Mini-Invasive Surgery for Distal Radius Fractures: A Double Incision under 12 mm.

Background Distal radius fracture is one of the most common lesions in adults. Surgical techniques have evolved considerably with a clear tendency toward mini-invasive techniques. Objective Our aim is to push the limits to a 12 mm approach and evaluate its clinical and radiological results. Patients and Methods Ten fractures in nine patients were operated by a double incision with mean size 11.50 ± 3.41 mm (range 8.00-1.00) and using a specially designed volar distal locking plate. Results At the latest follow-up, visual analogue scale score for pain (0.20 ± 0.63 during rest and 0.60 ± 1.07 while making efforts) and quick DASH (quick Disabilities of the Arm, Shoulder and Hand) score (6.14 ± 7.43) were extremely low. All the range of motion parameters and grip strength were above the 95% barrier of the contralateral side, with exception of ulnar deviation. Radiological parameters obtained were located within the normal ranges. Time to return to independent daily tasks and work was 6.67 ± 5.15 and 10.14 ± 14.24 days, respectively. One case of transient carpal tunnel syndrome was solved with watchful waiting and one case of extensor tendons impingement was improved after plate removal. All patients were completely satisfied at the end of the treatment. Conclusion In conclusion, mini-invasive volar technique for distal radius fractures with special designed plates in carefully selected patients allowed us to obtain good clinical and radiological results, minimal complications, fast recovery, and high-satisfactory rates. Level of Evidence This is a Level IV, case series study.

Bridging versus Nonbridging Dynamic External Fixation of Unstable Distal Radius Fractures in the Elderly with Polytrauma: A Randomized Study.

Background Despite the high prevalence of unstable distal radius fractures (DRFs), there is no consensus regarding the optimal method and treatment timing, especially for elderly patients with multiple associated injuries. Purpose This study aimed to compare the grip strength achieved with two different methods for definitive dynamic external fixation of DRFs in elderly patients with polytrauma operated on within the first 24 hours. Methods In this prospective randomized trial, 35 patients were assigned to undergo definitive external dynamic fixation of DRFs using the nonbridging (group A) or bridging (group B) method. The grip strength, range of motion (ROM), Disabilities of the Arm, Shoulder and Hand (QuickDASH) outcome measure, visual analog scale (VAS) score for pain, and radiographic characteristics were evaluated at 6 and 12 months. Results At 12 months, no significant between-group difference was observed with respect to grip strength. All patients showed results in the third or fourth quartiles. The mean ROMs were 96.94 and 96.38% and the mean QuickDASH scores were 3.53 and 3.85 in groups A and B, respectively. The VAS scores were 1.60 and 1.85 in groups A and B, respectively. The overall complication rates were 13.3 and 15% in groups A and B, respectively. Initial fracture reduction was maintained in 86.67 and 95% of the patients in groups A and B, respectively. Conclusions Both bridging and nonbridging external definitive dynamic fixation proved safe and reliable for the treatment of unstable DRFs in elderly patients with polytrauma. The grip strength results in both groups predicted the restoration of ability in elderly patients to perform activities of daily living independently.

Dorsal capsulodesis associated with arthoscopy-assisted scapholunate ligament reconstruction using a palmaris longus tendon graft.

