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Background: The tibial tubercle to trochlear groove (TT-TG) distance is often utilized for determining the surgical treatment for patients with patellar instability (PI). It is thought to directly represent the position of the TT on the tibia. Recent work has shown that the measurement of the TT-TG distance is multifactorial. Purpose: To investigate the relationship between relative tibial external rotation (rTER) and trochlear dysplasia (TD), as well as the location of the TG and TT in patients with and without PI, and to correlate these and other anatomic measurements with the TT-TG distance. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 89 patients with PI who underwent magnetic resonance imaging were identified with 92 matched control patients. A standardized measurement protocol on axial magnetic resonance imaging determined rTER, the proximal and distal TG lateralization (pTGL and dTGL, respectively) ratios, and the TT lateralization (TTL) ratio. Other measures of interest included the lateral trochlear inclination angle, sulcus angle, and lateral patellar inclination angle. Univariate regression was used to determine the associations of TD (lateral trochlear inclination angle, sulcus angle) with rTER and the TG position, and multivariate regression was used to model associations among all the variables with the proximal and distal TT-TG distances. Results: rTER was significantly higher in the study group ( P < .001), and univariate regression showed a significant association between dysplasia measures and rTER ( P < .001). The pTGL ratio was lower in the study group ( P = .025), but there was no difference in the dTGL ratio ( P = .090) or the TTL ratio ( P = .098) between the groups. There were no associations between dysplasia measures and the pTGL and dTGL ratios ( P > .05). Multivariate regression showed that the proximal TT-TG distance is predicted by the sulcus angle, pTGL ratio, rTER, and TTL ratio ( P < .05) and that the distal TT-TG distance is predicted by the lateral patellar inclination angle, dTGL ratio, sulcus angle, rTER, and TTL ratio ( P < .05). Conclusion: rTER had a significant association with TD. The position of the proximal TG was more medial in patients with PI. There was no significant difference in the TTL ratio between patients with and without PI. The TT-TG distance was associated with multiple anatomic measures and was not solely predicated on the position of the TT.

Background In the past few years 3-dimensional (3D) automated software for preoperative planning in shoulder arthroplasty has increased in practice. It has been used to improve accuracy on implant placement, size, and selection, especially on the glenoid side. New additions have been added however, to look at prediction of range of motion (ROM) for after surgery. Therefore, the purpose of this study was to assess the accuracy of the software feature of predicting impingement-free range of motion compared to postoperative functional outcomes. Methods A shoulder arthroplasty database including 192 patients was reviewed and 55 patients who underwent a primary RSA without evidence of preoperative fracture, trauma, or neurological associated diseases which could impact postoperative rehabilitation were included in the study. Preoperative plans for RSA were created for all patients based on preoperative shoulder CT scan and each patient's preoperative predictive ROM (PROM) suggested by the software was recorded. These PROM were then compared to postoperative final follow-up clinical range of motion for accuracy (CE ROM). Demographic information and Walch classification were recorded. Results Our cohort was composed of 30 males and 25 females with an average age of 71.2 years old and mean BMI 30.0 kg/m2. The predominant diagnosis was rotator cuff arthropathy (RCA: 32 patients) followed by severe osteoarthritis (SOA: 19 patients). The mean difference between clinical and predicted ROM for active FF was 42° (SD = 46°), passive FF was 61° (SD = 39°), passive ABD was 81° (SD = 33°), active ER was 22° (SD = 22°), and passive ER was 24° (SD = 25°). Our results also showed that the CE ROM was significantly higher than PROM for each clinical measurement (P Conclusion Not all features available in preoperative planning for RSA using 3D automated software can be translated into practice. Our results demonstrated PROM weakly correlated with CE ROM for patients who underwent RSA. Surgeons need to be aware that surgical decisions should not be altered based on this feature. More research needs to be done to validate this new tool incorporating both scapulothoracic motion and clinical correlation with predictive ROM. As we move into the era with 3D preoperative simulation and optimizing outcomes for shoulder arthroplasty these features incorporating clinical outcomes and function will be critical to consider. Level of Evidence Level III.

