The Hip of Children with Congenital Zika Syndrome: A Prospective Observational Study.

OBJECTIVE: To assess the clinical and radiographic characteristics of hip joint deformities in children with congenital Zika syndrome (CZS), and the evolution of hip joint deformities in affected infants for the first 3 years of life. STUDY DESIGN: This prospective observational study evaluated orthopedic clinical examinations performed every 3 months to assess hip flexion and extension, lateral and medial rotation, and abduction and adduction, as well as lower limb muscle length and tone. The biannual radiograph comprised anteroposterior panoramic pelvic radiographs with the lower limbs in extension. Percentage of migration was used as a radiographic study tool to measure and evaluate linear hip displacement. RESULTS: From November 2018 to March 2020, we followed 30 children with CZS, of whom 15 (50%) had normal pelvic radiographs on admission; 5 (33.3%) developed hip displacement by the second radiograph examination. During follow-up radiographic examinations, 20 of the 30 children (66.7%) were diagnosed with hip displacement and/or dislocation of at least 1 side, and 10 of the 30 (33.3%) remained normal. Among 30 affected patients, 13 (43.3%) had hip displacement on the right side and 9 (30%) on the left side. Logistic regression analysis revealed that spasticity (P = .0033; OR, 15.9) and ophthalmologic abnormalities (P = .0163; OR, 16.9) were associated with hip dislocation during follow-up. CONCLUSIONS: Pelvic radiographic follow-up for all children with CZS will complement physical examination, diagnosis, and monitoring for hip joint deformities.

STUDY BETWEEN SEMI-CONSTRAINED TOTAL KNEE ARTHROPLASTY WITH OR WITHOUT INTRAMEDULLARY STEM.

Objective: This research sought to carry out a comparative study observing the clinical and radiographic analysis of primary prostheses of the type TC3 Depuy Johnson® with or without a stem during a short-term follow-up. Methods: The sample was divided into three groups: Group 1 (with stem), Group 2 (without stem) and Group 3 (mixed). Patients were evaluated to assess whether the implants were loosening and a clinical analysis was performed. Results: Preoperative deformities were predominantly considered severe. The total range of motion in the postoperative period was above 96.7° in the three groups. In the postoperative period, the femoral-tibial angle oscillated on average between 5 to 6° valgus. There was no record of implant loosening for cases treated with stem, and the incidence of loosening was 14.3% for the group without stem and 16.7% among cases in the mixed group. Conclusion: In general, preoperative deformities were considered severe. In the postoperative period, the total range of motion was above 96.7°. The postoperative femoral-tibial angle obtained an average of 5 to 6° valgus. There is no significant difference in implants loosening in the three groups. Level of Evidence III, Retrospective Comparative Study.

Objetivo: Realizar um estudo comparativo observando a análise clínica e radiográfica das próteses primárias do tipo TC3 Johnson ® com ou sem haste durante um seguimento de curto prazo. Métodos: A amostra foi dividida em três grupos: Grupo 1 com haste, Grupo 2 sem haste e Grupo 3 misto. Foi realizada a análise clínica dos pacientes e verificado se ocorreu soltura dos implantes. Resultados: As deformidades pré-operatórias foram predominantemente graves. O arco de movimento total no pós-operatório foi acima de 96,7° nos três grupos. No pós-operatório o ângulo tíbio-femoral oscilou na média entre 5 e 6° de valgo. Não houve registro de soltura do implante para os casos tratados com haste; a incidência de soltura foi de 14,3% entre os casos do grupo sem haste e de 16,7% entre os casos do grupo misto. Conclusão: Em geral, as deformidades pré-operatórias foram consideradas graves. No pós-operatório a amplitude total do arco de movimento foi acima de 96,7°. O ângulo tíbio-femoral pós-operatório obteve uma média entre 5 e 6° de valgo. Não há diferença significativa na soltura dos implantes nos três grupos. Nível de Evidência III, Estudo Retrospectivo Comparativo.

