Comparative analysis of scaphoid nonunion treatment with screw fixation and angular stable plate

INTRODUCTION

Scaphoid fractures represent 5-10% of nonunion rate and the treatment options consist of an open reduction with correction of deformity, restoration of the scaphoid length with autologous wedge grafting and fixation. However, there is still no consensus in the literature on the best fixation method. Therefore, the purpose of the study is to compare plate fixation and screw fixation in treating scaphoid nonunion with humpback deformity and carpal instability.

METHODS

Prospective, non-randomised study comparing the treatment of two groups of patients with scaphoid nonunion. A total of 19 patients were included in the study, the first ten patients were included in group 1 (plate fixation), subsequently nine patients were included in group 2 (screw fixation). The nonunion duration was longer than 6 months and patients did not present type III Scaphoid Nonunion Advanced Collapse (SNAC). Clinical evaluations included pain intensity, range of motion, grip strength, pinch test and functional scales Disabilities of the Arm, Shoulder and Hand (DASH) and Mayo Wrist Score. Radiographic evaluations consisted of radiographs of both wrists in AP, AP with ulnar deviation, lateral and oblique views. Patients further underwent a tomography of the affected wrist for bone deformity, carpal collapse and later consolidation evaluation.

RESULTS

According to post-operative measurements, group 1 showed a significant improvement in the scapholunate angle (p = 0.011) and in the intrascaphoid angle (p = 0.002). Group 2 only showed an improvement in the scapholunate angle (p = 0.011). All patients in group 1 achieved consolidation in 8 weeks, while group 2 patients had a slower consolidation, with a mean of 14 weeks and standard deviation (SD) of 4.2, with statistical significance (p = 0.006).

CONCLUSION

Our prospective study, despite the limitations, contributes to the literature for demonstrating a better fixation using plate, with a better correction of humpback deformity and Dorsal Intercalated Segment Instability (DISI) and a faster consolidation.

LEVEL OF EVIDENCE

II, therapeutics studies; prospective comparative study.

EPIDEMIOLOGICAL ASPECTS OF DUPUYTREN'S DISEASE IN BRAZIL

Objectives:

The purpose of this study is to describe associated factors and epidemiological aspects of Dupuytren’s Disease in patients followed up in a Brazilian tertiary public hospital, at the Hand Surgery service.

Methods:

A cross-sectional study was performed from 2014 to 2019.

Data collected included:

age, gender, ancestry, associated comorbidity presence, phenobarbital, tobacco, and alcohol use, family history of Dupuytren’s Disease and associated fibrotic diseases. Then, the patients underwent a clinical examination to identify and characterize the involvement of the fingers. The patients were also assessed in regard to whether they presented Dupuytren’s Disease severity factors.

Results:

140 patients were included, 70.7% men and 29.3% women. Only 42.3% reported being of European ancestry; 20% had first-degree relatives with the disease; 59.3% presented comorbidities, including hypertension, diabetes, chronic heart disease, dyslipidemia, epilepsy, and HIV infection; 15.8% had Ledderhose disease, 7.1% had Peyronie’s disease. 31% were smokers, 16.6% were alcoholic, and 37.1% were phenobarbital users; 40% presented with a severe form of DD.

Conclusion:

The population studied was composed of Brazilians, most of whom did not report European ancestry; still, they presented several characteristics similar to those described in literature worldwide. Level of Evidence II; Prognostic Studies; Investigating the effect of a patient characteristic on the outcome of a disease .

Role of early shoulder tomography on the obstetric brachial plexus palsy

Objective:

To demonstrate the importance of performing early shoulder tomography in patients with obstetric brachial plexus palsy (OBPP).

Methods:

This series of cases retrospective study with level evidence IV was conducted by consulting 76 patient's medical records with OBPP divided into three age groups: ≤12 months, 13 to 24 months and ≥ 25 months. The patients were classified according to gender, affected side, type of paralysis according to Narakas classification, and by computed tomography, according to the Waters scale.

Results:

The association between the age groups with Waters classification was statistically significant (p=0,006), showing that patients in the group aged less than 12 months and in the group aged between 12 and 24 months had a relevant correlation between the physical examination and Waters > III when compared to patients from groups aged 25 months or older.

Conclusion:

This study shows a correlation between the findings in the physical examination and severe dysplasia on the shoulder of children under 24 months of age, justifying the early tomographic shoulder exam in order to achieve a better follow-up and a consider a more aggressive approach in the treatment of OBPP affected children. Level of Evidence IV, Case Series.

Extensor digitorum brevis flap on the treatment of lower limb injuries

OBJECTIVE:

To describe our pioneer national experience with 11 patients with soft tissue defects in the distal 1/3 of the leg, ankle and forefoot treated with extensor digitorum brevis muscle flap (EDB).

