Ezequiel Ernesto Zaidenberg

Simultaneous Bilateral Rupture of the Triceps Tendon in a Renal Transplant Patient

The unilateral rupture of the triceps brachii tendon is a rare lesion representing 1% of all tendon injuries. The most common causes are the result of a contraction against resistance (especially weightlifters) and direct trauma. It has also been associated with systemic diseases such as diabetes mellitus, chronic renal failure, secondary hyperparathyroidism, and use of systemic corticosteroids. Simultaneous bilateral rupture of the triceps tendons is less frequent and has been described in association with chronic metabolic disorders, especially in those patients on hemodialysis. This paper presents a case of bilateral triceps tendon rupture of a 36-year-old woman with renal transplantation secondary to chronic renal failure. Early surgical repair was performed using a bone tunnel technique with a nonabsorbable suture. Clinically active extension with 135 degrees of range of motion was achieved.

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

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

Radius Core Decompression for Kienböck Disease Stage IIIA: Outcomes at 13 Years Follow-Up

PURPOSE This study was designed to analyze the long-term clinical and radiological outcomes of a series of patients with Kienböck disease stage IIIA treated with radius core decompression. METHODS This retrospective study included 15 patients with Kienböck disease (Lichtman stage IIIA) who underwent distal radius metaphyseal core decompression between 1998 and 2005 and who were followed-up for at least 10 years. At the last follow-up, the patients were evaluated for wrist range of motion and grip strength. The overall results were evaluated by the modified Mayo wrist score and visual analog scale pain score. We also compared the radiological changes between the preoperative and the final follow-up in their Lichtman classification and the modified carpal height ratio. RESULTS The mean follow-up period was 13 years (range, 10-18 years). Based on the modified Mayo wrist score, clinical results were excellent in 6 patients, good in 8 patients, and poor in 1 patient who required a proximal row carpectomy as revision surgery. The mean preoperative pain according to the visual analog scale was 7 (range, 6-10) and was 1.2 (range, 0-6) at the final follow-up. Compared with the opposite side, the average flexion/extension arc was 77% and the grip strength was 80%. All patients, except 1, returned to their original employment. At the final follow-up, 3 patients had decreased modified carpal height ratio, 12 remained unchanged. Radiographic disease progression according to the Lichtman classification to stages IIIB to IV occurred in only 2 wrists. There were no complications related to the core decompression. CONCLUSIONS In this limited series, the radius core decompression demonstrated favorable long-term results and could be considered as a surgical alternative for stage IIIA of Kienböck disease. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

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

Introduction The purpose of this study was to analyze the clinical and radiological outcomes of a series of patients treated with the pedicled distal radius vascularized bone graft (VBG) for recalcitrant ulnar nonunions. Methods A retrospective study was perfomed. The inclusion criteria were patients with diaphyseal or proximal ulnar nonunions with bone defects smaller than 6 centimeters, at least three previous surgeries and a minimum follow-up of 2 years treated with pedicled VBG of the distal radius. The number of previous surgeries was recorded. The elbow and wrist range of motion, the comparative grip strength, the Visual Analogue Scale (VAS) for pain, the QuickDASH questionnaire and the Mayo Score for elbow were evaluated. Results Seven patients were included. The mean age was 42 years (range 26-64). The average number of previous surgeries was 4 (3-7). The mean follow-up was 21 months (range 24-36). All pseudoarthrosis consolidated. The Mayo score was good in 4 patients, excellent in 2 patients and moderate in one patient. The mean postoperative QuickDASH was 13 (0-29). The flexion-extension arch of the wrist was 81% of the contralateral. The elbow range of motion was > 100° in 5 patients and 50°- 100° in 2 patients. Conclusion The pedicled vascularized bone graft of the distal radius is an effective alternative for the treatment of recalcitrant ulnar nonunions.

Descompresión ósea metafisaria del radio distal para estadios tempranos de la enfermedad de Kienböck. Seguimiento mínimo de 10 años. [Metaphyseal bone decompression of distal radius for early stages of Kienböck's disease. Minimum follow-up of 10 years.]

Background The purpose of this study is to analyze the long-term clinical and radiological results of a series of patients with early stages of the Kienbock disease treated with radius core decompression. Methods This retrospective study included 23 patients with Kienbock’s disease (Lichtman stage II and IIIA) who underwent distal radius metaphyseal core decompression that were followed-up for at least 10 years. At the last follow-up, the patients were evaluated for wrist range of motion and grip strength. The overall results were evaluated by the modified Mayo wrist score and visual analogue scale pain score. We also compared the radiological changes between the preoperative and final follow-up in their Lichtman classification and the modified carpal height ratio. Results The mean follow-up period was 13 years (range 10-18). Based on the modified Mayo Wrist Score, clinical results were excellent in 9 patients, good in 11 patients, fair in 2 and poor in one patient. The mean preoperative pain according to VAS was 7 (range 6-10) and was 1.1 (range 0-6) at the final follow-up. Compared with the opposite side, the average flexion/extension arc was 78% and the grip strength was 81%. Radiographic disease progression according to the Lichtman classification occurred in four wrists. Conclusion This long-term follow-up study shows that radius core decompression is a valid alternative for the treatment of the early stages of the kienbock disease.

