Evaluation of Screws Positioning in Latarjet Surgery: Is There a Correlation between Parallelism to Glenoid and Radiographic Complications?

Objective To evaluate whether the parallelism of screws with glenoid in Latarjet surgery interferes in the positioning of the graft and to verify the reproducibility of a method of measuring screws positioning. Methods Retrospective, multicenter study, of patients with anterior shoulder instability submitted to modified Latarjet surgery and at least one year of postoperative follow-up. Two radiologists analyzed the postoperative tomographic images, acquired in a database, to evaluate the positioning of screws and radiographic complications. Results We evaluated 34 patients, aged between 21 and 60 years, one of them with bilateral shoulder involvement, totaling 35 shoulders evaluated. The tomographic evaluation of the inclination angles of the screws showed no difference between the observers. There was intra- and interobserver agreement to evaluate the following surgical parameters: graft position, presence or not of radiographic complications. Conclusion The technique described for measuring the parallelism of screws in Latarjet surgery presented a very good and excellent intra-observer agreement, respectively. Screw parallelism with glenoid is recommended; however, it is not a mandatory and unique condition to avoid radiographic complications.

MRI is a Reliable Method for Measurement of Critical Shoulder Angle and Acromial Index.

Objective The objectives of this study are to compare absolute values of acromial index (AI) and critical shoulder angle (CSA) obtained in both radiographs and magnetic resonance image (MRI) of the shoulder; and to compare the interobserver and intra-observer agreement for AI and CSA values measured in these image modalities. Methods Patients who had medical indication of investigating shoulders conditions through radiographs and MRI were included. Images were taken to two fellowship-trained shoulder surgeons, which conducted measurements of AI and CSA in radiographs and in MRI. Twelve weeks after the first evaluation, a second evaluation was conducted. Inter- and intra-observer reliability was presented as an Intraclass Correlation Coefficient (ICC) and agreement was classified according to Landis & Koch criteria. The differences between two measurements were evaluated using Bland-Altman plots. Results 134 shoulders in 124 subjects were included. Mean intra-observer ICC for CSA in X-rays and in MRI were 0.936 and 0.940, respectively; for AI, 0.908 and 0.022. Mean inter-observer ICC for CSA were 0.892 and 0.752 in X-rays and MRI respectively; for AI, ICC values were 0.849 and 0.685. All individual analysis reached statistical power ( p < 0.001). Mean difference for AI values measured in X-rays and in MRI was 0.01 and 0.03 for observers 1 and 2, respectively. Mean difference for CSA values obtained in X-rays and MRI was 0.16 and 0.58 for observers 1 and 2, respectively. Conclusion Both MRI and X-rays provided high intra- and interobserver agreement for measurement of AI and CSA. Absolute values found for AI and CSA were highly correlated in both image modalities. These findings suggest that MRI is a suitable method to measure AI and CSA. Level of Evidence II , Diagnostic Study.

MRI is a Reliable Method for Measurement of Critical Shoulder Angle and Acromial Index / A ressonância magnética é um método confiável para medida do ângulo crítico do ombro e do índice acromial

Abstract Objective The objectives of this study are to compare absolute values of acromial index (AI) and critical shoulder angle (CSA) obtained in both radiographs and magnetic resonance image (MRI) of the shoulder; and to compare the interobserver and intra-observer agreement for AI and CSA values measured in these image modalities. Methods Patients who had medical indication of investigating shoulders conditions through radiographs and MRI were included. Images were taken to two fellowship-trained shoulder surgeons, which conducted measurements of AI and CSA in radiographs and in MRI. Twelve weeks after the first evaluation, a second evaluation was conducted. Inter- and intra-observer reliability was presented as an Intraclass Correlation Coefficient (ICC) and agreement was classified according to Landis & Koch criteria. The differences between two measurements were evaluated using Bland-Altman plots. Results 134 shoulders in 124 subjects were included. Mean intra-observer ICC for CSA in X-rays and in MRI were 0.936 and 0.940, respectively; for AI, 0.908 and 0.022. Mean inter-observer ICC for CSA were 0.892 and 0.752 in X-rays and MRI respectively; for AI, ICC values were 0.849 and 0.685. All individual analysis reached statistical power (p< 0.001). Mean difference for AI values measured in X-rays and in MRI was 0.01 and 0.03 for observers 1 and 2, respectively. Mean difference for CSA values obtained in X-rays and MRI was 0.16 and 0.58 for observers 1 and 2, respectively. Conclusion Both MRI and X-rays provided high intra- and interobserver agreement for measurement of AI and CSA. Absolute values found for AI and CSA were highly correlated in both image modalities. These findings suggest that MRI is a suitable method to measure AI and CSA. Level of Evidence II, Diagnostic Study.