METHODS:

Between November 2009 and July 2012 11 patients were operated with the flap technique. We operated nine men and two women aged between 10 and 66 years. The surgical indications were acute trauma in four patients and post-traumatic osteomyelitis in seven patients. The small defects were covered ranging from 3x3 to 6x3 cm. The patch was applied with proximal stalk in most cases.

RESULTS:

Complete healing and infectious cure were obtained in all cases, despite one loss.

CONCLUSION:

The EDB flap is a feasible and safe technique to repair foot, ankle and distal leg losses. Suffering, dehiscence and delayed healing of the EDB end flap donor area may, however, occur. L-shaped incisions should be avoided for muscle lifting. Level of Evidence IV, Case series.

Results of ulnar nerve neurotization to biceps brachii muscle in brachial plexus injury

OBJECTIVE

To evaluate the factors influencing the results of ulnar nerve neurotization at the motor branch of the brachii biceps muscle, aiming at the restoration of elbow flexion in patients with brachial plexus injury.

METHODS

19 patients, with 18 men and 1 woman, mean age 28.7 years. Eight patients had injury to roots C5-C6 and 11, to roots C5-C6-C7. The average time interval between injury and surgery was 7.5 months. Four patients had cervical fractures associated with brachial plexus injury. The postoperative follow-up was 15.7 months.

RESULTS

Eight patients recovered elbow flexion strength MRC grade 4; two, MRC grade 3 and nine, MRC <3. There was no impairment of the previous ulnar nerve function.

CONCLUSION

The surgical results of ulnar nerve neurotization at the motor branch of brachii biceps muscle are dependent on the interval between brachial plexus injury and surgical treatment, the presence of associated fractures of the cervical spine and occipital condyle, residual function of the C8-T1 roots after the injury and the involvement of the C7 root. Signs of reinnervation manifested up to 3 months after surgery showed better results in the long term.

LEVEL OF EVIDENCE

IV, Case Series.

Limb replantation after avulsion injuries: techniques and tactics for success

Objectives

Retrospective evaluation of cases of limb replantation after avulsion injuries. Evaluation of the techniques and tactics used, that contributed to success and good functional results.

Methods

Forty-three patients' records were assessed. All the cases had been submitted to limb replantation after avulsion injuries.

Results

The majority of the cases were young men. The most common injury was to the thumbs. The surgical techniques and tactics used were: nerve grafting, vein grafting, transposition of the digital vessels, limb shortening, and heterotopic replantation. The most commonly used technique was vein graft. The limb survival rate was high (93%), as was patient satisfaction.

Conclusion

Replantation after avulsion injury depends on the correct diagnosis of the limb viability and the use of appropriate surgical techniques and tactics for each case. The experience of the team of surgeons and a good hospital structure are essential for good results. There are few articles in medical literature about the indications, techniques and results of limb replantation after avulsion injuries. We believe that this retrospective evaluation can bring new information and contributions to the correct management of this highly complex situation. Level of evidence IV, Case Series.

Avaliação histológica da neurorrafia término-lateral: estudo experimental em ratos

OBJETIVO: Realizar estudo histológico comparando o crescimento axonal após neurorrafia término-lateral com e sem epineurectomia. MÉTODOS: foram utilizados vinte ratos Wistar, machos, divididos em dois grupos de 10 ratos cada. Um segmento de 1,0cm do nervo tibial e, foi transposto para o lado contralateral, sendo suturado no nervo ciático D. No grupo I, a sutura foi realizada diretamente no epineuro, enquanto que no grupo II foi realizado epineurectomia. Após 4 semanas foi realizado avaliação histológica do segmento transposto e no nervo ciático D, no sitio distal à lesão. RESULTADOS: demonstrou-se baixa quantidade de fibras remielinizadas, variando de 7 a 51 fibras no Grupo I e de 10 a 91 fibras no Grupo II. Utilizou-se o teste U de Mann-Whitney, com p=0,31, demonstrando que não há diferença estatisticamente significante entre os dois grupos. Não há relação positiva entre o número de fibras remielinizadas no enxerto e no sitio distal à lesão do ciático. CONCLUSÃO: A neurorrafia término-lateral, com e sem janela epineural, não promove remielinização eficiente. Nivel de evidência: Nível II: Estudo prospectivo comparativo

Avaliação artroscópica e macroscópica da faceta medial do semilunar

OBJETIVO: avaliar a correlação entre a presença de uma faceta medial do semilunar e a incidência de lesões ligamentares e artrose do pólo proximal do hamato. MÉTODOS: Avaliação artroscópica e dissecação dos punhos foram efetuados em cadáveres. RESULTADOS: Houve uma correlação clara, estatisticamente significativa entre artrose do pólo proximal do hamato e a presença da faceta medial do semilunar. CONCLUSÃO: Artrose do pólo proximal do hamato está correlacionada com a presença do tipo II semilunar. Nível de Evidência III, Estudo de pacientes nãoconsecutivos; sem padrão de referência "ouro" aplicado uniformemente

