Surgical treatment of periprosthetic humerus fractures and algorithm. / Tratamiento quirúrgico de las fracturas periprotésicas de húmero y algoritmo de actuación.

INTRODUCTION: Periprosthetic humerus fractures are infrequent and sometimes difficult to treat. There is limited literature and no consensus on the handling of these fractures. The objective of this study was to compare our results with those published in the literature, in order to improve our care and propose a management algorithm. MATERIAL AND METHOD: Observational study of 10cases of periprosthetic humerus fractures with a mean follow-up of the patients of 23months. An analysis of sociodemographic, radiological and surgical variables was performed. They were reviewed clinically and by telephone using the UCLA Shoulder Score and Quick-DASH scales. A systematic search was made in Pubmed for periprosthetic humerus fractures, for a literature review with which to compare our series. RESULTS: We analysed 10patients with an average age of 69.4years (37-91). Of the patients, 90% underwent surgery through open reduction and internal fixation. Nine of the ten patients consolidated in a mean time of 6.2months (range 5-12), the remaining suffered a new fracture 5months after the intervention, who were reoperated and a new osteosynthesis performed with bone allograft. In the UCLA scale there was a decrease of 10.66points, and an increase of 27.3points in the Quick-DASH, at the end of the follow-up. CONCLUSIONS: In our series of cases we found similarities in the literature, in relation to demographic aspects and obtaining good radiographic results, which do not correspond to the functional outcome of patients.

Talus fractures. Functional results for polytraumatized patients. / Fracturas de astrágalo. Resultados funcionales en pacientes politraumatizados.

Talar fractures are uncommon lesions (0.1-0.9%) and have a high rate of complications. One of the situations in which a fracture of the talus can occur is in the context of polytrauma which may further compromise the functional prognosis. The aim of this study was to analyze the functional results in patients with talar fractures whether or not they occurred in the context of polytrauma. Observational study on a retrospective cohort of 24 patients operated in our centre (2008-2016). They were grouped according to whether they were polytraumatized (ISS>16) or not (ISS≤16). Review of sociodemographic, radiographic, functional variables (VAS pain scale and FADI -Foot and Ankle Disability Index-) and the onset of complications such as arthrosis, arthrodesis or avascular necrosis. Review of 25 talar fractures in 24 patients with a mean age of 38 years (19-75) and a mean follow-up of 4.2 years (0.5-9). According to the ISS, 44% of patients (11) were polytraumatized and 56% (14) were not. The average score according to the FADI scale was 62 points for the polytraumatized patients and 76.9 for the non-polytraumatized patients. The pain according to the VAS scale was 5.8 points in the group of polytraumatized patients and 4.3 in the non-polytraumatized patient group. Regarding complications, 64% of the polytraumatized patients and 43% of the non-traumatized patients had a complication. 36% of the polytraumatized patients had clinical and radiological signs of subtalar arthrosis compared to 35% of the non-traumatized patients, of whom 27% underwent arthrodesis compared to 28% of the non-traumatized patients. 27% of the polytraumatized patients were diagnosed with avascular necrosis as opposed to 0% of the non-polytraumatized patients.

Treatment of posttraumatic bone defects of the forearm with vascularized fibular grafts. Follow up after fourteen years.

BACKGROUND: Among several techniques proposed for the reconstruction of posttraumatic bone defects of the forearm, that of free vascularised fibular graft (FVFG) is one of the most widely used. PATIENTS AND METHOD: We study the long-term outcomes of 14 patients who underwent FVFG between 1994 and 2009, with a minimum follow up of 8 years and a maximum of 23 years (mean: 13.9 years). Demographic, clinical and radiological variables were collected retrospectively. The DASH scale was used for clinical assessment. RESULTS: Fourteen patients were operated on by the same surgeon, applying FVFG for the reconstruction of posttraumatic bone defects of the forearm (three septic non-union of the ulna or radius, five radius fractures, two ulna fractures and four fractures of both bones). The maximum length of the defect was 11 cm and the minimum length was 6 cm. In four cases, reconstruction of the two bones was achieved using the double barrel technique, and in another four cases, an osteoseptocutaneous flap was used. Fixation was performed with 3.5 mm reconstruction plates in thirteen cases and with 3.5 mm screws in one case. Consolidation was obtained in 12 cases (85.7%) after an average time of 4.2 months (range: 2-6.5 months). In one case, consolidation of the proximal ulnar fracture site was not achieved, and in another, following the failure of reconstruction attempts, an arthrodesis was performed. At the end of the follow-up period, the patients had an average DASH score of 17.1 points (range 1.8-68.1). CONCLUSIONS: FVFG is a valid option for the reconstruction of posttraumatic bone defects of the forearm. Its use via the double barrel method or as an osteocutaneous composite graft enables the simultaneous reconstruction of both forearm bones and associated soft tissue injuries. Long-term follow-up of patients who have undergone this technique confirms its satisfactory functional and radiological results.

