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1.
Bone Joint J ; 102-B(5): 632-637, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32349595

RESUMO

AIMS: Tibial plateau fractures are serious injuries about the knee that have the potential to affect patients' long-term function. To our knowledge, this is the first study to use patient-reported outcomes (PROs) with a musculoskeletal focus to assess the long-term outcome, as compared to a short-term outcome baseline, of tibial plateau fractures treated using modern techniques. METHODS: In total, 102 patients who sustained a displaced tibial plateau fracture and underwent operative repair by one of three orthopaedic traumatologists at a large, academic medical centre and had a minimum of five-year follow-up were identified. Breakdown of patients by Schatzker classification is as follows: two (1.9%) Schatzker I, 54 (50.9%) Schatzker II, two (1.9%) Schatzker III, 13 (12.3%) Schatzker IV, nine (8.5%) Schatzker V, and 26 (24.5%) Schatzker VI. Follow-up data obtained included: Visual Analogue Scale (VAS) or Numeric Rating Scale (NRS) pain scores, Short Musculoskeletal Functional Assessment (SMFA), and knee range of movement (ROM). Data at latest follow-up were then compared to 12-month data using a paired t-test. RESULTS: Patient-reported functional outcomes as assessed by overall SMFA were statistically significantly improved at five years (p < 0.001) compared with one-year data from the same patients. Patients additionally reported an improvement in the Standardized Mobility Index (p < 0.001), Standardized Emotional Index (p < 0.001), as well as improvement in Standardized Bothersome Index (p = 0.003) between the first year and latest follow-up. Patient-reported pain and knee ROM were similar at five years to their one-year follow-up. In total, 15 of the patients had undergone subsequent orthopaedic surgery for their knees at the time of most recent follow-up. Of note, only one patient had undergone knee arthroplasty following plateau fixation related to post-traumatic osteoarthritis (OA). CONCLUSION: Knee pain following tibial plateau fracture stabilizes at one year. However, PROs continue to improve beyond one year following tibial plateau fracture, at least in a statistical sense, if not also clinically. Patients displayed statistical improvement across nearly all SMFA index scores at their minimum five-year follow-up compared with their one-year follow-up. Cite this article: Bone Joint J 2020;102-B(5):632-637.


Assuntos
Fixação Interna de Fraturas/métodos , Redução Aberta/métodos , Medidas de Resultados Relatados pelo Paciente , Fraturas da Tíbia/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Amplitude de Movimento Articular , Recuperação de Função Fisiológica
2.
Medicine (Baltimore) ; 99(14): e19605, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32243383

RESUMO

Patients suffering from extremely medial clavicle fractures combined with distinct displacement generally need surgical intervention. Double-plate fixation is a widely applied technique in the treatment of distal radius fracture, which has been reported to fix lateral clavicle fracture as well. This study reveals the effect of double-plate fixation as an innovative procedure in the treatment of extremely medial clavicle fractures for the first time.Nine patients complaint of extremely medial clavicle fracture were enrolled in this research from May 2017 to March 2019. Patients were operated with an open reduction and internal fixation using the double-plate technique. Postoperative x-ray was taken regularly to observe the fracture healing at each visit, and the related complications were also recorded. The rating score systems of Constant Murley score of treated shoulder and contralateral shoulder, ROWE score as well as American Shoulder and Elbow Surgeons (ASES) were evaluated to comment on the postoperative shoulder joint function.All patients achieved postoperative fracture healing with no complications. Only 1 patient complained of slight restriction, 2 patients complained of pain during overhead work, and another patient was found with plate breakage. Meanwhile, the Constant Murley scores of treated and contralateral shoulder were 94.1 and 98.5 points, respectively, indicating the similar shoulder function. Furthermore, the ROWE and ASES scores of the involved shoulder were 96.7 and 96.3 points at average, respectively.It is the first time to introduce the surgical technique of vertical double-plate fixation implied in stable fixation of extremely medial clavicle fractures, which could provide the surgeons with an alternative method for this type of fracture.


Assuntos
Placas Ósseas , Clavícula/lesões , Fixação Interna de Fraturas/métodos , Fraturas Ósseas/cirurgia , Redução Aberta/métodos , Adulto , Idoso , Clavícula/cirurgia , Estudos de Viabilidade , Feminino , Consolidação da Fratura , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
3.
Lancet ; 395(10225): 698-708, 2020 02 29.
Artigo em Inglês | MEDLINE | ID: mdl-32050090

RESUMO

BACKGROUND: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. METHODS: HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896). FINDINGS: Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4-9) in the accelerated-surgery group and 24 h (10-42) in the standard-care group (p<0·0001). 140 (9%) patients assigned to accelerated surgery and 154 (10%) assigned to standard care died, with a hazard ratio (HR) of 0·91 (95% CI 0·72 to 1·14) and absolute risk reduction (ARR) of 1% (-1 to 3; p=0·40). Major complications occurred in 321 (22%) patients assigned to accelerated surgery and 331 (22%) assigned to standard care, with an HR of 0·97 (0·83 to 1·13) and an ARR of 1% (-2 to 4; p=0·71). INTERPRETATION: Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared with standard care. FUNDING: Canadian Institutes of Health Research.


