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.

[Association of morphological variables of acromion type with rotator cuff lesions by nuclear magnetic resonance]. / Asociación de variables morfológicas de tipo de acromion con lesiones del manguito rotador por resonancia magnética nuclear.

INTRODUCTION: the acromion is a small portion of the scapula that extends towards the anterior region from the spine of the scapula. Traditionally, the acromion is classified by the shape of its inferior surface in a sagittal plane. Acromial morphology has been found to be related to rotator cuff injury. OBJECTIVE: to determine the association between the type of acromion with a higher incidence of rotator cuff rupture. Study population: patients who come to the Traumatology and Orthopedics Service of a third level hospital at Monterrey, Mexico, due to a painful shoulder and who have undergone a simple magnetic resonance of the shoulder. MATERIAL AND METHODS: a cross-sectional, retrospective and descriptive study was carried out, in which 273 magnetic resonance studies were reviewed in patients who met the inclusion criteria. The type of acromion was reported according to the morphological classification in type I to IV and the state of the rotator cuff: without rupture, partial rupture or complete rupture, making a comparison between right and left shoulder. RESULTS: in this study we found a value of p = 0.473 which concludes that there is no relation between the type of acromion and the injury of the rotator cuff. CONCLUSION: in the present study, unlike what has been published in the literature, it was found that type II acromion was the one that was associated in most cases with a rotator cuff tear.

INTRODUCCIÓN: el acromion es una pequeña porción de la escápula que se extiende hacia la región anterior desde la espina de la escápula. Tradicionalmente se clasifica al acromion por la forma de su superficie inferior en un plano sagital. Se ha encontrado que la morfología acromial está rela­cionada con la lesión del manguito rotador. OBJETIVO: determinar la asociación entre el tipo de acromion con una mayor incidencia de ruptura de manguito rotador. Población de estudio: pacientes que acudan al Servicio de Traumatología y Ortopedia de un hospital privado de tercer nivel en la ciudad de Monterrey por hombro doloroso y a los cuales se les haya realizado una resonancia magnética simple de hombro. MATERIAL Y MÉTODOS: se realizó un estudio de tipo transversal, retrospectivo y descriptivo, en el cual se revisaron 273 estudios de resonancia magnética en pacientes que cumplieran los criterios de inclusión. Se reportó el tipo de acromion según la clasificación morfológica en tipo I a IV y el estado del manguito rotador: sin ruptura, ruptura parcial o ruptura completa, haciendo una comparación entre hombro derecho e izquierdo. RESULTADOS: se obtuvo un valor de p = 0.473 por lo que se concluye que no existe una asociación entre el tipo de acromion y el estado del manguito rotador. CONCLUSIÓN: en el presente estudio, a diferencia de lo publicado en la literatura, se obtuvo que el acromion tipo II fue al que se asoció la mayoría de los casos con ruptura del manguito rotador.

Morphological determination of glenohumeral joint and acromioclavicular joint with computed tomography / Determinación morfológica de la articulación glenohumeral y la articulación acromioclavicular con tomografía computarizada

SUMMARY: Although acute and chronic pathologies of the glenohumeral and acromioclavicular joints are frequently encountered in the population, the anatomy and morphometry are not fully known. The aim of this study is to determine the measurements of morphometric parameters according to age groups and sex in a large series of Turkish population. Nine hundred and forty-one shoulders computed tomography (CT) images were screened and those of subjects with healthy anatomical structure were included. Humeral head diameter (HDD) was measured on CT images. Measurements were made using 3D-CT images of: width (GW) and height (GH) of the glenoid cavity; width (CW) and height (CH) of the distal clavicular joint surface; and width (AW) and height (AH) of the acromial joint surface. Data were compared, stratified by age and sex. Images of 223 patients (118 men, 105 women) were analyzed. The following mean measurements were determined: HDD, 41.77±3.77 mm; GH, 34.66±3.26 mm; GW, 25.50±2.90 mm; CW, 14.85±3.51 mm; CH, 8.49±2.27 mm; AW, 12.97±2.94 mm; AH, 7.01±1.77 mm. When startified by sex, HDD (p<0.001), GH (p<0.001), GW (p<0.001), CW (p<0.001), CH (p=0.002), AW (p<0.001) and AH (p<0.001) measurements were significantly different and mean values were greater in men. Similarly for age, significant differences were found for GH (p=0.028), CW (p<0.001), AW (p<0.001), AH (p<0.001). The parametric values we have obtained in the Turkish population we measure differ from the measurements made in different populations according to age groups and sex. Knowing these features will contribute to treatment planning, implant and prosthesis applications.

Aunque las patologías agudas y crónicas de las articulaciones glenohumeral y acromioclavicular son frecuentes en la población, la anatomía y morfometría no se conocen por completo. El objetivo de este estudio fue determinar las medidas de los parámetros morfométricos según grupos de edad y sexo en una serie de individuos de población turca. Se examinaron 941 imágenes de tomografía computarizada (TC) de hombro y se incluyeron las de sujetos con una estructura anatómica sana. El diámetro de la cabeza humeral (HDD) se midió en imágenes de TC. Las mediciones se realizaron utilizando imágenes 3D-CT de: ancho (GW) y altura (GH) de la cavidad glenoidea; anchura (CW) y altura (CH) de la superficie articular clavicular; y anchura (AW) y altura (AH) de la superficie articular acromial. Los datos fueron comparados, estratificados por edad y sexo. Se analizaron imágenes de 223 pacientes (118 hombres, 105 mujeres). Se determinaron las siguientes medidas medias: HDD, 41,77±3,77 mm; GH, 34,66 ± 3,26 mm; GW, 25,50±2,90 mm; CW, 14,85±3,51 mm; CH, 8,49±2,27 mm; AW, 12,97±2,94 mm; AH, 7,01±1,77 mm. Cuando se inicia por sexo, HDD (p<0,001), GH (p<0,001), GW (p<0,001), CW (p<0,001), CH (p=0,002), AW (p<0,001) y AH (p <0,001) las mediciones fueron significativamente diferentes y los valores medios fueron mayores en los hombres. De igual forma para la edad se encontraron diferencias significativas para GH (p=0,028), CW (p<0,001), AW (p<0,001), AH (p<0,001). Los valores paramétricos que hemos obtenido en la población turca difieren de las medidas realizadas en diferentes poblaciones según grupos de edad y sexo. El conocimiento de estas características contribuirá a la planificación del tratamiento, aplicaciones de implantes y prótesis.

