Comparison between cotton test and tap test for the assessment of coronal syndesmotic instability: A cadaveric study.

INTRODUCTION: In surgically treated rotational malleolar fractures, residual syndesmotic instability is typically assessed following fixation with the widely used intraoperative Cotton test. However, due to its dynamic nature, there are inconsistencies of the magnitude and direction of the distraction force when attempting to pull the fibula away from the tibia using a bone hook. The novel Tap test advances a cortical tap through a drilled hole in the fibula with a stable, unidirectional distraction force applied to the tibia. The objective of this cadaveric study was to compare the Cotton and Tap tests as diagnostic tools for coronal plane syndesmotic instability. METHODS: Tibiofibular Clear Space (TFCS) of 10 cadaveric specimens was measured for: intact, non-stressed; intact, stressed; injured, non-stressed; and injured, stressed (Tap and Cotton tests). In injured conditions, the syndesmotic ligamentous complex was sectioned using an anterolateral longitudinal approach. Perfect fluoroscopic Mortise images were acquired for all conditions. Two independent and blinded Orthopaedic Foot and Ankle Surgeons measured TFCS 1 cm proximal to the ankle joint line. Intra and interobserver reliabilities were assessed by Intraclass Correlation Coefficient. Syndesmotic TFCS values for all conditions were compared by paired Wilcoxon. Diagnostic performance of the Cotton and Tap tests was assessed using a relative increase of TFCS > 2 mm when comparing intact stressed and injured stressed conditions. P-values <0.05 were considered significant. RESULTS: The intraclass correlation coefficient for intraobserver and interobserver reliability was respectively 0.96 and 0.79. TFCS measurements were similar in intact non-stressed, intact stressed (both Cotton and Tap tests) and injured non-stressed conditions, with mean values and 95% Confidence Intervals of: intact non-stressed, 3.5 mm; intact stressed, 3.6 mm (Cotton test) and 4.0 mm (Tap test); injured non-stressed, 3.8 mm. The Cotton test and Tap test had, respectively, 73.3% and 70% sensitivity, 100% and 90% specificity, 86.7% and 80% diagnostic accuracy. CONCLUSIONS: Our cadaveric study compared the Cotton and Tap tests for detection of coronal plane syndesmotic instability. Both tests demonstrated similar increases in the TFCS measurements in stressed injured conditions when compared to intact non-stressed and stressed conditions, as well as injured non-stressed conditions.

HALLUX PROXIMAL PHALANX FRACTURE IN ADULTS: AN OVERLOOKED DIAGNOSIS.

OBJECTIVES: To describe the surgical treatment of fractures that involves the hallux interphalangeal joint, current indications and management options. METHODS: we performed a literature review of relevant clinical studies in multiple databases, including PubMed, MedLine and Scopus, from January 1989 to October 2020. RESULTS: There is consensus for surgical treatment of intra-articular fractures with a deviation greater than 2 mm, metadiaphyseal fractures with malrotation and/or malangulation, open fractures and unstable fractures. CONCLUSION: The use of more rigid implants allow alignment maintenance during healing process and lower risk of reduction loss. Valgus deformity and interphalangeal joint osteoarthritis are possible complications that must be avoided. Level of Evidence III, Systematic review of Level III studies.

OBJETIVOS: destacar o tratamento cirúrgico das fraturas que envolvem a articulação interfalangiana do hálux, suas indicações atuais e as opções de tratamento. MÉTODOS: Realizamos uma revisão da literatura de estudos clínicos relevantes em múltiplas bases de dados, incluindo PubMed, MedLine e Scopus, de janeiro de 1989 a outubro de 2020. RESULTADOS: Há consenso para o tratamento cirúrgico de fraturas intra-articulares com desvio superior a 2 mm, fraturas metadiafisárias com má rotação e/ou malangulação, fraturas expostas e fraturas instáveis. CONCLUSÃO: O uso de implantes mais rígidos permite a manutenção do alinhamento durante o processo de consolidação e menor risco de perda da redução. As complicações que devem ser evitadas são a deformidade em valgo e a osteoartrite da articulação interfalangeana. Nível de Evidência III, Revisão sistemática de Estudos de Nível III.

