Sergio Luiz Checchia

Surgical treatment of acute and chronic posterior fracture-dislocation of the shoulder

Seventy-three shoulders (66 patients) with posterior fracture-dislocation of the shoulder were treated. Thirty patients were treated during the acute phase. One case was classified as subspinous, and 56 were considered subacromial; 4 cases had posterior fracture-dislocation in three parts, 3 in four parts, and 9 at the anatomic neck. Treatment consisted of closed reduction and immobilization in the emergency department, McLaughlins procedure, hemiarthroplasty, total shoulder, open reduction with internal fixation, arthroplastic resection, and arthrodesis. Ten shoulders were treated conservatively. The University of California-Los Angeles rating score was used to analyze 56 shoulders during a mean follow-up period of 32.7 months. Good and excellent results can be achieved in those cases that are treated up to 2 years of the lesion; after 2 years results tend to be fair. We do not suggest total shoulder arthroplasty as a treatment option for those surgeons without the necessary expertise.

Treatment of distal clavicle fractures using an arthroscopic technique.

Whenever indicated, distal clavicle fractures can be treated with a double loop of a nonabsorbable, #5 suture around the clavicle and under the coracoid. We developed an all arthroscopic technique to perform this procedure. From January to September 2004, 7 patients were treated. The mean age was 46 years. The coracoid is identified through the rotator interval. Using a special needle, a double #5 suture is passed around the coracoid. A hole is created at the clavicle and, through another guide wire, is sent to the anterior portal. The double #5 suture is transported to the clavicle. After the reduction of the fracture the sutures are tightened. All 7 cases have healed. The surgical treatment of these fractures is well established, and with the aid of arthroscopy, the morbidity can be decreased. The technique has been shown to be safe with no complications.

Subscapularis muscle enervation: The effect of arm position

Extensive subscapularis muscle release is common in major shoulder reconstructive surgery, and manipulation of the muscles anterior surface may damage its enervation. The subscapularis nerves and their points of entry into the muscle have rarely been described. The objective of this study was to define these points of entry into the subscapularis muscle and the possible modifications that may occur in such points according to the common positions in which the arm is placed during shoulder surgery, that is, internal, neutral, and external rotation. Twenty-five cadavers shoulders were studied by an extensive anterior approach. The nerves were dissected and marked at their points of entry into the muscle. Measurements were taken of the distances of these nerves in the three previously mentioned arm positions. The points of entry of the subscapularis nerves into the muscle may be very close to the surgical field (as close as 1 cm from the glenoid border). Therefore extensive release of the anterior surface of the subscapularis muscle may cause damage to the subscapularis nerves. The risk can be potentially increased by the position of the arm, especially for the upper nerve when the arm is in external rotation.

Comparison between the acromion index and rotator cuff tears in the Brazilian and Japanese populations

BACKGROUND We compared the acromion index, a lateral tilt of the acromion described by Nyffeler et al as a possible cause of rotator cuff tears (RCTs), in 2 different populations: Brazilian and Japanese. METHODS Patients with full-thickness RCTs diagnosed by magnetic resonance imaging and corroborated by intraoperative findings were included in this study. Controls were patients with shoulder radiographs that indicated instability or adhesive capsulitis. The studied population was subdivided into 2 major racial groups: Brazilian and Japanese. We compared 83 Brazilian adults (mean age, 54 years) with RCTs with 28 individuals with intact rotator cuffs matched by sex, age, and race. Similarly, 112 Japanese individuals (mean age, 59 years) with RCTs were compared with 56 controls. The radiographic images were digitally scanned (HP DeskJet F4180; Hewlett-Packard, Palo Alto, CA, USA) and analyzed. RESULTS The mean acromion index of the Brazilian patients with RCTs was 0.72; 0.68 was the result for the Japanese patients. When patients with RCTs were compared with those with intact rotator cuffs, a statistically significant difference was found in the Brazilian population (P = .001) but not in the Japanese population (P = .18). Therefore, Brazilian subjects with RCTs were found to have a greater lateral extension of the acromion than those with intact rotator cuffs. Such a difference, however, was not observed in the Japanese population. CONCLUSION The acromion index can be used as a predictive factor for RCTs in the Brazilian population but not in the Japanese population.

