Long-term recurrence of Dupuytren's disease treated with clostridium histolitycum collagenase. Surgical treatment and anatomopathological study.

OBJECTIVE: To present the functional results obtained and the possible surgical difficulties after the surgical treatment of Dupuytren's disease (DD) recurrence in patients previously treated with Clostridium histolyticum (CCH) collagenase. MATERIALS AND METHODS: In this prospective study, 178 patients with DD were treated with CCH from 2011 to 2018; During long-term postoperative follow-up, 34 patients (19.1%) had recurrence of DD. In all patients injected in the IFP the disease recurred; In patients injected in the MCP, recurrence was highest in grade III and IV of the Tubiana classification, with involvement of the 5th finger and the two-finger Y-chord. Fourteen patients (7,8%) required surgery by partial selective fasciectomy due to recurrence of cord DD infiltration. The clinical and functional results of the patients, the difficulty of the surgical technique and the anatomopathological analysis of the infiltrated cords were evaluated in comparison with those of cords and patients who had had no previous CCH treatment. RESULTS: In all patients, cord rupture was achieved after injection, reducing joint contracture. In 14 patients, we observed during the follow-up the existence of DD recurrence that required surgical treatment by selective partial fasciectomy. There were no major difficulties in surgery and good clinical and functional results at 6 months of follow-up. The anatomopathological study of the resected tissue did not present histological alterations with respect to the samples obtained from patients initially treated by selective partial fasciectomy. CONCLUSIONS: Selective fasciectomy after CCH injection does not lead to important operative difficulties, as long as the CCH injection is performed according to the recommendations. There were no histological changes in the tissue after CCH injection. LEVEL OF EVIDENCE: III.

Functional survival of cementless trapeziometacarpal total joint arthroplasty after upper extremity trauma.

INTRODUCTION: Our purpose with this publication is to document the survival of uncemented and unconstrained total trapeziometacarpal arthroplasty after energy trauma to the upper extremity. MATERIAL AND METHODS: From 1999 to the present, ten patients carrying total TMC arthroplasty suffered major traumatic injuries on the hand. Eight patients had fractures of the distal radius, one patient had scapho-lunate dissociation and one patient had a dorsal pullout of the triquetrum. A clinical and radiological examination of the patients after the trauma was carried out and compared with the pre-traumatic prosthesis status. RESULTS: Three patients required surgical intervention for the associated traumatic injury. The postraumatic clinical and functional follow-up of the patients was good, and no differences were documented with respect to mobility, strength and pain at the level of the thumb with respect to the prior to the trauma. No signs of loosening, instability or alteration in the alignment of the components of the protheses were observed in the radiological examinations following the trauma. CONCLUSIONS: There is a high survival rate of uncemented total trapeziometacarpal arthroplasty in the long term, even in the face of energy trauma. It is then a safe implant. Despite of being non-constrained, a good alignment of the prosthetic components is the key to avoid dislocation of the prosthesis.

Efficacy comparison of intraperitoneal anaesthesia and post-operative analgesia regimens in laboratory rats.

INTRODUCTION: Effective and safe anesthesia for rodents has long been a leading concern among biomedical researchers. Intraperitoneal injection constitutes an alternative to inhalant anesthesia. PURPOSE: The aim of this study was to identify a safe, reliable, and effective anesthesia and postoperative analgesia protocol for laboratory rats exposed to painful procedures. MATERIAL AND METHODS: Twenty-seven female Wistar rats in an ongoing study that required surgery were randomized into groups for three different intraperitoneal anesthesia protocols and three different analgesia regimens. The anesthesia groups were (1) medetomidine + ketamine (MK), (2) ketamine + xylacine (KX), and (3) fentanyl + medetomidine (FM). Three analgesia groups were equally distributed among the anesthesia groups: (1) local mepivacaine + oral ibuprofen (MI), (2) oral tramadol + oral ibuprofen (TI), and (3) local tramadol + oral tramadol + + oral ibuprofen (TTI). A core was assigned to measure anesthesia (0-3) and analgesia (0-2) effectiveness; the lower the score, the more effective the treatment. RESULTS: The mean MK score was 0.44 versus 2.00 for FM and 2.33 for KX. Mean score for analgesia on the first postoperative day was TTI (4.66) TI (9.13), and MI (10.14). Mean score 48 hours after surgery was TTI (3.4), TI (6.71), and MI (9.5). These differences were statistically significant. CONCLUSION: MK was shown to be a reliable, safe, and effective method of anesthesia. The TTI analgesia regimen is strongly recommended in light of these results.

Efficacy and safety of the topical application of tranexamic acid in primary cementless hip arthroplasty: prospective, randomised, double-blind and controlled study. / Eficacia y seguridad de la aplicación del ácido tranexámico tópico en la artroplastia primaria no cementada de cadera: estudio prospectivo, aleatorizado, doble ciego y controlado.

