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OBJECTIVES: We aimed to perform a systematic review and network meta-analysis to evaluate the preventive strategies for preterm birth in twin-to-twin transfusion syndrome. METHODS: PubMed, Embase and Cochrane Central were searched from inception to December 2023 with no filters. Additionally, the reference lists of the included studies were manually examined to identify any supplementary studies. We selected randomized controlled trials and cohorts comparing interventions to prevent preterm birth in twin pregnancies complicated by twin-to-twin transfusion syndrome. A random-effects frequentist network meta-analysis was performed using RStudio version 4.3.1. Randomized controlled trials and cohorts were assessed respectively using the Risk of Bias in Non-randomized Studies of interventions tool and Cochrane Collaboration's tool for assessing risk of bias in randomized trials. RESULTS: In this systematic review and meta-analysis, we included eight studies comprising a total of 719 patients. Compared with expectant management, cerclage stood out as the only intervention associated with an increase in the survival of at least one twin (risk ratio 1.12; 95 % confidence interval 1.01-1.23). Our subgroup analysis based on different thresholds for short cervix demonstrated a significant reduction in the risk of preterm birth before 32 weeks with ultrasound-indicated cerclage using a 15 mm criterion (risk ratio 0.65; 95 % confidence interval 0.47-0.92). CONCLUSIONS: Our study suggests the potential benefit of cerclage as a preventive strategy for preterm birth in pregnancies complicated by twin-to-twin transfusion syndrome. These findings highlight the necessity for further investigation to corroborate our results and address the optimal threshold for ultrasound-indicated cerclage.

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BACKGROUND: Both progestogens and cerclage are individually effective in preterm birth prevention in high risk pregnancies. However, national and international guidelines cite a lack of data available to comment on the potential benefit of concurrent progestogen therapy after cerclage has been placed. Studies to date have been small with mixed results regarding benefit of concurrent progestogen with cerclage leaving uncertainty regarding best clinical practice. OBJECTIVE: This study aimed to evaluate whether cerclage with progestogen therapy was superior to cerclage alone in the prevention of spontaneous preterm birth in singleton pregnancies. METHODS: This is an international retrospective cohort study of singleton pregnancies, without major anomaly or aneuploidy, and with cerclage placed at 10 different institutions in the United States and Colombia from June 2016 to June 2020. Exclusion criteria were lack of documentation regarding whether progestogen was prescribed, unavailable delivery outcome, and pregnancy termination (spontaneous or induced) before 16 weeks' gestation. The exposure of interest was progestogen use with cerclage placement, which included those who continued to use progestogen or who started progestogen after cerclage. The comparison group consisted of those without progestogen use after cerclage placement, which included those who had no progestogen use during the entire pregnancy or who initiated progestogen and then stopped it after cerclage placement. Progestogen type, cerclage indication, maternal baseline characteristics, and maternal/neonatal outcomes were collected. The primary outcome was spontaneous preterm birth at <37 weeks. The secondary outcomes were spontaneous preterm birth at <34 weeks, gestational age at delivery, and a composite neonatal outcome including ≥1 of the following: perinatal mortality, confirmed sepsis, grade III or IV intraventricular hemorrhage, retinopathy of prematurity, respiratory distress syndrome, and bronchopulmonary dysplasia. There were planned subgroup analyses by cerclage indication, progestogen type (vaginal progesterone vs 17-hydroxyprogesterone caproate), preterm birth history, and site. Continuous variables were compared in adjusted analyses with analysis of covariance, and categorical variables were compared with multivariable logistic regression, adjusting for potential confounders with adjusted odds ratio. A Cox regression survival curve was generated to compare latency to spontaneous delivery, censored after 37 weeks. RESULTS: During the study period, a total of 699 singletons met the inclusion criteria: 561 in the progestogen with cerclage group and 138 with cerclage alone. Baseline characteristics were similar, except the higher likelihood of previous spontaneous preterm birth in the progestogen group (61% vs 41%; P<.001). Within the progestogen group, 52% were on 17-hydroxyprogesterone caproate weekly, 44% on vaginal progesterone daily, and 3% on oral progesterone daily. Progestogen with cerclage was associated with a significantly lower frequency of spontaneous preterm birth <37 weeks (31% vs 39%; adjusted odds ratio, 0.59 [0.39-0.89]; P=.01) and <34 weeks (19% vs 27%; adjusted odds ratio, 0.55 [0.35-0.87]; P=.01), increased latency to spontaneous delivery (hazard ratio for spontaneous preterm birth <37 weeks, 0.66 [0.49-0.90]; P=.009), and lower frequency of perinatal death (7% vs 16%; adjusted odds ratio, 0.37 [0.20-0.67]; P=.001). In planned subgroup analyses, association with reduced odds of preterm birth <37 weeks persisted in those on vaginal progesterone, those without a previous preterm birth, those with ultrasound- or examination-indicated cerclage, those who started progestogen therapy before cerclage, and in sites restricted to the United States. CONCLUSION: Use of progestogen with cerclage was associated with reduced rates of spontaneous preterm birth and early spontaneous preterm birth compared with cerclage alone. Although this study was not sufficiently powered for subgroup analysis, the strength of evidence for benefit appeared greatest for those with ultrasound- or examination-indicated cerclage, and with vaginal progesterone. El resumen está disponible en Español al final del artículo.

