Mensuração de área de cicatrização por planimetria após aplicação do ultra-som de baixa intensidade em pele de rato / Measurement of healing area using planimetry after applying low-intensity ultrasound to the skin of rats

CONTEXTUALIZAÇÃO: A planimetria é um método utilizado para avaliar a evolução da cicatrização de feridas. A planimetria computacional é um método ainda em experimentação, mas cujas vantagens têm sido demonstradas em várias investigações. OBJETIVOS: Avaliar os efeitos do ultra-som pulsado de baixa intensidade sobre a cicatrização de lesão cutânea produzida na região dorsal de ratos, por meio da planimetria computacional. MATERIAIS E MÉTODOS: Utilizou-se 60 ratos machos Wistar (peso médio de 300g) divididos em dois grupos com 30 animais cada, de acordo com o tratamento: 1) irradiação simulada (controle); 2) irradiação efetiva (Freqüência fundamental de 1,5MHz, freqüência de repetição de pulsos de 1KHz, largura de pulso de 200µs, intensidade de 30mW/cm² SATA, dez minutos de aplicação em dias alternados). Cada grupo foi subdividido em três grupos, de acordo com o período de irradiação ultra-sônica, de três, sete e 14 dias, respectivamente, e a cicatrização foi avaliada por meio da planimetria, um decalque da lesão sendo obtido em papel especial, digitalizado e medido ao computador por meio de um programa gráfico. Análise estatística pelo método não-paramétrico de Mann-Whitney. RESULTADOS: Houve aumento significante (p<0,05) da área cicatrizada no grupo 2 (141,88±18,50mm²) em relação ao grupo 1 (117,38±15,14mm²), no 14º dia. Não houve diferenças significantes entre os grupos nos demais períodos. CONCLUSÕES: O ultra-som pulsado de baixa intensidade estimula a cicatrização cutânea por segunda intenção em condições experimentais. A planimetria computacional mostrou-se um recurso de baixo custo, fácil manuseio e de aplicabilidade clínica.

BACKGROUND: Planimetry is a method used to evaluate the progression of skin wound healing. Computerized planimetry is still an experimental method, but its advantages have been demonstrated in several investigations. OBJECTIVE: To evaluate the effects of low-intensity pulsed ultrasound on the healing of a skin lesion produced on the dorsal region of rats, by means of computerized planimetry. METHODS: Sixty male Wistar rats of mean weight 300g were used. They were divided into two groups according to the treatment applied: 1) simulated irradiation (control); 2) effective irradiation (fundamental frequency 1.5MHz, pulse repetition frequency 1KHz, pulse width 200µs, SATA intensity 30mW/cm² and application for ten minutes on alternate days). Each group was divided into three subgroups according to the length of time for which ultrasound irradiation was applied of three, seven and 14 days, respectively, and healing was evaluated by means of planimetry; a tracing of the wound was obtained on special paper and this was digitized and measured by means of a graphing software. Statistical analysis was performed using the Mann-Whitney non-parametric method. RESULTS: The healed area was significantly greater (p<0.05) in group 2 (141.88±18.50mm²) than in group 1 (117.38±15.14mm²) on the 14th day. There were no significant differences between the subgroups for the other experimental periods. CONCLUSIONS: Low-intensity pulsed ultrasound irradiation stimulated secondary skin healing under these experimental conditions. Computerized planimetry was shown to be a low cost method that was easy to use and present clinical applicability.

Mobilidade articular dos dedos não lesados pós-reparo em lesão dos tendões flexores da mão / Joint range of motion of uninjured fingers after repairs to flexor tendon injuries of the hand

