The aim of this study is to evaluate the effect of dynamic stabilizing strategy on handgrip and pinchgrip strength. Exercise utilized in this study was based on rehabilitative approach called Dynamic Neuromuscular Stabilization (DNS) - a developmental kinesiology approach. The exercise program consisted of four primal developmental positions (3½ month supine position, oblique sitting position with support on forearm, position on all fours, and the "bear" position). A study file consisted of ten females who were instructed in basic scheme of DNS exercise. They were instructed to exercise at home five times weekly for a 6- weeks period. One exercise lesson took about thirty minutes. Both handgrip and pinchgrip strength was measured using the digital dynamometer CITEC CT 3001 recording maximum voluntary isometric contraction (MVIC). Three-pinch grip strength and fist grip strength was measured for both upper extremities. Fist grip strength was measured in three positions of forearm (pronation, supination and neutral position). Overall eight variables (for each extremity, grip form and position of the forearm) measured before and after exercise program were compared using the paired t-test. Significant increase in muscle strength (p<0,05) was identified for all eight variables after a 6 weeks exercise...

Les troubles musculo-squelettiques de l’épaule constituent un problème majeur de santé au travail. Le principal mécanisme à l’origine de ces pathologies est le conflit sous-acromial, dont le développement est intimement lié à la qualité du contrôle neuromusculaire de l’épaule. Nos données montrent que les tâches expérimentales classiquement utilisées pour l’exploration des facteurs de développement du conflit sous-acromial sont insuffisantes pour rendre compte de la complexité du contrôle neuromusculaire mis en jeu lors des tâches industrielles. Il semble primordial que les actions de lutte contre les TMS considèrent la réalité de l’organisation motrice à l’origine de leur développement. L’application dans ce travail de la technique d’enregistrement électromyographique au secteur industriel met en évidence la pertinence de cet outil afin d’orienter et d’évaluer les actions ergonomiques qui visent à réduire la charge musculo-squelettique. Un moyen complémentaire de lutte contre les TMS a été proposé afin de pallier aux limites propres à la démarche ergonomique. Il s’agit d’un exercice de recentrage dynamique de la tête humérale exécuté en chaîne cinétique fermée, déployé lors d’un programme d’intervention destiné aux opérateurs ayant des symptômes de conflit sous-acromial. Nos données mettent en évidence une diminution de la douleur et une amélioration de la fonction de l’épaule suite à cette intervention. Les bénéfices associés à cette démarche répondent au double enjeu de santé et de performance, essentiel pour les individus comme pour l’entreprise. Finalement, l’ensemble des contributions expérimentales et des applications industrielles présentées dans ce travail de thèse souligne le rôle central que peuvent jouer les spécialistes de la motricité humaine dans la démarche de lutte contre les TMS. Leur intégration dans les équipes pluridisciplinaires de prévention constitue un réel enjeu pour la réduction de ce risque professionnel majeur / Shoulder disorders represent a major health problem at the workplace. The most common shoulder disorder is the subacromial impingement syndrome. Shoulder neuromuscular control has a critical role in the development of shoulder disorders. Our data show that the experimental tasks generally use to investigate subacromial impingement causative factors are insufficient to represent the complexity of shoulder neuromuscular control involved during industrial tasks. It is essential that workplace interventions take into consideration the actual motor control associated with the development of work-related musculoskeletal disorders. The use of the electromyography in the industrial context, during this thesis work, highlights the interest of this tool in order to conduct and evaluate ergonomic interventions that aimed to reduce exposure to physical risk factors. Another work-related musculoskeletal disorder management way was proposed as a supplement to ergonomic interventions. It is about a dynamic closed chain humeral head centering exercise performed by assembly line workers with clinical signs of subacromial impingement syndrome. Our data demonstrated that the intervention program was effective in decreasing shoulder pain as well as improving shoulder function. This study underlined the relevance of therapeutic exercises for shoulder disorders management at the workplace. Finally, the whole of this thesis work highlights the decisive role of specialists in human motor analysis for work-related musculoskeletal disorders management

Em indivíduos saudáveis o desempenho motor e os parâmetros cinemáticos e espaçotemporais da tarefa de alcance já estão descritos na literatura. Até o momento nenhum estudo investigou a influência da dor crônica no ombro nessas variáveis durante a tarefa de apontamento com o corpo todo em diferentes demandas, e nem estabeleceram como é o comportamento motor. Por este motivo, o objetivo do presente estudo foi caracterizar o comportamento motor de uma tarefa de apontamento em indivíduos com dor no ombro e avaliar parâmetros de padrão de movimento, desempenho motor e equilíbrio. Trata-se de um estudo transversal realizado no Laboratório de Bioengenharia Elétrica da Escola Politécnica da USP. Participaram do estudo 20 sujeitos, sendo 11 no grupo controle (GC) e 9 no grupo com dor (GD). O experimento consistiu em realizar um alcance em três angulações distintas (menor, igual e maior que 90°) em duas velocidades (normal e rápida). Foram coletados dados de cinemática e plataforma de força. As principais medidas foram (1) índice de retidão (IR); (2) tempo de reação e movimento (3) deslocamentos angulares e lineares (4) COP e COM. Os resultados mostraram que o GD apresentou pior IR, maior tempo de reação e de movimento, os deslocamentos lineares e angulares foram mais estereotipados, os deslocamentos do COM e a velocidade de deslocamento do COP foram menores e as estratégias de equilíbrio foram menos utilizadas, gerando manutenção do controle em bloco. Desta forma, conclui-se que o comportamento motor é alterado no GD e as variáveis de padrão de movimento, desempenho motor e de equilíbrio foram piores na comparação com indivíduos saudáveis / In healthy subjects the motor performance and the kinematic parameters and spatiotemporal parameters of the task of reaching have already been described in the literature. Until now no study has investigated the influence of chronic shoulder pain on these variables during whole body pointing in different demands and did not establish how motor behavior works. For this reason, the aim of the present study was to characterize the motor behavior of a pointing task in individuals with shoulder pain and to evaluate patterns of movement pattern, motor performance and balance. This is a cross-sectional study conducted at the Bioengineering Laboratory of the Polytechnic School of USP. Twenty subjects participated in the study, being 11 in the control group (CG) and 9 in the pain group (PG). The experiment consisted in achieving a range in three distinct angles (smaller, equal and greater than 90 °) in two speeds (normal and fast). Kinematics and force platform data were collected. The main measures were (1) straightness index (RI); (2) reaction time and movement (3) angular and linear displacements (4) COP and COM. The results showed that the GD presented worse IR, longer reaction time and movement, linear and angular displacements were more stereotyped, the COM displacements and the COP displacement velocity were smaller and the equilibrium strategies were less used, generating maintenance of block control. However, we conclude that motor behavior is altered in GD and the variables of movement pattern, motor performance and balance were worse in comparison with healthy individuals

Universidade de São Paulo, Faculdade de Medicina; 2015. Introdução: Diante de uma rotura traumática do manguito rotador, não há evidência direta que comprove que os reparos realizados precocemente são mais eficazes que aqueles realizados tardiamente. Para abordar essa questão, ensaios biomecânicos e de morfometria óssea foram realizados após roturas extensas do manguito rotador realizadas precocemente (lesões agudas) e tardiamente (lesões crônicas), mediante a utilização de um modelo experimental em ratos. Método: 30 ratos adultos da raça Wistar foram aleatoriamente divididos em três grupos (I, II e III) e submetidos à secção completa dos tendões do supraespinal e infraespinal nos ombros esquerdos. Após oito semanas, nos animais dos grupos I e II, os tendões rotos pertencentes aos ombros esquerdos foram cirurgicamente reparados, e os tendões equivalentes nos ombros direitos foram seccionados e imediatamente reparados. Quatro semanas após os reparos (para os ratos do grupo II) ou oito semanas após os reparos (para os ratos do grupo I), os animais foram submetidos à eutanásia. Os ratos do grupo III foram submetidos à eutanásia oito semanas após a cirurgia de secção tendínea sem que houvesse ocorrido o reparo dos tendões rotos. Os ombros direitos dos animais do grupo III permaneceram intactos e serviram como controles. Após a eutanásia, todos os ratos tiveram seus ombros dissecados e os espécimes foram encaminhados para a realização de testes biomecânicos e de microtomografia computadorizada. Resultados: Para todos os parâmetros biomecânicos analisados, foram encontradas interações significantes referentes aos fatores tempo de cicatrização e reparo, considerando os reparos precoces e tardios. Com relação ao tendão supraespinal para o período de oito semanas de cicatrização, a força máxima até a falha foi significantemente maior nos reparos precoces em comparação aos reparos tardios (31,81 ± 3,86N vs 19,36 ± 6,14N; p < 0,001), bem como a rigidez (17,22 ± 4,35N/mm vs 10,85 ± 4,25N/mm; p=0,034), a tensão máxima até a falha (4,49 ± 2,02N/mm2 vs 1,97 ± 0,61N/mm2; p < 0,001) e o módulo de elasticidade (13,72 ± 5,29N/mm2 vs 6,47 ± 2,42 N/mm2; p=0,033). Com relação ao tendão infraespinal com oito semanas de cicatrização, a força máxima até a falha foi significantemente maior nos reparos precoces em comparação aos reparos tardios (21,26 ± 3,94N vs 12,74 ± 2,87N; p=0,005), assim como a rigidez (12,86 ± 2,65N/mm vs 7,21 ± 3,30N/mm; p=0,014). O grupo com reparo tardio com oito semanas de cicatrização obteve resultados nos testes biomecânicos semelhantes aqueles obtidos nos testes do grupo com lesão sem reparo com oito semanas de cicatrização. A avaliação microtomográfica não apresentou diferenças significantes na microarquitetura óssea entre os reparos realizados precocemente e tardiamente. Conclusões: Os resultados desse estudo demonstram que as roturas extensas do manguito rotador reparadas precocemente produzem um tecido cicatricial na junção ósteo-tendínea com melhores propriedades biomecânicas que as roturas reparadas tardiamente. Porém, ao analisar a morfometria óssea da porção proximal do úmero, verificou-se que os efeitos são equivalentes, tanto para os reparos realizados tardiamente quanto para os reparos realizados precocemente / Introduction: In the event of a traumatic rotator cuff tear, there is no direct evidence that supports early over late surgical repair. To address this knowledge gap, biomechanical and bone morphometry outcomes were assessed following early (acute) and late (chronic) massive rotator cuff tear repairs in an experimental rat model. Methods: 30 adult Wistar rats were randomly divided into three groups (I, II and III), then subjected to combined supraspinatus and infraspinatus