Publications by authors named "Kodi Edson Kojima"

27 Publications

  • Page 1 of 1

THE MISSING LINK IN THE HISTORY OF THE LOCKED INTRAMEDULLARY NAIL.

Acta Ortop Bras 2021 Jul-Aug;29(4):228-231

Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Instituto de Ortopedia e Traumatologia, Grupo de Trauma, São Paulo, SP, Brazil.

Femoral Shaft intramedullary nails were first described by the Aztecs in 16th century, but the modern use of intramedullary nails as the gold standard treatment for femoral shaft fractures began with Gerald Kuntcher in 1939. From the first Kuntcher's study in 1939, to the creation of interlocking nail, a long and some minor developments were described around the world. However, a major development is missing: the first nail to have a rotational and vertical stability locking system was described by Flavio Godoy Moreira, but was never published on an indexed journal for the correct historical reference.
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http://dx.doi.org/10.1590/1413-785220212904246573DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8443011PMC
December 2020

Bioactive glass S53P4 to fill-up large cavitary bone defect after acute and chronic osteomyelitis treated with antibiotic-loaded cement beads: A prospective case series with a minimum 2-year follow-up.

Injury 2021 Jul 1;52 Suppl 3:S23-S28. Epub 2021 Jun 1.

Trauma Service, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.

Introduction: Bioactive glass S53P4 (BAG-S53P4) has been used in the treatment of osteomyelitis with excellent results. The aim of this study was to evaluate the clinical and radiographic results of patients treated with use of antibiotic-loaded cement beads, followed by bone defects filling using bioglass.

Methods: We treated a prospective series of patients presenting with acute or chronic osteomyelitis of a long bone of the upper or lower limb. The first-stage procedure involved debridement and filling of cavitary defects with antibiotic-loaded polymethylmethacrylate (PMMA) beads. When signs of infection subsided, the defects were filled with BAG-S53P4. The main outcomes assessed were the reinfection rate, need for reoperation, radiographic and functional evaluations (DASH and Lysholm scores).

Results: Ten patients were included, aged between 4 and 66 years (mean 25.4 years). The source of infection was hematogenic in five cases and post-traumatic in the other five. Hematogenic infections required two debridements before filling with bioglass, whereas post-traumatic cases required only one. The time between the first debridement and the application of bioglass varied from 1 to 63 weeks (average of 17 weeks). All patients showed a favorable evolution after bioglass procedure, with no need for reoperation or relevant wound problems. The radiographic evaluation showed partial incorporation of the material and adequate bone formation, and functional scores were satisfactory in all cases.

Conclusion: The treatment of osteomyelitis with surgical debridement and PMMA beads, followed by filling of bone defect with BAG-S53P4, was effective in all patients evaluated, with adequate infectious control and bone regeneration. No cases required reoperation after bioglass implantation. Patients with hematogenous osteomyelitis required a greater number of debridements before filling with bioglass.
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http://dx.doi.org/10.1016/j.injury.2021.05.030DOI Listing
July 2021

Factors associated with one year mortality in ill patients with proximal femoral fractures treated non operatively.

Injury 2021 Jul 1;52 Suppl 3:S60-S64. Epub 2021 Jun 1.

Trauma Service, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil. Electronic address:

Introduction: Non-operative treatment is an exceptional indication for the treatment of proximal femur fracture. The aim of the study was to analyze the mortality rate in one year and associated factors in severely ill patients submitted to non-operative treatment.

Methods: It was included 28 patients treated from August 2014 to September 2019. Eighteen (64.3%) patients were female and 10 (35.7%) were male. The mean age was 78.7 ± 11.9 years old. The main outcome evaluated was the mortality rate in one year. It was also evaluated the correlation with gender, age, personal habits, number of comorbidities and Charlson Comorbidity Index (CCI).

Results: The functional result was assessed with WOMAC score via telephone call. The mortality rate in one year was 42.8% without statistical positive correlation with any of the studied parameters. Patients with three or more comorbidities didn't have a higher mortality rate comparing to survived patients (83.3% vs 81.3%). The CCI also didn't show any correlation with high mortality (6.9 vs 7.1). The functional result of the survived patients was poor (78.2 points WOMAC).

Conclusion: The conclusion is that the mortality rate in one year of ill patients with hip fractures treated non-operatively is 42.8% without correlation with age, gender of number of comorbidities, and the functional result of the survived patients is poor.
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http://dx.doi.org/10.1016/j.injury.2021.04.059DOI Listing
July 2021

Intramedullary Steinmann pin nailing of the ulna: an option for the damage control orthopedics treatment of forearm fractures in open injuries in polytraumatized patients - A description of the technique and presentation of a case series.

Injury 2021 Jul 1;52 Suppl 3:S33-S37. Epub 2021 Jun 1.

Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil. Electronic address:

Introduction: Forearm shaft fracture is common in young adult patients and associated with soft tissue and organ injuries. In open fractures in polytrauma patients, damage control orthopaedics (DCO) is well indicated. The aim of this study is to describe intramedullary Steinmann pin fixation of the ulna as a DCO procedure for the forearm and present a case series.

