Posterior Atlantoaxial Screw Placement in a Portuguese Population: A Morphometric Analysis Based on Computed Tomography Scan Measurements / Colocação de parafusos atlantoaxiais posteriores em uma população portuguesa: Uma análise morfométrica baseada em medidas de tomografia computadorizada

Abstract Objective The present study aims to evaluate the screw length and trajectory angles for posterior atlantoaxial fixation in a Portuguese population, through the study of cervical computed tomography (CT) scans. Methods Cervical CT scans of 50 adults were measured according to predefined screw trajectories of C1-C2 transarticular (C1C2TA), C1 lateral mass (C1LM), C2 pedicle (C2P), C2 pars and C2 laminar (C2L) screws. For each of these trajectories, screw length and angles were measured and compared between males and females. Results For the C1C2TA screw trajectory, the mean length, medial, and cranial angles were 34.12 ± 3.19 mm, 6.24° ± 3.06, and 59.25° ± 5.68, respectively, and for the C1LM screw trajectory, they were 27.12 ± 2.15 mm, 15.82° ± 5.07, and 13.53° ± 4.80, respectively. The mean length, medial, and cranial angles for the C2P screw trajectory were 23.44 ± 2.49 mm, 27.40° ± 4.88, and 30.41° ± 7.27, respectively; and for the C2 pars screw trajectory, they were 16.84 ± 2.08 mm, 20.09° ± 6.83, and 47.53° ± 6,97. The mean length, lateral, and cranial angles for the C2L screw trajectory were 29.10 ± 2.48 mm, 49.80° ± 4.71, and 21.56° ± 7.76, respectively. There were no gender differences except for the lengths of the C1C2TA (p= 0,020) and C2L (p= 0,001) screws, which were greater in males than in females. Conclusion The present study provides anatomical references for the posterior atlantoaxial fixation in a Portuguese population. These detailed data are essential to aid spine surgeons to achieve safe and effective screw placement.

Resumo Objetivo O presente estudo tem como objetivo avaliar o comprimento e os ângulos de trajetória do parafuso para fixação atlantoaxial posterior em uma população portuguesa por meio do estudo de tomografia computadorizada (TC) cervical. Métodos Tomografias computadorizadas cervicais de 50 adultos foram analisadas quanto às trajetórias pré-definidas dos parafusos transarticulares C1-C2 (C1C2TA), na massa lateral de C1 (C1LM), no pedículo de C2 (C2P) e na pars de C2 e C2 laminar (C2L). O comprimento e os ângulos dos parafusos em cada uma destas trajetórias foram medidos e comparados entre homens e mulheres. Resultados O comprimento médio e ângulos medial e cranial da trajetória do parafuso C1C2TA foram de 34,12 ± 3,19 mm, 6,24° ± 3,06 e 59,25° ± 5,68, respectivamente; as medidas da trajetória do parafuso C1LM foram 27,12 ± 2,15 mm, 15,82° ± 5,07 e 13,53° ± 4,80. O comprimento médio e os ângulos medial e cranial da trajetória do parafuso C2P foram de 23,44 ± 2,49 mm, 27,40° ± 4,88 e 30,41° ± 7,27, respectivamente; as medidas da trajetória do parafuso da pars de C2 foram 16,84 ± 2,08 mm, 20,09° ± 6,83 e 47,53° ± 6,97. O comprimento médio e ângulos lateral e cranial da trajetória do parafuso C2L foram de 29,10 ± 2,48 mm, 49,80° ± 4,71 e 21,56° ± 7,76, respectivamente. Não houve diferenças entre os gêneros, à exceção do comprimento dos parafusos C1C2TA (p= 0,020) e C2L (p= 0,001), que foi maior no sexo masculino do que no feminino. Conclusão O presente estudo fornece referências anatômicas para a fixação atlantoaxial posterior em uma população portuguesa. Estes dados detalhados são essenciais para ajudar os cirurgiões de coluna a colocar os parafusos de maneira segura e eficaz.

Correction of the spinal sagittal plane: the application of convergent or divergent screws / Correção do plano sagital da coluna vertebral: aplicação de parafusos convergentes ou divergentes / Corrección del plano sagital de la columna vertebral: aplicación de tornillos convergentes o divergentes

ABSTRACT Objective To present a new principle for correction of the sagittal plane of the spine through the convergent or divergent placement of monoaxial pedicle screws in this plane, associated with compression or distraction, to provide lordotizing or kyphotizing leverage force. Method A statistical mechanical study of twenty-eight fixations in synthetic spine segments was performed. In fifteen pieces, pedicle screws were applied to the ends of the segments with positioning convergent to the center of the fixation. They were attached to the straight rods and subjected to compression force. The other thirteen segments were fixed with pedicle screws in a direction divergent to the center of the fixation, attached to the straight rods, and subjected to distraction force. Results To create kyphosis in the 15 synthetic segments of the spine, the mean pre-fixation Cobb angle was - 0.7° and the mean post-fixation angle was +15°. To create lordosis in the 13 segments, the mean pre-fixation Cobb angle was +1° and the mean post-fixation angle was +18°. The difference was confirmed by statistical mechanical tests and considered significant. However, there is no relevant difference between the mean angles for lordosis and kyphosis formation. Conclusions It was concluded that the correction of the sagittal plane of the spine by applying the new instrumentation method is efficient. A statistical mechanical test confirmed that the difference in Cobb degrees between pre- and post-fixation of the synthetic spine segments was considered significant in the creation of both kyphosis and lordosis. Level of evidence II C; Statistical mechanical study of synthetic spine segments.