Avaliação dos resultados das reoperações de pacientes com lesões do manguito rotador

OBJECTIVES: To assess the results from open or arthroscopic surgical treatment on patients with symptomatic recurrence of rotator cuff injuries. METHODS: Between December 1990 and July 2007, 30 patients were assessed and underwent reoperation performed by the Shoulder and Elbow Surgery Group of the Department of Orthopedics and Traumatology, Fernandinho Simonsen Wing, Santa Casa de Sao Paulo, because of dehiscence of the rotator cuff suture. The study included patients with symptomatic recurrence of the injury and with at least 24 months of postoperative follow- up. RESULTS: According to the UCLA evaluation criteria, 21 patients (70%) showed excellent or good outcomes; and nine patients (30%) showed fair or poor outcomes. CONCLUSION: Open or arthroscopic surgical treatment of recurrent rotator cuff injuries tended to present worse results than from the primary repair. In this study, we found that 70% of the results were excellent and good. The presence of extensive injuries in the reoperation tended to evolve with larger numbers of unsatisfactory results. In our study, we obtained better results from arthroscopic surgery than from open surgery.

Lesões extensas do manguito rotador: avaliação dos resultados do reparo artroscópico

OBJECTIVES: To assess the outcomes of the surgical treatment of extensive rotator cuff injuries through arthroscopy. METHODS: Between June 1998 and October 2006, 61 patients with extensive rotator cuff injuries and submitted to surgical arthroscopy technique by the Shoulder and Elbow Group of the Department of Orthopaedics and Traumatology, Santa Casa de Misericordia Medical School were reassessed. The study included all patients with at least two tendons affected or with retraction at least on two tendons up to the glenoidal cavity edge and with at least 12 months of follow-up. RESULTS: According to UCLAs evaluation criteria, 54 (89%) patients showed excellent or good outcomes; no fair outcome in none of the patients; and seven (11%) poor outcomes. A satisfaction rate of 92% was reported. Postoperative joint motion went from a mean lifting value of 93o to 141o, the mean lateral rotation went from 32o to 48o and the mean medial rotation went from L1 to T10. These differences were regarded as statistically significant. CONCLUSION: The arthroscopic repair of extensive rotator cuff injuries leads to satisfactory outcomes for most of the patients, with a high satisfaction degree.

Estudo radiográfico do índice acromial e sua relação com as lesões do manguito rotador

OBJECTIVE: The purpose of this study is to evaluate the association between lateral extension of the acromion and rotator cuff tears (RCT) in the Brazilian population. METHODS: Lateral extension of the acromion was measured using anteroposterior radiographs of the shoulders, carried out with glenoid cavity in the absolute profile and the humeral head in neutral or internal rotation. The acromion index (AI) was defined by the ratio of the distance from the glenoid cavity to the lateral border of the acromion, and the distance from the glenoid cavity to the lateral border of the humeral head. This index was measured in 83 patients with (average age 54 years) with RCT and compared with a group with 28 patients (average age 48 years) without RCT. The presence or absence of RCT was defined by Magnetic resonance Imaging. RESULTS: The average AI was 0.7194 in the patients with RCT and 0.6677 in the individuals without RCT, in the Brazilian population. This difference was highly significant, with P< 0.001. CONCLUSION: An association can be established between AI and rotator cuff tear in the Brazilian population.

