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

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

Dorsal Plating for Specific Fracture Pattern of the Distal Radius.

Background: Volar locking plates have provided the capability to repair both simple and complex fractures. However, complications related to the inability to fix or to maintain the fixation of some fracture patterns have been reported with volar locking plates. The purpose of this study was to evaluate the results of dorsal plating treatment for specific pattern of fractures. Methods: Patients with distal radius fractures were retrospectively evaluated. Inclusion criteria for this study were those related to the patient and treatment (adult patients, internal fixation with dorsal plating, a minimum follow-up of 12 months), and those related to the fracture pattern (displaced central articular fragment, volar distal fracture line not enough to allow volar fixation, displaced dorsal-ulnar fragment, dorsal partial fractures, combination of these patterns). Clinical outcome information including active range of motion, radiographs, PRWE and DASH questionnaires were collected. Complications were recorded. Results: During a 6-year period, 679 distal radius fractures were treated with open reduction and internal fixation. Of these, 27 patients fulfilled the inclusion criteria. Patients were examined at a median of 34 months' follow-up. All but pronation, supination, and radial deviation had a statistically significant difference compared to the opposite side. The median score on the DASH was 4.5 and 3.2 on the PRWE. No patient suffered loss of reduction during the follow-up nor were tendon ruptures recorded. Conclusions: Although most of the distal radius fractures can be treated with volar locking plates, almost 5% of them present specific patterns that are amenable to treatment with dorsal fixation, without postoperative loss of reduction. These specific patterns are: (1) displaced central articular fragment, (2) volar distal fracture with less of 1cm distance from the distal volar edge of the radius, (3) displaced dorso-ulnar fragment, (4) Barton's fracture, (5) combination of these patterns.

Estudio comparativo entre banda de tensión y tornillo compresivo para la artrodesis interfalángica proximal y metacarpofalángica / Comparative study between tension band and compression screw fixation in metacarpophalangeal and proximal interphalangeal joint arthrodesis

Introducción: Los métodos más utilizados para la artrodesis de la articulación interfalángica proximal y metacarpofalángica son la banda de tensión y el tornillo compresivo. El objetivo de este estudio fue comparar los resultados entre pacientes tratados con estas técnicas. Materiales y Métodos: Estudio comparativo retrospectivo de 10 años. Se incluyeron pacientes esqueléticamente maduros tratados por artrosis y artritis. Se analizaron la tasa de consolidación ósea, el tiempo hasta la consolidación, la incidencia de complicaciones y la tasa de reoperaciones. En un análisis secundario, se compararon los pacientes reumáticos y no reumáticos. Resultados: Se evaluaron 56 casos en 44 pacientes (edad promedio 53 años). Grupo 1: 35 casos tratados con banda de tensión y grupo 2: 21 tratados con tornillo compresivo. Había 32 casos reumáticos y 24 no reumáticos. El seguimiento promedio fue de 24 meses. La tasa promedio de consolidación fue del 94,2% en el grupo 1 y del 85,7% en el grupo 2. La incidencia de complicaciones fue del 11,4% en el primer grupo y 23,8% en el segundo, y la tasa de reoperaciones, del 17,1% y del 0%, respectivamente. Conclusiones: Ambos métodos permiten lograr tasas altas de consolidación, pero la incidencia de seudoartrosis fue casi tres veces superior con el tornillo compresivo que con la banda de tensión. La tasa más alta de reoperaciones en el grupo con banda de tensión fue por extracción del material. El tiempo de consolidación fue más corto en los pacientes no reumáticos, independientemente de la técnica. Nivel de Evidencia: III

Introduction: Tension band wiring (TBW) and compression screw fixation are the most common methods used for proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joint arthrodesis. The aim of this study was to compare outcomes between patients treated with those methods. Materials and Methods: A 10-year retrospective comparative study. The study population included skeletally mature patients treated for osteoarthritis or arthritis. Union rates, healing times, complications, and reoperation rates were compared between TBW and compression screw fixation methods. Outcomes were also studied in terms of rheumatic and nonrheumatic patients. Results: The study sample consisted of 56 cases and 44 patients (average age, 53 years). Group 1: 35 patients treated with TBW. Group 2: 21 patients treated with compression screw fixation. There were 32 rheumatic cases and 24 nonrheumatic cases. The average follow-up was 24 months. Union rates were 94.2% (Group 1) and 85.7% (Group 2). Complication rates were 11.4% (Group 1) and 23.8% (Group 2). Reoperation rates were 17.1% (Group 1) and 0% (Group 2). Conclusions: Both methods have high union rates; however, the nonunion incidence in the compression screw group was almost three times higher than in the TBW group. The reoperation rate was higher in the TBW group, mostly due to hardware removal. Healing time was shorter in non-rheumatic patients regardless of the method. Level of Evidence; III

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

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

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

Treatment of terrible triad injuries at a mean follow-up of nine years.

