Availability and use of resources for emergency fracture care of pelvic trauma associated with haemorrhagic shock in Latin America: A cross-sectional study.

Determining the true availability of resources and understanding the level of training of surgeons involved in the treatment of patients with pelvic fractures and haemorrhagic shock is critical. In the herein study, the availability of technical, technological, and human resources for the care of this injury in Latin America region was analysed, and the preferences of orthopaedic trauma surgeons when performing interventions for the diagnosis and treatment of patients with pelvic trauma and associated haemorrhagic shock was described. A cross sectional web-based survey containing questions on knowledge, attitudes, and practices with respect to imaging resources, emergency pelvic stabilization methods, and interventions used for bleeding control was sent to 948 Latin America orthopaedic trauma surgeons treating pelvic fractures in the emergency department. Differences between regional clusters, level of training, type of hospital, and pelvic surgery volume were assessed. 368 responses were obtained, with 37.5% of respondents reporting formal training in pelvic surgery and 36.0% having available protocol for managing these patients. The most frequently used interventions were the supra-acetabular pelvic external fixator and pelvic packing. Limited hospital and imaging resources are available for the care of patients with pelvic trauma and associated haemorrhagic shock throughout Latin America. In addition, the training of orthopaedic trauma surgeons dealing with this type of injury and the volume of pelvic surgeries per year is heterogeneous. It should be urgently considered to develop management protocols adapted to Latin America according to the availability of resources, as well as to promote training in this severe life-threatening traumatic condition.

Factors Associated with the Development of Early Complications after Total Knee Arthroplasty.

Objective To diagnose risk factors for the development of local or medical postoperative complications up to 30 days after surgery in patients undergoing total knee arthroplasty Methods The present analysis included all patients who underwent knee arthroplasty performed in this hospital during the study period, based on data from medical records of the patients, with the aim of investigating factors related to the occurrence of local or medical complications during hospitalization and up to 30 days after the procedure, if they needed any additional intervention. Results Out of the 157 patients included in the study, 17.1% had some complication. The most prevalent were arthrofibrosis (6.4%), deep infection (4.4%), and superficial infection (2.5%), among others. Older patients and a greater number of previous comorbidities were associated with a higher risk of postoperative complications. Conclusions Older patients and a greater number of comorbidities were related to an increased risk of postoperative complications. The American Society of Anesthesiologists (ASA) score proved to be insufficient to assess the occurrence of complications after knee arthroplasty and new tools should be used for this purpose.

Factors Associated with the Development of Early Complications after Total Knee Arthroplasty / Fatores associados ao desenvolvimento de complicações precoces após artroplastia total do joelho

Abstract Objective To diagnose risk factors for the development of local or medical postoperative complications up to 30 days after surgery in patients undergoing total knee arthroplasty Methods The present analysis included all patients who underwent knee arthroplasty performed in this hospital during the study period, based on data from medical records of the patients, with the aim of investigating factors related to the occurrence of local or medical complications during hospitalization and up to 30 days after the procedure, if they needed any additional intervention. Results Out of the 157 patients included in the study, 17.1% had some complication. The most prevalent were arthrofibrosis (6.4%), deep infection (4.4%), and superficial infection (2.5%), among others. Older patients and a greater number of previous comorbidities were associated with a higher risk of postoperative complications. Conclusions Older patients and a greater number of comorbidities were related to an increased risk of postoperative complications. The American Society of Anesthesiologists (ASA) score proved to be insufficient to assess the occurrence of complications after knee arthroplasty and new tools should be used for this purpose.

Resumo Objetivo Identificar fatores de risco para o desenvolvimento de complicações pós-operatórias locais ou clínicas ocorridas até 30 dias após a cirurgia em pacientes submetidos a artroplastia total do joelho. Métodos Todos os pacientes submetidos a artroplastia de joelho realizada neste hospital no período do estudo foram incluídos na análise, baseada em dados dos prontuários dos pacientes, para investigar os fatores associados à ocorrência de complicações locais ou clínicas durante o internamento até 30 dias após o procedimento que necessitaram de alguma intervenção. Resultados Dos 157 pacientes incluídos no estudo, 17,1% cursaram com alguma complicação. As mais prevalentes foram artrofibrose (6,4%), infecção profunda (4,4%) e infecção superficial (2,5%), dentre outras. A maior idade e maior número de comorbidades prévias foram relacionadas com maior risco de complicações pós-operatórias. Conclusões A maior idade e maior número de comorbidades foram relacionados a um risco aumentado de complicações pós-operatórias. O escore Sociedade Americana de Anestesiologistas (ASA, na sigla em inglês) se mostrou insuficiente para avaliar a ocorrência de complicações pós artroplastia de joelho e novas ferramentas devem ser empregadas para este fim.

