Tuberosity Healing after Reverse Shoulder Arthroplasty for Proximal Humerus Fractures: Is there Clinical Improvement? / Consolidação dos tubérculos na artroplastia reversa do ombro após fratura proximal do úmero: Existe melhoria nos resultados funcionais?

Abstract Objective To compare the functional results of patients with complex proximal humerus fracture submitted to total shoulder reverse arthroplasty with and without tuberosity healing. The secondary goal was to know the tuberosity healing rate after reverse shoulder arthroplasty with our surgical technique. Methods A retrospective, cohort type study, with a prospective database collection. In total, 28 patients fulfilled the inclusion criteria: age ≥ 65 years, reverse shoulder arthroplasty for complex proximal humerus fracture (type-3 or -4, according to Neer), and a minimum of 24 months of follow-up. At six months of follow-up, all of the patients were evaluated radiographically for tuberosity, and then they were divided into 2 groups: those with healed tuberosities and those with non-healed tuberosities. A clinical evaluation using the Constant score, active range of motion and the Visual Analog Scale (VAS) at the last follow-up was also performed. Results Tuberosity healing occurred in 21 patients (76.3%). There were statistically significant differences in the Constant scoring system (p < 0.001), forward elevation (p = 0.020), internal rotation (p = 0.001) and external rotation (p = 0.003) when comparing the group of healed tuberosities with the group of non-healed tuberosities. No differences were found regarding the VAS score. Conclusion Tuberosity healing results in an improvement of the functional outcomes of patients submitted to reverse shoulder arthroplasty as a treatment for complex proximal humeral fractures in the elderly.

Resumo Objetivo Comparar os resultados funcionais entre pacientes com fratura complexa do úmero proximal submetidos a artroplastia reversa com tubérculos consolidados e tubérculos não consolidados. O objetivo secundário foi determinar a taxa de consolidação dos tubérculos com este tipo de prótese. Métodos Estudo de tipo coorte, retrospectivo, com coleta prospectiva de dados. No total, 28 pacientes cumpriram os critérios de inclusão: idade superior a 65 anos, prótese reversa do ombro por fratura complexa do úmero proximal (3 ou 4 partes, segundo Neer), e tempo de seguimento mínimo de 24 meses. Aos seis meses, todos os pacientes foram avaliados radiograficamente quanto à consolidação dos tubérculos e divididos em dois grupos: grupo com tubérculos consolidados e grupo com tubérculos não consolidados. A avaliação funcional realizou-se segundo o sistema de pontuação de Constant, da amplitude de movimento ativo, e da Escala Visual Analógica (EVA) à data da última consulta. Registaram-se todas as complicações. Resultados A consolidação dos tubérculos ocorreu em 21 pacientes (76,3%). Verificou-se diferenças estatisticamente significativas no sistema de pontuação de Constant (p < 0.001), elevação anterior (p = 0.020), rotação interna (p = 0.001) e externa (p = 0.003), quando se comparou o grupo dos tubérculos consolidados com o grupo dos tubérculos não consolidados. Não houve diferenças significativas na EVA entre os 2 grupos. Conclusão A consolidação dos tubérculos traduz uma melhoria dos resultados funcionais em pacientes submetidos a artroplastia reversa do ombro como tratamento de fraturas complexas do úmero proximal em idosos.

Percutaneous Fixation without Bone Graft for Scaphoid Nonunion / Fixação percutânea sem enxerto ósseo para pseudartrose do escafóide