tendon tears of the left shoulder. Eight weeks following the injury, animals from groups I and II had the tendons of the injured shoulder surgically repaired. In addition, these animals were subjected to the same injury on the contralateral shoulder, which was immediately repaired. The rats were euthanized four weeks (group II) or eight weeks (group I) following the repairs. Group III was euthanized eight weeks following the injury, without surgical repair of the left shoulder, and the intact right shoulders of this group were used as controls. Tissues from all groups were harvested and subjected to biomechanical testing and bone morphometry analysis. Results: In all biomechanical parameters analyzed, a significant interaction was observed between healing and repair timing. For the supraspinatus tendon with eight weeks healing time, biomechanical properties were significant increased in the early repair group compared to the late repair group, including maximum load to failure (31,81 ± 3,86N vs 19,36 ± 6,14N; p < 0,001), stiffness (17,22 ± 4,35N/mm vs 10,85 ± 4,25N/mm; p=0,034), maximum stress to failure (4,49 ± 2,02N/mm2 vs 1,97 ± 0,61N/mm2; p < 0,001) and modulus of elasticity (13,72 ± 5,29N/mm2 vs 6,47 ± 2,42 N/mm2; p=0,033). For the infraspinatus tendon with eight weeks healing time, biomechanical properties were also significantly increased in the early repair group, including maximum load to failure (21,26 ± 3,94N vs 12,74 ± 2,87N; p=0,005) and stiffness (12,86 ± 2,65N/mm vs 7,21 ± 3,30N/mm; p=0,014). There were no significant differences between the late repair with eight weeks of healing time and the group without surgical repair for supraspinatus and infraspinatus tendons. Concerning bone morphometry of the humeral head, no significant differences were observed when comparing early and late repair groups. Conclusions: The results from this study indicate that early surgical repair of a massive rotator cuff tear leads to increased biomechanical properties of the tissue after healing. However, proximal humerus bone morphometry was unaffected by surgical repair timing

As restaurações metalocerâmicas apresentam relatos de sucesso clínico a longo prazo e as características de reforço (cinta lingual e poste proximal) das infra-estruturas metálicas parecem ser de grande importância para este sucesso. Estes reforços freqüentemente estão ausentes nas infraestruturas das restaurações ceramocerâmicas. O objetivo deste estudo foi testar a hipótese nula de que coroas confeccionadas com infra-estruturas cerâmicas com desenho com e sem reforço não resultam em valores de resistência à fratura diferentes de coroas com infra-estruturas metálicas confeccionadas com os mesmos desenhos. Para a realização deste trabalho foram fabricadas 40 coroas, dividas em quatro grupos (n=10): (1) coroas metalocerâmicas - infra-estrutura com reforço; (2) coroas metalocerâmicas - infra-estrutura sem reforço; (3) coroas ceramocerâmicas - infra-estrutura com reforço; e (4) coroas ceramocerâmicas - infra-estrutura sem reforço. Os corpos de prova foram cimentados com ionômero de vidro modificado por resina nos troquéis metálicos e submetidos à análise de resistência à fratura usando uma máquina de teste universal Kratos, a uma velocidade de 0,5 mm/min. Todos os corpos de prova foram mantidos sob pressão até a fratura. Os resultados de resistência à fratura (kgf) foram submetidos à análise de variância (ANOVA) a dois critérios e ao teste de Tukey. O nível de significância considerado em todas as análises foi de 5% (p<0,05). Os valores médios de resistência à fratura foram de 237,637 kgf para as coroas metalocerâmicas com infraestruturas com reforço, 171,738 kgf para as coroas metalocerâmicas com infraestruturas com reforço, 127,588 kgf para as coroas ceramocerâmicas com infra-estruturas com reforço e 93,914 kgf para as coroas ceramocerâmicas com infra-estruturas sem reforço, com diferença estatisticamente significante (p<0,05), entre os quatro grupos. As coroas metalocerâmicas com reforço (Grupo 1) apresentaram o maior valor de resistência à fratura e estatisticamente significante, entre todos os grupos. As coroas confeccionadas com infra-estruturas com reforço apresentaram maior resistência à fratura do que as confeccionadas sem reforço, tanto nas coroas metalocerâmicas como nas ceramocerâmicas. / Metal-ceramic restorations present reports of long-term clinical success, and the characteristics of reinforcement coping (lingual collar and buttressing shoulder) seem to be of great importance for this success. These reinforcements are often absent in all-ceramic coping restorations. The aim of the current study was to evaluate and compare the in vitro fracture resistance of metal-ceramic and In-Ceram Alumina all-ceramic crowns, with and without reinforced coping design. Forty crowns were fabricated and divided into four groups (n=10): group 1, metal-ceramic crown with reinforced coping design; group 2, metal-ceramic crown without reinforced coping design; group 3, allceramic crown with reinforced coping design and group 4, all-ceramic crown with out reinforced coping design. The forty crowns were cemented on stainless steel dies and axially loaded in a universal testing machine until fracture occurred, and the maximum load (kgf) was recorded. Data were analyzed by one-way analysis of variance (ANOVA) and Tukey test (p<0.05) The results showed a statistical significant superiority (p<0.05) of the reinforcement coping groups (237.637 kgf for metalo-ceramic crowns and 127.588 kgf for all-ceramic crowns), regarding to non reinforcement coping groups (171.738 kgf for metalo ceramic crowns and 93.914 kgf for all-ceramic crowns). These founds denote that: (1) crowns made with reinforcement coping had presented greater fracture resistance than those confectioned without it and (2) metal-ceramic crowns had presented greater fracture resistance than all-ceramic crowns.

