José Sergio Franco

Intraobserver and interobserver agreement of Goutallier classification applied to magnetic resonance images

BACKGROUND Fatty infiltration of the muscle bellies is an important prognostic factor in rotator cuff tears. It was described initially in computed tomography examinations, and there is an ongoing debate about whether magnetic resonance (MR) is a reliable method for staging fatty infiltration. This study sought to determine intraobserver and interobserver agreement for Goutalliers classification of fatty infiltration of the rotator cuff as evaluated through MR imaging. MATERIALS AND METHODS Twenty MR examinations of the shoulder showing full-thickness tear of the supraspinatus tendon, with or without associated lesions, were evaluated by 3 radiologists with experience in musculoskeletal system imaging and 3 fellowship-trained shoulder surgeons. The evaluators classified the fatty infiltration of the supraspinatus muscle according to the guidelines proposed by Goutallier et al. After 8 weeks, they re-evaluated the examinations, without access to their previous reports. Weighted κ index values were determined for intraobserver and interobserver agreement analyses, and intraobserver agreement κ values are reported with 95% confidence intervals (CIs). RESULTS The mean intraobserver agreement was 0.832 among the orthopedists (CI > 95%) and 0.741 among the radiologists (CI > 95%). Interobserver agreement was 0.8214 (evaluation 1) and 0.7231 (evaluation 2) among the orthopedists (P < .0001) and 0.6627 (evaluation 1) and 0.6067 (evaluation 2) among the radiologists (P < .0001). Intraobserver agreement was not associated with length of experience or frequency of routine evaluations. CONCLUSIONS When it is applied to MR images of rotator cuff musculature, Goutalliers fatty infiltration staging rubric yielded highly significant intraobserver and interobserver agreement.

Recommendations for avoiding knee pain after intramedullary nailing of tibial shaft fractures

BackgroundThe objective of this study is to analyze the proximal tibiofibular joint in patients with knee pain after treatment of tibial shaft fractures with locked intramedullary nail.FindingsThe proximal tibiofibular joint was analyzed in 30 patients, who reported knee pain after tibial nailing, and standard radiograph and computed tomography were performed to examine the proximal third of the tibia. Twenty patients (68.9%) presented the proximal screw crossing the proximal tibiofibular joint and 13 (44.8%) had already removed the nail and/or screw. Four patients (13.7%) reported complaint of knee pain. However, the screw did not reach the proximal tibiofibular joint. Five patients (17.2%) complained of knee pain although the screw toward the joint did not affect the proximal tibiofibular joint.ConclusionWhen using nails with oblique proximal lock, surgeons should be careful not to cause injury in the proximal tibiofibular joint, what may be one of the causes of knee pain. Thus, the authors suggest postoperative evaluation performing computed tomography when there is complaint of pain.

Tratamento das fraturas distais da tíbia

OBJECTIVE: to compare the results of fibula fixation (or non fixation) in the treatment of fractures located in the distal third of the tibia, by using intramedullary nailing and bridge plate. METHOD: 47 fractures on 47 patients were studied. Twenty-one patients were treated with non-reamed, interlocking intramedullary nailing, and 26 patients were treated with wide or narrow dynamic compression plates (using a minimally invasive technique). All of the fibular fractures were located at the same level or below tibial fractures. RESULTS: in the group of patients treated with fibula fixation, the average healing time was 14.6 weeks. In the group of patients treated without fibula fixation, the average healing time was 14.3 weeks. In the group of patients treated with fibula fixation a significantly smaller proportion of valgus angular deviation (6.3%) was observed compared to the group of patients treated without fibula fixation (32.3%). CONCLUSIONS: The benefits of fibula fixation remain controversial when tibial fractures are associated. Regarding fracture healing, there was no significant difference between the studied fracture groups.

Proximal humeral fractures: an understanding of the ideal plate positioning

PurposeThe present study aims to evaluate if the bicipital groove can be used as a parameter for ideal plate positioning in proximal humeral fixation applying locking compression plate.MethodThe authors questioned whether the bicipital groove can be used as a parameter for ideal plate positioning applying locking compression plate for proximal humeral fractures. A method using the bicipital groove as the main parameter was developed using computed tomography scan (CT-scan). Seventy shoulders presenting fracture absence were used to calculate proper plate positioning, allowing the largest area for locked screw placement into the humeral head. Intraclass correlation coefficient and Bland and Altman graphics calculated intra-observer reliability for CT-scan evaluation.ResultsAll observers presented satisfactory plate positioning using this method. The mean differences for observers were close to zero, suggesting high interobserver reproducibility. A significant (p <0.0001) intra-observer agreement existed for the three evaluators. Observer 2 agreement was the strongest (ICC = 0.98), showing almost perfect reproducibility measurement, followed by observer 3 (ICC = 0.84) with good reproducibility, and lastly observer 1 demonstrated moderate degree agreement (ICC = 0.47).ConclusionConsidering the CT-scan analysis, the bicipital groove can be used as a parameter for ideal plate positioning in proximal humeral fractures. This method demonstrated satisfactory intra-observer reproducibility. Adopting this method, longer and better distributed screw placement provides more stable fixation for proximal humeral fractures.

