CAN TEMPORARY ARTERY CATHETERIZATION EXTEND LIMITS OF ISCHEMIA TIME FOR MACROREPLANTATION?

We observe delayed referrals to appropriate Microsurgery Unit and definitive treatment of traumatic limb amputations. Cases with wrist proximal amputations have a deadline for surgical replantation as these configure life-threatening injuries. Objective: To analyze patients with traumatic proximal wrist upper limb amputations with prolonged ischemic time who underwent temporary artery catheterization to assess stump viability and results. Methods: A case-series study including all patients with a proximal wrist upper limb amputation and a cold ischemic time equal to or above six hours from 2017 to 2021. Results: In total, two surgeons operated eight patients who had experienced forearm amputation injuries. Median ischemia time totaled eight hours. All patients required additional surgeries, most commonly split-thickness skin graft or fixation revision (three patients). This study obtained five successful macroreimplantations. The mean cold ischemia time was longer in the group with successful macroreimplantations (7.4 hours) than of the unsuccessful group (9 hours). Conclusion: Macroreplantations require immediate referral to microsurgery and, although temporary artery catheterization helps surgical decision making, the technique seems to fail to influence outcomes. Level of Evidence IV, Retrospective Case Series.

Observa-se um atraso no referenciamento dos casos para o tratamento definitivo das amputações traumáticas de membros no Brasil. Casos com amputações proximais ao punho apresentam um prazo limite para reimplante, sendo lesões que promovem risco de vida ao paciente. Objetivo: Analisar os macrorreimplantes com tempo de isquemia prolongado submetidos à cateterização temporária da artéria, para determinar a viabilidade do coto de amputação, e seus resultados. Métodos: Série de casos de todos os pacientes com amputações traumáticas proximais ao punho, cujo tempo de isquemia fria foi igual ou superior a seis horas, entre 2017 e 2021. Resultados: A amostra foi composta por oito pacientes com amputações traumáticas de antebraço operados por dois cirurgiões. O tempo médio de isquemia foi de oito horas. Todos os pacientes necessitaram de cirurgias adicionais, sendo as mais comuns o enxerto de pele ou a revisão da fixação óssea. Sucesso do macrorreimplante foi observado em cinco pacientes. O tempo médio de isquemia fria foi maior no grupo com sucesso no macrorreimplante (7,4 horas) quando comparado com o grupo sem sucesso (9 horas). Conclusão: Os macrorreimplantes necessitam de transferência imediata para serviços especializados, e, apesar de a cateterização temporária arterial auxiliar no manejo cirúrgico, a técnica parece não interferir nos resultados. Nível de Evidência IV, Série de Casos.

Can temporary artery catheterization extend limits of ischemia time for macroreplantation? / Cateterização temporária arterial amplia o limite de tempo de isquemia no macrorreimplante?

ABSTRACT We observe delayed referrals to appropriate Microsurgery Unit and definitive treatment of traumatic limb amputations. Cases with wrist proximal amputations have a deadline for surgical replantation as these configure life-threatening injuries. Objective: To analyze patients with traumatic proximal wrist upper limb amputations with prolonged ischemic time who underwent temporary artery catheterization to assess stump viability and results. Methods: A case-series study including all patients with a proximal wrist upper limb amputation and a cold ischemic time equal to or above six hours from 2017 to 2021. Results: In total, two surgeons operated eight patients who had experienced forearm amputation injuries. Median ischemia time totaled eight hours. All patients required additional surgeries, most commonly split-thickness skin graft or fixation revision (three patients). This study obtained five successful macroreimplantations. The mean cold ischemia time was longer in the group with successful macroreimplantations (7.4 hours) than of the unsuccessful group (9 hours). Conclusion: Macroreplantations require immediate referral to microsurgery and, although temporary artery catheterization helps surgical decision making, the technique seems to fail to influence outcomes. Level of Evidence IV, Retrospective Case Series.

RESUMO Observa-se um atraso no referenciamento dos casos para o tratamento definitivo das amputações traumáticas de membros no Brasil. Casos com amputações proximais ao punho apresentam um prazo limite para reimplante, sendo lesões que promovem risco de vida ao paciente. Objetivo: Analisar os macrorreimplantes com tempo de isquemia prolongado submetidos à cateterização temporária da artéria, para determinar a viabilidade do coto de amputação, e seus resultados. Métodos: Série de casos de todos os pacientes com amputações traumáticas proximais ao punho, cujo tempo de isquemia fria foi igual ou superior a seis horas, entre 2017 e 2021. Resultados: A amostra foi composta por oito pacientes com amputações traumáticas de antebraço operados por dois cirurgiões. O tempo médio de isquemia foi de oito horas. Todos os pacientes necessitaram de cirurgias adicionais, sendo as mais comuns o enxerto de pele ou a revisão da fixação óssea. Sucesso do macrorreimplante foi observado em cinco pacientes. O tempo médio de isquemia fria foi maior no grupo com sucesso no macrorreimplante (7,4 horas) quando comparado com o grupo sem sucesso (9 horas). Conclusão: Os macrorreimplantes necessitam de transferência imediata para serviços especializados, e, apesar de a cateterização temporária arterial auxiliar no manejo cirúrgico, a técnica parece não interferir nos resultados. Nível de Evidência IV, Série de Casos.

Microsurgical Reconstruction in an Orthopedic Hospital: Indications and Outcomes in Adults.

