MMP-1, MMP-8, and MMP-13 Gene Polymorphisms and Haplotype Is a Risk Factor for Dupuytren Contracture: A Case-Control Study.

BACKGROUND: There is an increased tissue expression of matrix metalloproteinases (MMPs) on Dupuytren contracture (DC). Genetic polymorphisms (single nucleotide polymorphism [SNPs]) in genes of these enzymes may individually influence these transcriptions. Haplotype analysis, which is the observation of a group of alleles, could be more useful to identify the association between SNPs and DC. The purpose of this study was to evaluate the influence of MMP-1 g.-1607 G>GG (rs1799750), MMP-8 g.-799 C>T (rs11225395), and MMP-13 g.-77 A>G (rs2252070) SNPs individually and in haplotype on DC. METHODS: A total of 60 patients with a clinical diagnosis of DC were evaluated and matched, according to age and gender, with the control group of 100 patients without this clinical diagnosis. Genomic DNA was extracted from saliva samples, and genotypes were obtained by polymerase chain reaction-restriction fragment length polymorphism. Statistical analysis of the results included Mann-Whitney U test, Chi-squared test, and PHASE and R software, with a significance level of 5%. RESULTS: The 3 SNPs studied showed significant differences in allele and genotype frequencies between the groups: 2G in MMP-1 (P = .018; odds ratio [OR] 1.80 (95% confidence interval [CI], 1.13-2.88)), T in MMP-8 (P = .015; OR 0.53 (95% CI, 0.33-0.88)), and A in MMP-13 (rs2252070) SNPs (P = .040, OR 0.54 (95% CI, 0.33-0.90)) are risk alleles. The global haplotype analysis indicated a significant difference between both groups. CONCLUSIONS: In conclusion, MMP-1 g.-1607 G>GG (rs1799750), MMP-8 g.-799 C>T (rs11225395), and MMP-13 g.-77 A>G (rs2252070) SNPs, individually and in haplotype, are a risk factor for DC, indicating that these SNPs may be a potential diagnostic and prognostic factor for DC.

Functional and morphological evaluation of the trapezius muscle after spinal accessory nerve transfer to brachial plexus nerves.

INTRODUCTION: The main innervation of the trapezius muscle is provided by the spinal accessory nerve. Several studies describe the contributions of cervical plexus roots to the trapezius muscle innervation, either directly or through connections with the spinal accessory nerve. There is no adequate understanding of how the trapezius muscle is affected after using the spinal accessory nerve in nerve transfer procedures with the usual technique, preserving at least 1 branch for the upper trapezius. METHODS: We evaluated 20 patients with sequelae of traumatic brachial plexus injury who underwent surgical procedures for brachial plexus repair or free muscle transfer, which included the spinal accessory nerve transfer technique and were followed for a minimum of 1 year. The three portions trapezius muscle were evaluated by physical examination, magnetic resonance imaging (analysis of fatty degeneration) and electromyography. RESULTS: In all evaluation methods, the middle and lower portions of the trapezius muscle showed more significant morphological and/or functional impairment than the upper portion, in most cases. There was a statistically significant difference in all the complementary exams results, between the affected side (with sacrifice of the nerve) versus the normal side, in the middle and lower portions of the trapezius muscle. CONCLUSIONS: Physical examination alone is not sufficient to determine the residual functionality of the trapezius muscle. Magnetic resonance imaging and electromyography are useful tools to assess both morphological involvement of the trapezius muscle and nerve conduction impairment of the trapezius muscle, respectively. The results suggest that the middle and lower portions of the trapezius muscle are affected by previous SAN transfer and should be considered with caution for further muscle transfer procedures.

