Outcome and Predictors of Treatment Failure in Chronic Osteomyelitis Using Bioactive Glass Granules and Putty Formulations.

BACKGROUND: The aim of this study is to evaluate the outcome of patients with cavitary chronic osteomyelitis undergoing adjuvant treatment with bioactive glass (BAG) S53P4 and identify the independent risk factors (RFs) for recurrence in 6- and 12-month patient follow-up. METHODS: A retrospective, multicentre observational study conducted in tertiary specialised hospitals among patients undergoing the surgical treatment of chronic cavitary osteomyelitis using BAG-S53P4 in a granule and/or putty formulation to assess the clinical outcome and RFs for failure in 6- and 12-month patient follow-up. RESULTS: Of the 92 and 78 patients with 6-month and 12-month follow-ups, infection was eradicated in 85.9% and 87.2%, respectively. In the 6-month follow-up, BAG-S53P4 in the granule formulation presented a greater risk of recurrence compared to the bioactive glass putty formulation or combined granules and putty (prevalence ratio (PR) = 3.04; confidence interval 95% [CI95%]: 1.13-10.52) and neoplasia (PR = 5.26; CI95%: 1.17-15.52). In the 12-month follow-up cohort of 78 patients, smoking (PR = 4.0; 95% CI: 1.03-15.52) and nonfermenting GNB infection (PR = 3.87; CI95%: 1.09-13.73) presented a greater risk of recurrence. CONCLUSIONS: BAG-S53P4 is a viable option for bone-void filling and the treatment of chronic cavitary osteomyelitis. Formulations of BAG with putty or in combination with granules showed better results.

FACTORS ASSOCIATED WITH THE OUTCOMES OF OLDER PATIENTS OPERATED DUE TO HIP FRACTURES.

Objective: Evaluating clinical factors associated with mortality in older patients who underwent surgical correction of hip fractures. Methods: This observational and retrospective study analyzed the medical records of 67 patients (aged older than 60 years), both men and women, who underwent surgical correction of hip fractures from 2019 to 2020 at Hospital São Paulo. The following variables were analyzed: age, sex, presence of comorbidities, affected hip region, and trauma mechanism. Statistical analyses were performed using the SPSS software. Results: The mean age of patients was 78.12 ± 9.80 years and 80.6% of the sample were women. The prevalence of hip fractures on the right side (52.2%), in the transtrochanteric region (53.7%), and due to fall on the same level (88.1%) was higher. Systemic arterial hypertension (77.6%), diabetes mellitus (37.3%), and dementia (16.4%) were frequent comorbidities. The prevalence of death after fracture was 17.9% and it was associated with longer hospital stay after surgery (p = 0.028). Conclusion: The prevalence of mortality of patients with hip fractures who underwent surgery was 17.9%. A longer hospital stay due to pre-existing comorbidities was the main factor related to this outcome. Level of Evidence III, Retrospective Study.

Objetivo: Avaliar os fatores clínicos associados à mortalidade em pacientes idosos submetidos ao tratamento cirúrgico para correção de fraturas do quadril. Métodos: Estudo observacional e retrospectivo de análise de prontuários de 67 pacientes (idade superior a 60 anos). Foram incluídos indivíduos de ambos os sexos, submetidos ao tratamento cirúrgico para correção de fraturas do quadril, entre 2019 e 2020, no Hospital São Paulo. Foram analisadas as variáveis: idade, sexo, presença de comorbidades, região do quadril acometido e mecanismo de trauma. As análises estatísticas foram realizadas pelo software SPSS. Resultados: A idade média dos participantes foi de 78,12 ± 9,80 anos, e 80,6% da amostra era constituída por mulheres. Houve maior prevalência de fraturas do quadril no lado direito (52,2%), na região transtrocantérica (53,7%) e causada por queda sem desnível (88,1%). Hipertensão arterial sistêmica (77,6%), diabetes mellitus (37,3%) e demência (16,4%) foram frequentes. A prevalência de óbito após a fratura foi de 17,9%, sendo associada a maior tempo de internação hospitalar após a cirurgia (p = 0,028). Conclusão: A prevalência de mortalidade dos pacientes com fratura do quadril submetidos à cirurgia foi de 17,9%. O tempo prolongando de internação hospitalar por comorbidades pré-existentes foi o principal fator relacionado a este desfecho. Nível de Evidência III, Estudo Retrospectivo.

S53P4 BIOACTIVE GLASS PUTTY IN THE LOCAL TREATMENT OF CAVITARY CHRONIC OSTEOMYELITIS.

