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.

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.

Intra-articular arthroscopic biceps tenodesis with interference screw: clinical and isokinetic evaluation.

BACKGROUND: Although biceps tenodesis has been widely used to treat its pathologies, few studies looked at the objective evaluation of elbow strength after this procedure. The purpose of this study is to clinically evaluate patients submitted to long head of the biceps (LHB) tenodesis with interference screws through an intra-articular approach and analyze the results of an isokinetic test to measure elbow flexion and forearm supination strengths. METHODS: Patients who had biceps tenodesis were included in the study if they had a minimum follow-up of 24 months. Patients were excluded if they had concomitant irreparable cuff tears or previous or current contralateral shoulder pain or weakness. Postoperative evaluation was based on University of California-Los Angeles (UCLA) shoulder score and on measurements of elbow flexion and supination strength, using an isokinetic dynamometer. Tests were conducted in both arms, with velocity set at 60º/s with 5 concentric-concentric repetitions. RESULTS: Thirty-three patients were included and the most common concomitant diagnosis were rotator cuff tear (69%) and superior labrum anterior to posterior (SLAP) lesions (28%). The average UCLA score improved from 15.1 preoperatively to 31.9 in the final follow-up (P < .001). Isokinetic tests showed no difference in peak torque between the upper limbs. One patient had residual pain in the biceps groove. None of the patients had Popeye deformity. UCLA score and follow-up length did not demonstrate correlation with peak torque. CONCLUSION: Arthroscopic proximal biceps tenodesis with interference screw, close to the articular margin, yielded good clinical results. Isokinetic tests revealed no difference to the contralateral side in peak torque for both supination and elbow flexion.

ELASTOGRAPHIC ANALYSIS OF THE SUPRASPINATUS TENDON IN DIFFERENT AGE GROUPS.

OBJECTIVE: To compare the mechanical properties of the supraspinatus tendon in different age groups using Supersonic Shearwave Imaging (SSI) elastography. METHODS: We evaluated 38 healthy individuals of both genders, 20 being in the range of 20 to 35 years and 18 being over 60 years. The shear modulus of the supraspinatus tendon was measured by SSI elastography, always on the right side. Means between age groups were compared and statistically analyzed using the Shapiro-Wilk normality test followed by the student's t-test and were established as a statistically significant value of p ≤ 0.05. RESULTS: A statistically significant difference was observed when the mean values of the shear modulus of the supraspinatus tendon of young adults (23.98 ± 9.94 KpA) were compared with those of older adults (17.92 ± 6.17 KpA). CONCLUSION: We found a difference between the means of the shear modulus measured by the SSI elastography, showing a significant decrease of the shear modulus with the chronological age progression. Level of Evidence III, Diagnostic Studies - Investigating a Diagnostic Test.

OBJETIVO: Comparar as propriedades mecânicas do tendão supraespinal em diferentes grupos etários, utilizando a elastografia Supersonic Shearwave Imaging (SSI). MÉTODOS: Foram avaliados 38 indivíduos saudáveis de ambos os sexos, sendo 20 na faixa de 20 a 35 anos e 18 acima dos 60 anos de idade. Foi aferido o módulo de cisalhamento do tendão supraespinal por elastografia SSI, sempre do lado direito. As médias entre os grupos etários foram comparadas e analisadas estatisticamente, sendo utilizado o teste de normalidade Shapiro-Wilk seguido do student t-test e estabelecido como valor de significância estatística um p ≤ 0,05. RESULTADOS: Foi evidenciada diferença estatisticamente significativa quando comparadas as médias do módulo de cisalhamento do tendão supraespinal dos adultos jovens (23,98 ± 9,94 KpA) com a dos idosos (17,92 ± 6,17 KpA). CONCLUSÃO: Houve diferença entre as médias do módulo de cisalhamento medido pela elastografia com SSI, demonstrando diminuição significativa do módulo de cisalhamento com a progressão da idade cronológica. Nível de Evidência III, Estudos diagnósticos - Investigação de um exame para diagnóstico.

Proprioceptive deficit after total elbow arthroplasty: an observational study.

