Implementation of ultrasound-guided carpal tunnel release.

INTRODUCTION: Ultra-minimally invasive ultrasound-guided carpal tunnel release is a surgical procedure for treatment of carpal tunnel syndrome that is associated with less surgery-related morbidity and faster recovery than open surgery. The objectives of this study were to describe how the surgical technique may be acquired and to report the results obtained after implementation in a clinical setting. METHODS: The study consisted of two parts: 1) description of the surgical skills needed to perform the procedure, and 2) evaluation of the procedure in the first ten consecutively operated patients after 12-month follow-up using questionnaires and magnetic resonance imaging (MRI). RESULTS: The procedure was performed on 29 cadaveric arms and assessed regarding surgical release success and signs of iatrogenic damage. Subsequently, the procedure was performed on ten patients with carpal tunnel syndrome. The results of the six-item Carpal Tunnel Symptoms Scale (1-5) improved from 3.3 ± 0.9 (mean ± standard deviation) preoperatively to 1.2 ± 0.3, p = 0.002, after 12 months. Quick Disabilities of the Arm, Shoulder and Hand (DASH) (0-100) results improved from 33.4 ± 14.8 to 2.3 ± 4.0, p = 0.002. There were no infections or iatrogenic damage to nerves or blood vessels. CONCLUSIONS: This study presents a way to safely acquire the skills needed to perform the procedure and implement it in an out-patient setting. The results were comparable to previous findings regarding both effectiveness and safety. MRI documented the surgical gap in the transverse carpal ligament, release length, cross-sectional area changes in the carpal tunnel and median nerve, and reactive changes in the carpal tunnel. FUNDING: None. TRIAL REGISTRATION: Not relevant.

Ultrasound-Guided A1 Pulley Release Versus Classic Open Surgery for Trigger Digit: A Randomized Clinical Trial.

OBJECTIVES: We compared an ultra-minimally invasive ultrasound-guided percutaneous A1 pulley release and a classic open surgery for trigger digit. METHODS: We designed a single-center randomized control trial. All cases had clinical signs of primary grade III trigger digit. Concealed allocation (1:1) was used for assigning patients to each group and data collectors were blinded. The Quick-Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) questionnaire was our primary variable. Quick-DASH, two-point discrimination, grip strength, time until stopping analgesics, having full digital range of motion and restarting everyday activities were registered on the 1st, 3rd, and 6th weeks, 3rd and 6th months, and 1st year after the procedure. RESULTS: We randomized 84 patients to ultrasound-guided release and classic open surgery. Quick-DASH scores significantly favored the percutaneous technique until the 3rd month: 7.6 ± 1.2 versus 15.3 ± 2.4 (mean ± standard error of the mean). The percutaneous group obtained significantly better results in all the variables studied: time until stopping analgesics, achieving full range of motion and restarting everyday activities. Grip strength was significantly better in the percutaneous group for the 1st week only. Five cases of moderate local pain were observed in the open technique. There was one case of transient nerve numbness per group. CONCLUSIONS: The ultra-minimally invasive ultrasound-guided A1 pulley release was clinically superior to the classic open surgery in functional recovery with a lower complication rate.

Ultra-minimally Invasive Sonographically-guided Trigger Digit Release: An External Pilot Study.

Objectives: The most common surgical option for releasing the first annular pulley in trigger digit (TD) is classic open surgery followed by blind percutaneous release. However, they have been related to major complications and incomplete releases, respectively. Intrasheath sonographically-guided first annular pulley release has recently been shown to be safe and effective in every digit. The objectives of this pilot study were to preliminary compare clinically an intrasheath sonographically-guided first annular pulley release versus a classic open technique and to evaluate the feasibility of a future clinical trial in patients with TDs. Methods: Thirty patients were randomized 1:1 in an external pilot study comparing the two surgical techniques: a percutaneous sonographically-guided release performed through a 1 mm incision using a hook knife versus a classic open surgery with a 1 cm incision. Inclusion criteria were primary TD grade III (Froimson). We defined success if primary (safety and efficacy) and secondary (recruitment rates, compliance, completion, treatment blinding, personnel resources, and sample size calculation for the clinical trial) objectives could be matched. We registered the grip strength, the QuickDASH score and a set of postoperative clinical variables at one, three, and six weeks and at three months. We calculated the sample size for the clinical trial using the QuickDASH at the end of the follow-up. Outcomes assessors were blinded. Results: All patients in both groups showed resolution of their symptoms with no associated complications or relapses. Secondary feasibility objectives were matched: 76.9% of eligible patients were included in the study, 3.3% refused randomization, 20 patients per month were recruited, 100% received blinded treatment, 98.5% showed compliance, and 100% completed the study. The sample size for a future clinical trial was 84 patients. There were no differences in grip strength. The intrasheath sonographically-guided first annular pulley release showed significantly better QuickDASH scores, until the sixth postoperative week. Conclusions: The intrasheath sonographically-guided first annular pulley release is safe and efficacious, and shows a trend toward clinical superiority versus the classic open procedure, which should be confirmed with a clinical trial. Our study shows that a randomized clinical trial is feasible.

