Search

The vegetative growth and yield of strawberry in relation to irrigation levels and soil mulches are still not well known, mainly for different environmental conditions. Two experiments were carried out in Atibaia, SP, Brazil, during 1995, one in a protected environment and the other in an open field, to evaluate the cultivar Campinas IAC-2712, under different irrigation levels and soil mulches (black and clear polyethylene). Three water potential levels in the soil were used in order to define irrigation time, corresponding to -0.010 (N1), -0.035 (N2), and -0.070 (N3) MPa, measured through tensiometers installed at the 10 cm depth. A 2 x 3 factorial arrangement was adopted, as randomized complete block, with 5 replicates. In the protected cultivation, the irrigation levels of -0.010 and -0.035 MPa and the clear plastic mulch favored the vegetative growth, evaluated through plant height, maximum horizontal dimension of the plant, leaf area index, as well as by total marketable fruit yield and its components (mean number and weight of fruits per plant). In the open field cultivation, no effect of treatments due to rainfall were observed.

A antracnose do morangueiro, causada por Colletotrichum fragariae Brooks, é uma das mais importantes doenças da cultura. Além dos rizomas, o fungo causa lesões em estolhos, pecíolos, limbos foliares, pedúnculos e frutos. A inoculação de plantas com este patógeno é muitas vezes imprescindível em trabalhos que necessitam uniformidade de inóculo e reprodução de sintomas da doença. Isso ocorre em testes de patogenicidade, em testes de eficácia de métodos de controle, em estudos sobre a variabilidade de diferentes isolados do patógeno e em avaliação de germoplasma quanto à resistência à doença. Objetivou-se, neste trabalho, avaliar comparativamente sete métodos de inoculação de morangueiro com C. fragariae, descrevendo os sintomas obtidos em diferentes órgãos da planta. Sintomas foliares (mancha preta da folha) foram observados principalmente quando se utilizou pulverização do inóculo. Os métodos mais eficientes em produzir murcha e lesões nos rizomas foram: ferimento e deposição de 5 mL de inóculo nos rizomas, ferimento e deposição de uma gota de inóculo nos pecíolos e injeção de inóculo nos rizomas.

O presente estudo foi realizado no município de Atibaia, maior produtor de morangos do Estado de São Paulo, com o objetivo de avaliar a profundidade efetiva do sistema radicular do morangueiro em diferentes níveis de água e coberturas do solo. O experimento foi instalado em esquema fatorial 2 x 2 (coberturas do solo e níveis de água). Como coberturas do solo foram utilizados os plásticos transparente e preto. As irrigações foram realizadas sempre que o potencial de água no solo atingia -0,010 e -0,070 MPa, a 10 cm de profundidade. As amostragens de raiz foram realizadas ao lado da planta, de 10 em 10 cm até 60 cm de profundidade, com trado tipo caneca com 7 cm de diâmetro, aos 159 dias após o plantio, com cinco repetições. Os resultados obtidos em comprimento de raiz (cm) por unidade de volume do solo (cm³) indicam maior concentração de raízes nas camadas superficiais. As coberturas do solo e níveis de água não influenciaram no comprimento de raízes nas faixas de profundidade do solo avaliadas. Para fins de irrigação, a profundidade efetiva do sistema radicular foi de 30 cm.

Abstract Background The mosquito Culex quinquefasciatu s, a widespread insect in tropical and sub-tropical regions of the world, is a vector of multiple arboviruses and parasites, and is considered an important risk to human and veterinary health. Proteolytic enzymes play crucial roles in the insect physiology including the modulation of embryonic development and food digestion. Therefore, these enzymes represent important targets for the development of new control strategies. This study presents zymographic characterization and comparative analysis of the proteolytic activity found in eggs, larval instars and pupae of Culex quinquefasciatus. Methods The proteolytic profiles of eggs, larvae and pupa of Cx. quinquefasciatus were characterized by SDS-PAGE co-polymerized with 0.1% gelatin, according to the pH, temperature and peptidase inhibitor sensitivity. In addition, the proteolytic activities were characterized in solution using 100 μM of the fluorogenic substrate Z-Phe-Arg-AMC. Results Comparison of the proteolytic profiles by substrate-SDS-PAGE from all preimaginal stages of the insect revealed qualitative and quantitative differences in the peptidase expression among eggs, larvae and pupae. Use of specific inhibitors revealed that the proteolytic activity from preimaginal stages is mostly due to trypsin-like serine peptidases that display optimal activity at alkaline pH. In-solution, proteolytic assays of the four larval instars using the fluorogenic substrate Z-Phe-Arg-AMC in the presence or absence of a trypsin-like serine peptidase inhibitor confirmed the results obtained by substrate-SDS-PAGE analysis. The trypsin-like serine peptidases of the four larval instars were functional over a wide range of temperatures, showing activities at 25°C and 65°C, with an optimal activity between 37°C and 50°C. Conclusion The combined use of zymography and in-solution assays, as performed in this study, allowed for a more detailed analysis of the repertoire of proteolytic enzymes in preimaginal stages of the insect. Finally, differences in the trypsin-like serine peptidase profile of preimaginal stages were observed, suggesting that such enzymes exert specific functions during the different stages of the life cycle of the insect.