A literatura a respeito da capacidade da ressonância magnética em avaliar as afecções do tendão da cabeça longa do bíceps é escassa, a despeito da importância destas condições na gênese da dor e da disfunção do ombro. O objetivo primário deste estudo foi analisar o desempenho diagnóstico da ressonância magnética na detecção de roturas e de instabilidade na porção intra-articular deste tendão, comparando os achados de imagem com os dados de cirurgia artroscópica (padrão de referência). Foram objetivos secundários determinar as reprodutibilidades intraobservador e interobservador, avaliar a capacidade da ressonância magnética em classificar os tipos de rotura, avaliar a acurácia da associação entre alterações tendíneas e roturas do manguito rotador na instabilidade, além de pesquisar fatores preditores da acurácia da ressonância magnética. Foi realizado estudo transversal, com segmentos retrospectivo e prospectivo. Os critérios de inclusão foram indicação de cirurgia artroscópica do ombro para reparo do manguito rotador e exame de ressonância magnética préoperatória. Os critérios de exclusão foram: manipulação cirúrgica pregressa no ombro estudado; exames com imagens de má qualidade; intervalo entre exame pré-operatório e procedimento cirúrgico superior a um ano; indicação de técnica cirúrgica por via aberta. Foram estudados 100 ombros de 98 pacientes, operados consecutivamente de abril de 2013 a março de 2017 (47 meses). Todos os pacientes realizaram ressonância magnética de 1,5 Tesla em nossa instituição, sem utilização de contraste intra-articular. Todas as cirurgias foram realizadas pelos mesmos 3 cirurgiões, com 10 a 12 anos de experiência em cirurgia do ombro e cotovelo. Dois radiologistas, com 4 e 8 anos de experiência na área musculoesquelética, avaliaram as imagens de todos os exames, de forma independente e sem conhecimento prévio dos resultados intra-operatórios. Os mesmos casos foram revistos por um dos radiologistas, 4 meses após a primeira análise. Nossos resultados demostraram desempenho diagnóstico moderado da ressonância magnética para detecção de roturas do bíceps, com sensibilidades entre 71,1% a 73,3%, especificidades de 72,7% e acurácia entre 72 e 73%. A reprodutibilidade interobservador foi substancial (coeficiente Kappa de 0,62 a 0,69) e a reprodutibilidade intraobservador foi substancial ou quase perfeita na avaliação das roturas (coeficiente Kappa de 0,74 a 0,82). Houve correlação moderada entre os métodos para classificar o tipo de rotura (coeficiente Kappa de 0,38 a 0,47). Quando consideradas roturas completas, foram calculadas especificidades entre 75,0% e 95,7%, porém sensibilidades de 55,6% a 66,7%. Para o diagnóstico de instabilidade, observa-se sensibilidade de 52,4% a 59,1%, especificidade de 70,5% a 84% e acurácia de 64,4% a 69,5%. A avaliação combinada do deslocamento tendíneo e das roturas do manguito rotador resultou em sensibilidades de 17,5% a 47,7% e especificidades de 72,7% a 90,7%. A reprodutibilidade interobservador foi substancial (coeficiente Kappa de 0,59 a 0,7) e a reprodutibilidade intraobservador foi substancial ou quase perfeita (coeficiente Kappa de 0,76 a 0,80) para avaliação de instabilidade. Não identificamos fatores preditores para acurácia da ressonância magnética na pesquisa dessas afecções / There is paucity of literature regarding the performance of magnetic resonance imaging to assess long head of the biceps tendon disorders, despite the importance of such disorders in the genesis of pain and shoulder dysfunction. The primary objective of this study was to analyze the diagnostic performance of magnetic resonance imaging in the detection of tears and instability of the intra-articular portion of this tendon, comparing imaging findings with data from arthroscopic surgery (reference standard). Secondary objectives were to determine intraobserver and interobserver reproducibility; to evaluate the capability of MRI to classify types of tears; to evaluate the accuracy of the association between tendon displacement and rotator cuff tears to predict instability; to investigate predictive factors of magnetic resonance accuracy. A cross-sectional study was carried out, with retrospective and prospective segments. Inclusion criteria were indication of arthroscopic shoulder surgery for rotator cuff repair and preoperative magnetic resonance imaging. Exclusion criteria were: previous surgical manipulation in the studied shoulder; poor quality images; interval between preoperative examination and surgical procedure above one year; and indication of open surgical technique. We studied 100 shoulders of 98 consecutively operated patients from April 2013 to March 2017 (47 months). All patients underwent magnetic resonance imaging at our institution, using a 1.5 Tesla scanner, without use of intra-articular contrast. All surgeries were performed by the same 3 surgeons, with 10 to 12 years of experience in shoulder and elbow surgery. Two radiologists, with 4 and 8 years of experience in musculoskeletal radiology, evaluated the images independently and without previous knowledge of the intraoperative results. The same cases were reviewed by one of the radiologists, 4 months after the