Toward sustainability and resilience in Chilean cities: Lessons and recommendations for air, water, and soil issues.

Achieving sustainability and resilience depends on the conciliation of environmental, social, and economic issues integrated into a long-term perspective to ensure communities flourish. Many nations are transitioning toward both objectives, while at the same time addressing structural concerns that have not allowed them to look after the environment in the past. Chile is one of these nations dealing with such challenges within a particular administrative context, an increasing environmental awareness, and a set of unique and complex geophysical boundaries that impose a plethora of hazards for cities, ecosystems, and human health. This paper presents recent accomplishments and gaps, mostly from an environmental perspective, on issues related to air pollution, the urban water cycle, and soil contamination, in the path being followed by Chile toward urban sustainability and resilience. The focus is on the bonds between cities and their geophysical context, as well as the relationships between environmental issues, the built environment, and public health. The description and diagnosis are illustrated using two cities as case studies, Temuco and Copiapó, whose socioeconomic, geographical, and environmental attributes differ considerably. Particulate matter pollution produced by the residential sector, drinking water availability, wastewater treatment, stormwater management, and soil contamination from the mining industry are discussed for these cities. Overall, the case studies highlight how tackling these issues requires coordinated actions in multiple areas, including regulatory, information, and financial incentive measures. Finally, the policy analysis discusses frameworks and opportunities for Chilean cities, which may be of interest when conceiving transitional paths toward sustainability and resilience for other cities elsewhere.

Return to sport soccer after anterior cruciate ligament reconstruction: ISAKOS consensus.

INTRODUCTION: Many factors can affect the return to pivoting sports, after an Anterior Cruciate Ligament Reconstruction. Prehabilitation, rehabilitation, surgical and psychological aspects play an essential role in the decision to return to sports. The purpose of this study is to reach an international consensus about the best conditions for returning to sports in soccer-one of the most demanding level I pivoting sports after anterior cruciate ligament (ACL) reconstruction. METHODS: 34 International experts in the management of ACL injuries, representing all the Continents were convened and participated in a process based on the Delphi method to achieve a consensus. 37 statements related to ACL reconstruction were reviewed by the experts in three rounds of surveys in complete anonymity. The statements were prepared by the working group based on previous literature or systematic reviews. Rating agreement through a Likert Scale: strongly agree, agree, neither agree or disagree, disagree and strongly disagree was used. To define consensus, it was established that the assertions should achieve a 75% of agreement or disagreement. RESULTS: Of the 37 statements, 10 achieved unanimous consensus, 18 non-unanimous consensus and 9 did not achieve consensus. In the preoperative, the correction of the range of motion deficit, the previous high level of participation in sports and a better knowledge of the injury by the patient and compliance to participate in Rehabilitation were the statements that reached unanimous consensus. During the surgery, the treatment of associated injuries, as well as the use of autografts, and the addition of a lateral extra-articular tenodesis in some particular cases (active young athletes, <25 years old, hyperlaxity, high rotatory laxity and revision cases) obtained also 100% consensus. In the postoperative period, psychological readiness and its validation with scales, adequate physical preparation, as well as not basing the RTSS purely on the time of evolution after surgery, were the factors that reached unanimous Consensus. CONCLUSIONS: The consensus statements derived from this international ISAKOS leaders, may assist clinicians in deciding when to return to sports soccer in patients after an ACL reconstruction. Those statements that reached 100% consensus have to be strongly considered in the final decision to RTS soccer.

Reliable interobserver and intraobserver agreement of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) classification system of rotator cuff tears.

