Diagnosis of Achilles Insertional Tendinopathies by Algometry.

INTRODUCTION: Diagnosis of Achilles insertional tendinopathies (AIT) is based on pain by tendon palpation. However, there is no consensus or standard with regard to the amount of force to be used during the evaluation. Algometry is a method of measuring the pressure applied in a specific region and can be a method for determining diagnosis values. GOAL: To determine a cutoff value for pain threshold (PT) in the assessment of AIT. DESIGN: This is a prospective case-control study of diagnostic accuracy, to develop a diagnostic criterion. METHODS: Forty asymptomatic individuals and forty patients with AIT, matched by age and sex, were evaluated and submitted to algometry for PT and for visual analog scale (VAS) levels with 3 kgf at the insertion of the calcaneal tendon by two different evaluators. Inter-observer reproducibility was assessed through the interclass correlation coefficient (ICC). Sensitivity and specificity calculations of PT and of VAS were calculated and plotted on a receiver operating characteristic curve. RESULTS: The lowest ICC found was 0.788. With regard to the diagnosis through PT , the 4.08-kgf value showed the best relation between sensitivity and specificity (92.5% and 92.5%, respectively). Algometry values lower than 4.08 were considered positive for disease. For the diagnosis of AIT through VAS with 3 kgf, the value of 2.98 was estabilished (sensitivity of 92.5% and specificity of 97.5%). CONCLUSION: Algometry was shown to be a simple and reliable method for diagnosing AIT. Values of PT less than 4.08 kgf were found to be predictors of the disease.

Does Biceps Tenotomy or Tenodesis Have Better Results After Surgery? A Systematic Review and Meta-analysis.

BACKGROUND: Although tenotomy and tenodesis are frequently used for long head of the biceps tendon lesions, controversies remain as to which technique is superior regarding pain, functionality, complications, and cosmetic appearance. QUESTIONS/PURPOSES: (1) For long head of biceps tendon lesions, does tenotomy or tenodesis result in greater improvements in VAS score for pain? (2) Which approach has superior results when evaluating function outcome (Constant) scores? (3) Does tenotomy or tenodesis have fewer complications? (4) Does tenotomy or tenodesis result in better cosmesis (Popeye sign)? METHODS: A systematic review was performed in the Cochrane Library, Embase, PubMed, and Literatura Latino Americana e do Caribe em Ciências da Saúde (LILACS) using the keywords "long head of the biceps tendon," "biceps tenodesis," and "tenotomy." We completed the search in June 2020. The inclusion criteria were randomized controlled trials and quasirandomized controlled trials that investigated tenodesis and tenotomy with no language restriction and evaluation of adult patients who presented with a long head of the biceps tendon lesion, associated with other lesions or not, without previous shoulder surgeries and who had no response to nonoperative treatment. The initial search yielded 239 studies, 40 of which were duplicates. We assessed the titles and abstracts of 199 articles and excluded all studies that were not randomized controlled trials (literature reviews) or that compared different techniques. We assessed the full text of 14 articles and excluded the ones that were protocols and cohort studies. We evaluated the risk of bias using the Cochrane Collaboration tool. We included eight studies in this systematic review and meta-analysis, with a total of 615 participants, 306 of whom were treated with tenotomy and 309 with tenodesis. The median duration of follow-up was 2 years. Overall, the included studies had a low risk of bias. The complications evaluated were adhesive capsulitis, biceps brachii tear, cramps, and a subsequent second surgical procedure. We used a random model in this meta-analysis so that we could generalize the results beyond the included studies. In this study, we only reported differences between the groups if they were both statistically valid and larger than the minimum clinically important difference (MCID). RESULTS: Comparing tenotomy and tenodesis, we observed no difference between the groups regarding pain in the long term (mean difference 0.25 [95% confidence interval -0.29 to 0.80]; p = 0.36). There was no difference in Constant score in the long-term (mean difference -1.45 [95% CI -2.96 to 0.06]; p = 0.06). There were no differences when evaluating for major complications (odds ratio 1.37 [95% CI 0.29 to 6.56]; p = 0.70). There were not enough papers evaluating adhesive capsulitis, cramping, and risk of revision surgery. Popeye sign was more frequent in the tenotomy group than in the tenodesis group (OR 4.70 [95% CI 2.71 to 8.17]; p < 0.001). CONCLUSION: This systematic review demonstrated that tenotomy and tenodesis offer satisfactory treatment for long head of the biceps tendon lesions. In terms of pain improvement and Constant score, there was no difference between the techniques, but patients undergoing tenotomy have worse cosmetic results. Therefore, surgeons should choose the technique based on their skills and the patient's expectations of surgery, such as cosmesis and time to recovery. More studies are needed to evaluate complications such as adhesive capsulitis and cramping, as well as to compare duration of surgery and recovery time for each technique. LEVEL OF EVIDENCE: Level I, therapeutic study.