RESUMO Objetivo Apresentar um novo princípio para correção do plano sagital da coluna vertebral, posicionando os parafusos pediculares monoaxiais nesse plano de forma convergente ou divergente, associados à compressão ou distração, para proporcionar força em alavanca lordotizante ou cifotizante. Métodos Realizou-se um estudo de mecânica estatística de 28 fixações em segmentos de coluna sintética. Em quinze peças, foram aplicados parafusos pediculares monoaxiais nos extremos dos segmentos abordados com posicionamento no sentido convergente à fixação. Foram agregados às hastes retas e submetidos à força de compressão. Em outros treze segmentos, a fixação foi feita com parafusos pediculares monoaxiais, no sentido divergente ao centro da fixação, integrados às hastes retas e submetidos à força de distração. Resultados Para criar cifose nos 15 segmentos sintéticos da coluna vertebral, a média do ângulo de Cobb na pré-fixação foi de -0,7° e a média pós-fixação foi de +15°. Para cria lordose em 13 segmentos, a média do ângulo de Cobb na pré-fixação foi de +1° e a média pós-fixação foi de +18°. A diferença foi confirmada por testes de mecânica estatística e considerada significativa. Contudo, não existe diferença relevante entre os ângulos médio para formação da lordose e da cifose. Conclusões Conclui-se que a correção do plano sagital da coluna aplicando o novo método de instrumentação é eficiente. Confirmou-se com teste de mecânica estatística que a diferença em graus de Cobb entre o período pré e o pós-fixação dos segmentos de coluna sintética fixados foi considerada significativa, tanto na criação da cifose quanto da lordose. Nível de evidência II C; Estudo mecânico estatístico de segmentos de coluna sintética.

RESUMEN Objetivo Presentar un nuevo principio para corrección del plano sagital de la columna vertebral, posicionando los tornillos pediculares monoaxiales en ese plano de forma convergente o divergente, asociados a la compresión o distracción, para proporcionar fuerza en palanca lordotizante o cifosante. Métodos Se realizó un estudio de mecánica estadística de 28 fijaciones en segmentos de columna sintética. En quince piezas, fueron aplicados tornillos pediculares monoaxiales en los extremos de los segmentos abordados con posicionamiento en el sentido convergente a la fijación. Fueron agregados a las varillas rectas y sometidos a la fuerza de compresión. En otros trece segmentos, la fijación fue hecha con tornillos pediculares monoaxiales, en el sentido divergente del centro de la fijación, integrados a las varillas rectas y sometidos a la fuerza de distracción. Resultados Para crear cifosis en los 15 segmentos sintéticos de la columna vertebral, el promedio del ángulo de Cobb en la prefijación fue de -0,7° y el promedio de postfijación fue de +15°. Para crear lordosis en 13 segmentos, el promedio del ángulo de Cobb en la prefijación fue de +1° y el promedio de postfijación fue de +18°. La diferencia fue confirmada mediante tests de mecánica estadística y considerada significativa. Sin embargo, no existe diferencia relevante entre los ángulos promedios para la formación de lordosis y de cifosis. Conclusiones Se concluye que la corrección del plano sagital de la columna aplicando el nuevo método de instrumentación es eficiente. Se confirmó con test de mecánica estadística que la diferencia en los grados de Cobb entre el período de pre y postfijación de los segmentos de columna sintética fijados fue considerada significativa, tanto en la creación de cifosis como de la lordosis. Nivel de evidencia II C; Estudio mecánico estadístico de segmentos de columna sintética.

Mechanical evaluation of tibial fixation of the hamstring tendon in anterior cruciate ligament double-bundle reconstruction with and without interference screws

OBJECTIVE: The objective of this study was to compare two postero-lateral bundle (PLB) tibial fixation techniques for the reconstruction of the anterior cruciate ligament with double bundle: a technique without the use of an interference screw, preserving the native tibial insertion of the tendons of the gracilis and semitendineous muscles, and a technique with the use of an interference screw and without preserving the insertion of the tendons. METHODS: A comparative study was conducted in cadavers with a universal mechanical test machine. In total, 23 cadaver knees were randomized for tibial fixation of the PLB using the two techniques: Maintaining the tibial insertion of the tendons during reconstruction, without the use of an interference screw (group A, 11 cases); and fixating the graft with an interference screw, without maintaining the insertion of the tendons (group B, 12 cases). A continuous traction was performed (20 mm/min) in the same direction as the produced tunnel, and force (N), elongation (mm), rigidity (N/mm), and tension (N/mm2) were objectively determined in each group. RESULTS: Group A exhibited a maximum force (MF) of 315.4±124.7 N; maximum tension of 13.57±3.65 N/mm2; maximum elongation of 19.73±4.76 mm; force at the limit of proportionality (FLP) of 240.6±144.0 N; and an elongation at the limit of proportionality of 14.37±6.58 mm. Group B exhibited a MF of 195.7±71.8 N; maximum tension of 8.8±3.81 N/mm2; maximum elongation of 15.3±10.73 mm; FLP of 150.1±68.7 N; and an elongation at the limit of proportionality of 6.86±2.42 mm. When comparing the two groups, significant differences were observed in the variables of maximum force (p=0.016), maximum tension (p=0.019), maximum elongation (p=0.007), and elongation at the limit of proportionality (p=0.003). CONCLUSION: The use of the native insertion of the semitendineous and gracilis tendons, without an additional fixation device, presented mechanical superiority over their fixation with interference screws.

