Capsulitis adhesiva del hombro. Comparación entre métodos de tratamiento conservador / Adhesive capsulitis of the shoulder: Comparison between conservative treatment methods

Objetivo: Evaluar los resultados funcionales de tres protocolos distintos de tratamiento conservador en pacientes con capsulitis adhesiva del hombro. Materiales y Métodos: Se revisaron las historias clínicas de los pacientes tratados por capsulitis adhesiva en nuestra institución, entre enero de 2016 y enero de 2019. Se compararon tres protocolos diferentes de tratamiento: grupo 1, bloqueo del nervio supraescapular con un anestésico local y corticoide, analgésicos y fisioterapia después del alivio del dolor; grupo 2, bloqueo del nervio supraescapular con anestésico local sin corticoide, analgésicos y fisioterapia; grupo 3, analgésicos y fisioterapia, sin bloqueo del nervio supraescapular. Se determinaron los resultados funcionales con la escala ASES y el resultado subjetivo con el SSV. Resultados: Se dividió en tres grupos a 46 pacientes tratados por capsulitis adhesiva. Los pacientes del grupo 3 tuvieron, en promedio, más sesiones de fisioterapia (30,31 ± 21,07). Los del grupo 2 recibieron la mayor cantidad promedio de bloqueos del nervio supraescapular (3,27 ± 1,22). Los resultados de los puntajes funcionales fueron: grupo 1 (15 pacientes): media 84 ASES y 84 SSV; grupo 2 (15 pacientes): media 93,40 ASES y 91,67 SSV; grupo 3 (16 pacientes): media 79,4 ASES y 80,63 SSV. Conclusiones: Las distintas formas de tratamiento conservador para la capsulitis adhesiva logran excelentes resultados. La analgesia mediante bloqueos seriados del nervio supraescapular con un anestésico y corticoide logró mejores resultados funcionales y subjetivos, y disminuyó la necesidad de administrar analgésicos y de sesiones de fisioterapia (grupo 1). Nivel de Evidencia: IV

Objective: To evaluate the functional outcomes of three different conservative treatment protocols in patients with adhesive capsulitis of the shoulder. Materials and Methods: Reviews of medical records were carried out on patients treated at the institution for adhesive capsulitis in the period between January 2016 and January 2019. 3 different treatment protocols were compared. Group 1; Suprascapular nerve block (SSNB) with local anesthetic and corticosteroid, analgesics, and physiotherapy after pain reduction. Group 2: SSNB with local anesthetic without corticosteroids, analgesics, and physiotherapy, and group 3: analgesics and physiotherapy, without SSNB. The functional outcomes were determined with the ASES scale and the subjective results were assessed with the SSV. Results:A total of 46 patients treated for adhesive capsulitis were divided into 3 groups. Group 3 presented a higher mean number of physiotherapy sessions (30.31±21.07). Group 2 had the highest mean number of SSN blocks (3.27±1.22). The results of the functional scores were: group 1 (15 patients): mean ASES 84 and mean SSV 84; group 2 (15 patients): mean ASES 93.40 and mean SSV 91.67; group 3 (16 patients): mean ASES 79.4 and mean SSV 80.63. Conclusion: The various forms of conservative treatment for adhesive capsulitis achieve excellent outcomes. Analgesia through serial blocks of the suprascapular nerve with an anesthetic and corticosteroid achieved better functional and subjective outcomes and decreased the need to administer analgesics and physiotherapy sessions (group 1). Level of Evidence: IV

Técnica de Livani-Belangero (MIPO) en el tratamiento de las fracturas diafisarias de húmero. Experiencia latinoamericana en tres centros hospitalarios / Belangero-Livani Technique (MIPO) in the treatment of humeral shaft fractures. A Latin American experience in three medical centers

