Translation and Transcultural Adaptation of the Milestones Instrument to Assess Teaching in Medical Residency Services on Orthopedics and Traumatology / Tradução e adaptação transcultural do instrumento Milestones de avaliação do ensino dos serviços de residência médica em ortopedia e traumatologia

Abstract Objective Orthopedics is not very common in many Brazilian medical schools, and there is no questionnaire to assess the teaching of musculoskeletal disorders during medical training. The Orthopedic Surgery Milestone Project is an assessment tool for orthopedic residents in programs or fellowships recognized by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Orthopedic Surgery (ABOS). This study aims to translate the Orthopedic Surgery Milestone Project into Portuguese and to perform its transcultural adaptation. Methods The translation and transcultural adaptation consisted of the initial translation into Portuguese, back-translation into English, preparation of a pretest consensual text, and the subsequent elaboration of a final text. Results The final text was deemed adequate and equivalent to the original one for the evaluation of orthopedics residents throughout their program. Conclusions Given the lack of instruments for the assessment of orthopedic residents, the translation and transcultural adaptation of the Orthopedic Surgery Milestone Project were compatible; this can be an instrument for improved medical education.

Resumo Objetivo A ortopedia é uma especialidade pouco presente na formação de muitas escolas médicas brasileiras, sendo que não foi identificado nenhum questionário que avalie o ensino das desordens musculoesqueléticas durante a formação médica. O Orthopedic Surgery Milestone Project constitui um instrumento de avaliação de residentes de ortopedia nos programas de residência ou bolsas credenciados pela ACGME (The Accreditation Council for Graduate Medical Education) e pelo ABOS (The American Board of Orthopedic Surgery). O objetivo é realizar a tradução para a língua portuguesa e adaptação transcultural do Orthopedic Surgery Milestone Project. Métodos A tradução e adaptação transcultural consistiram na tradução inicial para o português, retro tradução para o inglês, análise para a obtenção de uma versão consensual pré-teste e posterior versão final. Resultados A versão final foi considerada adequada e equivalente à original para a avaliação dos residentes de ortopedia ao longo do programa de residência médica. Conclusões Diante da falta de instrumentos para a avaliação dos residentes em Ortopedia, a tradução e a adaptação transcultural do Orthopedic Surgery Milestone Project foi compatível, podendo ser um instrumento para uma formação médica mais adequada.

Osteochondroma: ignore or investigate? / Osteocondroma: ignorar ou investigar?

Osteochondromas are bone protuberances surrounded by a cartilage layer. They generally affect the extremities of the longbones in an immature skeleton and deform them. They usually occur singly, but a multiple form of presentation may be found. They have a very characteristic appearance and are easily diagnosed. However, an atypical site (in the axial skeleton) and/or malignant transformation of the lesion may sometimes make it difficult to identify osteochondromas immediately by means of radiographic examination. In these cases, imaging examinations that are more refined are necessary. Although osteochondromas do not directly affect these patients' life expectancy, certain complications may occur, with varying degrees of severity...

Osteocondromas são protuberâncias ósseas envolvidas por uma camada de cartilagem. Atingem, habitualmente, as extremidades dos ossos longos no esqueleto imaturo e os deformam. Em geral são únicos, mas a forma de apresentação múltipla pode ser encontrada. De aspecto bastante característico, são de fácil diagnóstico. Contudo, por vezes, a localização atípica (esqueleto axial) e/ou a malignização da lesão podem dificultar a sua pronta identificacão por exames radiográficos. Nesses casos, exames de imagem mais apurados são necessários. Apesar de não afetarem diretamente a expectativa de vida do portador, algumas complições, com variados graus de gravidade, podem ocorrer...

Existe diferença no prognóstico de pacientes com osteossarcoma primário com uma pobre resposta à quimioterapia neoadjuvante entre os graus I e II de huvos? / Is there any difference in the prognosis for patients with primary osteosarcoma with a poor response to neoadjuvant chemotherapy between huvos grades I and II?

OBJETIVO: Haveria diferença no prognóstico de pacientes que apresentam, por exemplo, 8 por cento ou 88 por cento de necrose tumoral induzida pela quimioterapia, apesar de ambos serem considerados maus respondedores? O objetivo deste estudo foi comparar o prognóstico da graduação histológica (grau I versus II de Huvos) após efeito quimioterápico nos pacientes portadores de osteossarcoma primário, não metastático ao diagnóstico. MÉTODOS: Vinte e quatro pacientes admitidos em um serviço de referência entre 2000 e 2004 foram eleitos para o estudo. As probabilidades de sobrevida acumuladas foram feitas pela técnica de Kaplan-Meier. Os índices I e II de Huvos, para o grau de necrose após efeito quimioterápico, foram avaliados como variáveis para determinação de seu valor prognóstico em relação à sobrevida livre de recidiva local, sobrevida livre de metástases e sobrevida global, utilizando-se o teste Log-Rank. RESULTADOS: Quando comparados, os graus I e II de Huvos atingiram os seguintes valores de P nas sobrevidas estudadas: sobrevida livre de recidiva local (P = 0,731), sobrevida livre de metástases (P = 0,596) e sobrevida global (P = 0,669). CONCLUSÃO: Nesta série, os graus I e II de Huvos, comparativamente, não são de valor prognóstico, comportando-se de forma semelhante.

