Carlos Vicente Andreoli

Pectoralis Major Muscle Rupture in Athletes A Prospective Study

Background In the past 20 years, there has been an increase in the incidence of upper extremity tendinous injuries, especially in sports including strong physical activity, such as in weight lifting, as well as with the concurrent use of anabolic steroids. Today, there are more than 200 cases describing rupture of the pectoralis major muscle in athletes. Hypothesis Surgical treatment will have a better outcome than nonsurgical treatment in total rupture of the pectoralis major muscle in athletes. Study Design Cohort study; Level of evidence, 2. Methods Twenty athletes with pectoralis major muscle (PMM) rupture were studied; 10 had surgical treatment, and the other 10 were treated nonoperatively. The mean age was 32.27 years (range, 27-47 years); all of them were men. The average follow-up was 36 months (range, 48-72 months). Injuries were diagnosed by history, physical examination, and subsidiary tests. Functional evaluation and isokinetic evaluation were performed on all 20 patients. Results The clinical evaluation revealed 70% (n = 7) excellent, 20% good (n = 2), and 10% poor (n = 1) outcomes for the cases treated with surgery and 20% good (n = 2), 50% fair (n = 5), and 40% poor (n = 4) outcomes for the cases treated nonsurgically. The isokinetic evaluation at 60-deg/s speed showed a decrease in strength of 53.8% in the nonsurgical group and 13.7% for the surgical group. Conclusion Total PMM rupture in athletes showed a better functional result after surgical treatment than after nonsurgical treatment.

Clinical Considerations for the Surgical Treatment of Pectoralis Major Muscle Ruptures Based on 60 Cases A Prospective Study and Literature Review

Background: Early recognition of the clinical signs of ruptures of the pectoralis major muscle (PMM) in athletes by orthopaedic surgeons, physical therapists, and physical trainers may prove to be critical for patient access to surgical treatment while the injury is still in the acute phase. Hypothesis: Total ruptures of the PMM may yield a better outcome with surgical treatment than with nonoperative treatment in athletes. Study Design: Cohort study; Level of evidence, 2. Methods: A prospective study was performed on 60 patients with total ruptures of the PMM. The patients were followed from 1997 to 2012, with a physical examination every 6 months for the first 2 years and every 12 months thereafter. The patients’ mean age was 31.21 years, and the mean length of follow-up was 48.25 months. The surgical treatment methods included reinsertion of the tendon in 51% of the patients and nonoperative treatment in 49% of the patients. All of the patients were evaluated using the Bak criteria. Results: The bench-press exercise was associated with 80% of the PMM ruptures (48 patients). Forty-one of the patients with chronic ruptures were seen after 3 months (80%). The outcomes were poor in 9 patients from the nonoperative group (31%) and in 3 patients from the surgical group (9.7%); the outcomes were fair in 12 patients from the nonoperative group and in no patients from the surgical group. Excellent results were not observed in any patient from the nonoperative group and were observed in 21 patients from the surgical group (67.7%). The isokinetic evaluation at 60 deg/s showed a decrease in strength of 41.7% in the nonsurgical group and 14.3% for the surgical group, which was significant at P < .05. Conclusion: Total ruptures of the PMM exhibit better outcomes with surgical treatment than with nonoperative treatment based on the Bak criteria in athletes.

Absorbable Versus Nonabsorbable Sutures for the Arthroscopic Treatment of Anterior Shoulder Instability in Athletes: A Prospective Randomized Study