OBJECTIVE: The ISAKOS Shoulder Committee developed a new comprehensive classification system aimed to describe all rotator cuff tears. The five characteristics of the tears included are pattern (P), extension (E), fatty atrophy (A), retraction (R), and location (L), conforming to the acronym "PEARL." The objective of this study is to assess if the ISAKOS Rotator Cuff Tear Classification System is reliable by measuring the intraobserver and interobserver multirater reliability. METHODS: Arthroscopic videos of 36 rotator cuff tears, including tears of varying sizes and configurations, were evaluated twice by four surgeons from different continents blinded to tear type. Intraobserver and interobserver reliability was measured using multirater and intraobserver Kappa coefficients. RESULTS: Intraobserver reliability: An almost perfect agreement for "location" (κ = 0.98), substantial agreement for "extension" (κ = 0.73) were obtained for mean intrarater kappa, lower κ agreement for "pattern" (κ = 0.58), and relatively high agreement of 0.79 for "retraction." Every characteristic of "location" had an almost perfect agreement among the surgeons (κ = 0.91). Intrarrater reliability: In the partial-thickness posterosuperior tears "location," there was good agreement in tears involving less than 50% of the tendon (κ = 0.74) and moderate in those deeper than 50% of the tendon thickness (κ = 0.58). "Extension" in full-thickness posterosuperior RCT achieved moderate agreement. Within the anterior subscapularis tears, we have a substantial agreement in Lafosse´s Type 1 (κ = 0.73), moderate in Types 2 and 3 (κ = 0.45 and κ = 0.46) and slight agreement in Type 4 (κ = 0.06). The overall kappa summarizing all categories indicated moderate agreement (κ = 0.52). The articular pattern in the partial-thickness posterosuperior RCT "location" had a perfect kappa of 1, while the bursal pattern showed an almost complete agreement (κ = 0.87). In the full-thickness posterosuperior RCTs, we observed fair agreement in C, U, and reverse L configurations and slight agreement in L pattern (κ = 0.18). The overall kappa is 0.44 with a confidence interval of 0.41-0.47. There was substantial agreement in every category and the overall kappa for "retraction" (k = 0.70). CONCLUSION: ISAKOS rotator cuff tear classification system provides sufficient interobserver reliability for communicating among surgeons and for pooling of data from clinical studies. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2.

Anterior and posterior glenoid bone augmentation options for shoulder instability: state of the art.

Bony lesions are highly prevalent in anterior shoulder instability and can be a significant cause of failure of stabilisation procedures if they are not adequately addressed. The glenoid track concept describes the dynamic interaction between the humeral head and glenoid defects in anterior shoulder instability. It has been beneficial for understanding the role played by bone defects in this entity. As a consequence, the popularity of glenoid augmentation procedures aimed to treat anterior glenoid bone defects; reconstructing the anatomy of the glenohumeral joint has risen sharply in the last decade. Although bone defects are less common in posterior instability, posterior bone block procedures can be indicated to treat not only posterior bony lesions, attritional posterior glenoid erosion or dysplasia but also normal or retroverted glenoids to provide an extended glenoid surface to increase the glenohumeral stability. The purpose of this review was to analyse the rationale, current indications and results of surgical techniques aimed to augment the glenoid surface in patients diagnosed of either anterior or posterior instability by assessing a thorough review of modern literature. Classical techniques such as Latarjet or free bone block procedures have proven to be effective in augmenting the glenoid surface and consequently achieving adequate shoulder stability with good clinical outcomes and early return to athletic activity. Innovations in surgical techniques have permitted to perform these procedures arthroscopically. Arthroscopy provides the theoretical advantages of lower morbidity and faster recovery, as well as the identification and treatment of concomitant pathologies.

Suprascapular Nerve Release: Technique Based on Anatomic Landmarks.

Dysfunction of the suprascapular nerve (SSN) is closely related to rotator cuff pathology; nerve dysfunction can lead to cuff disease and vice versa. Owing to repetitive microtrauma during overhead sports or massive cuff tears with significant tendon retraction, the SSN may suffer compression or traction neuropathy at the suprascapular notch. The SSN release technique has already been described. However, on the basis of the many hands-on cadaveric laboratories in which we have participated in the past 20 years, only a few instructors and almost none of the attendants have shown the experience and skill set needed to release the SSN at the suprascapular notch. Therefore, a review of the surgical technique following the anatomic descriptions of an expert anatomist (P.G.) of the shoulder girdle is quite valuable.

Evaluation and Management of Glenohumeral Instability With Associated Bone Loss: An Expert Consensus Statement Using the Modified Delphi Technique.

