¿Es el signo de Hawkins capaz de predecir la necrosis en las fracturas del cuello astragalino? / Is the Hawkins sign able to predict necrosis in fractures of the neck of the astragalus?

Objetivo. Determinar si el signo de Hawkins predice que el astrágalo fracturado a nivel del cuello desarrollará o no una necrosis avascular (NAV), y determinar la relación con el desplazamiento de la fractura, la lesión de partes blandas, o la demora en la reducción o en la cirugía. Material y métodos. Estudio retrospectivo de 23 fracturas de cuello de astrágalo recogidas durante 13 años. Se recogen las siguientes variables: desplazamiento de la fractura, lesión de partes blandas, demora y tipo de tratamiento, complicaciones, observación del signo de Hawkins y resultado funcional. Resultados. Se registraron 7 fracturas Hawkins tipo I , 11 tipo II , 4 tipo III y una tipo IV . Cuatro casos desarrollaron una NAV (2 Hawkins tipo II y 2 tipo III ). Se observó el signo de Hawkins en 12 casos, de los cuales ninguno desarrolló necrosis. Cuatro casos con signo de Hawkins negativo desarrollaron necrosis. No se hallaron diferencias al comparar el desarrollo de NAV con el desplazamiento de la fractura, la lesión de partes blandas o la demora en el tratamiento. Sí se hallaron diferencias al comparar el desarrollo de NAV con la observación del signo de Hawkins (p = 0,03). Conclusión. El signo de Hawkins positivo descarta que el astrágalo fracturado desarrolle una NAV, pero su ausencia no lo confirma (AU)

Introduction: The most common cause of osteoarthritis of the ankle is post-traumatic, and although tibiotalar arthrodesis remains the surgical gold standard, a number of techniques have been described to preserve joint mobility, such as joint distraction arthroplasty or arthrodiastasis. Objective: To evaluate the functional outcome and changes in Visual Analogue Scale (VAS) for pain after the application of the distraction arthroplasty for post-traumatic ankle osteoarthritis. Patients and methods: A prospective comparative study of a group of 10 young patients with post-traumatic ankle osteoarthritis treated by synovectomy and arthrodiastasis, compared to a control group of 10 patients treated by isolated synovectomy. Results were calculated using the AOFAS scale and the VAS for pain before and after treatment. Results: As regards the pain measured by VAS, no difference was observed between the two groups before surgery (P=.99), but there was a difference at 3 months (P<.001), 6 months (P=.005), and 12 months (P=.006). No differences were observed in the AOFAS scale between the two groups before surgery (P=.99), or at 3 months (P<.99), but there was a difference at 6 months (P<.001). Conclusions: Ankle arthrodiastasis is effective in reducing pain in post-traumatic ankle arthropathy, and is superior to isolated synovectomy (AU)

[Is the Hawkins sign able to predict necrosis in fractures of the neck of the astragalus?]. / ¿Es el signo de Hawkins capaz de predecir la necrosis en las fracturas del cuello astragalino?

OBJECTIVE: To assess if the Hawkins sign can predict whether or not astragalus fractures of the neck will develop avascular necrosis. It is also assessed whether the occurrence of this complication is related to the displacement of the fracture, soft tissue injury, or delay in the reduction or surgery. The results were compared with those found in the literature. MATERIAL AND METHODS: A retrospective study was conducted on 23 talar neck fractures recorded over a a period of thirteen years. The following variables were analysed: displacement of the fracture, soft tissue injury, delay and type of treatment, complications, observation of the Hawkins sign, and functional outcome. RESULTS: There were 7 type I Hawkins fractures, 11 type II, and 4 type III and 1 type IV. Four cases developed avascular necrosis (2 Hawkins type II and 2 type III). Hawkins sign was observed in 12 cases, of which none developed necrosis. Four cases with negative Hawkins sign developed necrosis. No statistically significant differences were found when comparing the development of avascular necrosis with the displacement of the fracture, soft tissue injury, or delay in treatment. Differences were found when comparing the development of avascular necrosis with the Hawkins sign (P=.03). CONCLUSION: A positive Hawkins sign rules out that the fractured talus has developed avascular necrosis, but its absence does not confirm it.