first analysis. Our results demonstrated a moderate diagnostic performance of MRI to detect biceps tears, with sensitivities between 71.1% and 73.3%, specificities of 72.7% and accuracy between 72 and 73%. Interobserver reproducibility was substantial (Kappa coefficient ranged from 0.62 to 0.69), and intraobserver reproducibility was substantial or almost perfect (Kappa coefficient ranged from 0.74 to 0.82). There was moderate correlation between the methods when classifying the type of tear (Kappa coefficient ranged from 0.38 to 0.47). Regarding full-thickness tears, specificities were calculated between 75.0% and 95.7%, but sensitivities from 55.6% to 66.7%. For the diagnosis of instability, sensitivity was from 52.4% to 59.1%, specificity was from 70.5% to 84% and accuracy was from 64,4% to 69,5%. The combined evaluation of tendon displacement and rotator cuff tears resulted in sensitivities from 17.5% to 47.7% and specificities from 72.7% to 90.7%. Interobserver reproducibility was substantial (Kappa coefficient ranged from 0.59 to 0.7), and intraobserver reproducibility was substantial or almost perfect (Kappa coefficient ranged from 0.76 to 0.80) for instability assessment. We did not identify predictive factors for magnetic resonance imaging accuracy in the assessment of these conditions

Zur Zeit gibt es keinen optimalen Sehnentransfer zur Behandlung von irreparablen Ruptur der Subscapularissehne. Obwohl der Pectoralis major Transfer als Therapie der Wahl gilt, bleibt der Kraftvektor der verlagerten Sehne-Muskeleinheit sehr unterschiedlich zum Kraftvektor des Subscapularismuskels. Das Ziel dieser Arbeit war, ein neues Konzept zur Behandlung von irreparablen Subscapularisrupturen zu definieren, bei dem die Subscapulariseinheit selektiv mittels Teres major(TM) und Pectoralis major (PM) wiederhergestellt wird. In den Kadaverstudien dieser Arbeit konnte gezeigt werden, dass sich der M. Teres major anatomisch-chirurgisch als Sehnentransfer zur Rekonstruktion der unteren Hälfte des M. Subscapularis eignet. Darüberhinaus wurde in einer dreidimensionalen Vektoranalyse gezeigt, dass der Kraftvektoren vom verlagerten Teres major sich nicht signifikant vom Kraftvektoir des unteren Anteils des Musculus subscapularis unterscheidet. Es wurde weiterhin gezeigt, dass Modifikationen des Pectoralis major transfer durch Reroutingmassnahmen zu einer deutlichen Verbesserung seines Kraftvektors im Vergleich zum oberen Amteil des Musculussubscapularis führt. Basierend auf den neuen anatomischen und biomechanischen Erkenntnissen wurde im letzten Teil dieser Schrift das neue Konzept klinisch angewandt. Dabei wurde bei 7 Patienten mit einer irreparablen Subscapularisruptur nach multiplen Voreingriffen eine selektive Rekonstruktion mittels kombinierten TM-PM Transfer durchgeführt. Es traten keine Komplikationen auf und alle Patienten hatten eine deutliche Linderung Ihrer Schmerzen und eine Verbesserung der Funktion. Somit erscheint diese neue Transferoperation eine sichere und effiziente Option zur Behandlung irreparabler Subscapularisrupturen darzustellen. / Currently there is no optimal tendon transfer procedure for the management of irreparable subscapularis lesions. Although the pectoralis major transfer is considered as the gold standard in the treatment of irreparable subscapularis tears, the force vector orientation of this transfer may not be optimal in comparision to the situation at the subscapularis muscle. Objective of this monograph was to establish the anatomical and biomechanical basis for a new concept of selective subscapularis reconstruction combining a teres major transfer to the pectoralis major transfer. In the cadaveric part of this work, it could be demonstrated that the teres major is a safe and biomechanically logical transfer for reconstruction of the lower part of the subscapularis. The analysis was carried on to define the optimal transfer for reconstruction of the upper part of the subscapularis. It was possible to determine the biomechanical effect of rerouting procedures of the pectoralis major transfer. Passing the tendon underneath the conjoined tendon appeared to be the most effective way to improve the direction of the pectoralis major transfer for subscapularis reconstruction. However this technique is demanding when the plane underneath the conjoined tendon is scarred and the pectoralis major is bulky. In such cases there is a risk to injure the musculocutaneous nerve. Therefore, rerouting the sternal part of the pectoralis major underneath its clavicular part (sPM tansfer) may be a safer option. Finally, based on the acquired anatomical and biomechanical data, early clinical experience in a series of 7 patients was reported. Although the clinical series was small, the combined TM-sPM transfer appeared to be a valuable and a safe alternative to treat irreparable subscapularis tears. An interesting observation in this study was that the transfer was able to recenter the statically subluxed humeral head in two cases. This could be attributed to the dynamic hammock built by the transferred teres major. The early promising subjective and objective results presented here encourage for further investigation.