Fixation of the Anterior Ligament Graft at the Tibial Pole: Biomechanical Analysis of Three Methods / Fixação do enxerto do ligamento cruzado anterior no polo tibial: Análise biomecânica de três métodos

Abstract Objective Comparative biomechanical analysis of tibial fixation strength for ligament reconstruction with interference screw compared with screw post and washer, and compared with the associated fixation of both methods (hybrid fixation). Method A total of 54 specimens were used (porcine tibias and bovine flexor digital tendons), which were divided into three groups with fixation types similar to those used in anterior cruciate ligament (ACL) reconstruction: 1) fixation with interference screw; 2) fixation with screw post and toothed washer over knot and suture strand; and )- fixation with screw post and washer combined with interference screw (hybrid fixation). The analyses were performed through pull-out biomechanical tensile tests to determine the stiffness and load to system failure (yield load). Results The hybrid fixation group presented a significantly higher final stiffness (59.10 ± 3.45 N/mm) in comparison to the other groups (p < 0.05) and a higher yield load (581.34 ± 33.48 N) compared to the interference screw group (p < 0.05). Conclusion Hybrid fixation had biomechanical advantages over the bovine digital flexor graft fixation system in swine tibia during tensile tests.

Resumo Objetivo Análise biomecânica comparativa da resistência da fixação tibial para reconstrução ligamentar com parafuso de interferência, comparada com parafuso do tipo poste com arruela, e com fixação associada entre os métodos (fixação híbrida). Métodos Foram utilizados 54 corpos de prova (tíbia suína e tendão digital bovino), que foram divididos em 3 grupos com tipos de fixação semelhantes àqueles utilizados na reconstrução do ligamento cruzado anterior: 1) fixação com parafuso de interferência; 2) fixação com parafuso do tipo poste com arruela dentada sobre nó e fios de sutura; e 3) fixação com parafuso do tipo poste com arruela combinada com parafuso de interferência (fixação híbrida). Os testes foram realizados por meio de ensaios biomecânicos de tração tipo pull-out para determinação da rigidez e carga para falha (yield load) do sistema. Resultados O grupo com fixação híbrida apresentou maior rigidez final (59,10 ± 3,45 N/mm) do que os demais grupos (p < 0,05), e carga superior para falha (581,34 ± 33,48 N) em relação ao grupo com parafuso de interferência (p < 0,05). Conclusão A fixação híbrida apresentou vantagens biomecânicas com relação ao sistema de fixação do enxerto de flexor digital bovino em tíbia suína durante os ensaios de tração.

Reconstrucción mandibular en una deformidad posquirúrgica por trauma / Mandibular reconstruction of a post-surgical deformity due to trauma

La necesidad de una reconstrucción mandibular está dictada por la pérdida de hueso debido, entre otras causas, a trauma. El propósito de este trabajo es caracterizar un caso de reconstrucción mandibular de una deformidad posquirúrgica por trauma. Se trata de un paciente masculino de 34 años que acude a consulta por inconformidad estética y dificultad para masticar. Aproximadamente un año atrás había padecido un trauma facial, por lo cual fue atendido de urgencia e intervenido quirúrgicamente. Se realizó estabilización ósea y colocación de placa de reconstrucción mandibular. Presentaba asimetría facial, disminución del tercio inferior facial y movilidad de los segmentos óseos mandibulares, por tal motivo se decide realizar retirada de la placa existente, reacomodamiento de los segmentos óseos, colocación de injerto autólogo de cresta ilíaca y fijación. Se observó buena evolución posoperatoria. La repercusión estética y funcional, en un paciente joven con una deformidad posquirúrgica por trauma; motivó el planeamiento de una reconstrucción mandibular mediante placa rígida e injerto de creta ilíaca. El tratamiento de este caso constituyó un reto profesional por tratarse de una deformidad posquirúrgica provocada por un trauma de alta energía; pero el trabajo quirúrgico en equipo aseguró resultados satisfactorios(AU)

The need for mandibular reconstruction is dictated by bone loss due to trauma among other causes. The purpose of the study was to present a case of mandibular reconstruction of a post-surgical deformity due to trauma. A 34-year-old male patient presents with dissatisfaction with his dentofacial appearance and difficulty chewing. About one year before he had undergone facial trauma, for which had been cared for at the emergency service and had been operated on. Bone stabilization was performed as well as placement of a mandibular reconstruction plate. The patient presented facial asymmetry, a diminished lower facial third and mobility in mandibular bone segments. Therefore, it was decided to perform removal of the existing plate, rearrangement of the bone segments, placement of an autologous iliac crest bone graft and surgical fixation. Good post-operative evolution was observed. Esthetic and functional impairment in a young patient with a post-surgical deformity due to trauma led to planning a mandibular reconstruction with a rigid plate and an iliac crest graft. Treatment in this case was professionally challenging, for the post-surgical deformity had been due to high energy trauma, but the surgical work performed ensured satisfactory results(AU)