Hallux proximal phalanx fracture in adults: an overlooked diagnosis / Fratura da falange proximal do hálux em adultos: um diagnóstico esquecido

ABSTRACT Objectives: To describe the surgical treatment of fractures that involves the hallux interphalangeal joint, current indications and management options. Methods: we performed a literature review of relevant clinical studies in multiple databases, including PubMed, MedLine and Scopus, from January 1989 to October 2020. Results: There is consensus for surgical treatment of intra-articular fractures with a deviation greater than 2 mm, metadiaphyseal fractures with malrotation and/or malangulation, open fractures and unstable fractures. Conclusion: The use of more rigid implants allow alignment maintenance during healing process and lower risk of reduction loss. Valgus deformity and interphalangeal joint osteoarthritis are possible complications that must be avoided. Level of Evidence III, Systematic review of Level III studies.

RESUMO Objetivos: destacar o tratamento cirúrgico das fraturas que envolvem a articulação interfalangiana do hálux, suas indicações atuais e as opções de tratamento. Métodos: Realizamos uma revisão da literatura de estudos clínicos relevantes em múltiplas bases de dados, incluindo PubMed, MedLine e Scopus, de janeiro de 1989 a outubro de 2020. Resultados: Há consenso para o tratamento cirúrgico de fraturas intra-articulares com desvio superior a 2 mm, fraturas metadiafisárias com má rotação e/ou malangulação, fraturas expostas e fraturas instáveis. Conclusão: O uso de implantes mais rígidos permite a manutenção do alinhamento durante o processo de consolidação e menor risco de perda da redução. As complicações que devem ser evitadas são a deformidade em valgo e a osteoartrite da articulação interfalangeana. Nível de Evidência III, Revisão sistemática de Estudos de Nível III.

Expanding the horizons of clinical applications of proximal humerus locking plates in the lower extremities: A technical note.

Pre-contoured anatomical locking plates were designed to address the clinical need of fixing small epiphyseal segments with a larger number of screws. Those plates match the contour and shape of a variety of bones allowing for optimal buttress properties. The aim of this manuscript is to highlight the benefits of applying proximal humerus locking plates in the fixation of lower extremity bones. Although designed for the proximal humerus, the low-profile plate shape and anatomic contour also provides versatile use in certain areas of the lower extremity. This technical narrative highlights the versatile and reliable use of this plate for other anatomical areas than the one to which it has been originally conceived.

Epidemiology of injuries due to ankle sprain diagnosed in an orthopedic emergency room.

OBJECTIVE: To use magnetic resonance imaging to assess the prevalence of foot and ankle ligament injuries and fractures associated with ankle sprain and not diagnosed by x-ray. METHODS: We included 180 consecutive patients with a history of ankle sprain, assessed at a primary care service in a 12-month period. Magnetic resonance imaging findings were recorded and described. RESULTS: Approximately 92% of patients had some type of injury shown on the magnetic resonance imaging. We found 379 ligament injuries, 9 osteochondral injuries, 19 tendinous injuries and 51 fractures. Only 14 magnetic resonance imaging tests (7.8%) did not show any sort of injury. We observed a positive relation between injuries of the lateral complex, syndesmosis and medial ligaments. However, there was a negative correlation between ankle ligament injuries and midfoot injuries. CONCLUSION: There was a high rate of injuries secondary to ankle sprains. We found correlation between lateral ligament injuries and syndesmosis and deltoid injuries. We did not observe a relation between deltoid and syndesmosis injuries or between lateral ligamentous and subtalar injuries. Similarly, no relation was found between ankle and midfoot injuries.

Rotator Cuff Tear Susceptibility Is Associated With Variants in Genes Involved in Tendon Extracellular Matrix Homeostasis.