In Vivo Mechanical Characterization of the Distraction Callus During Bone Consolidation.

Understanding the evolution of callus mechanical properties over time provides insights in the mechanobiology of fracture healing and tissue differentiation, can be used to validate numerical models, and informs clinical practice. Bone transport experiments were performed in sheep, in which a distractor type Ilizarov was implanted. The forces through the fixator evolution were measured and the callus stiffness was estimated from these forces. Computerized tomography images were taken and bone volume of the callus at different stages was obtained. The results showed that the maximum bone tissue production rate (0.146 cm³/day) was achieved 20 days after the end of the distraction phase. 50 days after the end of the distraction phase, the callus was ossified completely and had its maximum volume, 6-10 cm³ In addition, 80-90% of the load sustained by the operated limb was recovered and the callus stiffness increased exponentially until 5.4-11.4 kN/mm, still below 10% of the healthy level of callus stiffness. The effects of the bony bridging of the callus and the time of the fixator removal on callus force, stiffness and volume were analyzed. These outcomes allowed relating quantifiable biological aspects (callus volume and tissue production rate) with mechanical parameters (callus force and stiffness) using data from the same experiment.

Pacientes con fractura de pelvis inestables hemodinámicamente in extremis ¿packing pélvico o arteriografía? / Patients with hemodynamic unstable pelvic fractures in extremis: Pelvic packing or angiography?

El manejo multidisciplinar de los pacientes con traumatismo pélvico ha mejorado su pronóstico, sin embargo la mortalidad sigue siendo muy elevada. La estrategia de un tratamiento adecuado es aún controvertida, sobre todo respecto al control de la hemorragia en pacientes cuya situación clínica es extrema mediante el uso de arteriografía o packing pélvico. Planteamos mediante una herramienta de medicina basada en evidencia (CAT) el beneficio de la realización del packing pélvico en relación a una pregunta clínica específica desde una situación concreta, ¿qué es mejor para el manejo del sangrado, packing pélvico extraperitoneal o arteriografía, en pacientes con fractura de pelvis inestables hemodinámicamente in extremis? De este estudio podemos concluir que la arteriografía puede mejorar el control de la hemorragia en los pacientes con sangrado arterial y hemodinámicamente estables, pero el packing tiene prioridad en los pacientes con fracturas de pelvis e inestabilidad hemodinámica (AU)

The multidisciplinary management of patients with pelvic trauma has improved prognosis, but mortality is still very high. The appropriate treatment strategy remains controversial, especially regarding the control of bleeding in patients whose clinical situation is extreme by using angiography or pelvic packing. We propose using a tool of evidence-based medicine (CAT) the benefit of the completion of pelvic packing in relation to a specific clinical question from a specific situation. What is best for the management of bleeding, extraperitoneal pelvic packing or angiography, in patients with hemodynamically unstable pelvic fracture in extremis? From this study we can conclude that angiography may improve control of bleeding in patients with arterial bleeding and hemodynamically stable but the packing has priority in patients with pelvic fractures and hemodynamic instability (AU)

[Patients with hemodynamic unstable pelvic fractures in extremis: pelvic packing or angiography?]. / Pacientes con fractura de pelvis inestables hemodinámicamente in extremis ¿packing pélvico o arteriografía?

