Tratamiento mínimamente invasivo/percutáneo de fracturas de pilón tibial con asistencia artroscópica en Hospital Regional de Talca / Minimally invasive/percutaneous treatment of tibial pilon fractures with arthroscopic assistance at the Regional Hospital

Tibial pilon fractures are a complex injury to treat due to the great involvement of soft and bone tissues. The classic surgical treatment is based on open reduction with internal fixation (ORIF), adding morbidity to the soft tissues, increasing the risk of complications. This has motivated the development of minimally invasive and/or percutaneous techniques to reduce complications, and with the advent of arthroscopy, achieve anatomical reductions. METHODS: A retrospective observational study of twelve patients with tibial pilon fractures who were treated in our center with minimally invasive and/ or percutaneous osteosynthesis with arthroscopic support was carried out between January 2019 and June 2021. Fractures were characterized using the AO/OTA classification for tibial pilon. Age, sex, fracture mechanism, exposure and initial management in the emergency department (cast immobilization or external fixation), definitive treatment, complications and clinical and functional evaluation twelve months after definitive osteosynthesis. For this last point, plantar flexion, dorsiflexion and the AOFAS and FAOS Score were measured. RESULTS: The operated patients were 12, 8 were men (67%) and 4 were women (33%). The average age was 49 (17-68) years. The definitive treatment was carried out after an average of 8 days (5-12 days). Surgical treatment schemes were as follows: percutaneous osteosynthesis with medial anatomical plate and arthroscopic support (OPAA), minimally invasive osteosynthesis with cannulated screws and arthroscopic support (OMIAA) and osteosynthesis with external circular guide and arthroscopic support (OTCAA). In the AOFAS Score, three patients had excellent results (≥ 90 points), 6 patients had good results (≥ 80 points) and 3 patients had acceptable results (≥ 70 points). In the FAOS Score, eight patients had over 80% (good results) and 4 patients had over 60% (accep - table results). DISCUSSION: Historically, tibial pilon fractures have been considered non-reconstructable and with poor long-term results. Initially this paradigm changed with the principles of Rüedi for the reconstruction of the tibial pilon and improve the results. ORIF has been widely used until today, it allows achieving an anatomical joint reduction, it allows to give stability and length to the fibula, graft contribution and sta - bilization with the medial plate. Today this concept is changing again, since the emphasis is on the care of the soft tissues to allow a better recovery of the patient and reduce the complications of the classic approach, it is in this context that the appearance of minimally invasive and/or percutaneous techniques with arthroscopic assistance has allowed us to have excellent functional and clinical results with less da - mage to the soft tissues. CONCLUSION: The proper management and care of the soft tissues in a high-energy fracture of the tibial pilon is essential to obtain favorable clinical results and thus achieve restoration of ankle function. Percutaneous and minimally invasive management has optimized management of the tibial pilon, redu - cing the rates of complications, amputation, and pri - mary arthrodesis.

Outcomes of a Modified Arthroscopic-assisted Reconstruction Technique for Lateral Ankle Instability / Resultados de uma técnica modificada de reconstrução assistida por artroscopia para instabilidade lateral do tornozelo

Abstract Objective The present study assesses the results of a minimally invasive surgical technique for acute and chronic ankle instability management. Methods The present case series study retrospectively evaluated 40 patients undergoing arthroscopic-assisted percutaneous ankle ligament reconstruction from 2013 to 2019. Results The present study included 17 males and 23 females with an average age of 38.3 years old. Postintervention follow-up using American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scores identified improvement of > 30 points in function and pain control. The most frequently occurring associated injuries were osteochondral (35%). No patient required reintervention or had infection during follow-up. Conclusion The technique in the present study is easy and achieves satisfactory results for function and pain control. Level of Evidence IV.

Resumo Objetivo O presente estudo avalia os resultados de uma técnica cirúrgica minimamente invasiva para o manejo da instabilidade aguda e crônica do tornozelo. Métodos O presente estudo de uma série de casos avaliou retrospectivamente 40 pacientes submetidos à reconstrução percutânea assistida por artroscopia do ligamento do tornozelo entre 2013 e 2019. Resultados O estudo incluiu 17 homens e 23 mulheres com idade média de 38,3 anos. O acompanhamento pós-intervenção utilizou a pontuação American Orthopaedic Foot and Ankle Society (AOFAS, na sigla em inglês). As pontuações do tornozelo-retropé identificaram melhora > 30 pontos na função e no controle da dor. As lesões associadas mais frequentes foram as osteocondrais (35%). Nenhum paciente precisou de reintervenção ou teve infecção durante o acompanhamento. Conclusão A técnica do presente estudo é fácil e consegue resultados satisfatórios para a função e o controle da dor. Nível de Evidência IV.

Artroscopia de rodilla en pacientes mayores de 64 años con gonartrosis primaria / Knee Arthroscopy In Patients Over 64 Years Of Age With Primary Gonarthrosis

Introducción: La gonartrosis es una entidad frecuente, que afecta especialmente a personas mayores de 60 años de edad. Para su tratamiento se combinan modalidades conservadoras y quirúrgicas y dentro de esta última, las realizadas por la vía artroscópica. Objetivo: Evaluar los resultados de las técnicas quirúrgicas por vía artroscópica en pacientes con gonartrosis primaria mayores de 64 años de edad. Métodos: Se realizó un estudio pre experimental de diseño (preprueba-posprueba) en 40 pacientes mayores de 64 años tratados por vía artroscópica con el diagnóstico de gonartrosis primaria, en el Hospital Universitario Manuel Ascunce Domenech de la ciudad de Camagüey de octubre 2012 a mayo de 2019. La investigación tiene un nivel de evidencia IV y recomendación D. Resultados: El promedio de edad de los pacientes estudiados fue de 69,6 años con predominio del sexo femenino sobre el masculino, y una razón de 3:1. La afección tricompartimental predominó en la mayoría de los enfermos, así como el grado IV según la clasificación de Outerbridge. Predominaron las lesiones de cartílago y meniscos asociadas. Los tratamientos por vía artroscópica más empleados fueron el desbridamiento y la meniscectomía parcial. Se detectó significación estadística entre un antes y un después. Conclusiones: Los resultados de la investigación muestran que los procedimientos realizados a través de la vía artroscópica en pacientes mayores de 64 años de edad con gonartrosis primaria son efectivos en más de la mitad de los enfermos(AU)

Introduction: Gonarthrosis is a common entity that especially affects people over 60 years of age. For its treatment, conservative and surgical modalities are combined, and within the latter, those carried out by the arthroscopic route. Objective: To evaluate the results of arthroscopic surgical techniques in patients with primary gonarthrosis older than 64 years of age. Methods: A pre-experimental design study (pre-test-post-test) was carried out in 40 patients older than 64 years treated arthroscopically due to the diagnosis of primary gonarthrosis, at Manuel Ascunce Domenech University Hospital in Camagüey from October 2012 to May. of 2019. The research has a level of evidence IV and recommendation D. Results: The average age of the patients studied was 69.6 years, with a predominance of females, and a ratio of 3:1. Tricompartmental involvement prevailed in most of the patients, as well as grade IV according to the Outerbridge classification. Associated cartilage and meniscus injuries predominated. The most used arthroscopic treatments were debridement and partial meniscectomy. Statistical significance was detected between before and after. Conclusions: The results of the investigation show that the procedures carried out through the arthroscopic route in patients older than 64 years of age with primary gonarthrosis are effective in more than half of the patients(AU)

Ruptura inveterada del tendón patelar. Reconstrucción con tendones semitendinoso y recto interno / Neglected rupture of patellar tendon. Reconstruction with semitendinosus and gracilis tendon autografts