PURPOSE: To establish an international expert consensus, using the modified Delphi technique, on the evaluation and management of glenohumeral instability with associated bone loss. METHODS: A working group of 6 individuals generated a list of statements related to history and physical examination, imaging and specialized diagnostic tests, bone loss quantification and classification, treatment outcomes and complications, and rehabilitation for the management of glenohumeral instability associated with bone loss to form the basis of an initial survey for rating by a group of experts. The expert group (composed of 22 high-volume glenohumeral instability experts) was surveyed on 3 occasions to establish a consensus on the statements. Items with over 70% agreement and less than 10% disagreement achieved consensus. RESULTS: After a total of 3 rounds, 31 statements achieved consensus. Eighty-six percent of the experts agreed that a history of multiple dislocations and failed soft-tissue surgery should raise suspicion about the possibility of an associated bone deficit. Ninety-five percent of the experts agreed that 3-dimensional (3D) computed tomography (CT) is the most accurate diagnostic method to evaluate and quantify bone loss. Eighty-six percent of the experts agreed that any of the available methods to measure glenoid bone deficiency is adequate; however, 91% of the experts thought that an en face view of the glenoid using 3D CT provides the most accurate method. Ninety-five percent of the experts agreed that Hill-Sachs lesions are poorly quantified and classified by current imaging systems. Ninety percent of the experts agreed that in cases with a glenoid bone deficit greater than 20%, glenoid bone graft reconstruction should be performed and any of the available options is valid. There was no consensus among experts on how Hill-Sachs injuries should be managed or on how postoperative rehabilitation should be carried out. CONCLUSIONS: The essential statements on which the experts reached consensus included the following: A history of multiple dislocations and failed soft-tissue surgery should make surgeons consider the possibility of an associated bone deficit. Three-dimensional CT is the most accurate diagnostic method to evaluate and quantify bone loss. Although any of the available methods to measure glenoid bone deficiency is adequate, an en face view of the glenoid using 3D CT provides the most accurate method. Hill-Sachs lesions are poorly quantified and classified by current imaging systems. Finally, in cases with a glenoid bone deficit greater than 20%, glenoid bone graft reconstruction should be performed. LEVEL OF EVIDENCE: Level V, consensus statement.

Inestabilidad posterior de hombro. Resultados de la reconstrucción artroscópica en pacientes sin defectos óseos significativos / Posterior shoulder instability. Arthroscopic reconstruction in patients without significant bone defects

Presentamos los resultados de una serie de casos de pacientes con inestabilidad posterior de hombro, sin defectos óseos ni retroversión glenoidea significativos, tratados con técnica artroscópica de reparación cápsulolabral con anclajes. Entre 2010 y 2019, dieciocho pacientes con inestabilidad posterior de hombro fueron tratados con una reparación cápsulolabral artroscópica con anclajes, en el mismo centro quirúrgico y por el mismo cirujano. Fueron dieciséis hombres y dos mujeres con una edad promedio de 30.5 años (en un rango de diecinueve a cuarenta y cuatro años). Con un seguimiento promedio de 64.4 meses (en un rango entre trece y ciento dieciséis meses) los pacientes fueron evaluados clínicamente con el test de Kim, Jerk y test de aprehensión. También utilizamos los scores de WOSI, ASES, Rowe, radiografía, tomografía computada y resonancia magnética, para las evaluaciones pre y postoperatorias. Tipo de estudio: Serie de casos. Nivel de evidencia: IV

Objective: We present the results of a case series of patients with posterior shoulder instability without significant bone defects or excessive glenoid retroversion treated with arthroscopic capsule-labral repair with suture anchors.Methods: Between 2010 and 2019, 18 patients with posterior shoulder instability underwent an arthroscopic capsule-labral repair with suture anchors. All the cases were operated on at the same surgical center by the same surgeon. The patients were 16 men and two women with an average age of 30.5 years (range 19 to 44 years). With a mean follow up of 64.4 months (range 13-116 months), the patients were clinically evaluated by the Kim, Jerk, and Apprehension tests. Furthermore, the WOSI, ASES, and ROWE scores, X Rays, CT Scans, and MRIs were also used for pre and postoperative assessment. Results: We did not find any case of recurrence of instability. At the final follow up, the Kim's, Jerk, and Apprehension tests were negative in all the patients. The posterior drawer test decreased translation at an average of 2 pluses. The mean WOSI Score risen from 35.2 to 86.5, the ASES from 33.3 to 85.3, and the Rowe from 20.3 to 91.1. Two patients showed moderate to severe degenerative changes at the final X-Rays. The postoperative MRIs of 12 patients demonstrated an anatomic reduction and adequate healing of the posterior labrum.Conclusions: The arthroscopic repair of the labrum with anchors is a reliable, reproducible, and effective technique that warrants satisfactory results in selected posterior shoulder instability cases without significant glenoid bone loss or excessive retroversion. Type of study: Case series. Level of evidence: IV

An integrated study of health, environmental and socioeconomic indicators in a mining-impacted community exposed to metal enrichment.

