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1.
Rev. bras. ortop ; 57(1): 14-22, Jan.-Feb. 2022. tab, graf
Article in English | LILACS | ID: biblio-1365757

ABSTRACT

Abstract Much is discussed about the limits of the treatment of anterior shoulder instability by arthroscopy. The advance in understanding the biomechanical repercussions of bipolar lesions on shoulder stability, as well as in the identification of factors related to the higher risk of recurrence have helped us to define, more accurately, the limits of arthroscopic repair. We emphasize the importance of differentiation between glenoid bone loss due to erosion (GBLE) and glenoid edge fractures, because the prognosis of treatment differs between these forms of glenoid bone failure. In this context, we understand that there are three types of bone failure: a) bone Bankart (fracture); b) combined; and c) glenoid bone loss due to anterior erosion (GBLE), and we will address the suggested treatment options in each situation. Until recently, the choice of surgical method was basically made by the degree of bone involvement. With the evolution of knowledge, the biomechanics of bipolar lesions and the concept of glenoid track, the cutoff point of critical injury, has been altered with a downward trend. In addition to bone failures or losses, other variables were added and made the decision more complex, but a little more objective. The present update article aims to make a brief review of the anatomy with the main lesions found in instability; to address important details in arthroscopic surgical technique, especially in complex cases, and to bring current evidence on the issues of greatest divergence, seeking to guide the surgeon in decision making.


Resumo Muito se discute sobre os limites do tratamento da instabilidade anterior do ombro por artroscopia. O avanço no entendimento das repercussões biomecânicas das lesões bipolares sobre a estabilidade do ombro, bem como na identificação de fatores relacionados ao maior risco de recidiva têm nos ajudado a definir, de forma mais apurada, os limites do reparo por via artroscópica. Ressaltamos a importância de diferenciação entre perda óssea por erosão da glenoide (POAG) e fraturas da borda da glenoide, pois o prognóstico do tratamento diverge entre essas formas de falha óssea da glenoide. Neste contexto, entendemos que há três tipos de falha óssea: a) Bankart ósseo (fratura); b) combinada; e c) POAG, e abordaremos as opções de tratamento sugerido em cada situação. Até há pouco tempo, a escolha do método cirúrgico era norteada basicamente pelo grau de acometimento ósseo. Com a evolução do conhecimento, da biomecânica das lesões bipolares e do conceito do glenoid track (trilho da glenoide), o ponto de corte da lesão crítica, vem sendo alterado com tendência de queda. Além das falhas ou perdas ósseas, outras variáveis foram adicionadas e tornaram a decisão mais complexa, porém um pouco mais objetiva. O presente artigo de atualização tem como objetivo fazer uma breve revisão da anatomia com as principais lesões encontradas na instabilidade; abordar detalhes importantes na técnica cirúrgica artroscópica, em especial nos casos complexos, e trazer as evidências atuais sobre os assuntos de maior divergência, buscando guiar o cirurgião na tomada de decisão.


Subject(s)
Arthroscopy , Shoulder Dislocation , Shoulder Joint , Glenoid Cavity , Rotator Cuff Injuries , Shoulder Injuries
2.
Cuad. Hosp. Clín ; 62(2): 42-46, dic. 2021. ilus.
Article in Spanish | LILACS | ID: biblio-1358062

ABSTRACT

Paciente de sexo femenino, de 39 años y de ocupación modista, con antecedentes mórbidos de importancia de artritis reumatoide en tratamiento con corticoides desde los 31 años, presenta sintomatología en la articulación glenohumeral derecha de forma insidiosa con dolor leve y limitación funcional que va aumentando por ocho meses hasta hacerse invalidante, siendo controlada únicamente por consultorio de reumatología; acude a consultorio de traumatología en diciembre de 2018, al examen físico pre quirúrgico limitación completa de todos los arcos de movimiento de articulación glenohumeral derecha que se encontraba asociado a dolor intenso a la realización de movimientos forzados presentando los siguientes arcos de movimiento: flexión 50°, abducción 15°, rotación interna 20°, rotación externa 15°, extensión 10°y dolor a la movilización pasiva y activa. Por exámenes complementarios radiológicos, tomográficos y de resonancia magnética se llega al diagnóstico de necrosis de cabeza humeral derecha con ruptura completa de supraespinoso, infra espinoso y subescapular. Se realiza procedimiento en el complejo hospitalario de Miraflores; se decide la artroplastia reversa de hombro por el compromiso articular y afectación del componente musculo tendinoso del manguito rotador. Teniendo un post quirúrgico con excelentes resultados funcionales que le devuelven los arcos de movilidad para desempeñar una vida cotidiana normal sin dolor.(AU)


A 39 year old female patient with a dressmaker occupation, with a significant morbid history of rheumatoid arthritis under treatment with corticosteroids since the age of 31, presents insidious symptoms in the right glenohumeral joint with mild pain and functional limitation that increases due to eight months until it became invalidating, being controlled only by the rheumatology office; he attended the trauma clinic in December 2018, for the pre-surgical physical examination, complete limitation of all the arches of motion of the right glenohumeral joint, which was associated with severe pain when performing forced movements, presenting the following arches of movement: 50° flexion, abduction 15°, internal rotation 20°, external rotation 15°, extension 10° and pain on passive and active mobilization. By complementary radiological, tomographic and magnetic resonance examinations, the diagnosis of necrosis of the right humeral head with complete rupture of the supraspinatus, infraspinous and subscapularis was reached. Procedure is performed at the Miraflores hospital complex; Reverse shoulder arthroplasty was decided due to joint involvement and involvement of the muscletendon component of the rotator cuff. Having a surgical post with excellent functional results that return the mobility arches to carry out a normal daily life without pain.(AU)


Subject(s)
Humans , Female , Adult , Shoulder , Humeral Head , Shoulder Prosthesis , Arthritis, Rheumatoid , Shoulder Joint
3.
Rev. bras. ortop ; 56(1): 78-82, Jan.-Feb. 2021. tab, graf
Article in English | LILACS | ID: biblio-1288653

ABSTRACT

Abstract Objective To evaluate the feasibility of magnetic resonance imaging (MRI) to obtain the critical shoulder angle (CSA) comparing the results obtained through radiography and MRI, and assess the learning curves. Methods In total, 15 patients were evaluated in a blinded and randomized way. The CSA was measured and compared among groups and subgroups. Results The mean angles measured through the radiographic images were of 34.61 ± 0.67 and the mean angles obtained through the MRI scans were of 33.85 ± 0.53 (p = 0.29). No significant differences have been found among the groups. The linear regression presented a progressive learning curve among the subgroups, from fellow in shoulder surgery to shoulder specialist and radiologist. Conclusion There was no statistically significant difference in the X-rays and MRI assessments. The MRI seems to have its efficacy associated with more experienced evaluators. Data dispersion was smaller for the MRI data regardless of the experience of the evaluator.


