Artroplastia total de codo después de un proceso infeccioso. Cirugía en dos tiempos / Total elbow arthroplasty after an infection process. Two-stage surgery

Objetivo: Comunicar los resultados en pacientes con un proceso infeccioso del codo, tratados en 2 etapas quirúrgicas: la primera con un espaciador de cemento con antibiótico y la segunda con una artroplastia total de codo. materiales y métodos: Se descri-ben los criterios de inclusión, el diagnóstico de infección y las 2 etapas quirúrgicas. Resultados: Se incluyeron 10 pacientes (4 hombres y 6 mujeres, edad promedio 62 años). Causas iniciales: degenerativas (2 casos) y traumáticas (8 casos). Se realizaron 4 aloprótesis y 2 colgajos de dorsal ancho. Se identificaron 2 grupos: A (defectos óseos <4 cm) y B (>4 cm). El seguimiento fue de 5 años. La flexo-extensión fue de 117°/29° en el preoperatorio y 130°/29° en el posoperatorio; los puntajes de dolor fueron 6,5 y 2,5 (EAV); 40 y 80 (MEPS); y 56 y 30 (DASH), respectivamente. La fuerza de extensión fue de M5 (4 casos), M4 (2 casos), M3 (1 caso), M1 (2 casos) y M0 (1 caso). Un paciente tuvo una necrosis del colgajo que evolucionó con infección y 9 no tenían infección al final del seguimiento. Los pacientes del grupo A tenían menos cirugías previas y mejores resultados funcionales. Conclusiones: El tratamiento de un proceso infeccioso de codo mediante un espaciador de cemento con antibiótico permite controlar la infección en un alto porcentaje de los casos. La reconstrucción protésica secundaria es demandante y se asocia a complicaciones. Cabe esperar que, cuanto más grande sea el defecto óseo y mayor la cantidad de procedimientos previos, los resultados funcionales sean peores. Nivel de Evidencia: IV

Objective: to report the results of patients with an infectious elbow process, treated in 2 surgical stages: the first with an antibiotic cement spacer (ACE) and the second with a total elbow arthroplasty. Material and methods: the inclusion criteria, the diagnosis of infection and the 2 surgical stages are described. Results: 10 patients were included (7 men and 3 women), average age: 62 years old. Initial causes: degenerative in 2 cases and traumatic in 8. 4 alloprostheses and 2 latissimus dorsi flaps were performed.Follow-up was 5 years. Flexo-extension was 117°/29° in preoperative and 130°/29° in postoperative; pain according to EVA: 6.5 and 2.5; MEPS: 40 and 80; DASH 56 and 30 respectively. The extension force was M5 (4 cases), M4 (2), M3 (1), M1 (2) and M0 (1). One patient presented a necrosis of the flap that evolved with infection. In 9 of the 10 cases the patients were free of infection at the end of the follow-up. Two groups of patients were identified: Group A (bone defects less than 4 cm) and B (more than 4 cm). Group A patients had fewer previous surgeries and better functional outcomes. Conclusion: the treatment of an infectious elbow process through the placement of antibiotic cement spacer, allows a control of the infection in a high percentage of cases. Secondary prosthetic reconstruction is demanding and associated with complications. It is to be expected that the greater the bone defect and the greater the number of previous procedures, result in the worse the functional results. Level of Evidence: IV

Prótesis total de codo en el contexto de una seudoartrosis de olécranon. Técnica quirúrgica y reporte de tres casos / Total elbow arthroplasty in the context of a nonunion of the olecranon. Surgical technique and report of 3 cases

La indemnidad del aparato extensor es fundamental para un correcto funcionamiento de una prótesis de codo. Se ha considerado que la deficiencia del tríceps es una contraindicación relativa para la artroplastia, porque produce una contractura en flexión y un déficit de extensión activa. Estas limitaciones pueden afectar significativamente la mejora funcional que la artroplastia total de codo produce. Ante una seudoartrosis de olécranon, la colocación de una prótesis total de codo se presenta como un problema complejo que resolver. El objetivo de este artículo es describir la técnica quirúrgica para la colocación de una prótesis total de codo en el contexto de una seudoartrosis de olécranon, y comunicar tres casos. Nivel de Evidencia: IV

The integrity of the extensor apparatus is essential for the correct functioning of an elbow prosthesis. Triceps deficiency has been considered a relative contraindication for arthroplasty, because it produces a flexion contracture and an active extension deficit. These limitations can significantly affect the functional improvement that total elbow arthroplasty produces. Faced with an olec-ranon nonunion, the placement of a total elbow prosthesis is presented as a complex problem to be solved. The objective of this article is to describe the surgical technique for the placement of a total elbow prosthesis in the context of an olecranon nonunion, and to report three cases. Level of Evidence: IV

Olecranon osteotomy vs. triceps-sparing for open reduction and internal fixation in treatment of distal humerus intercondylar fracture: a systematic review and meta-analysis / 中华医学杂志(英文版)