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PURPOSE: Despite various existing surgical techniques, treatment of facial nerve palsy remains difficult. The purpose of this report is to present the cerclage sling technique using temporalis fascia to manage paralytic lagophthalmos. METHODS: A series of six patients underwent a cerclage sling technique using temporalis muscle fascia to treat paralytic lagophthalmos. The technique is presented in detail. Symptoms, palpebral fissures, and lagophthalmos were assessed pre- and postoperatively. Data were submitted for statistical analysis. RESULTS: After surgery, all patients achieved a reduction in clinical symptoms. The upper eyelids had lowered, and the inferior eyelids had elevated, reducing ocular exposure even if mild residual lagophthalmos was present. CONCLUSION: Cerclage using the temporalis muscle fascia sling technique is a safe and effective procedure to treat facial nerve paralytic lagophthalmos. A reduction in ocular exposure and lagophthalmos provides improvement in clinical symptoms and eyelid function.

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SUMMARY OBJECTIVE: This study aims to investigate the predictive value of hemogram parameters in early preterm delivery (32 gestational weeks and below) among pregnant women who have undergone cervical cerclage, based on cervical changes determined before the cerclage procedure. METHODS: Between 2010 and 2020, a total of 161 patients underwent cervical cerclage. The participants were divided into three groups. Group 1 (n=92) consisted of pregnant women who underwent prophylactic cerclage. Group 2 (n=31) included those with cervical shortening (<5 mm) and/or dilation (≤3 cm). Group 3 (n=38) comprised pregnant women with cervical dilation >3 cm. Each group was further divided based on delivery weeks, with a cutoff at 32 weeks. Demographic parameters and laboratory parameters were assessed. RESULTS: In Group 1, all hemogram parameters showed no significant differences between deliveries below and above 32 weeks. In Group 2, the neutrophil-to-lymphocyte ratio value before cerclage was higher in the early preterm delivery group (p=0.002), with a cutoff value of 4.75 in receiver operating characteristic analysis. In Group 3, the white blood cell value before cerclage was higher in the early preterm delivery group (p=0.005), with a cutoff value of 13.05×103/μL in receiver operating characteristic analysis. CONCLUSION: The use of hemogram parameters to predict early preterm delivery in pregnant women undergoing prophylactic cerclage is not appropriate. However, neutrophil-to-lymphocyte ratio value can predict early preterm delivery when cervical dilation is 3 cm or less and/or cervical shortening is 5 mm or less. When cervical dilation exceeds 3 cm, the white blood cell value is more appropriate for predicting early preterm delivery.

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Abstract Objective The aim of the present study is to compare the effectiveness of Arabin pessary and McDonald cervical cerclage on preterm delivery. Methods We conducted a retrospective analysis of data from patients who underwent either Arabin pessary or McDonald cerclage between January 1, 2019, and January 1, 2023. A total of 174 patients were included in the study, with 31 undergoing Arabin pessary and 143 receiving cervical cerclage using the McDonald technique in singleton pregnant women with cervical insufficiency, which applied between 14 and 22 gestational weeks. We included singleton pregnant women with normal morphology, and with normal combined test. The primary outcome was the impact of each method on preterm delivery (< 34 gestational weeks). Results The weeks of cervical cerclage or pessary application were compatible with each other (p< 0.680). The pessary group had a statistically significant longer time to delivery compared with the Cerclage group (cerclage group mean 30.8 c 7.1 standard deviation [SD] versus pessary group mean 35.1 ± 4.4 SD; p< 0.002). A statistically significant difference was found between the pessary and cerclage groups in terms of delivery at < 34 weeks (p= 0.002). In patients with cervical length between 25 and 15mm and < 15mm, no significant difference was found between the pessary and cerclage groups in terms of delivery week (p< 0.212; p< 0.149). Regardless of the technique applied, no statistically significant difference was observed between cervical length and birth < 34 weeks. Conclusion Our study found that pessary use for cervical insufficiency is statistically more effective than cervical cerclage surgery in preventing preterm births < 34 weeks in singleton pregnancy.

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PURPOSE: To determine the predictive value of maternal White Blood Cells (WBC), neutrophils, and C-Reactive Protein (CRP) for diagnosing Histological Chorioamnionitis (HCA) among women with Preterm Premature Rupture of Membranes (PPROM) who underwent cervical cerclage. METHODS: A retrospective cross-sectional study was conducted among women with singleton pregnancy and PPROM, who underwent cervical cerclage during 2018-2020. RESULTS: A total of 55 eligible women were included in the final analysis, including 36 (61.02%) cases with HCA and 19 (38.98%) without HCA. Women with HCA had higher WBC count (12.31 ± 2.80) × 109/L and neutrophil count (9.67 ± 2.90)×109/L than those without HCA (10.35 ± 2.53) × 109/L and 7.82 ± 2.82 × 109/L, respectively) (both p < 0.05). The cut-off value of WBC count at 10.15×109/L was found to be the most effective in identifying HCA, with an Area Under Curve (AUC) of 0.707 (95% CI: 0.56-0.86; p = 0.012), sensitivity of 86.11%, specificity of 57.90%, Positive Predictive Value (PPV) of 79.49%, Negative Predictive Value (NPV) of 68.75%, and Youden index of 0.44. The combination of WBC + neutrophil had a slightly higher (AUC = 0.711, 95% CI: 0.57-0.86; p = 0.011), specificity (68.42%), and PPV (81.25%), but lower sensitivity (72.22%), than the WBC count alone. A cut-off value of neutrophil at 7.46 × 109/L was effective in identifying HCA, with an AUC of 0.689 (95% CI: 0.53-0.84; p = 0.022). DISCUSSION: Combination use of WBC+neutrophil was found to be the most accurate predictor of HCA among women with PPROM after surgery of cervical cerclage.