A predictive model for the critical shoulder angle based on a three-dimensional analysis of scapular angular and linear morphometrics.

BACKGROUND: The purpose of this study was to define the features of scapular morphology that are associated with changes in the critical shoulder angle (CSA) by developing the best predictive model for the CSA based on multiple potential explanatory variables, using a completely 3D assessment. METHODS: 3D meshes were created from CT DICOMs using InVesalius (Vers 3.1.1, RTI [Renato Archer Information Technology Centre], Brazil) and Meshmixer (3.4.35, Autodesk Inc., San Rafael, CA). The analysis included 17 potential angular, weighted linear and area measurements. The correlation of the explanatory variables with the CSA was investigated with the Pearson's correlation coefficient. Using multivariable linear regression, the approach for predictive model-building was leave-one-out cross-validation and best subset selection. RESULTS: Fifty-three meshes were analysed. Glenoid inclination (GI) and coronal plane angulation of the acromion (CPAA) [Pearson's r: 0.535; -0.502] correlated best with CSA. The best model (adjusted R-squared value 0.67) for CSA prediction contained 10 explanatory variables including glenoid, scapular spine and acromial factors. CPAA and GI were the most important based on their distribution, estimate of coefficients and loss in predictive power if removed. CONCLUSIONS: The relationship between scapular morphology and CSA is more complex than the concept of it being dictated solely by GI and acromial horizontal offset and includes glenoid, scapular spine and acromial factors of which CPAA and GI are most important. A further investigation in a closely defined cohort with rotator cuff tears is required before drawing any clinical conclusions about the role of surgical modification of scapular morphology. LEVEL OF EVIDENCE: Level 4 retrospective observational cohort study with no comparison group.

Critical shoulder angle and failure of conservative treatment in patients with atraumatic full thickness rotator cuff tears.

BACKGROUND: Atraumatic full thickness rotator cuff tears (AFTRCT) are common lesions whose incidence increases with age. Physical therapy is an effective conservative treatment in these patients with a reported success rate near 85% within 12 weeks of treatment. The critical shoulder angle (CSA) is a radiographic metric that relates the glenoid inclination with the lateral extension of the acromion in the coronal plane. A larger CSA has been associated with higher incidence of AFTRCT and a higher re-tear rate after surgical treatment. However, no study has yet described an association between a larger CSA and failure of conservatory treatment in ARCT. The main objective of this study is to determine whether there is an association between CSA and failure of physical therapy in patients with AFTRCT. METHODS: We reviewed the imaging and clinical records of 48 patients (53 shoulders), 60% female, with a mean age of 63.2 years (95% CI ± 10.4 years); treated for AFTRCT who also underwent a true anteroposterior radiograph of the shoulder within a year of diagnosis of the tear. We recorded demographic (age, sex, type of work), clinical (comorbidities), and imaging data (CSA, size and location of the tear). We divided the patients into two groups according to success or failure of conservative treatment (indication for surgery), so 21 shoulders (39.6%) required surgery and were classified as failure of conservative treatment. Univariate and multivariate analysis was performed to detect predictors of failure of conservative treatment. RESULTS: The median CSA was 35.5º with no differences between those with failure (median 35.5º, range 29º to 48.2º) and success of conservative treatment (median 35.45º, range 30.2º to 40.3º), p = 0.978. The multivariate analysis showed a younger age in patients with failure of conservative treatment (56.14 ± 9.2 vs 67.8 ± 8.4, p < 0.001) and that male gender was also associated with failure of conservative treatment (57% of men required surgery vs 28% of women, p = 0.035). CONCLUSIONS: It is still unclear if CSA does predict failure of conservative treatment. A lower age and male gender both could predicted failure of conservative treatment in AFTRCT. Further research is needed to better address this subject.

Tratamiento quirúrgico del síndrome subacromial mediante la técnica de Neer. Estudio casuístico / Surgical treatment of the subacromial syndrome using Neer's technique. Case study

RESUMEN Introducción: el síndrome subacromial es una afección caracterizada por el pinzamiento tendinoso intraarticular por osteofitos o estrechamiento del espacio. Objetivos: evaluar la técnica de Neer en el tratamiento de pacientes con síndrome subacromial y los factores y actividades que favorecen esta afección. Materiales y métodos: se realizó un estudio observacional, descriptivo, prospectivo a pacientes con síndrome subacromial tratados con acromioplastia por la técnica de Neer. El universo lo conformaron 66 pacientes mayores de 20 años, que presentaron síndrome subacromial con síntomas por más de seis meses, y que fueron tratados con la técnica de Neer. Resultados: el sexo más afectado fue el femenino, con 65,2 %. Predominó el grupo etario de 41 a 50 años. El dolor en etapa prequirúrgica fue de moderado a severo en un 77,2 %, y nulo o leve después de la operación. La función en etapa prequirúrgica estuvo afectada de moderada a severa en un 68,1 %, y nula o leve después del tratamiento quirúrgico. La flexión anterior activa estuvo por debajo de 90º en un 83,1 % antes de ser operados, y por encima de 90º en un 80,3 % en el posquirúrgico. La fuerza muscular era mala o regular en etapa prequirúrgica en un 77,2 %, resultando ser excelente o buena después de la operación. Conclusiones: una vez aplicada la técnica de Neer, el dolor fue leve o nulo en la mayoría del universo, la función del hombro fue buena, la flexión anterior adecuada, y buena la fuerza muscular. Se recomienda emplear esta técnica quirúrgica en esta afección (AU).

ABSTRACT Introduction: subacromial syndrome is a condition characterized by intra-articular tendinous impingement by osteophytes or narrowing of space. Objective: to evaluate Neer's technique in the treatment of patients with subacromial syndrome and the factors and activities favoring this condition. Materials end methods: an observational, descriptive, prospective study was performed in patients with subacromial syndrome treated with acromioplasty using Neer's technique. The universe was formed by 66 patients aged over 20 years, who presented subacromial syndrome with symptoms for more than 6 months, and were treated with Neer's technique. Results: the most affected sex was the female one, with 65.2 %. The age group aged 41 to 50 years predominated. In pre-surgical stage, pain ranged from moderate to severe in 77.2 %, and from null to mild after surgery. Preoperative function was moderate to severe in 68.1 % and null or mild after surgical treatment. The previous active flexion was below 90° in 83.1 % before being operated, and above 90° in 80.3 % after surgery. Muscle strength was poor or regular in pre-surgical stage in 77.2 %, being excellent or good after surgery. Conclusions: once Neer's technique was applied, the pain was mild or null in most of the universe, the shoulder function was good, the anterior flexion adequate, and the muscle strength good (AU).

