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1.
Medicine (Baltimore) ; 100(12): e23794, 2021 Mar 26.
Artigo em Inglês | MEDLINE | ID: mdl-33761628

RESUMO

ABSTRACT: Diffuse pigmented villonodular synovitis (PVNS) of knee is a rare benign disease that has a destructive clinical course. Synovectomy and adjuvant radiotherapy (RT) have been reported as treatment options but literatures reporting functional outcomes were sparse. This study aimed to evaluate the long-term functional outcomes and disease control among treatment modalities through the 22 years of experience.A single-center database was searched for patients who received synovectomy of knee with the pathologic diagnosis of PVNS. General data, treatment modalities, and recurrent status were retrospectively collected from medical records. Functional outcomes were evaluated by Western Ontario and McMaster Universities Osteoarthritis Index through phone interviews by an independent orthopedist.From January 1995 to December 2017, 24 patients with diffuse PVNS of knee were identified, including 19 receiving open synovectomy (OP) and 5 undergoing arthroscopic surgery. Adjuvant RT was performed on 14 patients with a median dose of 35 Gy (range 20-40 Gy). After median follow up of 6 years, recurrences were recorded in 10 cases. The recurrence rate was significantly lower in the OP + RT group than the OP group (8.3% vs 57.1%, P = .038). Among those with preserved knee joints, there was no significant difference in the Western Ontario and McMaster Universities Osteoarthritis Index score and stiffness score between patients in the OP + RT and OP groups.For patients with diffuse PVNS of knee, the addition of moderate-dose adjuvant RT following OP provided excellent local control while maintaining good joint function with limited treatment-related morbidity. Our study emphasized the importance of moderate dose RT in diffuse PVNS of knee joint.


Assuntos
Artroscopia/efeitos adversos , Recidiva Local de Neoplasia/epidemiologia , Sinovectomia/métodos , Sinovite Pigmentada Vilonodular/terapia , Adulto , Idoso , Feminino , Seguimentos , Humanos , Articulação do Joelho/fisiopatologia , Articulação do Joelho/cirurgia , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/prevenção & controle , Radioterapia Adjuvante/efeitos adversos , Amplitude de Movimento Articular , Sinovectomia/efeitos adversos , Sinovite Pigmentada Vilonodular/epidemiologia , Sinovite Pigmentada Vilonodular/patologia , Resultado do Tratamento , Adulto Jovem
2.
Medicine (Baltimore) ; 100(10): e24998, 2021 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-33725876

RESUMO

BACKGROUND: Ankle fusion is the primary treatment for advanced ankle arthritis. With the advancement of arthroscopy technology, ankle arthroscopy fusion has shown many advantages over traditional surgery. However, there are few related studies globally, and evidence-based medicine is needed to verify the reliability and feasibility of ankle arthroscopy fusion. OBJECTIVE: To compare the clinical efficacy and safety of arthroscopic ankle arthrodesis and open ankle arthrodesis. METHODS: We searched the databases of PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure [CNKI], Wanfang Database, and VIP Database for published prospective or retrospective controlled studies of arthroscopic-assisted ankle fusion in the treatment of advanced ankle arthritis. The dates were limited from the construction of the library to June 30, 2019. Literature was included based on the principles and methods of evidence-based medicine. Literature retrieval, data extraction, and quality assessment were performed by 2 independent reviewers using the Cochrane 5.1 risk bias assessment tool. The methodological bias of the literature was evaluated, and a meta-analysis was using by RevMan 5.3 software. RESULTS: A total of 18 studies and 1102 patients were included in the study, including 551 in the arthroscopic surgery group and 551 in the open surgery group. Arthroscopy-assisted surgery for advanced ankle arthritis was more effective than open surgery in terms of fusion rate (odd ratio[OR] = 3.32, 95% confidence interval[CI]:2.16, 5.10), fusion time (mean difference[MD] = -2.31, 95% CI:-4.63, -2.21), intraoperative blood loss (MD = -43.37, 95%CI: -48.49, -38.25), hospital stay (MD = -1.80, 95%CI: -2.28, -1.33), and visual analog scale score (MD = -1.75, 95%CI: -2.04, -1.46). In addition, rate of complications (OR = 0.33, 95%CI: 0.21, 0.52) was superior to open ankle fusion (P < .00001). CONCLUSION: Arthroscopic ankle arthrodesis has more advantages than open ankle arthrodesis in improving the fusion rate and reducing complications, which is worthy of clinical application. PROSPERO REGISTRATION NUMBER: CRD42020195727.


Assuntos
Articulação do Tornozelo/cirurgia , Artrodese/métodos , Artroscopia/métodos , Osteoartrite/cirurgia , Complicações Pós-Operatórias/epidemiologia , Articulação do Tornozelo/fisiopatologia , Artrodese/efeitos adversos , Artroscopia/efeitos adversos , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Estudos de Viabilidade , Humanos , Tempo de Internação/estatística & dados numéricos , Osteoartrite/diagnóstico , Osteoartrite/fisiopatologia , Complicações Pós-Operatórias/etiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função Fisiológica , Reprodutibilidade dos Testes , Índice de Gravidade de Doença , Resultado do Tratamento
3.
Medicine (Baltimore) ; 100(13): e25372, 2021 Apr 02.
Artigo em Inglês | MEDLINE | ID: mdl-33787641

RESUMO

RATIONALE: The incidence of venous thromboembolism (VTE) after knee arthroscopy is remarkably lower than that of arthroplasty. We describe a patient with symptomatic bilateral massive pulmonary thromboembolism (PTE) and deep vein thrombosis (DVT) in the femoral and popliteal veins after arthroscopic meniscus repair surgery. PATIENT CONCERNS: The patient underwent arthroscopic meniscus repair with no intraoperative complication. There were no underlying diseases such as hypertension or diabetes. On day 5 postoperative, the patient complained of dyspnea, chest discomfort, and nausea after standing. DIAGNOSIS: On DVT and PTE computed tomography, there were multifocal PTEs in the distal portion of the main and segmental branches of both pulmonary arteries. There was a focal thrombosis in the left deep femoral vein, as well as small DVTs in the left popliteal and calf veins. INTERVENTIONS: After 3 days of low-molecular-weight heparin 1 mg/kg every 12 hours, treatment was changed to an oral drug, dabigatran, for 6 months. OUTCOMES: There were no PTE or DVT findings on computed tomography at 6 months postoperative. The patient did not complain of symptoms related to PTE or DVT at 6 months after the operation, has returned to work, and is living without discomfort. LESSIONS: The frequency of VTE is very low after arthroscopic meniscus surgery, but it represents a life-threatening event. Our patient had risk factors for VTE including obesity, surgery time of ∼60 minutes, and immobilization. Although arthroscopic meniscus surgery is relatively safe, evaluation of risk factors for VTE should be performed before and after surgery, and appropriate thromboprophylaxis should be provided when necessary.


