Jorge dos Santos Silva

Single, superiorly placed reconstruction plate compared with flexible intramedullary nailing for midshaft clavicular fractures: a prospective, randomized controlled trial.

BACKGROUND Previous studies have shown good clinical results in patients with midshaft clavicular fractures treated with reconstruction plate fixation or elastic stable intramedullary nailing. The objective of this study was to compare these methods in terms of clinical and radiographic results. METHODS In this prospective, randomized controlled trial, fifty-nine patients with displaced midshaft clavicular fractures were randomly assigned to receive fixation with either a reconstruction plate (thirty-three patients), known as the plate group, or elastic stable intramedullary nailing (twenty-six patients), known as the nail group. The primary outcome was the six-month Disabilities of the Arm, Shoulder and Hand (DASH) score. The secondary outcomes included the Constant-Murley score, time to fracture union, residual shortening, level of postoperative pain, percentage of satisfied patients, and complication rates. RESULTS The mean six-month DASH score was 9.9 points in the plate group and 8.5 points in the nail group (p = 0.329). Similarly, there were no differences in the twelve-month DASH and Constant-Murley scores. Time to union was equivalent (p = 0.352) between the groups at 16.8 weeks for the plate group and 15.9 weeks for the nail group, whereas the residual shortening was 0.4 cm greater in the plate group (p = 0.032). The visual analog scale pain score and the satisfaction rate were similar between the groups. Implant-related pain was more frequent in the nail group (p = 0.035). There were no differences in terms of major complications. CONCLUSIONS Reconstruction plates and elastic stable intramedullary nailing yielded similar functional results, time to union, level of postoperative pain, and patient satisfaction rates. Both methods were safe in terms of major complications.

Locking intramedullary nails compared with locking plates for two- and three-part proximal humeral surgical neck fractures: a randomized controlled trial.

BACKGROUND Previous studies have shown good clinical results in patients with proximal humeral fractures (PHFs) treated with locking intramedullary nails or locking plates. Our study compared the clinical and radiographic outcomes in patients with 2- and 3-part surgical neck fractures. METHODS In this prospective, randomized controlled trial, 72 patients with 2- or 3-part surgical neck PHFs were randomly assigned to receive fixation with locking intramedullary nails (nail group) or locking plates (plate group). The primary outcome was the 12-month Constant-Murley score. The secondary outcomes included the Disabilities of the Arm, Shoulder and Hand score, the visual analog scale pain score, the shoulder passive range of motion, the neck-shaft angle, and complication rates. RESULTS There was no significant mean treatment group difference in the Constant-Murley score at 12 months (70.3 points for the nail group vs. 71.5 points for the plate group; P = .750) or at individual follow-up assessments. There were no differences in the 3-, 6- and 12-month Disabilities of the Arm, Shoulder and Hand scores, visual analog scale scores, and range of motion, except for the medial rotation at 6 months. The neck-shaft angle was equivalent between the groups at 12 months. There were significant differences over 12 months in total complication rates (P = .002) and reoperation rates (P = .041). There were no significant differences for the rotator cuff tear rate (P = .672). CONCLUSION Fixation of PHFs with locking plates or locking intramedullary nails produces similar clinical and radiologic results. Nevertheless, the complication and reoperation rates were higher in the nail group.

Influence of time to surgery on the incidence of complications in femoral neck fracture treated with cannulated screws

BACKGROUND Osteosynthesis of femoral neck fractures is particularly indicated in patients aged under 60 years. A prolonged interval between the fracture and surgical fixation has been associated with avascular necrosis (AVN) of the femoral head. The primary objective of this study was to evaluate the association between the time to surgery and the development of complications in patients with femoral neck fractures. METHODS Patients with displaced fractures of the femoral neck (Garden III or IV) who underwent fixation with three cannulated screws in the inverted triangle configuration from January 2009 to December 2010 were evaluated retrospectively for the development of orthopaedic complications. Patients were divided into two groups according to the time to surgery (within 7 days or more than 7 days). Complication rates were compared between the two groups. Regression analyses were performed to assess the risk factors for complications. RESULTS Thirty-one patients were included in the study; the duration of follow-up ranged from 24 to 50 months. The time from fracture to surgery ranged from 3 to 18 days. Fifteen patients underwent surgery within 7 days, and 16 patients underwent surgery after 7 days. There were four cases of femoral head necrosis. One patient had an associated infection; one patient experienced non-union, and another demonstrated osteosynthesis failure. There were no statistically significant differences in the overall rate of complications between the groups (p = 0.999). None of the preoperative parameters or fracture characteristics were predictive factors for complications. The only factor associated with the development of complications was inadequate fracture reduction in the anteroposterior (AP) view (odds ratio [OR] = 35.50, 95% confidence interval [CI] = 2.56 to 548.36, p = 0.008). CONCLUSIONS The interval between the occurrence of the injury and surgical fixation is not associated with the development of complications in fractures of the femoral neck. Inadequate fracture reduction in the AP view is a predictive factor for complications in these fractures.

