Fernando Baldy dos Reis

Validity and reliability of the Western Ontario Rotator Cuff Index (WORC) for use in Brazil.

Objective:To evaluate the validity and reliability of the Brazilian Portuguese version of the Western Ontario Rotator Cuff Index (WORC). Design and Setting:A cross-sectional survey at the Physiotherapy Unit and Outpatient Orthopedic and Traumatology Clinic, Universidade Federal de São Paulo. Methods:To test validity, 100 patients with rotator cuff disorders were evaluated using the WORC, clinically relevant outcomes for patients with shoulder disorders (pain, range of motion, and strength), and the Disabilities of Arm, Shoulder, and Hand (DASH), University of California Los Angeles Shoulder Rating Scale (UCLA), and Short Form-36 (SF-36) self-report measures. The WORC was repeated on 50 patients on the same day (more than 1 hour later) and after a mean interval of 7 days to evaluate the test-retest reliability. Concurrent validity was tested by correlating the WORC to the other outcome measures using Pearsons correlation coefficient. Test-retest reliability and internal consistency were determined by the intraclass correlation coefficient and Cronbachs alpha coefficient, respectively. The scores were used to assess the standard error measurement (SEM) and minimal detectable change (MDC). Results:Analysis between the WORC and clinically relevant outcomes for patients with shoulder disorders revealed weak to strong correlations; the weakest for active internal rotation (r = -0.22) and the strongest for pain during movement (r = -0.75). Strong correlations were found among the WORC and the DASH and UCLA (r = -0.86 and r = 0.80, respectively). There were moderate correlations between the WORC and SF-36 domains (0.37 to 0.69); the best correlations related to the physical domains. Reliability analysis revealed excellent results, with the intraclass correlation coefficient ranging from 0.95 to 0.99 and Cronbachs alpha ranging from 0.88 to 0.97. The SEM was 5.2 and 3.0 for time 0 and after a mean interval of 7 days, respectively. The MDC was 7.1 over this mean time interval (90% confidence interval). Conclusions:The Brazilian version of the WORC proved to be a valid and reliable measurement tool for assessing health-related quality of life in patients with rotator cuff diseases.

Medidas de avaliação de qualidade de vida e estados de saúde em ortopedia

Measurements of quality of life and health status have been emphasized by the orthopedic community because they allow for an analysis of the health status and disease manifestations according to the own point of view of the individual. Studies have carefully analyzed the tools available and published recommendations for the most adequate choice of such tools. This study provides a brief description of the types of instruments, their application, their validation procedure, the instruments that are more commonly seen in the international literature, and those available for use in Brazil.

Failure of fixation of trochanteric femur fractures: Clinical recommendations for avoiding Z-effect and reverse Z-effect type complications.

BackgroundZ-effect and reverse Z-effect are complications that arise from the surgical treatment of pertrochanteric fractures of the femur with proximal femoral nails (PFN) comprising two interlocking head screws. Such complications are induced by the migration of screws in opposite directions, which may lead to failure of the osteosynthesis.FindingsThe paper describes three cases of pertrochanteric fractures that were treated with PFN with two interlocking screws that evolved to either Z-effect or reverse Z-effect. Literature-based explanations for this phenomenon are provided together with recommendations of how to avoid such complications.ConclusionsAlthough intramedullary fixation is an established method of treatment of femoral intertrochanteric and subtrochanteric fractures, the evolution of the procedure may include complications associated with the migration of the interlocking head screws. The occurrence of Z-effect and reverse Z-effect has not been completely elucidated, but the main causes of such complications are probably fracture fixation in varus position, severe medial comminution, inappropriate entry point of the nail and poor bone quality.

