Shoulder injuries in Brazilian professional football players: epidemiological analysis of 3828 games.

OBJECTIVES: Football is a globally played sport that poses potential risks for musculoskeletal injuries. Upper-limb injuries have a lower incidence rate than lower-limb injuries but can still cause absenteeism and performance impairment in football players. This descriptive epidemiological study aimed to evaluate and compare the epidemiological data on shoulder injuries among professional football players in two major Brazilian football championships. METHODS: Data were collected throughout the championships, and club physicians medically evaluated each player during official games using two online forms. The collected information included the player's age and position, injury diagnosis, laterality, location on the field where the injury occurred, playing time, imaging examinations performed, need for surgical treatment, time to return to play (TRP), and recurrence of the injury. The incidence of injuries was evaluated using the Federation Internationale de Football Association (FIFA) incidence formula. RESULTS: A total of 107 shoulder injuries were recorded (4.3% of all injuries), with a FIFA incidence of 0.847. Glenohumeral dislocations (GHDs) and acromioclavicular dislocations (ACDs) accounted for 37.38% and 35.51% of all shoulder injuries, respectively. Goalkeepers and defenders presented, respectively, a 2.15 and 1.57 times increased risk of suffering shoulder injuries, while attackers presented a 0.63 times decreased risk. Injury recurrence was observed in 14.95% of cases, with GHDs and ACDs showing recurrence rates of 35.00% and 5.26%, respectively. Surgery was performed in 9.35% of cases, with GHDs representing 50% of all surgeries. The average TRP was 22.37 days, with severe and major injuries accounting for 11.21% and 10.28% of all injuries, respectively. Goalkeepers had the highest average TRP of 36.15 days. Recurring injuries had a higher average TRP of 33.44 days compared to nonrecurring injuries, which had an average TRP of 20.43 days. Surgically treated injuries had the highest average TRP of 112.5 days. CONCLUSION: Shoulder injuries in the professional football scenario are of great concern due to the high recurrence rate and need for surgical treatment, which will lead to a long TRP. These findings emphasize the need to implement prevention protocols and effective treatments to reduce the consequences of such injuries, which are usually underestimated in this sport. LEVEL OF EVIDENCE: III.

Bristow-Latarjet Surgery: A Current Overview in Brazil.

Objective To provide a current overview of the Bristow-Latarjet surgery in Brazil. Materials and Methods This cross-sectional study was based on an electronic questionnaire with 26 items, which was sent to active members of the Brazilian Society of Shoulder and Elbow Surgery (Sociedade Brasileira de Cirurgia do Ombro e Cotovelo, SBCOC, in Portuguese). The questionnaire addressed training, surgical technique, complications, and postoperative management. Results We sent the questionnaire to 845 specialists from April 20 to May 12, 2021, and 310 of them answered i in full. During their specialization, most specialists participated in up to ten Bristow-Latarjet procedures. The most frequent complication was graft fracture, while the most common technical difficulty was screw positioning. In total, 50.6% and 73.9% reported having experienced intraoperative and postoperative complications respectively; 57.1% declared performing subscapularis suture; 99.7% indicated postoperative immobilization; and 61.9% considered graft consolidation fundamental. Conclusion Most specialists participated in up to ten Bristow-Latarjet procedures during the specialization, but 13.5% of them graduated without participating in the surgery. The most frequent complication was graft fracture. The most common technical difficulty was screw positioning. Most participants prefer postoperative immobilization since they believe graft consolidation is essential to resume the practiced of sports. The highest complication rate occurred with specialists who have obtained their titles 11 to 15 years ago. In Brazil, the Southeast region is the largest producer of specialists and has the highest concentration of these professionals.

Bristow-Latarjet Surgery: A Current Overview in Brazil / Cirurgia de Bristow-Latarjet: Um panorama atual do Brasil

Abstract Objective To provide a current overview of the Bristow-Latarjet surgery in Brazil. Materials and MethodsThis cross-sectional study was based on an electronic questionnaire with 26 items, which was sent to active members of the Brazilian Society of Shoulder and Elbow Surgery (Sociedade Brasileira de Cirurgia do Ombro e Cotovelo, SBCOC, in Portuguese). The questionnaire addressed training, surgical technique, complications, and postoperative management. Results We sent the questionnaire to 845 specialists from April 20 to May 12, 2021, and 310 of them answered i in full. During their specialization, most specialists participated in up to ten Bristow-Latarjet procedures. The most frequent complication was graft fracture, while the most common technical difficulty was screw positioning. In total, 50.6% and 73.9% reported having experienced intraoperative and postoperative complications respectively; 57.1% declared performing subscapularis suture; 99.7% indicated postoperative immobilization; and 61.9% considered graft consolidation fundamental. Conclusion Most specialists participated in up to ten Bristow-Latarjet procedures during the specialization, but 13.5% of them graduated without participating in the surgery. The most frequent complication was graft fracture. The most common technical difficulty was screw positioning. Most participants prefer postoperative immobilization since they believe graft consolidation is essential to resume the practiced of sports. The highest complication rate occurred with specialists who have obtained their titles 11 to 15 years ago. In Brazil, the Southeast region is the largest producer of specialists and has the highest concentration of these professionals.

