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1.
Injury ; 52(12): 3635-3639, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33902867

RESUMO

BACKGROUND: Scaphoid nonunion involving the proximal pole with the presence of avascular necrosis is difficult to reconstruct. We aimed to determine the efficacy of surgical treatment of proximal pole scaphoid nonunion with avascular necrosis using a dorsal capsular-based vascularized distal radius graft. METHODS: Between 2000 and 2018, 64 patients with established proximal pole scaphoid nonunion with avascular necrosis were treated using a dorsal capsular-based vascularized distal radius graft. This graft was harvested from the dorsal aspect of the distal radius with its dorsal wrist capsule attachment. Fixation of the scaphoid nonunion was performed with a small cannulated screw, followed by insertion of the vascularized graft into the dorsal trough at the scaphoid nonunion site. In the last 47 patients of this series, a micro suture anchor was placed into the scaphoid to augment graft fixation. RESULTS: Union rate was 86% (55 of 64 scaphoid nonunions with avascular necrosis) at a mean time of 12 weeks. Persistent non-union was noted in eight patients and fibrous union in one patient. No patients developed donor site morbidity. No graft dislodgment was noted. There was significant improvement of the wrist functional outcomes at the final follow up. CONCLUSIONS: The dorsal capsular-based vascularized distal radius graft is a safe and effective treatment in patients with scaphoid nonunion with avascular necrosis of the proximal pole. This pedicle vascularized bone graft is derived from a location that can easily reach the proximal third of the scaphoid avoiding microsurgical dissection or anastomosis.


Assuntos
Fraturas não Consolidadas , Osteonecrose , Osso Escafoide , Transplante Ósseo , Fraturas não Consolidadas/diagnóstico por imagem , Fraturas não Consolidadas/cirurgia , Humanos , Osteonecrose/cirurgia , Rádio (Anatomia)/cirurgia , Estudos Retrospectivos , Osso Escafoide/diagnóstico por imagem , Osso Escafoide/cirurgia
2.
Instr Course Lect ; 70: 73-84, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33438905

RESUMO

The carpal and cubital tunnel syndromes are the most common compression neuropathies of the upper extremity. Although the diagnosis and management of these neuropathies have evolved over the past few decades, the ideal primary surgical treatment has not yet been established and management of recurrence remains a challenge. Revision surgery with simple repeated nerve decompression even accompanied by neurolysis does not always result in satisfactory clinical outcomes. Coverage with soft tissue or wrapping of the nerve with biologic or synthetic protective barriers can be used as an ancillary technique in the revision surgery to enhance nerve healing, preventing perineural scarring and adhesions. Future randomized larger trials combined with better understanding of nerve biology may be necessary to optimize primary and revision surgical treatment for carpal and cubital tunnel syndrome.


Assuntos
Síndrome do Túnel Carpal , Síndrome do Túnel Ulnar , Síndromes de Compressão Nervosa , Síndrome do Túnel Carpal/diagnóstico , Síndrome do Túnel Carpal/cirurgia , Síndrome do Túnel Ulnar/diagnóstico , Síndrome do Túnel Ulnar/cirurgia , Descompressão Cirúrgica , Humanos , Síndromes de Compressão Nervosa/cirurgia , Reoperação , Extremidade Superior/cirurgia
3.
J Hand Surg Am ; 45(3): 252.e1-252.e6, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31420244

RESUMO

PURPOSE: To determine whether the triceps sling reconstruction technique is a safe and effective treatment of intraoperative ulnar nerve subluxation after in situ decompression. METHODS: Twelve patients who underwent a triceps sling reconstruction for intraoperative ulnar nerve subluxation after in situ release were retrospectively reviewed. The triceps sling technique consists of harvesting a small, distally based strip of triceps tendon and suturing the proximal end of the strip to the posterior aspect of the released Osborne ligament. Thus, a sling is created between the medial epicondyle and the olecranon, preventing the nerve from subluxating. Patients were clinically evaluated before and after surgery. Visual analog scale pain scores, static 2-point discrimination, strength, and Disabilities of the Arm, Shoulder, and Hand score were assessed. RESULTS: At a mean follow-up of 31 months (range, 24-38 months), there was a significant improvement in mean visual analog pain scores from 8.6 to 0.2. Static 2-point discrimination was improved from a mean of 9.1 mm before surgery to 5.7 mm afterward. Strength improved by a mean of 33% and 30% with grip and pinch, respectively. Mean Disabilities of the Arm, Shoulder, and Hand score improved from 45.9 to 3.7. No subluxation of the ulnar nerve was noted after surgery. No other complications were noted. No reoperations were required during the follow-up period. CONCLUSIONS: Triceps sling reconstruction is a safe treatment in patients with intraoperative ulnar nerve subluxation after in situ decompression. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.


