RESUMO
BACKGROUND: Despite recent advances in arthroscopic rotator cuff repair, the retear rate remains high. New methods to optimize healing rates must be sought. Bone channeling may create a quicker and more vigorous healing response by attracting autologous mesenchymal stem cells, cytokines, and growth factors to the repair site. HYPOTHESIS: Arthroscopic rotator cuff repair with bone channeling would result in a higher healing rate compared with arthroscopic rotator cuff repair without adjuvant channeling. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Our primary objective was to compare healing rates in patients undergoing arthroscopic rotator cuff repair for degenerative tears, with and without bone channeling. Secondary objectives included comparisons of the Western Ontario Rotator Cuff Index (WORC) score, American Shoulder and Elbow Surgeons (ASES) score, Constant score, Constant strength subscore, and visual analog scale (VAS) for pain score between groups. Patients undergoing arthroscopic rotator cuff repair were recruited at 3 sites and were randomized to receive either bone channeling augmentation or standard repair. Healing was determined via ultrasound at 24 months postoperatively. WORC, ASES, and Constant scores were compared between groups at baseline and at 3, 6, 12, and 24 months postoperatively. RESULTS: A total of 168 patients were enrolled between 2013 and 2018. Intention-to-treat analysis revealed no statistical differences in healing rates between the 2 interventions at 24 months postoperatively. Statistically significant improvements occurred in both groups from preoperatively to all time points for the WORC, the ASES score, the Constant score or Constant strength subscore, and the VAS for pain (P < .0001). No differences were observed between the bone channeling and control groups in WORC, ASES, Constant, and VAS pain scores at any time point. CONCLUSION: This trial did not demonstrate the superiority of intraoperative bone channeling in rotator cuff repair over standard rotator cuff repair at 24 months postoperatively. Healing rates, patient-reported function, and quality-of-life outcomes were similar between groups. REGISTRATION: NCT01877772 (ClinicalTrials.gov identifier).
Assuntos
Lesões do Manguito Rotador , Manguito Rotador , Humanos , Manguito Rotador/cirurgia , Lesões do Manguito Rotador/cirurgia , Resultado do Tratamento , Ombro , Artroscopia/métodos , DorRESUMO
Surgical skills education is in the process of a crucial transformation from a master-apprenticeship model to simulation-based training. Orthopaedic surgery is one of the surgical specialties where simulation-based skills training needs to be integrated into the curriculum efficiently and urgently. The reason for this strong and pressing need is that orthopaedic surgery covers broad human anatomy and pathologies and requires learning enormously diverse surgical procedures including basic and advanced skills. Although the need for a simulation-based curriculum in orthopaedic surgery is clear, several obstacles need to be overcome for a smooth transformation. The main issues to be addressed can be summarized as defining the skills and procedures so that simulation-based training will be most effective; choosing the right time period during the course of orthopaedic training for exposure to simulators; the right amount of such exposure; using objective, valid and reliable metrics to measure the impact of simulation-based training on the development and progress of surgical skills; and standardization of the simulation-based curriculum nationwide and internationally. In the new era of surgical education, successful integration of simulation-based surgical skills training into the orthopaedic curriculum will depend on efficacious solutions to these obstacles in moving forward.
Assuntos
Anestésicos Locais/administração & dosagem , Artroplastia do Ombro/métodos , Bupivacaína/administração & dosagem , Dexametasona/administração & dosagem , Bloqueio Nervoso/métodos , Ombro/cirurgia , Procedimentos Cirúrgicos Ambulatórios , Anestesia Geral , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Alta do PacienteRESUMO
BACKGROUND: Capitellar and trochlear fractures are uncommon fractures of the distal aspect of the humerus. There is limited information about the functional outcome of patients managed with open reduction and internal fixation. METHODS: The functional outcome of twenty-eight patients, with a mean age (and standard deviation) of 43 +/- 13 years, who were treated with open reduction and internal fixation for capitellar and trochlear fractures was evaluated at a mean duration of follow-up of 56 +/- 33 months. Patient outcomes were assessed with physical and radiographic examination, range-of-motion measurements, strength testing, and self-reported questionnaires (Short Form-36, Mayo Elbow Performance Index, American Shoulder and Elbow Surgeons Elbow Assessment Form, and Patient-Rated Elbow Evaluation scales). RESULTS: Eleven fractures involved the capitellum with or without fracture of the lateral ridge of the trochlea, four involved the capitellum and trochlea as one piece, and thirteen involved the capitellum and trochlea as separate fragments. These fractures were further characterized by the presence or absence of posterior comminution. Fourteen patients had isolated fractures, and fourteen had other elbow, forearm, or wrist injuries. Patients with more complex fractures required more extensive surgery, had more complications resulting in secondary procedures, and had poorer outcomes compared with those with simple fractures. The average score on the Mayo Elbow Performance Index (91 +/- 11), the average quality-of-life scores (46 on the physical component and 50 on the mental component of the Short Form-36), and the average range of motion (19 degrees to 138 degrees ) suggest favorable patient outcomes overall. Two comminuted fractures did not unite and required conversion to a total elbow arthroplasty. CONCLUSIONS: Patients with isolated noncomminuted capitellar and/or trochlear fractures have better results than those with more complex fractures. A classification system based on the radiographic patterns of these fractures is recommended.
Assuntos
Fixação Interna de Fraturas , Fraturas do Úmero/cirurgia , Adulto , Idoso , Artroplastia de Substituição , Articulação do Cotovelo/fisiopatologia , Feminino , Seguimentos , Fixação Interna de Fraturas/instrumentação , Fixação Interna de Fraturas/métodos , Fraturas Cominutivas/diagnóstico por imagem , Fraturas Cominutivas/fisiopatologia , Fraturas Cominutivas/cirurgia , Fraturas não Consolidadas/etiologia , Força da Mão/fisiologia , Humanos , Fraturas do Úmero/diagnóstico por imagem , Fraturas do Úmero/fisiopatologia , Masculino , Pessoa de Meia-Idade , Contração Muscular/fisiologia , Satisfação do Paciente , Complicações Pós-Operatórias , Qualidade de Vida , Radiografia , Amplitude de Movimento Articular/fisiologia , Reoperação , Estudos Retrospectivos , Resultado do TratamentoRESUMO
This case report introduces arthroscopic debridement as a new method of treating an irreducible knee dislocation. The clinical presentation of 2 patients with irreducible knee dislocations, including history, physical examination, a clinical photograph, radiographs, and magnetic resonance images, is presented. As well, intraoperative arthroscopic photographs are included that show the effectiveness of the treatment. A review of the literature reveals that irreducible knee dislocations are rare. The finding of a skin furrow along the joint line was present in all cases. Past treatment usually involved an open procedure to remove the capsuloligamentous structures from the joint. We show that arthroscopy with debridement of these structures resulted in reduction of the joint. Follow-up arthroscopy in 1 patient showed healing of the previously debrided ligament. The ability to debride the interposed soft tissue through the arthroscope allows for reduction of the joint without the need for an open procedure.