Histología del bíceps en pacientes con tendinopatía crónica tratados con tenodesis subpectoral / Histology of the biceps in patients with chronic tendinitis treated with subpectoral tenodesis

Introducción: El objetivo de este estudio fue evaluar los cambios morfológicos en la zona intrarticular y extrarticular de la porción larga del bíceps de pacientes sometidos a una tenodesis subpectoral.materiales y métodos: Se incluyeron 9 pacientes con diag-nóstico de tendinopatía del bíceps, a quienes se les realizó una tenodesis subpectoral de la porción larga del bíceps. La porción eliminada del tendón del bíceps se colocó en formalina al 10% y se dividió en 2 segmentos. Quedaron definidas la zona proximal, desde la inserción supraglenoidea hasta el borde proximal del pectoral mayor y la zona distal correspondiente a la inserción del pectoral mayor. Los segmentos se tiñeron con hematoxilina y eosina, y se evaluaron histológicamente utilizando el puntaje de Bo-nar.Resultados: Macroscópicamente todos los tendones estaban engrosados en la región proximal. En la evaluación histológica, entre las variables más relevantes evaluadas por el puntaje de Bonar, el puntaje de morfología celular en la zona proximal fue significativamente más alto que en la zona distal (p <0,0001).Conclusiones: Nuestros hallazgos mostraron niveles más altos de patología dentro del bíceps proximal, lo que respalda la eliminación de dicho segmento cuando se realiza un procedimiento para la tendinopatía crónica del bíceps, lo cual se puede lograr con una tenodesis subpectoral. Nivel de Evidencia: IV

Introduction: The objective of the present study was to evaluate the morphological changes in the intra- and extra-articular area of the long head of the biceps in patients who had undergone subpectoral tenodesis. methods: We included 9 patients with a diagnosis of biceps tendinitis, who underwent subpectoral tenodesis of the long head of the biceps. The removed portion of the biceps tendon was placed in 10% formalin and divided into 2 segments. The proximal area extended from the supraglenoid insertion to the proximal edge of the pectoralis major and the distal area corresponded to the insertion of the pectoralis major. The segments were histologically evaluated using the Bonar score. Results: Macroscopically, all the tendons were found to be thickened in the proximal region. In the histological evaluation, among the most relevant variables evaluated by the Bonar score, the cell morphology score in the proximal area was significantly higher than in the distal area (p <0.0001). Conclusion: Our findings showed higher levels of pathology within the proximal biceps, supporting the elimination of this segment for chronic biceps tendinopathy, which can be accomplished through subpectoral tenodesis. Level of Evidence: IV

Evaluation of the Functional Outcomes of Arthroscopic Surgical Treatment of Complete Rotator Cuff Lesion with Minimum Follow-up of 10 Years / Avaliação dos resultados funcionais do tratamento cirúrgico artroscópico da lesão completa do manguito rotador com seguimento mínimo de 10 anos

Abstract Objectives To analyze the functional outcomes in patients submitted to videoarthroscopic surgical treatment for compleat rotator cuff tears of the shoulder, with a minimum follow-up of 10 years. Methods A total of 63 patients (63 shoulders) underwent videoarthroscopic surgical repair for compleat rotator cuff tears with a minimum follow-up of 10 years. The postoperative functional outcomes of these patients were evaluated using the Constant and University of California at Los Angeles (UCLA) scores. Results The functional evaluation revealed mean UCLA and Constant scores of 26 and 93 points, respectively. Ninety-one percent of the subjects had satisfactory Constant scores, whereas 62% presented satisfactory UCLA scores. Conclusion The arthroscopic repair of rotator cuff complete tear was effective even in the long term (minimum follow-up period of 10 years). The age of the patients before surgery, size of the lesion, the degree of fatty infiltration, and evaluation of muscle trophism are important predictors of prognosis.

Resumo Objetivo Analisar o resultado funcional dos pacientes submetidos ao tratamento cirúrgico videoartroscópico da ruptura completa do manguito rotador do ombro, com seguimento mínimo de 10 anos. Métodos Foram avaliados 63 pacientes (63 ombros) submetidos ao reparo cirúrgico videoartroscópico da ruptura completa do manguito rotador com seguimento mínimo de 10 anos. O resultado funcional no pós-operatório desses pacientes foi avaliado pelos escores de Constant e UCLA. Resultados Os valores médios foram de 26 pontos no escore UCLA e de 93 no escore de Constant. Para o escore de Constant, 91% foram considerados satisfatórios; e para o UCLA, 62% dos pacientes apresentaram escores satisfatórios. Conclusão O reparo artroscópico da ruptura completa do manguito rotador mostrou-se efetivo mesmo a longo prazo (seguimento mínimo de dez anos). A idade dos pacientes antes da cirurgia, o tamanho da lesão, o grau de infiltração gordurosa e a avaliação do trofismo muscular foram importantes preditores de prognóstico.

Efficacy of ultrasound guided suprascapular block in patients with chronic shoulder pain: observational, retrospective study / Eficácia do bloqueio do nervo supraescapular guiado por ultrassom em pacientes com dor crônica no ombro: estudo observacional retrospectivo

Abstract Introduction: Painful shoulder syndrome is a frequent condition among the elderly and an important cause of functional disability. As the conservative treatment is not always effective, ultrasound guided suprascapular nerve blockade presents as an important alternative treatment. Objective: To evaluate the efficacy and safety of the use of 0.25% levobupivacaine and 40 mg of triamcinolone in the suprascapular nerve blockade in patients with chronic pain in the shoulder. Methods: A retrospective, descriptive and analytical study of 71 patients submitted to suprascapular nerve infiltration between August 2014 and March 2017. Surveys were carried out to patients before the technique was performed, after 72 hours and at 1, 3 and 6 months. Pain intensity was assessed using a numeric pain scale (NPS). Results: Out of the 71 patients who underwent a blockade of the suprascapular nerve, 81.2% reported a decrease in pain at 72 hours. In the first, third and sixth month, respectively, 89.8%, 76.1% and 61.8% of the patients presented pain relief. A statistically significant difference (p < 0.001) was verified between NPS and the 4 moments assessed after the technique. 43.7% had total pain remission (NPS = 0) at six months. Global effectiveness of suprascapular nerve blockade was 60.6% and for the subgroup of patients with rotators' cuff patology was 62.2%. No complications were reported regarding the suprascapular nerve block. Conclusion: The results show that ultrasound-guided blockade of the suprascapular nerve using 0.25% levobupivacaine and 40 mg of triamcinolone is a safe and effective treatment in patients with chronic shoulder pain.

