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VOL U ME 49 • Nº 1 • JANUARY/F EBRUARY 2014 V

The path toward editorial quality Current concepts on the sagittal balance and classification of spondylolisis and spondylolisthesis

CAPA

Level of evidence of knee surgery in national journal Analysis of using antirotacional device on cephalomedullary nail for proximal femoral fractures Results of open reduction and internal fixation of severe fractures of the proximal humerus in elderly patients Evaluation of surgical treatment of Dupuytren’s disease by modified open palm technique Results evaluation of the use of intra-articular sodium hyaluronate in the post-operative knee artrhoscopy Blood transfusion in hip arthroplasty: a laboratory hematic curve must be the single predictor of the need for transfusion? Clinical and radiographic medium-term evaluation on patients with developmental dysplasia of the hip, who were submitted to open reduction, capsuloplasty and Salter osteotomy Tibiotalocalcaneal arthrodesis with retrograde intramedullary nailling: 29 patients clinical and functional evaluation Effect of hyaluronic acids as chondroprotective in experimental model of osteoarthrosis Total arthoplastie in displaced dysplastic hips with acetabular reconstruction and femoral shortening - techinical note Lipoma arborescens of the knee: a case report Necrotizing fasciitis after internal fixation of fracture of femoral trochanteric Osteoid osteoma simulating the acromion acromion-clavicular pain Compartment syndrome after tibial plateau fracture Nodular fasciitis in finger simulating soft tissue malignancy Open anterior dislocation of the hip in an adult: a case report and review of literature The anterolateral ligament of the knee - visibility on magnetic resonance imaging Erratum on “Meniscal repair by all-inside technique with Fast-Fix device” [Rev. Bras. Ortop. 48 (5) (2013) 448–454]


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Editorial

The path toward editorial quality夽 O caminho da qualidade editorial

Since I began my functions as editor of RBO, I proposed myself to draw the attention of readers and authors to what, in my point of view, a medical journal should inform; in addition, our aim is that RBO be read. The other qualities that may be added to the journal (for instance, impact factors and quotes on specific search engines) are values that must be considered secondary. In our view, a good medical journal is reliable in the analysis of issues published and, besides, should be read by most people interested in the area. The quality indicators will result naturally. In any way our point of view rule out the importance of the indices that are used to qualify journals of a scientific nature, and the goal of achieving them remains one of the cornerstones of our editorial management. To be linked to a major publisher is an important factor to achieve one of the validation indices considered important, i.e., indexation factors. Undoubtedly, after a year of coexistence with our great publishing house, we could perceive the enormous difference in logistics and support, and that this should be considered as a positive factor in the analysis of a journal. Over the years, we noticed that the deterioration of the fundamental goals of medical journals began to occur, initially in a sporadic and limited basis, until reaching levels that, in our view, deserve consideration. The indexation, which should be seen as a recognition of the quality, suffered some distortions. To publish in indexed journals has become a bargaining chip for academic competitions and even for professional development. In our university environment, the Coordenac¸ão de Aperfeic¸oamento de Pessoal de Nível Superior (CAPES), which regulates postgraduate programs, considers that a paper published in a journal with impact index 4 or above is worth 10 times more than a paper published in RBO; an article with index 1.6 is worth six times more. It is worth noting that there is no orthopedic journal with impact 4 worldwide. This

misplaced appreciation of indexation caused some strange attitudes in the educational and scientific publication milieu. Some indexed journals charge for the analysis and publication of original works. We emphatically disagree with this custom, as certainly it can generate hidden interests that resemble the highly criticized “conflict of interest”. Now I wish to explain why this is my interpretation: - The fact that a physician is serving as consultant for a particular company gives us the right to imagine that he (she) will demonstrate bias on the publication of the result of usage of material produced by the company in question. - The fact that an author is paying for his (her) paper review and approval also gives us the right to imagine that the acceptance of the work will be facilitated. A good strategy is to hold a high impact factor. Lately, several new journals have been created. To demonstrate the consequences of this expedient, the journal Science, of unquestionable tradition and quality, published in its latest issue (2013; 342:60–5) an interesting text from an author who has forged a job on a forged product, made in a forged institution and with forged authors, entitled “Who’s afraid of peer review institution?” This author created this false paper about a chemotherapic agent and sent it to 400 journals. At the time of publication of his interesting experience in Science, the work had already been accepted in more than 150 journals in the world! Another good business: to have a scientific journal for publication. Here in RBO we chose a safe, slow and progressive path toward our international indexation, seeking to promote the scientific production of Brazilian orthopedics within its limits. Our goal has been a demand for increasing quality in the articles, an upgrade of our editorial board and the dissemination

Please cite this article as: Camanho GL. O caminho da qualidade editorial. Rev Bras Ortop. 2014;49:1–2.


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of the methodology required for the production of scientific papers. We believe that a work of good quality, carefully evaluated and criteriously corrected serves as an example for better works in the future. Certainly, to teach by example is a long, but safe, task. The indexation of RBO, now in international systems, continues to be one of our goals, but always within our limits. To SBOT and RBO, to be read by the Brazilian orthopedic community is our better business idea.

Gilberto Luis Camanho Revista Brasileira de Ortopedia E-mail: gilbertocamanho@uol.com.br 2255-4971/$ – see front matter © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved. http://dx.doi.org/10.1016/j.rboe.2014.01.014


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Update Article

Current concepts on the sagittal balance and classification of spondylolysis and spondylolisthesis夽 Marcos Antonio Tebet Discipline of Orthopaedics and Traumatology, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brazil

a r t i c l e

i n f o

a b s t r a c t

Article history:

Treatment of spondylolysis and spondylolisthesis remains a challenge for orthopaedic

Received 4 April 2013

surgeons, neurosurgeons and paediatrics. In spondylolisthesis, it has been clearly demon-

Accepted 9 April 2013

strated over the past decade that spino-pelvic morphology is abnormal and that it can be associated to an abnormal sacro-pelvic orientation as well as to a disturbed global sagittal

Keywords:

balance of spine. This article presents the SDSG (Spinal Deformity Study Group) classification

Spondylolisthesis

of lumbosacral spondylolisthesis. The proper treatment of spondylolisthesis is dependent

Spondylolysis/classification

on recognizing the type of slip, sacro-pelvic balance and overall sagittal balance and its nat-

Postural balance

ural history. Although a number of clinical radiographic features have been identified as

Radiography panoramic

risk factors, their role as primary causative factors or secondary adaptative changes is not clear. The conservative treatment of adult isthmic spondylolisthesis results in good outcome in the majority of cases. Of those patients who fail conservative treatment, success with surgery is quite good, with significant improvement in neurologic function in those patients with deficits, as well as improvement in patients with back pain. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

Conceitos atuais sobre equilíbrio sagital e classificac¸ão da espondilólise e espondilolistese r e s u m o Palavras-chave:

O tratamento da espondilólise e da espondilolistese permanece um desafio para ortopedis-

Espondilolistese

tas, neurocirurgiões e pediatras. Nas espondilolisteses, tem sido claramente demonstrado

Espondilólise/classificac¸ão

na última década que a morfologia sacro-pélvica está anormal e que isso pode estar

Equilíbrio postural

associado a uma anormal orientac¸ão sacro-pélvica e também alterar o equilíbrio sagital

Radiografia panorâmica

global da coluna. Este artigo apresenta a classificac¸ão SDSG (Spinal Deformity Study Group) da espondilolistese lombossacral. As propostas de tratamento para a espondiolistese são dependentes do reconhecimento do tipo de deslizamento, equilíbrio sacro-pélvico e balanc¸o sagital e de sua história natural. Apesar de haver diversos achados clínicos e radiográficos que são identificados como fatores de risco de progressão, os fatores primários ou secundários que causam a progressão permanecem obscuros. O tratamento conservador para espondilolistese ístmica do adulto apresenta bons resultados na maioria dos casos.

夽 Please cite this article as: Tebet MA. Conceitos atuais sobre equilíbrio sagital e classificac¸ão da espondilólise e espondilolistese. Rev Bras Ortop. 2014;49:3–12. E-mail: matebet@uol.com.br

2255-4971/$ – see front matter © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

http://dx.doi.org/10.1016/j.rboe.2014.02.003


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Naqueles em que há falha do tratamento conservador, o resultado do tratamento cirúrgico também é bom, com melhoria significativa da func¸ão neurológica tanto quanto melhoria da dor lombar. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Todos os direitos reservados.

Introduction The term spondylolisthesis is defined as a translation of one vertebra over another in the anterior or posterior direction. In the adult, this occurs in the lumbar column as a result of a defect in bone architecture, trauma or degenerative process.1 The term spondylolisthesis is derived from the Greek spondylos, meaning “vertebra”, and olisthesis, meaning “to slide”. The first observation of spondylolisthesis occurred in 1772 by the Belgian obstetrician Herbiniaux2 during a delivery complicated by a narrowing in the channel because of a slippage of L5 vertebra over the sacrum. This term was first used in 1854 by Kilian in Lonstein et al.3 Spondylolisthesis is defined as a translation of one vertebral body over the adjacent caudal vertebra in an anterior or, in more serious cases, anterior and caudal direction. Spondylolysis is a defect in the pars interarticularis, but without occurrence of slippage. Spondylolisthesis has been a condition difficult to understand for orthopaedists, neurosurgeons and paediatricians, because of the great variety of existing anatomical and clinical forms. There are few pathological conditions of the column in which there is so much therapeutic controversy. Considering that the spondylolisthesis is “a slippage of a portion of the column over other adjacent part”, we must remember that the column that slid also moved the entire trunk, and this may bring clinical consequence. The aetiology of this disease is multifactorial and is not yet perfectly clear. The natural history is not well established from the point of view of the knowledge of its real causes, pathogenesis and development.4 Spondylolisthesis and spondylolysis are usually well tolerated by patients, but in some cases the severity of the symptoms and a condition unresponsive to conventional medical treatment have caused the indication for surgical treatment.5

Epidemiology and aetiology The incidence of spondylolysis in the general population is about 6%, with a male: female ratio of 2:1.6 The incidence of spondylolisthesis in children under 6 years is 2.6%, while in adults it is 5.4%.6 The degenerative spondylolisthesis rarely affects individuals below the age of 40 years, and is four to five times more common in women than in men. In a study by Love et al.,7 subjects who had facet orientation >45◦ in the sagittal plane were 25 times more likely to develop degenerative spondylolisthesis. There seems to exist a genetic and familial association with spondylolysis and spondylolisthesis, because 26% of patients

with isthmic spondylolisthesis had first-degree relatives with the same disease.8 The incidence varies according to ethnicity: it is more common in Caucasian than in black people. In a tribe of Eskimos in Alaska the incidence reaches about 50%.9 The exact aetiology of most cases remains obscure. The dysplastic lesions of the pars interarticularis, fracture or of the elongament and of spina bifida conceal a broad distal spinal canal. Dysplasia in both facets (lower lumbar and upper sacral) is a common finding in spondylolisthesis, especially in those with high grade. The superior sacral facet together with the lower lumbar facet forms a bone hook which prevents translation. Dysplasia can occur in either or both facets. Thus, the hook effect is lost.6 The presence of spondylolysis/spondylolisthesis is rare in non-ambulatory patients, which attaches importance to the orthostatism role and of repeated microtraumas in the development of spondylolysis. Biomechanical studies have demonstrated an increase in stress in the pars interarticularis with the column in extension and increase of shear forces through the same area, with persistence of lordosis.7 Activities that increase lordosis and maintain the column in extension, such as olympic gymnastics, diving, weightlifting, volleyball, football and pathologies such as kyphosis, increase the incidence of fracture of the pars and of spondylolysis and spondylolisthesis.10

Sagittal balance in spondylolisthesis The spondylolistheses are divided into high (slippage >50%) and low (slippage <50%) grade. The classifications used for spondylolisthesis are not useful for surgical treatment indications and, as noted in the last decade, the sagittal balance is the key factor for surgical treatment.11 One explanation for the aetiology of developmental spondylolisthesis, which takes into account the sagittal balance, is that, in the presence of spondylolysis and bone dysplasia, the mechanical stress applied to the lumbosacral junction is increased because of the altered sacro-pelvic morphology, which leads to an abnormal secondary spino-pelvic equilibrium. Because of bone remodelling by growth plates (Heuter-Volkman law), a secondary deformity of the body of L5, sacrum and pelvis also alters the biomechanical forces in the lumbosacral column, which contributes to the progression of spondylolisthesis, in a process similar to what occurs in Blount disease. The pelvic incidence (PI) is a specific and constant parameter for each individual, measured in the lumbosacral radiograph on the profile incidence, and defined as the angle between the line connecting the midpoint of upper plateau of S1 and the centre of femoral rotation and the line


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A

A

B

B

b a

b

c a c

PT

Vertical reference line

PI

(VRL)

o

p PI

o

b

q

a

b

PT

c a c

o

PI

o

Fig. 1 – (A) Pelvic Incidence (PI) is defined as the angle formed by the intersection of a line drawn from the centre of the femoral head towards the midpoint of the sacral endplate (o–a) and a line perpendicular to the centre of the sacral endplate (a). The sacral endplate is defined by a segment (b–c) formed between the posterior horn of the sacrum and the anterior top of the S1 sacral promontory. (B) When the femoral heads are not perfectly overlapped, the centre of each one of them is marked and a line drawn between two points (q–p) will connect the centre of the two heads. The line (o–a) will be drawn from the centre of the line (q–p), i.e., point (o), to the centre of the sacral endplate.

perpendicular to the upper plateau of S1. PI increases slightly and consistently in adulthood.12 The value of PI is higher in spondylolisthesis, increasing linearly, according to the severity of slippage12 (Fig. 1). The pelvic tilt (PT) and the sacral slope (SS) measure the sacro-pelvic orientation in the sagittal plane, being evidenced in the lumbosacral lateral view. SS is defined as the angle between the upper horizontal plateau and S1, while PT is the angle between the line connecting the midpoint of the upper plateau of S1 and the centre of femoral rotation with a vertical line (Figs. 2A–B and 3B). PT has a value (+) when the line (o–a) is located posterior to VRL value and (–) when the line (o–a) is anterior to VRL. We must understand that PI is a measure of a static structure. PT and SS, on the other hand, are dependent positions, because they depend on the angular position of the sacrum/pelvis in relation to the femoral head, which changes

Fig. 2 – (A) Pelvic tilt (PT) is defined by the intersection of a vertical reference line, which originates from the femoral head centre (o) and the midpoint of the sacral endplate (a). (B) PT can be influenced by PI, since they share the line (o–a) and the terminal sacral plate is a common reference line for both.

in the orthostatic and sitting positions. PT/SS ratio is also affected by the bending and lumbosacral-pelvic extension. PI is the sum of SS and PT (Fig. 3B); then, IP is a strong determinant of the spatial orientation of the pelvis in the osthostatism, i.e. the higher the PI, the greater will be the PT or SS, or both. The normal values of PI, SS and PT in children are 49.1◦ , 41.4◦ and 7.7◦ , respectively.13 In adults the normal values are 51.8◦ , 39.7◦ and 12.1◦ .12 The values in spondylolisthesis12 are shown in Table 1. In the study by Roussouly et al.,14 patients with high PI and SS result in increased shear force incident on the lumbosacral junction, which creates more stress on the pars interarticularis of L5. But in those patients with low PI and a minor SS, there may be an impact among the posterior elements between L5 and those of L4 and S1 during extension, thereby causing an effect of “nutcracker” in pars interarticularis of the 5th lumbar vertebra.

Table 1 – Values of spondylolisthesis in accordance with the degree of slippage. Grade I PI SS PT

57.7 43.9◦ 13.8◦

Grade II ◦

66 49.8◦ 16.2◦

Grade III ◦

78.8 51.2◦ 27.6◦

Grade IV ◦

82.3 48.5◦ 33.9◦

Grade V 79.4◦ 45.9◦ 33.5◦


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A

B

VRL

b

SS

B

a

C7

c HRL

PI

SS

PT

o

b

c Horizontal reference line (HRL) PI = SS + PT

C7 PL

T12

Fig. 3 – (A) Sacral tilt (SS) is defined as the intersection of the horizontal reference line (HRL) and the sacral endplate (b–c). (B) The sacral slope (SS) is related to PI and PT because it shares a reference line (b–c) in common along the sacral endplate.

L5

A The sacral projection (distance from the sacrum to a plumb line from C7) is another biomechanical determinant. Typically, the plumb line (PL) passes through S1 (Fig. 4). Because of these morphological changes, the sagittal balance can only be achieved by hyperlordosis. Greater vertical tilt of the sacrum will be required to maintain sagittal balance, when this is not possible only with hyperlordosis. This verticalization of the sacrum is accompanied by contracture of the hamstrings, which circumvent caudally the ischial muscles, and the anterior pelvis cephalad.14 With these data, there are three possible biomechanical outcomes: first, the forces generated by an increase in lumbar lordosis have, as consequence, the development and progression of spondylolisthesis; and second, the biomechanical changes generate changes in posture and gait that are compensatory mechanisms to maintain sagittal balance; and finally the biomechanical changes mould the adjacent vertebrae.

Neutral balance: B=A Negative balance: B<A

+X

Positive balance: B>A

– Negative

0

+

Neutral

Positive

Fig. 4 – Sagittal Balance: PL = plumb line. The A line is drawn from the superior-posterior border of S1 perpendicular to the vertical edge of the radiograph. Its length is measured in millimetres. The B line is drawn from the centre of C7 perpendicular to the vertical edge of the radiograph. Its length is measured in millimetres.

Evidence of the presence of abnormal sagittal spino-pelvic alignment in spondylolisthesis Although the correlation between pelvic incidence (PI) and spondylolisthesis is evident, there are no published data in the literature that may confirm the cause/effect relationship between these two. However, as the pelvic incidence (PI) is

a morphological parameter that describes the shape of the pelvis, an increased PI is associated to an increase in lumbar lordosis, which predisposes to mechanical changes of the lumbar column and of the lumbosacral junction and increases the risk of spondylolisthesis occurrence.15


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Table 2 – Classification of Wiltse, Newman and Macnab. Type I – dysplastic congenital abnormalities of the posterior elements

SS SS

PI PI

Shear

“Nutcracker”

Fig. 5 – The posture in shear and in “nutcracker”, published by Roussouly et al.14 for low-grade spondylolistheses.

However, not all patients with spondylolisthesis at L5-S1 present with PI above the normal. Roussouly et al.14 observed, in a study with 82 subjects with low-grade spondylolisthesis, the presence of two distinct subgroups with respect to form and sacro-pelvic balance, which can be affected by different pathogenic mechanisms. According to these authors, patients with high PI and sacral slope (SS) show an increase in the shear forces incident at the lumbosacral junction, which causes further tension on the pars articularis of L5: the shear type (Fig. 5). On the other hand, those patients with low PI and SS may present clamping of the posterior elements of L5 between L4 and S1 during extension, which eventually causes an effect in “nutcracker” on the pars articularis of L5. For cases of high-grade spondylolisthesis, Hresko et al.16 identified two subgroups of sacro-pelvic alignment: with balanced or unbalanced pelvic posture (Fig. 6). The “balanced” group includes patients who in the orthostatic position show high SS and low pelvic tilt (PT). Patients in the group “unbalanced” include those who in the orthostatic position have retroverted pelvis and verticalized sacrum, which corresponds to a low SS and high PT. It has been shown that patients with high degree of vertebral slippage have a mean PI >60◦ .

Balanced pelvis

Retroversed pelvis

Fig. 6 – Balanced and retroversed pelvic posture published by Hresko et al.16 for high-grade spondylolistheses.

Type II – isthmic: defect in the pars interarticularis. Three types: Lithic – fatigue fracture of the pars Elongation of the pars Acute fracture of the pars Type III – Degenerative: degeneration of the disc and facets, which creates instability and mobility on segment Type IV – Traumatic: acute fracture of the pedicles, facets or blades (except pars) Type V – Pathologic: because of neoplastic or metabolic processes

This contrasts with those with low-grade spondylolisthesis, in whom PI values are low, normal or high. Furthermore, it was observed that the sagittal balance, i.e. the measurement of the plumb line from C7, was significantly increased (>3 cm) in those with retroverted posture (unbalanced); this suggests that the positive sagittal imbalance may be associated with this type of spino-pelvic alignment. MacThiong et al.17 showed in a comparative study between a group of 131 patients with spondylolisthesis and a control group of 120 patients, that the normal sagittal balance of the trunk was maintained in patients with low-grade spondylolisthesis, while the sagittal balance was changed in patients with high-grade spondylolisthesis. Again, the spino-pelvic balance was altered in the group of high-grade spondylolisthesis associated with sacral-pelvic imbalance.

