C. Lamas

Monteggia fractures in adults. Review of 54 cases

INTRODUCTION We present a review of Monteggia fractures treated in our hospital between 1992 and 1998. PATIENTS AND METHODS Fifty four patients with a Monteggia fracture were treated in our hospital with an average follow-up of 24 months (12-48 months). The average age was 41 years (18-81 years). According to the classification of Bado, there were 24 type I, 20 type II, 6 type III and 4 type IV. The etiology was in 27 cases a motor-vehicle and motorcycle accident, five a pedestrian struck by a car, 21 by a causal fall and only one by a direct hit by an iron bar in an assault. In 56% of the patients, the lesions were associated with polytrauma. In all the cases, treatment consisted of open reduction and internal fixation of the ulnar fracture using different methods of osteosynthesis (3.5 mm DCP, 3.5 mm reconstruction plates, 6.5 mm cancellous screw, tension band technique with Kirschner wires, and one-third tubular plates). Initial treatment of the radial head dislocation was attempted by closed reduction and verification under fluoroscopy. Subsequent open reduction and osteosynthesis were performed in 10 cases, and resection of radial head was necessary in three cases as the initial treatment. There were six open fractures with one case developing chronic infection. RESULTS Results were evaluated according to the criteria of Anderson (union fracture, elbow and wrist flexion/extension). The results were excellent in nine patients (17%), satisfactory in 33 (61%), unsatisfactory in nine (17%) and failure in three (5%). Complications could be attributed to the severity of injury, type of fixation and errors in technique (four non-union, three failure of one-third tubular plates, one distal radioulnar instability) and to some features peculiar to this lesion (five nerve injuries, three redislocations of the radial head and four radioulnar synostosis). We needed to perform 14 reoperations to resolve some of the above mentioned complications.

Silicone Proximal Interphalangeal Joint Arthroplasty for Primary Osteoarthritis Using a Volar Approach

PURPOSE To evaluate the short-term clinical and radiographic outcome of a silicone proximal interphalangeal (PIP) joint implant using a volar approach in patients with primary osteoarthritis. METHODS We retrospectively reviewed 36 proximal PIP joints that were replaced with Avanta silicone implants in 26 patients. Inclusion criteria were diagnosis of primary osteoarthrtitis of the PIP joint and failure to respond to conservative treatment. Clinical asessment included range of motion, patient satisfaction, and pain scores. The Quick-Disabilities of the Arm, Shoulder, and Hand questionnaire was administered at final follow-up. Radiographs were reviewed for alignment and implant fracture. Complications were also recorded. RESULTS After an average follow-up of 18 months (range, 12-60 mo), pain relief was markedly reduced in all patients, decreasing from a mean score of 7.2 preoperatively to 0.4 postoperatively. The arc of active motion of the PIP joint improved from 33° to 72°. Satisfaction averaged 4.8 on a 5-point Likert scale, and all patients stated they would repeat the surgery. The median final average Quick-Disabilities of the Arm, Shoulder, and Hand score was 7 (range, 4-12). Radiograph review showed 2 implant fractures at 1 and 2 years after surgery, respectively, but without clinical changes. The average deformity in the coronal plane changed from 12° (range, 8° to 18°) preoperatively to 4° (range, 3° to 8°) postoperatively, whereas the average flexion contracture changed from 18° (range, 10° to 30°) to 0° (all patients achieved full active extension). No other complications were observed. No revision surgery has been needed to date. CONCLUSIONS The volar approach to PIP joint silicone arthroplasty offers the advantages of maintaining the integrity of the extensor mechanism, providing pain relief, and improving postoperative range of motion with minimal complications. However, further research is needed to determine the long-term efficacy of this implant. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Fat pad and "little finger pulp" signs are good indicators of proper release of carpal tunnel.

OBJECTIVEThe release of the transverse carpal ligament (TCL) for relief of carpal tunnel syndrome has been a standard operative procedure since the early 1950s. Although complications are not common after the open surgical technique, a small but significant group of patients will have similar symptoms after surgery or will experience new symptoms in the postoperative period. Incomplete section of the TCL is the major cause of these complications. The authors have described two signs that confirm a complete release of the TCL, called the “fat pad” and “little finger pulp” signs. METHODSBetween 2000 and 2003, we treated 643 hands in 611 patients (45 men and 566 women; age range, 32–76 yr; mean age, 58.2 yr). All patients were examined 6 months after the procedure, with special attention given to the persistence or recurrence of symptoms. The presence of palmar scar pain, residual numbness, patient satisfaction, and time to return to work were also evaluated. A longitudinal incision (2 cm) at the base of the palm was used to release the TCL. A good indicator that the distal TCL has been released is the visualization of a fatty tissue (“fat pad” sign). This fatty tissue is always present underneath the most distal fibers of the TCL, covering the sensory digital branches of the median nerve. To confirm the complete release of the proximal fibers of the TCL, we should be able to introduce the little finger pulp in a proximal direction underneath the distal flexion crease of the wrist (“little finger pulp” sign). When both signs are confirmed, we can be certain that the TCL is completely released. RESULTSNight pain disappeared immediately after surgery in all patients except three. There were seven complications (1%) not related to the palmar scar and 10 complications (1.5%) related to it. However, all of these complications disappeared an average of 3 months postoperatively. Patient satisfaction was 100%, and the mean time to return to work and full activity was 22 days (range, 14–36 d). CONCLUSIONTwo surgical observations that are reliable to confirm a complete release of the TCL were described. The first, called the “fat pad” sign, is useful to determine whether or not the distal end of the TCL has been adequately released, whereas the “little finger pulp” sign indicates whether or not the proximal end of the TCL has been fully divided.