Resumo Introdução: A síndrome do ombro doloroso é uma condição frequente entre os idosos e uma causa importante de incapacidade funcional na população em geral. O tratamento conservador nem sempre é eficaz, pelo que o bloqueio do nervo supraescapular guiado por ecografia apresenta-se como uma opção de tratamento válida. Objetivo: Avaliação da eficácia e segurança do uso de levobupivacaína a 0,25% e 40 mg de triancinolona no bloqueio do nervo supraescapular ecoguiado em doentes com dor crônica no ombro. Métodos: Realizou-se um estudo retrospectivo observacional, descritivo e analítico com 71 doentes submetidos à infiltração do nervo supraescapular entre agosto de 2014 e março de 2017. Foram aplicados questionários antes da realização da técnica, após 72 horas; 1, 2 e 6 meses. A intensidade da dor foi avaliada usando a Escala de Avaliação Numérica (EAN). Resultados: Dos 71 doentes submetidos ao bloqueio do nervo supraescapular; 81,2% referiram diminuição da dor às 72 horas. Aos primeiro, terceiro e sexto mês, respectivamente 89,8%; 76,1% e 61,8% apresentaram melhoria da dor. Verificou-se uma diferença estatisticamente significativa (p < 0,001), entre a EAN inicial e os 4 momentos após a realização da técnica. 43,7% dos doentes tiveram remissão total da dor (EAN = 0) aos seis meses. A eficácia global do bloqueio do nervo supraescapular foi de 60,6% e, para o subgrupo com patologia da coifa dos rotadores, de 62,2%. Nenhuma complicação do bloqueio do NSE foi registrada. Conclusão: Este estudo mostra que o bloqueio eco-guiado do NSE usando levobupivacaína a 0,25% e 40 mg de triancinolona é um procedimento seguro e eficaz em doentes com dor crônica no ombro.

Outcomes after rotator cuff repair in the elderly as assessed by the American Shoulder and Elbow Surgeons shoulder score

Rotator cuff tears are common among the elderly, and studies on the outcomes after rotator cuff repair in the elderly are limited. We carried out this meta-analysis with systematic literature search, aiming to clarify the outcomes after rotator cuff repair in the elderly as assessed by the American Shoulder and Elbow Surgeons (ASES) shoulder score. We conducted a literature search through October 2019 in PubMed and EMBASE databases and performed meta-analysis to calculate the summary mean difference comparing the post- and pre-operation ASES scores under both fixed-effect and random-effect models. Among 4978 studies identified through literature search, four studies (two in the United States, one in France, and one in Republic of Korea) were eligible for the meta-analysis, including 282 patients who were aged over 70 years. These studies had low heterogeneity as measured by Cochran's Q test (p=0.88) and I2 statistic (0%). The ASES scores on average increased by 39.7 (95% confidence interval 28.3-51.1, p<0.001) after rotator cuff repair, in both fixed-effect and random-effect models. No substantial publication bias was indicated. Our findings suggest improved outcomes after rotator cuff repair in the elderly population as measured by the ASES score, and such improvements have been consistent in previous studies.

¿Es útil la monitorización con espectroscopia de infrarojo cercano en la cirugía artroscópica de hombro con anestesia regional y sedación? / Is near-infrared spectroscopy (NIRS) monitoring useful for patients undergoing shoulder surgery under regional anaesthesia and sedation?

BACKGROUND: Shoulder surgery in beach chair position is a very common procedure in our daily practice. It has been associated to regional cerebral saturation impairment detected by near-infrared spectroscopy (NIRS) under general anaesthesia. Severe neurological complications were previously reported, even in previously healthy patients. An anaesthetic protocol under regional anaesthesia and biespectral index (BIS) guided sedation seems to be a safer strategy in order to prevent complications. OBJECTIVE: To find out, in a group of patients undergoing shoulder surgery in beach chair position under regional anaesthesia and sedation, the prevalence of cerebral desaturation events detected by NIRS (defined as a decrease ≥ 20% from baseline or absolute value < 55%). MATERIAL AND METHOD: In this descriptive study, 30 patients undergoing shoulder surgery in beach chair position under regional anaesthesia (ultrasound guided interescalene brachial plexus block) and propofol infusion BIS guided sedation were enrolled to assess the prevalence of cerebral desaturation events. The baseline data for regional cerebral oxygen saturation and bispectral index and non invasive blood pressure measured at heart level were taken prior to surgery after beach chair positioning and thereafter all 5 min until discharge. RESULTS: No cerebral desaturation events were detected during this study. CONCLUSIONS: Although monitoring regional cerebral saturation with NIRS detects decreased cerebral perfusion allowing a rapid intervention, we consider it is not essential under this anaesthesia regimen, considering that no cerebral desaturation events were reported.

