Effect of damage control strategy combining pre-hospital emergency treatment with in-hospital treatment on pelvic fracture complicated by multiple injuries.

OBJECTIVE: To analyze the application value of damage control strategies combining pre-hospital emergency treatment with in-hospital treatment for multiple injuries in treating pelvic fracture complicated by multiple injuries. METHODS: 120 patients with pelvic fracture complicated by multiple injuries admitted to our hospital from January 2020 to January 2023 were selected and divided into a damage control group (early temporary reduction after resuscitation, n = 60) and a control group (no reduction and resuscitation only, n = 60) by treatment methods. The control group was treated with conventional methods, while the damage control group was treated with the damage control strategy combining pre-hospital emergency treatment combined with in-hospital treatment in addition to conventional methods. The mortality rate, complication rate, fracture reduction quality, long-term efficacy, and patient satisfaction of the two groups were compared. RESULTS: The mortality rate of the damage control group was lower than that of the control group, and the difference has statistical significance (P<0.05); the incidence of infection, DIC, and MODS of the damage control group were lower than that of the control group, with the difference being statistically significant (P<0.05); the incidence of ARDS in the two groups is not that different (P>0.05); the fracture reduction quality and long-term therapeutic effect of patients in the two groups were statistically different, with the damage control group outperforming the control group in both aspects; the difference between the two groups in terms of patient satisfaction was statistically significant (P<0.05), with the patient satisfaction of the damage control group being higher than that of the control group. CONCLUSION: For patients with pelvic fracture, the application of the damage control strategy combining pre-hospital emergency treatment and in-hospital treatment is a boon to the standardization of the treatment process, the improvement of the treatment success rate and fracture reduction quality and the reduction of complications, and therefore is worth promoting in clinical practice. the early application of external fixation has helped with the definitive reduction at a time when the patuent was stable.

Does a simultaneous ventral/dorsal approach provide better reduction quality in treating acetabular fracture involving both columns with displaced posterior wall?

INTRODUCTION: Various surgical techniques have been proposed to manage acetabular fractures involving both columns with posterior wall displacement. However, the optimal surgical approach to achieve satisfactory reduction quality remains controversial. MATERIALS AND METHODS: This retrospective study evaluated 34 patients with fractures who were treated at a single medical institution. The patients were divided into two groups according to the ventral/dorsal surgical approach employed: simultaneous (SI) and sequential (SE). Perioperative parameters, as well as radiological and functional outcomes, were analyzed and compared between the two groups. RESULTS: The SI and SE groups comprised 9 and 23 out of the 34 patients, respectively. The SI group exhibited a significantly shorter surgical time and lower estimated blood loss than the SE group (p = 0.04 and 0.03, respectively). The quality of reductions of the anterior and posterior columns was similar between the two groups; however, superior reduction in the fracture gap of the posterior wall was observed in the SI group, as revealed by axial and coronal computed tomography scans. CONCLUSIONS: A simultaneous ventral and dorsal approach through the pararectus and the modified Gibson approach confer clinical advantages in reducing the fracture gap, surgical time, and intraoperative blood loss when managing acetabular fractures involving both columns and a displaced posterior wall. Therefore, these surgical approaches may be considered to be optimal for achieving satisfactory reduction quality in such fractures.

Failure after intramedullary nailing for geriatric trochanteric fracture: does quality of fracture reduction on the AP and lateral planes show the same results?

PURPOSE: This study aimed to investigate the failure of trochanteric fracture fixation according to the quality of fracture reduction on the anteroposterior (AP) and lateral views. METHODS: Data from 340 female and 152 male patients ≥ 60 years of age who underwent intramedullary nailing for a trochanteric fracture between 2016 and 2020 were analysed retrospectively. The quality of fracture reduction was classified as type A, type E, and type I on the AP view and type N, type A, and type P on the lateral view according to the relative position of the proximal and distal fragments. The failure rate was evaluated and compared according to the quality of fracture reduction. The risk factors of the fixation failure were investigated by comparison of variables between patients with and without failure and by regression analysis. RESULTS: Patients with poor reduction, type I and type P had higher failure rates. However, a statistically significant difference was found only for patients with poor reduction (type P) on the lateral view (p < 0.001). Patients with failure showed significantly higher rates of poor reduction on the lateral view and AO/OTA type A3 fractures. The regression analysis also showed that poor reduction on the lateral view (odds ratio [OR] 12.70; 95% confidence interval [CI] 4.0-40.6; p < 0.001) and AO/OTA type A3 fractures (OR 5.40; 95% CI 1.24-23.49, p = 0.025) were risk factors for failure. CONCLUSION: Poor reduction such as type P reduction was associated with failure after intramedullary nailing for trochanteric fractures. Surgeons should check the quality of fracture reduction carefully with the proper fluoroscopic view to prevent failure in geriatric patients with trochanteric fractures.