Resumo Objetivo Avaliar a confiabilidade da obtenção do ângulo crítico do ombro (ACO) na ressonância magnética (RM) comparada com esse mesmo ângulo obtido por meio de radiografias, e avaliar a curva de aprendizado do método. Métodos As imagens de radiografias e RMs de 15 pacientes foram avaliadas prospectivamente de forma cega e randômica. O ACO foi medido e comparado entre os grupos e subgrupos. Resultados A média dos ACOs nas imagens de radiografia foi de 34,61º ± 0,67, e, na RM, 33,85º ± 0,53 (p = 0,29). Não houve diferença estatisticamente significativa. Houve curva de aprendizado progressiva na regressão linear entre os subgrupos, de especializando em ombro a especialista e radiologista. Conclusão Não houve diferença estatisticamente significativa entre o ACO por imagens de radiografia e RM. O método da RM parece ter sua eficiência associada a avaliadores mais experientes. Independente da experiência do avaliador, a variabilidade dos dados foi menor nas avaliações por RM.


Subject(s)
Humans , Shoulder Joint , Magnetic Resonance Imaging , Magnetic Resonance Spectroscopy , Radiography , Double-Blind Method , Reproducibility of Results , Rotator Cuff , Learning Curve
4.
Artrosc. (B. Aires) ; 28(3): 204-209, 2021.
Article in Spanish | LILACS, BINACIS | ID: biblio-1348316

ABSTRACT

Introducción: El objetivo de este trabajo es evaluar resultados clínicos y funcionales de pacientes con una rotura irreparable del manguito rotador posterosuperior, sometidos a una transferencia artroscópica del trapecio inferior. Materiales y métodos: estudio de una cohorte retrospectiva de pacientes con roturas irreparables del manguito rotador, en quienes se realizó una transferencia del trapecio inferior asistida por artroscopía. Se evaluó la evolución clínica mediante la ganancia del rango de movilidad del hombro y la disminución del dolor. Del mismo modo, se evaluó la evolución funcional usando el índice de Constant-Murley y la valoración subjetiva del hombro (SSV, por sus siglas en inglés). Resultados: se incluyeron ocho pacientes, con un seguimiento promedio de veintidós meses. Obtuvimos una ganancia estadísticamente significativa de rotación externa de 32°, disminución de 5 puntos en la escala del dolor, aumento de 31 puntos en el score de Constant y un aumento de 38% del SSV. Se registró un aumento de 12° de elevación, sin embargo, este no fue estadísticamente significativo. Dos pacientes presentaron un seroma en el sitio de la cosecha del trapecio, que se resolvió con manejo conservador. Conclusión: la transferencia del trapecio inferior con asistencia artroscópica, en pacientes con rotura irreparable del manguito rotador posterosuperior, es una técnica segura que mejora significativamente la rotación externa y los índices funcionales en este grupo de pacientes. Tipo de estudio: Serie de casos IV


Introduction: The purpose of this study is to compare clinical and functional outcomes of patients with irreparable posterosuperior rotator cuff tears treated by arthroscopic assisted lower trapezius transfer. Materials and methods: retrospective cohort design of patients with irreparable rotator cuff tear, treated by arthroscopy-assisted lower trapezius transfer. The clinical evolution was evaluated according to the gain in the range of shoulder movement and the decrease of pain. Functional outcomes were evaluated using the Constant-Murley score and the subjective shoulder value (SSV). Results: eight patients were included, with average follow-up of twenty-two months. We obtained a statistically significant gain in active external rotation of 32°, 5-point decrease in the pain scale (VAS), a 31-point increase in the Constant score, and a 38% increase in SSV. There was a 12° increase in active forward elevation, however this was not statistically significant. Two patients had a seroma at the trapezius harvest site, which resolved with conservative treatment. Conclusion: arthroscopically assisted lower trapezius transfer in patients with irreparable posterosuperior rotator cuff tears were a safe technique that significantly improves external rotation and functional scores in patients. Type of study: Case series IV


Subject(s)
Adult , Arthroscopy/methods , Shoulder Joint/surgery , Shoulder Joint/injuries , Tendon Transfer , Rotator Cuff Injuries/surgery
5.
Artrosc. (B. Aires) ; 28(2): 192-196, 2021.
Article in Spanish | LILACS, BINACIS | ID: biblio-1282688

ABSTRACT

La capsulitis adhesiva de hombro se caracteriza por la inflamación crónica de la capa subsinovial de la cápsula articular que produce fibrosis, contractura y adherencia de la cápsula a sí misma y al cuello anatómico del húmero. La rehabilitación enfocada en optimizar el rango de movilidad en forma activa y pasiva es la base del tratamiento, independientemente de la etapa. Sobre la base de la historia natural de la enfermedad, la inyección con corticoides en forma precoz tiene utilidad en acortar la duración general de los síntomas, y permite a los pacientes trabajar el rango de movilidad en las etapas de rehabilitación y así volver a sus actividades cotidianas más rápidamente. La mayoría de los pacientes tratados con terapia física logran la resolución completa de síntomas. En casos con rigidez refractaria, puede estar indicada la manipulación bajo anestesia o la liberación capsular artroscópica; debido a varios riesgos potenciales de complicaciones con las manipulaciones, se prefiere esta última. Existen escasos estudios con alto nivel de evidencia que comparen diferentes técnicas para la liberación capsular: tanto la liberación circunferencial como la capsular anteroinferior han demostrado ser efectivas como técnica quirúrgica. La cirugía debe ser seguida de forma temprana por una terapia física diligente y dirigida a prevenir la rigidez recurrente