OBJECTIVE: To evaluate the efficacy of topical tranexamic acid topical in cementless total hip arthroplasty from the point of view of bleeding, transfusion requirements and length of stay, and describe the complications of use compared to a control group. MATERIAL AND METHODS: A prospective, randomised, double-blinded and controlled study including all patients undergoing cementless total hip arthroplasty in our centre between June 2014 and July 2015. Blood loss was estimated using the formula described by Nadler and Good. RESULTS: The final analysis included 119 patients. The decrease in haemoglobin after surgery was lower in the tranexamic acid group (3.28±1.13g/dL) than in the controls (4.03±1.27g/dL, P=.001) and estimated blood loss (1,216.75±410.46mL vs. 1,542.12±498.97mL, P<.001), the percentage of transfused patients (35.9% vs. 19.3%, P<.05) and the number of transfused red blood cell units per patient (0.37±0.77 vs. 0.98±1.77; P<.05). There were no differences between groups in the occurrence of complications or length of stay. CONCLUSIONS: The use of topical tranexamic acid in cementless total hip arthroplasty results in a decrease in bleeding and transfusion requirements without increasing the incidence of complications.

Isolated scaphotrapeziotrapezoid osteoarthritis treatment using resurfacing arthroplasty with scaphoid anchorage. / Tratamiento de la artrosis escafotrapeciotrapezoidea aislada con artroplastia de recubrimiento con anclaje escafoideo.

OBJECTIVE: The aim of this study is to show the results of scaphotrapeziotrapezoid (STT) joint osteoarthritis treatment performing resurfacing arthroplasty with scaphoid anchorage. MATERIAL AND METHOD: An observational, descriptive and retrospective study was performed. Ten patients with isolated STT joint osteoarthritis were studied between 2013 and 2015. The mean follow-up time was 26months. Clinical results, functional and subjective scores were reviewed. RESULTS: The patients were satisfied, achieving an average of 2.1 (0-3) on the VAS score and 16 (2 to 28) in the DASH questionnaire, and returning to work in the first three months post-surgery. Recovery of range of motion compared to the contralateral wrist was 96% in extension, 95% in flexion, 87% in ulnar deviation and 91% in radial deviation. The average handgrip strength of the wrist was 95% and pinch strength was 95% compared to the contralateral side. There were no intraoperative complications or alterations in postoperative carpal alignment. CONCLUSION: Resurfacing arthroplasty is proposed as a good and novel alternative in treating isolated SST joint arthritis. Achieving the correct balance between the strength and mobility of the wrist, without causing carpal destabilisation, is important to obtain satisfactory clinical and functional results.

Repair of nerve injury by implanting prostheses obtained from isogenic acellular nerve segments. / Reparación de lesiones en nervios mediante el implante de prótesis obtenidas de segmentos acelulares de nervio isogénico.

INTRODUCTION: When a nerve section with a significant gap occurs, it is necessary to use a prosthesis to suture it. To date an autologous nerve segment graft appears to be the best treatment; but it has several important disadvantages. Our goal is to study the effectiveness of an isogenic acellular nerve prosthesis comparing a simple suture with tubulisation. MATERIAL AND METHOD: Four groups of Wistar rats were used. The animals in Group 0 served as donors of nerve segments to graft. Group 1 received the implant with an end-to-end suture. In group 2, the implant was sutured inside an ɛ-caprolactone tube. Group 3 received it in a polylactic-co-glycolic acid tube. We evaluated the motor function (sciatic index and step test in motion), and the regeneration length by histological study of regeneration, after a maximum of 3 weeks. RESULTS: Regeneration was uneven in the three groups. In all groups, there were implants with regenerated nerve fibres at the maximum studied length (15mm) and others where regeneration was scarce. The mean regeneration length was greater in the direct end-to-end suture group (G1), although the regeneration speed was similar in the three groups. Group 1 showed the highest percentage of regeneration, but the variability of results prevents this difference reaching statistical significance. We found no significant differences between the two groups with polymer tubes. CONCLUSION: For the implantation of isogenic acellular nerve prosthesis, under our experimental conditions, the direct end-to-end suture was more effective than when it isprotected with biopolymer tubes.

[Comparative clinical study of 2 surgical techniques for trapeziometacarpal osteoarthritis]. / Estudio clínico comparativo de 2 técnicas quirúrgicas de rizartrosis del pulgar.

OBJECTIVE: In trapeziometacarpal osteoarthritis (or rhizarthrosis), there is great controversy over the surgical technique to choose: simple trapeziectomy, resection-interposition arthroplasty, interposition arthroplasty suspension-or arthroplasty with implant or prosthesis. These latter 2 are the most used without consensus in the literature on the technique to choose and without sufficient comparative studies. The objective is to compare the 2 techniques most used today: suspension-interposition arthroplasty and arthroplasty with prosthesis. MATERIAL AND METHOD: A prospective study was conducted on 15 patients diagnosed with grade 2-3 rhizarthrosis treated with interposition arthroplasty-suspension (group 1) and 15 with prosthesis (group 2) showing clinical outcomes, advantages and disadvantages of each. The study variables were the visual analogue scale (VAS), the DASH questionnaire, the grip strength, the strength of end to end and end-lateral clamp, the joint balance adduction-abduction and preemption-retropositioning, and the opposition. The 2 groups are from 2 different hospitals operated on by a hand surgeon from the Hand Unit. The follow-up time for all patients included in the study was 12 months. RESULTS: The VAS, DASH and grip strength at 12 months did not show significant differences. As regards the strength of end to end and end-lateral clamp, group 2 showed the highest values in all follow-up periods with statistically significant differences. CONCLUSIONS: Patient selection and surgical experience is essential, given the satisfactory results of both techniques. Arthroplasty prosthesis is reserved for grades 2 and 3, middle-aged patients, good trapezium architecture, and experienced surgeons.

