Intramedullary nail versus locked plate in the treatment of two- and three-part proximal humerus fractures: a retrospective comparative study of 46 cases / Haste intramedular versus placa bloqueada no tratamento da fratura do úmero proximal em duas e três partes: um estudo comparativo retrospectivo de 46 casos

Objective: to retrospectively evaluate and compare the proportions of complications and radiographic findings of two- and three-part proximal humerus fracture osteosynthesis with two treatment methods: third-generation locked intramedullary nail and locked plate. Methods: 46 patients with a mean age of 58.9±16.6 years were evaluated between January 2020 and January 2021. In sixteen cases (34.8%), an intramedullary nail was used, and in thirty cases (65 .2%), the proximal humerus locked plate. The evaluation used included the rate of complications with a minimum follow-up of 6 months postoperatively and radiographic evaluation. Results: there was no significant difference between the groups regarding the proportion of complications (nail group 18.8%, plate group 13.3%; p=0.681). The nail group showed less residual loss in varus (cervicodiaphyseal angle, nail group 132.1º±2.3º, plate group 123.8º±10.1º; p<0.001). In the plaque group, women had a lower value (1.43±0.22) of the tuberosity-deltoid index (DTI) compared to men (1.58±0.11) (p=0.022). Conclusions: in the short-term follow-up, osteosynthesis, with locked plate and intramedullary nail, did not show differences in the proportions of complications. The nail group showed less change in the post-operative cervicodiaphyseal angle, however, there were two serious complications with cut out and varus deviation requiring a new surgical approach in the nail group.

Objetivo: avaliar intra, de modo retrospectivo, e comparando as complicações e os achados radiográficos da osteossíntese da úmero proximal em duas e três partes com dois métodos de tratamento: a terceira geração e placa bloqueada do tratamento. Métodos: foram obtidos 46 pacientes com média de idade de 58,9±16,6 anos entre janeiro de 2020 a janeiro de 2021. ,2%), uma placa bloqueada de úmero proximal. A utilização de uma taxa de acompanhamento com acompanhamento de acompanhamento pós-operatório e avaliação radiográfica. Resultados: não houve diferença significativa entre os grupos quanto à proporção de complicações (grupo pressa, 8%, grupo placa 13,61; p=0,61). O grupo pressa apresentou menor perda residual em varo (ângulo cervicodiafisário grupo pressa 132,1º±2,3º, grupo placa 123,8º±10,1º; p<0,001). No grupo placa, as mulheres apresentaram menor valor (1,43±0,22) do índice tuberosidade-deltoide (DTI) em relação aos homens (1,58±0,11) (p=0,022). Conclusões: sem seguimento de curto prazo, a osteoconformidade com placas fixadas e pressa intramedular, não apresentou diferenças nas proporções de complicações. O grupo apresentou menor alteração do projeto cervicodiafisário pós-operatório, entretanto, duas complicações graves com cut out e desvio em varo com necessidade de reabordagem integrada no grupo pressa. 22) do índice tuberosidade-deltoide (DTI) em relação aos homens (1,58±0,11) (p=0,022). Conclusões: sem seguimento de curto prazo, a osteoconformidade com placas fixadas e pressa intramedular, não apresentou diferenças nas proporções de complicações. O grupo apresentou menor alteração do projeto cervicodiafisário pós-operatório, entretanto, duas complicações graves com cut out e desvio em varo com necessidade de reabordagem integrada no grupo pressa. 22) do índice tuberosidade-deltoide (DTI) em relação aos homens (1,58±0,11) (p=0,022). Conclusões: sem seguimento de curto prazo, a osteoconformidade com placas fixadas e pressa intramedular, não apresentou diferenças nas proporções de complicações. O grupo apresentou menor alteração do projeto cervicodiafisário pós-operatório, entretanto, duas complicações graves com cut out e desvio em varo com necessidade de reabordagem integrada no grupo pressa. 

