Joint Dislocation

Hip arthroscopy will be performed with the patient under general anesthesia. The patient will be placed in supine position, and traction and joint access will be controlled by fluoroscopy. An anterolateral portal and an inferior mid-anterior portal will be used. Any labral, chondral, and/or bony pathology (cam or pincer) will be treated. Labral tears may be debrided or repaired. Labral repairs will be secured with suture anchors. Patient's functions will be evaluated preoperatively and postoperatively at 1, 3 and 6 months and 1 year and at the last follow-up using the Harris Hip Score (HHS), visual analog score (VAS), Hip Outcome Score Activities-Daily Living Subscale (HOS-ADL), and Sport-Specific Subscale (HOS-SSS).

The purpose of the research study is to determine the overall clinical and radiographic outcome differences between internal brace technique and the gold standard Kirschner wires (K-wire) technique for treatment of perilunate dislocations (e.g. nonunion, reoperation, infection, fixation failure, etc.). A secondary purpose is to determine the specific types of complications and their incidence rates with respect to internal brace technique and the gold standard Kirschner wires (K-wire) technique (e.g. range of motion losses, pain, numbness, weakness, etc).

Musculoskeletal disorders (MSDs) and injuries represent a significant global health concern, constituting the primary cause of disability on a global scale. With a high prevalence spanning various stages of life, from childhood to old age, MSDs exert a substantial burden on individuals and society alike. This burden is particularly amplified in the context of an aging population and the prevalence of multi-morbidity. Chronic illnesses and health conditions not only lead to reduced quality of life but also contribute to a substantial financial burden on societies due to increased healthcare costs and lost productivity. In this context, the inability to work and early retirement are often driven by these health issues, forming a critical dimension of the disease burden. Regular physical exercise is a crucial factor in promoting longevity and overall well-being. Unfortunately, MSDs can significantly impede individuals' ability to engage in exercise and pursue the hobbies and activities that bring them happiness. These disorders often limit mobility, cause pain, and hinder their capacity to lead an active lifestyle. Addressing and mitigating these MSDs becomes pivotal in restoring individuals' functional capabilities and quality of life. By effectively managing these conditions, we can empower patients to maintain regular exercise routines that contribute to their physical health, mental well-being, and happiness. Encouraging patients to stay active and engaged not only enhances their own lives but also contributes to a healthier and more vibrant society. Ultimately, the ability to exercise and partake in fulfilling activities stands as a cornerstone for longevity, fostering a balanced and fulfilling life journey. The spectrum of MSDs encompasses a diverse range of conditions, impacting vital musculoskeletal structures such as bones, joints, muscles, tendons, and ligaments \[3\]. These disorders can originate from a myriad of factors, including traumatic incidents, degenerative processes, autoimmune responses, and genetic predispositions. The consequence is often chronic pain, compromised mobility, diminished physical function, and a diminished quality of life. Among the array of MSDs, the pervasive influence of osteoarthritis is particularly noteworthy, contributing significantly to the global burden of disease. Addressing musculoskeletal injuries and degeneration presents an urgent imperative due to the widespread prevalence and devastating impact of these conditions. An emerging avenue of exploration lies in the utilization of mesenchymal stem cells (MSCs), which hold immense potential for revolutionizing regenerative medicine. MSCs, found within diverse tissues including bone marrow and adipose tissue, possess the remarkable ability to differentiate into various cell lineages such as osteocytes, chondrocytes, and myocytes. This intrinsic versatility positions them as key players in tissue regeneration and repair. The rationale for delving into MSC-based therapies rests upon their extraordinary regenerative potential. When applied to the site of injury or degeneration, MSCs can contribute to the reconstitution of damaged tissues, promoting structural and functional recovery. Moreover, MSCs wield immunomodulatory properties, a crucial attribute given the intricate role of the immune response in MSD progression. By modulating immune cell activity, MSCs can foster an anti-inflammatory environment, counteracting the detrimental effects of chronic inflammation observed in numerous MSDs. In the larger context, the exploration of mesenchymal stem cells as a therapeutic avenue for musculoskeletal injuries and/or degeneration signifies a pioneering leap within the realm of regenerative medicine. The aspiration to alleviate pain, restore mobility, and enhance functionality holds the promise of ameliorating the extensive repercussions endured by individuals grappling with musculoskeletal disorders. MSCs therapy holds the potential to not only alleviate symptoms and improve the quality of life for individuals with musculoskeletal conditions but also to reduce the economic strain caused by decreased workability and early retirement. By promoting tissue repair, reducing inflammation, and enhancing overall musculoskeletal health, MSCs treatment can contribute to extending a person's productive years and lessening the burden on both individuals and society. Learning more about stem cell applications for a diverse set of musculoskeletal disorders will allow for more specific studies to be designed and more niched groups of study participants to be targeted. A particularly interesting field of indications and study participants resides in the realm of elite sports. Elite athletes, sports teams, organizations, and federations invest huge resources to push the quality in sports to unprecedented levels. In that quest, sports injuries pose a devastating blocker for the athletes and the organizations as it can hamper an individual's career and the success of a team. With this study, one of our aspirations for the future is to partner up with relevant sports associations, teams, and institutions and leverage sought insights to design a study aimed at offering elite athletes the highest quality treatments to help them stay healthy, and in the unlucky event of an injury, return to their sport in the shortest time possible.