OBJECTIVES: To measure the quality of life, the time to work return, and clinical, functional, and radiographic parameters of patients treated with dorsal capsulodesis associated with scapholunate (SL) reconstruction, assisted by arthroscopy. METHODS: From January 2015 to September 2016, 14 adult patients with SL dissociation underwent surgical treatment with the SL reconstruction procedure assisted by arthroscopy, using the new technique proposed in this study. All patients were assessed by the occupational therapy department at regular intervals after surgery and performed the same sequence of rehabilitation. The parameters analyzed were: range of motion (ROM), Disability of the Arm, Shoulder, and Hand (DASH), visual analog scale (VAS), and radiographic analysis to visualize the pre- and postoperative SL gap and the pre- and postoperative dorsal intercalated segment instability (DISI) deformity the. The complications and the time to return to work activities were described. RESULTS: The follow-up time was 12 months (3-17). The ROM averaged 321° (96.9% of the normal side). VAS was 1.79/10 (1-6). DASH was 6.50/100 (1-30). The time to work return work was 4.42 months (2-17). As for complications, one patient developed SLAC, and underwent four-corner fusion one year after ligament reconstruction. Currently, he has experienced pain relief, with a functional range of motion of the wrist, and has not yet returned to professional activities.The preoperative SL gap was 4.29 mm (2-7); in the postoperative period, it was 1.79 mm (1-4). The DISI deformity was present in ten patients with SL angle > 70° (preoperative) and it was corrected after surgery, in all patients. SLAC stage I was identified in a patient. Arthroscopy was performed in all cases. The SL instability was classified as Geissler grade III in four cases and as grade IV in ten cases. CONCLUSION: The new approach (dorsal capsulodesis associated with SL reconstruction, assisted by arthroscopy) presented in this study is safe and effective in the treatment of SL dissociation, since it offers satisfactory clinical, radiographic and functional results, showing low rates of complications. For patients, it allows the return to their social and professional activities, and increases their life quality.

OBJETIVOS: Mensurar a qualidade de vida, o tempo de retorno ao trabalho, os resultados clínicos, funcionais e radiográficos dos pacientes submetidos à capsulodese dorsal associada à reconstrução ligamentar escafossemilunar assistida por artroscopia. MÉTODOS: De janeiro de 2015 a setembro de 2016, 14 pacientes, esqueleticamente maduros, adultos, com dissociação escafolunar (SL), foram submetidos ao tratamento cirúrgico com o procedimento de reconstrução do ligamento escafossemilunar assistido por artroscopia com a nova técnica proposta neste estudo. Todos os pacientes foram avaliados pelo setor de terapia ocupacional em intervalos regulares de pós-operatório e fizeram a mesma sequência de reabilitação. Os parâmetros analisados foram: arco de movimento (ADM), Disability Arm, Shoulder and Hand (Dash), escala visual analógica (EVA) e análise radiográfica pré e pós-operatória para visualizar o espaço escafolunar (sinal de Terry-Thomas) e deformidade em Dorsal Intercalated Segment Instability (DISI) pré e pós-operatória. Descrição das complicações e o tempo de retorno ao trabalho. RESULTADOS: O tempo de seguimento foi de 12 meses [3-17]. O ADM foi em média 321,07° (96,9% do lado normal). O valor da avaliação subjetiva da dor (VAS) foi 1,79/10 [1-6]. A mensuração da qualidade de vida pelo Dash foi de 6,50/100 [1-30]. O tempo de retorno ao trabalho foi de 4,42 meses [2-17]. Quanto às complicações, uma paciente evoluiu com SLAC e foi submetida à artrodese dos quatro cantos um ano após a reconstrução ligamentar. Evoluiu com melhoria da dor e está com o ADM do punho funcional, mas ainda não retornou às atividades profissionais. O intervalo do SL (gap) pré-operatório foi de 4,29 mm [2-7] e o pós-operatório foi de 1,79 mm [1-4]. A deformidade DISI estava presente em dez pacientes, com um ângulo SL acima de 70° (pré-operatório), e foi corrigida após a cirurgia em todos os pacientes. SLAC estágio I foi identificado em um paciente. A artroscopia foi feita em todos os casos. A instabilidade SL foi classificada como um grau Geissler III em quatro casos e grau IV em dez casos. CONCLUSÃO: A nova abordagem (capsulodese dorsal associada à reconstrução ligamentar escafossemilunar assistida por artroscopia) apresentada neste estudo é segura e eficaz no tratamento da dissociação escafolunar, já que apresenta resultados radiográficos, clínicos e funcionais satisfatórios, demonstra baixas taxas de complicações, permite o retorno às atividades sociais e profissionais e aumenta a qualidade de vida desses pacientes.