BACKGROUND: To evaluate the sustainability of the early clinical and radiological outcomes of terrible triad injuries at long-term follow-up. METHODS: Twelve consecutive patients who underwent fixation of terrible triad injuries with minimum of seven years of follow-up. Functional and radiological outcomes at one year and final follow-up were compared. We assessed Mayo Elbow Performance Score, Quick-Disability of the Arm Shoulder and Hand, and modified-American Shoulder and Elbow Surgeons Scores. Radiological evaluation included Broberg and Morrey classification and Hastings classification for heterotopic ossification. RESULTS: The mean age of patients was 55 years, with a median follow-up of 9.3 years. At final evaluation, mean flexion, extension, supination, and pronation were 145°, 6°, 82°, and 80°, respectively; mean Mayo Elbow Performance Score, modified-American Shoulder and Elbow Surgeons Scores, and Quick-Disability of the Arm Shoulder and Hand scores were, respectively, 97, 92, and 4.9 points. There was no statistical difference between early and final follow-up range of motion, Mayo Elbow Performance Score, and Quick-Disability of the Arm Shoulder and Hand. However, radiological changes were observed in 66% of the patients at final follow-up. Two patients underwent reoperation, with final satisfactory results. CONCLUSION: Our results suggested that using a standardized protocol, satisfactory clinical outcomes at early follow-up could be maintained over time. However, early complications and osteoarthritic changes at long-term follow-up can be expected. LEVEL OF EVIDENCE: Therapeutic IV Cases series.

Comparative Study of Internal Fixation of the Ulna and Distal Ulna Resection in Patients Older Than 70 Years With Distal Radius and Distal Metaphyseal Ulna Fractures.

Background: Acute management of fractures of the distal ulna that are associated with fractures of the distal radius remains difficult, particularly in the elderly. Methods: In this study, we investigated whether internal fixation of the distal ulna is associated with a higher rate of complications than resection of the distal ulna in patients older than 70 years. Twenty-four consecutive patients were included in this study, 12 of whom had undergone open reduction and internal fixation (ORIF) of the distal ulna, and 12 who had undergone distal ulna resection. Patients were retrospectively assessed for range of motion, grip strength, pain, and radiographic appearance. The functional outcome was evaluated by the Mayo Wrist Score. Complications were classified according to the Classification of Surgical Complications. Results: There were no differences in patient demographics between the 2 groups, except patient age. Clinical evaluation showed no difference at follow-up; however, there were significantly more complications associated with ORIF compared with resection. Conclusions: The results from our study show that women older than 70 years with fracture of the distal radius and distal ulna have a higher rate of complications if ORIF of the distal ulna is performed. Patients should be warned, by surgeons, of this in cases where ORIF of the distal ulna is suggested.

Bloqueo óseo metafisario de radio y fijación estable en seudoartrosis de polo proximal de escafoides sin necrosis / Radial metaphyseal core decompression and stable fixation of proximal pole scaphoid nonunion without osteonecrosis

