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ABSTRACT BACKGROUND: Congenital Anomalies of the Upper Limb (CAUL) are a group of structural or functional abnormalities that develop during intrauterine life and can lead to limb dysfunction. OBJECTIVES: To analyze the prevalence of congenital anomalies of the upper limbs in Brazil and assess maternal and neonatal variables. DESIGN AND SETTING: A cross-sectional, descriptive study was conducted on congenital upper limb malformations among live births across Brazil. METHODS: The study spanned from 2010 to 2019. Data were sourced from the Department of Informatics of the Unified Health System (DATASUS) and the Live Birth Information System (SINASC) portal. Analyses focused on the information reported in field 41 of the Live Birth Declaration Form entered into the computerized system. RESULTS: The most common anomaly in Brazil was supernumerary fingers, classified as ICD-Q69.0, affecting 11,708 children, with a prevalence of 4.02 per 10,000 live births. Mothers aged over 40 years had a 36% higher prevalence of having children with CAUL than mothers under 40 years old (OR = 1.36; 95% CI 1.19-1.56). Newborns weighing ≥ 2,499 g were 2.64 times more likely to have CAUL compared to those weighing ≥ 2,500 g (OR = 2.64; 95% CI 2.55-2.73). CONCLUSION: There was an observed increase in the reporting of CAUL cases over the decade studied. This trend serves as an alert for health agencies, as understanding the prevalence of CAUL and its associated factors is crucial for preventive medicine.

Abstract Objective To evaluate the efficacy of hypertonic saline infiltration as a sclerosing agent in the dorsal synovial cyst of the wrist. Method Patients of both genders, aged 18 years or older, with clinical and ultrasound diagnosis of synovial cyst, and without any previous treatment were selected. Case series in which 50 patients underwent aspiration of the contents of the cyst and infiltration of the hypertonic saline solution (2 ml sodium chloride solution 20% and 1 ml of lidocaine 2%). The patients were followed up for 24 weeks, when the parameters pain, strength, range of motion, function (quickDASH and Brief Michigan question), recurrence, and complications were evaluated. Results A total of 46 patients were evaluated for 24 weeks, 18 (39.1%) cysts evolved to resolution, and 28 (60.9%) presented recurrence. There was no statistically significant difference in the effect force or in the range of motion. There was no clinically significant difference in the scores of the questionnaires. The most frequent complications were pain and edema. Conclusion Infiltration with hypertonic saline solution for the treatment of dorsal synovial cyst of the wrist showed a recurrence rate of 60.9%.

ABSTRACT BACKGROUND: The diagnostic criteria for carpal tunnel syndrome (CTS) lack uniformity. Moreover, because CTS is a syndrome, there is no consensus as to which signs, symptoms, clinical and complementary tests are more reproducible and accurate for use in clinical research. This heterogeneity is reflected in clinical practice. Thus, establishing effective and comparable care protocols is difficult. OBJECTIVE: To identify the diagnostic criteria and outcome measures used in randomized clinical trials (RCTs) on CTS. DESING AND SETTING: Systematic review of randomized clinical trials carried out at the Federal University of São Paulo, São Paulo, Brazil. METHODS: We searched the Cochrane Library, PubMed, and Embase databases for RCTs with surgical intervention for CTS published between 2006 and 2019. Two investigators independently extracted relevant data on diagnosis and outcomes used in these studies. RESULTS: We identified 582 studies and 35 were systematically reviewed. The symptoms, paresthesia in the median nerve territory, nocturnal paresthesia, and special tests were the most widely used clinical diagnostic criteria. The most frequently assessed outcomes were symptoms of paresthesia in the median nerve territory and nocturnal paresthesia. CONCLUSION: The diagnostic criteria and outcome measures used in RCTs about CTS are heterogeneous, rendering comparison of studies difficult. Most studies use unstructured clinical criteria associated with ENMG for diagnosis. The Boston Questionnaire is the most frequently used main instrument to measure outcomes. REGISTRATION: PROSPERO (CRD42020150965- https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=150965).

ABSTRACT Objective: Heterotopic ossification is defined as the formation of trabecular bone in soft tissues. It is a common complication after surgical treatment of acetabular fractures. However, its prophylaxis and treatment are still controversial. The objective of this research is to evaluate the effectiveness of actions to prevent the development of heterotopic ossification after surgical correction of acetabular fractures. Methods: A systematic review was carried out with research in the databases PubMed/MEDLINE, Embase, LILACS and Cochrane until August 4, 2020, without restrictions on language and year of publication. Only randomized clinical studies carried out in humans without restrictions based on the dosage of treatments, use and duration of prophylaxis were included in this review. Results: Two studies compared the use of radiotherapy and indomethacin and three compared the use of indomethacin with a placebo or non-indomethacin group. The meta-analysis calculations did not indicate statistical differences between radiotherapy versus indomethacin (RR 1.45, IC 95% 0.97 to 2.17, p = 0,55) and indomethacin versus placebo or not indomethacin (RR 0.85, IC 95% 0.68 to 1.06, p = 0,59). Conclusion: There is insufficient evidence to affirm that the use of radiotherapy or indomethacin are effective to prevent the formation of heterotopic ossification after surgery for fractures of the acetabulum. In addition, the number of complications was higher in the indomethacin group when compared to placebo or no intervention. Level of Evidence I, Systematic Review.

ABSTRACT BACKGROUND: Carpal tunnel syndrome (CTS) is a common condition greatly affects patients’ quality of life and ability to work. Systematic reviews provide useful information for treatment and health decisions. OBJECTIVE: This study aimed to assess the methodological quality of previously published systematic reviews on the treatment of CTS. DESIGN AND SETTING: Overview of systematic reviews conducted at the Brazilian public higher education institution, São Paulo, Brazil METHODS: We searched the MEDLINE and Cochrane Library database for systematic reviews investigating the treatment of CTS in adults. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and measurement tool to assess systematic reviews (AMSTAR) were applied by two independent examiners. RESULTS: Fifty-five studies were included. Considering the stratification within the AMSTAR measurement tool, we found that more than 76% of the analyzed studies were “low” or “very low”. PRISMA scores were higher when meta-analysis was present (15.61 versus 10.40; P = 0.008), while AMSTAR scores were higher when studies performed meta-analysis (8.43 versus 5.59; P = 0.009) or when they included randomized controlled trials (7.95 versus 6.06; P = 0.043). The intra-observer correlation demonstrated perfect agreement (> 0.8), a Spearman’s correlation coefficient of 0.829, and an ICC of0.857. The inter-observer correlation indicated that AMSTAR was more reliable than PRISMA. CONCLUSION: Overall, systematic reviews of the treatment of CTS are of poor quality. Reviews with better-quality conducted meta-analysis and included randomized controlled trials. AMSTAR is a better tool than PRISMA because it has a better performance and should be recommended in future studies. REGISTRATION NUMBER IN PROSPERO: CRD42020172328 (https://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42020172328)

Introduction Subacromial injections are therapeutic options for rotator cuff injuries, with consistent results not well established yet for each drug applied. The objective of this systematic review and meta-analysis is to analyse the effectiveness of the substances used in subacromial injections for the treatment of rotator cuff injuries and shoulder impingement syndrome, considering the functional gain and pain improvement of the shoulder.Methods and analysis Beginning in November 2022, we will perform a detailed search using the MEDLINE/PubMed, EMBASE, Cochrane Central Register of Controlled Trials and LILACS databases. Relevant grey literature (reference lists, conference abstracts and academic papers) will also be included.Two reviewers will independently screen and extract the information from the literature. Bias and quality of the included studies will be evaluated using the risk of bias assessment tool provided by the Cochrane Collaboration. Statistical analyses will be performed using Review Manager V.5.4 software.Ethics and dissemination Approval and patient informed consent are not required because we will only include published literature. The results of this research will be disseminated in a peer-reviewed journal and likely through other scientific events.PROSPERO registration number CRD42020199292.

Abstract Objective The present study aimed to determine the frequency of trigger finger (TF) onset after surgery for carpal tunnel syndrome (CTS) using an open (OT) or an endoscopic technique (ET). As a secondary endpoint, the present study also compared paresthesia remission and residual pain rates in patients submitted to both techniques. Methods Trigger finger onset and remission rates of paresthesia and pain at the median nerve territory was verified prospectively in a series of adult patients submitted to an OT procedure (n = 34). These findings were compared with a retrospective cohort submitted to ET (n = 33) by the same surgical team. Patients were evaluated with a structured questionnaire in a return visit at least 6 months after surgery. Results Sixty-seven patients were evaluated. There was no difference regarding trigger finger onset (OT, 26.5% versus ET, 27.3%; p = 0.94) and pain (OT, 76.5% versus ET, 84.8%; p = 0.38). Patients submitted to OT had fewer paresthesia complaints compared with those operated using ET (OT, 5.9% versus ET, 24.2%; p = 0.03). Conclusions In our series, the surgical technique did not influence trigger finger onset and residual pain rates. Patients submitted to OT had less complaints of residual postoperative paresthesia.