Description Of The Technique: A 3.0 mm Steinmann pin is inserted retrograde in the ulna proximal fragment through the fracture site using the open wound as the approach. With direct visualization of the reduction, the pin is advanced into the distal fragment. The reduction of the longitudinal axis and shortening is thus achieved.

Patients And Methods: This method was used for all open fractures of forearm both-bone fractures in polytrauma patients undergoing DCO from 2014 to 2019. The alignment and length of the ulna were evaluated radiographically after pin fixation and before and after definitive fixation. Differences in the need for secondary procedures and infection rate between DCO and definitive fixation were also evaluated.

Results: There were 30 males (85.7%) with an average age of 32.9 ± 12.0 years and a mean ISS (Injury Severity Score) of 29.4 (range, 18.0-41.0). The most common associated injuries were thoracic trauma (62.8%) and head trauma (45.7%). In the radius and ulna, 51.4% and 60.0% of fractures, respectively, were multifragmentary (types B and C). Gustilo type IIIA represented 77.1% of the injuries. Pin fixation achieved good alignment and length in all cases. The mean time between DCO and definitive fixation was 12.0 days, and no secondary procedure was needed, nor any case developed either superficial or deep infection. The conversion from DCO to definitive fixation was considered easy in all cases.

Conclusion: Intramedullary Steinmann pin fixation of the ulna is a viable option for DCO for forearm both-bone fractures in open fractures in polytrauma patients.
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http://dx.doi.org/10.1016/j.injury.2021.05.033DOI Listing
July 2021

A novel translation system for circular external fixation to correct translational bony deformities.

Injury 2021 Apr 21;52(4):1079-1082. Epub 2020 Nov 21.

Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, USA. Electronic address:

Translational deformities are common complications of conservatively managed bone fractures and some surgically managed fractures with unstable patterns. Realigning the bones can be difficult when soft tissue, scars and calluses form. These deformities can be easily corrected with hexapodalic-based external fixators, but these fixators are not widely available in developing countries. We describe a stable and reliable Ilizarov frame that can be used to treat these deformities and show results of clinical cases.
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http://dx.doi.org/10.1016/j.injury.2020.11.058DOI Listing
April 2021

COMPARISON OF BICONDYLAR TIBIAL PLATEAU FRACTURES WITH DOUBLE OR SINGLE LATERAL LOCKED PLATE.

Acta Ortop Bras 2020 Jul-Aug;28(4):182-185

Universidade de São Paulo, Medical School, Institute of Orthopedics and Traumatology, São Paulo, SP, Brazil.

Objective: To compare postoperative radiographic outcomes of Schatzker type V and VI tibial plateau fractures treated with double-plate or single lateral locked plate.

Methods: Sixty-three patients operated from December 2011 to February 2016 were selected, 47 from the double-plate group and 16 from the single lateral locked plate group. Minimum follow-up for all patients was 6 months. Fracture reduction evaluation was based on radiographic parameters: joint reduction, sagittal alignment, coronal alignment, and condylar width.

Results: Radiographic evaluation showed no statistical difference in the immediate or late postoperative periods.

Conclusion: Despite the reduced sample, this study is aligned with current results published in the medical literature. The severity of Schatzker type V and VI tibial plateau fractures can be minimized by the correct indication for the implant regarding fracture morphology.
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http://dx.doi.org/10.1590/1413-785220202804233122DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7405846PMC
August 2020

Quick-DASH as a main early outcome of humeral shaft fractures: A Latin American multicenter prospective study.

J Orthop Surg (Hong Kong) 2020 Jan-Apr;28(2):2309499020929436

Orthopaedic Biomaterials Laboratory, School of Medical Sciences, University of Campinas, Brazil.

Purpose: The main objective of this study was to evaluate the Quick-Disabilities of the Arm, Shoulder and Hand Score (DASH) score as the main early (90 days) outcome in a prospective multicenter observational Latin American study on isolated humeral shaft fractures.

Methods: From December 2015 to April 2017, in six Latin American countries, patients 18 years or older with a closed, isolated nonpathological 12A, 12B, or 12C AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association) fractures were included. The 90 (±10)-day Quick-DASH score was used to compare the results of the different treatments. The secondary outcomes were patient treatment satisfaction, shoulder and elbow range of motion, and radiographic evaluation.

Results: A total of 92 patients successfully completed the Quick-DASH questionnaire. Surgical treatments resulted in better outcomes than nonsurgical treatment, but only minimally invasive plate osteosynthesis produced significantly lower Quick-DASH scores than nonsurgical treatment ( < 0.05). There were strong correlations between patient self-evaluation and the Quick-DASH score ( < 0.0005) but not between the Quick-DASH score and radiographic fracture healing. No significant difference was found between the treatments regarding the rate of return to work, but the medical center had a significant influence on treatment choice ( < 0.0005).

Conclusion: The high correlation between Quick-DASH score and patient satisfaction and functional outcome indicates that the Quick-DASH questionnaire is a suitable tool for evaluating adult humeral shaft fracture outcomes. Patients with a Quick-DASH score below 15 could be considered recovered, and patients with a Quick-DASH score above 40 could be considered not yet recovered. Quick-DASH scores were not significantly associated with radiographic fracture healing.
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http://dx.doi.org/10.1177/2309499020929436DOI Listing
February 2021

EVALUATION OF PREDICTIVE FACTORS OF IN HOSPITAL MORTALITY IN PATIENTS WITH PROXIMAL FEMORAL FRACTURE.