The most effective treatment for atlantoaxial dislocation is surgical treatment, with the principle of achieving reduction, reconstruction, and fusion of the atlantoaxial joint. The surgical strategies mainly include simple anterior approach, simple posterior approach, and combined anterior posterior approach. The investigators have summarized 904 cases of atlantoaxial instability or dislocation from 1998 to 2010 and preliminarily published the diagnosis and treatment strategy tree of the Third Hospital of Beijing Medical University. This strategy is divided into four types based on the severity of atlantoaxial dislocation: unstable, reversible, difficult to recover, and skeletal, and enters different surgical treatment processes. With the increase in the number of cases, accumulation of experience, and technological improvements in the past decade, spinal surgery colleagues have updated their classification diagnosis, diagnosis and treatment processes, and surgical techniques for atlantoaxial instability or dislocation. However, the selection of treatment strategies for atlantoaxial dislocation is mostly based on the surgeon's own experience, and there is a lack of standardized, large-scale, and high-level evidence-based medical research on the safety and effectiveness of current empirical strategies. Based on this, this study intends to adopt a multicenter, retrospective, and prospective study to construct a high-quality clinical cohort of atlantoaxial dislocation, update the classification and diagnosis and treatment strategies of atlantoaxial dislocation. And conduct long-term follow-up on patients to evaluate their safety and effectiveness, guide the surgical treatment of atlantoaxial dislocation, and thus form a recognized diagnostic and treatment standard for atlantoaxial dislocation.

Infection following severe lower extremity musculoskeletal injuries is a challenging problem. Several factors hypothesized to influence infection have been explored and, in many cases, optimized or found not to be influential. A persistent area of uncertainty and variability is the timing of acute soft tissue coverage. In the United States, the mean time to coverage from injury is 10 days, and infection rates are 20-35%. In the United Kingdom, there are national guidelines to support coverage within 72 hours of injury, and infection rates are less than 10%. While the data to support early coverage is promising, the necessary evidence to make this significant change is lacking. To justify the mobilization of resources and expense required to shift practice, a definitive trial is needed. This trial seeks to fill this critical knowledge gap. The primary objective of this trial is to determine if accelerated flap coverage (within 72 hours of injury) compared to standard flap coverage timing leads lower rates of infection and infection-related complications. The trial population includes patients 18 years and older with an acute open fracture and/or dislocation below the knee, with a diagnosed need for acute soft tissue coverage with a flap. Patients who undergo primary amputation prior to attempted flap coverage will be excluded. There will be 356 participants randomized in 1:1 ratio to receive either accelerated flap coverage (goal of flap within 72 hours from injury) or flap coverage at the time that reflects the standard of care at each institution. The timing of the trial interventions, other adjunctive treatments, the fracture fixation, and flap coverage procedures will be documented for both treatment groups. Management of the fracture or dislocation, selection of flap, and post-injury flap management will be at the discretion of the operating surgeons and documented for both treatment groups. Participants will have follow-up at 6 weeks, 3 months, 6 months, and 12 months post-randomization. The primary outcome will be a composite outcome to evaluate clinical status 6 months after randomization. Components of the composite outcome will be hierarchically assessed in the following order: 1) all-cause mortality, 2) amputation related to injury, 3) re-operation for infection and/or flap complication (flap compromise, partial and/or complete flap failure), and 4) days in hospital, defined as days in an acute in-patient hospital (i.e., not rehab or nursing facility). The secondary outcomes will independently assess the individual components of the primary outcome at 6 and 12 months, the composite outcome at 12 months, and health-related quality of life and patient satisfaction over 6 and 12 months. An Adjudication Committee will review primary and secondary endpoints and a Data Safety Monitoring Committee (DSMC) will review all safety events.