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

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

Comparative Study of Internal Fixation of the Ulna and Distal Ulna Resection in Patients Older Than 70 Years With Distal Radius and Distal Metaphyseal Ulna Fractures

Background: Acute management of fractures of the distal ulna that are associated with fractures of the distal radius remains difficult, particularly in the elderly. Methods: In this study, we investigated whether internal fixation of the distal ulna is associated with a higher rate of complications than resection of the distal ulna in patients older than 70 years. Twenty-four consecutive patients were included in this study, 12 of whom had undergone open reduction and internal fixation (ORIF) of the distal ulna, and 12 who had undergone distal ulna resection. Patients were retrospectively assessed for range of motion, grip strength, pain, and radiographic appearance. The functional outcome was evaluated by the Mayo Wrist Score. Complications were classified according to the Classification of Surgical Complications. Results: There were no differences in patient demographics between the 2 groups, except patient age. Clinical evaluation showed no difference at follow-up; however, there were significantly more complications associated with ORIF compared with resection. Conclusions: The results from our study show that women older than 70 years with fracture of the distal radius and distal ulna have a higher rate of complications if ORIF of the distal ulna is performed. Patients should be warned, by surgeons, of this in cases where ORIF of the distal ulna is suggested.

Delayed Repair of Ulnar Artery at the Distal Forearm

Background:The purpose of this study was to evaluate the rate of patency after delayed repair of the ulnar artery following primary ligation. Methods: Adult patients with primary ligation of the injured ulnar artery at the forearm who had a delayed repair of the artery were included. Postoperative arterial patency was determined by either physical examination or color Doppler ultrasonographic imaging. Postoperative complications and Disabilities of the Arm, Shoulder and Hand score were recorded. Results: Eight consecutive patients during a 3-year period were included. The mean age was 35 years. Four cases were women. The surgery was performed at a mean of 5 days after the injury and ligation. At a mean follow-up of 22 months, 7 patients had a patent artery. One patient suffered a hematoma. Conclusions: A high rate of patency can be obtained after delayed repair of the ulnar artery at the forearm.

Long-Term Outcomes of Distal Radius Metaphyseal Core Decompression for Kienböck Disease Stage IIIa

Background: Stage IIIa of the Lichtman classification is characterized by collapse of the lunate, with preservation of carpal height and intercarpal alignment. Although joint-leveling procedures and revascularization techniques have become the standard treatment during the past decade, these procedures have not been able to reverse Kienböck disease, and as many as 25% of patients have reported complications including infection, nonunion, and ulnar impingement. Core decompression techniques for the treatment of Kienböck disease stage I and II had demonstrated similar benefits as joint-leveling procedures (reduction in pain, improvement in functional activity, and improvement of motion) but a much simpler technique with almost no complications. The purpose of this study is to analyze the long-term clinical and radiological outcomes of a series of patients with Kienböck disease stage IIIa of the Lichtman classification treated with distal radius core decompression. Material and Methods: This retrospective study included 14 patients with Kienböck disease (Lichtman stage IIIa) who received distal radius metaphyseal core decompression between 1998 and 2005 and were followed-up for at least 10 years. Exclusion criteria were patients with previous surgery of the wrist, presence of osteoarthritis, and a history of major wrist trauma. At the last follow-up, the patients were evaluated for pain, comparative wrist range of motion and grip strength, and wrist functional status. The overall results were evaluated by the modified Mayo wrist score and visual analogue scale (VAS) pain score. We also compared the radiological changes preoperatively and postoperatively in their Lichtman classification and the modified carpal height ratio. Results: The mean follow-up period was 13 years (range, 10-18). The mean age of the patients was 42 years old (range, 28-64); 9 were men. Based on the modified Mayo wrist Score, clinical results were excellent in 6 patients, good in 7 patients, and poor in 1 patient who require a proximal row carpectomy as revision surgery. The mean postoperative pain was VAS 1.5 (range, 0-7). Moreover, at the final follow-up, 10 of the 14 patients had VAS either 0 or 1. Compared with the opposite side, the average flexion/extension arc was 76% and the grip strength was 78%. All patients, except one, returned to their original employment. Radiographic disease progression according to the Lichtman classification to stage IIIb to IV occurred in one wrist, while the other patients remained in the same stage as preoperatively. The average preoperative modified carpal height ratio was 1.38 (range, 1.5-1.28) and the postoperative was 1.34 (range, 1.42-1.25). There were no complications related to the metaphyseal core decompression. Summary Points: (1) In this limited series, distal radius metaphyseal core decompression demonstrated favorable long-term results and is recommended as a surgical alternative for stage IIIa of the Kienböck disease. (2) This procedure may be a reasonable option for patients who prefer a simpler operation that may have a good result and allows to perform a more complex alternative if needed.

Foreign-Body Reaction and Osteolysis in Dorsal Lunate Dislocation Repair With Bioabsorbable Suture Anchor

Background: In recent years the use of biodegradable suture anchors for treating tendon and ligament pathology in hand surgery became popular. These materials are biocompatible, radiolucent, and load sharing, as they incrementally transfer load to surrounding bone during the resorption process. Despite these numerous advantages, polyglycolic (PGA) and poly-L-lactic acid (PLLA) have become a problem because of the potential risk for foreign body reactions. Methods: This article presents a case of an intraosseous foreign body reaction and massive osteolysis of the proximal carpal after dorsal lunate dislocation repair with bioabsorbable suture anchors. Results: Because of the persistent pain and the decreased strength, a proximal row carpectomy was performed 12-months after the initial trauma. Conclusions: Hand surgeons should be aware of the possibility of a late foreign body reaction, that could be especially severe in carpal bones.