Open reduction and internal fixation of crescent fracture-dislocation: anterior or posterior approach?

INTRODUCTION: To date, the approach that prevails in the open reduction and internal fixation of crescent fracture-dislocations (CFD) remains unknown. This study aimed to compare the outcomes of CFD treated via the anterior or posterior approach. MATERIALS AND METHODS: Data from 64 cases of CFDs openly reduced through an anterior (group A, n = 31) or a posterior (group B, n = 33) approach were retrospectively analyzed. Functional results, reduction quality, residual displacements in the axial and coronal planes, pelvic asymmetry deformity, and correlations between Day's classification were compared. Complications and fracture union were also recorded. All patients were followed up for at least 12 months. RESULTS: The functional scores were similar between the two groups, and all fractures achieved good or excellent reduction postoperatively. In the coronal plane, the excellent/good ratio in group B was higher than in group A. The mean residual displacement in the coronal plane was significantly higher in group A than in group B, with group A showing greater displacement in both planes for Day I fractures and in the coronal plane for Day II fractures. The residual displacement in both planes for Day III fractures was comparable between the groups. The pelvic asymmetry deformity was equal between the two groups and among the different Day's fracture types. CONCLUSIONS: Open reduction and internal fixation of CFDs obtained satisfactory outcomes through an anterior or posterior approach. The posterior approach achieved a better sacroiliac joint reduction. The optimal indication for the posterior approach was a Day I fracture, followed by a Day II fracture. No correlation was found between the surgical approach and reduction quality in Day III fractures.

Outcomes after ORIF are similar in young and elderly patients with tibial plateau fractures: A minimum 2-year follow-up study.

BACKGROUND: This study aimed to compare the outcomes of open reduction internal fixation in young and elderly patients with tibial plateau fractures. METHODS: A total of 224 patients with tibial plateau fractures treated with open reduction internal fixation at a level I trauma center from 2014 to 2019 were reviewed. The patients with a minimum follow-up of 2 years were divided into two groups, with those aged 60 years and older divided into the elderly group and those under 60 years divided into the young group. The mean follow-up time was 55 months (range: 24-80), and the primary outcomes were quality of reduction and function. The secondary outcomes included complications, fracture healing time, and conversion to total knee arthroplasty. RESULTS: The elderly group had a higher proportion of women than the young group (61.1% vs. 23.9%, p < 0.001). Diabetes was more prevalent in the elderly cohort than in the young cohort (18.9% vs. 9.0%, p = 0.030). The rate of bone grafts was higher in the elderly group (57.8% vs. 41.8%, p = 0.019), but no significant differences were found between the groups regarding fracture characteristics, the operative time or intraoperative blood loss. The reduction quality, knee function, postoperative complications, healing time, and total knee arthroplasty conversion rate were not significantly different (p > 0.05) between the groups. CONCLUSIONS: Open reduction internal fixation remains a satisfactory technique to treat tibial plateau fractures in the elderly. Although the rate of bone grafts is higher in elderly patients, they had comparable outcomes compared with their younger counterparts.

Transformation of transverse fractures of the acetabulum in T-shaped fractures and sequential approaches.

Transverse acetabular fractures are difficult to reduce and generally associated with poorer clinical outcomes than other types of acetabular fractures. For these fractures affecting both columns, the surgical strategy is subject to controversy and there is currently no optimal method of management. The transformation of these transverse fractures in to a T-shaped fracture makes it possible to make the anterior and posterior components of the fracture independent and to reduce them sequentially. This technique has made it possible to obtain a satisfactory reduction of the fracture in certain cases and gives hope for good long-term functional results. LEVEL OF EVIDENCE: IV.

Finite element analysis of optimal fixation method for femoral neck fracture with different reduction conditions / 中国组织工程研究