Suppression of the reproductive hypothalamic-pituitary-gonadal (HPG) axis is a common physiological response to strenuous military training and can be difficult to replicate in simulated environments. Additionally, whether HPG suppression contributes to the physiological changes, performance decrements, and high MSK injury risk associated with multi-stressor military training is unknown. Thus, we will utilize pharmacological inhibition of the HPG axis to test if estrogen and testosterone replacement will mitigate injury risk and performance decrements following military-relevant multi-stressor training. This project aims to deliver a state-of-the-art evaluation of male and female adaptive responses to multi-stressor training and evidence-based guidance for the safe and ethical use of exogenous hormone replacement as a MSK injury mitigation solution during multi-stressor training and operations.

Intravenous analgesia (Paracetamol, NSAIDs, opioids) is preferred for patients during the treatment and reduction stages of anterior shoulder dislocation. Additionally, patients may receive regional anesthesia and analgesia (lidocaine, bupivacaine). The route and dosage of analgesic administration are chosen by the attending physician managing the patient. In this study, investigators plan to observationally evaluate the analgesic management of patients without intervening in the method and dosage chosen by the primary treating physician. Patients receiving analgesia will be chosen according to preffered treatment at emergency department. The study population will consist of patients presenting to the emergency department with shoulder dislocation who receive analgesia and fall into the following 4 treatment groups. These 4 group will consist in: 1. ketamine group 2. interscalene nerve block group 3. suprascapular nerve block group 4. intraarticular lidocaine injection group. The study will compare these 4 treatment methods in terms of analgesia management, reduction time, comfort, and length of hospital stay for patients presenting to the emergency department with shoulder dislocation and receiving analgesia. The researcher will not interfere with the treatment decision made by the responsible physician or the treatment process

The goal of this clinical trial is to determine if a new rehabilitation protocol (apprehension-based training), leads to better recovery after shoulder dislocation among military personnel. Participants will be randomly allocated to apprehension-based training or standard physical therapy. In apprehension-based training participants will train to control their shoulder under progressively more unstable conditions. Standard physical therapy will be provided based on the clinical judgment of the treating physical therapist The primary hypothesis is that participants undergoing apprehension-based training will experience a more complete recovery of function, better shoulder-related quality of life, and incur less recurrent dislocations.

Acromioclavicular joint injury (ACJI) is one of the most common injury of shoulder joint. Most common mechanism of injury is from direct force apply to the affected shoulder, in adduction position, in acromion process area. Most of the intervention that have been used for treat ACJI are focused on pain control, maintain the strength of the joint, no limitation in daily life activity and full range of motion of affected shoulder. Operative treatment is indicated in ACJI Rockwood classification grade III, IV, V, and VI. Nowadays there are over 60 surgical techniques without gold standard. Arthroscopic assisted CC-stabilzation is one of the most popular technique that has been used for ACJI. This RCT study is designed for comparing functional outcomes (ACJI score, VAS, Constant score and DASH score) and radioligic outcomes (CC-distance difference, GACA difference) between intervention group (Arthroscopic assisted CC-stabilzation with additional K-wire fixation) and control group (Arthroscopic assisted CC-stabilzation alone) for acute ACJI. The main question it aims to answer is: \- Does Arthroscopic assisted CC-stabilization with additional K-wire fixation provide different outcomes in functional outcomes, CC-distance and GACA difference compare with arthroscopic assisted CC-stabilization alone in acute acromioclavicular joint injury?