PURPOSE The purpose of this study was to compare the functional results of arthroscopic treatment for traumatic anterior shoulder instability in 2 groups of athletes. METHODS Fifty patients were randomly assigned to 2 different groups with comparable patient demographics. Group A was treated with anchors loaded with absorbable sutures, and group B was treated with the same type of anchors loaded with nonabsorbable sutures. The same type of absorbable anchor, surgical technique, and rehabilitation protocol was used in both groups. The outcomes were evaluated after a minimum postoperative period of 24 months. The Rowe score and the Athletic Shoulder Outcome Scoring System were applied, and statistical analysis was performed. RESULTS The mean Rowe score was 83.8 in group A and 79.5 in group B. The mean values for the Athletic Shoulder Outcome Scoring System were 84 and 79.2, respectively. Good or excellent results were found in 90.5% of patients in group A and 87.5% in group B. We had 2 failures (9.5%) in group A and 3 (12.5%) in group B. No statistically significant difference was found in the comparison of the outcomes (P > .05). CONCLUSIONS The type of suture used, absorbable or nonabsorbable, did not influence the functional results of arthroscopic treatment for traumatic anterior shoulder instability in this series.

Identification of Suitable Reference Genes for Investigating Gene Expression in Anterior Cruciate Ligament Injury by Using Reverse Transcription-Quantitative PCR.

The anterior cruciate ligament (ACL) is one of the most frequently injured structures during high-impact sporting activities. Gene expression analysis may be a useful tool for understanding ACL tears and healing failure. Reverse transcription-quantitative polymerase chain reaction (RT-qPCR) has emerged as an effective method for such studies. However, this technique requires the use of suitable reference genes for data normalization. Here, we evaluated the suitability of six reference genes (18S, ACTB, B2M, GAPDH, HPRT1, and TBP) by using ACL samples of 39 individuals with ACL tears (20 with isolated ACL tears and 19 with ACL tear and combined meniscal injury) and of 13 controls. The stability of the candidate reference genes was determined by using the NormFinder, geNorm, BestKeeper DataAssist, and RefFinder software packages and the comparative ΔCt method. ACTB was the best single reference gene and ACTB+TBP was the best gene pair. The GenEx software showed that the accumulated standard deviation is reduced when a larger number of reference genes is used for gene expression normalization. However, the use of a single reference gene may not be suitable. To identify the optimal combination of reference genes, we evaluated the expression of FN1 and PLOD1. We observed that at least 3 reference genes should be used. ACTB+HPRT1+18S is the best trio for the analyses involving isolated ACL tears and controls. Conversely, ACTB+TBP+18S is the best trio for the analyses involving (1) injured ACL tears and controls, and (2) ACL tears of patients with meniscal tears and controls. Therefore, if the gene expression study aims to compare non-injured ACL, isolated ACL tears and ACL tears from patients with meniscal tear as three independent groups ACTB+TBP+18S+HPRT1 should be used. In conclusion, 3 or more genes should be used as reference genes for analysis of ACL samples of individuals with and without ACL tears.

Identification of Suitable Reference Genes for Gene Expression Studies in Tendons from Patients with Rotator Cuff Tear

Rotator cuff tear is one of the most common causes of shoulder dysfunction. Gene expression analysis may be a useful tool for understanding tendon tears and the failure of cuff healing, and reverse-transcription quantitative polymerase chain reaction (RT-qPCR) has become an effective method for such studies. However, this technique requires the use of suitable reference genes for data normalization. Here, we evaluate the suitability of six reference genes (18S, ACTB, B2M, GAPDH, HPRT1 and TBP) using samples from the rotator cuff tendons of 28 individuals with tendon tears (3 tendons regions) and 8 controls (2 tendon regions); for the tear patients, we evaluated ruptured and non-ruptured tendon samples. The stability of the candidate reference genes was determined using the NormFinder, geNorm, BestKeeper and DataAssist software packages. Overall, HPRT1 was the best single reference gene, and HPRT1+TBP composed the best pair and HPRT1+TBP+ACTB composed the best trio of reference genes from the analysis of different groups, including the simultaneous analysis of all tissue samples. To identify the optimal combination of reference genes, we evaluated the expression of COL1A1 and COL3A1, and no obvious differences were observed when using 2, 3 or 4 reference genes for most of the analyses. However, COL3A1 expression differed between ruptured and non-ruptured (posterior superior region) tendons of patients only when normalized by HPRT1+TBP+B2M and HPRT1+TBP. On the other hand, the comparison between these two groups using the best trio of reference genes (HPRT1+TBP+ACTB) and 4 reference genes did not revealed a significant difference in COL3A1 expression. Consequently, the use of suitable reference genes for a reliable gene expression evaluation by RT-qPCR should consider the type of tendon samples investigated. HPRT1+TBP+ACTB seems to be the best combination of reference genes for the analysis of involving different tendon samples of individuals with rotator cuff tears.