BACKGROUND:The traditional fixation method for femoral neck fractures is three hollow screws inverted triangle fixation,and the optimal fixation method for femoral neck fractures that have not achieved anatomical reduction is inconclusive. OBJECTIVE:To compare the biomechanical properties of cannulated screws internal fixation for sub-capitated femoral neck fracture with different reduction qualities based on finite element analysis. METHODS:The three-dimensional digital model was reconstructed using CT data of the proximal femur from a healthy male volunteer.The femur was modeled to sub-capitated femoral neck fractures.Fracture models were divided into anatomical reduction group,coxa vara group,and coxa valgus group.All fracture model groups were transferred using the standard group,screw depression group,and screw elevation group.A vertical downward stress of 1 400 N was applied to the femoral head at the top of the acetabulum.The displacement and stress distribution of the femur and internal fixator under different fixation methods were observed,and the maximum stress and displacement of the femur and fixator were compared. RESULTS AND CONCLUSION:(1)For anatomical reduction femoral neck fracture,the peak stress of fixation in the standard group,screw depression group and screw elevation group was 41.35,31.27 and 43.32 MPa,respectively.The maximum peak stress of the femur was found on the screw elevation group(28.58 MPa),and the standard group had the maximum peak displacement.(2)During hip varus,the stresses in the three subgroups were relatively dispersed and even.The peak stress of the femur in the standard group was the smallest,but the peak displacement was the largest.The stability of fixation might be poor.The peak displacement of the femur in the screw depression group was the smallest.(3)In the hip valgus,obvious screw stress concentration appeared in the screw depression group,and the peak displacement was the largest among the three subgroups,and an in-out-in phenomenon appeared.The peak stress of the screws in the screw elevation group was the largest among the three subgroups,but the peak displacement was the smallest.(4)It is concluded that for sub-capitated femoral neck fractures that are completely anatomically reduced,it is recommended to use standard inverted triangular nails for fixation.When the hip varus and hip valgus occur within the allowable range of the reduction standard,it is recommended to use the inverted triangle screw to fix it by rotating the corresponding angle in the same direction as the hip varus or valgus.

[Standardized reduction and palmar plating of dorsally displaced distal radius fractures for safe and atraumatic reconstruction of the anatomy of the radius]. / Standardisierte Reposition und palmare Plattenosteosynthese dorsal dislozierter distaler Radiusfrakturen zur sicheren und atraumatischen Wiederherstellung der Radiusanatomie.

OBJECTIVE: Standardization of palmar plate osteosynthesis in order to consequently achieve physiologic anatomy of the distal radius end. INDICATIONS: Unstable dorsally displaced distal radius fractures or fractures that should be treated functionally. CONTRAINDICATIONS: Severe intraarticular joint depression that cannot be reduced with either a palmar or arthroscopic assisted approach. SURGICAL TECHNIQUE: Patient in supine position with the forearm supinated on arm table. Radiopalmar incision along the radial border of the flexor carpi radialis tendon. Detachment of the pronator quadratus muscle from radial to ulnar. Gross reduction with eventual correction of a dorsal or radial shift. Placement of the angular stable plate and preliminary fixation with a nonangular stable cortical screw in the long hole at the radius shaft. Fluoroscopic control of axial alignment in the anteroposterior view and of correct distal position of the plate in the lateral view under reduction condition. Placement of one or two angular stable screws at the shaft. Under subtle reduction with flexion, ulnar deviation and axial traction placement of two K­wires via the holes at the distal edge of the plate. These wires mostly keep reduction maintained while reduction maneuver can be paused. Fluoroscopic control in two planes. Replacement of the wires by distal angular stable screws with the help of the wires as an orientation. In case of insufficient reduction, reduction maneuver can be repeated while the first angular stable screw is locked. Final fluoroscopic control in two planes and ulnar deviation, eventually also in tangential view and clinical testing for stability of the distal radioulnar joint. Wound closure only by skin suture. Application of a sterile dressing and a palmar cast. POSTOPERATIVE MANAGEMENT: Arm consequently in upright position and active and complete movement of fingers. Palmar below-elbow cast for 2 weeks, then movement of wrist without exertion. After regular radiographic control 4-5 weeks postoperatively, increase of axial load to normal and, if needed, physiotherapy. Clinical control for irritation of tendons by plate or screws after 1 year and eventual plate removal.

Effect of O-arm on reduction quality and functional recovery of acetabular dome impaction fractures: a retrospective clinical study.

BACKGROUND: Acetabular dome impaction fractures (ADIF) are difficult to reduce and have a high failure rate. Consistency between the acetabulum and the femoral head is usually assessed using intraoperative X-ray fluoroscopy to evaluate the quality of fracture reduction. This study examines the effects of intraoperative mobile 2D/3DX imaging system (O-arm) on the reduction quality and functional recovery of ADIF. METHODS: We retrospectively analysed the data of 48 patients with ADIF treated at Honghui Hospital between October 2018 and October 2021.The patients were divided into the X-ray and O-arm groups. The residual step-off and gap displacements in the acetabular dome region were measured, and fracture reduction quality was evaluated. Hip function was evaluated using the modified Merle d'Aubigné and Postel scoring systems. RESULTS: There were no significant intergroup differences in the preoperative general data (p > 0.05). The mean residual average step displacement in the acetabular dome region was 3.48 ± 2.43 mm and 1.61 ± 1.16 mm (p < 0.05), while the mean gap displacement was 6.72 ± 3.69 mm and 3.83 ± 1.67 mm (p < 0.05) in the X-ray and the O-arm groups, respectively. In the X-ray group, according to the fracture reduction criteria described by Verbeek and Moed et al., one case was excellent, 13 cases were good, 11 cases were poor; 56% were excellent or good. In the O-arm group, seven cases were excellent, 12 cases were good, and four cases were poor; overall in this group, 82.6% were excellent or good (p < 0.05). A total of 46 patients achieved fracture healing at the last follow-up. In the X-ray group, according to the modified Merle d'Aubigné and Postel function score, three cases were excellent,12 cases were good, six cases were middle, three cases were poor; 62.5% were excellent or good, In the O-arm group, 15 cases were excellent, four cases were good, two cases were middle, one case was poor; 86.4% were excellent or good (p < 0.05). CONCLUSIONS: The application of O-arm in ADIF can improve fracture reduction quality and functional recovery.

