Arthroscopic Resection of Wrist Volar Synovial Cyst: Technique Description and Case Series.

Background Arthroscopy nowadays has become a widespread technique for the treatment of orthopaedic pathologies. Small-joint arthroscopy has evolved and, through direct visualization, enables diagnosis and immediate treatment of intra-articular lesions. The arthroscopic resection has become a minimally invasive alternative for the open technique. We intend to describe the technique, literature review, and results of arthroscopy for the surgical treatment of wrist volar synovial cysts. Methods Thirty-nine patients submitted to arthroscopy for the treatment of wrist volar synovial cyst were included and assessed in this study, during the period of January 2015 to May 2017 with a complete assessment in minimum follow-up of 6 months. The technique was indicated for patients with pain and functional impairment for longer than 4 months, with no improvement with conservative measures, or for patients with cosmetic complaints, or those who presented the cyst for more than 3 months. Results We demonstrated good outcomes in regard to pain, range of motion, and complications in arthroscopic resection of volar wrist ganglion. Conclusion Arthroscopic resection of volar synovial is a useful and safe technique. It is a low-morbidity, minimally invasive procedure that carries few complications and is a good alternative to the open technique.

Artrhoscopic Resection of Volar Wrist Ganglion: Surgical Technique and Case Series.

Objectives To describe the technique and results of the arthroscopic surgical treatment of volar ganglion cyst of the wrist. Materials and Methods The present study comprised 21 patients submitted to the arthroscopic treatment of volar ganglion cysts of the wrist from January 2015 to May 2017, with a full evaluation for at least 6 months. The technique was indicated for patients presenting pain and functional impairment for more than four months, with no improvement with the conservative treatment, or for those with cosmetic complaints and cyst present for more than three months. Results The mean age of the patients was 43.6 years; 16 (76%) patients were female, and 5 (24%) were male. The mean follow-up time from surgery to the final assessment was of 10.9 months. A total of 2 (9.6%) patients complained of mild pain after the procedure, and another patient presented slight motion restrictions. The 18 (90.4%) remaining patients reported cosmetic improvement, complete functional recovery, and pain improvement. There were no recurrences or infections. No patient required further surgery. Conclusions The arthroscopic resection of volar ganglion cysts is a useful and safe technique. It is a minimally-invasive procedure, with low morbidity and very few complications, representing a good alternative to the open technique.

Artrhoscopic Resection of Volar Wrist Ganglion: Surgical Technique and Case Series / Ressecção artroscópica do cisto sinovial volar do punho: Técnica cirúrgica e série de casos

Abstract Objectives To describe the technique and results of the arthroscopic surgical treatment of volar ganglion cyst of the wrist. Materials and Methods The present study comprised 21 patients submitted to the arthroscopic treatment of volar ganglion cysts of the wrist from January 2015 to May 2017, with a full evaluation for at least 6 months. The technique was indicated for patients presenting pain and functional impairment for more than four months, with no improvement with the conservative treatment, or for those with cosmetic complaints and cyst present for more than three months. Results The mean age of the patients was 43.6 years; 16 (76%) patients were female, and 5 (24%) were male. The mean follow-up time from surgery to the final assessment was of 10.9 months. A total of 2 (9.6%) patients complained of mild pain after the procedure, and another patient presented slight motion restrictions. The 18 (90.4%) remaining patients reported cosmetic improvement, complete functional recovery, and pain improvement. There were no recurrences or infections. No patient required further surgery. Conclusions The arthroscopic resection of volar ganglion cysts is a useful and safe technique. It is a minimally-invasive procedure, with low morbidity and very few complications, representing a good alternative to the open technique.