Microsurgical Reconstruction in an Orthopedic Hospital: Indications and Outcomes in Adults / Reconstrução microcirúrgica em um hospital ortopédico: Indicações e desfechos em adultos

Abstract Objective Advances in reconstructive microsurgery in orthopedic surgery provided better functional and aesthetic results and avoided many indications for amputation. In high-volume trauma and orthopedic hospitals, microsurgical reconstruction is essential to reduce costs and complications for these complex orthopedic defects. We describe a microsurgical approach to traumatic wounds, tumor resection, bone defects, and free muscle transfer, performed by an orthopedic microsurgery unit. The objective of the present study was to evaluate predictor factors for outcomes of microsurgical flaps for limb reconstruction, and to provide a descriptive analysis of microsurgical flaps for orthopedic indications. Methods Cross-sectional prospective study that included all consecutive cases of microsurgical flaps for orthopedic indications from 2014 to 2020. Data were collected from personal medical history, intraoperative microsurgical procedure, and laboratory blood tests. Complications and free-flap outcomes were studied in a descriptive and statistical analysis. Results We evaluated 171 flaps in 168 patients; the indications were traumatic in 66% of the patients. Type III complications of the Clavien-Dindo Classification were observed in 51 flaps. The overall success rate of the microsurgical flaps was 88.3%. In the multivariate analysis, the risk factors for complications were ischemia time ≥ 2 hours (p= 0.032) and obesity (p= 0.007). Partial flap loss was more common in patients with thrombocytosis in the preoperative platelet count (p= 0.001). Conclusion The independent risk factors for complications of microsurgical flaps for limb reconstruction are obesity and flap ischemia time ≥ 2 hours, and presence of thrombocytosis is a risk factor for partial flap loss.

Resumo Objetivo Os avanços da microcirurgia reconstrutiva na cirurgia ortopédica proporcionaram melhores resultados funcionais e estéticos, evitando as muitas indicações de amputação. Nos hospitais de ortopedia e traumatologia com um grande volume de atendimento, a reconstrução microcirúrgica é essencial, a fim de reduzir os custos e as complicações destes complexos defeitos ortopédicos. Descrevemos uma abordagem microcirúrgica para feridas traumáticas, ressecção tumoral, defeitos ósseos e transferência muscular livre realizada por uma unidade ortopédica especializada em microcirurgia. O objetivo do presente estudo é avaliar os fatores preditivos de resultados dos retalhos microcirúrgicos na reconstrução dos membros, fornecendo uma análise descritiva dos retalhos microcirúrgicos para as indicações ortopédicas. Métodos Estudo prospectivo transversal, que incluiu todos os casos consecutivos de retalhos microcirúrgicos com indicação ortopédica de 2014 a 2020. Foram coletados os dados do histórico clínico pessoal, procedimentos microcirúrgicos intraoperatórios e exames laboratoriais. As complicações e os desfechos de retalho livre foram estudados mediante uma análise descritiva e estatística. Resultados Avaliamos 171 retalhos em 168 pacientes. A indicação mais frequente para a realização de um retalho microcirúrgico foi a traumática, em 66% dos pacientes. Foram observadas complicações cirúrgicas em 51 retalhos, conforme a classificação de Clavien-Dindo do tipo III. A taxa de êxito global dos retalhos microcirúrgicos foi de 88,3%. Na análise multivariada, foram identificados como fatores de risco para complicações tempo de isquemia ≥ 2 horas (p= 0,032) e obesidade (p= 0,007). A perda parcial do retalho foi mais comum em pacientes com trombocitose, com contagem de plaquetas pré-operatória (p= 0,001). Conclusão Os fatores de risco independentes para complicações de retalhos microcirúrgicos para a reconstrução de membro são obesidade e tempo de isquemia do retalho ≥ 2 horas, e a presença de trombocitose como fator de risco para perda parcial do retalho.

Epidemiological aspects of dupuytren's disease in brazil / Aspectos epidemiológicos da doença de dupuytren no brasil

ABSTRACT 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 .

