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2.
Bone Joint J ; 98-B(10): 1320-1325, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27694584

RESUMO

As residency training programmes around the globe move towards competency-based medical education (CBME), there is a need to review current teaching and assessment practices as they relate to education in orthopaedic trauma. Assessment is the cornerstone of CBME, as it not only helps to determine when a trainee is fit to practice independently, but it also provides feedback on performance and guides the development of competence. Although a standardised core knowledge base for trauma care has been developed by the leading national accreditation bodies and international agencies that teach and perform research in orthopaedic trauma, educators have not yet established optimal methods for assessing trainees' performance in managing orthopaedic trauma patients. This review describes the existing knowledge from the literature on assessment in orthopaedic trauma and highlights initiatives that have recently been undertaken towards CBME in the United Kingdom, Canada and the United States. In order to support a CBME approach, programmes need to improve the frequency and quality of assessments and improve on current formative and summative feedback techniques in order to enhance resident education in orthopaedic trauma. Cite this article: Bone Joint J 2016;98-B:1320-5.


Assuntos
Competência Clínica/normas , Educação Baseada em Competências/métodos , Educação de Pós-Graduação em Medicina/métodos , Internato e Residência , Ortopedia/educação , Médicos/normas , Ferimentos e Lesões , Canadá , Humanos , Reino Unido , Estados Unidos
5.
Iowa Orthop J ; 33: 7-11, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-24027454

RESUMO

INTRODUCTION: Periprosthetic distal femur fractures are severe injuries occurring in the often osteoporotic bone of the elderly. Far cortical locking (FCL) screws, which have been shown to promote increased callus formation in animal models, have recently become available for clinical use. The purpose of this study is to report preliminary healing and complication rates of periprosthetic distal femur fractures treated with FCL constructs. MATERIALS AND METHODS: A retrospective review of 20 patients who underwent open reduction and internal fixation of periprosthetic distal femur fractures using FCL constructs was performed. Healing was assessed radiographically and clinically at 6, 12 and 24 weeks post-operatively. Construct failure was defined as any hardware breakage or bone-implant dissociation leading to loss of reduction. RESULTS: Complete data through the 24 week study period was available for 18/20 patients. Bridging callus was identified in 16/18 patients by the 24 week follow up for a healing rate of 88.9%. In patients that healed, the average time to medial bridging callus formation was 10.7 ± 6.7 weeks, 11.0 ± 6.6 weeks for anterior fracture line and 13.4 ± 7.5 weeks for the posterior fracture line. both patients that failed to heal underwent revision surgery. DISCUSSION: The initial results of this study are comparable to results reported for distal femur periprosthetic fractures treated with locking plate fixation without FCL screws, although it was difficult to compare time to healing between previously published studies. It is the impression of the authors that callus appears earlier and is more robust and uniform between the three cortices in FCL cases compared to their previous experiences with traditional locking plate periprosthetic distal femur fractures. This work suggests that FCL screws may be superior to traditional locking constructs but further studies are needed to directly compare the two methods.


Assuntos
Fraturas do Fêmur/cirurgia , Fixação Interna de Fraturas/instrumentação , Consolidação da Fratura/fisiologia , Fraturas Periprotéticas/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Placas Ósseas , Parafusos Ósseos , Feminino , Fraturas do Fêmur/diagnóstico por imagem , Fixação Interna de Fraturas/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Fraturas Periprotéticas/diagnóstico por imagem , Radiografia , Estudos Retrospectivos , Resultado do Tratamento
6.
J Knee Surg ; 26(1): 15-8, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23408343

RESUMO

Far cortical locking screws have been shown to form greater amounts of callus in ovine studies when compared to traditional locking plates. These screws have recently become available for clinical use. This article describes the indications and surgical technique for far cortical locking screws, with a focus on distal femur periprosthetic fractures.