Objective: Analyze the current evidence on the treatment and outcomes of hyperextension fractures of the tibial plateau and propose a treatment algorithm., Methods: An electronic search at PubMed/MEDLINE, Cochrane Library, Embase, and Google Scholar database from December 24th, 2023 to June 26th, 2024 was carried out. The terms for the database search included "Hyperextension AND Tibial plateau fractures" and "Reversed Tibial Slope AND Tibial Plateau Fractures". The research inclusion criteria were scientific articles written in English that addressed hyperextension fractures of the tibial plateau. Studies that have not specifically addressed hyperextension fractures of the tibial plateau or published in a different language than English were excluded. Considering that hyperextension fractures of the tibial plateau are relatively rare and the literature is scarce, studies with all levels of evidence were included. Critical analysis of titles, abstracts, inclusion and exclusion criteria of all potentially eligible articles was performed. A treatment algorithm based on the literature and authors perspective was proposed., Results: The search identified 34 potentially eligible studies. After application of inclusion and exclusion criteria, 22 articles were carefully analyzed in terms of the most relevant topics related to hyperextension fractures of the tibial plateau. An analysis of the risk of bias of the selected studies was performed according to the Cochrane Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I)., Conclusion: There is no consensus regarding the gold standard treatment method for this challenging fracture pattern. The hyperextension mechanism is a predictor of worse functional outcome and life quality comparing to other types of tibial plateau fractures., Study Design: Systematic review of the literature (Level of evidence:1)., Competing Interests: Declaration of competing interest REP has received honoraria from Zimmer Biomet, Johnson & Johnson, and Smith & Nephew for educational activities. VG has received honoraria from Zimmer Biomet for educational activities. RP has received honoraria from Johnson & Johnson for educational activities. FB and MK declare that they have no conflict of interest., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Purpose: The optimal duration of antibiotic therapy for fracture-related infection (FRI) has not been well defined. Our aim was to assess the recurrence rate of infection in patients who underwent six, 12, or 24 weeks of antibiotic therapy following surgical treatment for FRI one year after antibiotic discontinuation. Additionally, complications were monitored., Methods: Patients with FRI underwent surgical treatment, and antibiotic therapy was initiated. The patients were divided into groups at the 6th and 12th weeks of antibiotic therapy. The primary endpoint was the recurrence of deep or superficial infection at 90 days and one year after the end of antimicrobial therapy., Results: There was no difference in the recurrence of infection 90 days or one year after stopping antibiotic therapy among patients treated for six, 12, or 24 weeks (p = 0.98 and p = 0.19, respectively). The overall recurrence rate of infection 90 days after stopping antibiotic therapy was 4.9% (8/163), and one year after discontinuation of antibiotic therapy was 9.8% (16/163). There was a statistically significant difference in the incidence of adverse effects among the three groups (chi-square; p = 0.01). Adverse effects were more common in the group treated for 24 weeks than in the groups treated for 6 weeks (z score, p = 0.017) or 12 weeks (z score, p = 0.005)., Conclusion: Antibiotic therapy longer than 6 weeks did not reduce the recurrence of FRI after one year of follow-up. Additionally, antibiotic treatment for 24 weeks increases adverse events such as skin reactions and acute renal failure., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background and Objectives : Management of acetabular fractures is aimed at anatomically reducing and fixing all displaced or unstable fractures, as the accuracy of fracture reduction has been demonstrated to strongly correlate with clinical outcomes. However, there is a noticeable gap in the literature concerning the perioperative and postoperative care of patients with acetabular fractures, which ultimately can be potential risk factors for adverse outcomes and permanent disabilities. This study aimed to systematically review the available literature regarding rehabilitation practices, including weight-bearing protocols, across time points in surgically treated acetabular fracture patients and correlate these practices with functional outcomes. Methods : We systematically reviewed the Medline and PubMed databases and the Cochrane Central Register of Controlled Trials in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The inclusion criteria were studies with adult patients (19+ years), publications from the last 10 years, articles focusing on rehabilitation or mentioning any aspect related to rehabilitation (such as weight-bearing or muscle training), and describing the surgical management of acute, isolated acetabulum fractures. Specific information was collected, including the fracture classification, time to surgery, surgical approach, surgical time, blood loss, fixation strategy, quality of reduction, postoperative rehabilitation protocol, complication rate, type(s) of complication, and outcome measurement(s). The choice(s) of surgical approach, surgical time, blood loss, and fixation strategy were stratified based on the fracture classification. The complication rate and type(s) of complication were calculated for all studies. Fractures were classified based on the Letournel classification. Results : A total of 494 articles were identified from the initial search, of which 22 (1025 patients) were included in the final review. The most common rehabilitation protocol favored isometric quadriceps and abductor strengthening exercises starting on the first postoperative day, with passive hip movement at 1-3 days postoperatively and active hip movement ranging from the first postoperative day to 4 weeks postoperatively. Partial weight-bearing with a walker or a pair of crutches was permitted from 1 to 12 weeks after surgery, and full weight-bearing was allowed depending on the patient's general condition and fracture healing state (generally at the end of 3 months). In only three studies did the patients start bearing weight in the early postoperative period (≤1 week). Meta-regression analysis was not performed due to the discrepancy between studies that reported a weight-bearing protocol ≤1 week and >1 week postoperatively. Conclusions : Our study suggests that an accelerated postoperative rehabilitation protocol, including early permissive weight-bearing, does not appear to increase the risk of loss of reduction or the rate of complications after surgical treatment of acetabular fractures. However, a proper meta-analysis was not possible, and the heterogeneity of the included studies did not allow us to conclude anything about the potential biomechanical and clinical benefits nor the negative effects related to this rehabilitation regimen in terms of functional results. There is an inconsistent use of PROMs for objectively calculating the effect size of the accelerated protocol compared with restricted weight-bearing regimes. We pose the need for higher-level evidence to proof our hypothesis.

In orthopaedic surgery, as well as other areas in medicine, it is common for a surgical technique to carry the original authors' name describing the procedure. The Judet family represents a unique history, since several orthopaedic procedures are known as "Judet's technique". The aim of this historic review is to outline the genealogy of the orthopaedic arm of the Judet family, while crediting each surgical procedure to the specific family member that described the technique., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

Objective: To report on the experience and impressions of the Brazilian orthopedic trauma surgeons attending the Leadership Development Program (LDP) hosted by the Sociedade Brasileira do Trauma Ortopédico (SBTO) in Sao Paulo, Brazil on November 4, 2022., Methods: Forty-eight orthopedic trauma surgeons from five different regions throughout Brazil were provided a link to complete The Big Five Test, a validated online personality assessment. The questionnaire was available in Portuguese and was intended to provide a background on individual personality traits and their influence on interpersonal interactions. The LDP integrated content from literature reviews specific to Latin America, established leadership programs from leading business schools, and various subject matter experts. Prior to the start of the LDP, participants received a pre-course survey evaluating demographic information, a needs assessment, and the prioritization of leadership topics utilizing a 5-point Likert-scale. Attendees participated in the one-day, interactive LDP focusing on the fundamental principles of leadership development, communication, personal development, emotional intelligence and negotiation. Following the LDP, a post-course evaluation was administered to determine the participants' overall experience, and suggestions for LDP improvement., Results: Forty-one of the forty-eight course participants completed the pre-course evaluation, whereas forty-six of the forty-eight participants completed the post-course evaluations. Overwhelmingly, the lack of opportunity was most prevalently reported as the main obstacle to attending a leadership course, as cited by 56% of respondents., Conclusion: Expanding the accessibility, diversity, and customizability of leadership programs can facilitate the development of personal tools needed to move healthcare forward. Critical topics include emotional intelligence and other differentiating leadership qualities that distinguish true transformational and servant leaders. Advancing leadership skills can stimulate networking, expose learners to experiential learning styles, inspire others to create positive change, and engender creative solutions for systematic improvements and health outcomes. Level of Evidence III; Individual Case-Control Studies. , Competing Interests: All authors declare no potential conflict of interest related to this article.