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Introducción : el tratamiento de la insuficiencia cervical es el cerclaje cervical. Pese a este tratamiento el riesgo de parto prematuro persiste elevado en mujeres con insuficiencia cervical. La mejor forma y utilidad del seguimiento ecográfico de mujeres cercladas es desconocida. El objetivo de esta revisión fue evaluar la capacidad pronóstica de la ecografía transvaginal para predecir riesgo de parto prematuro luego de un cerclaje cervical. Materiales y métodos : realizamos una revisión sistemática de la literatura incluyendo estudios que evaluaran el valor pronóstico de la ecografía transvaginal luego de un cerclaje cervical, para predecir parto prematuro. Resultados : incluimos 14 estudios en la revisión. El parámetro más frecuentemente asociado con parto prematuro fue la longitud cervical posterior al cerclaje, aunque con capacidad predictiva moderada. El punto de corte para definir pacientes en riesgo varió entre 15-28 mm. Conclusión : la longitud cervical disminuida posterior a un cerclaje se asocia con mayor riesgo de parto prematuro. No se ha establecido un valor de corte único ni la utilidad clínica del seguimiento ecográfico de mujeres cercladas.

Introduction : The management of cervical insufficiency involves a cervical cerclage. Despite this treatment, patients with cervical insufficiency remain at high risk of preterm delivery. The best method and utility of ultrasound monitoring for women with cervical cerclage is unknown. The objective of this revision was to evaluate the prognostic performance of ultrasonographic cervical assessment to predict preterm labor after a cervical cerclage. Material and methods : We conducted a systematic literature review, including studies that assessed the prognostic value of transvaginal ultrasound after cervical cerclage in predicting premature birth. Results : We included 14 studies in our review. The most frequently evaluated parameter was cervical length after the cerclage, although with only moderate predictive capacity. The length used to define prognosis varied from 15 to 28 mm. Conclusion : Short cervical length after a cerclage is associated with a higher risk of preterm delivery. A single cutoff value and the clinical utility of ultrasound monitoring for women with cervical cerclage have not been established.

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This report describes the combination of two surgical fracture repair techniques and the postoperative management of a mandibular diastemal fracture in a two-year-old mare. The mare was referred to a veterinary hospital with a laceration over the body of the right mandible. Radiographic assessment revealed two mesial fracture lines involving the second premolar tooth and a ventrally displaced bone fragment. The mare was treated under general anesthesia and the fracture was corrected using open reduction and plate fixation. A 3.5 mm narrow 15-hole locking compression plate with seven locking screws were used in a bridge form. Cerclage wire was also used to anchor the incisor teeth to the second and third premolar teeth. The cerclage wire and incisor teeth were covered with polymethylmethacrylate to prevent implant failure and avoid injury to the oral mucosa. Implants were removed 55 days after surgery and the mare was discharged from hospital five days later. The mare returned for cerclage wire removal after 90 days and was allowed to resume exercise thereafter. The combination of two surgical techniques, proper implant choice and appropriate postoperative management, including use of pelleted feed, contributed to successful bone healing and return to function.

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ABSTRACT Purpose: To determine the predictive value of maternal White Blood Cells (WBC), neutrophils, and C-Reactive Protein (CRP) for diagnosing Histological Chorioamnionitis (HCA) among women with Preterm Premature Rupture of Membranes (PPROM) who underwent cervical cerclage. Methods: A retrospective cross-sectional study was conducted among women with singleton pregnancy and PPROM, who underwent cervical cerclage during 2018-2020. Results: A total of 55 eligible women were included in the final analysis, including 36 (61.02%) cases with HCA and 19 (38.98%) without HCA. Women with HCA had higher WBC count (12.31 ± 2.80) × 109/L and neutrophil count (9.67 ± 2.90)×109/L than those without HCA (10.35 ± 2.53) × 109/L and 7.82 ± 2.82 × 109/L, respectively) (both p < 0.05). The cut-off value of WBC count at 10.15×109/L was found to be the most effective in identifying HCA, with an Area Under Curve (AUC) of 0.707 (95% CI: 0.56-0.86; p = 0.012), sensitivity of 86.11%, specificity of 57.90%, Positive Predictive Value (PPV) of 79.49%, Negative Predictive Value (NPV) of 68.75%, and Youden index of 0.44. The combination of WBC + neutrophil had a slightly higher (AUC = 0.711, 95% CI: 0.57-0.86; p = 0.011), specificity (68.42%), and PPV (81.25%), but lower sensitivity (72.22%), than the WBC count alone. A cut-off value of neutrophil at 7.46 × 109/L was effective in identifying HCA, with an AUC of 0.689 (95% CI: 0.53-0.84; p = 0.022). Discussion: Combination use of WBC+neutrophil was found to be the most accurate predictor of HCA among women with PPROM after surgery of cervical cerclage.

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BACKGROUND: To evaluate the outcomes of transiliac cerclage with Dall-Miles cable in the internal fixation of the posterior complex in unstable pelvic ring fractures between January 1995 and December 2014. MATERIAL AND METHODS: A study of 42 men injured at work with an average age of 35.2 years (range, 23 to 61) was conducted. The mechanisms of injury were traffic accidents in 25 cases (59.5%), crushing accidents in 12 cases (28.6%), and fall from height in 5 cases (11.9%). Thirty-six cases were polytraumatized patients (85.7%). The patients were evaluated using Majeeds functional score and Mattas radiological criteria. RESULTS: The average follow-up time was 135.8 45.6 months. The clinical outcomes were excellent in 17 cases (40.5%), good in 19 cases (45.2%), fair in 5 cases (11.9%), and poor in 1 case (2.4%). The radiological outcomes were satisfactory in 32 cases (76.2%) and unsatisfactory in 10 cases (23.8%). All fractures were healed. The sequelae were 3 cases (7.2%) of lower limb dysmetria and 3 cases (7.2%) of chronic neuropathic pain. CONCLUSION: The internal fixation of the sacroiliac complex by Dall-Miles cable cerclage reinforced with small fragment plates should be considered as an alternative method for minimally invasive osteosynthesis in selected cases of unstable pelvic ring fractures.