[Results of surgical treatment of carpal scaphoid pseudarthrosis using the Fisk-Fernández technique]. / Resultados del tratamiento quirúrgico de la seudoartrosis de escafoides carpiano con la técnica de Fisk-Fernández.

AIM: The aim of the study was to evaluate the clinical and radiological results obtained in the treatment of carpal scaphoid non-union treated at the University Hospital of Valladolid using the Fisk Fernandez technique. MATERIAL AND METHODS: A review was performed on 43 cases of surgically treated non-union using Fisk Fernandez technique with a minimum of 6 months follow-up. The time until surgery, previous treatment, the mechanism of injury, type of non-union, and the existence of radio-carpal arthrosis were evaluated. A subjective evaluation was performed using the "Scaphoid Score" and the DASH, plus an objective assessment with the modified Green & O'Brien, together with the measurement of the intra-scaphoid, radioulnar, scapholunate angles, and carpal height. RESULTS: The median time to healing in the series was between 16 to 24 weeks, except in 3 patients who failed to heal and required salvage surgery. There was a statistically significant variation between the preoperative and postoperative angles and carpal height measured in the X-rays. DISCUSSION: There are different osteosynthesis techniques and materials for the treatment of non-union. The evaluation of results performed using objective and subjective scales showed variable results between studies. Different techniques are aimed at preventing the progression of the disease. CONCLUSION: The Fisk Fernandez technique enables the deformity of the scaphoid to be corrected by wedge grafting and internal fixation with Kirschner wires or screws.

Ambulatory surgery in orthopedics: experience of over 10,000 patients.

PURPOSE: The concept of day surgery is becoming an increasingly important part of elective surgery worldwide. Relentless pressure to cut costs may constrain clinical judgment regarding the most appropriate location for a patient's surgical care. The aim of this study was to determine clinical and quality indicators relating to our experience in orthopedic day durgery, mainly in relation to unplanned overnight admission and readmission rates. Additionally, we focused on describing the main characteristics of the patients that experienced complications, and compared the patient satisfaction rates following ambulatory and non-ambulatory procedures. METHODS: We evaluated 10,032 patients who underwent surgical orthopedic procedures according to the protocols of our Ambulatory Surgery Unit. All complications that occurred were noted. A quality-of-life assessment (SF-36 test) was carried out both pre- and postoperatively. Ambulatory substitution rates and quality indicators for orthopedic procedures were also determined. RESULTS: The major complication rate was minimal, with no mortal cases, and there was a high rate of ambulatory substitution for the procedures studied. Outcomes of the SF-36 questionnaire showed significant improvement postoperatively. An unplanned overnight admission rate of 0.14 % was achieved. CONCLUSIONS: Our institution has shown that it is possible to provide good-quality ambulatory orthopedic surgery. There still appears to be the potential to increase the proportion of these procedures. Surgeons and anesthesiologists must strongly adhere to strict patient selection criteria for ambulatory orthopedic surgery in order to reduce complications in the immediate postoperative term.

Tratamiento de la enfermedad de Dupuytren mediante la colagenasa del Clostridium histolyticum / Treatment of Dupuytren's disease using collagenase from Clostridium histolyticum

Objetivo. La colagenasa del Clostridium histolyticum es una nueva opción terapéutica y el primer tratamiento farmacológico en el tratamiento de la enfermedad de Dupuytren. Material y métodos. Estudio prospectivo de 35 pacientes afectos de la enfermedad de Dupuytren. Se evaluó los resultados clínicos, funcionales, la satisfacción del paciente y la seguridad del fármaco. Resultados. Los resultados funcionales y clínicos tras su administración son buenos sobre todo en la articulación metacarpofalángica, con una recuperación rápida. El índice de contractura del dedo MCF previo a la punción fue de 64° y tras la punción de 4°; en las IFP previo a la punción fue de 83,3 grados y tras la punción de 15°; en MCF/IFP previo a la punción fue de 140° y tras la punción de 25°. Conclusiones. Es una alternativa de tratamiento de la enfermedad de Dupuytren, fundamentalmente en los ancianos. La investigación es necesaria para clarificar el índice de recurrencia de la enfermedad, las posibles reacciones adversas y comparar la eficacia y durabilidad con otras alternativas de tratamiento (AU)

