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Original Article
Tibiotalocalcaneal arthrodesis using a humeral locking plate
Artrodesis tibiotalocalcánea con placa humeral bloqueada
M.P. Cabrera Méndeza,
Corresponding author
Mariapa.cabrera@gmail.com

Corresponding author.
, C. Gambab, E. Hernándezb, J. Molanob, J.C. Andradea
a Servicio de Ortopedia y Traumatología, Universidad Militar Nueva Granada, Hospital Militar Central, Bogotá, Colombia
b Unidad de Cirugía de Pie y Tobillo, Servicio de Ortopedia y Traumatología, Hospital Militar Central, Bogotá, Colombia
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Patients with complaints that involve the foot as well as the ankle may have significant pain&#44; deformity and functional limitation&#46; Many conditions can cause degeneration in the ankle and subtalus joint&#46; Arthrodesis is indicated in many complaints&#44; chiefly rheumatoid arthritis&#44; degenerative arthrosis&#44; injury or infection&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Other less common indications are avascular necrosis of the talus&#44; neuroarthropathy&#44; osteochondral lesions of the ankle and subtalus which are not treatable in other ways&#44; and rescue surgery such as the total arthroplasty of failed ankles&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In our fourth level hospital&#44; the most common complaint is injuries caused by fragmentation weapons &#40;antipersonnel mines&#41; which compromise the lower limbs&#46; They make it necessary for the reconstructive surgery team to innovate or use osteosynthesis products supplied by commercial companies for other purposes &#40;such as humeral osteosynthesis&#41; to resolve complex fractures in other joints&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The standard orthopaedic treatment of ankle and subtalus joint degeneration when conservative management has failed is tibiotalocalcaneal &#40;TTC&#41; arthrodesis&#46; One of the first descriptions of this technique was given by Lexter in 1908&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3&#8211;6</span></a> He had used this procedure in the ankle and subtalus joints with boiled bones from corpses&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Several materials may be used for TTC arthrodesis&#58; current implants include screws&#44;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">7&#44;8</span></a> plates&#44;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">9&#44;10</span></a> intramedular nails<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">11&#8211;13</span></a> and external fixation&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">9&#44;14</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">There is little information in the literature about the use of locked plates <span class="elsevierStyleItalic">in vivo</span> for TTC arthrodesis&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Nevertheless&#44; within the most representative studies of this technique at an international level&#44; the one by Ahmad et al&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a> stands out&#46; In this he found that the use of a locked plate in this technique increased the stability of the construct with consolidation in up to 94&#37; of cases&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In this work we report the clinical and functional results of patients treated using TTC arthrodesis with fixation by a humeral locking plate&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0045" class="elsevierStylePara elsevierViewall">A descriptive observational and retrospective study of a series of cases from January 2007 to December 2013 in the Hospital Militar Central&#44; Bogot&#225;&#46; This is a fourth level hospital&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">This study includes all of the patients diagnosed with symptomatic arthrosis of the tibiotalar and subtalar joints that did not improve with medical management&#44; and who also presented risk factors for pseudoarthrosis or poor consolidation&#44; such as obesity&#44; poor bone quality or deformities&#44; among others&#46; They were treated using TTC arthrodesis&#44; with a locking humeral plate and a transfibular approach&#46; Patients with TTC arthrosis were included after clinical or X-ray diagnosis&#44; with functional evaluation prior to surgery using the American Orthopaedics Foot and Ankle Society &#40;AOFAS&#41; scale&#44; and with a follow-up of at least 6 months&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Data were collected in a predesigned base for subsequent analysis using the SPSS 21 statistical analysis programme&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The exclusion criteria ruled out those patients with large scars or lesions on the side of the ankle&#44; or ones which required Plastic Surgery for treatment&#44; without excluding lesions on the soft medial or anterior parts of the ankle&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">This study was approved by the Independent Ethics Committee of the Hospital Militar Central&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Surgical technique</span><p id="par0070" class="elsevierStylePara elsevierViewall">Preoperatorative evaluation&#58;</p><p id="par0075" class="elsevierStylePara