Aloenxertos ósseos e enxerto sintético de hidroxiapatita em falha óssea ulnar em galinhas (Gallus gallus domesticus), aspectos radiográficos e histológicos / Bone allografts and synthetic grafts hydroxyapatite on ulnar bone defect in fowl (Gallus gallus domesticus), radiographic and histological aspects

Dos atendimentos ortopédicos realizados em aves no HCV-UFRGS, 86% são fraturas, sendo aproximadamente 30% delas cominutivas com perda óssea expressiva, justificando a importância da utilização de enxertos em fraturas de aves. O objetivo deste trabalho foi avaliar dois aloenxertos e enxerto sintético de hidroxiapatita em defeito ósseo de galinhas. Utilizaram-se 30 galinhas separadas em três grupos: aloenxerto congelado em ultra-freezer (GUF), aloenxerto congelado em nitrogênio líquido (GNL) e enxerto sintético de hidroxiapatita deficiente em cálcio (GHA). Nos três grupos, os enxertos foram aplicados com placas e parafusos bloqueados de 2mm na ulna direita das aves, avaliando-se a evolução por meio de exames radiográficos até serem completados 90 dias de pós-operatório e o resultado final mediante exame histológico. A média e desvio-padrão relacionando o tempo de consolidação óssea radiográfica foi: GNL 61,67±21,79 dias (90% de consolidação), GUF 47,14±13,50 dias (70% de consolidação) e GHA 70±18,17 dias (60% de consolidação). Houve diferença significativa no tempo de consolidação óssea entre o GUF e o GHA. Histologicamente, os enxertos do GUF foram os que estavam em consolidação mais avançada. Os aloenxertos do GNL foram superiores no preenchimento de falha óssea ulnar de galinhas.(AU)

Of the orthopedic visits performed on birds at HCV-UFRGS, 86% are fractures, and approximately 30% of them are comminuted with expressive bone loss, justifying the importance of the use of grafts in bird fractures. The objective of this work was to test two allografts and a synthetic HADC graft on finishing in Gallus gallus domesticus. 30 laying hens were used, divided in three groups: frozen allograft in ultrafreezer (UFG); frozen allograft in liquid nitrogen (LNG); calcium deficient synthetic hydroxyapatite graft (HAG). The three graft groups were exposed to serial radiographs until the 90 postoperative days, as well as the histological examination at the end of the experiment were: LNG 61.67±21.79 days (90% consolidation), UFG 47.14±13.50 days (70% consolidation) and HAG 70±18.17 days (60% consolidation). There was a significant difference in bone healing time between GUF and GHA. Histologically, GUF grafts were the ones that were in the most advanced consolidation. LNG allografts were superior in filling ulnar bone failure of fowl.(AU)

Results measured by means of a motion capture system in proximal humerus fractures treated by osteosynthesis with locking plate. / Resultados medidos con captura de movimiento en las fracturas de húmero proximal tratadas mediante osteosíntesis con placa bloqueada.

OBJECTIVE: To evaluate the results after locking plate internal fixation of proximal humerus fractures by means of a motion capture system, and functional scales. MATERIAL AND METHOD: Retrospective study of a cohort of 47 elderly patients undergoing surgery from January 2010 to December 2014. After a minimum follow-up of two years, two functional scales (Constant-Murley and Quick DASH), and a quality of life scale (EQ-5D) were used for clinical evaluation. For objective evaluation of the range of motion a kinematic marker-free analysis with cameras was performed. RESULTS: The average age was 74.85 years. Average functional scores were: Constant-Murley 70.06 points, Quick DASH 35.74 points and EQ-5D 6.79 points. The average range of motion was: flexion, 111.49°; extension: 24.13°; abduction: 109.40°; adduction: 15.13°; external rotation: 38.96°, and internal rotation: 49.28°. Correlation was found between the two functional scales, between them and the EQ-5D, and between range of motion and functional scales (except for external rotation) as well as between range of motion and EQ-5D (except for flexion and external rotation). CONCLUSION: Locking plate osteosynthesis in proximal humerus fragility fractures achieved good functional and quality of life scores. Motion capture systems can be a useful tool for the functional assessment of shoulder pathology allowing an objective evaluation of range of motion.

Osteosíntesis con placa bloqueada y técnica de mínima invasión para las fracturas de húmero proximal / Osteosynthesis with locking plate and minimally invasive technique for proximal humeral fractures