Adhesive capsulitis is characterized by chronic inflammation of the capsular subsynovial layer, which produces capsular fibrosis, contracture, and adherence of the capsule to itself and to the anatomic neck of the humerus. Physical therapy is the mainstay of treatment, regardless of stage. Based on the natural history of the disease, early corticosteroid injection has a role in shortening the overall duration of symptoms allowing patients to move faster in the stages of rehabilitation and thus return to their daily life activities more rapidly. Most patients will see complete resolution of symptoms with nonsurgical management. In cases with refractory stiffness, manipulation under anesthesia or arthroscopic capsular release may be indicated. Because of various potential risks of complications with manipulations, arthroscopic capsular release is preferred. There is a lack of high-level studies comparing different techniques for capsular release. Both circumferential and anteroinferior release have proven to be effective. Surgery should be followed by early, diligent and directed therapy to prevent recurrent stiffness


Subject(s)
Shoulder Joint , Bursitis/surgery , Bursitis/diagnosis , Bursitis/physiopathology , Bursitis/therapy , Shoulder Pain
6.
Article in Spanish | LILACS, BINACIS | ID: biblio-1353918

ABSTRACT

Introducción: El objetivo de este estudio fue describir las tasas de retorno al deporte y el nivel alcanzado por los pacientes con inestabilidad de hombro luego del procedimiento abierto y artroscópico de Latarjet. materiales y métodos:Seguimos un protocolo prespecificado y registrado en PROSPERO. Evaluamos la calidad de los estudios y utilizamos el sistema GRADE para evaluar la calidad general de la evidencia obtenida en los resultados. Incluimos estudios que evalúan el retorno al deporte de los pacientes luego de una cirugía de Latarjet con un seguimiento mínimo de 2 años. Resultados: Se incluyeron 24 estudios, con 1436 atletas, todos con cirugía y un seguimiento promedio de 57 meses (rango 24-240). La tasa general de retorno al deporte varió del 65% al 100% de los pacientes, de ellos, el 23-100% retornó al mismo nivel. El tiempo promedio de retorno al deporte fue de 6 meses (rango 1-36). El nivel de evidencia fue bajo debido a las características de los estudios incluidos (nivel de evidencia IV), las limitaciones de los estudios y sus inconsistencias. Conclusiones: La mayoría de los atletas con luxación recidivante de hombro sometidos a una cirugía de Latarjet retoman la práctica deportiva; sin embargo, el nivel alcanzado varía sustancialmente. El tiempo promedio de retorno al deporte fue de 6 meses, y no hubo diferencias significativas entre los deportistas competitivos y recreacionales. Nivel de Evidencia: IV


background: The purpose of this study was to describe rates of return to sports and the level achieved by patients after a Latarjet procedure.methods: We followed a protocol registered in PROSPERO (registration number CRD42018107606). A literature search was performed in May 2019 in MEDLINE, EMBASE, CENTRAL and clinical trials records. We used the GRADE approach for the assessment of the overall quality of the evidence per outcome. We included studies (evidence level I to IV) evaluating return to sports following shoulder stabilization with the Latarjet procedure with a minimum of 2-year follow-up. Results: We included 24 studies, including 1436 athletes, all treated surgically after an average follow-up of 57 months (range 24 to 240). The overall rate of return to sport ranged from 65% to 100%, including 23% to 100% at an equivalent level of play. The average time for return to sport was 6 months (range, 1 - 36 months). Competitive athletes appeared to return to the same level of competition and this difference was not statistically significant (p = 0.32). The quality of the evidence was very low due to study design (evidence level IV), study limitations and inconsistency. Conclusion: Most athletes with glenohumeral instability returned to sport, however the level maintained after shoulder stabilization with the Latarjet procedure varied substantially. The average time to return to sports was 6 months and results were equally favorable in competitive and recreational athletes


Subject(s)
Shoulder Dislocation , Shoulder Joint/surgery , Minimally Invasive Surgical Procedures , Return to Sport
7.
Article in Spanish | LILACS, BINACIS | ID: biblio-1353989

ABSTRACT

Objetivo: Comunicar los resultados y las complicaciones a corto plazo de la artropatía del manguito rotador tratada con artroplastia invertida lateralizada en pacientes >60 años. Materiales y Métodos: Se identificaron retrospectivamente las artropatías del manguito rotador tratadas con prótesis invertida lateralizada entre 2015 y 2019. Criterios de inclusión: edad >60 años, adecuada función deltoidea y seguimiento mínimo de 24 meses. Antes de la cirugía y después, se registraron el rango de movilidad activa, y los puntajes de Constant-Murley y de la escala analógica visual para dolor. En las radiografías, se determinaron los grados de artrosis glenohumeral, de muescas escapulares y de aflojamiento de la prótesis. Se documentaron las complicaciones, la satisfacción con el procedimiento y la supervivencia del implante. Resultados: La serie incluyó 40 hombros operados en 38 pacientes (edad promedio 72 años, rango 61-91), con un seguimiento promedio de 25 meses. La elevación anterior aumentó de 82,63° a 136,71° (p <0,001); la rotación externa, de 16,59° a 32,11° (p <0,001) y la rotación interna, de L5 a L3 (p <0,001). El puntaje de Constant-Murley ascendió de 28,25 a 69,97 (p <0,001) y el de dolor disminuyó de 8,34 precirugía a 1,26 poscirugía (p <0,001). La tasa de complicaciones fue del 12,5% y la supervivencia del implante, del 97,4%. Conclusiones: La artroplastia invertida lateralizada es una excelente alternativa quirúrgica para la artropatía del manguito rotador en pacientes >60 años, los resultados son satisfactorios, la tasa de complicaciones es aceptable y la supervivencia del implante es del 97,4%. Nivel de Evidencia: IV


Background: The purpose of this study is to show the short-term results and complications in a series of patients >60 who underwent a reverse arthroplasty for the treatment of rotator cuff arthropathy in a high complexity hospital. Materials and Methods: We retrospectively analyzed our Service's database to identify patients with rotator cuff arthropathy who had undergone a reverse shoulder arthroplasty between 2015 and 2019. Inclusion criteria: 60 years of age or older, functional deltoid, at least one year of follow-up. The range of motion was measured pre and postoperatively in flexion, external rotation, and internal rotation, as well as Constant score and visual analog scale for pain. The grade of arthritis, scapular notching, and prosthetic loosening was radiographically assessed. We identified complications, satisfaction, and prosthesis survivorship. Results: Forty shoulders in 38 patients of 72 years of age on average (61-91) underwent reverse shoulder arthroplasty, with 25 months of follow-up. Flexion increased from 82.86° to 136.71° (p<0.001), external rotation went from 16.59° to 32.11° (p<0.001), and internal rotation from L5 to L3 (p<0.001). Constant score rose from 28.25 to 69.97 (p<0.001) and visual analog scale for pain decreased from 8.34 to 1.26 (p<0.001). The complication rate was 12.5% and a 97.4% prosthesis survivorship was registered. Conclusions: We believe that reverse shoulder arthroplasty represents an excellent option in the treatment of rotator cuff arthropathy in patients older than 60 in view of the satisfactory functional outcomes with an acceptable complication rate. Level of Evidence: IV


