Paulo Roberto Barbosa de Toledo Lourenço

Interprosthetic femoral fractures: proposed new classification system and treatment algorithm

Interprosthetic femoral fracture is a rare and challenging fragility fracture issue. Due to aging of the population, the incidence of this type of fracture is gradually and constantly increasing. There is no complete and specific interprosthetic femoral fracture classification system that indicates treatment and prognosis in the literature. The aim of the present study was to describe a new classification system for interprosthetic femoral fractures, and to present a case series and a treatment algorithm derived from the current evidence in the literature.

RadiogRaphic anatomy of the pRoximal femuR: coRRelation with the occuRRence of fRactuRes

Objective To evaluate the correlation between radiographic parameters of the proximal femur anatomy and fractures. Methods Three hundred and five digital x-rays of the pelvis were analyzed in the anteroposterior view. Of these x-rays, twenty-seven showed femoral neck or transtrochanteric fractures. The anatomical parameters analyzed were: femoral neck width (FNW), femoral neck length (FNL), femoral axis length (FAL), cervicodiaphyseal angle (CDA), acetabular tear-drop distance (ATD) and great trochanter-pubic symphysis distance (GTPSD). The analysis was performed by comparing the results of the x-rays with and without proximal femoral fracture, to establish a correlation between them. Results No differences were found between the anatomical parameters of the groups with and without proximal femoral fracture. Conclusion There was no association between anatomical changes in the proximal femur and greater susceptibility to fractures. Level of evidence IV, Cross-sectional Study.

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.

Subtrochanteric fractures of the femur: update

Because of the anatomical peculiarities of the subtrochanteric region, treatment of fractures in this region remains challenging. The undeniable evolution of implants has not been accompanied by the expected decrease in the complication rate. The aim of this study was to discuss critical points in detail, such as preoperative planning, reduction tactics and the current scientific evidence concerning treatment of subtrochanteric fractures of the femur.

Expanding indications of the horizontal belt plate: A technical note

BACKGROUND Although the standard treatment for articular fractures usually involves open anatomic reduction and internal fixation with the concept of absolute stability, achieving adequate fracture stabilisation in multifragmentary patterns is always challenging. Several anatomical implants were developed to increase stabilisation and improve clinical outcomes in articular fractures. However modern implants, especially in developing countries, are expensive and not always available for routine use. Horizontal rafting plate has recently emerged as an alternative technique to treat complex tibial plateau fractures using simple implants that function as a large washer. OBJECTIVE This technical note aims to describe horizontal belt plate use for treatment of periarticular fractures including the tibial plateau, thereby expanding its initial indication. CONCLUSION Horizontal belt plate is an effective, safe, and inexpensive treatment alternative for complex articular fractures. However, the surgeon must carefully analyse the fracture pattern to verify if the horizontal belt plate can be used alone or with traditional techniques.

Ponto de entrada para as hastes intramedulares anterógradas do fêmur: estudo em cadáver

AbSTrACT Objective: To analyze the natural exit of the wire guides in major trochanter through retrograde femoral approach, in cadaver specimens. Material and Method: 100 femurs had been perforated between the femoral condyles, at 1.2 cm of the intercondylar region. A 3-mm straight wire guide was introduced, through retrograde approach, until the proximal extremity of femur was reached. Femurs were assessed for posterosuperior and anterosuperior portions of major tro-chanter, pear-shaped cavity, and upper median line between the head-neck and the major trochanter. Results: in 62%, the straight wire guides exited at the anterior surface of major trochanter. In the pear-shaped cavity, the median distance found was 1.0 cm and the interquartile range was 0.5 cm, ini-tially expressing, in relation to pear-shaped cavity, better ac-curacy. Conclusion: the central axis of the medullar canal, at coronal plane, projected better accuracy in the region of the pear-shaped cavity. Keywords – Femur; Fracture fixation; intramedullary; Cadaver

Estudo da relação anatômica do nervo sensitivo radial após fixação percutânea com fios de Kirschner