OBJETIVO: Verificar a amplitude de movimento (ADM) em mãos que sofreram reparo tendinoso dos músculos flexores superficial e profundo dos dedos, comparando os dados de cada dedo na mão lesada e entre mãos lesadas e não lesadas. MÉTODOS: Foi realizada a goniometria ativa em 15 pacientes e 120 dedos, 60 dedos de mãos lesadas e 60 de mãos controle não lesadas. Os sujeitos foram avaliados no momento da retirada da tala gessada, tendo sido realizada a movimentação precoce pelo método de Duran modificado. A partir dos dados goniométricos, foram registrados os valores do índice TAM (Total Active Motion) dos dedos nas mãos lesadas e controle. Para análise dos dados, foi acessada a fórmula de índices funcionais proposta pela American Society for Surgery of the Hand (ASSH) e para cálculo estatístico, foi escolhido o Modelo de Efeitos Mistos. RESULTADOS: A fórmula da ASSH para os dedos lesados mostrou que 18,33 por cento tiveram a classificação do movimento "bom", 18,33 por cento, "regular" e 63,34 por cento, "pobre". Foram comparadas as médias das medidas em graus de todos os dedos entre si dentro de cada grupo, controle ou lesado, e as médias das medidas entre os grupos, encontrando-se um p-valor significante apenas entre os grupos controle e lesado. Não houve diferença estatística entre o TAM de cada dedo na mão lesada. CONCLUSÃO: Independente de quantos dedos tenham sofrido lesão tendinosa em uma mão, os dedos não lesados também terão suas ADMs ativas diminuídas no período logo após a retirada da imobilização.

OBJECTIVE: To assess the range of motion (ROM) in hands that underwent tendon repair in the flexor digitorum superficialis and flexor digitorum profundus muscles of the fingers, comparing the data between the fingers on the injured hand, and between the injured and uninjured hands. METHOD: Active goniometry was performed on 15 patients, making a total of 120 fingers (60 on injured hands and 60 on noninjured control hands). The patients were examined at the time of removing the plaster splint. Early mobilization was performed using the modified Duran method. Goniometric data were used for recording the TAM (total active motion) values of the fingers on the injured and uninjured (control) hands. To analyze the data, the functional index formula proposed by the American Society for Surgery of the Hand (ASSH) was utilized, and for statistical calculations the mixed-effect model was selected. RESULTS: The ASSH formula for the injured fingers classified the movement as "good" in 18.33 percent, "fair" in 18.33 percent and "poor" in 63.34 percent. The means, in degrees, of the measurements for all the fingers were compared with each other within each group (control and injured) and between the groups. A significant difference was found between control and injured groups. There was no statistical difference between the TAM of each finger on the injured hand. CONCLUSION: Independent of how many fingers on one hand had suffered tendon injuries, the uninjured fingers also presented diminished active ROM during the period immediately after removal of the immobilization.

Os efeitos do ultra-som terapeutico nas lesões por esmagamento do nervo ciatico de ratos: analise funcional da marcha / Effects of therapeutic ultrasound on injuries due to crushing of the sciatic nerve in rats: functional evaluation of gait

Os efeitos da irradiacao ultra-sonica teraputica na regeneracao de nervos perifericos nao sao ainda bem conhecidos, particularmente no que se refere a recupercao funcional. Por outro lado o metodo da avaliacao da impressao da pegada do rato para medida do Indice Funcional do ciatico (IFC) ja esta bem sistematizado, mostrando streita correlacao com a regeneracao do nervo ciatico de ratos submetido a esmagamento ontrolado. Material e metodos: foram empregados 20 ratos da linhagem Wistar com peso corporal medio de 300g, divididos em dois grupos conforme o tipo de procedimento realizado: 1) somente esmagamento (n=10); 2)esmagamento e irradiacao com ultra-som (n=10). Sob anestesia geral, o nervo ciatico era exposto na coxa direita do animal e esmagado com um dispositivo especialmente confeccionado para essa finalidade, com uma carga fixa de 15 kg por 10minutos, num segmento de 5 mm proximal a sua bifurcacao. A irradiacao ultra-sonica pulsada de baixa intensidade (1:5, 0,4w/cm2, 1 MHz, duracao 2 minutos) era iniciada ja no rpimeiro dia pos-operatorio e realizada por dez dias consecutivos. As impressoes das pegadas dos animais, obtidas semanalmente, da primeira a terceira semana pos-operatoria em passarela especifica para essa finalidade, foram avaliadas por meio de um programa de computador igualmente especifico, segundo meto pre-existente ja testado em trabalhos anteriores, com calculo automatico do IFC. Resultados: o IFC aumentou progressivamente nos dois grupos, passando no Grupo 2 de 101 na primeira semana, para 59,21 na segunda e 26,68 na terceira, o que significou uma melhora de 73 por cento entre a primeira e a ultima medida. No grupo 1, o IFC subiu de -98,2 na primeira semana para -79,5 na segunda e -44 na terceira, o que significa uma melhora de 55 por cento entre a primeira medida e a ultima. As diferencas entre os grupos foram significativas no 14o. dia e no 21o. dia (p=0,02 e p=0,02, respectivamente). Conclusao: o ultra-som terapeutico de baixa intensidade acelerou a regeneracao do nervo ciatico do rato, demonstravel com maior significancia no 21o. dia pos-operatorio

