cause for removal being pain in pronosupination in 5 cases, and capitellar injuries in 4 cases, one dislocation, and one infections. The most frequent complication was rigidity (30.5%). There were 3 infections (3.7%). Popovic areas 1 and 7 had greater osteolysis. Conclusions. The presence of concomitant bone and ligament injuries determined a longer surgical time and more sequelae. Early surgery would achieve better clinical results (AU)

Radial head arthroplasty, 11 years experience: A series of 82 patients.

OBJECTIVES: The indications for radial head arthroplasty are essentially complex fractures with ligament damage (medial, lateral or Essex-Lopresti), and/or associated with bone damage (coronoids or olecranon). The aim of this study is to review our experience with the use of a radial head prosthesis in the context of a trauma. MATERIAL AND METHOD: An observational, descriptive and retrospective study, with a follow-up of 1- 11 years, was performed on a study group of 82 patients with a mean age of 41.6 (± 9.2) years. The inclusion criteria were: patients of working age (25-64 years) with complex radial head fractures (Mason II, III, IV), with soft tissue and bone injuries that caused instability, non-reconstructable by osteosynthesis and treated using arthroplasty. The primary variables analysed were social demographics, Mason classification, or surgical aspects such as delay, surgical time, type of prosthesis (where the bipolar prosthesis was most used, 88.6%), need of fixation or further surgery. Rehabilitation time, causes of prosthesis failure, radiological findings (according to Van-Riet), areas of loosening (according to Popovic), as well as the Mayo Elbow Performance Score (MEPS) and the Cassebaum scale. Various associated injuries were observed, such as injuries in the lateral collateral ligament of the elbow in 39% of cases, coronoid fractures in 25.6%, and an olecranon fracture in 15.9% of the series. There was one case of an Essex- Lopresti injury. The tests used for the statistical analysis were Chi squared and Fisher test for categorical variables and contingency tables. The Mann Whitney U or Kruskall Wallis tests were used for the numerical variables. Evidence level: IV. RESULTS: The mean surgical time was 100 (± 56.8) minutes. The prosthesis was fixed in 53.8% of cases. The mean score on the MEPS scale was 80.4 (± 19.3) points, being good-excellent in 71.6%. The elbow was stable in 93.7% of cases. There was moderate instability, with 10° or more in varus or valgus, and in 1.3% in the rest of the series. The rehabilitation time was lower in the fixed cases (P=.03), and there was greater rigidity (P=.03) and more sequelae (limitations in mobility, residual pain), (P<0.05) in the cases where the LCL had to be repaired (given that there were other serious injuries in these cases). When the surgical delay was less than one week, better results were obtained on the Cassebaum scale (P=.02), as well as more excellent results on the MEPS scale MEPS (P=.02). The prosthesis was removed in 11 cases (13.4%), with the main cause for removal being pain in pronosupination in 5 cases, and capitellar injuries in 4 cases, one dislocation, and one infections. The most frequent complication was rigidity (30.5%). There were 3 infections (3.7%). Popovic areas 1 and 7 had greater osteolysis. CONCLUSIONS: The presence of concomitant bone and ligament injuries determined a longer surgical time and more sequelae. Early surgery would achieve better clinical results.

Tratamiento quirúrgico de las fracturas de tercio distal del húmero a propósito de 36 casos / Surgical treatment of fractures of the distal third of the humerus: A series of 36 cases

