Staged reconstruction of the hallux for infected non-union using bulk autograft and a customized implant: Case report.

This case report illustrates the outcome of a deep infection following internal fixation of a fracture of the big toe. Hallux amputation could be avoided through staged salvage procedure. This paper can assist readers on how to effectively and safely recognize and treat this type of injury.

Imaging of progressive collapsing foot deformity with emphasis on the role of weightbearing cone beam CT.

The term progressive collapsing foot deformity (PCFD) is currently recommended as the replacement to adult-acquired flatfoot deformity and posterior tibial tendon dysfunction to better reflect its pathology, which consists of a complex three-dimensional deformity involving the foot and ankle. The new consensus has also provided a new classification that requires clinical and radiographic findings for patient stratification into each class. However, conventional radiographs are susceptible to errors resulting from the inadequate positioning of patients, incorrect angulation of the X-ray tube, and overlapping of bone structures. Weightbearing cone beam computed tomography (WBCBCT), which has greater diagnostic accuracy than conventional radiograph, is useful for evaluating progressive collapsing foot deformity to determine medial arch collapse, hindfoot alignment, peritalar subluxation, posterior subtalar joint valgus, intrinsic talus valgus, and lateral extra-articular bone impingement. The present review aimed to discuss the new recommendations for nomenclature, classification, and imaging evaluation of PCFD, with an illustrative and quantitative focus on the measurements used in conventional radiography and WBCBCT. The measurements presented here are important criteria for decision-making.

Staged salvage of diabetic foot with Chopart amputation and intramedullary nailing.

We present a stepwise surgical approach that can be used, in lieu of a transtibial amputation, to preserve the lower limb in the setting of severe diabetic foot infections. A 63-year-old male status post left midfoot (Lisfranc's) amputation presented to our hospital with a 4-year history of a left foot diabetic ulcer with associated purulent drainage and intermittent chills. On initial exam, the patient's left foot amputation stump was plantarflexed, grossly erythematous, and edematous. The associated diabetic foot ulcer was actively draining purulent fluid. Following workup with radiography and ultrasound, the patient was diagnosed with a post-operative infection of the midfoot at the level of the amputation stump secondary to diabetic neuropathy. Our approach to management was a staged and included (1) surgical irrigation and debridement of the distal stump wound, (2) provisional negative pressure therapy, (3) a second-look procedure, and (4) a tibiotalocalcaneal fusion was performed using a lateral transfibular and plantar approach, after wound closure and resolution of active infection was achieved. At 36-month follow-up, the patient was fully weight-bearing in stiff sole sneakers with no gross overt alteration of gait pattern. The patient scored 79 points when assessed by the hindfoot American Orthopaedic Foot and Ankle Society Ankle-Hindfoot outcome score. In the patient with diabetes and cardiological restrictions, a Chopart amputation is preferred due to the decreased level of energy expenditure required for ambulation as compared to over more proximal levels of amputation.

Biomechanical comparison of plantar-to-dorsal and dorsal-to-plantar screw fixation strength for subtalar arthrodesis.

OBJECTIVE: To compare screw fixation strength for subtalar arthrodesis. METHODS: Eight matched pairs of cadaver feet underwent subtalar joint arthrodesis with two 7.3mm cannulated screws. Randomization was used to assign screw orientation, such that one foot in each pair was assigned dorsal to plantar screw orientation (DP Group), and the other foot, plantar to dorsal orientation (PD Group). Standard surgical technique with fluoroscopy was used for each approach. Following fixation, each specimen was loaded to failure with a Bionix ® 858 MTS device, applying a downward axial force at a distance to create torque. Torque to failure was compared between DP and PD Groups using Student's t test, with p=0.05 used to determine statistical significance. RESULTS: Statistical analysis demonstrated that the mean torque to failure slightly favored the DP Group (37.3Nm) to the PD Group (32.2Nm). However, the difference between the two groups was not statistically significant (p=0.55). CONCLUSION: In subtalar arthrodesis, there is no significant difference in construct strength between dorsal-to-plantar and plantar-to-dorsal screw orientation. The approach chosen by the surgeon should be based on factors other than the biomechanical strength of the screw orientation.