Objective Advances in reconstructive microsurgery in orthopedic surgery provided better functional and aesthetic results and avoided many indications for amputation. In high-volume trauma and orthopedic hospitals, microsurgical reconstruction is essential to reduce costs and complications for these complex orthopedic defects. We describe a microsurgical approach to traumatic wounds, tumor resection, bone defects, and free muscle transfer, performed by an orthopedic microsurgery unit. The objective of the present study was to evaluate predictor factors for outcomes of microsurgical flaps for limb reconstruction, and to provide a descriptive analysis of microsurgical flaps for orthopedic indications. Methods Cross-sectional prospective study that included all consecutive cases of microsurgical flaps for orthopedic indications from 2014 to 2020. Data were collected from personal medical history, intraoperative microsurgical procedure, and laboratory blood tests. Complications and free-flap outcomes were studied in a descriptive and statistical analysis. Results We evaluated 171 flaps in 168 patients; the indications were traumatic in 66% of the patients. Type III complications of the Clavien-Dindo Classification were observed in 51 flaps. The overall success rate of the microsurgical flaps was 88.3%. In the multivariate analysis, the risk factors for complications were ischemia time ≥ 2 hours ( p = 0.032) and obesity ( p = 0.007). Partial flap loss was more common in patients with thrombocytosis in the preoperative platelet count ( p = 0.001). Conclusion The independent risk factors for complications of microsurgical flaps for limb reconstruction are obesity and flap ischemia time ≥ 2 hours, and presence of thrombocytosis is a risk factor for partial flap loss.

Comparative Analysis of the Treatment of Skin Lesions of the Lower Limbs with Sural Flap versus Propeller Flap.

Objective The objective of the present study was to prospectively compare the sural and propeller flaps for soft-tissues coverage of the lower extremity. The following variables were evaluated: incidence of complete or partial flap loss and donor area morbidity (primary closure versus skin graft). Methods Prospective and randomized analysis of data collected from all patients presenting with soft tissue defects of the lower third of the leg and heel treated with reverse sural or propeller flaps. Results Twenty-four patients aged between 4 and 60 years old were evaluated between 2011 and 2017. Complete coverage was obtained in 22 of the 24 patients (91.6%). Two flaps failed (8.4%). The sural flap, being the most popular option, continues to represent a safe and versatile alternative for skin defects of the lower third of the leg and heel region. Likewise, the propeller flap was a comparable option to treat these challenging defects. Conclusion Sural and propeller flaps are good options for soft tissues coverage of the lower extremity, with low complication rates (partial or total flap loss).

Microsurgical Reconstruction in an Orthopedic Hospital: Indications and Outcomes in Adults / Reconstrução microcirúrgica em um hospital ortopédico: Indicações e desfechos em adultos

Abstract Objective Advances in reconstructive microsurgery in orthopedic surgery provided better functional and aesthetic results and avoided many indications for amputation. In high-volume trauma and orthopedic hospitals, microsurgical reconstruction is essential to reduce costs and complications for these complex orthopedic defects. We describe a microsurgical approach to traumatic wounds, tumor resection, bone defects, and free muscle transfer, performed by an orthopedic microsurgery unit. The objective of the present study was to evaluate predictor factors for outcomes of microsurgical flaps for limb reconstruction, and to provide a descriptive analysis of microsurgical flaps for orthopedic indications. Methods Cross-sectional prospective study that included all consecutive cases of microsurgical flaps for orthopedic indications from 2014 to 2020. Data were collected from personal medical history, intraoperative microsurgical procedure, and laboratory blood tests. Complications and free-flap outcomes were studied in a descriptive and statistical analysis. Results We evaluated 171 flaps in 168 patients; the indications were traumatic in 66% of the patients. Type III complications of the Clavien-Dindo Classification were observed in 51 flaps. The overall success rate of the microsurgical flaps was 88.3%. In the multivariate analysis, the risk factors for complications were ischemia time ≥ 2 hours (p= 0.032) and obesity (p= 0.007). Partial flap loss was more common in patients with thrombocytosis in the preoperative platelet count (p= 0.001). Conclusion The independent risk factors for complications of microsurgical flaps for limb reconstruction are obesity and flap ischemia time ≥ 2 hours, and presence of thrombocytosis is a risk factor for partial flap loss.

Resumo Objetivo Os avanços da microcirurgia reconstrutiva na cirurgia ortopédica proporcionaram melhores resultados funcionais e estéticos, evitando as muitas indicações de amputação. Nos hospitais de ortopedia e traumatologia com um grande volume de atendimento, a reconstrução microcirúrgica é essencial, a fim de reduzir os custos e as complicações destes complexos defeitos ortopédicos. Descrevemos uma abordagem microcirúrgica para feridas traumáticas, ressecção tumoral, defeitos ósseos e transferência muscular livre realizada por uma unidade ortopédica especializada em microcirurgia. O objetivo do presente estudo é avaliar os fatores preditivos de resultados dos retalhos microcirúrgicos na reconstrução dos membros, fornecendo uma análise descritiva dos retalhos microcirúrgicos para as indicações ortopédicas. Métodos Estudo prospectivo transversal, que incluiu todos os casos consecutivos de retalhos microcirúrgicos com indicação ortopédica de 2014 a 2020. Foram coletados os dados do histórico clínico pessoal, procedimentos microcirúrgicos intraoperatórios e exames laboratoriais. As complicações e os desfechos de retalho livre foram estudados mediante uma análise descritiva e estatística. Resultados Avaliamos 171 retalhos em 168 pacientes. A indicação mais frequente para a realização de um retalho microcirúrgico foi a traumática, em 66% dos pacientes. Foram observadas complicações cirúrgicas em 51 retalhos, conforme a classificação de Clavien-Dindo do tipo III. A taxa de êxito global dos retalhos microcirúrgicos foi de 88,3%. Na análise multivariada, foram identificados como fatores de risco para complicações tempo de isquemia ≥ 2 horas (p= 0,032) e obesidade (p= 0,007). A perda parcial do retalho foi mais comum em pacientes com trombocitose, com contagem de plaquetas pré-operatória (p= 0,001). Conclusão Os fatores de risco independentes para complicações de retalhos microcirúrgicos para a reconstrução de membro são obesidade e tempo de isquemia do retalho ≥ 2 horas, e a presença de trombocitose como fator de risco para perda parcial do retalho.

