LIMB REPLANTATION AFTER AVULSION INJURIES: TECHNIQUES AND TACTICS FOR SUCCESS

Objectives: Retrospective evaluation of cases of limb replantation after avulsion injuries. Evaluation of the techniques and tactics used, that contributed to success and good functional results. Methods: Forty-three patients' records were assessed. All the cases had been submitted to limb replantation after avulsion injuries. Results: The majority of the cases were young men. The most common injury was to the thumbs. The surgical techniques and tactics used were: nerve grafting, vein grafting, transposition of the digital vessels, limb shortening, and heterotopic replantation. The most commonly used technique was vein graft. The limb survival rate was high (93%), as was patient satisfaction. Conclusion: Replantation after avulsion injury depends on the correct diagnosis of the limb viability and the use of appropriate surgical techniques and tactics for each case. The experience of the team of surgeons and a good hospital structure are essential for good results. There are few articles in medical literature about the indications, techniques and results of limb replantation after avulsion injuries. We believe that this retrospective evaluation can bring new information and contributions to the correct management of this highly complex situation. Level of evidence IV, Case Series.

PHOTOELASTIC ANALISYS IN THE LOWER REGION OF VERTEBRAL BODY L4

Objective: To analyze the shear forces on the vertebral body L4 when submitted to a compression force by means of transmission photoelasticity. Methods: Twelve photoelastic models were divided into three groups, with four models per group, according to the positioning of the sagittal section vertebrae L4-L5 (sections A, B and C). The simulation was performed using a 15N compression force, and the fringe orders were evaluated in the vertebral body L4 by the Tardy compensation method. Results: Photoelastic analysis showed, in general, a homogeneous distribution in the vertebral bodies. The shear forces were higher in section C than B, and higher in B than A. Conclusion: The posterior area of L4, mainly in section C, showed higher shear concentrations, corresponding to a more susceptible area for bone fracture and spondylolisthesis. Economic and Decision Analyses Development of an Economic or Decision Model. Level I

DEVELOPMENT OF AN EXPERIMENTAL MODEL OF INFECTED BONE VOID IN THE ULNA OF RABBITS

Objective: Develop a model that allowed the study of bone regeneration in infection conditions. Method: A 15 mm defect was surgically created in the rabbit ulna and inoculated with 5x10(8) colony-forming units (CFU) of S. aureus. Surgical debridement was performed two weeks after and systemic gentamicin was administered for four weeks. Animals were followed up to 12 weeks to evaluate infection control and bone regeneration. Result: Bone regeneration was inferior to 25% of the defect in radiological and histological analysis. Conclusion: Infected bone defect of 15 mm in the rabbit ulna was unable to achieve full regeneration without further treatment. Level of Evidence V, Experimental Study.

FOLLOW-UP OF TREATED OSTEOSARCOMA PATIENT

Objective: To evaluate the value of post-treatment follow-up in osteosarcoma patients. Methods: Data were collected through a clinical record, with socio-demographic and clinical data, and information relating to the medical appointment. Descriptive analysis of the data was carried out. The Chi-squared test was used to associate the independent variables with attendance at scheduled follow-up appointments. Results: We found a recurrence in 59.6% of cases, of which 58% were lung related; 44% presented clinical complaints and arrived on the scheduled date of the appointment. There was no statistically significant association between the demographic characteristics and early attendance of follow-up visits. 81.3% of the cases who came for the appointment earlier than originally scheduled presented complaints compared to those who did not (p=0.005). Of the cases who presented recurrence, 12.9% attended an appointment late and those who did not present recurrence, 47.6% were late for the appointment (p=0.006). Conclusion: It is seen that the patients who came for an earlier appointment presented more complaints and were associated with the positive result of the exams carried out. The patients who had recurrence and came for an earlier appointment did not present a statistically significant difference in recurrence-free survival. It was observed that distance was not a predominant factor in late attendance at appointments. Level of Evidence II, Retrospective Study.

INFLUENCE OF CORTICAL BONE THICKNESS ON THE ULTRASOUND VELOCITY

Objective: An experimental in vitro study was carried out to evaluate the influence of cortical bone thickness on ultrasound propagation velocity. Methods: Sixty bone plates were used, made from bovine femurs, with thickness ranging from 1 to 6 mm (10 of each). The ultrasound velocity measurements were performed using a device specially designed for this purpose, in an underwater acoustic tank and with direct contact using contact gel. The transducers were positioned in two ways: on opposite sides, with the bone between them, for the transverse measurement; and parallel to each other, on the same side of the bone plates, for the axial measurements. Results: In the axial transmission mode, the ultrasound velocity speed increased with cortical bone thickness, regardless of the distance between the transducers, up to a thickness of 5 mm, then remained constant thereafter. There were no changes in velocity when the transverse measures were made. Conclusion: Ultrasound velocity increased with cortical bone thickness in the axial transmission mode, until the thickness surpasses the wavelength, after which point it remained constant. Level of Evidence: Experimental Study.

