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Objective  To verify the prevalence of musculoskeletal pain in amateur golfers in the State of São Paulo, Brazil. Methods  The present is a cross-sectional study performed from September 2019 to March 2020 in golf clubs affiliated to Federação Paulista de Golfe (São Paulo Golf Federation). Federation players were evaluated regarding data on golf practice and sport routine by a main investigator, though an assessment form with multiple-choice questions, to determine sample characteristics and recent pain intensity by the Visual Analogue Scale. Results  Approximately 359 amateur golfers were analyzed. The prevalence of pain was of 55.15% (95% confidence interval [95%CI]: 50.0% to 60.3%); the average pain intensity according to the VAS was moderate (mean ± standard deviation: 5.21 ± 2.04; odds ration [OR]: 47,98%). The golfer's age range was significantly associated with the presence of pain ( p  < 0.05). The highest prevalence estimate of pain was of 68.80% in the age group between 30 and 39 years (OR: 7,33; 95%CI: 2,26 to 23,85; p  = 0,0009). The segments most affected by pain were the upper limbs (65.66%), followed by the spine (59.09%) and the lower limbs (32.83%). Conclusion  There is a high prevalence rate of pain in Brazilian amateur golfers, especially in younger players in the age group between 30 and 39 years., Competing Interests: Conflito de Interesses Os autores não têm conflito de interesses a declarar., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit ( https://creativecommons.org/licenses/by/4.0/ ).)

Objective:  To evaluate the usefulness of the Phalen test and the Tinel sign in the prognosis and the impact on quality of life in the clinical course of patients with carpal tunnel syndrome undergoing surgical treatment through the traditional open approach. Methods:  The present is a cohort study on prognosis. We included 115 patients with high probability of receiving a clinical diagnosis of carpal tunnel syndrome with indication for surgical treatment. All patients underwent the Phalen test and Tinel sign and answered the Boston Carpal Tunnel Questionnaire before and after the surgical treatment. Results:  The estimates for the probability of the time until remission of the Phalen test at 2, 4 and 16 weeks postoperatively were of 3.54% (95% confidence interval [95%CI]: 1.16%-8.17%), 0.88% (95%CI: 0.08%-4.38%) and 0.88% (95%CI: 0.08% to 4.38%) respectively, and, for the Tinel sign, they were of 12.39% (95%CI: 7.13%-19.18% ), 4.42% (95%CI : 1.65%-9.36%) and 2.65% (95%CI : 0.70%-6.94%) respectively. There was a reduction in the postoperative score on the Boston Carpal Tunnel Questionnaire of 1.8 points for symptom severity ( p  < 0.001) and of 1.6 points for functional status ( p  < 0.001). Conclusion:  Phalen test remission was earlier than that of the Tinel sign, but, when performed as of the second postoperative week, they were prognostic factors favorable to the clinical course, with improved quality of life., Competing Interests: Conflitos de Interesses Os autores declaram não haver conflitos de interesse., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit ( https://creativecommons.org/licenses/by/4.0/ ).)

Acute radiating low back pain is a frequently occurring clinical condition among the population, and it represents a significant portion of urgent care in public health services., Objective: Consider the clinical characteristics, demographics, as well as the intensity of the pain, discomfort, and dysfunction of patients who show a clinical diagnosis that is compatible with acute radicular pain, new or reoccurring after an asymptomatic period., Methods: Patients that display a clinical diagnosis that is compatible with acute sciatic nerve pain, with the beginning of it starting within three months, without previous history of a similar occurrence, were seen in an orthopedic health clinic from July 2020 to January 2021., Results: A total of 42 patients were seen with a compatible diagnosis, which represents 1.4% of all medical visits. To the best of our knowledge, no studies have considered the clinical and demographic characteristics of patients with acute radicular pain in the Brazilian population. This study has found a mean value on the disfunction index that is greater than what is suggested by the current literature., Conclusion: About 30% of individuals showed functional involvement that was considered crippling, which presented a stronger association with individuals with the presence of motor deficits, intensity of radiating pain, and professional inactivity. Level of Evidence IV, Cross-Sectional Study., Competing Interests: All authors declare no potential conflict of interest related to this article.

Introduction: Subacromial injections are therapeutic options for rotator cuff injuries, with consistent results not well established yet for each drug applied. The objective of this systematic review and meta-analysis is to analyse the effectiveness of the substances used in subacromial injections for the treatment of rotator cuff injuries and shoulder impingement syndrome, considering the functional gain and pain improvement of the shoulder., Methods and Analysis: Beginning in November 2022, we will perform a detailed search using the MEDLINE/PubMed, EMBASE, Cochrane Central Register of Controlled Trials and LILACS databases. Relevant grey literature (reference lists, conference abstracts and academic papers) will also be included.Two reviewers will independently screen and extract the information from the literature. Bias and quality of the included studies will be evaluated using the risk of bias assessment tool provided by the Cochrane Collaboration. Statistical analyses will be performed using Review Manager V.5.4 software., Ethics and Dissemination: Approval and patient informed consent are not required because we will only include published literature. The results of this research will be disseminated in a peer-reviewed journal and likely through other scientific events., Prospero Registration Number: CRD42020199292., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The study aimed to investigate the correlation between baropodometric parameters and the functional score in the evaluation of the results of surgery in patients with clubfoot. Fifty-one patients (77 feet) underwent surgical treatment, with a mean follow-up of 9.58 years (5-15 years), and a mean age of 10.2 years (7-16 years). A total of 39 males and 12 females were included, with 25 unilateral cases and 26 bilateral cases. The patients underwent a functional evaluation and an assessment of plantar pressure distribution using computerized baropodometry. The functional evaluation results were statistically analyzed to investigate any correlations. Unilateral and bilateral cases were studied in two different groups. The Mann-Whitney and Spearman correlation tests were used for these analyses. The static contact area, weight bearing time, gait speed, and plantar pressure peak were not correlated with the functional evaluation in the unilateral and bilateral cases. There was a statistically significant correlation (P < 0.05) among the integral plantar force, distribution of force, total plantar pressure, distance between the center of foot pressure and center of body mass, and dynamic contact area only in the bilateral cases. Baropodometry was correlated with the functional evaluation of several parameters in patients with bilateral involvement., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To verify the prevalence of patients who were victims of motorcycle trauma who were under the influence of alcohol and drugs., Methods: The study was observational and prospective, with patients hospitalized to the Orthopedics and Traumatology Ward of Hospital São Paulo (UNIFESP), from March 2015 to March 2016. The study included patients of all genders, over 18 years old, hospitalized due to motorcycle trauma and who needed orthopedic surgical treatment., Results: During the research, 282 patients were hospitalized, of which 23.8% were victims of motorcycle trauma. Of these, 49.3% motorcyclists reported the use of alcohol and drugs before the accident, while 50.7% denied their consumption. In the analysis of alcohol and drug consumption in patients with motorcycle injuries, the results showed that: 65% used only alcohol; 16% used both alcohol and drugs; and 19% used only illicit drugs., Conclusion: The incidence of patients who suffered motorcycle accidents under the influence of alcohol and drugs was 49.3%. Level of Evidence IV, Prospective Case Series., Competing Interests: All authors declare no potential conflict of interest related to this article.