Abstract Distal radial fractures are very common. Vicious consolidation can occur in up to one third of these fractures, resulting in wrist pain, restricted movement, and, eventually, physical limitation or disability. The treatment of this condition consists in corrective osteotomy, which requires careful preoperative planning due to its three-dimensional complexity, especially in injuries with joint involvement. Recently, prototyping based on three-dimensional (3D) reconstruction of computed tomography (CT) scans has been used for osteotomy planning in a 3D anatomical model. It allows a better understanding of the deformity in a realistic surgical approach, leading to safer, faster, and more predictable procedures. The aim of the present study is to present this technique and show its use in two clinical cases.

Abstract Background Lateral epicondylitis (LE), also known as tennis elbow, is the most common painful elbow condition. It affects approximately 1–3% of adults. There are various possible treatments described in the literature, but evidence to support a gold standard management protocol is lacking. Therefore, the objective of this study was to evaluate how Brazilian orthopaedists diagnose and treat lateral epicondylitis and compare these results with the available evidence. Methods This is an observational, analytical, cross-sectional study. A questionnaire was prepared to obtain information from the participants with eight specific questions (2 on diagnosis and 6 on treatment). These questions were answered voluntarily by participants at 3 major congresses of orthopaedists in Brazil in 2018. The results were analysed in accordance with the overall number of responses and were evaluated among groups according to subspecialty. Results We obtained a total of 501 questionnaires. Of these, 33 were excluded. The mean age was 38.67 years. The majority of respondents (91%) were male. We obtained 26.7% from specialists in hand surgery (Hand group), 36.5% from subspecialists in shoulder and elbow (Shoulder and Elbow group), and 36.8% from generalists in orthopaedics or from other subspecialties (General Orthopaedists group). For diagnosis, 24.4% did not initially request any imaging method. The most requested exam was ultrasonography (54.9%). The most prominent indication for initial treatment was physical therapy. For refractory cases, 78.3% of the respondents preferred doing a local infiltration. The most commonly used substance for local infiltrations was corticosteroids (89.6%). With respect to the surgical treatment option, 75.8% of those who recommend it prefer open techniques, and 24.2% prefer arthroscopic treatment. Of the total respondents, 12.8% did not recommend surgical treatment for LE. Conclusion Among Brazilian orthopaedists, the Cozen test is most frequently chosen, and ultrasound is the most commonly used imaging tool. Nonsurgically, oral nonsteroidal anti-inflammatory drugs (NSAIDs) plus physiotherapy is the most popular initial therapy, and corticosteroids are the most popular type of infiltration agent. Most surgeons recommended surgery after 6 months of nonsurgical treatment, and 75.8% preferred the open technique.

Abstract Objective The present paper aims to evaluate the therapeutic planning for trigger finger by Brazilian orthopedists. Methods This is a cross-sectional study with a population composed of participants from the 2018 Brazilian Congress on Orthopedics and Traumatology (CBOT-2018, in the Portuguese acronym), who answered a questionnaire about the conduct adopted for trigger finger diagnosis and treatment. Results A total of 243 participants were analyzed, with an average age of 37.46 years old; most participants were male (88%), with at least 1 year of experience (55.6%) and from Southeast Brazil (68.3%). Questionnaire analysis revealed a consensus on the following issues: diagnosis based on physical examination alone (73.3%), use of the Quinnell classification modified by Green (58.4%), initial nonsurgical treatment (91.4%), infiltration of steroids combined with an anesthetic agent (61.7%), nonsurgical treatment time ranging from 1 to 3 months (52.3%), surgical treatment using the open approach (84.4%), mainly the transverse open approach (51%), triggering recurrence as the main nonsurgical complication (58%), and open surgery success in > 90% of the cases (63%), with healing intercurrences (54%) as the main complication. There was no consensus on the remaining variables. Orthopedists with different practicing times disagree on treatment duration (p = 0.013) and on the complication rate of open surgery (p = 0.010). Conclusions Brazilian orthopedists prefer to diagnose trigger finger with physical examination alone, to classify it according to the Quinnell method modified by Green, to institute an initial nonsurgical treatment, to perform infiltrations with steroids and local anesthetic agents, to sustain the nonsurgical treatment for 1 to 3 months, and to perform the surgical treatment using a transverse open approach; in addition, they state that the main nonsurgical complication was triggering recurrence, and report open surgery success in > 90% of the cases, with healing intercurrences as the main complication.

Abstract Objective To describe the clinical and radiographic outcomes of patients submitted to percutaneous fixation without bone graft for scaphoid nonunion, with a minimum follow-up of six months. Methods A case series study of a convenience sample of hand surgeons with prospective evaluation. Patients with scaphoid (waist or proximal pole) nonunion and the following features were included: more than six months of history; X-rays showing sclerosis of the edges of the nonunion, with resorption of the nonunion focus measuring less than 4 mm (Slade & Gleissler I, II, III and IV) and no angular deformity; and no proximal pole necrosis on magnetic resonance imaging (MRI). Results After six months of follow-up, all nonunion were consolidated, with no major complications. The functional outcomes revealed good scores on the disabilities of the arm, shoulder and hand (DASH; n = 12; mean: 6.9; standard deviation [SD]: 2.1) and patient-rated wrist evaluation (PRWE; n = 12; mean: 7.97, SD: 1.5) questionnaires. The results of the visual analog scale (VAS) showed little residual pain (n = 12; mean: 0.71; SD: 0.2). Slight decreases in flexion (69 versus 59.1; p = 0.007), extension (62.4 versus 48.7; p = 0.001) and radial deviation (29.6 versus 24.6; p = 0.014) were detected in comparison to the contralateral side. Conclusions All cases in the series presented consolidation and good functional scores at the six-month evaluation. This is a promising option (with lower technical demand and morbidity) for the treatment of scaphoid nonunion. Comparative studies are required to assess the effectiveness of this technique in comparison with other options.

ABSTRACT BACKGROUND: There are several anesthetic techniques for surgical treatment of carpal tunnel syndrome (CTS). Results from this surgery using the “wide awake local anesthesia no tourniquet” (WALANT) technique have been described. However, there is no conclusive evidence regarding the effectiveness of the WALANT technique, compared with the usual techniques. OBJECTIVE: To evaluate the effectiveness of the WALANT technique, compared with intravenous regional anesthesia (IVRA; Bier’s block), for surgical treatment of CTS. DESIGN AND SETTING: Randomized clinical trial, conducted at Hospital Alvorada Moema and the Discipline of Hand Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil. METHODS: Seventy-eight patients were included. The primary outcome was measurement of perioperative pain through a visual analogue scale (VAS). The secondary outcomes were the Boston Questionnaire score, Hospital Anxiety and Depression Scale (HADS) score, need for use of analgesics, operating room times, remission of paresthesia, failures and complications. RESULTS: The WALANT technique (n = 40) proved to be superior to IVRA (n = 38), especially for controlling intraoperative pain (0.11 versus 3.7 cm; P < 0.001) and postoperative pain (0.6 versus 3.9 cm; P < 0.001). Patients spent more time in the operating room in the IVRA group (59.5 versus 46 minutes; P < 0.01) and needed to use more analgesics (10.8 versus 5.7 dipyrone tablets; P = 0.02). Five IVRA procedures failed (5 versus 0; P = 0.06). CONCLUSIONS: The WALANT technique is more effective than IVRA for CTS surgery.

Introduction Hip arthroplasties for the treatment of displaced femoral neck fractures in adults can be total replacement or hemiarthroplasty. Despite the high prevalence of these fractures and large number of studies on the topic, the best choice of arthroplasty to be used remains unclear. The present study aims to overview the results of systematic reviews of randomised controlled trials (RCTs) comparing outcomes between total hip replacement and hemiarthroplasty for displaced femoral neck fractures in adults.Methods and analysis Four electronic databases (Pubmed, Embase, Cochrane Library and Web of Science) and reference lists from previous reviews will be searched without language limitation. Eligible studies will be systematic reviews of RCT that compare total hip replacement and hemiarthroplasty for treatment of displaced femoral neck fractures in adults. Two reviewers will independently perform study selection, data extraction and quality assessment. Disagreements between reviewers will be resolved by a third reviewer. Comparisons of dichotomous data will report as the OR and 95% CI, and comparisons of functional and health-related quality of life outcomes are reported as the mean difference and 95% CI and as the risk difference, defined as the difference in the proportion achieving the minimum clinically important difference and 95% CI. As this overview will contribute to orthopaedic surgeons and health managers in better decision-making for the treatment of these fractures. The authors plan to complete the searches and analyses by 30 November 2021.Ethics and dissemination Ethical approval was obtained at Federal University of Sao Paulo. Findings will be disseminated through peer-reviewed publication.PROSPERO registration number CRD42021237885.

