Anatomical study of the latissimus dorsi muscle flap / Estudio anatómico del colgajo del músculo latísimo del dorso

SUMMARY: The latissimus dorsi is a broad muscle that originates from the inferior thoracic spinous processes, thoracolumbar fascia, iliac crest, and inferior ribs. It inserts on the inferior aspect of the intertubercular groove of the humerus through a thin tendon. The study was conducted on 10 cadavers (7 male and 3 female). These specimens were dissected and examined to study the gross anatomical characteristics of the latissimus dorsi muscle. The dimensions of the latissimus dorsi muscle and its surface area were measured in all the cadavers. The branching pattern of the thoracodorsal vessels was recorded. The pedicle length and caliper were measured using Vernier calipers. On the 20 dissected sides, the thoracodorsal artery was found to be one of the terminal branches of the subscapular artery that originates in the axillary region. In 19 (95 %) cases, the thoracodorsal artery terminated in a bifurcation, giving off a medial and a lateral branch. The average size of the elevated flap of the latissimus dorsi muscle was 18 cm x 36 cm. The average pedicle length was 9.5 cm (range: 5 cm-14 cm), and the average diameter at its origin was 2.5 mm (range: 1.5 mm-3.5 mm). The average diameter of the vena comitans was 3.3 mm. The current study focuses on the anatomical features of the latissimus dorsi muscle and its blood supply to increase the success rate of operations in clinical practice.

RESUMEN: El músculo latísimo del dorso se origina en los procesos espinosos de las vértebras torácicas inferiores, la fascia toracolumbar, la cresta ilíaca y las costillas inferiores y se inserta en el surco intertubercular del húmero a través de un delgado tendón. El estudio se realizó en 10 cadáveres (7 mujeres y 3 hombres). Estos especímenes fueron disecados y examinados para estudiar las características anatómicas macroscópicas del músculo latísimo del dorso. En todos los cadáveres se midieron las dimensiones del músculo y su superficie. Se registró el patrón de ramificación de los vasos toracodorsales. La longitud del pedículo y el calibre se midieron con paquímetro Vernier. En los veinte lados disecados, se encontró que la arteria toracodorsal era una de las ramas terminales de la arteria subescapular que se originaba en la región axilar. En 19 (95 %) casos, la arteria toracodorsal terminaba bifurcándose en dos ramas, una rama medial y otra lateral. El tamaño promedio del colgajo elevado del músculo latísimo del dorso era de 18 cm x 36 cm. La longitud promedio del pedículo era de 9,5 cm (rango: 5 cm-14 cm), y el diámetro promedio en su origen era de 2,5 mm (rango: 1,5 mm-3,5 mm). El diámetro medio de la vena comitans era de 3,3 mm. El estudio actual se centra en las características anatómicas del músculo latísimo del dorso y su irrigación para aumentar la tasa de éxito de las operaciones en la práctica clínica.

Efeitos do treinamento resistido nos músculos escapulares nas epicondilalgias: revisão sistemática e metanálise / Effects of resistant training on scapular muscles in epicondylalgia: systematic review and meta-analysis

As epicondilalgias medial e lateral são as causas mais frequentes de sintomas dolorosos nos membros superiores. Observa-se um aumento no número de publicações sobre os efeitos do treino da musculatura escapular no manejo clínico das epicondilalgias, porém desconhecemos uma revisão sistemática que avalie os efeitos do treinamento resistido nos músculos escapulares nessa condição. Objetivo: revisar sistematicamente os efeitos do treinamento resistido nos músculos escapulares nas epicondilalgias. Metodologia: foi realizada uma busca científica (SciELO, PubMed, LILASCS, PEDro) de estudos clínicos controlados sobre os efeitos do treinamento resistido nos músculos escapulares nas epicondilalgias publicados até maio 2021. A escala de PEDro foi aplicada para avaliação da qualidade metodológica. Resultados: foram encontrados 266 artigos e 3 foram incluídos na revisão sistemática. Os estudos inclusos enfatizaram o treinamento dos músculos trapézio médio, trapézio inferior e serrátil anterior associados a reabilitação convencional. Através da análise individual dos estudos observa-se efeitos positivos do treino escapular na dor, na função (Patient Rated Tennis Elbow Evaluation Questionnaire ­ PRTEE) e na força de preensão manual em indivíduos com epicondilalgias lateral. A metanálise revela que adicionar exercícios escapulares a fisioterapia convencional reduz a dor (EVA 0-10) em 1.23 (95% IC, 2,00-0,47, p=0,002, I2=47%, p para heterogeidade = 0.17) e aumenta a função (PRTEE 0-100) em 5.47 (95% IC, 10,00-0,93, p=0,02, I2=0%, p para heterogeidade = 0.84) na epicondilalgias lateral. A média de pontuação da escala PEDro foi de 6,33/10. Conclusão: o treinamento resistido dos músculos escapulares associados a reabilitação reduzem dor e aumentam função em indivíduos com epicondilalgia lateral. Sugere-se a realização de mais estudos com melhor qualidade metodológica para avaliar a importância do fortalecimento dos músculos escapulares em indivíduos com epicondilalgias. (AU)