Cirugía reconstructiva de la pelvis en el prolapso genital severo con uso de prótesis anterior y fijación al ligamento sacroespinoso

Una alternativa con algunas ventajas e iguales resultados en el manejo quirúrgico del prolapso genital total para la fijación de la cúpula al sacro por vía abdominal es la fijación de la cúpula al ligamento sacroespinoso. Objetivo: Evaluar los resultados del empleo de malla anterior y fijación al ligamento sacroespinoso en el prolapso genital total. Diseño: Estudio retrospectivo y descriptivo. Institución: Servicio de Ginecología Especializada, Hospital Nacional Edgardo Rebagliati Martins, EsSalud, Lima, Perú. Participantes: Mujeres con diagnóstico de prolapso genital total. Método: Revisión retrospectiva de 12 pacientes con diagnóstico de prolapso genital total y que tuvieron cirugía reconstructiva pélvica con empleo de malla anterior y fijación al ligamento sacroespinoso. Principales medidas de resultados: Resultados de las técnicas. Resultados: La edad promedio fue 64 años. La comorbilidad principal fue la obesidad. La histerectomía abdominal fue el antecedente quirúrgico más frecuente. Se realizó histerectomía vaginal más colocación de malla anterior con fijación al ligamento sacroespinoso a tres pacientes, solo malla anterior con fijación sacroespinosa a cuatro pacientes, malla anterior con fijación sacroespinosa y malla transobturatiz (TOT) a tres pacientes, histerectomía vaginal con malla anterior, fijación sacroespinosa y TOT a dos pacientes. Como complicaciones hubo extrusión de malla en un paciente; dos pacientes a las que no se colocó TOT presentaron incontinencia de orina al esfuerzo, una urgencia miccional nueva, una dispareunia; dos pacientes presentaron granuloma de sutura y una refirió dolor pélvico inespecífico, síntomas que evolucionaron favorablemente. La evaluación del prolapso genital después de la cirugía no fue mayor de grado I. Conclusiones: Al fijar el compartimento apical al sacroespinoso mediante el uso de TOT y de la malla anterior garantizó que no se presentara incontinencia urinaria de esfuerzo, recidiva o aparición de defectos del compartimiento anterior.

Changes in the population pyramid result in more adult female population consulting for pelvic floor dysfunction. Objective: To evaluate results of severe genital prolapse reconstructive pelvic surgery by anterior prosthesis with sacrospinous ligament fixation. Design: Retrospective and descriptive study. Setting: Specialized Gynecology Service, Hospital Nacional Edgardo Rebagliati Martins, EsSalud, Lima, Peru. Participants: Women with diagnosis of total genital prolapse. Method: A retrospective study of 12 patients admitted for genital prolapse and desire to retain vaginal function and having reconstructive pelvic surgery with mesh fixed to the sacrospinous ligament. Main outcome measures: Results of techniques used. Results: Average age was 64 years (range 56-75). Main comorbidity was obesity (body mass index 29.1). Patient's main complaint was a feeling of lump in genitalia in 91 Ofo, and most had had abdominal hysterectomy. Vaginal hysterectomy plus anterior mesh (Perigee) with sacrospinous fixation was performed in 3 patients, only anterior mesh with sacrospinous fixation in 4 patients, anterior mesh with sacrospinous fixation and trans-obturator tape (Mona re) - TOT- in 3 patients, vaginal hysterectomy with anterior mesh (Perigee), sacrospinous fixation and trans-obturator tape (Mona re) in two patients. Complications included mesh extrusion in one patient, two patients without TOT had stress urinary incontinence, one presented urinary urgency, one dyspareunia, two patients had granuloma in the suture area, and one referred nonspecific pelvic pain; symptoms were not present in subsequent vlsits, and vaginal prolapse was not over grade I. Conclusions: The use of TOT and anterior mesh resulted in cure of urinary stress incontinence and no recurrence of defects when the apical anterior compartment was fixed to the sacrospinous ligament.

Ortodontia Lingual: o preparo para cirurgia ortognática / Lingual Orthodontics: preparation for orthognathic surgery

A Técnica Lingual é uma opção mais atraente para os pacientes adultos que necessitam de tratamento ortodôntico. Atualmente, a demanda de pacientes com indicação de cirurgia ortognática, que fazem questão do uso de aparelhos linguais, tem levado os ortodontistas a desenvolver opções para essa situação, até então incomum, devido à ausência de bráquetes na superfície vestibular dos dentes utilizados como apoio para os elásticos intermaxilares necessários nos procedimentos cirúrgicos. Este artigo propõe-se a apresentar quatro formas de preparo ortodôntico para cirurgia ortognática que permitem a utilização de elásticos intermaxilares apoiados por vestibular mesmo com a utilização de bráquetes linguais.

The lingual technique is a more attractive option for adult patients in need of orthodontic treatment. Currently, the demand of patients requiring orthognathic surgery who insist on wearing lingual appliance has led orthodontists to create options to resolve the until then uncommon situation due to the absence of brackets on the labial and buccal surfaces of the teeth used as anchor for intermaxillary elastics necessary in surgical cases. This paper aims at presenting four different forms of orthodontic preparation for orthognathic surgery that allow the use of intermaxillary elastics attached to the labial and buccal surfaces of the teeth, even with the use of lingual brackets.

¿Intervenimos adecuadamente las hernias inguinales? / Do we adequately intervene inguinal hernias?