Confiabilidade interavaliador do método de Bigliani para classificação do tipo acromial / Inter-rater reliability of the method of Bigliani for classifying acromial type

Introdução: em 1875, Hamilton identificou o formato do acrômio como uma etiologia de dor no ombro. Neer, em 1972, descreveu a síndrome do impacto no ombro como uma relação de causa e efeito entre a morfologia do acrômio e o impacto subacromial. Em 1986, Bigliani et al. apresentaram um esquema de classificação do acrômio de acordo com o formato de sua superfície inferior: plano (tipo I), curvo (tipo II) e gancho (tipo III). Em 1993, Epstein et al. proporam que o acrômio tipo II apresentaria um declive em seu terço médio e o tipo III no seu terço anterior. Objetivo: avaliar a reprodutibilidade/confiabilidade interavaliador do método de Bigliani et al. (1986) refinado por Espstein et al. (1993) para a classificação do tipo acromial. Metodologia: casuística composta por 20 voluntários brasileiros, de ambos os gêneros, entre 21-25 anos. A incidência radiográfica utilizada para visualizar o formato do acrômio foi perfil de escápula. O tipo acromial foi classificado por três avaliadores. A reprodutibilidade e confiabilidade foram avaliadas pelo teste McNemar e pelo índice Kappa. Resultados: teste de McNemar com p > 0,05; índice Kappa entre 0,61 e 0,8; e probabilidade de significância p de Kappa < 0,05 confirmam a muito boa reprodutibilidade e confiabilidade do método para classificação do tipo acromial entre os três avaliadores. Conclusão: o método de Bigliani et al. (1986) refinado por Epstein et al. (1993) para classificação do tipo acromial mostrou concordância entre todos os avaliadores confirmando a muito boa reprodutibilidade e confiabilidade entre os avaliadores do estudo.

Introduction: in 1875, Hamilton identified that acromion shape was an etiology for shoulder pain. In 1972, Neer described shoulder impact syndrome as a cause and effect relationship between acromion morphology and subacromial impact. In 1986, Bigliani et al. presented an acromion classification scheme according to the shape of its lower surface: flat (type I), curved (type II) and hook (type III). In 1993, Epstein et al. proposed that the type II acromion would have a slope in its middle third and type III in its anterior third. Objective: to evaluate the inter-rater reproducibility and reliability of the method of Bigliani et al. (1986) for classifying acromial type, as refined by Epstein et al. (1993). Methodology: this was a case series composed of 20 Brazilian volunteers of both genders, aged 21-25 years. The shape of the acromion was visualized radiographically using the supraspinatus outlet view. Acromial type was classified by three evaluators. Reproducibility and reliability were assessed using the McNemar test and kappa index. Results: the McNemar test showed probability p > 0.05 and the kappa index was between 0.61 and 0.8 significant result: p < 0.05. These confirmed that this method had very good reproducibility and reliability for classifying acromial type among the three evaluators. Conclusion: the method of Bigliani et al. (1986) for classifying acromial type, as refined by Epstein et al. (1993) showed agreement among all the evaluators. This confirmed that there was very good reproducibility and reliability among the evaluators of this study.

A Simple Bone Cyst of the Acromion: Case Report / Cisto ósseo simples do acrômio: Relato de caso

Abstract Simple bone cysts rarely occur in the scapula, and, to our knowledge, they have not been reported in the acromion. In the present report, we present the case of a 24-year-old female patient who was successfully treated by curettage and grafting using xenografting. No recurrence findings were observed during the follow-up six months postoperatively, the patient had recovered full range of motion, and she was able to perform all routine activities satisfactorily.

Resumo Cistos ósseos simples são raros na escápula, e, pelo que sabemos, não foram relatados no acrômio. Aqui, apresentamos uma paciente do sexo feminino, de 24 anos, submetida com sucesso ao tratamento composto por curetagem e xenoenxerto. Não foram observados achados de recidiva no acompanhamento pós-operatório de seis meses, quando a paciente apresentou amplitude total de movimento e foi capaz de realizar todas as atividades rotineiras de maneira satisfatória.

Correlación de la morfología de la glenoides y la cobertura del acromion con rupturas de manguito rotador / Correlation of glenoid morphology and acromial coverage with rotator cuff tears

Introducción El objetivo de este estudio fue determinar si existen diferencias en el ángulo crítico del hombro medido por resonancia magnética en pacientes con ruptura de manguito rotador en comparación con pacientes sanos, así mismo, determinar la fiabilidad intraobservador del ángulo crítico del hombro. Se midieron diferentes variables en la resonancia magnética las cuales incluían: la extensión lateral del acromion, la altura acromial, la versión de la glenoides, el ángulo lateral del acromion y la inclinación glenoidea. Materiales y métodos Se evaluaron dos grupos de pacientes, el grupo control con un total de 16 pacientes y el grupo con ruptura de manguito rotador con 15 pacientes. Se midió en resonancia magnética el ángulo crítico del hombro, inclinación glenoidea, versión de la glenoides, altura acromial, extensión lateral del acromion y el ángulo lateral del acromion. Se utilizó la prueba T de student para comparación de medias y el coeficiente de correlación de Pearson para la asociación entre variables. Así mismo se utilizó el coeficiente de correlación intraclase para la valoración de la fiabilidad intraobservador. Resultados Se obtuvo un resultado de 0.961 en el coeficiente de correlación intraclase para la fiabilidad intraobservador del ángulo crítico del hombro. En la comparación de medias para el ángulo crítico del hombro entre el grupo control y el grupo con ruptura de manguito rotador se obtuvo un resultado de 32.3°(3.6) vs 35.01°(2.4) con una diferencia estadisticamente significativa(p=0.02). De igual manera se obtuvieron diferencias significativas en la inclinación glenoidea y la versión de la glenoides en ambos grupos (81.56°DE 4.04 vs 77.11° DE 3.84; p=0.004) y (-4.47° DE 4.56 vs -1.58°DE 3.94; p=0.04). Discusión Existen diferencias significativas en la medición del ángulo crítico del hombro medido por resonancia magnética en pacientes sanos y pacientes con ruptura de manguito rotador.