1. Introduction Ankle sprains are among the most prevalent lesions in the athletic and non-athletic population(1). Accounting to up than 14% of emergency visits and with an estimated year cost of more than U$6 billion, it has a high impact in the health care system(2,3). Approximately 10 to 40% of these cases will develop ankle instability. The most susceptive population are those with an erratic treatment and/or poor rehabilitation program(4). Over the past years, the open Brostrom Gould procedure has been state as the gold standard procedure for this specific group of patients. (5,6). (7,8). With the development and improvement intra-articular ligament reconstruction and repair for shoulder and knee, the possibility to perform the same type of procedure at the ankle has grown. Arthroscopic-assisted Brostrom techniques were first described by Nery et al and Corte-Real et al near the year 2010(9,10). Some authors proposed modifications to these original approaches, but the main surgery concept was maintained(11-14).. During the last few years, a good number of studies were able to present good clinical and functional results with this procedure(1,11,15-18). Ankle arthroscopy is a reliable procedure and has been indicated to evaluate and treat a great number of ankle pathologies over the past decades(19,20). Ankle impingement, osteochondral lesions and tibiotarsi arthrodesis are some of the conditions that have good literature support in favor for the arthroscopic approach(21). Also, its use, prior to an ankle ligament repair or reconstruction, is advocated and sustained by several studies(22-26). It allows a complete articular visualization, providing the surgeon with a definitive scenario when dealing with ankle instability. Cartilage lesions, impingement syndromes and loose bodies that could be neglected by subsidiary exams can be detected and treated arthroscopically. The intra-articular ligament reconstruction and repair is not novelty for others orthopedic areas. The development of the anterior cruciate ligament surgery went to from the open approach to the arthroscopic technique over the last decades until the least was proclaimed the gold standard(27,28). The Bankart lesion, a condition normally related to traumatic shoulder instability, has a similar history, although the arthroscopic approach wasn't able to produce superior general results when compared to its open counterpart (29,30). Advances in the "all-inside" ligament repair are taking place at the shoulder and hip segment as well, showing promising and solid outcomes(31,32). Despite all the solid results regarding the biomechanical profile and the clinical effects of the arthroscopic Brostrom, there is a gap in its bibliography when it comes to high-level studies. Only Yeo et al in 2016 were able to show similar results between the open and the all-inside procedures with one-year follow-up study (1). Lately, an attempt in producing on systematic review on the subject was published, but no clinical trials were found to be included(33). Herein, our objective is to evaluate the effectiveness of the arthroscopic Brostrom technique and compare it to the open Brostrom procedure regarding complications, function by the Cumberland Ankle Instability Tool (CAIT), the American Orthopedic Foot and Ankle Society score (AOFAS), the Foot Function Index (FFI) and the 36 Short Form Survey (SF-36). The primary hypothesis is that the arthroscopic Brostrom will mitigate pain and improve function as compared to the open approach. 2. Material and Method 2.1 Design, setting and recruitment This will be a multicentric, with parallel groups, randomized clinical trial. The study will be conducted at São Paulo Hospital, a tertiary, teaching hospital fully affiliated with the Federal university of São Paulo (UNIFESP), and at Hospital das Clínicas, another tertiary, teaching hospital fully affiliated with the Federal university of Minas Gerais (UFMG). Participants will be enrolled at both hospitals, which provide assessment and treatment to approximately 5 (five) new patients with ankle instability per week. They will be referred by local orthopedist doctors or health professionals. The information to these physicians will be delivered by e-mail addressed directly to them, as well as via posters exhibited in places containing orthopedic medical care (outpatient clinic, emergency room). 2.2 Inclusion Criteria * Individuals must be older than 18 and younger than 65 years of age, both genders; * Participants must be experiencing instability symptoms at the ankle over the last six months; * Clinical diagnosis of ankle instability, defined as the presence of at least one previous ankle sprain associated with a current instability sensation by the patient and the presence of a positive anterior drawer test; the previous lateral ligament injury must be confirmed by Magnetic Resonance Imaging (MRI) findings. 