Vitamin D and its relation to bone mineral density in postmenopause women

Resumo Objetivo Comparar o nivel de vitamina D com a densidade mineral ossea (DMO) em mulheres na pos-menopausa, com ou sem fraturas. Metodos Foram avaliadas 250 mulheres com idade media de 71,1 anos. Os niveis sericos de vitamina D foram considerados normais quando ≥ 30 ng/mL, insuficientes entre 20 e 30 ng/mL e deficientes Resultados Nao existiu diferenca significativa na dosagem de vitamina D (ng/mL) entre as faixas etarias (p = 0,25), os niveis de fratura (p = 0,79) e os niveis da DMO (p = 0,76). Conclusao Das pacientes, 82% apresentaram niveis sericos de vitamina D deficientes e insuficientes. Nossos resultados nao demonstraram correlacao significativa entre os niveis de vitamina D e DMO com a idade.

Estudo experimental da resistência das osteossínteses com placas e parafusos na fixação anterior da coluna cervical

In order to evaluate the stability of the anterior fixation with plate and screws, the author conducted an experimental study in segments of the cervical spine (C3-C7) in fresh human cadavers, comparing 3 different types of plates. He used a H-type Orozcos plate (4 specimens); a conventional plate of 1/3 tubular (4 specimens); plates described by Mendonca (5 specimens); and the control group without fixation (5 specimens). In all specimens a Corpectomy was used and the lateral walls of the vertebral bodies were left intact. The specimens were tested in axial compression machine, with slow and progressive loading, using mechanical graphic recorder. Results have shown that, concerning initial failure, stabilization of the fixations is similar among groups but inferior to the control group. Statistically, the difference was significant between the control group and the 1/3 tubular and Mendonca plates, but it was similar to the H plate. Concerning maximum resistance, no significant differences were observed in comparing fixations to the control group. Based on the results, the author concludes that fixation with the H plate offers better stability when compared to other fixations and that the plates and screws used in the study decreased resistance when compared to the control group.

Localização segura na colocação dos pinos percutâneos no calcâneo

OBJECTIVE: To determine the areas presenting risk in six zones of the calcaneus, and to quantify the risks of injury to the anatomical structures (artery, vein, nerve and tendon). METHOD: Fifty-three calcaneus from cadavers were used, divided into three zones and each subdivided in two areas (upper and lower) by means of a longitudinal line through the calcaneus. The risk of injury to the anatomical structures in relation to each Kirschner wire was determined using a graded system according to the Licht classification. The total risk of injury to the anatomical structures through placement of more than one wire was quantified using the additive law of probabilities and the product law for independent events. RESULTS: The injury risk calculation according to the Licht classification showed that the highest risk of injury to the artery or vein was in zone IA (43%), in relation to injuries to nerves and tendons (13% and 0%, respectively). CONCLUSION: This study made it possible to identify the most vulnerable anatomical structures and quantify the risk of injury to the calcaneus.

Clavicle fractures - incidence of supraclavicular nerve injury

Objective To analyze retrospectively 309 fractures in the clavicle and the relation with injury of the supraclavicular nerve after trauma. Methods It was analyzed 309 patients with 312 clavicle fractures. The Edinburgh classification was used. Four patients had fractures in the medial aspect of the clavicle, 33 in the lateral aspect and 272 in the diaphyseal aspect and three bilateral fractures. Results 255 patients were analyzed and five had paresthesia in the anterior aspect of the thorax. Four patients had type 2 B2 fracture and one type 2 B1 fracture. All patients showed spontaneous improvement, in the mean average of 3 months after the trauma. Conclusion Clavicle fractures and/or shoulder surgeries can injure the lateral, intermediary or medial branches of the supraclavicular nerve and cause alteration of sensibility in the anterior aspect of the thorax. Knowledge of the anatomy of the nerve branches helps avoid problems in this region.

Diagnóstico clínico da ruptura do tendão subescapular com a manobra semiológica bear hug

OBJECTIVE: To evaluate the Bear Hug maneuver for clinically diagnosing subscapularis tendon tears, and compare this with other maneuvers described previously (Lift-off, Napoleon and Belly Press). METHODS: Forty-nine patients with rotator cuff injuries who had undergone arthroscopy to repair the injury and had previously been assessed using the semiological maneuvers mentioned above were evaluated. RESULTS: The diagnostic values obtained for the Bear Hug test were as follows: sensitivity 75%, specificity 56%, positive predictive value 62%, negative predictive value 70% and accuracy 65%. CONCLUSION: The highest sensitivity and negative predictive value values were obtained with the Bear Hug test. The highest specificity value was seen with the Lift-off test. The Belly press test gave the greatest specificity, positive predictive and accuracy values.

Tuberculose refratária disseminada com acometimento do tendão bicipital em paciente imunocompetente

OBJETIVO: Relatar um caso raro de tuberculose disseminada em paciente imunocompetente, que evoluiu, durante o tratamento medicamentoso padrao, com envolvimento do tendao da porcao longa do biceps e da articulacao do ombro. METODOS: A primeira avaliacao, o diagnostico correto nao foi feito e o paciente foi tratado com fisioterapia para tendinopatia do manguito rotador. Entretanto, apresentou rapida formacao de massa na regiao anterior do terco proximal do braco e piora da dor. A puncao da massa revelou liquido amarelado, cuja analise laboratorial confirmou tratar-se de infeccao por M. tuberculosis. RESULTADOS: O paciente foi tratado com desbridamento cirurgico e troca do esquema medicamentoso e evoluiu com resolucao do quadro infeccioso e melhora completa da funcao do ombro direito. CONCLUSAO: Devido a sua alta prevalencia no Brasil, a tuberculose deve sempre ser considerada no diagnostico diferencial dos casos de comprometimento cronico e progressivo das articulacoes, ossos, musculos, tendoes e bursas, mesmo em individuos imunocompetentes.