Subject(s)
Middle Aged , Aged , Shoulder Joint/surgery , Treatment Outcome , Rotator Cuff , Rotator Cuff Tear Arthropathy , Arthroplasty, Replacement, Shoulder
8.
Artrosc. (B. Aires) ; 28(1): 56-61, 2021.
Article in Spanish | LILACS, BINACIS | ID: biblio-1252447

ABSTRACT

Introducción: El objetivo de este trabajo es evaluar el porcentaje de cicatrización y los resultados funcionales de una cohorte de pacientes sometidos a reparación artroscópica del tendón del supraespinoso mediante una técnica de doble fila transósea equivalente. Materiales y métodos: durante el período de enero de 2015 a diciembre de 2017, se realizó una reparación artroscópica del supraespinoso a cuarenta y ocho pacientes utilizando una técnica transósea equivalente, todas por el mismo cirujano; al cuarto mes de evolución, se evaluó la tasa de cicatrización del tendón mediante ecografía. Los resultados funcionales se analizaron mediante la escala de Constant-Murley (CS), valoración subjetiva del hombro (SSV) y la escala visual análoga (EVA) para objetivar el dolor. Para el análisis estadístico se utilizó t test para muestras pareadas. Población sometida a compensación laboral.Resultados: el seguimiento ecográfico objetivó una tasa de re-ruptura del 6%. El promedio de incremento en la escala de Constant-Murley fue de 55 puntos, del SSV de 55%, de flexión anterior 32° y de rotación externa de 13°. La escala visual análoga tuvo un descenso de 6 puntos. Todos estos cambios fueron estadísticamente significativos (p < 0.05). Conclusión: la reparación del tendón del supraespinoso, mediante una técnica transósea equivalente mejora los resultados clínicos y funcionales de los pacientes, objetivados con los índices de Constant-Murley y SSV. En nuestra serie obtuvimos una tasa de cicatrización en el 94% de los pacientes. Tipo de estudio: Serie de casos. Nivel de Evidencia: IV


Introduction: the objective of this work was to evaluate the healing rate and functional results in a retrospective cohort of patients undergoing arthroscopic repair of the supraspinatus tendon, using a double row transosseous equivalent technique. Materials and methods: during the period from January 2015 to December 2017, an arthroscopic repair of the supraspinatus was performed on forty-eight patients, using a transosseous technique, by the same surgeon. We evaluated the healing rate by an ultrasound exam at the fourth month of evolution. Functional results were evaluated using the Constant-Murley scale (CS), subjective shoulder assessment (SSV) and the visual analog scale (VAS) to objectify the pain. For the statistical analysis, t-tests were used for paired samples. This cohort of patients is subject to workers compensation. Results: the ultrasound follow-up showed a 6% re-rupture rate. The average increase in the Constant scale was 55 points, the SSV had a mean increase of 55% and the VAS score decrease 6 points. All these changes were statistically significant (p < 0.05).Conclusions: the supraspinatus tendon repair, using an equivalent transosseous technique, improves the clinical and functional results of patients, objectified with the Constant-Murley and SSV scores. In our series we obtained a healing rate on 94% of the patients. Type study: Case Series. Level of Evidence: IV


Subject(s)
Adult , Middle Aged , Arthroscopy/methods , Shoulder Joint/surgery , Treatment Outcome , Rotator Cuff/surgery , Rotator Cuff Injuries , Workers' Compensation
9.
Artrosc. (B. Aires) ; 28(1): 87-91, 2021.
Article in Spanish | LILACS, BINACIS | ID: biblio-1252456

ABSTRACT

Las transferencias tendinosas son consideradas para mejorar la función de la escápula y restablecer la biomecánica de la cintura escapular en aquellos pacientes con escápula alada que tienen alteración en la funcionalidad y que no han progresado con tratamiento conservador. Existen diferentes técnicas de transferencias tendinosas como parte del tratamiento. En este artículo realizamos una revisión narrativa, además, ilustramos con videos las siguientes técnicas: la triple transferencia tendinosa en parálisis del trapecio y la transferencia del pectoral mayor hacia la escápula en disfunción del serrato anterior


Tendon transfers are used in management of winged scapula refractory to conservative treatment to improve scapula function and reestablish adequate shoulder biomechanics. There are different techniques described for these tendon transfers. In this article we reviewed these techniques, in addition, we illustrate with videos on cadavers the following techniques: triple tendon transfer for trapezius paralysis and pectoralis mayor tendon transfer to scapula for serratus anterior disfunction


Subject(s)
Scapula , Shoulder Joint/pathology , Tendon Transfer , Cadaver
10.
Artrosc. (B. Aires) ; 28(1): 97-103, 2021.
Article in Spanish | LILACS, BINACIS | ID: biblio-1252458

ABSTRACT

El complejo articular del hombro está formado por cinco articulaciones. Tres de estas son verdaderas: glenohumeral (GH), acromioclavicular (AC) y esternoclavicular (EC); y dos, falsas: escapulotorácica (ET) y subacromial (Sa). Es la articulación con mayor rango de movimiento (ROM, por Range of Motion) del cuerpo y la más propensa a inestabilidades, ocupa el 45% de todas las luxaciones, y 95% de estas corresponden a luxación anteroinferior. Presentamos el acrónimo A.R.A.R.A.I., que nos detalla las iniciales del esquema ordenado a seguir en un traumatismo de hombro que exhiba luxación GH.A (Axilar valoración neurovascular): comprende la valoración neurológica y vascular, la más importante de todas, inclusive antes de la radiografía y la reducción. R (Radiografía): no se puede proceder a la reducción de una luxación glenohumeral sin antes tener una radiografía que descarte fractura, si se procediera a una reducción sin una radiografía y se presenta una fractura en el control posreducción, la maniobra de reducción sería la causa de la fractura por lo que, para evitar problemas legales, siempre se debe solicitar una radiografía antes de esta maniobra. A (Anestesia): todo paciente debe ser sometido a una reducción bajo anestesia, sobre todo si es atendido en un hospital donde se cuenta con servicio de anestesiología. R (Reducción): se utilizan diferentes métodos o técnicas, recomendamos que el médico realice la maniobra con la que tenga mayor afinidad. A (Axilar Rx Posreducción): una de las mayores complicaciones en una LGH es la fractura del borde anterior de la glena no diagnosticada, por lo que la radiografía axilar posreducción, sobre todo en primoluxaciones, nos permite diagnosticar una lesión de Bankart ósea (Bony Bankart) y tratarla desde el primer episodio para evitar la reabsorción del fragmento fracturado.I (Inmovilización en neutro):es importante el tiempo de inmovilización. Recomendamos veintiún días y posición neutra para disminuir el porcentaje de recidiva.La importancia de esta guía es la adecuada valoración clínica, neurovascular, radiológica y oportuno diagnóstico de patologías concomitantes