Acta Ortop Bras 2020 Jan-Feb;28(1):40-43

Universidade de São Paulo, Medical School, Institute of Orthopedics and Traumatology, Geriatrics Group, São Paulo, SP, Brazil.

Objective: To investigate the existence of a causal association between orthopedic treatment and the occurrence of in hospital death.

Methods: 338 patients with proximal femoral fracture were evaluated, of whom 27 faced in hospital death. Patients who faced in hospital death (case group) were compared to patients who did not (control group) regarding exposure to risk factors prior to injury and factors related to orthopedic treatment.

Results: The factors related to higher in hospital mortality rate were: male sex (case group: 52%, control: 26%; p = 0.005), lower Parker's score (case group: 5.0 points, control: 6.2; p = 0.048), delirium on admission (case group: 26%, control: 10%; p = 0.011); delirium developed during hospitalization (case group: 77%, control: 35%; p <0.001), and time until surgery (13.3 days, 9.1; p = 0.049).

Conclusion: The in hospital mortality rate of patients with proximal femoral fracture was 8%, and the main associated risk factors were male sex, reduced Parker's score, delirium diagnosed on hospital admission or developed during hospitalization, and time until surgery.
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http://dx.doi.org/10.1590/1413-785220202801215801DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7006536PMC
February 2020

A RETROSPECTIVE CASE-SERIES ON THE USE OF S53P4 BIOACTIVE GLASS FOR THE ADJUNCTIVE TREATMENT OF SEPTIC DIAPHYSEAL NON-UNION.

Acta Ortop Bras 2019 Sep-Oct;27(5):273-275

Universidade de São Paulo, Hospital das Clínicas - HCFMUSP, Faculdade de Medicina, Instituto de Ortopedia e Traumatologia, Reconstruction and Lengthening Group, São Paulo, SP, Brazil.

Objective: Non-union and persistence of infection at a fracture site for long periods are always described as a challenge to orthopedists, especially in cases of severe compound fractures with comminution and segmental bone loss. This is a case series of septic non-unions, using S53P4 bioactive glass for adjunctive treatment, using internal syntheses or external fixators. The objective is to retrospectively evaluate the results of the use of S53P4 bioglass for the adjunctive treatment of septic non-unions.

Methods: We reviewed 18 patients with septic non-unions. The patients were preoperatively classified using the Non-union Scoring System (NUSS) and union outcomes were assessed by the modified radiographic union scale in tibial (RUST) fractures. Of the 18 patients treated, six underwent internal osteosynthesis and 12 were treated with external fixators in combination with bioactive glass grafting.

Results: The patients had a mean NUSS score of 56.6 (standard deviation of 7.6) and fracture union was achieved according to the RUST score in 17 of 18 cases (94.4%), with a mean value of 10.2 (standard deviation of 1.0). One patient was lost to follow-up. Reevaluation using the modified RUST score was 12.3 (SD = 1.0), maintaining union of 17/18.

Conclusion: The fracture union rate was high, according to the literature, as was control of infection.
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http://dx.doi.org/10.1590/1413-785220192705220540DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6901156PMC
December 2019

Demographics and clinical features of humeral shaft fractures: The Latin American multicentre prospective study (HSF-LAMPS).

J Orthop Surg (Hong Kong) 2019 Sep-Dec;27(3):2309499019874506

School of Medical Sciences, University of Campinas, Campinas, Brazil.

Purpose: To present transversal data (demographic and clinical) on isolated humeral shaft fractures (HSFs) in Latin American countries.

Methods: Patients were enrolled between December 2015 and April 2017 at 11 medical institutions from six Latin America countries.

Inclusion Criteria: Age ≥18 years and a closed, isolated 12A, 12B, or 12C fracture (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification). The patients' demographic, comorbidity, and other baseline data were recorded. The outcome measures included the basal results of the research and the associations among the demographic factors, fracture features, and type of treatment applied.

Results: A total of 123 patients were included. There was a preponderance of men (61.8%), whose mean age was significantly lower than that of the women (31.48 vs. 60.55). Overweight or obesity was present in 61.0% of women; 56.1% of patients were sedentary, 75.6% were nonsmokers, and 74.0% had no chronic disease. The type or treatment (operative/nonoperative) was not significantly associated with the patient's or fracture's characteristics. Falls and traffic accidents were the main causes of HSFs. Intramedullary nailing treatment was performed significantly more often in women, elderly patients, patients who did not participate in sports, and patients participating in only home activities. Minimally invasive plate osteosynthesis was performed significantly more frequently in men and in those who were self-employed. Open reduction internal fixation was performed significantly more often when the cause of the fracture was a traffic accident and when radial nerve palsy was present.

Conclusion: The demographics and etiological differences observed in comparison to the current literature show the importance of regional studies for both preventive measures and educational guidance.
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http://dx.doi.org/10.1177/2309499019874506DOI Listing
July 2020

CLINICAL EVALUATION OF PATIENTS WITH VANCOMYCIN SPACER RETAINED FOR MORE THAN 12 MONTHS.