Comparative Analysis of the Treatment of Skin Lesions of the Lower Limbs with Sural Flap versus Propeller Flap / Análise comparativa do tratamento de lesões cutâneas dos membros inferiores com retalho sural versus retalho propeller

Abstract Objective The objective of the present study was to prospectively compare the sural and propeller flaps for soft-tissues coverage of the lower extremity. The following variables were evaluated: incidence of complete or partial flap loss and donor area morbidity (primary closure versus skin graft). Methods Prospective and randomized analysis of data collected from all patients presenting with soft tissue defects of the lower third of the leg and heel treated with reverse sural or propeller flaps. Results Twenty-four patients aged between 4 and 60 years old were evaluated between 2011 and 2017. Complete coverage was obtained in 22 of the 24 patients (91.6%). Two flaps failed (8.4%). The sural flap, being the most popular option, continues to represent a safe and versatile alternative for skin defects of the lower third of the leg and heel region. Likewise, the propeller flap was a comparable option to treat these challenging defects. Conclusion Sural and propeller flaps are good options for soft tissues coverage of the lower extremity, with low complication rates (partial or total flap loss).

Resumo Objetivo O objetivo do presente estudo foi comparar prospectivamente os retalhos sural e propeller para cobertura de partes moles da extremidade inferior. Foram avaliadas as seguintes variáveis: incidência de perda total ou parcial do retalho e morbidade da área doadora (fechamento primário versus enxerto de pele). Métodos Análise prospectiva e randomizada de dados coletados de todos os pacientes apresentando defeitos em tecidos moles da extremidade distal da perna e do retropé submetidos aos retalhos em questão. Resultados Foram avaliados 24 pacientes com idades entre 4 e 60 anos, entre 2011 e 2017. Cobertura completa foi obtida em 22 dos 24 pacientes (91,6%) e observamos falha em 2 retalhos (8,4%). O retalho sural, sendo a opção mais popular, continua a representar uma alternativa segura e versátil para defeitos cutâneos do terço distal da perna e da região do calcanhar. O retalho propeller, da mesma maneira, mostrou-se uma opção comparável para o tratamento destas lesões desafiadoras. Conclusão Os retalhos sural e propeller são boas opções para a cobertura de partes moles da extremidade inferior, demostrando baixas taxas de complicações como perda parcial ou total do retalho.

Evaluation of Circular Saw Injuries in a Reference Center in Microsurgery and Reimplantation.

Objective To evaluate the epidemiologic profile, the time until care, and the type of conduct taken regarding patients who are victims of accidents with circular saws and their resulting injuries, and to make a comparison with the literature. Methods A cross-sectional descriptive study reviewing the medical records of patients cared for from April to December 2018, analyzing age, gender, injured side, affected fingers, month and time of the accident, type of injuries, procedures performed in the emergency room, time elapsed between trauma and admission to the operating room, and reapproach during hospitalization. Results A total of 54 male patients aged between 15 and 72 years were care for. The left side was more affected, and the most frequent type of lesion involved the thumb, which had to be amputated in many cases. In total, 23 patients underwent reimplantation, 3 of which were macroreimplantations. Regarding the time of trauma, 26 cases occurred between noon and 4 p.m., and the time elapsed between the accident and the admission to the operating room was ≥ 6 hours in 84% of the patients. Conclusion Circular saw lesions are predominantly severe, with a potential for leaving permanent sequelae, and they affect mainly the thumb. The characterization of the type of injury and the initial care conditions obtained in the present study may contribute to the policy of prevention and care of patients who are victims of circular saw injuries. Level of Evidence IV; Case Series.

Evaluation of Circular Saw Injuries in a Reference Center in Microsurgery and Reimplantation / Avaliação de lesões por serra circular em um centro de referência em microcirurgia e reimplantes

Abstract Objective To evaluate the epidemiologic profile, the time until care, and the type of conduct taken regarding patients who are victims of accidents with circular saws and their resulting injuries, and to make a comparison with the literature. Methods A cross-sectional descriptive study reviewing the medical records of patients cared for from April to December 2018, analyzing age, gender, injured side, affected fingers, month and time of the accident, type of injuries, procedures performed in the emergency room, time elapsed between trauma and admission to the operating room, and reapproach during hospitalization. Results A total of 54 male patients aged between 15 and 72 years were care for. The left side was more affected, and the most frequent type of lesion involved the thumb, which had to be amputated in many cases. In total, 23 patients underwent reimplantation, 3 of which were macroreimplantations. Regarding the time of trauma, 26 cases occurred between noon and 4 p.m., and the time elapsed between the accident and the admission to the operating room was ≥ 6 hours in 84% of the patients. Conclusion Circular saw lesions are predominantly severe, with a potential for leaving permanent sequelae, and they affect mainly the thumb. The characterization of the type of injury and the initial care conditions obtained in the present study may contribute to the policy of prevention and care of patients who are victims of circular saw injuries. Level of Evidence IV; Case Series.