Abstract Objective To describe the clinical and radiographic outcomes of patients submitted to percutaneous fixation without bone graft for scaphoid nonunion, with a minimum follow-up of six months. Methods A case series study of a convenience sample of hand surgeons with prospective evaluation. Patients with scaphoid (waist or proximal pole) nonunion and the following features were included: more than six months of history; X-rays showing sclerosis of the edges of the nonunion, with resorption of the nonunion focus measuring less than 4 mm (Slade & Gleissler I, II, III and IV) and no angular deformity; and no proximal pole necrosis on magnetic resonance imaging (MRI). Results After six months of follow-up, all nonunion were consolidated, with no major complications. The functional outcomes revealed good scores on the disabilities of the arm, shoulder and hand (DASH; n = 12; mean: 6.9; standard deviation [SD]: 2.1) and patient-rated wrist evaluation (PRWE; n = 12; mean: 7.97, SD: 1.5) questionnaires. The results of the visual analog scale (VAS) showed little residual pain (n = 12; mean: 0.71; SD: 0.2). Slight decreases in flexion (69 versus 59.1; p = 0.007), extension (62.4 versus 48.7; p = 0.001) and radial deviation (29.6 versus 24.6; p = 0.014) were detected in comparison to the contralateral side. Conclusions All cases in the series presented consolidation and good functional scores at the six-month evaluation. This is a promising option (with lower technical demand and morbidity) for the treatment of scaphoid nonunion. Comparative studies are required to assess the effectiveness of this technique in comparison with other options.

Resumo Objetivo Descrever os resultados clínico-radiográficos de pacientes tratados por meio de fixação percutânea sem enxerto ósseo para pseudartrose do escafóide, com seguimento mínimo de seis meses. Métodos Série de casos de uma amostra de conveniência de grupo de cirurgiões de mão com avaliação prospectiva.. Foram incluídos pacientes com diagnóstico de pseudartrose do escafóide (cintura ou polo proximal) com as seguintes características: mais de seis meses de histórico; radiografias demonstrando esclerose das bordas da pseudartrose, com reabsorção do foco de pseudartrose menor do que 4 mm (Slade & Gleissler I, II, III e IV), sem deformidade angular; e sem necrose do polo proximal pela ressonância magnética (RM). Resultados Na avaliação com mais de seis meses, todas as pseudartroses estavam consolidadas e sem maiores complicações. Os resultados funcionais demonstraram boas pontuações nos questionários de disfunções do braço, ombro e mão (disabilities of the arm, shoulder and hand, DASH; n = 12; média: 6,9; desvio padrão [DP]: 2,1) e de avaliação do punho pelo paciente (patient-rated wrist evaluation, PRWE; n = 12; média: 7,97; DP: 1,5). Observou-se pouca dor residual de acordo com a escala visual analógica (EVA; n = 12; média: 0,71; DP: 0,2). Houve discreta diminuição da flexão (69 versus 59,1; p = 0,007), da extensão (62,4 versus 48,7; p = 0,001) e do desvio radial (29,6 versus 24.6; p = 0,014) em comparação ao lado contralateral. Conclusões Nesta série, todos os casos estavam consolidados ao sexto mês de avaliação, com bom status funcional. Trata-se de uma opção promissora (menor demanda técnica e morbidade) para o tratamento da pseudartrose do escafóide. Estudos comparativos serão úteis para avaliar a efetividade da técnica com relação a outras opções.

Efficacy of paravertebral block techniques in thoracic surgery: systematic literature review / Eficacia de las técnicas de bloqueo paravertebral en cirugía torácica. Revisión sistemática de la literatura

Abstract Introduction: Postoperative pain in thoracic surgery in adults is usually severe, and to control it there are many analgesic methods that include paravertebral blockade (PVB). Until now, there is no clarity on which is the most effective technique to perform this blockade. Objective: To describe the different PVB techniques and its analgesic effect in thoracic surgery. Methods: A systematic review of the literature was performed. We included studies that analyzed patients in open chest surgery and used PVB as analgesic technique. The Cochrane and Grading of Recommendation Assessment, Development and Evaluation strategies were used to analyze biases and evidence. The results are presented graphically by means of a visual analog scale (VAS) pain and opioid consumption equivalent to morphine for each technique found. We summarize the results with a qualitative approach without meta-analysis. Results: A total of 38 articles were analyzed (2188 patients). 13 using PVB guided by surface anatomy (SA-PVB), 7 Ultrasound-guided PVB (US-PVB), 1 neurostimulation guided PVB (NE-PVB) and the remaining using PVB performed under direct visualization by the surgeon (S-PVB). A VAS of less than 3 was found in studies with SA-PVB and US-PVB, and greater than 5 in studies with S-PVB; however, opioid consumption in the postoperative period was similar between the techniques described. Conclusion: PVB can be performed through 4 techniques. Techniques of US-PVB or SA-PVB have shown better consistency to manage postoperative acute pain in thoracic surgery.