Objetivo: Reportar la tasa de consolidación y los resultados de una serie de 22 pacientes con seudoartrosis del polo proximal del escafoides tratados con un bloqueo óseo metafisario asociado a un tornillo autocompresivo anterógrado. Materiales y Métodos: Serie prospectiva de pacientes con seudoartrosis del polo proximal del escafoides en quienes se constató un sangrado intraoperatorio en ambos fragmentos. Se excluyó a los pacientes con desplazamiento, cambios degenerativos, fragmentación del polo proximal, cavitación del foco, pérdida de altura, necrosis y aquellos con inestabilidad carpiana. Se tomaron radiografías e imágenes por tomografía computarizada para evaluar su consolidación; se registraron la movilidad y la fuerza de puño, y los pacientes completaron una escala analógica visual para dolor en reposo, dolor en actividad, estado subjetivo funcional y el cuestionario DASH. Resultados: La serie incluyó 18 pacientes. Diecisiete presentaron consolidación. El seguimiento promedio fue de 22 meses y la movilidad final promedio fue: flexión 87%, extensión 84%, desviación radial 78%, desviación cubital 84% y fuerza de puño 85%. El puntaje promedio de la escala analógica visual fue 0 para dolor en reposo; 2, para dolor en actividad y 9 para función, en tanto que el puntaje DASH promedio fue de 8. Conclusiones: Con esta técnica confiable y sencilla, obtuvimos una tasa de consolidación del 95% y un muy buen resultado funcional. El bloqueo óseo metafisario asociado a un tornillo anterógrado constituye una alternativa válida y eficaz para tratar la seudoartrosis del polo proximal del escafoides, vital en pacientes cuidadosamente seleccionados. Nivel de Evidencia: IV

Objective: To report the consolidation rate and the outcomes of a series of 22 patients with proximal pole scaphoid nonunion treated with a metaphyseal core decompression and an anterograde self-compressing screw. Methods: We present a prospective series of patients with proximal pole scaphoid nonunion and confirmation of intraoperative bleeding in both fragments. Patients presented with displacement, degenerative changes, proximal pole fragmentation, cavitation at the fracture site, reduced bone length, and necrosis, as well as those with carpal instability, were excluded. X-rays and computed tomography scans were performed to assess consolidation; range of motion and grip strength were recorded, and patients completed a visual analogue scale for pain at rest, pain during activity, and subjective functional status, as well as a DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire. Results: Eighteen patients were included. Union was observed in 17 patients. The average follow-up time was 22 months and the average final range of motion was as follows: 87% for flexion, 84% for extension, 78% for radial deviation, 84% for ulnar deviation, and 85% for grip strength. The average score on the visual analogue scale was 0 point for pain at rest, 2 for pain during activity, and 9 for function, while average DASH score was 8. Conclusions: Using this simple and reliable technique, we obtained 95% union and very good functional results. Metaphyseal core decompression with an antegrade screw is a valid and effective alternative for the treatment of proximal pole scaphoid nonunion in carefully selected patients. Level of Evidence: IV

Femoral Osteonecrosis after Medial Femoral Condyle Bone Graft Harvest.

The medial femoral condyle vascularized graft has become a useful resource in reconstructive microsurgery due to the rate of bony union, and the low rate of complication. We report osteonecrosis of the medial femoral condyle in a 65-year-old woman after harvesting a corticocancellous medial femoral condyle graft to treat a tarsometatarsal nonunion. We were not able to define whether a vascular or mechanical disorder could be the ultimate cause. However, because of the severity of the complication, we suggest informing patients who will undergo a medial femoral condyle flap about this infrequent complication.

Versatilidad del colgajo libre anterolateral de muslo en la reconstrucción de defectos de cobertura en los miembros superiores e inferiores / Versatility of the anterolateral thigh free flap in the reconstruction of coverage defects

Introducción: El colgajo libre anterolateral de muslo es actualmente una de las opciones reconstructivas más útiles. Su versatilidad se debe a la inclusión de distintos tipos de tejido en diferentes combinaciones, una anatomía local confiable y un pedículo largo con un calibre adecuado. El objetivo de este estudio es revisar nuestra experiencia y evaluar la versatilidad del colgajo en defectos de los miembros superiores e inferiores. Materiales y Métodos: Estudio retrospectivo. Se consideraron pacientes tratados por defectos en las extremidades. Se analizaron variables preoperatorias, intraoperatorias y posoperatorias. Resultados: Se incluyeron 12 pacientes (7 hombres y 5 mujeres) con una edad promedio de 44 años. La causa del defecto fue resección oncológica (9 casos) y trauma (3 casos). La localización fue el miembro superior en cuatro casos y el miembro inferior en ocho pacientes. El tiempo promedio entre el defecto y la cirugía fue de 8 días. La tasa de supervivencia del colgajo fue del 92%, con falla en un caso. El sitio donante no presentó complicaciones, el cierre fue primario en 10 pacientes y con injerto de piel en dos. Conclusiones: El colgajo libre anterolateral de muslo es un recurso válido y de gran utilidad para la cobertura de defectos de diferentes etiologías tanto en los miembros superiores como en los miembros inferiores, ya que su versatilidad permite que se adapte con éxito en defectos de localización y tamaño variados. Nivel de Evidencia: IV