Impact of the COVID-19 Pandemic in the Prevalence of Burnout among Residents in Orthopedics.

Objective The primary objective of the present study is to assess the impact of the COVID-19 pandemic on the prevalence of burnout syndrome among residents in orthopedic surgery. As a secondary objective, characteristics associated with the risk of developing the severe form of the syndrome were assessed. Method In the present cross-sectional study, graduating orthopedic residents were evaluated before and during the COVID-19 pandemic. Medical students formed a control group. The participants answered a sociodemographic questionnaire, the Maslach Burnout Inventory, and the Brazilian validated version of the 36-item short-form health survey questionnaire (SF-36). Fifty-two residents were appraised before the pandemic and 19 during the pandemic. Results Forty-four (84.6%) residents fulfilled the criteria for burnout syndrome, and the severe form of the syndrome was present in 16 (30.7%). There was no significant change in the evaluated scores after the beginning of the COVID-19 pandemic. There was also no increase in the prevalence of burnout syndrome or of the severe form of the syndrome. A negative correlation was observed between SF-36 items and the development of the severe form of burnout syndrome. Conclusion The prevalence of burnout syndrome and of the severe form of the disease was very high among residents in orthopedic surgery. The COVID-19 outbreak does not increase burnout in the residents.

Effectiveness of an Online Course on Fracture-Related Infections.

This study aims to evaluate the effectiveness of an online course to enable orthopaedic surgeons to acquire the core competencies necessary to prevent and treat fracture-related infections (FRI). This study included orthopaedic surgeons and residents from Latin American countries who attended an online course focused on FRI. The online course included: didactic lectures, small-group clinical case discussions, and panel case discussions. The course was delivered using Zoom® platform and designed to address four core competencies: prevention, definition and diagnosis, antimicrobial therapy, and surgical treatment. An online questionnaire was created distributing 16 questions through six clinical scenarios. Participants were invited to answer the questionnaire before and after the course. Sixty of the 78 course participants answered the pre-course, and 42 the post-course assessment. Relative to before the course, the mean post-course assessment score rose significantly for prevention of FRI (4.1 before and 4.5 after; p = 0.014), definition and diagnosis (2.4 before and 3.4 after; p = 0.001), and surgical treatment (2.2 before and 2.8 after; p = 0.011). The final score encompassing all four core competencies also rose significantly (2.7 before and 3.3 after; p = 0.001). The online course on FRI was feasible and effective, significantly increasing course users' knowledge of overall competency in managing FRI.

Impact of the COVID-19 Pandemic in the Prevalence of Burnout among Residents in Orthopedics / Impacto da pandemia COVID-19 na prevalência de burnout entre residentes em ortopedia

Abstract Objective The primary objective of the present study is to assess the impact of the COVID-19 pandemic on the prevalence of burnout syndrome among residents in orthopedic surgery. As a secondary objective, characteristics associated with the risk of developing the severe form of the syndrome were assessed. Method In the present cross-sectional study, graduating orthopedic residents were evaluated before and during the COVID-19 pandemic. Medical students formed a control group. The participants answered a sociodemographic questionnaire, the Maslach Burnout Inventory, and the Brazilian validated version of the 36-item short-form health survey questionnaire (SF-36). Fifty-two residents were appraised before the pandemic and 19 during the pandemic. Results Forty-four (84.6%) residents fulfilled the criteria for burnout syndrome, and the severe form of the syndrome was present in 16 (30.7%). There was no significant change in the evaluated scores after the beginning of the COVID-19 pandemic. There was also no increase in the prevalence of burnout syndrome or of the severe form of the syndrome. A negative correlation was observed between SF-36 items and the development of the severe form of burnout syndrome. Conclusion The prevalence of burnout syndrome and of the severe form of the disease was very high among residents in orthopedic surgery. The COVID-19 outbreak does not increase burnout in the residents.