Assuntos
Artroscopia/efeitos adversos , Menisco/lesões , Complicações Pós-Operatórias/etiologia , Embolia Pulmonar/etiologia , Trombose Venosa/etiologia , Adulto , Anticoagulantes/administração & dosagem , Dabigatrana/administração & dosagem , Eletrocardiografia , Veia Femoral/diagnóstico por imagem , Heparina de Baixo Peso Molecular/administração & dosagem , Humanos , Masculino , Menisco/cirurgia , Veia Poplítea/diagnóstico por imagem , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/tratamento farmacológico , Artéria Pulmonar/diagnóstico por imagem , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/tratamento farmacológico , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Trombose Venosa/diagnóstico , Trombose Venosa/tratamento farmacológico
4.
Sports Med Arthrosc Rev ; 29(1): 44-51, 2021 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-33395230

RESUMO

The surgical treatment of femoroacetabular impingement has been shown to have successful early and mid-term clinical outcomes. Despite these favorable clinical outcomes that have been published in the literature, there is a subgroup of patients that present with continued or recurrent symptoms after surgical treatment. Not only has there been an increase in the number of hip arthroscopy procedures, but also there has been a corresponding increase in the number of revision hip arthroscopy and hip preservation surgeries. Previous studies have reported residual deformity to be the most common reason for revision hip arthroscopy. However, chondral, labral, and capsular considerations also are important when addressing patients not only in the primary but also, the revision setting. In this review, we outline the evaluation and treatment of the patient that presents with continued hip and groin pain after undergoing a hip.


Assuntos
Artroscopia , Impacto Femoroacetabular/cirurgia , Artralgia/etiologia , Artroscopia/efeitos adversos , Cartilagem Articular/patologia , Cartilagem Articular/cirurgia , Impacto Femoroacetabular/complicações , Impacto Femoroacetabular/patologia , Articulação do Quadril/anatomia & histologia , Articulação do Quadril/patologia , Articulação do Quadril/cirurgia , Humanos , Cápsula Articular/anatomia & histologia , Cápsula Articular/patologia , Cápsula Articular/cirurgia , Instabilidade Articular/etiologia , Complicações Pós-Operatórias , Reoperação , Falha de Tratamento
5.
Anesth Analg ; 132(4): 1129-1137, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33464760

RESUMO

BACKGROUND: Bupivacaine and ropivacaine are the preferred long-acting local anesthetics for peripheral nerve blocks as they provide prolonged analgesia in the postoperative period. No studies have directly compared the analgesic duration of these commonly used local anesthetics in the setting of low-volume ultrasound-guided interscalene block (US-ISB). This study was designed to determine which local anesthetic and concentration provides superior analgesia (duration and quality) for low-volume US-ISB. METHODS: Sixty eligible patients scheduled for arthroscopic shoulder surgery were randomized (1:1:1) to receive US-ISB (5 mL) with 0.5% bupivacaine with 1:200,000 epinephrine, 0.5% ropivacaine, or 1% ropivacaine. All individuals were blinded including study participants, anesthesiologists, surgeons, research personnel, and statistician. All participants received a standardized general anesthetic and multimodal analgesia. The primary outcome was duration of analgesia defined as the time from the end of injection to the time that the patients reported a significant increase in pain (>3 numeric rating scale [NRS]) at the surgical site. RESULTS: The mean duration of analgesia for 0.5% bupivacaine with 1:200,000 epinephrine, 0.5% ropivacaine, or 1% ropivacaine was 14.1 ± 7.4, 13.8 ± 4.5, and 15.8 ± 6.3 hours, respectively (analysis of variance [ANOVA], P = .51). There were no observed differences in analgesic duration or other secondary outcomes between the 3 groups with the exception of a difference in cumulative opioid consumption up to 20h00 on the day of surgery in favor of ropivacaine 0.5% over bupivacaine of minimal clinical significance. CONCLUSIONS: In the context of single-injection low-volume US-ISB, we have demonstrated a similar efficacy between equal concentrations of ropivacaine and bupivacaine. In addition, increasing the concentration of ropivacaine from 0.5% to 1% did not prolong the duration of US-ISB.


Assuntos
Agonistas Adrenérgicos/administração & dosagem , Anestésicos Locais/administração & dosagem , Bloqueio do Plexo Braquial , Bupivacaína/administração & dosagem , Epinefrina/administração & dosagem , Dor Pós-Operatória/prevenção & controle , Ropivacaina/administração & dosagem , Ultrassonografia de Intervenção , Agonistas Adrenérgicos/efeitos adversos , Adulto , Idoso , Analgésicos Opioides/uso terapêutico , Anestésicos Locais/efeitos adversos , Artroscopia/efeitos adversos , Bloqueio do Plexo Braquial/efeitos adversos , Bupivacaína/efeitos adversos , Epinefrina/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Atividade Motora/efeitos dos fármacos , Ontário , Medição da Dor , Limiar da Dor/efeitos dos fármacos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/fisiopatologia , Ropivacaina/efeitos adversos , Articulação do Ombro/cirurgia , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
6.
Medicine (Baltimore) ; 99(51): e23713, 2020 Dec 18.
Artigo em Inglês | MEDLINE | ID: mdl-33371120