Resumo Objetivo Traçar um panorama atual da cirurgia de Bristow-Latarjet no Brasil. Materiais e Métodos Estudo transversal no qual um questionário eletrônico com 26 perguntas sobre aspectos de formação, técnica cirúrgica, complicações e manejo pós-cirúrgico foi enviado a membros ativos da Sociedade Brasileira de Cirurgia do Ombro e Cotovelo (SBCOC). Resultados Entre 20 de abril e 12 de maio de 2021, o questionário foi enviado a 845 especialistas, e obteve-se 310 respostas completas. Durante a especialização, a maior parte dos especialistas participou de até dez procedimentos de Bristow-Latarjet. A complicação mais frequente foi a fratura do enxerto, e a dificuldade técnica, o posicionamento dos parafusos. Ao todo, 50,6% já tiveram complicações no intraoperatório; 73,9% já tiveram complicações no pós-operatório; 57,1% fazem a sutura do subescapular; 99,7% indicam a imobilização no pós-operatório; e 61,9% consideram a consolidação do enxerto fundamental. Conclusão A maior parte dos especialistas participou de até dez procedimentos de Bristow-Latarjet durante a especialização, mas 13,5% se formaram sem ter participado de nenhuma cirurgia. A complicação mais frequente foi a fratura do enxerto. A dificuldade técnica mais frequente foi o posicionamento dos parafusos. Imobilização no pós-operatório é a preferência da maioria dos participantes, que consideram fundamental a consolidação do enxerto para o retorno ao esporte. O maior número de complicações ocorreu com especialistas que obtiveram o título de 11 a 15 anos atrás. A região Sudeste é a maior formadora de especialistas e onde está concentrada a maior parte deles.

Bristow versus Latarjet in high-demand athletes with anterior shoulder instability: a prospective randomized comparison.

BACKGROUND: Traumatic anterior shoulder instability is a common disease, especially in young athletes. The Latarjet and Bristow techniques are nonanatomical surgeries that involve the transfer of the coracoid process to the anterior border of the glenoid and are indicated in cases at a high risk for recurrence and in the presence of associated bone lesions. Studies have evaluated the recurrence and complications associated with these techniques, but they have important differences, and should not be considered synonymous. The objective of this study was to prospectively compare the Bristow and Latarjet techniques in high-demand athletes. Hypothesis: Bristow and Latarjet techniques lead to similar results. PATIENTS AND METHODS: Thirty-seven athletes (41 shoulders; three athletes underwent bilateral surgery) with anterior recurrent dislocation of the shoulder that was surgically treated using the Bristow or Latarjet technique were prospectively analyzed. The follow-up time was 5 years. The mean age was 26.4 years (range: 16-46 years). In 17 cases (41.5%), the dominant side was not affected. RESULTS: Elevation and external rotation (passive and active) decreased in the early postoperative period and achieved values in the final follow-up similar to those found in the preoperative period. The mean postoperative scores at 5 years were as follows: ASES, 79.1 (range: 66-95); ASORS, 77.8 (range: 60-100); WOSI, 52.6 (range: 18-77); and VAS, 1.88 (range: 0-6). All of the results presented statistical significance. There was a complication rate of 9.75% in the follow-up period. There were no new dislocations after the surgery. Most (75%) of the athletes returned to the sport after the surgery, and there was no correlation between poor results and any of the variables studied. There was a statistically significant difference in passive external rotation in favor of the Latarjet technique four weeks after surgery (P = .01). We also found a statistically significant difference in passive elevation in favor of the Latarjet technique eight weeks after the surgery (P = .04). When we compared the Bristow and Latarjet techniques regarding the ASES, ASORS, and WOSI scores, we found no statistically significant difference. In the comparison regarding whether the athletes returned to sports, we found no statistically significant difference. CONCLUSION: The Bristow and Latarjet techniques lead to good results in athletes with no new dislocation episodes and are suitable for treating patients with anterior recurrent dislocation of the shoulder. The Latarjet technique showed better results in some of the variables studied.

Acetabularization as a Protective Factor in Rotator Cuff Arthropathy.

Objective To check if shoulders with acetabularization have better functional results in cases of rotator cuff arthropathy. Methods A clinical and radiological cross-sectional evaluation of 65 shoulders with rotator cuff arthropathy by measuring the range of motion (RoM) of the shoulder, the Constant-Murley score, and the radiological classifications of Hamada and Seebauer. The clinical findings were compared with the radiographic findings. Results According to the classification of Seebauer, we observed better results regarding the RoM in type-A shoulders. There was a statistically significant difference regarding anterior elevation and medial rotation between types A and B ( p < 0.05). Lateral rotation did not show a statistically significant difference between types A and B. The Constant-Murley score presented better results in type A, and there was a statistically significant difference between groups A and B ( p < 0.05). According to the classification of Hamada, we observed that the RoM had better results in types 3, 2 and 1, and there was a statistically significant difference regarding anterior elevation and medial rotation ( p < 0.05) compared with groups 4A, 4B and 5. There was no statistically significant difference between the Hamada groups regarding lateral rotation. According to Hamada, the Constant-Murley score showed better results in types 3, 1 and 2, and there was a statistically significant difference between groups 3 and 5. Conclusion The RoM and shoulder function were better in patients with acetabularization (Seebauer 1A and Hamada 3), and worse in those with glenohumeral arthrosis (Seebauer 1B, 2B and Hamada 4A, 4B and 5).

