Eduardo Angeli Malavolta

Platelet-Rich Plasma in Rotator Cuff Repair: A Prospective Randomized Study

Background: Although platelet-rich plasma (PRP) has been used in rotator cuff repair, most authors have been unable to report the advantages of this method in clinical trials. Hypothesis: The use of PRP promotes better functional and structural results in arthroscopic rotator cuff repair. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: This was a prospective, randomized, double-blind study with 2 groups of 27 patients each (PRP group and control group). Complete supraspinatus tears with retraction of less than 3 cm were subjected to arthroscopic single-row repair; at the end of the surgical procedure, liquid PRP prepared by apheresis was given to the patients in the PRP group with autologous thrombin. The outcomes were assessed by the University of California at Los Angeles (UCLA) and Constant scales, visual analog scale (VAS) for pain, and magnetic resonance imaging (MRI) before and 3, 6, 12, and 24 months after surgery. The significance level was 5%. Results: The 2 groups of patients exhibited significant clinical improvement (P < .001). Between the preoperative assessment and 24-month follow-up, the mean UCLA score increased from 13.63 ± 3.639 to 32.70 ± 3.635 and from 13.93 ± 4.649 to 32.44 ± 4.318 in the control and PRP groups, respectively (P = .916). The mean Constant score increased from 47.37 ± 11.088 to 85.15 ± 9.879 in the control group and from 46.96 ± 11.937 to 84.78 ± 14.048 in the PRP group (P = .498). The mean VAS score varied from 7.00 ± 1.939 and 6.67 ± 1.617 before surgery to 1.15 ± 1.916 and 0.96 ± 2.244 at the 24-month assessment in the control and PRP groups, respectively (P = .418). The only difference was in the mean UCLA score at 12 months, with 30.04 ± 4.528 in the control group and 32.30 ± 3.506 in the PRP group (P = .046). The control group exhibited 1 case of a complete retear and 4 partial retears, and the PRP group exhibited 2 cases of partial retears (P = .42). Conclusion: Platelet-rich plasma prepared by apheresis and applied in the liquid state with thrombin did not promote better clinical results at 24-month follow-up. Given the numbers available for analysis, the retear rate also did not change.

Anterograde removal of broken femoral nails without opening the nonunion site: a new technique

OBJECTIVE: We describe a new technique for removing the distal fragments of broken intramedullary femoral nails without disturbing the nonunion site. METHODS: This technique involves the application of an AO distractor prior to the removal of the nail fragments, with subsequent removal of the proximal nail fragment in an anterograde fashion and removal of the distal fragment through a medial parapatellar approach. Impaction of the fracture site is then performed with a nail that is broader than the remaining fragmented material. RESULTS: Nails were removed from five patients using the technique described above without any complications. After a mean follow-up period of 61.8 months, none of these patients showed worsened knee osteoarthritis. CONCLUSION: The original technique described in this article allows surgeons to remove the distal fragment of fractured femoral intramedullary nails without opening the nonunion focus or using special surgical instruments.

Locking intramedullary nails compared with locking plates for two- and three-part proximal humeral surgical neck fractures: a randomized controlled trial.

BACKGROUND Previous studies have shown good clinical results in patients with proximal humeral fractures (PHFs) treated with locking intramedullary nails or locking plates. Our study compared the clinical and radiographic outcomes in patients with 2- and 3-part surgical neck fractures. METHODS In this prospective, randomized controlled trial, 72 patients with 2- or 3-part surgical neck PHFs were randomly assigned to receive fixation with locking intramedullary nails (nail group) or locking plates (plate group). The primary outcome was the 12-month Constant-Murley score. The secondary outcomes included the Disabilities of the Arm, Shoulder and Hand score, the visual analog scale pain score, the shoulder passive range of motion, the neck-shaft angle, and complication rates. RESULTS There was no significant mean treatment group difference in the Constant-Murley score at 12 months (70.3 points for the nail group vs. 71.5 points for the plate group; P = .750) or at individual follow-up assessments. There were no differences in the 3-, 6- and 12-month Disabilities of the Arm, Shoulder and Hand scores, visual analog scale scores, and range of motion, except for the medial rotation at 6 months. The neck-shaft angle was equivalent between the groups at 12 months. There were significant differences over 12 months in total complication rates (P = .002) and reoperation rates (P = .041). There were no significant differences for the rotator cuff tear rate (P = .672). CONCLUSION Fixation of PHFs with locking plates or locking intramedullary nails produces similar clinical and radiologic results. Nevertheless, the complication and reoperation rates were higher in the nail group.

Accuracy of preoperative MRI in the diagnosis of disorders of the long head of the biceps tendon.

OBJETIVES To evaluate the accuracy of magnetic resonance imaging (MRI) in the detection of disorders of the long head of the biceps tendon (LHBT). The secondary objective was to investigate predictive factors for tears and instability. METHODS This retrospective case series involved patients undergoing shoulder arthroscopy due to rotator cuff injury. MRI was performed in a 1.5T scanner and was evaluated by a musculoskeletal radiologist. The findings were compared with those of arthroscopic inspection. RESULTS A total of 90 shoulders were analyzed. Regarding tears, there was 67% sensitivity and 98% specificity. Regarding instabilities, the values were 53% and 72%, respectively. Tears and fatty degeneration of the infraspinatus are predictive factors for tears of the LHBT. Tears of the subscapularis and infraspinatus, retraction of the supraspinatus and infraspinatus equal to or greater than 30mm, and fatty degeneration of the infraspinatus and subscapularis are predictive factors for instability. CONCLUSION Compared to arthroscopy, the shoulder MRI has a sensitivity of 67% and a specificity of 98% for the detection of complete tears of the LHBT. For instability, the values are 53% and 72%, respectively.