RESUMO

ABSTRACT: Shoulder arthroscopy requires a large of irrigation for a better surgical view, leading circulatory overload. This study was performed to prove whether pulmonary edema will be lead by a large of irrigation.General anesthesia with interscalene block was induced before operation. The primary outcome was ultrasound evaluation of B lines from the time before nerve block to the time 10 hours after operation. The secondary outcomes included oxygenation index, arterial partial pressure of carbon dioxide, visual analogue scale, muscle strength grade.A total of 93 patients were evaluated. Before surgery, B lines failed to be detected. While the highest total incidence of B lines was 49.4%, occurred at 4 hours after surgery. The highest incidences of severe and moderate pulmonary edema were 3.2% (P = .081) and 9.7% (P = .002), respectively. B lines were also found on both the affected and healthy side. During operation, the incidence of type 1 respiratory failure was 5.4% (P = .023) and that of both type 1 and 2 respiratory failure were 6.5% (P = .013). Pain was relieved in 6 hours after surgery (VAS < 3). At 12 hours after operation, the VAS of resting and motion were 4.68 ±â€Š2.27, 6.90 ±â€Š2.43, respectively. While the grade of muscle strength was 4.48 ±â€Š0.51 at 12 hours after operation.There is a high incidence of pulmonary edema in shoulder arthroscopy, and ultrasound is a convenient tool to evaluate this complication. Pain is relieved in 6 hours after surgery by nerve block. While muscle strength can also recover at 12 hours after surgery.


Assuntos
Artroscopia/efeitos adversos , Artroscopia/métodos , Edema Pulmonar/etiologia , Edema Pulmonar/patologia , Articulação do Ombro/cirurgia , Adulto , Idoso , Anestesia Geral/métodos , Bloqueio do Plexo Braquial/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Força Muscular/fisiologia , Oxigênio/sangue , Medição da Dor , Dor Pós-Operatória/terapia , Edema Pulmonar/diagnóstico por imagem , Ultrassonografia
7.
J Am Acad Orthop Surg ; 28(16): 651-659, 2020 Aug 15.
Artigo em Inglês | MEDLINE | ID: mdl-32769716

RESUMO

Hip arthroscopy is rapidly growing as a treatment with good outcomes for pathologic conditions such as femoroacetabular impingement syndrome and labral tears. At the same time, it is one of the most technically challenging and demanding procedures in orthopaedics with a technically demanding skill. The first challenge is to safely access the joint, which requires accurate anatomical knowledge, a strong sense of spatial orientation, and repeated practice. Iatrogenic chondrolabral injury has been reported as the most common complication in hip arthroscopy and most frequently occurs during hip joint access. As such, basic foundations cannot be overstated. These complications can be minimized with adequate patient positioning, reproducible hip joint access techniques, and proper portals placement. Nonetheless, these three points are perhaps the greatest hurdles that orthopaedic surgeons face when entering the hip arthroscopy field. In this review, we outlined a stepwise approach for a safe access to hip arthroscopy.


Assuntos
Artroscopia/métodos , Articulação do Quadril/cirurgia , Posicionamento do Paciente/métodos , Decúbito Dorsal , Artroscopia/efeitos adversos , Impacto Femoroacetabular/cirurgia , Articulação do Quadril/anatomia & histologia , Humanos , Doença Iatrogênica/prevenção & controle , Lesões do Manguito Rotador/cirurgia , Segurança
8.
Br J Sports Med ; 54(22): 1332-1339, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32855201

RESUMO

OBJECTIVES: To assess the long-term effects of arthroscopic partial meniscectomy (APM) on the development of radiographic knee osteoarthritis, and on knee symptoms and function, at 5 years follow-up. DESIGN: Multicentre, randomised, participant- and outcome assessor-blinded, placebo-surgery controlled trial. SETTING: Orthopaedic departments in five public hospitals in Finland. PARTICIPANTS: 146 adults, mean age 52 years (range 35-65 years), with knee symptoms consistent with degenerative medial meniscus tear verified by MRI scan and arthroscopically, and no clinical signs of knee osteoarthritis were randomised. INTERVENTIONS: APM or placebo surgery (diagnostic knee arthroscopy). MAIN OUTCOME MEASURES: We used two indices of radiographic knee osteoarthritis (increase in Kellgren and Lawrence grade ≥1, and increase in Osteoarthritis Research Society International (OARSI) atlas radiographic joint space narrowing and osteophyte sum score, respectively), and three validated patient-relevant measures of knee symptoms and function (Western Ontario Meniscal Evaluation Tool (WOMET), Lysholm, and knee pain after exercise using a numerical rating scale). RESULTS: There was a consistent, slightly greater risk for progression of radiographic knee osteoarthritis in the APM group as compared with the placebo surgery group (adjusted absolute risk difference in increase in Kellgren-Lawrence grade ≥1 of 13%, 95% CI -2% to 28%; adjusted absolute mean difference in OARSI sum score 0.7, 95% CI 0.1 to 1.3). There were no relevant between-group differences in the three patient-reported outcomes: adjusted absolute mean differences (APM vs placebo surgery), -1.7 (95% CI -7.7 to 4.3) in WOMET, -2.1 (95% CI -6.8 to 2.6) in Lysholm knee score, and -0.04 (95% CI -0.81 to 0.72) in knee pain after exercise, respectively. The corresponding adjusted absolute risk difference in the presence of mechanical symptoms was 18% (95% CI 5% to 31%); there were more symptoms reported in the APM group. All other secondary outcomes comparisons were similar. CONCLUSIONS: APM was associated with a slightly increased risk of developing radiographic knee osteoarthritis and no concomitant benefit in patient-relevant outcomes, at 5 years after surgery. TRIAL REGISTRATION: ClinicalTrials.gov (NCT01052233 and NCT00549172).


