Planificar fracturas es sencillo: desarrollo de un método básico de planificación digital basado en la técnica tradicional con lápiz y papel / Fracture planning is easy: Development of a basic method of digital planning based on the traditional pencil and paper technique

Introducción: La planificación preoperatoria constituye una herramienta fundamental en el manejo de fracturas; sin embargo, su aplicación práctica dista de lo deseado, quizá debido a la ausencia de un método básico y sencillo, adaptado a los tiempos actuales. Describimos un método de planificación digital, entre lo tradicional y lo tecnológico, que conserva su esencia educativa, permite comprender la fractura e individualizar la osteosíntesis. Material y métodos: Tras el análisis inicial de la fractura y características del paciente, se realizan diferentes mediciones en las imágenes de Rx y TC con un programa de imagen médica digital. Estas imágenes se copian en un programa de presentación (Microsoft® PowerPoint o Keynote ©Apple Inc.), en el que se reproducen con el puntero del ordenador los principales fragmentos y líneas de fractura. A continuación, estos se mueven a una posición reducida y se representan gráficamente los implantes para la fijación interna junto con un guion de la estrategia quirúrgica. Resultados: Mostramos 4 casos de diferentes tipos de fracturas intervenidas mediante reducción y osteosíntesis tras una planificación preoperatoria según el método descrito. Se detallan los puntos básicos para la planificación quirúrgica, logística, táctica y los resultados radiológicos postoperatorios de cada caso. Conclusiones: A pesar del auge de programas informáticos avanzados de planificación, los métodos tradicionales con lápiz y papel siguen siendo fundamentales, más aún para el traumatólogo en formación. El método de planificación digital descrito resulta muy adecuado para este objetivo, al aunar las ventajas de ambos métodos: sencillez, accesibilidad, rapidez, bajo coste, reproducibilidad, carácter formativo y eficacia y por posibilitar la simulación, correcciones y la reutilización de casos.(AU)

Introduction: Preoperative planning constitutes a fundamental tool in the management of fractures; however, its practical application is far from the desired, perhaps due to the absence of a basic and simple method, adapted to the current times. We describe a digital planning method, halfway between the traditional and the technological, which preserves its educational essence, allows the understanding of the fracture and the individualization of the osteosynthesis. Material and methods: After the initial analysis of the fracture and the patient's characteristics, different measurements are made on X-ray and CT images with a digital medical imaging software. These images are then copied into a presentation program (Microsoft® PowerPoint or Keynote ©Apple Inc.), in which the main fragments and fracture lines are traced with the computer pointer. These are subsequently moved into a reduced position and the implants for internal fixation are graphically represented together with a guide of the surgical strategy. Results: We show 4 cases of different types of fractures operated through reduction and osteosynthesis after preoperative planning according to the described method. The basic points for the surgical planning, logistics, tactics and postoperative radiological results of each case are detailed. Conclusions: Despite rise of advanced planning software, traditional paper and pencil methods are still fundamental, even more so for the trauma surgeon in training. The digital planning method described is very appropriate for this purpose, as it combines the advantages of both methods: simplicity, accessibility, quickness, low-cost, reproducibility, educational character, efficiency and possibility of simulation, corrections and reuse of cases.(AU)

[Translated article] Fracture planning is easy: Development of a basic method of digital planning based on the traditional pencil and paper technique / Planificar fracturas es sencillo: desarrollo de un método básico de planificación digital basado en la técnica tradicional con lápiz y papel

Introducción: La planificación preoperatoria constituye una herramienta fundamental en el manejo de fracturas; sin embargo, su aplicación práctica dista de lo deseado, quizá debido a la ausencia de un método básico y sencillo, adaptado a los tiempos actuales. Describimos un método de planificación digital, entre lo tradicional y lo tecnológico, que conserva su esencia educativa, permite comprender la fractura e individualizar la osteosíntesis. Material y métodos: Tras el análisis inicial de la fractura y características del paciente, se realizan diferentes mediciones en las imágenes de Rx y TC con un programa de imagen médica digital. Estas imágenes se copian en un programa de presentación (Microsoft® PowerPoint o Keynote ©Apple Inc.), en el que se reproducen con el puntero del ordenador los principales fragmentos y líneas de fractura. A continuación, estos se mueven a una posición reducida y se representan gráficamente los implantes para la fijación interna junto con un guion de la estrategia quirúrgica. Resultados: Mostramos 4 casos de diferentes tipos de fracturas intervenidas mediante reducción y osteosíntesis tras una planificación preoperatoria según el método descrito. Se detallan los puntos básicos para la planificación quirúrgica, logística, táctica y los resultados radiológicos postoperatorios de cada caso. Conclusiones: A pesar del auge de programas informáticos avanzados de planificación, los métodos tradicionales con lápiz y papel siguen siendo fundamentales, más aún para el traumatólogo en formación. El método de planificación digital descrito resulta muy adecuado para este objetivo, al aunar las ventajas de ambos métodos: sencillez, accesibilidad, rapidez, bajo coste, reproducibilidad, carácter formativo y eficacia y por posibilitar la simulación, correcciones y la reutilización de casos.(AU)