Influencia da aplicacao previa do ultra-som terapeutico na penetracao transcutanea de diclofenaco sodico em humanos sadios / The influence of the prior application of the therapeutic ultrasound on the transdermal transmission of sodium diclofenac in health humans

A influencia do ultra-som terapeutico na transmissao transcutanea de diclofenaco sodico na forma de gel topico (Voltaren Emulgel) foi investigada em 14 voluntarios sadios (10 mulheres, 4 homens, 26,4 anos de idade, 62kg de peso corporal e 1,7 m de altura, em media). O ultra-som terapeutico (modo continuo, frequencia de 1MHz, 0,5 W/cm2) foi aplicado durante 5 minutos em duas areas de 225cm2 de cada lado do dorso dos voluntarios,utilizando gel comum para acoplamento do transdutor. Em seguida, o gel comum foi removido para aplicacao de 2,5 g do gel de diclofenaco nas mesmas areas. Amostras de sangue foram coletadas imediatamente antes e 60, 120 e 180 minutos apos a aplicacao do gel de diclofenaco, a fim de analisar a massa presente no plasma dos voluntarios por meio decromatografia liquida de alta eficiencia (HPLC)

The end-to-side peripheral nerve repair. Functional and morphometric study using the peroneal nerve of rats.

Morphologic and functional recovery following an end-to-side repair was studied comparatively with conventional end-to-end repair in a model of peroneal nerve lesion in rats. Twenty-eight rats were used and divided into four groups according to the reparative procedure following nerve division: (1) nerve stumps buried into neighboring muscles (n = 8); (2) conventional end-to-end repair (n = 7); (3) end-to-side repair onto the tibial nerve (n = 8); (4) sham operation (n = 5). The sciatic functional index (SFI) was evaluated at weekly intervals for 8 weeks, the peroneal nerve being resected on the 56th day for histologic and morphometric studies. The SFI progressively improved in Groups 2 (-16.9) and 3 (-22.7), although it did not reach normal values (around -8). The average nerve fiber density increased to normal values in both Groups 2 and 3, although accompanied by a marked decrease of average minimal and maximal nerve fiber diameter, myelin sheath area and G quotient. The differences between Groups 2 and 3 or Groups 2 and 4 were not significant. We conclude that, although resulting in significant morphologic and functional recovery, end-to-side repair is not as efficient as the conventional end-to-end nerve repair. However, end-to-side repair has a potential for application in selected cases in humans.

The use of a muscle graft to repair a segmentary nerve defect. An experimental study using the sciatic nerve of rats as model.

The use of a devitalized skeletal muscle graft and conventional nerve graft to repair a 5mm long segmentary sciatic nerve lesion was studied in rats by means of functional, morphometric and spinal cord motor neuron cell response evaluation. Thirty-four rats were used and divided into four groups according to the procedure: (1) sham operation; (2) conventional nerve grafting; (3) muscle grafting; (4) unrepaired lesion. The sciatic functional index (SFI) was evaluated every fortnight up to the 105th postoperative day by measuring three parameters in the rats' footprint. The animals of Groups 2 and 3 presented initial complete functional loss, followed by slow but steady recovery, with final similar SFIs. The histologic and morphometric studies showed an increased small diameter/thin myelin sheath nerve fiber density distally to the lesion site for both types of graft. An increased population of motor neurons was observed in the anterior horn of the lumbar spinal cord segment with both types of grafts, but not in the control groups. The SFI, histologic and morphometric data did not differ significantly between the two types of graft, thus indicating a similar behavior. The authors conclude that a 5mm long skeletal muscle graft works as well as a conventional nerve graft.