Fatores preditivos de infecção em pacientes com fraturas expostas nos membros inferiores

134 pacientes com fraturas expostas dos membros inferiores dos tipos II, IIIA, IIIB e IIIC foram estudados prospectivamente entre fevereiro de 1998 e maio de 2000 no Instituto de Ortopedia e Traumatologia da Faculdade de Medicina da Universidade de Sao Paulo para determinar os fatores de risco de infeccao previsiveis Todos os pacientes foram registrados em um protocolo no qual eles tiveram amostras de fragmentos osseos iniciais coletadas para cultura bacteriana, avaliacao de condicoes clinica e administracao precoce de antibiotico. Durante a abordagem inicial, as causas das fraturas, o tempo de exposicao da fratura e o local onde os primeiros socorros foram recebidos foram observados. Durante o debridamento inicial, o volume de transfusao sanguinea, a classificacao clinica ASA, o tempo cirurgico, o ferimento cirurgico e o tipo de estabilizacao esqueletica foram observados. Uma analise univariavel foi realizada para identificar os riscos pervisiveis estatisticamente significantes para o desenvolvimento de infeccoes, com os seguintes resultados: tempo de exposicao da fratura (p=0.0201), local dos primeiros socorros (p=0.400), tipo de fratura (p=0.0130), classificacao ASA (p=0.0005), volume de transfusao de sangue (p=0.0002) tipo de osso fraturado (p=0.0052), tipo de acidente (p=0.0450), ferimento cirurgico (p=0.0024), estabilizacao esqueletica (p=0.0446), cultura bacteriana positiva na admissao (p=0.5290) e cirurgias concomitantes (p=0.1867). As variaveis com associacao significante com a infeccao foram introduzidas em uma equacao de regresao multivariada (modelo logistico) para identificar as com efeitos independentes dos outros fatores. O modelo logistico final foi obtido e demonstrou as probabilidades de infeccao nas fratruras expostas estudadas. Os riscos relativos revelados no modelo logistico final foram : volume de transfusao sanguinea (mais do que 1 unidade) - 6.4;classificacao ASA nivel III - 5.2; fixacao interna do osso (imediata) - 3.9; osso fraturado (femur) - 3.5 and ferimento aberto - 3.0

Epidemiological study on talus fractures

Objective to analyze the characteristics of patients with talus fractures and the injuries that they present. Methods retrospective analysis on patients hospitalized in the Institute of Orthopedics and Traumatology, Hospital das Clínicas, School of Medicine of the University of São Paulo, between 2006 and 2011, with talus fractures. Patient profile parameters, risk factors, fracture characteristics, treatment data and acute complications were analyzed. Results analysis on 23 cases showed that men were more affected than women, with a ratio of 4.8:1. The most frequent trauma mechanism was traffic accidents, followed by falls from a height. The most frequent type of fracture was at the neck of the talus, with 17 cases. Among the 23 cases, seven had peritalar dislocation at the time of presentation, four had exposed fractures and 11 presented other associated fractures. The mean length of time between the trauma and the definitive treatment was six days, while the mean length of hospital stay was 11 days. Three patients presented acute postoperative complications. Conclusion talus fractures occurred most commonly in the region of the talar neck and most frequently in young males who suffered high-energy trauma. In almost half of the cases, there were other associated fractures. The length of hospital stay was 11 days.

Prevalence of acute diseases in the elderly assisted in emergency department of orthopedics

OBJECTIVE: To make an analysis of the care of elderly in an Emergency Department of Orthopedics with the primary objective to know the percentage of elderly treated, their conditions of origin and level of accidental conditions, and examine possible comorbidities, evolution and mortality rate. METHODS: Retrospective observational epidemiological study based on survey records of a tertiary hospital during one year (January to December 2006) RESULTS: In the year 2006 (January to December) 12,916 calls to patients older than 60 were performed. CONCLUSION: Massive attendance of the elderly population was observed, however, the vast majority related to chronic problems that do not require urgent attention. Patients requiring urgent attention suffer from trauma related to falls and are between the seventh and ninth decades of life, mostly female and requiring hospitalization for longer periods. Level of Evidence VI, Cases Series.

Impact of restriction of cefepime use on the antimicrobial susceptibility of gram-negative bacilli related to healthcare-associated infections in an orthopedic hospital

Introduction: In recent decades, antimicrobial resistance has become a public health problem, particularly in cases of healthcare-associated infections. Interaction between antibiotic consumption and resistance development is of particular interest regarding Gram-negative bacilli, whose growing resistance has represented a great challenge. Objective: Assess the impact of restriction of cefepime use on antimicrobial susceptibility among the Gram-negative bacilli (GNB) most frequently involved in healthcare-associated infections (HAI). Methods: Data relating to hospital occupancy and mortality rates, incidence of HAI, incidence of GNB as causative agents of HAI, antimicrobial consumption at the hospital and antimicrobial susceptibility of GNB related to HAI were compared between two periods: a 24-month period preceding restriction of cefepime use and a 24-month period subsequent to this restriction. Results: There was a significant drop in cefepime consumption after its restriction. Susceptibility of Acinetobacter baumanii improved relating to gentamicin, but it worsened in relation to imipenem, subsequent to this restriction. For Pseudomonas aeruginosa, there was no change in antimicrobial susceptibility. For Klebsiella pneumoniae and Enterobacter spp, there were improvements in susceptibility relating to ciprofloxacin. Conclusion: Restriction of cefepime use had a positive impact on K. pneumoniae and Enterobacter spp, given that after this restriction, their susceptibilities to ciprofloxacin improved. However, for A. baumanii, the impact was negative, given the worsening of susceptibility to imipenem.