Rotator cuff tears (RCT) is a multifactorial disease with genetic factors contributing for the disease etiology. We hypothesized that genetic variants in genes involved in extracellular matrix (ECM) homeostasis may alter susceptibility to RCT. We evaluated 20 polymorphisms of genes involved in ECM homeostasis in 211 cases of full-thickness tears of the supraspinatus (Nfemales = 130; Nmales = 81) and 567 age-matched controls (Nfemales = 317; Nmales = 250). Multivariate logistic regressions were carried out with age, gender, genetic ancestry (based on the analysis of 61 biallelic short insertion/deletion polymorphisms), and common co-morbidities (diabetes, dyslipidemia, and smoking habits) as covariates. We observed that carriers of the rare allele of both studied variants of TGFB1, as well as their G/A (rs1800470/rs1800469) haplotype, were less susceptible to RCT (p < 0.05). In contrast, carriers of the G allele of MMP9 rs17576 (p = 0.014) or G/G haplotype (rs17576/rs17577; p < 0.001) had an increased risk for tendon tears. The presence of the T allele of MMP2 rs2285053 (p = 0.033), the T allele of MMP3 rs679620 (p = 0.024), and the TT-genotype of TIMP2 rs2277698 (p = 0.01) was associated with susceptibility to tears, especially in females. In males, the A allele of COL5A1 rs3196378 (p = 0.032) and the G allele of TGFBR1 rs1590 (p = 0.039) were independent risk factors for RCT. The C/T COL5A1 (rs3196378/rs11103544) haplotype was associated with a reduced risk of tears in males (p = 0.03). In conclusion, we identified the genetic variants associated with RCT susceptibility, thereby reinforcing the role of genes involved in the structure and homeostasis of the ECM of tendons in disease development. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:192-201, 2020.

Epidemiology of injuries due to ankle sprain diagnosed in an orthopedic emergency room / Epidemiologia das lesões por entorse do tornozelo diagnosticadas em pronto atendimento de ortopedia

ABSTRACT Objective To use magnetic resonance imaging to assess the prevalence of foot and ankle ligament injuries and fractures associated with ankle sprain and not diagnosed by x-ray. Methods We included 180 consecutive patients with a history of ankle sprain, assessed at a primary care service in a 12-month period. Magnetic resonance imaging findings were recorded and described. Results Approximately 92% of patients had some type of injury shown on the magnetic resonance imaging. We found 379 ligament injuries, 9 osteochondral injuries, 19 tendinous injuries and 51 fractures. Only 14 magnetic resonance imaging tests (7.8%) did not show any sort of injury. We observed a positive relation between injuries of the lateral complex, syndesmosis and medial ligaments. However, there was a negative correlation between ankle ligament injuries and midfoot injuries. Conclusion There was a high rate of injuries secondary to ankle sprains. We found correlation between lateral ligament injuries and syndesmosis and deltoid injuries. We did not observe a relation between deltoid and syndesmosis injuries or between lateral ligamentous and subtalar injuries. Similarly, no relation was found between ankle and midfoot injuries.

RESUMO Objetivo Avaliar na ressonância magnética a prevalência das diferentes lesões ligamentares do tornozelo e do pé, bem como de fraturas não diagnosticáveis radiograficamente, em pacientes com queixa de entorse do tornozelo. Métodos Foram incluídos no estudo 180 pacientes consecutivos, com história de entorse do tornozelo, atendidos em um serviço de Atenção Primária no período de 12 meses. Os achados dos exames de ressonância magnética foram catalogados e descritos. Resultados Aproximadamente 92% dos pacientes apresentaram algum tipo de lesão na ressonância. Dentre as injúrias observadas, estavam 379 lesões ligamentares, 9 lesões osteocondrais, 19 lesões tendíneas e 51 fraturas. Apenas 14 ressonâncias magnéticas (7,8%) não mostraram qualquer tipo de lesão. Observamos relação positiva entre lesões do complexo lateral, sindesmose e medial. No entanto, houve correlação negativa entre lesões ligamentares do tornozelo e aquelas do mediopé. Conclusão Foi alta a ocorrência de lesões secundárias à entorse. Apontamos correlação entre as lesões ligamentares laterais com as sindesmodais e do deltoide. Não notamos relação entre as lesões do deltoide e da sindesmose, e nem entre as ligamentares laterais e a subtlalar. Também não foram observadas relações entre as lesões do tornozelo e as do mediopé.

Posterior quadratus lumborum block for primary total hip arthroplasty analgesia: a comparative study.