Assuntos
Placas Ósseas , Parafusos Ósseos , Fraturas do Fêmur/cirurgia , Fixação Interna de Fraturas/métodos , Fraturas Periprotéticas/cirurgia , Artroplastia do Joelho , Fraturas do Fêmur/etiologia , Humanos , Prótese do Joelho , Seleção de Pacientes , Fraturas Periprotéticas/etiologia , Cuidados Pós-Operatórios , Cuidados Pré-Operatórios
10.
J Orthop Trauma ; 25 Suppl 1: S8-14, 2011 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-21248560

RESUMO

OBJECTIVES: Fractures of the distal femur are severe injuries that present many clinical challenges. Nonunion, delayed union, implant failure, and the need for secondary procedures can reflect complications of healing. This article reviews the literature on distal femur fractures treated with locking plates to determine the reported rate of healing difficulties. DATA SOURCES: The PubMed database and the Orthopaedic Trauma Association and American Academy of Orthopedic Surgeons abstract archives were searched for studies including the key words distal femur fracture, supracondylar femur fracture, or locking plate from the year 2000 to the present. STUDY SELECTION: Reports were included when distal femur fractures were treated with locking plates and when the number of healed fractures was identified in the study. The reported healing rates and the rate of healing complications were determined from the studies. The time to implant failure was recorded. Those articles that included periprosthetic fractures were separated from those only including acute distal femur fractures. DATA SYNTHESIS: Fifteen full-length publications and three abstracts were included. The rate of complications related to healing ranged from 0% to 32% in these studies. Implant failures occurred late with 75% of the failures occurring after 3 months and 50% occurring after 6 months. CONCLUSIONS: Complications of healing including nonunion, delayed union, and implant failure are not infrequent and represent ongoing problems with distal femur fracture treatment. Further clinical research combined with innovation in surgical techniques and implant design will be necessary to improve the results of the last decade.


Assuntos
Placas Ósseas , Parafusos Ósseos , Fraturas do Fêmur/cirurgia , Fixação Interna de Fraturas/instrumentação , Consolidação da Fratura , Fixação Interna de Fraturas/métodos , Humanos
13.
Iowa Orthop J ; 30: 47-54, 2010.
Artigo em Inglês | MEDLINE | ID: mdl-21045971

RESUMO

Novel biomechanical methods have been developed to objectively measure acute fracture severity (from inter-fragmentary surface area) and chronic contact stress challenge (from patient-specific finite element analysis) in articular fractures. These new methods help clarify the pathomechanics of the development of post-traumatic osteoarthritis, and can contribute directly to the clinical care of patients. In this manuscript, the value of these two new measures is demonstrated in three illustrative tibial plafond fracture cases, in which both metrics are correlated with cartilage status and with patient outcomes at a minimum of two years after injury. These clinical cases demonstrate the utility of new biomechanical variables to advance clinical research and patient care, by providing a basis to predict outcome and select treatment.


Assuntos
Cartilagem Articular/fisiopatologia , Osteoartrite/epidemiologia , Fraturas da Tíbia/fisiopatologia , Índices de Gravidade do Trauma , Adulto , Fenômenos Biomecânicos , Feminino , Seguimentos , Fixação Interna de Fraturas , Humanos , Masculino , Prognóstico , Radiografia , Fatores de Risco , Fraturas da Tíbia/diagnóstico por imagem , Fraturas da Tíbia/cirurgia
14.
J Bone Joint Surg Am ; 92(13): e19, 2010 Oct 06.
Artigo em Inglês | MEDLINE | ID: mdl-20926717