Zur Diagnostik von Rupturen der Rotatorenmanschette wird häufig die im Vergleich zur Sonografie deutlich kostenintensivere Magnetresonanztomografie durchgeführt. Ein Grund hierfür ist, dass es zum Teil schwierig ist, standardisierte statische Sonografie-Bilder zu gewinnen, was die reproduzierbare, untersucherunabhängige diagnostische Information verringert. Ziel des ersten Teils der Arbeit war es einerseits, zu analysieren, ob mit der 3D-Sonografie diese Probleme verringert werden könnten und andererseits die Sensitivität mit dem 2D-Ultraschall zur Diagnostik von Komplett- und Partialrupturen zu vergleichen. Bei der Untersuchung von 114 Patienten konnten mit dem 3D-Ultraschall Rupturen der Rotatorenmanschette gut dargestellt werden. Der Vergleich zwischen 2D- und 3D-Ultraschall ergab keinen statistisch signifikanten Unterschied zwischen beiden Verfahren für die Diagnostik von Komplett- und Partialrupturen. Ein Vorteil war die Möglichkeit der untersucherunabhängigen simultanen Auswertung von drei standardisierten Schnittebenen zu einem späteren Zeitpunkt. Bei der Verwendung biodegradierbarer Anker zur Fixierung von Weichteilen können ossäre Reaktionen auftreten. Ziel war es, die frühen Reaktionen des umgebenden Gewebes auf einen Poly-(L-co-D/L-Lactid) 70/30 Anker im Vergleich zu einem Titananker im Schafsknochen zu analysieren. Innerhalb von 20 Wochen nach Implantation zeigte sich keinerlei Verlust von Knochensubstanz im Bereich des distalen Schafsfemur bei Ankern aus Titan oder aus Polylactid. Vielmehr zeigte sich eine ausgeprägte Neuformation von spongiösem Knochen in die Implantathohlräume vor allem für das biodegradierbare Material. Daher sollten neben materialbedingten Ursachen auch biomechanische Ursachen wie zyklische Belastungen für mögliche Osteolysen in Betracht gezogen werden. Die arthroskopische subacromiale Dekompression (ASD) ist ein häufig durchgeführtes Verfahren zur Therapie von Subachromialsyndromen. Es sollten die eigenen Ergebnisse seit 1993 unter Berücksichtigung von Nebendiagnosen sowie die Möglichkeit, verschiedene Scores und VAS auch telefonisch erheben zu können, analysiert werden. Die Untersuchung von 422 Schultern zwischen 1,5 und 9,5 Jahren (durchschnittlich 4,8 Jahre) nach der Operation zeigte, dass die ASD mit überwiegend guten und sehr guten subjektiven und objektiven Resultaten (ca. 75%) ein zuverlässiges operatives Verfahren ist. Im Gegensatz zu einem laufenden Rentenverfahren hatten Rupturen der Rotatorenmanschette zum Zeitpunkt der Operation keinen negativen Einfluss auf das Operationsergebnis. Bei Nichtbeachtung der Pathologie des superioren Labrums und bei Rezidivoperation kam es zu einem erhöhten Anteil an Therapieversagern. Die telefonische Erhebung verschiedener Schulter-Scores (ausgenommen Constant-Score) und der VAS lieferte valide Resultate, die eine klinische Untersuchung entbehrlich machen und insbesondere bei Langzeitstudien eine wesentlich höhere Nachuntersuchungsrate ermöglichen. Das Konzept der winkelstabilen Osteosynthese ermöglicht eine weichteilschonende, minimal-invasive Frakturstabilisierung. Um eine sichere Verankerung von winkelstabilen Schrauben zu erreichen, ist eine korrekte Positionierung der Schraube in der Platte erforderlich. In biomechanischen Testungen konnte gezeigt werden, dass bei einer geringen Abweichung des Insertionswinkels winkelstabiler Schrauben von bis zu 5° vom optimalen Winkel immer noch eine hohe Stabilität der Schrauben-/Plattenverbindung gewährleistet war. Ab einem Winkel von über 5° kam es zu einer signifikanten Abnahme der Festigkeit dieser Verbindung. Um eine optimale Festigkeit der Verbindung Schraube/Platte zu erreichen und das Risiko der Schraubenlockerung zu minimieren, ist die konsequente Benutzung eines Zielgerätes zu empfehlen. Die klinische Nachuntersuchung von 53 Patienten mit winkelstabiler Osteosynthese bei proximaler Humerusfraktur zeigte eine mit der Literatur vergleichbare Komplikationsrate bei verringertem sekundären Dislokationsrisiko. Es zeigte sich aber auch die Problematik dieser Fakturen mit langer Nachbehandlungsdauer und dem Risiko einer Humeruskopfnekrose im Verlauf. Winkelstabile Implantate ermöglichten eine sichere Stabilisierung von proximalen Humerusfrakturen, konnten jedoch eine insuffiziente Anwendung - wie eine fehlerhafte Verankerung der Kopfverriegelungsschrauben - nicht kompensieren. Erhöht war das Risiko einer Schraubenperforation durch die Sinterung des Kopfes auf das rigide Implantat. / Goal