Reconstrucción artroscópica de la seudoartrosis inestable del escafoides carpiano / Arthroscopic reconstruction for unstable scaphoid non-union

Objetivo. Evaluar los resultados de la reconstrucción artroscópica para el tratamiento de la seudoartrosis de escafoides inestable con autoinjerto de hueso esponjoso. Método. Se trató a 13 pacientes con una edad media de 26 (18-45) años. El tiempo medio desde la fractura hasta la intervención fue de 14 (6-48) meses. Se evaluaron parámetros clínicos y radiológicos preoperatorios y postoperatorios. El seguimiento medio fue de 16,8 (12-36) meses. Resultados. La consolidación se obtuvo en todos los casos a las 7 (4-10 semanas), ningún paciente presentó complicaciones ni precisó nuevas reintervenciones. El arco de movilidad, la dolor, la valoración funcional (cuestionario DASH) y las mediciones radiológicas mejoraron respecto al preoperatorio. El rango de movimiento promedio de flexión mejoró de 71,9° (55°-80°) a 81,7° (55°-90°), extensión de 66,3° (30°-80°) a 84,4° (70°-90°), desviación ulnar 21,5° (10°-25°) a 25,5° (20°-45°) y desviación radial 11,9° (5°-25°) a 13,3° (10°-20°). El dolor (EVA 0-10) mejoró de 6,8 (4-10) a 0,7 (0-3). Y la escala funcional DASH mejoró de 36 (12-78) a 8 (0-10). El ángulo escafolunar mejoró de 67,7° (62°-88°) a 47° (32°-55°) y el ángulo radiolunar mejoró de 30,8° (10°-45°) a 4° (0°-10°). Conclusión. El tratamiento de seudoartrosis de escafoides inestables con injerto esponjoso asistido por artroscopia presenta buenos resultados clínicos, con un corto tiempo de consolidación y recuperación (AU)

Objective. To evaluate the results of arthroscopic reconstruction for the treatment of unstable scaphoid non-union with cancellous bone autograft. Methods. 13 patients were treated with a mean age of 26 (18-45) years. The average time from injury until surgery was 14 (6-48) months. Preoperative and postoperative clinical and radiological parameters were evaluated. Mean follow-up was 16.8 (12-36) months. Results. Consolidation was achieved in all cases at 7 (4-10 weeks), no patient had complications or reoperations. Range of motion, pain, functional assessment (DASH questionnaire) and radiological measurements improved compared to preoperative measurements. The average range of flexion improved: flexion 71.9° (55°-80°) to 81.7° (55°-90°), extension 66.3° (30°-80°) to 84.4° (70° -90°), ulnar deviation 21.5 (10°-25°) to 25.5° (20°-45°) and radial deviation 11.9° (5°-25°) to 13.3° (10th-20th). Pain (VAS 0-10) improved from 6.8 (4-10) to 0.7 (0-3). DASH functional scale improved from 36 (12-78) to 8 (0-10). The Scapho-Lunate Angle improved from 67.7° (62°-88°) to 47° (32°-55°), and the Radio-Lunate Angle improved from 30.8° (10° -45°) to 4(0°-10°). Conclusion. Treatment of unstable scaphoid non-union with cancellous bone graft assisted by arthroscopy presents good clinical results with a short period of consolidation and recovery (AU)

Arthroscopic reconstruction for unstable scaphoid non-union. / Reconstrucción artroscópica de la seudoartrosis inestable del escafoides carpiano.

OBJECTIVE: To evaluate the results of arthroscopic reconstruction for the treatment of unstable scaphoid non-union with cancellous bone autograft. METHODS: 13 patients were treated with a mean age of 26 (18-45) years. The average time from injury until surgery was 14 (6-48) months. Preoperative and postoperative clinical and radiological parameters were evaluated. Mean follow-up was 16.8 (12-36) months. RESULTS: Consolidation was achieved in all cases at 7 (4-10 weeks), no patient had complications or reoperations. Range of motion, pain, functional assessment (DASH questionnaire) and radiological measurements improved compared to preoperative measurements. The average range of flexion improved: flexion 71.9° (55°-80°) to 81.7° (55°-90°), extension 66.3° (30°-80°) to 84.4° (70° -90°), ulnar deviation 21.5 (10°-25°) to 25.5° (20°-45°) and radial deviation 11.9° (5°-25°) to 13.3° (10th-20th). Pain (VAS 0-10) improved from 6.8 (4-10) to 0.7 (0-3). DASH functional scale improved from 36 (12-78) to 8 (0-10). The Scapho-Lunate Angle improved from 67.7° (62°-88°) to 47° (32°-55°), and the Radio-Lunate Angle improved from 30.8° (10° -45°) to 4(0°-10°). CONCLUSION: Treatment of unstable scaphoid non-union with cancellous bone graft assisted by arthroscopy presents good clinical results with a short period of consolidation and recovery.