Assuntos
Artroplastia de Quadril/métodos , Intervenção Médica Precoce/métodos , Fixação Interna de Fraturas/métodos , Hemiartroplastia/métodos , Fraturas do Quadril/cirurgia , Complicações Pós-Operatórias/epidemiologia , Tempo para o Tratamento/estatística & dados numéricos , Atividades Cotidianas , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/mortalidade , Comorbidade , Delírio/epidemiologia , Demência/epidemiologia , Diabetes Mellitus/epidemiologia , Feminino , Fraturas do Colo Femoral/epidemiologia , Fraturas do Colo Femoral/cirurgia , Fraturas do Quadril/epidemiologia , Humanos , Infecções/epidemiologia , Internacionalidade , Masculino , Pessoa de Meia-Idade , Mortalidade , Isquemia Miocárdica/epidemiologia , Casas de Saúde , Redução Aberta/métodos , Hemorragia Pós-Operatória/epidemiologia , Modelos de Riscos Proporcionais , Características de Residência/estatística & dados numéricos , Sepse/epidemiologia , Resultado do Tratamento
4.
Orthop Clin North Am ; 51(1): 13-26, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31739876

RESUMO

Open reduction and internal fixation of displaced acetabular fractures has been the gold standard for treatment of these complex injuries. The subset of older patients with dome impaction, femoral head impaction, or a posterior wall component are considered for treatment with concomitant open reduction and internal fixation and total hip arthroplasty. Little has been written on the surgical techniques to perform concomitant open reduction and internal fixation plus total hip arthroplasty safely. This article describes the important intrinsic factors for acetabular component stability, choice of surgical approach for management of these injuries, and surgical technique for anterior and posterior approaches.


Assuntos
Acetábulo/cirurgia , Cabeça do Fêmur/cirurgia , Fixação Interna de Fraturas/métodos , Redução Aberta/métodos , Acetábulo/lesões , Idoso , Artroplastia de Quadril/métodos , Cadáver , Cabeça do Fêmur/lesões , Fixação Interna de Fraturas/normas , Fraturas Ósseas/cirurgia , Fraturas do Quadril/cirurgia , Humanos , Redução Aberta/normas , Cuidados Pós-Operatórios , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Retrospectivos , Resultado do Tratamento
5.
Medicine (Baltimore) ; 98(52): e18429, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31876721

RESUMO

RATIONALE: Galeazzi fractures are uncommon, and are less common in children than in adults. Galeazzi-equivalent fractures, a variant of the classic Galeazzi fractures, mostly occur in children or adolescents. Galeazzi equivalent fractures may commonly accompany distal radial fractures or injury of the epiphyseal plate of the distal ulna. PATIENT CONCERNS: A 13-year-old man visited our emergency department after stumbling over a rock. Manual reduction and splinting was already done in a nearby medical center. Plain radiographs revealed fractures in the distal radius and fracture of the ulnar epiphyseal plate. DIAGNOSIS: Plain radiographs showed Galeazzi-equivalent fracture. The result of primary closed reduction was not enough and there was still displacement of fracture. INTERVENTIONS: Anatomical reduction of distal radius was fixed with a plate and screws, and K-wires were inserted percutaneously for reduction and fixation of ulnar fracture. OUTCOMES: Complete bone union was achieved and normal range of motion is shown 2 years postoperatively. The patient is able to perform daily activities and sport activities without any signs of ulnar growth arrest. LESSONS: Open reduction is required in patients with malalignment, failure to reduce the DRUJ or maintain its reduction, or older ages which are hard to expect sufficient bone remodeling.


Assuntos
Fraturas do Rádio/cirurgia , Fraturas da Ulna/cirurgia , Traumatismos do Punho/cirurgia , Acidentes por Quedas , Adolescente , Humanos , Masculino , Redução Aberta/métodos , Radiografia , Fraturas do Rádio/diagnóstico por imagem , Fraturas do Rádio/patologia , Fraturas da Ulna/diagnóstico por imagem , Fraturas da Ulna/patologia , Traumatismos do Punho/diagnóstico por imagem , Traumatismos do Punho/patologia
6.
Medicine (Baltimore) ; 98(48): e18186, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31770273

RESUMO

RATIONALE: Most pediatric distal radius fractures are effectively treated nonoperatively; however, operative intervention is indicated in patients with open and highly unstable fractures, in those with concomitant neurovascular injuries and in patients whom soft tissue interposition between fracture fragments precludes anatomical reduction. Notably, soft tissue interposition between fracture fragments is diagnostically challenging. Surgeons must be mindful of this rare complication for early detection and prompt treatment. PATIENT CONCERNS: A 14-year-old boy presented to the emergency department with left wrist pain after falling from a bicycle. Plain radiography and computed tomography revealed a displaced Smith fracture, which was irreducible by closed reduction, necessitating open reduction and volar plate fixation. The patient reported inability to extend his thumb at his 6-week postoperative follow-up visit. DIAGNOSIS: Ultrasonography showed extensor pollicis longus (EPL) tendon entrapment near the fracture site. INTERVENTIONS: A second operation was performed 10 weeks after the first surgery, and intraoperative exploration revealed EPL tendon entrapment. The EPL tendon was torn to shreds; therefore, extensor indicis proprius tendon transfer was performed for EPL tendon reconstruction. OUTCOMES: The patient's thumb motion was completely restored after the second operation. LESSENS: EPL tendon entrapment in a pediatric Smith fracture is rare. Signs of EPL tendon entrapment include inability to perform active thumb extension, dorsal wrist pain radiating along the course of the EPL tendon, which is exacerbated by thumb flexion, a tenodesis effect elicited on thumb examination, and difficulty in anatomical fracture reduction. Surgical exploration of the EPL tendon is warranted in patients presenting with any of these signs following attempted reduction of a Smith fracture.


