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ISSN 0102-3616

Revista Brasileira de Ortopedia – Janeiro/Fevereiro 2017 – Volume 52 número 1 p. 1–122

RBO

VOLUME 52 • Nº 1 • JANEIRO/FEVEREIRO/2017 V

SBOT e o relacionamento Potencial regenerativo do tecido cartilaginoso por células-tronco mesenquimais: atualização, limitações e desafios

CAPA

Reabilitação nas lesões musculares dos isquiotibiais: revisão da literatura Mortalidade em um ano de pacientes idosos com fratura do quadril tratados cirurgicamente num hospital do Sul do Brasil Estudo comparativo entre decúbito lateral e mesa de tração para tratamento de fraturas pertrocantéricas com hastes cefalomedulares Tratamento cirúrgico das fraturas intra-articulares do calcâneo: comparação dos resultados entre placa reta e placa própria para calcâneo Reprodutibilidade do escore radiográfico de consolidação das fraturas da tíbia (RUST) Avaliação da ressonância magnética sem contraste como método para diagnóstico de lesões parciais do tendão da cabeça longa do bíceps Tratamento cirúrgico artroscópico da epicondilite lateral recalcitrante – Série de 47 casos Avaliação biomecânica da fixação do tendão da cabeça longa do bíceps braquial por três técnicas: modelo em ovinos Avaliação dos resultados do tratamento artroscópico da capsulite adesiva do ombro Correlação entre a classificação radiográfica de Ahlbäck e o estado de conservação do ligamento cruzado anterior em gonartrose primária Transplante osteocondral a fresco no joelho no Brasil: mínimo de dois anos de seguimento Alongamento ósseo femoral com fixador externo monoplanar associado a haste intramedular bloqueada Osteotomia artroscópica de realinhamento subcapital no tratamento da epifisiólise proximal do fêmur crônica e estável: resultados precoces Avaliação do desempenho in vivo de pinos porosos de hidrogel para preenchimento de defeito osteocondral em coelhos Sutura elástica no fechamento de fasciotomia para tratamento de síndrome compartimental associada à fratura da tíbia Reparo de ruptura bilateral simultânea do bíceps distal: relato de caso Rupturas bilaterais simultâneas dos tendões patelares Modificação da incidência radiográfica axilar para o ombro: uma nova posição Osteotomia de ressecção para aplainamento do calcâneo após retalho microcirúrgico: nota técnica


REFERÊNCIAS BIBLIOGRÁFICAS: 1) IOLASCON, G. et al. Risendronate’s efficacy: from randomized clinical trials to real clinical practice. Clinical Cases in Mineral and Bone Metabolism, v. 7, n. 1, p. 19-22, 2010. 2) BRASIL. ANVISA. Agência Nacional de Vigilância Sanitária. Resolução - RE nº 1.101, de 9 de abril de 2015. Concede Certificação de Boas Práticas de Fabricação ao Aché. Diário Oficial da União, Brasília, DF, P. 133, 9 abril 2015. 3) Kairos Web Brasil. Disponível em: http://brasil. kairosweb.com. Acesso em: Jun/2016. 4) Programa Cuidados pela Vida (O Programa Cuidados pela Vida pode alterar ou interromper esta campanha sem aviso prévio. Desconto calculado sobre o Preço Máximo ao Consumidor).

CONTRAINDICAÇÕES: OSTEOTRAT está contraindicado em pacientes com hipersensibilidade a qualquer componente da fórmula, com hipocalcemia, durante a gravidez, lactação e para pacientes com insuficiência renal severa (“clearance” de creatinina < 30 mL/min). INTERAÇÕES MEDICAMENTOSAS: Não foram realizados estudos formais de interação medicamentosa, entretanto, durante os estudos clínicos não foi observada qualquer interação clinicamente relevante com outros medicamentos.

OSTEOTRAT. risedronato sódico 35 mg. comprimidos revestidos. USO ORAL. USO ADULTO. Indicações: tratamento e prevenção da osteoporose em mulheres no período pós-menopausa para reduzir o risco de fraturas vertebrais e não vertebrais. Tratamento da osteoporose em homens com alto risco de fraturas. Contraindicações: hipersensibilidade a qualquer componente da fórmula, hipocalcemia, gravidez e lactação e para pacientes com insuficiência renal severa (“clearance” de creatinina <30 mL/min), Precauções e advertências: Alimentos, bebidas (exceto água) e drogas contendo cátions polivalentes (tais como: cálcio, magnésio, ferro e alumínio) podem interferir na absorção dos bisfosfonatos e não devem ser administrados concomitantemente. Em mulheres mais idosas (> 80 anos), a evidência de manutenção da eficácia de risedronato sódico, é limitada. Alguns bisfosfonatos foram relacionados a esofagites e ulcerações esofágicas. Em pacientes que apresentam antecedentes de alteração esofágica que retardam o trânsito ou o esvaziamento esofágico (ex. estenosose ou acalasia), ou que são incapazes de permanecerem em posição ereta por pelo menos 30 minutos após a ingestão do comprimido, o risedronato deve ser utilizado com especial cautela. Os prescritores devem enfatizar a importância das instruções posológicas para pacientes que apresentam antecedentes de alterações esofágicas. A hipocalcemia deve ser tratada antes do início do tratamento com OSTEOTRAT. Outras alterações ósseas e do metabolismo devem ser tratadas quando iniciada a terapia com OSTEOTRAT. Osteonecrose de mandíbula, geralmente associada com extração dentária e/ou infecção local foi relatada em pacientes com câncer em regimes de tratamento com bisfosfonatos, principalmente, na administração intravenosa. Osteonecrose de mandíbula também foi relatada em pacientes com osteoporose recebendo bisfosfonatos orais. Este medicamento contém lactose. Pacientes com problemas hereditários raros de intolerância à galactose, a deficiência da Lapp lactaseou má absorção da glucose-galactose, não devem tomar esse medicamento. Gravidez e lactação: O risco potencial para humanos é desconhecido. Risedronato sódico só deve ser utilizado durante a gravidez, se o risco benefício justificar o potencial risco para a mãe e o feto. A decisão de descontinuar a amamentação ou o produto deve considerar a importância do medicamento para mãe. Interações medicamentosas: Se considerado apropriado, OSTEOTRAT pode ser utilizado concomitantemente com a terapia de reposição hormonal. A ingestão concomitante de medicamentos contendo cátions polivalentes (ex. cálcio, magnésio, ferro e alumínio) irá interferir na absorção de OSTEOTRAT. O uso concomitante de antiácidos pode reduzir a absorção de risedronato. OSTEOTRAT não é metabolizado sistemicamente, não induz as enzimas do citocromo P450 e apresenta baixa ligação protéica. Reações adversas: Estão listadas a seguir de acordo com a seguinte convenção: muito comum (>1/10); comum (>1/100; <1/10); incomum (>1/1000; <1/100); raro (>1/10000; <1/1000); muito raro (<1/10000). Comuns: dor de cabeça, constipação, dispepsia, náusea, dor abdominal, diarréia, dor musculoesquelética. Incomuns: gastrite, esofagite, disfagia, duodenite, úlcera esofágica Raros: glossite, estenose esofágica. Muito raramente foram observadas reações como: uveite, irite, osteonecrose de mandíbula, hipersensibilidade e reações cutâneas, incluindo angioedema, rachaduras generalizadas e reações bolhosas de pele, algumas severas. Raramente observaram-se anormalidades nos testes de função hepática. Relatos laboratoriais: foram observados em alguns pacientes discreta diminuição nos níveis de cálcio sérico e fosfato, as quais foram precoces, transitórias e assintomáticas. Posologia: A dose recomendada nos adultos é de 1 comprimido de 35 mg uma vez por semana, por via oral. Deve ser administrado no mínimo 30 minutos antes da primeira refeição, outra medicação ou bebida (exceto água) do dia. Os comprimidos devem ser engolidos inteiros, sem deixá-los dissolvendo na boca ou mastigá-los. Os pacientes devem utilizar OSTEOTRAT enquanto estiverem na posição vertical, com um copo de água (120 mL) para auxiliar a chegada ao estômago. Os pacientes não devem deitar por 30 minutos após ingestão de OSTEOTRAT. O comprimido de Osteotrat deve ser tomado no mesmo dia de cada semana, não devem ingeridos dois comprimidos no mesmo dia. Nenhum ajuste de dose é necessário para pacientes com insuficiência renal leve a moderada. O uso do risedronato sódico é contraindicado em pacientes com insuficiência renal severa (“clearance” de creatinina menor que 30 mL/min.) “SE PERSISTIREM OS SINTOMAS, O MÉDICO DEVERÁ SER CONSULTADO.” VENDA SOB PRESCRIÇÃO MÉDICA. MS - 1.0573.0418. MB 02_SAP 4389103. Material técnico científico de distribuição exclusiva a profissionais de saúde habilitados à prescrição e/ou dispensação de medicamentos. Para informações completas, consultar a bula na íntegra através da Central de Atendimento ao Cliente. Material técnico científico de distribuição exclusiva à classe médica. 7017316 - Agosto/2016


ISSN 0102-3616 impressa

ISSN 1982-4378 online

Órgão Oficial da Sociedade Brasileira de Ortopedia e Traumatologia Indexada em PubMed/PubMed Central (2015), SciELO (2007), ScopusTM (2011), LILACS (1992) e filiada à Associação Brasileira de Editores Científicos (ABEC).

Editor Chefe

Editores Eméritos

Gilberto Luis Camanho Departamento de Ortopedia e Traumatologia, Faculdade de Medicina, Universidade de São Paulo (DOT-FMUSP), São Paulo, SP, Brasil

Márcio Ibrahim de Carvalho, MG, Brasil; Donato D’Angelo, RJ, Brasil; Carlos Giesta, RJ, Brasil

Editores Associados Moisés Cohen Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brasil

Rames Mattar Junior Departamento de Ortopedia e Traumatologia, Faculdade de Medicina, Universidade de São Paulo (DOT-FMUSP), São Paulo, SP, Brasil

Osvandré Lech Instituto de Ortopedia e Traumatologia de Passo Fundo, Passo Fundo, RS, Brasil

Editores Internacionais Philippe Hernigou Orthopedic Surgery, University of Paris XII, Paris, França;

Michael Wagner Wilhelminenspital der Stadt Wien, Viena, Áustria;

Fernando Fonseca Universidade de Coimbra, Coimbra, Portugal;

Rodrigo F. Pesantez Departamento de Ortopedía y Traumatología, Fundación Santa Fé de Bogotá, Bogotá, Colômbia;

José Neves Faculdade de Medicina do Porto, Porto, Portugal;

Jaime Quintero Centro Médico Almirante Colon, Bogotá, Colômbia;

Jacinto Monteiro Serviço de Urgência de Ortopedia, Hospital Distrital do Barreiro, Lisboa, Portugal;

Mark Vrahas Orthopaedic Trauma Service, Brigham and Women’s Hospital, Massachusetts General Hospital, Boston, EUA;

Norbert P Hass Center for Musculoskeletal Surgery, Charité University Medicine, Berlim, Alemanha;

Marvin Tile Sunnybrook Health Sciences Centre, Toronto, Canadá;

Jesse B Júpiter Massachusetts General Hospital, Harvard Medical School, Boston, EUA; Cris Van Der Werken Department of Surgery, University Medical Centre Utrecht, Utrecht, Holanda; Edgardo Ramos Hospital de Urgencias Traumatológicas, Cidade do México, México; Sérgio Fernandez Facultad de Medicina, Universidad de los Andes Santiago de Chile, Santiago, Chile;

Juan Manoel Concha Facultad de Ciencias de la Salud, Manizales, Colômbia; Pierre Hoffmeyer Hôpital Cantonal Universitaire, Genebra, Suíça; Antonio Pace Instituto Ortopedico Galeazzi, Unità Operativa di Traumatologia, Via Riccardo Galeazzi, Palermo, Itália; Rami Mosheiff Department of Orthopedic Surgery, Hadassah Medical Center, Jerusalém, Israel; Joan Giros Hospital General de L’Hospitalet, Barcelona, Espanha.


Corpo Editorial Akira Ishida Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brasil; Arlindo Pardini Junior Faculdade de Medicina do Triângulo Mineiro (UFTM), Belo Horizonte, MG, Brasil; Caio Augusto de Souza Nery Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brasil; Carlos Roberto Schwartsmann Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brasil;

Luis Roberto Vialle Pontifícia Universidade Católica do Paraná (PUC-PR), Curitiba, PR, Brasil; Luiz Antonio M. da Cunha Universidade Federal do Paraná (UFPR), Paraná, PR, Brasil; Luiz Mestriner Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brasil; Marcelo Tomanik Mercadante Departamento de Ortopedia e Traumatologia, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil; Márcio Carpi Malta Universidade Federal Fluminense (UFF), Niterói, RJ, Brasil;

Cláudio Santili Departamento de Ortopedia e Traumatologia, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil;

Marco Antonio Percope de Andrade Departamento de Aparelho Locomotor, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brasil;

Fernando Baldy Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brasil;

Marcos Antonio Almeida Matos Escola Baiana de Medicina e Saúde Pública (EBMSP), Salvador, BA, Brasil;

Flávio Faloppa Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brasil; Geraldo Rocha Motta Filho Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, RJ, Brasil; Giancarlo Polesello Departamento de Ortopedia e Traumatologia, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil; Gildásio de Cerqueira Daltro Universidade Federal da Bahia (UFBA), Salvador, BA, Brasil; Helton Defino Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (RALFMRP-USP), Ribeirão Preto SP, Brasil; João Antonio Matheus Guimarães Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, RJ, Brasil; João Maurício Barretto Departamento de Ortopedia e Traumatologia, Santa Casa de Misericórdia do Rio de Janeiro, Rio de Janeiro, RJ, Brasil; José Batista Volpon Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (RAL-FMRP-USP), Ribeirão Preto SP, Brasil;

Olavo Pires de Camargo Departamento de Ortopedia e Traumatologia, Faculdade de Medicina, Universidade São Paulo (FMUSP), São Paulo, SP, Brasil; Osmar Avanzi Departamento de Ortopedia e Traumatologia, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil; Osmar Pedro Arbix Camargo Faculdade de Ciências Médicas da Santa de Misericórdia (FCMSCSP), São Paulo, SP, Brasil; Pedro José Labronici Serviço de Ortopedia e Traumatologia Prof. Dr. Donato D’Ângelo, Hospital Santa Teresa, Petrópolis, RJ, Brasil; Roberto Guarniero Departamento de Ortopedia e Traumatologia, Faculdade de Medicina, Universidade São Paulo (FMUSP), São Paulo, SP, Brasil; Roberto Santin Departamento de Ortopedia e Traumatologia, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil; Roberto Sérgio Tavares Canto Universidade Federal de Uberlândia (UFU), Uberlândia, MG, Brasil; Sérgio Checchia Faculdade de Ciências Médicas da Santa de Misericórdia (FCMSCSP), São Paulo, SP, Brasil;

José Maurício de Moraes Carmo Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro (HUPE-UERJ), Rio de Janeiro, RJ, Brasil;

Sérgio Nogueira Drumond Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brasil;

José Sérgio Franco Departamento de Traumatologia e Ortopedia, Faculdade de Medicina, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brasil;

Sergio Zylbersztejn Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brasil;

José Soares Hungria Neto Faculdade de Ciências Médicas da Santa de Misericórdia (FCMSCSP), São Paulo, SP, Brasil;

Tarcísio Eloy P. de Barros Filho Departamento de Ortopedia e Traumatologia, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil;

Karlos Celso de Mesquita Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brasil;

Willian Dias Belangero Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brasil.

Comissão Editorial

Produção Editorial

Sociedade Brasileira de Ortopedia e Traumatologia Alameda Lorena, 427 - 14º. Andar - São Paulo, SP, Brasil. CEP: 01424-000

Elsevier Editora Ltda. Rua Sete de Setembro, 111-16º andar, CEP: 20050-006 2017© Elsevier Editora Ltda.

Sociedade Brasileira de Ortopedia e Traumatologia Presidente: João Mauricio Barretto (RJ); 1º Vice-Presidente: Patrícia Maria de Moraes Barros Fucs (SP); 2º Vice-Presidente: Moises Cohen (SP); Secretário Geral: Alexandre Fogaça Cristante (SP); 1º Secretario: Marcelo Abagge (PR); 2º Secretário: Grimaldo Martins Ferro (GO); 1º Tesoureiro: Benno Ejnisman (SP); 2º Tesoureiro: Robson Alves do Nascimento (CE); Diretor de Comunicação e Marketing: Carlos César Vassalo (MG); Diretor de Regionais: Ivan Chakkour (SP); Diretor de Comitês: Carlos Roberto Galia (RS). Secretaria RBO - Sociedade Brasileira de Ortopedia e Traumatologia: Alamedad Lorena, 427 – 2º andar, Jd. Paulista. CEP: 01424-000, São Paulo, SP, Brasil. Tel: (11) 2137-5417. E-mail: rbo@sbot.org.br. Website: www.rbo.org.br Publicidade - Gislene Lemos. Tel: (11) 5071-7713. E-mail: comercial@sbot.org.br Assessoria Técnica - Diva da Silva Godoi


Normas para Publicações

INSTRUÇÕES AOS AUTORES A Revista Brasileira de Ortopedia (RBO) é o órgão de publicação científica da Sociedade Brasileira de Ortopedia e Traumatologia (SBOT) e se propõe a divulgar artigos que contribuam para o aperfeiçoamento e o desenvolvimento da prática, da pesquisa e do ensino da Ortopedia e de especialidades afins. Publicada bimestralmente nos meses de fevereiro, abril, junho, agosto, outubro e dezembro com absoluta regularidade desde sua primeira edição, em 1965. A revista recebe para publicação artigos para as seguintes seções: Artigos Originais, Artigos de Revisão, Artigos de Atualização, Relatos de casos, Notas Prévias, Notas Técnicas e Cartas ao Editor. Os artigos poderão ser escritos em Português, Espanhol ou Inglês. A revista é destinada a ortopedistas vinculados à SBOT, profissionais da área da saúde que se dedicam a atividades afins e ortopedistas de outros países. Seu título abreviado é Rev Bras Ortop e deve ser usado em bibliografias, notas de rodapé e em referências e legendas bibliográficas.

Peer Review (Revisão por Pares)

Ao Author Agreement devem ser anexados

O peer-review é um dos fatores que sustentam a qualidade de um veículo científico. No caso da RBO, a constituição de um corpo editorial formado, em sua maioria, por professores universitários permitiu um peer-review criterioso. Depois de recebidos, os artigos são remetidos a um técnico especializado em metodologia de trabalho científico e a três membros do conselho editorial que atuam na mesma área. Esses profissionais avaliam os trabalhos e os devolvem com seus pareceres. A avaliação é feita sob cinco aspectos: Grau de Prioridade para Publicação; Relevância do Trabalho; Qualidade Científica, Apresentação e Recomendação. Todos os manuscritos, após aprovação pelos Editores, serão avaliados por revisores qualificados, sendo o anonimato garantido em todo o processo de julgamento (blinded peer-review, revisão por pares cega). Os artigos que não apresentarem mérito, contenham erros significativos de metodologia ou não se enquadrem à política editorial da revista serão rejeitados, não cabendo recurso. Os comentários dos revisores serão devolvidos aos autores para modificações no texto ou justificativa de sua conservação. Somente após aprovação final dos revisores e editores, os manuscritos serão encaminhados para publicação.

Declaração de Conflito de Interesse, quando pertinente, que, segundo Resolução do Conselho Federal de Medicina nº 1595/2000, veda que em artigo científico seja feita promoção ou propaganda de quaisquer produtos ou equipamentos comerciais. Certificado de Aprovação do Trabalho pela Comissão de Ética em Pesquisa da Instituição em que o mesmo foi realizado. Informações sobre eventuais fontes de financiamento da pesquisa. Declaração de que os investigadores assinam documento de Consentimento Informado, quando o artigo tratar de pesquisa clínica com seres humanos. Toda pesquisa clínica ou experimental em humanos ou animais deve ser executada de acordo com a Declaração de Helsinki da Associação Médica Mundial (J Bone Joint Surg Am. 1997;79(7):1089-98). Os artigos devem ser escritos em português, espanhol ou inglês.

Copyright Todas as declarações publicadas nos artigos são de inteira responsabilidade dos autores. Entretanto, todo material publicado se torna propriedade da Revista Brasileira de Ortopedia (RBO), que passa a reservar os direitos autorais. Os autores devem encaminhar à RBO por Fax (+55-112137-5418) ou correio a declaração de transferência de direitos autorais, assinada por todos os coautores, assim que o manuscrito é submetido. Tipo de Artigo Original Revisãoa Atualizaçãoa Relato de Caso Nota Técnica Carta ao Editorb Editoriala

Resumo

nº de palavrasc

Referências

Figuras

Tabelas

Estruturado máx. 250 palavras Não estruturado máx. 250 palavras Não estruturado máx. 250 palavras Não estruturado máx. 250 palavras Não estruturado máx. 250 palavras 0

2.500

30

10

6

4.000

60

3

2

4.000

60

3

2

1.000

10

5

0

1.500

8

5

2

500

4

2

0

500

0

0

0

0

apublicadas

a convite dos Editores. a critérios dos Editores com réplica, quando pertinente. cexcluindo resumo, referências, tabelas e figuras. bpublicadas

Apresentação e submissão de manuscritos A Revista Brasileira de Ortopedia (Rev Bras Ortop - ISSN 0102-3616) é uma publicação bimestral da Sociedade Brasileira de Ortopedia e Traumatologia, com a finalidade publicar trabalhos originais de todas as especialidades da ortopedia. Os conceitos e declarações contidos nos trabalhos são de total responsabilidade dos autores. Os artigos publicados na revista seguem os requisitos uniformes propostos pelo Comitê Internacional de Editores de Revistas Médicas, atualizados em outubro de 2004 e disponíveis no endereço eletrônico www.icmje.org. Os artigos que envolvam seres humanos ou animais de laboratório devem apresentar claramente a adesão às diretrizes apropriadas e a aprovação de seus protocolos pelos comitês institucionais. O artigo enviado deverá ser submetido, acompanhado de: Author Agreement (Carta de Autorização para Publicação) Carta assinada por todos os autores (máximo seis), autorizando sua publicação, declarando que o mesmo é inédito e que não foi ou está submetido para publicação em outro periódico. Cover Letter (Carta de Apresentação) Carta de apresentação do estudo destinada exclusivamente ao Editor. Manuscript (Manuscrito) Arquivo completo do artigo com referências, preferencialmente com resumo e palavras-chave. Figuras, Tabelas, Gráficos Arquivos individuais enviados à parte.

Tipo de Artigo A Revista Brasileira de Ortopedia recebe para publicação os seguintes tipos de manuscritos: Artigo Original, Atualização, Revisão, Relatos de Caso, Nota Técnica, Resenhas e Resumos, Cartas e Editorais. Artigo Original Descreve pesquisa experimental ou investigação clínica prospectiva ou retrospectiva, randomizada ou duplo cego. Deve ter: Título em português e inglês, Resumo em português e inglês estruturado em (Objetivo, Métodos, Resultados e Conclusão), Palavras-chave, Introdução, Materiais e Métodos, Resultados, Discussão, Conclusões e Referências. Artigo de Atualização Revisões do estado da arte sobre determinado tema, escrito por especialista a convite dos Editores. Deve ter Resumo em português e inglês com Palavras-chave, Título e Referências. Relato de Caso Deve ser informativo e não deve conter detalhes irrelevantes. Só serão aceitos os relatos de casos clínicos de interesse, quer pela raridade como entidade nosológica, ou ainda pela forma não usual de apresentação. Deve ter Resumo em português e inglês com Palavras-chave, Título e Referências. Artigo de Revisão Tem como finalidade examinar a bibliografia publicada sobre determinado assunto fazendo avaliação crítica e sistematizada da literatura sobre certo tema, além de apresentar conclusões importantes baseadas nessa literatura. Somente serão aceitos para publicação quando solicitados pelos Editores. Deve ter Resumo em português e inglês com Palavras-chave, Título e Referências. Nota Técnica Destina-se à divulgação de método de diagnóstico ou técnica cirúrgica experimental, novo instrumental cirúrgico, implante ortopédico, etc. Deve ter: Resumo em português e inglês com Título, Palavras-chave, Introdução Explicativa, Descrição do Método, do Material ou da Técnica, Comentários Finais e Referências. Carta ao Editor Tem por objetivo comentar ou discutir trabalhos publicados na revista ou relatar pesquisas originais em andamento. É publicada a critério dos Editores, com a respectiva réplica quando pertinente. Editorial Escritos a convite, apresentando comentários de trabalhos relevantes da própria revista, pesquisas importantes publicadas ou comunicações dos editores de interesse para a especialidade.

Preparo dos manuscritos A) Folha de Rosto (Title Page): • Título do artigo, em português e inglês, redigido com dez ou doze palavras, sem considerar artigos e preposições. O Título deve ser motivador e deve dar ideia dos objetivos e do conteúdo do trabalho;


• Nome completo de cada autor (máximo seis), sem abreviaturas; • Indicação da afiliação institucional de cada autor, separadamente com cidade, estado e país; com indicação numérica e sequencial, utilizando letras minúsculas sobrescritas. Se houver mais de uma afiliação institucional, indicar apenas a mais relevante; • As afiliações devem ser apresentadas em ordem hierárquica decrescente (p.e Universidade de São Paulo, Faculdade de Medicina, Departamento de Pediatria) e na língua original da instituição ou na versão em inglês quando a escrita não é latina (p.e: Johns Hopkins University, Universidade de São Paulo, Université Paris-Sorbonne). • Indicação da Instituição onde o trabalho foi realizado com cidade, estado e país; • Nome, endereço e e-mail do autor correspondente; • Fontes de auxílio à pesquisa (se houver); • Declaração de inexistência de conflitos de interesse. Resumo e palavras-chave: Resumo e Palavras-chave, em português e inglês, com no máximo 250 palavras. Nos artigos originais, o Resumo deverá ser estruturado ressaltando os dados mais significativos do trabalho (Objetivo: Informar o porquê da pesquisa, ressaltando a sua motivação; Métodos: Descrever sucintamente o material avaliado e o método empregado em sua avaliação; Resultados: Descrever os achados relevantes com dados estatísticos e com a respectiva significância; Conclusões: Relatar exclusivamente as principais conclusões). Para Relatos de Caso, Revisões ou Atualizações e Nota Prévia, o Resumo dispensa estruturação, mas exige Palavras-chave. Abaixo do resumo, especificar no mínimo três e no máximo dez Palavras-chave que definam o assunto do trabalho. As palavraschave, ou descritores, devem ser baseadas no DECS (Descritores em Ciências da Saúde), disponível no endereço eletrônico http://decs. bvs.br/; ou em MeSH (Medical Subject Headings), em www.nlm.nih. gov/mesh/MBrowser.html. B) Texto (Manuscript) Deverá obedecer rigorosamente à estrutura para cada categoria de manuscrito. Em todas as categorias de manuscrito, a citação dos autores no texto deverá ser numérica e sequencial, utilizando algarismos arábicos entre colchetes. Preferencialmente com Resumo e Palavras-chave repetidas. Introdução: O autor deve justificar o porquê da realização do trabalho, descrevendo a relevância e o interesse do estudo. Poderá utilizar poucas (duas ou três) referências bibliográficas quando julgá-las necessárias para esclarecer a importância do trabalho. O objetivo do trabalho deve estar explícito ao final da introdução, podendo o autor colocá-lo como título à parte. Material: Trata-se do objeto do estudo e, portanto, deve ser descrito com detalhes; neste item será apontada a origem dos pacientes, sua identificação, sua qualificação, os critérios de inclusão e exclusão. Enfim, o autor deverá definir, de forma clara, o grupo com o qual estará ou esteve trabalhando. Método: O autor descreverá o procedimento que foi aplicado ou analisado no seu material, com detalhes. A descrição deve ser clara e suficiente para que outro pesquisador possa reproduzir ou dar continuidade ao estudo. Descrever a metodologia estatística empregada com detalhes suficientes para permitir que qualquer leitor com razoável conhecimento sobre o tema e o acesso aos dados originais possa verificar os resultados apresentados. Evitar o uso de termos imprecisos tais como: aleatório, normal, significativo, importante, aceitável, sem defini-los. A forma de aferir os resultados será descrevendo os parâmetros da literatura ou parâmetros próprios, ou seja, o que é bom, o que é regular etc., no conceito proposto pelos autores. A utilização da palavra significativa exige que o valor “p” seja relatado. A utilização da palavra correlação deve ser acompanhada do respectivo coeficiente. Informação sobre o manejo da dor pós-operatório, tanto em humanos como em animais, deve ser relatada no texto (Resolução nº 196/96, do Ministério da Saúde e Normas Internacionais de Proteção aos Animais). Resultados: Apresentar os resultados em sequência lógica do texto, usando tabelas e ilustrações, se necessário. Não repetir no texto todos os dados constantes das tabelas e ou ilustrações. No texto, enfatizar ou resumir somente os dados importantes. Discussão: Todos os itens do trabalho (introdução, material, métodos, resultados) devem ser discutidos e comparados com a literatura pertinente. Conclusões: Devem ser baseadas nos resultados obtidos. Agradecimentos: Podem ser mencionadas colaborações de pessoas, instituições ou agradecimento por apoio financeiro, auxílios técnicos que mereçam reconhecimento mas não justificam a inclusão entre os autores.

Conflitos de interesse: Devem ser reproduzidos objetivamente quando houver, e, quando não houver, apresentar a declaração: “Os autores declaram não haver conflitos de interesse." Referências: Devem ser atualizadas contendo, preferencialmente, os trabalhos mais relevantes publicados nos últimos cinco anos sobre o tema. Deve conter apenas trabalhos referidos no texto. Se pertinente, é recomendável incluir trabalhos publicados na RBO. As referências deverão ser numeradas consecutivamente, na ordem em que são citadas no texto, e identificadas com algarismos arábicos entre colchetes. A apresentação deverá seguir o formato denominado “Vancouver Style”, conforme modelos abaixo. Os títulos dos periódicos deverão ser abreviados de acordo com o estilo apresentado pela National Library of Medicine, disponível em “List of Journal Indexed in Index Medicus” no endereço eletrônico: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=journals Para todas as referências, citar todos os autores até seis. Quando em número maior, citar os seis primeiros autores seguidos da expressão “et al.” Artigos de Periódicos ou Revistas: 1) Borges JLP, Milani C, Kuwajima SS, Laredo Filho J. Tratamento da luxação congênita de quadril com suspensório de Pavlik e monitorização ultra-sonográfica. Rev Bras Ortop. 2002;37(1/2):5-12. 2) Bridwell KH, Anderson PA , Boden SD , Vaccaro AR , Wang JC. What’s new in spine surgery. J Bone Joint Surg Am. 2005;87(8):1892-901. 3) Schreurs BW, Zengerink M, Welten ML, van Kampen A, Slooff TJ. Bone impaction grafting and a cemented cup after acetabular fracture at 3-18 years. Clin Orthop Relat Res. 2005;(437):145-51. Livros: Baxter D. The foot and ankle in sport. St Louis: Mosby; 1995. Capítulos de Livro: Johnson KA. Posterior tibial tendon. In: Baxter D. The foot and ankle in sport. St Louis: Mosby; 1995. p. 43-51. Dissertações e Teses: Laredo Filho J. Contribuição ao estudo clínico-estatístico e genealógico-estatístico do pé torto congênito equinovaro [tese]. São Paulo: Universidade Federal de São Paulo. Escola Paulista de Medicina; 1968. Publicações eletrônicas: 1) Lino Junior W, Belangero WD. Efeito do Hólmio YAG laser (Ho: YAG) sobre o tendão patelar de ratos após 12 e 24 semanas de seguimento. Acta Ortop Bras [periódico na Internet]. 2005 [citado 2005 Ago 27];13(2):[about 5p.]. Disponível em: http:// www.scielo.br/scielo . 2) Feller J. Anterior cruciate ligament rupture: is osteoarthritis inevitable? Br J Sports Med [serial on the Internet]. 2004 [cited 2005 Ago 27]; 38(4): [about 2 p.]. Available at: http://bjsm. bmjjournals.com/cgi/content/full/38/4/383 C) Tabelas e Figuras: Tabelas: As tabelas devem ser numeradas por ordem de aparecimento no texto com números arábicos. Cada tabela deve ter um título e, se necessário, uma legenda explicativa. Os quadros e tabelas deverão ser enviados através de arquivos individuais (preferencialmente em Excel). Figuras: A apresentação desse material pode ser em cores, sendo impresso em preto e branco, com legendas e respectivas numerações. As figuras deverão ser enviadas através de arquivos individuais (300 dpi). Mais detalhes em: http://www.elsevier. com/author-schemas/artwork-and-media-instructions. Enviar cada figura individual para o sistema. A(s) legenda(s) deve(m) ser incorporada(s) no final do texto no manuscrito após a listagem de referências. Não incluir figuras no texto. As figuras incluem todas as ilustrações, tais como fotografias, desenhos, mapas, gráficos, etc. e devem ser numeradas consecutivamente em algarismos arábicos. Fotos em preto e branco serão reproduzidas gratuitamente, mas o editor reserva o direito de estabelecer o limite razoável, quanto ao número delas, ou cobrar do autor a despesa decorrente do excesso. Fotos coloridas serão cobradas do autor. Abreviaturas e Siglas: Devem sempre ser precedidas do nome completo quando citadas pela primeira vez no texto. No rodapé das figuras e tabelas devem sempre ser discriminados o significado de abreviaturas, símbolos, outros sinais e informada a fonte: local onde a pesquisa foi realizada. Se as ilustrações já tiverem sido publicadas, deverão vir acompanhadas de autorização por escrito do autor ou editor, constando a fonte de referência onde foi publicada. A RBO reserva o direito de não aceitar para avaliação os artigos que não preencham os critérios acima formulados. Envio dos manuscritos: As submissões devem ser feitas on-line pelo link www.evise.com/evise/jrnl/RBO. É imprescindível o envio por fax ou correio da permissão para reprodução do material e as cartas com a aprovação de um Comitê de Ética da Instituição onde foi realizado o trabalho - quando referente a intervenções (diagnósticas ou terapêuticas) em seres humanos - e o Author Agreement, aquele assinado por todos os autores em que se afirme o ineditismo do trabalho (fax: +55 11 2137-5418).


SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

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Volume 52 • Número 1 • Janeiro/Fevereiro 2017

SUMÁRIO Editorial SBOT e o relacionamento SBOT and the relationship Gilberto Luis Camanho . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

Artigo de Atualização Potencial regenerativo do tecido cartilaginoso por células-tronco mesenquimais: atualização, limitações e desafios Regenerative potential of the cartilaginous tissue in mesenchymal stem cells: update, limitations, and challenges Ivana Beatrice Mânica da Cruz, Antônio Lourenço Severo, Verônica Farina Azzolin, Luiz Filipe Machado Garcia, André Kuhn, Osvandré Lech . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2

Artigo de Revisão Reabilitação nas lesões musculares dos isquiotibiais: revisão da literatura Rehabilitation of hamstring muscle injuries: a literature review Gabriel Amorim Ramos, Gustavo Gonçalves Arliani, Diego Costa Astur, Alberto de Castro Pochini, Benno Ejnisman, Moisés Cohen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11

Artigos Originais Mortalidade em um ano de pacientes idosos com fratura do quadril tratados cirurgicamente num hospital do Sul do Brasil One-year mortality of elderly patients with hip fracture surgically treated at a hospital in Southern Brazil Marcelo Teodoro Ezequiel Guerra, Roberto Deves Viana, Liégenes Feil, Eduardo Terra Feron, Jonathan Maboni, Alfonso Soria-Galvarro Vargas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17

Estudo comparativo entre decúbito lateral e mesa de tração para tratamento de fraturas pertrocantéricas com hastes cefalomedulares Comparative study between lateral decubitus and traction table for treatment of pertrochanteric fractures with cephalomedullary nails Eric Fernando de Souza, José Octávio Soares Hungria, Lucas Romano Sampaio Rezende, Davi Gabriel Bellan, Jonas Aparecido Borracini . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

24

Tratamento cirúrgico das fraturas intra-articulares do calcâneo: comparação dos resultados entre placa reta e placa própria para calcâneo Surgical treatment of intraarticular fractures of the calcaneus: comparison between flat plate and calcaneal plate Luiz Carlos Almeida da Silva, João Mendonça de Lima Heck, Marcelo Teodoro Ezequiel Guerra . . . . . . . . . . . . . . . . . .

29

Reprodutibilidade do escore radiográfico de consolidação das fraturas da tíbia (RUST) Reliability of the radiographic union scale in tibial fractures (RUST) Fernando Antonio Silva de Azevedo Filho, Ricardo Britto Cotias, Matheus Lemos Azi, Armando Augusto de Almeida Teixeira . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35

Avaliação da ressonância magnética sem contraste como método para diagnóstico de lesões parciais do tendão da cabeça longa do bíceps Magnetic resonance imaging without contrast as a diagnostic method for partial injury of the long head of the biceps tendon Alexandre Tadeu do Nascimento, Gustavo Kogake Claudio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40

Tratamento cirúrgico artroscópico da epicondilite lateral recalcitrante – Série de 47 casos Arthroscopic surgical treatment of recalcitrant lateral epicondylitis – A series of 47 cases Alexandre Tadeu do Nascimento, Gustavo Kogake Claudio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

46


Sumário Avaliação biomecânica da fixação do tendão da cabeça longa do bíceps braquial por três técnicas: modelo em ovinos Biomechanical evaluation of the long head of the biceps brachii tendon fixed by three techniques: a sheep model Carlos Henrique Ramos, Júlio Cezar Uili Coelho . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

52

Avaliação dos resultados do tratamento artroscópico da capsulite adesiva do ombro Clinical evaluation of arthroscopic treatment of shoulder adhesive capsulitis Alberto Naoki Miyazaki, Pedro Doneux Santos, Luciana Andrade Silva, Guilherme do Val Sella, Leonardo Carrenho, Sergio Luiz Checchia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

61

Correlação entre a classificação radiográfica de Ahlbäck e o estado de conservação do ligamento cruzado anterior em gonartrose primária Correlation between Ahlbäck radiographic classification and anterior cruciate ligament status in primary knee arthrosis Glaucus Cajaty Martins, Gilberto Luis Camanho, Leonardo Marcolino Ayres, Eduardo Soares de Oliveiras . . . . . . . . .

69

Transplante osteocondral a fresco no joelho no Brasil: mínimo de dois anos de seguimento Fresh osteochondral knee allografts in Brazil with a minimum two-year follow-up Luís Eduardo Passarelli Tírico, Marco Kawamura Demange, Luiz Augusto Ubirajara Santos, José Ricardo Pécora, Alberto Tesconi Croci, Gilberto Luís Camanho . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75

Alongamento ósseo femoral com fixador externo monoplanar associado a haste intramedular bloqueada Femur lengthening with monoplanar external fixator associated with locked intramedullary nail Henrique Paradella Alvachian Fernandes, Danilo Gabriel do Nascimento Silva Barronovo, Fabio Lucas Rodrigues, Marcos Hono . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

82

Osteotomia artroscópica de realinhamento subcapital no tratamento da epifisiólise proximal do fêmur crônica e estável: resultados precoces Arthroscopic subcapital realignment osteotomy in chronic and stable slipped capital femoral epiphysis: early results Bruno Dutra Roos, Marcelo Camargo de Assis, Milton Valdomiro Roos, Antero Camisa Júnior, Ezequiel Moreno Ungaretti Lima, Rodolfo Cavanus Pagani . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

87

Avaliação do desempenho in vivo de pinos porosos de hidrogel para preenchimento de defeito osteocondral em coelhos In vivo evaluation of porous hydrogel pins to fill osteochondral defects in rabbits Túlio Pereira Cardoso, André Petry Sandoval Ursolino, Pamela de Melo Casagrande, Edie Benedito Caetano, Daniel Vinicius Mistura, Eliana Aparecida de Rezende Duek . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

95

Relatos de Caso Sutura elástica no fechamento de fasciotomia para tratamento de síndrome compartimental associada à fratura da tíbia Elastic suture (shoelace technique) for fasciotomy closure after treatment of compartmental syndrome associated to tibial fracture Paulo Sergio Martins Castelo Branco, Mauricio Cardoso Junior, Isaac Rotbande, José Antonio Fraga Ciraudo, Celso Ricardo Correa de Melo Silva, Paulo Cesar dos Santos Leal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Reparo de ruptura bilateral simultânea do bíceps distal: relato de caso Simultaneous bilateral distal biceps tendon repair: case report Thiago Medeiros Storti, Alexandre Firmino Paniago, Rafael Salomon Silva Faria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Rupturas bilaterais simultâneas dos tendões patelares Simultaneous bilateral patellar tendon rupture Diogo Lino Moura, José Pedro Marques, Francisco Manuel Lucas, Fernando Pereira Fonseca . . . . . . . . . . . . . . . . . . . . 111

Notas Técnicas Modificação da incidência radiográfica axilar para o ombro: uma nova posição Modified axillary radiograph of the shoulder: a new position Luís Filipe Senna, Rodrigo Pires e Albuquerque . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Osteotomia de ressecção para aplainamento do calcâneo após retalho microcirúrgico: nota técnica Resection osteotomy for calcaneus flattening after micro-surgical flap: technical note Mário Yoshihide Kuwae, Edegmar Nunes Costa, Ricardo Pereira da Silva, Alexandre Daher Albieri, Frederico Barra de Moraes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119


r e v b r a s o r t o p . 2 0 1 7;5 2(1):1

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

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Editorial

SBOT and the relationship SBOT e o relacionamento

Harvard University has recently published a study reporting the follow-up of the lives of 724 people in the city of Boston, from university students to ordinary people, during 76 years of their lives. One of the authors is Waldinger – this reference may help those who are interested in locating this study. The lives of these people were extremely varied, and the group even featured a United States president. Some had serious legal problems, others became very wealthy, and most lead a common life. The intent of the study was to assess what the most important element in the lives of these people was, and the conclusion was that relationships were the most important thing in the lives of most of the people studied. Wealth, poverty, and status or lack thereof was not as important as relationships and friendships. We have recently returned from the 48th Brazilian Congress of Orthopedics and Traumatology (Congresso Brasileiro de Ortopedia e Traumatologia [CBOT]), after three days of socializing in which I was able to properly appreciate the value of this Harvard study. In fact, the 4000 participants went to the congress basically in search of professional relationships, as learning can be achieved through other sources, unlike conviviality. I heard some theorists and prophets of the apocalypse saying that the age of congresses will end, that we should host the CBOT every two years, that the manufacturers will host their own conferences, and so many other idiocies that I could not register. We had a beautiful congress. For reasons that do not bear discussing in this editorial, the organization hosted the congress in a single space, divided only by the sound provided by headphones. Thus, a huge area was divided into six segments from the center; in each of them, the headphones would only transmit the sound of that segment. A questionable system, which raised one constant criticism:

When I have the headphones on, I cannot talk to the person next to me, and it is hard to ask questions. That is, I cannot create relations. Just as the Harvard study demonstrated, relationships are the backbone of our associations, and it will be through them that we will have more strength to continue to host CBOTs and become stronger. Manufacturers are well advised and know how to reach us. A reduction in the interest of surgical supplies distributors was indeed observed, but there was a significant increase in the interest of pharmaceutical industries, in search of our prescription strength. I believe that the regrettable episodes that occurred due to an incorrect reading by the distributors of surgical material, together with the poor remuneration of the physicians, are still the main cause of this reduction, disguised in the word “compliance.” This episode will surely be overcome, as it is inconceivable that an industry with so many new things to demonstrate and be used by us would not participate in a congress with 4000–5000 users of its products, concentrated in a single environment with the intention of learning. SBOT is a great promoter of relationships, and should continue to do so; otherwise, it will lose its strength. Our eventual sponsors will once again understand that the best way to relate to us is to occupy the spaces destined for them in our continuing medical education programs, the congresses. Gilberto Luis Camanho Revista Brasileira de Ortopedia E-mail: gilbertocamanho@uol.com.br 2255-4971/© 2017 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). http://dx.doi.org/10.1016/j.rboe.2017.01.002


r e v b r a s o r t o p . 2 0 1 7;5 2(1):2–10

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

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Update Article

Regenerative potential of the cartilaginous tissue in mesenchymal stem cells: update, limitations, and challenges夽 Ivana Beatrice Mânica da Cruz a,b , Antônio Lourenc¸o Severo c , Verônica Farina Azzolin b , Luiz Filipe Machado Garcia b , André Kuhn c , Osvandré Lech c,∗ a

Universidade Federal de Santa Maria (UFSM), Centro de Ciências da Saúde, Santa Maria, RS, Brazil Universidade Federal de Santa Maria (UFSM), Laboratório de Biogenômica, Santa Maria, RS, Brazil c Universidade Federal da Fronteira Sul (UFFS), Hospital São Vicente de Paulo, Instituto de Ortopedia e Traumatologia, Passo Fundo, RS, Brazil b

a r t i c l e

i n f o

a b s t r a c t

Article history:

Advances in the studies with adult mesenchymal stem cells (MSCs) have turned tissue

Received 12 February 2016

regenerative therapy into a promising tool in many areas of medicine. In orthopedics, one of

Accepted 15 February 2016

the main challenges has been the regeneration of cartilage tissue, mainly in diarthroses. In

Available online 6 December 2016

the induction of the MSCs, in addition to cytodifferentiation, the microenvironmental context of the tissue to be regenerated and an appropriate spatial arrangement are extremely

Keywords:

important factors. Furthermore, it is known that MSC differentiation is fundamentally

Stem cells

determined by mechanisms such as cell proliferation (mitosis), biochemical-molecular

Cartilaginous tissue

interactions, movement, cell adhesion, and apoptosis. Although the use of MSCs for car-

Regenerative potential

tilage regeneration remains at a research level, there are important questions to be resolved in order to make this therapy efficient and safe. It is known, for instance, that the expansion of chondrocytes in cultivation, needed to increase the number of cells, could end up producing fibrocartilage instead of hyaline cartilage. However, the latest results are promising. In 2014, the first stage I/II clinical trial to evaluate the efficacy and safety of the intra-articular injection of MSCs in femorotibial cartilage regeneration was published, indicating a decrease in injured areas. One issue to be explored is how many modifications in the articulate inflammatory environment could induce differentiation of MSCs already allocated in that region. Such issue arose from studies that suggested that the suppression of the inflammation may increase the efficiency of tissue regeneration. Considering the complexity of the events related to the chondrogenesis and cartilage repair, it can be concluded that the road ahead is still long, and that further studies are needed. © 2016 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

夽 Study conducted at the Institute of Orthopedics and Traumatology of Passo Fundo, Passo Fundo, and at the Health Sciences Center, Universidade Federal de Santa Maria (UFSM), Santa Maria, RS, Brazil. ∗ Corresponding author. E-mails: lech@lech.med.br, ensino@iotrs.com.br (O. Lech). http://dx.doi.org/10.1016/j.rboe.2016.11.005 2255-4971/© 2016 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).


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3

Potencial regenerativo do tecido cartilaginoso por células-tronco mesenquimais: atualizac¸ão, limitac¸ões e desafios r e s u m o Palavras-chave:

Os avanc¸os nos estudos com células-tronco mesenquimais (CTMs) adultas tornou a terapia

Células-tronco

regenerativa tecidual uma ferramenta promissora em diversas áreas da medicina. Na orto-

Tecido cartilaginoso

pedia, um dos principais desafios tem sido a regenerac¸ão do tecido cartilaginoso, sobretudo

Potencial regenerativo

em diartroses. Na induc¸ão de CTMs, além da citodiferenciac¸ão, o contexto microambiental do tecido a ser regenerado, bem como uma disposic¸ão espacial adequada, são fatores de extrema importância. Além disso, sabe-se que a diferenciac¸ão das CTMs é basicamente determinada por mecanismos como proliferac¸ão celular (mitose), interac¸ões bioquímicomoleculares, movimento, adesão celular e apoptose. Apesar de o uso de CTMs para a regenerac¸ão da cartilagem estar ainda em âmbito de pesquisa, existem questões importantes a serem resolvidas para tornar essa terapêutica eficaz e segura. Sabe-se, por exemplo, que a expansão de condrócitos em cultura, necessária para aumentar o número de células, pode produzir fibrocartilagem, e não cartilagem hialina. No entanto, os últimos resultados são promissores. Em 2014, foi publicado o primeiro ensaio clínico fase I/II para avaliar a eficácia e a seguranc¸a da injec¸ão intra-articular de CTMs na regenerac¸ão de cartilagem femorotibial e houve uma diminuic¸ão das áreas lesadas. Uma questão a ser explorada é o quanto modificac¸ões no próprio ambiente inflamatório articular poderiam induzir a diferenciac¸ão de CTMs já alocadas naquela região. Tal incógnita parte do princípio de estudos que sugerem que a supressão da inflamac¸ão articular aumentaria, potencialmente, a eficiência da regenerac¸ão tecidual. Considerando a complexidade dos eventos relacionados à condrogênese e ao reparo da cartilagem, conclui-se que o caminho ainda é longo, são necessárias pesquisas complementares. © 2016 Publicado por Elsevier Editora Ltda. em nome de Sociedade Brasileira de Ortopedia e Traumatologia. Este e´ um artigo Open Access sob uma licenc¸a CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction The human body fundamentally originates from embryonic stem cells: ectoderm, mesoderm, and endoderm. It is from these three leaflets that the 230 cell types found in the body are differentiated. In a differentiated organism, many tissues retain adult stem cell lines that work in tissue replacement and regeneration; the most abundant ones are of mesodermal origin, the mesenchymal stem cells (MSCs). MSCs are found in various places in the body, such as in the red bone marrow, hair follicles, muscle, umbilical cord, dental pulp, adipose tissue, bone, and cartilage, among others.1 With the increased knowledge on adult MSCs, their clinical use for tissue regeneration has become quite attractive. However, understanding and effectively and safely handling MSCs is still a considerable challenge, especially in tissues with difficult regeneration, such as cartilage. In this context, this review aimed to provide an update on the main processes related to morphodifferentiation and its potential role in the regeneration of cartilage tissue. Therefore, the information contained herein is based on scientific journal articles indexed in the databases of PubMed-MEDLINE and SciELO.

Cartilaginous tissue and challenges for regeneration In structural terms, the articular cartilage is rich in extracellular matrix, in which chondrocytes are distributed, whether isolated or arranged in clonal groups in small cell colonies.2 Chondrocytes are responsible for secreting cartilage matrix components such as collagen, proteoglycans, and glycoproteins. Cartilage tissue receives nutrition via capillaries contained in the perichondrium, a connective tissue that surrounds the cartilage and has adult MSCs termed chondroblasts. Nonetheless, as the cartilages lining the bones of movable joints do not have perichondrium, they receive nutrition through the synovial fluid present in the joint cavities. Synovial fluid is a plasma ultrafiltrate that passes through the synovial membrane, where it receives mucopolysaccharides that contain hyaluronic acid and a small amount of high molecular weight proteins. Therefore, even with a large amount of collagen protein, the small amount of cellular components in cartilage tissue hinders its regeneration capability leading repetitive joint injuries toward a tendency to become chronic.3


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In order to understand the role of MSCs in adult tissue regeneration, it is important to remember that the human organism is made of cells that have distinct differentiation and functions.4 It should be noted that tissue regeneration is not only focused on the induction of undifferentiated MSCs in a differentiated cell. Each type of tissue has an extracellular matrix, with a key role in body homeostasis. Thus, the microenvironmental context (extracellular matrix) of the tissue being regenerated must be taken into consideration. Five causal mechanisms are crucial for cell differentiation in tissues and organs, as well as the tissue regeneration process itself, namely: cell proliferation (mitosis), biochemical and molecular interactions, movement, cell adhesion, and apoptosis. As these mechanisms are of great importance for handling MSCs with the perspective of developing cartilaginous tissue regeneration techniques, they will be the focus of this review.

Proliferation and cellular senescence To understand in greater depth the biology of MSCs, it is necessary to understand some of the mechanisms associated with the cell cycle. Eukaryotic cells divide by mitosis, considered the final stage of the cycle, in which the two newly born cells will perform their respective metabolic functions. Nonetheless, the mitotic division is not an unlimited process. As they divide, most specialized cells lose their proliferative capacity. Some cells that will no longer divide remain constantly in the gap1 phase (G1) of mitosis, which is the case of the vast majority of chondrocytes. New chondrocytes are formed from chondroblasts from the perichondrium; it is through this mechanism that the cartilage tissue is renewed, albeit slowly when compared, for example, with bone tissue. Conversely, some mature specialized cells undergo the entire cell cycle until they lose their ability to proliferate, by a process termed replicative senescence or cellular aging (Fig. 1). Cellular aging is triggered by changes occurring in the terminal region of the chromosome, known as telomere, which comprises a single-stranded deoxyribonucleic acid (DNA) molecule, in contrast with the double-stranded structure present in the remainder of the genetic material. Telomeric DNA consists of a sequence of six nucleotides – thymine, thymine, adenine, guanine, guanine, guanine (TTAGGG) – which repeats thousands of times. This chromosomal region is synthesized by the reverse transcriptase enzyme telomerase, which synthesizes DNA and uses a ribonucleic acid (RNA) molecule as a scaffold. In cell division, a small telomere shortening is always observed. In embryonic cells, the telomere is reconstituted by the action of telomerase. In specialized cells, telomerase gene is silenced; therefore, when telomeric shortening occurs, telomere reconstitution is not possible. Over the divisions (approximately 50–80 mitoses), the telomere becomes too short and starts to inhibit mitosis, thus constituting cellular senescence or Hayflick limit. Unlike specialized cells, in MSCs, the telomerase gene is active; therefore, within the body, such cells do not present

a sharp cellular aging. However, the MSC proliferation rate is extremely low and thus the number of these cells in body tissues is quite limited. This is an important challenge to be overcome in regenerative therapy. Some studies have suggested that the induction of in vitro MSC proliferation can be done by exposure to reactive oxygen species (ROS) molecules, such as hydrogen peroxide. The study by Bornes et al.5 showed that in vitro chondrogenesis of MSCs induced in sheep bone marrow increased proliferation and cell differentiation. However, it appears that, despite the increase in cell growth, cells start to present significant DNA damage, indicating chromosomal instability.6 The study by Machado et al.6 supports the results of the research conducted by Brand et al.,7 suggesting that in vitro exposure to oxidative stress induces cellular senescence in chondrocytes. In turn, the study by Machado et al.6 showed a reversal of replicative senescence markers in human MSCs collected through liposuction by supplementing culture medium with a hydroalcoholic guarana (Paullinia cupana) extract. The guarana seed, used for the production of the extract, is rich in caffeine, theophylline, theobromine, and catechins. Another very surprising result was described by Sadeghiet et al.,8 who investigated the effect of estrogen supplementation on chondrogenesis induced in MSCs derived from adipose tissue. It was observed that the presence of estrogen had negative effects on the chondrogenesis process by inhibiting the expression of the collagen 2 gene and reducing the expression of the aggrecan protein gene.