La cirugía de hombro en posición de sentado constituye un procedimiento frecuente en la práctica diaria. Bajo anestesia general, se ha asociado con caída de la saturación regional cerebral de oxígeno (Src02) detectada por espectrospcopia infraroja (NIRS), reportándose complicaciones neurológicas severas, incluso en pacientes previamente sanos. El empleo de una técnica de anestesia regional más sedación titulada con índice biespectral (BIS) parecería ser una estrategia más segura a fin de evitar dichos eventos. OBJETIVO: Conocer, en pacientes sometidos a artroscopia de hombro en posición de sentado bajo anestesia regional más sedación, la prevalencia de episodios de desaturación cerebral (ECDs) determinada por NIRS (SrcO2 inferior a 55% o disminución del 20% respecto al basal). MATERIAL Y MÉTODO: Se realizó un estudio descriptivo en 30 pacientes sometidos a artroscopía de hombro en posición de sentado bajo anestesia regional (bloqueo interescalénico ecoguiado) más sedación titulada (infusión de propofol guiada por BIS). Se tomaron valores de referencia de Src02, BIS y presión no invasiva a nivel del corazón luego del posicionamiento y, consecutivamente en forma continua para las primeras dos variables y cada 5 minutos hasta el final para la última. Se ocultaron a los anestesiólogos los valores de Src02. RESULTADOS: No se ha detectado ningún EDC en la población estudiada. CONCLUSIÓN: Consideramos que el monitoreo de la perfusión cerebral con tecnología NIRS resulta útil aunque no imprescindible bajo este protocolo anestésico, dada la incidencia casi nula de eventos.

Rotator cuff repair in the Brazilian Unified Health System: Brazilian trends from 2003 to 2015 / Reparo do manguito rotador no Sistema Único de Saúde: tendência brasileira de 2003 a 2015

ABSTRACT OBJECTIVE: To assess the historical trend of rotator cuff repairs in Brazil between 2003 and 2015, using the database of the Brazilian Unified Health System's (Sistema Único de Saúde [SUS]) Department of Informatics (DataSUS). METHODS: Historical series using DataSUS. Surgeries performed between 2003 and 2015 were included and data relating to cuff tear repair were assessed, including decompression procedures were included. The numerator was the total number of rotator cuff repair and the denominator, the total population of the assessed locality. Population data were based on information from the Instituto Brasileiro de Geografia e Estatística (IBGE). RESULTS: During the period, 50,207 surgeries were performed. The rate was presented as number of procedures per 100,000 inhabitants, and increased from 0.83 to 2.81, a growth of 238%. In 2015, the South region had the highest rate, 6.32, followed by the Southeast, 3.62, while the North had the lowest rate, 0.13. The growing trend can be observed in the Southeast, South, and Midwest, while the rate is stable in the North and Northeast. CONCLUSION: The rate of rotator cuff repairs in Brazil performed through the SUS increased from 0.83 to 2.81 between 2003 and 2015, representing a growth of 238%, but remains lower than that of developed countries. A trend of growth can be observed in the Southeast, South, and Midwest, while the rate is stable in the North and Northeast.

RESUMO OBJETIVO: Avaliar a tendência histórica de reparos do manguito rotador no Brasil, entre 2003 e 2015, com o uso do banco de dados do Departamento de Informática do SUS (DataSUS). MÉTODOS: Série histórica com o uso do DataSUS. Foram incluídas cirurgias feitas entre 2003 e 2015 e coletados os dados referentes ao reparo de rotura do manguito, incluindo procedimentos descompressivos. Usamos como numerador o total de reparos do manguito rotador e como denominador a população total da localidade avaliada. Dados populacionais foram baseados nas informações do Instituto Brasileiro de Geografia e Estatística (IBGE). As taxas foram apresentadas por grupo de 100.000 habitantes. RESULTADOS: Durante o período, foram registradas 50.207 cirurgias. A taxa aumentou de 0,83 para 2,81, um acréscimo de 238%. Em 2015, a Região Sul apresentou a maior taxa, 6,32, seguida da Sudeste, 3,62, enquanto a Norte apresentou a menor taxa, 0,13. A tendência crescente pode ser observada nas regiões Sudeste, Sul e Centro-Oeste, enquanto o índice é estável nas regiões Norte e Nordeste. CONCLUSÃO: A taxa de reparos do manguito rotador no Brasil feitos pelo Sistema Único de Saúde aumentou de 0,83 para 2,81 entre 2003 e 2015, um aumento de 238%, mas permanece inferior à dos países desenvolvidos. Uma tendência crescente pode ser observada nas regiões Sudeste, Sul e Centro-Oeste, enquanto a taxa é estável nas regiões Norte e Nordeste.

Estilo de vida e nível de atividade física de indivíduos com dor no ombro atendidos em um serviço público / Lifestyle and physical activity level in shoulder pain individuals assisted in a public service

Esse estudo teve como objetivo caracterizar o Perfil de Estilo de Vida Individual (PEVI) de indivíduos com dor no ombro em relação à atividade física (AF), nutrição, controle do estresse, relacionamento social e comportamento preventivo e verificar a correlação entre o componente AF do PEVI e o domínio de incapacidade avaliado pelo Shoulder Pain and Disability Index (SPADI). Trata-se de um estudo transversal, com 100 indivíduos adultos e idosos com dor no ombro (55,3 ± 12 anos, 83% mulheres) atendidos em um serviço público de fisioterapia em 2015/2016. Os indivíduos responderam ao questionário PEVI e ao SPADI para avaliação da dor e incapacidade do ombro. Os resultados indicam que 84% dos avaliados apresentaram PEVI de regular a ruim (pontuação ≤ 33), sendo positivo (pontuação média = 2 a 3) para comportamento preventivo e relacionamento social em 94% e 53% dos indivíduos, respectivamente. Nos demais componentes, as respostas se concentraram no perfil regular (pontuação média = 1 a 1,99) e positivo, mas o componente AF apresentou o maior número de indivíduos (30%) com perfil negativo (pontuação média < 1) e identificou que a maioria não realiza AF moderada a intensa e exercícios de força e alongamento muscular. Os níveis de incapacidade do ombro e de AF apresentaram uma correlação baixa (-0,179; p=0,040). Em conclusão, indivíduos com dor no ombro apresentam estilo de vida regular, sendo importante incentivar a prática de atividade física para melhora da qualidade de vida.