Acta Ortop Bras 2019 Jan-Feb;27(1):55-58

Universidade de São Paulo, Faculdade de Medicina, Instituto de Ortopedia e Traumatologia, São Paulo, São Paulo, Brazil.

Objective: There is no consensus in the literature regarding the time taken to remove antibiotic spacers in the treatment of bone infections. The aim of this study is to evaluate the clinical results of patients with prolonged retention of the same.

Methods: Patients selected were diagnosed with post-osteosynthesis infection and/or osteomyelitis and were submitted to treatment using an orthopedic cement spacer (polymethylmethacrylate) with vancomycin, retaining it for a period of more than 12 months. They were clinically evaluated to determine the presence of local or systemic infectious signs via hemogram, investigations of inflammatory markers, liver, renal and, with radiographic control.

Results: Eighteen patients were included in the study. The mean retention time of the spacer was 30.4 months (15 - 61 months). No patient had clinical signs of local or systemic infectious relapse at the time of evaluation. Seven patients (39%) presented non-disabling pain in the operated limb. Seventeen patients (94%) presented a reduction in C-reactive protein values compared to the preoperative period. Radiographically, no migration, no spacer failure, or bone sequestration occurred.

Conclusion: In this retrospective case series, cement spacer retention with vancomycin for more than 12 months was associated with good clinical results, without relapse of the infectious condition. .
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http://dx.doi.org/10.1590/1413-785220192701213649DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6362697PMC
February 2019

VALIDITY AND RELIABILITY OF THE MANCHESTER SCALE USED IN THE ORTHOPEDIC EMERGENCY DEPARTMENT.

Acta Ortop Bras 2019 Jan-Feb;27(1):50-54

Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (IOT-HCFMUSP), Instituto de Ortopedia e Traumatologia, São Paulo, SP, Brazil.

Objectives: To describe the clinical utility of the Manchester triage scale adapted for orthopedic emergency departments and to evaluate its validity in identifying patients with the need for hospital care and its reliability when reproduced by different professionals.

Methods: Five triage flowcharts were developed based on the Manchester scale for the following orthopedic disorders: traumatic injuries, joint pain, vertebral pain, postoperative disorders, and musculoskeletal infections. A series of patients triaged by two orthopedists was analyzed to assess the concordance between the evaluators (reliability) and the validity of the Manchester scale as predictive of severity.

Results: The reliability analysis included 231 patients, with an inter-observer agreement of 84% (Kappa = 0.77, p <0.001). The validity analysis included 138 patients. The risk category had a strong association with the need for hospital care in patients with trauma (OR = 6.57, p = 0.001) and was not significant for non-traumatic disorders (OR = 2.42; p = 0.208). The overall sensitivity and specificity were 64% and 76%, respectively.

Conclusion: The evaluated system presented high reliability. Its validity was adequate, with good sensitivity for identifying patients requiring hospital care among those with traumatic lesions. However, the sensitivity was low for patients with non-traumatic lesions.
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http://dx.doi.org/10.1590/1413-785220192701191577DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6362691PMC
February 2019

Influence of postoperative immobilization on pain control of patients with distal radius fracture treated with volar locked plating: A prospective, randomized clinical trial.

Injury 2019 Feb 4;50(2):386-391. Epub 2018 Dec 4.

Universidade de Sao Paulo, Faculdade de Medicina, Hospital das Clinicas, Instituto de Ortopedia e Traumatologia (IOT-HCFMUSP), Sao Paulo, SP, Brasil.

Objectives: The purpose of this study was to compare the pain scores and the rates and doses of opioid use in patients undergoing volar locked plate fixation of intra-articular distal radius fractures using or not postoperative immobilization.

Methods: This was a prospective randomized controlled trial. Thirty-nine patients with distal radius fractures scheduled to receive volar plate fixation were randomly assigned to receive a short forearm splint for two weeks postoperatively or conventional bandage with early wrist mobilization. Thirty-six patients completed the follow-up. The outcome measurements included pain scores (0-10 points); rates and doses of tramadol use; DASH score; wrist range of motion; patient satisfaction; and complication rates. The last follow-up assessment was performed at 6 months.

Results: The pain scores were similar between the groups during hospital stay, as well as after hospital discharge within the first week and in subsequent assessments up to six months. The rates of tramadol use were greater in the No splint group during hospital stay, but this difference was not statistically significant (No splint = 65%; Splint = 47%; p = 0.296). Likewise, the doses of tramadol intake were higher in the No splint group during hospital stay (No splint = 218 mg; Splint = 167 mg; p = 0.273) and after discharge (2 day: No splint = 112 mg; Splint = 75 mg; p = 0.286), with no statistically significant differences. The functional results and complication rates were similar between the groups.

Conclusions: In this study, there was a trend to a greater use of tramadol in patients who did not use immobilization and started early wrist mobilization after volar locked plating of distal radius fracture, compared with patients who were immobilized for two weeks. The pain scores were similar but may have been influenced by the unbalanced use of opioids between the groups. The functional results and complication rates were not influenced by the use of immobilization.