The occurrence of toxic metals and metalloids associated with mine tailings is a serious public health concern for communities living in mining areas. This work explores the relationship between metal occurrence (e.g., spatial distribution in street dusts), human health indicators (e.g., metals in urine samples, lifestyle and self-reported diseases) and socioeconomic status (SES) using Chañaral city (in northern Chile) as study site, where a copper mine tailing was disposed in the periurban area. This study model may shed light on the development of environmental and health surveillance plans on arid cities where legacy mining is a sustainability challenge. High concentrations of metals were found in street dust, with arsenic and copper concentrations of 24 ± 13 and 607 ± 911 mg/kg, respectively. The arsenic concentration in street dust correlated with distance to the mine tailing (r = - 0.32, p-value = 0.009), suggesting that arsenic is dispersed from this source toward the city. Despite these high environmental concentrations, urinary levels of metals were low, while 90% of the population had concentrations of inorganic arsenic and its metabolites in urine below 33.2 µg/L, copper was detected in few urine samples (< 6%). Our results detected statistically significant differences in environmental exposures across SES, but, surprisingly, there was no significant correlation between urinary levels of metals and SES. Despite this, future assessment and control strategies in follow-up research or surveillance programs should consider environmental and urinary concentrations and SES as indicators of environmental exposure to metals in mining communities.

Enhancement of particle aggregation in the presence of organic matter during neutralization of acid drainage in a stream confluence and its effect on arsenic immobilization.

Acid drainage (AD) is an important environmental concern that impacts water quality. The formation of reactive Fe and Al oxyhydroxides during the neutralization of AD at river confluences is a natural attenuation process. Although it is known that organic matter (OM) can affect the aggregation of Fe and Al oxyhydroxides and the sorption of As onto their surfaces, the role of OM during the neutralization of AD at river confluences has not been studied. Field and experimental approaches were used to understand this role, using the Azufre River (pH 2) - Caracarani River (pH 8.6) confluence (northern Chile) as model system. Field measurements of organic carbon revealed a 10-15% loss of OM downstream the confluence, which was attributed to associations with Fe and Al oxyhydroxides that settle in the river bed. Laboratory mixtures of AD water with synthetic Caracarani waters under varying conditions of pH, concentration and type of OM revealed that OM promoted the aggregation of Fe oxyhydroxides without reducing As sorption, enhancing the removal of As at slightly acidic conditions (pH ∼4.5). At acidic conditions (pH ∼3), aggregation of OM - metal complexes at high OM concentrations could become the main removal mechanism. One type of OM promoted bimodal particle size distributions with larger mean sizes, possibly increasing the settling velocity of aggregates. This work contributes to a better understanding of the role of OM in AD affected basins, showing that the presence of OM during processes of neutralization of AD can enhance the removal of toxic elements.

Desarrollo sustentable desde el enfoque de autocuidado: Un aporte a la práctica de enfermería / Sustainable development from a self-care approach: A contribution to a nursing practice

La relación entre salud y ambiente no es una temática reciente, ya en el año 1974 la Agencia de Salud Pública de Canadá establece en su informe Lalonde los factores claves que parecían determinar el estado de salud de los individuos, identificando así el estilo de vida, el ambiente, la biología humana y los servicios de salud. En el año 2012, se realiza la Conferencia de las Naciones Unidas sobre el desarrollo sostenible, que en su documento final "El futuro que queremos" señala "la salud es una condición previa, un resultado y un indicador de las tres dimensiones del desarrollo sostenible", es decir, las dimensiones social, ambiental y económica. El impacto que tienen los cambios en el ecosistema sobre la salud de la población está en directa relación en cómo el ser humano se relaciona con su entorno y utiliza los recursos disponibles brindándoles la oportunidad de renovarse a través de ciclos naturales. Es así como desde el paradigma de sustentabilidad se propone observar, comprender e intervenir en nuestro entorno teniendo presente que todos los sistemas, tanto naturales como los creados por el hombre, interactúan e influyen entre sí. A través de dos de los requisitos de Autocuidado de la salud como son normalidad y peligros para la vida, planteados por Dorothea Orem se analizará cómo los cambios en nuestro ecosistema pueden repercutir en el continuo salud-enfermedad de las personas.

