Andre Wajnsztejn

Complications and outcomes of the transfibular approach for posterolateral fractures of the tibial plateau

OBJECTIVE Evaluate complication rates and functional outcomes of fibular neck osteotomy for posterolateral tibial plateau fractures. DESIGN Retrospective case series. SETTING University hospital. PATIENTS From January 2013 to October 2014, 11 patients underwent transfibular approach for posterolateral fractures of the tibial plateau and were enrolled in the study. All patients who underwent transfibular approach were invited the return to the hospital for another clinical and imaging evaluation. INTERVENTION Transfibular approach (fibular neck osteotomy) with open reduction and internal fixation for posterolateral fractures of the tibial plateau. MAIN OUTCOME MEASUREMENTS Complications exclusively related to the transfibular approach: peroneal nerve palsy; knee instability; loss of reduction; nonunion and malunion of fibular osteotomy; and functional outcomes related to knee function. RESULTS Two patients failed to follow-up and were excluded from the study. Of the 9 patients included in the study, no patients demonstrated evidence of a peroneal nerve palsy. One patient presented loss of fracture reduction and fixation of the fibular neck osteotomy, requiring revision screw fixation. There were no malunions of the fibular osteotomy. None of the patients demonstrated clinically detectable posterolateral instability of the knee following surgery. American Knee Society Score was good in 7 patients (77.8%), fair in 1 (11.1%), and poor in 1 (11.1%). American Knee Society Score/Function showed 80 points average (60-100, S.D:11). CONCLUSION The transfibular approach for posterolateral fractures is safe and useful for visualizing posterolateral articular injury. The surgeon must gently protect the peroneal nerve during the entire procedure and fix the osteotomy with long screws to prevent loss of reduction. LEVEL OF EVIDENCE Therapeutic level IV.

Effectiveness of intra-articular lidocaine injection for reduction of anterior shoulder dislocation: randomized clinical trial

CONTEXT AND OBJECTIVE Shoulder dislocation is the most common dislocation among the large joints. The aim here was to compare the effectiveness of reduction of acute anterior shoulder dislocation with or without articular anesthesia. DESIGN AND SETTING Prospective randomized trial conducted in Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-Unifesp). METHODS From March 2008 to December 2009, 42 patients with shoulder dislocation were recruited. Reductions using traction-countertraction for acute anterior shoulder dislocation with and without lidocaine articular anesthesia were compared. As the primary outcome, pain was assessed through application of a visual analogue scale before reduction, and one and five minutes after the reduction maneuver was performed. Complications were also assessed. RESULTS Forty-two patients were included: 20 in the group without analgesia (control group) and 22 in the group that received intra-articular lidocaine injection. The group that received intra-articular lidocaine had a statistically greater decrease in pain over time than shown by the control group, both in the first minute (respectively: mean 2.1 (0 to 5.0), standard deviation, SD 1.3, versus mean 4.9 (2.0 to 7.0, SD 1.5; P < 0.001) and the fifth minute (respectively: mean 1.0; 0 to 3.0; SD = 1.0 versus mean 4.0; 1.0 to 6.0; SD = 1.4; P < 0.001). There was one failure in the control group. There were no other complications in either group. CONCLUSION Reduction of anterior shoulder dislocation using intra-articular lidocaine injection is effective, since it is safe and diminishes the pain. CLINICAL TRIAL REGISTRATION ISRCTN27127703.

Reproducibility of three classifications of proximal humeral fractures

OBJECTIVE To propose a new system for classifying proximal humeral neck fractures, and to evaluate intra- and interobserver agreement using the Neer system that is the most commonly used in the area and the Arbeit Gemeinschaft für Osteosynthesefragen system created by an European group, and a new classification system proposed by the authors of this study. METHODS A total of 56 patients with proximal humeral fractures were selected, and submitted to digitized simple radiography in antero-posterior shoulder and scapular profile. Radiographs were analyzed by three observers at time one, and then three and six weeks later. The kappa coefficient modified by Fleiss was used for the analysis. RESULTS The mean intra-observer Kappa agreement index (k = 0.687) of the new classification, was higher than both the Neer classification (k = 0.362) and the Arbeit Gemeinschaft für Osteosynthesefragen (k = 0.46). The mean interobserver Kappa agreement index (0.446) of the new classification, also had better results than both the Neer classification (k = 0.063) and the Arbeit Gemeinschaft für Osteosynthesefragen (k = 0.028). CONCLUSION the new classification considering bone compression had higher results for intra- and interobserver compared to the Neer system, and the Arbeit Gemeinschaft für Osteosynthesefragen system.

Unusual presentation of a femoral stress fracture

Stress fractures are common injuries in sports medicine. Among these fractures, femoral neck stress fractures frequently have a benign course, especially when it happens in the medial aspect of the neck. This case report describes a stress fracture of the medial aspect of the femoral neck that developed a complete fracture and underwent surgical fixation.