Level Of Evidence: Therapeutic Level I.
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http://dx.doi.org/10.1016/j.injury.2018.12.001DOI Listing
February 2019

Epidemiological study on calcaneus fractures in a tertiary hospital.

Rev Bras Ortop 2018 Jul-Aug;53(4):472-476. Epub 2018 Jun 13.

Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.

Objective: To analyze the epidemiology and characteristics of patients with calcaneus fractures.

Methods: This is a retrospective revision of patients with calcaneus fractures hospitalized in the Institute of Orthopedics and Traumatology of this institution between 2006 and 2010. Data such as age, gender, laterality, trauma mechanism, type of fracture, associated injuries, compound fractures, and time from injury to surgery were analyzed.

Results: The analysis of 52 patients showed that men were more commonly affected than women, at a ratio of 5.5:1. Bilateral fractures were observed in ten cases, resulting in a total of 62 calcaneus fractures. A fall from a height was the most frequent trauma mechanism (75%), followed by motorcycle accidents (11.5%) and automobile accidents (9.6%). The most frequent fractures were intra-articular, with 47 cases. Compound fractures were observed in 15 patients (28.9%). Non-surgical management was adopted for 11 patients while 41 patients underwent surgery. The mean time between trauma and the definitive treatment was 7.8 days (range: 0-21 days), and 58.5% of cases were treated within seven days.

Conclusion: Patients with calcaneus fractures, most commonly young men, were admitted to a high complexity care hospital, victims of a fall from a height with associated injuries. The great severity of these fractures is characterized by the high prevalence of bilateral (19.2%) and compound fractures (28.9%) in this population group.
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http://dx.doi.org/10.1016/j.rboe.2018.05.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6052184PMC
June 2018

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.

Clinics (Sao Paulo) 2017 12;72(12):737-742

Consultor Independente, Sao Paulo, SP, BR.

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.
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http://dx.doi.org/10.6061/clinics/2017(12)04DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5738560PMC
December 2017

Effectiveness of a step-by-step oral recount before a practical simulation of fracture fixation.

Injury 2017 Oct;48 Suppl 4:S50-S53

Institute of Orthopaedics and Traumatology, University of São Paulo, São Paulo, Brazil.

Objective: To evaluate the effectiveness of a step-by-step oral recount by residents before the final execution of a practical exercise simulating a surgical fixation of a radial diaphyseal fracture.

Material And Methods: The study included 10 residents of orthopaedics and traumatology (four second- year and six first-year residents) divided into two groups with five residents each. All participants initially gathered in a room in which a video was presented demonstrating the practical exercise to be performed. One group (Group A) was referred directly to the practical exercise room. The other group (Group B) attended an extra session before the practical exercise, in which they were invited by instructors to recount all the steps that they would perform during the practical exercise. During this session, the instructors corrected the residents if any errors in the step-by-step recount were identified, and clarified questions from them. After this session, both Groups A and B gathered in a room in which they proceeded to the practical exercise, while being video recorded and evaluated using a 20-point checklist.

Results: Group A achieved a 57% accuracy, with results in this group ranging from 7 to 15 points out of a total of a possible 20 points. Group B achieved an 89% accuracy, with results in this group ranging from 15 to 20 points out of 20.

Conclusion: An oral step-by-step recount by the residents before the final execution of a practical simulation exercise of surgical fixation of a diaphyseal radial fracture improved the technique and reduced the execution time of the exercise.
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http://dx.doi.org/10.1016/S0020-1383(17)30775-1DOI Listing
October 2017

Functional results and isokinetic muscle strength in patients with Fraser type I floating knee treated with internal fixation.

Injury 2017 Oct;48 Suppl 4:S2-S5

Department of Orthopedics and Traumatology, University of Sao Paulo, Brazil.

Introduction: According to Fraser's description, ipsilateral femoral and tibial diaphyseal fractures are characterised as type I floating knee and have a better prognosis than fractures with joint involvement (type II). There are few reports of functional and muscle strength in these patients. The objective of this study was to evaluate the functional and isokinetic muscle strength of patients with type I floating knee undergoing femoral and tibial internal fixation.

Methods: Patients with type I floating knee undergoing concomitant femoral and tibial internal fixation were invited for clinical evaluation. The parameters evaluated included the following: Karlstrom and Olerud score; Lysholm score; isokinetic thigh and hip muscle evaluation; knee range of motion; pain level; investigation of associated knee injuries by clinical evaluation and MRI; and types of complications.

Results: Twenty-one patients were included in the study; 11 of these were clinically evaluated, with a mean follow-up of 23.9 months. Six patients had an acceptable result according to the Karlstrom criteria, whereas eight patients had a poor result based on the Lysholm scale. The peak torque deficit was 61% for knee extensors, 37% for flexors and -9% for hip abductors. The mean pain level was 5.9. Three patients had a partial anterior cruciate ligament (ACL) injury; one patient had a posterior cruciate ligament (PCL) injury; and three patients had a meniscal injury. There were four cases of tibial or femoral nonunion at one year and two cases of chronic osteomyelitis.

