Is There a Correlation between the Radiological and Clinical Outcome after Core Decompression of the Radius for Kienböck Disease?

Background: Despite the good clinical results in the treatment of Kienböck disease with distal radius core decompression, a radiological progression to a certain degree in the long-term follow-up is possible. Is there a negative correlation between the clinical improvement of the patients and the radiological progression? Methods: We retrospectively reviewed the radiological and clinical results of 24 patients (mean age: 38 years; 10 women) treated with core decompression for Kienböck disease. The mean follow-up was 10 years. Results: A radiologic progression in the Lichtman classification was seen in nine patients. The Spearman correlation did not show any correlation between this radiological progression and the clinical outcome. Namely -0.06 between Mayo and Lichtman classification and 0.16 between VAS and Lichtman classification. Conclusions: We found that the clinical outcomes do not deteriorate despite a radiological progression of patients treated with core decompression for Kienböck disease Level of Evidence: Level IV (Therapeutic).

Coverage of Palmar Mini Plates with Flexor Pulleys in the Treatment of Dorsal Fracture-Subluxation of the Proximal Interphalangeal Joint.

Introduction: Dorsal fracture dislocations (DFD) of the proximal interphalangeal joint (PIPJ) are challenging fractures. A palmar surgical approach and plate fixation has a high complication rate, including flexor contractions, reduction of range of motion (ROM) and secondary need for plate removal. Methods: We use the flexor tendon pulleys to cover the mini plate with the assumption that it may reduce the adhesion between the mini plates and the tendons and reduce postoperative complications. We present the outcomes of using this technique in eight patients. Results: All patients had an excellent outcome at a mean follow-up of 17 months, and none required removal of the implants. Conclusions: This study presents a surgical technique that may potentially reduce the high complication rate found after ORIF for treatment of DFD of the PIPJ. Therefore, improving the clinical outcomes after this type of surgery. Level of Evidence: Level IV (Therapeutic).

Does Age Affect the Outcomes of Core Decompression for the Treatment of Kienböck Disease?

Background: Core decompression of the distal radius is a minimally invasive technique that has demonstrated good clinical outcomes in the treatment of Kienböck disease. However, the effectiveness of core decompression has not been compared in different age groups. The aim of this study is to compare the outcomes of core decompression in patients <45 years of age to those ≥45 years of age. Methods: This retrospective study included 36 patients with Kienböck disease who were treated with core decompression over a 20-year period. The mean follow-up was 7 years. Outcome measures included visual analogue scale pain score (VAS), active range of flexion/extension at the wrist, grip strength, and modified Mayo wrist score. The patients were divided into two age groups namely <45 years (younger group; n = 22) and ≥45 years (older group; n = 12) and the outcome measures were compared between the two age groups. Results: There were no statistically significant differences between the outcomes of the two age groups. Conclusion: The outcomes of core decompression of the distal radius for Kienböck disease in older patients (≥45 years) are favorable and similar to those seen in younger patients (<45 years). Level of Evidence: Level III (Therapeutic).

The anatomy of the anconeus nerve redefined.

The anconeus nerve is the longest branch of the radial nerve and suitable as a donor for the neurotization of the axillary nerve. The aim of this study was to map its topographical course with reference to palpable, anatomical landmarks. The anconeus nerve was followed in 15 cadaveric specimens from its origin to its entry to the anconeus. It runs between the lateral and the medial head of the triceps before entering the medial head and running intramuscularly further distal. Exiting the muscle, it lies on the periosteum and the articular capsule of the elbow, before entering the anconeus muscle. Two types of anconeus nerve in relation to branches innervating triceps were found: nine nerves also innervated the lateral triceps head, while the other six only contributed two branches to its innervation. The course of the anconeus nerve is important for harvesting as a donor nerve and to protect the nerve in surgical elbow approaches.

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.

Bicortical versus unicortical fixation of plated clavicular fractures: A biomechanical study.

