Reconstrucción de ligamento colateral medial: descripción de una nueva técnica de aumentación con aloinjerto y tornillos biocompuestos interferenciales / Reconstruction of medial collateral ligament: Description of a new augmentation technique with allograft and interference biocomposite screws

Resumen: Introducción: La inestabilidad del ligamento colateral medial (LCM) se asocia con lesiones multiligamentarias. Existen varios procedimientos para la reconstrucción del LCM, presentamos una técnica percutánea de aumentación. Nuestro objetivo es describir una nueva técnica de reconstrucción del LCM mediante injerto y fijación con tornillos biocompuestos. Material y métodos: Presentamos la técnica en un total de 21 pacientes consecutivos con lesión del LCM operados en el período de Diciembre de 2011 a Octubre de 2014. La reconstrucción del LCM se realizó con aloinjertos del tendón del peroneo largo, tibial posterior o flexor largo del Hallux en 18 pacientes y solamente en un paciente se utilizó autoinjerto. De los 20 pacientes, 18 presentaron lesiones asociadas: cinco con lesión de menisco medial, ocho con lesión del ligamento cruzado anterior, (LCA), ocho con lesión condral y uno con lesión del menisco lateral. Conclusión: La técnica quirúrgica presentada es sencilla de realizar, sin daño a otras estructuras y con una fijación resistente.

Abstract: Introduction: Medial Collateral Ligament (LCM) instability is associated with multi-ligamentary lesions. There are several procedures for the reconstruction of MCL, we present a percutaneous technique of augmentation. Our goal is to describe a new technique of reconstruction of the LCM by grafting and fixing with biocomposite screws. Material and methods: We present the technique in a total of 21 consecutive patients with MCL injury operated in the period of December 2011 to October 2014. Reconstruction of MCL was performed with long, tibial or long hallux tendon allografts in 18 patients and only one patient was used autograft. Eighteen of the 20 patients had associated lesions: 5 with medial meniscus injury, 8 with anterior cruciate ligament injury, (ACL), 8 with condral injury and 1 with lateral meniscus injury. Conclusion: The surgical technique presented is simple to perform, without damage to other structures and with a strong fixation.

Unstable Simple Elbow Dislocation Treated with the Repair of Lateral Collateral Ligament Complex

BACKGROUND: Unstable simple elbow dislocation (USED) repair is challenged by the maintenance of joint reduction; hence, primary repair or reconstruction of disrupted ligaments is required to maintain the congruency and allow early motion of the elbow. We evaluated the effectiveness and the outcome of lateral collateral ligament (LCL) complex repair with additional medial collateral ligament (MCL) repair in cases of USED. METHODS: We retrospectively reviewed 21 cases of diagnosed USED without fractures around the elbow that were treated with primary ligament repair. In all cases, anatomical repair of LCL complex with or without common extensor origin was performed using suture anchor and the bone tunnel method. Next, the instability and congruency of elbow for a full range of motion were evaluated under the image intensifier. MCL was repaired only if unstable or incongruent elbow was observed. Clinical outcomes were evaluated using the Mayo elbow performance score (MEPS) and radiographic outcomes on last follow-up images. RESULTS: All cases achieved a stable elbow on radiographic and clinical results. LCL complex repair alone was sufficient to obtain the stable elbow in 17 of 21 cases. Four cases required additional MCL repair after restoration of the LCL complex. The overall mean MEPS was 91 (range, 70 to 100): excellent in 12 cases, good in 7 cases, and fair in 2 cases. All 17 cases with LCL complex repair only and 2 of 4 cases with additional MCL repair had excellent or good results by MEPS. CONCLUSIONS: USED requires surgical treatment to achieve a congruent and stable joint. If the repair of lateral stabilizer such as LCL complex acquires enough joint stability to maintain a full range of motion, it may not be necessary to repair the medial stabilizer in all cases of USED.

Ligament Preserving Technique for a Locked Metacarpophalangeal Joint of the Index Finger

BACKGROUND: Locking of metacarpophalangeal joint (MPJ) of the index finger occurs when volar radial osteophytes of the metacarpal head catch the accessory collateral ligament. We devised a ligament-preserving approach to quickly restore the MPJ motion while protecting the radial collateral ligament. METHODS: We retrospectively reviewed the results of nine patients treated for a locked MPJ of the index finger. In three patients, closed reduction was successful. In six cases, volar radial osteophytes were excised from the metacarpal head using a ligament-preserving technique through a longitudinal incision on the radial side. We analyzed osteophyte shape and height as demonstrated by X-ray and computed tomography (CT). Function was evaluated by examining the range of motion, recurrence, Disabilities of the Arm, Shoulder and Hand (DASH) score, and MPJ stability based on the key pinch strength. One male and eight female patients were followed for an average of 33 months (range, 12 to 65 months); the average age of patients was 41 years (range, 34 to 47 years). The average duration of locking of the MPJ was 23 days (range, 1 to 53 days). RESULTS: The sharp type of osteophytes was identified in six patients and the blunt type of osteophytes was indentified in three patients. The average height of radial osteophytes on the index finger metacarpal was 4.6 +/- 0.4 mm in the axial CT image. At the final follow-up, the average extension limitation decreased from 26degrees (range, 10degrees to 45degrees) to 0degrees, and further flexion increased from 83degrees (range, 80degrees to 90degrees) to 86degrees. There was no recurrent locking after surgery. The DASH score improved from 24.3 to 7.2. Key pinch strength improved from 67.3% to 90.4%. CONCLUSIONS: We obtained satisfactory outcomes in irreducible locking of the MPJ of the index finger by excising volar radial osteophytes of the metacarpal head using a ligament-preserving approach.

