The influence of the surgical approach concerning dislocation in total hip arthroplasty

OBJETIVO: Avaliar a ocorrência de luxação nas artroplastias totais do quadril não cimentadas, comparando-se os acessos posterior e lateral direto. Métodos: Estudo retrospectivo comparativo com 232 pacientes submetidos à artroplastia total do quadril não cimentada, por diagnóstico de osteoartrose primária e secundária, sendo 105 submetidos ao acesso posterior e 127 ao acesso lateral. O modelo protético utilizado foi único, assim como o protocolo de reabilitação e cuidados pós-operatórios. Foram verificados ocorrência de luxação, posicionamento acetabular e componentes utilizados. RESULTADOS: Ocorreu um caso isolado de luxação no grupo do acesso lateral direto (0,8%) contra 0% no grupo de pacientes submetidos ao acesso posterior, sem diferença significativa (p = 1). A luxação ocorreu em uma paciente de 47 anos de idade, que foi tratada com redução incruenta sem recidiva da luxação após três anos e um mês de seguimento. O tempo de seguimento dos dois grupos variou entre seis e 42 meses, com média de 23,7 meses. CONCLUSÃO: Os autores concluem que a prevalência de luxação nas artroplastias totais do quadril é similar nos dois acessos estudados e que medidas educativas, técnica cirúrgica adequada e utilização de próteses com offsets maiores podem diminuir o risco dessa complicação.OBJECTIVES: Our primary aim was to evaluate the occurrence of dislocation of non-cemented total hip arthroplasty, when using the posterior and the direct lateral approaches. METHODS: We performed a comparative retrospective study with 232 patients submitted to non-cemented total hip arthroplasty, due to the diagnosis of primary or secondary osteoarthritis. The posterior approach was used in 105 patients while direct lateral approach was used in 127 patients. There was only one prosthesis model and the same rehabilitation program and post-operative care was used for all patients. We checked the occurrence of dislocation, the acetabular positioning and also the size of the components. RESULTS: There was only one case of dislocation, treated with closed reduction successfully. This was a 47 year-old female, submitted to direct lateral approach. The mean follow-up time for both groups was 23.7 months, ranging from six to 42 months. Conclusion: The authors conclude that the prevalence of total hip arthroplasty dislocation is similar for both approaches, and educational measures besides the use of a higher femoral offset seem to reduce the risk of this complication

A new low-cost negative-pressure wound therapy versus a commercially available therapy device widely used to treat complex traumatic injuries: a prospective, randomized, non-inferiority trial

OBJECTIVES: Negative-pressure wound therapy has been widely adopted to reduce the complexity of treating a broad range of acute and chronic wounds. However, its cost is high. The objective of this study was to evaluate the following two different methods of negative-pressure wound therapy in terms of healing time: a low-cost method of negative-pressure wound therapy (a pressure stabilizer device connected to a hospital wall-vacuum system with a gauze-sealed dressing, USP) and the standard of care (vacuum-assisted closure, VAC). METHODS: This is a randomized, controlled, non-inferiority, unblinded trial. Patients admitted with complex injuries to a trauma center in a public referral hospital who were indicated for orthopedic surgery were randomized to a USP or VAC group. The primary outcome was the time required to achieve a “ready for surgery condition”, which was defined as a wound bed with healthy granulation tissue and without necrosis or purulent secretion. Wound bed area contraction, granulation tissue growth and the direct costs of the dressings were secondary outcomes. RESULTS: Variation in area and granulation tissue growth were essentially the same between the systems, and healing time was equal between the groups (p=0.379). In both systems, serial debridement increased wound area (p=0.934), and granulation tissue was also increased (p=0.408). The mean treatment cost was US$15.15 in the USP group and US$ 872.59 in the VAC group. CONCLUSIONS: For treating complex traumatic injuries, USP was non-inferior to and less expensive than VAC

Proposta de um novo teste clínico para o diagnóstico do ressalto lateral do quadril

ResumoO ressalto lateral do quadril é uma entidade nosológica muitas vezes desconhecida pela maioria dos ortopedistas e até mesmo por alguns especialistas em cirurgia do quadril. Trata‐se da presença de um estalido palpável e/ou audível na face lateral do quadril, por vezes doloroso, causado pelo atrito musculotendíneo sobre o grande trocanter durante a flexão e a extensão da articulação coxofemoral. Descreveremos a seguir um novo teste para o diagnóstico do ressalto lateral do quadril, que é eminentemente clínico.AbstractLateral hip snapping is a nosological entity that is often unknown to many orthopedists and even to some hip surgery specialists. It comprises palpable and/or audible snapping on the lateral face of the hip that is sometimes painful, caused by muscle‐tendon friction on the greater trochanter during flexion and extension of the coxofemoral joint. In the following, we describe a new test for diagnosing lateral hip snapping, which is eminently clinical

