The Perspective of Brazilian Women Orthopaedic Surgeons on Gender Discrimination: Initial Insights to Understand Gender Bias in the Brazilian Healthcare System.

Despite the societal progress made in recent years, gender discrimination is still common in healthcare, especially in some surgical specialties such as orthopaedics. In Brazil, where the participation of women in the medical profession has been increasing, little is known about women's perceptions on the issue of gender discrimination. This study aims to examine women orthopaedic surgeons' experiences in dealing with conflict in the workplace and contextualize the impact that gender discrimination has had or currently has on their careers and well-being. As a secondary objective, the work seeks to understand whether there are differences in the perception of the issue among practicing women orthopaedic surgeons and those in training. For a cross-sectional qualitative study, a survey was distributed exclusively to 300 practicing orthopaedic surgeons and orthopaedists in training (residents and fellows). A total of 99 women participated in the survey, of whom 66 were practicing orthopaedic surgeons and 33 were orthopaedists in training. The study showed that women orthopaedic surgeons in training in Brazil have a lower number of publications and a moderate level of involvement in academic society activity. In addition, orthopaedic surgeons in training experience a statistically significantly higher number of conflicts in the workplace. The comments from the questionnaires highlighted the physical and psychological consequences arising from these situations of professional conflict, most frequently occurring with orthopaedic surgeons who are men. Our findings indicate that respondents expressed a feeling of inequality towards women in the workplace, ultimately reducing the level of job satisfaction among female orthopaedic surgeons, which may contribute to disinterest and abandonment of the specialty. The results of this work support recent evidence that there is an implicit and often overlooked bias against the participation of women and ethnic minorities in the orthopaedic community in Brazil.

Doctor, When Should I Start Walking? Revisiting Postoperative Rehabilitation and Weight-Bearing Protocols in Operatively Treated Acetabular Fractures: A Systematic Review and Meta-Analysis.

Background and Objectives: Management of acetabular fractures is aimed at anatomically reducing and fixing all displaced or unstable fractures, as the accuracy of fracture reduction has been demonstrated to strongly correlate with clinical outcomes. However, there is a noticeable gap in the literature concerning the perioperative and postoperative care of patients with acetabular fractures, which ultimately can be potential risk factors for adverse outcomes and permanent disabilities. This study aimed to systematically review the available literature regarding rehabilitation practices, including weight-bearing protocols, across time points in surgically treated acetabular fracture patients and correlate these practices with functional outcomes. Methods: We systematically reviewed the Medline and PubMed databases and the Cochrane Central Register of Controlled Trials in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The inclusion criteria were studies with adult patients (19+ years), publications from the last 10 years, articles focusing on rehabilitation or mentioning any aspect related to rehabilitation (such as weight-bearing or muscle training), and describing the surgical management of acute, isolated acetabulum fractures. Specific information was collected, including the fracture classification, time to surgery, surgical approach, surgical time, blood loss, fixation strategy, quality of reduction, postoperative rehabilitation protocol, complication rate, type(s) of complication, and outcome measurement(s). The choice(s) of surgical approach, surgical time, blood loss, and fixation strategy were stratified based on the fracture classification. The complication rate and type(s) of complication were calculated for all studies. Fractures were classified based on the Letournel classification. Results: A total of 494 articles were identified from the initial search, of which 22 (1025 patients) were included in the final review. The most common rehabilitation protocol favored isometric quadriceps and abductor strengthening exercises starting on the first postoperative day, with passive hip movement at 1-3 days postoperatively and active hip movement ranging from the first postoperative day to 4 weeks postoperatively. Partial weight-bearing with a walker or a pair of crutches was permitted from 1 to 12 weeks after surgery, and full weight-bearing was allowed depending on the patient's general condition and fracture healing state (generally at the end of 3 months). In only three studies did the patients start bearing weight in the early postoperative period (≤1 week). Meta-regression analysis was not performed due to the discrepancy between studies that reported a weight-bearing protocol ≤1 week and >1 week postoperatively. Conclusions: Our study suggests that an accelerated postoperative rehabilitation protocol, including early permissive weight-bearing, does not appear to increase the risk of loss of reduction or the rate of complications after surgical treatment of acetabular fractures. However, a proper meta-analysis was not possible, and the heterogeneity of the included studies did not allow us to conclude anything about the potential biomechanical and clinical benefits nor the negative effects related to this rehabilitation regimen in terms of functional results. There is an inconsistent use of PROMs for objectively calculating the effect size of the accelerated protocol compared with restricted weight-bearing regimes. We pose the need for higher-level evidence to proof our hypothesis.

