João Baptista Gomes dos Santos

Are distal radius fracture classifications reproducible? Intra and interobserver agreement

CONTEXT AND OBJECTIVE Various classification systems have been proposed for fractures of the distal radius, but the reliability of these classifications is seldom addressed. For a fracture classification to be useful, it must provide prognostic significance, interobserver reliability and intraobserver reproducibility. The aim here was to evaluate the intraobserver and interobserver agreement of distal radius fracture classifications. DESIGN AND SETTING This was a validation study on interobserver and intraobserver reliability. It was developed in the Department of Orthopedics and Traumatology, Universidade Federal de São Paulo - Escola Paulista de Medicina. METHOD X-rays from 98 cases of displaced distal radius fracture were evaluated by five observers: one third-year orthopedic resident (R3), one sixth-year undergraduate medical student (UG6), one radiologist physician (XRP), one orthopedic trauma specialist (OT) and one orthopedic hand surgery specialist (OHS). The radiographs were classified on three different occasions (times T1, T2 and T3) using the Universal (Cooney), Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation (AO/ASIF), Frykman and Fernández classifications. The kappa coefficient (kappa) was applied to assess the degree of agreement. RESULTS Among the three occasions, the highest mean intraobserver k was observed in the Universal classification (0.61), followed by Fernández (0.59), Frykman (0.55) and AO/ASIF (0.49). The interobserver agreement was unsatisfactory in all classifications. The Fernández classification showed the best agreement (0.44) and the worst was the Frykman classification (0.26). CONCLUSION The low agreement levels observed in this study suggest that there is still no classification method with high reproducibility.

Treatment of Bankart Lesions in Traumatic Anterior Instability of the Shoulder: A Randomized Controlled Trial Comparing Arthroscopy and Open Techniques

PURPOSE The objective of this study was to compare the functional assessments of arthroscopy and open repair for treating Bankart lesion in traumatic anterior shoulder instability. METHODS Fifty adult patients, aged less than 40 years, with traumatic anterior shoulder instability and the presence of an isolated Bankart lesion confirmed by diagnostic arthroscopy were included in the study. They were randomly assigned to receive open or arthroscopic treatment of an isolated Bankart lesion. In all cases of both groups, the lesion was repaired with metallic suture anchors. The primary outcomes included the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. RESULTS After a mean follow-up period of 37.5 months, 42 patients were evaluated. On the DASH scale, there was a statistically significant difference favorable to the patients treated with the arthroscopic technique, but without clinical relevance. There was no difference in the assessments by University of California, Los Angeles and Rowe scales. There was no statistically significant difference regarding complications and failures, as well as range of motion, for the 2 techniques. CONCLUSIONS On the basis of this study, the open and arthroscopic techniques were effective in the treatment of traumatic anterior shoulder instability. The arthroscopic technique showed a lower index of functional limitation of the upper limb, as assessed by the DASH questionnaire; this, however, was not clinically relevant.

Treatment of trigger finger: randomized clinical trial comparing the methods of corticosteroid injection, percutaneous release and open surgery

OBJECTIVE The aim of this study is to evaluate the effectiveness of CS injection, percutaneous pulley release and conventional open surgery for treating trigger finger in terms of cure, relapse and complication rates. METHODS One hundred and thirty-seven patients with a total of 150 fingers were randomly assigned and allocated into one of the treatment groups, with treatments allocated into 150 opaque and sealed envelopes. We included patients >15 years of age with a trigger on any finger of the hand (Types II-IV) and used a minimum follow-up time of 6 months. The primary outcome measures were cures, relapses and failures. RESULTS Forty-nine patients were assigned to the conservative group to undergo CS injections, whereas 45 and 56 were assigned to undergo percutaneous release and outpatient open surgery, respectively. The trigger cure rate for patients in the injection method group was 57%, and wherever necessary, two injections were administered, which increased the cure rate to 86%. For the percutaneous and open release methods, remission of the trigger was achieved in all cases. CONCLUSIONS The percutaneous and open surgery methods displayed similar effectiveness and proved superior to the conservative CS method regarding the trigger cure and relapse rates. Trial registration. Current Controlled Trials, http://www.controlled-trials.com/, ISRCTN19255926.

Bone marrow cells are able to increase vessels number during repair of sciatic nerve lesion

The aim of this study was to compare the outcomes of nerve autografts (GRF) and venous grafts containing mononuclear bone marrow cells (BMCs) in sciatic nerve-lesioned rats. Control animals underwent sham operations (SHAM), received empty venous grafts (EPV), or received venous grafts containing BMC vehicle (AGR). Outcome was evaluated through sciatic functional index (SFI), morphometric and morphologic analyses of the nerve distal to the lesion, and the number of spinal cord motor neurons positive for the retrograde tracer, Fluoro-Gold. All groups exhibited poor results in SFI when compared to SHAM animals throughout the postoperative period. All groups also had a significantly greater fiber density, decreased fiber diameter, and decreased motor neuron number than the SHAM group. No significant difference between the GRF and BMC groups was observed in any of these parameters. On the other hand, vessel density was significantly higher in BMC than all other groups. BMC-containing venous grafts are superior to nerve autografts in increasing vessel density during sciatic nerve regeneration.

