Introduction: Foetal surgical repair of myelomeningo-cele protects the spinal cord and prevents the development of Chiari malformation and hydrocephalus. The procedure needs manipulation of the fragile foetal tissues and tension free closure of the skin.

With translational purposes, since January 2004 we have developed a novel foetal procedure in a sheep model that avoids foetal tissue manipulation. The technique consists in a gentle coverage of the defect using an inert patch sheet secured by a surgical sealant. results in the animal model showed adequate protection of the spinal cord and prevention of the Chiari malformation. Later on, this technique has been used in two human foetuses.

Case 1: Female foetus 24 weeks old. Lumbar myelo-meningocele, spontaneous mobility of the legs, mild ventricular dilatation, previous c-section and posterior placenta.

Foetal repair was done in August 2008 by means of closure of the dural sac and coverage with a patch of collagen-elastin matrix) secured with surgical sealant.

Birth delivery happened at 31 weeks due to uterine rupture in the scar from a previous c-section. At birth, the newborn weighted 1.5Kg, and showed a complete closure of the defect without leakage of cerebrospinal fluid, and normal legs mobility. Cranial MRI showed small cerebelar herniation and small ventricular dilatation. One year after birth the baby is able to walk, but the ventricular dilatation has progressed and a shunt was placed on at 11 months of life.

Case 2: Male foetus 23 weeks old. Lumbosacral defect, spontaneous mobility of the legs, mild ventricular dilatation, cerebelar herniation, previous c-section and anterior placenta.

Foetal repair was made in January 2009 by means of closure of the dural sac and coverage with a patch secured with surgical sealant.

Birth delivery was done at 30 weeks due to oligoamnios. At birth the newborn weighted 1Kg, and showed closure of the defect without leakage of cerebrospinal fluid, and normal legs mobility. Cranial MRI showed correction of the Chiari malformation and no ventricular dilatation. Eight months after birth the baby is fine and stable.

Conclusion: Surgical foetal coverage of myelomenin-gocele using inert patch and surgical sealant is a fast and gentle procedure for the foetus that avoids tissue manipulation, enhances closure of the defect and prevents Chiari malformation and hydrocephalus.

Amniotic band syndrome (ABS) is a congenital disorder characterized by limb constrictions. The disorder lacks precise definition, and its exact pathogenesis is unknown. Though theories have been advanced to explain the condition’s origin, none have been scientifically validated. The “exogenous” theory, popularized by Torpin, is the most widely accepted. It suggests that early amniotic rupture leads to formation of amniotic strands, which by means of progressive compression induce formation of extremity bands. In this disorder, histological examination of the excised bands demonstrates them to be composed of fibrous tissue. Multiple clinical and experimental data reveal this theory has only low plausibility. Our purpose is to assess whether annular external compression of a fetal rabbit limb will produce a band of subcutaneous fibrous tissue characteristic of amniotic band syndrome.

We operated on one limb of 10 different rabbit fetuses, each at 21 days of gestation. The extremity was ligated with a nylon suture at the infracondylar level. At 30 days gestation, each fetus was delivered by caesarean section. Limbs were analyzed histologically using different techniques. Histological analysis did not show subcutaneous fibrous tissue in the mechanically constricted zone. The distal segment showed dilatation of lymphatic vessels and edema of soft tissue.

Annular external compression of a fetal rabbit limb does not induce development of new fibrous tissue; therefore this experimental study does not support the theory of a mechanical exogenous pathogenesis in amniotic band syndrome.

The continuous leakage of cerebrospinal fluid in the mielomeningocele (MMC) area produces the Chiari II malformation. The aim of our study was to assess the effect of preterm delivery and prenatal corticosteroids administration in the degree of Chiari malformation.

Seventy-five out of 148 foetuses from 17 pregnant New Zealand White rabbits underwent lumbar three-level laminectomy and wide opening of dura-mater (surgical MMC). Animals were distributed in five groups: group T, foetuses with MMC, delivery at term and no other treatment; group TC, foetuses with MMC, delivery at term and prenatal administration of corticosteroids; group P, foetuses with MMC, delivery preterm and no other treatment; group PC, foetuses with MMC, delivery preterm and prenatal administration of corticosteroids; group C, controls. The degree of herniation was measured in percentage of decrease of the cerebellum between the inferior limit of the skull and the superior limit of the first vertebra, and compared among groups.

We obtained 7T, 5TC, 10P, 6PC, and 28C alive newborns. All groups with prenatal delivery or prenatal corticosteroids showed statistically significant minor degree of herniation than T-group: group TC IC 95% between 25.7 and 47.2% minor (p=0.000), group P IC 95% between 30.4 and 47.7% minor (p=0.000), group PC IC 95% between 32.6 and 55.4 minor (p=0.000). There were no statistically significant differences among groups TC and P (p=0,577), TC and PC (p=0,227) or P and PC (p=0,311).