Cell differentiation All body cells and tissues are formed from the zygote, in a highly controlled transcriptional regulation process. In general, the DNA of the eukaryotic gene has an initial sequence of nucleotides known as the promoter region. It is in this region that the signaling molecules bind, allow (or not) the transcription, and determining the amount of RNA to be transcribed. This modulation is known as gene regulation, a mechanism through which each cell type is formed by the production of proteins in different shapes and quantities. Endogenous molecules, such as transcription factors and hormones, can differentially regulate genes. Likewise, molecules derived from the diet, such as resveratrol (present in grapes), induce the production of sirtuins, proteins that increase cell life. Under in vitro conditions, the induction of MSC differentiation in the presence of certain molecules is very well known. Notwithstanding, when MSCs are placed in an injured organ, it is not always possible to know whether the microenvironmental conditions will favor the induction of differentiation (even when the inducing agents are co-inserted with the cells). Other molecules that regulate the maintenance of the undifferentiated state of MSCs, ensuring their pluripotentiality and self-renewal, have been identified. This is the case of Oct-4, Nanog, and Sox-2, which are found both in humans and in mice.9 When this protein is no longer expressed, the cell has entered the process of differentiation.10


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A

Epithelial cell

Chondrocyte

Cells (number)

Cells (number)

Go/G1

G2/M

S phase

DNA content (fluorescence)

DNA content (fluorescence)

B Chondrocyte

Articular cartilage composition

Type 2 collagen

H2O Proteoglycans

Hyaluronic acid

Binding protein

Added component of matrix proteoglycan

Fig. 1 – Comparison of the cell cycle of an epithelial cell and of a chondrocyte, assessed by flow cytometry. (A) In an epithelial tissue, cells are found in phase G0/G1, S, and G2/M, while in the cartilage tissue most chondrocytes are in the G1 phase. Only chondroblasts from perichondrium will present a complete cell cycle. (B) Chondrocytes, once formed, are usually clustered in about eight cells that continuously secrete an extracellular matrix composed mainly of type 2 collagen, proteoglycans, and hyaluronic acid.

To induce chondrogenic differentiation, MSCs are cultured without the presence of fetal or adult serum (animal or human), which is typically used to nourish the cells, and upon exposure to growth factor b3.11 Thus, the cells develop a multilayer with a proteoglycan-rich extracellular matrix. In 10–14-day cultures, cells begin to produce type 2 collagen, characteristic of the articular cartilage. Moreover, they present positive surface markers for chondrocytes and typical cell gaps visible at optical microscopy. The chondrocytes remain viable until approximately 90 days after initiation of differentiation.12

Chondrogenesis is induced through various inducing molecules, especially through supplementation of culture medium with TFN-␤3, IGF-1, BMP-2, and BMP-6. Chondrodifferentiation induction is confirmed by the identification of markers such as type 2 collagen, Sox-9, and aggrecan, through analysis of gene expression using real-time quantitative polymerase chain reaction (PCR). In addition to differential regulation of gene expression, methylation is an epigenetic modification that usually occurs in the promoter region of the gene to be silenced. This process is mediated by the DNA-methylases (DNMTs) enzymes.


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Genes can also be silenced via the acetylation process, which prevents histones from becoming relaxed when the DNA is exposed to transcriptional regulation.13

and stem cells appears to be the most promising option, although further studies are needed to confirm the efficacy and safety of this method.

Adhesion and cell movement, and production of scaffolds

Apoptosis and inflammation in cartilage degeneration and regeneration

During embryogenesis, in addition to differentiation process, cells need to migrate or grow toward a specific location and remain there to perform their roles. Cell adhesion and movement, which occur by chemical and spatial signals, are of vital importance for combining individual cells in a threedimensional format, such as in body tissues and organs. Cell adhesion mechanisms are highly regulated during tissue morphogenesis. Reversible phosphorylation by protein kinase C (PKC) is a key event in cell adhesion and migration during chondrogenesis.14 Adhesion and cell movement are also related to the architectural formation of tissues and organs. In vitro studies have shown that MSCs respond to their environmental format and that in vivo cells are also induced to differentiate by the topographical characteristics of the tissue in which they are arranged. Such evidence boosted the field of tissue engineering, which combines cellular therapy with use of biomaterial scaffolds. This area involves the use of compatible and biodegradable materials that act as a matrix for cell growth. Scaffolds are simple media in which cells are cultivated to create a tissue in vitro. Apart from providing mechanical support and spatial orientation for cell growth and differentiation, the structure of the scaffold must allow the transport of nutrients, metabolites, growth factors, and other important regulatory molecules to the cells and extracellular matrix. Scaffolds can be produced from natural or synthetic molecules. Among natural biomaterials, collagen, hyaluronic acid, hydroxyapatite, and glycosaminoglycans are noteworthy.15 Electrospinning produces scaffolds formed by fibers that can physically mimic a natural extracellular matrix. This condition creates a suitable microenvironment for cell and tissue differentiation. The creation of fibers of different diameters by electrospinning is performed using polymer solutions applied to a magnetic field. The polylactic-co-glycolic acid (PLGA) polymer has been widely used in the production of scaffolds by electrospinning, because it is biodegradable, bioabsorbable, and biocompatible. The use of PLGA-based scaffolds has been approved in humans by the US Food and Drug Administration (FDA). Investigations have shown that this biomaterial can induce growth in different cell types, such as fibroblasts, osteoblasts, and chondrocytes.16 Another technology derived from electrospinning is bioelectrospinning, which uses the processing of cellular suspensions that are subjected to a high intensity electric field and induced to pass through a sharp needle, generating fine droplets that contain cells. Thus, the scaffold is built with cells already integrated. This technique allows for a homogeneous distribution of MSCs in the scaffold and therefore, a greater regenerative potential.15 Considering the limited regenerative capacity of cartilaginous tissue, the mixture of biomaterials

Cells have the ability to self-regulate not only the rate of proliferation and differentiation, but also their death in many situations, from an event known as apoptosis or programmed cell death. Unlike necrosis and autophagy, apoptosis is a highly coordinated mechanism and does not cause a specific inflammatory process.17 However, evidence shows that chronic inflammation induces disorganization of the extracellular matrix and apoptosis of chondrocytes, which consequently leads to cartilage destruction. This occurs in many degenerative diseases, such as rheumatoid arthritis and osteoarthritis.18 It is known that monocytes/macrophages are essential components of the innate immune system and have a variety of functions. They control the onset and resolution of inflammation by phagocytosis, release of inflammatory cytokines, reactive oxygen species (ROS), and activation of the acquired immune system. Under normal circumstances, monocytes circulate in the bloodstream for a short period before spontaneously entering in apoptosis. The presence of stimulatory factors inhibits the apoptosis of monocytes that differentiate into macrophages, which can live for a long time in tissues.19,20 Macrophages produce many substances that are relevant to immune response and coordinate the inflammatory process (inflammatory cytokines L-1␤, IL-6, TNF␣, and the anti-inflammatory cytokine IL-10). Furthermore, they produce factors that are critical in combating microorganisms (such as oxygen metabolites and nitric oxide) and factors that promote tissue repair (such as fibroblast growth factor), among others.21 Nowadays, two types of macrophage activation in the inflammatory response are recognized: the “classical activation” and “alternative activation” (Fig. 2). In this process, when an increase in the activation of M1 macrophages compared to M2 macrophages is observed, there will be poor tissue repair with continued destruction in tissues with low regenerative capacity, such as cartilage. In osteoarthritis, the occurrence of intra-articular inflammation with synovitis indicates that synovial fluid can be the source of inflammatory cytokines and proteolytic enzymes. In synovitis, there is release of proinflammatory cytokines such as IL-1␤ and TNF␤; these molecules have an inhibitory effect on the type 2 collagen and aggrecan production by chondrocytes. Furthermore, these cytokines cause the release of metalloproteinases and aggrecanases that degrade the matrix, which results in the destruction of cartilage. Other molecules, such as M IL-1␤ and TNF␤, may also be involved in apoptosis of chondrocytes by increasing the release of nitric oxide and prostaglandin E2 (PGE2).18 Although there are MSCs in joint tissue, synovial membrane, tendons, and cartilages, the induction of these cells


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2

Interferon gamma (IFNγ)

Antigen + natural killer cells

Monocytes Classical pathway

Alternative pathway

1 IL-1B IL-10 TNFa

IL-10 4

M1 macrophages 3

M2 macrophages Phagocytosis Tissue damage

Tissue regeneration

Fig. 2 – Macrophages activated by the classical pathway act as inflammation inducers and are called M1. These macrophages produce high levels of IL-2 and low levels of IL-10. Studies have also shown that the activation of macrophages is dependent on the stimulation of inflammatory cytokines produced by helper lymphocytes or NK cells, in particular gamma interferon (INF␥). The activated macrophages that have microbial and tumoricidal activity are characterized by secreting large amounts of cytokines and proinflammatory mediators. In this inflammatory response, these macrophages release proinflammatory cytokines, such as IL-1, IL-6, TNF␣, and also produce reactive oxygen species (ROS) such as superoxide anion and hydrogen peroxide, as well as reactive intermediates, such as nitric oxide. Shortly after phagocytosis, the macrophages die by programmed cell death, known as apoptosis. The “alternative activation” involves the stimulation of macrophages by molecules such as the interleukins IL-4 and IL-13, which leads to an increase in IL-10 anti-inflammatory cytokine levels and induces tissue repair (anti-inflammatory response). In the body, the proinflammatory immune response is usually followed by an anti-inflammatory immune response. This is important for tissue repair after a microbial infection or physical injury. The imbalance between the two responses can lead to chronic diseases such as osteoarthritis.

to regenerate cartilage tissue has not been fully elucidated. It is known that the chondrogenesis process is triggered by factors such as bone morphogenetic proteins (BMPS) and growth factors such as TGF-␤. These factors act on genes, such as transcription factor SRY-box 9 (Sox9), which is essential for chondrocyte differentiation. Sox9 controls the transcription of genes that synthesize extracellular matrix molecules, such as type 2 collagen and aggrecan, while also suppressing the formation of hypertrophic chondrocytes. Chronic inflammatory processes appear to negatively influence the differentiation of MSCs into chondrocytes. In this case, the cytokine IL1␤ and TNF-a␤ have a suppressive effect on chondrogenesis. This is because these cytokines inhibit the expression of the Sox9 gene by suppressing the expression of the TFG-␤ molecule (an important initiation factor in the differentiation of chondrocytes) and increasing the expression of the Smad7 molecule (a chondrogenesis inhibitor). The inflammatory cytokine IL-17, which is a key molecule in chronic inflammation processes, also has the ability to suppress chondrogenesis. This molecule suppresses the phosphorylation of Sox9 protein and prevents its regenerative action.22 Therefore, considering all the evidence on the important role of chronic inflammation in the regenerative process of

cartilage, it is clear that, in an inflammatory environment with high levels of IL-1␤, TNF␤, and IL-17, MSCs may not respond adequately to regenerative therapy. This is because these cells can be induced to apoptosis before they differentiate into chondrocytes.

Clinical applications of stem cells in cartilage tissue regeneration Many preclinical and clinical studies involving potential cartilage regeneration with MSCs are conducted for various diseases, including osteoarthritis. Although the use of MSCs for cartilage regeneration is still at the research level, there are important issues to be resolved to make this an effective and safe therapy. The implantation of chondrocytes from one region of the body to the injured region has the disadvantage of requiring two surgical procedures. The need for growing chondrocytes in culture to increase the number of cells to be implanted is also another major problem, as these cells may dedifferentiate and produce fibrocartilage instead of hyaline cartilage.23–26 In an attempt to minimize these problems, some authors began to research the effect of intra-articular MSC injection in the treatment of osteoarthritis. This procedure apparently


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Eligible patients=22

18 patients allocated to MSCs (IIA- MSC) intra-articular injection

09 allocated to phase 1

09 allocated to phase 1

03 IIA- MSC low dose

Follow-up: 6 months

03 IIA- MSC moderate dose

Follow-up: 6 months

03 IIA-CTM high dose

03 IIA- MSC high dose

Follow-up: 6 months

Follow-up: 6 months 2 IIA- MSC high dose

Fig. 3 – Overall experimental design of the study by John et al.33 (2014), who assessed, in a phase I/II clinical trial the effect of intra-articular injection on the regeneration of the knee cartilage in patients with osteoarthritis. MSCs were obtained from abdominal lipoaspirate, cultured in the laboratory, and injected in the joint after three weeks. Low dose = 1 × 107 ; moderate dose = 5 × 107 ; high dose = 1 × 108 cells in saline. Pharmacological therapy was discontinued, with the exception of ketoprofen administration.

has many advantages, since it would avoid surgery in many cases.27–32 Nonetheless, the first phase I/II clinical trial to evaluate the efficacy and safety of intra-articular injection in knee articular cartilage regeneration through clinical, laboratory, radiological, arthroscopic, and histological analyses was only published in 2014, by Jo et al. (Fig. 3).33 The injected MSCs were obtained by liposuction of subcutaneous abdominal fat; the obtained MSCs were tested for their viability, purity (with evaluation of CD31 markers, CD34, CD45), identity (with evaluation of CD73 markers, CD90), sterility, and lack of contamination with endotoxins or mycoplasma. The procedures for intra-articular injection were performed in the supine position with spinal anesthesia three weeks after liposuction. A standard arthroscopic examination was performed and the knee articular cartilage lesions were measured with a calibrated and graduated arthroscopic probe, in accordance with the International Cartilage Repair Society (ICRS) classification of cartilage lesions. The MSCs diluted in saline were injected, without debridement, synovectomy, or meniscectomy during the procedure. No serious adverse effects were reported and the quality of knee condition was assessed by the Western Ontario and McMaster Universities Arthritis Index (WOMAC), and showed significant improvements in patients receiving high concentration of intra-articular MSCs. The cartilage defect size decreased in the medial femoral and tibial condyles, and also in the groups receiving high doses of MSCs. Thus, the authors concluded that intra-articular injection of 1 × 108

cells improved the function of osteoarthritic knee and pain, without causing adverse effects, through the reduction of cartilage defects by regenerating tissue similar to hyaline cartilage.

Final considerations Although the results of Joet et al.33 are encouraging, Kondo et al.,18 in their review on the subject, pointed out that the results of additional studies involving multiple protocols are needed in order to truly prove the efficacy and safety of this procedure. Furthermore, these latest authors commented that further investigations are being conducted, aiming to improve efficiency of MSC differentiation into chondrocytes by analyzing the supplementation of culture media with various regulatory molecules, such as TGF-␤1–3; BMP-2, -4, -6, -7; FGF-2, and IGF-1, among others. In addition to these, some compounds such as dexamethasone and ATP have shown a positive effect on chondrogenesis. Another important question concerns the inflammatory microenvironmental conditions of the MSC injection site. Evidence shows that MSCs have immunosuppressive and anti-inflammatory effects. Nonetheless, suppression of joint inflammation could potentially increase the efficiency of tissue regeneration. In this case, what remains unclear, requiring further exploration in future studies, is how changes in the inflammatory


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joint environment itself could induce the differentiation of MSCs already allocated in the region. The answer to this question could lead to the development of regenerative techniques associated with the already well-established surgical techniques, without transplantation of MSCs to other parts of the body. However, considering the complexity of the events related to chondrogenesis and cartilage repair, the road ahead is still long and a considerable volume of additional research is needed.

Conflicts of interest The authors declare no conflicts of interest.

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1. Baksh D, Song L, Tuan RS. Adult mesenchymal stem cells: characterization, differentiation, and application in cell and gene therapy. J Cell Mol Med. 2004;8(3):301–16. 2. Amorin B, Valim VS, Lemos NE, Moraes Júnior L, Silva AMP, Silva MAL, et al. Mesenchymal stem cells – characterization, cultivation, immunological properties, and clinical applications. Rev HCPA Fac Med Univ Fed Rio Gd do Sul. 2012;32(1):71–81. 3. Alberts B, Bray D, Lewis J, Raff M, Roberts K, Watson JD. Molecular biology of the cell. 3rd ed. New York: Garland Publishing; 1994. p. 971–84. The extracellular matrix of animals. 4. Bobis S, Jarocha D, Majka M. Mesenchymal stem cells: characteristics and clinical applications. Folia Histochem Cytobiol. 2006;44(4):215–30. 5. Bornes TD, Jomha NM, Sierra AM, Adesida AB. Hypoxic culture of bone marrow-derived mesenchymal stromal stem cells differentially enhances in vitro chondrogenesis within cell-seeded collagen and hyaluronic acid porous scaffolds. Stem Cell Res Ther. 2015;6(84):1–17. 6. Machado AK, Cadoná FC, Azzolin VF, Dornelles EB, Barbisan F, Ribeiro EE, et al. Guaraná (Paullinia cupana) improves the proliferation and oxidative metabolism of senescent adipocyte stem cells derived from human lipoaspirates. Food Res Int. 2015;67:426–33. 7. Brandl A, Hartmann A, Bechmann V, Graf B, Nerlich M, Angele P. Oxidative stress induces senescence in chondrocytes. J Orthop Res. 2011;29(7):1114–20. 8. Sadeghi F, Esfandiari E, Hashemibeni B, Atef F, Salehi H, Shabani F. The effect of estrogen on the expression of cartilage-specific genes in the chondrogenesis process of adipose-derived stem cells. Adv Biomed Res. 2015; 4:43. 9. Rodda DJ, Chew JL, Lim LH, Loh YH, Wang B, Ng HH, et al. Transcriptional regulation of nanog by OCT4 and SOX2. J Biol Chem. 2005;280(26):24731–7. 10. Lee J, Kim HK, Rho JY, Han YM, Kim J. The human OCT-4 isoforms differ in their ability to confer self-renewal. J Biol Chem. 2006;281(44):33554–65. 11. Mackay AM, Beck SC, Murphy JM, Barry FP, Chichester CO, Pittenger MF. Chondrogenic differentiation of cultured human mesenchymal stem cells from marrow. Tissue Eng. 1998;4(4):415–28. 12. Pittenger MF, Mackay AM, Beck SC, Jaiswal RK, Douglas R, Mosca JD, et al. Multilineage potential of adult human mesenchymal stem cells. Science. 1999;284(5411): 143–7.

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13. Tamburini BA, Tyler JK. Localized histone acetylation and deacetylation triggered by the homologous recombination pathway of double-strand DNA repair. Mol Cell Biol. 2005;25(12):4903–13. 14. Matta C, Mobasheri A. Regulation of chondrogenesis by protein kinase C: emerging new roles in calcium signalling. Cell Signal. 2014;26(5):979–1000. 15. Garg T, Goyal AK. Biomaterial-based scaffolds – current status and future directions. Expert Opin Drug Deliv. 2014;11(5):767–89. 16. Sachlos E, Reis N, Ainsley C, Derby B, Czernuszka JT. Novel collagen scaffolds with predefined internal morphology made by solid freeform fabrication. Biomaterials. 2003;24(8): 1487–97. 17. Sorrentino G, Comel A, Mantovani F, Del Sal G. Regulation of mitochondrial apoptosis by Pin1 in cancer and neurodegeneration. Mitochondrion. 2014;19 Pt A:88–96. 18. Kondo M, Yamaoka K, Tanaka Y. Acquiring chondrocyte phenotype from human mesenchymal stem cells under inflammatory conditions. Int J Mol Sci. 2014;15(11):21270–85. 19. Wiktor-Jedrzejczak W, Gordon S. Cytokine regulation of the macrophage (M phi) system studied using the colony stimulating factor-1-deficient op/op mouse. Physiol Rev. 1996;76(4):927–47. 20. Savill J, Fadok V. Corpse clearance defines the meaning of cell death. Nature. 2000;407(6805):784–8. 21. Cruvinel WM, Mesquita Júnior D, Araújo JAP, Catelan TTT, Souza AWS, Silva NP, et al. Sistema imunitário – Parte I: Fundamentos da imunidade inata com ênfase nos mecanismos moleculares e celulares da resposta inflamatória. Rev Bras Reumatol. 2010;50(4):434–61. 22. Morisset S, Frisbie DD, Robbins PD, Nixon AJ, McIlwraith CW. IL-1ra/IGF-1 gene therapy modulates repair of microfractured chondral defects. Clin Orthop Relat Res. 2007;462: 221–8. 23. von der Mark K, Gauss V, von der Mark H, Müller P. Relationship between cell shape and type of collagen synthesised as chondrocytes lose their cartilage phenotype in culture. Nature. 1977;267(5611):531–2. 24. Brittberg M, Lindahl A, Nilsson A, Ohlsson C, Isaksson O, Peterson L. Treatment of deep cartilage defects in the knee with autologous chondrocyte transplantation. N Engl J Med. 1994;331(14):889–95. 25. Knutsen G, Drogset JO, Engebretsen L, Grøntvedt T, Isaksen V, Ludvigsen TC, et al. A randomized trial comparing autologous chondrocyte implantation with microfracture. Findings at five years. J Bone Jt Surg Am. 2007;89(10):2105–12. 26. Vanlauwe J, Saris DB, Victor J, Almqvist KF, Bellemans J, Luyten FP. Five-year outcome of characterized chondrocyte implantation versus microfracture for symptomatic cartilage defects of the knee: early treatment matters. Am J Sports Med. 2011;39(12):2566–74. 27. Murphy JM, Fink DJ, Hunziker EB, Barry FP. Stem cell therapy in a caprine model of osteoarthritis. Arthritis Rheum. 2003;48(12):3464–74. 28. Lee KB, Hui JH, Song IC, Ardany L, Lee EH. Injectable mesenchymal stem cell therapy for large cartilage defects – a porcine model. Stem Cells. 2007;25(11): 2964–71. 29. Centeno CJ, Busse D, Kisiday J, Keohan C, Freeman M, Karli D. Increased knee cartilage volume in degenerative joint disease using percutaneously implanted, autologous mesenchymal stem cells. Pain Physician. 2008;11(3):343–53. 30. Mokbel AN, El Tookhy OS, Shamaa AA, Rashed LA, Sabry D, El Sayed AM. Homing and reparative effect of intra-articular injection of autologus mesenchymal stem cells in osteoarthritic animal model. BMC Musculoskelet Disord. 2011;12:259.


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31. Davatchi F, Abdollahi BS, Mohyeddin M, Shahram F, Nikbin B. Mesenchymal stem cell therapy for knee osteoarthritis. Preliminary report of four patients. Int J Rheum Dis. 2011;14(2):211–5. 32. Emadedin M, Aghdami N, Taghiyar L, Fazeli R, Moghadasali R, Jahangir S, et al. Intra-articular injection of autologous

mesenchymal stem cells in six patients with knee osteoarthritis. Arch Iran Med. 2012;15(7):422–8. 33. Jo CH, Lee YG, Shin WH, Kim H, Chai JW, Jeong EC, et al. Intra-articular injection of mesenchymal stem cells for the treatment of osteoarthritis of the knee: a proof-of-concept clinical trial. Stem Cells. 2014;32(5):1254–66.


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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

www.rbo.org.br

Review Article

Rehabilitation of hamstring muscle injuries: a literature review夽 Gabriel Amorim Ramos, Gustavo Gonc¸alves Arliani ∗ , Diego Costa Astur, Alberto de Castro Pochini, Benno Ejnisman, Moisés Cohen Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil

a r t i c l e

i n f o

a b s t r a c t

Article history:

Hamstring injuries are among the most frequent in sports. The high relapse rate is a chal-

Received 4 December 2015

lenge for sports medicine and has a great impact on athletes and sport teams. The treatment

Accepted 24 February 2016

goal is to provide the athlete the same functional level as before the injury. Thus, functional

Available online 15 December 2016

rehabilitation is very important to the success of the treatment. Currently, several physical

Keywords:

therapy, therapeutic ultrasound, therapeutic exercise, and manual therapy. However, the

Muscle skeletal/injuries

evidence of the effectiveness of these modalities in muscle injuries is not fully established

therapy modalities are used, according to the stage of the lesion, such as cryotherapy, laser

Athletic injuries

due to the little scientific research on the topic. This article presents an overview of the

Muscle stretching exercises

physiotherapy approach in the rehabilitation of hamstring muscle injuries.

Physical therapy modalities

© 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Reabilitac¸ão nas lesões musculares dos isquiotibiais: revisão da literatura r e s u m o Palavras-chave:

As lesões dos isquiotibiais estão entre as mais frequentes do esporte. A alta taxa de recidivas

Músculo esquelético/lesões

representa um desafio para a medicina esportiva e apresenta grande impacto para atletas e

Traumatismos em atletas

clubes esportivos. O objetivo do tratamento é proporcionar ao atleta o mesmo nível funcional

Exercícios de alongamento

anterior à lesão. Dessa forma, a reabilitac¸ão funcional é muito importante para o sucesso do

muscular

tratamento. Atualmente, usam-se várias modalidades fisioterápicas de acordo com o estágio

Modalidades de fisioterapia

da lesão: crioterapia, laserterapia, ultrassom terapêutico, terapia manual e cinesioterapia. Entretanto, as evidências da eficácia dessas modalidades nas lesões musculares ainda não estão completamente estabelecidas, devido à baixa investigac¸ão científica sobre o tema. O

夽 Study conducted at the Universidade Federal de São Paulo, Escola Paulista de Medicina, Centro de Traumatologia do Esporte, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil. ∗ Corresponding author. E-mail: ggarliani@hotmail.com (G.G. Arliani). http://dx.doi.org/10.1016/j.rboe.2016.12.002 2255-4971/© 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).


12

r e v b r a s o r t o p . 2 0 1 7;5 2(1):11–16

presente artigo apresenta uma revisão sobre a abordagem fisioterápica na reabilitac¸ão das lesões musculares de isquiotibiais. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Este e´ um artigo Open Access sob uma licenc¸a CC BY-NC-ND (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction Hamstring injuries are some of the most frequent in the field of sports medicine.1,2 A prospective study by Elkstrand et al.3 demonstrated that they account for 37% of muscle injuries in professional soccer players and for 25% of athletes’ absence in games. Other studies indicate that one-third of hamstring injuries relapse and that many of these relapses take place within the first two weeks after returning to sport.4,5 This high recurrence rate may be related to a combination of factors, such as ineffective rehabilitation and inadequate criteria for return to sport practice. The goals of hamstring injury rehabilitation are to achieve the same functional level observed prior to injury and to allow for the return to sports practice with minimal risk of recurrence.6 Many interventions are widely used to achieve full rehabilitation. These include PRICE (protection, rest, ice, compression, and elevation), to control the inflammatory process7 ; therapeutic exercises to strengthen and restore the functionality of the musculature8 ; photothermal therapy for inflammation modulation9 ; massage and mobilization to realign and relieve tension of soft tissues10 ; joint and nerve manual therapy11,12 ; and functional rehabilitation. However, evidence of the effectiveness of these treatment modalities is not yet fully established, due to the sparse scientific research on the subject. Therefore, the present study aimed to investigate the current evidence on physical therapy approaches used in the rehabilitation of hamstring injuries.

Methods A literature review in the databases PubMed, LILACS, SciELO, and the Cochrane Database of Systematic Reviews (Cochrane Library) was made. The following keywords were used: muscle injury, hamstrings injury, muscle strain, functional rehabilitation, and physical therapy. The inclusion criteria for this study were studies with high quality evidence, such as systematic reviews, meta-analyses, randomized controlled trials, and classical studies relevant to the proposed goals. The exclusion criteria were articles that did not match the proposed theme.

Classification Muscle injury is characterized by changes in the morphological and histochemical aspects that create a functionality deficit in the affected segment.13 There are two major forms of muscular injury in sports: muscle strain and contusion.14 Strain is the most common

muscle injury in sports, and is classified as follows: grade I, in which there is minimal structural disruption and rapid return to normal function; grade II, in which there is a partial rupture, with pain and some loss of function; and grade III, in which a complete tissue rupture is observed, with muscular retraction and functional disability.15 Ekstrand et al.3 demonstrated that hamstrings are the muscles most affected by this type of injury. The other form is muscle contusion, which is a direct result of external trauma forces, common in contact sports. It is characterized by the presence of pain, swelling, stiffness, and range of motion restriction.15 It can affect any muscle, but the quadriceps and the gastrocnemius are the most commonly affected.14 A new comprehensive classification system, known as the Munich consensus, was developed by specialists16 and distinguishes four types of injury. The first group is the functional muscle disorders, comprising type 1 (disorders related to overexertion) and type 2 (disorders of neuromuscular origin). These disorders are characterized by not presenting evidence of macroscopic lesions in the muscle fiber. The classification also includes structural muscle disorders, comprising type 3 (partial muscle injuries) and type 4 (total or subtotal lesions that may present tendon avulsion). In these cases, there is macroscopic evidence of injury, i.e., structural damage. Subclassifications are given for each type.

Injury mechanism Two specific mechanisms are described for hamstring injuries, which appear to influence the location and severity of the injury. Heiderscheit et al.6 demonstrated that, during terminal swing phase of running, the hamstrings absorb elastic energy to contract eccentrically and promote deceleration of the limb’s advance in preparation for the initial contact of the calcaneus. In this phase, muscles become more susceptible to damage; the biceps femoris muscle is the most affected, as it is more active than the semitendinosus and semimembranosus muscles.17,18 Another mechanism that commonly damages the proximal portion of the semitendinosus muscle is a movement of combined high power and extreme range of hip flexion with knee extension, which biomechanically matches the movements of kicking, running hurdles, and artistic dancing.19,20

Risk factors The proposed risk factors for hamstrings injuries are classified as modifiable and non-modifiable.21


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Modifiable factors comprise muscle imbalances, including the strength ratio of the quadriceps and hamstrings of the same limb, and the bilateral relationship of the hamstrings.22,23 Another factor is muscle fatigue, since studies have shown that the incidence of hamstring injuries is higher in the last stages of matches and competitive training, when the musculature is at a high level of fatigue.24,25 A hamstring flexibility deficit is also considered by some authors to be a risk factor,26,27 but it is not consensual, as other studies have shown that flexibility deficit was not associated with injury.28 During the rehabilitation process, the physical therapist should identify these factors so that the return of the athlete to sport practice can be more effective.21 Regarding the non-modifiable risk factors, history of previous hamstring injury is noteworthy, as many authors consider it to be the main risk factor for hamstring injury.29–31

Pathophysiology

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Therapeutic ultrasound (TUS) TUS is a commonly used resource in musculoskeletal injuries.38 According to Backer et al.,39 the acoustic vibration produced by TUS induces cellular changes that changes the concentration gradient of molecules, as well as calcium and potassium ions, which excites cellular activity. This event may result in several changes, such as increase in protein synthesis, secretion of mast cells, fibroblast proliferation, and angiogenesis stimulation, among others. Nonetheless, the effectiveness of TUS in muscle injury repairing process is still controversial. While some authors have observed positive results with use of TUS,40,41 others have not.36,42 Some factors, such as intensity and frequency of treatment with ultrasound, and, moreover, lack of calibration of the device and of a protocol for determining the specific dose for each individual contribute to the divergence of results.38

Low level laser therapy (LLLT) Jarvinen et al.32 described the stages of muscle injury healing: Step 1 destruction (three to seven days) – characterized by disruption and subsequent necrosis of myofibrils by hematoma formation in the space formed between the torn muscle and by proliferation of inflammatory cells. Step 2 repair (four to 21 days) – consists of phagocytosis of necrotic tissue, regeneration of myofibrils, and concomitant production of scar tissue, as well as vascular neoformation and nerve growth. Step 3 remodeling (14 days to 14 weeks) – period of maturation of the regenerated myofibrils, and reorganization of the muscle functional capacity. The physiotherapist needs to understand the healing process in order to use the adequate therapeutic approaches in the appropriate period, so that rehabilitation can be conducted properly.

Rehabilitation Cryotherapy The traditional treatment in acute muscle injury is described by the PRICE protocol.33,34 The most easily recognizable effect of cryotherapy is the reduction of tissue temperature. In fact, virtually all the effects observed in cryotherapy are direct results of the change in tissue temperature.35 These effects include reduced perfusion, reduced inflammatory signs (heat, redness, swelling, and pain), and reduced metabolic rate.7 It is believed that the most important goal of cryotherapy is the reduction of metabolic rate of the cold tissue. This reduction is beneficial, as it increases the ability of a tissue to survive the events of secondary injury following the primary trauma. Thus, the total amount of injured tissue is limited, reducing the time required to repair the damage and return to activity.7,36 The authors recommend cryotherapy for 20 minutes every two hours during the acute stage of muscular injuries.37

LLLT is a light source that differs from others because it is monochromatic, coherent in time and space, and collimated, which allows for a good tissue penetration.43 The high incidence of muscle injury has caused an increase in studies related to physical therapy resources that are involved in the injury healing process.44 Among the most widely used, LLLT is noteworthy, as it triggers the production of adenosine triphosphate (ATP),45 enhances the migration of satellite cells and fibroblasts, and promotes angiogenesis.46 These effects are essential to achieve more effective muscle regeneration and prevent tissue fibrosis.9 The conclusion of the most recent systematic review on the subject confirms these findings and highlights the positive effects of LLLT on muscle repair.47

Manual therapy This approach assesses and treats articular, neural, and muscular systems. The hand contact stimulates mechanoreceptors, which produce afferent impulses and cause neuromodulations in the central nervous system to provide an analgesic response and an improvement in muscle and joint function.48 Cibulka et al.11 hypothesized a relationship between hamstring injury and pelvic hypomobility. Their study observed a gain in torque in the flexor muscles as well as a faster return to sport in the experimental group, which received a traditional rehabilitation treatment of hamstring injuries, in addition to joint manipulations of the pelvis during treatment. Considering these facts, those authors recommend a detailed pelvic assessment in individuals with hamstring injury, as the patient may benefit from joint mobilizations. Another approach is neural mobilization, which is a set of manual therapy techniques that allow for controlled mobilization and stretching of the connective tissue surrounding the nerves and of the nerve itself, which in turn improves nerve conduction and its intrinsic mobility.49 Albeit an uncommon complication, some studies have reported that the formation of scar tissue after muscle injuries of the hamstrings can cause


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mobility deficit in the sciatic nerve.12 In a recent case study, Aggen and Reuteman50 reported this complication in an athlete who had suffered a grade III hamstring injury. In order to improve neural mobility and reduce its mechanical sensitivity, neural gliding techniques were initiated. Conservative treatment has shown to be effective. The authors suggest that neural gliding techniques should be used in cases of positive slump test after a hamstring injury.

Therapeutic exercises One of the initial goals of muscle injury rehabilitation is to restore normal neuromuscular control and prevent the formation of tissue fibrosis.6 Therapeutic exercises, such as isometric strengthening and controlled, pain-free, lowintensity active movements, are strategies recommended by experts to achieve these objectives at an early stage.51 In an intermediate phase, an increase in the intensity of exercises is allowed, with neuromuscular training at higher amplitudes and the initiation of eccentric resistance training.51 Askling et al.52 demonstrated the importance of eccentric strengthening in hamstring injuries, by comparing a protocol with conventional exercises and a protocol based on eccentric exercises with maximum dynamic stretching. Their study concluded that the eccentric exercise protocol was more effective, as it provided a faster return to sport and a lower relapse rate. Heiderscheit et al.6 stressed the importance of restoring flexibility at this stage, in order to promote better orientation of fibers during healing. Nonetheless, it is important to respect patient’s tolerance to stretching. In the final phase of rehabilitation, it is recommended to increase the eccentric training and the high-speed specific neuromuscular training of the sport movement, in preparation for the return to sport.32,51,53 Sherry et al.4 compared two intervention programs: one consisted of specific stretching exercises and progressive strengthening of hamstrings and the other comprised progressive agility training and lumbopelvic stabilization. The authors found that time to return to sport and recurrence rate were lower in the group that underwent functional training, which demonstrated the importance of agility exercises and of lumbopelvic stabilization during rehabilitation. Another strategy indicated to improve the reactive ability of the neuromuscular system is plyometric training, an exercise that activates the eccentric-concentric cycle of the musculoskeletal system and provides a gain of mechanical, elastic, and muscular reflex ability.54

Return to sport criteria The determination of objective criteria to define the appropriate time for an athlete to resume sport practice remains a challenge and an important area for future research. Based on the best evidence available,6,55,56 athletes who have been authorized to return to sports activities without restrictions should be able to perform functional skills (running, jumping, dribbling) at full speed without pain or stiffness complaints. Flexibility needs to be similar to the contralateral limb, without complaints. Regarding strength, the athlete should be able to complete four consecutive repetitions of maximal effort

without pain complaints in the manual test of knee flexion strength. If possible, isokinetic strength testing should also be performed, under both concentric and eccentric action conditions; the peak torque should have a deficit lower than 10% when compared with the contralateral side.

Final considerations Hamstring injuries are common in the athletic population and have a high recurrence rate. Through a complete physical evaluation and understanding of the mechanism of injury and risk factors, a rehabilitation specialist can determine the most appropriate and individualized treatment. Proper rehabilitation must address muscular strength deficits, flexibility, neuromuscular control, lumbopelvic stability, and eccentric strengthening, since these have been shown to be important therapeutic targets for a successful return of the athlete to sports, with lower risk of recurrence. Furthermore, LLLT has arisen as an important resource in helping to heal the injury. Future research should include evaluation of the effectiveness of current rehabilitation programs, identification of appropriate return-to-sport criteria, and the development of effective prevention strategies to reduce the occurrence of injuries.

Conflicts of interest The authors declare no conflicts of interest.

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30. Hägglund M, Waldén M, Ekstrand J. Previous injury as a risk factor for injury in elite football: a prospective study over two consecutive seasons. Br J Sports Med. 2006;40(9):767–72. 31. Gabbe BJ, Bennell KL, Finch CF, Wajswelner H, Orchard JW. Predictors of hamstring injury at the elite level of Australian football. Scand J Med Sci Sports. 2006;16(1):7–13. 32. Järvinen TA, Järvinen TL, Kääriäinen M, Kalimo H, Järvinen M. Muscle injuries: biology and treatment. Am J Sports Med. 2005;33(5):745–64. 33. Swenson C, Swärd L, Karlsson J. Cryotherapy in sports medicine. Scand J Med Sci Sports. 1996;6(4):193–200. 34. Bleakley CM, O’Connor S, Tully MA, Rocke LG, Macauley DC, McDonough SM. The PRICE study (Protection Rest Ice Compression Elevation): design of a randomised controlled trial comparing standard versus cryokinetic ice applications in the management of acute ankle sprain [ISRCTN13903946]. BMC Musculoskelet Disord. 2007;8:125. 35. Zemke JE, Andersen JC, Guion WK, McMillan J, Joyner AB. Intramuscular temperature responses in the human leg to two forms of cryotherapy: ice massage and ice bag. J Orthop Sports Phys Ther. 1998;27(4):301–7. 36. Wilkin LD, Merrick MA, Kirby TE, Devor ST. Influence of therapeutic ultrasound on skeletal muscle regeneration following blunt contusion. Int J Sports Med. 2004;25(1):73–7. 37. Mac Auley DC. Ice therapy: how good is the evidence? Int J Sports Med. 2001;22(5):379–84. 38. Shanks P, Curran M, Fletcher P, Thompson R. The effectiveness of therapeutic ultrasound for musculoskeletal conditions of the lower limb: a literature review. Foot (Edinb). 2010;20(4):133–9. 39. Baker KG, Robertson VJ, Duck FA. A review of therapeutic ultrasound: biophysical effects. Phys Ther. 2001;81(7): 1351–8. 40. Rantanen J, Thorsson O, Wollmer P, Hurme T, Kalimo H. Effects of therapeutic ultrasound on the regeneration of skeletal myofibers after experimental muscle injury. Am J Sports Med. 1999;27(1):54–9. 41. Karnes JL, Burton HW. Continuous therapeutic ultrasound accelerates repair of contraction-induced skeletal muscle damage in rats. Arch Phys Med Rehabil. 2002;83(1):1–4. 42. Markert CD, Merrick MA, Kirby TE, Devor ST. Nonthermal ultrasound and exercise in skeletal muscle regeneration. Arch Phys Med Rehabil. 2005;86(7):1304–10. 43. Baroni BM, Rodrigues R, Freire BB, Franke ReA, Geremia JM, Vaz MA. Effect of low-level laser therapy on muscle adaptation to knee extensor eccentric training. Eur J Appl Physiol. 2015;115(3):639–47. 44. Reddy GK. Photobiological basis and clinical role of low-intensity lasers in biology and medicine. J Clin Laser Med Surg. 2004;22(2):141–50. 45. Shefer G, Partridge TA, Heslop L, Gross JG, Oron U, Halevy O. Low-energy laser irradiation promotes the survival and cell cycle entry of skeletal muscle satellite cells. J Cell Sci. 2002;115 Pt 7:1461–9. 46. Vatansever F, Rodrigues NC, Assis LL, Peviani SS, Durigan JL, Moreira FM, et al. Low intensity laser therapy accelerates muscle regeneration in aged rats. Photonics Lasers Med. 2012;1(4):287–97. 47. Alves AN, Fernandes KP, Deana AM, Bussadori SK, Mesquita-Ferrari RA. Effects of low-level laser therapy on skeletal muscle repair: a systematic review. Am J Phys Med Rehabil. 2014;93(12):1073–85. 48. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. 2009;14(5):531–8. 49. Beltran-Alacreu H, Jiménez-Sanz L, Fernández Carnero J, La Touche R. Comparison of hypoalgesic effects of neural


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prospective randomised controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med. 2014;48(7): 532–9. 54. Chimera NJ, Swanik KA, Swanik CB, Straub SJ. Effects of plyometric training on muscle-activation strategies and performance in female athletes. J Athl Train. 2004;39(1): 24–31. 55. Verrall GM, Slavotinek JP, Barnes PG, Fon GT, Esterman A. Assessment of physical examination and magnetic resonance imaging findings of hamstring injury as predictors for recurrent injury. J Orthop Sports Phys Ther. 2006;36(4):215–24. 56. Orchard J, Best TM, Verrall GM. Return to play following muscle strains. Clin J Sport Med. 2005;15(6):436–41.


r e v b r a s o r t o p . 2 0 1 7;5 2(1):17–23

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

www.rbo.org.br

Original Article

One-year mortality of elderly patients with hip fracture surgically treated at a hospital in Southern Brazil夽 Marcelo Teodoro Ezequiel Guerra ∗ , Roberto Deves Viana, Liégenes Feil, Eduardo Terra Feron, Jonathan Maboni, Alfonso Soria-Galvarro Vargas Universidade Luterana do Brasil (ULBRA), Hospital Universitário Mãe de Deus, Servic¸o de Ortopedia e Traumatologia, Canoas, RS, Brazil

a r t i c l e

i n f o

a b s t r a c t

Article history:

Objective: To analyze the mortality rate at one-year follow-up of patients with hip fracture

Received 6 January 2016

who underwent surgery at the university hospital of this institution.

Accepted 18 April 2016

Method: The authors reviewed 213 medical records of hospitalized patients aged 65 years

Available online 7 December 2016

or older, following to the order they were admitted to the orthopedics and traumatology service from January 2012 to August 2013.

Keywords:

Results: One-year mortality rate was 23.6%. Mortality was higher among women, with a 3:1

Hip fractures

ratio. Anemia (p = 0.000) and dementia (p = 0.041) were significantly associated with the death

Mortality

group. Patients who remained hospitalized for less than 15 days and who were discharged

Elderly

within seven days after surgery showed increased survival. Conclusion: In the present sample of patients with hip fracture who underwent surgery, oneyear mortality rate was 23.6%, and the main comorbidities associated with this outcome were anemia and dementia. © 2016 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Mortalidade em um ano de pacientes idosos com fratura do quadril tratados cirurgicamente num hospital do Sul do Brasil r e s u m o Palavras-chave:

Objetivo: Analisar a mortalidade, em um ano de seguimento, de pacientes com fratura da

Fraturas do quadril

extremidade proximal do fêmur submetidos a procedimento cirúrgico no hospital univer-

Mortalidade

sitário da nossa instituic¸ão.

Idoso

Study conducted at the Universidade Luterana do Brasil (ULBRA), Hospital Universitário, Canoas, RS, Brazil. Corresponding author. E-mail: mguerraz@hotmail.com (M.T. Guerra). http://dx.doi.org/10.1016/j.rboe.2016.11.006 2255-4971/© 2016 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). ∗


18

r e v b r a s o r t o p . 2 0 1 7;5 2(1):17–23

Método: Foram revisados 213 prontuários de pacientes internados com 65 anos ou mais, conforme a ordem de admissão no Servic¸o de Ortopedia e Traumatologia de janeiro de 2012 a agosto de 2013. Resultados: A taxa de mortalidade em um ano foi de 23,6%. A mortalidade foi maior em mulheres, numa proporc¸ão 3:1. Anemia (p = 0,000) e demência (p = 0,041) estiveram significativamente associadas ao grupo óbito. Pacientes que permaneceram internados por até 15 dias e os que tiveram alta hospitalar em até sete dias após a cirurgia apresentaram um aumento na sobrevida. Conclusão: Em nossa amostra de pacientes com fratura de fêmur submetidos a procedimento cirúrgico, a taxa de mortalidade foi de 23,6%; as principais comorbidades associadas a esse desfecho foram anemia e demência. © 2016 Publicado por Elsevier Editora Ltda. em nome de Sociedade Brasileira de Ortopedia e Traumatologia. Este e´ um artigo Open Access sob uma licenc¸a CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction Hip fractures are very common and serious events in elderly patients. A significant increase in the incidence of proximal femur fractures has been observed in recent decades, mainly due to the increase of the elderly population, since this incidence progresses with advancing age.1 This type of fracture accounts for 84% of bone lesions in people aged over 60 years; it is a public health issue and a major cause of mortality, disability, excessive medical and hospital expenses, and social and family problems in this population.2–4 Fractures of the proximal end of the femur include subtrochanteric and transtrochanteric fractures, as well as those in the femoral neck. Most often, trauma is low-energy and is related to factors such as malnutrition, impaired activities of daily living, decreased visual acuity and reflexes, sarcopenia, and – particularly – bone fragility.1,5,6 In most cases, surgery is indicated. Conservative treatment is chosen in cases of incomplete fractures without displacement or when there are no clinical conditions for surgery. A period between 24 and 48 h after the fracture is considered ideal for the surgical procedure to take place, considering the general health of the patient.7–12 Several studies indicate advanced age, physical status, male gender, and delayed treatment as determining factors in mortality.6,11,13 Other factors related to an unfavorable outcome include nonambulatory condition prior to fracture, cognitive deficiencies, occurrence of a second fracture, low functional level at time of discharge, and lack of bisphosphonates and vitamin D replacement.6,14 Because fractures of the proximal end of the femur occur in patients with significant comorbidities and high risk of pre-operative complications, this condition has a high mortality rate when compared with other fractures.10,11,13,15 An important indicator in the evaluation of care provided in health institutions, mortality rate can also be used for two other purposes: determining the performance of a hospital over time and monitoring the performance of a number of hospitals.16 Given the importance of this issue, this study aimed to determine the mortality rate in the first year of follow-up of elderly patients with hip fracture who underwent surgery at

the university hospital of this institution and to identify the comorbidities associated with these patients.

Material and methods This was a retrospective study conducted at the university hospital of this institution. The study included elderly patients (65 years or older) admitted with a fracture of the proximal end of the femur and surgically treated from January 2012 to August 2013. This study was approved by the Research Ethics Committee of the institution. The research followed the recommendations of Resolution No. 196/96 of the National Health Council for Research in Human Beings, and was approved on 1/10/13 (CAAE: 21388913.1.0000.5349). Thus, no information that could identify individuals involved in the research will be published, ensuring the anonymity of the subjects and the privacy of information. The survey was conducted through a review of medical records and telephone contact with patients and their relatives. The information on death and its date were obtained through telephone contact or through the Canoas Health Department, when direct contact was not possible. Patients whose medical records were incomplete or who died prior to surgical treatment were excluded. Patients who underwent conservative treatment were not included. The following variables were studied: age, sex, comorbidities, type of fracture, surgical procedure, type of implant used, mean time between fracture and surgery, postoperative complications, and death. The cause of death was not assessed, as it had already been identified in a study conducted earlier in this service and because in most cases the cause of death was not directly related to the surgical procedure. Data were analyzed with tables, descriptive statistics, and chi-squared and Fisher’s exact tests, using SPSS software, version 13.0. A maximum significance level of 5% (p ≤ 0.05) was considered to be significant. The chi-squared test was used to assess the gender and age prevalence between groups, as


19

r e v b r a s o r t o p . 2 0 1 7;5 2(1):17–23

well as the number of comorbidities. The other variables were evaluated using Fisher’s exact and chi-squared tests.

The most prevalent fracture in the study group was transtrochanteric (56.8%), followed by femoral neck (37.7%) and subtrochanteric fractures (5%). Among the osteosynthesis implants, the most widely used was the dynamic hip screw, in 42.7% of cases. Table 4 indicates that three variables were associated with both groups: time between fracture and discharge (p = 0.018), time between surgery and discharge (p = 0.003), and osteosynthesis implant (p = 0.011). Regarding the variable of time between fracture and discharge, it was observed that the survival group was significantly associated with time <15 days and the death group, with time >30 days (p = 0.018). In the variable of time between surgery and discharge, the survival group was associated with time <7 days and the death group, with time 8–15 days and >15 days (p = 0.003). As for the implant used for osteosynthesis, dynamic hip screw was significantly associated with the survival group, and cemented partial hip prosthesis, with the death group (p = 0.011). Regarding complications, sepsis in the postoperative period was significantly associated with the death group (p = 0.001). Among other comorbidities studied, there was no significant relationship with the death group (Table 5).

Results From January 2012 to August 2013, the medical records of 213 patients with fractures of the proximal end of the femur were selected for inclusion in the study. Of these, 12 were excluded due to incomplete medical records and two due to death prior to the surgery, which resulted in a final sample of 199 patients. Of the total sample, 153 were contacted directly and 46 through the Department of Health system; 47 (23.6%) patients died within a year and 152 (76.4%) remained alive. Table 1 shows the comparison between the survival group and death group according to age and gender of patients. The survival group was significantly associated with age 65–75 years; conversely, the death group was associated with age range of over 86 years (p = 0.021). There was no difference between groups regarding sex (p = 0.849). Regarding the number of comorbidities per patient, it is observed that the presence of no comorbidities was associated with the survival group and that the presence of three comorbidities was associated with the death group (p = 0.004; Table 2). Two comorbidities were significantly associated with the death group: dementia (p = 0.041) and anemia (p = 0.000; Table 3).

Discussion This study investigated the mortality of elderly patients who underwent surgery for fractures of the proximal end of the

Table 1 – Comparison between the survival and death groups to sex and age of patients. Variable

pa

Group Death (n = 47)

Survival (n = 152)

n

%

n

Sex Female Male

34 13

72.3 27.7

114 38

Age 65–75 76–86 Over 86

9 20 18

19.1 42.6 38.3

54 67 31

Total (n = 199) %

n

75 25

148 51

74.4 25.6

0.849

63 87 49

31.7 43.7 24.6

0.21

35.5 44.1 20.4

%

Source: Authors. a

Chi-squared test.

Table 2 – Comparison between the survival and death groups according to the number of comorbidities presented. Nо· of comorbidities Death

None One Two Three More than three Total Source: Authors. a

Chi-squared test.

pa

Group Survival

Total

n

%

n

%

n

%

1 13 14 16 3 47

2.1 27.7 29.8 34 6.4 100

32 45 47 22 6 152

21.1 29.6 30.9 14.5 3.9 100

33 58 61 38 9 199

16.6 29.1 30.7 19.1 4.5 100

0.4


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r e v b r a s o r t o p . 2 0 1 7;5 2(1):17–23

Table 3 – Comparison between the survival and death groups according to the presence of comorbidities. Comorbidities Death (n = 47)

DM SAH Stroke NIHD IHD Dementia Depression COPD CRF Neoplasia Anemia Hypothyroidism Dyslipidemia Smoking/alcohol use Others

pa

Group Survival (n = 152)

Total (n = 199)

n

%

n

%

n

%

13 33 8 7 5 8 4 1 2 2 8 4 1 2 3

27.7 70.2 17 14.9 10.6 17 8.5 2.1 4.3 4.3 17 8.5 2.1 4.3 6.4

35 92 11 18 5 10 4 4 4 12 1 3 5 6 21

23 60.5 7.2 11.8 3.3 6.6 2.6 2.6 2.6 7.9 0.7 2 3.3 3.9 13.8

48 125 19 25 10 18 8 5 6 14 9 7 6 8 24

24.1 62.8 9.5 12.6 5 9 4 2.5 3 7 4.5 3.5 3 4 12.1

0.560 0.300 0.53 0.616 0.58 0.41 0.91 1.000 0.628 0.526 0.000 0.55 1.000 1.000 0.208

Source: Authors. IHD, ischemic heart disease; NIHD, non-ischemic heart disease; DM, diabetes mellitus; COPD, chronic obstructive pulmonary disease; SAH, hypertension; CRF, chronic renal failure. a

Chi-squared test and Fisher’s exact test.

Table 4 – Comparison of the study variables between the survival and death groups. Variable

Response Death (n = 47)

Fracture

Time of fracture/surgery

Time of fracture/admission

Time of fracture/discharge

Time of surgery/discharge

Osteosynthesis

Femoral neck Trochanteric Subtrochanteric Femoral neck + trochanteric Up to 7 days 8–15 days Over 15 days Up to 7 days 8–15 days Over 15 days Up to 15 days 16–30 days Over 30 days Up to 7 days 8–15 days Over 15 days DCS DHS Cannulated screw PFN Short PFN Cemented PHR Cementless PHR Cemented THR Cementless THR

pa

Group Survival (n = 152)

n

%

n

%

22 22 3 – 5 20 22 35 9 3 7 23 15 25 11 9 9 14 – 1 2 8 6 2 5

46.8 46.8 6.4 – 10.6 42.6 46.8 74.5 19.1 6.4 15.6 51.1 33.3 55.6 24.4 20 19.1 29.8 – 2.1 4.3 17 12.8 4.3 10.6

53 91 7 1 29 64 59 104 41 7 48 79 25 123 15 14 15 71 5 9 5 9 4 11 22

34.9 59.9 4.6 7 19.1 42.1 38.8 68.4 27 4.6 31.6 52 16.4 80.9 9.9 9.2 9.9 46.7 3.3 5.9 3.3 5.9 2.6 7.2 14.5

Total (n = 199) n

%

75 113 10 1 34 84 81 139 50 10 55 102 40 148 26 23 24 85 5 10 7 17 10 13 27

37.7 56.8 5 0.5 17.1 42.2 40.7 69.8 25.1 5 27.9 51.8 20.3 75.1 13.2 11.7 12.1 42.7 2.5 5 3.5 8.5 5 6.5 13.6

0.450

0.352

0.578

0.18

0.3

0.11

Source: Authors. DCS, dynamic condylar screw; DHS, dynamic hip screw; PFN, proximal femur nail; PHR, partial hip replacement; THR, total hip replacement. a

Chi-squared test and Fisher’s exact test.