elsevierViewall">It is important to evaluate bone quality before the procedure&#44; as if there is significant deformity the other limb must be compared as a template to estimate the position of the arthrodesis&#46; In addition to X-rays&#44; computerised tomography is recommended to evaluate failed joints and bone defects&#44; particularly when the integrity of the tibia metaphysis is in question&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">It is very important to take implant adaptation into account&#44; as it was designed for another purpose&#46; Preoperational planning takes place &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The surgical technique described below is the one used by the authors and is analysed in this study&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0090" class="elsevierStylePara elsevierViewall">The patient is positioned supine with a support under the ipsilateral hip and internal rotation of the ankle to facilitate exposure of the fibula&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0095" class="elsevierStylePara elsevierViewall">A standard transfibular longitudinal incision is made of 8&#8211;12<span class="elsevierStyleHsp" style=""></span>cm&#44; after which the distal fibula is resected to expose the tibiotalar and subtalar joint&#44; dissecting the distal portion of the calf nerve &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The incision is extended to the base of the fourth metatarsus&#44; making it possible to raise the digitorum brevis extensor muscle to suitably expose the subtalar joint&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0100" class="elsevierStylePara elsevierViewall">The remaining cartilage in the arthritic joint and subchondrial bone tissue is removed until the bleeding bone is visible&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Cuts in the bone are made and the soft tissues are freed to correct any deformity in the previous alignment of the limb&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall">After preparing the joint surfaces bone grafts must be put into place by filling or covering highly fragmented bone defects&#46; In some cases structural grafts must be put into place to prevent the limb from shortening &#40;obtained from previously partially dried fibula and the bone bank&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0115" class="elsevierStylePara elsevierViewall">A grooved 7&#46;3<span class="elsevierStyleHsp" style=""></span>mm screw with a partial thread is placed posterior-inferior to anterior-superior through the calcaneus to the astragalus and distal tibia&#44; compressing the ankle joint as well as the subtalar joint&#46; This screw is placed perpendicular to the locked plate&#44; with the screw in the sagital plane and the plate in the coronal plane&#44; to increase the rotational stability of the fixation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7&#46;</span><p id="par0120" class="elsevierStylePara elsevierViewall">The proximal part of the locked humeral plate is fixed to the calcaneus and astragalus by locked screws in multiple planes of fixation &#40;putting them into position inversely&#41;&#46; The distal part of the plate is fixed to the distal tibia by a combination of cortical and locked screws&#46; In the majority of cases fixing is achieved in the calcaneus using 4 locked screws&#44; with 2&#8211;3 in the talus and 4 bicortical screws in the distal tibia &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Postoperative care</span><p id="par0125" class="elsevierStylePara elsevierViewall">Immediately after the operation patients are fitted with a short immobiliser of the posterior calf and foot splint type until the bone callus is seen in the X-rays&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In all cases this immobilisation time lasts from 6 to 12 weeks after surgery&#44; especially in patients who are overweight or have severe osteopenia&#59; and most especially those with Charcot&#39;s arthropathy are immobilised during 10&#8211;12 weeks after the procedure&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Once X-rays show consolidation a physiotherapy programme commences&#44; in which more weight is gradually supported&#44; increasing this by 25&#37; of body weight every 2&#8211;3 weeks&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0140" class="elsevierStylePara elsevierViewall">35 patients were evaluated&#58; 7 &#40;20&#37;&#41; women and 28 &#40;80&#37;&#41; men&#46; The average age was 36&#46;3 years old&#44; ranging from 19 to 77 years old and with a median age of 32 years old &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">Respecting the aetiology of the arthrosis&#44; this was post-traumatic in 26 cases &#40;74&#37;&#41;&#44; in the majority of cases secondary to wounds caused by fragmentation weapons or firearm projectiles&#59; it was neuropathic in 7 cases &#40;20&#37;&#41;&#44; chiefly due to diabetic arthropathy&#59; it was metabolic in one case&#44; caused by gout arthritis in one case &#40;2&#46;8&#37;&#41; and congenital in one case &#40;2&#46;8&#37;&#41; due to fibula hemimelia&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The graft used was autogenous from previously dried fibula in 13 cases &#40;37&#46;1&#37;&#41;&#44; an