Background The purpose of this study was to determine if there is a difference between the critical shoulder angle measured by MRI in patients with rotator cuff tear and healthy patients, also to evaluate the intraobserver reliability in this measure. Other variables were included as well, lateral acromial extension, acromial height, glenoid version, glenoid inclination and lateral acromial angle. Materials and methods Two groups were evaluated, the control group consisted in a total of 16 patients and the group with rotator cuff tear consisted of 15 patients. The critical shoulder angle, glenoid inclination, glenoid version, acromial height, lateral acromial extension and lateral acromial angle were measured on MRI. A student T test was used for comparison of means between both groups, Pearson correlation coefficient was used for evaluating the association between variables. The intraobserver reliability was evaluated using the intraclass correlation coefficient. Results A result of 0.961 was obtained for the intraobserver reliability using the intraclass correlation coefficient for the critical shoulder angle. For the comparison of means of the critical shoulder angle in the control group and the rotator cuff tear group a result of 32.3° (3.6) vs. 35.01° (2.4) was obtained with a statistically significant difference of p=0.02. Likewise, statistically significant differences were obtained in the glenoid inclination and glenoid version in both groups (81.56° SD 4.04 vs 77.11° SD 3.84; p=0.004) and (−4.47° SD 4.56 vs −1.58° SD 3.94; p=0.04). Discussion Critical shoulder angle measured by MRI is statistically significant different in control group and in rotator cuff tear group.

Acromioplastía y fricción subacromial 2021. Perspectiva latinoamericana / Acromioplasty and subacromial decompression 2021. Latinoamerican perspective

Introducción: Si bien la acromioplastia es uno de los procedimientos más realizados por los cirujanos de hombro, numerosas publicaciones recientes han cuestionado su eficacia. El objetivo del siguiente estudio fue investigar las tendencias actuales en la utilización de la acromioplastia entre cirujanos de hombro de Latinoamérica.Materiales y métodos: se diseñó un cuestionario mediante Google Forms, con quince preguntas para recolectar información sobre la utilización de la acromioplastia en la práctica cotidiana. En total se convocaron sesenta y cinco cirujanos de dieciséis países de Latinoamérica. La modalidad de las respuestas fue de opción múltiple y anónimas.Resultados: la tasa de respuestas fue del 100% (65/65). La edad promedio de los encuestados fue de cuarenta y siete años (rango 32-68). El 84% de los cirujanos respondió que utiliza la acromioplastia asociada a las reparaciones del manguito rotador (MR) y de estos el 91% la realiza en forma artroscópica. Las ventajas de la acromioplastia referidas con mayor frecuencia fueron que mejora el campo operatorio (55%) y que descomprime el MR (48%) y la desventaja más citada fue la inestabilidad anterosuperior de hombro (46%). La forma más frecuente para determinar la cantidad de acromion a resecar fue la experiencia personal del cirujano (42%). El 67% de los cirujanos libera el ligamento coracoacromial cuando realiza la acromioplastia y el 57% expresó realizar la resección de la clavícula distal asociada a la descompresión. El 56.5% de los cirujanos no efectúa nunca coracoplastia al reparar el subescapular. En cuanto a la etiopatogenia de las rupturas del manguito rotador, el 55% dijo que las causas de las rupturas son intrínsecas (degenerativas).Conclusión: existe una alta variabilidad en la indicación y en la técnica quirúrgica utilizada para realizar la acromioplastia entre los cirujanos de hombro de Latinoamérica. No hay acuerdo entre las ventajas y desventajas ni en las contraindicaciones del procedimiento. A cincuenta años de la teoría de Neer, solo el 1.5% de los encuestados considera como principal productor de patología del MR la compresión extrínseca de los tendones. Finalmente, algunos de los argumentos referidos por los participantes para justificar la utilización de la acromioplastia no se ajustan a los preceptos propuestos por Neer sino a causas tales como liberar factores de crecimiento o mejorar la visión en el campo operatorio.Identificar los aspectos de mayor controversia y desacuerdo sirven de base para investigaciones futuras que permitan consensos que guíen la práctica diaria según el mejor nivel de evidencia disponible.

Introduction: Although acromioplasty is one of the procedures most performed by shoulder surgeons, numerous recent publications have questioned its efficacy. The objective of the following study was to investigate current trends in the use of acromioplasty among shoulder surgeons in Latin America. Materials and methods: a questionnaire was designed with the Google Forms methodology, with fifteen questions to collect information on the use of acromioplasty in daily practice. In total, sixty-five surgeons from sixteen Latin American countries were summoned. The modality of the answers was multiple choice and anonymous. Results: the response rate was 100% (65/65). The average age of the respondents was forty-seven years (range 32-68 years). Eighty four percent of surgeons responded that they use acromioplasty associated with rotator cuff (RC) repairs and of these 91% perform it arthroscopically. The most frequently reported advantages of acromioplasty were that it improves the operative field (55%) and that it decompresses the RC (48%), and the disadvantage most often referred was anterosuperior shoulder instability (46%). The most frequent way to determine the amount of acromion to resect was the personal experience of the surgeon (42%). Sixty seven percent of surgeons release the coracoacromial ligament when performing acromioplasty and 57% referred to perform decompression associated with the distal clavicle resection. Fifty six percent of surgeons never perform coracoplasty when repairing the subscapularis. Regarding the etiopathogenesis of rotator cuff tears, 55% reported that the causes of the tears are intrinsic (degenerative).Conclusion: there is a high variability in the indication and in the surgical technique used to perform acromioplasty among shoulder surgeons in Latin America. There is no agreement between the advantages and disadvantages or the contraindications of the procedure. Fifty years after Neer's theory, only 1.5% of those surveyed consider extrinsic tendon compression as the main etiology of RC pathology. Finally, some of the arguments referred to by the participants to justify the use of acromioplasty do not conform to the precepts proposed by Neer, but rather to causes such as releasing growth factors or improving visibility in the operative field.Identifying the aspects of greatest controversy and disagreement serve as the basis for future research that allows consensus to guide daily practice according to the best level of available evidence.

Anatomical variations of the acromial and coracoid process: clinical relevance.