This study aimed to characterize the Individual Lifestyle Profile (PEVI) of individuals with shoulder pain in relation to physical activity (PA), nutrition, stress management, social relationship and preventive behavior and to verify the correlation between PA component of PEVI and the disability domain assessed by the Shoulder Pain and Disability Index (SPADI). This is a cross-sectional study with 100 adult and elderly individuals with shoulder pain (55.3 ± 12 years, 83% female) attending in a public physiotherapy service in 2015/2016. Individuals answered the PEVI questionnaire and SPADI for shoulder pain and disability assessment. The results indicate that 84% of the patients presented PEVI from regular to poor (score ≤ 33), and positive (mean score = 2 to 3) for preventive behavior and social relationships in 94% and 53% of the individuals, respectively. For the other components, responses were concentrated in the regular profile (mean score = 1 to 1.99) and positive, but the PA component had the highest number of individuals (30%) with a negative profile (mean score <1) and identified most do not perform moderate to intense PA and muscle strength and stretching exercises. Shoulder disability levels and PA showed a low correlation (-0.179; p = 0.040). In conclusion, individuals with shoulder pain present a regular lifestyle, and it is important to encourage the practice of physical activity to improve the quality of life.

Posture and mobility of the upper body quadrant and pulmonary function in COPD: an exploratory study

ABSTRACT Background There is limited evidence regarding interactions between pulmonary (dys)function, posture, and mobility of the upper body quadrant in patients with chronic obstructive pulmonary disease (COPD). Objectives This exploratory study aimed to investigate whether postural alignment and mobility of the upper quadrant are related to changes in pulmonary function and compare such variables between patients with COPD and healthy individuals. Method Fifteen patients with COPD (67.93±9.71yrs) and 15 healthy controls (66.80±7.47yrs) participated. Pulmonary function (FEV1, FVC) was assessed with spirometry. Alignment and mobility of the head, thoracic spine, and shoulder were assessed using digital photographs. Pectoralis minor muscle (PmM) length and thoracic excursion were assessed with a measuring tape. Groups were compared and linear regression analyses were used to assess potential relationships between postural and mobility variables and pulmonary function. Results Patients with COPD were more likely to have a forward head position at maximal protraction (28.81±7.30º vs. 35.91±8.56º, p=0.02) and overall mobility of the head (21.81±10.42º vs. 13.40±7.84º, p=0.02) and a smaller range of shoulder flexion (136.71±11.91º vs. 149.08±11.58º, p=0.01) than controls. Patients’ non-dominant PmM length and maximal head protraction were predictors of FEV1 (r2adjusted=0.34). These variables, together with the upper thoracic spine at maximal flexion and thoracic kyphosis at maximal extension, were predictors of FVC (r2adjusted=0.68). Conclusion Our findings suggest that impaired pulmonary function is associated with muscle length and mobility adaptations. Further studies are needed to understand the underlying mechanisms and clinical value of these relationships.

Artropatia de manguito: o que esperar do resultado funcional da artroplastia reversa? / Rotator cuff arthropathy: what functional results can be expected from reverse arthroplasty?

Avaliar o resultado funcional da artroplastia reversa, suas complicações e relações com os tipos de lesões. Métodos: Foram tratados 27 ombros, de 26 mulheres e um homem. Os pacientes foram avalia dos pela escala funcional de UCLA. O modelo de implantes usado foi o Delta Xtend Depuy(r). As lesões foram classificadas segundo Seebauer para o grau de artropatia e Nerot para o notching. Resultado: Aidade média foi de 77,4 (67-89), o seguimento foi de 25,8 meses (6-51), o UCLA pré era de 10,1 (6-15) e o UCLA pós foi de 29,8 (22-35), com uma melhoria estatisticamente signi ficativa (p < 0,001). Pela classificação de Seebauer, cinco eram 1B, 19 eram 2 A e três eram 2 B. Tivemos 15 complicacões (55,5%), o notching foi o mais comum e ocorreu em 14 pacientes, nove deles grau I e cinco grau II, mas nenhum deles gerou instabilidade. Apenas uma paci ente (3,7%) teve complicação maior, com luxacão no pós-operatório imediato. Dois pacientes (7,4%) alegaram que não repetiriam o procedimento. Uma paciente (3,7%) foi submetida a revisão. Conclusão: A artroplastia reversa mostrou-se uma excelente opção para o tratamento de pacientes com artropatia do manguito rotador com baixo índice de complicações maio res. O notching é uma complicação frequente, mas que na maioria dos casos não apresenta repercussão clínica.

To evaluate the functional results from reverse arthroplasty and its complications and relationships with types of injury. METHODS: Twenty-seven shoulders (26 women and one man) were treated. The patients were assessed using the UCLA functional scale. The implant used was the Delta Xtend Depuy(r) model. The injuries were classified using the Seebauer method for the degree of arthroplasty and the Nerot method for notching. RESULT: The mean age was 77.4 years (range: 67-89) and the follow-up was 25.8 months (range: 6-51). The preoperative UCLA score was 10.1 (range: 6-15) and the postoperative UCLA score was 29.8 (range: 22-35), which was a statistically significant improvement (p < 0.001). According to the Seebauer classification, five patients were 1B, 19 were 2A and three were 2B. Fifteen cases presented complications (55.5%) and notching was the commonest of these, occurring in 14 patients (nine with grade 1 and five with grade 2), but this did not cause instability in any of them. Only one patient (3.7%) had a major complication, consisting of dislocation in the immediate postoperative period. Two patients (7.4%) said that they would undergo the procedure again. One patient (3.7%) underwent a revision procedure. CONCLUSION: Reverse arthroplasty was shown to be an excellent option for treating patients with rotator cuff arthropathy, with a low rate of major complications. Notching was a frequent complication, but in the majority of the cases, it did not present clinical repercussions.

