To evaluate the occurrence of partial or total loss of the reverse-flow sural flap used for coverage failures in the lateral, medial, and central regions of the ankle, as well as factors related to flap loss. A retrospective cohort study was conducted including data from 32 patients who underwent surgery with reverse sural flaps between February 2012 and September 2023 at the Institute of Orthopedics and Traumatology, HC/FMUSP. In the group of patients requiring coverage in the medial region, 40% had partial flap loss and 30% suffered total loss. In the lateral region, 20% experienced partial loss and 13.3% total loss. In the central area, 57.14% had partial coverage loss, with no cases of total loss. The reverse sural flap proved to be favorable for coverage of defects in the lateral region of the ankle, but showed higher rates of partial or total loss when used for coverage of defects in the medial region of the ankle. A negative effect was observed in the presence of patient comorbidities, in trauma-related cases, and in the early approach to flap construction. Level of Evidence II; Retrospective cohort study. Avaliar a ocorrência de perda parcial ou total do retalho sural de fluxo reverso utilizado nas falhas de cobertura na região lateral, medial e central do tornozelo, assim como fatores relacionados à perda do retalho. Foi realizado um estudo de coorte retrospectiva incluindo os dados de 32 pacientes submetidos à cirurgia com retalhos surais reversos entre fevereiro de 2012 a setembro de 2023 no Instituto de Ortopedia e Traumatologia do HC/FMUSP. No grupo de pacientes com necessidade de cobertura na região medial, 40% tiveram perda parcial do retalho e 30% sofreram perda total. Na região lateral, foram 20% de perdas parciais e 13,3% de perdas totais. E na área medial, 57,14% tiveram perda parcial da cobertura, sem nenhum caso de perda total. O retalho sural reverso se mostrou favorável para a cobertura de falhas na região lateral no tornozelo e mostrou maiores taxas de perdas parciais ou totais quando foi utilizado para a cobertura das falhas na região medial do tornozelo. Houve um efeito negativo na presença de comorbidades do paciente, nos casos causados por trauma e na abordagem precoce da confecção do retalho. Nível de Evidência II; Estudo de coorte retrospectiva.
Oral nutritional supplementation (ONS) is commonly prescribed in malnourished older adults after hip fracture, but formulations are heterogeneous, and their comparative association with mortality remains unclear. We aimed to evaluate whether HMB-containing ONS was associated with lower mortality than non-HMB ONS and to explore whether supplement formulation combined with treatment persistence was associated with differential mortality patterns. This was a formulation-specific subanalysis of a previously described prospective cohort of older adults with hip fracture and malnutrition or significant nutritional risk. Only patients with known ONS formulation were included (n = 107): 59 received HMB-containing ONS, and 48 received non-HMB ONS, including standard, diabetes-specific, and renal-oriented formulations. Mortality at 3, 6, and 12 months was analyzed using crude comparisons and multivariable logistic regression adjusted for sex, age, and Charlson comorbidity index. A 6-month adjusted Cox model was used as the main time-to-event analysis. Exploratory analyses assessed mortality according to supplement formulation and treatment persistence. Overall mortality was 14.0% at 3 months, 23.4% at 6 months, and 29.9% at 12 months. At 6 months, mortality was lower among patients receiving HMB-containing ONS than among those receiving non-HMB ONS (13.6% vs. 35.4%; p = 0.011), and the association remained significant after adjustment (OR 0.267; 95% CI 0.091-0.784; p = 0.016). Associations at 3 and 12 months were directionally consistent but not statistically significant. In the adjusted Cox model, prescription of HMB-containing ONS was associated with a lower hazard of death within 6 months (HR 0.358; 95% CI 0.145-0.885; p = 0.026). Exploratory analyses showed a 6-month mortality gradient according to formulation and persistence, ranging from 0.0% in patients receiving HMB-ONS for ≥3 months to 41.2% in those receiving non-HMB ONS for <3 months. In this formulation-specific subanalysis of malnourished older adults with hip fracture, an association between HMB-containing ONS and lower 6-month mortality was observed compared with non-HMB ONS. Exploratory findings suggested a clinically relevant mortality gradient according to both supplement formulation and treatment persistence, although these results should be interpreted cautiously. Larger prospective studies are warranted to confirm these findings.