RESUMO

BACKGROUND: Lecture-based courses are common in orthopaedic surgery; however, their effectiveness in improving medical knowledge has not been widely assessed. The Orthopaedic Trauma Association conducts a resident trauma course that occurs four to six weeks prior to the Orthopaedic In-Training Examination (OITE). The purposes of this study were to determine whether residents who had taken this course performed better on the trauma domain of the OITE and to compare the effect of the course with the effect of a focused rotation in orthopaedic trauma. METHODS: The percentile scores on the trauma domain of the OITE for forty-seven residents in postgraduate year (PGY) 2 were reviewed. Twenty-nine residents who took a trauma course within six weeks before the OITE were compared with eighteen residents who took the course after the OITE. As a secondary analysis, the effect of a trauma rotation for the same PGY-2 residents before and after the OITE was also assessed. Baseline orthopaedic knowledge was assessed with use of the overall OITE percentage scores. RESULTS: The trauma domain scores were not significantly better among the residents who took the course (mean and standard deviation, 62.2 ± 9.9) compared with those who had not taken it (mean, 59.2 ± 6.2) (p = 0.2). A significant difference (p = 0.04) was found for a trauma rotation, with the residents who had a trauma rotation scoring better (mean, 64.5 ± 6.8) than the residents who had not (mean, 58.8 ± 8.9). The subgroup of residents who had both a course and a trauma rotation before the test scored significantly better (p = 0.01) than the subgroup that had neither of these experiences before the test (mean, 65.6 ± 8.0 and 56.9 ± 6.4, respectively). CONCLUSIONS: An orthopaedic trauma course alone does not enhance an orthopaedic resident's trauma medical knowledge as assessed on a standardized test. However, a trauma rotation before, and in particular the combination of both a course and a trauma rotation, can improve trauma test scores.


Assuntos
Educação de Pós-Graduação em Medicina/normas , Avaliação Educacional , Internato e Residência , Ortopedia/educação , Traumatologia/educação , Competência Clínica , Currículo , Humanos , Estudos Retrospectivos
15.
J Orthop Trauma ; 24(8): 466-72, 2010 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-20657248

RESUMO

OBJECTIVES: The purpose of this study is to assess the initial results of percutaneously reducing and fixing calcaneus fractures compared with a concurrent control group that was openly reduced and internally fixed through an extensile lateral approach. DESIGN: Retrospective cohort study, consecutive series. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: One hundred twenty patients with 125 intra-articular calcaneus fractures were selected as a consecutive series with treatment method randomized by surgeon and time of presentation. INTERVENTION: Patients treated with open reduction and internal fixation (OR group) had an extended lateral approach and fractures were fixed with plates and screws. Patients treated with percutaneous reduction (PR group) had small incisions with indirect fragment manipulation, and the reduction achieved was secured with screws alone. MAIN OUTCOME MEASUREMENT: Clinical and radiographic assessment. RESULTS: There were 41 patients with 42 fractures in the OR group and 79 patients with 83 fractures in the PR group. There were no significant differences in sex, age, open fractures, fracture classification, or initial Bohler's angle between the two groups. Bohler's angle was improved after surgery by an average of 22.4 degrees in the OR group and 25.3 degrees in the PR group (P = 0.31). The average loss of reduction at healing (minimum 4 months postoperatively) was not significantly different between the two groups. Deep infection occurred in six of 42 of the OR group and zero of 83 of the PR group (P = 0.002). The incidence of minor wound complications was nine of 42 in the OR group and five of 83 in the PR group (P = 0.03). The need for late subtalar fusions (two of 26 and three of 41 with full 2-year follow-up) and implant removal (five of 42 and 10 of 83) was not significantly different. CONCLUSIONS: The results of this study suggest that in comparison to open reduction, this method of percutaneously reducing and fixing calcaneus fractures minimizes complications and achieves and maintains extra-articular reductions as well as the standard extensile open reduction and internal fixation. Further study of this technique is warranted. This should include assessment of articular reduction and longer follow-up of a larger number of patients.


