Classic Versus Congruent-Arc Latarjet Procedures.

Glenohumeral instability remains a frequent pathology, specifically in athletes and active patients. As such, several treatment options have been described. In the setting of significant glenoid bone loss (i.e., >20%), off-track Hill-Sachs lesions, and failed previous soft-tissue-based repairs, glenoid bone-augmentation techniques must be considered. These techniques restore stability by a triple blocking effect of the bony graft, the capsulolabral complex repair, and the dynamic sling effect of the conjoined tendon. The classic Latarjet procedure consists in performing a coracoid osteotomy along with the conjoined tendon attachment followed by transfer and fixation to the anterior glenoid, positioning the lateral surface of the coracoid to be flush with the articular side. Then, a modification of this technique defined as "congruent-arc Latarjet" (CAL) was described. This approach involves rotating the coracoid process 90° along its longitudinal axis using the inferior surface to recreate the native glenoid arc. Biomechanical studies have discussed advantages and disadvantages of these techniques. The CAL allows a greater glenoid surface area, which may be relevant in patients with increased glenoid bone loss. However, the bone contact area is reduced, which increases the technical difficulty of screw positioning with an increased risk of graft fragmentation. The classic Latarjet technique has a greater initial fixation strength between the graft and the glenoid and a greater potential for bone consolidation due to the broader contact bone area. Excellent clinical and sports outcomes with low recurrence rates have been observed in both techniques. Imaging findings have exhibited high bone block healing and no difference in graft placement, but CAL demonstrated a greater incidence of fibrous or nonunion rates and errors in screw fixation. Finally, while similar early complications have been reported, long-term outcomes are still needed in CAL for comparing osteoarthritis progression. These results emphasize that either technique can be considered to manage glenohumeral instability when appropriately indicated.

Fractura de Tillaux en adultos. Reporte de un caso y revisión de la bibliografía / Tillaux fracture in adults. Case report and literature review

Introducción: La fractura de la región anterolateral de la epífisis distal de la tibia, o tubérculo de Tillaux-Chaput, es conocida como fractura de Tillaux. Se trata de una fractura extremadamente rara en los adultos, pero tiene una importancia fundamental, porque compromete la superficie articular tibio-astragalina, la estabilidad de la sindesmosis y, en algunos casos, la incisura peronea. Se presenta el caso de una mujer de 45 años con un traumatismo rotatorio del tobillo izquierdo e impotencia funcional y dolor en la región anterolateral del tobillo. Las radiografías generaron la sospecha de un trazo de fractura correspondiente al tubérculo de Tillaux-Chaput. Por lo tanto, se realizó una tomografía computarizada que confirmó una fractura de Tillaux, que tenía un desplazamiento >2 mm y compromiso de la incisura peronea. La paciente fue sometida a reducción abierta y fijación interna. La fractura consolidó a los 3 meses. Al año de la cirugía, su estado clínico y funcional es excelente. Conclusión: La sospecha diagnóstica que surge de una completa anamnesis y un meticuloso examen físico, y la confirmación mediante estudios por imágenes son esenciales para abordar correctamente patrones de fracturas raros, como la fractura de Tillaux. Nivel de Evidencia: IV

Introduction: The fracture of the anterolateral region of the distal tibial epiphysis, or Tillaux-Chaput tubercle, is known as Tillaux fracture. It is an exceptional entity in adults, but it has significant importance because it affects the tibiotalar joint surface, the stability of the syndesmosis, and, in some cases, the fibular notch. We present the case of a 45-year-old woman treated in the Emergency Service due to rotational trauma to the left ankle and functional impairment and pain in the anterolateral region of the ankle. The radiographs led to the suspicion of a fracture line corresponding to the Tillaux-Chaput tubercle. Therefore, a CT scan was performed, which confirmed a Tillaux fracture with a >2 mm displacement and involvement of the fibular notch. The patient underwent open reduction and internal fixation. The fracture consolidated after 3 months. One year after surgery, her clinical and functional status was excellent. Conclusion:Diagnostic suspicion through meticulous physical examination and anamnesis and confirmation by imaging studies are essential for the proper management of rare fracture patterns, such as Tillaux fractures. Level of Evidence: IV

The playing position significantly influences return to sports and recurrences after an arthroscopic Bankart repair in competitive rugby players.