Introduction Fractures of the diaphysis of the clavicle are common; however, treatment guidelines for this condition are lacking. Surgery is associated with a lower risk of non-union and better functional outcomes but a higher risk of complications. Open reduction and internal fixation with plates and screws are the most commonly performed techniques, but they are associated with paraesthesia in the areas of incisions, extensive surgical exposure and high rates of implant removal. Minimally invasive techniques for treating these fractures have a lower rate of complications. The aim of this study is to evaluate which surgical treatment option (minimally invasive osteosynthesis or open reduction and internal fixation) has better prognosis in terms of complications and reoperations.Methods and analysis The study proposed is a multicentric, pragmatic, randomised, open-label, superiority clinical trial between minimally invasive osteosynthesis and open reduction and internal fixation for surgical treatment of patients with displaced fractures of the clavicle shaft. In the proposed study, 190 individuals with displaced midshaft clavicle fractures, who require surgery as treatment, will be randomised. The assessment will occur at 2, 6, 12, 24 and 48 weeks, respectively. The primary outcome of the study will be the number of complications and reoperations. For sample size calculation, a moderate effective size between the techniques was considered in a two-tailed test, with 95% confidence and 90% power. Complications include cases of infection, hypertrophic scarring, non-union, refracture, implant failure, hypoesthesia, skin irritation and shoulder pain. Reoperations are defined as the number of surgeries for pseudoarthrosis, implant failure, infection and elective removal of the implant.Ethics and dissemination Study approved by the institutional ethics committee (number 34249120.9.0000.5505—V.3). The results will be disseminated by publications in peer-reviewed journals and presentations in medical meetings.Trial registration number RBR-3czz68)/UTN U1111-1257-8953.

Purpose For displaced distal radius fracture, this trial aimed to compare an above-elbow (AE) and below-elbow (BE) cast at the end of a 24-week follow-up using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire as a primary outcome. Methods This is a clinical trial with parallel groups (1:1) and a blinded evaluator. There are two non-surgical interventions: AE and BE. A total of 128 adult patients with acute (up to 7 days) displaced distal radius fracture of type A2-3, C1-3 by the AO classification were included. The follow-up was 24 weeks. The primary outcome was the DASH questionnaire at 24 weeks. Secondary outcomes were the maintenance of reduction by the evaluation of radiographic parameters, pain measured by VAS, PRWE, objective functional evaluation and rate of adverse effects. Results The difference between the two groups in the DASH score at 24 weeks was not significant, with the mean (95% CI) DASH score being AE: 9.44 (2.70 to 16.17) vs. BE: 9.88 (3.19 to 16.57) (p = 0.895). The above-elbow group had a significantly greater worsening of the mean DASH score from baseline to 2 weeks (p < 0.001). No statistically significant differences were found between the 2 groups in any of the other follow-up assessments. Objective functional evaluation, PRWE, radiographical measures and rates of reduction loss were similar between groups. Above-elbow casting resulted in more adverse effects (mostly shoulder pain; 19 events vs. 9 events); RR = 0.39 (0.19–0.94); p = 0.033 at the end of six-month follow-up. Conclusions This study did not demonstrate a difference between above-elbow and below-elbow cast in terms of DASH outcome at 6 months in non-surgical treatment of deviated distal radius fractures. However, below-elbow casting is less debilitating during the treatment period, has comparable performance in maintaining the reduction, and is related to fewer minor adverse effects than above-elbow casting.

Introduction Anatomical total shoulder arthroplasty (TSA) is an effective treatment adopted for patients with glenohumeral osteoarthritis (OA). The glenoid component failure is the main risk that occurs in this therapeutic choice; however, doubts remain regarding the selection of the best implant for avoiding complication. This systematic review aims to evaluate the glenoid component in TSA by comparing the complications of different types of implants.Methods and analysis A systematic review of randomised clinical trials or quasi-randomised trials will be performed by applying the Preferred Reporting Items for Systematic Review and Meta-Analysis protocols and comparing polyethylene (keeled and pegged) versus metal-backed implants in adult patients with glenohumeral OA. Our search strategy will be performed using MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, EMBASE and Web of Science. Data management and extraction will be performed using a data withdrawal form and by analysing study method characteristics, participant characteristics, intervention characteristics, results and methodological domains. The database search will be performed by February 2021. The Grading of Recommendations Assessment, Development and Evaluation will be used for assessing the quality of evidence of each study selected; however, some critical and important outcomes were determined such as the shoulder function through functional scores (Constant-Murley and American Shoulder and Elbow Surgeons), complications represented by pain (Visual Analogue Scale), surgical revision, radiograph radiolucency and loosening. The confidence in estimated effects for these outcomes will be applied as the overall confidence. The outcomes will be defined as early or late, according to the postoperative follow-up of less than or greater than 1 year, respectively, for complications and radiographs. For the shoulder function, follow-ups will be divided into 6, 12 and 24 months. Heterogeneity is expected in systematic reviews; therefore, the selection of outcomes, as well as the sample size, and specific statistical analysis can lead to meta-analysis; however, if it fails, narrative evidence synthesis will be conducted. Other analyses such as descriptive, subgroup and sensitivity analyses will be performed whenever possible. This systematic review will, therefore, provide evidence concerning the best clinical practice for avoiding complications.Ethics and dissemination This study has been approved by the Institutional Review Board of Universidade Federal de São Paulo (protocols 0725/2017, 2.157.415 and 70473017.5.0000.5505), and the findings will be disseminated through peer-reviewed publication and conference presentations.PROSPERO registration number CRD42018079537.

ABSTRACT Objective: To verify if there is consensus about the treatment of each type of injury or amputation of the fingertips, and if there is a statistical difference among the treatment options according to the surgeon's length of time in the hand surgery specialty. Methods: A cross-sectional survey was conducted during the 37th Brazilian Congress of Hand Surgery, when one hundred and twenty questionnaires were randomly distributed. Observing the inclusion and exclusion criteria, ninety completed questionnaires were included. The answers were submitted to descriptive and inferential analysis with a significance level of p

ABSTRACT Objective To assess the applicability of randomized clinical trials and whether certain factors (surgeon experience/journal impact factor) influence their applicability. Methods In this survey study we used the Pubmed/Medline database to select 32 consecutive randomized clinical trials published between 2013 and 2015, involving hand surgery (high/low impact). These studies were independently assessed by 20 hand surgeons (with more or less than 10 years of practice) who answered 4 questions regarding their applicability. Agreement was assessed using Cohen’s kappa and comparison of proportions via chi-square statistics. P-value

Abstract Background The aim of this study was to evaluate the effectiveness of two diagnostic tests routinely used for diagnosing carpal tunnel syndrome (CTS)—ultrasonography (US) and nerve conduction studies (NCS)—by comparing their accuracy based on surgical results, with the remission of paresthesia as the reference standard. Methods We enrolled 115 patients, all of the female gender with a high probability of a clinical diagnosis of CTS. All patients underwent US and NCS for a diagnosis and subsequent surgical treatment. As a primary outcome, the accuracy of the US and NCS diagnoses was measured by comparing their diagnoses compared with those determined by the surgical outcomes. Their accuracy was secondarily evaluated based on before and after scores of the Boston Carpal Tunnel Questionnaire (BCTQ). Results Overall, 104 patients (90.4%) were diagnosed with CTS by the surgical reference standard, 97 (84.3%) by NCS, and 90 (78.3%) by US. The concordance of NCS and surgical treatment (p

Abstract Background A variety of cast options are available for the non-surgical treatment of distal radius fractures (DRF) in adults. However, the literature is inconclusive regarding the need to immobilize the elbow joint after reduction in order to prevent rotation of the forearm in order to maintain the reduction of DRF. This study aimed to evaluate the best method of immobilization between above-elbow (AE) and below-elbow (BE) cast groups at the end of six-month follow-up. Methods This is a randomized clinical trial with parallel groups and a blinded evaluator. There are two non-surgical interventions: AE and BE. Patients will be randomly assigned. A hundred twenty eight consecutive adult patients with acute (up to 7 days) displaced DRF of type A2, A3, C1, C2 or C3 by the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification will be included. The primary outcome will be the maintenance of reduction by evaluation of radiographic parameters and Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH). Secondary outcomes include function measured by Patient Rated Wrist Evaluation (PRWE), pain measured by the Visual Analogue Scale (VAS), objective functional evaluation (goniometry and dynamometry) and rate of complications. Evaluations will be performed at 1, 2, 3, 4, 6, 8, 12 and 24 weeks. For the Student’s t-test, a difference of 10 points in DASH score, with 95% confidence interval, a statistical power of 95%, and 20% sampling error. We consider an extra 10% for balancing follow up losses results in 64 patients per group. Discussion Results from this study protocol will help to define the need for elbow immobilization in maintenance of reduction, as well as functional performance of below elbow cast versus above elbow cast immobilization during the immobilization period. Trial registration NCT03126175 (http://clinicaltrials.gov). April 24, 2017.

ABSTRACT Objective: To evaluate tendencies in the planning, diagnosis, and treatment of carpal tunnel syndrome (CTS) by Brazilian hand surgery specialists. Methods: This cross-sectional study was performed at the 36th Brazilian Hand Surgery Congress. We prepared a questionnaire about preferences in the management of CTS, and board-certified hand surgeons that attended the congress were asked to fill out the questionnaires. A total of 174 questionnaires were analyzed. Results: Electromyography examination is used by most surgeons. Night splinting is the most commonly used conservative treatment option. Half of the surgeons utilized prophylactic antibiotics. Most of the interviewees conduct inpatient surgery in the operating room and prefer intravenous regional anesthesia. Most of surgeons use the standard open technique associated with proximal release of the antebrachial fascia and do not perform neurolysis. Compressive dressings are most commonly used for 7 days. Conclusion: The approach to CTS among Brazilian hand surgeons with regard to pre-, intra-, and post-operatory conduct is consistent with the international literature. However, there is a need to reflect and conduct new studies on non-surgical treatment involving local corticosteroid injection, use of prophylactic antibiotics, hospital admission, and type of anesthesia in order to provide more cost-effective approach to surgical treatment for CTS. Level of Evidence V; Expert opinion.