Resumo Objetivo O objetivo principal do presente estudo é avaliar o impacto da pandemia de COVID-19 na prevalência da síndrome de burnout entre residentes de ortopedia Como objetivo secundário, foram avaliadas características associadas ao risco de desenvolver a forma grave da síndrome. MétodoNo presente estudo transversal, foram avaliados residentes antes e durante a pandemia de COVID-19. Estudantes de medicina formaram um grupo de controle. Os participantes responderam a um questionário sociodemográfico, ao Inventário Maslach Burnout, e à versão validada brasileira do Short Form Health Survey 36 (SF-36). Cinquenta e dois residentes foram avaliados antes da pandemia e 19 durante a pandemia. Resultados Quarenta e quatro (84,6%) residentes tinham critérios para síndrome de burnout, e a forma grave da síndrome estava presente em 16 (30,7%). Não houve alteração significativa nos escores avaliados após o início da pandemia de COVID-19. Também não houve aumento na prevalência da síndrome de burnout ou da forma grave da síndrome. Observou-se correlação negativa entre os itens SF-36 e o desenvolvimento da forma grave da síndrome de burnout. Conclusão A prevalência da síndrome de burnout e da forma grave da doença foi muito alta entre os residentes em cirurgia ortopédica. A pandemia de COVID-19 não aumentou o burnout nos residentes.

Quick-DASH as a main early outcome of humeral shaft fractures: A Latin American multicenter prospective study.

PURPOSE: The main objective of this study was to evaluate the Quick-Disabilities of the Arm, Shoulder and Hand Score (DASH) score as the main early (90 days) outcome in a prospective multicenter observational Latin American study on isolated humeral shaft fractures. METHODS: From December 2015 to April 2017, in six Latin American countries, patients 18 years or older with a closed, isolated nonpathological 12A, 12B, or 12C AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association) fractures were included. The 90 (±10)-day Quick-DASH score was used to compare the results of the different treatments. The secondary outcomes were patient treatment satisfaction, shoulder and elbow range of motion, and radiographic evaluation. RESULTS: A total of 92 patients successfully completed the Quick-DASH questionnaire. Surgical treatments resulted in better outcomes than nonsurgical treatment, but only minimally invasive plate osteosynthesis produced significantly lower Quick-DASH scores than nonsurgical treatment (p < 0.05). There were strong correlations between patient self-evaluation and the Quick-DASH score (p < 0.0005) but not between the Quick-DASH score and radiographic fracture healing. No significant difference was found between the treatments regarding the rate of return to work, but the medical center had a significant influence on treatment choice (p < 0.0005). CONCLUSION: The high correlation between Quick-DASH score and patient satisfaction and functional outcome indicates that the Quick-DASH questionnaire is a suitable tool for evaluating adult humeral shaft fracture outcomes. Patients with a Quick-DASH score below 15 could be considered recovered, and patients with a Quick-DASH score above 40 could be considered not yet recovered. Quick-DASH scores were not significantly associated with radiographic fracture healing.

Induced-Membrane Technique in the Management of Posttraumatic Bone Defects.

BACKGROUND: Critical-size bone defects are defined as bone defects where spontaneous regeneration is not expected without treatment1. The characteristics of bone defects (etiology, location, size, presence of infection, and soft-tissue conditions) vary greatly and, to be effective, the treatment method should address this variability. The induced-membrane technique, or Masquelet technique, is a method for treating critical-size bone defects2,3 of various sizes and anatomic locations. It has been used to treat infected and noninfected bone defects and may be performed with a variety of fixation methods2,3. DESCRIPTION: The induced-membrane technique is a 2-stage procedure. The first stage consists of debridement followed by insertion of a polymethylmethacrylate (PMMA) spacer in the bone defect. The presence of the PMMA leads to a foreign-body reaction with the development of a thick pseudosynovial membrane that is extremely vascularized and rich in growth factors. The filling of the bone defect with the cement spacer prevents fibrous tissue invasion and allows the development of an optimal vascularized gap for bone-grafting. After 6 to 8 weeks, the membrane around the spacer is carefully opened for the removal of the spacer, which is then replaced by bone graft2,3, which can be expanded with allograft or biomaterials. ALTERNATIVES: Alternatives include vascularized or nonvascularized autologous bone graft, allograft, bone transport methods, titanium cages, megaprostheses, shortening, and amputation. RATIONALE: Posttraumatic bone defects frequently are associated with soft-tissue injury and infection that impair the local vascularization and the healing potential. The highly vascularized induced membrane may play a role in restoring the local regenerative capacity. Numerous studies have demonstrated its successful use in the treatment of posttraumatic bone defects in the hand, forearm, humerus, femur, tibia, and foot. The induced-membrane technique is especially advantageous in the treatment of infected bone defects because the presence of the spacer helps in the treatment of the infection by reducing dead space, acting as a local antibiotic carrier, and promoting some degree of bone stability3-5.