Resumo Objetivo Os objetivos deste estudo foram comparar os valores absolutos do índice acromial (IA) e do ângulo crítico do ombro (ACO) obtidos em radiografias e ressonâncias magnéticas (RM) do ombro e comparar a concordância interobservador e intraobservador dos valores de IA e ACO medidos nessas modalidades de imagem. Métodos Pacientes com indicação médica de investigação de doenças dos ombros por meio de radiografias e RM foram incluídos no estudo. As imagens foram levadas para dois cirurgiões de ombro treinados que realizaram medidas de IA e ACO em radiografias e RM. Doze semanas após a primeira avaliação, uma segunda avaliação foi realizada. A confiabilidade inter e intraobservador foi apresentada como coeficiente de correlação intraclasse (CCI) e a concordância foi classificada segundo os critérios de Landis e Koch. As diferenças entre duas medidas foram avaliadas por meio de gráficos de Bland-Altman. Resultados Cento e trinta e quatro ombros de 124 indivíduos foram incluídos no estudo. O CCI intraobservador médio para ACO em radiografias e RM foi 0,936 e 0,940, respectivamente; para IA, foi 0,908 e 0,022. O CCI interobservador médio para ACO foi 0,892 e 0,752 em radiografias e RM, respectivamente; para IA, os valores de CCI foram 0,849 e 0,685. Todas as análises individuais apresentaram poder estatístico (p < 0,001). A diferença média dos valores de IA em radiografias e RM foi 0,01 e 0,03 para os observadores 1 e 2, respectivamente. A diferença média dos valores de ACO em radiografias e RM foi 0,16 e 0,58 para os observadores 1 e 2, respectivamente. Conclusão Tanto a RM quanto as radiografias tiveram alta concordância intra e interobservador para medida de IA e ACO. Os valores absolutos de IA e ACO foram altamente correlacionados em ambas as modalidades de imagem. Esses achados sugerem que a RM é um método adequado para determinação de IA e ACO. Nível de Evidência II, Estudo Diagnóstico.

Acute Distal Biceps Tendon Injury: Diagnosis and Treatment / Lesões agudas do tendão distal do bíceps: Diagnóstico e tratamento

Abstract Acute distal biceps injuries clinically present with sudden pain and acute loss of flexion and supination strength. The main injury mechanism occurs during the eccentric load of the biceps. The hook test is the most significant examination test, presenting the highest sensibility and specificity for this lesion. Magnetic resonance imaging, the gold standard imaging test, can provide information regarding integrity and identify partial and/or complete tears. The surgical treatment uses an anterior or double approach and several reattachment techniques. Although there is no clinical evidence to recommend one fixation method over the other, biomechanical studies show that the cortical button resists better to failure. Although surgical treatment led to an 89% rate of return to work in 14 weeks, the recovery of high sports performance occurred in 1 year, with unsustainable outcomes.

Resumo As lesões agudas do tendão distal do bíceps se apresentam, clinicamente, com uma dor súbita associada a perda aguda de força de flexão e supinação. Seu principal mecanismo de lesão ocorre durante contração excêntrica do bíceps. O "Hook Test" é o principal teste semiológico, sendo o mais sensível e específico. A ressonância magnética, exame padrão ouro para o diagnóstico, pode fornecer informações sobre a integridade, identificando as lesões parciais e/ou completas. O tratamento cirúrgico pode ser realizado por duas vias principais: anterior e por dupla via porém as técnicas de reinserção tendínea são diversas não havendo evidência clínica que recomende um método de fixação em detrimento ao outro; embora o botão cortical apresente maior resistência a falha nos estudos biomecânicos. Com o tratamento cirúrgico o retorno as atividades laborais foi de 89% em 14 semanas (média) porém ao esporte de alto rendimento o prazo foi longo, média de 1 ano, e não duradouro.

Evaluation of Screws Positioning in Latarjet Surgery: Is There a Correlation between Parallelism to Glenoid and Radiographic Complications? / Avaliação do posicionamento dos parafusos na cirurgia de Latarjet: Existe correlação entre paralelismo à glenoide e complicações radiográficas?

Abstract Objective To evaluate whether the parallelism of screws with glenoid in Latarjet surgery interferes in the positioning of the graft and to verify the reproducibility of a method of measuring screws positioning. Methods Retrospective, multicenter study, of patients with anterior shoulder instability submitted to modified Latarjet surgery and at least one year of postoperative follow-up. Two radiologists analyzed the postoperative tomographic images, acquired in a database, to evaluate the positioning of screws and radiographic complications. Results We evaluated 34 patients, aged between 21 and 60 years, one of them with bilateral shoulder involvement, totaling 35 shoulders evaluated. The tomographic evaluation of the inclination angles of the screws showed no difference between the observers. There was intra- and interobserver agreement to evaluate the following surgical parameters: graft position, presence or not of radiographic complications. Conclusion The technique described for measuring the parallelism of screws in Latarjet surgery presented a very good and excellent intra-observer agreement, respectively. Screw parallelism with glenoid is recommended; however, it is not a mandatory and unique condition to avoid radiographic complications.

Resumo Objetivo Avaliar se o paralelismo dos parafusos com a glenoide na cirurgia de Latarjet interfere no posicionamento do enxerto e verificar a reprodutibilidade de um método de mensuração da posição dos parafusos. Métodos Estudo retrospectivo, multicêntrico, de pacientes com instabilidade anterior do ombro submetidos à cirurgia de Latarjet modificada e no mínimo 1 ano de seguimento pós-operatório. Dois médicos radiologistas analisaram as imagens tomográficas pós-operatórias, adquiridas em um banco de dados, para avaliação do posicionamento dos parafusos e das complicações radiográficas. Resultados Foram avaliados 34 pacientes, com idades entre 21 e 60 anos, sendo que um deles tinha acometimento bilateral dos ombros, totalizando 35 ombros avaliados. A avaliação tomográfica dos ângulos de inclinação dos parafusos não apresentou diferença entre os observadores. Houve concordância intra e interobservador para avaliação dos seguintes parâmetros cirúrgicos: posição do enxerto, presença ou não de complicações radiográficas. Conclusão A técnica descrita para mensuração do paralelismo dos parafusos na cirurgia de Latarjet apresentou uma concordância intra e inter observador muito boa e excelente, respectivamente. O paralelismo do parafuso com a glenoide é recomendado; no entanto, não é condição obrigatória e única para se evitar as complicações radiográficas.