Resumo Objetivo Descrever a técnica e os resultados da artroscopia no tratamento cirúrgico dos cistos sinoviais volares no punho. Materiais e Métodos Foram incluídos e analisados neste trabalho 21 pacientes submetidos a artroscopia para o tratamento de cisto sinovial volar no punho, no período entre janeiro de 2015 e maio de 2017, com avaliação completa e mínima de 6 meses. A técnica descrita foi indicada para os pacientes com dor e incapacidade funcional com duração de mais de quatro meses, sem melhora com o tratamento conservador, ou para aqueles com queixas estéticas e que apresentavam o cisto havia mais de três meses. Resultados A média de idade dos pacientes foi de 43,6 anos, sendo 16 (76%) do sexo feminino, e 5 (24%) do masculino. O tempo de seguimento médio entre a cirurgia e a avaliação final foi de 10,9 meses. Um total de 2 (9,6%) pacientes apresentaram dor leve e uma restrição da mobilidade no pós-operatório. Nos 18 (90,4%) pacientes restantes, houve melhora das queixas estéticas, recuperação funcional completa, e melhora completa da dor. Não houve recidivas ou infecções. Nenhum paciente necessitou ser submetido a nova cirurgia. Conclusões A ressecção artroscópica do cisto sinovial volar mostrou-se uma técnica útil e segura. É um procedimento minimamente invasivo, com baixa morbidade e poucas complicações, sendo uma boa alternativa à técnica aberta.

Robot-assisted surgery of the shoulder girdle and brachial plexus.

New developments in the surgery of the brachial plexus include the use of less invasive surgical approaches and more precise techniques. The theoretical advantages of the use of robotics versus endoscopy are the disappearance of physiological tremor, three-dimensional vision, high definition, magnification, and superior ergonomics. On a fresh cadaver, a dissection space was created and maintained by insufflation of CO2. The supraclavicular brachial plexus was dissected using the da Vinci robot (Intuitive Surgical, Sunnyvale, CA). A segment of the C5 nerve root was grafted robotically. A series of eight clinical cases of nerve damage around the shoulder girdle were operated on using the da Vinci robot. The ability to perform successful microneural repair was confirmed in both the authors' clinical and experimental studies, but the entire potential of robotically assisted microneural surgery was not realized during these initial cases because an open incision was still required. Robotic-assisted surgery of the shoulder girdle and brachial plexus is still in its early stages. It would be ideal to have even finer and more suitable instruments to apply fibrin glue or electrostimulation in nerve surgery. Nevertheless, the prospects of minimally invasive techniques would allow acute and subacute surgical approach of traumatic brachial plexus palsy safely, without significant and cicatricial morbidity.

Telerobotic manipulation of the brachial plexus.

OBJECTIVE: This study demonstrates the new technology of the robotic telesurgery on three brachial plexus reconstructions. We also discuss the implications, problems, and benefits of robotically assisted brachial plexus surgery. METHODS: After the first experimental experience in a cadaveric model, the authors performed three brachial plexus reconstructions. The surgery followed the traditional brachial plexus approach. From the moment that nervous sutures would be performed, the Da Vinci® (Intuitive Surgical™, Sunnyvale, CA) equipment was docked at the patients, positioned behind the patient's head, and the microsurgical steps were performed by using robotic telemanipulation. RESULTS: The first procedure was performed in a cadaver to gain experience and establish a surgical protocol by using the robot. In all the three living patients, the goals of the surgical procedure were achieved using the telerobotic manipulation. CONCLUSION: Robot-assisted surgery allows performance of high-dexterity surgical operations with the help of robotic arms and it improves the surgery due to tremor filtration, motion scaling, and ergonomics. The benefit of using the robot on microsurgery was reached, but its entire potential was not realized because the instruments used on those first experimental and clinical cases were not specifically designed for microsurgery.

Microsurgery and telemicrosurgery training: a comparative study.

Telemicrosurgery (TMS) is a new technique inspired by telesurgery and conventional microsurgery (CMS). One of the difficulties of CMS is learning to control physiological tremor. TMS eliminates the physiological tremor, thus theoretically simplifying microsurgical procedures, but no tactile feedback is provided while tying knots. The objective of this study was to assess if the learning curve for performing microsurgical anastomosis for TMS than with CMS was comparable. Thirty earthworms were anastomosed with 10/0 nylon sutures. In this study 15 anastomoses were performed under operating microscope and 15 under Da Vinci S® robot (Intuitive Surgical, Sunnyvale, CA). A single operator without experience in either technique performed all anastomoses. The evaluation consisted of measuring the time to perform each stitch, as well as to complete the anastomosis. The integrity of the anastomosis was tested by injection of saline solution into the earthworm to assess permeability and watertightness. The average time to complete a single suture was 296 seconds in the CMS group and 529 seconds in the TMS group. Permeability and watertightness of anastomosis was 86.66% in both groups. Learning was faster with CMS than with TMS. For untrained surgeon, the absence of tactile feedback is a limiting factor with TMS, however, the benefits of the TMS are: three-dimensional high definition vision, abolition of physiological tremor, motion scaling of gestures down to 5 times, use of three instruments at once, and extreme mobility.