BACKGROUND@#The open reduction and internal fixation (ORIF) was a standard treatment approach for fracture at distal humerus intercondylar, whereas the optimal way before ORIF remains inconclusive. We, therefore, performed a systematic review and meta-analysis to assess the efficacy and safety of olecranon osteotomy vs. triceps-sparing approach for patients with distal humerus intercondylar fracture.@*METHODS@#The electronic searches were systematically performed in PubMed, EmBase, Cochrane library, and Chinese National Knowledge Infrastructure from initial inception till December 2019. The primary endpoint was the incidence of excellent/good elbow function, and the secondary endpoints included Mayo elbow performance score, duration of operation, blood loss, and complications.@*RESULTS@#Nine studies involving a total of 637 patients were selected for meta-analysis. There were no significant differences between olecranon osteotomy and triceps-sparing approach for the incidence of excellent/good elbow function (odds ratio [OR]: 1.37; 95% confidence interval [CI]: 0.69-2.75; P = 0.371), Mayo elbow performance score (weight mean difference [WMD]: 0.17; 95% CI: -2.56 to 2.89; P = 0.904), duration of operation (WMD: 4.04; 95% CI: -28.60 to 36.69; P = 0.808), blood loss (WMD: 33.61; 95% CI: -18.35 to 85.58; P = 0.205), and complications (OR: 1.93; 95% CI: 0.49-7.60; P = 0.349). Sensitivity analyses found olecranon osteotomy might be associated with higher incidence of excellent/good elbow function, longer duration of operation, greater blood loss, and higher incidence of complications as compared with triceps-sparing approach.@*CONCLUSIONS@#This study found olecranon osteotomy did not yield additional benefit on the incidence of excellent/good elbow function, while the duration of operation, blood loss, and complications in patients treated with olecranon osteotomy might be inferior than triceps-sparing approach.

Abordaje medial modificado para dislocación codo crónico: un abordaje quirúrgico novedoso con buen resultado funcional / Modified medial approach for chronic elbow dislocation: a novel surgical approach with good functional outcome

Background : Chronic elbow dislocation is defined as untreated elbow dislocation for longer than 2 weeks. Goal of treatment is stable reduction of elbow joint and facilitation of early elbow motion for optimal end result. Known operative methods is the Kocher posterolateral approach.which can accumulate hematome, and longer time needed to identify Ulnar nerve. Therefore, we would like to introduce the new modified medial elbow joint incision approach. Methodology: This study utilized a cross-sectional review of patients with surgical treatment of simple chronic elbow dislocation. Questionnaires were taken using Oxford Elbow Score, Mayo Elbow Performance Index, and Disability of Arm, Shoulder, and Hand Questionnaire to assess current elbow status Result : Utilizing Oxford elbow score, the analytic group score value ranged from 21-46, while control group's score value were 37-42 (P-value <0.0001). Mayo Elbow Performance Index score, from the analytic group, scored ranges from 45 - 82. the control group, a mean value of 85 were scored (P-value <0.0001), the DASH score revealed total mean value of 8.3 in the analytic group, compared to score 6 in the control group (P-value = 0.0468 ). The range of motion is increased in total flexion and extension from both groups(P-value <0.0001) Conclusion: Modified medial elbow approach provides faster method of identifying ulnar nerve, requires less skin flap for closure and less space for blood accumulation. Modified medial elbow approach provides good functional outcome with no complications related to ulnar nerve reported in this study.

Compartment syndrome after distal biceps brachii tendon rupture in an athlete / Síndrome compartimental em paciente atleta após ruptura do tendão distal do músculo bíceps do braço

ABSTRACT This is a case report of a previously healthy athlete who did not use oral anticoagulant, suffered a rupture of the distal biceps brachii tendon, and evolved with arm compartment syndrome. An emergency fasciotomy and the repair of the tendon were performed. After surgery the patient had a good recovery of the paresthesia and sensibility. This complication is rare and, when reported, is usually associated with patients who use anticoagulant therapy. Due to growth of rupture of distal biceps tendon cases, physicians should be aware that this complication must be treated as an emergency.

RESUMO Relato de caso de paciente atleta, previamente hígido e que não utilizava anticoagulantes orais, com lesão do tendão distal do músculo bíceps braquial, que evoluiu com síndrome compartimental do braço. Realizaram-se fasciotomia de emergência e reparo cirúrgico do tendão, apresentando bom seguimento com recuperação da parestesia e sensibilidade. Essa complicação é bastante rara e, quando relatada, geralmente é associada a pacientes em uso de medicamentos anticoagulantes orais. Contudo, com o aumento da incidência de rupturas do tendão do músculo bíceps braquial, é preciso estar atento à tal complicação que deve ser conduzida como emergência.

Clinical study of movable external fixation for elbow tuberculosis / 中国骨伤

OBJECTIVE@#To compare clinical effect of movable external fixation and fusion fixation for the treatment of elbow tuberculosis.@*METHODS@#From October 2013 to June 2019, 52 patients with elbow tuberculosis treated with standard antituberculosis therapy were divided into movable external fixation group and fusion fixation group according to treatment methods. In group A, there were 25 patients, including 11 males and 14 females, aged from 24 to 75 years old with an average of (42.81± 9.01) years old; the courses of diseases ranged from 2 to 9 months with an average of (3.96±1.45) months. In group B, there were 27 patients, including 15 males and 12 females, aged from 23 to 77 years old with an averageof (44.08±7.44) years old; the courses of diseases ranged from 2 to 7 months with an average of (3.88±1.67) months. All patients were performed focus debridement. Intraoperative blood loss, operative time were compared between two groups. VAS score before operation, 2 weeks and 12 months after operation were applied to evaluate pain relieve;Mayo elbow performance score (MEPS) before operation, 1 and 12 months after operation were used to evaluate clinical effect;changes of erythrocyte sedimentation rate (ESR) and Creactive protein, CRP) before operation, 3 weeks after antituberculosis therapy, 1 week and 6 months after operation were compared between two groups.@*RESULTS@#All patients were followed up from 12 to 20 months with an average of (13.50±4.85) months. No mixed infection and recurrence of tuberculosis occurred. There were no statistical differences in intraoperative blood loss and operative time(@*CONCLUSION@#For elbow tuberculosis, movable external fixation and fusion fixation have equal effect in operative time, amount of bleeding and control of tuberculosis infection indicator. Movable external fixation need earlier functional exercise, not conducive to pain relief at early stage, which may be better than fusion fixation, it is worth clinical promoting.