Introducción: La ruptura inveterada del tendón patelar es una patología poco común y significa un reto para su resolución quirúrgica. El ascenso de la patela, la fibrosis en el lugar de la ruptura y la imposibilidad de afrontar los extremos del tendón hacen que su reparación primaria sea imposible, teniendo que recurrir a su reconstrucción con injerto. En este trabajo se describe la reconstrucción del tendón patelar con la utilización de injerto autólogo de semitendinoso - recto interno, técnica quirúrgica basada en los trabajos de Ecker y col.1 y Van der Zwaal y col.,2 con algunas modificaciones.Materiales y métodos: se intervinieron ocho pacientes, todos de sexo masculino, con una edad promedio de treinta y ocho años (22-50). El lapso entre la ruptura y el procedimiento quirúrgico fue en promedio de sesenta días (87­40). El tiempo de seguimiento postoperatorio fue en promedio de once meses (7­18). Resultados: todos lograron extensión completa de la rodilla y una flexión activa promedio de 130° (125-140°). El resultado fue excelente en seis de ellos y bueno en dos pacientes. El score postoperatorio de Lysholm fue de 92 (90-96). En la evaluación radiográfica presentaron un índice de Insall Salvati promedio de 1.16 (1.1­1.3). Estos dos últimos resultados fueron estadísticamente significativos (p <0.005) comparados con el preoperatorio.Conclusión: la ruptura inveterada del tendón patelar es una patología poco frecuente, cuya resolución quirúrgica es un reto para el cirujano ortopedista, la técnica descripta en este trabajo ofrece seguridad en su reconstrucción, y ofrece una recuperación íntegra del aparato extensor. Tipo de estudio: Serie de casos, retrospectivo. Nivel de evidencia: IV

Introduction: Neglected rupture of the patellar tendon is a rare pathology and is a challenge for its surgical resolution. The migration of the patela, fibrosis at the site of rupture and the impossibility of facing the ends of the tendon make its first repair impossible having to resort to its reconstruction with graft. This work describes the reconstruction of the patellar tendon semitendinosus and gracilis autograft, surgical technique based on the work of Ecker and col.1 and Van der Zwaal and col.2 with some modifications.Materials and methods: eight patients, all male, were involved with an average age of thirty-eight years (22-50). Whose time lapse between the rupture and the surgical procedure was on average sixty days (87­40). The postoperative follow-up was on average eleven months (7­18).Results: all achieved full knee extension and an average active flexion of 130° (125-140°). The result was excellent in six of them and good in two patients. Lysholm's post-operative score was 92 (90-96). In the radiographic evaluation they had an average Insall Salvati index of 1.16 (1.1 ­ 1.3). These last two results were statistically significant (p <0.005) compared to preoperative.Conclusions: the neglected rupture of the patellar tendon is a rare pathology, whose surgical resolution is a challenge for the orthopedic surgeon, the technique described in this work offers safety in the reconstruction of this ligament and offers a complete recovery of the extensor mechanism. Type of study: Case series, retrospective. Level of Evidence: IV

Evaluation of the Functional Outcomes of Arthroscopic Surgical Treatment of Complete Rotator Cuff Lesion with Minimum Follow-up of 10 Years / Avaliação dos resultados funcionais do tratamento cirúrgico artroscópico da lesão completa do manguito rotador com seguimento mínimo de 10 anos

Abstract Objectives To analyze the functional outcomes in patients submitted to videoarthroscopic surgical treatment for compleat rotator cuff tears of the shoulder, with a minimum follow-up of 10 years. Methods A total of 63 patients (63 shoulders) underwent videoarthroscopic surgical repair for compleat rotator cuff tears with a minimum follow-up of 10 years. The postoperative functional outcomes of these patients were evaluated using the Constant and University of California at Los Angeles (UCLA) scores. Results The functional evaluation revealed mean UCLA and Constant scores of 26 and 93 points, respectively. Ninety-one percent of the subjects had satisfactory Constant scores, whereas 62% presented satisfactory UCLA scores. Conclusion The arthroscopic repair of rotator cuff complete tear was effective even in the long term (minimum follow-up period of 10 years). The age of the patients before surgery, size of the lesion, the degree of fatty infiltration, and evaluation of muscle trophism are important predictors of prognosis.

Resumo Objetivo Analisar o resultado funcional dos pacientes submetidos ao tratamento cirúrgico videoartroscópico da ruptura completa do manguito rotador do ombro, com seguimento mínimo de 10 anos. Métodos Foram avaliados 63 pacientes (63 ombros) submetidos ao reparo cirúrgico videoartroscópico da ruptura completa do manguito rotador com seguimento mínimo de 10 anos. O resultado funcional no pós-operatório desses pacientes foi avaliado pelos escores de Constant e UCLA. Resultados Os valores médios foram de 26 pontos no escore UCLA e de 93 no escore de Constant. Para o escore de Constant, 91% foram considerados satisfatórios; e para o UCLA, 62% dos pacientes apresentaram escores satisfatórios. Conclusão O reparo artroscópico da ruptura completa do manguito rotador mostrou-se efetivo mesmo a longo prazo (seguimento mínimo de dez anos). A idade dos pacientes antes da cirurgia, o tamanho da lesão, o grau de infiltração gordurosa e a avaliação do trofismo muscular foram importantes preditores de prognóstico.

Resultados del tratamiento artroscópico de la rotura del manguito rotador en pacientes mayores de 60 años / Results of arthroscopic treatment of rotator cuff rupture in patients over 60 years of age

Resumen: Antecedentes: El aumento de la esperanza de vida de la población incrementa el número de pacientes con patología sintomática del manguito rotador. Nuestro objetivo fue determinar los resultados clínicos de una cohorte de pacientes mayores de 60 años con rotura del manguito rotador intervenidos mediante cirugía artroscópica de hombro (CAH). La hipótesis de trabajo fue que la CAH permitiría resultados clínicos satisfactorios. Material y métodos: De nuestra base de datos prospectiva de CAH seleccionamos los pacientes con: edad mayor de 60 años, rotura de manguito rotador, seguimiento mínimo de dos años. La valoración clínica se determinó según el test de Constant y el cuestionario Quick-DASH de calidad de vida. Resultados: 42 pacientes con una edad media de 66.7 años (rango de 60 a 83). La rotura del supraespinoso se reparó con sutura en doble fila en 25 pacientes (59.5%) y en fila única en 17 pacientes (40.5%). Lesiones asociadas: lesión de la porción larga del bíceps en 31 pacientes (48.4%), del subescapular en 24 pacientes (37.5%) y lesión tipo SLAP en tres pacientes (7.1%). El seguimiento medio fue de 32.4 meses. La puntuación media en la escala de Constant pasó de 48.3 puntos en el preoperatorio a 87.2 puntos al final del seguimiento. El cuestionario DASH síntomas/discapacidad disminuyó de 52.5 de media a 11.0 al final del seguimiento. Discusión: El tratamiento artroscópico de las roturas de manguito rotador en mayores de 60 años permite obtener resultados satisfactorios en los cuestionarios de valoración funcional y calidad de vida a mediano plazo.

Abstract: Introduction: Increasing life expectancies in population increase the number of patients with rotator cuff tears. The purpose of this study was to evaluate clinical outcomes after arthroscopy rotator cuff repair in patients over 60 years old. We hypothesized that shoulder arthroscopy would allow significant improvements in clinical outcomes without serious complications. Material and methods: We screened from our shoulder arthroscopy database patients older than 60 years old, with rotator cuff tear, and minimun 2-year follow-up. The patients were evaluated using Constant scores for clinical outcomes and Quick-DASH score for quality of life. Results: In total, 42 patients were enrolled in the study with a mean age of 66.7 years old (range 60 to 83). A double-row repair was indicated in 25 patients (59.5%), and single-row repair in 17 patients (40.5%). As associated injuries we found proximal biceps pathology in 31 patients (48.4%), subscapularis tears in 24 patients (37.5%), and SLAP tears in 3 patients (7.1%). Mean follow-up was 32.4 months. Constant scores improved from 48.3 preoperatively to 87.2 at final follow-up. Quick-DASH decreased from 52.5 preoperatively to 11.0 at final follow-up. Discussion: Arthroscopy cuff repair in patients older than 60 years old provides satisfactory clinical outcomes without morbidity at medium follow-up.

