RESUMO
Introducción: Las técnicas mínimamente invasivas son las preferidas para tratar las roturas agudas del tendón de Aquiles. Representan una opción para evitar las complicaciones tegumentarias, y la lesión del nervio sural es uno de sus principales problemas. El objetivo de este estudio fue comprobar la utilidad de la ecografía para prevenir la lesión del nervio sural durante la reparación del tendón de Aquiles con técnicas percutáneas. materiales y métodos: Estudio en 12 piezas cadavéricas. Se recreó una lesión en el tendón de Aquiles 5 cm proximales de su inserción distal. En uno de los miembros del cadáver, se identificó el nervio sural o su vena satélite mediante ecografía. Se reparó el nervio sural por vía percutánea con dos agujas proximales y dos agujas distales a la lesión, y se representó el recorrido del nervio sural. En el miembro contralateral, no se identificó el nervio sural mediante ecografía. Se efectuó la reparación percutánea de las lesiones mediante la técnica de Ma y Griffith. Resultados: En el grupo ecográfico, no se identificaron lesiones del nervio sural. En el grupo de control, se observaron dos lesiones del nervio sural (p = 0,6). En todos los casos, la identificación del nervio sural mediante ecografía fue correcta. Conclusión: La asistencia ecográfica en el tratamiento percutáneo de las lesiones del tendón de Aquiles es un método eficaz y confiable para evitar las lesiones del nervio sural. Nivel de Evidencia: III
Introduction: Minimally invasive techniques are preferred to treat acute Achilles tendon ruptures. They represent an option to avoid integumentary complications, and sural nerve injury is one of its main problems. This study aims to verify the usefulness of ultrasound in preventing sural nerve injury during Achilles repair with percutaneous techniques. materials and methods: Study in 12 cadaveric pieces. We recreated an injury at the level of the Achilles tendon, 5 cm proximally to its distal insertion. In one of the cadaver limbs, the sural nerve and/or its satellite vein were identified by ultrasonography. We repaired the sural nerve percutaneously with two needles at the proximal level and two needles at the distal level of the lesion and represented the path of the sural nerve. In the contralateral limb, the sural nerve was not identified by ultrasound. We performed the percutaneous repair of the injuries using the Ma & Griffith technique. Results: In the ultrasound group, no sural nerve injuries were identified. In the control group, two sural nerve injuries were observed (p=0.6). In all cases, the identification of the sural nerve by ultrasound was correct. Conclusion: Ultrasound assistance in the percutaneous treatment of Achilles tendon injuries is an effective and reliable method to prevent sural nerve injuries. Level of Evidence: III
Assuntos
Tendão do Calcâneo/cirurgia , Tendão do Calcâneo/lesões , Nervo Sural/lesões , Ultrassonografia , Procedimentos Cirúrgicos Minimamente Invasivos , Articulação do Tornozelo/cirurgiaRESUMO
Resumo Contexto Na insuficiência venosa crônica (IVC), a veia safena parva (VSP) é afetada em 15% dos casos. A cirurgia convencional é a técnica padrão para o tratamento da insuficiência da VSP, sendo a lesão no nervo sural uma complicação bastante temida. O tratamento de termoablação com endolaser tende a ser um método cirúrgico que diminui complicações da terapia cirúrgica da IVC. Objetivos Avaliar os pacientes com IVC submetidos à terapia por endolaser da VSP ao menos 30 dias após o procedimento. Métodos Foram analisados 54 membros inferiores de 46 pacientes submetidos à terapia por endolaser 1470 nm, sob anestesia local, para o tratamento da IVC em um hospital terciário. Os pacientes foram avaliados no período pré-operatório, intraoperatório e pós-operatório de 30 dias, através da clínica, exame físico e achados ecográficos. Resultados Nos 54 membros inferiores submetidos ao tratamento, comparando-se o período pré-operatório e o 30º dia pós-operatório, houve diferença significativa (p < 0,003) na redução do diâmetro da VSP tratada (6,37 mm pré-operatório e 5,15 mm no 30º dia pós-operatório) (IC95% 4,58-5,72) e na melhora do escore de gravidade clínica venosa (VCSS) (média de 8,02 pré-operatório e 6,11 no 30º dia pós-operatório) (IC95% 5,01-7,21) (p < 0,02). Complicações pós-operatórias, como parestesia e flebite, estiveram presentes e foram diagnosticadas em cinco e três pacientes, respectivamente, sem significar alteração na qualidade de vida e nas atividades de rotina. Conclusões A técnica de termoablação com laser da VSP mostrou-se segura e eficaz na redução dos sintomas clínicos e na melhora da qualidade de vida.