Ultrasound-guided costoclavicular block as an alternative for upper limb anesthesia in obese patients / Bloqueio costoclavicular guiado por ultrassonografia como alternativa para anestesia de membro superior em paciente obeso

Abstract Background and objectives: Costoclavicular brachial plexus block is an anesthesia performed through the infraclavicular route described in the literature as a safe and effective route for upper limb anesthesia distal to the elbow. The following report describes the case of a patient whose traditional plexus blocking techniques presented ultrasound visualization difficulty, but the costoclavicular approach was easy to visualize for anesthetic blockade. Case report: A grade 3 obese patient scheduled for repair of left elbow fracture and dislocation. Ultrasound examination revealed a distorted anatomy of the supraclavicular region and the axillary region with skin lesions, which made it impossible to perform the blockade in these regions. It was decided to perform an infraclavicular plexus block at the costoclavicular space, where the brachial plexus structures are more superficial and closer together, supported by a muscular structure, lateral to all adjacent vascular structures and with full view of the pleura. The anesthetic block was effective to perform the procedure with a single injection and uneventfully. Conclusion: Costoclavicular brachial plexus block is a good alternative for upper limb anesthesia distal to the elbow, being a safe and effective option for patients who are obese or have other limitations to the use of other upper limb blocking techniques.

Resumo Justificativa e objetivos: O bloqueio de plexo braquial via costoclavicular é uma anestesia feita por via infraclavicular, já descrita na literatura como uma via segura e efetiva para anestesia de membro superior distal ao cotovelo. O relato a seguir trata de um paciente em que as técnicas tradicionais para bloqueio de plexo apresentavam dificuldade de visibilização à ultrassonografia, já a via costoclavicular foi de fácil visibilização para execução do bloqueio anestésico. Relato de caso: Paciente com obesidade grau 3 a ser submetido a correção de fratura e luxação de cotovelo esquerdo apresentava anatomia da região supraclavicular distorcida à avaliação ultrassonográfica e região axilar com lesões de pele, que impossibilitavam o bloqueio nessas regiões. Optou-se por fazer o bloqueio de plexo via infraclavicular no espaço costoclavicular, região onde as estruturas do plexo braquial estão mais superficiais e unidas, amparadas por uma estrutura muscular, laterais a todas as estruturas vasculares adjacentes e com a visibilização plena da pleura. O bloqueio anestésico foi efetivo para a realização do procedimento sob punção única em pele e sem intercorrências. Conclusão: O bloqueio de plexo braquial via costoclavicular é uma boa opção para anestesia de membro superior distal ao cotovelo, é uma opção segura e efetiva para pacientes obesos ou que tenham outras limitações à aplicação de outras técnicas de bloqueio de membro superior.

An anterior neurovascular interval approach to coronal shear fractures of the distal humerus: a prospective clinical study with short- to mid-term follow-up

SUMMARY OBJECT: To explore the treatment effect of the anterior medial neurovascular interval approach to coronal shear fractures of the distal humerus. METHODS: This prospective study included two female patients who were 30-64 years old, with a mean age of 47 years. Fractures were caused by falling from a bicycle. The time between the injury and operation was 1-2 days, with a mean time interval of 1.5 days. Two patients with coronal shear fracture of the distal humerus were treated with open reduction and internal fixation using anterior neurovascular interval approach. RESULTS: There were no intraoperative and postoperative neurological and vascular complications or infections, and the fracture was united. At 12 months after the surgery, the patient returned to work without pain, and with a normal range of motion for elbow and forearm rotation. The X-rays revealed excellent fracture union, no signs of heterotopic ossification, and no traumatic arthritis. According to Mayo's evaluation standards for elbow function, a score of 100 is excellent. CONCLUSIONS: The application of the anterior neurovascular interval approach of the elbow in the treatment of shear fracture of the articular surface of the distal humerus, particularly the trochlea of the humerus, can reduce the stripping of the soft tissue.

RESUMO OBJETIVO: Explorar o efeito do tratamento com uma abordagem anterior do intervalo neurovascular médio para fraturas de cisalhamento coronal da porção distal do úmero. METODOLOGIA: Este estudo prospectivo incluiu duas pacientes do sexo feminino de 30-64 anos de idade, com idade média de 47 anos. As fraturas foram causadas por quedas de bicicleta. O tempo entre a lesão e a operação foi de 1-2 dias, com um intervalo de tempo médio de 1,5 dias. Duas pacientes com cisalhamento coronal da porção distal do úmero foram tratadas com redução aberta e fixação interna utilizando a abordagem anterior do intervalo neurovascular. RESULTADOS: Não houve complicações neurológicas e vasculares intra e pós-operatórias, nem complicações ou infecções, e a fratura foi unida. Após 12 meses da cirurgia, as pacientes retornaram ao trabalho sem dor e com uma amplitude normal de movimento de rotação do antebraço e cotovelo. Os raios-X revelaram excelente união das fraturas, sem sinais de ossificação heterotópica e sem artrite traumática. De acordo com as diretrizes da clínica Mayo para avaliação da função do cotovelo, uma pontuação de 100 é considerada excelente. CONCLUSÃO: A aplicação da abordagem anterior do intervalo neurovascular do cotovelo no tratamento de uma fratura de cisalhamento da superfície articular da porção distal do úmero, especificamente da tróclea do úmero, pode reduzir o desgaste do tecido mole.