RANDOMIZED CONTROLLED CLINICAL TRIALS IN ORTHOPEDICS: DIFFICULTIES AND LIMITATIONS

Randomized controlled clinical trials (RCTs) are considered to be the gold standard for evidence-based medicine nowadays, and are important for directing medical practice through consistent scientific observations. Steps such as patient selection, randomization and blinding are fundamental for conducting a RCT, but some additional difficulties are presented in trials that involve surgical procedures, as is common in orthopedics. The aim of this article was to highlight and discuss some difficulties and possible limitations on RCTs within the field of surgery.

Ensaios clínicos controlados e randomizados na ortopedia: dificuldades e limitações

Os ensaios clinicos controlados e randomizados (ECCR) sao considerados o padrao ouro da medicina baseada em evidencias na atualidade, sendo importantes para direcionar a conduta medica atraves de observacoes cientificas consistentes. Passos como selecao dos pacientes, randomizacao e cegamento sao fundamentais na realizacao de um ECCR e apresentam algumas dificuldades extras nos ensaios que envolvem procedimentos cirurgicos, como e comum na Ortopedia. O objetivo deste artigo e destacar e discutir algumas dificuldades e eventuais limitacoes dos ECCR na area cirurgica.

Publication rates of papers presented at the Brazilian Orthopedic Meeting

OBJECTIVE: To quantify the publication rates of the papers presented at the 2007 Brazilian Orthopedics Meeting (Congresso Brasileiro de Ortopedia - CBOT). METHODS: Evaluation of the proportion of abstracts submitted by the various orthopedic subspecialties and according to the Brazilian states. Then, a Lilacs and PubMed search was performed in order to determine which presentations generated national or international published papers. RESULTS: São Paulo and the Southeast region were responsible for the greatest number of presentations at the congress (54.1% and 68.3% respectively). Shoulder and Elbow were the subspecialty responsible for more presentations (13.8%). Among the 653 studies presented at the congress, 174 (26.6%) were published. Oral presentations obtained a publication rate 3.58 times higher than posters. CONCLUSION: The CBOT publication rate is lower than 30%. Many of the papers presented at the CBOT does not pass the scrutiny of scientific journals and therefore should not be the only source of scientific update of the participants: Descriptive Epidemiologic.

PROCEDIMENTO DE LATARJET ARTROSCÓPICO: AVALIAÇÃO DA SEGURANÇA EM CADÁVERES

OBJECTIVE: To evaluate the safety of arthroscopic Latarjet procedure in cadavers. METHODS : Twelve cadaveric shoulders underwent arthroscopic Latarjet procedure in our laboratory for arthroscopy, by four different surgeons. Following surgery, the specimens were subjected to radiographic examination and evaluated by an independent examiner. Nineteen parameters were evaluated, including the coracoid graft fixation, positioning and angulation of the screws, neurological damage and integrity of tendons. RESULTS : Four procedures were considered to be satisfactory, with no difference among the surgeons. The mean angulation of the screws was 27.2°. The subscapularis splitting was, on average, 17.8mm from the upper edge. The coracoid graft was properly positioned relative to equator of the glenoid in 11 cases. There was no injury to the axillary or musculocutaneous nerves. The main complications were: interposition of soft tissue, suprascapular nerve injury, articular deviation of the graft, diastasis and conjoined tendon injury. CONCLUSION : The arthroscopic Latarjet procedure is a complex technique in which each step must be precise to reduce the risk of complications. Our study showed a high risk of failure of the procedure. Level of Evidence IV, Case Series.

Fratura avulsão do planalto tibial medial (Segond reverso)

SUMMARY This article reports an injury pattern described only twice in literature, totaling four cases, and referred to as reverse Segond injury for its clinical and radiological findings are precisely opposite to those observed in the classical Segond injury. Similarly to the previously described cases, our case reported avulsion fracture of the medial tibial plateau at the insertion of the deep tibial collateral ligament, associated to posterior cruciate ligament injury. Similarly to one of the previous cases, anterior cruciate ligament injury was found in our case, although it differs from the previous ones because it does not show medial meniscal injury.

Tomographic evaluation of Hill-Sachs lesions: is there a correlation between different methods of measurement?

Background Several methods are currently available to evaluate and quantify the glenoid or humeral bone loss; however, none is universally accepted, particularly in the case of Hill–Sachs (HS) lesions. Purpose To establish whether there is correlation among different methods of measuring HS lesions, and to investigate the correlation between glenoid bone loss and the various HS lesion measurements and to assess the inter-observer reliability of such measurements. Material and Methods We assessed computed tomography (CT) or arthro-CT scans taken from individuals with recurrent anterior glenohumeral dislocation. The scans were independently assessed by two examiners. The parameters assessed were as follows: HS lesion width and depth on the axial and coronal planes, articular arc loss on the axial plane, and percentage of glenoid bone loss on the sagittal plane. Results Scans from 50 shoulders were assessed. The percentage of articular arc loss and HS lesion width on the axial plane were the only measurements that exhibited strong correlation (r = 0.83; P < 0.001). The values of the correlation coefficient corresponding to HS lesion depth on the coronal plane were the lowest. Most of the measurements exhibited moderate correlation. The inter-examiner reliability was good relative to all measurements except for HS lesion width and depth on the coronal plane, for which it was moderate. Conclusion The measurements of articular arc loss and HS lesion width on the axial plane exhibited strong correlation. The inter-examiner reliability relative to articular arc loss, HS lesion width and depth on the axial plane, and glenoid bone loss was good.