CROSS-SECTIONAL STUDY ON DIFFERENT ENTRY POINTS FOR ANTEROGRADE FEMORAL INTRAMEDULLARY OSTEOSYNTHESIS

Objective: To analyze the degree of knowledge among professionals who treat fractures using the recommended technique, with regard to correlating the nail with the entry point that is considered appropriate. Methods: A questionnaire that presented five types of nail and simulated a transverse diaphyseal fracture of the femur was developed. Results: Responses regarding the entry points corresponding to choosing the type of nail were obtained from 370 orthopedists who were participating in the 41st Brazilian Congress of Orthopedics and Traumatology. It was observed that only 20% correctly identified the entry point and that there was no difference between the professionals within the specialty of Traumatology and the others. Conclusion: It was concluded that the majority of the physicians attending the congress were unaware of the entry points.

Estudo transversal sobre os diferentes pontos de entrada na osteossíntese intramedular femoral anterógrada

OBJECTIVE: To analyze the degree of knowledge among professionals who treat fractures using the recommended technique, with regard to correlating the nail with the entry point that is considered appropriate. METHODS: A questionnaire that presented five types of nail and simulated a transverse diaphyseal fracture of the femur was developed. RESULTS: Responses regarding the entry points corresponding to choosing the type of nail were obtained from 370 orthopedists who were participating in the 41st Brazilian Congress of Orthopedics and Traumatology. It was observed that only 20% correctly identified the entry point and that there was no difference between the professionals within the specialty of Traumatology and the others. CONCLUSION: It was concluded that the majority of the physicians attending the congress were unaware of the entry points.

Fratura periprotética após artroplastia reversa do ombro. Relato de caso

RESUMO As fraturas periproteticas do ombro representam uma grave complicacao apos a substituicao da articulacao. Devido ao rapido aumento do numero de cirurgias de artroplastia reversa no ombro, as fraturas periprotese do umero, descritas como raras, podem aumentar no futuro proximo. Descrevemos um caso de fratura desviada do umero abaixo do componente umeral de uma artroplastia reversa. A paciente era uma mulher de 85 anos de idade, que tinha uma artroplastia reversa do ombro ha 6 anos. O tratamento cirurgico [...]

Minimally invasive posteromedial percutaneous plate osteosynthesis for diaphyseal tibial fractures: technique description

PURPOSE The aim of this study was to evaluate the feasibility of performing minimally-invasive plate osteosynthesis (MIPO) in tibial fractures using two posteromedial incisions, and to measure the distance between the plate and neurovascular structures. MATERIALS AND METHODS We performed nine dissections of specimens that were submitted to tibial MIPO with two posteromedial incisions. One locking compression plate (LCP) of 14 to 16 holes was inserted into the submuscular tunnel in a retrograde manner. Incisions were linked to evaluate the distance between neurovascular structures and the plate. RESULTS During the proximal incision, a blunt dissection between semitendinosus and medial gastrocnemius tendons, as well as their lateral shift, helped to protect the main local neurovascular structures. In its distal portion, the submuscular plate tunnel insertion and its direction to the proximal incision prevented direct contact and possible damage to neurovascular structures. Moreover, we obtained successful results from a patient submitted to this procedure. CONCLUSION Posteromedial MIPO represents a safe and attractive alternative for tibial fractures, particularly if there are damaged soft tissues in the anterior and medial side, or when access to intramedullary osteosynthesis is blocked.

Periprosthetic humeral fractures after reverse shoulder arthroplasty. Case report

ABSTRACT Periprosthetic fractures is a severe complication after joint replacement. The rapidly increase of reverse shoulder arthroplasty surgeries, periprosthetic humeral fractures, which are described as rare, may increase in the near future. We report the case of displaced humeral fracture bellow the stem of reverse shoulder prosthesis. The patient was an 85-year-old woman who had a total shoulder replacement 6 years previously. The surgical solution consisted of plate osteossynthesis and cerclage. This report describes an unprecedented case in Brazilian literature; and gives an overview of the existing literature including this injury classification.

Cesarean section and osteosynthesis of lower limb fractures in the same surgical procedure

INTRODUCTION Orthopedic trauma during pregnancy can cause serious complications such as premature birth, stillbirth and maternal morbidities. PRESENTATION OF CASE We report the case of a patient at 38 weeks pregnancy who fractured the left ankle and the right fifth metatarsal after falling. Cesarean section and osteosynthesis were performed in the usual manner in the same surgical procedure. There were no postoperative complications. DISCUSSION Pregnancy and puerperium are associated with a hypercoagulable state. The early mobilization provided by surgical treatment of the fractures reduced the risks of thromboembolic events. CONCLUSION The approach adopted may be used as an example for future procedures done in similar situations.