Classification The spondylolisthesis has been described by Wiltse et al.18 classification (Table 2), based on etiological and topographical criteria, with five types. It is difficult to predict its progression and response to treatment. The recognition that surgical decompression may lead to instability of the column made necessary a sixth type: iatrogenic spondylolisthesis. Another system used is the one proposed by Meyerding et al.19 in 1932 (Fig. 7), in which the degree of slippage is calculated by the ratio between the anterosuperior diameter of the sacrum and the distance of previous slippage of vertebra L5. Thus, it can be considered: grade I – 25% or less, grade II – between 25% and 50%, grade III – between 50% and 75%, and grade IV – greater than 75%. The degree V, as spondyloptosis, does not belong to the original description. The scale of Meyerding only describes the degree of tangential slippage, though in high-grade dysplasias there is kyphosis, in addition to the tangential translation. The more used grading system for high-grade slippages is that proposed by Newman and modified by DeWald et al.,20 in which the dome and the anterior surface of the sacrum are divided into ten parts (Fig. 8). The measure is taken based on the position of the posterior-inferior corner of the body of the fifth vertebra in relation to the dome of the sacrum (first measure) and the second measure is given by the position of the anteriorinferior corner of the body of the vertebra L5 in relation to the anterior surface of S1. Marchetti et al. and Bartolozzi et al.21 developed a classification system that distinguishes spondylolisthesis acquired


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Table 3 – SDSG classification based in spino-pelvic posture.

I

Spondylolisthesis Low grade < 50% Type 1: PI < 45◦ (“nutcracker”) Type 2: PI = 45–60◦ Type 3: PI > 60◦

II

25% 50% 75%

III

IV

V

Fig. 7 – Meyerding classification.

versus developmental type and also divides the developmental spondylolisthesis in dysplastic of low and high grade. None of these classification systems were designed with the goal of assisting in surgical planning of spondylolistheses. Thus, the guidelines and outcome studies and clinical follow-up are mostly based on the degree of slippage.21,22 Furthermore, these classifications20,21 do not take into account the sacro-pelvic sagittal balance, although more recent studies suggest the importance of this balance in the assessment, progression and treatment of spondylolisthesis.23,24 This may be the explanation for the large amount of published studies on surgical techniques.

A

B

C

Fig. 8 – Newman graduation system, modified by DeWald.20

High grade > 50% Type 4: Balanced pelvis Retroversed pelvis Type 5: Balanced column Type 6: Unbalanced column

Recently, Mac-Thiong et al. and Labelle et al.25 proposed a new classification system for spondylolisthesis, with the goal of assisting in the evaluation and treatment of lumbosacral spondylolisthesis. This classification clarifies the concepts of dysplasia of low and high grade presented by Marchetti et al. and Bartolozzi et al.21 and incorporates the latest knowledge of the morphology and the sacral-pelvic sagittal balance. Eight types of spondylolisthesis are described as follows: (1) degree of slippage (low and high grade), (2) degree of dysplasia (low and high grade) and (3) sagittal sacro-pelvic balance. The classification is organized into groups and subgroups in ascending degrees of seriousness, in order to develop a progressive algorithm of surgical complexity proportional to the increase in the severity of spondylolisthesis.

Classification proposed by the study group of spinal deformities (Spinal Deformity Study Group [SDSG]) The SDSG submitted a classification for spondylolisthesis between L5 and S1 that has been simplified and refined. This classification is based on three characteristics that can be evaluated in lateral view (sagittal) radiograph of the column and pelvis: (1) degree of slippage (low or high), (2) pelvic incidence (low, normal or high) and (3) spino-pelvic balance (balanced or unbalanced). Thus, six subtypes can be identified (Table 3).23–25 To apply the classification, in the first place the degree of slippage is measured on a lateral radiograph of the column. So it can be determined whether the slippage is low-grade (0, 1 and 2: <50% slippage) or high grade (3, 4 or spondyloptosis: >50% slippage). Then, the sagittal balance is measured to determine the sacro-pelvic and spino-pelvic alignment. The measures of PI, SS, PT and of the plumb line of C7 are used. For low-grade spondylolistheses, three types of sacro-pelvic balance can be found: type 1, “nutcracker”, a subgroup with low PI (<45◦ ); Type 2, a subgroup with normal PI (between 45◦ and 60◦ ); and type 3, a shear type, a subgroup with high PI (>60◦ ). For those cases with high-grade spondylolisthesis, three types are also found. Each case must first be classified as if presenting a balanced or unbalanced sacro-pelvic, using values of PI and SS.16 The spino-pelvic balance is determined with the use of the plumb line of C7. If this line falls on or behind the femoral head, the column will be balanced; if it falls in front of the femoral head, the column will be unbalanced. The three types of high-grade spondylolisthesis are: type 4 (balanced pelvis), type 5 (pelvis retroverted with balanced


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Type1

Type2

Type3

Type4

Type5

Type6

PI=32

PI=55

PI=95

PI=86

PI=62

PI=82

PS=24

PS=43

PS=74

PS=63

PS=27

PS=37

PT=8

PT=12

PT=21

PT=23

PT=35

PT=45

Fig. 9 – Classification of the Spinal Deformity Study Group. PI = pelvic incidence, SS = sacral slope, PT = pelvic tilt.

column) and type 6 (retroverted pelvis with unbalanced column). Fig. 9 shows six clinical examples of these positions.

Progression factors According to Boxal et al.,26 the best parameter to predict progression is a great slippage angle (>55◦ ); this angle is formed by the intersection of a line drawn parallel to the inferior face of L5 and a perpendicular to the posterior face of the body of S1. The authors also report that a progression may occur, even after a solid posterior arthrodesis. Patients with low PI and low SS (“nutcracker” mechanism) have a low risk of progression. Dysplasia and slippage of high grade (>50%) were also reported as a factor for progression of spondylolisthesis.27 Other factors in favour of progression to isthmic spondylolistheses are female gender, slippage >50% and children before the growth spurt.24 It was observed that patients with spondylolisthesis caused by dysplasia have a higher chance of progression versus those with spondylolitic spondylolisthesis.28

Clinical manifestations The symptoms can be divided into symptoms in children and adults.

In children, the spondylolisthesis is usually asymptomatic. Exaggerated lumbar lordosis may be the first warning sign and a shortening of hamstrings occurs. With the verticalization of the sacrum, the buttocks become heart-shaped, because of the bony prominence. With the progression, the patient develops a typical posture, because of the hamstring shortening, verticalization of the sacrum and increased lordosis, known as Phalen-Dickson signal (bending of the knees and hips). In symptomatic cases, the mechanical low back pain is the most common complaint.3 The severity of pain may or may not be related to the degree of slippage. Radiculopathy is less common, but is observed with the progressive translation, when instability is present. Radiculopathy of L5 occurs more often than radiculopathy of S1. S1 root compression occurs in high degrees of slippage because of the root stretching stress above the edge of the sacrum. The pain increases with the extension of the column and improves with rest.29 In adults the lumbar pain with or without irradiation to the lower limbs is common; this is typically a mechanical pain that worsens with extension. The pain must be differentiated from discogenic pain, which worsens with flexion and in the sitting position. Neurogenic claudication is also a common symptom, defined as a pain in the lower extremities, numbness or weakness associated with ambulation or with the seated position.30 Pain is the predominant symptom, present in 94% of patients, followed by paresthesia (63%) and weakness (43%).31 Neurogenic claudication must be differentiated from vascular claudication, as shown in Tables 3 and 4.


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r e v b r a s o r t o p . 2 0 1 4;4 9(1):3–12

Table 4 – Differential diagnosis between neurogenic claudication and vascular claudication. Evaluation Walking distance Factors of worsening Factors of worsening Climb slopes Ergometric cycle Pulses Skin Weakness Low back pain Lumbar mobility Muscular atrophy Pain characteristics

Vascular

Neurogenic

Fixed Orthostatism Walking Worsening Positive (painful) Absent Glossy/phaner loss Rare Occasional Normal Unusual Cramps/distal to proximal

Diagnosis The diagnosis is established on radiographs of the lumbar column in frontal and profile incidences with the patient in the orthostatic position. Other views used are located profile and right and left oblique incidences. In radiographs in oblique incidence, the “Scottish dog” can be seen, where the “collar” represents lysis in the pars.26 Computed tomography has little value in the diagnosis; this technique can demonstrate sclerosis and the defect in the pars. MRI is the exam of choice to view the disc at the level of the deformity. This imaging technique is used in cases of radiculopathy and to visualize bone oedema and defects in the pars articularis. More advanced image examinations, such as computed tomography by single photon emission (SPECT),32 are more sensitive and provide more details. Anderson et al.33 reported that 20% of patients with negative results on a standard bone scan with suspected acute spondylolysis showed a lesion of the pars when assessed with SPECT.

Treatment of spondylolisthesis The spondylolisthesis can be of low grade (slippage <50%) or of high grade (slippage >50%) and both types can be treated conservatively. However, the high-degree spondylolistheses respond more poorly to conservative treatment when compared with those conditions of low degree.31 The conservative treatment is best suited for displacements smaller than 30–50% in the growing child and for some displacements larger than 50% in young adults. For symptomatic patients, excellent clinical response has been obtained with restriction of physical activity and the use of ortheses (TLSO) in order to avoid repetitive movements of hyperextension of the lumbar column.13 For patients with chronic low back pain, Panjabi et al.34 demonstrated that the strengthening of specific muscle groups improves the patient’s response to pain; so, these authors started to recommend the strengthening of the transverse abdominal, internal oblique and multifidus muscles. Besides the strengthening of these specific muscle groups, the strengthening of the hip flexors and the stretching of hamstrings also improve the patient response to low back pain.13

Variable Sitting/flexion of column Walking/standing Improvement Negative (painless) Present Normal Common Common Limited Occasional Paresthesia/proximal to distal

According to DeWald,20 the goal in the surgical treatment of spondylolisthesis is the fusion of the smallest possible number of mobile segments of the column, which restores the sagittal vertical axis, with the sacrum and lumbar column in as normal as possible a position, and the fusion of the noncompetent disc spaces. This type of treatment is indicated in asymptomatic children with greater than 50% slippage, for asymptomatic patients with skeletal maturity and greater than 75% slippage, for symptomatic patients who do not respond to conservative treatment, progression of deformity and neurological deficit.30 In symptomatic adult patients with low-grade degenerative spondylolisthesis, posterolateral arthrodesis (PLA) in situ has better clinical outcomes when compared to supervised exercise programmes.35,36 However, PLA has been unable to maintain intraoperative correction of the slippage angle, due to the progressive degeneration of the anterior disc space.35 Suk et al.37 and La Rosa et al.38 conducted a comparative study between PLA and 360◦ arthrodesis (PLA + PLIF) and found that many postoperative radiological parameters, such as fusion rate, reduction of the slippage angle and maintenance of the correction of the deformity, were superior in patients with arthrodesis 360◦ . However, clinically in none of these studies PLA or PLIF was statistically superior. 39 A decompression is indicated in cases of radiculopathy. Usually the L5 root is involved at the foraminal level and compressed by the proximal portion of the pars as the slippage is enhanced by fibrocartilaginous tissue in the defective pars. In cases of radiculopathy or other neurological deficits, such as cauda equina, decompression is indicated. The Gill procedure is the basis for decompression by removing the loose blade.39 The decompression of the nerve root can be done only in adult patients with radiculopathy and low grade spondylolisthesis through the procedure of Gill et al.40 However, this procedure is contraindicated in paediatric patients, in whom it should always be accompanied by an arthrodesis. The reduction of high grade spondylolisthesis has been indicated, since this procedure is able to improve the aesthetic appearance, correct the lumbar angles, improve the pelvic index and the sagittal balance and even recover the kyphosis that occurs in the lower lumbar region.40 In most cases, this reduction is not made in adult patients with spondylolisthesis. This is due not only to the degree of slippage, but also to the anatomic position of the roots, which are more cephalad; and to the presence of a bend formed in the dural sac, which is


r e v b r a s o r t o p . 2 0 1 4;4 9(1):3–12

relatively more elongated. Because of these anatomical findings, the reduction manoeuvre can apply tension to the roots, with the risk of neurological injury.41

Final considerations The isthmic spondylolisthesis is an acquired disease that becomes symptomatic in young adults, because of the premature degenerative process of the intervertebral disc and facet joints, as well as the mechanical imbalances that lead to changes in the sagittal balance of the column. The progression of slippage is more rare in adults than in children. The radiographic examination of these patients should include the panoramic radiograph of the column and the visualization of the femoral heads, to allow an angular evaluation of the lumbosacral junction and of the sagittal balance. Conservative treatment with physical rehabilitation and analgesics has generally shown good results. The surgical treatment with nerve root decompression and arthrodesis is indicated in cases where the conservative treatment has failed or there is a progressive neurological deficit. The result of surgical treatment has been good in terms of relieving the chronic low back and radicular pain. The classification system proposed by SDSG is practical and easy to apply and should be used and more studied in our country. The purpose of this classification emphasizes that patients with spondylolisthesis L5/S1 form a heterogeneous group with several postural adjustments and that this should be considered by physicians when indicating any type of treatment. While we cannot employ an algorithm that establishes a specific treatment for each subtype, it is suggested that in patients with type 4 of spino-pelvic alignment, forced attempts at reduction may not be necessary. Obtaining the sagittal alignment with arthrodesis and surgical instrumentation is enough. For those patients with type 5, we should preferably try to reduce and realign, but in very difficult cases, instrumentation and arthrodesis after postural reduction may be sufficient for obtaining the proper sagittal alignment, since that the alignment of the column is maintained. The reduction and alignment are mandatory in type 6 patients, in whom the sagittal alignment is seriously impaired. The circumferential fusion (360◦ ) with surgical instrumentation has shown a lower rate of non-union, but this cannot be correlated with results superior to those of the posterolateral arthrodesis.

Conflicts of interest The author declares no conflicts of interest.

references

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3. Lonstein JE. Spondylolisthesis in children. Cause, natural history, and management. Spine (Philadelphia, PA, 1976). 1999;24(24):2640–8. 4. Nazarian S. Spondylolysis and spondylolytic spondylolisthesis. A review of current concepts on pathogenesis, natural history, clinical symptoms, imaging, and therapeutic management. Eur Spine J. 1992;1(2):62–83. 5. Harris IE, Weinstein SL. Long-term follow-up of patients with grade-III and IV spondylolisthesis treatment with and without posterior fusion. J Bone Joint Surg Am. 1987;69(7):960–9. 6. Fredrickson BE, Baker D, McHolick WJ, Yuan HA, Lubicky JP. The natural history of spondylolysis and spondylolisthesis. J Bone Joint Surg Am. 1984;66(5):699–707. 7. Love TW, Fagan AB, Fraser RD. Degenerative spondylolisthesis developmental or acquired? J Bone Joint Surg Br. 1999;81(4):670–4. 8. Wiltse LL. The etiology of spondylolisthesis. J Bone Joint Surg Am. 1962;44:539–60. 9. Stewart TD. The age incidence of neural-arch defects in Alaskan natives, considered from the standpoint of etiology. J Bone Joint Surg Am. 1953;35(4):937–50. 10. Mohriak R, Silva PDV, Trandafilov Junior M, Martins DE, Wajchenberg M, Cohen M, et al. Espondilólise e espondilolistese em ginastas jovens. Rev Bras Ortop. 2010;45(1):79–83. 11. Mardjetko S, Albert T, Andersson G, Bridwell K, DeWald C, Gaines R, et al. Spine/SRS spondylolisthesis summary statement. Spine (Philadelphia, PA, 1976). 2005;30 6 Suppl.:S3. 12. Berthonnaud E, Dimnet J, Roussouly P, Labelle H. Analysis of the sagittal balance of the spine and pelvis using shape and orientation parameters. J Spinal Disord Tech. 2005;18(1):40–7. 13. Legaye J, Duval-Beaupère G, Hecquet J, Marty C. Pelvic incidence: a fundamental pelvic parameter for three-dimensional regulation of spinal sagittal curves. Eur Spine J. 1998;7(2):99–103. 14. Roussouly P, Gollogly S, Berthonnaud E, Labelle H, Weidenbaum M. Sagittal alignment of the spine and pelvis in the presence of L5-s1 isthmic lysis and low-grade spondylolisthesis. Spine (Philadelphia, PA, 1976). 2006;31(21):2484–90. 15. Labelle H, Mac-Thiong JM, Roussouly P. Spino-pelvic sagittal balance of spondylolisthesis: a review and classification. Eur Spine J. 2011;20 (Suppl. 5):641–6. 16. Hresko MT, Labelle H, Roussouly P, Berthonnaud E. Classification of high-grade spondylolistheses based on pelvic version and spine balance: possible rationale for reduction. Spine (Philadelphia, PA, 1976). 2007;32(20):2208–13. 17. Mac-Thiong JM, Wang Z, de Guise JA, Labelle H. Postural model of sagittal spino-pelvic alignment and its relevance for lumbosacral developmental spondylolisthesis. Spine (Philadelphia, PA, 1976). 2008;33(21):2316–25. 18. Wiltse LL, Newman PH, Macnab I. Classification of spondylolysis and spondylolisthesis. Clin Orthop Relat Res. 1976;(117):23–9. 19. Meyerding HW. Spondylolisthesis. Bone Joint Surg. 1931;13(1):39–48. 20. DeWald RL. Spondylolisthesis. In: Bridwell KH, DeWald RL, editors. The textbook of spinal surgery. 2th ed. Philadelphia: Lippincott-Raven; 1997. p. 1202–10. 21. Marchetti PC, Bartolozzi P. Classification of spondylolisthesis as a guideline for treatment. In: Bridwell KH, DeWald RL, Hammerberg KW, editors. The textbook of spinal surgery. 2nd ed. Philadelphia: Lippincott-Raven; 1997. p. 1211–54. 22. Herman MJ, Pizzutillo PD, Cavalier R. Spondylolysis and spondylolisthesis in the child and adolescent athlete. Orthop Clin North Am. 2003;34(3):461–7. 23. Smith JA, Hu SS. Management of spondylolysis and spondylolisthesis in the pediatric and adolescent population. Orthop Clin North Am. 1999;30(3):487–99.


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24. Curylo LJ, Edwards C, DeWald RW. Radiographic markers in spondyloptosis: implications for spondylolisthesis progression. Spine (Philadelphia, PA, 1976). 2002;27(18):2021–5. 25. Mac-Thiong JM, Labelle H. A proposal for a surgical classification of pediatric lumbosacral spondylolisthesis based on current literature. Eur Spine J. 2006;15(10):1425–35. 26. Boxall D, Bradford DS, Winter RB, Moe JH. Management of severe spondylolisthesis in children and adolescents. J Bone Joint Surg Am. 1979;61(4):479–95. 27. Tebet MA, Pasqualini W, Alves AP, Azuaga TL. Espondilolistese. In: Cristante AF, Barros Filho TEP, editors. Coluna. Rio de Janeiro: Elsevier; 2012. p. 125–37. 28. McPhee IB, O’Brien JP, McCall IW, Park WM. Progression of lumbosacral spondylolisthesis. Australas Radiol. 1981;25(1):91–5. 29. Jankowski R, Nowak S, Zukiel R, Pucher A, Blok T. Surgical strategies in degenerative lumbar spondylolisthesis. Columna. 2006;5(1):99–103. 30. Katz JN, Dalgas M, Stucki G, Katz NP, Bayley J, Fossel AH, et al. Degenerative lumbar spinal stenosis diagnostic value of the history and physical examination. Arthritis Rheum. 1995;38(9):1236–41. 31. Labelle H, Roussouly P, Berthonnaud E, Transfeldt E, O’Brien M, Chopin D, et al. Spondylolisthesis, pelvic incidence, and spinopelvic balance: a correlation study. Spine (Philadelphia, PA, 1976). 2004;29(18):2049–54. 32. Robilotta CC. A tomografia por emissão de positrons: uma nova modalidade na medicina nuclear brasileira. Rev Panam Salud Publica. 2006;20(2–3):134–42. 33. Anderson K, Sarwark JF, Conway JJ, Logue ES, Schafer MF. Quantitative assessment with SPECT imaging of stress injuries of the pars interarticularis and response to bracing. J Pediatr Orthop. 2000;20(1):28–33.