Arthrodesis of the metacarpophalangeal joint of the thumb using a Herbert screw.

We describe a technique for thumb metacarpophalangeal joint arthrodesis by using a Herbert screw. This method of fixation helps in avoiding some of the potential problems associated with wire fixation, tension-band arthrodesis, or plate fixation. Therefore, it eliminates the risk of pin track infection, pin breakage, and painful protrusion under the skin requiring metalwork removal.

Treatment of Little Finger Carpometacarpal Posttraumatic Arthritis With a Silicone Implant

PURPOSE To evaluate the short-term clinical and radiographic outcome of a flexible silicone proximal interphalangeal joint implant between the hamate and the metacarpal, to treat posttraumatic little finger carpometacarpal (CMC) osteoarthritis. METHODS We treated 3 men with a mean age of 30 years by means of a proximal interphalangeal silicone implant arthroplasty for CMC osteoarthritis of the little finger. Indications were disabling pain on the ulnar side of the hand, grip weakness, loss of CMC joint mobility, and disability for work and daily activities. RESULTS All patients were free of pain at a mean follow-up of 20 months. Transverse metacarpal arch mobility and grip strength were restored. The appearance was acceptable, without misalignment, malrotation, or shortening of the little finger ray. Radiographic evaluation showed no fractures or dislocations of the implant and no signs of foreign body reaction to silicone particles. CONCLUSIONS This technique offers the advantages of eliminating pain, maintaining length, and restoring mobility of the transverse metacarpal arch, and results in acceptable function and grip strength.

Tratamiento quirúrgico de las fracturas diafisarias y conminutas de la clavícula mediante placa anatómica de bajo perfil

OBJECTIVES In this study we evaluate the treatment of displaced mid-shaft clavicle fractures or comminuted fractures with a third fragment using a superior anatomic plate. MATERIALS AND METHODS A retrospective study was conducted on 34 patients operated on between January 2006 and June 2010 with this type of fracture. Mean follow up was 25 months (6-54 months). By Robinson Classification, 12 cases were type 2B, 17 type 2B1 and 5 type 2B2. Clinical evaluation was performed with the VAS and Constant test. For the radiological evaluation, we used neutral AP projections, and another with 30 degrees of cranio-caudal inclination. RESULTS The mean pre-operative VAS was 6.5 (4-8) and the postoperative was 1 (0-2). The mean Constant test score was 85, with 30% good results and 70% excellent results. The mean consolidation time was 14 weeks. CONCLUSION Internal fixation of comminuted fractures with an anatomic plate, particularly those with a vertical third fragment and fractures type 2B, 2B1 and 2B2, provides a good treatment option, as it gives good functional results and minimises the incidence of non-union.

Treatment of Midshaft Clavicular Non-unions by Means of the Herbert Cannulated Bone Screw

The incidence of non-union of the clavicle is reported to be between 0.1% and 15%. Various surgical procedures have been proposed for the treatment of this potentially disabling condition, including interfragmentary screws or wire suture, intramedullary pinning with Kirschner wires, Knowles pins, Steinmann pins, modified Hagie pins, external fixation, and compression plates with or without bone grafting. We present an alternative technique for the successful treatment of non-union of the midshaft of the clavicle, consisting of open intramedullary fixation using a Herbert cannulated bone screw, a technique that avoids the need for removing the implant after bone union occurs.

Estudio biomecánico del tornillo canulado de Herbert en el tratamiento de la pseudoartrosis de clavícula

Objetivo Valorar biomecanica y clinicamente una tecnica alternativa quirurgica para el tratamiento de la pseudoartrosis del tercio medio de la clavicula. Material y metodo Estudio mecanico: diecinueve especimenes de claviculas humanas fueron divididos en tres grupos: grupo A, 5 claviculas intactas, grupo B, 5 claviculas osteotomizadas perpendicularmente al eje longitudinal del hueso, en su parte media, y tratadas con placas DCP de 3,5 mm y 6 orificios, y grupo C, 9 claviculas osteotomizadas y tratadas con clavo canulado de Herbert, de 4,5 mm. Todas las claviculas fueron sometidas a ensayos mecanicos en una maquina de ensayos servohidraulica obteniendo la resistencia maxima (N), la rigidez (N/Mm) y la tension maxima (Mpa). Resultados Estudio mecanico: tanto la placa recta DCP como el tornillo canulado de Herbert se comportaron mecanicamente de forma similar. Conclusiones La ventaja de la sintesis intramedular con tornillo canulado de Herbert es que no requiere una segunda operacion para retirar el implante una vez conseguida su consolidacion.