Assuntos
Traumatismos do Tornozelo/cirurgia , Placas Ósseas , Parafusos Ósseos , Calcâneo/cirurgia , Fixação Interna de Fraturas/instrumentação , Fixação Interna de Fraturas/métodos , Adulto , Traumatismos do Tornozelo/diagnóstico por imagem , Calcâneo/diagnóstico por imagem , Estudos de Coortes , Feminino , Humanos , Masculino , Projetos Piloto , Radiografia , Estudos Retrospectivos , Resultado do Tratamento
16.
Oncogene ; 28(47): 4133-46, 2009 Nov 26.
Artigo em Inglês | MEDLINE | ID: mdl-19749792

RESUMO

Constitutive activation of the Wnt/beta-catenin pathway has been implicated as the primary cause of colon cancer. However, the major transducers of Wnt signaling in the intestine, T-cell factor 1 (TCF-1) and TCF-4, have opposing functions. Knockout of TCF-4 suppresses growth and maintenance of crypt stem cells, whereas knockout of TCF-1 leads to adenomas. These phenotypes suggest that TCF-4 is Wnt-promoting, whereas TCF-1 acts like a tumor suppressor. Our study of TCF expression in human colon crypts reveals a mechanistic basis for this paradox. In normal colon cells, a dominant-negative isoform of TCF-1 (dnTCF-1) is expressed that is equally distributed between nuclear and cytoplasmic compartments. In colon cancer cells, TCF-1 is predominantly cytoplasmic. Localization is because of active nuclear export and is directed by an autocrine-acting Wnt ligand that requires Ca2+/calmodulin-dependent kinase II (CaMKII) activity for secretion and a downstream step in the export pathway. TCF-4 remains nuclear; its unopposed activity is accompanied by downregulation of dnTCF-1 and increased expression of full-length isoforms. Thus, the dnTCF-1 and TCF-4 balance is corrupted in cancer by two mechanisms, a Wnt/CaMKII kinase signal for nuclear export and decreased dnTCF-1 expression. We propose that dnTCF-1 provides homeostatic regulation of Wnt signaling and growth in normal colon, and the alterations in nuclear export and promoter usage contribute to aberrant Wnt activity in colon cancer.


Assuntos
Adenoma/metabolismo , Núcleo Celular/metabolismo , Neoplasias do Colo/metabolismo , Fator 1 de Transcrição de Linfócitos T/metabolismo , Proteínas Supressoras de Tumor/metabolismo , Proteínas Wnt/metabolismo , Transporte Ativo do Núcleo Celular/genética , Adenoma/genética , Fatores de Transcrição de Zíper de Leucina e Hélice-Alça-Hélix Básicos/genética , Fatores de Transcrição de Zíper de Leucina e Hélice-Alça-Hélix Básicos/metabolismo , Proteína Quinase Tipo 2 Dependente de Cálcio-Calmodulina/genética , Proteína Quinase Tipo 2 Dependente de Cálcio-Calmodulina/metabolismo , Núcleo Celular/genética , Neoplasias do Colo/genética , Regulação Neoplásica da Expressão Gênica/genética , Humanos , Células Jurkat , Transdução de Sinais/genética , Fator 1 de Transcrição de Linfócitos T/genética , Fator de Transcrição 4 , Fatores de Transcrição/genética , Fatores de Transcrição/metabolismo , Proteínas Supressoras de Tumor/genética , Proteínas Wnt/genética
18.
Neurobiol Dis ; 34(2): 389-95, 2009 May.
Artigo em Inglês | MEDLINE | ID: mdl-19268537

RESUMO

Huntington's Disease is a neurodegenerative condition caused by a polyglutamine expansion in the huntingtin (Htt) protein, which aggregates and also causes neuronal dysfunction. Pathogenic N-terminal htt fragments perturb axonal transport in vitro. To determine whether this occurs in vivo and to elucidate how transport is affected, we expressed htt exon 1 with either pathogenic (HttEx1Q93) or non-pathogenic (HttEx1Q20) polyglutamine tracts in Drosophila. We found that HttEx1Q93 expression causes axonal accumulation of GFP-tagged fast axonal transport vesicles in vivo and leads to aggregates within larval motor neuron axons. Time-lapse video microscopy, shows that vesicle velocity is unchanged in HttEx1Q93-axons compared to HttEx1Q20-axons, but vesicle stalling occurs to a greater extent. Whilst HttEx1Q93 expression did not affect locomotor behaviour, external heat stress unveiled a locomotion deficit in HttEx1Q93 larvae. Therefore vesicle transport abnormalities amidst axonal htt aggregation places a cumulative burden upon normal neuronal function under stressful conditions.