Objective: The collagenase from Clostridium histolyticum is a new therapeutic option, and the first pharmacological one, in the treatment of Dupuytren’s disease. Material and methods: A prospective study was conducted on 35 patients with Dupuytren’s disease. The clinical and functional variables, as well as patient satisfaction and drug safety were evaluated. Results: The functional and clinical results after its administration were good, with a rapid recovery, especially at the metacarpophalangeal (MCP) joint. The index finger contracture prior to MCP puncture was 64 degrees and after puncture it was 4 degrees. In the proximal interphalangeal (PIP) prior to puncture it was 83.3 degrees and after puncture it was 15 degrees; In the MCP/PIP prior to puncture it was 140 degrees, and after puncture it 25 degrees. Conclusions: Collagenase from Clostridium histolyticum an alternative of treatment of Dupuytren’s disease, mainly in the elderly. More research is required in order to clarify the rate of recurrence of the disease, the possible adverse reactions, and to compare the efficiency and permanence with other treatment options (AU)

[Treatment of Dupuytren's disease using collagenase from Clostridium histolyticum]. / Tratamiento de la enfermedad de Dupuytren mediante la colagenasa del Clostridium histolyticum.

OBJECTIVE: The collagenase from Clostridium histolyticum is a new therapeutic option, and the first pharmacological one, in the treatment of Dupuytren's disease. MATERIAL AND METHODS: A prospective study was conducted on 35 patients with Dupuytren's disease. The clinical and functional variables, as well as patient satisfaction and drug safety were evaluated. RESULTS: The functional and clinical results after its administration were good, with a rapid recovery, especially at the metacarpophalangeal (MCP) joint. The index finger contracture prior to MCP puncture was 64 degrees and after puncture it was 4 degrees. In the proximal interphalangeal (PIP) prior to puncture it was 83.3 degrees and after puncture it was 15 degrees; In the MCP/PIP prior to puncture it was 140 degrees, and after puncture it 25 degrees. CONCLUSIONS: Collagenase from Clostridium histolyticum an alternative of treatment of Dupuytren's disease, mainly in the elderly. More research is required in order to clarify the rate of recurrence of the disease, the possible adverse reactions, and to compare the efficiency and permanence with other treatment options.

La cirugía del síndrome del túnel carpiano en pacientes de edad avanzada / The surgery of carpal tunnel syndrome in elderly patients

Objetivo: Presentamos los resultados a largo plazo de la cirugía de descompresión del nervio mediano en la muñeca en pacientes de edad avanzada. Métodos: Estudio prospectivo histórico, de larga evolución, en 98 pacientes intervenidos de síndrome del túnel carpiano, considerados por grupos de edad, con un tiempo postoperatorio medio de diez años. Se realizó la valoración con el cuestionario clínico-funcional de Levine, electromiografía y dinamometría de los pacientes estudiados. Resultados: Para la mayor parte de las preguntas del cuestionario de Levine, así como para los valores de velocidad sensitiva y latencia motora del nervio mediano, encontramos diferencias favorables con respecto a la valoración preoperatoria. Sin embargo, los datos de fuerza de presión manual fueron desfavorables. Conclusiones: En pacientes de edad avanzada, la sección completa del ligamento transverso del carpo permite mantener diferencias favorables en la mayoría de los parámetros estudiados tras diez años desde la cirugía, siendo el tratamiento quirúrgico una opción recomendable(AU)

Purpose: We present in this article the long term outcomes of median nerve release at the wrist in elderly patients. Methods: Historical prospective long term study over 98 patients that received surgical treatment of carpal tunnel syndrome considered by aging and with a mean follow-up of ten years. A clinical-functional (with the Levine Questionnaire), electromyographic and dynamometric evaluation of the patients studied have been carried out. Results: For most of the items of the Questionnaire of Levine, as well as for the values of sensitive velocity and motor latency of the median nerve, we have found favourable differences with respect to the preoperative evaluation. The data of grip strength are unfavourable. Conclusions: In elderly patients, complete section of the carpal transverse ligament, allows maintaining favourable differences in most of the parameters studied, after ten years from the surgery, being the surgical treatment a recommendable option(AU)

[Regeneration of critical injuries of the peripheral nerve with growth factors]. / Regeneración de las lesiones críticas del nervio periférico con factores de crecimiento. Estudio experimental.

INTRODUCTION: This project aims to study the regeneration of non-repairable lesions of peripheral nerve by muscle grafts enhanced with growth factors. MATERIAL AND METHODS: The experiment was carried out in two phases. The first one compared direct suture of a critical defect in the sciatic nerve of ten rats, with the interposition of autologous muscle graft, denatured by heat, in another ten. The second phase compared ten rats with nerve repair using an acellular muscle graft, with injection of 2cc of IGF-1 (10mg/ml mecasermin, Injectable solution) into the acellular graft of another ten. A clinical and functional follow-up was carried out including, ambulation, footprint measurement, and "grasping test". . The animals were sacrificed at 90-100 days, and samples obtained for macro- and microscopic studies with toluidine blue, haematoxylin-eosin and Masson's trichrome staining. RESULTS: The first experiment showed the characteristic findings of nerve tissue in muscle graft level sections. The second was an enhancement of the results: post-surgical clinical improvement, early ambulation, decrease in the rate of pressure ulcers in toes, recovery of the footprint, and increasing the percentage of nerve endings in distal sciatic regeneration (47-62%). CONCLUSIONS: In this study the experimental and clinical possibilities of nerve defect repair by denatured muscle are demonstrated, confirming the suitability of the technique. Furthermore, it confirms our hypothesis with clinical and cellular determinations enriched by the addition of growth factors that promote nerve regeneration.