Shoulder Arthroplasty for the Treatment of Proximal Humeral Fractures: Current Concepts / Artroplastia do ombro no tratamento das fraturas da extremidade proximal do úmero: Conceitos atuais

Abstract Complex proximal humeral fractures, especially in elderly patients, often require arthroplastic surgical treatment. Traditionally, shoulder hemiarthroplasty (HA) is the method of choice, resulting in long implant survival and a painless shoulder; however, shoulder HA has heterogeneous clinical outcomes related to the correct position of the implant, both in terms of height and version, and the anatomical consolidation of tuberosities. Today, reverse shoulder arthroplasties are increasingly used to treat such fractures. These techniques result in better functional outcomes compared to HAs, especially regarding anterior flexion, but implant longevity has not been established. The development of specific prosthetic humeral components for the treatment of fractures, which were recently introduced in the clinical practice, led to better clinical outcomes.

Resumo Fraturas complexas da extremidade proximal do úmero, especialmente em idosos, frequentemente necessitam de tratamento cirúrgico artroplástico. Tradicionalmente, a hemiartroplastia (HA) do ombro é o método de escolha, com longa sobrevida do implante, e oferece um ombro indolor, mas com resultados clínicos heterogêneos, relacionados ao correto posicionamento do implante quanto à altura e à versão, além da consolidação anatômica dos tubérculos. Atualmente, a utilização de artroplastias reversas do ombro para o tratamento dessas fraturas vêm aumentando exponencialmente, com melhores resultados funcionais do que as HAs, principalmente quanto à flexão anterior, apesar de a longevidade do implante ainda não ter sido estabelecida. O desenvolvimento de componentes umerais protéticos específicos para o tratamento de fraturas, introduzidos na prática clínica nos últimos anos, levou a resultados clínicos melhores.

Correlation Between Implant Positioning and Functional Outcomes in Partial Shoulder Resurfacing.

Objective The present study aimed to correlate functional outcomes and implant positioning in a case series of partial shoulder resurfacing arthroplasties. Methods A total of 25 patients were assessed for range of motion, functional outcome per the University of California at Los Angeles (UCLA) score and radiographic findings. Pre- and postoperative data were compared. In addition, patients were grouped according to the cervical-diaphyseal angle (CDA) determined by an anteroposterior radiography and to the retroversion angle (RVA) determined by an axillary radiography. A CDA from 130° to 140° and a RVA from 20° to 40° consisted in ideal positioning (anatomical standard). Data were analyzed using the Wilcoxon signed-rank test, analysis of variance (ANOVA) followed by the Kruskal-Wallis test or the Mann-Whitney test as appropriate. Results The mean follow-up time was 48.3 months (12 to 67 months). The postoperative functional score (31.5) was higher than the preoperative score (15.5) ( p < 0.001). In 6 patients, the implant was in anatomical positioning, while implant positioning was considered "nonstandard" in 19 subjects. Seven patients had a CDA < 130°, and 14 patients had a CDA ranging from 130° to 140°; in addition, the CDA was > 140° in 4 subjects. The RVA was up to 20° in 15 patients and ranged from 20° to 40° in 10 subjects. Using these criteria to group patients, the postoperative clinical-functional parameters were not statistically different from the preoperative findings ( p > 0.05). Conclusion Partial shoulder resurfacing results in significant postoperative functional recovery in patients with degenerative joint diseases. However, implant positioning assessed by CDA and RVA does not correlate with clinical-functional outcomes and, therefore, it is an inaccurate indicator of surgical success. Level of Evidence IV; Case Series.

Correlation Between Implant Positioning and Functional Outcomes in Partial Shoulder Resurfacing / Correlação entre posicionamento do implante das artroplastias parciais de recobrimento do ombro e os resultados funcionais

Abstract Objective The present study aimed to correlate functional outcomes and implant positioning in a case series of partial shoulder resurfacing arthroplasties. Methods A total of 25 patients were assessed for range of motion, functional outcome per the University of California at Los Angeles (UCLA) score and radiographic findings. Preand postoperative data were compared. In addition, patients were grouped according to the cervical-diaphyseal angle (CDA) determined by an anteroposterior radiography and to the retroversion angle (RVA) determined by an axillary radiography. A CDA from 130° to 140° and a RVA from 20° to 40° consisted in ideal positioning (anatomical standard). Data were analyzed using the Wilcoxon signed-rank test, analysis of variance (ANOVA) followed by the Kruskal-Wallis test or the Mann-Whitney test as appropriate. Results The mean follow-up time was 48.3 months (12 to 67 months). The postoperative functional score (31.5) was higher than the preoperative score (15.5) (p < 0.001). In 6 patients, the implant was in anatomical positioning, while implant positioning was considered "nonstandard" in 19 subjects. Seven patients had a CDA < 130°, and 14 patients had a CDA ranging from 130° to 140°; in addition, the CDA was > 140° in 4 subjects. The RVA was up to 20° in 15 patients and ranged from 20° to 40° in 10 subjects. Using these criteria to group patients, the postoperative clinical-functional parameters were not statistically different from the preoperative findings (p > 0.05). Conclusion Partial shoulder resurfacing results in significant postoperative functional recovery in patients with degenerative joint diseases. However, implant positioning assessed by CDA and RVA does not correlate with clinical-functional outcomes and, therefore, it is an inaccurate indicator of surgical success. Level of Evidence IV; Case Series.