Study between semi-constrained total knee arthroplasty with or without intramedullary stem / Estudo entre artroplastia total do joelho semi-constrita com ou sem haste intramedular

ABSTRACT Objective: This research sought to carry out a comparative study observing the clinical and radiographic analysis of primary prostheses of the type TC3 Depuy Johnson® with or without a stem during a short-term follow-up. Methods: The sample was divided into three groups: Group 1 (with stem), Group 2 (without stem) and Group 3 (mixed). Patients were evaluated to assess whether the implants were loosening and a clinical analysis was performed. Results: Preoperative deformities were predominantly considered severe. The total range of motion in the postoperative period was above 96.7° in the three groups. In the postoperative period, the femoral-tibial angle oscillated on average between 5 to 6° valgus. There was no record of implant loosening for cases treated with stem, and the incidence of loosening was 14.3% for the group without stem and 16.7% among cases in the mixed group. Conclusion: In general, preoperative deformities were considered severe. In the postoperative period, the total range of motion was above 96.7°. The postoperative femoral-tibial angle obtained an average of 5 to 6° valgus. There is no significant difference in implants loosening in the three groups. Level of Evidence III, Retrospective Comparative Study.

RESUMO Objetivo: Realizar um estudo comparativo observando a análise clínica e radiográfica das próteses primárias do tipo TC3 Johnson ® com ou sem haste durante um seguimento de curto prazo. Métodos: A amostra foi dividida em três grupos: Grupo 1 com haste, Grupo 2 sem haste e Grupo 3 misto. Foi realizada a análise clínica dos pacientes e verificado se ocorreu soltura dos implantes. Resultados: As deformidades pré-operatórias foram predominantemente graves. O arco de movimento total no pós-operatório foi acima de 96,7° nos três grupos. No pós-operatório o ângulo tíbio-femoral oscilou na média entre 5 e 6° de valgo. Não houve registro de soltura do implante para os casos tratados com haste; a incidência de soltura foi de 14,3% entre os casos do grupo sem haste e de 16,7% entre os casos do grupo misto. Conclusão: Em geral, as deformidades pré-operatórias foram consideradas graves. No pós-operatório a amplitude total do arco de movimento foi acima de 96,7°. O ângulo tíbio-femoral pós-operatório obteve uma média entre 5 e 6° de valgo. Não há diferença significativa na soltura dos implantes nos três grupos. Nível de Evidência III, Estudo Retrospectivo Comparativo.

Osteosphere Model to Evaluate Cell-Surface Interactions of Implantable Biomaterials.

Successful biomaterials for bone tissue therapy must present different biocompatible properties, such as the ability to stimulate the migration and proliferation of osteogenic cells on the implantable surface, to increase attachment and avoid the risks of implant movement after surgery. The present work investigates the applicability of a three-dimensional (3D) model of bone cells (osteospheres) in the evaluation of osteoconductive properties of different implant surfaces. Three different titanium surface treatments were tested: machined (MA), sandblasting and acid etching (BE), and Hydroxyapatite coating by plasma spray (PSHA). The surfaces were characterized by Scanning Electron Microscopy (SEM) and atomic force microscopy (AFM), confirming that they present very distinct roughness. After seeding the osteospheres, cell-surface interactions were studied in relation to cell proliferation, migration, and spreading. The results show that BE surfaces present higher densities of cells, leaving the aggregates towards than titanium surfaces, providing more evidence of migration. The PSHA surface presented the lowest performance in all analyses. The results indicate that the 3D model allows the focal analysis of an in vitro cell/surfaces interaction of cells and surfaces. Moreover, by demonstrating the agreement with the clinical data observed in the literature, they suggest a potential use as a predictive preclinical tool for investigating osteoconductive properties of novel biomaterials for bone therapy.

Anterior minimally invasive plating osteosynthesis technique (MIPO) for humeral shaft fractures: an anatomical study of neuromuscular structures at risk.