Assuntos
Redução Aberta , Fraturas do Rádio , Encarceramento do Tendão , Transferência Tendinosa/métodos , Traumatismos do Punho , Adolescente , Placas Ósseas , Fratura-Luxação/diagnóstico , Fratura-Luxação/cirurgia , Humanos , Masculino , Redução Aberta/efeitos adversos , Redução Aberta/instrumentação , Redução Aberta/métodos , Radiografia/métodos , Rádio (Anatomia)/diagnóstico por imagem , Rádio (Anatomia)/lesões , Fraturas do Rádio/diagnóstico , Fraturas do Rádio/fisiopatologia , Fraturas do Rádio/cirurgia , Amplitude de Movimento Articular , Reoperação/métodos , Encarceramento do Tendão/diagnóstico , Encarceramento do Tendão/etiologia , Encarceramento do Tendão/cirurgia , Polegar/fisiopatologia , Resultado do Tratamento , Traumatismos do Punho/diagnóstico , Traumatismos do Punho/fisiopatologia , Traumatismos do Punho/cirurgia
7.
Bone Joint J ; 101-B(11): 1385-1391, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31674242

RESUMO

AIMS: The primary aim of this study was to determine if delayed clavicular fixation results in a greater risk of operative complications and revision surgery. PATIENTS AND METHODS: A retrospective case series was undertaken of all displaced clavicular fractures that underwent plate fixation over a ten-year period (2007 to 2017). Patient demographics, time to surgery, complications, and mode of failure were collected. Logistic regression was used to identify independent risk factors contributing towards operative complications. Receiver operating characteristic (ROC) curve analysis was used to determine if a potential 'safe window' exists from injury to delayed surgery. Propensity score matching was used to construct a case control study for comparison of risk. RESULTS: A total of 259 patients were included in the analysis. Postoperative infection occurred in 3.9% of all patients (n = 10); the only variable associated was a greater time interval from injury to fixation (p = 0.001). Failed primary surgery requiring revision fixation was required in 7.7% of the cohort (n = 20), with smoking (p < 0.001), presence of a postoperative infection (p < 0.001), increasing age (p = 0.018), and greater time delay from injury to surgery (p = 0.015) identified as significant independent predictors on regression analysis. ROC analysis revealed that surgery beyond 96 days from injury increased the rate of major complications and revision surgery. Using a matched case cohort of cases before (n = 67) and after (n = 77) the 'safe window', the risk of postoperative infection increased (odds ratio (OR) 7.7, 95% confidence interval (CI) 1.9 to 62.9; p = 0.028), fixation failure (OR 3.8, 95% CI 1.2 to 12.1; p = 0.017) and revision surgery (OR 4.8, 95% CI 1.5 to 15.0; p = 0.004). CONCLUSION: A delay to primary fixation of up to three months following injury may be acceptable, beyond which there is an increased risk of major operative complications and revision surgery. Cite this article: Bone Joint J 2019;101-B:1385-1391.


Assuntos
Clavícula/lesões , Fixação Interna de Fraturas/métodos , Fraturas Ósseas/cirurgia , Redução Aberta/métodos , Adulto , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fraturas Periprotéticas/etiologia , Fraturas Periprotéticas/cirurgia , Complicações Pós-Operatórias/etiologia , Curva ROC , Reoperação/estatística & dados numéricos , Fatores de Risco , Infecção da Ferida Cirúrgica , Tempo para o Tratamento , Adulto Jovem
8.
J Hand Surg Asian Pac Vol ; 24(4): 462-468, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31690187

RESUMO

Background: The purpose of this study was to determine whether baseline characteristics predict outcomes twelve weeks after open reduction and internal fixation of proximal phalangeal fracture. Methods: A cohort of patients (n = 48, mean 35 years; SD 11) commencing outpatient rehabilitation within one week of surgery were reviewed. Outcomes of interest were active PIP extension; active total range of motion; pain at rest; comprehensive pain; strength; and hand use (reported difficulty performing specific activities such as turning a door handle, as well as usual activities including housework and recreation) at twelve weeks. Possible predictors included which finger is injured, whether the fracture is intra or extra-articular, whether the dominant or non-dominant hand is injured and/or how much pain is experienced in the first post-operative week. Multiple linear regression was performed to produce a model of the prediction for each outcome of interest at Week 1 (baseline). Results: Results from multivariate linear regression analyses suggest that pain at rest at baseline was significantly predictive of pain at rest (OR = 1.25, 95% CI = 1.06-1.47), p = 0.01), comprehensive pain (OR = 3.18, 95% CI = 1.47-6.84, p = 0.01), and hand use (OR = 2.38, 95% CI = 1.18-4.80, p = 0.02) twelve weeks after open reduction and internal fixation of proximal phalangeal fracture. The turning point on the receiver-operator characteristic curve of false versus true risk (AUC = 0.94, p = 0.04) indicated that at least a score of 4.5 on the 10 cm visual analogue scale for baseline resting pain was needed for significant likelihood of reduced hand use. Which finger was injured, location of fracture and side of injury were not predictive of any outcomes. Conclusions: Moderate to high levels of resting pain in the week following surgery for proximal phalangeal fracture is predictive of pain and hand use at twelve weeks. Moderate to high levels of resting pain should be recognised as unusual, and could be targeted in rehabilitation. Further prospective studies are needed to determine whether early identification and targeted intervention to reduce pain improves outcomes at 12 weeks.