Objective: Evaluating the clinical results of bioactive glass S53P4 putty for the treatment of cavitary chronic osteomyelitis. Methods: Retrospective observational study, including patients of any age with clinical and radiological diagnosis of chronic osteomyelitis, who underwent surgical debridement and implantation of bioactive glass S53P4 putty (BonAlive® Putty, Turku, Finland). Patients who underwent any plastic surgery on the soft tissues of the affected site or had segmental bone lesions or septic arthritis were excluded. Statistical analysis was performed using Excel®. Demographic data, as well as data on the lesion, treatment, and follow-up, were collected. Outcomes were classified as "disease-free survival," "failure," or "indefinite." Results: This study included 31 patients, of which 71% were men and had with a mean age of 53.6 years (SD ± 24.2). In total, 84% were followed-up for at least 12 months and 67.7% had comorbidities. We prescribed combination antibiotic therapy for 64.5% of patients. In 47.1%, Staphylococcus aureus was isolated. Finally, we classified 90.3% of cases as "disease-free survival" and 9.7% as "indefinite." Conclusion: Bioactive glass S53P4 putty is safe and effective to treat cavitary chronic osteomyelitis, including infections by resistant pathogens, such as methicillin-resistant S. aureus. Level of Evidence IV, Case Series.

Objetivo: Avaliar a atividade do vidro bioativo S53P4 em pasta no tratamento de osteomielite crônica. Métodos: Estudo observacional retrospectivo, com inclusão de indivíduos de qualquer idade com diagnóstico clínico e radiológico de osteomielite que realizaram tratamento cirúrgico com limpeza e desbridamento, seguido do preenchimento da cavidade com biovidro S53P4 em pasta (BonAlive ® Putty, Turku, Finland). Foram excluídos pacientes submetidos a procedimentos de cirurgia plástica nos tecidos moles do local afetado, com lesões ósseas segmentares e com presença de artrite séptica. A análise estatística foi realizada em Excel ® . Foram coletados dados demográficos, sobre a lesão, o tratamento e o acompanhamento. O desfecho foi classificado em "sobrevida livre de doença", "falha" ou "indeterminado". Resultados: Dos 31 pacientes analisados, 71% eram homens, com idade média de 53,6 anos (DP ± 24,26). Do total, 84% foram acompanhados por no mínimo 12 meses, e 67,7% apresentaram comorbidades. A terapia antibiótica combinada foi realizada em 64,5% dos pacientes, sendo o patógeno mais frequente o Staphylococcus aureus (47,1%). Ao final, 90,3% dos pacientes obtiveram "sobrevida livre de doenças" e 9,7% foram considerados "indeterminados". Conclusão: O vidro bioativo S53P4 em pasta é seguro e eficaz no tratamento da osteomielite cavitária e de infecções por patógenos resistentes, incluindo o S. aureus multirresistente. Nível de Evidência IV, Série de Casos.

In vitro elution characteristics of antibiotic-loaded polymethylmethacrylate cement and a calcium sulfate bone substitute using staphylococci isolated from orthopedic implant-associated infections.

Polymethylmethacrylate (PMMA) remains the gold standard antibiotic carrier in the management of osteomyelitis. However, biodegradable ceramic carriers may exhibit more efficient antibiotic elution properties. Through zone of inhibition (ZOI) testing and biofilm killing assays, we assessed the in vitro elution efficacy of vancomycin released from calcium sulfate (PG-CSH) and PMMA beads as carriers on clinical strains of Staphylococcus aureus and Staphylococcus epidermidis, which were isolated from sonication fluid of orthopedic implant-associated infections. Overall, vancomycin-loaded PMMA and PG-CSH beads showed potency (ZOI above 4 cm2 ) for up to 14 days against ATCC and clinical strains. Vancomycin-loaded PG-CSH beads displayed higher rates, exhibited a more stable antibiotic elution, had greater impacts on bacterial colony-forming unit counts and produced higher ZOIs; additionally, statistically significant differences (Student's t test) were observed in different time sets during the experiment. In the biofilm killing assay, PG-CSH loaded with vancomycin resulted in more bacterial deaths. In conclusion, in the present study, both PG-CSH and PMMA beads acted as good carriers, but greater antimicrobial elution and biofilm bacterial killing were observed with PG-CSH than PMMA. Future in vitro research should focus on testing other difficult-to-treat clinical strains, including multidrug resistant coagulase-negative staphylococci and Gram-negative bacilli.

Type of antibiotic but not the duration of prophylaxis correlates with rates of fracture-related infection.