LOW INFECTION AND NON-UNION RATES IN POLYTRAUMA FEMORAL FRACTURES: A RETROSPECTIVE STUDY

ABSTRACT Objective: Assess complications and risks in staged femoral shaft fracture treatment using external fixation and intramedullary nailing (DCO). Methods: Analysis involved 37 patients with 40 fractures, mostly male (87.5%), average age 32.9 years. Data included ASA score, AO/OTA and Gustilo classifications, Glasgow Coma Score, Injury Severity Score, times to external fixation and conversion, ICU duration, nail type, and reaming status. Complications tracked were mortality, deep infection, and non-union. Results: Predominant fracture type was AO/OTA A (45%), with 40% open (Gustilo A, 93.8%). Average ISS was 21; GCS was 12.7. Median ICU stay was 3 days; average time to conversion was 10.2 days. Retrograde nails were used in 50% of cases, with reaming in 67.5%. Complications included deep infections in 5% and non-union in 2.5%. Conclusion: DCO strategy resulted in low infection and non-union rates, associated with lower GCS and longer ICU stays. Level of Evidence III; Retrospective Cohort Study

RISK FACTORS AT NON-UNION OF TIBIAL FRACTURE TREATED WITH INTRAMEDULLARY NAIL

ABSTRACT Objective: Identify the predictors associated with delayed union at 6 months and non-union at 12 months in tibial shaft fractures treated with intramedullary nailing (IMN). Methods: This retrospective longitudinal study included a cohort of 218 patients who sustained tibial shaft fractures and received IMN between January 2015 and March 2022. We gathered data on a range of risk factors, including patient demographics, trauma intensity, associated injuries, fracture characteristics, soft tissue injuries, comorbidities, addictions, and treatment-specific factors. We employed logistic bivariate regression analysis to explore the factors predictive of delayed union and non-union. Results: At the 6-month follow-up, the incidence of delayed union was 28.9%. Predictors for delayed union included flap coverage, high-energy trauma, open fractures, the use of external fixation as a staged treatment, the percentage of cortical contact in simple type fractures, RUST score, and postoperative infection. After 12 months, the non-union rate was 15.6%. Conclusion: the main predictors for non-union after IMN of tibial shaft fractures are related to the trauma energy. Furthermore, the initial treatment involving external fixation and postoperative infection also correlated with non-union. Level of Evidence III; Retrospective Longitudinal Study

Comparative study of osseointegration of uncemented femoral stem in total hip replacements in patients with poor bone quality and good bone quality

