OBJETIVO: Avaliar os óbitos por causas externas em uma microrregião do Estado de São Paulo. MÉTODOS: Estudo descritivo exploratório transversal retrospectivo. Foi feito um levantamento e revisão de 511 prontuários das vítimas de causas externas fornecidos pelo Instituto Médico Legal de Catanduva - SP de 2008 a 2011. Os dados foram classificados por sexo, idade, intencionalidade e mecanismo de causa externa. RESULTADOS: A mortalidade foi predominante no sexo masculino, com 77,9% dos casos (p<0,001). As mortes classificadas como não intencionais representaram 66,9%, enquanto as intencionais, 33,1% (p<0,001). Os acidentes de transporte terrestre foram responsáveis por 45,6% dos casos, sendo a principal causa dos óbitos analisados. O segundo lugar foi atribuído aos suicídios, com 16%, seguido pelos homicídios (13,9%). CONCLUSÃO: Os resultados encontrados diferem dos perfis encontrados em outros estudos brasileiros, aproximando-se mais da realidade de países desenvolvidos, já que a não intencionalidade foi preponderante e as principais causas foram os acidentes de transporte terrestre, suicídios e homicídios, respectivamente. Foi constatada a necessidade de melhorias no preenchimento da declaração de óbito pelos legistas, visto que isto foi uma dificuldade encontrada pelos autores na realização do estudo.

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

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Objectives:To determine the proportion of traumatologists who investigate osteoporosis in elderly patients with fractures and recommend secondary prevention of osteoporotic fractures.Methods:We distributed questionnaires to 244 physicians attending the 2015 Brazilian Congress of Orthopedic Trauma. We determined the respondents’ profiles and assessed how they investigated and treated osteoporosis in elderly patients with fractures.Results:Overall, 32% of the respondents reported that their knowledge level regarding osteoporosis ranged from 0-5 (out of 0-10). In total, 42% of the participants reported that they usually requested DXA for elderly patients with fractures and less than 30% reported prescribing supplemental calcium and/or vitamin D. We considered physicians conducting a complete treatment for the patient as those who in addition to requesting DXA prescribed supplemental calcium, vitamin D, and specific medications for their elderly patients, and recommended non-pharmacological measures. Only 0.8% of the participants fulfilled all these criteria. In addition, 47% of the traumatologists reported that they did not treat osteoporosis directly but instead, referred osteoporotic patients to a qualified physician.Conclusion:Less than 50% of the surveyed traumatologists investigated and performed secondary prevention against osteoporotic fractures after treating an elderly patient with a fracture. Level of evidence III, Economic and Decision Analyses - Developing an Economic or Decisions Model.

We present a stepwise surgical approach that can be used, in lieu of a transtibial amputation, to preserve the lower limb in the setting of severe diabetic foot infections. A 63-year-old male status post left midfoot (Lisfranc’s) amputation presented to our hospital with a 4-year history of a left foot diabetic ulcer with associated purulent drainage and intermittent chills. On initial exam, the patient’s left foot amputation stump was plantarflexed, grossly erythematous, and edematous. The associated diabetic foot ulcer was actively draining purulent fluid. Following workup with radiography and ultrasound, the patient was diagnosed with a post-operative infection of the midfoot at the level of the amputation stump secondary to diabetic neuropathy. Our approach to management was a staged and included (1) surgical irrigation and debridement of the distal stump wound, (2) provisional negative pressure therapy, (3) a second-look procedure, and (4) a tibiotalocalcaneal fusion was performed using a lateral transfibular and plantar approach, after wound closure and resolution of active infection was achieved. At 36-month follow-up, the patient was fully weight-bearing in stiff sole sneakers with no gross overt alteration of gait pattern. The patient scored 79 points when assessed by the hindfoot American Orthopaedic Foot and Ankle Society Ankle-Hindfoot outcome score. In the patient with diabetes and cardiological restrictions, a Chopart amputation is preferred due to the decreased level of energy expenditure required for ambulation as compared to over more proximal levels of amputation.

Measurement of hindfoot malalignment and flexibility is essential for treatment decision-making in cavovarus foot deformity. Weight-bearing computed tomography (WBCT) shows greater diagnostic accuracy and allows the study of osteoarticular alignment in the physiological upright position. The most commonly used method for measurements on WBCT scans is the foot and ankle offset (FAO), which is based on the structural tripod of the foot: the calcaneus and the first and fifth metatarsal heads. During the Coleman block test, the first metatarsal head is not resting on the ground and, therefore, does not represent the physiological support of the tripod. We describe a new measurement, the forefoot/hindfoot offset (FHO), for assessing hindfoot alignment on WBCT scans. Level of Evidence V; Diagnostic Studies; Expert Opinion.

Objective: To compare screw fixation strength for subtalar arthrodesis. Methods: Eight matched pairs of cadaver feet underwent subtalar joint arthrodesis with two 7.3mm cannulated screws. Randomization was used to assign screw orientation, such that one foot in each pair was assigned dorsal to plantar screw orientation (DP Group), and the other foot, plantar to dorsal orientation (PD Group). Standard surgical technique with fluoroscopy was used for each approach. Following fixation, each specimen was loaded to failure with a Bionix ® 858 MTS device, applying a downward axial force at a distance to create torque. Torque to failure was compared between DP and PD Groups using Student's t test, with p=0.05 used to determine statistical significance. Results: Statistical analysis demonstrated that the mean torque to failure slightly favored the DP Group (37.3Nm) to the PD Group (32.2Nm). However, the difference between the two groups was not statistically significant (p=0.55). Conclusion: In subtalar arthrodesis, there is no significant difference in construct strength between dorsal-to-plantar and plantar-to-dorsal screw orientation. The approach chosen by the surgeon should be based on factors other than the biomechanical strength of the screw orientation.

The surgical treatment of large post-traumatic osteochondral defects related to open tibial pilon fractures is challenging. Staged treatment with soft tissue damage control and bone reconstruction in the second half is often the best therapeutic option. We present a technical tip using osteochondral allograft to reconstruct an area with extensive bone loss in the distal tibial epiphysis after a gunshot wound, describing the treatment stages and good clinical results. Level of Evidence V; Therapeutic Studies; Expert Opinion.