Transposição do enxerto vascularizado da fíbula pro fêmur diafisário sem microanastomoses

OBJETIVO: O estudo descreve uma maneira nova e simples de transplantar o enxerto ósseo vascularizado da fíbula pro fêmur diafisário sem necessidade de microcirurgia, demonstra o caso clínico operado com bom resultado quanto a vascularização e consolidação óssea e, por último, especula sobre possíveis outras aplicações dentro da cirurgia reconstrutiva. MÉTODOS: A fíbula vascularizada é transportada até o fêmur sem necessidade de microcirurgia, alcançando até sua metáfise proximal através das comunicações das perfurantes do músculo gêmeo lateral com as septais fibulares via retalho de pele póstero-lateral da perna que intersecciona os dois sistemas. RESULTADOS: O paciente operado evoluiu sem infecção. Cintilografia esquelética precoce demonstrou vascularização óssea. CONCLUSÃO: O retalho gêmeo fibular é nova arma no arsenal do cirurgião. Sua técnica é factível, reprodutível, seu tempo cirúrgico reduzido e o princípio de construção com ponte através de ilhas de pele e perfurantes poderá ser aplicado na construção de novos retalhos.

Fibrin glue application in microvascular anastomosis: comparative study of two free flaps series

BACKGROUND

Since the first experiments with fibrin glue application in microvascular anastomoses in 1977, several studies have reported its benefits on suture reduction and anastomosis decreased time. In spite of that, clinical experience has been limited to two neurosurgical and two replantation case series, all of them with good results. This study was conducted to evaluate the feasibility and the potential benefits of fibrin glue application in free flaps.

METHODS

We performed 24 free flaps in 24 patients, from March 2005 to June 2006. Twenty were included in this study. They were divided into two groups according to the anastomosis technique: conventional group (n = 7 patients) and fibrin glue group (n = 13 patients). In the conventional group, the anastomosis was performed with interrupted sutures, whereas in the fibrin glue group, they were performed using less sutures and fibrin glue application.

RESULTS

The application of fibrin glue cut by half the number of sutures required to complete the anastomoses. The mean arterial and venous anastomotic times in the conventional group were 27.2 and 24.0 minutes, respectively. In the fibrin glue group, they were 13.6 and 12.6 minutes, respectively. All these differences were statistically significant. There was no significant difference of ischemic time between two groups (P = 0.26). The survival rate of the flaps was similar in both groups: 84.6% (11 of 13) in the fibrin glue group and 85.7% (6 of 7) in the conventional group (P = 1.0).

CONCLUSIONS

Fibrin glue application in free flaps was feasible and allowed us to complete the anastomoses with fewer sutures and less time. The survival rate of the flaps was not adversely affected by the fibrin glue.

Comparative study of skin folding of dominant and nondominant hemibodies in spastic hemiplegic cerebral palsy

OBJECTIVE

To compare skin folds in the dominant and nondominant halves of the body in a group (A) of 20 individuals with cerebral palsy and spastic hemiplegia and a group (B) of 30 normal volunteers.

METHOD

Body mass, height and skin folds were measured, and the percentage of body fat was estimated by adipose tissue measurement and densitometry. The mean age in group (A) was 24.6 +/- 5.6 years (ranging from 16.1 to 38.1 years). The mean age in group (B) was 25.3 +/- 3.8 years (ranging from 19.0 to 34.11 years).

RESULTS

Statistically significant differences were observed between the dominant and nondominant halves of the body for biceps, triceps, thoracic, suprailiac, thigh and midcalf skin folds in group A; the biceps, subscapular, midaxillary, suprailiac, abdominal, thigh and midcalf skin folds in group B; and the percentage fat obtained by adipose tissue measurement in both groups. Statistically significant differences were observed for the triceps skin fold when the dominant halves of the body in groups A and B were compared. Statistically significant differences were also observed for the biceps, triceps, thigh and midcalf skin folds as well as the adipose tissue measurements between the dominant and nondominant halves of the body in the two groups. The percentage fat as estimated by densitometry was significantly correlated with the adipose tissue measurement.

CONCLUSION

There were statistically significant differences between the skin folds in the dominant and nondominant halves of the body, both in group A and in group B (greater in group A). There was a statistically significant correlation in the percentage fat as estimated by densitometry and as measured by adipose tissue in groups A and B.