PURPOSE: The issue of optimal prophylactic antibiotic administration for closed and open fracture surgeries remains controversial. The purpose of this study was to assess the role of type and duration longer than 48 h of antibiotic prophylaxis on the rates of fracture-related infection (FRI). METHODS: This is a single-center, prospective observational cohort study carried out with patients undergoing surgery for implants insertion to fracture stability. Risk estimates were calculated on the variables associated with factors for FRI and reported as a prevalence ratio (PR) with respect to the 95% confidence interval (CI). RESULTS: Overall, 132 patients were analyzed. The global rate of FRI was 15.9% (21/132), with open and closed fractures accounting for 30.5% (11/36) and 10.4% (10/96), respectively. The FRI rates in patients undergoing orthopedic surgery for fracture stabilization who received prophylactic antibiotic for up to and longer than 48 h were 8.9% and 26.4%, respectively. This difference did not reach statistical significance (prevalence ratio [PR] = 2.6, 95% confidence interval [95% CI]: 0.9-7.3. p = 0.063). CONCLUSIONS: Duration of antibiotic prophylaxis for surgical orthopedic fractures was not correlated with rates of FRI.

Factors associated with the outcomes of older patients operated due to hip fractures / Fatores associados aos desfechos de pacientes idosos operados por fraturas do quadril

ABSTRACT Objective: Evaluating clinical factors associated with mortality in older patients who underwent surgical correction of hip fractures. Methods: This observational and retrospective study analyzed the medical records of 67 patients (aged older than 60 years), both men and women, who underwent surgical correction of hip fractures from 2019 to 2020 at Hospital São Paulo. The following variables were analyzed: age, sex, presence of comorbidities, affected hip region, and trauma mechanism. Statistical analyses were performed using the SPSS software. Results: The mean age of patients was 78.12 ± 9.80 years and 80.6% of the sample were women. The prevalence of hip fractures on the right side (52.2%), in the transtrochanteric region (53.7%), and due to fall on the same level (88.1%) was higher. Systemic arterial hypertension (77.6%), diabetes mellitus (37.3%), and dementia (16.4%) were frequent comorbidities. The prevalence of death after fracture was 17.9% and it was associated with longer hospital stay after surgery (p = 0.028). Conclusion: The prevalence of mortality of patients with hip fractures who underwent surgery was 17.9%. A longer hospital stay due to pre-existing comorbidities was the main factor related to this outcome. Level of Evidence III, Retrospective Study.

RESUMO Objetivo: Avaliar os fatores clínicos associados à mortalidade em pacientes idosos submetidos ao tratamento cirúrgico para correção de fraturas do quadril. Métodos: Estudo observacional e retrospectivo de análise de prontuários de 67 pacientes (idade superior a 60 anos). Foram incluídos indivíduos de ambos os sexos, submetidos ao tratamento cirúrgico para correção de fraturas do quadril, entre 2019 e 2020, no Hospital São Paulo. Foram analisadas as variáveis: idade, sexo, presença de comorbidades, região do quadril acometido e mecanismo de trauma. As análises estatísticas foram realizadas pelo software SPSS. Resultados: A idade média dos participantes foi de 78,12 ± 9,80 anos, e 80,6% da amostra era constituída por mulheres. Houve maior prevalência de fraturas do quadril no lado direito (52,2%), na região transtrocantérica (53,7%) e causada por queda sem desnível (88,1%). Hipertensão arterial sistêmica (77,6%), diabetes mellitus (37,3%) e demência (16,4%) foram frequentes. A prevalência de óbito após a fratura foi de 17,9%, sendo associada a maior tempo de internação hospitalar após a cirurgia (p = 0,028). Conclusão: A prevalência de mortalidade dos pacientes com fratura do quadril submetidos à cirurgia foi de 17,9%. O tempo prolongando de internação hospitalar por comorbidades pré-existentes foi o principal fator relacionado a este desfecho. Nível de Evidência III, Estudo Retrospectivo.

