The "Bubble Test" in the Arthroscopic Diagnosis of Triangular Fibrocartilage Central Lesion: Description and Relevance to Treatment.

Background Ulnarly sided wrist pain is a common and challenging symptom. Arthroscopy has become a safe and effective tool for the correct diagnosis and treatment, proving to be better than all other clinical and imaging diagnostic methods. Some tests have been described for the diagnosis of triangular fibrocartilage (TFC) lesions, such as the trampoline test for peripheral lesions and the hook, ghost, and suction tests for foveal detachments. In tears at the disc level, when they affect all layers of the TFC (complete lesion) at the same point, testing with the probe will usually suffice for the diagnosis. However, in some apparently partial lesions, the probe cannot pass through all layers because the proximal and distal sites of the lesion are not aligned. There has been no arthroscopic test described for such cases. Case Description We describe a simple and practical test that we have called the "bubble test" in a typical case to diagnose TFC central injuries, aiming to discriminate partial from complete lesions, which are eventually hard to differentiate through direct vision and arthroscopic probing, leading to a direct influence onto the treatment. The bubble test is performed with external compression of the distal radioulnar joint (DRUJ) aspect, with the thumb on the back of the DRUJ and the index and middle fingers onto the volar aspect. The abrupt compression of this region causes the passage of air mixed with synovial fluid from the DRUJ to the radiocarpal joint, generating bubble formation. Clinical Relevance The bubble test should correlate to physical examination and imaging (magnetic resonance imaging [MRI]) findings and is particularly useful in central and degenerative (Type II) TFC lesions in patients complaining of chronic pain on the ulnar region of the wrist, with no history of trauma and with inconclusive MRI findings. Once the diagnosis is confirmed, arthroscopic treatment consists of wide debridement of the lesion with resection of the injured tissue and the local inflammatory reaction. Thus, it is essential for the correct treatment to define the exact location of the lesion and to know whether the disc injury is complete.

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).

Unicortical versus bicortical plate fixation for midshaft clavicular fractures.

BACKGROUND: The aim of this study was to compare the functional and radiological outcomes of unicortical vs bicortical fixation in patients with midshaft clavicular fractures who were treated using pre-contoured locking plates. METHODS: We performed a prospective multicenter study of 45 individuals who underwent open reduction and internal fixation of midshaft clavicular fractures with precontoured locking plates between March 2017 and December 2019. Twenty-five patients were treated with bicortical screws and 20 patients with unicortical screws. Functional outcomes were assessed at 6 months and 12 months after surgery using the Constant score, the 11-item version of the Disabilities of Arm, Shoulder and Hand (Quick- DASH) score and the Single Assessment Numeric Evaluation (SANE) score. Pain was evaluated using a visual analog scale (VAS). The rate of return to work and sports was also recorded. Radiologic evaluation was obtained in the immediate postoperative day, monthly until fracture consolidation, at 6 months and 12 months. All intraoperative and postoperative complications were documented. RESULTS: At both 6 and 12 months, the follow-up rates were 100%, and the mean age was 28.5 years (range, 20 to 45 years). The mean postoperative Constant score, Quick DASH, and SANE score at 12 months were 93.5 (±6), 2.3 (±3), and 92% (±7), respectively. There were no significant differences in the functional scores between the groups neither at 6 months nor at 12 months. Of the 30 active workers, 97% were able to return to their previous working routine and from the 25 patients who practiced sports before the injury,92% returned to sports all at the same level. All the fractures healed in both groups. There were 6 complications (13%). CONCLUSION: In young, active patients with displaced midshaft clavicular fractures, both unicortical and bicortical locked plates achieved 100% bone consolidation, with excellent functional outcomes and a low rate of complications without significant differences between the groups. Therefore, locked plates with unicortical fixation could be a very good alternative for the management of young patients with midshaft clavicular fractures, potentially avoiding severe neurovascular complications. LEVEL OF EVIDENCE: Prospective comparative (Level II).