OBJECTIVE: To compare analgesia and opioid consumption for patients undergoing primary total hip arthroplasty with preoperative posterior quadratus lumborum block with patients who did not receive quadratus lumborum block. METHODS: The medical records of patients undergoing unilateral total hip arthroplasty between January 1st, 2017 and March 31, 2018 were reviewed, and 238 patients were included in the study. The primary outcome was postoperative opioid consumption in the first 24 postoperative hours. Secondary outcomes were intraoperative, post anesthesia care unit, and 48-hour opioid consumption, postoperative pain Visual Analog Scale scores, and post-anesthesia care unit length of stay. Primary and secondary endpoint data were compared between patients undergoing primary total hip arthroplasty with preoperative posterior quadratus lumborum block with patients who did not receive quadratus lumborum block. RESULTS: For the patients who received quadratus lumborum block, the 24-hour total oral morphine equivalent (milligram) requirements were lower (53.82mg±37.41), compared to the patients who did not receive quadratus lumborum block (77.59mL±58.42), with p=0.0011. Opioid requirements were consistently lower for the patients who received quadratus lumborum block at each additional assessment time point up to 48 hours. Pain Visual Analog Scale scores were lower up to 12 hours after surgery for the patients who received a posterior quadratus lumborum block, and the post-anesthesia care unit length of stay was shorter for the patients who received quadratus lumborum block. CONCLUSION: Preoperative posterior quadratus lumborum block for primary total hip arthroplasty is associated with decreased opioid requirements up to 48 hours, decreased Visual Analog Scale pain scores up to 12 hours, and shorter post-anesthesia care unit length of stay. Level of evidence: III.

Genetic variants involved in extracellular matrix homeostasis play a role in the susceptibility to frozen shoulder: A case-control study.

Frozen shoulder is a condition of loss of active and passive motion as result of inflammatory contracture and fibrosis of the joint capsule. We hypothesize that genetic variants in genes involved in these processes such as genes that play a role in extracellular matrix homeostasis (collagens, glycoproteins, genes involved in TGFß signaling, and metalloproteinases and its inhibitors) may contribute to the susceptibility to frozen shoulder. We evaluated eighteen SNPs of genes involved in extracellular matrix homeostasis in 186 cases (Nfemales = 114; Nmales = 72) of frozen shoulder and 600 age-matched controls (Nfemales = 308; Nmales = 292). Multivariate logistic regressions were carried out with age, gender, genetic ancestry, and common comorbidities as covariates. Carriers of the C allele of MMP13 rs2252070 and G/G MMP9 (rs17576 A>G/rs17577 G>A) haplotype may have an increased risk of frozen shoulder (p = 0.002, OR = 1.64, 95%CI = 1.20-2.26, and p = 0.046, OR = 1.40, 95%CI = 1.01-1.95, respectively), especially in females (p = 0.005, OR = 1.91, 95%CI = 1.22-2.99, and p = 0.046, OR = 1.59, 95%CI = 1.01-2.51, respectively). In females, the G allele of MMP9 rs17576 tended to contribute to the susceptibility to the studied disease (p = 0.05, OR = 1.51, 95%CI = 0.97-2.33). In contrast, the presence of the C allele of TGFB1 rs1800470 seems to be associated with a reduced risk (p = 0.04, OR = 0.47, 95%CI = 0.23-0.96) while the GG-genotype of TGFBR1 rs1590 was associated with increased risk (p = 0.027, OR = 4.11, 95%CI = 1.17-14.38) to frozen shoulder development in males. Thus, we identified genetic variants that were independent risk factors that can aid in the risk assessment of frozen shoulder reinforcing the involvement of MMP and TGFß signaling in disease development. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

Calf Augmentation Implant Disruption Following a Tibial Plateau Fracture Fixation: An Extremely Rare Complication.

INTRODUCTION: Calf augmentation is a procedure to enhance leg contour, therefore, providing better aesthetic aspect. Patient satisfaction is extremely high, and reported complications following this procedure are rare. CASE REPORT: The aim of this study is to report an as yet described complication related to calf implants: Prosthesis disruption in a 60-year-old female patient who fell downstairs and presented a closed bicondylar tibial plateau fracture on the right knee (Schatzker V). CONCLUSION: We believe this case report can alert orthopaedic surgeons to carefully evaluate leg images in traumatized extremities and look for calf augmentation implants, especially in unconscious patients.

