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OBJECTIVES 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.

Background The external rotation and abduction of shoulder are considered one of the priorities of reconstruction in brachial plexus injury. The aim of this study was to evaluate the functional results and complications of shoulder arthrodesis in patients with brachial plexus injury to better comprehend the benefits of this procedure. Methods Between 2015 and 2019, 15 shoulder arthrodesis were performed in patients with long-standing brachial plexus injury. The main indication for arthrodesis was absent or poor recovery of shoulder abduction and external rotation. Patients presented different levels of injury. Shoulder measurements of active abduction and external rotation were made based on image records of the patients. A long 4.5-mm reconstruction plate was fit along the scapular spine, acromion, and lateral proximal third of the humerus. Structured bone graft was fit into the subacromial space. Results The mean preoperative abduction was 16°, and the mean postoperative abduction was 42°. The mean preoperative external rotation was −59°, and the mean postoperative external rotation was −13°. The mean increase in abduction and external rotation was 25° and 45°, respectively. Bone union was achieved in all cases at an average time of 5.23 months. We experienced humeral fractures in 26.66% of the cases, which were all successfully treated nonoperatively. Conclusions Shoulder arthrodesis is a rewarding procedure for patients with brachial plexus injuries. A marked improvement in the upper limb positioning was observed in all patients. It should be considered as the main therapeutic option in cases where nerve reconstruction is no longer possible.

BACKGROUND: Microsurgical flaps are widely used to treat complex traumatic wounds of upper and lower limbs. Few studies have evaluated whether the vascular changes in preoperative computed tomography angiography (CTA) influence the selection of recipient vessel and type of anastomosis and the microsurgical flaps outcomes including complications. OBJECTIVE: The aim of this study was to evaluate if preoperative CTA reduces the occurrence of major complications (revision of the anastomosis, partial or total flap failure, and amputation) of the flaps in upper and lower limb trauma, and to describe and analyze the vascular lesions of the group with CTA and its relationship with complications. METHODS: A retrospective cohort study was undertaken with all 121 consecutive patients submitted to microsurgical flaps for traumatic lower and upper limb, from 2014 to 2020. Patients were divided into two groups: patients with preoperative CTA (CTA+) and patients not submitted to CTA (CTA–). The presence of postoperative complications was assessed and, within CTA+, we also analyzed the number of patent arteries on CTA and described the arterial lesions. RESULTS: Of the 121 flaps evaluated (84 in the lower limb and 37 in the upper limb), 64 patients underwent preoperative CTA. In the CTA+ group, 56% of patients with free flaps for lower limb had complete occlusion of one artery. CTA+ patients had a higher rate of complications (p = 0.031), which may represent a selection bias as the most complex limb injuries and may have CTA indicated more frequently. The highest rate of complications was observed in chronic cases (p = 0.034). There was no statistically significant difference in complications in patients with preoperative vascular injury or the number of patent arteries. CONCLUSIONS: CTA should not be performed routinely, however, CTA may help in surgical planning, especially in complex cases of high-energy and chronic cases, since it provides information on the best recipient artery and the adequate level to perform the microanastomosis, outside the lesion area.

Objective: Brachial plexus injury can lead to significant functional deficit for the patient. Elbow flexion restoration is a priority in surgical treatment. Free functional muscle transfer is an option for early or late treatment failure. This study evaluated patient characteristics and elbow flexion muscle strength after gracilis functioning muscle transfer. Methods: Medical records of 95 patients operated from 2003 to 2019 were analyzed and the following variables recorded: age, gender, nerve transfer used to motorize the gracilis muscle, time between trauma and surgery, age at surgery and elbow flexion strength after a minimum of 12 months following functioning muscle transfer. Results: 87 patients were included, averaging 30 years of age (17 to 57 years). Fifty-five achieved elbow flexion muscle strength ≥ M3 (55/87, 65%), with a mean follow-up of 37 months. The nerves used for activation of the transferred gracilis were: 45 spinal accessory, 10 intercostal, 8 median n. fascicles, 22 ulnar n. fascicles and 2 phrenic nerves. Conclusion: Functional muscle transfer is a viable surgical procedure for elbow flexion in chronic traumatic brachial plexus injuries in adults. Level of Evidence II, Retrospective study. RESUMO Objetivo: A lesão do plexo braquial pode determinar sequelas para o paciente. A restituição da flexão do cotovelo é prioridade no tratamento cirúrgico. A transferência muscular funcional livre é opção na falha do tratamento precoce ou tardio. Este estudo avaliou características dos pacientes e força muscular de flexão do cotovelo após transferência muscular funcional livre. Métodos: Prontuários de 95 pacientes, operados de 2003 a 2019, foram analisados e as seguintes variáveis registradas: idade, sexo, transferência nervosa utilizada para motorizar o músculo grácil, tempo entre o trauma e a cirurgia, idade na cirurgia, força de flexão do cotovelo após prazo mínimo de 12 meses da transferência muscular livre. Resultados: 87 pacientes foram incluídos no estudo, com idade média de 30 anos (17 a 57 anos). Cinquenta e cinco pacientes obtiveram força muscular de flexão de cotovelo ≥ M3 (55/87, 65%), com tempo de seguimento médio pós-operatório de 37 meses. Os nervos utilizados para ativação do músculo grácil foram: 45 espinhais acessórios, 10 intercostais, oito fascículos do n. mediano, 22 fascículos do n. ulnar e dois frênicos. Conclusão: A transferência muscular funcional livre é um procedimento cirúrgico viável para flexão do cotovelo nas lesões traumáticas crônicas do plexo braquial no adulto. Nível de Evidência II, Estudo retrospectivo .