Objetivo: Evaluar los datos demográficos, como edad, sexo, profesión, lado afectado, lesión única o múltiple, tipo de material utilizado, tiempo de cicatrización ósea y posibles complicaciones de los pacientes con fracturas diafisarias de húmero tratados mediante la técnica MIPO en tres centros hospitalarios de Ecuador, Paraguay y Brasil. Materiales y Métodos: Estudio retrospectivo, longitudinal, observacional de los datos de 133 pacientes recolectados en tres Servicios: de Quito (Ecuador), Asunción (Paraguay) y Passo Fundo (Brasil). Se compararon las distribuciones entre diferentes Servicios mediante la prueba x2 de Pearson. Resulta-dos: La edad de los pacientes varió entre 17 y 76 años, con una media de 36 años. El tiempo promedio hasta la consolidación fue de 11 semanas (126 de 132 pacientes). Predominó el sexo masculino (70,45%), el lado derecho era el más afectado (55,3%), la mayoría de las fracturas eran únicas (85,61%), se logró la consolidación en el 95,45%. Solo el 9,09% tuvo complicaciones y el 6,82% fueron severas. El 87,12% no tuvo complicaciones; el 0,76% sufrió neuropraxia posquirúrgica; el 3,03%, infección y el 4,55%, seudoartrosis. Conclusión: Con la técnica MIPO para el tratamiento de las fracturas diafisarias de húmero, las tasas de complicaciones y de morbilidad son bajas, y la tasa de consolidación es buena. Nivel de Evidencia: IV

Objective: To determine the demographic data of the patients in relation to age, sex, profession, affected side, single or multiple lesions, type of material used, bone healing time and possible complications of the treatment of diaphyseal fractures of the humerus treated using the MIPO technique in a series of patients from three hospital units in Ecuador, Paraguay, and Brazil. Materials and Methods: A retrospective, longitudinal, observational study of data from 133 patients collected in 3 services in Quito, Ecuador; Asunción, Paraguay; and Passo Fundo, Brazil. The distributions between different services were compared using Pearson's chisquare test. Results: The age of the patients ranged from 17 to 76 years, with a mean of 36 years. The median time to union which occurred in 126 of the 132 patients, was 11 weeks. Most of the patients were male (70.45%), the right side was the most affected (55.3%), most of the fractures were single (85.61%), consolidation occurred in 95.45% of cases, complications occurred only in 9.09% of patients, 6.82% of them were severe. In relation to complications, they were divided according to the absence (87.12%) or presence of the following: post-surgical neuropraxia (0.76%), infection (3.03%), and pseudarthrosis (4.55%). Conclusion: The MIPO technique for the treatment of diaphyseal fractures of the humerus presents low rates of complications and morbidity, demonstrating good rates of consolidation. Level of Evidence: IV

Disease-Modifying Adjunctive Therapy (DMAT) in Osteoarthritis-The Biological Effects of a Multi-Mineral Complex, LithoLexal® Joint-A Review.

Modern advances in molecular medicine have led to the reframing of osteoarthritis as a metabolically active, inflammatory disorder with local and systemic contributing factors. According to the 'inflammatory theory' of osteoarthritis, immune response to an initial damage is the key trigger that leads to progressive joint destruction. Several intertwined pathways are known to induce and govern articular inflammation, cartilage matrix degradation, and subchondral bone changes. Effective treatments capable of halting or delaying the progression of osteoarthritis remain elusive. As a result, supplements such as glucosamine and chondroitin sulphate are commonly used despite the lack of scientific consensus. A novel option for adjunctive therapy of osteoarthritis is LithoLexal® Joint, a marine-derived, mineral-rich extract, that exhibited significant efficacy in clinical trials. LithoLexal® has a lattice microstructure containing a combination of bioactive rare minerals. Mechanistic research suggests that this novel treatment possesses various potential disease-modifying properties, such as suppression of nuclear factor kappa-B, interleukin 1ß, tumor necrosis factor α, and cyclooxygenase-2. Accordingly, LithoLexal® Joint can be considered a disease-modifying adjunctive therapy (DMAT). LithoLexal® Joint monotherapy in patients with knee osteoarthritis has significantly improved symptoms and walking ability with higher efficacy than glucosamine. Preliminary evidence also suggests that LithoLexal® Joint may allow clinicians to reduce the dose of nonsteroidal anti-inflammatory drugs in osteoarthritic patients by up to 50%. In conclusion, the multi-mineral complex, LithoLexal® Joint, appears to be a promising candidate for DMAT of osteoarthritis, which may narrow the existing gap in clinical practice.

Brazilian authors don't cite Brazilian authors: Nothing has changed since 1994.