Reduction quality in lateral view of X-ray and hypoalbuminemia are associated with postoperative mortality in elderly pertrochanteric fracture patients.

Background: Pertrochanteric fracture is one of the most prevalent public health issues across the world for the elderly population. The purpose of this study was to investigate the association between surgical factors and postoperative mortality in patients with intramedullary nail-treated pertrochanteric fractures. Methods: A retrospective cohort study was designed to evaluate the pertrochanteric fracture patients treated with intramedullary nail between January 2016 to February 2021. The surgical factors included the Dorr morphology, Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) classification of fractures, the tip-apex distance (TAD), location of the cephalic screw, reduction quality in anterior-posterior (AP) and lateral views, the integrity of the lateral wall, and the design of cephalic screws. Using univariate and multivariate Cox proportional hazard models, the association between these risk factors and postoperative mortality in patients with this type of fractures was evaluated. Results: A total of 169 pertrochanteric fracture patients treated with intramedullary nails were included in our study, with the average age of 82.68±5.93 years. The mortality rates at 3 months, 1 year, and the end of follow-up were 4.14%, 11.24%, and 26.04%, respectively. According to the univariate Cox analysis, age, gender, preoperative levels of hemoglobin (Hb) and albumin (Alb) were associated with a poor overall survival (OS) (P<0.05). After multivariate adjustment, the pre-operative level of Alb (P<0.001) and the reduction in lateral view (P<0.001) were shown to be independent risk factors for poor OS. Conclusions: The preoperative hypoalbuminemia and reduction quality in lateral view were associated with postoperative mortality in our study. Therefore, optimizing both parameters could improve the prognosis in elderly pertrochanteric fracture patients.

Intramedullary Fibular Fixation in One-Stage Ankle Fracture Surgery With Soft Tissue Damage: A Study of 19 Cases.

This study investigates the efficacy of one-stage surgical intramedullary fibular fixation in managing ankle fractures with associated soft tissue damage. Ankle fractures, often encountered, can lead to complications when coupled with soft tissue injury. Traditional plate and screw fixation can exacerbate infection risks and reduce wound healing. To address this, a minimally invasive approach employing intramedullary fixation of the fibula has been proposed. This retrospective analysis, conducted between 2019 and 2021, explores cases of intramedullary fibular fixation for ankle fractures with stage 2-3 soft tissue injuries. A total of 19 patients were included in the study. The procedure involved either ulna intramedullary nails or locking screws. Results indicate that the approach led to successful union (100%), one superficial infection (5.26%), and no complication was observed. While limitations include the retrospective nature and small sample size, this study contributes valuable insights into the use of intramedullary fibular fixation in one-stage surgery for ankle fractures with concurrent soft tissue damage.

Parameters Governing the Fate of Fracture Fixation With Proximal Femoral Nailing (PFN) for Intertrochanteric Femur Fractures.