[Experiences with a helical femoral nail (LFN®). A multicenter study]. / Erfahrungen mit einem helikalen Femurmarknagel (LFN®). Eine multizentrische Studie.

INTRODUCTION: Antegrade intramedullary nailing is the method of choice in most femoral shaft fractures. The trochanteric entry portal of classic femoral nails is in close proximity to the piriformis tendon, the gluteus minimus tendon, the obturator tendons, and the medial femoral circumflex artery. Nail insertion lateral to the tip of the greater trochanter may be more favorable but needs the use of a helical implant. MATERIAL AND METHODS: Measurement of the reamer pathway through an entry point lateral to the superior trochanteric border was performed with a three-dimensional motion tracking sensor in human cadaveric femurs. These results provided a scientific rationale for the design of a helical femoral nail (LFN®). In a prospective multicenter study a total of 227 femoral shaft fractures were treated by nailing with the LFN. Patients were followed at 3 months (n=193) and 12 months (n=167). RESULTS: The ease of defining the entry point and inserting the nail was rated as"very good and good" by 90% of the surgeons. Intraoperative technical complications included incomplete reduction (14%), additional iatrogenic fractures (6%), and difficulties in interlocking (3.5%). At the 1-year follow-up, delayed unions were seen in 10%, secondary loss of reduction in 3%, and deep infection in 1.8% of the patients. Angular malalignment of more than 5° was seen in 5%, mostly in valgus. A normal walking capacity was seen in 68% and normal active hip flexion in 45%. CONCLUSION: The results obtained in this study during 1 year do not provide evidence for an advantage of the LFN over conventional antegrade femoral nails.

Fracturas abiertas / Open fractures

Se presenta una revisión del estado actual del tratamiento de las fracturas abiertas. Procurando despejar controversias y establecer los principios básicos de su tratamiento actual. El empleo de antibióticos en el tratamiento inicial de las fracturas abiertas es un concepto bien establecido, cuanto más precoz es su administración mayor es la reducción de la posibilidad de infección. Cuanto más radical es el desbridamiento, menor es la tasa de infección. El método de fijación de elección para las fracturas abiertas de las diáfisis de la extremidad inferior es el enclavado endomedular. El uso de fijadores externos debería limitarse a los casos de politraumatismos. Si el desbridamiento ha sido exhaustivo, se obtiene un mejor resultado con el cierre primario de la herida. Se debe reparar la pérdida de partes blandas tan pronto como sea posible y mediante el uso del sistema más simple pero eficaz en la escalera ortoplástica: cierre secundario, injerto libre, colgajo rotacional, colgajo libre microvascularizado. Aunque algunas pautas de tratamiento son claras, cada fractura abierta es distinta por lo cual el tratamiento debe ajustarse a cada fractura y a cada paciente (AU)

A review is presented on the current status of open fracture treatments, and an attempt is made to clear up controversies and establish the basic principles of their current treatment. The use of antibiotics in the initial treatment of open fractures is a well known concept, and the earlier they are given the greater is the reduction in the likelihood of infection. The more radical the debridement is, the lower the rate of infection. The fixation method of choice for open fractures of the diaphysis of the leg is the intramedullary nail. The use of external fixation should be limited to cases of multiple traumas. If the debridement has been exhaustive, a better result is obtained with the primary closure of the wound. The loss of soft tissue must be repaired as soon as possible and using the simplest but most efficient system on the orthoplastic ladder; secondary closure, free graft, rotational flap, free microvascularised flap. Although some treatment guidelines are clear, each open fracture is different and must be adapted to each fracture and to each patient (AU)

Carta 2 / Letter 2

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