Resumo Objetivo O objetivo do presente estudo é correlacionar os resultados funcionais de uma série de casos de artroplastias parciais de recobrimento do ombro com o posicionamento do implante. Métodos Um total de 25 pacientes foram avaliados em relação à amplitude de movimentos, à avaliação funcional pelo escore de Universidade da Califórnia Los Angeles (UCLA) e por análise radiográfica. Os dados pré- e pós-operatórios foram comparados. Adicionalmente, os pacientes foram agrupados quanto ao ângulo cérvico-diafisário (ACD) avaliado na radiografia em anteroposterior e quanto ao ângulo de retroversão (ARV) avaliado na radiografia em posição axilar. Foi considerado como posicionamento ideal (padrão anatômico) um ACD entre 130° e 140° e um ARV entre 20° e 40°. Os dados foram analisados pelo teste pareado de Wilcoxon, pela análise de variância (ANOVA, na sigla em inglês) seguida pelo pós-teste de Kruskal-Wallis ou pelo teste de Mann-Whitney, quando apropriado. Resultados O seguimento médio foi de 48,3 meses (12 a 67 meses). A avaliação funcional pós-operatória (31,5) foi melhor do que a pré-operatória (15,5) (p < 0,001). Seis pacientes apresentaram posicionamento anatômico do implante, enquanto 19 pacientes foram considerados "fora do padrão." Sete pacientes apresentaram um ACD < 130°, quatorze apresentaram um ACD entre 130° e 140°, e quatro apresentaram um ACD >140°. Quinze pacientes apresentaram um ARV ≤ 20°, e 10 entre 20° e 40°. Utilizando esses critérios para agrupar os pacientes, a comparação dos parâmetros da avaliação clínico-funcional pós-operatória não foi estatisticamente diferente (p > 0,05). Conclusão A artroplastia parcial de recobrimento do ombro oferece significativa recuperação funcional pós-operatória em pacientes com doenças degenerativas articulares. Entretanto, o posicionamento do implante avaliado pelos ACD e ARV não se correlaciona com o resultado clínico-funcional, sendo, portanto, uma medida imprecisa de sucesso da cirurgia. Nível de Evidência IV, Série de Casos.

Bone Integration and Prevalence of Radiolucent Lines around the Pegs of Minimally Cemented Glenoid Components in Total Shoulder Arthroplasty.

Objectives Glenoid component failure is the main cause of total shoulder arthroplasty (TSA) revision, and component design seems to influence the failure rate. The aim of the present study was to clinically and radiographically (through X-rays and computed tomography scan) evaluate the results of TSA using a minimally cemented glenoid component. Methods Total should arthroplasties performed using the minimally cemented Anchor Peg (DuPuy Synthes, Warsaw, IN, USA) glenoid component between 2008 and 2013 were evaluated. University of California at Los Angeles (UCLA) scores were calculated, and standardized plain film and computed tomography images were obtained, at a minimum follow-up of 24 months. The presence of bone between the fins of the central component peg, which indicates its integration, was assessed on the images, as well the presence of radiolucent lines around the glenoid component. Results Nineteen shoulders in 17 patients were available for evaluation. According to the UCLA score, clinical results were satisfactory in 74% of cases and fair in 21% of cases. One patient had a poor result. Component integration was found in 58% of patients (total in 42% and partial in 16%). Radiolucent lines were observed in 52% of cases. No relationship was detected between component integration and clinical results. Conclusion Satisfactory clinical results were achieved in most patients undergoing TSA using a minimally cemented glenoid component. Radiolucent lines around the glenoid component are common, but do not interfere with the clinical results. Level of evidence IV; Case series; Treatment study.

Humerus Diaphyseal Stress Fracture in a Teenage Tennis Athlete: Case Report.

A teenage male tennis player had chronic pain in his dominant arm during tennis practice. Magnetic resonance imaging (MRI) suggested humerus diaphyseal stress injury. After 4 weeks, he became asymptomatic and resumed playing. However, pain recurred after 3 days. A new MRI revealed a diaphyseal undisplaced humerus fracture and significant bone marrow edema. The patient remained in rest for 4 weeks. After that, strengthening exercises were introduced and return to training was allowed after 12 weeks. Even if asymptomatic, we suggest that these patients should not return to play before 12 weeks, depending on the physical exam and imaging findings.

Humerus Diaphyseal Stress Fracture in a Teenage Tennis Athlete: Case Report / Fratura por estresse diafisária do úmero em atleta de tênis adolescente: Relato de caso

Abstract A teenage male tennis player had chronic pain in his dominant arm during tennis practice. Magnetic resonance imaging (MRI) suggested humerus diaphyseal stress injury. After 4 weeks, he became asymptomatic and resumed playing. However, pain recurred after 3 days. A new MRI revealed a diaphyseal undisplaced humerus fracture and significant bone marrow edema. The patient remained in rest for 4 weeks. After that, strengthening exercises were introduced and return to training was allowed after 12 weeks. Even if asymptomatic, we suggest that these patients should not return to play before 12 weeks, depending on the physical exam and imaging findings.