Introduction: Preoperative planning constitutes a fundamental tool in the management of fractures; however, its practical application is far from the desired, perhaps due to the absence of a basic and simple method, adapted to the current times. We describe a digital planning method, halfway between the traditional and the technological, which preserves its educational essence, allows the understanding of the fracture and the individualization of the osteosynthesis. Material and methods: After the initial analysis of the fracture and the patient's characteristics, different measurements are made on X-ray and CT images with a digital medical imaging software. These images are then copied into a presentation program (Microsoft® PowerPoint or Keynote ©Apple Inc.), in which the main fragments and fracture lines are traced with the computer pointer. These are subsequently moved into a reduced position and the implants for internal fixation are graphically represented together with a guide of the surgical strategy. Results: We show 4 cases of different types of fractures operated through reduction and osteosynthesis after preoperative planning according to the described method. The basic points for the surgical planning, logistics, tactics and postoperative radiological results of each case are detailed. Conclusions: Despite rise of advanced planning software, traditional paper and pencil methods are still fundamental, even more so for the trauma surgeon in training. The digital planning method described is very appropriate for this purpose, as it combines the advantages of both methods: simplicity, accessibility, quickness, low-cost, reproducibility, educational character, efficiency and possibility of simulation, corrections and reuse of cases.(AU)

[Translated article] Fracture planning is easy: Development of a basic method of digital planning based on the traditional pencil and paper technique.

INTRODUCTION: Preoperative planning constitutes a fundamental tool in the management of fractures; however, its practical application is far from the desired, perhaps due to the absence of a basic and simple method, adapted to the current times. We describe a digital planning method, halfway the traditional and the technological, which preserves its educational essence, allows for the understanding of the fracture and the individualisation of the osteosynthesis. MATERIAL AND METHODS: After the initial analysis of the fracture and the patient's characteristics, different measurements are made on X-ray and CT images with a digital medical imaging software. These images are then copied into a presentation programme (Microsoft® PowerPoint or Keynote ©Apple Inc.), in which the main fragments and fracture lines are traced with the computer pointer. These are subsequently moved into a reduced position and the implants for internal fixation are graphically represented together with a guide of the surgical strategy. RESULTS: We show 4 cases of different types of fractures operated through reduction and osteosynthesis after preoperative planning according to the described method. The basic points for the surgical planning, logistics, tactics and postoperative radiological results of each case are detailed. CONCLUSIONS: Despite the rise of advanced planning software, traditional paper and pencil methods are still fundamental, even more so for the trauma surgeon in training. The digital planning method described is very appropriate for this purpose, as it combines the advantages of both methods: simplicity, accessibility, quickness, low cost, reproducibility, educational character, efficiency and possibility of simulation, corrections and reuse of cases.

Suprapatellar tibial nailing, why have we changed? / Enclavado de tibia suprapatelar, ¿por qué hemos cambiado?

INTRODUCTION: Endomedullary nailing using the infrapatellar approach (IP) is considered the gold standard for the treatment of tibial diaphyseal fractures, however, it has been associated with greater difficulty in reduction and complications such as malalignment in procurvatum and anterior knee pain. The suprapatellar approach (SP) arises as an alternative to solve these aspects, also being associated with a shorter intraoperative time and a lower dose and fluoroscopy time. MATERIAL AND METHODS: Retrospective comparative study between a group of 22 fractures treated by SP approach and another of 30 fractures intervened by IP transtendinous approach. Perioperative variables were analyzed, as well as clinical, radiological, and functional aspects in outpatient visits at 3, 6 and 12 months. RESULTS: No differences were found between groups in terms of intraoperative time, anemization, quality of reduction or complications during follow-up, among others. At 12 months, 12 (54.5%) SP cases and 16 (53.3%) IP presented anterior knee pain, without significant differences. In the evaluation scales, significant differences were recorded in the IKDC (International Knee Documentation Committee) in favor of the SP technique 88.45 (76.44-91.1) vs. IP 69 (49.95-80) (p=.006), with no significant differences in other functional scales analyzed. CONCLUSIONS: According to what has been described so far in the literature, the present study supports the tendency toward SP nailing by improving the functional results (IKDC) in the medium term compared to the traditional IP technique, without increasing complications. Likewise, surgeons perceive greater technical ease for reduction and simplicity in obtaining intraoperative radiological images.