Resumo Objetivo Avaliar o perfil epidemiológico, o tempo até o atendimento, e o tipo de conduta tomada em pacientes vítimas de acidentes com serra circular e lesões decorrentes, e fazer uma comparação com a literatura. Métodos Estudo descritivo transversal, com revisão do prontuário de pacientes atendidos de abril a dezembro de 2018, analisando idade, sexo, lado lesado, dedos acometidos, mês e horário do acidente, tipo de lesões, procedimentos realizados na urgência, tempo decorrido entre o trauma e entrada em sala cirúrgica, e reabordagem durante a internação. Resultados Foram atendidos 54 pacientes do sexo masculino com idade entre 15 e 72 anos. O lado esquerdo foi o mais acometido, e o tipo de lesão mais frequente, a amputação, envolvendo principalmente o polegar. No total, 23 pacientes foram submetidos a reimplante, e, entre eles, 3 macrorreimplantes. Quanto ao horário do trauma, 26 ocorreram entre 12h e 16h, e o tempo decorrido entre o acidente e a entrada em sala cirúrgica foi ≥ 6 horas em 84% dos pacientes. Conclusão As lesões por serra circular são predominantemente graves, com potencial de deixar sequelas permanentes, e acometem principalmente o polegar. A caracterização do tipo de lesão e as condições de atendimento inicial obtidas neste trabalho poderão ajudar na política de prevenção e atendimento a pacientes vítimas de ferimentos por serra circular. Nível de Evidência IV; Série de Casos.

EFFECT OF HYPERBARIC OXYGEN THERAPY ON NERVE REGENERATION IN RATS.

Objective: To evaluate histological changes in peripheral nerves of rats after sciatic nerve neurorrhaphy, according to the time of exposure to hyperbaric oxygen chamber treatment. Methods: Twenty-five Wistar rats were divided into 5 groups according to the amount of exposure to hyperbaric oxygen chamber treatment. Group 1 was the control and there was no use of hyperbaric oxygen chamber; group 2 received one week of therapy; group 3, two weeks; group 4, three weeks; and group 5, four weeks. After the fourth postoperative week, the animals were submitted to euthanasia and a sciatic nerve sample sent for histological analysis. Axons proximal and distal to the neurorrhaphy were counted with axonal regeneration index measurement. Results: We observed that the number of axons distal to neurorrhaphy increases with the amount of hyperbaric oxygen chamber exposure, the results were more expressive from the third week of treatment. However, the statistical analysis found no significant difference between the groups. Conclusion: The descriptive analysis suggests benefit of using hyperbaric oxygen chamber directly proportional to the time of therapy. The study, however, did not present statistically relevant results, probably due to the reduced sample size. Subsequent studies with more significant sampling would be of great value. Level of Evidence II, Prospective Comparative Study.

Objetivo: Avaliar as alterações histológicas nos nervos periféricos após neurorrafia do nervo ciático de ratos, de acordo com o tempo de exposição ao tratamento com câmara hiperbárica de oxigênio. Métodos: Vinte e cinco ratos da raça Wistar foram divididos em cinco grupos conforme o tempo de exposição ao tratamento com câmara hiperbárica de oxigênio. O grupo 1 não recebeu o tratamento; o grupo 2 recebeu uma semana de terapia; o grupo 3, duas semanas; o grupo 4, três semanas; e o grupo 5, quatro semanas. Após quatro semanas de pós-operatório, os animais foram submetidos à eutanásia e uma amostra do nervo ciático foi enviada para análise histológica. Foram feitas contagens do número de axônios proximalmente e distalmente à neurorrafia, com medição do índice de regeneração axonal. Resultados: Observamos que o aumento do número de axônios distais à neurorrafia foi diretamente proporcional ao tempo de exposição à câmara hiperbárica de oxigênio, sendo mais expressivo a partir da terceira semana de tratamento. Entretanto, a análise estatística não encontrou diferença significativa entre os grupos. Conclusão: A análise descritiva sugere benefício do uso da câmara hiperbárica de oxigênio. Porém, devido à amostra reduzida, o estudo não apresentou resultados estatisticamente relevantes, sendo necessária a realização de estudos subsequentes com amostragem mais significativa. Nível de Evidência II, Estudo Prospectivo Comparativo.

Orthoplastic reconstruction in children: are the risk factors similar to those observed in adults?

Free flaps in the pediatric population are less common and when indicated the expectations to avoid amputation are high. The objective of this study is to describe indications and results of free flaps for limb reconstruction. Patients undergoing microsurgical free flaps in an orthopedic hospital were consecutively included in this cross-sectional study, from 2014 to 2020. Data regarding personal medical history, intraoperative microsurgical procedure and laboratory tests were collected. Patients under 18 years of age were included. Complications and free flap outcomes were observed during follow-up. This study included 23 free flaps in 23 patients with orthoplastic reconstruction. The free flap was performed as a reconstructive elevator concept. The most common indications were skin or bone defects caused by trauma (nine patients), tumor (six patients) and congenital pseudarthrosis of the tibia (four patients). The most indicated flap was a vascularized fibular flap in 10 patients, followed by an anterolateral thigh flap in 5 patients. Complications were observed in five patients. In total 93% of patients with inferior limb reconstruction walked at the final evaluation. Among risk factors studied, cases had a higher incidence of complications (P = 0.03) when only the superficial venous system was used. Free flaps in children are well-tolerated and indications are restricted to precise indications to provide alternatives to amputations and improve patient's function. We observed an increase in the incidence of complications when only superficial veins were used for free flap outflow in children.

Effect of hyperbaric oxygen therapy on nerve regeneration in rats / Efeito da terapia hiperbárica de oxigênio na regeneração nervosa em ratos

ABSTRACT Objective: To evaluate histological changes in peripheral nerves of rats after sciatic nerve neurorrhaphy, according to the time of exposure to hyperbaric oxygen chamber treatment. Methods: Twenty-five Wistar rats were divided into 5 groups according to the amount of exposure to hyperbaric oxygen chamber treatment. Group 1 was the control and there was no use of hyperbaric oxygen chamber; group 2 received one week of therapy; group 3, two weeks; group 4, three weeks; and group 5, four weeks. After the fourth postoperative week, the animals were submitted to euthanasia and a sciatic nerve sample sent for histological analysis. Axons proximal and distal to the neurorrhaphy were counted with axonal regeneration index measurement. Results: We observed that the number of axons distal to neurorrhaphy increases with the amount of hyperbaric oxygen chamber exposure, the results were more expressive from the third week of treatment. However, the statistical analysis found no significant difference between the groups. Conclusion: The descriptive analysis suggests benefit of using hyperbaric oxygen chamber directly proportional to the time of therapy. The study, however, did not present statistically relevant results, probably due to the reduced sample size. Subsequent studies with more significant sampling would be of great value. Level of Evidence II, Prospective Comparative Study.