Objective: Compare the biomechanical effectiveness of four different bone-implant constructs in preventing fracture displacement under axial loading., Methods: Twenty artificial femora had a standardized coronally oriented fracture of the lateral femoral condyle, representing a Hoffa fracture classified as a Letenneur type I. Four different fixation constructs were applied to the synthetic bones for biomechanical testing. The constructs consisted of a posterolateral (PL) buttressing locking plate in conjunction with two cannulated lag screws inserted from posterior to anterior (PA) - Group 1; Two cannulated screws inserted from anterior to posterior (AP) without plating- Group 2; A posterolateral (PL) buttressing locking plate in isolation - Group 3; and a combination of two lag screws from anterior to posterior (AP) in addition to a horizontal one-third tubular locking plate - Group 4. An axial load was applied to the fracture site with a constant displacement speed of 20 mm/min, and the test was interrupted when a secondary displacement was detected determining a fixation failure. We recorded the maximum applied force and the maximum fracture displacement values., Results: Group 1 demonstrated the highest overall bone-implant axial stiffness with the lowest secondary displacement under loading. Groups 3 and 4 showed equivalent mechanical behavior. Group 2 presented the lowest mechanical stiffness to axial loading. The combination of the one-third tubular locking plate with anterior-to-posterior lag screws (Group 4) resulted in 302 % increase in fixation stiffness when compared to anterior-to-posterior lag screws only (Group 2)., Conclusions: This study confirms the mechanical superiority of having a plate applied parallel to the main fracture plane in the setting of coronally oriented femoral condyle fractures. The addition of a horizontal plate, perpendicular to the main fracture plane, significantly increased the resistance to shearing forces at the fracture site when compared to constructs adopting just cannulated screws., Level of Evidence: Biomechanical study., Competing Interests: Declaration of Competing Interest REP has received honoraria from Zimmer Biomet and Smith & Nephew for educational activities. MAPA has received honoraria from Zimmer Biomet for educational activities. For the remaining authors none were declared., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Objective: The aim of this study is to investigate stiffness and the maximum load to failure values of single- and double-screw fixation of oblique medial malleolus fractures using partially threaded cancellous screws. Our hypothesis is that single-screw fixation of medial malleolus fractures after SER injuries provides similar stiffness when compared with double-screw fixation., Design: Biomechanical study., Methods: Twelve composite polyurethane synthetic right distal tibiae were used in the experiment. Oblique fractures of the medial malleolus were created with a band saw using a custom-made osteotomy guide to standardize the cuts in all models. Bone models were randomly separated into two groups and fixed with one (n = 6) or two (n = 6) 4.0 mm partially threaded cancellous screws placed perpendicular to the fracture line. These were tested by applying an offset axial tension at 10 mm/minute up to maximum load displacement, defined as subsidence of the medial malleolus fragment. Maximum load to failure was determined for the groups at the point where the curve ceased to be linear and suffered an inflection. Force versus displacement curves were obtained and recorded. The student's t-test for independent samples was used to compare stiffness (N / mm) and maximum load (N) between experimental groups, with a p value of < 0.05., Results: There were no significant differences in stiffness (p = 0.290) and maximum load (p = 0.191) among the two fixation constructs. Mean stiffness was 62.26 (±SD 21.11) N/mm for double-screw fixation group and 48.24 (±SD 22.40) N/mm for single-screw fixation group. Mean maximum load was 387.83 (±SD 115.78) N for double-screw fixation group and 306.64 (±SD 81.97) N for single-screw fixation group., Conclusion: Fixation with one 4.0 mm partially threaded cancellous screw was not shown to be biomechanically inferior to fixation with two 4.0 mm partially threaded cancellous screws in an oblique fracture of the medial malleolus, supporting previous clinical studies that have shown that one screw is sufficient for fractures of the medial malleolus., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest related to content of this article., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Introduction: Fixation of distal femur fractures with a lateral pre-contoured locking plate provides stable fixation and is the standard treatment in most cases, allowing early range of motion with a high rate of union. However, in situations, the stability achieved with the lateral plate alone may be insufficient, predisposing to fixation failure. The objective of the study was to compare, in synthetic bone models, the biomechanical behaviour of the fixation with a distal femur lateral pre-contoured locking plate solely and associated with a 3.5 mm proximal humeral locking plate applied upside down or a 4.5 mm helical locking compression plate on the medial side., Material and Methods: A total of 15 solid synthetic left femur samples were used. A metaphysical defect at the level of the medial cortex was simulated. The samples were randomly distributed into three groups equally. All groups received a 4.5/5.0 mm single lateral 9-hole distal femur lateral pre-contoured locking plate. Group 1 had no supplementary plate. Group 2 received a supplementary 6-hole 3.5 mm proximal humeral locking plate and Group 3 received a supplementary 4.5/5.0 mm helical 14-hole narrow locking compression plate., Results: Both supplementary plate types used in groups 2 and 3 contributed to increase the apparent stiffness of the construct, but pairwise comparison showed statically significant difference only between group 1 and 3. No significant difference was observed between groups 2 and 3., Conclusion: Both supplementary plates might be considered for improving the fixation in distal femur fracture in selected cases., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Accomplish a thorough review on the existing biomechanical and clinical studies about coronal plane fractures of the distal femur., Methods: We performed an electronic search of PubMed/MEDLINE database from April to June, 2023. The terms for the database search included "Hoffa fractures," OR "Busch-Hoffa fractures" OR "coronal plane fractures of the distal femur.", Results: The search identified 277 potentially eligible studies. After application of inclusion and exclusion criteria, 113 articles were analyzed in terms of the most important topics related to coronal plane fractures of the distal femur., Conclusion: Lateral coronal plane fractures of the distal femur are more frequent than medial, present a more vertical fracture line, and usually concentrate on the weight bearing zone of the condyle. The Letenneur system is the most used classification method for this fracture pattern. Posterior-to-anterior fixation using isolated lag screws (for osteochondral fragments-Letenneur type 2) or associated with a posterior buttressing plate (when the fracture pattern is amenable for plate fixation-Letenneur types 1 and 3) is biomechanically more efficient than anterior-to-posterior fixation. Anterior-to-posterior fixation using lag screws complemented or not by a plate remains a widely used treatment option due to the surgeons' familiarity with the anterior approaches and lower risk of iatrogenic neurovascular injuries. There is no consensus in the literature regarding diameter and number of screws for fixation of coronal plane fractures of the distal femur., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: We investigated the biomechanical behaviour of different fixations of the tibial posterior malleolus (TPM), simulating distinct situations of involvement of the tibiotalar articular surface (TTAS) through a finite element model (FEM). Material and methods: A 3D computer-aided design model of the left ankle was obtained. The materials used were divided according to their characteristics into ductile and non-ductile, and all materials were assumed to be linear elastic, isotropic, and homogenous. Three different fracture lines of the TPM were defined, with sagittal angles of 10°, 25°, and 45°. For biomechanical comparison, different constructions using a trans-syndesmotic screw (TSS) only (Group T), a one-third tubular plate only with (Group PT) and without (Group PS) a TSS, and a locked compression plate with (Group LCPT) and without (Group LCPS) a TSS were tested. FEM was used to simulate the boundary conditions of vertical loading. Load application regions were selected in the direction of the 700 N Z-axis, 90% on the tibia and 10% on the fibula. Data on the displacement and stress in the FEM were collected, including the total principal maximum (MaxT) and total principal minimum (MinT) for non-ductile materials, total displacement (desT), localized displacement at the fragment (desL), localized displacement at syndesmosis (desS), and Von Mises equivalent stress for ductile materials. The data were analysed using ANOVA and multiple comparison LSD tests were used. Results: For TPM fractures with sagittal angles 10° and 25°, desL in the PT and LCP groups was significantly lower, as well as Von Mises stress in Group LCPT in 10°, and PT and LCPT groups in 25°. For TPM fractures with a sagittal angle of 45°, desL in the LCP group and Von Mises stress in Group LCPS and LCPT were significantly lower. We found that any TPM fracture may indicate instability of the distal tibiofibular syndesmosis, even when the fragment is small. Conclusion: Our study showed that in fragments involving 10% of the TTAS, the use of a TSS is sufficient, but when the involvement is greater than 25% of the TTAS, either a non-locked or locked plate must be used to buttress the TPM. In posterior fragments affecting 45% or more of the TTAS, the use of a locking plate is recommended.

Vertically unstable pelvic injuries associated with sacroiliac disruption are challenging. Although percutaneous iliosacral fixation using two screws at S1 vertebral body has been shown beneficial, the use of two transiliac screws at S1 has been proposed to increase the fixation strength of the construct. In the herein study, the finite element method (FEM) was performed to analyse the biomechanical behaviour of five different constructions using iliosacral screws only, transiliac screws only, and combining an iliosacral and a transiliac screw. A vertically unstable AO 61C1.2 type pelvic injury was produced for the evaluation of the posterior pelvic displacement and implant stress, and the anterior implant stress using FEM. The symphysis pubis was fixed with a 3.5-mm reconstruction plate in all cases. The model was axially loaded with 800N applied in the centre of S1 body, perpendicular to the ground (Y-axis), simulating the bipodal stance moment. There was a statistically significant reduction in both posterior displacement and implant stresses in the groups fixed with at least one transiliac screw compared to the groups fixed with iliosacral screws. In our FEM study, the construct using two transiliac screws in S1 is biomechanically superior for stabilizing the sacroiliac joint in vertically unstable pelvic ring injuries compared to the other configurations. Lateral displacement, posterior displacement, and von Mises stress were reduced with this construct. A good option can be the use of one iliosacral screw and one transiliac screw in S1., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023. Published by Elsevier Ltd.)

Postoperative bone infection is a severe complication in the treatment of fractures. The management of this pathology is challenging, but recent advances have been made to achieve standardization that can help diagnosis and decision-making. However, we are unaware of studies validating these models in Latin America. Therefore, this study aims to collect data from patients with fracture-related infections treated in different institutions in Latin America to create a registry that will assist in future clinical decision-making regarding the diagnostic process and the surgical and medical treatment of these patients., Competing Interests: Declaration of Competing Interest None of the authors has received any financial support from any commercial company or institution directly or indirectly related to the subject of this article., (Copyright © 2023. Published by Elsevier Ltd.)