Medial and lateral epicondylalgia are the most requente causes of painful symptoms in the upper limbs. There is na increase in the number of publications on the effects of scapular muscle training in the clinical management of epicondylalgia, but we do not know of a systematic review that assesses the effects of resistance training on scapular muscles in this condition. The aim of the study was to systematically review the effects of resistance training on scapular muscles in epicondylalgia. A scientific search (SciELO, PubMed, LILASCS, PEDro) of controlled clinical studies on the effects of resistance training for the scapular muscles in epicondylagias published until May 2021 was performed. The PEDro scale was applied to assess the methodological quality. 266 articles were found and 3 were included in the systematic review. The included studies emphasized the training of the middle trapezius, lower trapezius and serratus anterior muscles associated with conventional rehabilitation. Through the individual analysis of the studies, positive effects of scapula training on pain, function Patient Rated Tennis Elbow Evaluation Questionnaire ­ PRTEE) and handgrip strength were observed in individuals with lateral epicondylalgia. The meta-analysis reveals that adding scapular exercises to conventional physical therapy reduces pain (VAS 0-10) by 1.23 (95% CI, 2.00-0.47, p=0.002, I2=47%, p for heterogeneity = 0.17) and increases function (PRETEE 0-100) by 5.47 (95% CI, 10.00- 0.93, p=0.02 I2=0%, p for heterogeneity = 0.84) in lateral epicondylalgia. The average score of the studies on the PEDro scal e was 6.33 out 10. In conclusion, resistance training of scapular muscles associated with rehabilitation reduces pain the increases function in individuals with lateral apicondylalgia. It is suggested that more studies be carried out with better methodological quality to assess the importance of strengthening the scapular muscles in individuals with epicondylalgia. (AU)

Reliability of quantitative sensory testing on myofascial trigger points in the upper trapezius muscle of individuals with chronic neck pain

SUMMARY OBJECTIVE: The objective of this study was to measure the intra- and inter-rater reliability of the quantitative sensory testing for measuring the thermal pain threshold on myofascial trigger points in the upper trapezius muscle of individuals with chronic neck pain. METHODS: Thirty female participants were included, aged between 18 and 45 years and with bilateral myofascial trigger points, active and centrally located in the upper trapezius muscle. Two measurements with quantitative sensory testing were performed by each examiner at an interval of 1 week between them. RESULTS: We observed substantial reliability for the intra-rater analysis (intraclass correlation coefficient ranging between 0.876 and 0.896) and excellent reliability for the inter-rater analysis (intraclass correlation coefficient ranging between 0.917 and 0.954). CONCLUSION: The measurement of the thermal pain threshold on myofascial trigger points in individuals with chronic neck pain has acceptable reliability values, supporting the use of the quantitative sensory testing in the research setting and the clinical environment.

Clinical effects of free latissimus dorsi myocutaneous flap combined with artificial dermis and split-thickness skin graft in the treatment of degloving injury in lower extremity / 中华烧伤杂志