Resumen Introducción: El dolor posoperatorio en cirugía de tórax en adultos usualmente es grave, y para su control existen varios métodos analgésicos que incluyen el bloqueo paravertebral (BPV). En la actualidad no hay claridad acerca de la técnica más efectiva para su realización. Objetivo: Describir las diferentes técnicas de colocación del BPV y su efecto en el control analgésico en cirugía de tórax. Métodos: Se realizó una revisión sistemática de la literatura. Se incluyeron estudios que analizaron pacientes sometidos a cirugía de tórax abierta y que utilizaron el BPV como técnica analgésica. Se emplearon las estrategias Cochrane y GRADE (Grading of Recommendation Assessment, Development and Evaluation) para valorar la evidencia disponible. Se presentan los resultados de manera gráfica mediante escala visual análoga de dolor y consumo de opioide equivalente a morfina para cada técnica encontrada. Se realizó síntesis cualitativa de los resultados sin metanálisis. Resultados: Se analizaron en total 38 artículos (2188 pacientes). 13 estudios usaban BPV guiado por anatomía de superficie (BPV-AS), 7 BPV con guía ecográfica (BPV-US), 1 BPV guiado por neuroestimulación (BPV-NE) y los restantes BPV bajo visualización directa por el cirujano (BPV-C). Se encontró una escala visual análoga (EVA) menor a 3 en los estudios con BPV-AS y BPV-US y mayor a 5 en estudios con BPV-C; sin embargo, el consumo de opioides en el posoperatorio fue similar entre las técnicas descritas. Conclusión: Se han descrito cuatro técnicas para la realización del BPV. Las técnicas de BPV-US o BPV-AS han mostrado mejor consistencia para el manejo del dolor agudo posoperatorio en cirugía de tórax.

Transforaminal Endoscopic Lumbar Discectomy: Clinical Outcomes and Complications / Discectomia endoscópica transforaminal lombar: Resultados clínicos e complicações

Abstract Objective To evaluate the clinical and functional results of transforaminal endoscopic lumbar discectomy. Materials and Methods From August 2015 to January 2017, 101 patients with lumbar disc hernia refractory to clinical treatment underwent endoscopic discectomy. Through clinical evaluation by the Visual Analogue Scale and functional evaluation by the Oswestry Disability Index questionnaire, the patients were analyzed in the preoperative period, the immediate postoperative period, at 1 month, 3 months, 6 months and 1 year after surgery. Results The mean age of the participants was 48.1 years. The most affected disc levels were L4-L5 and L5-S1. A total of 29 patients were treated at 2 disc levels. After 1 month of postoperative follow-up, the mean scores on the questionnaires (VAS and ODI) decreased significantly (p < 0.001). Conclusion Transforaminal endoscopic Lumbar discectomy has been shown to be a safe, effective and minimally-invasive alternative for the treatment of lumbar disc herniation. The procedure has advantages, such as short hospital stay, surgery performed under local anesthesia and sedation, early return to daily activities, and low rate of complications.