The aim of the present study was to investigate changes in the maxillary sinus and nasal cavity in patients submitted to Le Fort I osteotomy using Cone Beam Computed Tomography (CBCT). A retrospective study was conducted involving the analysis of preoperative (T1) and postoperative (T2) CBCT scans of 34 patients undergoing orthognathic surgery. The outcome variables were sinus and nasal cavity volumes, presence and patency of the maxillary ostium, sinus mucosal thickening, nasal septal deviation, and changes in sinonasal anatomy. The paired-sample t-test and Wilcoxon test were used to compare differences between T1 and T2, with the significance level set at 5% (p < 0.05). Age ranged from 18 to 55 years (mean: 29.97 ± 9.85). Most patients were women (64.7%) and had a type III facial profile (52.9%). Statistically significant differences were found between T1 and T2 in the mean volume of the maxillary sinus (p = 0.001) and nasal cavity (p = 0.042) and the degree of mucosal thickening of the maxillary sinuses (p = 0.013; p = 0.046). Le Fort I osteotomy is associated with significant changes in the volume of the maxillary sinus and nasal cavity as well as thickening of the sinus mucosa.
Although minimally invasive transverse osteotomy and akin (META) for hallux valgus has demonstrated favorable radiological and patient-reported outcome measures, these do not capture the practical questions patients typically ask, such as when they can return to driving, work, wearing shoes, or resume sports. This study aimed to identify the timeframe to return to daily activities and sports after META. Secondarily, to explore potential perioperative factors that may influence this timeframe. Prospective cohort. Seventy-five consecutive adults underwent META between September 2023 and December 2024. The primary outcome was the timeframe to return to 8 activities, measured using a purpose-designed questionnaire administered at least 3 months postoperatively. Secondary outcomes were explored using multivariable quantile regression. Fifty-seven eligible patients (90 feet) completed follow-up (mean 12.4 months). Median return times (weeks, IQR): wide shoes 3.0 (2-4), driving 4.0 (2-5), work 4.0 (2-5), normal walking 4.0 (3-6), athletic footwear 6.0 (4-8), low-impact sports 8.0 (5.5-10), regular footwear 12.0 (6.5-16), and high-heels 16.0 (13.5-20.5). The absence of previous physical activity delayed driving among slower recoverers (P90: β + 6.5 weeks; 95% CI 2.3-10.8; p = 0.004), bilateral procedures delayed work return (P75: β + 4.1 weeks; 95% CI 1.5-6.7; p = 0.004), concomitant lesser toe procedures delayed athletic footwear transition (P50: β + 3.0 weeks; 95% CI 0.7-5.3; p = 0.013), and physical therapy showed no consistent association after age adjustment. Most patients resumed driving, work, and normal walking by 4 weeks, low-impact sports by 8 weeks, and footwear transitions over 3-16 weeks, providing empirical milestones for perioperative counseling after META.
The coexistence of periprosthetic joint infection (PJI) and periprosthetic fracture (PPFx) is one of the most challenging complications after total hip arthroplasty (THA) and total knee arthroplasty (TKA). Evidence regarding the management and outcomes of concomitant PJI and PPFx remains limited. This systematic review aimed to evaluate treatment strategies for infected PPFx in order to optimise infection eradication, fracture healing, implant survival, and limb function. A systematic review was conducted according to PRISMA and Cochrane guidelines and registered in the PROSPERO database (CRD420251051853). Studies of level II-V evidence reporting on the management of infected PPFx following THA or TKA were included. Extracted data comprised patient demographics, fracture classification, pathogens, treatment strategies, complications, infection control, and fracture healing outcomes. Thirteen studies involving 210 patients were included, with a percentage of hip fractures of 81.9%. The most frequently isolated pathogens were Staphylococcus epidermidis, Staphylococcus aureus, and Cutibacterium acnes. Treatment strategies varied and included revision arthroplasty, plating, intramedullary fixation, distally locked stems, and staged reconstruction with antibiotic-loaded cement or spacers. Fracture union rates ranged from 58 to 100%, while reinfection or recurrence occurred in 6-28% of cases. Stable fixation was associated with improved outcomes, particularly in Vancouver B1 fractures, whereas B2 and B3 fractures showed higher mechanical complication rates. Mortality was reported up to 22% predominately in frail populations. Infected periprosthetic fractures remain rare but involve severe complications. Staged protocols combining infection eradication with stable fixation provide the most consistent outcomes, although treatment should be individualised.