Resumo Um tenista adolescente tinha dor crônica no braço dominante durante os treinos de tênis. A ressonância magnética (RM) sugeriu lesão por estresse na diáfise do úmero. Depois de 4 semanas, ele se tornou assintomático e voltou a jogar. No entanto, houve recidiva da dor após 3 dias. A nova RM revelou fratura diafisária não desviada do úmero e edema significativo da medula óssea. O paciente ficou em repouso por 4 semanas. Depois disso, exercícios de fortalecimento foram introduzidos e o retorno aos treinamentos foi permitido após 12 semanas. Mesmo que assintomáticos, sugerimos que esses pacientes não voltem a jogar antes das 12 semanas, dependendo dos exames físicos e dos achados por imagem.

Bone Integration and Prevalence of Radiolucent Lines around the Pegs of Minimally Cemented Glenoid Components in Total Shoulder Arthroplasty / Integração óssea e prevalência de linhas radiotransparentes ao redor dos pinos de componentes glenoidais minimamente cimentados na artroplastia total de ombro

Abstract Objectives Glenoid component failure is the main cause of total shoulder arthroplasty (TSA) revision, and component design seems to influence the failure rate. The aim of the present study was to clinically and radiographically (through X-rays and computed tomography scan) evaluate the results of TSA using a minimally cemented glenoid component. Methods Total should arthroplasties performed using the minimally cemented Anchor Peg (DuPuy Synthes, Warsaw, IN, USA) glenoid component between 2008 and 2013 were evaluated. University of California at Los Angeles (UCLA) scores were calculated, and standardized plain film and computed tomography images were obtained, at a minimum follow-up of 24 months. The presence of bone between the fins of the central component peg, which indicates its integration, was assessed on the images, as well the presence of radiolucent lines around the glenoid component. Results Nineteen shoulders in 17 patients were available for evaluation. According to the UCLA score, clinical results were satisfactory in 74% of cases and fair in 21% of cases. One patient had a poor result. Component integration was found in 58% of patients (total in 42% and partial in 16%). Radiolucent lines were observed in 52% of cases. No relationship was detected between component integration and clinical results. Conclusion Satisfactory clinical results were achieved in most patients undergoing TSA using a minimally cemented glenoid component. Radiolucent lines around the glenoid component are common, but do not interfere with the clinical results. Level of evidence IV; Case series; Treatment study.

Resumo Objetivos A falha do componente glenoidal é a principal causa de revisão da artroplastia total do ombro (ATO) e sua frequência parece ser influenciada pelo design do componente. O objetivo deste estudo foi a avaliação clínica e radiográfica (através de raios X e tomografia computadorizada) dos resultados da ATO com componente glenoidal minimamente cimentado. Métodos O presente trabalho analisou ATOs realizadas com componente glenoidal Anchor Peg (DuPuy Synthes, Warsaw, IN, EUA) minimamente cimentado entre 2008 e 2013. Por um período mínimo de acompanhamento de 24 meses, escores segundo critérios da University of California at Los Angeles (UCLA) e imagens padronizadas de radiografia simples e tomografia computadorizada foram analisadas. A presença de osso entre as aletas do pino do componente central, que é um indicador de sua integração, foi avaliada nas imagens, bem como a presença de linhas radiotransparentes ao redor do componente glenoidal. Resultados Dezenove ombros de 17 pacientes foram avaliados. De acordo com o escore da UCLA, os resultados clínicos foram satisfatórios em 74% dos casos e moderados em 21% dos casos. O resultado foi ruim em um paciente. A integração de componentes foi observada em 58% dos pacientes, sendo total em 42% e parcial em 16% dos casos. Linhas radiotransparentes foram observadas em 52% dos pacientes. Nenhuma relação entre a integração de componentes e os resultados clínicos foi detectada. Conclusão A maioria dos pacientes submetidos à ATO com componente glenoidal minimamente cimentado apresentou resultados clínicos satisfatórios. Linhas radiotransparentes ao redor do componente glenoidal são comuns, mas não interferem nos resultados clínicos Nível de evidência IV; Série de caso; Estudo terapêutico.

Treatment of chronic locked posterior dislocation of the shoulder with the modified McLaughlin procedure.

BACKGROUND: Locked posterior dislocation of the shoulder (LPDS) is a challenging condition for the orthopedic surgeon. The problem with cases of chronic LPDS is that they may result in worse clinical outcomes because the size of the reverse Hill-Sachs lesion and cartilage damage can increase over time. Multiple treatment strategies have been reported in the literature for the treatment of chronic cases. The purpose of this study was to report our experience with the modified McLaughlin technique for the treatment of chronic LPDS and evaluate the mid- and long-term functional outcomes. METHODS: This was a retrospective single-center study including a consecutive series of 10 patients who underwent the modified McLaughlin procedure for the treatment of chronic LPDS. The time between dislocation and treatment ranged from 6 weeks to 14 months (mean, 20.9 weeks). Postoperative imaging and functional evaluation were performed with a minimum of 2 years' follow-up (range, 24-110 months). Functional outcomes were assessed by means of a visual analog scale score for pain and patient satisfaction regarding the operation, the Constant-Murley score, and the University of California, Los Angeles shoulder rating scale. RESULTS: The mean follow-up period was 59.4 months (range, 24-110 months). Range of motion improved significantly after surgery: Mean forward flexion improved from 71° ± 5° to 126°± 37° (P < .001), mean external rotation improved from 7°± 7° to 52° ± 18° (P = .012), and mean internal rotation improved from gluteal region ± 1 vertebral level to L1 ± 4 vertebral levels (P = .001). Functional outcome measures demonstrated significant improvements: The mean Constant-Murley score improved from 22 ± 2.4 (range, 20-26) to 65 ± 21.5 (P < .001); the mean University of California, Los Angeles score improved from 9.8 ± 1.3 (range, 8-12) to 27 ± 9.7 (P < .001); and the mean visual analog scale score improved from 4.6 ± 0.8 (range, 3-6) to 2.4 ± 2.3 (P < .001). Of the patients, 8 (80%) were satisfied with the procedure. The 2 remaining cases had a delay from injury to diagnosis > 6 months and evolved with poor functional outcomes and severe glenohumeral degenerative joint disease. There were no cases of recurrent dislocation, infection, or neurologic injury during the follow-up. CONCLUSION: Our study findings demonstrated that the modified McLaughlin procedure showed good results over a 2-year minimum follow-up period. The clinical outcomes of this procedure are worse when there is a delay from injury to diagnosis > 6 months.

