Mechanical consequences at the tendon-bone interface of different medial row knotless configurations and lateral row tension in a simulated rotator cuff repair.

PURPOSE: Little is known about the direct influence of different technical options at the rotator cuff tendon-bone interface (TBI) and, more specifically, at the medial bearing row (MBR), regarding local contact force, area and pressure. We evaluated the mechanical repercussions of different medial row anchor configurations for that setting using different values of tension in the lateral row anchors. METHODS: Knotless transosseous equivalent (TOE) rotator cuff repairs with locked versus nonlocked medial anchors and single versus double-hole suture passage were tested in a synthetic rotator cuff mechanical model, using 2 different values of lateral row tension. Contact force, area, pressure, peak force and MBR force were compared at the simulated TBI using a pressure mapping sensor. RESULTS: When compared to locked anchors, medial row sliding configurations generate lower values for all the above-mentioned parameters. The use of double-hole suture passage in the medial cuff generated slightly higher values contact area regardless of lateral row tension. At higher lateral row tension values, lower values of the remaining parameters, including MBR force, were found when compared to single-hole suture passage. Lateral row anchor tension increase induced an increase of all parameters regardless of the medial row configuration and TBI contact force and MBR force were the most susceptible parameters, regardless of the medial row pattern. CONCLUSION: Medial row mechanism, suture configuration and lateral row tension interfere with the mechanical force, area and pressure at by TBI. Lateral row tension increase is a major influencer in those parameters. These results can help surgeons choose the right technique considering its mechanical effect at the TBI.

Glomus Tumor: "A-Not-So-Rare" Cause of Chronic Shoulder Pain-A Case Report and Literature Review.

CASE: A 61-year-old male presented with chronic shoulder pain resistant to conservative treatment. Imaging identified a nodular lesion in the deltoid muscle, which histology after resection identified as a glomus tumor. After surgery, the patient became asymptomatic and at 4-year follow-up has not shown signs of recurrence. CONCLUSION: Glomus tumors around the shoulder should be considered when investigating chronic shoulder pain, as they are more common than thought. Despite being elusive, when diagnosed, excellent outcomes may be expected, with surgery resection being curative.

"Bone-shot fracture" - An unusual iliac wing fracture caused by a projectile of autologous bone fragment. A case report.

CASE: A young adult male sustained a high-energy crash suffering multiple injuries including a comminuted right femoral shaft fracture and an ipsilateral iliac wing fracture. The iliac fracture was caused by a femoral fragment which was projected and pierced the iliac wing. The patient underwent surgery with retrieval of the femoral fragment and fixation of the iliac and femoral fractures. The lesions healed uneventfully. CONCLUSION: This is the first reported case of an iliac fracture caused by a projectile of autologous bone. High-energy trauma may present unusual or never seen injury patterns to the trauma surgeon.

Why are tapes better than wires in knotless rotator cuff repairs? An evaluation of force, pressure and contact area in a tendon bone unit mechanical model.

PURPOSE: Knotless repairs have demonstrated encouraging performance regarding retear rate reduction, but literature aiming at identifying the specific variables responsible for these results is scarce and conflictive. The purpose of this paper was to evaluate the effect of the material (tape or wire suture) and medial tendon passage (single or double passage) on the contact force, pressure and area at the tendon bone interface in order to identify the key factors responsible for this repairs´ success. METHODS: A specific knotless transosseous equivalent cuff repair was simulated using 2 tape or suture wire loaded medial anchors and 2 lateral anchors, with controlled lateral suture limb tension. The repair was performed in a previously validated sawbones® mechanical model. Testing analyzed force, pressure and area in a predetermined and constant size "repair box" using a Tekscan® sensor, as well as peak force and pressure, force applied by specific sutures and force variation along the repair box. RESULTS: Tapes generate lower contact force and pressure and double medial passage at the medial tendon is associated with higher contact area. Suture wires generate higher peak force and pressure on the repair and higher mean force in their tendon path and at the medial bearing row. Force values decrease from medial to lateral and from posterior to anterior independently of the material or medial passage. CONCLUSION: Contrary to most biomechanical literature, suture tape use lowers the pressure and force applied at the tendon bone junction, while higher number of suture passage points medially increases the area of contact. These findings may explain the superior clinical results obtained with the use uf suture tapes because its smaller compressive effect over the tendon may create a better perfusion environment healing while maintaining adequate biomechanical stability.

Neuroimmune expression in hip osteoarthritis: a systematic review.