of the study was evaluation of advantages and limitations of shoulder diagnosis and different techniques of minimal invasive shoulder surgery. MRI has become the standard for diagnosis of rotator cuff lesions, since it can be difficult to obtain standardized ultrasound images. Goal of the study was analysis of sensitivity of 3D- in comparison to 2D-ultrasound. Examination of 114 patients showed excellent visualization of rotor cuff defects with 3D-ultrasound. Comparison to 2D-ultrasound showed no statistical significant difference between both methods for diagnosis of full- and partial thickness defects of the rotator cuff. Advantage of 3D-ultrasound was the possibility of simultaneous visualization of three standardized planes. For the reattachment of ligaments and tendons biodegradable implants are increasingly used today. However, with the use of biodegradable implants early and late osteolysis has been reported. Goal of this study was to analyze the early osseous integration of a newly designed suture anchor in comparison to a titanium implant. The implants made of Poly-(L-co-D/L-lactide) 70/30 or titanium were inserted into the cancellous bone of the distal femoral condyle in four sheep. The animals were followed radiographically over a period of 20 weeks in which no final implant degradation was anticipated. After sacrifice new bone formation was quantitatively and local tissue response qualitatively analyzed from microradiographs and histological sections were examined. New bone formation was seen around both implant materials within 20 weeks. Inside the recess of the polylactide suture anchor there was significantly higher bony ingrowth (p = 0.026) as compared to the titanium implant. Histologically non of the materials did show any inflammatory reaction. These data indicate that early osteolysis around Poly-(L-co-D/L-lactide) 70/30 suture anchors in cancellous bone may not be attributable to the material properties but rather to other reasons such as the mechanical situation at the implant-bone interface. Arthroscopic subacromial decompression (ASD) has become a well established procedure to treat chronic subacromial impingement syndrome. Goal of the study was to retrospectively evaluate the outcome and to evaluate the validity of data collection by telephone interview. The examination of 422 patients average 4.8 years after peration showed in 75% goog and excellent results. The average Constant score (raw score) improved from 46 to 80 Pts. Patients who had a second ASD had good results in only 25%. Patients with running workers compensation application showed no satisfying outcome. Lesions of the rotator cuff were shown to have no significant influence on the outcome in comparison to patients with intact rotator cuff. Additionally, it was shown that the assessment of various shoulder scores (except Constant Score) by telephone interview is possible. Internal fixators with angular stability have been developed in order to provide high stability without compression of the plate on to the bone. The insertion angle of the screw must correspond precisely to the axis of the screw hole. The objective of this study was to examine the relationship between the stability of the locked screw-plate on the insertion angle of the screw. Locking screws were inserted in a isolated or combined locking hole with the use of an aiming device. The screws were inserted with an axis deviation of 0°(optimal condition), 5° and 10°. The samples were tested under shear or axial (push out) loading conditions until failure occurred. Locking screws inserted in the isolated locking hole (PC-Fix) showed a significant decrease of failure load if inserted at 5° and 10° angle. Screws inserted in the combined locking hole (LCP) also showed a significant decrease of push-out force of 77% with 10° axis deviation. A locking head screw exhibits a high stability with a moderate axis deviation in the angle of insertion of up to 5°. However there is a significant decrease in stability with increasing axis deviation (>5°). A aiming device is recommended to provide an optimal fixation with angular stability. Clinical Examination of 53 patients with angular stable osteosynthesis of proximal humeral fractures showed a rate of complications, which can be compared with literature with lower risk of secondary dislocation. Implants with angular stability allow stable fixation of proximal humeral fractures however the risk of screw perforation is higher.