34. Panjabi MM. The stabilizing system of the spine Part I. Function, dysfunction, adaptation, and enhancement. J Spinal Disord. 1992;5(4):383–9. 35. Möller H, Hedlund R. Surgery versus conservative management in adult isthmic spondylolisthesis – a prospective randomized study: part 1. Spine (Philadelphia PA, 1976). 2000;25(13):1711–5. 36. Tebet MA, Pasqualini W, Carvalho MP, Fusão AF, Segura EL. Tratamento cirúrgico da espondilolistese degenerativa e ístmica da coluna lombar: avaliac¸ão clínica e radiológica. Coluna. 2006;5(1):109–16. 37. Suk SI, Lee CK, Kim WJ, Lee JH, Cho KJ, Kim HG. Adding posterior lumbar interbody fusion to pedicle screw fixation and posterolateral fusion after decompression in spondylolytic spondylolisthesis. Spine (Philadelphia, PA, 1976). 1997;22(2):210–9. 38. La Rosa G, Conti A, Cacciola F, Cardali S, La Torre D, Gambadauro NM, et al. Pedicle screw fixation for isthmic spondylolisthesis: does posterior lumbar interbody fusion improve outcome over posterolateral fusion? J Neurosurg. 2003;99 (Suppl. 2):143–50. 39. Jacobs WC, Vreeling A, De Kleuver M. Fusion for low-grade adult isthmic spondylolisthesis: a systematic review of the literature. Eur Spine J. 2006;15(4):391–402. 40. Gill GG, Manning JG, White HL. Surgical treatment of spondylolisthesis without spine fusion; excision of the loose lamina with decompression of the nerve roots. J Bone Joint Surg Am. 1955;37(3):493–520. 41. McPhee IB, O’Brien JP. Reduction of severe spondylolisthesis. A preliminary report. Spine (Philadelphia, PA, 1976). 1979;4(5):430–4.


r e v b r a s o r t o p . 2 0 1 4;4 9(1):13���16

www.rbo.org.br

Review Article

Level of evidence of knee surgery in national journal夽,夽夽 Davi Araújo Veiga Rosário ∗ , Guilherme Conforto Gracitelli, Marcus Vinícius Malheiros Luzo, Mario Carneiro Filho, Moisés Cohen, Carlos Eduardo da Silveira Franciozi Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, 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:

Select the studies related to knee surgery in the orthopedic literature published by Acta

Received 28 February 2013

Ortopédica Brasileira (AOB) and the Revista Brasileira de Ortopedia (RBO) and classify them

Accepted 13 May 2013

according to the levels of evidence. We selected all studies published from 2000 to 2011 related to knee surgery in AOB and RBO. The following categorization was adopted: level

Keywords:

1: systematic review; level 2: clinical trial; level 3: cohort studies and case–control; level 4:

Evidence-based medicine

number of cases; level 5: narrative review and others. We found in the national literature

Knee

selected 255 studies related to knee surgery. In the Southeast were developed 212 articles

Bibliometric indicators

(83.1%), 30 publications in the South (11.7%), Northeast 5 (2%), North and Central West 2 jobs each (0.8%). Four work performed in other country (1.6%). The most common issue was the anterior cruciate ligament in 58 studies (22.7%) and arthroplasty in 55 studies (21.5%). Most studies presented evidence level IV (27.8%) and V (50.2%). The national scientific production related to knee surgery presents itself expanding with predominant expression in the Southeast. Most studies related to knee surgery published in national journals have low level evidence and focuses on the approach of the anterior cruciate ligament and arthroplasty. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

Níveis de evidência da cirurgia de joelho em periódicos nacionais r e s u m o Palavras-chave:

Selecionar os estudos relacionados à cirurgia do joelho publicados na literatura ortopédica

Medicina baseada em evidências

nacional por meio da Acta Ortopédica Brasileira (AOB) e da Revista Brasileira de Ortopedia

Joelho

(RBO) e classificá-los de acordo com os níveis de evidência. Foram selecionados todos os

Indicadores bibliométricos

estudos publicados de 2000 a 2011. A seguinte categorizac¸ão foi adotada: nível 1 - revisão sistemática; nível 2 - ensaio clínico; nível 3 - estudos de coorte e caso-controle; nível 4 - série de casos; nível 5 - revisão narrativa e outros. Foram encontrados 255. Na região Sudeste foram 212 artigos (83,1%), na Sul 30 (11,7%), na Nordeste cinco (2%), na Norte e na Centro-Oeste dois cada (0,8%). Quatro trabalhos foram desenvolvidos no exterior (1,6%). O tema mais

Please cite this article as: Rosário DAV, Gracitelli GC, Luzo MVM, Filho MC, Cohen M, Franciozi CEdaS. Níveis de evidência da cirurgia de joelho em periódicos nacionais. Rev Bras Ortop. 2014;49:13–16. 夽夽 Study conducted at Knee Group, Department of Orthopaedia and Traumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil. ∗ Corresponding author. E-mail: daviveiga@hotmail.com (D.A.V. Rosário). 2255-4971/$ – see front matter © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

http://dx.doi.org/10.1016/j.rboe.2014.01.011


14

r e v b r a s o r t o p . 2 0 1 4;4 9(1):13–16

comum foi ligamento cruzado anterior, em 58 estudos (22,7%), e artroplastias, em 55 estudos (21,5%). A maior parte dos estudos apresentou nível de evidência IV (27,8%) e V (50,2%). A produc¸ão científica nacional relacionada à cirurgia do joelho apresenta-se em expansão, com predomínio de expressão na região Sudeste. A maioria dos estudos tem baixo nível de evidência e concentra-se na abordagem do ligamento cruzado anterior e das artroplastias. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Todos os direitos reservados.

Introduction The concept of evidence-based medicine (EBM) was introduced in 2001 and since then has raised the interest of the scientific community.1 These concepts began to appear in major conferences and symposia from 2003.2,3 Unlike traditional medicine, this new branch is not grounded in intuition, in unsystematic clinical experience nor in pathophysiological rationale as sufficient reasons for the process of clinical decision-making. Evidence-based medicine requires new skills of the physician, including knowledge of research in the literature, their tools and the evaluation of clinical evidence. There was an increase in the production of articles that instruct the physician on how to access, evaluate and interpret medical literature.3,4 This critical sense becomes mandatory, considering the large number of publications and frequent methodological pitfalls which may lead the reader to misleading and potentially dangerous conclusions for his or her clinical and surgical practice.5,6 The orthopedic literature followed the line of international publications in the search of better levels of evidence in the publications, and the methodological quality of the articles began to be analyzed under more rigorous criteria.4 However, to date, the national literature lacks critical studies of levels of evidence in orthopedics and traumatology. In the present study, we carried out a review with the aim of selecting articles related to knee surgery and published from 2000 to 2011 in the national orthopedic literature by Acta Ortopédica Brasileira (AOB) and Revista Brasileira de Ortopedia (RBO), and classify them according to levels of evidence. These two journals were chosen because of their insertion into the national scenario and also for being indexed, via SciELO, as an international bibliographic database. Secondary variables to be observed: the number of studies published per year, the region in which they were developed, and the main issue addressed in the study.

Materials and methods For evaluation, this review has taken into consideration studies published in the national orthopedic literature: Acta Ortopédica Brasileira (AOB) and Revista Brasileira de Ortopedia (RBO). All published studies from 2000 to 2011 related to knee surgery were selected. The inclusion criteria were: knee surgery-related studies, selected manually in the published editions containing in the title: knee, distal femoral and proximal tibial fracture, knee arthroscopy, meniscus, anterior cruciate ligament, posterior cruciate ligament, patella, posterolateral complex or corner,

knee arthroplasty, and knee biomechanics. Exclusion criteria were articles with topics not related to knee surgery. This study was approved by the research ethics committee (number: 120,790). The identification of the studies was electronically done, edition by edition, by identifying those items which fit in the inclusion criteria. A new selection was made based on the summary and on the full text. Doubts in the selection of articles were resolved by consensus between two researchers, David Rosario Veiga and Guilherme Araújo Conforto Gracitelli (DAVR and GCG). Having persistence of doubt, a third reviewer was consulted: Carlos Eduardo da Silveira Franciozi (CESF). After the identification of the studies, two reviewers (DAVR and GCG) independently collected the qualitative characteristics of the studies: journal (AOB and RBO), year of publication (before 2005 and before 2011) and region of the country where they were conducted. After selection, the items were categorized by two raters according to level of evidence and type of study. The categorization was made after the reading of the entire article. The following categorization was adopted: level 1 – systematic review, level 2 – clinical trial; level 3 – cohort and case–control studies, level 4 – number of cases; level 5 – narrative review and others (example: a biomechanical, anatomical, of accuracy, or of basic science study). The possible doubts on the categorization of articles were resolved by consensus between two of the researchers (DAVR and GCG). Having persistence of doubt, a third reviewer was consulted (CESF). The descriptions of the articles were made with the use of absolute and relative frequencies for presentation of data by year of publication, region of the country, main theme of the article, and type of study. The results are illustrated graphically for presentation. The descriptive statistical analysis was done using the Excel 2007 program.

Results The evidence-based medicine requires concern, by part of researchers, regarding the quality of the studies. From 2000 to 2011 255 studies related to knee surgery were found in the national literature evaluated. Over the years, we observed an increasing number of publications in national journals (Fig. 1). In 2000, only 11 papers related to knee surgery in the national literature were presented to the scientific community; this number reached 26 in 2005 and 50 in 2011. In the analysis of the region of generation of these articles (Fig. 2), the Southeast region takes clear advantage, with 212 (83.1%). The South region had 30 (11.7%), the Northeast region five (2%) and the North and Midwest regions two articles


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r e v b r a s o r t o p . 2 0 1 4;4 9(1):13–16

50

TEND 1.0%

OCL 3.0%

PLC 0.3%

PCL 3.0%

40

GFT 4.7% FX 4.7%

ACL 22.7%

ME 4.7%

30

ACL: anterior cruciate ligament, ARTHRO: arthroplasty, OA: osteoarthritis, OST: osteotomy, TU: tumor, PI: patellar instability, PL: patellar lesion, OT: other themes, ME: meniscus, FX: fracture, GFT: graft, PCL: posterior cruciate ligament, OCL: osteochondral lesion TEND: tendonitis, PLC: posterolateral complex.

OT 5.0% PL 5.0%

ARTHRO 21.5%

PI 5.4%

20

TU 6.0%

OST 6.0%

OA 7.0%

10

0 2000

2002

2004

2006

2008

2010

Fig. 1 – Sum of publications on knee in AOB and RBO journals.

Fig. 3 – Main theme addressed in the study. ACL: anterior cruciate ligament, ARTHRO: arthroplasty, OA: osteoarthritis, OST: osteotomy, TU: tumor, PI: patellar instability, PL: patellar lesion, OT: other themes, ME: meniscus, FX: fracture, GFT: graft, PCL: posterior cruciate ligament, OCL: osteochondral lesion, TEND: tendonitis, PLC: posterolateral complex.

50.2%

83.10%

27.8% 12.2% 11.70% 0.80% 0.80% 1.60%

23.4% 21.0%

19.0%

8.5%

c

sc

ie

nc

e

rs e

8.5%

si

an sv e

om at

ac An

cu r Ac

Tr

y

y

9.5%

Ba

Bi

om

e

ec

ha

re vi

ni

cs

ew

10.1%

tiv

each (0.8%). Four projects developed abroad were published in national journals (1.6%). Regarding the main topic approached, it became clear the interest in publications on the topics “anterior cruciate ligament”, with 58 studies (22.7%), and “arthroplasty”, with 55 studies (21.5%). Other issues have the distribution shown in Fig. 3. Fig. 4 illustrates the level of evidence of the selected studies. Most of the studies presented evidence level IV (27.8%) and V (50.2%). Fig. 5 shows the subdivision of level V studies.

Fig. 4 – Level of evidence from studies. Level I, systematic review; level II, clinical trial, level III, case control/cohort; level IV, case series, level V, other types.

re po rt

Fig. 2 – Scientific production by region. SE, Southeast; NE, Northeast; ST, South; NO, North; MW, Midwest; INTER, International.

LEVEL LEVEL LEVEL LEVEL LEVEL V II IV I III Level I, systematic review; Level II, clinical trial, Level III, case control/cohort; Level IV, case series, Level V, other types.

e

MW INTER

ar ra

NO

SE, Southeast, NE, Northeast, ST, South, NO, North, MW, Midwest, INTER, International.

N

ST

as

NE

C

2% SE

9.0%

0.8%

Fig. 5 – Stratification of evidence level V.

Discussion The analysis of the national literature, in search of papers published on the subject “knee surgery”, demonstrated a similar trend to the international literature, with increasing scientific production over the years.6,7 In 2000, 11 papers were published, increasing to 26 in 2005 and to 50 in 2011. This stimulus to scientific production can be explained by an increasing demand for evidence to justify the application of a therapeutic

method. In the past, an expert opinion was sufficient for the adoption of a treatment protocol. Our study found that the majority of published studies pertain to the evidence levels IV and V. These data are similar to those found in the international literature and in the national literature on other orthopedic issues.4,8 Some hypotheses may explain the large number of studies of levels IV and V: usually,


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r e v b r a s o r t o p . 2 0 1 4;4 9(1):13–16

they are of low cost and depend on little planning/prior knowledge. These studies can be part of the routine of the health care team, and generally do not require long follow-ups, and can be conducted in a short time.1,8 It should be borne in mind that open observational studies are also important, especially in the early stages of testing a new intervention; these studies can provide valuable information for patient care. However, in this case, it is crucial that elaborate techniques for data analysis be used, with construction of multivariate regression models to control for potential confounding factors.5,7 It is recommended that the authors make every effort and use a control group in their studies, since this practice can substantially raise the rating of the level of evidence and improve the confidence with which one can apply the information obtained to clinical and surgical practice.6 A secondary endpoint showed great difference in relation to the scientific production in the various regions of our country. This difference has already been mentioned in other papers of the national literature, that always viewed the Southeast region (83.1%) as the national scientific production center, followed by the South (11.7%).8 This finding should be viewed as an incentive to the other regions, to increase their scientific production and follow the trend of the national and international literature. Another secondary variable indicates the preference of the conduction of scientific work on anterior cruciate ligament (22.7%) and knee arthroplasties (21.5%) themes. The enormous scientific literature that addresses these issues may explain the improvement of techniques, in therapeutic options, and in the prevalence of increasingly satisfactory postoperative results over the years. The limitations of this study is the possibility of publication of works related to knee surgery in other national journals that were not investigated, and the possibility of publication of studies developed in Brazil in international journals with higher level of evidence.

Conclusion The national scientific production related to knee surgery has been growing, with predominant expression in the Southeast region.

Most of the studies related to knee surgery published in national journals have low level of evidence and concentrate on the approach to the anterior cruciate ligament and arthroplasty.

Conflicts of interest The authors declare no conflicts of interest.

references

1. Evidence-Based Medicine Working Group. Evidence-based medicine. A new approach to teaching the practice of medicine. JAMA. 1992;268(17):2420–5. 2. Bhandari M, Richards RR, Sprague S, Schemitsch EH. The quality of reporting of randomized trials in the Journal of Bone and Joint Surgery from 1988 through 2000. J Bone Joint Surg Am. 2002;84(3):388–96. 3. Bhandari M, Swiontkowski MF, Einhorn TA, Tornetta 3rd P, Schemitsch EH, Leece P, et al. Interobserver agreement in the application of levels of evidence to scientific papers in the American volume of the Journal of Bone and Joint Surgery. J Bone Joint Surg Am. 2004;86(8):1717–20. 4. Siebelt M, Siebelt T, Pilot P, Bloem RM, Bhandari M, Poolman RW. Citation analysis of orthopaedic literature; 18 major orthopaedic journals compared for Impact Factor and SCImago. BMC Musculoskelet Disord. 2010;11: 4. 5. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52(6):377–84. 6. Moraes VY, Moreira CD, Tamaoki MJS, Faloppa F, Belloti JC. Ensaios clínicos randomizados na ortopedia e traumatologia: avaliac¸ão sistemática da evidência nacional. Rev Bras Ortop. 2010;45(6):601–5. 7. Malavolta EA, Demange MK, Gobbi RG, Imamura M, Fregni F. Ensaios clínicos controlados e randomizados na ortopedia: dificuldades e limitac¸ões. Rev Bras Ortop. 2011;46(4): 452–9. 8. Moraes VY, Belloti JC, Moraes FY, Galbiatti JA, Palácio EP, Santos JB, et al. Hierarchy of evidence relating to hand surgery in Brazilian orthopedic journals. São Paulo Med J. 2011;129(2):94–8.


r e v b r a s o r t o p . 2 0 1 4;4 9(1):17–24

www.rbo.org.br

Original Article

Analysis of using antirotational device on cephalomedullary nail for proximal femoral fractures夽,夽夽 Marcelo Itiro Takano, Ramon Candeloro Pedroso de Moraes ∗ , Luis Gustavo Morato Pinto de Almeida, Roberto Dantas Queiroz Hospital do Servidor Público Estadual de São Paulo, 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 analyze the influence of femoral neck diameter in the positioning of the sliding

Received 9 May 2013

screw in cefalomedulares nails for treatment of unstable transtrochanteric fractures.

Accepted 16 May 2013

Methods: Prospectively throughout 2011, patients with unstable fractures transtrochanteric

Keywords:

were evaluated for sex, age and fracture classification according to Tronzo. Through digital

Hip fractures

radiographs angle reduction, tip apex distance (TAD), stem diameter and measures between

Fracture fixation, internal

the positioning of the screws and the limits of the cervix were measured.

undergoing osteosynthesis with cephalomedullary nail using antirotacional device. They

Bone nails

Results: Of the 58 patients, 42 (72.4%) were female and 16 (27.6%) were male. 33 patients were classified as Tronzo III (56.9%), 6 patients as Tronzo IV (10.4%) and 19 as Tronzo V (19.8%). The majority were in between the eighth and ninth decade of life. The average reduction in the angle was 130.05◦ for females and 129.4◦ for males. The TAD average was 19.7 mm for females and 21.6 for males. The average diameter of the neck and head vary with statistical significance between men and women. In 19 patients the placement of the sliding bolt can be optimal. If the ideal positioning was not possible, the mean displacement for non-infringement of higher cortical neck was 4.06 mm. Conclusion: The optimal placement would not be possible for the majority of the population, for the average diameter of the neck of the sample. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

Análise do emprego do parafuso antirrotacional nos dispositivos cefalomedulares nas fraturas do fêmur proximal r e s u m o Palavras-chave:

Objetivo: analisar a influência do dispositivo antirrotacional no posicionamento do parafuso

Fraturas do quadril

deslizante das hastes cefalomedulares usadas no tratamento das fraturas transtrocanteri-

Fixac¸ão interna de fraturas

anas.

Pinos ortopédicos 夽

Please cite this article as: Takano MI, de Moraes RCP, de Almeida LGMP, Queiroz RD. Análise do emprego do parafuso antirrotacional nos dispositivos cefalomedulares nas fraturas do fêmur proximal. Rev Bras Ortop. 2014;49:17–24. 夽夽 Study conducted at Hip Group, Department of Orthopedics and Traumatology, Hospital do Servidor Público Estadual de São Paulo, SP, Brazil. ∗ Corresponding author. E-mail: ramoncpm@yahoo.com.br (R.C.P. de Moraes). 2255-4971/$ – see front matter © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

http://dx.doi.org/10.1016/j.rboe.2014.01.001


18

r e v b r a s o r t o p . 2 0 1 4;4 9(1):17–24

Métodos: estudo prospectivo de série de casos composta por 58 pacientes com diagnóstico de fraturas transtrocanterianas instáveis submetidos à osteossíntese com haste cefalomedular dotada de dispositivo antirrotacional. A casuística foi avaliada quanto a sexo, idade e classificac¸ão da fratura. Os parâmetros radiográficos avaliados no pós-operatório imediato foram: ângulo de reduc¸ão, limites anatômicos, distância “ponta-ápice” (TAD), deslocamento do parafuso deslizante em relac¸ão ao eixo central do colo femoral e posicionamento do dispositivo antirrotacional. Resultados: houve preponderância do sexo feminino, com maioria na oitava e nona décadas de vida. Foram classificados como Tronzo III 33 pacientes (56,9%), seis como Tronzo IV (10,4%) e 19 como Tronzo V (19,8%). O ângulo de reduc¸ão médio no sexo feminino foi 130,5◦ e 129,4◦ no masculino. O diâmetro médio do colo e da cabec¸a variou com significância estatística entre homens e mulheres. O TAD médio foi de 19,7 mm no sexo feminino e 21,6 mm no masculino. Em 10 pacientes (17,85%) o TAD foi superior a 25 mm. Em 19 pacientes (33,9%) a colocac¸ão do parafuso deslizante poderia ocorrer no eixo central do colo. O deslocamento médio do implante para não violac¸ão da cortical superior do colo foi de 4,06 mm do eixo central. Conclusão: no implante estudado, dotado de dispositivo antirrotacional, o posicionamento do parafuso deslizante no eixo central do colo está condicionado a diâmetro mínimo de 34 mm do colo femoral. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Todos os direitos reservados.

Introduction The transtrochanteric fractures correspond to extracapsular fractures of the proximal femur included between the greater and lesser trochanters.1,2 Of the annual 250,000 proximal femoral fractures in the U.S.A., 25% are transtrochanteric.3,4 Each year, in developed countries this lesion affects one in every 1000 people. It is estimated that in 2050 the incidence will be three times higher3,5 and the annual cost of US$ 8 billion will be duplicated.3,6 Thus, worldwide these fractures are considered as a major public health problem.1,2 These are the most frequent fractures, with higher associated mortality rate (12–41% in the first six months),7 and 90% of them, arising from low-energy trauma, occur in patients older than 65 years.8 Usually, the treatment is surgical. Only exceptionally the procedure will be conservative in patients with comorbidities that contraindicate anesthesia, surgery, or both.1,8,9 It is essential that the stability of the fracture be determined, so that the surgeon can properly choose the method to be employed. Unstable fractures are those lesions involving the posteriormedial cortex and that feature reverse trace or subtrochanteric extension.1,8 Recently, the critical importance of the lateral cortex in regional stability was recognized.10–13 In stable fractures, the implant of choice is the sliding hip screw (DHS); however, because of the biomechanical advantages of intramedullary location, cephalomedullary implants have been advocated for the treatment of unstable fractures.1,14–17 Both for DHS and for cephalomedullary pins, placing the sliding screw in the correct position is crucial to the success of osteosynthesis. The method of Baumgartner corresponds to the parameter of good positioning currently more accepted.1 Anatomical characteristics of certain populations and factors related to the experience of the surgeon were

related to a placement not always considered “ideal” for these implants.18–20 In the evolution process of cephalomedullary pins, the anti-rotational device evolved in order to provide additional stability to the system, both at the time of its implementation and in maintaining the reduction until the consolidation. However, the presence of an anti-rotational device is related to early complications arising from its position, and later, like as a “Z effect.”1,21 The present study aimed to analyze the influence of the use of anti-rotational device in cephalomedullary pins used in our institution in the average displacement of the sliding screw in its positioning along the central axis of the femoral neck. Furthermore, our study aims to determine the percentage of patients whose tip-apex distance was beyond the recommended measure, and the relation of minimum diameter of femoral neck for implant positioning.