Resumo Objetivo Avaliar os resultados clínicos e funcionais da discectomia endoscópica transforaminal lombar. Materiais e Métodos De agosto de 2015 a janeiro de 2017, 101 pacientes portadores de hérnia de disco lombar refratária ao tratamento clínico foram submetidos a discectomia endoscópica. Por meio de avaliação clínica pela Escala Visual Analógica e análise funcional pelo questionário Oswestry Disability Index, os pacientes foram analisados no período pré-operatório, no pós-operatório imediato, com 1 mês, 3 meses, 6 meses e 1 ano após a cirurgia. Resultados A média de idade dos participantes foi de 48.1 anos. Os níveis discais mais acometidos foram L4-L5, seguidos de L5-S1. Um total de 29 pacientes foram abordados em 2 níveis discais. Após 1 mês de seguimento pós-operatório, a média das pontuações nos questionários (EVA e ODI) diminuiu significativamente (p < 0.001). Conclusão A discectomia endoscópica transforaminal lombar mostrou ser uma alternativa segura, eficaz e minimamente invasiva para o tratamento de hérnia de disco lombar. O procedimento tem vantagens, como curto período de internação hospitalar, cirurgia realizada sob anestesia local e sedação, retorno precoce às atividades diárias, e baixa taxa de complicações.

Use of Exogenous Hyaluronic Acid for the Treatment of Patellar Chondropathy- A Six-Month Randomized Controlled Trial / Uso do ácido hialurônico exógeno no tratamento da condropatia patelar - Ensaio clínico randomizado com acompanhamento de seis meses

Abstract Objective To evaluate the clinical and radiological benefits of intra-articular exogenous hyaluronic acid for the treatment of chondral patellar injury. Method Randomized clinical trial with 70 patients divided into 2 groups: those submitted to physical therapy for 3 months, and those submitted to physical therapy associated with the intra-articular administration of 2 mL of hyaluronic acid for the same period, who had anterior knee pain and patellar cartilage injury of grades II or III with no significant bone abnormalities. The functional scores and the characteristics of the physical and imaging exams were evaluated before and 3 and 6 months after the treatment. Result The average age of the patients was 32 ± 7.6 years. Patients from the hyaluronic acid group had better Kujala et al and Lysholm scores, and lower pain scores after 3 and 6 months of treatment when compared to the control group. The incidence of positive Clarke maneuver was lower in the treated group, but there was no difference in the magnetic resonance imaging classification. Conclusion Patients with patellar chondropathy of grades II or III treated with hyaluronic acid and physical therapy had less pain (visual analogue scale, VAS), and better functional results in the Lysholm and Kujala et al questionnaires after 3 and 6 months of treatment compared to patients undergoing physical therapy alone. In addition, the number of cases with a negative Clarke maneuver was larger in the treated group after 6 months of treatment.

Resumo Objetivo Avaliar os benefícios clínicos e radiológicos do uso do ácido hialurônico exógeno intra-articular para o tratamento da lesão condral da patela. Método Ensaio clínico randomizado com 70 pacientes divididos em dois grupos: o de tratamento fisioterápico por 3 meses, e o de tratamento fisioterápico associado à aplicação de 2 ml de ácido hialurônico intra-articular pelo mesmo período, composto por pacientes com dor na região anterior do joelho e lesão de graus II ou III da cartilagem da patela, sem anormalidades ósseas significativas. Foram avaliados os escores funcionais e as características do exame físico e de imagem antes, e após 3 e 6 meses de tratamento. Resultado A idade média dos pacientes foi de 32 ± 7,6 anos. Os pacientes do grupo submetido à aplicação de acido hialurônico apresentaram melhores escores de Kujala et al e de Lysholm, e menor pontuação de dor após 3 e 6 meses de tratamento quando comparados ao grupo controle. A manobra de Clarke positiva foi menor no grupo em que foi feita a aplicação do ácido, mas não houve diferença na classificação da imagem obtida pela ressonância magnética. Conclusão Pacientes com condropatia patelar de graus II ou III do joelho tratados com ácido hialurônico e fisioterapia apresentaram menos dor (escala visual analógica, EVA), e melhores resultados funcionais nos questionários de Lysholm e de Kujala et al após 3 e 6 meses de tratamento quando comparados com os pacientes submetidos apenas à fisioterapia. Além disso, estes pacientes apresentaram manobra de Clarke negativa em maior número após 6 meses de tratamento.