Elevada morbimortalidade e reduzida taxa de diagnóstico de osteoporose em idosos com fratura de fêmur proximal na cidade de São Paulo

OBJECTIVE To know the morbid-mortality following an osteoporotic hip fracture in elderly patients living in São Paulo. PATIENTS AND METHODS This study evaluated prospectively all patient over 60 years admitted in 2 school-hospitals in the city of São Paulo in a following 6-month period due to a osteoporotic proximal femur fracture. All of them filled up the Health Assessment Questionnaire (HAQ) and had their chart reviewed. After 6 months they were re-interviewed. Linear regression analysis was utilized to determine the factors related to functional ability. RESULTS 56 patients were included (mean age 80.7 +/- 7.9 years old, 80.4% females). After the 6-month follow up the mortality rate was 23.2%. Only 30% of the patients returned to their previous activities, and 11.6% became totally dependent. Factors related to worse functional ability after fracture were HAQ before fracture, institutionalization after fracture and age (r(2) 0.482). The diagnosis of osteoporosis was informed only by 13.9% of them, and just 11.6% received any treatment for that. CONCLUSION Our results showed the great impact of these fractures on mortality and in the functional ability of these patients. Nevertheless, many of our physicians do not inform the patients about the diagnosis of osteoporosis and, consequently, the treatment of this condition is jeopardized.

Outcome of diaphyseal forearm fracture-nonunions treated by autologous bone grafting and compression plating

BackgroundThe treatment of forearm fracture-nonunions continues to represent a therapeutic challenge, and reported outcomes are moderate at best. Limiting aspects of this particular anatomic location include the relation between restoration of shaft length with the anatomy and long-term functional outcome of adjacent joints, as well as the risk of elbow and wrist stiffness related to prolonged immobilization. The present study was designed to assess the outcome of autologous bone grafting with compression plating and early functional rehabilitation in patients with forearm fracture non-unions.MethodsProspective follow-up study in 31 consecutive patients presenting with non-unions of the forearm diaphysis (radius, n = 11; ulna, n = 9; both bones, n = 11). Surgical revision was performed by restoring anatomic forearm length by autologous bone grafting of the resected non-union from the iliac crest and compression plating using a 3.5 mm dynamic compression plate (DCP) or limited-contact DCP (LC-DCP). The main outcome parameters consisted of radiographic bony union and functional outcome, as determined by the criteria defined by Harald Tscherne in 1978. Patients were routinely followed on a short term between 6 weeks to 6 months, with an average long-term follow-up of 3.6 years (range 2 to 6 years).ResultsRadiographically, a bony union was achieved in 30/31 patients within a mean time of 3.5 months of revision surgery (range 2 to 5 months). Clinically, 29/31 patients showed a good functional outcome, according to the Tscherne criteria, and 26/31 patients were able to resume their previous work. Two postoperative infections occurred, and one patient developed a persistent infected nonunion. No case of postoperative failure of fixation was seen in the entire cohort.ConclusionRevision osteosynthesis of forearm nonunions by autologous iliac crest bone grafting and compression plating represents a safe and efficacious modality for the treatment of these challenging conditions.

Como são tratadas as fraturas expostas da tíbia no Brasil? Estudo transversal

Este estudo transversal foi realizado durante o 36o Congresso Brasileiro de Ortopedia e Traumatologia, para identificar a opiniao do ortopedista brasileiro a respeito das preferencias de tratamento das fraturas expostas da tibia nos adultos. Foram respondidos 507 questionarios, sendo que os resultados demonstram consenso em relacao aos seguintes aspectos: classificacao, 78,5% utilizam a de Gustilo-Anderson; indicacao de tratamento cirurgico, 76,3% preferem operar todos as fraturas; pressao de irrigacao e produto utilizado, 80,3% utilizam irrigacao manual e 85,4% solucao salina; metodo de estabilizacao da fratura, fixador externo foi apontado em 52,1% das fraturas expostas tipo II, 74,4% nas IIIA, 88,6% nas IIIB e 89% nas IIIC; e indicacao de fechamento primario, escolhido em 74,2% nas tipo I. Nao houve consenso em relacao ao tempo para cobertura de partes moles e tempo de uso de antibioticos. Os principais aspectos que discordaram da literatura foram: metodo de estabilizacao, tempo de uso de antibioticos e indicacoes de fechamento primario.