RESUMO Obejtivo: Descrever fatores associados e aspectos epidemiológicos da Doença de Dupuytren em uma população de pacientes acompanhados em serviço de Cirurgia de Mão de hospital público terciário brasileiro. Métodos: Realizou-se um estudo transversal entre os anos de 2014 e 2019. Coletamos dados como idade, gênero, ascendência, comorbidades associadas, doenças fibróticas associadas, uso de fenobarbital, uso de tabaco e álcool e histórico familiar de Doença de Dupuytren. Em seguida, realizamos exame clínico, caracterizando o acometimento dos dedos da mão. Também foi avaliado se os pacientes da amostra apresentavam fatores de gravidade da Doença de Dupuytren. Resultados: 140 pacientes foram incluídos, 70,7% eram homens e 29,3% mulheres. Apenas 42,3% dos pacientes relataram ascendência europeia; 20% apresentaram parentes de primeiro grau com a doença; 59,3% apresentaram comorbidades, incluindo hipertensão, diabetes, cardiopatia crônica, dislipidemia e infecção por HIV; 15,8% tinham doença de Ledderhose e 7,1% tinham doença de Peyronie. 31% eram fumantes, 16,6% declararam alcoolismo, 37,1% faziam uso de fenobarbital e 40% apresentaram a forma grave da DD. Conclusão: A população estudada foi composta por brasileiros que apesar de, em sua maioria, não relatarem ascendência europeia, apresentaram diversas características semelhantes às descritas na literatura mundial. Nível de Evidência II; Estudos Prognósticos; Investigação do efeito de característica de um paciente sobre o desfecho da doença.

Effect of hyperbaric oxygen therapy on nerve regeneration in rats / Efeito da terapia hiperbárica de oxigênio na regeneração nervosa em ratos

ABSTRACT Objective: To evaluate histological changes in peripheral nerves of rats after sciatic nerve neurorrhaphy, according to the time of exposure to hyperbaric oxygen chamber treatment. Methods: Twenty-five Wistar rats were divided into 5 groups according to the amount of exposure to hyperbaric oxygen chamber treatment. Group 1 was the control and there was no use of hyperbaric oxygen chamber; group 2 received one week of therapy; group 3, two weeks; group 4, three weeks; and group 5, four weeks. After the fourth postoperative week, the animals were submitted to euthanasia and a sciatic nerve sample sent for histological analysis. Axons proximal and distal to the neurorrhaphy were counted with axonal regeneration index measurement. Results: We observed that the number of axons distal to neurorrhaphy increases with the amount of hyperbaric oxygen chamber exposure, the results were more expressive from the third week of treatment. However, the statistical analysis found no significant difference between the groups. Conclusion: The descriptive analysis suggests benefit of using hyperbaric oxygen chamber directly proportional to the time of therapy. The study, however, did not present statistically relevant results, probably due to the reduced sample size. Subsequent studies with more significant sampling would be of great value. Level of Evidence II, Prospective Comparative Study.

RESUMO Objetivo: Avaliar as alterações histológicas nos nervos periféricos após neurorrafia do nervo ciático de ratos, de acordo com o tempo de exposição ao tratamento com câmara hiperbárica de oxigênio. Métodos: Vinte e cinco ratos da raça Wistar foram divididos em cinco grupos conforme o tempo de exposição ao tratamento com câmara hiperbárica de oxigênio. O grupo 1 não recebeu o tratamento; o grupo 2 recebeu uma semana de terapia; o grupo 3, duas semanas; o grupo 4, três semanas; e o grupo 5, quatro semanas. Após quatro semanas de pós-operatório, os animais foram submetidos à eutanásia e uma amostra do nervo ciático foi enviada para análise histológica. Foram feitas contagens do número de axônios proximalmente e distalmente à neurorrafia, com medição do índice de regeneração axonal. Resultados: Observamos que o aumento do número de axônios distais à neurorrafia foi diretamente proporcional ao tempo de exposição à câmara hiperbárica de oxigênio, sendo mais expressivo a partir da terceira semana de tratamento. Entretanto, a análise estatística não encontrou diferença significativa entre os grupos. Conclusão: A análise descritiva sugere benefício do uso da câmara hiperbárica de oxigênio. Porém, devido à amostra reduzida, o estudo não apresentou resultados estatisticamente relevantes, sendo necessária a realização de estudos subsequentes com amostragem mais significativa. Nível de Evidência II, Estudo Prospectivo Comparativo.

