Nicola Archetti Netto

Treatment of Bankart Lesions in Traumatic Anterior Instability of the Shoulder: A Randomized Controlled Trial Comparing Arthroscopy and Open Techniques

PURPOSE The objective of this study was to compare the functional assessments of arthroscopy and open repair for treating Bankart lesion in traumatic anterior shoulder instability. METHODS Fifty adult patients, aged less than 40 years, with traumatic anterior shoulder instability and the presence of an isolated Bankart lesion confirmed by diagnostic arthroscopy were included in the study. They were randomly assigned to receive open or arthroscopic treatment of an isolated Bankart lesion. In all cases of both groups, the lesion was repaired with metallic suture anchors. The primary outcomes included the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. RESULTS After a mean follow-up period of 37.5 months, 42 patients were evaluated. On the DASH scale, there was a statistically significant difference favorable to the patients treated with the arthroscopic technique, but without clinical relevance. There was no difference in the assessments by University of California, Los Angeles and Rowe scales. There was no statistically significant difference regarding complications and failures, as well as range of motion, for the 2 techniques. CONCLUSIONS On the basis of this study, the open and arthroscopic techniques were effective in the treatment of traumatic anterior shoulder instability. The arthroscopic technique showed a lower index of functional limitation of the upper limb, as assessed by the DASH questionnaire; this, however, was not clinically relevant.

Result from surgical treatment on the terrible triad of the elbow

Objective To evaluate the results from surgical treatment of the terrible triad of the elbow, with a minimum of six months of follow-up, taking elbow function into consideration. Methods The analyzed aspects of 20 patients, who underwent surgical treatment of the terrible triad of the elbow, were given as follows: Dash score (Disabilities of the Arm, Shoulder and Hand), Meps (Mayo Elbow Performance Score), pain according to VAS (visual analog scale), ROM (range of motion), patient satisfaction, degree of energy of the trauma, complications and radiographs. Results The mean length of follow-up among the patients was 38 months. There were statistically significant relationships between the following set of parameters: trauma mechanism and patient satisfaction; radiological outcome of “heterotopic ossification” and satisfaction; functional flexion–extension ROM and satisfaction; and between type of radial head fracture and presence of a radiological outcome. Conclusion The surgical treatment for the terrible triad of the elbow generally provided satisfactory results, when the functioning of this joint upon the return to activities was taken into consideration.

A mechanical comparison between conventional and modified angular plates for proximal humeral fractures

The objective of this study is to present a modified angular blade plate for fixing 2-part and even 3-part fractures of the proximal humerus, as well as the results of the comparative mechanical test between the conventional angular blade plate and this new modified plate. The plates were tested in flexion and rotational trials in a wooden model that simulated a 2-part humeral fracture of the proximal extremity. The results (mean +/- SD) of bending strength and stiffness obtained after testing showed findings of 601 +/- 349 N and 0.5 +/- 0.2 N/mm, respectively, for the conventional plate and 4005 +/- 164 N and 3.9 +/- 0.7 N/mm, respectively, for the modified plate. The torsional stiffness test showed findings of 1.26 +/- 0.09 KN.mm degrees for the conventional plate and 1.74 +/- 0.21 KN.mm degrees for the modified plate. The test of torsional moment showed findings of 57.0 +/- 7.6 KN.mm for the conventional plate and 115.2 +/- 9.3 KN.mm for the modified plate. The test of angular displacement at the torsional moment showed findings of 50.8 degrees +/- 7.2 degrees for the conventional plate and 70.2 degrees +/- 2.6 degrees for the modified plate. The results of the mechanical trials of flexion and rotation were superior for the modified angular blade plate compared with the conventional angular blade plate.