Objetivo: Revisar el tratamiento de las fracturas de paleta humeral comparando resultados clínicos y laborales entre un grupo tratado con doble placa y otro sin ella y analizar los resultados clínicos obtenidos tras osteosíntesis en paralelo o de modo perpendicular en el grupo tratado con doble placa. Material y métodos: Estudio observacional, descriptivo y retrospectivo, nivel de evidencia IIIa, donde se analizaron 36 pacientes con una edad media de 43 (DE: 10) años. El 30.6% fueron fracturas abiertas. El tiempo de seguimiento fue de 16 (DE: 5) meses. Se obtuvo la escala MEPS (Mayo Elbow Performance Score) entre un grupo tratado con doble placa y otro sin ella y los resultados entre los casos con doble placa en paralelo, frente a aquellos en perpendicular. Resultados: La escala MEPS no presentó diferencias estadísticamente significativas entre las fracturas tratadas con doble placa y aquellas sin ella (p=0,5) pero la osteosíntesis sin dos placas supone tasas de pseudoartrosis de hasta el 12,5% con una mayor tasa de complicaciones (81,3% / 73,3%) que la osteosíntesis con doble placa. Conclusiones: No hallamos diferencias clínicas entre ambos grupos aunque las fracturas tratadas con doble placa presentan una menor tasa de pseudoartrosis (AU)

Objetive: To review the management of fractures of the distal third of the humerus, comparing the clinical and occupational results between a group treated with double plates and a group without plates, and analyzing the clinical results after osteosynthesis in parallel or perpendicular in the group subjected to double plate treatment. Material and methods: A descriptive, observational retrospective study with evidence level IIIa was carried out, analyzing 36 patients with a mean age of 43 years (SD: 10). A total of 30.6% corresponded to open fractures. The mean duration of follow-up was 16 months (SD: 5). The MEPS (Mayo Elbow Performance Score) was compared between the group treated with double plates and the group without plates, and between osteosynthesis in parallel or perpendicular in the group subjected to double plate treatment. Results: The MEPS showed no statistically significant differences between the group treated with double plates and the group without plates (p=0.5), though osteosynthesis without double plating was associated with a pseudoarthrosis rate of up to 12.5%, and involved a higher complications rate (81.3% versus 73.3%) than osteosynthesis with double plating. Conclusions: No clinical differences were found between the two groups, though the fractures treated with double plates showed a lower pseudoarthrosis rate (AU)

Roturas del tendón distal del bíceps braquial. Revisión de 40 casos / Distal biceps brachii tendon ruptures. A review of 40 cases

Objetivo: conocer la evolución de las roturas distales del músculo bíceps braquial tratadas conservadora y quirúrgicamente. Pacientes y metodología: se evaluaron retrospectivamente 39 varones y una mujer, 26 fueron tratados quirúrgicamente con una reinserción anatómica del tendón y un caso precisó plastia con fascia lata de cadáver, con distintos sistemas de fijación. Los 14 casos restantes se trataron ortopédicamente. El mecanismo de producción habitual de la lesión fue la contracción contrariada con peso a la flexión del codo. Los síntomas habituales fueron el dolor y la pérdida de fuerza en flexión y supinación. La sospecha clínica se corroboró con la ecografía. Para el análisis comparativo de los resultados de los distintos tratamientos se aplicó la escala de la Clínica Mayo, la valoración de secuelas por parte de las Unidades de Evaluación de Incapacidades del INSS (al tratarse de accidentes laborales) y la valoración isocinética en la mitad de los casos. Resultados: los resultados fueron pobres en los pacientes tratados conservadoramente, aunque no fueron desdeñables las complicaciones derivadas del tratamiento quirúrgico (25%). Hubo mayor tasa de reintervenciones cuando se utilizó un tornillo en la reinserción del tendón. Conclusión: el tratamiento quirúrgico, con reinserción del tendón en la tuberosidad radial proporciona mejores resultados. Sin embargo, no se deben menospreciar las complicaciones derivadas de la cirugía, que se pueden evitar con una minuciosa técnica quirúrgica

Objective: evaluation of 40 cases which where treated of distal m biceps brachii tendon, both conservatively and surgically. Patients and methodology: 39 men and one woman were evaluated, on 26 patients the reinsertion of the tendon were made, in one case with fascia lata allograft using different sort of fixation to the bone. Fourteen cases were treated in a conservative manner. The injury was often caused by the opposed contraction of the biceps within the flexion of the elbow. The symptoms were pain and the lack of strength for the flexion and supination. Suspecting the tendon rupture by the clinical examination was confirmed by ultrasonography. Results: we used for the evaluation the Mayo Elbow Performance Score. The sequels have been evaluated by the INSS (National Institute of the Spanish Security Law). The isocinetic study has been used at least for half cases of the sample to value the results, as well. The results have been poor in those patients who where treated with the conservative method but we cannot avoid the importance of the surgical treatment complications (25%). The number of re-surgery increases when using a screw for the reinsertion of the tendon. Conclusion: the reinsertion of the tendon in the radius tuberosity brings better functional results. Nevertheless we must keep attention to the surgical complications, trying to minimize them thanks to a careful technique

