RESUMO
OBJECTIVE: To examine the effect of severe lower extremity trauma on meeting Physical Activity Guidelines for Americans (PAGA) 18 months after injury and perform an exploratory analysis to identify demographic, clinical, and psychosocial factors associated with meeting PAGA. DESIGN: Secondary analysis of observational cohort study. SETTING: A total of 34 United States trauma centers PARTICIPANTS: A total of 328 adults with severe distal tibia, ankle and mid- to hindfoot injuries treated with limb reconstruction (N=328). INTERVENTIONS: None. MAIN OUTCOME MEASURES: The Paffenbarger Physical Activity Questionnaire was used to assess physical activity levels 18 months after injury. Meeting PAGA was defined as combined moderate- and vigorous-intensity activity ≥150 minutes per week or vigorous-intensity activity ≥75 minutes per week. RESULTS: Fewer patients engaged in moderate- or vigorous-intensity activity after injury compared with before injury (moderate: 44% vs 66%, P<.001; vigorous: 18% vs 29%; P<.001). Patients spent 404±565 minutes per week in combined moderate- to vigorous-intensity activity before injury compared with 224±453 minutes postinjury (difference: 180min per week; 95% confidence interval [CI], 103-256). The adjusted odds of meeting PAGA were lower for patients with depression (adjusted odds ratio [AOR], 0.45; 95% CI, 0.28-0.73), women (AOR, 0.59; 95% CI, 0.35-1.00), and Black or Hispanic patients (AOR, 0.49; 95% CI, 0.28-0.85). Patients meeting PAGA prior to injury were more likely to meet PAGA after injury (odds ratio, 2.0; 95% CI, 1.20-3.31). CONCLUSIONS: Patients spend significantly less time in moderate- to vigorous-intensity physical activity after injury. Patients with depression are less likely to meet PAGA. Although the causal relationship is unclear, results highlight the importance of screening for depression.
Assuntos
Tornozelo , Tíbia , Adulto , Exercício Físico , Feminino , Humanos , Razão de Chances , Centros de Traumatologia , Estados UnidosRESUMO
The purpose was to compare plate and screw fixation (open reduction internal fixation [ORIF]) and functional bracing (FB) of isolated humeral shaft fractures with treatment and patient-based outcomes. We performed a prospective trial of ORIF v. FB at 12 centers. Surgeons counseled patients on treatment options and a patient centered decision was made. We enrolled 179 patients, of which 6-month data was analyzed for 102 (39 female; 63 male). Forty-five were treated with ORIF and 57 with FB. We found no difference in the disability of the arm, shoulder and hand (DASH) score, visual analogue score (VAS) or elbow range of motion (ROM) at 6 months. However, 11% of the FB group developed nonunion. Complications in the ORIF group included a 2% infection and nonunion rate and 13% iatrogenic radial nerve dysfunction (RND). ORIF can be expected to result in higher union rates with the inherent risks of infection and RND. Finally, at 6 months, both groups demonstrated higher DASH scores than population norms, indicating a lack of full recovery. (Journal of Surgical Orthopaedic Advances 30(2):067-072, 2021).
Assuntos
Fixação Interna de Fraturas , Fraturas do Úmero , Placas Ósseas , Feminino , Humanos , Fraturas do Úmero/cirurgia , Úmero , Masculino , Redução Aberta , Estudos Prospectivos , Resultado do TratamentoRESUMO
Our purpose was to evaluate radiographic alignment of nonoperatively treated humerus fractures and determine if there is a critical angle associated with worse outcomes. All patients with humeral shaft fractures that were prospectively followed as part of a larger multicenter trial were reviewed. These patients were selected for nonoperative management based on shared decision making. There were 80 patients that healed with adequate data. The receiver operating characteristic (ROC) had best fit with a sagittal radiographic angle of 10° (AUC: 0.731) and coronal angle of 15° (AUC: 0.580) at 1-year follow-up. We found increased or worse disabilities of the arm, shoulder and hand (DASH) scores with > 10° sagittal alignment or > 15° of coronal alignment. Poor DASH scores were observed at angles lower than previously accepted for nonoperative treatment. These findings are useful in decision making and patient guidance. (Journal of Surgical Orthopaedic Advances 30(2):073-077, 2021).