Demographics and clinical features of humeral shaft fractures: The Latin American multicentre prospective study (HSF-LAMPS).

PURPOSE: To present transversal data (demographic and clinical) on isolated humeral shaft fractures (HSFs) in Latin American countries. METHODS: Patients were enrolled between December 2015 and April 2017 at 11 medical institutions from six Latin America countries. INCLUSION CRITERIA: Age ≥18 years and a closed, isolated 12A, 12B, or 12C fracture (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification). The patients' demographic, comorbidity, and other baseline data were recorded. The outcome measures included the basal results of the research and the associations among the demographic factors, fracture features, and type of treatment applied. RESULTS: A total of 123 patients were included. There was a preponderance of men (61.8%), whose mean age was significantly lower than that of the women (31.48 vs. 60.55). Overweight or obesity was present in 61.0% of women; 56.1% of patients were sedentary, 75.6% were nonsmokers, and 74.0% had no chronic disease. The type or treatment (operative/nonoperative) was not significantly associated with the patient's or fracture's characteristics. Falls and traffic accidents were the main causes of HSFs. Intramedullary nailing treatment was performed significantly more often in women, elderly patients, patients who did not participate in sports, and patients participating in only home activities. Minimally invasive plate osteosynthesis was performed significantly more frequently in men and in those who were self-employed. Open reduction internal fixation was performed significantly more often when the cause of the fracture was a traffic accident and when radial nerve palsy was present. CONCLUSION: The demographics and etiological differences observed in comparison to the current literature show the importance of regional studies for both preventive measures and educational guidance.

Computed Tomography vs Standard Radiograph in Preoperative Planning of Distal Radius Fractures with Articular Involvement.

INTRODUCTION: Distal radius fractures with articular involvement are more likely to require surgical management. Treatment decisions are based on parameters which are obtained from plain radiographs. This study aims to determine the differences between computed tomography and standard radiographs in the preoperative planning of distal radius fractures with articular involvement. This was performed by measuring the intraobserver and interobserver reliability between three systems used to interpret the main fracture characteristics and two treatment decisions. MATERIALS AND METHODS: Forty-three cases of distal radius fractures with articular involvement were included. Fracture displacement was measured using plain radiographic and computed tomography. Five orthopedic surgeons evaluate the images to determine the AO/OTA classification, the articular fragments, the biomechanical columns involved, and recommend a surgical approach and implant for fracture fixation. RESULTS: An articular step-off was identified in 13 cases (30%) with the standard radiographs and in 22 (51%) cases with the computed tomography (p = 0.00). Interobserver variation for preoperative planning was slight when evaluated using the standard radiographs. Computed tomography improves reliability for AO/OTA classification and articular fragments but not for the biomechanical columns. Intraobserver variation for preoperative planning was slight to moderate for AO/OTA classification and slight to fair for identification of articular fragments and biomechanical columns. With regard to selection of the surgical approach, there was slight to moderate variation and, finally, for fracture fixation it was slight to fair. CONCLUSION: Information provided by conventional radiography and computed tomography are sufficiently different as to induce the surgeon to select different treatments for the same fracture. HOW TO CITE THIS ARTICLE: Azi ML, Teixeira MB, de Carvalho SF, et al. Computed Tomography vs Standard Radiograph in Preoperative Planning of Distal Radius Fractures with Articular Involvement. Strategies Trauma Limb Reconstr 2019;14(1):15-19.

FACTORS ASSOCIATED WITH THE DEVELOPMENT OF EARLY INFECTION AFTER SURGICAL TREATMENT OF FRACTURES.

OBJECTIVE: Infection after the internal fixation of fractures is a major complication. Early infection is particularly challenging, because it occurs when the fracture is not yet united. The objective of this study is to identify possible factors related to the development of early infection in patients treated with internal fixation for fractures. METHOD: This retrospective observational study analyzed 24 patients with long bone fractures who underwent internal fixation and developed infections in the post-operatory period. The infections were classified as early (diagnosis in the first two weeks after surgery) or late (diagnosis after 2 weeks). RESULTS: Of the 24 patients studied, 11 (46%) developed early infections and 13 (54%) were diagnosed with late infections. The early infection group was significantly younger (37.8 versus 53.1 [p = 0.05]) and underwent more surgeries prior to internal fixation (1.2 versus 0.2 [p < 0.00]). CONCLUSION: Risk factors for the development of early infection in the postoperative period should be considered when treating patients with internal fracture fixation in order to diagnose this condition as early as possible. Level of Evidence IV; Case series.