Acetabularization as a Protective Factor in Rotator Cuff Arthropathy / A acetabularização como fator protetor na artropatia do manguito rotador

Abstract Objective To check if shoulders with acetabularization have better functional results in cases of rotator cuff arthropathy. Methods A clinical and radiological cross-sectional evaluation of 65 shoulders with rotator cuff arthropathy by measuring the range of motion (RoM) of the shoulder, the Constant-Murley score, and the radiological classifications of Hamada and Seebauer. The clinical findings were compared with the radiographic findings. Results According to the classification of Seebauer, we observed better results regarding the RoM in type-A shoulders. There was a statistically significant difference regarding anterior elevation and medial rotation between types A and B (p< 0.05). Lateral rotation did not show a statistically significant difference between types A and B. The Constant-Murley score presented better results in type A, and there was a statistically significant difference between groups A and B (p< 0.05). According to the classification of Hamada, we observed that the RoM had better results in types 3, 2 and 1, and there was a statistically significant difference regarding anterior elevation and medial rotation (p< 0.05) compared with groups 4A, 4B and 5. There was no statistically significant difference between the Hamada groups regarding lateral rotation. According to Hamada, the Constant-Murley score showed better results in types 3, 1 and 2, and there was a statistically significant difference between groups 3 and 5. Conclusion The RoM and shoulder function were better in patients with acetabularization (Seebauer 1A and Hamada 3), and worse in those with glenohumeral arthrosis (Seebauer 1B, 2B and Hamada 4A, 4B and 5).

Resumo Objetivo Verificar se os ombros com acetabularização têm melhores resultados funcionais nos casos de artropatia do manguito rotador. Métodos Avaliação transversal clínica e radiológica de 65 ombros com artropatia do manguito rotador por meio da mensuração da amplitude de movimento (ADM) do ombro, do escore de Constant-Murley, e das classificações radiológicas de Hamada e Seebauer. Os achados clínicos foram comparados com os radiográficos. Resultados Segundo a classificação de Seebauer, com relação à ADM, observamos melhores resultados nos tipos A. Houve diferença estatística significativa na elevação anterior, e rotação medial entre os tipos A e B (p< 0.05). A rotação lateral não demonstrou diferença estatística significativa entre os tipos A e B. O escore de Constant-Murley apresentou melhores resultados nos tipos A, e houve diferença estatística significativa entre os grupos A e B (p< 0,05). Segundo a classificação de Hamada, observamos que a ADM teve melhores resultados nos tipos 3, 2 e 1, e houve diferença estatística significativa para a elevação anterior e a rotação medial (p< 0,05) quando comparadas com os grupos 4A, 4B e 5. Não houve diferença estatística significativa entre os grupos de Hamada em relação à rotação lateral. Ainda segundo Hamada, o escore de Constant-Murley apresentou melhores resultados nos tipos 3, 1 e 2, e houve diferença estatística significativa entre os grupos 3 e 5. Conclusão A ADM e a função do ombro apresentavam-se melhores nos pacientes com acetabularização (Seebauer 1A e Hamada 3), e piores naqueles com artrose glenoumeral (Seebauer 1B, 2B e Hamada 4A, 4B e 5).

Saúde global, inovação biotecnológica e risco(s) / Global health, biotechnological innovation and risk(s) / Salud global, innovación biotecnológica y riesgo(s)

Objetivo: Refletir sobre o conceito de saúde global, a sua origem, sentido(s) e notas caraterizadoras. Compreender em que medida a doutrina se vem referindo a um Direito da Saúde Global, analisando quais os seus principais méritos, limitações e inconvenientes. Analisar alguns dos avanços biotecnológicos que têm aberto as portas a novas potencialidades de incrementação da saúde e do bem-estar à escala global. Metodologia: foi utilizado o método dedutivo a partir da análise de obras monográficas, artigos de revistas da especialidade, bem como de documentos emanados por diversas entidades nacionais e estrangeiras. Resultados: num contexto de crise tecnocientífica, a inovação biotecnológica, embora contribua para a melhoria da saúde global, acarreta inúmeros riscos. Cada vez mais, se tem afirmado a importância do chamado Direito da Saúde Global, o qual procura contribuir para a otimização das possibilidades de melhoria dos índices de saúde à escala global, mormente através da formulação de respostas precaucionais adequadas. Conclusão: a melhoria dos índices de saúde à escala global depende, inter alia, da inovação biotecnológica, a qual só será viabilizada através de uma adequada gestão do risco a realizar a partir do conceito de diligência devida. O Direito da Saúde Global, enquanto sub-ramo jusinternacional do Direito da Saúde, poderá dar valiosos contributos nesse sentido, não obstante as suas múltiplas limitações e dificuldades.

Objective: to reflect on the concept of global health, its origins, meaning(s) and main characteristics. To understand to what extent the doctrine has been referring to a Global Health Law, analyzing its main merits, limitations and inconveniences. To examine some of the biotechnological advances that have opened the doors to the possibility of increasing health and well-being on a global scale. Methodology: the deductive method was used from the analysis of monographies, articles from specialized reviews, as well as documents originating from several national and international entities. Results: in the context of a techno-scientific crisis, biotechnological innovation, although contributing to the improvement of global health, carries numerous risks. Increasingly, the importance of the so-called Global Health Law has been affirmed; it seeks to contribute to the optimization of health indices on a global scale, especially through the development of adequate precautionary responses. Conclusion: the improvement of health indices on a global scale depends, inter alia, on biotechnological innovation, which will only be made possible through an adequate risk management to be carried out on the concept of due diligence. The Global Health Law, understood as an international branch of Health Law, can make valuable contributions in this regard, despite its multiple limitations and difficulties.