RESUMO Objetivo: Avaliar as alterações histológicas nos nervos periféricos após neurorrafia do nervo ciático de ratos, de acordo com o tempo de exposição ao tratamento com câmara hiperbárica de oxigênio. Métodos: Vinte e cinco ratos da raça Wistar foram divididos em cinco grupos conforme o tempo de exposição ao tratamento com câmara hiperbárica de oxigênio. O grupo 1 não recebeu o tratamento; o grupo 2 recebeu uma semana de terapia; o grupo 3, duas semanas; o grupo 4, três semanas; e o grupo 5, quatro semanas. Após quatro semanas de pós-operatório, os animais foram submetidos à eutanásia e uma amostra do nervo ciático foi enviada para análise histológica. Foram feitas contagens do número de axônios proximalmente e distalmente à neurorrafia, com medição do índice de regeneração axonal. Resultados: Observamos que o aumento do número de axônios distais à neurorrafia foi diretamente proporcional ao tempo de exposição à câmara hiperbárica de oxigênio, sendo mais expressivo a partir da terceira semana de tratamento. Entretanto, a análise estatística não encontrou diferença significativa entre os grupos. Conclusão: A análise descritiva sugere benefício do uso da câmara hiperbárica de oxigênio. Porém, devido à amostra reduzida, o estudo não apresentou resultados estatisticamente relevantes, sendo necessária a realização de estudos subsequentes com amostragem mais significativa. Nível de Evidência II, Estudo Prospectivo Comparativo.

Structured evaluation of a comprehensive microsurgical training program.

OBJECTIVES: This study proposed a structured microsurgical training program and evaluated it with the assistance of a large sample of surgeons. METHODS: The practical course comprised 16 sessions of approximately 4 hours each. This included two sessions for suturing rubber gloves and two sessions for suturing arteries, veins, and nerves in chicken thighs. The other sessions were performed on the femoral vessels of rats: 5 sessions for end-to-end arterial anastomosis, 5 for end-to-end venous anastomosis, 1 for arterial grafting, and 1 for end-to-side anastomosis. We conducted a structured assessment of the microsurgical skills in each training session. RESULTS: In this study, 89 surgeons were evaluated. The mean scores for the different procedures were as follows: glove suturing, 33.3±0.59; chicken nerve end-to-end anastomosis, 40.3±0.49; chicken artery suturing, 40.9±0.36; chicken vein suturing, 42.3±0.36; graft interposition, 44.8±0.7; and end-to-side anastomosis, 43.7±0.63 (p<0.05 for all). The chicken thigh suturing scores were significantly higher than the rubber gloves suturing scores (p<0.01). There were no differences between scores of the rat artery and chicken thigh suturing procedures (p=0.24). The rat venous anastomosis scores were higher than the rat arterial anastomosis scores (p=0.02), as were graft interposition scores when compared with end-to-end venous anastomosis scores. The end-to-side anastomosis scores did not differ significantly from the grafting scores (p=0.85). The most common errors were inadequate knotting technique and suture rupture due to inadequate technique (both n=88 [98.9%]). CONCLUSION: We propose a 16-step, progressive microsurgical training program to learn the basic microsurgical techniques comprehensively and reliably. The program was evaluated in a large sample of trainees, and it demonstrated the adequacy of the training sequence and results.

Do technical components of microanastomoses influence the functional outcome of free gracilis muscle transfer for elbow flexion in traumatic brachial plexus injury?

INTRODUCTION: The traumatic lesions of the brachial plexus in adults are devastating injuries causing continuous severe functional impairment for both work and daily living activities. The restoration of elbow flexion is one of the most important movements for patient recovery to previous activities. Free gracilis muscle transfer has good outcomes for cases with late presentation or as a rescue surgery to regain elbow flexion, however, bad results are present in all cohorts with insufficient recovery of muscle strength for elbow flexion. A number of hypotheses can be postulate to explain the fair results observed in some cases of free gracilis muscle transfer for elbow flexion. Most studies in the current literature compare the choice of the donor nerve used in neurotization and nerve grafts. The aim of this study is to evaluate if technical components of microvascular anastomosis could influence the functional outcome of free functional muscle transfer for elbow flexion in adult patients with traumatic brachial plexus injury. MATERIAL AND METHODS: Included all adult patients with traumatic brachial plexus injury submitted to free functional gracilis muscle transfer for elbow flexion. The complications and functional results according to British Medical Research Council (BMRC) score were recorded. RESULTS: We assessed 26 patients with mean age of 32.8 years. The most common donor nerve for gracilis muscle was the accessory nerve in 18 patients. Eighteen patients presented with good result (M3/M4). The mean ischemia time was higher for patients with bad results (132 minutes) comparing with patients with good results (122 minutes). Patients with only one venous anastomosis had 41% of poor functional outcome compared with 22% of cases with two venous anastomoses. No statistically significant difference in the ischemia time of the cases with good or poor functional outcome was observed (p=0.657), as for the number of venous anastomoses (p=0.418). CONCLUSION: Our study observes that patients with only one venous anastomoses for drainage of free gracilis and those with longer intraoperative ischemia time had higher incidence of poor functional outcome of free gracilis muscle transfer for elbow flexion, but not statistically significant. LEVEL OF PROOF: II; prospective cross-sectional study.