OBJECTIVE: The aim of this study was to evaluate the neuromuscular structures at risk during modified anterior minimally invasive plating osteosynthesis technique (Belangero-Livani) for humeral shaft fractures. METHODS: Eight fresh-frozen human specimens ranging from 38 to 82 years old were used. Specimens were positioned supine with the shoulder in 70° abduction and the forearm in full supination. Anterior minimally invasive plating osteosynthesis technique according to Belangero-Livani technique was performed in each specimen. Under radioscopic control, the plate was introduced in retrograde fashion through the subbrachialis path. Anatomical structures were inspected and different anatomical parameters were measured after dissection at the end of the surgical procedures. Measurements were performed using a high digital caliper. Statistical analysis was performed using the Pearson's correlation coefficient test. A p value of < 0.05 was used to define statistical significance. RESULTS: There were no macroscopic lesions of myotendinous or neurovascular structures in any specimen. The mean distance between the radial nerve to the distal lateral end of the plate was 8.63 mm (range 4.14-13.83 mm). The mean total length of the humerus was 328.59 mm. We found a significant direct correlation between the total length of the humerus and both specimen height and weight. CONCLUSION: The modified Belangero-Livani anterior MIPO technique for humeral shaft fractures performed in retrograde fashion is safe and useful, without major risk to the soft tissue of the anterior compartment of the arm, including the radial nerve in the lateral intermuscular septum. Intraoperative dissection, avoiding deep lateral retraction on the distal approach, minimizes the risk of radial nerve damage. Strict surgical planning and appreciation for the anatomic landmarks can reduce the risk of damage to neuromuscular structures. LEVEL OF EVIDENCE: Level IV; Case series with no comparison group; Treatment study.

The cortical matrix of femur in adult-aged Wistar rats is critically affected by maternal malnutrition during lactation period / La matriz cortical del fémur en ratas Wistar de edad adulta se ve críticamente afectada por la malnutrición materna durante el período de lactancia

Osteoporosis is associated with poor dietary habits. Malnutrition is characterized as a deficit on the intake of necessary nutrients that are essential for optimal health maintenance. It is known that malnutrition during the lactation period can affect the offspring. The present study aims to evaluate the chronic effects caused by maternal energy-protein restriction during lactation period in the offspring. At parturition, Wistar rat dams were divided in three groups: (1) Control group (C) - which received a 23 % protein diet without restrictions; (2) Protein-Energy restriction group (PER)- which received a 8 % protein diet; (3) Energy restriction group (ER) which received a 23 % protein diet in limited amounts, according to the ingestion of the second group. Each group had 12 pups. After weaning, all pups received free access to a 23 % protein diet until 180 days and then were euthanized. Their femur was excised, decalcified, histologically processed and analyzed under a microscope. The measurements of the osteon lacunae on the C, ER and PER groups were, respectively: 2.1 µm, 10.9 µm and 14.7 µm (p<0.05). A poor ingestion of proteins and calories during lactation period provoked critical and permanent changes on the bone matrix of the femur, which simulated osteoporosis.

La osteoporosis se asocia con malos hábitos alimenticios. La desnutrición se caracteriza como un déficit en la ingesta de los nutrientes necesarios que son esenciales para un mantenimiento óptimo de la salud. Se sabe que la malnutrición durante el período de lactancia puede afectar a la descendencia. El presente estudio tiene como objetivo evaluar los efectos crónicos causados por la restricción energética-proteína materna durante el período de lactancia en la descendencia. En el parto, las hijas de rata Wistar se dividieron en tres grupos: (1) grupo control (C) - que recibió una dieta con 23 % de proteína sin restricciones; (2) Grupo restricción de energía de proteína (PER) - que recibió una dieta con 8 % de proteína; (3) Grupo restricción de energía (ER) - que recibió una dieta de 23 % de proteína en cantidades limitadas, de acuerdo con la ingestión del segundo grupo. Cada grupo tenía 12 crías. Después del destete, todas las crías recibieron acceso libre a una dieta con 23 % de proteína hasta 180 días y luego fueron sacrificadas. Su fémur fue extirpado, descalcificado, procesado histológicamente y analizado bajo un microscopio. Las mediciones de las lagunas de osteón en los grupos C, ER y PER fueron, respectivamente: 2,1 mm, 10,9 mm y 14,7 mm (p <0,05). Una mala ingesta de proteínas y calorías durante el período de lactancia provocó cambios críticos y permanentes en la matriz ósea del fémur, que simulaba osteoporosis.

Pre-operative templating for knee arthroplasty shows low accuracy with standard X-rays.