Objective  Histological and macroscopic evaluation of the healing process of acute lesions of the femoral rectus muscle using stem cells derived from adipose tissue-derived stem cells (ADSCs). Method  An experimental study was conducted with 18 hind legs of New Zealand rabbits, which were divided into three study groups according to the intervention to be performed. In group I, no surgical procedure was performed; in group II-SHAN, the experimental lesion was performed without any additional intervention protocol; in group III-Intervention, the addition of ADSCs was performed in the same topography of the experimental lesion. After the proposed period, 2 weeks, the material was collected and submitted to macroscopic and histological evaluation. Results  The quantitative analysis showed that the addition of ADSCs is related to the reduction of inflammatory cells in the 2-week evaluation (164.2 cells in group II - SHAN to 89.62 cells in group III - ADSC). The qualitative analysis of the slides with Picrosirius red, noticed an increase in orange/yellow fibers in group III - ADSC, which evidences a final healing process. The macroscopic evaluation found no difference between the groups. Conclusion  The use of ADSCs in the treatment of acute muscle injury presented histological advantages when compared to their non-use., Competing Interests: Conflito de interesses Os autores declaram não haver conflito de interesses., (Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Background: Shoulder maneuvers and magnetic resonance imaging (MRI) are performed to diagnose supraspinatus tendon tears regardless of arthroscopy exam. Although there are many studies on this subject, there is a lack of studies comparing the sensitivity (Se) and specificity (Sp) of shoulder maneuvers and MRI to arthroscopic findings (intact, partial, or full thickness supraspinatus tendon tear)., Aim: To compare the diagnostic values of shoulder maneuvers with MRI for supraspinatus tendon tears in patients undergoing shoulder arthroscopy., Methods: A total of 199 consecutive patients from four orthopedic centers met the eligibility criteria of shoulder pain persisting for at least four weeks. They were prospectively enrolled in this study from April 2017 to April 2019. Seven clinical tests (full can, empty can, drop arm, Hawkins', painful arc, Neer's sign and resisted external rotation) and MRI were performed, and all were compared with surgical findings. Full can, empty can and resisted external rotation tests were interpreted as positive in the case of pain and/or weakness. We assessed the Se, Sp, accuracy, positive predictive value (PPV) and negative predictive value (NPV), positive and negative likelihood ratio and diagnostic odds ratio for overall, partial and full-thickness supraspinatus tears., Results: MRI had the highest Se for overall (0.97), partial (0.91) and full-thickness (0.99) tears; moreover, MRI had the highest NPV: 0.90, 0.88 and 0.98 for overall, partial and full-thickness tears, respectively. For overall supraspinatus tears, the Se and PPV were: Painful arc (Se = 0.85/PPV = 0.91), empty can (pain) (Se = 0.80/PPV = 0.89), full can (pain) (Se = 0.78/PPV = 0.90), resisted external rotation (pain) (Se = 0.48/PPV = 0.87), drop arm (Se = 0.19/PPV = 0.97), Neer's sign (Se = 0.78/PPV = 0.93) and Hawkins' (Se = 0.80/PPV = 0.88). MRI had the highest PPV (0.99). The Hawkin's test had the highest false positive rate in patients with intact tendons (0.36). The Sp of the empty can and full can (both tests positive for pain and weakness), drop arm and MRI were: 0.93, 0.91, 0.98 and 0.96, respectively. For partial and full-thickness tears, the empty can test (positive for pain and weakness) had a Sp of 0.93, and the drop arm and MRI had the same Sp (0.98)., Conclusion: Physical examination demonstrated good diagnostic value, the drop arm test had a Sp as good as MRI for supraspinatus tears; however, MRI was more accurate in ruling out tears. The Hawkins' test had high false-positive findings in patients with intact tendons., Competing Interests: Conflict-of-interest statement: The authors declare any conflicting interests related to this study., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.)

