Arthroscopic repair of humeral avulsion of glenohumeral ligament lesion : anterior and posterior techniques

Humeral avulsion of the inferior glenohumeral ligament complex is an unusual pathology, often implicated in traumatic shoulder instability. Traditional open techniques involve at least partial detachment of the subscapularis, and arthroscopic techniques are limited by neurovascular boundaries. The technique described here presents an anterior and posterior arthroscopic approach that can be used individually or in combination to treat different types of humeral avulsion of the inferior glenohumeral ligament lesions. The anterior approach is based on anatomic guidelines described in the literature. The posterior approach is based on the arthroscopic and cadaveric anatomic studies described by one of the authors (D.N.B.); use of the recently described axillary pouch portal (Bhatia portal) permits safe arthroscopic instrumentation access in the entire inferior glenohumeral recess and provides adequate access to the posteroinferior aspect of the humeral head. The differential mattress stitch technique ensures secure fixation of the avulsed ligaments and eliminates excessive capsular redundancy. Technical tips to avoid complications are discussed, and a detailed rehabilitation protocol is presented.

Evaluation of sixth grade primary schoolchildren's knowledge about avulsion and dental reimplantation

Dental trauma, particularly tooth avulsion, is a frequent cause of tooth loss in children, adolescents, and young adults. The avulsed tooth should be immediately reimplanted in its alveolus. This procedure can be performed by anyone at the accident site and not only by dental surgeons. Therefore, the purpose of this study is to evaluate the knowledge of sixth graders of the city of Aracatuba, SP, about dental avulsion and tooth reimplantation through a structured and standardized survey. Our sample consisted of 778 students. The data collected was processed using the program epiinfo 2000. Most students were around 12 years of age and 94.5% related to practice some kind of sports. Results demonstrated that the possibility of tooth reimplantation after dental avulsion is not acknowledged among these students and dental traumatism was associated to caries, toothache, and use of orthodontic appliances. Only 18.9% of the students associated dental traumatism to an impact trauma; 3.6% would store the tooth in milk, and 3.1% believed the tooth could be reimplanted by anyone present at the accident site. In summary, the results show an overall the lack of knowledge about dental traumatism and highlight the need of special programs designed to educate school-aged students about emergency procedures to handle cases of dental traumatisms.

Analysis of procedures used in tooth avulsion by 100 dental surgeons

Accurate diagnosis and adequate treatment plan may constitute very complex tasks, particularly in tooth avulsion, because several variables are involved. In addition to the technical knowledge and clinical experience directed toward the quality of treatment, patient education may favorably influence the survival of replanted teeth. The aim of this study was to analyze the procedures used in the management of tooth avulsion by 100 dental surgeons (DSs). Thus, by means of a descriptive questionnaire, information was obtained about the profile of the professionals interviewed, procedures used in cases of tooth avulsion, and patient orientation and education. One hundred properly filled questionnaires were obtained. Descriptive statistics was used for the data, and the chi-squared statistics was employed (EPI-INFO 3.2 software). According to the results, this type of trauma is part of the routine of 15 DSs, although 71 have reported some experience with avulsed,teeth. Great deficiencies were found regarding root surface treatment and occlusal adjustment. Positive findings were related to socket treatment, adjunctive therapy, and patient education and orientation (extra-alveolar period, storage medium, manipulation of the avulsed tooth, replantation by the own patient). It was possible to conclude that 47.5% of the procedures reported by, 100 professionals interviewed are adequate, and patient education is favorable in 87.7% of cases, a fact that can positively interfere with the prognosis of tooth replantation.

Severe fracture of the maxillary alveolar process associated with extrusive luxation and tooth avulsion: A case report

Aim: The aim of this report is to present a case of severe fracture of the maxillary anterior alveolar process with substantial bone dislodgement associated with extrusive tooth luxation and avulsion. Background: Dentoalveolar trauma is a challenge to dentistry, especially in young patients, for it can lead to early tooth loss which compromises oral function, esthetics, self-esteem, and alter the long-term plan of care for the victim. Case Report: A 12-year-old girl with severe dentoalveolar trauma to the maxillary anterior region presented for emergency care for her injury. Treatment consisted of fracture reduction of the alveolar process, repositioning of the teeth that had suffered extrusive luxation, placement of a semi-rigid splint, and suturing of soft tissue lacerations. The traumatized teeth presented with pulpal necrosis and were treated endodontically. After 24 months of follow up, the fracture of the alveolar process was completely healed and the displaced teeth presented no signs of ankylosis or root resorption. Summary: First-aid care contributed remarkably to this case allowing the re-establishment of esthetics, function, and patient's self-esteem. In spite of trauma extension the treatment outcomes were favorable. Clinical Significance: Cases of dentoalveolar trauma should be evaluated on an individual basis. However, early emergency management and adequate follow-up can prevent further complications and contribute to treatment success.