Luxación de codo asociada a fractura de cóndilo externo y cabeza del radio: Presentación de un caso y revisión bibliográfica / Elbow luxation associated with external condyle and radial head fracture. Case report and literature review

Se presenta el caso atípico de una luxación compleja de codo, en un adulto, asociada a fractura de la cabeza del radio y de cóndilo humeral externo. Se efectuó una reducción cerrada de la luxación y el posterior tratamiento quirúrgico con reducción abierta y fijación interna de la fractura de cóndilo externo. Se obtuvo un codo estable que, luego de la rehabilitación, logró una buena movilidad y el paciente se reintegró al trabajo rápidamente. Nivel de Evidencia: IV

We report the unusual case of a complex elbow dislocation in an adult associated with radial head and external humeral condyle fracture. Closed reduction of dislocation and subsequent surgical treatment were performed with open reduction and internal fixation of lateral condyle fracture. A stable elbow after rehabilitation was achieved showing a good range of motion and the patient returned to work rapidly. Level of Evidence: IV

Luxación bilateral del vientre medial del tríceps (snapping triceps) asociada a luxación del nervio cubital. presentación de un caso / Bilateral dislocation of the medial fold of the triceps tendon (snapping triceps) with ulnar nerve dislocation. a case report

Snapping triceps es la luxación del vientre medial del tríceps por encima de la epitróclea, asociada o no a la luxación del nervio cubital. En algunos casos publicados, los pacientes eran intervenidos por luxación del nervio cubital y, durante la cirugía, se diagnosticaba la luxación del vientre medial del tríceps, incluso algunos pacientes eran operados en varias oportunidades. Presentamos un paciente de 16 años que refiere un resalto en la región medial de ambos codos. En el examen físico, es evidente un doble resalto tanto del nervio cubital, como del vientre medial del tríceps. Estos hallazgos se confirman por ecografía comparativa bilateral. El tratamiento quirúrgico consistió en la transposición cubital transmuscular y la resección del vientre medial del tríceps que se luxaba anterior a la epitróclea. Los dos codos fueron operados con diferencia de un mes. El paciente tuvo una excelente evolución sin complicaciones a los dos meses de las operaciones. Esta patología poco frecuente debe ser considerada con atención, ya que puede llevar a errores de diagnóstico y de tratamiento. Nivel de Evidencia: IV.

Snapping triceps is the dislocation of the medial triceps belly above the medial epicondyle, with or without the ulnar nerve. In some cases described in the literature, patients were operated on by ulnar nerve dislocation and dislocation of the medial triceps belly was diagnosed during surgery; some patients were even operated on several occasions. We report the case of a 16-year-old patient with a snap in the medial region of both elbows. Physical examination reveals a clear doublé click of the ulnar nerve and the medial triceps belly. These findings are confirmed by bilateral comparative ultrasound. Surgical treatment consisted of transmuscular ulnar transposition and resection of dislocated medial triceps belly. Both elbows were operated on one month apart. Two months after surgeries, the patient achieved an excellent outcome without complications. This rare condition must be carefully considered since it may lead to diagnostic and therapeutic errors. Level of Evidence: IV.

Bloqueo articular de codo por condromatosis sinovial: reporte de caso y revisión de literatura / Articular block of synovial chondromatosis of the elbow: case report and literature review

Introducción: La condromatosis sinovial es una patología benigna, infrecuente, de etiología desconocida en la que se desarrollauna metaplasia cartilaginosa del tejido sinovial. Se caracteriza por la formación de nódulos que son liberados en la cavidadarticular. El tratamiento consiste en la extracción de los cuerpos libres intraarticulares, preferentemente por vía artroscópica.Objetivo: reportar un caso de condromatosis sinovial de codo con bloqueo articular al que se le realizó extracción artroscópicade los cuerpos libres intraarticulares. Conjuntamente se efectuó una revisión bibliográfica de dicha infrecuente patología.Reporte de caso: Paciente masculino que presenta dolor, tumefacción, crepitación y limitación del rango de movimientoen flexo-extensión. En la radiografía se observan múltiples imágenes nodulares calcificadas en la cámara anterior yposterior del codo. En RMN y TAC se evidencian dichos nódulos depositados en las fosas olecraneana y coronoidea,asociados con cambios degenerativosarticulares. Se realiza extracción de los cuerpos libres intraarticulares ycapsulectomía parcial por vía artroscópica. Se confirma el diagnóstico de condromatosis sinovial por histopatología. En elpostoperatorio el paciente mejoró la sintomatología y aumentó el rango de flexo-extensión...

Introduction: Synovial chondromatosis is an infrequent, benign pathology of unknown etiology in which a cartilaginous metaplasia of synovial tissue develops. It is characterized by the formation of nodules that are released into the joint cavity. Treatment involves removal of intra-articular loose bodies, preferably arthroscopically. Objective: To report a case of synovial chondromatosis elbow joint to lock who underwent arthroscopic removal of intra-articular loose bodies. Together a literature review of this rare entity was made. Case report: Male patient has pain, swelling, crepitus and limitation of range of motion in flexion and extension. Multiple nodular radiographic images calcified in the anterior and posterior chamber elbow observed. MRI and CT in these nodules deposited in the olecranon and coronoid pits associated with degenerative articular changes are evident. Removal of intra-articular loose bodies and partial capsulectomy is performed arthroscopically. The diagnosis of synovial chondromatosis confirmed by histopathology. Postoperatively the patient improved symptoms and increased the range of flexion and extension...

