Prior use of antibiotics and immunosuppression are risk factors for fracture-related infection during the COVID-19 pandemic period: a Brazilian prospective cohort study.

BACKGROUND: Little is known about the role of COVID-19 pandemic period on the epidemiology of fracture-related infection (FRI). The present study summarizes the changes in the prevalence, microbiology, and risk factors of FRI during this period. METHODS: A prospective single-center cohort study assessed in the setting of COVID-19 pandemic (2020-2021), clinical, microbiological aspects, and independent risk factors (RF) of FRI. RFs were estimated by bivariate and multivariable analyses using prevalence ratio (PR) with significance at P < 0.05. Kaplan-Meier analysis was performed to evaluate treatment outcomes. RESULTS: Overall, 132 patients were analyzed, with patients with age over 65 years accounting 65.1%. FRI was diagnosed in 21(15.9%) patients. Independent RFs for FRI were recent and preoperative use of systemic antibiotics (PR: 7.0, 95% confidence interval (95% CI): 2.2 - 22.4, p = 0.001) and cancer (PR: 9.8, 95% CI: 2.0 - 48.8, p = 0.005). Cultures yielded Gram-negative bacteria in 77.8%, 33.3% were MDR. CONCLUSIONS: We found higher rates of FRI, predominating in the elderly with closed femoral fractures during the COVID-19 pandemic. Prior use of antibiotics and immunosuppression conditions were independent factor for FRI. Our outcomes provide evidence to avoid the empirical use of antibiotics prior to surgery for fracture stabilization.

Three-dimensional printing models increase inter-rater agreement for classification and treatment of proximal humerus fractures.

BACKGROUND: Proximal humerus fractures (PHF) are frequent, however, several studies show low inter-rater agreement in the diagnosis and treatment of these injuries. Differences are usually related to the experience of the evaluators and/or the diagnostic methods used. This study was designed to investigate the hypothesis that shoulder surgeons and diagnostic imaging specialists using 3D printing models and shoulder CT scans in assessing proximal humerus fractures. METHODS: We obtained 75 tomographic exams of PHF to print three-dimensional models. After, two shoulder surgeons and two specialists in musculoskeletal imaging diagnostics analyzed CT scans and 3D models according to the Neer and AO/OTA group classification and suggested a treatment recommendation for each fracture based on the two diagnostic methods. RESULTS: The classification agreement for PHF using 3D printing models among the 4 specialists was moderate (global k = 0.470 and 0.544, respectively for AO/OTA and Neer classification) and higher than the CT classification agreement (global k = 0.436 and 0.464, respectively for AO/OTA and Neer). The inter-rater agreement between the two shoulder surgeons were substantial. For the AO/OTA classification, the inter-rater agreement using 3D printing models was higher (k = 0.700) than observed for CT (k = 0.631). For Neer classification,  inter-rater agreement with 3D models was similarly higher (k = 0.784) than CT images (k = 0.620). On the other hand, the inter-rater agreement between the two specialists in diagnostic imaging was moderate. In the AO/OTA classification, the agreement using CT was higher (k = 0.532) than using 3D printing models (k = 0.443), while for Neer classification, the agreement was similar for both 3D models (k = 0.478) and CT images (k = 0.421). Finally, the inter-rater agreement in the treatment of PHF by the 2 surgeons was higher for both classifications using 3D printing models (AO/OTA-k = 0.818 for 3D models and k = 0.537 for CT images). For Neer classification, we saw k = 0.727 for 3D printing models and k = 0.651 for CT images. CONCLUSION: The insights from this diagnostic pilot study imply that for shoulder surgeons, 3D printing models improved the diagnostic agreement, especially the treatment indication for PHF compared to CT for both AO/OTA and Neer classifications On the other hand, for specialists in diagnostic imaging, the use of 3D printing models was similar to CT scans for diagnostic agreement using both classifications. TRIAL REGISTRATION: Brazil Platform under no. CAAE 12273519.7.0000.5505.

Surgical Gloves in Orthopedic Trauma Procedures: How Many Lose Their Integrity?