Introducción. La herniorrafia inguinal es la intervención quirúrgica más frecuente en el ámbito de la cirugía general. El uso de técnicas quirúrgicas con malla ha traído numerosos beneficios, entre los que se pueden mencionar la disminución de la tasa de recidiva y de las complicaciones posoperatorias, y la reducción del tiempo de convalecencia y de reintegración a las actividades cotidianas. Materiales y métodos. Se llevó a cabo un estudio de tipo observacional retrospectivo desde noviembre de 2010 hasta septiembre de 2012 de pacientes diagnosticados con hernia inguinal, que fueron intervenidos quirúrgicamente en una institución de tercer nivel de atención en salud. La recolección de la información se hizo mediante un formato estructurado y la revisión de las historias clínicas. Resultados. De 102 pacientes intervenidos en este lapso de tiempo, 86,3 % eran hombres y 13,7 % mujeres, entre los 14 y 88 años. El 57 % tenía una hernia indirecta unilateral y 28 % presentó una directa unilateral. En 68 % de los pacientes se usó malla y, de estos, a todos se les practicó fijación de la misma. El tipo de malla usada fue mayormente de polipropileno (88 %). El 18,6 % de los pacientes presentó complicaciones posoperatorias. Discusión. La institución estudiada presentó una tasa de utilización de la técnica de Lichtenstein menor a la esperada con relación a otros estudios. La tasa de morbilidad general fue menor, pero el hematoma se presentó el doble de veces que en la mayoría de los reportes de la literatura científica.

Background. Inguinal herniorraphy is the most common surgical procedure performed in general surgery. Using mesh surgical techniques has greatly reduced the relapse rate after the procedure, postoperative complications, recovery time and reintegration to daily activities. Methods. A retrospective observational study of patients diagnosed and surgically treated of inguinal hernia from November 2010 to September 2012 in a third level of care general hospital was performed. The data collection was done through a structured format and review of medical records. Results. In a total of 102 patients, 86.3% were male and 13.7% female, with ages ranging from14 to 88 years old. Most of them had a unilateral indirect hernia (57%) and 28% had a unilateral direct hernia 68 % of the patients were intervened with a mesh technique and all patients received mesh fixation. Most of mesh's type used in the procedures was polypropylene (88%); 18.6 % of patients presented posoperative complications (POP). Discussion. The studied institution showed a lower utilization rate of the Lichtenstein technique than expected according to current literature. The general morbidity rate was lower, but hematoma occurred twice as often than in most literature reports.

Radiographic evaluation of the use of transverse traction device in vertebral arthrodesis for degenerative diseases / Avaliação radiográfica do uso do dispositivo de traço transversa nas artrodeses vertebrais de patologias degenerativas / Evaluación radiográfica de la utilización del dispositivo de tracción transversal en la artrodesis vertebral para las enfermedades degenerativas

OBJECTIVE: Perform radiographic analysis of the use of Transverse Traction Device (DTT) with respect to fusion rate in patients submitted to vertebral arthrodesis for degenerative lumbar diseases. METHODS: We selected x-ray images on anteroposterior, lateral and oblique views and with maximum flexion and extension dynamics of 23 patients submitted to posterolateral arthrodesis of the lumbar spine with a minimum follow-up period of six months. The images were evaluated and classified by the Linovitz's system by two spine surgeons. RESULTS: We evaluated the radiographs of 23 patients after the minimum postoperative period of 6 months and of these, 11 have used DTT. With regard to the consolidation rate, seven patients (63.6%) in the group of DTT were classified as fusion as well as six patients (50%) who were not submitted to the treatment. There was no statistical difference between the groups regarding the consolidation rate. CONCLUSION: The use of transverse traction device in this study showed no significant difference in the rate of consolidation in radiographic evaluation. Studies on the effective participation of this device in the stability of pedicle fixation systems are still lacking in the literature. .

OBJETIVO: Realizar análise radiográfica do uso do dispositivo de tração transversa (DTT) quanto a taxa de consolidação em pacientes submetidos à artrodese vertebral da coluna lombar em patologias degenerativas. MÉTODOS: Foram selecionadas radiografias nas incidências anteroposterior, perfil, oblíquas e dinâmicas em flexão e extensão máxima de 23 pacientes submetidos à artrodese posterolateral da coluna lombar com seguimento pós-operatório mínimo de seis meses. As imagens foram avaliadas e classificadas pelo sistema de Linovitz, por dois cirurgiões de coluna. RESULTADOS: Avaliamos as radiografias de 23 pacientes no pós-operatório mínimo de 6 meses sendo que destes, 11 fizeram uso do DTT. Quanto à taxa de consolidação foram classificados como fusão sete pacientes (63,6%) no grupo que recebeu o DTT e seis pacientes (50%) naqueles em que o dispositivo não foi utilizado. Não observamos diferença estatística entre os grupos quanto à taxa de consolidação. CONCLUSÃO: A utilização do dispositivo de tração transversa neste estudo não apresentou diferença significativa quanto à taxa de consolidação na avaliação radiográfica. Ainda faltam na literatura estudos sobre a efetiva participação deste dispositivo na estabilidade dos sistemas de fixação pedicular. .