OBJECTIVES: The purpose of this study was to evaluate the accuracy and reliability of pre-operative templating in predicting the size of femoral and tibial components and the effect of coronal deformity on templating accuracy. METHODS: This was a retrospective study of 39 pre-operative templates prepared by three different surgeons with different levels of training. The accuracy and reliability measures were evaluated by alpha and kappa coefficients of agreement. The analysis of the effect of coronal deformity on the accuracy of the template was measured by the Spearman's correlation test. RESULTS: Templating was accurate for the femoral component in 28.21% of anterposterior (AP) radiographs and 35.90% of lateral radiographs. Kappa coefficients were respectively 0.111 (95% confidence interval [95%CI]: -0.19 to 0.241) and 0.200 (95%CI: -0.010 to 0.401), indicating poor agreement. Templating accuracy for the tibial component were, respectively, 37.61% and 47.01% for AP and lateral views. Kappa coefficients were 0.186 (95%CI: -0.070 to 0.379) for the AP view and 0.315 (95%CI: -0.199 to 0.431) for the lateral view, showing poor and slight agreement respectively. Considering a margin of error of ±1 sizes, the agreement level improved for all components, particularly for tibia, where agreement levels become very good. The inter-observer agreement was fair for all components, except for the lateral view of the femoral component, whose agreement was good. The Spearman correlation test showed no correlation between accuracy of templating and coronal deformity. CONCLUSION: Pre-operative templating is an unreliable and inaccurate tool. There is no relation between coronal deformity and accuracy of templating.

Congenital syphilis with bone lesion: case report.

The authors report a case of congenital syphilis in a newborn with a bone lesion, resulting in left ankle periostitis.

Os autores apresentam um caso de um recém-nascido portador de sífilis congênita com lesão óssea que evoluiu com periostite no tornozelo esquerdo.

Congenital syphilis with bone lesion: case report / Sífilis congênita com lesão óssea: relato de caso

ABSTRACT The authors report a case of congenital syphilis in a newborn with a bone lesion, resulting in left ankle periostitis.

RESUMO Os autores apresentam um caso de um recém-nascido portador de sífilis congênita com lesão óssea que evoluiu com periostite no tornozelo esquerdo.

Viscosupplementation in patients with severe osteoarthritis of the knee: six month follow-up of a randomized, double-blind clinical trial.

PURPOSE: To analyze the early outcomes of viscosupplementation in patients with severe knee osteoarthritis. METHOD: A randomized, double-blind clinical trial of 143 knees divided into three groups: Group 1 - intra-articular injection of triamcinolone; Group 2 - hylan GF20; and Group 3 - triamcinolone + hylan GF20. Outcomes were evaluated using Lysholm and KSS scores before treatment and after one, three and six months. RESULTS: Within-group comparisons revealed improvements in Lysholm scores in all groups in the one month evaluation relative to pre-treatment levels (p < 0.01). This improvement was maintained in the third month after treatment (p > 0.05). Scores at six months were significantly lower than those observed in the previous follow-up assessments (p < 0.05), but still higher than pre-treatment levels (p < 0.05). KSS scores also improved after one month relative to pre-treatment levels (p < 0.01). This improvement was still present at three and six months after treatment in the corticosteroid group (p > 0.05). Patients treated with hylan GF20 showed lower scores in the last evaluation relative to month one (p < 0.05). No significant differences were observed between the treatment groups (p > 0.05). CONCLUSIONS: Viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. However, it was not superior to the use of triamcinolone.

Anthropometric study of the knee in patients with osteoarthritis: intraoperative measurement versus magnetic resonance imaging.

OBJECTIVE: To compare intraoperative measurements of the knee with those obtained by magnetic resonance imaging, in order to validate the latter method for use in anthropometric studies. MATERIALS AND METHODS: We studied 20 knees in 20 patients with osteoarthritis, all of whom underwent total arthroplasty between August and December of 2013. We took six measurements in the distal femur and two in the proximal tibia. Using the information system of the institution, we made the measurements on magnetic resonance imaging scans that had been obtained in the axial plane. Intraoperative measurements were obtained using a caliper, after the initial cuts made during the arthroplasty. The anatomical parameters determined by magnetic resonance imaging were the same as those determined by intraoperative measurement. The intraclass correlation coefficient was used in order to assess the level of agreement in anthropometric measurements of the knee performed by magnetic resonance imaging and by intraoperative measurement. RESULTS: Statistical analysis revealed a highly significant correlation between the knee anthropometric parameters of the knee determined by intraoperative measurement and those determined by magnetic resonance imaging. CONCLUSION: The dimensions of osteoarthritic knees measured by magnetic resonance imaging were similar to those measured intraoperatively. Therefore, magnetic resonance imaging can be considered a reliable method for use in large-scale anthropometric studies that will allow the available implants to be adapted and improved.