Hypothesis/Background: Treatment options for the biceps brachii tendon include tenotomy, arthroscopic tenodesis, and open tenodesis. Few studies to date have compared all treatment options in the context of a rotator cuff repair. Methods: A retrospective review of 100 patients who underwent arthroscopic supraspinatus repair between 2013 and 2018 with a minimum of one-year follow-up was performed. Patients were separated into the following 4 groups: (1) 57 had isolated supraspinatus repair with no biceps tendon surgery (SSP); (2) 16 had supraspinatus repair and biceps tenotomy; (3) 18 had supraspinatus repair and arthroscopic biceps tenodesis; (4) 9 had supraspinatus repair and an open biceps tenodesis (SSP + OT). The primary outcome was operative time. The secondary outcomes were cost analysis, complications, patient-reported outcome measures, range of motion, and strength testing. Results: The operative time for the SSP + OT group was significantly longer than that of the SSP group (P

A transfusão sanguínea é um procedimento que coloca os antígenos do doador em contato com os anticorpos do receptor. Embora este processo seja uma terapia efetiva, existem riscos causados por procedimentos inadequados, erros ou omissões. Os anticorpos irregulares (aloanticorpos) estão relacionados à maioria das reações transfusionais hemolíticas fatais notificadas, sendo a segunda principal causa de morte relacionada à transfusão. Para evitar essas reações, a bolsa fenotipada é uma ferramenta fundamental, no entanto, nem sempre está disponível em tempo hábil, onde muitas vezes a transfusão é de caráter emergencial. O presente estudo teve como objetivo avaliar a frequência de anticorpos irregulares e descrever o perfil fenotípico dos pacientes atendidos no Hospital do Câncer de Muriaé. Foram 149 protocolos de atendimento de pacientes oncológicos com resultados positivos para Pesquisa de Anticorpos Irregulares (PAI). O perfil desses pacientes correspondeu ao observado para a população brasileira, prevalecendo o sexo feminino (59,7%) e indivíduos acima de 50 anos. O grupo sanguíneo mais prevalente foi o tipo O (34,9%). Quanto ao tipo de neoplasia, prevaleceram as leucemias e linfomas (18,8%). Aproximadamente 23% dos pacientes aloimunizados desenvolveram anemia e 33,6% já haviam sido submetidos a transfusões sanguíneas. Entre os anticorpos detectados, 29,7% foram equivalentes a anticorpos sem especificidade, 25,5% autoanticorpos e 45% são anticorpos de especificidade determinada, onde anti-E > anti-c > anti-D > anti-K > anti-M foram os mais frequentes. Com relação aos sistemas de anticorpos, os mais frequentes foram: Rh (37,6%), Kidd (26,2%), Duffy e MNS (21,5%). Observamos que a aloimunização ocorreu já nos primeiros contatos com a transfusão, diferentemente do que relatam outros estudos, onde a maioria dos pacientes aloimunizados eram politransfundidos. A presença desses anticorpos representa um risco para a prática transfusional. Acreditamos que a realização da imunofenotipagem no próprio hospital traria maior agilidade e segurança no processo transfusional, especialmente para pacientes aloimunizados.

Objectives: Calcific tendinitis of the shoulder is a painful condition characterized by the presence of calcium deposits within the tendons of the rotator cuff (RTC) and accounts for up to 7% of all presentations of shoulder pain. Conservative treatment with physical therapy (PT) and corticosteroid injection is often the first line treatment. When conservative management fails, arthroscopic surgery for removal of the calcium may be considered. Surgical removal is often followed by rotator cuff repair to address the resulting tendon defect. This study was performed to assess predictive factors for failure of conservative management as well as to characterize the rate of rotator cuff repair in the setting of calcific tendinitis. We hypothesize that larger calcific lesion would have a higher likelihood to fail conservative treatment and the majority of patients requiring surgery will require a concomitant rotator cuff repair. Methods: A retrospective review of patients who were diagnosed with calcific tendinitis at our institution between 2009 and 2019 was performed. Demographics, comorbidities, pain score (VAS), ASES, ROM and patient-reported quality of life measures were recorded and analyzed. All patients underwent a radiograph and MRI. Size of the calcific lesion was measured based on its largest diameter on radiograph. Statistical analysis included chi-square, independent t test and ANOVA. Descriptive statistics were used to report data. pResults: 239 patients were identified in the study period; 127 (53.1%) were female. Mean age was 54 years and BMI 29.2 with mean follow up of 6 months. Preoperative pain score was 6.3 and ASES score was 47.9. 160 had an intact RTC (67.2%) and 78 had a partial RTC tear (32.8%). The calcific lesion was located in the supraspinatus in 148 patients (63.8%), infraspinatus in 32 patients (13.8%), subscapularis in 9 patients (3.9%), teres minor in 1 patient (0.4%) and combined tendons in 42 patients (18.1%). 93/239 (38.9%) patients failed conservative treatment after an average of 4.4 months necessitating surgical management. Failure rate for PT was 36.6% (24/71), for subacromial corticosteroid injection was 31.6% (25/79) and 33.8% (24/71) for ultrasound guided aspiration. Among patients who underwent surgery the majority of patients, 77/93 (82.8%) required a concomitant rotator cuff repair. Sub-analysis demonstrates that calcific lesions > 1 cm was significantly associated with failure of conservative treatment (odds ratio=2.81, 95% CI 1.25-6.29, pConclusions: Patients with calcific lesions >1 cm have a 2.8x-increased likelihood of failing conservative treatment in the setting of calcific tendinitis of the shoulder. The majority of patients who undergo surgical management for removal of the calcific deposit will require a concomitant rotator cuff repair and have significant improvements in shoulder pain and function. While conservative management is often considered a first-line treatment, the size of the lesion may play a significant role regarding whether conservative treatment will be successful, and patients should be counseled accordingly. Once surgery is decided, orthopedic surgeons should also be aware of the high likelihood of concomitant rotator cuff repair for preoperative planning and discussion.

