Robinson Esteves Santos Pires

Failure of fixation of trochanteric femur fractures: Clinical recommendations for avoiding Z-effect and reverse Z-effect type complications.

BackgroundZ-effect and reverse Z-effect are complications that arise from the surgical treatment of pertrochanteric fractures of the femur with proximal femoral nails (PFN) comprising two interlocking head screws. Such complications are induced by the migration of screws in opposite directions, which may lead to failure of the osteosynthesis.FindingsThe paper describes three cases of pertrochanteric fractures that were treated with PFN with two interlocking screws that evolved to either Z-effect or reverse Z-effect. Literature-based explanations for this phenomenon are provided together with recommendations of how to avoid such complications.ConclusionsAlthough intramedullary fixation is an established method of treatment of femoral intertrochanteric and subtrochanteric fractures, the evolution of the procedure may include complications associated with the migration of the interlocking head screws. The occurrence of Z-effect and reverse Z-effect has not been completely elucidated, but the main causes of such complications are probably fracture fixation in varus position, severe medial comminution, inappropriate entry point of the nail and poor bone quality.

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.

Tratamento das fraturas da pelve e acetábulo pela via de stoppa modificada

This study describes the modified Stoppa access port for treating fractures on pelvic anterior region and fractures affecting the acetabulum anterior column. In this access port, a suprapubic cross-sectioned incision is performed on skin, longitudinal opening of the abdominal rectus muscle with lateral displacement of venters, and subperiosteal bone dissection through the medial surface of the hemipelvis addressed, so that implant materials can be placed on that inner surface. This access port, little used in our area, presents advantages over the traditional ports, such as the ilioinguinal and iliofemoral, due to the potential for a smaller surgical wound and soft parts dissection, enabling implants to be placed directly on quadrilateral layer, achieving a stable fixation and reducing the risks of infection and injuries to neurovascular structures. As a result of current literature and of the experience of the authors with the use of that access port, we can conclude that it is a good alternative for accessing those fractures.

Anatomia patológica da sinóvia de pacientes submetidos à liberação do túnel do carpo

OBJECTIVE: To determine whether a biopsy of the synovia of the carpal tunnel is able to identify systemic diseases that were not diagnosed by clinical examination and laboratory tests. METHODS: Anatomical pathology P examinations of synovial tissue were performed in 46 patients that underwent open carpal tunnel release. Anatomical pathology examination with hematoxylin-eosin staining determined the intensity of the inflammatory process and the authors proposed a new classification of the injury according to the intensity of the inflammatory process. RESULTS: The anatomical pathology examination showed that 56.6% were classified as grade I (unchanged inflammation), 32.6%, grade II (leukocyte infiltration and discreetmoderate fibrosis), 4.3%, grade III (leukocyte infiltrate and intense fibrosis, the presence of fibrin and vascular neoformation) and 6.5%, grade IV (changes described above associated with the presence of local calcification and giant cells). Two patients with amyloidosis were classified as grade I and II and no stockpiles of amyloid material were found on their slides. Two patients with hyperparathyroidism and another with chronic kidney failure were classified as grade IV. CONCLUSION: Synovial biopsy of the carpal tunnel did not make early diagnosis of potential systemic diseases possiblein patients with carpal tunnel syndrome, and adds extra costs to the procedure.

Radiographies under Traction Influence Surgeon Choice in Implant Selection for Intertrochanteric Fractures