Correlation between functional disability and quality of life in patients with adhesive capsulitis

OBJECTIVE: To determine the correlation between functional disability and quality of life of patients with adhesive capsulitis. METHODS: Two instruments (WHOQOL-BREF and DASH) were applied to evaluate the quality of life and functional capacity of patients with adhesive capsulitis. Inclusion criteria were age between 35 and 75 years old and achievement of shoulder imaging. Each domain of the WHOQOL-BREF was correlated with DASH. Pearson's correlation coefficient was used for parametric variables and Spearman's correlation coefficient was used when at least one variable had a non-normal distribution. The level of significance was p <0.05. RESULTS: Forty three patients with mean age of 54.7 years old were evaluated. The mean values found in the physical, psychological, social and environmental domains of the WHOQOL-BREF and DASH were 45.3, 63.9, 68.2, 60.2 and 61.6, respectively. A moderate negative correlation was found between DASH and the physical domain of WHOQOL-BREF (r= - 0.583, p<0.001). CONCLUSION: The only domain where WHOQOL-BREF correlates with DASH is the physical domain, suggesting that measures to promote the improvement of functional capacity may lead to better quality of life of patients with adhesive capsulitis. Level of Evidence IV, Prospective Study.

Strength deficits of the shoulder complex during isokinetic testing in people with chronic stroke

OBJECTIVES: To examine the strength deficits of the shoulder complex after stroke and to characterize the pattern of weakness according to type of movement and type of isokinetic parameter. METHOD: Twelve chronic stroke survivors and 12 age-matched healthy controls had their shoulder strength measured using a Biodex isokinetic dynamometer. Concentric measures of peak torque and work during shoulder movements were obtained in random order at speeds of 60°/s for both groups and sides. Type of movement was defined as scapulothoracic (protraction and retraction), glenohumeral (shoulder internal and external rotation) or combined (shoulder flexion and extension). Type of isokinetic parameter was defined as maximum (peak torque) or sustained (work). Strength deficits were calculated using the control group as reference. RESULTS: The average strength deficit for the paretic upper limb was 52% for peak torque and 56% for work. Decreases observed in the non-paretic shoulder were 21% and 22%, respectively. Strength deficit of the scapulothoracic muscles was similar to the glenohumeral muscles, with a mean difference of 6% (95% CI -5 to 17). Ability to sustain torque throughout a given range of motion was decreased as much as the peak torque, with a mean difference of 4% (95% CI -2 to 10). CONCLUSIONS: The findings suggest that people after stroke might benefit from strengthening exercises directed at the paretic scapulothoracic muscles in addition to exercises of arm elevation. Clinicians should also prescribe different exercises to improve the ability to generate force and the ability to sustain the torque during a specific range of motion. .

Artroplastia do ombro na osteoartrose: correlação entre função e parâmetros radiográficos / Shoulder arthroplasty in osteoarthritis: correlation between function and radiographic parameters

Objetivos: Avaliar a correlação entre os parâmetros radiográficos e as avaliações funcionais de pacientes com osteoartrose do ombro submetidos à artroplastia do ombro e descrever os resultados funcionais deste procedimento em nosso serviço. Métodos: Foram avaliados 21 pacientes (22 ombros) que realizaram artroplastias do ombro entre 1998 e 2010 e que apresentassem tempo mínimo de seguimento de 12 meses. A avaliação clínica foi realizada através das escalas de Constant-Murley, UCLA, EVA e da medida do arco de movimento ativo. Aferimos parâmetros radiográficos pré-operatórios (distância entre o topo da cabeça e o úmero e o acrômio, migração superior, inclinação do colo,“offset” medial, subluxação do úmero, erosão da glenóide) e pós-operatórios (inclinação da haste, migração dos componentes e sinais de soltura). Resultados: Os pacientes apresentaram melhora significativa em todos os parâmetros avaliados: flexão (p=0,0083), abdução (p=0,0266), rotação externa (p=0,0062), Constant-Murley (p=0,0001), UCLA (p<0,0001) e EVA (p=0,0002). A migração superior do úmero e as escalas de UCLA e de Constant-Murley apresentaram uma correlação significativa (p=0,0480 e p=0,0110, respectivamente). Os demais parâmetros radiográficos não demonstraram correlação com os resultados clínicos. Conclusão: a migração superior do úmero está relacionada a uma piora dos indicadores funcionais. Nível de Evidência IV, Série de Casos.

Objectives: To evaluate the correlation between radiographic parameters and functional assessments of patients with osteoarthritis of the shoulder who underwent shoulder arthroplasty and describe the functional outcomes of this procedure in our institution. Methods: we evaluated 21 patients (22 shoulders) who underwent shoulder arthroplasty between 1998 and 2010 with a minimum follow-up of 12 months. Clinical evaluation was performed using the Constant-Murley scale, UCLA, VAS and measuring the arc of active motion. We analysed preoperative radiographic parameters (distance from the top of the head and the humerus and the acromion, superior migration, neck angulation, medial “offset”, subluxation, glenoid cavity erosion) and postoperatively we evaluated rod inclination, migration of components and loosening. Results: patients showed significant improvement in all parameters: flexion (p = 0.0083), abduction (p = 0.0266), external rotation (p = 0.0062), Constant-Murley (p = 0.0001 ), UCLA (p < 0.0001) and VAS (p = 0.0002). The superior migration of the humerus showed a significant correlation with UCLA and Constant-Murley scores (p = 0.0480 and p = 0.0110, respectively). The other radiographic parameters had no correlation with the clinical outcomes. Conclusion: the superior migration of the humerus is related to a worsening of clinical scores. Level of Evidence IV, Case Series.

Bloqueio do nervo supraescapular: procedimento importante na prática clínica / Suprascapular nerve block: important procedure in clinical practice

JUSTIFICATIVA E OBJETIVOS: A dor no ombro é uma queixa frequente que ocasiona grande incapacidade funcional no membro acometido, assim como redução na qualidade de vida dos pacientes. O bloqueio do nervo supraescapular é um método terapêutico eficaz e vem sendo cada vez mais utilizado pelos anestesiologistas tanto para anestesia regional quanto para analgesia pós-operatória de cirurgias realizadas nesta articulação, o que justifica a presente revisão, cujo objetivo principal é descrever a técnica aplicada e as indicações clínicas. CONTEÚDO: Apresenta-se a anatomia do nervo supraescapular, desde a sua origem do plexo braquial até os seus ramos terminais, assim como as características gerais e a técnica empregada na execução do bloqueio deste nervo, as principais drogas utilizadas e o volume e as situações em que se faz jus a sua aplicação. CONCLUSÕES: O bloqueio do nervo supraescapular é um procedimento seguro e extremamente eficaz na terapia da dor no ombro. Também de fácil reprodutibilidade, está sendo muito utilizado por profissionais de várias especialidades médicas. Quando bem indicado, este método deve ser considerado.