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La insuficiencia del cérvix es una alteración del tejido cervical que impide mantener el embarazo hasta su término, provocando pérdidas fetales recurrentes en el segundo trimestre de embarazo. Se presenta un caso de incompetencia cervical, causante de tres abortos previos, el último pese a cerclaje vaginal; por tanto, se realiza cerclaje por vía abdominal, logrando un embarazo viable hasta las 35,6 semanas, que termina en cesárea por amenaza de parto pretérmino y ruptura prematura de membranas. Además, se expone una revisión de la literatura sobre el tratamiento de esta patología..Au

Incompetence of the cervix is an alteration of the cervical tissue that prevents maintaining the pregnancy until its term, causing recurrent fetal losses in the second trimester of pregnancy. A case of cervical incompetence is presented, causing three consecutive abortion, the last one despite vaginal cerclage, therefore, abdominal cerclage is performed,achieving a viable pregnancy until 35,6 weeks, ending in caesarean section due to threat of preterm delivery plus premature rupture of membranes. In addition, a review of the literature on the treatment of this pathology is presented..Au

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Introducción: El parto pretérmino constituye una causa importante de morbimortalidad perinatal con repercusiones sociales y económicas a nivel mundial. La intervención oportuna ante la identificación de factores de riesgo y un adecuado manejo consiguen reducir su incidencia y evitar las consecuencias de la prematurez. Objetivo: El presente trabajo se realiza con el objetivo de destacar al pesario cervical como una herramienta mecánica en la prevención del parto pretérmino, y una opción de tratamiento en embarazos mayores de 25 semanas con insuficiencia cervical. Presentación del caso: Se trata de una paciente de 38 años de edad con antecedente de parto pretérmino espontaneo (de 33 semanas), que ingresa a las 21 semanas de embarazo con dilatación cervical de 3cm y acortamiento de la longitud cervical de 14mm, signos ecográficos: sludge y funneling. Se optó por manejo expectante con medidas complementarias: administración de antibiótico, progesterona y uso de pesario cervical. Tras el control clínico de la infección y mayor acortamiento cervical a 7mm a pesar del uso de progesterona, se colocó un pesario cervical a las 25,5 semanas, a las 27,5 semanas fue dada de alta, a las 36,6 semanas se retiró el pesario tras inicio de actividad uterina. Discusión: La progesterona y el cerclaje son medidas de elección en casos de insuficiencia cervical, sin embargo, ante las dificultades técnicas de colocación; el pesario representó una alternativa. El uso de pesario permitió que el embarazo progrese al término con resultados beneficiosos y sin evidencia de efectos adversos.

Introduction: Preterm delivery is an important cause of perinatal morbidity and mortality with global social and economic repercussions. Timely intervention in the identification of risk factors and proper management reduce their incidence and avoid the consequences of prematurity. Objective:This work is carried out with the aim of highlight the cervical pessary as a mechanical tool in the prevention of preterm birth and a treatment option in pregnancies over 25 weeks with cervical insufficiency. Case presentation: This is a 38-year-old patient with a history of spontaneous preterm delivery (33 weeks), who was admitted at 21 weeks of pregnancy with cervical dilation of 3cm and shortening of the cervical length of 14mm, ultrasound signs: sludge and funneling. Expectant management was opted, with complementary measures: administration of antibiotics, progesterone and use of a cervical pessary. After clinical control of the infection and greater cervical shortening to 7mm despite the use of progesterone, a cervical pessary was placed at 25.5 weeks, at 27.5 weeks she was discharged, at 36.6 weeks she was discharged. The pessary was removed after the start of uterine activity. Discussion: Progesterone and cerclage are the measures of choice in cases of cervical insufficiency, however, given the technical difficulties of placement; the pessary represented an alternative. Conclusion: The use of the pessary allowed the pregnancy to progress to term with beneficial results and without evidence of adverse effects.