Modified-tension band suturing: 'the pulling the reins technique' - a technique for displaced proximal humeral fracture with medial column instability.

Fractures of the proximal humerus with medial column instability are challenging and present an unacceptable rate of complications and reoperations. Despite good results reported with the use of locking plates and augmentation techniques using bone graft or a second plate, varus subsidence and fixation failure have been frequently reported. We describe the case of a patient presenting with a complex, multifragmentary proximal humerus fractures successfully treated with open anatomic reduction and internal fixation using a locking plate augmented with lateral traction using three bone anchors in the humerus head. After 18 months, the patient reported fully recovering the mobility and functionality of the operated shoulder. The use of bone anchors pulling the humeral in three different directions like three vectors applied from medial to lateral, posterior to anterior and lateral to anterior help to reduce the most important deformities (varus and retroversion) by applying the tension band principle. This is an interesting approach to avoid primary and secondary reduction loss of the proximal fractures of the humerus with postero-medial cortical defect. The procedure is a good alternative to be used in patients with failure or insufficiency of the medial wall and marked varus.

Geriatric proximal femur fracture updates.

Proximal femur fractures in the aging population present a variety of challenges. Physiologically, patients incurring this fracture are typically frail, with significant medical comorbidities, yet require early surgical treatment to restore mobility to prevent deterioration. Socioeconomically, the occurrence of a fragility fracture may be the beginning of the loss of independence, and the burdens of rehabilitation and support are borne by the individual patient and health care systems.

The role of computed tomography with external rotation and dorsiflexion in decision making for acute isolated non-displaced posterior malleolar fractures Bartonícek and Rammelt type II: a prospective study.

PURPOSE: Our objective was to evaluate the syndesmotic and fracture instability using conventional ankle computed tomography (CT) with stress maneuvers. METHODS: A consecutive sample of 123 individuals with an ankle sprain was assessed for eligibility. In total, 33 patients met the inclusion criteria. All patients underwent a magnetic resonance imaging (MRI) and CT scan with stress maneuvers (CTSM). The patterns of ligament tears f were classified using West Point grades I, IIA, IIB, III. Mann-Whitney test was used to test the differences in the numerical variables between injured and uninjured syndesmoses. The Spearman correlation tested the strength of the association between the tibial joint surface involved in posterior malleolus fracture and syndesmotic instability. RESULTS: In MRI, two patterns of syndesmotic ligament injury predominated. A completely torn anterior inferior tibiofibular (AITFL) and interosseous tibiofibular ligaments (ITFL) and a completely torn AITFL were combined with a partially torn ITFL. In the neutral phase CTSM and during the stress phase the median difference of the narrowest tibiofibular distance between injured and uninjured syndesmoses was 0.2 mm (P = 0.057) and 2.3 mm (P < 0.0001), respectively. There was no association between the percentage of involvement of the posterior tibial joint surface in the posterior malleolar fracture and syndesmotic instability as measured with CTSM. CONCLUSION: The conventional computed tomography with external rotation and dorsiflexion represents a reproducible and accurate diagnostic option for detecting syndesmosis instability and fracture instability in acute isolated non-displaced posterior malleolar fractures Bartonícek and Rammelt type II. LEVEL OF EVIDENCE: Prospective study among consecutive patients (Diagnosis); Level of evidence, 2.

Novel implant design for comminuted posterior wall acetabular fractures.