Two Compound Heterozygous Were Identified in SLC26A4 Gene in Two Chinese Families With Enlarged Vestibular Aqueduct

OBJECTIVES: To investigate the genetic causes of hearing loss with enlarged vestibular aqueduct (EVA) in two children from unrelated two Chinese families. METHODS: Sanger sequencing of all coding exons in SLC26A4 (encoding Pendrin protein) was performed on the two patients, their sibling and parents respectively. To predict and visualize the potential functional outcome of the novel variant, model building, structure analysis, and in silico analysis were further conducted. RESULTS: The results showed that the proband from family I harbored a compound heterozygote of SLC26A4 c.1174A>T (p.N392Y) mutation and c.1181delTCT (p.F394del) variant in exon 10, potentially altering Pendrin protein structure. In family II, the proband was identified in compound heterozygosity with a known mutation of c.919-2A>G in the splice site of intron 7 and a novel mutation of c.1023insC in exon 9, which results in a frameshift and translational termination, consequently leading to truncated Pendrin protein. Sequence homology analysis indicated that all the mutations localized at high conservation sites, which emphasized the significance of these mutations on Pendrin spatial organization and function. CONCLUSION: In summary, this study revealed two compound heterozygous mutations (c.1174A>T/c.1181delTCT; c.919- 2A>G/c.1023insC) in Pendrin protein, which might account for the deafness of the two probands clinically diagnosed with EVA. Thus this study contributes to improve understanding of the causes of hearing loss associated with EVA and develop a more scientific screening strategy for deafness.

Auditory Outcome of Cochlear Implantation in Adolescent and Adult Patients with Enlarged Vestibular Aqueduct and Biallelic SLC26A4 Mutations / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Mutations of the SLC26A4 gene cause congenital hearing loss and enlarged vestibular aqueduct (EVA). A considerable proportion of patients with SLC26A4 mutations have significant residual hearing at birth that eventually worsen and become the cause for cochlear implantation (CI) later in their adolescence or adulthood. We analyzed the auditory outcome and prognostic factors of CI in patients with EVA and biallelic SLC26A4 mutations showing progressive early-onset hearing loss, who eventually had implantation in their adolescent or adult periods. SUBJECTS AND METHOD: Sixteen patients with EVA carrying biallelic SLC26A4 mutations who received CI after 12 years of age were included for analysis. The outcome and prognostic factors of CI were analyzed. The postoperative follow-up period ranged from 3 to 48 months. RESULTS: The age at CI ranged from 12 to 44 years. The categories of auditory performance score was significantly improved after CI from 3.1 to 4.9 (p < 0.05). The mean sentence scores improved significantly in the auditory-visual and auditory-only conditions (p < 0.05). The significant prognostic factors were measurable bone conduction thresholds, preoperative residual hearing, recent history of sudden aggravation of hearing loss, and preoperative speech intelligibility rating scores. There was a tendency of lower postoperative sentence scores in the group with homozygous H723R mutation, but statistical significance was not reached. CONCLUSION: Despite the early-onset of hearing loss, significant improvement in auditory performance can be expected after CI in adolescent and adult patients with EVA and biallelic SLC26A4 mutations. Significant prognostic factors should be considered in selecting candidates and preoperative counseling for CI.

A Case of Bilateral Benign Paroxysmal Positional Vertigo in Bilateral Mondini Malformation With Right Enlarged Vestibular Aqueduct Syndrome / 대한평형의학회지

Enlarged vestibular aqueduct syndrome (EVAS) is well known congenital bony ear anomaly. It's audiologic symptoms and radiological findings are reported in many literatures. However vestibular symptoms of EVAS are rarely reported. A patient with right EVAS developed sudden spinning vertigo on casual observation. He is diagnosed as bilateral benign paroxysmal positional vertigo and recovered by canal repositioning maneuver. We present this case with reviews of previous literatures.

