RESUMO
Neonatal brachial plexus palsy is a devastating complication after a difficult delivery. The incidence of this injury has not significantly decreased over the past decades, despite all the advances in perinatal care. Although primary repair of the nerves with microsurgical techniques is the common treatment strategy nowadays, there are late cases in which secondary procedures in tendons or bones are necessary. Moreover, secondary procedures may be needed to improve the results of primary repair. A careful preoperative assessment of all the residual defects and deformities in upper limbs of these patients is essential. The aim of these procedures is usually to restore the deficient shoulder abduction and external rotation, release of any elbow flexion contracture or to correct a weak elbow flexion. More distally a supination or pronation deformity is usually apparent, and available options include tendon transfers or radial osteotomy. The wrist of these patients may be ulnarly deviated or may has absent extension, so tendon transfers or free muscle transfers can also be used for correction of these deformities. In severe cases, wrist fusion is an alternative option. The clinical presentation of the hand is highly variable due to complex deformities including thumb adduction deformity, metacarpophalangeal joints drop, and weak finger flexion or extension depending on the level of the injury. Each of these deformities can be restored with a combination of soft tissue procedures like local or free muscle transfer and bony procedures like arthrodesis.
Assuntos
Paralisia do Plexo Braquial Neonatal/fisiopatologia , Paralisia do Plexo Braquial Neonatal/cirurgia , Extremidade Superior/fisiopatologia , Extremidade Superior/cirurgia , Contratura/etiologia , Contratura/cirurgia , Articulação do Cotovelo/fisiopatologia , Humanos , Paralisia do Plexo Braquial Neonatal/complicações , Pronação , Amplitude de Movimento Articular , Reoperação , Rotação , Articulação do Ombro/fisiopatologia , SupinaçãoRESUMO
BACKGROUND: To evaluate the effect of lumbar microdiscectomy (LM) in pain, disability and quality of life in a 5-year period and to identify potential demographic and clinical risk factors. METHODS: One hundred patients who underwent LM by the same surgeon participated in this prospective study. Clinical assessment was made with validated questionnaires preoperatively and up to 5 years postoperatively. Subsequently, associations between clinical outcomes and demographic data were recorded. RESULTS: In every assessment questionnaire, there was a significant improvement in the first postoperative month, which lasted up to 1 year post-discectomy. After that, improvement was statistically significant (p < 0.05) but without clinical importance. Women reported more pain preoperatively and 1 month after surgery. Urban residents also presented more pain preoperatively. Older patients had more pain, disability and worse quality of life 1-5 years postoperatively. Similarly, patients with lower education presented the worst scores in every questionnaire at the same time. Smokers reported less pain 1.5-4 postoperative years. Higher alcohol consumption and obesity were associated with lower levels of preoperative pain. However, obese patients had worse SF-36 and ODI scores after the 6th postoperative month. Patients with heavy jobs presented the worst preoperative ODI scores. CONCLUSION: Significant clinical improvement was recorded from the first postoperative month to the first postoperative year; stabilization was noticed later on. Feminine gender, urban residency, older age, low level of education, obesity and heavy physical occupation were negative prognostic factors. Oddly smoking and alcohol were correlated with less pain.
Assuntos
Deslocamento do Disco Intervertebral/complicações , Deslocamento do Disco Intervertebral/cirurgia , Dor Lombar/etiologia , Microcirurgia , Qualidade de Vida , Adulto , Fatores Etários , Consumo de Bebidas Alcoólicas , Avaliação da Deficiência , Escolaridade , Feminino , Seguimentos , Humanos , Vértebras Lombares , Masculino , Pessoa de Meia-Idade , Obesidade/complicações , Ocupações , Estudos Prospectivos , Fatores de Proteção , Fatores de Risco , Fatores Sexuais , Fumar , Inquéritos e Questionários , Fatores de Tempo , População UrbanaRESUMO
Congenital deficiency of the thumb greatly compromises hand function, because the normal thumb contributes at least 40% of its usefulness. The method of choice in the treatment of this functional liability is the pollicization of the index finger. This study presents the long term outcome of 21 index finger pollicizations in 18 patients, with a mean follow-up time of 9 years. The thumb deficiency was bilateral in 3 patients, whereas in 7 it was associated with radial club hand. The result was considered excellent in 75%, good in 19%, and poor in 6% of the 21 pollicizations, according to Percival's scoring system. The less rewarding function was obtained in the presence of associated radial club hand in combination with late reconstruction. Index finger pollicization is the method of choice in the treatment of thumb aplasia or severe hypoplasia. The younger patients adapt easier and use the new thumb in a more natural way.