Antegrade fixation of posterior column fractures of the acetabulum is challenging due to the narrow corridor and risk of screw misplacement. Although both antegrade and retrograde lag screws have been previously described for posterior column fracture fixation, the literature lacks a standardized technique for correct and safe screw placement, especially in an antegrade fashion. This technical note aims to optimize intraoperative images during posterior screw insertion using the antegrade technique, according to predetermined landmarks to save surgical time, decrease radiation exposition, and prevent surgical complications., Competing Interests: Declaration of Competing Interest The authors of the study “Antegrade posterior column screw fixation for acetabular fractures: It's time to standardize the surgical technique” declare that they have no conflict of interest related to this manuscript., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Introduction: Ankle fractures are one of the most frequent injuries managed by any trauma surgeon. Literature has shown that adequate reduction is of utmost importance to achieve satisfactory functional outcomes. However, malreduction rates remain high worldwide. The objective of the present study is to evaluate the quality of ankle fracture reduction in two major trauma centers in a large Brazilian city and to analyze the factors associated with malreduction METHODS: Epidemiologic data of 382 patients (189 men; 193 women) aged between 7 and 87 years who underwent osteosynthesis of the ankle in two trauma centers in a large Brazilian city. Electronic clinical records, preoperative and immediate postoperative radiographs in anteroposterior (AP), lateral and mortise views were evaluated. Pettrone's criteria were used to evaluate the quality of ankle fractures reduction. All radiographs were independently evaluated by two foot and ankle senior surgeons RESULTS: Overall, malreduction rate was 22.2%. Forty-seven (55.2%) fractures classified as malreduced had medial malleolar displacement The results showed three factors that significantly affected the quality of reduction (p<0.05), patients over 60 years, open fractures and fracture-dislocations. Patients aged over 60 years were twice more likely to have poor reduction of ankle fractures than younger ones. The risk of poor fracture reduction among those individuals with open fractures is 2.15 times greater than among patients with closed injuries. Fracture-dislocation imposed a 2.7 higher risk for malreduction DISCUSSION: We found a malreduction rate below most series previously published. Further results agree with the literature. Elderly people aged over 60 years, fracture dislocations and open fractures are associated with worse results, influencing the quality of the reduction, clinical outcomes, and the development of post-traumatic arthrosis CONCLUSION: Ankle fractures malreduction are associated with higher age, open fractures, and fracture-dislocations., Competing Interests: Declaration of Competing Interest Daniel Baumfeld is Consultant/Speaker for Arthrex and Stryker. Tiago Baumfeld is Speaker for Medartis. Robinson Esteves is Speaker for Zimmer/Biomet and Smith Nephew Túlio Campos, Vinicius Burgos and Vinicius Souza have no conflict of interest., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Femoral neck fractures (FNFs) affect the young adult population and are intimately related to high-energy trauma. Despite innovations in osteosynthesis materials, the rate of complications remains at 10%-59% in Pauwels type III (PIII) fractures. The authors thus propose a fixation model with a novel self-compression screw, comparing it to a sliding hip screw plate associated with a derotation screw in the fixation of a PIII fracture with posterior inferior comminution. The finite element method (FEM) was used in this comparison along with a virtual femur model with structural characteristics similar to those of a healthy young human bone. We formed 4 groups: Group 1 (GC), intact bone; Group 2 (SHS+S), sliding hip screw plate with derotation screw; Group 3 (XS), X-pin + SS (self-compression model with superior positioning screw); Group 4 (XI), X-pin + IS (self-compression model with inferior positioning screw). A 700 N monotonic load was applied to the apex of the femur head towards the ground so that stress was mainly focused on the fracture site and osteosynthesis. Analyses included total displacement and maximum principal stress and were performed for all groups. Fracture displacement, rotation, and von Mises were assessed only in groups that underwent osteosynthesis. Total displacement values in groups with self-compression screws (XS and XI) were closer to those for healthy femurs, with a 38.5% reduction when comparing the XS group with the SHS+S group. Fracture displacement and rotation values presented reductions of over 60% when comparing the XS and XI groups with the SHS+S group. Equivalent Von Mises stress values were similar between XS and XI and presented a reduction of approximately 5.25% when compared with the SHS+S group. Our FEM analyses demonstrated that the self-compression screw model has potential biomechanical advantages over the SHS+S model., Competing Interests: Declaration of Competing Interest The authors received no financial support for researching and/or authoring this study. The authors received financial support from HEXAGON Ltd. to acquire the virtual Sawbone model, perform the finite element testing, and publish this article., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Dysesthesia, electrical and burning sensations, in addition to allodynia are frequent symptoms of neuropathic pain. Despite the high frequency, scientific data on the development of neuropathic pain after surgery for fracture fixation are scarce. The goal of the present study was to determine the prevalence, risk factors, and evaluate potential associations among neuropathic pain, pain intensity, sociodemographic, and clinical variables after wrist, hip, and ankle fracture fixation., Methods: A cross-sectional retrospective study involving a cohort of 166 patients who underwent surgery for distal radius, proximal femur, malleolar fracture fixation was performed. Neuropathic pain was assessed one year after fracture fixation using the Doleur Neuropathique Questionnaire (DN4)., Results: The incidence of neuropathic pain in our sample was 49 (29.5%). Predictors for the development of neuropathic pain included patients with a high body mass index (BMI), female gender, diabetes mellitus, long-term use of analgesics (especially using pain-modulating medication), patients who presented some fracture-related complication during the course of the treatment, who had limitations for daily activity, and who were away from work due to chronic pain., Conclusion: In our study, neuropathic pain after wrist, hip, and ankle fracture fixation was prevalent and associated with higher BMI values and amount of medication, in addition to higher proportions of female sex, absence from work, DM, limitation for daily activities, postoperative complications, and use of pain modulating medications., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest in relation with the submission of this original manuscript., (Copyright © 2023. Published by Elsevier Ltd.)