Objective  Semiquantitative and automated measurement of nuclear material removal and cell infiltration in decellularized tendon scaffolds (DTSs). Method  16 pure New Zealand rabbits were used, and the gastrocnemius muscle tendon was collected bilaterally from half of these animals (16 tendons collected); 4 were kept as control and 12 were submitted to the decellularization protocol (DTS). Eight of the DTSs were used as an in vivo implant in the experimental rotator cuff tear (RCT) model, and the rest, as well as the controls, were used in the semiquantitative and automated evaluation of nuclear material removal. The eight additional rabbits were used to make the experimental model of RCT and subsequent evaluation of cellular infiltration after 2 or 8 weeks, within the DTS. Results  The semiquantitative and automated analysis used demonstrated a removal of 79% of nuclear material ( p  < 0.001 and power > 99%) and a decrease of 88% (p < 0.001 and power >99%) in the area occupied by nuclear material after the decellularization protocol. On cell infiltration in DTS, an increase of 256% (p < 0.001 and power >99%) in the number of cells within the DTS was observed in the comparison between 2 and 8 weeks postoperatively. Conclusion  The proposed semiquantitative and automated measurement method was able to objectively measure the removal of nuclear material and cell infiltration in DTS., Competing Interests: Conflito de Interesses Os autores declaram não haver conflito de interesses., (Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Introduction: Diagnosis of Achilles insertional tendinopathies (AIT) is based on pain by tendon palpation. However, there is no consensus or standard with regard to the amount of force to be used during the evaluation. Algometry is a method of measuring the pressure applied in a specific region and can be a method for determining diagnosis values., Goal: To determine a cutoff value for pain threshold (PT) in the assessment of AIT., Design: This is a prospective case-control study of diagnostic accuracy, to develop a diagnostic criterion., Methods: Forty asymptomatic individuals and forty patients with AIT, matched by age and sex, were evaluated and submitted to algometry for PT and for visual analog scale (VAS) levels with 3 kgf at the insertion of the calcaneal tendon by two different evaluators. Inter-observer reproducibility was assessed through the interclass correlation coefficient (ICC). Sensitivity and specificity calculations of PT and of VAS were calculated and plotted on a receiver operating characteristic curve., Results: The lowest ICC found was 0.788. With regard to the diagnosis through PT , the 4.08-kgf value showed the best relation between sensitivity and specificity (92.5% and 92.5%, respectively). Algometry values lower than 4.08 were considered positive for disease. For the diagnosis of AIT through VAS with 3 kgf, the value of 2.98 was estabilished (sensitivity of 92.5% and specificity of 97.5%)., Conclusion: Algometry was shown to be a simple and reliable method for diagnosing AIT. Values of PT less than 4.08 kgf were found to be predictors of the disease., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Hip arthroplasties for the treatment of displaced femoral neck fractures in adults can be total replacement or hemiarthroplasty. Despite the high prevalence of these fractures and large number of studies on the topic, the best choice of arthroplasty to be used remains unclear. The present study aims to overview the results of systematic reviews of randomised controlled trials (RCTs) comparing outcomes between total hip replacement and hemiarthroplasty for displaced femoral neck fractures in adults., Methods and Analysis: Four electronic databases (Pubmed, Embase, Cochrane Library and Web of Science) and reference lists from previous reviews will be searched without language limitation. Eligible studies will be systematic reviews of RCT that compare total hip replacement and hemiarthroplasty for treatment of displaced femoral neck fractures in adults. Two reviewers will independently perform study selection, data extraction and quality assessment. Disagreements between reviewers will be resolved by a third reviewer. Comparisons of dichotomous data will report as the OR and 95% CI, and comparisons of functional and health-related quality of life outcomes are reported as the mean difference and 95% CI and as the risk difference, defined as the difference in the proportion achieving the minimum clinically important difference and 95% CI. As this overview will contribute to orthopaedic surgeons and health managers in better decision-making for the treatment of these fractures. The authors plan to complete the searches and analyses by 30 November 2021., Ethics and Dissemination: Ethical approval was obtained at Federal University of Sao Paulo. Findings will be disseminated through peer-reviewed publication., Prospero Registration Number: CRD42021237885., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Heterotopic ossification is defined as the formation of trabecular bone in soft tissues. It is a common complication after surgical treatment of acetabular fractures. However, its prophylaxis and treatment are still controversial. The objective of this research is to evaluate the effectiveness of actions to prevent the development of heterotopic ossification after surgical correction of acetabular fractures., Methods: A systematic review was carried out with research in the databases PubMed/MEDLINE, Embase, LILACS and Cochrane until August 4, 2020, without restrictions on language and year of publication. Only randomized clinical studies carried out in humans without restrictions based on the dosage of treatments, use and duration of prophylaxis were included in this review., Results: Two studies compared the use of radiotherapy and indomethacin and three compared the use of indomethacin with a placebo or non-indomethacin group. The meta-analysis calculations did not indicate statistical differences between radiotherapy versus indomethacin (RR 1.45, IC 95% 0.97 to 2.17, p = 0,55) and indomethacin versus placebo or not indomethacin (RR 0.85, IC 95% 0.68 to 1.06, p = 0,59). Conclusion: There is insufficient evidence to affirm that the use of radiotherapy or indomethacin are effective to prevent the formation of heterotopic ossification after surgery for fractures of the acetabulum. In addition, the number of complications was higher in the indomethacin group when compared to placebo or no intervention. Level of Evidence I, Systematic Review. , Competing Interests: All authors declare no potential conflict of interest related to this article.

