Effect of interscalene nerve block on the inflammatory response in shoulder surgery: a randomized trial.

BACKGROUND: Comparing techniques of general anesthesia and regional anesthesia in arthroscopic shoulder surgery, some studies have shown differences in the intensity of immediate postoperative pain and neuroendocrine response, but the inflammatory response when using balanced general anesthesia (BGA) vs. an ultrasound-guided (USG) single-dose interscalene block (SDIB) has not been compared. MATERIALS AND METHODS: In a single-center, prospective, randomized clinical trial, the inflammatory response of 2 groups of 10 patients scheduled to undergo arthroscopic shoulder surgery was evaluated through measurement of a panel of cytokines that act on cells of the adaptive immune response to promote or inhibit inflammation, chemokines involved in chemotaxis, the erythrocyte sedimentation rate (ESR), the high-sensitivity C-reactive protein (CRP) level, and the white blood cell (WBC) count in 3 blood samples (before anesthesia, immediately postoperatively, and 24 hours postoperatively) with 2 types of anesthesia (BGA vs. USG SDIB). Postoperative pain intensity (immediately, at 12 hours, and at 24 hours) was also assessed. RESULTS: The ESR and CRP level increased significantly at 24 hours after surgery; however, the increase in ESR (P < .0001) and CRP level (P < .0001) was lower in the USG SDIB group. Significant increases in the levels of soluble interleukin 2 receptor α (P = .022) and interleukin 12p40 (P = .016) occurred in the immediate postoperative period in the USG SDIB group. Immediate postoperative pain showed a significant increase (P < .001) in the BGA group. CONCLUSIONS: In arthroscopic shoulder surgery, the use of a USG SDIB compared with the use of BGA is possibly associated with improved pain control in the immediate postoperative period and lower immunosuppression, even at 24 hours after surgery.

Single-row or Double-row Rotator Cuff Repair.

Rotator cuff tears are potentially a career-ending injury for athletes. The surgeon must identify which patients will benefit from surgical repair. The factors to consider are age, type of sport, time since injury, athlete's level, and the patient's expectations. An essential and independent fact determining the surgical treatment is whether the damage is due to overuse or from a traumatic/collision injury. Some sports are more demanding than others resulting in different return-to-participation (RTP) rates. This RTP return rate can present a real challenge and more so by a desire to reach the pre-injury level of play. The incidence of rotator cuff tearing varies from one sport to another. In football players this can be 12% whereas for tennis players this incidence is 4% to 17%. The RTP rate must be considered when making treatment decisions and is influenced by the level of the athlete: for professional athletes, the rate is 61%, and for recreational 73%. When the surgeon and the patient decide on the surgical treatment, the surgeon must consider whether to perform a double-row or a single-row rotator cuff tendon repair. The decision-making and the surgical technique will be addressed.

Interscalene block in the context of enhanced recovery for shoulder: A case series. / Bloqueo interescalénico en el contexto de la recuperación acelerada para artroscopía de hombro: serie de casos.

Introduction: The application of enhanced recovery in shoulder surgery has not had such a favorable acceptance, therefore, the objective of this study was to present and describe the use of interscalene block to promote enhanced recovery in a series of patients undergoing shoulder arthroscopic surgery. Methods: Thirty-five patients undergoing arthroscopic shoulder surgery were included, in whom interscalene blockade and sedation were administered. Subsequently, pain intensity, nausea, vomiting, dyspnea, presence of Horner's syndrome, blurred vision, hoarseness, time elapsed to discharge, unplanned readmissions, patient satisfaction, and compliance with hospital discharge criteria in the first 12 weeks were evaluated, hours following the criteria of an enhanced recovery. Results: 27 patients (77,1%) had ASA I and 8 patients (22,8%) ASA II, 97,1% were rotator cuff repairs. Before discharge, two patients (5.7%) had nausea. At discharge, no patient had dyspnea or blurred vision, two patients (5.7%) developed hoarseness, and the median pain intensity was 1.0 (0.0-7.0). Between 24 and 48 hours only one patient (2.8%) presented nausea and the median pain intensity was 1.0 (0.0-8.0). All the patients were satisfied with their willingness to repeat the experience, 100% of the patients met the criteria for medical discharge after 12 hours, 30 patients (85.7%) were discharged the same day, the stay was 12 (11.5 to 12.5) hours, and no patient was readmitted. Conclusion: In selected patients with a committed, trained and experienced surgical-anesthetic team, there is a high possibility that the interscalene block will favor the performance of enhanced recovery programs in shoulder arthroscopic surgery.