Background: The purpose of our study was to investigate the influence of the different rugby playing positions on return to sports, functional outcomes, and recurrences after an arthroscopic Bankart repair. Methods: A total of 88 rugby players were treated for anterior shoulder instability in our institution between 2010 and 2018. Functional outcomes, return to sports, recurrences, complications, and revisions rates were evaluated according to the playing position. Results: Overall, 73.8% of the patients returned to rugby and 60% returned at the same level as before the injury. The tight forwards and outside backs experienced a significant decrease in their competitive level after surgery, and showed the lowest functional outcomes. The tight forwards and outside backs showed a statistically significant increase in recurrence and revision rates, and an OR for recurrence of 12.8 and 9.6, respectively. Discussion: The playing position significantly influenced return to sports and recurrences after an arthroscopic Bankart repair in competitive rugby players. Specifically, the tight forwards and outside backs have returned to a lower level than they had before surgery, showed the lowest functional outcomes, and a significant increase in recurrences and revisions rates than the other groups.

Enclavado endomedular suprarrotuliano vs. infrarrotuliano en el tratamiento de fracturas diafisarias y distales de tibia: análisis comparativo y técnica quirúrgica / Suprapatellar vs. infrapatellar intramedullary nailing for the treatment of distal and diaphyseal tibial fractures: Comparative analysis and surgical technique

Introducción: Las fracturas diafisarias y distales de tibia son lesiones frecuentes en personas jóvenes que sufren un trauma de alta energía y en ancianos por un trauma de baja energía. El objetivo de este estudio fue comparar el tiempo quirúrgico, el uso de radioscopia, la evaluación funcional y el dolor en el tratamiento de fracturas diafisarias y distales de tibia mediante una técnica suprarrotuliana y una infrarrotuliana. Materiales y métodos: Se realizó un estudio retrospectivo entre marzo de 2018 y octubre de 2019. La información de los pacientes se obtuvo de la historia clínica electrónica. Se incluyó a pacientes con fracturas diafisarias y distales de tibia. Se estudiaron y compararon los tiempos de radioscopia y de cirugía. El dolor posoperatorio se evaluó mediante la escala analógica visual y la función, con el puntaje de Lysholm. Resultados:Ochenta pacientes cumplían con los criterios de inclusión. Sus datos sociodemográficos fueron pareados en dos grupos similares. Treinta y seis pacientes fueron tratados con la técnica infrarrotuliana y 44, con la técnica suprarrotuliana. Se obtuvieron diferencias estadísticamente significativas en el tiempo de cirugía, el tiempo de radioscopia y en el puntaje de la escala analógica visual para dolor al año. Conclusiones: Los resultados mostraron un menor tiempo de cirugía y de radioscopia, y mejores resultados en la escala analógica visual para dolor con la técnica suprarrotuliana para el tratamiento de las fracturas mediodiafisarias y distales de tibia. Nivel de Evidencia: III

Introduction: Fractures of the medial and distal tibial segment often occur in young patients with high-energy trauma and older patients with low-energy trauma. The objective of this study is to compare the time of surgery, time of use of fluoroscopy, functional outcomes, and postoperative pain in patients treated with the suprapatellar vs. infrapatellar technique for tibial nailing. materials and methods: We carried out a retrospective study between March 2018 and October 2019. All the data was collected from the electronic clinical record (ECR). We included patients with diaphyseal and distal tibial fractures. The variables analyzed were: fluoroscopy and surgery time, pain evaluation, and functional outcomes of the patients using the Lysholm score. Results: 80 patients met all the inclusion criteria. Sociodemographic data were divided into 2 similar groups. The suprapatellar approach was used in 44 patients and the infrapatellar in 36 of them. A statistical difference was obtained in the analysis for the time of surgery, use of fluoroscopy, and pain evaluation in favor of the suprapatellar technique. Conclusions: The results of our study showed shorter surgery and fluoroscopy times with the use of the suprapatellar technique compared with the infrapatellar technique. The suprapatellar technique also yielded better pain results in the visual analog scale. Level of Evidence: III

Traditional versus congruent-arc Latarjet anatomic and biomechanical perspective.