The shoulder joint complex is made up of five joints. Three of them are true: glenohumeral (GH), acromioclavicular (AC) and sternoclavicular (SC) and two are false: scapulothoracic (ST) and subacromial (SA). It is the joint with the highest Range of Motion (ROM) in the body and the most prone to instability, occupying 45% of all dislocations, 95% of which correspond to the anteroinferior dislocation. We present the acronym A.R.A.R.A.I., which details the initials of the scheme ordered to follow in a shoulder trauma with GH dislocation.A (Axillary nerve anesthesia): includes the neurological and vascular evaluation, the most important of all, even before radiography and reduction.R (Radiography): it is not possible to proceed to the reduction of a glenohumeral dislocation without first having an X-ray that rules out a fracture, if a reduction is carried out without an X-ray and a fracture occurs in the post-reduction control, the maneuver of reduction is the cause of the fracture so, to avoid legal problems, always request an X-ray before a reduction.A (Anesthesia): every patient must undergo a reduction under anesthesia, especially if the patient is cared for in a hospital where there is an anesthesiology service


Subject(s)
Shoulder Dislocation , Shoulder Joint , Practice Guidelines as Topic
11.
Article in Chinese | WPRIM | ID: wpr-888318

ABSTRACT

OBJECTIVE@#To compare the clinical efficacy between open and arthroscopic Latarjet procedure in the treatment of anterior shoulder instability by using Meta-analysis.@*METHODS@#Search PubMed, Medline, Embase, Cochrane, China National Knowledge Infrastructure(CNKI), Wanfang database, China Biological Literature system(CBM) and VIP database. Review all retrospective or prospective cohort studies and randomized controlled trials on open and arthroscopic Latarjet procedure for anterior shoulder instability. Binary variables (postoperative recurrence rate, incidence of intraoperative and postoperative complications) and continuousvariables [shoulder external rotation range of motion, Walch-Duplay score, Rowe score, WOSI score, postoperative visual analogue scale (VAS), postoperative anxiety degree and operation time] were selected for analysis. NOS bias risk assessment criteria (recommended by Cochrane collaboration Network) were used to evaluate the literature quality of retrospective or prospective cohort studies, and modified Jadad scale was used to evaluate the quality of randomized controlled trials. Literature screening, literature quality evaluation and data extraction were carried out independently by two observers. RevMan 5.3 software was used for Meta analysis.@*RESULTS@#(1)A total of 9 studies were included, including 8 retrospective cohort studies and 1 prospective cohort study. A total of 956 patients were included in this study, including open Latarjet procedure(@*CONCLUSION@#The arthroscopic Latarjet stabilisation shows satisfactory and comparable results to open procedure, and the postoperative recurrence and complication rates are low in both group. Both open and arthroscopic Latarjet procedure are reliable surgical procedures in the treatment of anteriorly shoulder instability. Arthroscopic procedure has longer learning curve than open procedure, the doctors may either choose arthroscopic or open Latarjet procedure based on personal skills and preference, as well as the patient's condition. However, all the literatures included in this study are cohort studies with low level of evidence. The research lack randomized controlled trials, and small sample size is small. In the future, randomized controlled studies with large sample size and high level of evidence are still needed to determine the efficacy difference between the two.


Subject(s)
Arthroscopy , China , Humans , Joint Instability , Prospective Studies , Recurrence , Retrospective Studies , Shoulder , Shoulder Dislocation , Shoulder Joint
12.
Article in Chinese | WPRIM | ID: wpr-888302

ABSTRACT

OBJECTIVE@#To investigate the method and clinical effects of the treatment of recurrent anterior dislocation of shoulder with Hill-Sachs injury by arthroscopic Bankart repair and Remplissage.@*METHODS@#From March 2016 to March 2019, 106 patients with recurrent anterior dislocation of shoulder with glenoid bone defect less than 20% underwent arthroscopic Bankart repair, including 76 males and 30 females, aged from 18 to 45 (27.3±8.6) years, 59 cases of left shoulder and 47 cases of right shoulder. Range of motion (ROM), American Shoulder and Elbow Surgeons(ASES) score, Constant-Murley score and Rowe score were used to evaluate shoulder functionand stability before and after operation.@*RESULTS@#All patients were followed up, and the duration ranged from 21 to 60 months, with a mean of (41.5± 8.5) months. One patient developed infection after operation, and the infection was controlled after arthroscopic debridement again. The remaining patients did not have clinical complications such as infection, intra articular hematocele and redislocation. Shoulder flexion and lifting increased from (158.33±15.72) ° preoperatively to (169.43±10.04) ° at the latest follow up, and internal rotation changed from T7 (T4 to T10) preoperatively to T8 (T5 to T10) at the latest follow up;the average lateral external rotation and abduction 90 ° external rotation decreased from (58.46±15.51) ° preoperatively and (99.37±14.09) ° to (53.18±14.90) ° and (92.52±13.10) ° at the latest follow up, respectively. The ASES score, Constant -Murley score and Rowe score were significantly improved.@*CONCLUSION@#The clinical effect of rehabilitation of Bankart repair combined with Remplissageunder arthroscopy in the treatment of recurrent dislocation of shoulder joint in adults with Hill-Sachs defect is satisfactory. Although the external rotation function is weaker than that before operation, it can effectively reconstruct the shoulder function and avoid the occurrence ofdislocation after operation.


