Metacarpophalangeal portal safety. An anatomical study

AIM

To quantify the risk of dorsal innervation injury when performing direct metacarpophalangeal joint portals of the second to fifth fingers.

MATERIAL AND METHOD

An anatomical study of 11 upper limbs of fresh corpses was carried out. After placing them in a traction tower, the metacarpophalangeal portals were developed on both sides of the extensor tendon. The dorsal sensory branches were dissected and the distances between the portal and the nearest nerve were measured by a digital caliper. The portals of all the fingers were compared globally to assess the safest finger and two to two radial and ulnar portals were compared in each of the fingers to assess the safest portal within each finger.

RESULTS

The overall comparison of all portals and fingers showed that the third finger is the safest in any of its portals, while the ulnar side of the second and radial of the fourth are the portals with the highest risk of nerve injury (P=8.96·10^-5). Comparing two to two of the radial and ulnar portals in each of the fingers showed that the ulnar portal is safer than the radial on the fourth finger (P=.042), while the radial is safer than the ulnar on the fifth finger (P=.003).

CONCLUSIONS

The third finger was the safest to perform metacarpophalangeal portals, while the ulnar side of the second finger and radial side of the fourth had the highest risk of nerve injury.

Técnica de sutura tendinosa «un paso, 4-hilos Kessler-Tsuge»

A pesar de haber numerosas técnicas de sutura tendinosa y de no existir un acuerdo general sobre cuál es la mejor, sí hay acuerdo en las características generales que debe tener una buena sutura. Debe ser sencilla su realización, tener nudos bloqueados, conseguir una aposición sin tensión y perfecta de los extremos tendinosos con un mínimo o ningún «gap» en el sitio de la reparación sin producir una lesión de la vascularización del tendón y con una fuerza y resistencia suficientes para permitir una movilización precoz.

En este trabajo presentamos una nueva técnica quirúrgica cuyo diseño sigue 5 principios: (1) cruzar la zona de reparación solo 2 veces para hacer más sencilla la técnica y la aposición perfecta de los cabos tendinosos; (2) conseguir una sutura de 4 hilos de un material resistente; (3) evitar nudos abultados en el sitio de reparación, para facilitar la reparación con el menor material interpuesto; (4) evitar nudos abultados sobre la superficie del tendón, de tal forma que la sutura deslice mejor bajo las poleas; y (5) con una resistencia y fuerza superiores a las admitidas como óptimas.

Volar Central Portal in Wrist Arthroscopy

Background Nowadays, the wrist is not limited to a dorsal visualization; the joint can be thought of as a "box," which can be visualized from almost every perspective. The purpose of this study was to describe a new volar central portal for the wrist, following three principles: a single incision that allows access to both the radiocarpal and midcarpal joints, centered on the lunate, with the volar structures at risk protected not only by retractors, but also by tendons. Description of Technique The incision begins in the distal wrist crease and extended 1.5 cm proximally up to the proximal wrist crease, following the axis of the third intermetacarpal space. The flexor superficialis tendons are identified and retracted toward the radial side. Next, the fourth and fifth flexor digitorum profundus tendons are retracted toward the ulnar side, while the third and second tendons are retracted toward the radial side. The volar central midcarpal portal is performed under direct vision just over the anterior horn of the lunate through the Poirier space. The volar central radiocarpal portal is created under the lunate through the interval between the ulnocarpal ligaments and the short radioulnar ligament. Methods An anatomical study was performed on 14 cadaver specimens. Two data were recorded: iatrogenic injuries of the structures at risk and the distances to the structures at risk. Results The median (interquartile range [IQR]) distances from the volar central radiocarpal portal to the median nerve, palmar cutaneous branch of the median nerve, and ulnar neurovascular bundle were 10.5 (7.8-15.0), 18.5 (15.8-20.3), and 7.0 (5.0-10.5) mm, respectively. The median (IQR) distances from the volar central midcarpal portal to the median nerve, palmar cutaneous branch of the median nerve, and ulnar neurovascular bundle were 7.0 (4.8-10.3), 16.0 (14.8-19.0), and 4.5 (3.8-9.0) mm, respectively. No iatrogenic injuries were observed. Conclusion The volar central portal is reproducible and safe. The risk of iatrogenic injury is low. The capsule is pierced through one of its thinner portions, and both the radiocarpal and midcarpal joints can be inspected through one single incision.