Objective: The aim of this study was to evaluate the Latin American orthopaedic trauma surgeons preference regarding knee positioning and entry portals for IM nailing and identify the reasons of these preferences., Methods: Using the AO Trauma database, 22.285 surveys were distributed by email to Latin American orthopaedic surgeons. Demographic data and practice patterns, especially regarding knee positioning and approach for tibial nailing, were then evaluated and statistically treated., Results: amongst one thousand five hundred fourteen responses, 990 orthopaedic surgeons (4.4% of response rate) fully responded to the survey. Transpatellar tendon approach (613 / 61.9%,) with the knee in flexion (518 / 52.3%) on a radiolucent table remains the standard practice for intramedullary tibial nailing. Even for proximal and distal tibial nailing, the transpatellar tendon approach (455 / 46%) with the knee in flexion (562 / 56.8%) hold on the most used method. Only 55 (9.36%) orthopaedic surgeons reported that they have migrated to the supra-patellar tibial nailing in the recent years. The main reasons for a low rate of migration were lack of knowledge about the technique and unavailability of specific gigs and cartilage protectors for a safe suprapatellar nailing., Conclusion: Even with the potential benefits of the semi-extended knee positioning for tibial nailing, the Latin American orthopaedic community remains using the transpatellar tendon approach with the knee in flexion as the standard technique. Lack of surgical training for suprapatellar and parapatellar approaches with the knee in semi-extension, added by the unavailability of suprapatellar jigs and soft outer protection sleeves contribute to counter the trend towards the semi-extended techniques., Competing Interests: Declaration of Competing Interest The authors of the study “Is there a trend towards semi-extended knee positioning during intramedullary tibial nailing in Latin America? A survey amongst 990 orthopaedic surgeons” declare that they have no conflict of interest related to this manuscript., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Determining the true availability of resources and understanding the level of training of surgeons involved in the treatment of patients with pelvic fractures and haemorrhagic shock is critical. In the herein study, the availability of technical, technological, and human resources for the care of this injury in Latin America region was analysed, and the preferences of orthopaedic trauma surgeons when performing interventions for the diagnosis and treatment of patients with pelvic trauma and associated haemorrhagic shock was described. A cross sectional web-based survey containing questions on knowledge, attitudes, and practices with respect to imaging resources, emergency pelvic stabilization methods, and interventions used for bleeding control was sent to 948 Latin America orthopaedic trauma surgeons treating pelvic fractures in the emergency department. Differences between regional clusters, level of training, type of hospital, and pelvic surgery volume were assessed. 368 responses were obtained, with 37.5% of respondents reporting formal training in pelvic surgery and 36.0% having available protocol for managing these patients. The most frequently used interventions were the supra-acetabular pelvic external fixator and pelvic packing. Limited hospital and imaging resources are available for the care of patients with pelvic trauma and associated haemorrhagic shock throughout Latin America. In addition, the training of orthopaedic trauma surgeons dealing with this type of injury and the volume of pelvic surgeries per year is heterogeneous. It should be urgently considered to develop management protocols adapted to Latin America according to the availability of resources, as well as to promote training in this severe life-threatening traumatic condition., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest related to the content of this article., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Purpose: To systematically review the currently available existing evidence related to the presentation and management of simultaneous floating hip and knee injuries to identify injury characteristics, treatment strategies, and complications., Methods: Data sources: Relevant articles were identified by searching Medline, PubMed, and Google Scholar databases with no language restrictions. Manual searches of other relevant databases (SciELO and grey literature databases) and reference lists of primary articles found from initial searches were also conducted., Study Selection: All types of study designs published from January 1st, 2000 to October 1st, 2022 involving skeletally mature patients with simultaneous floating hip and knee injuries were included., Data Extraction: Basic information and specific injury-related information were collected., Results: Eight case reports were included. No study adequately reported the case with sufficient detail to allow other investigators to make inferences, nor was the result properly calculated, nor was the follow-up considered adequate for adequate functional assessment to occur in 80% of the studies., Conclusion: The exact treatment strategy and the follow-up time are not uniform across the included studies; therefore, they are not sufficient to adequately recommend surgical approach, timing of fixation, and fixation method. Our findings warrant the need for better documentation and reporting information about the mode of treatment of simultaneous floating hip and knee injuries., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Purpose: Non-prosthetic peri-implant fractures are challenging injuries. Multiple factors must be carefully evaluated for an adequate therapeutic strategy, such as the state of bone healing, the type of implant, the time and performed personnel of previous surgery, and the stability of fixation. The aim of this study is to propose a rationale for the treatment., Methods: The peri-implant femoral fractures (PIFFs) system, a therapeutic algorithm was developed for the management of all patients presenting a subtype A PIFF, based on the type of the original implant (extra- vs. intra-medullary), implant length and fracture location. The adequacy and reliability of the proposed algorithm and the fracture healing process were assessed at the last clinical follow-up using the Parker mobility score and radiological assessment, respectively. In addition, all complications were noticed. Continuous variables were expressed as mean and standard deviation, or median and range according to their distribution. Categorical variables were expressed as frequency and percentages., Results: This is a retrospective case series of 33 PIFFs, and the mean post-operative Parker mobility score was (5.60 ± 2.54) points. Five patients (15.1%) achieved complete mobility without aids (9 points) and 1 (3.0%) patient was not able to walk. Two other patients (6.1%) were non-ambulatory prior to PPIF. The mean follow-up was (21.51 ± 9.12) months (range 6 - 48 months). There were 7 (21.2%) complications equally distributed between patients managed either with nailing or plating. There were no cases of nonunion or mechanical failure of the original implant., Conclusion: The proposed treatment algorithm shows adequate, reliable and straightforward to assist the orthopaedic trauma surgeon on the difficult decision-making process regarding the management of PIFF occurring in previously healed fractures. In addition, it may become a useful tool to optimize the use of the classification, thus potentially improving the outcomes and minimizing complications., (Copyright © 2022 Chinese Medical Association. Production and hosting by Elsevier B.V. All rights reserved.)

The widespread adoption of smartphones and other mobile devices amongst healthcare providers opened new possibilities arising from the use of non-medical apps, social media, meeting platforms, and non-medical devices with intended medical purposes, thus expanding the communication and imaging chat systems between these professionals and their patients, as well as amongst healthcare professionals. However, adapting non-medical applications, social media, videoconference platforms and devices for medical use present potential limitations, barriers, and risks, which should be fully recognized to reduce crossing the fine line between ethical and unethical. In the herein study, we analyse the ethical limits, coverage, and validation of non-medical applications adapted for medical use. Level of evidence: IV (evidence from well-designed case-control or cohort studies)., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Introduction: The standard treatment of anterior glenaoid fractures carrying > 20% of the glenoid fossa is open reduction and internal fixation (ORIF). In the herein study, we report our outcomes in a retrospective cohort of anterior and anteroinferior glenoid rim fractures using an accelerated postoperative rehabilitation protocol. A secondary aim is to describe the surgical steps for ORIF of anterior and anteroinferior glenoid rim fractures using the anterior axillary approach, describing the tricks, pearls, and pitfalls of this surgical technique., Methods: A retrospective cohort of skeletally mature patients treated for an anterior glenoid rim fracture carrying > 20% of the glenoid fossa during a 10-year period were operated on using a vertical axillary incision, osteosynthesis with 2.0-mm cortical screws, and labral repair with small diameter metallic anchors and non-absorbable sutures. Rehabilitation began on the first postoperative day, including passive external rotation exercises and active-assisted flexion, adduction, and abduction exercises as tolerated. The exercises are performed with the patient sitting or lying down. Phase 1 is continued for 6-10 weeks until the patient regains painless, normal, or near-normal ROM. Usually by 10 weeks, the fracture and labrum are healed, so phase 2 rehabilitation begins with strengthening and ROM exercises. Radiologic and clinical outcomes, including active range of motion (ROM), glenohumeral stability, and visual analogue scale (VAS) were measured., Results: About 33 patients (35 fractures) had complete medical records and pre- and post-operative imaging exams available for further analysis regarding the surgical protocol, with a mean of 4.8 years. The mean DASH questionnaire was 3.75 ± 9.0 and the mean CM score was 62.5 ± 0.1. Active flexion and internal rotation were recovered in all patients, while external rotation presented an average loss of 8° (p = 0.12) and abduction of 5° (p = 0.33). The mean VAS was 1.1 ± 0.8. No patient reported major or disabling symptoms, or great difficulty or inability to perform daily or recreational activities. No patient presented residual instability of the glenohumeral joint., Conclusion: In this retrospective cohort, ORIF using a vertical axillary incision, osteosynthesis with 2.0-mm screws, and labral repair with small diameter metallic anchors and non-absorbable sutures was a safe approach, with a minimal risk of complications and residual instability. The accelerated postoperative rehabilitation protocol, allowing immediate passive external rotation of the operated shoulder, resulted in a non-significant loss of ROM compared to the contralateral side. Therefore, we recommend this management strategy for anterior glenoid rim fractures in patients with unstable shoulder joint after traumatic glenohumeral dislocation., Level of Evidence Iv: Therapeutic Study (Surgical technique and Retrospective cohort)., (© 2022. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: The primary aim was to analyse the lateral malleolus morphology with a focus on the shape of the distal fibula for IM fixation of the fibula in infra- and transsyndesmotic fracture patterns. The secondary aim was to propose a treatment algorithm according to the lateral malleolar anatomy., Methods: 77 healthy, skeletally mature volunteers underwent CT scanning of the ankle. The fibula medullary canal and its cortical thickness were quantitatively analysed at 4 different levels measured from the fibular tip (1.5 cm, 3.0 cm, 4.5 cm, and 6.0 cm). A geometric classification was proposed, and a decision algorithm was developed. Statistical significance was set at a p-value < 0.05., Results: The smallest diameter of the medullary canal of the fibula was at 6.0 cm from the tip of the fibula, in 98.2% of the ankles. The distal fibula can be classified into triangular and rectangular type, according to the cortical thickness index (p < 0.0001). In 16.7% ankles, the internal diameter of the fibula at 6.0 cm was equal or narrower than 3.5 mm (p < 0.05)., Conclusion: The shape of the distal fibula as evaluated by CT-guided analysis allows for IM osteosynthesis of the lateral malleolus in 83% of individuals. In our study, the smallest diameter of the medullary canal of the fibula was located 6.0 cm from the tip of the lateral malleolus. Coronal CT evaluation is advantageous in indicating which type of IM implant should be used safely for infra- and transsyndesmotic fracture patterns, potentially reducing intraoperative risks., (© 2022. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Historically, proximal ulna fractures have been simplistically diagnosed and treated as simple olecranon fractures, leading to an unacceptable number of complications. Our hypothesis was that the recognition of lateral, intermediate, and medial stabilizers of the proximal ulna and ulnohumeral and proximal radioulnar joints would facilitate decision-making, including the choice of approach and type of fixation. The primary aim was to propose a new classification for complex fractures of the proximal ulna based on morphological characteristics seen on three-dimensional computed tomography (3D CT). The secondary aim was to validate the proposed classification regarding its intra- and inter-rater agreement. Three raters with different levels of experience analyzed 39 cases of complex fractures of the proximal ulna using radiographs and 3D CT scans. We presented the proposed classification (divided into four types with subtypes) to the raters. In this classification, the medial column of the ulna involves the sublime tubercle and is where the anterior medial collateral ligament is inserted, the lateral column contains the supinator crest and is where the lateral ulnar collateral ligament is inserted, and the intermediate column involves the coronoid process of the ulna, olecranon, and anterior capsule of the elbow. Intra- and inter-rater agreement was analyzed for two different rounds, and the results were evaluated according to Fleiss kappa, Cohen kappa, and Kendall coefficient. Intra- and inter-rater agreement values were very good (0.82 and 0.77, respectively). Good intra- and inter-rater agreement attested to the stability of the proposed classification among the raters, regardless of the level of experience of each one. The new classification proved to be easy to understand and had very good intra- and inter-rater agreement, regardless of the level of experience of each rater.