Posterior quadratus lumborum block for primary total hip arthroplasty analgesia: a comparative study / Bloqueio anestésico do quadrado lombar posterior para analgesia na artroplastia total do quadril primária: estudo comparativo

ABSTRACT Objective To compare analgesia and opioid consumption for patients undergoing primary total hip arthroplasty with preoperative posterior quadratus lumborum block with patients who did not receive quadratus lumborum block. Methods The medical records of patients undergoing unilateral total hip arthroplasty between January 1st, 2017 and March 31, 2018 were reviewed, and 238 patients were included in the study. The primary outcome was postoperative opioid consumption in the first 24 postoperative hours. Secondary outcomes were intraoperative, post anesthesia care unit, and 48-hour opioid consumption, postoperative pain Visual Analog Scale scores, and post-anesthesia care unit length of stay. Primary and secondary endpoint data were compared between patients undergoing primary total hip arthroplasty with preoperative posterior quadratus lumborum block with patients who did not receive quadratus lumborum block. Results For the patients who received quadratus lumborum block, the 24-hour total oral morphine equivalent (milligram) requirements were lower (53.82mg±37.41), compared to the patients who did not receive quadratus lumborum block (77.59mL±58.42), with p=0.0011. Opioid requirements were consistently lower for the patients who received quadratus lumborum block at each additional assessment time point up to 48 hours. Pain Visual Analog Scale scores were lower up to 12 hours after surgery for the patients who received a posterior quadratus lumborum block, and the post-anesthesia care unit length of stay was shorter for the patients who received quadratus lumborum block. Conclusion Preoperative posterior quadratus lumborum block for primary total hip arthroplasty is associated with decreased opioid requirements up to 48 hours, decreased Visual Analog Scale pain scores up to 12 hours, and shorter post-anesthesia care unit length of stay. Level of evidence: III

RESUMO Objetivo Comparar a analgesia e o uso de opioides em pacientes submetidos à artroplastia total do quadril primária com bloqueio pré-operatório do quadrado lombar posterior e pacientes que não receberam o bloqueio do quadrado lombar. Métodos Revisamos os prontuários de pacientes submetidos à artroplastia total do quadril unilateral entre 1º de janeiro de 2017 e 31 de março de 2018, e 238 pacientes foram incluídos no estudo. O desfecho primário foi o consumo de opioides no pós-operatório nas primeiras 24 horas. Os desfechos secundários foram consumo de opioide no intraoperatório, na sala de recuperação pós-anestésica e nas primeiras 48 horas, escores de Escala Visual Analógica de dor pós-operatória, e tempo de permanência na recuperação pós-anestésica. Os desfechos primário e secundários foram comparados entre os pacientes submetidos à artroplastia total do quadril primária com bloqueio pré-operatório do quadrado lombar posterior e aqueles que não receberam o bloqueio do quadrado lombar. Resultados Para o grupo que recebeu o bloqueio, as doses totais de morfina por via oral em 24 horas foram menores (53,82mg±37,41) em comparação ao grupo sem bloqueio (77,59mg±58,42), com p=0,0011. A utilização de opioides foi consistentemente menor para o grupo que recebeu o bloqueio em cada tempo adicional de avaliação até 48 horas. Os escores da Escala Visual Analógica até 12 horas após a cirurgia para os pacientes que receberam o bloqueio do quadrado lombar posterior e o tempo de permanência na sala de recuperação pós-anestésica foram menores para o grupo que recebeu o bloqueio. Conclusão O bloqueio anestésico do quadrado lombar posterior para artroplastia total do quadril primária está associado à diminuição do uso de opioides nas primeiras 48 horas, diminuição do escore de dor da Escala Visual Analógica em até 12 horas, e menor tempo de permanência na sala de recuperação pós-anestésica. Nível de evidência: III

Clamshell Osteotomy for Acute Fractures in the Malunion Setting: A Technical Note.

Surgical management of lower extremity malunions and acute fractures in the setting of lower extremity deformities presents a unique challenge for orthopaedic surgeons. The objective of this study was to evaluate the outcomes of using the clamshell osteotomy in patients with acute fractures involving a malunion or deformity. A retrospective review of the cases performed by various orthopaedic traumatologists at 4 different trauma centers was performed to identify cases using the clamshell osteotomy from January 2012 to January 2016. Nine clamshell osteotomy cases were identified, 4 presenting fractures in the setting of previous malunions. All osteotomies healed within 15 months (average 6.8 ± 4.4 SD). In this multicenter case series, we demonstrate that using clamshell osteotomies can result in excellent outcomes for permitting intramedullary nailing of acute fractures in patients with lower extremity deformity.