Introduction The possibility of perforation of gloves during orthopedic surgeries can reach 56.8%, and it mainly related to the manipulation of blunt instruments. Surgeries for the treatment of fractures and trauma present additional risk due to contact with bone spires. Objective Analysis of the prevalence of loss of integrity of surgical gloves in orthopedic trauma procedures, especially fractures, and evaluation of the surgeon's exposure and contact with secretions from the patient. Methods Macroscopic inspection of the gloves of two surgeons specialized in trauma, over a period of 4 months. Both used two gloves for all procedures and, at the end of the surgery, analyzed the presence or absence of blood stains on the internal gloves and/or fingers. The procedures were categorized according to the time and type of surgery. The intercurrence investigated was the perforation of one or two gloves; if the tear was perceived immediately or only at the end of the surgery, and the location of and reason for the tear, if identified. Results A total of 210 surgeries were included, 87 of which presented perforations, with 17 cases occurring in both gloves and 70 only in the outer glove. Finally, there was a more significant relationship with open focus surgeries and duration > 60 minutes. Conclusion Our results suggest that greater care and inspection of gloves to look for damage are needed in prolonged surgeries with an open focus.

Surgical Gloves in Orthopedic Trauma Procedures: How Many Lose Their Integrity? / Luvas cirÚrgicas em procedimentos ortopédicos de trauma: Quantas perdem a integridade?

Abstract Introduction The possibility of perforation of gloves during orthopedic surgeries can reach 56.8%, and it mainly related to the manipulation of blunt instruments. Surgeries for the treatment of fractures and trauma present additional risk due to contact with bone spires. Objective Analysis of the prevalence of loss of integrity of surgical gloves in orthopedic trauma procedures, especially fractures, and evaluation of the surgeon's exposure and contact with secretions from the patient. Methods Macroscopic inspection of the gloves of two surgeons specialized in trauma, over a period of 4 months. Both used two gloves for all procedures and, at the end of the surgery, analyzed the presence or absence of blood stains on the internal gloves and/or fingers. The procedures were categorized according to the time and type of surgery. The intercurrence investigated was the perforation of one or two gloves; if the tear was perceived immediately or only at the end of the surgery, and the location of and reason for the tear, if identified. Results A total of 210 surgeries were included, 87 of which presented perforations, with 17 cases occurring in both gloves and 70 only in the outer glove. Finally, there was a more significant relationship with open focus surgeries and duration > 60 minutes. Conclusion Our results suggest that greater care and inspection of gloves to look for damage are needed in prolonged surgeries with an open focus.

Resumo Introdução Cirurgias ortopédicas apresentam a possibilidade de perfuração das luvas, que pode chegar a 56,8%, relacionada principalmente à manipulação de instrumentos cortantes. O tratamento de fraturas e cirurgias de trauma apresenta risco adicional pelo contato com espiculas ósseas. Objetivo Análise da prevalência de perda de integridade das luvas cirÚrgicas em procedimentos ortopédicos de trauma, principalmente fraturas, avaliando a exposição do cirurgião e o contato com secreções provenientes do paciente. Métodos Inspeção macroscópica das luvas de dois cirurgiões especializados em trauma, durante um período de 4 meses. Ambos usaram duas luvas para todos os procedimentos e, ao término da cirurgia, analisaram a presença ou ausência de manchas de sangue nas luvas internas e/ou nos dedos. Os procedimentos foram categorizados quanto ao tempo e tipo de cirurgia. A intercorrência investigada foi a perfuração de uma ou duas luvas; se a perfuração foi percebida imediatamente ou apenas ao final da cirurgia, e qual o local e o motivo do rasgo, se identificado. Resultados Foram incluídas 210 cirurgias, das quais 87 apresentaram perfurações, sendo 17 casos em ambas as luvas e 70 apenas na luva externa. Um total de 27,5% dos danos foram descobertos apenas no final da cirurgia; os rasgos se concentraram no indicador esquerdo em 62,5% dos casos. Por Último, houve uma relação mais significativa com cirurgias de foco aberto e com duração superior a 60 minutos. Conclusão O nosso resultado sugere que em cirurgias prolongadas e com foco aberto, é necessário maior cuidado e inspeção à procura de danos nas luvas.

Three-dimensional models increase the interobserver agreement for the treatment of proximal humerus fractures.