Objective: the management of septic metaphyseal nonunions is challenging, with inconsistent outcomes. Antibiotic cement-coated implants have been demonstrated good outcome for diaphyseal infected nonunions, however there is no data in metaphyseal infected nonunions., Methods: fifteen adult patients with septic metaphyseal nonunions of the femur or tibia were treated with antibiotic cement-coated plates. The antibiotic cement-coated plate was prepared with either gentamicin or vancomycin. Outcome measures were infection control, bone healing, return to pre-injury level on daily activities, and quality of life at the last follow-up visit. A p value of <5% was considered significant., Results: Methicillin-susceptible S. aureus was isolated in 53.3% cases. Average postoperative follow-up time was 18 months. Local infection control and radiographic bone healing were adequately achieved in 93.3% patients. No patient presented recurrent symptoms of surgical site infection. Fourteen patients reported to be either able, or on the same level as before injury, with 73.3% reporting no problems in all five dimensions of the EQ-5D-3L. Persistent infection was the only variable associated with a reduced long-term quality of life., Conclusion: antibiotic cement-coated plate is a viable and efficient surgical technique for the definitive management of juxta-articular metaphyseal septic nonunions of the femur and tibia.

Over the last year, with the social isolation imposed by the coronavirus disease pandemic, there has been a significant increase in complaints associated with physical violence against women. In the present study, an exploratory literature review was carried out on the role of the on-call orthopedic surgeon when faced with a suspicion of domestic violence, in accordance with Brazilian legislation. The main objective of the study was to show the role of this specialist in identifying victims of domestic violence by recognizing their profiles and associated risk factors. The secondary objectives were to demonstrate the most common skeletal and non-skeletal injuries in this type of violence and to present a quick and practical guide on how to identify, approach, and manage cases of domestic violence against women. The findings revealed that the main aggressors were close partners, such as spouses and ex-spouses. Young adult women, black or multiracial, and low socioeconomic status are major risk factors for intimate partner violence. Head and neck injuries are the most frequently observed lesions in this population, with more than one-third of victims reporting falls. Musculoskeletal injuries are present in up to 42% of victims of domestic violence, occurring predominantly in the upper limbs and chest, and are the leading cause of death in women aged 1 to 34 years. A practical guide for orthopedic surgeons who work in emergency departments is proposed, with basic information about their role and responsibility in identifying potential victims of intimate partner violence., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background and Objectives: Proximal humerus fractures are the second most frequent site of avascular necrosis (AVN), occurring in up to 16% of cases. The Hertel criteria have been used as a reference for the prediction of humerus head ischemia. However, these are based solely on the use of radiographs, which can make interpretation extremely difficult due to several reasons, such as the overlapping fragments, severity of the injury, and noncompliant acute pain patients. The objectives of the study were to evaluate the role of computed tomography (CT) in the interpretation of the Hertel criteria and to evaluate the intra- and interobserver agreement of orthopedic surgeons, comparing their area of expertise. Materials and Methods: The radiographs and CT scans of 20 skeletally mature patients who had fractures of the proximal humerus were converted to jpeg and mov, respectively. All images were evaluated by eight orthopedic surgeons (four trauma surgeons and four shoulder surgeons) in two different occasions. The intra- and interobserver agreement was assessed by using the Kappa coefficient. The level of significance was 5%. Results: There was a weak-to-moderate intraobserver agreement (κ < 0.59) for all examiners. Only the medial metaphyseal hinge greater than 2 mm was identified by 87.5% of evaluators both in the radiographic and CT examinations in the two rounds of the study (p < 0.05). There was no significant interobserver agreement (κ < 0.19), as it occurred only in some moments of the second round of evaluation. Conclusions: The prognostic criteria for humeral head ischemia evaluated in this study showed weak intra- and interobserver agreement in both the radiographic and tomographic evaluation. CT did not help surgeons in the primary interpretation of Hertel prognostic criteria used in this study when compared to the radiographic examination.

Objective  To evaluate the biomechanical capacity of two forms of fixation for Pipkin type-II fractures, describing the vertical fracture deviation, the maximum and minimum principal stresses, and the Von Mises equivalent stress in the syntheses used. Materials and Methods  Two internal fasteners were developed to treat Pipkin type-II fractures through finite elements: a 3.5-mm cortical screw and a Herbert screw. Under the same conditions, the vertical fracture deviation, the maximum and minimum principal stresses, and the Von Mises equivalent stress in the syntheses used were evaluated. Results  The vertical displacements evaluated were of 1.5 mm and 0.5 mm. The maximum principal stress values obtained in the upper region of the femoral neck were of 9.7 KPa and 1.3 Kpa, and the minimum principal stress values obtained in the lower region of the femoral neck were of -8.7 KPa and -9.3 KPa. Finally, the peak values for Von Mises stress were of 7.2 GPa and 2.0 GPa for the fixation models with the use of the 3.5-mm cortical screw and the Herbert screw respectively. Conclusion  The fixation system with the Herbert screw generated the best results in terms of reduction of vertical displacement, distribution of the maximum principal stress, and the peak Von Mises equivalent stress, demonstrating mechanical superiority compared to that of the 3.5-mm cortical screw in the treatment of Pipkin type-II fractures., Competing Interests: Conflito de Interesses Os autores declaram não haver conflito de interesses., (Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Femoral neck fractures in young adults are uncommon, resulting from high-energy trauma. Despite their infrequency in this population, there is higher rate of complications, especially in the more vertical fracture line, classified by Pauwels as a type-3 femoral neck fracture. The implant type is of paramount importance for maintaining anatomical reduction, since it must resist the deforming forces that act on the fracture. We comparatively evaluated two constructions of the novel locking autocompression implant (X-PIN and X-PIN+P) using the finite element method and previously established methods for treating Pauwels type-3 femoral neck fractures. Six fixation models were developed for the study: a dynamic hip screw (DHS), a DHS with an anti-rotation screw (DHS+P), the inverted triangle multiple cannulated screws construction (ASNIS), the multiple cannulated screws in an L-configuration (L), and the two models of the novel locking autocompression screw (X-PIN and X-PIN+P). Under the same conditions with a load of 2100 N, the following parameters were evaluated using SIMLAB ® software: the main maximum (Max P), main minimum (Min P), localized maximum P1 (Max P1), localized maximum P2 (Max P2), total displacement, localized displacement, rotation displacement, and von Mises stress. Compared to the DHS+P and ASNIS models, the X-PIN+P model presented, respectively, increases of 51.6% and 64.7% for Max P, 85% and 247% for Min P, and 18.9% and 166.7% for von Mises stress. Max P1 did not differ between the models, but Max P2 was 55% and 50% lower for X-PIN+P than ASNIS and L, respectively. All displacement values were lower for X-PIN+P than the other models. In this FEM testing, the X-PIN+P was superior to the other models, which was due to improvement in all parameters of stress distribution, displacement, and von Mises stress compared to models using a lateral plate (DHS and DHS+P) or not (ASNIS and L).