Assuntos
Síndrome do Túnel Ulnar , Nervo Ulnar , Braço , Síndrome do Túnel Ulnar/cirurgia , Descompressão Cirúrgica , Humanos , Estudos Retrospectivos , Nervo Ulnar/cirurgia
4.
Injury ; 50 Suppl 5: S50-S53, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31679828

RESUMO

INTRODUCTION: Scaphoid nonunions (SN) are rare in adolescents. The use of vascularized bone grafts (VBG) from the distal radius as an alternative to conventional grafting for the treatment of established SN in adolescents is described. PATIENTS AND METHODS: The technique was applied in 13 patients with symptomatic SN resulting from fractures. All patients were male with average age of 16.5 years (15-17.5). The average period from injury to surgery was 8.3 months (4-13). Patients underwent vascularized bone grafting and internal fixation with K-wires. In 6 patients with proximal pole nonunion a VBG from the dorsal distal radius was used, and in 7 with a waist nonunion a VBG from the palmar distal radius was used. The valuation was clinical (grip strength, range of motion, VAS pain score, DASH) and radiographic. The time to return to activity was also recorded. RESULTS: The mean follow-up was 9.8 years (range, 4-16). The union rate was 100% (11/11 cases). Union was achieved in a mean period of 7.2 weeks (range, 6-10), without growth disturbance or other complications from the epiphyseal plate of the distal radius. The range of motion and grip strength was 89% and 92% of the contralateral respectively. The mean postoperative DASH score was 8 and the VAS score was 1. All patients returned to daily activities and sports in a mean period of 4.5 months. CONCLUSIONS: The use of VBG from the distal radius provided a permanent solution in the rare case of SN in adolescents, without donor site morbidity or epiphyseal plate disturbance. The deformity and carpal height were corrected resulting in painless motion and grip strength.


Assuntos
Transplante Ósseo/métodos , Fixação Interna de Fraturas/métodos , Consolidação da Fratura , Fraturas Ósseas/cirurgia , Fraturas não Consolidadas/cirurgia , Rádio (Anatomia)/transplante , Osso Escafoide/lesões , Adolescente , Adulto , Fios Ortopédicos , Seguimentos , Força da Mão , Humanos , Masculino , Radiografia , Amplitude de Movimento Articular , Osso Escafoide/cirurgia , Resultado do Tratamento , Escala Visual Analógica , Adulto Jovem
5.
Eur J Orthop Surg Traumatol ; 29(2): 337-342, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30474741

RESUMO

PURPOSE: We retrospectively reviewed the results of 89 patients with proximal pole scaphoid nonunion, 58 with avascular necrosis, treated with a capsular-based vascularized distal radius graft. METHODS: Seventy-one male and eighteen female patients with symptomatic nonunion at the proximal pole of the scaphoid were included in this study. No patient had a humpback deformity. In all patients, the vascularized bone graft was harvested from the dorsum of the distal radius and was attached to a capsular flap of the dorsal wrist capsule. After fixation of the scaphoid with a small cannulated screw, the graft was inserted press-fit into the scaphoid trough in the nonunion site. Supplementary fixation of the graft with a microsuture anchor into the scaphoid was used in 66 patients. RESULTS: At a mean time of 12.3 weeks (range 6-24) after surgery, solid union was achieved in 76 of 89 patients (49 of 58 with avascular necrosis). Eleven patients had persistent nonunion and two fibrous union as determined by CT scan. Sixty-six of the patients with solid bone union were completely pain free, and ten complained of slight pain with strenuous activities. No donor site morbidity was observed. CONCLUSIONS: The capsular-based vascularized bone graft from the distal radius is a reliable alternative technique for scaphoid nonunions. It is a simple and expedient harvesting technique without the need for a microsurgical anastomoses. The supplemental fixation with a microsuture anchor eliminates the risk of graft displacement.


Assuntos
Fraturas Ósseas/cirurgia , Fraturas não Consolidadas/cirurgia , Rádio (Anatomia)/transplante , Osso Escafoide/lesões , Traumatismos do Punho/cirurgia , Articulação do Punho/fisiopatologia , Adulto , Autoenxertos/irrigação sanguínea , Feminino , Fraturas Ósseas/complicações , Fraturas Ósseas/fisiopatologia , Fraturas não Consolidadas/fisiopatologia , Força da Mão , Humanos , Cápsula Articular/irrigação sanguínea , Masculino , Procedimentos Ortopédicos/instrumentação , Procedimentos Ortopédicos/métodos , Osteonecrose/etiologia , Amplitude de Movimento Articular , Estudos Retrospectivos , Osso Escafoide/irrigação sanguínea , Traumatismos do Punho/fisiopatologia , Articulação do Punho/irrigação sanguínea , Adulto Jovem
6.
J Hand Surg Am ; 42(12): 1032.e1-1032.e7, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28888570