Volar Capsulodesis With Early Active Motion for the Treatment of Chronic Proximal Interphalangeal Joint Hyperextension Deformity.

PURPOSE: We evaluated the clinical outcomes of a series of patients with hyperextension deformity of the proximal interphalangeal joint treated with volar capsulodesis. METHODS: This retrospective study included 16 patients with symptomatic locking of the proximal interphalangeal joint who underwent volar capsulodesis and were followed for at least 2 years. We excluded patients with severe, degenerative changes on plain radiographs. Clinical evaluation included the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire; Catalano's scale for proximal interphalangeal joint hyperextension deformity correction; a visual analog scale for pain; range of motion; and grip strength. Hyperextension recurrence and residual flexion contracture were also recorded. RESULTS: There were 2 women and 14 men, with a mean age of 36 years (range, 22-60 years). The mean preoperative pain scores according to the visual analog scale were 3.6 (range,1-8) and 0.5 (range, 0-3) at the final follow-up. No patient had a recurrence of the hyperextension deformity. The average Quick Disabilities of the Arm, Shoulder, and Hand score was 5, and the mean grip strength was 87% of the contralateral side. Five patients were rated as having excellent results, 9 patients as having good results, and 2 patients as having fair results. Residual flexion contracture was less than 10° in 13 patients and more than 10° in 3 cases. All patients returned to unrestricted activities. CONCLUSION: Volar capsulodesis with early active motion demonstrated favorable results and could be considered as a surgical option for the treatment of chronic hyperextension deformity of the proximal interphalangeal joint. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

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.

Time until union in absolute vs. relative stability MIPO plating in simple humeral shaft fractures.

PURPOSE: The objective of this study is to evaluate the effect of absolute stability (AS) versus relative stability (RS) performed through a minimally invasive plate osteosynthesis (MIPO) in AO/OTA 12A1 and 12A2 fractures on healing and the time to radiographic union. METHODS: This was a retrospective cohort study of all patients treated with plate fixation for AO/OTA type 12A1-A2 fractures at a single institution. Patients were grouped according to the type of stability used in their surgery. Time until radiographic union was estimated using the Kaplan-Meier method, which was compared by long-rank test between both types of surgical techniques. RESULTS: A total of 70 patients were included in this study with 35 patients in each group. The median follow-up was 9 (IQR 6-14) months. The median time to radiographic union was significantly lower in the AS group than in the RS group: 12 (interquartile range (IQR) 10-14) weeks versus 18 (IQR 16-19) weeks, respectively (p < 0.001). Non-union was seen in two cases (7%) in the relative stability group. Three patients in the RS group developed a post-operative radial nerve palsy. CONCLUSION: The main finding of this study is that the median time to radiographic union was significantly shorter in the patients treated with AS compared to those with a RS technique. These findings support the recommendations of the AO foundation in that simple metaphyseal fractures (type A) that require surgical treatment should be treated with an AS construct. RS techniques should be reserved to multifragmentary fractures where fragment preservation of blood supply is paramount.

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.

Trapeziometacarpal osteoarthritis: Arthroscopic hemitrapeziectomy using the Thenar Portal.