Assuntos
Transporte Axonal/genética , Axônios/metabolismo , Sistema Nervoso Central/metabolismo , Drosophila/metabolismo , Neurônios Motores/metabolismo , Proteínas do Tecido Nervoso/genética , Proteínas do Tecido Nervoso/metabolismo , Proteínas Nucleares/genética , Proteínas Nucleares/metabolismo , Animais , Axônios/patologia , Temperatura Corporal/genética , Sistema Nervoso Central/patologia , Sistema Nervoso Central/fisiopatologia , Drosophila/genética , Feminino , Transtornos Neurológicos da Marcha/genética , Transtornos Neurológicos da Marcha/metabolismo , Transtornos Neurológicos da Marcha/fisiopatologia , Transtornos de Estresse por Calor/genética , Transtornos de Estresse por Calor/metabolismo , Transtornos de Estresse por Calor/fisiopatologia , Humanos , Proteína Huntingtina , Doença de Huntington/genética , Doença de Huntington/metabolismo , Doença de Huntington/fisiopatologia , Masculino , Neurônios Motores/patologia , Peptídeos/genética , Peptídeos/metabolismo , Estresse Fisiológico/genética , Vesículas Transportadoras/metabolismo , Vesículas Transportadoras/patologia
19.
Health Technol Assess ; 13(13): iii, ix-x, 1-121, 2009 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-19232157

RESUMO

OBJECTIVE: To estimate the clinical effectiveness and cost-effectiveness of three methods of ankle support compared with double layer tubular compression bandage. DESIGN: A randomised controlled trial, designed to reflect practice in UK hospital emergency departments. SETTING: Eight emergency departments in England. PARTICIPANTS: Aged 16 or over with acute severe ankle sprain, unable to weight bear, no fracture. INTERVENTIONS: 584 participants were randomised to one of four treatment arms: tubular bandage, below knee cast, Aircast ankle brace or Bledsoe boot, all applied 2-3 days after presentation to allow swelling to resolve. MAIN OUTCOME MEASURES: Response to treatment was assessed using the Foot and Ankle Outcome Score and generic measures (Functional Limitations Profile, SF-12 and EQ-5D). RESULTS: When adjusted for age, sex and baseline scores, the below knee cast offered a small but statistically significant benefit at 4 weeks in terms of pain (FAOS pain difference 5.1; 95% CI 0.4-9.8), foot- and ankle-related quality of life (QoL) (FAOS QoL difference 5.9; 95% CI 0.1-11.8) and the physical component of the SF-12 (SF-12 score difference 2.2; 95% CI 0.0-4.4). Neither the Aircast brace nor the Bledsoe boot was statistically or clinically better. At 12 weeks the below knee cast was significantly better than tubular bandage in terms of pain (FAOS pain difference 5.1; 95% CI 0.3-10.0), activities of daily living (FAOS ADL difference 3.5; 95% CI 0.4-6.6), sports (FAOS sports difference 8.7; 95% CI 1.6-15.7) and QoL (FAOS QoL difference 8.7; 95% CI 2.4-15.0), and the Aircast brace was better only in terms of ankle-related QoL and mental health. The Bledsoe boot conferred no significant advantage over tubular bandage. By 9 months there were no significant differences. Based on mean direct health-care costs per participant, the Bledsoe boot was the most expensive (215 pounds) and tubular bandage the least so (1 pound 44 pence). Inclusion of indirect costs (sick leave) raised overall costs substantially and removed any significant differences between the therapies. Cost-utility analysis demonstrated that the Aircast brace [301 pounds per quality-adjusted life-year (QALY)] and below knee cast (339 pounds per QALY) were more cost-effective than the Bledsoe boot (2116 pounds per QALY). However, inclusion of indirect costs produced different rank orders, depending on the assumptions made, and results should be treated with caution. CONCLUSIONS: The below knee cast and the Aircast brace offered cost-effective alternatives to tubular bandage for acute severe ankle sprain, the former having the advantage in terms of overall recovery at 3 months. As there were no differences in long-term outcome, practitioners should consider likely compliance and acceptability to patients when choosing a brace.