Estudio prospectivo y aleatorizado en pacientes con lumbalgias o lumbociatálgias tratados con ozonoterapia / Prospective and randomized study in patients with low back pain or sciatic pain with ozonetherapy treatment

Objetivo: estudiar los resultados clínicos en pacientes con lumbalgias y ciáticas, tratados con ozono (O3) paravertebral e intradiscal. Pacientes y método: se incluyeron 103 pacientes, 44 diagnosticados de lumbalgia y 59 de ciatalgia tratados, prospectiva y aleatoriamente, con ozono o con reposo y analgesia. Se evaluaron con la escala de intensidad de dolor, cuestionario Oswestry, distancia mano-suelo, Lasseguè e incorporación laboral. El seguimiento clínico fue de 6 meses. Resultados: en el grupo de lumbagos encontramos diferencias con el tratamiento en ambos grupos (p 0,001) sin ver diferencias entre el grupo control y el tratado con ozono. En el grupo de ciatalgia tratado con O3 encontramos diferencia inicial y final del dolor (p 0,001) y la escala de Oswestry presentó una mejoría del 40,4% (p 0,001). En el grupo control con ciatalgia no mejoró el dolor y empeoró en la escala de Oswestry (p 0,5). En el grupo control un 36,2% mostraron un Lasseguè negativo después del tratamiento, mientras que en los tratados con O3 fueron un 83,2%. En el grupo de lumbalgia control causaron alta laboral, por curación o mejoría el 46,6% y el 58,3% tratados con O3; en el grupo ciatalgia control fueron el 18,2% frente al 78,6% de los tratados con O3. Las hernias de disco contenidas respondieron mejor al tratamiento con O3. Conclusiones: el O3 paravertebral no mejora la evolución clínica de las lumbalgias. El tratamiento con O3 intradiscal y paravertebral puede indicarse en el tratamiento de ciáticas y lumbociáticas secundarias a hernias discales cuando fracasa el tratamiento conservador

Objective: A prospective and randomized study to compare the clinical results between conservative vs. intra-discal/para-lumbar vertebrae ozone treatment in patients with low back pain and patients affected of sciatic pain. Patients and method: This is a randomized study for 103 patients (44 with low back pain and 59 with sciatic pain) whose treatment was ozone versus relative rest and analgesic (control group). To evaluate: scale for measuring the intensity of pain, the Oswestry questionnaire for the disability caused by lumbar pain, the hand-flow distance, the Lasseguè test and the reinsertion of the patients to their labour activities. The clinical follow-up was 6 months. Results: Using the scale for the intensity of pain and the Oswestry questionnaire for all the patients with low back pain (ozone or conservative treatment) we found an improvement of their symptoms (p 0.001), with no differences in the results between the control group and the ozone group. For the group of patients affected of sciatic pain treated with ozone we found improvement of the pain after the treatment (p 0,001) and the Oswestry questionnaire 40,4% (p 0.001).The Lasseguè test was negative or improved in 83,2% patients after the treatment in the ozone group. In the patients with low back pain treated with ozone the 58,3% re-started working in their jobs. For the ozone group with sciatic pain the 78,6% were able to develope their ordinary work. The contained discal herniasdisk responded better to the treatment with O3. Conclusions: paralumbar vertebrae ozone does not improve the clinical evolution of low back pain, although it present analgesic effects in the short term. The treatment with intradisk more paralumbar ozone can be one first option in the treatment of the sciatic pain when the conservative treatment fail