Gene expression analysis in patients with traumatic anterior shoulder instability suggests deregulation of collagen genes

Shoulder dislocation occurs in 1–2% of the population. Capsular deformation is a key factor in shoulder dislocation; however, little is known about capsule biology. We evaluated, for the first time in literature, the expression of COL1A1, COL1A2, COL3A1 and COL5A1 in the antero‐inferior, antero‐superior and posterior regions of the glenohumeral capsule of 31 patients with anterior shoulder instability and eight controls. The expression of collagen genes was evaluated by quantitative reverse transcription‐PCR. The expression of COL1A1, COL3A1 and the ratio of COL1A1/COL1A2 were increased in all three portions of the capsule in patients compared to controls (p < 0.05). COL1A2 expression was upregulated in the antero‐superior and posterior sites of the capsule of patients (p < 0.05). The ratio of COL1A2/COL3A1 expression was reduced in capsule antero‐inferior and posterior sites of patients compared to controls (p < 0.05). In the capsule antero‐inferior site of patients, the ratios of COL1A1/COL5A1, CO1A2/COL5A1 and COL3A1/COL5A1 expression were increased (p < 0.05). In patients, COL1A1/COL5A1 was also increased in the posterior site (p < 0.05). We found deregulated expression of collagen genes across the capsule of shoulder instability patients. These molecular alterations may lead to modifications of collagen fibril structure and impairment of the healing process, possibly with a role in capsular deformation.

Disorder of the long head of the biceps tendon

This paper focuses on biceps injuries in shoulder surgery. This topic is currently of great interest, and there has been much discussion about diagnosis, treatment and prevention. Biceps tendon pathology exists in many forms and is frequently associated with other shoulder disorders. These facts must be taken into consideration in the evaluation and treatment of patients with long head of the biceps pathology. There is much controversy about the long head of the biceps tendon (LHBT). The clinical significance to shoulder function, diagnosis and treatment are still a source of debate. The purpose of this review is to discuss the anatomy, function, pathology, clinical manifestation, physical examination, imaging and treatment of disorders of the LHBT.

Identification of suitable reference genes for gene expression studies of shoulder instability.

Shoulder instability is a common shoulder injury, and patients present with plastic deformation of the glenohumeral capsule. Gene expression analysis may be a useful tool for increasing the general understanding of capsule deformation, and reverse-transcription quantitative polymerase chain reaction (RT-qPCR) has become an effective method for such studies. Although RT-qPCR is highly sensitive and specific, it requires the use of suitable reference genes for data normalization to guarantee meaningful and reproducible results. In the present study, we evaluated the suitability of a set of reference genes using samples from the glenohumeral capsules of individuals with and without shoulder instability. We analyzed the expression of six commonly used reference genes (ACTB, B2M, GAPDH, HPRT1, TBP and TFRC) in the antero-inferior, antero-superior and posterior portions of the glenohumeral capsules of cases and controls. The stability of the candidate reference gene expression was determined using four software packages: NormFinder, geNorm, BestKeeper and DataAssist. Overall, HPRT1 was the best single reference gene, and HPRT1 and B2M composed the best pair of reference genes from different analysis groups, including simultaneous analysis of all tissue samples. GenEx software was used to identify the optimal number of reference genes to be used for normalization and demonstrated that the accumulated standard deviation resulting from the use of 2 reference genes was similar to that resulting from the use of 3 or more reference genes. To identify the optimal combination of reference genes, we evaluated the expression of COL1A1. Although the use of different reference gene combinations yielded variable normalized quantities, the relative quantities within sample groups were similar and confirmed that no obvious differences were observed when using 2, 3 or 4 reference genes. Consequently, the use of 2 stable reference genes for normalization, especially HPRT1 and B2M, is a reliable method for evaluating gene expression by RT-qPCR.