Resumen: Objetivo: Dar a conocer nuestra experiencia en el tratamiento de las fracturas de húmero proximal de 2 a 3 partes con técnica de mínima invasión mediante el uso de un implante con estabilidad angular bloqueado e investigar los factores que afectan los resultados de los pacientes. Material y métodos: Estudio descriptivo y prospectivo tipo serie de casos. De 22 pacientes fueron intervenidos 13 mujeres y nueve hombres en el período comprendido entre Febrero de 2010 y Agosto de 2012. El rango de edad media fue 50.8 años (24-82 años). Se hizo un abordaje acromial lateral con el paciente en posición de silla de playa bajo visión fluoroscópica. El tiempo de seguimiento mínimo fue de 24.3 meses (11-32). El seguimiento se hizo mediante revisión de radiografías para la consolidación y necrosis avascular y la valoración funcional de la escala de Constant. Resultados: En todos los casos se observó consolidación de la fractura a los seis meses. No se detectaron casos con necrosis avascular. Dos pacientes mostraron consolidación en varo (109o). Dos pacientes presentaron pinzamiento por la placa. El resultado funcional según la escala de valoración de Constant-Murley fue de 68.8 puntos. No hubo lesiones neurológicas asociadas. Conclusiones: La fijación con técnica mínimamente invasiva para las fracturas de húmero proximal con placas bloqueadas es una alternativa válida como tratamiento quirúrgico. La incidencia de necrosis avascular fue baja y se permitió una rehabilitación temprana en pacientes de mala calidad ósea.

Abstract: Objective: To report our experience in the treatment of 2-3 fragment proximal humeral fractures using a minimally invasive technique that involves an angular-stable locking implant and find out the factors affecting patients' outcomes. Material and methods: Descriptive, prospective study of the case series type. Twenty-two patients, 13 females and 9 males, were operated on between February 2010 and August 2012. Mean age was 50.8 years (24-82 years). Patients were placed in a beach-chair position. A lateral acromial approach was used under fluoroscopic guidance. Minimal follow-up period was 24.3 months (11-32). Follow-up consisted of X-ray review to check for bone healing and avascular necrosis, and functional assessment using the Constant-Murley scale. Results: Bone healing occurred in all cases at 6 months. There were no cases of avascular necrosis. Two patients had varus healing (109º), and two had plate impingement. The functional assessment score according to the Constant-Murley scale was 68.8. There were no associated neurologic lesions. Conclusions: Fixation of proximal humeral fractures with a minimally invasive technique using locking plates represents a valid surgical approach. The avascular necrosis rate was low and early rehabilitation was possible in patients with poor bone quality.

Interprosthetic femoral fractures: Treatment with a lateral angular-stable plate. / Fracturas interprotésicas femorales. Tratamiento con placa lateral de estabilidad angular.

OBJECTIVE: To study the causes and outcomes of patients with interprosthetic femoral fractures. MATERIAL AND METHODS: A retrospective review conducted on 7 patients treated between 2010 and 2013. The knee arthroplasties had been implanted for at least 5 years, and those of the hip less than a year. They were bipolar cemented in 6 patients and totally non-cemented in one patient, all of them implanted due to a displaced femoral neck fracture. They were treated using osteosynthesis with angular stability plate covering the whole interprosthetic femoral segment. Except for one patient, all have been reviewed at least 12 months. RESULTS: The patients included 6 women and one man, with a mean age of 84.7. The fracture, always by low energy, occurred between 2 and 8 months after that of the hip without the implants being mobilized. Four of them were located at diaphyseal level, and 3 at supracondylar level, and unrelated to the type of knee implant. There was consolidation in all patients at a mean of 4.5 months, without a re-operation in any of them, and with no mortality during the follow-up period. All patients walked independently at the time of the fracture, and all of them have managed to return to walking independently, having lost as average 20° of knee flexion in cases of supracondylar fracture. CONCLUSIONS: The most important factors in our patients regarding the producing of the fracture have been the changes in the ability to walk after knee replacement and bone fragility. Angular stability plates give good results in the treatment of interprosthetic femoral fractures.

Manejo de fractura en hueso patológico en la infancia: picnodisostosis / Management of fractures in pathological bone in childhood: pycnodysostosis

La picnodisostosis es una enfermedad poco común que pertenece a las displasias esqueléticas que presentan fragilidad ósea y fracturas frecuentes. Radiológicamente se caracteriza por incremento de la densidad y fragilidad óseas. OBJETIVO: Presentar el caso de un escolar con displasia esquelética con fracturas en hueso patológico y manejo quirúrgico. CASO CLÍNICO: Escolar de sexo femenino, con antecedente de picnodisostosis detectado en etapa preescolar. Consulta posterior a caída de bicicleta con fractura de ambos fémures que se manejan quirúrgicamente con placa de compresión bloqueada.