Aneurysmal bone cyst with chromosomal changes involving 7q and 16p.

An aneurysmal bone cyst was submitted to cytogenetic analysis. The modal chromosome number was 46. The composite karyotype was 40 approximately 48,XY,-Y[4],-6[3],del(7)(q32)[3],-9[3],+12[2],+13[2], inv(16)(p13.1q24)[4],-17[3],-19[4],-20[3][cp13]. The clonal structural changes detected were del(7)(q32) and inv(16)(p13.1q24). The breakpoints involved affected areas to which important genes for cell cycle regulation have been mapped. There is only one report in the literature of three aneurysmal bone cysts presenting clonal karyotypic alterations. The cytogenetic study of the aneurysmal bone cyst reported here showed different results when compared to those previously described in the literature.

Correlation between functional index and morphometry to evaluate recovery of the rat sciatic nerve following crush injury: experimental study.

An experimental study on the correlation between functional and morphologic recovery of crushed sciatic nerves was carried out in rats. The sciatic nerve of 33 rats, divided into three groups, was submitted to controlled crushing injury on a 5-mm long segment, in a universal testing machine for 10 min with three different loads (100, 500, and 15,000 g, respectively). Functional recovery was evaluated, using a modified sciatic functional index (SFI) at weekly intervals up to the 60th postoperative day, at which time, the animals were sacrificed for histologic and morphometric studies of the nerves. Results were compared with those of normal untouched nerves and nerves submitted to segmentary resection without repair. Initial loss of function was observed in all animals with crush injury, but recovery to a nearly normal SFI occurred after progressively longer intervals (25, 39, and 53 days), as a function of load. Nerve-fiber density was increased in the groups submitted to lower loads, but statistically significantly decreased in the animals submitted to the 15,000-g crush. The authors conclude that the SFI is directly correlated with nerve-fiber density and, therefore, is an adequate tool for evaluating sciatic functional deficiency in the rat.

Scintigraphic evaluation of tibial shaft fracture healing.

A scintigraphic study of the healing process of type A and B closed tibial shaft fractures was carried out in 40 cases treated non-operatively, comprising 32 men and eight women aged 30.6 yr on average. Scintigraphic scans were obtained with technetium methylenediphosphonate (MDP-Tc99m, 25 mCi) at 6, 12 and 24 weeks after the fracture and an activity index was calculated taking the mean of three consecutive uptake counts for both fractured and normal opposite leg, used for comparison. The results showed that the activity index in general decreased progressively from the first to the third evaluation, with little difference in behaviour between the two types of fractures. However, for B type fractures the activity index remained stable from the first to the second evaluation, followed by a marked decrease at the third evaluation, with a comparable end result for both fracture types. It was concluded that a decrease of the activity index occurs in both types of closed fractures undergoing uneventful healing and that such a decrease can be taken as a parameter for further studies which include delayed union and non-union.

Use of a delayed cortical bone graft to treat diaphyseal defects in the forearm.

The technique of delayed autogenous cortical bone grafting was used in 17 patients (6 women, 11 men, with an average age of 22 years) to treat diaphyseal defects resulting mainly from closed or compound fractures complicated by infection and bone tissue loss. Bones affected were the humerus in 1 case, the radius in 7 cases, the ulna in 4 cases, the radius and ulna in 2 cases, the first metacarpal in 1 case, and the femur in 2 cases. The average length of the defect was 5.7 cm and the graft, prepared from the anteromedial aspec of the tibia, was at least 1.5 cm longer than the defect. The graft application was combined with rigid internal fixation using an AO 3.5 mm DCP plate in most cases and this permitted early active movement. Union occurred without the need for any additional grafting procedure in 14 patients and within an average of 23 weeks. In most cases there was an increase in the thickness of the graft probably as a result of osteo-induction, with consequent restoration of the original diameter of the recipient bone diaphysis. The most frequent complication was infection (4 cases), and this was controlled by means of debridement, cleaning and antibiotics. A delayed graft provides mechanical support, incorporates quickly and is therefore a reasonable alternative method for treating diaphyseal defects of long bones, particularly in the upper limb.

