Modified-tension band suturing: 'the pulling the reins technique' - a technique for displaced proximal humeral fracture with medial column instability.

Fractures of the proximal humerus with medial column instability are challenging and present an unacceptable rate of complications and reoperations. Despite good results reported with the use of locking plates and augmentation techniques using bone graft or a second plate, varus subsidence and fixation failure have been frequently reported. We describe the case of a patient presenting with a complex, multifragmentary proximal humerus fractures successfully treated with open anatomic reduction and internal fixation using a locking plate augmented with lateral traction using three bone anchors in the humerus head. After 18 months, the patient reported fully recovering the mobility and functionality of the operated shoulder. The use of bone anchors pulling the humeral in three different directions like three vectors applied from medial to lateral, posterior to anterior and lateral to anterior help to reduce the most important deformities (varus and retroversion) by applying the tension band principle. This is an interesting approach to avoid primary and secondary reduction loss of the proximal fractures of the humerus with postero-medial cortical defect. The procedure is a good alternative to be used in patients with failure or insufficiency of the medial wall and marked varus.

No dose response effect in shockwave therapy applied to bone conditions: a systematic review, meta-analysis and meta-regression.

Background: Shock waves have been widely used to treat bone conditions, but despite the articles and meta-analyses, there are still doubts about its effectiveness, with a meta-analysis pointing to uncertain evidence of positive effects for pain and delayed or non-union, while others point to a positive effect on the same outcomes. One hypothesis for this conflict in the results is the lack of research on the relationship between the applied dose and clinical outcomes. Purpose: Identify the effect of the dose applied in shockwave therapy on clinical results in bone conditions by meta-regression of controlled trials. Methods: Our search was conducted on PubMed (MEDLINE), EMBASE, Cochrane, Web of Science and Scopus in November 2022. The results of 3, 6, 12 and 24 months, post treatment of shockwave therapy of long bone fractures, osteonecrosis of femoral head and bone marrow edema were analyzed for pain, functional scores, size of lesion and non-union with meta-analysis and meta-regressions were conducted with the clinical results and the parameters of the quantity of pulses and energy flux density (EFD). Results: 3641 studies were retrieved and after the selection process eight of them were included for analyses. Shockwave therapy applied at the moment of surgery led to significant lower raw mean difference (RMD) pain scores at six months (RMD: -1.53[-2.58; -0.48], p=0.004) and at 3 and 12 months. Better functional standard mean difference (SMD) scores were found at six months (SMD: 0.83[0.32; 1.33], p<0.001) and at 3 and 24 months. A reduction in the size of lesion for the osteonecrosis of the femoral head was found at 12 months (RMD: -19.01[-35.63; -2.39], p=0.02). The meta-regression analyses showed no association between EFD (R2=0.00; p=0.42), or the number of pulses (R2=0.00; p=0.36) with pain scores; or EFD (R2=0.00; p=0.75), and the number of pulses (R2=0.00; p=0.65) with functional values. Discussion: The results point that shockwave therapy had positive effects in pain and functional scores at different time points after bone fractures or osteonecrosis of the femoral head, however, neither the quantity of pulses or the energy flux density showed any relationship with these positive outcomes.

Benefits of Patch Augmentation on Rotator Cuff Repair: A Systematic Review and Meta-analysis.

Background: Despite technological advances, the overall retear rate on rotator cuff repair is still high. Patches have shown significant reduction in retear rate and pain scores; however, this is not a universal finding and conflicting results have been shown among functional shoulder scales. Purpose: To analyze previous controlled trials of the literature to bring a consensus about the effectiveness of patch use on rotator cuff repair. Study Design: Systematic review; Level of evidence, 1. Methods: The search was conducted in PubMed, Web of Science, EMBASE, Scopus, and Cochrane in April 2020. The results of rotator cuff repair with patch augmentation versus without augmentation (control) were compared through odds ratio (OR), raw mean difference (RMD), and standardized mean difference (SMD) of retear rate; functional shoulder scales; strength; and range of motion (ROM). Results: Of 733 initial studies, 7 of them met the criteria to be included in the analysis. Compared with the control group, the patch augmentation group had a significantly lower retear rate (OR, 0.32 [95% CI, 0.18 to 0.55]; P < .001), lower pain (SMD, -0.42 [-0.71 to -0.12]; P < .01), a higher University of California Los Angeles Shoulder Rating Scale (RMD, 0.87 [0.15 to 1.60], P = .017), and a trend toward higher strength (SMD, 0.95 [-0.03 to 1.94], P = .05) and lower forward elevation ROM (RMD, -10.50 [-21.86 to 0.67]; P = .06), while no changes were noted for other functional scales or for internal and external rotation ROM. Conclusion: The results point to benefits of patch augmentation in rotator cuff repair, particularly a reduction in retear rate. More interventional studies with better methodological quality should be conducted to confirm the results of this initial review.