[Radiocarpal dislocation after a trivial injury]. / Luxación radiocarpiana tras traumatismo banal.

Radiocarpal dislocation is an extremely uncommon injury in Traumatology, and is usually produced by high energy trauma. There are two types of dislocation, type I: pure radiocarpal dislocation and type II: fracture-dislocation. The gold standard treatment according to the literature is surgical treatment fixing the fractures and repairing the injured ligaments. We report a clinical case of radiocarpal dislocation type I in a healthy 19 year-old male after a minor trauma. The dislocation was reduced by traction, and the wrist immobilized in a plaster cast. The functional outcome 12 months after the injury was excellent.

Actualización en el manejo terapéutico del fenómeno de Raynaud / Update on the therapeutic management of raynaud´s Phenomenon

El fenómeno de Raynaud es un proceso vasoespástico que afecta típicamente a las partes acras de las extremidades en respuesta al frío o a estímulos mecánicos o emocionales. Este fenómeno se clasifica como primario cuando no se evidencia una causa subyacente, y secundario cuando existe una entidad patológica asociada. Esta distinción es importante pues condiciona el pronóstico, la gravedad y el tratamiento. Fisiológicamente, el equilibrio vasomotor se mantiene por complejas interacciones entre el endotelio, músculo liso y el sistema nervio autónomo que inerva los vasos. En esta revisión se analizan los mecanismos implicados en su desregulación, así como las diversas aproximaciones terapéuticas de acuerdo con la evidencia médica más reciente (AU)

Raynaud´s phenomenon is a vasospactic process that typically affects the acral parts of the limbs in response to cold or emotional or mechanical stimuli. This phenomenon is classified as primary when no evidence of an underlying cause, and secondary when there is an associated pathological entity. This distinction is important because it determines the prognosis, severity and treatment. Physiologically, the vasomotor balance is maintained by complex interactions between endothelium, smooth muscle and autonomic nervous system innervates the vessels. This review discusses the mechanisms involved in deregulation, and the various therapeutic approaches according the latest medical evidence (AU)

[Renal colic and lithiasis in HIV(+)-patients treated with protease inhibitors]. / Cólico renal y litiasis en pacientes HIV (+) tratados con inhibidores de proteasas.

INTRODUCTION: Protease inhibitors, mainly Indinavir, are widely used drugs for the treatment of patients infected by the human immunodeficiency virus (HIV) and are related to renal colic and urinary obstruction. These conditions are the result of urine excretion of these drugs which favours the formation of small calculi (crystalluria and lithiasis). MATERIAL AND METHODS: Five PI treated HIV(+) patients; four males, one female, have recently been seen for renal colic at the Lithiasis Unit, Fundación Jiménez Díaz (FJD). All five patients had renal colic, one bilateral and one renal obstruction and fever. Small lithiasic concretions of null or minor radiological calcium density were identified by urinary X-ray and UIV. The patients had haematuria, crystalluria and urinary pH 5.0-6.0. Treatment was symptomatic, pharmacologic, emergency in situ extracorporeal shock-wave lithotrity (ESWL), or ureteral catheterisation, as appropriate. RESULTS: Patients had been treated with these antiviral agents for several months. They all required urologic care: pharmacologic, ureteral catheterisation, or ESWL, with good results. No stones were obtained for mineralogic analysis, but crystalluria was identified as being due to Indinavir and calcium oxalate. CONCLUSIONS: Renal excretion and urinary elimination of PIs (or their metabolites) results in asymptomatic crystalluria in HIV(+) patients treated with this class of drugs. Other cases present genuine calcium oxalate calculi with sings of renal colic and urinary obstruction requiring urologic care.