OBJETIVO: Comparar a mensuração do joelho realizada por meio de ressonância magnética com a medida obtida intraoperatoriamente, a fim de validar o método para estudos antropométricos. MATERIAIS E MÉTODOS: Foram estudados 20 joelhos em 20 pacientes portadores de osteoartrite submetidos a artroplastia total, entre agosto e dezembro de 2013. Realizaram-se seis medidas no fêmur distal e duas na tíbia proximal. As mensurações nas imagens foram feitas no plano axial, por meio do sistema informatizado da instituição. As mensurações intraoperatórias foram obtidas utilizando-se um paquímetro, após os cortes iniciais da artroplastia. Os parâmetros anatômicos foram os mesmos. O coeficiente de correlação intraclasses foi utilizado para avaliar a concordância nas medidas antropométricas de joelho realizadas pela ressonância magnética e pelo paquímetro de forma intraoperatória. RESULTADOS: A análise estatística revelou que existe concordância altamente significativa entre as medidas antropométricas do joelho conseguidas por meio do uso do paquímetro intraoperatoriamente e pela ressonância magnética. CONCLUSÃO: A mensuração das dimensões dos joelhos osteoartríticos por meio de ressonância magnética apresentou-se como método semelhante à mensuração intraoperatória, sendo confiável para a realização de estudos antropométricos amplos que permitam a adequação e melhoria de implantes disponíveis.

Anthropometric study of the knee in patients with osteoarthritis: intraoperative measurement versus magnetic resonance imaging / Estudo antropométrico do joelho em portadores de osteoartrite: comparação da mensuração intraoperatória e por ressonância magnética

Abstract Objective: To compare intraoperative measurements of the knee with those obtained by magnetic resonance imaging, in order to validate the latter method for use in anthropometric studies. Materials and Methods: We studied 20 knees in 20 patients with osteoarthritis, all of whom underwent total arthroplasty between August and December of 2013. We took six measurements in the distal femur and two in the proximal tibia. Using the information system of the institution, we made the measurements on magnetic resonance imaging scans that had been obtained in the axial plane. Intraoperative measurements were obtained using a caliper, after the initial cuts made during the arthroplasty. The anatomical parameters determined by magnetic resonance imaging were the same as those determined by intraoperative measurement. The intraclass correlation coefficient was used in order to assess the level of agreement in anthropometric measurements of the knee performed by magnetic resonance imaging and by intraoperative measurement. Results: Statistical analysis revealed a highly significant correlation between the knee anthropometric parameters of the knee determined by intraoperative measurement and those determined by magnetic resonance imaging. Conclusion: The dimensions of osteoarthritic knees measured by magnetic resonance imaging were similar to those measured intraoperatively. Therefore, magnetic resonance imaging can be considered a reliable method for use in large-scale anthropometric studies that will allow the available implants to be adapted and improved.

Resumo Objetivo: Comparar a mensuração do joelho realizada por meio de ressonância magnética com a medida obtida intraoperatoriamente, a fim de validar o método para estudos antropométricos. Materiais e Métodos: Foram estudados 20 joelhos em 20 pacientes portadores de osteoartrite submetidos a artroplastia total, entre agosto e dezembro de 2013. Realizaram-se seis medidas no fêmur distal e duas na tíbia proximal. As mensurações nas imagens foram feitas no plano axial, por meio do sistema informatizado da instituição. As mensurações intraoperatórias foram obtidas utilizando-se um paquímetro, após os cortes iniciais da artroplastia. Os parâmetros anatômicos foram os mesmos. O coeficiente de correlação intraclasses foi utilizado para avaliar a concordância nas medidas antropométricas de joelho realizadas pela ressonância magnética e pelo paquímetro de forma intraoperatória. Resultados: A análise estatística revelou que existe concordância altamente significativa entre as medidas antropométricas do joelho conseguidas por meio do uso do paquímetro intraoperatoriamente e pela ressonância magnética. Conclusão: A mensuração das dimensões dos joelhos osteoartríticos por meio de ressonância magnética apresentou-se como método semelhante à mensuração intraoperatória, sendo confiável para a realização de estudos antropométricos amplos que permitam a adequação e melhoria de implantes disponíveis.