Materials and methods The study was submitted to and approved by the Ethics and Research Committee of Hospital do Servidor Público Estadual de São Paulo (HSPE). All patients signed an informed consent to participate. From January to December 2011, a case series comprised of 58 patients admitted to the emergency room of the HSPE with preoperative radiographic diagnosis of unstable proximal femur fracture was prospectively analyzed. The participants were evaluated for age, gender, and fracture classification. According to the classification of Tronzo,13 fractures type III, variant III, IV and V (Fig. 1) were considered unstable. In the osteosynthesis, we employed the principle of relative stability, with the cephalomedullary tutor used in our institution. The surgical technique was common to all patients and consisted of an indirect reduction of the fracture and osteosynthesis in


r e v b r a s o r t o p . 2 0 1 4;4 9(1):17–24

Type I

Type II

Type III

Type III variant

Type IV

Type V

Fig. 1 – Tronzo’s classification.

orthopedic table by the closed focus technique, with the aid of fluoroscopy. We used pins with a distal diameter of 10 or 12 mm and with a single proximal diameter of 17 mm, mediolateral angle of 6◦ and cervicodiaphyseal angle of 130◦ between the neck and the intramedullary nail screws. The choice of implant was taken after preoperative planning, according to the cervicodiaphyseal angle of the proximal end of the contralateral femur and the diameter of the medullary diaphyseal region. All patients received antithrombotic and antibiotic prophylaxis. Two cases were excluded because, during the operation, it was decided not to use the anti-rotational device. These

19

patients were considered only in the assessment of gender, age and Tronzo’s classification. In the immediate post-operative period, plain digital radiographies (anteroposterior [AP] and profile [P] views) of the pelvis and of the hip ipsilateral to the osteosynthesis were obtained, according to the standardization proposed by Polesello et al.22 In AP view, the patient was positioned supine with the legs in internal rotation of 15–20◦ and with the beam of X-rays directed at the midline just above the pubic symphysis. In Acelin’s profile view, the patient was positioned supine with 90◦ of flexion of the contralateral hip, with the X-ray tube angled at 45◦ cranially in the horizontal plane, toward the root of the affected thigh (Fig. 2). With the use of filing and transmission system Impax® (version 6.3.1.7501, AGFA Health Care NV), the measures (in millimeters) of the diameter of the femoral head at its greatest axis, diameter of the neck in its smaller thickness (AB), angle of reduction, distance between the center of the sliding screw and the top edge of the anti-rotational device (ZX), and distance from the center of the sliding screw to the inferior margin of the neck (XB) were digitally obtained in the AP position. The central axis of the neck was determined using the midpoint of the smaller thickness of the femoral neck (AB). The distance from the tip of the screw to the apex of the femoral head was assessed in AP and P (Tip Apex Distance, TAD) views, according to Baumgartner and Solbert method. Fig. 3 shows schematically the points of reference used for these measurements, and Fig. 4 demonstrates the use of digital tools of the Impax® program for obtaining the aforementioned measures. The value of ZX (15 mm) is constant and supplied by the manufacturer. Such information was confirmed in an implant sample with the use of a universal caliper (Fig. 5). To ensure reliability of the data obtained, we applied as individual correction factor for each measurement made the relation of the measurement of ZX obtained on the digital radiography versus value provided by the manufacturer. Considering as ideal the positioning of the sliding screw on the central axis of the neck, we examined the feasibility of this positioning in our sample with the analysis of the minimum neck diameter required and its relation to the size of ZX. Then, we attributed the minimum distance of 2 mm from each

Fig. 2 – Standard positioning for AP and P radiographs.


20

r e v b r a s o r t o p . 2 0 1 4;4 9(1):17–24

B'

Z

X

A

B

Fig. 5 – True measure of distance ZX, with universal caliper.

Fig. 3 – Reference points for the proposed measures. AB: diameter of the femoral neck in its smaller thickness. AB : radius of the femoral neck. X: axis of sliding screw. Z: line tangent to the upper edge of the anti-rotational device. ZX: distance from the axis of the screw to the upper edge of the anti-rotational device.

osseous margin and determined the equation: AB = (ZX + 2) 2. As the value of ZX corresponds to 15 mm, the minimum size of the femoral neck for such positioning is 34 mm. Then, we calculated the percentage of the sample in which the positioning here considered as ideal could be obtained. We measured the average separation of the sliding screw in relation to the central axis of the neck in situations where an optimum positioning cannot be achieved. The analyses of the quantitative variables were evaluated statistically with respect to the mean, median, standard

Fig. 4 – Use of Impax® for the taking of measures. (A) AP radiograph of the pelvis, as described. (B) Diameter of the neck and head. (C) Angle of reduction. (D) TAD in AP. (E) TAD in PF. (F) Distance ZX.


21

r e v b r a s o r t o p . 2 0 1 4;4 9(1):17–24

Table 1 – Age distribution by gender. Gender

Mean

Median

Standard deviation

Minimum

Age F M

81.83 77.07

84.00 77.00

10.23 6.23

48.00 68.00

Maximum

P value

97.00 90.00

0.0743

Table 2 – Association between gender and Tronzo’s classification (P = 0.7744). Tronzo

Gender

Total

F

M

N

%

N

%

N

%

III IV V

24 5 13

57.1 11.9 31.0

9 1 6

56.3 6.3 37.5

33 6 19

56.9 10.3 32.8

Total

42

100.0

16

100.0

58

100.0

Table 3 – Intraoperative parameters related to the reduction and implant positioning. Gender

Mean

Angle of reduction (AP) 130.05 F 129.40 M TAD F M

19.70 21.67

Median

Standard deviation

Minimum

Maximum

P value

132.00 131.00

10.42 9.81

108.00 108.00

158.00 144.00

0.8755

20.10 21.90

6.82 6.82

1.90 2.40

38.50 30.00

0.2401

deviation, minimum, and maximum. In the comparison between the genders, we applied the nonparametric Wilcoxon test. The qualitative variables were evaluated for distribution of absolute and relative frequencies, and their associations were tested by Pearson Chi-square test or Fisher exact test, when the approximation of the first test was not appropriate. The significance level used in these tests was 5%, and optional two-tailed hypotheses always were considered.

Results Of the 58 patients in the series, 42 (72.4%) were women and 16 (27.6%) men. In the analysis of the age distribution, most of the study patients were between the eighth and ninth decades of life, and there was no statistically significant difference in the comparison between genders (Table 1).

Regarding the classification of the fracture and according to Table 2, 33 (56.9%) patients were grouped as Tronzo III, six (10.4%) as Tronzo IV, and 19 (19.8%) as Tronzo V. The associative analysis between Tronzo’s classification and gender revealed no statistically significant difference. With the help of standard X-rays, we obtained data concerning the angle of reduction achieved during the intraoperatory period and the implant positioning; no statistical significance was demonstrated when comparing gender, according to Table 3. Regarding the TAD, it was observed that in 46 cases (82.15%) the values were smaller than 25 mm, thus being considered ideal. A comparison of neck and head diameter values of the selected patients showed statistically significant differences between genders, which also occurred for the measure of Z X (Table 4).

Table 4 – Diameter of femoral head and neck obtained according to gender. Gender

Mean

Median

Standard deviation

Minimum

Maximum

P value

Head (AP) F M

49.41 53.05

50.00 54.40

3.04 4.45

43.80 43.60

55.10 58.80

0.0084

Neck (AB) F M

34.69 37.23

34.30 38.00

2.99 4.19

28.90 26.70

41.80 43.10

0.0086

Z X (implant) F M

16.75 15.42

16.80 15.50

1.85 1.65

11.90 11.60

22.00 17.70

0.0192


22

r e v b r a s o r t o p . 2 0 1 4;4 9(1):17–24

Table 5 – Spreadsheet with values obtained after applying the individual correction of measurement factor. Nr.

Age

1 2 3 4 5 6 7 8 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 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58

85 78 74 48 89 97 70 77 79 89 78 94 92 90 80 85 92 79 92 74 93 87 73 63 69 79 80 86 75 90 64 92 84 91 77 87 77 86 66 72 76 74 70 95 90 81 68 73 82 78 90 75 85 87 84 72 81 80

Gender

AB

 reduction

AB

ZX

Correction factor

TAD

Tronzo

Neck

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

42 33 31 35 36 35 33 43 35 33 35 34 40 40 41 36 37 37 32 35 39 30 30 29 41 42 39 34 38 38 33 37 33 31 30 33 38 36 33 37 39 34 39 34 34 33 35 37 31 33 35 27 32 35 37 37 38 34

139 121 147 158 141 140 141 142 136 131 144 117 115 131 135 115 136 140 108 125 133 125 110 122 123 119 143 130 127 126 132 119 139 113 135 121 120 122 137 128 134 135 134 123 127 116 134 125 132 133 124 108 132 123 125 136 142 138

20.9 16.5 15.3 17.5 18 17.7 16.6 21.6 17.7 16.7 17.3 16.8 20 19.8 20.5 17.9 18.6 18.7 15.8 17.5 19.4 15.1 15.2 14.5 20.7 20.8 19.3 17.2 19 18.8 16.3 18.3 16.7 15.3 14.8 16.5 19.2 17.8 16.5 18.6 19.5 16.9 19.7 17.2 16.9 16.7 17.7 18.7 15.7 16.5 17.4 13.4 16 17.7 18.4 18.7 19 16.8

22 20.5 20.6 17.1 15.8 15.3 17.2 15.2 16.1 15.4 12.8 17.5 16 16.5 18 20.8 17.5 16.7 16.8 18 11.9 15.3

1.466666667 1.366666667 1.373333333 1.14 1.053333333 1.02 1.146666667 1.013333333 1.073333333 1.026666667 0.853333333 1.166666667 1.066666667 1.1 1.2 1.386666667 1.166666667 1.113333333 1.12 1.2 0.793333333 1.02 0 1.186666667 1.133333333 1.006666667 1.026666667 1.16 1.033333333 1.16 0.926666667 1.146666667 1.066666667 1.086666667 1 1.033333333 1.133333333 1.013333333 0.993333333 0.773333333 1.18 1.1 0.98 1.166666667 1.12 1.126666667 0.973333333 1.126666667 1.053333333 1.073333333 0 1.14 1.02 1.073333333 1.12 1.053333333 0.973333333 1.186666667

17.9 20.1 13.3 12.6 20.2 18.6 20.3 19.7 19.7 18.6 16.2 12.2 11 24.8 23 22.5 17.6 22 22 26 21 29.1 28.3 15.4 26.3 30 20.1 25.3 24.7 29.3 16.3 29 15.3 19.5 14.1 17 20.1 23.2 30 21.9 2.4 24.6 28.4 1.9 16.9 23.2 21 13 17.5 38.5 20.1 28.9 20.3 18.6 24 20 24.5 32

V III III III III III V V V V V III III V V III IV IV III V III III IV III IV III III IV III III III III III III V III V V IV III III V III V III III III V V V III V III III III III III V

28.5 24.07 22.28 30.61 34.08 34.7 23.09 42.53 31.21 32.53 40.54 28.71 37.5 35.9 34.16 25.74 31.81 33.59 28.12 29.16 27.54 30 Excluded 24.35 36.52 41.32 37.59 29.65 36.67 32.41 34.74 31.83 31.31 28.06 29.6 31.93 33.79 35.03 33.12 47.97 33.05 30.72 40.1 29.4 30.08 29.64 36.26 33.19 28.71 30.74 Excluded 23.42 31.37 32.88 32.76 35.5 39.04 28.23

Applying the correction factor for each individual measurement, values taken as real were obtained. These values are shown in Table 5. Given the corrected diameter of the femoral neck, it was found that an ideal positioning would be

17.8 17 15.1 15.4 17.4 15.5 17.4 13.9 17.2 16 16.3 15 15.5 17 15.2 14.9 11.6 17.7 16.5 14.7 17.5 16.8 16.9 14.6 16.9 15.8 16.1 17.1 15.3 16.1 16.8 15.8 14.6 17.8

possible in 19 patients with CI (95%) = 21.8%; 47.8% (Table 6). For those cases in which the position of the sliding screw could not be ideal, the mean inferior separation value (XB) found with relation to the central axis was 4.06 (Table 7).


23

r e v b r a s o r t o p . 2 0 1 4;4 9(1):17–24

population is of lower stature than that of the European subjects, the length of the proximal femur and the diameter of the femoral neck are also smaller, which leads to the inappropriate positioning of the cephalomedullary pin’s spiral blade used in the study, or to redundancy of the proximal end of the pin. In the utilization of the cephalomedullary pin used in our service, the minimum diameter for an optimal placement is 34 mm, which corresponds to twice the Z X measure, taking into account a thickness of cortical (top and bottom) of 4 mm. In our series, in only 19 patients (32.8%) the placement of the sliding screw could be performed in the situation regarded as ideal by our methodology. Extrapolating the confidence interval for the Brazilian population, only in 21.8–47.8% of patients in 95% of the time the implant could be placed optimally (i.e., the center of the sliding screw located along the central axis of the neck). According to Baumgaertner et al.,15 the correct implant placement occurs when the distance between the tip of the sliding screw and the femoral head center does not exceed 25 mm after the sum of the values obtained on anteroposterior and profile views (tip-apex index, or TAD <25 mm). This facilitates the telescoping of the dynamic system of the implant and reduces the risk of cutout.9 Although described for osteosynthesis with DHS, the method can be used to assess the correct positioning of the cephalomedullary pins.1 However, in pins with two proximal fixation screws, there is difficulty in the positioning of the sliding screw in the center of the femoral head in the anteroposterior view. Thus, there is a greater tendency for the positioning of the sliding screw in a more inferior location in the AP radiographic view, particularly in patients with short femoral neck and head.21 The location of the screws in the profile position is not affected, since the screws are parallel. In the osteosynthesis using the cephalomedullary pin in question, the mean displacement necessary for the introduction of the nail without violating the anti-rotational upper cortical neck was of 4.6 mm (i.e., the amount of downward displacement of the system, in millimeters, from the axis of the femoral neck). To calculate the required displacement of the sliding screw relative the central axis of the neck in situations where this option is not possible, the following formula: = displacement required = 34 mm − neck size (AB) was applied.

Table 6 – Percentage of patients whose placement of the system could be ideal. Ideal possible?

Nr.

%

% valid

Not Yes Total Excluded Total

37 19 56 2 58

63.8 32.8 96.6 3.4 100.0

66.1 33.9 100.0

Discussion The treatment of unstable transtrochanteric fractures with use of cephalomedullary pins presents biomechanical advantages due to its intramedullary location, such as reducing the bending moment, better rotational control, shortening, and collapse in varus.1,14–17 Although controversial, there are reports of superiority of cephalomedullary pins versus DHS in relation to early return to ambulation, reduced surgical time, and less blood loss.1,8,19 Thus, at our institution cephalomedullary pins are applied in the treatment of unstable fractures.1 Regarding the epidemiological findings observed in the present study, there is a vast literature attesting the female predominance and an age close to 80 years in other series.1,9,18,21,23 This reflects the decrease in bone mineral density. We found no statistically significant difference between the ages of male and female patients. Although the pattern fracture of reverse obliquity (Tronzo V or AO 31 A3) has been reported as the most frequent type in some case series of unstable fractures,9,24 most studies have described as the most prevalent types those classified as Tronzo III or IV (or AO 31 A2),1,18,25,26 which agrees with our results. When comparing males and females, we found no statistically significant differences in relation to fracture type according to the classification of Tronzo. According to Werner-Tutschku et al.,27 the main predictor of the cutout is unsatisfactory initial reduction, especially in varus, besides favoring Trendelenburg gait. We found a mean value of 130.5◦ for men (with a standard deviation of 10.42) and 129.40◦ (9.81) for women, and this assessment was not statistically significant. These findings are similar to those found in another study with unstable transtrochanteric fractures.1 There was a statistically significant difference in the comparison between male and female genders in the measurements related to diameter of the head and neck. When comparing the bone structure of the neck in young and elderly subjects of Chinese and Caucasian origin, Wang et al.28 showed that male subjects have larger diameters, that this value tends to increase with age, being higher in populations of white origin. According to Pu et al.,18 as the Chinese

Conclusion Considering the mean diameter of the neck in our sample, the positioning on the central axis of the neck would not be possible for the majority of the population. Considering the implant studied, the minimum size of the neck which allows positioning the central axis is 34 mm.

Table 7 – Displacement of the system in relation to the central axis. Mean

Standard deviation

CI (95%) Inf. thres.

Neck corrected

4.06

2.95

3.07

Median

Q25

Q75

Minimum

3.91

1.59

5.29

0.21

Maximum

Sup. thres. 5.04

11.72


24

r e v b r a s o r t o p . 2 0 1 4;4 9(1):17–24

In situations where the positioning in the central axis is not possible due to the minimal size of the neck, the downward displacement required can be calculated by the formula: displacement required = 34 − neck size (AB).

Conflicts of interest The authors declare no conflicts of interest.

references

1. Borger RA, Leite FA, Araújo RP, Pereira TFN, Queiroz RD. Avaliac¸ão prospectiva, radiográfica e funcional do tratamento das fraturas trocantéricas instáveis do fêmur com haste cefalomedular. Rev Bras Ortop. 2011;46(4):380–9. 2. Guimarães FAM, Lima RR, Souza AC, Livani B, Belangero WD. Avaliac¸ão da qualidade de vida em pacientes idosos um ano após o tratamento cirúrgico de fraturas transtrocanterianas do fêmur. Rev Bras Ortop. 2011;46 Suppl. 1:48–55. 3. Kyle RF. Fractures of the proximal part of the femur. J Bone Joint Surg Am. 1994;76(6):924–50. 4. Fratura transtrocanteriana. Rev Assoc Med Bras. 2009;55:637–40, http://dx.doi.org/10.1590/S0104-42302009000600004. Available from: http://www.scielo.br/scielo.php?script=sci arttext&pid= S0104-42302009000600004&lng=en&nrm=iso [accessed 08.05.13]. 5. Haidukewych GJ. Intertrochanteric fractures: ten tips to improve results. J Bone Joint Surg Am. 2009;91(3):712–9. 6. Cummings SR, Rubin SM, Black D. The future of hip fractures in the United States Numbers, costs, and potential effects of postmenopausal estrogen. Clin Orthop Relat Res. 1990;(252):163–6. 7. Russel TA. Intertrochanteric fractures. In: Bucholz RW, Heckman JD, Court-Brown CM, Tornetta 3rd P, editors. Rockwood and Green’s fractures in adults. Philadelphia: Lippincott Williams & Wilkins; 2010. p. 1597–640. 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. Guimarães JAM, Guimarães ACA, Franco JS. Avaliac¸ão do emprego da haste femoral curta na fratura trocantérica instável do fêmur. Rev Bras Ortop. 2008;43(9):406–17. 10. Kulkarni GL, Kulkarni M, Kulkarni S. Intertrochanteric fractures. Indian J Orthop. 2006;40(1):16–23. 11. Gotfried Y. The lateral trochanteric wall. Clin Orthop Relat Res. 2004;425:82–6. 12. Müller ME. Classification and international AO-documentation of femur fractures. Unfallheilkunde. 1980;83(5):251–9. 13. Tronzo RG. Symposium on fractures of the hip Special considerations in management. Orthop Clin N Am. 1974;5(3):571–83.