Cólico renal y litiasis en pacientes HIV (+) tratados con inhibidores de proteasas / Renal colic and lithiasis in HIV (+) patients treated with protease inhibitors

INTRODUCCIÓN: Los Inhibidores de Proteasas, fundamentalmente Indinavir, drogas de gran uso actual en el tratamiento de pacientes afectos por el virus de la Inmunodeficiencia Adquirida (HIV), se relacionan con episodios de cólico renal y obstrucción urinaria. Se produce como consecuencia de la eliminación por la orina de estos medicamentos, y/o favorecer la formación de pequeños cálculos (cristaluria y litiasis). MATERIAL Y MÉTODOS: En la Unidad de Litiasis de la Fundación "Jiménez Díaz" (FJD), se ha atendido recientemente por cólico renal a cinco pacientes HIV(+) que seguían tratamiento con Inhibidores de Proteasas. Fueron cuatro varones y una mujer. Los cinco sufrieron cólico renal, bilateral en un caso, y otro obstrucción renal y fiebre. La radiografía simple de aparato urinario y la UIV identificó pequeñas concreciones litiásicas de nula o escasa densidad cálcica radiológica. Presentaron hematuria, cristaluria y un pH urinario 5,0-6,0. El tratamiento aplicado fue sintomático, farmacológico, litotricia extracorpórea (LEOC) "in situ" inmediata de urgencia, o cateterismo ureteral, según el caso. RESULTADOS: Los pacientes llevaban meses en tratamiento con estos agentes antivirales. Todos precisaron atención urológica: farmacológica, cateterismo ureteral o LEOC, consiguiendo resultados satisfactorios. No fue posible obtener cálculos para su análisis minerealógico, pero si se identificó cristaluria Indinavir y oxalato cálcico. CONCLUSIONES: La excreción renal y la eliminación urinaria de los Inhibidores de Proteasas (o sus metabolitos) pro-duce cristaluria asintomática en pacientes HIV(+) tratados con estos fármacos. En otros casos tienen auténticos cálculos oxalocálcicos que se manifiestan por cólico renal y obstrucción urinaria precisando asistencia urológica inmediata. (AU)

[Bone abnormalities. Muscular dystrophy and lithiasis: lithogenic factors and therapeutic difficulties]. / Deformidades esqueléticas. Distrofia muscular y litiasis: factores litogénicos y dificultades terapéuticas.

UNLABELLED: Duchenne's muscular dystrophy with kypho-scoliosis, progressive muscle weakness and abnormal fatigue of the muscles results in an immobilisation syndrome with increased bone resorption and hypercalciuria. The accompanying chest deformity alters the respiratory capacity, causing pulmonary insufficiency, acidosis and acid urine. Dorso-lumbar kypho-scoliosis, occasionally very serious, alters the status of the upper urinary tract affecting urine transportation (stasis). Thus, hypercalciuria, urinary acidosis, stasis and infection will determine the formation of urinary lithiasis that can take place in these patients. MATERIAL AND METHODS: 15 patients with a variety of myopathies (Duchenne's disease, Myasthenia gravis,...) or serious skeletal deformities with metabolic renal lithiasis (pyelic or calyceal) were seen by our group. Other patients presented post-traumatic (paraplegia, hemiplegia,...) or poliomyelitic skeletal sequels or Pott's disease, with septic lithiasis. After evaluating all likely approaches including ESWL, the latter was chosen being the least aggressive. Conventional surgery, either percutaneous or endoscopic, foretells technical problems in terms of lithiasis approach. Both the case introducing the subject, Duchenne's muscular dystrophy, with bilateral renal lithiasis and the others are a reflection of complexity of finding the righ approach for these patients, including ESWL. RESULTS: Scoliosis was not a technical obstacle, since patients could be placed in lateral/oblique position to situate the stone in the right spot for lithotrity. Debris removal was easy, with no obstructive complications, in spite of the significant immobilisation of these patients. CONCLUSION: Immobilisation syndrome, acidosis, stasis and infection could jointly determine the lithogenesis mechanism in patients with muscle diseases or serious skeletal deformities and with renal lithiasis. ESWL has an opportunity in serious cases, where other techniques including surgery have major difficulties.