Objective: To observe the clinical effects of free latissimus dorsi myocutaneous flap combined with artificial dermis and split-thickness skin graft in the treatment of degloving injury in lower limbs. Methods: A retrospective observational study was conducted. From December 2017 to December 2020, 8 patients with large skin and soft tissue defect caused by degloving injury in lower extremity were admitted to Ningbo No.6 Hospital, including 5 males and 3 females, aged from 39 to 75 years, with wound area of 25 cm×12 cm-61 cm×34 cm. The free latissimus dorsi myocutaneous flap with latissimus dorsi muscle in the width of 12-15 cm and flap area of 20 cm×8 cm-32 cm×8 cm was used to repair the skin and soft tissue defect of bone/tendon exposure site or functional area. The other defect was repaired with bilayer artificial dermis, and the flap donor site was sutured directly. After the artificial dermis was completely vascularized, the split-thickness skin graft from thigh was excised and extended at a ratio of 1∶2 to 1∶4 and then transplanted to repair the residual wound, and the donor site of skin graft was treated by dressing change. The survival of latissimus dorsi myocutaneous flap, artificial dermis, and split-thickness skin graft after operation was observed, the interval time between artificial dermis transplantation and split-thickness skin graft transplantation was recorded, and the healing of donor site was observed. The appearance and function of operative area were followed up. At the last outpatient follow-up, the sensory recovery of flap was evaluated by British Medical Research Council evaluation criteria, the flap function was evaluated by the comprehensive evaluation standard of flap in Operative Hand Surgery, the scar of lower limb skin graft area and thigh skin donor area was evaluated by Vancouver scar scale, and the patient's satisfaction with the curative effects was asked. Results: The latissimus dorsi myocutaneous flap survived in 6 patients, while the distal tip of latissimus dorsi myocutaneous flap was partially necrotic in 2 patient and was repaired by skin grafting after resection at split-thickness skin grafting. The artificial dermis survived in all 8 patients after transplantation. The split-thickness skin graft survived in 7 patients, while partial necrosis of the split-thickness skin graft occurred in one patient and was repaired by skin grafting again. The interval time between artificial dermis transplantation and split-thickness skin graft transplantation was 15-26 (20±5) d. The donor site of latissimus dorsi myocutaneous flap healed with linear scar after operation, and the thigh skin graft donor site healed with scar after operation. The patients were followed up for 6-18 (12.5±2.3) months. The color and elasticity of the flap were similar to those of the surrounding skin tissue, and the lower limb joint activity returned to normal. There was no increase in linear scar at the back donor site or obvious hypertrophic scar at the thigh donor site. At the last outpatient follow-up, the sensation of the flap recovered to grade S2 or S3; 3 cases were excellent, 4 cases were good, and 1 case was fair in flap function; the Vancouver scar scale score of lower limb skin graft area was 4-7 (5.2±0.9), and the Vancouver scar scale score of thigh skin donor area was 1-5 (3.4±0.8). The patients were fairly satisfied with the curative effects. Conclusions: In repairing the large skin and soft tissue defect from degloving injury in lower extremity, to cover the exposed bone/tendon or functional area with latissimus dorsi myocutaneous flap and the residual wound with artificial dermis and extended split-thickness skin graft is accompanied by harvest of small autologous flap and skin graft, good recovery effect of functional area after surgery, and good quality of healing in skin grafted area.

Clinical application of three-dimensional printed preformed titanium mesh combined with free latissimus dorsi muscle flap in the treatment of squamous cell carcinoma with skull defect in the vertex / 中华烧伤杂志

Objective: To explore the clinical effects of three-dimensional printed preformed titanium mesh combined with latissimus dorsi muscle flap free transplantation in the treatment of wounds with skull defect after radical surgery of squamous cell carcinoma in the vertex. Methods: A retrospective observational study was conducted. From January 2010 to December 2019, 5 patients with squamous cell carcinoma in the vertex accompanied with skull invasion who met the inclusion criteria were admitted to the Department of Burns and Plastic Surgery of the Second Affiliated Hospital of Air Force Medical University, including four males and one female, aged 50 to 65 years. The original lesion areas ranged from 5 cm×4 cm to 15 cm×8 cm. The titanium mesh was prefabricated via three-dimensional technic based on the result the scope of skull resection predicted with computerized tomography three-dimensional reconstruction before surgery. During the first stage, the soft tissue defect area of scalp (8 cm×7 cm to 18 cm×11 cm) after tumor enlargement resection was repaired with the preformed titanium mesh, and the titanium mesh was covered with latissimus dorsi muscle flap, with area of 10 cm×9 cm to 20 cm×13 cm. The thoracodorsal artery/vein was anastomosed with the superficial temporal artery/vein on one side. The muscle ends in the donor site were sutured together or performed with transfixion, and then the skin on the back were covered back to the donor site. On the 10th day after the first-stage surgery, the second-stage surgery was performed. The thin intermediate thickness skin graft was taken from the anterolateral thigh to cover the latissimus dorsi muscle flap. The duration and intraoperative blood loss of first-stage surgery were recorded. The postoperative muscle flap survival after the first-stage surgery and skin graft survival after the second-stage surgery was observed. The occurrence of complications, head appearance, and recurrence of tumor were followed up. Results: The average first-stage surgery duration of patients was 12.1 h, and the intraoperative blood loss was not more than 1 200 mL. The muscle flaps in the first-stage surgery and the skin grafts in the second-stage surgery all survived well. During the follow-up of 6-18 months, no complications such as exposure of titanium mesh or infection occurred, with good shape in the recipient sites in the vertex, and no recurrence of tumor. Conclusions: Three-dimensional printed preformed titanium mesh combined with latissimus dorsi muscle flap free transplantation and intermediate thickness skin graft cover is an effective and reliable method for repairing the wound with skull defect after extended resection of squamous cell carcinoma in the vertex. This method can cover the wound effectively as well as promote both recipient and donor sites to obtain good function and appearance.