14. Schipper IB, Steyerberg EW, Castelein RM, van der Heijden FH, den Hoed PT, Kerver AJ, et al. Treatment of unstable trochanteric fractures randomised comparison of gamma nail and the proximal femoral nail. J Bone Joint Surg Br. 2004;86(1):86–9. 15. Baumgaertner MR, Curtin SL, Lindskog DM. Intramedullary versus extramedullary fixation for the treatment of intertrochanteric hip fractures. Clin Orthop Related Res. 1998;(348):87–9. 16. Bridle SH, Patel AD, Bircher M, Calvert PT. Fixation of intertrochanteric fractures of the femur. A randomized prospective comparison of the gamma nail and the dynamic hip screw. J Bone Joint Surg Br. 1991;73(2): 330–4. 17. Schipper IB, Bresina S, Wahl D, Linke B, van Vugt AB, Schneider E, et al. Biomechanical evaluation of the proximal femoral nail. Clin Orthop Related Res. 2002;(405): 277–86. 18. Pu JS, Liu L, Wang GL, Fang Y, Yang TF. Results of the proximal femoral nail anti-rotation (PFNA) in elderly Chinese patients. Int Orthop. 2009;33(5):1441–4. 19. Gadegone WM, Salphale YS. Short proximal femoral nail fixation for trochanteric fractures. J Orthop Surg. 2010;18(1):39–44. 20. Heinert G, Parker MJ. Intramedullary osteosynthesis of complex proximal femoral fractures with the Targon PF nail. Injury. 2007;38(11):1294–9. 21. Kawatani Y, Nishida K, Anraku Y, Kunitabe K, Tsutsumi Y. Clinical results of trochanteric fractures treated with the Targon® proximal femur intramedullary nailing fixation system. Injury. 2011;42(Suppl 4):S22–7. 22. Polesello GC, Nakao TS, Queiroz MC, Daniachi D, Ricioli Junior W, Guimaraes RP, et al. Proposta de padronizac¸ão do estudo radiográfico do quadril e da pelve. Rev Bras Ortop. 2011;46(6):634–42. 23. Hungria Neto JO, Dias CR, Almeida JDB. Características epidemiológicas e causas da fratura do terc¸o proximal do fêmur em idosos. Rev Bras Ortop. 2011;46(6):660–7. 24. Ertürer RE, Sönmez MM, Sari S, Sec¸kin MF, Kara A, Öztürk I. Intramedullary osteosynthesis of instable intertrochanteric femur fractures with Proflim® nail in elderly patients. Acta Orthop Traumatol Turc. 2010;46(2):107–12. 25. Chou DT, Taylor AM, Boulton C, Moran CG. Reverse oblique intertrochanteric femoral fractures treated with the intramedullary hip screw (IMHS). Injury. 2012;43(6):817–21. 26. Sahin S, Ertürer E, Öztürk I, Toker S, Sec¸kin F, Akman S. Radiographic and functional results of osteosynthesis using the proximal femoral nail antirotational (PFNA) in the treatment of unstable intertrochanteric femoral fractures. Acta Orthop Traumatol Turc. 2010;44(2):127–34. 27. Werner-Tutschku W, Lajtai G, Schmiedhuber G, Lang T, Pirkl C, Orthner E. Intra-and perioperative complications in the stabilization of per-and subtrochanteric femoral fractures by means of PFN. Unfallchirurg. 2002;105(10):881–5. 28. Wang XF, Duan Y, Beck TJ, Seeman E. Varying contributions of growth and ageing to racial and sex differences in femoral neck structure in old age. Bone. 2005;36(6):978–86.


r e v b r a s o r t o p . 2 0 1 4;4 9(1):25–30

www.rbo.org.br

Original Article

Results of open reduction and internal fixation of severe fractures of the proximal humerus in elderly patients夽,夽夽 Alberto Naoki Miyazaki, Marcelo Fregoneze, Pedro Doneux Santos, Luciana Andrade da Silva ∗ , Guilherme do Val Sella, João Manoel Fonseca Filho, Marco Tonding Ferreira, Paulo Roberto Davanso Filho, Sergio Luiz Checchia Department of Orthopaedics and Traumatology, Faculdade de Ciências Médicas, Santa Casa de São Paulo, São Paulo, 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 clinical and radiological results with open reduction and internal

Received 22 March 2013

fixation of severe fractures of the proximal humerus in the patients over the age of 60 years.

Accepted 20 May 2013

Methods: Between June 1992 and February 2011, 21 patients with FGEPU over the age of 60 years were treated by open reduction and internal fixation at the Group of Shoulder and

Keywords:

Elbow Department of Orthopaedics and Traumatology of Santa Casa de São Paulo Medical

Humeral fractures

School. 18 patients were reviewed.

Elderly

Results: Two patients had excellent results, 12 good, three regular and one bad. Therefore, we

Fracture fixation, internal

find that 77.7% of these had good and excellent results. All patients were satisfied with the

Avascular necrosis

treatment and only three patients did not return to previous activities. Mean postoperative mobilities were 122◦ elevation (90–150◦ ), 39 lateral rotation (20–60◦ ) and medial rotation of T11 (T5 to sacro iliac joint). Conclusion: Open reduction and internal fixation of FGEPU may also be indicated for elderly patients and obtained 77.7% of good and excellent results. Statistically (p < 0.05), the anatomical reduction of the fracture was found to be important for obtaining good results. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

Avaliac¸ão dos resultados da reduc¸ão aberta e da fixac¸ão interna das fraturas graves da extremidade proximal do úmero em idosos r e s u m o Palavras-chave:

Objetivo: avaliar clinica e radiologicamente os resultados obtidos com a reduc¸ão aberta e a

Fraturas do humero

fixac¸ão interna das fraturas graves da extremidade proximal do úmero (FGEPU) na populac¸ão

Idoso

com idade igual ou superior a 60 anos.

Fixac¸ão interna de fraturas

Métodos: entre junho de 1992 e fevereiro de 2011, o Grupo de Ombro e Cotovelo do Depar-

Necrose avascular

tamento de Ortopedia e Traumatologia da Faculdade de Ciências Médicas da Santa Casa de

Please cite this article as: Miyazaki AN, et al. Avaliac¸ão dos resultados da reduc¸ão aberta e da fixac¸ão interna das fraturas graves da extremidade proximal do úmero em idosos. Rev Bras Ortop. 2014;49:25–30. 夽夽 Study conducted at Group of Shoulder and Elbow, Department of Orthopaedics and Traumatology of Santa Casa de São Paulo Medical School, Santa Casa de São Paulo, São Paulo, SP, Brazil. ∗ Corresponding author. E-mail: lucalu01@me.com (L.A. da Silva). 2255-4971/$ – see front matter © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

http://dx.doi.org/10.1016/j.rboe.2014.01.002


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São Paulo tratou, com reduc¸ão aberta e fixac¸ão interna, 21 pacientes com FGEPU e com idade superior a 60 anos. Desses, 18 foram reavaliados. Resultados: dois pacientes evoluíram com resultados excelentes, 12 bons, três regulares e um ruim. Portanto, verificamos que 77,7% evoluíram com bons e excelentes resultados. Todos os pacientes estavam satisfeitos com o tratamento e apenas três não retornaram às atividades prévias. As médias de mobilidade pós-operatória foram de 122◦ de elevac¸ão (90◦ –150◦ ), 39◦ de rotac¸ão lateral (20◦ –60◦ ) e T11 de rotac¸ão medial (T5 a Glúteo). Conclusão: a reduc¸ão aberta e a fixac¸ão interna das FGEPU podem ser indicadas também para pacientes idosos e obtivemos 77,7% de bons e excelentes resultados. Estatisticamente (p < 0,05), a reduc¸ão anatômica da fratura mostrou-se importante para a obtenc¸ão de bons resultados. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Todos os direitos reservados.

Introduction Fractures of the proximal end of the humerus in four parts and fracture-dislocations in three parts are characterized by loss of joint congruity and severe impairment of vascularity of humeral head.1,2 The epiphyseal fractures, that compromise the head of humerus, are infrequent, being caused by an impact against the glenoid cavity; these lesions are associated with injury to the humeral head blood supply or their fragments and, therefore, are difficult to treat and its evolution is accompanied by high complication rates.2,3 Those aforementioned injuries (excluding fractures in four parts impacted in valgus) are called severe fractures of the proximal humerus (SFPU). The four-part fractures impacted in valgus were excluded because, according to Jakob et al.4 and later Resch et al.,5 preserve intact the medial periosteum of the anatomical neck, and this is essential for maintaining the vascularization of the humeral head, which would explain the lower rate of osteonecrosis.5,6 Some studies have attempted to demonstrate the benefits and disadvantages of the treatment options of four-part fractures and fracture-dislocations in three parts, but what is the best way to treat? This remains challenging and controversial.7–9 In the literature, there are descriptions of several methods of treatment, including conservative ones, and different types of surgical techniques, such as percutaneous fixation, open reduction and internal fixation with various types of synthesis, and the replacement of humeral head.10–12 The natural history of the treatment of these fractures suggests that they can evolve to nonunion, pseudoartrosis and/or avascular necrosis,13 leading to unsatisfactory results. The occurrence of persistent pain and stiffness, regardless of treatment chosen, is common.8,9,11,14 Helmy and Hinterman15 claim that, in the literature, there is no unanimity of opinion as to the best method of treatment of these fractures. The only apparent consensus is about the importance of an anatomical reduction and of a stable osteosynthesis.12,16 In the elderly population, the treatment of these lesions remains even more controversial. Internal fixation of these fractures, especially in patients with osteopenia and in those with comminuted fractures, resulted in high complication rates.10,16–18 For these patients, hemiarthroplasty remains the treatment of choice, because of the anatomical and technical

difficulties in its maintenance1,4,5,10,19 and of the high complication rates, such as post-traumatic osteonecrosis of the humeral head.17,20 However, it is known that the functional outcome of hemiarthroplasties for the treatment of fractures is unsatisfactory, as compared with the initial descriptions of Neer.5,6 Usually, patients develop loss of lift force and decreased range of motion, despite the low incidence of pain.5,10 It is important to remember that sometimes the osteonecrosis of the humeral head will not evolve with unfavourable clinical and functional outcomes, especially in the case of an anatomical reconstruction of the fracture and in the absence of a complete collapse of the subchondral bone due to osteonecrosis.13 The objective of this study is to evaluate clinically and radiographically the results obtained with open reduction and internal fixation of SFPU in a population aged over 60 years.

Patients and methods Between June 1992 and February 2011, 21 patients older than 60 years with SFPU were treated with open reduction and internal fixation at the Group of Shoulder and Elbow, Department of Orthopaedics and Traumatology, Faculty of Medical Sciences, Santa Casa de São Paulo. Of these, two died and one is bedridden, so 18 were reassessed. Patients with fractures in two parts, in three parts without associated dislocation, in four-part impacted in valgus and those not classified by Neer were excluded.20 Also excluded were those patients who were less than 60 years of age and who underwent hemiarthroplasty with postoperative follow-up <12 months. Eight patients were male (44%) and ten females (56%), with a mean age of 68 years (range 60–78). The dominant limb was affected in nine cases (50%) (Table 1). The mechanisms of injury were: falls from a height in three cases (17%) and falls to the ground in fifteen (83%). All patients underwent radiographs of the shoulder (trauma series), for diagnosis and classification of fractures; computed tomography was used in ten cases to complement the study. The fractures were classified according to Neer,20 as shown in Table 2. Four patients (22%) had associated injuries: anterior border of the glenoid cavity (case 16) fracture; fracture of the


27

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Table 1 – Demographic data of patients, classification of fractures, associated injuries, fracture reduction and fixation type. Nr

G

Age

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

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

62 65 77 75 70 62 64 74 66 77 65 64 60 69 64 65 72 78

D

+ +

+

+ + + + + +

Class E (4P) 4P – vr E (3P) E (4P) E (3P) E (3P) 4P – vr 4P – vr 4P – vr E (4P) 4P – vr 4P – vr 4P – vr E (3P) 3P – ant. disl. 3P – ant. disl. 4P – vl 4P – vr

T (days) 3 5 7 7 19 13 21 3 4 3 15 19 9 14 6 18 17 4

Associated injuries

fract. post. border glen.

Rotator cuff injury

Lesion of Bankart fract. Ant. border glen.

Operation tw + sut + gr (aut) Philos® tw + sut Philos® Philos® Philos® Philos® tw + sut Philos® PhiloS® + gr (sin) Philos® tw + sut tw + sut tw + sut Interfragmentary screw Philos® tw + sut tw + sut

Reduction anat. vr vr vl (T↑) anat. vr vl anat. anat. anat. vr (T↑) anat. vl anat. anat. vr vr (T↓) vl (T↑)

G, gender, Age, age, D, dominance, class, classification of Neer; T, time interval between trauma and surgery, M, male; F, female; E, epiphyseal fracture associated; 3P, fracture into three parts; 4P, fracture into four parts; anat., anatomic reduction; vr, varus deviation, vl, valgus deviation; ant. disl., anterior dislocation associated; fract., fracture;. Glen., glenoid;. post., posterior; ant., anterior; tw, threaded wires, gr (sin), synthetic graft; gr (aut), autograft; sut, suture with transosseous points of greater/lesser tuberosity, T, reduction of greater tuberosity (↓ - low; ↑ - high). Source: Hospital Medical File.

posterior border of the glenoid cavity (case 4); lesion of the anterior–inferior lip of the glenoid cavity, diagnosed intraoperatively (case 15); and rotator cuff injury (case 10) (Table 1). The mean time interval between trauma and surgery was 10 days (range 3–21) (Table 1). The surgical method of choice was open reduction and internal fixation by deltopectoral approach, with the most atraumatic surgical technique possible. The fixation methods varied according to the type of fracture: threaded wires associated with nonabsorbent suture band nr. 5 (Ethibond® ) (eight cases), locked plate (Philos® ) (nine cases) and interfragmentary screws (one case). Autologous cancellous bone graft from the iliac crest was used in one case (case 1) (Table 1). In the postoperative period, Velpeau sling immobilization was applied, with permission to exercise only for elbow and wrist for six to eight weeks, depending on the radiographic

Table 2 – Distribution of fractures according to Neer classification. Neer classification Fract. disl. anterior 3P Fract. 4P Epifisary

Total w/fract. tub > w/fract. tub < vl deviation of head vr deviation of head fract. 3P epifisary trait fract. 4P epifisary trait Total

2 – 1 8 4 3 18

Fract. disl, fracture-dislocation; 3P, three parts, w/, with; fract. fracture; tub., tuberosity (< - less; > - larger); 4P, four parts; vl, valgus; vr, varus; head, humeral head. Source: Hospital Medical File.

fracture union. After evidence of consolidation, the patients began passive exercises to gain range of motion (ROM), and at 12 weeks active exercises to gain muscle strength. The results were evaluated by a score system defined by University of California at Los Angeles (UCLA)21 and ROM was measured according to American Academy of Orthopaedic Surgeons (AAOS) criteria.22 The classification of Ficat et al. and Enneking et al., modified by Neer et al., was used for evaluation of osteonecrosis of the humeral head, when present.23 Statistical analysis was performed using the Fisher exact test. The following variables were calculated: end result of UCLA by type of fracture, age, type of reduction, for presence or absence of osteonecrosis, and for presence or absence of arthrosis. Also the following were statistically analyzed: age, depending on the type of fracture and presence or absence of osteonecrosis, as well as the variables “reduction depending on the type of fracture and of fixation”, and “osteonecrosis according to the type of fixation and reduction”. The analyses were performed with the aid of statistical software Minitab® version 16. A significance level of 5% for all tests of hypothesis was adopted; therefore, the hypotheses with a significance level (p value) <0.05 were rejected.

Results With an average time of postoperative follow-up of 53 months (range 12–188), it was found that the mean score of UCLA was 29 points (range 19–35; Table 3); two patients evolved with excellent results, 12 good, three regular and one poor. Therefore, 77.7% progressed with good and excellent results. All patients were satisfied with the treatment and only three (16%) did not return to their previous activities.


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Table 3 – Results. Nr 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

T (months) 45 28 17 28 29 29 36 12 12 17 29 188 183 109 107 29 18 45

E, LR, MR 140, 45, T10 130, 45, T12 90, 30, GL 100, 20, L2 120, 30, T7 80, 20, T8 130, 30, T12 150, 45, T7 140, 60, T8 150, 60, T12 110, 30, GL 150, 45, T8 150, 30, T5 130, 60, T7 110, 50, L2 90, 30, GL 120, 45, L3 110, 30, L4

Complications

Other surgeries

UCLA (total)

RSM

34 29 26 28 29 19 29 30 29 33 24 35 33 33 26 30 31 30

RSM Necrosis II Arthrosis (ecc.) + Necrosis IV

RSM RSM

Arthrosis (cent.) + Necrosis III RSM RSM RSM Necrosis II RSM RSM

T, follow-up time; E, elevation in degrees; LR, lateral rotation in degrees; MR, medial rotation according to vertebral level; T, thoracic vertebra; GL, gluteus; cent., centric; ecc., eccentric, RSM, removal of synthesis material. Source: Hospital Medical File.

Mean postoperative mobility was 122◦ of elevation (90–150◦ ), 39◦ of lateral rotation (20–60◦ ) and T11 of medial rotation (T5-gluteus) (Table 3). After the analysis of postoperative radiographs, the results of fracture reduction obtained during surgery were: anatomical reduction in eight (44%), varus in six (33%) and valgus in four (23%). The greater tuberosity remained high in three cases (cases 4, 11 and 18) and low in one (case 17). Consolidation occurred in all fractures. The observed complications were: two cases of transient neuropraxia of the axillary nerve (11%, cases 5 and 6), two superficial infections (11%, cases 17 and 18), one with impingement syndrome associated with malunion of the greater tuberosity (5%, case 18), two with osteoarthritis of the shoulder in association with osteonecrosis (11%, cases 6 and 11),

six varus consolidations as a result of unsatisfactory reduction (39%, cases 2, 3, 6, 11, 16 and 17), a poor placement of the implant (5%, case 6), four with osteonecrosis of the humeral head: two of type II (cases 4 and 15), one of type III (case 11) and one of type IV (case 6), which amounted to 22% of patients (Table 3). The mean UCLA score of the two shoulders that developed arthrosis was 21 (19–24) points, with mean elevation of 95◦ . In the four cases which developed osteonecrosis of the humeral head, the mean score was 24 (19–29) points and the mean elevation was 105◦ . In the 12 cases which did not develop osteoarthritis and/or necrosis, the mean score was 30 (28–35) points, with a mean elevation of 130◦ . In patients in whom we obtained anatomical reduction of the fracture, the UCLA mean score was 31 (28–35) points, with mean elevation of 138◦ , and

Fig. 1 – Case 5: Radiographs of left shoulder (frontal view), showing a three-part fracture with epiphyseal trait; (a) preoperative, (b) postoperative, 29 months.


r e v b r a s o r t o p . 2 0 1 4;4 9(1):25–30

29

Fig. 2 – Case 3: Radiographs of the right shoulder (frontal view), showing a three-part fracture with epiphyseal trait; (a) preoperative, (b) postoperative, 17 months.

in those without anatomic reduction, the mean score was 27 (18–33) points, with a mean elevation of 111◦ .

Discussion In literature there is no consensus regarding the treatment of SFPU.12 In 1970, Neer et al. published their experience with the treatment of SFPU with use of hemiarthroplasty; these authors obtained good and excellent results in 90% of their patients.11 These results were not reproduced later by other authors, and high rates of complications and unsatisfactory results were observed.24–26 In recent decades, studies have shown that open reduction and internal fixation of SFPU led to satisfactory results in most patients. Age, type of fracture, achieving (or not) the reduction, reduction technique, quality of fixation, evolution with or without osteonecrosis of the humeral head, and evolution with or without arthritis in the shoulder joint are the main prognostic factors in treatment.12,13,27,28 The advanced age of patients who underwent open reduction and internal fixation of SFPU (mostly osteoporotic people) is quoted by Gerber et al.12 as a negative prognostic factor. However, in our study, no statistically significant correlation between age and worse outcomes by UCLA score (p = 0.23) was noted, which agrees with the findings of Moonot et al.29 The type of fracture, as described in the literature, influences the worst results, especially in the higher rates of complications related to more severe cases.27 However, in our study we could not correlate statistically fracture severity with worse outcomes (p = 0.33). Studies describe the importance of anatomic reduction of the fracture during surgery; and the best results were obtained in cases in which this objective was achieved and maintained until consolidation5,13,27 (Fig. 1). However, the achievement of this objective is dependent on factors such as type of fracture and type of fixation.12 In our study, non-anatomical reduction occurred in 11 cases. This factor influenced statistically

in the worst results, when compared with the cases in which anatomic reduction was achieved (p = 0.03). In recent years, studies have demonstrated that the quality of fixation is of utmost importance in the treatment of SFPU, mainly to maintain the reduction achieved during the surgery also in the postoperative period.12,16 However, in our study, when fixation methods (threaded wires associated with suture band or Philos® plate) were compared, there was no statistically significant difference with respect to the results by UCLA score (p = 0.33). Osteonecrosis of humeral head occurred in four patients (22%), a result slightly below the value reported in the literature.12,17,20 These four patients had the worst functional results (p = 0.006). Three cases were fixed with Philos® plate and one case with threaded wires associated with suture band. In three cases, anatomic reduction was not obtained (Fig. 2). However, with regard to the presence of osteonecrosis, the variables “type of fixation” and “fracture reduction” showed no statistically significant difference (p = 0.37 and p = 1.0); this is consistent with the findings of Südkamp et al.16 In our study, age and type of fracture were also not correlated with osteonecrosis (p = 0.67 and p = 0.26), which is consistent with the findings of Gerber et al.12 Our low rate of osteonecrosis of the humeral head can be explained by the group’s experience in the treatment of SFPU and by the use of the more atraumatic technique possible. Another explanation would be the difficulty to correctly classify the fractures according to Neer et al. classification,20 and this could cause a incorrectly greater number of SFPU. The interpretation of images of the proximal humerus fracture and, thus, its classification, are quite controversial.12 According to Gerber et al.,13 in fractures in which anatomic reduction was obtained and the bone healing progressed to osteonecrosis, there is an indication for hemiarthroplasty. However, it is known that patients who develop osteonecrosis may maintain a reasonable function.30 This was verified in our work, since the four patients who developed osteonecrosis had an average elevation of 105◦ and an UCLA mean score of


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24 points in the final evaluation. So far, none of these patients required arthroplastic treatment.