The relationship between health and environment is not recent-In 1974 the Public Health Agency of Canada established in its Lalonde report, the key factors that seemed to determine the health condition of individuals, thus identifying the lifestyle, the environment, human biology and health services.In 2012, the UN Conference on Sustainable Development takes place and in its final document "The future we want" says: "health is a precondition, an outcome and an indicator of the three dimensions of sustainable development" -that is -the social, environmental and economic dimensions. The impact of changes in the ecosystem about the health of the population is directly related to how human beings interact with their environment and use available resources giving them the opportunity to renew it through natural cycles. Thereby, since the sustainability paradigm is proposed to observe, understand and intervene in our environment bearing in mind that all systems, both natural and manmade, interact and influence each other. Through two of the requirements of self-care such as normality and hazards to life, raised by Dorothea Orem will analyze how changes in our ecosystem can affect the health-disease continuum of individuals.

Ruptura irreparable del manguito rotador en artroplastia de hombro: resolución simple con artroplastia inversa / Rotator cuff tear after anatomic shoulder arthroplasty: simple revision to reverse arthroplasty

La lesión del manguito rotador en pacientes con una prótesis total de hombro anatómica es cada vez más frecuente. Ante esta situación surge el dilema de reparar la ruptura o efectuar una revisión hacia una artroplastia inversa. Se presenta el caso de un paciente que consulta por una ruptura masiva del manguito rotador del hombro derecho, de seis meses de evolución, luego de haber intentado levantar un objeto de 30 kg. Como antecedente se le había implantado una artroplastia total del hombro derecho modular y universal por artrosis glenohumeral primaria. Dada la irreparabilidad de la lesión y la adecuada integración biológica proximal del tallo humeral cementado y el platillo metálico glenoideo no cementado, se procedió a la reconversión a artroplastia inversa de hombro intercambiando solo los componentes modulares de la prótesis. La evolución posquirúrgica fue favorable, recuperó un rango de movilidad satisfactorio durante la rehabilitación. Las prótesis modulares universales ofrecen la posibilidad de la conversión “simple” de una artroplastia de hombro total a una inversa, sin necesidad de revisar el tallo humeral ni el platillo glenoideo, y así disminuir la morbilidad del procedimiento. Nivel de Evidencia: IV.

Rotator cuff injury in patients with anatomical total shoulder prosthesis is becoming more frequent. These cases present with the dilemma of whether to repair the rupture or make a revision towards a reverse arthroplasty. We present the case of a patient who suffered a massive rotator cuff rupture of the right shoulder, after lifting a 30-kg object, 6 months ago. Because of glenohumeral osteoarthritis, the patient underwent a modular total shoulder arthroplasty 16 months before. Given the irreparable lesion, the adequate proximal biological integration of the cemented humeral stem, and the uncemented glenoid metallic plate, a conversion to reverse shoulder arthroplasty was performed by exchanging only the modular components of the prosthesis. Postoperative evolution was favorable; the patient regained a satisfactory range of motion during rehabilitation. Universal modular prostheses offer the possibility of “simple” conversion to a reverse arthroplasty, without exchanging the humeral stem or the glenoid plate, and thus reducing the morbidity of the procedure. Level of Evidence: IV.

Shoulder Stiffness: Current Concepts and Concerns.

UNLABELLED: Shoulder stiffness can be caused by various etiologies such as immobilization, trauma, or surgical interventions. The Upper Extremity Committee of ISAKOS defined the term "frozen shoulder" as idiopathic stiff shoulder, that is, without a known cause. Secondary stiff shoulder is a term that should be used to describe shoulder stiffness with a known cause. The pathophysiology of frozen shoulder is capsular fibrosis and inflammation with chondrogenesis, but the cause is still unknown. Conservative treatment is the primary choice. Pain control by oral medication, intra-articular injections with or without joint distension, and physical therapy are commonly used. In cases with refractory stiffness, manipulation under anesthesia or arthroscopic capsular release may be indicated. Because of various potential risks of complications with manipulations, arthroscopic capsular release is preferred. After the capsular release, stepwise rehabilitation is mandatory to achieve satisfactory outcome. LEVEL OF EVIDENCE: Level V, evidence-based review.