Assuntos
Artroscopia/métodos , Meniscectomia/métodos , Osteoartrite do Joelho/diagnóstico por imagem , Lesões do Menisco Tibial/cirurgia , Adulto , Idoso , Artroscopia/efeitos adversos , Progressão da Doença , Finlândia , Seguimentos , Humanos , Imagem por Ressonância Magnética , Meniscectomia/efeitos adversos , Pessoa de Meia-Idade , Osteoartrite do Joelho/prevenção & controle , Medidas de Resultados Relatados pelo Paciente , Complicações Pós-Operatórias , Radiografia , Fatores de Risco
9.
Int J Surg ; 79: 222-232, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32522685

RESUMO

BACKGROUND: Degenerative meniscal tear is a chronic disorder which presents with knee pain, swelling and loss of motion. It is currently unknown whether arthroscopic partial meniscectomy combined with medical exercise therapy is superior to isolated medical exercise therapy for degenerative meniscal tear. OBJECTIVE: To determine if medical exercise therapy alone is as effective as arthroscopic partial meniscectomy combined with medical exercise therapy in treating degenerative meniscal tear. METHOD: Electronic searches were performed using MEDLINE, EMBASE, and the Cochrane Library Databases for all randomized studies. Two reviewers independently completed the literature screening, data extraction, and risk evaluation of bias. The outcome measures were visual analogue scale (VAS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), range of motion, the Lysholm Knee Scoring Scale (LKSS), Knee injury and Osteoarthritis Outcome Score (KOOS) and postoperative complications. STATA 13.0 software was applied for meta-analysis. RESULT: Six randomized controlled trials (RCTs) were conducted, with 900 patients included. The present study revealed that there were significant differences between the two groups regarding the VAS at two months, as well as, WOMAC and range of motion. No significant differences were found in terms of LKSS, KOOS or postoperative complications. LIMITATIONS: (1) Only 6 RCTs were included in our meta-analysis and the sample sizes were small; (2) The follow-up period was too short in some included studies. Long-term follow-up studies should be conducted in the future; (3) Heterogeneity among the included studies was unavoidable due to different grade of degenerative meniscal tear and program of exercise. Heterogeneity was also caused by a variety of other factors. (4) Publication bias that came from the process of literature searching was unavoidable and was hard to overcome. (5) There are many other words which could yielded more studies (Ex. physiotherapy, physical therapy modalities, exercise therapy, rehabilitation, knee, placebo, groups, tibial meniscus, meniscus, arthroscopy, meniscectomy, partial meniscectomy, randomized controlled trial, controlled clinical trial, randomized, systematic review, and meta-analysis). Implications of key findings: This meta-analysis suggests that doctors can choose arthroscopic partial meniscectomy combined with medical exercise therapy for the treatment of degenerative meniscal tear. CONCLUSION: Arthroscopic partial meniscectomy combined with medical exercise therapy is effective in reducing pain and improving range of motion in the early postoperative period. Therefore, arthroscopic partial meniscectomy combined with medical exercise therapy may be recommended for the treatment of degenerative meniscal tear. Further research is necessary to determine the type, frequency, and duration of the best exercise program. Systematic review registration number: Reviewregistry884.


Assuntos
Artroscopia/métodos , Terapia por Exercício/métodos , Meniscectomia/métodos , Lesões do Menisco Tibial/terapia , Adulto , Artroscopia/efeitos adversos , Terapia Combinada , Humanos , Meniscectomia/efeitos adversos , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto
10.
Acta Orthop Belg ; 86(1): 162-165, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32490788

RESUMO

Heterotopic ossification is a well-known complication after orthopaedic surgical procedures, with a pre-dilection of the hip and elbow. Heterotopic ossification is a rare complication after shoulder arthroscopy and is rarely clinically significant. We report a case of a 65-year old Caucasian man with a slow and painful recovery after arthroscopic shoulder surgery encompassing rotator cuff repair, biceps tenotomy and acromioplasty, with recurrence of impingement symptoms unresponsive to conservative therapy (physiotherapy and one sub- acromial injection). He developed a severe heterotopic ossification at the acromial insertion of the deltoid and in the coraco-acromial ligament. This was successfully treated by arthroscopic excision of the lesion and postoperative prophylactic therapy with nonsteroidal anti-inflammatory drugs.


Assuntos
Articulação Acromioclavicular/cirurgia , Artroscopia/efeitos adversos , Ossificação Heterotópica/etiologia , Ossificação Heterotópica/terapia , Complicações Pós-Operatórias/terapia , Lesões do Manguito Rotador/cirurgia , Idoso , Anti-Inflamatórios não Esteroides/uso terapêutico , Terapia Combinada , Humanos , Masculino , Ombro/cirurgia , Tenotomia
11.
Ann R Coll Surg Engl ; 102(6): 408-411, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32538097

RESUMO

INTRODUCTION: Axillary nerve injury is a major complication of shoulder surgery during glenoid exposure. The aim of this study was to measure the mean distance between the inferior glenoid and the axillary nerve in healthy shoulders and then to compare this distance between osteoarthritic and rotator cuff deficient glenohumeral joints. METHODS: The magnetic resonance images of 50 patients with normal glenohumeral joints were reviewed. The infra-glenoid tubercle was determined as a fixed point and the distance to the axillary nerve was measured. Two separate assessors measured on the same sagittal sections. With a study power of 80%, the sample needed in each comparison group was 28 patients. Measurements were then performed on scans in patients with osteoarthritis and cuff tear arthropathy. The mean distance was compared between groups. RESULTS: The mean distance between the infra-glenoid tubercle and axillary nerve was 12mm (standard deviation, SD, 5.6mm) in normal shoulders, 10.6mm (SD 5.4mm) in shoulders with osteoarthritis and 9.7mm (SD 3.7mm) in those with cuff tear arthropathy. For this sample size of 50 patients with a confidence interval of 95%, the mean range is 12mm (95% CI 10.4-13.6). A comparison between normal shoulder and osteoarthritis showed a p-value of 0.3, and between normal and cuff tear arthropathy a p-value of 0.06. This was not statistically significant. CONCLUSIONS: The axillary nerve lies on average 12mm from the infra-glenoid tubercle. The presence of inferior osteophytes in glenohumeral osteoarthritis and the proximal migration of humeral head in cuff tear arthropathy does not seem to alter the course of the nerve significantly in relation to the inferior glenoid tubercle.