Conclusion Open reduction and internal fixation of SFPU may also be indicated for elderly patients. We obtained 77.7% of good and excellent results. Statistically (p = 0.03), an anatomic reduction of the fracture was found to be important for obtaining good results.

Conflicts of interest The authors declare no conflicts of interest.

references

1. Naranja RJ, Iannotti JP. Displaced three- and four-part proximal humerus fractures: evaluation and management. J Am Acad Orthop Surg. 2000;8(6):373–82. 2. Neer CS. Four-segment classification of proximal humeral fractures: purpose and reliable use. J Shoulder Elbow Surg. 2002;11(4):389–400. 3. Chesser TJS, Langdon IJ, Ogilvie C, Sarangi PP, Clarke AM. Fractures involving splitting of the humeral head. J Bone Joint Surg Br. 2001;83(3):423–6. 4. Jakob RP, Miniaci A, Anson PS, Jaberg H, Osterwalder A, Ganz R. Four part valgus impacted fractures of the proximal humerus. J Bone Joint Surg Br. 1991;73(2):295–8. 5. Resch H, Beck E, Bayley I. Reconstruction of the valgus-impacted humeral head fracture. J Shoulder Elbow Surg. 1995;4(2):73–80. 6. Resch H, Hübner C, Schwaiger R. Minimally invasive reduction and osteosynthesis of articular fractures of the humeral head. Injury. 2001;32(1):25–32. 7. Zyto K, Wallace WA, Frostick SP, Preston BJ. Outcome after hemiarthroplasty for three- and four-part fractures of the proximal humerus. J Shoulder Elbow Surg. 1998;7(2):85–9. 8. Kristiansen B, Christensen SW. Plate fixation of proximal humeral fractures. Acta Orthop Scand. 1986;57:320–3. 9. Paavolainen P, Bjorkenheim JM, Slatis P, Paukku P. Operative treatment of severe proximal humeral fractures. Acta Orthop Scand. 1983;54(3):374–9. 10. Resch H, Povacz P, Fröhlich R, Wambacher M. Percutaneous fixation of three- and four-part fractures of the proximal humerus. J Bone Joint Surg Br. 1997;79(2):295–300. 11. Neer CS. Displaced proximal humeral fractures II. Treatment of three-part and four-part displacement. J Bone Joint Surg Am. 1970;52(6):1090–103. 12. Gerber C, Werner CML, Vienne P. Internal fixation of complex fractures of the proximal humerus. J Bone Joint Surg Br. 2004;86:848–55. 13. Gerber C, Hersche O, Berberat C. The clinical relevance of posttraumatic avascular necrosis of the humeral head. J Shoulder Elbow Surg. 1998;7(6):586–90.

14. Robinson CM, Page RS. Severely impacted valgus proximal humeral fractures. Results of operative treatment. J Bone Joint Surg Am. 2003;85(9):1647–55. 15. Helmy N, Hintermann B. New trends in the treatment of proximal humerus fractures. Clin Orthop Relat Res. 2006;(442):100–8. 16. Südkamp N, Bayer J, Hepp P, Voigt C, Oestern H, Kääb M, et al. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Joint Surg Am. 2009;91(6):1320–8. 17. Robinson CM, Page RS, Hill RM, Sanders DL, Court-Brown CM, Wakefield AE. Primary hemiarthroplasty for treatment of proximal humeral fractures. J Bone Joint Surg Am. 2003;85(7):1215–23. 18. Mittlmeier TW, Stedtfeld HW, Ewert A, Beck M, Frosch B, Gradl G. Stabilization of proximal humeral fractures with an angular and sliding stable antegrade locking nail (Targon PH). J Bone Joint Surg Am. 2003;85 Suppl. 4:136–46. 19. Jakob RP, Kristiansen T, Mayo K, Ganz R, Müller ME. Classification and aspects of treatment of fractures of the proximal humerus. In: Bateman JE, Welsh RP, editors. Surgery of the shoulder. Philadelphia: B.C. Decker; 1984. p. 330–43. 20. Neer 2nd CS. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am. 1970;52(6):1077–89. 21. Ellman H, Kay SP. Arthroscopic subacromial decompression for chronic impingement. Two- to five-year results. J Bone Joint Surg Br. 1991;73(3):395–8. 22. American Academy of Orthopaedic Surgeons (AAOS). Joint motion: method of measuring and recording. Chicago: American Academy of Orthopaedics; 1965. 23. Neer CS. Glenohumeral arthroplasty in shoulder reconstruction. Philadelphia: Saunders; 1990. p. 143–272. 24. Bigliani LU, Flatow EL. Failed prostetic replacement for displaced proximal humeral fractures. Orthop Trans. 1991;15:747–8. 25. Tanner MW, Cofield RH. Prosthetic arthroplasty for fractures and fracture-dislocations of the proximal humerus. Clin Orthop Relat Res. 1983;(179):116–28. 26. Checchia SL, Doneaux P, Miyasaki AN, Fregonese M, Silva LA, Faria FN, et al. Tratamento das fraturas do terc¸o proximal do úmero com a prótese parcial Eccentra® . Rev Bras Ortop. 2005;40(3):130–40. 27. Ko JY, Yamamoto R. Surgical treatment of complex fracture of the proximal humerus. Clin Orthop Relat Res. 1996;(327):225–37. 28. Boileau P, Trojani C, Walch G, Krishnan SG, Romeo A, Sinnerton R. Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus. J Shoulder Elbow Surg. 2001;10(4):299–308. 29. Moonot P, Ashwood N, Hamlet M. Early results for treatment of three- and four-part fractures of the proximal humerus using the Philos plate system. J Bone Joint Surg Br. 2007;89(9):1206–9. 30. Hubert L, Dayez J. Results of the standard Aequalis prosthesis for proximal humeral fractures. In: Walch G, Boileau P, Molé D, editors. 2000 shoulder prostheses: two to ten year follow-up. Montpellier: Sauramps Medical; 2001. p. 527–9.


r e v b r a s o r t o p . 2 0 1 4;4 9(1):31–36

www.rbo.org.br

Original Article

Evaluation of surgical treatment of Dupuytren’s disease by modified open palm technique夽,夽夽 Thiago Almeida Guilhen ∗ , Ana Beatriz Macedo Vieira, Marcelo Claudiano de Castro, Helton Hiroshi Hirata, Itibagi Rocha Machado Instituto Jundiaiense de Ortopedia e Traumatologia, Jundiaí, 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 assess the surgical technique using the modified palm open technique for the

Received 11 March 2013

treatment of severe contractions of Dupuytren’s disease.

Accepted 20 May 2013

Methods: over a period of four years, 16 patients underwent surgical treatment, and in its entirety belonged to stages III and IV of the classification proposed by Tubiana et al. We per-

Keywords:

formed measurements of the extension deficit of the metacarpophalangeal joints, proximal

Dupuytren contracture

and distal interphalangeal in preoperative, postoperative (3 months) and late postoperative

Hand

period (5–8 years). Angles greater than 30◦ metacarpophalangeal joints and 15◦ proximal

Surgical procedures operative

interphalangeal the results were considered surgical recurrence. Results: there was obtained an average of 6.3◦ at the metacarpophalangeal joint, 13.8◦ in the proximal interphalangeal and distal interphalangeal at 1.9◦ . Conclusion: the modified open palm technique is an effective method in the surgical treatment of severe contractures in Dupuytren’s disease. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

Avaliac¸ão do tratamento cirúrgico da doenc¸a de Dupuytren pela técnica da palma aberta modificada r e s u m o Palavras-chave:

Objetivo: avaliar o tratamento cirúrgico com o uso da técnica da palma aberta modificada

Contratura de Dupuytren

para o tratamento das contraturas graves da doenc¸a de Dupuytren.

Mãos

Métodos: em quatro anos, foram submetidos ao tratamento cirúrgico 16 pacientes, que per-

Procedimentos cirúrgicos

tenciam aos estágios III e IV da classificac¸ão proposta por Tubiana et al. Foram feitas aferic¸ões

operatórios

do déficit de extensão das articulac¸ões metacarpofalangeanas e inferfalangeana proximal e distal nos períodos pré-operatório, pós-operatório (três meses) e pós-operatório tardio (cinco a oito anos). Angulac¸ões maiores do que 30◦ nas articulac¸ões metacarpofalangeanas e 15◦ nas interfalangeanas proximais foram consideradas como recidiva cirúrgica.

夽 Please cite this article as: Guilhen TA, Vieira ABM, de Castro MC, Hirata HH, Machado IR. Avaliac¸ão do tratamento cirúrgico da doenc¸a de Dupuytren pela técnica da palma aberta modificada. Rev Bras Ortop. 2014;49:31–36. 夽夽 Study conducted at Instituto Jundiaiense de Ortopedia e Traumatologia, Jundiaí, SP, Brazil. ∗ Corresponding author. E-mail: tguilhen@hotmail.com (T.A. Guilhen).

2255-4971/$ – see front matter © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

http://dx.doi.org/10.1016/j.rboe.2014.01.012


32

r e v b r a s o r t o p . 2 0 1 4;4 9(1):31–36

Resultados: obtivemos uma média de déficit de extensão de 6,3◦ ao nível da articulac¸ão metacarpofalangeana, 13,8◦ na interfalangeana proximal e 1,9◦ na interfalangeana distal. Conclusão: a técnica da palma aberta modificada é um método eficaz no tratamento cirúrgico das contraturas graves na doenc¸a de Dupuytren. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Todos os direitos reservados.

Introduction Dupuytren’s disease was named after Baron Guillaume Dupuytren,1 a celebrated French surgeon, whose complete monograph guided the current knowledge of this pathology. In 1831, Dupuytren described the disease as an anatomopathological change, with thickening and retraction of the palmar fascia with flexion deformity of the fingers. This monograph associated the disease to local chronic trauma on the palm, usually related to heavy duty. But Dupuytren cautioned that not all cases could be explained this way. The condition is due to metaplasia of the palmar fascia fibrous framework, which basically compromise the pretendinous band, superficial transverse ligament, spiral band, natatory ligament, lateral sagittal ligament, and Grayson’s ligament. The Dupuytren’s contracture follows a progressive evolution, and its initial manifestations are an invagination of the skin and the appearance of nodules that unite among them, forming hard consistency cords in the palm and advancing longitudinally to the finger. The condition is usually painless, and after its maturation may suffer retractions, which cause a flexion deformity of the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. The condition affects more men than women (ranging from 7:1 to 10:1), from the fourth to sixth decade of life; and the fourth and fifth fingers are the most commonly affected. Additionally, there may be an association with the formation of fibrous strands in the plantar fascia (Lederhose’s disease, 5%) and in the penile fascia (Peyronie’s disease, 3%).2 Its etiology is still unknown, but the importance of heredity was proved, because of the high incidence in the descendents of northern Europe. The condition is even known as “disease of the Vikings”. Its inheritance is autosomal dominant with reduced penetrance in women. There is a significant association with epilepsy, diabetes, trauma, and alcohol intake, and no evidence that it is an occupational disease.2–4 The anatomopathologic aspect is that of an aggressive lesion, displaying a large number of cells and mitoses. The basic cell present is the myofibroblast (similar to fibroblast), usually found in the palmar fascia, but with significant ability to generate contractile forces. The transforming growth factor ␤ (TGF-␤) is an abundant cytokine present in the tissue, being largely responsible for the proliferation and differentiation of fibroblasts into myofibroblasts. Moreover, it improves the contractile behavior of myofibroblasts and causes rapid and stronger contractions in response to mechanical stimuli.2,5 Other factors influencing the differentiation, growth, and contractility of myofibroblasts include platelet-derived protein, fibroblast growth factor, epidermal growth factor, and

interleukin-1, as well as cells that synthesize the proteins periostin and tenascin.5 The diagnosis is clinical, being established by inspection and palpation. The differential diagnosis includes acamptodactilia, rheumatoid arthritis, retraction of the scar caused by burn or injury, palmar callus of effort, and ulnar nerve deficit.5 Compared to conservative treatment, the most promising therapy is the application of intrafocal clostridium collagenase in the cord, now in an advanced clinical trial phase.5 Nowadays, the surgical option is the most acceptable. In the development of the therapeutic plan, it is important to determine the stage at which the disease is, as this knowledge influences the intraoperative technical difficulty and in the post-operative complications, as well as the recurrence of the disease. The need for more extensive dissection, the devitalized skin and the excessive tension on the suture are predisposing factors for post-operative complications, such as hematomata, skin necrosis, infection and pain.5,6 The original surgical treatment was the removal of the contracted fascia; since then, various techniques and modifications have been described: fasciotomy, dermofasciotomy with skin graft, regional fasciotomy, radical fasciotomy, open palm technique, partial fasciotomy with preservation of the skin, limited fasciotomy, segmental aponeurectomy, and percutaneous fasciotomy.1,4,6–10 In the open palm technique, originally described by Dupuytren1 and popularized by McCash,7 a regional fasciotomy in the palm of the hand is done, allowing the extension of the fingers. This procedure results in a large skin defect. The wound is left open to heal by secondary intention, to avoid stress and hematomai formation; this reduces the incidence of necrosis and the possibility of infection and scar adhesions.6

Objective The objective of this study is to evaluate the results of surgical treatment of patients with Dupuytren’s disease grades III and IV operated in our department with the use of the open palm technique (McCash) modified with the association of proximal and distal longitudinal incisional extensions on the palm, besides Brunner incisions in the fingers.11

Materials and methods From March 2004 to December 2007, 16 patients with clinical diagnosis of Dupuytren’s disease underwent surgical treatment. The mean age was 65 years (range, 54–75), with postoperative follow-up of 5–8 years. Six patients were affected only in the fifth finger, five were bilateral and five


33

r e v b r a s o r t o p . 2 0 1 4;4 9(1):31–36

Table 1 – Preoperatory, post-operatory (three months) and late post-operatory (5–8 years) angulation. Preoperatory

Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Patient 9 Patient 10 Patient 11 Patient 12 Patient 13 Patient 14 Patient 15 Patient 16

Post-operatory

Late post-operatory

MCP

PIP

DIP

MCP

PIP

DIP

MCP

PIP

DIP

45 50 40 50 45 40 50 45 50 45 50 40 45 55 50 45

35 30 30 40 30 30 35 30 35 30 40 30 35 40 45 30

20 20 15 20 15 20 10 10 20 20 10 20 20 25 25 25

05 05 00 00 05 00 00 05 05 00 00 00 05 00 00 00

00 05 00 05 10 05 05 00 00 00 00 00 00 00 05 00

00 00 00 05 00 00 00 00 00 00 00 00 05 05 05 00

15 05 00 10 25 00 00 05 05 00 15 00 05 10 05 00

20 20 10 30 20 05 05 05 10 10 20 10 10 20 15 10

00 00 00 05 00 00 00 05 05 00 00 00 05 05 05 00

MCP, metacarpophalangeal; PIP, proximal interphalangeal; DIP, distal interphalangeal.

unilateral, with involvement of the fourth and fifth fingers. Thirteen patients were male Caucasians, including the three women. In our study, we used the classification proposed by Tubiana et al.,12 which consists of the sum of the extension deficits of the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints, measured with a goniometer. This classification is divided into four stages: grade I (0–45◦ ), grade II (46–90◦ ), grade III (91–135◦ ), and grade IV (>135◦ ). In this study, were included only patients with Grades III and IV, and it was taken into account only the finger with greater involvement.11,12 In all patients, the surgical technique used was that recommended by McCash, with transverse incision in the distal palmar crease, associated with a modification with proximal and distal longitudinal incisional extensions on the palm. In the fingers, Brunner incisions were made. We made a partial fasciotomy, which left open only the transverse incision.4 Post-operative care consisted of daily dressing changes during the first 48 h, daily changes in the next two weeks, and every three days in subsequent weeks. The fingers were immobilized in extension for the first five days and the patient was referred for early chirotherapy rehabilitation. The extension deficits for MCP, PIP, and DIP joints were gauged in preoperative, post-operative (three months) and late post-operative periods (5–8 years). Extension deficits exceeding 30◦ in MCP, 15◦ in PIP, and 10◦ in DIP joints were considered as surgical recurrences.11,12

To compare the angle of the MCP, PIP, and DIP joints of patients with respect to preoperative, post-operative (three months) and late post-operative period (5–8 years), we applied the non-parametric statistical test of Mann–Whitney for paired samples, and the p values were corrected by Bonferroni method for multiple comparisons. Table 2 shows the results of the tests. For the three joints, a statistically significant decrease was observed for the average angle of the pre- to post-operative period, at the level of 5% (p < 0.05). For the MCP and DIP joints, no significant difference between the post-operative period (three months) and late post-operative period (5–8 years) was noted. However, for the PIP joint a significant mean increase between the post-operative and late post-operative periods vas noted (p = 0.0025), but still at a lower value than that observed preoperatively. Fig. 2 displays the scatter plot and the Spearman’s correlation coefficient among the joints for the angulations measured. A strong positive correlation among measures of different joints, with coefficients between 0.75 and 0.85 (all statistically significant, p > 0.0001) was noted.

Table 2 – Results of the Mann–Whitney test for comparison of measurements of the joints between periods. pa

Comparisons

Results Table 1 lists the measurements of the extension deficit, in degrees, of the three joints (MCP, PIP, and DIP) obtained with a goniometer. Fig. 1 displays the results of measurements of the extension deficits in each joint in the pre-, post-, and late post-operative period.

Pre × post Pre- × post-late Post- × post-late

MCP-FL

PIP

0.0012 0.0012 0.1020

0.0013 0.0013 0.0025

DIP 0.0012 0.0012 1.0000

PIP, proximal interphalangeal; DIP, distal interphalangeal. p values less than 0.05 indicate significant difference at the 5% level. a

p values corrected by the Bonferroni method for multiple comparison tests.


34

r e v b r a s o r t o p . 2 0 1 4;4 9(1):31–36

MCP-FL

PIP Mean value

Mean value 50

40

40

Grades

Grades

30 30

20

20

10 10

0

0 Preoperative

Post-operative

Late post-operative

Preoperative

Post-operative

Period

Late post-operative

Period

DIP 50

Mean value

Grades

50

50

50

50

50 Preoperative

Post-operative

Late post-operative

Periodo Fig. 1 – Boxes for the joint angulation, according to the joint and by period. In this figure the results of measurements of the extension deficits in each joint in the preoperative, post-operative, and late post-operative period are depicted.

Spearman correlation =0,8586

Spearman correlation =0,7844

Spearman correlation =0,7558

25

25

20

20

15

15

40

20

10

0

DIP

DIP

PIP

30

10

10

5

5

0

0 0

10

20

30

MCP-FL

40

50

0

10

20

30

40

50

0

10

MCP-FL

Fig. 2 – Dispersion for angulation measures among different joints.

20

DIP

30

40


35

r e v b r a s o r t o p . 2 0 1 4;4 9(1):31–36

Table 3 – Values of minimum, median, mean, maximum and standard deviation (SD) for the angulation of the joints, according to joint and period. Joint

Period

MCP

Preoperatory Post-operatory Late post-operatory Preoperatory Post-operatory Late post-operatory Preoperatory Post-operatory Late post-operatory

PIP

DIP

Minimum 40.0 0.0 0.0 30.0 0.0 5.0 10.0 0.0 0.0

Median

Mean

Maximum

SD

45.0 0.0 5.0 32.5 0.0 10.0 20.0 0.0 0.0

46.6 1.9 6.3 34.1 2.2 13.8 18.4 1.3 1.9

55.0 5.0 25.0 45.0 10.0 30.0 25.0 5.0 5.0

4.4 2.5 7.2 4.9 3.1 7.2 5.1 2.2 2.5

MCP, metacarpophalangeal, PIP, proximal interphalangeal, DIP, distal interphalangeal. This table presents descriptive measures of deficits. Clearly occurs a decrease in the angle of the joints in all patients after surgery.

Discussion The literature is controversial as to the advantages and disadvantages of the open palm technique, which determines more skin stretching, besides preventing complications such as hematoma, necrosis, skin ischemia, tension and pain. A disadvantage would be an increased risk of infection and the patient discomfort by having an “open” injury and by the necessity of more frequent dressings. Lubahn et al.13 conducted a comparative study between the two techniques and concluded that patients operated by techniques in which the palm was completely closed came to suffer greater residual contracture.8,13,14 In the present study, 13 (81.25%) males and three (18.75%) females were recruited, all Caucasians, which is consistent with the literature, which reports 80% of male and dominance of Caucasians. In this study, the mean age of patients was 65 years (range, 54–75), similar to that of most studies.15,16 In our study we found 37.5% of surgical recurrence. These rates vary widely (28–50%), regardless of the technique used. However, to obtain good results the patient must have an adequate post-operative care, and an stimulus for early active mobilization after removal of immobilization, under orientation of a chiropractor. McGrouther is most emphatic that, in a long-term post-operative period, the recurrence rate reaches 100% for some degree of contracture. This fact occurs because there is a residual pathological fascia, or what is called the extent of the disease, in which there is the formation of new fascia in a place near the surgical site.12,17,18 Recurrence in MCP joint is very low. On the other hand, in PIP joint the incidence of recurrence is higher. Our study described six cases of surgical recurrence, all in the PIP joint, because of an angulation > 15◦ in the late postoperative period (5–8 years), which agrees with the literature.9,19 Concerning MCP and DIP joints, no significant differences in the angulations between the post-operative period (three months) and late post-operative period (5–8 years) were observed. However, for the PIP joint there was a significant mean increase in angulation between the post-operative (mean, 2.2◦ ) and late post-operative (mean, 13.8◦ ) periods, which shows a higher rate of recurrence in the PIP joint–also observed in other works.9,19

An extension deficit decrease for all patients in the two postoperative periods compared to the preoperative period was observed, which is shown in the boxes (Fig. 1). This demonstrates the effectiveness of the open palm technique (modified), provided there is an appropriate therapeutic plan, which is consistent with the literature.5,6 In comparing the three joints in the three periods (Table 3), only the PIP joint showed significant mean increase between the post-operative and late post-operative periods, which demonstrate a higher recurrence in PIP, also evident in the literature.9,19

Conclusion The modified McCash technique is an effective option for severe cases (stages III and IV) of Dupuytren’s disease.