Objetivo: reflexionar sobre el concepto de salud global, sus origines, significados y notas características. Comprender en qué medida la doctrina se ha referido a un Derecho de la Salud Global, analizando sus principales méritos, limitaciones e inconvenientes. Examinar algunos de los avances biotecnológicos que han abierto la puerta a nuevas potencialidades para la mejora de la salud y del bienestar a la escala mundial. Metodología: el método deductivo ha sido utilizado a partir del análisis de trabajos monográficos, artículos de revistas especializadas, así como de documentos emitidos por varias entidades nacionales y extranjeras. Resultados: en un contexto de crisis tecnocientífica, la innovación biotecnológica, aunque contribuya para la mejora de la salud global, conlleva numerosos riesgos. Cada vez más, se ha afirmado la importancia del llamado Derecho de la Salud Global, el cual busca contribuir para la optimización de las posibilidades florecimiento de los índices de salud global, especialmente a través de la formulación de respuestas precauciónales adecuadas. Conclusión: la mejora de los índices de salud global depende, inter alia, de la innovación biotecnológica, la cual sólo será posible a través de la gestión adecuada del riesgo a partir de la movilización del concepto de debida diligencia. El Derecho de la Salud Global, entendido como una rama internacional del Derecho de la Salud, puede hacer contribuciones valiosas a este respeto, a pesar de sus múltiples limitaciones y dificultades.

Partial Rupture of the Distal Triceps in an Athlete: Case Report and Description of Surgical Technique.

Brachial triceps tendon ruptures account for less than 1% of all upper limbs tendinous ruptures. Partial ruptures are underdiagnosed, and a partial rupture may become a total lesion. Complete ruptures usually require surgical treatment; however, there is no well-defined conduct for partial ruptures. This article presents the case of a 42-year-old male jiu-jitsu athlete with partial rupture of the brachial triceps who underwent surgical treatment due to persistent loss of elbow extension strength, even after conservative treatment. The repair was performed with grafting of the long palmar muscle tendon, using a technique developed by the authors. No complications were observed, and the patient presented a satisfactory result, evidenced by the improvement in the parameters of isokinetic studies, which were performed before surgery and at 5 months postoperatively. This technique has proven to be an option for cases of partial rupture of the brachial triceps in patients with high physical demand who do not show improvement with the conservative treatment.

Partial Rupture of the Distal Triceps in an Athlete: Case Report and Description of Surgical Technique / Ruptura parcial do tríceps distal em um atleta: Relato de caso e descrição de técnica cirúrgica

Abstract Brachial triceps tendon ruptures account for less than 1% of all upper limbs tendinous ruptures. Partial ruptures are underdiagnosed, and a partial rupture may become a total lesion. Complete ruptures usually require surgical treatment; however, there is no well-defined conduct for partial ruptures. This article presents the case of a 42-year-old male jiu-jitsu athlete with partial rupture of the brachial triceps who underwent surgical treatment due to persistent loss of elbow extension strength, even after conservative treatment. The repair was performed with grafting of the long palmar muscle tendon, using a technique developed by the authors. No complications were observed, and the patient presented a satisfactory result, evidenced by the improvement in the parameters of isokinetic studies, which were performed before surgery and at 5 months postoperatively. This technique has proven to be an option for cases of partial rupture of the brachial triceps in patients with high physical demand who do not show improvement with the conservative treatment.

Resumo A ruptura do tendão do tríceps braquial corresponde a menos de 1% de todas as rupturas tendíneas nos membros superiores. As rupturas parciais são subdiagnosticadas, o que pode fazer com que uma ruptura parcial se torne total. As rupturas completas geralmente requerem tratamento cirúrgico; entretanto, para rupturas parciais não há uma conduta bem definida. Este artigo apresenta o caso de um atleta de jiu-jitsu, do sexo masculino, de 42 anos, com ruptura parcial do tríceps braquial submetido a tratamento cirúrgico devido à persistência de perda de força de extensão do cotovelo, mesmo após tratamento conservador. Foi feito o reparo com enxerto do tendão do músculo palmar longo com técnica desenvolvida pelos autores. Não foram observadas complicações e o paciente apresentou resultado satisfatório, comprovado pela melhoria nos parâmetros dos estudos isocinéticos, os quais foram aferidos antes da cirurgia e com 5 meses de pós-operatório. Essa técnica demonstrou ser uma opção para casos de ruptura parcial do tríceps braquial em pacientes com alta demanda física que não apresentaram melhoria com o tratamento conservador.

SLAP IV IN OVERHEAD SPORTS PRACTICE.

Superior labral tear from anterior to posterior (SLAP) is the most common disease in overhead sports practice. OBJECTIVE: to evaluate the functional outcome after tenodesis of long head biceps tendon (LHBT) in high-performance patients with isolated SLAP lesion refractory to conservative treatment. METHODS: Patients underwent the same open repair procedure, using an interference screw. RESULTS: Both patients presented good clinical results and returned to the sport with performance similar to that prior to the injury. CONCLUSION: The results favor the surgical treatment of these athletes with SLAP IV. Level of Evidence IV, Série de Casos.

A lesão labral superior anteroposterior (SLAP) é a doença mais comum em atletas em suspensão do solo. OBJETIVO: avaliar o resultado funcional após tenodese do TCLB (tendão do cabo longo do bíceps) nos pacientes atletas em suspensão de alta performance com lesão SLAP isolada refratária ao tratamento conservador. MÉTODOS: Os pacientes foram submetidos ao mesmo procedimento de reparo por via aberta, com uso de parafuso de interferência. RESULTADOS: Ambos os pacientes apresentaram bons resultados clínicos e retornaram ao esporte com performance semelhante ao prévio à lesão. CONCLUSÃO: Os resultados favorecem o tratamento cirúrgico desses atletas com SLAP IV. Nível de evidencia IV, Series of Cases.