Anatomical Study of the A1 Pulley: Length and Location by Means of Cutaneous Landmarks on the Palmar Surface

PURPOSE The objectives of this study were to evaluate palmar surface parameters to identify the exact location of the proximal edge of the flexor tendon A1 pulley relative to the digital palmar crease of the index, middle, ring, and little fingers and to evaluate the length of this pulley. METHODS We studied 280 fingers on 70 hands from 35 fresh human cadavers, initially by measuring the distance between the digital-palmar and proximal interphalangeal creases (measure A), followed by dissection of the fingers and measurement of the distance between the proximal edge of the A1 pulley and the digital-palmar crease (measure B) and the length of the A1 pulley (measure C). We carried out statistical analysis using Hotellings multivariate T(2)-test and the paired-samples t-test. RESULTS We found no statistically significant difference between measures A and B in each finger (p > .05). The mean lengths, in tenths of millimeters, were as follows: measure A: index finger 22.0 mm, middle finger 24.4 mm, ring finger 22.0 mm, and little finger 17.9 mm; measure B: index finger 21.9 mm, middle finger 24.2 mm, ring finger 22.3 mm, and little finger 18.1 mm. The average lengths of the A1 pulley were: index finger 9.8 mm, middle finger 10.7 mm, ring finger 9.6 mm, and little finger 8.1 mm. CONCLUSIONS The distance between the digital-palmar and proximal interphalangeal creases may be used as a cutaneous landmark on the palmar surface for the exact location of the proximal edge of the A1 pulley in the palm of the hand, thereby ensuring greater safety in surgical procedures such as percutaneous release of trigger finger.

Influence of compensation status on time off work after carpal tunnel release and rotator cuff surgery: a meta-analysis

BackgroundThe assessment of post-surgical outcomes among patients with Workers’ Compensation is challenging as their results are typically worse compared to those who do not receive this compensation. These patients’ time to return to work is a relevant outcome measure as it illustrates the economic and social implications of this phenomenon. In this meta-analysis we aimed to assess the influence of this factor, comparing compensated and non-compensated patients.FindingsTwo authors independently searched MEDLINE (Ovid), Embase (Ovid), CINAHL, Google Scholar, LILACS and the Cochrane Library and also searched for references from the retrieved studies. We aimed to find prospective studies that compared carpal tunnel release and elective rotator cuff surgery outcomes for Workers’ Compensation patients versus their non-compensated counterparts. We assessed the studies’ quality using the Guyatt & Busse Risk of Bias Tool. Data collection was performed to depict included studies characteristics and meta-analysis. Three studies were included in the review. Two of these studies assessed the outcomes following carpal tunnel release while the other focused on rotator cuff repair. The results demonstrated that time to return to work was longer for patients that were compensated and that there was a strong association between this outcome and compensation status - Standard Mean Difference, 1.35 (IC 95%; 0.91-1.80, p < 0.001).ConclusionsThis study demonstrated that compensated patients have a longer return to work time following carpal tunnel release and elective rotator cuff surgery, compared to patients who did not receive compensation. Surgeons and health providers should be mindful of this phenomenon when evaluating the prognosis of a surgery for a patient receiving compensation for their condition.Type of study/level of evidenceMeta-analysis of prospective Studies/ Level III

Hierarchy of evidence relating to hand surgery in Brazilian orthopedic journals

CONTEXT AND OBJECTIVE There is no systematic assessment of the quality of scientific production in the specialty of hand surgery in our setting. This study aimed to systematically assess the status of evidence generation relating to hand surgery and to evaluate the reproducibility of the classification method based on an evidence pyramid. DESIGN AND SETTING Secondary study conducted at Universidade Federal de São Paulo (Unifesp) and Faculdade Estadual de Medicina de Marília (Famema). METHODS Two researchers independently conducted an electronic database search for hand surgery studies published between 2000 and 2009 in the two main Brazilian orthopedic journals (Acta Ortopédica Brasileira and Revista Brasileira de Ortopedia). The studies identified were subsequently classified according to methodological design (systematic review of the literature, randomized clinical trial, cohort study, case-control study, case series and other studies) and evidence level (I to V). RESULTS A total of 1,150 articles were evaluated, and 83 (7.2%) were included in the final analysis. Studies with evidence level IV (case series) accounted for 41 (49%) of the published papers. Studies with evidence level V (other studies) accounted for 12 (14.5%) of the papers. Only two studies (2.4%) were ranked as level I or II. The inter-rater reproducibility was excellent (k = 0.94). CONCLUSIONS Hand surgery articles corresponded to less than one tenth of Brazilian orthopedic production. Studies with evidence level IV were the commonest type. The reproducibility of the classification stratified by evidence level was almost perfect.

