Evaluación subjetiva de la hipoestesia subclavicular luego de una reducción abierta y fijación interna de fracturas de clavícula / Subjective evaluation of subclavicular hypoesthesia after open reduction and internal fixation of clavicle fractures

Introducción: Las fracturas de clavícula representan el 4% de las fracturas del adulto; el 80% son mediodiafisarias. Se ha de-mostrado que el tratamiento quirúrgico disminuye el riesgo de seudoartrosis, consolidación viciosa y dolor residual, aunque no está exento de complicaciones, como la hipoestesia regional (12-29%), entre otras. Objetivo: Evaluar la incidencia de hipoestesia subclavicular luego de una reducción abierta y fijación interna para una fractura de clavícula, si afecta la calidad de vida del paciente y cómo la afecta. Materiales y Métodos: Se realizó un estudio transversal analítico prospectivo de pacientes con una fractura mediodiafisaria desplazada de clavícula tratados con reducción abierta y fijación interna entre 2018 y 2021. Se utilizó un cuestionario elaborado por el equipo, que consistió en 6 preguntas para responder de forma anónima. Se evaluó la presencia de hipoestesia subclavicular, dolor regional y afectación de la vida cotidiana. Resultados: Se evaluó a 29 pacientes con un seguimiento posoperatorio mínimo de un año, operados mediante un abordaje longitudinal. Veintidós (76%) tenían alteración de la sensibilidad y siete (24%) negaron este síntoma. La hipoestesia subclavicular afectó la calidad de vida de manera leve o nula del 97% de los pacientes. Conclusión: Es importante advertirle al paciente antes de la cirugía sobre la posibilidad de hipoestesia cutánea como complicación posoperatoria, debido a su alta frecuencia, aunque es poco probable que dicha complicación afecte la calidad de vida. Nivel de Evidencia: IV

Introduction: Clavicle fractures account for 4% of adult fractures, with mid-shaft fractures accounting for 80%. Although surgical treatment reduces the risk of pseudarthrosis, malunion, and residual pain, it is not without complications such as regional hypoesthesia (12-29%). Objective: To determine the prevalence of subclavicular hypoesthesia following open reduction and internal fixation for clavicle fracture, as well as if and how it impacts the patient's quality of life. Materials and Methods: A prospective cross-sectional analytical study of patients with displaced clavicle midshaft fractures treated with ORIF between 2018-2021 was performed. The research team used a questionnaire with six items that were completed anonymously. The presence of infraclavicular hypoesthesia, regional pain, and daily life interference was assessed. Results: Twenty-nine patients treated surgically with a longitudinal approach and with a minimum postoperative follow-up of one year were evaluated. Twenty-two patients (76%) had altered sensitivity, whereas seven (24%) denied the existence of the symptom. In 97% of individuals with subclavicular hypoesthesia, quality of life was impaired minimally or not at all. Conclusions: Before undergoing surgery, it is important to inform the patient about the risk of cutaneous numbness as a postoperative consequence due to its high frequency but improbable impact on daily activities. Level of Evidence: IV

Current concepts in anterior glenohumeral instability: diagnosis and treatment.

The glenohumeral joint is the most dislocated articulation, accounting for more than 50% of all joint dislocations. The reason behind shoulder instability should be investigated in detail for successful management, and the treatment plan should be individualized for all patients. Several classification systems have been proposed for glenohumeral instability. A physical exam is mandatory no matter what classification system is used. When treating patients with anterior shoulder instability, surgeons need to be aware of the critical size of the bone loss, which is commonly seen. The glenoid track concept was clinically adopted, and the measurement of the glenoid track for surgical decision-making is recommended. Detailed assessment of existing soft tissue injury to the labrum, capsule, glenohumeral ligaments, and rotator cuff is also mandatory as their presence influences the surgical outcome. Rehabilitation, arthroscopic repair techniques, open Bankart procedure, capsular plication, remplissage, Latarjet technique, iliac crest, and other bone grafts offer the surgeon different treatment options according to the type of patient and the lesions to be treated. Three-dimensional (3D) technologies can help to evaluate glenoid and humeral defects. Patient-specific guides are low-cost surgical instruments and can be used in shoulder instability surgery. 3D printing will undoubtedly become an essential tool to achieve the best results in glenohumeral instability surgery.

Fingerbreadths Rule in Determining the Safe Zone of the Radial Nerve and Posterior Interosseous Nerve for a Lateral Elbow Approach: An Anatomic Study.