Abstract Background The small saphenous vein (SSV) is affected in 15% of chronic venous insufficiency (CVI) cases. Conventional surgery is the standard technique for treatment of SSV insufficiency, but sural nerve injury is a complication of great concern. Endovenous laser ablation is a surgical technique for treatment of CVI that is considered likely to reduce morbidity and mortality. Objectives To evaluate patients with CVI undergoing endovenous laser ablation of the SSV at least 30 days after the procedure. Methods We analyzed 54 lower extremities in 46 patients scheduled for 1470-nm endovenous laser ablation under local anesthesia to treat CVI in a tertiary hospital. Patients were evaluated preoperatively, intraoperatively, and postoperatively over 30 days with clinical examination, physical examination, and ultrasound. Results In the 54 lower extremities treated, there was a significant difference (p < 0.003) in terms of reduction in the diameter of treated veins (6.37 mm preoperatively and 5.15 mm on the 30th postoperative day) and improvement in the venous clinical severity score (VCSS) (means of 8.02 preoperative and 6.11 on the 30th postoperative day) (95%CI, 5.01—7.21) (p < 0.02). Postoperative complications such as paresthesia and phlebitis were present and diagnosed in 5 and 3 patients, respectively, but did not affect their quality of life or routine activities. Conclusions Intravenous laser ablation of the SSV proved to be safe and effective for reducing clinical symptoms and improving quality of life.
Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Insuficiência Venosa/cirurgia , Procedimentos Endovasculares/efeitos adversos , Complicações Pós-Operatórias , Veia Safena , Nervo Sural/lesões , Doença Crônica , Estudos Retrospectivos , Estudos Longitudinais , Extremidade Inferior , Terapia a Laser/métodos , Anestesia LocalRESUMO
Introdução: Lesões no terço distal dos membros inferiores, com exposição de ossos, articulações, tendões e vasos sanguíneos, não são passíveis do uso de enxertos de pele. Isto ocorre porque o leito vascular é exíguo e pela pobre granulação das feridas, podendo apenas ser corrigidas com retalhos musculares, miocutâneos, fasciocutâneos ou transferência microcirúrgica. Métodos: O retalho em seu limite inferior é demarcado a partir de 5 cm acima dos maléolos. Superiormente, é marcado num comprimento suficiente para cobertura total da lesão. Realizada incisão em demarcação prévia, e elevados pele e tecido subcutâneo juntamente com a fáscia muscular. O nervo sural é preservado em seu leito original. A elevação do retalho se dá até o ponto inferior marcado (o pedículo). Neste ponto, o retalho é transposto numa angulação suficiente para alcançar a lesão. Resultados: Oito casos foram operados utilizando o retalho descrito. Todos apresentavam exposição de ossos e tendões em região distal da perna, dorso do pé ou ambos, nos quais foram utilizados o retalho fasciocutâneo reverso da perna com a técnica proposta por Carriquiry. Os casos apresentaram resultados estético e funcional satisfatórios. Conclusão: O retalho utilizado se presta à correção de lesões do terço inferior da perna e do pé. É relativamente fácil de ser confeccionado, com bom suprimento vascular, e não há perda funcional do leito doador.
Introduction: Skin grafts are not effective to cover lesions in the distal third of the lower limbs that expose the bones, joints, tendons, and blood vessels due to a limited vascular bed and poor granulation of the wounds. These lesions can only be corrected with microsurgical transfer or muscle, myocutaneous, or fasciocutaneous flaps. Methods: The lower border of the flap was marked 5 cm above the malleolus. The upper border was marked after providing sufficient length for complete coverage of the lesion. The incision was performed at the marked upper border, and the skin and subcutaneous tissue were elevated together with muscle fascia. The sural nerve was preserved in its original bed. The flap was lifted to the marked lower border (the pedicle). At this point, the flap was transposed at a sufficient angle to cover the lesion. Results: Eight cases of surgery were conducted using the flap described above. All cases had exposed bones and tendons in the distal region of the limb, back of the foot, or both, in which the reverse sural fasciocutaneous flap with the technique proposed by Carriquiry was used. The cases showed satisfactory esthetic and functional results. Conclusion: The used flap can correct lesions of the lower third of the limbs and foot. It is relatively easy to make, with good vascular supply, and there is no functional loss of the donor area.
