Orientador: William Dias Belangero / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-19T13:05:04Z (GMT). No. of bitstreams: 1 Sawaia_RogerioNaim_D.pdf: 9806060 bytes, checksum: d75ddfca6472ebb85dbfad46a0daa1a4 (MD5) Previous issue date: 2011 / Resumo: INTRODUÇÃO: O tratamento cirúrgico das fraturas intertrocanterianas do fêmur ainda é motivo de estudo e controvérsias. As vantagens da utilização de técnicas minimamente invasivas para essas fraturas já despontam na literatura. O objetivo deste estudo foi avaliar as complicações da técnica minimamente invasiva que utiliza um implante e um instrumental desenvolvidos especificamente (Sistema Minus) para o tratamento dessas fraturas. CASUÍSTICA E MÉTODO: Foram estudados 172 pacientes com fratura intertrocanteriana do fêmur, tratados com o Sistema Minus, dos quais 52 pacientes foram excluídos do estudo por não terem preenchido os critérios de inclusão. No protocolo inicial foram registrados o gênero, a idade, detalhes operatórios como tempo cirúrgico, tempo de uso da fluoroscopia, qualidade da redução e da fixação da fratura. Como parâmetros clínicos foram incluídos a capacidade de marcha, dor, classificação da fratura segundo os critérios de Tronzo e o risco anestésico segundo a classificação de ASA. Dividimos as complicações em dois grupos. As complicações gerais, subdivididas em infecção e mortalidade e as complicações específicas, subdivididas em migração do implante, a perda da redução e a falta de união. Embora a migração do pino deslizante não seja considerada na literatura como uma complicação do DHS (Hrubna e Skotak, 2010)1, no presente estudo ela foi incluída. Cabendo salientar que foi considerada como migração, a impacção lateral da fratura sem a ocorrência de perda de redução. RESULTADOS: O gênero feminino ocorreu em 93 casos e obteve percentual de 77,5%, foi prevalente em relação ao masculino com 27 casos e 22,5%. A idade variou de 52 a 95 anos, com a média de 80,06 anos e desvio padrão de 7,87 anos. A média de idade do gênero masculino foi de 76,19 anos e desvio padrão de 8,321. O gênero feminino obteve a média de 81,18 anos com desvio padrão de 7,407. O tempo cirúrgico médio foi de 39,35 minutos, variando de 25 a 65 minutos. O tempo médio de radioscopia foi 1min7s, variando de 0,6 a 2 minutos e 3s. A redução foi considerada adequada em 92 casos (76,6%), quando obteve-se o alinhamento do eixo de carga, como valgo em 20 casos (16,6%) e como varo em oito casos (6,6%). O somatório médio do TAD (Tip Apex Distance) na incidência Ântero-posterior (AP) foi de 1,19cm, variando de 0,2 a 2,8cm; e no Perfil (P), de 1,14cm, variando de 0,3 a 2,52cm. Dos pacientes, 112 (93,3%) voltaram a andar e a dor pós-operatória em uma escala de 0 a 10, teve a média de 4,44. Dos 120 pacientes, 11 foram classificados como Tronzo I (9,1%), 24 como Tronzo II (20%), 58 como Tronzo III (48,3%), sete Tronzo III variante (5,8%) e 20 Tronzo IV (16,7%). As fraturas instáveis ocorreram em 85 (70,8%) pacientes, os quais 74 (61,6%) tinham idade superior a 75 anos. Já as fraturas estáveis em 35 (29,1%) pacientes, os quais 17 (14,1%) possuíam idade superior a 75 anos. Em relação ao risco anestésico, oito (6,6%) foram classificados como ASA I, 33 (27,5%) ASA II, 74 (61,6%) ASA III e cinco ASA IV (4,16%). Houve um caso de infecção (0,83%). Ocorreram 13 óbitos (10,8%) dentro do primeiro ano de pós-operatório. Desses, um (0,83%) foi classificado como Asa II, cinco (4,16%) como Asa III e sete (5,83%) Asa IV. Dos 85 pacientes com fraturas instáveis, 36 (30%) apresentaram complicações, como perda de redução em 7(5,88%) e migração do pino deslizante em 29 (24,1%). No grupo das 35 fraturas estáveis, as complicações ocorreram em 4 casos (3,33 %), sendo que a perda de redução ocorreu em um caso (0,83%) e a migração em 3 casos (2,5%). No total, a migração ocorreu em 33 casos (27,6%), sendo que desses, todos evoluíram para consolidação. A perda de redução ocorreu em oito (6,7%) e a falta de união, em um caso (0,83%). CONCLUSÃO: Concluímos que a técnica minimamente invasiva, Sistema Minus, é uma técnica segura, que permite a realização da cirurgia com baixa incidência de complicações, quando comparada aos demais métodos existentes / Abstract: INTRODUCTION: The surgical treatment of intertrochanteric fractures is still controversial, resulting in further studies. Many papers have appeared in reference to the advantages of minimal invasive procedures for these fractures. The aim of this study was to evaluate the complications of a minimal invasive procedure using a specific implant and instruments developed for the treatment of intertrochanteric fractures (Minus System). MATERIAL AND METHOD: One hundred and seventy two patients with intertrochanteric fractures of the femur were studied, and submitted to treatment with the Minus System. Fifty two patients were excluded from the study as they did not fulfil all criteria for inclusion. The initial protocol registered gender, age, operative details such as length of operation, length of fluoroscopy use, quality of reduction and fixation of the fracture. The clinical parameters considered included deambulatory ability, pain, Tronzo fracture classification and anesthesia risk according to ASA classification. Complications were divided into two groups: general complications (infection and mortality rate) and specific complications (implant migration, loss of reduction and non-union). Although the migration of a sliding nail has not been considered in the literature as a DHS complication (Hrubna e Skotak, 2010)1 RESULTS: There were 93 feminine cases (77.5%) prevailing on 27 masculine cases (22.5%). Age span was 52 to 95 years, with an average of 80.06 years (standard deviation of 7.87 years). The average age for men was 76.19 years with a standard deviation of 8.321. The average age for women was 81.18 years with a standard deviation of 7.407. The average operative length of time was 39.35 minutes (25 to 65 minutes). The average time of fluoroscopy was 1min 7sec (0.6 to 2min 3sec). Fracture reduction was considered adequate in 92 cases (76.6%), , in the present study it was taken into account. It is important to mention that migration here is the lateral impaction of the fracture without loss of reduction. when alignment with weight-bearing axis was obtained, valgus in 20 cases (16.6%) and varus in eight cases (6.6%). The average Tip Apex Distance (TAD) on an anteroposterior view was 1.19cm (variation of 0.2 to 2.52 cm) and lateral view was 1.14cm (variaton of 0.3 to 2.52cm). One hundred and twelve patients (93,3%) were able to walk with postoperative pain (average of 4.4 on a pain scale of 0 to 10). The classification of the 120 patients is as follows: 11 patients with Tronzo I (9,1%), 24 cases of Tronzo II (20%), 58 Tronzo III (48.3%), seven Tronzo III variant (5.8%) and 20 Tronzo IV (16.7%). Unstable fractures occured in 85 (70.8%) patients, and 74 (61.6%) were over 75 years of age. There were 35 stable fractures (29.1%), with 17 patients (14.1%) over 75 years of age. As to the anesthesia risk eight (6.6%) were classified as ASA I, 33 (27.5%) ASA II, 74 (61.6%) ASA III and five patients as ASA IV (4.16%). There was one case of infection (0.83%). During the first postoperative year there were 13 deaths (10.8%). Of these, one patient (0.83%) had been classified as ASA II, five (4.16%) as ASA III and seven (5.83%) as ASA IV. There were 36 patients (30%) with complications out of 85 patients with unstable fractures, with loss of reduction in seven (5.88%) and migration of the sliding nail in 29 (24.1%). In the group of 35 stable fractures there were complications in four cases (3.3 %), with loss of reduction in one case (0.83%) and migration in three (2.5%). The total number of migrations was 33 (27.5%), but resulted in union in all patients. The loss in reduction occurred in eight patients (6.7%) and non-union in one case (0.83%). CONCLUSION: The minimal invasive procedure, the Minus System, is a safe procedure, that provides adequate surgery with a low incidence of complications, when compared to other existing techniques / Doutorado / Fisiopatologia Cirúrgica / Doutor em Ciências