allograft &#40;demineralised bone matrix&#41; in 8 cases &#40;22&#46;8&#37;&#41; and combined in 14 cases &#40;40&#37;&#41;&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The bone took an average of 4&#46;37 months to fuse&#44; with a rate of joining as detected by X-ray of 91&#46;4&#37; at 6 months&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Among the complications which arose with this procedure&#44; consolidation was delayed in 3 cases&#44; due to which 2 were operated again and one is awaiting programmed revision surgery for arthrodesis&#44; with a new placement of autogenous iliac crest bone graft&#46; Secondly&#44; there are 4 cases of infections at the site of the operation&#46; 2 of these cases were resolved using antibiotics as outpatients&#44; while the other 2 were resolved with the aid of surgical washing&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Functionality was evaluated using the AOFAS scale&#46; The median functionality score before surgery was 20&#46;34&#47;100 points&#44; and after surgery it was 66&#46;7&#47;100 points&#44; with an overall improvement of 46 points on this scale with a value of <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#46; This shows a statistically significant improvement in the patients after the operation&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">On the VAS pain scale the average score prior to surgery was 8&#44; and after surgery it was 2&#46;35&#46; The average time taken to consolidate was 4&#46;5 months&#44; and patients began walking again without support or pain after 6 months&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0175" class="elsevierStylePara elsevierViewall">TTC arthrodesis using locked plates is a useful tool when it is necessary to fuse large bones&#44; ones with defects and angular deformities that have to be corrected&#44; and when the substrate is weakened bone and&#44; in many cases&#44; the soft tissues are in poor condition&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Several systems have been used historically and are now used to fix arthrodesis&#44; including crossed screws&#44; endomedular nails and even external fixation&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Several attempts have been made to determine which implant is superior in biomechanical terms&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Bennett et al&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> found that using 3 crossed screws gave better biomechanical stability than retrograde endomedular nails and 2 crossed screws&#46; Chiodo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> compared the use of retrograde nails with fixation using plates at a fixed angle and one screw&#46; They found the latter system to be biomechanically superior in osteoporotic bone&#44; with a low rate of complications and that it failed to join in 7&#8211;14&#37; of cases&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Subsequently&#44; Chodos et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> compared the use of a fixed angle plate with a plate locked at a variable angle&#46; They found the latter to be more stable&#44; a more rigid construct and able to support greater loads with less deformation&#46; This is mainly due to the characteristics of the locking mechanism of the system and its divergence in the distal screws&#44; which allows it to include more of the astralagus and calcaneus in the fixation&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">In 2014&#44; Heck et al&#46;&#44;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">19&#44;20</span></a> in their study of 12 patients treated using TTC arthrodesis with a locked humeral plate&#44; showed 100&#37; consolidation and only one case of delayed consolidation&#44; with an incidence of infection at the site of the operation of 15&#37; that improved without any subsequent complications&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">In our institution high energy trauma is the main cause of extensive lesions that compromise these joints&#44; especially wounds caused by firearms and fragmentation weapons&#46; We have therefore tried to standardise this technique with the aim of performing the procedure in a single operation while&#44; together with achieving a suitable level of stability&#44; correcting any deformities that may be present&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">The results in our series of cases are similar to those in other works in the literature in terms of consolidation time&#44; percentage of joining and functionality&#46; It even shows fewer complications when compared with other patients having similar characteristics&#46; In our experience&#44; the locked humeral plate may be of use in patients with severely compromised bone at the level of the ankle that requires arthrodesis as rescue surgery and in patients with a very high risk of failure to join&#44; while always understanding that it is an alternative form of management in comparison with different types of implants&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusion</span><p id="par0215" class="elsevierStylePara elsevierViewall">The patients included in this work presented a wide range of medical conditions that altered the bone quality and