MESENCHYMAL CELLS IN ROTATOR CUFF REPAIR - TECHNIQUE DESCRIPTION AND CASE REPORTS

Objective

To describe a protocol of obtention of mesenchymal stem cells and to report their use as a biological adjuvant in three patients undergoing arthroscopic rotator cuff repair.

Methods

Case series of patients who underwent arthroscopic repair of isolated full-thickness supraspinatus tear using mesenchymal stem cells obtained from the bone marrow as a biological adjuvant. All patients were operated on at the same institution, by a surgeon with 13 years of experience. The cells were applied at the end of the procedure, at the tendon-bone interface, at an approximate concentration of 2,000,000 mesenchymal cells/mm3 and a total volume of 5 ml.

Results

All patients improved with the procedure, with one excellent and two good results. All cases overcame the minimally important clinical difference. All cases reached tendon healing, without partial or complete re-tears. We observed no complications.

Conclusion

Arthroscopic rotator cuff repair with added mesenchymal cells obtained from bone marrow and submitted to a cell expansion process led to good functional results and healing in all cases in the sample, with no complications. Level of Evidence IV, Case Series.

HUMERAL SHAFT FRACTURE WITH AN INTACT WEDGE FRAGMENT: MIPO VS CONVENTIONAL PLATING

Objectives

Evaluate bone healing time, consolidation, and the complication rate between the minimally invasive plate osteosynthesis and open reduction with plate osteosynthesis in humeral diaphyseal fractures with an intact wedge (AO 12B2).

Methods

A retrospective study was carried out between 2016 and 2020. The medical records and radiographs of 18 patients were analyzed, and data were collected regarding the time of consolidation, age, sex, plate size, number of screws, complications such as iatrogenic injury damage to the radial nerve, material failure, and postoperative infection.

Results

No statistically significant differences were observed in the variables of age, sex, plate size, and number of screws used or in the RUSHU index (Radiographic Union Score for Humeral fractures). There were no postoperative infections, material failure, or need for reoperation, nor cases of secondary radial nerve injury. After one year, all patients had a consolidation index analyzed by RUSHU >11.

Conclusion

both techniques showed similar results, with a high consolidation rate and low rates of complications or iatrogenic damage to the radial nerve. Evidence level III; Retrospective comparative study .

WEDGE FRAGMENT VARIATIONS OF TIBIAL SHAFT FRACTURES WITH INTRAMEDULLARY NAILING

Introduction

Tibial shaft fracture is the most common long-bone fracture, and the standard treatment is intramedullary (IM) nail fixation. Regardless of the development of this technique pseudoarthrosis remains prevalent.

Objectives

Evaluate the correlation between wedge fragment size and displacement, displacement of the main fragments of the 42B2 type, and pseudoarthrosis incidence.

Methods

We retrospectively assessed all patients with 42B2 type fracture treated with IM nailing between January, 2015 and December, 2019. Six radiographic parameters were defined for preoperative radiographs in the anteroposterior (AP) and lateral views. Another six parameters were defined for postoperative radiographs at three, six, and 12 months. The Radiographic Union Score for Tibial Fractures score was used to assess bone healing.

Results

Of 355 patients with tibial shaft fractures, 51 were included in the study. There were 41 (82.0%) male patients, with a mean age of 36.7 years, 37 (72.5%) had open fractures, and 28 (54.9%) had associated injuries. After statistical analysis, the factors that correlated significantly with nonunion were wedge height > 18 mm, preoperative translational displacement of the fracture in the AP view > 18 mm, and final distance of the wedge in relation to its original anatomical position after IM nailing > 5 mm.

Conclusion

Risk factors for nonunion related to the wedge and42B2 fracture are wedge height > 18 mm, initial translation in the AP view of the fracture > 18 mm, and distance > 5 mm of the wedge from its anatomical position after IM nailing. Evidence level III; Retrospective comparative study .