Introduction: The anterolateral thigh free flap is currently one of the most useful reconstructive options. A long pedicle with suitable vessel diameter, reliable anatomy and the availability of different tissues with large amounts of skin make this flap versatile. The purpose of this study was to evaluate the flap versatility in a series of patients with coverage defects in both, the upper and lower limbs. Methods: A retrospective study was performed. Inclusion criteria were patients with defects in the limbs to whom this flap was made as a reconstructive treatment. Preoperative, intraoperative and postoperative variables were analyzed. Results: Twelve patients (7 men and 5 women) with an average age of 44 years were included. Defects were caused by oncological resection (9 patients) and trauma (3 cases). In 4 cases the defect was in the upper limb and in 8 cases in the lower limb. The average time from the defect to the reconstructive surgery was 8 days. The survival rate of the flap was 92%, with only one failure. Donor site presented no complications and primary closure was performed in all cases, except for two requiring closure with skin graft. Conclusions: Anterolateral thigh free flap is a valid and very useful resource to cover defects of different etiologies in the upper and lower limbs since its versatility allows its successful adaptation in defects of varied location and size. Level of Evidence: IV

Colgajo de recto anterior del abdomen para el tratamiento de los defectos de cobertura lumbosacros / Rectus abdominis flap for the treatment of lumbosacral coverage defects

Introducción: El principio de tratamiento de los defectos de cobertura lumbosacros se basa en el manejo del espacio muerto y la cobertura del defecto. El objetivo de este estudio es presentar la técnica quirúrgica, los resultados y las complicaciones de una serie de pacientes tratados con colgajo de recto anterior para defecto lumbosacro. Materiales y Métodos: Se efectuó una revisión retrospectiva durante un período de seis años. Se analizaron variables demográficas preoperatorias. Se describen la técnica quirúrgica y las complicaciones intraoperatorias. Se analizaron las variables posoperatorias, como complicaciones del sitio donante, complicaciones del sitio receptor y duración del colgajo. Resultados: Cinco pacientes cumplieron con los criterios de inclusión (edad promedio 50 años): cuatro con tumor sacro y una paciente con osteomielitis lumbosacra. El seguimiento promedio fue de 20 meses. El tamaño promedio de la pastilla cutánea fue de 8 x 13 cm. Entre las complicaciones, se registró una lesión del pedículo intraoperatoria (reparación microquirúrgica) y el óbito de un paciente. Se evidenció una infección con dehiscencia de la herida como complicación posoperatoria. No hubo complicaciones vasculares posoperatorias en los colgajos y todos permanecieron vitales durante el seguimiento. Conclusión: El colgajo de recto anterior ha de ser considerado una opción válida en el tratamiento de heridas con grandes defectos de partes blandas a nivel lumbosacro. Provee de suficiente volumen de piel y tejido muscular para la cobertura de dichos defectos. La técnica es relativamente sencilla sin necesidad de procedimiento microquirúrgico. Nivel de Evidencia: IV

Introduction: Treatment of soft tissue lumbosacral defects is based on dead space management and defect coverage. The aim of this study is to describe the surgical technique, results and complications of patients who underwent rectus abdominis flap for lumbosacral defects coverage. Methods: A six-year retrospective review was performed. Demographic characteristics are analyzed. Surgical technique and intra-operative complications are described. Postoperative variables, such as donor site complications, recipient site complications, and flap survival were also reported. Results: Five patients met the inclusion criteria (average age, 50 years). Four patients presented sacral tumor diagnosis and one patient had lumbosacral osteomyelitis. Mean follow-up was 20 months. Flap average size was 8 x 13 cm. Intraoperative complications were one pedicle injury (microsurgical repair) and the death of a patient. Regarding postoperative complications, one wound dehiscence was reported. None of the flaps suffered vascular complications and all remained vital throughout follow-up. Conclusion: Rectus abdominis flap should be considered a valid option in the management of large soft tissue lumbosacral defects. This flap provides sufficient skin volume and muscular tissue. Surgical technique is relatively simple with no need for microsurgical procedure. Level of Evidence: IV