Minimally Invasive Osteosynthesis with a Bridge Plate Versus a Functional Brace for Humeral Shaft Fractures: A Randomized Controlled Trial

Background: Nonoperative treatment has historically been considered the standard for fractures of the shaft of the humerus. Minimally invasive bridge-plate osteosynthesis for isolated humeral shaft fractures has been proven to be a safe technique, with good and reproducible results. This study was designed to compare clinical and radiographic outcomes between patients who had been treated with bridge plate osteosynthesis and those who had been managed nonoperatively with a functional brace. Methods: A prospective randomized trial was designed and included 110 patients allocated to 1 of 2 groups: surgery with a bridge plate or nonoperative treatment with a functional brace. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) score at 6 months. The score on the Short Form-36 (SF-36) life-quality questionnaire, complications of treatment, Constant-Murley score for the shoulder, pain level, and radiographic results were assessed as secondary outcomes. Participants were assessed at 2 weeks; 1, 2, and 6 months; and 1 year after the interventions. Results: The mean DASH score of the bridge plate group was statistically superior to that of the functional brace group (mean scores, 10.9 and 16.9, respectively; p = 0.046) only at 6 months. The bridge plate group also had a significantly more favorable nonunion rate (0% versus 15%) and less mean residual angular displacement seen on the anteroposterior radiograph (2.0° versus 10.5°) (both p < 0.05). No difference between the groups was detected with regard to the SF-36 score, pain level, Constant-Murley score, or angular displacement seen on the lateral radiograph. Conclusions: This trial demonstrates that, compared with functional bracing, surgical treatment with a bridge plate has a statistically significant advantage, of uncertain clinical benefit, with respect to self-reported outcome (DASH score) at 6 months, nonunion rate, and residual deformity in the coronal plane as seen on radiographs. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Do computed tomography and its 3D reconstruction increase the reproducibility of classifications of fractures of the proximal extremity of the humerus

Objective to determine whether 3D reconstruction images from computed tomography (CT) increase the inter and intraobserver agreement of the Neer and Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification systems. Methods radiographic images and tomographic images with 3D reconstruction were obtained in three shoulder positions and were analyzed on two occasions by four independent observers. Results the radiographic evaluation demonstrated that using CT improved the inter and intraobserver agreement of the Neer classification. This was not seen with the AO classification, in which CT was only shown to increase the interobserver agreement. Conclusion use of 3D CT allows better evaluation of fractures with regard to their component parts and their displacements, but nevertheless the intraobserver agreement presented is less than ideal.

Effectiveness of intra-articular lidocaine injection for reduction of anterior shoulder dislocation: randomized clinical trial

CONTEXT AND OBJECTIVE Shoulder dislocation is the most common dislocation among the large joints. The aim here was to compare the effectiveness of reduction of acute anterior shoulder dislocation with or without articular anesthesia. DESIGN AND SETTING Prospective randomized trial conducted in Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-Unifesp). METHODS From March 2008 to December 2009, 42 patients with shoulder dislocation were recruited. Reductions using traction-countertraction for acute anterior shoulder dislocation with and without lidocaine articular anesthesia were compared. As the primary outcome, pain was assessed through application of a visual analogue scale before reduction, and one and five minutes after the reduction maneuver was performed. Complications were also assessed. RESULTS Forty-two patients were included: 20 in the group without analgesia (control group) and 22 in the group that received intra-articular lidocaine injection. The group that received intra-articular lidocaine had a statistically greater decrease in pain over time than shown by the control group, both in the first minute (respectively: mean 2.1 (0 to 5.0), standard deviation, SD 1.3, versus mean 4.9 (2.0 to 7.0, SD 1.5; P < 0.001) and the fifth minute (respectively: mean 1.0; 0 to 3.0; SD = 1.0 versus mean 4.0; 1.0 to 6.0; SD = 1.4; P < 0.001). There was one failure in the control group. There were no other complications in either group. CONCLUSION Reduction of anterior shoulder dislocation using intra-articular lidocaine injection is effective, since it is safe and diminishes the pain. CLINICAL TRIAL REGISTRATION ISRCTN27127703.

Reproducibility of three classifications of proximal humeral fractures

OBJECTIVE To propose a new system for classifying proximal humeral neck fractures, and to evaluate intra- and interobserver agreement using the Neer system that is the most commonly used in the area and the Arbeit Gemeinschaft für Osteosynthesefragen system created by an European group, and a new classification system proposed by the authors of this study. METHODS A total of 56 patients with proximal humeral fractures were selected, and submitted to digitized simple radiography in antero-posterior shoulder and scapular profile. Radiographs were analyzed by three observers at time one, and then three and six weeks later. The kappa coefficient modified by Fleiss was used for the analysis. RESULTS The mean intra-observer Kappa agreement index (k = 0.687) of the new classification, was higher than both the Neer classification (k = 0.362) and the Arbeit Gemeinschaft für Osteosynthesefragen (k = 0.46). The mean interobserver Kappa agreement index (0.446) of the new classification, also had better results than both the Neer classification (k = 0.063) and the Arbeit Gemeinschaft für Osteosynthesefragen (k = 0.028). CONCLUSION the new classification considering bone compression had higher results for intra- and interobserver compared to the Neer system, and the Arbeit Gemeinschaft für Osteosynthesefragen system.