BACKGROUND AND OBJECTIVES: Shoulder pain is a frequent complaint that results in great functional disability in the affected shoulder as well as the decrease in patients' quality of life. Suprascapular nerve block is an effective therapeutic method and has been increasingly used by anesthesiologists both for regional anesthesia and postoperative analgesia of surgeries carried out in this articulation, which justifies this review, whose main purpose was to describe the applied technique and clinical indications. CONTENT: It is presented the anatomy of suprascapular nerve, since its brachial plexus origin until its terminal branches, as well as general characteristics and technique employed to carry out the block of this nerve, main drugs used, volume and situations that give rise to its applications. CONCLUSIONS: Suprascapular nerve block is a safe and extremely effective procedure in shoulder pain therapy. It also has an easy reproducibility and has been very used by professionals of many medical specialties. When it is well-indicated, this method must be taken into consideration.

JUSTIFICATIVA Y OBJETIVOS: El dolor en el hombro es un quejido frecuente que ocasiona una gran incapacidad funcional en el miembro perjudicado, como también la reducción en la calidad de vida de los pacientes. El bloqueo del nervio supraescapular es un método terapéutico eficaz y ha venido siendo cada vez más utilizado por los anestesiólogos tanto para la anestesia regional como para la analgesia postoperatoria de cirugías realizadas en esa articulación, lo que justifica la presente revisión cuyo objetivo principal es describir la técnica aplicada y las indicaciones clínicas. CONTENIDO: Presentamos la anatomía del nervio supraescapular, desde su origen, y desde el plexo braquial hasta sus ramas terminales, como también las características generales y la técnica usada en la ejecución del bloqueo de ese nervio, los principales fármacos utilizados y el volumen y las situaciones en que se justifica su aplicación. CONCLUSIONES: El bloqueo del nervio supraescapular es un procedimiento seguro y extremadamente eficaz en la terapia del dolor en el hombro. También es fácilmente reproducible y está siendo muy utilizado por profesionales de varias especialidades médicas. Cuando está bien indicado, el método debe ser tenido en cuenta.

Lipomatose simétrica benigna e pelagra, associadas ao alcoolismo / Benign symmetrical lipomatosis and pellagra associated with alcoholism

A 42-year-old male patient, alcoholic, presented showing signs of tumors in the neck and around the shoulders, scaly, erythematous-violaceous lesions and some bullous lesions in sun-exposed areas of upper and lower limbs. Based on clinical features, laboratory tests and imaging studies we have established the diagnosis of pellagra associated with benign symmetrical lipomatosis, both justified by chronic alcoholism. Treated with intravenous B-complex and oriented about the importance of alcohol withdrawal, the patient showed complete remission of skin lesions, but with no change in the lipomatosis.

Paciente masculino, 42 anos, etilista crônico, apresentando quadro de tumorações em região cervical e ao redor dos ombros, lesões eritemato-violáceas, descamativas e algumas lesões bolhosas, nas áreas fotoexpostas dos membros superiores e inferiores. Baseado no quadro clínico e nos exames complementares, foi estabelecido o diagnóstico de pelagra associada à lipomatose simétrica benigna, sendo ambos os quadros justificados pelo etilismo crônico. Tratado com reposição de complexo B intravenoso e orientado quanto à importância da abstinência alcoólica, apresentou remissão completa do quadro cutâneo, porém sem alteração da lipomatose.

Amiloidosis extrema asociada a mieloma múltiple e insuficiencia renal terminal: Caso clínico / Primary amyloidosis associated with multiple myeloma and renal failure: Case report

We report a 53-year-old female on chronic dialysis, presenting with weight loss, the development of big soft masses in the shoulders ("shoulder pads"), forearms and buttocks, macroglossia and rigidity of hands and lower limbs. Laboratory confirmed the presence of amyloidosis and myeloma with lambda chain restricted plasma cell infiltration of bone marrow. The diagnosis of multiple myeloma associated with primary amyloidosis in a patient with terminal renal failure, was reached.

Strategy for respiratory exercise pattern associated with upper limb movements in COPD patients

INTRODUCTION: Upper limb exercises are frequently used in respiratory physiotherapy, with UL elevation and controlled inspiratory timing. However, the use of expiration during upper limb elevation appears to be a strategy that could minimize the action of accessory muscles in patients with chronic obstructive pulmonary disease. In this context, little is known about the synchrony of upper limb (UL) movements associated with breathing. The aim of this study was to investigate the respiratory pattern of chronic obstructive pulmonary disease patients during different UL exercises associated with respiratory exercises. METHODS: Fifteen chronic obstructive pulmonary disease patients participated in this study. Respiratory pattern analysis by inductance plethysmography was performed during four types of upper limb exercises, two shoulder flexion-extension (one associated with inspiratory time during the concentric phase and the other associated with expiratory time) and two shoulder abduction-adduction (same timing as above). Statistical analysis was performed by the Kolmogorov-Smirnov test and ANOVA with Tukey tests (p< 0.05). RESULTS: The thoracoabdominal coordination measurements increased in the two exercises using both inspiration during shoulder flexion (PhRIB: 172 percent; PhREB: 131 percent; PhRTB: 142 percent and PhAng: 238 percent) as well as in shoulder horizontal abduction (PhRIB: 145 percent; PhREB: 109 percent; PhRTB: 130 percent and PhAng: 229 percent), differing from the exercises with expiration at the time of shoulder flexion and horizontal abduction. CONCLUSION: The exercises performed with inverted respiratory time produced less asynchrony and can be used as important strategies during physical exercise programs in these patients.