How one treats lateral epicondylitis - a survey among Brazilian orthopedists.

BACKGROUND: Lateral epicondylitis (LE), also known as tennis elbow, is the most common painful elbow condition. It affects approximately 1-3% of adults. There are various possible treatments described in the literature, but evidence to support a gold standard management protocol is lacking. Therefore, the objective of this study was to evaluate how Brazilian orthopaedists diagnose and treat lateral epicondylitis and compare these results with the available evidence. METHODS: This is an observational, analytical, cross-sectional study. A questionnaire was prepared to obtain information from the participants with eight specific questions (2 on diagnosis and 6 on treatment). These questions were answered voluntarily by participants at 3 major congresses of orthopaedists in Brazil in 2018. The results were analysed in accordance with the overall number of responses and were evaluated among groups according to subspecialty. RESULTS: We obtained a total of 501 questionnaires. Of these, 33 were excluded. The mean age was 38.67 years. The majority of respondents (91%) were male. We obtained 26.7% from specialists in hand surgery (Hand group), 36.5% from subspecialists in shoulder and elbow (Shoulder and Elbow group), and 36.8% from generalists in orthopaedics or from other subspecialties (General Orthopaedists group). For diagnosis, 24.4% did not initially request any imaging method. The most requested exam was ultrasonography (54.9%). The most prominent indication for initial treatment was physical therapy. For refractory cases, 78.3% of the respondents preferred doing a local infiltration. The most commonly used substance for local infiltrations was corticosteroids (89.6%). With respect to the surgical treatment option, 75.8% of those who recommend it prefer open techniques, and 24.2% prefer arthroscopic treatment. Of the total respondents, 12.8% did not recommend surgical treatment for LE. CONCLUSION: Among Brazilian orthopaedists, the Cozen test is most frequently chosen, and ultrasound is the most commonly used imaging tool. Nonsurgically, oral nonsteroidal anti-inflammatory drugs (NSAIDs) plus physiotherapy is the most popular initial therapy, and corticosteroids are the most popular type of infiltration agent. Most surgeons recommended surgery after 6 months of nonsurgical treatment, and 75.8% preferred the open technique.

Supraspinatus tears: predictability of magnetic resonance imaging findings based on clinical examination.

BACKGROUND: The shoulder physical examination is frequently performed to diagnose rotator cuff tears in clinical practice; however, there is insufficient evidence on which physical tests are efficient for shoulder impingements in primary care settings. The purposes of this study were (1) to analyze the accuracy of 8 clinical tests to diagnose supraspinatus tendon lesions and investigate whether the combination of these tests can improve the diagnostic values; (2) to assess which are the best positivity criteria for shoulder maneuvers-pain and/or weakness; and (3) to investigate the ability of these tests to distinguish between partial- and full-thickness tears. METHODS: A total of 733 consecutive patients were prospectively evaluated by 4 shoulder surgeons in this multicenter diagnostic study from May 2017 to December 2018, and 8 clinical tests (empty-can, full-can test, drop arm, painful arc, Neer sign, Hawkins test, Patte test, and resisted external rotation) were compared with magnetic resonance imaging performed by blinded radiologists. We assessed the sensitivity, specificity, accuracy, positive and negative predictive values, and diagnostic odds ratio (DOR) for all tests. RESULTS: For overall supraspinatus tears, the empty-can test showed the highest sensitivity (0.81), the Patte test (positive for pain and weakness) and the drop-arm test showed the highest specificity (0.99 and 0.98, respectively), and the best combination was the Neer sign and the drop-arm test (DOR, 12.92). The positivity criteria for pain associated with weakness showed the highest performance, with DORs of 16.94 for the Patte test and 10.45 for the empty-can test. The Patte test and resisted external rotation, positive for pain and weakness, showed the highest ability to distinguish between full- and partial-thickness tears (DOR, 5.69 and 5.35, respectively). The shoulder maneuvers showed low negative predictive values; the highest value (0.58) was found with the empty-can test. CONCLUSIONS: (1) The clinical tests demonstrated excellent diagnostic values; the empty-can test had the highest sensitivity, whereas the drop-arm test and the Patte test had the highest specificity; and the best combination for detecting supraspinatus tears was the Neer sign and the drop-arm test. On the other hand, the physical examination findings showed limited values to rule out tears. (2) The best positivity criterion for shoulder maneuvers was pain associated with weakness. (3) The Patte test and resisted external rotation showed the highest ability to distinguish between full- and partial-thickness tears.

Crossed versus lateral K-wire fixation of supracondylar fractures of the humerus in children: a meta-analysis of randomized controlled trials.

