REPLANTATION OF THE THUMB OR REVISION OF AMPUTATION: AN EPIDEMIOLOGICAL STUDY.

OBJETIVE: This article presents a retrospective cohort study analyzing patients from IOT-FMUSP who underwent replantation or revision amputation procedures for traumatic thumb amputation between 2013 and 2020. METHODS: The study included 40 patients in the replanted group and 41 patients in the amputed group. The patients were divided according to the level of amputation and their medical records were analyzed. RESULTS: A total of 81 patients with digital amputation were analyzed, consisting of 79 males and 2 females, with mean ages of 43 and 49 for the amputed and replanted groups, respectively. According to the Biemer classification, 28.4% had proximal amputation, while 71.6% had distal amputation. The most common occupation was bricklayer (19.75%), and 80.24% were manual workers. Of the patients, 65% returned to their previous work, with 77.77% of them having amputation on their non-dominant hand, mostly caused by circular saw accidents (77.77%). The replantation success rate was 78%, with an average ischemia time of 9 hours and door-to-room time of 2 hours. CONCLUSION: the study findings revealed that traumatic thumb amputation predominantly affects working-age males with a low education level and the success rate of replantation was high in this ischemia time and door-to-room conditions. Level of Evidence II, Retrospective study.

OBJETIVO: Este artigo consiste em um corte retrospectivo que analisou vítimas de amputação traumática do polegar submetidas a reimplante ou procedimentos de regularização da amputação no Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medica da Universidade de São Paulo (IOT-FMUSP). Métodos: Foram analisados 40 pacientes reimplantados e 41 pacientes regularizados, que foram separados conforme o nível da amputação e, após, tiveram seus prontuários médicos analisados. RESULTADOS: Foram analisados 81 pacientes com amputação digital (79 homens e 2 mulheres), com idade média de 43 anos e 49 anos (Grupo Amputado e Grupo Reimplante, respectivamente) e 28,4% deles tinham amputação proximal, de acordo com a classificação de Biemer, enquanto 71,6% tinham amputação distal. A ocupação mais comum foi a de pedreiro (19,75%), mas 80,24% eram trabalhadores manuais. 65% dos pacientes retornaram ao trabalho anterior. 77,77% dos pacientes afetaram a mão não dominante, e a serra circular causou 77,77% das amputações. A taxa de sucesso para reimplantes foi de 78%. O tempo de isquemia foi de 9 horas e o tempo de porta-quarto foi de 2 horas. Conclusão: O estudo revelou que as taxas de reimplante foram altas nas condições de isquemia e tempo porta-sala, e a maioria dos pacientes vítimas de amputação traumática do polegar são homens em idade de trabalho e com baixa escolaridade. Nível de Evidência II, Estudo retrospectivo.

Replantation of the thumb or revision of amputation: an epidemiological study / Reimplante de polegar ou revisão da amputação: um estudo epidemiológico

ABSTRACT Objetive: This article presents a retrospective cohort study analyzing patients from IOT-FMUSP who underwent replantation or revision amputation procedures for traumatic thumb amputation between 2013 and 2020. Methods: The study included 40 patients in the replanted group and 41 patients in the amputed group. The patients were divided according to the level of amputation and their medical records were analyzed. Results: A total of 81 patients with digital amputation were analyzed, consisting of 79 males and 2 females, with mean ages of 43 and 49 for the amputed and replanted groups, respectively. According to the Biemer classification, 28.4% had proximal amputation, while 71.6% had distal amputation. The most common occupation was bricklayer (19.75%), and 80.24% were manual workers. Of the patients, 65% returned to their previous work, with 77.77% of them having amputation on their non-dominant hand, mostly caused by circular saw accidents (77.77%). The replantation success rate was 78%, with an average ischemia time of 9 hours and door-to-room time of 2 hours. Conclusion: the study findings revealed that traumatic thumb amputation predominantly affects working-age males with a low education level and the success rate of replantation was high in this ischemia time and door-to-room conditions. Level of Evidence II, Retrospective study.