Inestabilidad de hombro: ¿es la estabilización artroscópica adecuada para tratar los deportistas de colisión?. Resultados / Shoulder instability: Is it appropriate to treat arthroscopic stabilization for collision athletes?

Evaluar los resultados de la estabilización artroscópica de la lesión de Bankart en la inestabilidad anterior de hombro en pacientes que practican deportes de contacto y colisión. Método: Se realizó una revisión sistemática siguiendo los protocolos de PRISMA. La búsqueda fue hecha en Pubmed, utilizando los siguientes términos: “anterior”, “shoulder instability”, “collision”, “arthroscopic treatment”, “results”. Esta búsqueda fue realizada en mayo del 2015 y se dirigió en el período desde enero del 2005 a mayo del 2015. Los criterios de inclusión fueron: deportistas de contacto o colisión, reparación artroscópica de lesión de Bankart por inestabilidad anterior y evaluación objetiva de los resultados con dicha técnica. Se excluyeron aquellos casos que no presentaban lesión de Bankart clásica, o que presentaban inestabilidad multidireccional, inestabilidad posterior, o cambios degenerativos. Resultados: Solo cuatro trabajos reunieron el criterio de elegibilidad y fueron incluidos para esta revisión sistemática. Se evaluaron un total de 236 hombros, con una edad promedio de 21,4 años y un seguimiento promedio de 58,3 meses. Todas las publicaciones analizadas son de nivel de evidencia IV. La escala de Rowe reveló buenos y excelentes resultados en todos los pacientes evaluados en el post-operatorio. La tasa de recurrencia fue de 8,89 % y la tasa de retorno al deporte fue de 89,6 %. Conclusión: Las publicaciones evaluadas junto con los resultados que derivan de dicho análisis ponen de manifiesto que la técnica de reparación artroscópica en la inestabilidad gleno-humeral de hombro en deportistas de contacto y colisión constituye una opción correcta con resultados aceptables. Tipo de Estudio: Revisión Sistemática. Nivel de Evidencia: IV...

To evaluate the results of arthroscopic stabilization of Bankart lesion in anterior instability of the shoulder in collision or contact sports athetes. Methods: We conducted a systematic review using the PRISMA guidelines. The literature search was performed in PubMed, using the following terms: “Previous”, “shoulder instability”, “collision”, “arthroscopic treatment”, “results”. This search was made in May 2015 and was limited to the period from January 2005 to May 2015. Studies that described arthroscopic Bankart lesion repair for anterior instability in collision and contact athletes were included. Cases who had no classic Bankart lesion, or who had multidirectional, posterior instability or degenerative changes were excluded. Results: Only four studies were found that met eligibility criteria and were included in this systematic review. A total of 236 shoulders were evaluated, with an average age of 21.4 years and an average of 58.3 months follow-up. All the studies had a level of evidence of IV. Rowe score reported good and excellent results in all postoperative patients. The recurrence rate found was 8.89% and the rate of return to sport was 89.6%. Conclusion: The results show that arthroscopic repair for glenohumeral shoulder instability in contact and collision athletes is a good choice with acceptable results. Type of Sudy: Sistematic Review. Level of Evidence: IV...

Primary Frozen Shoulder Syndrome: Arthroscopic Capsular Release.

Idiopathic adhesive capsulitis, or primary frozen shoulder syndrome, is a fairly common orthopaedic problem characterized by shoulder pain and loss of motion. In most cases, conservative treatment (6-month physical therapy program and intra-articular steroid injections) improves symptoms and restores shoulder motion. In refractory cases, arthroscopic capsular release is indicated. This surgical procedure carries several advantages over other treatment modalities. First, it provides precise and controlled release of the capsule and ligaments, reducing the risk of traumatic complications observed after forceful shoulder manipulation. Second, release of the capsule and the involved structures with a radiofrequency device delays healing, which prevents adhesion formation. Third, the technique is straightforward, and an oral postoperative steroid program decreases pain and allows for a pleasant early rehabilitation program. Fourth, the procedure is performed with the patient fully awake under an interscalene block, which boosts the patient's confidence and adherence to the physical therapy protocol. In patients with refractory primary frozen shoulder syndrome, arthroscopic capsular release emerges as a suitable option that leads to a faster and long-lasting recovery.