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STUDY OBJECTIVE: To demonstrate the surgical technique of laparoscopic cerclage (LAC) in nonpregnant women with a clinical diagnosis of cervical incompetence. In this video, the authors describe the complete procedure in 10 steps to standardize and facilitate the comprehension and performance of the procedure in a simple and safe way. DESIGN: Step-by-step video demonstration of the surgical technique. SETTING: Private hospital in Curitiba, Paraná, Brazil. INTERVENTIONS: The patient was 32 years old (gravidity and parity, G3A3; late progressive miscarriage), had no comorbidities, and had a radiologic diagnosis of cervical incompetence. The main steps of LAC are described in detail. A complete laparoscopic approach was performed. Under general anesthesia, the patient was placed in the 0-degree supine decubitus position with arms alongside her body. The operative setup included a 15-mm Hg pneumoperitoneum created using the closed Veress technique and 4 trocars: a 10-mm trocar at the umbilicus for a 0-degree laparoscope; a 5-mm trocar in the right iliac fossa; a 5-mm trocar in the left iliac fossa; and a 5-mm trocar in the suprapubic area. After systematic exploration of the pelvic and abdominal cavities, the procedure began. Step 1 involved identification of anatomic key landmarks and exposure of the operation field. Step 2 involved opening of the anterior peritoneum. The anterior peritoneal reflection was opened over the peritoneum uterovesicalis and then extended laterally until the uterine artery could be clearly identified on both sides. Step 3 involved dissection of the avascular space on each side of the uterus. The vesical-cervical avascular space was created, and the bladder was pushed down, away from the isthmus area. Step 4 involved preparation for a perfect stitch placement. A 5-mm Mersilene suture (Ethicon, Somerville, NJ) with a straight needle was introduced by a suprapubic trocar into the abdominal cavity before a complete identification of uterine vessels at both the sides using atraumatic graspers. Step 5 involved identification of the perfect space in the posterior aspect for Mersilene suture placement. Step 6 was to make a perfect anterior stitch. For this, the needle was grasped at the proximal portion in a 90-degree angle. In posterior position and when helped by a cranial and posterior uterine mobilization, the needle passed through the right, broad ligament in the avascular space created on the anterior leaf and medially from the uterine artery until the tip of the needle was seen on the posterior face above the uterosacral ligament. All steps were possible by synchronic uterine mobilization. Step 7 was to make a perfect posterior stitch. The procedure was then repeated contralaterally following the same anatomic and technical precepts but from posteriorly to anteriorly. Step 8 involved correct positioning and orientation of the Mersilene suture far away from the ureter and medial to the uterine arteries 2 cm over the uterosacral ligaments. Step 9 involved fixation of the Mersilene suture with an adequate blocking sequence. Step 10 involved fixation of the Mersilene suture and reperitonealization. The tape was knotted with an adequate blocking intracorporeal suturing sequence at the cervicoisthmic junction, and a Monocryl 2-0 stitch (Ethicon, Somerville, NJ) was made to fix the knot and left it horizontally. Finally, the procedure was ended with anterior reperitonealization, covering all the plica uterovesicalis and mesh, leaving it completely extraperitoneal. The surgery ended without any intraoperative complications and within 30 minutes. Patient was discharged on the first day postoperatively and became pregnant 6 months after surgery, with a C-section delivery of a healthy term newborn at 39 weeks of gestational age. CONCLUSION: LAC in nonpregnant women with a diagnosis of cervical incompetence is safe and feasible in experienced hands, adding all the intrinsic advantages of minimally invasive surgery and providing better obstetric outcomes. In this patient, the procedure was performed without any intra- or postoperative complications, and the patient had an uneventful term pregnancy in the follow-up period. We must remember that adequate standardization of surgical procedures will help reduce the learning curve.

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Resumen OBJETIVO: Reportar la experiencia en la práctica de cerclajes con indicación profiláctica y terapéutica en pacientes con embarazo único o múltiple, con insuficiencia cervical. Además, informar los días de gestación ganados y comparar las técnicas quirúrgicas con los cerclajes. MATERIALES Y MÉTODOS: Estudio retrospectivo, descriptivo, comparativo y transversal efectuado entre enero de 2011 y enero de 2018. Criterios de inclusión: pacientes a quienes se efectuó un cerclaje y el embarazo finalizó en nuestra unidad. Variables de estudio: edad, IMC, embarazos, abortos, días de gestación ganados, días en que se efectuó el procedimiento quirúrgico, semanas de gestación cumplidas a la finalización del embarazo, tiempo quirúrgico, medicamentos (tocolíticos y antibióticos), complicaciones a partir del cerclaje hasta la finalización del embarazo. Para el análisis descriptivo se utilizó el paquete estadístico IBM SPSS (versión 22); la distribución se obtuvo con t de Student, se aplicó la prueba de normalidad Shapiro-Wilk y las variables con distribución normal se analizaron, comparativamente, con ANOVA y las de distribución anormal con la prueba Kruskal-Wallis. RESULTADOS: Se analizaron 37 casos en los que el cerclaje prolongó 116.14 ± 47.4 días la gestación, con finalización promedio del embarazo a los 246.41 ± 26.54 días. El cerclaje Shirodkar fue superior: prolongó la gestación 134.69 días con finalización del embarazo a las 36 ± 2 semanas. CONCLUSIONES: En pacientes con insuficiencia cervical el cerclaje es una opción para prolongar el embarazo. La técnica Shirodkar tuvo márgenes de mayor seguridad hasta la finalización del embarazo (más de 34 semanas). El comportamiento en embarazos múltiples es similar, por lo que en caso de insuficiencia cervical debe aplicarse.

Abstract OBJECTIVE: To report the experience in the practice of cerclages with prophylactic and therapeutic indication in patients with single or multiple pregnancy, with cervical incompetence. In addition, report the days of pregnancy gained, compare surgical techniques and cerclages in single and multiple gestations. MATERIALS AND METHODS: Retrospective, descriptive, comparative and cross-sectional study carried out between January 2011 and January 2018. Inclusion criteria: patients who had a cerclage and the pregnancy ended in our unit. Study variables: age, BMI, pregnancies, abortions, days of gestation earned, days in which they were placed, weeks of gestation completed at the end of pregnancy, surgical time, medications (tocolytics and antibiotics), complications from the placement of the cerclage until the end of pregnancy. For the descriptive analysis the statistical package IBM SPSS (version 22) was used; the distribution was obtained with Student's t test, the Shapiro-Wilk normality test was applied and the variables with normal distribution were analyzed, comparatively, with ANOVA and those with abnormal distribution with the Kruskal-Wallis test. RESULTS: 37 cases were analyzed in which the placement of cerclage prolonged 116.14 ± 47.4 days gestation, with an average termination of pregnancy at 246.41 ± 26.54 days. The Shirodkar cerclage was superior: it extended gestation 134.69 days with the end of pregnancy at 36 ± 2 weeks. CONCLUSIONS: In patients with cervical incompetence cerclages are an option to prolong pregnancy. The Shirodkar technique had higher safety margins until the end of pregnancy (more than 34 weeks). The behavior in multiple pregnancies is similar, so in case of cervical incompetence should be applied.