Objective: Determine whether preoperative AP pelvis radiographies under manual traction influence surgeon choice for implants in intertrochanteric fractures compared with standard radiographies. Methods: Fifty-eight patients with intertrochanteric fractures were prospectively enrolled from four tertiary teaching hospitals. All patients had standard AP pelvis radiographies taken as well as radiographies under manual traction of affected limb, 116 images total. Three fellowship trained trauma surgeons and three hip surgeons blindly reviewed the images and indicated their implant choice for each case: extra or intramedullary fixation. The observers received randomly assigned images and were unaware of the radiography technique, patient number, and repetition of patients within the set of images. Statistical analyses were performed using Cohen Kappa method and McNemar, Q Cochran, and Wilcoxon tests. Results: Manual traction radiographies changed surgeon-implant choice in 35.06% (range: 27.6% to 43.1%). However, traction radiographies provided no improvement in weak inter-observer reliability for treatment indication (k=0.264, p<0.001) compared to standard radiographies (k=0.220, p<0.001), when using Mann-Whitney test (p=0.359). Traction views did not increase predilection for either method. Hip surgeons agreed more than trauma surgeons concerning implant choice. Conclusions: Manual traction radiographies modified surgeon choice in up to one third of intertrochanteric fracture cases.

Humerus shaft fracture associated with traumatic radial nerve palsy: An international survey among orthopedic trauma surgeons from Latin America and Asia/Pacific:

Purpose: The purpose of this article is to explore the real-life practice of clinical management of humeral shaft fracture associated with traumatic radial nerve palsy among orthopedic trauma surgeons. Methods: Two hundred seventy-nine orthopedic surgeons worldwide reviewed 10 real cases of a humeral shaft fracture associated with traumatic radial nerve palsy answering two questions: (1) What treatment would you choose/recommend: nonoperative or operative? (2) What are the reasons for your decision-making? The survey was developed in an online survey tool. All participants were active members from AOTrauma International. Results: Two hundred sixty-six (95.3%) participants were from Latin America and Asia/Pacific. One hundred sixty-two participants (58.1%) had more than 10 years in practice and 178 (63.8%) of them did trauma as the main area of interest. One hundred fifty-one (54.1%) participants treated less than three humeral shaft fractures a month. Traumatic radial nerve palsy was the main reason (88.4%) for surgeons to recommend surgical treatment. Open reduction and internal fixation (ORIF) or percutaneous fixation of the fracture associated with acutely explore of radial nerve was the first option in 62.0% of the cases. A combination of morphology and level of the fracture and the presence of the radial nerve palsy was the most suggested reason to surgically treat the humerus fracture. The main isolated factor was the morphology of the fracture. Conclusion: Our survey highlight the tendency for a more aggressive management of any humeral shaft fracture associated with a traumatic radial nerve palsy, with surgeons preferring to use ORIF with acute exploration of the radial nerve. Nonsurgical management was the less chosen option among the 279 respondents. Fracture morphology, level of the fracture, and the presence of the radial nerve palsy were most influential for guiding their treatment.