FUNCTIONAL OUTCOME OF TREATMENT OF DEVIATED OLECRANON FRACTURE (MAYO 2A) BY AN INTRAMEDULLARY SCREW WITH TENSION BAND COMPARED TO CLASSIC TENSION BAND - A PROSPECTIVE RANDOMIZED STUDY

Objective

evaluate the functional treatment outcome of deviated transverse olecranon fractures (Mayo 2A) after treatment with tension-banded intramedullary screw (PIBT) compared to classical tension band (BTC).

Methods

Prospectively collect all deviated transverse olecranon fractures from 2012 to 2016 and randomize them into PIBT and BTC groups. Range of motion (ROM) was measured after 2 and 5 weeks, 3 and 6 months, and 1 and 2 years. Functional assessments (DASH, Oxford Elbow Score, and Mayo Elbow Performance Index) were performed after 3 and 6 months and 1 and 2 years. Complications were collected up to 2 years of follow-up.

Results

22 patients were included, 11 in each group. The mean age was 47.9 years, and the left side was injured in 13 (59.0%) patients. All patients completed the 2-year follow-up. There was no ROM difference at any time between the two groups (p> 0.005). Flexion and extension gain was maximum at three months and remained unchanged until two years. Neither flexion nor extension returned to normal, missing around 10°. Pronation and supination returned to normal. All three functional scores showed almost complete recovery of elbow function after three months postoperatively, with no difference between the groups. No group had complications, no reoperation, and no implant removal.

Conclusion

PIBT had similar results in ROM and functional score compared to BTC. Both had low complication rates and no need for implant removal. Level of evidence I; Randomized Trial .

Nonoperative Treatment of Psoas Tendon Avulsion in a Professional Athlete: A Case Report and Evidence Based Review

CASE

A 36-year-old male professional soccer player sustained an acute left hip injury during a tournament game while defending the goal. Magnetic resonance imaging demonstrated a complete avulsion of the iliopsoas tendon from the left trochanter. The patient was treated nonoperatively, and after 10 weeks, he was able to return to full activity. After 1 year of follow-up, the patient was completely asymptomatic, and was still playing professional soccer without flexion strength deficit.

CONCLUSION

In this professional soccer athlete, nonoperative treatment of complete psoas avulsion resulted in a good functional outcome and successful return to play.

Diagnostic accuracy of preoperative magnetic resonance imaging for detecting subscapularis tendon tears: a diagnostic test study

BACKGROUND

The accuracy of magnetic resonance imaging (MRI) for making the diagnosis of subscapularis tears presents wide variation in the literature and there are few prospective studies.

OBJECTIVE

To compare the findings from MRI and arthroscopy for diagnosing subscapularis tears.

DESIGN AND SETTING

Diagnostic test study performed in a tertiary care hospital.

METHODS

We included patients who underwent arthroscopic rotator cuff repair and who had firstly undergone high magnetic field MRI without contrast. The images were independently evaluated by a shoulder surgeon and two musculoskeletal radiologists. Sensitivity, specificity, positive and negative predictive values, accuracy and inter and intra-observer agreement were calculated.

RESULTS

MRIs on 200 shoulders were evaluated. The incidence of subscapularis tears was 69.5% (41.5% partial and 28.0% full-thickness). The inter and intra-observer agreement was moderate for detection of subscapularis tears. The shoulder surgeon presented sensitivity of 51.1% to 59.0% and specificity of 91.7% to 94.4%. The radiologists showed sensitivity of 83.5% to 87.1% and specificity of 41% to 45.9%. Accuracy ranged from 60.5% to 73.0%.

CONCLUSION

The 1.5-T MRIs without contrast showed mean sensitivity of 70.2% and mean specificity of 61.9% for detection of subscapularis tears. Sensitivity was higher for the musculoskeletal radiologists, while specificity was higher for the shoulder surgeon. The mean accuracy was 67.6%, i.e. lower than that of rotator cuff tears overall.

EFFECT OF SUBSCAPULARIS TEARS ON FUNCTIONAL SCORES OF PATIENTS UNDERGOING ROTATOR CUFF REPAIR

OBJECTIVE

To evaluate the influence of partial- and full-thickness upper third subscapularis tendon tears on the functional scores of patients undergoing arthroscopic rotator cuff repair.