Background: Oberlin et al presented a new technique for nerve transfer that completely changed the prognosis of patients with brachial plexus injury. Currently, most of the literature addresses cases submitted to early surgical intervention, before 12 months from injury, showing consistent good results. The aim of this study was to evaluate the feasibility of the Oberlin procedure in late presentation cases (≥12 months), comparing the elbow flexion strength with patients operated earlier. Methods: We retrospectively reviewed 49 patients with partial brachial plexus injuries submitted to the Oberlin procedure. They were divided into 2 groups. Group A included 39 patients operated with

In upper and chronic brachial plexus injuries for which neurological surgery is not a good treatment option, one possibility for gaining elbow flexion is free functional muscle transfer. The primary aim of our study was to evaluate the elbow flexion gain achieved by free gracilis muscle transfer with partial ulnar nerve neurotization. This surgery was performed in 21 patients with upper and chronic (> 12 months) brachial plexus injuries. The level of injury, patient age, the time between trauma and surgery, the affected side, and the aetiology of the lesion were recorded. The primary outcome evaluated was elbow flexion muscle strength, which was measured using the British Medical Research Council (BMRC) scale, in patients with a minimum follow-up period of 12 months. The criterion used to classify elbow flexion as good was a grade of M4 or higher. An M4 elbow flexion strength gain was observed in 61.9% of the patients. A gain of M2 or higher was observed in 95.2% of the patients. The mean range of active motion was 77° (range 10 minimum–110 maximum). In patients with upper and chronic brachial plexus injuries, free gracilis muscle transfer with ulnar nerve neurotization yields a satisfactory gain in elbow flexion strength and is therefore a good treatment option.

To compare magnetic resonance imaging and intraoperative findings in patients diagnosed with traumatic injury to the brachial plexus.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).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.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.Comparar resultados de ressonância magnética e achados intraoperatórios de pacientes com diagnóstico de lesão traumática do plexo braquial.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).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.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.

Indication of free tissue transfer for limb reconstruction continues to grow, and despite the good results with this treatment option, complications can impair the functional results and cause a raise in health costs, with prolonged hospitalization. Therefore, peri-operative surgical information and comorbidities were described and analyzed, for identification of independent risk factors for complications of free flaps results for traumatic wounds. For our knowledge, intraoperative ischemia time of free flap was not previously studied for post-traumatic limb reconstruction, which could influence results, in these traumatic cases, with the highest rates of complications among microsurgical flap reconstructions. From July 2014 to January 2017, all patients with free flaps for limb reconstruction were consecutively included. Data on personal medical history, intra-operative microsurgical procedure, and laboratory tests were collected and complications analyzed. Descriptive and inferential statistics were performed. Sixty-two free flaps for traumatic limb reconstruction in 60 patients were studied. We observed a higher rate of complications in patients who underwent surgery > seven days after the trauma, patients with obesity, when used recipient veins from the superficial system for drainage of the flap, and in those in whom the ischemia time of the free flap was higher in univariate analyzes. After logistic regression, the remaining independent risk factors for complications were ischemia time of free flap > two hours and obesity. The presence of thrombocytosis was associated with partial flap loss. The independent risk factors for complications were ischemia time of free flap > two hours and obesity.

BACKGROUND The optimal number of veins to be anastomosed in perforator flaps for limb reconstruction and its influence on the results remain controversial. Venous thrombosis of microvascular anastomoses is a commonly recorded complication in soft tissue reconstruction. OBJECTIVE To evaluate the effect of two venous anastomoses in the incidence of venous thrombosis for limb reconstruction using anterolateral thigh (ALT) microsurgical free flaps. METHODS This was a cross-sectional study on patients undergoing limb reconstruction using ALT flap during 2014-2017. Perioperative information was recorded and patients were divided in two groups: group 1 (one venous anastomosis; 17 patients) and group 2 (two venous anastomoses; 21 patients). Complications were investigated. RESULTS Overall, 38 microsurgical flaps were included. The mean age was 33 years, and 32 patients were male. The most prevalent wounds were traumatic. Group 1 presented a higher complication rate than group 2 (47% vs. 24%; p = 0.065), although the difference was not significant. Group 1 presented a higher rate of venous anastomotic thrombosis (p = 0.032) than group 2. The overall success rate was 92%. CONCLUSION For limb reconstruction using ALT microsurgical free flaps, two venous anastomoses are associated with a low rate of venous thrombosis in microvascular anastomoses.

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.

Purpose Although a reasonable number of studies report satisfactory results with fibrin glue application in microvascular anastomosis since 1977, its utilization in the clinical setting has being scant in the literature. The aim of this study was to report the cumulated experience with the fibrin glue in free flaps over a period of 10 years, comparing the survival rate with the standard sutured anastomosis. Patients and methods From August 2001 through November 2014, 83 consecutive free flaps were performed by a team of surgeons from two hospitals. About 56 flaps were performed in 56 patients using the fibrin glue augmented microvascular anastomosis and 27 flaps were performed in 27 patients using the conventional anastomosis technique. The decision on whether or not the fibrin glue should be used at the anastomoses was based on its availability and whose surgeon was performing the anastomoses. About approximately 60% of sutures stitches were used that would be used in a conventional anastomosis, when fibrin glue application was anticipated (ranging from 5 to 7 sutures in the arteries and 5 to 8 in the veins). Results The overall survival rate of the flaps performed with fibrin glue application was 92.85%. In one case, a revision of the venous anastomosis was required due to early flap congestion. Four cases (7.14%) had failure of the first free flap and two of them were submitted to another free flap without fibrin glue application. In the flaps performed with the conventional anastomosis technique the survival rate was 92.59%. This difference was not statistically significant (P = 0.97). Conclusion The application of fibrin glue in microvascular anastomoses did not increase the rate of flap loss and had a potential to reduce the number of sutures required to complete an anastomosis by its sealing effect. © 2016 Wiley Periodicals, Inc. Microsurgery, 2016.