ABSTRACT Compressive syndromes of the radial nerve have different presentations. There is no consensus on diagnostic and therapeutic methods. The aim of this review is to summarize such methods. Eletronic searches related terms, held in databases (1980-2016): Pubmed (via Medline), Lilacs (via Scielo) and Google Scholar. Through pre-defined protocol, we identified relevant studies. We excluded case reports. Aspects of diagnosis and treatment were synthesized for analysis and tables. Quantitative analyzes were followed by their dispersion variables. Fourteen studies were included. All studies were considered as level IV evidence. Most studies consider aspects of clinical history and provocative maneuvers. There is no consensus on the use of electromyography, and methods are heterogeneous. Studies have shown that surgical treatment (muscle release and neurolysis) has variable success rate, ranging from 20 to 96.5%. Some studies applied self reported scores, though the heterogeneity of the population does not allow inferential analyzes on the subject. few complications reported. Most studies consider the diagnosis of compressive radial nerve syndromes essentially clinical. The most common treatment was combined muscle release and neurolysis, with heterogeneous results. There is a need for comparative studies . Level of Evidence III, Systematic Review.

BackgroundMany systematic reviews (SRs) have been published about the various treatments for distal radius fractures (DRF). The heterogeneity of SRs results may come from the misuse of SR methods, and literature overviews have demonstrated that SRs should be considered with caution as they may not always be synonymous with high-quality standards. Our objective is to evaluate the quality of published SRs on the treatment of DRF through these tools.MethodsThe methods utilized in this review were previously published in the PROSPERO database. We considered SRs of surgical and nonsurgical interventions for acute DRF in adults. A comprehensive search strategy was performed in the MEDLINE database (inception to May 2017) and we manually searched the grey literature for non-indexed research. Data were independently extracted by two authors. We assessed SR internal validity and reporting using AMSTAR (Assessing the Methodological Quality of Systematic Reviews and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyzes). Scores were calculated as the sum of reported items. We also extracted article characteristics and provided Spearman's correlation measurements.ResultsForty-one articles fulfilled the eligibility criteria. The mean score for PRISMA was 15.90 (CI 95%, 13.9-17.89) and AMSTAR was 6.48 (CI 95% 5.72-7.23). SRs that considered only RCTs had better AMSTAR [7.56 (2.1) vs. 5.62 (2.3); p = 0.014] and PRISMA scores [18.61 (5.22) vs. 13.93 (6.47), p = 0.027]. The presence of meta-analysis on the SRs altered PRISMA scores [19.17 (4.75) vs. 10.21 (4.51), p = 0.001] and AMSTAR scores [7.68 (1.9) vs. 4.39 (1.66), p = 0.001]. Journal impact factor or declaration of conflict of interest did not change PRISMA and AMSTAR scores. We found substantial inter observer agreement for PRISMA (0.82, 95% CI 0.62-0.94; p = 0.01) and AMSTAR (0.65, 95% CI 0.43-0.81; p = 0.01), and moderate correlation between PRISMA and AMSTAR scores (0.83, 95% CI 0.62-0.92; p = 0.01).ConclusionsDRF RCT-only SRs have better PRISMA and AMSTAR scores. These tools have substantial inter-observer agreement and moderate inter-tool correlation. We exposed the current research panorama and pointed out some factors that can contribute to improvements on the topic.

ABSTRACTOBJECTIVE: To evaluate the reproducibility of the AO/Asif classification for humeral shaft fractures. METHODS: Consecutive radiographs of the arm in both anteroposterior and lateral view from 60 patients with humeral shaft fractures were analyzed. Six observers who were familiar with the AO/Asif classification (three shoulder and elbow surgery specialists and three general orthopedists) were selected to make the analysis, which was done at three different times. The data were subjected to statistical analysis using the kappa coefficient. RESULTS: The intra and interobserver concordance was statistically significant in all the analyses. CONCLUSIONS: All the evaluators showed concordance between the three evaluations that was considered to be statistically significant. However, the highest values were found among the specialists.

ABSTRACT BACKGROUND: Hierarchy of evidence is an important measurement for assessing quality of literature. Information regarding quality of evidence within the Brazilian hand surgery setting is sparse, especially regarding whether research has improved in either quality or quantity. This study aimed to identify and classify hand surgery studies published in the two most important Brazilian orthopedics journals based on hierarchy of evidence, with comparisons with previously published data. DESIGN AND SETTING: Bibliometric analysis study performed in a federal university. METHODS: Two independent researchers conducted an electronic database search for hand surgery studies published between 2010 and 2016 in Acta Ortopédica Brasileira and Revista Brasileira de Ortopedia. Eligible studies were subsequently classified according to methodological design, based on the Haynes pyramid model (HP) and the JBJS/AAOS levels of evidence and grades of recommendations (LOR). Qualitative and quantitative data were gathered regarding all studies. Previous data were considered to assess whether the proportion of high-quality studies had improved over time (2000-2009 versus 2010-2016). RESULTS: The final analysis included 123 studies, mostly originating from the southeastern region (78.8%) and private institutions (65%), with self-funding (91.8%). Methodological assessment showed that 15.4% were classified as level I/II using HP and 16.4% using LOR. No significant difference in proportions of high-quality studies was found between the two periods of time assessed (5% versus 12%; P = 0.13). CONCLUSION: Approximately 15% of hand surgery studies published in two major Brazilian journals were likely to be classified as high-quality through two different systems. Moreover, no trend towards quality-of-evidence improvement was found over the last 15 years.

Clinical research is focused in generating evidence that is feasible to be applicable to practitioners. However, translating research-focused evidence into practice may be challenging and often misleading. This article aims is to pinpoint these challenges and suggest some methodological safeguards, taking platelet-rich plasma therapies and knee osteochondral injuries as examples. Studies and systematic reviews involving the following concepts will be investigated: clinically relevant outcomes, systematic errors on sample calculation, internal and external validity. Relevant studies on platelet-rich plasma for muscle-tendon lesions and updates on osteochondral lesions treatment were included in this analysis. Authors and clinicians should consider these concepts for the implementation and application of dissemination of the best evidence. Research results should be challenged by a weighted analysis of its methodological soundness and applicability. Level of Evidence V, Therapeutic Studies - Investigating the Results of Treatment.

In surgical interventions, randomization and blinding may be difficult to implement. In this situation, non-randomized prospective studies (EPNR) can generate the best evidence. The objective of this study is to evaluate, by means of the scale proposed by Downs & Black, the quality of EPNR published in our country and to assess the interobserver reproducibility of this scale. EPNR published in Acta Ortopedica Brasileira and Revista Brasileira de Ortopedia until 2011 and prior to 2006 were included. Two of us independently applied the Downs & Black scale. The studies were stratified by period of publication, journal and type of intervention. The scores obtained were considered to assess the reliability of the scale and groups comparison. 59 studies were considered, seven excluded during the assessments. There were no differences between the scores, except for the type of intervention, which showed better methodological quality for studies involving clinical interventions (p < 0.001). The correlation coefficient for the Downs & Black score was 0.79 (95% CI 0.65 to 0.88), demonstrating good reliability. EPNR present methodological quality similar when stratified by the periodic publication and publication period. Studies with clinical interventions have better methodological quality. The Downs & Black scale shows good interobserver reproducibility.Nas intervenções cirúrgicas, a randomização e o mascaramento podem ser de difícil aplicabilidade. Nessa situação, os estudos prospectivos e não randomizados (EPNR) podem gerar a melhor evidência disponível. O objetivo deste estudo é avaliar, por meio da escala proposta por Downs & Black, a qualidade dos EPNR publicados em nosso meio e avaliar a reprodutibilidade interobservadores dessa escala. EPNR publicados na Acta Ortopédica Brasileira e Revista Brasileira de Ortopedia até 2011 e anteriores a 2006 foram incluídos e aplicou-se a escala de Downs & Black - de forma independente por dois pesquisadores. Os estudos foram estratificados pelo período de publicação, periódico e tipo de intervenção. Os escores obtidos de Downs & Black foram considerados para a avaliação da reprodutibilidade da escala. Foram considerados 59 estudos, sendo sete excluídos durante as avaliações. Não houve diferenças entre os escores, exceto para o tipo de intervenção, que demonstrou melhor qualidade metodológica para os estudos que envolvem intervenções clínicas (p < 0,001). O índice de correlação intraclasse para o escores de Downs & Black foi de 0,79 (IC95% 0,65-0,88), demonstrando boa reprodutibilidade. EPNR apresentam qualidade metodológica semelhante quando estratificados pelo periódico de publicação e período de publicação. Estudos com intervenções clínicas apresentam melhor qualidade metodológica. A escala de Downs & Black apresenta boa reprodutibilidade interobservadores.