Assuntos
Humanos , Nervo Sural/cirurgia , Nervo Sural/lesões , Retalhos Cirúrgicos/cirurgia , Ossos do Pé/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Extremidade Inferior/cirurgia , Extremidade Inferior/lesões , Ossos da Perna/cirurgiaRESUMO
Here we propose a model of a peripheral axon with a great deal of autonomy from its cell body-the autonomous axon-but with a substantial dependence on its ensheathing Schwann cell (SC), the axon-SC unit. We review evidence in several fields and show that (i) axons can extend sprouts and grow without the concurrence of the cell body, but regulated by SCs; (ii) axons synthesize their proteins assisted by SCs that supply them with ribosomes and, probably, with mRNAs by way of exosomes; (iii) the molecular organization of the axoplasm, i.e., its phenotype, is regulated by the SC, as illustrated by the axonal microtubular content, which is down-regulated by the SC; and (iv) the axon has a program for self-destruction that is boosted by the SC. The main novelty of this model axon-SC unit is that it breaks with the notion that all proteins of the nerve cell are specified by its own nucleus. The notion of a collaborative specification of the axoplasm by more than one nucleus, which we present here, opens a new dimension in the understanding of the nervous system in health and disease and is also a frame of reference to understand other tissues or cell associations.
Assuntos
Potenciais de Ação/fisiologia , Axônios/metabolismo , Regeneração Nervosa/fisiologia , Redes Neurais de Computação , Ribossomos/metabolismo , Células de Schwann/metabolismo , Animais , Axônios/ultraestrutura , Transporte Biológico , Comunicação Celular , Exossomos/metabolismo , Humanos , Microtúbulos/metabolismo , Microtúbulos/ultraestrutura , Fenótipo , RNA Mensageiro/metabolismo , Ratos , Células de Schwann/ultraestrutura , Transdução de Sinais , Nervo Sural/lesões , Nervo Sural/metabolismoRESUMO
El objetivo de este estudio fue determinar la influencia de la extensibilidad isquiosural en la morfología sagital del raquis e inclinación pélvica en deportistas jóvenes. Métodos. Un total de 152 deportistas (media de edad: 16,22 +/- 0,80 años) participaron voluntariamente en este estudio. La morfología sagital de las curvas torácica y lumbar, así como la inclinación pélvica, fueron evaluadas con un Spinal Mouse al realizar los test sit-and-reach, toe-touch y McRae & Wright. La extensibilidad isquiosural fue determinada mediante el test de elevación de la pierna recta (EPR). En base al valor obtenido en el test EPR, la muestra fue dividida en tres grupos (Grupo A: EPR < 76, n=49; Grupo B, EPR entre 76-88, n=45; y Grupo C, EPR > 88, n=50). Resultados. Los deportistas con menor extensibilidad isquiosural adoptaron posturas de mayor cifosis torácica y una mayor retroversión pélvica en los test sit-and-reach y toe-touch. No obstante, no se encontraron diferencias significativas entre grupos en el test McRae & Wright. Además, la extensibilidad isquiosural no tuvo influencia alguna en la morfología sagital del raquis lumbar. Conclusiones. Una menor extensibilidad isquiosural está relacionada con una mayor cifosis torácica y una mayor retroversión pélvica cuando se realizan movimientos de flexión máxima del tronco con rodillas extendidas. La extensibilidad isquiosural no afecta a la disposición sagital del raquis lumbar en movimientos de flexión máxima del tronco.
The objective of this study was to determine the influence of hamstring extensibility in sagittal spinal curvatures and pelvic inclination on young athletes. Methods: A hundred and fifty-two young athletes (mean age: 16.22 +/- 0.80 years) were recruited. Thoracic and lumbar curvatures and pelvic inclination were evaluated with a Spinal Mouse system in the sit-and-reach test, toe-touch test and McRae & Wright test. Hamstring muscle extensibility was determined by passive straight leg raise test (PSLR). The sample was divided into three groups with regard to straight leg raise angle (Group A: PSLR < 76, n=49; Group B, PSLR between 76-88, n=45; and Group C, PSLR > 88, n=50). Results. Athletes with lower extensibility presented higher thoracic angle and a more posterior pelvic tilt in the sit-and-reach and toe-touch tests. However, no significant differences were found between groups when maximal trunk flexion with knees flexed was performed (McRae & Wright test). The lumbar curve was not affected by hamstring extensibility in any position. Conclusions: Lower hamstring extensibility is related to increased thoracic curve and more posterior pelvic tilt when maximal trunk flexion with knees extended is performed. Hamstring extensibility has not any influence in sagittal lumbar morphology when trunk flexion is performed.