OBJETIVO: A infecção após a fixação interna das fraturas é uma complicação grave, sendo a infecção precoce particularmente desafiadora, pois acontece quando a fratura ainda não está consolidada. O objetivo deste estudo é identificar fatores relacionados com o desenvolvimento de infecção precoce em pacientes submetidos à fixação interna de fraturas. MÉTODO: Estudo retrospectivo que envolveu 24 pacientes com fraturas de ossos longos submetidos à fixação interna, que evoluíram com infecção no pós-operatório. A infecção foi classificada como precoce (diagnóstico nas primeiras duas semanas após a fixação interna) e tardia (diagnóstico após 2 semanas da realização da fixação). RESULTADOS: Dos 24 pacientes estudados, 11 (46%) desenvolveram infecção precoce e 13 (54%) tiveram infecção tardia. Os pacientes portadores de infecção precoce eram mais jovens (37,8 anos versus 53,1 anos [p = 0,05]) e foram submetidos a um maior número de cirurgias antes da fixação interna (1,2 versus 0,2 [p < 0,00]). CONCLUSÃO: É recomendável levar em consideração os fatores de risco de desenvolvimento de infecção no pós-operatório em pacientes submetidos à fixação interna de fraturas visando realizar o diagnóstico o mais breve possível. Nível de Evidência IV; Série de casos.

Factors associated with the development of early infection after surgical treatment of fractures / Fatores associados ao desenvolvimento de infecção precoce após tratamento cirúrgico das fraturas

ABSTRACT Objective: Infection after the internal fixation of fractures is a major complication. Early infection is particularly challenging, because it occurs when the fracture is not yet united. The objective of this study is to identify possible factors related to the development of early infection in patients treated with internal fixation for fractures. Method: This retrospective observational study analyzed 24 patients with long bone fractures who underwent internal fixation and developed infections in the post-operatory period. The infections were classified as early (diagnosis in the first two weeks after surgery) or late (diagnosis after 2 weeks). Results: Of the 24 patients studied, 11 (46%) developed early infections and 13 (54%) were diagnosed with late infections. The early infection group was significantly younger (37.8 versus 53.1 [p = 0.05]) and underwent more surgeries prior to internal fixation (1.2 versus 0.2 [p < 0.00]). Conclusion: Risk factors for the development of early infection in the postoperative period should be considered when treating patients with internal fracture fixation in order to diagnose this condition as early as possible. Level of Evidence IV; Case series.

RESUMO Objetivo: A infecção após a fixação interna das fraturas é uma complicação grave, sendo a infecção precoce particularmente desafiadora, pois acontece quando a fratura ainda não está consolidada. O objetivo deste estudo é identificar fatores relacionados com o desenvolvimento de infecção precoce em pacientes submetidos à fixação interna de fraturas. Método: Estudo retrospectivo que envolveu 24 pacientes com fraturas de ossos longos submetidos à fixação interna, que evoluíram com infecção no pós-operatório. A infecção foi classificada como precoce (diagnóstico nas primeiras duas semanas após a fixação interna) e tardia (diagnóstico após 2 semanas da realização da fixação). Resultados: Dos 24 pacientes estudados, 11 (46%) desenvolveram infecção precoce e 13 (54%) tiveram infecção tardia. Os pacientes portadores de infecção precoce eram mais jovens (37,8 anos versus 53,1 anos [p = 0,05]) e foram submetidos a um maior número de cirurgias antes da fixação interna (1,2 versus 0,2 [p < 0,00]). Conclusão: É recomendável levar em consideração os fatores de risco de desenvolvimento de infecção no pós-operatório em pacientes submetidos à fixação interna de fraturas visando realizar o diagnóstico o mais breve possível. Nível de Evidência IV; Série de casos.