BACKGROUND: The agreement for the treatment of proximal humerus fractures is low. Interpretation of exams used for diagnosis can be directly associated with this limitation. This study proposes to compare the agreement between experts and residents in orthopedics for treatment indication of proximal humerus fractures, utilizing 3D-models, holography (augmented reality), x-rays, and tomography as diagnostic methods. METHODS: Twenty orthopedists (ten experts in shoulder and elbow surgery and ten experts in traumatology) and thirty resident physicians in orthopedics evaluated nine fractures of the proximal humerus, randomly distributed as x-rays, tomography, 3D-models and holography, using the Neer and AO / OTA Classifications. After, we evaluated the interobserver agreement between treatment options (conservative, osteosynthesis and arthroplasty) and whether the experience of the evaluators interfered with the results. RESULTS: The interobserver agreement analysis showed the following kappa-values: κ = 0.362 and κ = 0.306 for experts and residents (3D-models); κ = 0.240 and κ = 0.221 (X-ray); κ = 0.233 and κ = 0.123 (Tomography) and κ = 0.321 and κ = 0.160 (Holography), for experts and residents respectively. Moreover, residents and specialists were discordant in the treatment indication using Tomography as a diagnostic method (p = 0.003). The same was not seen for the other diagnostic methods (p > 0.05). CONCLUSIONS: Three-dimensional models showed, overall, the highest interobserver agreement (experts versus residents in orthopedics) for the choice of treatment of proximal humerus fractures compared to X-ray, Tomography, and Holography. Agreement in the choice of treatment among experts that used Tomography and Holography as diagnostic methods were two times higher compared to residents. TRIAL REGISTRATION: Registered in Brazil Platform under no. CAAE 12273519.7.0000.5505.

Intramedullary reaming modality for management of postoperative long bone infection: a prospective randomized controlled trial in 44 patients.

BACKGROUND: Studies addressing the management of intramedullary infection are mainly retrospective and with a limited number of cases. Reaming can be performed using either conventional reaming or using the reamer/irrigator/aspirator (RIA) system. Until now there have been no comparative prospective studies between these two methods. We aimed to compare the efficacy of RIA with conventional reaming followed by insertion of antibiotic-loaded cement, for the treatment of intramedullary nail infection of long bones. We assessed the rate of remission between groups after two-year follow-up and identified microorganisms using tissue cultures and sonication of explanted intramedullary nail (IMN). METHODS: A noninferiority, randomized clinical trial was carried out between August 2013 and August 2015 involving 44 patients of whom a locked IMN implant of the femur and/or tibia was retrieved and who all met the clinical and radiological criteria for IMN-associated osteomyelitis. Patients were randomized into two groups: RIA alone versus conventional reaming followed by antibiotic-loaded cement insertion. Both groups also underwent six-weeks of antibiotic treatment according to the results of the antibiogram. Patients were evaluated after 1, 3, 6, 12 and 24 months for radiological and clinical follow-up. RESULTS: After 24 months, the rate of infection remission was similar between the two groups, 87% in the RIA group and 95.5% in the conventional reaming group (p = 0.60). Among four patients who had recurrence of infection, the time to reappearance of symptoms varied from 20 days to twenty-two months. Staphylococcus aureus and coagulase-negative Staphylococci were isolated in 23 (40.4%) and 13 (22.9%) patients, respectively. Interestingly, we identified 20% (9/45) of polymicrobial infection. CONCLUSION: This study concludes that the RIA system alone, is noninferior to conventional reaming followed by antibiotic cement spacer in the treatment of IMN infection. However, RIA shows greater efficacy in the collection of infected medullary bone tissue, mainly in cases of infected retrograde nail of the femur. TRIAL REGISTRATION: ISRCTN82233198. Retroactively registered on July 29, 2019.

DEMOGRAPHIC ANALYSIS OF ACETABULAR FRACTURES TREATED IN A QUATERNARY CARE HOSPITAL FROM 2005 TO 2016.