Assuntos
Adulto Jovem , Ossos Pélvicos/anatomia & histologia , Ísquio/anatomia & histologia , Ísquio/lesões , Nervo Sural/lesões , Canal Medular , Atletas , Ossos Pélvicos/lesões , PosturaRESUMO
OBJECTIVES: This study evaluates the results of an alternative technique developed to minimize the risk of complications associated with sural nerve biopsy for histopathological analysis. METHODS: Twelve subjects underwent sural nerve biopsy and the defect created in the nerve was bridged by a 50-mm-length segment of the saphenous vein; the control group enrolled 23 patients in whom the entire length of the nerve was harvested to be used as autograft for reconstruction of nerves in the upper limb. Sensory reinnervation was quantified by use of the monofilament test and the static 2-point discrimination test, after a follow-up period of 18 months. RESULTS: The mean time for recovery of protective sensation was 8.7 months in patients submitted to nerve repair, and 10.3 months in the control group (P > .05). The monofilament test and static 2-point discrimination testing demonstrated a mean value of 3.22 and 8 mm (S3), respectively, in the group who underwent sural nerve repair; and 4.17 and 13 mm (S2), respectively, for the control group (P <.05). CONCLUSION: The use of vein as conduits for the repair of the sural nerve did not shorten the time for sensory recovery at the autonomous zone of the nerve; however, the quality of the reinnervation was considered better than the control group. This study suggests that empty veins could be used as conduits to bridge gaps with a length up to 50 mm in cases of injuries of the sural nerve and, possibly, for injuries of other pure sensory nerves as well.
Assuntos
Biópsia/efeitos adversos , Microcirurgia/métodos , Procedimentos Neurocirúrgicos/métodos , Nervo Sural/cirurgia , Transplante de Tecidos/métodos , Veias/transplante , Adolescente , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Regeneração Nervosa/fisiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Recuperação de Função Fisiológica/fisiologia , Veia Safena/anatomia & histologia , Veia Safena/transplante , Transtornos de Sensação/etiologia , Transtornos de Sensação/fisiopatologia , Transtornos de Sensação/cirurgia , Nervo Sural/irrigação sanguínea , Nervo Sural/lesões , Transplante Autólogo/métodos , Veias/anatomia & histologia , Veias/inervação , Adulto JovemRESUMO
El colgajo neurocutáneo sural invertido está basado en el nervio sural con la arteria sural superficial, que por sus anastomosis con la arteria peronea en su parte distal, es posible diseñarlo a pedículo distal. Usamos este colgajo en 18 pacientes con diversas lesiones localizadas en el tercio distal de la pierna o del pie que comprometían el tendón de Aquiles, tendones extensores del pie y los dedos, o el sistema osteoarticular. Se logró cobertura en todos los pacientes. Sólo uno presentó necrosis del colgajo pero con viabilidad de la fascia profunda. El colgajo neurocutáneo sural invertido es una buena alternativa en los defectos de cobertura de la parte distal de la pierna, región históricamente difícil para lograr este objetivo.