Objective To outline the profile of self-citations from Revista Brasileira de Ortopedia (Rev Bras Ortop) and citations of this journal in other medical orthopaedic journals with general or specific content in a knowledge area of the specialty. Methods This is an observational cross-sectional study of the frequency of self-citations and citations from Rev Bras Ortop in five other medical orthopaedic journals from different countries, all published in English. The last 15 articles published in 2020 in each of the six journals were analyzed. The references used in each of them were evaluated to identify the journal in which they were originally published. The frequency of distribution of the four main journals cited, their position, and the relative percentage to the total number of citations were observed and recorded in each of the six journals. The number of times that the Rev Bras Ortop was cited in each of the selected foreign journals was assessed using its absolute and relative frequencies. Results The total number of citations evaluated in this study was 2,527 (ranging from 386 to 486 per magazine). Rev Bras Ortop showed a low rate of self-citation (2.6%), being the sixth journal cited in the journal itself (10 out of a total of 386 references). Moreover, Rev Bras Ortop was not mentioned in any of the other five medical journals included in the study (absolute frequency 0, relative frequency 0). Conclusion Rev Bras Ortop has a low reference of itself, with a self-citation rate of 2.6% in the studied period, showing that the Brazilian orthopaedic surgeons do not mention the Brazilian orthopaedic surgeon who publishes in the journal. We suggest the elaboration and implementation of strong strategies to improve the journal's visibility in the world academic-scientific scenario. In addition, it is essential that Brazilian orthopaedic surgeons understand this reality and assist directly and effectively to change this scenario.

Brazilian authors don't cite Brazilian authors: Nothing has changed since 1994 / Os Autores brasileiros não citam os autores brasileiros: Nada mudou desde 1994

Abstract Objective To outline the profile of self-citations from Revista Brasileira de Ortopedia (Rev Bras Ortop) and citations of this journal in other medical orthopaedic journals with general or specific content in a knowledge area of the specialty. Methods This is an observational cross-sectional study of the frequency of self-citations and citations from Rev Bras Ortop in five other medical orthopaedic journals from different countries, all published in English. The last 15 articles published in 2020 in each of the six journals were analyzed. The references used in each of them were evaluated to identify the journal in which they were originally published. The frequency of distribution of the four main journals cited, their position, and the relative percentage to the total number of citations were observed and recorded in each of the six journals. The number of times that the Rev Bras Ortop was cited in each of the selected foreign journals was assessed using its absolute and relative frequencies. Results The total number of citations evaluated in this study was 2,527 (ranging from 386 to 486 per magazine). Rev Bras Ortop showed a low rate of self-citation (2.6%), being the sixth journal cited in the journal itself (10 out of a total of 386 references). Moreover, Rev Bras Ortop was not mentioned in any of the other five medical journals included in the study (absolute frequency 0, relative frequency 0). Conclusion Rev Bras Ortop has a low reference of itself, with a self-citation rate of 2.6% in the studied period, showing that the Brazilian orthopaedic surgeons do not mention the Brazilian orthopaedic surgeon who publishes in the journal. We suggest the elaboration and implementation of strong strategies to improve the journal's visibility in the world academic-scientific scenario. In addition, it is essential that Brazilian orthopaedic surgeons understand this reality and assist directly and effectively to change this scenario.