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.

Wrist Arthroscopy in Athletes / Artroscopia de punho em atletas

Abstract Arthroscopy is a surgical technique whose indication for wrist injuries has grown in recent years. Athletes are subject to traumatic injury to the wrist due to training overload or the intensity of the activity during competition. The need of a quick return to sports practice makes arthroscopy a very useful minimally invasive technique in these situations. The authors present indications of sports-related injuries to the wrist that can be treated by arthroscopy. A literature review is also presented.

Resumo A artroscopia é uma técnica cirúrgica que tem sido cada vez mais usada para a abordagem de lesões no punho. Atletas estão sujeitos a lesões traumáticas no punho devido à sobrecarga de treinamento ou à intensidade da atividade em competição. A necessidade de retornar o mais breve possível à pratica esportiva faz da artroscopia uma técnica minimamente invasiva muito útil nessas situações. Os autores apresentam as principais indicações de tratamento de lesões esportivas por artroscopia. Foi feita uma revisão da literatura.

The increase of anterior pelvic tilt after semitendinosus transfer to distal femur in patients with spastic diplegic cerebral palsy.

The aim of this study was to compare semitendinosus transfer to distal femur (STTX) to semitendinosus surgical lengthening (STL) regarding the increase of anterior pelvic tilt after flexed knee gait treatment. Thirty-nine patients were evaluated, and they were divided according surgical procedures at knees: STL group (22 patients/44 knees), which included patients who received medial hamstrings surgical lengthening as part of multilevel approach, and STTX group (17 patients/34 knees), which was represented by patients who underwent orthopedic surgery including a STTX instead of STL. In the present study, the mean anterior pelvic tilt increased in all groups after treatment and STTX was not effective to prevent it in a medium-term follow-up.

Medial femoral condyle corticoperiosteal flap: anatomic study / Retalho corticoperiosteal do côndilo femoral medial: estudo anatômico

ABSTRACT Objective The medial femoral condyle corticoperiosteal flap is irrigated by the descending genicular artery, and when this is absent, by the superior medial genicular artery. The descending genicular artery divides into the muscular, saphenous, and osteoarticular branches. The objective of this study was to describe the variables involved in the dissection of the medial femoral condyle flap. Methods Thirty thighs from 20 cadavers were dissected and the following variables were recorded: age, height, weight, thigh length, presence of the descending genicular artery, whether the saphenous branch originated from the descending genicular artery, the length of the branches originating from the descending genicular artery, and the diameter of the descending genicular artery and the vena comitans. Results The descending genicular artery was present in 93.3% of the specimens (28/30). The saphenous branch originated from this artery in 76.7% of the dissections (23/70). The mean distance between the origin of the descending genicular artery and the knee joint was 13.4 cm (±١.4), the mean length of the descending genicular artery was 7.5 cm (±1.5), the mean diameter of the descending genicular artery was 1.9 mm (±٠.3), and the mean diameter of the vena comitans was 1.7 mm (±٠.3). Conclusion The vascularized medial femoral condyle is a versatile option for reconstruction of musculoskeletal injuries. It allows transference of bone associated with muscle and skin, which are each nourished by independent branches. Level of Evidence IV; Case series.