Objective: To analyze 10 consecutive cases of microsurgical arteriovenous loops created to reconstruct complex injuries from March 2011 to May 2012. Methods: This observational cohort-type study conducted by the Hand and Microsurgery Group at the HC-FMUSP included patients who were candidates for microsurgical reconstruction as a last alternative to amputation of the limb with proven absence of adequate recipient vessels for primary microsurgical anastomosis, in a prospective and consecutive manner. We analyzed 14 variables (epidemiological, clinical, procedure-related, and outcome) in patients who underwent reconstruction using an arteriovenous loop utilizing a single-stage or two-stage procedure. Results: The injuries were mostly traumatic (80%). The success rate of the single-stage procedure was 75%, and 17% for the two-stage procedure. The rate of preservation for the injured limb was 44%. Conclusion: This study reinforces the more recent understanding that the indication for single-stage or two-stage reconstruction should be individualized; our findings favor the single-stage reconstruction. This technique should be used in selected cases, as a last reconstructive alternative before amputation, and further studies are necessary to confirm its safety and efficacy in our practice. Level of Evidence IV; Case series. RESUMO Objetivo: Analisar dez casos consecutivos de alças vasculares microcirúrgicas realizadas para reconstrução de feridas complexas no período de março de 2011 a maio de 2012. Métodos: Estudo de observação, analítico do tipo coorte, realizado pelo Grupo de Mão e Microcirurgia do Instituto de Ortopedia e Traumatologia do HC-FMUSP. Foram incluídos, prospectivamente e de maneira consecutiva, os pacientes candidatos à reconstrução microcirúrgica como última alternativa à amputação do membro, com comprovada ausência de vasos receptores adequados para anastomose microcirúrgica primária. Foram analisadas 14 variáveis (epidemiológicas, clínicas, relacionadas ao procedimento e resultados) nos pacientes submetidos à reconstrução com alça em tempo único e em dois tempos. Resultados: As lesões foram de etiologia traumática em sua maioria (80%). A taxa de sucesso do procedimento em tempo único foi de 75%, e em dois tempos de 17%. A taxa de manutenção do membro lesado foi de 44%. Conclusão: Este estudo reforça o entendimento mais recente de que a indicação de reconstrução em um ou dois tempos deve ser individualizada, e nossos resultados favorecem a reconstrução em tempo único. A técnica deve ser usada em casos selecionados, como última opção reconstrutiva à amputação, sendo necessários mais estudos para atestar sua segurança e eficácia em nosso meio. Nível de Evidência IV; Série de casos.

The purpose of this report is to critically evaluate our results of two intercostal nerve transfers directly to the biceps motor branch in complete traumatic brachial plexus injuries. From January 2007 to November 2012, 19 patients were submitted to this type of surgery, but only 15 of them had a follow-up for ≥2 years and were included in this report. The mean interval from trauma to surgery was 6.88 months (ranging from 3 to 9 months). Two intercostals nerves were dissected and transferred directly to the biceps motor branch. The mean follow-up was 38.06 months (ranging from 24 to 62 months). Ten patients (66.6%) recovered an elbow flexion strength ≥M3. Four of them (26.66%) recovered a stronger elbow flexion ≥M4. One patient (6.25%) recovered an M2 elbow flexion and four patients (26.66%) did not regain any movement. We concluded that two intercostal nerve transfers to the biceps motor branch is a procedure with moderate results regarding elbow flexion recovery, but it is still one of the few options available in complete brachial plexus injuries, especially in five roots avulsion scenario.

Objective: To demonstrate the importance of performing early shoulder tomography in patients with obstetric brachial plexus palsy (OBPP). Methods: This series of cases retrospective study with level evidence IV was conducted by consulting 76 patient's medical records with OBPP divided into three age groups: ≤12 months, 13 to 24 months and ≥ 25 months. The patients were classified according to gender, affected side, type of paralysis according to Narakas classification, and by computed tomography, according to the Waters scale. Results: The association between the age groups with Waters classification was statistically significant (p=0,006), showing that patients in the group aged less than 12 months and in the group aged between 12 and 24 months had a relevant correlation between the physical examination and Waters > III when compared to patients from groups aged 25 months or older. Conclusion: This study shows a correlation between the findings in the physical examination and severe dysplasia on the shoulder of children under 24 months of age, justifying the early tomographic shoulder exam in order to achieve a better follow-up and a consider a more aggressive approach in the treatment of OBPP affected children. Level of Evidence IV, Case Series.

The reverse sural flap has often been used for cutaneous coverage of the distal region of the leg and ankle. When the flap is performed in 2 stages, the vascular pedicle is exteriorized and later resected. Our goal was to assess the reverse sural flap performed in 2 stages regarding its viability and low morbidity along the flap-donor area. Eleven patients with cutaneous coverage loss found in the area between the distal third of the leg and ankle underwent cutaneous coverage surgery with a reverse-flow sural flap with an exteriorized pedicle, without violation of the skin between the base of the flap pedicle to the margin of the wound. After a minimum period of 15 days with flap autonomy, the pedicle was resected. The flap dimensions, its viability before and after the pedicle ligature, and the distance from the intact skin between the flap base and the margin of the wound were evaluated. Any losses were measured as a percentage of the total flap size. The respective length and width of the flap were a mean average of 7.45 cm × 4.18 cm. All the flaps survived. Partial loss of the flap occurred in 3 patients, ranging from 20% to 30%. The mean average distance of the intact skin between the pedicle base and the margin of the wound was 5.59 (range 4 to 8) cm. Our results showed that the 2-stage reverse sural flap ensures good flap survival and low morbidity.