Assuntos
Artroscopia/efeitos adversos , Cavidade Glenoide/inervação , Osteoartrite/diagnóstico por imagem , Traumatismos dos Nervos Periféricos/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Lesões do Manguito Rotador/diagnóstico por imagem , Adulto , Cavidade Glenoide/diagnóstico por imagem , Humanos , Imagem por Ressonância Magnética , Osteoartrite/cirurgia , Traumatismos dos Nervos Periféricos/etiologia , Complicações Pós-Operatórias/etiologia , Lesões do Manguito Rotador/cirurgia , Articulação do Ombro/diagnóstico por imagem , Articulação do Ombro/inervação , Articulação do Ombro/cirurgia
12.
J Am Acad Orthop Surg ; 28(13): 538-545, 2020 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-32574474

RESUMO

There has been an exponential increase in the diagnosis and treatment of patients with femoroacetabular impingement, leading to a rise in the number of hip arthroscopies done annually. Despite reliable pain relief and functional improvements after hip arthroscopy in properly indicated patients, and due to these increased numbers, there is a growing number of patients who have persistent pain after surgery. The etiology of these continued symptoms is multifactorial, and clinicians must have a fundamental understanding of these causes to properly diagnose and manage these patients. Factors contributing to failure after surgery include those related to the patient, the surgeon, and the postoperative physical therapy. This review highlights common causes of failure, including those related to residual bony deformity as well as capsular deficiency, and provides a framework for diagnosis and treatment of these patients.


Assuntos
Artroscopia/efeitos adversos , Artroscopia/métodos , Impacto Femoroacetabular/cirurgia , Articulação do Quadril/cirurgia , Dor Pós-Operatória/etiologia , Lesões do Manguito Rotador/cirurgia , Falha de Tratamento , Acetábulo/cirurgia , Impacto Femoroacetabular/diagnóstico , Impacto Femoroacetabular/diagnóstico por imagem , Humanos , Manejo da Dor , Dor Pós-Operatória/diagnóstico , Seleção de Pacientes , Cuidados Pós-Operatórios
13.
J Shoulder Elbow Surg ; 29(7): 1310-1315, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32553436

RESUMO

BACKGROUND: We investigated the effectiveness of cocktail therapy after arthroscopic rotator cuff repair (ARCR). METHODS: We evaluated 128 shoulders undergoing ARCR and used block randomization to divide patients into 2 groups in this double-blind trial: The cocktail group received 20 mL of 0.75% ropivacaine, 5 mg of morphine, 0.3 mg of epinephrine, 2 mg of betamethasone, and saline solution to a total of 42 mL, whereas the control group received 20 mL of 0.75% ropivacaine and saline solution to a total of 42 mL. Postoperatively, one of the drug mixtures was injected into the glenohumeral joint, subacromial bursa, suprascapular nerve, and anterior, middle, and posterior parts of the deltoid muscle according to the treatment group. We recorded patients' visual analog scale scores preoperatively and at 4, 8, 16, 24, and 48 hours postoperatively; the number of patients using postoperative diclofenac suppositories and buprenorphine hydrochloride; the number of patients experiencing nausea; the number of patients with infection and delayed wound healing as adverse effects; the surgery time; the retear rate; and passive shoulder range of motion. RESULTS: The cocktail group constituted 64 shoulders (50.0%), with 39 men (60.9%) and 25 women (39.1%); the mean age was 64.2 ± 10.2 years. The control group constituted 64 shoulders (50.0%), with 41 men (64.1%) and 23 women (35.9%); the mean age was 65.2 ± 7.5 years. We found no significant difference in age or sex between the 2 groups. There was also no significant difference in rotator cuff tear size or surgery time between the 2 groups. The visual analog scale scores at 8, 16, and 24 hours postoperatively were significantly lower in the cocktail group. The number of patients using suppositories was also significantly lower in the cocktail group. The number of patients receiving buprenorphine injections tended to be lower in the cocktail group, but the difference was not significant. Nausea occurred in 6.3% of patients in the cocktail group and 15.6% in the control group, but the difference was not significant. No infection or delayed wound healing occurred in either group. There was no significant difference in the retear rate between the 2 groups. Passive anterior elevation at 3 months postoperatively was significantly better in the cocktail group than in the control group. CONCLUSION: We compared cocktail therapy and ropivacaine after ARCR and found no difference in results except for VAS score at 8, 16, and 24 hours postoperatively and frequency of postoperative suppository use without an apparent risk of infection or a detrimental effect on tendon healing.


Assuntos
Anestésicos Locais/uso terapêutico , Artroscopia/efeitos adversos , Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Ropivacaina/uso terapêutico , Lesões do Manguito Rotador/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Analgésicos Opioides/uso terapêutico , Anestésicos Locais/administração & dosagem , Anti-Inflamatórios não Esteroides/uso terapêutico , Betametasona/uso terapêutico , Buprenorfina/uso terapêutico , Diclofenaco/uso terapêutico , Método Duplo-Cego , Quimioterapia Combinada , Epinefrina/uso terapêutico , Feminino , Humanos , Injeções Intra-Articulares , Injeções Intramusculares , Masculino , Pessoa de Meia-Idade , Morfina/uso terapêutico , Náusea/etiologia , Bloqueio Nervoso , Duração da Cirurgia , Amplitude de Movimento Articular , Recidiva , Ropivacaina/administração & dosagem , Articulação do Ombro , Infecção da Ferida Cirúrgica/etiologia , Vasoconstritores/uso terapêutico , Cicatrização
14.
Medicine (Baltimore) ; 99(19): e20141, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32384496