Structured evaluation of a comprehensive microsurgical training program

OBJECTIVES: This study proposed a structured microsurgical training program and evaluated it with the assistance of a large sample of surgeons. METHODS: The practical course comprised 16 sessions of approximately 4 hours each. This included two sessions for suturing rubber gloves and two sessions for suturing arteries, veins, and nerves in chicken thighs. The other sessions were performed on the femoral vessels of rats: 5 sessions for end-to-end arterial anastomosis, 5 for end-to-end venous anastomosis, 1 for arterial grafting, and 1 for end-to-side anastomosis. We conducted a structured assessment of the microsurgical skills in each training session. RESULTS: In this study, 89 surgeons were evaluated. The mean scores for the different procedures were as follows: glove suturing, 33.3±0.59; chicken nerve end-to-end anastomosis, 40.3±0.49; chicken artery suturing, 40.9±0.36; chicken vein suturing, 42.3±0.36; graft interposition, 44.8±0.7; and end-to-side anastomosis, 43.7±0.63 (p<0.05 for all). The chicken thigh suturing scores were significantly higher than the rubber gloves suturing scores (p<0.01). There were no differences between scores of the rat artery and chicken thigh suturing procedures (p=0.24). The rat venous anastomosis scores were higher than the rat arterial anastomosis scores (p=0.02), as were graft interposition scores when compared with end-to-end venous anastomosis scores. The end-to-side anastomosis scores did not differ significantly from the grafting scores (p=0.85). The most common errors were inadequate knotting technique and suture rupture due to inadequate technique (both n=88 [98.9%]). CONCLUSION: We propose a 16-step, progressive microsurgical training program to learn the basic microsurgical techniques comprehensively and reliably. The program was evaluated in a large sample of trainees, and it demonstrated the adequacy of the training sequence and results.

THE DESIGN OF THE ARTERIOVENOUS VASCULAR LOOP DOES NOT AFFECT ITS PATENCY: EXPERIMENTAL STUDY.

OBJECTIVE: To evaluate the effect of the design of a femoral vascular loop with anastomosis in the femoral artery of rabbits on the presence of flow (patency) after seven days. METHODS: A total of 39 rabbits underwent arteriovenous microanastomosis using the microsurgical technique. Two loop designs were used: one circular and the other angled. The parameters evaluated were presence or absence of flow, signs of hemolysis and hemodynamic changes. RESULTS: After seven days, flow was present in 68% of the angled loops and 75% of the circular loops (p > 0.05). There was a significant intragroup decrease in pCO2 and a significant increase in pH. For the other parameters evaluated, no significant differences between the two loop models were found. CONCLUSIONS: A reproducible vascular loop model was shown. There was no significant difference between the two vascular loop models about the presence of flow after seven days. Level of Evidence V, Animal experimental study.

OBJETIVO: Avaliar, em coelhos, qual é a influência do desenho da alça de veia femoral com anastomose na artéria femoral, na presença de fluxo (patência) após sete dias. MÉTODO: 39 coelhos foram submetidos à microanastomose arteriovenosa com técnica microcirúrgica. As alças foram acomodadas em dois desenhos, um circular e outro, o mais alongado possível sem dobras na alça. Os parâmetros avaliados foram: presença ou não de fluxo, sinais de hemólise, alterações hemodinâmicas. RESULTADOS: após sete dias, o fluxo estava presente em 68% das alças anguladas e em 75% das alças circulares (p > 0,05). Houve, intragrupo, diminuição estatisticamente significante da pCO 2 e aumento estatisticamente significante do pH. Não houve diferença estatística no restante dos parâmetros avaliados entre os dois modelos de alça. CONCLUSÕES: apresentamos um modelo reprodutível de alça vascular. Não houve diferença estatística quanto à presença de fluxo após sete dias nos dois modelos de alça vascular. Nível de Evidência V, Estudo experimental em animais.

IS OBESITY A RISK FACTOR FOR FREE VASCULARIZED FIBULAR FLAP COMPLICATIONS?

OBJECTIVE: Although our knowledge of bone reconstruction through microsurgery has increased, the vascularized fibula flap remains one of the most difficult free flap reconstructions to perform, and complications remain a challenge. The incidence of obesity is increasing and is associated with higher rates of free flap complications, which can lead to disastrous results. Since there is no consensus in literature regarding the influence of obesity on free flap outcomes in orthopedic surgeries that require segmental bone reconstruction, the objective of this study was to determine whether obesity increases the risk of post-operative complications (Clavien-Dindo grade III) after free vascularized fibular flap surgery. METHODS: A cohort study was conducted in all patients undergoing free flap limb reconstructions between July 2014 and July 2018. Patients were separated in two groups based on their body mass index (BMI): non-obese and obese (BMI≥30 kg/m2). RESULTS: Twenty-three free vascularized fibular flaps were studied. The indications included trauma in 13, tumors in 7, and congenital pseudarthrosis of the tibia in 3. Obese patients were associated with an increase in surgical complications (p=0.038). During the final follow-up, consolidation was obtained in 17 patients (74%). CONCLUSION: Obesity is a risk factor for complications in free vascularized fibular flap surgery. Level of evidence IV, original article.