Resumo Objetivo Observar o perfil de autocitações da Revista Brasileira de Ortopedia (Rev Bras Ortop) e de citações deste periódico em outras revistas médicas de ortopedia de conteúdo geral ou específico de uma determinada área de conhecimento da especialidade. Métodos Trata-se de estudo observacional transversal da frequência de autocitações e citações da Rev Bras Ortop em outros cinco periódicos médicos de ortopedia de diferentes países, todas publicadas em língua inglesa. Foram analisados os 15 últimos artigos publicados em 2020 em cada uma das seis revistas estudadas. As referências usadas em cada um delas foi avaliada para identificação do periódico em que foram publicadas originalmente. A distribuição de frequência dos quatro principais periódicos citados, sua posição e o percentual relativo ao total de citações foram observados e registrados em cada uma das seis revistas. O número de vezes em que a Rev Bras Ortop foi citada em cada um dos periódicos estrangeiros selecionados foi avaliado por meio de suas frequências absoluta e relativa. Resultados O total de citações avaliadas neste estudo foi de 2527 (variando de 386 a 486 por revista). A Rev Bras Ortop apresentou baixa taxa de autocitação (2,6%), sendo citada na própria revista na sexta posição (10 de um total de 386 referências). No período estudado, a Rev Bras Ortop não foi citada em nenhum dos outros cinco periódicos médicos incluídos no estudo (frequência absoluta 0, frequência relativa 0). Conclusão Observou-se que a Rev Bras Ortop apresenta baixa referência de si própria, com taxa de autocitação de 2,6% no período estudado, mostrando que de fato o ortopedista brasileiro não cita o ortopedista brasileiro que publica na revista. Sugerimos a elaboração e a implementação de estratégias fortes de melhora da visibilidade do periódico no cenário acadêmico-científico mundial. Além disso, é fundamental que os ortopedistas brasileiros entendam esta realidade e auxiliem direta e efetivamente em sua mudança.

Evaluation and Management of Glenohumeral Instability With Associated Bone Loss: An Expert Consensus Statement Using the Modified Delphi Technique.

PURPOSE: To establish an international expert consensus, using the modified Delphi technique, on the evaluation and management of glenohumeral instability with associated bone loss. METHODS: A working group of 6 individuals generated a list of statements related to history and physical examination, imaging and specialized diagnostic tests, bone loss quantification and classification, treatment outcomes and complications, and rehabilitation for the management of glenohumeral instability associated with bone loss to form the basis of an initial survey for rating by a group of experts. The expert group (composed of 22 high-volume glenohumeral instability experts) was surveyed on 3 occasions to establish a consensus on the statements. Items with over 70% agreement and less than 10% disagreement achieved consensus. RESULTS: After a total of 3 rounds, 31 statements achieved consensus. Eighty-six percent of the experts agreed that a history of multiple dislocations and failed soft-tissue surgery should raise suspicion about the possibility of an associated bone deficit. Ninety-five percent of the experts agreed that 3-dimensional (3D) computed tomography (CT) is the most accurate diagnostic method to evaluate and quantify bone loss. Eighty-six percent of the experts agreed that any of the available methods to measure glenoid bone deficiency is adequate; however, 91% of the experts thought that an en face view of the glenoid using 3D CT provides the most accurate method. Ninety-five percent of the experts agreed that Hill-Sachs lesions are poorly quantified and classified by current imaging systems. Ninety percent of the experts agreed that in cases with a glenoid bone deficit greater than 20%, glenoid bone graft reconstruction should be performed and any of the available options is valid. There was no consensus among experts on how Hill-Sachs injuries should be managed or on how postoperative rehabilitation should be carried out. CONCLUSIONS: The essential statements on which the experts reached consensus included the following: A history of multiple dislocations and failed soft-tissue surgery should make surgeons consider the possibility of an associated bone deficit. Three-dimensional CT is the most accurate diagnostic method to evaluate and quantify bone loss. Although any of the available methods to measure glenoid bone deficiency is adequate, an en face view of the glenoid using 3D CT provides the most accurate method. Hill-Sachs lesions are poorly quantified and classified by current imaging systems. Finally, in cases with a glenoid bone deficit greater than 20%, glenoid bone graft reconstruction should be performed. LEVEL OF EVIDENCE: Level V, consensus statement.

Trans-scaphoid perilunate fracture dislocation beyond Mayfield stage IV: a case report on a new classification proposal / Fratura luxação transescafoperissemilunar além do estágio IV de Mayfield. Estudo preliminar. Proposta de nova classificação: relato de caso

ABSTRACT This report and review of the literature aims to recognize the complete enucleation beyond stage IV of the classification proposed by Mayfield. The addition of a fifth category is proposed, added for complete ligament injuries that lead to nonexistent circulation for the radiolunate ligament, preventing surgical reconstruction, thus influencing surgical treatment.

RESUMO Esse relato e revisão na literatura tem como objetivo reconhecer a enucleação total além do estágio IV da classificação proposta por Mayfield. Propõe-se a adição de uma quinta categoria, para lesões ligamentares completas que levam a uma circulação inexistente do ligamento radiolunar, impedem a reconstrução cirúrgica e influenciam, assim, o tratamento cirúrgico.

