MESENCHYMAL CELLS IN ROTATOR CUFF REPAIR - TECHNIQUE DESCRIPTION AND CASE REPORTS.

Objective: To describe a protocol of obtention of mesenchymal stem cells and to report their use as a biological adjuvant in three patients undergoing arthroscopic rotator cuff repair. Methods: Case series of patients who underwent arthroscopic repair of isolated full-thickness supraspinatus tear using mesenchymal stem cells obtained from the bone marrow as a biological adjuvant. All patients were operated on at the same institution, by a surgeon with 13 years of experience. The cells were applied at the end of the procedure, at the tendon-bone interface, at an approximate concentration of 2,000,000 mesenchymal cells/mm3 and a total volume of 5 ml. Results: All patients improved with the procedure, with one excellent and two good results. All cases overcame the minimally important clinical difference. All cases reached tendon healing, without partial or complete re-tears. We observed no complications. Conclusion: Arthroscopic rotator cuff repair with added mesenchymal cells obtained from bone marrow and submitted to a cell expansion process led to good functional results and healing in all cases in the sample, with no complications. Level of Evidence IV, Case Series.

Objetivo: Descrever o protocolo de obtenção de células mesenquimais e relatar seu uso como adjuvante biológico em três pacientes submetidos ao reparo artroscópico do manguito rotador. Métodos: Série de casos de pacientes submetidos ao reparo artroscópico de rotura transfixante do músculo supraespinal utilizando como adjuvante biológico células mesenquimais obtidas da medula óssea. Todos ospacientes foram operados na mesma instituição por um cirurgião com 13 anos de experiência. As células foram aplicadas ao final do procedimento, na interface do tendão com o osso, na concentração aproximada de 2 milhões de células mesenquimais/mm3 e volume total de 5 ml. Resultados: Todos os pacientes melhoraram após o procedimento, havendo um resultado excelente e dois bons. Todos superaram a diferença clínica minimamente importante. Em todos os casos ocorreu cicatrização tendínea, sem a presença de rerroturas parciais ou completas. Não observamos complicações. Conclusão: O reparo do manguito rotador artroscópico com adição de células mesenquimais obtidas da medula óssea e submetidas a processo de expansão celular levou a bons resultados funcionais e cicatrização, sem complicações, em todos os casos da amostra. Nível de Evidência IV, Série de Casos.

TREATMENT OF RECURRENT ANTERIOR SHOULDER DISLOCATION USING THE LATARJET TECHNIQUE.

Objective: To describe the functional results, recurrence rate, postoperative radiographic appearance, and complications of patients undergoing the Latarjet procedure over 24 months. Methods: Retrospective case series, including adult patients with recurrent traumatic anterior glenohumeral dislocation undergoing the Latarjet procedure. We clinically evaluated patients preoperatively by the Rowe score and at six, 12, and 24 months after the procedure. The positioning, consolidation, and resorption of the graft were analyzed by plain radiography. The recurrence rates and other complications were also described. Results: We analyzed 40 patients (41 shoulders). The Rowe score median increased from 25 before surgery to 95 at 24 months after surgery (p < 0.001). We observed graft resorption in three cases (7.3%) and consolidation in 39 (95.1%). Most grafts presented adequate placement. We observed two recurrences (4.8%), one case of dislocation and one of subluxation. Seven patients (17.1%) had a positive apprehension test. The study had no cases of infection, neuropraxia, or graft breakage. Conclusion: Latarjet surgery is a safe and effective procedure in the treatment of recurrent anterior dislocation of the shoulder. This surgery enables a statistically significant improvement according to the Rowe score, with a low number of recurrences. Level of Evidence IV, Case Series.