OBJETIVO: Apesar do crescente conhecimento em reconstrução óssea por meio de microcirurgia, o retalho livre de fíbula vascularizada ainda permanece como uma das reconstruções mais difíceis de ser executada, e suas complicações ainda são um desafio. A incidência da obesidade tem aumentado e está associada a taxas mais altas de complicações de retalhos livres, o que pode levar a resultados desastrosos. Uma vez que não há consenso na literatura a respeito da influência da obesidade nos desfechos dos retalhos livre em cirurgias ortopédicas que requeiram reconstrução de segmento ósseo, o objetivo deste estudo foi avaliar se a obesidade aumenta o risco de complicações pós-operatórias (Clavien-Dindo grau III) após a cirurgia de retalho livre de fíbula vascularizada. MÉTODOS: Foi realizado um estudo de coorte transversal, com a inclusão de todos os pacientes submetidos à reconstrução de membros com retalho livre de fíbula vascularizada, entre julho de 2014 e julho de 2018. Os pacientes foram separados em dois grupos, com base no índice de massa corporal: não obesos e obesos (no índice de massa corporal ≥ 30 kg/m2). RESULTADOS: Foram analisados 23 retalhos livres de fíbula vascularizada. As indicações foram trauma em 13 casos, tumor em sete e pseudoartrose congênita da tíbia em três. Pacientes obesos foram associados a aumento nas complicações cirúrgicas (p = 0,038). No final do acompanhamento, a consolidação óssea foi obtida em 17 pacientes (74%). CONCLUSÃO: A obesidade é um fator de risco para complicações no retalho livre de fíbula vascularizada. Nível de evidência IV, artigo original.

Life quality evaluation using "time trade off" method for rheumatoid hands / Avaliando qualidade de vida do paciente com artrite nas mãos pelo método "time trade off"

ABSTRACT Objective: Rheumatoid arthritis is a prevalent disease in the population (range 0.5% to 1%) and involves both orthopedic and rheumatologic treatment. The Time Trade-Off (TTO) technique, which determines the number of years the patient or the professional would be allowed before a successful procedure in terms of life expectancy and value of the procedure, has been gaining ground in clinical protocols. From this standpoint, we sought to compare evaluations provided by the patients, orthopedists, and rheumatologists in determining the TTO and to correlate their responses with the clinical repercussions using previously established scores such as the Brief Michigan Hand Questionnaire and the Disease Activity Score-28 (DAS-28). Methods: A prospective study was conducted that involved 37 patients with rheumatoid arthritis, orthopedists, and rheumatologists. The TTO questionnaire was administered by an independent evaluator for evaluation using the DAS-28 and the Brief Michigan Hand Questionnaire. Results: The descriptive analysis revealed similar medians between the orthopedists, rheumatologists, and patients for single assessments. However, there was a weak correlation between the results from the patient and rheumatologist, the patient and Brief Michigan Questionnaire, and those of the orthopedic surgeon and the DAS-28. Conclusion: Similar median values demonstrated equivalent TTO among the orthopedist, rheumatologist, and patient. However, given the weak correlations between the scores, it was not possible to substitute results using a single evaluation scale. Level of Evidence II, Prognostic Studies.

RESUMO Objetivo: Artrite reumatoide é uma doença prevalente na população (0,5% a 1%), envolvendo tratamento tanto ortopédico, quanto reumatológico. A técnica do "Time Trade Off", que determina a quantidade de anos que o paciente ou o profissional daria para ter sucesso absoluto em determinado procedimento, vem ganhando espaço nos protocolos modernos. Diante disto, comparamos a avaliação dada pelo paciente, pelo ortopedista e pelo reumatologista usando "Time Trade Off" e correlacionamos com repercussão clínica e escores já estabelecidos: Brief Michigan Questionnaire (Anexo I) e Disease Activity Score-28 (DAS-28) (Anexo II). Métodos: Estudo prospectivo com 37 pacientes diagnosticados com artrite reumatoide, que foram submetidos ao questionário "Time Trade Off" pelo ortopedista, pelo reumatologista e por um avaliador independente, e avaliação através do DAS-28 e do Brief Michigan. Resultados: Através da análise descritiva, notou-se medianas semelhantes entre ortopedista, reumatologista e paciente. Entretanto, evidenciou-se correlação fraca entre paciente e reumatologista, paciente e o Brief Michigan; e ortopedista e o DAS-28. Conclusão: Valores de mediana semelhantes demonstram "Time Trade Off" equivalentes entre ortopedista, reumatologista e paciente. Mas, diante das correlações fracas entre os escores, não foi possível substituí-los por uma escala única de avaliação. Nível de Evidência II, Estudo Prognóstico.

ARTHROSCOPIC ASSESSMENT OF THE WRIST WITH KIENBÖCK'S DISEASE.

OBJECTIVE: Treatment of Kienböck's disease is challenging and the variability of results, despite the surgical technique, shows that there must be other aspects that can influence outcomes. The objective of this study is determine, through arthroscopic approach, the pattern of impairment of the carpal bones in Lichtman stage III patients. METHOD: Wrist arthroscopy was performed in patients with symptoms and evidence of lunate necrosis on x-rays, with signs of 3A and 3B stages. The Outerbridge classification was used to grade the articular status of the carpal bones. RESULTS: Fifteen patients with stage 3 disease were assessed, five of whom were staged as type 3A and ten as 3B using the Lichtman stages. According to the Outerbridge classification, the lunate sulcus was the most affected with means of 2.8 at 3A and 2.9 at 3B. Other areas were significantly less affected with means of 1.1 and 1.3, respectively. CONCLUSION: Arthroscopic assessment of the wrist could aid in surgical decision making, offering more details on cartilage status in stage 3 Kienböck's disease. Level of Evidence III, Study of nonconsecutive patients, without consistently applied reference "gold" standard.

OBJETIVO: O tratamento da doença de Kienböck é desafiador, e a variabilidade dos resultados, apesar da técnica cirúrgica, mostra que deve haver outros aspectos que influenciam os desfechos. O objetivo deste estudo é determinar, por via artroscópica, o padrão de comprometimento dos ossos do carpo em pacientes com estágio 3 de Lichtman. MÉTODO: A artroscopia de punho foi realizada em pacientes com sintomas e evidências de necrose do semilunar à radiografia, com sinais de estágios 3A e 3B. A classificação de Outerbridge foi usada para determinar a condição articular dos ossos do carpo. RESULTADOS: Foram avaliados 15 pacientes com doença em estágio 3, sendo que cinco classificados como tipo 3A e dez como tipo 3B usando os estágios de Lichtman. De acordo com a classificação de Outerbridge, o sulco semilunar foi mais afetado, com médias de 2,8 em 3A e 2,9 em 3B. Outras áreas foram significativamente menos afetadas, com médias de 1,1 e 1,3, respectivamente. CONCLUSÃO: A avaliação artroscópica do punho pode auxiliar na tomada de decisão cirúrgica, oferecendo mais detalhes sobre a condição da cartilagem no estágio 3 da doença de Kienböck. Nível de Evidência III, Estudo de pacientes não-consecutivos, sem padrão de referência "ouro" aplicado uniformemente.