Super-Man syndrome: vulnerability(ies) and enhancement(s). Legal and ethical implications of human genetic enhancement / Síndrome de Super-Man: vulnerabilidad(es) y mejora(s). Implicaciones legales y éticas de la mejora genética humana

In this article, I analyse the emerging phenomenon of human genetic enhancement, as an attempt to surpass the intrinsic vulnerability of human beings. With this purpose, I begin by scrutinizing the main international, supranational and national (Portuguese) norms which aim to protect the human genome. Afterward, I briefly reflect on the main ethical and juridical challenges posed by this polemic practice. What is to enhance? Is there, in the present days, an acceptable ethical and juridical basis for human genetic enhancement? And, if so, is it correct, with no need for further considerations, to carry out this kind of genetic interventions? These are some of the questions which we will try to answer subsequently

En este artículo, analizaremos el fenómeno emergente del mejoramiento genético humano, como posible medio de superar la vulnerabilidad intrínseca de los seres humanos. Con este propósito, comenzamos por examinar las principales normas internacionales, supranacionales y nacionales (portuguesas) concebidas para proteger el genoma humano. A continuación, nos proponemos reflexionar sobre los principales desafíos éticos y jurídicos planteados por esta práctica tan polémica. ¿Qué es mejorar? ¿Existe, actualmente, un fundamento ético y jurídico aceptable para el mejoramiento genético humano? Y, de ser así, ¿es correcto, sin más, llevar a cabo este tipo de intervenciones genéticas? Estas son algunas de las preguntas que trataremos de contestar a continuación

Due Diligence, Precautionary Principle and the so-called GMO Directive: a brief commentary on the ECJ's judgement on the case "Confédération paysanne and Others v. Premier Ministre and Ministre de l'Agriculture, de l'Agroalimentaire et de la Forêt" / Diligencia Debida, Principio de Precaución y la Directiva de OMG: un breve comentario sobre la sentencia del TJUE en el caso "Confédération paysanne and Others v. Premier Ministre and Ministre de l'Agriculture, de l'Agroalimentaire et de la Forêt"

Recently, on the 25th July 2018, the ECJ decided that "organisms obtained by mutagenesis are GMOs and are, in principle, subject to the obligations laid down by the GMO Directive". Considering the huge impact of the Court's decision, I decided to write a brief commentary on the arguments invoked by the Luxembourg judges, analysing specifically the scope, content and role of the precautionary principle in the context of a World Risk Society (Beck). Also, I criticize the activist attitude of the Court, which I consider may have gone too far in the interpretation of Directive 2001/18/EC. Finding balance between the "guaranteeing" role of bioethics and Law and the need for a free and highly encouraged scientific activity is, undoubtedly, one of the main challenges we must face nowadays. This judgement is, in that context, a good example of the difficulties one may encounter on the way

Recientemente, el 25 de julio de 2018, el Tribunal de Justicia de la Unión Europea decidió que "los organismos obtenidos por mutagénesis son OMG y, en principio, están sujetos a las obligaciones establecidas por la Directiva de OMG". Teniendo en cuenta el enorme impacto de la decisión de la Corte, resulta oportuno el comentario jurisprudencial que, a continuación, se incluye, sobre los argumentos invocados por los jueces de Luxemburgo, especialmente analizando el alcance, contenido y el papel del principio de precaución en el contexto de la Sociedad Mundial del Riesgo (Beck). Además, el trabajo incluye una crítica a la actitud activista de la Corte, que, en opinión del autor, ha ido demasiado lejos en la interpretación de la Directiva 2001/18/EC. Encontrar el equilibrio entre el papel "garantista" de la Bioética y del Derecho y la necesidad de una actividad científica libre y altamente alentada es, sin duda, uno de los principales desafíos a los que nos enfrentamos en la actualidad. Esta decisión jurisprudencial es, en ese contexto, un buen ejemplo de las dificultades que uno se podrá encontrar en el camino

Displaced midshaft clavicle fracture in athletes - should we operate?

OBJECTIVE: To assess the results of the treatment of fractures of the middle third of the clavicle with a pre-contoured plate in athletes. METHODS: The authors performed 26 osteosyntheseis in 25 patients with fractures of the middle third of the clavicle. The fractures were classified according to Robinson as 16 type B1 and ten type B2. The mean age was 37 years, ranging from 15 to 63 years, 20 patients were male and five were female, and all play sports in an amateur or professional manner. All patients were operated on in the acute phase of fracture within five days after trauma. Patients were treated with open reduction and internal fixation using pre-contoured plates. The technique and the implant used were the same, but the time of immobilization and rehabilitation protocol were individualized for each patient according to physical activity. Mean follow-up was 16.8 months (6-48 months), with return to sport activities in 45.6 days. RESULTS: Functional assessment was performed using the University of California at Los Angeles (UCLA) score. The results averaged 34.07 of 35 points. No cases presented nonunion. Only one complication was observed (thrombosis of the subclavian vein with good response to conservative treatment); two patients required implant removal. CONCLUSION: The surgical treatment of clavicle fractures in athletes presented satisfactory functional outcome and early return sport.