Introducción: La aplicación de la recuperación acelerada en cirugía de hombro no ha tenido una aceptación tan favorable. Por ello, el objetivo de este estudio fue presentar y describir el uso de bloqueo interescalénico para favorecer la recuperación acelerada en una serie de pacientes sometidos a cirugía artroscopica de hombro. Métodos: Se incluyeron 35 pacientes sometidos a cirugía artroscópica de hombro, en quienes se administró bloqueo interescalénico y sedación. Posteriormente se evaluó la intensidad del dolor, náuseas, vómito, disnea, presencia de síndrome de Horner, visión borrosa, ronquera, tiempo transcurrido hasta el alta, reingresos no planeados, satisfacción del paciente y cumplimiento de los criterios de alta hospitalaria en las primeras 12 horas siguiendo los criterios de una recuperación acelerada. Resultados: En total, 27 pacientes (77,1%) tuvieron clasificación de la (ASA) I y 8 pacientes (22,9%) ASA II. Además, 97,1% fueron reparaciones de manguito rotador. Previo al alta, dos pacientes (5,7%) presentaron náuseas. Al momento del alta ningún paciente presentó disnea o visión borrosa, dos pacientes (5,7%) presentaron ronquera y la mediana de intensidad del dolor fue de 1,0 (0,0 a 7,0). Entre las 24 y 48 horas solo un (2,8%) paciente presentó náuseas y la mediana de intensidad del dolor fue de 1,0 (0,0 a 8,0). Todos los pacientes se mostraron satisfechos con disposición a repetir la experiencia. El 100% de pacientes cumplió los criterios médicos de alta a las 12 horas y 30 pacientes (85,7%) se dieron de alta el mismo día. La estancia fue de 12 (11,5 a 12,5) horas y ningún paciente reingresó. Conclusión: En pacientes seleccionados, con un equipo quirúrgico-anestésico comprometido, capacitado y con experiencia, hay una alta posibilidad de que el bloqueo interescalénico favorezca la realización de programas de recuperación acelerada en cirugía artroscópica de hombro.

Rotator cuff repair augmentation using a novel polycarbonate polyurethane patch: preliminary results at 12 months' follow-up.

BACKGROUND: Preventing anatomic failure after rotator cuff repair (RCR) remains a challenge. Augmentation with a surgical mesh may permanently reinforce the repair and decrease failure rates. The purpose of this study is to assess the postoperative outcomes of open RCR augmented with a novel reticulated polycarbonate polyurethane patch. MATERIALS AND METHODS: Ten patients with supraspinatus tendon tears underwent open RCR augmented with a polycarbonate polyurethane patch secured in a 6-point fixation construct placed over the repaired tendon. Patients were evaluated with preoperative and postoperative outcome measures, including the Simple Shoulder Test, visual analog pain scale, American Shoulder and Elbow Surgeons shoulder score, Cumulative Activities of Daily Living score, and University of California, Los Angeles shoulder scale, as well as range of motion. Postoperative magnetic resonance imaging was used to evaluate repair status. RESULTS: Patients showed significant improvements in visual analog pain scale, Simple Shoulder Test, and American Shoulder and Elbow Surgeons shoulder scores at both 6 and 12 months postoperatively (P < .05 and P < .01, respectively). The University of California, Los Angeles postoperative score was good to excellent in 7 patients at 6 months and in 8 patients at 12 months. Range of motion in forward flexion, abduction, internal rotation, and external rotation was significantly improved at both 6 and 12 months postoperatively (P < .05 and P < .01, respectively). Magnetic resonance imaging at 12 months showed healing in 90%; one patient had a definitive persistent tear. We found no adverse events associated with the patch, including the absence of fibrosis, mechanical symptoms, or visible subacromial adhesions. DISCUSSION: The polycarbonate polyurethane patch was designed to support tissue in growth and enhance healing as shown by preclinical animal studies. Clinically, the patch is well tolerated and shows promising efficacy, with a 10% retear rate at the 12-month time point.

Cyclic load testing and ultimate failure strength of suture anchors in the acetabular rim.