Conflicts of interest The authors declare no conflicts of interest.

references

1. Dupuytren G. De la retraction des doigts par suite d’uneaffection de l’aponeurosepalmaire Description de la maladie. Operation chirurgical equiconvient dans de cas. J Univ Hebd Med Chirprat. 1831;5:352–65. 2. Barros F, Barros A, Almeida S. Enfermidade de Dupuytren: avaliac¸ão de 100 casos. Rev Bras Ortop. 1997;32(3): 177–83. 3. Galbiatti JA, Fiori JM, Mansano RT, Durigan Junior A. Tratamento da moléstia de Dupuytren pela técnica de incisão longitudinal reta, complementada com z-plastia. Rev Bras Ortop. 1998;31(4):347–50. 4. Skoog I. Dupuytren’s contracture: pathogenesis and surgical treatment. Surg Clin North Am. 1967;47(7):433–44. 5. Black ME, Blazar PE. Dupuytren disease an envolving understanding of an age-old disease. J Am Acad Orthop Surg. 2011;19(2):746–57. 6. Bryan AS, Ghorbal MS. Long term result of closed palmar fasciotomy in the management of Dupuytren’s contracture. J Hand Surg Br. 1988;13(3):254–7. 7. McCash CR. The open palm technique in Dupuytren’s contracture. Br J Plast Surg. 1964;17:271–80.


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r e v b r a s o r t o p . 2 0 1 4;4 9(1):31–36

8. Hueston JI, Wolfe I. Digital grafts in recurrent Dupuytren’s contracture. Plast Reconstr Surg. 1962;29:342–4. 9. McFarlane RM. Dupuytren’s contracture. In: Green DP, editor. Operative hand surgery. New York: Churchill Livingstone; 1993. 10. Hamlin JR. Limited excision of Dupuytren’s contracture. Ann Surg. 1952;135:94–7. 11. Tubiana R. The principles of surgical treatment of Dupuytren’s contracture. GEM Monography. 1974: 123–8. 12. Tubiana R, Fahrer M, McCullough MA. Recurrence and other complications in surgery of Dupuytren’s contracture. Clin Plast Surg. 1981;8(1):45–9. 13. Freitas AD, Pardini AG, Neder AL. Contratura de Dupuytren: tratamento pela técnica da palma aberta. Rev Bras Ortop. 1997;32(4):301–4.

14. Lubahn JD, Lister GD, Wolfe I. Fasciotomy and Dupuytren’s disease: a comparison between the open palm and wound closure. J Hand Surg. 1984;9(1):53–8. 15. McFarlane RM. The current status of Dupuytren’s disease. J Hand Surg Am. 1983;8 5 Pt 2:703–8. 16. Lamb DW. The practice of hand surgery. London: Blackwell Scientific Publication; 1981. 17. Hueston JI. Recurrent Dupuytren’s contracture. Plast Reconstr Surg. 1962;31:66–9. 18. McFarlane RM. Patterns of the diseased fascia in the fingers in Dupuytren’s contracture. Plast Reconstr Surg. 1974;54(1):31–44. 19. Tonkin MA, Burke FD, Varian JP. Surgical treatment of Dupuytren’s contracture: a comparative study of fasciectomy and dermofasciectomy in one hundred patients. J Hand Surg Br. 1984;9(2):156–62.


r e v b r a s o r t o p . 2 0 1 4;4 9(1):37–43

www.rbo.org.br

Original Article

Results evaluation of the use of intra-articular sodium hyaluronate in the post-operative knee arthroscopy夽,夽夽 Ayrton de Paula Pereira Junior a , Ricardo Pozzi Fasolin a , Felipe Ayusso Correa Sossa a , Ozorio de Almeida Lira Neto b , Marcelo Schmidt Navarro c , Antonio Milani a,b,∗ a b c

Departamento de Ortopedia, Hospital Ifor, São Bernardo do Campo, SP, Brazil Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, São Paulo, SP, Brazil Disciplina de Ortopedia, Faculdade de Medicina do ABC, 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: to evaluate the efficacy of hyaluronic acid in the post-operative of knee

Received 3 September 2012

arthroscopy.

Accepted 7 December 2012

Methods: we have evaluated 49 patients undergoing arthroscopic procedure with the use of intra-articular hyaluronic acid (Group 1) and 49 patients undergoing arthroscopic procedure

Keywords:

without the use of hyaluronic acid (Group 2). Patients were evaluated based on the Visual

Arthroscopy

Analogue Scale, household analgesia, assessment of the Range of Motion with a goniometer,

Knee

and the Lysholm questionnaire.

Hyaluronic acid

Results: there were no substantial adverse effects on either group.

Viscosuplementation

Conclusion: the use of hyaluronic acid in the post-operative of knee arthroscopy is justified due/because it leads to a decrease in pain in the early stage, enabling faster recovery of the patient. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

Avaliac¸ão dos resultados do uso do hialuronato de sódio intra-articular no pós-operatório da artroscopia do joelho r e s u m o Palavras-chave:

Objetivo: avaliar a eficácia do uso do ácido hialurônico no pós-operatório de artroscopia de

Artroscopia

joelho.

Joelho

Métodos: foram avaliados 49 pacientes submetidos ao procedimento artroscópico associ-

Ácido hialurônico

ado ao uso do ácido hialurônico intra-articular (Grupo I) e 49 pacientes submetidos ao

Viscossuplementac¸ão

procedimento artroscópico sem uso do ácido hialurônico (Grupo II). Os pacientes foram avaliados com base na Escala Visual Analógica de dor (EVA), analgesia domiciliar, amplitude do movimento do joelho com goniômetro e no questionário Lysholm. Resultados: não ocorreram efeitos adversos significativos em nenhum dos dois grupos.

夽 Please cite this article as: de Paula Pereira Junior A, Fasolin RP, Sossa FAC, de Almeida Lira Neto O, Navarro MS, Milani A. Avaliac¸ão dos resultados do uso do hialuronato de sódio intra-articular no pós-operatório da artroscopia do joelho. Rev Bras Ortop. 2014;49:37–43. 夽夽 Study conducted at the Hospital Ifor, São Bernardo do Campo, SP, Brazil. ∗ Corresponding author. E-mail: pilot@osite.com.br (A. Milani).

2255-4971/$ – see front matter © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

http://dx.doi.org/10.1016/j.rboe.2014.01.005


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r e v b r a s o r t o p . 2 0 1 4;4 9(1):37–43

Conclusão: o uso do ácido hialurônico no pós-operatório de artroscopia de joelho é justificado por levar a uma diminuic¸ão da dor na fase inicial e possibilitar uma recuperac¸ão mais rápida do paciente. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Todos os direitos reservados.

Introduction The use of intra-articular medication in the immediate postoperative period in the area of arthroscopic knee surgeries is controversial, with prospects for new behaviors and routines, and with authors for and against the use of hyaluronic acid post-operatively.1,2 A knee arthroscopy is a medical procedure more usual in the United States of America (USA), and is effective for symptom relief in patients with intra-articular loose bodies, chondral injury and meniscal pathology.2 The performance of human joints is strictly related to the viscoelastic properties of synovial fluid, which determines the strength transmission, lubrication and protection of articular cartilage. This viscoelasticity depends on the concentration of hyaluronic acid in the sinovial fluid.3 Other actions of hyaluronic acid would be an antiinflammatory effect (decreased gene expression of cytokines, prostaglandin production, and intra-articular concentration of metalloproteinases) and analgesic (inhibition of nociceptors), stabilization of cartilaginous matrix, chondrocyte proliferation, increased production of type II collagen and its decreased degradation.4–6 Some authors believe that exogenous hyaluronic acid also stimulates the production of endogenous hyaluronic acid, which would explain its long-term effect.7 With respect to the analgesic effect of intra-articular hyaluronic acid, it is believed that, initially, it would be smaller than the intra-articular corticosteroid injection, but with persistence for longer periods.8 Another source of debate is the discussion regarding the number of doses of hyaluronic acid to be effective, but there was no difference in the comparison between three and six doses at weekly intervals.9 Some authors claim that, during an arthroscopic knee surgery, a decrease in intra-articular hyaluronic acid concentration may occur and, as immediate therapy, recommend intra-articular applications of sodium hyaluronate 20 mg after surgery, and subsequently four injections at weekly intervals.10 The aim of this study was to compare the results of the use of intra-articular sodium hyaluronate in a group of patients undergoing arthroscopic surgery due to meniscal lesions versus results observed in a group of patients not treated by this complementary therapy.

Materials and methods Ninety-eight patients with meniscal lesions were studied. These patients were treated from March to November 2005 by arthroscopic surgery with partial meniscectomy of the medial meniscus, always by the same surgical team.

Their ages ranged from 18 to 65 years (mean: 34 years). Sixty-five (63%) were men and 33 (37%), women. The participants were randomly divided into two groups of 49. The first group was treated with intra-articular sodium hyaluronate 20 mg (Polireumim, TRB Pharma) in the immediate post-operative period and, subsequently, with a weekly application for four consecutive weeks. In the second group, this treatment was not done. The surgeon was unaware of the group to which each patient belonged, having been informed only after skin suture, at the time of completion (or not) of the infiltration (Table 1). All patients were rehabilitated according to the same protocol, with evaluations after three, eight, 15, 30 and 60 days, and were instructed to return to sport practice after 60 days of surgery. All patients underwent the same surgical technique, with the use of only two infrapatellar portals (medial and lateral) and, on average, with joint infusion (6 L of saline 0.9%), using an infusion pump at a mean pressure of 50 mmHg. All randomized patients showed no significant changes in cartilage and, in this study, only cases of Outerbridge grade I and II chondropathy (Table 1) were included. All patients were anesthetized by subarachnoid block with bupivacaine 0.5% associated with glucose 12.5 to 15 mg, without opioids. A pneumatic tourniquet was also used, with an average time of 35 min. After hospital discharge (mean: 12 h after the intervention), both groups were treated with cephalexin 500 mg PO 6/6 h for seven days and, in case of pain, dipyrone 50 drops to the limit of 6/6 h. The use of analgesics was controlled in a form, in which the patient had to check the date and time of use until the eighth day. In Group 1, after skin suture the infiltrations were made in the lateral suprapatellar area, (once a week for four consecutive weeks). Besides the control on the form with the date and time of use of analgesics, patients underwent VAS. In all reviews, the range of motion of the knee was also measured with a goniometer; the Lysholm questionnaire was applied in the preoperatory on the day of surgery and on the 15th, 30th and 60th days post-operatively. All evaluations were performed by the same examiner who did not know at which group the patient belonged. To avoid bias in the results because of the pain of infiltration, the assessments in the 8th, 15th and 30th days were always made before this procedure. In the statistical analysis, analysis of variance with two factors and repeated measures on the time factor were made, assuming a first-order autoregressive correlation matrix between time points.11 After the analysis, Tukey multiple comparisons were made12 to see between which groups or time points occurred differences in scales. The tests were performed with a significance level of 5%.


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r e v b r a s o r t o p . 2 0 1 4;4 9(1):37–43

Table 1 – Characterization of sample. Variables

n = 98

Group 1 = 49

Group 2 = 49

Age (years) – mean (SD) Minimum–maximum

34 (12.1) 18–65

36 (11.3) 20–65

33 (12.1) 18–61

Gender – n (%) Female Male

33 (37) 65 (63)

15 (30.6) 34 (69.4)

18 (36.7) 31 (63.3)

Operated site – n (%) Right Left

58 (59.2) 40 (40.8)

26 (53) 23 (47)

32 (65.3) 17 (34.7)

Chondral lesiona – n (%) Without lesion Grade I Grade II

43 (43.9) 31 (31.6) 24 (24.5)

22 (44.9) 14 (28.6) 13 (26.5)

21 (42.9) 17 (34.7) 11 (22.4)

a

Outerbridge.

Results Considering the assessments by VAS, the results suggest more rapid reduction of pain in Group 1 versus Group 2. The analysis showed that the mean behavior of VAS was statistically different between groups over the evaluation time points (p < 0.001) (Fig. 1). In comparing the different evaluation time points, the data in Table 2 show that both groups had a mean reduction in VAS with statistical significance at all evaluation time points, when compared to the previous time point (p < 0.001), but in the eighth and 15th days, Group 1 showed, on average, statistically lower VAS versus Group 2 (p < 0.001 and p < 0.001) and in other time points, there was no statistically significant difference in VAS between groups (p > 0.05) (Table 2). With respect to the need for use of home analgesia, there was no statistical difference between the groups until the eighth day. With regard to assessments made with the goniometer, it was observed that after 15 days the Group 1 had greater range of motion versus Group 2. After 30 days, this difference could still be observed, to a lesser extent, but without statistical significance. In the assessment made on the 60th day, the results were similar in both groups. 8 7 6

VAS

5 4 3 2 1

In the evaluation with the Lysholm questionnaire (excellent: patients between 95 and 100 points, good: 94–84; regular: 83–65, and poor score: <64), we noted in the preoperative that the Groups 1 and 2 had an average of 46 and 48 points, respectively, classified then as poor (Table 3). Table 3 shows that in both Groups (1 and 2), the mean Lysholm score decreased statistically from the preoperatory to 15 days post-operatively (p = 0.003 and p < 0.001, respectively), with “poor” rating in both groups. However, in the evaluation of the questions, we found that the largest difference between groups was observed in the items “pain” and “swelling”, in which the Group 1 had better results versus Group 2. In other questions, the results were similar between groups. In the 30th day the results showed the greatest statistical difference between groups. Group 1 averaged 90 points, classified as good, and Group 2 averaged 77 points, classified as regular. We perceived a greater difference in the questions about claudication, instability, swelling and squatting, and noticed that, just as that in the 15th day, the swelling was also an important factor. At the last evaluation period, 60 days after the surgery, the two groups differed statistically, with 94 points in Group 1 and 90 points in Group 2, both classified as good. In this evaluation, we realized that the two groups differed primarily in the item “climbing stairs”, but without statistical difference between values. In the allocation of the results of the Lysholm et al. questionnaire on a graph, earlier improvement of function in Group 1 versus Group 2 was noted in all assessments (p < 0.001) (Fig. 2). In this study, some complications occurred: eight patients in Group 1 reported a need for analgesia after infiltration. In six of these cases, two patients required only one dose of dipyrone 50 drops, and in two of them, two days of dipyrone 50 drops 8/8 h were required. None of the patients had post-operative infections, joint stiffness, or scar changes.

0 0

10

20

30

40

50

60

70

Dia Groups 1

Groups 2

Fig. 1 – Graphical representation of the mean profiles and respective standard errors of VAS, according to groups.

Discussion Hyaluronic acid is a natural polymer of glycosaminoglycan family. It is an important constituent of the extracellular


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r e v b r a s o r t o p . 2 0 1 4;4 9(1):37–43

Table 2 – Result of multiple comparisons of VAS among groups and time points. Group/time point

Group 1

Group 2

3 days 8 days 15 days 30 days 60 days

Comparison

3 days–8 days 3 days–15 days 3 days–30 days 3 days–60 days 8 days–15 days 8 days–30 days 8 days–60 days 15 days–30 days 15 days–60 days 30 days–60 days 3 days–8 days 3 days–15 days 3 days–30 days 3 days–60 days 8 days–15 days 8 days–30 days 8 days–60 days 15 days–30 days 15 days–60 days 30 days–60 days Group 1–Group 2 Group 1–Group 2 Group 1–Group 2 Group 1–Group 2 Group 1–Group 2

Mean estimated difference 3.86 5.20 6.22 7.02 1.35 2.37 3.16 1.02 1.82 0.80 2.27 4.33 6.37 7.06 2.06 4.10 4.80 2.04 2.73 0.69 −0.10 −1.69 −0.98 0.04 −0.06

matrix and is present in high concentrations in cartilage and synovial fluid.10 Some authors claim that sodium hyaluronate, which is a defined fraction of hyaluronic acid, has analgesic and anti-inflammatory properties, contributes to the normalization of fluidity or viscoelasticity of the synovial fluid and to the activation of tissue regeneration in the affected cartilage, and restores the functional balance of the joint. Therefore, they recommend its use for the treatment of osteoarthritis.4,13,14 Some studies have reported that, in addition to relieving pain and improving function, the use of hyaluronic acid could

Standard error

0.10 0.13 0.14 0.15 0.10 0.13 0.14 0.10 0.13 0.10 0.10 0.13 0.14 0.15 0.10 0.13 0.14 0.10 0.13 0.10 0.16 0.16 0.16 0.16 0.16

t value

38.60 41.05 44.25 47.27 13.48 18.67 22.49 10.21 14.33 7.97 22.67 34.12 45.26 47.55 20.63 32.35 34.09 20.42 21.57 6.94 −0.64 −10.59 −6.12 0.26 −0.38

gL

p

384 384 384 384 384 384 384 384 384 384 384 384 384 384 384 384 384 384 384 384 384 384 384 384 384

<0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 >0.999 <0.001 <0.001 >0.999 >0.999

alter the course of osteoarthrosis and improve qualitatively and quantitatively the articular cartilage. These indications are based on studies of imaging such as X-ray and MRI, in which there was an increase in cartilage volume and a decrease in joint space after the treatment versus placebo. These benefits are also based on the best quality of the matrix and on a higher density of chondrocytes in biopsy studies after the implementation of treatment.4 In animal studies, Plaas et al.15 concluded that hyaluronic acid suppresses synovial hyperplasia and the development of periarticular fibrosis, and protect against cartilage erosion, and also acts to relieve pain in the short term (dilution of joint

Table 3 – Result of multiple comparisons of Lysholm questionnaire among groups and time points. Group/time point

Group 1

Group 2

Pre 15 days 30 days 60 days

Comparison

Pre–15 days Pre–30 days Pre–60 days 15 days–30 days 15 days–60 days 30 days–60 days Pre–15 days Pre–30 days Pre–60 days 15 days–30 days 15 days–60 days 30 days–60 days Group 1–Group 2 Group 1–Group 2 Group 1–Group 2 Group 1–Group 2

Mean estimated difference 1.10 −43.47 −47.76 −44.57 −48.86 −4.29 12.02 −28.88 −41.84 −40.90 −53.86 −12.96 −1.73 9.18 12.86 4.18

Standard error

0.28 0.33 0.34 0.28 0.33 0.28 0.28 0.33 0.34 0.28 0.33 0.28 0.35 0.35 0.35 0.35

t value

gL

p

3.92 −133.55 −140.79 −158.49 −150.11 −15.24 42.74 −88.72 −123.34 −145.43 −165.47 −46.08 −5.01 26.54 37.16 12.09

288 288 288 288 288 288 288 288 288 288 288 288 288 288 288 288

0.003 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001


r e v b r a s o r t o p . 2 0 1 4;4 9(1):37–43

100 90 80

Lysholm

70 60 50 40 30 20 10 0 -10

0

10

20

30

40

50

60

70

Dia Group 1

Group 2

Fig. 2 – Graphical representation of the mean profiles and respective standard errors of Lysholm questionnaire, according to groups.

fluid) and in the long term (blocking of pain receptors), and improve the gait pattern of the osteoarthrosis knee. Currently, the use of intra-articular hyaluronic acid is also widely discussed because of the different formulations, with different molecular weights and the results of some metaanalyses. These studies also differ in the parameter used and further increase the discussion as to the effectiveness of its use.16 Huang et al.,13 in a randomized, double-blind, multicenter study, evaluated in one sample of the Asian population the use of intra-articular hyaluronic acid versus placebo. These authors found statistically significant improvement in reducing the pain and in the knee function, especially after the fifth week of treatment. These benefits have remained effective for up to 25 weeks. In the subjective evaluation, favorable results with its use also were noted. Regarding the consumption of acetaminophen and the volume of joint fluid, there was no statistically significant difference for any group.11 These results are consistent with the study by NavarroSarabia et al.,17 in which there was a statistically significant difference in favor of hyaluronic acid in the categories of pain relief, improved function and overall improvement of the patient versus placebo. Bannuru et al.,14 in a meta-analysis comparative of the use of intra-articular hyaluronic acid versus placebo, concluded that hyaluronic acid is effective as early as the fourth week of treatment, with peak effectiveness at eight weeks, and remaining beneficial for up to 24 weeks. These authors evaluated the effectiveness for pain relief, improved function and decreased joint stiffness. Lee et al.18 believe that the analgesic effect of hyaluronic acid in the first five weeks is equal to that of placebo. In their prospective and randomized study, the authors concluded that the use of cetorolac associated with hyaluronic acid showed more rapid analgesia versus monotherapy with hyaluronic acid. In the fifth week this analgesia achieved equal intensity in both groups (hyaluronic acid with cetorolac × hyaluronic acid alone). But it is worth bearing in mind that the aforementioned studies evaluate the hyaluronic acid in the treatment of