Surgical reconstruction of PIP joint collateral ligament in chronic instability in a high performance athlete: case report and description of technique.

We present a case report describing the surgical technique for the reconstruction of the proximal interphalangeal (PIP) joint collateral ligament using autograft palmaris longus tendon graft. We accomplished this successfully in a high performance professional athlete presenting with chronic instability of the PIP joint. Our surgical reconstructive technique recreated anatomic ligament position, while correcting multidirectional instability without disruption of the other dynamic anatomic structures of the PIP joint. Our results demonstrated excellent clinical and functional results, and we offer our technique as an alternative to tenodesis procedures for individuals with professions that demand PIP motion.

Endoscopic exploration and repair of brachial plexus with telerobotic manipulation: a cadaver trial.

OBJECT: The aim of this paper was to develop an effective minimally invasive approach to brachial plexus surgery and to determine the feasibility of using telerobotic manipulation to perform a diagnostic dissection and microsurgical repair of the brachial plexus utilizing an entirely endoscopic approach. METHODS: The authors performed an endoscopic approach using 3 supraclavicular portals in 2 fresh human cadaver brachial plexuses with the aid of the da Vinci telemanipulation system. Dissection was facilitated inflating the area with CO(2) at 4 mm Hg pressure. The normal supraclavicular plexus was dissected in its entirety to confirm the feasibility of a complete supraclavicular brachial plexus diagnostic exploration. Subsequently, an artificial lesion to the upper trunk was created, and nerve graft reconstruction was performed. Images and video of the entire procedure were obtained and edited to illustrate the technique. RESULTS: All supraclavicular structures of the brachial plexus could be safely dissected and identified, similar to the experience in open surgery. The reconstruction of the upper trunk with nerve graft was successfully completed using an epineural microsurgical suture technique performed exclusively with the aid of the robot. There were no instances of inadvertent macroscopic damage to the vascular and nervous structures involved. CONCLUSIONS: An endoscopic approach to the brachial plexus is feasible. The use of the robot makes it possible to perform microsurgical procedures in a very small space with telemanipulation and minimally invasive techniques. The ability to perform a minimally invasive procedure to explore and repair a brachial plexus injury may provide a new option in the acute management of these injuries.

Is haptic feedback necessary to microsurgical suturing? Comparative study of 9/0 and 10/0 knot tying operated by 24 surgeons.

Robotically assisted telemanipulators are often criticised for their lack of direct haptic feedback. However, robotically assisted microsurgical sutures have already been achieved successfully. The aim of this study was to demonstrate that haptic feedback is not necessary in microsurgery. Our series included 24 surgeons of whom 14 were micro-surgeons. Each of them had to tighten a 9/0 and a 10/0 pre-tied nylon thread until getting the sensation of optimal knot tying. The procedure was performed four times, with open and closed eyes. The quality of knot tying was evaluated (fully tied, fairly or incompletely tied, or broken thread). The results obtained with the eyes open were significantly better. Neither the material size, nor the surgeon's expertise was shown to have an impact on knot tying quality. Our results demonstrate the uselessness of haptic feedback in microsurgery.

Telerobotic anterior translocation of the ulnar nerve.

The application of telerobotics in the biomedical field has grown rapidly and is showing very promising results. Robotically assisted microsurgery and nerve manipulation are some of its latest innovations. The purpose of this article is to update the community of shoulder and elbow surgeons on that field. Simple anterior subcutaneous translocation of the ulnar nerve was first experimented in two cadavers, and then performed in one live patient who presented with cubital tunnel syndrome. This procedure is the first reported case using the robot in elbow surgery. In this paper we attempt to analyze various aspects related to human versus robotically assisted surgery.

TFCC reattachment after traumatic DRUJ instability: a simple alternative to arthroscopic management.