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Table 5 – Comparison between the survival and death groups according to the presence of complications in the postoperative period. Complications Death (n = 47)

UTI BPN SSI Osteosynthesis infection Osteosynthesis rupture/dislocation Delirium Sepsis without focus ARF Anemia PTB Others

pa

Group Survival (n = 152)

Total (n = 199)

n

%

n

%

n

%

3 6 4 1 1 2 8 1 1 3 3

6.4 12.8 8.5 2.1 2.1 4.3 17 2.1 2.1 6.4 6.4

17 11 7 2 5 5 3 3 5 2 3

11.2 7.2 4.6 1.3 3.3 3.3 2 2 3.3 1.3 2

20 17 11 3 6 7 11 4 6 5 6

10.1 8.5 5.5 1.5 3 3.5 5.5 2 3 2 3

0.418 0.370 0.464 1.000 1.000 1.000 0.001 1.000 1.000 0.87 0.145

Source: Authors. BPN, bronchopneumonia; SSI, surgical site infection; ARF, acute renal failure; UTI, urinary tract infection; PTB, pulmonary thromboembolism. a

Chi-squared test.

femur after one year of follow-up. The results showed a mortality rate of 23.6%, associated with variables such as age, comorbidities, osteosynthesis, time between fracture and discharge, and time between surgery and discharge. By presenting these data, the authors aim to encourage the improvement of the quality of the current services, initially by making health officials, hospital administrators, doctors, and other professionals aware of the real problem that these conditions represent. A higher incidence was observed in female patients (74.4%); this finding is consistent with the literature, which indicates a ratio of two to five women for every man.1,3–5,9,13,15–21 The mean age of patients included in the study was 79.84 years, similar to that found in the literature.1,3,17,21,22 One-year mortality rates show great variability in the literature.2,12,17–20 The mortality rate in the present study was 23.6%. Ricci et al.20 analyzed 202 patients and observed a mortality rate of 28.7% after one year of follow-up. In turn, Pereira et al.18 observed a rate of 35% in a sample of 246 patients with hip fracture. In a study conducted in Italy, Meessen et al.,23 with a sample of 828 patients, observed a mortality rate of only 20.7%. In the present study, it was observed that mortality rate was higher in patients older than 86 years. Pugely et al.,24 in a prospective study of 4331 patients, showed a similar increase in mortality in patients over 80 years with hip fracture, which was significant for their overall mortality rate. The most prevalent comorbidities were hypertension, diabetes mellitus, heart disease, stroke, anemia, and dementia. This profile is consistent with that observed in several studies, in accordance to natural aging process.1,9,16,17,24 Although hypertension and diabetes mellitus combined accounted for over 80% of prevalence, these comorbidities are not determinant of an unfavorable outcome. Anemia and dementia were significantly associated with the death group, and are mentioned in the literature as factors associated with increased morbidity and mortality.20,25–28 In the present study,

an increase was observed in mortality among patients with three comorbidities prior to the fracture. Studies show that the number of previous diseases influences the mortality of patients with proximal end of femur fractures and that the presence of two or more comorbidities is associated with increased morbidity and mortality.29 The ideal time between fracture and surgical treatment has been widely discussed in the literature. The ideal time for surgery is considered to be between 24 and 48 h after fracture.9–12,15,17,22 In the present study, the mean interval from fracture to surgery was 16.19 days, with a minimum of two and maximum of 100 days. Despite the disagreement with the literature, the death group was not associated with delay of surgery. As this is a tertiary hospital, there is a bias regarding time between fracture and surgery. As this hospital does not have an emergency care unit, patients are first treated at an emergency department and only after stabilization transferred to the definitive treatment. The authors believe that this generates a significant bias in the outcome of these patients, since the treatment is rarely performed in its ideal form due to the system itself. Time between fracture and discharge was significant in this analysis. Patients who remained hospitalized for over 30 days presented a higher mortality rate. Astur et al.3 reported an increase in mortality of more than five times in patients who were hospitalized for over ten days when compared with those who remained less than ten days. The time between surgery and discharge was statistically significant in the analysis, but this relationship was not observed in the literature. Osteosynthesis was shown to be relevant to survival and mortality of patients. The use of dynamic hip screws was significantly associated with the survival group. The literature, however, does not indicate a difference between the type of implant used and the mortality of patients with proximal femoral fractures.18,21


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Regarding complications, only 10% were linked to surgery and the osteosynthesis implant used. The most prevalent clinical complications were urinary tract infection (10.1%), nosocomial pneumonia (8.5%), sepsis (5.5%), and delirium (5.5%), all frequently cited in the literature.10,13,14,16,24 Sepsis was significantly associated with the death group (p = 0.001). In a study published in 2014, Gibson et al.30 demonstrated that one-third of patients with proximal femoral fracture admitted to the intensive care unit with sepsis died in the unit and another one-third died outside the unit before discharge.

Conclusion In this sample of patients with hip fracture who underwent surgery, the mortality rate at one year was 23.6%; the major comorbidities significantly associated with this outcome were anemia and dementia.

Conflicts of interest The authors declare no conflicts of interest.

references

1. Hungria Neto JS, Dias CR, Almeida JD. Características epidemiológicas e causas da fratura do terc¸o proximal do fêmur em idosos. Rev Bras Ortop. 2011;46(6):660–7. 2. Pires RES, Prata EF, Gibram AV, Santos LEN, Lourenc¸o PRBT, Belloti JC. Anatomia radiográfica da região proximal do fêmur: correlac¸ão com a ocorrência de fraturas. Acta Ortop Bras. 2012;20(2):79–83. 3. Astur DC, Arliani GG, Balbachevsky D, Fernandes HJ, Reis FB. Fraturas da extremidade proximal do fêmur tratadas no Hospital São Paulo/Unifesp – Estudo epidemiológico. RBM Espec Ortop. 2011;68(4):11–5. 4. Diamantopoulos AP, Rohde G, Johnsrud I, Skoie IM, Johnsen V, Hochberg M, et al. Incidence rates of fragility hip fracture in middle-aged and elderly men and women in southern Norway. Age Ageing. 2012;41(1):86–92. 5. Cardoso FJ, Nakano AS, Frisene M, Hereda ME, Batista BF, Kanaji PR. Fraturas transtrocanterianas: uso de alendronato no pós-operatório. Acta Ortop Bras. 2011;19(1):45–8. 6. Lustosa LP, Bastos EO. Fraturas proximais do fêmur em idosos: qual o melhor tratamento? Acta Ortop Bras. 2009;17(5): 309–12. 7. Griffiths EJ, Cash DJ, Kalra S, Hopgood PJ. Time to surgery and 30-day morbidity and mortality of periprosthetic hip fractures. Injury. 2013;44(12):1949–52. 8. Kaplan K, Miyamoto R, Levine BR, Egol KA, Zuckerman JD. Surgical management of hip fractures: an evidence-based review of the literature. II: intertrochanteric fractures. J Am Acad Orthop Surg. 2008;16(11):665–73. 9. Wang CB, Lin CF, Liang WM, Cheng CF, Chang YJ, Wu HC, et al. Excess mortality after hip fracture among the elderly in Taiwan: a nationwide population-based cohort study. Bone. 2013;56(1):147–53. 10. Dubljanin-Raspopovic E, Markovic-Denic L, Marinkovic J, Nedeljkovic U, Bumbasirevic M. Does early functional outcome predict 1-year mortality in elderly patients with hip fracture? Clin Orthop Relat Res. 2013;471(8): 2703–10.

11. Daugaard CL, Jorgensen HL, Riis T, Lauritzen JB, Duus BR, van der Mark S. Is mortality after hip fracture associated with surgical delay or admission during weekends and public holidays? A retrospective study of 38,020 patients. Acta Orthop. 2012;83(6):609–13. 12. Khan SK, Rushton SP, Dosani A, Gray AC, Deehan DJ. Factors influencing length of stay and mortality after first and second hip fractures: an event modeling analysis. J Orthop Trauma. 2013;27(2):82–6. 13. Eschbach DA, Oberkircher L, Bliemel C, Mohr J, Ruchholtz S, Buecking B. Increased age is not associated with higher incidence of complications, longer stay in acute care hospital and in hospital mortality in geriatric hip fracture patients. Maturitas. 2013;74(2):185–9. 14. Travassos C, Noronha JC, Martins M. Mortalidade hospitalar como indicador de qualidade: uma revisão. Ciênc Saúde Colet. 1999;4(2):367–81. 15. Omsland TK, Emaus N, Tell GS, Magnus JH, Ahmed LA, Holvik K, et al. Mortality following the first hip fracture in Norwegian women and men (1999–2008). A Norepos study. Bone. 2014;63:81–6. 16. Silva CA [Dissertac¸ão] Fraturas osteoporóticas proximais do fémur – Estudo da mortalidade e custos hospitalares. Covilhã, Portugal: Universidade da Beira Interior; 2013. 17. Belmont PJ Jr, Garcia EJ, Romano D, Bader JO, Nelson KJ, Schoenfeld AJ. Risk factors for complications and in-hospital mortality following hip fractures: a study using the National Trauma Data Bank. Arch Orthop Trauma Surg. 2014;134(5):597–604. 18. Pereira SR, Puts MT, Portela MC, Sayeg MA. The impact of prefracture and hip fracture characteristics on mortality in older persons in Brazil. Clin Orthop Relat Res. 2010;468(7):1869–83. 19. Matos MA, Barros RM, Silva BV, Santana FR. Avaliac¸ão intra-hospitalar de pacientes portadores de fraturas do fêmur proximal. Rev Baiana Saúde Colet. 2010;34(1): 30–5. 20. Ricci G, Longaray MP, Gonc¸alves RZ, Ungaretti Neto AS, Manente M, Barbosa LBH. Avaliac¸ão da taxa de mortalidade em um ano após fratura de quadril e fatores relacionados à diminuic¸ão da sobrevida no idoso. Rev Bras Ortop. 2012;47(3):304–9. 21. Ribeiro TA, Premaor MO, Larangeira JA, Brito LG, Luft M, Guterres LW, et al. Predictors of hip fracture mortality at a general hospital in South Brazil: an unacceptable surgical delay. Clinics (Sao Paulo). 2014;69(4):253–8. 22. Frost SA, Nguyen ND, Center JR, Eisman JA, Nguyen TV. Excess mortality attributable to hip-fracture: a relative survival analysis. Bone. 2013;56(1):23–9. 23. Meessen JM, Pisani S, Gambino ML, Bonarrigo D, van Schoor NM, Fozzato S, et al. Assessment of mortality risk in elderly patients after proximal femoral fracture. Orthopedics. 2014;37(2):e194–200. 24. Pugely AJ, Martin CT, Gao Y, Klocke NF, Callaghan JJ, Marsh JL. A risk calculator for short-term morbidity and mortality after hip fracture surgery. J Orthop Trauma. 2014;28(2):63–9. 25. Tarazona-Santabalbina FJ, Belenguer-Varea A, Rovira Daudi E, Salcedo Mahiques E, Cuesta Peredo D, Domenech-Pascual JR, et al. Severity of cognitive impairment as a prognostic factor for mortality and functional recovery of geriatric patients with hip fracture. Geriatr Gerontol Int. 2015;15(3): 289–95. 26. Seitz DP, Gill SS, Gruneir A, Austin PC, Anderson GM, Bell CM, et al. Effects of dementia on postoperative outcomes of older adults with hip fractures: a population-based study. J Am Med Dir Assoc. 2014;15(5):334–41. 27. Potter LJ, Doleman B, Moppett IK. A systematic review of pre-operative anaemia and blood transfusion in patients with fractured hips. Anaesthesia. 2015;70(4):483–500.


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28. Shokoohi A, Stamworth S, Mistry D, Lamb S, Staves J, Murphy MF. The risk of red cell transfusion for hip fracture surgery in elderly. Vox Sang. 2012;103(3):223–30. 29. Shebubakar L, Hutagalung E, Sapardan S, Sutrisna B. Effects of older age and multiple comorbidities on functional

outcome after partial hip replacement surgery for hip fractures. Acta Med Indones. 2009;41(4):195–9. 30. Gibson AA, Hay AW, Ray DC. Patients with hip fracture admitted to critical care: epidemiology, interventions, and outcome. Injury. 2014;45(7):1066–70.

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

www.rbo.org.br

Original Article

Comparative study between lateral decubitus and traction table for treatment of pertrochanteric fractures with cephalomedullary nails夽 Eric Fernando de Souza ∗, José Octávio Soares Hungria, Lucas Romano Sampaio Rezende, Davi Gabriel Bellan, Jonas Aparecido Borracini Hospital Municipal do Campo Limpo Dr. Fernando Mauro Pires da Rocha, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil

a r t i c l e

i n f o

a b s t r a c t

Article history:

Objective: To perform a retrospective radiographic assessment of the reduction and implant

Received 11 November 2015

position in the femoral head in patients with pertrochanteric fractures treated with

Accepted 18 April 2016

cephalomedullary nailing in the lateral position versus traction table.

Available online 14 December 2016

Methods: Radiographs of patients with pertrochanteric fracture of the femur treated with cephalomedullary nailing in the lateral position and traction table were retrospectively eval-

Keywords:

uated. For the evaluation we used the anteroposterior radiographic view of the pelvis and the

Bone nails

lateral view of the affected side. The cervicodiaphyseal angle, the tip-apex distance (TAD),

Bone screws

and the spatial position of the cephalic component in the head were measured. Two patient

Femural fractures

groups were created, one group operated on the traction table and another group operated in the lateral position. Results: Regarding the cervicodiaphyseal angle observed in the traction table group, the results of 11 patients (61.1%) were outside the acceptable parameters proposed in the present study. Both groups were equivalent regarding TAD and the position of the cephalic component in the head. Conclusion: A difference in the cervicodiaphyseal angle was observed; the group operated on the traction table had 11 patients (61.1%) whose measurements were outside the acceptable parameters. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

夽 Study conducted at the Hospital Municipal do Campo Limpo Dr. Fernando Mauro Pires da Rocha, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil. ∗ Corresponding author. E-mail: ericefs@gmail.com (E.F. Souza). http://dx.doi.org/10.1016/j.rboe.2016.04.009 2255-4971/© 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).


25

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Estudo comparativo entre decúbito lateral e mesa de trac¸ão para tratamento de fraturas pertrocantéricas com hastes cefalomedulares r e s u m o Palavras-chave:

Objetivo: Fazer uma avaliac¸ão comparativa radiográfica retrospectiva da reduc¸ão e posic¸ão

Pinos ortopédicos

do implante na cabec¸a femoral em pacientes com fraturas pertrocantéricas tratados com

Parafusos ósseos

haste cefalomedular em decúbito lateral ou em mesa de trac¸ão.

Fraturas de fêmur

Métodos: Foram avaliadas retrospectivamente radiografias de pacientes com diagnóstico de fratura pertrocantérica do fêmur tratados com haste cefalomedular em decúbito lateral ou em mesa de trac¸ão. Para avaliac¸ão radiográfica ambulatorial usamos as incidências anteroposterior da pelve e o perfil do lado afetado. Aferimos o ângulo cervicodiafisário, a tip-apex distance (TAD) e a posic¸ão espacial do elemento cefálico na cabec¸a. Foram criados dois grupos de pacientes, um operado na mesa de trac¸ão e outro em decúbito lateral. ¯ ao ângulo cervicodiafisário, observamos no grupo da mesa de trac¸ão Resultados: Com relac¸ao 11 pacientes (61,1%) fora dos parâmetros aceitáveis propostos em nosso trabalho. Para a TAD e a posic¸ão do elemento cefálico na cabec¸a, os dois grupos se mostraram equivalentes. Conclusão: Observamos diferenc¸a com relac¸ão ao ângulo cervicodiafisário, no qual o grupo operado em mesa de trac¸ão apresentou 11 pacientes (61,1%) fora dos parâmetros aceitáveis. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Este e´ um artigo Open Access sob uma licenc¸a CC BY-NC-ND (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Patients and methods

Pertrochanteric fractures are common in the elderly, due to osteoporosis, and their incidence has increased significantly because of the longer life expectancy of the population. Their incidence is expected to double in the next 25 years.1,2 Currently, there is a consensus that pertrochanteric fractures of the femur should be treated surgically.3,4 The techniques for fixation of these fractures with cephalomedullary nails are best conducted with a traction table. However, in the absence or impossibility of its use, it is necessary to adopt another position, such as lateral decubitus.5 In an earlier study conducted in the present hospital by de Oliveira et al.,6 conditions that could influence the efficiency of the reduction and the positioning of the cephalic element in the femoral head in pertrochanteric fractures, when fixated in lateral decubitus, were assessed. Given the encouraging results of that study,6 the present authors conducted a comparative study to assess the results regarding the reduction and the spatial positioning of the cephalic element (CE) in the femoral head (cervicodiaphyseal angle), tip-apex distance (TAD), and spatial position of the CE in the femoral head (circle of Baumgaertner et al.7 ) in pertrochanteric fractures treated on a traction table. The goal was to assess whether the reduction and positioning of the cephalic element in both positioning methods were equivalent. The present study aimed to evaluate whether there are differences in the quality of reduction and in the spatial positioning of the CE of cephalomedullary nails in pertrochanteric fractures treated with these nails in lateral decubitus and on a traction table.

Patients Between January 2014 and June 2015, 35 patients diagnosed with pertrochanteric femoral fracture were treated with cephalomedullary nail on a traction table in a teaching hospital in a large urban center. Of those, 18 attended the retrospective final assessment, 14 could not be located, and three died, one in the hospital and two postoperatively. Five (27.8%) were female and 13 (72.2%) were male, with a mean age of 65 years (range 41–91 years). Regarding the trauma mechanism, ten had a ground-level fall; two, a fall from bed; two, a fall from stairs; one had suffered a beating; one, a fall from the roof; one, a motorcycle accident; and one, a fracture after the use of ® Reamer Irrigator Aspiration (RIA). Five patients had fracture of the left side and 13, on the right side. Twenty-nine fractures treated in the lateral decubitus position between June 2012 and November 2013 were assessed. Of those, 19 attended the retrospective final assessment, eight could not be located, and two died in the hospital, due to postoperative trauma complications; 11 were female and eight male, mean age 60 years (range 18–87 years). The mechanisms of trauma were groundlevel falls in 13 patients; motorcycle falls, in four; injury by firearm, in one; and bicycle fall, in one. Eleven patients presented fracture of the left side and eight on the right.6 Two groups of patients were created: Group 1 comprised patients with pertrochanteric fractures fixated with cephalomedullary nails treated in the lateral decubitus position and Group 2, patients with pertrochanteric fractures fixed with cephalomedullary nails treated on a traction table.


26

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Of the preoperative radiographs analyzed from Group 2, six (33.3%) patients presented the A1 pattern; seven (38.9%), A2; and five (27.8%), A3. The minimum time of postoperative evaluation for that group was one month. In turn, in Group 1 one (5.3%) patient presented the A1 pattern, 11 (57.9%), A2; and seven (36.8%), A3. The minimum time of postoperative evaluation for that group was six months.

Superior

4

2

5

3

6

Methods To classify the fractures, authors used pelvic radiographs of the affected hip in anteroposterior (AP) and lateral (L) views, and applied the AO rating for pertrochanteric fractures (31): A1 are simple, two-part fractures with good bone support in the medial cortical; A2 are multifragmentary fractures in which the medial and dorsal cortices (lesser trochanter) are broken on different levels, but the lateral cortex is intact; in A3 fractures, the lateral cortex is also broken (reverse oblique fractures).8 To perform the surgical procedure on a traction table, patient was placed under general or spinal anesthesia in the supine position in an orthopedic surgical table with mounted traction boots, properly positioned; the non-fractured limb was placed in a flexed and abducted position to provide more room for the C-arm. Closed reduction of the fracture, with traction and internal or external rotation, depending on the fracture pattern, was confirmed by radioscopy. Then, surgical site was prepped from the iliac crest to the foot of the affected ® ® side. Cephalomedullary nails (GammaTM nail or TFN ) were used, adopting the standard technique for internal fixation of fractures.9 For the proximal fixation, it was sought to position the cephalic fixation element on the center of the head, at 1-cm from the subchondral bone in normal bone and at 0.5cm in porotic bone in AP and L. Distal fixation was performed with a guide when a standard-size cephalomedullary nail was used, or freehand when a long nail was used. Radioscopic control was performed in both AP and L at every step. All cases were operated by a third year resident, overseen by the same attending physician. In the group in which osteosynthesis was performed in the lateral position, patient was placed in the lateral decubitus position with the aid of cushions on the back and abdomen; AP and L radiographs were made to assess the correct visualization of the entire femur and pelvis in two planes, as described by Oliveira et al.6 For outpatient radiographic evaluation, the AP view of the pelvis was used, with the patient in the supine position; the incident ray was positioned on the midline of the pubic symphysis, with the feet internally rotated at 15◦ –20◦ using the standard technique. The L view was also used, with the patient positioned in supine, the affected hip at 45◦ flexion and 20◦ abduction, and the incident ray was centered vertically on the hip joint, following the standard technique.10 For these incidences, the following variables were evaluated: Cervicodiaphyseal angle: angle between two lines, one that crosses the center of rotation of the femoral head and the longitudinal axis of the femoral neck and the other, the long axis of the femoral shaft.11 Values between 130◦ and 135◦ were considered as normal.

7

Posterior

Anterior

1

9 8

Lower Fig. 1 – Arrangement of the quadrants in nine zones.

TAD: defined in accordance with Baumgaertner et al.7 ; distances shorter than 25 mm from the subchondral bone in the central portion of the femoral head to the end of the cephalic pin of the nail are ideal. Spatial position of the CE in relation to the head: the femoral head is divided into nine separate areas in which the CE is located. These are: superior-, middle-, and lower-third in the AP radiograph and anterior-, center-, and posterior-third in the L radiograph.7 The central-central zone in quadrant 5 was considered ideal (Fig. 1), and quadrants with increased risk of cut-out were avoided. Two groups of patients were created, separated by the positioning and reduction method used in the surgical treatment of fractures. To compare them, three parameters were used: cervicodiaphyseal angle, TAD, and spatial position of the CE. The quantitative characteristics of the groups were described as mean, standard deviation, median, and minimum and maximum, and compared with Student’s t-test. The qualitative characteristics of the groups were described by absolute and relative frequencies; the associations between the groups were verified using the chi-squared test, Fisher’s exact test, or the likelihood ratios.12 A 5% significance level was adopted.

Results The data collected from both groups were tabulated. Patient characteristics, such as age, sex, weight, and height, were chosen for analysis. Fracture characteristics analyzed were side, AO classification, and mechanism of injury, as described in Table 1. Table 1 shows that patients operated in the lateral decubitus position and on the traction table showed similar characteristics (p > 0.05). Similarly, to assess the results of surgery by the criteria set forth in the present study, the results of both groups were organized and described in Table 2. Table 2 shows that the cervicodiaphyseal angle was significantly more altered in patients who underwent surgery with the use of a traction table than in those whose surgery was


27

r e v b r a s o r t o p . 2 0 1 7;5 2(1):24–28

Table 1 – Description of the personal characteristics and the procedure by groups and results of statistical tests. Variable

Group Lateral decubitus (n = 19)

Sex, n (%) Female Male

11 (57.9) 8 (42.1)

Age (years) Mean (SD) Median Weight (kg) Mean (SD) Median Height (m) Mean (SD) Median

Total (n = 37)

p

Traction table (n = 18) 0.65 5 (27.8) 13 (72.2)

16 (43.2) 21 (56.8)

60 (20.9) 64 (18; 87)

65.9 (16.4) 64 (41; 91)

62.9 (18.8) 64 (18; 91)

68.2 (21.4) 67.8 (40; 121)

66.6 (11.7) 67 (50; 90)

67.4 (17.2) 67.8 (40; 121)

0.340a

0.788a

0.433a 1.62 (0.11) 1.62 (1.45; 1.85)

1.65 (0.07) 1.65 (1.55; 1.79)

1.64 (0.09) 1.65 (1.45; 1.85)

Side, n (%) Right Left

8 (42.1) 11 (57.9)

13 (72.2) 5 (27.8)

21 (56.8) 16 (43.2)

0.65

Classification, n (%) A1 A2 A3

1 (5.3) 11 (57.9) 7 (36.8)

6 (33.3) 7 (38.9) 5 (27.8)

7 (18.9) 18 (48.6) 12 (32.4)

Trauma mechanism, n (%) Ground-level fall Others

13 (68.4) 6 (31.6)

10 (55.6) 8 (44.4)

23 (62.2) 14 (37.8)

0.076b

0.420

Chi-squared test. a b

Student’s t-test. Likelihood ratio test.

Table 2 – Description of the surgical evaluation criteria according to groups and results of statistical tests. Variable

Group Lateral decubitus (n = 19)

Position of cephalic implant, n (%) Quadrant 5 Other quadrants

Total (n = 37)

p

Traction table (n = 18) 0.823

7 (36.8) 12 (63.2)

6 (33.3) 12 (66.7)

13 (35.1) 24 (64.9) 0.660a

TAD, n (%) Normal Altered

17 (89.5) 2 (10.5)

15 (83.3) 3 (16.7)

32 (86.5) 5 (13.5)

Cervicodiaphyseal, n (%) Normal Altered

18 (94.7) 1 (5.3)

7 (38.9) 11 (61.1)

25 (67.6) 12 (32.4)

<0.001

Chi-squared test. a

Fisher’s exact test.

performed in the lateral decubitus position (p < 0.001). Both groups were similar regarding TAD and implant positioning.

Discussion There are some options for reduction and patient positioning in the treatment of pertrochanteric fractures.13 The present hospital did not use to have a traction table, so patients were treated in the lateral position, a method that was shown to be effective in this service regarding spatial positioning of the

CE, TAD, and cervicodiaphyseal angle. The hospital now has a traction table, and it has become the method of choice for the treatment of these fractures. Therefore, most professionals have started to perform this type of osteosynthesis in the present hospital, as the method is widely described among orthopedic surgeons and the procedure requires a smaller team. In contrast, the lateral decubitus positioning is a more meticulous technique that requires experience and expertise on the part of the surgeon and a larger, trained team. For the reduction of pertrochanteric femoral fractures, traction of the affected limb is necessary in most cases. In the


28

r e v b r a s o r t o p . 2 0 1 7;5 2(1):24–28

lateral decubitus technique, this is controlled by the surgeons themselves, who can have more precise control of the reduction at each stage of osteosynthesis. With the traction table, this adjustment is made at the initial position and is difficult to make in other stages of osteosynthesis, as the fine adjustment is made with a non-sterile device. Considering both groups of patients (one treated on the traction table and the other in lateral decubitus), the results of both methods were assessed, aiming to reconstruct the normal cervicodiaphyseal angle between 130◦ and 135◦ , so that the implant could be properly positioned, avoiding reductions in varus.14,15 For the proximal fixation, it was sought to position the cephalic fixation element on the center of the head, in AP and L at 1-cm from the subchondral bone in normal bone and at 0.5-cm in porotic bone, following the concept introduced by Baumgaertner et al.7 In both groups, the parameters were successfully achieved. Regarding the TAD (described for osteosynthesis with dynamic hip screws, it can be used to assess the correct positioning of cephalomedullary nails)15,16 and the spatial position of the cephalic fixation element, the safest quadrants were always obtained, avoiding those with higher cutout risk.5,7 As for the cervicodiaphyseal angle, unsatisfactory results were observed in the cases operated on the traction table; 61.1% of cases did not fall within the stipulated standard. In the patients operated in lateral decubitus, only one (5.3%) was found to be outside the accepted standards in the present study.

Conclusion A statistically significant difference was observed regarding the cervicodiaphyseal angle (p-value < 0.001); the group operated on the traction table presented 11 patients (61.1%) outside the acceptable parameters.

Conflicts of interest The authors declare no conflicts of interest.

references

1. Haidukewych GJ. Intertrochanteric fractures: ten tips to improve results. J Bone Joint Surg Am. 2009;91(3):712–9.

2. Uliana CS, Abagge M, Malafaia O, Kalil Filho FA, Cunha LAM. Fraturas transtrocantéricas – Avaliac¸ão dos dados da admissão à alta hospitalar. Rev Bras Ortop. 2014;49(2): 121–8. 3. Butler M, Forte ML, Joglekar SB, Swiontkowski MF, Kane RL. Evidence summary: systematic review of surgical treatments for geriatric hip fractures. J Bone Joint Surg Am. 2011;93(12):1104–15. 4. Canto RS, Sakaki M, Susuki I, Tucci P, Belangero W, Kfuri M Jr, et al. Fratura transtrocanteriana. São Paulo: Sociedade Brasileira de Ortopedia e Traumatologia; 2007. Projeto Diretrizes. 5. Bucholz RW, Court-Brown CM, Tornetta P 3rd. Fraturas em adultos de Rockwood e Green. 7a ed. Barueri: Manole; 2013. 6. de Oliveira EJ, Hungria JO, Bellan DG, Borracini JA. Decúbito lateral para tratamento das fraturas pertrocantérica com hastes cefalomedulares. Rev Bras Ortop. 2015;40(4): 409–15. 7. Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am. 1995;77(7):1058–64. 8. Rüedi TP. Princípios AO do tratamento de fraturas. 2a ed. Porto Alegre: Artmed; 2009. 9. Canale ST. Campbell’s operative orthopaedics. 12th ed. St. Louis: Mosby; 2013. 10. Polesello GC, Nakao TS, Queiroz MC, Daniachi D, Ricioli W Jr, Guimarães RP, et al. Proposta de padronizac¸ão do estudo radiográfico do quadril e da pelve. Rev Bras Ortop. 2011;46(6):634–42. 11. Giordano V, Dias MC, Santos GF, Cabral S, Amaral NP, Albuquerque RP. Estudo radiográfico da extremidade proximal do fêmur para avaliac¸ão do risco de fratura osteoporótica. Rev Bras Ortop. 2007;42(4):88–96. 12. Kirkwood BR, Sterne JA. Essential medical statistics. 2nd ed. Massachusetts, USA: Blackwell Science; 2006. 13. Ozsoy MH, Basarir K, Bayramoglu A, Erdemli B, Tuccar E, Eksioglu MF. Risk of superior gluteal nerve and gluteus medius muscle injury during femoral nail insertion. J Bone Joint Surg Am. 2007;89(4):829–34. 14. Guimarães JA, Guimarães AC, Franco JS. Avaliac¸ão do emprego da haste femoral curta na fratura trocantérica instável do fêmur. Rev Bras Ortop. 2008;43(9): 406–7. 15. Borger RM, Leite FA, Araújo RP, Pereira TF, Queiroz RD. Avaliac¸ão prospectiva da evoluc¸ão clínica, radiográfica e funcional do tratamento das fraturas trocantéricas instáveis do fêmur com haste cefalomedular. Rev Bras Ortop. 2011;46(4):380–9. 16. De Bruijn K, den Hartog D, Tuinebreijer W, Roukema G. Reliability of predictors for screw cutout in intertrochanteric hip fractures. J Bone Joint Surg Am. 2012;94(14):1266–72.


r e v b r a s o r t o p . 2 0 1 7;5 2(1):29–34

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

www.rbo.org.br

Original Article

Surgical treatment of intraarticular fractures of the calcaneus: comparison between flat plate and calcaneal plate夽 Luiz Carlos Almeida da Silva ∗ , João Mendonc¸a de Lima Heck, Marcelo Teodoro Ezequiel Guerra Universidade Luterana do Brasil (Ulbra), Hospital Universitário, Canoas, RS, Brazil

a r t i c l e

i n f o

a b s t r a c t

Article history:

Objective: To evaluate the clinical results of surgical treatment of intraarticular fractures of

Received 16 February 2016

the calcaneus, comparing the use of calcaneal plate and flat plate.

Accepted 2 May 2016

Methods: This was a retrospective study assessing the postoperative results of 25 patients

Available online 29 December 2016

between 2013 and 2015. Patients undergoing surgical treatment of intraarticular fractures

Keywords:

complete appropriate follow-up after surgery were excluded from the study.

of the calcaneus without concomitant surgical lesions were included. Patients who did not Calcaneus/injuries

Results: The unavailability of calcaneal plates at resource-limited settings, associated with

Calcaneus/surgery

the availability and lower cost of flat plates, may have been a confounding factor in the

Fractures, bone/surgery

present study. However, there was no statistical difference between the outcomes of frac-

Fracture fixation, internal

tures treated with calcaneal plates or flat plates. Conclusion: Statistical inference shows that, when calcaneal plates are not available, it is possible to use flat plates with similar clinical outcomes. © 2016 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Tratamento cirúrgico das fraturas intra-articulares do calcâneo: comparac¸ão dos resultados entre placa reta e placa própria para calcâneo r e s u m o Palavras-chave:

Objetivo: Avaliar os resultados clínicos do tratamento cirúrgico das fraturas intra-articulares

Calcâneo/lesões

do calcâneo (TCFIAC) e comparar o uso de placa própria para calcâneo (PPC) e placa reta (PR).

Calcâneo/cirurgia

Métodos: Estudo retrospectivo que avaliou o resultado pós-operatório de 25 pacientes entre

Fraturas ósseas/cirurgia

2013 e 2015. Foram incluídos pacientes submetidos ao TCFIAC e que não apresentavam

Fixac¸ão interna de fraturas

lesões cirúrgicas concomitantes. Pacientes que não foram devidamente acompanhados no pós-operatório foram excluídos da análise.

夽 Study conducted at the Universidade Luterana do Brasil (Ulbra), Hospital Universitário, Departamento de Ortopedia e Traumatologia, Canoas, RS, Brazil. ∗ Corresponding author. E-mail: luizcarlosmedicina@gmail.com (L.C. Silva). http://dx.doi.org/10.1016/j.rboe.2016.05.007 2255-4971/© 2016 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).


30

r e v b r a s o r t o p . 2 0 1 7;5 2(1):29–34

Resultados: A indisponibilidade da PPC em servic¸os com recursos limitados, associada à disponibilidade e ao menor custo da PR, pode ter sido fator de confusão no presente estudo. Contudo, não houve diferenc¸a estatística entre os resultados das fraturas tratadas com PPC ou PR. Conclusão: A inferência estatística permite concluir que, na ausência da PPC, é possível usar a PR com desfechos clínicos semelhantes. © 2016 Publicado por Elsevier Editora Ltda. em nome de Sociedade Brasileira de Ortopedia e Traumatologia. Este e´ um artigo Open Access sob uma licenc¸a CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction Calcaneal fractures correspond to 2% of skeletal fractures and about 60% of fractures of the tarsal bones.1,2 Despite the great development of orthopedic traumatology in the last century, treatment of these fractures is still controversial and results are often unsatisfactory, due to the complex anatomical shape of the calcaneus, its cancellous structure, and the fact that it is subjected to constant weight load.3–6 Thus, this injury causes major socioeconomic and functional impairment to patients, and represents a burden to public and private compensation policies.1 In recent decades, with the improvement of imaging studies, a better understanding of the mechanisms of trauma, and observance of the principles of anatomical reduction and absolute stability for joint fractures, it is now possible to improve clinical outcome for this type of fracture. For this purpose, several types of implants are available, including calcaneal plates (CP) and flat plates (FP).7 Therefore, this study aimed to evaluate the clinical outcomes of surgical treatment of intra-articular fractures of the calcaneus (STIAFC) and compare the use of CP and FP.

Material and methods This was a retrospective cohort study, which evaluated late postoperative results of 25 patients operated between January 2013 and January 2015. This study was approved by the Research Ethics Committee under No. 117817/2014/CAAE 40266114.9.0000.5328. Inclusion criteria comprised patients who underwent surgical treatment by open reduction and internal fixation (ORIF) of a unilateral calcaneal intra-articular closed fracture without other associated fractures, who had preoperative computed tomography and radiographs of the foot, ankle, and calcaneus, and who had signed an informed consent form. Exclusion criteria were patients who were operated using the Essex-Lopresti technique or those in whom a minimally invasive surgery was performed; fractures treated conservatively due to patient’s own reasons or lack of surgical indication; associated fractures; lack of adequate skin condition, edema, and blisters in the lateral aspect of the foot, not resolved by the date of the surgery; absence of clinical conditions due to vascular disorders, heart disease, or decompensated diabetes; severe traumatic brain injury; psychosocial problem; heavy smoking; refusal to undergo surgical

treatment; bilateral fractures; and refusal to sign the inform consent form. During this period, 64 feet of 52 patients were operated by the same surgeon. All patients were called for reevaluation; 25 patients undergoing STIAFC met the inclusion criteria and were included in the study. All patients were evaluated by the same surgeon who performed all surgeries. The following assessment scales were used: American Orthopaedic Foot and Ankle Society (AOFAS), the Global Social Functioning Scale (GSFS), visual analog (VAS), and the Medical Outcomes Study 36 (SF-36).8 Clinically, the following aspects were analyzed: subtalar joint in the standing and supine positions; varus and valgus deviation of the hindfoot; abduction; adduction; pronation and supination of the forefoot; range of motion for ankle flexion and extension; appearance of surgical scars; and need for crutches. For the classification of fractures, the Sanders9 and Essex-Lopresti10 classifications were used. Similarly, all patients underwent late postoperative analysis with radiographic study in Bröden’s view; calcaneus radiographs in profile and axial; bilateral radiographic evaluation of the feet with monopodal support; radiographic evaluation of the ankle in profile, anteroposterior, and in 15◦ of internal rotation; and bilateral computed tomography with 5mm thick axial, coronal, and sagittal cuts. The sample was divided into two groups according to the type of ORIF made. Group I consisted of patients treated with 3.5-mm one-third tubular FP. Group II included patients undergoing treatment with CP. The criterion for the choice of material was random and based on the possibility of using CP, which was not always available. As fixation criteria, isolated FP or two combined FP were used when CP was not available. CP was used whenever available. All patients were operated with the classic L-shaped lateral access route, starting 3 cm from the posterior region of the lateral malleolus, passing 3 cm below that, extending to the calcaneocuboid joint. Due to the high risk of skin necrosis, dissection was made at the subperiosteal level. The flap was folded down and maintained cranially with three 2.0 mm Kirschner wires attached to the talus, with visualization of the sheath of the peroneus muscles, which was preferably preserved. Under direct visualization of the fracture, reduction was carried out, with temporary fixation using Kirschner wires performed after intraoperative radiographic confirmation of the reduction. Definite fixation was made with either CP or FP. After closure by planes, an elastic compression bandage ® was made with Portovac drain for 48 h and casting for four


31

r e v b r a s o r t o p . 2 0 1 7;5 2(1):29–34

Table 1 – Demographic and clinical characteristics of the sample. pa

Type of plate CP (n = 14) Age Sex Female Male Trauma mechanism Bicycle × motorcycle collision Fall from height

FP (n = 11)

47.7

10.4

45.5

3 11

21.4% 78.6%

0 11

0.0% 100.0%

1 13

7.1% 92.9%

0 11

0.0% 100.0%

0.617a 0.230

11.29

1.000

Operated side Right Left

7 7

50% 50%

8 3

72.7% 27.3%

0.414

Rearfoot position in orthostasis Neutral Valgus

8 6

57.1% 42.9%

5 6

45.5% 54.5%

Subtalar arthrosis No Yes

5 9

35.7% 64.3%

3 8

27.3% 72.7%

0.695

1.000

CP, calcaneal plates; FP, flat plates. a

p-value for Fisher’s exact test.

weeks. Partial load was authorized at the sixth postoperative week. Autografts to fill the space created inside the calcaneus were not used. Quantitative variables were described as mean and standard deviation; categorical variables were described as simple (n) and relative (%) frequency. To assess the mean difference between types of material, the t-test for independent samples test was used. To verify the existence of an association between types of material and categorical variables, Fisher’s exact test was used. The significance level was set at 5%. Statistical analyses were performed with SPSS version 18.0.

Results Regarding gender, among patients undergoing treatment with CP, 11 (78.6%) were men and three (21.4%) were women. Among patients who were treated with RP, 11 (100%) were men. Regarding type of trauma, of the patients undergoing treatment with CP, one (7.1%) had suffered trauma due to a bicycle collision with a motorcycle and 13, fall from height; in turn, all 11 (100%) patients treated with FP had suffered a fall from height (Table 1). The operated side of patients treated with CP was the right side in seven patients (50%) and left in seven (50%). Among patients undergoing treatment with FP, eight (72.7%) had the right side operated and three (27.3%), left. Regarding the postoperative position of the hindfoot while standing, among patients who underwent treatment with CP, eight (57.1%) presented the hindfoot in a neutral position, and six (42.9%), hindfoot in valgus. In turn, among patients who underwent treatment with FP, five (45.5%) presented the hindfoot in a neutral position and six (54.5%) in valgus. Regarding subtalar arthrosis, among patients who underwent treatment with CP, five (35.7%) evolved without subtalar

arthrosis and nine (64.3%) presented it. Among patients who underwent treatment with RP, three (27.3%) evolved without subtalar arthrosis, while eight (72.7%) developed the condition (Table 1). Regarding the classification of fractures, 19 patients (76%) had joint depression fracture and six (24%), tongue-type fracture. As for the Sanders classification, eight (32%) patients had type 2 A fracture; two (8%), type 2B; six (24%), type 3AB; three (12%), type 3AC; two (8%), type 3BC; and four (16%), type 4 (Table 2). The results of both groups regarding waiting time for surgery and physical examination are shown in Table 3. Regarding clinical assessment scales, Tables 4 and 5 show results without statistical difference between the two types of plates. Therefore, there was no difference in clinical outcomes between ORIF in the comparison of CP and FP.

Table 2 – Classification of fractures. pa

Type of plate CP (n = 14) Essex-Lopresti classification Joint depression Tongue Sanders classification 2A 2B 3AB 3AC 3BC 4

0.350 12 2

85.7% 14.3%

7 4

63.6% 36.4%

5 1 2 3 1 2

35.7% 7.1% 14.3% 21.4% 7.1% 14.3%

3 1 4 0 1 2

27.3% 9.1% 36.4% 0% 9.1% 18.2%

0.655

CP, calcaneal plates; FP, flat plates. a

FP (n = 11)

p-value for Fisher’s exact test.


32

r e v b r a s o r t o p . 2 0 1 7;5 2(1):29–34

Table 3 – Results of the groups in relation to the waiting time for surgery and measurements of the physical examination. Type of plate

p

CP (n = 14)

Waiting time until surgery (days) Difference in calf diameter Width of the hindfoot Ankle extension Ankle flexion Forefoot supination Forefoot pronation Subtalar supination Subtalar pronation

FP (n = 11)

Mean

SD

Mean

SD

23.1 1.9 6.7 11.5 24.6 13 13.4 7.6 1

17.28 0.53 0.71 10.41 9.90 12.88 9.81 6.12 6.6

19.5 1.5 7.1 11.8 27.2 20.7 11.1 4 0.1

6.67 1.35 0.82 7.17 9.87 11.19 9.97 7.75 1.58

0.913a 0.308a 0.270b 0.67.6a 0.519b 0.084a 0.359a 0.057a 0.240a

Data presented as mean and standard deviation (SD). CP, calcaneal plates; FP, flat plates. a b

p-value for Mann–Whitney test. p-value for independent sample t-test.

Table 4 – Results assessed by the clinical assessment scales. Type of plate

p

CP (n = 14)

PF-SF36 Scale Scores RP-SF36 Scale Scores BP-SF36 Scale Scores GH-SF36 Scale Scores VT-SF36 Scale Scores SF-SF36 Scale Scores RE-SF36 Scale Scores MH-SF36 Scale Scores PF-SF36 Norm-based Scale Scores RP-SF36 Norm-based Scale Scores BP-SF36 Norm-based Scale Scores GH-SF36 Norm-based Scale Scores VT-SF36 Norm-based Scale Scores SF-SF36 Norm-based Scale Scores RE-SF36 Norm-based Scale Scores MH-SF36 Norm-based Scale Scores PCS-SF36 MCS-SF36

FP (n = 11)

Mean

SD

Mean

SD

52.9 25.0 47.0 74.6 65.7 63.4 38.1 69.1 37.4 35.1 40.0 52.1 54.1 41.2 35.8 46.6 38.1 47.3

36.15 39.22 34.90 27.77 20.27 36.51 43.8 20.12 15.15 11.7 14.94 13.1 9.61 15.85 13.61 11.43 13.37 10.9

52.3 25.0 54.3 74.7 71.8 63.9 36.4 68.7 37.1 35.0 43.2 52.2 57.0 41.3 35.2 46.3 39.2 47.4

28.84 35.36 27.67 25.41 24.52 36.43 43.35 25.85 12.10 9.98 11.85 11.89 11.62 15.80 13.70 14.70 9.47 13.92

0.912a 0.804a 0.578b 0.889a 0.502b 0.846a 0.907a 0.964b 0.967b 0.804a 0.575b 0.889a 0.502b 0.868a 0.907a 0.962b 0.817b 0.975b

Data were presented as means and standard deviations (SD). CP, calcaneal plates; FP, flat plates. a b

p-value for Mann–Whitney test. p-value for independent sample t-test.

Table 5 – Results according to the assessment scales. pa

Type of plate CP (n = 14) Mean VAS AOFAS Radiological width of the hindfoot Pitch angle of the calcaneus Talus declination angle

4.6 66.1 4.7 21 18

FP (n = 11) SD 2.73 26.37 0.38 5.88 4.79

Data presented as mean and standard deviation (SD). CP, calcaneal plates; FP, flat plates. a

p-value for independent sample t-test.

Mean 3.6 52 4.4 16.6 18.9

SD 2.38 20.64 0.60 5.66 2.95

0.344 0.160 0.217 0.74 0.587


r e v b r a s o r t o p . 2 0 1 7;5 2(1):29–34

Discussion Calcaneal joint fractures are severe injuries and may cause permanent and disabling sequelae. They usually affect young and economically active men, and thus these fractures can have an important socioeconomic impact. In this sample, we found that 88% of patients were male and had a mean age of 47.6 years. According to the literature, the most common cause of intra-articular fractures of the calcaneus is a fall from height,1 which was confirmed in the present study, as this cause accounted for 96% of the fractures. The Essex-Lopresti10 radiological classification is a classical tool that determines the line of fracture and allows treatment planning. Tomographic classifications help to assess the severity and prognosis of the injury; the Sanders classification is the most commonly used.9 However, tomographic classifications are not uniform and each group aims to create its own classification, which makes it difficult to compare results as well as to identify the type of injury they describe. Tomography is considered to be an excellent test to identify details of the fragments and the joint impairment; however, it is not available in all services. This limitation justifies the use of a radiological classification. According to the Essex-Lopresti classification, intraarticular fractures can be tongue-type or joint depression type. In most series, joint depression is the most frequent type of fracture, accounting for 43%–61% of intra-articular fractures.11,12 In the present study, 76% of fractures were joint depression-type and 24%, tongue-type. For open surgery, there is a consensus to wait between seven and 14 days between trauma and operation, so that the edema reduces and blister formation is prevented, except in open fractures, which should receive immediate surgical treatment, or when percutaneous fixation is indicated.7,13 In the present study, the mean time between trauma and operation of the 25 fractures was 23.1 days (SD 17.28) for CP and 19.5 days for FP (SD 6.67). The lateral L-shaped access route has been widely used because it allows better visibility of the fracture, fragment reduction, and internal fixation.7,13 In this study, the extended lateral L-shaped access was efficient; it was used as a standard technique for all cases. Wound necrosis is usually the result of improper incision and exposure or long surgery.14 Necrosis is observed more frequently in the end of the lateral L-shaped incision.15 In the present study, a patient treated with CP needed surgical debridement due to skin necrosis, which solved the problem without the need of a skin graft. Symptoms associated with implants problems, which are rarely reported in the literature, include prominent implant, skin irritation, and heel pain. Problems usually arise because plate and screws cause irritation to the skin, tendons, or nerves, or because a screw penetrates the facet joint.16,17 Tendon involvement due to implants can result in tendinitis or rupture, and lead to tendinitis and secondary pain.18 In the present study, the CP had to be removed in one patient due to skin irritation and pain. Furthermore, in three patients who were treated with FP, the synthesis material had to be removed due to FP and screw prominence.

33

The use of bone graft is controversial; some authors consider it to be osteoinductive and osteoconductive, while others consider it unnecessary.7,19 It is noteworthy that the use of bone graft increases the incidence of morbidity, as another incision is made for graft harvesting. In the present study, bone grafts from the iliac bone were not used. Instead, a graft taken from the lateral wall of the calcaneus was used to fill the remaining bone loss after fracture reduction. Assessing the results using the AOFAS scale, the literature presents rates of excellent results, ranging from 42.22% to 62%.20–22 In this study, 47.6% of the results were considered good or excellent. It is not possible to state with certainty that the type of fracture may have influenced the score, as in the present sample, the number of tongue-type fractures was small when compared with joint depression. Post-traumatic arthrosis usually occurs in the subtalar and calcaneocuboid joints.23 The literature reports an incidence rate of 1.2% in studies with long term follow-up.6,16 When intractable pain cannot be controlled by analgesics, subtalar arthrodesis may be the best option.16 In the present study, one patient treated with FP, with a fracture classified as Sanders 4, presented intractable pain and underwent subtalar arthrodesis, which improved the symptoms. There are many controversies regarding the type of implant and its selection criteria. For ORIF, most studies applied a plate to the lateral wall of the calcaneus.24 Regarding stabilization screws for the sustentaculum tali, there are also controversies regarding whether they should be fixated through the plate. Plates in several shapes can be used for ORIF of calcaneal fractures, and different types of synthetic materials are advocated by different authors.24–30 Modern plates have a lower profile, which has solved problems related to excessive skin tension, prominence of the implant under the skin, and subsequent dehiscence of the surgical wound.24 The choice for a lateral plate depends on the severity of the calcaneal fracture and on bone quality. Simple fractures in good quality bone appear to be adequate for FP fixation, while complex fractures with comminution may require CP or even locking plates.24 FP has been used for many years. In the early 1990s, due to post-operative complications at the time, ORIF techniques using two FPs for fixation were developed. Then, the development of single, H- and Y-shaped plates started.30 The literature features numerous articles on the use of locked plate with minimally invasive technique. Few studies, however, address the use of FP for the treatment of calcaneal fractures, which, for the Brazilian surgeon, is still a reality, due to the country’s health care system. Although this was a retrospective study, it helped to assess the outcome of patients. It can be concluded that the results were very similar to those reported in the literature. The present study also indicates the need to develop treatment protocols that allow prospective studies, which could provide more reliable information on fractures, both pre-operatively and during their evolution. Another important factor is that CP is not always available, especially in public services that face financial difficulties. In turn, FP is more readily available and inexpensive. These factors impact surgical treatment. The unavailability of CP in public services, associated with the availability and lower cost


34

r e v b r a s o r t o p . 2 0 1 7;5 2(1):29–34

of FP, may have been confounding factor in the present study. However, this study demonstrated that there appears to be no significant impairment in the treatment of calcaneal fractures when CP is not available.

Conclusion Statistical inference allows for the conclusion that, in the absence of CP, FP can be used with similar clinical outcomes.

Conflicts of interest The authors declare no conflicts of interest.

references

1. Mitchell MJ, McKinley JC, Robinson CM. The epidemiology of calcaneal fractures. Foot (Edinb). 2009;19(4):197–200. 2. Griffin D, Parsons N, Shaw E, Kulikov Y, Hutchinson C, Thorogood M, et al. Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial. BMJ. 2014;349:g4483. 3. Zhang T, Su Y, Chen W, Zhang Q, Wu Z, Zhang Y. Displaced intra-articular calcaneal fractures treated in a minimally invasive fashion: longitudinal approach versus sinus tarsi approach. J Bone Joint Surg Am. 2014;96(4):302–9. 4. Lim EV, Leung JP. Complications of intraarticular calcaneal fractures. Clin Orthop Relat Res. 2001;391:7–16. 5. Wiley WB, Norberg JD, Klonk CJ, Alexander IJ. Smile incision: an approach for open reduction and internal fixation of calcaneal fractures. Foot Ankle Int. 2005;26(8):590–2. 6. Yu X, Pang QJ, Chen L, Yang CC, Chen XJ. Postoperative complications after closed calcaneus fracture treated by open reduction and internal fixation: a review. J Int Med Res. 2014;42(1):17–25. 7. Sanders R. Current consepts review – displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am. 2000;82(2):225–50. 8. SooHoo NF, Vyas R, Samimi D. Responsiveness of the foot function index, AOFAS clinical rating systems, and SF-36 after foot and ankle surgery. Foot Ankle Int. 2006;27(11):930–4. 9. Sanders R. Radiological evaluation and CT classification of calcaneal fractures. In: Jahss M, editor. Disorders of the foot and ankle. 3rd ed. Philadelphia: WB Saunders; 1990. p. 2326–54. 10. Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis. Br J Surg. 1952;39(157):395–419. 11. Chhabra N, Sherman SC, Szatkowski JP. Tongue-type calcaneus fractures: a threat to skin. Am J Emerg Med. 2013;31(7):1151.e3–4. 12. de Vroome SW, van der Linden FM. Cohort study on the percutaneous treatment of displaced intra-articular fractures of the calcaneus. Foot Ankle Int. 2014;35(2):156–62.

13. Wu K, Wang C, Wang Q, Li H. Regression analysis of controllable factors of surgical incision complications in closed calcaneal fractures. J Res Med Sci. 2014;19(6):495–501. 14. Melcher G, Degonda F, Leutenegger A, Ruedi T. Ten-year follow-up after operative treatment for intra-articular fractures of the calcaneus. J Trauma. 1995;38(5):713–6. 15. Zwipp H, Rammelt S, Barthel S. Calcaneal fractures – open reduction and internal fixation (ORIF). Injury. 2004;35 Suppl. 2:SB46–54. 16. Huang PJ, Huang HT, Chen TB, Chen JC, Lin YK, Cheng YM, et al. Open reduction and internal fixation of displaced intra-articular fractures of the calcaneus. J Trauma. 2002;52(5):946–50. 17. Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, et al. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2002;84(10):1733–44. 18. Walde TA, Sauer B, Degreif J, Walde HJ. Closed reduction and percutaneous Kirschner wire fixation for the treatment of dislocated calcaneal fractures: surgical technique, complications, clinical and radiological results after 2–10 years. Arch Orthop Trauma Surg. 2008;128(6):585–91. 19. Singh AK, Vinay K. Surgical treatment of displaced intra-articular calcaneal fractures: is bone grafting necessary? J Orthop Traumatol. 2013;14(4):299–305. 20. Gwak HC, Kim JG, Kim JH, Roh SM. Intraoperative three-dimensional imaging in calcaneal fracture treatment. Clin Orthop Surg. 2015;7(4):483–9. 21. Schepers T, Backes M, Schep NW, Carel Goslings J, Luitse JS. Functional outcome following a locked fracture-dislocation of the calcaneus. Int Orthop. 2013;37(9):1833–8. 22. Rammelt S, Zwipp H, Schneiders W, Durr C. Severity of injury predicts subsequent function in surgically treated displaced intraarticular calcaneal fractures. Clin Orthop Relat Res. 2013;471(9):2885–98. 23. Gallino RM, Gray AC, Buckley RE. The outcome of displaced intra-articular calcaneal fractures that involve the calcaneocuboid joint. Injury. 2009;40(2):146–9. 24. Dhillon MS, Bali K, Prabhakar S. Controversies in calcaneus fracture management: a systematic review of the literature. Musculoskelet Surg. 2011;95(3):171–81. 25. Benirschke SK, Sangeorzan BJ. Extensive intraarticular fractures of the foot. Surgical management of calcaneal fractures. Clin Orthop Relat Res. 1993;292:128–34. 26. Illert T, Rammelt S, Drewes T, Grass R, Zwipp H. Stability of locking and non-locking plates in an osteoporotic calcaneal fracture model. Foot Ankle Int. 2011;32(3):307–13. 27. Rak V, Ira D, Masek M. Operative treatment of intra-articular calcaneal fractures with calcaneal plates and its complications. Indian J Orthop. 2009;43(3):271–80. 28. Geel CW, Flemister ASJ. Standardized treatment of intraarticular calcaneal fractures using an oblique lateral incision and no bone graft. J Trauma. 2001;50:1083–9. 29. Rammelt S, Barthel S, Biewener A, Gavlik JM, Zwipp H. Calcaneus fractures. Open reduction and internal fixation. Zentralbl Chir. 2003;128(6):517–28. 30. Dhillon MS. Fractures of the calcaneus. London: Jaypee Brothers Medical Publishers (P) Ltd; 2013.


r e v b r a s o r t o p . 2 0 1 7;5 2(1):35–39

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

www.rbo.org.br

Original Article

Reliability of the radiographic union scale in tibial fractures (RUST)夽 Fernando Antonio Silva de Azevedo Filho a,b,∗ , Ricardo Britto Cotias a , Matheus Lemos Azi b , Armando Augusto de Almeida Teixeira a a b

Hospital do Subúrbio, Salvador, BA, Brazil Hospital Manoel Victorino, Salvador, BA, Brazil

a r t i c l e

i n f o

a b s t r a c t

Article history:

Objective: This study aimed to evaluate the inter- and intra observer reproducibility of the

Received 13 April 2016

radiographic score of consolidation of the tibia shaft fractures.