Assuntos
Traumatismos do Tornozelo/terapia , Bandagens/economia , Braquetes/economia , Moldes Cirúrgicos/economia , Restrição Física/instrumentação , Entorses e Distensões/terapia , Atividades Cotidianas , Adolescente , Adulto , Traumatismos do Tornozelo/economia , Traumatismos do Tornozelo/fisiopatologia , Análise Custo-Benefício , Feminino , Humanos , Masculino , Modalidades de Fisioterapia/economia , Recuperação de Função Fisiológica , Restrição Física/métodos , Entorses e Distensões/fisiopatologia , Inquéritos e Questionários , Avaliação da Tecnologia Biomédica , Resultado do Tratamento , Adulto Jovem
20.
Lancet ; 373(9663): 575-81, 2009 Feb 14.
Artigo em Inglês | MEDLINE | ID: mdl-19217992

RESUMO

BACKGROUND: Severe ankle sprains are a common presentation in emergency departments in the UK. We aimed to assess the effectiveness of three different mechanical supports (Aircast brace, Bledsoe boot, or 10-day below-knee cast) compared with that of a double-layer tubular compression bandage in promoting recovery after severe ankle sprains. METHODS: We did a pragmatic, multicentre randomised trial with blinded assessment of outcome. 584 participants with severe ankle sprain were recruited between April, 2003, and July, 2005, from eight emergency departments across the UK. Participants were provided with a mechanical support within the first 3 days of attendance by a trained health-care professional, and given advice on reducing swelling and pain. Functional outcomes were measured over 9 months. The primary outcome was quality of ankle function at 3 months, measured using the Foot and Ankle Score; analysis was by intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN37807450. RESULTS: Patients who received the below-knee cast had a more rapid recovery than those given the tubular compression bandage. We noted clinically important benefits at 3 months in quality of ankle function with the cast compared with tubular compression bandage (mean difference 9%; 95% CI 2.4-15.0), as well as in pain, symptoms, and activity. The mean difference in quality of ankle function between Aircast brace and tubular compression bandage was 8%; 95% CI 1.8-14.2, but there were little differences for pain, symptoms, and activity. Bledsoe boots offered no benefit over tubular compression bandage, which was the least effective treatment throughout the recovery period. There were no significant differences between tubular compression bandage and the other treatments at 9 months. Side-effects were rare with no discernible differences between treatments. Reported events (all treatments combined) were cellulitis (two cases), pulmonary embolus (two cases), and deep-vein thrombosis (three cases). INTERPRETATION: A short period of immobilisation in a below-knee cast or Aircast results in faster recovery than if the patient is only given tubular compression bandage. We recommend below-knee casts because they show the widest range of benefit. FUNDING: National Co-ordinating Centre for Health Technology Assessment.


Assuntos
Traumatismos do Tornozelo/terapia , Bandagens , Braquetes , Dor/classificação , Restrição Física/métodos , Entorses e Distensões/terapia , Atividades Cotidianas , Adulto , Feminino , Humanos , Masculino , Qualidade de Vida , Recuperação de Função Fisiológica , Fatores de Tempo
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