Assuntos
Fraturas do Úmero , Fixação Interna de Fraturas , Humanos , Fraturas do Úmero/diagnóstico por imagem , Fraturas do Úmero/terapia , Úmero , Resultado do TratamentoRESUMO
BACKGROUND: The management of open fractures requires wound irrigation and débridement to remove contaminants, but the effectiveness of various pressures and solutions for irrigation remains controversial. We investigated the effects of castile soap versus normal saline irrigation delivered by means of high, low, or very low irrigation pressure. METHODS: In this study with a 2-by-3 factorial design, conducted at 41 clinical centers, we randomly assigned patients who had an open fracture of an extremity to undergo irrigation with one of three irrigation pressures (high pressure [>20 psi], low pressure [5 to 10 psi], or very low pressure [1 to 2 psi]) and one of two irrigation solutions (castile soap or normal saline). The primary end point was reoperation within 12 months after the index surgery for promotion of wound or bone healing or treatment of a wound infection. RESULTS: A total of 2551 patients underwent randomization, of whom 2447 were deemed eligible and included in the final analyses. Reoperation occurred in 109 of 826 patients (13.2%) in the high-pressure group, 103 of 809 (12.7%) in the low-pressure group, and 111 of 812 (13.7%) in the very-low-pressure group. Hazard ratios for the three pairwise comparisons were as follows: for low versus high pressure, 0.92 (95% confidence interval [CI], 0.70 to 1.20; P=0.53), for high versus very low pressure, 1.02 (95% CI, 0.78 to 1.33; P=0.89), and for low versus very low pressure, 0.93 (95% CI, 0.71 to 1.23; P=0.62). Reoperation occurred in 182 of 1229 patients (14.8%) in the soap group and in 141 of 1218 (11.6%) in the saline group (hazard ratio, 1.32, 95% CI, 1.06 to 1.66; P=0.01). CONCLUSIONS: The rates of reoperation were similar regardless of irrigation pressure, a finding that indicates that very low pressure is an acceptable, low-cost alternative for the irrigation of open fractures. The reoperation rate was higher in the soap group than in the saline group. (Funded by the Canadian Institutes of Health Research and others; FLOW ClinicalTrials.gov number, NCT00788398.).
Assuntos
Fraturas Expostas/terapia , Sabões/uso terapêutico , Cloreto de Sódio/uso terapêutico , Irrigação Terapêutica/métodos , Adulto , Feminino , Seguimentos , Fraturas Expostas/cirurgia , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Pressão , Reoperação , Método Simples-Cego , Cicatrização , Infecção dos Ferimentos/prevenção & controle , Infecção dos Ferimentos/cirurgiaRESUMO
The structure-specific nuclease human flap endonuclease-1 (hFEN1) plays a key role in DNA replication and repair and may be of interest as an oncology target. We present the crystal structure of inhibitor-bound hFEN1, which shows a cyclic N-hydroxyurea bound in the active site coordinated to two magnesium ions. Three such compounds had similar IC50 values but differed subtly in mode of action. One had comparable affinity for protein and protein-substrate complex and prevented reaction by binding to active site catalytic metal ions, blocking the necessary unpairing of substrate DNA. Other compounds were more competitive with substrate. Cellular thermal shift data showed that both inhibitor types engaged with hFEN1 in cells, and activation of the DNA damage response was evident upon treatment with inhibitors. However, cellular EC50 values were significantly higher than in vitro inhibition constants, and the implications of this for exploitation of hFEN1 as a drug target are discussed.