Arthroscopic assessment of the wrist with kienböck's disease / Avaliação artroscópica de punho com doença de kienböck

ABSTRACT Objective: Treatment of Kienböck's disease is challenging and the variability of results, despite the surgical technique, shows that there must be other aspects that can influence outcomes. The objective of this study is determine, through arthroscopic approach, the pattern of impairment of the carpal bones in Lichtman stage III patients. Method: Wrist arthroscopy was performed in patients with symptoms and evidence of lunate necrosis on x-rays, with signs of 3A and 3B stages. The Outerbridge classification was used to grade the articular status of the carpal bones. Results: Fifteen patients with stage 3 disease were assessed, five of whom were staged as type 3A and ten as 3B using the Lichtman stages. According to the Outerbridge classification, the lunate sulcus was the most affected with means of 2.8 at 3A and 2.9 at 3B. Other areas were significantly less affected with means of 1.1 and 1.3, respectively. Conclusion: Arthroscopic assessment of the wrist could aid in surgical decision making, offering more details on cartilage status in stage 3 Kienböck's disease. Level of Evidence III, Study of nonconsecutive patients, without consistently applied reference "gold" standard.

RESUMO Objetivo: O tratamento da doença de Kienböck é desafiador, e a variabilidade dos resultados, apesar da técnica cirúrgica, mostra que deve haver outros aspectos que influenciam os desfechos. O objetivo deste estudo é determinar, por via artroscópica, o padrão de comprometimento dos ossos do carpo em pacientes com estágio 3 de Lichtman. Método: A artroscopia de punho foi realizada em pacientes com sintomas e evidências de necrose do semilunar à radiografia, com sinais de estágios 3A e 3B. A classificação de Outerbridge foi usada para determinar a condição articular dos ossos do carpo. Resultados: Foram avaliados 15 pacientes com doença em estágio 3, sendo que cinco classificados como tipo 3A e dez como tipo 3B usando os estágios de Lichtman. De acordo com a classificação de Outerbridge, o sulco semilunar foi mais afetado, com médias de 2,8 em 3A e 2,9 em 3B. Outras áreas foram significativamente menos afetadas, com médias de 1,1 e 1,3, respectivamente. Conclusão: A avaliação artroscópica do punho pode auxiliar na tomada de decisão cirúrgica, oferecendo mais detalhes sobre a condição da cartilagem no estágio 3 da doença de Kienböck. Nível de Evidência III, Estudo de pacientes não-consecutivos, sem padrão de referência "ouro" aplicado uniformemente.

USE OF MAGNETIC RESONANCE IMAGING TO DIAGNOSE BRACHIAL PLEXUS INJURIES.

OBJECTIVE: To compare magnetic resonance imaging and intraoperative findings in patients diagnosed with traumatic injury to the brachial plexus. METHODS: Patients with a diagnosis of traumatic injury to the brachial plexus admitted to the hand and microsurgery outpatient consult of the Hospital das Clínicas at the University of São Paulo were selected during December 2016. A total of three adult patients with up to six months of injury who underwent surgical treatment were included in the study. A diffusion-weighted sequence magnetic resonance protocol and fluid-sensitive volumetric reformatting sequence were applied. The magnetic resonance results were compared with the diagnoses obtained from the injuries observed during the surgery. The study was double-blind (surgeon and radiologist). RESULTS: A descriptive correlation was found between the magnetic resonance imaging results and the diagnostic findings from the surgeries, for both pre- and post-ganglionic injuries. CONCLUSION: Magnetic resonance imaging has shown to be a promising diagnostic method in preoperative assessment of brachial plexus lesions; it is less invasive than other common methods, showing not only avulsion lesions but also localized postganglionic lesions in the supra- and infraclavicular region. Level of Evidence III; Diagnostic studies - Investigating a diagnostic test.

OBJETIVO: Comparar resultados de ressonância magnética e achados intraoperatórios de pacientes com diagnóstico de lesão traumática do plexo braquial. MÉTODOS: Foram selecionados pacientes com diagnóstico de lesão traumática do plexo braquial admitidos no ambulatório de mão e microcirurgia do Hospital das Clínicas de São Paulo no mês de dezembro de 2016. Foram incluídos pacientes adultos com até seis meses de lesão que seriam submetidos a tratamento cirúrgico, totalizando três para o estudo. Foi aplicado um protocolo de ressonância magnética com sequência ponderada em difusão e sequência com reformatação volumétrica fluido-sensível. Os resultados da ressonância magnética foram comparados com os diagnósticos das lesões obtidos na cirurgia. O estudo foi duplo-cego (cirurgião e radiologista). RESULTADOS: Houve correlação em termos descritivos entre os laudos das ressonâncias magnéticas e os achados diagnósticos das cirurgias, tanto para as lesões pré como pós-ganglionares. CONCLUSÃO: A ressonância magnética mostrou ser um método diagnóstico promissor na avaliação pré-operatória das lesões do plexo braquial, sendo menos invasiva que os outros métodos mais utilizados, permitindo o estudo não somente das lesões por avulsão, mas também das lesões pós-ganglionares localizadas na região supra e infraclavicular. Nível de Evidência III; Estudos diagnósticos - Investigação de um exame para diagnóstico.