BACKGROUND: Although the standard 1Radial and 1Ulnar portals allow for visualisation of most of the trapezium articular surface, the proximity of these two portals can often make arthroscopic triangulation and visualisation of the most lateral capsule and joint surface challenging. Despite its already reported advantages in improving visualisation, there is little literature reporting the clinical experience with the Thenar Portal. The purpose of this study is to describe potential complications and the short-term clinical-radiographic outcomes of arthroscopic hemitrapeziectomy using the Thenar Portal in order to determine its safety and efficacy as a standard working portal. PATIENTS AND METHODS: A retrospective chart review was conducted for all patients diagnosed with first carpometacarpal (CMC) osteoarthritis who were treated surgically with an arthroscopic hemitrapeziectomy. Only patients with stage II or III osteoarthritis and a minimum of 1-year follow-up were included. Twenty-two patients (24 thumbs) with an average age of 62 years met the inclusion criteria. The average follow-up was 52 months. Intra-operative and post-surgical complications were recorded. Objective evaluation consisted of an assessment of range of motion (ROM), grip and pinch strength. Subjective evaluation consisted of a DASH questionnaire and the visual analog scale to score pain at rest, during activities, and function. RESULTS: There were no intra- or post-surgical complications. In one case, pain persisted with a poor functional result, requiring a revision surgery. Average range of motion (compared with the contralateral) showed a statistically significant improvement in palmar abduction and radial abduction of the CMC joint: 50° vs. 55° (p=0.01235), and 50° vs. 55° (p=0.06009), respectively. There was no statistically significant improvement in thumb adduction, grip strength, or lateral and tip-pinch. All patients achieved retropulsion with their affected thumb. According to the VAS, average rest pain improved from 7.5 to 0 (p<0.001) and from 9 to 0 (p<0.001) during activity. The average final function and QuickDASH were 9 (VAS) and 8, respectively (p<0.001). The average radiographic proximal migration of the first metacarpal was 2.9mm (range: 0.7-5.8mm). DISCUSSION: Arthroscopic hemitrapeziectomy using the Thenar portal: 1) improved visualisation of the trapeziometacarpal joint, 2) facilitated arthroscopic triangulation, and 3) represents a safe and effective alternative for the treatment of thumb osteoarthritis, with pain relief and function improvement in most patients without a higher risk of complications. LEVEL OF EVIDENCE: IV.

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

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

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

Osteotomía en cuña sustractiva supracondílea para el tratamiento del codo valgo del adulto / Supracondylar subtraction wedge osteotomy for the treatment of adult cubitus valgus

Objetivo: Comunicar los resultados de una serie de adultos con consolidaciones en valgo del codo tratados con una osteotomía en cuña sustractiva monoplanar. materiales y métodos: Se incluyeron 5 pacientes. Se describe la técnica quirúrgica que consistió en un abordaje posterior paratricipital, resección en cuña sustractiva y transposición anterior del nervio cubital. El seguimiento promedio fue de 17 meses. Resultados: Se trató a 4 hombres y una mujer, con una edad promedio de 27 años. La movilidad preoperatoria promedio fue de 138-7° y la posoperatoria, de 138-6°, el puntaje de dolor en la EAV fue de 4 y 1, el MEPS de 71 y 97, y el DASH de 26 y 8, respectivamente. La evaluación radiográfica preoperatoria arrojó un valgo promedio de 30° con un valgo contralateral de 11°. La corrección radiográfica demostró un valgo de 13°. Se obtuvo una corrección promedio de 2° menos que del otro lado. Todas las osteotomías consolidaron, y la medición de la prominencia medial fue, en promedio, un 32% mayor que en el preoperatorio. Según la escala de Oppenheim, el resultado fue excelente en 4 pacientes y bueno en uno. La satisfacción personal fue, en promedio, de 8,6. Conclusiones: La osteotomía en cuña sustractiva para tratar un codo valgo es una buena opción terapéutica, con recuperación de valores angulares comparables con el lado contralateral, y alta tasa de satisfacción de los pacientes. Como es una técnica menos compleja que las osteotomías multiplanares, es nuestra elección ante una consolidación viciosa en valgo del codo del adulto. Nivel de Evidencia: IV