Assuntos
Inibidores Enzimáticos/farmacologia , Endonucleases Flap/antagonistas & inibidores , Endonucleases Flap/metabolismo , Domínio Catalítico/efeitos dos fármacos , Linhagem Celular Tumoral , Relação Dose-Resposta a Droga , Inibidores Enzimáticos/química , Endonucleases Flap/química , Humanos , Modelos Moleculares , Estrutura Molecular , Relação Estrutura-Atividade , TemperaturaRESUMO
The outcomes of pediatric talus fractures have been minimally reported in published studies. The purpose of the present retrospective study was to determine the clinical and radiographic outcomes after talus fractures in pediatric and adolescent patients and to define the differences among the different age groups in this population. A total of 52 children and adolescents (54 fractures) with 24 type 1 (44.44%), 13 type 2 (24.07%), 8 type 3 (14.81%), and 9 type 4 (16.67%) Marti-Weber fractures were considered. Of the 52 patients, 19 (35.19%; 21 talus fractures) with follow-up data available for >12 months were included in the final study population. Of the 21 fractures, 9 (42.86 %) were type 1, 4 (19.05%) were type 2, 1 (4.76%) was type 3, and 7 (33.33%) were type 4. The mean patient age was 14.7 (range 4 to 18) years. The patients were divided into 3 age groups: group 1, age ≤11.9 years; group 2, age 12.0 to 15.8 years; and group 3, age 16.1 to 18.0 years. Of the 21 fractures, 3 (14.29%) were treated nonoperatively and 18 (85.71%) operatively. The overall mean follow-up duration was 40.3 (range 14 to 95) months. The outcomes of interest included fracture nonunion, talar avascular necrosis, ankle range of motion, pain, arthrosis, and arthrodesis. After treatment, the mean ankle range of motion was 20° (range 0° to 35°) of dorsiflexion and 40° (range 0° to 45°) of plantarflexion. Complications included persistent pain in 10 fractures (47.62%), 3 cases of nonunion (14.29%), 3 cases of avascular necrosis (14.29%; of which, 1 [4.76%] required ankle and subtalar fusion), and arthrosis developing in ≥1 surrounding joint in 12 fractures (57.14%). Of the 12 fractures in group 3, 9 (75.00%) developed arthrosis and 2 (16.67%) subsequently required arthrodesis. Our observations suggest that the incidence of displaced talus fractures, as well as complications, increases with patient age.
Assuntos
Fixação Interna de Fraturas/métodos , Fraturas Ósseas/cirurgia , Tálus/lesões , Adolescente , Fatores Etários , Parafusos Ósseos , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Seguimentos , Consolidação da Fratura/fisiologia , Fraturas Ósseas/diagnóstico por imagem , Humanos , Escala de Gravidade do Ferimento , Masculino , Estudos Retrospectivos , Tálus/cirurgia , Fatores de Tempo , Tomografia Computadorizada por Raios X/métodos , Resultado do TratamentoRESUMO
Surgical exposures for the management of extremity fractures continue to evolve. Strategies to achieve satisfactory articular reconstitution require surgeons to have an appreciation and understanding of various conventional and contemporary surgical approaches. The recent literature has witnessed a surge in studies on surgical approaches for the fixation of extremity fractures. This increased interest in surgical exposures resulted from not only a desire to enhance outcomes and minimize complications but also a recognition of the inadequacies of traditionally accepted surgical exposures. Contemporary exposures may be modifications or combinations of existing exposures. All surgical exposures require proper surgical execution and familiarity with regional anatomic structures. Exposures, whether conventional or contemporary, must provide sufficient access for reduction and implant insertion. Proper exposure selection can greatly enhance a surgeon's ability to achieve acceptable reduction and adequate fixation. Unique characteristics of both the patient and his or her fracture pathoanatomy may dictate the surgical approach. Patient positioning, imaging access, and concomitant comorbidities (medical, systemic trauma, and regional extremity related) also must be considered. Minimally invasive methods of reduction and fixation are attractive and have merit; however, adherence to them while failing to achieve satisfactory reduction and fixation will not generate a desirable outcome. Surgeons should be aware of several site-specific anatomic regions in which evolving surgical exposures and strategies for extremity fracture management have had favorable outcomes.
Assuntos
Extremidades , Fixação de Fratura , Fraturas Ósseas , Próteses e Implantes , Extremidades/diagnóstico por imagem , Extremidades/lesões , Fixação de Fratura/efeitos adversos , Fixação de Fratura/instrumentação , Fixação de Fratura/métodos , Fraturas Ósseas/classificação , Fraturas Ósseas/diagnóstico , Fraturas Ósseas/cirurgia , Humanos , Modelos Anatômicos , Avaliação de Resultados em Cuidados de Saúde , Seleção de Pacientes , RadiografiaRESUMO
INTRODUCTION: Different reasons for lost to follow-up are assumed. Besides "objective" reasons, "subjective" reasons and satisfaction contribute to treatment adherence. Retrospective studies usually lack the possibility of acquisition of additional outcome information. Purpose of this study was to determine outcome and factors for patients not returning for follow-up. METHODS: Between 2002 and 2009, 380 patients underwent internal fixation for tibial plateau fractures. Short Musculoskeletal Function Assessment (SMFA) was collected at 6, 12, and 24 months as long as patients returned for follow-up. Pain and range of motion were measured. Records were studied for reasons of termination of follow-up. Statistical analysis was performed comparing lost to follow-up versus continued office visits regarding demographics, contributing factors, and SMFA. RESULTS: Two hundred fifty-nine patients were followed until treatment was completed (PRN), while 120 patients (32 %) terminated further follow-up. Patients in the 12- and 24-month follow-up groups were older (p = 0.02; p < 0.01, respectively). Pain (VAS ≥ 3) was noticed in 22 % of the patients terminating follow-up before the 6-month survey and 41 % of the patients returning for the 24-month SMFA survey (χ 2 = 0.06). Improvements were found with time in SMFA subscores but arm and hand. No differences in SMFA subscores at 6 or 12 months were found between those leaving treatment untimely and those being released from office visits. CONCLUSION: Follow-up remains important to obtain as much up-to-date information as possible. The current study does not support the assumption that patients lost to follow-up have a different SMFA outcome than patients returning until PRN. LEVEL OF EVIDENCE: III.