S53p4 bioactive glass putty in the local treatment of cavitary chronic osteomyelitis / Biovidro ativo s53p4 em pasta no tratamento local da osteomielite crônica cavitária

ABSTRACT Objective: Evaluating the clinical results of bioactive glass S53P4 putty for the treatment of cavitary chronic osteomyelitis. Methods: Retrospective observational study, including patients of any age with clinical and radiological diagnosis of chronic osteomyelitis, who underwent surgical debridement and implantation of bioactive glass S53P4 putty (BonAlive® Putty, Turku, Finland). Patients who underwent any plastic surgery on the soft tissues of the affected site or had segmental bone lesions or septic arthritis were excluded. Statistical analysis was performed using Excel®. Demographic data, as well as data on the lesion, treatment, and follow-up, were collected. Outcomes were classified as "disease-free survival," "failure," or "indefinite." Results: This study included 31 patients, of which 71% were men and had with a mean age of 53.6 years (SD ± 24.2). In total, 84% were followed-up for at least 12 months and 67.7% had comorbidities. We prescribed combination antibiotic therapy for 64.5% of patients. In 47.1%, Staphylococcus aureus was isolated. Finally, we classified 90.3% of cases as "disease-free survival" and 9.7% as "indefinite." Conclusion: Bioactive glass S53P4 putty is safe and effective to treat cavitary chronic osteomyelitis, including infections by resistant pathogens, such as methicillin-resistant S. aureus. Level of Evidence IV, Case Series.

RESUMO Objetivo: Avaliar a atividade do vidro bioativo S53P4 em pasta no tratamento de osteomielite crônica. Métodos: Estudo observacional retrospectivo, com inclusão de indivíduos de qualquer idade com diagnóstico clínico e radiológico de osteomielite que realizaram tratamento cirúrgico com limpeza e desbridamento, seguido do preenchimento da cavidade com biovidro S53P4 em pasta (BonAlive ® Putty, Turku, Finland). Foram excluídos pacientes submetidos a procedimentos de cirurgia plástica nos tecidos moles do local afetado, com lesões ósseas segmentares e com presença de artrite séptica. A análise estatística foi realizada em Excel ® . Foram coletados dados demográficos, sobre a lesão, o tratamento e o acompanhamento. O desfecho foi classificado em "sobrevida livre de doença", "falha" ou "indeterminado". Resultados: Dos 31 pacientes analisados, 71% eram homens, com idade média de 53,6 anos (DP ± 24,26). Do total, 84% foram acompanhados por no mínimo 12 meses, e 67,7% apresentaram comorbidades. A terapia antibiótica combinada foi realizada em 64,5% dos pacientes, sendo o patógeno mais frequente o Staphylococcus aureus (47,1%). Ao final, 90,3% dos pacientes obtiveram "sobrevida livre de doenças" e 9,7% foram considerados "indeterminados". Conclusão: O vidro bioativo S53P4 em pasta é seguro e eficaz no tratamento da osteomielite cavitária e de infecções por patógenos resistentes, incluindo o S. aureus multirresistente. Nível de Evidência IV, Série de Casos.

FRAGILITY FRACTURES IN BRAZIL: CROSS-SECTION STUDY.

Objective: To evaluate the involvement of orthopedists and orthopedic residents with fragility fractures, in its clinical, therapeutic, and social aspects. Methods: Cross-sectional observational and prospective study that took place in the period from June to August 2020. Results: 540 participants were analyzed. The population consisted of orthopedists (85.56%; N = 462) and residents (14.44%; N = 78), with a greater proportion of individuals from 41 to 50 years of age (36.67%; N = 198) and from the Southeast region (57.22%; N = 309). For 47.04% (N = 254) of the participants, the profile of the patient at risk for fragility fracture corresponds to: woman, sedentary, smoker and over 60 years of age. The consensus among the participants (97.96%; N = 529) is that fragility fractures occur in or near home environments. Moreover, 47.59% (N = 257) believe that the first fragility fracture is the most important predictive risk factor for subsequent occurrences and 63.89% (N = 345) of the participants claim to attend more than 15 cases per year. Regarding treatment, 74.44% (N = 402) are dedicated exclusively to orthopedic aspects (68.33%; N = 369). However, 62.41% (N = 337) of the participants believe that patients with fragility fractures should receive medication and supplements. Likewise, 70.74% (N = 382) of the participants consider that home security measures and training of family members are important, and they attribute the role to the multidisciplinary team. Conclusions: Fragility fractures are frequent in the routine of Brazilian orthopedists. However, they are not familiar with adjuvant treatments for fragility fractures, acting almost exclusively in the orthopedics aspects of these injuries. Level of Evidence II, Prospective Study.