OBJECTIVE: To establish the risk of lesion to the radial sensory nerve after percutaneous fixation in the distal radius region of cadavers. METHODS: The authors used 24 upper limbs of 12 skeletally mature cadavers, 10 male, and 2 female, mean age estimated as 50 years. A Kirschner wire was introduced in the styloid process of the radius to make the following determinations: distance between the wire and the radial sensory nerve, between the wire and the closest dorsal nerve branch, between the wire and the tendons of the first osteofibrous tunnel, and, finally, the number of branches of the radial sensory nerve. RESULTS: The site were the nerve appeared, between the two tendons and the Kirschner wire in the radial styloid process was a mean 5.09 cm, with a standard deviation of 0.75 cm. The distance between the Kirschner wire and the first dorsal branch was a mean 4.33 cm, ranging from zero to 10 cm. The number of nervous branches was a mean of four, ranging from two to eight branches. CONCLUSION: Results of this experimental study showed that when the wire is introduced in the styloid process of the radius, the risk of lesioning the radial sensory nerve is not a big risk. This risk is directly related to the number of nervous branches and to the angles of the wires while they are being introduced in the distal end of the radius.

ENTRY POINT FOR THE ANTEGRADE FEMORAL INTRAMEDULLARY NAIL: A CADAVER STUDY.

Objective: To analyze the natural exit of the wire guides in major trochanter through retrograde femoral approach, in cadaver specimens. Material and Method: 100 femurs had been perforated between the femoral condyles, at 1.2 cm of the intercondylar region. A 3-mm straight wire guide was introduced, through retrograde approach, until the proximal extremity of femur was reached. Femurs were assessed for posterosuperior and anterosuperior portions of major trochanter, pear-shaped cavity, and upper median line between the head-neck and the major trochanter. Results: in 62%, the straight wire guides exited at the anterior surface of major trochanter. In the pear-shaped cavity, the median distance found was 1.0 cm and the interquartile range was 0.5 cm, initially expressing, in relation to pear-shaped cavity, better accuracy. Conclusion: the central axis of the medullar canal, at coronal plane, projected better accuracy in the region of the pear-shaped cavity.

Tratamento das fraturas do terço distal da tíbia: fixar ou não a fíbula?

OBJETIVO: Comparar os resultados da fixacao ou nao da fibula no tratamento das fraturas do terco distal da tibia, com haste intramedular e placa em ponte. METODOS: Foram 47 fraturas em 47 pacientes, sendo que em 21 pacientes foi utilizada a haste intramedular bloqueada nao fresada e em 26 a placa em ponte (placa de compressao dinâmica larga ou estreita) pela tecnica minimamente invasiva. Todas as fraturas da fibula se encontravam no mesmo nivel ou abaixo da fratura da tibia. RESULTADOS: No grupo tratado com fixacao da fibula, a media do tempo de consolidacao foi de 14,6 semanas. No grupo tratado sem fixacao da fibula, a media do tempo de consolidacao foi de 14,3 semanas. No grupo de pacientes tratados com fixacao da fibula observou-se uma proporcao de desvio angular em varo (6,3%) significativamente menor que o subgrupo sem fixacao de fibula (32,3%), e com desvio angular em valgo (62,5%) significativamente maior que o grupo sem fixacao de fibula (32,3%). CONCLUSAO: Os beneficios da fixacao da fibula permanecem ainda controversos quando ocorrem fraturas associadas com a tibia. Em relacao a consolidacao, nao houve diferenca significativa entre os grupos.

FRACTURES OF THE DISTAL EXTREMITY OF THE TIBIA TREATED WITH INTRAMEDULLARY NAIL OR BRIDGE PLATE: COMPARISON OF RADIATION EXPOSURE DURATION BETWEEN THE TWO METHODS

Objective: To compare the duration of exposure to radiation among patients with fractures of the distal third of the tibia treated with an intramedullary nail or with a bridge plate. Methods: Intramedullary nails were used for 33 fractures, and bridge plates were used for 41 fractures. In the nail group, according to the AO classification, 14 patients had type A fractures, 15 had type B and four had type C. Twelve patients had closed fractures and 21 had open fractures. In the plate group, 10 patients had type A fractures, 22 had type B and nine had type C. Twenty-seven patients had closed fractures and 14 had open fractures. Results: There was a significant difference in the duration of exposure to radiation between the patients treated using a nail and those treated using a plate (p = 0.0001). The group treated using a nail had significantly greater exposure to radiation than did the group treated using a plate. Comparing the type of fracture (A, B or C), it was observed that there was no significant difference in the duration of exposure to radiation between the nail technique (p = 0.19) and the plate technique (p = 0.80). Conclusion: Fractures of the distal third of the tibia treated with an intramedullary nail present significantly greater exposure to radiation than do fractures treated with a bridge plate, independent of the fracture type.