PURPOSE: To determine the resistance to cyclic stress and load-to-failure strength of several suture anchors suitable for hip arthroscopy. METHODS: Ten polyetheretherketone (PEEK) PushLock, PEEK SutureTak, and Bio-SutureTak anchors (Arthrex, Naples, FL); Lupine Loop BR anchors (DePuy Mitek, Norwood, MA); Bio-Mini Revo anchors (ConMed Linvatec, Largo, FL); and BioRaptor 2.9 AB anchors (Smith & Nephew, Andover, MA) were inserted in rotation into different locations on the rim of 4 matched pairs of potted acetabula clamped to the base of a servohydraulic testing machine. The anchors' sutures were cyclically pulled in line with the insertion angle. Displacement at 100 and 500 cycles, yield load, ultimate failure load, and failure mode were recorded. Statistical analysis was performed. RESULTS: Most of the displacement observed during cyclic loading occurred in the first 100 cycles, except for the BioRaptor 2.9 AB, which showed twice as much displacement at 500 cycles as at 100 cycles. The Lupine Loop BR cyclic displacement was greater than that of the PEEK PushLock (at 100 cycles also), Bio-SutureTak, and PEEK SutureTak at 500 cycles (P < .05). The BioRaptor 2.9 AB cyclic displacement was significantly greater at 100 and 500 cycles than that of the PEEK PushLock and Bio-SutureTak (P < .05). The mean ultimate failure loads for these anchors ranged from 154 N (PEEK SutureTak) to 255 N (Bio-Mini Revo) and was statistically equivalent (P = .139). Correlation analysis showed no significant associations between anchor stiffness, cyclic load displacement, or failure load. CONCLUSIONS: Anchors with specific indications for hip arthroscopy showed very little displacement and had consistent failure loads under cyclic conditions in the acetabular rim. All hip anchors except the BioRaptor 2.9 AB showed less than 2.0 mm of displacement after 500 cycles. CLINICAL RELEVANCE: Biomechanical testing of suture anchors designated for hip arthroscopy should be performed in the acetabular rim before their use. Suture anchors used for shoulder arthroscopy may not perform as well in the hip.

Cyclic load testing and ultimate failure strength of biodegradable glenoid anchors.

PURPOSE: The purpose of this study was to compare biodegradable glenoid suture anchors by cyclic loading and load to failure testing. METHODS: Seven different suture anchors (BioKnotless and Lupine Loop [DePuy-Mitek, Norwood, MA]; BioPushLock, BioSutureTak, and BioFasTak [Arthrex Corp, Naples, FL]; BioAnchor [Conmed Linvatec, Largo FL]; and BioRaptor [Smith & Nephew, Andover, MA]) were tested in 8 matched pairs of human cadaver fresh-frozen glenoids. The anchors were inserted in rotation into different glenoid rim positions. Sutures attached to the anchors were fixed to an Instron 8871 machine (Instron, Canton, MA) and cyclic loading and destructive testing were performed. The cyclic displacement at 100 and 500 cycles, stiffness, ultimate failure strength, and mode of failure were determined. RESULTS: No statistical difference was found in the ultimate failure load for any of these anchors. The Lupine Loop and BioAnchor had greater 100 cycle and 500 cycle mean displacements than the BioPushLock and BioSutureTak. The Lupine Loop also had greater 100 cycle and 500 cycle mean displacement than the BioFasTak (P < .05). The BioAnchor had greater mean 500 cyclic displacement than the BioFasTak (P < .05). Mean BioSutureTak stiffness was greater than the Lupine Loop, BioAnchor, BioKnotless, and BioRaptor (P < .05). CONCLUSIONS: No differences in ultimate failure strength after cyclic loading were found in these seven biodegradable glenoid anchors (BioKnotless, Lupine Loop, BioPushLock, BioSutureTak, BioFasTak, BioAnchor, and BioRaptor). Most displacement occurred in the first 100 cycles. Displacement at 500 cycles was greater for the Lupine Loop and the BioAnchor than the BioPushLock, BioSutureTak, and BioFasTak. Failure was principally by the anchor pulling out of bone except for the BioSutureTak, which also failed by the suture loop eyelet pulling out of the anchor body, and the BioPushLock which failed by the suture slipping past anchor. CLINICAL RELEVANCE: Biodegradable glenoid anchors did not show statistical difference in ultimate failure load after cyclic loading.