[Clinical and functional outcome of unicompartmental knee arthroplasty: influence of the mechanical axis correction]

OBJECTIVES

Clinical and functional outcome of the knee after Unicompartmental Knee Arthroplasty (UKA) and its correlation with lower limb mechanical axis correction.

MATERIAL AND METHODS

We have reviewed the outcome of 29 UKA, corresponding to 29 patients, with an average follow-up of 4.5 years (3-6 years). The distribution was, 21 women and 8 men, 11 unicompartmental osteoarthritis, 17 femoral condyle necrosis and 1 tibial plateau necrosis, and 27 medial versus 2 lateral affected compartments. The clinical-functional situation of the knees was assessed through the Knee Society Score (KSS), and the mechanical axis through long standing film. To calculate the statistical non-parametric correlation between the different parameters, Spearman's coefficient was used.

RESULTS

In the last review, the increases in the mean clinical KSS and functional KSS were significantly different, with +31.24 (±15.7) and +43.66 (±18.4) points, respectively. The mean change in the femorotibial angle was 2°±4°. We did not find any correlation with statistical significance between the average increases obtained in KS scores and: the alignment of the knee before and after the surgery; the thickness of the inserted polyethylene; the variation of the posterior tibial inclination; Insall-Salvati's index. There was no statistically significant association between the variation in the total KS score and the type of implant or the surgical technique used.

CONCLUSION

We did not find any correlation between the clinical results and the radiological measurements in this population.

Arthroscopic ligamentoplasty (bone-tendon-tenodesis). A new surgical technique for scapholunate instability: preliminary cadaver study

We present an anatomical study and description of a new surgical technique for arthroscopic treatment of scapholunate ligament injuries. Five cadaver specimens were used to perform the technique. After arthroscopic surgery, anatomic dissection was performed to measure the distances to critical wrist structures such as the posterior interosseous nerve and the radial artery, and the size and position of the plasty. This arthroscopic technique offers three advantages: soft tissue damage is reduced (avoiding an extensive approach and injury to the secondary stabilizers and reducing scar tissue); injury to the posterior interosseous nerve is avoided (maintaining wrist proprioception and the role of the dynamic stabilizers); and a biotenodesis is made that ensures proper placement, tension and functionality of the flexor carpi radialis ligament reconstruction.

[A case of cutaneous extramedullary hematopoiesis associated with idiopathic myelofibrosis]

Cutaneous extramedullary hematopoiesis is a rare manifestation of chronic myeloproliferative processes, mainly chronic idiopathic myelofibrosis. In adults, it manifests as macules, papules, nodules, and ulcers on the trunk. The lesions usually appear soon after diagnosis and the possibility of a relationship between splenectomy and the appearance of extramedullary foci of hematopoiesis is still debated. Diagnosis is based on histopathology showing an infiltrate with different combinations of myeloid and erythroid cell precursors and megakaryocytes. Symptomatic treatment is provided alongside treatment of the underlying disease. We report a new case associated with chronic idiopathic myelofibrosis in which foci of cutaneous extramedullary hematopoiesis were observed 9 years after initial diagnosis. The lesions were progressive and the patient went on to develop acute myeloid leukemia.

A Case of Vulvar Pyoderma Gangrenosum Associated with Collagenous Colitis

Pyoderma gangrenosum is a reactive inflammatory dermatosis which belongs to the spectrum of neutrophilic dermatoses. Due to a lack of diagnostic criteria, pyoderma gangrenosum is mainly a diagnosis of exclusion. It is rarely observed on the perineum, and vulvar involvement is even less frequent. Collagenous colitis is an idiopathic inflammatory colonic disease that is included in the microscopic colitides. The colonic mucosa and the crypt architecture are preserved but histologic alterations are found. We describe a case of collagenous colitis associated with vulvar pyoderma gangrenosum that improved spectacularly with cyclosporine 3 mg/kg/day and the twice-daily application of topical tacrolimus 0.1%.