Avaliação dos resultados do reparo artroscópico de lesões do manguito rotador em pacientes com até 50 anos de idade

OBJECTIVE: To assess the results from arthroscopic surgical treatment of rotator cuff injuries among patients under 50 years of age. METHODS: Sixty-three patients with rotator cuff injuries who underwent arthroscopic surgical treatment performed by the Shoulder and Elbow Group of the Department of Orthopedics and Traumatology, in the Fernandinho Simonsen wing of Santa Casa Medical School, Sao Paulo, between August 1998 and December 2007, were reassessed. The study included all patients with rotator cuff injuries who were under 50 years of age and had been followed up postoperatively for at least 24 months. RESULTS: According to the UCLA evaluation criteria, 59 patients (92%) showed excellent and good results; five (8%) showed fair results; and none showed poor results. The postoperative evaluation showed that the mean range of motion was 145˚ for elevation, 47˚ for lateral rotation and T10 for medial rotation. Unsatisfactory results were associated with prolonged duration of the injury, with a statistically significant relationship. CONCLUSION: Arthroscopic repair of rotator cuff injuries in young patients produces excellent or good results for most patients.

Avaliação dos resultados da tenodese artroscópica do bíceps, utilizando-se parafuso de interferência bioabsorvível

OBJECTIVE: To evaluate results obtained with arthroscopic tenodesis of the long head of the biceps (LHB) using a bioabsorbable interference screw Arthrex® biotenodesis. METHODS: Between March 2004 and April 2005, 16 shoulders of 16 patients were submitted to LHB tenodesis using this technique. Minimum follow-up was 12 months, with a mean of 19.5 months. Age ranged from 32 to 69 years, mean of 56.1 years. Male patients prevailed, with 75% of the cases. The dominant limb was involved in 62.5% of the patients. Partial lesion of the LHB was found in 75% of the patients, and instability in 25%. Association to rotator cuff lesion (RCL) was found in 93.75% of the cases. Clinical evaluation was based on the University of California at Los Angeles (UCLA) criteria. RESULTS: The authors observed excellent results in all cases. No case displayed signs of biceps muscle retraction (Popeye sign) that characterized the loosening of the tenodesis. CONCLUSION: Arthroscopic LHB tenodesis using a bioabsorbable interference screw Arthrex® biotenodesis showed to be an efficient technique for the treatment of LHB alterations.

Avaliação dos resultados do tratamento cirúrgico das fraturas-luxações da extremidade proximal do antebraço no adulto

OBJETIVO: Avaliar os resultados obtidos no tratamento das fraturas-luxacoes da extremidade proximal do antebraco (FLEPA), procurando identificar fatores que possam influenciar no prognostico desse tipo de lesao traumatica. METODOS: De outubro de 1994 a dezembro de 2005, 30 pacientes com FLEPA foram submetidos ao tratamento cirurgico. Em todos os casos, o seguimento ambulatorial minimo foi de 12 meses. As lesoes foram classificadas pelo metodo de Chick et al. A media de idade foi de 48 anos, com minima de 25 e maxima de 76 anos. Os mecanismos de trauma foram: queda da propria altura em 17 pacientes (57%), acidentes de via publica em 11 casos (37%), trauma direto em um caso (3%) e agressao fisica em um caso (3%). As fraturas expostas corresponderam a oito casos (27%). Realizou-se a analise estatistica pelo teste exato de Fisher para avaliar os seguintes dados: exposicao do foco de fratura e resultados; sexo e resultados; mecanismo de trauma e resultados; idade e mecanismo de trauma; sexo e mecanismo de trauma. RESULTADOS: Em 11 casos (37%) os resultados foram satisfatorios e em 19 casos (63%), insatisfatorios. Estabeleceu-se apenas relacao estatistica significativa entre exposicao da fratura e resultados. CONCLUSAO: Os tratamentos das FLEPA tem, em sua maioria, resultados insatisfatorios, principalmente nas fraturas expostas, fato estatisticamente significativo neste estudo. Nao foi possivel definir outros fatores prognosticos. Encontrou-se tendencia a melhores resultados nos pacientes do sexo feminino, nos idosos e nas vitimas de traumas de baixa energia.