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

What has changed in brachial plexus surgery?

Brachial plexus injuries, in all their severity and complexity, have been extensively studied. Although brachial plexus injuries are associated with serious and often definitive sequelae, many concepts have changed since the 1950s, when this pathological condition began to be treated more aggressively. Looking back over the last 20 years, it can be seen that the entire approach, from diagnosis to treatment, has changed significantly. Some concepts have become better established, while others have been introduced; thus, it can be said that currently, something can always be offered in terms of functional recovery, regardless of the degree of injury. Advances in microsurgical techniques have enabled improved results after neurolysis and have made it possible to perform neurotization, which has undoubtedly become the greatest differential in treating brachial plexus injuries. Improvements in imaging devices and electrical studies have allowed quick decisions that are reflected in better surgical outcomes. In this review, we intend to show the many developments in brachial plexus surgery that have significantly changed the results and have provided hope to the victims of this serious injury

Use of gastrocnemius muscle on treatment of infected injuries of the knee

OBJETIVO: Avaliar prospectivamente o emprego do retalho do músculo gastrocnêmio no tratamento de lesões infectadas do joelho. MÉDOTOS: foram operados 12 pacientes, onze do sexo masculino, com idade variando de 19 a 78 anos, média de 55 anos. A cobertura com músculo gastrocnêmio medial foi realizada em 11 pacientes, e lateral em um. A média de desbridamentos pré-operatórios foi de 3,2 procedimentos, variando de um a nove. RESULTADOS: todos os retalhos sobreviveram. O agente etiológico mais comum foi o S. aureus, em 54,5%. Após seguimento médio de 20,08 meses (13 a 31), todos os pacientes apresentam cobertura estável sem sinais ou sintomas de reinfecção. CONCLUSÃO: a utilização do músculo gastrocnêmio no tratamento de lesões infectadas do joelho proporcionou bons resultados com baixa morbidade.OBJECTIVE: to prospectively evaluate the use of gastrocnemius muscle flap in the treatment of knee infected injuries. METHODS: twelve patients were operated on: eleven males with ages ranging from 19 to 78 years, mean: 55 years. Coverage of injuries with medial gastrocnemius muscle was accomplished in 11 patients and a lateral in 1. The mean number of preoperative surgical debridement procedures was 3.2, ranging from 1 to 9. RESULTS: all flaps survived. The most common etiological agent was S. aureus, in 54.5%. After a mean follow-up of 20.08 months (13 to 31), all patients show stable coverage without recurrence of infection signs or symptoms. CONCLUSION: gastrocnemius muscle use in knee infected injuries treatment presented good results and low morbity rates

Estudo experimental da ação dos anti-inflamatórios não hormonais inibidores seletivos da ciclooxigenase 2 (COX-2) e anti-inflamatórios tradicionais na regeneração óssea

OBJECTIVE: The aim of this study is to compare the effects of traditional nonsteroidal anti-inflammatory drugs with nonsteroidal anti-inflammatory drugs that are selective cyclooxygenase-2 (COX-2) inhibitors in the process of bone regeneration in a rat model. MATERIALS AND METHODS: Forty-four Wistar strain rats were subjected to osteotomy of the right femur and randomly divided into 3 groups according to the drug to be given (diclofenac, rofecoxib, or placebo). Each group was divided into 2 subgroups according to the time to euthanasia after the surgery. The animals of Subgroup 1 were submitted to euthanasia 2 weeks after surgery, and those of Subgroup 2, underwent euthanasia 4 weeks after surgery. Radiographic examinations and bone callus histomorphometry were analyzed. RESULTS: No intergroup statistical difference was found in the bone callus area or in bone formation area 2 and 4 weeks after surgery. Intra-group analysis concerning the bone neoformation area inside the callus showed a significant difference within the diclofenac group, which presented less tissue. CONCLUSIONS: Fracture consolidation in Wistar rats occurs within less than 2 weeks, and the use of nonsteroidal anti-inflammatory drugs does not significantly influence this process.OBJETIVO: Comparar os efeitos do uso de antiinflamatórios não-esteróides tradicionais (AINES) e AINES que são inibidores seletivos da ciclooxigenase-2 (COX-2), no processo de regeneração óssea em ratos. MATERIAL E MÉTODO: Quarenta e quatro ratos da linhagem Wistar submetidos a osteotomia do femur direito e divididos em três grupos, conforme o medicamento que receberam (diclofenaco, rofecoxib e placebo). Cada grupo foi dividido em dois subgrupos, conforme o tempo até o sacrifício, após a cirurgia. Os animais do subgrupo 1 foram sacrificados duas semanas após a cirurgia e os do subgrupo 2, quatro semanas após a cirurgia. Foram analisados exames radiográficos e a histomorfometria do calo ósseo. RESULTADOS: Não foram encontradas diferenças estatísticas na área do calo ósseo 2 e 4 semanas após a cirurgia. No que se refere à área de neoformação óssea dentro do calo, observou-se diferença estatisticamente significante apenas dentro do grupo do diclofenaco, que apresentou menos tecido. CONCLUSÕES: A consolidação da fratura em ratos Wistar ocorre dentro de 2 semanas e o uso de antiinflamatórios não-esteróides não influi de forma significante neste processo