Presence of incomplete superficial axillary arch and pectoralis quartus muscle in one male body / Presencia en un individuo de un arco axilar superficial incompleto y de un músculo pectoral cuarto

SUMMARY: The anatomical variations of the pectoralis major muscle (PMM) and latissimus dorsi muscle (LDM) range from agenesis to the presence of supernumerary fascicles with a variety of insertions and relationships with the muscles, fascia, vessels, nerves and skeletal components of the shoulder girdle and the axilla. Many of these variations are clinically irrelevant, but extremely interesting and revealing from the perspective of comparative anatomy, ontogeny, and phylogeny. In this report, we present two different supernumerary muscles in the chest of one adult male body, identified during dissection practice of undergraduate medical students at Universidad Surcolombiana. These supernumerary fascicles in the axillary region were caudal to the lower edge of the PMM on the right side of the chest, and in contact with the anterior edge of the LDM on the left side of the chest; each fascicle was inserted in the ipsilateral coracoid process. These observations are congruent with the pectoralis quartus muscle and an incomplete and superficial axillary arch, respectively.

RESUMEN: Las variaciones anatómicas del músculo pectoral mayor (MPM) y del músculo latísimo del dorso (MLD) van desde la agenesia hasta la presencia de fascículos supernumerarios con una variedad de inserciones y relaciones con los músculos, fascias, vasos, nervios y componentes esqueléticos de la cintura escapular y la axila. Clínicamente, muchas de las variaciones son irrelevantes, pero extremadamente interesantes y reveladoras desde la perspectiva de la anatomía comparada, la ontogenia y la filogenia. En este estudio, presentamos dos músculos supernumerarios diferentes en la pared torácica de un hombre adulto, identificados durante la práctica de disección de estudiantes de medicina de la Universidad Surcolombiana. Estos fascículos supernumerarios en la región axilar estaban caudales al margen inferior del MPM en el lado derecho del tórax y en contacto con el margen anterior del MLD en el lado izquierdo del tórax; cada fascículo se insertaba en el proceso coracoides ipsilateral. Estas observaciones son congruentes con el músculo pectoral cuarto y un arco axilar incompleto y superficial, respectivamente.

Avaliação eletromiográfica da musculatura mastigatória e da coluna cervical com uso de placa oclusal: relato de caso / Electromyographic evaluation of masticatory and cervical musculature with occlusal splint: case report

Objetivo: Avaliar a atividade elétrica de músculos mastigatórios e cervicais e sua inter-relação na estabilização da cadeia crânio cervico umeral com uso da placa oclusal, por meio da avaliação eletromiográfica. Relato de caso: Paciente sexo feminino, 39 anos, queixando-se de dores na cabeça, faciais e cervicais, com prejuízo em suas atividades diárias. Relatou apertar os dentes durante o dia e a noite e ser uma pessoa muito ansiosa. Pratica exercício físico de 5 a 6 vezes por semana. Foi submetida ao tratamento com placa oclusal estabilizadora. O exame eletromiográfico foi realizado nos músculos masseter e trapézio, bilateralmente. A coleta de dados foi realizada antes da instalação da placa e passados 90 dias de uso. Considerações finais: Após o tempo de tratamento, foi relatado redução do comportamento de apertamento noturno e diurno dos dentes, redução do nódulo muscular antes visível na região supraescapular, eliminação das dores e melhor rendimento muscular durante a prática de atividade física.(AU)

Objective: To evaluate the electrical activity of masticatory and cervical muscles and their relationship in the stabilization of the craniocervicohumeral chain using a occlusal splint, through electromyographic evaluation. Case report: Female patient, 39 years old, complaining of headaches, facial and cervical pain, with impairment in her daily activities. She reported teeth clenching during the day and night, and being a very anxious person. She practices physical exercise 5 to 6 times a week. She underwent treatment with a stabilizing occlusal splint. The electromyographic examination was performed on the masseter and trapezius muscles, bilaterally. Data was collected before occlusal splint installation and after 90 days of use. Final considerations: After the treatment period, it was reported a reduction in the behavior of nocturnal and daytime teeth clenching, reduction of the muscle nodule previously visible in the suprascapular region, elimination of pain and better muscle performance during the practice of physical activities.(AU)

Effect of kinesio tape on scapular kinematics in subjects with scapular dyskinesis