Objectives: Calcific tendinitis of the shoulder is a painful condition characterized by the presence of calcium deposits within the tendons of the rotator cuff (RTC) that accounts for up to 7% of cases of shoulder pain1. The most common conservative treatments typically include physical therapy (PT), corticosteroid injection (CSI), or ultrasound-guided aspiration (USA). When conservative management fails, the patient may require arthroscopic surgery to remove the calcium with concomitant rotator cuff repair. The purpose of this study was to characterize the failure rates, defined as the need for surgery, of each of these three methods of conservative treatment, as well as to compare post-operative improvement in patient-reported outcomes (PROs) – including subjective shoulder values (SSV) and visual analog scale (VAS) pain scores – based on the type of pre-operative conservative intervention provided. A secondary aim was to compare post-operative range of motion (ROM) outcomes between groups that failed conservative management. We hypothesized that all preoperative conservative treatments would have equivalent success rates, PROs, and ROM. Bosworth B. Calcium deposits in the shoulder and subacromial bursitis: a survey of 12122 shoulders. JAMA. 1941;116(22):2477-2489. Methods: A retrospective review of all patients who were diagnosed with calcific tendinitis at our institution treated among 3 fellowship trained orthopedic surgeons between 2009 and 2019 was performed. VAS, SSV, and ROM in forward flexion (FF) and external rotation (ER) was abstracted from the medical records. Scores were recorded at the initial presentation as well as final post-operative follow-up visit for those who underwent surgery. The conservative treatment method utilized by each patient was recorded and included PT, CSI, or USA. Failure of conservative management was defined as eventual progression to surgical intervention. Statistical analysis included chi-square, independent t test and ANOVA. Descriptive statistics were used to report data. A pResults: 239 patients diagnosed with calcific tendinitis were identified in the study period with mean age of 54 years and follow up of at least 6 months. In all, 206 (86.2%) patients underwent a method of conservative treatment. Of these patients, 71/239 (29.7%) underwent PT, 67/239 (28%) attempted CSI, and 68/239 (28.5%) underwent USA. The overall failure rate across all treatment groups was 29.1%, with injections yielding the highest success rate of 54/67 (80.6%). Physical therapy saw the highest failure rate, with 26/71 (36.7%) proceeding to surgical intervention. Patients undergoing physical therapy were statistically more likely to require surgery compared to those undergoing corticosteroid injection (RR 1.88, p= 0.024). Of all 93 patients who underwent surgery, VAS, SSV, ROM improved significantly in all groups. On average, VAS decreased by 4.02 points (6.3 to 2.3), SSV increased by 33 points (51 to 84), FF improved by 13.8º, and ER improved 8.4º between the pre- and post-operative visits (pConclusions: Conservative treatment in the form of physical therapy, corticosteroid injection, and ultrasound-guided aspiration is largely successful in managing calcific tendinitis of the shoulder. Of these, PT demonstrated the highest rate of failure in terms of requiring surgical management. PRO improvement varied among the conservative modalities used, however patients who did not attempt conservative management experienced the greatest improvements following surgery. If surgery is necessary following failed conservative treatment, excellent outcomes can be expected with significant improvements in ROM and PROs. This information should be considered by the surgeon when deciding whether to recommend conservative treatment for the management of calcific tendinitis, as well as which specific method to employ.