Assuntos
Fixação Interna de Fraturas , Perda de Seguimento , Complicações Pós-Operatórias , Fraturas da Tíbia , Assistência ao Convalescente/métodos , Assistência ao Convalescente/estatística & dados numéricos , Feminino , Fixação Interna de Fraturas/efeitos adversos , Fixação Interna de Fraturas/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde/métodos , Medição da Dor/métodos , Preferência do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Amplitude de Movimento Articular , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fraturas da Tíbia/epidemiologia , Fraturas da Tíbia/cirurgia , Estados Unidos/epidemiologiaRESUMO
PURPOSE: A preliminary project to correlate MR findings with mapping prostate biopsy to help differentiate malignant transitional zone lesions form benign prostatic hyperplasia (BPH) nodules. MATERIALS AND METHODS: Institutional IRB approved retrospective study with 14 patients suspected of having prostate cancer who underwent both prostate 3T MRI using endorectal coil and 3D transperineal mapping prostate biopsy. MR exams were independently reviewed by two abdominal radiologists blinded to pathology with disagreement resolved by consensus. An MRI lesion was defined as having hypointense T2 signal subjectively without corresponding T1 high signal intensity and low signal on ADC maps in the central gland. Mapping biopsy consisted of systematic transperineal US guided biopsy with 55-108 cores per patient. RESULTS: Twenty-nine lesions were detected on MRI. Of these, 13 correlated with Gleason 6 or higher biopsy samples. 16 were biopsy negative. Among the various MRI characteristics assessed, lack of T2 hypointense rim demonstrated the highest specificity (93%) and positive predictive value (89%). Highest sensitivity (85%) and negative predictive value (78%) were seen with ill-defined nodules. When suspicious MR characteristics were combined, the specificity and PPV rose to 100% while sensitivity decreased to 45% and NPV decreased to 73%. CONCLUSIONS: Preliminary study indicates MR findings which can help differentiate a BPH nodule from transitional zone prostate cancers which could help direct biopsy in the large and growing number of people suspected of having prostate cancer. Further work will be needed for validation.
Assuntos
Imageamento Tridimensional , Imageamento por Ressonância Magnética/métodos , Neoplasias da Próstata/diagnóstico , Biópsia , Diagnóstico Diferencial , Humanos , Interpretação de Imagem Assistida por Computador , Masculino , Variações Dependentes do Observador , Próstata/patologia , Hiperplasia Prostática/diagnóstico , Estudos Retrospectivos , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Double disruptions of the superior suspensory shoulder complex, commonly referred to as 'floating shoulder' injuries, are ipsilateral midshaft clavicular and scapular neck/body fractures with a loss of bony attachment of the glenoid. The treatment of 'floating shoulder' injuries has been debated controversially for many years. The purpose of this study was to demonstrate the clinical and functional outcomes of patients with 'floating shoulder' injuries who underwent operative fixation of the clavicle fracture only. MATERIALS AND METHODS: Between 2002 and 2010, 32 consecutive floating shoulder injuries were identified in skeletally mature patients at a level I trauma center and followed in a single private practice. Thirteen patients met the inclusion and exclusion criteria for this retrospective study with a minimum 12-month follow-up. Clavicle and scapular fractures were identified by Current Procedural Technology codes and classified based on Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen criteria. 'Floating shoulder' injuries were surgically managed with only clavicular reduction and fixation utilizing modern plating techniques. Nonunion, malunion, implant removal, range of motion, need for secondary surgery, pain according to the visual analog scale (VAS), and return to work were measured. RESULTS: All injuries were the result of high-energy mechanisms. Fracture union of the clavicle was seen after initial surgical fixation in the majority of patients (12; 92.3 %). Final pain was reported as minimal (11 cases; 1-3 VAS), moderate (1 case; 4-6 VAS), and high (1 case; 7-10 VAS) at last follow-up. Excellent range of motion (180° forward flexion and abduction) was observed in the majority of patients (8; 61.5 %). The Herscovici score was 12.9 (range 10-15) at 3 months. Unplanned surgeries included two clavicular implant removals and one nonunion revision. None of the patients required reconstruction for scapula malunion after nonoperative management. Twelve patients returned to previous work without restrictions. CONCLUSIONS: 'Floating shoulder' injuries with only clavicular fixation return to function despite persistent scapular deformity and some residual pain. LEVEL OF EVIDENCE: Level IV.