Scapular dyskinesis is an abnormality in scapula static or dynamic position. There are several techniques for scapular dyskinesis conservative treatment, including Kinesio Tape application, which is used to promote and support scapula joint alignment, decrease pain and improve local muscle control. The study aim to investigate the effect of kinesio tape on scapular kinematics in subjects with scapular dyskinesis. Fourteen subjects with scapular dyskinesis performed flexion and scaption movements in two conditions: (1) without load and (2) holding a dumbbell. A scapular tape was applied over the lower trapezius (Y shaped) muscle with a 20% tension. Kinematic data were captured with 10 infrared cameras and analyzed based on Euler angles, peak values of upward rotation, internal rotation, and posterior tilt angles. To compare the situations with and without kinesio tape the repeated measures two-way ANOVAs (α = 0.05) was performed using SPSS software. Scapular tape increase upward rotation and posterior tilt during flexion of the shoulder. No interaction (Load x KT) was found during flexion, suggesting that KT effect in the peak values is the same, regardless the load condition. Scapular tape decreases internal rotation during scaption and a significant interaction was found between load x KT, suggesting the effect of using KT could depend the load u sed during this movement. The results suggest that kinesio tape may can be use as assistant to increase upward rotation, posterior tilt and decrease internal rotation in scapular dyskinesis subjects. (AU)

Non-traumatic myositis ossificans

Myositis ossificans (MO) is a benign, ossifying lesion that usually affects the skeletal muscle. The rare non-traumatic form of MO can cause diagnostic dilemma and management issues. These lesions, however, have similar radiology and histopathological characteristics described in the more frequently encountered traumatic forms. Depending on the stage of the lesion, the inherent feature of myositis ossificans varies, and so does the management of the lesion. We describe a non-traumatic MO occurring in latissimus dorsi of a young girl and discuss the review of literature on this rare subtype.

Lower trapezius myocutaneous flap with latissimus dorsi for repairing parietal and occipital defect after cancer surgery / 中华耳鼻咽喉头颈外科杂志

Objective: To evaluate the functional outcomes of repairing parietal and occipital defect after surgery for cancer by lower trapezius myocutaneous flap with latissimus dorsi. Methods: Retrospective analyses of eight patients were performed who underwent repairing parietal and occipital defects with dural exposure after surgeries for cancers from January 2015 to January 2020 in Tianjin Institute of Occupational Disease Control and Prevention (Tianjin Workers Hospital) and the Second Hospital of Tianjin Medical University, including 6 males and 2 females aged from 26 to 68 years old. The method for harvesting the lower trapezius myocutaneous flap was improved and thus the lower trapezius myocutaneous flaps with latissimus dorsi were used for repairing the parietal and occipital defects. The area of myocutaneous flap depended on the size of defect. Results: The defects were repaired with the flaps with areas ranging from 12 cm×8 cm to 17 cm×15 cm. Seven flaps survived after surgery and the wounds were healed. Blisters and bruise were observed at the distal end of one flap 2 days after operation, which were cured with dressing change for 10 days. All cases were followed-up for six months, with normal functions of the shoulder joints, aside from mild hypertrophic scar in donor site on the back. Conclusion: It is feasible to use the lower trapezius myocutaneous flap with latissimus dorsi to repair the parietal and occipital defect after surgery for cancer, and the clinical effect is satisfactory.

Obstetric Paralysis: Evaluation of the Sever-L'Episcopo Technique Modified by Hoffer / Paralisia obstétrica: Avaliação da técnica Sever-L'Episcopo modificada por Hoffer

Abstract Evaluate the results of a series of 28 cases of high obstetric paralysis treated with the Sever-L'Episcopo technique modified by Hoffer, between 2003 and 2016. Children (mean age, four years and seven months) with adduction contracture and internal rotation of the shoulder without secondary bone deformities (Mallet class II) underwent lengthening of the pectoralis major muscle and tenotomy of the subscapularis muscle associated with transfer of the latissimus dorsi and teres major muscle to the infraspinatus muscle, moving to the function of external rotators and elevators. The mean follow-up was three years and 10 months. At the end of the study, 24 patients achieved excellent functional assessment scores, mainly of the abduction and external rotation, passing from Mallet class II to class IV. Four patients still demonstrated some degree of global movement limitation, passing from class II to class III. Regardless of the final functional gain, all patients were able to perform tasks that were previously difficult. The data from this study suggest that Hoffer's surgery is an effective method in the treatment of the sequelae of high obstetric paralysis without secondary bone deformities.

Resumo Avaliar os resultados de uma série de 28 casos de paralisia obstétrica alta tratadas com a técnica Sever-L'Episcopo modificada por Hoffer, entre 2003 e 2016. As crianças (idade média, quatro anos e sete meses) com contratura em adução e rotação interna do ombro sem deformidades ósseas secundárias (Mallet classe II) foram submetidas ao alongamento do músculo peitoral e tenotomia do músculo subescapular associada à transferência do latissimus dorsi e músculo redondo maior para o músculo infraespinhal, movendo-se para a função de rotadores externos e elevadores. O seguimento médio foi de 3 anos e 10 meses. Ao final do estudo, 24 pacientes obtiveram excelentes escores de avaliação funcional, principalmente de abdução e rotação externa, passando de Mallet classe II para classe IV. Quatro pacientes ainda demonstraram algum grau de limitação de movimento global, passando da classe II para a classe III. Independentemente do ganho funcional final, todos os pacientes foram capazes de realizar tarefas que antes eram difíceis. Os dados deste estudo sugerem que a cirurgia de Hoffer é um método eficaz no tratamento das sequelas de paralisia obstétrica alta sem deformidades ósseas secundárias.