Dorsal capsulodesis associated with arthoscopy-assisted scapholunate ligament reconstruction using a palmaris longus tendon graft / Capsulodese dorsal associada à reconstrução assistida por artroscopia do ligamento escafossemilunar com enxerto do tendão do músculo palmar longo

ABSTRACT OBJECTIVES: To measure the quality of life, the time to work return, and clinical, functional, and radiographic parameters of patients treated with dorsal capsulodesis associated with scapholunate (SL) reconstruction, assisted by arthroscopy. METHODS: From January 2015 to September 2016, 14 adult patients with SL dissociation underwent surgical treatment with the SL reconstruction procedure assisted by arthroscopy, using the new technique proposed in this study. All patients were assessed by the occupational therapy department at regular intervals after surgery and performed the same sequence of rehabilitation. The parameters analyzed were: range of motion (ROM), Disability of the Arm, Shoulder, and Hand (DASH), visual analog scale (VAS), and radiographic analysis to visualize the pre- and postoperative SL gap and the pre- and postoperative dorsal intercalated segment instability (DISI) deformity the. The complications and the time to return to work activities were described. RESULTS: The follow-up time was 12 months (3-17). The ROM averaged 321° (96.9% of the normal side). VAS was 1.79/10 (1-6). DASH was 6.50/100 (1-30). The time to work return work was 4.42 months (2-17). As for complications, one patient developed SLAC, and underwent four-corner fusion one year after ligament reconstruction. Currently, he has experienced pain relief, with a functional range of motion of the wrist, and has not yet returned to professional activities. The preoperative SL gap was 4.29 mm (2-7); in the postoperative period, it was 1.79 mm (1-4). The DISI deformity was present in ten patients with SL angle > 70° (preoperative) and it was corrected after surgery, in all patients. SLAC stage I was identified in a patient. Arthroscopy was performed in all cases. The SL instability was classified as Geissler grade III in four cases and as grade IV in ten cases. CONCLUSION: The new approach (dorsal capsulodesis associated with SL reconstruction, assisted by arthroscopy) presented in this study is safe and effective in the treatment of SL dissociation, since it offers satisfactory clinical, radiographic and functional results, showing low rates of complications. For patients, it allows the return to their social and professional activities, and increases their life quality.

RESUMO OBJETIVOS: Mensurar a qualidade de vida, o tempo de retorno ao trabalho, os resultados clínicos, funcionais e radiográficos dos pacientes submetidos à capsulodese dorsal associada à reconstrução ligamentar escafossemilunar assistida por artroscopia. MÉTODOS: De janeiro de 2015 a setembro de 2016, 14 pacientes, esqueleticamente maduros, adultos, com dissociação escafolunar (SL), foram submetidos ao tratamento cirúrgico com o procedimento de reconstrução do ligamento escafossemilunar assistido por artroscopia com a nova técnica proposta neste estudo. Todos os pacientes foram avaliados pelo setor de terapia ocupacional em intervalos regulares de pós-operatório e fizeram a mesma sequência de reabilitação. Os parâmetros analisados foram: arco de movimento (ADM), Disability Arm, Shoulder and Hand (Dash), escala visual analógica (EVA) e análise radiográfica pré e pós-operatória para visualizar o espaço escafolunar (sinal de Terry-Thomas) e deformidade em Dorsal Intercalated Segment Instability (DISI) pré e pós-operatória. Descrição das complicações e o tempo de retorno ao trabalho. RESULTADOS: O tempo de seguimento foi de 12 meses [3-17]. O ADM foi em média 321,07° (96,9% do lado normal). O valor da avaliação subjetiva da dor (VAS) foi 1,79/10 [1-6]. A mensuração da qualidade de vida pelo Dash foi de 6,50/100 [1-30]. O tempo de retorno ao trabalho foi de 4,42 meses [2-17]. Quanto às complicações, uma paciente evoluiu com SLAC e foi submetida à artrodese dos quatro cantos um ano após a reconstrução ligamentar. Evoluiu com melhoria da dor e está com o ADM do punho funcional, mas ainda não retornou às atividades profissionais. O intervalo do SL (gap) pré-operatório foi de 4,29 mm [2-7] e o pós-operatório foi de 1,79 mm [1-4]. A deformidade DISI estava presente em dez pacientes, com um ângulo SL acima de 70° (pré-operatório), e foi corrigida após a cirurgia em todos os pacientes. SLAC estágio I foi identificado em um paciente. A artroscopia foi feita em todos os casos. A instabilidade SL foi classificada como um grau Geissler III em quatro casos e grau IV em dez casos. CONCLUSÃO: A nova abordagem (capsulodese dorsal associada à reconstrução ligamentar escafossemilunar assistida por artroscopia) apresentada neste estudo é segura e eficaz no tratamento da dissociação escafolunar, já que apresenta resultados radiográficos, clínicos e funcionais satisfatórios, demonstra baixas taxas de complicações, permite o retorno às atividades sociais e profissionais e aumenta a qualidade de vida desses pacientes.