Accepted 3 May 2016

Methods: Fifty-one sets of radiographs in anteroposterior (AP) and profile (P) of the tibial

Available online 15 December 2016

shaft treated with intramedullary nail were obtained. The analysis of X-rays was performed in two stages, with a 21-day interval between assessments by a group of nine evaluators.

Keywords:

To evaluate the reproducibility of RUST score between the evaluators, the intra-class corre-

Tibia

lation coefficient (ICC) with a 95% confidence interval was used. ICC values range from +1,

Fracture healing

representing perfect agreement, to −1, complete disagreement.

Radiography

Results: There was a significant correlation among all evaluators: ICC = 0.87 (95% CI 0.81 to 0.91). The intraobserver agreement proved to be substantial with ICC = 0.88 (95% CI 0.85 to 0.91). Conclusion: This study confirms that the RUST scale shows a high degree of reliability and agreement. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Reprodutibilidade do escore radiográfico de consolidac¸ão das fraturas da tíbia (RUST) r e s u m o Palavras-chave:

Objetivo: Avaliar a reprodutibilidade inter e intraobservador do escore radiográfico de

Tíbia

consolidac¸ão das fraturas (RUST) da diáfise da tíbia.

Consolidac¸ão da fratura

Métodos: Foram obtidos 51 conjuntos de radiografias nas incidências anteroposterior (AP) e

Radiografia

perfil (P) da diáfise da tíbia tratadas com haste intramedular. A análise das radiografias foi feita em dois momentos, com intervalo de 21 dias entre as avaliac¸ões, por nove avaliadores.

Study conducted at Hospital do Subúrbio, Salvador, BA, Brazil. Corresponding author. E-mail: azevedofilho@gmail.com (F.A. Azevedo Filho). http://dx.doi.org/10.1016/j.rboe.2016.05.006 2255-4971/© 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). ∗


36

r e v b r a s o r t o p . 2 0 1 7;5 2(1):35–39

Para avaliar a reprodutibilidade do escore RUST entre os avaliadores foi usado o coeficiente de correlac¸ão intraclasse (CCI) com intervalo de confianc¸a de 95%. O valor do CCI varia de +1, que representa concordância perfeita, a −1, que corresponde a total discordância. Resultados: Houve uma concordância significativa entre todos os avaliadores: CCI = 0,87 (IC 95% 0,81 a 0,91). A concordância intraobservador mostrou-se substancial, com CCI = 0,88 (IC 95% 0,85 a 0,91). Conclusão: Este trabalho confirma que a escala RUST apresenta um elevado grau de confiabilidade e concordância. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Este e´ um artigo Open Access sob uma licenc¸a CC BY-NC-ND (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction Tibial shaft fracture is the most common among those of long bones; it has a high incidence and mainly affects young males of working age. These injuries result from high-energy kinetic trauma, such as fall from height and car accidents; the latter are a major cause of fractures and lead to disability, with high socioeconomic costs.1–6 The use of reamed locked intramedullary nails for the internal fixation in the treatment of tibia shaft fractures is well established in the literature.2 Despite advances in surgical techniques, local anatomical conditions may contribute to the onset of complications, such as delayed consolidation and pseudoarthrosis.7,8 The incidence of pseudoarthrosis after internal fixation with intramedullary nail has been reported in the literature as ranging from 5% to 33%, which often results in the need for secondary intervention or additional treatment to stimulate bone union.2,3,9,10 Bone consolidation process is a simple biological phenomenon that occurs in stages: hematoma, inflammation, angiogenesis, cartilage formation (with subsequent calcification, cartilage removal, and then bone formation), and bone remodeling. Complete fracture healing may take several months, and only occurs after the completion of all stages.2,4,11 From a clinical standpoint, a fracture can be considered consolidated at the end of the repair phase. The criteria used for this definition can be subdivided into clinical examination data (e.g., weight bearing without local pain and lack of mobility at the fracture site) and patient-related factors (quality of life).4,7,12,13 Corrales et al.,13 in a review of 77 clinical studies that used clinical criteria to define the consolidation of long bone fractures, found that the three most commonly used criteria were absence of pain or tenderness with weight bearing, absence of pain or tenderness at the fracture site during the examination. For the radiological evaluation of fractures, plain radiography remains the most common method to assess healing.7 Some authors suggest as a criterion to determine fracture consolidation the presence of at least three consolidated cortices observed in two radiographic views (anteroposterior [AP] and lateral [L]).14 Panjabi et al.,15 in an experimental study, demonstrated that cortical continuity was the best predictor of fracture healing, while callus area was the least important predictor.

McClelland et al.,15 when studying patients with tibial fractures treated with external fixation, observed a moderate correlation between radiographic healing and stiffness at the fracture site. These authors suggested that the presence of bone callus in two cortices was the best indicator to consider a fracture as healed. Various scales and classifications have been proposed to define fracture consolidation, with a combination of radiographic criteria.5,7,9,10,16 Kooistra et al.2 recommend the use of the Radiographic Union Scale for Tibial Fractures (RUST) for assessing consolidation. This method evaluates two orthogonal radiographic views; each cortex is attributed points ranging from 1 to 3. A fracture in the immediate postoperative period will receive the minimum score, 4, and a fully consolidated considered fracture will be assigned the maximum score, 12. Studies show that RUST is a simple, systematic, and continuous indicator in the evaluation of tibial fractures treated with intramedullary nail.2 This study aimed to evaluate the inter- and intraobserver reproducibility of the RUST scale in patients treated with reamed locked intramedullary nail.

Material and methods A retrospective study was conducted to evaluate the intra- and interobserver reproducibility of the RUST scale. The study included radiographs of patients with fractures of the tibial shaft treated with reamed locked intramedullary nail, aged over 16 years, of both sexes; the exams had good technical quality, and were made during the follow-up period (eight weeks to nine months) in AP and L. Patients with pathological fractures, who presented infection or consolidation delay, or who evolved to pseudarthrosis and needed a new procedure were excluded. A total of 77 sets of AP and L radiographs of the tibial shaft of outpatients treated with intramedullary nails in 2014 were retrieved; 51 sets met all inclusion criteria. Exams were selected from the electronic hospital records, in various stages of consolidation. Radiographs were made in two stages, with an interval of 21 days between assessments by nine evaluators: two first-year orthopedic and traumatology residents, two second-year residents, two third-year residents, and three traumatologists with over ten years of specialization.


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Table 1 – Radiographic scale of tibial fracture consolidation. Cortex

Visible fracture line, without callus Score = 1

Visible fracture line, with callus Score = 2

No fracture line, with visible callus Score = 3

Total score Minimum 4 Maximum 12

Lateral Medial Anterior Posterior

Images were simultaneously presented to all evaluators in ® an air-conditioned environment using Sony VPL-DX130B image projector. Radiographs in AP and L of each patient were projected simultaneously, with one minute for each evaluation. The RUST scale assigns a score for a given set of AP and L radiographs, based on the assessment of healing in each of the four cortices visible on these projections (medial and lateral cortices in AP, and anterior and posterior cortices in L). Each cortex is assigned 1 point if a fracture line without the presence of callus is observed; 2, if there is callus, but a fracture line is still visible; and 3, if there is callus with no evidence of fracture line (Table 1). The scores on each cortex are added, resulting in a total value for each set of radiographs; 4 is the minimum score, indicative that the fracture is not healed and 12 is the maximum score, indicating that the fracture completely cured.2,10,17 A score ≥7 is equivalent to a minimum of three

A

cortices with bone callus. A fracture with this score can be considered as radiologically consolidated17 (Fig. 1). The examiners did not have access to patient history, age, fracture time, and any other clinical information. Radiographs were identified by numbers and only the main researcher had access to this identification. The interobserver reproducibility was assessed by comparing the total scores of each observer obtained in the initial visualization of the radiographs. The intraobserver reproducibility was determined by the comparison of the scores of the first and second evaluation by each participant. To evaluate the reproducibility of the RUST score among raters, the intraclass correlation coefficient (ICC) was used with a 95% confidence interval. ICC values range from +1, representing perfect agreement, to −1, complete disagreement. The study was approved by the Research Ethics Committee of the Health Secretariat of the State of Bahia, Opinion No. 788,655.

B

Lateral cortex Absence of callus, visible fracture line RUST: 1

Anterior cortex Absence of callus, visible fracture line RUST: 1

Medial cortex Absence of callus, visible fracture line RUST: 1

Posterior cortex Absence of callus, visible fracture line RUST: 1

Lateral cortex Absence of callus, visible fracture line RUST: 2

Anterior cortex Presence of callus, visible fracture line RUST: 2

Posterior cortex Presence of callus, visible fracture line RUST: 2

Medial cortex Absence of callus, visible fracture line RUST: 2

C Lateral cortex Presence of callus, absence of fracture line RUST: 3

Medial cortex Presence of callus, absence of fracture line RUST: 3

Anterior cortex Presence of callus, absence of fracture line RUST: 3

Posterior cortex Presence of callus, absence of fracture line RUST: 3

Fig. 1 – RUST score in three phases of consolidation: A = 4; B = 8; C = 12.


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r e v b r a s o r t o p . 2 0 1 7;5 2(1):35–39

Intraobserver agreement was substantial, with ICC of 0.88 (95% CI: 0.85–0.91). By analyzing the evaluators according to the degree of training, it was observed that traumatologists showed a near-perfect reproducibility (ICC 0.94; 95% CI 0.91 to 0.95). Among the residents, the highest ICC was observed for second-year residents (ICC 0.89), followed by first-year (ICC 0.87) and finally third-year (ICC 0.83; Table 2).

20

%

15

10

5

0

4

5

6

7

8

9

10

11

12

RUST score 1st assessment

2nd assessment

Fig. 2 – Distribution of the RUST score in the 1st and 2nd assessment. Table 2 – RUST score inter- and intra-observer interclass correlation coefficient.

Traumatologists 3rd year-resident 2nd year-resident 1st year-resident General

Interobserver ICC 95% CI

Intraobserver ICC 95% CI

0.94 (0.90–0.96) 0.90 (0.84–0.94) 0.92 (0.87–0.95) 0.80 (0.67–0.88) 0.87 (0.81–0.91)

0.94 (0.91–0.95) 0.83 (0.71–0.90) 0.89 (0.84–0.93) 0.87 (0.79–0.90) 0.89 (0.85–0.91)

Results The RUST score of the 51 sets of radiographs (AP and L) ranged from 4 to 12, with a score of 7.53 ± 2.53 (median 7) in the first assessment and 7.88 ± 2.49 (median 8) in the second (Figs. 2 and 3). There was a significant correlation among the evaluators, with ICC of 0.87 (95% CI: 0.81–0.91). Among traumatologists, there was greater reliability when compared with first-, second-, and third-year residents (ICC: 0.94, 0.80, 0.92, and 0.90, respectively; Table 2).

12 11 10

RUST

9 8 7 6 5 4 a1

a2

a3

a4

a5

a6

a7

a8

a9

Fig. 3 – Comparison of the mean RUST score among evaluators. a1, a2, a3; traumatologists; a4, a5, third-year residents; a6, a7, second-year residents; a8, a9, first-year residents.

Discussion Despite the numerous studies related to the development of scales to assess the radiographic consolidation of tibial fractures, a reliable and effective method, a gold standard, is not yet established in the literature.18,19 The definition of radiological union is inconsistent due to the degree of imprecision of the selected variables. Some investigations use a single parameter, such as the presence of callus in at least two cortices.5 Several variables are observed when analyzing the evolution of fracture healing, including number of consolidated cortices and presence of bone callus and fracture line.17,18 Based on these parameters, Kooistra et al.2 developed a radiographic scale to determine the consolidation of tibial shaft fractures, the RUST scale. Using the presence of callus in each cortex, associated with the presence of a fracture line, the hypothesis that the RUST scale would present greater validity and reliability than other proposed systems was raised. The RUST scale assesses the fracture unequivocally and completely. It presents some advantages when compared with other methods, among which stands out the fact that each cortex is evaluated separately, making the scale more reliable, since each individual cortex contributes to the final score. This classification is easy to apply, with high inter- and intraobserver agreement.2,10,17–19 Whelan et al.10 assessed the reproducibility of the RUST scale when using radiographs of 45 patients treated with locked intramedullary nails. They observed a correlation among all evaluators (ICC: 0.86, 95% CI: 0.79 to 0.91), with a trend toward greater reliability for traumatologists when compared with orthopedic surgeons and residents, a result similar to that found in the present study. Ali et al.18 corroborated these results when assessing the reproducibility between orthopedic surgeons and radiologists. When evaluating radiographs with conservative treatment for fractures of the tibia, they observed a significant interobserver correlationship. Macri et al.17 observed an interobserver agreement, assessed by ICC, of 0.93 (95% CI: 0.89 to 0.96). The ability to bear weight on the fractured limb is directly related to the bone consolidation phase. This inability can cause changes in gait; therefore, gait pattern may be a practical way of monitoring fracture healing. A strong association between gait pattern and RUST score has been observed.17 By correlating the clinical and radiological criteria, Cekic et al.19 observed that the RUST score corresponds directly to the clinical conditions of the patients. Callus in two or three cortices were not observed in the images of patients who had a high pain index, indicating the accuracy of this score regarding both the clinical and radiological consolidation.


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Conclusion The present study confirmed that the RUST score features a high degree of reliability and compliance. As there is no gold standard radiographic classification to evaluate the healing of tibial fractures, the authors suggest that this is a useful functional tool, but more research relating the radiographic findings on clinical examination is needed to establish it as an essential tool in daily practice.

Conflicts of interest The authors declare no conflicts of interest.

references

1. Court-Brown CM, Rimmer S, Prakash U, McQueen MM. The epidemiology of open long bone fractures. Injury. 1998;29(7):529–34. 2. Kooistra BW, Dijkman BG, Busse JW, Sprague S, Schemitsch EH, Bhandari M. The radiographic union scale in tibial fractures: reliability and validity. J Orthop Trauma. 2010;24 Suppl. 3:S81–6. 3. Chua W, Murphy D, Siow W, Kagda F, Thambiah J. Epidemiological analysis of outcomes in 323 open tibial diaphyseal fractures: a nine-year experience. Singapore Med J. 2012;53(6):385–9. 4. Kojima KE, Ferreira RV. Fraturas da diáfise da tíbia. Rev Bras Ortop. 2011;46(2):130–5. 5. Whelan DB, Bhandari M, McKee MD, Guyatt GH, Kreder HJ, Stephen D, et al. Interobserver and intraobserver variation in the assessment of the healing of tibial fractures after intramedullary fixation. J Bone Joint Surg Br. 2002;84:15–8. 6. Zeckey C, Mommsen P, Andruszkow H, Macke C, Frink M, Stübig T, et al. The aseptic femoral and tibial shaft non-union in healthy patients – an analysis of the health-related quality of life and the socioeconomic outcome. Open Orthop J. 2011;5:193–7.

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7. Dijkiman BG, Sprague S, Schemitsch EH, Bhandari M. When is a fracture healed? Radiographic and clinical criteria revisited. J Orthop Trauma. 2010;24 Suppl. 3:S76–80. 8. Antonova E, Kim Le T, Burge R, Mershon J. Tibia shaft fractures: costly burden of nonunions. BMC Musculoskelet Disord. 2013;14:42. 9. Davis BJ, Roberts PJ, Moorcroft CI, Brown MF, Thomas PB, Wade RH. Reliability of radiographs in defining union of internally fixed fractures. Injury. 2004;35(6):557–61. 10. Whelan DB, Bhandari M, Stephen D, Kreder H, McKee MD, Zdero R, et al. Development of the radiographic union score for tibial fractures for the assessment of tibial fracture healing after intramedullary fixation. J Trauma. 2010;68(3): 629–32. 11. Phillips AM. Overview of the fracture healing cascade. Injury. 2005;36 Suppl. 3:S5–7. 12. Bhandari M, Guyatt GH, Swiontkowski MF, Tornetta P 3rd, Sprague S, Schemitsch EH. A lack of consensus in the assessment of fracture healing among orthopaedic surgeons. J Orthop Trauma. 2002;16(8):562–6. 13. Corrales LA, Morshed S, Bhandari M, Miclau T 3rd. Variability in the assessment of fracture-healing in orthopaedic trauma studies. J Bone Joint Surg Am. 2008;90(9):1862–8. 14. Hungria JOS, Mercadante MT. Fratura exposta da diáfise da tíbia – Tratamento com osteossíntese intramedular após estabilizac¸ão provisória com fixador externo não transfixante. Rev Bras Ortop. 2013;48(6):82–90. 15. Panjabi MM, Walter SD, Karuda M, White AA, Lawson JP. Correlations of radiographic analysis of healing fractures with strength: a statistical analysis of experimental osteotomies. J Orthop Res. 1985;3(2):212–8. 16. Freedman EL, Johnson EE. Radiographic analysis of tibial fracture malalignment following intramedullary nailing. Clin Orthop Relat Res. 1995;(315):25–33. 17. Macri F, Marques LF, Backer RC, Santos MJ, Belangero WD. Validation of a standardised gait score to predict the healing of tibial fractures. J Bone Joint Surg Br. 2012;94(4):544–8. 18. Ali S, Singh A, Agarwal A, Parihar A, Mahdi AA, Srivastava RN. Reliability of the RUST score for the assessment of union in simple diaphyseal tibial fractures. IJBR. 2014;5(5):333–5. 19. C¸ekic E, Alici E, Yesil M. Reliability of the radiographic union score for tibial fractures. Acta Orthop Traumatol Turc. 2014;48(5):533–40.


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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

www.rbo.org.br

Original article

Magnetic resonance imaging without contrast as a diagnostic method for partial injury of the long head of the biceps tendon夽 Alexandre Tadeu do Nascimento ∗ , Gustavo Kogake Claudio Hospital Orthoservice, Grupo de Ombro e Cotovelo, São José dos Campos, SP, Brazil

a r t i c l e

i n f o

a b s t r a c t

Article history:

Objective: To evaluate the use of magnetic resonance imaging (MRI) without contrast as

Received 12 November 2015

a diagnostic method of partial lesions of the long head of the biceps, using arthroscopic

Accepted 7 January 2016

surgery as the gold standard.

Available online 20 December 2016

Methods: We evaluated data from MRI and arthroscopic surgical findings of patients operated due to rotator cuff and SLAP injuries. MRI without contrast of at least 1.5 T, with a radiologist

Keywords:

report, was used as a criterion for the detection of long head of the biceps injury. All cases

Sensitivity and specificity

were operated by the same surgeon at this hospital.

Rotator cuff

Results: This study evaluated data from 965 patients, 311 women (32%) and 654 men (68%),

Magnetic resonance imaging

with a mean age of 45 years, who underwent arthroscopic surgery for rotator cuff and SLAP repair from September 2012 to September 2015. Overall, the sensitivity and specificity of MRI was 0.22 (CI: 0.17–0.26) and 0.98 (CI: 0.96–0.99), respectively. Conclusions: MRI has a low sensitivity and high specificity for detection of partial tears of the long head of the biceps tendon. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Avaliac¸ão da ressonância magnética sem contraste como método para diagnóstico de lesões parciais do tendão da cabec¸a longa do bíceps r e s u m o Palavras-chave:

Objetivo: Avaliar a ressonância magnética (RM) sem contraste como método diagnóstico da

Sensibilidade e especificidade

lesão parcial da cabec¸a longa do bíceps com o uso da cirurgia artroscópica como padrão

Manguito rotador

ouro.

Imagem por ressonância magnética

Study conducted at the Hospital Orthoservice, Grupo de Ombro e Cotovelo, São José dos Campos, SP, Brazil. Corresponding author. E-mails: dr.nascimento@icloud.com, jangadamed@hotmail.com (A.T. Nascimento). http://dx.doi.org/10.1016/j.rboe.2016.12.003 2255-4971/© 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). ∗


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Métodos: Foram avaliados dados de RM e achados cirúrgicos artroscópicos de pacientes operados devido à lesão do manguito rotador e à lesão do alto do labrum de anterior para posterior (do inglês superior labral anterior to posterior SLAP). Foi usado como critério de detecc¸ão de lesão da cabec¸a longa do bíceps ressonância magnética sem contraste de no mínimo 1,5 Tesla, com laudo de radiologistas. Todos os casos foram operados por um único cirurgião em nosso hospital. Resultados: O estudo avaliou dados de 965 pacientes, 311 mulheres (32%) e 654 homens (68%), com média de 45 anos, que se submeteram a cirurgia artroscópica para reparo do manguito rotador e da SLAP, entre setembro de 2012 e setembro de 2015. De forma geral, a sensibilidade e a especificidade da RM fora, de 0,22 (IC:0,17 a 0,26) e 0,98 (IC: 0,96 a 0,99), respectivamente. Conclusões: A RM tem baixa sensibilidade e alta especificidade para detecc¸ão de roturas parciais do tendão da cabec¸a longa do bíceps. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Este e´ um artigo Open Access sob uma licenc¸a CC BY-NC-ND (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction Injuries of the long head of the biceps tendon are common in patients with shoulder pain; surgery is required in approximately half of cases. Pathological changes of the long head of the biceps tendon include tenosynovitis, partial rupture, complete rupture, subluxation, and dislocation.1,2 Although in most cases the lesion of the long head of the biceps is part of a syndrome or is associated with other conditions, it is not uncommon to identify it as the sole cause of shoulder pain.3–5 Magnetic resonance imaging (MRI) is routinely used as a method to assess cases of shoulder pain and diagnose rotator cuff injury and injuries of the long head of the biceps. The literature on the effectiveness of MRI without contrast consists of small case series that examined biceps injury, but as a secondary objective.1,6 There are only four studies that specifically examined the validity of MRI without contrast in the detection of partial injuries of the long head of the biceps tendon as the primary goal, none of which were conducted in Brazil.3,7–9 This study aimed to assess the use of MRI as a diagnostic method for partial rupture of the long head of the biceps tendon. Arthroscopic surgery was adopted as the gold standard (Fig. 1).

Material and methods Data from 965 patients operated at a single center by a single surgeon were retrospectively evaluated. Data from the MRI report of patients who would undergo arthroscopic surgery for rotator cuff repair or SLAP lesions were recorded, with special attention to the description of the conditions of the long head of the biceps. After arthroscopy, data on the long head of the biceps were recorded in cases of partial rupture of its fibers. Inclusion criteria comprised patients with a diagnosis of rotator cuff injury or SLAP injury, who had undergone MRI without contrast of at least 1.5 Tesla, with a radiologist report, and who had undergone arthroscopic shoulder surgery.

Patients with MRI of less than 1.5 Tesla, with a diagnosis of instability of the glenohumeral joint, with complete rupture of the long head biceps, and those who had undergone previous surgery, in which tenotomy or tenodesis of the long head of the biceps was performed, were excluded from the study. Cases of previous surgery that did not approach the long head of biceps were not excluded.

Arthroscopic treatment All surgical procedures were performed by the same surgeon, with patient under general anesthesia and nerve block, in the beach chair position. Both glenohumeral joint and subacromial space were examined, which allowed for the assessment of the glenoid labrum, rotator cuff, and long head of the biceps. The long head of the biceps tendon was directly visualized and inspected for tendinitis and partial or total rupture. Only the exams in which there was partial rupture of the fibers of the long head of the biceps tendon were considered as positive.

Statistical analysis Surgical findings were recorded in 2 × 2 tables as true and false positives and true and false negatives for partial rupture of the biceps tendon. Tables were created to determine sensitivity, specificity, predictive values, likelihood ratio, and odds ratio, which were calculated by Excel. A 95% confidence interval was considered for the analysis of all data. Pearson’s correlation coefficient was used to assess the correlation between the severity of the condition and the presence of partial damage, through Excel. Values between 0 and 0.3 were considered as a weak correlation; between 0.3 and 0.6, moderate correlation; and greater than 0.6, strong correlation. To assess this relationship, the Mann–Whitney test was also used in the Minitab program.

Results Data were collected from 965 patients, 311 women (32%) and 654 men (68%), mean age 45 years, who underwent


42

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Fig. 1 – Examples of partial lesion of the long head of the biceps seen on arthroscopy.

Table 1 – Effectiveness of MRI for the diagnosis of lesions of the long head of the biceps.

No MRI lesion MRI lesion Total Sensitivity Specificity Accuracy Positive predictive value Negative predictive value Positive likelihood ratio Negative likelihood ratio Diagnostic odds ratio

No IO lesion

IO lesion

Total

615 14 629 22% 98% 71% 84% 70% 9.8 0.8 12.2

263 73 336 CI (0.17–0.26)* CI (0.96–0.99)* CI (0.68–0.74)* CI (0.74–0.91)* CI (0.67–0.73)* CI (5.6–17.0)* CI (0.76–0.85)* CI (6.8–22.0)*

878 87 965

IO, intraoperative; MRI, magnetic resonance imaging. ∗

95% confidence interval.

arthroscopic surgery for rotator cuff injury repair and SLAP from September 2012 to September 2015. The results obtained from the assessment of all patients together were compiled in Table 1. The prevalence of lesions of the long head of the biceps was 0.35 (CI: 0.32–0.38). Patients were divided into four groups, depending on the disorder concerned and the severity of the injury: SLAP injury (Table 2); partial rotator cuff tear (Table 3); rotator cuff tear <3 cm (Table 4); and rotator cuff tear >3 cm (Table 5). The prevalence of complete rotator cuff tears was 33% (319/965) throughout the sample, with 53% partial rotator cuff

tears (513/965) and 14% SLAP lesions (133/965). Of the complete tears, 7% (70 of 965) were larger than 3 cm and 26% (249 of 965) were smaller than 3 cm. The prevalence of partial lesion of the long head of the biceps was 9% (12 of 133) in SLAP injuries, 28% (144 of 513) in partial supraspinatus lesions, 48% (119 of 249) in complete lesions of the supraspinatus smaller than 3 cm, and 87% (61 of 70) in lesions greater than 3 cm. Pearson’s coefficient showed a moderate correlation (0.38) between the severity of the injury and the presence of partial injuries of the long head of the biceps. The Mann–Whitney test showed a statistically significant value for this correlation, with p < 0.0001.

Table 2 – Effectiveness of MRI for the diagnosis of lesions of the long head of the biceps, when associated with SLAP lesions.

No MRI lesion MRI lesion Total Sensitivity Specificity Accuracy Positive predictive value Negative predictive value Positive likelihood ratio Negative likelihood ratio Diagnostic odds ratio IO, intraoperative; MRI, magnetic resonance imaging. ∗

95% confidence interval.

No IO lesion

IO lesion

Total

117 4 121 25% 97% 90% 43% 93% 7.56 0.78 9.75

9 3 12 CI (0.08–0.53)* CI (0.92–0.98)* CI (0.85–0.95)* CI (0.11–0.79)* CI (0.86–0.96)* CI (1.9–29.9)* CI (0.56–1.08)* CI (1.9–50.4)*

126 7 133


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Table 3 – Effectiveness of MRI for the diagnosis of lesions of the long head of the biceps, when associated with partial lesion of the supraspinatus tendon.

No MRI lesion MRI lesion Total Sensitivity Specificity Accuracy Positive predictive value Negative predictive value Positive likelihood ratio Negative likelihood ratio Diagnostic odds ratio

No IO lesion

IO lesion

Total

364 5 369 24% 99% 78% 87% 77% 17.4 0.77 22.5

110 34 144 CI (0.17–0.31)* CI (0.97–0.99)* CI (0.74–0.82)* CI (0.72–0.95)* CI (0.73–0.80)* CI (6.9–43.7)* CI (0.7–0.85)* CI (8.6–58.9)*

474 39 513

IO, intraoperative; MRI, magnetic resonance imaging. ∗

95% confidence interval.

Table 4 – Effectiveness of MRI for the diagnosis of lesions of the long head of the biceps, when associated with complete lesion of the supraspinatus tendon <3 cm.

No MRI lesion MRI lesion Total Sensitivity Specificity Accuracy Positive predictive value Negative predictive value Positive likelihood ratio Negative likelihood ratio Diagnostic odds ratio

No IO lesion

IO lesion

Total

125 5 130 24% 96% 62% 85% 58% 6.34 0.79 8.05

90 29 119 CI (0.17–0.32)* CI (0.91–0.98)* CI (0.56–0.68)* CI (0.68–0.94)* CI (0.51–0.64)* CI (2.53–15.8)* CI (0.70–0.87)* CI (3.0–21.6)*

215 34 249

IO, intraoperative; MRI, magnetic resonance imaging. ∗

95% confidence interval.

Table 5 – Effectiveness of MRI for the diagnosis of lesions of the long head of the biceps, when associated with complete lesion of the supraspinatus tendon >3 cm. No IO lesion

IO lesion

Total

9 0 9 11% 100% 23% 100% 14% NC 0.89 NC

54 7 61 CI (0.05–0.21)* CI (0.7–1.0)* CI (0.13–0.33)* CI (0.56–1.0)* CI (0.07–0.26)*

63 7 70

No MRI lesion MRI lesion Total Sensitivity Specificity Accuracy Positive predictive value Negative predictive value Positive likelihood ratio Negative likelihood ratio Diagnostic odds ratio

CI (0.8–0.96)*

IO, intraoperative; MRI, magnetic resonance imaging. ∗

95% confidence interval.

Discussion In the literature, studies that assess imaging methods for the diagnosis of partial lesions of the long head of the biceps are rare. Almost all studies evaluate the accuracy of these tests only for complete injuries of this tendon. Literature

review retrieved only four studies that specifically examined validity of MRI without contrast in the detection of partial damage to the long head of the biceps tendon as primary goal.3,7–9 The present study showed that MRI without contrast has high specificity for partial lesions of the long head of the biceps tendon, but low sensitivity. There appears to be an agreement


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among studies reporting lower sensitivity and higher specificity of MRI in detecting pathologies of the long head of the biceps.7 In their study, Houtz et al.10 observed low sensitivity, which ranged from 7% to 33%, versus specificity values ranging from 95% to 100% in the 31 cases of alterations of the long head of the biceps out of 104 cases evaluated by MRI without contrast, regardless of the radiologists’ place of work (community vs. academia). Nourissat et al.11 addressed only tendinopathy in the intra-articular portion of the long head of biceps and reported a sensitivity of 43% and a lower specificity value (75%). Beall et al.,3 with a sample size of 111 patients, reported sensitivity and specificity of 52% and 86%, respectively, for total or partial ruptures of the long head of the biceps, with a prevalence of 21% (23 of 111). In partial ruptures of the long head of the biceps, previous studies are consistent with the low sensitivity observed in the present study.7,11 Mohtadi et al.,1 who examined the long head of the biceps in a prospective study of 58 patients, observed a prevalence of partial lesions of 19%, with sensitivity and specificity of 50% and 70%, respectively. Dubrow et al.7 reported a sensitivity of 28% and specificity of 84% for the detection of partial rupture of the long head of the biceps. Mohtadi et al.1 reported sensitivity of 0% and a specificity of 94% for full-thickness biceps tendon tear. Partial ruptures remain a challenge for diagnosis by MRI without contrast due to several reasons. The long head of the biceps is subject to an MRI artifact that occurs in the cranial portion of the intertubercular groove, which is surrounded by collagen and appears hyperintense, and thus can be mistaken for a pathological change.12 The anatomy of the rotator interval is complex, and rotator cuff tears may hinder the interpretation of the long head of the biceps due to fluid that extends to the region. Another factor is that positioning the patient with the arm in internal rotation increases the difficulty of assessing the tendon. In the present study, the reduced sensitivity values in patients with rotator cuff tears larger than 3 cm indicate that the most serious injuries probably add difficulty to diagnosis of injuries of the long head of the biceps. In their study, Razmajou et al.9 found results similar to those of the present study, demonstrating that the severity of the rotator cuff injury decreases the sensitivity of the MRI to detect the biceps injury. In the present study, rotator cuff injuries that appeared more severe at the MRI presented lower sensitivity; in these cases, the prevalence of partial ruptures of the long head of the biceps presents its highest value. Therefore, as also shown in other studies, the severity of the rotator cuff injury (retraction of the tendon, muscle atrophy, and fat infiltration) may result in underestimation of the biceps injury and contribute to lower sensitivity.13 Some considerations should be made in relationship to the present study. As it was a retrospective study, it presents the inherent shortcomings of this type of study. Another issue is the fact that the scans were interpreted by radiologists from the community, who were not necessarily trained to interpret musculoskeletal MRIs; nonetheless, some studies have failed to identify differences in MRI interpretation by academic and community radiologists.10 As a positive aspect, this study had a significant sample of 965 patients; to the best

of the authors’ knowledge, that is the largest sample in the subject.1–14

Conclusion MRI without contrast has low sensitivity and high specificity for the detection of partial lesions of the long head of the biceps tendon. In partial rotator cuff injuries, complete smalland-medium lesions smaller than 3 cm, and in SLAP lesions, MRI sensitivity is a little better, but still far from optimal. The higher the severity of the rotator cuff injury, the lower the sensitivity of MRI for the diagnosis of partial rupture of the long head of the biceps tendon.

Conflicts of interest The authors declare no conflicts of interest.

references

1. Mohtadi NG, Vellet AD, Clark ML, Hollinshead RM, Sasyniuk TM, Fick GH, et al. A prospective, double-blind comparison of magnetic resonance imaging and arthroscopy in the evaluation of patients presenting with shoulder pain. J Shoulder Elbow Surg. 2004;13(3):258–65. 2. Murthi AM, Vosburgh CL, Neviaser TJ. The incidence of pathologic changes of the long head of the biceps tendon. J Shoulder Elbow Surg. 2000;9(5):382–5. 3. Beall DP, Williamson EE, Ly JQ, Adkins MC, Emery RL, Jones TP, et al. Association of biceps tendon tears with rotator cuff abnormalities: degree of correlation with tears of the anterior and superior portions of the rotator cuff. Am J Roentgenol. 2003;180(3):633–9. 4. Cervilla V, Schweitzer ME, Ho C, Motta A, Kerr R, Resnick D. Medial dislocation of the biceps brachii tendon: appearance at MR imaging. Radiology. 1991;180(2):523–6. 5. Chan TW, Dalinka MK, Kneeland JB, Chervrot A. Biceps tendon dislocation: evaluation with MR imaging. Radiology. 1991;179(3):649–52. 6. Halma JJ, Eshuis R, Krebbers YM, Weits T, de Gast A. Interdisciplinary inter-observer agreement and accuracy of MR imaging of the shoulder with arthroscopic correlation. Arch Orthop Trauma Surg. 2012;132(3):311–20. 7. Dubrow SA, Streit JJ, Shishani Y, Robbin MR, Gobezie R. Diagnostic accuracy in detecting tears in the proximal biceps tendon using standard nonenhancing shoulder MRI. Open Access J Sports Med. 2014;5:81–7. 8. Spritzer CE, Collins AJ, Cooperman A, Speer KP. Assessment of instability of the long head of the biceps tendon by MRI. Skeletal Radiol. 2001;30(4):199–207. 9. Razmjou H, Fournier-Gosselin S, Christakis M, Pennings A, ElMaraghy A, Holtby R. Accuracy of magnetic resonance imaging in detecting biceps pathology in patients with rotator cuff disorders: comparison with arthroscopy. J Shoulder Elbow Surg. 2016;25(1):38–44. 10. Houtz CG, Schwartzberg RS, Barry JA, Reuss BL, Shoulder Papa L. MRI accuracy in the community setting. J Shoulder Elbow Surg. 2011;20(4):537–42. 11. Nourissat G, Radier C, Aim F, Lacoste S. Arthroscopic classification of posterior labrum glenoid insertion. Orthop Traumatol Surg Res. 2014;100(2):167–70.


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12. Erickson SJ, Cox IH, Hyde JS, Carrera GF, Strandt JA, Estkowski LD. Effect of tendon orientation on MR imaging signal intensity: a manifestation of the magic angle phenomenon. Radiology. 1991;181(2):389–92. 13. Chen CH, Hsu KY, Chen WJ, Shih CH. Incidence and severity of biceps long head tendon lesion in patients with

complete rotator cuff tears. J Trauma. 2005;58(6): 1189–93. 14. Patten RM. Tears of the anterior portion of the rotator cuff (the subscapularis tendon): MR imaging findings. Am J Roentgenol. 1994;162(2):351–4.

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

www.rbo.org.br

Original article

Arthroscopic surgical treatment of recalcitrant lateral epicondylitis – A series of 47 cases夽 Alexandre Tadeu do Nascimento ∗ , Gustavo Kogake Claudio Hospital Orthoservice, Grupo de Ombro e Cotovelo, São José dos Campos, SP, Brazil

a r t i c l e

i n f o

a b s t r a c t

Article history:

Objective: To evaluate the results of patients undergoing arthroscopic surgical treatment of

Received 14 December 2015

refractory lateral epicondylitis, identifying poor prognosis factors.

Accepted 18 March 2016

Methods: A retrospective study of 44 patients (47 elbows) who underwent arthroscopic

Available online 21 December 2016

debridement of the extensor carpi radialis brevis (ECRB) tendon to treat refractory lateral

Keywords:

ter. Patients were assessed by DASH score, visual analog scale of pain (VAS), and ShortForm

Tennis elbow/pathology

36 (SF-36). The mean age at surgery was 44.4 years (32–60). The duration of symptoms prior

epicondylitis from February 2013 to February 2015, operated by a single surgeon at one cen-

Tennis elbow/therapy

to the surgery was approximately 2.02 years (range: 6 months to 10 years). Mean follow-up

Tennis elbow/surgery

was 18.6 months (range of 6–31.9).

Arthroscopy

Results: The mean postoperative DASH score was 25.9 points; mean VAS, 1.0 point at rest

Retrospective studies

(all the patients with mild pain) and 3.0 points at activity, of which 31 (66%) cases presented mild pain, 10 (21%) moderate pain, and six (13%) severe pain; mean SF-36 score was 62.5. A moderate correlation was observed between duration of pain before surgery and the DASH score with the final functional outcome. No significant complications with the arthroscopic procedure were observed. Conclusions: Arthroscopic surgical treatment for recalcitrant lateral elbow epicondylitis presented good results, being effective and safe. The shorter the time of pain before surgery and the lower the preoperative DASH score, the better the prognosis. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Study conducted at the Hospital Orthoservice, Grupo de Ombro e Cotovelo, São José dos Campos, SP, Brazil. Corresponding author. E-mail: dr.nascimento@icloud.com (A.T. Nascimento). http://dx.doi.org/10.1016/j.rboe.2016.03.008 2255-4971/© 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). ∗


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Tratamento cirúrgico artroscópico da epicondilite lateral recalcitrante – Série de 47 casos r e s u m o Palavras-chave:

Objetivo: Avaliar os resultados dos pacientes submetidos a tratamento cirúrgico artroscópico

Cotovelo de tenista/patologia

da epicondilite lateral refratária a tratamento conservador e identificar fatores de pior

Cotovelo de tenista/terapia

prognóstico.

Cotovelo de tenista/cirurgia

Métodos: Estudo retrospectivo de 44 pacientes (47 cotovelos) submetidos a desbridamento

Artroscopia

cirúrgico artroscópico do tendão extensor radial curto do carpo (ERCC) para tratamento de

Estudos retrospectivos

epicondilite lateral refratária a tratamento conservador de fevereiro de 2013 a fevereiro de 2015, operados por um único cirurgião em um único centro. Os pacientes foram avaliados pelo escore de DASH, pela classificac¸ão visual analógica de dor (EVA) e pelo Short-Form 36 (SF-36). A média de idade na cirurgia foi de 44,4 anos (32 a 60). O tempo de sintomas antes da cirurgia foi de 2,02 anos (variac¸ão de seis meses a 10 anos). O seguimento médio foi de 18,6 meses (variac¸ão de seis a 31,9). Resultados: A média dos escores pós-operatórios foi de 25,9 pontos no DASH; 1 ponto no EVA de repouso (todos os casos de dores leve) e 3 pontos na EVA em atividade, 31 (66%) casos de dores leves, 10 (21%) de moderadas e seis (13%) de intensas; SF-36 de 62,5. Observou-se uma correlac¸ão moderada entre o tempo de dor antes da cirurgia e a pontuac¸ão no escore de DASH com o resultado funcional final. Não foram observadas complicac¸ões significativas com o procedimento por via artroscópica. Conclusões: O tratamento cirúrgico artroscópico para epicondilite lateral recalcitrante do cotovelo apresenta bons resultados, é eficaz e seguro. Quanto menor o tempo de dor antes da cirurgia e quanto menor o DASH pré-operatório, melhor o prognóstico. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Este e´ um artigo Open Access sob uma licenc¸a CC BY-NC-ND (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction Lateral epicondylitis, or “tennis elbow” is the most common complaint related to the elbow, affecting 1–3% of the adult population annually.1,2 Despite the classical description related to tennis practice, only 5–10% of patients with epicondylitis practice this sport; the condition is more related to work activities.3 Although the name suggests an inflammatory process, epicondylitis is characterized as a non-inflammatory condition, a type of tendinosis with fibroblast and vascular response, called angiofibroblastic degeneration.4 This is a selflimiting pathology, and the vast majority of patients improve with conservative treatment only. However, some factors such as duration of symptoms, previous infiltration, prior orthopedic surgery, and work-related compensation, are known to be related to poor prognosis, increasing the chance of a need for surgery.5 The recurrence rate is 8.5%, and patients whose symptoms last over six months have a high risk of presenting them for long periods and will probably require surgical intervention6 ; these are estimated to represent 4–16% of cases.5,7,8 Numerous surgical procedures to treat this condition have been described.4,9–11 The vast majority have in common the release or debridement of the extensor carpi radialis brevis (ECRB) tendon. Some factors have been attributed to poor prognosis after surgical treatment, especially female gender and injury of the common extensor tendon greater than 6 mm in magnetic resonance imaging12 (Fig. 1). Arthroscopic surgical treatment of lateral epicondylitis has advantages over open surgery, including the ability to

debride the inferior surface of the tendon without invading the aponeurosis of the common extensor (Fig. 2), the ability to assess the joint for intra-articular pathology, and a shorter rehabilitation period.7,13

Material and methods Patients included in this study were operated from February 2013 to February 2015 by a single surgeon at a single center. The study included patients diagnosed with lateral epicondylitis who showed either no improvement or unsatisfactory improvement after conservative treatment, which consisted of six months of physical therapy associated with an orthosis for lateral epicondylitis, two infiltrations or two intramuscular steroid injections, and medications for pain relief. Patients with lateral epicondylitis who had chondral lesions, incipient arthrosis, or cases with previous elbow surgery were excluded. The DASH, VAS, and SF-36 scores were calculated for all patients preoperatively and at the postoperative follow-up.

Surgical technique The surgical technique adopted was based on published reports,1,9 with some adjustments. Patient underwent general anesthesia and brachial plexus block and was then placed in lateral decubitus, opposite to the side to be operated. An elbow support attached to the operating table was positioned under the arm, allowing for the elbow


48

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enhance its positioning. A complete analysis of the anterior compartment of the elbow joint is made, including the joint and the capsule surfaces. Then, a partial capsulotomy of the lateral region is performed to allow the visualization of the ECRB origin, which is extra-articular. With a radiofrequency device, the ECRB tendon is detached from the humerus. Then, the disengaged tendon is debrided with a soft tissue shaver and the lateral portion of the humerus, with a bone shaver, in order to cause bleeding and cell migration to the region. The origin of the ECRB tendon is not reinserted. The collateral ligament may be damaged if the ECRB resection is made “blindly,” due to the collapse of the anterior soft tissue into the viewing space. For this reason, an infusion pump was used in all cases (approximately 60 mmHg), maintaining the joint inflated.

Postoperative period

Fig. 1 – Magnetic resonance imaging showing common extensor tendon lesion (arrow).

In the immediate postoperative period, patients were immobilized with a sling (for three to five days), for comfort only; movement was authorized according to pain, and only exertion with the affected limb was avoided. Physiotherapy for range of motion gain was started after two weeks; isometric strengthening was initiated after full range of motion was achieved, typically around four weeks postoperatively. Resistance exercises were initiated four to six weeks after surgery. Unrestricted use of the limb was authorized after approximately 12 weeks.

Statistical analysis to be moved from 90◦ of flexion to full extension. A pneumatic tourniquet was placed at the root of the arm. Surgical landmarks were drawn on the elbow, including the olecranon, lateral epicondyle, medial epicondyle, radial head, and ulnar nerve. The elbow joint was inflated with 40 mL of saline, placed at the elbow puncture site in the middle of a triangle formed by the lateral epicondyle, the radial head, and the olecranon, to facilitate entrance of the arthroscope into the intra-articular space. The anterosuperomedial and anterosuperolateral portals were preferred, starting with the former, where the trochanter and the arthroscope were placed. The second portal is made with the help of a needle under intra-articular visualization to

Statistical analysis compared the pre- and postoperative measurements with Student’s t-test. Two-tailed paired tests were used in all cases; p-values <0.05 were considered as significant. Pearson’s coefficient was used to assess possible factors that interfere in the final result; values between 0 and 0.3 were considered as weak correlation, between 0.3 and 0.6, as moderate, and greater than 0.6, as strong. Negative values indicate an inverse correlation; positive values, a direct correlation.

Results Inclusion criteria were met by 44 patients (47 elbows), 30 men and 14 women. Mean age at surgery was 44.4 years (32–60). The mean duration of symptoms before surgery was 2.02

Fig. 2 – Arthroscopic images showing a case of a Baker II epicondylitis,7 opening of the lateral capsule, debridement, and detachment of the ECRB tendon.


49

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Preoperative period Postoperative at rest Postoperative during activity p-Value a

VAS

50.1 ± 19.9 (3.33–90) 25.9 ± 23.8 (0–85)a 25.9 ± 23.8 (0–85)a

7.8 ± 1.8 (3–10)a 1.0 ± 0.9 (0–3)a 3.0 ± 2.7 (0–9)a

<0.001

<0.001

a

Values are expressed as mean and standard deviation; the range is presented in parentheses.

years (range: six months to 10 years). Mean follow-up was 18.6 months (range: 6–31.9). A total of 31 right elbows and 16 left were operated. The dominant arm was affected in 65% of cases. Overall, 82% of all patients described their work as “repetitive motion”; 24% received some social security benefit. The cause of the disease was classified as associated with labor activity in 32 patients (73%); in three (7%), due to tennis practice; and in five (11%), due to trauma. The study included patients diagnosed with lateral epicondylitis who showed either no improvement or unsatisfactory improvement after conservative treatment, which consisted of six months of physical therapy associated with an orthosis for lateral epicondylitis, two infiltrations or two intramuscular steroid injections, and medications for pain relief. The results for the improvement in the VAS and DASH scores are shown in Table 1. The mean postoperative DASH score was 25.9 points. Mean post-operative VAS was 3 points; 31 patients (66%) presented mild pain, 10 (21%), moderate pain, and six (13%), intense pain. For the VAS, pain was assessed during activities, not during rest. Mean SF-36 was 62.5. Three patients (6.3%) showed no improvement with the procedure. Thirteen patients (29%) were amateur athletes; after the procedure, 10 (77%) were able to return to the same level of activity prior to the injury and three (23%) were unable to return to previous sport. Pearson’s coefficient demonstrated a moderate correlation between duration of pain before surgery and DASH score with final functional outcome. The results of SF-36 were subdivided according to its areas; the detailed results are presented in Table 2. After evaluating results of scores, the correlation of some variables with the outcome was assessed (Table 3). Pearson’s coefficient was used for this analysis, and no variable was shown to have a strong correlation with the outcome. Two variables showed moderate correlation with the final DASH

Patient receives pension benefit Repetitive work Age Duration of preoperative Pre-op functional capacity by SF-36 Pre-op limitation due to physical aspects by SF-36 Pre-op pain by SF-36 Pre-op general health by the SF-36 Pre-op vitality by SF-36 Pre-op social aspects by SF-36 Pre-op limitations due to emotional aspects Pre-op mental health DASH VAS Female gender

DASH

VAS

0.25 0.01 −0.24 0.30 −0.09 0.3

0.20 0.01 −0.15 0.16 −0.16 0.18

−0.22 −0.17 −0.18 −0.29 −0.13 −0.13 0.58 0.15 0.1

−0.13 −0.09 −0.21 −0.29 −0.10 −0.18 0.52 0.22 0.17

Relation between pre-op DASH and post-op VAS Linear (Series 1) VAS post-po

DASH

Table 3 – Pearson’s coefficient for the correlation between the variables and the outcome of treatment by DASH and VAS.

10 5 0 –5

0

20

40

60

80

100

DASH pre-op

Fig. 3 – Scatter plot (variable: DASH pre-op). Relation between DASH pre-op and post-op 10

DASH post-op

Table 1 – Results of DASH and VAS scores.

5

Series 1 0 0

50

100

Linear (Series 1)

–5

DASH pre-op

Fig. 4 – Scatter plot (variable: DASH pre-op).

and VAS; the correlation was stronger for preoperative DASH score than for duration of pain before surgery. This superiority in the correlation can be observed in Table 3 (Pearson’s coefficient), and in the scatter plots shown in Figs. 3–5.

Table 2 – SF-36 – comparison of the pre- and postoperative periods.a

Pre-op Post-op p-Value a

Functional capacity

Limitation due to physical aspects

Pain

67.5 ± 16.9 (25–100) 72 ± 21.5 (15–100) 0.03

22.4 ± 35.7 (0–100) 37.5 ± 46.2 (0–100) 0.01

35.8 ± 21.3 (0–80) 55.5 ± 25.2 (10–90) 0.000003

General health

69 ± 19.6 (30–100) 65.7 ± 21 (15–100) 0.25

Vitality

Social aspects

Limitations due to emotional aspects

Mental health

55.4 ± 24.5 (5–100) 68 ± 23.5 (0–100) 0.004

78.3 ± 27.2 (0–100) 76.9 ± 24.6 (0–100) 0.007

39.5 ± 45.1 (0–100) 47 ± 45.3 (0–100) 0.40

63.5 ± 23 (4–100) 77.7 ± 17.6 (28–100) 0.0003

Values are presented as mean and standard deviation; the range is in parentheses.


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DASH post-op

Relation between duration of pain pre-op and DASH post-op 100

Series 1 Linear (Series 1)

50

0 0

100

200

300

Duration of pain in months

Fig. 5 – Scatter plot (variable: duration of pain before surgery).

Complications Two patients had superficial infection, which improved after one week of oral antibiotic therapy. A second debridement was not necessary, and no additional complications were observed.

Discussion Lateral epicondylitis is a common diagnosis that responds well to conservative treatment. Surgical intervention is necessary when symptoms do not improve or when improvement is unsatisfactory after at least six months of treatment, which occurs in 4–16% of cases.5,7,8 The present study evaluated the functional response and pain in this group of patients with recalcitrant epicondylitis who underwent arthroscopic debridement of the ECRB tendon. Significant improvements were observed in scores studied, with the exception of only two items from SF-36. Results obtained at the VAS are consistent with the literature, which shows slightly better results when the score is measured with the patient at rest than during activity with the upper limb.14 The literature indicates that the DASH score results for this type of treatment are good. In a study comparing the arthroscopic procedure with a percutaneous technique, the DASH score was assessed before and after surgery, showing significant results (p < 0.05). The DASH score changed from 72 to 48 points in arthroscopic cases and from 70 to 50 in the percutaneous group.15 In the present study, patients had a lower mean final score (25.9 points), but the mean preoperative values were also lower. Other Brazilian studies have also shown good results with this surgery, observing a significant improvement in the scores evaluated.16–18 Despite the good results, it should be noted that approximately 23% of patients who were amateur athletes failed to return to the level of activity prior to the injury or had to change sports. Another point to consider is that three patients (6% of cases) did not observe any improvement with surgical treatment. Some studies indicate that, regardless of the technique used, results of epicondylitis surgery are not uniform. Verhaar et al.19 reported a patient satisfaction rate of 66% in one year of follow-up. Only one-third of the patients had returned to work. Nirschl and Pettrone4 reported that 85% of patients treated with open technique had complete relief of symptoms and had no activity restrictions. In the present study, only seven patients (15%) had complete remission of symptoms even during manual activity.

One of the advantages of the arthroscopic treatment is earlier rehabilitation. Owens et al.11 reported improvements in 16 patients after arthroscopic release, with a mean return to work without restriction of six days. Baker and Baker20 published the long-term results of a cohort study and indicated that they did not deteriorate over time. Patients who were well after two years maintained their functional level, without worsening pain in some cases, even ten years after the procedure. As for prognostic factors, preoperative DASH and duration of pain presented a moderate correlation. These factors may be related to the severity of the condition. Other studies12 have detected as prognostic factors the female gender, which in the present study showed no association, and the stage of the condition at resonance, not assessed in the present study.

Conclusions Arthroscopic surgery for the treatment of recalcitrant lateral epicondylitis showed good results, representing an effective and safe technique. With this treatment, a significant improvement in all scores was observed. The shorter the duration of pain before surgery and the lower the preoperative DASH, the better the postoperative results are.

Conflicts of interest The authors declare no conflicts of interest.

references

1. Lattermann C, Romeo AA, Anbari A, Meininger AK, McCarty LP, Cole BJ, et al. Arthroscopic debridement of the extensor carpi radialis brevis for recalcitrante lateral epicondylitis. J Shoulder Elbow Surg. 2010;19(5):651–6. 2. Cohen M, Motta Filho GR. Epicondilite lateral do cotovelo. Rev Bras Ortop. 2012;47(4):414–20. 3. Boyer MI, Hastings H 2nd. Lateral tennis elbow: is there any science out there? J Shoulder Elbow Surg. 1999;8(5):481–91. 4. Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 1979;61(6):832–9. 5. Knutsen EJ, Calfee RP, Chen RE, Goldfarb CA, Park KW, Osei DA. Factors associated with failure of nonoperative treatment in lateral epicondylitis. Am J Sports Med. 2015;43(9):2133–7. 6. Sanders TL Jr, Maradit Kremers H, Bryan AJ, Ransom JE, Smith J, Morrey BF. The epidemiology and health care burden of tennis elbow: a population-based study. Am J Sports Med. 2015;43(5):1066–71. 7. Baker CL Jr, Murphy KP, Gottlob CA, Curd DT. Arthroscopic classification and treatment of lateral epicondylitis: two-year clinical results. J Shoulder Elbow Surg. 2000;9(6):475–82. 8. Coonrad RW, Hooper WR. Tennis elbow: its course, natural history, conservative and surgical management. J Bone Joint Surg Am. 1973;55(6):1177–82. 9. Baker CL. Arthroscopic versus open techniques for extensor tenodesis of the elbow. Tech Shoulder Elbow Surg. 2000;1:184–91. 10. Baumgard SH, Schwartz DR. Percutaneous release of the epicondylar muscles for humeral epicondylitis. Am J Sports Med. 1982;10(4):233–6.


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11. Owens BD, Murphy KP, Kuklo TR. Arthroscopic release for lateral epicondylitis. Arthroscopy. 2001;17(6):582–7. 12. Yoon JP, Chung SW, Yi JH, Lee BJ, Jeon IH, Jeong WJ, et al. Prognostic factors of arthroscopic extensor carpi radialis brevis release for lateral epicondylitis. Arthroscopy. 2015;31(7):1232–7. 13. Szabo SJ, Savoie FH 3rd, Field LD, Ramsey JR, Hosemann CD. Tendinosis of the extensor carpi radialis brevis: an evaluation of three methods of operative treatment. J Shoulder Elbow Surg. 2006;15(6):721–7. 14. Oki G, Iba K, Sasaki K, Yamashita T, Wada T. Time to functional recovery after arthroscopic surgery for tennis elbow. J Shoulder Elbow Surg. 2014;23(10):1527–31. 15. Othman AM. Arthroscopic versus percutaneous release of common extensor origin for treatment of chronic tennis elbow. Arch Orthop Trauma Surg. 2011;131(3):383–8. 16. Martynetz FA, Fariac FF, Supertic MJ, Mussi Filho S, Oliveira LMM. Avaliac¸ão de pacientes submetidos ao tratamento

17.