RESUMO

PURPOSE: To evaluate the outcome of revision surgery for failed thumb carpometacarpal (CMC) arthroplasty. METHODS: We retrospectively analyzed 32 patients with failed thumb CMC arthroplasty. The primary reason for revision was pain caused by metacarpal subsidence. Revision surgery included soft tissue interposition and distraction pinning to address the metacarpal subsidence. Additional ligament reconstruction was performed in patients with thumb instability. Eight patients required additional metacarpophalangeal joint fusion for concomitant joint hyperextension. Eleven required additional partial excision of the trapezoid for concomitant scaphotrapezoidal joint arthritis. All patients were evaluated clinically and radiographically. RESULTS: Mean follow-up was 57 months (range, 24-121 months). Pain levels evaluated by visual analog scale were significantly reduced in all patients after revision surgery. Mean grip strength and key pinch strength significantly increased. Twenty-seven patients achieved good functional results; those for 5 patients were fair. CONCLUSIONS: This study showed that revision surgery with distraction pinning and soft tissue interposition with or without ligament reconstruction was an effective treatment for failed CMC arthroplasty of the thumb. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.


Assuntos
Artrite/cirurgia , Artroplastia , Articulações Carpometacarpais , Reoperação , Polegar , Adulto , Artrite/diagnóstico por imagem , Artrite/etiologia , Feminino , Força da Mão , Humanos , Masculino , Pessoa de Meia-Idade , Amplitude de Movimento Articular , Estudos Retrospectivos , Resultado do Tratamento
7.
J Hand Surg Am ; 42(11): 889-893, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28802534

RESUMO

PURPOSE: To determine whether open cheilectomy and debridement of the distal interphalangeal (DIP) joint is a safe and effective alternative to joint arthrodesis for the treatment of symptomatic osteoarthritis. METHODS: Seventy-eight patients with symptomatic DIP joint osteoarthritis and with a minimum follow-up of 24 months were retrospectively reviewed. Preoperative radiographs were graded. Open cheilectomy and debridement of the DIP joint was performed in all patients. The DIP joint was immobilized for 4 weeks after surgery. Patients were evaluated clinically and radiographically. Visual analog scale pain scores and range of motion were assessed. RESULTS: At a median final follow-up of 36 months (minimum, 24 months), there was a significant improvement in mean visual analog scale pain scores from 8 to 1. Distal interphalangeal joint flexion contracture was improved by a mean of 6° and DIP joint range of motion was improved by a mean of 20°. No postoperative infections or other complication were noted. No reoperations were required/performed during the follow-up period. CONCLUSIONS: Open DIP joint cheilectomy is a safe and effective alternative to DIP joint arthrodesis in patients with symptomatic osteoarthritis who wish to preserve joint motion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.


Assuntos
Articulações dos Dedos/cirurgia , Osteoartrite/cirurgia , Osteotomia/métodos , Amplitude de Movimento Articular/fisiologia , Idoso , Artrodese/métodos , Estudos de Coortes , Desbridamento/métodos , Feminino , Articulações dos Dedos/diagnóstico por imagem , Força da Mão , Humanos , Masculino , Pessoa de Meia-Idade , Osteoartrite/diagnóstico por imagem , Medição da Dor , Prognóstico , Radiografia/métodos , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Resultado do Tratamento
8.
Instr Course Lect ; 66: 91-101, 2017 Feb 15.
Artigo em Inglês | MEDLINE | ID: mdl-28594491

RESUMO

Cubital tunnel syndrome is the most common cause of symptomatic ulnar neuropathy. The unique anatomic course of the ulnar nerve around the elbow makes it particularly vulnerable at a location far from its terminal destination. The natural progression of cubital tunnel syndrome allows patients who have mild symptoms to be adequately treated nonsurgically. Minor changes in activity combined with appropriate splinting may acceptably alleviate symptoms. Surgical intervention is recommended for patients who have more severe symptoms. Current data confirm that in situ ulnar nerve decompression, partial medial epicondylectomy, and anterior transposition result in equal success rates; however, more invasive techniques may increase the risk for complications. If primary surgical intervention fails, revision surgery can provide good results. Modern techniques for revision surgery incorporate the placement of a protective circumferential barrier around the pathologic nerve to mitigate cicatrix formation. Although several attractive options are currently available for the management of cubital tunnel syndrome, further research is necessary to guide treatment.