The congruent-arc Latarjet (CAL) allows reconstruction of a greater percentage of glenoid bone deficit because the inferior surface of the coracoid is wider than the lateral edge of the coracoid used with the traditional Latarjet (TL).Biomechanical studies have shown higher initial fixation strength between the graft and the glenoid with the TL.In the TL, the undersurface of the coracoid, which is wider than the medial edge used with the CAL, remains in contact with the anterior edge of the glenoid, increasing the contact surface between both bones and thus facilitating bone consolidation.The shorter bone distance around the screw with the CAL is potentially less tolerant of screw-positioning error compared to the TL. Moreover, the wall of the screw tunnel is potentially more likely to fracture with the CAL due to the minimal space between the screw and the graft wall.CAL may be very difficult to perform in patients with very small coracoids such as small women or skeletally immature patients.Radius of curvature of the inferior face of the coracoid graft (used with the CAL) is similar to that of the native glenoid. This may potentially decrease contact pressure across the glenohumeral joint, avoiding degenerative changes in the long term. Cite this article: EFORT Open Rev 2021;6:280-287. DOI: 10.1302/2058-5241.6.200074.

Intramedullary nail for the surgical treatment of unstable fractures of the femur in previously amputated patients / [Clavo endomedular para el tratamiento quirúrgico de fracturas inestables de fémur en pacientes previamente amputados]

Introduction: Femoral fractures in previously amputated patients (PAP) have been poorly reported in international literature, however it is worth mentioning that advances in the manufacture of orthotics for lower limbs have allowed these patients to remain functionally active. Surgery is then an option but difficulties may appear in positioning the patient for surgery due to the absence of the foot or ankle from where to pull and optimize the fracture reduction. Objective: We report 3 cases of PAP with ipsilateral unstable femur fractures, treated surgically with cervicodiaphyseal endomedular nail. The surgical technique used in each case is described. Results: Good long-term results were obtained demonstrating the effectiveness of surgical treatment and the reduction technique used. Conclusion: Surgical treatment of unstable fractures of the proximal femur with an endomedullary nail should be considered a valid therapeutic option.

Introducción: Las fracturas de fémur en pacientes previamente amputados (PPA) han sido escasamente reportadas en la literatura internacional, sin embargo, cabe mencionar que los avances en la fabricación de ortesis para miembros inferiores han permitido que estos pacientes, se mantengan funcionalmente activos. La cirugía entonces es una opción, pero representa una dificultad en el posicionamiento del paciente a la hora de planificar su cirugía debido a la ausencia del pie o tobillo del cual traccionar y optimizar la reducción de la fractura. Objetivo: Reportamos a continuación 3 casos de PPA con fracturas inestables ipsilaterales de fémur, tratadas mediante reducción y osteosíntesis con clavo endomedular cervicodiafisario. Se describe la técnica quirúrgica utilizada en cada caso. Resultados: Se obtuvieron buenos resultados a largo plazo demostrando la efectividad del tratamiento quirúrgico y la técnica de reducción utilizada. Conclusión: El tratamiento quirúrgico de fracturas inestables de fémur proximal con clavo endomedular, ha de ser considerado una opción terapéutica válida.

Dedo azul agudo idiopático no isquémico: síndrome de Achenbach. Presentación de un caso y revisión bibliográfica / Acute non-ischemic idiopathic blue finger. Achenbach's syndrome. Case report and literature review

El síndrome de Achenbach es un cuadro de baja incidencia y de etiología idiopática. Se caracteriza por la aparición aguda de coloración azul digital sin un episodio desencadenante, imitando a un cuadro isquémico, pero, al contrario, el síndrome de Achenbach se autolimita sin dejar secuelas. Se presenta una mujer de 75 años que consultó en la central de emergencias por dolor y cambio de coloración violácea del dedo índice de su mano derecha, de inicio súbito. Los estudios complementarios no aportaron información relevante. Se administró un tratamiento sintomático y se logró la resolución completa del cuadro. La anamnesis y el examen físico exhaustivo tienen un rol fundamental para sospechar este cuadro y los estudios complementarios se reservan para descartar otras enfermedades, si es necesario. Consideramos que conocer esta enfermedad y un abordaje correcto conducen a un diagnóstico apropiado. Nivel de Evidencia: IV