OBJETIVO: Avaliar os resultados do tratamento de fraturas do terço médio da clavícula com placas pré-contornadas em atletas. MÉTODOS: Os autores fizeram 26 osteossínteses em 25 pacientes com fratura do terço médio da clavícula. As fraturas foram classificadas de acordo com Robinson como tipo 2B1 (16) e tipo 2B2 (dez). A média de idade foi de 37,6 anos, entre 15 e 63; 20 pacientes eram do sexo masculino e cinco do feminino, todos praticantes de alguma atividade esportiva de forma amadora ou profissional. Todos os pacientes foram tratados com redução aberta e fixação interna com placas pré-contornadas na fase aguda da fratura, dentro de, no máximo, cinco dias após o trauma. A técnica usada e o implante foram os mesmos para todos os pacientes, mas o tempo de imobilização e o protocolo de reabilitação foram individualizados para cada paciente, de acordo com a atividade física. A média do seguimento foi de 16,8 meses (6-48), com liberação para atividade esportiva com média de 45,6 dias. RESULTADOS: A avaliação funcional foi feita através do escore da Universidade da Califórnia em Los Angeles (UCLA). Os resultados tiveram como mediana 34,07 de 35 pontos. Nenhum caso apresentou pseudartrose. Apenas uma complicação (trombose da veia subclávia com boa resposta ao tratamento conservador) foi observada; dois pacientes necessitaram remoção do implante. CONCLUSÃO: O tratamento cirúrgico das fraturas da clavícula em atletas apresentou resultado funcional satisfatório e retorno precoce ao esporte.

Displaced midshaft clavicle fracture in athletes - should we operate? / Fratura do terço médio da clavícula em atletas -Devemos operar?

ABSTRACT Objective: To assess the results of the treatment of fractures of the middle third of the clavicle with a pre-contoured plate in athletes. Methods: The authors performed 26 osteosyntheseis in 25 patients with fractures of the middle third of the clavicle. The fractures were classified according to Robinson as 16 type B1 and ten type B2. The mean age was 37 years, ranging from 15 to 63 years, 20 patients were male and five were female, and all play sports in an amateur or professional manner. All patients were operated on in the acute phase of fracture within five days after trauma. Patients were treated with open reduction and internal fixation using pre-contoured plates. The technique and the implant used were the same, but the time of immobilization and rehabilitation protocol were individualized for each patient according to physical activity. Mean follow-up was 16.8 months (6-48 months), with return to sport activities in 45.6 days. Results: Functional assessment was performed using the University of California at Los Angeles (UCLA) score. The results averaged 34.07 of 35 points. No cases presented nonunion. Only one complication was observed (thrombosis of the subclavian vein with good response to conservative treatment); two patients required implant removal. Conclusion: The surgical treatment of clavicle fractures in athletes presented satisfactory functional outcome and early return sport.

RESUMO Objetivo: Avaliar os resultados do tratamento de fraturas do terço médio da clavícula com placas pré-contornadas em atletas. Métodos: Os autores fizeram 26 osteossínteses em 25 pacientes com fratura do terço médio da clavícula. As fraturas foram classificadas de acordo com Robinson como tipo 2B1 (16) e tipo 2B2 (dez). A média de idade foi de 37,6 anos, entre 15 e 63; 20 pacientes eram do sexo masculino e cinco do feminino, todos praticantes de alguma atividade esportiva de forma amadora ou profissional. Todos os pacientes foram tratados com redução aberta e fixação interna com placas pré-contornadas na fase aguda da fratura, dentro de, no máximo, cinco dias após o trauma. A técnica usada e o implante foram os mesmos para todos os pacientes, mas o tempo de imobilização e o protocolo de reabilitação foram individualizados para cada paciente, de acordo com a atividade física. A média do seguimento foi de 16,8 meses (6-48), com liberação para atividade esportiva com média de 45,6 dias. Resultados: A avaliação funcional foi feita através do escore da Universidade da Califórnia em Los Angeles (UCLA). Os resultados tiveram como mediana 34,07 de 35 pontos. Nenhum caso apresentou pseudartrose. Apenas uma complicação (trombose da veia subclávia com boa resposta ao tratamento conservador) foi observada; dois pacientes necessitaram remoção do implante. Conclusão: O tratamento cirúrgico das fraturas da clavícula em atletas apresentou resultado funcional satisfatório e retorno precoce ao esporte.

Desafios jurídicos da Medicina personalizada / Legal challenges of personalized medicine

A Medicina personalizada - atualmente em notável ascensão graças aos consideráveis progressos científicos no domínio da genética - tem potencial para se afirmar, neste Terceiro Milênio, como uma das mais promissoras abordagens no domínio da saúde. A implementação de um modelo de apoio medico personalizado e adaptado a constituição genética de cada individuo acarreta evidentes vantagens para a prevenção e tratamento de patologias. No entanto, são pertinentes e complexos os desafios que a mesma colocará, sendo necessária uma profunda reflexão sobre eles, de modo a encontrarem-se respostas satisfatórias. É esse o contributo que esperamos dar com esse breve artigo, alertando para problemas e abrindo a porta a certas soluções, embora seja claro que ainda são mais as perguntas que respostas disponíveis.

Acute distal biceps ruptures: single incision repair by use of suture anchors.