Objetivo: Avaliar o entendimento entre ortopedistas e residentes em ortopedia sobre as fraturas por fragilidade, em seus aspectos clínicos, terapêuticos e sociais. Métodos: Estudo transversal, observacional e prospectivo que ocorreu no período de junho de agosto de 2020. Resultados: Foram analisados 540 participantes. A população foi composta por ortopedistas (85,56%; N = 462) e residentes (14,44%; N = 78), com prevalência de idade entre 41 e 50 anos (36,67%; N=198) e oriundos da região Sudeste (57,22%; N = 309). Para 47,04% (N = 254) dos participantes o perfil do paciente em risco para fratura por fragilidade corresponde a: mulher, sedentária, tabagista e acima dos 60 anos de idade. Sendo consenso entre os participantes (97,96%; N = 529) que as fraturas por fragilidade ocorrem em ambientes domiciliares ou próximo a eles. Além disso, 47,59% (N = 257) dos participantes acreditam que a primeira fratura por fragilidade seja o fator de risco preditivo mais importante para novo episódio de fratura e 63,89% (N = 345) dos avaliadores atendem mais de 15 casos por ano. Em relação ao tratamento, 74,44% (N = 402) dedicam-se exclusivamente aos aspectos ortopédicos (68,33%; N = 369). No entanto, 62,41% (N = 337) dos participantes acreditam que paciente devam receber medicamentos e suplementos. Da mesma forma, 70,74% (N = 382) dos avaliadores consideram que medidas de segurança domiciliar e treinamento de familiares sejam importantes e atribuídas a equipe multiprofissional. Conclusão: As fraturas por fragilidade são frequentes na rotina dos ortopedistas brasileiros. No entanto, estes não estão familiarizados com tratamentos adjuvantes nas fraturas consideradas por fragilidade, atuando quase que exclusivamente nos aspectos ortopédicos envolvidos nestas lesões. Nível de Evidência II, Estudo Prospectivo.

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.

Fragility fractures in brazil: cross-section study / Fraturas por fragilidade no brasil: estudo transversal

ABSTRACT Objective: To evaluate the involvement of orthopedists and orthopedic residents with fragility fractures, in its clinical, therapeutic, and social aspects. Methods: Cross-sectional observational and prospective study that took place in the period from June to August 2020. Results: 540 participants were analyzed. The population consisted of orthopedists (85.56%; N = 462) and residents (14.44%; N = 78), with a greater proportion of individuals from 41 to 50 years of age (36.67%; N = 198) and from the Southeast region (57.22%; N = 309). For 47.04% (N = 254) of the participants, the profile of the patient at risk for fragility fracture corresponds to: woman, sedentary, smoker and over 60 years of age. The consensus among the participants (97.96%; N = 529) is that fragility fractures occur in or near home environments. Moreover, 47.59% (N = 257) believe that the first fragility fracture is the most important predictive risk factor for subsequent occurrences and 63.89% (N = 345) of the participants claim to attend more than 15 cases per year. Regarding treatment, 74.44% (N = 402) are dedicated exclusively to orthopedic aspects (68.33%; N = 369). However, 62.41% (N = 337) of the participants believe that patients with fragility fractures should receive medication and supplements. Likewise, 70.74% (N = 382) of the participants consider that home security measures and training of family members are important, and they attribute the role to the multidisciplinary team. Conclusions: Fragility fractures are frequent in the routine of Brazilian orthopedists. However, they are not familiar with adjuvant treatments for fragility fractures, acting almost exclusively in the orthopedics aspects of these injuries. Level of Evidence II, Prospective Study.

RESUMO Objetivo: Avaliar o entendimento entre ortopedistas e residentes em ortopedia sobre as fraturas por fragilidade, em seus aspectos clínicos, terapêuticos e sociais. Métodos: Estudo transversal, observacional e prospectivo que ocorreu no período de junho de agosto de 2020. Resultados: Foram analisados 540 participantes. A população foi composta por ortopedistas (85,56%; N = 462) e residentes (14,44%; N = 78), com prevalência de idade entre 41 e 50 anos (36,67%; N=198) e oriundos da região Sudeste (57,22%; N = 309). Para 47,04% (N = 254) dos participantes o perfil do paciente em risco para fratura por fragilidade corresponde a: mulher, sedentária, tabagista e acima dos 60 anos de idade. Sendo consenso entre os participantes (97,96%; N = 529) que as fraturas por fragilidade ocorrem em ambientes domiciliares ou próximo a eles. Além disso, 47,59% (N = 257) dos participantes acreditam que a primeira fratura por fragilidade seja o fator de risco preditivo mais importante para novo episódio de fratura e 63,89% (N = 345) dos avaliadores atendem mais de 15 casos por ano. Em relação ao tratamento, 74,44% (N = 402) dedicam-se exclusivamente aos aspectos ortopédicos (68,33%; N = 369). No entanto, 62,41% (N = 337) dos participantes acreditam que paciente devam receber medicamentos e suplementos. Da mesma forma, 70,74% (N = 382) dos avaliadores consideram que medidas de segurança domiciliar e treinamento de familiares sejam importantes e atribuídas a equipe multiprofissional. Conclusão: As fraturas por fragilidade são frequentes na rotina dos ortopedistas brasileiros. No entanto, estes não estão familiarizados com tratamentos adjuvantes nas fraturas consideradas por fragilidade, atuando quase que exclusivamente nos aspectos ortopédicos envolvidos nestas lesões. Nível de Evidência II, Estudo Prospectivo.