INTRODUCTION: The purpose of this study was to investigate whether a safe zone rule could be applied to prevent iatrogenic injuries to the radial nerve (RN); and determine whether there is a relationship between the diameter of the radial head and capitellum and the distance of the posterior interosseous nerve (PIN) to the radiocapitellar joint. METHODS: Ten fresh-frozen cadaveric specimens were used to measure the distances between the RN and the lateral epicondyle; the PIN and the radiocapitellar joint; the lateral epicondyle and the PIN as it crossed the ulnohumeral joint; the diameter of the radial head; the width of the capitellum; and the fingerbreadths of the specimens. RESULTS: Four fingerbreadths determined a safe zone between the lateral epicondyle and the RN proximally at the point at which it pierced the intermuscular septum and the mid-lateral portion of the humeral shaft. Two fingerbreadths provided a safe zone for the PIN from the radiocapitellar joint to the midpoint of the axis of the radius only with the forearm in pronation. CONCLUSION: A four-finger rule, two-finger rule, and radial head diameter or capitellum size may predict a safe zone for the RN and PIN except for the segment of the nerve where it crosses the anterior cortex of either the humerus or radius. LEVEL OF EVIDENCE: Preclinical cadaveric study.

Lesión complejo ligamentario interno del codo por valgo forzado sin luxación previa / Internal ligament complex elbow injury without previous dislocation

Se presenta el reporte de un caso de un paciente que consulta por dolor e inestabilidad de codo izquierdo tras un traumatismo directo realizando práctica deportiva. En el examen físico se constata bostezo medial de más de 4 mm tras maniobras de stress. Los estudios por imágenes informan avulsión del complejo ligamentario interno y desprendimiento de la masa muscular flexopronadora. Se realizó la reparación directa de las estructuras dañadas, se utilizó el DASH score (00.0), el score de la Clínica Mayo (100.0) para la evaluación y seguimiento del paciente

We present the case report of a patient who consulted for pain and instability of the left elbow after a direct trauma doing sports practice. In the physical examination, a medial opening of more than 4mm was observed after stress maneuvers. Imaging studies report avulsion of the internal ligament complex and detachment of flexopronator muscle mass. Direct repair of the damagedstructures was performed, the DASH score (00.0), the Mayo Clinic score(100.0) was used for the evaluation and follow-up of the patient

Change in the Distance From the Axillary Nerve to the Glenohumeral Joint With Shoulder External Rotation or Abduction Position.

BACKGROUND: This study investigated whether axillary nerve (AN) distance to the inferior border of the humeral head and inferior glenoid would change while placing the glenohumeral joint in different degrees of external rotation and abduction. METHODS: A standard deltopectoral approach was performed on 10 fresh-frozen cadaveric specimens. The distance between AN and the inferior border of the humeral head and inferior glenoid while placing the shoulder in 0°, 45°, and 90° of external rotation or abduction was measured. Continuous variables for changes in AN position were compared with paired 2-tailed Student t test. RESULTS: The mean distance between the AN and the humeral head with the shoulder in 0°, 45°, and 90° of external rotation and 0° of abduction was 13.77 mm (SD 4.31), 13.99 mm (SD 4.12), and 16.28 mm (SD 5.40), respectively. The mean distance between the AN and glenoid with the shoulder in 0°, 45°, and 90° of external rotation was 16.33 mm (SD 3.60), 15.60 mm (SD 4.19), and 16.43 (SD 5.35), respectively. The mean distance between the AN and the humeral head with the shoulder in 0°, 45°, and 90° of abduction and 0° of external rotation was 13.76 mm (SD 4.31), 10.68 mm (SD 4.19), and 3.81 mm (SD 3.08), respectively. The mean distance between the AN and glenoid with the shoulder in 0°, 45°, and 90° of abduction was 16.33 mm (SD 3.60), 17.66 mm (SD 5.80), and 12.44 mm (SD 5.57), respectively. CONCLUSIONS: The AN position relative to the inferior aspect of the glenohumeral joint does not significantly change despite position of external rotation. Increasing shoulder abduction over 45° decreases the distance from the glenohumeral joint to the AN and should be avoided.

Revision of failed humeral head resurfacing arthroplasty.