Hip fracture has increased in the last decades and has been considered one of the major causes of mortality and morbidity in elderly people. In most cases is an event with catastrophic consequences to elderly life with impairment in your physical, psychical and social welfare. Is often responsible for the permanent institutionalization of the elderly. Epidemiologic studies contribute to specify certain orthopedic and traumatologic injuries and it helps in the treatment and prevention of these injuries. These actions are essential to health promotion. In Latin America, there are few epidemiological studies on mortality associated with hip fracture in elderly. Aims to assess mortality one year after hip fracture and in-hospital mortality in elderly subjects who were treated at the Orthopaedics and Traumatology division of University Hospital of Santa Maria. Identifying risk factors for one year mortality in-hospital mortality in these subjects and determinate one year subjects survival. This is a prospective cohort study that evaluates one year mortality by Cox s Regression and in-hospital mortality by Logistic Regression. The survival time was evaluate by Kaplan Meier analyze. The mean age was 80.6±7.5(SD) years, 76.4% were female gender, 57.8% were transtrochanteric fracture and 44.9% had ASA grade I or II. One year mortality was 25.2% and in-hospital mortality was 12.5%. One year mortality predictor s were ASA (HR 1.922, 95% CI 1.150 3.211) and time to surgery (HR 1.049, 95% CI 1.012 1.087). Only ASA grade were risk factor for in-hospital mortality (OR 6.373, 95% CI 2.954 13.747). The survival time was 297.7±11.3 days. The mean time to surgery was 7.8±5.4 days. In our study for every day that the surgery was delayed the one year survival was shortened by 9 days. Improvements in public health that would decrease time to surgery could have an impact at the survival of these subjects. The ASA grade is a useful tool to evaluate the patient clinical status. / A fratura do terço proximal do fêmur tem aumentado significativamente nas últimas décadas e tem sido uma das maiores causas de morbimortalidade em idosos. Constitui-se muitas vezes em um evento com consequências catastróficas para a vida do paciente, com grandes implicações no seu bem-estar físico, psíquico e social. É uma causa frequente de institucionalização permanente. Estudos epidemiológicos contribuem para especificar características de determinadas lesões traumato-ortopédicas, bem como, a partir daí, auxiliar na sua prevenção e tratamento. Estas ações são essenciais para a promoção da saúde. Na América Latina, existem poucos estudos epidemiológicos sobre a mortalidade associada a fraturas da extremidade proximal do fêmur em idosos. Este estudo tem como objetivos: avaliar a mortalidade um ano após fratura do fêmur proximal (FFP) e mortalidade intra-hospitalar nos pacientes com 65 anos ou mais, que foram atendidos no Serviço de Ortopedia e Traumatologia do Hospital Universitário de Santa Maria (SOT - HUSM); Identificar os fatores de risco para mortalidade um ano após FFP e mortalidade intra-hospitalar nestes pacientes; Determinar a sobrevida dos pacientes um ano após o evento trauma. Trata-se de um estudo de coorte prospectivo que avaliou através de Regressão de Cox os fatores de risco para mortalidade um ano após FFP e por meio de Regressão Logística, os preditores para mortalidade intra-hospitalar. A análise de sobrevida foi feita pelo método de Kaplan Meier. A idade média dos pacientes foi de 80,6±7,5(DP) anos, 76,4% eram do sexo feminino, 57,8% tiveram fratura transtrocantérica e 44,9% tinham escore ASA I ou ASA II. Ao final de um ano morreram 25,2% dos pacientes e 12,5% morreram durante a internação hospitalar. Foram fatores preditores de aumento de mortalidade em um ano o escore ASA (American Society of Anesthesiologists) (HR 1,922, 95% IC 1,150 3,211) e o tempo porta-cirurgia (HR 1,049, 95% IC 1,012 1,087). Apenas o escore ASA (OR 6,373, 95% IC 2,954 13,747) foi preditor de aumento da mortalidade intra-hospitalar. O tempo de sobrevida médio foi de 297,7±11,3 dias. O tempo médio entre a internação e a realização da cirurgia foi 7,8±5,4 dias. Em nosso estudo, para cada dia de espera, a sobrevida no primeiro ano foi encurtada em 9 dias. A tomada de medidas de saúde pública que venham a diminuir o tempo de espera para a cirurgia pode vir a apresentar um impacto positivo na diminuição dessa mortalidade. O escore ASA é uma importante ferramenta para avaliar o estado clínico do paciente.