Bloqueo interescalénico en el contexto de la recuperación acelerada para artroscopía de hombro: serie de casos / Interscalene block in the context of enhanced recovery for shoulder: A case series

Introducción La aplicación de la recuperación acelerada en cirugía de hombro no ha tenido una aceptación tan favorable. Por ello, el objetivo de este estudio fue presentar y describir el uso de bloqueo interescalénico para favorecer la recuperación acelerada en una serie de pacientes sometidos a cirugía artroscopica de hombro. Métodos Se incluyeron 35 pacientes sometidos a cirugía artroscópica de hombro, en quienes se administró bloqueo interescalénico y sedación. Posteriormente se evaluó la intensidad del dolor, náuseas, vómito, disnea, presencia de síndrome de Horner, visión borrosa, ronquera, tiempo transcurrido hasta el alta, reingresos no planeados, satisfacción del paciente y cumplimiento de los criterios de alta hospitalaria en las primeras 12 horas siguiendo los criterios de una recuperación acelerada. Resultados En total, 27 pacientes (77,1%) tuvieron clasificación de la (ASA) I y 8 pacientes (22,9%) ASA II. Además, 97,1% fueron reparaciones de manguito rotador. Previo al alta, dos pacientes (5,7%) presentaron náuseas. Al momento del alta ningún paciente presentó disnea o visión borrosa, dos pacientes (5,7%) presentaron ronquera y la mediana de intensidad del dolor fue de 1,0 (0,0 a 7,0). Entre las 24 y 48 horas solo un (2,8%) paciente presentó náuseas y la mediana de intensidad del dolor fue de 1,0 (0,0 a 8,0). Todos los pacientes se mostraron satisfechos con disposición a repetir la experiencia. El 100% de pacientes cumplió los criterios médicos de alta a las 12 horas y 30 pacientes (85,7%) se dieron de alta el mismo día. La estancia fue de 12 (11,5 a 12,5) horas y ningún paciente reingresó. Conclusión En pacientes seleccionados, con un equipo quirúrgico-anestésico comprometido, capacitado y con experiencia, hay una alta posibilidad de que el bloqueo interescalénico favorezca la realización de programas de recuperación acelerada en cirugía artroscópica de hombro.

Introduction The application of enhanced recovery in shoulder surgery has not had such a favorable acceptance, therefore, the objective of this study was to present and describe the use of interscalene block to promote enhanced recovery in a series of patients undergoing shoulder arthroscopic surgery. Methods Thirty-five patients undergoing arthroscopic shoulder surgery were included, in whom interscalene blockade and sedation were administered. Subsequently, pain intensity, nausea, vomiting, dyspnea, presence of Horner's syndrome, blurred vision, hoarseness, time elapsed to discharge, unplanned readmissions, patient satisfaction, and compliance with hospital discharge criteria in the first 12 weeks were evaluated, hours following the criteria of an enhanced recovery. Results 27 patients (77,1%) had ASA I and 8 patients (22,8%) ASA II, 97,1% were rotator cuff repairs. Before discharge, two patients (5.7%) had nausea. At discharge, no patient had dyspnea or blurred vision, two patients (5.7%) developed hoarseness, and the median pain intensity was 1.0 (0.0-7.0). Between 24 and 48 hours only one patient (2.8%) presented nausea and the median pain intensity was 1.0 (0.0-8.0). All the patients were satisfied with their willingness to repeat the experience, 100% of the patients met the criteria for medical discharge after 12 hours, 30 patients (85.7%) were discharged the same day, the stay was 12 (11.5 to 12.5) hours, and no patient was readmitted. Conclusion In selected patients with a committed, trained and experienced surgical-anesthetic team, there is a high possibility that the interscalene block will favor the performance of enhanced recovery programs in shoulder arthroscopic surgery.

Cyclic load testing of biodegradable suture anchors containing 2 high-strength sutures.