RESUMO

OBJECTIVE: Femoroacetabular impingement (FAI) is a common cause of hip pain and even tearing of the acetabular labrum in young adults and athletes. Either arthroscopic labral debridement (LD) or labral repair (LR) technique for FAI patients is needed to choose. We conducted this systematic review and meta-analysis to compare the clinical outcomes of arthroscopic LD versus LR intervention. METHODS: The five studies were acquired from PubMed, Medline, Embase, and Cochrane Library. The data were extracted by two of the coauthors independently and were analyzed by RevMan5.3. Mean differences (MDs), odds ratios (ORs), and 95% confidence intervals (CIs) were calculated. Cochrane Collaboration's Risk of Bias Tool and Newcastle-Ottawa Scale were used to assess risk of bias. RESULTS: Four observational studies and one prospective randomized study were assessed. The methodological quality of the trials indicated a low to moderate risk of bias. The pooled results of Non-Arthritic Hip Score (NAHS), failure rate of surgeries and complications showed that the differences were not statistically significant between the two interventions. The difference of modified Harris Hip Score (mHHS), the Visual Analogue Scale (VAS) score and satisfaction rate was statistically significant between LD and LR intervention, and LR treatment was more effective. Sensitivity analysis proved the stability of the pooled results and there were too less included articles to verify the publication bias. CONCLUSIONS: Hip arthroscopy with either LR or LD is an effective treatment for symptomatic FAI. The difference of mHHS, VAS score, and satisfaction rate was statistically significant between LD and LR intervention, and arthroscopic LR could re-create suction-seal effect, potentially reduce microinstability, which demonstrated a trend toward better clinical efficacy and comparable safety compared with LD. The arthroscopic LR technique is recommended as the optical choice for acetabular labrum tear with FAI.


Assuntos
Artroscopia/métodos , Desbridamento/métodos , Impacto Femoroacetabular/cirurgia , Fibrocartilagem/cirurgia , Adulto , Artroscopia/efeitos adversos , Desbridamento/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Complicações Pós-Operatórias/epidemiologia
15.
Tunis Med ; 98(2): 156-160, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32395806

RESUMO

BACKGROUND: The practice of hypnoanalgesia in orthopedics is rare and the literature is poor. AIM: The purpose of this pilot study was to verify the efficacy of hypnosis for the management of postoperative analgesia after arthroscopic repair of anterior cruciate ligament. METHODS: This was a prospective clinical trial over a period of 6 months (March - August 2015) including 25 patients scheduled for arthroscopic repair of anterior cruciate ligament under spinal anesthesia. All these patients had preoperative hypnosis in addition to the standard multimodal analgesia protocol (group H) and were compared to historical group (group S) who received only a standard multimodal analgesia protocol. RESULTS: Pain scores were significantly lower for the hypnosis group during the first 48 hours postoperatively (p = 0,006). The total dose of morphine at 48 hours was: 13,6 mg (95% CI [4,58; 22,62]) in the group H and 10,2 mg (95% CI [1,64 ; 18,76]) in group S with no statistically significant difference (p = 0,178) Conclusion: Results of this pilot study in orthopedic surgery suggested that hypnosis reduced postoperative pain scores as demonstrated in other surgeries.


Assuntos
Reconstrução do Ligamento Cruzado Anterior , Ligamento Cruzado Anterior/cirurgia , Artroscopia , Hipnose , Manejo da Dor/métodos , Dor Pós-Operatória/prevenção & controle , Cuidados Pré-Operatórios/métodos , Analgesia/métodos , Anestesia Epidural/métodos , Lesões do Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior/efeitos adversos , Reconstrução do Ligamento Cruzado Anterior/métodos , Artroscopia/efeitos adversos , Artroscopia/métodos , Terapia Combinada/métodos , Estudo Historicamente Controlado , Humanos , Hipnose/estatística & dados numéricos , Manejo da Dor/efeitos adversos , Medição da Dor , Dor Pós-Operatória/etiologia , Projetos Piloto , Resultado do Tratamento
16.
Cochrane Database Syst Rev ; 5: CD005259, 2020 05 06.
Artigo em Inglês | MEDLINE | ID: mdl-32374919