Introduction: Fractures of the diaphysis of the clavicle are common; however, treatment guidelines for this condition are lacking. Surgery is associated with a lower risk of non-union and better functional outcomes but a higher risk of complications. Open reduction and internal fixation with plates and screws are the most commonly performed techniques, but they are associated with paraesthesia in the areas of incisions, extensive surgical exposure and high rates of implant removal. Minimally invasive techniques for treating these fractures have a lower rate of complications. The aim of this study is to evaluate which surgical treatment option (minimally invasive osteosynthesis or open reduction and internal fixation) has better prognosis in terms of complications and reoperations., Methods and Analysis: The study proposed is a multicentric, pragmatic, randomised, open-label, superiority clinical trial between minimally invasive osteosynthesis and open reduction and internal fixation for surgical treatment of patients with displaced fractures of the clavicle shaft. In the proposed study, 190 individuals with displaced midshaft clavicle fractures, who require surgery as treatment, will be randomised. The assessment will occur at 2, 6, 12, 24 and 48 weeks, respectively. The primary outcome of the study will be the number of complications and reoperations. For sample size calculation, a moderate effective size between the techniques was considered in a two-tailed test, with 95% confidence and 90% power. Complications include cases of infection, hypertrophic scarring, non-union, refracture, implant failure, hypoesthesia, skin irritation and shoulder pain. Reoperations are defined as the number of surgeries for pseudoarthrosis, implant failure, infection and elective removal of the implant., Ethics and Dissemination: Study approved by the institutional ethics committee (number 34249120.9.0000.5505-V.3). The results will be disseminated by publications in peer-reviewed journals and presentations in medical meetings., Trial Registration Number: RBR-3czz68)/UTN U1111-1257-8953., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective  To evaluate the prevalence of anatomical variations encountered in patients with carpal tunnel syndrome who underwent carpal tunnel classical open release. Methods  A total of 115 patients with a high probability of clinical diagnosis for carpal tunnel syndrome and indication for surgical treatment were included. These patients underwent electroneuromyography and ultrasound for diagnostic confirmation. They underwent surgical treatment by carpal tunnel classical open release, in which a complete inventory of the surgical wound was performed in the search and visualization of anatomical variations intra- and extra-carpal tunnel. Results  The total prevalence of anatomical variations intra- and extra-carpal tunnel found in this study was 63.5% (95% confidence interval [CI]: 54.5-72.4). The prevalence of the carpal transverse muscle was 57.4% (95% CI: 47.8-66.6%), of the bifid median nerve associated with the persistent median artery was 1.7% (95% CI: 0.0-4.2%), and the median bifid nerve associated with the persistent median artery and the transverse carpal muscle was 1.7% (95% CI: 0.0-4.2%). Conclusion  The most prevalent extra-carpal tunnel anatomical variation was carpal transverse muscle. The most prevalent intra-carpal tunnel anatomical variation was median bifid nerve associated with the persistent median artery. The surgical finding of an extra-carpal tunnel anatomical variation, such as the transverse carpal muscle, may indicate the presence of other associated carpal intra tunnel anatomical variations, such as the bifid median nerve, persistent median artery, and anatomical variations of the recurrent median nerve branch., Competing Interests: Conflito de interesses Os autores declaram não haver conflito de interesses., (Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Background: There remains a lack of consensus regarding the treatment of Achilles insertional tendinopathy. The condition is typically treated with eccentric exercises despite the absence of satisfactory and sustained results. Shockwave therapy was presented as an alternative, but there is a paucity of literature, with good outcomes, supporting its use. The purpose of the present single-center, double-blinded, placebo-controlled, randomized trial was to determine if the use of shockwave therapy in combination with eccentric exercises improves pain and function in patients with Achilles insertional tendinopathy., Methods: A total of 119 patients with Achilles insertional tendinopathy were evaluated and enrolled in the study from February 2017 to February 2019. Patients were allocated to 1 of 2 treatment groups, eccentric exercises with extracorporeal shockwave therapy (SWT group) and eccentric exercises with sham shockwave therapy (control group). Three sessions of radial shockwaves (or sham treatment) were performed every 2 weeks and eccentric exercises were undertaken for 3 months. The primary outcome was the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A) at 24 weeks. Secondary outcomes included the visual analogue scale, algometry, the Foot and Ankle Outcome Score, and the 12-Item Short Form Health Survey., Results: Both groups showed significant improvement during the study period; however, there were no between-group differences in any of the outcomes (all p >0.05). At the 24-week evaluation, the SWT group exhibited a mean VISA-A of 63.2 (95% confidence interval, 8.0) compared with 62.3 (95% confidence interval, 6.9) in the control group (p = 0.876). There was a higher rate of failure (38.3%) but a lower rate of recurrence (17.0%) in the SWT group compared with the control group (11.5% and 34.6%, respectively; p = 0.002 and p = 0.047). There were no complications reported for either group., Conclusions: Extracorporeal shockwave therapy does not potentiate the effects of eccentric strengthening in the management of Achilles insertional tendinopathy., Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The authors indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G513)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Lateral epicondylitis (LE), also known as tennis elbow, is the most common painful elbow condition. It affects approximately 1-3% of adults. There are various possible treatments described in the literature, but evidence to support a gold standard management protocol is lacking. Therefore, the objective of this study was to evaluate how Brazilian orthopaedists diagnose and treat lateral epicondylitis and compare these results with the available evidence., Methods: This is an observational, analytical, cross-sectional study. A questionnaire was prepared to obtain information from the participants with eight specific questions (2 on diagnosis and 6 on treatment). These questions were answered voluntarily by participants at 3 major congresses of orthopaedists in Brazil in 2018. The results were analysed in accordance with the overall number of responses and were evaluated among groups according to subspecialty., Results: We obtained a total of 501 questionnaires. Of these, 33 were excluded. The mean age was 38.67 years. The majority of respondents (91%) were male. We obtained 26.7% from specialists in hand surgery (Hand group), 36.5% from subspecialists in shoulder and elbow (Shoulder and Elbow group), and 36.8% from generalists in orthopaedics or from other subspecialties (General Orthopaedists group). For diagnosis, 24.4% did not initially request any imaging method. The most requested exam was ultrasonography (54.9%). The most prominent indication for initial treatment was physical therapy. For refractory cases, 78.3% of the respondents preferred doing a local infiltration. The most commonly used substance for local infiltrations was corticosteroids (89.6%). With respect to the surgical treatment option, 75.8% of those who recommend it prefer open techniques, and 24.2% prefer arthroscopic treatment. Of the total respondents, 12.8% did not recommend surgical treatment for LE., Conclusion: Among Brazilian orthopaedists, the Cozen test is most frequently chosen, and ultrasound is the most commonly used imaging tool. Nonsurgically, oral nonsteroidal anti-inflammatory drugs (NSAIDs) plus physiotherapy is the most popular initial therapy, and corticosteroids are the most popular type of infiltration agent. Most surgeons recommended surgery after 6 months of nonsurgical treatment, and 75.8% preferred the open technique.