Assuntos
Falanges dos Dedos da Mão/lesões , Fixação Interna de Fraturas/métodos , Fraturas Ósseas/cirurgia , Força da Mão/fisiologia , Redução Aberta/métodos , Dor Pós-Operatória/diagnóstico , Amplitude de Movimento Articular/fisiologia , Adolescente , Adulto , Idoso , Feminino , Falanges dos Dedos da Mão/cirurgia , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento , Adulto Jovem
9.
J Hand Surg Asian Pac Vol ; 24(4): 435-439, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31690190

RESUMO

Background: The role of early radiographic imaging in the management of distal radius fractures (DRFs) is unclear. The aim of this study was to assess whether early post-operative radiographs for DRFs influences the ongoing management of this patient group. We hypothesize that routine early radiographs do not influence the management of DRFs. Methods: This was a retrospective review of patients undergoing open reduction and internal fixation using a volar locking plate between 2012 and 2017 at our institution. Patients were identified using hospital electronic databases. Clinical information was gathered from the electronic health records and PACS systems and analysed on a spreadsheet. An early post-operative radiograph was defined by the authors as imaging on a patient's first postoperative visit. Results: 237 patients were identified. The median number of days patients were reviewed post-operatively was 13 (interquartile range 9-16). 172 (73.1%) patients had early post-operative radiographs, with 100 (58.1%) intra-articular and 72 (41.9%) extra-articular fractures. Of patients who underwent imaging, 7 (4.0%) had their post-operative fracture management altered (7 intra-articular, 0 extra-articular) with 1 (0.58%) requiring immediate surgical revision as indicated by imaging. Conclusions: Our study questions the value of routine early post-operative radiographs in the management of distal radius fracture fixations, in particular if the fracture is extra-articular. This is of importance in the setting of constrained resources and represents a poor use of limited healthcare facilities, as well as unnecessary radiation exposure.


Assuntos
Placas Ósseas , Fixação Interna de Fraturas/métodos , Fraturas Intra-Articulares/cirurgia , Redução Aberta/métodos , Fraturas do Rádio/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Seguimentos , Humanos , Fraturas Intra-Articulares/diagnóstico , Pessoa de Meia-Idade , Radiografia , Fraturas do Rádio/diagnóstico , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
10.
J Pediatr Orthop B ; 28(6): 530-535, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31568219

RESUMO

The aim of this study was to analyse the management of Gartland type III supracondylar humerus fractures in children older than 10 years at our paediatric orthopaedics and to determine the clinical and radiographic long-term effects following open reduction by the small medial approach and cross-fixation with three kirschner wires. Eighty-three cases of Gartland type III supracondylar humerus fractures in children older than 10 years were treated by open reduction by the small medial approach and cross-fixation with three kirschner wires from January 2010 to December 2015. All patients were followed up from 12 to 15 months (mean: 13 months). Assessments after 1 year included neurovascular examination, Flynn's criteria (elbow function and carrying angle), pain and complications (infections, growth disturbances or iatrogenic nerve injuries). All fractures healed within 2 months. According to Flynn's criteria, 80 (96.4%) patients achieved satisfactory outcomes, whereas three (3.6%) were graded as unsatisfactory because of limited elbow motion. The mean carrying angle measured 9.4° (1°-16°) compared with 10.8° on the contralateral side (5°-16°). No case of cubitus varus was noted. No wound infection and displacement of bone fracture occurred. No case of iatrogenic ulnar nerve injury and vascular deficits was noted. There were no cases of myositis ossificans or Volkmann's ischaemic contracture. It is safe and effective to treat Gartland type III paediatric supracondylar humerus fractures in older children with open reduction by the medial approach and crossed K-wires fixation.


Assuntos
Fraturas do Úmero/diagnóstico por imagem , Fraturas do Úmero/cirurgia , Redução Aberta/métodos , Adolescente , Criança , Feminino , Seguimentos , Humanos , Masculino , Estudos Retrospectivos
11.
Bone Joint J ; 101-B(10): 1272-1279, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31564147