PURPOSE: The purpose of this study was to test 4 different biodegradable suture anchors threaded with 2 high-strength sutures under cyclic loading conditions in humeral cadaveric specimens divided into 2 different age groups. METHODS: Thirty-two paired human cadaveric humeri were stripped of all soft tissue. Two groups were studied: group 1, in which the mean age was 54 years, and group 2, in which the mean age was 70 years. We placed 1 suture anchor at 3 humeral sites per bone (anterior, middle, and posterior greater tuberosity). We tested 24 specimens using each of 4 anchors: TwinFix AB (Smith & Nephew Endoscopy, Andover, MA), BioZip (Stryker Endoscopy, San Jose, CA), Bio-Corkscrew FT (Arthrex, Naples, FL), and SpiraLok (DePuy Mitek, Raynham, MA). The anchor's sutures were grasped with an Instron clamp (Instron, Canton, MA), preloaded, and cycled from 10 to 60 N 500 times, followed by destructive testing. The mean displacement at 500 cycles, yield loads, failure modes, and ultimate loads were recorded. RESULTS: Most cyclic motion occurred during the first 100 cycles. More motion occurred in older bones than in younger bones (P < .05). The mean yield loads were greater for the young group for the SpiraLok anchors than for Bio-Corkscrew FT anchors in the young and old groups (P < .001), TwinFix anchors in the old group (P < .05), and BioZip anchors in the old group (P < .05). The ultimate failure loads for SpiraLok anchors in the young group were greater than for Bio-Corkscrew FT anchors in the young and old groups and BioZip anchors in the old group (P < .05). In group 1 TwinFix AB (P = .01) and BioZip (P = .02) ultimate loads were statistically greater than that for Bio-Corkscrew FT. The TwinFix AB failed by anchor pullout. The Bio-Corkscrew FT failed by eyelet pullout. The BioZip and SpiraLok pulled out in older bone and experienced eyelet breakage in younger bone. None of the 4 anchors reached 5 mm of displacement even after 500 loading cycles. CONCLUSIONS: Most of the displacement occurred in the first 100 cycles. Of all anchors tested, the Bio-Corkscrew FT recorded the lowest displacement after 500 cycles (P < .05). The SpiraLok had the highest ultimate load of all anchors tested (P < .01). CLINICAL RELEVANCE: Rotator cuff anchors perform differently in younger humeral bone than in older humeral bone. Most displacement with cyclic loading occurring between the anchor and bone takes place in the first 100 cycles. Anchors in older bones can be expected to fail at lower loads.

Meniscal repair with the RapidLoc meniscal repair device.

BACKGROUND: The RapidLoc is an all-inside, self-adjusting, flexible meniscal repair device that combines a suture with an anchor component and, by using a reinforced sliding knot, allows for tightening to compress and hold the repaired meniscal segments. The purpose of this study was to evaluate the clinical success of the RapidLoc device. METHODS: A prospective consecutive series of meniscal repairs performed with the RapidLoc device was studied. Lysholm, Tegner, Cincinnati, IKDC (International Knee Documentation Committee) activity scores, clinical examination findings, and adverse events were recorded on all patients. Associated procedures were recorded. An accelerated postoperative rehabilitation program was followed, independent of whether anterior cruciate ligament (ACL) surgery was also performed. RESULTS: A total of 32 patients underwent 32 meniscal repairs, with an average follow-up of 31 months (18 to 48 months). In all, 23 repairs were done in conjunction with ACL reconstruction, and 9 repairs were carried out in stable knees. Repairs were made to 25 medial menisci and 7 lateral menisci. Tears repaired consisted of peripheral longitudinal tears with an average length of 2 cm (range, 15 to 30 mm). Four failures (12.5%) were arthroscopically documented. Clinical success occurred in 87.5% at the time of last follow-up. At follow-up, mean Tegner score was 5.1 (2.8 preoperative), IKDC activity score was 3.1 (1.8 preoperative), Lysholm score was 93.6 (48.4 preoperative), and mean Cincinnati score was 88.1 (43.7 preoperative). The most common adverse event was cutting of the suture during RapidLoc insertion. One patient had excoriation and grooving of the medial femoral condyle associated with failed repair. Another patient developed a postoperative infection. CONCLUSIONS: The early clinical success rate was 87.5% with the RapidLoc device. Chondral grooving was observed in a single case. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

[Interscalene block for total shoulder arthroplasty: comparative study (ultrasound vs. neurostimulation)]. / Bloqueo interescalénico para artroplastia total de hombro: estudio comparativo ultrasonido vs neuroestimulación.