Assuntos
Síndrome do Túnel Ulnar , Descompressão Cirúrgica , Síndrome do Túnel Ulnar/cirurgia , Cotovelo , Humanos , Reoperação , Nervo Ulnar/cirurgia
9.
JBJS Essent Surg Tech ; 7(1): e3, 2017 Mar 27.
Artigo em Inglês | MEDLINE | ID: mdl-30233938

RESUMO

INTRODUCTION: The step-cut ulnar shortening osteotomy for the treatment of ulnar impaction syndrome is a safe, reliable, and less expensive technique that uses a 7-hole 3.5-mm standard neutralization plate and a lag screw for fixation, thus avoiding the need for the special instrumentation that other ulnar shortening techniques require. STEP 1 PREOPERATIVE PLANNING: Perform a physical examination and obtain imaging studies to identify all associated abnormalities. STEP 2 WRIST ARTHROSCOPY VIDEO 1: Verify the diagnosis of ulnar impaction syndrome and treat concurrent intra-articular abnormalities. STEP 3 INCISION FOR THE ULNAR SHORTENING OSTEOTOMY VIDEO 2: Make a longitudinal skin incision along the distal third of the ulna. STEP 4 DESIGN THE STEP-CUT ULNAR SHORTENING OSTEOTOMY VIDEO 2: Design the step-cut ulnar shortening osteotomy. STEP 5 PERFORM THE STEP-CUT ULNAR SHORTENING OSTEOTOMY VIDEO 2: Create the step-cut ulnar shortening osteotomy using an oscillating saw. STEP 6 FIXATION OF THE OSTEOTOMY VIDEO 3: Fix the osteotomy with a lag screw and volar plate. STEP 7 WOUND CLOSURE: Meticulously close the wound in layers. STEP 8 POSTOPERATIVE CARE: Protect the affected arm for the first 6 weeks. RESULTS: In our original study, 164 patients with symptomatic ulnar impaction syndrome were treated with a step-cut ulnar shortening osteotomy using a volar 3.5-mm standard neutralization plate and a lag screw14.

10.
J Bone Joint Surg Am ; 98(21): 1814-1820, 2016 Nov 02.
Artigo em Inglês | MEDLINE | ID: mdl-27807114

RESUMO

BACKGROUND: Extra-articular ulnar shortening osteotomy is a common procedure for the surgical treatment of ulnar impaction syndrome. Several techniques for this osteotomy have been developed to avoid the morbidity associated with a standard transverse osteotomy. However, these techniques require special instrumentation and are expensive. The purpose of this study was to evaluate the outcome of step-cut ulnar shortening osteotomy without special jigs for ulnar impaction syndrome. METHODS: A retrospective study of 164 consecutive patients who underwent step-cut ulnar shortening osteotomy between 2000 and 2010 was performed. The long arm of the step-cut osteotomy was oriented in the coronal plane parallel to the long axis of the ulna. The short arms of the osteotomy were perpendicular to the long axis in the axial plane. Fixation was performed with a palmar 3.5-mm standard neutralization plate and a lag screw. The goal of the osteotomy was to reduce ulnar variance, which was assessed in all patients with pronated grip-view radiographs preoperatively and postoperatively. Preoperative ulnar variance ranged from +1 to +6 mm. RESULTS: All patients were followed for at least 24 months. Union of the osteotomy site was achieved at a mean of 8.2 weeks. The union rate was 98.8%. There were 2 cases of nonunion, which required additional surgery. The mean postoperative ulnar variance was +0.2 mm (range, -1 to +1.5 mm) after a mean overall ulnar shortening of 2.5 mm. All patients returned to their previous work, in a mean of 4 months. The plate was removed from 12 patients because of plate-related symptoms. No other complications were encountered. CONCLUSIONS: The step-cut ulnar shortening osteotomy provides ample bone-to-bone contact and simplifies control of rotation. Stable internal fixation with standard techniques allowed an early return to functional activities. Palmar placement of the plate diminishes the need for plate removal. This is a simple and less expensive technique for ulnar shortening that does not require the use of special instrumentation in patients with ulnar impaction syndrome. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Doenças Ósseas/cirurgia , Osteotomia/métodos , Ulna/cirurgia , Adolescente , Adulto , Artroscopia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Articulação do Punho/cirurgia , Adulto Jovem
11.
J Shoulder Elbow Surg ; 25(3): 355-61, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26927431

RESUMO

BACKGROUND: Currently, there are many techniques used in the surgical release of elbow contracture, but no single technique has gained widespread acceptance. The purpose of this study was to report the outcomes of a lateral-column approach combined with a mini-open triceps-splitting technique for elbow contracture release. METHODS: Thirty-six patients with a mean age of 39 years were included in the study. All patients underwent a combined lateral and minimal posterior triceps-splitting open elbow contracture release. Elbow range of motion and visual analog scale pain scores were recorded. The Mayo Elbow Performance Score was used to assess functional outcome. RESULTS: The mean follow-up period was 38 months. Mean pain levels decreased from 7.59 preoperatively to 0.44 postoperatively (P < .05). The total arc of elbow motion increased from 52° preoperatively to 109° postoperatively, with an improvement of 57° (P < .05). The Mayo Elbow Performance Score improved from 44.17 preoperatively to 90.83 postoperatively (P < .05). CONCLUSION: This study shows that a combined lateral and mini-open triceps-splitting approach is a safe and effective alternative technique for the treatment of elbow contractures.