Conclusion: Patients with type I floating knee had unsatisfactory functional results, significant knee extensor and flexor muscle strength deficits and a significant rate of complications at the two-year follow-up.
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http://dx.doi.org/10.1016/S0020-1383(17)30767-2DOI Listing
October 2017

Absolute and relative stabilities for fracture fixation: the concept revisited.

Injury 2017 10;48 Suppl 4:S1

Department of the Locomotive Apparatus, Federal University of Minas Gerais, Belo Horizonte - MG, Brazil.

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http://dx.doi.org/10.1016/S0020-1383(17)30766-0DOI Listing
October 2017

Ultrasound evaluation of the rotator cuff after osteosynthesis of proximal humeral fractures with locking intramedullary nail.

Rev Bras Ortop 2017 Sep-Oct;52(5):601-607. Epub 2017 Aug 23.

Universidade de São Paulo, Instituto de Ortopedia e Traumatologia, Grupo de Ombro e Cotovelo, São Paulo, SP, Brazil.

Objective: To evaluate supraspinatus tendon integrity with ultrasound (US) in patients submitted to proximal humeral fracture (PHF) fixation with a locking intramedullary nail.

Methods: Thirty-one patients with PHF treated with curvilinear locking intramedullary nail, aged between 50 and 85 years, were assessed by US at six months postoperatively and clinically at six and 12 months postoperatively. The primary aim was supraspinatus tendon integrity, evaluated by US at six months postoperatively. Secondary aims included the Constant-Murley, DASH score, and visual analog pain scores, as well as complications and reoperation rates.

Results: Full-thickness rotator cuff ruptures were observed in four patients (13%), supraspinatus ruptures in three cases (10%), and subscapularis ruptures in one case (3%). Partial ruptures were diagnosed in 10 cases (32%). The results using the Constant-Murley score at 12 months were 71.3 ± 15.2 points for the entire series, with 73.2 ± 16.1 points for patients without rotator cuff ruptures and 68.7 ± 14.1 points for those with partial or complete ruptures, without a statistically significant difference ( = 0.336). Complications, exclusively for rotator cuff ruptures, were observed in nine patients (29%).

Conclusion: A high rate of rotator cuff ruptures was demonstrated, with partial ruptures in 32% of cases and full-thickness ruptures in 13%. However, clinical results are satisfactory, and are not influenced by the presence of rotator cuff ruptures.
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http://dx.doi.org/10.1016/j.rboe.2016.10.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5643895PMC
August 2017

A comparison study of radiographic and computerized tomographic angles in slipped capital femoral epiphysis.

Rev Bras Ortop 2017 Sep-Oct;52(5):528-534. Epub 2017 Aug 30.

Universidade de São Paulo, Faculdade de Medicina, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil.

Objective: To compare proximal femur radiologic angles in patients with slipped capital femoral epiphysis and to analyze whether computerized tomography may modify the treatment.

Methods: Cross-sectional study comparing and analyzing the similarity between angles and radiologic classification of interest in slipped capital femoral epiphysis (SCFE).

Results: It was observed that the therapeutic management in slipped capital femoral epiphysis might be modified depending on the classification and radiologic acquisition method adopted.

Conclusion: Multiplanar assessment of proximal femoral deformity in patients with slipped capital femoral epiphysis is a viable option, with the potential to modify the disease classification and, consequently, the therapeutic management.
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http://dx.doi.org/10.1016/j.rboe.2017.08.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5643907PMC
August 2017

Are diaphyseal clavicular fractures still treated traditionally in a non-surgical way?

Rev Bras Ortop 2017 Jun-Jul;52(4):410-416. Epub 2017 Jul 8.

Universidade de São Paulo, Faculdade de Medicina, Instituto de Ortopedia e Traumatologia, Grupo de Trauma Ortopédico, São Paulo, SP, Brazil.

Objective: To evaluate the decision of orthopedics surgeons regarding which cases they would indicate surgery or non-surgical treatment.

Methods: 20 images of radiographs with fracture in the of the collar bone (AO/OTA 15-B) in anteroposterior view were analyzed, and divided into four groups: group 1 - fracture type AO/OTA 15-B1 without displacement; group 2 - fracture type AO/OTA 15-B1 with displacement; group 3 - fracture type AO/OTA 15-B2; group 4 - fracture type AO/OTA 15-B3. The evaluator was requested to indicate the choice of treatment, surgical or non-surgical.

Results: There was no strong correlation between the amount of surgical indications and the working experience or age of the medical evaluator. It was observed that the average of surgical indications in the total sample was 52%. When indications were studied in different areas of Brazil, there was no significant difference among them. No pattern for the Brazilian regions studied was observed in the case analysis. Even within a group (cases of the same complexity), no specific pattern of surgical indication was observed.

Conclusion: No association between surgical indication and the length of professional experience was found. The Southern and Southeastern regions were those that most recommended surgeries in groups 2, 3, and 4. In no region the same level of surgical indication for cases of the same complexity rate was kept.
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http://dx.doi.org/10.1016/j.rboe.2017.06.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5582807PMC
July 2017

FEMORAL NECK FRACTURES GARDEN I AND II: EVALUATION OF THE DEVIATION IN LATERAL VIEW.