RESUMO

AIMS: To compare complication-related reoperation rates following primary arthroplasty for proximal humerus fractures (PHFs) versus secondary arthroplasty for failed open reduction and internal fixation (ORIF). PATIENTS AND METHODS: We identified patients aged 50 years and over, who sustained a PHF between 2004 and 2015, from linkable datasets. We used intervention codes to identify patients treated with initial ORIF or arthroplasty, and those treated with ORIF who returned for revision arthroplasty within two years. We used multilevel logistic regression to compare reoperations between groups. RESULTS: We identified 1624 patients who underwent initial arthroplasty for PHF, and 98 patients who underwent secondary arthroplasty following failed ORIF. In total, 72 patients (4.4%) in the primary arthroplasty group had a reoperation within two years following arthroplasty, compared with 19 patients (19.4%) in the revision arthroplasty group. This difference was significantly different (p < 0.001) after covariable adjustment. CONCLUSION: The number of reoperations following arthroplasty for failed ORIF of PHF is significantly higher compared with primary arthroplasty. This suggests that primary arthroplasty may be a better choice for patients whose prognostic factors suggest a high reoperation rate following ORIF. Prospective clinical studies are required to confirm these findings. Cite this article: Bone Joint J 2019;101-B:1272-1279.


Assuntos
Artroplastia do Ombro/efeitos adversos , Redução Aberta/efeitos adversos , Complicações Pós-Operatórias/cirurgia , Amplitude de Movimento Articular/fisiologia , Reoperação/estatística & dados numéricos , Fraturas do Ombro/cirurgia , Idoso , Artroplastia do Ombro/métodos , Estudos de Coortes , Intervalos de Confiança , Feminino , Seguimentos , Humanos , Incidência , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Razão de Chances , Redução Aberta/métodos , Medição da Dor , Complicações Pós-Operatórias/fisiopatologia , Falha de Prótese , Estudos Retrospectivos , Medição de Risco , Fraturas do Ombro/diagnóstico por imagem , Resultado do Tratamento
12.
J Bone Joint Surg Am ; 101(19): 1768-1774, 2019 Oct 02.
Artigo em Inglês | MEDLINE | ID: mdl-31577682

RESUMO

BACKGROUND: As orthopaedic surgery moves toward bundled payments, there is growing interest in identifying patients at high risk of early postoperative adverse events. The purpose of this study was to develop and validate a risk-stratification system for the occurrence of early adverse events among patients treated with open reduction and internal fixation (ORIF) for a closed fracture of the ankle. METHODS: Patients undergoing ORIF for a closed ankle fracture during the period of 2006 to 2017, as documented by the American College of Surgeons National Surgical Quality Improvement Program, were identified. For the 60% of patients randomly selected as the development cohort, multivariate Cox proportional hazards modeling was used to identify factors that were independently associated with the occurrence of adverse events (including events such as reoperation, surgical site infection, and pulmonary embolism). On the basis of these results, a nomogram analysis was used to generate a point-based risk-stratification system. To evaluate the validity of the point-based system, the system was applied to the remaining 40% of patients constituting the validation cohort and tested for its ability to predict adverse events. RESULTS: Of the 7,582 patients in the development cohort, 455 developed an adverse event (estimated adverse event risk of 6%). On the basis of Cox proportional-hazards regression, patients were assigned points for each of the following significant risk factors: +1 point for age of 40 to 59 years, +3 points for age of 60 to 79 years, +5 points for age of ≥80 years, +1 point for female sex, +2 points for chronic obstructive pulmonary disease (COPD), +2 points for insulin-dependent diabetes, +3 points for anemia, and +4 points for end-stage renal disease. The validation cohort included 5,263 patients. Among this second cohort, the risk-stratification system predicted the risk of early adverse events (p < 0.001; Harrell C = 0.697). CONCLUSIONS: The occurrence of early adverse events following ORIF for closed ankle fractures was associated with greater age, female sex, COPD, insulin-dependent diabetes, anemia, and end-stage renal disease. We present and validate a simple point-based risk-stratification system to predict the risk of early adverse events. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Fraturas do Tornozelo/terapia , Fixação Interna de Fraturas/métodos , Redução Aberta/métodos , Adulto , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Ambulatórios/estatística & dados numéricos , Anemia/complicações , Fraturas do Tornozelo/complicações , Diabetes Mellitus Tipo 1/complicações , Feminino , Humanos , Falência Renal Crônica/complicações , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/complicações , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores Sexuais
13.
J Shoulder Elbow Surg ; 28(11): 2215-2224, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31630752

RESUMO

BACKGROUND: The treatment of multifragment Mason type III fractures is challenging. Open reduction-internal fixation (ORIF), radial head arthroplasty, and in some cases, even radial head resection are the current options; however, each of these treatment methods is associated with characteristic benefits and complications. We present our experience with a radial head salvage procedure in comminuted radial head fractures irrespective of concomitant injuries, which are not accompanied by typical ORIF-related complications. METHODS: The first group comprised 29 patients with multifragment Mason type III fractures treated surgically with biological radial head spacers (group S). The fragments were reduced and fixated in an extracorporeal manner, and the reconstructed radial head was placed in its anatomic position without fixation to the shaft. The second group comprised 12 patients treated with conventional ORIF using mini-fragment plates (group P). RESULTS: Thirty patients were enrolled to undergo clinical and radiographic follow-up at an average of 76 months (range, 12-152 months). In group S, nonunion at the head-neck junction developed in 70% of the cases; however, the overall Mayo Elbow Performance Index averaged 94.8, which was superior to the average Mayo Elbow Performance Index of 83.1 in group P. Radiographic evaluation showed development of osteoarthritic changes in 75% of patients in group S and 62.5% in group P. None of the patients had wrist-joint pain. CONCLUSIONS: Preserving the native radial head in comminuted Mason type III fractures without fixation to the radial shaft is a reliable option. Excellent functional results can be expected; however, the development of osteoarthritis cannot be impeded.