Assuntos
Contratura/cirurgia , Articulação do Cotovelo/cirurgia , Artropatias/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Músculo Esquelético/cirurgia , Procedimentos Ortopédicos/métodos , Amplitude de Movimento Articular/fisiologia , Adulto , Articulação do Cotovelo/fisiopatologia , Feminino , Humanos , Artropatias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Músculo Esquelético/fisiopatologia , Adulto Jovem
12.
J Wrist Surg ; 4(3): 174-8, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26261742

RESUMO

Background Combined scaphoid and capitate fractures of the wrist are rare entities, and delayed diagnosis is frequent. Scaphocapitate fractures may be associated with reversal of the capitate head 90° or 180° (Fenton syndrome). Different treatment options have been proposed, with variable results. Case Description We report two cases of scaphocapitate fractures of the wrist, diagnosed 3 and 15 days after the injury. The first patient suffered from Fenton syndrome, a combined displaced fracture of the waist of the scaphoid with 180° reversal of capitate head. The second patient had combined fractures of the scaphoid, capitate, and distal radius. In both our cases, anatomic reduction and internal fixation were achieved, resulting in union of all fractures. The long-term results, after 5.5 and 7 years respectively, were very satisfactory, both clinically and radiographically, without signs of avascular necrosis of the head of the capitate or the scaphoid. Literature Review Few reports of scaphocapitate fractures were found in literature. Mechanism of injury, treatment, and outcomes of the reported cases in correlation to our cases are discussed. Clinical Relevance Given the high rate of complications of scaphocapitate fractures, long-term follow-up is important to assess the natural history of the wrist joint after such injuries. The restoration of normal anatomic relationships can lead to a successful long-term functional outcome despite the severity of the injury.

13.
BMC Musculoskelet Disord ; 16: 138, 2015 Jun 07.
Artigo em Inglês | MEDLINE | ID: mdl-26049932

RESUMO

BACKGROUND: Dupuytren's disease (DD) is a slow, progressive fibroproliferative disorder affecting the palms of the hands. The disease is characterized by the formation of collagen rich- cords which gradually shorten by the action of myofibroblasts resulting in finger contractures. It is a disease that is confined to humans, and a major limiting factor in investigating this disorder has been the lack of a faithful animal model that can recapitulate its distinct biology. The aim of this study was to develop such a model by determining if Dupuytren's disease (DD)- and control carpal tunnel (CT)-derived fibroblasts could survive in the forepaw of the nude rats and continue to exhibit the distinct characteristics they display in in vitro cultures. METHODS: 1x10(7) fluorescently labeled DD- and CT-derived fibroblasts were transplanted into the left and right forepaws of nude rats respectively. Cells were tracked at regular intervals for a period of two months by quantifying emitted fluorescent signal using an IVIS imaging system. After a period of 62 days rat forepaw connective tissues were harvested for histology and total RNA was isolated. Human-specific probes were used to perform real time RT-PCR assays to examine the expression patterns of gene products associated with fibrosis in DD. Rat forepaw skin was also harvested to serve as an internal control. RESULTS: Both CT- and DD-derived fibroblasts survived for a period of 62 days, but DD-derived cells showed a significantly greater level of persistent fluorescent signal at the end of this time than did CT-derived cells. mRNA expression levels of α-smooth muscle actin (α-SMA), type I- and type III- collagens were all significantly elevated in the forepaw receiving DD cord-derived fibroblasts in comparison to CT-derived fibroblasts. Masson's trichrome stain confirmed increased collagen deposition in the forepaw that was injected with DD cord-derived fibroblasts. CONCLUSIONS: For the first time we describe an animal model for Dupuytren's disease at the orthotopic anatomical location. We further show that gene expression differences between control (CT) and diseased (DD) derived fibroblasts persist when these cells are transplanted to the forepaw of the nude rat. These preliminary findings indicate that, with further refinements, this animal model holds promise as a baseline for investigating novel therapeutic regimens to determine an effective strategy in treating DD.