Artroscopía de rodilla bajo bloqueos de nervios femoral y ciático en paciente COVID-19 con artritis séptica. Reporte de caso / Knee arthroscopy under femoral and sciatic nerve blocks in a COVID-19 patient with septic arthritis. A case report

Since the start of the COVID-19 pandemic, several anesthetic societies have generated clinical recommendations for the perioperative management of these patients, including the Chilean Society of Anesthesiology. Among these recommendations, the advantages of regional anesthesia have been highlighted. In this article, we report and discuss the case of a 59-year-old patient with diabetes mellitus II, Chronic Arterial Hypertension, Gout, and Stage IV Chronic Renal Failure admitted with a multifocal septic condition characterized by suppurative collections including a large subcutaneous lumbar abscess recently drained. The patient evolved with left knee septic arthritis and was scheduled for arthroscopic irrigation and debridement. As per protocol a SARS-COV2 PCR was tested and resulted positive. It was decided to proceed to surgery under anesthetic ultrasound-guided femoral and sciatic nerve blocks using an adrenalized (2.5 ug/mL) solution of 0.33% Levobupivacaine- 0.66% Lidocaine (15 mL each). Fifteen minutes later, the knee was mobilized passively without pain. Surgery started after 30 minutes. The surgical and anesthetic conditions were described as adequate by the surgeon and the patient, respectively. The postoperative evolution was satisfactory without presenting respiratory symptoms and the patient was discharged 17 days after under oral antibiotic treatment.

Desde el comienzo de la pandemia de COviD-19, varias sociedades de anestesia han generado recomendaciones clínicas para el tratamiento perioperatorio de estos pacientes, incluida la Sociedad Chilena de Anestesiología. Entre estas recomendaciones, se han destacado las ventajas de la anestesia regional. En este artículo, reportamos y discutimos el caso de un paciente de 59 años con diabetes mellitus tipo 2, hipertensión arterial, gota e insuficiencia renal crónica en etapa IV, admitido por una sepsis multifocal caracterizada por colecciones supurativas que incluyen un gran absceso lumbar subcutáneo drenado recientemente. El paciente evolucionó con artritis séptica de rodilla requiriendo de una exploración y aseo artroscópico. Por protocolo perioperatorio COviD-19, se solicitó PCR para SARS-COv2 con un resultado positivo. Se decidió proceder a la cirugía bajo bloqueos anestésicos guiados por ultrasonido de nervios femoral y ciático utilizando una solución adrenalizada (2,5 ug/mL) de levobupivacaína al 0,33% lidocaína al 0,66% (15 mL en cada uno). Quince minutos después, la rodilla se movilizó pasivamente sin dolor. La cirugía se inició tras media hora empleando una ligera sedación con propofol. Las condiciones quirúrgicas y anestésicas fueron descritas como adecuadas por el cirujano y el paciente. Este último evolucionó favorablemente, sin síntomas respiratorios y fue dado de alta 17 días después con tratamiento antibiótico oral.

Outcomes after rotator cuff repair in the elderly as assessed by the American Shoulder and Elbow Surgeons shoulder score

Rotator cuff tears are common among the elderly, and studies on the outcomes after rotator cuff repair in the elderly are limited. We carried out this meta-analysis with systematic literature search, aiming to clarify the outcomes after rotator cuff repair in the elderly as assessed by the American Shoulder and Elbow Surgeons (ASES) shoulder score. We conducted a literature search through October 2019 in PubMed and EMBASE databases and performed meta-analysis to calculate the summary mean difference comparing the post- and pre-operation ASES scores under both fixed-effect and random-effect models. Among 4978 studies identified through literature search, four studies (two in the United States, one in France, and one in Republic of Korea) were eligible for the meta-analysis, including 282 patients who were aged over 70 years. These studies had low heterogeneity as measured by Cochran's Q test (p=0.88) and I2 statistic (0%). The ASES scores on average increased by 39.7 (95% confidence interval 28.3-51.1, p<0.001) after rotator cuff repair, in both fixed-effect and random-effect models. No substantial publication bias was indicated. Our findings suggest improved outcomes after rotator cuff repair in the elderly population as measured by the ASES score, and such improvements have been consistent in previous studies.

Resultados del tratamiento del sindrome de impactación ulnar mediante procedimiento de Wafer artroscópico / Treatment of ulnar carpal impingement syndrome. Arthroscopic Wafer procedure. Results

Introducción: El síndrome de pinzamiento cubito carpiano es una de las causas más frecuentes de dolor cubital de la muñeca. Es una patología de tipo degenerativa y progresiva. El objetivo del tratamiento quirúrgico se basa en la descompresión articular del cubito con el carpo proximal. Con los avances tecnológicos es posible realizar la osteotomía del cubito por via artroscópica y así tratar también lesiones asociadas. Material y Métodos: Evaluamos 13 pacientes con síndrome de impactación cubital desde el 01/01/2018 hasta el 01/03/19, utilizando la clasificación de Palmer para evaluar las lesiones. Evaluamos 7 mujeres y 6 hombres. La edad de los pacientes fue desde los 47-82 años (62 años promedio). El 69,2% en edad laboral (9 pacientes) y el 30,7% jubilados (4 pacientes) con un seguimiento de 3 a 12 meses (8,9 meses de promedio). Todos los pacientes fueron tratados por artroscopia. Se evaluó el Rango de Movilidad (ROM), fuerza de agarre, escala de Mayo de Muñeca y escala de DASH. Resultados: Hemos tenido mejoras en test del dolor y la fuerza, el ROM promedio fue de 80° extensión, 80° de flexión, 30° para la desviación radial y 25° de desviación cubital. El Score de muñeca de mayo fue: excelente 8 pacientes (61,5%), bueno en 5 pacientes (38,4%) y un mal resultado (7,69). La fuerza comparativa final fue del 82%. El Dash Score preoperatorio fue de 87 puntos y en el Post operatorio de 5 puntos. Conclusión: La osteotomía de cubito tipo wafer o en oblea artroscópica da resultados satisfactorios mejorando los ROM, recuperando la fuerza de forma total o parcial y disminuyendo el dolor siempre y cuando está bien indicada la cirugía. Tipo de estudio: Serie de casos. Nivel de evidencia: IV

Introduction: The ulnar carpal impingement syndrome is one of the most frequent causes of ulnar pain in the wrist. It is a pathology of degenerative and progressive type. The objective of surgical treatment is based on the joint decompression of the ulna with the proximal carpus. With technological advances, it is possible to perform the osteotomy of the ulna by arthroscopic route and thus also treat associated injuries. Material and Methods: We evaluated 13 patients with ulnar impaction syndrome from 01/01/2018 to 03/01/19 using the Palmer classification to evaluate the lesions. We evaluated seven women and six men. The age of the patients was from 47-82 years (62 years average). 69.2% of working age (9 patients) and 30.7% retired (4 patients) with a follow-up of 3 to 12 months (8.9 months on average). All patients were treated by arthroscopy. The Mobility Range (ROM), grip strength, Wrist May scale and DASH scale were evaluated. Results: We have had improvements in pain and strength tests, the average ROM was 80° extension, 80° flexion, 30° for radial deviation and 25° ulnar deviation. The Wrist Score of May was excellent 8 patients (61.5%), Good in 5 patients (38.4%) and a poor result (7.69). The final comparative strength was 82%. The preoperative Dash Score was 87 points and in the post-operative of 5 points. Conclusion: The osteotomy of ulnar type wafer or arthroscopic wafer gives satisfactory results improving the ROM, recovering the strength totally or partially and decreasing the pain as long as surgery is well indicated. Type of study: Case series. Level of evidence: IV