Enclavado de tibia suprapatelar, ¿por qué hemos cambiado? / Suprapatellar tibial nailing, why have we changed?

Introducción: El enclavado endomedular mediante abordaje infrapatelar (IP) se considera el gold estándar del tratamiento de las fracturas diafisarias de tibia, sin embargo, se ha asociado a mayor dificultad para la reducción y complicaciones como la mala alineación en procurvatum y al dolor anterior de rodilla. El abordaje suprapatelar (SP) surge como alternativa para solventar estos aspectos, asociándose también con un menor tiempo intraoperatorio y menor dosis y tiempo de fluoroscopia. Material y métodos: Estudio retrospectivo comparativo entre: un grupo de 22 fracturas intervenidas mediante abordaje SP y otro de 30 fracturas intervenidas por abordaje IP trastendinoso. Se analizaron variables perioperatorias y aspectos clínicos, radiológicos y funcionales en consulta a los 3, 6 y 12 meses. Resultados: No se encontraron diferencias entre grupos en cuanto a tiempo intraoperatorio, anemización, calidad de la reducción, o complicaciones en el seguimiento, entre otros. A los 12 meses, 12 (54,5%) casos SP y 16 (53,3%) IP presentaban dolor anterior de rodilla, sin diferencias significativas. En las escalas de evaluación, se registraron diferencias significativas en la IKDC (International Knee Documentation Committee) a favor de la técnica SP (88,45 [76,44-91,1] vs. IP 69 [49,95-80]) (p=0,006), sin diferencias significativas en otras escalas funcionales analizadas. Conclusiones: En consonancia con lo hasta ahora descrito en la literatura, el presente estudio apoya la tendencia hacia el enclavado SP por mejorar los resultados funcionales (IKDC) a medio plazo respecto a la técnica tradicional IP, sin aumentar las complicaciones. Asimismo se percibe por los cirujanos una mayor facilidad técnica para la reducción y sencillez en la obtención de imágenes radiológicas intraoperatorias.(AU)

Introduction: Endomedullary nailing using the infrapatellar approach (IP) is considered the gold standard for the treatment of tibial diaphyseal fractures, however, it has been associated with greater difficulty in reduction and complications such as malalignment in procurvatum and anterior knee pain. The suprapatellar approach (SP) arises as an alternative to solve these aspects, also being associated with a shorter intraoperative time and a lower dose and fluoroscopy time. Material and methods: Retrospective comparative study between a group of 22 fractures treated by SP approach and another of 30 fractures intervened by IP transtendinous approach. Perioperative variables were analyzed, as well as clinical, radiological, and functional aspects in outpatient visits at 3, 6 and 12 months. Results: No differences were found between groups in terms of intraoperative time, anemization, quality of reduction or complications during follow-up, among others. At 12 months, 12 (54.5%) SP cases and 16 (53.3%) IP presented anterior knee pain, without significant differences. In the evaluation scales, significant differences were recorded in the IKDC (International Knee Documentation Committee) in favor of the SP technique 88.45 (76.44–91.1) vs. IP 69 (49.95–80) (p=.006), with no significant differences in other functional scales analyzed. Conclusions: According to what has been described so far in the literature, the present study supports the tendency toward SP nailing by improving the functional results (IKDC) in the medium term compared to the traditional IP technique, without increasing complications. Likewise, surgeons perceive greater technical ease for reduction and simplicity in obtaining intraoperative radiological images.(AU)

Suprapatellar tibial nailing, why have we changed? / Enclavado de tibia suprapatelar, ¿por qué hemos cambiado?