Pycnodysostosis is a rare condition within skeletal dysplasias presenting with brittle bones and frequent fractures. Radiologically, it is characterised by increased bone density and fragility. OBJECTIVE: To present the case of a primary schoolchild with skeletal dysplasia with pathological bone fractures and their surgical management. CASE REPORT: A female primary schoolchild with a history of pycnodysostosis detected during the pre-school period. She was seen after bicycle fall that resulted in the fracture of both femurs, that were surgically managed with a locking compression plate.

Tratamiento con placa precontorneada bloqueada de fracturas desplazadas del tercio medio de la clavicula / Precontoured locking plate treatment for displaced midshaft clavicle fractures

Introducción: El objetivo de este trabajo es analizar los resultados de un grupo de pacientes con fracturas mediodiafisarias desplazadas de clavícula tratadas con placa precontorneada bloqueada. Se analizaron la tasa de consolidación ósea, los resultados funcionales y las complicaciones. Materiales y Métodos: Cuarenta y seis fracturas de clavícula desplazadas de tipo 2B de Edimburgo fueron tratadas con placa bloqueada precontorneada. Los pacientes eran 36 hombres (uno con fractura bilateral) y nueve mujeres, con una edad promedio de 33 años (rango 17-56). Los pacientes fueron evaluados con radiología y el puntaje de Constant, el test QuickDASH y la escala analógica visual para dolor. Resultados: El seguimiento promedio fue de 30 meses (rango 12-46). Cuarenta y cinco fracturas consolidaron y una no. El puntaje de Constant promedio fue de 96 (rango 56-100) y el de QuickDASH promedio, 2 (rango 0-32). El dolor en el seguimiento fue de 0,3 puntos (rango 0-6). Se registraron 10 complicaciones en nueve pacientes (21%), aunque solo tres (6,5%) fueron consideradas mayores. En siete pacientes (15%), se retiró la placa por intolerancia (uno de ellos fue el paciente con mala consolidación, se registró como segunda complicación en el mismo paciente). Conclusiones: La reducción y estabilización de las fracturas desplazadas del tercio medio de la clavícula con placas precontorneadas y bloqueadas son un tratamiento eficaz con un bajo índice de complicaciones mayores relacionadas, a veces, con errores técnicos.

Introduction: The aim of this paper is to analyze the results in a group of patients with displaced diaphyseal fractures treated with precontoured clavicle locking plate. The rate of bone healing, functional outcome and complications were analyzed. Methods: Forty-six displaced clavicle fractures (Edinburgh type 2B) were treated with precontoured locking plate. Thirty- six were men (one with bilateral fracture) and 9 were women, with an average age of 33 years (range 17-56). Patients were assessed with radiology and the Constant score, the QuickDASH test, and the visual analogue scale for pain. Results: The average follow-up was 30 months (range 12-46). Forty-five fractures healed and one did not. The Constant score averaged 96 points (range 56-100) and the QuickDASH test averaged 2 points (range 0-32). Pain was 0.3 points (range 0-6). There were 10 complications in 9 patients (21%), but only three (6.5%) were considered major. In 7 patients (15%) the plate had to be removed due to intolerance (one of them was a patient with malunion, registering as a second complication in the same patient). Conclusions: The reduction and stabilization of displaced midshaft fractures of the clavicle with precontoured clavicle locking plate is an effective treatment with a low rate of major complications, sometimes related to technical errors.

Fractura de radio distal: abordaje mininvasivo con preservación del pronador cuadrado / Distal radius fracture: minimally invasive approach with pronator quadratus preservation

Objetivo: Describir y analizar una técnica de osteosíntesis palmar de radio distal con preservación del pronador cuadrado. Materiales y Métodos: Se revisaron, en forma retrospectiva, 24 pacientes operados con esta técnica (16 mujeres y 8 hombres; edad promedio 65 años). Doce fracturas eran de tipo A; 7, de tipo B y 5, de tipo C. La técnica quirúrgica consiste en practicar una incisión cutánea de 25 mm y profundizar hasta observar el pronador cuadrado. Sin seccionarlo, se realiza una disección de su borde distal, a fin de introducir la placa bloqueada volar por debajo del músculo. Se colocan los tornillos distales bajo visión directa y los tornillos proximales, en forma percutánea. La evaluación posoperatoria se llevó a cabo mediante análisis clínico-funcional y radiográfico. Resultados: En el último control, todos los pacientes presentaban signos clínicos y radiográficos de consolidación ósea. El puntaje en la escala DASH fue, en promedio, de 4,8. Se observó una inclinación palmar posoperatoria de la superficie articular del radio de 14,3º promedio y una inclinación radial de 26,3º promedio. No se detectaron complicaciones relacionadas con la fractura, el implante o la herida quirúrgica en ninguno de los controles posoperatorios. Conclusiones: Sin bien no existe bibliografía que demuestre que la técnica mininvasiva sea superior, sostenemos que el hecho de obtener resultados similares con ambos abordajes (mininvasivo y convencional) justifica llevar a cabo esta técnica con preservación del pronador cuadrado, sobre todo en los pacientes preocupados por el aspecto estético de la cicatriz. Nivel de evidencia: IV.