Laserterapia versus técnica de compressão isquêmica: avaliação comparativa dos efeitos terapêuticos e funcionais da contratura do músculo trapézio / Laser therapy versus ischemic compression technique: comparative evaluation of the therapeutic and functional effects of trapezius contracture

Introdução: A contratura muscular ocorre quando o músculo se contrai de maneira incorreta e não volta ao seu estado normal de relaxamento, em resposta a uma sobrecarga de esforço. Objetivos: Comparou-se a utilização de duas técnicas e os benefícios proporcionados ao tratamento dos pacientes acometidos com contratura do músculo trapézio superior. Métodos: Tratou-se de um estudo transversal, intervencionista, comparativo e quantitativo no período de agosto de 2015 a junho de 2016, com 49 acadêmicos, que foram divididos em dois grupos (G1/G2). Os dados foram obtidos através da ficha de avaliação cinético-funcional desenvolvida para o estudo, que foi aplicada antes e ao término do tratamento fisioterapêutico, Escala dos Sintomas de Dyrek e Escala Visual Analógica. Resultados: Dos 49 acadêmicos, 80% eram do sexo feminino, sendo 95% solteiras, todos naturais de Fortaleza, todos cursando o ensino superior, com média de idade de 23,33 anos. No G1 (Compressão isquêmica) antes da aplicação a maior predominância foi a de nível de dor 7 e logo depois da aplicação o nível de maior predominância foi de dor 2, conforme Escala Visual Analógica. No G2 (Laserterapia) o nível de dor antes da aplicação foi de 7 e logo depois da aplicação, foi de dor 1 conforme Escala Visual Analógica. Conclusão: As técnicas de Laserterapia e a Compressão Isquêmica melhoraram o aporte sanguíneo da área tratada, porém na laserterapia houve a diminuição do limiar de dor e restabelecimento da normalidade funcional local. (AU)

Introduction: Muscle contracture occurs when the muscle contracts incorrectly and does not return to its normal state of relaxation in response to effort overload. Objectives: We compared the use of two techniques and the benefits provided to the treatment of patients with upper trapezius contracture. Methods: This was a cross-sectional, interventional, comparative and quantitative study between August 2015 and June 2016, with 49 academics divided into two groups (G1/G2). The data were obtained through the functional kinetic evaluation sheet developed for the study, which was applied before and at the end of the physiotherapeutic treatment, Dyrek Symptom Scale and Visual Analog Scale. Results: Of the 49 students, 80% were female, 95% single, all of them from Fortaleza/CE, all of them attending higher education, with a mean age of 23.33 years. In G1 (Ischemic Compression), before the application, the greatest predominance was pain level 7 and soon after the application the greater predominance was level pain 2, according to Visual Analog Scale. In G2 (Laser Therapy) the level of pain before the application was 7 and soon after the application was level pain 1 according to Visual Analog Scale. Conclusion: Laser therapy and ischemic compression improved the blood supply of the treated area, and laser therapy decreased th pain threshold and restored the local functional normality. (AU)

Spinal Accessory Neuropathy Secondary to Diffuse Large B-Cell Lymphoma

Spinal accessory neuropathy (SAN) is commonly caused by an iatrogenic procedure, and that caused by tumors is very rare. We present a case of a 49-year-old man suffering from weakness in the right trapezius and sternocleidomastoid muscle. An electrophysiology study confirmed proximal SAN. Fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) revealed a diffuse large B-cell lymphoma compressing the right spinal accessory nerve. Ultrasonography showed definite atrophy on the trapezius and sternocleidomastoid muscles. In addition, post-chemotherapy FDG-PET/CT showed increased FDG uptake in the right upper trapezius, suggestive of denervation. This is the first report of SAN caused by direct compression by a diffuse large B-cell lymphoma, comprehensively assessed by an electrophysiology study, ultrasonography, and FDG-PET/CT.