Assuntos
Procedimentos de Cirurgia Plástica/métodos , Polegar/anormalidades , Polegar/cirurgia , Adolescente , Criança , Pré-Escolar , Dedos/transplante , Humanos , Lactente , MasculinoRESUMO
PURPOSE: To examine the afferent pathways of the scapholunate interosseous ligament (SLIL)-generated stimuli and their contribution to the overall carpal proprioception. METHODS: We examined 5 selected patients with preganglionic global root avulsion, confirmed by previous brachial plexus exploration, during the initial stage of carpal arthrodesis surgery. Despite their anesthetic-flail extremity, both the distal axon and the ganglionic cell were intact and able to transfer afferent stimuli. We placed electrodes subcutaneously over the adjacent areas of the ulnar, median, and radial nerves at the elbow region and performed an intraoperative neurophysiologic study. We studied the homologous sensory action potentials (SAPs) generated at the wrist in relaxation, flexion, extension, radial deviation, and ulnar deviation positions at each nerve and repeated them in 2 stages. The first took place with the SLIL intact and the second with the SLIL lacerated. The noise from the rest of the wrist elements was digitally eliminated. RESULTS: After the SLIL laceration, SAP intensities recorded at the median nerve in every wrist position were reduced. The radial and ulnar nerves showed differences of lesser degrees between the recorded SAP intensities before and after the ligament sectioning in every carpal position, with only the radial nerve following a specific pattern. The SAP intensity recorded at the median nerve in every carpal motion after the SLIL laceration was similar to the SAP intensity at relaxation with the SLIL intact, whereas recordings of various intensities were present for the radial and ulnar nerves. CONCLUSIONS: The SLIL generates proprioceptive stimuli at every wrist position. The main innervation of the whole SLIL derives from the anterior interosseous nerve; a partial contribution of the posterior interosseous nerve focused on the dorsal subregion of the ligament may also be present.
Assuntos
Vias Aferentes/fisiologia , Ligamentos Articulares/inervação , Propriocepção/fisiologia , Articulação do Punho/inervação , Potenciais de Ação , Adulto , Feminino , Humanos , Ligamentos Articulares/lesões , Masculino , Nervo Mediano/fisiologia , Adulto JovemRESUMO
Large skeletal defects of the upper extremity pose a serious clinical problem with potentially deleterious effects on both function and viability of the limb. Recent advances in the microsurgical techniques involved in free vascularized bone transfers for complex limb injuries have dramatically improved limb salvage and musculoskeletal reconstruction. This study evaluates the clinical and radiographic results of 18 patients who underwent reconstruction of large defects of the long bones of the upper extremity with free vascularized fibular bone grafts. Mean patient age was 27 years (7-43 years) and mean follow-up was 4 years (1-10 years). The results confirm the value of vascularized fibular grafts for bridging large bone defects in the upper extremity.
Assuntos
Transplante Ósseo/métodos , Fíbula/transplante , Retalhos de Tecido Biológico , Salvamento de Membro/métodos , Microcirurgia/métodos , Extremidade Superior/lesões , Extremidade Superior/cirurgia , Adolescente , Adulto , Criança , Feminino , Seguimentos , Humanos , Masculino , Cuidados Pós-Operatórios , Radiografia , Resultado do Tratamento , Extremidade Superior/diagnóstico por imagem , Adulto JovemRESUMO
Successful free vascularized bone transfers have revolutionized the limb salvage and musculoskeletal reconstruction. The free vascularized fibula remains the mainstay in bone reconstruction combines the benefits of blood supply, biological potential, and callus formation with its unique biomechanical characteristics offering a supreme candidate for various dissolvable issues. Especially in conditions where there was lack of other applicable method and the free vascularized fibular graft was introduced as the only alternative. Extensive traumatic bone loss, tumor resection, femoral head osteonecrosis and congenital defects have been managed with exceptional results beyond expectations. The present manuscript updates several issues in application of free vascularized fibular graft in extremity and trunk reconstruction. It also highlights tips and pearls of surgical technique in some crucial steps of harvesting the vascularized fibular graft in order to offer a vascularized bone with safety and low donor site morbidity.
