Simultaneous dislocation of both joints of the thumb with a fracture involving the interphalangeal joint. A case report and a review of the literature.

Combined dislocation of the metacarpophalangeal and interphalangeal joints of the thumb is uncommon, only five cases having been previously reported. In this case report, a previously unreported case characterized by volar-ulnar dislocation of the metacarpophalangeal joint and dorsal dislocation of the interphalangeal joint, associated with a unicondilar open fracture of the proximal phalanx, is presented. Only open reduction for the interphalangeal joint was needed and both (metacarpophalangeal and interphalangeal) joints were treated with K-wire fixation after reduction. Internal fixation of the phalangeal fracture was not performed because of the size of the bone fragment. Although the diagnosis of dislocation of the interphalangeal joint is obvious, a simultaneous dislocation of the metacarpophalangeal joint can be easily overlooked, which is a fact that underlines the importance of this article. It is therefore recommended to examine the whole hand.

Efficacy and safety of bemiparin compared with enoxaparin in the prevention of venous thromboembolism after total knee arthroplasty: a randomized, double-blind clinical trial.

In this randomized, multicenter, controlled, double-blind, sequential trial, 381 patients undergoing primary total knee replacement were randomly assigned to receive subcutaneous injections of either 3500 IU anti-factor Xa of bemiparin sodium, first dose 6 h after surgery, or 40 mg of enoxaparin, first dose 12 h before surgery, followed by daily doses for 10 +/- 2 days, for the prophylaxis of venous thromboembolism. The primary efficacy endpoint was venous thromboembolism up to postoperative day 10 +/- 2, defined as deep vein thrombosis detected by mandatory bilateral venography, documented symptomatic deep vein thrombosis and/or documented symptomatic pulmonary embolism. The primary safety endpoint was major bleeding. Eighty-seven percent of all randomized patients (333 of 381 patients) were evaluable for efficacy. The incidence of venous thromboembolism was 32.1% (53 of 165 patients) in the bemiparin group and 36.9% (62 of 168 patients) in the enoxaparin group. The absolute risk difference was 4.8% in favor of bemiparin [95% confidence interval (CI), -15.1% to 5.6%; non-inferiority P-value: 0.02; superiority P-value: 0.36]. The incidence of proximal deep vein thrombosis was 1.8% (three of 165 patients) in the bemiparin group and 4.2% (seven of 168 patients) in the enoxaparin group. Major bleeding occurred in six patients (three in each group). There were no deaths during the study. This trial shows that bemiparin started postoperatively is as effective and safe as enoxaparin started preoperatively in the prevention of venous thromboembolism in patients undergoing total knee replacement.

Artroplastia de silicona del semilunar en la enfermedad de Kienböck: seguimiento a largo plazo / Lunate bone silicone arthroplasty in Kienböck's disease: long-term follow-up

Entre 1986 y 1993 se trataron 20 pacientes con implantes de silicona para la enfermedad de Kienböck con un seguimiento medio de 7 años. La edad media de los pacientes era de 33 años y según la clasificación de Lichtman ocho fueron Grado II, ocho Grado IIIA y cuatro Grado IIIB. Al final del seguimiento el 75 por ciento presentaban persistencia del dolor y un balance articular limitado. A nivel radiológico hubo un colapso carpiano (altura carpiana media de 0,49) y una traslación cubital (distancia cubitocarpiana media de 0,26).Se presentaron las siguientes complicaciones: luxación del implante hacia cubital en dos pacientes; subluxación en dos, una palmar y otra dorsal; presencia de inestabilidad en DISI en seis y en VISI en dos; siliconitis e imágenes líticas intraóseas en ocho y presencia de artropatía degenerativa radio e intercarpiana en 10.Cuatro pacientes precisaron de reintervención: tres artrodesis del carpo y una resección de la primera fila. El implante de silicona genera a largo plazo una sinovitis reactiva con destrucción del carpo, siendo incapaz de frenar la evolución a colapso carpiano y a traslación cubital. A causa de sus limitaciones no creemos que tenga indicación actualmente en el tratamiento de la enfermedad de Kienböck (AU)

The muscles in chronic ligamentous instability of the knee: an experimental study.

Several authors have formulated the idea that insufficiency of the anterior cruciate ligament (ACL) might lead to a biological adaptation, consisting of atrophy of the quadriceps and other extensors (antagonists of the ACL) and relative preservation of the hamstrings and other flexors (agonists of the ACL). We studied the modifications in hindlimb muscles that spontaneously occurred in 36 rabbits with surgically-induced chronic ligamentous instability of the right knee. The unoperated left hindlimb served as a control. Three months after surgery the rabbits were sacrificed and the muscles dissected for macroscopic and microscopic evaluation. In the anterior cruciate ligament-deficient limbs the extensors (quadriceps, glutei and extensor digitorum longus) showed significantly greater atrophy than the other muscles (p < 0.05). Six hundred twenty-two fibers from atrophic muscles, 373 from hypertrophic muscles and 879 from control muscles were evaluated by microscopy. The atrophic muscles showed a significantly lower percentage of type I fibers (responsible for maintenance of posture) and a reduction in the diameter of both type I and II (responsible for rapid movement) fibers with respect to the controls (p < 0.05). The hypertrophic muscles showed a significantly greater proportion of type I fibers and an increase in the diameter of type II fibers with respect to the controls (p < 0.05). Our results support the idea that there is spontaneous adaptation of the muscles to compensate for ligamentous instability.

Meniscal repair by synovial flap transfer. Healing of the avascular zone in rabbits.

We studied repair of a longitudinal incision of the right medial meniscus in 44 rabbits after the transfer of a pedunculated synovial flap, without immobilization of the knee. The left medial meniscus was used as the control, after creating the same lesion without synovial flap. Healing was analyzed by histologic studies, including India ink perfusion after 8, 12, 24, and 48 weeks. In three quarters of the cases, the meniscus showed healing with vascularization of an originally avascular zone.

Contralateral median nerve autograft.

Interfascicular nerve autografting is a useful method to repair nerves with gaps, mainly if the removal of a nerve does not imply a defect to the donor area. Final results of peripheral nerve repair definitely depend on the size of the nerve gap, the level of the injury and the time elapsed from the time of injury until the nerve is repaired.

Condylocephalic nailing in pertrochanteric fractures.

Because of the spectacular increase in the number of fractures of the proximal end of the femur, especially in the elderly, there is a great interest to find surgical techniques that are simple, decrease mortality, and restore early the functional status of the patients, thus reducing the hospital stay. From 1969 until 1989, 2660 fractures were treated with the Küntscher condylocephalic (KC) nail. The mean age of patients was 79 years, and the general condition was considered to be good in only 23%. Death in the ensuing three months occurred in 12.5%. Complications of the technique were supracondylar fractures (1.8%) and migrations of the nails (17.4%). Bone healing occurred at eight to 12 weeks. Only 15% of patients failed to walk. Mean cervicodiaphyseal postoperative angle was 155 degrees. As compared with other surgical techniques, the KC nail was easier to insert, in relatively less operating time, and knee problems of Ender's nail operations can be avoided. The KC nail was most suitable for the treatment of pertrochanteric fractures in elderly patients.