Subject(s)
Adult , Arthroplasty , Arthroscopy , Female , Humans , Joint Instability/surgery , Male , Range of Motion, Articular , Recurrence , Shoulder/surgery , Shoulder Dislocation/surgery , Shoulder Joint/surgery
13.
Article in Chinese | WPRIM | ID: wpr-888301

ABSTRACT

OBJECTIVE@#To evaluate the reliability and repeatability of three-dimensional (3D)-CT measurement of glenoid track.@*METHODS@#Glenoid and Hill-Sachs bone defects in 60 patients with recurrent anterior dislocation of the unilateral shoulder were evaluated by 3D-CT and analyzed by three independent observers(shoulder orthopedists) according to the Di Giacomo method. These injuries were classified to formulate a surgical protocol. All the patients were repeatedly measured 1 week later. Intraclass correlation coefficient (ICC) and coefficient of variation (COV) were used for reliability analysis.@*RESULTS@#Interobserver reliability was "very good" for both measurements of glenoid diameter and glenoid bone defects, and "good" for measurements of Hill-Sachs interval. Interobserver agreement was high on the assessment of the extent of the glenoid defect, and poor on track/off track assessment of the Hill-Sachs lesion. Intraobserver reliability for measurements of glenoid diameter, glenoid defect, and Hill-Sachs interval was "very good". The COV was 4.1% for glenoid diameter, 4.4% for glenoid defect, and 21.1% for Hill-Sachs interval.@*CONCLUSION@#The reliability and reproducibility of 3D-CT measurements of glenoid bone defects are good, but the assessment of humeral head bone defects shows large variability with poor reliability.


Subject(s)
Humans , Joint Instability , Reproducibility of Results , Shoulder , Shoulder Dislocation , Shoulder Joint , Tomography, X-Ray Computed
14.
Article in Chinese | WPRIM | ID: wpr-921922

ABSTRACT

The incidence of posterior instability of shoulder joint was significantly lower than that of anterior instability, but the clinical diagnosis and treatment was difficult, and the misdiagnosis and missed diagnosis rate were high. Its etiology, clinical manifestation and treatment strategy are totally different from the anterior instability. Therefore, the deep understanding of the anatomical structure around the shoulder joint, the mastery of the examination method, and the classification of the shoulder instability based on the anatomy and injury mode are of great importance to improve the accuracy of diagnosis. CT three-dimensional reconstruction is helpful to evaluate the defect of humeral head and glenoid bone, and MRA is helpful for the accurate diagnosis of posterior glenoid lip and joint capsule. The treatment was divided into conservative treatment and surgical treatment. Conservative treatment is recommended for muscular instability. Surgical treatment is recommended for traumatic and dysplastic instability. Different operative methods should be performed according to the injury of glenoid side or humeral head side. According to the condition of bone defect, soft tissue operation, bone grafting or osteotomy were performed to reconstruct the posterior stable structure of the glenoid injury; according to the area of the anterior bone defect, bone grafting or subscapular muscle packing were performed to the head of humerus defect. The former has the advantages of short learning curve and firm fixation, while the latter has the advantages of minimally invasive operation and the ability to observe the lesions from multiple angles and accurately control the location of bone masses. This paper summarizes the above problems.


Subject(s)
Humans , Humeral Head , Joint Instability/surgery , Scapula , Shoulder , Shoulder Dislocation , Shoulder Joint/surgery
15.
Article in Chinese | WPRIM | ID: wpr-921911

ABSTRACT

Recurrent anterior dislocation of shoulder with bone defect is one of the common diseases of shoulder joint. How to effectively repair glenoid bone defect and reduce recurrence rate of shoulder dislocation is a problem that clinicians focus on. Bone grafting could stimulate bone, promote bone regeneration and bone remodeling, and restore the normal anatomical structure of glenoid. Among them, Bristow-Latarjet procedure is a classic operation for recurrent shoulder dislocation. Latarjet procedure could repair larger glenoid bone defects, but with higher surgical skills for surgeons;autogenous iliac grafting is the first choice for revision once Latarjet procedure failed;osteochondral grafting (autogenous and allogenous) has certain advantages in reconstructing original articular surface and preventing joint degeneration, but autologous osteochondral grafting may cause secondary injury, while immune rejection is difficult to avoid for allogenous osteochondral grafting. With the improvement of composite materials, and the mechanism of bone regeneration and remodeling, as well as the advantages and disadvantages of bone grafting, tissue engineering technology may become an effective method for the treatment of glenoid bone defect in the future.


Subject(s)
Bone Transplantation , Humans , Joint Instability , Recurrence , Shoulder , Shoulder Dislocation/surgery , Shoulder Joint
16.
Article in Chinese | WPRIM | ID: wpr-879467

ABSTRACT

The surgical treatment of recurrent anterior shoulder dislocation is a difficult problem in the field of sports injury medicine. The main reason focus on dynamic and osseous constraints of shoulder joint could not recover well. At present, arthroscopic surgery is used at home and abroad, and could receive statisfied postoperative effect, but the choice of specific surgical methods is still controversial. According to presence and size of glenoid and humeral skull defects, different treatments should be selected in clinic. The author recommends that no articular glenoid defect or glenoid defect 40% or Bristow-Latarjet if the surgical repair fails, bone grafting is used. In addition, if (humeral avulsion of glenohumeral ligaments, HAGL) injury existed, HAGL injury repair should be used. In addition to considering the important factor of bone defects, it is necessary to combine patient's age, exercise level and surgeon's technique to comprehensively select the bestsurgical method.


Subject(s)
Arthroscopy , Humans , Joint Instability , Recurrence , Scapula , Shoulder Dislocation/surgery , Shoulder Joint
17.
Article in Chinese | WPRIM | ID: wpr-879284

ABSTRACT

The real physical image of the affected limb, which is difficult to move in the traditional mirror training, can be realized easily by the rehabilitation robots. During this training, the affected limb is often in a passive state. However, with the gradual recovery of the movement ability, active mirror training becomes a better choice. Consequently, this paper took the self-developed shoulder joint rehabilitation robot with an adjustable structure as an experimental platform, and proposed a mirror training system completed by next four parts. First, the motion trajectory of the healthy limb was obtained by the Inertial Measurement Units (IMU). Then the variable universe fuzzy adaptive proportion differentiation (PD) control was adopted for inner loop, meanwhile, the muscle strength of the affected limb was estimated by the surface electromyography (sEMG). The compensation force for an assisted limb of outer loop was calculated. According to the experimental results, the control system can provide real-time assistance compensation according to the recovery of the affected limb, fully exert the training initiative of the affected limb, and make the affected limb achieve better rehabilitation training effect.