Dimensional changes in reconstructed nipples: autologous versus prosthetic breast reconstruction

PURPOSE: The creation of the nipple-areola complex is the final stage in breast reconstruction and highly affects patient satisfaction. The neo-nipple is well known to shrink over time, particularly in the nipple projection. Currently, no reconstruction technique is clearly superior in terms of nipple size maintenance. We evaluated nipple size changes among several methods of breast mound reconstruction. METHODS: Seventy-eight patients received nipple-areola complex reconstruction secondarily after breast reconstruction. C-V flap nipple reconstructions were performed using a free transverse rectus abdominis myocutaneous (TRAM) flap in 25 cases (TRAM group), a latissimus dorsi (LD) myocutaneous flap in 27 cases (LD group), and an implant in 26 cases (implant group). The circumference and projection of the neo-nipple were measured using a flexible ruler, immediately after reconstruction and average 10 months after surgery. RESULTS: The overall circumference and projection at the final measurement were 91.43% ± 7.11% and 62.16% ± 21.55%, respectively, of immediate postoperative values. The change in circumference did not significantly differ among the 3 groups. In contrast, the change in projection was significantly worse in implant group compared to that in TRAM and LD groups. In addition, among the patients in implant group, greater inflation was significantly associated with greater decrease in the nipple projection. CONCLUSION: Breast mound reconstruction with autologous musculocutaneous flap techniques achieves better long-term maintenance of the neo-nipple projection compared to that achieved with expanded tissue and implantation. Considering the prospective loss of long-term nipple dimension, the preoperative design should be oversized in accordance with its origin in mound reconstruction.

Arthroscopic-assisted Latissimus Dorsi Tendon Transfer for the Management of Irreparable Rotator Cuff Tears in Middle-aged Physically Active Patients

BACKGROUND: Latissimus dorsi (LD) tendon transfer is used as a treatment option for massive irreparable posterosuperior rotator cuff tears, and recently, an arthroscopic-assisted technique was introduced. This study was undertaken to evaluate the clinical and radiological outcomes of arthroscopic-assisted LD tendon transfer for the management of irreparable rotator cuff tears in active middle-aged patients. METHODS: The records of five patients (two males) with irreparable tears involving the supraspinatus and infraspinatus tendons managed by arthroscopic-assisted LD tendon transfer were retrospectively reviewed. Clinical outcomes were assessed using the visual analogue scale (VAS) pain scale, American Shoulder and Elbow Surgeon's (ASES) scores, the University of California Los Angeles (UCLA) scale, and ranges of motion. Postoperative integrities of transferred tendon were evaluated by magnetic resonance imaging in 4 patients and by ultrasound in one. RESULTS: Mean patient age was 55 years (range, 48–61 years), and mean follow-up period was 20 months (range, 12.0–27.2 months). Mean VAS score significantly improved from 6.6 ± 2.6 preoperatively to 1.8 ± 2.5 postoperatively (p=0.009), mean ASES score increased from 67.6 ± 9.2 to 84.6 ± 15.1, and mean UCLA score from 18.0 ± 1.4 to 28.8 ± 8.5 (all p<0.001). Postoperative imaging of the transferred LD tendon showed intact repair in 4 patients. The remaining patient experienced LD transfer rupture and a poor outcome. CONCLUSIONS: Arthroscopic-assisted LD tendon transfer improved shoulder pain and function in patients with massive, irreparable rotator cuff tears, and may be an option for this condition, especially in physically active patients.

Volumetric change of the latissimus dorsi muscle after immediate breast reconstruction with an extended latissimus dorsi musculocutaneous flap

BACKGROUND: In immediate breast reconstruction using an extended latissimus dorsi musculocutaneous (eLDMC) flap, the volume of the flap decreases, which causes a secondary deformity of the breast shape. Since little research has investigated this decrease in muscle volume, the authors conducted an objective study to characterize the decrease in muscle volume after breast reconstruction using an eLDMC flap. METHODS: Research was conducted from October 2011 to November 2016. The subjects included 23 patients who underwent mastectomy due to breast cancer, received immediate reconstruction using an eLDMC flap without any adjuvant chemotherapy or radiotherapy, and received a computed tomography (CT) scan from days 7 to 10 after surgery and 6 to 8 months postoperatively. In 10 patients, an additional CT scan was conducted 18 months postoperatively. Axial CT scans were utilized to measure the volumetric change of the latissimus dorsi muscle during the follow-up period. RESULTS: In the 23 patients, an average decrease of 54.5% was observed in the latissimus dorsi muscle volume between the images obtained immediately postoperatively and the scans obtained 6 to 8 months after surgery. Ten patients showed an average additional decrease of 11.9% from 6–8 months to 18 months after surgery. CONCLUSIONS: We studied changes in the volume of the latissimus dorsi muscle after surgery using an eLDMC flap performed after a mastectomy without adjuvant chemotherapy or radiotherapy. In this study, we found that immediate breast reconstruction using a latissimus dorsi muscle flap led to a decrease in muscle volume of up to 50%.

