Túlio Vinícius de Oliveira Campos

This study was an investigation of the influence of using wool felt-based hospital bedding as a way of preventing the incidence of pressure injuries in patients with high risk of developing them. The influence of the number of wash cycles on lipid content, morphology, and mechanical performance of wool felt-based bedding was studied. A combined approach was adopted, including Soxhlet extraction for lipid content analysis, mechanical testing (traction, stretching, and tearing), scanning electron microscopy, and a randomized clinical evaluation in hospitalized patients with high risk. Chemical testing showed a decreasing trend in lipids with the number of washes, reaching a final value of 0.13%. Clinical results showed that the use of wool felt bedding generated a lower incidence of pressure injuries compared with conventional polyester-based bedding (4.2% vs. 12.6%; p = 0.04), along with good patient acceptance. Scanning electron microscopy showed that washing promotes the reorganization of fibers, changing from an initial compact structure to a more open and porous configuration. Mechanical tests indicated that the material presents greater elongation and adequate behavior under tension and rupture stresses, contributing to load redistribution. In the tensile and elongation tests, maximum tensile stress ranged from 4.11 to 6.13 MPa and elongation from 21.8% to 48.9% in the transverse direction; in the longitudinal direction, values ranged from 2.04 to 5.71 MPa and from 21.8% to 48.9%, respectively, for the unwashed condition and after nine wash cycles. In the tear resistance test, strain values ranged from 100% to 166% in the transverse direction and from 54% to 149% in the longitudinal direction, for the unwashed condition and after nine wash cycles, respectively. Analyses of chemical, structural, and mechanical properties suggest that wool felt provides better adaptability to the skin–material interface, reducing localized pressure concentrations. The lipid extraction test showed a trend of decreasing lipid content with the number of washes, reaching a final value of 0.13%; however, the increased porosity (increase in volume) of the material may contribute to greater water adsorption from the environment and consequent skin hydration. Mechanical tests showed that transverse elongation of 50% can contribute to a more efficient entanglement of fibers, resulting in a greater ability to withstand tensile loads. These findings highlight the potential of the material for hospital bedding applications, contributing to pressure injury prevention and improved patient comfort.

Purpose: Knee dislocations (KDs) can be limb‐threatening injuries that may require a temporising knee‐spanning external fixator (KSEF) for stabilisation. Precise indications for this commonly utilised invasive immobilisation technique remain controversial and poorly defined. The purpose of this study was to establish consensus‐driven indications for temporising KSEF use in the initial management of KDs. Methods: A working group of fellowship‐trained orthopaedic surgeons generated clinical scenarios reflecting commonly debated indications for temporising KSEF application. Utilising a modified Delphi technique, 23 surgeons from the International Knee Dislocation Study Group completed two anonymous online survey rounds. Consensus was defined a priori as ≥70% agreement or disagreement. Results: Response rates were 100% for Round 1 and 96% for Round 2. Four scenarios achieved unanimous consensus: (1) KD without post‐reduction instability (100% disagreement), (2) inability to maintain tibiofemoral reduction in the sagittal/coronal plane with non‐invasive knee immobilisation (NIKI) after initial reduction (i.e., redislocation/subluxation) (100% agreement), (3) tibial plateau fracture‐dislocation with post‐reduction subluxation (100% agreement), and (4) in bilateral closed KDs where one limb is indicated and the other is NOT, span ONLY the indicated limb (100% agreement). Two scenarios achieved strong positive consensus (90%–99.9% agreement): (1) morbid obesity (BMI ≥ 40) without NIKI of sufficient size (91.3% agreement), and (2) extensor mechanism injury with post‐reduction subluxation (91.3% agreement). Four and one additional scenarios achieved positive and negative consensus, respectively. Conclusions: This modified Delphi study established consensus‐driven indications for temporising KSEF application in the initial management of KDs, which advocate for more selective use than what is demonstrated in the literature. Level of Evidence: Level V.

Objectives: To evaluate, using ultrasonography and the AOFAS (The American Orthopaedic Foot and Ankle Society) score, changes in the peroneal tendons of patients with ankle fractures resulting from a supination-external rotation (SER) mechanism treated with either lateral or posterolateral plate fixation. Methods: This retrospective observational study was conducted at a tertiary level III trauma center. Adult patients (> 18 years) with unilateral SER ankle fractures, a minimum follow-up of 1 year, no persistent symptoms, and fixation using a 1/3 tubular 3.5-mm locking plate (lateral or posterolateral) were included. Exclusion criteria comprised bilateral injuries, Weber A/C fractures, pathological fractures, previous ankle disorders, infection, postoperative pain, or functional limitations. The primary outcomes were peroneal tendon thickness on ultrasonography and functional performance assessed using the AOFAS Ankle-Hindfoot Scale. Outcomes were compared between fixation techniques. Results: Seventy-six patients were included (65.8% aged 35–64 years, 60.5% women, 53.9% left-sided injuries). In most cases (71.1%), tendon thickness was greater on the operated side. Posterolateral plating demonstrated a higher frequency of positive tendon-thickness differences. Most differences measured 0–2 mm (56.6%), with a statistically significant difference between lateral and posterolateral fixation groups ( p < 0.001). AOFAS scores were high in both groups, indicating satisfactory postoperative functional outcomes. Conclusions: A difference in peroneal tendon thickness between the operated and contralateral sides was observed in 89.5% of patients, and these differences were significantly greater after posterolateral plating. Although plate position directly influenced postoperative tendon thickness, no clinically relevant consequences were identified. Level of evidence: Level III.