BACKGROUND: During total elbow arthroplasty (TEA), most of the joint capsule is removed, including many mechanoreceptors important for proprioception, which potentially limits the patient's postoperative functional recovery. We quantified proprioceptive loss by measuring the threshold to detection of passive motion (TTDPM) in patients after unilateral TEA compared with the contralateral side. METHODS: A continuous passive motion device moving the elbow at 0.5°/s was used to evaluate TTDPM in 8 patients (mean ± standard deviation age, 69.1 ± 9.93 years) at least 1 year after unilateral semiconstricted linked TEA for a range of diagnoses. Elbow function after TEA was assessed using the Mayo Elbow Performance Scale. RESULTS: Postsurgical Mayo scores revealed 4 excellent results, 2 good, and 2 poor. The TTDPM in the elbows undergoing arthroplasty was still significantly higher compared with the contralateral elbow at 4.2° (15.6 ± 6.9 seconds vs. 7.2 ± 2.6 seconds; D = 3.23, P = .01) equivalent to 8.4 seconds. CONCLUSIONS: Patients who have had severe joint disease requiring semiconstrained TEA have long-term proprioception deficits. A more conservative technique that maximally preserves insertions and soft tissues, might minimize upper limb proprioceptive deficit.

Prevalence of hypothyroidism in patients with frozen shoulder.

BACKGROUND: Hypothyroidism and frozen shoulder (FS) have been associated, although this relationship remains uncertain. The main objective of this study was to determine the prevalence of hypothyroidism in patients with FS. METHODS: A case-control study was performed to compare FS patients (cases) with patients who visited an orthopedic service for other clinical conditions (controls). FS was diagnosed according to specific criteria based on anamnesis, physical examination, and shoulder radiographs. A specific questionnaire was applied, and measurements of serum thyroid-stimulating hormone (TSH) and free tetraiodothyronine were performed in all subjects. RESULTS: We evaluated 401 shoulders from 93 FS patients and 151 controls. The prevalence of hypothyroidism diagnosis was significantly higher in the FS group (27.2% vs. 10.7%; P = .001). There was also a tendency for higher prevalence of bilateral FS among patients with elevated TSH levels (P = .09). Mean serum TSH levels were higher in patients with bilateral FS compared with those with unilateral compromise (3.39 vs. 2.28; P = .05) and were higher in patients with severe FS compared with those with mild and moderate FS together (3.15 vs. 2.21; P = .03). Multivariate analysis showed that FS was independently related to a diagnosis of hypothyroidism (odds ratio, 3.1 [1.5-6.4]; P = .002). There was a trend toward independent association between high serum TSH levels and both severe (odds ratio, 3.5 [0.8-14.9]; P = .09) and bilateral (odds ratio, 11.7 [0.9-144.8]; P = .05) compromise. CONCLUSION: The prevalence of hypothyroidism was significantly higher in FS patients than in controls. The results suggest that higher serum TSH levels are associated with bilateral and severe cases of FS.

Intraobserver and interobserver agreement of Goutallier classification applied to magnetic resonance images.

BACKGROUND: Fatty infiltration of the muscle bellies is an important prognostic factor in rotator cuff tears. It was described initially in computed tomography examinations, and there is an ongoing debate about whether magnetic resonance (MR) is a reliable method for staging fatty infiltration. This study sought to determine intraobserver and interobserver agreement for Goutallier's classification of fatty infiltration of the rotator cuff as evaluated through MR imaging. MATERIALS AND METHODS: Twenty MR examinations of the shoulder showing full-thickness tear of the supraspinatus tendon, with or without associated lesions, were evaluated by 3 radiologists with experience in musculoskeletal system imaging and 3 fellowship-trained shoulder surgeons. The evaluators classified the fatty infiltration of the supraspinatus muscle according to the guidelines proposed by Goutallier et al. After 8 weeks, they re-evaluated the examinations, without access to their previous reports. Weighted κ index values were determined for intraobserver and interobserver agreement analyses, and intraobserver agreement κ values are reported with 95% confidence intervals (CIs). RESULTS: The mean intraobserver agreement was 0.832 among the orthopedists (CI > 95%) and 0.741 among the radiologists (CI > 95%). Interobserver agreement was 0.8214 (evaluation 1) and 0.7231 (evaluation 2) among the orthopedists (P < .0001) and 0.6627 (evaluation 1) and 0.6067 (evaluation 2) among the radiologists (P < .0001). Intraobserver agreement was not associated with length of experience or frequency of routine evaluations. CONCLUSIONS: When it is applied to MR images of rotator cuff musculature, Goutallier's fatty infiltration staging rubric yielded highly significant intraobserver and interobserver agreement.