Treatment of the humeral shaft fractures - minimally invasive osteosynthesis with bridge plate versus conservative treatment with functional brace: study protocol for a randomised controlled trial

BackgroundHumeral shaft fractures account for 1 to 3% of all fractures in adults and for 20% of all humeral fractures. Non-operative treatment is still the standard treatment of isolated humeral shaft fractures, although this method can present unsatisfactory results. Surgical treatment is reserved for specific conditions. Modern concepts of internal fixation of long bone shaft fractures advocate relative stabilisation techniques with no harm to fracture zone. Recently described, minimally invasive bridge plate osteosynthesis has been shown to be a secure technique with good results for treating humeral shaft fractures. There is no good quality evidence advocating which method is more effective. This randomised controlled trial will be performed to investigate the effectiveness of surgical treatment of humeral shaft fractures with bridge plating in comparison with conservative treatment with functional brace.Methods/DesignThis randomised clinical trial aims to include 110 patients with humeral shaft fractures who will be allocated after randomisation to one of the two groups: bridge plate or functional brace. Surgical treatment will be performed according to technique described by Livani and Belangero using a narrow DCP plate. Non-operative management will consist of a functional brace for 6 weeks or until fracture consolidation. All patients will be included in the same rehabilitation program and will be followed up for 1 year after intervention. The primary outcome will be the DASH score after 6 months of intervention. As secondary outcomes, we will assess SF-36 questionnaire, treatment complications, Constant score, pain (Visual Analogue Scale) and radiographs.DiscussionAccording to current evidence shown in a recent systematic review, this study is one of the first randomised controlled trials designed to compare two methods to treat humeral shaft fractures (functional brace and bridge plate surgery).Trial registrationCurrent Controlled Trials: ISRCTN24835397

Avaliação do questionário de Boston aplicado no pós-operatório tardio da síndrome do tunel do carpo operados pela técnica de retinaculótomo de paine por via palmar

Entre os anos de 1995 e 1998, foram realizadas 112 cirurgias para tratamento da Sindrome do Tunel do Carpo (STC) pela tecnica de incisao palmar e utilizacao do retinaculo de Paine. Com o objetivo de avaliar os resultados em longo prazo, os pacientes foram convocados. Houve o retorno de 44 pacientes. Deste total, tres pacientes, por terem doencas associadas, foram excluidos, resultando, um total de 53 maos analisadas. Apresentaremos os resultados da avaliacao subjetiva, obtidos atraves da aplicacao de um teste de auto-avaliacao chamado de questionario de Boston. Este questionario consiste em perguntas que avaliam a gravidade dos sintomas e o estado funcional no momento da aplicacao do mesmo. Atraves da aplicacao do referido questionario encontramos um escore de 1,41 ± 0,57 para gravidade dos sintomas e 1,59 ± 0,93 para o estado funcional. Como este questionario nao foi aplicado no pre-operatorio deste grupo de pacientes analisados, comparou-se a pontuacao obtida com as encontradas na literatura pertinente. Os resultados obtidos demonstraram que as pontuacoes pos-operatorias sao similares aquelas existentes na literatura, mesmo sendo referidas a tempos diferentes de seguimento pos-operatorios, concluindo que havendo uma melhora dos sintomas, o questionario de Boston e sensivel a esta mudanca clinica.

Peripheral nerve regeneration with conduits: use of vein tubes.

Treatment of peripheral nerve injuries remains a challenge to modern medicine due to the complexity of the neurobiological nerve regenerating process. There is a greater challenge when the transected nerve ends are not amenable to primary end-to-end tensionless neurorraphy. When facing a segmental nerve defect, great effort has been made to develop an alternative to the autologous nerve graft in order to circumvent morbidity at donor site, such as neuroma formation, scarring and permanent loss of function. Tubolization techniques have been developed to bridge nerve gaps and have been extensively studied in numerous experimental and clinical trials. The use of a conduit intends to act as a vehicle for moderation and modulation of the cellular and molecular ambience for nerve regeneration. Among several conduits, vein tubes were validated for clinical application with improving outcomes over the years. This article aims to address the investigation and treatment of segmental nerve injury and draw the current panorama on the use of vein tubes as an autogenous nerve conduit.