BACKGROUND: In recent years, the medical community has witnessed a notable increase in high-energy traumatic injuries, leading to a surge in complex fracture patterns that challenge existing treatment methodologies. Among these, the posterior approach to acetabular fractures stands out for offering direct visualization of the retro-acetabular surface, with current fixation methods relying on 3.5 mm low-profile reconstruction plates and various other implants. Despite the effectiveness of these methods, there is a burgeoning demand for a singular, adaptable implant that not only streamlines the surgical process but also optimizes patient outcomes. METHODS: In an innovative approach to address this need, three-dimensional (3D) models of the posterior acetabular wall were meticulously crafted using AutoCAD® software. The chosen material for the implant was 316L surgical steel for its durability and strength. The design of the implant featured a low-profile mesh structure, which was instrumental in facilitating osteosynthesis. This design allowed for the placement of screws of varying lengths in multiple directions, ensuring the initial reconstruction of the joint in an anatomical position without hindering the placement of the definitive implant. The primary objective was to secure the fixation and stabilization of the fracture by specifically targeting the smaller bone fragments. A comparative analysis was then conducted between this novel plate and a conventional 316L surgical steel, seven-hole, 3.5 mm reconstruction plate through finite element analysis. RESULTS: The comparative analysis unveiled that both plates demonstrated comparable deformation capacities, with no significant differences in load-bearing capabilities observed. This finding suggests that the innovative plate can match the performance of traditional plates used in such surgeries. CONCLUSIONS: The finite element analysis revealed that the newly developed anatomical plate for posterior wall acetabular fractures meets the necessary physical and mechanical criteria for permanent implementation in patients with these fractures. This breakthrough represents a promising advancement that could simplify surgical procedures and potentially elevate patient outcomes. LEVEL OF EVIDENCE II: This study is classified as a Level II, diagnostic study.

LEADERSHIP DEVELOPMENT TRAINING FOR BRAZILIAN ORTHOPEDIC SURGEONS.

Objective: To report on the experience and impressions of the Brazilian orthopedic trauma surgeons attending the Leadership Development Program (LDP) hosted by the Sociedade Brasileira do Trauma Ortopédico (SBTO) in Sao Paulo, Brazil on November 4, 2022. Methods: Forty-eight orthopedic trauma surgeons from five different regions throughout Brazil were provided a link to complete The Big Five Test, a validated online personality assessment. The questionnaire was available in Portuguese and was intended to provide a background on individual personality traits and their influence on interpersonal interactions. The LDP integrated content from literature reviews specific to Latin America, established leadership programs from leading business schools, and various subject matter experts. Prior to the start of the LDP, participants received a pre-course survey evaluating demographic information, a needs assessment, and the prioritization of leadership topics utilizing a 5-point Likert-scale. Attendees participated in the one-day, interactive LDP focusing on the fundamental principles of leadership development, communication, personal development, emotional intelligence and negotiation. Following the LDP, a post-course evaluation was administered to determine the participants' overall experience, and suggestions for LDP improvement. Results: Forty-one of the forty-eight course participants completed the pre-course evaluation, whereas forty-six of the forty-eight participants completed the post-course evaluations. Overwhelmingly, the lack of opportunity was most prevalently reported as the main obstacle to attending a leadership course, as cited by 56% of respondents. Conclusion: Expanding the accessibility, diversity, and customizability of leadership programs can facilitate the development of personal tools needed to move healthcare forward. Critical topics include emotional intelligence and other differentiating leadership qualities that distinguish true transformational and servant leaders. Advancing leadership skills can stimulate networking, expose learners to experiential learning styles, inspire others to create positive change, and engender creative solutions for systematic improvements and health outcomes. Level of Evidence III; Individual Case-Control Studies.