Distal radial fractures are very common. Vicious consolidation can occur in up to one third of these fractures, resulting in wrist pain, restricted movement, and, eventually, physical limitation or disability. The treatment of this condition consists in corrective osteotomy, which requires careful preoperative planning due to its three-dimensional complexity, especially in injuries with joint involvement. Recently, prototyping based on three-dimensional (3D) reconstruction of computed tomography (CT) scans has been used for osteotomy planning in a 3D anatomical model. It allows a better understanding of the deformity in a realistic surgical approach, leading to safer, faster, and more predictable procedures. The aim of the present study is to present this technique and show its use in two clinical cases., Competing Interests: Conflito de Interesses Os autores não têm nenhum conflito de interesse a declarar., (Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Introduction: Anatomical total shoulder arthroplasty (TSA) is an effective treatment adopted for patients with glenohumeral osteoarthritis (OA). The glenoid component failure is the main risk that occurs in this therapeutic choice; however, doubts remain regarding the selection of the best implant for avoiding complication. This systematic review aims to evaluate the glenoid component in TSA by comparing the complications of different types of implants., Methods and Analysis: A systematic review of randomised clinical trials or quasi-randomised trials will be performed by applying the Preferred Reporting Items for Systematic Review and Meta-Analysis protocols and comparing polyethylene (keeled and pegged) versus metal-backed implants in adult patients with glenohumeral OA. Our search strategy will be performed using MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, EMBASE and Web of Science. Data management and extraction will be performed using a data withdrawal form and by analysing study method characteristics, participant characteristics, intervention characteristics, results and methodological domains. The database search will be performed by February 2021. The Grading of Recommendations Assessment, Development and Evaluation will be used for assessing the quality of evidence of each study selected; however, some critical and important outcomes were determined such as the shoulder function through functional scores (Constant-Murley and American Shoulder and Elbow Surgeons), complications represented by pain (Visual Analogue Scale), surgical revision, radiograph radiolucency and loosening. The confidence in estimated effects for these outcomes will be applied as the overall confidence. The outcomes will be defined as early or late, according to the postoperative follow-up of less than or greater than 1 year, respectively, for complications and radiographs. For the shoulder function, follow-ups will be divided into 6, 12 and 24 months. Heterogeneity is expected in systematic reviews; therefore, the selection of outcomes, as well as the sample size, and specific statistical analysis can lead to meta-analysis; however, if it fails, narrative evidence synthesis will be conducted. Other analyses such as descriptive, subgroup and sensitivity analyses will be performed whenever possible. This systematic review will, therefore, provide evidence concerning the best clinical practice for avoiding complications., Ethics and Dissemination: This study has been approved by the Institutional Review Board of Universidade Federal de São Paulo (protocols 0725/2017, 2.157.415 and 70473017.5.0000.5505), and the findings will be disseminated through peer-reviewed publication and conference presentations., Prospero Registration Number: CRD42018079537., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The increasing incidence of calcaneal tendon ruptures has substantially impacted orthopedic care and costs related to its treatment and prevention. Primarily motivated by the increasing of life expectancy, the growing use of tenotoxic drugs and erratic access to physical activity, this injury accounts for considerable morbidity regardless of its outcome. In recent years, the evolution of surgical and rehabilitation techniques gave orthopedists better conditions to decide the most appropriate conduct in acute tendon rupture. Although still frequent due to their high neglect rate, Achilles chronic ruptures currently find simpler and more biological surgical options, being supported by a new specialty-focused paradigm., Competing Interests: Conflito de Interesses Os autores declaram não haver conflito de interesses., (Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Calcaneal tendon injuries are extremely common in the general population and in orthopedics routine care. Its increasing incidence, which is motivated by an aging population, improved access to the health care system, increased prescription of continuous-use medication, erratic participation in sports and other factors, has had a direct impact on society. Consolidated treatment options for tendinopathies lack quality scientific support for many modalities. New therapies have emerged to enhance nonsurgical approach outcomes and to reduce the number of patients requiring surgery. Although these operative procedures provide good pain relief and functional outcomes, they are costly and may lead to complications., Competing Interests: Conflito de Interesses Os autores declaram não haver conflito de interesses., (Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

The conditions affecting the calcaneal tendon remain extremely prevalent in the clinical practice. The search for information about these diseases in national and international scientific databases are commonly hampered in the use of search tools, requiring the use if an eponym in the strategy. Achilles, in reference to the hero of the Greek mythology, is often used by several authors in scientific publications despite the new Nomina Anatomica., Objective: This article intends to recover the history behind the use of this term, which heroically resists in the clinical discussions of everyday life in articles and textbooks. Level of Evidence V, Literature Review., Competing Interests: All authors declare no potential conflict of interest related to this article.

Background: Scaffolds have considerably advanced in recent years. In orthopaedic surgery, scaffolds have been used as grafts in procedures involving tendon and ligament reconstruction. This paper aimed to produce and evaluate decellularized tendon scaffolds (DTSs) from biomechanical, microscopic, macroscopic and in vivo perspectives., Methods: Bilateral gastrocnemius muscle tendons from 18 adult New Zealand rabbits were collected. Of these 36 tendons, 11 were used as controls (Group A - control), and 25 were used in the decellularization protocol (Group B - DTS). The groups were subjected to histological, biomechanical and macroscopic analyses, and Group B - DTS was subjected to an additional in vivo evaluation. In the decellularization protocol, we used a combination of aprotinin, ethylenediamine tetraacetic acid (EDTA), sodium dodecyl sulfate (SDS) and t-octyl-phenoxypolyethoxyethanol (Triton X-100) for six days. During this period, the scaffolds were kept at room temperature on an orbital shaker with constant motion., Results: The DTSs showed an increased cross-sectional area and inter-fascicular distance and no change in parallelism or matrix organization. The nuclear material was not organized in the DTSs as it was in the control. In the biomechanical analysis, no significant differences were found between the groups after analysing the ultimate tensile load, stiffness, and elongation at the ultimate tensile load. During the in vivo evaluation, mononuclear cell infiltration was noted., Conclusions: The evaluated decellularization protocol generated a tendon scaffold, maintained the most important biomechanical characteristics and permitted cell infiltration.

Background: Total knee arthroplasty (TKA) is the treatment option for patients with severe osteoarthritis (OA) of the knee whose symptoms are refractory to conservative management. Unfortunately, the level of patient dissatisfaction is high, reaching up to 25%. The reasons for this dissatisfaction are multifactorial, but bone-implant mismatch significantly increases the chance of pain and functional limitation. Sex-specific prosthesis designs have been developed to overcome this issue, but their use is still controversial. The primary objective of this study was to evaluate possible sex differences in the shape of the distal femur in patients with osteoarthritis. Secondary objectives were to investigate interpersonal variability of the distal femur and to determine the number of femoral implant sizes required to meet shape variations., Methods and Findings: A cross-sectional observational study prospectively compared 294 knees of 293 patients with osteoarthritis according to sex (201 female/93 male). Six intraoperative measurements were performed on the distal femur (height and width of both lateral and medial condyles, total medial-lateral width of the femur, and intercondylar distance). Sex differences and interpersonal variability were analyzed by multiple linear regressions. Measurements were also correlated with patient height. An optimization analysis was used to estimate the number of femoral implant sizes required. There were significant sex differences in the distal femur, where men had higher values than women in all measurements. Great interpersonal variability was found. The height of the lateral condyle was correlated with patient height, but the correlation was not strong. Twenty-five femoral implant sizes were required to meet the shape variations in our sample., Conclusions: The shape of the distal femur in patients with osteoarthritis shows great interpersonal variability, with men showing significantly higher values than women. A total of 25 different implant sizes would be necessary to adequately meet the variations observed in our study population., Competing Interests: The authors have declared that no competing interests exist.