Purpose Elbow flexion deficit is a frequent problem in traumatic brachial plexus injuries and reestablishment of this function is the primary treatment goal. When management is delayed, or the initial acute approach fails, free functional transfer of the gracilis muscle for elbow flexion is the treatment of choice. In this report, the authors present the results of a comparison study on different donor nerves (spinal accessory and ulnar) in elbow flexion reconstruction with gracilis flap for traumatic adult brachial plexus injuries. Methods Retrospective analysis of patients with both total or partial traumatic brachial plexus injuries was carried out. Of the 38 patients enrolled, 37 were male (97.4%) with a mean age of 28.3 years. The mean follow-up period was 25 months. Postoperative function of the gracilis muscle flap was recorded and patients were divided into two groups according to donor nerve: spinal accessory nerve (SAN) (18 cases), and motor fascicles of the ulnar (ULNAR) (20 cases). Results Twenty-six cases obtained elbow flexion strength M3 or M4 (68.4%): 0 M0 (0.0%), 4 M1 (10.5%), 8 M2 (21.1%), 9 M3 (23.7%) and 17 M4 (44.7%). The mean interval to first recorded M3 muscular strength was 12.4 months. Functional elbow flexion strength (≥ M3) had the following distribution: SAN 83.3% (15/18) and ULNAR 55.0% (11/20) (p = .086). Conclusion No statistical difference for final muscle strength was found between donor nerve groups.

OBJECTIVE: Gain in elbow flexion in patients with brachial plexus injury is extremely important. The transfer of a fascicle from the ulnar nerve to the motor branch of the musculocutaneous nerve (Oberlin surgery) is a treatment option. However, in some patients, gain in elbow flexion is associated with wrist and finger flexion. This study aimed to assess the frequency of this association and the functional behavior of the limb. METHODS: Case-control study of 18 patients who underwent the Oberlin surgery. Group 1 included patients without disassociation of range of elbow flexion and that of the fingers and wrist; Group 2 included patients in whom this disassociation was present. In the functional evaluation, the Sollerman and DASH tests were used. RESULTS: It was observed that 38.89% of the patients did not present disassociation of elbow flexion with flexion of the wrist and fingers. Despite the existence of a favorable difference in the group with disassociation of the movement, when the Sollerman protocol was applied to the comparison between both groups, this difference was not statistically significant. With the DASH test, however, there was a statistically significant difference in favor of the group of patients who managed to disassociate the movement. CONCLUSION: The association of elbow flexion with flexion of the wrist and fingers, in the group studied, was shown to be a frequent event, which influenced the functional result of the affected limb. RESUMO OBJETIVO: O ganho da flexão do cotovelo em pacientes com lesão no plexo braquial é de suma importância. A cirurgia de transferência de fascículo do nervo ulnar para ramo motor do nervo musculocutâneo (cirurgia de Oberlin) é uma opção de tratamento. Contudo, o ganho da flexão do cotovelo, em alguns pacientes, vem associado à flexão do punho e dos dedos. O objetivo deste trabalho é avaliar a frequência dessa associação e o comprometimento funcional do membro. MÉTODOS: Estudo tipo caso-controle de 18 pacientes submetidos à cirurgia de Oberlin. No Grupo 1 foram incluídos os pacientes que não apresentavam dissociação do ganho da flexão do cotovelo com a dos dedos e do punho; no Grupo 2, os pacientes em que havia dissociação. Os testes de Sollerman e Disabilities of the Arm, Shoulder and Hand (Dash) foram usados na avaliação funcional. RESULTADOS: Observou-se que 38,89% dos pacientes não dissociavam flexão de cotovelo de flexão de punho e dos dedos. Apesar de existir uma diferença favorável ao grupo que dissociava o movimento quando aplicado o protocolo de Sollerman na comparação entre os pacientes dos dois grupos, essa não se mostrou estatisticamente significante. Já no teste Dash, observou-se diferença estatisticamente significante, favorável ao grupo de pacientes que consegue dissociar o movimento. CONCLUSÃO: A associação da flexão do cotovelo com a flexão de punho e dos dedos no grupo estudado mostrou ser um evento frequente, teve influência no resultado funcional do membro acometido.

The purpose of this study was to observe whether the results of the median nerve fascicle transfer to the biceps are equivalent to the classical ulnar nerve fascicle transfer, in terms of elbow flexion strength and donor nerve morbidity. Twenty-five consecutive patients were operated between March 2007 and July 2013. The patients were divided into two groups. In Group 1 (n = 8), the patients received an ulnar nerve fascicle transfer to the biceps motor branch. In Group 2 (n = 15), the patients received a median nerve fascicle transfer to the biceps motor branch. Two patients with follow-up less than six months were excluded. Both groups were similar regarding age (P = 0.070), interval of injury (P = 0.185), and follow-up period (P = 0.477). Elbow flexion against gravity was achieved in 7 of 8 (87.5%) patients in Group 1, versus 14 of 15 (93.3%) patients in Group 2 (P = 1.000). The level of injury (C5-C6 or C5-C7) did not affect anti-gravity elbow flexion recovery in both the groups (P = 1.000). It was concluded that the median nerve fascicle transfer to the biceps is as good as the ulnar nerve fascicle transfer, even in C5-C7 injuries. © 2014 Wiley Periodicals, Inc. Microsurgery 34:511–515, 2014.

Most of the literature about the sural flap deals with soft tissue defects at the lower leg and foot based on the classical description of Masquelet et al. Nevertheless, some authors have shown that the lesser saphenous vein and its accompanying artery play an important role in the vascularization of the posterior skin of the leg. This finding allowed a more proximal design of the flap, increasing its arc of rotation. Thirteen cases of distally based sural flaps were performed and divided in two groups according to the level where the flaps were harvested. In group A, the entire flap was outlined distal to the midpoint of the leg, and in group B, the flap was outlined proximal to the midpoint of the leg. In group A, all the soft tissue defects were located at the lower leg and the foot, and in group B, they involved the anterior the tibia. In group A, the complication rate was 33.33% and the flap survival rate was 83.33%. In group B, the complication rate was 42.85% and survival rate was 100%. The proximally designed sural flap can safely reach the anterior aspect of the tibia in its middle and distal thirds.