PURPOSE: To compare the biomechanical properties of three plate stabilization techniques for midshaft clavicle fractures: anatomical bicortical locking construct, anatomical unicortical locking construct, and reconstruction bicortical locking construct. METHODS: We analyzed superior plating of the clavicle using an anatomical clavicle plate (Acumed) with both bicortical or unicortical screw fixation and a locking reconstruction plate (DePuy-Synthes). Twenty-one fourth generation composite clavicles were used for non-destructive stiffness testing in axial loading, bending, and torsion. Fifteen composite clavicles and 17 foam clavicles were used for cyclic failure testing using a combined loading method that included all three loading modes. RESULTS: No significant differences were found between the three constructs in torsional stiffness nor in vertical bending loading. In axial loading, the anatomical bicortical locking construct was significantly stiffer than either anatomical unicortical locking construct or the reconstruction bicortical locking construct. The unicortical fixation was also significantly stiffer than the reconstruction bicortical locking construct. Regarding failure testing, there was not a significant difference between the bicortical and unicortical anatomical locking constructs; however, both were significantly stronger than bicortical screw fixation in the reconstruction plate. CONCLUSION: Based on the biomechanical performance of these constructs, unicortical locked plate fixation may be a reasonable option in the treatment of displaced midshaft clavicle fracture fixation.

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

Colgajo dorsolateral versus colgajo en isla mediopalmar radial para el tratamiento de lesiones traumáticas distales del pulgar. Evaluación clínica / Dorsolateral flap vs. radial midpalmar island flap in the treatment of traumatic distal thumb injuries. Clinical evaluation

Objetivo: Evaluar clínicamente a pacientes con lesiones distales combinadas del pulgar tratados mediante colgajo dorsolateral o colgajo en isla mediopalmar radial. Materiales y Métodos: Se comparó retrospectivamente a 20 pacientes (14 hombres y 6 mujeres; promedio de edad 35 años) con lesiones traumáticas combinadas distales del pulgar, operados por dos cirujanos, con técnicas diferentes. Los pacientes no tenían antecedentes quirúrgicos y el seguimiento mínimo fue de 24 meses. Se evaluaron el resultado subjetivo usando el índice de satisfacción, la escala analógica visual para dolor y el puntaje QuickDASH, y el resultado objetivo mediante el test de discriminación de 2 puntos, el tiempo quirúrgico promedio y la necesidad de reeducación espacial digital. Resultados: La media desde el ingreso hasta el alta laboral fue de 7 semanas (rango 6-8). Resultados promedio posoperatorios: escala analógica visual 01/10, ambos grupos. Grupo con colgajo dorsolateral: índice de satisfacción 97%, test de discriminación de 2 puntos 4 mm, puntaje QuickDASH 2,5; tiempo quirúrgico 45 min, sin necesidad de reeducación espacial digital. Grupo con colgajo en isla mediopalmar radial: índice de satisfacción 92%, test de discriminación de 2 puntos 6 mm, puntaje QuickDASH 8, tiempo quirúrgico 60 min; 4 pacientes requirieron reeducación espacial digital. Conclusión: Los colgajos dorsolateral y en isla mediopalmar radial resultaron eficaces en el tratamiento de lesiones traumáticas distales del pulgar, aunque el colgajo dorsolateral tuvo mejores puntajes de evaluación objetiva y requirió menos tiempo quirúrgico. Nivel de Evidencia: III