UNO O DOS TORNILLOS EN LA FRACTURA DEL PROCESO ODONTOIDES? EVALUACIÓN POR TOMOGRAFIA AXIAL COMPUTADORIZADA

Resumo Objetivo: Avaliar a area ossea do processo odontoide, por meio de tomografia computadorizada, e sua relacao com a area de um e dois parafusos no genero masculino e feminino. Material e Metodos: Foram analisadas 188 tomografias computadorizadas de adultos. A area do istmo foi selecionada e o diâmetro transverso foi medido a 1,2 mm da base do odontoide. Resultados: Apos a colocacao de um parafuso, a area da odontoide permanece com 82% de osso livre, tanto para homens quanto para mulheres. Com dois parafusos, 45,6% das mulheres, passaram a ter area ossea livre do processo odontoide entre 50% e 75% e 54,4% ficaram acima de 75%. Entre os homens este percentual foi de 26,6% entre 50% a 75% de area ossea livre e 73,4% acima de 75% (p-valor=0,07). Apos a colocacao de dois parafusos, a area ossea foi, em media, 77,3% nos homens e 75,4% nas mulheres. Utilizando o teste t-de Student, as diferencas entre as medias de homens e mulheres dos percentuais da area ossea livre, sao significativamente menores nas mulheres (p-valor=0,0012). Conclusao: O planejamento no pre-operatorio, por meio de TC, pode ajudar na escolha do numero de parafusos no processo odontoide. A escolha deve ser criteriosa especialmente quando for necessaria a utilizacao de dois parafusos no genero feminino.Objetivo:Evaluar el area osea del proceso odontoides por medio de la tomografia axial computarizada, y su relacion con el area de uno y dos tornillos en individuos del sexo masculino y femenino.Metodos:Fueron analizadas 188 tomografias axiales computarizadas de adultos. Se selecciono el area del istmo y el diametro transversal fue medido en 1,2 mm de la base del odontoides.Resultados:Despues de la colocacion de un tornillo, el area de la odontoides queda con 82% de hueso libre, tanto en hombres como en mujeres. Con dos tornillos, el 45,6% de las mujeres tuvieron area de hueso libre en el proceso odontoides entre el 50% y el 75%, y 54,4% estaban por encima del 75%. Entre los hombres este porcentaje fue del 26,6% desde el 50% al 75% de area de hueso libre y el 73,4% por encima del 75%, (p = 0,07). Despues de la colocacion de dos tornillos, el area de hueso fue, en promedio, el 77,3% de los hombres y el 75,4% de las mujeres. Utilizando la prueba t de Student, las diferencias entre las medias de hombres y mujeres del porcentaje de area de hueso libre son significativamente mas bajos en las mujeres (p = 0,0012).Conclusion:La planificacion prequirurgica mediante TC puede ayudar a elegir el numero de tornillos a usar en el proceso odontoides. La eleccion debe ser cuidadosa, especialmente cuando se utilizan dos tornillos en las mujeres.

UM OU DOIS PARAFUSOS NA FRATURA DO PROCESSO ODONTOIDE? AVALIAÇÃO PELA TOMOGRAFIA COMPUTADORIZADA

Resumo Objetivo: Avaliar a area ossea do processo odontoide, por meio de tomografia computadorizada, e sua relacao com a area de um e dois parafusos no genero masculino e feminino. Material e Metodos: Foram analisadas 188 tomografias computadorizadas de adultos. A area do istmo foi selecionada e o diâmetro transverso foi medido a 1,2 mm da base do odontoide. Resultados: Apos a colocacao de um parafuso, a area da odontoide permanece com 82% de osso livre, tanto para homens quanto para mulheres. Com dois parafusos, 45,6% das mulheres, passaram a ter area ossea livre do processo odontoide entre 50% e 75% e 54,4% ficaram acima de 75%. Entre os homens este percentual foi de 26,6% entre 50% a 75% de area ossea livre e 73,4% acima de 75% (p-valor=0,07). Apos a colocacao de dois parafusos, a area ossea foi, em media, 77,3% nos homens e 75,4% nas mulheres. Utilizando o teste t-de Student, as diferencas entre as medias de homens e mulheres dos percentuais da area ossea livre, sao significativamente menores nas mulheres (p-valor=0,0012). Conclusao: O planejamento no pre-operatorio, por meio de TC, pode ajudar na escolha do numero de parafusos no processo odontoide. A escolha deve ser criteriosa especialmente quando for necessaria a utilizacao de dois parafusos no genero feminino.Objetivo:Evaluar el area osea del proceso odontoides por medio de la tomografia axial computarizada, y su relacion con el area de uno y dos tornillos en individuos del sexo masculino y femenino.Metodos:Fueron analizadas 188 tomografias axiales computarizadas de adultos. Se selecciono el area del istmo y el diametro transversal fue medido en 1,2 mm de la base del odontoides.Resultados:Despues de la colocacion de un tornillo, el area de la odontoides queda con 82% de hueso libre, tanto en hombres como en mujeres. Con dos tornillos, el 45,6% de las mujeres tuvieron area de hueso libre en el proceso odontoides entre el 50% y el 75%, y 54,4% estaban por encima del 75%. Entre los hombres este porcentaje fue del 26,6% desde el 50% al 75% de area de hueso libre y el 73,4% por encima del 75%, (p = 0,07). Despues de la colocacion de dos tornillos, el area de hueso fue, en promedio, el 77,3% de los hombres y el 75,4% de las mujeres. Utilizando la prueba t de Student, las diferencias entre las medias de hombres y mujeres del porcentaje de area de hueso libre son significativamente mas bajos en las mujeres (p = 0,0012).Conclusion:La planificacion prequirurgica mediante TC puede ayudar a elegir el numero de tornillos a usar en el proceso odontoides. La eleccion debe ser cuidadosa, especialmente cuando se utilizan dos tornillos en las mujeres.