Use of Abnobaviscum to treat refractory seroma after breast reconstruction with a latissimus dorsi flap: A case report

In recent years, there has been a notable increase in the rate of refractory donor site seroma, defined as seroma that persists for at least 3 months postoperatively, as the number of breast reconstructions using a latissimus dorsi (LD) musculocutaneous flap has increased. Various factors have been proposed to be related, including smoking, obesity, flap mass, and body weight, and several studies have been conducted to explore treatment methods. Typically, surgical treatment, such as capsulectomy, has been considered for refractory seroma, but in this case report, we describe positive outcomes achieved by using Abnobaviscum to treat three female patients who developed a donor site seroma at least 3 months after breast reconstruction using an LD flap.

Total quilting suture at latissimus dorsi muscle donor site: Drain tube is no longer needed

PURPOSE: The purpose of this study was to assess the effect of quilting suture extent on the latissimus dorsi myocutaneous flap (LDMCF) donor site and the necessity of drainage.METHODS: Clinical data of 136 breast cancer patients, who underwent breast reconstruction using LDMCF between May 2014 and December 2015, were retrospectively reviewed. Patients were divided into three groups. Group A: quilting sutures were performed on half of the LDMCF donor site and a closed suction drain was inserted. Group B: quilting sutures were performed for the entire LDMCF donor site and a closed suction drain was inserted. Group C: quilting sutures were performed for the entire LDMCF donor site and no drain was inserted. The duration of drainage, total drainage, length of hospital stay, number of postoperative aspirations for seroma removal, and total aspirated volume were compared.RESULTS: In the comparison of groups A and B, group B showed better results including the total amount of drained seroma, drain maintenance period, number of aspirations for seroma removal after drainage tube removal, total aspirated seroma, and hospitalization period with statistical significance (P<0.05). In the comparison of groups B and C, group C without drain showed no difference in all other variables except mean total drained seroma volume. Therefore, group C was superior to group A and there was no difference compared to group B with drain, even though the drain was not inserted.CONCLUSION: Total quilting suture at LDMCF donor site can reduce seroma formation and eliminate the need for a drain tube.

Effect of Shoulder Protraction Exercise on the Supine position for Selective Activation of the Serratus Anterior according to Weight in Winging Scapula

PURPOSE: This study investigated the effects of shoulder protraction exercise according to weight by examining the surface electromyography (EMG) amplitude in the serratus anterior (SA), upper trapezius (UT), and pectoralis major (PM) as well as the activity ratio of each muscle. METHODS: Twenty three winging scapula subjects participated in the study. The subjects performed scapula protraction at shoulder 90° flexion and 60° horizontal abduction with up to four (none, 1kg, 1.5kg, and 2kg) dumbbells in the supine position. The EMG data were collected from the dominant side muscles during a shoulder protraction exercise according to weight in the supine position. One way repeated measures analysis of variance (ANOVA) was used to compare the normalized activities of the SA, UT, and PM and the ratios of PM/SA and UT/SA. RESULTS: The results showed that the activities of both the SA and UT were highest for the shoulder protraction exercise at 2kg in the supine position. The UT/SA ratio also was the lowest for exercise at 2kg. On the other hand, the activities of both the UT and PM/SA ratio were similar under all conditions. CONCLUSION: These results show that there is a need to selectively strengthen the SA muscle in the case of patients with the shoulder dysfunction. In particular, it is necessary to weigh 2kg when performing shoulder protraction exercises in the supine position to activate the SA muscle in patients with a winging scapula.

The Effect of Postural Correction and Visual Feedback on Muscle Activity and Head Position Change During Overhead Arm Lift Test in Subjects with Forward Head Posture

PURPOSE: This study aimed to investigate the immediate effects of posture correction and real-time visual feedback using a video display on muscle activity and change of head position during overhead arm lift test in individuals with forward head posture. METHODS: Fifteen subjects with forward head posture and fifteen normal subjects who volunteered were included in this study. During both groups performed the overhead arm lift test, the muscle activity of the upper trapezius, serratus anterior, sternocleidomastoid, and lower trapezius muscle were measured using electromyography, and head position change was measured using photographs. Then, forward head posture group was asked to perform overhead arm lift test again after posture correction and real-time visual feedback using a video display respectively. One-way analysis of variance (ANOVA) was used to analyze four conditions: pre-test, posture correction, real-time visual feedback, and the control group. RESULTS: The upper trapezius and lower trapezius muscle activity significantly decreased posture correction, real-time visual feedback, and control group than pre-test of forward head posture group (p<0.05). The sternocleidomastoid muscle significantly decreased real-time visual feedback and control group than pre-test of forward head posture group. Head position change significantly decreased three conditions than pre-test of forward head posture group and real-time visual feedback and control group significantly decreased than posture correction. CONCLUSION: This study recommend for maintaining cervical stability during the overhead arm lift test, postural control using real-time visual feedback is more effective in subjects with forward head posture.