Comparación de los resultados funcionales de los pacientes con reparación artroscópica de rupturas masivas del manguito rotador sola o combinada con acromioplastía y/o tenotomía del bíceps / Comparison of the functional outcomes of patients with arthroscopic repair of massive rotator cuff ruptures alone or combined with acromioplasty or biceps tenotomy

Resumen: Antecedentes: La lesión del manguito rotador (LMR) es una de las causas más comunes de dolor y discapacidad funcional del hombro con una incidencia anual reportada de 4.5 millones de casos en Estados Unidos. La LMR es una de las principales causas de dolor de hombro en pacientes mayores de 60 años. En México, no existen reportes de la incidencia ni de los resultados de la reparación artroscópica de las lesiones masivas de manguito rotador sola o combinada con otros procedimientos. Objetivo: Evaluar la evolución clínica de los pacientes postoperados de reparación artroscópica de lesión masiva del manguito rotador (RA-LMMR), sola o combinada con otras técnicas. Métodos: Evaluación de expedientes de pacientes postoperados de RA-LMMR en la que se compararon los resultados de las escalas: simple shoulder test y EVA antes y después de la cirugía a un seguimiento promedio de 2.6 años. Los procedimientos combinados fueron acromioplastía, tenotomía de bíceps o ambas. Resultados: 65 pacientes con diagnóstico de lesión masiva con edad promedio de 62.8 años (DE ± 9.42), 27.7% fueron hombres y 72.3% mujeres. La evaluación se realizó en cuatro grupos: reparación artroscópica (RA), reparación artroscópica + tenotomía del bíceps (RA + TB), reparación artroscópica + acromioplastía (RA + A) y reparación artroscópica + tenotomía del bíceps + acromioplastía (RA + TBA). Todos los grupos mostraron disminución significativa del dolor: RA (-44.1%, p = 0.0001), RA + A (-36.9%, p = 0.001), RA + TB (-36.3%, p = 0.0001), RA + TB + A (-38.5%, p = 0.0001). De igual forma todos los grupos mostraron mejoría significativa de la función evaluada con la escala SST.

Abstract: Background: The rotator cuff injury it is one of the most common causes of pain and functional disability of the shoulder with an annual reported incidence of 4.5 million cases in the United States. It is one of the leading causes of pain of shoulder in patients older than 60 years. In Mexico, there are no reports of the incidence or the results of arthroscopic repair of massive rotator cuff lesions alone or combined with other procedures. Objective: To evaluate the clinical evolution of patients post-surgery of arthroscopic rotator cuff massive injury repair AR-RCMI alone or in combination with other techniques. Methods: Evaluation of records of patients with AR-RCMI post-surgery, comparing the results of the scales: simple shoulder test and VAS before and after surgery with a follow up of 2.6 years. The combined procedures were acromioplasty, tenotomy of biceps or both. Results: 65 patients with diagnosis of massive injury; with an average age of 62.8 years (SD ± 9. 42), 27.7% were men and 72.3% women. The evaluation was conducted in four groups: arthroscopic repair (AR); arthroscopic repair + biceps tenotomy (AR + BT); arthroscopic repair + acromioplasty (AR + A) and arthroscopic repair + biceps tenotomy + acromioplasty (AR + BTA). All groups showed significant reduction in pain: AR (-44.1%, p = 0.0001), AR + A (-36.9%, p = 0.001), AR + BT (-36.3%, p = 0.0001), AR + BT + A (-38.5%, p = 0.0001). All groups had significant improvement in function with the SST scale.

¿Es útil la monitorización con espectroscopia de infrarojo cercano en la cirugía artroscópica de hombro con anestesia regional y sedación? / Is near-infrared spectroscopy (NIRS) monitoring useful for patients undergoing shoulder surgery under regional anaesthesia and sedation?

BACKGROUND: Shoulder surgery in beach chair position is a very common procedure in our daily practice. It has been associated to regional cerebral saturation impairment detected by near-infrared spectroscopy (NIRS) under general anaesthesia. Severe neurological complications were previously reported, even in previously healthy patients. An anaesthetic protocol under regional anaesthesia and biespectral index (BIS) guided sedation seems to be a safer strategy in order to prevent complications. OBJECTIVE: To find out, in a group of patients undergoing shoulder surgery in beach chair position under regional anaesthesia and sedation, the prevalence of cerebral desaturation events detected by NIRS (defined as a decrease ≥ 20% from baseline or absolute value < 55%). MATERIAL AND METHOD: In this descriptive study, 30 patients undergoing shoulder surgery in beach chair position under regional anaesthesia (ultrasound guided interescalene brachial plexus block) and propofol infusion BIS guided sedation were enrolled to assess the prevalence of cerebral desaturation events. The baseline data for regional cerebral oxygen saturation and bispectral index and non invasive blood pressure measured at heart level were taken prior to surgery after beach chair positioning and thereafter all 5 min until discharge. RESULTS: No cerebral desaturation events were detected during this study. CONCLUSIONS: Although monitoring regional cerebral saturation with NIRS detects decreased cerebral perfusion allowing a rapid intervention, we consider it is not essential under this anaesthesia regimen, considering that no cerebral desaturation events were reported.

La cirugía de hombro en posición de sentado constituye un procedimiento frecuente en la práctica diaria. Bajo anestesia general, se ha asociado con caída de la saturación regional cerebral de oxígeno (Src02) detectada por espectrospcopia infraroja (NIRS), reportándose complicaciones neurológicas severas, incluso en pacientes previamente sanos. El empleo de una técnica de anestesia regional más sedación titulada con índice biespectral (BIS) parecería ser una estrategia más segura a fin de evitar dichos eventos. OBJETIVO: Conocer, en pacientes sometidos a artroscopia de hombro en posición de sentado bajo anestesia regional más sedación, la prevalencia de episodios de desaturación cerebral (ECDs) determinada por NIRS (SrcO2 inferior a 55% o disminución del 20% respecto al basal). MATERIAL Y MÉTODO: Se realizó un estudio descriptivo en 30 pacientes sometidos a artroscopía de hombro en posición de sentado bajo anestesia regional (bloqueo interescalénico ecoguiado) más sedación titulada (infusión de propofol guiada por BIS). Se tomaron valores de referencia de Src02, BIS y presión no invasiva a nivel del corazón luego del posicionamiento y, consecutivamente en forma continua para las primeras dos variables y cada 5 minutos hasta el final para la última. Se ocultaron a los anestesiólogos los valores de Src02. RESULTADOS: No se ha detectado ningún EDC en la población estudiada. CONCLUSIÓN: Consideramos que el monitoreo de la perfusión cerebral con tecnología NIRS resulta útil aunque no imprescindible bajo este protocolo anestésico, dada la incidencia casi nula de eventos.

Dolor crónico del tobillo: banda fibrosa (Web Impingement) / Chronic ankle pain. Web impingement

Objetivo: Presentamos una serie de pacientes con dolor crónico de tobillo y estudios por imágenes negativos, en los que hallamos solamente una banda fibrosa intraarticular como causa probable del dolor en la artroscopia diagnóstica. Métodos: Entre el año 2010 y 2016 se realizaron 212 artroscopias anteriores de tobillo. En 19 pacientes (8,96%) se encontró una banda fibrosa intrarticular. En 13 pacientes se encontraban asociadas con otras patologías y solo en 6 pacientes (2,83%) fueron aisladas, sin lesión asociada. El promedio de edad fue de 40,42 años. El seguimiento promedio de 20,42 meses. La mayoría de los pacientes fueron atendidos en centros de aseguradoras de riesgo de trabajo. Resultados: Se utilizó el score AOFAS con un promedio para el preoperatorio de 55,63 y para el postoperatorio de 92.26. No hubo complicaciones en esta serie. Conclusiones: La banda fibrosa es una patología infrecuente, con sintomatología clínica similar a la de otras patologías que producen un síndrome friccional anterior de partes blandas del tobillo. La mayoría tenía antecedentes traumáticos. Los estudios por imágenes utilizados fueron la radiografía y la Resonancia. Ninguno de ellos fue de utilidad en el diagnóstico. La banda fibrosa es una de las diferentes formas de impingement en la cara anterior del tobillo y puede ser una causa de fricción y dolor. Dado que los estudios por imágenes no fueron concluyentes, la artroscopía fue nuestro método de elección para el diagnóstico y tratamiento en los pacientes con dolor crónico de tobillo con imágenes negativas. Tipo de trabajo: Serie de casos. Nivel de evidencia: IV.