18.

19.

20.

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artroscópico da epicondilite lateral refratária ao tratamento conservador. Rev Bras Ortop. 2013;48(6):532–7. Miyazaki AN, Fregoneze M, Santos PD, da Silva LA, Pires DC, Mota Neto J, et al. Avaliac¸ão dos resultados do tratamento artroscópico da epicondilite lateral. Rev Bras Ortop. 2010;45(2):136–40. Zoppi Filho A, Vieira LAG, Ferreira Neto AA, Benegas E. Tratamento artroscópico da epicondilite lateral do cotovelo. Rev Bras Ortop. 2004;39(3):93–101. Verhaar J, Walenkamp G, Kester A, van Mameren H, van der Linden T. Lateral extensor release for tennis elbow. A prospective long-term follow-up study. J Bone Joint Surg Am. 1993;75(7):1034–43. Baker CL Jr, Baker CL 3rd. Long-term follow-up of arthroscopic treatment of lateral epicondylitis. Am J Sports Med. 2008;36(2):254–60.


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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

www.rbo.org.br

Original article

Biomechanical evaluation of the long head of the biceps brachii tendon fixed by three techniques: a sheep model夽 Carlos Henrique Ramos ∗ , Júlio Cezar Uili Coelho Universidade Federal do Paraná, Curitiba, PR, Brazil

a r t i c l e

i n f o

a b s t r a c t

Article history:

Objective: To evaluate the biomechanical properties of the fixation of the long head of the

Received 22 February 2016

biceps brachii into the humeral bone with suture anchors, interference screw, and soft tissue

Accepted 18 March 2016

suture, comparing strength, highest traction load, and types of fixation failure.

Available online 30 December 2016

Methods: Thirty fresh-frozen sheep shoulders were used, separated into three groups of ten for each technique. After fixation, the tendons were subjected to longitudinal continuous

Keywords:

loading, obtaining load-to-failure (N) and displacement (mm).

Biceps braquii

Results: The mean load-to-failure for suture anchors was 95 ± 35.3 N, 152.7 ± 52.7 N for

Humerus

interference screw, and 104.7 ± 23.54 N for soft tissue technique. There was a statistically sig-

Biomechanic

nificant difference (p < 0.05), with interference screw demonstrating higher load-to-failure

Tendons

than suture anchor fixation (p = 0.00307) and soft tissue (p = 0.00473). The strength of interference screw was also superior when compared with the other two methods (p = 0.0000127 and p = 0.00000295, respectively). There were no differences between suture anchors and soft tissue technique regarding load-to-failure (p = 0.9420) and strength (p = 0.141). Conclusion: Tenodesis of the long head of the biceps brachii with interference screw was stronger than the suture anchors and soft tissue techniques. The other two techniques did not differ between themselves. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Avaliac¸ão biomecânica da fixac¸ão do tendão da cabec¸a longa do bíceps braquial por três técnicas: modelo em ovinos r e s u m o Palavras-chave:

Objetivo: Avaliar biomecanicamente a fixac¸ão da cabec¸a longa do bíceps braquial no úmero

Bíceps braquial

com âncoras ósseas, parafuso de interferência e sutura em partes moles e comparar resistên-

Úmero

cia, forc¸a máxima de trac¸ão e tipos de falha na fixac¸ão.

夽 Study conducted at the Centro Universitário (UniBrasil), at the Pontifícia Universidade Católica do Paraná, and at the Universidade Federal do Paraná, Curitiba, PR, Brazil. ∗ Corresponding author. E-mail: chramos@hotmail.com (C.H. Ramos). http://dx.doi.org/10.1016/j.rboe.2016.12.008 2255-4971/© 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).


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r e v b r a s o r t o p . 2 0 1 7;5 2(1):52–60

Biomecânica

Métodos: Foram usados 30 ombros de ovinos frescos, divididos em três grupos de dez para

Tendões

cada técnica. Após fixac¸ão, os tendões foram submetidos a trac¸ão longitudinal contínua até falha do sistema e obtiveram-se forc¸a máxima de trac¸ão (N) e deslocamento (mm). Resultados:

A forc¸a máxima de trac¸ão foi em média 95 ± 35,3 N para âncoras ósseas,

152,7 ± 52,7 N para parafuso de interferência e 104,7 ± 23,54 N para partes moles. Houve diferenc¸a estatisticamente significativa (p < 0,05): o parafuso de interferência demonstrou forc¸a máxima de trac¸ão superior às fixac¸ões com âncoras ósseas (p = 0,00307) e partes moles (p = 0,00473). A resistência com parafuso de interferência também foi superior à dos outros dois métodos (p = 0,0000127 e p = 0,0000029,5 respectivamente). Âncoras ósseas e partes moles não apresentaram diferenc¸as, tanto para forc¸a máxima de trac¸ão (p = 0,9420) quanto para resistência (p = 0,141). Conclusão: A tenodese da cabec¸a longa do bíceps braquial com parafuso de interferência demonstra maior resistência quando comparada com as técnicas com âncoras ósseas e partes moles. As duas últimas técnicas não diferem. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Este e´ um artigo Open Access sob uma licenc¸a CC BY-NC-ND (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction Disorders of the long head of biceps brachii tendon (LHBBT) are frequent causes of shoulder pain. Treatment should be conservative (analgesics, anti-inflammatories, and physiotherapy, among others); however, when conservative treatment is unsuccessful, surgery is indicated. The recommended procedure is tenotomy of the long head of the biceps (sectioning the tendon at the level of its insertion in the glenoid cavity) with or without tenodesis of the long head of the biceps (fixating the biceps tendon into the bicipital groove of the humerus). Tenodesis has been suggested as advantageous over isolated tenotomy, as it maintains the length/tension ratio and the flexion and supination strength of the elbow, preventing atrophy, pain at the site, and cosmetic deformity. Recent advances have allowed tenodesis to be preferably performed arthroscopically, which, despite promoting results similar to open surgery, offers advantages such as smaller surgical wound, lower post-operative pain, preservation of the deltoid muscle, and earlier return to activities, especially when associated with simultaneous repair of the rotator cuff.1–3 Among the arthroscopic fixation methods, the most frequently used are bone anchors, interference screw (IS), and soft tissue suture without the need for implants.1,2,4–8 Early postoperative mobilization of the upper limb is important for recovery, but may endanger tenodesis with possible release of the tendon. To avoid this issue, the system that provides the highest resistance should be used. Another aspect is the increased cost of the procedure when implants are used; soft tissue technique is cheaper. Identifying which method is more resistant would justify the use or nonuse of implants, defining the most cost-effective technique. There is no consensus in the literature regarding which fixation method is more resistant.9–24 This study aimed to compare three techniques for fixation of the LHBBT in the humerus (bone anchors, IS, and soft tissue suture) regarding

resistance of the fixation, load-to-failure (LTF), and system failure.

Materials and methods After approval by the Research Ethics Committee of the Hospital do Trabalhador of Universidade Federal do Paraná, 30 fresh shoulder specimens from skeletally immature Texel sheep, aged between six and 12 months, were acquired from a specialized company. The specimens were frozen immediately after slaughter and were kept at −20 ◦ C until 24 h before preparation. Samples were then thawed at room temperature to undergo tenodesis. Samples were prepared with dissection of the humeral bone; only the biceps and the anterior portion of the rotator cuff inserted into the greater tuberosity of the humerus were preserved. The proximal biceps tendon was sectioned at the glenoid labrum in the upper portion of the glenoid cavity (scapular bone), maintaining its distal insertion into the cubitus bone (Fig. 1). The specimens were divided into three groups of ten, according to the type of tenodesis; ten pieces were thawed at a time, with an interval of 15 days between each test.

Tenodesis with bone anchors After two holes were made in the humeral metaphyseal region (bicipital groove), two bone anchor screws, made of titanium, ®

with a diameter of 4.0 mm, positioned with an Ethibond 2 suture (braided polyester) were inserted with a distance of 5 mm between them (Fig. 2). Then, the biceps tendon was fixated into the humerus with a single stitch in each anchor (Fig. 3).

Tenodesis with interference screw The metaphyseal humeral region (biceps groove) was drilled at 2 cm from the apex of the humeral head with a bone drill that matched the diameter and length of the screw


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a

b Rc

Bc H

Bg

Cb

H

Fig. 1 – Photograph of the parts obtained by dissection; the distal insertion of the biceps in the cubitus bone (a) and the rotator cuff to the humerus (b) were maintained, Cb, cubital bone; Bc, biceps; Bg, bicipital groove; H, humerus; Rc, rotator cuff.

(7 × 20 mm). The free end of the tendon was repaired using ®

continuous suture with Ethibond 2 and inserted into the humeral orifice for fixation with IS, parallel to the tendon fibers (Figs. 4 and 5). During screw insertion, the tendon was kept in traction against the opposite cortex through prior transfixation of the repair wire with a fenestrated steel guidewire to keep it within the bone hole.

Biceps tenodesis in soft tissue The bicipital tendon suture was made on the remaining portion of the rotator cuff that was maintained in the greater tuberosity of the humerus, with three simple stitches using ® Ethibond 2 sutures (Fig. 6). ®

Measurements were made with a Vonder precision metallic caliper (150 mm-6 ). After surgical preparation, material was sent to the Biomechanics Laboratory of the Universidade Tecnológica Federal do Paraná (UTFPR) for testing. For axial traction, the universal MTS 810 (100 KN) hydraulic equipment for tensile tests was used, with a second actuator

(MTS 242.02) adapted with a load cell (model 661.19F-02, MTS Systems Corporation, with a capacity of 10KN, and applied at a speed of 5 mm/min. Models were fitted so that the traction to be exerted in the longitudinal direction in relation to the axes of the tendon and humerus would simulate the normal direction of contraction by the biceps. Iron devices were developed and placed on the tensile equipment to fixate the ends of the specimen. At the top, the ulnar bone was supported on this device and the tendon was passed through the center hole. For lower stabilization, a cylindrical adapter was fixed on the traction table. This piece had interior lateral perforations for humeral stabilization, with two strong steel wires of a diameter (5 mm), cross-transfixated in the metaphyseal region. The distance between the extremities varied according to the length of the muscle/tendon pair. For a better fit, the length of the humerus was cut at the middle third during assembly (Fig. 7). With the help of MTS-Test Star II software, 790.90, TestWorks – 1994, graphics indicating the LTF (N) were made. LTF was defined

Fig. 2 – Photographs showing the humeral preparation with bone perforations (a), insertion of the anchors in the bicipital groove (b) and type of anchor used (c).


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a

b

a

b

Bg Bg

Is

Bg

H

H Bc

Bg

Is

H

Is

Bc

Ba

Bc

Bc

H

Bc

Fig. 5 – Drawing (a) and specimen photograph (b) showing the fixation technique with interference screw. Bc, biceps; Bg, bicipital groove; Is, interference screw; H, humerus.

Fig. 3 – Drawing (a) and specimen photograph (b) showing the fixation technique with bone anchors. Ba, bone anchors; Bc, biceps; Bg, bicipital groove; H, humerus.

®

The tests were done with Microsoft Excel XP and Origin ® 6.1 Pro programs. For the statistical analysis and adjustment of the reliability/survival models, the statistical software R, which is open source, was used.

as the force required to break the fixation (system failure), obtained with peak of the curve, represented by the vertical axis of the graph. The system was considered to have failed when it lost tensile strength, whether by tendon slip or loosening or rupture of the fixation, even in cases without complete separation of the tendon-bone system. The dislocation until failure was represented by the horizontal axis. Resistance was calculated by dividing the LTF by the dislocation (Fig. 8). The results were statistically analyzed with Kaplan–Meier non-parametric estimation of the survival function. The 95% confidence intervals for the probability of the system not failing until a certain force (LTF and resistance) were compared for every method. For quantitative evidence, the logrank significance test was used and the p-value was calculated (significant at p < 0.05).

a

Results The LTF and resistance results for the three methods, presented as maximums, minimums, and means, are described in Tables 1 and 2. The central data values, dispersion, and possible outliers are shown in box-plot graphs for the same variables (Fig. 9). The mean LTF for the three methods was: 95 ± 35.3 N (range 50–156 N) for bone anchors; 52.7 ± 152.7 N (57–212 N) for IS; 104.7 ± 23.54 N (75.9–145 N) for soft tissues. In the technique with bone anchors, failure occurred mainly at the junction of the suture in the tendon (nine tests), with fiber tear in the longitudinal direction without release of the bone

b

c

Bc

H

Fig. 4 – Photographs showing the fixation technique with interference screw: humeral perforation (arrow) (a), tendon repair (b) and type of screw (c) Bc, biceps; H, humerus; Arrow, humeral drilling.


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a

Rc

200.00

b

Rc Peak force

Bc

150.00

Traction force

Bc

H

100.00

50.00

H 0.00 36 000

41 000

46 000 Actuator2 (mm)

51 000

56 000

Dislocation (mm)

Fig. 8 – Values recorded for peak force and displacement until system failure. Fig. 6 – Drawing (a) and specimen photograph (b) showing the fixation technique in soft tissue. Bc, biceps; Rc, rotator cuff; H, humerus.

anchor(s) (Fig. 10). In one test, a suture at the distal anchor failed, and a tendon rupture was observed in the suture. In the tests with IS, failure occurred mainly due to tendon slip (eight tests), and there were no cases of implant loosening (Fig. 11). In two cases, the failure occurred due to a rupture in the myotendinous junction, without loosening of fixation. All tests with soft tissue fixation presented failure by tendon slip; the sutures in the biceps and rotator cuff fibers remained intact. The Kaplan–Meier curves and the logrank p-values applied to the three methods studied demonstrated that the fixation with IS is significantly different (p < 0.05) from the

a

b

other methods, presenting higher LTF when compared with fixation with bone anchors (p = 0.00307) and soft tissue suture (p = 0.00473). IS resistance was also superior to the other two methods (p = 0.0000127 and p = 0.00000295, respectively). Bone anchors and soft tissue suture did not differ significantly for both LTF (p = 0.9420) and resistance (p = 0.141).

Discussion Tenodesis of the long head of the biceps has been preferably performed by arthroscopy, and safe fixation must ensure early return to postoperative mobilization without release of the tendon.2 Among the most commonly used fixation methods (soft tissue suture, bone fixation with bone anchors, and IS)

c Bc

H

Fig. 7 – Photos showing the final assembly of the model (a), humeral fixation with transfixed steel wires (b) and direction/axis of the traction (arrows) (c) Bc, biceps; H, humerus; Arrows, direction of traction.


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r e v b r a s o r t o p . 2 0 1 7;5 2(1):52–60

14

Resistance (N / mm)

12

10

Bc 8

6

H 4

Bone anchors

Interference screws

Soft tissue

Fig. 9 – Central data values, dispersion, and possible outliers of the long head of the biceps strength after tenodesis by bone anchors, interference screw, and soft tissue fixation without implant (n = 30).

Fig. 11 – Specimen photograph showing the slip of the tendon fixated with interference screw (arrow). Bc, biceps; H, humerus; Arrow, tendon slip.

Table 2 – Resistance of the tendon of the long head of the biceps after tenodesis with bone anchors, interference screw, and soft parts suture without implant (n = 30). Bone anchors N/mm

Bc Mean Maximum Minimum SD

H

4.7 7.7 2.8 1.5

IS N/mm

9.9 13.9 6.4 2.3

Soft tissue N/mm

4.1 5.6 3.2 0.6

SD, standard deviation; n, number of tests; N, Newton/mm; IS, interference screw.

Fig. 10 – Specimen photograph showing suture slip in the tendon due to tear in the test with bone anchors (arrow). Bc, biceps; H, humerus; Arrow, tendon tear.

Table 1 – Load-to-failure of the tendon of the long head of the biceps after tenodesis with bone anchors, interference screw, and soft parts suture without implant (n = 30).

Mean Maximum Minimum SD

Bone anchors N

IS N

Soft tissue N

95 15 50 35.3

152.7 212 57 52.7

104.7 145 75.9 23.5

SD, standard deviation; n, number of tests; N, Newton; IS, interference screw.

there is no consensus on which offers greater resistance. Most studies have compared the resistance between bone anchors and IS; there is less information regarding soft tissue suture. No studies that compared the three types were retrieved in the literature. Nevertheless, according to the literature, the mean LTF for bone anchors is 188 N, ranging from 68.5 N to 310 N. For IS, the mean is 241 N (159–480 N) and for soft tissue fixation, the mean is 179 N (142–216 N).9–24 In the present study, these values were 95 N, 152.7 N, and 104.7 N, respectively; when compared separately with the literature, these values were lower for the three methods. This difference can be attributed to the different methodologies adopted, or to factors such as types of specimens (human cadavers, sheep, pigs), bone density, nature of the implants (metal, bioabsorbable), different types of sutures and bone anchors, frequency in the displacement of traction throughout the tendon, or surgical technique. For bone anchors and soft tissue sutures, simple sutures were made. U-type or loop sutures can modify the resistance to the test.22,25 Alterations can also occur with use of one or two anchors, as two-implant models are generally


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more resistant.14 Anchors prepared with double wire have also showed greater resistance.21 Another factor is the difference observed between cyclical or continuous tensile tests. The present study followed a similar model to that described by Bradbury et al.,18 who tested biceps resistance with continuous traction and justified that fixation failures would occur postoperatively in a single, sudden flexion or supination movement of the forearm, unlike the plastic deformation simulated by cyclic testing. Nonetheless, those authors suggested that cyclic tests should be used for comparing techniques, due to the possibility of variation. This can be considered one of the limitations of the present study. Although some authors included other techniques in their studies, some comparisons between IS and bone anchors were retrieved in the literature. Most showed a statistically significant difference. This suggests that fixation with IS provides greater resistance compared with bone anchors.10,12,15,16,22 Other studies observed no statistical difference between these techniques, despite the fact that the LTF was always higher for fixation with IS.11,14,19–21,23 Regarding soft tissue fixation, two biomechanical studies that compared bone anchors with IS were retrieved in the literature, and no statistical difference in resistance was observed in both studies. Nevertheless, in the second study, the soft tissue suture was made in the tendon of the pectoralis major muscle with more than two stitches, which may explain the higher LTF when compared with IS.17,24 The present study demonstrated that IS fixation is more resistant and presents higher LTF than the other two methods. The main mechanism of failure in the IS method in the present study was tendon slip without screw loosening, observed in 80% of the tests. In only two situations was the system resistance higher, with failure at the myotendinous junction. This situation is similar to the literature, which indicates that failures in the implant-bone system are rare.26 In the methods with bone anchors and soft tissue, failure occurred mainly in the tendon-suture junction, without wire rupture or implant release. Failures occurred in the longitudinal direction of the tendon fibers and of the tensile forces, which produced tear. Lopez-Vidriero et al.17 observed the same effect and concluded that the quality of the tendon is important for these two types of fixation. Another possible failure is due to a wire rupture at the junction with the anchor; other authors indicated that these represent the majority of cases. In these, failure may occur due to lower resistance and quality of the suture or due to the quality of the anchor, as irregularities in the wire passage hole would cause greater friction and would make the wire fragile.10,12,27,28 For practical comparisons regarding the safety of tenodesis, the observations by Jazrawi et al. should be added29 : those authors defined 52 N as the mean force exerted on the biceps tendon to keep the arm in flexion without resistance, and 110 N as the force to sustain 1 kg. When performing tenotomy without fixation, the possibility of retraction of the tendon is high, as demonstrated by Wolf et al. after mean traction of only 110 N caused migration.13 Even with the articular portion of the thickened tendon (the common degenerative process), failure occurs on average after traction of 33 N.30 Attempts to increase resistance with preservation of the superior portion of the labrum at the biceps during tenotomy were not shown to be safe, with medium strength of only 73 N.18

Therefore, tenodesis should be performed when the objective is to prevent retraction of the tendon. With this data, even with the lower resistance values observed in the present study when compared with the literature, the authors suggest that all three techniques would be safe for early active postoperative mobilization of the upper limb, provided that this mobilization is made no weight or resistance. Nevertheless, significant fluctuations were observed; in one study with bone anchors, fixation failed at 50 N traction, and in one study with IS, failed at 57 N. Fixation with IS, despite demonstrating greater mean resistance, presented a higher standard deviation with greater variation of high and low values. Perhaps this technique is more susceptible to errors under greater influence of factors such as variations in the ratio of screw diameter/tendon and/or bone hole, as well as bone and/or tendon quality. Other factors to be considered are variations that can occur in surgical procedures, including surgical technique and surgeon’s experience. This could justify the oscillations; however, in the present study’s methodology, these variables were carefully kept equal. Brand et al.31 demonstrated that bone density may interfere with the resistance of IS fixation. This factor should be taken into if the fixation is made at the supra or sub-pectoral level, especially if performed in patients with osteoporosis. Moreover, variable diameters of the tendon, of the screw, and of the bone drilling, as well as the nature of the implant (metallic or bioabsorbable), do not appear to interfere with the ultimate resistance.32,33 The techniques with bone anchors and soft tissues, albeit offering less resistance, were more constant. Other studies are needed to explain this finding. Some considerations can be made about the use of the three techniques: in elderly patients or patients with osteoporosis, fixation of LHBBT in the soft tissues may be more resistant than bone anchors and IS, which depend on good bone quality. Similarly, soft tissue suture should perhaps be avoided in situations in which tendons are affected by degeneration, thus presenting poor quality. Young patients with good bone quality and higher functional demands would be favorable candidates for the use of implants. This profile includes patients who need greater security in the fixation, cases in which IS is preferred to bone anchors. If the cost factor is relevant, soft tissue fixation could be justified if tendon quality is favorable.

Conclusion The LHBBT fixation method with IS is more resistant than fixation with bone anchors and soft tissue technique. No statistically significant difference in resistance was observed between the latter two methods. The fixation method with IS presents a significantly higher LTF when compared with bone anchors and soft tissues methods. No statistically significant difference in LTF was observed between the latter two methods. Main failure mechanism of IS fixation is tendon slip. In fixation with bone anchors and/or soft tissue fixation, failure occurs predominantly due to tendon rupture. No failure due to implant loosening was observed in the IS and bone anchor methods.


r e v b r a s o r t o p . 2 0 1 7;5 2(1):52–60

Conflicts of interest The authors declare no conflicts of interest.

Acknowledgements To Professor Mauro Albano and Edmar Stieven Filho for the guidance provided during this study. To Professor Dr. Paulo Borges and to the mechanical engineering undergraduate Roberto Luis de Assumpc¸ão for technical support in the tests performed in the laboratory of the Universidade Tecnológica Federal do Paraná.

references

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

www.rbo.org.br

Original article

Clinical evaluation of arthroscopic treatment of shoulder adhesive capsulitis夽 Alberto Naoki Miyazaki, Pedro Doneux Santos, Luciana Andrade Silva ∗ , Guilherme do Val Sella, Leonardo Carrenho, Sergio Luiz Checchia Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), Departamento de Ortopedia e Traumatologia, Grupo de Cirurgia do Ombro e Cotovelo, São Paulo, SP, Brazil

a r t i c l e

i n f o

a b s t r a c t

Article history:

Objective: To evaluate the results of arthroscopic releases performed in patients with adhe-

Received 29 October 2015

sive capsulitis refractory to conservative treatment.

Accepted 11 April 2016

Methods: This was a retrospective study, conducted between 1996 and 2012, which included

Available online 20 December 2016

56 shoulders (52 patients) that underwent surgery; 38 were female, and 28 had the dominant side affected. The mean age was 51 (29–73) years. The mean follow-up was 65 (12–168)

Keywords:

months and the mean preoperative time was 8.9 (2–24) months. According to Zukermann’s

Shoulder pain

classification, 23 cases were considered primary and 33 secondary. With the patient in the

Arthroscopy

lateral decubitus position, circumferential release of the joint capsule was performed: joint

Bursitis

debridement; rotator interval opening; coracohumeral ligament release; anterior, posterior, inferior, and finally antero-inferior capsulotomy. A subscapularis tenotomy was performed when necessary. All patients underwent intense physical therapy in the immediate postoperative period. In 33 shoulders, an interscalene catheter was implanted for anesthetic infusion. Functional results were evaluated by the UCLA criteria. Results: Improved range of motion was observed: mean increase of 45◦ of elevation, 41◦ of external rotation and eight vertebral levels of medial rotation. According to the UCLA score excellent results were obtained in 25 (45%) patients; good, in 24 (45%); fair, in two (3%); and poor, in two (7%). Patients who had undergone inferior capsulotomy achieved better results. Only 8.8% of patients who used the anesthetic infusion catheter underwent postoperative manipulation. Seven patients had complications. Conclusion: There was improvement in pain and range of motion. Inferior capsulotomy leads to better results. The use of the interscalene infusion catheter reduces the number of reapproaches. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

夽 Study conducted at the Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), Departamento de Ortopedia e Traumatologia, Grupo de Cirurgia do Ombro e Cotovelo, São Paulo, SP, Brazil. ∗ Corresponding author. E-mail: lucalu@terra.com.br (L.A. Silva). http://dx.doi.org/10.1016/j.rboe.2016.12.004 2255-4971/© 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).


62

r e v b r a s o r t o p . 2 0 1 7;5 2(1):61–68

Avaliac¸ão dos resultados do tratamento artroscópico da capsulite adesiva do ombro r e s u m o Palavras-chave:

Objetivo: Avaliar os resultados das liberac¸ões artroscópicas feitas em pacientes com cap-

Dor de ombro

sulite adesiva refratária ao tratamento conservador.

Artroscopia

Métodos: Trabalho retrospectivo feito entre 1996 e 2012, com 56 ombros (52 pacientes) sub-

Bursite

metidos a cirurgia; 38 eram do sexo feminino e 28 tinham o lado dominante acometido. A média de idade foi de 51 (29-73) anos. O seguimento médio, de 65 (12-168) meses e o tempo médio de pré-operatório, de 8,9 (2-24) meses. Pela classificac¸ão de Zukermann, 23 casos foram considerados primários e 33 secundários. Com o paciente em decúbito lateral, fizemos a liberac¸ão circunferencial da cápsula articular: desbridamento articular, abertura do intervalo rotador, liberac¸ão do ligamento coracoumeral, capsulotomia anterior, posterior, inferior e finalmente, anteroinferior. A tenotomia do subescapular foi feita quando necessária. Todos foram submetidos a fisioterapia intensa no pós-operatório imediato. Em 33 ombros foi implantado o catéter interescalênico para infusão de anestésico. Os resultados funcionais foram avaliados pelos critérios do escore da University of California at Los Angeles (UCLA). Resultados: Obtivemos melhoria do arco de movimento: aumento médio de 45◦ de elevac¸ão, 41◦ de rotac¸ão lateral e oito níveis vertebrais de rotac¸ão medial. Pelo escore da UCLA, tivemos 25 resultados excelentes (45%), 25 bons (45%), dois razoáveis (3%) e quatro ruins (7%). Os pacientes que fizeram capsulotomia inferior evoluíram melhor do que os que não fizeram. Apenas 8,8% dos pacientes que usaram cateter de infusão anestésico foram submetidos a manipulac¸ão no pós-operatório. Sete pacientes apresentaram complicac¸ões. Conclusão: Houve melhoria da dor e do arco de movimento. A capsulotomia inferior leva a melhores resultados. O uso do catéter interescalênico de infusão anestésica diminui o número de reabordagens. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Este e´ um artigo Open Access sob uma licenc¸a CC BY-NC-ND (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction The term “adhesive capsulitis” was first described by Neviaser in 1945, as an inflammatory disease of the shoulder joint capsule that develops with contracture and results in stiffness and pain.1 Treatment aims to control pain and recover range of motion. Initially, treatment is conservative, especially in the acute phase2,3 ; there are several therapeutic options, such as physical therapy, corticosteroids and/or non-steroidal anti-inflammatory drugs (NSAIDs), and suprascapular nerve blocks.4–7 In review articles, Checchia et al.7 and Robinson et al.5 demonstrated good results when treating patients with physical therapy associated with anti-inflammatory drugs (hormonal and non-hormonal) and serial suprascapular nerve blocks. Invasive treatment is indicated in case of failure of conservative treatment conducted for a minimum period of six months; however, according to the literature reviewed, this interval may range from six weeks to 12 months.8–13 Procedures described as invasive include hydraulic distention of the capsule (the literature differ on its effectiveness due to high recurrence rates), joint manipulation under anesthesia, and capsular release, which can be done through open or arthroscopic surgery.4–6,14

Joint manipulation under anesthesia, which was once widely used, is currently being discontinued due to its complications: fractures, glenoid labrum injuries, neurapraxis, rotator cuff tear, and persistent pain.14–17 One of the first descriptions of the surgical technique for shoulder release through the open access route was made by Ozaki et al.,18 who advocated resection of the coracohumeral ligament and opening of the rotator interval. Literature shows that open surgery presents good results, but adds a greater morbidity than arthroscopy: it is difficult to release the posterior capsule and the intraoperative bleeding is greater, as well as postoperative pain, which extends hospital stay; furthermore, it is necessary to restrict movements until the subscapularis tendon heals.4,5,8,14,19 Recent studies have shown excellent results, both in terms of pain relief and range of motion gain, with arthroscopic release of adhesive capsulitis. It is currently considered to be a reproducible method, which enables better access to the entire joint capsule of the shoulder with low rates of complications, since the release is done gradually under direct vision through a minimally invasive method, which nonetheless requires proper training.8–11,19–21 Literature mentions as complications of this procedure the risk of iatrogenic injury to the axillary nerve,22 chondral lesion due to the insertion of the instruments in a joint with reduced space,9 and


r e v b r a s o r t o p . 2 0 1 7;5 2(1):61–68

chondrolysis due to thermal injury caused by the use of intraarticular radiofrequency.23 This study aimed to evaluate the results of arthroscopic releases performed in this department in patients with adhesive capsulitis refractory to conservative treatment.

Material and methods This study retrospectively analyzed 56 shoulders of 52 patients who underwent arthroscopic release due to adhesive capsulitis refractory to conservative treatment. Surgeries were performed between February 1996 and May 2012 by the Shoulder and Elbow Group of the Santa Casa de São Paulo School of Medical Sciences – Fernandinho Simonsen Pavilion. Patients with adhesive capsulitis refractory to conservative treatment, with a minimum follow-up period of one year, with no other abnormalities that could justify the loss of range of motion (osteoarthritis, malunion, and necrosis, among others) were included. The clinical and epidemiological data are shown in Table 1. Patients underwent conservative treatment for a mean period of 8.9 months (2–24). Most of them (66%) were treated with serial suprascapular nerve blocks associated with physiotherapy, with a mean of 12.2 blocks.2–23 Surgery was indicated when there was no response to conservative treatment, i.e., there was improvement in pain but patient remained with limited joint mobility, which hindered their day-to-day activities or even work activities. It was also indicated when patient could not attend the office with the regularity needed for undergoing blocks, that is, every 15 days until complete improvement of the condition, which takes seven months, on average.7 Mean postoperative follow-up was 65 months (12–168) and patients’ age ranged from 29 to 73 years (mean 51.2); 38 patients were female (73%) and 14 male (27%). In 28 (54%) patients, the dominant limb underwent arthroscopic release; in four patients (three female and one male), involvement was bilateral and both shoulders were subjected to this procedure (8%). Regarding the etiology, 23 shoulders were classified according to Zuckerman and Rokito24 as primary capsulitis (41%) and 33 as secondary (59%), 20 of systemic origin. Of these, 15 patients were diabetic (29% of total), 12 had intrinsic causes (92.3%), and one had extrinsic causes (3.7%). Patients underwent several arthroscopic procedures, which varied according to the need and improvement of the surgical technique, as shown in Table 2. With the patient positioned in lateral decubitus, the following steps were taken: through the anterior portal, joint debridement was made, the rotator interval was opened, the coracohumeral ligament was released, and an interior capsulotomy was performed. Then, portal was changed. Through the posterior portal, posterior and inferior capsulotomies were made. Finally, again through the anterior portal, an anteroinferior capsulotomy was made with the aid of a basket-type forceps to avoid axillary nerve injury. At the end of these procedures, circumferential release of the joint capsule was achieved. Lateral rotation was clinically assessed; if the gain was considered

63

to be insufficient, a partial tenotomy of the subscapularis was made (Fig. 1). From the first day post-operative onwards, patients were subjected to an intensive physical therapy work with potent analgesia. An interscalene catheter was used in 33 shoulders (59%) for anesthesia infusion (bupivacaine). At discharge, the catheter was removed and patient was referred for outpatient physiotherapy sessions and received guidelines for performing capsular stretching exercises at home. Patients were hospitalized an average of four days. In the first weeks, patients were instructed to attend 4–5 therapy sessions per week; this schedule was modified according to patient’s improvement. On average, patients attended 53.4 sessions (12–139). The shoulder functional analysis criteria by the University of California at Los Angeles (UCLA)25 was used to assess the present results; shoulder range of motion was measured according to the criteria set forth by the American Academy of Orthopedic Surgeons.26 For the statistical analysis, the following programs were used: SPSS (Statistical Package for Social Sciences) version 17, Minitab 16, and Excel Office 2010, and the following tests were applied: ANOVA, Student’s t-test for paired samples, equality of two proportions, and Pearson’s correlation. To obtain the results, the 95% confidence interval was considered statistically significant (p < 0.05). This study was approved by the hospital’s ethics committee under CAAE No. 14412713.2.0000.5479.

Results Patients presented an improved range of motion. Mean preoperative range of motion was 96◦ of elevation, 16◦ of lateral rotation, and L5 medial rotation; after arthroscopic release, means became 141◦ of elevation, 57◦ of lateral rotation, and T9 medial rotation (p < 0.001). When postoperative results were compared with the contralateral limb, excluding patients who underwent bilateral arthroscopic release, a mean deficit of 3◦ of elevation was observed (p = 0.03). Regarding the procedures, patients undergoing inferior capsulotomy had a mean of 8◦ of elevation (p = 0.057, close to significance margin), 13◦ of lateral rotation (p = 0.003), four vertebral levels (p = 0.002), and 3.2 points in the UCLA score (p = 0.021) more than those patients who did not undergo inferior capsulotomy. Patients undergoing partial tenotomy of the subscapularis (25%) had lower preoperative lateral rotation (p = 0.010) and elevation (p = 0.062). The mean elevation for this group was 86◦ , and mean lateral rotation was 5◦ , which was lower than the 99◦ of elevation and 20◦ of lateral rotation observed in patients who did not undergo this procedure. Regarding postoperative analgesia, only 8.8% of patients in whom the anesthetic infusion catheter was used underwent manipulation during the postoperative follow-up, in contrast with the 31.8% of patients in whom said catheter was not used, which proves its effectiveness in preventing a new procedure (p = 0.028).


45

47 64 49 52 36

F

F M F F M

F

F F

M F F M F F F M F M F M F F M M M

9

10 11 12 13 14

15

16 17

18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34

55 67 60 60 55 57 57 57 53 51 45 50 49 44 43 43 42

56 55

42

56 43 55 44 56 61 47 45

F F F F F F F F

T/years

Age

1 2 3 4 5 6 7 8

Sex

− + + + + + − − − + + − + − + + −

+ +

+

− + + + − − + + − − + + − + + +

Dominant side

Table 1 – Patient clinical data.

– DM II, SAH, breast CA – – Hypot. SAH, Dep. – DM, Coron. SAH DM II – DM I – – – – – DM I DM I

SAH, Tab.

DM II, SAH SAH, DM II DM I – SAH SAH, DM II Epilep. – – SAH, DM II – Asthma DMII, SAH DMI – Tab.

Comorbidities

Post-op cal. tend. – – – – – – – – Tend. calc. – – – – Sd. impact – –

– – – – – – – – – – – – – – Post-op RCI Post-op ft GT + glenoid Ft. humeral neck surg. cons. treat. – –

Associated lesions

60 8 2.5 3.5 5 24 13 3 9.5 36 12 10 24 6 16 13 11

24 24

49

36 36 26 7 17 12 24 22 15 18 13 18 22 42 13 34

T/months

Symptoms

9 8 2.5 3 5 8 6 3 7 12 8 10 24 6 4 5 8

22 24

10

11 18 11 5 11 10 18 13 15 15 11 14 14 7 13 23

T/months

Pre-op treatment

LR ◦

20◦ 45◦

90◦ 80◦ 85◦ 10◦ 70◦ 0◦ 110◦ 60◦ 60◦ −10◦ 110◦ 10◦ 80◦ 10◦ 90◦ 20◦ 90◦ 10◦ 80◦ 0◦ 100◦ 0◦ 80◦ 10◦ 90◦ 0◦ 100◦ 20◦ 100◦ 20◦ 130◦ 45◦ 120◦ 0◦ ◦ 130 20◦

40◦

90◦

90 35 95◦ 10◦ 90◦ 20◦ 70◦ 20◦ 90◦ 0◦ 100◦ 15◦ 70◦ 30◦ 90◦ 0◦ 100◦ 10◦ 90◦ 0◦ 90◦ 10◦ 30◦ −10◦ 70◦ 25◦ 90◦ 0◦ 100◦ 30◦ 125◦ 0◦

Elev.

Pre-op.

L5 GT L5 S1 L4 S1 L4 S1 L5 L5 L3 L5 L5 L5 L1 L3 L3

S1 Glut

Glut

L5 L4 Glut Glut L5 L3 S1 S1 T12 Glut Glut GT GT Glut L2 L4

MR

130◦ 150◦ 140◦ 150◦ 160◦ 140◦ 150◦ 150◦ 150◦ 150◦ 150◦ 140◦ 140◦ 160◦ 140◦ 150◦ 150◦

100◦ 130◦

120◦

140 130◦ 150◦ 150◦ 125◦ 150◦ 120◦ 130◦ 150◦ 150◦ 150◦ 90◦ 130◦ 120◦ 140◦ 140◦

Elev. ◦

70◦ 45◦ 60◦ 60◦ 60◦ 60◦ 80◦ 80◦ 60◦ 60◦ 60◦ 60◦ 60◦ 70◦ 60◦ 60◦ 60◦

20◦ 45◦

60◦

45 40◦ 60◦ 60◦ 30◦ 45◦ 40◦ 50◦ 60◦ 60◦ 60◦ 20◦ 40◦ 30◦ 60◦ 40◦

LR

Post-op.

Range of motion

T12 T10 T8 L4 T2 L5 T5 T6 T7 T10 T7 T10 T8 T5 L1 T10 T8

L3 Glut

L3

T6 T10 T11 T8 T8 T7 T12 S1 T10 T7 L5 GT L1 T10 T9 T10

MR

30 34 32 35 35 35 35 35 35 35 30 34 35 35 35 35 35

18 15

30

31 27 33 33 30 31 15 25 31 35 31 15 30 30 32 28

Score

Good Good Good Excellent Excellent Excellent Excellent Excellent Excellent Excellent Good Excellent Excellent Excellent Excellent Excellent Excellent

Bad Bad

Good

Good Fair Good Good Good Good Bad Fair Good Excellent Good Bad Good Good Good Good

Result

Post-op UCLA

22 115 84 84 39 79 27 70 83 69 74 92 118 86 122 128 95

16 27

42

23 50 26 14 36 72 128 138 72 124 124 51 76 75 64 67

T/months

Follow-up

– – – – – – – – – – – – – – – – –

– –

Radial neurap. – – – – – Pre-op + RCI RSD – – Pain AC Pre-op + RSD – – – –

Complications

64 r e v b r a s o r t o p . 2 0 1 7;5 2(1):61–68


F F F M F F F F M M F F F F

F M F

F 51.2

37 38 39 40 41 42 43 44 45

49 50 51

52 Means

50

48 46 51

49 53

51

35 73 65 58 52 55 57 56 52

42 29

T/years

Age

Tob. – Breast CA

− + +

DM I 8.9

Hypot. SAH, DM II – – Dep. Hypot. DLP DLP SAH, Hypot. SAH, Hypot. – – – Sd. Panic

− − − + − − − + + − − + + +

+ 15.3

– Tab.

Comorbidities

− −

Dominant side

– Ft. GT (cons. treat.) – Osteoarthritis AC – – – – Tend. calc. – – – Wrist ft. + imob. – Sd. impact Cal. tend. of the sub. – Post-op SLAP Post-op epiphyseal ft – 96◦

Associated lesions

6 16◦

5 8 12

5 4 3 5 4 8 12 12 7 3 8 6 6 5

30 3

T/months

Symptoms

8 L5

7 12 12

3 3 3 5 4 6 6 8 2 3 6 2 2 2

6 3

T/months

Pre-op treatment

S1 S1 S1 L4 Glut L4 L5 T12 L4 L5 L2 L3 L4 L4 L3 T8 Glut Glut T9

80◦ 0◦ 130◦ 60◦ 70◦ 0◦ 120◦ 30◦ 40◦ −20◦ 100◦ −10◦ 120◦ 45◦ 120◦ 60◦ ◦ 100 20◦ 120◦ 30◦ ◦ 90 10◦ 130◦ 45◦ ◦ 150 20◦ 100◦ 10◦ 90◦ 0◦ ◦ 140 45◦ 90◦ −10◦ 80◦ 141◦

0◦ 57◦

T10 L2

45◦ 10◦

140◦ 100◦

MR

LR

Elev.

Pre-op.

110◦ 31.4

130◦ 145◦ 130◦

160◦ 140◦ 150◦ 140◦ 160◦ 150◦ 150◦ 160◦ 150◦ 150◦ 150◦ 140◦ 140◦ 150◦

150◦ 140◦

Elev.

60◦

70◦ 70◦ 30◦

45◦ 60◦ 70◦ 30◦ 80◦ 60◦ 70◦ 80◦ 80◦ 80◦ 70◦ 70◦ 70◦ 70◦

60◦ 30◦

LR

Post-op.

Range of motion

T10 64.8

T5 T5 T9

T5 L4 T7 L1 T5 T6 T7 T3 T7 T6 T5 T6 T5 T5

T6 T12

MR

30

28 35 29

35 34 34 32 34 33 33 35 34 35 35 34 32 33

35 28

Score

Good

Good Excellent Good

Excellent Excellent Excellent Good Excellent Good Good Excellent Excellent Excellent Excellent Excellent Good Good

Excellent Good

Result

Post-op UCLA

13

14 19 21

16 12 25 69 107 44 14 19 85 54 96 49 52 72

70 168

T/months

Follow-up

– – –

– – Axillary neurap. – Radial neurap. – – – – – – – – –

– –

Complications

Source: Santa Casa de São Paulo Archives. AC, acromioclavicular joint; CA, cancer; dep., depression; RSD, reflex sympathetic dystrophy; DLP, dyslipidemia; DM, diabetes mellitus; elev., elevation; epilep., epilepsy; F, female; ft., fracture; glut, gluteus; GT, greater trochanter of the femur; SAH, systemic hypertension; hypot., hypothyroidism; imob., immobilization; RCI, rotator cuff injury; neurap., neurapraxia; post-op., post-operative period; pre-op., pre-operative period; LR, lateral rotation; MR, medial rotation; sd, syndrome; sub, subscapularis tendon; tob, tobacco smoker; cal. tend., calcareous tendinitis.; GT, greater tuberosity; cons. treat., conservative treatment prior to the fracture; M, male.

47 48

46

F M

35 36

Sex

Table 1 – (Continued)

r e v b r a s o r t o p . 2 0 1 7;5 2(1):61–68

65


66

r e v b r a s o r t o p . 2 0 1 7;5 2(1):61–68

Fig. 1 – Surgical steps of the arthroscopic release for treating adhesive capsulitis. Sagittal section of the left shoulder showing (a) release of coracohumeral ligament (arrow), (b) anterior capsulotomy performed through the anterior portal, (c) posterosuperior capsulotomy, and (d) anteroinferior capsulotomy, along the axillary nerve, with both capsulotomies performed using the posterior portal, and (e) tenotomy of the superior quarter of the subscapularis muscle tendon, again through the anterior portal.

Table 2 – Procedures performed during arthroscopy. Procedures

Discussion

Number of shoulders

%

56 55 52 44 20 14 24 11 2

100 98 93 78 36 25 43 19 3.5

Opening of the rotator interval Coracohumeral ligament release Anterior capsulotomy Posterior capsulotomy Inferior capsulotomy Subscapularis tenotomy Acromioplasty Mumford Calcareous tendinitis drainage Source: Santa Casa de São Paulo Archives.

No statistical significance was observed in relationship to the results and variables age, sex, and comorbidities among the diabetic and non-diabetic populations and between primary and secondary capsulitis. Based on the results of the UCLA criteria,25 25 shoulders were classified as excellent (45%), 25 as good (45%), two as fair (3%), and four as poor (7%). Seven patients had complications (12.5%), including two with radial neurapraxia, one with axillary neurapraxia, two reoperations, two cases of reflex sympathetic dystrophy, one rotator cuff injury, and one case of acromioclavicular pain.

The primary goal of treatment of adhesive capsulitis is pain relief and restoration of range of motion in the shortest time possible. Initial treatment should be conservative, because the literature shows that physical therapy associated with adjuvant methods yields good results. The minimum duration recommended by most authors is six months, but it can vary from six weeks to 12 months.5,8,9,12,13,27 In the present study, the mean time of evolution to surgical indication was 8.9 (2–24) months. In this service, cases of adhesive capsulitis are treated with physical therapy associated with serial suprascapular nerve blocks, and a rate of 84% good results was observed in a study by the present authors published in 20067 ; 37 (66%) patients in the current study underwent this treatment with a mean of 12 (range: 2–23) nerve blocks until surgical indication. It is noteworthy that the nerve block is done on an outpatient basis, in a minimally invasive manner; however, it must be done regularly every 15 days and its initial analgesic effect, on average, starts after the fourth block.7 For these reasons, many patients refused to follow the treatment and chose surgery, despite the initial guidance for conservative treatment. Regarding invasive procedures, the authors prefer arthroscopic release rather than other techniques, due to the lower rates of complications and excellent results.


r e v b r a s o r t o p . 2 0 1 7;5 2(1):61–68

Gerber et al.19 reported a gain of 38◦ of elevation and 18◦ of lateral rotation; Warner et al.,9 an increase of 49◦ of flexion, 42◦ of lateral rotation, and eight levels of spinal processes in medial rotation; Cohen et al.,21 an increase of 64◦ of flexion, 43.5◦ of lateral rotation, and eight levels in spinal medial rotation; other authors have also reported good results.8,12,13,20 The present results showed an improvement in the elevation of 45◦ , 38◦ of lateral rotation, and eight levels in the spinal medial rotation, with a final mean range of motion of 141◦ of elevation, 57◦ of medial rotation, and 9T medial rotation, results that are in agreement with the literature. Mean elevation and lateral and medial rotation of the contralateral limb of these patients, excluding those who underwent bilateral release, were 143◦ , 56◦ , and T9, respectively. Comparing mean postoperative elevation, excluding patients who had bilateral release, a deficit of only 3◦ was observed (p = 0.030). This demonstrates that, albeit with a small deficit of elevation, generally it is possible to restore range of motion in these patients. Regarding the procedures performed during arthroscopic release, initial cases were limited to opening of the rotator interval, resection of the coracohumeral ligament, anterior and posterior capsular releases, and a final joint manipulation for rupture of the inferior capsule. In their study, Pollock et al.20 performed arthroscopy immediately after manipulation of the shoulder joint and found a rate of 30% of inferior capsule rupture failure with this procedure. Studies of the arthroscopic anatomy of the axillary nerve10,28,29 provided a better understanding, allowing the development of safe techniques for inferior capsular release; therefore, circumferential releases have become standard in the service. The 20 (36%) patients who underwent inferior capsulotomy had better results compared with other patients in the final mean elevation (146◦ vs. 138◦ , p = 0.057), mean lateral rotation (65◦ vs. 52◦ , p = 0.003), mean medial rotation (T7 vs. T11, p = 0.002), and mean postoperative UCLA score25 (33.4 vs. 30.2, p = 0.021). The authors believe that circumferential capsulotomy reduces the risks of complications associated with joint manipulation, as well as the recurrence rate, restoring more functional range of motion in a shorter time. As for the tenotomy of the subscapularis, the procedure was performed in the intra-articular portion of the tendon that is visualized during arthroscopy; it was indicated during surgery, after complete capsular release, when it was not possible to achieve the same lateral rotation (in degrees) as the contralateral side. Pollock et al.20 and Cinar et al.30 observed worse outcomes in diabetic patients when compared with non-diabetic patients after arthroscopic release. In the present study, results of arthroscopic treatment were similar in these two populations, with no statistical significance, both in relationship to the range of motion and final UCLA,2 which was in agreement with results observed with conservative treatment.7 Regarding final mean range of motion, diabetics showed a slight limitation in relation to non-diabetic patients, with mean post-operative elevation (p = 0.551), lateral rotation (p = 0.357), and medial rotation (p = 0.154) of 140◦ , 54◦ , and T11. In turn, these results in non-diabetics were 142◦ , 58◦ , and T9, respectively. Regarding the mean UCLA,25 it was 31.4 for both groups (p = 0.995), although none of these data were statistically significant.

67

Another very important point in the surgical treatment of adhesive capsulitis is postoperative rehabilitation. Physical therapy protocol should be initiated on the first postoperative day, in an intensive regimen associated with potent analgesia, in order to maintain movement gain achieved intraoperatively. The use of interscalene catheter for anesthetic infusion in the early postoperative period is recommended by some authors.2,9,13 Mariano et al.31 concluded that continuous interscalene block is superior to the single application block, providing greater pain relief, minimizing the use of additional opioids, improving sleep quality, and increasing patient satisfaction after shoulder surgery. This analgesia facilitates the physical therapy rehabilitation work, thus leading to a better result. In the present study, of the 33 shoulders (59%) in which this catheter was used, only 8.8% patients required joint manipulation during the postoperative follow-up period: in one patient, the catheter moved out of the interscalene space and lost its analgesic effect on the second postoperative day. Conversely, 31.8% of those in whom this catheter was not used required joint manipulation due to loss of motion in the postoperative follow-up, which proves the effectiveness of this analgesia in preventing relapse (p = 0.028). This manipulation is performed within a maximum of 30 days postoperatively. Complications were observed in seven patients: two patients developed radial neurapraxia, with reversal of symptoms after 2–3 months. This complication probably originated during the interscalene anesthetic block. This patient did not use interscalene catheter for anesthetic infusion. One patient developed axillary neurapraxia postoperatively. He presented a complete recovery of function in four months. This patient did not undergo inferior capsulotomy, but rather the manipulation for inferior capsule rupture. The authors believe that there was a probable traction of the axillary nerve during manipulation, causing symptoms. Although mentioned as a possible complication of inferior capsulotomy,1 no cases of injury or neurapraxia of this nerve were observed in patients who underwent this procedure. Therefore, we can conclude that inferior capsulotomy is a safe procedure, as long as the correct surgical technique is performed. Regarding the other complications, one patient had residual pain in the acromioclavicular joint (case 9), two (cases 8 and 10) developed reflex sympathetic dystrophy in the operated limb, and one had a rotator cuff injury. This patient (case 7) underwent two arthroscopic procedures for treatment of adhesive capsulitis with joint release; during follow-up after second surgery, as the patient still presented range of motion limitation and pain, a magnetic resonance imaging exam was performed, which disclosed rotator cuff injury. In the two previous surgical procedures, patient had undergone joint manipulation to complement capsular release, which may have contributed to the cause of injury. Another patient (case 10) required reoperation, and a wider capsular release was performed; nonetheless, patient still presented range of motion limitation and pain. In the initial surgery, joint access was difficult due to the small articular space, which eventually compromised the procedure: the release of the joint capsule was incomplete. Another patient (case 16) had poor UCLA score25 results; an osteochondral lesion of the humeral head, observed during arthroscopic inspection, may have negatively influenced rehabilitation.


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One patient (case 17), although the range of motion was satisfactorily restored, persisted in pain and was dissatisfied with the results. The two patients (cases 2 and 8) with regular results obtained range of motion improvement; however, they still had restrictions and pain during daily activities, and one of them presented reflex sympathetic dystrophy (case 8).

Conclusion Arthroscopic release of patients with adhesive capsulitis refractory to conservative treatment is effective for improving pain and range of motion. The best results were obtained in patients who underwent inferior capsulotomy. Lower reoperation rates were observed in patients in whom the interscalene catheter for anesthetic infusion was used, demonstrating its importance in postoperative rehabilitation.

Conflicts of interest The authors declare no conflicts of interest.

references

1. Neviaser JS. Adhesive capsulitis of the shoulder. J Bone Joint Surg Am. 1945;27:211–22. 2. Reeves B. The natural history of the frozen shoulder syndrome. Scand J Rheumatol. 1975;4(4):193–6. 3. Grey RG. The natural history of idiopathic frozen shoulder. J Bone Joint Surg Am. 1978;60(4):564. 4. Endres NK, ElHassan B, Higgins LD, Warner JP. The stiff shoulder. In: Rockwood CA Jr, Matsen FA 3rd, Wirth MA, Lippitt SB, editors. The shoulder. 4th ed. Philadelphia: Saunders; 2009. p. 1405–28. 5. Robinson CM, Seah KT, Chee YH, Hindle P, Murray IR. Frozen shoulder. J Bone Joint Surg Br. 2012;94(1):1–9. 6. Ferreira Filho AA. Capsulite adesiva. Rev Bras Ortop. 2005;40(10):565–74. 7. Checchia SL, Fregoneze M, Miyazaki AN, Santos PD, Silva L, Ossada A, et al. Tratamento da capsulite adesiva com bloqueios seriados do nervo supraescapular. Rev Bras de Ortop. 2006;41(7):245–52. 8. Lafosse L, Boyle S, Kordasiewicz B, Aranberri-Gutiérrez M, Fritsch B, Meller R. Arthroscopic arthrolysis for recalcitrant frozen shoulder: a lateral approach. Arthroscopy. 2012;28(7):916–23. 9. Warner JJ, Allen A, Marks PH, Wong P. Arthroscopic release for chronic, refractory adhesive capsulitis of the shoulder. J Bone Joint Surg Am. 1996;78(12):1808–16. 10. Jerosch J. 360 degrees arthroscopic capsular release in patients with adhesive capsulitis of the glenohumeral joint-indication, surgical technique, results. Knee Surg Sports Traumatol Arthrosc. 2001;9(3):178–86. 11. Harryman DT 2nd, Matsen FA 3rd, Sidles JA. Arthroscopic management of refractory shoulder stiffness. Arthroscopy. 1997;13(2):133–47. 12. Segmüller HE, Taylor DE, Hogan CS, Saies AD, Hayes MG. Arthroscopic treatment of adhesive capsulitis. J Shoulder Elbow Surg. 1995;4(6):403–8.