Assuntos
Contratura de Dupuytren/etiologia , Fibroblastos/transplante , Membro Anterior/cirurgia , Actinas/genética , Actinas/metabolismo , Animais , Estudos de Casos e Controles , Células Cultivadas , Colágeno Tipo I/genética , Colágeno Tipo I/metabolismo , Colágeno Tipo III/genética , Colágeno Tipo III/metabolismo , Modelos Animais de Doenças , Contratura de Dupuytren/genética , Contratura de Dupuytren/metabolismo , Contratura de Dupuytren/patologia , Fibroblastos/metabolismo , Fibroblastos/patologia , Membro Anterior/metabolismo , Membro Anterior/patologia , Humanos , Masculino , Fenótipo , RNA Mensageiro/metabolismo , Ratos Nus , Fatores de Tempo , Regulação para Cima
14.
J Hand Surg Am ; 40(5): 987-92, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-25911210

RESUMO

PURPOSE: To evaluate the clinical results of revision neurolysis and wrapping with porcine extracellular matrix (AxoGuard Nerve Protector, AxoGen Inc., Alachua, FL) for cubital tunnel syndrome after one previous surgical decompression. METHODS: Twelve patients with recurrent cubital tunnel syndrome were treated with decompression, porcine extracellular matrix nerve wrap, and minimal medial epicondylectomy (if not previously performed). The average follow-up period was 41 months (range, 24-61 mo). All patients had recurrent symptoms after having previously undergone one surgical decompression. The mean patient age was 45 years (range, 30-58 y). All patients were evaluated subjectively and objectively (pain, satisfaction, static 2-point discrimination, grip strength, and pinch strength). RESULTS: A significant improvement was demonstrated in postoperative pain levels (from 8.5 to 1.7), grip strength (from 41% to 86% of the unaffected side), and pinch strength (from 64% to 83% of the unaffected side). Static 2-point discrimination improved from an average 10.4 mm preoperatively to 7.6 mm postoperatively. Eleven of 12 patients demonstrated 2 mm or more improvement in 2-point discrimination postoperatively. There were no complications related to the use of the porcine extracellular matrix for nerve wrapping. CONCLUSIONS: This study found that secondary decompression combined with porcine extracellular matrix nerve wrapping was an effective and safe treatment for patients with recurrent cubital tunnel syndrome. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.


Assuntos
Bandagens Compressivas , Síndrome do Túnel Ulnar/cirurgia , Matriz Extracelular , Procedimentos Neurocirúrgicos/métodos , Adulto , Animais , Descompressão Cirúrgica , Feminino , Força da Mão , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/instrumentação , Medição da Dor , Satisfação do Paciente , Suínos , Resultado do Tratamento
15.
Instr Course Lect ; 64: 273-80, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25745913

RESUMO

Although open and endoscopic techniques for carpal tunnel release can provide excellent results, neither technique has demonstrated clinical superiority. A permanent nerve injury remains the most devastating complication regardless of the technique used. Symptoms in carpal tunnel syndrome recur in up to 30% of patients, usually secondary to scarring of the median nerve. Repeated nerve decompression alone does not always provide satisfactory results in patients with recalcitrant carpal tunnel syndrome. Supplementary techniques with either biologic or synthetic adhesion barriers can be used to cover the nerve, improving functional recovery and preventing recurrent scarring. Direct end-to-end repair without tension remains the gold standard treatment of peripheral nerve lacerations. When primary repair is not possible, biologic or synthetic nerve conduits and nerve allografts are an alternative to autografts. Future advances in bioengineering and better understanding of nerve biology combined with randomized, multicenter, larger studies may lead to the optimal method of peripheral nerve reconstruction.


Assuntos
Síndrome do Túnel Carpal/cirurgia , Descompressão Cirúrgica/métodos , Endoscopia/métodos , Nervo Mediano/cirurgia , Procedimentos de Cirurgia Plástica , Guias de Prática Clínica como Assunto , Humanos
17.
J Shoulder Elbow Surg ; 23(6): 861-6, 2014 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-24766790

RESUMO

BACKGROUND: Currently, no technique has met general acceptance for the restoration of forearm longitudinal stability in chronic Essex-Lopresti injuries. The purpose of this study is to present an alternative treatment method for chronic Essex-Lopresti lesions by radial head replacement and ulnar shortening osteotomy. METHODS: Seven patients with a mean age of 42.4 years were included in the study. Five patients had a staged approach, and 2 underwent both procedures simultaneously. The pain level was assessed with the use of a visual analog scale. Elbow, forearm, and wrist range of motion was evaluated. The Mayo Elbow Performance Score and Mayo Wrist Score were used to assess the postoperative outcomes. RESULTS: The mean follow-up time was 33 months. The mean pain level was reduced from 8.4 points preoperatively to 3.3 points postoperatively (P < .05). The elbow arc of motion was increased on average from 79° preoperatively to 121° postoperatively (P < .05). Forearm rotation improved from 76° preoperatively to 119° postoperatively (P < .05). The wrist arc of motion improved from 94° preoperatively to 114° postoperatively (P < .05). The mean postoperative Mayo Elbow Performance Score and Mayo Wrist Score were 82 points and 71 points, respectively. The mean ulnar variance was reduced from +8 mm to +3.5 mm postoperatively. CONCLUSION: This study shows that radial head replacement in combination with ulnar shortening osteotomy can be used as an alternative reconstructive procedure in the case of a complex chronic Essex-Lopresti injury. This combination of known procedures yields predictable and satisfactory outcomes and a low complication rate. LEVEL OF EVIDENCE: Level IV, case series, treatment study.