OBJECTIVES: To describe the new IDEAL method from classifying distal radius fractures. METHODS: IDEAL classification system is based on the most important literature evidences about clinical and radiographic characteristics that influence in the treatment and prognosis for patients that suffered from a distal radius fractures. In this method, we classify the fracture in patients first consultation, in which we collect demographical (age and trauma energy) and radiographic characteristics ( fracture deviation, articular fracture, and associated lesions). For each feature a score is attributed for grouping purposes. Group I - Stable fractures, good prognosis; Group II - potentially unstable fractures, commonly treated by surgical methods. Prognosis depends on surgeons' success after method choice. Group III - complex and instable fractures, poor outcome is expected. CONCLUSION: IDEAL classification staging rationale was presented, which is based on the best available evidence. The evidence of its scientific plausibility will be settled with the assessment of the classification reliability and its capacity to aid in therapeutical decisions and as a tool to predict prognosis. Further studies are under development to support these properties. OBJETIVOS: Descrição do método de Classificação IDEAL - para as fraturas da extremidade distal do rádio. MÉTODOS: O sistema de classificação IDEAL fundamenta-se nas principais evidências da literatura sobre fatores clínicos e radiográficos que influenciam o tratamento e prognóstico das fraturas do rádio distal. Classificamos as fraturas no atendimento inicial do paciente mediante a verificação de dois dados epidemiológicos e três dados radiográficos: Idade do paciente, energia do trauma, desvio dos fragmentos, incongruência articular e lesões associadas. RESULTADOS: Conforme a pontuação obtida, agrupamos os casos em três grupos: Grupo I - fraturas estáveis com bom prognóstico, Grupo II - fraturas potencialmente instáveis que normalmente exigem tratamento cirúrgico, e que o prognóstico depende do sucesso do tratamento adotado, Grupo III - fraturas instáveis e complexas, decorrentes de traumatismos de alta energia e cujo prognóstico é reservado independente do tratamento adotado. CONCLUSÃO: Apresentamos descrição e método de categorização deste sistema de classificação, alicerçados nas melhores evidências disponíveis. A comprovação de sua plausibilidade científica se estabelecerá com a análise de resultados de estudos clínicos que mensurem sua reprodutibilidade e capacidade de determinar o tratamento e inferir o prognóstico destas frequentes fraturas e encontram-se em desenvolvimento.

OBJETIVO: Avaliar se existe correlação entre parâmetros radiográficos da anatomia da região proximal do fêmur e a ocorrência de fraturas. MÉTODOS: Trezentas e cinco radiografias digitais da bacia foram analisadas na incidência ântero-posterior. Destas radiografias, vinte e sete apresentavam fratura do colo femoral ou transtrocantérica. Os parâmetros anatômicos analisados foram: Largura do colo femoral (LCF), comprimento do colo femoral (CCF), comprimento do eixo femoral (CEF), ângulo cérvico-diafisário (ACD), distância entre as lágrimas acetabulares (DLA) e a distância grande trocânter- sínfise púbica (DGTSP).Foram analisadas, comparativamente, as radiografias com e sem fratura da região proximal do fêmur, para verificar se existem parâmetros radiográficos que estão associados com maior probabilidade de ocorrência de fratura do colo femoral ou transtrocantérica. RESULTADOS: Não foi encontrada diferença entre os parâmetros anatômicos dos grupos com e sem fratura na região proximal do fêmur. CONCLUSÃO: Não foi encontrada nenhuma associação entre alterações anatômicas na região proximal do fêmur e maior susceptibilidade à ocorrência de fraturas. Nível de evidência IV, Estudo Transversal.OBJECTIVE: To evaluate the correlation between radiographic parameters of the proximal femur anatomy and fractures. METHODS: Three hundred and five digital x-rays of the pelvis were analyzed in the anteroposterior view. Of these x-rays, twenty-seven showed femoral neck or transtrochanteric fractures. The anatomical parameters analyzed were: femoral neck width (FNW), femoral neck length (FNL), femoral axis length (FAL), cervicodiaphyseal angle (CDA), acetabular tear-drop distance (ATD) and great trochanter-pubic symphysis distance (GTPSD). The analysis was performed by comparing the results of the x-rays with and without proximal femoral fracture, to establish a correlation between them. RESULTS: No differences were found between the anatomical parameters of the groups with and without proximal femoral fracture. CONCLUSION: There was no association between anatomical changes in the proximal femur and greater susceptibility to fractures. Level of evidence IV, Cross-sectional Study.

CONTEXT AND OBJECTIVE: Shoulder dislocation is the most common dislocation among the large joints. The aim here was to compare the effectiveness of reduction of acute anterior shoulder dislocation with or without articular anesthesia. DESIGN AND SETTING: Prospective randomized trial conducted in Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-Unifesp). METHODS: From March 2008 to December 2009, 42 patients with shoulder dislocation were recruited. Reductions using traction-countertraction for acute anterior shoulder dislocation with and without lidocaine articular anesthesia were compared. As the primary outcome, pain was assessed through application of a visual analogue scale before reduction, and one and five minutes after the reduction maneuver was performed. Complications were also assessed. RESULTS: Forty-two patients were included: 20 in the group without analgesia (control group) and 22 in the group that received intra-articular lidocaine injection. The group that received intra-articular lidocaine had a statistically greater decrease in pain over time than shown by the control group, both in the first minute (respectively: mean 2.1 (0 to 5.0), standard deviation, SD 1.3, versus mean 4.9 (2.0 to 7.0, SD 1.5; P < 0.001) and the fifth minute (respectively: mean 1.0; 0 to 3.0; SD = 1.0 versus mean 4.0; 1.0 to 6.0; SD = 1.4; P < 0.001). There was one failure in the control group. There were no other complications in either group. CONCLUSION: Reduction of anterior shoulder dislocation using intra-articular lidocaine injection is effective, since it is safe and diminishes the pain. CLINICAL TRIAL REGISTRATION: ISRCTN27127703.CONTEXTO E OBJETIVO: A luxação do ombro é a mais frequente luxação das grandes articulações. O objetivo foi comparar a efetividade da redução da luxação anterior aguda do ombro, com ou sem anestesia articular. TIPO DE ESTUDO E LOCAL: Ensaio clínico randomizado desenvolvido na Escola Paulista de Medicina - Universidade Federal de São Paulo (EPM-Unifesp). MÉTODOS: De março de 2008 a dezembro de 2009 foram recrutados 42 pacientes com luxação anterior do ombro agudas. Foi comparada a redução de tração e contra-tração com e sem anestesia intra-articular com lidocaína. Como desfecho primário, a dor foi avaliada por meio da escala visual analógica antes da redução e um e cinco minutos após a redução do ombro. Complicações também foram avaliadas. RESULTADOS: Foram incluídos 42 pacientes: 20 no grupo sem anestesia (grupo controle) e 22 no grupo que recebeu injeção intra-articular de lidocaína. O grupo que recebeu lidocaína intra-articular teve estatisticamente menos dor no primeiro (média = 2,1; 0 a 5,0, desvio padrão, DP, de 1,3, versus média = 4,9; 2,0 a 7,0; DP = 1,5; respectivamente; P < 0,001) e no quinto minutos (média = 1,0; 0 a 3,0; DP = 1,0 versus 4,0; 1,0 a 6,0; DP = 1,4; respectivamente; P < 0,001) após a redução em comparação ao grupo controle. Houve uma falha no grupo controle. Não houve complicações adicionais em ambos os grupos. CONCLUSÃO: A redução da luxação do ombro com o uso de lidocaína intra-articular é efetiva, pois é segura e proporciona menos dor. REGISTRO DE ENSAIO CLÍNICO: ISRCTN27127703

OBJETIVO: Avaliar a prevalência das lesões associadas à instabilidade anterior traumática do ombro e a relação entre o número de episódios e o tempo do início dos sintomas com a prevalência destas lesões. MÉTODO: Foram selecionados 57 pacientes com instabilidade anterior traumática do ombro, entre 18 e 40 anos, com mais de um episódio de luxação do ombro e com no mínimo, seis meses da primeira luxação, que necessitaram de cirurgia para tratamento da instabilidade. Foi realizada inspeção artroscópica em todos os pacientes para avaliação das lesões associadas. RESULTADOS: Foi avaliada a prevalência das lesões, sendo a lesão de Bankart a mais prevalente seguida pela lesão de Hill-Sachs e as lesões do manguito rotador as menos prevalentes. Não houve correlação comparando o número de episódios de luxação com a prevalência de lesões associadas. Já em relação ao tempo de sintomas, os pacientes com maior tempo de sintomas tiveram menos lesão de Hill-Sachs. CONCLUSÃO: Não foi possível afirmar que, em pacientes com instabilidade crônica do ombro, as lesões associadas aumentam com o tempo de sintomas ou com o número de episódios de luxação.OBJECTIVE: To evaluate the prevalence of lesions associated with traumatic anterior shoulder instability and the relationships between the prevalence of these lesions and the number of episodes and time since symptoms started. METHOD: Fifty-seven patients aged 18 to 40 years, with traumatic anterior shoulder instability, more than one episode of shoulder dislocation and at least six months since the first dislocation, who required surgery to treat the instability, were selected. Arthroscopic inspection was performed on all the patients to assess any associated lesions. RESULTS: The prevalence of lesions was assessed, and Bankert lesions were the most prevalent, followed by Hill-Sachs lesions, while rotator cuff injuries were the least prevalent. There was no correlation from comparison between the number of episodes of dislocation and the prevalence of associated lesions. On the other hand, in relation to the time since symptoms started, the patients who had had symptoms for longer times had fewer Hill-Sachs lesions. CONCLUSION: It was not possible to affirm that, in patients with chronic shoulder instability, the numbers of associated lesions increased with the time since symptoms started, or with the number of episodes of dislocation.