We present the case of a 16-year-old female polytrauma patient who sustained a rare and highly unstable pelvic ring injury following a high-energy motor vehicle collision with partial ejection. The injury pattern was classified as Tile C3, combining a right anterior crescent-type fracture with anterior sacroiliac (SI) joint dislocation, a left-sided Denis II sacral fracture, a distal T-shaped sacral fracture, and bilateral pubic rami fractures. Neurological deficits included right L5 and left S1-S2 involvement. Initial management adhered to damage control principles, including pelvic binder application, preperitoneal packing, and temporary external fixation. Due to cranial migration of the right hemipelvis and neurovascular compression, urgent anterior open reduction and SI joint plating were performed via an ilioinguinal approach. Definitive fixation, performed on day five, included percutaneous dual iliosacral screws for the Denis II fracture and bilateral retrograde pubic ramus screws, while the distal T-shaped sacral fracture was treated conservatively. The patient achieved stable fixation without implant failure, enabling early mobilization. At 12 months, radiographs demonstrated consolidation of the pelvic ring injuries with maintained alignment and no implant failure. She walked independently with an ankle-foot orthosis for persistent right foot drop, although residual L5-S1 motor weakness and altered reflexes persisted. Functional scores demonstrated marked recovery (Majeed 70/80; Iowa 85/100). This case highlights the importance of individualized, staged surgical strategies in managing complex pelvic fractures with combined rotational and vertical instability, especially in the presence of neurological injury and visceral trauma.
Surgical management of intermediate and malignant tumours in the pelvis is complex. Complications are frequent and either related to the surgery itself or to post-surgical failure of the reconstruction technique. This systematic review and meta-analysis aims at analyzing all reported complications following PI to PIII pelvic resections for intermediate and malignant tumours. Based on a systematic literature search on PubMed adhering to the PRISMA guidelines, 1,683 study records were identified, of which we included 90 original studies published until 22 July 2025. Overall complication rates were assessed with random-effects meta-analysis. Differences in complication rates between reconstruction types (i.e. megaprosthetic, mostly biological, none) were evaluated with meta regression analysis. Data on 2,199 patients (1,250 males (57%)) with mainly PI to PIII pelvic resections were analyzed. The most common reconstruction types were custom-made implants (21%; n = 451) and ice-cream cone prostheses (14%; n = 312). Pooled rates of infections, wound healing problems, nerve injuries, and deep vein thrombosis (DVT) amounted to 15% (95% CI 12% to 18%), 13% (95% CI 10% to 15%), 7% (95% CI 5% to 9%), and 4% (95% CI 2% to 6%), respectively. Further, pooled implant revision/removal and secondary external hemipelvectomy rates were 14% (95% CI 11% to 17%) and 4% (95% CI 3% to 5%). Mostly biological reconstructions were associated with higher rates of nerve injuries (p < 0.001), construct failures (p = 0.010), and secondary implant revision/removal (p = 0.003) compared to megaprosthetic reconstruction. Further, biological reconstructions were associated with increased secondary external hemipelvectomy rates compared to megaprosthetic reconstructions (p = 0.005) or no reconstructions (p = 0.001). Treatment of pelvic malignancies is challenging, with technically demanding resections and complex reconstructions. Across all reconstruction techniques following sacrum-sparing pelvic resections, infections and wound healing problems are the most common complications, yet there is also a considerable proportion of patients with neurovascular complications and DVTs.