Objetivo: Relatar a experiência e as impressões de cirurgiões de trauma ortopédico brasileiros participantes do Programa de Desenvolvimento de Liderança (PDL), organizado pela Sociedade Brasileira do Trauma Ortopédico (SBTO), em São Paulo, Brasil, em 4 de novembro de 2022. Métodos: Quarenta e oito cirurgiões de trauma ortopédico de cinco regiões diferentes do Brasil receberam um link para preencher o The Big Five Test, uma avaliação de personalidade on-line validada. O questionário estava disponível em português e pretendia fornecer informações básicas sobre traços de personalidade individuais e sua influência nas interações interpessoais. O PDL integrou conteúdo de análises de literatura específicas da América Latina, e programas de liderança estabelecidos pelas principais escolas de negócios e por vários especialistas no assunto. Antes do início do PDL, os participantes receberam uma pesquisa pré-curso solicitando informações demográficas, uma avaliação de necessidades e a priorização de tópicos de liderança utilizando uma escala Likert de 5 pontos. Os participantes participaram do PDL interativo de um dia com foco nos princípios fundamentais de desenvolvimento de liderança, comunicação, desenvolvimento pessoal, inteligência emocional e negociação. Após o PDL, foi realizada uma avaliação pós-curso para determinar a experiência geral dos participantes e sugestões para melhoria do PDL. Resultados: Quarenta e um dos quarenta e oito participantes do curso concluíram a avaliação pré-curso, enquanto quarenta e seis dos quarenta e oito participantes concluíram a avaliação pós-curso. A falta de oportunidade foi relatada com maior prevalência como o principal obstáculo para frequentar um curso de liderança, conforme citado por 56% dos entrevistados. Conclusão: Expandir a acessibilidade, a diversidade e a personalização dos programas de liderança podem facilitar o desenvolvimento de ferramentas pessoais necessárias para fazer avançar os cuidados de saúde. Os tópicos críticos incluem inteligência emocional e outras qualidades de liderança diferenciadas, que distinguem verdadeiros líderes transformacionais e servidores O avanço das competências de liderança pode estimular o networking, expor os alunos a estilos de aprendizagem experiencial, inspirar outros a criar mudanças positivas e gerar soluções criativas para melhorias sistemáticas dos resultados na saúde. Nível de Evidência III; Estudos de caso-controle individuais.

Standing on shoulder of giants: the incredible legacy of the Judet family in orthopaedic surgery.

In orthopaedic surgery, as well as other areas in medicine, it is common for a surgical technique to carry the original authors' name describing the procedure. The Judet family represents a unique history, since several orthopaedic procedures are known as "Judet's technique". The aim of this historic review is to outline the genealogy of the orthopaedic arm of the Judet family, while crediting each surgical procedure to the specific family member that described the technique.

Real-World Experience of Carglumic Acid for Methylmalonic and Propionic Acidurias: An Interim Analysis of the Multicentre Observational PROTECT Study.

BACKGROUND AND OBJECTIVE: Methylmalonic aciduria (MMA) and propionic aciduria (PA) are organic acidurias characterised by the accumulation of toxic metabolites and hyperammonaemia related to secondary N-acetylglutamate deficiency. Carglumic acid, a synthetic analogue of N-acetylglutamate, decreases ammonia levels by restoring the functioning of the urea cycle. However, there are limited data available on the long-term safety and effectiveness of carglumic acid. Here, we present an interim analysis of the ongoing, long-term, prospective, observational PROTECT study (NCT04176523), which is investigating the long-term use of carglumic acid in children and adults with MMA and PA. METHODS: Individuals with MMA or PA from France, Germany, Italy, Norway, Spain, Sweden and the UK who have received at least 1 year of carglumic acid treatment as part of their usual care are eligible for inclusion. The primary objective is the number and duration of acute metabolic decompensation events with hyperammonaemia (ammonia level >159 µmol/L during a patient's first month of life or >60 µmol/L thereafter, with an increased lactate level [> 1.8 mmol/L] and/or acidosis [pH < 7.35]) before and after treatment with carglumic acid. Peak plasma ammonia levels during the last decompensation event before and the first decompensation event after carglumic acid initiation, and the annualised rate of decompensation events before and after treatment initiation are also being assessed. Secondary objectives include the duration of hospital stay associated with decompensation events. Data are being collected at approximately 12 months' and 18 months' follow-up. RESULTS: Of the patients currently enrolled in the PROTECT study, data from ten available patients with MMA (n = 4) and PA (n = 6) were analysed. The patients had received carglumic acid for 14-77 (mean 36) months. Carglumic acid reduced the median peak ammonia level of the total patient population from 250 µmol/L (range 97-2569) before treatment to 103 µmol/L (range 97-171) after treatment. The annualised rate of acute metabolic decompensations with hyperammonaemia was reduced by a median of - 41% (range - 100% to + 60%) after treatment with carglumic acid. Of the five patients who experienced a decompensation event before treatment and for whom a post-treatment rate could be calculated, the annualised decompensation event rate was lower after carglumic acid treatment in four patients. The mean duration of hospital inpatient stay during decompensation events was shorter after than before carglumic acid treatment initiation in four of five patients for whom length of stay could be calculated. CONCLUSIONS: In this group of patients with MMA and PA, treatment with carglumic acid for at least 1 year reduced peak plasma ammonia levels in the total patient population and reduced the frequency of metabolic decompensation events, as well as the duration of inpatient stay due to metabolic decompensations in a subset of patients. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT04176523. Registered 25 November, 2019, retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04176523 .