Subject(s)
Electromyography , Humans , Movement , Muscle Strength , Robotics , Shoulder Joint , Stroke Rehabilitation
18.
Rev. bras. anestesiol ; 70(6): 588-594, Nov.-Dec. 2020. tab, graf
Article in English, Portuguese | LILACS | ID: biblio-1155777

ABSTRACT

Abstract Background and objectives: In shoulder arthroscopy, on an outpatient basis, the patient needs a good control of the postoperative pain that can be achieved through regional blocks. Perineural dexamethasone may prolong the effect of these blocks. The aim of this study was to evaluate the effect of perineural dexamethasone on the prolongation of the sensory block in the postoperative period for arthroscopic shoulder surgery in outpatient setting. Methods: After approval by the Research Ethics Committee and informed consent, patients undergoing arthroscopic shoulder surgery under general anesthesia and ultrasound-guided interscalene brachial plexus block were randomized into Group D - blockade performed with 30 mL of 0.5% levobupivacaine with vasoconstrictor and 6 mg (1.5 mL) of dexamethasone and Group C - 30 mL of 0.5% levobupivacaine with vasoconstrictor and 1.5 mL of 0.9% saline. The duration of the sensory block was evaluated in 4 postoperative moments (0, 4, 12 and 24 hours) as well as the need for rescue analgesia, nausea and vomiting incidence, and Visual Analog Pain Scale (VAS). Results: Seventy-four patients were recruited and 71 completed the study (Group C, n = 37; Group D, n = 34). Our findings showed a prolongation of the mean time of the sensitive blockade in Group D (1440 ± 0 min vs. 1267 ± 164 min, p < 0.001). It was observed that Group C had a higher mean pain score according to VAS (2.08 ± 1.72 vs. 0.02 ± 0.17, p < 0.001) and a greater number of patients (68.4% vs. 0%, p < 0.001) required rescue analgesia in the first 24 hours. The incidence of postoperative nausea and vomiting was not statistically significant. Conclusion: Perineural dexamethasone significantly prolonged the sensory blockade promoted by levobupivacaine in interscalene brachial plexus block, reduced pain intensity and rescue analgesia needs in the postoperative period.


Resumo Justificativa e objetivos: Na artroscopia de ombro em regime ambulatorial, o paciente necessita de um bom controle da dor pós-operatória, que pode ser conseguido por meio de bloqueios regionais. A dexametasona perineural pode prolongar o efeito desses bloqueios. O objetivo deste estudo foi avaliar o efeito da dexametasona perineural quanto ao prolongamento do bloqueio sensitivo no período pós-operatório para cirurgia artroscópica de ombro em regime ambulatorial. Métodos: Após aprovação do Comitê de Ética em Pesquisa e consentimento informado, foram incluídos no estudo pacientes submetidos a cirurgia artroscópica de ombro sob anestesia geral e bloqueio de plexo braquial interescalênico guiado por ultrassonografia. Eles foram randomizados nos Grupo D - bloqueio com 30 mL de levobupivacaína 0,5% com vasoconstritor e 6 mg (1,5 mL) de dexametasona, e Grupo C - bloqueio com 30 mL de levobupivacaína 0,5% com vasoconstritor e 1,5 mL solução salina. A duração do bloqueio sensitivo foi avaliada em quatro momentos pós-operatórios (0, 4, 12 e 24 horas), assim como a necessidade de analgesia de resgate, incidência de náuseas e vômitos e Escala Visual Analógica de Dor (EVA). Resultados: Setenta e quatro pacientes foram randomizados e 71 completaram o estudo (Grupo C, n = 37; Grupo D, n = 34). Observou-se um prolongamento do tempo médio de bloqueio sensitivo no Grupo D (1440 ± 0 min vs. 1267 ± 164 min; p< 0,001). Pacientes do Grupo C apresentaram maior média de escore de dor de acordo com a EVA (2,08 ± 1,72vs. 0,02 ± 0,17; p< 0,001) e um maior número de pacientes solicitou analgesia de resgate nas primeiras 24 horas (68,4%vs.0%; p< 0,001). A incidência de náuseas e vômitos não foi estatisticamente significante. Conclusão: A dexametasona perineural prolongou significativamente o bloqueio sensitivo da levobupivacaína no bloqueio de plexo braquial interescalênico, reduziu a intensidade de dor e a necessidade de analgesia de resgate pelo paciente no período pós-operatório.


Subject(s)
Humans , Male , Female , Arthroscopy/methods , Shoulder Joint/surgery , Dexamethasone/administration & dosage , Ultrasonography, Interventional/methods , Brachial Plexus Block/methods , Anti-Inflammatory Agents/administration & dosage , Pain, Postoperative/diagnosis , Pain, Postoperative/drug therapy , Arthroscopy/adverse effects , Time Factors , Vasoconstrictor Agents/administration & dosage , Pain Measurement , Double-Blind Method , Prospective Studies , Analysis of Variance , Postoperative Nausea and Vomiting/epidemiology , Saline Solution/administration & dosage , Levobupivacaine , Analgesia , Anesthetics, Local , Middle Aged
19.
Rev. bras. anestesiol ; 70(6): 583-587, Nov.-Dec. 2020. tab, graf
Article in English, Portuguese | LILACS | ID: biblio-1155765

ABSTRACT

Abstract Background and objectives Several airway complications can occur during shoulder arthroscopy including airway obstruction, pleural puncture, and subcutaneous emphysema. It was hypothesized that the irrigation fluid used during a shoulder arthroscopic procedure might increase the cuff pressure of the endotracheal tube, which can cause edema and ischemic damage to the endotracheal mucosa. Therefore, this study aimed to evaluate the relationship between irrigation fluid and endotracheal tube cuff pressures. Methods Forty patients aged 20 to 70 years with an American Society of Anesthesiologists (ASA) score I or II, scheduled for elective arthroscopic shoulder surgery under general anesthesia, participated in our study. We recorded endotracheal tube cuff pressures and neck circumferences every hour from the start of the operation. We also recorded the total duration of the anesthesia, operation, and the total volume of fluid used for irrigation. Results A positive correlation was shown between endotracheal tube cuff pressures and the amount of irrigation fluid (r = 0.385, 95% CI 0.084 to 0.62, p = 0.0141). The endotracheal tube cuff pressure significantly increased at 2 and 3 hours after starting the operation (p = 0.0368 and p = 0.0245, respectively). However, neck circumference showed no significant difference. Conclusions Endotracheal tube cuff pressures increased with operation time and with increased volumes of irrigation fluid used in patients who underwent shoulder arthroscopy. We recommend close monitoring of endotracheal tube cuff pressures during shoulder arthroscopy, especially during long operations using a large amount of irrigation fluid, to prevent complications caused by raised cuff pressures.