RESUMO Objetivo: Este artigo consiste em um corte retrospectivo que analisou vítimas de amputação traumática do polegar submetidas a reimplante ou procedimentos de regularização da amputação no Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medica da Universidade de São Paulo (IOT-FMUSP). Métodos: Foram analisados 40 pacientes reimplantados e 41 pacientes regularizados, que foram separados conforme o nível da amputação e, após, tiveram seus prontuários médicos analisados. Resultados: Foram analisados 81 pacientes com amputação digital (79 homens e 2 mulheres), com idade média de 43 anos e 49 anos (Grupo Amputado e Grupo Reimplante, respectivamente) e 28,4% deles tinham amputação proximal, de acordo com a classificação de Biemer, enquanto 71,6% tinham amputação distal. A ocupação mais comum foi a de pedreiro (19,75%), mas 80,24% eram trabalhadores manuais. 65% dos pacientes retornaram ao trabalho anterior. 77,77% dos pacientes afetaram a mão não dominante, e a serra circular causou 77,77% das amputações. A taxa de sucesso para reimplantes foi de 78%. O tempo de isquemia foi de 9 horas e o tempo de porta-quarto foi de 2 horas. Conclusão: O estudo revelou que as taxas de reimplante foram altas nas condições de isquemia e tempo porta-sala, e a maioria dos pacientes vítimas de amputação traumática do polegar são homens em idade de trabalho e com baixa escolaridade. Nível de Evidência II, Estudo retrospectivo.

Structured evaluation of a comprehensive microsurgical training program.

OBJECTIVES: This study proposed a structured microsurgical training program and evaluated it with the assistance of a large sample of surgeons. METHODS: The practical course comprised 16 sessions of approximately 4 hours each. This included two sessions for suturing rubber gloves and two sessions for suturing arteries, veins, and nerves in chicken thighs. The other sessions were performed on the femoral vessels of rats: 5 sessions for end-to-end arterial anastomosis, 5 for end-to-end venous anastomosis, 1 for arterial grafting, and 1 for end-to-side anastomosis. We conducted a structured assessment of the microsurgical skills in each training session. RESULTS: In this study, 89 surgeons were evaluated. The mean scores for the different procedures were as follows: glove suturing, 33.3±0.59; chicken nerve end-to-end anastomosis, 40.3±0.49; chicken artery suturing, 40.9±0.36; chicken vein suturing, 42.3±0.36; graft interposition, 44.8±0.7; and end-to-side anastomosis, 43.7±0.63 (p<0.05 for all). The chicken thigh suturing scores were significantly higher than the rubber gloves suturing scores (p<0.01). There were no differences between scores of the rat artery and chicken thigh suturing procedures (p=0.24). The rat venous anastomosis scores were higher than the rat arterial anastomosis scores (p=0.02), as were graft interposition scores when compared with end-to-end venous anastomosis scores. The end-to-side anastomosis scores did not differ significantly from the grafting scores (p=0.85). The most common errors were inadequate knotting technique and suture rupture due to inadequate technique (both n=88 [98.9%]). CONCLUSION: We propose a 16-step, progressive microsurgical training program to learn the basic microsurgical techniques comprehensively and reliably. The program was evaluated in a large sample of trainees, and it demonstrated the adequacy of the training sequence and results.