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Hip fractures in the elderly constitute a severe public health problem. Its primary cause is a fall due to sarcopenia, sensory impairments, polypharmacy, or architectural barriers, among other factors. Prevention is based on correcting these factors, engaging in regular physical exercise, and maintaining adequate nutrition throughout life to acquire efficient muscle mass that declines as little as possible during old age and achieve peak bone mass, although bone mass will gradually decrease with age. This paper, in two parts (I. Basic Science and II. Interventions), analyzes prevention, with particular attention to sarcopenia, bone fragility, and socioeconomic status.
To characterize the prevalence and patterns of psychoactive substance use among fatal traffic crash victims across four Brazilian metropolitan areas and to identify the demographic and temporal factors independently associated with substance positivity. Cross-sectional study of 524 fatal traffic crash victims from Recife (n = 272), Curitiba (n = 96), Vitória (n = 93), and Belém (n = 63), March 2022-June 2024. Standardized blood toxicological screening for alcohol, cocaine (benzoylecgonine), benzodiazepines, amphetamines, and cannabis was performed at a single reference laboratory. Multivariable logistic regression identified independent predictors of alcohol and any substance positivity. Overall, 46.0% of victims tested positive for at least one substance. Alcohol was detected in 38.0%, with mean blood alcohol concentration (BAC) of 1.83 g/L (SD = 0.88); no significant difference across cities (p = 0.095). Cocaine or metabolites were detected in 9.9%, with uniform regional distribution (p = 0.392). Vitória showed markedly higher benzodiazepine positivity (9.7% vs. 1.0-4.4%; p = 0.019). Cannabis was not detected. Night time (OR = 2.45, 95%CI 1.63-3.67) and weekend crashes (OR = 2.05, 95%CI 1.38-3.04) were the strongest independent predictors of alcohol positivity. After adjustment, Vitória showed significantly higher odds of any substance positivity compared to Recife (OR = 1.73, 95%CI 1.01-2.98, p = 0.046). Psychoactive substances were involved in nearly half of fatal traffic crashes across four Brazilian cities. Temporal factors-night time and weekend crashes-were the primary independent predictors of substance involvement. Vitória's elevated benzodiazepine positivity persisted after adjustment, suggesting distinct regional prescribing patterns. These findings support temporally targeted enforcement strategies and region-specific pharmaceutical interventions.
The release of a pneumatic tourniquet during total knee arthroplasty (TKA) causes an abrupt increase in blood flow to the lower limb, which may result in transient haemodynamic instability. The aim of this study was to quantify the magnitude and duration of these changes in a real-world clinical setting. A multicentre retrospective observational study was conducted including 149 patients undergoing primary TKA under pneumatic tourniquet ischemia. Systolic (SBP), diastolic (DBP), and mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), and oxygen saturation (SpO2) were recorded at three time points: baseline (pre-release), 3 minutes (T3), and 6 minutes (T6) after tourniquet release. Statistical analysis was performed using repeated-measures ANOVA or the Friedman test, according to data distribution, with p < 0.05 considered statistically significant. Following tourniquet release, a significant immediate decrease in SBP and DBP was observed (p < 0.001), with mean reductions of 19.8% and 21.2%, respectively, at T3. HR showed a mild but significant increase (p = 0.012). SpO2 decreased slightly (p = 0.034) without clinical relevance. Transient arrhythmias were recorded in 8.7% of patients. At 6 minutes post-release, all parameters returned to baseline values. Tourniquet release during TKA is associated with transient haemodynamic changes and early recovery. These findings support the need for reinforced monitoring in patients classified as ASA III and/or with ischemia times longer than 85 minutes, and provide a rationale for future prospective studies incorporating advanced haemodynamic monitoring. Level of evidence Level III, retrospective study.
Achondroplasia is the most common skeletal dysplasia associated with disproportionate short stature, with an estimated prevalence of 4.6 per 100 000 births. It is caused by a pathogenic variant in the gene encoding fibroblast growth factor receptor 3 (FGFR3), which disrupts endochondral ossification of the growing skeleton. To provide an updated overview of the therapeutic approach to achondroplasia, including currently approved treatments and those under investigation. The approval of vosoritide in 2021 has brought a major shift in the management of these patients. Updated follow-up guidelines have been published, along with initial outcomes in treated patients, with the aim of determining not only the impact on growth and final height but also on associated comorbidities, such as foramen magnum stenosis, and body proportions. We also review other emerging therapeutic strategies currently under development. The availability of targeted therapies has modified the traditional approach to the management of achondroplasia, which makes ongoing updates on approved and investigational treatments essential.