Time Course of Skeletal Muscle miRNA Expression after Resistance, High-Intensity Interval, and Concurrent Exercise.

INTRODUCTION: Exercise-induced microRNA (miRNA) expression has been implicated in the regulation of skeletal muscle plasticity. However, the specificity and acute time course in miRNA expression after divergent exercise modes are unknown. In a randomized crossover design, we compared the acute expression profile of eight skeletal muscle miRNAs previously reported to be involved in skeletal muscle development, growth, and maintenance after a bout of either resistance exercise (RE), high-intensity interval exercise (HIIE), and concurrent resistance and high-intensity interval exercises (CE). METHODS: Nine untrained young men (23.9 ± 2.8 yr, 70.1 ± 14.9 kg, 177.2 ± 3.0 cm, 41.4 ± 5.2 mL·kg-1·min-1) underwent a counterbalanced crossover design in which they performed bouts of RE (2 × 10 repetitions maximum 45° leg press and leg extension exercises), HIEE (12 × 1-min sprints at V˙O2peak with 1-min rest intervals between sprints), and CE (RE followed by HIIE), separated by 1 wk. Vastus lateralis biopsies were harvested immediately before (Pre) and immediately (0 h), 4 h, and 8 h after each exercise bout. RESULTS: There were similar increases (main effect of time; P < 0.05) in miR-1-3p, miR-133a-3p, miR-133b, miR-181a-3p, and miR-486 expression at 8 h from Pre with all exercise modes. Besides a main effect of time, miR-23a-3p and miR-206 presented a main effect of condition with lower expression after HIIE compared with RE and CE. CONCLUSIONS: Select miRNAs (miR-1-3p, miR-133a-3p, miR-133b, miR-23a-3p, miR-181a-3p, miR-206, miR-486) do not exhibit an expression specificity in the acute recovery period after a single bout of RE, HIIE, or CE in skeletal muscle. Our data also indicate that RE has a higher effect on the expression of miR-23a-3p and miR-206 than HIIE. As upregulation of these miRNAs seems to be confined to the 8-h period after exercise, this may subsequently affect the expression patterns of target mRNAs forming the basis of exercise-induced adaptive responses.

Time-Dependent Effect of Platelet-Rich Plasma in Reducing Donor-Site Pain After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) has a high incidence among sports players, and one important side effect of the surgery is graft donor site morbidity. Although some evidence suggests that application of platelet-rich plasma (PRP) during ACLR reduces pain and improves knee function, it is not a universal finding. PURPOSE: To perform a meta-analysis of previous studies testing the effects of PRP on donor site morbidity after ACLR. STUDY DESIGN: Systematic review and meta-analysis. METHODS: We reviewed PubMed (Medline), Web of Science, Embase, Scopus, and Cochrane databases to find studies testing the effects of PRP on the donor site of ACLR autograft. After identifying 4 studies, we conducted 2 meta-analyses, 1 for the effects of PRP on pain, assessed by visual analog scale (VAS), and the other for the functional knee scores. We also tested the ability of time after ACLR to predict the PRP-related reduction of pain. RESULTS: In the 4 studies identified, 157 patients were analyzed. Although the VAS score was lower with PRP at 6 months (raw mean difference [RMD], -0.97 [95% CI, -1.59 to -0.36]; P = .001) and 12 months (RMD, -0.61 [95% CI,-1.02 to -0.21]; P = .003), the effects of PRP disappeared at 24 months (RMD, -0.08 [95% CI,-0.38 to 0.22]; P = .586). A univariate regression analysis reinforced the ability of time after ACLR to predict the PRP-related reduction of VAS pain score (r2 = 0.98). However, knee function after ACLR was not improved by the use of PRP (standardized mean difference, 0.71 [95% CI,-0.17 to 1.60]; P = .114). CONCLUSION: PRP applied to a bone-patellar tendon-bone donor site could reduce knee pain within a year, and this reduction had a correlation with time, meaning that the effect of PRP decreased with time after surgery. However, pain reduction did not reach clinical relevance and did not lead to better functional knee scores.