13. Baums MH, Spahn G, Nozaki M, Steckel H, Schultz W, Klinger HM. Functional outcome and general health status in patients after arthroscopic release in adhesive capsulitis. Knee Surg Sports Traumatol Arthrosc. 2007;15(5):638–44. 14. Tasto JP, Elias DW. Adhesive capsulitis. Sports Med Arthrosc. 2007;15(4):216–21. 15. Loew M, Heichel TO, Lehner B. Intraarticular lesions in primary frozen shoulder after manipulation under general anesthesia. J Shoulder Elbow Surg. 2005;14(1):16–21. 16. Koh KH, Kim JH, Yoo JC. Iatrogenic glenoid fracture after brisement manipulation for the stiffness of shoulder in patients with rotator cuff tear. Eur J Orthop Surg Traumatol. 2013;23 Suppl. 2:S175–8. 17. Magnussen RA, Taylor DC. Glenoid fracture during manipulation under anesthesia for adhesive capsulitis: a case report. J Shoulder Elbow Surg. 2011;20(3):e23–6. 18. Ozaki J, Nakagawa Y, Sakurai G, Tamai S. Recalcitrant chronic adhesive capsulitis of the shoulder. Role of contracture of the coracohumeral ligament and rotator interval in pathogenesis and treatment. J Bone Joint Surg Am. 1989;71(10):1511–5. 19. Gerber C, Espinosa N, Perren TG. Arthroscopic treatment of shoulder stiffness. Clin Orthop Relat Res. 2001;(390):119–28. 20. Pollock RG, Duralde XA, Flatow EL, Bigliani LU. The use of arthroscopy in the treatment of resistant frozen shoulder. Clin Orthop Relat Res. 1994;(304):30–6. 21. Cohen M, Amaral MV, Brandão BL, Pereira MR, Monteiro M, Motta Filho GR. Avaliac¸ão dos rersultados do tratamento artroscópico da capsulite adesiva. Rev Bras Ortop. 2013;48(3):272–7. 22. Jerosch J, Filler TJ, Peuker ET. Which joint position puts the axillary nerve at lowest risk when performing arthroscopic capsular release in patients with adhesive capsulitis of the shoulder? Knee Surg Sports Traumatol Arthrosc. 2002;10(2):126–9. 23. Jerosch J, Aldawoudy AM. Chondrolysis of the glenohumeral joint following arthroscopic capsular release for adhesive capsulitis: a case report. Knee Surg Sports Traumatol Arthrosc. 2007;15(3):292–4. 24. Zuckerman JD, Rokito A. Frozen shoulder: a consensus definition. J Shoulder Elbow Surg. 2011;20(2):322–5. 25. Ellman H, Hanker G, Bayer M. Repair of the rotator cuff. End-result study of factors influencing reconstruction. J Bone Joint Surg Am. 1986;68(8):1136–44. 26. Hawkins RJ, Bokos DJ. Clinical evaluation of shoulder problems. In: Rockwood CA Jr, Matsen FA 3rd, editors. The shoulder. 2nd ed. Philadelphia: Saunders; 1998. p. 175–80. 27. Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev. 2003;(2):CD004258. 28. Price MR, Tillett ED, Acland RD, Nettleton GS. Determining the relationship of the axillary nerve to the shoulder joint capsule from an arthroscopic perspective. J Bone Joint Surg Am. 2004;86(10):2135–42. 29. Yoo JC, Kim JH, Ahn JH, Lee SH. Arthroscopic perspective of the axillary nerve in relation to the glenoid and arm position: a cadaveric study. Arthroscopy. 2007;23(12):1271–7. 30. Cinar M, Akpinar S, Derincek A, Circi E, Uysal M. Comparison of arthroscopic capsular release in diabetic and idiopathic frozen shoulder patients. Arch Orthop Trauma Surg. 2010;130(3):401–6. 31. Mariano ER, Afra R, Loland VJ, Sandhu NS, Bellars RH, Bishop ML, et al. Continuous interscalene brachial plexus block via an ultrasound-guided posterior approach: a randomized, triple-masked, placebo-controlled study. Anesth Analg. 2009;108(5):1688–94.


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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

www.rbo.org.br

Original article

Correlation between Ahlbäck radiographic classification and anterior cruciate ligament status in primary knee arthrosis夽 Glaucus Cajaty Martins a,∗ , Gilberto Luis Camanho b , Leonardo Marcolino Ayres a , Eduardo Soares de Oliveiras a a b

Hospital Federal de Ipanema, Servic¸o de Ortopedia e Traumatologia, Rio de Janeiro, RJ, Brazil Universidade de São Paulo, Faculdade de Medicina, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil

a r t i c l e

i n f o

a b s t r a c t

Article history:

Objective: To correlate the Ahlbäck radiographic classification with the anterior cruciate

Received 24 January 2016

ligament (ACL) status in knee arthritis patients.

Accepted 18 February 2016

Methods: The study evaluated 89 knees of patients who underwent total knee arthroplasty

Available online 30 December 2016

due to primary osteoarthritis: 16 male and 69 females, with mean age 69.79 years (53–87

Keywords:

cation into five grades. The ACL was classified in the surgery as present or absent. The

Anterior cruciate ligament

correlation of ACL status and Ahlbäck classification was assessed, as well as those of ACL

years). Osteoarthritis was classified radiographically by the Ahlbäck radiographic classifi-

Knee arthrosis

status and the parameters age, gender, and tibiofemoral angulation (varus–valgus).

Arthroplasty, knee

Results: In cases of varus knees, there was a correlation between grades I to III and ACL presence in 41/47 (86.7%) cases and between grades IV and V and ACL absence in 15/17 (88.2%) cases (p < 0.0001). In valgus knees, no statistically significant correlation was observed between the ACL status and the Ahlbäck classification. In the present study, absence of the ACL was more common in men (9/17; 52%) than in women (19/72; 26%). Conclusion: In cases of medial osteoarthritis, the Ahlbäck radiographic classification is a useful parameter to predict ACL status (presence or absence). In gonarthritis in genu valgum, ACL status was not predicted by Ahlbäck’s classification. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

夽 Study conducted at the Hospital Federal de Ipanema, Rio de Janeiro, RJ, Brazil, and at the Department of Orthopedics and Traumatology, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil. ∗ Corresponding author. E-mail: glaucusc@terra.com.br (G.C. Martins). http://dx.doi.org/10.1016/j.rboe.2016.02.012 2255-4971/© 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).


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Correlac¸ão entre a classificac¸ão radiográfica de Ahlbäck e o estado de conservac¸ão do ligamento cruzado anterior em gonartrose primária r e s u m o Palavras-chave:

Objetivo: Correlacionar a classificac¸ão radiográfica de Alhbäck com o estado de conservac¸ão

Ligamento cruzado anterior

do ligamento cruzado anterior (LCA).

Artrose do joelho

Métodos: Avaliados 85 pacientes (89 joelhos) submetidos à artroplastia total de joelho por

Artroplastia do joelho

osteoartrose primária. Foram 16 homens e 69 mulheres com média de 69,79 anos (53 a 87). A osteoartrose foi subdividida em cinco graus de acordo com a classificac¸ão radiográfica de Alhbäck. O LCA foi avaliado na cirurgia como presente ou ausente. Foi feita a correlac¸ão entre o estado do LCA e a classificac¸ão de Alhbäck. Foi também analisada a correlac¸ão entre o estado do LCA e os parâmetros idade, sexo, angulac¸ão tibiofemoral (varo-valgo). Resultados: Nos casos de joelho varo, foi observada uma correlac¸ão entre os graus I até III e a presenc¸a do LCA em 41/47 (86,7%) casos, bem como entre a ausência do LCA e os graus IV e V em 15/17 (88,2%) casos (p < 0,0001). Por outro lado, nos casos de joelho valgo não houve relac¸ão estatisticamente significante entre a presenc¸a ou ausência do LCA e a classificac¸ão de Alhbäck. Nesta série, foi observado que a ausência do LCA foi mais comum entre os homens 9/17 (52%) do que em mulheres 19/72 (26%). Conclusões: Nos casos de gonartrose do compartimento medial, a classificac¸ão de Alhbäck é parâmetro confiável para prever a condic¸ão do LCA (presente ou ausente). Nos casos de gonartrose em genu valgo não se observou correlac¸ão entre a classificac¸ão de Alhbäck e a condic¸ão do LCA. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Este e´ um artigo Open Access sob uma licenc¸a CC BY-NC-ND (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction The Ahlbäck radiographic classification for knee osteoarthritis was originally described by the author1 in 1968 and modified in 1992 by Keyes et al.,2 who subdivided it into five grades (I–V). This classification is the most commonly used by orthopedic surgeons, not only to assess the degree of radiographic involvement, but also to monitor disease progression and assist in surgical planning. Despite the widespread use of this classification, some studies criticize the inadequate levels of interobserver agreement with different degrees of experience. However, this classification is more reproducible when used by experienced observers.3,4 One of the factors to be taken into account before a surgical procedure in the treatment of knee arthrosis is the preservation status of the anterior cruciate ligament (ACL). Keyes et al.,2 in their work, recommended osteotomy or unicompartmental prosthesis for cases with intact ACL. When the ACL is compromised, total knee arthroplasty would be indicated. In this classic study,2 although the authors analyzed 200 cases of medial arthrosis of the knee, in only 25% of the cases (50 knees) was the presence or absence of the ACL evaluated and described. No other studies evaluating the same correlation were retrieved in the literature. This raises the question of what the relationship between ACL preservation status and Ahlbäck classification would effectively be. The possibility of determining the ACL preservation status preoperatively through a radiographic examination of the knee based on Alhbäck classification would be relevant in

choosing the most appropriate surgical technique2 for cases of knee arthrosis. This information becomes more significant when considering the increasing trend to use implants that aim to preserve the still intact structures in cases of knee arthrosis. Examples of this trend include the use of unicompartmental prosthesis5 and prostheses that allow preservation of both cruciate ligaments, currently under evaluation.6,7 The present study aimed to correlate the Ahlbäck radiographic arthrosis classification with the ACL preservation status (absent/present). The secondary goal was to correlate the ACL preservation status with the parameters age, gender, and tibiofemoral angle (varus/valgus).

Material and methods This study was approved by the Research Ethics Committee of this hospital and follows the Helsinki Convention norms. Eighty five (89 knees) consecutive patients who underwent total knee arthroplasty with substitution of the posterior cruciate ligament between November 2010 and November 2014 were studied. Of the 85 patients, 16 were male and 69 female; their age ranged from 53 to 87 years (mean 69.79). Only cases of primary arthrosis in individuals over 50 years were included. Patients who had undergone previous knee osteosynthesis surgery, osteotomies, and arthrotomies were not included, as well as cases of osteonecrosis, rheumatologic disease, or post-traumatic sequelae. Standard digital weight bearing radiographs of the knee were made including the shafts of the distal femur and


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Table 1 – Ahlbäck radiological classification. Grade I II III IV V

Anteroposterior radiography

Profile radiography

Joint space narrowing Joint space obliteration Bone contact smaller than 5 mm Bone contact between 5 and 10 mm Severe subluxation

proximal tibia. A goniometer was used to measure the tibiofemoral angle, which is formed by the intersection of the femoral and tibial anatomical axes, as described by Kraus et al.8 and Hinman et al.9 When the tibiofemoral axis was diverted to the medial compartment, the knee was considered to be in varus. When it was on the lateral compartment, the knee was considered to be in valgus. In 25 (28%) cases, the knee was described as valgus, and in 64 (72%), as varus. Patients with varus knee were divided into two subgroups: varus equal to or above 10◦ , and varus below 10◦ . Patients with valgus knee were divided into two subgroups: valgus equal to or above 15◦ , and valgus below 15◦ . The abovementioned radiographs were classified into five grades of arthrosis using the Ahlbäck1 classification (1968) modified by Keyes et al.2 (Table 1). Two specialist surgeons with over 15 years experience in arthroplasty analyzed the radiographic parameters (Ahlbäck classification and tibiofemoral angle). The two evaluators analyzed the X-rays simultaneously, working together. In case of disagreement, a third colleague with equal experience helped determining the final result. During the process of radiographic analysis, the evaluators did not have access to the identification or data of patients. The Ahlbäck classification was available for consultation by the evaluators throughout the process of radiographs analysis.

– – Normal posterior region Posterior osteophytes Anterior subluxation of the tibia greater than 10 mm

Table 2 – Correlation between the ACL preservation status and clinical-radiographic parameters. Variable

ACL preservation status Absent

Gender Male Female Age TF Ang Varus Valgus Varus <=10 >10◦ Valgus <15◦ ≥15

Present

Statistical analysis

9 (52%) 19 (26%) 70.1 + 6.7

8 (48%) 53 (74%) 69.6 = −7.9

p = 0.044

21 (35.5%) 7 (28%)

38 (64.5%) 18 (72%)

p = 0.274

16 (29.6%) 5 (50%)

38 (69.4%) 5 (50%)

p = 0.275

2 (15.4%) 5 (41.6%)

11 (84.6%) 7 (58.4%)

p = 0.202

p = 0.38

TF Ang, tibiofemoral angle; ACL, anterior cruciate ligament.

During surgery, the state of ACL preservation was assessed by the lead author. Only the presence or absence of the ligament was recorded (Fig. 1). The ACL was classified as absent when there was complete loss of continuity of its fibers. When the fibers of this ligament still presented continuity from its femoral origin to its tibial insertion, the ligament was considered present. In the case of ACL presence, no attempt was made to classify the case according to the degree of macroscopic degeneration (preserved vs. degenerated), as this classification is extremely subjective.10 The ACL condition (presence or absence) was correlated with the five grades Ahlbäck classification; the assessment in varus and valgus knees was made separately. The presence or absence of the ACL was correlated with the parameters age, gender, and tibiofemoral angle.

Statistical analysis The chi-squared and Fisher’s exact tests were used for analysis of parametric data. The Kruskal–Wallis and the G2-Wilks tests were used nonparametric data. p-Values <0.05 were considered as significant.

Results

Fig. 1 – Present ACL, shown on the surgical clamp.

In 27/89 patients (30.4%), the ACL was not detectable during surgery; it was present in the remaining 62 cases. The ACL was absent in 19/72 (26%) of the female patients and in 9/17 (52%) of the male patients. Fisher’s test indicated statistical significance (p = 0.0442; Table 2).


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Table 3 – Correlation between the ACL preservation status and the Ahlbäck classification (varus). Ahlbäck classification

ACL preservation status Absent

I II III IV V

Statistical analysis

Present

Total

7 8 26 2 0

7 11 29 12 5

0 3 3 10 5

p < 0.0001

ACL, anterior cruciate ligament.

Table 4 – Correlation between the ACL preservation status and the Ahlbäck classification (valgus). Ahlbäck classification

I II III IV V

ACL preservation status

Statistical analysis

Absent

Present

Total

1 1 1 4 0

8 3 3 3 1

9 4 4 7 1

p = 0.307

ACL, anterior cruciate ligament.

The ACL was absent in 7/25 (28%) of cases of valgus knee and in 16/64 (35.5%) of varus knee, with no statistical significance at the G2-Wilks test (p = 0.24). No statistically significant correlation was observed between varus greater than or less than 10◦ and the ACL preservation status according to Fisher’s test (p = 0.202). Valgus knee greater than or less than 15◦ was also not correlated with the state of the ACL (Fisher’s exact test, p = 0.275). Individuals with preserved ACL had a mean age of 69.9 years (SD ± 7.9); in turn, the mean age of patients with absent ACL was 70.1 (SD ± 6.7), with no statistical difference by Student’s t-test (p = 0.385). In cases of knee arthrosis with varus deformity, the analysis of the correlation between the Ahlbäck radiographic classification and the ACL status indicated a relationship between grades I through III and the presence of ACL in 41/47 (86.7%) of cases; and between grades IV and V and the absence of the ACL in 15/17 (88.2%) cases (G2-Wilks test; p < 0.0001; Table 3). In cases of valgus deformity, no statistically significant correlation was observed between the Ahlbäck radiographic classification and the condition of the ACL. In knees classified as grades I through III, the ACL was present in 14/17 (82.4%); in those classified as grade IV and V, the ACL was present in 4/8 (50%) patients (Table 4).

Discussion Ideally, a classification in the medical field should be able to identify the severity of the injury assessed and have predictive value, as well as assist in therapeutic indication. Furthermore, it should be simple, easy to remember, and present high levels of inter- and intra-observer agreement.3,11 In practice, such a classification is rarely available. Studies assessing radiographic classifications that evaluate arthritic degeneration in knees have demonstrated that

narrowing of the tibiofemoral joint space was the most sensitive parameter in detecting articular involvement.12–15 This parameter presents high intra- and inter-observer correlation, and is more reliable to radiographically grade arthrosis than subchondral sclerosis.13 The Kelgren–Lawrence (KL),14,15 the joint space narrowing (JSN),14 and the American College of Rheumatology (ACR)14 classifications are reliable for early diagnosis of knee arthrosis and for monitoring the clinical-radiographic evolution. For these reasons, the classifications are widely used by rheumatologists in the clinical management of knee disorders. When arthrosis progresses, no longer being amenable to conservative treatment and requiring surgical treatment, the radiographic changes also worsen. The KL, JSN, and ACR ratings would no longer be so useful to the orthopedic surgeon, as the higher grades described by them are not detailed enough to aid in the choice of the most appropriate surgical option. For example, grade 4, the highest in the KL classification, is defined by an evident reduction in the tibiofemoral area, with evident subchondral sclerosis and osteophytes. This definition corresponds to grade II in the Ahlbäck classification.15 Although widely used, some studies3,4 indicate that the Ahlbäck classification presents low reproducibility and poor differentiation between grades I through III. Weidow et al.4 reported that, for Ahlbäck classification purposes, signs of bone contact in radiographs are more important than the tibiofemoral narrowing measurement. These authors described that patients who still disclose an evident radiographic tibiofemoral space and who would be initially classified as grade I could present significant bone friction and joint wear during surgery. In fact, such a case would functionally be a grade III. In other words, these researchers have shown that it would be difficult to differentiate Ahlbäck grades I through III. In their classical article, Keyes et al.2 established that in varus knees rated as Ahlbäck grades I to III, the ACL would


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generally be present, while in grade IV, the ACL injury would determine a greater destruction of the medial plateau in its central and posterior portions, and would eventually evolve to anterior subluxation of the tibia (grade V). Grades IV and V would present similarities and would be, by definition and radiographically, significantly different from grades I to III. Orthopedic surgeons widely use the Ahlbäck classification, adopting it as a guideline for the choice of surgical treatment. According to Keyes et al.,2 grades I through III are amenable to treatment by osteotomy or unicompartmental prosthesis, although a total prosthesis can be safely used when factors such as age and level of physical activity are taken into account. In turn, due to the association of ACL insufficiency and more severe joint destruction, grades IV and V should be treated with total knee prosthesis. In their seminal article, Keyes et al.,2 despite having assessed 200 cases of medial knee arthrosis, describe in the text only 50 knees in which the presence of the ACL was actually assessed; there is no reference in this regard for the remaining 150 cases. This fact raises the question of what the real correlation between the ACL preservation status and Ahlbäck classification effectively would be. The original article gives the initial impression that the ACL would be present and functional in almost 100% of cases classified as Ahlbäck I through III. Since an extensive search in literature could not find any other studies that assessed the correlation between this classification and the presence of the ACL, which would confirm or disprove the findings of Keyes et al.,2 the authors decided to conduct the present study. The absence of ACL leads to greater destruction of the medial knee plateau.2,16 Moschella et al.,16 in a study of the joint wear pattern in 70 varus knees undergoing TKA, demonstrated that in cases where the ACL was present, the joint wear would be central in the medial plateau. However, when the ACL was deficient, the wear would be in the anteroposterior plane of this plateau, and therefore wider. Similar findings were reported by Garrido et al.17 Lee et al.18 reported that ACL absence would be associated with a significant involvement of the articular cartilage of the contralateral compartment in patients with medial knee arthrosis. This would indicate a higher severity due to the joint involvement of both knee plateaus. In the present study, it was shown that the ACL was present in 86.7% of cases described as Ahlbäck grades I, II, and III while in grades IV and V the ACL was absent in 88.2% of cases in varus knees; this difference was statistically significant (p < 0.0001). These results are in agreement with Keyes et al.2 and demonstrate that the Ahlbäck classification can provide a relatively reliable idea of the ACL condition and is therefore useful in surgical planning in cases of medial compartment knee arthrosis. In this study, the Ahlbäck classification was not able to predict the presence or absence of the ACL in knees with valgus deformity and arthrosis. In grades I through III, the ACL was present in 82.4% of the cases, similar to the rates found in knees with varus deformity, while in grade IV and V, it was absent in only 50%. These less reliable results are partially due to the fact that the radiographic femoral bone contact cannot be adequately shown in osteoarthritis of the lateral compartment.4 This fact shows that the use of Ahlbäck

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classification would not be suitable for assessing cases of gonarthrosis in valgus,4 despite its widespread use in everyday clinical practice.3,4,11 In the present study, the ACL was absent in 30.3% of the sample, similar to that observed by Allain et al.10 and Lee et al.,18 who described absence of ACL in 40% and 39%, respectively, in their series of knee arthroplasties. No studies that assessed the ACL preservation status and its correlation with clinical or radiographic parameters were retrieved in the literature. In the present study, it was statistically shown that males had a higher prevalence of absent ACL observed during knee arthroplasty surgery than women (52% vs. 26%). There is a growing movement in orthopedics for surgical procedures to be as little aggressive as possible; the goal is to intervene effectively in the affected and pathologygenerating structures. This trend is evident in the cases of medial gonarthrosis in which the ACL is competent; in these cases, osteotomy or partial arthroplasty procedures are preferred to total knee arthroplasty.2,5,18 Another current area of study is the use of total knee prosthesis with maintenance of both cruciate ligaments, which must obviously be functional for the proper functioning of the arthroplasty.6,7 These trends highlight the need for assessing ACL integrity during surgical planning. It is important to note that ACL integrity can also be evaluated by magnetic resonance imaging.12,14 Nevertheless, despite being an excellent imaging method, it is an expensive method with a long waiting queue and unfortunately it is seldom accessible to patients from the Brazilian Public Health System (Sistema Único de Saúde [SUS]), except for some university hospitals and reference centers. This reinforces the importance of information that can be obtained through simple knee radiographs. A limitation of the present study is the fact that it is based on the use of Ahlbäck classification, which some authors3,4,11 describe as having low levels of intra- and inter-observer correlation. In order to increase the reliability of this study, the cases were classified in agreement by two specialists in knee surgery who have extensive experience in using this classification.3,4 Furthermore, the results were assessed in two more homogeneous groups (Ahlbäck grades I to III and another formed by grades IV and V), which would increase the reproducibility and reliability.3,4 A positive finding of the present study is the fact that the results confirmed the usefulness of the Ahlbäck classification to predict ACL preservation status in varus knees, which has not been demonstrated in cases of valgus knees.

Conclusions 1. In the case of medial compartment gonarthrosis, the Ahlbäck classification is a reliable parameter to predict ACL status (present or absent). 2. In valgus knee arthrosis, the ACL status was not predicted by the Ahlbäck classification.

Conflicts of interest The authors declare no conflicts of interest.


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references

1. Ahlbäck S. Osteoarthrosis of the knee. A radiographic investigation. Acta Radiol Diagn (Stockh). 1968;277 (Suppl.):7–72. 2. Keyes GW, Carr AJ, Miller RK, Goodfellow JW. The radiographic classification of medial gonarthrosis. Correlation with operation methods in 200 knees. Acta Orthop Scand. 1992;63(5):497–501. 3. Galli M, De Santis V, Tafuro L. Reliability of the Ahlbäck classification of knee osteoarthritis. Osteoarthritis Cartilage. 2003;11(8):580–4. 4. Weidow J, Cederlund CG, Ranstam J, Kärrholm J. Ahlbäck grading of osteoarthritis of the knee: poor reproducibility and validity based on visual inspection of the joint. Acta Orthop. 2006;77(2):262–6. 5. Goodfellow J, O’Connor J. The anterior cruciate ligament in knee arthroplasty. A risk-factor with unconstrained meniscal prostheses. Clin Orthop Relat Res. 1992;276:245–52. 6. Ries MD. Effect of ACL sacrifice, retention, or substitution on kinematics after TKA. Orthopedics. 2007;30 (8 Suppl.):74–6. 7. Christen M, Aghayev E, Christen B. Short-term functional versus patient-reported outcome of the bicruciate stabilized total knee arthroplasty: prospective consecutive case series. BMC Musculoskelet Disord. 2014;6(15):435. 8. Kraus VB, Vail TP, Worrell T, McDaniel G. A comparative assessment of alignment angle of the knee by radiographic and physical examination methods. Arthritis Rheum. 2005;52(6):1730–5. 9. Hinman RS, May RL, Crossley KM. Is there an alternative to the full-leg radiograph for determining knee joint alignment in osteoarthritis? Arthritis Rheum. 2006;55(2):306–13.

10. Allain J, Goutallier D, Voisin MC. Macroscopic histological assessments of the cruciate ligaments in arthrosis of the knee. Acta Orthop Scand. 2001;72(3):266–9. 11. Vilardi AM, Mandarino M, Veiga LT. Evaluation of reproducibility from modified Ahlback’s classification for knee osteoarthrosis. Rev Bras Ortop. 2006;41(5):157–61. 12. Wada M, Baba H, Imura S, Morita A, Kusaka Y. Relationship between radiographic classification and arthroscopic findings of articular cartilage lesions in osteoarthritis of the knee. Clin Exp Rheumatol. 1998;16(1):15–20. 13. Günther KP, Scharf HP, Puhl W, Willauschus W, Kalke Y, Glückert K, et al. Reproducibility of radiologic diagnosis in gonarthrosis. Z Orthop Ihre Grenzgeb. 1997;135(3):197–202. 14. Wu CW, Morrell MR, Heinze E, Concoff AL, Wollaston SJ, Arnold EL, et al. Validation of American College of Rheumatology classification criteria for knee osteoarthritis using arthroscopically defined cartilage damage scores. Semin Arthritis Rheum. 2005;35(3):197–201. 15. Petersson IF, Boegård T, Saxne T, Silman AJ, Svensson B. Radiographic osteoarthritis of the knee classified by the Ahlbäck and Kellgren & Lawrence systems for the tibiofemoral joint in people aged 35–54 years with chronic knee pain. Ann Rheum Dis. 1997;56(8):493–6. 16. Moschella D, Blasi A, Leardini A, Ensini A, Catani F. Wear patterns on tibial plateau from varus osteoarthritic knees. Clin Biomech (Bristol, Avon). 2006;21(2):152–8. 17. Garrido CA, Sampaio TCF, Ferreira FS. Estudo comparativo entre a classificac¸ão radiológica e análise macro e microscópica das lesões na osteoartrose do joelho. Rev Bras Ortop. 2011;46(2):155–9. 18. Lee GC, Cushner FD, Vigoritta V, Scuderi GR, Insall JN, Scott WN. Evaluation of the anterior cruciate ligament integrity and degenerative arthritic patterns in patients undergoing total knee arthroplasty. J Arthroplasty. 2005;20(1):59–65.


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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

www.rbo.org.br

Original article

Fresh osteochondral knee allografts in Brazil with a minimum two-year follow-up夽 Luís Eduardo Passarelli Tírico ∗ , Marco Kawamura Demange, Luiz Augusto Ubirajara Santos, José Ricardo Pécora, Alberto Tesconi Croci, Gilberto Luís Camanho Universidade de São Paulo (USP), Faculdade de Medicina, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil

a r t i c l e

i n f o

a b s t r a c t

Article history:

Objective: The present study aimed to report the results of the first series of cases of fresh

Received 28 March 2016

ostechondral allografts in the knee joint in Brazil with a minimum follow-up of two years.

Accepted 11 April 2016

Methods: A protocol of procurement, harvesting, processing, and utilization of fresh

Available online 28 December 2016

osteochondral allografts in the knee joint was established, beginning with legislation mod-

Keywords:

utilization of two surgical techniques of osteochondral transplantation. Eight patients were

Knee injuries

treated and followed-up for a minimum of two years.

ifications, graft harvesting techniques, immediate processing, storage of fresh grafts, and

Cartilage, articular

Results: Patients were evaluated with subjective IKDC, KOOS, and modified Merle D’Aubigne

Transplantation, homologous

and Postel questionnaires. Mean subjective IKDC score was 31.99 ± 13.4 preoperative and

Orthopedics

81.26 ± 14.7 at the latest follow-up; preoperative KOOS score was 46.8 ± 20.9 and postoperative was 85.24 ± 13.9, indicating a significant improvement over time (p < 0.01). Mean modified Merle D’Aubigne-Postel score was 8.75 ± 2.25, preoperatively, and 16.1 ± 2.59 postoperatively. Friedman test for non-parametric samples demonstrated a significant improvement in postoperative scores (p < 0.01). Conclusion: The use of fresh osteochondral allografts in Brazil is a safe procedure, with good clinical results in the short- and medium-term for the treatment of osteochondral lesions greater than 4 cm2 in the knee joint. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Study conducted at Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brazil. Corresponding author. E-mail: luis.tirico@hc.fm.usp.br (L.E. Tírico). http://dx.doi.org/10.1016/j.rboe.2016.12.009 2255-4971/© 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). ∗


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Transplante osteocondral a fresco no joelho no Brasil: mínimo de dois anos de seguimento r e s u m o Palavras-chave:

Objetivo: Relatar os resultados dos primeiros casos de transplante osteocondral a fresco na

Traumatismos do joelho

articulac¸ão do joelho no Brasil com um mínimo de seguimento de dois anos.

Cartilagem articular

Métodos: Foi feito um protocolo de captac¸ão, processamento e uso de transplantes osteo-

Transplante homólogo

condrais a fresco na articulac¸ão do joelho. Iniciou-se com modificac¸ões na legislac¸ão vigente,

Ortopedia

técnicas de captac¸ão de enxertos, processamento imediato, armazenamento a fresco dos enxertos e uso de duas técnicas cirúrgicas de transplante osteocondral. Oito pacientes foram transplantados e acompanhados com mínimo de dois anos de seguimento. Resultados: Os pacientes foram avaliados por meio dos questionários do International Knee Documentation Committee (IKDC) subjetivo, Knee Injury and Osteoarthritis Outcome Score (KOOS) e índice de Merle D’Aubigne e Postel modificado. A média da pontuac¸ão da escala IKDC subjetiva pré-operatória foi de 31,99 ± 13,4 e de 81,26 ± 14,7 no pós-operatório e da escala KOOS pré-operatória foi de 46,8 ± 20,9 e de 85,24 ± 13,9 no pós-operatório, com melhoria significativa ao longo do tempo (p < 0,01). A média da pontuac¸ão pelo índice de Merle D’Aubigne e Postel modificado foi de 8,75 ± 2,25 no pré-operatório e de 16,1 ± 2,59 no pós-operatório. O resultado do teste de Friedman para amostras não paramétricas demonstrou melhoria significativa ao longo do tempo (p < 0,01). Conclusões: O transplante osteocondral a fresco no Brasil é um procedimento seguro, com bons resultados clínicos em curto e médio prazo para o tratamento de lesões osteocondrais maiores do que 4 cm2 na articulac¸ão do joelho. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Este e´ um artigo Open Access sob uma licenc¸a CC BY-NC-ND (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction Chondral lesions in the knee joint affect approximately 900,000 US citizens each year, resulting in over 200,000 surgical procedures for diagnosis and treatment.1 There are no statistics on this disease in Brazil. The goal in the treatment of traumatic chondral and osteochondral lesions is to reestablish anatomy and function of the joint as well as eliminate pain. The treatment of chondral lesions greater than 4 cm2 by debridement or microfracture techniques does not promote good results, as it does not address the subchondral bone injury and promotes repair with fibrocartilaginous tissue instead of hyaline cartilage, therefore not being recommended for the treatment of these injuries.2,3 Autologous osteochondral transplantation is a good treatment option, as it promotes repair with hyaline cartilage and grafts possible defects of the subchondral bone. However, it is limited by the morbidity of the donor site; it can be ideally used in injuries of up to 2.5 cm in diameter and up to 10 mm deep.4–6 Currently, treatment options for chondral and osteochondral knee lesions larger than 4 cm2 are autologous chondrocyte implantation and fresh osteochondral allografts (FOA). Autologous chondrocyte transplantation is a complex technique that requires two operations for biopsy and cell transplantation, and has a very high cost.7 The use of FOA for the treatment of large osteochondral lesions of the knee is a biological option in young patients; its main advantage is that it is a tissue with live hyaline cartilage, featuring chondrocytes in a chondral matrix with preserved collagen fiber architecture.8,9

In other countries, FOA have been used for decades.10–14 This technique was first introduced to treat post-traumatic bone defects.15,16 However, it is now used for the treatment of various disorders of the knee, such as osteochondritis dissecans (OD), secondary osteonecrosis, and degenerative disease of the knee, as well as in fracture sequelae.17–20 The principle of FOA is to restore the biological structure of the joint, rebuild the articular hyaline cartilage surface, and provide an osteochondral tissue capable of supporting the mechanical load of the individual.21,22 To the best of the authors’ knowledge, there are no studies or case reports on the use of the FOA technique in Brazil, because until 2009 the laws regulating tissue banks did not allow fresh tissues to be used for transplantation in time for the release of cultures; it was necessary to wait for the results of these tests before use.23 This study aimed to report the results of the first cases of FOA transplantation in the knee joint in Brazil, with a minimum follow-up of two years.

Methods This study was conducted at the Institute of Orthopedics and Traumatology of this institution and was approved by the Ethics Committee for Research Project Analysis (CAPPesq). The inclusion criteria comprised young patients, between 15 and 45 years of age, with traumatic or acquired osteochondral lesions in the knee, chondral or osteochondral lesions


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Fig. 1 – (A) Osteotomy of the femur 10 cm above the joint line without violation of the joint capsule; (B) Tibial osteotomy 2 cm below the ATT; (C) Final result of the piece before transportation to the Tissue Bank.

larger than 4 cm2 , and whose chondral or osteochondral lesions failed previous treatment for articular cartilage repair. Patients with inflammatory arthropathy, with active infection in the knee or elsewhere in the body, and smokers were excluded. For donor selection, the inclusion and exclusion criteria for musculoskeletal tissues set forth by the Brazilian Association of Organ Transplantation (Associac¸ão Brasileira de Transplante de Órgãos [ABTO]) was used, and individuals between 15 and 45 years were selected. The sample consisted of five organ donors and eight recipients (eight knees), which were operated from March to October 2012.

discounting the magnification (Fig. 2). In the donor, this measurement was made using a caliper. For lesions of the proximal portion of the tibia, patella, femoral trochlea, and massive lesions of the femoral condyles, a difference of at most 5 mm between the donor and recipient was used as a parameter for matching. For focal lesions of the femoral condyle, a positive pairing was made when the donor condyle was equal to or larger than that of the receiver. Once donor and recipient were matched, all analysis exams were performed. The selected tissues were packed in triple vacuum-sealed packages, containing a preservation medium with nutrients. It took a mean of 14 days for the tissue cultures to be released; during this period, the receiver was prepared

Harvesting In the present study, all tissues for FOA were obtained from organ donors, harvested in an operating room with laminar airflow after the heart, liver and kidney had been harvested. The knees were harvested as a block; only the skin and subcutaneous tissue were dissected, and the joint capsule was kept intact. Osteotomy was performed on the distal femur 10 cm above the joint line and on the proximal tibia and fibula, 2 cm below the distal part of the anterior tibial tuberosity (ATT) (Fig. 1A–C). The pieces, as a block, were placed in lactated Ringer’s solution and transported at a temperature of 2◦ –8 ◦ C. After harvesting, tissues were sent to the Tissue Bank for processing within 12 h of the harvest procedure.

Processing The processing stage was performed in a proper operating room, classified as class 100 or ISO 5, and equipped with a laminar flow module. The articular capsule of the knee was opened through the medial parapatellar access route and structures were measured with a caliper to pair with the recipients in the FOA list. At this stage, the articular cartilage was analyzed and only pieces in which this structure was intact were used. Pairing was performed by comparing the actual size of the proximal tibia of the affected knee at the level of the joint in the donor and in the recipient. This measurement was obtained by assessing this receptor segment through digital radiographs of the affected knee in anteroposterior view,

Fig. 2 – Measurement of the proximal tibia of the recipient for donor matching.


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Fig. 3 – (A) Macroscopic appearance of osteochondritis dissecans lesion in the left medial femoral condyle; (B) Donor left medial femoral condyle with a cylinder prepared in the same anatomical site of the recipient’s defect; (C) FOA restoring the articular surface of the medial femoral condyle; (D) Macroscopic lateral view of the transplant, the perfect congruence of the articular surface of the medial femoral condyle can be observed.

and the surgical procedure was scheduled to be performed as close as possible to the date of culture release.

Storage and preservation The medium used for tissue preservation was the commercial Ham F-12 – GIBCO with glutamax medium (Invitrogen, Life Technologies, USA), which contains amino acids, vitamins, and minerals. To the medium, amphotericin B (12.5 mg/500 mL), streptomycin (50 mg/500 mL), gentamicin (25 mg/500 mL), and penicillin G (5,000,000 UI/500 mL) were added as prophylaxis against microorganisms. Tissues were stored in a refrigerator below 4 ◦ C while awaiting culture results.

Surgical technique Surgery was scheduled for the day after cultures release, in order to minimize the time between collection and transplantation. The knees were approached by medial or lateral parapatellar arthrotomy depending on the site of the lesion to be transplanted. For cases of multiple lesions, a large arthrotomy was made, similar to the incision for total knee arthroplasty, which facilitated the access to all structures and preserved the meniscal insertions during the access route. In lesions of the posterior condyle, in which the approach is difficult, the anterior horn of the meniscus was cut radially; the meniscus was shifted for better access to injury, with subsequent suture. Two types of surgical techniques for FAO were used: the osteochondral cylinder technique, in which a specific instrument was used to prepare the recipient bed and the donor graft (Biotechnology Ortopedia Importac¸ão e Exportac¸ão Ltd.;

Fig. 3); and the surface technique, in which both the receiver and the donor were prepared manually with the aid of chisels, curettes, and a bone saw (Fig. 4). The donor graft was taken from the same anatomical location as the lesion in the recipient. For this, the tissue bank was asked for a donor graft that corresponded to the lesion of the recipient.

Functional assessment Patients were evaluated preoperatively, intraoperatively, and postoperatively through the International Knee Documentation Committee (IKDC) 2000 Subjective Knee Evaluation Form,24 the Knee Injury and Osteoarthritis Outcome Score (KOOS),25 and the Merle D’Aubigne and Postel Score, modified for the knee26,27 for a detailed assessment of the lesion and of limb function.

Statistical analysis Continuous and discrete data, such as subjective IKDC, KOOS, and modified Merle D’Albigne and Postel Score, were described as means and standard deviations. The Kolmogorov–Smirnov test was used to test the distribution of all data. For inferential statistics, the Subjective IKDC and the KOOS presented normal distribution; for the comparison over time, the oneway ANOVA for repeated measures and the post hoc Bonferroni test were used. To test the improvement by modified Merle D’Albigne and Postel Score, which did not present normal distribution, the Friedman test for related measures was used, as well as the Wilcoxon post hoc test to compare pairs of related measures with their respective corrections.


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Fig. 4 – (A) Osteonecrosis sequelae in the lateral femoral condyle (LFC) with lateral parapatellar access route and medial patellar luxation; (B) LFC of the donor during surgery; (C) Aspect of the provisional fixation of the graft showing the congruence of the articular surface; (D) Final fixation of the LFC that restores the anatomy of the joint.

For statistically significant differences, a type I error equal to or lower than 5% was adopted. SPSS v. 20.0 software for Mac was used in data analysis.

Results Eight FOA were conducted from March 2012 to October 2012, from five donors and eight operated knees. Patients were followed-up for at least two years after surgery (30–37 months). Five patients had an initial diagnosis of OD, one patient had post-chemotherapy femoral condyle necrosis, and two had post-traumatic sequelae. The mean age of the transplanted patients was 30.1 years (17–44) and the mean transplanted area was 10.6 cm2 (4.6–22.4 cm2 ). Mean number of days between harvesting and transplantation was 15.3 (14–16) and mean number of surgeries prior to FOA was two (0–4) (Table 1). Six transplants were performed in the femoral condyle, one in the tibial plateau with the meniscus, and one in the patella. One patient was lost to follow-up at six months (patient 5); in this case, all data of the scores were replaced by the worst value among all patients, which characterized the use of the worst case scenario and analysis by intention to treat by not excluding this patient from the study. Mean preoperative IKDC subjective score was 31.99 ± 13.4 and 81.26 ± 14.7 postoperatively. Mean preoperative KOOS was 46.8 ± 20.9 and 85.24 ± 13.9 postoperatively. ANOVA

indicated that patients showed significant improvement over time, when comparing preoperative and postoperative results (p < 0.01). The mean modified Merle D’Aubigne and Postel Score for the knee was 8.75 ± 2.25 preoperatively and 16.1 ± 2.59 postoperatively. The Friedman test for nonparametric samples indicated that the patients showed significant improvement over time, when comparing preoperative and postoperative results (p < 0.01).

Discussion FOA transplantation in the knee joint were not performed until 2009 in Brazil, as the legislation in the country did not allow the storage of fresh tissues long enough for the procedure to be performed safely.28 This study is the first reported use of FOA in South America. As the first study of FOA in Brazil, only patients between 15 and 45 years old with a history of traumatic or acquired lesions of the knee greater than 4 cm2 were included, and patients with degenerative lesions were excluded. All grafts were obtained from organ donors harvested in the operating room, after the heart, liver, and kidneys were collected, unlike the study by Vangsness et al.29 in the United States, where only 33% of the harvest procedures occurred in an operating room, while the remaining occurred in morgues


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Table 1 – Transplant characteristics: transplant site, lesion size in cm2 , time between harvesting and transplantation in days, type of surgical technique, age, diagnosis, and number of previous surgeries. Patient

Transplant site

1 2 3 4 5 6 7 8

MFC LFC Patella MFC Medial plateau LFC MFC MFC

Lesion size

4.6 12.96 13.3 8.75 22.4 5.2 4.8 13

Time interval Har – Tx (days)

Surgical technique

14 15 16 15 15 15 16 16

Cylinder Surface Surface Cylinder Surface Cylinder Cylinder Cylinder

Age

Diagnosis

Prior surgeries

44 27 43 25 29 17 18 38

OD LFC necrosis post-chem Patellar Fx sequelae OD Plateau Fx sequelae OD OD OD

3 0 2 1 4 2 2 2

Har, harvest; LFC, lateral femoral condyle; MFC, medial femoral condyle; Fx, fracture; OD, osteochondritis dissecans; post-chem, postchemotherapy; Tx, transplantation.

or mortuaries. To date, harvesting in these facilities in Brazil is not possible due to legal aspects, which limits the number of grafts available for transplantation. After being harvested, grafts were sent immediately to the tissue bank for processing, which occurred within 12 h of the procedure. This agility between harvesting and processing allowed for a short interval between collection and transplantation (15.3 days), a fact that contributes to increased cell viability of the transplanted chondrocytes in cartilage grafts when compared with grafts stored for longer periods.30 Another factor that contributed to the short time between harvesting and transplantation was the fact that all grafts were harvested within a 100 km radius from the city of São Paulo, with no need for air transportation, which decreased the time interval between harvesting and transplantation. Transplants were performed using two surgical techniques: osteochondral cylinder and surface. The specific instruments for the osteochondral cylinder technique were not available in Brazil at the beginning of this study; therefore, an instrumental set was manufactured by a national company for the surgical procedure with this technique. In this technique, the diameter of the osteochondral cylinder of the donor must be equal to or 1 mm smaller than the recipient bed. However, in the instrument set used, this difference was slightly greater than the optimum; therefore, it was necessary to fixate some grafts with 3-mm cannulated compression screws, which were removed by arthroscopy 12 weeks after transplantation. Clinical evaluations made through objective and subjective questionnaires (IKDC, KOOS, and modified Merle D’Aubigne and Postel) demonstrated a significant improvement between the preoperative period and last follow-up (p < 0.01). Only one patient had a postoperative complication at follow-up. This patient had a history of medial tibial plateau fracture that developed acute infection after fracture fixation; it was treated with serial surgical debridement and removal of any hardware material. This patient had a recurrence of the prior infection three months after the osteochondral transplantation (three years after the fracture), with graft failure. Radiographic images of all other patients showed incorporation of the grafts, without subchondral cyst formation or graft collapse. Patients returned to their daily activities of work and leisure, as well as to low-impact sports. The level of patient satisfaction with the procedure was considered high by all transplant recipients.

The present study has several limitations. It had a small sample of patients, with a short follow-up period, and without a control group for comparison of results. Another limitation is the fact that two surgical techniques were evaluated together, which may present different results due to the difference in the size of the grafts and surgical technical difficulties.

Conclusion In Brazil, FOA is a safe procedure with good clinical results in the short and medium term for the treatment of osteochondral lesions of the knee joint larger than 4 cm2 . This is a complex procedure that relies on a database of specialized tissues and a surgical team trained in harvesting and processing the tissue.

Conflicts of interest The authors declare no conflicts of interest.

Acknowledgements To the teams of the Tissue Bank and the Knee Group of this institution for their cooperation with the present study.

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

www.rbo.org.br

Original Article

Femur lengthening with monoplanar external fixator associated with locked intramedullary nail夽 Henrique Paradella Alvachian Fernandes ∗ , Danilo Gabriel do Nascimento Silva Barronovo, Fabio Lucas Rodrigues, Marcos Hono Hospital Estadual Mario Covas, Faculdade de Medicina do ABC, Disciplina de Ortopedia e Traumatologia, Santo André, SP, Brazil

a r t i c l e

i n f o

a b s t r a c t

Article history:

Objective: This study aimed to demonstrate that the lengthening technique of an external

Received 28 October 2015

fixator associated with locked intramedullary nail is an efficient method that decreases the

Accepted 29 March 2016

duration of the external fixation and improves the rehabilitation period.

Available online 13 December 2016

Methods: From January of 2005 to May of 2014, 31 patients with mean lower limb discrepancy of 5.31 cm were treated. The etiologies of the deformity were femur fracture sequelae,

Keywords:

infection, hip development dysplasia, polio, and congenital short femur.

Bone lengthening

Results: The mean duration of external fixation was 2.47 months (external fixation index

External fixators

of 16.15 days per cm). The mean time for bone healing was 6.66 months (consolidation

Fracture fixation

index 43 days per cm). Initial mean knee range of motion was −1◦ to 100◦ , progressing to

Intramedullary

0◦ –115◦ at the end of treatment. The complications observed were incomplete osteotomies, hip subluxation, broken fixator, decreased knee range of motion, and need for locking screw removal. Conclusion: Femur lengthening with a monoplanar external fixator associated with locked intramedullary nail allowed for a shorter period of external fixation use, better protection for the regenerated bone tissue, and early rehabilitation with possible complications. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Study conducted at the Faculdade de Medicina do ABC, Hospital Estadual Mario Covas, Santo André, SP, Brazil. Corresponding author. E-mail: henriquepaf@gmail.com (H.P. Fernandes). http://dx.doi.org/10.1016/j.rboe.2016.03.007 2255-4971/© 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). ∗


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Alongamento ósseo femoral com fixador externo monoplanar associado a haste intramedular bloqueada r e s u m o Palavras-chave:

Objetivo: Demonstrar que a técnica de alongamento do fixador externo associado a haste

Alongamento ósseo

intramedular bloqueada é eficaz e traz benefícios quanto ao tempo de uso do fixador e a

Fixadores externos

melhoria na reabilitac¸ão.

Fixac¸ão intramedular de fraturas

Método: Entre janeiro de 2005 e maio de 2014 foram tratados 31 pacientes com discrepância de membros inferiores com média de encurtamento de 5,31 cm. As etiologias da deformidade foram sequelas de fratura de fêmur, infecc¸ão, displasia de desenvolvimento do quadril, paralisia infantil e fêmur curto congênito. Resultados: O tempo médio de fixac¸ão externa foi de 2,47 meses (índice de fixac¸ão externa de 16,15 dias por centímetro). O tempo médio necessário para consolidac¸ão óssea foi 6,66 meses (índice de consolidac¸ão 43 dias por centímetro). A amplitude de movimento do joelho média inicial era de -1 a 100 graus e no término do tratamento de 0 a 115 graus. As complicac¸ões observadas foram osteotomias incompletas, subluxac¸ão de quadril, quebra do fixador, limitac¸ão da amplitude do joelho e necessidade de retirada de material. Conclusão: A técnica de alongamento femoral com fixador externo monolateral sobre haste intramedular propicia um tempo menor de uso do fixador externo, melhor protec¸ão do regenerado ósseo e reabilitac¸ão precoce, não isenta de complicac¸ões. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Este e´ um artigo Open Access sob uma licenc¸a CC BY-NC-ND (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Material and methods

Lower limb shortening due to fracture sequelae or congenital defects leads, in the short term, to pelvic tilt and secondary scoliosis; in the long term, it leads to early osteoarthritis of the knee, hip, and spine.1 Another problem is patient discomfort due to the time spent with a external fixator. Traditionally, the most used surgical technique for bone shortening is that recommended by IIizarov. It uses a system of rings anchored by transfixing Kirschner wires in tensions ranging from 50 to 130 N, followed by osteotomy and subsequent gradual bone distraction. The lengthening speed is 1 mm per day, but the fixator should remain in place until complete fracture consolidation. Bone regenerate fracture has been described in cases of premature fixator removal.2–6 Moreover, patients tolerate the lengthening period well, which is shorter, but the long wait until consolidation may present complications, such as pin site infection and limited joint mobility. The need to use the external fixator until consolidation is not well tolerated by most patients.7,8 Femoral lengthening with a monolateral external fixator associated with locked intramedullary nail is an alternative technique that brings benefits such as shorter duration of treatment and improved knee range of motion without compromising the bone regenerate.9–12 This study aimed to demonstrate whether the lengthening technique with an external fixator associated with locked intramedullary nail is effective and beneficial regarding duration of external fixator use and improved rehabilitation.

Between January 2005 and May 2014, 31 patients with femoral shortening who underwent lengthening technique with external fixator were retrospectively studied. Regarding the cause of shortening, 23 patients had fracture sequelae, three had congenital short femur, two had polio, two had previously resolved infection, and one had developmental dysplasia of the hip. Age ranged from 15 to 62 years; 26 patients were male and five female. Initial shortening ranged from 2.5 cm to 8 cm, assessed at a scanogram of the lower limbs, with a mean of 5.31 cm. The mean initial knee range of motion was 1◦ –100◦ . All patients were treated with a monolateral external fixator and locked intramedullary nails, with 23 anterograde and eight retrograde nails. The nail diameter was 9 mm for solid nails and 10 mm for milled nails.

Surgical technique Patient is positioned in lateral decubitus for the anterograde nails and in dorsal decubitus for the retrograde nails, on a radiolucent operating table. Femoral osteotomy is made by a small longitudinal lateral incision in the middle third of the thigh. Subsequently, a semi-circumferential bone drilling is made with a 3.5-mm drill in the lateral, medial, and anterior cortices, and a complete linear osteotomy is finalized with the osteotome in the posterior cortex. After the nail is introduced, the locking screws are positioned closest to the entrance of the guide. A Schanz screw is then placed in the fragment proximal to the osteotomy, perpendicularly to the lateral cortex, from lateral to medial, in order to avoid an impact on the previously inserted intramedullary nail. Then, the screw head is


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Fig. 2 – Radiographic image of the femur after the final lengthening, in which bone healing can be observed.

The external fixation duration, time interval until consolidation, knee range of motion, and complications were assessed.

Results

Fig. 1 – Radiographic image of a femur in the lengthening phase after osteotomy, undergoing lengthening.

positioned on the screw and the lengthening device is installed in the same direction of the mechanical axis of the femur. The distal head is coupled onto the device and, guided by its orifices, a Schanz screw of same dimension is inserted in the same orientation. After bone alignment, positioning of the screws, and structure of the external device are assessed and confirmed, device assembly is completed with two or three screws in the proximal and distal fragments (Fig. 1). In the present study, antibiotic therapy was performed with 1 g intravenous cephalothin every 6 h during hospitalizations, followed by 500 mg oral cephalexin every 6 h for seven days after discharge. Patients were instructed to initiate distraction on the seventh day, with a frequency of one-quarter of a turn every 6 h, or 1 mm per day. All patients were followed-up every two weeks until the end of the lengthening phase. One week after the programmed bone lengthening was reached, distal locking screws of the nails were made; the external fixator was removed and the knee was manipulated. Then, active and passive movements of the hip, knee, and ankle were initiated. Partially-loaded gait with the aid of crutches was stimulated as tolerated; patients were followed-up monthly thereafter (Fig. 2). A bone regenerate was considered consolidated when frontal and profile radiographs presented visible bone callus in three cortices.

Bone consolidation was observed in all patients. The mean lengthening was 4.65 cm per patient. The mean duration of external fixation use was 2.47 months (external fixation index of 16.15 days per centimeter). The mean time to bone healing was 6.665 months (consolidation index of 43 days ratio per centimeter). The mean knee range of motion was 0◦ –115◦ . No fractures or residual deformities were observed in the bone regenerate. Regarding complications, four patients were re-approached due to osteotomies that were considered incomplete; the patient with dysplasia sequela had hip subluxation. The fixator of one patient broke, and was replaced on an outpatient basis; a locking screw was removed in one patient. Two patients evolved with knee limitation, and were treated with arthroscopic release, which improved range of motion.

Discussion The lengthening method over intramedullary nails was developed by Paley et al.9 to accelerate the healing and onset of rehabilitation. The present study was not comparative. However, the external fixation technique with intramedullary nails showed satisfactory results in relation to consolidation time, duration of external fixator use, and mobility of the knee joint. The bone lengthening method introduced by IIizarov is currently the treatment of choice for limb length discrepancy, regardless of the etiology. The major disadvantage described is the prolonged use of external fixation, especially during the regenerated bone healing time. This imposes psychological complications to both the patients and their families.7,8 The use of locked intramedullary nails associated with external fixator allows the removal of the external fixator after


r e v b r a s o r t o p . 2 0 1 7;5 2(1):82–86

the lengthening phase. The consolidation period, which is at least twice as long as the lengthening, can be completed using only a locked intramedullary nail. This technique allows for early joint mobility and protects the bone regenerate.9–12 In 1992, García-Cimbrelo et al.7 reported that, of 100 patients treated with the traditional technique using the circular external fixator, in which 47 patients were subjected to lengthening, complications such as intolerance to the device occurred in 6%, muscle contracture in 22%, and two patients presented fractures in the bone regenerate. They concluded that the prolonged duration of external fixation use contributed to complications. In the present study, as the fixator was removed after the lengthening period, these complications did not occur. Several authors have described the advantages of bone lengthening through the association of external fixator and locked intramedullary nails.9,13 In 2011, Sun et al.14 conducted a retrospective comparative study in tibial bone lengthening in which they compared 176 patients (289 tibias) that were elongated with (143) and without (146) the association of intramedullary nails. They concluded that the group of external fixation associated with intramedullary nails presented better results regarding bone healing time. In 2012, in a systematic review comparing the traditional Ilizarov method with the technique of external fixator associated with intramedullary nails in tibial lengthening, Jain and Harwood15 assessed whether the healing time and the duration of external fixator use decreased. They concluded that there was no change in the time of consolidation, and that the duration of external fixation in the combined technique was lower. Complications were similar in both methods. These results are in agreement with those obtained in the present study. Mahboubian et al.,16 in 2011, compared the use of external fixator over nails with telescopic intramedullary nail in femoral lengthening. They reported that patients who used external fixator over nails had fewer complications and better control of the lengthening speed. El-Husseini et al.,17 in a randomized prospective clinical study, compared lower limb lengthening (femur and tibia) through the Ilizarov technique with the technique of external fixator associated with intramedullary nails They concluded that the healing time was shorter in the group that used the fixator over nails. In addition, more complications observed in the group in which only an external fixator was used. The present study was not comparative; therefore, it was not possible to conclude whether the consolidation time was shorter. The technique of lengthening over nails is not free of complications. Some studies on femur lengthening reported that, when lengthening reached 20% of total limb length, patients evolved with posterior subluxation of the knee or patellar subluxation. Although lengthening over nails reduces the duration of external fixation use, caution is required to prevent the main complications reported.18 In the present study, some complications (28.7%) related to the osteotomy technique were observed. In four patients, a new osteotomy was necessary. Intraoperative maneuvers with fragment translation, confirmed by fluoroscopy, facilitated the confirmation that the osteotomy was complete.