Objective: To describe and analyze a volar locking plate technique for distal radius fractures with pronator quadratus preservation. Methods: We retrospectively reviewed 24 patients who underwent minimally invasive approach (16 women, 8 men; mean age 65 years). Twelve fractures were type A, 7 type B and 5 type C. The surgical technique involves making an incision of 25 mm and deepened to expose the pronator quadratus. Afterwards, a distal edge dissection of the pronator quadratus is performed in order to introduce the volar locking plate under the muscle. Distal screws are placed under direct vision and proximal screws are placed percutaneously. Postoperative evaluation included clinical, functional and radiological analyses. Results: At last control, all patients had clinical and radiographic signs of bone healing. The average score on the DASH scale was 4.8 points. Postoperative average volar tilt was 14.3° and the average radial inclination was 26.3°. There were no complications related to the fracture, implant or surgical wound in the postoperative controls. Conclusions: Although we did not obtain better results with this technique than with the conventional one, and there is no literature available which demonstrates that the minimally invasive technique is superior, we believe that the fact of getting similar results with both approaches justifies carrying out this technique with pronator quadratus preservation, especially in patients concerned about the cosmetic appearance of the scar. Level of evidence: IV.

[Percutaneous osteosynthesis in tibial pilon fractures. Does the surgical technique determine the final result?]. / Osteosíntesis percutánea en fracturas de pilón tibial, ¿condiciona la técnica quirúrgica el resultado final?

OBJECTIVE: To analyze the outcomes of distal tibia fractures with or without extension into the ankle joint, treated by percutaneous cannulated screws or locking plates. MATERIAL AND METHOD: A retrospective study was conducted on 107 patients treated between 2001 and 2012. INCLUSION CRITERIA: fractures 43-A and 43-C1 and C2 according to the AO/OTA system, treated with percutaneous osteosynthesis by locking plate or two cannulated screws in X -letter setting. A total of 33 patients were evaluated: 16 tibial fractures were performed with locking plate (G1) and 17 with cannulated screws (G2). Mean time to surgery was 8.31 days (0-14) in G1, and 2 days (0-7) in G2. The mean follow-up was 72 months (12-132). Mean time to healing: 17.08 weeks (8-48) in G1, and 14.56 weeks (8-24) in G2. The results were evaluated according to the AOFAS scale, with plain X-rays, and complications during follow-up. RESULTS: The mean evaluation according to the AOFAS score was 78.62 in G1 (22-93), and 90.63 in G2 (70-100), and this was statistically significant. In G1, 61.4% (8) of the results were excellent or good, while in G2 it was 76% (13). There were no axial deformity cases or shortenings. There were 4 superficial infections and one broken device recorded in G1. DISCUSSION: The percutaneous cannulated screw fixation is a suitable alternative for the management of fractures without significant joint involvement, and seems to offer better functional results than plates. The shortest time from injury to intervention in this group improves the progress of the soft tissues, and can improve the final result.

Análise retrospectiva dos pacientes com fratura do terço distal de rádio submetidos à fixação interna com placa bloqueada e enxerto sintético

Objetivo: analisar os resultados do tratamento cirúrgico com fixação interna utilizando placa volar LCP e enxerto sintético das fraturas do terço distal do rádio.

Análise retrospectiva dos pacientes com fratura do terço distal de rádio submetidos à fixação interna com placa bloqueada e enxerto sintético / Retrospective analyze of patients with fracture of distal third of the radio submitted to internal fixation locked plate and synthetic grafting

Objetivo: analisar os resultados do tratamento cirúrgico com fixação interna utilizando placa volar LCP e enxerto sintético das fraturas do terço distal do rádio. (AU)