OBJETIVO: Análisis del uso del dispositivo de tracción transversal (DTT) respecto a la tasa de consolidación en las enfermedades degenerativas de la columna vertebral en pacientes sometidos a la artrodesis, a partir del estudio de los resultados radiológicos. MÉTODOS: Se seleccionaron radiografías de la zona anteroposterior, oblicua y de perfil, así como, dinámicas de la flexión y extensión máxima, de 23 pacientes sometidos a la operación quirúrgica de artrodesis posterolateral de la columna lumbar, con un mínimo de seis meses después de la realización de la cirugía. Las imágenes fueron evaluadas y clasificadas mediante el sistema de Linovitz por dos cirujanos de columna. RESULTADOS: Evaluamos las radiografías de 23 pacientes después de la cirugía, mínimo de seis meses después y en 11 de los 23 pacientes anteriormente mencionados, se usó DTT. En cuanto a la tasa de consolidación, siete pacientes (63,6%) fueron clasificados como de fusión en el grupo con la DTT, así como seis pacientes (50%) del grupo en el que no se utilizó el tratamiento. Por lo tanto, no se observó diferencia estadística entre los grupos respecto a la tasa de consolidación en el análisis radiográfico. CONCLUSIONES: El uso del dispositivo de tracción transversal en este estudio no mostró diferencias significativas con respecto a la tasa de consolidación radiográfica. Además, no existen todavía estudios suficientes sobre la efectiva participación de este dispositivo en la estabilidad de los sistemas de fijación pedicular. .

Dynamic compared to rigid fixation in lumbar spine: a systematic review / Fixação pedicular dinâmica comparada com a fixação rígida na coluna lombar: uma revisão sistemática

Objective: The objective of this review is to reveal the quality of published data and the effect size of DPFs compared to rigid fixation in lumbar spine. Summary of background data: since 2002, several dynamic pedicle fixation (DPF) systems have been developed with the aim to stabilize the spine without the undesirable effects of rigid lumbar spine fixation. Nearly ten years later, there are several studies on these dynamic systems. Methods: A systematic review was done in MEDLINE/PubMED, Embase, Cochrane Central Register of Randomized Trials and Google Scholar to assess the quality of published literature and the available studied outcomes in randomized controlled trials of DPF. Results: Only three papers described randomized trials studying DPF. One of them focused on protection of adjacent level disease provided by DPF. Conclusion: It was not possible to reveal any evidence for benefits using DPF compared to rigid fixation in surgery for lumbar spine. .

Objetivo: Desde 2002, vários sistemas de fixação dinâmica pedicular (FDP) foram desenvolvidos com o objetivo de estabilizar a coluna vertebral, sem os efeitos indesejáveis da fixação da coluna lombar rígida. Cerca de 10 anos mais tarde, existe uma série de estudos sobre os sistemas dinâmicos. Revelar a qualidade dos dados publicados e o tamanho do efeito da FDP em comparação com a fixação rígida na coluna lombar. Métodos: Uma revisão sistemática foi feita utilizando MEDLINE/ PubMed, Embase, a CENTRAL Cochrane de ensaios randomizados e Google Scholar para avaliar a qualidade da literatura publicada e os desfechos estudados disponíveis em ensaios clínicos randomizados. Resultados: Apenas três estudos randomizados foram encontrados. Um deles estudou a proteção de degeneração no nível adjacente à fixação rígida proporcionada pela FDP. Conclusão: Não foi possível revelar qualquer evidência de benefícios da FPD, em comparação com a fixação rígida em cirurgia para a coluna lombar. .

Experimental model for the study of soft tissue fixation methods on skin-pericranium flaps in rats

PURPOSE: To develop an experimental model to study and radiologically monitor displacement of skin flaps in the pericranium of rats subjected to traction and surgical fixation using suture anchored in a skull bone tunnel or with N-butyl-2-cyanoacrylate (HistoacrylTM) surgical adhesive. METHODS: Radiological markers were placed in the subcutis of Wistar rats undergoing subperiosteal detachment of the pericranium with pulling and fixation of the flap. We performed radiography on postoperative days 3, 7, 14, 21, and 45. A p-value of <0.05 was considered significant. RESULTS: Qualitative analysis of the data indicated that the flaps in the surgical adhesive group remained in place with no change from the immediate postoperative position. However, the flaps in the suture anchored in the skull bone tunnel group and in the control group showed similar healing, with a loss of attachment of 9.7% and 22%, respectively, compared with the immediate postoperative position. There was no quantitative difference between the groups. CONCLUSIONS: This experimental model created acceptable experimental conditions for testing different soft tissue fixation methods. The use of tissue fixatives contributed to better placement of pericranium-cutaneous flaps, and surgical adhesive was superior to suture anchor in the skull bone tunnel for fixation of pericranium-cutaneous flaps.

Redoable Tie-Over Dressing Using Multiple Loop Silk Threads

After skin grafting, to prevent hematoma or seroma collection at the graft site, a tie-over dressing has been commonly used. However, although the conventional tie-over dressing by suture is a useful method for securing a graft site, refixation is difficult when repeated tie-over dressing is needed. Therefore, we recommend a redoable tie-over dressing technique with multiple loops threads and connecting silk threads. After the raw surface of each of our cases was covered with a skin graft, multiple loop silk thread attached with nylon at the skin graft margin. We applied the ointment gauze and wet cotton/fluffy gauze over the skin graft, then fixed the dressing by connecting cross-counter multiple loop thread with connecting silk threads. When we opened the tie-over dressing by cutting the connecting silk threads, we repeated the tie-over dressing with the same method. The skin graft was taken successfully without hematoma or seroma collection or any other complications. In conclusion, we report a novel tie-over dressing enabling simple fixation of the dressing to maintain proper tension for wounds that require repetitive fixation. Further, with this reliable method, the skin grafts were well taken.