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RESUMEN Introducción: La insuficiencia cervical se concibe hoy día como un proceso biológico continuo con grados progresivos de insuficiencia. La expresión más extrema de la insuficiencia cervical se conoce como "bolsa en reloj de arena". La mayoría de los autores están de acuerdo en recomendar el reposo en cama y realizar cerclaje cervical de emergencia. Objetivo: Presentar el caso de una gestante en la que se logró la reversión del prolapso de las membranas amnióticas en "reloj de arena" con buenos resultados perinatales. Presentación de caso: Paciente de 31 años con antecedentes de parto anterior a las 36,5 semanas, que en los momentos actuales cursa una gestación de 20,6 semanas. Acude a la consulta por dolor en hipogastrio y al examen físico se comprueba que la bolsa amniótica protruye por el orificio cervical externo y presenta una dilatación cervical de 2 cm. Se aplica tratamiento medicamentoso y se reduce el prolapso de la bolsa. Conclusiones: Con el tratamiento conservador se logró una buena evolución de la gestación, con parto eutócico y buenos resultados perinatales(AU)

ABSTRACT Introduction: Cervical insufficiency is conceived today as a continuous biological process with progressive degrees of insufficiency. The most extreme expression of cervical insufficiency is known as "hourglass bag". Most authors agree to recommend bed rest and perform emergency cervical cerclage. Objective: To report the case of a pregnant woman in whom the prolapse reversal of the amniotic membranes in hourglass was achieved with good perinatal results. Case report: A 31-year-old patient who is currently pregnant at 20.6 weeks and has history of childbirth prior to 36.5 weeks. She comes to the consultation complaining of pain in hypogastrium. The physical examination shows that the amniotic sac protrudes through the external cervical orifice and there is 2cm cervical dilation. Drug treatment is applied and the prolapse of the sac is reduced. Conclusions: The conservative treatment achieved good evolution of the gestation, with eutócico childbirth and good perinatal results(AU)

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SUMMARY BACKGROUND: The gestational and neonatal outcomes of women with early cervical dilatation undergoing emergency cerclage were evaluated and compared with women treated with expectant management and bed rest. METHODS: Retrospective analysis of pregnant women admitted between 2001 and 2017 with a diagnosis of early cervical dilatation and/or bulging membranes. Patients with a singleton pregnancy of a fetus without malformations, between 16 and 25 weeks and 6 days, with cervical dilatation of 1 to 3 cm were included; patients who delivered or miscarried within 2 days after admission were excluded. RESULTS: The study enrolled 30 patients: 19 in the cerclage group and 11 in the rest group. There was a significant difference, with the cerclage group showing better results concerning gestational age at delivery (28.7 vs. 23.3 weeks; p=0.031) and latency between hospital admission and delivery (48.6 vs. 16 days; p=0.016). The fetal death rate was lower in the cerclage group (5.3% vs. 54.5%, p=0.004). Considering gestational age at delivery of live newborns, no difference was observed between the cerclage and rest groups (29.13 vs. 27.4 weeks; p=0.857). CONCLUSIONS: Emergency cerclage was associated with longer latency, a significant impact on gestational age at delivery and reduction in the fetal death rate.

RESUMO OBJETIVO: Os resultados gestacionais e neonatais de mulheres com cervicodilatação precoce submetidas à cerclagem de emergência foram avaliados e comparados com mulheres tratadas com manejo expectante com repouso no leito. MÉTODOS: Análise retrospectiva de gestantes admitidas entre 2001 e 2017 com diagnóstico de cervicodilatação precoce e/ou membranas protrusas. Foram incluídas pacientes com gestação única de feto sem malformações, entre 16 semanas e 25 semanas e 6 dias, com dilatação cervical de 1 a 3 cm; as pacientes que tiveram parto ou aborto dentro de 2 dias após admissão foram excluídas. RESULTADOS: O estudo envolveu 30 pacientes: 19 no grupo cerclagem e 11 no grupo repouso. Houve diferença significativa, com o grupo cerclagem apresentando melhores resultados em relação à idade gestacional no parto (28,7 vs. 23,3 semanas; p=0,031) e à latência entre a admissão hospitalar e o parto (48,6 vs. 16 dias; p=0,016). A taxa de mortalidade fetal foi menor no grupo cerclagem (5,3% vs. 54,5%, p=0,004). Considerando a idade gestacional no nascimento dos recém-nascidos vivos, não houve diferença entre os grupos cerclagem e expectante (29,13 vs. 27,4 semanas; p=0,857). CONCLUSÕES: A cerclagem de emergência foi associada a maior período de latência com impacto significativo na idade gestacional do parto e à redução da taxa de mortalidade fetal.