Biomechanical comparison of plantar-to-dorsal and dorsal-to-plantar screw fixation strength for subtalar arthrodesis / Comparação biomecânica da força de fixação de parafuso com orientação de plantar para dorsal e vice-versa para artrodese subtalar

ABSTRACT Objective To compare screw fixation strength for subtalar arthrodesis. Methods Eight matched pairs of cadaver feet underwent subtalar joint arthrodesis with two 7.3mm cannulated screws. Randomization was used to assign screw orientation, such that one foot in each pair was assigned dorsal to plantar screw orientation (DP Group), and the other foot, plantar to dorsal orientation (PD Group). Standard surgical technique with fluoroscopy was used for each approach. Following fixation, each specimen was loaded to failure with a Bionix ® 858 MTS device, applying a downward axial force at a distance to create torque. Torque to failure was compared between DP and PD Groups using Student's t test, with p=0.05 used to determine statistical significance. Results Statistical analysis demonstrated that the mean torque to failure slightly favored the DP Group (37.3Nm) to the PD Group (32.2Nm). However, the difference between the two groups was not statistically significant (p=0.55). Conclusion In subtalar arthrodesis, there is no significant difference in construct strength between dorsal-to-plantar and plantar-to-dorsal screw orientation. The approach chosen by the surgeon should be based on factors other than the biomechanical strength of the screw orientation.

RESUMO Objetivo Comparar a força de fixação dos parafusos para artrodese subtalar. Métodos Oito pares de pés de cadáveres frescos foram submetidos à artrodese da articulação subtalar com dois parafusos canulados de 7,3mm. A randomização foi usada para atribuir a orientação do parafuso, de modo que um pé em cada par foi designado com orientação de dorsal para plantar (Grupo DP), e o outro pé com orientação de plantar para dorsal (Grupo PD). Técnica cirúrgica padrão com radioscopia foi usada para os procedimentos. Após a fixação, cada amostra foi testada até a falha com um dispositivo Bionix®858 MTS, aplicando força axial descendente a uma distância para criar torque. O torque de falha foi comparado entre os Grupos DP e PD, usando o teste t de Student, com p=0,05 usado para determinar significância estatística. Resultados A análise estatística demonstrou que a média do torque até a falha favoreceu ligeiramente o Grupo DP (37,3Nm) em relação ao PD (32,2Nm). No entanto, a diferença entre os dois grupos não foi estatisticamente significativa (p=0,55). Conclusão Na artrodese subtalar, não há diferença significativa na força de compressão entre as orientações dos parafusos dorsal-plantar e plantar-dorsal. A abordagem escolhida pelo cirurgião deve ser baseada em outros fatores, sem preocupação com a força biomecânica da orientação dos parafusos.

Posterior quadratus lumborum block for primary total hip arthroplasty analgesia: a comparative study.

OBJECTIVE: To compare analgesia and opioid consumption for patients undergoing primary total hip arthroplasty with preoperative posterior quadratus lumborum block with patients who did not receive quadratus lumborum block. METHODS: The medical records of patients undergoing unilateral total hip arthroplasty between January 1st, 2017 and March 31, 2018 were reviewed, and 238 patients were included in the study. The primary outcome was postoperative opioid consumption in the first 24 postoperative hours. Secondary outcomes were intraoperative, post anesthesia care unit, and 48-hour opioid consumption, postoperative pain Visual Analog Scale scores, and post-anesthesia care unit length of stay. Primary and secondary endpoint data were compared between patients undergoing primary total hip arthroplasty with preoperative posterior quadratus lumborum block with patients who did not receive quadratus lumborum block. RESULTS: For the patients who received quadratus lumborum block, the 24-hour total oral morphine equivalent (milligram) requirements were lower (53.82mg±37.41), compared to the patients who did not receive quadratus lumborum block (77.59mL±58.42), with p=0.0011. Opioid requirements were consistently lower for the patients who received quadratus lumborum block at each additional assessment time point up to 48 hours. Pain Visual Analog Scale scores were lower up to 12 hours after surgery for the patients who received a posterior quadratus lumborum block, and the post-anesthesia care unit length of stay was shorter for the patients who received quadratus lumborum block. CONCLUSION: Preoperative posterior quadratus lumborum block for primary total hip arthroplasty is associated with decreased opioid requirements up to 48 hours, decreased Visual Analog Scale pain scores up to 12 hours, and shorter post-anesthesia care unit length of stay. Level of evidence: III.