PURPOSE: The purpose of this study is to assess the outcomes of a consecutive series of patients who underwent revision surgery after humeral head resurfacing (HHR). Our joint registry was queried for all patients who underwent revision arthroplasty for failed HHR at our institution from 2005 to 2010. Eleven consecutive patients (average age 54 years; range 38-69 years) that underwent revision of 11 resurfacing arthroplasties were identified. The primary indication for resurfacing had been osteoarthritis in six, glenoid dysplasia in two, a chondral lesion in two, and postinstability arthropathy in one patient. The indication for revision was pain in 10 and infection in one patient. Seven patients had undergone an average of 1.9 surgeries prior to resurfacing (range 1-3). MATERIALS AND METHODS: All patients were revised to stemmed arthroplasties, including one hemiarthroplasty, two reverse, and eight anatomic total shoulder arthroplasties at a mean 33 months after primary resurfacing (range 10-131 months). A deltopectoral approach was used in seven patients; four patients required an anteromedial approach due to severe scarring. Subscapularis attenuation was found in four cases, two of which required reverse total shoulder arthroplasty. Bone grafting was required in one glenoid and three humeri. RESULTS: At a mean follow-up of 3.5 years (range 1.6-6.9 years), modified Neer score was rated as satisfactory in five patients and unsatisfactory in six. Abduction and external rotation improved from 73° to 88° (P = 0.32) and from 23° to 32° (P = 0.28) respectively. Reoperation was required in two patients, including one hematoma and one revision for instability. CONCLUSION: Outcomes of revision of HHR arthroplasty in this cohort did not improve upon those reported for revision of stemmed humeral implants. A comparative study would be required to allow for definitive conclusions to be made.

Anterior glenohumeral instability: a pathology-based surgical treatment strategy.

The glenohumeral joint is the most frequently dislocated major joint, and most cases involve an anterior dislocation. Young male athletes competing in contact sports are at especially high risk of recurrent instability. Surgical timing and selection of surgical technique continue to be debated. Full characterization of the injury requires an accurate history and physical examination. Diagnostic imaging assists in identifying the underlying anatomic lesions, which range from no discernible lesion to significant bone loss of the glenoid or humeral head and/or capsulolabral stretching or avulsion from the glenoid or humerus. Historically, open Bankart repair has been considered to be the standard method of managing capsulolabral injuries, but comparable results have been achieved with arthroscopic techniques. In the setting of anterior glenoid bone loss >20% of the articular surface, iliac crest bone grafting or coracoid transfer via the Bristow or Latarjet procedures has demonstrated satisfactory outcomes. Favorable results have been reported with bone grafting or remplissage for engaging Hill-Sachs lesions and those that affect >30% of the humeral circumference.

Low transcondylar fractures of the distal humerus: results of open reduction and internal fixation.

BACKGROUND: This study presents the outcomes of low transcondylar fractures of the distal humerus treated by open reduction and internal fixation. METHODS: Between 1996 and 2010, 263 distal humeral fractures were managed at our institution. Patients with a true low transcondylar fracture treated by open reduction and internal fixation were included. Fourteen patients form the basis of this study. Fracture fixation was achieved through a triceps-sparing approach, a triceps tongue, or an olecranon osteotomy. Internal fixation was performed with parallel plates, orthogonal plates, a single lateral plate, or a single medial plate. The clinical outcome was measured with pain levels, range of motion, and the Mayo Elbow Performance Score. Radiographs at latest follow-up were assessed for union, delayed union, nonunion, and hardware failure. RESULTS: At most recent follow-up, 11 patients had no pain, 2 had mild pain, and 1 had moderate pain. The mean Mayo Elbow Performance Score was 85. The mean arch of motion was 95°. Complications included nonunion, delayed union, wound complications, deep infection, and heterotopic ossification. DISCUSSION: Stable internal fixation of low transcondylar fractures is perceived as difficult to achieve because of the very small size of the distal fragment. However, the results of our study indicate that internal fixation of low transcondylar fractures of the distal humerus is associated with a high union rate and satisfactory clinical results. Elbow arthroplasty does not need to be considered for most patients with a low transcondylar distal humeral fracture.

Thirty and ninety-day reoperation rates after shoulder arthroplasty.

BACKGROUND: The purpose of the present study was to assess thirty and ninety-day reoperation rates after shoulder arthroplasty from 2000 to 2010. METHODS: Our institution's joint registry was queried to identify shoulder arthroplasties performed from January 2000 to December 2010. Data regarding patient demographics and the type of procedure were reviewed. Reoperations within thirty and ninety days after the index procedure were analyzed. During the eleven-year study period, 2305 primary arthroplasties (502 hemiarthroplasties, 1440 anatomic total shoulder arthroplasties, and 363 reverse total shoulder arthroplasties) and 518 revision arthroplasties (twenty-one hemiarthroplasties, 356 anatomic total arthroplasties, and 141 reverse arthroplasties) were performed. Fifty-four percent of patients were female; mean age was sixty-eight years (range, eighteen to ninety-seven years) and body mass index was 30.3 kg/m2 (range, 14.7 to 65.9 kg/m2). RESULTS: Reoperation was required within thirty days after fourteen primary arthroplasties (0.6%) and eight revision arthroplasties (1.5%); it was required within ninety days after thirty-two primary arthroplasties (1.4%) and thirteen revision arthroplasties (2.5%). The most frequent causes for reoperation after primary and revision arthroplasty were instability (n = 14 and 6) and infection (n = 13 and 3). The mean number of additional procedures required was 1.3 (range, one to four) for primary arthroplasties and 1.8 (range, one to three) for revision arthroplasties; 20% of patients undergoing reoperation required two or more additional procedures. Reoperations led to readmission in 82% of cases. CONCLUSIONS: Short-term reoperation after shoulder arthroplasty was infrequent. Wound complications and shoulder instability were the most frequent causes for reoperation. Reoperation was twice as frequent after revision surgery as after primary shoulder arthroplasty.