Objective: To clinically evaluate patients with combined distal thumb lesions treated by a dorsolateral flap or radial midpalmar island flap. Materials and Methods: We retrospectively compared 20 patients (14 males and 6 females, averaging 35 years) with combined distal thumb traumatic lesions, who were operated on by two surgeons using different techniques. Patients had no previous surgical history and a minimum follow-up period of 24 months. Subjective outcome was evaluated by satisfaction index (SI), visual analogue scale (VAS), and QuickDASH score. Objective outcome was evaluated by two-point discrimination test (TPDT), average surgical time (ST), and need for digital spatial reeducation (DSR). Results: Time from admission to medical discharge averaged 7 weeks (range, 6-8). Average postoperative results: VAS for pain, 01/10 (both groups); IS, 97% vs. 92% (dorsolateral flap group vs. radial midpalmar island flap); TPDT, 4 mm vs. 6 mm; QuickDASH, 2.5 vs. 8; ST, 45 minutes vs. 60 minutes; need for DSR, 0 vs. 4 cases. Conclusion: Both the dorsolateral flap and the radial midpalmar island flap techniques were effective in the treatment of distal thumb traumatic lesions, although the dorsolateral flap achieved better objective evaluation scores and required less ST. 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

Pedicled Vascularized Bone Graft of the Distal Radius for Recalcitrant Nonunion of the Distal Humerus.

OBJECTIVES: To analyze the clinical and radiological outcomes of a series of patients treated with a pedicled vascularized bone graft (VBG) of the distal radius for the treatment of recalcitrant atrophic nonunions of the distal humerus. DESIGN: Retrospective clinical study. SETTING: University-affiliated teaching hospital. PATIENTS: Fifteen patients with supracondylar humeral atrophic nonunions with at least 3 previous failed surgical interventions were included. INTERVENTION: Debridement of the distal humerus nonunion through a posterior elbow approach with provisional fixation was performed. Then, a pedicled VBG was harvested from the distal radius and tunneled back into the humeral bone defect. Iliac crest was used as needed, both for the nonunion and to stabilize the radius. Finally, definitive fixation with 2 locked plates was performed. MAIN OUTCOME MEASUREMENTS: Radiological results, complications, elbow range of motion, Mayo elbow performance score, and subjective pain were evaluated. RESULTS: There were 4 male and 11 female patients, with a mean age of 51 (range, 28-73) years. The mean follow-up period was 46 (range, 37-72) months with a minimum of 3 years. Radiological consolidation was achieved in all patients. Elbow range of motion was >100 degrees in 11 patients and between 50 and 100 degrees in 4 patients. Preoperative Mayo scores were poor in all patients. At final follow-up, Mayo scores were excellent in 3, good in 9, and fair in 3 patients. The mean postoperative visual analog scale score was 1.2 (range 0-3). CONCLUSIONS: Pedicled VBG of the distal radius was shown to be a reliable and effective alternative for the treatment of recalcitrant atrophic nonunions of the distal humerus, when other methods have failed. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Innervation of the interphalangeal joint of the thumb: anatomical study.

We dissected 30 cadaveric thumb interphalangeal joints to delineate the sensory nerve anatomy of its capsule. Four articular branches supplying the interphalangeal joint capsule of the thumb were found in all specimens. Ulnar and radial proper digital nerves provide one palmar capsular nerve branch on their respective sides. Of the two dorsal branches of the radial nerve at the dorsum of the thumb, we observed that each nerve provided one branch to the interphalangeal dorsal capsule. Our findings demonstrate a consistent pattern of innervation and may provide the anatomical basis to the treating surgeon for an effective and safe denervation of the interphalangeal joint of the thumb.

Injerto óseo vascularizado pediculado del radio distal para tratar la seudoartrosis recalcitrante del cúbito / Vascularized bone graft of the distal radius for recalcitrant ulnar pseudoarthrosis