Assuntos
Clavícula/lesões , Fixação Interna de Fraturas , Fraturas Ósseas/cirurgia , Escápula/lesões , Lesões do Ombro , Adolescente , Adulto , Feminino , Fraturas Ósseas/diagnóstico , Fraturas Ósseas/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Anatomic reduction of some displaced pediatric supracondylar humerus fractures is not attainable via closed manipulation, thus necessitating open reduction. Open reduction has been associated with increased complications, including elbow stiffness, scarring, iatrogenic neurovascular injury, and longer hospital stays. Using a Schanz pin to aid in closed reduction may decrease the need for conversion to an open procedure, possibly reducing morbidity. DESCRIPTION OF TECHNIQUE: A percutaneously placed 2.5-mm Schanz pin was drilled into the posterior humeral diaphysis and used as a joystick to reduce anterior and posterior, varus and valgus, and rotational deformity. The fracture then was stabilized with 0.62-mm K-wires placed under fluoroscopy and the Schanz pin then was removed. METHODS: We retrospectively reviewed all displaced pediatric supracondylar humerus fractures treated by one surgeon from March 2002 through December 2010, with 143 fractures meeting criteria for inclusion. These fractures then were divided into two groups. Group 1 (90 fractures) included fractures treated before implantation of the Schanz pin. In this group, if successful reduction could not be achieved via closed manipulations, a formal open reduction was performed. In Group 2, (53 fractures) the Schanz pin technique was used to assist with reduction of fractures that were not reduced successfully by closed manipulations. All fractures were stabilized with the 0.62-mm K-wires after the reductions. To equalize group size, the 37 most remote fractures in Group 1 were removed, leaving a final 53 fractures in each group for analysis. Demographics, injury data, operative technique, complications, and radiographic reduction were analyzed. The minimum followup for both groups was 3.3 weeks (average, 13 weeks; range, 3.3-130 weeks). RESULTS: Fewer fractures in Group 2 (one of 53, 1.9%) compared with Group 1 (seven of 53, 13%) underwent open reduction. Ten fractures in Group 2 underwent the Schanz pin technique, and none of these had open reductions. We found no difference between the groups concerning fracture alignment at final followup or postoperative complications. CONCLUSIONS: A posteriorly placed Schanz pin aids in anatomic reduction and decreases the need for open treatment of displaced pediatric supracondylar humerus fractures, without compromising the complication rate or final radiographic outcome.
Assuntos
Fixação Interna de Fraturas/métodos , Fraturas do Úmero/cirurgia , Pinos Ortopédicos , Fios Ortopédicos , Distribuição de Qui-Quadrado , Criança , Pré-Escolar , Feminino , Fluoroscopia , Fixação Interna de Fraturas/efeitos adversos , Fixação Interna de Fraturas/instrumentação , Consolidação da Fratura , Humanos , Fraturas do Úmero/diagnóstico por imagem , Lactente , Masculino , Radiografia Intervencionista , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
Metadiaphyseal fractures of long bones are associated with considerable deforming forces, tenuous soft-tissue envelopes, and, often, severely compromised osseous integrity. Contemporary methods to fix complex metadiaphyseal fractures must achieve a balance between the biomechanical and biologic environments. The advent of precontoured locking plates inserted with evolving minimally invasive techniques may achieve both goals. Enthusiasm for their application demands continued scientific validation. Indications and outcomes must be carefully evaluated, and the benefits and limitations of this combination of implant design and surgical execution must be recognized.