BACKGROUND: Supracondylar fractures of the humerus are common in children. Whether fixation should be performed with crossed or lateral wires remains controversial. We performed a meta-analysis of randomized controlled trials to evaluate both techniques in terms of the function of the elbow and the risk of neurologic injury and loss of reduction. We also assessed the quality of the evidence currently available. METHODS: The MEDLINE, Embase, Cochrane Library, and LILACS (Latin American and Caribbean Health Sciences Literature) databases, as well as ongoing clinical trial databases, were searched until March 2020. The main outcomes were function, measured by the Flynn criteria, and complications (neurologic lesions and loss of reduction). A meta-analysis was conducted using relative risk (RR) analysis for dichotomous variables and difference in means for continuous variables. Heterogeneity was tested using the I2 statistic. RESULTS: Twelve trials, with a total of 930 patients, met the inclusion criteria. Both groups (crossed-wire and lateral-wire fixation) presented satisfactory functional results, with no difference between them (RR, 0.99; 95% confidence interval [CI], 0.96-1.02; P = .44). Patients undergoing crossed-wire fixation had a higher risk of iatrogenic neurologic injury (RR, 0.45; 95% CI, 0.21-0.99; P = .05). The crossed group showed greater fixation stability, with a lower incidence of loss of fracture reduction (RR, 1.39; 95% CI, 1.04-1.85; P = .03). The GRADEpro GDT (Guideline Development Tool) showed that the quality of evidence of the evaluated outcomes was low or very low. CONCLUSION: There is evidence of very low quality that fixation with lateral wires is safer regarding iatrogenic nerve lesions whereas fixation with crossed wires is more effective at maintaining fracture reduction.

Magnetic resonance imaging reproducibility for rotator cuff partial tears in patients up to 60 years.

BACKGROUND: Magnetic resonance imaging (MRI) is the gold standard in diagnosing rotator cuff pathology; however, there is a lack of studies investigating the reliability agreement for supraspinatus partial-thickness tears among orthopaedic surgeons and musculoskeletal (MSK) radiologists. METHODS: Sixty digital MRI scans (1.5 Tesla) were reviewed by two orthopaedic shoulder surgeons, two MSK radiologists, two fellowship-trained shoulder surgeons, and two fellowship-trained orthopaedic surgeons at two distinct times. Thirty-two scans of partial-thickness tears and twenty-eight scans of the supraspinatus tendon with no tears were included. Supraspinatus tendonosis and tears, long head of the biceps pathology, acromial morphology, acromioclavicular joint pathology and muscle fatty infiltration were assessed and interpreted according to the Goutallier system. After a four-week interval, the evaluators were asked to review the same scans in a different random order. The statistical analyses for the intra- and interobserver agreement results were calculated using the kappa value and 95% confidence intervals. RESULTS: The intraobserver agreement for supraspinatus tears was moderate among the MSK radiologists (k = 0.589; 95% CI, 0.446-0.732) and the orthopaedic shoulder surgeons (k = 0.509; 95% CI, 0.324-0.694) and was fair among the fellowship-trained shoulder surgeons (k = 0.27; 95% CI, 0.048-0.492) and the fellowship-trained orthopaedic surgeons (k = 0.372; 95% CI, 0.152-0.592). The overall intraobserver agreement was good (k = 0.627; 95% CI, 0.576-0.678). The intraobserver agreement was moderate for biceps tendonosis (k = 0.491), acromial morphology (k = 0.526), acromioclavicular joint arthrosis (k = 0.491) and muscle fatty infiltration (k = 0.505). The interobserver agreement results for supraspinatus tears were fair and poor among the evaluators: the MSK radiologists and the orthopaedic shoulder surgeons had the highest agreement (k = 0.245; 95% CI, 0.055-0.435). CONCLUSIONS: In this sample of digital MRI scans, there was an overall good intraobserver agreement for supraspinatus partial tears; however, there were also poor and fair interobserver agreement results. The evaluators with higher levels of experience (the orthopaedic shoulder surgeons and the MSK radiologists) demonstrated better results than evaluators with lower levels of experience.

Correlation of the degree of clavicle shortening after non-surgical treatment of midshaft fractures with upper limb function.