OBJECTIVE: Analyze the clinical and sociodemographic data on acetabular fractures in a Brazilian quaternary care hospital and compare with data reported in the literature. METHODS: A descriptive, analytical cross-sectional epidemiological study analyzing 87 patients with acetabular fractures at Hospital São Paulo (UNIFESP/EPM) between 2005 and 2016. Demographic variables such as age, sex, occupation, educational level and color were investigated. Acetabular fractures were classified according to the AO/OTA group and Judet and Letournel classification. Therapeutic approach, hospital length of stay and waiting time for surgery as well as complications were analyzed. Associations were established among the various variables obtained. RESULTS: The mean age of patients with acetabulum fractures was 39.8 years (SD 13.1 years). There was a predominance of posterior wall (34.5%) and dual-column (14.9%) fractures. The average hospital length of stay was 14.4 days. More than 90% of patients underwent a surgical procedure. One-fourth of patients had complications, the main one being infection (12.6%). CONCLUSIONS: Unimodal age distribution was obtained with a predominance of white male economically active patients. There was a predominance of posterior wall fractures. More than 90% of patients underwent surgery before they had been in hospital for 14 days. A statistically significant association was found between complications and exceeded length of hospital stay. Level of evidence II, Retrospective study.

OBJETIVO: Analisar os dados clínicos e sociodemográficos das fraturas acetabulares em um hospital quaternário brasileiro e comparar com dados relatados na literatura. MÉTODOS: Estudo epidemiológico, descritivo, analítico transversal, em que foram analisados 87 pacientes com fraturas acetabulares no Hospital São Paulo (UNIFESP/EPM) entre 2005 e 2016. Variáveis demográficas como idade, sexo, profissão, escolaridade e cor foram pesquisadas. As fraturas acetabulares foram classificadas conforme o grupo AO/OTA e conforme Judet e Letournel. A terapêutica, o tempo de internação e de espera para cirurgia bem como as complicações foram analisadas. Foram feitas associações entre as diversas variáveis obtidas. RESULTADOS: A média de idade dos pacientes vítimas de fraturas do acetábulo foi de 39,8 anos (DP 13,1 anos). Houve predomínio das fraturas da parede posterior (34,5%) e dupla coluna (14,9%). Os pacientes ficaram, em média, 14,4 dias internados. Mais de 90% dos pacientes foram submetidos à abordagem cirúrgica. Um quarto dos pacientes tiveram complicações, sendo a principal, infecção (12,6%). CONCLUSÕES: Foi obtida uma amostra etária unimodal com predomínio de pacientes do sexo masculino, brancos e economicamente ativos. Houve um predomínio das fraturas da parede posterior. Mais de 90% dos pacientes foram operados antes dos 14 dias de internação. Constatou-se uma associação estatisticamente significante entre complicações e tempo excedido de permanência hospitalar. Nível de evidência II, Estudo retrospectivo.

Inter-observer reliability of alternative diagnostic methods for proximal humerus fractures: a comparison between attending surgeons and orthopedic residents in training.

BACKGROUND: Proximal humerus fractures are frequent, and several studies show low diagnostic agreement among the observers, as well as an inaccurate classification of these lesions. The divergences are generally correlated with the experience of the surgeons as well as the diagnostic methods used. This paper challenges these problems including alternative diagnostic methods such as 3D models and augmented reality (holography) and including the observers' period of medical experience as a factor. METHODS: Twenty orthopedists (ten experts in shoulder surgery and ten experts in traumatology) and thirty resident physicians in orthopedics classified nine proximal humerus fractures randomly distributed as x-ray, tomographies, 3D models and holography, using AO/ASIF and Neer's classification. In the end, we evaluated the intra- and inter-observer agreement between diagnostic methods and whether the experience of the observers interfered in the evaluations and the classifications used. RESULTS: We found overall kappa coefficients ranging from 0.241 (fair) to 0.624 (substantial) between the two classifications (AO / ASIF and Neer), concerning the diagnostic methods used. We identified image modality differences (p = 0.017), where 3D models presented an average kappa coefficient value superior to that of tomographies. There were no differences between kappa scores for x-ray and holography compared to the others. The kappa scores for AO / ASIF classification and Neer classification and subdivided by observer period of experience showed no differences concerning the diagnostic method used. CONCLUSIONS: 3D models can substantially improve diagnostic agreement for proximal humerus fractures evaluation among experts or resident physicians. The holography showed good agreement between the experts and can be a similar option to x-ray and tomography in the evaluation and classification of these fractures. The observers' period of experience did not improve the diagnostic agreement between the image modalities studied. TRIAL REGISTRATION: Registered in the Brazil Platform under no. CAAE 88912318.1.0000.5487.