Pediatric radial neck fractures, though rare, pose significant management challenges with several treatment options. Open reduction is typically used for more complex cases, where greater fracture severity may contribute to higher complication rates and poorer outcomes. This study aims to evaluate functional outcomes, complications, and risk factors in a large cohort of pediatric patients treated with open reduction, performed after unsuccessful closed reduction. A retrospective cohort study was conducted on 53 pediatric patients (mean age 8 years) with radial neck fractures (Judet 4) treated surgically with open reduction, performed after unsuccessful closed reduction, at a single institution between March 2014 and October 2024. Data on surgical delay, complications, and functional outcomes (Oxford Elbow Score) were collected. Statistical analyses included correlation tests, t-tests, and multivariate regression models to assess predictors of outcomes and complications. The mean Oxford Elbow Score was 96, indicating excellent functional outcomes. Complications occurred in 13.5% of patients, including heterotopic ossification (9.6%), posterior interosseous nerve injury (1.9%), and avascular necrosis (1.9%). Surgical delay was significantly longer in patients with complications (p = 0.038). Multivariate analysis revealed that complications were the most significant predictor of poorer functional outcomes (β = -17.12, p < 0.001), while the surgical delay did not significantly impact outcomes or complication rates. Open reduction, performed after unsuccessful closed reduction, for pediatric severe radial neck fractures yields excellent functional outcomes with a low complication rate. Complications, such as heterotopic ossifications, are the primary determinant of poor outcomes, whereas surgical delay and age do not significantly affect results. Level III - Retrospective cohort study.
Complications after open reduction and internal fixation (ORIF) of ankle fractures are not uncommon, negatively impacting the postoperative outcome. Tibiotalocalcaneal (TTC) arthrodesis has been shown to be a viable treatment option in these cases. The aim of this study was to describe the operative technique and the outcome of patients presenting failed osteosynthesis of the ankle joint managed with TTC using a retrograde femoral IM nail. This is a retrospective observational study of adult patients (18 years or older) operated on for failure in osteosynthesis of the ankle joint (malleolar or tibial pilon fractures) using a retrograde femoral nail to perform TTC arthrodesis, with a minimum follow-up of 24 months. Patient demographics, initial injury characterization, comorbidities, initial treatment, time from initial injury to TTC arthrodesis, time to union, secondary procedures, and complications were recorded. Patients were evaluated clinically and radiographically at 12 and 24 months using, respectively, a modified version of the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores and full-weight-bearing anteroposterior and lateral radiographs. During the study period, 17 patients were treated with TTC arthrodesis using a retrograde femoral nail. The initial injury was a pilon fracture in 4 patients and a malleolar ankle fracture in 13 patients. The time between the initial injury and TTC arthrodesis ranged from 8 to 52 months, with a mean of 14.7 months. Complete radiographic fusion of the tibiotalar joint occurred uneventfully in all patients, whereas in four (23.5%) cases, complete radiographic fusion of the subtalar joint was not observed, although these patients were considered to have a satisfactory outcome due to a functional, painless, and properly aligned hindfoot after TTC arthrodesis. The mean time to union was 8 months, with a range of 5 to 10 months. Secondary procedures were performed in 2 patients. Four patients experienced minor complications. There were no statistically significant differences between patients who sustained a tibial pilon fracture and a malleolar ankle fracture in all variables analysed. The modified AOFAS score at 24 months ranged from 64 to 94, with a mean of 81 points. The use of a femoral retrograde IM nail for TTC arthrodesis is a viable option for patients with sequelae of tibial pilon and ankle malleolar fractures due to fixation failure.