INTRODUCTION: A high mortality rate is associated with hip fractures in the elderly. This is because their bones are osteoporotic with implants having less hold and there are more co-morbidities associated with the elderly. Osteosynthesis with the proximal femoral nail (PFN) features the advantages of high rotational stability of the head-neck fragment. However, the use of the nail is technically ambitious and is accompanied by some risks of error, which can lead to failure. This study aims to understand the technical difficulties related to PFN and methods to mitigate them and radiological indicators for successful outcomes of PFN. METHODS: Our study aims to analyze the radiological parameters as indicators for the successful outcome of intertrochanteric fractures fixed using PFN and also the factors responsible for intraoperative conversion to dynamic hip screw (DHS). This is a prospective, observational study conducted from January 2020 to December 2020, on all the patients with intertrochanteric fractures who were planned to be treated by PFN and consented to be part of the study group at our institute. This study includes 99 cases of intertrochanteric fractures classified according to AO (Arbeitsgemeinschaft für Osteosynthesefragen)/Association of the Study of Internal Fixation (ASIF) and Evan's classification systems and followed postoperatively at regular intervals up to one year. Different methods of fracture reduction, intraoperative radiological parameters, and postoperative radiological parameters dictating the fate of PFN along with factors responsible for the intraoperative conversion to DHS were analyzed and discussed. RESULTS:  Out of 99 patients planned for PFN, four were converted to DHS intraoperatively and 15 patients expired within the follow-up period of one year, leaving only 80 patients in the study group. Of them, seven patients (11.4%) had implant-related complications. According to Chang's reduction quality criteria (CRQC), two cases have CRQC 1 (poor reduction), 11 cases have CRQC 2 (acceptable reduction), 39 cases have CRQC 3 (acceptable reduction), and 28 cases have CRQC 4 (excellent reduction). CONCLUSIONS: Though PFN is technically challenging, with proper guidelines and technique, it gives excellent results. Most importantly, a nonvarus reduction, proper nail insertion and accurate placement of lag screws are the crucial factors for a successful outcome. Biomechanically stable reduction, by closed, percutaneous, or open means, is the key to treating unstable intertrochanteric fracture successfully.

AP3×ML3 reduction quality classification for femoral trochanteric fractures: validation for reliability focusing on positive medial cortical support.

INTRODUCTION: This study evaluated the validity of the AP3 × ML3 reduction quality classification, which applies the concept of positive medial cortical support. METHODS: A total of 120 trochanteric fractures classified as AO Foundation/Orthopedic Trauma Association 31A1 and A2 were retrospectively analyzed. The validity of the AP3 × ML3 classification was evaluated by comparison with the Baumgaertner reduction quality criteria. When using the AP3 × ML3 classification, reduction quality was divided into three classes based on the degree of anterior cortical contact between the proximal and distal fragments. Reduction quality was also divided into three classes when using the Baumgaertner criteria. The frequency of mechanical complications, including cut-out, delayed union, and excessive migration of the lag screw, was retrospectively assessed. Intra-observer and inter-observer reliability was assessed using the intraclass correlation coefficient (ICC). RESULTS: Mechanical complications included 4 cases of cutout (3.3%) and 1 of delayed union (0.8%). Mechanical complications occurred for all levels of reduction quality in both classifications, except for the acceptable of the Baumgaertner criteria. When reduction quality was rated as good, acceptable, and poor the incidence of mechanical complications was 2.5%, 5.7%, and 16%, respectively, under the AP3 × ML3 classification and 3.3%, 0%, and 15.0%, respectively, under the Baumgaertner criteria. The ICC was 0.80 for intra-observer reliability and 0.57 for inter-observer reliability when using the AP3 × ML3 classification and 0.85 and 0.34, respectively, when using the Baumgaertner criteria. CONCLUSION: The AP3 × ML3 classification was reliable and easy to use compared with the widely used Baumgaertner reduction quality criteria. Level of evidence 4.

Short-term clinical and radiographic outcomes in patients treated with a modern intramedullary nailing system for 2-part proximal humerus fractures.

OBJECTIVES: The optimal surgical treatment of displaced proximal humerus fractures (PHFs) remains controversial. There are advocates for both open reduction and internal fixation with plate and screws (ORIF) and intramedullary nailing (IMN). The purpose this study was to evaluate the early-term clinical and radiographic outcomes of IMN for isolated, displaced 2-part surgical neck PHFs using a modern, straight nail system and to determine the effect of preoperative patient and fracture characteristics on outcome. METHODS: This was a case series of 23 patients with displaced 2-part surgical neck PHFs who were treated with ORIF using a straight IMN with minimum follow-up of 1 year (mean 2.5 years [range, 1.1-4.6]). Patients were identified retrospectively and contacted for measurement of active range of motion (AROM) and patient reported outcome measures (PROMs) including the American Shoulder and Elbow Surgeons (ASES) score, Oxford Shoulder Score (OSS), and Single Assessment Numeric Evaluation (SANE), EuroQol-5D (EQ-5D), and Visual Analog Scale Pain score (VAS Pain). Plain radiographs were evaluated to assess the quality of the reduction and failure of fixation. Complications and reoperations were identified. RESULTS: Reduction was anatomic in 12 (52%) patients, acceptable in 9 (39%), and 2 (9%) were malreduced. There were no differences in reduction quality based on sex (p = 0.37), age at surgery (p = 0.68), calcar comminution (p = 0.68), number of screws in the head (p = 0.99), or medial hinge disruption (p = 0.06). At final follow-up, the mean ASES score was 92 ± 10, OSS was 45 ± 4, SANE was 93 ± 7, EQ-5D of 0.85 ± 0.17, and VAS Pain was 0 ± 1. The mean active forward flexion was 143° ± 16°, active external rotation was 68° ± 20°, and internal rotation was T11 ± 4 vertebrae. Two (9%) patients underwent reoperation and 2 (9%) patients experienced clinical failure not requiring reoperation. CONCLUSIONS: Straight IMN is a reliable treatment for displaced 2-part surgical neck PHFs with excellent radiographic and clinical outcomes in early follow-up. The implant facilitated anatomic or acceptable alignment of the fracture in the vast majority of patients.