TOMOGRAPHIC ANALYSIS FOR C2 SCREW PLACEMENT IN RHEUMATOID ARTHRITIS PATIENTS

Objective: A morphological analysis of the bone structure of 02 in patients with rheumatoid arthritis in order to enhance the security of the stabilization procedures for this vertebra. Methods: We retrospectively analyzed 20 CT scans of the cervical spine performed in patients with rheumatoid arthritis; the following parameters were measured: spinolaminar angle, thickness and length of C2 lamina. Results: The mean values are: 5.92mm and 5.87mm for thickness of right and left laminae retrospectively, 27.75mm for right lamina length and 27.94mm for left lamina length, and 44.7 degrees for spinolaminar angle. Conclusion: The values obtained are consistent with studies in normal subjects published by other groups, with no apparent need for change in the screw placement technique. Level of Evidence IV, Case Series.

TOMOGRAPHIC ANALYSIS OF ANATOMICAL PARAMETERS OF THE AXIS IN CHILDREN

Objective: To carry out an anatomical study of the axis with the use of computed tomography (CT) in children aged from two to ten years, measuring the lamina angle, lamina and pedicle length and thickness, and lateral mass length. Methods: Sixty-four CTs were studied from patients aged 24 to 120 months old, of both sexes and without any cervical anomaly. The measurements obtained were correlated with the data on age and sex of the patients. Statistical analysis was performed using the Students "t" tests. Results: We found that within the age range 24-48 months, 5.5% of the lamina and 8.3% of the pedicles had thicknesses of less than 3.5mm, which is the minimum thickness needed for insertion of the screw. Between 49 and 120 months, there were no lamina thicknesses of less than 3.5mm, and 1.2% of the pedicle thicknesses were less than 3.5mm values. Neither of the age groups had any lamina and pedicle lengths of less than 12mm, or lateral mass lengths greater than 12mm. Conclusion: The analysis of the data obtained demonstrates that most of the time, is possible to use a 3.5mm pedicle screw in the laminas and pedicles of the axis in children. Level of Evidence: II, Development of diagnostic criteria in consecutive patients.

TRANSLATION AND VALIDATION OF THE KNEE SOCIETY SCORE - KSS FOR BRAZILIAN PORTUGUESE

Objective: To translate, culturally adapt and validate the "Knee Society Score"(KSS) for the Portuguese language and determine its measurement properties, reproducibility and validity. Method: We analyzed 70 patients of both sexes, aged between 55 and 85 years, in a cross-sectional clinical trial, with diagnosis of primary osteoarthritis,undergoing total knee arthroplasty surgery. We assessed the patients with the English version of the KSS questionnaire and after 30 minutes with the Portuguese version of the KSS questionnaire, done by a different evaluator. All the patients were assessed preoperatively, and again at three, and six months postoperatively. Results: There was no statistical difference, using Cronbach's alpha index and the Bland-Altman graphical analysis, for the knees core during the preoperative period (p=1), and at three months (p=0.991) and six months postoperatively (p=0.985). There was no statistical difference for knee function score for all three periods (p=1.0). Conclusion: The Brazilian version of the Knee Society Score is easy to apply, as well providing as a valid and reliable instrument for measuring the knee score and function of Brazilian patients undergoing TKA. Level of Evidence: Level I - Diagnostic Studies Investigating a Diagnostic Test- Testing of previously developed diagnostic criteria on consecutive patients (with universally applied 'gold' reference standard).

TRAUMATIC SPONDYLOLISTHESIS OF THE AXIS: EPIDEMIOLOGY, MANAGEMENT AND OUTCOME

Objective: To evaluate cases of traumatic spondylolisthesis of the axis and describe them in relation to epidemiology, classification, neurological deficit, healing time and treatment method. Method: A retrospective analysis of the medical records of patients treated between 2002 and 2010 at IOT-FMUSP. Inclusion criteria: pars interarticularis fracture of C2. Results: 68% were male patients, with a mean age of 39.1 years. We used the classification by Effendi, modified by Levine-Edwards. Type I fractures were observed in five patients (31.2%) and type II in eight patients (50%). Only three patients (18%) had type IIa fracture. There were no cases of type III. Mechanism: Eight car accidents and four falls. Other mechanisms: being run over, and diving accidents. Treatment with halo traction was used in eleven patients, using minerva cast and halo-cast. Healing time: 3.6 months. Follow-up time: 9.6 months. Discussion: In general, hangman fracture has a good prognosis, which is confirmed by our results. There was no need for surgery in any of the cases. The incidence of neurological deficit is low. No patient had unstable fracture (type III). Conclusion: This paper suggests that traumatic spondylolisthesis of the axis continues to be an injury that is successfully treated by conservative treatment in most cases. Level of Evidence IV, Case series.