BACKGROUND: Modern anesthesiology has integrated the use of ultrasonography as a tool that has displaced neurostimulation as a technique for locating peripheral nerves. The aim of this study was to determine which procedure is more effective for guiding interscalene block for total shoulder arthroplasty. METHODS: We carried out a comparative, prospective non-randomized study comprised of the group guided by neurostimulation interscalene block and the group guided by ultrasound. All patients in both groups were scheduled for total shoulder arthroplasty. Latency, degree of sensory and motor block, success rate, postoperative pain intensity at 6, 12, and 24 h, patient satisfaction and complications were measured. RESULTS: We included 110 patients, 55 per group. Patients were placed in beach chair position and the deltopectoral approach was used. There were no differences in demographic characteristics. Results for neurostimulation vs. ultrasound group: latency 19.11 ± 2.27 vs. 17.24 ± 1.42 min, p= 0.23. Block sensitivity in both groups was grade 0 motor block grade 0 in 76.4% and grade 1 in 23.6% vs. grade 0 to 100%. There was 100% success rate for both groups. Postoperative pain at 6 h was 0.13 ± 0.54 vs. 0.11 ± 0.13 p= 0.90, at 12 h 1.67 ± 1.15 vs. 1.65 ± 0.59 p= 0.89 and at 24 h 3.15 ± 1.66 vs. 2.99 ± 1.15 p= 0.78. Satisfaction 54.5% very satisfied and 45.5% satisfied 96.36% vs 3.6% very satisfied and satisfied. Complications 18.18% vs. 3.6% p= 0.023. CONCLUSION: Ultrasound-guided interscalene nerve block is the technique of choice in elective total shoulder arthroplasty.

ANTECEDENTES: la anestesiología moderna ha integrado a la ultrasonografía como una herramienta que ha desplazado a la neuroestimulación como técnica de localización de nervios periféricos: ¿cuál es más efectiva para guiar el bloqueo interescalénico en artroplastia total de hombro? OBJETIVO: comparar dos técnicas de localización del plexo braquial bloqueo interescalénico como técnica anestésica en artroplastia total de hombro. MATERIAL Y MÉTODOS: estudio comparativo, prospectivo, sin asignación al azar. Se incluyeron todos los pacientes programados para artroplastia total de hombro; se formaron 2 grupos: grupo neuroestimulación donde el bloqueo interescalénico fue guiado por neuroestimulación, grupo ultrasonido que fue guiado por ultrasonido. Se midió el tiempo de latencia, grado de bloqueo sensitivo y motor, tasa de éxito, intensidad del dolor postoperatorio a las 6, 12 y 24 horas, satisfacción, y complicaciones. RESULTADOS: se incluyeron 110 pacientes, 55 por grupo, posición de silla de playa y abordaje deltopectoral. No hubo diferencias en las características demográficas, neuroestimulación vs ultrasonografía: latencia 19.11 ± 2.27 vs 17.24 ± 1.42 minutos p= 0.23. Bloqueo sensitivo en ambos grupos grado 0, bloqueo motor grado 0 en 76.4% y grado 1 en 23.6%, vs grado 0 en 100%. Tasa de éxito 100% en ambos grupos, dolor postoperatorio 6 horas 0.13 ± 0.54 vs 0.11 ± 0.13 p= 0.90; 12 horas de 1.67 ± 1.15 vs 1.65 ± 0.59 p= 0.89, 24 horas 3.15± 1.66 vs 2.99 ± 1.15 p= 0.78. Satisfacción: 54.5% muy satisfecho, y 45.5% satisfecho vs 96.36% muy satisfecho y 3.6% satisfecho. Complicaciones 18.18% vs 3.6% p= 0.023. CONCLUSIÓN: el ultrasonido es la técnica de localización del plexo braquial de elección en artroplastia total de hombro.

Postoperative pain control after shoulder arthroscopy.

Successful postoperative pain management after arthroscopic shoulder surgery allows patients to go home earlier, decreases the potential for hospital readmission, and facilitates rehabilitation. Optimal pain control considers the physiological and psychological states of the patient, the resulting alterations due to the surgery, and the technical and economic resources available during recovery. A comprehensive approach to pain control should include preoperative, intraoperative, and postoperative efforts. Efforts at postoperative pain reduction should begin preoperatively with the establishment of an excellent patient/physician relationship. Preoperative analgesia should be administered. Intraoperative efforts should include the administration of anesthetic medication intra-articularly. Postoperative management should include sleep medication, continuous cold-flow therapy, oral analgesics, and, if necessary, the use of narcotics.