Introducción: El objetivo de este trabajo es presentar los resultados clínicos y radiológicos de una serie de pacientes tratados con injerto óseo vascularizado pediculado del radio distal para seudoartrosis recalcitrantes de cúbito diafisario o proximal. Materiales y Métodos: Se realizó un estudio retrospectivo que incluyó a pacientes con seudoartrosis del cúbito diafisario o proximal con defectos <6 cm y, al menos, tres cirugías previas y un seguimiento mínimo de dos años tratados con injerto óseo vascularizado pediculado del radio distal. Se registró la cantidad de cirugías previas. Se evaluaron el rango de movilidad del codo y la muñeca, la fuerza de puño comparativa, el dolor mediante la escala analógica visual, el cuestionario QuickDASH y el puntaje de la Clínica Mayo para codo. Resultados: Se incluyó a siete pacientes. La edad media fue de 42 años (rango 26-64). El número promedio de cirugías previas fue 4 (rango 3-7). El seguimiento medio fue de 31 meses (rango 24-43). Todas las seudoartrosis consolidaron. El puntaje de la Clínica Mayo fue bueno en 4 pacientes, excelente en 2 pacientes y moderado en uno. El puntaje QuickDASH posoperatorio promedio fue de 13 (rango 0-29). El arco de flexo-extensión de la muñeca fue del 81% del contralateral. El rango de movilidad del codo fue >100° en 5 pacientes y de 50°-100° en 2 pacientes. Conclusión: El injerto óseo vascularizado pediculado del radio distal es una alternativa eficaz para el tratamiento de la seudoartrosis del cúbito. Nivel de Evidencia: IV

Introduction: The purpose of this study was to analyze the clinical and radiological outcomes of a series of patients treated with pedicled distal radius vascularized bone graft for recalcitrant ulnar nonunions. Methods: A retrospective study was performed. The inclusion criteria were patients with diaphyseal or proximal ulnar nonunions with bone defects <6 cm, at least three previous surgeries and a minimum follow-up of 2 years, treated with pedicled vascularized bone graft of distal radius. The number of previous surgeries was recorded. Elbow and wrist range of motion, comparative grip strength, and pain using the Visual Analogue Scale, QuickDASH questionnaire and Mayo Clinic score for elbow were evaluated. Results: Seven patients were included. The mean age was 42 years (range 26-64). The average number of previous surgeries was 4 (range 3-7). The mean follow-up was 31 months (range 24-43). All pseudoarthrosis consolidated. The Mayo Clinic score was good in 4 patients, excellent in 2 patients and moderate in one patient. The mean postoperative Quick- DASH score was 13 (range 0-29). Flexion-extension arch of the wrist was 81% of the contralateral. The elbow range of motion was >100° in 5 patients and 50°- 100° in 2 patients. Conclusion: The pedicled vascularized bone graft of the distal radius is an effective alternative for the treatment of recalcitrant ulnar nonunions. 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

Volar Plate Fixation in Patients Older Than 70 Years with AO Type C Distal Radial Fractures: Clinical and Radiologic Outcomes.

Introduction Treatment of unstable distal radial fractures (DRFs) in elderly patients is controversial, and considering the increasing life expectancy, their appropriate treatment is of growing importance. Our aim was to analyze the clinical and radiologic outcomes in the elderly patients with AO type C DRF treated with volar locking plate (VLP). Materials and Methods Between 2007 and 2011, 572 DRFs were operated on in our hospital with open reduction and internal fixation with VLP. Of these, only 64 patients (66 DRFs) met the selection criteria (AO type C DRF, age > 70 years, minimum 12-month follow-up). Mean follow-up was 28 months. Outcome assessment included range of motion, grip strength, VAS pain, Mayo Clinic Score, and DASH score. Analysis of pre- and postoperative radiographs was performed. Complications were recorded. Statistical analysis was performed comparing the results with the contralateral side. Results Mean postoperative range of motion of the injured wrist compared with the control contralateral side was 86% for flexion ( p < 0.001), 92% for extension ( p < 0.001). The average DASH was 12. Mayo Clinic Wrist Score showed 43 excellent results, 15 good, 4 satisfactory, and 4 poor. Articular step-offs were reduced in 34 of 38 wrists. Five (7%) patients required plate removal. Conclusion The treatment of articular DRF (AO type C) with VLP in the elderly patients achieved greater than 90% of the wrist range of motion and grip strength with no residual pain in greater than 90% of the patients. Level of Evidence Therapeutic IV, case series.