Assuntos
Placas Ósseas , Fraturas do Fêmur/cirurgia , Fixação Interna de Fraturas/métodos , Fraturas do Fêmur/diagnóstico por imagem , Fixação Interna de Fraturas/tendências , Fraturas Cominutivas/cirurgia , Humanos , Fraturas do Úmero/cirurgia , Radiografia , Fraturas da Tíbia/cirurgia , Resultado do TratamentoRESUMO
The midfoot is a complex association of five bones and many articulations between the forefoot metatarsals and the talus and calcaneus, which make up the hindfoot. These anatomic relationships are connected and restrained by an even more complex network of ligaments, capsules, and fascia, which must function as a unit to provide normal and painless locomotion. The common eponyms of Lisfranc and Chopart refer to the distal and proximal joint relationships of the midfoot, respectively. Midfoot injuries range from single ligament strains to complicated fracture-dislocations involving multiple bones and joints. To provide best outcomes for patients, it is important to understand the anatomy and the mechanical function of the midfoot; to review the epidemiology, mechanism, and classification of injuries encountered in an orthopaedic clinical practice; and to review the principles, indications, and surgical techniques for managing midfoot fractures and dislocations.
Assuntos
Traumatismos do Pé/cirurgia , Fraturas Ósseas/cirurgia , Luxações Articulares/cirurgia , Procedimentos Ortopédicos/métodos , Ossos do Tarso/lesões , Fenômenos Biomecânicos , Traumatismos do Pé/fisiopatologia , Fixação Interna de Fraturas/métodos , Humanos , Ligamentos/lesões , Ossos do Metatarso/lesões , Ossos do Metatarso/cirurgia , Cuidados Pós-Operatórios , Lesões dos Tecidos Moles/cirurgia , Ossos do Tarso/cirurgiaRESUMO
OBJECTIVES: To compare anterior hook plating with established fixation constructs biomechanically and report outcomes and complications in a cohort of patella fractures treated with the technique. DESIGN: Laboratory-based biomechanical study and clinical multicenter retrospective cohort study. SETTING: 2 US Level 1 trauma centers. PATIENTS/PARTICIPANTS: 51 patients (28 M and 23 F) with 30 simple transverse and 21 comminuted patella fractures. Thirty-six cadaveric patellae were used for the biomechanical study. INTERVENTION: Biomechanical-dorsal plating was compared with cerclage wiring and modified tension band cable fixation in a comminuted patella fracture model in 36 cadaveric patellae. Constructs were tested at 0° and 45 degrees of flexion. Clinical-we reviewed a consecutive series of patella fractures in 2 centers for outcome and complications. MAIN OUTCOME MEASUREMENTS: Biomechanical-construct stiffness. Clinical-reduction, union, complications, and range of motion. RESULTS: Stiffness was greatest in dorsal plating at both 0° and 45 degrees. Dorsal plating (976 N, 1643 N) > modified tension band (317 N, 297 N) > cerclage (89.8 N, 150.3 N) at 0 and 45 degrees, respectively. 51 patients with patella fractures had them fixed with dorsal 2.7-mm mini fragment plates including a distal to proximal lag screw through the plate from the nose of the patella. 9 cases were small distal fragments not easily managed with screws and cables. All patients were followed up to union. There were 2 infections (1 superficial and 1 deep with nonunion), and 5 had implant removal (9.8%). CONCLUSIONS: Dorsal plating is biomechanically and clinically superior to modified tension band and cerclage techniques in comminuted patella fractures. This method allows for fixation of small distal pole fractures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Fraturas Ósseas , Fraturas Cominutivas , Traumatismos do Joelho , Fratura da Patela , Humanos , Estudos Retrospectivos , Fios Ortopédicos , Fraturas Ósseas/cirurgia , Fixação Interna de Fraturas/métodos , Patela/cirurgia , Patela/lesões , Traumatismos do Joelho/cirurgia , Cadáver , Fenômenos Biomecânicos , Fraturas Cominutivas/cirurgia , Estudos Multicêntricos como AssuntoRESUMO