Tranexamic Acid Reduces Blood Loss and Transfusion in Patients Undergoing Total Knee Arthroplasty without Tourniquet: A Prospective Randomized Controlled Trial.

INTRODUCTION: Blood loss during and after total knee arthroplasty (TKA) can lead to substantial morbidity and the need for blood transfusions. There are several methods to minimize blood loss and to decrease transfusion rates in patients undergoing TKA. Tranexamic acid is an antifibrinolytic agent with known efficacy for achieving these goals. Currently, many surgeons are performing TKA without the use of tourniquet. Consequently, the aim of the study is to evaluate whether tranexamic acid reduces blood loss during and after TKA without the adjunctive use of above-the-knee tourniquet. METHODS: We performed a prospective randomized controlled trial (1:1 fashion) on the use of tranexamic acid versus placebo in 50 patients undergoing TKA (without tourniquet). The treatment group received two (preoperative and postoperative) 15 mg/kg doses. The primary endpoint was blood transfusion rate. We collected data about demographic and procedural characteristics, hemoglobin and hematocrit values, drain blood loss at 24 hours as well as adverse events. RESULTS: There were no transfusions in the treatment group, whereas 32% of the control group required transfusion (p<0.01). The treatment group had higher hematocrit and hemoglobin levels at 24, 48 and 72 hours after surgery (all p<0.01) and lower drain loss at 24hours (363.4±141 vs 626±260ml, p=<0,001). There were no in-hospital or six-month thromboembolic complications. DISCUSSION: A double-dose of tranexamic acid was safe and effective, reducing blood loss and preventing the need of blood transfusion in patients undergoing TKA without above-the-need tourniquet.

ISAKOS upper extremity committee consensus statement on the need for diversification of the Rockwood classification for acromioclavicular joint injuries.

Optimal treatment for the unstable acromioclavicular (AC) joint remains a highly debated topic in the field of orthopaedic medicine. In particular, no consensus exists regarding treatment of grade III injuries, which are classified according to the Rockwood classification by disruption of both the coracoclavicular and AC ligaments. The ISAKOS Upper Extremity Committee has provided a more specific classification of shoulder pathologies to enhance the knowledge on and clinical approach to these injuries. We suggest the addition of grade IIIA and grade IIIB injuries to a modified Rockwood classification. Grade IIIA injuries would be defined by a stable AC joint without overriding of the clavicle on the cross-body adduction view and without significant scapular dysfunction. The unstable grade IIIB injury would be further defined by therapy-resistant scapular dysfunction and an overriding clavicle on the cross-body adduction view.

Tenodesis bicipital supra-pectoral artroscópica / Arthroscopic suprapectoral biceps tenodesis

Como resultado de inestabilidad o cambios degenerativos del tendón, el compromiso de la porción larga del bíceps es una fuente frecuente de dolor del hombro en la práctica diaria. A pesar de los buenos resultados reportados de la tenotomía, la tenodesis del bíceps es preferible para los pacientes de alta demanda. Con respecto a la fuerza de flexión y la supinación del antebrazo y el resultado estético, la tenodesis supera los resultados de la tenotomía. La tenodesis proximal tiene una alta incidencia de dolor postoperatorio a nivel de la corredera, por lo cual realizar tenodesis más distales llevaría a prevenir este dolor luego del procedimiento. En el presente artículo, describimos la técnica quirúrgica de la Tenodesis Bicipital Supra-pectoral Artroscópica.

As a result of tendon instability or degenerative changes, the involvement of the long head of the biceps tendon constitutes a common source of shoulder pain in daily practice. Despite the rewarding results obtained with biceps tenotomy, biceps tenodesis is preferable in patients with high demands. The biceps tenodesis yields to improved outcomes as regards forearm flexion and supination strength and cosmesis. Proximal biceps tenodesis has a high incidence of postoperative soreness at the groove. Thus it may be beneficial to move distal with the tenodesis to prevent postoperative pain. In the present article, we describe the surgical technique of the Arthroscopic Supra-pectoral Biceps Tenodesis.

Management of disorders of the rotator cuff: proceedings of the ISAKOS upper extremity committee consensus meeting.