RESUMO

BACKGROUND: Knee arthroscopy (KA) is a routine orthopedic procedure recommended to repair cruciate ligaments and meniscus injuries and in eligible patients, to assist the diagnosis of persistent knee pain. KA is associated with a small risk of thromboembolic events. This systematic review aims to assess if pharmacological or non-pharmacological interventions may reduce this risk. This review is the second update of the review first published in 2007. OBJECTIVES: To assess the efficacy and safety of interventions, whether mechanical, pharmacological, or in combination, for thromboprophylaxis in adult patients undergoing KA. SEARCH METHODS: For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, the CENTRAL, MEDLINE, Embase and CINAHL databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registries, on 14 August 2019. SELECTION CRITERIA: We included randomized controlled trials (RCTs) and controlled clinical trials (CCTs), whether blinded or not, of all types of interventions used to prevent deep vein thrombosis (DVT) in males and females aged 18 years and older undergoing KA. There were no restrictions on language or publication status. DATA COLLECTION AND ANALYSIS: Two authors independently selected studies for inclusion, assessed trial quality with the Cochrane 'Risk of bias' tool, and extracted data. A third author addressed discrepancies. We contacted study authors for additional information when required. We used GRADE to assess the certainty of the evidence. MAIN RESULTS: This update adds four new studies, bringing the total of included studies to eight and involving 3818 adult participants with no history of thromboembolic disease undergoing KA. Studies compared daily subcutaneous (sc) low-molecular-weight heparin (LMWH) versus control (five studies); oral rivaroxaban 10 mg versus placebo (one study); daily sc LMWH versus graduated compression stockings (GCS) (one study); and aspirin versus control (one study). The incidence of pulmonary embolism (PE) in all trials combined was low, with seven cases in 3818 participants.There were no deaths in any of the intervention or control groups. LMWH versus control When compared with control, LMWH probably results in little to no difference in the incidence of PE in patients undergoing KA (risk ratio (RR) 1.81, 95% confidence interval (CI) 0.49 to 6.65; 1820 participants; 3 studies; moderate-certainty evidence). LMWH showed no reduction of the incidence of symptomatic DVT (RR 0.61, 95% CI 0.18 to 2.03; 1848 participants; 4 studies; moderate-certainty evidence). LMWH may reduce the risk of asymptomatic DVT but the evidence is very uncertain (RR 0.14, 95% CI 0.03 to 0.61; 369 participants; 2 studies; very low-certainty evidence). There was no evidence of an increased risk of all adverse events combined (RR 1.85, 95% CI 0.95 to 3.59; 1978 participants; 5 studies; moderate-certainty evidence). No evidence of a clear effect on major bleeding (RR 0.98, 95% CI 0.06 to 15.72; 1451 participants; 1 study; moderate-certainty evidence), or minor bleeding was observed (RR 1.79, 95% CI 0.84 to 3.84; 1978 participants; 5 studies; moderate-certainty evidence). Rivaroxaban versus placebo One study with 234 participants compared oral rivaroxaban 10 mg versus placebo. No evidence of a clear impact on the risk of PE (no events in either group), symptomatic DVT (RR 0.16, 95% CI 0.02 to 1.29; moderate-certainty evidence); or asymptomatic DVT (RR 0.95, 95% CI 0.06 to 15.01; very low-certainty evidence) was detected. Only bleeding adverse events were reported. No major bleeds occurred in either group and there was no evidence of differences in minor bleeding between the groups (RR 0.63, 95% CI 0.18 to 2.19; moderate-certainty evidence). Aspirin versus control One study compared aspirin with control. No PE, DVT or asymptomatic events were detected in either group. Adverse events including pain and swelling were reported but it was not clear what groups these were in. No bleeds were reported. LMWH versus GCS One study with 1317 participants compared the use of LMWH versus GCS. There was no clear difference in the risk of PE (RR 1.00, 95% CI 0.14 to 7.05; low-certainty evidence). LMWH use did reduce the risk of DVT compared to people using GCS (RR 0.17, 95% CI 0.04 to 0.75; low-certainty evidence). No clear difference in effects was seen between the groups for asymptomatic DVT (RR 0.47, 95% CI 0.21 to 1.09; very low-certainty evidence); major bleeding (RR 3.01, 95% CI 0.61 to 14.88; moderate-certainty evidence) or minor bleeding (RR 1.16, 95% CI 0.64 to 2.08; moderate-certainty evidence). Levels of thromboembolic events were higher in the GCS group than in any other group. We downgraded the certainty of the evidence for imprecision resulting from overall small event numbers; risk of bias due to concerns about lack of blinding, and indirectness as we were uncertain about the direct clinical relevance of asymptomatic DVT detection. AUTHORS' CONCLUSIONS: There is a small risk that healthy adult patients undergoing KA will develop venous thromboembolism (PE or DVT). There is moderate- to low-certainty evidence of no benefit from the use of LMWH, aspirin or rivaroxaban in reducing this small risk of PE or symptomatic DVT. There is very low-certainty evidence that LMWH use may reduce the risk of asymptomatic DVT when compared to no treatment but it is uncertain how this directly relates to incidence of DVT or PE in healthy patients. No evidence of differences in adverse events (including major and minor bleeding) was seen, but data relating to this were limited due to low numbers of events in the studies reporting within the comparisons.


Assuntos
Anticoagulantes/uso terapêutico , Artroscopia/efeitos adversos , Heparina de Baixo Peso Molecular/uso terapêutico , Articulação do Joelho/cirurgia , Complicações Pós-Operatórias/prevenção & controle , Trombose Venosa/prevenção & controle , Adulto , Anticoagulantes/efeitos adversos , Aspirina/administração & dosagem , Aspirina/efeitos adversos , Inibidores do Fator Xa/administração & dosagem , Inibidores do Fator Xa/efeitos adversos , Hemorragia/induzido quimicamente , Heparina de Baixo Peso Molecular/efeitos adversos , Humanos , Complicações Pós-Operatórias/induzido quimicamente , Embolia Pulmonar/prevenção & controle , Ensaios Clínicos Controlados Aleatórios como Assunto , Rivaroxabana/administração & dosagem , Rivaroxabana/efeitos adversos , Meias de Compressão
17.
Sports Health ; 12(3): 225-233, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32271136

RESUMO

CONTEXT: The prescription of opioids after elective surgical procedures has been a contributing factor to the current opioid epidemic in North America. OBJECTIVE: To examine the opioid prescribing practices and rates of opioid consumption among patients undergoing common sports medicine procedures. DATA SOURCES: A systematic review of the electronic databases EMBASE, MEDLINE, and PubMed was performed from database inception to December 2018. STUDY SELECTION: Two investigators independently identified all studies reporting on postoperative opioid prescribing practices and consumption after arthroscopic shoulder, knee, or hip surgery. A total of 119 studies were reviewed, with 8 meeting eligibility criteria. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: The quantity of opioids prescribed and used were converted to milligram morphine equivalents (MMEs) for standardized reporting. The quality of each eligible study was evaluated using the Methodological Index for Non-Randomized Studies. RESULTS: A total of 8 studies including 816 patients with a mean age of 43.8 years were eligible for inclusion. A mean of 610, 197, and 613 MMEs were prescribed to patients after arthroscopic procedures of the shoulder, knee, and hip, respectively. At final follow-up, 31%, 34%, and 64% of the prescribed opioids provided after shoulder, knee, and hip arthroscopy, respectively, still remained. The majority of patients (64%) were unaware of the appropriate disposal methods for surplus medication. Patients undergoing arthroscopic rotator cuff repair had the highest opioid consumption (471 MMEs), with 1 in 4 patients receiving a refill. CONCLUSION: Opioids are being overprescribed for arthroscopic procedures of the shoulder, knee, and hip, with more than one-third of prescribed opioids remaining postoperatively. The majority of patients are unaware of the appropriate disposal techniques for surplus opioids. Appropriate risk stratification tools and evidence-based recommendations regarding pain management strategies after arthroscopic procedures are needed to help curb the growing opioid crisis.