OBJECTIVES: The main 2 forms of treatment for extraarticular proximal tibial fractures are intramedullary nailing (IMN) and locked lateral plating (LLP). The goal of this multicenter, randomized controlled trial was to determine whether there are significant differences in outcomes between these forms of treatment. DESIGN: Multicenter, randomized controlled trial. SETTING: 16 academic trauma centers. PATIENTS/PARTICIPANTS: 108 patients were enrolled. 99 patients were followed for 12 months. 52 patients were randomized to IMN, and 47 patients were randomized to LLP. INTERVENTION: IMN or lateral locked plating. MAIN OUTCOME MEASUREMENTS: Functional scoring including Short Musculoskeletal Functional Assessment, Bother Index, EQ-5Dindex and EQ-5DVAS. Secondary measures included alignment, operative time, range of motion, union rate, pain, walking ability, ability to manage stairs, need for ambulatory aid and number, and complications. RESULTS: Functional testing demonstrated no difference between the groups, but both groups were still significantly affected 12 months postinjury. Similarly, there was no difference in time of surgery, alignment, nonunion, pain, walking ability, ability to manage stairs, need for ambulatory support, or complications. CONCLUSIONS: Both IMN and LLP provide for similar outcomes after these fractures. Patients continue to improve over the course of the year after injury but remain impaired even 1 year later. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Fixação Intramedular de Fraturas , Fraturas da Tíbia , Humanos , Tíbia , Resultado do Tratamento , Fraturas da Tíbia/cirurgia , Consolidação da Fratura , Estudos RetrospectivosRESUMO
OBJECTIVES: The 2 main forms of treatment for distal femur fractures are locked lateral plating and retrograde nailing. The goal of this trial was to determine whether there are significant differences in outcomes between these forms of treatment. DESIGN: Multicenter randomized controlled trial. SETTING: Twenty academic trauma centers. PATIENTS/PARTICIPANTS: One hundred sixty patients with distal femur fractures were enrolled. One hundred twenty-six patients were followed 12 months. Patients were randomized to plating in 62 cases and intramedullary nailing in 64 cases. INTERVENTION: Lateral locked plating or retrograde intramedullary nailing. MAIN OUTCOME MEASUREMENTS: Functional scoring including Short Musculoskeletal Functional Assessment, bother index, EQ Health, and EQ Index. Secondary measures included alignment, operative time, range of motion, union rate, walking ability, ability to manage stairs, and number and type of adverse events. RESULTS: Functional testing showed no difference between the groups. Both groups were still significantly affected by their fracture 12 months after injury. There was more coronal plane valgus in the plating group, which approached statistical significance. Range of motion, walking ability, and ability to manage stairs were similar between the groups. Rate and type of adverse events were not statistically different between the groups. CONCLUSIONS: Both lateral locked plating and retrograde intramedullary nailing are reasonable surgical options for these fractures. Patients continue to improve over the course of the year after injury but remain impaired 1 year postoperatively. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Fraturas Femorais Distais , Fraturas do Fêmur , Fixação Intramedular de Fraturas , Fraturas Ósseas , Humanos , Fixação Intramedular de Fraturas/efeitos adversos , Placas Ósseas , Fixação Interna de Fraturas , Fraturas Ósseas/cirurgia , Resultado do Tratamento , Fraturas do Fêmur/cirurgia , Fraturas do Fêmur/etiologia , Consolidação da FraturaRESUMO
Osteoporosis presents a dilemma for the orthopedic surgeon. Screw fixation within the bone is crucial for mechanical stabilization, maintenance of reduction, and ultimately, fracture healing. For the patient, soft bones and physiological fragility usually benefit from immediate weight bearing and mobility to avoid further disuse osteoporosis, deconditioning, and immobility. For implant companies, traditional screws, plates, and nails function for simple fractures and compliant patients. Locked plating has improved screw purchase in osteoporotic bone and has expanded fracture fixation capabilities but is not the panacea for all fractures. For orthopedic surgeons, traditional surgical augmentation for osteoporosis consisting of dual plating, augmentation with polymethyl methacrylate, joint replacement, and now locked plating are beneficial. In order to advance orthopedic care in the expanding population of elderly osteoporotic patients, modern solutions utilizing the dual properties of secure fixation and relatively flexible implants are required. Endosteal substitution, extraosteal substitution, and combined nail/plate combinations are methods of utilizing traditional implants in a nontraditional way. Nonsurgical augmentation of fracture fixation is also paramount.