Objetivo: Descrever os resultados funcionais, a taxa de recidiva, o aspecto radiográfico pós-operatório e as complicações de pacientes submetidos ao procedimento de Latarjet ao longo de 24 meses. Métodos: Série de casos retrospectiva que inclui pacientes adultos com luxação glenoumeral recidivante anterior traumática submetidos ao procedimento de Latarjet. Avaliamos clinicamente os pacientes pela escala de Rowe pré-operatória e aos 6, 12 e 24 meses após o procedimento. O posicionamento, a consolidação e a reabsorção do enxerto foram analisados por radiografia simples. Descrevemos ainda as taxas de recidiva e as demais complicações. Resultados: Analisamos 40 pacientes (41 ombros). A mediana da escala de Rowe evoluiu de 25,0 antes da cirurgia para 95,0 passados 24 meses desde a cirurgia (p < 0,001). Foi observada reabsorção do enxerto em três casos (7,3%), e consolidação em 39 (95,1%). A maioria dos enxertos apresentava posicionamento adequado. Ocorreram duas recidivas (4,8%), sendo um caso de luxação e outro de subluxação. Sete pacientes (17,1%) referiam sensação de apreensão. Não ocorreram casos de infecção, neuropraxia ou quebra do enxerto. Conclusão: A cirurgia de Latarjet é um procedimento seguro e eficaz no tratamento da luxação anterior recidivante do ombro, possibilitando melhora funcional significativa de acordo com a escala de Rowe, com baixo número de recidivas. Nível de Evidência IV, Série de Casos.

TREATMENT OF RECURRENT ANTERIOR SHOULDER DISLOCATION WITH BRISTOW-LATARJET PROCEDURE.

OBJECTIVES: To describe the clinical and radiographic results of patients with traumatic recurrent anterior shoulder dislocation treated with the Bristow-Latarjet procedure. METHODS: Retrospective case series including 44 patients (45 shoulders) who underwent the Bristow-Latarjet procedure. The graft was fixed "standing" in 84% of the shoulders, and "lying" in 16%. RESULTS: The follow-up was 19.25 ± 10.24 months. We obtained 96% of good results, with 2 recurrences presented as subluxation. Graft healing occurred in 62% of cases. The graft was positioned below the glenoid equator in 84% of the cases, and less than 10 mm from its edge in 98%. The external rotation had a limitation of 20.7º ± 15.9º, while the internal rotation was limited in 4.0º ± 9.6º. The limitation of rotation and the position of the graft ("standing" or "lying") did not correlate with graft healing (p>0.05). Bicortical fixation was positively correlated with healing (p <0.001). CONCLUSION: The Bristow-Latarjet technique is indicated for the treatment of recurrent anterior dislocations and subluxations of the shoulder. It is a safe treatment method, which can be used in people with intense physical activity. Limiting shoulder mobility does not prevent patients from returning to their usual occupations. Level of Evidence IV, Case series.

OBJETIVOS: Descrever os resultados clínicos e radiográficos do tratamento da luxação anterior recidivante traumática do ombro pela técnica de Bristow-Latarjet. MÉTODOS: Série de casos retrospectiva, incluindo 44 pacientes (45 ombros) submetidos à técnica de Bristow-Latarjet. O enxerto foi fixado "em pé" em 84% dos ombros, e "deitado" em 16%, utilizando 1 parafuso metálico. RESULTADOS: O seguimento foi de 19,25 ± 10,24 meses. Obtivemos 96% de bons resultados, sendo 2 recidivas sob a forma de subluxação. A consolidação ocorreu em 62% dos casos. O enxerto foi posicionado abaixo do equador da glenoide em 84% das vezes, e a menos de 10 mm da sua borda em 98%. A rotação externa apresentou limitação de 20,7º ± 15,9º, enquanto a rotação interna 4,0º ± 9,6º. A limitação das rotações e a posição do enxerto ("em pé" ou 'deitado") não se correlacionaram com a consolidação do enxerto. A fixação bicortical correlacionou-se positivamente com a consolidação. CONCLUSÕES: A técnica de Bristow-Latarjet está indicada para o tratamento da instabilidade anterior recidivante do ombro. É um método de tratamento seguro, que pode ser utilizado em pessoas com atividade física intensa. A limitação da mobilidade do ombro não impede os pacientes de voltarem às suas ocupações habituais. Nível de Evidência IV, Série de casos.

EFFECT OF SUBSCAPULARIS TEARS ON FUNCTIONAL SCORES OF PATIENTS UNDERGOING ROTATOR CUFF REPAIR.