Assuntos
Traumatismos do Antebraço/cirurgia , Fraturas do Rádio/cirurgia , Ulna/cirurgia , Traumatismos do Punho/cirurgia , Adulto , Doença Crônica , Articulação do Cotovelo/cirurgia , Feminino , Fraturas Cominutivas/diagnóstico por imagem , Fraturas Cominutivas/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Osteotomia , Radiografia , Fraturas do Rádio/diagnóstico por imagem , Amplitude de Movimento Articular , Resultado do Tratamento , Ulna/lesões , Lesões no Cotovelo
18.
J Hand Surg Am ; 39(5): 872-9, 2014 May.
Artigo em Inglês | MEDLINE | ID: mdl-24656393

RESUMO

PURPOSE: To determine the outcome of an alternative treatment for wrists with stages I to III scaphoid nonunion advanced collapse using a closing-wedge osteotomy of the distal radius and a vascularized bone graft for scaphoid reconstruction. METHODS: Twelve patients with scaphoid nonunion advanced collapse (stage I, 3; stage II, 7; stage III, 2) treated with a vascularized bone graft interposition for the scaphoid and a closing-wedge osteotomy for the distal radius were retrospectively reviewed. Data were obtained and analyzed from the radiographs, and we assessed the pre- and postoperative range of motion, grip strength, visual analog scale pain score, as well as the Mayo and Disabilities of the Arm, Shoulder, and Hand (DASH) functional scores. RESULTS: Follow-up ranged from 2 to 11 years. All scaphoid nonunions united after an average of 9 weeks, and all osteotomies united after an average of 8 weeks. Although there was radiographic progression of the scaphoid nonunion advanced collapse stage in 5 of 12 cases, there was major improvement in visual analog scale pain score (from 6.1 to 0.8) and in both Mayo (from 64 to 85) and DASH (from 40 to 9) functional scores. The range of motion remained unchanged, and grip strength trended toward minor improvement. The carpal height was preserved, and the dorsal intercalated segmental instability was corrected. CONCLUSIONS: Scaphoid reconstruction with vascularized bone graft combined with closing-wedge distal radius osteotomy preserved wrist function for scaphoid nonunion advanced collapse. The method offers pain relief and does not compromise wrist motion or grip strength. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.


Assuntos
Transplante Ósseo/métodos , Fixação Interna de Fraturas/métodos , Fraturas não Consolidadas/cirurgia , Osteotomia/métodos , Rádio (Anatomia)/transplante , Osso Escafoide/lesões , Adulto , Avaliação da Deficiência , Feminino , Humanos , Masculino , Medição da Dor , Rádio (Anatomia)/irrigação sanguínea , Estudos Retrospectivos , Resultado do Tratamento
19.
Clin Orthop Relat Res ; 472(7): 2084-91, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-24474322

RESUMO

BACKGROUND: The "terrible triad" of the elbow is a complex injury that can lead to pain, stiffness, and posttraumatic arthritis if not appropriately treated. The primary goal of surgery for these injuries is to restore stability of the joint sufficient to permit early motion. Although most reports recommend repair and/or replacement of all coronoid and radial head fractures when possible, a recent cadaveric study demonstrated that type II coronoid fractures are stable unless the radial head is removed and not replaced. QUESTIONS/PURPOSES: The purposes of this study were to determine the (1) range of motion; (2) clinical scores using the Disabilities of the Arm, Shoulder and Hand (DASH) and the Broberg-Morrey questionnaires; and (3) rate of arthritic changes, heterotopic ossification (HO), or elbow instability postoperatively in patients whose terrible triad injuries of the elbow included Reagan-Morrey type I or II coronoid fractures that were treated without fixation. METHODS: Between April 2008 and December 2010, 14 consecutive patients were treated for acute terrible triad injuries that included two Regan-Morrey type I and 12 Regan-Morrey type II coronoid fractures. Based on the senior author's (DGS) clinical experience that coronoid fractures classified as such do not require fixation to restore intraoperative stability to the posterolaterally dislocated elbow, all injuries were treated by the senior author with a surgical protocol that included radial head repair or prosthetic replacement and repair of the lateral ulnar collateral ligament (LUCL) followed by intraoperative fluoroscopic examination through a range of 20° to 130° of elbow flexion to confirm concentric reduction of the ulnohumeral joint. Using this protocol, intraoperative stability was confirmed in all cases without any attempt at coronoid or anterior capsular repair. Repair of the medial collateral ligament or application of external fixation was not performed in any case. All patients were available for followup at a minimum of 24 months (mean, 41 months; range, 24-56 months). The mean patient age was 52 years (range, 32-58 years). At the followup all patients were evaluated clinically and radiographically by the senior author. Outcome measures included elbow range of motion, forearm rotation, elbow stability, and radiographic evidence of HO or arthritic changes using the Broberg and Morrey scale. Elbow instability was defined as clinical or radiographic evidence of recurrent ulnohumeral dislocation or subluxation at final followup. Clinical outcomes were assessed with the patient-reported DASH questionnaire and the physician-administered Broberg-Morrey elbow rating system. RESULTS: The mean arc of ulnohumeral motion at final followup was 123° (range, 75°-140°) and mean forearm rotation was 145° (range, 70°-170°). The mean Broberg and Morrey score was 90 of 100 (range, 70-100, higher scores reflecting better results) and the average DASH score was 14 of 100 (range, 0-38, higher scores reflecting poorer results). Radiographs revealed mild arthritic changes in one patient. One patient developed radiographically apparent but asymptomatic HO. None of the patients demonstrated instability postoperatively. CONCLUSIONS: These findings demonstrate that terrible triad injuries with type I and II coronoid process fractures can be effectively treated without fixation of coronoid fractures when repair or replacement of the radial head fracture and reconstruction of the LUCL complex sufficiently restores intraoperative stability of the elbow through a functional range of motion. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines to Authors for a complete description of levels of evidence.