PURPOSE: The acromial and coracoid process morphology is of clinical relevance due to associations with functional limitations and shoulder pathology. Our objective was to describe the anatomical characteristics of the acromial and coracoid process using computed tomography (CT). METHODS: Descriptive, observational, transversal and retrospective study. A total of 155 CT of patients without shoulder pathology, of both genders, and indistinct age were evaluated and grouped by age: Group 1 < 25 years; group 2 25-40 years; group 3 > 40 years. The following parameters were evaluated: Acromial type (AcT), vertical coracoid distance (VCD), acromial tilt (AT), acromial projection (AP), critical shoulder angle (CSA), type of the subcoracoid outlet (TSO), and the area of the subcoracoid outlet (ASO). RESULTS: Statistically significant differences were found between men and women for VCD (14.44 ± 4.79 vs. 11.76 ± 4.00 mm; p < 0.001) and AP (3.66 ± 4.71 vs. 1.62 ± 4.99 mm; p < 0.05) as well as between age groups 1 and 3 for AT (35.08 ± 11.53 vs. 28.41 ± 6.60; p < 0.05) and ASO (398.99 ± 153.91 vs. 255.56 ± 124.58 mm2; p < 0.001). An unexpected high ASO variation was identified with 11% of S-shaped acromion and 1.3% clock-shaped TSO. CONCLUSION: The age group between 25-40 years had the most uniform distribution of data. There is a high morphological variability present in an asymptomatic population, which should be considered in the clinical assessment such as shoulder impingement syndrome.

Reconstrucción anatómica del Acromion en casos de fracturas traumáticas y posterior a artroplastia reversa del Hombro. Reporte de Casos / Anatomic reconstruction of the acromion in cases of traumatic fractures after reverse shoulder arthroplasty. Report of a series of cases

Introducción Tanto las fracturas traumáticas del acromion, así como las fracturas acromiales por insuficiencia posterior a artroplastia reversa del hombro, son entidades poco frecuentes. Con la ampliación des los criterios operativos para la artroplastia reversa del hombro, es de suponer un aumento en el caso des las fracturas acromiales por insuficiencia posteriores a dicho procedimiento quirúrgico. Al ser estas entidades poco frecuentes hacen falta en la literatura recomendaciones basadas en la evidencia para el manejo de estas, las cuales representan un reto para el especialista tratante. Materiales y Métodos Reporte de seis casos entre 2013 y 2016 en el hospital cantonal de Frauenfeld (Suiza) de dos grupos de pacientes con fracturas del Acromion. En el grupo A se clasificaron tres pacientes que presentaron fractura por insuficiencia del acromion posterior a artroplastia reversa del Hombro. En el grupo B clasificaron tres pacientes con fracturas traumáticas del acromion en las cuales el manejo conservador no fue exitoso. Los dos grupos de pacientes fueron sometidos al mismo método quirúrgico con reducción abierta y reconstrucción anatómica del Acromion por medio de fijación con placa y tornillos interfragmentarios. Resultados Posterior a la intervención quirúrgica, la función del hombro se recuperó en todos los pacientes del Grupo A. La flexión anterior aumentó en promedio de 53° a 127°, y la abducción mejoró de 52° a 125°. Las mediciones posteriores al año de la intervención mostraron puntajes constantes entre 55-71, así como un valor subjetivo de hombro (SSV) de 50-90. En el Grupo B, el rango de movimiento preoperatorio se mantuvo constante. La flexión hacia delante mejoró de 133° a 157° y la abducción aumentó de 147° a 153°. Un año después de la cirugía, los puntajes de Constant en el grupo B variaron de 70 a 86 y el SSV se encontró entre 80 a 100. Los tres pacientes del Grupo B consiguieron retomar sus actividades diarias sin dolor y pudieron regresar al trabajo. La extracción de la placa fue necesaria en la mitad de los pacientes de la cohorte (Grupo A n=1, Grupo B n=2). Discusión La fractura del acromion es una condición seria que puede causar daño significativo al funcionamiento del hombro. Tanto en pacientes con ARH así como en pacientes sin ARH previa, nuestra técnica operativa abierta de reconstrucción anatómica del acromion mostró buenos resultados. Recomendamos el manejo quirúrgico por medio de reconstrucción con placa y clavos de fijación. Nivel de evidencia: IV

Aim To propose a surgical technique to treat the traumatic acromion fractures, as well as acromion fractures before reverse total Shoulder Replacement (TSR). Methods Six patients were treated with the same fixation technique between December 2013 and December 2016. Three patients had acromial insufficiency fractures (type II) following TSR (Group A). The other three patients, who had traumatic acromion fractures, underwent unsuccessful conservative treatment (Group B). Surgical treatment involved reconstruction of the acromion using an open technique with plate and interfragmentary screw fixation. Results Following reconstruction, shoulder function was regained in all patients in Group A. Forward flexion increased, on average, from 53° to 127°, and abduction improved from 52° to 125°. Measurements at one-year follow-up were Constant scores from 55-71, and subjective shoulder value (SSV) from 50-90. In Group B, preoperative range of motion was not substantially diminished. Forward flexion improved from 133° to 157°, and abduction increased from 147° to 153°. One year following surgery, the Constant scores in Group B ranged from 70-86, and SSV was 80-100. All three patients performed daily activities without pain, and were able to return to work. Plate removal was necessary in half the patients in the cohort (Group A n=1; Group B n=2). Conclusion An acromion fracture is a serious condition that can cause significant damage to shoulder functioning. In patients with or without previous TSR, this fixation technique was used successfully to reconstruct the anatomic lateral and basal acromion. Evidence Level: IV

Diminutive Incision Acromioplasty Assisted with Arthroscopy in the Treatment of Chinese Patients with Subacromial Impingement Syndrome / Acromioplastia de Incisión Diminuta Asistida con Artroscopia en el Tratamiento de Pacientes Chinos con Síndrome de Pinzamiento Subacromial

ABSTRACT Background: Many causes can lead to shoulder pain and subacromial impingement syndrome (SIS) is the most frequently recorded disorders. The aim of this study was to evaluate the clinical effects of diminutive incision acromioplasty assisted with arthroscopy for the treatment of Chinese patients with subacromial impingement syndrome. Subject and Methods: Twenty-two patients with 24-painful shoulders subacromial impingement syndrome were enrolled. All painful shoulders were in Grades II (8) and III (16) according to Neer's classification. Detailed physical examination was performed. Conventional radiography and subsequent magnetic resonance imaging (MRI) of the shoulder region of all patients were done. The University of California at Los Angeles Shoulder (UCLA) score system was used for all patients to evaluate their satisfaction after surgery. The preoperative recordings of the UCLA scores were collected and all enrolled cases including 24-painful shoulders were available for follow-up in 1, 3, 6, 12 months after surgery. Results: According to the UCLA scoring system, the symptom of all painful shoulders were improved after one year postoperatively. The average score before surgery from 15.4 points increased to 31.2 points postoperatively, showing a statistical difference (p < 0.05). Conclusions: A diminutive incision acromioplasty assisted with arthroscopy is a reliable approach to treat Chinese patients with subacromial impingement syndrome. All painful shoulders were obviously improved in one year after surgery.