Assuntos
Transplante Ósseo/métodos , Fíbula/transplante , Retalhos de Tecido Biológico , Procedimentos de Cirurgia Plástica/métodos , Transplante Ósseo/efeitos adversos , Extremidades/cirurgia , Humanos , Salvamento de Membro/efeitos adversos , Salvamento de Membro/métodos , Procedimentos de Cirurgia Plástica/efeitos adversos , TóraxRESUMO
Massive bony defects of the lower extremity are usually the result of high-energy trauma, tumor resection, or severe sepsis. Vascularized fibular grafts are useful in the reconstruction of large skeletal defects, especially in cases of scarred and avascular recipient sites, or in patients with combined bone and soft-tissue defects. Microvascular free fibula transfer is considered the most suitable autograft for reconstruction of the middle tibia because of its long cylindrical straight shape, mechanical strength, predictable vascular pedicle, and hypertrophy potential. The ability to fold the free fibula into two segments or to combine it with massive allografts is a useful technique for reconstruction of massive bone defects of the femur or proximal tibia. It can also be transferred with skin, fascia, or muscle as a composite flap. Proximal epiphyseal fibula transfer has the potential for longitudinal growth and can be used in the hip joint remodeling procedures. Complications can be minimized by careful preoperative planning of the procedure, meticulous intraoperative microsurgical techniques, and strict postoperative rehabilitation protocols. This literature review highlights the different surgical techniques, indications, results, factors influencing the outcome, and major complications of free vascularized fibular graft for management of skeletal or composite defects of the lower limb.
Assuntos
Transplante Ósseo/métodos , Fíbula/transplante , Retalhos de Tecido Biológico , Extremidade Inferior/lesões , Extremidade Inferior/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Neoplasias Ósseas/cirurgia , Transplante Ósseo/efeitos adversos , Fêmur/lesões , Fêmur/patologia , Fêmur/cirurgia , Humanos , Extremidade Inferior/patologia , Microcirurgia/efeitos adversos , Microcirurgia/métodos , Osteomielite/cirurgia , Pseudoartrose/congênito , Pseudoartrose/cirurgia , Procedimentos de Cirurgia Plástica/efeitos adversos , Sarcoma/cirurgia , Tíbia/lesões , Tíbia/patologia , Tíbia/cirurgia , Ferimentos e Lesões/cirurgiaRESUMO
Only 18 cases of congenital radial pseudarthrosis have been reported in the English literature; of these, 4 have been treated with free vascularized fibular graft. We present a case of a 9-year-old female patient with neurofibromatosis type 1 who underwent gradual distraction through the pseudarthrosis site and subsequent vascularized fibular grafting for isolated congenital pseudarthrosis of her left radius and concomitant longitudinal and angular deformity of the wrist joint. At the last follow-up, 10 years postoperatively, the patient has maintained bony union, with full wrist flexion-extension and forearm pronation-supination.
Assuntos
Fíbula/transplante , Neurofibromatose 1/cirurgia , Pseudoartrose/congênito , Pseudoartrose/cirurgia , Rádio (Anatomia)/cirurgia , Criança , Feminino , Humanos , Pseudoartrose/diagnóstico por imagem , Radiografia , Rádio (Anatomia)/diagnóstico por imagemRESUMO
For the past 45 years, the advent of microsurgery has led to replantation of almost every amputated part such as distal phalanx, finger tip, etc. Replantation of digits and hand can restore not only circulation, but also function and cosmetic of the amputated part. The goals of replantation are to restore circulation and regain sufficient function and sensation of the amputated part. Strict selection criteria are necessary to optimize the functional result. The management of this type of injuries includes meticulous preoperative management, microsurgical experience and continuous postoperative care. Among various factors influencing the outcome, the most important are the type and the level of injury, ischemia time, history of diabetes, age, sex, and smoking history. During the replantation procedure, bone stabilization, tendon repair, arterial anastomoses, venous anastomoses, nerve coaptation, and skin coverage should be performed. All structures should be repaired primarily, unless a large nerve gap or a flexor tendon avulsion injury is present. Adequate postoperative evaluation is mandatory to avoid early or late complications. To improve functional results, many replantation patients may need further reconstructive surgery.