Objective: To report the results of a series of adult patients with a valgus malunion of the elbow treated with a supracondylar subtractive monoplanar wedge osteotomy, materials and methods: 5 patients were included. The surgical technique consisted of a posterior paratricipital approach, with resection of a subtractive wedge and the anterior transposition of the ulnar nerve. The average follow-up was 17 months.Results: 4 patients were men and 1 woman with an average age of 27 years. The preoperative range of motion was 138°-7° and the postoperative range of motion was 138-6°. Pain according to VAS was 4 and 1, MEPS was 71 and 97, and DASH was 26 and 8, respectively. The preoperative radiological evaluation showed an average valgus of 30° with a contralateral valgus of 11º. The final valgus obtained was 13°. The final correction was, on average, 2° less than the contralateral side. All osteotomies healed and the medial prominence was on average 32%, more than before surgery. According to Oppenheim scale, the results were excellent in 4 patients and good in 1. Personal satisfaction was, on average, 8.6. Conclusions: Supracondylar subtractive wedge osteotomy is a good option for the treatment of adult cubitus valgus with a recovery of angular values similar to the contralateral side and a high satisfaction rate. As it is a simpler technique, compared to the multiplanar osteotomies, it is our treatment of choice for adult cubitus valgus. Level of Evidence: IV

Prótesis total de codo en el contexto de una seudoartrosis de olécranon. Técnica quirúrgica y reporte de tres casos / Total elbow arthroplasty in the context of a nonunion of the olecranon. Surgical technique and report of 3 cases

La indemnidad del aparato extensor es fundamental para un correcto funcionamiento de una prótesis de codo. Se ha considerado que la deficiencia del tríceps es una contraindicación relativa para la artroplastia, porque produce una contractura en flexión y un déficit de extensión activa. Estas limitaciones pueden afectar significativamente la mejora funcional que la artroplastia total de codo produce. Ante una seudoartrosis de olécranon, la colocación de una prótesis total de codo se presenta como un problema complejo que resolver. El objetivo de este artículo es describir la técnica quirúrgica para la colocación de una prótesis total de codo en el contexto de una seudoartrosis de olécranon, y comunicar tres casos. Nivel de Evidencia: IV

The integrity of the extensor apparatus is essential for the correct functioning of an elbow prosthesis. Triceps deficiency has been considered a relative contraindication for arthroplasty, because it produces a flexion contracture and an active extension deficit. These limitations can significantly affect the functional improvement that total elbow arthroplasty produces. Faced with an olec-ranon nonunion, the placement of a total elbow prosthesis is presented as a complex problem to be solved. The objective of this article is to describe the surgical technique for the placement of a total elbow prosthesis in the context of an olecranon nonunion, and to report three cases. Level of Evidence: IV

Uso de la matriz dérmica acelular para el tratamiento de zonas críticas en defectos de cobertura. Serie de casos / The role of dermal regeneration templates in severe soft tissue defects. Management of "critical zones". Case series

Introducción: El objetivo de esta serie de casos es describir los resultados y las complicaciones de pacientes con heridas gra-ves con defecto de cobertura en zonas críticas tratadas con una matriz dérmica acelular. materiales y métodos: Se realizó una revisión retrospectiva de los pacientes con déficit de cobertura en zonas críticas tratados con matriz dérmica acelular en nuestro centro. Definimos como zona crítica al déficit de cobertura que no pueda ser tratado solo con injerto de piel. Evaluamos variables preoperatorias, intraoperatorias y posoperatorias. Resultados: Los diagnósticos iniciales fueron tumor (3 pacientes), trauma agu-do (3 pacientes) y secuela de síndrome compartimental (2 pacientes). El defecto de cobertura estaba localizado en la pierna (3 casos), en la mano (2 casos), en el muslo (1 caso), en el antebrazo (1 caso) y en el pie (1 caso). La zona crítica se caracterizó por exposición tendinosa con pérdida de peritenon (5 casos), exposición ósea y pérdida de periostio (1 caso), exposición de injerto de nervio (1 caso) y exposición de osteosíntesis (1 caso). Se registraron tres complicaciones. Dos pacientes requirieron una nueva colocación de matriz y, en otro paciente, se realizó un colgajo neurocutáneo de safeno interno por fracaso de la cobertura con membrana. Conclusiones: Los sustitutos dérmicos se caracterizan por su fácil uso y versatilidad. Esta técnica otorga protección en situaciones de exposición ósea, además de proveer un plano de deslizamiento en caso de exposición tendinosa. El uso de matriz dérmica permite, además, ahorrar el empleo de colgajos. Nivel de Evidencia: IV