Objective: Flexor tendon tenolysis on zone 2 is a difficult and really challenging for hand surgery. With the objective of comparing the results obtained between tenolyses with intraoperative awakening, performed with locoregional anesthesia (group 1), from those obtained with traditional tenolysis performed under general anesthesia or total blockage of the brachial plexus (group 2), the authors conducted a prospective and controlled study. Methods: 22 patients with 39 fingers with flexor tendon injuries on zone 2 evolving to adherences were assessed. All patients were operated after three months and before one year of the primary tendinous suture. All patients showed limited active motion not improved by rehabilitation. Groups 1 and 2 showed to be homogenous concerning patients' age and gender, preoperative compromising, and absence of associated injuries or pathologies. All patients were assessed according to active motion (TAMs) both preoperatively and at 6 months postoperatively. Results: The statistical analysis of data obtained for groups 1 and 2 shows that the tenolysis performed with both techniques produce good results. By comparing the results for total active motion after six months of the tenolysis, group 1 patients (treated by the intraoperative awakening technique) were found to present better outcomes. Conclusions: Flexor tenolysis on zone 2 provide good results in terms of joint range of motion. The intraoperative awakening technique with locoregional anesthesia provides improved outcomes when compared to the traditional technique.

The use of internal fixation for spine surgery has become a standard approach for virtually all types of procedures that require bone stabilization. The potential advantages include rigid fixation with early mobilization and more comfort in the post-operative period. However, complications like wound infections can jeopardize the final outcome of these procedures. These infections range from small areas of dehiscence to large wounds with hardware exposure. The conventional approach of serial wound debridement and antibiotic administration can last for a very long period and is only successful in cases of mild infections. Paraspinous muscle flaps have been reported to be a simple and very ef-fective method of treating difficult wounds.

Background: Microvascular anastomosis is the most critical step during free flap transfers or replantations. Although the conventional suture is still considered the standard technique, it is technically difficult, time consuming, and traumatic to the vessel wall. The aim of this study was to evaluate the effectiveness of fibrin adhesive to overcome these problems when applied in microvascular anastomosis. Methods: Sixty-eight Wistar rats were used in this study. Eight animals were used in a pilot study to determine the minimum amount of suture stitches required per anastomosis when the fibrin adhesive was applied. In the definitive study, we performed 30 anastomoses in the femoral artery and 30 anastomoses in the carotid artery. In each artery, half of the anastomoses were performed using interrupted sutures without fibrin adhesive (control groups), and the other half were performed using fibrin adhesive and fewer sutures (experimental groups). Results: The application of fibrin adhesive significantly reduced the number of sutures and the time taken to perform the anastomosis. The anastomotic bleeding was also significantly reduced in both experimental groups. The immediate and late patency rates were not compromised by fibrin glue application. No significant differences were observed in the histologic analysis of the anastomosed vessels between the two techniques. Conclusions: The application of fibrin adhesive did not result in any harmful effects in the microvascular anastomosis. The authors encourage the clinical application of fibrin adhesive in more complex cases, when more than one microvascular anastomosis is required.

Objective: To test an alternative method of arterial microanastomosis, reducing the number of sutures by the association of fibrin adhesive. Mastering the vascular microanastomosis technique is an essential prerequisite to perform microsurgical procedures. The conventional suturing technique is mostly accepted in clinical practice so far. However, there are some unfavorable features: it is technically demanding, and causes additional injury to the blood vessel wall. Material and Methods: Thirty Wistar rats were divided in two groups according to the suturing technique employed: SC (conventional suturing), and SA (minimum suturing, with fibrin adhesive application). Mean sutures tied per anastomosis of group SC was 7.7, whereas only four sutures were tied per anastomosis in group SA. Anastomosis lasted longer in group SC (mean, 15.81 minutes), in comparison to group SA (mean, 13.62 minutes). Results: When assessing early and late permeability, there was only a sole RESUMO Objetivo: Testar um metodo alternativo de microanastomose arterial, reduzindo o numero de pontos de sutura associando-se o adesivo de fibrina. O dominio da tecnica de microanastomose vascular e um pre-requisito essencial para a realizacao de procedimentos microcirurgicos. Ate hoje, a tecnica de sutura convencional e a mais aceita na pratica clinica. Entretanto, ela apresenta algumas caracteristicas desfavoraveis: e tecnicamente dificil e causa traumatismo adicional a parede do vaso. Material e metodos: Foram divididos em dois grupos 30 ratos da linhagem Wistar, de acordo com a tecnica de sutura empregada: SC (sutura convencional) e SA (sutura minima com aplicacao de adesivo de fibrina). A media de pontos de sutura por anastomose no grupo SC foi de 7,7, enquanto no grupo SA todas as anastomoses foram realizadas com somente quatro pontos. O tempo de anastomose foi maior no grupo SC (media de 15,81 minutos), em relacao ao gruR. MATTAR JR., A.B. CHO & V.A.T. GRILLO 350 Rev Bras Ortop _ Vol. 40, No 6 – Junho, 2005 po SA (media de 13,62 minutos). Resultados: Na avaliacao da permeabilidade imediata e tardia, observou-se apenas um caso de trombose tardia no grupo SA. A aplicacao do adesivo de fibrina reduziu, significativamente, o numero de pontos e o tempo necessario para realizacao das anastomoses no grupo SA, alem de ter demonstrado importante propriedade hemostatica. Nao foram observadas diferencas significativas entre as duas tecnicas, em relacao aos parâmetros histopatologicos avaliados (processo inflamatorio, fibrose da camada media e hiperplasia subintimal). Conclusao: Os autores concluiram que a tecnica com aplicacao do adesivo de fibrina tornou mais facil, rapida e hemostatica a anastomose, em relacao a tecnica de sutura convencional, sem aumento da trombogenicidade das anastomoses. Descritores – Suturas; anastomose vascular; adesivo de fibrina; ratos Wistar