Motor Recovery and Synaptic Preservation after Ventral Root Avulsion and Repair with a Fibrin Sealant Derived from Snake Venom

Background:Ventral root avulsion is an experimental model of proximal axonal injury at the central/peripheral nervous system interface that results in paralysis and poor clinical outcome after restorative surgery. Root reimplantation may decrease neuronal degeneration in such cases. We describe the use of a snake venom-derived fibrin sealant during surgical reconnection of avulsed roots at the spinal cord surface. The present work investigates the effects of this fibrin sealant on functional recovery, neuronal survival, synaptic plasticity, and glial reaction in the spinal motoneuron microenvironment after ventral root reimplantation.Methodology/Principal Findings:Female Lewis rats (7 weeks old) were subjected to VRA and root replantation. The animals were divided into two groups: 1) avulsion only and 2) replanted roots with fibrin sealant derived from snake venom. Post-surgical motor performance was evaluated using the CatWalk system twice a week for 12 weeks. The rats were sacrificed 12 weeks after surgery, and their lumbar intumescences were processed for motoneuron counting and immunohistochemistry (GFAP, Iba-1 and synaptophysin antisera). Array based qRT-PCR was used to evaluate gene regulation of several neurotrophic factors and receptors as well as inflammatory related molecules. The results indicated that the root reimplantation with fibrin sealant enhanced motor recovery, preserved the synaptic covering of the motoneurons and improved neuronal survival. The replanted group did not show significant changes in microglial response compared to VRA-only. However, the astroglial reaction was significantly reduced in this group.Conclusions/Significance:In conclusion, the present data suggest that the repair of avulsed roots with snake venom fibrin glue at the exact point of detachment results in neuroprotection and preservation of the synaptic network at the microenvironment of the lesioned motoneurons. Also such procedure reduced the astroglial reaction and increased mRNA levels to neurotrophins and anti-inflammatory cytokines that may in turn, contribute to improving recovery of motor function. © 2013 Barbizan et al.

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.

Motor recovery and synaptic preservation after ventral root avulsion and repair with a fibrin sealant derived from snake venom

Background: Ventral root avulsion is an experimental model of proximal axonal injury at the central/peripheral nervous system interface that results in paralysis and poor clinical outcome after restorative surgery. Root reimplantation may decrease neuronal degeneration in such cases. We describe the use of a snake venom-derived fibrin sealant during surgical reconnection of avulsed roots at the spinal cord surface. The present work investigates the effects of this fibrin sealant on functional recovery, neuronal survival, synaptic plasticity, and glial reaction in the spinal motoneuron microenvironment after ventral root reimplantation. Methodology/Principal Findings: Female Lewis rats (7 weeks old) were subjected to VRA and root replantation. The animals were divided into two groups: 1) avulsion only and 2) replanted roots with fibrin sealant derived from snake venom. Post-surgical motor performance was evaluated using the CatWalk system twice a week for 12 weeks. The rats were sacrificed 12 weeks after surgery, and their lumbar intumescences were processed for motoneuron counting and immunohistochemistry (GFAP, Iba-1 and synaptophysin antisera). Array based qRT-PCR was used to evaluate gene regulation of several neurotrophic factors and receptors as well as inflammatory related molecules. The results indicated that the root reimplantation with fibrin sealant enhanced motor recovery, preserved the synaptic covering of the motoneurons and improved neuronal survival. The replanted group did not show significant changes in microglial response compared to VRA-only. However, the astroglial reaction was significantly reduced in this group. Conclusions/Significance: In conclusion, the present data suggest that the repair of avulsed roots with snake venom fibrin glue at the exact point of detachment results in neuroprotection and preservation of the synaptic network at the microenvironment of the lesioned motoneurons. Also such procedure reduced the astroglial reaction and increased mRNA levels to neurotrophins and anti-inflammatory cytokines that may in turn, contribute to improving recovery of motor function.

Longterm follow-up of children with traumatic optic nerve avulsion

We report the longterm follow-up of children with optic nerve avulsion (ONA) caused by traumatic events. The remarkable differences in courses and outcomes may elucidate the spectrum of ONA-associated symptoms and injuries.

Adductor insertion avulsion syndrome, "thigh splints": relevance of radiological follow-up

We present a case of chronic osteomyelitis in a 13-year-old girl which was originally diagnosed as adductor insertion avulsion syndrome ("thigh splints") on the basis of the clinical presentation, patient history, initial radiographs and MRI examination. However, at follow-up with persistent pain and altered radiographic and MRI appearances, surgical biopsy was indicated. Histopathological findings confirmed a bone abscess. This case underlines the necessity of clinical follow-up and imaging in certain patients with apparent thigh splints.