2.3 Exclusion Criteria * Previous surgery involving the affected foot or ankle; * History or documented evidence of autoimmune or peripheral vascular diseases; * History or documented evidence of peripheral neuropathy (nervous compression syndrome, tarsal tunnel syndrome) or systemic inflammatory disease a (rheumatoid arthritis, spondylitis, Reiter Syndrome, etc.); * Associated injuries, such as osteochondral lesions, tendon ruptures and fractures; * Associated instability, such as syndesmotic and medial instability; * Cavovarus foot; * BMI over 35; * Previous infiltration in the ankle over the six months preceding the initial assessment; * Pregnancy; * Any condition that represents a contraindication of the proposed therapies; * Impossibility or incapacity to sign the informed Consent Form; * History or documented evidence of blood coagulation disorders (including treatment with anti-coagulants, but excluding aspirin); * Use of heart pacemaker; * Presence of infectious process (superficial on skin and cellular tissue, or deep in the bone) in the region to be treated; 2.4 Sampling The objective of this study is to right evaluate the efficacy of the Brostrom arthroscopic technique and compare it to the open Brostrom procedure in relation to the function by the American Orthopedic Foot and Ankle Society Score (AOFAS), the foot function Index (FFI) and o 36 Short Form Survey (SF-36). Thus, considering a 7.2 million population in the city of Sao Paulo that fit the criteria of inclusion and/or exclusion (Source: Census 2010) and respecting an involvement index of 0.072% value (0.72 by 1000 Exposition, according to the Ankle Consortium). Therefore, the target population estimated for the study is 5,155 people. Using the formula shown in appendix I to calculate the sample size with a 10% error, we estimated a sampling of 98. This sample quantity was defined according to the methodology expressed in appendix I, where, based in the central boundary theorem and the laws of large numbers, this sample size ensures that statistical analyses will be reliable. 2.5 Procedures A written, signed and dated informed consent will be obtained from the subject before any study-related procedures are performed. The patients will have to fill out an initial questionnaire in order to be enrolled (Attachment 2). After that, the assistant doctor will do the physical diagnostic examination. Then, X-rays and the MRI procedures will take place, to complete the diagnostic assessment. The patient will be included in the protocol and duly randomized after the diagnostic confirmation and fulfilment of all the inclusion criteria and non-adequacy to the exclusion criteria. The randomization sequence will be generated via computing software (http://www.randomizer.org/form.htm), producing a list from 1 - 98, and each number will be related to a sole treatment method. We will do a randomization with interchanged blocks, with the same number of patients in each group. Each non-transparent, opaque, sealed envelope, numbered from 1 to 98, will contain either a paper with the word "open" or with the words "arthroscopic". Each treatment method will have the same number of envelopes. The patients will be initially assessed individually, being randomized and allocated in the same way. The intervention procedures will be the same, with the same positioning and preparations, but differing regarding the lateral ligament repair approach. The evaluator doctor won't have access to the protocol test applied to each patient, and the surgeries (open or arthroscopic) will be conducted by different physicians. The patients in both groups will receive a large bandage at the operation site before every consultation, blinding the evaluator. 2.6 Interventions 2.6.1 Open Brostrom Approach 1. Period from diagnosis to intervention: up to 1 month. 2. Patient will receive a general anesthesia and a popliteal peripheral block. After surgical site preparation, the traditional arthroscopic portals will be performed. 3. An ankle arthroscopy will be held, to confirm the nonexistence of chondral lesions, medial instability or syndesmotic instability. The ankle will be cleaned, and all impingements removed. The proximal ligament insertion at the lateral malleolus will be debrided. 4. All the arthroscopic instruments will be removed. A lateral longitudinal incision will be held over the lateral capsule. The fibula apex, at the ATFL and CFL footprint, will receive a 3.0mm suture anchor (with two n2 high-resistant sutures). 5. The ligaments will be reattached with tension in a paints-over-vest fashion, using one suture for the ATFL region and one for the CFL region. 6. The incisions will be closed, and the patient placed in a post-operative boot. Weight-bearing will start at the 1st week (with the boot) and range of motion (ROM) will begin at the 3rd week (limiting inversion until the 6th week). Patients will be transitioned to an ankle brace at the 4th week. 7. Patients will be evaluated, and the questionnaires applied at the 3rd, 6th, 12th, 24th and 48th post-operative week. 2.6.2 Arthroscopic Brostrom Approach 1. Period from diagnosis to intervention: up to 1 month. 2. Patient will receive a general anesthesia and a popliteal peripheral block. After surgical site preparation, the traditional arthroscopic portals will be performed. 