Inestabilidad posterolateral cronica de codo. reconstruccion ligamentaria / Chronic posterolateral elbow instability. ligament reconstruction

Introducción: El objetivo de este trabajo es evaluar los resultados de una serie de pacientes con inestabilidad posterolateral crónica de codo, tratados con reconstrucción del ligamento colateral cubital con injerto tendinoso. Materiales y Métodos: Se presentan 10 pacientes, con una edad promedio de 47 años. El tiempo entre la luxación y la cirugía fue de 16 meses. El pivot shift test bajo anestesia fue positivo en todos los casos. Bajo control radioscópico, siete pacientes tenían un estadio 1 de Horii; dos, estadio 3 y uno tenía un estadio 2. En la mayoría de los casos, se utilizó el tendón del palmar menor. El seguimiento promedio fue de 21 meses. Resultados: La flexo-extensión fue de 126-3º. El dolor fue 0 en reposo y 1 en actividad, según la escala analógica visual. El puntaje DASH promedio fue 12 y el de la Clínica Mayo de 95. Ningún paciente reportó sensación de inestabilidad. El pivot shift test con el paciente despierto fue negativo en todos los casos. Conclusiones: La reconstrucción del ligamento lateral del codo con injerto tendinoso en pacientes con inestabilidad posterolateral crónica es eficaz para lograr la estabilidad articular. Los mejores resultados se observaron en pacientes con estadios 1 y 2 de inestabilidad. No hubo casos de inestabilidad residual.

Introduction: The objective of this paper is to evaluate the results of a series of patients with posterolateral elbow instability treated with reconstruction of the ulnar collateral ligament using tendon graft. Methods: We reported 10 patients with a mean age of 47 years. Time from posterolateral dislocation to surgery was 16 months. The pivot shift test under anesthesia was positive in all patients. Seven patients had stage 1 instability according to Horii, one patient with stage 2 and two patients with stage 3 under fluoroscopy. Palmaris minor was the most common tendon used for reconstruction. Follow-up was 21 months. Results: Flexo-extension was 126-3º. Pain according to visual analogue scale was 0 at rest and 1 in activity. DASH score was 12 and Mayo Clinic score was 95. Sensation of instability was not reported by any patient. The pivot shift test in an awake patient was always negative. Conclusions: Ulnar collateral ligament reconstruction with tendon graft in patients with posterolateral elbow instability is useful to restore joint stability. Best results were observed in patients with stage 1 or 2 instability according to Horii. Residual instability was not observed.

Artroplastía total de codo para el tratamiento de fracturas de húmero distal en pacientes mayores de 65 años / Total elbow arthroplasty for distal humerus fractures in patients older than 65 years old

Objetivo: Comunicar los resultados clínico-radiológicos del tratamiento de las fracturas de húmero distal con prótesis total de codo en pacientes >65 años. Materiales y Métodos: Estudio retrospectivo en dos centros quirúrgicos. Criterios de inclusión: pacientes con fractura de húmero distal, >65 años, operados con prótesis total de Coonrad-Morrey y seguimiento >1 año. Se incluyeron 21 pacientes (20 mujeres), edad promedio: 79 años. Según la clasificación AO, 13 C3, siete C2 y una A2. Todos fueron operados sin desinserción del aparato extensor. Seguimiento promedio: 40 meses. Resultados: La flexo-extensión fue de 123-17°, arco de movilidad de 106° (80% con respecto al lado sano). Dolor según la escala analógica visual: 1 punto. El puntaje de la Clínica Mayo promedio fue 83: resultado excelente (8 pacientes), bueno (11 pacientes), regular (1 caso) y malo (1 caso). El puntaje DASH promedio fue de 24. No hubo aflojamientos en 13 pacientes. Se produjeron nueve complicaciones: dos pacientes fueron operados nuevamente por desgaste del polietileno, uno operado otra vez al mes de la cirugía para la recolocación del perno de ensamble, dos parestesias del nervio cubital, una falsa vía intraoperatoria, un hematoma de la herida que necesitó de un colgajo braquial y dos aflojamientos protésicos. Conclusiones: El tratamiento de las fracturas de húmero distal con prótesis total de codo en pacientes >65 años puede ofrecer una opción terapéutica razonable, pero las indicaciones deben limitarse a fracturas complejas donde la fijación interna puede ser precaria, en pacientes con osteoporosis y con baja demanda funcional.

Objective: To report the clinical-functional results of humeral distal fracture treatment with total elbow prosthesis in patients older than 65 years. Methods: Retrospective study performed in two surgical centers. Inclusion criteria: patients with humeral distal fractures, >65 years, operated on with Coonrad-Morrey prostheses, and with a follow-up >1 year. Twenty-one patients were included (20 women) with an average age of 79 years. According to AO classification: 13 type C3 fractures, 7 C2 and 1 A2. All patients were operated on without disinsertion of the extensor mechanism. Average follow-up: 40 months. Results: Flexion-extension: 123-17°, with a total arc of mobility of 106° (80% of the contralateral side). Pain according to visual analogue scale was 1. The Mayo Clinic score was 83 points, results were excellent (8 patients), good (11 patients), regular (one case) and bad (one case). Average DASH score was 24 points. No loosening of the implants was evidenced in 13 patients. Nine complications were reported: 2 reoperations for polyethylene wear, one early decoupling of the prosthesis, 2 ulnar nerve paresthesia, one patient presented a false intraoperative via, one hematoma that needed a local flap and 2 loosening of the prosthesis. Conclusions: Treatment of humeral distal fractures with total elbow arthroplasty in patients older than 65 years may be a good therapeutic option, but indications must be limited to patients with complex fractures, bad bone quality, with osteoporosis and low functional demands.