¿Se debe fijar la malla durante una herniorrafia inguinal? / Should mesh prosthesis be fixed in inguinal herniorraphy?

Introducción. La fijación de la malla durante una herniorrafia inguinal ha sido recomendada rutinariamente. La información disponible es controversial. En este estudio se hace una revisión crítica de la literatura científica, evaluando la efectividad clínica de esta intervención en cirugía laparoscópica y abierta (técnica de Lichtenstein). Métodos. Se hizo una búsqueda de la literatura científica siguiendo la metodología BET (Best Evidence Topic), para identificar artículos que compararan fijar contra no fijar la malla durante una herniorrafia inguinal. Los artículos se revisaron según los criterios de apreciación de la Journal of the American Medical Association (JAMA). Se extrajeron los datos de la efectividad de la intervención y se analizaron resultados primarios como reproducción, dolor posoperatorio, infección, seroma y hematoma. Se analizaron como resultados secundarios costo, tiempo de estancia hospitalaria, retorno laboral y tiempo quirúrgico. Resultados. Se encontraron una revisión sistemática de la literatura científica y nueve estudios de asignación aleatoria. En herniorrafia totalmente extraperitoneal, transabdominal preperitoneal y abierta, no existe diferencia en la frecuencia de reproducción, infección, seroma ni hematoma. La presencia de dolor posoperatorio disminuye tardíamente cuando no se fija la malla, tanto en herniorrafia abierta como laparoscópica. En herniorrafia laparoscópica el tiempo de incapacidad no disminuye si se fija la malla. Fijar la malla incrementa el costo y el tiempo quirúrgico. Conclusiones. La fijación de la malla puede omitirse en herniorrafia laparoscópica totalmente extraperitoneal, en la transabdominal preperitoneal y en la abierta por vía anterior (Lichtenstein). La principal ventaja de no fijar la malla, documentada en los estudios disponibles, tiene que ver con la reducción del dolor posoperatorio crónico, sin que exista diferencia en la tasa de reproducción. No hay información disponible sobre esta intervención en otros tipos de herniorrafia abierta, como la preperitoneal (Nyhus).

Introduction / aims: Mesh fixation in groin hernia repair has been recommended routinely; however there is pertinent controversial information. In this study we review the clinical effectiveness of the intervention in open (Lichtenstein repair) and laparoscopic repair. Methods: We used a Best Bets methodology to identify clinical trials comparing mesh fixation versus no mesh fixation during inguinal herniorraphy. Studies were evaluated according with JAMA criteria. Information about clinical effectiveness was extracted from articles, and we considered as primary outcomes the recurrence rate, postoperative pain, and development of infection, seroma, and hematoma. Secondary outcomes were cost, length of stay, operating time, and return to labor activity. Results: One systematic review and nine RCT were identified. In TEP, TAPP and open repair there is no difference in the recurrence rate or in the development of infection, seroma, and hematoma. Postoperative pain decreases when mesh is unfixed in both repairs. For laparoscopic repair the time to return labor activity is not modified under mesh fixation. Fixation increases cost and operative time. Conclusions: Fixation could be omitted during laparoscopic and Lichtenstein repair. Main advantage of non fixation is related to the reduction of postoperative pain, with no modifications in recurrence rate. There is no information regarding other surgical techniques such as the preperitoneal repair (Nyhus procedure).

May titanium spiral tacks contribute to intra-abdominal adhesion formation? / Grampos espirais de titânio podem contribuir para a formação de aderências intra-abdominais?

PURPOSE: To verify if titanium spiral tacks may contribute to intra-abdominal adhesion formation in rabbits. METHODS: Ten New Zealand white rabbits were used. Through videolaparoscopic surgery two titanium spiral tacks (ProTack®, Covidien®) were applied in the right flank. After 30 days the animals were submitted to evaluate peritoneal cavity by videolaparoscopy. RESULTS: No adhesion was found where the titanium spiral tacks were placed. CONCLUSION: Titanium spiral tacks for fixation do not cause adhesions in rabbits.

OBJETIVO: Verificar se grampos espirais de titânio podem contribuir para a formação de aderências intra-abdominais em coelhos. MÉTODOS: Foram utilizados 10 coelhos albinos linhagem Nova Zelândia. Por meio de vídeo laparoscopia foram aplicados dois grampos metálicos espirais de titânio (ProTack®, Covidien®) na região do flanco direito. Após 30 dias, os animais foram submetidos à laparoscopia para avaliação da cavidade peritoneal. RESULTADOS: Não foi encontrada nenhuma aderência aos grampos aplicados. CONCLUSÃO: Os grampos em espiral de titânio para a fixação não causam aderências em coelhos.