Periprosthetic humeral fractures after reverse shoulder arthroplasty. Case report.

Periprosthetic fractures is a severe complication after joint replacement. The rapidly increase of reverse shoulder arthroplasty surgeries, periprosthetic humeral fractures, which are described as rare, may increase in the near future. We report the case of displaced humeral fracture bellow the stem of reverse shoulder prosthesis. The patient was an 85-year-old woman who had a total shoulder replacement 6 years previously. The surgical solution consisted of plate osteossynthesis and cerclage. This report describes an unprecedented case in Brazilian literature; and gives an overview of the existing literature including this injury classification.

Periprosthetic humeral fractures after reverse shoulder arthroplasty. Case report / Fratura periprotética após artroplastia reversa do ombro. Relato de caso

ABSTRACT Periprosthetic fractures is a severe complication after joint replacement. The rapidly increase of reverse shoulder arthroplasty surgeries, periprosthetic humeral fractures, which are described as rare, may increase in the near future. We report the case of displaced humeral fracture bellow the stem of reverse shoulder prosthesis. The patient was an 85-year-old woman who had a total shoulder replacement 6 years previously. The surgical solution consisted of plate osteossynthesis and cerclage. This report describes an unprecedented case in Brazilian literature; and gives an overview of the existing literature including this injury classification.

RESUMO As fraturas periprotéticas do ombro representam uma grave complicação após a substituição da articulação. Devido ao rápido aumento do número de cirurgias de artroplastia reversa no ombro, as fraturas periprótese do úmero, descritas como raras, podem aumentar no futuro próximo. Descrevemos um caso de fratura desviada do úmero abaixo do componente umeral de uma artroplastia reversa. A paciente era uma mulher de 85 anos de idade, que tinha uma artroplastia reversa do ombro há 6 anos. O tratamento cirúrgico consistiu em osteossíntese com placa, parafusos e cerclagem. Os objetivos do presente trabalho foram reportar um caso inédito na literatura brasileira, e revisar a literatura existente e as classificações da lesão.

Minimally invasive posteromedial percutaneous plate osteosynthesis for diaphyseal tibial fractures: technique description.

PURPOSE: The aim of this study was to evaluate the feasibility of performing minimally-invasive plate osteosynthesis (MIPO) in tibial fractures using two posteromedial incisions, and to measure the distance between the plate and neurovascular structures. MATERIALS AND METHODS: We performed nine dissections of specimens that were submitted to tibial MIPO with two posteromedial incisions. One locking compression plate (LCP) of 14 to 16 holes was inserted into the submuscular tunnel in a retrograde manner. Incisions were linked to evaluate the distance between neurovascular structures and the plate. RESULTS: During the proximal incision, a blunt dissection between semitendinosus and medial gastrocnemius tendons, as well as their lateral shift, helped to protect the main local neurovascular structures. In its distal portion, the submuscular plate tunnel insertion and its direction to the proximal incision prevented direct contact and possible damage to neurovascular structures. Moreover, we obtained successful results from a patient submitted to this procedure. CONCLUSION: Posteromedial MIPO represents a safe and attractive alternative for tibial fractures, particularly if there are damaged soft tissues in the anterior and medial side, or when access to intramedullary osteosynthesis is blocked.

Submuscular double bridge plating for complex distal fractures of the humerus: an alternative, safe, and efficient treatment method.

PURPOSE: The aim of our study is to show the functional outcomes and complication rates of humeral complex fractures in adults, using osteosynthesis with two bridging orthogonal submuscular plates. METHODS: The study consists of a prospective case series of 13 patients with isolated humeral complex fractures treated with two bridging orthogonal submuscular plates. Functional assessment was performed using disabilities of the arm, shoulder, and hand (DASH) score with 30 items. The age ranged from 22 to 68 years, with a mean age of 39 years. Functional assessment with DASH score was performed at the twelfth postoperative week. RESULTS: All patients presented fracture healing in the fourth postoperative month. Of the 13 patients, five (38%) had a DASH score of zero (best function possible). One patient developed neuropraxis and presented with a score of 100 (worst possible). One case developed superficial infection, which was treated with oral antibiotics and local debridement. CONCLUSIONS: This study demonstrated satisfactory functional outcome in patients with distal-third diaphyseal humeral complex fractures treated with two locked submuscular plates. The authors consider it as a safe method and an efficient alternative, especially in younger patients who require early functional recovery.