Regeneración de las lesiones críticas del nervio periférico con factores de crecimiento. Estudio experimental / Regeneration of critical injuries of the peripheral nerve with growth factors

Introducción. El objetivo del proyecto es estudiar la regeneración de las lesiones no reparables del nervio periférico, mediante un injerto muscular enriquecido con factores de crecimiento. Material y método. La experimentación se desarrolla en 2 fases: primero, comparamos la sutura directa del defecto crítico en el nervio ciático de 10 ratas, con la interposición de un injerto de músculo autólogo desnaturalizado por calor en otras 10. En la segunda, se comparan 10 ratas con reparación mediante injerto muscular acelular, con la inyección de 2 cc de IGF-1 (10 mg/ml de mecasermina, en solución inyectable) dentro del injerto acelular de otras 10. Realizamos el seguimiento clínico y el control funcional de la marcha, medición de la huella plantar y «Grasping Test». Fueron sacrificadas a los 90-100 días, obteniendo muestras para macro y microscopía, con tinciones de azul de toluidina, hematoxilina-eosina y tricrómico de Masson. Resultados. La primera experimentación demostró el hallazgo de tejido de características nerviosas en las secciones del injerto muscular. La segunda supuso una potenciación de los resultados: mejoría clínica posquirúrgica, precoz deambulación, descenso en la tasa de úlceras por presión en partes acras, recuperación de la huella plantar, e incremento del porcentaje de terminaciones nerviosas en regeneración del cabo distal (47-62%). Conclusiones. Exponemos en este trabajo las posibilidades experimentales y clínicas de la reparación del defecto nervioso mediante músculo desnaturalizado, confirmando la adecuación de la técnica. Además, confirmamos nuestra hipótesis con clínica y determinaciones celulares enriquecidas por la adicción de factores de crecimiento que impulsan la regeneración nerviosa (AU)

Introduction. This project aims to study the regeneration of non-repairable lesions of peripheral nerve by muscle grafts enhanced with growth factors. Material and methods. The experiment was carried out in two phases. The first one compared direct suture of a critical defect in the sciatic nerve of ten rats, with the interposition of autologous muscle graft, denatured by heat, in another ten. The second phase compared ten rats with nerve repair using an acellular muscle graft, with injection of 2 cc of IGF-1 (10 mg/ml mecasermin, Injectable solution) into the acellular graft of another ten. A clinical and functional follow-up was carried out including, ambulation, footprint measurement, and «Grasping Test». The animals were sacrificed at 90-100 days, and samples obtained for macro- and microscopic studies with toluidine blue, haematoxylin-eosin and Masson's trichrome staining. Results. The first experiment showed the characteristic findings of nerve tissue in muscle graft level sections. The second was an enhancement of the results: post-surgical clinical improvement, early ambulation, decrease in the rate of pressure ulcers in toes, recovery of the footprint, and increasing the percentage of nerve endings in distal sciatic regeneration (47-62%). Conclusions. In this study the experimental and clinical possibilities of nerve defect repair by denatured muscle are demonstrated, confirming the suitability of the technique. Furthermore, it confirms our hypothesis with clinical and cellular determinations enriched by the addition of growth factors that promote nerve regeneration (AU)

The long-term post-operative electromyographic evaluation of patients who have undergone carpal tunnel decompression.

We present the electromyographic (EMG) results ten years after open decompression of the median nerve at the wrist and compare them with the clinical and functional outcomes as judged by Levine's Questionnaire. This retrospective study evaluated 115 patients who had undergone carpal tunnel decompression at a mean of 10.47 years (9.24 to 11.36) previously. A positive EMG diagnosis was found in 77 patients (67%), including those who were asymptomatic at ten years. It is necessary to include both clinical and functional results as well as electromyographic testing in the long-term evaluation of patients who have undergone carpal tunnel decompression particularly in those in whom revision surgery is being considered. In doubtful cases or when there are differing outcomes, self-administered scales such as Levine's Questionnaire should prevail over EMG results when deciding on the need for revision surgery.

Síndromes de Atrapamiento nervioso (SAN) / Entrapment nerve syndromes

Presentamos en este estudio una revisión actualizada de los criterios de tratamiento de los síndromes de atrapamiento nervioso (SAN) más frecuentes de las extremidades. En un principio de revisa su etiología; se estudia la patogenia, se argumentan los criterios y las pruebas de diagnóstico, y finalmente, las bases del tratamiento médico y los fundamentos e indicaciones del tratamiento quirúrgico: la neurolisis, con gestos asociados o no según la localización. Se pasa después a hacer un análisis detallado de los SAN de la extremidad superior, según el nervio afectado: síndrome del desfiladero cervico-tóraco-braquial; síndromes de atrapamiento del nervio mediano en el codo, antebrazo y muñeca, profundizando en el STC, que es el SAN más frecuente; síndromes de atrapamiento del nervio cubital y del nervio radial en el codo y en la muñeca; la existencia de los atrapamientos a doble nivel y, por último, los SAN de la extremidad inferior: el del CPE y en síndrome del túnel tarsiano y la enfemedad de Baxter de reciente publicación, los cuales son menos frecuentes que los de la extremidad superior, pero igual de incapacitantes (AU)