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Surgical manipulation of the knee was performed in all patients; in two cases, arthroscopy was used. These maneuvers allow the improvement of the knee range of motion.

Conclusion Femoral lengthening technique with monolateral external fixator over intramedullary nail is an effective method, allows a shorter duration of external fixator use, better protection of the bone regenerate, and early joint rehabilitation; however, it is not free of complications.

Conflicts of interest The authors declare no conflicts of interest.

references

1. Kelly DM. Anomalias congênitas da extremidade inferior. In: Canale ST, Beaty JH, editors. Campbell’s operative orthopaedics. 11th ed. St Louis: Mosby; 2007. p. 1048–9. 2. Fleming B, Paley D, Kristiansen T, Pope M. A biomechanical analysis of the Ilizarov external fixator. Clin Orthop Relat Res. 1989;241:95–105. 3. Kummer FJ. Biomechanics of the Ilizarov external fixator. Clin Orthop Relat Res. 1992;280:11–4. 4. Iizarov GA. Osteosintesis: técnica de IIizarov. Madrid: Ediciones Norma; 1990. 5. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues. Part I. The influence of stability of fixation and soft-tissue preservation. Clin Orthop Relat Res. 1989;238:249–81. 6. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues. Part II. The influence of the rate and frequency of distraction. Clin Orthop Relat Res. 1989;239:263–85. 7. García-Cimbrelo E, Olsen B, Ruiz-Yagüe M, Fernandez-Baíllo N, Munuera-Martínez L. Ilizarov technique. Results and difficulties. Clin Orthop Relat Res. 1992;283:116–23. 8. Song HR, Oh CW, Mattoo R, Park BC, Kim SJ, Park IH, et al. Femoral lengthening over an intramedullary nail using the external fixator: risk of infection and knee problems in 22 patients with a follow-up of 2 years or more. Acta Orthop. 2005;76(2):245–52. 9. Paley D, Herzenberg JE, Paremain G, Bhave A. Femoral lengthening over an intramedullary nail. A matched-case comparison with Ilizarov femoral lengthening. J Bone Jt Surg Am. 1997;79(10):1464–80. 10. Simpson AH, Cole AS, Kenwright J. Leg lengthening over an intramedullary nail. J Bone Jt Surg Br. 1999;81(6):1041–5. 11. Bost FC, Larsen LJ. Experiences with lengthening of the femur over an intramedullary rod. J Bone Jt Surg Am. 1956;38-A(3):567–84. 12. Min WK, Min BG, Oh CW, Song HR, Oh JK, Ahn HS, et al. Biomechanical advantage of lengthening of the femur with an external fixator over an intramedullary nail. J Pediatr Orthop B. 2007;16(1):39–43. 13. Raschke MJ, Mann JW, Oedekoven G, Claudi BF. Segmental transport after unreamed intramedullary nailing. Preliminary report of a Monorail system. Clin Orthop Relat Res. 1992;282:233–40. 14. Sun XT, Easwar TR, Manesh S, Ryu JH, Song SH, Kim SJ, et al. Complications and outcome of tibial lengthening using the


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Ilizarov method with or without a supplementary intramedullary nail: a case-matched comparative study. J Bone Jt Surg Br. 2011;93(6):782–7. 15. Jain S, Harwood P. Does the use of an intramedullary nail alter the duration of external fixation and rate of consolidation in tibial lengthening procedures? A systematic review. Strateg Trauma Limb Reconstr. 2012;7(3):113–21. 16. Mahboubian S, Seah M, Fragomen AT, Rozbruch SR. Femoral lengthening with lengthening over a nail has fewer

complications than intramedullary skeletal kinetic distraction. Clin Orthop Relat Res. 2012;470(4):1221–31. 17. El-Husseini TF, Ghaly NA, Mahran MA, Al Kersh MA, Emara KM. Comparison between lengthening over nail and conventional Ilizarov lengthening: a prospective randomized clinical study. Strateg Trauma Limb Reconstr. 2013;8(2):97–101. 18. Kocaoglu M, Eralp L, Kilicoglu O, Burc H, Cakmak M. Complications encountered during lengthening over an intramedullary nail. J Bone Jt Surg Am. 2004;86(11):2406–11.


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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

www.rbo.org.br

Original article

Arthroscopic subcapital realignment osteotomy in chronic and stable slipped capital femoral epiphysis: early results夽 Bruno Dutra Roos ∗ , Marcelo Camargo de Assis, Milton Valdomiro Roos, Antero Camisa Júnior, Ezequiel Moreno Ungaretti Lima, Rodolfo Cavanus Pagani Universidade de Passo Fundo, Faculdade de Medicina, Hospital Ortopédico de Passo Fundo, Passo Fundo, RS, Brazil

a r t i c l e

i n f o

a b s t r a c t

Article history:

Objective: This study aimed to evaluate the clinical and radiographic outcomes, as well as

Received 1 February 2016

the complications of arthroscopic subcapital realignment osteotomy in chronic and stable

Accepted 29 March 2016

slipped capital femoral epiphysis (SCFE). As indicated by the literature review, this is the

Available online 29 December 2016

first time this type of arthroscopic osteotomy was described.

Keywords:

scopic subcapital realignment osteotomy in chronic and stable SCFE. The mean age was 11

Methods: Between June 2012 and December 2014, seven patients were submitted to arthroEpiphyses, slipped

years and 4 months, and the mean follow-up period was 16.5 months (6–36). Clinical results

Hip

were evaluated using the Modified Harris Hip Score (MHHS), which was measured pre- and

Femur head

postoperatively. Radiographs were evaluated using the Southwick quantitative classification

Arthroscopy

and the epiphysis–diaphysis angle (pre- and postoperatively). Complications were assessed.

Child

Results: The mean preoperative MHHS was 35.8 points, and 97.5 points post-operatively (p < 0.05). Radiographically, five patients were classified as Southwick classification grade II and two as grade III. The mean correction of the epiphysis-diaphysis angle was 40◦ . No immediate postoperatively complications were observed. One patient presented femoral head avascular necrosis, without collapse or chondrolysis at the most recent follow-up (22 months) Conclusion: The arthroscopic technique presented for subcapital realignment osteotomy in chronic and stable SCFE showed satisfactory clinical and radiographic outcomes in a 16.5 months follow-up period. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Study conducted at the Hospital Ortopédico de Passo Fundo (HOPF), Cirurgia do Quadril, Passo Fundo, RS, Brazil. Corresponding author. E-mail: brunodroos@gmail.com (B.D. Roos). http://dx.doi.org/10.1016/j.rboe.2016.12.007 2255-4971/© 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). ∗


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Osteotomia artroscópica de realinhamento subcapital no tratamento da epifisiólise proximal do fêmur crônica e estável: resultados precoces r e s u m o Palavras-chave:

Objetivo:

Epífise deslocada

osteotomia de realinhamento subcapital por via artroscópica para tratamento da epifisiólise

Quadril

proximal do fêmur (EPF) crônica e estável, relativos a uma série inicial de pacientes. Con-

Avaliar os resultados clínicos e radiográficos, bem como as complicac¸ões da

Cabec¸a do fêmur

forme análise da literatura, o estudo apresenta a primeira descric¸ão de técnica artroscópica

Artroscopia

desse tipo de osteotomia.

Crianc¸a

Métodos: Entre junho de 2012 a dezembro de 2014, sete pacientes foram submetidos à osteotomia de realinhamento subcapital por via artroscópica para tratamento da EPF crônica e estável. A idade média dos pacientes foi de 11 anos e quatro meses. O seguimento mínimo foi de seis a 36 meses (média de 16,5 meses). Os pacientes foram avaliados clinicamente de acordo com o Harris Hip Score modificado por Byrd e radiograficamente conforme a classificac¸ão quantitativa de Southwick e o ângulo epifisio-diafisário. Complicac¸ões pósoperatórias foram analisadas. Resultados: Com relac¸ão à avaliac¸ão do escore clínico Harris Hip Score Modificado por Byrd, observou-se média pré-operatória de 35,8 pontos e pós-operatória de 97,5 pontos (p < 0,05). Radiograficamente, cinco pacientes foram classificados como grau II e dois como grau III de Southwick. Observou-se correc¸ão média do ângulo epifisio-diafisário de 40o . Não houve complicac¸ões pós-operatórias imediatas. Um paciente evoluiu com necrose avascular da cabec¸a femoral, sem colapso ou condrólise no último seguimento (22 meses). Conclusão: A técnica artroscópica apresentada pelos autores para tratamento da EPF crônica e estável resultou em melhoria clínica e radiográfica dos pacientes nesta série inicial. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Este e´ um artigo Open Access sob uma licenc¸a CC BY-NC-ND (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction Slipped capital femoral epiphysis (SCFE) is the most common disease of the adolescent hip, with an estimated frequency of 10.8 per 100,000 individuals.1 Recent studies on the biomechanics of femoroacetabular impingement (FAI) indicate that small anatomical deformities that may arise from SCFE potentially cause permanent acetabular chondral damage,2,3 leading to early osteoarthritis. There is no consensus regarding the best SCFE treatment option, especially considering high-grade slips (grades II and III of the Southwick classification).4 Some authors indicate treatment with in situ fixation in these cases, because this procedure has a low complication rate. They believe that the residual hip deformity remodels during growth allowing proper function.5,6 Others, including the present authors, indicate correcting the deformity site (subcapital realignment osteotomy) in order to achieve an anatomical reduction of the epiphysis and decrease the risk of subsequent chondral degeneration.7 The main criticism of the authors contrary to the use of the subcapital realignment osteotomy technique is the risk of complications such as avascular necrosis (AVN) of the femoral head and chondrolysis, which can occur in up to 28% of cases.8 However, the growing number of studies in this area has led to a reduction in complications. It is essential to observe technical details to preserve the vascular supply of the epiphysis during the procedure.7

This study aimed to assess the clinical and radiographic results and the complications of arthroscopic subcapital realignment osteotomy as a treatment for chronic and stable SCFE in an initial series of patients. According to our literature search, this is the first description of arthroscopic subcapital realignment osteotomy for the treatment of chronic and stable SCFE.

Materials and methods This was a retrospective study of patients who underwent arthroscopic subcapital realignment osteotomy for treatment of SCFE, operated from June 2012 to December 2014. Patients with chronic SCFE (over three weeks of symptoms, without pain exacerbation), stable,3 Southwick grade II or III, without prior treatment, without preoperative signs of necrosis or chondrolysis, and with an open epiphyseal plate were included. During this period, seven patients underwent the treatment, six males and one female; the left side was affected in five cases. Age ranged from 11 years to 12 years and three months old (SD = 6.9, mean = 11 years and four months). Minimum follow-up was six months and the maximum was 36 months (SD = 10.3, mean 16.5 months). All surgeries were performed by the same surgeon (BDR). All patients were called upon for a reassessment. The study was approved by the Research Ethics Committee.


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A

B

Proximal

Anterior

D

L Medial

Lateral

H Medial

Lateral

FN H

FN

Distal Posterior

Fig. 1 – (A) Intraoperative image of hip arthroscopy for subcapital realignment in the treatment of chronic and stable SCFE, disclosing the exposure of the labrum (L), femoral head (H), and femoral neck (FN). (B) Axial characterization of the left hip showing the femoral head (H), femoral neck (FN), and CAM-type deformity of the femoral neck (D) resulting from the chronicity of the SCFE.

Regarding clinical aspects, the patients were evaluated preand postoperatively according to the Harris Hip Score modified by Byrd (MHHS) apud Guimarães et al.9 The cases were radiographically evaluated in the pelvic anteroposterior and frog leg views. To determine the degree of preoperative slippage, the Southwick4 criteria were used and the cases were classified as grade I (up to 30◦ ), grade II (30◦ –60◦ ), or grade III (above 60◦ ). The degree of slip correction was also determined, by comparing the pre- and postoperative measures of the epiphyseal-diaphyseal angle4 (EDA) in the frog leg view. During follow-up, the presence of AVN and/or chondrolysis was analyzed. The statistical method used for the analysis of paired variables (MHHS, EDA) was the Wilcoxon test, considered statistically significant at p < 0.05.

Surgical technique General anesthesia with femoral nerve block was used to all cases. Physical examination of the hip with the patient under anesthesia was used to passively assess bilateral range of motion. The patient was placed in the supine position on a radiolucent table. The orthopedic traction table was not used, due to the need for greater hip mobility for the multiple intraoperative maneuvers. The pelvis was slightly tilted to the contralateral side, and a radiolucent cushion was placed under the affected hemipelvis. The anatomical references were marked with an appropriate pen. A vertical line was drawn from the anterosuperior iliac spine toward the center of the patella. The anterior, posterior, and proximal borders of the greater trochanter of the femur were marked. The portals were positioned with the assistance of fluoroscopy. The first portal was the mid-anterior (MAP), which is used for the camera. Subsequently, the proximal mid-anterior portal (PMAP), which is the working portal, is

positioned to provide a parallel access to the proximal femoral physis. The arthroscopic approach used for subcapital realignment was extracapsular,10 following the access to the peripheral joint compartment described by Sampson.11 With the affected limb in a neutral position and after establishing the arthroscopic portals, the anterior joint capsule and the iliocapsular muscle were dissected with radiofrequency and shaver to obtain proper exposure. Then, a T-capsulotomy of the femoral neck was made, which could be extended as required. Subsequently, capsulectomy was made until a proper exposure of the anterior metaphysis and epiphysis of the proximal femur in its mid-lateral extension was obtained. With radiofrequency, the longitudinal opening of the periosteum and its detachment from the femoral neck were made, forming a retinacular flap together with the epiphysis (Fig. 1). After proper exposure, an osteochondroplasty of the femoral neck-head transition is made, which allows the resection of a CAM-type deformity originated by the SCFE chronicity; it also allows a better identification of physis (Fig. 2). In more severe degrees of slippage, external rotation and limb extension may be required to expose the epiphyseal plate. The osteotomy is performed 2 mm distal to the growth plate (to facilitate a subsequent neck shortening) with a specific curved osteotome at different locations of the epiphyseal plate, until the epiphysis and metaphysis are completely separated. All patients had open epiphyseal plate, and no difficulties were observed at this surgical step (Fig. 3). When the femoral metaphysis was separated from the epiphysis, the hip was externally rotated and gently tractioned to enable the shortening of the neck and growth plate resection using arthroscopic curette (Fig. 4). Subsequently, the hip was adducted to remove the neoformed bone tissue in the posteromedial femoral neck region, which can be an obstacle to subsequent reduction. Finally, abduction and internal rotation hip maneuvers were performed for osteotomy reduction (Fig. 5). A 6.5


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A

B

Proximal

Anterior

H Medial

FN

Medial

Lateral

FN

Lateral

H

Distal Posterior

Fig. 2 – (A) Intraoperative image of the left hip after femoral neck osteochondroplasty for the correction of CAM-type deformity showing the femoral head (H) and femoral neck (FN). (B) Axial characterization of the left hip, showing the femoral head (H) and femoral neck (FN) after femoral neck osteochondroplasty for the correction of CAM-type deformity.

A

B

Proximal

Anterior

CO

CO

Lateral

Medial Medial

Lateral

FN H

FN

Distal

GP Posterior

Fig. 3 – Intraoperative image of the left hip showing the femoral neck (FN) and the curved osteotome (CO) during neck osteotomy at the level of the growth plate. (B) Axial characterization of the left hip showing the femoral head (H), femoral neck (FN), the growth plate (GP), and the curved osteotome (CO) positioned for neck osteotomy.

B

A

Anterior

Proximal

AC AC Lateral

Medial Medial

Lateral

FN

FN

H

Distal Posterior

Fig. 4 – (A) Intraoperative image of the left hip showing the femoral neck (FN) and arthroscopic curette (AC) during curettage of the femoral neck for shortening and resection of the posterior-bone formation. (B) Axial characterization of the left hip showing the femoral head (H), the femoral neck (FN), and the arthroscopic curette (AC).


r e v b r a s o r t o p . 2 0 1 7;5 2(1):87–94

Anterior

Medial

Lateral

H FN

Posterior

Fig. 5 – Axial characterization of the left hip showing the femoral head (H) and femoral neck (FN) after osteotomy reduction.

partially threaded cancellous screw was used for percutaneous fixation (Figs. 6–8). To reduce the risk of avascular necrosis of the proximal femoral epiphysis, at the time of the neck osteotomy it is essential to avoid directing the osteotome toward the posterosuperior retinaculum (which contains the terminal branches of the medial circumflex artery) and toward the lower retinacular artery (which is directed toward the epiphysis outside the retinacular tissue of the femoral neck in the medial Weitbrecht ligament), which are not visualized during arthroscopy. Likewise, shortening of the femoral neck and appropriate

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resection of the posteromedial bone formation are essential to avoid excessive tensioning of the vessels during the osteotomy reduction maneuver. Postoperatively, patients were hospitalized for 24 h for observation of clinical outcome. Naproxen was used for 30 days to prevent heterotopic ossification; patients were oriented to use crutches without weight bearing on the operated limb for the same period, without restrictions to the hip range of motion. At 30 postoperative days, control radiographs were made and full weight bearing was authorized.

Results Regarding the assessment of the MHHS score, the mean preoperative score was 35.8 points (SD = 4.1, range = 30.8–41.8) and the mean postoperative score, 97.5 (SD = 2.9, range = 93.5–100), with a mean postoperative increase of 61.7. There was a statistically significant difference (p < 0.05) when comparing the pre- and postoperative MHHS.9 Regarding the radiographic evaluation, five patients were preoperatively classified as Southwick4 grade II and two as grade III. The mean pre-operative EDA4 was 51.2◦ (SD = 12.4, range = 32◦ –68◦ ) and postoperative, 11.2◦ (SD = 5.1, range = 6◦ –18◦ ), with a mean postoperative correction of 40◦ . A statistically significant difference was observed (p < 0.05) when comparing the pre- and postoperative EDA4 (Table 1). There were no immediate postoperative complications. One patient (case 2) evolved with AVN 60 days after surgery, without collapse or chondrolysis until the last follow-up (22 months). This case had a large posteromedial bone formation

Fig. 6 – Male patient aged 11 years. Pain in the right hip for two months, was able to walk without crutches. Hip locked in IR, 80◦ of flexion. (A) and (B) Preoperative radiographs showing Southwick grade II SCFE on the right, EDA 54◦ . (C) and (D) Postoperative radiographs at 20 months of follow-up showing the correction of the deformity, EDA 8◦ .


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Fig. 7 – Female patient aged 12 years and two months. Pain in the left hip for one month, was able to walk without crutches. Hip locked in IR, 90◦ of flexion. (A) and (B) Preoperative radiographs showing Southwick grade II SCFE to the left, EDA 45◦ . (C) and (D) Postoperative radiographs at six months of follow-up disclosing deformity correction, EDA 6◦ .

in the femoral neck, which the authors believe to have been insufficiently resected.

progressive injury on the chondrolabral junction due to excessive shear stress on the structure. In severe SCFE, the degenerative biomechanical mechanism is PINCERtype FAI, since the large deformity generates compression and primary failure of the acetabular labrum, as well as contrecoup injury in the posteroinferior cartilage of the acetabulum.8 Leunig et al.2 evidenced labral and chondral acetabular injuries in 14 patients with unstable SCFE3 during surgery using the surgical dislocation of the hip technique; they observed that these injuries occurred when the femoral metaphysis was at or extended beyond the epiphyseal line. Likewise, Sink et al.,12 using the same technique, demonstrated the presence of intra-articular injuries in 39 patients with SCFE, 34 labral and 33 chondral.

Discussion SCFE is the most common disease of the adolescent hip, estimated at 10.8 per 100,000 individuals.1 Recent studies on the biomechanics of FAI indicate that small anatomical deformities of the hip that may arise from SCFE are a potential cause of permanent acetabular chondral damage2 and lead to early osteoarthritis. The anterior displacement of the femoral metaphysis caused by mild or moderate slips (Southwick classification)4 leads to CAM-type FAI and generates a

Table 1 – Operated cases, description, and mean measurements. Patient

Gender

1 2 3 4 5 6 7

M M M M F M F

Mean

Age (months)

147 130 132 133 134 135 146 136.7

Side

L R R L L L L

Follow-up (months)

MHHS pre-op

MHHS post-op

36 22 20 12 10 10 6

30.8 30.8 34.1 37.4 38.5 41.8 37.4

93.5 93.5 100 97.9 97.9 100 100

16.5

35.8

97.5

EDA pre-op

EDA post-op

62 42 54 56 68 32 45

18 6 8 12 18 11 6

51.2

11.2

Complications

AVN

EDA, epiphyseal-diaphyseal angle; R, right; L, left; F, female; M, male; MHHS, modified Harris Hip Score; AVN, aseptic necrosis of the femoral head.


r e v b r a s o r t o p . 2 0 1 7;5 2(1):87–94

Anterior

X Distal

X

Proximal

∗ Posterior

Fig. 8 – Aspect of the incisions showing the arthroscopic portals (X) and the incision for percutaneous fixation of the femoral neck (*).

Dunn’s original procedure for the treatment of SCFE, described in 1964, consisted of a trapezoidal proximal femoral neck osteotomy for further reduction and fixation of the slippage.13 Their results were first published in 1978, comprising 78 hips (25 acute and 48 chronic); nine cases progressed to AVN (two cases with complete epiphyseal necrosis).14 Ganz et al.15 described the use of the surgical hip dislocation technique in a modified Dunn osteotomy (subcapital realignment osteotomy) in the treatment of high-grade SCFE.4 According to the authors, this approach provides access to the hip, preserves the epiphyseal vascular supply, and allows adequate resection of the posteromedial bone formation in the femoral neck and satisfactory reduction of the epiphysis. This makes it possible to restore the anatomy of the proximal femur with a technique that reduces the risk of AVN.15 Leunig et al.16 published the first results of this technique in 2007, with 30 hips treated and a mean follow-up of 55 months. Of these, 24 cases were considered chronic slips, and no case progressed to AVN. Two cases (6.66%) underwent reoperation due to failure of the fixation with screws. Ziebarth et al.7 also retrospectively evaluated this technique in 40 patients, divided into two cohorts from different centers, with mean follow-ups of 5.4 and 2.2 years. The alpha angle and the slip angle were normalized in all cases, with no cases of AVN or chondrolysis.7 Other authors who have published their results on the use of the technique described by Ganz showed a greater number of complications. Sankar et al.,17 in a multicenter study that evaluated 27 patients with unstable SCFE3 in mean follow-up of 22.3 months, observed four patients (15%) requiring reoperation for failure of fixation and seven cases (26%) of AVN. The mean postoperative course until osteonecrosis was 21.4 weeks; patients who did not develop this complication presented a significantly lower clinical pain score and greater postoperative satisfaction.17 Upasani et al.18 presented the results of 43 patients treated with this technique; 60% of cases patients had unstable SCFE,3 40% were considered acute, and 86% were classified as severe slip.4 Those authors observed 22 complications in 16 patients; there were 15 reoperations due

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to AVN, fixation failure, and postoperative hip dislocation. Two patients received indication for total hip arthroplasty. Two Brazilian studies reported the arthroscopic treatment of chronic-acutized SCFE (unstable).3 Akkari et al.19 presented the results of five cases treated with arthroscopic trapezoidal osteotomy with a mean preoperative EDA4 of 82◦ and a mean postoperative EDA of 14◦ ; one case developed AVN.19 Dobashi et al.20 presented a case report of a 12-year-old patient who underwent a Dunn-type arthroscopic femoral neck osteotomy; the slippage was corrected from 70◦ to 30◦ . The present study presented an alternative to classical techniques of subcapital realignment for the treatment of chronic and stable SCFE3 that allows adequate access to the hip joint and appropriate reduction of the slippage, with a theoretical advantage of rapid rehabilitation. The period of slippage evolution is not a limiting factor for the application of this technique; nonetheless, it was only indicated in cases with open epiphyseal plate. According to a literature search, this is the first description of an arthroscopic subcapital realignment osteotomy for the treatment of chronic and stable SCFE. The authors reiterate that, prior to the performance of the arthroscopic technique described, it is essential that the surgeon receives adequate training in hip arthroscopy, as well as experience in open subcapital osteotomy, due to the multiple technical difficulties of treatment.

Conclusion The arthroscopic technique presented by the authors for the treatment of chronic and stable proximal femoral epiphysiolysis resulted in clinical and radiographic improvement of patients in this initial series, with a mean follow-up of 16.5 months. One case of AVN, without collapse or chondrolysis, was observed at 22 months of follow-up.

Conflicts of interest The authors declare no conflicts of interest.

references

1. Lehmann CL, Arons RR, Loder RT, Vitale MG. The epidemiology of slipped capital femoral epiphysis: an update. J Pediatr Orthop. 2006;26(3):286–90. 2. Leunig M, Casillas MM, Hamlet M, Hersche O, Notzli H, Slongo T, et al. Slipped capital femoral epiphysis: early mechanical damage to the acetabular cartilage by a prominent femoral metaphysis. Acta Orthop Scand. 2000;71(4):370–5. 3. Loder RT, Richards BS, Shapiro PS, Reznick LR, Aronson DD. Acute slipped capital femoral epiphysis: the importance of physeal stability. J Bone Joint Surg Am. 1993;75(8):1134–40. 4. Southwick WO. Osteotomy through the lesser trochanter for slipped capital femoral epiphysis. J Bone Joint Surg Am. 1967;49(5):807–35. 5. Bellemans J, Fabry G, Molenaers G, Lammens J, Moens P. Slipped capital femoral epiphysis: a long-term follow-up, with special emphasis on the capacities for remodeling. J Pediatr Orthop B. 1996;5(3):151–7.


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6. Jones JR, Paterson DC, Hillier TM, Foster BK. Remodelling after pinning for slipped capital femoral epiphysis. J Bone Joint Surg Br. 1990;72(4):56873. 7. Ziebarth K, Zilkens C, Spencer S, Leunig M, Ganz R, Kim Y. Capital realignment for moderate and severe SCFE using a modified Dunn procedure. Clin Orthop Relat Res. 2009;467:704–16. 8. Sucato DJ, De La Rocha A. High grade SCFE: the role of surgical hip dislocation and reduction. J Pediatr Orthop. 2014;34(1):18–24. 9. Guimarães RP, Alves DPL, Azuaga TL, Ono NK, Honda E, Polesello GC, et al. Traduc¸ão e adaptac¸ão transcultural do Harris Hip Score modificado por Byrd. Acta Ortop Bras. 2010;18(6):339–43. 10. Roos BD, Roos MV, Camisa Júnior A, Lima EMU, Gyboski DP, Martins LS. Abordagem extracapsular para tratamento do impacto femoroacetabular: resultados clínicos, radiográficos e complicac¸ões. Rev Bras Ortop. 2015;50(4):430–7. 11. Sampson TG. Arthroscopic treatment of femoroacetabular impingement. Tech Orthop. 2005;20(1):56–62. 12. Sink EL, Zaltz I, Heare T, Dayton M. Acetabular cartilage and labral damage observed during surgical hip dislocation for stable slipped capital femoral epiphysis. J Pediatr Orthop. 2010;30(1):26–30. 13. Dunn DM. The treatment of adolescent slipping of the upper femoral epiphysis. J Bone Joint Surg Br. 1964;46:621–9.

14. Dunn DM, Angel JC. Replacement of the femoral head by open operation in severe adolescent slipping of the proximal femoral epiphysis. J Bone Joint Surg. 1978;60(3):394–403. 15. Ganz R, Gill TJ, Gautier E, Ganz K, Krugel N, Berlemann U. Surgical dislocation of the adult hip. A technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br. 2001;83(8):1119–24. 16. Leunig M, Slongo T, Kleinschmidt M, Ganz R. Subcapital correction osteotomy in slipped capital femoral epiphysis by means of surgical hip dislocation. Oper Orthop Traumatol. 2007;19(4):389–410. 17. Sankar WN, Vanderhave KL, Matheney T, Herrera-Soto JA, Karlen JW. The modified Dunn procedure for unstable slipped capital femoral epiphysis: a multicentric perspective. J Bone Joint Surg Am. 2013;95(7):585–91. 18. Upasani VV, Matheney TH, Spencer SA, Kim YJ, Millis MD, Kasser JR. Complications after modified Dunn osteotomy for the treatment of adolescent slipped capital femoral epiphysis. J Pedriatr Orthop. 2014;34(7):661–7. 19. Akkari M, Santili C, Braga SR, Polessello GC. Trapezoidal bony correction of the femoral neck in the treatment of severe acute-on-chronic slipped capital femoral epiphysis. Arthroscopy. 2010;26(11):1485–95. 20. Dobashi ET, Blumetti FC, Pinto JP, Milani C, Ishida A. Artroscopia do quadril na epifisiólise grave. Rev Bras Ortop. 2010;45 Suppl.:59–62.


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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

www.rbo.org.br

Original article

In vivo evaluation of porous hydrogel pins to fill osteochondral defects in rabbits夽 Túlio Pereira Cardoso a,∗ , André Petry Sandoval Ursolino a , Pamela de Melo Casagrande a , Edie Benedito Caetano a , Daniel Vinicius Mistura b , Eliana Aparecida de Rezende Duek a a b

Pontifícia Universidade Católica de São Paulo, Faculdade de Ciências Médicas e da Saúde de Sorocaba, Sorocaba, SP, Brazil Universidade Federal de São Carlos, Sorocaba, SP, Brazil

a r t i c l e

i n f o

a b s t r a c t

Article history:

Objective: This experimental study aimed to evaluate the biological performance of poly

Received 14 January 2016

(l-co-D, l-lactic acid)-co-trimetilene carbonate/poly (vinyl alcohol) (PLDLA-co TMC/PVA),

Accepted 29 March 2016

hydrogel scaffolds, as an implant in the filling (and not in the repair) of osteochondral defects

Available online 29 December 2016

in New Zealand rabbits, assessing the influence of the material in tissue protection in vivo. Methods: Twelve rabbits were divided into groups of nine and 16 weeks. In each animal, an

Keywords:

osteochondral defect was created in both medial femoral condyles. In one knee, a hydrogel

Articular cargilage

scaffold was implanted (pin group) and in the other, the defect was maintained (control

Hydrogels/chemistry

group). A histological analysis of the material was performed after euthanasia.

Rabbits

Results: The condyles of the pin group showed no inflammatory reaction and were surrounded by a fibrous capsule. The control group presented higher bone growth in the areas of the defect, but with disorganized articular cartilage, evident fibrosis, bone exposure, atrophy, and proliferation of synovial membrane. Conclusion: The hydrogel pins are promising in filling osteochondral defects, generally do not cause inflammatory reactions, and are not effective in the repair of osteochondral defects. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

夽 Study conducted at the Pontifícia Universidade Católica de São Paulo, Laboratório de Biomateriais, Faculdade de Ciências Médicas e da Saúde de Sorocaba, Sorocaba, SP, Brazil. ∗ Corresponding author. E-mail: tuliopcardoso@gmail.com (T.P. Cardoso). http://dx.doi.org/10.1016/j.rboe.2016.03.009 2255-4971/© 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).


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Avaliac¸ão do desempenho in vivo de pinos porosos de hidrogel para preenchimento de defeito osteocondral em coelhos r e s u m o Palavras-chave:

Objetivo: Trabalho experimental para avaliar o desempenho biológico de arcabouc¸os de

Cartilagem articular

hidrogel poli (l-co-D, l ácido lático)-co-trimetileno carbonato/poli (álcool vinílico) (PLDLA-

Hidrogéis/química

co-TMC/PVA) como implante no preenchimento, e não no reparo, de defeito osteocondral

Coelhos

em coelhos Nova Zelândia e verificar a influência do material na protec¸ão tecidual in vivo. Métodos: Foram usados 12 coelhos divididos em grupos de nove e 16 semanas. Em cada animal foi criado um defeito osteocondral em ambos os côndilos femorais mediais, em um foi implantado um arcabouc¸o de hidrogel (grupo pino) e no outro foi mantido o defeito (grupo controle). Após o sacrifício dos animais, foi feita análise histológica do material. Resultados: Os côndilos do grupo pino não evidenciaram reac¸ão inflamatória e estavam rodeados por cápsula fibrosa. Já no grupo controle, uma maior proliferac¸ão óssea foi observada nas áreas do defeito, porém com cartilagem articular desorganizada, fibrose evidente, atrofia com exposic¸ão óssea e proliferac¸ão de membrana sinovial. Conclusão: Os pinos de hidrogel são promissores na func¸ão de preenchimento de defeitos osteocondrais, não ocasionam, de modo geral, reac¸ão inflamatória e não são eficazes no reparo de defeitos osteocondrais. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Este e´ um artigo Open Access sob uma licenc¸a CC BY-NC-ND (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction Osteoarthritis is one of the diseases that most commonly affect humans.1 Its prevalence increases with age, being common after 60 years.2 The articular cartilage and the subchondral bone form a lubrication, stabilization, and uniform load distribution system, absorbing shocks and allowing movement with low friction for several decades.2–4 Thus, cartilage protects subchondral bone from high stress and reduces normal contact pressure.2,5 Degraded cartilage evolves to joint pain, stiffness, and decreased movement. Due to low chondral regeneration capacity, osteoarthritis is one of the most important problems in orthopedics. With increasing human longevity and the practice of sports in recent decades, osteochondral injuries have been increasingly observed.2 Normal joint cartilage features a solid phase consisting mostly of collagen and proteoglycans (15–32%) and a fluid phase composed predominantly of water (68–85%).2 Hyaline cartilage consists of 10% cells (chondrocytes) and a dense extracellular matrix, composed of 60–80% water, 10–20% type II collagen fibers, and 10–15% proteoglycans. The mechanical properties of the articular cartilage allow it to transmit loads of approximately eight times the body weight, due to exudation and movement of the fluid through the pores of cartilage, conferring a friction coefficient of 0.008 ␮ (mi).4,6 The subchondral bone is a thin layer of dense, hard bone in contact with the articular cartilage, while trabecular bone is composed of an abundant matrix (collagen fibers and minerals) that serves to transmit loads.6 Being avascular, the cartilage depends on the vascularization of the bone marrow for the migration of mesenchymal

cells responsible for the healing process.7,8 Furthermore, superficial lesions of the articular cartilage without subchondral bone involvement have little intrinsic repair capacity.9 Both in primary and secondary osteoarthritis, cartilage is the tissue that undergoes the greatest damage. Morphological changes to the cartilage include loss of its homogeneous nature, fragmentation, fibrillation, fissures, and ulcerations. With disease progression, occasionally no cartilage remains and areas of the subchondral bone become exposed.10 Three stages can be considered in the process of tissue regeneration: necrosis, inflammation, and repair.11,12 Nonetheless, healing of lesions restricted to the hyaline cartilage may not occur this way.13 Superficial lesions of the articular cartilage that do not reach the subchondral bone tend not to heal.9 In these lesions, there is a degeneration of the cartilage from the surface area; thin portions of collagen fibers with scaly appearance are observed. With lesion progression, vertical cracks with an uneven and dull appearance can be observed in the articular cartilage.4,14 Chondral lesions trigger an inflammatory process and the hematoma quickly organizes itself into fibrin clots, white blood cells, and bone marrow elements. Undifferentiated bone marrow and vascular endothelium cells are converted into primitive fibroblasts, which, with input of capillaries and fibrin clots, turn into vascular fibroblastic repair tissue.11 Depending on the mechanical and biological stimuli, this fibrocartilage tissue will form a cartilaginous tissue.13 Newly formed bone migrates from the base of the defect to the articular surface in the area in contact with subchondral bone. Fibrocartilaginous tissue fills the transition zone and interrupts the formation of bone tissue.4,11,14


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Osteochondral defect repair tissue has a different composition than normal cartilage.15 Chondrocytes synthesize proteoglycans of lower molecular weight. As collagen type II fibers have a smaller diameter and more irregular arrangement, this configuration favors water permeability. This newly formed tissue presents a lower elastic modulus when compared with normal cartilage tissue.4,16,17 Surgical treatment of chondral and osteochondral lesions is a major challenge. The formation of cartilaginous or fibrocartilaginous tissue can be stimulated, repairing or replacing such injuries with a tissue that presents similar characteristics.4,13 There are no replacement tissues whose mechanical properties are similar to that of the original tissue.18 Currently, there is ongoing research on tissue engineering using synthetic three-dimensional systems with porous scaffolds.19,20 Polymers such as poly-p-dioxanone (PPD), polylactic acid (PLA), polyglycolic acid (PGA) and its copolymers PLLA and PLGA, and poly-␣-hydroxy acids, as well as their decay, bioreabsorption, and biocompatibility characteristics, have been thoroughly studied.4,21–24 A non-porous and non-absorbable hydrogel (PLDLA-coTMC/PVA) was used in the present study to fill the osteochondral defect rather than to make a repair that allowed the growth of new tissue. The in vivo biological response to PLDLA-co-TMC/PVA hydrogel pins in the filling of osteochondral defects is unknown. This study aimed to evaluate the biological performance of PLDLA-co-TMC/PVA hydrogel scaffolds as an implant in the filling, rather than in the repair of osteochondral defects in New Zealand rabbits, and to assess the influence of the material in in vivo tissue protection.

Material and methods

Fig. 1 – PLDLA-co-TMC/PVA hydrogel pins and scaffold used for making the devices.

(5 mg/kg). A trichotomy of the operated area was made, and rabbits were placed on a proper operating table in the supine position. Sterilization was conducted with alcoholic chlorhexidine 0.5%, applied with sterile gauze. Surgeon used sterile surgical gloves and the surgical materials were sterilized by autoclaving at 180 ◦ C for 2 h. A medial parapatellar incision was used, with dissection by planes (subcutaneous and capsulotomy for patellar medial). Then, a lateral patellar dislocation was made to expose the femoral condyles. With the knee flexed at 90◦ , a cylindrical defect was created in the articular cartilage and in the subchondral bone of the medial femoral condyle with the use of a 3.3 mm/38.5 mm trephine drill; a 1 cm deep osteochondral cylinder was removed from both knees7,13 (Figs. 2 and 3).

This study was approved by the Research Ethics Committee of this institution (CEUA/FCMS/PUCSP, Number 2013/10).

Preparation of polymer scaffolds (hydrogel pins) Hydrogel pins are composed of a semi-interpenetrating polymer based on polyvinyl alcohol (PVA) and poly-l-co-d, l-lactic acid-co-trimethylene carbonate (PLDLA-TMC). The hydrogel was made with a 10% m/v PVA solution in water and 10% of the PLDLA-TMC compound relative to the mass of the PVA used. The solution was then poured into polytetrafluoroethylene (PTFE) scaffolds with a 4.1 mm diameter, and was submitted to a freeze–thaw process for two days. After this process, pins were removed from the scaffolds, cut at a length of 13 mm, sterilized with UV radiation, and implanted (Fig. 1).

In vivo study of the implanted pins and controls Twelve New Zealand rabbits of both sexes were used, aged between 120 and 150 days and weighing between 3.5 kg and 4.5 kg. After a preoperative eight-hour fasting, the animals were submitted to general anesthesia with intramuscular ketamine hydrochloride (30 mg/kg) associated with xylazine chloride

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Fig. 2 – Hydrogel and trephine implant.


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Removal of the material – euthanasia and tissue collection Seven animals were euthanized after nine weeks, and five, after 16 weeks. Halothane inhalation was used. After death was confirmed, the animal was placed in the supine position. Then, the medial femoral condyles of both knees were resected through the medial patellar access route.

Macroscopic evaluation The condyles were individually identified, macroscopically observed, and photographed (Fig. 5). According to the modified Outerbridge classification, no tissue growth was observed on the pin (both at 9 and 16 weeks), and the pin group could not be included in the classification. In the control group, with nine or 16 weeks, alterations characteristic of Outerbridge II were observed.

Material processing – histological analysis

Fig. 3 – Implant and osteochondral cylinder.

The chondral defect was created in both medial and femoral condyles; on one side, the hydrogel pin was implanted (implant side) while on the other (control side), the defect was kept (Fig. 4). Sutures were made in planes after washing with 0.9% saline solution; no bandages or immobilization devices were used. All animals were kept in individual cages with food and water ad libitum.

The femoral condyles were placed in glass containers with Bouin’s solution (consisting of picric acid, acetic acid, and formaldehyde) for 24 h for fixation, which maintains tissue integrity after death. The material was decalcified in EDTA 4.13% (the decalcification solution consisted of tetrasodium EDTA, sodium tartrate, potassium sodium tartrate, hydrochloric acid, and distilled water) for 21 days. For histological processing, longitudinal parallel (craniocaudal) incisions were made and sequentially identified for each sample. This technique allowed a precise evaluation of the entire area of the condyle, including the initially injured area and the entire surface around the lesion. Samples, properly identified, were dehydrated in a series of alcohol solutions, sequentially cleared in xylene I, II, and III,

Fig. 4 – (A) Osteochondral defect in situ; (B) defect after removal of the osteochondral cylinder; (C) defect filled with the implanted hydrogel pin.


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Fig. 5 – (A) With the hydrogel pin; (B) without the pin (control group).

and embedded in paraffin at 70 ◦ C. After cutting 3 ␮m slices, samples were stained with hematoxylin–eosin and analyzed by conventional light microscopy.

Microscopic evaluation On histologic examination of the sections of the distal femur, attention was directed particularly to the following elements: 1. type of tissue covering the articular surface: hyaline cartilage, fibrocartilage, bone tissue, or fibrous tissue; 2. state of the cartilaginous surface: smooth, with a depression, or irregular with the presence of cracks or fragments; 3. subchondral bone pattern; 4. presence or absence of necrosis and proper inflammatory response; 5. presence or absence of hyperplastic alterations on the cartilage or bone; 6. assessment of synovial membranes, when possible.

Results The evaluation of results considered the amount of fibrosis, bone neoformation, and presence of cartilaginous tissue on the condylar surface.

In the pin group, euthanized nine weeks after the implant was placed, mild fibrosis was found in four animals, and marked fibrosis in two; no animal presented moderate fibrosis. In the control group, euthanized nine weeks after the creation of the osteochondral defect, mild fibrosis was found in two animals, moderate in two, and severe in two. In the pin group, euthanized after nine weeks after the implant was placed, one animal showed bone neoformation; in five, this neoformation was not observed. In the control group, bone neoformation was present in four animals, and absent in one. Regarding the presence of cartilage in the joint surface, it was absent in four rabbits in the control group and present in one case. In one of the rabbits, an area that could not be defined as organized cartilaginous tissue was observed. In the pin group, presence of cartilage tissue was observed in four rabbits, while in two, it was not observed (Table 1 and Figs. 6 and 7). One of the animals included in the group euthanized at 16 weeks presented surgical site infection and was excluded from the study. Four rabbits from the pin group had mild fibrosis and one had no fibrosis. Bone neoformation occurred in four rabbits in the control group; fragmentation of the material was observed

Table 1 – Group of rabbits at nine weeks. Euthanasia at nine weeks

Groups

Fibrosis

Bone neoformation

Rabbit 1-9 Rabbit 1-9 Rabbit 2-9 Rabbit 2-9 Rabbit 3-9 Rabbit 3-9 Rabbit 4-9 Rabbit 4-9 Rabbit 5-9 Rabbit 5-9 Rabbit 6-9 Rabbit 6-9

Control Pin Control Pin Control Pin Control Pin Control Pin Control Pin

Marked Discreet Moderate Marked Discreet Discreet Discreet Discreet Marked Discreet Moderate Marked

Absent Absent Present Present Present Absent Present Absent Present Absent Absent Absent

Cartilaginous surface Absent Present Disorganized Absent Absent Absent Absent Present Present Present Absent Present


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Fig. 6 – Histological slide of the pin group at nine weeks showing no inflammatory reaction and mild fibrosis.

Fig. 8 – Histological slide of the pin group at 16 weeks showing mild fibrosis without bone formation.

one rabbit. In the pin group, five rabbits presented cartilage, vs. one in which it was absent (Table 2 and Figs. 8 and 9).

Discussion

Fig. 7 – Histological slide of the control group at nine weeks showing bone neoformation, marked fibrosis, and tissue disorganization.

in one rabbit, which prevented the correct analysis. Bone neoformation was not observed in the pin group. In the control group at 16 weeks, cartilage degeneration was observed in one case, while in the case with fragmentation of the material, it was not possible to analyze the presence or absence of cartilage. In the control group, cartilage on the joint surface was observed in two rabbits, and it was not present in

Of the 12 rabbits studied, only one from the group euthanized at nine weeks was excluded due to local infection. Thus, 11 animals were included in this study. The histological analysis of the PLDLA-co-TMC/PVA scaffold implants after nine weeks showed that the pin does not induce an inflammatory reaction, but also does not stimulate bone neoformation. There is a stimulus of fibrous proliferation at the edges of the lesion from the articular cartilage, with formation of mainly fibrocartilage, as an attempt to heal the injury. In the control group after nine weeks, more fibrosis and more bone formation were observed, either from articular cartilage from the edges of the lesion or from the trabeculae of compact bone surrounded by osteoprogenitor cells. However, there was no evidence of chondral lesion repair.

Table 2 – Group of rabbits at 16 weeks. Euthanasia at 16 weeks

Groups

Fibrosis

Rabbit 1-16 Rabbit 1-16 Rabbit 2-16 Rabbit 2-16 Rabbit 3-16 Rabbit 3-16 Rabbit 4-16 Rabbit 4-16 Rabbit 5-16 Rabbit 5-16

Control Pin Control Pin Control Pin Control Pin Control Pin

Discreet Discreet Discreet Discreet Discreet Discreet Discreet Moderate Discreet

Bone neoformation Present Absent Present Absent Present Absent Fragmented Absent Present Absent

Cartilaginous surface Present Absent Present Present Degenerated Present Infeasible analysis Present Absent Present


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references

Fig. 9 – Histological slide of the control group at 16 weeks showing bone formation and fibrosis.

After 16 weeks, the condyles with hydrogel implants showed no inflammatory reaction and were surrounded by a fibrous capsule. The surrounding trabecular bone presented a preserved aspect and closure of the joint surface was observed, with the presence of hyaline cartilage or atrophic cartilage of fibro-hyaline appearance. In the control group at 16 weeks, bone proliferation was observed in the defect areas. However, the articular cartilage was disorganized, with obvious fibrosis; atrophy with exposed bone and proliferation of the synovial membrane were observed. Regarding bone neoformation, to the authors’ surprise, one animal from the nine-week pin group presented growth of bone tissue with fibrous pattern. The other rabbits from this group showed no bone growth; in turn, bone formation was observed in the entire control group. As expected, bone filling in osteochondral defect was observed in the control group euthanized at 16 weeks, most likely due to the increased time between surgery and euthanasia. Conversely, no animals in the pin group presented bone growth in the defect. This suggests that the presence of the implanted pin filled the entire space created by the defect.

Conclusion Hydrogel pins were superior regarding the protection of the cartilaginous joint surface as devices for filling osteochondral defects. Nonetheless, they showed no reparative effect. In contrast, cartilage degradation in both the defect and the surrounding area were observed in the control group.

Conflicts of interest The authors declare no conflicts of interest.

1. Redman SN, Oldfield SF, Archer CW. Current strategies for articular cartilage repair. Eur Cell Mater. 2005;9:23–32. 2. Swieszkowski W, Tuan BH, Kurzydlowski KJ, Hutmacher DW. Repair and regeneration of osteochondral defects in the articular joints. Biomol Eng. 2007;24(5):489–95. 3. Buckwalter JA, Einhorn TA, Simon SR, editors. Orthopaedic basic science. Biology and biomechanics of the musculoskeletal system. 2nd ed. Rosemont, IL: AAOS; 2000. 4. Garrido LF. Avaliac¸ão do desempenho de implantes de polietileno e de fosfato tricalcio, recobertos por hidrogel, em defeitos osteocondrais no joelho de cães. Campinas: Universidade Estadual de Campinas, Faculdade de Ciências Médicas; 2007. Dissertac¸ão. 5. Little K. Nature of osteopetrosis. Br Med J. 1969;2(5648):49–50. 6. Ding M, Dalstra M, Linde F, Hvid I. Mechanical properties of the normal human tibial cartilage–bone complex in relation to age. Clin Biomech (Bristol Avon). 1998;13(4–5):351–8. 7. Souza TD, Del Carlo RJ, Viloria MIV. Efeitos da eletroterapia no processo da reparac¸ão da superfície articular de coelhos. Ciênc Rural. 2001;31:819–24. 8. Lammi PE, Lammi MJ, Tammi RH, Helminen HJ, Espanha MM. Strong hyaluronan expression in the full-thickness rat articular cartilage repair tissue. Histochem Cell Biol. 2001;115(4):301–8. 9. Slatter D. Manual de cirurgia de pequenos animais. Baureri, SP: Manole; 1998. 10. Rezende UM, Hernandez AJ, Camanho GL, Amatuzzi MM. Cartilagem articular e osteoartrose. Acta Ortop Bras. 2000;8(2):100–4. 11. Mankin HJ. The response of articular cartilage to mechanical injury. J Bone Joint Surg Am. 1982;64(3):460–6. 12. Cook SD, Patron LP, Salkeld SL, Rueger DC. Repair of articular cartilage defects with osteogenic protein-1 (BMP-7) in dogs. J Bone Joint Surg Am. 2003;85 Suppl. 3:116–23. 13. Ribeiro JL, Camanho GL, Takita LC. Estudo macroscópico e histológico de reparos osteocondrais biologicamente aceitáveis. Acta Ortop Bras. 2004;12(1):16–21. 14. Espósito AR, Bonadio AC, Pereira NO, Cardoso TP, Barbo MLP, Duek EAR. The use of PLDLA/PCL-T scaffold to repair osteochondral defects in vivo. Mat Res. 2013;16(1):105–15. 15. Huntley JS, McBirnie JM, Simpson AH, Hall AC. Cutting-edge design to improve cell viability in osteochondral grafts. Osteoarthritis Cartilage. 2005;13(8):665–71. 16. Henderson I, Francisco R, Oakes B, Cameron J. Autologous chondrocyte implantation for treatment of focal chondral defects of the knee – a clinical, arthroscopic, MRIn and histologic evaluation at 2 years. Knee. 2005;12(3):209–16. 17. Hattori K, Takakura Y, Ohgushi H, Habata T, Uematsu K, Ikeuchi K. Novel ultrasonic evaluation of tissue-engineered cartilage for large osteochondral defects – non-invasive judgment of tissue-engineered cartilage. J Orthop Res. 2005;23(5):1179–83. 18. Buma P, Ramrattan NN, van Tienen TG, Veth RP. Tissue engineering of the meniscus. Biomaterials. 2004;25(9):1523–32. 19. Martin I, Miot S, Barbero A, Jakob M, Wendt D. Osteochondral tissue engineering. J Biomech. 2007;40(4):750–65. 20. Jansen EJ, Pieper J, Gijbels MJ, Guldemond NA, Riesle J, Van Rhijn LW, et al. PEOT/PBT based scaffolds with low mechanical properties improve cartilage repair tissue formation in osteochondral defects. J Biomed Mater Res A. 2009;89(2):444–52. 21. Duek EA, Zavaglia CA, Belangero WD. In vitro study of poly(lactic acid) pin degradation. Polymer. 1999;40:6465–73.


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22. Rahman MS, Tsuchiya T. Enhancement of chondrogenic differentiation of human articular chondrocytes by biodegradable polymers. Tissue Eng. 2001;7(6):781–90. 23. Zhao K, Deng Y, Chun Chen J, Chen GQ. Polyhydroxyalkanoate (PHA) scaffolds with good mechanical properties and biocompatibility. Biomaterials. 2003;24(6):1041–5.

24. Sakata MM, Alberto-Rincon MC, Duek EA. Estudo da interac¸ão polímero/cartilagem/osso utilizando poli(ácido lático-co-ácido glicólico) e poli(p-dionaxona) em côndilofemoral de coelhos. Polímeros. 2004;14(3):176–80.


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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

www.rbo.org.br

Case Report

Elastic suture (shoelace technique) for fasciotomy closure after treatment of compartmental syndrome associated to tibial fracture夽 Paulo Sergio Martins Castelo Branco ∗ , Mauricio Cardoso Junior, Isaac Rotbande, José Antonio Fraga Ciraudo, Celso Ricardo Correa de Melo Silva, Paulo Cesar dos Santos Leal Casa de Saúde Nossa Senhora do Carmo, Rio de Janeiro, RJ, Brazil

a r t i c l e

i n f o

a b s t r a c t

Article history:

This article reports the use of elastic suture as an adjuvant in surgical wound closure caused

Received 6 October 2015

by decompressive fasciotomy after compartment syndrome associated with a compound

Accepted 14 December 2015

fracture of the tibia. Widely used in other medico-surgical specialties, this technique is

Available online 2 December 2016

unusual in orthopedics surgery, but the simplicity of the procedure and the successful outcome observed in this case allows for its consideration as indicated for situations similar to

Keywords: Fascia/surgery Fractures, bone

that presented in this study. © 2016 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Tibia Sutures/utilization

Sutura elástica no fechamento de fasciotomia para tratamento de síndrome compartimental associada à fratura da tíbia r e s u m o Palavras-chave:

Relata-se neste trabalho o uso da sutura elástica como adjuvante no fechamento de

Fáscia/cirurgia

ferida cirúrgica provocada por fasciotomia descompressiva após síndrome do compar-

Fraturas ósseas

timento associada a fratura exposta de tíbia. Muito usada em outras especialidades

Tíbia

médico-cirúrgicas, a técnica não é habitual em ortopedia; entretanto, a simplicidade do pro-

Sutura/utilizac¸ão

cedimento e o resultado satisfatório observado neste caso permite reputá-la como indicada para situac¸ões similares à apresentada neste trabalho. © 2016 Publicado por Elsevier Editora Ltda. em nome de Sociedade Brasileira de Ortopedia e Traumatologia. Este e´ um artigo Open Access sob uma licenc¸a CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Study conducted at Casa de Saúde Nossa Senhora do Carmo, Rio de Janeiro, RJ, Brazil. Corresponding author. E-mail: p.castelobranco@ig.com.br (P.S. Branco). http://dx.doi.org/10.1016/j.rboe.2016.11.004 2255-4971/© 2016 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). ∗


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Introduction The elastic suture allows progressive closure of lesions, encompassing all its levels, restoring normal anatomy and all containment and resistance functions of the skin layers without new morbidity factors for the patient. It was first used to bring together the edges of a fasciotomy after compartmental syndrome in the upper limb.1 This study aimed to report the use of elastic suture for surgical wound closure in a fasciotomy after compartmental syndrome in a leg with traumatic fractures of the proximal third of the tibia and fibula associated with vascular injury.