Objective assessment of plaster cast quality in pediatric distal forearm fractures: Is there an optimal index?

BACKGROUND: Several so-called casting indices are available for objective evaluation of plaster cast quality. The present study sought to investigate four of these indices (gap index, padding index, Canterbury index, and three-point index) as compared to a reference standard (cast index) for evaluation of plaster cast quality after closed reduction of pediatric displaced distal forearm fractures. METHODS: Forty-three radiographs from patients with displaced distal forearm fractures requiring manipulation were reviewed. Accuracy, sensitivity, specificity, false-positive probability, false-negative probability, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio were calculated for each of the tested indices. RESULTS: Comparison among indices revealed diagnostic agreement in only 4.7% of cases. The strongest correlation with the cast index was found for the gap index, with a Spearman correlation coefficient of 0.94. The gap index also displayed the best agreement with the cast index, with both indices yielding the same result in 79.1% of assessments. CONCLUSION: When seeking to assess plaster cast quality, the cast index and gap index should be calculated; if both indices agree, a decision on quality can be made. If the cast and gap indices disagree, the padding index can be calculated as a tiebreaker, and the decision based on the most frequent of the three results. Calculation of the three-point index and Canterbury index appears unnecessary.

Posterior dislocation of the sternoclavicular joint: report of two cases.

The authors report the cases of two young patients who had suffered a sporting accident with posterior traumatic dislocation of sternoclavicular joint. In one of the patients closed reduction was accomplished by keeping the limb in a sling. The second patient, after reduction was done, presented recurrence of the dislocation, thus requiring surgical treatment. It is important to observe the relevance of computed tomography to help diagnosing, as well as monitoring the reduction procedure. The objective of this study was to demonstrate two different types of treatment in a rare injury such as the posterior dislocation of sternoclavicular joint.

Relato de caso de dois jovens que se acidentaram no esporte e apresentaram luxação traumática posterior da articulação esternoclavicular. Em um paciente foi feita a redução incruenta e manutenção com tipoia. O segundo paciente, após a redução, apresentou recidiva da luxação, foi necessário o tratamento cirúrgico. Vale salientar a importância da tomografia computadorizada no auxílio do diagnóstico, assim como para monitorar a redução. O objetivo deste estudo foi demonstrar dois tipos diferentes de tratamento em uma lesão rara como a luxação traumática posterior da articulação esternoclavicular.

Posterior dislocation of the sternoclavicular joint: report of two cases / Luxação posterior da articulação esternoclavicular: relato de dois casos

ABSTRACT The authors report the cases of two young patients who had suffered a sporting accident with posterior traumatic dislocation of sternoclavicular joint. In one of the patients closed reduction was accomplished by keeping the limb in a sling. The second patient, after reduction was done, presented recurrence of the dislocation, thus requiring surgical treatment. It is important to observe the relevance of computed tomography to help diagnosing, as well as monitoring the reduction procedure. The objective of this study was to demonstrate two different types of treatment in a rare injury such as the posterior dislocation of sternoclavicular joint.

RESUMO Relato de caso de dois jovens que se acidentaram no esporte e apresentaram luxação traumática posterior da articulação esternoclavicular. Em um paciente foi feita a redução incruenta e manutenção com tipoia. O segundo paciente, após a redução, apresentou recidiva da luxação, foi necessário o tratamento cirúrgico. Vale salientar a importância da tomografia computadorizada no auxílio do diagnóstico, assim como para monitorar a redução. O objetivo deste estudo foi demonstrar dois tipos diferentes de tratamento em uma lesão rara como a luxação traumática posterior da articulação esternoclavicular.

Where is the true location of the femoral piriform fossa?