Effectiveness of lidocaine patches for pain treatment after total knee arthroplasty / Eficácia do tratamento adjuvante da dor pós-artroplastia total do joelho utilizando emplastros com lidocaína

BACKGROUND: Effective analgesic therapy in the postoperative period of total knee arthroplasty is essential for good surgical outcomes. The current trend is to use multimodal treatment, in which the use of patches with lidocaine as adjuvant therapy has an increasingly relevant role. OBJECTIVE: To investigate the potential benefits of lidocaine patch association with the basic analgesia regimen for pain relief during the postoperative period of total knee arthroplasty. METHOD: A retrospective cohort study was performed , with a total of 24 patients in each group, who underwent total knee arthroplasty. Pain levels using a visual analogue scale and opioid intake were controlled from the immediate postoperative to the end of a 28-day interval. RESULTS: During the postoperative period, pain was less intense in patients who used lidocaine patches. In these same patients, the doses of opioids needed to control pain were lower in 15 of the 28 days analyzed. The relative frequency of nausea was higher in the group that did not use adjuvant therapy. Patients older than 70 years and females predominated. CONCLUSION: Adjuvant treatment after total knee arthroplasty using lidocaine patches was effective in reducing pain and decreasing the use of opioids in the period analyzed, and represents a good addition to multimodal analgesic therapy.

OBJETIVO: A terapia analgésica eficaz no pós-operatório de artroplastia total do joelho é imprescindível para bons resultados cirúrgicos. A tendência atual é a de se utilizar o tratamento multimodal, no qual a utilização de emplastros com lidocaína como terapia adjuvante tem papel crescente e relevante. Investigar os potenciais benefícios da associação do emplastro com lidocaína ao esquema terapêutico básico de analgesia para o alívio da dor durante o período pós-operatório de artroplastia total de joelho. MÉTODO: Foi realizado um estudo de coorte retrospectivo cuja população foi a de pacientes submetidos a artroplastia total do joelho, divididos em dois grupos com 24 integrantes em cada, acompanhados por um período de 28 dias. RESULTADOS: Durante o pós-operatório analisado a dor foi menos intensa nos pacientes que utilizaram os emplastros com lidocaína. Nesses mesmos pacientes, as doses de opióides necessárias para controlar a dor foram menores em 15 dos 28 dias analisados. A frequência relativa de náuseas foi maior no grupo que não utilizou a terapia adjuvante. Predominaram os pacientes com mais de 70 anos e o gênero feminino. CONCLUSÃO: O tratamento adjuvante após a artroplastia total do joelho utilizando emplastros com lidocaína mostrou ser eficaz na redução da dor e diminuição do uso de opióides no período analisado, constituindo um bom incremento para a terapia analgésica multimodal.

Reliability of the radiographic union scale in tibial fractures (RUST).

OBJECTIVE: This study aimed to evaluate the inter- and intra observer reproducibility of the radiographic score of consolidation of the tibia shaft fractures. METHODS: Fifty-one sets of radiographs in anteroposterior (AP) and profile (P) of the tibial shaft treated with intramedullary nail were obtained. The analysis of X-rays was performed in two stages, with a 21-day interval between assessments by a group of nine evaluators. To evaluate the reproducibility of RUST score between the evaluators, the intra-class correlation coefficient (ICC) with a 95% confidence interval was used. ICC values range from +1, representing perfect agreement, to -1, complete disagreement. RESULTS: There was a significant correlation among all evaluators: ICC = 0.87 (95% CI 0.81 to 0.91). The intraobserver agreement proved to be substantial with ICC = 0.88 (95% CI 0.85 to 0.91). CONCLUSION: This study confirms that the RUST scale shows a high degree of reliability and agreement.

OBJETIVO: Avaliar a reprodutibilidade inter e intraobservador do escore radiográfico de consolidação das fraturas (RUST) da diáfise da tíbia. MÉTODOS: Foram obtidos 51 conjuntos de radiografias nas incidências anteroposterior (AP) e perfil (P) da diáfise da tíbia tratadas com haste intramedular. A análise das radiografias foi feita em dois momentos, com intervalo de 21 dias entre as avaliações, por nove avaliadores. Para avaliar a reprodutibilidade do escore RUST entre os avaliadores foi usado o coeficiente de correlação intraclasse (CCI) com intervalo de confiança de 95%. O valor do CCI varia de +1, que representa concordância perfeita, a −1, que corresponde a total discordância. RESULTADOS: Houve uma concordância significativa entre todos os avaliadores: CCI = 0,87 (IC 95% 0,81 a 0,91). A concordância intraobservador mostrou-se substancial, com CCI = 0,88 (IC 95% 0,85 a 0,91). CONCLUSÃO: Este trabalho confirma que a escala RUST apresenta um elevado grau de confiabilidade e concordância.