Liberación artroscópica con bisturí para el tratamiento de la epicondilitis recalcitrante / Arthroscopic release for recalcitrant epicondylitis

La epicondilitis es una frecuente causa de dolor e incapacidad funcional del codo. Suele deberse a la repetición de determinados gestos tanto deportivos como laborales. La amplia mayoría de los casos resuelven a través de tratamientos no quirúrgicos. El tratamiento quirúrgico de la epicondilitis recalcitrante a demostrado resultados satisfactorios tanto por las vías abierta, artroscópica como percutánea, sin que exista aún consenso sobre la mejor terapéutica quirúrgica para la patología. La presente nota técnica describe el procedimiento artroscópico de tenotomía del segundo radial externo y capsulotomía lateral del codo, ambas con bisturí, en un paciente con epicondilitis recalcitrante. Nivel de evidencia: V...

Lateral epicondylitis is a common cause of pain and functional impairment of the elbow. Usually is due to the repetition not only of certain sporting gestures but also of repetitive working activities. The vast majority of cases resolve through nonsurgical treatments. The surgical treatment of recalcitrant lateral epicondylitis has shown satisfactory results through open, percutaneous and arthroscopic procedures, with no consensus on the best surgical therapy for the disease yet. This technical note describes the arthroscopic procedure of tenotomy of the extensor carpi radials brevis and lateral capsulotomy of the elbow both using scalpel blade in a patient with recalcitrant epicondylitis. Level of Evidence: V...

Hemiartroplastía de cúpula radial en pacientes con fractura tipo III y IV según Mason Johnston / Hemiarthroplasty of the radial head in patients with Mason Johnston types III and IV fracture

Introducción: La cabeza radial es un estabilizador primario e importante del codo mayormente para la estabilidad en valgo, desplazamiento postero-lateral, axial del radio y carga en varo. Las fracturas de cabeza radial representan de 1.7 al 5% de todas las fracturas en adultos, de 17 al 19% en los traumas de codo y 33% de todas las fracturas del codo, siendo ésta la más común a este nivel. Para una fractura de cabeza radial que no se puede reconstruir, las opciones de tratamiento son excisión de la cabeza radial o hemiartroplastía. Objetivo: Evaluar la funcionalidad de los pacientes con hemiartroplastía de cúpula radial por fracturas tipo III y IV según Mason-Johnston, por medio de las escalas de Índice de Mayo de desempeño del codo (Mayo Elbow Performance Índex (IMDC)) y Quick-Dash (QD). Material y métodos: Se realizó un estudio, observacional, transversal y ambiespectivo, en el Servicio de Miembro Torácico del Hospital de Traumatología y Ortopedia "Lomas Verdes", en un período de un año, se incluyeron pacientes de 18 a 60 años de edad, con diagnóstico de fractura de cúpula radial tipo III y IV según Mason-Johnston manejados con hemiartroplastía de cúpula radial. Resultados: Fueron incluidos siete pacientes, de los cuales 3 fueron del sexo femenino (42.9%) y 4 fueron del sexo masculino (57.1%). De la clasificación de funcionalidad IMDC se obtuvieron los siguientes resultados. Excelente, 6 pacientes (85.7%); Bueno, 1 paciente (14.3%). La escala de funcionalidad y sintomatología de QD se obtuvieron seis pacientes con puntuación de 0 a 5 y un paciente con puntuación de más de 10. Conclusiones: El tratamiento quirúrgico consistente en hemiartroplastía de cúpula radial por fracturas tipo III y IV según Mason-Johnston es un buen tratamiento quirúrgico a corto plazo, debido a que nos ofrece una funcionalidad de excelente a buena, estabilidad en valgo y varo del codo, así como sintomatología mínima del codo.

Introduction: The radial head is a primary and important stabilizer of the elbow, mainly for valgus stability, posterolateral and axial displacement of the radius and varus loading. Radial head fractures account for 1.7-5% of all fractures in adults, 17-19% of elbow trauma, and 33% of all elbow fractures. The latter is the most common one at this level. The alternatives for a radial head fracture that cannot be reconstructed include excision of the radial head or hemiarthroplasty. Objective: To assess the function of patients who underwent radial head hemiarthroplasty for Mason-Johnston types III and IV fractures, using the Mayo Elbow Performance Index (MEPI) and Quick-Dash (QD). Material and methods: A one-year long observational, cross-sectional and ambispective study was conducted at the Thoracic Limb Service, "Lomas Verdes" Orthopedics and Traumatology Hospital. The patients included were ages 18 to 60 years, had a diagnosis of Mason-Johnston types III and IV radial head fractures and were treated with radial head hemiarthroplasty. Results: A total of seven patients were included, 3 females (42.9%) and 4 males (57.1%). The results of elbow function according to the MEPI were as follows: Excellent, 6 patients (85.7%); Good, one patient (14.3%). The results of the QD functionality and symptoms scale were: 6 patients had a score of 0-5, and one patient more than 10. Conclusions: Surgical treatment consisting of radial head hemiarthroplasty for Mason-Johnston types III and IV fractures yields good short-term results, because it provides excellent to good function, valgus and varus elbow stability, and minimum elbow symptoms.