Introduction: The aim of this study is to report outcomes and complications in a series of patients suffering soft tissue defects in critical areas treated using an acellular dermal matrix. Materials and Method: A retrospective review of patients with soft tissue coverage deficits in critical areas treated with acellular dermal matrix in our center over a five-year period was conducted. The preoperative variables analyzed were: age, sex, comorbidities, number of previous surgeries, size and characteristics of the critical area and cause of the coverage defect. The intraoperative variables analyzed were: size of the dermal substitute used, surgical time and complications. The postoperative variables were: incorporation of the dermal substitute, time elapsed until the placement of the skin graft, and postoperative complications. Results: The initial diagnoses were tumor (3 patients), acute trauma (3 patients) and sequelae of compartment syndrome (2 patients). The soft tissue defect was located in the leg (3 cases), in the hand (2 cases), in the thigh (1 case), in the forearm (1 case) and in the foot (1 case). In 5 cases the critical zone was characterized by tendon exposure with loss of peritenon; in one case bone exposure and loss of periosteum; in one case exposure of nerve graft and in one case exposure of osteosynthesis material. Three complications were recorded. Conclusion: Dermal substitutes are characterized by their versatility. This technique can provide protection in situations of bone exposure, in addition to providing a gliding plane in case of tendon exposure. In situations of failure or impossibility of performing a biological reconstruction, dermal substitutes havea role within reconstructive options. Level of Evidence: IV

Artroplastia total de codo después de un proceso infeccioso. Cirugía en dos tiempos / Total elbow arthroplasty after an infection process. Two-stage surgery

Objetivo: Comunicar los resultados en pacientes con un proceso infeccioso del codo, tratados en 2 etapas quirúrgicas: la primera con un espaciador de cemento con antibiótico y la segunda con una artroplastia total de codo. materiales y métodos: Se descri-ben los criterios de inclusión, el diagnóstico de infección y las 2 etapas quirúrgicas. Resultados: Se incluyeron 10 pacientes (4 hombres y 6 mujeres, edad promedio 62 años). Causas iniciales: degenerativas (2 casos) y traumáticas (8 casos). Se realizaron 4 aloprótesis y 2 colgajos de dorsal ancho. Se identificaron 2 grupos: A (defectos óseos <4 cm) y B (>4 cm). El seguimiento fue de 5 años. La flexo-extensión fue de 117°/29° en el preoperatorio y 130°/29° en el posoperatorio; los puntajes de dolor fueron 6,5 y 2,5 (EAV); 40 y 80 (MEPS); y 56 y 30 (DASH), respectivamente. La fuerza de extensión fue de M5 (4 casos), M4 (2 casos), M3 (1 caso), M1 (2 casos) y M0 (1 caso). Un paciente tuvo una necrosis del colgajo que evolucionó con infección y 9 no tenían infección al final del seguimiento. Los pacientes del grupo A tenían menos cirugías previas y mejores resultados funcionales. Conclusiones: El tratamiento de un proceso infeccioso de codo mediante un espaciador de cemento con antibiótico permite controlar la infección en un alto porcentaje de los casos. La reconstrucción protésica secundaria es demandante y se asocia a complicaciones. Cabe esperar que, cuanto más grande sea el defecto óseo y mayor la cantidad de procedimientos previos, los resultados funcionales sean peores. Nivel de Evidencia: IV