RESUMO Objetivo O retalho ósseo vascularizado do côndilo femoral medial deve sua irrigação à artéria genicular descendente e, na ausência desta, à artéria genicular superior medial. A artéria genicular descendente comumente ramifica-se em: ramo muscular, safeno e osteoarticular. O estudo teve por objetivo analisar as variáveis relativas à dissecção do retalho ósseo do côndilo femoral medial. Métodos Foram dissecados 30 joelhos (20 cadáveres), registrando-se: idade; estatura; peso; comprimento da coxa; presença da artéria genicular descendente; se o ramo safeno tem origem na artéria genicular descendente; comprimento dos ramos da artéria genicular descendente e os diâmetros da artéria genicular descendente e veia comitante. Resultados A artéria genicular descendente esteve presente em 93,3% dos espécimes (28/30). O ramo safeno originou-se da artéria genicular descendente em 76,7% das dissecções (23/70). Distância entre origem da artéria genicular descendente e interlinha articular = 13,4 (±1,4) cm, comprimento da artéria genicular descendente = 7,5 (±1,5) cm, diâmetro da artéria genicular descendente = 1,9 (±0,3) mm, diâmetro da veia comitante = 1,7 (±0,3) mm. Conclusão O retalho ósseo vascularizado do côndilo femoral medial mostrou-se a opção versátil para reconstrução de lesões do sistema músculo-esquelético. Permite a elevação de retalho ósseo associado à pele e tecido muscular, cada qual nutrido por ramos independentes. Nível de Evidência IV; Série de casos.

Early versus late repair of rotator cuff tears in rats.

BACKGROUND: In the event of a traumatic rotator cuff tear, patients are routinely advised that early surgical intervention produces an optimal repair, despite a lack of direct evidence to support this recommendation. To address this knowledge gap, massive rotator cuff tears in rats were assessed by biomechanical and bone morphometric analyses after early or late repair. METHODS: Combined supraspinatus and infraspinatus tendon tears of the left shoulder were created in 21 adult Wistar rats, which were divided into 2 groups. The tendons of the injured shoulder in the animals in group I were surgically repaired 8 weeks after the injury. Under the same anesthesia, the same injury was created on the right shoulder, which was immediately repaired. The rats from group I were euthanized 8 weeks after the repairs. No repair was performed in the rats from group II, which were euthanized 8 weeks after the injury. Tissues from both groups were harvested and biomechanically tested for supraspinatus tendon and bone morphometry analysis of the humeral head. RESULTS: All biomechanical properties were significantly increased in the early repair group compared with the late repair group. No significant differences were observed in bone morphometry of the humeral head when early and late repair groups were compared. CONCLUSION: Early surgical repair of a massive rotator cuff tear leads to improved biomechanical properties of the tissue after healing. Proximal humerus bone morphometry was unaffected by surgical repair timing.

A new low-cost negative-pressure wound therapy versus a commercially available therapy device widely used to treat complex traumatic injuries: a prospective, randomized, non-inferiority trial

OBJECTIVES: Negative-pressure wound therapy has been widely adopted to reduce the complexity of treating a broad range of acute and chronic wounds. However, its cost is high. The objective of this study was to evaluate the following two different methods of negative-pressure wound therapy in terms of healing time: a low-cost method of negative-pressure wound therapy (a pressure stabilizer device connected to a hospital wall-vacuum system with a gauze-sealed dressing, USP) and the standard of care (vacuum-assisted closure, VAC). METHODS: This is a randomized, controlled, non-inferiority, unblinded trial. Patients admitted with complex injuries to a trauma center in a public referral hospital who were indicated for orthopedic surgery were randomized to a USP or VAC group. The primary outcome was the time required to achieve a "ready for surgery condition", which was defined as a wound bed with healthy granulation tissue and without necrosis or purulent secretion. Wound bed area contraction, granulation tissue growth and the direct costs of the dressings were secondary outcomes. RESULTS: Variation in area and granulation tissue growth were essentially the same between the systems, and healing time was equal between the groups (p=0.379). In both systems, serial debridement increased wound area (p=0.934), and granulation tissue was also increased (p=0.408). The mean treatment cost was US$ 15.15 in the USP group and US$ 872.59 in the VAC group. CONCLUSIONS: For treating complex traumatic injuries, USP was non-inferior to and less expensive than VAC.

A new low-cost negative-pressure wound therapy versus a commercially available therapy device widely used to treat complex traumatic injuries: a prospective, randomized, non-inferiority trial.