RESULTS OF ULNAR NERVE NEUROTIZATION TO BICEPS BRACHII MUSCLE IN BRACHIAL PLEXUS INJURY

Objective: To evaluate the factors influencing the results of ulnar nerve neurotization at the motor branch of the brachii biceps muscle, aiming at the restoration of elbow flexion in patients with brachial plexus injury. Methods: 19 patients, with 18 men and 1 woman, mean age 28.7 years. Eight patients had injury to roots C5-C6 and 11, to roots C5-C6-C7. The average time interval between injury and surgery was 7.5 months. Four patients had cervical fractures associated with brachial plexus injury. The postoperative follow-up was 15.7 months. Results: Eight patients recovered elbow flexion strength MRC grade 4; two, MRC grade 3 and nine, MRC <3. There was no impairment of the previous ulnar nerve function. Conclusion: The surgical results of ulnar nerve neurotization at the motor branch of brachii biceps muscle are dependent on the interval between brachial plexus injury and surgical treatment, the presence of associated fractures of the cervical spine and occipital condyle, residual function of the C8-T1 roots after the injury and the involvement of the C7 root. Signs of reinnervation manifested up to 3 months after surgery showed better results in the long term. Level of Evidence: IV, Case Series.

HIGH VOLTAGE PULSED CURRENT STIMULATION OF THE SCIATIC NERVE IN RATS: ANALYSIS BY THE SFI

Objective: To analyze the efficiency of high voltage pulsed current (HVPC) with early application in three different sites, in the regeneration of the sciatic nerve in rats submitted to crush injury, the sciatic functional index (SFI) was used to assess the functional recovery. Methods: After crushing of the nerve, 57 animals were submitted to cathodal HVPC at frequency of 50Hz and voltage of 100V, 20 minutes per day, 5 days per week. The rats were divided into five groups: control group; ganglion group; ganglion + muscle group; muscle group; and sham group. The SFI was determined weekly for seven weeks, from the preoperative period to the 6th postoperative week. Results: Compared with the control group, the results showed a significantly better performance of group 2 for the first 3 weeks; group 3 showed significantly better performance in the third week; and group 4 showed a significantly negative performance during the 481 and 6th weeks. Conclusion: Early application of HVPC had a positive effect in the treatment of the spinal cord region and the sciatic nerve root ganglion with a dispersive electrode on the contralateral lumbar region or on the gastrocnemius. However, HVPC had a negative effect in the treatment with an active electrode on the gastrocnemius and a dispersive electrode on the contralateral thigh. Level of evidence II, Prospective comparative study.

ANATOMICAL AND FUNCTIONAL STUDY OF THE MEDIAL COLLATERAL LIGAMENT COMPLEX OF THE ELBOW

Objective: To carry out an anatomical study of the medial collateral ligament, an important elbow stabilizer in different degrees of elbow flexion-extension. Methods: Forty elbows were dissected in order to analyze the functional behavior of the anterior, posterior and transverse ligament bands during valgus stress maneuvers of the elbow in different degrees of flexion and extension. Two groups were determined; in the group GPA the posterior band of the ligament was sectioned initially, then the articular capsule and finally the anterior band; in group GAP this order was reversed. Results: Instability was observed in GPA only in the third stage, when there was a greater mean elbow's opening during the flexion (between 50 degrees and 70 degrees); in GAP the instability was present since the first stage; the degrees of flexion with greater instability were the same as in group GPA. Conclusion: The anterior band of the medial collateral ligament of the elbow is the most important stabilizer of the elbow valgus instability, and its principal action occurs between 50 degrees and 70 degrees of elbow flexion. Level of Evidence III, Diagnostic Studies Investigating a diagnostic test.

STUDY ON IMPLANT STABILITY IN CEMENTLESS TOTAL KNEE ARTHROPLASTY

Objetives: Determine the stability of tibial and femoral components of 20 cementless knee arthroplasties with rotating platform. Methods: The 20 patients (20 knees) underwent an analysis of dynamic radiographs with an image amplifier and maneuvers of varus and valgus which were compared to static frontal and lateral radiographs of the knees and analyzed by two experienced surgeons in a double-blind way. Results: We could observe in this study that both methods showed very similar results for the stability of the tibial and femoral components (p<0.001) using the Kappa method for comparison. Conclusion: The tibial component was more unstable in relation to the femoral component in both static and dynamic studies. Level of Evidence IV, Case Series.