High-energy fractures of the proximal tibia with extensive fragmentation of the posterolateral (PL) quadrant of the tibial plateau are challenging to manage. Herein, we present a review of the literature on the patterns and options of approach and fixation of the PL fragment of the tibial plateau to optimize the treatment of this specific injury pattern. We searched PubMed (1980-May 2020) to identify and summarize the most relevant articles evaluating both the morphology and treatment recommendations, including the choice of approach and fixation strategy, for the PL tibial plateau fracture. We found PL fragment can present in several patterns as a pure split, split depression, contained pure depression, and noncontained depression (rim crush), which are mostly determined by the position of the knee and the force magnitude applied during the course of the accident. Based on previous concepts described by Schatzker and Kfuri, we suggest a simplified treatment algorithm highlighting the two concepts (buttressing and containment) used for plating the PL tibial plateau fragments. Based on the available current evidence, we propose an algorithm for these two morphological types of PL tibial plateau fracture. Shear-type fractures need buttressing (the "rule of thumb"), whereas noncontained peripheral rim-type fractures need peripheral repair and containment. Contained pure depression fractures are not frequent and need percutaneous-assisted elevation and subchondral rafting, either controlled by fluoroscopy or arthroscopically. It is believed that such an approach would simplify their assessment and preoperative planning and would assist the clinicians to appreciate and manage more consistently these complex injuries., Competing Interests: None declared., (Thieme. All rights reserved.)

»: COVID-19 is a disease that is challenging science, health-care systems, and humanity. An astonishingly wide spectrum of manifestations of multi-organ damage, including musculoskeletal, can be associated with SARS-CoV-2., »: In the acute phase of COVID-19, fatigue, myalgia, and arthralgia are the most common musculoskeletal symptoms., »: Post-COVID-19 syndrome is a group of signs and symptoms that are present for >12 weeks. The associated musculoskeletal manifestations are fatigue, arthralgia, myalgia, new-onset back pain, muscle weakness, and poor physical performance., »: Data on COVID-19 complications are growing due to large absolute numbers of cases and survivors in these 2 years of the pandemic. Additional musculoskeletal manifestations encountered are falls by the elderly, increased mortality after hip fracture, reduced bone mineral density and osteoporosis, acute sarcopenia, rhabdomyolysis, Guillain-Barré syndrome, muscle denervation atrophy, fibromyalgia, rheumatological disease triggering, septic arthritis, adhesive capsulitis, myositis, critical illness myopathy, onset of latent muscular dystrophy, osteonecrosis, soft-tissue abscess, urticarial vasculitis with musculoskeletal manifestations, and necrotizing autoimmune myositis., »: A wide range of signs and symptoms involving the musculoskeletal system that affect quality of life and can result in a decrease in disability-adjusted life years. This powerful and unpredictable disease highlights the importance of multimodality imaging, continuing education, and multidisciplinary team care to support preventive measures, diagnosis, and treatment., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/A841)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Purpose: This study aims to present a novel classification system and a rationale for treatment of medial Hoffa fractures., Methods: We developed a simple comprehensive classification system for medial Hoffa fractures based on the fragment size and presence of fracture comminution. Furthermore, we propose a treatment algorithm based on two pillars: our case series of nine patients presenting medial Hoffa fractures and the best evidence-based pertinent literature. Fracture healing, range of motion, function, and complications were evaluated after a minimum of 6 months follow-up., Results: All fractures healed with no loss of reduction. Knee flexion ranged from 90 - 130° (mean 110°, standard deviation 15.2). Knee extension ranged from 0 - 10° (mean 1°, standard deviation 3.3). Knee function according to the Lysholm score ranged from 74 - 96 points (mean 85, standard deviation 6.3). There were no complications such as infection, fixation failure, or medial femoral condyle osteonecrosis. One patient required hardware removal due to soft tissue irritation and one patient underwent knee mobilization under anesthesia after 8 weeks of fracture fixation due to knee stiffness., Conclusion: The presented rationale for treatment based on the new classification system is a simple and effective strategy on the decision-making process for adequate management of medial Hoffa fractures., Competing Interests: I confirm that I received an honorarium for educational activities from Zimmer Biomet and from the AO Foundation., (Thieme. All rights reserved.)

Objective: The goal of this study is to verify how commercially available pre-contoured superior plates fit on clavicle midshaft fractures., Methods: 100 cadaveric clavicles were evaluated by three distinct observers applying the clavicle congruence score and comparing four different 6 to 8-hole pre-contoured anatomic locking-plate systems., Results: the inter-observer agreement was considered moderate by the percentage agreement and fair by the Fleiss' Kappa, with no significant differences between evaluations. Only 1 of the 8 plates presented an anatomic fit greater than 70%. Long plates (8 holes) presented a poor fit compared to short plates (6 or 7 holes)., Conclusions: the overall evaluation showed that currently-available pre-contoured superior plate systems provide a poor fit on clavicles for midshaft fracture fixations. Long plates present a worse fit compared to short ones.

Background: The Reamer-Irrigator-Aspirator system was initially developed to reduce fat embolism and thermic necrosis during reamed intramedullary nail fixation of femoral shaft fractures. Currently, this system is used in extended applications including accessing large volume of autologous bone graft, as alternative for iliac crest harvesting. Antegrade femoral bone graft harvesting using the Reamer-Irrigator-Aspirator system is considered the standard technique. The aim of our study is to evaluate the efficacy (bone graft volume) and the complications (blood loss, postoperative pain, and incidence of iatrogenic fractures) of the Reamer-Irrigator-Aspirator system through the retrograde femoral route in a series of patients with post-traumatic bone defects or nonunions., Methods: A non-controlled single center retrospective observational cohort study was conducted in a level1 trauma center to evaluate all patients who were treated using the RIA system. Between November 2015 and May 2019, 24 patients (8 women and 16 men; mean age: 41 years [range 27-55 years]) with bone defects or nonunions underwent bone graft harvesting using the Reamer-Irrigator-Aspirator system through retrograde femoral route. Postoperative pain, complications, and bone graft volume were analyzed. Inclusion criteria was patients older than 18 years with a diagnosis of post-traumatic bone defect or associated tibial or femoral nonunion, with minimum 6-months follow, treated using the RIA. We hypothesized that the retrograde route of the RIA system is a safe and efficacious method for bone harvesting., Results: The average volume of collected graft was 45 cc (range 30-60 cc). In 83% of the cases, bone grafting was sufficient, while in 17% it was necessary to add iliac crest bone graft to completely fill the bone defect. A mean drop in postoperative hemoglobin of 4.1 g / dL (range 0.5-6.0 g / dL) was evidenced. In 4 cases (33%), a unit of packed red blood cells was required. Regarding postoperative pain, visual analogue scale after 3 months postoperatively was 1.6 in average. After 6 months, the value has decreased to 0.4. There were no perioperative or postoperative complications at 6-month follow-up., Conclusion: In this limited case series, large volumes of bone graft were harvested using the retrograde route of the RIA system and there were no intra-/ postoperative complications observed at 6-month follow-up. Therefore this novel technique appears safe and efficacious. However, it's important to highlight that future prospective controlled studies are necessary to validate the insights from this pilot study., (© 2021. The Author(s).)