Purpose: We present a series of patients with chronic anterior ankle pain and negative imaging studies, in which we found an isolated fibrous intrarticular band as a probable cause of pain in diagnostic arthroscopy. Methods: Between 2010 and 2016 we performed 212 anterior ankle arthroscopies. In 19 patients (8,96%) a fibrous web like band was found. In 13 cases they were associated with other diseases and only 6 of them (2.83 %) were isolated. Average age was 42 years. Follow up was between 4 months and 3 years (average 20.42 months). Most of them were workers compensation patients. Results: We used the AOFAS scores with an average value of 55,63 preoperative and 92.26 points postoperative. No complications were found in this series. Conclusions: Intra articular fibrous band is an infrequent pathology, with clinical presentation similar to other soft tissues anterior impingement. Most of them had previous trauma. Imaging studies performed were radiographs and MRI, but they have not proven to be useful due to their low or none sensitivity to this condition. Intra articular fibrous bands is one of the causes of anterior impingement of the ankle, and may be a cause of friction and pain. Most of them had history of previous trauma. Imaging studies were not conclusive, and arthroscopy was our election method for diagnosis and treatment in patients with chronic ankle pain and negative imaging studies. Type of study: Case series. Level Of Evidence: IV.

Inestabilidad lateral de tobillo. Reconstrucción anatómica con injerto autólogo. Técnica percutánea y artroscopía de tobillo / Chronic ankle instability. Anatomic percutaneous reconstruction with autologous graft

Objetivo: El propósito de este estudio fue evaluar los resultados funcionales y radiográficos a mediano plazo de la reconstrucción anatómica percutánea con injerto de semitendinoso autólogo de los ligamentos talofibular anterior (LTFA) y el ligamento calcaneofibular (LCF), más artroscopía de tobillo en los casos de inestabilidad crónica de tobillo. Materiales y métodos: Este estudio retrospectivo implicó una revisión de los registros de 20 pacientes con inestabilidad lateral crónica de tobillo, tratados desde el año 2010 hasta el año 2014. Se utilizaron la escala de puntuación VAS y de Karlsson–Peterson. Se evaluó el grado de satisfacción de los pacientes. Radiográficamente se midieron ángulos de inclinación talar y cajón anterior, se evaluaron en posiciones de estrés pre y postoperatorio del tobillo. Resultados: La inestabilidad del tobillo evaluada radiográficamente mejoró significativamente: disminuyó la inclinación talar de11,5 º a 3,5º y la prueba de cajón anterior disminuyó de 7 mm preoperatoria a 3 mm postoperatoria. No hubo perdida de la movilidad articular postoperatoria: la dorsiflexión promedio, medida con un goniómetro, fue de 14,8°, en comparación con 15,1° en el tobillo no operados, y la flexión plantar promedio 46.0°, en comparación con 46.7° en el tobillo no operados. Discusión: El tratamiento combinado de reparación percutánea de los ligamentos laterales de tobillo y artroscopía es una opción viable para el tratamiento de la inestabilidad lateral crónica del tobillo y sus lesiones intrarticulares asociadas, proporcionando una fijación estable, disminuyendo los signos clínicos y radiológicos de inestabilidad, mejorando los síntomas y proporcionando resultados clínicos satisfactorios en el mediano plazo.

Objective:The purpose of this study was to evaluate the functional and radiographic results at medium term of the anatomic percutaneous reconstruction with autologus graft of the semitendinosus, of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL), in addition to a arthroscopy in cases of chronic ankle instability. Materials and methods: This retrospective study involved a review of the records of 20 patients with chronic lateral ankle instability treated between 2010 to 2014. The Karlsson–Peterson ankle rating score was used.Measured radiografically was the tilt angle and distance of the anterior drawer test, in stress positioning preoperative and postoperative of the ankle. Results: Ankle instability evaluated radiographically improved significantly decreased : talar tilt de11,5º about 3.5° and anterior drawer test decreased from 7 mm to 3 mm preoperative postoperative. There was no loss of joint mobility postoperative: The average dorsiflexion measured with goniometer was 14.8°, 15.1° compared to non-operated ankle and plantar flexion average 46.0°, compared with 46.7° ankle unoperated. Discussion: The combined treatment of percutaneous repair of the lateral ligaments and arthroscopy is a viable option for the treatment of chronic lateral instability of theankle and associated intra-articular injuries, providing a stable fixation, reducing the clinical and radiological signs of instability, improving symptoms and producing satisfactory clinical results in the medium term.

Tratamiento de la inestabilidad acromioclavicular crónica / Treatment of chronic acromioclavicular joint instability

Valorar los resultados de la técnica quirúrgica asistida por artroscopía indicada para el tratamiento de la inestabilidad acromioclavicular crónica (IAC), basada en la fijación coracoclavicular (CC) no-rígida más reconstrucción CC anatómica con aloinjerto tendinoso. Se incluyó a los pacientes con IAC intervenidos entre 2008 y 2012. Las valoraciones clínicas se realizaron mediante el SF36, la EVA y el DASH, aplicados en la visita previa (VPI) a la intervención y en la última visita de seguimiento (UVS). El Constant score y la Escala de Satisfacción General (0-10) se aplicaron en la última visita de seguimiento. Se valoró el desarrollo de subluxaciones secundarias. Se incluyeron 10 pacientes. Edad media 41 años [rango 33-55]. Seguimiento medio 25.50 meses [rango 24-30].En todos los pacientes el tratamiento quirúrgico se indicó cuando el tratamiento conservador fracasó. Cuestionarios aplicados en la VPI y en la UVS: 1. SF36 físico: VPI 29.60 ± 3.41 y UVS 59.58 ± 1.98 (p = 0.000); 2. SF36 mental: VPI 46.57 ± 3.80 y UVS 56.62 ± 1.89 (p = 0.000); 3. EVA: VPI 5.17 ± 2.40 y UVS 1.67 ± 2.07 (p = 0.022); y 4. DASH: VPI 63.33 ± 23.56 y UVS 2.61 ± 1.79 (p = 0.000). El Constant score y la satisfacción general de la UVS fueron 95.56 ± 3.28 y 9.22 ± 0.67 respectivamente. No hubo subluxaciones secundarias. El tratamiento de la IAC mediante un dispositivo de suspensión CC y una reconstrucción anatómica de los ligamentos CC asistida por artroscopía, puede ofrecer una mejoría significativa de la calidad de vida de los pacientes y representa una estrategia que al contemplar una fijación CC mecánica primaria, puede minimizar las posibilidades de fracaso y desarrollo de subluxaciones secundarias.