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Background The frequency of intra-amniotic infection/inflammation (IAI/I) in patients with midtrimester cervical insufficiency is up to 50%. Our purpose was to determine the perinatal outcomes of cervical cerclage in patients with acute cervical insufficiency with bulging membranes, and to compare the admission-to-delivery interval and pregnancy outcomes according to the results of amniotic fluid (AF) analysis and cerclage placement. Methods This was a retrospective cohort study including singleton pregnancies with cervical insufficiency between 15 and 26.9 weeks in two tertiary health centers. IAI/I was defined when at least one of the following criteria was present in AF: (a) a white blood cell (WBC) count >50 cells/mm3; (b) glucose concentration <14 mg/dL; and/or (c) a Gram stain positive for bacteria. Three different groups were compared: (1) absence of IAI/I with placement of a cerclage; (2) amniocentesis not performed with placement of a cerclage; and (3) IAI/I with or without a cerclage. Results Seventy patients underwent an amniocentesis to rule out IAI/I. The prevalence of IAI/I was 19%. Forty-seven patients underwent a cerclage. Patients with a cerclage had a longer median admission-to-delivery interval (33 vs. 2 days; P < 0.001) and delivered at a higher median gestational age (27.4 vs. 22.6 weeks; P = 0.001) than those without a cerclage. The neonatal survival rate in the cerclage group was 62% vs. 23% in those without a cerclage (P = 0.01). Patients without IAI/I who underwent a cerclage had a longer median admission-to-delivery interval (43 vs. 1 day; P < 0.001), delivered at a higher median gestational age (28 vs. 22.1 weeks; P = 0.001) and had a higher neonatal survival rate (67% vs. 8%; P < 0.001) than those with IAI/I. Conclusion The pregnancy outcomes of patients with midtrimester cervical insufficiency and bulging membranes are poor as they have a high prevalence of IAI/I. Therefore, a pre-operative amniocentesis is key to identify the best candidates for the subsequent placement of a cerclage.

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BACKGROUND: Amputation at the level of the hindfoot results in an equinus deformity from an imbalance of muscle-tendons acting across the ankle. Boyd's reconstruction for hindfoot amputations is a well-known technique that retains the calcaneus and fuses it with the distal tibia at the ankle mortise. It provides an excellent weight-bearing stump and in most cases does not require an artificial limb but its use has been restricted because of the difficulty in obtaining high union rates in the tibiocalcaneal fusion. MATERIALS AND METHODS: Five patients (four unilateral and one bilateral) underwent leg amputations from January 2012 to November 2013 using the Boyd technique for reconstructing the stump and were stabilized with a tension band. The study sample consisted of adult patients who had traumatic reasons for the amputation. Patients under 18 years old with a hindfoot that was inadequate for Boyd reconstruction (i.e., insufficient soft tissue coverage or no posterior tibial artery pulse) were excluded. One (case #2) had systemic comorbidities (e.g., hypertension, diabetes, chronic vascular insufficiency) as well as being a smoker. Three men and two women (mean age 39 years; range 21-61 years) were included. Three patients underwent amputation on the right side, one on the left side, and one bilaterally (case #5). All patients presented with Gustillo and Anderson IIIC open fractures. The mean time from lesion to amputation was 2.25 weeks (range 1-4 weeks). The mean follow-up duration was 16 (range 12-24) months. The post-surgery examination included a clinical examination and radiography. A 6 minute walk test (6 MWT) was performed on week 32 after the amputation. This study was carried out with the approval of our institution's ethics committee. All patients provided a written informed consent form in accordance with the World Medical Association and the Declaration of Helsinki. RESULTS: All six stumps fused successfully. The 6 MWT results were comparable to those found in the literature for other lower limb amputees. CONCLUSION: The tension band technique used as part of the Boyd amputation to achieve tibiocalcaneal fusion was effective in all five trauma patients. Sound fusion was achieved in all cases with the 6 MWT scores comparable to that in the literature. This technique should be considered an osteosynthesis option for the Boyd procedure. LEVEL OF EVIDENCE: Level IV, retrospective study. HOW TO CITE THIS ARTICLE: Mongon MLD, Sposito AL, Nunes GMN, et al. Boyd Amputation Using the Tension Band Technique. Strategies Trauma Limb Reconstr 2019;14(2):102-105.

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OBJECTIVES: This study aimed to evaluate, by means of a systematic review, the efficiency of new methods for sternal closure in order to prevent sternal wound complications after sternotomy. METHODS: The method of study was a systematic review of randomized clinical trials. We included studies that used rigid plates, thermoreactive clips, cables and flat wires, in comparison with the standard closure method. Patients included adults, regardless of gender and race. RESULTS: Seven clinical trials were included involving 1810 patients. Five trials were carried out in the USA, 1 in Australia and 1 in Italy, and the trials include both male and female patients. The included studies compared conventional sternal closure with new closure methods (rigid plate, thermoreactive clips, cables and flat wires). The new sternal closure methods make little or no difference compared to the standard closure when we analyse deep sternal wound infection [risk ratio 0.38, 95% confidence interval (CI) 0.02-7.63; I2 = 74%; 5 studies], superficial wound infection (risk ratio 1.34, 95% CI 0.46-3.92; I2 = 11%, 3 studies) and death (risk ratio 1.16, 95% CI 0.42-3.21; I2 = 0%, 3 studies), but pain score was lower in new sternal closure methods (mean difference -0.57, 95% CI -0.98 to -0.16, I2 = 0%, 3 studies). There were no meta-analyses of sternal union, hospital stay, reoperation or mechanic ventilation time because of the high heterogeneity between the studies in terms of these outcomes. CONCLUSIONS: New sternal closure methods probably make little or no difference regarding the prevention of sternal complications in the postoperative period when compared to the standard closure method.