ABSTRACT Antecedentes: Muchas causas pueden provocar dolor de hombro y síndrome de compresión subacromial (SIS) es el trastorno más frecuentemente registrado. El objetivo de este estudio fue evaluar la clínica. Efectos de la acromioplastia con incisión diminuta asistida con artroscopia para el tratamiento de Pacientes chinos con síndrome de pinzamiento subacromial. Sujeto y métodos: Se incluyeron veintidós pacientes con síndrome de afectación subacromial de 24-hombros dolorosos. Todos los hombros dolorosos estaban en Grados II (8) y III (16) de acuerdo con la clasificación de Neer. Se realizó examen físico detallado. Se realizaron radiografías convencionales y, posteriormente, imágenes de resonancia magnética (IRM) de la región del hombro de todos los pacientes. El sistema de puntuación de la Universidad de California en Los Angeles Shoulder (UCLA) se utilizó para que todos los pacientes evaluaran su satisfacción después de la cirugía. Los registros preoperatorios de las puntuaciones de UCLA se recopilaron y todos los casos incluidos, incluidos 24-hombros dolorosos, estaban disponibles para el seguimiento en 1, 3, 6 y 12 meses después de la cirugía. Resultados: De acuerdo con el sistema de puntuación de UCLA, el síntoma de todos los hombros dolorosos mejoró después de un año después de la operación. La puntuación promedio antes de la cirugía de 15.4 puntos aumentó a 31.2 puntos después de la operación, mostrando una diferencia estadística (p < 0.05) Conclusiones: Una acromioplastia de incisión diminuta asistida con artroscopia es un enfoque confiable para tratar a pacientes chinos con síndrome de pinzamiento subacromial. Todas las lesiones dolorosas se mejoraron obviamente en un año después de la cirugía.

Assessment of scapular morphometry / Evaluación de la morfometría escapular

The current study was undertaken to assess the incidence of different types of suprascapular notch, acromion dimensions and the lower and upper scapular angles. The suprascapular notch and variations of the acromion are clinically important in suprascapular nerve compression and subacromial impingement. Measurements were taken from 73 Anatolian dry scapulae of unknown age or sex. The suprascapuar notch was classified according to that of Rengachary et al. (1979). Its width and depth, the distance between supraglenoid tubercle and the deepest point of notch, as well as the upper and lower scapular angles were also determine measured. The type of acromion was assessed according to shape (type I (cobra), type II (square), type III (intermediate)) and tilt (type I (flat), type II (curve). Acrmion length and the distance between acromion and coracoid process were also measured. The frequency of different types of suprascapular notch were type I (28.8 %), type II (23.3 %), type III (13.7 %), type IV (20.5 %), type V (2.7 %), type VI (5.5 %)and absence (5.5 %). Acromion type were type I (45.5 %), type II (7.5 %) and type III (47.0 %), acromion tilt type I (15.2 %), and type II (84.8 %). An understanding of the association between the anatomical structures of the scapula and morphometric measurements is clinically important.

En este trabajo se evaluó la incidencia de diferentes tipos de incisura supraescapular, dimensiones de acromion y los ángulos escapulares superior e inferior. La incisura supraescapular y las variaciones del acromion son clínicamente importantes en la compresión del nervio supraescapular y el pinzamiento subacromial. Las mediciones se tomaron de 73 escápulas secas de Anatolia, de edad y sexo desconocidos. La incisura supraescapular se clasificó según Rengachary et al. (1979). Se determinaron también el ancho y la profundidad, la distancia entre el tubérculo supraglenoide y el punto más profundo de la incisura, así como los ángulos escapulares superior e inferior. El tipo de acromion se evaluó de acuerdo con la forma [tipo I (cobra), tipo II (cuadrado), tipo III (intermedio)] y la inclinación [tipo I (plano), tipo II (curvo)]. También se midieron la longitud del elemento y la distancia entre el acromion, como así también el proceso coracoide. La frecuencia de los diferentes tipos de incisura supraescapular fueron: tipo I (28,8 %), tipo II (23,3 %), tipo III (13,7 %), tipo IV (20,5 %), tipo V (2,7 %), tipo VI (5,5 %) y ausencia (5,5 %). Los tipos de acromion fueron: tipo I (45,5 %), tipo II (7,5 %) y tipo III (47,0 %), tipo de inclinación de acromion I (15,2 %) y tipo II (84,8 %). En conclusión, el conocimiento de la asociación entre las estructuras anatómicas de la escápula y las mediciones morfométricas es clínicamente importante.

Predictors of shoulder degeneration in the Kwazulu-Natal population of South Africa / Indicadores de la degeneración del hombro en la poblacion Kwazulu/Natal de Sudáfrica

SUMMARY: The critical shoulder angle and acromion index are conventional radiological tools employed as predictors of shoulder degeneration. As they represent the static components of glenohumeral stability, the scapulo-humeral geometry and underlying subacromial tissue appear as the resultant cause-effect factors. Consequently, the purpose of this study was to investigate the critical shoulder angle and acromion index as interrelated parameters within the South African population. The measurement of both biomechanical parameters was conducted on two-hundred and sixty (n = 260) true AP radiographs. This was a cross-sectional study that also incorporated the demographic representation of the population group which was analysed accordingly. The mean values recorded for both the critical shoulder angle (36.31±5.84º) and acromion index (0.74±0.13) suggested rotator cuff arthropathy. The results confirmed the theories of Nyffeler et al. (2006) and Moor et al. (2012) who alluded to glenoid inclination and the acromial coverage over the humeral head. A significant proportionality correlation, verified by a P value of 0.000, was established between the acromion index and critical shoulder angle which may assist to differentiate between normal asymptomatic shoulders and those with cuff disease. Furthermore, these predictors of shoulder degeneration may present as a preventative tool against tear progression.

RESUMEN: El ángulo crítico del hombro y el índice acromial son herramientas radiológicas convencionales empleadas como indicadores de la degeneración del hombro. Debido a que representan los componentes estáticos de la estabilidad glenohumeral, la geometría escápulo-humeral y el tejido subacromial subyacente aparecen como los factores causa-efecto resultantes. En consecuencia, el propósito de este estudio fue investigar el ángulo crítico del hombro y el índice acromial como parámetros interrelacionados dentro de la población sudafricana. La medición de ambos parámetros biomecánicos se realizó en 260 radiografías antero-posteriores (AP). Se realizó un estudio transversal que también incorporó la representación demográfica del grupo de la población que fue analizada. Los valores medios registrados tanto para el ángulo crítico del hombro (36,31 ± 5,84º) como para el índice del acromión (0,74 ± 0,13) sugirieron una artropatía del manguito rotador. Los resultados confirmaron las teorías de Nyffeler et al. (2006) y Moor et al. (2012) que aludían a la inclinación glenoide y a la cobertura acromial sobre la cabeza humeral. Se estableció una correlación de proporcionalidad significativa, verificada por un valor de P de 0,000, entre el índice acromial y el ángulo crítico del hombro, lo que puede ayudar a diferenciar entre los hombros asintomáticos normales y aquellos con enfermedad del manguito rotador. Además, estos predictores de degeneración del hombro pueden ser útiles como una herramienta preventiva contra la progresión del desgarro.