Assuntos
Amputação Traumática/cirurgia , Dedos/cirurgia , Mãos/cirurgia , Microcirurgia/métodos , Reimplante/métodos , Feminino , Dedos/irrigação sanguínea , Dedos/inervação , Mãos/irrigação sanguínea , Mãos/inervação , Humanos , Masculino , Complicações Pós-Operatórias/fisiopatologia , Recuperação de Função Fisiológica , Fluxo Sanguíneo Regional , Reimplante/efeitos adversos , Resultado do TratamentoRESUMO
Background Vascularized bone grafts have become one of the first treatment options for scaphoid nonunions and Kienböck's disease. The aim of this study is to review the current body of the literature regarding the use of four vascularized bone grafts (1,2 ICSRA [1,2 intercompartmental supraretinacular artery] graft, 4+5 ECA [4+5 extracompartmental artery] graft, volar radial graft, and free medial femoral condyle graft) in these pathologies. Patients and Methods A search on MEDLINE and Google Scholar was performed. Exclusion criteria included language other than English, studies with no full text available, case reports, letters, editorials, and review articles. The primary outcomes included consolidation rate of the grafts and time to union regarding scaphoid nonunion, as well as the clinical outcomes (pain, grip strength, range of motion), revascularization of the lunate, and progression of the disease regarding Kienböck's disease. Results A total of 37 articles were included in the study enrolling 917 patients. Regarding scaphoid nonunion, the consolidation rate was 86.3% for the 1,2 ICSRA graft, 93.9% for the volar radial bone graft, and 88.8% for the free medial femoral condyle graft. In patients with Kienböck's disease, progression of the disease was observed in 13% of patients, and grip strength and pain were substantially improved whereas range of motion did not demonstrate statistically significant improvement ( p < 0.05). Conclusion Vascularized bone grafts yield successful outcomes in patients with scaphoid nonunions demonstrating a high union rate. In patients with Kienböck's disease, vascularized grafts lead to revascularization of the lunate in most of the cases with concomitant improvement of the clinical parameters.
RESUMO
Birth brachial plexus injury usually affects the upper roots. In most cases, spontaneous reinnervation occurs in a variable degree. This aberrant reinnervation leaves characteristic deformities of the shoulder, elbow, forearm, wrist, and hand. Common sequelae are the internal rotation and adduction deformity of the shoulder, elbow flexion contractures, forearm supination deformity, and lack of wrist extension and finger flexion. Nowadays, the strategy in the management of obstetrical brachial plexus palsy focuses in close follow-up of the baby up to 3-6 months and if there are no signs of recovery, microsurgical repair is indicated. Nonetheless, palliative surgery consisting of an ensemble of secondary procedures is used to further improve the overall function of the upper extremity in patients who present late or fail to improve after primary management. These secondary procedures include transfers of free vascularized and neurotized muscles. We present and discuss our experience in treating early and/or late obstetrical palsies utilizing the above-mentioned microsurgical strategy and review the literature on the management of brachial plexus birth palsy.
Assuntos
Neuropatias do Plexo Braquial/cirurgia , Microcirurgia/métodos , Músculo Esquelético/transplante , Cuidados Paliativos/métodos , Paralisia Obstétrica/cirurgia , Adolescente , Adulto , Neuropatias do Plexo Braquial/classificação , Neuropatias do Plexo Braquial/fisiopatologia , Criança , Pré-Escolar , Articulação do Cotovelo/fisiopatologia , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Músculo Esquelético/fisiopatologia , Amplitude de Movimento Articular , Articulação do Ombro/fisiopatologia , Supinação , Resultado do Tratamento , Articulação do Punho/fisiopatologiaRESUMO
Intrinsic haemangioma of the median nerve is an extremely rare tumor that represents a challenge to diagnose and treat. Only a few cases have been reported in the literature. We present a 10-year-old girl who was diagnosed having an intrinsic haemangioma of the median nerve and treated with total surgical resection of the tumor, under high magnification, using microneurolysis and without the need to resect and graft the median nerve. Three years later, the patient is free of symptoms and no recurrence of the mass was noticed.