Trans-scaphoid perilunate fracture dislocation beyond Mayfield stage IV: a case report on a new classification proposal.

This report and review of the literature aims to recognize the complete enucleation beyond stage IV of the classification proposed by Mayfield. The addition of a fifth category is proposed, added for complete ligament injuries that lead to nonexistent circulation for the radiolunate ligament, preventing surgical reconstruction, thus influencing surgical treatment.

Esse relato e revisão na literatura tem como objetivo reconhecer a enucleação total além do estágio IV da classificação proposta por Mayfield. Propõe-se a adição de uma quinta categoria, para lesões ligamentares completas que levam a uma circulação inexistente do ligamento radiolunar, impedindo a reconstrução cirúrgica, influenciando assim o tratamento cirúrgico.

Undertreatment of pain and low use of opioids in Latin America.

Pain is highly prevalent among the adult Latin American population. However, many patients with moderate to severe pain do not have access to effective pain management with opioids due to limited access to healthcare, overuse of nonopioid analgesics, regulatory barriers and lack of appropriate information about opioids. There is scarce training on use of opioids among physicians and other healthcare providers, which leads to misconceptions, mainly related to a fear of prescribing opioids. Although opioids are safe and effective drugs for the treatment of moderate to severe chronic pain, the use of opioids in Latin American nations is clearly below standards compared with developed countries.

Bone graft in the treatment of nonunion of the scaphoid with necrosis of the proximal pole: a literature review.

Scaphoid fractures are the most common fractures of the carpal bones, corresponding to 60%. Of these, 10% progress to nonunion; moreover, 3% can present necrosis of the proximal pole. There are various methods of treatment using vascularized and non-vascularized bone grafts. To evaluate and compare the rate of scaphoid consolidation with necrosis of the proximal pole using different surgical techniques. The authors conducted a review of the literature using the following databases: PubMed and BIREME/LILACS, where 13 case series were selected (ten with use of vascularized bone grafts and three of non-vascularized bone grafts), according to inclusion and exclusion criteria. In most cases VBGs were used, especially those based on the 1,2 intercompartmental supraretinacular artery, due to greater reproducibility in performing the surgical technique.

As fraturas do escafoide são as mais comuns dos ossos do carpo, correspondem a 60%. Dessas, 10% evoluem para não consolidação; além disso, 3% podem apresentar necrose do polo proximal. Existem vários métodos de tratamento com enxertos ósseos, vascularizados e não vascularizados.Avaliar e comparar as taxas de consolidação do escafoide com necrose do polo proximal com diferentes técnicas cirúrgicas.Fez-se uma revisão na literatura nas bases de dados PubMed e Bireme/Lilacs, das quais foram selecionadas 13 séries de casos (dez com uso de enxertos ósseos vascularizadose três enxertos ósseos não vascularizados), de acordo com os critérios de inclusão e exclusão.Enxertos ósseos vascularizados foram usados na maioria dos casos, principalmente naqueles baseados na artéria intercompartimental suprarretinacular 1 e 2, devido à maior reprodutibilidade na técnica cirúrgica.

Bone graft in the treatment of nonunion of the scaphoid with necrosis of the proximal pole: a literature review / Enxerto ósseo no tratamento da não consolidação do escafoide com necrose do polo proximal: revisão da literatura

ABSTRACT Scaphoid fractures are the most common fractures of the carpal bones, corresponding to 60%. Of these, 10% progress to nonunion; moreover, 3% can present necrosis of the proximal pole. There are various methods of treatment using vascularized and non-vascularized bone grafts. To evaluate and compare the rate of scaphoid consolidation with necrosis of the proximal pole using different surgical techniques. The authors conducted a review of the literature using the following databases: PubMed and BIREME/LILACS, where 13 case series were selected (ten with use of vascularized bone grafts and three of non-vascularized bone grafts), according to inclusion and exclusion criteria. In most cases VBGs were used, especially those based on the 1,2 intercompartmental supraretinacular artery, due to greater reproducibility in performing the surgical technique.