Descompresión ósea metafisaria del radio distal para estadios tempranos de la enfermedad de Kienböck: Seguimiento mínimo de 10 años / Metaphyseal bone decompression of distal radius for early stages of Kienböck's disease. Minimum follow-up of 10 years

Introducción: El objetivo de este estudio es analizar los resultados clínicos y radiológicos a largo plazo de una serie de pacientes con enfermedad de Kienböck en estadios II y IIIA de la clasificación de Lichtman, tratados mediante descompresión metafisaria del radio distal. Materiales y Métodos: Estudio retrospectivo y descriptivo que incluyó a 23 pacientes con enfermedad de Kienböck (estadios II y IIIA de Lichtman) tratados mediante descompresión metafisaria del radio distal con, al menos, 10 años de seguimiento. Al final del seguimiento, se evaluaron el rango de movilidad de la muñeca, la fuerza de puño, mediante la escala de la Clínica Mayo modificada y el dolor, según la escala analógica visual. Se valoró a los pacientes radiográficamente según la clasificación de Lichtman y el índice de altura carpiana. Resultados: El seguimiento promedio fue de 14 años (rango 10-19). Nueve pacientes eran mujeres y catorce, hombres. Quince casos correspondían al estadio IIIA y ocho, al estadio II. Según la escala de la Clínica Mayo, los resultados fueron excelentes en 9 pacientes, buenos en 11 pacientes, moderados en 2 y pobres en uno. El puntaje en la escala analógica visual preoperatoria fue 7 (rango 6-10) y 1,1 (rango 0-6) al final del seguimiento. El arco de flexión/extensión promedio fue del 78% y la fuerza de puño, del 81%. Según la clasificación de Lichtman, hubo progresión en 4 pacientes, mientras que los otros 19 permanecieron en la misma etapa que en el preoperatorio. Conclusión: La descompresión metafisaria del radio distal logró resultados favorables a largo plazo para los estadios II y IIIA de la enfermedad de Kienböck. Nivel de Evidencia: IV

Introduction: The purpose of this study is to analyze the long-term clinical and radiological results of a series of patients with early stages of Kienböck disease treated with radius core decompression. Methods: This retrospective study included 23 patients with Kienböck's disease (Lichtman stage II and IIIA) who underwent distal radius metaphyseal core decompression, and were controlled for at least 10 years. At the last follow-up, wrist range of motion and grip strength using the modified Mayo wrist score and pain using the visual analogue scale were evaluated. Patients were also radiographically evaluated with the Lichtman classification and the modified carpal height ratio. Results: The mean follow-up period was 14 years (range 10-9). Nine patients were women and fourteen were men. Fifteen cases belonged to IIIA stage and 8 to II stage. Based on the modified Mayo wrist score, results were excellent in 9 patients, good in 11 patients, fair in 2 and poor in one patient. Preoperative pain score according to VAS was 7 (range 6-10) and 1.1 (range 0-6) at the final follow-up. Average flexion/extension arc was 78% and the grip strength was 81%. Radiographic disease progression according to Lichtman classification occurred in four wrists, while the remaining 19 patients remained without changes. Conclusion: Radius core decompression achieved long-term favorable results in the early stages of Kienböck disease. Level of Evidence: IV

Refractory actinomycosis of the humerus.

Actinomycosis is a chronic, opportunistic infection caused by Actinomyces species, such as Actinomyces bacillus. Actinomycosis in long bones is very rare. To the best of our knowledge, isolated primary actinomycosis of the humerus is rarely reported in literature. We present a rare case of a refractory primary actinomycosis of the humerus. A 66-year-old man with no history of concomitant conditions was admitted to our hospital with a history of a tumour on the distal third of the left arm as a result of a closed trauma without fracture 20 years before. Pathological anatomy samples showed the presence of Actinomyces. Cultures were subjected to a prolonged incubation of 21 days under aerobic and anaerobic conditions and were always negative. He underwent several surgical procedures and received long-term antibiotic therapy with poor outcome. Primary actinomycosis in long bones is uncommon. Diagnosis may be challenging: considering the small number of case studies reported in the literature, symptoms are not specific, and the organism is difficult to isolate. Antibiotic treatment may not be sufficient to improve the clinical condition, and surgical alternatives should be considered.