Relationship between the critical shoulder angle and the development of rotator cuff lesions: a retrospective epidemiological study / Associação entre o ângulo crítico do ombro e lesão do manguito rotador: um estudo epidemiológico retrospectivo

ABSTRACT OBJECTIVE: To perform a retrospective epidemiological study of radiographs in order to evaluate the relationship between the anatomy of the scapula and the development of rotator cuff injuries (RCIs). METHODS: This study retrospectively evaluated the relation of the critical shoulder angle (CSA) and RCIs from January 2011 to November 2013; patients were examined in the Orthopedics and Traumatology Department of a university hospital. The CSA was measured by radiographic standardization of two groups: a control group of 34 asymptomatic shoulders and a study group of 44 shoulders with complete RCIs. RESULTS: The mean age in the control group was 59.97 years (45-84) and the mean age in the group with RCIs was 59.75 years (45-84). Regarding the CSA, the control group had a mean angle of 33.59° (±3.37) and the group with RCIs had a mean angle of 39.75° (±5.35; p< 0.007). CONCLUSION: There is an association between CSA and RCIs.

RESUMO OBJETIVO: Fazer um estudo epidemiológico retrospectivo em radiografias para avaliar a relação entre a anatomia da escápula e o desenvolvimento de lesões do manguito rotador (LMR). MÉTODOS: O presente estudo avaliou retrospectivamente a relação do ângulo crítico do ombro (ACO) e LMR de janeiro de 2011 a novembro de 2013, em pacientes atendidos em um hospital universitário pelo Departamento de Ortopedia e Traumatologia. Para tanto, o ACO foi medido após a padronização radiográfica de dois grupos, um grupo controle de 34 ombros assintomáticos e um segundo grupo de 44 ombros com LMR. RESULTADOS: A média de idade no grupo controle foi de 59,97 anos (45-84) e de 59,75 anos no grupo com LMR (45-84). Em relação ao ACO, os pacientes do grupo controle tiveram média de 33,59 graus de angulação (± 3,37) e o grupo de pacientes com LMR apresentou uma média de 39,75 graus de angulação (± 5,35; p < 0,007). CONCLUSÃO: Há uma relação entre ACO e LMR.

Arthroscopic in Situ Repair of Partial Bursal Rotator Cuff Tears Without Acromioplasty.

PURPOSE: To evaluate functional outcomes and complications in a consecutive group of patients with partial bursal rotator cuff tears (PBRCTs) treated with insitu repair without acromioplasty. METHODS: Seventy-four patients who had undergone an arthroscopic single row in situ repair for bursal-sided rotator cuff tears were evaluated. Clinical assessment consisted of glenohumeral range of motion measurement, the American Shoulder and Elbow Surgeons score, and the University of California at Los Angeles score. Pain was recorded using a visual analog scale. Postoperative complications were also assessed. RESULTS: Mean age was 55.2 years (±6.3) with a minimum of 2-year follow-up. After arthroscopic repair, all active range of motion parameters improved significantly (P < .0001). The American Shoulder and Elbow Surgeons scores improved from 42.5 to 86.1; the University of California at Los Angeles scores improved from 15.8 to 31.4, and the visual analog scale scores improved from 6.6 to 0.7 (P < .0001). Only 3 patients developed a postoperative adhesive capsulitis that responded to physical therapy. CONCLUSIONS: In the midterm follow-up (42 months), arthroscopic in situ repair of PBRCTs without acromioplasty is a reliable procedure that produces significant functional improvements and pain relief. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

A natação aumenta a amplitude de movimento e a força dos músculos rotadores mediais do ombro sem alterar o espaço subacromial / Swimming increases range of motion and strength of the medial rotator muscles of the shoulder without altering the subacromial space

Introdução: Na natação, de modo geral, as estruturas que compõem o ombro são afetadas pelo gestual esportivo, porém, não se pode afirmar que isso promove o impingement. Objetivo: Avaliar o efeito da natação sobre o espaço subacromial, a amplitude de movimento e a força de rotação medial e lateral dos ombros de nadadores. Métodos: Foram analisados 52 sujeitos de ambos os gêneros, entre 12 e 17 anos e divididos em 2 grupos pareados: 1) grupo experimental: 26 nadadores (14 homens e 12 mulheres) e grupo controle: 26 sujeitos ativos não nadadores (13 homens e 13 mulheres). Resultados: Os dados foram analisados no SPSS (20.0) pelos testes t Student (independente) e Mann-Whitney, considerando-se α ≤ 0,05. A força de rotação medial foi 57 e 54% maior que a força de rotação lateral no grupo experimental (P<0,01), e 32 e 25% no grupo controle (P<0,01) para o membro dominante e membro não dominante, respectivamente. A razão força de rotação medial/força de rotação lateral e a amplitude de movimento foram maiores no grupo experimental (P<0,02 e P<0,01, respectivamente) quando comparada ao grupo controle. Conclusão: Os nadadores apresentaram maior amplitude de movimento, força de rotação medial e razão força de rotação medial/força de rotação lateral comparados ao grupo controle, sem alterar o espaço subacromial, comparado a valores normativos.(AU)

Introduction: In swimming, in general, the structures that make up the shoulder are affected by the sportive gesture, however, it cannot be said that this promotes the impingement. Objective: To evaluate the swimming effect on the subacromial space, range of motion and medial and lateral rotation force shoulders of swimmers. Methods: Fifty-two subjects of both genders were analyzed between 12 and 17 years and divided into two matched groups: 1) experimental group: 26 swimmers (14 men and 12 women) and control group: 26 active subjects not swimmers (13 men and 13 women). Results: The results were analyzed using SPSS (20.0) by Student t (independent) and Mann-Whitney tests, considering α ≤ 0.05. The medial rotation force was 57 and 54% greater than the lateral rotation force in the experimental group (P<0.01), and 32 e 25% in the control group (P<0.01) for the dominant limb and non-dominant limb, respectively. The ratio medial rotation force/lateral rotation force and range of motion performed higher in the experimental group (P<0.02 and P<0.01, respectively) compared to the control. Conclusion: The swimmers had greater range of motion, medial rotation force and medial rotation force / ateral rotation force ratio compared to control without changing the subacromial space compared to normative values.(AU)