OBJECTIVES: Negative-pressure wound therapy has been widely adopted to reduce the complexity of treating a broad range of acute and chronic wounds. However, its cost is high. The objective of this study was to evaluate the following two different methods of negative-pressure wound therapy in terms of healing time: a low-cost method of negative-pressure wound therapy (a pressure stabilizer device connected to a hospital wall-vacuum system with a gauze-sealed dressing, USP) and the standard of care (vacuum-assisted closure, VAC). METHODS: This is a randomized, controlled, non-inferiority, unblinded trial. Patients admitted with complex injuries to a trauma center in a public referral hospital who were indicated for orthopedic surgery were randomized to a USP or VAC group. The primary outcome was the time required to achieve a "ready for surgery condition", which was defined as a wound bed with healthy granulation tissue and without necrosis or purulent secretion. Wound bed area contraction, granulation tissue growth and the direct costs of the dressings were secondary outcomes. RESULTS: Variation in area and granulation tissue growth were essentially the same between the systems, and healing time was equal between the groups (p=0.379). In both systems, serial debridement increased wound area (p=0.934), and granulation tissue was also increased (p=0.408). The mean treatment cost was US$ 15.15 in the USP group and US$ 872.59 in the VAC group. CONCLUSIONS: For treating complex traumatic injuries, USP was non-inferior to and less expensive than VAC.

Estudo comparativo entre osteossíntese em fratura de tornozelo com implantes convencionais e bioabsorvíveis / Comparative study between osteosynthesis in conventional and bioabsorbable implants in ankle fractures

Objetivo: Comparar os resultados funcionais de fraturas de tornozelo tratadascom placas metálicas e absorvíveis. Métodos: Vinte pacientes foramrandomizados e seguidos de forma prospectiva em dois grupos, metálicoe absorvível. No período pós-operatório imediato os pacientes foram imobilizadoscom tala gessada por uma semana, que foi substituída por órteseremovível por quatro semanas adicionais. Carga parcial foi autorizada comtrês semanas, e carga total com seis semanas. Os vinte pacientes foramseguidos por nove meses e avaliados funcionalmente aos seis e nove meses.Resultados: A recuperação funcional foi similar nos dois grupos. Aosseis meses, três pacientes no grupo metálico queixaram-se de problemaslocais, e tiveram seus implantes removidos. Um paciente do grupo absorvívelteve uma deiscência precoce da sutura, submetida a desbridamentoe sutura com boa evolução. Aos seis e nove meses o escore da AmericanOrthopaedic Foot and Ankle Society (AOFAS) foi aplicado para todosexceto um paciente do grupo metálico, que foi perdido do seguimento.Os resultados funcionais foram semelhantes nos dois grupos, nos doismomentos. Conclusão: Os implantes absorvíveis permitiram resultadosclínicos e funcionais semelhantes aos metálicos em fraturas de tornozelo.Nível de Evidência II, Estudo Prospectivo Comparativo.

Objective: To compare the functional results of ankle fracturestreated with metallic and absorbable plates. Twentypatients were randomized into two groups (metallic and absorbableimplant groups) and followed prospectively. In theimmediate postoperative period, patients were immobilizedwith plaster casts for one week, which was replaced by aremovable cast for another four weeks. Partial weight-bearingwas allowed after three weeks, and full weight-bearing aftersix weeks. Functional recovery was similar in both groups. Atsix months, three patients in the metallic group complainedof local pain, and had their implants removed. One patientin the absorbable group exhibited early dehiscence of thesuture and underwent debridement and suturing with goodevolution. The American Orthopaedic Foot and Ankle Society(AOFAS) score was similar between the two groups after sixand nine months of follow-up. The absorbable implants showedclinical and functional results that were similar to thoseof metallic implants. Level of Evidence II, ProspectiveComparative Study.

Intercostal nerve transfer to the biceps motor branch in complete traumatic brachial plexus injuries.