Effect of Fibrin Adhesive Application in Microvascular Anastomosis: A Comparative Experimental Study

BACKGROUND

Microvascular anastomosis is the most critical step during free flap transfers or replantations. Although the conventional suture is still considered the standard technique, it is technically difficult, time consuming, and traumatic to the vessel wall. The aim of this study was to evaluate the effectiveness of fibrin adhesive to overcome these problems when applied in microvascular anastomosis.

METHODS

Sixty-eight Wistar rats were used in this study. Eight animals were used in a pilot study to determine the minimum amount of suture stitches required per anastomosis when the fibrin adhesive was applied. In the definitive study, we performed 30 anastomoses in the femoral artery and 30 anastomoses in the carotid artery. In each artery, half of the anastomoses were performed using interrupted sutures without fibrin adhesive (control groups), and the other half were performed using fibrin adhesive and fewer sutures (experimental groups).

RESULTS

The application of fibrin adhesive significantly reduced the number of sutures and the time taken to perform the anastomosis. The anastomotic bleeding was also significantly reduced in both experimental groups. The immediate and late patency rates were not compromised by fibrin glue application. No significant differences were observed in the histologic analysis of the anastomosed vessels between the two techniques.

CONCLUSIONS

The application of fibrin adhesive did not result in any harmful effects in the microvascular anastomosis. The authors encourage the clinical application of fibrin adhesive in more complex cases, when more than one microvascular anastomosis is required.

Anatomic study of the dorsal arterial system of the hand

Historically, the dorsal arterial system of the hand received less attention than the palmar system. The studies concerning dorsal arterial anatomy present some controversies regarding the origin and presence of the dorsal metacarpal artery branches. Knowledge of the anatomy of dorsal metacarpal arteries is especially applied in the surgical planning for flaps taken from the dorsum of the hand. The purpose of this study is to analyze the arterial anatomy of the dorsum of the hand, compare our observations with those of previous studies from the literature, and therefore to define parameters for surgical planning for flaps supplied by the dorsal metacarpal arteries. METHOD: Twenty-six dissections were performed at the dorsum of the right hand of 26 cadavers by making a distal-based U-shaped incision. After catheterization of the radial artery at the wrist level, a plastic dye solution with low viscosity and quick solidification was injected to allow adequate exposure of even small vessels. The radial artery and its branches, the dorsal arterial arch, the dorsal metacarpal arteries, the distal and proximal communicating branches of the palmar system, and the distal cutaneous branches were carefully dissected and identified. RESULTS: The distal cutaneous branches originating from the dorsal metacarpal arteries were observed in all cases; these were located an average of 1.2 cm proximal from the metacarpophalangeal joint. The first dorsal metacarpal artery presented in 3 different patterns regarding its course: fascial, subfascial, and mixed. The branching pattern of the radial artery at the first intermetacarpal space was its division into 3 branches. We observed the presence of the dorsal arterial arch arising from the radial artery in 100% of the cases. The distance between the dorsal arterial arch and the branching point of the radial artery was an average of 2 cm. The first and second dorsal metacarpal arteries were visualized in all cases. The third and fourth dorsal metacarpal arteries were visualized in 96.2% and 92.3% of cases, respectively. There was proximal and distal communication between the dorsal arterial arch and the palmar system through the communicating branches contributing to the dorsal metacarpal artery formation. CONCLUSION: At the dorsum of the hand there is a rich arterial net that anastomoses with the palmar arterial system. This anatomical characteristic allows the utilization of the dorsal aspect of the hand as potential donor site for cutaneous flaps.

[Study of the frequency of diabetes mellitus and glucose intolerance in patients with cystic fibrosis]

OBJECTIVE: To evaluate the frequency of diabetes mellitus and glucose intolerance in patients with cystic fibrosis treated at the Pediatric Gastroenterology Service of HC-FMRP-USP. METHODS: A cross-sectional analytical study was conducted on a group of 25 patients with mucoviscidosis who were followed up at HC-FMRP-USP. Oral glucose tolerance tests (OGTT) were performed, with simultaneous determination of glycemia and insulinemia. Areas under the curve were obtained for glycemia (G) and insulinemia (I) and the I/G ratio was calculated and correlated with the duration of clinical manifestation and pancreatic exocrine function. RESULTS: Five patients presented alterations: one was diabetic and four had glucose intolerance and/or hyperinsulinemia. There was a direct correlation between the area under the curve for insulinemia and the duration of mucoviscidosis. A significant inverse correlation was also observed between the area under the curve for insulinemia and I/G ratio, and number of enzyme capsules/kg/day. CONCLUSIONS: The frequency of alterations in glucose homeostasis observed in patients with mucoviscidosis was higher than in the population at large (20% of the total sample and 33% of the group of patients with glycemia and insulinemia on OGTT). Therefore, it is important that glucose tolerance tests be performed systematically in patients with mucoviscidosis so that metabolic abnormalities can be early detected, and proper treatment can be initiated.