This study deals with an updated review of the criteria for treatment of nerve entrapment syndromes more frequent in the limbs. At first we review its etiology; we studied the pathogenesis, and argue the criteria for diagnostic tests, and finally, the basis of medical treatment and the rationale and indications of surgical treatment: neurolysis, and associated surgical gestures according to location. It goes on to make a detailed analysis of the entrapment syndromes in the upper limb, as the nerve affected: Thoraco-cervico- brachial syndrome; median nerve entrapment syndromes at the elbow, forearm and wrist, furthering the STC, which is the most common of all; entrapment syndromes of the ulnar nerve and radial nerve at the elbow and wrist, the existence of twolevel entrapment and, finally, the entrapment nerve syndromes of the lower extremity: Peroneal nerve entrapment, tarsal tunnel syndrome, and Baxter illness, recently published, which are less common than upper extremity, but just as disabling (AU)

Microosteosíntesis con tornillos a cielo cerrado en las fracturas de la mano / Percutaneous screw fixation in hand fractures

Objetivo: Exponer la experiencia de los autores en la realización de la técnica de microosteo síntesis percutánea con tornillos para el tratamiento de ciertas fracturas de la mano. Material y método: Se realizó un estudio prospectivo en el período comprendido entre noviembre de 2002 y noviembre de 2006 en el que 84 pacientes con fracturas en la mano se trataron mediante osteosíntesis a cielo cerrado con tornillos. La localización de la lesión fue en la base del primer metacarpiano en 12 (14,28%) ocasiones y el resto fueron fracturas de las falanges (85,71%). Todas las fracturas eran cerradas y 40 fracturas eran intraarticulares (47,61%). El tipo de fractura más frecuente fue la oblicua larga en 68 casos (80,95%). Resultado: Los resultados funcionales obtenidos tras la última revisión (6 meses) fueron excelentes en 64 pacientes (76,19%), fueron buenos en 15 pacientes (17, 86%) y fueron malos en 5 pacientes (5,95%). Conclusiones: La osteosíntesis percutánea con tornillos disminuye el tiempo de inmovilización de la fractura al mínimo, favorece una recuperación funcional más temprana y no deja defectos estéticos. Es una técnica muy útil en fracturas y en pacientes especialmente seleccionados (AU)

Purpose: To expound our experience of percutaneous screw fixation in the treatment of certain hand fractures. Materials and methods: We carried out a prospective study between November 2002 and November 2006, in which 84 patients with hand fractures were treated by means of closed screw osteosynthesis. The injury was located at the base of the first metacarpal in 12 cases (14.28%) the remainder being phalangeal fractures (85.71%). All fractures were closed, 40 of them intra-articular (47.61%). The most frequent fracture type was the long oblique fracture, which was present in 68 cases (80.95%). Results: Functional results obtained at the last follow-up visit (6 months) were excellent in 64 patients (76.19%), good in 15 (17.86%) and poor in 5 (5.95%). Conclusions: Percutaneous screw fixation sharply reduces immobilization time permitting earlier functional recovery without causing any cosmetic defects. It is a highly useful technique for carefully selected fractures and patients (AU)

Prótesis metacarpofalángicas de carbón pirolítico. Seguimiento a medio plazo / Pyrolytic carbon metacarpophalangeal implants. Medium-term follow-up

Objetivo. Evaluar a medio plazo en los pacientes con artroplastia metacarpofalángica de carbón pirolítico la disminución del dolor, el incremento del arco de movilidad, la funcionalidad de la mano, así como la incidencia y tipos de complicaciones. Valorar la disminución de la desviación cubital y el grado de satisfacción del paciente.Material y método. Estudio retrospectivo de 28 prótesis metacarpofalángicas de carbón pirolítico, en 16 pacientes en el Hospital Clínico Universitario de Valladolid por un mismo cirujano, con un seguimiento medio de 39 meses.Resultados. Disminución del dolor en 6,3 puntos. Incremento de 21,5° del arco de movilidad. Incremento del 23% de funcionalidad. Escasa incidencia de complicaciones intra y posquirúrgicas. La desviación cubital disminuyó en 10° y la satisfacción de los pacientes fue de 7,1 puntos.Conclusiones. Hemos observado a medio plazo una buenaresistencia y biocompatibilidad de la prótesis. El dolor disminuyó, así como aumentó el arco de movilidad posibilitando las actividades básicas de los pacientes. Las complicaciones intra y posquirúrgicas son escasas, y los pacientes se encuentran satisfechos. Estamos expectantes con la evolución de algunas imágenes osteolíticas periprotésicas pese a que no han evolucionado en el tiempo y son asintomáticas.Las prótesis que presentamos nos parecen hoy en día la mejor opción en patologías crónicas destructivas de las articulaciones metacarpofalángicas no demasiado evolucionadas, sobre todo en reumáticos jóvenes y en pacientes con artrosis (AU)