3D surgical printing for preoperative planning of trabecular augments in acetabular fracture sequel.

We describe the methodical and possibilities of 3D surgical printing in preoperative planning for a total hip arthroplasty in acetabular deformity after acetabular fractures, showing a case of a 43-year-old with posttraumatic arthritis after both column fracture of the left acetabulum that was treated non operatively, supporting the do it yourself mode.

Ultrasound-guided supra-acetabular pin placement in pelvic external fixation: description of a surgical technique and results.

INTRODUCTION: Pelvic fracture in trauma patients can lead to hemodynamic instability. External fixation is a treatment capable of stabilizing these injuries in the context of damage control surgery. Supra-acetabular pin offers the greater biomechanical stability but requires the use of intraoperative fluoroscopy. The aim of this study was to analyze our results for an ultrasound-guided supra-acetabular pinning. MATERIAL AND METHODS: Cross-sectional study with cadaveric specimens. Ultrasound-guided pin placement assessed by fluoroscopy and dissection. RESULTS: Fourteen ultrasound-guided supra-acetabular pins were placed in seven cadaveric specimens. Excellent placement in all cases, evaluated with radiological control. Good qualitative bone fixation after dissection. One femoral cutaneous nerve was not found during anatomic dissection and was assumed injured. CONCLUSION: Ultrasound-guided supra-acetabular pin placement is a feasible and effective technique. Our study indicates that pin placement without intraoperative fluoroscopy is feasible without compromising the reliability of its placement.

3D surgical printing and pre contoured plates for acetabular fractures.

We describe the methodical and possibilities of 3D surgical printing in preoperative planning of acetabular fractures showing a case of a 45-year-old with an associated transverse fracture of the left acetabulum with posterior wall fracture, with multiple fragments, and posterior ipsilateral hip dislocation, defending the do it your-self mode.

Ultra-Minimally Invasive Ultrasound-Guided Carpal Tunnel Release: A Randomized Clinical Trial.

OBJECTIVES: The purpose of this study was to compare the outcomes of 1-mm ultra-minimally invasive ultrasound-guided carpal tunnel release and 2-cm blind mini-open carpal tunnel release. METHODS: We conducted a single-center individual parallel-group controlled-superiority randomized control trial in an ambulatory office-based setting at a third-level referral hospital. Eligible participants had clinical signs of primary carpal tunnel syndrome and positive electrodiagnostic test results and were followed for 12 months. Independent outcome assessors were blinded. Patients were randomized by concealed allocation (1:1) by an independent blocked computer-generated list. The postoperative score on the Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire was the primary variable. Grip strength and time for discontinuation of oral analgesics, complete wrist flexion-extension, relief of paresthesia, and return to normal daily activities (including work) were assessed. RESULTS: Ninety-two of 128 eligible patients were randomly allocated and analyzed. QuickDASH scores were 2.2 to 3.3 times significantly lower in the ultra-minimally invasive group for the first 6 months: 23.6 [95% confidence interval (CI), 20.5, 27.4] versus 52.6 [95% CI, 49.4, 57.0] at the first week and 4.09 [95% CI, 1.5, 7.1] versus 13.0 [95% CI, 9.4, 18.9] at 6 months. Return to normal daily activities occurred significantly sooner in the ultra-minimally invasive group: 4.9 [95% CI, 3.2, 6.5] versus 25.4 [95% CI, 18.2, 32.6] days. CONCLUSIONS: Ultra-minimally invasive carpal tunnel release provides earlier functional return and less postoperative morbidity with the same neurologic recovery as mini-open carpal tunnel release for patients with symptomatic primary carpal tunnel syndrome.