Assuntos
Hemangioma/cirurgia , Neuropatia Mediana/cirurgia , Microcirurgia/métodos , Neoplasias do Sistema Nervoso Periférico/cirurgia , Criança , Feminino , Hemangioma/diagnóstico , Humanos , Imageamento por Ressonância Magnética , Neuropatia Mediana/diagnóstico , Microdissecção , Neoplasias do Sistema Nervoso Periférico/diagnósticoRESUMO
The aim of the present study is to evaluate the effects of erythropoietin to the collateral sprouting by using systemically delivered erythropoietin in an end-to-side nerve repair model. Forty-five rats were evaluated in four groups: (A) end-to-side neurorrhaphy only, (B) end-to-side neurorrhaphy and erythropoietin administration, (C) end-to-end neurorrhaphy and (D) nerve stumps buried into neighboring muscles. In all animals, the contralateral healthy side served as control. Functional assessment of nerve regeneration was performed at intervals up to 5 months using the Peroneal Function Index. Evaluation 150 days after surgery included peroneal and tibial nerve morphometric examination, and wet weights of the tibialis anterior muscle. During the first three weeks after surgery, when erythropoietin was regularly administered, functional evaluation showed that erythropoietin may facilitate peripheral nerve regeneration. However, there was rapid deterioration in the functional recovery when erythropoietin's administration was discontinued. As a consequence, at the end of this study, erythropoietin failed to maintain its initial stimulating effect in axonal regeneration. The results of wet muscle weights revealed statistically significant differences between Groups A and C, and Group B. Furthermore, data on axonal counting showed significant difference between Groups A and C, and Group B. Erythropoietin appears to facilitate peripheral nerve regeneration at the initial phase of its administration. Further investigation will be necessary to optimise the conditions (dose, mode of administration) in order to maintain its effects.
Assuntos
Eritropoetina/farmacologia , Cones de Crescimento/efeitos dos fármacos , Fatores de Crescimento Neural/farmacologia , Regeneração Nervosa/efeitos dos fármacos , Nervos Periféricos/efeitos dos fármacos , Animais , Denervação/efeitos adversos , Eritropoetina/uso terapêutico , Gânglios Espinais/efeitos dos fármacos , Gânglios Espinais/metabolismo , Gânglios Espinais/fisiopatologia , Cones de Crescimento/fisiologia , Masculino , Neurônios Motores/efeitos dos fármacos , Neurônios Motores/metabolismo , Músculo Esquelético/inervação , Músculo Esquelético/patologia , Músculo Esquelético/fisiopatologia , Fatores de Crescimento Neural/uso terapêutico , Regeneração Nervosa/fisiologia , Neurônios Aferentes/efeitos dos fármacos , Neurônios Aferentes/metabolismo , Procedimentos Neurocirúrgicos/métodos , Tamanho do Órgão , Traumatismos dos Nervos Periféricos , Nervos Periféricos/cirurgia , Nervo Fibular/efeitos dos fármacos , Nervo Fibular/lesões , Nervo Fibular/cirurgia , Ratos , Ratos Wistar , Recuperação de Função Fisiológica/efeitos dos fármacos , Recuperação de Função Fisiológica/fisiologia , Nervo Tibial/efeitos dos fármacos , Nervo Tibial/lesões , Nervo Tibial/cirurgia , Resultado do Tratamento , Suspensão de TratamentoRESUMO
Erythropoietin (Epo) is a cytokine which controls red cell production. Apart from the red cell surface, erythropoietin's receptor (Epo-R) is also expressed in a large variety of normal tissues. Erythropoietin, as well as its receptor, is present in the central and peripheral nervous system. As erythropoietin having direct and indirect effect on nerve cells, enhances antioxidotic enzyme production, antagonizes glutamate's cytotoxic action, metabolizes free radicals, normalizes cerebral blood flow, affects neurotransmitters release and stimulates neoangiogenesis. After injury of the central as well as the peripheral nervous system, Epo presents an anti-apoptotic action. In combination with its anti-apoptotic effect, Epo, by reducing the inflammatory response plays a crucial role in neuroprotection in many types of injury in the central and the peripheral nervous system. Epo's administration contributes to the recovery of mechanical allodynia and may be effective in peripheral nerve regeneration after neurorrhaphy.