The purpose of this master thesis was to investigate if using both X-ray images and patient's register data could increase the performance of a neural network in discrimination of two types of fractures in the thigh bone, called atypical femoral fractures (AFF) and normal femoral fractures (NFF). We also examined and evaluated how the fusion of the two data types could be done and how different types of fusion affect the performance. Finally, we evaluated how the number of variables in the register data affect a network's performance. Our image dataset consisted of 1,442 unique images from 580 patients (16.85% of the images were labelled AFF corresponding to 15.86% of the patients). Since the dataset is very imbalanced, sensitivity is a prioritized evaluation metric. The register data network was evaluated using five different versions of register data parameters: two (age and sex), seven (binary and non-binary) and 44 (binary and non-binary). Having only age and sex as input resulted in a classifier predicting all samples to class 0 (NFF), for all tested network architectures. Using a certain network structure (celled register data model 2), in combination with the seven non-binary parameters outperforms using both two and 44 (both binary and non-binary) parameters regarding mean AUC and sensitivity. Highest mean accuracy is obtained by using 44 non-binary parameters. The seven register data parameters have a known connection to AFF and includes age and sex. The network with X-ray images as input uses a transfer learning approach with a pre-trained ResNet50-base. This model performed better than all the register data models, regarding all considered evaluation metrics.        Three fusion architectures were implemented and evaluated: probability fusion (PF), feature fusion (FF) and learned feature fusion (LFF). PF concatenates the prediction provided from the two separate baseline models. The combined vector is fed into a shallow neural network, which are the only trainable part in this architecture. FF fuses a feature vector provided from the image baseline model, with the raw register data parameters. Prior to the concatenation both vectors were normalized and the fused vector is then fed into a shallow trainable network. The final architecture, LFF, does not have completely frozen baseline models but instead learns two separate feature vectors. These feature vectors are then concatenated and fed into a shallow neural network to obtain a final prediction. The three fusion architectures were evaluated twice: using seven non-binary register data parameters, or only age and sex. When evaluated patient-wise, all three fusion architectures using the seven non-binary parameters obtain higher mean AUC and sensitivity than the single modality baseline models. All fusion architectures with only age and sex as register data parameters results in higher mean sensitivity than the baseline models. Overall, probability fusion with the seven non-binary parameters results in the highest mean AUC and sensitivity, and learned feature fusion with the seven non-binary parameters results in the highest mean accuracy.

The mevalonate pathway is an important biosynthetic pathway, found in all cells of virtually all known pro- as well as eukaryotic organisms. This thesis is an investigation into the use of two drugs, originally developed for different applications, but both affecting the mevalonate pathway, in to models of fracture repair. Using two different rodent models of fracture repair, a commonly used cholesterol lowering drug (statin) and two drugs used to treat osteoporosis (bisphosphonate) were applied both systemically as well as locally in order to enhance fracture repair. Papers I and II investigate the potential of simvastatin to improve the healing of femoral fractures in mice. Papers III and IV explore the use of two bisphosphonates to improve early fixation of stainless steel screws into rat bone. The statin simvastatin lead to an increased strength of the healing cellus. The application of bisphosphonates increased early screw fixation. It seems clear that both drugs have uses in orthopaedic applications. One interesting avenue of further research would be to combine the two classes of drugs and see if we can get the benefits while at the same time diminishing the drawbacks.