Evaluation of post-surgical management of fragility fractures / Avaliação da conduta pós cirúrgica nas fraturas por fragilidade óssea

ABSTRACT Objective: To evaluate the conduct of Brazilian orthopedists regarding preventive treatment after fragility fracture surgery. Methods: A questionnaire was applied to Brazilian orthopedists. Statistical analyses were performed using the SPSS 16.0 program. Results: 257 participants were analyzed. Most participants, 90.7% (n = 233), reported that they cared for patients with fractures and 62.3% (n = 160) treated them. The most indicated treatments were vitamin D (22.6%; n = 134) and calcium supplementation (21.4%; n = 127). According to the experience of the physicians - experienced (n = 184) and residents (n = 73) - fragility fractures were more common in the routine of residents (98.6%; n = 72) than experienced physicians (87.5%; n = 161), p = 0.0115. While treatment conduction was more reported by experienced physicians (63.6%; n = 117) than residents (58.9%; n = 43), p = 0.004. More experienced orthopedists (21.4%; n = 97) indicated treatment with bisphosphates than residents (14.2%; n = 20), p = 0.0266. Conclusion: Although most professionals prescribe treatment after fragility fracture surgery, about 40% of professionals still do not treat it, with differences in relation to experience. In this sense, we reinforce the importance of secondary prevention in the management of fragility fractures. Level of Evidence II, Prospective comparative study.

RESUMO Objetivo: Avaliar a conduta adotada por ortopedistas brasileiros em relação ao tratamento adjuvante após a cirurgia de fraturas de fragilidade. Métodos: Foi aplicado um questionário aos ortopedistas brasileiros. A estatística foi realizada no programa SPSS 16.0. Resultados: Foram analisados 257 participantes. A maioria dos participantes 90,7% (n = 233) relataram atender os pacientes com fraturas e 62,3% (n = 160) relataram tratar. Os tratamentos mais indicados foram a suplementação de vitamina D (22,6%; n = 134) e de cálcio (21,4%; n = 127). De acordo com a comparação médicos experientes (n = 184) versus médicos residentes (n = 73), a rotina de fraturas de fragilidade foi mais observada por médicos residentes (98,6%; n = 72) que por médicos experientes (87,5%; n = 161), p = 0,0115. Enquanto a conduta de tratamento foi mais relatada por médicos experientes (63,6%; n = 117) versus médicos residentes (58,9%; n = 43), p = 0,004. A maior proporção de médicos experientes (21,4%; n = 97) indicaram o tratamento com bifosfatos versus médicos residentes (14,2%; n = 20), p = 0,0266. Conclusão: Apesar da maioria dos profissionais prescreverem um tratamento após a cirurgia de fraturas de fragilidade, cerca de 40% dos profissionais ainda não tratam, sendo observadas diferenças em relação à experiência. Neste contexto, reforçamos a importância da prevenção secundária na conduta de fraturas de fragilidade. Nível de Evidência II, Estudo prospectivo comparativo.

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.

EVALUATION OF POST-SURGICAL MANAGEMENT OF FRAGILITY FRACTURES.

OBJECTIVE: To evaluate the conduct of Brazilian orthopedists regarding preventive treatment after fragility fracture surgery. METHODS: A questionnaire was applied to Brazilian orthopedists. Statistical analyses were performed using the SPSS 16.0 program. RESULTS: 257 participants were analyzed. Most participants, 90.7% (n = 233), reported that they cared for patients with fractures and 62.3% (n = 160) treated them. The most indicated treatments were vitamin D (22.6%; n = 134) and calcium supplementation (21.4%; n = 127). According to the experience of the physicians - experienced (n = 184) and residents (n = 73) - fragility fractures were more common in the routine of residents (98.6%; n = 72) than experienced physicians (87.5%; n = 161), p = 0.0115. While treatment conduction was more reported by experienced physicians (63.6%; n = 117) than residents (58.9%; n = 43), p = 0.004. More experienced orthopedists (21.4%; n = 97) indicated treatment with bisphosphates than residents (14.2%; n = 20), p = 0.0266. CONCLUSION: Although most professionals prescribe treatment after fragility fracture surgery, about 40% of professionals still do not treat it, with differences in relation to experience. In this sense, we reinforce the importance of secondary prevention in the management of fragility fractures. Level of Evidence II, Prospective comparative study.