Guidelines for the management of traumatic dental injuries. II. Avulsion of permanent teeth

Avulsion of permanent teeth is the most serious of all dental injuries. The prognosis depends on the measures taken at the place of accident or the time immediately after the avulsion. Replantation is the treatment of choice, but cannot always be carried out immediately. An appropriate emergency management and treatment plan is important for a good prognosis. Guidelines are useful for delivering the best care possible in an efficient manner. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. Experienced researchers and clinicians from various specialties were included in the group. In cases in which the data did not appear conclusive, recommendations were based on the consensus opinion of the IADT board members. The guidelines represent the current best evidence based on literature research and professional opinion. In this second article of three, the IADT Guidelines for management of avulsed permanent teeth are presented.

CT myelography for diagnosis of brachial plexus avulsion in small animals

Avulsion of nerve roots of the brachial plexus can be diagnosed clinically, neurologically, radiographically and by electromyography. But like the myelography these techniques are inprecise for determination of the severity (partial or complete disruption) and the localization of the lesion. In human medicine the combination of computerized tomography with myelography shows high accuracy. Veterinary reports of experience in this field are not yet known. The aim of the present study was to demonstrate nerve root avulsions using myelography and computerized tomography. Three dogs and one cat with traumatic lesions of the brachial plexus were examined. The lesion could be seen in all patients. Thus CT-myelography results in an improved prognostic assessment of brachial plexus paralysis. Moreover, this technique could become one of the most important diagnostic methods for brachial plexus lesions involving nerve root reinsertion--neurotizations in veterinary medicine.

Channel Migration and Avulsion Hazards at Sunshine Point Campground, Mount Rainier National Park, Washington

In November 2006, the flood of record on the upper Nisqually River destroyed part of Sunshine Point Campground in Mount Rainier National Park, Washington. The Nisqually River migrated north and reoccupied five acres of its floodplain; Tahoma Creek partially avulsed into the west floodplain, topping banks of an undersized channel and flooding the campground. I assessed hazards to infrastructure at the old campground location, where the Park proposes to rebuild the remaining campground roads and sites. This assessment focuses on two major hazards: northward Nisqually River migration, which may reincorporate the floodplain into the river destroying infrastructure; and Tahoma Creek avulsions, which may flood the campgroud and deposit sediment burying campground infrastructure. I quantify northward migration by: estimating migration rates and changes to channel width; evaluating river occupation of the pre- and post-2006 campground; and estimating scour depths at revetments protecting the campground. I digitized the Nisqually River channels and channel centerlines from maps and images between 1955 and 2013 into a GIS, which I used to estimate migration rate and river width changes. Centerline migration rates average 9 ft/yr along the length of the Nisqually River study reach; at Sunshine Point lateral migration rates average 11 ft/yr. Maximum migration along the study reach was 19 ft/yr between 2006 and 2009. Greater than average migration rates and channel widths correspond to river confluences and include the Tahoma Creek confluence at Sunshine Point. To determine historical channel locations and the frequency that the river occupied different parts of its floodplain, I digitized the river from maps and images between 1903 and 2013. The Nisqually River flows through Sunshine Point Campground in eight out of 15 historical images. I assess scour at revetments protecting infrastructure from the Nisqually River during a 100-year recurrence interval flood using measured cross-sections. During a 100-year flood, the Nisqually River may scour up to 10 feet below the bed elevation. These scour depths can destabilize critical revetments leaving loose unconsolidated riverbanks exposed to Nisqually River flows. To determine the causes, locations, and frequency of flood hazards from Tahoma Creek avulsions, I field map avulsion channels and compare the results with imagery and channel width changes between 1955 and 2013. Mapped avulsion channels occur with swaths of dead vegetation or nascent vegetation; both dead and recent vegetation are visibly distinct from surrounding vegetation in aerial images. Times of changes to these vegetation anomalies correspond to increases in Tahoma Creek channel width. Avulsions have occurred at least three times in the study period: pre-1955, between 1979 and 1984, and in 2006. The 1984 and 2006 avulsions both occur after increases in Tahoma Creek reach averaged width. The NPS is considering two options to rebuild Sunshine Point Campground, both at the same location. The hazards posed by the Nisqually River and Tahoma Creek at Sunshine Point will affect both construction options equally. Migration hazards to the campground may be reduced by limiting the proposed campground infrastructure to an elevated ridge that has not been occupied by the Nisqually River since 1903. The hazards of damage from migration may be reduced by revetments, which were effective in preventing northward Nisqually River migration in 1959 and 1965. Tahoma Creek avulsions are related increased of Tahoma Creek reach averaged widths, which are near a 58- year maximum, and occurred during a 10-year flood in 1984. The campground may be as susceptible to flooding from avulsions during as little as a 10-year flood. A large avulsion may occur with the next significant Tahoma Creek width increase. Glacial retreat has been shown to increase debris flow activity and increase sediment delivery to Mount Rainier rivers. Increased sediment discharge has been correlated with aggradation, which will further encourage Tahoma Creek avulsions.