PRP does not improve the objective outcomes of anterior cruciate ligament reconstruction: a systematic review and meta-analysis.

PURPOSE: Platelet rich plasma (PRP) has been used in association with anterior cruciate ligament resconstruction (ACLR) to improve rehabilitation. The purpose was to systematically review the literature to compare the effects of PRP on ACLR in its objective and subjective outcomes. METHODS: A systematic review of the MEDLINE, Web of Science, Embase, Scopus, and Cochrane databases was performed. Two independent reviewers included all the English language literature of patients undergoing primary ACLR with autograft combined with PRP. The outcomes analyzed were graft ligamentization (MRI), tibial and femoral tunnel widening (MRI), knee laxity, IKDC, Lysholm, Tegner activity scale and visual analog scale. RESULTS: Nine studies were included with a total of 525 patients. PRP did not improve ligamentization of graft (standardized mean difference (SMD): 0.01 [95% CI: - 0.37; 0.39]), did not lead to lesser tunnel widening (SMD: 0.71 [95% CI: - 0.12; 1.54]), or lead to lesser knee laxity (raw mean difference: 0.33 [95% CI: - 0.84; 0.19]). Although there was statistical significance for PRP effects on Lysholm score and VAS (p < 0.01), their magnitude was limited. CONCLUSION: PRP showed no improvement in objective outcomes like ligamentization and less tunnel widening, while it showed just small improvements in terms of Lysholm, VAS and knee laxity. Therefore, there is not enough evidence to support a recommendation in favor of PRP and more research is needed. LEVEL OF EVIDENCE: I.

Association between Lysholm score and muscular torque deficit after anterior cruciate ligament reconstruction.

PURPOSE: The asymmetry of muscular strength after anterior cruciate ligament reconstruction (ACLR) is associated with increase in the development of new lesions. This asymmetry is precisely assessed by isokinetic dynamometry which is a high-cost technique, limited to major centers and hospitals. Thus, the aim of this study was to test the accuracy of one of the most frequently used functional questionnaires, the Lysholm score, to diagnose the knee torque deficit. METHODS: In total, 115 patients were evaluated after ACLR. Knee symptoms were evaluated using the Lysholm questionnaire and knee extensor and flexor peak torque during maximal isokinetic concentric contractions at 60° s-1 (5 repetitions) and 180° s-1 (15 repetitions). Patients with <20% peak torque deficit were considered symmetric (normal). RESULTS: An increase in the Lysholm score was associated with a deficit reduction in the peak torque of knee extensors at 60° s-1 (r = -0.294) and 180° s-1 (r = -0.297) (p < 0.05 for both). Cutoff Lysholm scores of >90 points for 60° s-1 allowed the correct diagnosis of symmetry in 71% and of >89 points for 180º·s-1 allowed the correct diagnosis of symmetry in 73%, for knee extensors. Patients with a Lysholm score of >89 points presented an isokinetic deficit 36% lower than patients with a Lysholm score of ≤89 points (p < 0.05). CONCLUSION: A Lysholm score of >89 points has predictive value for deficits in the peak torque of knee extension (<20%). However, replacement of the isokinetic evaluation by this instrument must be performed with caution because of its accuracy.

"Clothesline technique" for proximal tibial shaft fracture fixation using conventional intramedullary nail: a simple, useful, and inexpensive technique to prevent fracture malalignment.

Treatment of proximal tibial shaft fractures is always challenging. Despite the development of modern techniques, the literature still shows high complication rates, especially regarding proximal fragment malalignment. It is well known that knee position in flexion during tibial nailing is responsible for extension and valgus deformities of the proximal fragment. Unlike in tibial shaft fractures, nails do not reduce proximal tibial fractures due to the medullary canal width. This study aims to describe a simple, useful, and inexpensive technique to prevent valgus and extension deformities when treating proximal tibial fractures using conventional nails: the so-called clothesline technique.

Attenuated PGC-1α Isoforms following Endurance Exercise with Blood Flow Restriction.