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

Evaluation of functional gain of the elbow following Steindler surgery for brachial plexus injury

OBJETIVO: Avaliar ganho de força e amplitude de movimento do cotovelo após cirurgia de Steindler Modificada em pacientes com lesão do tronco superior do plexo braquial. MÉTODO: Foram acompanhados de 1998 a 2007 onze pacientes com lesão traumática fechada do tronco superior do plexo braquial. Todos apresentavam evolução de pelo menos 1 ano da lesão e grau de força de flexão do cotovelo que variou de M1 a M3. Os pacientes foram submetidos à cirurgia de Steindler modificada e seguidos por período mínimo de 6 meses. Realizadas avaliações pré e pós-operatórias do ganho de força muscular, amplitude de movimento do cotovelo e pontuação conforme escala DASH. RESULTADOS: Dos onze pacientes analisados, nove (82%) atingiram nível de força igual ou maior a M3 (MRC). Dois (18%) chegaram ao nível de força M2(MRC). Observamos que os pacientes apresentaram ganho médio de amplitude de movimento do cotovelo pós-operatória de 43,45 graus. A média de flexão do cotovelo pós-operatória foi de 88 graus. Houve melhora da função do cotovelo demonstrada na Escala DASH em 81% dos pacientes do estudo. CONCLUSÃO: A cirurgia de Steindler Modificada mostrou-se eficaz no tratamento dos pacientes com lesão de tronco superior de plexo braquial, com ganho estatisticamente significativo de amplitude de movimento. Em todos os casos algum grau de ganho de força e amplitude de flexão do cotovelo, sendo tanto maior quanto maior a força muscular inicial. Nível de Evidência: Nível II, ensaio clínico prospective.OBJECTIVE: To evaluate the gain in strength and range of motion after modified Steindler surgery of the elbow in patients with lesions of the upper trunk of the brachial plexus. METHOD: From 1998 to 2007, eleven patients with traumatic closed upper trunk lesion of the brachial plexus were studied. All the patients had development of at least 1 year of injury and degree of strength of elbow flexion ranging from M1 to M3. The patients underwent Steindler surgery with at least 6 months of follow-up. Pre- and post-operative assessments were carried out to determine gain in muscle strength, range of motion of the elbow, and DASH scale score. RESULTS: Of the eleven patients studied, nine (82%) achieved a level of strength equal to or greater than M3 (MRC) with good functional recovery. Two (18%) reached strength level M2 (MRC). We observed that the patients had an average postoperative gain in range of motion of the elbow of 43.45 degrees. The average elbow flexion after surgery was 88 degrees. There was an improvement in elbow function, as demonstrated in the DASH Scale, in 81% of the patients studied. CONCLUSION: Modified Steindler surgery was effective in the treatment of patients with injuries of the upper trunk of the brachial plexus, with statistically significant gains in range of motion. In all the cases studied, there was some degree of gain in strength and range of elbow flexion, the gain being correlated with the initial muscle strength. Level of Evidence: Level II, prospective clinical trial

Classifying radius fractures with X-ray and tomography imaging

INTRODUÇÃO: Este estudo avaliou a confiabilidade interobservador da radiografia simples versus tomografia computadorizada para as classificações Universal e AO em fraturas do rádio distal. PACIENTES e MÉTODOS: Cinco observadores classificaram 21 fraturas do rádio distal utilizando radiografias e tomografias independentemente. O índice Kappa foi utilizado para estabelecer o nível de concordância entre os observadores. RESULTADOS: A confiabilidade interobservador da classificação Universal foi moderada e a confiabilidade interobservador da classificação AO foi baixa. Reduzindo a clas-sificação AO a nove categorias e às três categorias básicas houve melhora do nível de confiabilidade para "moderado". Não houve diferença entre a confiabilidade interobservador da classificação Universal baseada em imagens radiográficas em comparação com a classificação Universal baseada em imagens tomográficas. A confiabilidade interobservador da classificação AO baseada em radiografias simples foi significativamente maior que a confiabilidade interobservador da classificação AO baseada apenas em tomografias computadorizadas. CONCLUSÃO: A partir destes dados, concluímos que classificar fraturas do rádio distal utilizando tomografias computadorizadas sem o auxílio das radiografias simples não traz benefício.INTRODUCTION: This study evaluated the interobserver reliability of plain radiograpy versus computed tomography (CT) for the Universal and AO classification systems for distal radius fractures. PATIENTS AND METHODS: Five observers classified 21 sets of distal radius fractures using plain radiographs and CT independently. Kappa statistics were used to establish a relative level of agreement between observers for both readings. RESULTS: Interobserver agreement was rated as moderate for the Universal classification and poor for the AO classification. Reducing the AO system to 9 categories and to its three main types reliability was raised to a "moderate" level. No difference was found for interobserver reliability between the Universal classification using plain radiographs and the Universal classification using computed tomography. Interobserver reliability of the AO classification system using plain radiographs was significantly higher than the interobserver reliability of the AO classification system using only computed tomography. CONCLUSION: From these data, we conclude that classification of distal radius fractures using CT scanning without plain radiographs is not beneficial