Comprehensive selection of reference genes for expression studies in meniscus injury using quantitative real-time PCR

The meniscus plays critical roles in the knee function. Meniscal tears can lead to knee osteoarthritis. Gene expression analysis may be a useful tool for understanding meniscus tears, and reverse-transcription quantitative polymerase chain reaction (RT-qPCR) has become an effective method for such studies. However, this technique requires the use of suitable reference genes for data normalization. We evaluated the suitability of six reference genes (18S, ACTB, B2M, GAPDH, HPRT1 and TBP) using meniscus samples of (1) 19 patients with isolated meniscal tears, (2) 20 patients with meniscal tears and combined anterior cruciate ligament injury (ACL), and (3) 11 controls without meniscal tears. The stability of the candidate reference genes was determined using the NormFinder, geNorm, BestKeeper DataAssist and RefFinder software packages and comparative ΔCt method. Overall, HPRT1 was the best single reference gene. However, GenEx software demonstrated that two or more reference genes should be used for gene expression normalization, which was confirmed when we evaluated TGFβR1 expression using several reference gene combinations. HPRT1+TBP was the most frequently identified pair from the analysis of samples of (1) meniscal tear samples of patients with a concomitant ACL tears, (2) all meniscal tears, and (3) all samples. HPRT1+GAPDH was the most frequently identified pair from the analysis of samples of isolated meniscal tear samples and controls. In the analysis involving only controls, GAPDH+18S was the most frequently identified pair. In the analysis of only isolated meniscal tear samples and in the analysis of meniscal tear samples of patients with concomitant ACL tears and controls, both HPRT1+TBP and HPRT1+GAPDH were identified as suitable pairs. If the gene expression study aims to compare non-injured meniscus, isolated meniscal tears and meniscal tears of patients with ACL tears as three independent groups, the trio of HPRT1+TBP+GAPDH is the most suitable combination of reference genes.

Anatomic study of the coracoid process: safety margin and practical implications.

PURPOSE The aim of this study was to define a safety margin for coracoid process osteotomy that does not compromise the coracoclavicular ligaments and that can be used in the coracoid transfer procedures. METHODS Thirty shoulders from 15 cadavers were dissected, exposing the coracoid process and attached anatomic structures. The distance of the insertion of these structures to the coracoid process apex was measured. RESULTS The average length of the coracoid process was 4.26 ± 0.26 cm. The average width and height at the tip were 2.11 ± 0.2 and 1.49 ± 0.12 cm, respectively. The average distance from the tip to the anterior and posterior margin of the pectoralis minor was 0.1 ± 1.17 and 1.59 ± 0.27 cm, respectively. The average distance from the tip to the posterior margin of the coracoacromial ligament was 2.79 ± 0.33 cm. The average distance from the apex to the most anterior part of the trapezoid ligament was 3.33 ± 0.38 cm. We obtained a constant value of 0.85 cm for this measure, and the value increased with each 1.0-cm increase in the distance from the tip to the posterior margin of the pectoralis minor. The safety margin for osteotomy (i.e., available bone distance for the coracoid process transfer) was 2.64 cm. CONCLUSIONS This study established a safety margin of 2.64 cm for the osteotomy of the coracoid process and its relation with the posterior margin of the pectoralis minor. The anatomic descriptions of bone and soft tissue, as well as a measure of correlation for the safety margin of the coracoid, provide tools for surgeons performing anatomic surgical procedures to correct glenohumeral instability with significant bone loss. CLINICAL RELEVANCE Knowing the safety margin allows the surgeon to perform a safe osteotomy without direct visualization of the coracoclavicular ligaments attachments, thereby making procedures more anatomic.