Trends of impact factor contributors to the Injury Journal: A bibliometric analysis.

PURPOSE: This study aims to analyse papers concerning journal impact factors published in the Injury-International Journal of the Care of the Injured between 1997 and 2022. Through this analysis, the research offers valuable insights into the publication performance and contributors to the journal impact factor, encompassing papers, authors, institutions, and countries. METHODS: Articles and reviews published in the Injury between 1995 and 2021 were examined using the Science Citation Index Expanded database. The study employed the journal impact factor contributing indicator to compare highly cited and high journal impact factor papers across various aspects, including papers, authors, institutions, and countries. RESULTS: A notable correlation exists between prolific authors, institutions, and countries, alongside those who contribute to high journal impact factors. However, a less distinct connection was observed between highly cited papers/authors and high journal impact factor contributors. The Injury serves as a well-regarded international journal. Notably, editorial members of the journal play a substantial role, serving as model editors and contributing significantly to the journal's success. Out of the Top 25 IF contributing papers with the CN of 34 or more the following themes were noted to dominate: bone healing/tissue regeneration (40 %) of papers, covid-19 pandemic (24 %), polytrauma/coagulopathy (12 %) and infection (8 %). CONCLUSIONS: Utilizing the journal impact factor to assess research performance at the individual, institutional, or national levels appears not to be the most appropriate method. The results show that highly cited authors did not hold the distinction of being the primary contributors to the IF. Analysis revealed a low significant relationship among the primary contributors to the IF, highly cited papers, and the most influential papers in 2022. A more effective indicator could involve considering the total number of citations a publication receives from its year of publication up to the end of the most recent year.

Biomechanics of internal fixation in Hoffa fractures - A comparison of four different constructs.

OBJECTIVE: Compare the biomechanical effectiveness of four different bone-implant constructs in preventing fracture displacement under axial loading. METHODS: Twenty artificial femora had a standardized coronally oriented fracture of the lateral femoral condyle, representing a Hoffa fracture classified as a Letenneur type I. Four different fixation constructs were applied to the synthetic bones for biomechanical testing. The constructs consisted of a posterolateral (PL) buttressing locking plate in conjunction with two cannulated lag screws inserted from posterior to anterior (PA) - Group 1; Two cannulated screws inserted from anterior to posterior (AP) without plating- Group 2; A posterolateral (PL) buttressing locking plate in isolation - Group 3; and a combination of two lag screws from anterior to posterior (AP) in addition to a horizontal one-third tubular locking plate - Group 4. An axial load was applied to the fracture site with a constant displacement speed of 20 mm/min, and the test was interrupted when a secondary displacement was detected determining a fixation failure. We recorded the maximum applied force and the maximum fracture displacement values. RESULTS: Group 1 demonstrated the highest overall bone-implant axial stiffness with the lowest secondary displacement under loading. Groups 3 and 4 showed equivalent mechanical behavior. Group 2 presented the lowest mechanical stiffness to axial loading. The combination of the one-third tubular locking plate with anterior-to-posterior lag screws (Group 4) resulted in 302 % increase in fixation stiffness when compared to anterior-to-posterior lag screws only (Group 2). CONCLUSIONS: This study confirms the mechanical superiority of having a plate applied parallel to the main fracture plane in the setting of coronally oriented femoral condyle fractures. The addition of a horizontal plate, perpendicular to the main fracture plane, significantly increased the resistance to shearing forces at the fracture site when compared to constructs adopting just cannulated screws. LEVEL OF EVIDENCE: Biomechanical study.

Does the type of medial plate fixation matter for supplemental fixation of distal femur fractures manage with a lateral pre-contoured locked plate? A Biomechanical study.