Objective: To evaluate the effectiveness of single-dose focal shockwave therapy in plantar fasciitis treatment., Methods: a primary, prospective study of a series of cases, conducted in the city of São Paulo, Brazil, by the Department of Orthopedics and Traumatology of the Universidade Federal de São Paulo, in Hospital São Paulo. All outcomes were measured at the time of inclusion of the patient in the study and at the post-intervention moments as it follows: three, six and twelve weeks. The VAS, AOFAS and SF-36 scales were applied by teams other than those who performed the SWT., Results: Data from 56 patients were collected during 2017 and 2018. There was improvement of the parameter evaluated (p < 0.005 and 95%CI) in all the periods in which the patients were reevaluated (3, 6 and 12 weeks), progressive improvement were observed in the three outcomes evaluated., Conclusion: Shock wave therapy was effective for plantar fasciitis treatment according to the proposed protocol considering pain, function and quality of life. Level of Evidence Ic, Case-series Study ., Competing Interests: All authors declare no potential conflict of interest related to this article.

Objective  To evaluate the inter- and intraobserver agreement regarding the Walch classification system for shoulder arthritis. Methods  Computed tomography scans of the shoulder joint of adult patients were selected between 2012 and 2016, and they were classified by physicians with different levels of expertise in orthopedics. The images were examined at three different times, and the analyses were evaluated by the Fleiss Kappa index to verify the intra- and interobserver agreement. Results  The Kappa index for the intraobserver agreement ranged from 0.305 to 0.545. The inter-observer agreement was very low at the end of the three evaluations (κ = 0.132). Conclusion  The intraobserver agreement regarding the modified Walch classification varied from moderate to poor. The interobserver agreement was low., Competing Interests: Conflitos de Interesse Os autores declaram não haver conflitos de interesse.

Background . The usual initial treatment for insertional Achilles tendinopathy is nonsurgical. Yet there is no standard conservative treatment for Achilles insertional tendinopathy. Shockwave therapy (SWT) has become a reliable option for the management of this illness over the past years. The aim of this study is to report the effectiveness of low-energy SWT associated with an eccentric strengthening protocol in 19 consecutive patients. Methods . This is a prospective study with 19 patients aged between 26 and 72 years diagnosed with insertional Achilles tendinopathy. The protocol consisted of SWT associated with eccentric exercises for 12 weeks. All patients were evaluated on the first day and after 24 weeks (final follow-up) with the Victorian Institute of Sports Assessment-Achilles (VISA-A) score, visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) questionnaire, and by algometry. At the last follow-up, patients were also assessed for adherence to the protocol, complications and final outcome (in their perception as success or fail). Results and Conclusion . Fifteen (79%) patients were fully adherent to the Alfredson protocol, and 13 (68%) patients considered the treatment protocol successful. At the last evaluation, patients demanded higher pressure on calcaneus to trigger pain (algometry 1), reported less pain when the algometer was applied with 3 kg (algometry 2), had less global pain (VAS), and had higher AOFAS and VISA-A scores. This study evidences that eccentric loading associated with SWT can dramatically improve patients' symptoms. We can conclude that eccentric loading associated with SWT is an effective treatment for Achilles insertional tendinopathy. Levels of Evidence: Therapeutic, Level III: Prospective cohort.

The use of Adipose-Derived Stem Cells (ADSC) has been presented as a new alternative for tendon reconstruction. Have been admitted that ADSCs are related to better outcomes when used in tendon healing. This research was designed to apply the potential of ADSCs in tendon healing. Flexor digitorum superficialis tendon lesion was performed on both legs of eleven New Zealand rabbits and them, at the same time, treated as follows: Suture alone (Group III - Suture, n:10), suture associated with ADSC (Group IV - Suture + ADSC, n:10) or without suture (Group II - SHAN, n:2). At four weeks after the tendon surgery, the animal was euthanized, and the tendon evaluated (biomechanically and macroscopically). We used 5 additional New Zealand rabbits in the control group "Group I - Control, n:10". In the macroscopic evaluation, the group with ADSC presented a more homogeneous gross morphology compared with the group III. Biomechanical testing showed a lower ultimate tensile load, stiffness and a higher cross-sectional area in the group III and IV compared with the control group. The group with ADSC showed a greater ultimate tensile load, a larger cross-sectional area and bigger deformation at the ultimate tensile load when compared to the group without ADSC. In general terms, the use of ADSCs in tendon healing have biomechanical advantages compared to the non-use of ADSCs at 4 weeks after surgery. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1281-1286, 2019., (© 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

Background: This study was designed to define the accuracy of shoulder ultrasonography for diagnosing supraspinatus tendon tears. This examination is routinely used by orthopedists and may do away with the need for other examinations for diagnosing these tendon injuries. The aim of this study was to evaluate the sensitivity and specificity of shoulder ultrasonography for diagnosing supraspinatus tendon injuries, using magnetic resonance imaging as the reference., Design and Setting: Prospective accuracy study at a single center: the Shoulder and Elbow Surgery Clinic of the Department of Orthopedics and Traumatology., Methods: Shoulder ultrasonography was performed on 80 patients of both genders, over 18 years of age, with complaints of shoulder pain and clinically suspected supraspinatus tendon lesions. Jobe's test and a full can test were performed. In addition, they underwent magnetic resonance imaging in a 3.0-tesla machine, as the reference standard. The examinations were performed and interpreted by radiologists., Results: Ultrasonography showed sensitivity of 36.3% and specificity of 91.7% for supraspinatus tears overall: sensitivity of 25.8% and specificity of 91.8% for partial tears and sensitivity of 46.2% and specificity of 100% for full-thickness tears. Ultrasonography showed high accuracy for diagnosing full-thickness tears: 91.3%. The p-values were 0.003 for tears overall, 0.031 for partial tears and < 0.001 for full-thickness tears., Conclusions: Ultrasonography showed low sensitivity for detecting supraspinatus tears, but high specificity for both partial and full-thickness tears.

