Hélio Jorge Alvachian Fernandes

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.

LESÕES DO APARELHO LOCOMOTOR NOS ACIDENTES COM MOTOCICLETA

Study conducted in the city of Sao Paulo from January 2001 to July 2002 with the goal of analyzing the profiles of individuals involved in motorcycle accidents, evaluating the riders profile, the circumstances of the accidents, injuries, and the use of protective gear. 387 patients needing only traumatic orthopedic treatment were found, between 16 and 44 years of age, of which 354 were males (91.0%). The most common mechanism of trauma involved a collision between the motorcycle and another vehicle (67.0%) at a speed between 12.5-37.5 mph (73.0%) involving less experienced riders (67.0%) between 21 and 24 years of age (45%), and in which 532 (53.9%) lower limb injuries occurred. Of the injuries, 393 (39.8%) were wounds, 314 (31.8%) were bruises and 212 (21.5%) were fractures [foot, 34 (16%); femur, 32 (15.1%); ankle, 27 (12.7%); tibia, 25 (11.8%)]. Recurring accidents were observed in 231 (60.0%) cases and only 6.0% of the riders were not using protective equipment. Increased speed showed a higher rate of fractures when the Mann-Whitney test was applied (p = 0.001). Research on mechanical and traffic engineering, in combination with supervision and awareness-raising of the population, should be considered the most effective methods of prevention.

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.

Como são tratadas as fraturas diafisárias fechadas do fêmur no Brasil? Estudo transversal

A cross-sectional study was performed during the 36th Brazilian Congress of Orthopaedics and Traumatology, where the opinions of Brazilian orthopaedic surgeons addressing the treatment of femoral diaphyseal fractures in adults were surveyed. Five hundred and seven questionnaires were fully completed and the results show agreement in the following topics: fracture trace configuration and injuries of soft parts or neurovascular structures as key parameters for determining treatment; fractures classification, in which AO was most frequently adopted; milled blocked anterograde intramedullary nail for treating cross-sectioned and short oblique factures at the isthmus; bridge plate for treating complex trace fractures; pre-operative skeletal traction; infection as the most frequent complication, and; postoperative low molecular weight heparin. There were opinion conflicts for the following topics: use of traction table for performing intramedullary osteosynthesis, time interval between trauma and surgery; time of antibiotics use, and; mean hospitalization time. Regarding literature, there was agreement concerning key parameters for determining treatment; fixation method for simple-traces fractures at the isthmus; adopted classification; antithrombotic prophylaxis. Issues such as fixation method for complex-traced fractures; time of antibiotics use; average interval between trauma and osteosynthesis, and; hospitalization time were different from literature.

Treatment of pelvic fractures - a national survey.

INTRODUCTION This survey was conducted during the 38(th) Brazilian Congress of Orthopaedics and Traumatology to identify the opinion of Brazilian orthopaedic surgeons on the standard treatment of pelvic fractures. MATERIALS AND METHODS Participants were randomly selected and invited to voluntarily answer a questionnaire of 10 multiple choice questions addressing the main aspects of the treatment of pelvic fractures: classification, fixation methods in unstable patients, optimal surgical timing in stable patients, and fixation methods in different types of anterior and posterior pelvic injuries. RESULTS/CONCLUSION Three hundred and fifty-two questionnaires were completed, and the following main observations were made: most orthopaedists prefer to use an external fixator in the iliac crest for the emergency stabilisation of pelvic injuries in haemodynamically unstable patients (79.5%); they consider a period of up to one week as optimal for fixation in stable patients (55.1%); they use a plate for the fixation of fractures of the iliopubic rami through a Pfannenstiel or ilio-inguinal approach (53.9%); and they use reconstruction plates for the fixation of fractures of the iliac wing (63.1%). Regarding other studied aspects, there was no predominance of more than 50% of the choices among respondents.

Minimal invasive ostheosintesis for treatment of diaphiseal transverse humeral shaft fractures

OBJECTIVE: To evaluate patients with transverse fractures of the shaft of the humerus treated with indirect reduction and internal fixation with plate and screws through minimally invasive technique. METHODS: Inclusion criteria were adult patients with transverse diaphyseal fractures of the humerus closed, isolated or not occurring within 15 days of the initial trauma. Exclusion criteria were patients with compound fractures. RESULTS: In two patients, proximal screw loosening occurred, however, the fractures consolidated in the same mean time as the rest of the series. Consolidation with up to 5 degrees of varus occurred in five cases and extension deficit was observed in the patient with olecranon fracture treated with tension band, which was not considered as a complication. There was no recurrence of infection or iatrogenic radial nerve injury. CONCLUSION: It can be concluded that minimally invasive osteosynthesis with bridge plate can be considered a safe and effective option for the treatment of transverse fractures of the humeral shaft. Level of Evidence III, Therapeutic Study.

Risk of injury to vascular-nerve bundle after calcaneal fracture: comparison among three techniques

Objective To ascertain whether the number of screws or pins placed in the calcaneus might increase the risk of injury when three different techniques for treating calcaneal fractures. Method 126 radiographs of patients who suffered displaced calcaneal fractures were retrospectively analyzed. Three surgical techniques were analyzed on an interobserver basis: 31 radiographs of patients treated using plates that were not specific for the calcaneus, 48 using specific plates and 47 using an external fixator. The risk of injury to the anatomical structures in relation to each Kirschner wire or screw was determined using a graded system in accordance with the Licht classification. The total risk of injury to the anatomical structures through placement of more than one wire/screw was quantified using the additive law of probabilities for the product, for independent events. Results All of the models presented high explanatory power for the risk evaluated, since the coefficient of determination values (R2) were greater than 98.6 for all the models. Therefore, the set of variables studied explained more than 98.6% of the variations in the risks of injury to arteries, veins or nerves and can be classified as excellent models for prevention of injuries. Conclusion The risk of injury to arteries, veins or nerves is not defined by the total number of pins/screws. The region and the number of pins/screws in each region define and determine the best distribution of the risk.