OBJECTIVE: The aim of this study was to analyze the effect of high-energy extracorporeal shockwave therapy on tendon angiogenesis in the patellar tendons of rabbits. We sought to investigate whether different voltage and number pulses modify the angiogenesis pattern. INTRODUCTION: High-energy extracorporeal shockwave therapy is an option in the treatment of orthopedic diseases such as chronic tendonitis. Despite its potential clinical applicability, there have been few studies on this technique that examine both its clinical effectiveness and its effect on angiogenesis. METHODS: High-energy extracorporeal shockwave therapy was applied at the tibial insertion of the left patellar ligament in 30 rabbits that were separated into six groups that differed in terms of the voltage and number of pulses that were applied by high-energy extracorporeal shockwave therapy. The tibial insertion in the right legs of the animals was used as the control. After six weeks, we performed histological analysis on the region and quantified the number of blood vessels. RESULTS: No significant differences in the number of blood vessels between the left and right patellar tendons were found within groups. Additionally, no significant differences in the number of blood vessels in the left patellar tendons were found between groups. CONCLUSIONS: The application of high-energy extracorporeal shockwave therapy did not cause a change in vascularization in the patellar tendon in rabbits.

OBJETIVO: Verificar se houve melhora da qualidade e quantidade dos ensaios clínicos randomizados (ECRs) publicados na literatura nacional, por meio da aplicação de escores estruturados e validados na literatura. MÉTODOS: Selecionamos, eletronicamente, todas as edições das duas revistas indexadas e de escopo ortopédico da literatura nacional - Acta Ortopédica Brasileira (AOB) e Revista Brasileira de Ortopedia (RBO), no período de 2000-2009, todos os ECRs publicados. Dois pesquisadores independentes identificaram e pontuaram os ECRs de acordo com as escalas de JADAD e do grupo de trauma musculoesquelético da Colaboração Cochrane. Os trabalhos selecionados foram agrupados: 1) pelo período de publicação 2000-2004 e 2004-2009; 2) periódico de publicação (AOB e RBO). RESULTADOS: Vinte e dois trabalhos foram selecionados, sendo10 da AOB e 12 da RBO. Não houve diferença entre o número proporcional (nECR/nTotal de trabalhos publicados) de ensaios clínicos randomizados publicados nos dois periódicos (p = 0,458), assim como para os escores de JADAD (p = 0,722) e da Colaboração Cochrane (p = 0,630). CONCLUSÃO: A qualidade e quantidade relativa de ensaios clínicos randomizados nos periódicos analisados foi semelhante. Há uma tendência de melhora da qualidade; contudo, não há acréscimo da quantidade de ensaios clínicos randomizados nos dois períodos analisados.OBJECTIVE: To assess whether there was an improvement in the quality and quantity of randomized controlled trials (RCTs) in nationally published journals through an application of standardized and validated scores. METHODS: We selected, electronically, for the period of 2000-2009, all RCTs published at the two indexed, orthopaedics-focused Brazilian journals: Acta Ortopédica Brasileira(AOB) and Revista Brasileira de Ortopedia (RBO). These RCTs were identified and scored by two independent researchers according to the JADAD scale and Cochrane Bone, Joint and Muscle Trauma Group score. The selected studies were grouped: 1) by publication period (2000-2004 and 2004-2009); 2) journal of publication (AOB and RBO). RESULTS: Twenty-two papers were selected, 10 from AOB and 12 from RBO. No statistically significant differences were found between the proportion (nRCT/nTotal of published papers) of RCTs published in the two journals (p=0.458), as well as for the JADAD score (p=0.722) and Cochrane score (p=0.630). CONCLUSION: The quality and quantity of randomized clinical trials in the period was similar in the journals analyzed. There is a trend of improvement of quality, yet there was no increase in the number of randomized clinical trials in both periods.

OBJETIVO: A entorse lateral aguda do tornozelo (ELAT) é uma afecção frequente cujo tratamento ainda não se encontra totalmente estabelecido. O objetivo do estudo foi verificar a conduta do médico ortopedista brasileiro (incluindo residentes) em relação ao diagnóstico, classificação, tratamento e complicações da entorse lateral aguda do tornozelo (ELAT). MÉTODOS: Um questionário de múltipla escolha foi elaborado com objetivo de abordar os principais aspectos do tratamento da ELAT. O questionário foi veiculado na página eletrônica oficial da Sociedade Brasileira de Ortopedia e Traumatologia, no período de 15 de junho a 1º de agosto de 2004. RESULTADOS: Foram incluídos para análise um total de 444 questionários. Os resultados demonstraram concordância da maioria dos entrevistados em relação aos seguintes aspectos: 90,8% utilizam alguma classificação para nortear o tratamento da entorse; 59% classificam a ELAT com segurança; 63,7% utilizam imobilização rígida nas lesões ligamentares completas; 60,6% utilizam medicação anti-inflamatória na ruptura ligamentar parcial; 75,9% relataram que a dor residual é a complicação mais frequente. Não houve consenso quanto ao método de imobilização da ELAT parcial visto que imobilização e tratamento funcional foram escolhidos com a mesma frequência (47%). Não houve diferenças significativas entre as respostas dos residentes e a dos ortopedistas (p = 0,81). CONCLUSÕES: Os ortopedistas e residentes em ortopedia do Brasil têm dificuldade em classificar a ELAT e não há consenso quanto à melhor opção para a ELAT parcial.OBJECTIVE: Acute lateral ankle sprain (ALAS) is one of the most common injuries, the treatment of which has yet to be firmly established. The purpose of this study was to determine the Brazilian Orthopaedic Surgeon's behavior in relation to diagnosis, classification, treatment and complications of the Acute Lateral Ankle Sprain. METHODS: A multiple choice questionnaire was developed which addressed the main aspects related to the treatmentof acute lateral ankle sprains (ALAS). The questionnaire was made available from June 15 to August 1, 2004, at the Official site of the Brazilian Society of Orthopedics and Traumatology. RESULTS: 444 questionnaires were included in the analysis. The results showed agreement among most of those interviewed in the following regards: 90.8% use some classification to guide treatment of the sprain; 59% classify the ankle sprain with certainty; 63.7% use the immobilization in cases of totally ruptured ligaments; 60.6% use anti-inflammatory medication in partial ligament ruptures; 75.9% reported that residual pain was the most frequent complication. There was no consensus regarding treatment of partial ALAS, as immobilization and functional treatment were chosen with the same frequency (47% each). There was no significant difference between the answers of residents and orthopedists. CONCLUSIONS: Orthopedic surgeons and orthopedic residents in Brazil have difficulty classifying ALAS and there is no consensus about the best therapeutic option for partial ALAS.

OBJETIVO: O objetivo do presente estudo transversal é verificar como o ortopedista brasileiro interpreta as lesões acromioclaviculares quanto aos critérios para a indicação do tratamento cirúrgico ou não, seus métodos preferidos, as complicações mais frequentes e os resultados obtidos. MÉTODOS: Durante o 6º Congresso Brasileiro de Cirurgia do Ombro e Cotovelo (CBOC) e o 38º Congresso Brasileiro de Ortopedia e Traumatologia (CBOT) foram distribuídos 507 questionários, sendo considerados 478 para análise. RESULTADOS: Em relação ao tratamento das LAC tipo I e II, a maioria dos entrevistados utilizam métodos não cirúrgicos. Em contraposição nas LAC IV, V e VI 475 (99,4%) dos entrevistados tratam essas lesões cirurgicamente. Nas LAC tipo III não existe uma definição na escolha do tratamento cirúrgico ou não cirúrgico para 386 (80,7%) entrevistados, sendo que o fator mais importante para tomada de decisão para a maioria dos entrevistados é a atividade esportiva do paciente e a idade. CONCLUSÃO: Nas LAC tipo III não há consenso, sendo o tratamento determinado conforme as características do paciente, contudo na literatura atual há uma tendência para o tratamento não cirúrgico destas lesões.The objective of the present transversal study is to check how Brazilian orthopedists treat these injuries, their criteria for choosing the treatment, results and complications. METHODS: During the 6th Brazilian Congress of Shoulder and Elbow Surgery (CBOC) and the 38th Brazilian Congress of Orthopaedics and Traumatology (CBOT) 507 questionnaires were distributed (148 CBOC and 359 CBOT), with 478 being considered for analysis. RESULTS: Regarding type-I and -II ACIs, most of the respondents use traditional non-surgical methods. On the other hand, for type-IV, V and VI injuries, 475 (99.4%) of the respondents indicate surgical methods. Concerning type-III injuries, there is no consensus in the selection between traditional and surgical treatment for 386 (80.7%) respondents, with the most important factor for selecting a given treatment method being the patient's level of sports practice and age. CONCLUSION: There is no consensus regarding type-III ACIs, and the selection of the best treatment method is made according to patient's individual characteristics. However, current literature shows a trend towards non-operative methods.