functioning of the joint&#46; Nevertheless&#44; a high rate of bone consolidation was achieved&#44; with suitable stability of the construct and postoperative functionality&#46; This is a reproducible technique that gives good postoperative results which agree with those reported in the literature&#44; so that it should be taken into account when treating a patient with TTC arthrodesis&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Level of evidence</span><p id="par0220" class="elsevierStylePara elsevierViewall">Level of evidence <span class="elsevierStyleSmallCaps">iv</span>&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Ethical responsibilities</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Protection of people and animals</span><p id="par0225" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Confidentiality of data</span><p id="par0230" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work centre on the publication of patient data&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Right to privacy and informed consent</span><p id="par0235" class="elsevierStylePara elsevierViewall">The authors must have obtained the informed consent of the patients and&#47;or subjects mentioned in the article&#46; The author for correspondence must be in possession of this document&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of interests</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To describe the results of tibiotalocalcaneal arthrodesis &#40;TTC&#41; using a humeral locking plate&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods and materials</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective&#44; observational study was conducted between January 2007 and December 2013 in the Hospital Militar Central de Bogot&#225;&#46; The study included patients with symptomatic osteoarthritis diagnosed clinically and radiologically&#44; and who underwent TTC arthrodesis using a humeral locking plate with a minimum follow up of 6 months&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The total number patients was 35&#44; of whom 7 &#40;20&#37;&#41; were women and 28 &#40;80&#37;&#41; men&#44; with a mean age 36&#46;3 years &#40;19&#46;77&#41;&#46; Aetiology&#58; 74&#37; with post-traumatic arthritis&#44; most of them secondary to gunshot wounds and fragmentation weapons&#44; and neuropathic in 20&#37;&#46; An autogenous graft was used in 13 cases&#44; and 14 cases using both&#44; with a mean consolidation time of 4&#46;37 months&#46; Complications include&#44; delayed union in 3 cases&#44; and surgical site infection in 4&#46; The postoperative functionality &#40;AOFAS&#41; mean was 66&#46;7&#47;100 points&#44; with a score of 2&#46;35 on a visual analogue pain scale&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">TTC arthrodesis using a humeral locking plate is a suitable option for fixing this type of arthrodesis&#44; with a low rate of complications&#44; and postoperative results that revealed satisfactory improvement in pain and consolidation&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Describir los resultados obtenidos en la artrodesis tibiotalocalc&#225;nea &#40;TTC&#41; con placa humeral bloqueada&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos y materiales</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio descriptivo observacional&#44; retrospectivo tipo serie de casos&#44; entre enero de 2007 y diciembre de 2013 en el Hospital Militar Central de Bogot&#225;&#46; Se incluy&#243; a pacientes con artrosis TTC sintom&#225;tica diagnosticada tanto cl&#237;nica como radiol&#243;gicamente tratados mediante artrodesis TTC con placa humeral bloqueada con seguimiento m&#237;nimo de 6 meses&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Un total de 35 pacientes&#58; 7 &#40;20&#37;&#41; mujeres y 28 &#40;80&#37;&#41; hombres&#46; Edad promedio 36&#44;3 a&#241;os &#40;19&#44;77&#41;&#46; Etiolog&#237;a&#58; 74&#37; con artrosis de origen postraum&#225;tico&#44; en la mayor&#237;a de los casos&#44; secundaria a heridas por arma de fragmentaci&#243;n y heridas por proyectil de arma de fuego&#59; neurop&#225;ticas 20&#37;&#46; El injerto utilizado fue aut&#243;geno en 13 casos y combinado en 14 casos&#44; con un tiempo de fusi&#243;n promedio de 4&#44;37 meses&#46; Respecto a complicaciones&#44; se present&#243; retraso en la consolidaci&#243;n en 3 casos e infecci&#243;n del sitio operatorio en 4&#46; La puntuaci&#243;n postoperatoria promedio en la escala AOFAS fue&#58; 66&#44;7&#47;100 puntos con un puntaje en la Escala Visual An&#225;loga del dolor de 2&#44;35&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La artrodesis TTC con placa humeral bloqueada es una adecuada opci&#243;n para la fijaci&#243;n de este tipo de artrodesis con una baja tasa de complicaciones y con resultados postoperatorios satisfactorios en cuanto a mejor&#237;a de dolor y consolidaci&#243;n&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Cabrera M&#233;ndez MP&#44; Gamba C&#44; Hern&#225;ndez E&#44; Molano J&#44; Andrade JC&#46; Artrodesis tibiotalocalc&#225;nea con placa humeral bloqueada&#46; Rev Esp Cir Ortop Traumatol&#46; 2016&#59;60&#58;119&#8211;124&#46;</p>"
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ISSN: 19888856
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