Purpose: Despite the fact that open reduction and internal fixation with a plate, either non-locked or locked, is the standard of care for managing lateral malleolus fractures, intramedullary (IM) fixation of the fibula has been recently introduced as an alternative, mainly for some potential complicated situations. We hypothesized that almost all patterns of distal fibula fracture can be safely fixed with an IM device, with the potential benefit of providing biomechanical efficiency, but using a soft-tissue friendly implant. Here, we present a multicenter case series based on a proposed algorithm., Patients and Methods: Sixty-nine consecutive patients were managed with fibular IM fixation for closed malleolar fractures. Twenty patients were managed by IM screw fixation and 49 by fibular nailing. Outcome was measured both according to the American Orthopaedic Foot and Ankle Society (AOFAS) score for ankle and hindfoot, and the time to bone union., Results: The mean AOFAS for Group I was 99.35 ± 1.95 points and that for Group II was 89.30 ± 16.98 points. There were no significant differences between the fracture pattern, according to the Lauge-Hansen classification, and post-operative levels of pain and functional activity among patients in both groups (p > 0.05). All fractures healed uneventfully in both groups. The mean time to union for Group I was 8.15 weeks and for Group II was 8.25 weeks (p > 0.05)., Conclusion: In this multicenter case series, intramedullary fixation for the lateral malleolus fracture presented itself as a viable and safe option for the treatment of almost all patterns of fibula fracture in adults. Overall, we were able to demonstrate the potential indications of the proposed algorithm for the choice of IM implant for the lateral malleolus fracture in terms of the Lauge-Hansen staged classification., (© 2020. Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives: This study aimed to correlate a higher Pelvic-Trochanteric Index (PTI) with an increased varus of the femoral neck with greater trochanteric pain syndrome (GTPS). The secondary objective was to check whether the pelvic width changes with age., Methods: A prospective study was conducted to compare female patients diagnosed with GTPS (case group) with asymptomatic female participants (control group) from March 2011 to June 2017. On an anteroposterior pelvic radiograph, lines were drawn by two radiologists, and the PTI (ratio of the distance between the greater trochanters and distance between the iliac crests) was defined and the femoral neck-shaft angle was measured., Results: Data collected based on radiographs of 182 female patients (cases) and 150 female participants (controls) showed that the mean PTI was 1.09 (SD=0.01) in the case group and 1.07 (SD=0.01) in the control group (p<0.05), regardless of age. The distance between iliac crests increased with age (p<0.05) in symptomatic and asymptomatic individuals. It was also found that the mean femoral neck-shaft angle was 130.6° (SD=0.59) and progression of the varus angulation occurred with age in both groups, with a significance level of 5%., Conclusions: The PTI was higher in patients with GTPS. The femoral neck-shaft angle does not differ between individuals with and without GTPS; however, it does decrease with age. The pelvic width tends to increase with aging in symptomatic or asymptomatic individuals; therefore, the increase in the pelvic width and decrease in the femoral neck-shaft angle can be interpreted as normal in aging women, which could alter the biomechanics of the hips and pelvis.

An anatomical variant of flexor digitorum superficialis brevis is an uncommon condition that may be a pitfall in diagnosing carpal tunnel syndrome, involving palpable mass and even characteristic symptoms. We present an unusual case of bilateral symptomatic carpal tunnel syndrome related to the presence of a flexor digitorum superficialis brevis muscle of the little finger, and a critical review of the literature., (Copyright © 2021 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Malunion, nonunion, congenital abnormalities, and osteometabolic diseases are the main causes of long bone deformities 1 . Although the exact incidence is unclear, it is estimated that about 10% of all fractures have some complication in terms of fracture-healing. In addition to the aesthetic impact, malunions generally substantially impair function and quality of life 1 . Every malunion is unique, and treatment is usually planned according to the degree of deformity and the postoperative expectations of the patient 2 . However, it is noteworthy that deformity correction usually requires a high degree of surgical expertise. Several techniques have been proposed over the years, and new techniques that utilize current technologies are available, such as computer-assisted single-cut osteotomy 3 . In 2009, Russell et al. proposed the clamshell technique for diaphyseal malunions 4-6 . This technique is our preferred treatment for diaphyseal malunions and acute fractures in the setting of a previous malunion or deformity. The following videos will thoroughly describe the steps to perform this useful and effective surgical technique for malunion correction., Description: The key principle of the "clamshell osteotomy" is to create a comminuted fracture at the malunion site and utilize an intramedullary rod as a template for deformity correction 4,5 ., Alternatives: Multiple osteotomy types and fixation methods are currently available for diaphyseal malunion correction. Among the osteotomies, opening or closing wedge, uniplanar, multiplanar, oblique, and dome methods may be utilized. In addition, several fixation methods can be utilized, including plates and screws, intramedullary rods, and external fixators 2,6 ., Rationale: The clamshell technique is a useful and effective treatment option for diaphyseal malunions of the lower extremity. The ability to utilize an intramedullary nail as a template for deformity correction makes the procedure simpler than previously described techniques, which require perfect preoperative planning to avoid over- and undercorrection. The versatility of this procedure justifies its incorporation into the therapeutic arsenal for treatment of complex diaphyseal malunions., Expected Outcomes: To our knowledge, all previously reported cases utilizing the clamshell osteotomy have resulted in positive outcomes 4-6 . Russell et al. presented a case series of 10 patients with posttraumatic diaphyseal malunions (4 femoral and 6 tibial), in which all patients showed coronal and sagittal-plane correction to within 4°, limb-length inequality correction to within 2 cm, and complete correction of translation, rotation, and joint-line orientation angles 4 . In addition, all osteotomies healed uneventfully. The reported complications included broken interlocking screws in 1 case, need for dynamization in 1 case, and superficial wound dehiscence in 2 cases (1 of which required surgical debridement). Pires et al. presented 4 cases of clamshell osteotomies performed for the treatment of acute fractures in the setting of a previous malunion. All osteotomies healed by 15 months (mean time to healing [and standard deviation], 6.8 ± 4.4) 6 . One of these 4 cases was a Gustilo-Anderson grade-IIIB open fracture that required muscle flap coverage and a subsequent Hernigou procedure 6 . When discussing treatment options with patients, it is important to clarify that there is currently no clear best technique to treat complex malunions; however, the clamshell osteotomy is a simpler procedure compared with others that have previously been described and has the benefits of quick rehabilitation and good deformity correction without the drawbacks of an external fixator 4-6 ., Important Tips: Preserve the blood supply in the opposite cortex.Close the fascia before reaming the medullary canal.Do not ream the osteotomy site.Be sure to perform a bicortical osteotomy.Create a stable construct., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSEST/A343)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Extensor tendon ruptures caused by bicortical screws impingement following distal radius fracture fixation with volar plates are extensively reported in the literature. Thus, a biomechanical study comparing unicortical and bicortical fixations in intra-articular distal radius fracture models is critical in decision-making regarding distal radius fracture management. Forty-two synthetic radius models were fixed using a variable angle volar distal locking plate with seven screws. They were divided into 6 groups (n = 7): G1/G3/G4 unicortical fixation (75% of anteroposterior distal radius lenght); G2/G4/G6 bicortical fixation. Each group underwent a different mechanical test: axial compression (G1/G2), dorsal flexion (G3/G4), and volar flexion (G5/G6). The load application rate was 5 mm/min and 1000 cycles of 50 to 250 N at 1 Hz were performed between both static tests. Comparative results in the first static test, in the second static test, and in failure generally showed a very similar behavior. Models depicted similar behavior in the second static test when cyclic load was performed. Therefore, one can realize that stiffness differed during dorsal flexion only in the first static test. Maximum force to break the model in axial compression was greater in bicortical than in unicortical construct. Since biomechanical properties are similar, we recommend using unicortical distal locking screws in distal radius fracture fixation with volar plates to prevent extensor tendon ruptures., Competing Interests: Declaration of Competing Interest ATNF received honorarium for educational activities from Medartis, IBRA, Depuy Synthes, and AO Foundation. REP received honorarium for educational activities from Zimmer Biomet and AO Foundation. NM, APM, LRB, and ACS declare that they have no conflict of interest., (Copyright © 2021. Published by Elsevier Ltd.)