Assuntos
Sistema Nervoso Central/efeitos dos fármacos , Eritropoetina/farmacologia , Sistema Nervoso Periférico/efeitos dos fármacos , Animais , Lesões Encefálicas/prevenção & controle , Eritropoetina/uso terapêutico , Humanos , Regeneração Nervosa/efeitos dos fármacos , Receptores da Eritropoetina/fisiologiaRESUMO
Lipomas are space-occupying lesions that may rarely be responsible for compression neuropathies. Here we report a case of a lipoma arising from flexor tenosynovium that was responsible for a sensory disturbance resulting from the compression of the median nerve in the carpal tunnel. The patient had complete relief from the neurologic symptoms six months after lipoma excision.
Assuntos
Síndrome do Túnel Carpal/etiologia , Lipoma/complicações , Neoplasias de Tecidos Moles/complicações , Tendões , Adulto , Mãos/patologia , Humanos , Lipoma/diagnóstico , Lipoma/cirurgia , Imageamento por Ressonância Magnética , Masculino , Neoplasias de Tecidos Moles/diagnóstico , Neoplasias de Tecidos Moles/cirurgia , Membrana SinovialRESUMO
A 17-yr-old male patient was admitted with a transverse sharp transection caused by broken glass at the volar aspect of his left wrist. Clinical examination showed loss of sensation at the distribution of the median nerve to the thumb, index, and middle finger and an inability to flex the middle finger. Under regional anesthesia and a high humerus tourniquet, surgical exploration of the wound with binocular loupe magnification showed a bifid median nerve with a persistent thin median artery running between the two nerve trunks. The bifid median nerve was sharply and transversely transected, slightly proximal to the transverse carpal ligament. The palmaris longus tendon and the flexor digitorum superficialis tendon of the middle finger were also cut. The flexor digitorum tendon was sutured with a two-strand technique augmented with a running epitendinous suture. The two trunks of the bifid median nerve were repaired separately using microsurgical technique and 8-0 nylon epineural sutures. Postoperatively, the hand was immobilized in a palmar short-arm splint that was removed at 40 d. A progressive Tinel sign was evident 30 d postoperatively. At 3 mo, the patient experienced light touch sensation at the tip of the index and middle fingers. At the last follow-up, 2.5 yr after his injury, the patient has complete nerve functional recovery without atrophy of the thenar muscles and with strong thumb opposition.
RESUMO
BACKGROUND: The optimum fixation device for the critical size bone defect is not established yet. OBJECTIVE: A reliable, feasible and low-cost fixation device for the long-term maintenance of a critical bone defect. METHODS: A custom-made plate made of poly-methyl-methacrylate was used for the fixation of a critical defect of rats' femurs. The screws were securely fixing both on the plate and the bone. A three point bending test, aimed to resemble the in vivo loading pattern, a Finite Element Analysis and a 24-week in vivo monitoring of the integrity of the plate fixation were utilized. RESULTS: The plate has linear and reproducible behavior. It presents no discontinuities in the stress field of the fixation. Its properties are attributed to the material and the locking principle. It fails beyond the level of magnitude of the normal ambulatory loads. In vivo, 100% of the plates maintained the bone defect intact up to 12 weeks and 85% of them at 24 weeks. CONCLUSION: This novel locking plate shows optimal biomechanical performance and reliability with high long-term in vivo survival rate. It is fully implantable, inexpensive and easily manufactured. It can be qualified for long term critical defect fixation in bone regeneration studies.