Diagnóstico clínico da ruptura do tendão subescapular com a manobra semiológica bear hug / Clinical diagnosis of subscapularis tendon tear using the bear hug semiological maneuver

OBJETIVO: Avaliar a manobra bear hug no diagnóstico clínico da lesão do tendão subescapular e compará-la com manobras previamente descritas (lift-off, Napoleão e belly press). MÉTODOS: Foram analisados 49 pacientes com lesão do manguito rotador, submetidos à artroscopia para reparo da lesão e avaliados previamente pelas manobras semiológicas citadas. RESULTADOS: Os valores diagnósticos obtidos para o teste bear hug foram os seguintes: sensibilidade = 75%; especificidade = 56%; VPP = 62%; VPN = 70%; acurácia = 65%. CONCLUSÃO: Os maiores valores de sensibilidade e valor preditivo negativo foram obtidos com o bear hug. O maior valor de especificidade foi encontrado no teste lift-off. O teste belly press forneceu os maiores valores de especificidade, valor preditivo positivo e acurácia.

OBJECTIVE: To evaluate the Bear Hug maneuver for clinically diagnosing subscapularis tendon tears, and compare this with other maneuvers described previously (Lift-off, Napoleon and Belly Press). METHODS: Forty-nine patients with rotator cuff injuries who had undergone arthroscopy to repair the injury and had previously been assessed using the semiological maneuvers mentioned above were evaluated. RESULTS: The diagnostic values obtained for the Bear Hug test were as follows: sensitivity 75%, specificity 56%, positive predictive value 62%, negative predictive value 70% and accuracy 65%. CONCLUSION: The highest sensitivity and negative predictive value values were obtained with the Bear Hug test. The highest specificity value was seen with the Lift-off test. The Belly press test gave the greatest specificity, positive predictive and accuracy values.

CLINICAL DIAGNOSIS OF SUBSCAPULARIS TENDON TEAR USING THE BEAR HUG SEMIOLOGICAL MANEUVER.

OBJECTIVE: To evaluate the Bear Hug maneuver for clinically diagnosing subscapularis tendon tears, and compare this with other maneuvers described previously (Lift-off, Napoleon and Belly Press). METHODS: Forty-nine patients with rotator cuff injuries who had undergone arthroscopy to repair the injury and had previously been assessed using the semiological maneuvers mentioned above were evaluated. RESULTS: The diagnostic values obtained for the Bear Hug test were as follows: sensitivity 75%, specificity 56%, positive predictive value 62%, negative predictive value 70% and accuracy 65%. CONCLUSION: The highest sensitivity and negative predictive value values were obtained with the Bear Hug test. The highest specificity value was seen with the Lift-off test. The Belly press test gave the greatest specificity, positive predictive and accuracy values.

Tuberculose refratária disseminada com acometimento do tendão bicipital em paciente imunocompetente / Disseminated refractary tuberculosis with biceps tendon involvement in an immunocompetent patient

OBJETIVO: Relatar um caso raro de tuberculose disseminada em paciente imunocompetente, que evoluiu, durante o tratamento medicamentoso padrão, com envolvimento do tendão da porção longa do bíceps e da articulação do ombro. MÉTODOS: À primeira avaliação, o diagnóstico correto não foi feito e o paciente foi tratado com fisioterapia para tendinopatia do manguito rotador. Entretanto, apresentou rápida formação de massa na região anterior do terço proximal do braço e piora da dor. A punção da massa revelou líquido amarelado, cuja análise laboratorial confirmou tratar-se de infecção por M. tuberculosis. RESULTADOS: O paciente foi tratado com desbridamento cirúrgico e troca do esquema medicamentoso e evoluiu com resolução do quadro infeccioso e melhora completa da função do ombro direito. CONCLUSÃO: Devido a sua alta prevalência no Brasil, a tuberculose deve sempre ser considerada no diagnóstico diferencial dos casos de comprometimento crônico e progressivo das articulações, ossos, músculos, tendões e bursas, mesmo em indivíduos imunocompetentes.

OBJECTIVE: The authors report a rare case of disseminated tuberculosis which had compromised the long head of biceps tendon and shoulder joint, during standard drug therapy. METHODS: On a first sight, the accurate diagnosis wasn't accomplished and the patient had been treated with physiotherapy for rotator cuff tear. However, the patient presented with a fast growing mass in anterior region of the proximal third of the arm, complaining of pain increase. Aspirative punction of the mass revealed a yellow fluid and the laboratorial analysis confirmed infection by M. Tuberculosis. The patient was treated with surgical debridement and his drug therapy was changed. RESULTS: Resolution of infectious status and complete shoulder function restoration was succeeded. CONCLUSION: Due to its high prevalence in Brazil, tuberculosis must always be considered as a possible cause of inflammatory joint disease, even in immunocompetent patients.