BACKGROUND: Despite the use of non-surgical methods to treat for the majority of midshaft fractures of the clavicle, it is remains controversial whether shortening of this bone following non-surgical treatment of a middle third fracture affects upper limb function. METHODS: We conducted a cohort study by sequentially recruiting 59 patients with a fracture of the middle third of the clavicle. All patients were treated nonsurgically with a figure-of-eight bandage until clinical and radiological findings indicated healing of the fracture. Functional outcome was assessed using the Disability of Arm, Hand and Shoulder (DASH) score revalidated for the Portuguese language, other outcomes assessed included: pain measured by visual analogue scale (VAS); radiographies to measure the degree of shortening, fracture consolidation and fracture malunion. Information were also collected regarding the mechanism of injury, patient's daily activities level and epidemiological features of the patient cohort. The results of our findings are expressed as the comparison of the functional outcome with the degree of shortening. RESULTS: Patients were assessed six weeks and one year after injury. In the first evaluation, the mean DASH score was 28.84 and pain measured by VAS was 2.57. In the second evaluation (one year after injury) the mean DASH score was 8.18 and pain was 0.84. The mean clavicle shortening was 0.92 cm, ranging from 0 to 3 cm (SD = 0.64). There were no correlation between the degree of shortening and DASH score after six weeks and one year (p = 0.073 and 0.706, respectively). When only patients with of shortening greater than 2 cm were assessed for correlation, the result did not change. CONCLUSION: We conclude that clavicle shortening after nonsurgical treatment with a figure-of-eight bandage does not affect limb function, even when shortening exceeds 2 cm. TRIAL REGISTRATION: ISRCTN85206617 . Registered 12 May 2014.

Comparing shoulder maneuvers to magnetic resonance imaging and arthroscopic findings in patients with supraspinatus tears.

BACKGROUND: Shoulder maneuvers and magnetic resonance imaging (MRI) are performed to diagnose supraspinatus tendon tears regardless of arthroscopy exam. Although there are many studies on this subject, there is a lack of studies comparing the sensitivity (Se) and specificity (Sp) of shoulder maneuvers and MRI to arthroscopic findings (intact, partial, or full thickness supraspinatus tendon tear). AIM: To compare the diagnostic values of shoulder maneuvers with MRI for supraspinatus tendon tears in patients undergoing shoulder arthroscopy. METHODS: A total of 199 consecutive patients from four orthopedic centers met the eligibility criteria of shoulder pain persisting for at least four weeks. They were prospectively enrolled in this study from April 2017 to April 2019. Seven clinical tests (full can, empty can, drop arm, Hawkins', painful arc, Neer's sign and resisted external rotation) and MRI were performed, and all were compared with surgical findings. Full can, empty can and resisted external rotation tests were interpreted as positive in the case of pain and/or weakness. We assessed the Se, Sp, accuracy, positive predictive value (PPV) and negative predictive value (NPV), positive and negative likelihood ratio and diagnostic odds ratio for overall, partial and full-thickness supraspinatus tears. RESULTS: MRI had the highest Se for overall (0.97), partial (0.91) and full-thickness (0.99) tears; moreover, MRI had the highest NPV: 0.90, 0.88 and 0.98 for overall, partial and full-thickness tears, respectively. For overall supraspinatus tears, the Se and PPV were: Painful arc (Se = 0.85/PPV = 0.91), empty can (pain) (Se = 0.80/PPV = 0.89), full can (pain) (Se = 0.78/PPV = 0.90), resisted external rotation (pain) (Se = 0.48/PPV = 0.87), drop arm (Se = 0.19/PPV = 0.97), Neer's sign (Se = 0.78/PPV = 0.93) and Hawkins' (Se = 0.80/PPV = 0.88). MRI had the highest PPV (0.99). The Hawkin's test had the highest false positive rate in patients with intact tendons (0.36). The Sp of the empty can and full can (both tests positive for pain and weakness), drop arm and MRI were: 0.93, 0.91, 0.98 and 0.96, respectively. For partial and full-thickness tears, the empty can test (positive for pain and weakness) had a Sp of 0.93, and the drop arm and MRI had the same Sp (0.98). CONCLUSION: Physical examination demonstrated good diagnostic value, the drop arm test had a Sp as good as MRI for supraspinatus tears; however, MRI was more accurate in ruling out tears. The Hawkins' test had high false-positive findings in patients with intact tendons.

Effectiveness of subacromial injections in rotator cuff lesions: systematic review and meta-analysis protocol.

INTRODUCTION: Subacromial injections are therapeutic options for rotator cuff injuries, with consistent results not well established yet for each drug applied. The objective of this systematic review and meta-analysis is to analyse the effectiveness of the substances used in subacromial injections for the treatment of rotator cuff injuries and shoulder impingement syndrome, considering the functional gain and pain improvement of the shoulder. METHODS AND ANALYSIS: Beginning in November 2022, we will perform a detailed search using the MEDLINE/PubMed, EMBASE, Cochrane Central Register of Controlled Trials and LILACS databases. Relevant grey literature (reference lists, conference abstracts and academic papers) will also be included.Two reviewers will independently screen and extract the information from the literature. Bias and quality of the included studies will be evaluated using the risk of bias assessment tool provided by the Cochrane Collaboration. Statistical analyses will be performed using Review Manager V.5.4 software. ETHICS AND DISSEMINATION: Approval and patient informed consent are not required because we will only include published literature. The results of this research will be disseminated in a peer-reviewed journal and likely through other scientific events. PROSPERO REGISTRATION NUMBER: CRD42020199292.

Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fracture: a protocol for an overview of systematic reviews.

INTRODUCTION: Hip arthroplasties for the treatment of displaced femoral neck fractures in adults can be total replacement or hemiarthroplasty. Despite the high prevalence of these fractures and large number of studies on the topic, the best choice of arthroplasty to be used remains unclear. The present study aims to overview the results of systematic reviews of randomised controlled trials (RCTs) comparing outcomes between total hip replacement and hemiarthroplasty for displaced femoral neck fractures in adults. METHODS AND ANALYSIS: Four electronic databases (Pubmed, Embase, Cochrane Library and Web of Science) and reference lists from previous reviews will be searched without language limitation. Eligible studies will be systematic reviews of RCT that compare total hip replacement and hemiarthroplasty for treatment of displaced femoral neck fractures in adults. Two reviewers will independently perform study selection, data extraction and quality assessment. Disagreements between reviewers will be resolved by a third reviewer. Comparisons of dichotomous data will report as the OR and 95% CI, and comparisons of functional and health-related quality of life outcomes are reported as the mean difference and 95% CI and as the risk difference, defined as the difference in the proportion achieving the minimum clinically important difference and 95% CI. As this overview will contribute to orthopaedic surgeons and health managers in better decision-making for the treatment of these fractures. The authors plan to complete the searches and analyses by 30 November 2021. ETHICS AND DISSEMINATION: Ethical approval was obtained at Federal University of Sao Paulo. Findings will be disseminated through peer-reviewed publication. PROSPERO REGISTRATION NUMBER: CRD42021237885.

HETEROTOPIC OSSIFICATION IN ACETABULAR FRACTURES: SYSTEMATIC REVIEW AND META-ANALYSIS OF PROPHYLAXIS.

OBJECTIVE: Heterotopic ossification is defined as the formation of trabecular bone in soft tissues. It is a common complication after surgical treatment of acetabular fractures. However, its prophylaxis and treatment are still controversial. The objective of this research is to evaluate the effectiveness of actions to prevent the development of heterotopic ossification after surgical correction of acetabular fractures. METHODS: A systematic review was carried out with research in the databases PubMed/MEDLINE, Embase, LILACS and Cochrane until August 4, 2020, without restrictions on language and year of publication. Only randomized clinical studies carried out in humans without restrictions based on the dosage of treatments, use and duration of prophylaxis were included in this review. RESULTS: Two studies compared the use of radiotherapy and indomethacin and three compared the use of indomethacin with a placebo or non-indomethacin group. The meta-analysis calculations did not indicate statistical differences between radiotherapy versus indomethacin (RR 1.45, IC 95% 0.97 to 2.17, p = 0,55) and indomethacin versus placebo or not indomethacin (RR 0.85, IC 95% 0.68 to 1.06, p = 0,59). Conclusion: There is insufficient evidence to affirm that the use of radiotherapy or indomethacin are effective to prevent the formation of heterotopic ossification after surgery for fractures of the acetabulum. In addition, the number of complications was higher in the indomethacin group when compared to placebo or no intervention. Level of Evidence I, Systematic Review.

OBJETIVO: A profilaxia e o tratamento da ossificação heterotópica ainda são controversos. O objetivo desta pesquisa foi avaliar a efetividade das intervenções para prevenir o desenvolvimento da ossificação heterotópica após a fixação cirúrgica das fraturas do acetábulo. MÉTODOS: Foi realizada uma revisão sistemática com pesquisa nas bases de dados PubMed/MEDLINE, Embase, LILACS e Cochrane até 4 de agosto de 2020, sem restrições quanto ao idioma e ano de publicação. Foram incluídos apenas ensaios clínicos randomizados realizados em humanos sem restrições com base na dosagem dos tratamentos, no uso e na duração da profilaxia. Cálculos de metanálise foram realizados utilizando o software Review Manager desenvolvido pela Cochrane. RESULTADOS: Dois estudos compararam o uso de radioterapia e indometacina e três compararam o uso de indometacina com um grupo placebo ou não indometacina. Os cálculos de metanálise não indicaram diferenças estatísticas entre radioterapia versus indometacina (RR 1.45, IC de 95% 0.97 a 2.17, p = 0,55) e indometacina versus placebo ou não indometacina (RR 0.85, IC de 95% 0.68 a 1.06, p = 0,59). CONCLUSÃO: Não há evidências suficientes para afirmar que a utilização da radioterapia ou da indometacina é efetiva para prevenir a formação da ossificação heterotópica após cirurgias por fraturas do acetábulo. Além disso, o número de complicações foi maior no grupo indometacina quando comparado ao placebo ou à não intervenção. Nível de Evidência I, Revisão Sistemática.