METHODS

Patients who underwent arthroscopic rotator cuff repair were divided into three groups according to the subscapularis tendon condition: intact, partial-thickness tear, or full-thickness upper third tear. Functional scores were compared among groups. Second, the influence of biceps and infraspinatus tears on the scores was tested using multivariate regression analysis.

RESULTS

We evaluated 307 shoulders in 297 patients. Full-thickness upper third subscapularis tears presented significantly worse scores than intact tendons. Partial-thickness tears had scores that did not differ significantly from those of the other groups. Patients with full-thickness upper third tears presented a greater rate of injured and unstable biceps tendons. The multivariate analysis showed that biceps and infraspinatus tendon tears did not influence the scores or the intergroup comparison.

CONCLUSION

Full-thickness upper third subscapularis tendon tears presented worse functional scores than intact subscapularis tendons among patients undergoing posterosuperior rotator cuff repair. Patients with full-thickness subscapularis tears were more likely to suffer biceps tears, but this fact did not influence functional scores. Level of Evidence I; Clinical randomized trial.

Influence of postoperative immobilization on pain control of patients with distal radius fracture treated with volar locked plating: A prospective, randomized clinical trial

OBJECTIVES

The purpose of this study was to compare the pain scores and the rates and doses of opioid use in patients undergoing volar locked plate fixation of intra-articular distal radius fractures using or not postoperative immobilization.

METHODS

This was a prospective randomized controlled trial. Thirty-nine patients with distal radius fractures scheduled to receive volar plate fixation were randomly assigned to receive a short forearm splint for two weeks postoperatively or conventional bandage with early wrist mobilization. Thirty-six patients completed the follow-up. The outcome measurements included pain scores (0-10 points); rates and doses of tramadol use; DASH score; wrist range of motion; patient satisfaction; and complication rates. The last follow-up assessment was performed at 6 months.

RESULTS

The pain scores were similar between the groups during hospital stay, as well as after hospital discharge within the first week and in subsequent assessments up to six months. The rates of tramadol use were greater in the No splint group during hospital stay, but this difference was not statistically significant (No splint = 65%; Splint = 47%; p = 0.296). Likewise, the doses of tramadol intake were higher in the No splint group during hospital stay (No splint = 218 mg; Splint = 167 mg; p = 0.273) and after discharge (2^nd day: No splint = 112 mg; Splint = 75 mg; p = 0.286), with no statistically significant differences. The functional results and complication rates were similar between the groups.

CONCLUSIONS

In this study, there was a trend to a greater use of tramadol in patients who did not use immobilization and started early wrist mobilization after volar locked plating of distal radius fracture, compared with patients who were immobilized for two weeks. The pain scores were similar but may have been influenced by the unbalanced use of opioids between the groups. The functional results and complication rates were not influenced by the use of immobilization.

LEVEL OF EVIDENCE

Therapeutic Level I.

Functional results and isokinetic muscle strength in patients with Fraser type I floating knee treated with internal fixation

INTRODUCTION

According to Fraser's description, ipsilateral femoral and tibial diaphyseal fractures are characterised as type I floating knee and have a better prognosis than fractures with joint involvement (type II). There are few reports of functional and muscle strength in these patients. The objective of this study was to evaluate the functional and isokinetic muscle strength of patients with type I floating knee undergoing femoral and tibial internal fixation.

METHODS

Patients with type I floating knee undergoing concomitant femoral and tibial internal fixation were invited for clinical evaluation. The parameters evaluated included the following: Karlstrom and Olerud score; Lysholm score; isokinetic thigh and hip muscle evaluation; knee range of motion; pain level; investigation of associated knee injuries by clinical evaluation and MRI; and types of complications.