Comparação entre o uso de placas e o de hastes flexíveis para a osteossíntese de fraturas do terço médio da clavícula: resultados preliminares

OBJETIVO: Comparar os resultados clinicos e radiograficos de dois diferentes metodos de fixacao para fraturas do terco medio da clavicula, a saber, placas e hastes intramedulares. METODOS: De maio de 2010 a fevereiro de 2011, 22 pacientes com fraturas desviadas do terco medio da clavicula foram randomizados para a fixacao com placa (dez pacientes) e fixacao com haste (doze pacientes). Entre os principais desfechos analisados estao: o escore funcional de Constant, o escore DASH, a presenca de complicacoes relacionadas aos metodos e as caracteristicas radiograficas. RESULTADOS: Treze pacientes completaram pelo menos 4 meses de seguimento (seis do grupo placa e sete do grupo haste). O tempo de consolidacao radiografica foi semelhante entre os dois grupos, com media de 12,3 semanas no grupo haste e 12,4 semanas no grupo placa. Tambem nao houve diferenca quanto a amplitude de movi- mento do ombro, dor pos-operatoria ou presenca de pseudartrose. Um paciente do grupo haste apresentou re-fratura apos a retirada da sintese aos 3 meses de PO e um pacientes do grupo placa apre- sentou angulacao da placa e soltura, sendo necessaria re-operacao. As avaliacoes funcionais foram semelhantes entre os dois grupos. CONCLUSAO: Ha uma tendencia para que os resultados nos dois grupos clinicos avaliados sejam muito semelhantes quanto ao tempo medio de consolidacao, numero de complicacoes e funcao do ombro. A ampliacao desta casuistica deve, no futuro, oferecer resultados mais conclusivos.

Outpatient parenteral antimicrobial therapy for orthopedic infections - a successful public healthcare experience in Brazil.

Treatment of orthopedic infections usually requires prolonged antimicrobial therapy, ranging from 14 days up to 6 months. Nowadays, rising levels of antimicrobial resistance demands parenteral therapy for many patients. Outpatient parenteral antimicrobial therapy (OPAT) is a modality that allows treatment out of hospital in these situations. In Brazil, where a public universal healthcare system allows full coverage for all citizens, implantation and dissemination of OPAT programs would be beneficial for patients and for the system, because it would allow a better allocation of health resources. The Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medicina da USP (IOT) started, in July 2013, a partnership with municipal health authorities in Sao Paulo, Brazil, in order to initiate an OPAT program in which patients discharged from that hospital would be able to continue antimicrobial therapy at primary care facilities. When necessary, patients could also receive their therapy at the day-hospital located at IOT. Primary care nursing and physician staff were trained about antimicrobial infusion and peripherally inserted central catheter manipulation. An OPAT specific antimicrobial protocol was designed and a special reference and counter-reference organized. As a result, 450 primary healthcare professionals were trained. In the first year of this program, 116 patients were discharged for OPAT. Chronic and acute osteomyelitis were most frequent diagnosis. Teicoplanin, ertapenem and tigecycline were the most used drugs. Duration of treatment varied from 10 to 180 days (average 101, median 42). Total sum of days in OPAT regimen was 11,698. Only 3 patients presented adverse effects. Partnership between services of different levels of complexity allowed implantation of a safe and effective public healthcare OPAT program for treatment of orthopedic infections. This program can serve as a model for developing similar strategies in other regions of Brazil and Latin America.

Estudo anatômico da via de acesso suprapatelar lateral para a haste intramedular bloqueada na fratura da tíbia

OBJECTIVE: Intramedullary nails are the gold standard for treating tibial shaft fractures. Knee pain is a frequent complication after the procedure. Alternative routes such as the suprapatellar approach for nail insertion are seen as an option for avoiding late postoperative knee pain. The question is whether this approach might give rise to any injury to intra-articular structures of the knee. METHODS: This study analyzed the suprapatellar approach and the risk to adjacent structures by reproducing it in 10 knees of five cadavers. RESULTS: This approach was seen to make it easy to locate the entry point, with lesions only occurring in the Hoffa fat. In three of our cases, there were lesions of the chondral surface, which is an obstacle that is difficult to overcome. CONCLUSION: There is a need to develop specific material to minimize injury to intra-articular structures when using this route.