Retained Sponge: A Rare Complication in Acetabular Osteosinthesis.

Retained sponges after a surgical treatment of polytrauma may cause a broad spectrum of clinical symptoms and present a difficult diagnostic problem. We report a case of retained surgical sponge in a 35-year-old man transferred from another hospital, that sustained a open acetabular fracture. The fracture was reduced through a limited ilio-inguinal approach. After 4 days, he presented massive wound dehiscence of the surgical approach. An abdominal CT scan showed, lying adjacent to the outer aspect of the left iliac crest, a mass of 10 cm, identified as probable foreign body. The possibility of this rare complication should be in the differential diagnosis of any postoperative patient who presents with pain, infection, or palpable mass.

Methods and Guidelines for Venous Thromboembolism Prevention in Polytrauma Patients with Pelvic and Acetabular Fractures.

Sequential compression devices and chemical prophylaxis are the standard venous thromboembolism (VTE) prevention for trauma patients with acetabular and pelvic fractures. Current chemical pharmacological contemplates the use of heparins or fondaparinux. Other anticoagulants include coumarins and aspirin, however these oral agents can be challenging to administer and may need monitoring. When contraindications to anticoagulation in high-risk patients are present, prophylactic inferior vena cava filters can be an option to prevent pulmonary emboli. Unfortunately strong evidence about the most effective method, and the timing of their commencement, in patients with pelvic and acetabular fractures remains controversial.

Lesiones auriculares inducidas por cloroquina: estudio histopatológico / Chloroquine-induced atrial lesions: histopathological studies

La cloroquina y sus derivados son fármacos antipalúdicos utilizados en enfermedades del colágeno y afecciones dermatológicas. Describimos un caso de cardiotoxicidad en una mujer de 59 a˜nos diagnosticada de lupus eritematoso discoide y tratada con cloroquina durante 25 a˜nos. La paciente desarrolló trastornos de la conducción y fallo cardiaco, falleciendo finalmente. El corazón mostró hipertrofia biventricular. Describimos el primer caso de auriculopatía inducida por cloroquina. La microscopia óptica y electrónica demostraron vacuolización autofágica de los miocardiocitos auriculares granulares y agranulares, presencia de cuerpos curvilíneos y figuras mieloides, alteraciones mitocondriales y de miofilamentos. La cardiotoxicidad de la cloroquina afectó más intensamente a la aurícula derecha que al resto del corazón. Ello podría explicar, en parte, la aparición de arritmias que ocurre en algunos casos de cardiomiopatía inducida por cloroquina(AU)

The antimalarian agents chloroquine and its derivatives are used in the treatment of connective tissue disease and dermatological disorders. We report a case of carditoxicity in a 59 year-old woman with a 25 year history of chloroquine treatment for a discoid lupus erythematosus. She developed conduction disturbances, cardiac failure and subsequently died. Macroscopically, cardiac biventricular hypertrophy was evident. Light and electronmicroscopic studies of the granular and agranular myocardiocytes of the atria revealed the presence of autophagic vacuoles, curvilinear bodies and myelin-like figures, myofilaments and mitochondrial change. The right atrium was the most damage region of the heart. These lesions may partly explain the appearance of arrhythmias reported in some cases of chloroquine induced myocardiopathy(AU)

Tantalum cones in revision total knee arthroplasty. A promising short-term result with 29 cones in 21 patients.