OBJECTIVE: To evaluate the influence of partial- and full-thickness upper third subscapularis tendon tears on the functional scores of patients undergoing arthroscopic rotator cuff repair. METHODS: Patients who underwent arthroscopic rotator cuff repair were divided into three groups according to the subscapularis tendon condition: intact, partial-thickness tear, or full-thickness upper third tear. Functional scores were compared among groups. Second, the influence of biceps and infraspinatus tears on the scores was tested using multivariate regression analysis. RESULTS: We evaluated 307 shoulders in 297 patients. Full-thickness upper third subscapularis tears presented significantly worse scores than intact tendons. Partial-thickness tears had scores that did not differ significantly from those of the other groups. Patients with full-thickness upper third tears presented a greater rate of injured and unstable biceps tendons. The multivariate analysis showed that biceps and infraspinatus tendon tears did not influence the scores or the intergroup comparison. CONCLUSION: Full-thickness upper third subscapularis tendon tears presented worse functional scores than intact subscapularis tendons among patients undergoing posterosuperior rotator cuff repair. Patients with full-thickness subscapularis tears were more likely to suffer biceps tears, but this fact did not influence functional scores. Level of Evidence I; Clinical randomized trial.

OBJETIVO: Avaliar a influência das lesões do terço superior do tendão subescapular nos escores funcionais de pacientes submetidos ao reparo artroscópico do manguito. MÉTODOS: Divisão em três grupos, conforme condição do tendão subescapular: intacto; ruptura de espessura parcial ou ruptura do terço superior de espessura total. Comparamos escores funcionais. Em seguida, a influência das lesões do bíceps e do infraespinhal nos escores foi testada através de análise de regressão multivariada. RESULTADOS: Avaliamos 307 ombros em 297 pacientes. Rupturas subescapulares no terço superior de espessura total apresentaram escores significativamente piores aos pacientes com tendão intacto. Rupturas de espessura parcial apresentaram escore sem diferença significativa em relação aos demais. Pacientes com rupturas do terço superior de espessura total apresentaram maior taxa de lesão e instabilidade tendínea do bíceps. Análise multivariada mostrou que as rupturas tendíneas do bíceps e infraespinal não influenciaram os escores. CONCLUSÃO: Pacientes com lesão do terço superior de espessura total do tendão do subescapular apresentaram escores funcionais piores do que pacientes com tendão intacto submetidos ao reparo artroscópico posterossuperior do manguito. Pacientes com rupturas do subescapular com espessura total foram mais propensos a apresentar rupturas do bíceps, sem influenciar escores funcionais. Nível de Evidência I, Estudo clínico randomizado.

Multifocal osteonecrosis secondary to occupational exposure to aluminum.

Multifocal osteonecrosis is a rare disease; chronic use of corticosteroids is considered the main risk factor. Patients with chronic renal failure can develop aluminum toxicity, which can lead to osteomalacia and encephalopathy. An association between osteonecrosis and aluminum toxicity has been reported among patients with dialytic renal insufficiency. Occupational exposure to aluminum rarely causes lung disease and no cases of bone lesions resulting from exposure to this metal have been reported. In this manuscript, we describe a novel case of a patient with multifocal osteonecrosis associated with chronic occupational exposure to aluminum. Level of Evidence IV, Case Report.

A osteonecrose multifocal é uma doença rara. O uso crônico de corticoides é considerado seu principal fator de risco. Em pacientes com insuficiência renal crônica é descrita a intoxicação por alumínio, causando osteomalácia e encefalopatia. A relação entre osteonecrose e toxicidade pelo alumínio já foi relatada em estudos que envolveram pacientes com insuficiência renal dialítica. A exposição ocupacional ao alumínio pode, raramente, ocasionar doenças pulmonares. Não existem casos relatados de lesões ósseas decorrentes da exposição a esse metal. Descrevemos neste artigo, o relato inédito de um paciente com osteonecrose multifocal associada à exposição ocupacional crônica ao alumínio. Nível de Evidência IV, Relato de Caso.

Shoulder disorders in an outpatient clinic: an epidemiological study.