Preterm delivery and prenatal administration of corticosteroids, together or separately, result in lower degree of Chiari malformation in a model of surgical MMC in rabbit fetuses.

Introduction. With the use of fetoscopy (minimally invasive surgery), the indications for foetal surgery have been expanded. Extremities at risk of amputation by EAB are amenable to foetal surgery. A previous model of in uterus reparation of moderate EAB has been reported. The purpose of this study is to evaluate the feasibility of intrauterine foetal release of amputating EAB.

Material and methods. Right limbs of fifteen 60-days gestational age pregnant sheep were ligated with silk suture at the infracondilar level. Left limbs were used for paired comparison. Foetuses were randomized in three groups: early repair group (n=5), late repair group (n=5) and no-repair group (n=5). The limbs of repaired groups underwent foetal release. The limbs obtained from at term foetuses were analyzed morphologically, functionally, radiologically, and histologically. Statistical analysis with paired test was used to compare data.

Results. Non-repaired limbs showed amputation or quasi-amputation; the repaired ones did not. However, those late repaired had significantly reduced passive ankle range of motion, shorter limb length, and mild residual changes.

Conclusions. In uterus release of potentially severe EAB avoids limb amputation and permits its morphological and functional recovery. Early release shows better results.

Open fetal surgery for reparation in myelomeningocele reverses Chiari II malformation and protects exposed neural elements from secondary lesion, but the technique is associated with a high rate of complications. The aim of our study was to assess whether a simple and fast technique of coverage produces the same results as a complete and longer technique of reparation in terms of neural protection.

Twelve sheep’s foetuses underwent lumbar three-level laminectomy and opening of the dura-mater on the 75th day of the gestation. Four of them were not-repaired (NR group). Eight of them underwent coverage with inert material sheet and synthetic surgical sealant on the 95th day (R group). At birth, clinical and histological examination and comparison between groups was performed.

None NR animal were able to stand or to walk nor had sphincter continence; all of them showed a wide defect of closure in the lumbar area, continuous leakage of cerebrospinal fluid (CSF), and histological neural damage; the mean vermis herniation was 75%. All R animals were able to stand and to walk and all of them showed sphincter continence; none of them showed leakage of CSF and showed coverage of the 93% of the defect; all of them showed regeneration of dura-mater, muscle and skin; the mean vermis herniation was 10%.

A simplified technique of coverage produces the same clinical results than a more complex reconstruction in a model of surgical MMC in sheep and the histological study reveals the regeneration of several layers of soft tissues.

Introduction and purpose: Different neurovascular structures may be damaged when making arthroscopic portals to the shoulder joint. The description of new portals poses new challenges. The goal of the present study is to provide an update on the anatomic vasculonervous responses of the current approaches to shoulder arthroscopy.

Materials and methods: 16 fresh cadavers were systematically dissected. The most usual arthroscopic portals were marked and, then, the dissection started on a plane-to-plane basis. Relationships were identified and distances were measured to the most important neurovascular elements with a standard caliber (accuracy: 0.5mm).

Results: The portals studied and the structures at risk were the following:

* Posterior portal: anterior branch of the axillary nerve and posterior circumflex artery 3.4 cm (range: 1.4 – 5); cutaneous branch of the axillary nerve 6.3 cm (range: 3.8 – 8.3), suprascapular nerve 2.8 cm (range: 2.1–3.3).

Conclusions: Although the crucial elements at risk when performing a shoulder arthroscopy are multiple, the axillary and suprascapular nerves were the most vulnerable structures to the different approaches. In spite of the presence of the “safe areas” described above, the neurovascular bundle was frequently affected by passage through the anteroinferior subaxillary portal. The results suggest that the use of this portal is not safe for routine arthroscopic practice.

Introduction and Objectives: Arthrodesis of the knee is the method that most readily controls septic processes and results in a non-painful, stable knee joint. However, the disadvantages of this technique are shortening of the limb and a loss of joint function.

Materials and Methods: We present here our unit’s experience in the use of the Orthofíx ® transport system on the anterior surface to stabilise this type of arthrodesis. We used radiological techniques to evaluate the alignment and coaptation of the surfaces to be arthodesed. We also assessed functional capacity, postoperative patient satisfaction, rate of repeat arthrodesis, consolidation time, and complications associated with this method.

Results: According to our results, femorotibial arthrodesis with the bone transport system provides all the advantages of monolateral external fixation while allowing compression of the point of arthrodesis, achieving perfect coaptation, and providing extraordinary rigidity to the mounting.

Discussion and Conclusions: As with all other procedures, femorotibial arthrodesis has its complications. The complication directly related to knee arthrodesis is femorotibial non-union, which is correlated with a loss of bone stock, incomplete coaptation, poor alignment of the limb, persistent infection, and inadequate immobilisation. We believe this procedure produces a functional limb with significant relief of pain in most patients.