Twenty-nine porous tantalum metaphyseal cones were implanted in 21 patients (14 women and 7 men) during revision TKA. The average age at the time of the procedure was 73.3 years. Sixteen revisions were considered aseptic and 5 were reimplantations after sepsis. Eight patients had stemmed revision implants and thirteen primary designs. According to the Anderson Orthopaedic Research Institute bone defect classification, femoral defects were rated as F3 in 14 knees and F2B in 3 knees. Tibial defects were rated as T2A in 3 cases, T2B in 3 cases and T3 in 5 cases. A femoral cone was inserted in 10 patients, a double cone (femur and tibia) in 8, and a single tibial cone in 3. A rotating hinge knee prosthesis (RHK, Zimmer) was inserted in 10 patients and a constrained condylar prosthesis (LCCK, Zimmer) in 11 patients. The diaphysis was cemented in 9 cases and, in 11 cases, just the metaphysis. At an average follow up of 36 months only one reconstruction was removed due to persistent infection. All metaphyseal cones showed evidence of stable osseointegration. According to the Knee Society Score the results were rated as excellent in 12 cases, good in 5 cases, fair in 3 and poor in 1 case. In the short term, porous tantalum metaphyseal cones provided structural support for large femoral and tibial defects. They also provided the environment for bone graft osseointegration, repair of femoral fractures and effective interdigitation of cement mantle into the trabecular metal cone.

Ultra-minimally invasive sonographically guided carpal tunnel release: anatomic study of a new technique.

OBJECTIVES: The purposes of this study were to measure a safe zone and a path for ultra-minimally invasive sonographically guided carpal tunnel release with a 1-mm incision in healthy volunteers and then test the procedure in cadavers. METHODS: First, a previously reported sonographic zone was defined as the space between the median nerve and the closest ulnar vascular structure. Axially, the safest theoretical cutting point for carpal tunnel release was set by bisecting this zone. Magnetic resonance imaging was used for axially determining the limits of the sectors (origin at the cutting point) that did not enclose structures at risk (arteries and nerves) and coronally for determining whether our release path could require directions that could potentially compromise safety (origin at the pisiform's proximal pole). Second, in cadavers, we performed ultra-minimally invasive sonographically guided carpal tunnel release from an intracarpal position through a 1-mm antebrachial approach. Efficacy (deepest fibrous layer release rate), safety (absence of neurovascular or tendon injury), and damage to any anatomy superficial to transverse carpal ligament were assessed by dissection. RESULTS: All 11 of our volunteers (22 wrists) had safe axial sectors located volar and radially of at least 80.4º (considered safe). Release path directions were theoretically safe (almost parallel to the longitudinal axis of the forearm). In 10 cadaver wrists, ultra-minimally invasive sonographically guided carpal tunnel release was effective (100% release rate) and safe without signs of intrusion into the superficial anatomy. CONCLUSIONS: Ultra-minimally invasive sonographically guided carpal tunnel release in a safe sonographic zone may be feasible The technique preserves the superficial anatomy and diminishes the damage of a surgical approach.

Stoppa approach, an alternative for total hip arthroplasty in an intra-pelvic cup.

Removal of an acetabular prosthesis that has migrated into the pelvis can be hazardous. We describe the preoperative planning and the surgical procedure for removing a severely displaced acetabular component in one patient and outline our recommendation for the use of Stoppa approach because it has advantages of simple dissection, a low complication rate, and may help in preventing life-threatening problems.

Selective 360° percutaneous extensor carpi radialis brevis tendon release for tennis elbow: an experimental study.

OBJECTIVES: The purpose of this study was to define in volunteers and cadavers the positions of structures at risk and the extensor carpi radialis brevis (ECRB) origin limits for sonographically guided percutaneous tendon release in tennis elbow. METHODS: First, in volunteers, we used Doppler sonography to determine the position (danger zone) of the structures at risk (neurovascular bundle and radial collateral ligament) from the most lateral point of the epicondyle (point of entry). Second, in cadavers, we studied the footprint of the ECRB's origin for finally performing sonographically guided tendon release (1- to 2-mm incision) away from the danger zone. Efficacy was measured in terms of detachment ratios for the ECRB and safety as the absence of neurovascular bundle or radial collateral ligament injuries. RESULTS: In 10 volunteers (20 elbows), the neurovascular bundle was located 18.1 mm or greater anteromedially from the point of entry. The neurovascular bundle was not in direct contact with the bone. In 13 formaldehyde-embalmed cadaver elbows, the distance between the origin of the ECRB and the radial collateral ligament was 0 mm or greater. The anterior origin of the ECRB did not contact the neurovascular bundle. The maximum attachment limits of the ECRB were at 15, 5, 15, and 16 mm from the point of entry (anterior, posterior, proximal, and distal margins, respectively). Average detachment ratios were excellent for anterior and distal margins and good for posterior and proximal margins, without neurovascular bundle or radial collateral ligament injuries. CONCLUSIONS: This study determined a danger zone to avoid and an area of probability in which to enclose most of the ECRB's origin for sonographically guided percutaneous tendon release. A 360° ECRB detachment can be performed safely and effectively. Clinically, sonographically guided percutaneous tendon release should selectively target pathologic regions.