OBJECTIVE: Clinical and functional assessment of the surgical treatment for acute injury of the distal insertion of the biceps brachial performed with a surgical technique using a single incision in proximal forearm and fixation with suture anchors in the radial tuberosity. METHODS: This study reviewed the medical records of patients who underwent surgical treatment of distal biceps injury during the period between January 2008 and July 2014. In a mean follow-up of 12 months, 22 patients with complete and acute injury, diagnosed through physical examination and imaging studies, were functionally assessed in the postoperative period regarding the range of motion (degrees of flexion-extension and pronation-supination), the presence of pain (VAS), the Andrews Carson-score, and the Mayo Elbow Performance Score (MEPS). RESULTS: During the postoperative follow-up assessment, no patient reported pain by VAS scale; all were satisfied with the esthetic appearance of the surgery. The range of articular movement remained unchanged at 95.4% of patients, with the loss of 8° of supination in one patient. No changes in muscle strength were observed. The results of the Andrews-Carson score were good in 4.6% and excellent in 95.4% of cases; the MEPS presented 100% of excellent results. The rate of complications was 27.2%, similar to the literature. CONCLUSION: Surgical repair of acute injury of the distal biceps trough a single incision in the proximal forearm and fixation with two suture anchors in the radial tuberosity is an effective and safe therapeutic option, allowing early motion and good functional results.

OBJETIVO: Avaliação clínica e funcional do tratamento cirúrgico da lesão aguda da inserção distal do bíceps braquial pela técnica cirúrgica por via de acesso única no antebraço proximal e fixação com âncoras de sutura na tuberosidade radial. MÉTODO: Estudo feito por meio da revisão dos prontuários de pacientes submetidos a tratamento cirúrgico de lesão da inserção distal do bíceps braquial entre janeiro de 2008 e julho de 2014. Em um seguimento médio de 12 meses, 22 pacientes com lesão completa e aguda, diagnosticados por exame físico e exames de imagem, foram avaliados funcionalmente no pós-operatório por meio da mensuração da amplitude de movimentos (graus de flexoextensão e pronossupinação), pela presença de dor (EVA) e pelas escores de Andrews-Carson e Mayo Elbow Performance Score (MEPS). RESULTADOS: Durante a avaliação dos pacientes no seguimento pós-operatório, nenhum paciente referia dor pela escala EVA e todos estavam satisfeitos com a aparência estética da cirurgia. A amplitude de movimento articular encontrava-se inalterada em 95,4% dos pacientes, com a perda de 8° de supinação em um paciente. Os resultados segundo o escore de Andrews-Carson foram bons em 4,6% e excelentes em 95,4% dos casos; no MEPS, observaram-se 100% de resultados excelentes. A taxa de complicações foi de 27,2%, valor semelhante aos dados da literatura. CONCLUSÃO: O tratamento cirúrgico das lesões agudas do bíceps distal por via única com fixação com o uso de duas âncoras de sutura mostrou-se uma opção terapêutica segura e eficaz, permitiu movimentação precoce e bons resultados clínicos e funcionais.

Acute distal biceps ruptures: single incision repair by use of suture anchors / Lesão do bíceps distal aguda: reparo por via única e fixação por âncora de sutura

ABSTRACT OBJECTIVE: Clinical and functional assessment of the surgical treatment for acute injury of the distal insertion of the biceps brachial performed with a surgical technique using a single incision in proximal forearm and fixation with suture anchors in the radial tuberosity. METHODS: This study reviewed the medical records of patients who underwent surgical treatment of distal biceps injury during the period between January 2008 and July 2014. In a mean follow-up of 12 months, 22 patients with complete and acute injury, diagnosed through physical examination and imaging studies, were functionally assessed in the postoperative period regarding the range of motion (degrees of flexion-extension and pronation-supination), the presence of pain (VAS), the Andrews Carson-score, and the Mayo Elbow Performance Score (MEPS). RESULTS: During the postoperative follow-up assessment, no patient reported pain by VAS scale; all were satisfied with the esthetic appearance of the surgery. The range of articular movement remained unchanged at 95.4% of patients, with the loss of 8° of supination in one patient. No changes in muscle strength were observed. The results of the Andrews-Carson score were good in 4.6% and excellent in 95.4% of cases; the MEPS presented 100% of excellent results. The rate of complications was 27.2%, similar to the literature. CONCLUSION: Surgical repair of acute injury of the distal biceps trough a single incision in the proximal forearm and fixation with two suture anchors in the radial tuberosity is an effective and safe therapeutic option, allowing early motion and good functional results.

RESUMO OBJETIVO: Avaliação clínica e funcional do tratamento cirúrgico da lesão aguda da inserção distal do bíceps braquial pela técnica cirúrgica por via de acesso única no antebraço proximal e fixação com âncoras de sutura na tuberosidade radial. MÉTODO: Estudo feito por meio da revisão dos prontuários de pacientes submetidos a tratamento cirúrgico de lesão da inserção distal do bíceps braquial entre janeiro de 2008 e julho de 2014. Em um seguimento médio de 12 meses, 22 pacientes com lesão completa e aguda, diagnosticados por exame físico e exames de imagem, foram avaliados funcionalmente no pós-operatório por meio da mensuração da amplitude de movimentos (graus de flexoextensão e pronossupinação), pela presença de dor (EVA) e pelas escores de Andrews-Carson e Mayo Elbow Performance Score (MEPS). RESULTADOS: Durante a avaliação dos pacientes no seguimento pós-operatório, nenhum paciente referia dor pela escala EVA e todos estavam satisfeitos com a aparência estética da cirurgia. A amplitude de movimento articular encontrava-se inalterada em 95,4% dos pacientes, com a perda de 8o de supinação em um paciente. Os resultados segundo o escore de Andrews-Carson foram bons em 4,6% e excelentes em 95,4% dos casos; no MEPS, observaram-se 100% de resultados excelentes. A taxa de complicações foi de 27,2%, valor semelhante aos dados da literatura. CONCLUSÃO: O tratamento cirúrgico das lesões agudas do bíceps distal por via única com fixação com o uso de duas âncoras de sutura mostrou-se uma opção terapêutica segura e eficaz, permitiu movimentação precoce e bons resultados clínicos e funcionais.