OBJECTIVE: Would there be any difference in the prognosis for patients who presented, for example, 8 percent or 88 percent tumor necrosis induced by chemotherapy, even though both individuals were considered to be poor responders? The aim of this study was to compare the prognoses for different histological grades (Huvos grade I versus grade II), consequent to chemotherapy, among patients with primary osteosarcoma that was not metastatic at diagnosis. METHODS: Twenty-four patients admitted to a referral center between 2000 and 2004 were selected for the study. The accumulated chances of survival were calculated using the Kaplan-Meier technique. Huvos grades I and II for necrosis consequent to chemotherapy were evaluated as variables in order to determine their prognostic value, in relation to local recurrence-free survival, metastasis-free survival and overall survival, using the log-rank test. RESULTS: Comparing Huvos grades I and II, the following P values for survival were attained: local recurrence-free survival (P = 0.731), metastasis-free survival (P = 0.596) and overall survival (P = 0.669). CONCLUSION: In this series, Huvos grades I and II did not have any comparative prognostic value and had similar behavior.

Primary malignancy in giant cell tumor: a case report / Malignização primária no tumor de células gigantes: um estudo de caso

Context: Primary malignancy in giant cell tumor (PMGCT) is rare. It is defined as a high-grade sarcoma originating in a giant cell tumor (GCT) and seems to behave less aggressively than its secondary counterpart does. Case report: This report presents the case of a 39-year-old female with pain in her left shoulder for one month. Radiography showed a pathological fracture of the proximal humerus associated with an osteolytic lesion. Histopathological analysis showed typical areas of GCT juxtaposed with a sarcomatous component. Conclusions: PMGCT seems to behave less aggressively than secondary malignancy in GCT, and it may simulate its more common benign counterpart clinically and radiographically. However, it requires a more aggressive type of treatment.

Contexto: Malignização primária no tumor de células gigantes (MPTCG) é rara. Ela é definida como um sarcoma de alto grau originário de um tumor de células gigantes que parece ser menos agressivo que o tipo secundário. Relato de Caso: Relatamos um caso de uma paciente de 39 anos de idade, com dor no ombro esquerdo há um mês. A radiografia mostrou uma fratura patológica do úmero proximal associada a uma lesão osteolítica. O exame histopatológico revelou típicas áreas de tumor de células gigantes justapostas por um componente sarcomatoso. Conclusão: MPTCG parece se comportar menos agressivamente que a neoplasia secundária do tumor de células gigantes (TCG), e pode simular o TCG, que é mais comum, tanto clínica como radiograficamente. Entretanto, exige tratamento mais agressivo.

Fatores prognósticos da sobrevida no osteossarcoma primário: grau I versus II de Huvos / Prognostic factors of survivor in primary osteosarcoma: Huvos´s grade I versus II

O objetivo deste trabalho foi comparar o prognóstico de sobrevida da graduação histológica após efeito da quimioterapia (graus I versus II de Huvos), visando também identificar fatores prognósticos no que diz respeito à sobrevida livre de recidiva local (SLRL), sobrevida livre de metástase (SLM) e sobrevida global (SG), em pacientes portadores de osteossarcoma primário não metastático ao diagnóstico. Vinte e quatro entre 45 pacientes admitidos no Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo IOT/HC/FMUSP, entre 2000 e 2004, foram eleitos para o estudo, segundo os critérios de inclusão e exclusão utilizados. As probabilidades de sobrevida acumuladas foram feitas pela técnica de Kaplan-Meier e os índices I e II de HUVOS comparados pelos testes de Log Rank. A análise multivariada foi feita pela técnica de regressão logística com modelo de risco proporcional de COX e a validade estatística estabelecida para valores de p<0,05. Os graus I e II de Huvos, quando comparados, não foram considerados de valor prognóstico em nenhuma das sobrevidas estudadas (SLRL, SLM e SG). Os fatores adversos que influenciaram o risco de recidiva local e a sobrevida global, na análise univariada foram: subtipo histológico diferente do osteoblástico (p=0,017) e o tamanho tumoral maior que 15 cm (p=0,048). Em relação à SLM o subtipo não osteoblástico (p=0,007) teve um pior prognóstico. O subtipo histológico manteve sua significância na análise multivariada em todas as sobrevidas estudadas.