Patología tendinosa en pacientes con placa bloqueada palmar de radio distal: incidencia y resultado clínico del tratamiento / Tendon pathology in patients with distal radius palmar locked plate: incidence and clinical outcome of their treatment

Introducción: El objetivo de este estudio es comunicar la incidencia de complicaciones tendinosas en pacientes con fracturas de radio distal tratados con placa bloqueada palmar y el resultado clínico del tratamiento mediante la sola extracción del implante. Materiales y Métodos: Se realizó una evaluación retrospectiva de 992 pacientes con fracturas de radio distal. Se incluyó a quienes se les extrajo la placa por irritación o rotura tendinosa. La evaluación final de los resultados, una vez extraído el implante, se efectuó con el puntaje DASH y una escala analógica visual de 0 a 10 para dolor en reposo, durante la actividad y para el resultado funcional. Resultados: Treinta y cuatro pacientes tuvieron complicaciones tendinosas: 20 tendinitis de flexores (2%), 13 tendinitis de extensores (1,3%) y una rotura de tendón flexor. Todos fueron tratados sólo con extracción del implante. En la escala analógica visual, los pacientes con tendinitis flexora obtuvieron un puntaje de 1 para dolor en reposo, de 1 para dolor durante la actividad y de 8 para resultado funcional, y un puntaje DASH de 13. La evaluación final promedio de los pacientes con tendinitis extensora fue: dolor en reposo 0, dolor durante la actividad 3, funcional 9 y DASH 15, respectivamente. Conclusiones: La incidencia de complicaciones tendinosas en el tratamiento de las fracturas de radio distal con placas palmares es baja. El tratamiento precoz mediante la sola extracción del implante lleva a la desaparición de los síntomas y evita la rotura tendinosa. Nivel de Evidencia: IV

Introduction: The aim of this paper is to report the incidence of tendon complications in patients with distal radius fractures treated with volar locking plates and the clinical results after plate removal. Methods: A total of 992 patients with distal radial fracture treated with volar locking plates were retrospectively evaluated. Cases with plate removal due to tendon irritation were included in this study. Clinical results were evaluated using DASH score and a visual analogue scale for pain at rest, during activity and functional result. Results: Thirty-four patients had tendon complications: 20 with flexor tendonitis (2%), 13 with extensor tendonitis (1.3%), and a flexor tendon rupture. All cases were treated only with implant removal. Final mean results were: visual analogue scale, 1 for pain at rest, 1 for pain during activity, and 8 for function; DASH score 13 in patients with flexor tendinitis; and 0, 3, 9, respectively, and DASH score 15 for those with extensor tenosinovitis. Conclusions: Tendon complications are infrequent in patients with distal radial fractures treated with volar locking plate. The early removal of the implant improves tendon irritation symptoms and prevents tendon rupture. Level of Evidence: IV

Delayed Repair of Ulnar Artery at the Distal Forearm.

Background:The purpose of this study was to evaluate the rate of patency after delayed repair of the ulnar artery following primary ligation. Methods: Adult patients with primary ligation of the injured ulnar artery at the forearm who had a delayed repair of the artery were included. Postoperative arterial patency was determined by either physical examination or color Doppler ultrasonographic imaging. Postoperative complications and Disabilities of the Arm, Shoulder and Hand score were recorded. Results: Eight consecutive patients during a 3-year period were included. The mean age was 35 years. Four cases were women. The surgery was performed at a mean of 5 days after the injury and ligation. At a mean follow-up of 22 months, 7 patients had a patent artery. One patient suffered a hematoma. Conclusions: A high rate of patency can be obtained after delayed repair of the ulnar artery at the forearm.

Combined Tenodesis-Capsulodesis for Scapholunate Instability: Minimum 2-Year Follow-Up.