RESUMO INTRODUÇÃO: As fraturas do escafoide são as mais comuns dos ossos do carpo, correspondem a 60%. Dessas, 10% evoluem para não consolidação; além disso, 3% podem apresentar necrose do polo proximal. Existem vários métodos de tratamento com enxertos ósseos, vascularizados (EOV) e não vascularizados (EONV). OBJETIVO: Avaliar e comparar as taxas de consolidação do escafoide com necrose do polo proximal com diferentes técnicas cirúrgicas. MATERIAL E MÉTODOS: Fez-se uma revisão na literatura nas bases de dados PubMed e Bireme/Lilacs, das quais foram selecionadas 13 séries de casos (dez com uso de EOV e três EONV), de acordo com os critérios de inclusão e exclusão. CONCLUSÃO: Enxertos ósseos vascularizados foram usados na maioria dos casos, principalmente naqueles baseados na artéria intercompartimental suprarretinacular 1 e 2, devido à maior reprodutibilidade na técnica cirúrgica.

The role of tramadol in pain management in Latin America: a report by the Change Pain Latin America Advisory Panel.

OBJECTIVE: Change Pain Latin America (CPLA) was created to enhance chronic pain understanding and develop pain management improving strategies in this region. During its seventh meeting (August 2016), the main objective was to discuss tramadol's role in treating pain in Latin America. Furthermore, potential pain management consequences were considered, if tramadol was to become more stringently controlled. METHODS: Key topics discussed were: main indications for prescribing tramadol, its pharmacological characteristics, safety and tolerability, effects of restrictions on its availability and use, and consequent impact on pain care quality. RESULTS: The experts agreed that tramadol is used to treat a wide spectrum of non-oncological pain conditions (e.g. post-surgical, musculoskeletal, post-traumatic, neuropathic, fibromyalgia), as well as cancer pain. Its relevance when treating special patient groups (e.g. the elderly) is recognized. The main reasons for tramadol's high significance as a treatment option are: its broad efficacy, an inconspicuous safety profile and its availability, considering that access to strong analgesics - mainly controlled drugs (classical opioids) - is highly restricted in some countries. The CPLA also agreed that tramadol is well tolerated, without the safety issues associated with long-term nonsteroidal anti-inflammatory drug (NSAID) use, with fewer opioid-like side effects than classical opioids and lower abuse risk. CONCLUSIONS: In Latin America, tramadol is a valuable and frequently used medication for treating moderate to severe pain. More stringent regulations would have significant impact on its availability, especially for outpatients. This could cause regression to older and frequently inadequate pain management methods, resulting in unnecessary suffering for many Latin American patients.

Regenerative potential of the cartilaginous tissue in mesenchymal stem cells: update, limitations, and challenges.

Advances in the studies with adult mesenchymal stem cells (MSCs) have turned tissue regenerative therapy into a promising tool in many areas of medicine. In orthopedics, one of the main challenges has been the regeneration of cartilage tissue, mainly in diarthroses. In the induction of the MSCs, in addition to cytodifferentiation, the microenvironmental context of the tissue to be regenerated and an appropriate spatial arrangement are extremely important factors. Furthermore, it is known that MSC differentiation is fundamentally determined by mechanisms such as cell proliferation (mitosis), biochemical-molecular interactions, movement, cell adhesion, and apoptosis. Although the use of MSCs for cartilage regeneration remains at a research level, there are important questions to be resolved in order to make this therapy efficient and safe. It is known, for instance, that the expansion of chondrocytes in cultivation, needed to increase the number of cells, could end up producing fibrocartilage instead of hyaline cartilage. However, the latest results are promising. In 2014, the first stage I/II clinical trial to evaluate the efficacy and safety of the intra-articular injection of MSCs in femorotibial cartilage regeneration was published, indicating a decrease in injured areas. One issue to be explored is how many modifications in the articulate inflammatory environment could induce differentiation of MSCs already allocated in that region. Such issue arose from studies that suggested that the suppression of the inflammation may increase the efficiency of tissue regeneration. Considering the complexity of the events related to the chondrogenesis and cartilage repair, it can be concluded that the road ahead is still long, and that further studies are needed.