With current trends favoring open reduction with internal fixation for distal radius fractures, distal radius-ulnar joint instabilities that were once clinically silent as a result of prolonged immobilization are now being recognized as a significant cause of morbidity. Arthroscopic management has proven to be both an effective and technically challenging treatment for triangular fibrocartilage complex (TFCC) tears. TFCC reattachment offers a safe, reproducible means of managing acute posttraumatic distal radioulnar join (DRUJ) instability after distal radius volar plating. With this technique, 30 patients at an average of 43 months were examined for continued DRUJ instability, range of motion, and radiographic evaluation for radius union, posttraumatic DRUJ arthritis, and hardware failure. Postoperative Gartland scores showed 88.6% excellent, 5.7% good, and 5.7% fair results. We conclude TFCC reattachment is a safe and effective alternative for treatment of acute DRUJ instability after open reduction with internal fixation of the distal radius, especially when equipment or experience does not support arthroscopic treatment.

Alternative to the distal interphalangeal joint arthrodesis: lateral approach and plate fixation.

PURPOSE: Several fixation techniques for distal interphalangeal (DIP) joint arthrodesis have been described, with good clinical results and complication rates between 10% and 20%. We propose an alternative technique and fixation method using a lateral approach and 1.3-mm plate and screws fixation. METHODS: Between March and September 2005, 11 patients, totaling 15 fingers, had DIP joint arthrodesis by the described technique. The indications were posttraumatic arthritis in 8 fingers, degenerative or rheumatoid arthritis in 5 fingers, and isolated flexor digitorum profundus tendon lesions in 2 fingers. Patients were analyzed for osseus union, pain relief, and functional mobility of the finger. RESULTS: Arthrodesis relieved pain and restored stability at the 12th week, on average, with osseous union in all patients. All patients maintained full proximal interphalangeal joint motion with pulp-to-palm distance of zero at 6 months of follow-up evaluation. There were no rotational or angular deformities, nail bed lesions, or skin complications. CONCLUSIONS: The lateral approach with plate and screws fixation is an option for DIP joint arthrodesis. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Reimplante de mão e dedo mínimo / Digital and upper limb replantation

As amputações traumáticas de membros representam grandemutilação para o ser humano. O reimplante do membro é umapossibilidade terapêutica e a outra é a regularização do coto deamputação. Objetivo: Apresentar o resultado clínico e funcionalobservado neste reimplante. Discutiremos os pontos maiscríticos destas lesões, as dificuldades, vantagens e riscos. Relatode caso: Paciente de 25 anos decepou o dedo mínimo e a mãoesquerda em uma prensa gráfica e foi submetido ao reimplante.O reimplante teve como objetivo reconstruir a mão e restabelecera função. O tempo de isquemia foi de 5 h, a fixação realizada comfios de Kirschner e a reabilitação iniciada na terceira semana.Comentários: O nível de amputação ocorrido, mão esquerdacom acometimento do dedo mínimo é sem dúvida de maiorcomplexidade, devido ao número de estruturas comprometidase que necessita da reconstrução. Os resultados funcionais têmsido melhores, quanto maior o número de estruturas reparadasprimariamente, sem comprometer as anastomoses vasculares quesão as estruturas mais delicadas. O resultado clínico do DASHapós três meses foi 40. O paciente encontra-se em recuperação,acreditamos que este reimplante foi muito importante na vidado paciente. Demonstramos organização, estrutura internacompatível para a realização de cirurgia com alta complexidadee a notoriedade foi por ter sido o primeiro reimplante de mãoe dedo com sucesso na região do Grande ABC.

Limb traumatic amputations represent a major mutilation to thehuman being. Limb reimplantation is a therapeutic possibility,and another one is the regularization of the amputation stump.Objective: The aim of this work is to present the clinical andfunctional outcome of this reimplantation. We also discuss thecritical points of these lesions, the difficulties, advantages, andrisks. Case report: A 25 year-old male patient had cut off his littlefinger and left hand in a printing press, and has been submittedto a reimplantation surgery. The procedure aimed to reconstructthe hand and reestablish its function. The ischemia time was of5 hours, the osteosynthesis was performed using K-wire suturethread, and the rehabilitation took place in the third week.Comments: The level of amputation, left hand involving also thelittle finger, is complex due to the number of involved structures,which need to be reconstructed. The functional outcomes havebeen making progress according to the sum of structures thatare primarily repaired, with no involvement of the vascularanastomosis, which are the most sensitive structures. The clinicaloutcome after three months using DASH questionnaire was 35.The patient is recovering. We think that this reimplantationwas quite significant for the patient, as well for our team, whichshowed organization and the required structure to carry out thishigh complexity surgery. Nevertheless, this was the first handreimplantation at Grande ABC region.