Histopathological Analysis of the Lunate in Rheumatoid Disorders: Role of the Angiogenesis and Synovitis in Kienböck Disease

Introduction: Avascular necrosis of the lunate in Systemic Lupus Erythematous (SLE) and rheumatoid arthritis (RA) are not rare. Our study aimed to describe the histopathology of the lunates after removing them in the operating room in patients with rheumatoid diseases and lunate palmar dislocation. We correlated the histopathological findings with magnetic resonance imaging (MRI), radiological parameters, and blood test parameters. Methods: From January 2006 to January 2015, 12 patients were operated for rheumatoid disorders, 8 RA, 1 SLE, and 3 psoriatic arthritis (PA). There were 8 female and 4 male with a mean age 65 (53-79) years. Antinuclear antibodies and other relevant tests were performed. Anticardiolipin antibody, anti-double-stranded DNA, and anti-β-2 glycoprotein I were measured by enzyme-linked immunosorbent assay (ELISA). All patients underwent MRI study. T1-weighted images were evaluated for bone necrosis of the lunate. In the operating room, we excised whole lunates and we studied the macroscopical aspect inside and outside. We evaluated the size, cartilage surfaces, number of foraminas, and ligament insertions. After that, we cut the bone and showed the bleeding bone and collapse areas. Histopathological analysis was performed with lunate sections. The lunates were fixed in formalin, decalcified, embedded in paraffin, and cut in 5 microm sections, and stained with hematoxylin and eosin. We visualized lunates sections by microscope. The surgical treatment was a wrist arthrodesis in 8 cases and wrist arthroplasty in the other 4 cases. We evaluated x-rays data such as lunate morphology, Stahl Index, Carpal Height ratio (CHR), and Carpal Ulnar distance ratio (CUDR). We correlated preoperative x-rays and MRI data with histopathological findings. We correlated blood test parameters with the histology. Statistical analysis of data was performed with chi-square test (significance level P < .05). Results: In 2 cases, we showed a lunate flattening associated with a partial hypointensity in coronal sections in T1-weighted images in MRI. Microscopic analysis showed synovial hyperplasia, fatty marrow, and fibrovascular tissue. We did not find avascular necrosis in any complete lunate but we found a focal necrosis (empty lacunae) in 2 cases. Mean CHR was 0.385, CUDR 0.301, Index Stahl 56.95, and radio-scaphoid angle 76°. We showed more ulnar translation in RA than in other rheumatoid disorders (CUDR P = .002). The correlation focal lunate necrosis with MRI was P = .371. The correlation focal lunate necrosis with scapholunate ligament rupture was P = .640. We showed 2 blood test parameters statistically significant with focal lunate necrosis (C reactive Protein P = .046 and Rheumatoid Factor P = .053). Conclusion: Neoangiogenesis and wrist synovitis in rheumatoid disorders, with an increased number of synovial cells and vessels, seem to contribute to the progression of autoimmune diseases. It is possible that the patients with rheumatoid wrists have hypervascularity and therefore a chronic adaptation to a decrease number of vessels in the lunate and to ligament injuries. This could avoid to have Kienböck disease in a chronic palmar lunate dislocation in rheumatoid disorders.

Vascularised bone graft with mini-acutrak® fixation in scaphoid pseudoarthrosis with proximal pole necrosis

Objectives: We studied the use of vascularized bone graft (VBG) in combination with a fixation with screw in patients with scaphoid nonunion and avascular proximal poles. Materials and methods: Between January 2006 and December 2009, we treated 10 patients with scaphoid nonunion with avascular proximal poles. There were 10 males with nonunion. Their average age was 27 years (range: 18-46 years). The average followup was 18 months (range: 12-43 months). The clinical valuation was the scale of pain (VAS), the range of motion and grip strength. The radiological valuation included radiographies, CT and MRI. We studied the scapholunate angle, the Carpal Height Index by Nattrass et al. and the Mayo Wrist Score. Results: The mean preoperative VAS was 4.5 (2-8) and postoperative VAS 1 (0-2). All patients achieved union in an average time of 15 weeks (range: 6-25 weeks). X-rays and CT showed a complete osseous union in all patients. Carpal Height Index was a mean of 1.50 preoperative and 1.58 postoperative. The scapholunate angle was a mean of 52o preoperative and 49o postoperative. Mayo Wrist Score was 53 preoperative and 92 postoperative. Conclusions: We have found that the technique which combines VBG with mini acutrak