The goal of this article is to consolidate the International Society of Arthroscopy, Knee Surgery & Orthopaedic Sports Medicine (ISAKOS) Upper Extremity Committee's (UEC's) current knowledge on rotator cuff disease and management, as well as highlight key unresolved issues. The rotator cuff is an anatomically complex structure important for providing glenohumeral function and stability as part of a closed chain system. Current consensus suggests rotator cuff injuries are most accurately diagnosed, at levels similar to diagnosis by magnetic resonance imaging, with a combination of cuff- and impingement-specific clinical tests. Updates in the understanding of acromion morphology, the insertional anatomy of the rotator cuff, and the role of suprascapular nerve release may require changes to current classification systems and surgical strategies. Although initial management focuses on nonoperative protocols, discussion continues on whether surgery for isolated impingement is clinically more beneficial than rehabilitation. However, clear indications have yet to be established for the use of single- versus double-row repair because evidence confirms neither is clinically efficacious than the other. Biceps tenodesis, however, in non-isolated cuff tears has proven more successful in addressing the etiology of shoulder pain and yields improved outcomes over tenotomy. Data reviewing the benefits of tendon transfers, shoulder prostheses, and mechanical scaffolds, as well as new research on the potential benefit of platelet-rich plasma, pluripotential stem cells, and gene therapies, will also be presented.

¿Es la cirugía artroscópica adecuada para las revisiones en inestabilidad de hombro? Selección de pacientes y resultados / Arthroscopic surgery is appropriate for revisions in shoulder instability?: patients selection and results

Introducción: Tradicionalmente tanto la luxación recidivante de hombro como los casos de recurrencias en hombros ya operados, han sido tratadas con técnicas quirúrgicas abiertas. Con el advenimiento de técnicas de reconstrucción artroscópicas, en un principio, se reportaron tasas de recurrencia más altas que con las técnicas abiertas. Esos trabajos publicados evaluaron pacientes con una gran diversidad de problemas, incluyendo pacientes con déficit óseo y que además continuaron con la práctica de deportes de contacto. Surge el interrogante si esas tasas de recurrencia serían altas también en pacientes sin déficit óseo y que decidieran abandonar la práctica de deportes de colisión. Objetivo: Determinar la tasa de recurrencia y los resultados funcionales luego de la cirugía de revisión artroscópica para la estabilización del hombro, en pacientes sin déficit óseo considerable y en aquellos que discontinuaron su participación en deportes de contacto. Material y Métodos: Dieciséis (16) pacientes en los cuales se realizó cirugía de revisión artroscópica, luego de procedimientos primarios fallidos, fueron evaluados en forma retrospectiva. En todos los casos se utilizaron anclajes óseos para la reparación de la lesión labral y ligamentaria. La técnica artroscópica fue seleccionada en pacientes con lesión unilateral traumática y con déficit óseos leves a moderados. La estabilización artroscópica fue contraindicada en pacientes con: 1) Inestabilidad multidireccional, 2) Pérdida ósea de la glenoides mayor al 25 por ciento, 3) Lesión de Hill Sachs con compromiso mayor a un tercio de la superficie articular de la cabeza humeral, y 4) Pacientes decididos a retomar deportes de contacto. Con un promedio de seguimiento de 31 meses (rango entre 24-46 meses), se realizó la evaluación clínica comparativa de ambos hombros con el examen físico y varias escalas funcionales validadas (Rowe, UCLA, y Constant & Murley). Resultados: El promedio del puntaje de las escalas de evaluación aumentó en todos los casos. El de UCLA fue de 22-31, el de Constant & Murley 69-80 y el de Rowe 33-80. Hubo 3 fallas o recidivas entre los 16 pacientes, 2 presentaron luxaciones y un episodio de subluxación el restante. Una de estas fallas fue causada por un nuevo evento traumático y fue resuelto quirúrgicamente con técnica abierta de Latarjet. Los otros 2 pacientes se negaron a un nuevo procedimiento quirúrgico. Conclusiones: La cirugía de revisión, por artroscopía de casos fallidos de inestabilidad del hombro mediante anclajes óseos, demostró una baja tasa de recurrencia y una aceptable recuperación de la función en pacientes sin déficit óseos considerables y que no participan en deportes de contacto.