Structured evaluation of a comprehensive microsurgical training program

OBJECTIVES: This study proposed a structured microsurgical training program and evaluated it with the assistance of a large sample of surgeons. METHODS: The practical course comprised 16 sessions of approximately 4 hours each. This included two sessions for suturing rubber gloves and two sessions for suturing arteries, veins, and nerves in chicken thighs. The other sessions were performed on the femoral vessels of rats: 5 sessions for end-to-end arterial anastomosis, 5 for end-to-end venous anastomosis, 1 for arterial grafting, and 1 for end-to-side anastomosis. We conducted a structured assessment of the microsurgical skills in each training session. RESULTS: In this study, 89 surgeons were evaluated. The mean scores for the different procedures were as follows: glove suturing, 33.3±0.59; chicken nerve end-to-end anastomosis, 40.3±0.49; chicken artery suturing, 40.9±0.36; chicken vein suturing, 42.3±0.36; graft interposition, 44.8±0.7; and end-to-side anastomosis, 43.7±0.63 (p<0.05 for all). The chicken thigh suturing scores were significantly higher than the rubber gloves suturing scores (p<0.01). There were no differences between scores of the rat artery and chicken thigh suturing procedures (p=0.24). The rat venous anastomosis scores were higher than the rat arterial anastomosis scores (p=0.02), as were graft interposition scores when compared with end-to-end venous anastomosis scores. The end-to-side anastomosis scores did not differ significantly from the grafting scores (p=0.85). The most common errors were inadequate knotting technique and suture rupture due to inadequate technique (both n=88 [98.9%]). CONCLUSION: We propose a 16-step, progressive microsurgical training program to learn the basic microsurgical techniques comprehensively and reliably. The program was evaluated in a large sample of trainees, and it demonstrated the adequacy of the training sequence and results.

COMPARATIVE STUDY BETWEEN TRADITIONAL TENOLYSES AND WITH INTRAOPERATIVE AWAKENING PERFORMED ON THE FLEXOR OSTEOFIBROUS TUNNEL REGION OF THE HANDS (ZONE 2).

OBJECTIVE: Flexor tendon tenolysis on zone 2 is a difficult and really challenging for hand surgery. With the objective of comparing the results obtained between tenolyses with intraoperative awakening, performed with locoregional anesthesia (group 1), from those obtained with traditional tenolysis performed under general anesthesia or total blockage of the brachial plexus (group 2), the authors conducted a prospective and controlled study. METHODS: 22 patients with 39 fingers with flexor tendon injuries on zone 2 evolving to adherences were assessed. All patients were operated after three months and before one year of the primary tendinous suture. All patients showed limited active motion not improved by rehabilitation. Groups 1 and 2 showed to be homogenous concerning patients' age and gender, preoperative compromising, and absence of associated injuries or pathologies. All patients were assessed according to active motion (TAMs) both preoperatively and at 6 months postoperatively. RESULTS: The statistical analysis of data obtained for groups 1 and 2 shows that the tenolysis performed with both techniques produce good results. By comparing the results for total active motion after six months of the tenolysis, group 1 patients (treated by the intraoperative awakening technique) were found to present better outcomes. CONCLUSIONS: Flexor tenolysis on zone 2 provide good results in terms of joint range of motion. The intraoperative awakening technique with locoregional anesthesia provides improved outcomes when compared to the traditional technique.

Estudo comparativo entre as tenólises convencionais e com despertar intraoperatório realizadas na região do túnel osteofibroso flexor das mãos (zona 2) / Comparative study between traditional tenolyses and with intraoperative awakening performed on the flexor osteofibrous tunnel region of the hands (zone 2)

OBJETIVO: As tenólises dos tendões flexores na zona 2 são procedimentos difíceis e um verdadeiro desafio na cirurgia da mão. Com o objetivo de comparar os resultados obtidos entre as tenólises com despertar intraoperatório, realizadas sob anestesia locorregional (grupo 1), daqueles obtidos com as tenólises convencionais, realizadas sob anestesia geral ou bloqueio total do plexo braquial (grupo 2), os autores realizam um estudo prospectivo e controlado. MÉTODOS: Foram avaliados 22 pacientes com 39 dedos portadores de lesão de tendão flexor na zona 2 que evoluíram para aderências. Todos os pacientes foram operados após três meses e antes de um ano da sutura tendinosa primária. Todos apresentavam limitação da movimentação ativa sem melhora com a reabilitação. Os grupos 1 e 2 mostraram-se homogêneos em relação à idade dos pacientes, sexo, comprometimento pré-operatório e ausência de lesões ou patologias associadas. Todos os pacientes foram avaliados de acordo com a movimentação ativa (TAMs) no período pré-operatório e com seis meses de pós-operatório. RESULTADOS: A análise estatística dos dados obtidos nos grupos 1 e 2 demonstra que as tenólises realizadas pelas duas técnicas proporcionam bons resultados. Ao comparar os resultados da movimentação ativa total após seis meses da tenólise, observa-se que os pacientes do grupo 1, tratados pela técnica do despertar intraoperatório, apresentavam melhores resultados. CONCLUSÕES: As tenólises dos flexores na zona 2 proporcionam bons resultados em termos de ganho de amplitude articular. A técnica de despertar intraoperatório com anestesia locorregional proporciona resultados mais satisfatórios que a técnica convencional.