Assuntos
Placas Ósseas , Parafusos Ósseos , Fraturas do Fêmur/fisiopatologia , Fraturas do Fêmur/cirurgia , Fixação Interna de Fraturas/instrumentação , Modelos Biológicos , Animais , Cadáver , Cimentação/métodos , Simulação por Computador , Desenho Assistido por Computador , Análise Custo-Benefício , Análise de Falha de Equipamento , Fraturas do Fêmur/diagnóstico , Análise de Elementos Finitos , Fixação Interna de Fraturas/métodos , Fricção , Masculino , Desenho de Prótese , Ratos , Ratos Wistar , Resistência à Tração , Resultado do TratamentoRESUMO
Femoral neck fractures, frequently complicated by non-union and femoral head osteonecrosis,present a difficult clinical situation, especially when young patients are concerned. Existing treatment options are valgus osteotomy to address the biomechanical factors or bone grafting to address the biologic factor. The authors describe the operative technique and results of combined subtrochanteric valgus osteotomy and free vascularized fibular grafting in management of five young patients with both non-union and avascular necrosis.
Assuntos
Fraturas do Colo Femoral/cirurgia , Necrose da Cabeça do Fêmur/diagnóstico , Fíbula/transplante , Fixação Interna de Fraturas/métodos , Fraturas não Consolidadas/cirurgia , Adolescente , Adulto , Transplante Ósseo/métodos , Terapia Combinada , Feminino , Fraturas do Colo Femoral/complicações , Fraturas do Colo Femoral/diagnóstico por imagem , Necrose da Cabeça do Fêmur/complicações , Fíbula/irrigação sanguínea , Seguimentos , Consolidação da Fratura/fisiologia , Fraturas não Consolidadas/diagnóstico por imagem , Humanos , Masculino , Osteotomia/métodos , Radiografia , Medição de Risco , Estudos de Amostragem , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
Generalized osteonecrosis of the knee may include, in addition to osteonecrosis of the medial femoral condyle that occurs most frequently, osteonecrosis of the patella or the tibial plateau. Such involvement is known as the osteonecrotic triad of the knee. Although the clinical picture of idiopathic osteonecrosis of the medial femoral condyle seems similar to several other disorders, certain distinct features, including its typical location,clinical symptoms, and late onset of cartilaginous erosion, facilitate differential diagnosis. Despite the progress made in the diagnosis and treatment of idiopathic osteonecrosis of the medial femoral condyle, the prognosis remains severe. More than 80% of the patients deteriorate to the extent that surgical reconstruction is necessary, whereas only about 20%of the patients demonstrate spontaneous resolution or no additional deterioration of the osteonecrotic lesion.
Assuntos
Articulação do Joelho/patologia , Prótese do Joelho , Osteonecrose/diagnóstico , Osteonecrose/cirurgia , Osteotomia/métodos , Adulto , Idoso , Feminino , Seguimentos , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Medição de Risco , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
INTRODUCTION: While recommendations for early exploration and nerve repair in cases of open fractures of the humeral shaft associated with radial nerve palsy are clear, the therapeutic algorithm for the management of closed humeral shaft fractures complicated by radial nerve palsy is still uncertain. The purpose of this study was to determine whether patients with complete sensory and motor radial nerve palsy following a closed fracture of the humeral shaft should be surgically explored. PATIENTS AND METHODS: Twenty-five patients with closed humeral shaft fractures complicated by complete radial nerve palsy were retrospectively reviewed during a 12-year period. Surgical intervention was indicated if functional recovery of the radial nerve was not present after 16 weeks of expectant management. RESULTS: Surgical exploration was performed in 12 patients (48%) after a mean period of expectant management of 16.8 weeks (range: 16-18 weeks). In 2 of them (10%) total nerve transection was found. In the rest 10 patients underwent surgical exploration the radial nerve was found to be macroscopically intact. All intact nerves were fully recovered after a mean time of 21.6 weeks (range: 20-24 weeks) post-injury. In 13 patients (52%) in whom surgical exploration was not performed the mean time to full nerve recovery was 12 weeks (range: 7-14 weeks) post-injury. CONCLUSIONS: We proposed immediate exploration of the radial nerve in case of open fractures of the humeral shaft, irreducible fractures or unacceptable reduction, associated vascular injuries, radial nerve palsy after manipulation or intractable neurogenic pain. Due to high rate of spontaneous recovery of the radial nerve after closed humeral shaft fractures we recommend 16-18 weeks of expectant management followed by surgical intervention.