OBJECTIVE: To describe shoulder disorders in patients evaluated by two shoulder and elbow surgeons. METHODS: This cross-sectional study analyzed patients evaluated by two authors, excluding acute fractures and dislocations and patients with symptoms not involving the shoulder. Age and sex distribution was determined for the different diagnoses. RESULTS: We evaluated 1001 patients. Mean age was 51.43±15.15 years and 51.0% were female. Disorders of the rotator cuff occurred in 64.3% (41.2% tendinopathy, 11.0% partial tears and 12.2% full-thickness tears). Adhesive capsulitis occurred in 13.5% of cases and glenohumeral instability in 8.1%. Rotator cuff disorders were more common in women, with a peak between 50 and 59 years for tendinopathy and partial tears and between 60 and 69 years for full-thickness tears. Glenohumeral instability was more frequent in men, with a peak between 30 and 39 years. CONCLUSION: The most frequent diagnosis was rotator cuff tendinopathy, followed by adhesive capsulitis, full-thickness rotator cuff tears, partial rotator cuff tears and glenohumeral instability. Rotator cuff lesions were more common in women, with a peak between 60 and 69 years for full-thickness tears. Level of Evidence IV, Case Series.

OBJETIVO: Descrever as afecções do ombro atendidas por dois membros da Sociedade Brasileira de Ombro e Cotovelo. MÉTODOS: Estudo transversal que avaliou atendimentos de dois dos autores. Excluímos fraturas e luxações agudas e pacientes com sintomatologia que não envolvia o ombro. A distribuição etária e por sexo foi determinada para os diferentes diagnósticos. RESULTADOS: Avaliamos 1001 pacientes. A idade foi de 51,43 ± 15,15 anos e 51,0% eram do sexo feminino. As afecções do manguito rotador ocorreram em 64,3%, sendo 41,2% de tendinopatia, 11,0% de rotura parcial e 12,2% de rotura completa. A capsulite adesiva ocorreu em 13,5% e instabilidade glenoumeral em 8,1%. As afecções do manguito rotador foram mais frequentes em mulheres, com pico entre 50 e 59 anos para tendinopatia e rotura parcial, e entre 60 e 69 anos para rotura completa. A instabilidade glenoumeral foi mais frequente em homens, com pico entre 30 e 39 anos. CONCLUSÃO: Os diagnósticos mais frequentes foram tendinopatia do manguito rotador, seguido de capsulite adesiva, rotura completa do manguito rotador, rotura parcial do manguito rotador e instabilidade glenoumeral. As afecções do manguito rotador foram mais frequentes em mulheres, com pico entre 60 e 69 anos para rotura completa. Nível de Evidência IV, Série de Casos.

QUALITY OF LIFE IN PATIENTS WITH ROTATOR CUFF ARTHROPATHY.

OBJECTIVE: To compare quality of life (according to the SF-12) in patients with rotator cuff arthropathy with controls paired by sex and age. Secondary objectives are to compare the groups according to the ASES and VAS scales. METHODS: This cross-sectional study with controls paired by sex and age compared patients with rotator cuff arthropathy with surgical indication for reverse shoulder arthroplasty. The groups were compared according to the SF-12, ASES, and VAS scales. RESULTS: The groups consisted of 38 individuals, 28 women. The SF-12 demonstrated a significant difference in the physical component, with the cases scoring 31.61 ± 6.15 and the controls 49.39 ± 6.37 (p<0.001). For the mental component, the difference was not significant, with the cases scoring 44.82 ± 13.18 and the controls 48.96 ± 8.65 (p=0.109). The cases scored 7.34 ± 2.11 on the VAS and 31.26 ± 15.12 on the ASES, while the controls scored 0.55 ± 1.31 and 97.53 ± 6.22, respectively (p<0.001). CONCLUSION: Patients with rotator cuff arthropathy had poorer results for the physical component of the SF-12 than the controls. They also had poorer functional results according to the ASES scale, and more pain according to the VAS. Level of Evidence III, Case Control Study.

OBJETIVO: Comparar a qualidade de vida, de acordo com o SF-12, entre pacientes com artropatia do manguito rotador e controles pareados por sexo e idade. É objetivo secundário a comparação dos grupos de acordo com as escalas ASES e EVA. MÉTODOS: Estudo transversal com controles pareados por sexo e idade, que comparou pacientes com artropatia do manguito rotador e indicação de artroplastia reversa do ombro com indivíduos sadios. Os grupos foram comparados quanto às escalas SF-12, ASES e EVA. RESULTADOS: Os grupos foram formados por 38 indivíduos, sendo 28 do sexo feminino. O SF-12 apresentou diferença significativa no componente físico, tendo os casos registrado 31,61 ± 6,15 e os controles 49,39 ± 6,37 (p < 0,001). Para o componente mental, a diferença não foi significativa, tendo os casos apresentado 44,82 ± 13,18 e os controles 48,96 ± 8,65 (p=0.109). Os casos apresentaram EVA de 7,34 ± 2,11 e ASES de 31,26 ± 15,12, enquanto os controles apresentaram 0,55 ± 1,31 e 97,53 ± 6,22, respectivamente (p < 0,001). CONCLUSÃO: Os pacientes com artropatia do manguito rotador apresentam piores resultados no componente físico do SF-12 quando comparados aos controles. Têm, ainda, piores resultados funcionais pela escala da ASES e mais dor pela EVA. Nível de Evidência III, Estudo de Caso-Controle.