Accuracy of mucocutaneous leishmaniasis diagnosis using polymerase chain reaction: systematic literature review and meta-analysis

The diagnosis of mucocutaneous leishmaniasis (MCL) is hampered by the absence of a gold standard. An accurate diagnosis is essential because of the high toxicity of the medications for the disease. This study aimed to assess the ability of polymerase chain reaction (PCR) to identify MCL and to compare these results with clinical research recently published by the authors. A systematic literature review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA Statement was performed using comprehensive search criteria and communication with the authors. A meta-analysis considering the estimates of the univariate and bivariate models was performed. Specificity near 100% was common among the papers. The primary reason for accuracy differences was sensitivity. The meta-analysis, which was only possible for PCR samples of lesion fragments, revealed a sensitivity of 71% [95% confidence interval (CI) = 0.59; 0.81] and a specificity of 93% (95% CI = 0.83; 0.98) in the bivariate model. The search for measures that could increase the sensitivity of PCR should be encouraged. The quality of the collected material and the optimisation of the amplification of genetic material should be prioritised.

Prótesis de cúpula monopolar en el tratamiento de fracturas y luxofracturas del radio / Monopolar radial head arthroplasty in the treatment of fracture and fracture-dislocation of the radius

Objetivo: Evaluar retrospectivamente los resultados clínicos y radiológicos de una serie consecutiva de pacientes con fracturas y luxofracturas de la cúpula radial a quienes se les realizó el reemplazo por una prótesis monopolar. Materiales y Métodos: Se incluyeron 20 pacientes. Criterios de inclusión: <18 años, con fracturas o luxofracturas de la cúpula radial, tratados con prótesis monoblock de titanio y seguimiento mínimo de un año. Quince eran mujeres, edad promedio 59 años. Siete eran fracturas aisladas y 13, luxofracturas. Se evaluaron el grado de aflojamiento protésico, la erosión capitelar, el ensanchamiento del espacio articular humeral lateral y las calcificaciones heterotópicas. El seguimiento fue de 26 meses. Resultados: La flexo-extensión fue de 139º-5º y la pronosupinación, de 79-79°. El arco total fue de 134°. Fuerza de puño: 84% del lado contralateral. El dolor según la escala analógica visual fue de 2, DASH: 11 puntos, 13 resultados excelentes y 6 buenos. Se detectó aflojamiento del implante (12 casos), aumento de la radiolucidez capitelar (4 casos) y ensanchamiento del espacio ulnohumeral lateral (2 casos). Hubo 2 complicaciones: una neurodocitis cubital que debió ser operada y una extracción de implante por aflojamiento y dolor. Conclusiones: El reemplazo de la cúpula radial en lesiones no reconstruibles es una opción terapéutica viable, con buenos resultados funcionales a corto y mediano plazo. La recuperación de la estabilidad articular fue posible en todos los casos y el índice de aflojamiento protésico asintomático fue elevado.

Objective: To retrospectively evaluate the clinical and radiological results of a consecutive series of patients with fracture and fracture-dislocations of the radius, treated with a monopolar radial head arthroplasty. Methods: Twenty patients were included. Inclusion criteria: <18 years old, with fracture and fracture-dislocations of the radius, treated with a titanium monopolar radial head arthroplasty and a minimun follow-up of one year. Fifteen were female, average age of 59 years old. Seven were isolated radial head fractures and 13 were fracturedislocations. Loosening of the implant, capitelar erosion, overstuffing and heterotopic ossification were evaluated. Average follow-up was 26 months. Results: Flexo-extension was 139°-5° and prono-supination 79°-79°. Total arc of motion was 134°. Grip strength was 84% of the contralateral side. Pain according to a visual analogue scale was 2, DASH: 11 points. Thirteen patients had excellent results and 6 good. Loosening of the implant (12 patients), capitelar erosion (4 patients) and overstuffing (2 patients) were detected. One patient had an ulnar neuropathy and he was operated on and one patient required implant removal due to loosening and pain. Conclusions: The replacement of the radial head in a non-reconstructable fracture is a feasible treatment option, with good functional results in a short and medium term. Joint stability was restored in all cases and the index of asymptomatic implant loosening was elevated.

Análise comparativa da força muscular entre pacientes tenotomizados artroscopicamente da cabeça longa do bíceps com relação à deformidade estética / Comparative analysis on muscle strength among patients who underwent arthroscopic tenotomy of the long head of the biceps in relation to esthetic deformity