Objective: to report the results of patients with an infectious elbow process, treated in 2 surgical stages: the first with an antibiotic cement spacer (ACE) and the second with a total elbow arthroplasty. Material and methods: the inclusion criteria, the diagnosis of infection and the 2 surgical stages are described. Results: 10 patients were included (7 men and 3 women), average age: 62 years old. Initial causes: degenerative in 2 cases and traumatic in 8. 4 alloprostheses and 2 latissimus dorsi flaps were performed.Follow-up was 5 years. Flexo-extension was 117°/29° in preoperative and 130°/29° in postoperative; pain according to EVA: 6.5 and 2.5; MEPS: 40 and 80; DASH 56 and 30 respectively. The extension force was M5 (4 cases), M4 (2), M3 (1), M1 (2) and M0 (1). One patient presented a necrosis of the flap that evolved with infection. In 9 of the 10 cases the patients were free of infection at the end of the follow-up. Two groups of patients were identified: Group A (bone defects less than 4 cm) and B (more than 4 cm). Group A patients had fewer previous surgeries and better functional outcomes. Conclusion: the treatment of an infectious elbow process through the placement of antibiotic cement spacer, allows a control of the infection in a high percentage of cases. Secondary prosthetic reconstruction is demanding and associated with complications. It is to be expected that the greater the bone defect and the greater the number of previous procedures, result in the worse the functional results. Level of Evidence: IV

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

Resultados de la osteotomía y la osteosíntesis rígida en la consolidación viciosa de falange / Outcomes of osteotomy and rigid internal fixation treatment for the correction of phalangeal malunions

Objetivo: Evaluar los resultados y las complicaciones de una serie de pacientes con consolidación viciosa de falange. Materiales y Métodos: Se realizó un estudio retrospectivo que incluyó a pacientes con consolidación viciosa de falange tratados mediante osteotomía en el sitio de la deformidad, estabilizados con osteosíntesis rígida. Se registró la movilidad de los dedos. La valoración subjetiva consistió en el puntaje DASH y una escala analógica visual para el dolor en reposo, en actividad y la función. Resultados: Doce pacientes (13 falanges) cumplieron los criterios de inclusión. El tiempo promedio entre la lesión inicial y la osteotomía fue 14 meses y el seguimiento promedio, 34 meses. La movilidad final promedio en flexo-extensión fue 89° metacarpofalángica, 74° interfalángica proximal, 54° interfalángica distal y la distancia pulpejo-palma, 3 mm. El puntaje promedio de la escala analógica visual en reposo fue 0; en actividad, 1 y la función promedio fue de 7 puntos; el puntaje DASH promedio fue 6. No hubo casos de seudoartrosis. Cinco pacientes requirieron el retiro de la placa. Los pacientes con osteotomía articular no presentaron signos de artrosis. Conclusiones: La osteotomía de falange en el sitio de la deformidad es un procedimiento eficaz con un buen resultado objetivo y subjetivo a corto plazo. La utilización de placas y tornillos conlleva una tasa más alta de complicaciones; por lo tanto, los pacientes deben ser advertidos sobre la posibilidad de una segunda intervención quirúrgica. Nivel de Evidencia: IV

Objective: To present the results and complications of a series of phalangeal malunion patients. Materials and Methods: A retrospective study was conducted on phalangeal malunion patients treated with an osteotomy at the deformity site and stabilized with rigid internal fixation. Postoperative mobility of the digit was recorded. The subjective assessment used the Disabilities of the Arm, Shoulder and Hand (DASH) score and a Visual Analogue Scale (VAS) to rate their function and pain at rest and during activity. Results: Twelve patients (13 phalanges) met the inclusion criteria. The average time between fracture and osteotomy was 14 months and the mean follow-up was 34 months. Final mobility in flexo-extension was: 89 degrees for metacarpophalangeal joint, 74 degrees proximal interphalangeal joint, 54 degrees distal interphalangeal joint. The average VAS pain score was 0 at rest and 1 during activity, and the average function was 7 points. The average DASH score was 6. There were no cases of nonunion. Five patients required plate removal. No patients with articular osteotomy presented signs of Osteoarthritis. Conclusions: Phalangeal osteotomy at the deformity site is an effective procedure with good objective and subjective short-term outcomes. Patients should be warned about the possibility of a second procedure in cases of plate fixation due to a higher complication rate associated with plate and screw fixations. Level of Evidence: IV