Acta Ortop Bras 2017 Mar-Apr;25(2):107-109

1 Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto de Ortopedia e Traumatologia, São Paulo, SP, Brazil.

Objective: To evaluate the rate of deviation in the lateral radiographic incidence in patients with femoral neck fracture classified as non-diverted in the anteroposterior view (Garden I and II).

Methods: Nineteen selected patients with femoral neck fractures classified as Garden I and II were retrospectively evaluated, estimating the degree of deviation in the lateral view.

Results: Fifteen cases (79%) presented deviations in lateral view, with a mean of 18.6 degrees (±15.5).

Conclusion: Most fractures of the femoral neck classified as Garden I and II present some degree of posterior deviation in the X-ray lateral view.
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http://dx.doi.org/10.1590/1413-785220172502169349DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5474424PMC
June 2017

Effectiveness of a physical exercise intervention program in improving functional mobility in older adults after hip fracture in later stage rehabilitation: protocol of a randomized clinical trial (REATIVE Study).

BMC Geriatr 2016 11 29;16(1):198. Epub 2016 Nov 29.

Master's and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, Rua Cesáreo Galeno 448, Tatuapé, São Paulo, CEP: 03071-000, Brazil.

Background: Hip fractures resulting from falls increase substantially with advancing age and less than half of older hip fracture survivors regain their former levels of mobility. There is increasing evidence that rehabilitation interventions with exercises that goes beyond the sub-acute phase or even in a later stage of care have a positive impact on various functional abilities. The purpose of this study is to determine if exercise program training for people who have suffered a fall-related hip fracture will improve functional mobility when compared with usual care.

Methods: A randomized controlled trial with blinded assessors and intention-to-treat analysis will be undertaken. We will recruit 82 older adults, 60 years or over who have suffered a hip fracture due to a fall in the previous 6 to 24 months. Participants randomized to the Intervention Group (IG) will undertake a physical exercise program involving progressive and challenging balance training and neuromuscular and functional training of the lower limbs, conducted at home by physiotherapists, once a week, lasting about one hour, in the first, second and third month after randomization and will be taught to perform exercises at home, twice a week, using a booklet. Visits to monitor and progress the home exercise program will be conducted once a month, from the fourth to the sixth month and each 2 months until the end of the follow up at the 12 month, i.e., a total of 18 sessions. Participants will receive monthly phone calls to encourage exercise adherence. The control group will receive usual care. The primary outcome will be mobility-related disability and participants will be assessed at baseline, and at 3 months, 6 and 12 months. Participants will receive monthly phone calls to ask about falls and exercise adherence. Adverse effects will be monitored.

Discussion: This study proposes a home-based exercise program, which may in part overcome some barriers for rehabilitation, such as difficulties with public transportation and lack of a caregiver to accompany older patients to sessions. If a positive effect is observed this program has the potential to be incorporated into the public health system and contribute to building a pathway of care for older people with hip fracture.

Trial Registration: Clinicaltrials.gov Identifier: NCT02295527 .
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http://dx.doi.org/10.1186/s12877-016-0370-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5126860PMC
November 2016

Single, superiorly placed reconstruction plate compared with flexible intramedullary nailing for midshaft clavicular fractures: a prospective, randomized controlled trial.

J Bone Joint Surg Am 2015 Apr;97(8):620-6

Institute of Orthopedics and Traumatology, University of São Paulo, Brazil, Rua Ovidio Pires de Campos 333, 05403-010 São Paulo, Brazil. E-mail address for F.B. Andrade-Silva:

Background: Previous studies have shown good clinical results in patients with midshaft clavicular fractures treated with reconstruction plate fixation or elastic stable intramedullary nailing. The objective of this study was to compare these methods in terms of clinical and radiographic results.

Methods: In this prospective, randomized controlled trial, fifty-nine patients with displaced midshaft clavicular fractures were randomly assigned to receive fixation with either a reconstruction plate (thirty-three patients), known as the plate group, or elastic stable intramedullary nailing (twenty-six patients), known as the nail group. The primary outcome was the six-month Disabilities of the Arm, Shoulder and Hand (DASH) score. The secondary outcomes included the Constant-Murley score, time to fracture union, residual shortening, level of postoperative pain, percentage of satisfied patients, and complication rates.

Results: The mean six-month DASH score was 9.9 points in the plate group and 8.5 points in the nail group (p = 0.329). Similarly, there were no differences in the twelve-month DASH and Constant-Murley scores. Time to union was equivalent (p = 0.352) between the groups at 16.8 weeks for the plate group and 15.9 weeks for the nail group, whereas the residual shortening was 0.4 cm greater in the plate group (p = 0.032). The visual analog scale pain score and the satisfaction rate were similar between the groups. Implant-related pain was more frequent in the nail group (p = 0.035). There were no differences in terms of major complications.

Conclusions: Reconstruction plates and elastic stable intramedullary nailing yielded similar functional results, time to union, level of postoperative pain, and patient satisfaction rates. Both methods were safe in terms of major complications.
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http://dx.doi.org/10.2106/JBJS.N.00497DOI Listing
April 2015

Influence of time to surgery on the incidence of complications in femoral neck fracture treated with cannulated screws.