Quality of life after antegrade intramedullary nail fixation of humeral fractures: a survey in a selected cohort of Brazilian patients.

BACKGROUND: The treatment of humeral fractures remains controversial. Systematic reviews demonstrate similar results between dynamic compression plating and locked intramedullary nailing in the surgical treatment of these fractures. However, it appears that antegrade intramedullary nailing causes higher residual pain in the shoulder. The proposal of this work is to evaluate through the WORC protocol (Western Ontario Rotator Cuff Index) the consequences in the quality of life of patients submitted to osteosynthesis of the humerus with antegrade locked intramedullary nailing. METHODS: This work is a cohort retrospective study in addition to the application of a questionnaire for self-rated quality of life with its 05 domains (WORC - Western Ontario Rotator Cuff Index) for patients (N = 26) classified in the Trauma Sector of the Department of Orthopedics and Traumatology of the Federal University of São Paulo (DOT/UNIFESP) submitted to Humerus Osteosynthesis with Antegrade Locked Intramedullary Nailing. There was also the inclusion of data related to the time since surgery, age, sex, surgical laterality, dominance among members and work leave, which were not considered in the original protocol. After, the data were statistically assessed to evaluate the association between numerical and categorical variables. RESULTS: The overall WORC score was 82.75 ± 17.00 (Mean ± SD) and was not different considering sex, age and postoperative period. Among the WORC domains, both Work and Sport / Recreation Protocols were the most unfavorable factors in the evaluation of patients. Although not statistically significant, those who had the procedure on the dominant side presented a lower quality of life score than those who had the surgery on the non-dominant side. Although non-significant again, those who were away from work had an overall lower quality of life score than those who were not. CONCLUSIONS: The WORC Quality of Life Protocol shows good results for evaluating patients submitted to humerus osteosynthesis with antegrade locked intramedullary nailing. The data stratified by domains were good, however, Work and Sport/Recreation domains showed the lowest means compared to the other domains. TRIAL REGISTRATION: Research Ethics Commitee (CEP 0676/2016) and Plataforma Brasil 56381216.3.0000.550. CAAE: 56381216.3.0000.5505.

Interlocking screws placed with freehand technique and uni-planar image intensification: the "dip-stick" technique.

OBJECTIVE: To report our experience with a novel alternative method of freehand interlocking of intramedullary nails. This method requires the use of only anterior-posterior image intensification and an intramedullary guide wire to verify screw placement. Our results are compared with historical results in the literature. METHODS: A total of 815 patients were treated using this technique from January 2008 to December 2012; 603 patients had fractures of the tibia and 212 had fractures of the femur. RESULTS: The mean duration of surgery for tibial shaft fractures was 55.6 minutes (range 42-60 minutes) and that for fractures of the femur was 78 minutes (range 50-90 minutes). The mean time for each distal locking was 3.8 minutes (2.5-5.1 minutes), with 7.65 seconds of exposure to radiation during each block. CONCLUSIONS: The surgical technique is simple, easy and reproducible. Mean time of surgery and radiation exposure was less than that in the literature. A comparative study should be performed.

Treatment of pelvic fractures - a national survey.

INTRODUCTION: This survey was conducted during the 38(th) Brazilian Congress of Orthopaedics and Traumatology to identify the opinion of Brazilian orthopaedic surgeons on the standard treatment of pelvic fractures. MATERIALS AND METHODS: Participants were randomly selected and invited to voluntarily answer a questionnaire of 10 multiple choice questions addressing the main aspects of the treatment of pelvic fractures: classification, fixation methods in unstable patients, optimal surgical timing in stable patients, and fixation methods in different types of anterior and posterior pelvic injuries. RESULTS/CONCLUSION: Three hundred and fifty-two questionnaires were completed, and the following main observations were made: most orthopaedists prefer to use an external fixator in the iliac crest for the emergency stabilisation of pelvic injuries in haemodynamically unstable patients (79.5%); they consider a period of up to one week as optimal for fixation in stable patients (55.1%); they use a plate for the fixation of fractures of the iliopubic rami through a Pfannenstiel or ilio-inguinal approach (53.9%); and they use reconstruction plates for the fixation of fractures of the iliac wing (63.1%). Regarding other studied aspects, there was no predominance of more than 50% of the choices among respondents.