OBJECTIVE: To analyze knowledge of the anatomic location of the piriform fossa using a questionnaire with anatomic figures. MATERIALS AND METHODS: Participants taking AO Trauma Brasil courses were requested to complete a questionnaire containing a photograph of the superior surface and a photograph of the lateral surface of the femur and answer a question asking which of four numbered points corresponded to the piriform fossa. RESULTS: Just 4.5% of respondents correctly chose point 2 (the piriform fossa) in both images, while 75.4% of respondents chose point 4 (the trochanteric fossa) as the correct anatomic structure. The subset of 4th-year residents' answers was significantly different from those of the other subsets, with 7.5% of correct answers. CONCLUSIONS: The low rate of correct answers indicates a tendency for the respondents to be influenced by illustrations in text books or examples in scientific publications that indicate the site of the piriform fossa incorrectly. Interest in the specialty of traumatology is possibly the reason why the subset of 4th-year residents had a better- than-average rate of correct answers.

Lead Toxicity Risks in Gunshot Victims.

BACKGROUND: Gunshot wounds require surgeons to decide whether to remove or leave bullet fragments in the body. Surgeons also decide how to follow up with patients who have lead fragments retained in their body. Current literature recommends to remove only intra-articular fragments without the need for a follow-up for patients with the metal retained. Therefore, this study investigates chronic lead toxicity for gunshot wounds. METHODS: The study was performed in the metropolitan area of Rio de Janeiro/Brazil, between 2013 and 2015. It was a case-control study that included 45 victims of gunshot lesions with metallic fragments retained for more than 6 months. The 45 controls were matched for gender, age, and race. We compared the lead blood levels and frequency of symptoms. RESULTS: The control group had average blood lead levels of 2.17 µg/dL (95% Confidence Interval [CI]; 1.71-2.63) and median 2.1 µg/dL. The case group had average values of 9.01 µg/dL (CI; 6.07-11.96) and median values of 6.5 µg/dL with p-values < = 0.001. The case group reported the following more frequently: irritancy, bad mood, headache, memory losses, daylight drowsiness, myalgia, weakness, abdominal pain, joint pain, trembling, tingling limbs. There was statistical significance for the differences of symptoms frequencies and for odds ratio between groups. CONCLUSIONS: Although the mean lead levels found were lower than the current laboratory references, low levels have been associated with both rising morbidity and mortality. The WHO stated: "There is no known level of lead exposure that is considered safe". In conclusion, this work showed that bullets retained in the body are not innocuous. There are impacts in the blood lead levels and symptoms related to it, even with few fragments, extra-articular located or existing with low blood lead levels.

Patellar ligament rupture in an adolescent.

Rupture of the patellar tendon is a well-known injury in the orthopaedic literature. However, it is unusual and rarely reported in adolescent children. On the one hand, in the immature skeleton, the most frequent lesion above the kneecap is the sleeve fracture. On the other hand, in the distal region, avulsion of the tibial tuberosity is more common. Patellar tendon rupture in an adolescent is a rare lesion. We report a case in which an adolescent sustained a fall when jumping. No predisposing factors have been found. The injury was treated with surgical repair with transosseous suturing and reinforcement with semitendinosus tendon. The aim of this study is to present a case of traumatic rupture of the extensor mechanism of the knee in an adolescent and the therapy used.

Spinal tuberculosis presenting with hip abscesses: a diagnostic challenge.

Spinal tuberculosis is the most common manifestation of extra-pulmonary tuberculosis. It is difficult to diagnose the disease due to its insidious onset and non-specific clinical presentation. A high degree of suspicion and appropriate imaging studies are necessary for its early diagnosis and treatment. The authors report a case of lumbosacral tuberculosis in an adult patient presenting with hip pain and abscesses.

Fracture of tibial tuberosity in an adult.

The fracture of tibial tuberosity is a rare lesion and still more unusual in adults. We describe a case in an adult who suffered a left knee injury due to a fall from height. No risk factors were identified. The lesion was treated with surgical reduction and internal fixation. The rehabilitation method was successful, resulting in excellent function and rage of motion of the knee. The aim of this study was to present an unusual case of direct trauma of the tibial tuberosity in an adult and the therapy performed.