Realizou-se um estudo transversal no 36º Congresso Brasileiro de Ortopedia e Traumatologia, onde foi pesquisada a opinião de ortopedistas brasileiros sobre aspectos do tratamento de fraturas diafisárias do fêmur no adulto. Quinhentos e sete questionários foram respondidos integralmente e encontrou-se concordância entre os ortopedistas em relação aos seguintes aspectos: configuração do traço de fratura e lesão de partes moles ou de estruturas neurovasculares como parâmetros principais para decisão sobre o tratamento; classificação das fraturas, em que a AO foi a mais adotada; haste intramedular anterógrada bloqueada fresada para tratamento das fraturas transversas e oblíquas curtas no istmo; placa ponte para o tratamento das fraturas com traço complexo; tração esquelética pré-operatória; infecção como complicação mais freqüente e uso de heparina de baixo peso molecular no pós-operatório. Houve conflito de opiniões nas seguintes questões: uso de mesa de tração para realização de osteossíntese intramedular; intervalo de tempo entre o trauma e a cirurgia; tempo de utilização de antibióticos e tempo médio de hospitalização. Em relação à literatura, houve concordância em relação aos parâmetros principais para decisão sobre o tratamento; método de fixação das fraturas com traço simples no istmo; classificação adotada; profilaxia antitrombótica. Diferiram da literatura questões como o método de fixação das fraturas com traço complexo; tempo de utilização dos antibióticos, intervalo médio entre o trauma e a osteossíntese e tempo de internação.A cross-sectional study was performed during the 36th Brazilian Congress of Orthopaedics and Traumatology, where the opinions of Brazilian orthopaedic surgeons addressing the treatment of femoral diaphyseal fractures in adults were surveyed. Five hundred and seven questionnaires were fully completed and the results show agreement in the following topics: fracture trace configuration and injuries of soft parts or neurovascular structures as key parameters for determining treatment; fractures classification, in which AO was most frequently adopted; milled blocked anterograde intramedullary nail for treating cross-sectioned and short oblique factures at the isthmus; bridge plate for treating complex trace fractures; pre-operative skeletal traction; infection as the most frequent complication, and; postoperative low molecular weight heparin. There were opinion conflicts for the following topics: use of traction table for performing intramedullary osteosynthesis, time interval between trauma and surgery; time of antibiotics use, and; mean hospitalization time. Regarding literature, there was agreement concerning key parameters for determining treatment; fixation method for simple-traces fractures at the isthmus; adopted classification; antithrombotic prophylaxis. Issues such as fixation method for complex-traced fractures; time of antibiotics use; average interval between trauma and osteosynthesis, and; hospitalization time were different from literature.

Este estudo transversal foi realizado durante o 36º Congresso Brasileiro de Ortopedia e Traumatologia, para identificar a opinião do ortopedista brasileiro a respeito das preferências de tratamento das fraturas expostas da tíbia nos adultos. Foram respondidos 507 questionários, sendo que os resultados demonstram consenso em relação aos seguintes aspectos: classificação, 78,5% utilizam a de Gustilo-Anderson; indicação de tratamento cirúrgico, 76,3% preferem operar todos as fraturas; pressão de irrigação e produto utilizado, 80,3% utilizam irrigação manual e 85,4% solução salina; método de estabilização da fratura, fixador externo foi apontado em 52,1% das fraturas expostas tipo II, 74,4% nas IIIA, 88,6% nas IIIB e 89% nas IIIC; e indicação de fechamento primário, escolhido em 74,2% nas tipo I. Não houve consenso em relação ao tempo para cobertura de partes moles e tempo de uso de antibióticos. Os principais aspectos que discordaram da literatura foram: método de estabilização, tempo de uso de antibióticos e indicações de fechamento primário.This cross-sectional study was performed during the 36th Brazilian Congress of Orthopaedics and Traumatology, aiming to know the Brazilian orthopaedic surgeons’ opinion regarding the standards of care in cases of tibial diaphyseal open fractures in adults. Five hundred and seven questionnaires were considered and the results show agreement in the following topics: classification, 78.5% uses the Gustilo-Anderson; surgical treatment indication, with the majority (76.3%) preferring to operate all kinds of fracture with manual irrigation (80.3%) and saline solution (85.4%); stabilization method, predominantly the external fixator, with 52.1%, 74.4%, 88.6%, and 89.0% for types II, IIIA, IIIB, and IIIC, respectively, and; primary closure indication, chosen by 74.2% for the type I. There was no consensus regarding the timing of soft tissues reconstruction and the duration of antibiotics treatment. Surgeons’ opinions agreed with literature only for classification, surgical treatment indications, irrigation pressure, and indication for primary closure. The irrigation product, stabilization method and duration of antibiotics treatment differed from literature current evidences.

INTRODUCTION: Previous reviews have demonstrated that patient outcomes following orthopaedic surgery are strongly influenced by the presence of Workers' Compensation. However, the variability in the reviews' methodology may have inflated the estimated strength of this association. The main objective of this meta-analysis is to evaluate the influence of Workers' Compensation on the outcomes of orthopaedic surgical procedures. METHODS: We conducted a systematic search of the literature published in this area from 1992-2012, with no language restrictions. The following databases were used MEDLINE (Ovid), Embase (Ovid), CINAHL, Google Scholar, LILACS and Pubmed. We also hand-searched the reference sections of all selected papers. We included all prospective studies evaluating the effect of compensation status on outcomes in adult patients who had undergone surgery due to orthopaedic conditions or diseases. Outcomes of interest included disease specific, region specific and/or overall quality of life scales/questionnaires and surgeons' personal judgment of the results. We used an assessment tool to appraise the quality of all included studies. We used Review Manager to create forest plots to summarize study data and funnel plots for the assessment of publication bias. RESULTS: Twenty studies met our eligibility criteria. The overall risk ratio for experiencing an unsatisfactory result after orthopaedic surgery for patients with compensation compared to non-compensated patients is 2.08 (95% CI 1.54-2.82). A similar association was shown for continuous data extracted from the studies using assessment scales or questionnaires (Standard Mean Difference = -0.70 95% CI -0.97- -0.43). CONCLUSIONS: Among patients who undergo orthopaedic surgical procedures, those receiving Workers' Compensation experience a two-fold greater risk of a negative outcome. Our findings show a considerably lower estimate of risk compared to previous reviews that include retrospective data. Further research is warranted to determine the etiological explanation for the influence of compensation status on patient outcomes. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42012002121.

CONTEXT AND OBJECTIVE: Various classification systems have been proposed for fractures of the distal radius, but the reliability of these classifications is seldom addressed. For a fracture classification to be useful, it must provide prognostic significance, interobserver reliability and intraobserver reproducibility. The aim here was to evaluate the intraobserver and interobserver agreement of distal radius fracture classifications. DESIGN AND SETTING: This was a validation study on interobserver and intraobserver reliability. It was developed in the Department of Orthopedics and Traumatology, Universidade Federal de São Paulo - Escola Paulista de Medicina. METHOD: X-rays from 98 cases of displaced distal radius fracture were evaluated by five observers: one third-year orthopedic resident (R3), one sixth-year undergraduate medical student (UG6), one radiologist physician (XRP), one orthopedic trauma specialist (OT) and one orthopedic hand surgery specialist (OHS). The radiographs were classified on three different occasions (times T1, T2 and T3) using the Universal (Cooney), Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation (AO/ASIF), Frykman and Fernández classifications. The kappa coefficient (κ) was applied to assess the degree of agreement. RESULTS: Among the three occasions, the highest mean intraobserver k was observed in the Universal classification (0.61), followed by Fernández (0.59), Frykman (0.55) and AO/ASIF (0.49). The interobserver agreement was unsatisfactory in all classifications. The Fernández classification showed the best agreement (0.44) and the worst was the Frykman classification (0.26). CONCLUSION: The low agreement levels observed in this study suggest that there is still no classification method with high reproducibility.