Although a reasonable number of studies report satisfactory results with fibrin glue application in microvascular anastomosis since 1977, its utilization in the clinical setting has being scant in the literature. The aim of this study was to report the cumulated experience with the fibrin glue in free flaps over a period of 10 years, comparing the survival rate with the standard sutured anastomosis.From August 2001 through November 2014, 83 consecutive free flaps were performed by a team of surgeons from two hospitals. About 56 flaps were performed in 56 patients using the fibrin glue augmented microvascular anastomosis and 27 flaps were performed in 27 patients using the conventional anastomosis technique. The decision on whether or not the fibrin glue should be used at the anastomoses was based on its availability and whose surgeon was performing the anastomoses. About approximately 60% of sutures stitches were used that would be used in a conventional anastomosis, when fibrin glue application was anticipated (ranging from 5 to 7 sutures in the arteries and 5 to 8 in the veins).The overall survival rate of the flaps performed with fibrin glue application was 92.85%. In one case, a revision of the venous anastomosis was required due to early flap congestion. Four cases (7.14%) had failure of the first free flap and two of them were submitted to another free flap without fibrin glue application. In the flaps performed with the conventional anastomosis technique the survival rate was 92.59%. This difference was not statistically significant (P = 0.97).The application of fibrin glue in microvascular anastomoses did not increase the rate of flap loss and had a potential to reduce the number of sutures required to complete an anastomosis by its sealing effect. © 2016 Wiley Periodicals, Inc. Microsurgery 37:218-221, 2017.

The purpose of this report is to critically evaluate our results of two intercostal nerve transfers directly to the biceps motor branch in complete traumatic brachial plexus injuries. From January 2007 to November 2012, 19 patients were submitted to this type of surgery, but only 15 of them had a follow-up for ≥2 years and were included in this report. The mean interval from trauma to surgery was 6.88 months (ranging from 3 to 9 months). Two intercostals nerves were dissected and transferred directly to the biceps motor branch. The mean follow-up was 38.06 months (ranging from 24 to 62 months). Ten patients (66.6%) recovered an elbow flexion strength ≥M3. Four of them (26.66%) recovered a stronger elbow flexion ≥M4. One patient (6.25%) recovered an M2 elbow flexion and four patients (26.66%) did not regain any movement. We concluded that two intercostal nerve transfers to the biceps motor branch is a procedure with moderate results regarding elbow flexion recovery, but it is still one of the few options available in complete brachial plexus injuries, especially in five roots avulsion scenario.

This article describes a modification of the double-osteotomy radial technique that has been described previously and summarizes our clinical experience with this method in 4 female patients. All patients had improvement in functional motion and were satisfied with the improved appearance of their wrist after surgery.

The purpose of this study was to observe whether the results of the median nerve fascicle transfer to the biceps are equivalent to the classical ulnar nerve fascicle transfer, in terms of elbow flexion strength and donor nerve morbidity. Twenty-five consecutive patients were operated between March 2007 and July 2013. The patients were divided into two groups. In Group 1 (n = 8), the patients received an ulnar nerve fascicle transfer to the biceps motor branch. In Group 2 (n = 15), the patients received a median nerve fascicle transfer to the biceps motor branch. Two patients with follow-up less than six months were excluded. Both groups were similar regarding age (P = 0.070), interval of injury (P = 0.185), and follow-up period (P = 0.477). Elbow flexion against gravity was achieved in 7 of 8 (87.5%) patients in Group 1, versus 14 of 15 (93.3%) patients in Group 2 (P = 1.000). The level of injury (C5-C6 or C5-C7) did not affect anti-gravity elbow flexion recovery in both the groups (P = 1.000). It was concluded that the median nerve fascicle transfer to the biceps is as good as the ulnar nerve fascicle transfer, even in C5-C7 injuries.

Introduction: Elbow flexion deficit is a frequent problem in traumatic brachial plexus injuries and reestablishment of this function is the primary treatment goal. When management is delayed or the initial acute approach fails, free functional transfer of the gracilis muscle for elbow flexion is the treatment of choice: the authors seek to determine which donor nerve (spinal accessory, intercostal, median, or ulnar) results in better elbow flexion after microsurgical reconstruction. Methods: Retrospective analysis of patients with traumatic brachial plexus injuries who underwent functional free gracilis muscle flap for elbow flexion between February 2003 and October 2014 was carried out. Postoperative function of the gracilis functional flap was recorded and patients were divided into 4 groups according to donor nerve: spinal accessory nerve (SAN), intercostal nerves (ICN), motor fascicles of the median (MED), and ulnar nerve (ULNAR). Cases in which a primary neurorrhaphy was not possible were further subdivided into 2 groups: SAN with graft interposition (SAN graft) and ICN with graft interposition (ICN graft). The final elbow flexion strength was evaluated by the British Medical Research Council (BMRC) scale and time in months when the authors first observed M3 muscle power was also of note. Results: Fifty-nine patients met inclusion criteria for this retrospective study. Two cases were excluded due to flap loss (3%) and 3 were lost to follow up (5%). Of the 54 patients enrolled, 53 were males (98.2%) with a mean age of 29 years. The mean follow-up period was 28 months. Thirty-four cases obtained muscle strength of ≥ M3 (62.9%), 6 M0 (11.1%), 4 M1 (7.5%), 10 M2 (18.5%), 13 M3 (24%), and 21 M4 (38.9%). The mean interval to first recorded M3 muscular strength was 16 months. Patients stratified by donor nerve achieving ≥ M3 had the following distribution: SAN 83.3% (15/18), SAN graft 50% (2/4), ICN 50% (2/4), ICN graft 33.3% (1/3), MED 40% (2/5), and ULNAR 60% (12/20). No statistical difference for final muscle strength was found between donor nerve groups. SAN transfer with graft interposition took longer to reach muscle strength of M3 or greater ( P < .05). Conclusion: Free functional gracilis muscle flap for traumatic brachial plexus injuries is a viable option for elbow flexion recovery. Comparison between 4 different nerve transfers—SAN, ICN, MED, and ULNAR—did not clearly indicate a better alternative over the others.