Comparison of quality of life, satisfaction with surgery and shoulder-arm morbidity in breast cancer survivors submitted to breast-conserving therapy or mastectomy followed by immediate breast reconstruction

OBJECTIVES: This study was designed to compare the prevalence of shoulder-arm morbidity, patient satisfaction with surgery and the quality of life of women submitted to breast-conserving therapy or modified radical mastectomy and immediate breast reconstruction . METHODS: This study was a cross-sectional study of women who underwent breast-conserving therapy (n=44) or modified radical mastectomy and immediate breast reconstruction (n=26). Quality of life was evaluated with the SF-36 Health Survey Questionnaire. RESULTS: No differences were found in the prevalence of lymphedema. The movements that were most commonly affected by these procedures were abduction, flexion and external rotation. When the two groups were compared, however, we only found a statistically significant difference for the prevalence of restricted internal rotation, which occurred in 32 percent of women in the breast-conserving therapy group and 12 percent of those in the modified radical mastectomy and immediate breast reconstruction group (OR: 7.23; p=0.03 following adjustment for potential confounding factors). No difference in quality of life or satisfaction with surgery was found between the two groups. CONCLUSIONS: These data suggest that the type of surgery did not affect the occurrence of lymphedema. Breast-conserving therapy, however, increased the risk of shoulder movement limitation. No differences were found between the two surgical techniques with respect to quality of life or satisfaction with surgery.

Bloqueo interescalénico continuo: bupivacaína 0, 125 por ciento versus 0, 0625 por ciento para manejo del dolor postoperatorio en la cirugía mayor del hombro asistida por artroscopía / Continuous interscalenic block: bupivacaine 0.125 percent versus 0.0625 percent pain management in major post shoulder arthroscopy assisted surgery

Introducción: Bloqueo Interescalénico Continuo (BIEC) se utiliza para el manejo del dolor postoperatorio de las cirugías mayores de hombro con buenos resultados. Diferentes soluciones de anestésicos locales han sido usadas. Objetivo: Evaluar la utilidad del BIEC, comparando dos concentraciones de bupivacaína asociada a sufentanil en infusión continua sobre la calidad de la analgesia postoperatoria e índice de satisfacción en pacientes intervenidos de reparación del manguito rotator del hombro (RMRH). Material y Método: Ensayo prospectivo aleatorizado en 43 pacientes, divididos en dos grupos. Grupo 1 (n = 21): Bupivacaína 0,125 por ciento + Sufentanyl 1 ug/ml (B 0,125 + S) en infusión continua (IC) a 7 ml/hr; Grupo 2 (n = 22): B 0,0625 por ciento + S, IC a 7 ml/hr. El dolor posquirúrgico se registro entre las 2 y 48 horas, mediante Escala Visual Análoga (EVA). Se utilizó como analgesia de rescate morfina endovenosa. Se registró el consumo de morfina, bupivacaína, el grado de satisfacción experimentados por los pacientes y la incidencia de efectos adversos. Resultados: No hubo diferencias en los parámetros demográficos de ambos grupos. El EVA postoperatorio y el consumo de morfina entre las 4 y 48 horas fueron similares entre los grupos. El consumo de bupivacaína fue menor en el grupo 1 (p< 0,005). El grado de satisfacción fue elevado en ambos grupos. Conclusiones: El BIEC es útil para el manejo del dolor postoperatorio en la RMRH. Ambas concentraciones de bupivacaína asociada a sufentanyl proveen excelente analgesia. Al utilizar B 0,0625 por ciento se disminuye el consumo de AL, sin desmejorar la calidad de la analgesia.

Introduction: Continuous Interscalenic Block (CIB) is used forpostoperative analgesia in major shoulder surgery with good results, with advantages over other local, regional or intravenous analgesia techniques. Objective: The objective of this study was to clinically evaluate the usefulnes of two concentrations of bupivacaine associated to sufentanyl in CIB for postoperative analgesia after rotator cuff repair (RCR). Patients and Methods: Randomized clinical prospective study including 43 patients ASA I and II. Stable patients were divided into 2 groups. Group 1 (n = 21): continuous infusion (CI) 7 ml/hr bupivacaine 0.125 percent associated with sufentanil 1 g/ml and Group 2 (n = 22): 7 ml/hr bupivacaine 0.0625 percent associated with sufentanil 1 ug/ml. Surgery was performed under general anesthesia. Postoperative pain was managed with intravenous morphine PCA. Postoperative pain was recorded at 2, 4, 6, 24, 36 and 48 hours after surgery using Visual Analog Scale (VAS). Morphine and bupivacaine consumption, Satisfaction Score and complications are recorded. Results: No differences in demographics data were found between the two groups. The postoperative VAS between 4 and 48 hours, morphine consumption, levels of satisfaction and incidence of complications are not different in the two groups. The consumption of bupivacaine is reduced in the B 0.0625 percent group (p< 0.005). Conclusions: The CIB with bupivacaine and sufentanil in continuous infusion at rate of 7 ml/hr provides efficient analgesia after RCR. Patient Shows a high level of satisfaction that is associated to a significantly less consumption of intravenous morphine. Bupivacaine consumption is lower in the B 0.0625 percent group.

Registro de artroplastias do ombro / Shoulder arthroplasty records

Objetivo: Determinar as características clínico-cirúrgicas referentes a 145 artroplastias do ombro realizadas no período entre julho de 2004 a dezembro de 2006. Métodos: No período de estudo foram realizadas 145 artroplastias de ombro. Através de protocolo prospectivo, informações demográficas, da anamnese, exame físico e exame radiográfico foram armazenadas em umbanco de dados. Os dados coletados foram organizados em três grandes grupos: doenças articulares degenerativas, fraturas e seqüelas traumáticas. Esses dados foram correlacionados a fim de definir o perfil epidemiológico dos pacientes, das lesões e artroplastias. Resultados: Das 145 artroplastias de ombro realizadas37% foram por seqüelas traumáticas, 30% por doença articular degenerativa e 33% com diagnóstico de fratura. Foram 12% artroplastias totais e 88% parciais. Ocorreram cinco complicaçõesno pós-operatório recente. Conclusão: As artroplastias de ombro tornaram-se um procedimento frequente na prática ortopédica. Registros cirúrgicos são importantes a fim de demonstrar essaevolução progressiva e permitir avaliações de resultados clínicos no futuro.