Functional outcomes of traumatic and non-traumatic rotator cuff tears after arthroscopic repair

AIM To compare the functional outcomes of traumatic and non-traumatic rotator cuff tears after arthroscopic repair. METHODS Eighty-seven patients with rotator cuff tears following arthroscopic treatment were divided into traumatic and non-traumatic tear groups. Postoperative muscle strength and outcomes using the modified University of California, Los Angeles score were evaluated. Sex, age, affected limb and dominant limb were correlated between groups. Muscle strength of the repaired and unaffected shoulders was compared. Rotator cuff injury size was measured. RESULTS Of the 87 patients who underwent rotator cuff repairs, 35 had traumatic tears and 52 had non-traumatic tears. In patients with non-traumatic tears, the average age was 59 years, 74.5% were female, 96.1% were right-hand dominant and 92.3% had their dominant shoulder affected. Patients with traumatic tears were 59.5 years old on average, 51.4% were female, 91.4% were right-hand dominant and 88.5% had their dominant shoulder affected. No difference existed in the mean modified University of California, Los Angeles score between patients with traumatic tears (33.7) compared with those with non-traumatic tears (32.8). No strength differences were observed between groups: The strength difference between the non-affected and affected sides was 1.21 kg in the non-traumatic group and 1.39 kg in the traumatic group (P = 0.576), while the strength ratio between the non-affected/affected sides was 0.805 in the non-traumatic group and 0.729 in the traumatic group (P = 0.224). CONCLUSION The functional results of traumatic rotator cuff repairs are similar to non-traumatic tears. Both outcomes are satisfactory.

Avascular necrosis of the sternal end of the clavicle: A case report

Avascular necrosis of the sternal end of the clavicle was described by Friedrich in 1924 and is known as Friedrich disease. Since then, few cases have been reported in the literature. Most patients have been women and without histologic confirmation of the disease. The disease is rare, and the etiology is unknown. In general, it presents with pain in the sternoclavicular joint (SCJ) and an increase in the volume of the sternal end of the clavicle that progresses to an insidious functional limitation of the shoulder joint. Conservative treatment results in remission of the symptoms in most patients, and resection of the sternal end of the clavicle is reserved for resistant cases. We report a man with Friedrich disease confirmed by histologic examination who underwent resection of the sternal end of the clavicle.

Sensitivity and specificity of ultrasonography in diagnosing supraspinatus lesions: a prospective accuracy diagnostic study

BACKGROUND This study was designed to define the accuracy of shoulder ultrasonography for diagnosing supraspinatus tendon tears. This examination is routinely used by orthopedists and may do away with the need for other examinations for diagnosing these tendon injuries. The aim of this study was to evaluate the sensitivity and specificity of shoulder ultrasonography for diagnosing supraspinatus tendon injuries, using magnetic resonance imaging as the reference. DESIGN AND SETTING Prospective accuracy study at a single center: the Shoulder and Elbow Surgery Clinic of the Department of Orthopedics and Traumatology. METHODS Shoulder ultrasonography was performed on 80 patients of both genders, over 18 years of age, with complaints of shoulder pain and clinically suspected supraspinatus tendon lesions. Jobes test and a full can test were performed. In addition, they underwent magnetic resonance imaging in a 3.0-tesla machine, as the reference standard. The examinations were performed and interpreted by radiologists. RESULTS Ultrasonography showed sensitivity of 36.3% and specificity of 91.7% for supraspinatus tears overall: sensitivity of 25.8% and specificity of 91.8% for partial tears and sensitivity of 46.2% and specificity of 100% for full-thickness tears. Ultrasonography showed high accuracy for diagnosing full-thickness tears: 91.3%. The p-values were 0.003 for tears overall, 0.031 for partial tears and < 0.001 for full-thickness tears. CONCLUSIONS Ultrasonography showed low sensitivity for detecting supraspinatus tears, but high specificity for both partial and full-thickness tears.