Trends in incidence and outcomes of revision total hip arthroplasty in Spain: a population based study.

BACKGROUND: To analyze changes in incidence and outcomes of patients undergoing revision total hip arthroplasty (RTHA) over an 8-year study period in Spain. METHODS: We selected all surgical admissions in individuals aged ≥ 40 years who underwent RTHA (ICD-9-CM procedure code 81.53) between 2001 and 2008 from the Spanish National Hospital Discharge Database. Age- and sex-specific incidence rates, Charlson co-morbidity index, length of stay (LOS), costs and in-hospital mortality (IHM) were estimated for each year. Multivariate analyses were conducted to asses time trends. RESULTS: 32,280 discharges of patients (13, 391 men/18, 889 women) having undergone RTHA were identified. Overall crude incidence showed a small but significant increase from 20.2 to 21.8 RTHA per 100, 000 inhabitants from 2001 to 2008 (p < 0.01).The incidence increased for men (17.7 to 19.8 in 2008) but did not vary for women (22.3 in 2001 and 22.2 in 2008). Greater increments were observed in patients older than 84 years and in the age group 75-84. In 2001, 19% of RTHA patients had a Charlson Index ≥ 1 and this proportion rose to 24.6% in 2008 (p < 0.001). The ratio RTHA/THA remained stable and around 20% in Spain along the entire period. The crude overall in-hospital mortality (IHM) increased from 1.16% in 2001 to 1.77% (p = 0.025) in 2008. For both sexes the risk of death was higher with age, with the highest mortality rates found among those aged 85 or over. After multivariate analysis no change was observed in IHM over time. The mean inflation adjusted cost per patient increased by 78.3%, from 9, 375 to 16, 715 Euros from 2001 to 2008.After controlling for possible confounders using Poisson regression models, we observed that the incidence of RTHA hospitalizations significantly increased for men and women over the period 2001 to 2008 (IRR 1.10, 95% CI 1.03-1.18 and 1.08, 95% CI 1.02-1.14 respectively). CONCLUSIONS: The crude incidence of RTHA in Spain showed a small but significant increase from 2001 to 2008 with concomitant reductions in LOS, significant increase in co-morbidities and cost per patient.

Sonographically guided intrasheath percutaneous release of the first annular pulley for trigger digits, part 1: clinical efficacy and safety.

OBJECTIVES: For trigger digits, intrasheath sonographically guided first annular (A1) pulley release has shown safety and effectiveness in cadavers. This clinical study describes sonographically guided A1 pulley release results in terms of resolution of symptoms, safety, and functional recovery. METHODS: Sonographically guided A1 pulley release (11-MHz probe) was used in 48 digits of 48 patients prospectively followed for 11.3 months and examined 1, 3, and 6 weeks, 3 and 6 months, and 1 year later. Resolution of triggering (primary variable of interest) was expressed as the "success rate" per digit. The time for taking postoperative pain killers, range of motion recovery, grip strength, QuickDASH test scores, return to normal activities (including work), cosmetic results, satisfaction, and complications were assessed. RESULTS: The success rate was 100%, and no cases recurred. Mean times were 1.9 days for taking pain killers, 6.6 days for returning to normal activities, and 9.9 and 3.8 days for complete extension and flexion recovery, respectively. Mean QuickDASH scores were 39.8 preoperatively and 7.8, 1.7, and 0 after 6 weeks, 6 months, and 1 year postoperatively. Grip strength reached greater than 90% of the individual's normal strength by the sixth week in men and by the third month in women (P < .001). Radial digital nerve numbness developed in 1 finger, which disappeared by the third week. No other complications were noted. All wounds were cosmetically excellent, and final satisfaction was excellent or good in 98%. CONCLUSIONS: With adequate anatomic knowledge, technical training, and a basic ultrasound machine, sonographically guided A1 pulley release can be performed safely and successfully, offering an alternative to classic open surgery in the ambulatory setting.