Objective: The study's objective is to evaluate the characteristics and problems of patients who underwent shoulder arthroplasties between July 2004 and November 2006. Methodology: During the period of the study, 145 shoulder arthroplasties were performed. A prospective protocol was used for every patient; demographic,clinical and surgical procedure data were collected. All gathered data were included in the data base. The patients were divided in three major groups: fractures, degenerative diseases and trauma sequels. Information obtained from the data base was correlated in order to determine patients' epidemiologic, injuries, and surgical procedure profiles. Results: Of the 145shoulder arthroplasties performed, 37% presented trauma sequels, 30% degenerative diseases, and 33% proximal humerus fracture. 12% of the cases required total arthroplasties and 88% partial arthroplasties. Five major complications were observed on early postoperative period. Conclusion: Shoulder arthroplasties have become a common procedure in orthopaedic practice. Surgical records are important in evidencing progressive evolution and in enabling future clinical outcomes evaluation.

Estudo comparativo da eficácia analgésica pós-operatória de 20 mL de ropivacaína a 0,5, 0,75 ou 1 por cento no bloqueio de plexo braquial pela via posterior / Estudio comparativo de la eficacia analgésica postoperatoria de 20 mL de ropivacaina a 0,5, 0,75 ó 1 por ciento en el bloqueo de plexo braquial por la vía posterior / Comparative study for the postoperative analgesic efficacy of 20 mL at 0.5, 0.75, and 1 percent ropivacaine in posterior brachial plexus block

JUSTIFICATIVA E OBJETIVOS: As intervenções cirúrgicas por via artroscópica no ombro estão relacionadas com a dor pós-operatória de grande intensidade. Dentre as técnicas de analgesia, o bloqueio do plexo braquial é a que oferece os melhores resultados. O objetivo deste estudo foi determinar qual concentração de anestésico local no bloqueio de plexo braquial pela via posterior propicia analgesia pós-operatória mais prolongada para essas operações. MÉTODO: Noventa pacientes submetidos ao bloqueio do plexo braquial pela via posterior foram divididos aleatoriamente em três grupos de 30. Grupo 1: 20 mL de ropivacaína a 0,5 por cento; Grupo 2: 20 mL de ropivacaína a 0,75 por cento; Grupo 3: 20 mL de ropivacaína a 1 por cento. O bloqueio foi avaliado por meio da pesquisa de sensibilidade térmica utilizando-se algodão embebido em álcool e a dor pós-operatória foi avaliada seguindo-se uma escala numérica verbal (ENV) nas primeiras 48 horas. RESULTADOS: Nos três grupos a analgesia pós-operatória foi similar segundo os parâmetros avaliados; ENV de dor média, tempo até a primeira queixa de dor e consumo de opióides no pós-operatório. CONCLUSÕES: Este estudo mostrou que o bloqueio do plexo braquial pela via posterior é uma técnica que promove analgesia eficaz para intervenções cirúrgicas no ombro. Utilizando-se 20mL de ropivacaína, as três diferentes concentrações estudadas promovem analgesia similar.

BACKGROUND AND OBJECTIVES: Arthroscopic shoulder surgeries are associated with severe postoperative pain. Among the analgesic techniques available, brachial plexus block has the best results. The objective of this study was to determine which concentration of local analgesic used in the posterior brachial plexus block provides longer postoperative analgesia. METHODS: Ninety patients undergoing posterior brachial plexus block were randomly divided into three groups of 30 patients each. Group I: 20 mL of 0.5 percent ropivacaine; Group 2: 20 mL of 0.75 percent ropivacaine; and Group 3: 20 mL of 1 percent ropivacaine. The blockade was evaluated by assessing the thermal sensitivity using a cotton pad with alcohol and postoperative pain was evaluated according to a Verbal Numeric Scale (VNS) in the first 48 hours. RESULTS: Postoperative analgesia was similar in all three groups according to the parameters evaluated: mean VNS, time until the first complaint of pain, and postoperative opioid consumption. CONCLUSIONS: This study demonstrated that posterior brachial plexus block provides effective analgesia for shoulder surgeries. Twenty milliliters of ropivacaine in the different concentrations used in this study promoted similar analgesia.

JUSTIFICATIVA Y OBJETIVOS: Las intervenciones quirúrgicas por vía artroscópica en el hombro se relacionan con el dolor postoperatorio de gran intensidad. Entre las técnicas de analgesia, el bloqueo del plexo braquial es la que ofrece los mejores resultados. El objetivo de este estudio fue determinar cuál concentración de anestésico local en el bloqueo de plexo braquial por la vía posterior, propicia analgesia postoperatoria más prolongada para esas operaciones. MÉTODO: Noventa pacientes sometidos al bloqueo del plexo braquial por la vía posterior se dividieron aleatoriamente en tres grupos de 30. Grupo 1: 20 mL de ropivacaina a 0,5 por ciento; Grupo 2: 20 mL de ropivacaina a 0,75 por ciento; Grupo 3: 20 mL de ropivacaina a 1 por ciento. El bloqueo se evaluó a través de la investigación de sensibilidad térmica utilizando algodón con alcohol y el dolor postoperatorio se evaluó según una escala numérico verbal (ENV) en las primeras 48 horas. RESULTADOS: En los tres grupos la analgesia postoperatoria fue similar según los parámetros evaluados; ENV de dolor medio, tiempo hasta el primer quejido de dolor y consumo de opioides en el postoperatorio. CONCLUSIONES: Este estudio mostró que el bloqueo del plexo braquial por la vía posterior es una técnica que promueve una analgesia eficaz para intervenciones quirúrgicas en el hombro. Utilizando 20 mL de ropivacaina, las tres diferentes concentraciones estudiadas promueven analgesia similar.