Shockwave Therapy Plus Eccentric Exercises Versus Isolated Eccentric Exercises for Achilles Insertional Tendinopathy: A Double-Blinded Randomized Clinical Trial.

BACKGROUND: There remains a lack of consensus regarding the treatment of Achilles insertional tendinopathy. The condition is typically treated with eccentric exercises despite the absence of satisfactory and sustained results. Shockwave therapy was presented as an alternative, but there is a paucity of literature, with good outcomes, supporting its use. The purpose of the present single-center, double-blinded, placebo-controlled, randomized trial was to determine if the use of shockwave therapy in combination with eccentric exercises improves pain and function in patients with Achilles insertional tendinopathy. METHODS: A total of 119 patients with Achilles insertional tendinopathy were evaluated and enrolled in the study from February 2017 to February 2019. Patients were allocated to 1 of 2 treatment groups, eccentric exercises with extracorporeal shockwave therapy (SWT group) and eccentric exercises with sham shockwave therapy (control group). Three sessions of radial shockwaves (or sham treatment) were performed every 2 weeks and eccentric exercises were undertaken for 3 months. The primary outcome was the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A) at 24 weeks. Secondary outcomes included the visual analogue scale, algometry, the Foot and Ankle Outcome Score, and the 12-Item Short Form Health Survey. RESULTS: Both groups showed significant improvement during the study period; however, there were no between-group differences in any of the outcomes (all p >0.05). At the 24-week evaluation, the SWT group exhibited a mean VISA-A of 63.2 (95% confidence interval, 8.0) compared with 62.3 (95% confidence interval, 6.9) in the control group (p = 0.876). There was a higher rate of failure (38.3%) but a lower rate of recurrence (17.0%) in the SWT group compared with the control group (11.5% and 34.6%, respectively; p = 0.002 and p = 0.047). There were no complications reported for either group. CONCLUSIONS: Extracorporeal shockwave therapy does not potentiate the effects of eccentric strengthening in the management of Achilles insertional tendinopathy. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Protocol of BRICS: Brazilian multicentric pragmatic randomised trial of surgical interventions for displaced diaphyseal clavicle fracture study: MIPO versus ORIF for the treatment of displaced midshaft clavicle fractures.

INTRODUCTION: Fractures of the diaphysis of the clavicle are common; however, treatment guidelines for this condition are lacking. Surgery is associated with a lower risk of non-union and better functional outcomes but a higher risk of complications. Open reduction and internal fixation with plates and screws are the most commonly performed techniques, but they are associated with paraesthesia in the areas of incisions, extensive surgical exposure and high rates of implant removal. Minimally invasive techniques for treating these fractures have a lower rate of complications. The aim of this study is to evaluate which surgical treatment option (minimally invasive osteosynthesis or open reduction and internal fixation) has better prognosis in terms of complications and reoperations. METHODS AND ANALYSIS: The study proposed is a multicentric, pragmatic, randomised, open-label, superiority clinical trial between minimally invasive osteosynthesis and open reduction and internal fixation for surgical treatment of patients with displaced fractures of the clavicle shaft. In the proposed study, 190 individuals with displaced midshaft clavicle fractures, who require surgery as treatment, will be randomised. The assessment will occur at 2, 6, 12, 24 and 48 weeks, respectively. The primary outcome of the study will be the number of complications and reoperations. For sample size calculation, a moderate effective size between the techniques was considered in a two-tailed test, with 95% confidence and 90% power. Complications include cases of infection, hypertrophic scarring, non-union, refracture, implant failure, hypoesthesia, skin irritation and shoulder pain. Reoperations are defined as the number of surgeries for pseudoarthrosis, implant failure, infection and elective removal of the implant. ETHICS AND DISSEMINATION: Study approved by the institutional ethics committee (number 34249120.9.0000.5505-V.3). The results will be disseminated by publications in peer-reviewed journals and presentations in medical meetings. TRIAL REGISTRATION NUMBER: RBR-3czz68)/UTN U1111-1257-8953.

Glenoid failure after total shoulder arthroplasty with cemented all-polyethylene versus metal-backed implants: a systematic review protocol.