Assuntos
Artroplastia de Substituição do Cotovelo , Articulação do Cotovelo/cirurgia , Fixação Interna de Fraturas , Luxações Articulares/cirurgia , Instabilidade Articular/cirurgia , Fraturas do Rádio/cirurgia , Rádio (Anatomia)/cirurgia , Adulto , Artrite/etiologia , Artroplastia de Substituição do Cotovelo/efeitos adversos , Fenômenos Biomecânicos , Ligamentos Colaterais/fisiopatologia , Ligamentos Colaterais/cirurgia , Avaliação da Deficiência , Articulação do Cotovelo/diagnóstico por imagem , Articulação do Cotovelo/fisiopatologia , Feminino , Fixação Interna de Fraturas/efeitos adversos , Humanos , Luxações Articulares/diagnóstico , Luxações Articulares/fisiopatologia , Instabilidade Articular/diagnóstico , Instabilidade Articular/fisiopatologia , Masculino , Pessoa de Meia-Idade , Ossificação Heterotópica/etiologia , Radiografia , Rádio (Anatomia)/diagnóstico por imagem , Rádio (Anatomia)/lesões , Rádio (Anatomia)/fisiopatologia , Fraturas do Rádio/diagnóstico , Fraturas do Rádio/fisiopatologia , Amplitude de Movimento Articular , Recuperação de Função Fisiológica , Estudos Retrospectivos , Inquéritos e Questionários , Resultado do Tratamento , Lesões no Cotovelo
20.
Exp Mol Pathol ; 96(1): 9-14, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-24200492

RESUMO

INTRODUCTION: Femoral head avascular necrosis (AVN) is a recalcitrant disease of the hip that leads to joint destruction. Osteoprotegerin (OPG), Receptor Activator of Nuclear Factor kappa-B (RANK) and RANK ligand (RANKL) regulate the balance between osteoclasts-osteoblasts. The expression of these genes affects the maturation and function of osteoblasts-osteoclasts and bone remodeling. In this study, we investigated the molecular pathways leading to AVN by studying the expression profile of OPG, RANK and RANKL genes. MATERIAL AND METHODS: Quantitative Real Time-PCR was performed for evaluation of OPG, RANK and RANKL expression. Analysis was based on parallel evaluation of mRNA and protein levels in normal/necrotic sites of 42 osteonecrotic femoral heads (FHs). OPG and RANKL protein levels were estimated by western blotting. RESULTS: The OPG mRNA levels were higher (insignificantly) in the necrotic than the normal site (p > 0.05). Although the expression of RANK and RANKL was significantly lower than OPG in both sites, RANK and RANKL mRNA levels were higher in the necrotic part than the normal (p < 0.05). Protein levels of OPG and RANKL showed no remarkable divergence. CONCLUSIONS: Our results indicate that differential expression mechanisms for OPG, RANK and RANKL that could play an important role in the progress of bone remodeling in the necrotic area, disturbing bone homeostasis. This finding may have an effect on the resulting bone destruction and the subsequent collapse of the hip joint.


Assuntos
Necrose da Cabeça do Fêmur/genética , Osteoprotegerina/genética , Ligante RANK/genética , Receptor Ativador de Fator Nuclear kappa-B/genética , Adulto , Idoso , Western Blotting , Feminino , Necrose da Cabeça do Fêmur/metabolismo , Necrose da Cabeça do Fêmur/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Osteoprotegerina/metabolismo , Ligante RANK/metabolismo , RNA Mensageiro/genética , Reação em Cadeia da Polimerase em Tempo Real , Receptor Ativador de Fator Nuclear kappa-B/metabolismo , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Adulto Jovem
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