[Open surgical treatment in post-traumatic elbow stiffness]. / Tratamiento quirúrgico a cielo abierto de la rigidez postraumática de codo.

PURPOSE: To show how open treatment of the elbow stiffness offers an improvement in the range of motion, pain control, and patient's satisfaction. METHODS: We present a case series analysis of patients who suffer elbow stiffness and were treated with open surgery. We analyzed the range of motion (ROM), visual analogue scale (VAS) for pain and satisfaction, and the Mayo Score. Statistical analysis was performed using Student's t-test, Fisher's exact and Pearson correlation coefficient. RESULTS: 33 patients were included mean, age was 30.3 +/- 13.4. Twenty patients were male and 13 female, 32 patients had an articular fracture of the elbow and 1 with ectopic ossification. In 90.9% the column procedure was the option and in 9.1% open reduction and internal fixation was made. Compared with preoperative ROM was 58.8 degrees +/- 28.6 degrees, postoperative 96.10 +/- 25.5 (p < 0.001). Pain versus registered 5.06 points in the Preoperative 1.7 points in the postoperative period (p = 0.001). 75% of the patients were satisfied. Preoperative Mayo score was 47.2 +/- 17.8 versus 89.2 +/- 13.4 in the postoperative (p < 0.0001). CONCLUSION: The open treatment of the stiff elbow offers the patient pain relief; increased motion and most patients report final results as satisfactory.

Medición del conocimiento de bioética en residentes y médicos de base de cirugía general del Hospital General de México / Assessment of the bioethical knowledge in residents and tenure physicians of General Surgery at the General Hospital of Mexico

Objetivo: Medir el conocimiento bioético de los médicos de base y residentes de cirugía general. Sede: Hospital General de México. Diseño: Estudio prospectivo, transversal, comparativo y observacional. Análisis estadístico: Prueba t de Student y Kruskal-Wallis. Metodología: Se evaluaron 22 médicos de base y 61 residentes de los cuatro años de la especialidad de cirugía general, a los cuales se les aplicó un cuestionario basado en cuatro casos clínicos, elaborado por la Universidad de Toronto, para evaluar la capacidad de reconocer problemas bioéticos. Resultados: Se recabaron un total de 52 cuestionarios contestados (62%), 15 médicos de base con una edad promedio de 48.6 años y 37 residentes con una edad promedio de 26.5 años. Se reconoció el 12% de los problemas bioéticos presentes en los cuatro casos clínicos. El 53% de problemas relacionados a justicia, el 30% en autonomía y el 28% en beneficencia. El grupo que presentó mayor promedio total de conocimiento bioético fueron los residentes de cuarto año, seguidos de los de segundo y primer año y en último lugar los médicos de base y los residentes de tercer año. Los médicos con formación bioética previa a la respuesta de los casos clínicos reconocieron un mayor número de problemas. Conclusión: El bajo puntaje obtenido en el cuestionario se traduce en una deficiente capacidad para reconocer problemas bioéticos, tanto por médicos de base como por residentes de cirugía general.

Objective: To measure the bioethical knowledge in tenure physicians and general surgery residents. Setting: General Hospital of Mexico. Design: Prospective, cross-sectional, comparative, and observational study. Statistical analysis: Student's t and Kruskal-Wallis tests. Methodology: We evaluated 22 physicians and 61 residents of the four years of the General Surgery speciality, to whom a questionnaire based on four clinical cases, elaborated by the University of Toronto, was applied to assess their ability to recognize bioethical conflicts. Results: We obtained a total of 52 answered questionnaires (62%), 15 graduated surgeons with an age average of 48,6 years and 37 surgical residents with an age average of 26,5 years. Only 12% of the bioethics problem in the four clinical cases was clear. 53% of problems related to justice, 30% in autonomy and 28% in charity. The fourth year resident group has the major average of bioethics knowledge, followed of those of second and first year and last was the graduated surgeons and the residents of third year. The surgeons with bioethics formation recognized a greater number of problems. Conclusion: The low score obtained in the questionnaire is translated in a deficient capacity to recognize bioethics problems, as much by graduated surgeons as by residents of general surgery.