Correçäo de falhas ósseas diafisárias dos ossos do antebraço: emprego do enxerto ósseo em bloco do ilíaco / Correction of diaphyseal defect of the forearm bones: use of bone block graft from the iliac crest

Os autores relatam sua experiência com o emprego do enxerto ósseo em bloco da crista ilíaca na correçao de falhas diafisárias dos ossos do antebraço. A técnica foi utilizada em 12 pacientes (dez homens e duas mulheres, idade média de 29 anos), para falhas resultantes principalmente de fraturas fechadas ou expostas, que apresentaram infecçao e perda de substância óssea. As dimensoes médias do enxerto necessário para corrigir o defeito foram de 3,5 x 1,8cm. A aplicaçao do enxerto foi combinada com a fixaçao rígida com uma placa AO de compressao dinâmica de 3,5mm, permitindo mobilizaçao ativa. O enxerto integrou-se sem necessidade de procedimentos adicionais de enxertia em dez casos, num prazo médio de 17,2 semanas. A complicaçao mais freqüente foi a infecçao (quatro casos), controlada por meio de desbridamentos, limpeza cirúrgica e antibióticos. A análise comparativa das radiografias iniciais e finais mostrou perdas média de 30 por cento da massa óssea do enxerto, apesar da integraçao. Os autores concluíram que a técnica do enxerto em bloco para a correçao das falhas ósseas diafisárias do rádio e da ulna é relativamente fácil de executar e apresenta alto índice de sucesso.

Mechanical strengths of tendon sutures. An in vitro comparative study of six techniques.

A comparative study of six tendon suturing techniques (1. Modified Kessler + simple epitendinous running suture; 2. Modified Kessler + Halsted epitendinous suture; 3. "Six strand" suture; 4. "Interlocking" suture; 5. "Cross stitch" suture; 6. simple epitendinous running suture) was carried out by evaluating strength in relation to the beginning of separation between the tendon stumps, a 3 mm separation and rupture in porcine flexor tendons. The technique most resistant to initial separation was the modified Kessler + Halsted epitendinous suture followed by the "Six strand" suture. The "Six strand" suture was the most resistant to the 3 mm separation and rupture followed by the modified Kessler + Halsted epitendinous suture. Despite the greater resistance to rupture of the "Six strand" technique, we conclude that modified Kessler + Halsted epitendinous suture showed the best overall performance and was easier to use.

Use of a bone block graft from the iliac crest with rigid fixation to correct diaphyseal defects of the radius and ulna.

We report our experience with the use of a bone block graft from the iliac crest to correct diaphyseal defects of the forearm bones. The technique was used in 12 patients (ten men and two women, average age 29 years) for defects resulting mainly from either closed or compound fractures, which later developed infection and bone tissue loss. The average dimensions of the graft required to correct the defect was 3.5 x 1.8 cm. The graft application was combined with rigid fixation with an AO 3.5 mm DCP plate, permitting early active motion. The graft incorporated without any additional grafting procedure in ten cases within 17.2 weeks on average. The most frequent complication was infection (four cases), controlled by means of debridement, cleansing and antibiotics. A comparative analysis of the immediate and final radiographs of the graft showed an average 30% loss of bone mass despite integration. We conclude that the technique of bone block grafting to correct diaphyseal defects of the radius or ulna is relatively easy to carry out and has a high success rate.

The posterior interosseous forearm island flap for skin defects in the hand and elbow. A prospective study of 51 cases.

The authors' experience of 51 posterior interosseous forearm island flaps is presented. Its main indications were inadequate scar or scar contraction and complex trauma with gross skin loss, either acute or postprimary. The flap healed uneventfully in 45 cases (88%), but in six it was partially or subtotally lost due to necrosis. Late complications included hair growth in the first web and palm, flap redundancy and hypertrophic scar at the donor site. The posterior interosseous island flap produces excellent skin coverage but is difficult to raise and tends to develop oedema and occasionally necrosis.