INTRODUCTION: Fixation of distal femur fractures with a lateral pre-contoured locking plate provides stable fixation and is the standard treatment in most cases, allowing early range of motion with a high rate of union. However, in situations, the stability achieved with the lateral plate alone may be insufficient, predisposing to fixation failure. The objective of the study was to compare, in synthetic bone models, the biomechanical behaviour of the fixation with a distal femur lateral pre-contoured locking plate solely and associated with a 3.5 mm proximal humeral locking plate applied upside down or a 4.5 mm helical locking compression plate on the medial side. MATERIAL AND METHODS: A total of 15 solid synthetic left femur samples were used. A metaphysical defect at the level of the medial cortex was simulated. The samples were randomly distributed into three groups equally. All groups received a 4.5/5.0 mm single lateral 9-hole distal femur lateral pre-contoured locking plate. Group 1 had no supplementary plate. Group 2 received a supplementary 6-hole 3.5 mm proximal humeral locking plate and Group 3 received a supplementary 4.5/5.0 mm helical 14-hole narrow locking compression plate. RESULTS: Both supplementary plate types used in groups 2 and 3 contributed to increase the apparent stiffness of the construct, but pairwise comparison showed statically significant difference only between group 1 and 3. No significant difference was observed between groups 2 and 3. CONCLUSION: Both supplementary plates might be considered for improving the fixation in distal femur fracture in selected cases.

Is just one screw really enough? Single- versus double-screw in the medial malleolus in supination-external rotation ankle fractures: A comparative biomechanical study using partially threaded cancellous screws.

OBJECTIVE: The aim of this study is to investigate stiffness and the maximum load to failure values of single- and double-screw fixation of oblique medial malleolus fractures using partially threaded cancellous screws. Our hypothesis is that single-screw fixation of medial malleolus fractures after SER injuries provides similar stiffness when compared with double-screw fixation. DESIGN: Biomechanical study. METHODS: Twelve composite polyurethane synthetic right distal tibiae were used in the experiment. Oblique fractures of the medial malleolus were created with a band saw using a custom-made osteotomy guide to standardize the cuts in all models. Bone models were randomly separated into two groups and fixed with one (n = 6) or two (n = 6) 4.0 mm partially threaded cancellous screws placed perpendicular to the fracture line. These were tested by applying an offset axial tension at 10 mm/minute up to maximum load displacement, defined as subsidence of the medial malleolus fragment. Maximum load to failure was determined for the groups at the point where the curve ceased to be linear and suffered an inflection. Force versus displacement curves were obtained and recorded. The student's t-test for independent samples was used to compare stiffness (N / mm) and maximum load (N) between experimental groups, with a p value of < 0.05. RESULTS: There were no significant differences in stiffness (p = 0.290) and maximum load (p = 0.191) among the two fixation constructs. Mean stiffness was 62.26 (±SD 21.11) N/mm for double-screw fixation group and 48.24 (±SD 22.40) N/mm for single-screw fixation group. Mean maximum load was 387.83 (±SD 115.78) N for double-screw fixation group and 306.64 (±SD 81.97) N for single-screw fixation group. CONCLUSION: Fixation with one 4.0 mm partially threaded cancellous screw was not shown to be biomechanically inferior to fixation with two 4.0 mm partially threaded cancellous screws in an oblique fracture of the medial malleolus, supporting previous clinical studies that have shown that one screw is sufficient for fractures of the medial malleolus.

Leadership development training for brazilian orthopedic surgeons / Treinamento de desenvolvimento de liderança para cirurgiões ortopédicos brasileiros