Introduction: Endomedullary nailing using the infrapatellar approach (IP) is considered the gold standard for the treatment of tibial diaphyseal fractures, however, it has been associated with greater difficulty in reduction and complications such as malalignment in procurvatum and anterior knee pain. The suprapatellar approach (SP) arises as an alternative to solve these aspects, also being associated with a shorter intraoperative time and a lower dose and fluoroscopy time. Material and methods: Retrospective comparative study between a group of 22 fractures treated by SP approach and another of 30 fractures intervened by IP transtendinous approach. Perioperative variables were analyzed, as well as clinical, radiological, and functional aspects in outpatient visits at 3, 6 and 12 months. Results: No differences were found between groups in terms of intraoperative time, anemization, quality of reduction or complications during follow-up, among others. At 12 months, 12 (54.5%) SP cases and 16 (53.3%) IP presented anterior knee pain, without significant differences. In the evaluation scales, significant differences were recorded in the IKDC (International Knee Documentation Committee) in favor of the SP technique 88.45 (76.44–91.1) vs. IP 69 (49.95–80) (p=.006), with no significant differences in other functional scales analyzed. Conclusions: According to what has been described so far in the literature, the present study supports the tendency toward SP nailing by improving the functional results (IKDC) in the medium term compared to the traditional IP technique, without increasing complications. Likewise, surgeons perceive greater technical ease for reduction and simplicity in obtaining intraoperative radiological images.(AU)

Introducción: El enclavado endomedular mediante abordaje infrapatelar (IP) se considera el gold estándar del tratamiento de las fracturas diafisarias de tibia, sin embargo, se ha asociado a mayor dificultad para la reducción y complicaciones como la mala alineación en procurvatum y al dolor anterior de rodilla. El abordaje suprapatelar (SP) surge como alternativa para solventar estos aspectos, asociándose también con un menor tiempo intraoperatorio y menor dosis y tiempo de fluoroscopia. Material y métodos: Estudio retrospectivo comparativo entre: un grupo de 22 fracturas intervenidas mediante abordaje SP y otro de 30 fracturas intervenidas por abordaje IP trastendinoso. Se analizaron variables perioperatorias y aspectos clínicos, radiológicos y funcionales en consulta a los 3, 6 y 12 meses. Resultados: No se encontraron diferencias entre grupos en cuanto a tiempo intraoperatorio, anemización, calidad de la reducción, o complicaciones en el seguimiento, entre otros. A los 12 meses, 12 (54,5%) casos SP y 16 (53,3%) IP presentaban dolor anterior de rodilla, sin diferencias significativas. En las escalas de evaluación, se registraron diferencias significativas en la IKDC (International Knee Documentation Committee) a favor de la técnica SP (88,45 [76,44-91,1] vs. IP 69 [49,95-80]) (p=0,006), sin diferencias significativas en otras escalas funcionales analizadas. Conclusiones: En consonancia con lo hasta ahora descrito en la literatura, el presente estudio apoya la tendencia hacia el enclavado SP por mejorar los resultados funcionales (IKDC) a medio plazo respecto a la técnica tradicional IP, sin aumentar las complicaciones. Asimismo se percibe por los cirujanos una mayor facilidad técnica para la reducción y sencillez en la obtención de imágenes radiológicas intraoperatorias.(AU)

Fracture planning is easy: Development of a basic method of digital planning based on the traditional pencil and paper technique. / Planificar fracturas es sencillo: desarrollo de un método básico de planificación digital basado en la técnica tradicional con lápiz y papel.

INTRODUCTION: Preoperative planning constitutes a fundamental tool in the management of fractures; however, its practical application is far from the desired, perhaps due to the absence of a basic and simple method, adapted to the current times. We describe a digital planning method, halfway between the traditional and the technological, which preserves its educational essence, allows the understanding of the fracture and the individualization of the osteosynthesis. MATERIAL AND METHODS: After the initial analysis of the fracture and the patient's characteristics, different measurements are made on X-ray and CT images with a digital medical imaging software. These images are then copied into a presentation program (Microsoft® PowerPoint or Keynote ©Apple Inc.), in which the main fragments and fracture lines are traced with the computer pointer. These are subsequently moved into a reduced position and the implants for internal fixation are graphically represented together with a guide of the surgical strategy. RESULTS: We show 4 cases of different types of fractures operated through reduction and osteosynthesis after preoperative planning according to the described method. The basic points for the surgical planning, logistics, tactics and postoperative radiological results of each case are detailed. CONCLUSIONS: Despite rise of advanced planning software, traditional paper and pencil methods are still fundamental, even more so for the trauma surgeon in training. The digital planning method described is very appropriate for this purpose, as it combines the advantages of both methods: simplicity, accessibility, quickness, low-cost, reproducibility, educational character, efficiency and possibility of simulation, corrections and reuse of cases.

Tension subcutaneous haematomas associated with anticoagulants in the elderly: Do they have earlier morbidity and mortality than hip fractures? / Hematomas subcutáneos a tensión por anticoagulantes en ancianos: ¿más morbimortalidad precoz que las fracturas de cadera?