Prognostic factors for clinical outcomes after rotator cuff repair.

OBJECTIVE: To identify prognostic factors of postoperative functional outcomes. METHODS: Retrospective case series evaluating patients undergoing rotator cuff repair, analyzed by the UCLA score (pre and 12-month postoperative) and Magnetic Resonance Imaging (preoperative). Patients' intrinsic variables related to the injury and intervention were evaluated. Multivariate linear regression analysis was performed to determine variables impact on postoperative functional assessment. RESULTS: 131 patients were included. The mean UCLA score increased from 13.17 ± 3.77 to 28.73 ± 6.09 (p<0,001). We obtained 65.7% of good and excellent results. Age (r= 0.232, p= 0.004) and reparability of posterosuperior injuries (r= 0.151, p= 0.043) correlated with the functional assessment at 12 months. After multivariate linear regression analysis, only age was associated (p = 0.008). CONCLUSIONS: The surgical treatment of rotator cuff tears lead to good and excellent results in 65.6% of patients. Age was an independent predictor factor with better clinical outcomes by UCLA score in older patients. Level of Evidence IV, Case Series.

Humeral internal rotation osteotomy for the treatment of Erb-Duchenne-type obstetric palsy: clinical and radiographic results.

OBJECTIVE: To evaluate the functional and radiographic results in patients undergoing shoulder anterior soft tissue stretching in association with open reduction and internal rotation osteotomy to centralize the humeral head as a treatment for Erb-Duchenne obstetric palsy sequelae. METHOD: A total of 35 patients underwent this surgical treatment, and the mean follow-up was 4.6 years. The Mallet scale was applied before and after the surgical procedure. A total of 20 patients underwent computed tomography to assess the glenoid version and humeral head subluxation. RESULTS: Functional improvement was achieved, as evidenced by an increase in the Mallet scale score from 12.14 to 16.46 (p<0.001). The correction of retroversion was achieved once the glenoid version ranged from -21.4 to -12 degrees (p<0.001). The humeral head subluxation improved from 6.5 to 35.2% (p<0.001). Patients older than 6 years of age did not achieve glenohumeral joint improvement with respect to dysplastic abnormalities. CONCLUSION: Internal rotation osteotomy in association with the stretching of anterior soft tissues of the shoulder in patients under the age of 7 years provided improvements in the function, retroversion, and subluxation of the glenohumeral joint.

Arthroscopic latarjet procedure: safety evaluation in cadavers.

OBJECTIVE: To evaluate the safety of arthroscopic Latarjet procedure in cadavers. METHODS: : Twelve cadaveric shoulders underwent arthroscopic Latarjet procedure in our laboratory for arthroscopy, by four different surgeons. Following surgery, the specimens were subjected to radiographic examination and evaluated by an independent examiner. Nineteen parameters were evaluated, including the coracoid graft fixation, positioning and angulation of the screws, neurological damage and integrity of tendons. RESULTS: : Four procedures were considered to be satisfactory, with no difference among the surgeons. The mean angulation of the screws was 27.2°. The subscapularis splitting was, on average, 17.8mm from the upper edge. The coracoid graft was properly positioned relative to equator of the glenoid in 11 cases. There was no injury to the axillary or musculocutaneous nerves. The main complications were: interposition of soft tissue, suprascapular nerve injury, articular deviation of the graft, diastasis and conjoined tendon injury. CONCLUSION: : The arthroscopic Latarjet procedure is a complex technique in which each step must be precise to reduce the risk of complications. Our study showed a high risk of failure of the procedure. Level of Evidence IV, Case Series .