Objective: To evaluate the prevalence and microbiological profile of contamination in reusable tourniquets in Brazilian hospitals. Methods: A multicenter study conducted in six hospitals. Swabs were collected from 54 tourniquets immediately after surgical use and before disinfection, covering an estimated area of 10 cm². The samples were cultured and identified using automated methods. The microbial load was described by median and interquartile range (IQR), and comparisons between public and private hospitals were performed using Fisher's exact test and Mann-Whitney test. Results: The prevalence of contamination was 70.4% (38/54). The median overall microbial load was 101 CFU per device (IQR: 0–153), corresponding to approximately 10.1 CFU/cm². The predominant microorganisms were coagulase-negative Staphylococcus (48.1%) and Staphylococcus aureus (18.5%), with isolation of Pseudomonas aeruginosa, Bacillus sp., and Candida sp. The contamination rate was 78.6% in public hospitals and 61.5% in private hospitals (p=0.081), with no statistically significant difference in the median bacterial load between the institutions (p=0.412). Conclusion: There is a high prevalence of contamination by clinically relevant pathogens in reusable tourniquets, regardless of the type of hospital. The results indicate systemic failures in reprocessing and suggest the need for high-level disinfection protocols or the adoption of disposable sterile devices to mitigate the risk of cross-contamination. Level of evidence III; multicenter cross-sectional study of microbiological prevalence.

The tourniquet (TNQ) interrupts blood flow to a given anatomical segment and has critical applications in orthopedic surgeries by providing a blood-free operating field. The risks and complications attributed to its use are increased pain, reperfusion injury, edema, deep venous thrombosis, and peripheral nerve injury. The main recommendations for TNQ use and to reduce the occurrence of complications include adequate limb padding; TNQ inflation to pressures of 50 mmHg and 100 mmHg above the perfusion pressure for the upper and lower limbs respectively; avoid TNQ use in children and patients with cachexia, lupus, and coagulopathy; avoid keeping the device inflated for more than 2 hours; and have a trained team alert to deflation, which is characterized by the possibility of bleeding, pulmonary embolism, and myonephropathic metabolic syndrome. The present update article summarizes the best evidence on TNQ use in orthopedic surgeries and proposes a protocol for its safe use.

Resumo: O torniquete (TNQ) interrompe o fluxo sanguíneo para um determinado segmento anatômico e tem aplicação importante nas cirurgias ortopédicas ao proporcionar um campo operatório limpo de sangue. Os riscos e complicações atribuídos ao seu uso são aumento da dor, lesão por reperfusão, edema, trombose venosa profunda e lesão de nervos periféricos. As principais recomendações para se utilizar o TNQ e diminuir a ocorrência de complicações são: acolchoar adequadamente o membro; insuflar o torniquete até pressão 50 mmHg acima da pressão de perfusão para os membros superiores e 100 mmHg para os membros inferiores; evitar o uso em pacientes com caquexia, crianças, portadores de lúpus e coagulopatia; evitar manter o dispositivo insuflado por período superior a 2 horas; e ter equipe treinada e atenta para a desinsuflação, caracterizada pela possibilidade de sangramento, embolia pulmonar e síndrome metabólica mionefropática. Este artigo de atualização resume a melhor evidência acerca do emprego do TNQ nas cirurgias ortopédicas e propõe um protocolo para sua utilização segura.

Purpose Patients with indication for medial UKA may present with some degree of patellofemoral joint degeneration. The main purpose of this study was to identify the impact of patellofemoral osteoarthritis (PFOA) on the clinical outcomes of medial fixed-bearing UKA. Methods A retrospective cohort study evaluating the clinical outcomes of medial UKA in patients with isolated medial OA, with or without patellofemoral involvement. Data collected included demographic information, pain analog scale scores, range of motion (ROM), KOOS and Oxford Knee Score, and knee radiographs. Results The statistical analysis included 112 patients. The average follow-up was 34.1 months. One patient in the non-PFOA group presented with deep vein thrombosis. No difference was found between groups regarding PROMs, OKS, Pain or KOOS. Postoperative range of motion values in Groups A and B were, respectively, 114.5 ± 2.4 and 112.5 ± 3.6 (p = 0.39). Postoperative Oxford Knee Scale in Groups A and B were, respectively, 40.2 ± 2.0 and 40.5 ± 2.5 (p = 0.86). Pain scale reduction in Groups A and B were, respectively, 5 ± 2.1 and 5.0 ± 2.6 (p = 0.17). Postoperative KOSS values in Groups A and B were, respectively, 80.6 ± 2.5 and 82.5 ± 3.0 (p = 0.45). Conclusion UKA is a good option for medial isolated tibiofemoral osteoarthritis in patients without PFOA (Iwano’s Grade 1) or with asymptomatic PFOA (Iwano’s Grade 2 and 3). Improvements in pain, Oxford Knee Score and KOOS were observed without differences between groups.