Introduction: Tibia shaft fractures are among the most common in orthopedic practice, but Brazilian literature remains limited on the subject., Objective: To evaluate the characteristics of tibia shaft fractures and conduct a comparison between exposed and closed fractures of the tibia., Methods: This comparative prospective study examined all tibia shaft fractures admitted to our services over a twelve-month period. The cases were evaluated according to age, trauma mechanism, sex, associated fractures, treatment, hospital stay, and readmission rate during the six months after discharge., Results: Fifty-three cases met the inclusion criteria. The average age was 36 years (SD 14.3) and 83% were males (p<0.001). Traffic accidents were responsible for 73.6% of fractures (p<0.001). Exposed fractures were found in 52.8% of the cases (p=0.56). When initial treatment consisted of stabilization with external fixation, these cases were more likely to be rehospitalized (p=0.009). Cases of open fracture also had longer hospital stays (p<0.001) and a higher readmission rate (p=0.028)., Conclusion: Open fractures are associated with more severe trauma, expressed in longer hospital stays and high rates of readmission. Cases of fracture which were initially treated with external fixation had a higher readmission rate. Level of Evidence II; Prospective comparative study. , Competing Interests: All authors declare no potential conflict of interest related to this article.

Background: The aim of this study was to evaluate the effectiveness of two diagnostic tests routinely used for diagnosing carpal tunnel syndrome (CTS)-ultrasonography (US) and nerve conduction studies (NCS)-by comparing their accuracy based on surgical results, with the remission of paresthesia as the reference standard., Methods: We enrolled 115 patients, all of the female gender with a high probability of a clinical diagnosis of CTS. All patients underwent US and NCS for a diagnosis and subsequent surgical treatment. As a primary outcome, the accuracy of the US and NCS diagnoses was measured by comparing their diagnoses compared with those determined by the surgical outcomes. Their accuracy was secondarily evaluated based on before and after scores of the Boston Carpal Tunnel Questionnaire (BCTQ)., Results: Overall, 104 patients (90.4%) were diagnosed with CTS by the surgical reference standard, 97 (84.3%) by NCS, and 90 (78.3%) by US. The concordance of NCS and surgical treatment (p < 0.001; kappa = 0.648) was superior to that of US and surgical treatment (p < 0.001; kappa = 0.423). The sensitivity and specificity of US and NCS were similar (p = 1.000 and p = 0.152, respectively: McNemar's test). The BCTQ scores were lower after surgery in patients diagnosed by both US and NCS (p < 0.001and p < 0.001, respectively: analysis of variance)., Conclusions: US and NCS effectively diagnosed CTS with good sensitivity but were not effective enough to rule out a suspicion of CTS., Trial Registration: This study was registered at September, 10 th, 2015, and the registration number was NCT02553811 .

Objective: This study aims to assess the quality of articles published in the leading orthopedic surgery journals, by measuring the relation between the impact factor and the number studies with a high level of evidence., Methods: A literature review was performed of articles published in four previously selected journals. A score of journal evidence (RER - Relation between Randomized clinical trials and Systematic reviews) was calculated, considering the number of RCTs and SR published and the total number of full-text articles., Results: The selected journals were JBJS-Am, ASMJ, BJJ-Br and Arthroscopy, with Impact factors of 5.280, 4.362, 3.309 and 3.206 respectively in 2015. In the study, the RER Scores, in the same order, were 9.408, 6.153, 7.456 and 7.779., Conclusion: The journal JBJS-Am is the best available source of information on orthopedic surgery from this point of view. It has the highest Impact Factor and clearly the highest RER Score. On the other hand, we could conclude that the number of published RCT and good quality SR is very low, with less than 10% of all the articles. Level of evidence III, Analyses based on limited alternatives and costs, and poor estimates. , Competing Interests: All authors declare no potential conflict of interest related to this article.

Study Design: Animal experimental study., Objective: Evaluate the effect of physical activity and overtraining condition on glycosaminoglycan concentration on the intervertebral disc (IVD) using a rat running model., Summary of Background Data: Some guidelines recommend the implementation of a physical exercise program as treatment for low back pain; however, cyclic loading impact on the health of the IVD and whether there is a dose-response relationship is still incompletely understood., Methods: Thirty-two rats ages 8 weeks were divided into four groups with eight animals each. The first 8 weeks were the adaptive phase, the overtraining phase was from the ninth to the eleventh week, which consisted of increasing the number of daily training sessions from 1 to 4 and the recovery phase was represented by the 12th and 13th weeks without training. Control group 1 (CG1) did not undergo any kind of training. Control group 2 (CG2) completed just the adaptive phase. Overtraining group 1 (OT1) completed the overtraining phase. Overtraining group 2 (OT2) completed the recovery phase. Running performance tests were used to assess the "overtraining" status of the animals. IVD glycosaminoglycans were extracted and quantified, and identified by electrophoresis., Results: Glycosaminoglycans showed a distribution between chondroitin sulfate and dermatan sulfate. Glycosaminoglycans quantification showed decreasing concentration at the following order: OT1 > CG2 > OT2 > CG1. Increased expression of dermatan sulfate was verified at the groups submitted to any training., Conclusion: Overtraining condition, as assessed by muscle and cardiovascular endurance did not lessen glycosaminoglycan concentration in the IVD. In fact, physical exercise increased glycosaminoglycan concentration in the IVD in proportion to the training load, even at overtraining condition, returning to normal levels after the recovery phase and glycosaminoglycan production is a reversible acute positive response for mechanical stimulation of the IVD., Level of Evidence: N/A.

Background: The treatment of supracondylar humerus fracture in children (SHFC) is associated with complications such as functional deficit, residual deformity, and iatrogenic neurological damage. The standard treatment is closed reduction and percutaneous Kirschner wire fixation with different configurations. Despite this fact, there is still no consensus on the most effective technique for the treatment of these fractures., Objective: The aim of this systematic review will be to evaluate the effect of surgical interventions on the treatment of Gartland type II and III SHFC by assessing function, complications, and error as primary outcomes. Clinical outcomes such as range of motion and pain and radiographic outcomes will also be judged., Methods: A systematic review of randomized controlled trials or quasi-randomized controlled trials evaluating the surgical treatment of SHFC will be carried out in the Cochrane Central Register of Controlled Trials, PubMed, Literatura Latino-Americana e do Caribe em Ciências da Saúde, and Excerpta Medica Database. The search will also occur at ongoing and recently completed clinical trials in selected databases. Data management and extraction will be performed using a data withdrawal form and by analyzing the following: study method characteristics, participant characteristics, intervention characteristics, results, methodological domains, and risk of bias. To assess the risk of bias of the included trials, the Cochrane Risk of Bias Tool will be used. Dichotomous outcome data will be analyzed as risk ratios, and continuous outcome data will be expressed as mean differences, both with 95% confidence intervals. Also, whenever possible, subgroup analysis, sensitivity analysis, and assessment of heterogeneity will be performed., Results: Following the publication of this protocol, searches will be run and included studies will be deeply analyzed. We hope to obtain final results in the next few months and have the final paper published by the end of 2018. This study was funded by a government-based noncommercial agency, Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)., Conclusions: This study may provide surgical treatment effects evidence for SHFC. The results will assist clinical practice by demonstrating the effectiveness and potential complications of these interventions and might serve as a reference for future clinical trials on the topic., Trial Registration: PROSPERO CRD42014009304; https://www.crd.york.ac.uk/prospero/display&#95;record.php?RecordID=9304 (Archived by WebCite at http://www.webcitation.org/6usiDHzD7)., (©Oreste Lemos Carrazzone, João Carlos Belloti, Fabio Teruo Matsunaga, Nacime Salomão Barbachan Mansur, Marcelo Hide Matsumoto, Flavio Faloppa, Marcel Jun Sugawara Tamaoki. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 21.11.2017.)