Valoración de la utilidad del injerto y el sustituto óseo en el tratamiento de las fracturas del radio distal / Utility of bone graft and bone substitute for treatment of distal radius fractures

Introducción: El objetivo del presente trabajo fue analizar el impacto de la utilización de injerto óseo autólogo o sustituto óseo en la consolidación de las fracturas del radio distal y, secundariamente, en sus resultados funcionales y radiográficos. Materiales y métodos: Se analizaron en forma retrospectiva 49 casos de fracturas del radio distal tratados con reducción abierta y osteosíntesis. En el grupo A se utilizó injerto óseo o sustituto óseo, no así en el grupo B. Se compararon las tasas de seudoartrosis y los resultados radiográficos y funcionales entre ambos grupos. Se utilizaron las pruebas de la X2 de Pearson y de la t de Student y se consideró significativo un valor de p < 0,05 para las distintas variables. Resultados: No hubo ningún caso de seudoartrosis. El resultado funcional, según el puntaje de Green y OÆBrien, fue en promedio de 81 en el grupo A y de 84 en el grupo B, estadísticamente no significativo. Hubo una diferencia significativa para los grados de extensión de la muñeca en el grupo B. No se observó una diferencia radiológica significativa entre ambos grupos. Conclusiones: No se encontraron pruebas suficientes para aconsejar la utilización sistemática de injerto o sustituto óseo en la osteosíntesis de las fracturas del radio distal a fin de prevenir la seudoartrosis (AU)

Valoración de la utilidad del injerto y el sustituto óseo en el tratamiento de las fracturas del radio distal / Benefits of bone graft and bone substitute for utility treatment distal radius fractures

Introducción: El objetivo del presente trabajo fue analizar el impacto de la utilización de injerto óseo autólogo o sustituto óseo en la consolidación de las fracturas del radio distal y, secundariamente, en sus resultados funcionales y radiográficos. Materiales y métodos: Se analizaron en forma retrospectiva 49 casos de fracturas del radio distal tratados con reducción abierta y osteosíntesis. En el grupo A se utilizó injerto óseo o sustituto óseo, no así en el grupo B. Se compararon las tasas de seudoartrosis y los resultados radiográficos y funcionales entre ambos grupos. Se utilizaron las pruebas de la X2 de Pearson y de la t de Student y se consideró significativo un valor de p < 0,05 para las distintas variables. Resultados: No hubo ningún caso de seudoartrosis. El resultado funcional, según el puntaje de Green y O’Brien, fue en promedio de 81 en el grupo A y de 84 en el grupo B, estadísticamente no significativo. Hubo una diferencia significativa para los grados de extensión de la muñeca en el grupo B. No se observó una diferencia radiológica significativa entre ambos grupos. Conclusiones: No se encontraron pruebas suficientes para aconsejar la utilización sistemática de injerto o sustituto óseo en la osteosíntesis de las fracturas del radio distal a fin de prevenir la seudoartrosis.

Background: The purpose of the following study is to measure the impact of bone substitute or bone graft to heal distal radius fractures, and its functional and radiographic results. Methods: We retrospectively analyzed 49 cases of distal radius fracture treated with open reduction and internal fixation. Group A used bone graft or bone substitute while cases in group B did not. Non-union rates, as well as functional and radiographic results were comparedbetween both groups. Pearson’s Chi square test and T Student test were used to assess outcomes; p < 0.05 wasconsidered significant. Results: There were no non-unions. GroupA had an average Green & O’Brien score of 81, and group B 84, the difference was not significant. Better extension wasachieved in group B with a significant difference. There was no difference regarding radiological results. Conclusions: We have not found sufficient evidence in our results to recommend the systematic use of bone graft or bone substitute in distal radius fractures to prevent non-union.

Correlación clínico-radiológica funcional del tratamiento de las fracturas distales del radio con osteodesis percutánea / Clinical-radiological correlation of wrist function after distal radius fracture treated with percutaneous pinning

El objetivo del trabajo es evaluar la función residual de la articulación de la muñeca luego de sufrir una fractura distal del radio desplazada, reducción incruenta, osteodesis percutánea y correlacionarlo con las imágenes radiológicas residuales.