Injury 2014 Nov;45 Suppl 5:S36-9

Department of Orthopaedics and Traumatology, University of São Paulo, Brazil; Rua Ovidio Pires de Campos, São Paulo - SP, Brazil.

Background: Osteosynthesis of femoral neck fractures is particularly indicated in patients aged under 60 years. A prolonged interval between the fracture and surgical fixation has been associated with avascular necrosis (AVN) of the femoral head. The primary objective of this study was to evaluate the association between the time to surgery and the development of complications in patients with femoral neck fractures.

Methods: Patients with displaced fractures of the femoral neck (Garden III or IV) who underwent fixation with three cannulated screws in the inverted triangle configuration from January 2009 to December 2010 were evaluated retrospectively for the development of orthopaedic complications. Patients were divided into two groups according to the time to surgery (within 7 days or more than 7 days). Complication rates were compared between the two groups. Regression analyses were performed to assess the risk factors for complications.

Results: Thirty-one patients were included in the study; the duration of follow-up ranged from 24 to 50 months. The time from fracture to surgery ranged from 3 to 18 days. Fifteen patients underwent surgery within 7 days, and 16 patients underwent surgery after 7 days. There were four cases of femoral head necrosis. One patient had an associated infection; one patient experienced non-union, and another demonstrated osteosynthesis failure. There were no statistically significant differences in the overall rate of complications between the groups (p = 0.999). None of the preoperative parameters or fracture characteristics were predictive factors for complications. The only factor associated with the development of complications was inadequate fracture reduction in the anteroposterior (AP) view (odds ratio [OR] = 35.50, 95% confidence interval [CI] = 2.56 to 548.36, p = 0.008).

Conclusions: The interval between the occurrence of the injury and surgical fixation is not associated with the development of complications in fractures of the femoral neck. Inadequate fracture reduction in the AP view is a predictive factor for complications in these fractures.
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http://dx.doi.org/10.1016/S0020-1383(14)70019-1DOI Listing
November 2014

Outcomes evaluation of locking plate osteosynthesis in displaced fractures of the proximal humerus.

Rev Bras Ortop 2013 Nov-Dec;48(6):491-499. Epub 2013 Dec 25.

Instituto de Ortopedia e Traumatologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.

Objective: To evaluate functional outcomes, radiographic findings and complications of proximal humeral fractures treated with locking plates and to determine prognostic factors for successful clinical outcomes.

Methods: Forty patients undergoing internal fixation of fractures of the proximal humerus with the Philos plate were included in the study. The surgeries were performed between 2004 and 2011 and the patients underwent radiographic and clinical evaluation, by Constant-Murley and Dash score. Outcomes were analyzed by use of multivariate regression with several different variables.

Results: Patients were on average of 61.8 ± 16.28 years, and most were female (70%). The Constant-Murley score was 72.03 ± 14.01 and Dash score was 24.96 ± 19.99. The postoperative radiographs showed a head-shaft angle of 135.43° ± 11.82. Regression analysis showed that the patient's age and the Hertel classification influenced the Constant-Murley scale ( = 0.0049 and 0.012, respectively). Other prognostic criteria such as Neer and AO classification, head-shaft angle, the presence of metaphyseal comminution and extension of the humeral metaphyseal fragment showed no effect on prognosis. Complications occurred in four patients (10%).

Conclusion: The fixation with the Philos plate provided good clinical and radiographic results in fractures of the proximal humerus, with a low complication rate. Patient's age and Hertel classification were defined as prognostic factors that led to worse functional outcomes.
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http://dx.doi.org/10.1016/j.rboe.2013.12.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6565971PMC
December 2013

TIBIAL SHAFT FRACTURES.

Rev Bras Ortop 2011 Mar-Apr;46(2):130-5. Epub 2015 Dec 6.

Student Trainee of the Trauma Group of the Institute of Orthopedics and Traumatology, HC / FMUSP.

The long-bone fractures occur most frequently in the tibial shaft. Adequate treatment of such fractures avoids consolidation failure, skewed consolidation and reoperation. To classify these fractures, the AO/OTA classification method is still used, but it is worthwhile getting to know the Ellis classification method, which also includes assessment of soft-tissue injuries. There is often an association with compartmental syndrome, and early diagnosis can be achieved through evaluating clinical parameters and constant clinical monitoring. Once the diagnosis has been made, fasciotomy should be performed. It is always difficult to assess consolidation, but the RUST method may help in this. Radiography is assessed in two projections, and points are scored for the presence of the fracture line and a visible bone callus. Today, the dogma of six hours for cleaning the exposed fracture is under discussion. It is considered that an early start to intravenous antibiotic therapy and the lesion severity are very important. The question of early or late closure of the lesion in an exposed fracture has gone through several phases: sometimes early closure has been indicated and sometimes late closure. Currently, whenever possible, early closure of the lesion is recommended, since this diminishes the risk of infection. Milling of the canal when the intramedullary nail is introduced is still a controversial subject. Despite strong personal positions in favor of milling, studies have shown that there may be some advantage in relation to closed fractures, but not in exposed fractures.
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http://dx.doi.org/10.1016/S2255-4971(15)30227-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4799215PMC
March 2016
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