Gluteal Compartment Syndrome Secondary to Pelvic Trauma.

Gluteal compartment syndrome (GCS) is extremely rare when compared to compartment syndrome in other anatomical regions, such as the forearm or the lower leg. It usually occurs in drug users following prolonged immobilization due to loss of consciousness. Another possible cause is trauma, which is rare and has only few reports in the literature. Physical examination may show tense and swollen buttocks and severe pain caused by passive range of motion. We present the case of a 70-year-old man who developed GCS after prolonged anterior-posterior pelvis compression. The physical examination revealed swelling, scrotal hematoma, and left ankle extension weakness. An unstable pelvic ring injury was diagnosed and the patient was taken to surgery. Measurement of the intracompartmental pressure was measured in the operating room, thereby confirming the diagnosis. Emergent fasciotomy was performed to decompress the three affected compartments. Trauma surgeons must be aware of the possibility of gluteal compartment syndrome in patients who have an acute pelvic trauma with buttock swelling and excessive pain of the gluteal region. Any delay in diagnosis or treatment can be devastating, causing permanent disability, irreversible loss of gluteal muscles, sciatic nerve palsy, kidney failure, or even death.

Snapping scapular syndrome secondary to rib intramedullary fixation device.

BACKGROUND: Scapulo-thoracic joint disorders, including bursitis and crepitus, are commonly misdiagnosed problems and can be a source of persistent pain and dysfunction PRESENTATION OF THE CASE: This article describes an unusual case of a snapping scapula syndrome secondary to a migration through the lateral cortex of a rib splint intramedullary fixation device into the scapulothoracic joint. DISCUSSION: Recently, the operative fixation of multiple ribs fractures with intramedullary fixation devices has become popular. Despite the good outcomes with new rib splint designs, concern remains about the potential complications related to potential loss of fracture reduction with migration of the wire resulting in pain or additional injury to the surrounding tissues. CONCLUSION: Surgeons should pay attention to any protrusion of intramedullary rib implants, especially in the evaluation of routine X-rays following surgical treatment. We should be aware of the possibility of this rare cause of snapping scapula syndrome to avoid delayed diagnosis and consider removing the implant will resolve the pain.

Use of Massive Allografts to Manage Hydatid Bone Disease of the Femur.

Hydatid disease is caused by the parasitic tapeworm Echinococcus granulosus. Osseous involvement accounts for 0.5% to 4% of cases in humans. Patients usually are from endemic zones and are initially asymptomatic, presenting with pain and edema at a later stage of disease. However, large lesions may present initially as pathologic fractures. Standard radiographs usually show expansive osteolytic lesions associated with initial cortical thinning, with compromise of the metaphysis or epiphysis, and may involve the diaphysis. The finding of periosteal reaction, osteocondensation, calcification, and clear delimitation of the lesions excludes the diagnosis of osseous hydatidosis. However, there are no specific radiographic signs in the affected bone. There is no generally accepted treatment algorithm for osseous hydatid disease. The usual treatment is surgical resection of the affected bone, followed by antihelmintic therapy. Some patients can be treated with intralesional procedures, such as curettage and allograft or polymethyl methacrylate cement. However, in some advanced cases, such as those with pathologic fractures or recurrences, wide resection may be needed. Several reconstructive alternatives have been reported, such as megaprosthesis, massive allograft, or alloprosthesis composite. The authors retrospectively reviewed 2 cases of femoral hydatidosis treated with wide resection and reconstruction with massive bone allograft. One patient had 5 years of follow-up, and the other had 9 years. No signs of relapse or complications were recorded, and functional outcomes evaluated with the Musculoskeletal Tumor Society scale showed excellent results. These 2 cases support the use of a massive bone allograft as a valid alternative to reconstruction after extensive bone resection for hydatidic disease.