Resumo Justificativa e objetivos Diversas complicações das vias aéreas podem ocorrer durante a artroscopia do ombro, incluindo obstrução das vias aéreas, punção pleural e enfisema subcutâneo. Levantou‐se a hipótese de que o fluido de irrigação utilizado durante artroscopia do ombro possa aumentar a pressão do balonete do tubo endotraqueal, podendo causar edema e lesão isquêmica na mucosa traqueal. Portanto, este estudo teve como objetivo avaliar a relação entre o fluido de irrigação e a pressão do balonete do tubo endotraqueal. Métodos Participaram do estudo 40 pacientes com idades entre 20 e 70 anos com classificação do estado físico I ou II da American Society of Anesthesiologists (ASA), programados para cirurgia artroscópica do ombro, eletiva e sob anestesia geral. Registramos as pressões do balonete do tubo endotraqueal e as circunferências do pescoço a cada hora, a partir do início da cirurgia. Também registramos a duração anestésica e cirúrgica, assim como o volume total de líquido de irrigação empregado. Resultados Foi encontrada correlação positiva entre a pressão do balonete do tubo endotraqueal e a quantidade de líquido de irrigação (r = 0,385; 95% IC 0,084 a 0,62; p = 0,0141). A pressão do balonete do tubo endotraqueal registrou aumento significante 2 e 3 horas após o início da cirurgia (p = 0,0368 e p = 0,0245, respectivamente). No entanto, a circunferência do pescoço não mostrou diferença significante. Conclusões As pressões do balonete do tubo endotraqueal aumentaram com o tempo de cirurgia e com o aumento do volume de líquido de irrigação utilizado em pacientes submetidos a artroscopia do ombro. Recomendamos a monitorização rigorosa da pressão do balonete do tubo endotraqueal durante artroscopia do ombro, especialmente nos procedimentos longos em que grandes volumes de fluido de irrigação são empregados, para evitar complicações causadas por pressões elevadas do balonete.


Subject(s)
Humans , Male , Female , Adult , Aged , Young Adult , Pressure/adverse effects , Shoulder Joint/surgery , Intubation, Intratracheal/adverse effects , Time Factors , Elective Surgical Procedures/adverse effects , Elective Surgical Procedures/methods , Operative Time , Intubation, Intratracheal/instrumentation , Therapeutic Irrigation/adverse effects , Anesthesia, General/statistics & numerical data , Neck/anatomy & histology
20.
Rev. bras. ortop ; 55(5): 585-590, Sept.-Oct. 2020. tab, graf
Article in English | LILACS | ID: biblio-1144216

ABSTRACT

Abstract Objective Coracoid osteolysis has been described as a possible complication after the Latarjet procedure. The aim of the present study was to investigate the incidence and risk factors associated to coracoid graft osteolysis and to correlate them with clinical results. Methods A retrospective review of 38 Latarjet procedures was conducted. Computed tomography (CT) scans were obtained from all of the patients before and at least 1 year after the surgery. Coracoid osteolysis was evaluated and correlated to preoperative factors, namely: age, smoking status, and preoperative glenoid bone loss. The patients were divided into 2 groups: A (no or minor bone resorption) and B (major or total bone resorption). The functional outcome was determined by the Rowe score. Results Coracoid graft osteolysis occurred in 22 cases (57.8%). The mean preoperative glenoid defect was 22.8% in group A, and 13.4% in group B (p= 0.0075). The mean ages of the subjects in both groups were not significantly different. Smoking did not seem to affect the main outcome either, and no correlation was found between graft osteolysis and postoperative range of motion, pain, or Rowe score. There were no cases of recurrent dislocations in our sample, although four patients presented with a positive anterior apprehension sign. Conclusion Bone resorption of the coracoid graft is present in at least 50% of the patients submitted to the Latarjet procedure, and the absence of significant preoperative glenoid bone loss showed to be the only risk factor associated with severe graft osteolysis, even though this did not influence significantly the clinical outcome.


Resumo Objetivo Osteólise do processo coracoide é descrita como uma possível complicação da cirurgia de Latarjet. O objetivo do presente estudo foi avaliar a incidência e fatores de risco associados à osteólise do enxerto do coracoide e correlacioná-los com resultados clínicos. Métodos Foi realizada uma revisão retrospectiva incluindo 38 casos submetidos ao procedimento de Latarjet. Em todos os casos, foi realizada uma tomografia computadorizada antes e pelo menos 1 ano após a cirurgia. A presença de osteólise do coracoide foi avaliada e correlacionada com os seguintes fatores de risco: idade, tabagismo, e perda óssea pré-operatória da glenóide. Os pacientes foram divididos em dois grupos: A (ausência ou menor reabsorção óssea) e B (maior reabsorção óssea ou total). A avaliação funcional foi determinada através do escore de Rowe. Resultado Osteólise do processo coracoide ocorreu em 22 casos (57,8%). O defeito ósseo médio pré-operatório da glenóide foi de 22,8% no grupo A e de 13,4% no grupo B (p= 0.0075). A média de idade dos casos em ambos os grupos não apresentou diferença estatística. Tabagismo também não esteve relacionado com diferenças no resultado. Não houve correlação entre a presença de osteólise e o arco de movimento, dor ou ao escore de Rowe. Não houve casos de reluxação; entretanto, quatro pacientes apresentaram apreensão anterior no exame físico. Conclusão A reabsorção do processo coracoide ocorreu em pelo menos 50% dos pacientes submetidos à cirurgia de Latarjet, e a ausência pré-operatória de perda óssea significativa da glenóide foi o único fator de risco associado a osteólise mais severa do enxerto, porém sem influência no resultado clínico.


Subject(s)
Humans , Male , Adult , Osteolysis , Pain , Shoulder Dislocation , Shoulder Joint , Tobacco Use Disorder , Bone and Bones , Bone Resorption , Smoking , Tomography, X-Ray Computed , Range of Motion, Articular , Coracoid Process , Joint Instability
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