Effects of Intrabullar Gentamicin Application on Guinea Pig Vestibulo-Ocular Reflex

BACKGROUND AND OBJECTIVES: Unilateral vestibular loss can be induced by intratympanic gentamicin instillation. Despite accumulated reports on the morphologic changes after gentamicin treatment, there are limited reports regarding the effects of gentamicin ototoxicity on the vestibulo-ocular reflex (VOR), in especially unilateral vestibular deficit by local gentamicin instillation. Aim of this study is to provide the functional changes after local gentamicin application in guinea pigs. MATERIALS AND METHODS: Ten white guinea pigs (5 each for control and gentamicin treatment group) were used. Following surgical exposure of the left bulla, 0.9% saline solution or 40 mg/ml of gentamicin soaking gelfoam were applied on the round window. Horizontal vestibulo-ocular reflex (hVOR) was tested during earth vertical axis (EVA) sinusoidal harmonic acceleration rotation at 4 frequencies (0.04, 0.08, 0.16 and 0.32 Hz, 60 deg/sec of peak velocity). In one gentamicin treated animal, hVOR was tested during step velocity off-vertical axis rotation (OVAR) to clockwise and counterclockwise direction (30 degrees forward tilt from EVA with constant velocity of 100 deg/sec). Every test was repeated before treatment and at 2 days, 5 days and 7 days after treatment. RESULTS: The hVOR gain was significantly lowered after gentamicin treatment at all tested frequencies (p<0.05), while the gain does not change over time in control animals. Loss of bias component was evident and some decrease of modulation component was observed in counter-clockwise (lesion side) rotation after gentamicin treatment. CONCLUSION: This study provides characteristics of hVOR during EVA rotation and OVAR in unilateral vestibular deficit animal model by intrabullar gentamicin application.

Danger of Hormone Replacement Therapy on Cardiovascular Disease

A myriad of the retrospective studies have shown the benefit of hormone replacement therapy (HRT) on cardiovascular disease. It has been consistently shown that estrogen decreases total and LDL cholesterol, but increases the HDL cholesterol, resulting in a favorable cardiovascular outcome. In addition, it has been reported that estrogen has a beneficial role toward vascular function. The benefit of HRT on cardiovascular disease did not become a matter for suspicion or skepticism until the arrival of primary and secondary prevention clinical trial data. A large body of evidence from secondary prevention trials, such as HERS, EVA and WAVE, revealed that HRT has no beneficial effect at all toward cardiovascular disease protection; conversely, it was revealed to even be harmful. HRT increased the risk of CHD, DVT and strokes, as well as of cancers in postmenopausal women with CHD, with the worst evidence coming from a primary prevention trial. The Women's Health Initiative (WHI) study, the largest of the HRT trials, revealed the same findings as those of secondary prevention trials. In this trial, HRT significantly increased the risks of CHD, DVT, strokes and cancers, further confirming the previous findings. The lack of benefit of HRT in those trials can not be explained by the beneficial influence of HRT on the lipid profile and vascular function. Many researchers that still regard HRT as cardioprotective argue that the route, combination of drugs or even the dose of the drug administered would make differences. However, it is the increased VLDL synthesis and risk of thrombosis that make HRT harmful. HRT increase, VLDL synthesis that results in the generation of atherogenic small dense LDL and thrombus formation. In addition, HRT increases the risk of thrombosis by activating the coagulation pathway independently of VLDL synthesis. It has been reported that transdermal estrogen therapy does not increase VLDL synthesis or thrombus formation, being allegedly beneficial. However, it should not be forgotten that even the present data is not decisive and not confirmative for performing another new clinical trial of HRT being potentially harmful

Familial Enlarged Vestibular Aqueduct Syndrome (FEVAS) / 대한이비인후과학회지

The enlarged vestibular aqueduct syndrome (EVAS) is a clinical disease causing anatomical abnormality of bony canal in the temporal bone containing endolymphatic duct and sac. It is also associated with progressive sensorineural hearing loss with an isolated enlarged vestibular aqueduct. Familial inheritance of enlarged vestibular aqueduct syndrome (FEVAS) is rare and the correct mode of inheritance is not yet discovered. We studied familial inheritance in EVAS by performing clinical, audiological, radiographic and chromosomal analyses, and found strong indications that FEVAS may be an autosomal recessive trait. Further study would be focused on genetic evaluation of FEVAS.