Complications and outcomes of the transfibular approach for posterolateral fractures of the tibial plateau.

OBJECTIVE: Evaluate complication rates and functional outcomes of fibular neck osteotomy for posterolateral tibial plateau fractures. DESIGN: Retrospective case series. SETTING: University hospital. PATIENTS: From January 2013 to October 2014, 11 patients underwent transfibular approach for posterolateral fractures of the tibial plateau and were enrolled in the study. All patients who underwent transfibular approach were invited the return to the hospital for another clinical and imaging evaluation. INTERVENTION: Transfibular approach (fibular neck osteotomy) with open reduction and internal fixation for posterolateral fractures of the tibial plateau. MAIN OUTCOME MEASUREMENTS: Complications exclusively related to the transfibular approach: peroneal nerve palsy; knee instability; loss of reduction; nonunion and malunion of fibular osteotomy; and functional outcomes related to knee function. RESULTS: Two patients failed to follow-up and were excluded from the study. Of the 9 patients included in the study, no patients demonstrated evidence of a peroneal nerve palsy. One patient presented loss of fracture reduction and fixation of the fibular neck osteotomy, requiring revision screw fixation. There were no malunions of the fibular osteotomy. None of the patients demonstrated clinically detectable posterolateral instability of the knee following surgery. American Knee Society Score was good in 7 patients (77.8%), fair in 1 (11.1%), and poor in 1 (11.1%). American Knee Society Score/Function showed 80 points average (60-100, S.D:11). CONCLUSION: The transfibular approach for posterolateral fractures is safe and useful for visualizing posterolateral articular injury. The surgeon must gently protect the peroneal nerve during the entire procedure and fix the osteotomy with long screws to prevent loss of reduction. LEVEL OF EVIDENCE: Therapeutic level IV.

Where is the true location of the femoral piriform fossa?

OBJECTIVE: To analyze knowledge of the anatomic location of the piriform fossa using a questionnaire with anatomic figures. MATERIALS AND METHODS: Participants taking AO Trauma Brasil courses were requested to complete a questionnaire containing a photograph of the superior surface and a photograph of the lateral surface of the femur and answer a question asking which of four numbered points corresponded to the piriform fossa. RESULTS: Just 4.5% of respondents correctly chose point 2 (the piriform fossa) in both images, while 75.4% of respondents chose point 4 (the trochanteric fossa) as the correct anatomic structure. The subset of 4th-year residents' answers was significantly different from those of the other subsets, with 7.5% of correct answers. CONCLUSIONS: The low rate of correct answers indicates a tendency for the respondents to be influenced by illustrations in text books or examples in scientific publications that indicate the site of the piriform fossa incorrectly. Interest in the specialty of traumatology is possibly the reason why the subset of 4th-year residents had a better- than-average rate of correct answers.

Cesarean section and osteosynthesis of lower limb fractures in the same surgical procedure.

INTRODUCTION: Orthopedic trauma during pregnancy can cause serious complications such as premature birth, stillbirth and maternal morbidities. PRESENTATION OF CASE: We report the case of a patient at 38 weeks pregnancy who fractured the left ankle and the right fifth metatarsal after falling. Cesarean section and osteosynthesis were performed in the usual manner in the same surgical procedure. There were no postoperative complications. DISCUSSION: Pregnancy and puerperium are associated with a hypercoagulable state. The early mobilization provided by surgical treatment of the fractures reduced the risks of thromboembolic events. CONCLUSION: The approach adopted may be used as an example for future procedures done in similar situations.

Unusual presentation of a femoral stress fracture.

Stress fractures are common injuries in sports medicine. Among these fractures, femoral neck stress fractures frequently have a benign course, especially when it happens in the medial aspect of the neck. This case report describes a stress fracture of the medial aspect of the femoral neck that developed a complete fracture and underwent surgical fixation.