Case report Male patient, 30 years old, who had been struck by a passenger vehicle, suffered open fractures of the tibia and fibula. He underwent surgical debridement and lavage, and transarticular external fixation from the femur to the tibia in a public hospital of the State of Rio de Janeiro, and was then transferred to our institution. During clinical and orthopedic examination, the patient presented mild pain, swelling ++++/4+, suture on the anterior aspect of the leg, with normal capillary perfusion and thin pulse in the affected limb. Routine lower limb and trauma Xrays were made, as well as a CT scan of the injured limb. The images disclosed isolated leg injuries, with comminuted fractures of the proximal third of the tibia and fibula, which were aligned, stabilized, and maintained by a transarticular external fixator (Fig. 1). Laboratory tests indicated alterations from the normal parameters for the following items: neutrophils, 9128; reactive C protein, 34.4; and creatine kinase, 3940. Over the course of a few hours, the patient developed progressive and severe pain that did not resolve with analgesic use, paresthesia of the ipsilateral hallux, edema, and tense shiny skin. Decompressive fasciotomy was performed. During the surgery, disruption of the tibiofibular trunk was observed and ligated. The fasciotomy was not directly sutured, and the incision site was protected with occlusive dressings (Fig. 2). The patient was then transferred to the intensive care unit for rhabdomyolysis treatment. The vascular surgery department was consulted and an arteriography of the limb was performed, which showed disruption of tibiofibular trunk compatible with the trauma (Fig. 3); it was observed that the posterior tibial and fibular arteries were perfused by retrograde flow. Seven days after fasciotomy, the patient presented a clean wound, without signs of infection. At that moment, the elastic suture system was positioned. An elastic band for vascular surgery was attached to the skin with metal clips, which were applied with surgical stapler 0.5 cm from the incision edges, starting at the proximal apex and continuing toward the distal vertex. The wire was attached to one side and passed through the incision to be attached on the opposite side, in a sequence that resembles a zigzag from the proximal to the distal regions – the shoelace technique. After 7 days, an overall approximation of the wound edges was observed; when the elastic

Fig. 1 – (a) Plain lateral view radiograph; (b) plain anteroposterior radiography; (c) lateral view 3D reconstruction CT scan; (d) anteroposterior 3D reconstruction CT scan.

wire and the metal clips were removed, permanent suture was made with nylon 2-0 thread (Fig. 4A–D). The final treatment of the fracture was conducted with a hybrid external fixator (Fig. 5).

Discussion The identification of compartment syndrome is not always easy, as peripheral perfusion and arterial pulses are usually observed, not representing good parameters for clinical suspicion. In laboratory tests, an increase in creatine kinase (CK) is observed, which indicates myoglobinuria and suggests the diagnosis.2 Fracture of the tibial shaft is one of the most frequent causes of compartment syndrome.3 The repair of its surgical wounds is performed with grafts or large skin flaps; this leads to new wounds, which also demand

Fig. 2 – Decompressive fasciotomy.


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105

Fig. 5 – Wound aspect 25 days after elastic suture.

Fig. 3 – Arteriography disclosing vascular injury.

treatment. These measures are accompanied by pain, increased incidence of infections, scar retraction, rejection, and failure.4 Proximal fractures of the tibia present increased risk for compartment syndrome.5 This condition is more frequent in cases with vascular injury and is characterized by increased blood pressure in regions surrounded by inelastic muscle fascia, altering the local microcirculation and undermining tissue viability. Compartment syndrome is an

orthopedic emergency; decompression fasciotomy is a therapeutic resource for damage control and reducing the risk of severe sequelae.6 Severe pain is the earliest objective clinical finding,7 and increased pressure and turgid compartment may be observed at palpation. Its severity is associated to the speed in which the pressure increases, its duration and the degree of tissue microcirculation impairment.8 The fasciotomy incision represents itself an injury to the patient; furthermore, it increases the risk of infections and the length of hospital stay. Several procedures have been described for closing this type of incision, using various types of materials; there are even reports on the use of properly sterilized common elastic string fixated to the skin adjacent to the incision with surgical suture, providing good approximation of the wound edges in just 5 days after the procedure, with full

Fig. 4 – (a) Zero-hour elastic suture; (b) 48 h of elastic suture; (c) skin aspect after removal of the elastic suture kept for 7 days; (d) 0-h secondary suture after removal of elastic suture.


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closure of the skin 20 days after surgery, without the need for secondary skin suture.9 In the present case, the elastic suture effectively assisted the definitive closure of the fasciotomy incision allowing a secondary suture, and waived the need for an autograft skin, being a feasible, easy-to-perform, and low-cost technique. There is an association between tibial fractures and the development of compartment syndrome. Differential diagnosis from early recognition of signs and symptoms is necessary for initiating appropriate therapy, which improves prognosis and reduces the morbidity rate. Leg fasciotomy closure10 with elastic suture is cheaper method and contributes to a shorter hospital stay when compared to the vacuum technique.11

Conflicts of interest The authors declare no conflicts of interest.

references

1. Raskin KB. Acute vascular injuries of the upper extremity. Hand Clin. 1993;9(1):115–30. 2. Ernest CB, Brennaman BH, Haimovici H. Fasciotomia. In: Haimovici H, Ascer E, Hollier LH, Strandness DE Jr, Towne JB, editors. Cirurgia vascular: princípios e técnicas. 4a ed. São Paulo: Di Livros; 2000. p. 1290–8.

3. McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J. Bone Joint Surg Br. 2000;82(2):200–3. 4. Cipolla J, Stawicki SP, Hoff WS, McQuay N, Hoey BA, Wainwright G, et al. A proposed algorithm for managing the open abdomen. Am Surg. 2005;71(3):202–7. 5. Camacho SP, Lopes RC, Carvalho MR, Carvalho ACF, Bueno RC, Regazzo PH. Análise da capacidade funcional de indivíduos submetidos a tratamento cirúrgico após fratura do planalto tibial. Acta Ortop Bras. 2008;16(3):168–72. 6. Blanco MG, López AA, Lorenzo YG. Síndrome compartimental agudo en lesiones de la tibial. Arq Med Camagüey. 2008;4(12):1–10. 7. Kojima KE, Ferreira RV. Fraturas da diáfise da tíbia. Rev Bras Ortop. 2011;46(2):130–5. 8. Sayum Filho J, Ramos LA, Sayum J, Carvalho RT, Ejnisman B, Matsuda MM, et al. Síndrome compartimental em perna após reconstruc¸ão de ligamento cruzado anterior: relato de caso. Rev Bras Ortop. 2011;46(6):730–2. 9. Petroianu A, Sabino KR, Alberti LR. Closure of large wound with rubber elastic circular strips – case report. Arq Bras Cir Dig. 2014;27(1):86–7. 10. Pitta GBB, Santos TFA, Santos FTA, Costa Filho EM. Síndrome compartimental pós-fratura de platô tibial. Rev Bras Ortop. 2014;49(1):86–8. 11. Kakagia D, Karadimas EJ, Drosos G, Ververidis A, Trypsiannis G, Verettas D. Wound closure of leg fasciotomy: comparison of vacuum-assisted closure versus shoelace technique. A randomised study. Injury. 2014;45(5):890–3.


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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

www.rbo.org.br

Case report

Simultaneous bilateral distal biceps tendon repair: case report夽 Thiago Medeiros Storti ∗ , Alexandre Firmino Paniago, Rafael Salomon Silva Faria Instituto do Ombro de Brasília, Brasília, DF, Brazil

a r t i c l e

i n f o

a b s t r a c t

Article history:

Simultaneous bilateral rupture of the distal biceps tendon is a rare clinical entity, seldom

Received 11 January 2016

reported in the literature and with unclear therapeutic setting. The authors report the case

Accepted 5 February 2016

of a 39-year-old white man who suffered a simultaneous bilateral rupture while working

Available online 23 December 2016

out. When weightlifting with elbows at 90◦ of flexion, he suddenly felt pain on the anterior

Keywords:

of the biceps muscle belly and ecchymosis in the antecubital fossa, extending distally to

Rupture/diagnosis

the medial aspect of the forearm, as well as a marked decrease of supination strength and

aspect of the arms, coming for evaluation after two days. He presented bulging contour

Rupture/etiology

pain in active elbow flexion. MRI confirmed the rupture with retraction of the distal biceps

Rupture/surgery

bilaterally. The authors opted for performing the tendon repairs simultaneously through the

Tendon injuries

double incision technique and fixation to the bicipital tuberosity with anchors. The patient progressed quite well, with full return to labor and sports activities, being satisfied with the result after two years of surgery. In the literature search, few reports of simultaneous bilateral rupture of the distal biceps were retrieved, with only one treated in the acute phase of injury. Therefore, the authors consider this procedure to be a good option to solve this complex condition. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Reparo de ruptura bilateral simultânea do bíceps distal: relato de caso r e s u m o Palavras-chave:

A ruptura bilateral simultânea dos tendões distais do bíceps é uma entidade rara, pouco

Rotura/diagnóstico

relatada na literatura e com definic¸ão terapêutica pouco clara. Relatamos o caso de um

Rotura/etiologia

homem branco de 39 anos que sofreu ruptura bilateral simultânea durante treino de

Rotura/cirurgia

academia em que ao pegar peso com os cotovelos em flexão de 90◦ sentiu dor súbita na

Traumatismos dos tendões

face anterior dos brac¸os e compareceu para avaliac¸ão após dois dias. Apresentava abaulamento do contorno do ventre muscular do bíceps braquial e equimose na região da fossa antecubital que se estendia distalmente para a face medial do antebrac¸o, além de grande

夽 Study conducted at the Hospital Ortopédico e Medicina Especializada (Home), Servic¸o de Cirurgia de Ombro e Cotovelo, Brasilia, DF, Brazil. ∗ Corresponding author. E-mail: thiago storti@hotmail.com (T.M. Storti). http://dx.doi.org/10.1016/j.rboe.2016.12.006 2255-4971/© 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).


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diminuic¸ão da forc¸a de supinac¸ão e dor à flexão ativa do cotovelo. Ressonância nuclear magnética (RNM) confirmou a ruptura com retrac¸ão do bíceps distal, bilateralmente. Optou-se pelo reparo das lesões simultaneamente com a técnica de dupla incisão e fixac¸ão do tendão à tuberosidade bicipital com âncoras. O paciente evoluiu de forma bastante satisfatória, com retorno completo às atividades laborais e esportivas, está bastante satisfeito com o resultado após dois anos da cirurgia. Na pesquisa da literatura, foram achados muito poucos casos descritos de ruptura bilateral simultânea do bíceps distal. Desses, somente um foi tratado na fase aguda da lesão. Portanto, os autores consideram o procedimento descrito como uma boa opc¸ão para a resoluc¸ão dessa complexa condic¸ão. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Este e´ um artigo Open Access sob uma licenc¸a CC BY-NC-ND (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction Simultaneous bilateral rupture of the distal biceps tendon is an extremely rare entity with few reports in the literature, which can lead to devastating functional effects for the patient. The literature describes several surgical options for unilateral rupture of the distal biceps tendon, with different approaches, types of suture, and fixation methods. For bilateral ruptures, in turn, there is no consensus on the surgical technique, the most appropriate moment to perform the surgery, or rehabilitation protocols. In a literature review, it was observed that there are very few reported cases of simultaneous bilateral rupture of the distal biceps. Among them, the surgical treatment took place during the acute phase in only one case, but fixation was performed with a six-week interval between procedures.1 The authors report the case of a patient with bilateral simultaneous distal biceps tendon rupture during elbowflexion resistance exercise, who underwent surgical repair of both sides in one time.

Case report A 39-years-old white male and right-handed patient presented to our service with history of sudden-onset pain and deformity on the anterior aspect of both arms after attempting to lift weights in the gym with elbows flexed at about 90◦ two days before. He had no significant history of previous disease or elbow pain. He practiced weightlifting only as a physical activity seeking health maintenance; he denied seeking substantial muscle hypertrophy. He had been on endocrinological treatment for hormone replacement for six months. Upon physical examination, an obvious deformity was observed on the anterior aspect of the arm, with bulging contour of the biceps muscle belly and bruisings on the antecubital fossa area extending distally to the medial aspect of the forearm. The patient had pain on palpation and absence of the biceps tendon on the anterior aspect of both elbows. He also presented great strength loss for and pain on flexing the elbows. Neurological and vascular functions were preserved bilaterally.

The images obtained by magnetic resonance imaging disclosed complete rupture of the distal biceps tendons, with 5 cm retraction on the right and 4.6 cm on the left side. After discussing the case with the patient and family, the authors opted for immediate surgical treatment and repaired the ruptures in both limbs during the same procedure. The technique used for both limbs was the double incision and tendon anchor fixation.

Surgical technique The patient was placed on the operating table in supine position, without tourniquets. The surgery was initiated on the right upper limb. A transverse incision of approximately 3 cm was made above the cubital skin fold (Fig. 1). The biceps tendon is easily captured when the skin is retracted proximally and away from the deep tissues. The most distal portion of the degenerated tendon was resected; the tendon was repaired using Bunnell sutures with nonabsorbable No. 5 threads. Then, the radial tuberosity was palpated and a curved Kelly forceps was passed through the biceps tendon tunnel, between the ulna and the radius, and it was advanced until its tip could be palpated on the dorsal aspect of the proximal forearm (Fig. 2). A second incision was made over the forceps; the tuberosity

Fig. 1 – Incision mark on the anterior cubital crease.


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109

was instructed to interrupt the use of the slings. Muscle strengthening exercises were initiated after the sixth week, progressively increasing the load. Three months after surgery, the patient had full range of motion without pain, but still presented decreased muscle strength. After the fourth month, he was allowed to return to the gym for progression of muscle strengthening. At five months post-operative, the patient had recovered full muscle strength and returned to daily activities. The last assessment took place two years after the procedure. The patient reported having recovered 100% of pre-injury function and having made a complete return to labor and sports activities.

Discussion Fig. 2 – Intraoperative image showing the prominence of the Kelly forceps passed through the bicipital tunnel.

was exposed through muscle divulsion with the forearm in maximal pronation (Fig. 3). The radial tuberosity was scarified until it presented bleeding. Two bioabsorbable, double-loaded 2.9-mm anchors were positioned, and the biceps tendon was transported through its tunnel with the repair wire. The anchor wires were passed through the tendon for a U-suture. The nots were held with the forearm pronated and the elbow at 90◦ flexion. After testing the stability of the fixation, the skin was sutured and both limbs were immobilized with slings. The sling was maintained for one week; thereafter, physical therapy was initiated. Initially, exercises of passive flexion and active extension with the forearm in supination were performed, as well as passive supination and active pronation to 50◦ . The limbs were immobilized with the slings when not in physiotherapy. This phase lasted until the end of the third week, when exercises to increase flexion and active supination without load were initiated; at this phase, the patient

Fig. 3 – Intraoperative image showing the exposed radial tuberosity.

Simultaneous rupture of the distal biceps tendon is a rare diagnosis, and the most suitable treatment of such an injury depends on numerous factors. Bayat et al.2 reported the case of a 50-year-old mountain climber who had suffered a simultaneous bilateral rupture during practice. He underwent reconstruction with fascia lata graft two years after injury, with a six-month interval between the two limbs. Bell et al.3 reported 26 cases of rupture of the distal biceps, one of which was a simultaneous bilateral rupture. Those authors did not report the type and time of surgery for this case. Rokito and Iofin4 reported the case of a recreational bodybuilder, aged 51 years, who suffered a simultaneous bilateral rupture when performing a Scott curl with a 40 kg load. He underwent primary repair in one side seven weeks after injury, followed by allograft reconstruction at 13 weeks post-injury in the contralateral limb. DaCambra et al.1 described the only case found in the literature review in which the injury was repaired bilaterally while still in the acute phase, but in a staged manner. They presented the case of a 43-year-old patient initially submitted to acute repair in the right limb, and six weeks after in the left limb, both with a single anterior approach technique with Endobutton fixation. The current literature defines as acute injuries those with less than six weeks and as chronic, those over six weeks. This six-week cut-off is arbitrary, but it creates a guideline. After this period, repair becomes increasingly difficult. The present case featured acute ruptures, a few days from injury. To avoid the risk of tendon transfer reconstruction, the authors decided to address both limbs in the same surgical time. None of the few cases described in the literature were treated in this way. The decision regarding whether to carry out the repair of both injuries in the same time or in a staged manner should be made after assessing certain patient variables, such as socioeconomic status, the level of understanding, dominant limb, occupation, and general health status.1 Several studies5,6 have shown satisfactory results with the Boyd and Anderson double incision technique.7 However, it requires a tendon of sufficient length to allow its attachment to the radial tuberosity. Delayed treatment, proximal retraction, possible degenerative changes, and scarring around the


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site can cause difficulties for using this technique.1 In the present case, the authors opted for this approach due to the familiarity of the surgeons with the technique and the fact that the injury had happened just a few days before surgery.

Conclusions The present patient presented an excellent functional result in the two-year follow-up, with complete return to labor and sports activities; he reported to have fully recovered the preinjury function. The authors believe that this is the first case described in the literature of a simultaneous bilateral acute rupture of the distal biceps successfully repaired in a single surgical time using the double incision technique and fixation anchors, which represents a valid option for this challenging condition.

Conflicts of interest The authors declare no conflicts of interest.

references

1. Dacambra MP, Walker RE, Hildebrand KA. Simultaneous bilateral distal biceps tendon ruptures repaired using an endobutton technique: a case report. J Med Case Rep. 2013;23(7):213. 2. Bayat A, Neumann L, Wallace WA. Late repair of simultaneous bilateral distal biceps brachii tendon avulsion with fascia lata graft. Br J Sports Med. 1999;33(4):281–3. 3. Bell RH, Wiley WB, Noble JS, Kuczynski DJ. Repair of distal biceps brachii tendon ruptures. J Shoulder Elbow Surg. 2000;9(3):223–6. 4. Rokito AS, Lofin I. Simultaneous bilateral distal biceps tendon rupture during a preacher curl exercise: a case report. Bull NYU Hosp Jt Dis. 2008;66(1):68–71. 5. Baker BE, Bierwagen D. Rupture of the distal tendon of the biceps brachii. Operative versus non-operative treatment. J Bone Joint Surg Am. 1985;67(3):414–7. 6. Agins HJ, Chess JL, Hoekstra DV, Teitge RA. Rupture of the distal insertion of the biceps brachii tendon. Clin Orthop Relat Res. 1988;(234):34–8. 7. Boyd MM, Anderson LD. A method for reinsertion of the distal biceps brachii tendon. J Bone Joint Surg Am. 1961;43:1041–3.


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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

www.rbo.org.br

Case report

Simultaneous bilateral patellar tendon rupture夽 Diogo Lino Moura ∗ , José Pedro Marques, Francisco Manuel Lucas, Fernando Pereira Fonseca Centro Hospitalar e Universitário de Coimbra, Departamento de Ortopedia, Coimbra, Portugal

a r t i c l e

i n f o

a b s t r a c t

Article history:

Bilateral patellar tendon rupture is a rare entity, often associated with systemic diseases

Received 22 March 2016

and patellar tendinopathy. The authors report a rare case of a 34-year-old man with simul-

Accepted 28 March 2016

taneous bilateral rupture of the patellar tendon caused by minor trauma. The patient is

Available online 22 June 2016

a retired basketball player with no past complaints of chronic knee pain and a history of

Keywords:

temporarily with cerclage wiring, followed by a short immobilization period and intensive

Patellar ligament

rehabilitation program. Five months after surgery, the patient was able to fully participate

Rupture, spontaneous

in sport activities.

steroid use. Surgical management consisted in primary end-to-end tendon repair protected

Tendon injuries

© 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://

Steroids

creativecommons.org/licenses/by-nc-nd/4.0/).

Rehabilitation

Rupturas bilaterais simultâneas dos tendões patelares r e s u m o Palavras-chave:

As rupturas bilaterais dos tendões patelares são uma entidade rara, muitas vezes associadas

Ligamento patelar

com doenc¸as sistêmicas e tendinopatia patelar. Apresentamos um caso raro de um homem

Ruptura espontânea

de 34 anos com rotura bilateral simultânea dos tendões patelares causada por trauma leve.

Traumatismos dos tendões

O paciente é um jogador de basquetebol aposentado, sem queixas de dor crônica do joelho e

Esteroides

com história de consumo de esteroides. O tratamento cirúrgico consistiu na reparac¸ão tendi-

Reabilitac¸ão

nosa primária de ponta a ponta, protegida temporariamente com banda de cerclage, seguida de curto tempo de imobilizac¸ão e programa intensivo de reabilitac¸ão. Aos cinco meses após a cirurgia, o paciente era capaz de participar sem restric¸ões em atividades desportivas. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Este e´ um artigo Open Access sob uma licenc¸a CC BY-NC-ND (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Work performed at the Orthopedics Department, Coimbra Hospital and University Center, Coimbra, Portugal. Corresponding author. E-mails: dflm12345@gmail.com, dflmoura@gmail.com (D.L. Moura). http://dx.doi.org/10.1016/j.rboe.2016.03.006 2255-4971/© 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). ∗


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Introduction Disruption of knee’s extensor mechanism is not unusual and affects the patella bone more frequently.1,2 Bilateral simultaneous ruptures of the patellar tendons are rarely seen and have only been documented in case reports.1,3,4

Case presentation We present a 34-year-old black male that after a sudden running stop with both knees in slight flexion associated with a twisting movement, he experienced failure sensation and a severe sharp pain in both knees. He fell to the ground and was unable to stand and walk. At the emergency orthopedic department the patient referred bilateral knee pain and tenderness. Both knees displayed some superficial abrasions and a mild effusion. A bilateral infrapatellar gap with cephalic migration of both patellae could be felt. Active straight leg raising test was negative for both extremities and the patient was unable to perform active extension of both knees. Neurovascular examination was unremarkable. The presumptive clinical diagnosis of bilateral rupture of the patellar tendon was made. The patient had been a professional basketball player from 18 to 25 years old and practiced competitive weightlifting until 30 years old. He admitted having taken a few cycles of oral and injectable steroids during the weightlifting competitive practice time. Currently, he is a bouncer and a recreational weightlifting practitioner. The patient assured not having taken steroids or any other supplements for the last three years. He reported no previous injuries to his knees and denied chronic knee pain. At the time of the trauma, the patient body type was athletic, weighing 120 kg and was 192 cm tall. The X-rays showed cephalic patellar migration and small calcification avulsions of the inferior poles of both patellae. An isolated undisplaced spiral fracture of the left fibular

Fig. 1 – Lateral projection knee radiographs after bilateral patellar tendon rupture, showing cephalic patellar migration (“patella alta”), avulsion fractures of inferior poles of both patellae and an isolated undisplaced spiral fracture of the left fibular neck (left side).

Fig. 2 – Bilateral patella tendon rupture at surgery: monofilament loop suture that allowed, by its passage in the middle of the loop, a proper tendon suture tension.

neck was also identified (Fig. 1). Ultrasound confirmed total bilateral rupture of the patellar tendons. Intraoperatively we found both tendons torn in their substance near the inferior patellar poles, with some segments avulsed from the patellar insertion. Lateral and medial retinacula were disrupted bilaterally. An end-to-end primary Kessler-type tendon repair reinforced with intraosseous sutures was performed in both knees. We temporarily protected it with cerclage wiring, followed by immobilization with a leg cylinder cast. We chose a nonabsorbable monofilament loop suture that allowed a proper tendon suture tension, by its second passage through the middle of the loop (Fig. 2). The tension within stitches was carefully adjusted to avoid shortening of infrapatellar length, according to the patellae position. The ruptured retinacula were repaired with Vicryl sutures. The strength of the repair was tested by careful flexion of both knees (Fig. 3). Cerclage wiring was applied in a figure-of-eight tension band running around the superior pole of the patellae, passing in front of the tendon, fixed with a transverse screw through the tibia tubercle and tied at average 60◦ of knee flexion (Fig. 4).

Fig. 3 – Flexion knee movement testing the sewing integrity and resistance.


r e v b r a s o r t o p . 2 0 1 7;5 2(1):111–114

Fig. 4 – Cerclage wiring application in eight form tension band between the distal quadricipital tendon and a transversal screw in the anterior tibial tuberosity.

The postoperative course was uneventful and radiographic control was satisfactory (Fig. 5). The cast immobilization was removed at the third postoperative day and the patient began ambulation with crutches using extension knee braces and full weight-bearing allowed as tolerated. At the 2rd postoperative week he began periodic removal of knee braces and a daily rehabilitation program, initially consisting in isometric muscle strengthening and knee flexion exercises restricted to 60◦ , complemented with peripatellar soft tissue massage. At the 4th week the patient could walk without crutches, had no pain and attained 40◦ of maximum bilateral active knee flexion. At the 6th week he had 60◦ of flexion and the knee braces were discontinued. At the 8th postoperative week, the cerclage wire was removed and the patient continued the daily

113

physiotherapy program with progression to full knee flexion allowed and emphasis on muscle strengthening exercises. Stationary bicycle was introduced at the 9th week. Eleven weeks after surgery, the patient presented 100◦ maximum bilateral knee flexion and returned to work. On examination 5 months after surgery, the patient presented a satisfactory range of motion of both knees (135◦ flexion, 0◦ extension) good quadriceps strength and no signs of muscular atrophies or extensor lag (fig. 6). He denied any sense of instability or swelling, and therefore he returned to recreational sportive activities. He reported feeling that his knees were as strong as they were prior to the lesions and he was able to run, squat, and hop in place without difficulty.

Discussion Patellar tendon ruptures are mostly associated with unhealthy patellar tendons.1 This patient had anabolic steroid consumption history, which could be held accountable for degenerative changes that weaken the structural tendon integrity with a higher risk for rupture, even in the context of minor trauma.1,2,4–8 In addition, the patient’s heavy body weight and the previous participation in high-level competitive sport activities might have inflicted chronic degenerative changes to his patellar tendons, as we can suppose because of the inferior patella pole calcifications, despite his denial for any chronic knee pain or discomfort compatible with patellar tendinopathy.9

Fig. 5 – Two weeks after surgery: radiographic control.

Fig. 6 – Five months after surgery: 135◦ flexion, 0◦ extension at both knees.


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Primary tendon repair should be performed as soon as possible to avoid proximal patellar retraction, scarring, complicated repair and diminished long-term function.1,6 Local repair secured by a tension band wire technique to counteract the forces generated across the extensor mechanism, diminishing tension at the repair sites and permitting an uneventful healing. Although the use of cerclage wiring in bilateral patellar tendon ruptures is still controversial, we believe this allowed all the benefits of a minimal cast immobilization and an early controlled physiotherapy beginning two weeks postoperatively, which was important to avoid quadriceps atrophy. The rehabilitation program prescribed allowed fast amplitude gaining and an earlier return to work and sport activities when compared with reports in the literature.1,6,9,10 In conclusion, we present a bilateral patellar tendon rupture case likely associated with anabolic steroids intake and repetitive local stress. The bilateral injury nature can make rehabilitation difficult. We believe the main reasons for the excellent and early functional results were: early tendon repair and proper suture tension and strength; cerclage wire use; minimal cast immobilization time; intensive, controlled and specialized physiotherapy program and a strongly committed patient.

Conflict of interests The authors declare no conflict of interests.

references

1. Kellersmann R, Blattert TR, Weckbach A. Bilateral patellar tendon rupture without predisposing systemic disease or steroid use: a case report and review of the literature. Arch Orthop Trauma Surg. 2005;125:127–33. 2. Enad JG. Patellar tendon ruptures. South Med J. 1999;92:563–6. 3. Splain SH, Ferenz C. Bilateral simultaneous infrapatellar tendon rupture: support for Davidsson’s theory. Orthop Rev. 1988;17:802–5. 4. Stinner DJ, Orr JD, Hsu JR. Fluoroquinolone-associated bilateral patellar tendon rupture: a case report and review of the literature. Mil Med. 2010;175:457–9. 5. Carson WG Jr. Diagnosis of extensor mechanism disorders. Clin Sports Med. 1985;4:231–46. 6. Rose PS, Frassica FJ. Atraumatic bilateral patellar tendon rupture. A case report and review of the literature. J Bone Joint Surg Am. 2001;83:1382–6. 7. Van Glabbeek F, De Groof E, Boghemans J. Bilateral patellar tendon rupture: case report and literature review. J Trauma. 1992;33:790–2. 8. Kannus P, Józsa L. Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. J Bone Joint Surg Am. 1991;73:1507–25. 9. Rosenberg JM, Whitaker JH. Bilateral infrapatellar tendon rupture in a patient with jumper’s knee. Am J Sports Med. 1991;19:94–5. 10. Muller ME, Allgower M. Manual of internal fixation: techniques recommended by the AO-ASIF. Berlin: Springer-Verlag; 1970.


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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

www.rbo.org.br

Technical Note

Modified axillary radiograph of the shoulder: a new position夽 Luís Filipe Senna a,∗ , Rodrigo Pires e Albuquerque b a b

Hospital Estadual Adão Pereira Nunes, Servic¸o de Ortopedia e Traumatologia, Duque de Caxias, RJ, Brazil Universidade Federal Fluminense, Servic¸o de Ortopedia e Traumatologia, Niterói, RJ, Brazil

a r t i c l e

i n f o

a b s t r a c t

Article history:

Obtaining axillary radiographs of the shoulder in acute trauma is not always feasible. The

Received 18 December 2015

authors present a new modification of this radiographic view, in order to assess the anatomic

Accepted 28 January 2016

relationship between the humeral head and the glenoid cavity. The incidence is performed

Available online 9 December 2016

with the patient sitting on X-ray table, with the affected limb supported thereon. The authors describe the case of a 28-year-old male who suffered an anterior glenohumeral disloca-

Keywords:

tion that was clearly evidenced by this modified radiograph. The concentric relationship

Shoulder

between the humeral head and the glenoid cavity was also easily confirmed by obtaining

Shoulder dislocation

such radiograph after the reduction maneuver.

Shoulder joint

© 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://

Radiography

creativecommons.org/licenses/by-nc-nd/4.0/).

Modificac¸ão da incidência radiográfica axilar para o ombro: uma nova posic¸ão r e s u m o Palavras-chave:

A obtenc¸ão de radiografias em perfil axilar do ombro em situac¸ão de trauma agudo nem

Ombro

sempre é tarefa fácil. Os autores apresentam uma modificac¸ão inédita dessa incidência

Luxac¸ão do ombro

radiográfica, com o objetivo de avaliar a relac¸ão anatômica da cabec¸a umeral com a cavi-

Articulac¸ão do ombro

dade glenoide. A incidência é medida com o paciente sentado sobre a mesa de exames de

Radiografia

raios X, com o membro acometido apoiado sobre ela. Os autores descrevem o caso de um paciente de 28 anos que sofreu um episódio de luxac¸ão glenoumeral anterior que foi claramente evidenciada pela radiografia modificada. A relac¸ão de concentricidade entre a cabec¸a umeral e a cavidade glenoide foi facilmente confirmada pela obtenc¸ão da referida incidência radiográfica obtida após a manobra de reduc¸ão. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Este e´ um artigo Open Access sob uma licenc¸a CC BY-NC-ND (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

夽 Study conducted at Hospital Municipal Dr. Nelson de Sá Earp, Petrópolis, Rio de Janeiro, RJ, Brazil, and at Hospital Estadual Adão Pereira Nunes, Duque de Caxias, RJ, Brazil. ∗ Corresponding author. E-mail: lfsenna@yahoo.com.br (L.F. Senna). http://dx.doi.org/10.1016/j.rboe.2016.12.001 2255-4971/© 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).


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Introduction There is a general recommendation for the care of orthopedic trauma patients, which is to obtain at least two radiographic views in orthogonal planes for proper evaluation of the traumatized limb or joint.1 In the case of the shoulder joint, such recommendation is particularly valuable, as failure to obtain X-rays in orthogonal planes, especially failure to obtain axillary radiographs, is considered to be the main cause of misdiagnosis in glenohumeral dislocations.2 Radiographs in anteroposterior, lateral scapula, and axillary views are known as the shoulder trauma series3 and must be performed on all patients with trauma of such joint. The axillary view was first described in 1915 by Lawrence apud Jensen and Rockwood,4 and can be done with the patient standing or sitting. Ideally, it is necessary to position the shoulder in approximately 70◦ –90◦ of abduction to obtain this radiograph. In patients with mild trauma, this degree of abduction is feasible; however, for patients with more severe trauma, and especially those with glenohumeral joint dislocation, it is extremely difficult to obtain the axial image, because pain and joint incongruity greatly limit the abduction capacity of the joint. Thus, modifications in the classical axillary view have been proposed.5,6 The view described by Bloom and Obata5 is perhaps the best known method, as it allows for an axillary radiography without removing the patient’s arm from the sling – which would in principle be more comfortable. Nonetheless, the authors have found this view to be difficult to obtain, especially in the elderly, since it requires leaning the trunk posteriorly with the patient standing; maintaining balance is difficult and limb positioning is hindered. The view described by Cleaves6 requires the use of a curved chassis, which is not widely available. Faced with these difficulties, the authors identified the need to develop a modification of the Lawrence technique in a position that was more comfortable for the patient and easier to reproduce. The patient’s positioning for the radiograph was named the Senna position, in reference to the author and creator of the technique. The incidence described below aims to show, in axial projection, the relationship between the humeral head and glenoid cavity.

Technique To obtain the present modification of the axillary radiograph, the patient is required to sit with the feet hanging on the radiographic table. Then, the patient is requested to position the open hand of the affected side on the table. Only a small degree of abduction is required. The abduction angle formed between the medial aspect of the arm and the lateral chest should be approximately 30◦ . The X-rays are pointed to the glenohumeral joint, perpendicular to the table, 60 cm from the shoulder. The chassis with radiographic film is positioned on the table, directly under the shadow formed by the shoulder contour, with its anterior border just behind the greater trochanter of the femur (Fig. 1). It is important to note that the patient’s body should slightly lean approximately 10◦ to the affected side. The trunk should also be tilted back and the patient should be asked to try to accentuate the

Fig. 1 – Schematic illustration representing the frontal (A) and superior view (B) of the patient and the chassis positioning, as well as the incidence angle of X-rays for the modified axillary radiograph.

thoracic kyphosis. Interestingly, this lateral inclination of the trunk, with accentuation of the thoracic kyphosis, is naturally adopted by most patients suffering from glenohumeral dislocation when seated, which makes the exam easier and less painful for the patient as it respects the natural antalgic position.

Case report A male 28-year-old mixed-race patient was admitted to the emergency room, walking without assistance, complaining pain, deformity, and functional impairment in his left shoulder after a motorcycle accident. He was lucid and oriented in time and space, with no signs of other injuries and no other complaints. According to the patient, the accident had occurred approximately 30 min before he arrived at the hospital. He denied any previous episode of glenohumeral dislocation or fracture in the region. Physical examination revealed shoulder squaring (epaulet sign) and the patient


r e v b r a s o r t o p . 2 0 1 7;5 2(1):115–118

117

Fig. 3 – Radiographs before reduction (A) and after reduction (B) of the glenohumeral dislocation of the patient in Fig. 2.

which confirmed the concentric joint reduction (Fig. 3). The patient was then immobilized with a Velpeau shoulder sling and referred to outpatient treatment.

Final remarks

Fig. 2 – Frontal (A) and lateral (B) photographs of the patient for the radiographic Senna position.

The present modified axillary incidence was shown to be easy to perform, with minimal discomfort to the patient. The obtained images clearly evidenced the anatomical relationship between the humeral head and glenoid cavity in an axial view, and allowed for the safe assessment of glenohumeral dislocation and its reduction.

Conflicts of interest reported severe pain at any manipulation of the affected limb. The neurovascular examination of the upper limbs was unaltered. Given the suspected dislocation of the glenohumeral joint, two X-rays of the left shoulder, in orthogonal planes, were necessary. In addition to the anteroposterior radiography, a modified axillary view (in the Senna position) was also obtained (Fig. 2). The latter clearly evidenced an anterior glenohumeral dislocation. The patient underwent successful closed reduction through traction and countertraction. After reduction, a new radiograph in Senna position was obtained,

The authors declare no conflicts of interest.

references

1. Moghadamian ES, Bosse MJ, MacKenzie EJ. Principles of mangled extremity management. In: Bucholz RW, Heckman JD, Court-Brown CM, Tornetta P, editors. Rockwood and Green’s fractures in adults. Lippincott Williams & Wilkins; 2010. p. 334.


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2. Rowe C, Zarins B. Chronic unreduced dislocation of the shoulder. J Bone Jt Surg Am. 1982;64(4):494–505. 3. Neer CS 2nd. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Jt Surg Am. 1970;52(6):1077–89. 4. Jensen KL, Rockwood CA Jr. Radiographic evaluation of shoulder problems. In: Rockwood CA Jr, Matsen FA 3rd, Wirth

MA, Lippitt SB, editors. The shoulder. Philadelphia: Saunders Elsevier; 2004. p. 188. 5. Bloom MH, Obata WG. Diagnosis of posterior dislocation of the shoulder with use of Velpeau axillary and angle-up roentgenographic views. J Bone Jt Surg Am. 1967;49(5):943–9. 6. Cleaves EN. A new film holder for roentgen examinations of the shoulder. Am J Roentgenol. 1941;45(2):88–90.


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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

www.rbo.org.br

Technical Note

Resection osteotomy for calcaneus flattening after micro-surgical flap: technical note夽 Mário Yoshihide Kuwae, Edegmar Nunes Costa, Ricardo Pereira da Silva, Alexandre Daher Albieri, Frederico Barra de Moraes ∗ Universidade Federal de Goiás (UFG), Faculdade de Medicina, Goiânia, GO, Brazil

a r t i c l e

i n f o

a b s t r a c t

Article history:

An open fracture of the calcaneus with loss of substance is a challenging injury and requires

Received 21 February 2016

specialized care, involves high costs, and demands attention despite its lower incidence. The

Accepted 18 March 2016

main complications are osteomyelitis, pressure ulcers, and fistulas, as well as pain condi-

Available online 1 December 2016

tions in the lateral, medial, and plantar regions. This is due to the wide loss of tissue and the change in anatomical conformation of the calcaneus in some cases. However, in cases of flat-

Keywords:

tening of the calcaneus bone, these complications may be prevented or treated successfully.

Fractures, open

This technical note describes the resection osteotomy technique for calcaneus flattening to

Calcaneus

prevent and treat complications after micro-surgical flap in cases of open fracture or loss of

Orthopedic procedures/methods

substance. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora

Surgical flaps

Ltda. This is an open access article under the CC BY-NC-ND license (http://

Osteotomy/methods

creativecommons.org/licenses/by-nc-nd/4.0/).

Osteotomia de ressecc¸ão para aplainamento do calcâneo após retalho microcirúrgico: nota técnica r e s u m o Palavras-chave:

A fratura exposta do calcâneo com perda de substância é uma lesão desafiadora, demanda

Fraturas expostas

cuidados especializados, envolve elevados custos e exige atenc¸ão, apesar de sua menor

Calcâneo

incidência. As principais complicac¸ões são osteomielite, úlceras de pressão, fistulas, além

Procedimentos

de quadros álgicos nas regiões lateral, medial e plantar. Essa relac¸ão se deve à grande perda

ortopédicos/métodos

de tecido e à mudanc¸a da conformac¸ão anatômica do calcâneo em alguns casos. Porém,

Retalhos cirúrgicos

quando ocorre uma modelac¸ão do formato ósseo do calcâneo com seu aplainamento, essas

Osteotomia/métodos

夽 Study conducted at the Universidade Federal de Goiás, Faculdade de Medicina, Hospital das Clínicas, Departamento de Ortopedia e Traumatologia, Goiânia, GO, Brazil. ∗ Corresponding author. E-mail: frederico barra@yahoo.com.br (F.B. Moraes). http://dx.doi.org/10.1016/j.rboe.2016.11.003 2255-4971/© 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).


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complicac¸ões podem ser prevenidas ou tratadas com sucesso. O objetivo desta nota técnica é descrever a técnica de osteotomia de ressecc¸ão para aplainamento do calcâneo na prevenc¸ão e no tratamento de complicac¸ões após retalho microcirúrgico em casos de fratura exposta ou perda de substância. © 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Este e´ um artigo Open Access sob uma licenc¸a CC BY-NC-ND (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Technical note

Open fractures of the calcaneus classified as Gustilo and Anderson type III1–4 are associated with short- and long-term complications. The main complications are infections, pain and fistulas or pressure ulcers in the topography of the lower calcaneal tuberosity, even after myocutaneous covering with vascularized flaps, which can be observed in up to one-third of cases.5–11 This is due to the extensive tissue loss and to changes in the shape of the calcaneus in some cases. However, in cases of flattening of the calcaneus bone, these complications may be successfully prevented or treated. The purpose of this note is to describe a resection osteotomy technique for calcaneus flattening, aiming to prevent and treat complications after microsurgical flap in cases of open fracture or tissue loss.

The steps of the proposed surgery are: (1) Resection of ulcers and fistulas in the calcaneal region under the existing microsurgical flap; or preparation of the area for the flap that will be made (Fig. 1); (2) Resection osteotomy for calcaneus flattening in the posteroinferior tuberosity, avoiding areas of overpressure on the old or the new flap (Fig. 2); (3) Coverage with a microsurgical flap (Fig. 3).

Discussion Open calcaneal fractures with loss of substance are challenging injuries that require specialized care, involve high costs,

Fig. 1 – (A) Complication of calcaneal flap with plantar ulcer and fistula and (B) debridement of devitalized tissue and local preparation.

Fig. 2 – Lateral radiographs of the calcaneus. (A) Preoperative, with no evidence of osteomyelitis and areas of overpressure and (B) postoperative, highlighting the resection of the posteroinferior calcaneal tuberosity, correcting the deformities.


r e v b r a s o r t o p . 2 0 1 7;5 2(1):119–122

121

Fig. 6 – Lateral radiograph of the calcaneus, with no evidence of osteomyelitis and natural flattening of posteroinferior calcaneal tuberosity.

Fig. 3 – Post-operative aspect of the latissimus dorsi microsurgical flap.

and demand attention, despite their low incidence. The main complications are osteomyelitis, pressure ulcers and fistulas, as well as pain conditions in the lateral, medial, and plantar regions.5–11

This new technique was designed after following-up a teenage patient (Fig. 4) who had had a calcaneal injury, healed by second intention and then developed ulcers and fistulas due to the presence of increased pressure points. The lesion was resected and a microsurgical flap of the latissimus dorsi was made for better coverage of the area (Fig. 5), but the calcaneus was left unapproached. After approximately ten years, the patient suffered an ankle sprain during a soccer game; when the ankle radiographs were assessed (Fig. 6), a natural flattening of the plantar portion of the calcaneus was observed, without complications such as ulcers, fistulas, or pain (Fig. 7).

Fig. 4 – (A) Preoperative clinical aspect of a patient with ulcer and active fistula in pressure areas in the calcaneal region and (B) intraoperative image of lesion resection and microsurgical flap transplantation.

Fig. 5 – (A) Postoperative clinical aspect of a patient with microsurgical flap in the calcaneus and (B) with bone graft.


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Fig. 7 – Clinical aspect of the microsurgical flap and graft on the calcaneus (A and B) after ten years, without the presence of ulcers, fistulae, or regional pain.

Final considerations The resection osteotomy technique for flattening the calcaneus can be used for the prevention or treatment of complications after a microsurgical flap in the region. Clinical and surgical studies with a larger number of cases should be performed for better evaluation of the technique.

Conflicts of interest The authors declare no conflicts of interest.

references

1. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984;24(8):742–6. 2. Acello AN, Wallace GF, Pachuda NM. Treatment of open fractures of the foot and ankle: a preliminary report. J Foot Ankle Surg. 1995;34(4):329–46. 3. Gustilo RB. Current concepts in the management of open fractures. Instr Course Lect. 1987;36:359–66.

4. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58(4):453–8. 5. Siebert CH, Hansen M, Wolter D. Follow-up evaluation of open intra-articular fractures of the calcaneus. Arch Orthop Trauma Surg. 1998;117(8):442–7. 6. Heier KA, Infante AF, Walling AK, Sanders RW. Open fractures of the calcaneus: soft-tissue injury determines outcome. J Bone Joint Surg Am. 2003;85-A(12):2276–82. 7. Aldridge JM 3rd, Easley M, Nunley JA. Open calcaneal fractures: results of operative treatment. J Orthop Trauma. 2004;18(1):7–11. 8. Berry GK, Stevens DG, Kreder HJ, McKee M, Schemitsch E, Stephen DJ. Open fractures of the calcaneus: a review of treatment and outcome. J Orthop Trauma. 2004;18(4): 202–6. 9. Benirschke SK, Kramer PA. Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma. 2004;18(1):1–6. 10. Abidi NA, Dhawan S, Gruen GS, Vogt MT, Conti SF. Wound-healing risk factors after open reduction and internal fixation of calcaneal fractures. Foot Ankle Int. 1998;19(12):856–61. 11. Levin LS, Nunley JA. The management of soft-tissue problems associated with calcaneal fractures. Clin Orthop Relat Res. 1993;(290):151–6.


Na dor aguda, meu Profenid tem alívio rápido e prolongado.

®

2

Bi-Profenid : rápido início de ação, eficácia e segurança diante de quadros dolorosos traumáticos e reumatológicos.1,2 ®

Mecanismo exclusivo de liberação em 2 fases.3

Camada branca 15 minutos Início da absorção

Camada amarela 24 horas Controle da dor

BI-PROFENID® (cetoprofeno). INDICAÇÕES: algias diversas como lombalgia, cervicalgia, enxaqueca com e sem aura e outros processos ortopédicos, incluindo lesões traumáticas; pós-operatório; sinusites, otites, faringites, laringites, amigdalites; dismenorreia e processos anexiais; processos reumatológicos, urológicos e odontológicos. CONTRAINDICAÇÕES: pacientes com histórico de hipersensibilidade ao cetoprofeno, ao ácido acetilsalicílico ou outros AINEs. Histórico de úlcera péptica, complicada ou não, relacionada ao uso de AINES. Insuficiência hepática, renal ou cardíaca severa. Durante a gravidez e pacientes pediátricos. REAÇÕES ADVERSAS: dispepsia, dor abdominal, náusea, vômito, diarreia, constipação, flatulência, gastrite, estomatite, úlcera péptica, exacerbação de colite e doença de Crohn, hemorragia e perfurações gastrintestinais. Erupção cutânea (rush), prurido, alopecia, urticária e angioedema. Fotossensibilidade podem ocorrer erupções bolhosas incluindo síndrome de Stevens-Johnson e necrólise epidérmica tóxica, pustulose exantematosa aguda generalizada. Crise asmática, broncoespasmo, reações anafiláticas (incluindo choque). Vertigem, cefaleia, parestesia e convulsões, disgeusia, meningite asséptica. Sonolência, alterações do humor, depressão, alucinação, confusão. Visão embaçada e zumbidos. Anormalidade nos testes de função renal, insuficiência renal aguda, nefrite túbulo-intersticial e síndrome nefrótica. Exacerbação da falência cardíaca, fibrilação atrial. Hipertensão, vasodilatação e vasculite (incluindo vasculite leucocitoclástica). Elevação dos níveis de transaminase e raros casos de hepatite. Trombocitopenia, anemia hemolítica, agranulocitose, leucopenia e aplasia medular. Edema, ganho de peso, hiponatremia e hipotassemia. ADVERTÊNCIAS: pacientes com Lúpus Eritematoso Sistêmico podem apresentar maior predisposição à toxicidade em sistema nervoso central e renal com o uso de AINEs. O uso concomitante com corticosteroides orais, anticoagulantes como a varfarina, inibidores seletivos da recaptação de serotonina ou agentes antiplaquetários como o ácido acetilsalicílico pode aumentar o risco de sangramento ou úlcera. Pacientes hepatopatas ou com alteração de função hepática devem ser monitorados quanto às transaminases, principalmente em tratamentos prolongados. A ingestão de álcool durante o tratamento com AINEs deve ser evitada, em decorrência do maior risco de toxicidade hepática e sangramento gastrintestinal. Pacientes com insuficiência renal, cardíaca, cirrose, em uso de diurético e idosos devem ter sua função renal monitorada. Deve-se ter cautela na administração a pacientes com doenças cardiovasculares e cerebrovasculares. Sinais de infecção como febre, eventualmente podem ser mascarados com o uso de AINEs. Os pacientes devem ser advertidos sobre o risco de ocorrência de sonolência, tontura ou convulsão durante o tratamento com cetoprofeno e orientados a não dirigir veículos ou operar máquinas caso estes sintomas apareçam. Aumento do risco de fibrilação atrial foi reportado em associação com o uso de AINES. Pode ocorrer hiperpotassemia, especialmente em pacientes com diabetes de base, insuficiência renal e/ou tratamento concomitante com agentes que promovem a hiperpotassemia. INTERAÇÕES MEDICAMENTOSAS: associações desaconselhadas com salicilatos, outros AINEs, inclusive inibidores seletivos da COX-2; álcool; anticoagulantes; inibidores da agregação plaquetária; lítio; outros medicamentos fotossensibilizantes; metotrexato em doses superiores a 15 mg/semana. Associações que requerem precauções: Categorias terapêuticas e medicamentos que podem promover hiperpotassemia; corticosteroides; diuréticos; inibidores da ECA e antagonistas da agiotensina II; metotrexato em doses inferiores a 15 mg/semana; pentoxifilina; tenofovir. Associações a ser consideradas: agentes anti-hipertensivos; trombolíticos; probenecida; inibidores seletivos da recaptação da serotonina. POSOLOGIA: Ataque: 150mg 2 vezes ao dia. Manutenção: 150mg 1 vez ao dia. No tratamento da enxaqueca, iniciar com ½ comprimido, caso necessário tome uma segunda dose durante a mesma crise. Se a dose de 75 mg mostrar-se ineficaz, a dose de 150 mg (1 comprimido) deve ser administrada no início do novo ataque. USO ADULTO. VENDA SOB PRESCRIÇÃO MÉDICA. REGISTRO MS: 1.1300.0271. IB051115. “Para maiores informações antes de prescrever, favor ler bula completa do produto”.

SABR.GKETZ.16.03.0264 - Março/2016

CONTRAINDICADO EM PACIENTES COM HISTÓRICO DE ÚLCERA PÉPTICA. INTERAÇÃO MEDICAMENTOSA: OUTROS AINES, INCLUSIVE COXIBES E ALTAS DOSAGENS DE SALICILATOS.

Referências bibliográficas: 1. Flouvat B, et al. Profil pharmacocinétique d’une formulation à libération prolongée dekétoprofène. Sem Hop. 1983 Dec;59(46): 3187-90. 2. PROFENID® (cetoprofeno) [bula do produto]. Sanofi-Aventis Farmacêutica. 3. Étude du Bi-Profenid em pathologie traumatique sportive. Sport Med. 1985;2:32-5.

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Exclusividade* que faz a diferença no tratamento da Osteoartrite. 5,6

Uso por longo prazo

permite retardar alterações

Dupla ação condroproteção e condroestimulação.1

estruturais articulares.2

Boa tolerabilidade

Reduz o uso de AINEs e analgésicos.3

e seguro no uso prolongado.2

ATÉ

%

DE DESCONTO

4

+ ATENÇÃO FARMACÊUTICA

MAIOR ACESSO AO TRATAMENTO4

SOMENTE

1 CÁPSULA1

AO DIA

* Medicamento Exclusivo e Tecnologia patenteada.5 **Desconto sobre PMC de acordo com a alíquota de ICMS de R$ 277,04 na aliquota de 18% para a apresentação de 300mg – 30 cáps. Desconto de 45% válido para compra de 1 caixa de Piascledine 300 mg com 30 cáps, 50% válido para compra de 2 caixas de Piascledine 300 mg com 30 cáps e 55% válido para compra de 3 caixas de Piascledine 300 mg com 30 cáps. através do programa Abrace a Vida. O serviço de atenção farmacêutica é exclusivo para pacientes participantes do Abrace a vida. A Abbott reserva-se o direito de alterar ou interromper o Programa Abrace a Vida e o serviço personalizado a qualquer momento, sem aviso prévio. Serviço oferecido via e-mail ou telefone, para pacientes ativos no Programa Abrace a Vida.

Referências bibliográficas: 1. Bula de Piascledine. 2. Maheu, E. et al. Randomised, controlled trial of avocado-soybean unsaponifiable (Piascledine) effect on structure modification in hip osteoarthritis: the ERADIAS study. Ann Rheum Dis. 2014 Feb;73(2):376-84. 3. Appelboom T. et al. Symptoms modifying effect of avocado/soybean unsaponifiables (ASU) in knee osteoarthritis. A double blind, prospective, placebo-controlled study. Scand J Rheumatol. 2001;30(4):242-7. 4. Conforme regras e limites do programa Abrace a Vida https://abraceavida.com.br. 5. P. Msicka, et al. Avocado/soybean unsaponifiables, ASU EXPANSCIENCE, are strictly different from the nutraceutical products claiming ASU appellation. Osteoarthritis and Cartilage (2008) 16, 1275e1276. 6. Christensen R, et al. Symptomatic efficacy of avocado-soybean unsaponifiables (ASU) in osteoarthritis (OA) patients: a meta-analysis of randomized controlled trials. Osteoarthritis and Cartilage (2008) 16, 399 e 408. PIASCLEDINE® 300 (Persea americana Mill + Glycine max (L.) Merr). MS: 1.0553.0356. USO ADULTO. VIA ORAL. Indicações: PIASCLEDINE® 300 é indicado no tratamento sintomático de ação lenta para quadros dolorosos de osteoartrite de quadril e joelho e como coadjuvante do tratamento das periodontites e gengivites. Contraindicações: Este medicamento é contraindicado a pacientes com histórico de hipersensibilidade a qualquer um dos componentes da fórmula presentes no item COMPOSIÇÃO e com alergia a amendoim. Precauções e advertências: Gravidez e amamentação: não existem estudos disponíveis sobre o uso de PIASCLEDINE® em mulheres grávidas. Portanto, não se recomenda a sua utilização durante a gravidez e amamentação. Gravidez: categoria C - Pré-clínicos: não há evidência de relevante efeito teratogênico de PIASCLEDINE® em animais. Este medicamento não deve ser utilizado por mulheres grávidas sem orientação médica ou do cirurgião dentista. Uso em crianças: não se recomenda o uso em crianças, pois não há estudos nesta população. Uso em pacientes idosos: manter os mesmos cuidados recomendados para pacientes adultos. PIASCLEDINE® não influencia na capacidade de dirigir ou operar máquinas. Interações medicamentosas: Não há dados sobre a interação do produto com outras drogas. Reações adversas: Reações muito raras (< 1/10.000 pacientes – 0,01%): - desordens gastrointestinais: regurgitação com odor lipídico (que pode ser evitada com a ingestão da cápsula durante a refeição), diarreia e dor epigástrica desordens hepatobiliares: aumento das transaminases, da fosfatase alcalina, da bilirrubina e da gama glutamiltranspeptidase. - desordens do sistema imune: reações de hipersensibilidade. Em casos de eventos adversos, notifique ao Sistema de Notificações em Vigilância Sanitária – NOTIVISA, disponível em www.anvisa.gov.br/hotsite/notivisa/index.htm, ou para a Vigilância Sanitária Estadual ou Municipal. Informe também à empresa através do seu serviço de atendimento. Posologia: 1 cápsula de PIASCLEDINE® ao dia, durante a refeição. O tratamento deve perdurar por 3 a 6 meses nos casos de osteoartrites e por 1 a 3 meses nos casos de periodontopatias. Modo de usar: a cápsula deve ser ingerida inteira, com um copo cheio de água. VENDA SOB PRESCRIÇÃO MÉDICA. Registrado e importado por Abbott Laboratórios do Brasil Ltda. Rua Michigan, 735 São Paulo – SP CNPJ 56.998.701/0001-16 ABBOTT CENTER: 0800 703 1050 MB 01 (BU 01)

INTERAÇÕES MEDICAMENTOSAS: NÃO HÁ DADOS SOBRE A INTERAÇÃO DO PRODUTO COM OUTRAS DROGAS. CONTRAINDICAÇÃO: ESTE MEDICAMENTO É CONTRAINDICADO A PACIENTES COM HISTÓRICO DE HIPERSENSIBILIDADE A QUALQUER UM DOS COMPONENTES DA FÓRMULA. Central de Relacionamento com o Cliente Abbott Center - 0800 703 1050 www.abbottbrasil.com.br

MATERIAL DESTINADO PARA PROFISSIONAIS DE SAÚDE, PRESCRITORES E DISPENSADORES DE MEDICAMENTO. JAN/2017

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Rbo vol 52#1 layout final ing