BACKGROUND: Neuroimmune axis is central in the physiopathology of hip osteoarthritis (OA), but its specific pathways are still unclear. This systematic review aims to assess the nervous and immune system profile of patients with hip osteoarthritis (OA) when compared to healthy controls. METHODS: A systematic review followed PRISMA guidelines was conducted. A two-step selection process was completed, and from 609 references 17 were included. The inclusion criteria were: original articles on adult patients with hip OA, with assessment of neuroimmune expression. Articles with other interventions prior to analysis and those without a control group were excluded. RESULTS: Thirty-nine relevant neuroimmune markers were identified, with assessments in bone, cartilage, synovial membrane, synovial fluid, whole blood, serum and/or immune cells. GM-CSF, IFN-γ, IL-1α, IL-6, IL-8, IL-1 and TNF-α presented variable expression among tissues studied when compared between hip OA and controls. VEGFs and TGF-ß isoforms showed similar tendencies among tissues and studies. On nervous expression, CGRP, Tuj-1 and SP were increased in synovial membrane. Overall, patients with hip OA presented a higher number of overexpressed markers. CONCLUSIONS: For the first time a systematic review on neuroimmune expression in patients with hip OA found an upregulation of neuroimmune markers, with deregulated balance between pro and anti-inflammatory cytokines. However, no clear systematic pattern was found, and few information is available on nervous expression. This highlights the importance of future research with clear methodologies to guide the management of these patients.

Reverse shoulder arthroplasty for the treatment of nonunions of the surgical neck of the proximal part of the humerus (type-3 fracture sequelae).

BACKGROUND: Fracture sequelae of the proximal part of the humerus are challenging conditions, and various treatment options have been described. The purpose of this multicenter study was to analyze the clinical and radiographic outcomes as well as the complications following semiconstrained reverse total shoulder arthroplasty for the treatment of nonunion of a surgical neck fracture of the proximal part of the humerus. METHODS: Thirty-two patients with a mean age of sixty-eight years (range, forty-eight to eighty-three years) managed with a reverse shoulder arthroplasty for the treatment of nonunion of a proximal humeral fracture were analyzed clinically and radiographically. The mean duration of follow-up was four years (range, two to twelve years). The Constant score, active shoulder mobility, all complications, and revision procedures were recorded. RESULTS: The mean Constant score increased from 14.2 points (range, 2 to 35 points) to 46.6 points (range, 6 to 75 points) (p < 0.001). The mean shoulder flexion increased from 42.9° (range, 0° to 160°) to 109.7° (range, 0° to 170°) (p < 0.001), and the mean external rotation increased from 0.5° (range, -40° to 60°) to 13.1° (range, -30° to 60°) (p < 0.005). No component loosening occurred, but 50% (sixteen) of the patients had radiographic evidence of scapular notching. There were thirteen complications (41%) leading to nine revision surgical procedures (28%). The most common complication was a dislocation following reverse shoulder arthroplasty, which occurred in 34% (eleven) of the patients. An intraoperative resection of the humeral head fragment and the tuberosities was associated with increased risk of dislocation (p < 0.007). CONCLUSIONS: Nonunions of the proximal part of the humerus can be treated with reverse shoulder arthroplasty. Although clinical outcomes improved significantly, we found an unacceptably high rate of dislocations associated with intraoperative resection of the tuberosities. The tuberosities and the attached rotator cuff should be preserved if possible to reduce the risk of dislocation after reverse total shoulder arthroplasty.

[New perspectives on degenerative disease treatment]. / Novas perspectivas no tratamento da doença degenerativa discal.

The degenerative disc disease (DDD) is a chronic and multifactorial condition of the intervertebral disc that can manifest itself by axial pain, radiculopathy, myelopathy and spinal stenosis. It constitutes an increasing cause of lumbar pain and morbidity in Western Societies, with important socio-economic implications. The available treatment options do not modify the intervertebral disc degeneration process and they are not always capable of relieving symptoms. The loss of proteoglycan content of nucleus pulposus appears to be the main event on DDD pathophysiology. The balance between synthesis and catabolism of the extracellular matrix can be altered by the use of several proteins, including growth factors. The transfer of genes encoding these proteins is an attractive treatment option and has been successfully achieved in animal models. Moreover, the transfer of steam cells in order to repopulate the degenerated disc and to revert the pathologic process might be another promissory strategy. The authors describe the actual knowledge about DDD and the investigation that has been made in gene therapy for DDD. The comprehension of the biological mechanisms of degeneration, as well as genetic manipulation and transfer of steam cells could be decisive and revolutionary in the understanding and treatment of this epidemic condition.