Background The aim of this study is to evaluate the clinical and radiological midterm results of a combined dorsal tenodesis-capsulodesis for static and reducible scapholunate dissociation (SLD). Patients and Methods We evaluated 20 of 22 consecutive patients with static SLD minimum with follow-up of 2 years operated between 2003 and 2012. The mean age was 40 years (range: 23-65 years). Seventeen were men. Final evaluation included comparative wrist range of motion (ROM) and grip strength, pre- and postoperative pain and function by visual analog scale, and QuickDASH and Wrightington scores. Radiographs included preoperative, early postoperative, and final X-rays. Scapholunate space (SLS) and scapholunate and radioscaphoid angles (SLA and RSA) were measured. Statistical significance was evaluated with Student t-test, considered significant when p < 0.05. Results Mean follow-up was 67 months (range: 24-126 months). Mean final ROM was: flexion 55 degrees (73%), extension 62 degrees (90%), radial deviation 19 degrees (82%), and ulnar deviation 44 degrees (90%). Mean grip strength was 44 kg (92%). Pain at rest improved from 3.4 to 0.5 (p < 0.05). Pain in activity improved from 7 to 1.7 (p < 0.05). Final function was 8.5 (preoperative, 5.2; p < 0.05). Mean QuickDASH score improved from 38 to 8 (p < 0.05). Functional Wrightington score was as follows: 13 excellent, 3 good, 1 regular, and 3 poor. There were three postoperative minor complications. Radiological results (preoperative/early postoperative/final follow-up) were as follows: SLS, 4.7/1.6/1.8 mm; and SLA, 60/50/62 degrees; RSA, 39/45/37 degrees. Four patients showed arthritic changes (two SLAC wrist). Conclusion The clinical and radiological results with more than 2-year follow-up suggest that this technique may be effective, reproducible, and safe for symptomatic static and reducible SLD. Level of Evidence Level IV, case series.

Ganglion dorsal de muñeca: reseccion artroscopica con tecnica "en seco". Seguimiento minimo de dos años / Dorsal wrist ganglion: arthroscopic resection with "dry" technique. Minimum follow-up of two Years

Introducción: El objetivo de este estudio fue comunicar los resultados a mediano plazo de la reseccion artroscopica de gangliones dorsales de muneca utilizando la tecnica "en seco". Materiales y Métodos: Se evaluo retrospectivamente a 22 pacientes (22 munecas) con un seguimiento minimo de 2 años. Once mujeres y 11 hombres con una edad promedio de 29 anos (rango 18-57). Se realizaron evaluaciones clinicas preoperatoria, al mes de la cirugia y en el ultimo control. Se evaluaron la movilidad y la fuerza de puno comparativas, el dolor y la funcion segun la escala analogica visual, los puntajes funcionales QuickDASH y de Wrightington, el retorno laboral y las complicaciones intraquirurgicas y posquirurgicas. Seguimiento promedio: 42 meses (rango 24-60). Se realizo un analisis estadistico mediante la prueba t. Resultados: Hubo 2 recidivas del ganglion. No se registraron otras complicaciones. La movilidad y la fuerza de puno comparativas mejoraron significativamente, 99% y 100%, respectivamente. El dolor y la funcion tambien mejoraron significativamente, al igual que el puntaje QuickDASH. Segun la escala de Wrightington, 18 casos resultaron excelentes; 3, buenos, y uno fue malo. Veintiuno de los 22 pacientes retornaron a sus tareas laborales sin limitaciones, 20 refirieron estar satisfechos con el resultado. Conclusión: La reseccion artroscopica utilizando la tecnica "en seco" representa una alternativa segura y eficaz para el tratamiento de los gangliones dorsales de muneca, logra aliviar el dolor, y una mejoria funcional y estetica en la mayoria de los pacientes mediante una rehabilitacion temprana, con una baja incidencia de recidiva. Nivel de Evidencia: IV

Introduction: The purpose of this study is to describe the medium-term results of arthroscopic resection of dorsal wrist ganglia using the "dry technique". Methods: Twenty-two patients (22 wrists) were retrospectively evaluated with a minimum follow-up of 2 years. Eleven women and 11 men with an average age of 29 years (range 18-57). A clinical evaluation was performed preoperatively, at one month, and at the last control visit. Comparative wrist motion and grip strength, pain and function according to the visual analogue scale, functional QuickDASH and Wrightington scores, return to work, and intra and postoperative complications were evaluated. Mean follow-up was 42 months (range 24-60). Statistical analysis was performed using t test. Results: Two cases of ganglion recurrence were observed. No other complication was reported. Wrist motion and grip strength improved significantly, reaching 99% and 100%, respectively. Pain and function also improved significantly, as the functional QuickDASH score. According to Wrightington score, 18 cases were excellent, 3 were good, and one poor result. Twenty-one patients returned to their tasks without limitation, 20 of them refered to be satisfied with the final result. Conclusion: Arthroscopic resection using the "dry technique " represents a safe and effective alternative for the treatment of dorsal wrist ganglia, achieving pain relief, and functional and aesthetic improvement in most patients with early rehabilitation and a low incidence of recurrence. Level of Evidence: IV

Glenohumeral Arthrodesis With Locking Compression Plate.