Assuntos
Fixação Interna de Fraturas/métodos , Fraturas Cominutivas/cirurgia , Redução Aberta/métodos , Fraturas do Rádio/cirurgia , Adulto , Placas Ósseas , Estudos de Casos e Controles , Articulação do Cotovelo/fisiopatologia , Articulação do Cotovelo/cirurgia , Epífises/lesões , Epífises/cirurgia , Feminino , Seguimentos , Fixação Interna de Fraturas/instrumentação , Fraturas Cominutivas/diagnóstico por imagem , Fraturas Cominutivas/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Osteoartrite/etiologia , Fraturas do Rádio/diagnóstico por imagem , Fraturas do Rádio/fisiopatologia , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
14.
BMC Musculoskelet Disord ; 20(1): 403, 2019 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-31484528

RESUMO

BACKGROUND: The Constant score (CS) is one of the most frequently applied tools for the assessment of the shoulder joint. However, evaluation of strength is not standardized leading to potential bias when comparing different studies. METHODS: Seventy-six patients with fractures of the proximal humerus undergoing open reduction and internal fixation (ORIF) were assessed using standardized CS strength measurements at the deltoid muscle insertion and at the wrist in three different arm positions. Variation coefficients were evaluated for each patient and position. RESULTS: Forty women (57%) and 36 men (43%) were examined 96 months in mean after ORIF. We could state a maximum of 105.3 N difference if measurements were performed at the wrist or the insertion of the deltoid muscle in 90° forward flexion on the injured arm (167.9 ± 83.1 N; 62.6 ± 29.4 N). The lowest variation coefficient of the three performed measurements could be stated at the deltoid muscle insertion in a 90° abduction position in the scapula plane (6.94 ± 5.5). CONCLUSION: Following our study results, different positions of force measurement can change the total CS by a whole category (e.g. "very good" to "good"). We recommend performing the measurement at the insertion of the deltoid muscle in a 90° abduction position in the scapula plane. Otherwise, even in the non-injured, it is hard to reach a "normal" shoulder function, based on the CS. When using the CS as outcome parameter, authors must give detailed information about the force measuring and use an exact measuring device.


Assuntos
Músculo Deltoide/fisiologia , Avaliação da Deficiência , Amplitude de Movimento Articular/fisiologia , Fraturas do Ombro/cirurgia , Articulação do Ombro/fisiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Placas Ósseas , Proteína de Capeamento de Actina CapZ , Feminino , Seguimentos , Fixação Interna de Fraturas/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Força Muscular/fisiologia , Redução Aberta/instrumentação , Redução Aberta/métodos , Fragmentos de Peptídeos , Reprodutibilidade dos Testes , Fraturas do Ombro/fisiopatologia
15.
BMC Musculoskelet Disord ; 20(1): 397, 2019 Aug 31.
Artigo em Inglês | MEDLINE | ID: mdl-31472691

RESUMO

BACKGROUND: Thoracolumbar fractures are most frequent along the spine, and surgical treatment is indicated for unstable fractures. Percutaneous minimally invasive surgery was introduced to reduce the pain associated with the open posterior approach and reduce the morbidity of the procedure by avoiding damage and dissection of the paravertebral muscles. The goal of this study is to compare the surgical treatment of fractures of the thoracolumbar spine treated by the conventional open approach and the percutaneous minimally invasive approach using similar types of pedicle spine fixation systems. METHODS/DESIGNS: This study is designed as a multi-center, randomized controlled trial of patients aged 18-65 years who are scheduled to undergo surgical posterior fixation. Treatment by the conventional open approach or percutaneous minimally invasive approach will be randomly assigned. The primary outcome measure is postoperative pain, which will be measured using the visual analogue scale (VAS). The secondary outcome parameters are intraoperative bleeding, postoperative drainage, surgery time, length of hospital stay, SF-36, EQ-5D-5 l, HADS, pain medication, deambulation after surgery, intraoperative fluoroscopy time, vertebral segment kyphosis, fracture vertebral body height, compression of the vertebral canal, accuracy of the pedicle screws, and breakage or release of the implants. Patient will be followed up for 1, 2, 3, 6, 12 and 24 months postoperatively and evaluated according to the outcomes using clinical and radiological examinations, plain radiographs and computed tomografy (CT). DISCUSSION: Surgical treatment of thoracolumbar fractures by the open or percutaneous minimally invasive approach will be compared in a multicenter randomized study using similar types of fixation systems, and the results will be evaluated according to clinical and radiological parameters at 1, 2, 3, 6, 12 and 24 months of follow-up. TRIAL REGISTRATION: ClinicalTrial.gov approval number: 1.933.631, code: NCT03316703 in may 2017.