Assuntos
Analgésicos Opioides/uso terapêutico , Traumatismos em Atletas/cirurgia , Dor Pós-Operatória/tratamento farmacológico , Padrões de Prática Médica , Uso Excessivo de Medicamentos Prescritos , Artroscopia/efeitos adversos , Lesões do Quadril/cirurgia , Humanos , Traumatismos do Joelho/cirurgia , Manejo da Dor/métodos , Lesões do Ombro/cirurgia
18.
J Am Acad Orthop Surg ; 28(17): 730-736, 2020 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-32324708

RESUMO

INTRODUCTION: Musculoskeletal injury can substantially affect orthopaedic surgeons and productivity. The objective of this study was to assess occupation-related neck pain and cervical radiculopathy/myelopathy among orthopaedic surgeons and to identify the potential risk factors for injury. METHODS: An online survey was sent to orthopaedic surgeons via their state orthopaedic society. The survey consisted of items related to orthopaedic practices, such as the number of arthroscopic procedures done and the use of microscopes/loupes. The prevalence, potential causes, and reporting practices of neck pain and cervical radiculopathy/myelopathy among orthopaedic surgeons were also assessed. RESULTS: There were 685 responses from surgeons representing 27 states. A total of 59.3% of respondents reported neck pain and 22.8% reported cervical radiculopathy. After adjusting for age and sex, surgeons performing arthroscopy had an odds ratio of 3.3 (95% confidence interval: 1.4 to 8.3, P = 0.007) for neck pain. Only five of the surgeons with neck pain and one of the surgeons with cervical radiculopathy/myelopathy had ergonomic evaluations. CONCLUSION: Neck pain and cervical radiculopathy/myelopathy are common among orthopaedic surgeons. Associated factors included older age, higher stress levels, and performing arthroscopy. Cervical injuries are rarely reported, and ergonomic workplace evaluations are infrequent.


Assuntos
Cervicalgia/epidemiologia , Doenças Profissionais/epidemiologia , Cirurgiões Ortopédicos/estatística & dados numéricos , Radiculopatia/epidemiologia , Doenças da Medula Espinal/epidemiologia , Adulto , Fatores Etários , Artroscopia/efeitos adversos , Artroscopia/estatística & dados numéricos , Vértebras Cervicais , Ergonomia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cervicalgia/etiologia , Doenças Profissionais/etiologia , Radiculopatia/etiologia , Fatores de Risco , Doenças da Medula Espinal/etiologia , Inquéritos e Questionários , Local de Trabalho
19.
Medicine (Baltimore) ; 99(16): e19417, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32311920

RESUMO

INTRODUCTION: The impact of dexamethasone on pain management for knee arthroscopy remains controversial. We conduct a systematic review and meta-analysis to explore the influence of dexamethasone for knee arthroscopy. METHODS: We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through October 2018 for randomized controlled trials (RCTs) assessing the effect of dexamethasone on pain intensity for patients with dental implant. This meta-analysis is performed using the random-effect model. RESULTS: Four RCTs involving 228 patients are included in the meta-analysis. Overall, compared with control group for knee arthroscopy, dexamethasone supplementation has no notable effect on pain scores at 4 to 6 hours (Std. MD = 0.99; 95% CI = -2.97 to 4.95; P = .62), but exerts significantly favorable promotion to pain scores at 12 hours (Std. MD = -1.06; 95% CI = -1.43 to -0.69; P < .00001), duration of block (Std. MD = 1.87; 95% CI = 0.65 to 3.10; P = .003), time to first analgesic requirement (Std. MD = 0.90; 95% CI = 0.51 to 1.29; P < .00001), analgesic consumption (Std. MD = -1.62; 95% CI = -2.31 to -0.93; P < .00001), and patient satisfaction (Std. MD = 1.15; 95% CI = 0.73 to 1.58; P < .00001). CONCLUSIONS: Dexamethasone supplementation has importantly positive influence on pain control for knee arthroscopy.


Assuntos
Anti-Inflamatórios/uso terapêutico , Dexametasona/uso terapêutico , Bloqueio Nervoso , Dor Pós-Operatória/tratamento farmacológico , Analgésicos/uso terapêutico , Artroscopia/efeitos adversos , Humanos , Articulação do Joelho/cirurgia , Manejo da Dor/métodos , Medição da Dor , Dor Pós-Operatória/etiologia , Satisfação do Paciente , Ensaios Clínicos Controlados Aleatórios como Assunto
20.
Ann R Coll Surg Engl ; 102(6): e136-e140, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32326733

RESUMO

Acromioclavicular joint injuries are common and account for up to 12% of all shoulder girdle injuries and have been reported as being as high as 50% in sports-related shoulder injuries. While the majority of acromioclavicular joint dislocations can be treated non-operatively, there are certain injury configurations, which can include high-grade dislocations in overhead athletes, where surgery may be indicated. The surgical management of acromioclavicular joint instability has moved towards recreating the action of the coracoclavicular ligaments by resuspending the clavicle on to the coracoid. Multiple techniques using high-strength sutures, synthetic ligaments, tendon allografts or autografts passed either around or through the coracoid process have been described. However, an unusual, but significant, complication associated with these techniques is an iatrogenic fracture of the coracoid process. We report the case of a patient with an iatrogenic coracoid fracture following two failed acromioclavicular joint resuspensory reconstructions using a synthetic ligament. This injury was successfully treated with an autologous hamstring graft reconstruction, initially protected with a hook plate.


Assuntos
Articulação Acromioclavicular/cirurgia , Fraturas Ósseas/cirurgia , Luxações Articulares/cirurgia , Complicações Pós-Operatórias/cirurgia , Reoperação/métodos , Adulto , Artroscopia/efeitos adversos , Artroscopia/instrumentação , Artroscopia/métodos , Placas Ósseas , Processo Coracoide/lesões , Processo Coracoide/cirurgia , Tendões dos Músculos Isquiotibiais/transplante , Humanos , Masculino , Procedimentos Cirúrgicos Reconstrutivos/efeitos adversos , Procedimentos Cirúrgicos Reconstrutivos/instrumentação , Procedimentos Cirúrgicos Reconstrutivos/métodos , Recidiva , Reoperação/instrumentação , Transplante Autólogo/métodos , Resultado do Tratamento
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