INTRODUCTION: Anatomical total shoulder arthroplasty (TSA) is an effective treatment adopted for patients with glenohumeral osteoarthritis (OA). The glenoid component failure is the main risk that occurs in this therapeutic choice; however, doubts remain regarding the selection of the best implant for avoiding complication. This systematic review aims to evaluate the glenoid component in TSA by comparing the complications of different types of implants. METHODS AND ANALYSIS: A systematic review of randomised clinical trials or quasi-randomised trials will be performed by applying the Preferred Reporting Items for Systematic Review and Meta-Analysis protocols and comparing polyethylene (keeled and pegged) versus metal-backed implants in adult patients with glenohumeral OA. Our search strategy will be performed using MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, EMBASE and Web of Science. Data management and extraction will be performed using a data withdrawal form and by analysing study method characteristics, participant characteristics, intervention characteristics, results and methodological domains. The database search will be performed by February 2021. The Grading of Recommendations Assessment, Development and Evaluation will be used for assessing the quality of evidence of each study selected; however, some critical and important outcomes were determined such as the shoulder function through functional scores (Constant-Murley and American Shoulder and Elbow Surgeons), complications represented by pain (Visual Analogue Scale), surgical revision, radiograph radiolucency and loosening. The confidence in estimated effects for these outcomes will be applied as the overall confidence. The outcomes will be defined as early or late, according to the postoperative follow-up of less than or greater than 1 year, respectively, for complications and radiographs. For the shoulder function, follow-ups will be divided into 6, 12 and 24 months. Heterogeneity is expected in systematic reviews; therefore, the selection of outcomes, as well as the sample size, and specific statistical analysis can lead to meta-analysis; however, if it fails, narrative evidence synthesis will be conducted. Other analyses such as descriptive, subgroup and sensitivity analyses will be performed whenever possible. This systematic review will, therefore, provide evidence concerning the best clinical practice for avoiding complications. ETHICS AND DISSEMINATION: This study has been approved by the Institutional Review Board of Universidade Federal de São Paulo (protocols 0725/2017, 2.157.415 and 70473017.5.0000.5505), and the findings will be disseminated through peer-reviewed publication and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42018079537.

Achilles Tendon Lesions - Part 1: Tendinopathies.

Calcaneal tendon injuries are extremely common in the general population and in orthopedics routine care. Its increasing incidence, which is motivated by an aging population, improved access to the health care system, increased prescription of continuous-use medication, erratic participation in sports and other factors, has had a direct impact on society. Consolidated treatment options for tendinopathies lack quality scientific support for many modalities. New therapies have emerged to enhance nonsurgical approach outcomes and to reduce the number of patients requiring surgery. Although these operative procedures provide good pain relief and functional outcomes, they are costly and may lead to complications.

Achilles Tendon Lesions - Part 2: Ruptures.

The increasing incidence of calcaneal tendon ruptures has substantially impacted orthopedic care and costs related to its treatment and prevention. Primarily motivated by the increasing of life expectancy, the growing use of tenotoxic drugs and erratic access to physical activity, this injury accounts for considerable morbidity regardless of its outcome. In recent years, the evolution of surgical and rehabilitation techniques gave orthopedists better conditions to decide the most appropriate conduct in acute tendon rupture. Although still frequent due to their high neglect rate, Achilles chronic ruptures currently find simpler and more biological surgical options, being supported by a new specialty-focused paradigm.

Intra and Interobserver Agreement Regarding the Walch Classification System for Shoulder Joint Arthritis.

Objective To evaluate the inter- and intraobserver agreement regarding the Walch classification system for shoulder arthritis. Methods Computed tomography scans of the shoulder joint of adult patients were selected between 2012 and 2016, and they were classified by physicians with different levels of expertise in orthopedics. The images were examined at three different times, and the analyses were evaluated by the Fleiss Kappa index to verify the intra- and interobserver agreement. Results The Kappa index for the intraobserver agreement ranged from 0.305 to 0.545. The inter-observer agreement was very low at the end of the three evaluations (κ = 0.132). Conclusion The intraobserver agreement regarding the modified Walch classification varied from moderate to poor. The interobserver agreement was low.

Shockwave Therapy Associated With Eccentric Strengthening for Achilles Insertional Tendinopathy: A Prospective Study.

Background. The usual initial treatment for insertional Achilles tendinopathy is nonsurgical. Yet there is no standard conservative treatment for Achilles insertional tendinopathy. Shockwave therapy (SWT) has become a reliable option for the management of this illness over the past years. The aim of this study is to report the effectiveness of low-energy SWT associated with an eccentric strengthening protocol in 19 consecutive patients. Methods. This is a prospective study with 19 patients aged between 26 and 72 years diagnosed with insertional Achilles tendinopathy. The protocol consisted of SWT associated with eccentric exercises for 12 weeks. All patients were evaluated on the first day and after 24 weeks (final follow-up) with the Victorian Institute of Sports Assessment-Achilles (VISA-A) score, visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) questionnaire, and by algometry. At the last follow-up, patients were also assessed for adherence to the protocol, complications and final outcome (in their perception as success or fail). Results and Conclusion. Fifteen (79%) patients were fully adherent to the Alfredson protocol, and 13 (68%) patients considered the treatment protocol successful. At the last evaluation, patients demanded higher pressure on calcaneus to trigger pain (algometry 1), reported less pain when the algometer was applied with 3 kg (algometry 2), had less global pain (VAS), and had higher AOFAS and VISA-A scores. This study evidences that eccentric loading associated with SWT can dramatically improve patients' symptoms. We can conclude that eccentric loading associated with SWT is an effective treatment for Achilles insertional tendinopathy. Levels of Evidence: Therapeutic, Level III: Prospective cohort.