Saving Tendons on Distal Radius Fractures: A Simple Surgical Pearl to Prevent FPL Tendon Conflict with Volar Locking Plates.

Injury to the flexor pollicis longus (FPL) tendon is one of the most frequent complications when fixing distal radius fractures with the volar locking plates. The author proposed a simple surgical technique providing a reliable soft tissue protection to prevent friction on the FPL with the volar locking plate, using a flap of the FCR sheath sutured to attachments of the volar capsule on the lunate buttress facet of the distal radius.

The proximally designed sural flap based on the accompanying artery of the lesser saphenous vein.

Most of the literature about the sural flap deals with soft tissue defects at the lower leg and foot based on the classical description of Masquelet et al. Nevertheless, some authors have shown that the lesser saphenous vein and its accompanying artery play an important role in the vascularization of the posterior skin of the leg. This finding allowed a more proximal design of the flap, increasing its arc of rotation. Thirteen cases of distally based sural flaps were performed and divided in two groups according to the level where the flaps were harvested. In group A, the entire flap was outlined distal to the midpoint of the leg, and in group B, the flap was outlined proximal to the midpoint of the leg. In group A, all the soft tissue defects were located at the lower leg and the foot, and in group B, they involved the anterior the tibia. In group A, the complication rate was 33.33% and the flap survival rate was 83.33%. In group B, the complication rate was 42.85% and survival rate was 100%. The proximally designed sural flap can safely reach the anterior aspect of the tibia in its middle and distal thirds.

Diagnóstico precoce e o tratamento cirúrgico do polegar em gatilho congênito na criança utilizando o sistema de internação hospital-dia / Early diagnosis and surgical treatment of congenital trigger thumb in children using the day hospital admission system

Introdução: o polegar em gatilho congênito ou tenossinovite estenosante do polegar é a dificuldade de extensão do polegar, identificada nos primeiros meses de vida. Objetivo: a proposta deste estudo foi discutir o tratamento cirúrgico com os resultados, as complicações e as vantagens na utilização da internação hospital-dia. Método: no período de fevereiro de 2001 até janeiro de 2008, verificaram-se 25 crianças entre 3 meses e 6 anos, portadoras de polegar em gatilho congênito. Foram operadas 35 mãos, e 10 casos eram bilaterais. Observamos que a manifestação clínica quanto à dificuldade de extensão do polegar estava presente em todas as mãos operadas e nenhuma criança queixava-se de dor. As crianças foram submetidas à mesma técnica cirúrgica, anestesia geral inalatória, com incisão transversa na prega volar metacarpofalangeana do polegar acometido e abertura longitudinal da polia flexora A1. Não foi utilizado antibiótico e as crianças foram internadas pelo sistema hospital-dia. Resultados: Quinze crianças eram do sexo masculino e dez do sexo feminino. Dos pacientes com lesão bilateral, sete eram do sexo masculino e três do feminino. Quanto ao lado acometido, obtivemos sete polegares direitos, oito esquerdos e dez bilaterais. Como complicações, não houve nenhuma recidiva; um polegar evoluiu com infecção cutânea superficial e dois polegares apresentaram deiscência parcial da sutura após a retirada dos pontos. Conclusões: o polegar em gatilho congênito ou tenossinovite estenosante do polegar na criança pode ser tratado com segurança através da abertura simples da polia flexora A1, utilizando-se a internação hospital-dia.