Incidence and Risk Factors of the Complications Related to the Latarjet Surgery.

Objective The Latarjet procedure is a well-accepted treatment of shoulder instability. This technique is associated with a unique set of complications with overall rates of up to 30%. The purpose of the present study was to investigate the incidence and risk factors associated with complications after open Latarjet procedure. Methods We retrospectively reviewed 102 patients submitted to open Latarjet procedure. Complications were divided into three types: clinical; graft-related; and screw-related. All of the patients were submitted to radiography and computed tomography (CT). The risk factors analyzed were gender, age, previous surgery, epilepsy, experience of the surgeon. Results A total of 102 consecutive patients (108 cases) underwent the Latarjet procedure. The mean age was 33.7 years old (18 to 61 years old), with 88 males and 14 females. The overall complication rate was 21.2%, being 12% clinical-related, 7.4% graft-related, and 2.7% screw-related. The most frequent were anterior apprehension (eight cases) and lateral overhang of the graft in six patients. Computed tomography scan at a minimum of 6 months was performed in 79 cases (73%), and graft union occurred in 75 patients (94.9%). There were no cases of instability in the remaining four cases of nonunion. Ten patients (9.2%) required revision surgery. The risk factors associated with complications were epilepsy ( p = 0.0325), experience of the surgeon ( p = 0.0499) and patients ≥ 40 years old at the time of the surgery ( p = 0.0151). There was no correlation with gender and previous surgery. Conclusion The complication rate following the Latarjet procedure was 21.2%, with 9% requiring revision surgery. Epilepsy, age > 40 years old and experience of the surgeon were risk factors.

Superior Capsular Reconstruction using the Long Head of the Biceps Tendon: The Biceps Loop Technique.

Irreparable rotator cuff tears can be treated in several ways. Superior capsular reconstruction has been reported as an excellent option, particularly for the young and active patients. We propose capsule reconstruction using the long head of the biceps tendon in a modified way. After its tenotomy at the musculotendinous junction, the long head is rerouted through a humeral bone tunnel and attached to a suture anchor in the posterior aspect of the superior glenoid rim. Further investigation is required, but this modified technique appears promising.

Impact of the Strategies Adopted to Face the COVID-19 Pandemic in a Brazilian Reference Institute for High Complexity Surgery in Orthopedics and Traumatology.

COVID-19 pandemics required substantial reorganization and adaptation of healthcare services all over the world. This study aims to analyze the effect of operational strategies implemented in Brazil to manage the extra strain placed on healthcare services by the COVID-19 pandemic of 2020. In particular, this investigation examines the strategy to convert an institute specialized in elective orthopedic procedures of high complexity into a trauma unit for all musculoskeletal trauma patients of an entire federative unit. A retrospective study was conducted comparing hospital variables at the peak period of the pandemic (from March 16, 2020 to June 30, 2020) with the same period in 2019 as a comparative baseline. The variables analyzed included number of professionals away from work, surgeries performed, outpatient care, transfers, length of stay, number of patients diagnosed with COVID-19 and patient mortality. During the COVID-19 peak period, there was a 48.5% reduction in surgical productivity and 72.4% reduction in outpatient care compared with the same period in 2019. The number of transfers increased substantially (124.5%), while 94 confirmed cases and 77 suspected cases of COVID-19 were reported. The mortality rate increased by 245%. The present study highlighted the effect of COVID-19 on a tertiary orthopedic hospital. Despite the dramatic changes in hospital operations, due to the implementation of protocols to manage the pandemic, the results demonstrated the feasibility and efficiency of such protocols in prioritizing quality and safety for patients and the healthcare workforce.

Impact of the "Mind the risk" Campaign of Sociedade Brasileira de Ortopedia e Traumatologia on Risk Perception and Use of the Surgical Checklist by Brazilian Orthopedists.