Posterior quadratus lumborum block for primary total hip arthroplasty analgesia: a comparative study / Bloqueio anestésico do quadrado lombar posterior para analgesia na artroplastia total do quadril primária: estudo comparativo

ABSTRACT Objective To compare analgesia and opioid consumption for patients undergoing primary total hip arthroplasty with preoperative posterior quadratus lumborum block with patients who did not receive quadratus lumborum block. Methods The medical records of patients undergoing unilateral total hip arthroplasty between January 1st, 2017 and March 31, 2018 were reviewed, and 238 patients were included in the study. The primary outcome was postoperative opioid consumption in the first 24 postoperative hours. Secondary outcomes were intraoperative, post anesthesia care unit, and 48-hour opioid consumption, postoperative pain Visual Analog Scale scores, and post-anesthesia care unit length of stay. Primary and secondary endpoint data were compared between patients undergoing primary total hip arthroplasty with preoperative posterior quadratus lumborum block with patients who did not receive quadratus lumborum block. Results For the patients who received quadratus lumborum block, the 24-hour total oral morphine equivalent (milligram) requirements were lower (53.82mg±37.41), compared to the patients who did not receive quadratus lumborum block (77.59mL±58.42), with p=0.0011. Opioid requirements were consistently lower for the patients who received quadratus lumborum block at each additional assessment time point up to 48 hours. Pain Visual Analog Scale scores were lower up to 12 hours after surgery for the patients who received a posterior quadratus lumborum block, and the post-anesthesia care unit length of stay was shorter for the patients who received quadratus lumborum block. Conclusion Preoperative posterior quadratus lumborum block for primary total hip arthroplasty is associated with decreased opioid requirements up to 48 hours, decreased Visual Analog Scale pain scores up to 12 hours, and shorter post-anesthesia care unit length of stay. Level of evidence: III

RESUMO Objetivo Comparar a analgesia e o uso de opioides em pacientes submetidos à artroplastia total do quadril primária com bloqueio pré-operatório do quadrado lombar posterior e pacientes que não receberam o bloqueio do quadrado lombar. Métodos Revisamos os prontuários de pacientes submetidos à artroplastia total do quadril unilateral entre 1º de janeiro de 2017 e 31 de março de 2018, e 238 pacientes foram incluídos no estudo. O desfecho primário foi o consumo de opioides no pós-operatório nas primeiras 24 horas. Os desfechos secundários foram consumo de opioide no intraoperatório, na sala de recuperação pós-anestésica e nas primeiras 48 horas, escores de Escala Visual Analógica de dor pós-operatória, e tempo de permanência na recuperação pós-anestésica. Os desfechos primário e secundários foram comparados entre os pacientes submetidos à artroplastia total do quadril primária com bloqueio pré-operatório do quadrado lombar posterior e aqueles que não receberam o bloqueio do quadrado lombar. Resultados Para o grupo que recebeu o bloqueio, as doses totais de morfina por via oral em 24 horas foram menores (53,82mg±37,41) em comparação ao grupo sem bloqueio (77,59mg±58,42), com p=0,0011. A utilização de opioides foi consistentemente menor para o grupo que recebeu o bloqueio em cada tempo adicional de avaliação até 48 horas. Os escores da Escala Visual Analógica até 12 horas após a cirurgia para os pacientes que receberam o bloqueio do quadrado lombar posterior e o tempo de permanência na sala de recuperação pós-anestésica foram menores para o grupo que recebeu o bloqueio. Conclusão O bloqueio anestésico do quadrado lombar posterior para artroplastia total do quadril primária está associado à diminuição do uso de opioides nas primeiras 48 horas, diminuição do escore de dor da Escala Visual Analógica em até 12 horas, e menor tempo de permanência na sala de recuperação pós-anestésica. Nível de evidência: III

Are traumatologists treating osteoporosis to prevent new fractures in brazil? / Os traumatologistas tratam osteoporose, para prevenir uma nova fratura, no brasil?

ABSTRACT Objectives: To determine the proportion of traumatologists who investigate osteoporosis in elderly patients with fractures and recommend secondary prevention of osteoporotic fractures. Methods: We distributed questionnaires to 244 physicians attending the 2015 Brazilian Congress of Orthopedic Trauma. We determined the respondents' profiles and assessed how they investigated and treated osteoporosis in elderly patients with fractures. Results: Overall, 32% of the respondents reported that their knowledge level regarding osteoporosis ranged from 0-5 (out of 0-10). In total, 42% of the participants reported that they usually requested DXA for elderly patients with fractures and less than 30% reported prescribing supplemental calcium and/or vitamin D. We considered physicians conducting a complete treatment for the patient as those who in addition to requesting DXA prescribed supplemental calcium, vitamin D, and specific medications for their elderly patients, and recommended non-pharmacological measures. Only 0.8% of the participants fulfilled all these criteria. In addition, 47% of the traumatologists reported that they did not treat osteoporosis directly but instead, referred osteoporotic patients to a qualified physician. Conclusion: Less than 50% of the surveyed traumatologists investigated and performed secondary prevention against osteoporotic fractures after treating an elderly patient with a fracture. Level of evidence III, Economic and Decision Analyses - Developing an Economic or Decisions Model.