ABSTRACT Objective: To report on the experience and impressions of the Brazilian orthopedic trauma surgeons attending the Leadership Development Program (LDP) hosted by the Sociedade Brasileira do Trauma Ortopédico (SBTO) in Sao Paulo, Brazil on November 4, 2022. Methods: Forty-eight orthopedic trauma surgeons from five different regions throughout Brazil were provided a link to complete The Big Five Test, a validated online personality assessment. The questionnaire was available in Portuguese and was intended to provide a background on individual personality traits and their influence on interpersonal interactions. The LDP integrated content from literature reviews specific to Latin America, established leadership programs from leading business schools, and various subject matter experts. Prior to the start of the LDP, participants received a pre-course survey evaluating demographic information, a needs assessment, and the prioritization of leadership topics utilizing a 5-point Likert-scale. Attendees participated in the one-day, interactive LDP focusing on the fundamental principles of leadership development, communication, personal development, emotional intelligence and negotiation. Following the LDP, a post-course evaluation was administered to determine the participants' overall experience, and suggestions for LDP improvement. Results: Forty-one of the forty-eight course participants completed the pre-course evaluation, whereas forty-six of the forty-eight participants completed the post-course evaluations. Overwhelmingly, the lack of opportunity was most prevalently reported as the main obstacle to attending a leadership course, as cited by 56% of respondents. Conclusion: Expanding the accessibility, diversity, and customizability of leadership programs can facilitate the development of personal tools needed to move healthcare forward. Critical topics include emotional intelligence and other differentiating leadership qualities that distinguish true transformational and servant leaders. Advancing leadership skills can stimulate networking, expose learners to experiential learning styles, inspire others to create positive change, and engender creative solutions for systematic improvements and health outcomes. Level of Evidence III; Individual Case-Control Studies.

RESUMO Objetivo: Relatar a experiência e as impressões de cirurgiões de trauma ortopédico brasileiros participantes do Programa de Desenvolvimento de Liderança (PDL), organizado pela Sociedade Brasileira do Trauma Ortopédico (SBTO), em São Paulo, Brasil, em 4 de novembro de 2022. Métodos: Quarenta e oito cirurgiões de trauma ortopédico de cinco regiões diferentes do Brasil receberam um link para preencher o The Big Five Test, uma avaliação de personalidade on-line validada. O questionário estava disponível em português e pretendia fornecer informações básicas sobre traços de personalidade individuais e sua influência nas interações interpessoais. O PDL integrou conteúdo de análises de literatura específicas da América Latina, e programas de liderança estabelecidos pelas principais escolas de negócios e por vários especialistas no assunto. Antes do início do PDL, os participantes receberam uma pesquisa pré-curso solicitando informações demográficas, uma avaliação de necessidades e a priorização de tópicos de liderança utilizando uma escala Likert de 5 pontos. Os participantes participaram do PDL interativo de um dia com foco nos princípios fundamentais de desenvolvimento de liderança, comunicação, desenvolvimento pessoal, inteligência emocional e negociação. Após o PDL, foi realizada uma avaliação pós-curso para determinar a experiência geral dos participantes e sugestões para melhoria do PDL. Resultados: Quarenta e um dos quarenta e oito participantes do curso concluíram a avaliação pré-curso, enquanto quarenta e seis dos quarenta e oito participantes concluíram a avaliação pós-curso. A falta de oportunidade foi relatada com maior prevalência como o principal obstáculo para frequentar um curso de liderança, conforme citado por 56% dos entrevistados. Conclusão: Expandir a acessibilidade, a diversidade e a personalização dos programas de liderança podem facilitar o desenvolvimento de ferramentas pessoais necessárias para fazer avançar os cuidados de saúde. Os tópicos críticos incluem inteligência emocional e outras qualidades de liderança diferenciadas, que distinguem verdadeiros líderes transformacionais e servidores O avanço das competências de liderança pode estimular o networking, expor os alunos a estilos de aprendizagem experiencial, inspirar outros a criar mudanças positivas e gerar soluções criativas para melhorias sistemáticas dos resultados na saúde. Nível de Evidência III; Estudos de caso-controle individuais.

Biomechanical Efficacy of Three Methods for the Fixation of Posterior Malleolar Fractures: A Three-Dimensional Finite Element Study.

