Kodi Edson Kojima

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.

Fraturas da diáfise da tíbia

A fratura de osso longo mais frequente e a da diafise da tibia, e seu tratamento adequado evita o aparecimento de falhas da consolidacao, consolidacao viciosa e reoperacoes. Para classificar a fratura ainda se utiliza a classificacao AO/OTA, mas vale a pena conhecer a classificacao de Ellis, que tambem inclui a avaliacao da lesao das partes moles. A sindrome compartimental e uma associacao frequente, e o diagnostico precoce pode ser feito precocemente com avaliacao dos parâmetros clinicos e uma monitorizacao clinica constante. Feito o diagnostico, deve-se realizar a fasciotomia. A avaliacao da consolidacao sempre e dificil, mas o metodo de RUST pode ajudar nessa avaliacao. Avalia-se a radiografia em duas projecoes, dando-se pontos para a presenca da linha de fratura e a presenca de calo osseo visivel. Hoje em dia se discute o dogma das seis horas para a limpeza da fratura exposta. Considera-se de mais importância o inicio precoce da antibioticoterapia endovenosa e a gravidade da lesao. A questao do fechamento precoce ou tardio da lesao em uma fratura exposta passou por varias fases, com epocas se indicando o fechamento precoce e epocas o tardio. Atualmente se preconiza, sempre que possivel, o fechamento precoce da lesao, pois isso diminui o risco de infeccao. A fresagem do canal quando da introducao da haste intramedular ainda e um assunto controverso. Apesar de fortes posicoes pessoais a favor da fresagem, os estudos mostram haver alguma vantagem nas fraturas fechadas, mas nao nas expostas.

Intraobserver and interobserver agreement in the classification and treatment of proximal humeral fractures

BACKGROUND There is controversy surrounding the reliability of radiographic measurements and existing classifications for proximal humeral fractures. METHODS Ten orthopedists, divided into 2 groups by length of experience, evaluated radiographs in 3 views from 40 proximal humeral fractures. We evaluated 11 radiographic criteria (including the Neer and pathomorphologic classifications, head-shaft angle, displacement of the humeral shaft, and lesser and greater tuberosities) and treatment indication. We also analyzed the criteria that most influenced the choice of treatment. RESULTS Interobserver reliability was substantial for the presence of fracture of the greater tuberosity (κ = 0.749) and medial metaphyseal comminution (κ = 0.627) and moderate for the pathomorphologic classification (κ = 0.504), displacement of the greater tuberosity (κ = 0.422), and treatment decision (κ = 0.565). Intraobserver reliability was substantial for treatment indication (κ = 0.620) and presence of displacement of the fracture of the greater tuberosity (κ = 0.627 and 0.611) and moderate for the Neer (κ = 0.490) and pathomorphologic (κ = 0.607) classifications. The results were influenced by the observers experience. The surgical indication was influenced by the pathomorphologic classification in 50% of the evaluators (odds ratio, 4.85; range, 3.30-8.65). CONCLUSION The pathomorphologic classification has higher reliability than the Neer classification and was the factor that most influenced the surgical decision. The determination of the presence of fracture and displacement of the greater tuberosity and medial metaphyseal comminution is reliable with the use of simple radiographs, and the results were influenced by the observers experience.

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.

Resistência mecânica às forças de tração e flexão: proposta de novo desenho para os pinos de Schanz dos fixadores externos monolaterais

OBJECTIVE: To determine the mechanical resistance to traction and flexion of three models of Schanz pins, two of them available in Brazil, and the one proposed in this study: a conic pin with 5.0 mm diameter, 40 mm thread length, 3.2 mm bore, and the one proposed in this paper, with 5.0 mm in diameter, 3.2 mm bore, and 15 mm thread length, in order to show which one is the most effective. METHODS: The authors built 48 test samples divided in six groups, with eight sample per group. Traction strength was tested in groups 1, 2, and 3 using a traction machine manufactured by ITM®. To check flexion strength in groups 4, 5, and 6, they used a bench perforator manufactured by Cardoso® FFC-20 in the pin installation, and then the Universal Assay Machine ZD100PU. RESULTS: In traction tests, the conic pins stood a mean traction of 98.462 kgf, those with uniform long thread (40 mm) 283.70 kgf, and the proposed pins with uniform thread of 15 mm, stood the mean strength of 116.947 kgf. The statistic difference among the groups was not significant. In the flexion test, the conic pins stood a strength of 6.563 kgf, the pins with uniform thread of 40 mm stood the mean strength of 6.177 kgf, and the proposed pins stood the mean strength of 30.275 kgf, there being a significant difference when compared to the previous groups. CONCLUSIONS: The three models of Schanz pins presented equivalent traction strength, and the proposed model - thread length of 15 mm - is significant more resistant to flexion strengths.