Dimensionamento do quadro de pessoal de enfermagem na atenção básica no distrito de Cacau Pirêra, Amazonas / Sizing of the nursing staff in basic care in the district of Cacau Pirêra, Amazonas / Tamaño del marco del personal de enfermería en la atención básica del distrito de Pyrêra Cococoa, Amazonas

Objetivo: Descrever o dimensionamento do quadro de pessoal de Enfermagem na atenção básica em um município do Amazonas. Metodologia: Método qualitativo de caráter descritivo, com investigação do objeto fundamentada no Estudo de Casos Múltiplos, segundo Yin (2015). A pesquisa foi realizada em duas Unidades Básicas de Saúde ­ UBS, localizadas no distrito do Cacau Pirêra, município de Iranduba, no estado do Amazonas. Aprovada pelo Comitê de Ética em Pesquisa da Universidade Paulista ­ CEP/UNIP, sob o Parecer de nº 5.968.666 e CAAE 67017022.1.0000.5512. Resultados: Conforme Resolução COFEN n° 543 de 2017, as unidades em estudo obtiveram quantidade insuficiente de profissionais de determinadas categorias que resulta em pressão da carga de trabalho, porém também obtiveram números de profissionais de outras categorias em equilíbrio conforme suas respectivas demandas. Considerações Finais: Percebe-se o quão importante é essa ferramenta de gestão, que permite ampliar a visão para as condições de trabalho da equipe no momento atual, uma vez que projeta o quantitativo adequado de profissionais para favorecer assistência qualificada. Espera-se, portanto, que essa pesquisa estimule futuras investigações que levem em consideração o dimensionamento para além do ambiente intra-hospitalar e subsidie políticas que efetivem esse olhar mais ampliado sobre o tema.

Objective: To describe the dimensioning of nursing staff in primary care in a municipality of Amazonas. Methodology: Qualitative method of descriptive character, with investigation of the object based on the Multiple Case Study, according to Yin (2015). The research was carried out in two Basic Health Units - UBS, located in the district of Cacau Pirêra, Iranduba municipality, in the state of Amazonas. Approved by the Research Ethics Committee of Universidade Paulista - CEP/UNIP, under the Opinion No. 5.968.666 and CAAE 67017022.1.0000.5512. Results: According to COFEN Resolution n° 543 of 2017, the units under study obtained an insufficient number of professionals of certain categories that results in workload pressure, but also obtained numbers of professionals of other categories in balance according to their respective demands. Final Considerations: We realize how important this management tool is, which allows us to broaden the vision for the working conditions of the team at the current moment, since it designs the appropriate number of professionals to favor qualified assistance. It is hoped, therefore, that this research will stimulate future investigations that take into consideration the dimensioning beyond the intra-hospital environment and will provide input for policies that will make this broader view of the theme effective.

Propósito: Describir el tamaño del personal de enfermería en la atención básica de un municipio de Amazonas. Metodología: Método cualitativo de carácter descriptivo, con investigación de objetos basada en el estudio de casos múltiples según Yin (2015). La investigación se llevó a cabo en dos Unidades Básicas de Salud ­ UBS, ubicadas en el distrito de Cacau Pirêra, en el municipio de Iranduba, en el estado de Amazonas. Aprobado por el Comité de Ética de la Investigación de la Universidad Paulista (CEP/UNIP), con arreglo a los dictámenes no 5.968.666 y CAAE 67017022.1.000.5512. Resultados: De acuerdo con la Resolución 543 de la COFEN de 2017, las unidades estudiadas obtuvieron un número insuficiente de profesionales de ciertas categorías que resultan en presión de la carga de trabajo, pero también obtuvieron un número de profesionales de otras categorías en equilibrio de acuerdo con sus respectivas demandas. Consideraciones finales: Se puede ver lo importante que es esta herramienta de gestión, que permite ampliar la visión de las condiciones de trabajo del equipo en este momento, ya que proyecta la cantidad apropiada de profesionales para favorecer la asistencia calificada. Por lo tanto, se espera que esta investigación estimule futuras investigaciones que tengan en cuenta la dimensión más allá del entorno intrahospitalario y subvencionen políticas que lleven a cabo este enfoque más amplio sobre el tema.

The postoperative prognosis of older intertrochanteric fracture patients as evaluated by the Chang reduction quality criteria.