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

Background: High-energy traumatic fractures represent a challenge for orthopaedic surgeons because there are a great variety of morphologic patterns and associated injuries ¹ . Although the incidence is higher in developing countries, these fractures pose a major financial burden all over the world because of their considerable hospital length of stay, time away from work, rate of failure to return to work, complications, and cost of treatment ^2–4 . Since the fracture patterns are so variable, some cases may have a lack of available specific osteosynthesis implants, despite recent advancements in implant engineering ⁵ . However, experienced surgeons are capable of using their knowledge and creativity to treat challenging lesions with use of preexisting plates while following the principles of fracture fixation and without compromising outcomes. In 2012, Hohman et al. described for the first time the use of a calcaneal plate to treat distal femoral fractures ⁶ . In 2020, Pires et al. further expanded the indications for use of a calcaneal plate ⁵ . This technical trick is widely utilized in our trauma center, especially in comminuted fractures around the knee. The present video article provides a stepwise description of the off-label use of a calcaneal plate in a medial distal femoral fracture. Description: The key principles of this procedure involve following common fundamentals during open reduction and internal fixation, approaching the fracture, preserving soft-tissue attachments of the comminution, and reducing the main fragments. Afterwards, the off-label use of a calcaneal plate adds the special feature of being able to contain fracture fragments with plate contouring. If necessary and if osseous morphology allows, bone grafting through the plate may also be performed. Alternatives: Multiple fixation implants can be utilized in medial distal femoral fractures. Surgeon-contoured plates (i.e., locking compression plates or low-contact dynamic compression plates), multiple mini-fragment plates, cortical screws alone, cannulated cancellous screws alone, or proximal humeral plates are among the alternatives ^5–9 . However, the lack of specific implants for fixation of fractures involving the medial femoral condyle is notable, even in developed countries ¹⁰ . Rationale: The small-fragment calcaneal plate is a widely available and cheaper implant compared with locking compression plates, which is especially important in developing countries. Additionally, this plate has a lower profile, covers a greater surface area, and allows multiple screws in different planes and directions. The use of this plate represents a great technical trick for surgeons to contain comminution. Expected Outcomes: Patient education regarding fracture severity is mandatory, and it is important to highlight that there is no current gold standard to treat these fractures because of the wide variability of morphological patterns. To our knowledge, all studies reporting the use of a calcaneal plate to treat these fractures have shown promising results, including good functional outcomes and 100% fracture healing with no cases of nonunion, infection, or implant failure ^5,6,10–14 . In the largest case series to date, Shekar et al. performed an interventional prospective study of 30 patients undergoing calcaneal plating for distal femoral unicondylar fractures ¹⁴ . They reported a mean range of motion of 108° ± 28.27° at 6 months, with excellent or satisfactory results in 80% of patients as measured with use of the Neer scoring system ¹⁴ . Important Tips: Preserve the blood supply by performing minimal soft-tissue dissection. Do not detach comminuted fragments from the soft tissues, which will help fracture reduction. Reduce the main fragments anatomically and fix as necessary. Contain the comminution using the spanning property and large covering area of the calcaneal plate. Perform bone grafting through the plate as necessary.

Introdução: A entorse de tornozelo é uma lesão comum na população geral e, principalmente, em atletas. O diagnóstico e tratamento adequados permitem o retorno precoce às atividades habituais, evitando recorrência, instabilidade crônica e artrose pós-traumática. O objetivo deste trabalho é avaliar a abordagem diagnóstica e terapêutica desta lesão por ortopedistas do estado de Minas Gerais. Métodos: Esse trabalho foi conduzido pela Comissão Científica da Sociedade Brasileira de Ortopedia e Traumatologia-SBOT/MG em 2023. Foi criado um questionário na plataforma Google Forms com perguntas sobre a abordagem não cirúrgica da entorse de tornozelo. Esse questionário foi distribuído por e-mail e WhatsApp aos membros titulares da SBOT de Minas Gerais. Resultados: 116 ortopedistas responderam ao questionário, sendo 27,6% especialistas em pé e tornozelo. A maioria trabalha em Belo Horizonte e realiza entre 10 e 30 atendimentos relacionados à entorse de tornozelo por mês. A maior parte dos profissionais solicita radiografias e prescreve anti-inflamatórios. A maior divergência de respostas ocorreu quanto ao uso de imobilização. O encaminhamento para tratamento fisioterapêutico variou com o grau da lesão. Discussão: Os dados coletados apontam que a abordagem inicial nas entorses de tornozelo é heterogênea, porém a maioria utiliza protocolos de reabilitação convencionais, apesar da abordagem funcional ser preconizada pela literatura científica. Conclusão: Em Minas Gerais, o protocolo convencional de imobilização e reabilitação é utilizado com maior frequência.