Reliability of the radiographic union scale in tibial fractures (RUST) / Reprodutibilidade do escore radiográfico de consolidação das fraturas da tíbia (RUST)

ABSTRACT OBJECTIVE: This study aimed to evaluate the inter- and intra observer reproducibility of the radiographic score of consolidation of the tibia shaft fractures. METHODS: Fifty-one sets of radiographs in anteroposterior (AP) and profile (P) of the tibial shaft treated with intramedullary nail were obtained. The analysis of X-rays was performed in two stages, with a 21-day interval between assessments by a group of nine evaluators. To evaluate the reproducibility of RUST score between the evaluators, the intra-class correlation coefficient (ICC) with a 95% confidence interval was used. ICC values range from +1, representing perfect agreement, to -1, complete disagreement. RESULTS: There was a significant correlation among all evaluators: ICC = 0.87 (95% CI 0.81 to 0.91). The intraobserver agreement proved to be substantial with ICC = 0.88 (95% CI 0.85 to 0.91) . CONCLUSION: This study confirms that the RUST scale shows a high degree of reliability and agreement.

RESUMO OBJETIVO: Avaliar a reprodutibilidade inter e intraobservador do escore radiográfico de consolidação das fraturas (RUST) da diáfise da tíbia. MÉTODOS: Foram obtidos 51 conjuntos de radiografias nas incidências anteroposterior (AP) e perfil (P) da diáfise da tíbia tratadas com haste intramedular. A análise das radiografias foi feita em dois momentos, com intervalo de 21 dias entre as avaliações, por nove avaliadores. Para avaliar a reprodutibilidade do escore RUST entre os avaliadores foi usado o coeficiente de correlação intraclasse (CCI) com intervalo de confiança de 95%. O valor do CCI varia de +1, que representa concordância perfeita, a -1, que corresponde a total discordância. RESULTADOS: Houve uma concordância significativa entre todos os avaliadores: CCI = 0,87 (IC 95% 0,81 a 0,91). A concordância intraobservador mostrou-se substancial, com CCI = 0,88 (IC 95% 0,85 a 0,91) . CONCLUSÃO: Este trabalho confirma que a escala RUST apresenta um elevado grau de confiabilidade e concordância.

Autologous bone graft in the treatment of post-traumatic bone defects: a systematic review and meta-analysis.

BACKGROUND: This meta-analysis aimed to determine the bone union rate of bone defects treated with the different autologous bone graft techniques. METHODS: The PubMed and the Cochrane Library databases were searched using the terms: 'fracture' AND ('bone loss' OR 'defect' OR 'defects') AND 'bone graft', restricted to English language, to human species, and to a publication period from January 1999 to November 2014. Data were extracted by one of the reviewers and then checked by the second. A quality of evidence score and a methodology score were used. Heterogeneity was assessed. A random effects model approach was used to combine estimates. RESULTS: Out of 376 selected studies only 34 met the inclusion criteria. The summary pooled union rate was 91 % (95 % CI: 87-95 %) while union rate after additional procedures raised to 98 % (95 % CI 96-99 %). No association between union rate and bone defect size was found. (Univariable regression model: vascularized: P = 0.677; non-vascularized: 0.202. Multivariable regression model: vascularized: P = 0.381; non-vascularized: P = 0.226). Vascularized graft was associated with a lower risk of infection after surgery when compared to non-vascularized graft (95 % CI 0.03 to 0.23, p < 0.001). CONCLUSION: The results of this meta-analysis demonstrate the effectiveness of autologous graft for bone defects. Furthermore, from the available clinical evidence bone defect size does not seem to have an impact on bone union when treated with autologous bone graft techniques.

Membrane Induced Osteogenesis in the Management of Posttraumatic Bone Defects.

OBJECTIVE: To evaluate the union rate of posttraumatic bone defects treated with the induced membrane technique. DESIGN: Single-center retrospective case series. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Thirty-three patients who sustained 34 posttraumatic bone defects (19 tibia, 15 femur). INTERVENTION: Staged management using the induced membrane technique described by Masquelet. After extensive debridement at the fracture site, a polymethylmethacrylate (PMMA) spacer was inserted into the resulting void. After soft tissue recovery, the spacer was removed, and the void, now enveloped by an induced membrane, was filled with an autologous iliac crest bone graft. MAIN OUTCOME MEASURES: Bone union rate, time to achieve bone union, length of hospital stay, number of surgeries, infection resolution, range of motion, musculoskeletal tumor society system functional score, and limb shortening. RESULTS: The mean defect size was 6.7 cm, and infection was present in 23 (68%) of the bone defects. Bone union was evident in 91% of cases (31/34). The average time to union was 8.5 months. In 7 of 23 (30%) of infected cases, the infection recurred, and in 3 of them, the graft was resorbed, resulting in treatment failure. CONCLUSION: The induced membrane technique was effective for managing posttraumatic bone defects. A recurrence of infection was associated with treatment failure. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Development of an experimental model of infected bone void in the ulna of rabbits.