Achenbach's Syndrome (AS) is a pathology with low incidence and its etiology is unknown. It is characterized by the acute appearance of blue coloration in the finger without a triggering event and might be confused with an ischemic event. However, AS is a self-limited disease without sequelae. This case report is about a 75-year-old woman who presented sudden onset pain and purple coloration in the index finger of her right hand. Diagnostic tests were unhelpful and did not provide relevant information. She received symptomatic treatment, achieving complete resolution. The anamnesis and an exhaustive physical examination play a primary role in the suspicion; leaving diagnostic tests for the exclusion of other pathologies when they are required. We believe that knowing about this pathology allows a correct approach leading to an appropriate diagnosis. Level of Evidence: IV

Soporte circunferencial posterior en fracturas de platillo tibial / Posterior circumferential support in tibial plateau fractures

Las técnicas quirúrgicas que más se utilizan en la actualidad para fracturas de platillo tibial no contemplan correctamente la conminución ósea multiplanar ni la presencia de fragmentos óseos posteriores. Nos hemos enfrentado con esta problemática al tratar a un paciente con fractura de platillo tibial tipo Schatzker VI, en la cual se suplementó la osteosíntesis habitualmente utilizada con una placa horizontal circunferencial posterior. Se logró la consolidación ósea y los resultados funcionales a corto plazo fueron buenos. Del análisis de la bibliografía citada, se concluye en que se han desarrollado varias técnicas de contención posterior de los platillos tibiales, y la osteosíntesis circunferencial es una técnica por considerar. Nivel de Evidencia: IV

Surgical techniques commonly used today for tibial plateau fractures do not properly contemplate multiplanar bone comminution nor the presence of posterior bone fragments. We have faced this problem when treating a patient with a Schatzker VI type fracture, in which the commonly used osteosynthesis was supplemented with a posterior horizontal circumferential plate. Bone consolidation and good results were achieved in the short term in the case we present. From the analysis of the cited literature, we concluded that several techniques for containing posterior tibial plateau bone comminution have been developed. Among them, circumferential osteosynthesis is a technique to take into account. Level of Evidence: IV

Luxación periastragalina medial pura: reporte de casos y revisión bibliográfica / Pure medial subtalar dislocation: case report and literature review

Las luxaciones subastragalinas (periastragalinas) sin fractura asociada son un cuadro poco frecuente. Representan solo el 1% de las luxaciones en el ser humano. Presentamos tres casos de luxaciones mediales puras en pacientes que sufrieron un traumatismo de alta energía. En todos los casos, el tratamiento consistió en la reducción cerrada bajo anestesia y posterior inmovilización; la evolución fue satisfactoria. Las luxaciones subastragalinas requieren de un diagnóstico temprano y una rápida resolución. Con estos casos se quiere demostrar la importancia de la sospecha diagnóstica y el beneficio de un tratamiento precoz y acertado. Nivel de evidencia: IV

Isolated subtalar dislocations without associated fracture are a rare entity. They represent only 1% of dislocations in humans. We present a series of 3 cases of pure medial dislocations in patients who suffered high-energy trauma. In all cases, the treatment was closed reduction under anesthesia and subsequent immobilization; all with good results. Subtalar dislocations require early diagnosis and rapid resolution. The aim of this presentation is to demonstrate the importance of diagnostic suspicion and the benefit of early treatment for successful outcome. Level of evidence: IV

Coracoclavicular Double-Button Fixation of Displaced Lateral Clavicular Fracture in a Patient without Coracoid Process.

BACKGROUND: Displaced distal clavicular fractures are generally operated on because of the high nonunion rate after nonoperative treatment. Several surgical techniques have been developed to reduce the nonunion rate and improve functional outcomes. One of them is closed reduction and minimally invasive coracoclavicular double-button fixation, which requires the integrity of the coracoid process to be performed. CASE SUMMARY: We present a 35-year-old male patient who had been successfully subjected to a modified Latarjet procedure for glenohumeral instability with bony defect treatment, and 7 months later suffered a distal clavicle fracture in his ipsilateral shoulder. With a CT scan, we analyzed the coracoid remnant size (7 mm), and we consider it enough to perform a minimally invasive double-button technique, using this remnant as a distal fixation. POSTOPERATIVE AND FOLLOW-UP: Radiographic and clinical fracture union occurred 10 weeks after the procedure. The patient returned to sports at the same level he had before surgery and achieved full strength and range of motion. CONCLUSION: Closed reduction and minimally invasive double-button fixation of displaced distal clavicular fractures is a safe, reproducible, and versatile technique, which can even be performed without an intact coracoid process.