Triradiate skin incision for dorsal approach to the wrist.

A new triaradiate skin incision is presented as an approach to the wrist. Centred over Lister's tubercle, it consists of one longitudinal proximal and two oblique distal rays, making three 120 degrees skin flaps. These provide an excellent triangular operating field to the distal radius, the radiocarpal joint and the carpus itself, allowing for most procedures in this region. There have been no complications in 32 patients, and the cosmetic appearance has been excellent in most of them.

The effect of venous occlusion on the integration of vascularized cortical bone graft.

The biologic phenomena involved in the healing process of vascularized, cortical bone grafts, vascularized grafts with venous occlusion, and conventional cortical bone grafts, were studied in rabbits. The middle third of the radial diaphysis was the donor site, with a 1.6-cm-long bone cylinder delimited by double transverse osteotomies. The vascularized grafts were raised by extraperiosteal dissection, with preservation of their vascular pedicle, while the conventional grafts were obtained by subperiosteal dissection. The vascularized graft with venous occlusion had its draining vein ligated. Radiologic, scintigraphic, and histologic studies were undertaken at days 7, 15, 30, and 60 postoperatively. Results demonstrated that the vascularized graft healed earlier than the corresponding vascularized graft with venous occlusion and than the conventional graft, respectively. The vascularized graft with venous occlusion suffered some degree of impairment of its irrigation, probably due to retrograde block of the arterial blood flow. It underwent a degree of bone necrosis, followed by resorption and creeping substitution, which delayed its integration. This seemed to be a temporary effect, for it healed earlier than the conventional graft.

Síndrome do túnel carpal aguda associada a trombose da artéria mediana persistente / Acute carpal tunnel syndrome associeted to thrombosis of the persistent median artery

Os atores apresentam três casos de síndrome do túnel carpal agudamente precipitados por trombose de artéria mediana persistente. Säo discutidos aspectos referentes a anatomia e a patologia da lesäo.

The fate of tendon grafts used to reconstruct the digital annular pulleys.

An experimental morphological study on the reconstruction of the digital annular pulleys has been carried out in dogs. The segment corresponding to zones 1 and 2 of the flexor apparatus of the 2nd and 5th digits of the left forepaw was chosen for the experiment. The whole flexor apparatus was resected and a single digital pulley (A 2) was reconstructed, using segments of the animals own deep flexor tendon. A length of silicone rubber tube was used as tendon spacer. The new pulleys showed marked degeneration of the collagen fibres and thinning which increased with time and may be the cause of decrease in strength. A layer of mesothelial cells with secretory properties developed at the interface between the tendon graft and the spacer.

Studies on tendon healing. A comparison between suturing techniques.

An experimental study comparing Kessler's and Tsuge's techniques for tendon suture was undertaken in dogs. Both second and fifth flexor digitorum profundi tendons of the left forepaw were divided in the segment corresponding to zone 2 of human hands. Following division, the tendons to the second digit were repaired by Kessler's technique and those to the fifth digit by Tsuge's method. Results were evaluated by means of standard and polarized--light microscopy, intravascular dye injections and tensile strength tests. Both ordinary and polarized--light microscopy showed that a microscopical gap develops between the tendon ends, being filled in with healing tissue which undergoes progressive maturation. The tensile strength tests showed that the deformation (elongation) progress directly with load, up to the point of rupture; the suture thread does not interfere with this. Furthermore, strength increases with time. Intravascular dye injection showed that a net of newly formed blood vessels develops at the site of section and suture, previously destitute of macroscopical vessels. The new vessels tended to redistribute them selves to resemble the pattern in normally vascularized regions. It was not possible to detect, by means of the methods employed, any important difference between Kessler's and Tsuge's techniques for tendon suture.

Aneurysmal bone cyst of the hand. An unusual situation.

Three cases of aneurysmal bone cyst affecting the hand are reported. Some aspects of incidence, aetiology and treatment are discussed.