Jorge Henrique Assunção

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.

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.

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.

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.

Fatores preditivos para marcha na fratura transtrocanteriana do fêmur

OBJECTIVE: The objective of this study was to identify variables that could predict the quality of gait in patients with transtrochanteric femoral fractures after treatment. MATERIALS AND METHODS: Hospitalized patients diagnosed with transtrochanteric femoral fractures were selected between September/2005 and August/2006 and followed-up for 6 months after the trauma date. An observational prospective study was conducted to assess the quality of gait 3 and 6 months after fracture in 31 patients (13 males and 18 females). The mean age was 76±2,7. RESULTS: Seven patients (22,6%) passed away during the follow-up period. The patients with associated fractures or with four or more co-morbidities showed a worse quality of gait after 6 months. Patients without orthopaedic complications or who got partial weight load prior to 30 days showed a better performance. CONCLUSION: The quantification of predictive gait indexes allows us to propose new treatment approaches consistently to the different realities showed by each group of patients.

Intraobserver and interobserver agreement in the classification and treatment of proximal humeral fractures

BACKGROUND There is controversy surrounding the reliability of radiographic measurements and existing classifications for proximal humeral fractures. METHODS Ten orthopedists, divided into 2 groups by length of experience, evaluated radiographs in 3 views from 40 proximal humeral fractures. We evaluated 11 radiographic criteria (including the Neer and pathomorphologic classifications, head-shaft angle, displacement of the humeral shaft, and lesser and greater tuberosities) and treatment indication. We also analyzed the criteria that most influenced the choice of treatment. RESULTS Interobserver reliability was substantial for the presence of fracture of the greater tuberosity (κ = 0.749) and medial metaphyseal comminution (κ = 0.627) and moderate for the pathomorphologic classification (κ = 0.504), displacement of the greater tuberosity (κ = 0.422), and treatment decision (κ = 0.565). Intraobserver reliability was substantial for treatment indication (κ = 0.620) and presence of displacement of the fracture of the greater tuberosity (κ = 0.627 and 0.611) and moderate for the Neer (κ = 0.490) and pathomorphologic (κ = 0.607) classifications. The results were influenced by the observers experience. The surgical indication was influenced by the pathomorphologic classification in 50% of the evaluators (odds ratio, 4.85; range, 3.30-8.65). CONCLUSION The pathomorphologic classification has higher reliability than the Neer classification and was the factor that most influenced the surgical decision. The determination of the presence of fracture and displacement of the greater tuberosity and medial metaphyseal comminution is reliable with the use of simple radiographs, and the results were influenced by the observers experience.

RESULTS FROM FILLING “REMPLISSAGE” ARTHROSCOPIC TECHNIQUE FOR RECURRENT ANTERIOR SHOULDER DISLOCATION

Objective: To evaluate the clinical result from the filling (“remplissage”) technique in association with Bankart lesion repair for treating recurrent anterior shoulder dislocation. Methods: Nine patients (10 shoulders), with a mean follow-up of 13.7 months, presented traumatic recurrent anterior shoulder dislocation. All of them had a Bankart lesion, associated with a Hill-Sachs lesion showing the “engaging” sign. The Hill-Sachs lesion defect was measured and showed an average bone loss of 17.3% (7.7% to 26.7%) in relation to the diameter of the humeral head. All the cases underwent arthroscopic repair of the Bankart lesion, together with filling of the Hill-Sachs lesion by means of tenodesis of the infraspinatus. Results: The Rowe score ranged from 22.5 (10 to 45) before the operation to 80.5 (5 to 100) after the operation (p > 0.001). The UCLA score ranged from 18.0 (8 to 29) to 31.1 (21 to 31) (p > 0.001). The measurements of external and internal rotation at abduction of 90° after the operation were 63.5° (45° to 90°) and 73° (50° to 92°) respectively. Two patients presented recurrence (one with dislocation and the other with subluxation). None of the patients presented pain in the region of the infraspinatus tendon after the operation. Conclusion: Over the short term, the filling (“remplissage”) arthroscopic technique produced improvements in functional scores and a low complication rate when used for treating glenohumeral instability associated with Hill-Sachs lesions.