The roles of Tenascin C and Fibronectin 1 in adhesive capsulitis: a pilot gene expression study.

OBJECTIVES: We evaluated mRNA expression levels of genes that encode TGF-ß1; the TGF-ß1 receptor; the collagen-modifying enzymes LOX, PLOD1, and PLOD2; and the extracellular matrix proteins COMP, FN1, TNC and TNXB in synovial/capsule specimens from patients with idiopathic adhesive capsulitis. Possible associations between the measured mRNA levels and clinical parameters were also investigated. METHODS: We obtained glenohumeral joint synovium/capsule specimens from 9 patients with idiopathic adhesive capsulitis who had not shown improvement in symptoms after 5 months of physiotherapy. Adhesive capsulitis was confirmed in all patients by magnetic resonance imaging. We also obtained specimens from 8 control patients who had underwent surgery for acute acromioclavicular joint dislocation and who had radiological indication of glenohumeral capsule alteration based on arthroscopic evaluation. mRNA expression in the synovium/capsule specimens was analyzed by quantitative reverse transcription PCR. The B2M and HPRT1 genes were used as references to normalize target gene expression in the shoulder tissue samples. RESULTS: The synovium/capsule samples from the patients with adhesive capsulitis had significantly higher TNC and FN1 expression than those from the controls. Additionally, symptom duration directly correlated with expression of TGFß1 receptor I. CONCLUSION: Elevated levels of TNC and FN1 expression may be a marker of capsule injury. Upregulation of TGFß1 receptor I seems to be dependent on symptom duration; therefore, TGFß signaling may be involved in adhesive capsulitis. As such, TNC, FN1 and TGFß1 receptor I may also play roles in adhesive capsulitis by contributing to capsule inflammation and fibrosis.

The roles of Tenascin C and Fibronectin 1 in adhesive capsulitis: a pilot gene expression study

OBJECTIVES: We evaluated mRNA expression levels of genes that encode TGF-β1; the TGF-β1 receptor; the collagen-modifying enzymes LOX, PLOD1, and PLOD2; and the extracellular matrix proteins COMP, FN1, TNC and TNXB in synovial/capsule specimens from patients with idiopathic adhesive capsulitis. Possible associations between the measured mRNA levels and clinical parameters were also investigated. METHODS: We obtained glenohumeral joint synovium/capsule specimens from 9 patients with idiopathic adhesive capsulitis who had not shown improvement in symptoms after 5 months of physiotherapy. Adhesive capsulitis was confirmed in all patients by magnetic resonance imaging. We also obtained specimens from 8 control patients who had underwent surgery for acute acromioclavicular joint dislocation and who had radiological indication of glenohumeral capsule alteration based on arthroscopic evaluation. mRNA expression in the synovium/capsule specimens was analyzed by quantitative reverse transcription PCR. The B2M and HPRT1 genes were used as references to normalize target gene expression in the shoulder tissue samples. RESULTS: The synovium/capsule samples from the patients with adhesive capsulitis had significantly higher TNC and FN1 expression than those from the controls. Additionally, symptom duration directly correlated with expression of TGFβ1 receptor I. CONCLUSION: Elevated levels of TNC and FN1 expression may be a marker of capsule injury. Upregulation of TGFβ1 receptor I seems to be dependent on symptom duration; therefore, TGFβ signaling may be involved in adhesive capsulitis. As such, TNC, FN1 and TGFβ1 receptor I may also play roles in adhesive capsulitis by contributing to capsule inflammation and fibrosis.

Differential expression of extracellular matrix genes in glenohumeral capsule of shoulder instability patients.

Anterior shoulder instability is a common orthopedic problem. After a traumatic shoulder dislocation, patients present a plastic deformation of the capsule. The shoulder instability biology remains poorly understood. We evaluated the expression of genes that encode the cartilage oligomeric matrix protein (COMP), fibronectin 1 (FN1), tenascin C (TNC) and tenascin XB (TNXB) in the glenohumeral capsule of anterior shoulder instability patients and controls. Moreover, we investigated the associations between gene expression and clinical parameters. The gene expression was evaluated by quantitative reverse transcription-polymerase chain reaction in the antero-inferior (macroscopically injured region), antero-superior and posterior regions of the capsule of 29 patients with shoulder instability and 8 controls. COMP expression was reduced and FN1 and TNC expression was increased in the antero-inferior capsule region of cases compared to controls (p < 0.05). TNC expression was increased in the posterior capsule portion of shoulder instability patients (p = 0.022). COMP expression was reduced in the antero-inferior region compared to the posterior region of shoulder instability patients (p = 0.007). In the antero-inferior region, FN1 expression was increased in the capsule of patients with more than one year of symptoms (p = 0.003) and with recurrent dislocations (p = 0.004) compared with controls. FN1 and TNXB expression was correlated with the duration of symptoms in the posterior region (p < 0.05). Thus, COMP, FN1, TNC and TNXB expression was altered across the capsule of shoulder instability patients. Dislocation episodes modify FN1, TNC and TNXB expression in the injured tissue. COMP altered expression may be associated with capsule integrity after shoulder dislocation, particularly in the macroscopically injured portion.