The purpose of this study was to compare the prognostic of survivor of histologic graduation post chemotherapy (Huvos´s grade I versus II), aiming to identify prognostic factors concerning to local recurrence free survival (LRFS), metastases free survival (MFS) and overall survival (OS) in patients with nonmetastatic primary osteosarcoma. This study included 24 patients registred in the Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Brazil, from 2000 to 2004. Survivor rates were calculed using Kaplan-Meier method. Huvos´s grade (I e II) were compared using the Log Rank test. Cox proportional hazards model was used for multifatorial analysis. Statistical significance was defined as a p value less than 0, 05. The Huvos´s grade I versus II was not significant factor for LRFS, MFS or OS. The adverse factors for LRFS and OS in univariate analysis were nonosteoblastic histologic subtypes (p=0,017) and large tumor (p=0,048). For MFS nonosteoblastic histologic subtypes (p=0,007) had worse prognostic. The histologic subtypes maintained their significance in multivariate testing on all studied survivor.

Prognostic factors in the survival of patients diagnosed with primary non-metastatic osteosarcoma with a poor response to neoadjuvant chemotherapy

INTRODUCTION: Identification of variables that determine the prognosis for osteosarcoma may enable stratification of patients into subgroups with better or worse risk of local recurrence, metastases and death due to the disease. Discovery of such prognostic factors would permit selection of a subgroup of at-risk patients, with the aim of improving the therapeutic effectiveness. OBJECTIVE: To identify prognostic factors related to local recurrence-free survival, metastasis-free survival and overall survival among patients with highly malignant primary osteosarcoma that was non-metastatic on diagnosis and had poor response to neoadjuvant chemotherapy. SAMPLE AND METHODS: Out of 45 patients admitted to a referral center in Brazil between 2000 and 2004, 24 were selected for this study. RESULTS: The adverse factors that influenced the risk of local recurrence and the overall survival in univariate analysis were histological subtype other than osteoblastic (p = 0.017) and tumor size greater than 15 cm (p = 0.048). In relation to metastasis-free survival, the non-osteoblastic subtype had a worse prognosis (p = 0.007). The association of histological subtype maintained its significance in multivariate analysis for all studied survival categories. CONCLUSIONS: Tumor size greater than 15 cm is an adverse factor for local recurrence-free survival and overall survival but did not influence metastasis-free survival. The osteosarcoma histological type is a significant independent predictor for local recurrence-free survival, metastasis-free survival and overall survival.

Chronic multiple knee ligament injuries: epidemiological analysis of more than one hundred cases

INTRODUCTION: Diagnosis and treatment of multiple ligament injuries of the knee remain a real challenge for most surgeons. OBJECTIVE: To find out the epidemiological profile of patients surgically treated at a Reference Service with more than one chronic ligament injury in the knee joint. MATERIALS AND METHODS: Of a total of 978 operated patients, 109 presented at least two associated ligament injuries in the same knee. Demographic and clinical variables were evaluated. RESULTS: The anterior cruciate ligament group presented a larger number of cases of ligament injuries related with sports practice and falls, while the posterior cruciate ligament and anterior cruciate ligament + posterior cruciate ligament groups presented more cases related to traffic accidents and trauma with object (weight on the knee) (p<0.001). The varus group presented significantly higher values of time since injury (p<0.01). In the group with new anterior cruciate ligament injury (neoligament) associated with other ligament injuries the disruption times were higher, showing statistical significance (p<0.001). CONCLUSIONS: Anterior cruciate ligament injury associated with other ligament injuries other than posterior cruciate ligament injury are related to sports practice and falls. Posterior cruciate ligament injury associated to other ligament injuries, including or not anterior cruciate ligament injury, are related to traffic accidents and direct trauma caused by an object on the knee. Significant delay between primary ligament injuries and their reconstructions generates varus deformity of the affected knee. In spite of the large delay in seeking medical treatment, few patients with neoligament anterior cruciate ligament injury and other combined disruptions will develop varus deformity.

Prognostic factors and expression of MDM2 in patients with primary extremity liposarcoma

OBJECTIVE: The objective of this study was to investigate MDM2 (murine double minute 2) protein expression and evaluate its relationship with some anatomical and pathological aspects, aiming also to identify prognostic factors concerning local recurrence-free survival, metastasis-free survival and overall survival in patients with primary liposarcomas of the extremities. MATERIALS AND METHODS: Of 50 patients with primary liposarcomas of the extremities admitted to a Reference Service, between 1968 and 2004, 25 were enrolled in the study, following eligibility and exclusion criteria. RESULTS: The adverse factors that influenced the risk for local recurrence in the univariant analysis included male sex (P = 0.023), pleomorphic histological subtype (P = 0.027), and high histological grade (P = 0.007). Concerning metastasis-free survival, age less than 50 years (P = 0.040), male sex (P = 0.040), pleomorphic subtype (P < 0.001), and high histological grade (P = 0.003) had a worse prognosis. Adverse factors for overall survival were age under 50 years (P = 0.040), male sex (P = 0.040), pleomorphic subtype (P < 0.001), and high histological grade (P = 0.003). CONCLUSIONS: There was no correlation between immunohistochemically observed MDM2 protein expressions and the anatomical and pathological variables studied. The immunohistochemical expression of MDM2 protein was not considered to have a prognostic value for any of the surviving patients in this study (local recurrence-free survival, metastasis-free survival, or overall survival). The immunoexpression of MDM2 protein was a frequent event in the different subtypes of liposarcomas.