Introdução: Com o desenvolvimento das artroplastias não cimentadas, estudos vêm sendo realizados com o objetivo de se determinar se as hastes femorais não cimentadas poderiam ser utilizadas em qualquer paciente,ou estaria reservada apenas para aqueles que possuem boa qualidade óssea. Um estudo comparativo é realizado para avaliar a osteointegração de hastes femorais não cimentadas nas artroplastias totais de quadril em pacientes que apresentam má qualidade óssea, comparando com pacientes que apresentam boa qualidade óssea. Materiais e métodos: Este estudo inclui 196 pacientes submetidos à artroplastia total do quadril primária não cimentada por diagnóstico de osteoartrite primária e secundária com no mínimo de 12 meses de seguimento, divididos em dois grupos: um contendo pacientes com boa qualidade óssea (DorrA); e outro com pacientes com má qualidade óssea (Dorr B e C). Foi avaliada a osteointegração através da análise radiográfica seguindo os critérios estabelecidos por Engh, além de avaliar o resultado clínico e funcional através do questionário de WOMAC. Foram também avaliadas as complicações decorrentes do processo cirúrgico em ambos os grupos. Resultados:Há diferença na frequência do gênero no grupo Má Qualidade Óssea (MQO) (p=0,009) com predomínio de mulheres e diferença no diagnóstico inicial,havendo um número maior de casos de patologias reumatológicas e sequelas de displasia no grupo MQO (p=0,0002). Não observamos diferença quanto a idade, lado operado e tempo de seguimento entre os dois grupos. Não observamos diferença entre os grupos quando avaliado o escore clínico, a osteointegração ou a necessidade de revisão. Observamos um maior risco de fratura intraoperatória do fêmur proximal no grupo MQO (p=0.03) comparando-se com o grupo Boa Qualidade Óssea (BQO). Conclusão: Concluímos que as hastes femorais não cimentadas osteointegram igualmente, independentemente da qualidade óssea do paciente e que fraturas intraoperatórias ocorrem mais quando realizadas hastes femorais não cimentadas em pacientes com má da qualidade ósseaIntroduction: With the development of the non cemented total hip replacement, many studies were carried out to determinate if uncemented femoral stem can be used in every patient, or if this kind of implants are reserved for those patients with good bone quality. A comparative study was carried out to evaluate the osseointegration of uncemented femoral stem in total hip replacements in patients that have poor bone quality, comparing with patients that have good bone quality. Methods: The study included 196 cases of primary uncemented total hip arthroplasties due to a diagnosis of primary or secondary osteoarthritis, with a minimum of 12 months of follow-up, divided in two groups: one with patients that have good bone quality (Type A Dorr), and another with patients that have poor bone quality (Types B and C Dorr). Osseointegration was evaluated by X ray analysis, following the Engh\'s criteria. Clinical and functional results were also evaluated by the application of the WOMAC questionnaire, and complication in both groups were reported. Results: Regarding our patient\' gender, we observed a significant difference between the two groups: there was more women in the group of Poor Bone Quality (PBQ) (p=0,009). We also observed a significant difference in the initial diagnosis of the patients: there was more osteoarthritis secondary to rheumatic pathologies and hip dysplasia in the PBQ group (p=0,0002). There was no difference when observed the mean age, operation\' side and mean time of follow-up between the two groups. We also did not observed differences between the groups when evaluated the clinical scores, the osseointegration of the femoral stem and the need of revision of the arthroplasty by any reason. But, in the PBQ, we observed a higher risk of intra operative fracture in the proximal femur compared with the group Good Bone Quality (GBQ) (p=0,03). Conclusion: We concluded that the uncemented femoral stem has an equal rate of osseointegration, despite the bone quality and that there is a higher risk of intra operative fracture when implanted an uncemented femoral stem in bone with poor qualit

Comparative study of osseointegration of uncemented femoral stem in total hip replacements in patients with poor bone quality and good bone quality

Introdução: Com o desenvolvimento das artroplastias não cimentadas, estudos vêm sendo realizados com o objetivo de se determinar se as hastes femorais não cimentadas poderiam ser utilizadas em qualquer paciente,ou estaria reservada apenas para aqueles que possuem boa qualidade óssea. Um estudo comparativo é realizado para avaliar a osteointegração de hastes femorais não cimentadas nas artroplastias totais de quadril em pacientes que apresentam má qualidade óssea, comparando com pacientes que apresentam boa qualidade óssea. Materiais e métodos: Este estudo inclui 196 pacientes submetidos à artroplastia total do quadril primária não cimentada por diagnóstico de osteoartrite primária e secundária com no mínimo de 12 meses de seguimento, divididos em dois grupos: um contendo pacientes com boa qualidade óssea (DorrA); e outro com pacientes com má qualidade óssea (Dorr B e C). Foi avaliada a osteointegração através da análise radiográfica seguindo os critérios estabelecidos por Engh, além de avaliar o resultado clínico e funcional através do questionário de WOMAC. Foram também avaliadas as complicações decorrentes do processo cirúrgico em ambos os grupos. Resultados:Há diferença na frequência do gênero no grupo Má Qualidade Óssea (MQO) (p=0,009) com predomínio de mulheres e diferença no diagnóstico inicial,havendo um número maior de casos de patologias reumatológicas e sequelas de displasia no grupo MQO (p=0,0002). Não observamos diferença quanto a idade, lado operado e tempo de seguimento entre os dois grupos. Não observamos diferença entre os grupos quando avaliado o escore clínico, a osteointegração ou a necessidade de revisão. Observamos um maior risco de fratura intraoperatória do fêmur proximal no grupo MQO (p=0.03) comparando-se com o grupo Boa Qualidade Óssea (BQO). Conclusão: Concluímos que as hastes femorais não cimentadas osteointegram igualmente, independentemente da qualidade óssea do paciente e que fraturas intraoperatórias ocorrem mais quando realizadas hastes femorais não cimentadas em pacientes com má da qualidade ósseaIntroduction: With the development of the non cemented total hip replacement, many studies were carried out to determinate if uncemented femoral stem can be used in every patient, or if this kind of implants are reserved for those patients with good bone quality. A comparative study was carried out to evaluate the osseointegration of uncemented femoral stem in total hip replacements in patients that have poor bone quality, comparing with patients that have good bone quality. Methods: The study included 196 cases of primary uncemented total hip arthroplasties due to a diagnosis of primary or secondary osteoarthritis, with a minimum of 12 months of follow-up, divided in two groups: one with patients that have good bone quality (Type A Dorr), and another with patients that have poor bone quality (Types B and C Dorr). Osseointegration was evaluated by X ray analysis, following the Engh\'s criteria. Clinical and functional results were also evaluated by the application of the WOMAC questionnaire, and complication in both groups were reported. Results: Regarding our patient\' gender, we observed a significant difference between the two groups: there was more women in the group of Poor Bone Quality (PBQ) (p=0,009). We also observed a significant difference in the initial diagnosis of the patients: there was more osteoarthritis secondary to rheumatic pathologies and hip dysplasia in the PBQ group (p=0,0002). There was no difference when observed the mean age, operation\' side and mean time of follow-up between the two groups. We also did not observed differences between the groups when evaluated the clinical scores, the osseointegration of the femoral stem and the need of revision of the arthroplasty by any reason. But, in the PBQ, we observed a higher risk of intra operative fracture in the proximal femur compared with the group Good Bone Quality (GBQ) (p=0,03). Conclusion: We concluded that the uncemented femoral stem has an equal rate of osseointegration, despite the bone quality and that there is a higher risk of intra operative fracture when implanted an uncemented femoral stem in bone with poor qualit