Assuntos
Fixação Interna de Fraturas/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Redução Aberta/efeitos adversos , Dor Pós-Operatória/diagnóstico , Fraturas da Coluna Vertebral/cirurgia , Adolescente , Adulto , Idoso , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Feminino , Seguimentos , Fixação Interna de Fraturas/instrumentação , Fixação Interna de Fraturas/métodos , Humanos , Tempo de Internação/estatística & dados numéricos , Vértebras Lombares/lesões , Vértebras Lombares/cirurgia , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/instrumentação , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Estudos Multicêntricos como Assunto , Redução Aberta/instrumentação , Redução Aberta/métodos , Duração da Cirurgia , Medição da Dor , Dor Pós-Operatória/epidemiologia , Dor Pós-Operatória/etiologia , Parafusos Pediculares , Ensaios Clínicos Controlados Aleatórios como Assunto , Índice de Gravidade de Doença , Vértebras Torácicas/lesões , Vértebras Torácicas/cirurgia , Resultado do Tratamento , Adulto Jovem
16.
Iowa Orthop J ; 39(1): 51-55, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31413674

RESUMO

Background: Lateral condyle fractures are associated with high morbidity due to their risk of nonunion and avascular necrosis (AVN). This study aims to assess the outcomes between closed reduction and the more traditional open techniques for operative fractures. Methods: All lateral condyle fractures that required operative fixation (pins or screws) over a ten-year period were included. We compared open versus closed reduction for OR time, infection rate, AVN, nonunion, premature physeal closure, ulnohumeral angle, and interepicondylar width (IEW). Results: 28 patients were identified in the closed reduction group while 41 were identified in the open reduction group. Average displacement at surgery for these two groups was significantly different at 3.95mm for the closed group and 9.47mm for the open group (p<0.0001). Operating room time was significantly greater for the open reduction group by an average of 45 minutes (p <0.0001). Additionally, the closed reduction group was significantly less likely to require postoperative admission compared to the open reduction group (p=0.0004). There were no significant differences between the two groups with regard to abnormal ulnohumeral angles, infection rates, avascular necrosis, nonunion, lateral spur formation, premature physeal closure, or reoperation rate. Conclusions: The significant differences in OR time and post-operative admission make closed reduction the preferred approach from a hospital system quality improvement standpoint.Level of Evidence: IV.


Assuntos
Articulação do Cotovelo/lesões , Fixação Interna de Fraturas/métodos , Consolidação da Fratura/fisiologia , Fraturas do Úmero/cirurgia , Redução Aberta/métodos , Amplitude de Movimento Articular/fisiologia , Adolescente , Pinos Ortopédicos , Criança , Pré-Escolar , Articulação do Cotovelo/cirurgia , Feminino , Seguimentos , Fixação Interna de Fraturas/instrumentação , Humanos , Fraturas do Úmero/diagnóstico por imagem , Escala de Gravidade do Ferimento , Masculino , Radiografia/métodos , Medição de Risco , Fatores de Tempo , Resultado do Tratamento
17.
BMJ Case Rep ; 12(8)2019 Aug 04.
Artigo em Inglês | MEDLINE | ID: mdl-31383681

RESUMO

Capitellum fractures represent 1% of elbow fractures. A coronal shear fracture which involves the trochlea is classified as a type IV McKee fracture. The combination of its rarity in the paediatric population as well as its unique appearance on X-ray make diagnosis of this fracture a challenge. We present the case of a 14-year-old boy who sustained this fracture falling from his bike. It was diagnosed from the double arc sign on X-ray. In addition, a CT scan was obtained to aid preoperative planning. It was treated by open reduction and fixation with two headless compression screws. Follow-up at 6 months showed no avascular necrosis. The patient could achieve full extension, while flexion was reduced only by 5°. Final follow-up was conducted at 15 months. Anatomic reduction and stable internal fixation are essential for a good outcome in these uncommon paediatric fractures.


Assuntos
Ciclismo/lesões , Cotovelo/lesões , Fixação Interna de Fraturas/métodos , Fraturas do Úmero/cirurgia , Redução Aberta/métodos , Adolescente , Parafusos Ósseos , Cotovelo/cirurgia , Humanos , Fraturas do Úmero/etiologia , Masculino
18.
Orthopedics ; 42(5): e480-e484, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31408519

RESUMO

Ankle syndesmosis malreduction is a common problem that leads to significantly worse functional outcomes. This report describes the replacement of a rigid syndesmotic screw with a flexible suture button fixation device to correct fibular translation and tibiotalar malalignment related to screw contact with other tibial implants. Suture button devices, although more expensive, can result in less postoperative malreduction and lead to better functional outcomes. As seen in these cases, careful attention should be given to syndesmotic or tibiotalar reduction after screw placement around other tibial implants, and the screw can be exchanged to a suture button device to address malreduction, if needed. [Orthopedics. 2019; 42(5):e480-e484.].