The congenital trigger disorder or stenosing tenosynovitis of the thumb is the difficulty of extending the thumb, identified in early months of life. Objective: The purpose this study was to discuss the operative results, complications and advantages of the day hospital system. Method: This study was carried out from February 2001 to January 2008, with 25 children aging from 3 months to 6 years old with congenital trigger finger thumb. Thirty-five hands were submitted to surgery, and ten children had both hands attacked. The limited extension of the thumb was the clinical characteristic observed in all operated hands and no child had pain complaint. All children were submitted to the same surgical technique, by the use of inhalational general anesthetics, with transversal incision in the metacarpophalangeal volar pleat of the thumb and longitudinal resection of the flexor pulley A1. Antibiotic therapy was not used and all children were admitted by the day hospital system. Results: fifteen were boys and ten were girls. Seven boys and three girls had the pathology in both hands. Comparing the incidence of each side, we have found seven right congenital trigger thumbs, eight left and ten occurring in both sides. The complications found were: one thumb had superficial cutaneous infection and two thumbs presented dehiscence of the incision after the removal of the suture. There were no cases of recurrence of the disease after surgery. Conclusion: we concluded that congenital trigger disorder or stenosing tenosynovitis in children can be safely treated with simple incision of flexor pulley A1 and with day hospital system.

Síndrome do túnel carpal: resultados do tratamento cirúrgico com a técnica de mini-incisão / Carpal tunnel syndrome: results of surgical treatment with mini-incision technique

Introdução: A síndrome do túnel carpal é constituída por um conjunto de sinais e sintomas característicos como parestesia, formigamento, dor e perda da força nas mãos. Inicialmente os sintomas são brandos, progredindo ao longo do tempo. Objetivo: Apresentar os resultados do tratamento cirúrgico com mini-incisão, bem como discutir a relação entre os resultados e a técnica cirúrgica utilizada. Método: Esta pesquisa foi realizada na Faculdade de Medicina do ABC, onde foram avaliados 79 punhos de 71 pacientes, todos submetidos ao tratamento cirúrgico da síndrome do túnel carpal por ?mini-incisão?, entre janeiro de 1996 e maio de 2007. A média de idade entre os pacientes foi de 52,4 anos, sendo a idade mínima 27 e a máxima 80 anos. Sessenta e cinco pacientes eram do sexo feminino e seis do masculino. Quanto ao lado acometido, foram obtidos 36 punhos do lado direito e 27 do lado esquerdo, sendo 8 bilaterais. Resultados: Os resultados clínicos mostraram que 60 pacientes ficaram satisfeitos com os sintomas, com os resultados estéticos e funcionais e com a melhora da força muscular para apreensão. Dois pacientes apresentaram complicações cutâneas com infecção superficial e necessitaram de antibioticoterapia oral. Conclusões: Concluímos que o tratamento cirúrgico por ?mini-incisão? é uma técnica segura, com poucas complicações e resultados clínicos e estéticos satisfatórios para o tratamento da síndrome do túnel do carpo.