Introduction: We investigated the biomechanical behaviour of different fixations of the tibial posterior malleolus (TPM), simulating distinct situations of involvement of the tibiotalar articular surface (TTAS) through a finite element model (FEM). Material and methods: A 3D computer-aided design model of the left ankle was obtained. The materials used were divided according to their characteristics into ductile and non-ductile, and all materials were assumed to be linear elastic, isotropic, and homogenous. Three different fracture lines of the TPM were defined, with sagittal angles of 10°, 25°, and 45°. For biomechanical comparison, different constructions using a trans-syndesmotic screw (TSS) only (Group T), a one-third tubular plate only with (Group PT) and without (Group PS) a TSS, and a locked compression plate with (Group LCPT) and without (Group LCPS) a TSS were tested. FEM was used to simulate the boundary conditions of vertical loading. Load application regions were selected in the direction of the 700 N Z-axis, 90% on the tibia and 10% on the fibula. Data on the displacement and stress in the FEM were collected, including the total principal maximum (MaxT) and total principal minimum (MinT) for non-ductile materials, total displacement (desT), localized displacement at the fragment (desL), localized displacement at syndesmosis (desS), and Von Mises equivalent stress for ductile materials. The data were analysed using ANOVA and multiple comparison LSD tests were used. Results: For TPM fractures with sagittal angles 10° and 25°, desL in the PT and LCP groups was significantly lower, as well as Von Mises stress in Group LCPT in 10°, and PT and LCPT groups in 25°. For TPM fractures with a sagittal angle of 45°, desL in the LCP group and Von Mises stress in Group LCPS and LCPT were significantly lower. We found that any TPM fracture may indicate instability of the distal tibiofibular syndesmosis, even when the fragment is small. Conclusion: Our study showed that in fragments involving 10% of the TTAS, the use of a TSS is sufficient, but when the involvement is greater than 25% of the TTAS, either a non-locked or locked plate must be used to buttress the TPM. In posterior fragments affecting 45% or more of the TTAS, the use of a locking plate is recommended.

Modified gastrocnemius splitting anatomic approach to the tibial plateau. Medium-term evaluation.

BACKGROUND: Posterior tibial plateau fractures, including avulsion fractures of the posterior cruciate ligament (PCL) insertion, represent a challenge for the orthopedic trauma surgeon. These injuries have gained a new perspective both diagnostically and therapeutically after the regular use of multiplanar computed tomography. In the herein study, we describe the outcome of patients sustaining a tibial plateau fracture with posterior articular involvement treated by open reduction and internal fixation (ORIF) using our modified gastrocnemius splitting anatomic approach. METHODS: This observational retrospective descriptive study was conducted at Complejo Medico de la Policia Federal Argentina Churruca-Visca. All patients were treated by ORIF by our team through our modified gastrocnemius splitting anatomic approach, and followed-up for a minimum of 12 months. RESULTS: A total of 18 patients sustaining plateau fracture were treated by this approach. Satisfactory tomographic reduction with articular gap and/or step-off <2 mm was achieved in 16. The mean time to the return to activities of daily living was 192.2 days. CONCLUSION: The modified gastrocnemius splitting anatomic approach represents a good alternative for the management of tibial plateau fractures involving the posterior quadrants.

Is there a trend towards semi-extended knee positioning during intramedullary tibial nailing in Latin America? A survey among 990 orthopaedic surgeons.

OBJECTIVE: The aim of this study was to evaluate the Latin American orthopaedic trauma surgeons preference regarding knee positioning and entry portals for IM nailing and identify the reasons of these preferences. METHODS: Using the AO Trauma database, 22.285 surveys were distributed by email to Latin American orthopaedic surgeons. Demographic data and practice patterns, especially regarding knee positioning and approach for tibial nailing, were then evaluated and statistically treated. RESULTS: amongst one thousand five hundred fourteen responses, 990 orthopaedic surgeons (4.4% of response rate) fully responded to the survey. Transpatellar tendon approach (613 / 61.9%,) with the knee in flexion (518 / 52.3%) on a radiolucent table remains the standard practice for intramedullary tibial nailing. Even for proximal and distal tibial nailing, the transpatellar tendon approach (455 / 46%) with the knee in flexion (562 / 56.8%) hold on the most used method. Only 55 (9.36%) orthopaedic surgeons reported that they have migrated to the supra-patellar tibial nailing in the recent years. The main reasons for a low rate of migration were lack of knowledge about the technique and unavailability of specific gigs and cartilage protectors for a safe suprapatellar nailing. CONCLUSION: Even with the potential benefits of the semi-extended knee positioning for tibial nailing, the Latin American orthopaedic community remains using the transpatellar tendon approach with the knee in flexion as the standard technique. Lack of surgical training for suprapatellar and parapatellar approaches with the knee in semi-extension, added by the unavailability of suprapatellar jigs and soft outer protection sleeves contribute to counter the trend towards the semi-extended techniques.