Tratamento artroscópico da luxação acromioclavicular aguda com âncoras

OBJETIVO: Apresentar os resultados clinicos e radiograficos de uma serie de casos com diagnostico de Luxacao Acromioclavicular (LAC) Aguda, tratados atraves da fixacao coracoclavicular com âncoras por via artroscopica. METODO: Vinte pacientes apresentando LAC com menos de 30 dias de evolucao foram operados pela tecnica da estabilizacao coracoclavicular com âncoras por via artroscopica. Duas âncoras metalicas com dois fios cada, foram inseridas no coracoide. Os fios foram amarrados sobre a clavicula passando por tuneis transosseos claviculares. Para a avaliacao radiografica, foi utilizada a medida comparativa da distância coracoclavicular com o lado contralateral e a avaliacao funcional atraves dos escores de Constant e UCLA o seguimento foi de seis meses. RESULTADO: Dos vinte casos inicialmente selecionados, seis necessitaram de novo procedimento cirurgico e foram excluidos do estudo. Dos quatorze pacientes restantes, apenas dois mantiveram reducao da articulacao acromioclavicular, enquanto os demais apresentaram algum grau de desvio no decorrer da evolucao. Desconsiderando os pacientes excluidos, os escores de Constant e UCLA tiveram media 94,79 (82-100) e, 32,64 (26-35), respectivamente. CONCLUSAO: A tecnica apresentou um alto indice de perda da reducao ao longo da evolucao de seis meses. A avaliacao funcional apresentou resultado satisfatorio com escore medio elevado de Evidencia: Nivel de Evidencia: Nivel III, estudo retrospectivo.

Comments on: Evaluation of platelet-rich plasma and fibrin matrix to assist in healing and repair of rotator cuff injuries: a systematic review and meta-analysis

We recently read the article “Evaluation of platelet-rich plasma and fibrin matrix to assist in healing and repair of rotator cuff injuries: A systematic review and meta-analysis”, by Chun-Jiang Fu et al.,1 published OnlineFirst in this journal on 29 February 2016. We’re researching the use of platelet-rich plasma (PRP) in rotator cuff repair since 2008, and one of the articles included in this metaanalysis is ours.2 Several systematic reviews on the subject have been published3–7, and all of them evaluate the retear rate after rotator cuff repair. In the recent article by Chun-Jiang Fu et al.,1 the objective is described as the assessment of the effect of the PRP on the healing of the rotator cuff, although the authors studied only clinical outcomes. The results of this recent study indicated that the PRP does not improve clinical outcomes after rotator cuff repair, which is in line with previous metaanalysis.3–7 However, to conclude that “the results of this meta-analysis do not support the use of platelet-rich plasma/platelet-rich fibrin matrix in patients with rotator cuff injuries” the authors do not report exactly all the outcomes studied in the included articles. Chahal et al.3 and Zhang et al.4 demonstrated in their meta-analysis lower incidence of retears in small and medium-sized lesions treated with PRP. Warth et al.6 showed that tears larger than 3 cm treated with double-row technique with addition of PRP leads to less retears. Cai et al.,7 in the metaanalysis with the highest level of evidence to date, including only level I studies, concluded that the PRP led to an overall smaller retear rate. This decrease was higher in small and medium-sized tears. We believe that the stratification by tear size is crucial for a detailed analysis, because retear rate can vary from 4 to 94% after rotator cuff repair,2,8 and the tear size is a well known predictor for this complication.9 Finally, we find that the inclusion of the study of Kesikburun et al.10 was not appropriate. These authors studied PRP applications in patients with tendinopathy or partial tears, that did not undergo surgery, unlike the other articles. This can lead to a inaccurate analysis. We consider more appropriate to include only patients submitted to rotator cuff repair, increasing the internal validity of the review. We agree that the current literature does not support the use of PRP in all cases, and more randomized studies of adequate quality should be performed to determine the true role of PRP in the treatment of rotator cuff injuries. However, to date, the evidence points to a positive effect of platelet concentrate in reducing the retear rate.