Objective To analyze the impact of the educational actions included in the "Mind the Risk" campaign of Sociedade Brasileira de Traumatologia e Ortopedia (Brazilian Society of Traumatology and Orthopedics, SBOT, in Portuguese), to increase the perception of the risk involved in the surgical activity and the use of the surgical checklist. Methods A comparative research was performed during the 50th Brazilian Congress on Orthopedics and Traumatology (50° CBOT, in Portuguese) in November 2018, using a questionnaire similar to the one used in previous two versions. Results The number of participants was 730, corresponding to 18,7% of the total of 3,903 enrolled in the 50° CBOT. Among the participants, 542 orthopedists (74,2%) reported having experienced errors within the surgical units and 218 (29,8%) surgeries in wrong sites. In total, 624 participants (85,5%) reported marking the surgical site and 402 (55%) using the surgical checklist systematically. Conclusion In the sample studied, it was evidenced that SBOT's efforts to disseminate the World Health Organization (WHO) protocol were effective, reducing the number of orthopedists who were unaware of it from 65.3% (in 2012) to 20.7% (in 2018), and expanding its use. In 2018, 402 participants (55%) reported the systematic use of the protocol, compared with 301 (40,8%) in 2014. These data confirm the need for educational campaigns and systematic training, not only to promote behavioral change, but especially a cultural change.

Incidence and Risk Factors of the Complications Related to the Latarjet Surgery / Incidência e fatores de risco das complicações da cirurgia de Latarjet

Abstract Objective The Latarjet procedure is a well-accepted treatment of shoulder instability. This technique is associated with a unique set of complications with overall rates of up to 30%. The purpose of the present study was to investigate the incidence and risk factors associated with complications after open Latarjet procedure. Methods We retrospectively reviewed 102 patients submitted to open Latarjet procedure. Complications were divided into three types: clinical; graft-related; and screw-related. All of the patients were submitted to radiography and computed tomography (CT). The risk factors analyzed were gender, age, previous surgery, epilepsy, experience of the surgeon. Results A total of 102 consecutive patients (108 cases) underwent the Latarjet procedure. The mean age was 33.7 years old (18 to 61 years old), with 88 males and 14 females. The overall complication rate was 21.2%, being 12% clinical-related, 7.4% graft-related, and 2.7% screw-related. The most frequent were anterior apprehension (eight cases) and lateral overhang of the graft in six patients. Computed tomography scan at a minimum of 6 months was performed in 79 cases (73%), and graft union occurred in 75 patients (94.9%). There were no cases of instability in the remaining four cases of nonunion. Ten patients (9.2%) required revision surgery. The risk factors associated with complications were epilepsy (p = 0.0325), experience of the surgeon (p = 0.0499) and patients ≥ 40 years old at the time of the surgery (p = 0.0151). There was no correlation with gender and previous surgery. Conclusion The complication rate following the Latarjet procedure was 21.2%, with 9% requiring revision surgery. Epilepsy, age ≥ 40 years old and experience of the surgeon were risk factors.

Resumo Objetivo A cirurgia de Latarjet é bem estabelecida para o tratamento da instabilidade anterior do ombro. Apresenta complicações específicas com taxas de até 30%. Nosso objetivo é avaliar a incidência e os fatores de risco associados às complicações após a cirurgia de Latarjet. Métodos Analisamos retrospectivamente 102 pacientes submetidos ao procedimento. Dividimos as complicações em três tipos: clínicas, relacionadas ao enxerto e relacionadas aos implantes. Todos os pacientes foram submetidos a radiografias e tomografia computadorizada (TC). Os fatores de risco analisados foram gênero, idade, cirurgia prévia, epilepsia e experiência do cirurgião. Resultados Um total de 102 pacientes consecutivos (108 casos) foram avaliados. A média de idade foi 33,7 anos (18 a 61 anos), com 88 homens e 14 mulheres. A taxa de complicações foi de 21,2%, sendo 12% clínicas, 7,4% relacionadas ao enxerto e 2,7% relacionadas ao implante. As mais frequentes foram apreensão anterior (oito casos) e posicionamento lateral do enxerto, em seis casos. A TC foi realizada com o mínimo de 6 meses em 79 casos (73%), evidenciando a consolidação do enxerto em 75 pacientes (94.9%). Nenhum caso de não união apresentou instabilidade. Dez pacientes (9.2%) precisaram de cirurgia de revisão. Os fatores de risco relacionados às complicações foram epilepsia (p = 0.0325), experiência do cirurgião (p = 0.0499) e pacientes ≥ 40 anos (p = 0.0151). Não houve correlação com gênero e cirurgia prévia. Conclusão A taxa de complicações após a cirurgia de Latarjet foi de 21,2%, com 9% necessitando de revisão cirúrgica. Epilepsia, idade ≥ 40 anos e experiência do cirurgião foram fatores de risco.

Impact of the Strategies Adopted to Face the COVID-19 Pandemic in a Brazilian Reference Institute for High Complexity Surgery in Orthopedics and Traumatology / Impacto das estratégias adotadas para enfrentar a pandemia de COVID-19 em um Instituto Brasileiro de referência em cirurgia de alta complexidade em Ortopedia e Traumatologia

Abstract COVID-19 pandemics required substantial reorganization and adaptation of healthcare services all over the world. This study aims to analyze the effect of operational strategies implemented in Brazil to manage the extra strain placed on healthcare services by the COVID-19 pandemic of 2020. In particular, this investigation examines the strategy to convert an institute specialized in elective orthopedic procedures of high complexity into a trauma unit for all musculoskeletal trauma patients of an entire federative unit. A retrospective study was conducted comparing hospital variables at the peak period of the pandemic (from March 16, 2020 to June 30, 2020) with the same period in 2019 as a comparative baseline. The variables analyzed included number of professionals away from work, surgeries performed, outpatient care, transfers, length of stay, number of patients diagnosed with COVID-19 and patient mortality. During the COVID-19 peak period, there was a 48.5% reduction in surgical productivity and 72.4% reduction in outpatient care compared with the same period in 2019. The number of transfers increased substantially (124.5%), while 94 confirmed cases and 77 suspected cases of COVID-19 were reported. The mortality rate increased by 245%. The present study highlighted the effect of COVID-19 on a tertiary orthopedic hospital. Despite the dramatic changes in hospital operations, due to the implementation of protocols to manage the pandemic, the results demonstrated the feasibility and efficiency of such protocols in prioritizing quality and safety for patients and the healthcare workforce.