RESUMO Objetivo: Avaliar a proporção de traumatologistas que investigam a osteoporose nos pacientes idosos com fraturas e recomendam a prevenção secundária das fraturas osteoporóticas. Métodos: Distribuímos questionários para 244 médicos participantes do Congresso Brasileiro de Traumatología Ortopédica em 2015. Determinamos o perfil dos mesmos e avaliamos como os entrevistados investigam e tratam a osteoporose nos pacientes idosos com fraturas. Resultados: Entre os entrevistados, 32% relataram que seu nível de conhecimento sobre osteoporose seria algo entre 0 e 5 (de 0 a 10). No total, 42% dos participantes relataram que frequentemente solicitam DXA para pacientes idosos com fraturas, mas menos de 30% relataram prescrever suplementação com cálcio e/ou vitamina D. Consideramos como prescritores do tratamento completo para o paciente aqueles médicos que, além de solicitar DXA, prescrevem suplementação de cálcio, vitamina D e medicamentos específicos para seus pacientes idosos, além de recomendar medidas não farmacológicas. Apenas 0,8% dos participantes preencheram todos esses critérios. Além disso, 47% dos traumatologistas relataram que não tratam a osteoporose, mas encaminham seus pacientes com osteoporose para um médico que o faz. Conclusão: Menos de 50% dos traumatologistas pesquisados investigam e realizam prevenção secundária contra fraturas osteoporóticas após tratamento de paciente idoso com fratura. Nível de evidência III, Análises econômicas e de decisão - Desenvolvimento de modelo econômico ou de decisão.

ARE TRAUMATOLOGISTS TREATING OSTEOPOROSIS TO PREVENT NEW FRACTURES IN BRAZIL?

OBJECTIVES: To determine the proportion of traumatologists who investigate osteoporosis in elderly patients with fractures and recommend secondary prevention of osteoporotic fractures. METHODS: We distributed questionnaires to 244 physicians attending the 2015 Brazilian Congress of Orthopedic Trauma. We determined the respondents' profiles and assessed how they investigated and treated osteoporosis in elderly patients with fractures. RESULTS: Overall, 32% of the respondents reported that their knowledge level regarding osteoporosis ranged from 0-5 (out of 0-10). In total, 42% of the participants reported that they usually requested DXA for elderly patients with fractures and less than 30% reported prescribing supplemental calcium and/or vitamin D. We considered physicians conducting a complete treatment for the patient as those who in addition to requesting DXA prescribed supplemental calcium, vitamin D, and specific medications for their elderly patients, and recommended non-pharmacological measures. Only 0.8% of the participants fulfilled all these criteria. In addition, 47% of the traumatologists reported that they did not treat osteoporosis directly but instead, referred osteoporotic patients to a qualified physician. CONCLUSION: Less than 50% of the surveyed traumatologists investigated and performed secondary prevention against osteoporotic fractures after treating an elderly patient with a fracture. Level of evidence III, Economic and Decision Analyses - Developing an Economic or Decisions Model.

OBJETIVO: Avaliar a proporção de traumatologistas que investigam a osteoporose nos pacientes idosos com fraturas e recomendam a prevenção secundária das fraturas osteoporóticas. MÉTODOS: Distribuímos questionários para 244 médicos participantes do Congresso Brasileiro de Traumatología Ortopédica em 2015. Determinamos o perfil dos mesmos e avaliamos como os entrevistados investigam e tratam a osteoporose nos pacientes idosos com fraturas. RESULTADOS: Entre os entrevistados, 32% relataram que seu nível de conhecimento sobre osteoporose seria algo entre 0 e 5 (de 0 a 10). No total, 42% dos participantes relataram que frequentemente solicitam DXA para pacientes idosos com fraturas, mas menos de 30% relataram prescrever suplementação com cálcio e/ou vitamina D. Consideramos como prescritores do tratamento completo para o paciente aqueles médicos que, além de solicitar DXA, prescrevem suplementação de cálcio, vitamina D e medicamentos específicos para seus pacientes idosos, além de recomendar medidas não farmacológicas. Apenas 0,8% dos participantes preencheram todos esses critérios. Além disso, 47% dos traumatologistas relataram que não tratam a osteoporose, mas encaminham seus pacientes com osteoporose para um médico que o faz. CONCLUSÃO: Menos de 50% dos traumatologistas pesquisados investigam e realizam prevenção secundária contra fraturas osteoporóticas após tratamento de paciente idoso com fratura. Nível de evidência III, Análises econômicas e de decisão - Desenvolvimento de modelo econômico ou de decisão.