OBJECTIVE: The aim of this study was to investigate the relationship between the Chang reduction quality criteria (CRQC) and the outcome of intertrochanteric fractures in older adults according to follow-up time. METHODS: This was a retrospective analysis of 389 older adult patients with intertrochanteric fractures treated surgically from January 2019 to June 2021, including 130 males and 259 females aged 84.6 (77.5-89.7) years. Patient survival was determined by telephone as the time between admission to hospital for fracture and death or until the study deadline (June 1, 2022). According to the CRQC, the patients were divided into the Poor, Acceptable, and Excellent groups. Univariate and multivariate Cox proportional hazard models were used to assess the association between CRQC and all-cause mortality in older adult intertrochanteric fractures at 1 year and the total follow-up time. Further subgroup analysis was performed according to different clinical and biological characteristics to improve the accuracy of the results. RESULTS: The mortality rates were 24.7% and 15.4% at 1 year and the total follow-up time, respectively. Both at one year and the total follow-up time, the mortality of the CRQC-Excellent group was significantly lower than that of the CRQC-Acceptable group (p.adj < 0.05) and the CRQC-Poor group (p.adj < 0.05). After multifactor adjustment, CRQC grades of Acceptable and Poor were independent risk factors affecting the overall and 1-year mortality. In addition, advanced age, ≥ 1 comorbidities, ASA 3 + 4, and prolonged preoperative waiting time were independent risk factors for survival at the total follow-up time. At 1 year, only ASA 3 + 4 and prolonged preoperative waiting time were independent risk factors for survival. Subgroup analysis according to different characteristics at the total follow-up time and at one year showed that in most subgroups, a decrease in the CRQC grade was significantly associated with an increase in all-cause mortality (p for trend < 0.05). CONCLUSIONS: This study highlights that CRQC grades of Acceptable and Poor are associated with increased all-cause mortality in older adult intertrochanteric fractures. We should attempt to achieve good reduction of these fractures.

Pre-operative predictors of poor reduction in acetabular fractures submitted to surgical treatment.

INTRODUCTION: Acetabular fractures are among the most complex orthopedic injuries, and their treatment and understanding have evolved remarkably in the last 50 years. Several factors affect the reduction quality of the surgically treated displaced acetabular fractures. Thus, this study aimed to identify these factors by analyzing patients' data. PATIENTS AND METHODS: Retrospective data from fractures operated in one center over 8 years were analyzed. Patients with a mature skeleton who underwent open reduction and internal fixation and had a minimum follow-up period of 6 weeks were included. Non-displaced fractures were excluded from the study. Radiographic assessment of the reduction was performed before surgery and at follow-up using the method described by Borelli et al. The effects of age (<40 or >40 years), sex, initial displacement (< 20 mm or > 20 mm), time to surgery (<14 days or>14 days), fracture pattern (elementary or associated), number of associated fractures (< 3 or > 3), and associated pelvic injury were analyzed RESULTS: The study included 115 (83.9%) men and 22 (16.1%) women, with a mean age of 34.1 years (range 16-74 years). In the sixth week of follow-up, reductions were satisfactory in 96 (70.7%) patients and unsatisfactory in 41 (29.3%). The most prevalent patterns were the posterior wall (23.1%) and both column (15.7%). Linear regression showed that residual displacement was directly correlated with initial displacement (p = 0.027) but without association with reduction quality. Age, sex, and initial displacement had no effect on reduction quality, which is in contrast with longer time to surgery (p = 0.004), associated fracture pattern (p = 0.002), three or more associated fractures (p = 0.001), and presence of associated pelvic injury (p = 0.021). CONCLUSION: Attempting to shorten the time to operate the fractures can lead to better results for patients because the other factors associated with poor reduction are inherent the trauma and cannot be modified by the surgeon.

Calcar fracture gapping: a reliable predictor of anteromedial cortical support failure after cephalomedullary nailing for pertrochanteric femur fractures.