OBJETIVO: Avaliar a conduta adotada por ortopedistas brasileiros em relação ao tratamento adjuvante após a cirurgia de fraturas de fragilidade. MÉTODOS: Foi aplicado um questionário aos ortopedistas brasileiros. A estatística foi realizada no programa SPSS 16.0. RESULTADOS: Foram analisados 257 participantes. A maioria dos participantes 90,7% (n = 233) relataram atender os pacientes com fraturas e 62,3% (n = 160) relataram tratar. Os tratamentos mais indicados foram a suplementação de vitamina D (22,6%; n = 134) e de cálcio (21,4%; n = 127). De acordo com a comparação médicos experientes (n = 184) versus médicos residentes (n = 73), a rotina de fraturas de fragilidade foi mais observada por médicos residentes (98,6%; n = 72) que por médicos experientes (87,5%; n = 161), p = 0,0115. Enquanto a conduta de tratamento foi mais relatada por médicos experientes (63,6%; n = 117) versus médicos residentes (58,9%; n = 43), p = 0,004. A maior proporção de médicos experientes (21,4%; n = 97) indicaram o tratamento com bifosfatos versus médicos residentes (14,2%; n = 20), p = 0,0266. CONCLUSÃO: Apesar da maioria dos profissionais prescreverem um tratamento após a cirurgia de fraturas de fragilidade, cerca de 40% dos profissionais ainda não tratam, sendo observadas diferenças em relação à experiência. Neste contexto, reforçamos a importância da prevenção secundária na conduta de fraturas de fragilidade. Nível de Evidência II, Estudo prospectivo comparativo.

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.

Microbiological diagnosis of intramedullary nailing infection: comparison of bacterial growth between tissue sampling and sonication fluid cultures.

BACKGROUND: Intramedullary nailing (IMN) has been frequently indicated to treat long bone open and closed fractures, but IMN infection (IMNI) may have devastating consequences. Sonication has been regarded as an important add-on for microbial identification on a variety of orthopaedic implant-associated infections, but its role in the IMNI is poorly studied. We aim at evaluating the accuracy obtained by conventional peri-implant tissue culture (TC) samples with sonication fluid cultures (SCs) of IMNI. METHODS: Longitudinal prospective cohort study ongoing since June 2014, which included patients with indication for IMN removal due to any reason. Clinical diagnosis of INMI was defined according to publication addressing fracture-related infections. Minimal of two samples from TC were cultured. SCs followed the protocol previously published. Statistical analysis was performed using McNemar's test for related proportions. RESULTS: We included 54 patients submitted to IMN retrieval, of whom 47 presenting clinical signs of IMNI. Sensitivity for detecting microorganisms using TC and SC was 89.4% (42/47) and 97.6% (40/41), and specificity was 71.4% (5/7) for both TC and SC (p = 1.00). Positive and negative predictive values for TC and SC were 95.5% (42/44), 95.2% (40/42), 50% (5/10), and 83.3% (5/6), respectively. The most frequent organisms isolated in both TC and SC were Staphylococcus aureus, S. epidermidis, and Enterococcus sp. Polymicrobial infection was diagnosed in 14.8% (8/54) and 25% (12/48) by TC and SC, respectively (p = 0.19). CONCLUSION: Sonication fluid and tissue samples presented similar accuracy on the diagnosis of IMNI, but SC was advantageous of detecting polymicrobial infection.

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.

Intervention Protocol of the Orthopedics and Traumatology Department of a High-Complexity University Hospital to Cope with the COVID-19 Pandemic.