RELATION BETWEEN IMPACT FACTOR IN ORTHOPEDIC JOURNALS AND LEVEL OF EVIDENCE.

OBJECTIVE: This study aims to assess the quality of articles published in the leading orthopedic surgery journals, by measuring the relation between the impact factor and the number studies with a high level of evidence. METHODS: A literature review was performed of articles published in four previously selected journals. A score of journal evidence (RER - Relation between Randomized clinical trials and Systematic reviews) was calculated, considering the number of RCTs and SR published and the total number of full-text articles. RESULTS: The selected journals were JBJS-Am, ASMJ, BJJ-Br and Arthroscopy, with Impact factors of 5.280, 4.362, 3.309 and 3.206 respectively in 2015. In the study, the RER Scores, in the same order, were 9.408, 6.153, 7.456 and 7.779. CONCLUSION: The journal JBJS-Am is the best available source of information on orthopedic surgery from this point of view. It has the highest Impact Factor and clearly the highest RER Score. On the other hand, we could conclude that the number of published RCT and good quality SR is very low, with less than 10% of all the articles. Level of evidence III, Analyses based on limited alternatives and costs, and poor estimates.

OBJETIVO: Este estudo tem como objetivo avaliar a qualidade dos artigos publicados nos principais periódicos de cirurgia ortopédica, medindo a relação entre o fator de impacto e o número de estudos com alto nível de evidência. MÉTODOS: Realizou-se a revisão de literatura com artigos publicados em quatro periódicos previamente selecionados. Um escore de evidência de periódicos (RER - Relação entre Ensaios Clínicos Randomizados e Revisões Sistemáticas) foi calculado, considerando-se o número de ECR e RS publicados e número total de artigos com textos completos. RESULTADOS: Os periódicos selecionados tiveram o fator de impacto de 5.280, 4.362, 3.309 e 3.206 respectivamente para JBJS-Am, ASMJ, BJJ-Br e Arthroscopy no ano de 2015. No estudo, os escores RER foram, na mesma ordem, 9.408, 6.153, 7.456 e 7.779. CONCLUSÃO: A revista JBJS-Am é a melhor fonte disponível de informações sobre cirurgia ortopédica deste ponto de vista. Tem o maior fator de impacto e claramente o maior escore RER. Por outro lado, pudemos concluir que o número de ECR e RS publicados de boa qualidade é muito baixo, com menos de 10% do total de artigos. Nível de Evidência III, Análises baseadas em alternativas e custos limitados, e estimativas ruins.

Sensitivity and specificity of ultrasonography in diagnosing supraspinatus lesions: a prospective accuracy diagnostic study.

BACKGROUND: This study was designed to define the accuracy of shoulder ultrasonography for diagnosing supraspinatus tendon tears. This examination is routinely used by orthopedists and may do away with the need for other examinations for diagnosing these tendon injuries. The aim of this study was to evaluate the sensitivity and specificity of shoulder ultrasonography for diagnosing supraspinatus tendon injuries, using magnetic resonance imaging as the reference. DESIGN AND SETTING: Prospective accuracy study at a single center: the Shoulder and Elbow Surgery Clinic of the Department of Orthopedics and Traumatology. METHODS: Shoulder ultrasonography was performed on 80 patients of both genders, over 18 years of age, with complaints of shoulder pain and clinically suspected supraspinatus tendon lesions. Jobe's test and a full can test were performed. In addition, they underwent magnetic resonance imaging in a 3.0-tesla machine, as the reference standard. The examinations were performed and interpreted by radiologists. RESULTS: Ultrasonography showed sensitivity of 36.3% and specificity of 91.7% for supraspinatus tears overall: sensitivity of 25.8% and specificity of 91.8% for partial tears and sensitivity of 46.2% and specificity of 100% for full-thickness tears. Ultrasonography showed high accuracy for diagnosing full-thickness tears: 91.3%. The p-values were 0.003 for tears overall, 0.031 for partial tears and < 0.001 for full-thickness tears. CONCLUSIONS: Ultrasonography showed low sensitivity for detecting supraspinatus tears, but high specificity for both partial and full-thickness tears.