RESULTS

Twenty-one patients were included in the study; 11 of these were clinically evaluated, with a mean follow-up of 23.9 months. Six patients had an acceptable result according to the Karlstrom criteria, whereas eight patients had a poor result based on the Lysholm scale. The peak torque deficit was 61% for knee extensors, 37% for flexors and -9% for hip abductors. The mean pain level was 5.9. Three patients had a partial anterior cruciate ligament (ACL) injury; one patient had a posterior cruciate ligament (PCL) injury; and three patients had a meniscal injury. There were four cases of tibial or femoral nonunion at one year and two cases of chronic osteomyelitis.

CONCLUSION

Patients with type I floating knee had unsatisfactory functional results, significant knee extensor and flexor muscle strength deficits and a significant rate of complications at the two-year follow-up.

Single, superiorly placed reconstruction plate compared with flexible intramedullary nailing for midshaft clavicular fractures: a prospective, randomized controlled trial

BACKGROUND

Previous studies have shown good clinical results in patients with midshaft clavicular fractures treated with reconstruction plate fixation or elastic stable intramedullary nailing. The objective of this study was to compare these methods in terms of clinical and radiographic results.

METHODS

In this prospective, randomized controlled trial, fifty-nine patients with displaced midshaft clavicular fractures were randomly assigned to receive fixation with either a reconstruction plate (thirty-three patients), known as the plate group, or elastic stable intramedullary nailing (twenty-six patients), known as the nail group. The primary outcome was the six-month Disabilities of the Arm, Shoulder and Hand (DASH) score. The secondary outcomes included the Constant-Murley score, time to fracture union, residual shortening, level of postoperative pain, percentage of satisfied patients, and complication rates.

RESULTS

The mean six-month DASH score was 9.9 points in the plate group and 8.5 points in the nail group (p = 0.329). Similarly, there were no differences in the twelve-month DASH and Constant-Murley scores. Time to union was equivalent (p = 0.352) between the groups at 16.8 weeks for the plate group and 15.9 weeks for the nail group, whereas the residual shortening was 0.4 cm greater in the plate group (p = 0.032). The visual analog scale pain score and the satisfaction rate were similar between the groups. Implant-related pain was more frequent in the nail group (p = 0.035). There were no differences in terms of major complications.

CONCLUSIONS

Reconstruction plates and elastic stable intramedullary nailing yielded similar functional results, time to union, level of postoperative pain, and patient satisfaction rates. Both methods were safe in terms of major complications.

Influence of time to surgery on the incidence of complications in femoral neck fracture treated with cannulated screws

BACKGROUND

Osteosynthesis of femoral neck fractures is particularly indicated in patients aged under 60 years. A prolonged interval between the fracture and surgical fixation has been associated with avascular necrosis (AVN) of the femoral head. The primary objective of this study was to evaluate the association between the time to surgery and the development of complications in patients with femoral neck fractures.

METHODS

Patients with displaced fractures of the femoral neck (Garden III or IV) who underwent fixation with three cannulated screws in the inverted triangle configuration from January 2009 to December 2010 were evaluated retrospectively for the development of orthopaedic complications. Patients were divided into two groups according to the time to surgery (within 7 days or more than 7 days). Complication rates were compared between the two groups. Regression analyses were performed to assess the risk factors for complications.

RESULTS

Thirty-one patients were included in the study; the duration of follow-up ranged from 24 to 50 months. The time from fracture to surgery ranged from 3 to 18 days. Fifteen patients underwent surgery within 7 days, and 16 patients underwent surgery after 7 days. There were four cases of femoral head necrosis. One patient had an associated infection; one patient experienced non-union, and another demonstrated osteosynthesis failure. There were no statistically significant differences in the overall rate of complications between the groups (p = 0.999). None of the preoperative parameters or fracture characteristics were predictive factors for complications. The only factor associated with the development of complications was inadequate fracture reduction in the anteroposterior (AP) view (odds ratio [OR] = 35.50, 95% confidence interval [CI] = 2.56 to 548.36, p = 0.008).

CONCLUSIONS

The interval between the occurrence of the injury and surgical fixation is not associated with the development of complications in fractures of the femoral neck. Inadequate fracture reduction in the AP view is a predictive factor for complications in these fractures.