BACKGROUND Off-track lesions are strongly associated with failure after arthroscopic Bankart repair. However, on-track lesions with a small distance-to-dislocation (DTD) value, or "near-track lesions," also may be at risk for failure. The purpose of the present study was to determine the association of DTD with failure after arthroscopic Bankart repair. METHODS We performed a retrospective analysis of 173 individuals who underwent primary arthroscopic Bankart repair between 2007 and 2015. Glenoid bone loss and Hill-Sachs lesion size were measured with use of previously reported methods. Patients with failure were defined as those who sustained a dislocation after the index procedure, whereas controls were defined as individuals who did not. DTD was defined as the distance from the medial edge of the Hill-Sachs lesion to the medial edge of the glenoid track. Receiver operating characteristic (ROC) curves were constructed for DTD to determine the critical threshold that would best predict failure. The study population was subdivided into individuals ≥20 years old and

To identify the rate and risk factors of posterior labral involvement in operatively managed Bankart lesions and assess the effectiveness of MRI arthrogram for preoperative identification of such injury patterns.A consecutive cohort of patients undergoing arthroscopic Bankart repair were retrospectively reviewed. All subjects underwent a prearthroscopy MRI arthrogram. Operative findings were used as the gold standard for posterior labral tear extension. Patient demographic and surgical data were then analyzed to identify independent factors associated with the presence of concomitant posterior labral injury.Of 124 patients undergoing arthroscopic Bankart stabilization, 23 (19%) were noted to demonstrate posterior labral injury on arthroscopic evaluation. Factors associated with injury to the posterior labrum included those sustaining two or fewer dislocations events (Posterior propagation of Bankart lesions is relatively common following shoulder dislocations, with a rate of 18.5%. Risk factors for posterior labral extension include two or fewer dislocations, early presentation from the time of injury, and contact sports. On the basis of these findings, careful assessment of the posterior labrum on MRI arthrogram may reveal the majority, but not all, of these lesions.Level III, retrospective case-controlled study.

This study aimed to analyze the impact of a criteria-based return-to-sport (CBRTS) testing protocol on recurrent instability following arthroscopic Bankart repair. We hypothesized that patients who underwent an objective CBRTS testing protocol to guide their clearance to return to sports would have less recurrent instability than those who did not undergo testing.Thirty-six consecutive patients who underwent arthroscopic Bankart repair from 2016 to 2018, had a minimum of 1 year of follow-up, and completed functional and strength testing to evaluate readiness to return to sports were included in this retrospective case-control study. Patients with critical glenoid bone loss13.5%, multidirectional instability, and off-track Hill-Sachs lesions necessitating a remplissage or bone augmentation procedure were excluded from the study. Recurrence was defined as dislocation or subluxation symptoms requiring revision surgery. Statistical analysis included analysis of variance and the independent t test.There was no difference between the study and control groups regarding age (P = .15), sex (P = .11), hand dominance (P = .56), or participation in contact sports (P = .78). Patients who underwent the CBRTS testing protocol had a reduced rate of recurrent shoulder instability (5% vs. 22%; odds ratio, 4.85; P.001). There was no difference in the time from surgery to recurrence between the groups (12 months vs. 13.6 months, P = .43).Athletes who underwent an objective CBRTS testing protocol to guide their clearance to return to sports had a lower rate of recurrent instability following arthroscopic Bankart repair than those cleared to return based on the time from surgery. Athletes who did not undergo CBRTS testing after arthroscopic shoulder stabilization had a 4.85 times increased likelihood of recurrent instability development after return to sports.

The lack of greater tuberosity (GT) healing in proximal humerus fractures has been negatively correlated with outcomes for hemiarthroplasty; however, there is still debate regarding the effects of GT healing in reverse shoulder arthroplasty (RSA). Our goal was to examine the effects of GT healing using a kinematic finite element analysis (FEA) model.Computer-aided design models of a medialized glenoid with a lateralized humerus (MGLH) RSA design were uploaded into an FEA shoulder model in 2 different configurations: healed greater tuberosity (HGT) and nonunion greater tuberosity (NGT). Deltoid muscle forces and joint reaction forces (JRFs) on the shoulder were calculated during abduction (ABD), forward flexion (FF), and external rotation (ER).Force magnitude of the anterior, middle, and posterior deltoid muscle as well as JRFs modeled in both GT scenarios were similar for ABD (muscle forces P = .91, P = .75, P = .71, respectively; and JRF P = .93) and for FF (muscle forces P = .89, P = .83, P = .99, respectively; and JRF P = .90). For ER, the force magnitude between 2 GT settings showed statistically significant differences (HGT: 9.51 N vs. NGT: 6.13 N) (P.001). Likewise, during ER, JRFs were different, and the NGT group showed a steep drop in JRF after 10° of ER (HGT: 28.4 N vs. NGT: 18.38 N) (P.001).GT healing does not seem to impact RSA biomechanics during abduction or forward flexion; however, it does affect biomechanics during external rotation. Overall orthopedic surgeons can expect good results for patients after RSA even with poor GT healing.