The purpose of this paper is to assess the results obtained with the arthroscopy-assisted surgical technique for the treatment of chronic acromioclavicular joint instability (CACJI), based on non-rigid coracoclavicular (CC) fixation and anatomical CC reconstruction with a tendinous allograft. Patients with CACJI who underwent surgery between 2008 and 2012 were included in the study. Clinical assessments included SF36, VAS and DASH, applied at the preoperative visit (POV) and at the last follow-up visit (LFUV). The Constant score and the General Satisfaction Score (0-10) were applied at the last follow-up visit. Occurrence of secondary subluxations was assessed. Ten patients were included; mean age was 41 years (range 33-55). Mean follow-up was 25.50 months (range 24-30). Surgical treatment was indicated in all patients after failure of conservative treatment. Questionnaires applied at the POV and the LFUV showed the following results: 1. SF36: physical, POV = 29.60 ± 3.41 and LFUV = 59.58 ± 1.98 (p = 0.000); 2. SF36 mental, POV = 46.57 ± 3.80 and LFUV = 56.62 ± 1.89 (p = 0.000); 3. VAS: POV = 5.17 ± 2.40 and LFUV: 1.67 ± 2.07 (p = 0.022); and 4. DASH: POV = 63.33 ± 23.56 and LFUV = 2.61 ± 1.79 (p = 0.000). The Constant score and the general satisfaction at the LFUV were 95.56 ± 3.28 and 9.22 ± 0.67, respectively. There were no secondary subluxations. Treatment of CACJI with a CC suspension device and arthroscopically-assisted anatomical reconstruction of CC ligaments may provide a significant quality of life improvement to patients. It is a strategy that, upon considering primary mechanical CC fixation, may minimize the chance of failure and occurrence of secondary subluxations.

Fatores preditivos de hemotransfusão na artroplastia total de joelho / Predictive factors of hemotransfusion in total knee arthroplasty

A Osteoartrose (OA) é uma doença crônica de origem multifatorial, que resulta em falência articular por degeneração da cartilagem, culminando com limitação funcional da articulação. Estima-se que atualmente 12% da população mundial com idade superior a 60 anos tenha OA sintomática da articulação do joelho. A artroplastia total do joelho (ATJ) é considerada a melhor opção terapêutica para os casos avançados de OA. A ATJ resulta em alívio álgico, melhora da função articular e da qualidade de vida do paciente. Entretanto, por se tratar de um procedimento cirúrgico de grande porte, a ATJ se associa a perdas sanguíneas intra-operatórias expressivas, cuja base do tratamento é a transfusão de hemoconcentrados. Embora as complicações relacionadas com transfusão sanguínea tenham diminuído nas últimas décadas, ainda existem riscos relacionados com a transmissão de doenças e com o desenvolvimento de reações imunomediadas. Considerando o papel do Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad (INTO) na formulação de uma política nacional sobre a prevenção, diagnóstico, tratamento e reabilitação de pacientes ortopédicos no âmbito do SUS, desenvolvemos este projeto com o objetivo de identificar os fatores preditivos de risco de transfusão sanguínea alogênica durante a realização da ATJ. Todos os pacientes internados no INTO entre agosto de 2010 e agosto de 2013 submetidos à ATJ constituíram a amostra inicial deste estudo. Após aplicação dos critérios de exclusão, permaneceram no estudo 234 voluntários com idade entre 30-83 anos, portadores de OA primária ou secundária a artrite reumatóide. Os procedimentos cirúrgicos foram realizados sob isquemia com manguito pneumático que foi liberado após a cimentação dos componentes protéticos. Foram avaliados os valores da hemoglobina 24h antes e 48h após a cirurgia, o tempo de isquemia com o manguito pneumático e o volume total de hemoconcentrados transfundidos. Os dados numéricos foram avaliados pelo teste t de Student e Mann-Whitney; o teste χ 2 ou exato de Fisher foi aplicado para a comparação de dados categóricos e a análise de regressão logística para identificar os preditores independentes para hemotransfusão. A análise dos resultados mostrou que valores de hemoglobina pré-operatória ≤ 12,3 g/dL e tempo de isquemia ≥ 87 minutos são preditores independentes para hemotransfusão em ATJ, com risco relativo de 2,48 e 1,78, respectivamente. Aproximadamente metade dos pacientes (51,3%) submetidos a ATJ com essas duas variáveis necessitaram de hemotransfusão. A partir destes resultados propomos um algoritmo de decisões para serem implementadas no pré e intra-operatório dos pacientes que serão submetidos à ATJ no INTO visando diminuir a necessidade de hemotransfusão e promover a racionalização de recursos públicos para reduzir o custo de cirurgias ortopédicas de alta complexidade como a ATJ.

Osteoarthritis (OA) is a chronic disease of multifactorial origin that results in joint failure due to cartilage degeneration, which culminates with functional limitation of the joint. It is estimated that currently 12% of the population aged over 60 years have symptomatic OA of the knee joint. Total knee arthroplasty (TKA) is considered the best treatment option for advanced cases of OA. TKA results in pain relief, improved joint function and in the patient's quality of life. However, because it is a large surgical procedure, TKA is associated with significant intraoperative blood loss, that it is treated with the transfusion of hemoconcentrates. Although complications related to blood transfusion have decreased in the recent decades, there are still risks associated with the transmission of diseases and development of reactions mediated by the immune system. Considering the role of the National Institute of Traumatology and Orthopedics Jamil Haddad (INTO) in the formulation of a national policy on the prevention, diagnosis, treatment and rehabilitation of orthopedic patients in the SUS, we developed this project in order to identify the predictors of risk of allogeneic blood transfusion during the course of TKA. All patients admitted in INTO between August 2010 to August 2013, undergoing TKA were the initial sample of this study. After applying the exclusion criteria, 234 volunteers aged 30-83 years with primary or secondary OA remained in the study. The surgical procedures were performed under ischemia with pneumatic cuff that was released after cementation of the prosthetic components. We evaluated hemoglobin values before 24h and 48h after surgery, the ischemic time with the pneumatic cuff and the total volume of hemoconcentrates transfused. Numerical data were evaluated by Student's t test and Mann-Whitney; χ2 or Fisher's exact test was used to compare categorical data and the logistic regression analysis to identify independent predictors of blood transfusion. The results showed that preoperative hemoglobin ≤ 12,3 g / dL and ischemia time ≥ 87 minutes are independent predictors of blood transfusion in TKA, with a relative risk of 2,48 and 1,78, respectively. Approximately half of the patients (51,3%) who underwent TKA with these two variables required blood transfusion. Based on these results we propose an algorithm decision tree to be used in patients undergoing TKA at INTO pre and intra-operatively aiming to reduce the need for blood transfusion and to promote the rationalization of public funds to reduce the cost of high complexity orthopedic procedures such as TKA.

La edad avanzada del paciente es una contraindicación para la reparación artroscópica del manguito rotador ? / Is advanced age a contraindication for rotator cuff arthroscopic repair?

Objetivo: Evaluar la evolución posoperatoria de una serie de pacientes mayores de 80 años sometidos a cirugía artroscópica para reparar el manguito rotador. Materiales y Métodos: Entre junio de 2004 y marzo de 2007, se evaluó a 20 pacientes de 80 años o más, a los que se les realizó una reparación artroscópica del manguito rotador. Todos habían recibido tratamiento conservador que no fue eficaz. En el seguimiento, se emplearon los puntajes de UCLA, Constant y Quick-DASH, y la escala analógica visual para el dolor, la función y la calidad de vida. Resultados: El seguimiento promedio fue de 28 meses (rango 24-48). El puntaje de UCLA fue de 10,4 preoperatorio y 28,6 posoperatorio (p < 0,05). El puntaje de Constant mejoró de 31,5 antes de la cirugía a 69,3 después de ella (p < 0,05). El puntaje de Quick-DASH mostró una mejoría de 33 a 16 puntos en el posoperatorio (p < 0,05). La escala analógica visual para el dolor preoperatorio arrojó 8 puntos y, en el posoperatorio, se obtuvo un promedio de 2,2 puntos (p < 0,05). No hubo complicaciones. Conclusiones: En esta serie de reparación del manguito rotador en personas mayores de 80 años, se obtuvieron mejoras significativas en todos los pacientes.