OBJECTIVE: Flexor tendon tenolysis on zone 2 is a difficult and really challenging for hand surgery. With the objective of comparing the results obtained between tenolyses with intraoperative awakening, performed with locoregional anesthesia (group 1), from those obtained with traditional tenolysis performed under general anesthesia or total blockage of the brachial plexus (group 2), the authors conducted a prospective and controlled study. METHODS: 22 patients with 39 fingers with flexor tendon injuries on zone 2 evolving to adherences were assessed. All patients were operated after three months and before one year of the primary tendinous suture. All patients showed limited active motion not improved by rehabilitation. Groups 1 and 2 showed to be homogenous concerning patients' age and gender, preoperative compromising, and absence of associated injuries or pathologies. All patients were assessed according to active motion (TAMs) both preoperatively and at 6 months postoperatively. RESULTS: The statistical analysis of data obtained for groups 1 and 2 shows that the tenolysis performed with both techniques produce good results. By comparing the results for total active motion after six months of the tenolysis, group 1 patients (treated by the intraoperative awakening technique) were found to present better outcomes. CONCLUSIONS: Flexor tenolysis on zone 2 provide good results in terms of joint range of motion. The intraoperative awakening technique with locoregional anesthesia provides improved outcomes when compared to the traditional technique.

Análise crítica dos reimplantes no membro superior / Critical analysis of upper limb replantations

Os autores analisam a evolução dos resultados obtidosem 62 pacientes adultos vítimas de amputação traumática no membro superior e submetidos a procedimento de reimplante com sucesso, entre 1994 e 2004. Métodos: Os níveis da amputação foram em dedos ou polegar em 48, mão em 5, punho em 4, antebraço em 2 e braço em 3 pacientes. Todos os pacientes realizaram reabilitação em programa de terapia de mão especializada. Foi utilizado um questionário simplificado para avaliar o retorno à atividade de trabalho utilizando o membro superior operado, seja na economia formal ou informal, e o índice de satisfação do paciente em relação à sua cirurgia. Observou-se que 85,5% dospacientes retornam a alguma atividade de trabalho usando o membro operado e que 96,8% dos pacientes estão satisfeitos como resultado obtido. Existe alto índice de retorno a uma atividade laborativa e satisfação de pacientes submetidos areimplantes com sucesso.

Sinostose escafóide-trapézio completa congênita não sindrômica: relato de caso e revisão da literatura / Complete congenital and nonsyndromic scaphoid-trapezium synostosis: case report and literature review

Objetivo: Apresentar um caso de sinostose escafóide-trapézio, completa, congênita, sintomática, não sindrômica, bilateral. Material: Paciente branca, com 32 anos de idade, nega dor e apresenta limitação da amplitude de movimento do punho sem quadro degenerativo associado. A separação incompleta do precursor cartilaginoso dos ossos do carpo, durante a 4ª a 8ª semana de vida intra-uterina, resulta em fusões cartilaginosas (sincondroses) ou ósseas (sinostoses) entre os ossos do carpo, que se tornam radiograficamente aparentes quando há ossificação carpal. Essas anomalias de separação são de ocorrência rara. Acredita-se que sejam assintomáticas e usualmente diagnosticadas de forma acidental em exames radiográficos. A sinostose no carpo pode ser denominada coalizão carpa. Essa anomalia ocorre mais freqüentemente no sexo feminino, na raça negra e entre o semilunar e piramidal. A sinostose no lado radial do punho é extremamente rara