Resumo A pandemia de COVID-19 exigiu reorganização e adaptação substanciais dos serviços de saúde em todo o mundo. Este estudo tem como objetivo analisar o efeito das estratégias operacionais implementadas no Brasil em resposta à pressão extra imposta aos serviços de saúde pela pandemia de COVID-19 de 2020. Esta pesquisa examina principalmente a estratégia de conversão de um instituto especializado em procedimentos ortopédicos eletivos de alta complexidade em uma unidade de trauma para todos os pacientes com traumatismo musculoesquelético de toda uma unidade federativa. Um estudo retrospectivo comparou as variáveis hospitalares no período de pico da pandemia (de 16 de março de 2020 a 30 de junho de 2020) com o mesmo período de 2019, que representou os valores basais. As variáveis analisadas foram número de profissionais afastados do trabalho, cirurgias realizadas, atendimento ambulatorial, transferências, tempo de internação, número de pacientes com diagnóstico de COVID-19 e mortalidade dos pacientes. Durante o período de pico de COVID-19, houve uma redução de 48,5% na produtividade cirúrgica e de 72,4% no atendimento ambulatorial em comparação ao mesmo período de 2019. O número de transferências aumentou de maneira substancial (124,5%), com relato de 94 casos confirmados e 77 casos suspeitos de COVID-19. A taxa de mortalidade aumentou 245%. Este estudo destacou o efeito da COVID-19 em um hospital ortopédico terciário. Apesar das mudanças dramáticas no funcionamento do hospital devido à instituição de protocolos em resposta à pandemia, os resultados demonstraram a viabilidade e a eficiência de tais protocolos em priorizar a qualidade e a segurança dos pacientes e dos profissionais de saúde.

Impact of the "Mind the risk" Campaign of Sociedade Brasileira de Ortopedia e Traumatologia on Risk Perception and Use of the Surgical Checklist by Brazilian Orthopedists / Impacto da campanha "Considere o Risco", da Sociedade Brasileira de Ortopedia e Traumatologia, na percepção do risco e na utilização do checklist cirúrgico por ortopedistas brasileiros

Abstract Objective To analyze the impact of the educational actions included in the "Mind the Risk" campaign of Sociedade Brasileira de Traumatologia e Ortopedia (Brazilian Society of Traumatology and Orthopedics, SBOT, in Portuguese), to increase the perception of the risk involved in the surgical activity and the use of the surgical checklist. Methods A comparative research was performed during the 50th Brazilian Congress on Orthopedics and Traumatology (50º CBOT, in Portuguese) in November 2018, using a questionnaire similar to the one used in previous two versions. Results The number of participants was 730, corresponding to 18,7% of the total of 3,903 enrolled in the 50º CBOT. Among the participants, 542 orthopedists (74,2%) reported having experienced errors within the surgical units and 218 (29,8%) surgeries in wrong sites. In total, 624 participants (85,5%) reported marking the surgical site and 402 (55%) using the surgical checklist systematically. Conclusion In the sample studied, it was evidenced that SBOT's efforts to disseminate the World Health Organization (WHO) protocol were effective, reducing the number of orthopedists who were unaware of it from 65.3% (in 2012) to 20.7% (in 2018), and expanding its use. In 2018, 402 participants (55%) reported the systematic use of the protocol, compared with 301 (40,8%) in 2014. These data confirm the need for educational campaigns and systematic training, not only to promote behavioral change, but especially a cultural change.

Resumo Objetivo Analisar o impacto das ações educacionais inseridas na campanha "Considere o Risco", da Sociedade Brasileira de Traumatologia e Ortopedia (SBOT), para aumentar a percepção do risco envolvido na atividade cirúrgica e a utilização do checklist cirúrgico. Métodos Realização de pesquisa comparativa, durante o 50º Congresso Brasileiro de Ortopedia e Traumatologia (50º CBOT), em novembro de 2018, utilizando questionário semelhante ao de duas versões anteriores. Resultados O número de participantes foi de 730, correspondendo à 18,7% do total de 3903 inscritos no 50º CBOT. No total, 542 ortopedistas (74,2%) relataram já ter vivenciado erros dentro do centro cirúrgico e 218 (29,8%) cirurgias em locais errados; 624 participantes (85,5%) afirmaram marcar o local da cirurgia e 402 (55%) utilizar regularmente o checklist cirúrgico. Conclusão Na amostra pesquisada, ficou evidenciado que os esforços da SBOT para a disseminação do conhecimento do protocolo da Organização Mundial de Saúde (OMS) foram efetivos, reduzindo a quantidade de ortopedistas que o desconheciam de 65,3% (em 2012) para 20,7% (em 2018), e ampliando sua utilização. Em 2018, 402 ortopedistas (55% da amostra) referiram fazer uso frequente do protocolo no ambiente cirúrgico, em comparação com 301 (40,2%) em 2014. Estes dados confirmam a necessidade de campanhas educacionais e treinamentos sistemáticos, não apenas para promover uma mudança de comportamento, como também, principalmente, uma mudança cultural.