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Resumen Las fracturas de la mandíbula no son raras en equinos, siendo este el hueso de la cabeza más fracturada. En la mayoría de los casos, se abren y se ven involucrados tejidos blandos adyacentes. Como los huesos de la cabeza no son sometidos a fuerzas de carga de apoyo, la fijación de la fractura es menos desafiante. El presente trabajo describe el tratamiento quirúrgico en campo de una fractura mandibular en una yegua Criolla Colombiana de 64 meses de edad. Esta presenta mala oclusión con desgarro de la mucosa bucal. La proyección radiográfica oral muestra una fractura abierta transversal en el cuerpo mandibular a nivel de la región de la placa alveolar derecha. La anestesia se inicia con acepromazina (0,04 mg/kg intramuscular) e inducción con xilacina (1,1 mg/kg) y ketamina (2,2 mg/kg Intravenosa). Se utilizó una anestesia total intravenosa con triple goteo para mante nimiento (2 g de ketamina + 500 mg de xilacina en 1 litro de guaifenesina al 5%) en infusión constante (2-3 ml/kg/h). Después de limpiar y desbridar la herida se realiza una incisión a través de la mejilla sobre los premolares 406 y 407. Se perforó un orificio con una broca entre los espacios interalveolares de los premolares. Se pasó el alambre a través del agujero, el fue dirigido rostralmente y atado a través de los agujeros previamente hechos entre los incisivos 402 y 403. El alambre se torció para aumentar la compresión en la línea de la fractura. Después de apretar, los extremos de los cables se doblaron. El manejo posoperatorio se basó en la administración de ketoprofeno durante 5 días, Penicilina G (20.000 UI/kg) y desinfección diaria de la herida con Clorhexidina 0,12%. El alambre se dejó 4 semanas, observando una rápida cicatrización y consolidación de la fractura. El restablecimiento de las funciones de aprehensión y masticación se obtuvieron rápidamente. Se puede afirmar que esta técnica proporciona una estabilidad segura, es fácil de realizar y de bajo costo.

Abstract Secondary mandible fracture due to external trauma is not uncommon in horses, that being the most commonly fractured bone when the injure is on the animal´s head. In most cases, the injuries are open and damaging to surrounding soft tissues. As the bones of the head are not subjected to load forces, the support requirements for fracture fixation are less challenging. This paper describes the surgical treatment in field of a mandibular fracture in e 64-month-old Colombian Creole mare. It shows malocclusion with a tear on the buccal mucosa. Oral radiographic projection shows an open transverse fracture in the mandibular body at the level of the right alveolar plate region. Anesthesia is initiated with acepromazine (0.04 mg/kg intramuscular) and induction with xylazine (1.1 mg/kg) and ketamine (2.2 mg/kg intravenous). Total intravenous anesthesia with triple drip was used for maintenance (2 g of ketamine + 500 mg of xylazine in 1 liter of 5% guaifenesin) in constant infusion (2-3 ml/kg/h). After cleaning and debriding the wound, an incision is made through the cheek on the premolars 406 and 407. An orifice is drilled between the interalveolar spaces of the premolars. The wire is passed through the hole, which is routed rostrally and tied through the holes previously made between the incisors 402 and 403. The wire is twisted to increase compression in the fracture line. After tightening, the ends of the cables are bent. Post-operative management was based on the ad ministration of ketoprofen for 5 days, Penicillin G (20,000 IU/kg) and daily disinfection of the wound with Chlorhexidine 0.12%. The wire was left for 4 weeks, observing rapid healing and consolidation of the fracture. The restoration of the functions of apprehension and chewing were obtained quickly. It can be said that this technique provides a safe stability, is easy to perform and inexpensive.

Resumo Fraturas da mandíbula secundárias a trauma externo não são raras em equinos, sendo este o osso mais comumente fraturado quando o trauma é na região da cabeça. Na maioria dos casos, são abertas e com dano aos tecidos moles adjacentes. Como os ossos da cabeça não são submetidos às forças de carga do apoio, a exigência para fixação da fratura é menos desafiadora. O presente trabalho descreve o tratamento cirúrgico em campo de uma fractura da mandibula em uma égua criolla colombiana de 64 meses. Ela mostra maloclusão com uma lágrima na mucosa bucal. A projeção radiográfica oral mostra uma fratura transversal aberta no corpo mandibular ao nível da região da placa alveolar direita. A anestesia é iniciada com acepromazina (0,04 mg/kg intramuscular) e indução com xilazina (1,1 mg/kg) e cetamina (2,2 mg/kg por via intravenosa). Anestesia venosa total com tríplice gotejamento foi utilizada para manutenção (2 g de cetamina + 500 mg de xilazina em 1 litro de guaifenesina a 5%) em infusão constante (2-3 ml/kg/h). Após a limpeza e desbridamento da ferida, uma incisão é feita através da bochecha nos pré-molares 406 e 407. Um orifício é perfurado entre os espaços interalveolares dos pré-molares. O fio é passado através do orifício, que é encaminhado rostralmente e amarrado através dos orifícios feitos anteriormente entre os incisivos 402 e 403. O fio é torcido para aumentar a compressão na linha de fractura. Após o aperto, as extremidades dos cabos são dobradas. O tratamento pós-operatório foi baseado na administração de cetoprofeno por 5 dias, Penicilina G (20.000 UI/kg) e desinfecção diária da ferida com Clorexidina 0,12%. O fio foi deixado por 4 semanas, observando-se rápida cicatrização e consolidação da fratura. A restauração das funções de apreensão e mastigação foram obtidas rapidamente. Pode-se dizer que esta técnica proporciona uma estabilidade segura, é fácil de executar e barata.