Evaluation of the mortality due to external causes.

OBJECTIVE: External causes have become an important public health problem due to their high mortality, morbidity, costs, the loss of potential years of life and the impact for individuals, their families and society. The aim of this study was to analyze the characteristics of fatal victims of trauma in a microregion from São Paulo State. METHOD: This was a retrospective, transverse, exploratory and descriptive study. The Coroner's Office (IML) of Catanduva - SP - provided 511 medical records of the victims of external causes from 2008-2011. It was performed a survey and a review of those records and the data retrieved regarded gender, age, intentionality and mechanism of external cause. RESULTS: The mortality predominance was on male individuals (77.9% of the cases - p<0.001). Deaths classified as non intentional represented 66.9%, where as the intentional ones represented 33.1% (p<0.0001). Accidents caused by land transports were responsible for 45.6% of cases, being the main cause for the deaths analyzed. On second place there were suicides (16%), followed by the homicides (13.9%). CONCLUSION: The results of the present study were different from the profiles found in some other Brazilian studies, approaching to the reality of the developed countries, considering non-intentionality as preponderant and the main causes were accidents by land transports, suicides and homicides, respectively. Improvements should be done to assure the quality of information in the documentation of Forensic Physicians, since the lack of information in the Death Certificate was one of the difficulties found by the authors.

Avaliação da mortalidade por causas externas / Evaluation of the mortality due to external causes

OBJETIVO: Avaliar os óbitos por causas externas em uma microrregião do Estado de São Paulo. MÉTODOS: Estudo descritivo exploratório transversal retrospectivo. Foi feito um levantamento e revisão de 511 prontuários das vítimas de causas externas fornecidos pelo Instituto Médico Legal de Catanduva - SP de 2008 a 2011. Os dados foram classificados por sexo, idade, intencionalidade e mecanismo de causa externa. RESULTADOS: A mortalidade foi predominante no sexo masculino, com 77,9% dos casos (p<0,001). As mortes classificadas como não intencionais representaram 66,9%, enquanto as intencionais, 33,1% (p<0,001). Os acidentes de transporte terrestre foram responsáveis por 45,6% dos casos, sendo a principal causa dos óbitos analisados. O segundo lugar foi atribuído aos suicídios, com 16%, seguido pelos homicídios (13,9%). CONCLUSÃO: Os resultados encontrados diferem dos perfis encontrados em outros estudos brasileiros, aproximando-se mais da realidade de países desenvolvidos, já que a não intencionalidade foi preponderante e as principais causas foram os acidentes de transporte terrestre, suicídios e homicídios, respectivamente. Foi constatada a necessidade de melhorias no preenchimento da declaração de óbito pelos legistas, visto que isto foi uma dificuldade encontrada pelos autores na realização do estudo.

OBJECTIVE: External causes have become an important public health problem due to their high mortality, morbidity, costs, the loss of potential years of life and the impact for individuals, their families and society. The aim of this study was to analyze the characteristics of fatal victims of trauma in a microregion from São Paulo State. METHOD: This was a retrospective, transverse, exploratory and descriptive study. The Coroner's Office (IML) of Catanduva - SP - provided 511 medical records of the victims of external causes from 2008-2011. It was performed a survey and a review of those records and the data retrieved regarded gender, age, intentionality and mechanism of external cause. RESULTS: The mortality predominance was on male individuals (77.9% of the cases - p<0.001). Deaths classified as non intentional represented 66.9%, where as the intentional ones represented 33.1% (p<0.0001). Accidents caused by land transports were responsible for 45.6% of cases, being the main cause for the deaths analyzed. On second place there were suicides (16%), followed by the homicides (13.9%). CONCLUSION: The results of the present study were different from the profiles found in some other Brazilian studies, approaching to the reality of the developed countries, considering non-intentionality as preponderant and the main causes were accidents by land transports, suicides and homicides, respectively. Improvements should be done to assure the quality of information in the documentation of Forensic Physicians, since the lack of information in the Death Certificate was one of the difficulties found by the authors.