3. An ankle arthroscopy will be held, to confirm the nonexistence of chondral lesions, medial instability or syndesmotic instability. The ankle will be cleaned, and all impingements removed. The proximal ligament insertion at the lateral malleolus will be debrided. 4. The fibula apex (by arthroscopic view), at the ATFL and CFL footprint, will receive a 3.0mm suture anchor (with two n2 high-resistant sutures). 5. One suture will be passed at the most superior anterolateral capsular site and the other at the most inferolateral capsular site, respecting the safe zone between the superficial fibular nerve and the peroneal tendons. These maneuvers will be executed in a percutaneous and arthroscopic assisted technique. The ligaments will be reattached with tension using an arthroscopic knot. 6. The incisions will be closed, and the patient placed in a post-operative boot. Weight-bearing will start at the 1st week (with the boot) and range of motion (ROM) will begin at the 3rd week (limiting inversion until the 6th week). Patients will be transitioned to an ankle brace at the 4th week. 7. Patient will be evaluated, and the questionnaires applied at the 3rd, 6th, 12th, 24th and 48th post-operative week. 2.6.3 Adjuvant therapies Both groups will be submitted to the same post intervention care program, and they will be advised to use the following adjuvant therapies according to the intensity of their symptoms: Elevation Every patient will be oriented to perform limb elevation during the post-operative period. Pain Killers Level 1: * Dipyrone 1g every 6 hours, in case of pain, or * Paracetamol 750mg every 6 hours Level 2 (in case the pain does not diminish with level 1): * Tramadol 50mg every 6 hours, in case of pain, or * Codeine 30mg every 6 hours, in case of pain. The patient must present, at each visit to the doctor, the daily annotation concerning the used sedative medication. The medication will be supplied to the patient after the intervention, with the respective orientation concerning its use. After the period of five days of sedation, in case the pain persists, the patient will be reassessed, to check the necessity of changing the medication. If after the sixth week assessment the pain is stronger than in the initial painful stage, the patient will have the option of either change the treatment or being excluded from the study. 2.7 Primary outcome • Major complications such as dehiscence, neural damage, infection and re-rupture. Significant difference between groups. * Dehiscence: inability to heal the soft tissue coverage until the end of the 4th post-operative week. * Peripherical nerve damage: hypoesthesia or paresthesia not solved until the end of the 6th month after the surgery. * Infection: clinical signs infection or pus drainage at the wound that required the use of antibiotics. * Re-rupture: an ankle sprain event during the follow-up. 2.8 Secondary outcomes * CAIT * VAS * FFI * AOFAS score * SF-36 * Minor complications such as neuropraxia and prominent suture knots. 2.9 Subject Discontinuation Subjects may be discontinued from the study at any time. Reasons for discontinuation include: 1. Voluntary discontinuation by the subject without prejudice to further treatment. 2. Development of Complex Regional Pain Syndrome or any huge inflammatory response. 3. Pain and function severe impairment. 2.10 Statistical Analysis: After collecting the information, we will characterize the relative frequency (percentages) distribution of the qualitative variables through the Equal Test of Two Proportions. For relationship between qualitative variables analysis, the Chi-Squared test will be used. If a correlation between quantitative covariables reveals necessary, the Pearson's Correlation Test will be used. For the quantitative covariant comparison (effect measurement), we will make use of the ANOVA test. 3\. Discussion Chronic ankle instability (CAI) can be a consequence in up to 40% of ankle sprains. Considering that this type of trauma can occur in more than 10,000 Americans per day and consume more than U$6 billion in related costs per year, it's fair to say that we might be dealing with a worldwide public health challenge. Although this instability may be managed with conservative treatment, many patients will require surgical resolution due their demands and expectations. In this scenario, the Brostrom-Gould technique has emerged as the standard procedure in ankle instability operative care. Based on sustained and long-term results, its open fashion still is the preferable procedure for most of the Foot and Ankle and Sports Traumatology surgeons. Meanwhile, orthopedic arthroscopic techniques have progressed over the past decades and at the end of this century's first decade, the all-inside ankle ligament reconstruction started to be performed and published. A moderate number of surveys regarding these techniques in the past few years showed its efficacy and safety. Yet, there is no consensus concerning what is the best way to approach ankle instability when contrasting the open and the arthroscopic approach due the lack of quality comparative studies. Our research intends to try to answer this question by a randomized clinical trial with robust outcomes and a long follow-up.