Correlation between psychological status, revised Müller AO classification and patient-reported outcomes: a prospective cohort analysis.

INTRODUCTION: The impact of psychological status on clinical outcomes is valued in several medical conditions, but rare attention is given to it in orthopedic trauma. We aimed to assess the correlation between psychological status, fracture severity and patient-reported outcomes in fractured patients needing urgency surgical treatment. MATERIALS AND METHODS: We prospectively followed 139 consecutive patients undergoing urgency surgical treatment of a lower/upper limb fracture. Before surgery, all patients were divided into grades of fracture severity according to the Revised AO Müller Classification (AO grades). On the 15th and the 120th days after surgery, all patients underwent a psychological status assessment through the Hospital Anxiety and Depression Score (HADS), in addition to a pain evaluation through VAS. One year after surgery, patient-reported outcomes were obtained by using specific scales depending on the site of fracture. RESULTS: AO grades and VAS scores were significantly correlated to scores at HADS-A (anxiety component) and HADS-D (depression component), both on the 15th and the 120th. Patients presenting persistent HADS-A and HADS-D scores equal or greater than 8 points had a risk of more than 2.5 or 2.0 times of experiencing unsatisfactory surgical outcomes, respectively [HADS-A: RR = 2.8 (95% CI: 2.2-3.5)] [HADS-D: RR = 2.2 (95% CI: 1.7-3.1)]. AO grade C and the persistency of significant symptoms of anxiety or depression were independent predictors of unsatisfactory patient-reported outcomes (OR: 1.7, p = 0.03 // OR: 2.9, p < 0.01). Female gender, age, and BMI did not present any statistically significant utility in predicting unsatisfactory patient-reported outcomes. CONCLUSION: In fractured patients needing urgency surgical treatment, the risk of presenting unsatisfactory outcomes is more than twice as high in patients that present significant persistent changes in psychological status. Changes in psychological status are more frequent in patients presenting more severe pain and more severe fractures. AO grades and HADS scores are independent predictors of unsatisfactory outcomes in these patients.

Clamshell Osteotomy for Acute Fractures in the Malunion Setting: A Technical Note.

Surgical management of lower extremity malunions and acute fractures in the setting of lower extremity deformities presents a unique challenge for orthopaedic surgeons. The objective of this study was to evaluate the outcomes of using the clamshell osteotomy in patients with acute fractures involving a malunion or deformity. A retrospective review of the cases performed by various orthopaedic traumatologists at 4 different trauma centers was performed to identify cases using the clamshell osteotomy from January 2012 to January 2016. Nine clamshell osteotomy cases were identified, 4 presenting fractures in the setting of previous malunions. All osteotomies healed within 15 months (average 6.8 ± 4.4 SD). In this multicenter case series, we demonstrate that using clamshell osteotomies can result in excellent outcomes for permitting intramedullary nailing of acute fractures in patients with lower extremity deformity.

CLINICAL AND ANATOMICAL COMPARISON OF THE FIBULAR NERVE IN GERDY's SAFE ZONE.

OBJECTIVE: To clinically and anatomically compare the limits of the fibular nerve in Gerdy's safe zone in cadavers. METHODS: Fifty anatomical knee specimens were clinically measured (before dissection) to determine the distances and angles between Gerdy's tubercle and the posterior region of the fibula (cm); the angle between the line corresponding to the posterior region of the fibula and the tibial crest (degrees); and the angle between Gerdy's tubercle and the tibial crest (degrees). After dissection of the anatomical specimens, the knees were measured again, to determine the distances and angles between Gerdy's tubercle and the fibular nerve (cm); the angle between the fibular nerve, in the posterior region of the fibula, and the tibial crest (degrees); and the angle between Gerdy's tubercle and the tibial crest (degrees). RESULTS: There was a significant increase in the distance between Gerdy's tubercle and the posterior region of fibula (cm), after dissection: an average of 0.26 cm (p = 0.018), corresponding to 8.6% (p = 0.007). There was also a significant reduction in the angle between the posterior region of the fibula and the tibial crest after dissection: an average of 3° (p = 0.047), corresponding to 2.1% (p = 0.06). CONCLUSION: Despite the difference from before to after dissection, Gerdy's safe zone can be considered safe for orthopedic procedures involving the proximal region of the tibia, thereby avoiding damage to the fibular nerve and its branches.

Comparação clínica e anatômica do nervo fibular na zona de segurança de Gerdy / Clinical and anatomical comparison of the fibular nerve in the Gerdy safe zone