Evaluation of the acromiohumeral distance by means of magnetic resonance imaging umerus / Avaliação da distância úmero-acromial por meio da ressonância magnética

OBJECTIVE: To demonstrate the relationship between the size, degree of retraction and topography of rotator cuff injuries and the degree of rise of the humeral head, and to evaluate the influence of gravity, using magnetic resonance imaging (MRI). METHODS: We evaluated 181 shoulder MRIs from 160 patients aged over 45 years, between November 2013 and July 2014. The patients were divided into two groups: one control (no lesion or partial damage to the rotator cuff); and the other with complete tears of the rotator cuff. We measured the acromiohumeral distance in the sagittal plane, and established the shortest distance between the apex of the head and the acromion. RESULTS: In this study, 96 examinations on female patients (53.04%) and 58 on male patients (46.96%) were evaluated. The mean age was 63.27 years: in the control group, 61.46; and in the group with injuries, 65.19. From analysis on the measurements of the subacromial space, we observed significantly higher values in the control group (7.71 mm) than in the group with injuries (6.99). In comparing the control group with some specific subgroup, i.e. posterosuperior (6.77), anteroposterior-superior (4.16) and retraction Patte III (5.01), we confirmed the importance of topography and degree of retraction in relation to the rise of the humeral head. CONCLUSION: The rise of the humeral head was directly related to the size, degree of retraction and topography of the rotator cuff injuries, with greater degrees of rise in cases of superior and posterior lesions and anteroposterior-superior (massive) lesions. The assessment using MRI was not influenced by the force of gravity.

OBJETIVO: Demonstrar a relação entre o tamanho, grau de retração e topografia das lesões do manguito rotador com o grau de ascensão da cabeça umeral e avaliar a influência da força da gravidade na ressonância magnética. MÉTODOS: Avaliamos 181 ressonâncias magnéticas de ombro de 160 pacientes com mais de 45 anos, entre novembro de 2013 e julho de 2014. Os pacientes eram divididos em dois grupos, um de controle (sem lesão ou com lesão parcial do MR) e outro com lesão completa do MR. Fizemos a mensuração da distância acrômio-umeral nos cortes sagitais e foi estabelecida a menor distância entre o ápice da cabeça e o acrômio. RESULTADOS: Foram avaliados neste estudo 96 (53,04%) exames de pacientes do sexo feminino e 58 de pacientes do sexo masculino (46,96%). A idade média foi 63,27 anos, a do grupo controle 61,46 e a do grupo com lesão 65,19. Ao analisar as medidas do espaço subacromial, observamos valores significativamente maiores no grupo controle (7,71 mm) do que no grupo com lesão (6,99). Quando comparamos o grupo controle com alguns subgrupos específicos, posterossuperior (6,77), anteroposterossuperior (4,16) e retração Patte III (5,01), confirmamos a importância da topografia e grau de retração para ascensão da cabeça umeral. CONCLUSÃO: A ascensão da cabeça umeral tem relação direta com o tamanho, grau de retração e a topografia das lesões do manguito rotador, com graus maiores de ascensão nas lesões posterossuperiores e anteroposterossuperiores (extensas). A avaliação feita pela ressonância magnética não sofre influência da força da gravidade.

Fixação perpendicular com dupla-placa e sistema de bloqueio para fratura de pedículo do acrômio / Perpendicular double-plate fixation with locking system for acromion pedicle fracture

Objetivo: Descrever a técnica cirúrgica e os resultados clínicos preliminares em uma série de cirurgias de redução aberta e fixação interna de fraturas do processo acrômio basais aplicando a técnica de dupla placa. Métodos: Nove pacientes consecutivos, com idade média de33,4 anos (intervalo, 23-61 anos) com fratura unilateral do acrômio (Tipo 3 AO/OTA) com mais de 1 cm de deslocamento submetidos afixação utilizando uma técnica de dupla placa bloqueada, tiveram os resultados avaliados em média após 7,8 meses (intervalo, 3-15 meses)referente à dor, função do ombro, e complicações cirúrgicas. Resultados:Oito pacientes se recuperaram com união radiográfica completa e função do ombro favorável. Um caso deixou de ser completamente avaliado por mais de 3 meses de seguimento. Os escores totais de Constant, dor no ombro e Disability Index (SPADI) e DASH para os oito pacientes revistos foram 91,9 ± 6,31, 3,11 ± 3,79 e 5,2 ± 6,35,respectivamente. Não houve infecção ou irritação decorrente das ferragens cirúrgicas no pós-operatório ao final do seguimento destes oito pacientes. Conclusão: Apesar de serem necessárias mais evidências para justificar suas vantagens sobre os implantes tradicionais, a dupla placa perpendicular com sistema de bloqueio pode ser indicada para tratamento de fratura do pedículo do acrômio, uma vez que apresentou bom desempenho na cicatrização óssea e reabilitação da função articular. Nível de Evidência IV, Estudo Terapêutico.

Objective: To describe the surgical technique and preliminaryclinical outcomes in a series of open reduction internal fixationof basal acromion process fractures applying a double-platingtechnique. Methods: Nine consecutive patients, mean age 33.4years old (range, 23–61 years old) with unilateral acromion fracture(Type 3 AO/OTA) with more than 1cm displacement whounderwent fixation utilizing a locked double-plating technique,were evaluated on average at 7.8 months (range, 3-15 months)for outcomes related to pain, shoulder function, and surgicalcomplications. Results: Eight patients recovered with complete radiographicunion and favorable shoulder function. One case failedto be fully evaluated for more than 3 months follow-up. The overallscores of Constant, Shoulder Pain and Disability Index (SPADI)and DASH for the eight patients reviewed were 91.9± 6.31, 3.11±3.79 and 5.2± 6.35, respectively. No post-operative infection orsurgical hardware irritation was identified at final follow-up ofthese eight patients. Conclusion: While more evidence is neededto justify its advantages over traditional implants, perpendiculardouble-plate with a locking system may be indicated for acromionpedicle fracture treatment, since it performed well for fracturehealing and joint function rehabilitation. Level of Evidence IV,Therapeutic Study.