OBJETIVO: Comparar a força muscular dos rotadores internos e adutores do ombro (propulsores da natação) dos estilos com braçada simultânea (borboleta e peito) e estilos com braçada alternada (livre e costas). CASUÍSTICA E MÉTODOS: Foram avaliados 46 ombros de nadadores federados dos estilo livre e costas (nado alternado GNA) com idade de 21,8 ± 3,8 anos; peso de 71,2 ± 10,0 kg, altura de 177,6 ± 8,5 cm e IMC= 22,3 ± 1,3; 44 ombros de nadadores federados dos estilos peito e borboleta (nado simultâneo - GNS) com idade de 20,3 ± 4,5 anos; peso de 70,5 ± 9,3 kg, altura 167,2 ± 37,6 cm e IMC= 22,6 ± 1,9; 28 ombros de nadadores recreacionais (grupo recreacional GR) com idade de 24,5 ± 4,5 anos; peso de 70,8 ± 16 kg, altura de 173,4 ± 9,2 cm e IMC= 23,3 ± 3,9 e 42 ombros de indivíduos controle (Grupo - GC) com idade de 25,8 ± 3,5 anos; peso de 68,7 ± 11,2 kg, altura 171,9 ± 9,3 cm e IMC= 23,2 ± 2,6. Todos foram avaliados no dinamômetro isocinético Biodex Multi-joint System 3® (Shirley, NY, USA) nas velocidades de 60º/segundo e 300º/segundo. Foram avaliados os movimentos de adução e rotação interna. As variáveis estudadas foram pico de torque corrigido pelo peso corpóreo (PTPC), trabalho total (TT) e relação agonista/antagonista. RESULTADOS: Não houve diferença na musculatura adutora entre os grupos GNS e GNA nas variáveis PTPC (GNS = 114,4 Nm e GNA = 109,4 Nm) e TT (GNS = 642,9J e GNA = 641,5J). Não houve diferença na relação abdução/adução do ombro entre GNS (67,4%) e GNA (68,3%). Não houve diferença na musculatura rotadora interna entre os grupos GNS e GNA nas variáveis PTPC (GNS = 66,4Nm e GNA = 63,4Nm) e TT (GNS = 517,4J e GNA 526,7J). Não houve diferença na relação rotação externa e rotação interna o ombro entre GNS (65,7%) e GNA (61,5%). CONCLUSÃO: Não há diferença na força muscular dos músculos adutores e rotadores internos do ombro quando se compara nados com braçadas simultâneas e alternadas / OBJECTIVE: To compare the muscle strength of internal rotators and adductors of the shoulder (of the propellants swimming) of styles with simultaneous stroke (butterfly and breaststroke) and stroke with alternating colors (free and back). PATIENTS AND METHODS: We evaluated 46 shoulders of competitive swimmers of freestyle and back (alternating swimming - GNA) aged 21.8 ± 3.8 years, weight 71.2 ± 10.0 kg, height 177.6 ± 8.5 cm and BMI = 22.3 ± 1.3. 44 shoulders of competitive swimmers of styles breast and butterfly (swimming simultaneously - GNS) aged 20.3 ± 4.5 years, weight 70.5 ± 9.3 kg, height 167.2 ± 37.6 cm and BMI = 22.6 ± 1.9. Shoulders of 28 recreational swimmers (group recreational - GR) aged 24.5 ± 4.5 years, weight 70.8 ± 16 kg, height 173.4 ± 9.2 cm and BMI = 23.3 ± 3, 9:42 shoulders of individuals (control group - CG) aged 25.8 ± 3.5 years, weight 68.7 ± 11.2 kg, height 171.9 ± 9.3 cm and BMI = 23, 2 ± 2.6. All were assessed using an isokinetic dynamometer Biodex Multi-joint System 3 ® (Shirley, NY, USA) at 60 ° / second and 300 º / second. We evaluated the movements of adduction and internal rotation. The variables were peak torque corrected for body weight (PTPC), total work (TW) and agonist / antagonist. RESULTS: There was no difference in the adductor muscle between the groups in the variables and GNA GNS PTPC (Nm) (GNS = 114.4 and 109.4 = GNA) and TT (J) (GNS = 642.9 and 641.5 = GNA). There was no difference in the abduction / adduction (%) of the shoulder between GNS (GNS = GNA = 67.4 and 68.3). There was no difference in the internal rotator muscles between the groups in the variables and GNA GNS PTPC (Nm) (GNS and GNA = 66.4 = 63.4) and TT (J) (GNS = 517.4 and 526.7 GNA). There was no difference in the external rotation and internal rotation (%) of the shoulder between GNS (GNS = GNA = 65.7 and 61.5). CONCLUSION: No difference in muscle strength of adductor muscles and internal rotators of the shoulder when comparing births with simultaneous and alternate strokes

Les prothèses totales d’épaule ont une survie limitée due essentiellement au descellement de l’implant scapulaire. Le but de ce travail de recherche est la contribution à la mise au point d’un nouvel implant scapulaire à fixation sans ciment.Une première partie a concerné la caractérisation de l’anisotropie et des hétérogénéités de l’os spongieux de la glène par une expérimentation en compression, cette partie a abouti à l’élaboration d’une loi de comportement de l’os spongieux de la glène. La seconde partie de ce travail s’est focalisée sur la modélisation par éléments finis des contraintes aux points d’ancrage de l’implant.Les résultats des tests de simulation montrent l’incapacité du spongieux à assurer un effet press-fit dans le plan transversal, car on observe le dépassement des contraintes maximales pour un déplacement minime. Ce résultat met en question les modes de fixation primaire utilisés ce jour dans les prothèses sans ciment. Nos résultats montrent que la modification de la direction de chargement serait susceptible d’améliorer la fixation primaire ce qui ouvre des perspectives nouvelles pour le dessin d’une prothèse sans ciment. / Total shoulder prostheses have a limited survival due mainly to the loosening of the glenoid implant. The purpose of this research is the contribution to the development of a new glenoid implant with cementless fixation.The first part concerned the characterization of the anisotropy and heterogeneity of cancellous bone of the glenoid by a compression experimental tests, this part has led to the drafting of a law of behavior of cancellous bone of the glenoid . The second part of this work has focused on finite element modeling of stress around the anchors of the glenoid implant.Simulation test results show the inability of the transversal plane of the glenoid to ensure effective press-fit fixation with stresses above strength properties of the cancellous bone with a minimal displacement. This calls into question the current modes of primary fixation of cementless implant. However, it appears that a change in the direction of loading would be beneficial for the primary fixation, which opens new perspectives for the design of a cementless prosthesis.