The multidisciplinary management of patients with pelvic trauma has improved prognosis, but mortality is still very high. The appropriate treatment strategy remains controversial, especially regarding the control of bleeding in patients whose clinical situation is extreme by using angiography or pelvic packing. We propose using a tool of evidence-based medicine (CAT) the benefit of the completion of pelvic packing in relation to a specific clinical question from a specific situation. What is best for the management of bleeding, extraperitoneal pelvic packing or angiography, in patients with hemodynamically unstable pelvic fracture in extremis? From this study we can conclude that angiography may improve control of bleeding in patients with arterial bleeding and hemodynamically stable but the packing has priority in patients with pelvic fractures and hemodynamic instability.

Análisis del síndrome Inestable-Doloroso de la articulación subastragalina mediante el sistema estrés dinámico BaroPodoTAC / Analysis of Unstable-painful Subtalar Joint Syndrome using Dynamic Stress System CT scan

Introducción: La inestabilidad de tobillo y de retropié coexisten frecuentemente sin que existan en la actualidad métodos objetivos no quirúrgicos para su diagnóstico diferencial. Además, la inestabilidad y el dolor en la articulación subastragalina pueden desembocar en la temida artrosis de retropié en pacientes de cualquier edad. El presente trabajo tiene como propósito principal comparar el rango de movilidad del retropié sintomático respecto al retropié sano en una serie consecutiva de pacientes afectos de inestabilidad de tobillo. Material y Método: Se diseñó un dispositivo que simula condiciones de carga con movimientos extremos de la articulación subastragalina sobre la mesa de TAC (Estrés-BaroPodo-TAC). Se realizó TAC en carga y en dos posiciones extremas de inversión-rotación interna y eversión-rotación externa sobre 26 pies de 13 pacientes diagnosticados de inestabilidad crónica de tobillo. Se midieron los ángulos de divergencia y flexión astrágalo-calcánea en las dos posiciones mencionadas y se calculó el rango de movimiento total. Se comparó el retropié problema con el retropié sano en cada paciente. Resultados: Los pies problemas presentaron mayor rango de movilidad de divergencia astrágalo-calcáneo que los pies sanos de los pacientes. No hubo diferencias en el rango de movilidad de flexión astrágalo-calcáneo. No se correlacionó estadísticamente el movimiento de divergencia en el plano axial con el movimiento de flexión astrágalo-calcánea en el plano sagital. Conclusión: Mediante este método se midió objetivamente mediante TAC el rango de movimiento de la articulación subastragalina. Los pacientes con inestabilidad de tobillo y dolor en retropié presentaron mayor rango de movilidad en la articulación subastragalina en el retropié doloroso respecto al contralateral (AU)

Introduction: In many cases, unstable ankle and heel coexist without there currently being any objective, non-surgical method for a differential diagnosis. Moreover, instability and pain in the subtalar joint could deteriorate into the so dreaded osteoarthritis of the heel in patients of any age. The main objective of this work is to compare the movement range of a symptomatic heel with regards to a healthy heel in a consecutive series of patients affected with ankle instability. Material and method: A device was designed to simulate weight-bearing conditions with extreme subtalar joint movement on the CAT scan examination table (Estrés-BaroPodo-TAC). A CAT scan was performed during weight-bearing and in two extreme positions of internal inversion rotation and external eversion rotation of 26 feet in 13 patients, all diagnosed with chronic, unstable ankle. The divergence and flexion of heel angles in the two positions mentioned and the total movement range was calculated. The heel problem was compared with the healthy heel in each patient. Results: The problem foot presented a greater range of heel divergence mobility than the patient’s healthy foot. There were no differences in the mobility range for heel flexion. The divergence of movement in the axial plane was not statistically correlated with the heel flexion movement in the sagittal plane. Conclusion: With this method, we objectively measured the movement range of the heel joint, using CAT scan. Patients with unstable ankle and heel pain presented a greater range of movement in the heel joint of the painful heel with respect to the contralateral movement (AU)

Secuela de fractura de pelvis. A propósito de un caso y revisión de la literatura / Pelvis fracture sequelae. A case report and literature review