Internal fixation of scaphoid injuries using the herbert screw through a dorsal approach

This prospective study reports on the use of the Herbert screw for fixation of fractures and nonunions of the scaphoid through a dorsal approach. In cases of delayed union and nonunion, screw fixation was combined with bone grafting. Twenty-five patients were treated in this manner, and union rates of 100% for acute fractures and 87% for delayed union and nonunion were achieved. We believe that the dorsal approach provides ready access to the scaphoid, enabling placement of the screw in the best possible position to provide fracture fixation.

Correlação entre tempo para o tratamento cirúrgico e mortalidade em pacientes idosos com fratura da extremidade proximal do fêmur

OBJETIVO: O objetivo primario do estudo e analisar a possivel associacao entre o atraso para a realizacao do tratamento cirurgico e mortalidade em pacientes idosos com fratura da extremidade proximal do femur. METODOS: Foram estudados 269 pacientes com fraturas da extremidade proximal do femur (fraturas do colo do femur e fraturas intertrocanterianas), tratadas cirurgicamente no Hospital Sao Paulo - Unifesp-SP, no periodo de janeiro de 2003 a dezembro de 2007. Foram analisados e comparados com a literatura referente ao assunto os seguintes atributos: sexo, idade, tipo de fratura, classificacao da mesma, lado acometido, sintese utilizada, mecanismo de trauma, tempo de internacao, tempo para cirurgia, comorbidades associadas, hemograma de entrada, tipo de anestesia, necessidade de transfusao sanguinea, dia da semana e estacao do ano da fratura. RESULTADOS: O estudo apresentou correlacao entre maior numero de comorbidades clinicas, maior tempo de internacao e utilizacao de anestesia geral na cirurgia com maior mortalidade dos pacientes. CONCLUSAO: Nao houve associacao entre tempo para realizacao da cirurgia e mortalidade.

Recommendations for avoiding knee pain after intramedullary nailing of tibial shaft fractures

BackgroundThe objective of this study is to analyze the proximal tibiofibular joint in patients with knee pain after treatment of tibial shaft fractures with locked intramedullary nail.FindingsThe proximal tibiofibular joint was analyzed in 30 patients, who reported knee pain after tibial nailing, and standard radiograph and computed tomography were performed to examine the proximal third of the tibia. Twenty patients (68.9%) presented the proximal screw crossing the proximal tibiofibular joint and 13 (44.8%) had already removed the nail and/or screw. Four patients (13.7%) reported complaint of knee pain. However, the screw did not reach the proximal tibiofibular joint. Five patients (17.2%) complained of knee pain although the screw toward the joint did not affect the proximal tibiofibular joint.ConclusionWhen using nails with oblique proximal lock, surgeons should be careful not to cause injury in the proximal tibiofibular joint, what may be one of the causes of knee pain. Thus, the authors suggest postoperative evaluation performing computed tomography when there is complaint of pain.

Tratamento das fraturas distais da tíbia

OBJECTIVE: to compare the results of fibula fixation (or non fixation) in the treatment of fractures located in the distal third of the tibia, by using intramedullary nailing and bridge plate. METHOD: 47 fractures on 47 patients were studied. Twenty-one patients were treated with non-reamed, interlocking intramedullary nailing, and 26 patients were treated with wide or narrow dynamic compression plates (using a minimally invasive technique). All of the fibular fractures were located at the same level or below tibial fractures. RESULTS: in the group of patients treated with fibula fixation, the average healing time was 14.6 weeks. In the group of patients treated without fibula fixation, the average healing time was 14.3 weeks. In the group of patients treated with fibula fixation a significantly smaller proportion of valgus angular deviation (6.3%) was observed compared to the group of patients treated without fibula fixation (32.3%). CONCLUSIONS: The benefits of fibula fixation remain controversial when tibial fractures are associated. Regarding fracture healing, there was no significant difference between the studied fracture groups.