Glenohumeral arthrodesis is performed for paralytic disorders. Internal fixation with plates has been described to diminish the rate of nonunion associated with this procedure. Because plates are located over the scapular spine and the acromion to add a point of bony union between the acromion and the humeral head, skin irritation and hardware removal are the main complications associated with plates. We describe a technique using a locking compression plate placed under the acromion to decrease complications associated with the hardware without increasing the risk of nonunion. The technique presented here has 2 biomechanical principles of fixation: compression and neutralization. Compression by 2 screws allows for a bony union at the glenohumeral joint, and neutralization by the locking compression plate allows for early postoperative motion.

Inestabilidad posterolateral cronica de codo. reconstruccion ligamentaria / Chronic posterolateral elbow instability. ligament reconstruction

Introducción: El objetivo de este trabajo es evaluar los resultados de una serie de pacientes con inestabilidad posterolateral crónica de codo, tratados con reconstrucción del ligamento colateral cubital con injerto tendinoso. Materiales y Métodos: Se presentan 10 pacientes, con una edad promedio de 47 años. El tiempo entre la luxación y la cirugía fue de 16 meses. El pivot shift test bajo anestesia fue positivo en todos los casos. Bajo control radioscópico, siete pacientes tenían un estadio 1 de Horii; dos, estadio 3 y uno tenía un estadio 2. En la mayoría de los casos, se utilizó el tendón del palmar menor. El seguimiento promedio fue de 21 meses. Resultados: La flexo-extensión fue de 126-3º. El dolor fue 0 en reposo y 1 en actividad, según la escala analógica visual. El puntaje DASH promedio fue 12 y el de la Clínica Mayo de 95. Ningún paciente reportó sensación de inestabilidad. El pivot shift test con el paciente despierto fue negativo en todos los casos. Conclusiones: La reconstrucción del ligamento lateral del codo con injerto tendinoso en pacientes con inestabilidad posterolateral crónica es eficaz para lograr la estabilidad articular. Los mejores resultados se observaron en pacientes con estadios 1 y 2 de inestabilidad. No hubo casos de inestabilidad residual.

Introduction: The objective of this paper is to evaluate the results of a series of patients with posterolateral elbow instability treated with reconstruction of the ulnar collateral ligament using tendon graft. Methods: We reported 10 patients with a mean age of 47 years. Time from posterolateral dislocation to surgery was 16 months. The pivot shift test under anesthesia was positive in all patients. Seven patients had stage 1 instability according to Horii, one patient with stage 2 and two patients with stage 3 under fluoroscopy. Palmaris minor was the most common tendon used for reconstruction. Follow-up was 21 months. Results: Flexo-extension was 126-3º. Pain according to visual analogue scale was 0 at rest and 1 in activity. DASH score was 12 and Mayo Clinic score was 95. Sensation of instability was not reported by any patient. The pivot shift test in an awake patient was always negative. Conclusions: Ulnar collateral ligament reconstruction with tendon graft in patients with posterolateral elbow instability is useful to restore joint stability. Best results were observed in patients with stage 1 or 2 instability according to Horii. Residual instability was not observed.

Simultaneous Bilateral Rupture of the Triceps Tendon in a Renal Transplant Patient.

The unilateral rupture of the triceps brachii tendon is a rare lesion representing 1% of all tendon injuries. The most common causes are the result of a contraction against resistance (especially weightlifters) and direct trauma. It has also been associated with systemic diseases such as diabetes mellitus, chronic renal failure, secondary hyperparathyroidism, and use of systemic corticosteroids. Simultaneous bilateral rupture of the triceps tendons is less frequent and has been described in association with chronic metabolic disorders, especially in those patients on hemodialysis. This paper presents a case of bilateral triceps tendon rupture of a 36-year-old woman with renal transplantation secondary to chronic renal failure. Early surgical repair was performed using a bone tunnel technique with a nonabsorbable suture. Clinically active extension with 135 degrees of range of motion was achieved.