Objetivos: Presentación y análisis crítico de paciente con secuela post-fractura de pelvis que permita exponer la complejidad de su manejo y tratamiento. Caso clínico: Mujer de 29 años con dolor invalidante en región sacroilíaca a la sedestación y la marcha. Exploración: Deformidad externa pélvica con repercusión estética, dismetría de miembro inferior izquierdo de 4 cm y dolor sacroilíaco a la apertura pélvica o al apoyo monopodal izquierdo. Limitación funcional a la marcha con cojera y problemas de sedestación (sitting imbalance). Estudio radiográfico convencional y TAC con signos de asimetría pélvica, elevación de hemipelvis izquierda y pseudoartrosis sacra y de ramas ilioisquiopubianas izquierdas post-fractura. Diagnóstico: Secuela compleja de Fractura de Pelvis con deformidad, tipo III de Mears y Velyvis. Tratamiento: Secuenciado en 2 fases. (1) Liberación Anterior: Desarticulación sinfisaria, esqueletización de ramas y osteotomía sacra anterior. Liberación Posterior: Liberación ligamentos suelo pélvico y osteotomía sacra posterior. Tracción progresiva de la extremidad izquierda 2 semanas. (2) Osteosíntesis Anterior: Fijación sacroilíaca anterior con placa de reconstrucción, doble placa anterior sinfisaria y aporte de autoinjerto. Osteosíntesis Posterior: Fijación posterior mediante barra transilíaca. Evolución: Infección herida quirúrica posterior que se resolvió con curas quirúrgicas y antibioterapia. Se consiguió disminución del nivel de dolor, resolución del trastorno de sedestación y mejora de la cojera. SF-36 con PCS 60 y MCS de 50, Majeed-Score excelente. Discusión: La pseudoartrosis y la deformidad son entidades infrecuentes generadas por tratamientos conservadores o inadecuados en lesiones con gran inestabilidad pélvica. El tratamiento puede ser realizado de forma directa o en varias fases. Los pacientes deben ser informados de que el tratamiento implica riesgos más elevados que respecto a la cirugía aguda convencional. Suele obtener mejoras en resultados de consolidación y funcionalidad. El paciente aquí referido ha sido tratado de forma análoga a lo establecido por la comunidad científica, a pesar de ello, no existe evidencia clínica respecto a protocolos de manejo en dicha enfermedad. La realización de estudios multicéntricos ayudaría a la comprensión de los patrones lesionales y al desarrollo de herramientas estandarizadas de tratamiento. Conclusión: La secuela de la fractura pélvica es una entidad compleja de dificultosa resolución y difícil manejo incluso para expertos en dicha materia. Es preciso un abordaje multidisciplinar de dichos paciente en centros de tercer nivel para la obtención de los mejores resultados en esta patología (AU)

Objectives: Critical assessment of a case report related to complications in pelvis fracture. The aim is to determine the complexity in management and treatment of pelvic sequelae. Case Report: 29 years old woman with disabling pain in sacroiliac joint when sitting and walking. External pelvic deformity with aesthetic evidence, left lower limb with 4 cm dysmetria and sacroiliac pain pelvic when examination maneuvers opening pelvis or standing on one foot. Functional limitation with sitting and gait problems. Conventional X-rays and CT-scan reveal pelvic asymmetry, upper left hemipelvis and nonunions in sacrum and left ilioischiopubic ramus fractures. Diagnosis: Pelvic fracture complication Velyvis and Mears type III. A two phases sequenced treatment was performed: (1) Anterior Release: Symphyseal disjoint, branches skeletonization and anterior sacral osteotomy. Posterior Release: Posterior sacroiliac complex and pelvic floor ligaments release with posterior sacral osteotomy. Progressive left extremity traction 2 weeks. (2) Anterior Osteosynthesis: Anterior sacroiliac fixation with reconstruction plate, double symphyseal plate and patient bonegrafting. Posterior Osteosynthesis: Transiliac bar. Outcome with surgical wound infection solved with antibiotics and surgical treatment. A pain decrease, sitting disorder resolution and improvement of lameness was achieved. SF-36 with 60 PCS and 50 MCS. Excelent Majeed-Score. Discussion: Pelvic malalignement and nonunions are rare entities, usually associated with initial conservative or inadequate treatment in pelvic instable fractures. Treatment may be accomplished directly or in stages. Patients should be informed that treatment involves higher risks than over conventional acute surgery. It often obtains improved consolidation and functionality results. The patient here referred has been treated similarly to that established by the scientific community, nevertheless, there is no clinical evidence regarding management protocols in the disease. Multicenter studies would help the understanding about patterns and development of standardized treatment algorithms. Conclusion: Pelvic fracture complications are complex entities. It involves a hard resolution and difficult management even for expert surgeons. A multidisciplinary approach of these patients in tertiary centers is needed to obtain the best results in this pathology (AU)

Biomechanical analysis of a new minimally invasive system for osteosynthesis of pubis symphysis disruption.