Objective: The primary objective of our study was to evaluate the results of the free transfer of the gracilis muscle with neurotization in the ulnar nerve to recover the elbow flexion strength in patients with upper brachial plexus injury. Methods: We performed retrospective study that evaluated 21 patients with upper brachial plexus injury. The patients underwent surgical treatment free transfer of the gracilis muscle (21 patients, the free group) for elbow flexors with neurotization in part of the ulnar nerve. The primary outcome was evaluated using the scale defined by The British Medical Research Council (BMRC) and a minimum follow-up of 12 months was defined. The BMRC scale classifies muscle strength from M0 (no contraction) to M5 (normal strength). We used the criteria of M4 or more to classify the elbow flexion as a good result. Results: The ability to obtain an M4 score or higher was 61.9% in the free groups. Considering the possibility of an M2 score or higher, which would allow for complementary surgery, 95.2% of patients in the free group obtained this score. Conclusion: The free transfer of the gracilis muscle and neurotization in the ulnar nerve in patients with upper brachial plexus injury showed satisfactory results considering the elbow flexion strength.

Introducao: A sindrome do tunel carpal e constituida por um conjunto de sinais e sintomas caracteristicos como parestesia, formigamento, dor e perda da forca nas maos. Inicialmente os sintomas sao brandos, progredindo ao longo do tempo. Objetivo: Apresentar os resultados do tratamento cirurgico com mini-incisao, bem como discutir a relacao entre os resultados e a tecnica cirurgica utilizada. Metodo: Esta pesquisa foi realizada na Faculdade de Medicina do ABC, onde foram avaliados 79 punhos de 71 pacientes, todos submetidos ao tratamento cirurgico da sindrome do tunel carpal por “mini-incisao”, entre janeiro de 1996 e maio de 2007. A media de idade entre os pacientes foi de 52,4 anos, sendo a idade minima 27 e a maxima 80 anos. Sessenta e cinco pacientes eram do sexo feminino e seis do masculino. Quanto ao lado acometido, foram obtidos 36 punhos do lado direito e 27 do lado esquerdo, sendo 8 bilaterais. Resultados: Os resultados clinicos mostraram que 60 pacientes ficaram satisfeitos com os sintomas, com os resultados esteticos e funcionais e com a melhora da forca muscular para apreensao. Dois pacientes apresentaram complicacoes cutaneas com infeccao superficial e necessitaram de antibioticoterapia oral. Conclusoes: Concluimos que o tratamento cirurgico por “mini-incisao” e uma tecnica segura, com poucas complicacoes e resultados clinicos e esteticos satisfatorios para o tratamento da sindrome do tunel do carpo.

Introducao: o polegar em gatilho congenito ou tenossinovite estenosante do polegar e a dificuldade de extensao do polegar, identificada nos primeiros meses de vida. Objetivo: a proposta deste estudo foi discutir o tratamento cirurgico com os resultados, as complicacoes e as vantagens na utilizacao da internacao hospital-dia. Metodo: no periodo de fevereiro de 2001 ate janeiro de 2008, verificaram-se 25 criancas entre 3 meses e 6 anos, portadoras de polegar em gatilho congenito. Foram operadas 35 maos, e 10 casos eram bilaterais. Observamos que a manifestacao clinica quanto a dificuldade de extensao do polegar estava presente em todas as maos operadas e nenhuma crianca queixava-se de dor. As criancas foram submetidas a mesma tecnica cirurgica, anestesia geral inalatoria, com incisao transversa na prega volar metacarpofalangeana do polegar acometido e abertura longitudinal da polia flexora A1. Nao foi utilizado antibiotico e as criancas foram internadas pelo sistema hospital-dia. Resultados: Quinze criancas eram do sexo masculino e dez do sexo feminino. Dos pacientes com lesao bilateral, sete eram do sexo masculino e tres do feminino. Quanto ao lado acometido, obtivemos sete polegares direitos, oito esquerdos e dez bilaterais. Como complicacoes, nao houve nenhuma recidiva; um polegar evoluiu com infeccao cutânea superficial e dois polegares apresentaram deiscencia parcial da sutura apos a retirada dos pontos. Conclusoes: o polegar em gatilho congenito ou tenossinovite estenosante do polegar na crianca pode ser tratado com seguranca atraves da abertura simples da polia flexora A1, utilizando-se a internacao hospital-dia.

A restauracao de lesoes nos tendoes flexores da zona II e um procedimento dificil devido a sua complexidade anatomica, facilidade de formar aderencias e dificuldade de estabelecer protocolos de reabilitacao que reduzam o numero de rupturas. O objetivo deste trabalho foi atualizar o tratamento cirurgico das lesoes nos tendoes flexores da zona II. Foram analisados cinco artigos, tres sobre avaliacao de diferentes tecnicas de sutura e dois sobre reabilitacao pos-operatoria. No estudo de Buendia et al ., os valores absolutos mostraram a tecnica de ancoragem como sendo a melhor, apesar do desvio padrao ser grande. Ja na analise estatistica, a ancoragem e o protocolo de Indiana possuem mesma significância. No grupo de imobilizacao ocorreu tenolise em 21,2% dos casos sem ruptura tendinosa. Entretanto, no grupo de flexao ativa ocorreu ruptura de tendao em 13,5% dos casos apos duas semanas de mobilizacao ativa. A sutura de lesao tendinosa na zona II de tendoes flexores com quatro passadas apresenta melhores resultados, mas realcamos a importância de analisar a tecnica de sutura segundo a resistencia, o tempo cirurgico, a quantidade de material utilizado, o aumento do volume, a capacidade traumatica e a dificuldade da tecnica.