Introduction: The carpal tunnel syndrome is composed of signs and characteristic symptoms as parestesis, tingling, pain and hand power loose. Initially, the symptoms appear softly, progressing along the time. Objective: To present the results of surgical treatment using mini-incision, as well as to discuss the relationship between the results and the surgical technique used. Method: This study was accomplished at Faculdade de Medicina do ABC where 79 wrists of 71 patients were evaluated. All of them were submitted to the surgical treatment of the carpal tunnel syndrome using ?mini-open? technique between January 1996 and May 2007. The mean age of the patients was 52.4 years old, the minimum age was 27 years old and the maximum was 80 years old. Sixty-five patients were females and six were males. Thirty-six subjects had the right side affected and 27 had the left side, though 8 patients presented both sides affected. Results: The clinical results showed that 60 patients were satisfied with the symptomatic, aesthetic and functional results, as well as with the muscular power improvement for apprehension. Two patients presented cutaneous complications with superficial infection and were treated with oral antibiotic therapy. Conclusions: The surgical treatment using ?mini-incision? is a safe technique, with few complications and satisfactory clinical and aesthetic results for the carpal tunnel syndrome treatment.

Abordagem das lesões de tendões flexores na zona II / Approach on flexor tendons injuries at zone II

A restauração de lesões nos tendões flexores da zona II é um procedimento difícil devido à sua complexidade anatômica, facilidade de formar aderências e dificuldade de estabelecer protocolos de reabilitação que reduzam o número de rupturas. O objetivo deste trabalho foi atualizar o tratamento cirúrgico das lesões nos tendões flexores da zona II. Foram analisados cinco artigos, três sobre avaliação de diferentes técnicas de sutura e dois sobre reabilitação pós-operatória. No estudo de Buendia et al., os valores absolutos mostraram a técnica de ancoragem como sendo a melhor, apesar do desvio padrão ser grande. Já na análise estatística, a ancoragem e o protocolo de Indiana possuem mesma significância. No grupo de imobilização ocorreu tenólise em 21,2% dos casos sem ruptura tendinosa. Entretanto, no grupo de flexão ativa ocorreu ruptura de tendão em 13,5% dos casos após duas semanas de mobilização ativa. A sutura de lesão tendinosa na zona II de tendões flexores com quatro passadas apresenta melhores resultados, mas realçamos a importância de analisar a técnica de sutura segundo a resistência, o tempo cirúrgico, a quantidade de material utilizado, o aumento do volume, a capacidade traumática e a dificuldade da técnica.

The flexor tendon injury repair at zone II is a hard procedure due to its anatomical complexity, easiness in forming adherences and difficulty in establishing rehabilitation protocols to reduce the rupture number. The purpose of this paper was to update the surgical treatment of flexor tendon injuries at zone II. Five articles were analyzed: three about the evaluation of different suture techniques and two about postoperative rehabilitation. In Buendia et al. study, the absolute values demonstrated that the anchorage technique was better than the others, in spite of its greater standard deviation. At statistical analysis, anchorage and Indiana technique had the same significance. In the immobilization group, tenolysis appeared in 21.2% of the cases without tendon rupture. However, in the active flexion group, tendon ruptures appeared in 13.5% of the cases, after two weeks of active mobilization. The four strands repair technique for zone II flexor tendon injury presented better results, but we emphasized the suture technique analysis according to its resistance, surgical time, amount of material applied on it, volume increase, trauma capacity and technical difficulty.

Cisto ósseo aneurismático na falange proximal da mão: relato de caso e revisão de literatura / Aneurysmal bone cyst in the proximal phalange: case report and review of the literature

O cisto ósseo aneurismático é uma lesão benigna bastante comum caracterizada por ser expansiva, radioluzente, multiloculada e excêntrica, podendo acometer qualquer osso. O presente artigo relata o caso de uma criança com dor e aumento do volume no quarto dedo da mão direita há três semanas, decorrente de um cisto ósseo aneurismático. Os autores destacam as características de imagens na radiografia, tomografia computadorizada e ressonância magnética, com posteriorcorrelação cirúrgica.

Aneurysmal bone cyst is a common benign lesion characterized by its insuflative, radiolucent, excentric and multiloculated pattern. It also can occur in any kind of bone. The present article report case of a child with pain and swelling in the fourth right finger forthree weeks caused by an aneurysmal bone cyst. The authors highlightthe characteristics of images in radiography, computed tomographyand magnetic resonance imaging, with subsequent surgical correlation.