OBJETIVO: Comparar clínica e anatomicamente os limites do nervo fibular na zona de segurança de Gerdy em cadáveres. MÉTODOS: Foram utilizados 50 espécimes anatômicos de joelhos e medidos clinicamente (antes de dissecção) para determinar as distâncias e ângulos entre: o tubérculo de Gerdy e a região posterior da fíbula (cm), ângulo entre a linha correspondente à região posterior da fíbula e a crista tibial (graus) e o ângulo entre o tubérculo de Gerdy e crista tibial (graus). Após a dissecção das peças anatômicas, os joelhos foram novamente medidos, para determinar as distâncias e ângulos entre: o tubérculo de Gerdy e o nervo fibular (cm), ângulo entre o nervo fibular, na região posterior da fíbula e a crista tibial (graus) e o ângulo entre o tubérculo de Gerdy e crista tibial (graus). RESULTADOS: Existe aumento significativo da distância entre o tubérculo de Gerdy e a região posterior da fíbula (cm), após dissecção, em média 0,26cm (p = 0,018), o que corresponde a 8,6 por cento (p = 0,007) e também existe diminuição significativa do ângulo entre a região posterior da fíbula e a crista tibial após dissecção, em média de 3º (p = 0,047), que corresponde a 2,1 por cento (p = 0,06). CONCLUSÃO: Apesar da diferença antes e depois da dissecção, a zona de segurança de Gerdy pode ser considerada segura para os procedimentos ortopédicos, na região proximal da tíbia, evitando danos ao nervo fibular e seus ramos.

OBJECTIVE: to clinically and anatomically compare the limits of the fibular nerve in Gerdy's Safe Zone in cadavers. METHODS: Fifty anatomical knee specimens were clinically measured (before dissection) to determine the distances and angles between: Gerdy's tubercle and the posterior region of fibula (cm); the angle between the line corresponding to the posterior region of fibula and the tibia crest (degrees); and the angle between Gerdy's tubercle and tibial crest (degrees). After dissection of the anatomical parts, the knees were measured again, to determine the distances and angles between: Gerdy's tubercle and the fibular nerve (cm), the angle between the fibular nerve, in the posterior region of the fibula, and the tibial crest (degrees), and the angle between Gerdy's tubercle and the tibial crest (degrees). RESULTS: There was a significant increase in the distance between Gerdy's tubercle and the posterior region of fibula (cm), after dissection, of an average 0.26 cm (p = 0.018), corresponding to 8.6 percent (p = 0.007). There was also a significant reduction in the angle between the posterior region of fibula and the tibial crest after dissection, of an average 3º (p = 0.047), corresponding to 2.1 percent (p = 0.06). CONCLUSION: Despite the difference before and after dissection, Gerdy's Safety Zone can be considered safe for orthopedic procedures involving the proximal region of the tibia, preventing damage to the fibular nerve and its branches.

ENTRY POINT FOR THE ANTEGRADE FEMORAL INTRAMEDULLARY NAIL: A CADAVER STUDY.

OBJECTIVE: To analyze the natural exit of the wire guides in major trochanter through retrograde femoral approach, in cadaver specimens. MATERIAL AND METHOD: 100 femurs had been perforated between the femoral condyles, at 1.2 cm of the intercondylar region. A 3-mm straight wire guide was introduced, through retrograde approach, until the proximal extremity of femur was reached. Femurs were assessed for posterosuperior and anterosuperior portions of major trochanter, pear-shaped cavity, and upper median line between the head-neck and the major trochanter. RESULTS: in 62%, the straight wire guides exited at the anterior surface of major trochanter. In the pear-shaped cavity, the median distance found was 1.0 cm and the interquartile range was 0.5 cm, initially expressing, in relation to pear-shaped cavity, better accuracy. CONCLUSION: the central axis of the medullar canal, at coronal plane, projected better accuracy in the region of the pear-shaped cavity.

Ponto de entrada para as hastes intramedulares anterógradas do fêmur: estudo em cadáver / Entry point for the anterograde femur intramedullary nail: a cadaver study

OBJETIVO: Analisar a saída natural do fio-guia no trocânter maior pela via retrógrada do fêmur, em espécimes de cadáver. Métodos: 100 fêmures foram perfurados entre os côndilos femorais, a 1,2cm da região intercondilar. Um fio-guia reto de 3mm foi introduzido, de forma retrógrada, até alcançar a extremidade proximal do fêmur. Foram avaliados em relação à região posterossuperior e anterossuperior do trocânter maior, fossa piriforme e linha mediana superior entre a cabeça-colo e trocânter maior. RESULTADOS: Em 62 por cento o fio-guia reto saiu na face anterior do trocânter maior. Na fossa piriforme, a distância mediana observada foi de 1,0cm e a amplitude interquartílica, de 0,5cm, expressando inicialmente, em relação à fossa piriforme, melhor precisão. CONCLUSÃO: O eixo central do canal medular, na incidência coronal, projetou melhor precisão na região da fossa piriforme.

OBJECTIVE: To analyze the natural exit of the wire guides in major trochanter through retrograde femoral approach, in cadaver specimens. Material and Method: 100 femurs had been perforated between the femoral condyles, at 1.2 cm of the intercondylar region. A 3-mm straight wire guide was introduced, through retrograde approach, until the proximal extremity of femur was reached. Femurs were assessed for posterosuperior and anterosuperior portions of major trochanter, pear-shaped cavity, and upper median line between the head-neck and the major trochanter. RESULTS: in 62 percent, the straight wire guides exited at the anterior surface of major trochanter. In the pear-shaped cavity, the median distance found was 1.0 cm and the interquartile range was 0.5 cm, initially expressing, in relation to pear-shaped cavity, better accuracy. CONCLUSION: the central axis of the medullar canal, at coronal plane, projected better accuracy in the region of the pear-shaped cavity.