CONTEXT AND OBJECTIVE: Total knee arthroplasty (TKA) has evolved particularly since the 1970s, with improvements in implants and surgical instruments, and has thus become an effective intervention for treating knee arthrosis. Many studies have presented rates of satisfactory clinical and radiological results greater than 90%, from follow-ups of over ten years. Nevertheless, despite scientific evidence showing the efficacy of TKA, the approaches taken present controversies in certain respects. The objective of this study was to evaluate how the Brazilian orthopedists deal with TKA, with investigation of the main aspects of this procedure. DESIGN AND SETTING: Cross-sectional survey conducted during the 39th Brazilian Congress of Orthopedics and Traumatology, in São Paulo, Brazil, in November 2007. METHODS: We applied a questionnaire to orthopedists registered at the congress. The questionnaire was randomly distributed and participation was voluntary; 858 completed questionnaires were included in the analysis. RESULTS: Most of the Brazilian orthopedists were members of SBOT and worked in the southeastern region. They used imported cemented implants through an anterior access route centered on the patella, with replacement of the joint surface of the patella and preservation of the posterior cruciate ligament. They did not have experience with simultaneous bilateral TKA. Postoperatively, they used antibiotics and suction drains for 48 hours. There was no consensus regarding prophylaxis for venous thromboembolism or the frequency of the main complications. CONCLUSION: The majority of Brazilian orthopedists work in the southeastern region of the country and agree about the main aspects of the approaches towards TKA.

CONTEXT AND OBJECTIVE: Although Colles' fracture is a common clinical situation for the orthopedist, we did not find any information in the literature that would allow safe decision-making on the best treatment for each fracture type. The aim of the present study was to investigate Brazilian orthopedists' opinions regarding the main aspects of treatments for Colles' fracture. DESIGN AND SETTING: Cross-sectional study conducted during the 34th Brazilian Congress of Orthopedics and Traumatology. METHODS: Five hundred questionnaires containing 12 items were randomly distributed to orthopedists who were attending the congress; 439 were filled out correctly and were considered in this study. RESULTS: The main factors in making decisions on interventions in fracture cases were whether the fracture was intra-articular, the existence of shortening of the distal radius and the patient's age. The classification method most used was Frykmann. The closed reduction method most used was manual reduction. The principal surgical interventions were percutaneous pinning (39%), external fixation (27%) and volar plate (19%). Most of the interviewees only used bone grafts for osseous gaps in special cases. The most frequent complications were impairment of joint mobility and residual pain. CONCLUSIONS: Brazilian orthopedists have concordant opinions regarding conservative treatment methods and the use of bone grafts. There were conflicting opinions regarding surgical treatment methods, classification types and complications.

CONTEXT AND OBJECTIVE: There is controversy regarding which imaging method is best for identifying early degenerative alterations in intervertebral discs. No correlations between such methods and histological finds are presented in the literature. The aim of this study was to correlate the thickness of intervertebral discs measured on simple radiographs with the degree of degeneration seen on magnetic resonance images and the histological findings relating to nerve ends inside the discs. DESIGN AND SETTING: Cross-sectional correlation study on the lumbar spines of human cadavers, at Universidade Federal de São Paulo (Unifesp), São Paulo, Brazil. METHODS: Ten lumbar spinal columns were extracted from human cadavers and subjected to magnetic resonance imaging and simple radiography. They were classified according to the degree of disc degeneration seen on magnetic resonance, and the thickness of the discs was measured on radiographs. The intervertebral discs were then extracted, embedded in paraffin and analyzed immunohistochemically with protein S100, and the nerve fibers were counted and classified. RESULTS: No correlation was observed between the thickness of the intervertebral discs and the degree of degeneration seen on magnetic resonance images. Only the uppermost lumbar discs (L1/L2 and L2/L3) presented a correlation between their thickness and type I and IV nerve endings. CONCLUSION: Reduced disc thickness is unrelated to increased presence of nerve ends in intervertebral discs, or to the degree of disc degeneration.

CONTEXT AND OBJECTIVE: There is no systematic assessment of the quality of scientific production in the specialty of hand surgery in our setting. This study aimed to systematically assess the status of evidence generation relating to hand surgery and to evaluate the reproducibility of the classification method based on an evidence pyramid. DESIGN AND SETTING: Secondary study conducted at Universidade Federal de São Paulo (Unifesp) and Faculdade Estadual de Medicina de Marília (Famema). METHODS: Two researchers independently conducted an electronic database search for hand surgery studies published between 2000 and 2009 in the two main Brazilian orthopedic journals (Acta Ortopédica Brasileira and Revista Brasileira de Ortopedia). The studies identified were subsequently classified according to methodological design (systematic review of the literature, randomized clinical trial, cohort study, case-control study, case series and other studies) and evidence level (I to V). RESULTS: A total of 1,150 articles were evaluated, and 83 (7.2%) were included in the final analysis. Studies with evidence level IV (case series) accounted for 41 (49%) of the published papers. Studies with evidence level V (other studies) accounted for 12 (14.5%) of the papers. Only two studies (2.4%) were ranked as level I or II. The inter-rater reproducibility was excellent (k = 0.94). CONCLUSIONS: Hand surgery articles corresponded to less than one tenth of Brazilian orthopedic production. Studies with evidence level IV were the commonest type. The reproducibility of the classification stratified by evidence level was almost perfect.

CONTEXT AND OBJECTIVE: Shoulder dislocation is the most common dislocation among the large joints. The aim here was to compare the effectiveness of reduction of acute anterior shoulder dislocation with or without articular anesthesia. DESIGN AND SETTING: Prospective randomized trial conducted in Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-Unifesp). METHODS: From March 2008 to December 2009, 42 patients with shoulder dislocation were recruited. Reductions using traction-countertraction for acute anterior shoulder dislocation with and without lidocaine articular anesthesia were compared. As the primary outcome, pain was assessed through application of a visual analogue scale before reduction, and one and five minutes after the reduction maneuver was performed. Complications were also assessed. RESULTS: Forty-two patients were included: 20 in the group without analgesia (control group) and 22 in the group that received intra-articular lidocaine injection. The group that received intra-articular lidocaine had a statistically greater decrease in pain over time than shown by the control group, both in the first minute (respectively: mean 2.1 (0 to 5.0), standard deviation, SD 1.3, versus mean 4.9 (2.0 to 7.0, SD 1.5; P < 0.001) and the fifth minute (respectively: mean 1.0; 0 to 3.0; SD = 1.0 versus mean 4.0; 1.0 to 6.0; SD = 1.4; P < 0.001). There was one failure in the control group. There were no other complications in either group. CONCLUSION: Reduction of anterior shoulder dislocation using intra-articular lidocaine injection is effective, since it is safe and diminishes the pain. CLINICAL TRIAL REGISTRATION: ISRCTN27127703.

Abstract Objective To define the major epidemiological features of upper limb penetrating injuries, as well as to identify the causes and the frequency of these lesions at the Instituto de Ortopedia e Traumatologia, a hand surgery center in the city of São Paulo, state of São Paulo, Brazil. Methods The present study was based on a sample of consecutive patients from our orthopedics and traumatology institute from May 2014 to May 2016. Data were collected by telephone, and a prestructured questionnaire regarding data and features of the lesions was applied. Descriptive statistics and proportions comparison with the chi-squared test were performed with a p-value < 5% considered as statistically significant. Results At first, 1,648 records were considered and, after applying the exclusion criteria and eliminating duplicate records, 598 records were included in the present study. Most of the patients weremale (77.8%), right-handed (95.82%), with an average age of 37.27 years old.Manual laborers were the most injured individuals (50.00%), and fingers were the most affected site (51.84%). Glass was the most frequent etiologic agent (33.77%). The prevalence of amputation was higher in industrial machinery injuries (p < 0.05) when compared with other causes. Younger patients (< 18 years old) had more glass-related injuries, while older patients ( 60 years old) had more traumas caused by power tools (p < 0.05). Women had more injuries resulting from razors and glass (p < 0.05). Manual laborers had a higher frequency of power tools and industrial machinery-related injuries (p < 0.05) and a higher prevalence of amputations (p < 0.05). Conclusion Themost frequent etiology was glass, especially in individuals < 18 years old.Women and older patients (> 60 years old) presented a high frequency of traumas caused by razors and power tools, respectively. More severe injuries were caused by machinery and were related with work activity.

OBJECTIVES: Machinery injuries account for a substantial share of traumatic upper limb injuries (TULIs) affecting young active individuals. This study is based on the hypothesis that there is an important relationship between the improper use of power saws and TULIs. The aim of the study is to assess the prevalence and epidemiology of TULIs caused by power saws and determine the risks related to power saw use. METHODS: A cross-sectional evaluation of medical records from a two-year period was performed. Patients sustaining TULIs related to power saws were analyzed. Data on the epidemiology, site of injury, mechanism of trauma, technical specifications of the tool, cutting material, personal protective equipment, time lost and return to work were obtained. RESULTS: A database search retrieved 193 TULI records, of which 104 were related to power saws. The majority of patients were male (102/104; 98.1%), right-handed (97/104; 93.3%), and manual workers (46/104; 44.2%), with an average age of 46.8 years. The thumb was the most frequently injured site (32/93; 34.4%). Most of the injuries were caused by manual saws (85/104; 81.7%), and masonry saws accounted for 68.2% (58/85) of the cases. Masonry saws improperly used for woodwork resulted in 86.2% (50/58) of the injuries. TULI caused by masonry saws was 5 times higher in manual workers than in other patients. In addition, masonry saws had a risk of kickback 15 times higher than that of other saws, and the risk of injury increased by 5.25 times when the saws were used improperly for wood cutting. CONCLUSIONS: The profile of TULIs related to power saws was demonstrated and was mainly associated with manual saws operated by manual workers that inappropriately used masonry saws for woodworking.