Background: The purpose of the study was to evaluate the functional postoperative outcome in patients aged 80 years or over undergoing arthroscopic rotator cuff repair. Methods: From June 2004 to March 2007, 20 patients aged 80 years or over underwent arthroscopic rotator cuff repair. All patients included had a history of unsatisfactory conservative treatment. Patients were evaluated in the preoperative and postoperative period using the UCLA score, Constant score, Quick-DASH score and visual analogue scale for pain, function, and quality of life. Results: The mean follow-up period was 28 months (range 24-48 months). The mean UCLA score improved from 10.4 points preoperatively to 28.6 postoperatively (p < 0.05). The Constant score improve 31.5 points preoperatively to 69.3 postoperatively (p < 0.05). The mean Quick-DASH score improved from 33 points preoperatively to 16 postoperatively (p < 0.05). The visual analogue scale for pain improved from 8 (range 5-9 points) to 2.2 (p < 0.05). There were not postoperative complications. Conclusions: In this series arthroscopic rotator cuff repair in patients aged 80 years or over demonstrates significant improvement in clinical outcomes and pain relief.

Fatores preditivos de resultados desfavoráveis da meniscectomia medial artroscópica em pacientes com mais de 50 anos de idade / Predictors of poor outcomes of arthroscopic medial meniscectomy in patients over 50 years old

A evolução do conhecimento acerca das funções dos meniscos e do tratamento das suas lesões, impulsionada pelo advento da cirurgia artroscópica, consagrou e popularizou a meniscectomia por esta via, por ser uma técnica menos invasiva, com menor morbidade e menores custos hospitalares, a ponto de torná-la, atualmente, a cirurgia ortopédica mais frequentemente realizada no mundo. Embora a maior parte dos pacientes submetidos a esta intervenção cirúrgica tenha resultados favoráveis e resolução rápida dos sintomas, percebe-se que parte considerável dos pacientes, especialmente os mais idosos, não apresenta uma evolução póscirúrgica satisfatória, apresentando piora dos sintomas e, eventualmente, necessitando de nova cirurgia. Partindo da hipótese que em determinados pacientes a meniscectomia, em vez de tratar, precipita e acentua um desequilíbrio biomecânico do joelho, o autor realizou estudo observacional prospectivo não-controlado com 86 pacientes de ambos os gêneros, com idade superior a 50 anos (média de 60,2 ± 7,1 anos), submetidos à meniscectomia artroscópica para tratamento de lesão do menisco medial de natureza degenerativa, com o objetivo de determinar variáveis demográficas, clínicas, anatômicas e cirúrgicas relacionadas aos resultados desfavoráveis. As avaliações funcionais pré e pós-operatórias foram realizadas utilizandose o Índice do KOOS (Knee Injury and Osteoarthritis Outcome Score), aplicado a todos os pacientes antes da cirurgia e 60 meses depois. Após análise estatística dos resultados obtidos, o autor verificou que 10 fatores podem ser considerados preditivos das meniscectomias mediais artroscópicas neste grupo etário, sendo quatro fatores fortemente associados aos resultados desfavoráveis: lesão da raiz posterior do menisco medial, dor pré-operatória intensa, claudicação antes da cirurgia e tempo decorrido entre o início dos sintomas e a cirurgia; dois fatores foram considerados moderadamente associados aos resultados...

The evolution of knowledge concerning meniscal functions and the treatment of their injuries, boosted by the development of arthroscopic surgery, has established and popularized arthroscopic meniscectomy due to its less invasiveness, less post-operative morbidity and lower hospital costs, to the point it has become, nowadays, the most frequently performed orthopedic procedure in the world. Although the majority of patients undergoing this operation is quite pleased with the outcomes and with the prompt resolution of their symptoms, it is noticeable that a considerable amount of patients with meniscal injuries, mainly the older, does not have a satisfactory postoperative outcome, with worsening of symptoms after being operated on and occasionally requiring another surgery. Based on observations of his medical practice and on the assumption that meniscectomy, rather than treat, can hasten and accentuate a biomechanical imbalance of the knee in those patients, the author conducted an observational prospective uncontrolled study with 86 patients of both genders, aged over 50 years old (average 60.2 ± 7.1 years), who underwent arthroscopic meniscectomy for the treatment of degenerative medial meniscal lesions, aiming to determine demographic, anatomical, clinical and surgical variables related to poor outcomes. The functional pre and post-operative evaluations were performed using the KOOS index (Knee Injury and Osteoarthritis Outcome Score) applied to all patients before surgery and 60 months later. After statistical analysis of the results, the author found that 10 factors can be considered predictors of arthroscopic medial meniscectomy in this age group: four factors were strongly associated with unfavorable results - posterior root lesion of the medial meniscus, intense pre-operative pain, claudication before surgery and time elapsed between onset of symptoms and surgery; two factors were moderately associated with unfavorable results - bone marrow...

Bloqueio do nervo femoral: avaliação da analgesia pós-operatória na operação de reconstrução artroscópica do ligamento cruzado anterior / Femoral nerve block: assessment of postoperative analgesia in arthroscopic anterior cruciate ligament reconstruction / Bloqueo del nervio femoral: evaluación de la analgesia postoperatoria en la operación de reconstrucción artroscópica del ligamento cruzado anterior

JUSTIFICATIVA E OBJETIVOS: A operação de reconstrução do ligamento cruzado anterior do joelho (RLCA) pode ter pós-operatório doloroso. O objetivo principal deste estudo foi avaliar se o emprego do bloqueio do nervo femoral (BNF) associado à raquianestesia melhoraria o tratamento da dor pós-operatória na RLCA; os objetivos secundários foram avaliar solicitação do tramadol e eventos adversos. MÉTODO: 53 pacientes foram divididos aleatoriamente nos grupos A e B. No Grupo A, 26 receberam raquianestesia e no Grupo B, 27 receberam raquianestesia e BNF. Todos receberam analgesia multimodal e poderiam solicitar analgésico de resgate a qualquer momento. As avaliações ocorreram em 6, 12 e 24 horas. RESULTADOS: Os grupos não apresentaram diferenças quanto às variáveis demográficas e clínico-cirúrgicas. A intensidade da dor não mostrou diferença entre os grupos. Escores médios de dor foram mais elevados 12 horas no Grupo A e não houve variação no Grupo B; 55,6% relataram dor moderada no Grupo A e 53,8% dor leve no Grupo B. Não houve diferença na solicitação de tramadol. Os eventos adversos não foram graves: 80,8% dos pacientes do Grupo B apresentaram bloqueio motor da coxa e dois caíram. CONCLUSÕES: A analgesia foi mais efetiva com a associação de raquianestesia e BNF, que permitiu melhor controle da dor pós-operatória na avaliação em 12 horas após a anestesia. Não houve diferença na solicitação do tramadol. Os eventos adversos apresentados pelos pacientes neste estudo não foram graves, porém deve-se estar atento à paralisia motora e à possibilidade de queda dos pacientes quando o BNF for feito.

BACKGROUND AND OBJECTIVES: Knee anterior cruciate ligament reconstruction (ACLR) may be painful in the postoperative period. The primary objective of this study was to evaluate whether the use of femoral nerve block (FNB) associated with spinal anesthesia would improve the postoperative pain treatment in ACLR and the secondary objectives were to evaluate tramadol request and adverse events. METHOD: 53 patients were randomly divided into two groups: GA (n =26) received spinal anesthesia and GB (n = 27) received spinal anesthesia and FNB. All patients received multimodal analgesia and rescue analgesics could be requested anytime. Assessments were performed at 6, 12 and 24 hours. RESULTS: There was no difference between both groups regarding demographic and clinical-surgical variables. There was no difference between groups regarding pain intensity. Mean pain scores were higher at 12 hours in GA and there was no change in GB; 55.6% of patients reported moderate pain in GA and 53.8% mild pain in GB. There was no difference regarding tramadol request. There were no serious adverse events: 80.8% of patients in GB had motor block of the thigh and two fell. CONCLUSIONS: Analgesia was more effective with the combination of spinal and FNB, which allowed better control of postoperative pain, assessed 12 hours after anesthesia. There was no difference in tramadol request. Patients in this study had no serious adverse events; however, one must be attentive to motor paralysis and the possibility of falling when FNB is performed.