Os avanços nos estudos com células-tronco mesenquimais (CTMs) adultas tornou a terapia regenerativa tecidual uma ferramenta promissora em diversas áreas da medicina. Na ortopedia, um dos principais desafios tem sido a regeneração do tecido cartilaginoso, sobretudo em diartroses. Na indução de CTMs, além da citodiferenciação, o contexto microambiental do tecido a ser regenerado, bem como uma disposição espacial adequada, são fatores de extrema importância. Além disso, sabe-se que a diferenciação das CTMs é basicamente determinada por mecanismos como proliferação celular (mitose), interações bioquímico-moleculares, movimento, adesão celular e apoptose. Apesar de o uso de CTMs para a regeneração da cartilagem estar ainda em âmbito de pesquisa, existem questões importantes a serem resolvidas para tornar essa terapêutica eficaz e segura. Sabe-se, por exemplo, que a expansão de condrócitos em cultura, necessária para aumentar o número de células, pode produzir fibrocartilagem, e não cartilagem hialina. No entanto, os últimos resultados são promissores. Em 2014, foi publicado o primeiro ensaio clínico fase I/II para avaliar a eficácia e a segurança da injeção intra-articular de CTMs na regeneração de cartilagem femorotibial e houve uma diminuição das áreas lesadas. Uma questão a ser explorada é o quanto modificações no próprio ambiente inflamatório articular poderiam induzir a diferenciação de CTMs já alocadas naquela região. Tal incógnita parte do princípio de estudos que sugerem que a supressão da inflamação articular aumentaria, potencialmente, a eficiência da regeneração tecidual. Considerando a complexidade dos eventos relacionados à condrogênese e ao reparo da cartilagem, conclui-se que o caminho ainda é longo, são necessárias pesquisas complementares.

Latin-American guidelines for opioid use in chronic nononcologic pain.

AIM: Latin-American experts in the use of opioids in patients with chronic nononcologic pain (CNOP) have updated existing recommendations to current Latin-American reality. METHODS: Several key opinion leaders from Latin America participated in a face-to-face meeting in Guatemala (April 2015) to discuss the use of opioids in CNOP. Subgroups of experts worked on specific topics, reviewed the literature and shaped the final manuscript. RESULTS: The expert panel developed guidelines taking into consideration the utility of both opioid and nonopioid analgesics and factors pertaining to their efficacy, safety, adherence, administration and risks for abuse/addiction. CONCLUSION: Latin-American guidelines for the use of opioids in CNOP should improve pain relief and patients' quality of life by increasing access to these effective agents.

Regenerative potential of the cartilaginous tissue in mesenchymal stem cells: update, limitations, and challenges / Potencial regenerativo do tecido cartilaginoso por células-tronco mesenquimais: atualização, limitações e desafios

ABSTRACT Advances in the studies with adult mesenchymal stem cells (MSCs) have turned tissue regenerative therapy into a promising tool in many areas of medicine. In orthopedics, one of the main challenges has been the regeneration of cartilage tissue, mainly in diarthroses. In the induction of the MSCs, in addition to cytodifferentiation, the microenvironmental context of the tissue to be regenerated and an appropriate spatial arrangement are extremely important factors. Furthermore, it is known that MSC differentiation is fundamentally determined by mechanisms such as cell proliferation (mitosis), biochemical-molecular interactions, movement, cell adhesion, and apoptosis. Although the use of MSCs for cartilage regeneration remains at a research level, there are important questions to be resolved in order to make this therapy efficient and safe. It is known, for instance, that the expansion of chondrocytes in cultivation, needed to increase the number of cells, could end up producing fibrocartilage instead of hyaline cartilage. However, the latest results are promising. In 2014, the first stage I/II clinical trial to evaluate the efficacy and safety of the intra-articular injection of MSCs in femorotibial cartilage regeneration was published, indicating a decrease in injured areas. One issue to be explored is how many modifications in the articulate inflammatory environment could induce differentiation of MSCs already allocated in that region. Such issue arose from studies that suggested that the suppression of the inflammation may increase the efficiency of tissue regeneration. Considering the complexity of the events related to the chondrogenesis and cartilage repair, it can be concluded that the road ahead is still long, and that further studies are needed.