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.

Reconstrução das lesões crônicas do ligamento colateral ulnar da articulação metacarpofalângica do polegar utilizando enxerto tendinoso / Reconstruction of chronic injuries from the ulnar collateral ligament to the thumb metacarpophalangeal joint using tendon grafting

Objetivo: Os autores avaliam os resultados do tratamento cirúrgico em oito pacientes com lesão crônica do ligamento colateral ulnar (LCU) da articulação metacarpofalângica do polegar. Métodos: Os casos foram tratados utilizando enxerto tendinoso com a técnica de Littler modificada e avaliados retrospectivamente em relação ao resultado clínico, com 12 meses de pós-operatório, avaliando-se os critérios de mobilidade, força de pinça, dor e satisfação pessoal. Resultados: Todos os pacientes evoluíram com melhora clínica evidente. Conclusão: Nossa avaliação, baseada na escala de Glickel, reforça a indicação do tratamento cirúrgico pela técnica de Littler modificada, nas lesões crônicas do ligamento colateral ulnar do polegar.

[Serious sprains of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb]

The sever strain of the thumb's metacarpophalangeal joint interest specially the ulnar collateral ligament [UCL]. The authors reported their experience about managing the acute rupture of the UCL. Authors reported 26 cases of severe strain of the UCL of the thumb's metacarpophalangeal joint. There were 22 mans and 4 women. The mean age was 27 years [17-50 years]. The sports accident caused 77% of all injuries. The diagnosis was allowed by physical exam, standard and stress radiographies. There were 8 patients with avulsion fractures of the UCL [2 undisplaced], 7 with corporeal rupture and 11 with distal desinsetion of the UCL. Two patients [with undisplaced fracture avulsion] had an orthpaedic treatment and 24 were operated. With a mean follow-up of 3, 5 years 22 patients [85%] had a very good or good results, 2 patients [8%] had average result and 2 authors [8%] had poor result. The severe strain of UCL of the thumb's metacar-pophangeal joint may have a good result if diagnosed and treated correctly in the acute phases. Excepted undisplaced fracture avulsion, all these injuries must be treated surgically, immobilised in plaster for 4 weeks and reeducated adequately

Tratamento da lesäo aguda do ligamento colateral ulnar do polegar: emprego da miniâncura / Repair of thumb's ulnar colateral ligament: use of minianchor

Os autores apresentam resultados preliminares de estudo de viabilidade do emprego da miniâncora na reparação da lesão aguda do ligamento colateral ulnar (LCU) da articulação metacarpofalangiana do polegar ("gamekeeper", "polegar do esquiador"). Foram operados sete pacientes com tal lesão; todos apresentavam abertura > 30 graus na radiografia de estresse. Foram analisados fatores tais como idade, sexo, mecanismo de lesão, tempo decorrido até o atendimento, presença de lesão de Stener e local da avulsão ligamentar. O tempo de seguimento médio foi de oito meses; foi investigado o grau de movimentação articular e a força de pinça em relação ao outro lado, presença de dor ou instabilidade e o tempo para o retorno às atividades. São demonstrados detalhes técnicos do uso daminiâncora, comparados com a técnica do "pull-out" e com a revisão da literatura. Concluem que se trata de método simples que torna a cirurgia menos trabalhosa e proporciona boa estabilidade articular.

Tratamento cirúrgico da lesäo aguda do ligamento colateral elnal da articulaçäo metacarpofalângica do polegar / Surgical treatment of acute lesions of the ulnar collateral ligament of the metacarpophalangeal joint of the thump

Os autores avaliam os resultados de 40 pacientes com ruptura total aguda do ligamento colateral ulnal (LCU) da articulaçäo metacarpofalângica (MF) do polegar, com ou sem fratura, e que foram submetidos a cirurgia. Consideram como lesäo aguda aquelas ocorridas até duas semanas após o trauma. Com relaçäo aos tipos de lesäo, observaram ruptura ligamentar em 25 pacientes (62,5 por cento), 13 (32,5 por cento) associadas a fratura e duas (5 por cento) com fratura articular somente. Quanto a técnica cirúrgica, realizaram a ligamentorrafia simples em 29 pacientes (72,5 por cento), a ligamentorrafia associada a reduçäo e fixaçäo da fratura com fio de Kirschner em nove (22,5 por cento) e a reduçäo e fixaçäo da fratura com fio de Kirschner em dois (5 por cento). O tempo médio de imobilizaçäo foi de quatro semanas. Os resultados foram avaliados pela soma das pontuaçöes dos seguintes itens: dor, mobilidade da flexäo (MF + IF), "oponência", força ("pinça da chave"), instabilidade, satisfaçäo e retorno ao trabalho. Encontraram 36 pacientes (90 por cento) com conceito excelente, três (7,5 por cento) bom e um (2,5 por cento) mau. Tiveram complicaçöes em quatro pacientes.