Objective To describe the protocols implemented to adapt the orthopedic team to the COVID-19 pandemic; a secondary objective is to assess the behavior of hospital and departmental variables when implementing such measures. Methods The present is a retrospective study describing three protocols: 1) reduction in the risk of infection for patients and healthcare workers; 2) adaptation of work, academic and scientific activities; and 3) adaptation of the orthopedic treatment during the pandemic. We analyzed hospital and departmental variables, including the number of patients seen in the emergency room and outpatient clinic, the number of hospitalized patients, suspected and confirmed cases in patients and orthopedic team members, changes in teaching activities from on-site attendance to videoconferencing, and number of surgeries. Period A, from March 3 to 16, was compared with period B, from March 17 to 30, 2020, which corresponded to the implementation of the protocols. Results There was a decrease in the number of outpatients and inpatients. One confirmed and two suspected cases were notified. Among the departmental members, there were 12 suspected and 6 confirmed cases. The weekly frequency of classes was maintained, while the clinical-scientific meetings decreased from ten to three. In addition, the number of surgeries was reduced. Conclusions The present study demonstrated the feasibility and efficiency of the rapid implementation of intervention protocols in the midst of the COVID-19 pandemic. The protocols focused on reducing the risk of infection for patients and healthcare professionals, adapting work, academic and scientific activities, and modifying the orthopedic treatment. With the application of the protocols, the healthcare, academic and scientific activities remained functional, prioritizing measures to confront the COVID-19 pandemic.

Intervention Protocol of the Orthopedics and Traumatology Department of a High-Complexity University Hospital to Cope with the COVID-19 Pandemic / Protocolo de intervenção do Departamento de Ortopedia e Traumatologia de um hospital universitário de alta complexidade para enfrentamento da pandemia de COVID-19

Abstract Objective To describe the protocols implemented to adapt the orthopedic team to the COVID-19 pandemic; a secondary objective is to assess the behavior of hospital and departmental variables when implementing such measures. Methods The present is a retrospective study describing three protocols: 1) reduction in the risk of infection for patients and healthcare workers; 2) adaptation of work, academic and scientific activities; and 3) adaptation of the orthopedic treatment during the pandemic. We analyzed hospital and departmental variables, including the number of patients seen in the emergency room and outpatient clinic, the number of hospitalized patients, suspected and confirmed cases in patients and orthopedic team members, changes in teaching activities from on-site attendance to videoconferencing, and number of surgeries. Period A, from March 3 to 16, was compared with period B, from March 17 to 30, 2020, which corresponded to the implementation of the protocols. Results There was a decrease in the number of outpatients and inpatients. One confirmed and two suspected cases were notified. Among the departmental members, there were 12 suspected and 6 confirmed cases. The weekly frequency of classes was maintained, while the clinical-scientific meetings decreased from ten to three. In addition, the number of surgeries was reduced. Conclusions The present study demonstrated the feasibility and efficiency of the rapid implementation of intervention protocols in the midst of the COVID-19 pandemic. The protocols focused on reducing the risk of infection for patients and healthcare professionals, adapting work, academic and scientific activities, and modifying the orthopedic treatment. With the application of the protocols, the healthcare, academic and scientific activities remained functional, prioritizing measures to confront the COVID-19 pandemic.

Resumo Objetivo Descrever os protocolos implementados para adequar a equipe ortopédica à pandemia de COVID-19 e, secundariamente, avaliar o comportamento de variáveis hospitalares e departamentais frente à implementação das medidas. Métodos Estudo retrospectivo com descrição de três protocolos: 1) Redução do risco de contágio dos pacientes e profissionais de saúde; 2) Adaptação das atividades laborais, acadêmicas e científicas; e 3) Adaptação do tratamento ortopédico frente à pandemia. Foram analisadas variáveis hospitalares e departamentais como: número de pacientes atendidos no pronto-socorro e ambulatórios, pacientes internados, casos suspeitos e confirmados nos pacientes e na equipe ortopédica, mudança das atividades de ensino do modo presencial para videoconferência, e número cirurgias. Foi comparado o período A, de 03 a 16 de março, com o período B, de 17 a 30 de março, que corresponde à implementação dos protocolos. Resultados Houve diminuição do número de pacientes atendidos e do número de pacientes internados. Foram notificados dois suspeitos e um confirmado. Dos integrantes do departamento, 12 foram suspeitos e 6 confirmados. Manteve-se a frequência semanal das aulas e as reuniões clinico-científicas diminuíram de dezpara três. Houve redução no volume de cirurgias. Conclusões O presente estudo demonstrou a viabilidade e a eficiência da rápida implementação de protocolos de intervenção em meio ao cenário de pandemia por COVID-19. Os protocolos focaram na redução do risco de contágio dos pacientes e profissionais de saúde, na adaptação das atividades laborais, acadêmicas e científicas, e na adaptação do tratamento ortopédico. Com sua aplicação, mantiveram-se as atividades assistencial, acadêmica e científica funcionantes, priorizando-se medidas de enfrentamento à COVID-19.

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.