DISSEMINATED REFRACTARY TUBERCULOSIS WITH BICEPS TENDON INVOLVEMENT IN AN IMMUNOCOMPETENT PATIENT.

OBJECTIVE: The authors report a rare case of disseminated tuberculosis which had compromised the long head of biceps tendon and shoulder joint, during standard drug therapy. METHODS: On a first sight, the accurate diagnosis wasn't accomplished and the patient had been treated with physiotherapy for rotator cuff tear. However, the patient presented with a fast growing mass in anterior region of the proximal third of the arm, complaining of pain increase. Aspirative punction of the mass revealed a yellow fluid and the laboratorial analysis confirmed infection by M. Tuberculosis. The patient was treated with surgical debridement and his drug therapy was changed. RESULTS: Resolution of infectious status and complete shoulder function restoration was succeeded. CONCLUSION: Due to its high prevalence in Brazil, tuberculosis must always be considered as a possible cause of inflammatory joint disease, even in immunocompetent patients.

Avaliação dos resultados do tratamento cirúrgico das fraturas-luxações da extremidade proximal do antebraço no adulto / Evaluation of the outcome in fracture-dislocation surgeries in the proximal end of the adult forearm

OBJETIVO: Avaliar os resultados obtidos no tratamento das fraturas-luxações da extremidade proximal do antebraço (FLEPA), procurando identificar fatores que possam influenciar no prognóstico desse tipo de lesão traumática. MÉTODOS: De outubro de 1994 a dezembro de 2005, 30 pacientes com FLEPA foram submetidos ao tratamento cirúrgico. Em todos os casos, o seguimento ambulatorial mínimo foi de 12 meses. As lesões foram classificadas pelo método de Chick et al. A média de idade foi de 48 anos, com mínima de 25 e máxima de 76 anos. Os mecanismos de trauma foram: queda da própria altura em 17 pacientes (57 por cento), acidentes de via pública em 11 casos (37 por cento), trauma direto em um caso (3 por cento) e agressão física em um caso (3 por cento). As fraturas expostas corresponderam a oito casos (27 por cento). Realizou-se a análise estatística pelo teste exato de Fisher para avaliar os seguintes dados: exposição do foco de fratura e resultados; sexo e resultados; mecanismo de trauma e resultados; idade e mecanismo de trauma; sexo e mecanismo de trauma. RESULTADOS: Em 11 casos (37 por cento) os resultados foram satisfatórios e em 19 casos (63 por cento), insatisfatórios. Estabeleceu-se apenas relação estatística significativa entre exposição da fratura e resultados. CONCLUSÃO: Os tratamentos das FLEPA têm, em sua maioria, resultados insatisfatórios, principalmente nas fraturas expostas, fato estatisticamente significativo neste estudo. Não foi possível definir outros fatores prognósticos. Encontrou-se tendência a melhores resultados nos pacientes do sexo feminino, nos idosos e nas vítimas de traumas de baixa energia.

OBJECTIVE: To evaluate results obtained in the treatment of fracture-dislocation of the proximal end of the forearm (FLEPA), in an attempt at identifying factors that may influence the prognosis of this type of traumatic lesion. METHODS: From October 1994 to December 2005, 30 patients with FLEPA were submitted to surgical treatment. In all cases, minimum office follow-up lasted 12 months. The lesions were classified according to the method of Chick et al. Mean age was 48 years, with minimum age of 25, and maximum age of 76 years. Traumas were caused by: falling to the ground in 17 patients (57 percent), street accidents in 11 cases (37 percent), direct trauma in one case (3 percent), and bodily aggression in one case (3 percent). Open fractures were seen in eight cases (27 percent). Statistical analysis was run by the exact Fisher test to evaluate the following data: exposure of the fracture focus and results; gender and results; mechanism of the trauma and results; age and mechanism of trauma; gender and trauma mechanism. RESULTS: In 11 cases (37 percent), results were satisfactory, and in 19 cases (63 percent) results were unsatisfactory. They only established the significant statistical ratio between fracture exposure and results. CONCLUSION: Most FLEPA treatments have unsatisfactory results, particularly in cases of open fractures. Other prognosis factures could not be defined. The authors identified a trend towards better results in female patients, among the elderly, and in the victims of low energy traumas.