Objectives: Recurrent shoulder instability after arthroscopic shoulder stabilization is a challenging complication that often manifests after return to sports. Many physicians use an arbitrary minimum of 5 months from surgery for clearance, although there is little data to support the use of temporal based criteria. Prior literature on ACL reconstruction has demonstrated overwhelming evidence for improved failure rates following return to sport after criteria based testing compared to time based clearance, but no such studies to date have evaluated the use of objective return to play testing protocols on recurrence rates following arthroscopic shoulder stabilization. We have prior presented on a return to sport criteria-based protocol that has demonstrated that a majority of athletes have residual strength and functional limitations which would preclude them from full clearance and return to play at 6 months postoperatively. The purpose of this study is to analyze the impact of a return to play criteria-based testing protocol on recurrent instability following arthroscopic shoulder stabilization. We hypothesized that patients who meet return to play criteria would have less recurrent instability compared to those who did not undergo the testing and were cleared to return based on time from surgery. Methods: Forty eight patients (group I) who underwent arthroscopic shoulder stabilization surgery from 2016 to 2018 with minimum 1 year follow up and were referred during postoperative rehabilitation for functional testing to evaluate readiness for return to sport were included in this retrospective case controlled study. These patients were compared to a control group of forty-eight historical consecutive cases (group II) who did not undergo return to sports testing and were cleared for sports after a minimum of 5 months following surgery. Patients with critical glenoid bone loss or off-track Hill-Sach’s lesions necessitating a remplissage or bone augmentation procedure were excluded from the study. ANOVA and independent t test were performed to analyze recurrence shoulder instability rates defined as dislocations or subluxation symptoms. Results: There was no difference between groups with regard to age ( p=0.64), sex (p=0.24), hand dominance (p=0.84), or participation in contact sports (p=0.66). Patients who underwent return to play criteria based testing protocol had a statistically significant difference in the rate of recurrent shoulder instability (10% vs. 31%, odds ratio=3.9, pConclusion: Athletes who undergo an objective return to play criteria based testing protocol have lower rates of recurrent instability following arthroscopic shoulder stabilization surgery than those cleared by time from surgery. Based on our findings, we strongly recommend the utilization of a criteria based testing protocol for return to play following arthroscopic shoulder stabilization, particularly for sports that have known higher risks of recurrence.

Introduction In January 2013 was received in our lab service a bone marrow sample for cytogenetic analysis. The 61 years old female patient presents an elevated white blood cell count (118,000 x10³/mm³) and clinical diagnosis as Chronic Myeloid Leukemia (CML). According the medical information the treatment began with hydroxyurea 3g daily and allopurinol 300mg daily. Methods We proceeded with cytogenetic examination of the patient’s bone marrow aspirate by conventional G-banding analysis performed on unstimulated short-term cultures (24 hrs). FISH for BCR/ABL translocation was tested using a dual fusion dual color probe. Because of the sample stability we were unable to performed RT-PCR test. Results Chromosome analysis showed the translocation (9;22)(p24;q11.2) as a sole abnormality in 100% (20/20) of analyzed metaphases. Chronic myeloid leukemia presents as a specific chromosomal abnormality the Philadelphia chromosome, t(9;22)(q34;q11) which is different from the results obtained where the region of translocation of chromosome 9 was p24 instead of the classic q34. This result suggests it is BCR/JACK2 translocation. The FISH analysis showed the presence of a complex Ph chromosome: ABL con BCRx1 (one fusion) and BCRx2;ABLx2. Conclusion The patient took imatinib without answer. She is still in clinical monitoring with persistent hyperleucocytosis and the treatment is following with hydroxyurea 500mg daily and Interferon 5000 UI three times a week. Further molecular and cytogenetic tests will be performed in a second sample to contribute with evaluation of disease progression and monitoring treatment response. Disclosures: No relevant conflicts of interest to declare.