The purpose of this report is to critically evaluate our results of two intercostal nerve transfers directly to the biceps motor branch in complete traumatic brachial plexus injuries. From January 2007 to November 2012, 19 patients were submitted to this type of surgery, but only 15 of them had a follow-up for ≥2 years and were included in this report. The mean interval from trauma to surgery was 6.88 months (ranging from 3 to 9 months). Two intercostals nerves were dissected and transferred directly to the biceps motor branch. The mean follow-up was 38.06 months (ranging from 24 to 62 months). Ten patients (66.6%) recovered an elbow flexion strength ≥M3. Four of them (26.66%) recovered a stronger elbow flexion ≥M4. One patient (6.25%) recovered an M2 elbow flexion and four patients (26.66%) did not regain any movement. We concluded that two intercostal nerve transfers to the biceps motor branch is a procedure with moderate results regarding elbow flexion recovery, but it is still one of the few options available in complete brachial plexus injuries, especially in five roots avulsion scenario.

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.

Arthroscopic study of injuries in articular fractures of distal radius extremity.

OBJECTIVE: To analyze the incidence of wrist ligament and cartilage associated fractures of the distal radius, through arthroscopy, correlating with AO/ASIF classification. METHODS: Thirty patients aged between 20 and 50 years old, with closed fracture from groups B and C according to AO/ASIF classification were selected. All of them were submitted to wrist arthroscopy to address intra-articular injuries and reduction and osteosynthesis of the fracture. RESULTS: A high incidence of intra-articular injuries was noticed, and 76.6% of them presented injury of the triangular fibrocartilage complex, 36.6% of the intrinsic scapholunate ligament, 6.6% of the intrinsic triquetrolunate ligament, and 33% articular cartilage injury larger than three millimeters. Patients with fractures from type C according to AO/ASIF classification presented a higher incidence of ligament injuries. CONCLUSION: There is no relationship between the presence of chondral injury and the AO/ASIF classification of the fractures in the cases reported in this study.

Median nerve fascicle transfer versus ulnar nerve fascicle transfer to the biceps motor branch in C5-C6 and C5-C7 brachial plexus injuries: nonrandomized prospective study of 23 consecutive patients.

The purpose of this study was to observe whether the results of the median nerve fascicle transfer to the biceps are equivalent to the classical ulnar nerve fascicle transfer, in terms of elbow flexion strength and donor nerve morbidity. Twenty-five consecutive patients were operated between March 2007 and July 2013. The patients were divided into two groups. In Group 1 (n = 8), the patients received an ulnar nerve fascicle transfer to the biceps motor branch. In Group 2 (n = 15), the patients received a median nerve fascicle transfer to the biceps motor branch. Two patients with follow-up less than six months were excluded. Both groups were similar regarding age (P = 0.070), interval of injury (P = 0.185), and follow-up period (P = 0.477). Elbow flexion against gravity was achieved in 7 of 8 (87.5%) patients in Group 1, versus 14 of 15 (93.3%) patients in Group 2 (P = 1.000). The level of injury (C5-C6 or C5-C7) did not affect anti-gravity elbow flexion recovery in both the groups (P = 1.000). It was concluded that the median nerve fascicle transfer to the biceps is as good as the ulnar nerve fascicle transfer, even in C5-C7 injuries.

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. .

Arthroscopic study of injuries in articular fractures of distal radius extremity

OBJECTIVE: To analyze the incidence of wrist ligament and cartilage associated fractures of the distal radius, through arthroscopy, correlating with AO/ASIF classification. METHODS: Thirty patients aged between 20 and 50 years old, with closed fracture from groups B and C according to AO/ASIF classification were selected. All of them were submitted to wrist arthroscopy to address intra-articular injuries and reduction and osteosynthesis of the fracture. RESULTS: A high incidence of intra-articular injuries was noticed, and 76.6% of them presented injury of the triangular fibrocartilage complex, 36.6% of the intrinsic scapholunate ligament, 6.6% of the intrinsic triquetrolunate ligament, and 33% articular cartilage injury larger than three millimeters. Patients with fractures from type C according to AO/ASIF classification presented a higher incidence of ligament injuries. CONCLUSION: There is no relationship between the presence of chondral injury and the AO/ASIF classification of the fractures in the cases reported in this study. Level of Evidence III, Non Randomized Controlled Trial. .