Radiological and Clinical Results of Laminectomy and Posterior Stabilization for Severe Thoracolumbar Burst Fracture : Surgical Technique for One-Stage Operation

OBJECTIVE: This study aimed to show the possibility of neural canal enlargement and restoration of bony fragments through laminectomy and minimal facetectomy without pediculectomy or an anterior approach, and also to prove the adequacy of posterior stabilization of vertebral deformities after thoracolumbar bursting fracture. METHODS: From January 2003 to June 2009, we experienced 45 patients with thoracolumbar burst fractures. All patients enrolled were presented with either a neural canal compromise of more than 40% with a Benzel-Larson Grade of VI, or more than 30% compromise with less than a Benzel-Larson Grade of V. Most important characteristic of our surgical procedure was repositioning retropulsed bone fragments using custom-designed instruments via laminectomy and minimal facetectomy without removing the fractured bone fragments. Beneath the dural sac, these custom-designed instruments could push the retropulsed bone fragments within the neural canal after the decompression and bone fragment repositioning. RESULTS: The mean kyphotic deformities measured preoperatively and at follow-up within 12 months were 17.7 degrees (+/-6.4 degrees) and 9.6 degrees (+/-5.2 degrees), respectively. The mean midsagittal diameter improved from 8.8 mm (+/-2.8 mm) before surgery to 14.2 mm (+/-1.6 mm) at follow-up. The mean traumatic vertebral body height before surgery was 41.3% (+/-12.6%). At follow-up assessment within 12 months, this score showed a statistically significant increase to 68.3% (+/-12.8%). Neurological improvement occurred in all patients. CONCLUSION: Though controversy exists in the treatment of severe thoracolumbar burst fracture, we achieved effective radiological and clinical results in the cases of burst fractures causing severe canal compromise and spinal deformity by using this novel custom-designed instruments, via posterior approach alone.

Rigid Fixation using Bioabsorbable Mesh and Screws in Facial Bone Fracture

PURPOSE: Absorbable plate and screw fixation is widely used technique for internal rigid fixation in craniomaxillofacial surgery. However, there are some potential problems associated with the use of plate. The purpose of this study is to evaluate the feasibility of bone fixation in facial fracture using absorbable mesh in place of absorbable plate. METHODS: The records of 55 patients with zygomaticomaxilla fractures treated by open reduction, performed by the author from February 2008 to May 2009, were retrospectively reviewed. Patients were selected to receive absorbable mesh fixation. The incidence of all complications including infection, hypoesthesia, and deformity was examined. Analysis with postoperative computed tomography follow-up demonstrates degree of reduction. RESULTS: Forty-six patients met criteria for inclusion in the study. All patients went on to satisfactory healing without complication. Postoperative computed tomography revealed good bony alignment similarly non affected side. CONCLUSION: This study demonstrates that the rigid internal fixation of fractured bone fragments using absorbable mesh is more effective than absorbable plate, especially in comminuted fracture of maxilla.

Rigid Fixation using Bioabsorbable Mesh and Screws in Facial Bone Fracture

PURPOSE: Absorbable plate and screw fixation is widely used technique for internal rigid fixation in craniomaxillofacial surgery. However, there are some potential problems associated with the use of plate. The purpose of this study is to evaluate the feasibility of bone fixation in facial fracture using absorbable mesh in place of absorbable plate. METHODS: The records of 55 patients with zygomaticomaxilla fractures treated by open reduction, performed by the author from February 2008 to May 2009, were retrospectively reviewed. Patients were selected to receive absorbable mesh fixation. The incidence of all complications including infection, hypoesthesia, and deformity was examined. Analysis with postoperative computed tomography follow-up demonstrates degree of reduction. RESULTS: Forty-six patients met criteria for inclusion in the study. All patients went on to satisfactory healing without complication. Postoperative computed tomography revealed good bony alignment similarly non affected side. CONCLUSION: This study demonstrates that the rigid internal fixation of fractured bone fragments using absorbable mesh is more effective than absorbable plate, especially in comminuted fracture of maxilla.

Load Sharing Mechanism Across Graft-Bone Interface in Static Cervical Locking Plate Fixation

OBJECTIVE: This study is a retrospective clinical study over more than 4 years of follow up to understand the mechanism of load sharing across the graft-bone interface in the static locking plate (SLP) fixation compared with non-locking plate (NLP). METHODS: Orion locking plates and Top non-locking plates were used for SLP fixation in 29 patients and NLP fixation in 24 patients, respectively. Successful interbody fusion was estimated by dynamic X-ray films. The checking parameters were as follows : screw angle (SA) between upper and lower screw, anterior and posterior height of fusion segment between upper and lower endplate (AH & PH), and upper and lower distance from vertebral endplate to the end of plate (UD & LD). Each follow-up value of AH and PH were compared to initial values. Contributions of upper and lower collapse to whole segment collapse were estimated. RESULTS: Successful intervertebral bone fusion rate was 100% in the SLP group and 92% in the NLP group. The follow-up mean value of SA in SLP group was not significantly changed compared with initial value, but follow-up mean value of SA in NLP group decreased more than those in SLP group (p=0.0067). Statistical analysis did not show a significant difference in the change in AH and PH between SLP and NLP groups (p>0.05). Follow-up AH of NLP group showed more collapse than PH of same group (p=0.04). The upper portion of the vertebral body collapsed more than the lower portion in the SLP fixation (p=0.00058). CONCLUSION: The fused segments with SLP had successful bone fusion without change in initial screw angle, which was not observed in NLP fixation. It suggests that there was enough load sharing across bone-graft interface in SLP fixation.