Assuntos
Traumatismos do Pé , Fraturas Expostas , Traumatismos da Perna , Nervo Sural/lesões , Retalhos CirúrgicosRESUMO
Introdução: as perdas de substância localizadas no pé mostram-se bastante desafiadoras quanto a sua reconstrução. Os retalhos livres microcirúrgicos eram primeira escolha quando se necessitava de uma cobertura mais elaborada. Com a publicação de Masquelet e Col. (1992), abriu-se uma nova possibilidade de tratamento dessas lesões. Objetivo: mostrar que o retalho neurocutâneo sural constitui-se numa alternativa efetiva para o tratamento de lesões extensas no pé. Métodos: o retalho sural foi utilizado em 24 pacientes, no período de 1990 a 2006. Descreve-se a técnica de confecção deste retalho para cobrir lesões situadas no pé. Resultados: todos os defeitos foram corrigidos, com baixo índice de complicações. Discussão: Os retalhos microcirúrgicos, por muito tempo, foram a opção principal para o tratamento de lesões extensas localizadas no pé. Para a realização deste procedimento faz-se necessária a participação de equipe especializada e material especial. O retalho neurocutâneo sural substitui, em parte, os retalhos microcirúrgicos, com a vantagem de apresentar menor dificuldade técnica, confecção mais rápida, pequena morbidade e ser eficaz. Conclusão: o retalho neurocutâneo sural é eficiente na cobertura de lesões com perda de substância no pé e substitui, em muitos casos, o retalho microcirúrgico.
Background: the reconstructions related to loose of foot substance are challenging. The microsurgical flaps were the first choice when a more elaborated coverture was needed. With Masquelet e Col's publication (1992) a new possibility of treating those lesions was opened: the sural neurocutaneus flap. Objective: to show that the sural neurocutaneus flap is an effective alternative to treat extensive injuries on the foot. Methods: the sural neurocutaneus flap was used to cover the traumatic injuries on the foot of 24 patients, between the years of 1990 and 2006. This flap is made from the vascularization that follows the sural nerve and has become an excellent option for the treatment of lost of foot substance. Resultads: all the flaps were corrected with a low complication average.Discussion: the microsurgical flap asforalong time the main option when itcametotreating extensive injuries on the foot. The sural neurocutaneus flap replaces, partially, this flap, with the advantage of presenting a lower technical difficulty and also for being produced quicker, with small morbidity. Conclusions: the sural neurocutaneus flap is efficient in covering injuries with lost of foot substance.
Assuntos
Humanos , Pé , Deformidades Adquiridas do Pé , Nervo Sural , Deformidades Adquiridas do Pé/cirurgia , Deformidades Adquiridas do Pé/diagnóstico , Deformidades Adquiridas do Pé/reabilitação , Nervo Sural/anatomia & histologia , Nervo Sural/cirurgia , Nervo Sural/lesões , Torniquetes/história , TorniquetesRESUMO
The success of peripheral nervous system regeneration has been associated with changes on the microenvironment, particularly on the extracellular matrix (ECM) components. In the present study we analyzed by indirect immunohistochemistry, electron microscopy and Western blotting, the distribution of ECM components, metalloproteinases (MMPs) and their tissue inhibitors (TIMPs), during Wallerian degeneration (WD) and nerve regeneration (2nd, 7th and 21st days after injury) on crushed rat sural nerves. Our results showed that laminin alpha3-chain and alpha2-chain are over expressed during the early stages of degeneration and regeneration respectively, whereas type IV collagen expression increased progressively after crush. On the other hand, the expression of chondroitin sulfate was down regulated during the early stages of degeneration, returning progressively to normal values during nerve regeneration. The expression of MMP-3 was almost normal immediately after lesion, and then reduced progressively achieving the smallest expression at 21 days after crush; on the contrary, the expression of MMP-7 increased significantly immediately after crush (2nd day) returning to normal values afterwards. TIMP-1 and TIMP-2 were over expressed at the beginning of WD, returning progressively to normal values after that. These results indicate that the modifications of ECM components, which are favorable for nerve regeneration, are correlated with changes on the balance between MMPs and TIMPs.
Assuntos
Matriz Extracelular/metabolismo , Metaloproteases/metabolismo , Degeneração Neural/metabolismo , Regeneração Nervosa/fisiologia , Nervo Sural/metabolismo , Animais , Colágeno Tipo IV/metabolismo , Laminas/metabolismo , Metaloproteinase 3 da Matriz/metabolismo , Metaloproteinase 7 da Matriz/metabolismo , Compressão Nervosa , Ratos , Ratos Wistar , Nervo Sural/lesões , Nervo Sural/ultraestrutura , Fatores de Tempo , Inibidor Tecidual de Metaloproteinase-1/metabolismo , Inibidor Tecidual de Metaloproteinase-2/metabolismo , Cicatrização/fisiologiaRESUMO
The clinical and neuropathological findings an a patient with "neuritic" leprosy are described. In this rare form of leprosy, skin changes are only minimal or absent anf the diagnosis can be established only by nerve biopsy