INTRODUCTION: Complications related to anticoagulant therapy have been widely described, although tension haematomas in the extremities are frequently undervalued, and commonly considered banal pathologies. MATERIAL AND METHOD: Retrospective descriptive study between 2014 and 2017, including patients with limb haematomas after minimal trauma related with anticoagulant therapy, and surgically treated by Traumatology. RESULTS: 32 cases were eventually included, 81% were women, average age of 83.56 years, and a mean aCCI of 5.97. Anatomical location of haematomas was 65.6% in leg/foot, 15.6% in thigh/buttock, and 18.8% in the upper limb. Seventy-eight point thirteen percent received acenocoumarol, 15.63% LMWH, and 3.13% NOACs. Of the cases, 59.38% were due to AF, 15.63% to valvular heart disease/valve prosthesis, and 12.5% to PE/DVT. The mean time from diagnosis to surgical drainage was 2.66 days, mainly as a result of alterations in coagulation parameters. Forty-six point eighty-eight percent were reoperated for new drainage, cure or skin defect coverage, and 3 patients required embolisation. Of the patients, 78% needed consultation with other specialties. The average length of stay was 22.34 days, and the in-hospital mortality rate was 9.38%. CONCLUSION: Tension haematomas in the extremities associated with anticoagulants occur in patients with multiple comorbidities that make them vulnerable. Surgical drainage is usually delayed by numerous factors which lead to skin defects that require further surgical operations, and prolonged hospital stays that are associated with medical complications. In our study, the average length of stay and in-hospital mortality rate were higher than those for hip fractures, so we should not underestimate this pathology.

[Effect of intramedullary reaming and nailing on the production of growth factors in the femur fracture callus in rats]. / Efecto del fresado y enclavado endomedular sobre la producción de factores de crecimiento en el callo de fractura de fémur en ratas.

INTRODUCTION: Many studies have been conducted to determine the different effects that reaming or intramedullary nailing have on fracture healing, but there is no evidence in the literature of the effect of intramedullary reaming on osteogenesis. We performed a prospective study to analyse the effect of intramedullary reaming and nailing on the production of growth factors during the process of fracture healing in the femur of rats. MATERIAL AND METHODS: A transverse mid-shaft non-comminuted femur fracture was produced in 64 rats; 34 rats did not receive any treatment, and a standardized surgical procedure was performed on 30 rats, by exposing the left knee, reaming the medullary canal from distal to proximal, and then fixing the fracture with a steel pin. The rats were sacrificed at the 24th hour, 4th, 7th and 15th days after the fracture. The amount of growth factors that appeared in the callus fracture was measured using histopathology studies. The primary categorical variables analysed were PDGFA, TGF2 and TGFß-R2. These variables were analysed in each group at the different sacrifice times. RESULTS: The results of the primary variables of the study, stratified by the time until sacrifice, showed no statistically significant differences. DISCUSSION: Even if the presence of an intramedullary wire facilitates the fracture repair and the stabilising the bridge of bone between both edges of the fracture site, no evidence was found that reaming changes the expression of the growth factors studied (PDGFA, TGFß-R2 and TGFß2) during the callus formation in rats.

[Posterolateral approach in trimalleolar ankle fractures: surgical technique]. / El abordaje posterolateral en las fracturas trimaleolares de tobillo. Técnica quirúrgica.

INTRODUCTION: Ankle fractures involving a posterior malleolar fragment are associated with worse clinical outcomes. The standard indication for its fixation is a displaced fragment that involves more than 25% of the distal articular tibia. The method of reduction and fixation of these fractures has not received much attention. The purpose of this paper is to describe the surgical technique and clinical results. MATERIAL AND METHODS: Over a 6 year period 10 patients with an ankle fracture involving more than 25% posterior malleolus were admitted for surgery, which was performed by the first author. Postoperative management and complications were recorded, reduction accuracy evaluated in the first postoperative radiograph, and functional outcomes were measured using the American Orthopaedic Foot and Ankle Society (AOFAS) hind foot-ankle score and the modified Weber protocol. The surgical technique is described. RESULTS: A total of 10 patients were included in the study; and the overall mean age was 53.8 (range: 19-82) years. With regard to complications, none of the 10 patients had any postoperative complication. No cases of reflex sympathetic dystrophy syndrome, superficial infection, iatrogenic lesion of the sural nerve or failure of internal fixation were recorded. One of them had screw and plate removal surgery. Clinical results were good; 9 patients regained their pre-injury activity level, with excellent or good results in both AOFAS and modified Weber protocol. DISCUSSION: Given that posterior malleolus fractures are usually posterolateral, this approach allows perfect visualization of the fracture, articular anatomical reduction, and strong fixation. Clinical results obtained were at least equal to other case series published.