Profile of trauma victims of motorcycle accidents treated at hospital São Paulo.

OBJECTIVE: To evaluate retrospectively, through analysis of medical records, the epidemiological aspects of patients traumatized by motorcycle accidents treated at the orthopedics ward, Hospital São Paulo, Brazil. METHODS: It is a retrospective observational study. The analysis of patients' medical records comprised the period from January 2008 to December 2009. The data checked were: age, gender, type of collision, type and location of fracture, treatment performed (conservative or surgical), type of surgery, cost of synthesis material and hospitalization, period of hospitalization and postoperative complications. After data collection, statistical analysis was performed. RESULTS: We analyzed 381 victims involved in motorcycle accidents. Patients were predominantly male (85%), with a mean age of 30.7 years old. Referring to distribution and site of lesions, 75.5% of individuals had lower limb fractures and in 95.4% of the cases, the treatment of choice was surgery. Twenty-nine patients were rehospitalized due to postoperative complications, such as exposure and failure of synthesis material, wound infection, necrosis, osteomyelitis, and pseudoarthrosis. CONCLUSION: It was possible to identify useful characteristics for planning preventative strategies to reduce the rate of motorcycle accidents and redirect public investment in health. Level of Evidence III, Retrospective Study.

Minimally invasive percutaneous plate osteosynthesis for ankle fractures: a prospective observational cohort study.

BACKGROUND: The gold standard for the surgical management of ankle fractures is through open reduction and internal fixation. The rate of wound problems has been reported to be as high as 18%, especially in patients with poor vascular supply or in diabetics. Minimally invasive percutaneous plate osteosynthesis (MIPPO) has been described as a potential solution for these patients. PATIENTS AND METHODS: This is a prospective observational cohort study. From October 2009 to February 2010, and following ethical approval of our research, adult patients admitted at our level I trauma center with a closed lateral malleolar displaced unstable fracture (Lauge-Hansen supination-external rotation) with or without a medial-sided injury and patients with an undisplaced fracture associated with medial clear space opening on external rotation stress radiographs were recruited and managed using MIPPO technique. All patients were followed up for a minimum of 12 months post-surgery (12-20 with a mean of 16.5 months). Trauma mechanism, comorbidities, classifications, trauma-surgery interval, image intensifier duration, surgery duration, complications, and function American Orthopaedic Foot and Ankle Society (AOFAS) were analyzed. RESULTS: Thirty-two patients were recruited of which 20 fulfilled the inclusion criteria (16 females, 4 males) and were available for follow-up. Ten fractures (50%) were classified as 44-B1, 7 fractures (35%) as 44-B2, and 3 fractures (15%) as 44-B3 according to the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association classification (100% were supination-external rotation injuries). At 8 weeks post-surgery, all fractures had healed. The duration of surgery ranged between 15 and 73 min (average 32.8) from skin incision to closure. There were 2 complications (1 malunion and 1 skin necrosis requiring implant removal). At 12-month follow-up, AOFAS average was 88.3 (72-100 standard deviation of 6.8 points). CONCLUSION: MIPPO technique proved to be a viable option for lateral malleolar fracture treatment with a low complication rate and high functional outcome at 1 year. It is particularly useful in patients with a high risk of wound complication.

Recommendations for avoiding knee pain after intramedullary nailing of tibial shaft fractures.

BACKGROUND: The objective of this study is to analyze the proximal tibiofibular joint in patients with knee pain after treatment of tibial shaft fractures with locked intramedullary nail. FINDINGS: The proximal tibiofibular joint was analyzed in 30 patients, who reported knee pain after tibial nailing, and standard radiograph and computed tomography were performed to examine the proximal third of the tibia. Twenty patients (68.9%) presented the proximal screw crossing the proximal tibiofibular joint and 13 (44.8%) had already removed the nail and/or screw. Four patients (13.7%) reported complaint of knee pain. However, the screw did not reach the proximal tibiofibular joint. Five patients (17.2%) complained of knee pain although the screw toward the joint did not affect the proximal tibiofibular joint. CONCLUSION: When using nails with oblique proximal lock, surgeons should be careful not to cause injury in the proximal tibiofibular joint, what may be one of the causes of knee pain. Thus, the authors suggest postoperative evaluation performing computed tomography when there is complaint of pain.