Purpose. To assess the medium-term effect of pyrolytic carbon metacarpophalangeal arthroplasty on pain relief, ROM increase and hand function, as well as the incidence and type of complications observed. We also set about evaluating the reduction on ulnar deviation and the patients’ degree of satisfaction.Materials and methods. This was a retrospective study of28 pyrolytic carbon metacarpophalangeal prostheses implanted into 16 patients at the Valladolid UniversityHospital by one single surgeon, with a mean follow-up of39 months.Results. Pain decreased by 6.3 points, ROM increased by21.5° and function improved by 23%. Low incidence ofintra– and postoperative complications. Ulnar deviationdecreased by 10°, while patient satisfaction stood at7.1 points.Conclusions. The prosthesis under study showed good medium-term levels of resistance and biocompatibility. Pain decreased and ROM increased, making it possible for patients to carry out their elementary activities. Intra–and postoperative complications were few and patients were satisfied. Periprosthetic osteolysis was observed in a few cases, but it has not got worse and has remained asymptomatic. The prosthesis presented hereby seem to us the best option available at present to address early to mid-stage chronic disease of the metacarpophalangeal joint, especially in young RA patients and in patients with OA (AU)

Luxaciones y fracturas-luxaciones perilunares del carpo / Perilunate carpal dislocations and fracturedislocations

Introducción. Las luxaciones y fracturas-luxaciones perilunares del carpo son lesiones mucho menos frecuentes que las fracturas de radio distal; sin embargo, son unas lesiones graves que puede alterar definitivamente la biomecánica de la muñeca, debido a algunas lesiones irreparables que se producen y a la dificultad de su tratamiento. Lo más importantees hacer un diagnóstico temprano de todas las estructurasafectadas (óseas, cartilaginosas y ligamentosas) y, paraello, además de la radiología convencional de la muñeca,será de gran utilidad la radiografía realizada en tracción continua. Es importante saber que las lesiones óseas no descartan la existencia de lesiones ligamentosas asociadas. La fractura de escafoides se asocia algunas veces a rotura del ligamento escafo-lunar.Tratamiento. Nunca se debe comenzar el tratamiento sinhaber clasificado la lesión según los criterios de Larsen et al en los que hay que evaluar: antigüedad, persistencia, etiología, localización anatómica, dirección y tipo o modelo de inestabilidad. Los criterios actuales se inclinan por el tratamientoquirúrgico mediante abordaje dorsal, palmar o doble,según lo requiera la lesión. Las técnicas incluyen suturao reinserciones ligamentosas, osteosíntesis preferiblemente con tornillo a compresión en el escafoides y agujas de K en el resto de las fracturas. Habrá que utilizar también agujas de K entre los diferentes huesos para que se mantengan lasrelaciones de reducción anatómica entre ellos en el tiempo en que curan las lesiones ligamentosas (8 a 12 semanas). Sólo unos pocos casos muy especiales de fracturas-luxaciones transescafoperilunares pueden ser susceptibles de hacer tratamiento conservador. La reducción anatómica de estas lesiones no garantiza un resultado final perfecto, aunque los resultados generales publicados en las series más representativasse relacionan directamente con el grado de reducción,mantenida durante el período de consolidación, que se haya conseguido. El resultado clínico suele ser mejor que el radiográfico, aunque en general no se supera el 50% de resultados buenos y excelentes. Las condiciones de la lesión parece que influyen tanto o más en el resultado que el tratamiento realizado.Conclusiones. La inestabilidad carpiana, las pseudoartrosis del escafoides y la artrosis postraumática radiocarpiana e intercarpianason complicaciones que afectan a más del 50%de los pacientes que han padecido estas lesiones, aunque hayan sido tratados en servicios especializados. Esto quiere decir que se debe seguir investigando en nuevas formas de tratamiento por parte del cirujano ortopédico y del médico rehabilitador

Introduction. Although the incidence of perilunate carpaldislocations and fracture-dislocations is much lower thanthat of distal radial fractures, their severity is much more significant since they are extremely difficult to treat and they could irreparably alter wrist biomechanics. It is essential to perform an early diagnosis of all involved structures (bone, chondral and ligamentous). For this reason, in additionto conventional films, it is very useful to carry out continuous traction radiographs. One should bear in mind that bone injury does not rule out the existence of associated ligament lesions. Scaphoid fractures are sometimes associated to scapholunate ligament tears.Treatment. Treatment should never be started without having classified the injury according to the criteria laid down by Larsen et al, according to which an assessment must be made of: time of progression, persistence, etiology, anatomical location, direction, and instability type or model. Current practice tends to favor surgical treatment by means of a dorsal, palmar or dual approach, as appropriate. Additional indications include suturing and ligament reattachmentsand osteosynthesis preferably with compression screws inthe scaphoid and K-wires in the remaining fractures. K-wires must also be used between the different bones so that anatomical reduction relations are preserved between as ligamentous injuries heal (8 to 12 weeks). Only very few special trans-scaphoid-lunate fracture dislocations are eligible for nonsurgical treatment. Anatomical reduction of these injuriesdoes not guarantee a perfect final result, but the results published in the most representative series are directly related to the degree of reduction achieved. Clinical results tend to outperform radiological results, but in general good and excellent results evaluated together do not exceed 50% of the total. The characteristics of the lesion seem to havean equal or higher influence on the result, rather than the treatment applied.Conclusions. Carpal instability, scaphoid nonunion and radiocarpal and intercarpal post-traumatic osteoarthritis are complications affecting over 50% of patients who have sustained these lesions, even if they were treated in specialized units. This means that further research is needed as new typesof treatment that can be administered both by the orthopedic surgeon and the rehabilitation physician