OBJETIVO: Determinar se há discrepância na força de flexão do cotovelo entre pacientes com (CD) e sem a deformidade clínica (SD) evidente resultante da tenotomia artroscópica da cabeça longa do bíceps (TACLB). MÉTODOS: Foi analisado um grupo de 120 pacientes submetidos à TACLB, que após os critérios de exclusão, resultaram em 89. Foi avaliada, com uma mediana de 18 meses de pós-operatório, a força de flexão do cotovelo em Newton (N) por meio de um dinamômetro digital. Foram realizadas três medidas consecutivas e considerada a média comparando o lado dominante com o não dominante. Foram estudados: sexo, idade, média da força de flexão do cotovelo no MS operado e do MS contralateral de pacientes com e sem a deformidade clínica aparente. RESULTADOS: Foi comparada a força de flexão do cotovelo no grupo CD e verificada uma mediana 17,78N para o membro superior dominante e uma mediana 20,87N para o membro superior não dominante. A diferença foi de 2,51N. No grupo SD a diferença foi de 2,14N. Foi verificada uma mediana de força muscular dos MS operados de 17,26N, enquanto os MS não operados tiveram uma mediana de 20,06N sugerindo perda de força muscular significativa (p = 0,005). A diferença entre a perda de força muscular entre os pacientes com e sem deformidade evidente não foi considerada estatisticamente significativa (p = 0,977). CONCLUSÃO: Os pacientes submetidos à TACLB com ou sem deformidade clínica aparente de sua migração distal apresentam força muscular de flexão do cotovelo semelhantes.

OBJECTIVE: To determine whether there was any discrepancy in elbow flexion strength among patients with and without evident clinical deformity resulting from arthroscopic tenotomy on the long head of the biceps. METHOD: A group of 120 patients who underwent this procedure were evaluated. After applying the exclusion criteria, 89 patients remained in the analysis. Eighteen months after the operation (median), the elbow flexion strength was measured in newtons using a digital dynamometer. Three consecutive measurements were made and the average was used. The dominant and non-dominant sides were compared. Sex, age and mean elbow flexion strength in the operated and contralateral arms of patients with and without apparent clinical deformity were evaluated. RESULTS: The median elbow flexion strength among the patients with evident clinical deformity was 17.78 N for the dominant arm and 20.87 N for the non-dominant arm. The difference was 2.51 N. In the group without evident clinical deformity, the difference was 2.14 N. The median muscle strength in the operated arm was 17.26 N, while the median was 20.06 N in the non-operated arm, thus suggesting that there was a significant loss of muscle strength (p = 0.005). The difference in muscle strength loss between the patients with and without evident deformity was not considered statistically significant (p = 0.977). CONCLUSION: The patients who underwent arthroscopic tenotomy on the long head of the biceps with or without apparent clinical deformity from distal migration presented similar elbow flexion muscle strength.

Epicondilitis lateral: la liberación del nervio radial debe ser parte del tratamiento / Lateral epicondylitis: radial nerve release must be part of the treatment

Resumen: El nervio interóseo posterior (NIP) ha sido implicado en la fisiopatología de las epicondilalgias laterales. Existe suficiente evidencia anatómica para relacionar al compromiso del mismo con las epicondilitis lateral. El propósito de nuestro estudio es evaluar los resultados obtenidos al combinar la tenotomía y desinsersión del tendón conjunto con la liberación del IP utilizando la misma vía de abordaje en pacientes con diagnóstico de epicondilitis lateral rebelde al tratamiento médico. Materiales y métodos: Entre los años 1994 y 2005, 127 casos de epicondilitis lateral fueron operados. Ochenta y cinco codos en 82 pacientes fueron incluidos en este estudio retrospectivo. En todos los casos se realizó el mismo tratamiento quirúrgico. Los resultados fueron evaluados con el Mayo Elbows Performance Score. Una evaluación subjetiva de satisfacción fue realizada al final del seguimiento. Los datos estadísticos fueron evaluados con el test de Student. Resultados: El tiempo medio de seguimiento fue de 5,1 años. 70 pacientes presentaron excelentes y buenos resultados. Los pacientes se re insertaron a sus actividades previas en un promedio de 15,2 semanas. La evolución del dolor mostro valores preoperatorios de 2,79 y postoperatorios de 0,97. 12 casos tuvieron complicaciones de las cuales 8 evolucionaron favorablemente. 8 casos presentaron una recidiva y 6 fueron re-operados. La escala subjetiva de satisfacción presento un valor promedio de 3,3, para un máximo de 4. Conclusión: Compararando nuestra experiencia con los resultados publicados, encontramos que la exploración del nervio interóseo posterior realizada de rutina no aumenta la morbilidad del procedimiento, pero tampoco mejora los resultados

Protocolo de tratamiento para la tríada terrible del codo / Treatment protocol for the terrible triad of the elbow

Introducción: La asociación de la luxación del codo con la fractura de la cúpula radial y de la apófisis coronoides se denomina la “tríada terrible del codo” debido a las dificultades en su tratamiento y a sus pobres resultados. Objetivos: Evaluar los resultados de los pacientes con la tríada terrible del codo y describir el protocolo de tratamiento. Materiales y métodos: Se incluyeron 15 pacientes (12 eran mujeres) en los que se había tratado quirúrgicamente la coronoides, la cúpula radial y el ligamento lateral. Edad promedio: 57 años. El protocolo de tratamiento consistió en: restaurar la estabilidad de la coronoides, la cúpula radial y el ligamento lateral; reparar el ligamento medial en caso de inestabilidad residual; inmovilizar durante 2 semanas. El dolor se evaluó según la EVA, y los resultados funcionales, según el DASH y el puntaje de la Clínica Mayo. El seguimiento fue de 34 meses. Resultados: La flexión-extensión fue de 139°-11º (arco total 128°). El dolor fue de 2, el DASH de 12. Siete resultados fueron excelentes y 8 buenos. Complicaciones: una seudoartrosis de la cúpula, una neurodocitis cubital, una rigidez y una inestabilidad en valgo. Conclusiones: La aplicación de un correcto protocolo de tratamiento puede favorecer los resultados. Las complicaciones son esperables.