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

BACKGROUND: Z-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. FINDINGS: The 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. CONCLUSIONS: Although 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.

CORRELATION BETWEEN TIME UNTIL SURGICAL TREATMENT AND MORTALITY AMONG ELDERLY PATIENTS WITH FRACTURES AT THE PROXIMAL END OF THE FEMUR.

OBJECTIVE: The primary aim of this study was to analyze the possible association between delay in receiving surgical treatment and mortality among elderly patients with fractures at the proximal end of the femur. METHODS: 269 patients with fractures at the proximal end of the femur (femur neck and intertrochanteric fractures) who were treated surgically at Hospital São Paulo, UNIFESP, São Paulo, between January 2003 and December 2007, were studied. The following attributes were analyzed and compared with the literature relating to this subject: sex, age, type of fracture, classification of the fracture, affected side, synthesis used, trauma mechanism, length of hospitalization, waiting time for surgery, associated comorbidities, hemogram on admission, type of anesthesia, need for blood transfusion, day of the week and season of the year of the fracture. RESULTS: The study showed that higher mortality correlated with higher numbers of clinical comorbidities, longer hospitalization and use of general anesthesia during the surgery. CONCLUSION: There was no association between the time spent waiting for surgery and mortality.

Outcome of diaphyseal forearm fracture-nonunions treated by autologous bone grafting and compression plating.

BACKGROUND: The treatment of forearm fracture-nonunions continues to represent a therapeutic challenge, and reported outcomes are moderate at best. Limiting aspects of this particular anatomic location include the relation between restoration of shaft length with the anatomy and long-term functional outcome of adjacent joints, as well as the risk of elbow and wrist stiffness related to prolonged immobilization. The present study was designed to assess the outcome of autologous bone grafting with compression plating and early functional rehabilitation in patients with forearm fracture non-unions. METHODS: Prospective follow-up study in 31 consecutive patients presenting with non-unions of the forearm diaphysis (radius, n = 11; ulna, n = 9; both bones, n = 11). Surgical revision was performed by restoring anatomic forearm length by autologous bone grafting of the resected non-union from the iliac crest and compression plating using a 3.5 mm dynamic compression plate (DCP) or limited-contact DCP (LC-DCP). The main outcome parameters consisted of radiographic bony union and functional outcome, as determined by the criteria defined by Harald Tscherne in 1978. Patients were routinely followed on a short term between 6 weeks to 6 months, with an average long-term follow-up of 3.6 years (range 2 to 6 years). RESULTS: Radiographically, a bony union was achieved in 30/31 patients within a mean time of 3.5 months of revision surgery (range 2 to 5 months). Clinically, 29/31 patients showed a good functional outcome, according to the Tscherne criteria, and 26/31 patients were able to resume their previous work. Two postoperative infections occurred, and one patient developed a persistent infected nonunion. No case of postoperative failure of fixation was seen in the entire cohort. CONCLUSION: Revision osteosynthesis of forearm nonunions by autologous iliac crest bone grafting and compression plating represents a safe and efficacious modality for the treatment of these challenging conditions.

Comparative multicenter study of treatment of multi-fragmented tibial diaphyseal fractures with nonreamed interlocking nails and with bridging plates.

OBJECTIVE: A prospective, randomized study to compare patients with closed, multi-fragmented tibial diaphyseal fractures treated using one of two fixation methods undertaken during minimally invasive surgery: nonreamed interlocking intramedullary nails or bridging plates. MATERIALS AND METHODS: Forty-five patients were studied; 22 patients were treated with bridging plates, 23 with interlocking nails without reaming. All fractures were Type B and C (according to the AO classification). RESULTS: Clinical and radiographic healing occurred in all cases. No cases of infection occurred. The healing time for patients who received nails was longer (4.32 weeks on average) than the healing time for those who received plates (P = 0.026). No significant differences were observed between the two methods regarding ankle mobility for patients in the two groups. CONCLUSIONS: The healing time was shorter with the bridging plate technique, although no significant functional differences were found.