Luxaciones y fracturas-luxaciones perilunares del carpo / Perilunate carpal dislocations and fracture-dislocations

Introducción. Las luxaciones y fracturas-luxaciones perilunares del carpo son lesiones mucho menos frecuentes que las fracturas de radio distal; sin embargo, son unas lesiones graves que puede alterar definitivamente la biomecánica dela muñeca, debido a algunas lesiones irreparables que seproducen y a la dificultad de su tratamiento. Lo más importante es hacer un diagnóstico temprano de todas las estructuras afectadas (óseas, cartilaginosas y ligamentosas) y, para ello, además de la radiología convencional de la muñeca, será de gran utilidad la radiografía realizada en traccióncontinua. Es importante saber que las lesiones óseas no descartan la existencia de lesiones ligamentosas asociadas. La fractura de escafoides se asocia algunas veces a rotura del ligamento escafo-lunar.Tratamiento. Nunca se debe comenzar el tratamiento sinhaber clasificado la lesión según los criterios de Larsen et al en los que hay que evaluar: antigüedad, persistencia, etiología, localización anatómica, dirección y tipo o modelo de inestabilidad. Los criterios actuales se inclinan por el tratamientoquirúrgico mediante abordaje dorsal, palmar o doble,según lo requiera la lesión. Las técnicas incluyen suturao reinserciones ligamentosas, osteosíntesis preferiblemente con tornillo a compresión en el escafoides y agujas de K en el resto de las fracturas. Habrá que utilizar también agujasde K entre los diferentes huesos para que se mantengan las relaciones de reducción anatómica entre ellos en el tiempo en que curan las lesiones ligamentosas (8 a 12 semanas). Sólo unos pocos casos muy especiales de fracturas-luxaciones transescafoperilunares pueden ser susceptibles de hacer tratamientoconservador. La reducción anatómica de estas lesionesno garantiza un resultado final perfecto, aunque losresultados generales publicados en las series más representativas se relacionan directamente con el grado de reducción, mantenida durante el período de consolidación, que se haya conseguido. El resultado clínico suele ser mejor que el radiográfico,aunque en general no se supera el 50% de resultadosbuenos y excelentes. Las condiciones de la lesión pareceque influyen tanto o más en el resultado que el tratamiento realizado.Conclusiones. La inestabilidad carpiana, las pseudoartrosis del escafoides y la artrosis postraumática radiocarpiana e intercarpianason complicaciones que afectan a más del 50%de los pacientes que han padecido estas lesiones, aunque hayan sido tratados en servicios especializados. Esto quiere decir que se debe seguir investigando en nuevas formas de tratamiento por parte del cirujano ortopédico y del médico rehabilitador

Introduction. Although the incidence of perilunate carpaldislocations and fracture-dislocations is much lower thanthat of distal radial fractures, their severity is much more significant since they are extremely difficult to treat and they could irreparably alter wrist biomechanics. It is essential to perform an early diagnosis of all involved structures (bone, chondral and ligamentous). For this reason, in additionto conventional films, it is very useful to carry out continuous traction radiographs. One should bear in mind that bone injury does not rule out the existence of associated ligament lesions. Scaphoid fractures are sometimes associated to scapholunate ligament tears.Treatment. Treatment should never be started without having classified the injury according to the criteria laid down by Larsen et al, according to which an assessment must be made of: time of progression, persistence, etiology, anatomicallocation, direction, and instability type or model. Current practice tends to favor surgical treatment by means of a dorsal, palmar or dual approach, as appropriate. Additional indications include suturing and ligament reattachments and osteosynthesis preferably with compression screws in the scaphoid and K-wires in the remaining fractures. K-wires must also be used between the different bones so thatanatomical reduction relations are preserved between as ligamentous injuries heal (8 to 12 weeks). Only very few special trans-scaphoid-lunate fracture dislocations are eligible for nonsurgical treatment. Anatomical reduction of these injuries does not guarantee a perfect final result, but the results published in the most representative series are directlyrelated to the degree of reduction achieved. Clinical results tend to outperform radiological results, but in general good and excellent results evaluated together do not exceed 50% of the total. The characteristics of the lesion seem to have an equal or higher influence on the result, rather than the treatment applied.Conclusions. Carpal instability, scaphoid nonunion and radiocarpal and intercarpal post-traumatic osteoarthritis are complications affecting over 50% of patients who have sustained these lesions, even if they were treated in specialized units. This means that further research is needed as new types of treatment that can be administered both by the orthopedicsurgeon and the rehabilitation physician