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Evidence suggests that posterior approaches may be superior to the anterior percutaneous approach in terms of reduction quality and functional outcomes. There is no consensus regarding the definition of the posteromedial approach and its modifications, which can cause confusion when evaluating outcomes. Several variables must be considered when choosing a surgical approach, with particular importance given to the morphology of the posterior malleolus fracture, the presence of a complex fibula fracture, and the presence of Tillaux-Chaput or Le Fort-Wagstaffe fractures. This article provides an overview of approaches to posterior malleolus fractures and presents recommendations for approach selection in specific clinical scenarios.
Major hand replantation at the carpometacarpal level is rare and technically demanding. We report the case of a 69-year-old right-hand-dominant man who sustained traumatic amputation of the right hand while cleaning a metal-cutting guillotine. On admission, he was hemodynamically stable, and physical examination showed complete amputation at the carpometacarpal level with exposed bone and tendons. Radiography confirmed the level of injury. The patient underwent urgent replantation under general anesthesia with Kirschner-wire fixation from the metacarpals to the carpus, arterial anastomosis of the ulnar artery and a radial arterial branch, repair of multiple flexor and extensor tendons, and neurorrhaphy of the median and ulnar nerves. Postoperatively, the replanted hand remained viable, with preserved distal perfusion. The patient developed acute anemia and multifactorial acute kidney injury with concern for ischemia-reperfusion injury, which improved with medical treatment and monitoring. At discharge, the wound was well approximated, distal filling was preserved in all digits, and limited but present motion and partial sensory recovery were noted. Follow-up demonstrated maintained perfusion, stable fixation, and no evidence of infection. This case underscores that carpometacarpal-level hand replantation can achieve successful limb salvage in selected patients when timely multidisciplinary microsurgical management is available.
The objective of the Continuous Update Project of the RICA Pathway (Enhanced Recovery After Surgery in Adults) is to maintain updated and consensual recommendations based on scientific evidence, facilitating their implementation and evaluation. The project was developed between November 2021 and October 2025, focusing on elective major surgery in adults. Evidence was evaluated using the GRADE methodology, with reviews in PubMed, Embase, and the Cochrane Library, including systematic reviews, meta-analyses, randomized clinical trials, consensus guidelines, and multicenter studies. The project was structured into a coordinating group, a consulting group, and various reviewing groups, and the recommendations were evaluated and accepted by consensus. 106 recommendations were approved, compared to 135 in the 2021 edition. 83% of these presented high or moderate evidence, and 76% had a strong grade of recommendation in favor. The recommendations were grouped into sets of measures ("bundles") to improve their applicability.
Lipoxin A4 (LXA4) is a specialized pro-resolving lipid mediator with reported antitumor and immunomodulatory activity, but its translation is limited by chemical lability and formulation constraints. Here, we evaluated free LXA4 ("Lipoxin") versus a Pluronic F-127 micellar nanoformulation ("Nanolipoxin") in a human osteosarcoma patient-derived xenograft (PDX) model and assessed In vivo biodistribution using 99mTc labeling. Nanolipoxin exhibited nanostructures with heterogeneous dimensions by SEM (mean length 65 nm; mean diameter 41 nm) and was stored at 2-8 °C to preserve stability. PDX-bearing NSG mice received intraperitoneal treatment (1 µg; n = 3/group) and were monitored for 15 days. Both Lipoxin and Nanolipoxin produced a modest inhibition of tumor growth versus saline, reaching statistical significance on day 9 (*P = 0.0319) and day 15 (**P = 0.0076), while no significant differences were detected between the two active treatments. No clinical toxicity was observed (clinical score 0; stable body weight). Serum biochemistry showed no ALT differences versus control and an AST decrease for both treatments; Nanolipoxin increased lipase relative to control (*P = 0.0334). Dynamic planar scintigraphy demonstrated preferential tumor retention of 99mTc-Nanolipoxin at 60 min (lesion 350.47 kBq), with moderate renal/hepatic uptake and low bladder signal. Collectively, these data support LXA4-based strategies in osteosarcoma and demonstrate that nanoformulation provides tumor-localizing behavior while maintaining an acceptable short-term tolerability profile in this PDX setting.