ONE OR TWO SCREWS IN THE FRACTURE OF THE ODONTOID PROCESS? EVALUATION USING COMPUTED TOMOGRAPHY

Resumo Objetivo: Avaliar a area ossea do processo odontoide, por meio de tomografia computadorizada, e sua relacao com a area de um e dois parafusos no genero masculino e feminino. Material e Metodos: Foram analisadas 188 tomografias computadorizadas de adultos. A area do istmo foi selecionada e o diâmetro transverso foi medido a 1,2 mm da base do odontoide. Resultados: Apos a colocacao de um parafuso, a area da odontoide permanece com 82% de osso livre, tanto para homens quanto para mulheres. Com dois parafusos, 45,6% das mulheres, passaram a ter area ossea livre do processo odontoide entre 50% e 75% e 54,4% ficaram acima de 75%. Entre os homens este percentual foi de 26,6% entre 50% a 75% de area ossea livre e 73,4% acima de 75% (p-valor=0,07). Apos a colocacao de dois parafusos, a area ossea foi, em media, 77,3% nos homens e 75,4% nas mulheres. Utilizando o teste t-de Student, as diferencas entre as medias de homens e mulheres dos percentuais da area ossea livre, sao significativamente menores nas mulheres (p-valor=0,0012). Conclusao: O planejamento no pre-operatorio, por meio de TC, pode ajudar na escolha do numero de parafusos no processo odontoide. A escolha deve ser criteriosa especialmente quando for necessaria a utilizacao de dois parafusos no genero feminino.Objetivo:Evaluar el area osea del proceso odontoides por medio de la tomografia axial computarizada, y su relacion con el area de uno y dos tornillos en individuos del sexo masculino y femenino.Metodos:Fueron analizadas 188 tomografias axiales computarizadas de adultos. Se selecciono el area del istmo y el diametro transversal fue medido en 1,2 mm de la base del odontoides.Resultados:Despues de la colocacion de un tornillo, el area de la odontoides queda con 82% de hueso libre, tanto en hombres como en mujeres. Con dos tornillos, el 45,6% de las mujeres tuvieron area de hueso libre en el proceso odontoides entre el 50% y el 75%, y 54,4% estaban por encima del 75%. Entre los hombres este porcentaje fue del 26,6% desde el 50% al 75% de area de hueso libre y el 73,4% por encima del 75%, (p = 0,07). Despues de la colocacion de dos tornillos, el area de hueso fue, en promedio, el 77,3% de los hombres y el 75,4% de las mujeres. Utilizando la prueba t de Student, las diferencias entre las medias de hombres y mujeres del porcentaje de area de hueso libre son significativamente mas bajos en las mujeres (p = 0,0012).Conclusion:La planificacion prequirurgica mediante TC puede ayudar a elegir el numero de tornillos a usar en el proceso odontoides. La eleccion debe ser cuidadosa, especialmente cuando se utilizan dos tornillos en las mujeres.

Percutaneous Lag Screw Fixation for Lateral Malleolar Fracture: Technique Description and Case Report

Open reduction and internal fixation with plate and screws is the standard treatment for displaced or unstable lateral malleolar fractures. Despite functional satisfactory results obtained using this technique, complications including infection, skin necrosis, and discomfort caused by the plate are reported in 10-20% of cases. Several minimally invasive techniques have emerged as alternatives to avoid these complications. The present study aims to describe a technique and case report for percutaneous treatment of lateral malleolar fractures applying only screw fixation.