RESUMO Os avanços nos estudos com células-tronco mesenquimais (CTMs) adultas tornou a terapia regenerativa tecidual uma ferramenta promissora em diversas áreas da medicina. Na ortopedia, um dos principais desafios tem sido a regeneração do tecido cartilaginoso, sobretudo em diartroses. Na indução de CTMs, além da citodiferenciação, o contexto microambiental do tecido a ser regenerado, bem como uma disposição espacial adequada, são fatores de extrema importância. Além disso, sabe-se que a diferenciação das CTMs é basicamente determinada por mecanismos como proliferação celular (mitose), interações bioquímico-moleculares, movimento, adesão celular e apoptose. Apesar de o uso de CTMs para a regeneração da cartilagem estar ainda em âmbito de pesquisa, existem questões importantes a serem resolvidas para tornar essa terapêutica eficaz e segura. Sabe-se, por exemplo, que a expansão de condrócitos em cultura, necessária para aumentar o número de células, pode produzir fibrocartilagem, e não cartilagem hialina. No entanto, os últimos resultados são promissores. Em 2014, foi publicado o primeiro ensaio clínico fase I/II para avaliar a eficácia e a segurança da injeção intra-articular de CTMs na regeneração de cartilagem femorotibial e houve uma diminuição das áreas lesadas. Uma questão a ser explorada é o quanto modificações no próprio ambiente inflamatório articular poderiam induzir a diferenciação de CTMs já alocadas naquela região. Tal incógnita parte do princípio de estudos que sugerem que a supressão da inflamação articular aumentaria, potencialmente, a eficiência da regeneração tecidual. Considerando a complexidade dos eventos relacionados à condrogênese e ao reparo da cartilagem, conclui-se que o caminho ainda é longo, são necessárias pesquisas complementares.

Use of Opioids in Latin America: The Need of an Evidence-Based Change.

OBJECTIVE: The subject of this publication has been focused on local considerations for facilitating regional best practice, including identifying and uniformly adopting the most relevant international guidelines on opioid use (OU) in chronic pain management. DESIGN AND SETTING: The Change Pain Latin America (CPLA) Advisory Panel conducted a comprehensive, robust, and critical analysis of published national and international reviews and guidelines of OU, considering those most appropriate for Latin America. METHODS: A PubMed search was conducted using the terms "opioid," "chronic," and "pain" and then refined using the filters "practice guidelines" and "within the last 5 years" (2007-2012). Once the publications were identified, they were selected using five key criteria: "Evidence based," "Comprehensive," "From a well-recognized source," "Current publications," and "Based on best practice" and then critically analyzed considering 10 key criteria for determining the most relevant guidelines to be applied in Latin America. RESULTS: The initial PubMed search identified 177 reviews and guidelines, which was reduced to 16 articles using the five preliminary criteria. After a secondary analysis according to the 10 key criteria specific to OU in Latin America, 10 publications were selected for critical review and discussion. CONCLUSIONS: The CPLA advisory panel considered the "Safe and effective use of opioids for chronic non-cancer pain" (published in 2010 by the NOUGG of Canada) to be valid, relevant to Latin America, practical, evidence-based, concise, unambiguous, and sufficiently educational to provide clear instruction on OU and pain management and, thus, recommended for uniform adoption across the Latin America region.

Osteoma osteoide em escafoide: relato de caso / Osteoid osteoma in scaphoid: case report

O osteoma osteoide é um tumor benigno osteoblástico, incomum na mão. A localização nos ossos do carpo é infrequente, a qual leva a erros no diagnóstico em decorrência do polimorfismo de sinais clínicos. Na revisão bibliográfica foram referidos nove casos de osteoma osteoide no escafoide. Relata-se um caso de osteoma osteoide no escafoide, tratado inicialmente como tenossinovite estenosante de De Quervain, tendo diagnóstico definitivo retardado por cinco anos.

Osteoid osteoma is a benign osteoblastic tumor that is unusual in the hand. A location in the carpal bones is infrequent, which leads to errors in diagnosing it because of polymorphism of the clinical symptoms. Reviewing the literature shows that nine cases of osteoid osteoma in the scaphoid have been reported. Here, one case of osteoid osteoma in the scaphoid that was initially treated as De Quervain's stenosing tenosynovitis is reported, with a definitive diagnosis that was delayed for five years.