JUSTIFICATIVA Y OBJETIVOS: La operación de reconstrucción del ligamento cruzado anterior de la rodilla (RLCA) puede tener un postoperatorio doloroso. El objetivo principal de este estudio fue evaluar si el empleo del bloqueo del nervio femoral (BNF) asociado con la raquianestesia mejoraría el tratamiento del dolor Postoperatorio en la RLCA. Los objetivos secundarios eran evaluar la solicitación del tramadol y eventos adversos. MÉTODO: Cincuenta y tres pacientes fueron divididos aleatoriamente en los grupos A y B. En el Grupo A, 26 recibieron raquianestesia y en el Grupo B, 27 recibieron raquianestesia y BNF. Todos recibieron analgesia multimodal y podrían solicitar analgésico de rescate a cualquier momento. Las evaluaciones se dieron en 6, 12 y 24 horas. RESULTADOS: Los grupos no presentaron diferencias en cuanto a las variables demográficas y clínico-quirúrgicas. La intensidad del dolor no arrojó diferencia entre los grupos. Las puntuaciones promedios de dolor fueron más elevadas 12 horas en el Grupo A y no hubo variación en el Grupo B; 55,6% relataron dolor moderado en el Grupo A y 53,8% dolor leve en el Grupo B. No hubo diferencia en la solicitación de tramadol. Los eventos adversos no fueron graves: 80,8% de los pacientes del Grupo B tenían bloqueo motor del muslo y dos se cayeron. CONCLUSIONES: La analgesia fue más efectiva con la asociación de la raquianestesia y BNF, lo que permitió un mejor control del dolor postoperatorio en la evaluación en 12 horas después de la anestesia. No hubo diferencia en la solicitación del tramadol. Los eventos adversos presentados por los pacientes en este estudio no fueron graves, pero debemos estar atentos a la parálisis motora y a la posibilidad de alguna caída de los pacientes cuando el BNF se realice.

Estudio comparativo de la fijación percutánea dorsal de las fracturas de escafoides con y sin asistencia artroscópica, y su infuencia en el pronóstico / Comparative study in percutaneous fixation of scaphoid fractures with and without arthroscopic assistance, and its infuence on prognosis

Introducción: la fractura de escafoides es la más frecuente entre las fracturas del carpo. Su tratamiento puede ser conservador o quirúrgico. Este último ofrece una gama de opciones: la reducción abierta y la fijación interna, la osteosíntesis percutánea y la osteosíntesis percutánea bajo asistencia artroscópica. La asociación de lesiones ligamentarias intracarpianas detectadas en la artroscopía es frecuente. El objetivo del presente trabajo consiste en analizar una serie de casos, procurando determinar si dichas lesiones diagnosticadas mediante asistencia artroscópica son responsables de una evolución subóptima cuando no son tratadas. Materiales y Métodos: se evaluaron 71 pacientes con fracturas de escafoides tratados mediante osteosíntesis percutánea. Cuarenta y cuatro cumplieron con los criterios de inclusión. Se compararon de forma retrospectiva 2 grupos tratados mediante osteosíntesis percutánea con asistencia artroscópica y sin ella. Resultados: los pacientes tratados mediante asistencia artroscópica tuvieron un mayor porcentaje de resultados funcionales más satisfactorios que los tratados sin asistencia artroscópica, expresado por un resultado estadísticamente significativo (p < 0,05). Discusión: hay muchos casos de fracturas de escafoides tratados adecuadamente mediante osteosíntesis que determinan una “muñeca dolorosa con radiografía normal”. No se ha determinado hasta el momento si las lesiones ligamentarias asociadas a estas fracturas determinen una evolución menos favorable cuando no son tratadas precozmente. A pesar del número poblacional reducido del grupo control, se identificó que la mejor evolución en el grupo tratado mediante asistencia artroscópica representa una diferencia estadísticamente significativa. Conclusión: el diagnóstico oportuno y el tratamiento temprano de...

Background: scaphoid fracture is the most common among carpal fractures. Treatment may be conservative or surgical, that offers a range of options: open reduction and internal fixation, percutaneous osteosynthesis and percutaneous fixation under arthroscopic assistance. The association of intracarpal ligament injuries detected by arthroscopy is common. The aim of this study is to analyze a series of cases to determine whether these lesions diagnosed by arthroscopic assistance are responsible for a suboptimal evolution when untreated. Materials and Methods: we evaluated 71 patients with scaphoid fractures treated by percutaneous osteosynthesis. Forty four met the inclusion criteria. We compared retrospectively two groups treated by percutaneous osteosynthesis with and without arthroscopic assistance. Results: patients treated with arthroscopic assistance had a greater percentage of satisfactory functional outcomes than those treated without arthroscopic assistance, expressed by a statistically significant result ( p < 0,05 ). Discussion: there are many cases of scaphoid fractures treated properly by osteosynthesis than determine a “painful wrist with normal radiograph”. It has not been determined so far if ligament injuries associated with these fractures determine a less favorable prognosis if not treated early. Despite the small population size of the control group, it was found that the improved performance in the group treated with arthroscopic assistance represents a statistically significant difference. Conclusion: early diagnosis and early treatment of intracarpal ligament injuries associated with scaphoid fractures using arthroscopic assistance establish a more favorable clinical outcome in the medium term. Study Design: Comparative Retrospective. Level of evidence: III.

Reconstrucción del ligamento colateral medial y del ligamento posterior oblicuo en inestabilidad crónica de rodilla / Reconstruction of medial collateral ligament and posterior oblique ligament in chronic knee instability

Introducción: Existen diversas publicaciones que describen técnicas quirúrgicas para resolver la inestabilidad medial de la rodilla, sin embargo no todas reconstruyen todos los elementos estabilizadores. El objetivo de este trabajo fue analizar los resultados en un grupo de pacientes con reconstrucción del ligamento lateral medial y posterior oblicuo, detallar la técnica quirúrgica y realizar una descripción de la anatomía del lado medial de la rodilla. Material y Métodos: Se analizaron retrospectivamente 11 pacientes con inestabilidad medial de la rodilla tratados quirúrgicamente entre diciembre del 2009 y julio del 2011 mediante la reconstrucción del ligamento colateral medial (LCM) y del ligamento posterior oblicuo (LPO). 8 fueron del sexo masculino y 3 del femenino, con una edad promedio de 37,18 años. El seguimiento mínimo fue de 6 meses (promedio 13,63 meses; rango 6 a 25 meses). Todos los casos fueron crónicos y presentaron signos y síntomas de inestabilidad en actividades de la vida cotidiana. Los pacientes fueron evaluados funcionalmente con los Scores de Lysholm, Tegner e IKDC Subjetivo. Ningún paciente se perdió en el seguimiento. Resultados: El score de Lysholm pre operatorio promedio fue de 45,18 ptos. y el post operatorio de 77,09 ptos. (p<0.001- IC 95 por ciento=25.98 a 37.83). El score de Tegner pre operatorio promedio fue de 3,09 ptos., mientras que el post operatorio fue de 6,27 (p<0.001-IC 95 por ciento=2.59 a 3.76 ). El IKDC Subjetivo arrojó un valor pre operatorio promedio de 38,54 ptos. y el post operatorio fue de 71,54 (p<0.001-IC 95 por ciento=26.66 a 39,33). Conclusión: En nuestra serie el tratamiento quirúrgico empleado resultó eficaz tanto en la estabilización de lesiones crónicas grado III del LCMs y el LPO, como en la inestabilidad multidireccional de la rodilla. Diseño del estudio: serie de casos. Nivel de evidencia: IV.