Estudo anatômico do Filum Terminalis: dissecção de 31 cadáveres

To describe the intra-dural anatomy of the Filum Terminales (FT), analysing morphological parameters, relevant for clinical relations to the Tight Filum Terminale Syndrome, aiming at the meticulous analysis of its diagnostic criteria and therapeutics. Methods: Thirty-eight fresh cadavers were dissected, and the following parameters were evaluated: FT lenght, diameters at the initial and medium point of the FT, topographical relation of the starting and ending points of the FT to the vertebrae, height, weight sex and age. Results: The average FT lenght was 157,56 mm (range 112,8 – 211,1), its average initial diameter 1,38 mm (range 0,4 – 2,5) and its medium point 0,75 mm (range 0,1 – 1,55). Four (10,53%) cadavers presented a FT thicker than 2 mm in its initial point. The FT begins most frequently at the mid-L1 level (18,42%) and ends at the upper-S2 level (34,21%). The variation range for both levels is large. Significant correlations were found (Pearson correlation) between weight and height (p = 0,018), initial and middle diameters (p< 0,001), initial vertebral level and height (p = 0,012) and starting and ending vertebrals levels (p = 0,005). Conclusion: Through this analysis of the FT, we discuss the diagnostic criteria and the therapeutic conduct for the Tight Filum Terminale Syndrome. There are evidences that about 10% of the normal population possess one of the criteria for the diagnosis of the Tight Filum Terminale Syndrome.Descrever a anatomia intradural do filum terminalis (FT) e relacionar sua origem, comprimento e inserção com a coluna lombar e sacral em 31 cadáveres de adultos sem patologias da coluna, visando acesso cirúrgico para a porção inferior intradural do FT. Métodos: Foram realizadas 31 dissecções em cadáveres frescos no Sistema de Verificação de Óbitos da Capital de São Paulo no período de março de 2000 a janeiro de 2001. A anatomia do filum terminalis foi estudada através de ampla laminectomia tóraco-lombo-sacral, identificando o nível de origem e inserção (porção superior, média ou inferior da vértebra ou espaço intervertebral em questão), comprimento e diâmetros na sua origem e terço médio. Resultados: Treze (42,0%) FT apresentaram origem em L1, sete (22,5%) em L2, cinco (16,1%) em T12, dois (6,5%) em L1-L2, dois (6,5%) em L2-L3, um (3,2%) em T12-L1 e um (3,2%) em T11. Dezoito (58,1%) FT apresentaram inserção em S2, cinco (16,1%) em S1, cinco (16,1%) em S3, dois (6.5%) em S2-S3 e um (3,2%) S1-S2. A média dos comprimentos aferidos da origem até a inserção do filum terminalis foi 158,86 mm, variando de 112,80 a 211,10 mm. A média dos diâmetros, na sua origem e terço médio, foram 1,36 mm e 0,72 mm, variando de 0,35 a 2,50 mm e 0,10 a 1,55 mm, respectivamente. Conclusões: Em nosso estudo, a maioria dos FT apresentou origem em L1 (42,0%) e inserção dural em S2 (58,1%), 16,1% apresentaram inserção em S1; dessa forma para devida exposição cirúrgica do filum terminalis na sua porção livre não inserida na dura-máter, além de laminectomia de S1, torna-se prudente a realização adicional de laminectomia parcial ou total de L5