OBJETIVO: Avaliar prospectivamente os resultados obtidos no tratamento de pacientes portadores de lesões do revestimento cutâneo de dimensões menores ou iguais a 20cm de comprimento por 10cm de largura com a utilização do retalho microcirúrgico lateral do braço ampliado distalmente ao epicôndilo lateral do cotovelo. MÉTODOS: Foram operados 23 pacientes, 69,5% do sexo masculino, 73,9% de origem traumática e a região receptora foi o membro inferior em 65.2% dos casos. A idade variou de 6 a 62 anos, com média de 32 anos. O seguimento mínimo foi de 5 meses. RESULTADOS: Obtivemos sucesso na realização em 100% dos casos. As dimensões dos retalhos variaram de 9 a 20cm em comprimento, com média de 14cm e em largura, de 3 a 8 cm, com média de 5.5cm. A maior distância entre o epicôndilo lateral e a extremidade distal do retalho foi de 8 cm, variando de 2 cm até 8 cm, com média de 4.9cm. CONCLUSÃO: O retalho microcirúrgico lateral do braço ampliado distalmente ao epicôndilo lateral do cotovelo mostrou-se seguro para a cobertura cutânea de lesões de dimensões iguais ou menores a 20cm de comprimento por 10 cm de largura, com o prolongamento do retalho até 8cm distal ao epicôndilo lateral. OBJECTIVE: To prospectively evaluate the results obtained in the treatment of patients with cutaneous lesions smaller or equal to 20cm long by 10cm wide with the use of lateral arm flap extended distally to the lateral epicondyle of the elbow. METHODS: 23 patients underwent surgery, 69.5% of them male, 73.9% of traumatic origin, and the receiving region was the lower limb in 65.2% of cases. The age ranged from 6 to 62 years, with an average of 32 years. Minimum follow-up care was 5 months. RESULTS: We succeeded in 100% of cases. The size of flaps ranged from 9 to 20 cm in length, with an average of 14cm, and width, from 3 to 8cm, with an average of 5.5cm. The greatest distance between the lateral epicondyle and the distal flap was 8cm, ranging from 2cm to 8cm, with an average of 4.9cm. CONCLUSION: The lateral arm flap, extended distally to the lateral epicondyle of the elbow, was safe to cover cutaneous lesions of size equal to or smaller than 20cm long by 10cm wide, with the extension of the flap up to 8cm distal to the lateral epicondyle.

We present 20 patients, who had a four corner arthrodesis, from July 2006 to March 2008, using a dorsal circular plate, to treat scaphoid nonunion and scapholunate dissociation with advanced collapse (SNAC, SLAC). The surgical technique was a fusion restricted to the central area filled with one piece of cancellous bone graft taken from the excised scaphoid. Wrist motion, grip strength, and Disabilities of Arm Shoulder and Hand (DASH) score improved after surgery at a mean follow-up of 20.2 months. Fusion occurred in 19/20 patients. Two patients (10%) had persistent pain. The rest had a good clinical result. We found that four-corner fusion using a dorsal circular plate using the specific technical modifications was successful.

OBJETIVO: As tenólises dos tendões flexores na zona 2 são procedimentos difíceis e um verdadeiro desafio na cirurgia da mão. Com o objetivo de comparar os resultados obtidos entre as tenólises com despertar intraoperatório, realizadas sob anestesia locorregional (grupo 1), daqueles obtidos com as tenólises convencionais, realizadas sob anestesia geral ou bloqueio total do plexo braquial (grupo 2), os autores realizam um estudo prospectivo e controlado. MÉTODOS: Foram avaliados 22 pacientes com 39 dedos portadores de lesão de tendão flexor na zona 2 que evoluíram para aderências. Todos os pacientes foram operados após três meses e antes de um ano da sutura tendinosa primária. Todos apresentavam limitação da movimentação ativa sem melhora com a reabilitação. Os grupos 1 e 2 mostraram-se homogêneos em relação à idade dos pacientes, sexo, comprometimento pré-operatório e ausência de lesões ou patologias associadas. Todos os pacientes foram avaliados de acordo com a movimentação ativa (TAMs) no período pré-operatório e com seis meses de pós-operatório. RESULTADOS: A análise estatística dos dados obtidos nos grupos 1 e 2 demonstra que as tenólises realizadas pelas duas técnicas proporcionam bons resultados. Ao comparar os resultados da movimentação ativa total após seis meses da tenólise, observa-se que os pacientes do grupo 1, tratados pela técnica do despertar intraoperatório, apresentavam melhores resultados. CONCLUSÕES: As tenólises dos flexores na zona 2 proporcionam bons resultados em termos de ganho de amplitude articular. A técnica de despertar intraoperatório com anestesia locorregional proporciona resultados mais satisfatórios que a técnica convencional. OBJECTIVE: Flexor tendon tenolysis on zone 2 is a difficult and really challenging for hand surgery. With the objective of comparing the results obtained between tenolyses with intraoperative awakening, performed with locoregional anesthesia (group 1), from those obtained with traditional tenolysis performed under general anesthesia or total blockage of the brachial plexus (group 2), the authors conducted a prospective and controlled study. METHODS: 22 patients with 39 fingers with flexor tendon injuries on zone 2 evolving to adherences were assessed. All patients were operated after three months and before one year of the primary tendinous suture. All patients showed limited active motion not improved by rehabilitation. Groups 1 and 2 showed to be homogenous concerning patients' age and gender, preoperative compromising, and absence of associated injuries or pathologies. All patients were assessed according to active motion (TAMs) both preoperatively and at 6 months postoperatively. RESULTS: The statistical analysis of data obtained for groups 1 and 2 shows that the tenolysis performed with both techniques produce good results. By comparing the results for total active motion after six months of the tenolysis, group 1 patients (treated by the intraoperative awakening technique) were found to present better outcomes. CONCLUSIONS: Flexor tenolysis on zone 2 provide good results in terms of joint range of motion. The intraoperative awakening technique with locoregional anesthesia provides improved outcomes when compared to the traditional technique.

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.