INTRODUCTION: We analysed the effectiveness of a new percutaneous osteosynthesis system for the treatment of pelvis fractures with rotational instability. METHODS: A pre-clinical cross-sectional experimental study wherein Tile type B1 injuries (open-book fractures) were produced in 10 specimens of fresh human cadavers, including the L4-5 vertebrae, pelvic ring, and proximal third of the femur, keeping intact the capsular and ligamentous structures, is presented in this paper. The physiological mobility of the intact pelvis in a standing position post-injury was compared to that following the performance of a minimally invasive osteosynthesis of the symphysis with two cannulated screws. A specially designed test rig capable of applying loads simulating different weights, coupled with a photogrammetry system, was employed to determine the 3D displacements and rotations in three test cases: intact, injured and fixed. RESULTS: After applying an axial load of 300 N, no differences were observed in the average displacement (mm) of the facet joints of the intact pubic symphysis in comparison to those treated with screws (p >0.7). A statistical difference was observed between the average displacements of the sacroiliac facet joints and pelvises with symphyseal fractures treated with screws after the application of a load (p <0.05). CONCLUSION: The symphyseal setting with two crossed screws appears to be an effective alternative to osteosynthesis in pelvic fractures with rotational instability.

Diseño y desarrollo de un modelo experimental para estudios biomecánicos de fracturas tipo B de Tile del anillo pélvico / Design and development of an experimental model for biomechanical studies of Tile type B1 fracture of the pervic ring

Objetivo: Diseñar un modelo estandarizado y reproducible para la realización de ensayos biomecánicos de fracturas tipo B1 de Tile del anillo pélvico. Metodología: Establecida en dos fases. Fase 1, determinación de requerimientos fundamentales del sistema. Fase 2, diseño, testado y elección de las piezas del modelo experimental. Se empleó una máquina universal de ensayos (MTS- 810), programas de diseño gráfico (Solid Edge Academic), fantomas, rail de carga deslizante y materiales industriales de Fabricación del Sistema de Fijación. Resultados: Se obtuvo un modelo constituido por dos sistemas de anclaje, superior e inferior, que permiten articular la pelvis a la máquina de ensayo tanto proximalmente, a través del sacro y L5, como a nivel distal con ambos fémures. El sistema permitió fijación adecuada de especímenes a máquina de ensayo, mantener la estática postural de bipedestación a la carga y reproductibilidad de lesión B1 de Tile. Conclusión: Es posible diseñar y fabricar un sistema estandarizado de fijación de pelvis humanas a una máquina de análisis de materiales para el estudio biomecánico de las fracturas tipo B1 de Tile del anillo pélvico (AU)

Objetive: The aim of the study is to design a standardized and reproducible procedure for biomechanical testing of Tile B1 fractures of the pelvic ring. Methodology: The methodology for this study was divided in two phases. In the first phase, the requirements to be covered by the system were determined, and in the second one experimental model pieces were designed and chosen. An Universal Testing Machine (MTS-810), Graphic Design Plans Program Software (Solid Edge Academic), Fantomas, Bearing, Sliding Rail and Manufacturing Material Fixing System were used. Results: A specific loading biomechanic system has been created, consisting on an upper and a lower anchor, which allows pelvis ring fix to the test machine both proximally through the sacrum and the last lumbar vertebra, and in terms of both femurs to the database of the testing machine. The procedure make a correct bone fixation, place the pelvis in a stand position, getting to align the upper and lower anterior iliac spines in the same plane and reproduce Tile B1 fracture. Conclusion: It is possible to design and manufacture a simple standard system for determining human pelvis to a testing machine for biomechanical studies of Tile type B1 pelvic ring fractures (AU)