Are diaphyseal clavicular fractures still treated traditionally in a non-surgical way?☆

Objective To evaluate the decision of orthopedics surgeons regarding which cases they would indicate surgery or non-surgical treatment. Methods 20 images of radiographs with fracture in the middle third of the collar bone (AO/OTA 15-B) in anteroposterior view were analyzed, and divided into four groups: group 1 – fracture type AO/OTA 15-B1 without displacement; group 2 – fracture type AO/OTA 15-B1 with displacement; group 3 – fracture type AO/OTA 15-B2; group 4 – fracture type AO/OTA 15-B3. The evaluator was requested to indicate the choice of treatment, surgical or non-surgical. Results There was no strong correlation between the amount of surgical indications and the working experience or age of the medical evaluator. It was observed that the average of surgical indications in the total sample was 52%. When indications were studied in different areas of Brazil, there was no significant difference among them. No pattern for the Brazilian regions studied was observed in the case analysis. Even within a group (cases of the same complexity), no specific pattern of surgical indication was observed. Conclusion No association between surgical indication and the length of professional experience was found. The Southern and Southeastern regions were those that most recommended surgeries in groups 2, 3, and 4. In no region the same level of surgical indication for cases of the same complexity rate was kept.

Ultrasound evaluation of the rotator cuff after osteosynthesis of proximal humeral fractures with locking intramedullary nail

Objective To evaluate supraspinatus tendon integrity with ultrasound (US) in patients submitted to proximal humeral fracture (PHF) fixation with a locking intramedullary nail. Methods Thirty-one patients with PHF treated with curvilinear locking intramedullary nail, aged between 50 and 85 years, were assessed by US at six months postoperatively and clinically at six and 12 months postoperatively. The primary aim was supraspinatus tendon integrity, evaluated by US at six months postoperatively. Secondary aims included the Constant-Murley, DASH score, and visual analog pain scores, as well as complications and reoperation rates. Results Full-thickness rotator cuff ruptures were observed in four patients (13%), supraspinatus ruptures in three cases (10%), and subscapularis ruptures in one case (3%). Partial ruptures were diagnosed in 10 cases (32%). The results using the Constant-Murley score at 12 months were 71.3 ± 15.2 points for the entire series, with 73.2 ± 16.1 points for patients without rotator cuff ruptures and 68.7 ± 14.1 points for those with partial or complete ruptures, without a statistically significant difference (p = 0.336). Complications, exclusively for rotator cuff ruptures, were observed in nine patients (29%). Conclusion A high rate of rotator cuff ruptures was demonstrated, with partial ruptures in 32% of cases and full-thickness ruptures in 13%. However, clinical results are satisfactory, and are not influenced by the presence of rotator cuff ruptures.

A new low-cost negative-pressure wound therapy versus a commercially available therapy device widely used to treat complex traumatic injuries: a prospective, randomized, non-inferiority trial

OBJECTIVES: Negative-pressure wound therapy has been widely adopted to reduce the complexity of treating a broad range of acute and chronic wounds. However, its cost is high. The objective of this study was to evaluate the following two different methods of negative-pressure wound therapy in terms of healing time: a low-cost method of negative-pressure wound therapy (a pressure stabilizer device connected to a hospital wall-vacuum system with a gauze-sealed dressing, USP) and the standard of care (vacuum-assisted closure, VAC). METHODS: This is a randomized, controlled, non-inferiority, unblinded trial. Patients admitted with complex injuries to a trauma center in a public referral hospital who were indicated for orthopedic surgery were randomized to a USP or VAC group. The primary outcome was the time required to achieve a “ready for surgery condition”, which was defined as a wound bed with healthy granulation tissue and without necrosis or purulent secretion. Wound bed area contraction, granulation tissue growth and the direct costs of the dressings were secondary outcomes. RESULTS: Variation in area and granulation tissue growth were essentially the same between the systems, and healing time was equal between the groups (p=0.379). In both systems, serial debridement increased wound area (p=0.934), and granulation tissue was also increased (p=0.408). The mean treatment cost was US