Aim: To compare the functional outcomes of traumatic and non-traumatic rotator cuff tears after arthroscopic repair., Methods: Eighty-seven patients with rotator cuff tears following arthroscopic treatment were divided into traumatic and non-traumatic tear groups. Postoperative muscle strength and outcomes using the modified University of California, Los Angeles score were evaluated. Sex, age, affected limb and dominant limb were correlated between groups. Muscle strength of the repaired and unaffected shoulders was compared. Rotator cuff injury size was measured., Results: Of the 87 patients who underwent rotator cuff repairs, 35 had traumatic tears and 52 had non-traumatic tears. In patients with non-traumatic tears, the average age was 59 years, 74.5% were female, 96.1% were right-hand dominant and 92.3% had their dominant shoulder affected. Patients with traumatic tears were 59.5 years old on average, 51.4% were female, 91.4% were right-hand dominant and 88.5% had their dominant shoulder affected. No difference existed in the mean modified University of California, Los Angeles score between patients with traumatic tears (33.7) compared with those with non-traumatic tears (32.8). No strength differences were observed between groups: The strength difference between the non-affected and affected sides was 1.21 kg in the non-traumatic group and 1.39 kg in the traumatic group ( P = 0.576), while the strength ratio between the non-affected/affected sides was 0.805 in the non-traumatic group and 0.729 in the traumatic group ( P = 0.224)., Conclusion: The functional results of traumatic rotator cuff repairs are similar to non-traumatic tears. Both outcomes are satisfactory., Competing Interests: Conflict-of-interest statement: There is no conflict-of-interest.

Background: Most midshaft clavicle fractures affect the economically active population, which is negatively impacted by transient limb impairment during the treatment. There is still debate about the advantages and disadvantages of surgical treatment for these fractures., Methods: In this prospective randomized controlled trial, 117 patients were allocated to 1 of 2 groups: nonsurgical treatment with a figure-of-eight harness or surgical treatment with anteroinferior plate osteosynthesis. The primary outcome was upper-limb limitation measured with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire at 6 months. Other outcomes included pain, radiographic findings, satisfaction with the cosmetic result, complications, and time to return to previous work and activities. Participants were assessed at 6 weeks, 6 months, and 1 year after the intervention., Results: No difference between the 2 groups was detected in the DASH score at any time point (p = 0.398, 0.403, and 0.877 at 6 weeks, 6 months, and 1 year, respectively), pain levels measured with a visual analogue scale (VAS), time to return to previous activities, or dissatisfaction with the cosmetic result. Seven patients (14.9%) developed nonunion after nonsurgical treatment, a nonunion rate that was significantly higher than that in the surgical group, in which all fractures had healed (p = 0.004). The patients in the nonsurgical group had radiographic evidence of greater clavicle shortening (p < 0.001) and more of the patients in that group answered "yes" when asked if their clavicle felt short (p < 0.001) and if they felt bone prominence (p < 0.001). More patients answered "yes" when asked if they felt paresthesia in the surgical group (7; 13.7%) than in the nonsurgical group (1; 2.1%) (p = 0.036)., Conclusions: This study did not demonstrate a difference in limb function between patients who underwent surgical treatment and those nonsurgically treated for a dislocated midshaft clavicle fracture. Meanwhile, surgical treatment decreased the likelihood of nonunion., Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Objective: The objective of this study was to compare inter- and intra-observer agreement using the Garnavos and AO/ASIF systems for classifying humeral diaphysis fractures ., Methods: Eighty X-ray images taken of humeral diaphysis fractures in adult patients (age≥18 years) between January 2013 and September 2015 in the Radiology Department of Hospital São Paulo were selected for subsequent classification by five orthopedic surgeons with differing levels of experience. The images were examined at two different times and reproducibility analysis was evaluated using Fleiss' kappa to verify intra- and inter-observer agreement ., Results: High-level agreement was observed for both classification systems, but particularly for the AO/ASIF classification. Inter-observer evaluation yielded excellent levels of agreement for both classifications, but principally for the Garnavos classification ., Conclusions: Good or excellent inter- and intra-observer agreement was seen for both the AO/ASIF and Garnavos classification systems. However, intra-observer agreement was higher for the AO/ASIF system and inter-observer agreement was higher for the Garnavos classification. Level of Evidence II, Diagnostic Studies - Investigating a Diagnostic Examination., Competing Interests: All authors declare no potential conflict of interest related to this article

Objectives: To describe the new IDEAL method from classifying distal radius fractures., Methods: IDEAL classification system is based on the most important literature evidences about clinical and radiographic characteristics that influence in the treatment and prognosis for patients that suffered from a distal radius fractures. In this method, we classify the fracture in patients first consultation, in which we collect demographical (age and trauma energy) and radiographic characteristics (fracture deviation, articular fracture, and associated lesions). For each feature a score is attributed for grouping purposes. Group I - Stable fractures, good prognosis; Group II - potentially unstable fractures, commonly treated by surgical methods. Prognosis depends on surgeons' success after method choice. Group III - complex and instable fractures, poor outcome is expected., Conclusion: IDEAL classification staging rationale was presented, which is based on the best available evidence. The evidence of its scientific plausibility will be settled with the assessment of the classification reliability and its capacity to aid in therapeutical decisions and as a tool to predict prognosis. Further studies are under development to support these properties.