INTRODUCTION: Exercise performed with blood flow restriction simultaneously enhances the acute responses to both myogenic and mitochondrial pathways with roles in training adaptation. We investigated isoform-specific gene expression of the peroxisome proliferator-activated receptor gamma coactivator 1 and selected target genes and proteins regulating skeletal muscle training adaptation. METHODS: Nine healthy, untrained males participated in a randomized, counterbalanced, crossover design in which each subject completed a bout of low-intensity endurance exercise performed with blood flow restriction (15 min cycling at 40% of V˙O2peak, BFR-EE), endurance exercise (30 min cycling at 70% of V˙O2peak, EE), or resistance exercise (4 × 10 repetitions of leg press at 70% of one-repetition maximum) separated by at least 1 wk of recovery. A single resting muscle biopsy (vastus lateralis) was obtained 2 wk before the first exercise trial (rest) and 3 h after each bout. RESULTS: Total PGC-1α mRNA abundance, along with all four isoforms, increased above rest with EE only (P < 0.05) being higher than BFR-EE (P < 0.05). PGC-1α1, 2, and 4 were higher after EE compared with resistance exercise (P < 0.05). EE also increased vascular endothelial growth factor, Hif-1α, and MuRF-1 mRNA abundance above rest (P < 0.05), whereas COXIV mRNA expression increased with EE compared with BFR-EE (P < 0.05). CONCLUSION: The attenuated expression of all four PGC-1α isoforms when EE is performed with blood flow restriction suggests this type of exercise provides an insufficient stimulus to activate the signaling pathways governing mitochondrial and angiogenesis responses observed with moderate- to high-intensity EE.

Evaluation of patients undergoing rotator cuff suture with the modified mason-allen technique.

OBJECTIVE: : The purpose of this study was to clinically evaluate patients who underwent Arthroscopic Rotator Cuff Repair (RC) using the Modified Manson-Allen technique. METHODS: : We evaluated 79 patients who underwent shoulder arthroscopy. The lesions were repaired using the modified Mason-Allen suture between 2003 and 2009, divided by Cofield classification and clinically evaluated by the scoring system of the University of Los Angeles (UCLA) in the pre- and postoperative periods. RESULTS: : The evaluation of lesion sizes showed 7 small lesions (<1cm), 55 average lesions (1-3cm) and 17 large lesions (3-5cm), and in this last group there were 5 reruptures and the patients were reoperated by the same technique. Comparing the pre (14.1) and postoperative (32.6) values by UCLA system there was a significant improvement of score (142.3%), regardless of lesion size. The modified Mason-Allen suture provided satisfactory clinical results, regardless of lesion size, similar to those found in literature. The rerupture rate was high in large lesions. New suture techniques have been developed with the aim of reducing the incidence of rerupture. CONCLUSION: : The modified Mason-Allen suture technique provided clinical improvement, regardless of lesion size. Level of Evidence IV, Cases Series .

TRANSLATION TO PORTUGUESE LANGUAGE AND CROSS-CULTURAL ADAPTATION OF THE MODIFIED ROWE SCORE FOR OVERHEAD ATHLETES.

UNLABELLED: Objetctive: Study was to translate and culturally adapt the modified Rowe score for overhead athletes. METHODS: The translation and cultural adaptation process initially involved the stages of translation, synthesis, back-translation, and revision by the Translation Group. It was than created the pre-final version of the questionnaire, being the areas "function" and "pain" applied to 20 athletes that perform overhead movements and that suffered SLAP lesions in the dominant shoulder and the areas "active compression test and anterior apprehension test" and "motion" were applied to 15 health professionals. RESULTS: During the translation process there were made little modifications in the questionnaire in order to adapt it to Brazilian culture, without changing the semantics and the idiomatic concept originally described. CONCLUSION: The questionnaire was easily understood by the subjects of the study, being possible to obtain the Brazilian version of the modified Rowe score for overhead athletes that underwent surgical treatment of the SLAP lesion.

Translation and cross-cultural adaptation of the rowe score for portuguese.

OBJECTIVE: To translate and culturally adapt the Rowe score for use in Brazil. METHODS: The translation and cross-cultural adaptation process initially involved the steps of translation, synthesis, back-translation and revision by the Translation Group. The pre-final version of the questionnaire was then created. The Stability and Function fields were applied to 20 patients with anterior shoulder luxation, and the Mobility field was applied to 20 health professionals. RESULTS: It was found that some of the patients had difficulty understanding some of the expressions of the questionnaire, so these were replaced with terms that were easier to understand. All health professionals understood the translation of the Mobility field. The altered questionnaire was then reapplied to another 20 patients, and this time it was understood by all the assessed subjects. CONCLUSION: After a careful process of translation and cultural adaptation, a definitive version of the Rowe questionnaire was obtained in Brazilian Portuguese. Level of Evidence II, Development of diagnostic criteria on consecutive patients.