OBJECTIVE: Develop a model that allowed the study of bone regeneration in infection conditions. METHOD: A 15 mm defect was surgically created in the rabbit ulna and inoculated with 5x10(8) colony-forming units (CFU) of S. aureus. Surgical debridement was performed two weeks after and systemic gentamicin was administered for four weeks. Animals were followed up to 12 weeks to evaluate infection control and bone regeneration. RESULT: Bone regeneration was inferior to 25% of the defect in radiological and histological analysis. CONCLUSION: Infected bone defect of 15 mm in the rabbit ulna was unable to achieve full regeneration without further treatment. Level of Evidence V, Experimental Study.

Desenvolvimento de um modelo experimental de falha óssea infectada na ulna de coelhos / Development of an experimental model of infected bone void in the ulna of rabbits

OBJETIVO: Desenvolver um modelo experimental que permita estudar a regeneração de grandes falhas ósseas em condições de infecção. MÉTODO: Falhas ósseas segmentares de 15mm foram criadas cirurgicamente na ulna de 12 coelhos e inoculadas com 5x10(8) unidades formadoras de colônia (UFC) de S. aureus. O desbridamento da infecção foi realizado duas semanas após, seguida da aplicação sistêmica de gentamicina por quatro semanas. Os animais foram acompanhados por um período de 12 semanas para avaliação do controle da infecção e da regeneração óssea. RESULTADOS: A regeneração espontânea foi inferior a 25% do defeito na avaliação radiográfica e histológica. CONCLUSÃO: A Falha óssea infectada de 15mm na ulna de coelhos é incapaz de alcançar a regeneração completa sem tratamentos adicionais. Nível de Evidência V, Estudo experimental.

OBJECTIVE: Develop a model that allowed the study of bone regeneration in infection conditions. METHOD: A 15 mm defect was surgically created in the rabbit ulna and inoculated with 5x10(8) colony-forming units (CFU) of S. aureus. Surgical debridement was performed two weeks after and systemic gentamicin was administered for four weeks. Animals were followed up to 12 weeks to evaluate infection control and bone regeneration. RESULT: Bone regeneration was inferior to 25% of the defect in radiological and histological analysis. CONCLUSION: Infected bone defect of 15 mm in the rabbit ulna was unable to achieve full regeneration without further treatment. Level of Evidence V, Experimental Study.

Cimento ósseo com gentamicina no tratamento da infecção óssea: Estudo da eluição in vitro / Bone cement and gentamIcin in the treatment of bone infection: Background and in vitro study

OBJETIVO: Determinar as características de eluição da gentamicina. MÉTODO: 480mg de gentamicina foram adicionadas a 40g de cimento ósseo. Dez corpos de teste semelhantes foram produzidos e imersos individualmente em solução salina tamponada por 28 dias. Amostras dos dias 1, 2, 7, 14, 21 e 28 foram analisadas pelo método de imunofluorescência polarizada. RESULTADO: A maior parte da gentamicina foi liberada do cimento nas primeiras 24 horas. Uma queda gradual se deu do 2º ao 14º dia. No 28º dia, a maior parte das amostras não apresentava mais níveis detectáveis do antibiótico. CONCLUSÃO: A mistura liberou quantidades elevadas e em doses terapêuticas do antibiótico de forma previsível ate o décimo quarto dia.

OBJECTIVE: To determine the elution characteristics of the antibiotic (gentamicin) mixed with bone cement. METHODS: 480mg of gentamicin was added to 40g of bone cement. Ten specimens were immersed in buffered saline solution for 28 days. Samples of days 1, 2, 7, 14, 21 and 28 were analyzed by the fluorescence polarization immunoassay method. RESULTS: Most of the gentamicin was eluted from the cement in the first 24 hours. A gradual downslide occurred between days 2 and 14. By the 28th day, there was no trace of the antibiotic. CONCLUSION: The mixture released high amounts of the antibiotic in a predictable (therapeutic) manner during at least fourteen days.