BACKGROUND: Maintaining anteromedial cortical support is essential for controlling sliding and decreasing postoperative implant-related complications. However, adequate fracture reduction with cortical support in immediate postoperative fluoroscopy is not invariable in postoperative follow-ups. This study was conducted to investigate the risk factors leading to anteromedial cortical support failure in follow up for pertrochanteric femur fractures treated with cephalomedullary nails. METHODS: This retrospective study enrolled 159 patients with pertrochanteric fractures (AO/OTA- 31A1 and 31A2) that fixed with cephalomedullary nails. All patients were evaluated as adequate fracture reduction in immediate postoperative fluoroscopy before leaving the operation theater. The patients were separated into two groups based on the condition of the anteromedial cortex in the postoperative 3D CT with full-range observation: those with calcar support maintained in Group 1 and those with calcar support lost in Group 2. Demographic information, fracture classification, TAD (tip-apex distance), Cal-TAD, Parker ratio, NSA (neck-shaft angle), reduction quality score, and calcar fracture gapping were collected and compared. Logistic regression analysis was conducted to explore the risk factors leading to anteromedial cortex change. RESULTS: Anteromedial cortical support failure was noted in 46 cases (29%). There was no significant difference between the two groups concerning age, sex, side injury, TAD, Cal-TAD, Parker ratio, or NSA. There was a significant difference in the AO/OTA fracture classification in univariate analysis but no difference in the multivariable analysis. The reduction quality score, calcar fracture gapping in the AP (anteroposterior), and lateral views were significantly associated with anteromedial cortical support failure in follow-up after cephalomedullary nailing in the multivariable analysis. The threshold value of calcar fracture gapping for the risk of loss was 4.2 mm in the AP and 3.8 mm in the lateral fluoroscopies. Mechanical complications (lateral sliding and varus) were frequently observed in the negative anteromedial cortical support group. CONCLUSIONS: Good reduction quality was a protective factor, and larger calcar fracture gapping in the AP and lateral views were risk factors leading to the postoperative loss of anteromedial cortical support. Therefore, we should pay close attention to fracture reduction and minimize the calcar fracture gap during surgery.

Influence of reduction quality on functional outcome and quality of life in the surgical treatment of tibial plateau fractures: A retrospective cohort study.

BACKGROUND: Despite a substantial improvement in the operative treatment of tibial plateau fractures, the surgical procedure remains controversial and is generally challenging, as patients may develop postoperative arthritis and functional impairment of the knee joint. HYPOTHESIS: In the surgical treatment of tibial plateau fractures the intraoperative reposition quality has the greatest influence on the postoperative outcome, whereby misalignments of≥2mm lead to a worse result. PATIENTS AND METHODS: Forty-one patients with tibial plateau fractures were postoperatively examined. The operative treatment was performed under reduction control using an intraoperative 3D C-arm. The follow-up collective was divided into two groups depending on the intraoperative reduction result. The postoperative results were then evaluated using the following parameters: Lysholm score, Rasmussen score, Tegner score, SF-36 score, range of motion and pain level. RESULTS: Group 1 (articular surface incongruencies<2mm) tended to achieve a better result in all scores than group 2 (articular surface incongruencies≥2mm), in the Lysholm score (p=0.039), in the comparison of the range of motion (p=0.012) and the pain level (p=0.039) this was significant. Group 1 achieved an average of 90.71 points (group 2: 78.74) in the Lysholm score. The average range of motion of the knee joint was 138.93° in group 1 (group 2: 127.78°). The average value of the current pain level in group 1 was 1.14 (group 2: 2.63). DISCUSSION: Both study groups achieved a very good result compared to the available literature. It appears that reduction quality - which can be analyzed with intraoperative 3D imaging - plays the most important role in postoperative quality of life and functional outcome. Intraoperative adjustments of the reduction should therefore be performed on joint surface irregularities with a size above 2mm. LEVEL OF EVIDENCE: III; retrospective case control study.

Sub-Classification of AO/OTA-2018 Pertrochanteric Fractures Is Associated With Clinical Outcomes After Fixation of Intramedullary Nails.

BACKGROUND: The new edited AO/OTA-2018 classification of pertrochanteric fractures was revised and no longer based on the status of lesser trochanter. This paper aimed to explore the clinical and technical outcomes among the subgroups (31A1 and 31A2) of the new classification treated with cephalomedullary nails. METHODS: A retrospective research of 154 patients diagnosed with pertrochanteric fractures (AO/OTA-2018 31A1.2/3 and 31A2.1/2/3) treated with intramedullary nails was conducted. The baseline data and outcomes were compared among the subgroups. The outcomes included tip-apex distance (TAD), Cal-TAD, Parker ratio, neck shaft angle (NSA), blood loss, varus displacement, and over lateral sliding rate of the blade. RESULTS: There were 154 cases involving 48 males and 106 females. The average age was higher in the sub-classifications of A2.2 and A2.3 than A1.2. Furthermore, the subgroups of A2.2 and A2.3 presented inferior outcomes with regard to blood loss and reduction quality score than A1.2 and A1.3. The subgroup of A2.3 was further poor with respect to calcar fracture gapping in the anteroposterior view and excessive lateral migration occurrence rate than A1.2. CONCLUSIONS: Complex pertrochanteric fractures indicated inferior outcomes compared to simple sub-classifications, which might lead by the incompetent of lateral wall and instability of the fracture. The newly proposed AO/OTA-2018 classification was conductive to forecast the prognosis.