Assuntos
Traumatismos do Tornozelo/cirurgia , Fixação Interna de Fraturas/instrumentação , Redução Aberta/instrumentação , Idoso , Articulação do Tornozelo/cirurgia , Parafusos Ósseos/efeitos adversos , Fíbula/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Redução Aberta/métodos , Tíbia/cirurgia
19.
J Bone Joint Surg Am ; 101(15): 1335-1341, 2019 Aug 07.
Artigo em Inglês | MEDLINE | ID: mdl-31393423

RESUMO

BACKGROUND: Fractures of the lateral aspect of the clavicle with complete displacement have a high nonunion rate and are associated with poor functional outcomes following nonoperative treatment. Various techniques are available to treat these fractures, but preliminary studies of open reduction and tunneled suspensory device (ORTSD) fixation have shown good early functional outcomes with a low rate of complications; our goal was to assess the functional outcomes and complications in the medium term in a larger series of patients treated using this technique. METHODS: Sixty-seven patients with displaced lateral-end clavicular fractures were treated with ORTSD fixation. Outcome was assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and the Oxford shoulder score at 6 weeks and 3, 6, and 12 months postoperatively. Fifty-five of 64 surviving patients were subsequently contacted at a mean of 69 months (range, 27 to 120 months) postoperatively to complete DASH and Oxford shoulder scores, to evaluate their overall level of satisfaction, and to document any further complications. RESULTS: At 1 year postoperatively, the mean Oxford shoulder score was 46.4 points and the mean DASH score was 2.4 points in 59 of the 67 patients assessed at this time interval. At the later follow-up (mean, 69 months), the mean Oxford shoulder score was 46.5 points and the mean DASH score was 2.2 points in the 55 surviving patients who were able to be contacted. There were no significant differences between the 1-year functional scores and those at the latest follow-up. Two patients developed a symptomatic nonunion requiring reoperation, and 2 patients developed an asymptomatic fibrous union not requiring a surgical procedure. The 5-year survival when considering only obligatory revision for implant-related complications was 97.0%. CONCLUSIONS: ORTSD fixation for isolated displaced lateral-end clavicular fractures in medically fit patients is associated with good functional outcomes and a low rate of complications in the medium term. Routine implant removal was not necessary. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Clavícula/cirurgia , Fratura-Luxação/cirurgia , Fraturas Ósseas/cirurgia , Redução Aberta/instrumentação , Amplitude de Movimento Articular/fisiologia , Adolescente , Adulto , Idoso , Clavícula/lesões , Estudos de Coortes , Feminino , Seguimentos , Fratura-Luxação/diagnóstico por imagem , Consolidação da Fratura/fisiologia , Fraturas Ósseas/diagnóstico por imagem , Humanos , Escala de Gravidade do Ferimento , Fixadores Internos , Masculino , Pessoa de Meia-Idade , Redução Aberta/efeitos adversos , Redução Aberta/métodos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Articulação do Ombro/fisiologia , Estatísticas não Paramétricas , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
20.
J Bone Joint Surg Am ; 101(15): 1342-1350, 2019 Aug 07.
Artigo em Inglês | MEDLINE | ID: mdl-31393424

RESUMO

BACKGROUND: Routine radiography in the follow-up of distal radial fractures is common practice, although its usefulness is disputed. The aim of this study was to determine whether the number of radiographs in the follow-up period can be reduced without resulting in worse patient outcomes. METHODS: In this multicenter, prospective, randomized controlled trial with a non-inferiority design, patients ≥18 years old with a distal radial fracture could participate. They were randomized between a regimen with routine radiographs at 6 and 12 weeks of follow-up (usual care) and a regimen without routine radiographs at those time points (reduced imaging). Randomization was performed using an online registration and randomization program. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) score. Secondary outcomes included the Patient-Rated Wrist/Hand Evaluation (PRWHE) score, health-related quality of life, pain, and complications. Outcomes were assessed at baseline and after 6 weeks, 3 months, 6 months, and 1 year of follow-up. Data were analyzed using mixed models. Neither the patients nor the health-care providers were blinded. RESULTS: Three hundred and eighty-six patients were randomized, and 326 of them were ultimately included in the analysis. The DASH scores were comparable between the usual-care group (n = 166) and the reduced-imaging group (n = 160) at all time points as well as overall. The adjusted regression coefficient for the DASH scores was 1.5 (95% confidence interval [CI] = -1.8 to 4.8). There was also no difference between the groups with respect to the overall PRWHE score (adjusted regression coefficient, 1.4 [95% CI = -2.4 to 5.2]), quality of life as measured with the EuroQol-5 Dimensions (EQ-5D) (-0.02 [95% CI = -0.05 to 0.01]), pain at rest as measured with a visual analog scale (VAS) (0.1 [95% CI = -0.2 to 0.5]), or pain when moving (0.3 [95% CI = -0.1 to 0.8]). The complication rate was similar in the reduced imaging group (11.3%) and the usual-care group (11.4%). Fewer radiographs were made for the participants in the reduced-imaging group (median, 3 versus 4; p < 0.05). CONCLUSIONS: This study shows that omitting routine radiography after the initial 2 weeks of follow-up for patients with a distal radial fracture does not affect patient-reported outcomes or the risk of complications compared with usual care. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Avaliação da Deficiência , Redução Aberta/métodos , Radiografia/estatística & dados numéricos , Fraturas do Rádio/diagnóstico por imagem , Procedimentos Desnecessários , Traumatismos do Punho/diagnóstico por imagem , Adolescente , Adulto , Análise de Variância , Feminino , Seguimentos , Humanos , Escala de Gravidade do Ferimento , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Países Baixos , Estudos Prospectivos , Fraturas do Rádio/cirurgia , Medição de Risco , Fatores de Tempo , Traumatismos do Punho/cirurgia , Adulto Jovem
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