Assuntos
Artroplastia de Substituição/métodos , Fixação Interna de Fraturas/métodos , Fixadores Internos , Fraturas por Osteoporose/cirurgia , Conservadores da Densidade Óssea/uso terapêutico , Transplante Ósseo , Consolidação da Fratura , Humanos , Polimetil MetacrilatoRESUMO
BACKGROUND: Traditional screw or plate fixation options can be used to fix the majority of sacral fractures. However, these techniques are unreliable with dysmorphic upper sacral segments, U-fractures, osseous compression of neural elements, and previously failed fixation. Lumbopelvic fixation can potentially address these injuries but is a technically demanding procedure requiring spinal and pelvic fixation and it is unclear whether it reliably corrects the deformity and restores function. QUESTIONS/PURPOSES: We therefore assessed reduction quality and loss of fixation, pain related to prominent hardware, subjective dysfunction measured by the Short Musculoskeletal Function Assessment (SMFA), and complications. METHODS: We retrospectively reviewed 15 patients with unstable sacral fractures treated with lumbopelvic fixation between 2002 and 2010. Patients had radiographic monitoring regarding reduction quality and loss of fixation and clinical followup using the SMFA. The minimum followup was 12 months (mean, 23 months; range, 12-41 months). RESULTS: Posterior reduction quality was 11 of 15 with less than 5 mm persistent displacement and four of 15 with 5 to 10 mm displacement. Loss of fixation was observed in one patient as a result of a technical error. Prominent hardware resulted in greater pain. Despite daily activity and bother subscores improving over time, we found long-term dysfunction in the SMFA. Eleven of the 15 patients were able to return to previous work or activities. CONCLUSION: Complex posterior pelvic ring injuries of the sacrum not amenable to traditional fixation options can be salvaged with adherence to the technical details of lumbopelvic fixation. Hardware prominence and pain are markedly reduced with screw head recession. Long-term impairment is noted in patients with complex pelvic ring injuries requiring lumbopelvic fixation compared with normative data. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Assuntos
Mau Alinhamento Ósseo/cirurgia , Fixação de Fratura/métodos , Salvamento de Membro/métodos , Articulação Sacroilíaca/cirurgia , Sacro/lesões , Fraturas da Coluna Vertebral/cirurgia , Fusão Vertebral/métodos , Adolescente , Adulto , Idoso , Mau Alinhamento Ósseo/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Estudos Retrospectivos , Fraturas da Coluna Vertebral/complicações , Resultado do TratamentoRESUMO
BACKGROUND: Recently, fixation of lateral compression (LC) pelvic fractures has been advocated to improve patient comfort and to allow earlier mobilization without loss of reduction, thus minimizing adverse systemic effects. However, the degree of acceptable deformity and persistence of disability are unclear. QUESTIONS/PURPOSES: We determined if (1) injury pattern; (2) demographics; (3) final posterior displacement; (4) L5/S1 involvement; (5) associated injuries; and (6) time influence outcome measurements, sexual dysfunction, and pain. METHODS: We retrospectively reviewed 119 patients with unstable LC injuries treated surgically between 2000 and 2010. There were 52 males and 67 females; mean age was 39 years with a mean body mass index of 27 kg/m(2). All patients underwent clinical examination and radiographic imaging for instability and accompanying injuries. We obtained Short Musculoskeletal Function Assessment (SMFA). The minimum followup was 12 months (mean, 33 months; range, 12-100 months). RESULTS: SMFA subscores were not affected by injury pattern and demographics. Posterior reduction was less than 5 mm with persistent displacement in 99 of 119 (83%). Displacement of 5 to 10 mm did not affect any SMFA subscore at any time interval. Patients with additional lower extremity injuries had worse SMFA scores. Function improved with time. A visual analog scale pain score of 4 or more at 6 months predicted pain and overall SMFA score at last followup. CONCLUSIONS: Unstable LC pelvic ring injuries result in persistent disability based on validated outcome measurements. Near anatomical reduction can be achieved and maintained. While our findings need to be confirmed in studies with high rates of followup, patients with unstable LC pelvic injuries should be counseled concerning the possibility of some degree of persistent disability. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Assuntos
Fixação Interna de Fraturas , Fraturas por Compressão/cirurgia , Fraturas do Quadril/cirurgia , Ossos Pélvicos/lesões , Complicações Pós-Operatórias , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Fraturas por Compressão/etiologia , Indicadores Básicos de Saúde , Fraturas do Quadril/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/etiologia , Qualidade de Vida , Recuperação de Função Fisiológica , Recidiva , Estudos Retrospectivos , Disfunções Sexuais Fisiológicas/etiologia , Resultado do Tratamento , Adulto JovemRESUMO
Unstable posterior pelvic ring injuries are commonly treated with percutaneous iliosacral screw fixation. Despite the efficiency of the minimally invasive technique, complications and failures occur. To maximize reduction quality and fixation stability, open techniques for pelvic ring fixation exist. Timing, approaches, clamp positioning, and implant options determine the effectiveness of the open techniques.