Sonographically guided intrasheath percutaneous release of the first annular pulley for trigger digits, part 2: randomized comparative study of the economic impact of 3 surgical models.

OBJECTIVES: Trigger digit surgery can be performed by an open approach using classic open surgery, by a wide-awake approach, or by sonographically guided first annular pulley release in day surgery and office-based ambulatory settings. Our goal was to perform a turnover and economic analysis of 3 surgical models. METHODS: Two studies were conducted. The first was a turnover analysis of 57 patients allocated 4:4:1 into the surgical models: sonographically guided-office-based, classic open-day surgery, and wide-awake-office-based. Regression analysis for the turnover time was monitored for assessing stability (R(2) < .26). Second, on the basis of turnover times and hospital tariff revenues, we calculated the total costs, income to cost ratio, opportunity cost, true cost, true net income (primary variable), break-even points for sonographically guided fixed costs, and 1-way analysis for identifying thresholds among alternatives. RESULTS: Thirteen sonographically guided-office-based patients were withdrawn because of a learning curve influence. The wide-awake (n = 6) and classic (n = 26) models were compared to the last 25% of the sonographically guided group (n = 12), which showed significantly less mean turnover times, income to cost ratios 2.52 and 10.9 times larger, and true costs 75.48 and 20.92 times lower, respectively. A true net income break-even point happened after 19.78 sonographically guided-office-based procedures. Sensitivity analysis showed a threshold between wide-awake and last 25% sonographically guided true costs if the last 25% sonographically guided turnover times reached 65.23 and 27.81 minutes, respectively. However, this trial was underpowered. CONCLUSIONS: This trial comparing surgical models was underpowered and is inconclusive on turnover times; however, the sonographically guided-office-based approach showed shorter turnover times and better economic results with a quick recoup of the costs of sonographically assisted surgery.

Cup-cage construct for acute fractures of the acetabulum, re-defining indications.

Acetabular fractures in the elderly are challenging injuries. The use of a trabecular metal acetabular cage was investigated as the treatment option in a series of elderly patients with acetabular fractures. At a 2-year follow up, 6 elderly patients were found to have mimimum pain, increased function, and increased scores using the Merle d'Aubigné and Postel system modified by Charnley. Radiographically, the areas of morsellised autograft that surrounded the cups were seen to have incorporated uniformly well, and the acetabular fractures were healed within six months after surgery. No mechanical failure, screw breakage, loosening, or migration was noticed. This novel indication of the cup-cage construction that uses revision techniques, for selected patients and fractures, to achieve an acute stable reconstruction, should be considered as an alternative reconstruction option in elderly patients presenting with acetabular fractures.

Percutaneous intrasheath ultrasonographically guided first annular pulley release: anatomic study of a new technique.

OBJECTIVE: The purpose of this study was to define in volunteers a safe area for performing a percutaneous intrasheath first annular (A1) pulley release under ultrasonographic guidance in cadavers for the treatment of trigger fingers. METHODS: First, in 100 fingers of 10 volunteers, we used Doppler ultrasonography to determine the limits of the sectors enclosing structures at risk (arteries and tendons). From the synovial sheath's most volar point, we determined the relative position of the arterial walls and the distance to the flexor tendons. A scatterplot overlay of the arterial positions was digitally analyzed for determining the limits of the safe area. Second, we released the A1 pulley in 46 fingers from 5 cadavers, directing the edge of the cutting device toward our safe area from an intrasheath instrument position. The precision, safety, and efficacy of the release were evaluated by surgical exposure of the A1 and A2 pulleys and the neurovascular bundles. RESULTS: In our volunteers, we observed a volar safe area from +6.1° to +180°. Surgical precision was good in the cadavers, with no injuries to adjacent structures, a complete release in 44 fingers (95.7%), and an incomplete release of less than 1.6 mm in 2 fingers. CONCLUSIONS: This study determined a safe volar area for aiming surgical instruments from an intrasheath position for percutaneous ultrasonographically guided A1 pulley release. The technique can be performed safely in all fingers, but we suggest being cautious in the thumb and converting the surgery to an open procedure if ultrasonographic visualization is not optimal.