41

osteoarthrosis; hence, it is interesting to quote them, because they discuss the efficacy of hyaluronic acid as a means of improving function and pain. Regarding the use of hyaluronic acid in the post-operative of arthroscopy, Forster and Straw19 compared pain and function in activities of daily living in patients with isolated arthroscopy versus arthroscopy associated with hyaluronic acid. These authors concluded that there was improvement of function with the use of HA, but without difference in the category of pain. Heybeli et al.1 compared pain and function in patients with 40–65 years old with mild to moderate osteoarthrosis and who underwent arthroscopy with and without the use of hyaluronic acid (HA) post-operatively. There was no statistically significant difference with respect to pain, but there was improvement in function in patients who used HA. In our study, we observed the same result with respect to function improvement, mainly until the 30th day, both by the Lysholm questionnaire and by the goniometer mensuration. However, with regard to pain, until the third day the results confirm the literature, with no difference with the use of the medication in question; thereafter, patients treated with hyaluronic acid had less pain versus control group, and this analgesia achieved equal intensity in the 30th day-evaluation and from then on. Hempfling10 also contrasted isolated arthroscopy versus arthroscopy associated with HA in the items of night pain, pain when walking, and ability to walk 100 meters without pain. A clear symptomatic improvement occurred in both groups, compared with preoperative values; but in the group using HA this improvement lasted longer. In our study, there was also significant improvement in pain and function versus preoperative assessments, but this difference was observed in the initial evaluations. After the 60th day, an important difference between the ratings of Groups 1 and 2 was not observed, which can be justified by the lack of assessment of patients over a longer period, when maybe we could observe results equivalent to the literature. In 2007, Ulucay et al.20 compared the use of three types of HA in women 40–60 years old with mild osteoarthrosis and degenerative meniscal lesion, after arthroscopy. These authors concluded that HA is effective therapy for these patients. Also in 2008, Atay et al.21 compared the effect of HA of high and low molecular weight versus placebo in terms of pain, stiffness and functional ability at six and 12 months after arthroscopic debridement in patients with mild to moderate osteoarthrosis. After six months, there was no statistically significant difference, but this occurred after 12 months. The authors concluded that the use of HA results beneficial and improves the effectiveness of treatment, regardless of the substance’s high or low molecular weight. In our study, pain improvement was observed until the 15th day, with better range of motion and functional capacity until the 30th day. There was no statistical difference for the items evaluated from the 60th day. Waddell and Bert,2 in a systematic review conducted in 2010, concluded that more studies are necessary to support the use of HA in the post-operatory of knee arthroscopy patients. However, it seems that the use of HA helps to


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decrease pain and improve the function of a significant number of patients post-operatively. In our study, the improvement of pain, function, and range of motion in patients who were treated with HA infiltration was observed. The improvement of pain is observed in the initial stage, especially until the 15th day; on the other hand, the function and range of motion improved after this period. We believe in a direct relation with this effect: with less pain, the patient can achieve a faster rehabilitation, with more quality, besides a faster return to his/her daily functions. When interpreting more deeply the Lysholm questionnaire, our results demonstrated, in the initial evaluation, that although both groups were classified as poor, the superiority of the patients in Group 1 was justified by the best assessments in relation to pain and swelling. This finding corroborates the results of VAS and can be explained by the analgesic and anti-inflammatory effect of hyaluronic acid. 4,13,14

In the 30th day evaluation, we found the greatest difference between Groups 1 and 2: 90 and 77 points, respectively. The main differences are in the item “swelling”, again because the anti-inflammatory effect of HA. As of “claudication”, “instability” and “squatting”, we believe that, by this time, with a more effective therapy and because of a lower intensity of pain, it is possible that the patient be submitted to more intense demands and achieve an earlier gain of muscle mass and proprioception. This would facilitate the activities above evaluated. From the 30th, the pain was similar in both groups, and in the assessment of the 60th day both groups were classified as good, with statistical superiority in Group 1 versus Group 2 (94 × 90, respectively). This superiority was due to the improved ability to climb stairs by Group HA patients, likely due to the better muscle reserves acquired in the initial 60 days.

Conclusion Given the subjective parameters evaluated, we believe that the use of intra-articular infiltrations of sodium hyaluronate 20 mg in procedures of arthroscopic surgery of the knee is fully justified, as this practice leads to a decrease in pain in the initial phase, enables faster patient recovery and generates a faster return and better quality to the activities of daily living. Our study has some limitations: the short period of evaluation of patients (we were unable to verify the effects of hyaluronic acid in the medium and long term), and also the fact of the subjectivity of the evaluation of patients’ function. This implies that perhaps an isokinetic evaluation with cybex could better demonstrate a muscle differences between the two groups of individuals. We believe that this is the main cause of improvement of the function on the 60th day. Unfortunately, we could not proceed with this option for lack of money.

Conflicts of interest The authors declare no conflicts of interest.

references

1. Heybeli N, Doral MN, Atay OA, Leblebicioglu G, Uzumcugil A. Intra-articular sodium hyaluronate injections after arthroscopic debridement for osteoarthritis of the knee: a prospective, randomized, controlled study. Acta Orthop Traumatol Turc. 2008;42(4):221–7. 2. Waddell DD, Bert JM. The use of hyaluronan after arthroscopic surgery of the knee. Arthroscopy. 2010;26(1):105–11. 3. Carulli C, Matassi F, Civinini R, Morfini M, Tani M, Innocenti M. Intra-articular injections of hyaluronic acid induce positive clinical effects in knees of patients affected by haemophilicarthropathy. Knee. 2013;20(1):36–9. 4. Rezende MU, Campos GC. Viscossuplementac¸ão. Rev Bras Ortop. 2012;47(2):160–4. 5. Conrozier T, Jerosch J, Beks P, Kemper F, Euller-Ziegler L, Bailleul F, et al. Prospective, multi-centre, randomized evaluation of the safety and efficacy of five dosing regimens of viscosupplementation with hylan G-F 20 in patients with symptomatic tibio-femoral osteoarthritis: a pilot study. Arch Orthop Trauma Surg. 2009;129(3):417–23. 6. Pavelka K, Uebelhart D. Efficacy evaluation of highly purified intra-articular hyaluronic acid (Sinovial® ) hylan G-F20 (Synvisc® ) in the treatment of symptomatic knee osteoarthritis. A double-blind, controlled, randomized, parallel-group non-inferiority study. Osteoarthritis Cartil. 2011;19(11):1294–300. 7. Bagga H, Burkhardt D, Sambrook P, March L. Longterm effects of intraarticular hyaluronan on synovial fluid in osteoarthritis of the knee. J Rheumatol. 2006;33(5):946–50. 8. Clarke S, Lock V, Duddy J, Sharif M, Newman JH, Kirwan JR. Intra-articular hylan G-F (Synvisc® ) in the management of patellofemoral osteoarthritis of the knee (POAK). Knee. 2005;12(1):57–62. 9. Petrella R, Petrella M. A prospective, randomized, double-blind, placebo controlled study to evaluate the efficacy of intraarticular hyaluronic acid for osteoarthritis of the knee. J Rheumatol. 2006;33(5):951–6. 10. Hempfling H. Intra-articular hyaluronic acid after knee arthroscopy: a two-year study. Knee Surg Sports Traumatol Arthrosc. 2007;15(5):537–46. 11. Singer JM, Andrade DF. Analysis of longitudinal data. In: Sen PK, Rao CR, editors. Handbook of statistics: bio-environmental and public health statistics. Amsterdam: North Holland; 2000. p. 115–60. 12. Neter J, Kutner MH, Nachtsheim CJ, Wasserman W. Applied linear statistical models. 4th ed. Illinois: Richard D. Irwing; 1996. 13. Huang TL, Chang CC, Lee CH, Chen SC, Lai CH, Tsai CL. Intra-articular injections of sodium hyaluronate (Hyalgan® ) in osteoarthritis of the knee. A randomized, controlled, double-blind, multicenter trial in the Asian population. BMC Musculoskelet Disord. 2011;12:221–8. 14. Bannuru RR, Natov NS, Dasi UR, Schmid CH, McAlindon TE. Therapeutic trajectory following intra-articular hyaluronic acid injection in knee osteoarthritis – meta-analysis. Osteoarthritis Cartil. 2011;19(6):611–9. 15. Plaas A, Li J, Riesco J, Das R, Sandy JD, Harrison A. Intraarticular injection of hyaluronan prevents cartilage erosion, periarticular fibrosis, and mechanical allodynia and normalizes stance time in murine knee osteoarthritis. Arthritis Res Ther. 2011;13(2):R46. 16. Curran MP. Hyaluronic acid (Supartz® ). A review of its use in osteoarthritis of the knee. Drugs Aging. 2010;27(11):925–41. 17. Navarro-Sarabia F, Coronel P, Collantes E, Navarro FJ, De La Serna AR, Naranjo A, et al. A 40-month multicentre, randomised placebo-controlled study to assess the efficacy


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and carry-over effect of repeated intra-articular injections of hyaluronic acid in knee osteoarthritis: the AMELIA project. Ann Rheum Dis. 2011;70(11):1957–62. 18. Lee SC, Rha DW, Chang WH. Rapid analgesic onset of intra-articular hyaluronic acid with ketorolac in osteoarthritis of the knee. J Back Musculoskelet Rehabil. 2011;24(1):31–8. 19. Forster MC, Straw R. A prospective randomized trial comparing intra-articular Hyalgan injection and arthroscopic washout for knee osteoarthritis. Knee. 2003;10(3):291–3.

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20. Ulucay C, Altintas F, Ugutmen E, Beksac B. The use of arthroscopic debridement and viscosupplementation in knee osteoarthritis. Acta Orthop Traumatol Turc. 2007;41(5): 337–42. 21. Atay T, Aslan A, Baydar ML, Ceylan B, Baykal B, Kirdemir V. The efficacy of low- and high-molecular-weight hyaluronic acid applications after arthroscopic debridement in patients with osteoarthritis of the knee. Acta Orthop Traumatol Turc. 2008;42(4):228–33.


r e v b r a s o r t o p . 2 0 1 4;4 9(1):44–50

www.rbo.org.br

Original Article

Blood transfusion in hip arthroplasty: a laboratory hematic curve must be the single predictor of the need for transfusion?夽,夽夽 Felipe Roth a,∗ , Felipe Cunha Birriel a , Daniela Furtado Barreto a , Leonardo Carbonera Boschin b , Ramiro Zilles Gonc¸alves a,b , Anthony Kerbes Yépez a , Marcelo Faria Silva c , Carlos Roberto Schwartsmann a a b c

Complexo Hospitalar Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil Complexo Hospitalar Santa Casa de Misericórdia de Porto Alegre, Hospital Cristo Redentor, Porto Alegre, RS, Brazil Centro Universitário Metodista, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, 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 determine whether the laboratory hematic curve must be the single predictor

Received 23 July 2012

of postoperative blood transfusion in total hip arthroplasty.

Accepted 23 November 2012

Methods: the laboratory blood samples of 78 consecutive patients undergoing total hip arthroplasty was analyzed during five distinct moments: one preoperative and four postop-

Keywords:

erative. There was a count of hemoglobin, hematocrit and platelets of the patients samples.

Arthroplasty, replacement, hip

Other catalogued variables ascertain possible risk factors related to transfusional practice.

Blood transfusion

They characterized the anthropometric, behavioral and co morbidities data in this popula-

Hemoglobin

tion. The study subjects were divided and categorized into two groups: those who received blood transfusion during or after surgery (Group 1, G1), and those who did not accomplish blood transfusion (Group 2, G2). Transfusion rules were lead by guidelines of American Academy of Anesthesiology and the British Society of Hematology. Results: a total of 27 (34.6%) patients received blood transfusions. The curves of hemoglobin, hematocrit and platelet transfusions between G1 and G2 were similar (p > 0.05). None of the analyzed risk factors modified the rate of transfusion rate in their analysis with p value > 0.05, except the race. The sum of clinical co morbidities associated with patients in G1 was a median of 3 (95% CI 2.29–3.40), while in G2 the median was 2 (95% CI 1.90–2.61) with p = 0.09. Conclusion: the curve in red blood cells has limited reliability when used as sole parameter. The existence of tolerant patients hematimetric curve variations assumes that their assessments of clinical, functional evaluation and co-morbidities are parameters that should influence the decision to transfusion red blood cells. © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

Please cite this article as: Roth F, Birriel FC, Barreto DF, Boschin LC, Gonc¸alves RZ, Yépez AK, Silva MF, Schwartsmann CR. Transfusão sanguínea em artroplastia de quadril: a curva laboratorial hemática deve ser o único preditor da necessidade de transfusão?. Rev Bras Ortop. 2014;49:44–50. 夽夽 Study conducted at the Department of Orthopaedics, Hospital Santa Casa de Porto Alegre, Porto Alegre, RS, Brazil. ∗ Corresponding author. E-mail: feliperoth@yahoo.com.br (F. Roth). 2255-4971/$ – see front matter © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

http://dx.doi.org/10.1016/j.rboe.2013.12.016


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Transfusão sanguínea em artroplastia de quadril: a curva laboratorial hemática deve ser o único preditor da necessidade de transfusão? r e s u m o Palavras-chave:

Objetivo: verificar se a curva laboratorial hemática deve ser o único preditor de transfusão

Artroplastia de quadril

sanguínea pós-operatória em artroplastia total de quadril (ATQ).

Transfusão sanguínea

Métodos: amostras laboratoriais sanguíneas de 78 pacientes consecutivos submetidos à

Hemoglobina

ATQ foram analisadas em cinco em períodos distintos (um pré-operatório e quatro pós-operatórios). Verificou-se a contagem de hemoglobina, hematócrito e plaquetas desses pacientes. Foram analisadas características antropométricas e comportamentais e comorbidades referentes à amostra, para verificac¸ão de fatores de risco associados à prática transfusional. Os indivíduos do estudo foram divididos em dois grupos: aqueles que receberam transfusão sanguínea foram alocados no Grupo 1 (G1) e os que não a receberam, no Grupo 2 (G2). As condutas transfusionais respaldaram-se dos critérios da Academia Americana de Anestesiologia e da Sociedade Britânica de Hematologia. Resultados: receberam transfusão de hemoderivados 27 (34,6%) pacientes. As análises das curvas de hemoglobina, hematócrito e plaquetas entre o G1 e o G2 nas cinco visitas distintas foram similares (p > 0,05). Todos os fatores de risco analisados, com excec¸ão da etnia, não apresentaram repercussões nos índice de transfusão em suas análises com valor p > 0,05. A soma das comorbidades clínicas associadas aos pacientes no G1 foi mediana de 3 (IC 95% 2,29–3,40), enquanto no G2 a mediana foi 2 (IC 95% 1,90–2,61) com valor p = 0,09. Conclusão:

a curva hemática apresenta confiabilidade limitada quando usada como

parâmetro exclusivo e absoluto. A existência de pacientes tolerantes às variac¸ões da curva hematimétrica pressupõe que as suas avaliac¸ões de caráter clínico, funcional e de comorbidades sejam parâmetros que devam influenciar na decisão do uso de hemoderivados. © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Todos os direitos reservados.

Introduction The indication for blood transfusion in prosthetic orthopedic procedures – especially hip arthroplasty – generates disagreement among medical professionals as the management of post-surgical anemia.1–4 The standardization of transfusional procedures in the post-operative management with laboratory thresholds was initially done in 1942,5 because of the fear of complications such as fatigue and inability to recover and rehabilitate the patient, together with the high costs and with the morbidity and long hospital stays. Further understanding of human physiology brought greater doubt about the use of preset laboratory thresholds for transfusion. Because of the risk of bleeding during and after surgery, and of drainage and secretion of the surgical wound, its imposition as routine practice was countered by the risks related to the consequences of its use. We report an association of this practice with highest rates of surgical site infection,4,6 and increase of post-operative pneumonia index and mortality in the short term, and vascular events, besides autoimmune reactions, systemic inflammatory response syndrome, and transmission of contagious diseases.6–8 Numerous guidelines depict the local experience of specific centers, or demonstrate the scenario of medical groups’ procedures in several countries,9–11 but there is no support or specific worldwide standardization for these conducts.12 Prominent studies warn about the risk factors associated with blood transfusions, being adamant in defining optional preoperative methods for reducing the costs and morbidities related

to the use of allogeneic blood products. The use before, during and after the surgical procedures of substances such as ferrous sulphate, erythropoietin, trenexamic acid, recombinant factor VII and fibrin glue, and the promotion of protocols of autotransfusion, hemodilution and rescue of red blood cells,8 are the main approaches, although not without risks,8 to solve this issue.4,6,13–17 The gaps related to the conducts regarding the use of blood products led us to define the overall functioning of the postoperatory laboratory hematic curve of patients undergoing primary total hip arthroplasty (THA) in this orthopedic referral service. The objective was to understand the real need for blood transfusions based on their laboratory results. In this study, possible factors that could influence the transfusion procedures were examined, to explain why some patients presented clinical and laboratory recovery without the use of blood transfusion, based on absolute numbers. This analysis questions and alerts about necessary precautions of routine blood transfusion.

Materials and methods From January 2011 to June 2012 those patients undergoing THA in the Santa Casa de Porto Alegre (HSCPOA) Hospital Complex were enrolled in this prospective study. Seventy-eight participants were randomized and provided written informed consent. This study was approved by the HSCPOA institutional ethics and research board. Patients with any hematopoietic disorder, hemoglobin levels below 10 g/dL, active contagious


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Table 1 – Risk factors among transfused (G1) and not transfused (G2) patients (comparison between means of parametric continuous variables and median of the nonparametric variable). Variable (means ± standard deviation) a

Age Weighta BMIa MBPa Preoperatory hemoglobina Trans-operatory bleedinga Post-operatory bleedinga Sum of comorbitiesb (median and CI 95%)

Transfused (G1) 56.44 ± 15.07 71.68 ± 17.53 25.97 ± 5.58 93.11 13.51 ± 1.55 540 ± 272.11 262.42 ± 219. 52 4 (IC 95% 2.29–3.40)

Not transfused (G2) 59.58 ± 11.82 73.18 ± 13.72 27.59 ± 4.57 98.34 13.60 ± 1.36 414.84 ± 142.37 218.66 ± 175.35 2 (IC 95% 1.9–2.61)

Total

p

58.5 ± 13.02 72.6 ± 15.05 27.09 ± 4.97 96.54 13.59 ± 1.42 458.98 ± 205.08 238.56 ± 205.27

0.31 0.67 0.17 0.11 0.91 0.019 0.09 0.09

CI, confidence interval. a b

Student t-test. Mann–Whitney U-test.

or infectious chronic liver disease, and with malignant tumor were excluded from the study. Patients rigidly followed a protocol for collecting data through serial visits. The first visit (V1) occurred preoperatively (from seven to three days before surgery); in this stage, first hematimetric laboratory tests and demographics and physical data of the participants (gender, age, ethnicity, weight, height, body weight index [BMI], comorbidities, alcoholism, smoking, and vital signs) were collected; in the second visit (V2), which occurred on the first post-operative day (6–12 h after surgery), the second laboratory hematimetric sample and data regarding surgery were collected, and the drainage of the suction drain was calculated; the third visit (V3) occurred on the second post-operative day (24–48 h after surgery), with the same procedures of V2; the fourth (V4) and the fifth (V5) visits occurred in the first (between 4 and 7 days) and third weeks (14–17 days) post-operatively, respectively, and were characterized by laboratory collection and data from late post-operative period. In the laboratory evaluation, we analyzed the red series hemocytometry (hemoglobin, hematocrit and platelets). The sample collections were done during the hospital stay (V2–V3–V4) and in the outpatient clinic (V1 and V5). All patients were operated on by the same surgical team, consisting of two surgeons and two anesthetists. The surgical routine consisted of calculating the intraoperative bleeding (through the suction volume of the drains and by weighing the pads) and of a general description of the prosthetic procedure. The anesthetic routine was similar in all patients: spinal anesthesia followed by sedation. The posterior surgical technique for access for all cases of THA was chosen. During the closure of the surgical plans, all patients received closed suction drains, which were maintained for 48 h. The mean operative time was 98.3 ± 4.2 min (range: 80–120 min). Post-operatively, all patients used prophylactic unfractionated heparin (5000 units 12/12 h) for a minimum of seven days and vacuum suction drain for two days. No patient received steroid or anti-inflammatory medication. Analgesic drugs were based on opioids and non-narcotic pirazolonic derivatives (dipyrone). The procedures of intraoperative and post-operative transfusion of the anesthetic/surgical team were obeyed, and criteria based on guidelines were used in their conduct.18,19 Blood products were used during surgery when there was significant bleeding that would interfere with the patient’s

hemodynamic status. The anesthetist was solely responsible for the use/degree of the blood product. Post-operatively, of necessity the healthy patients received blood products with Hb < 7 g/dL, whereas those with cerebrovascular disease, coronary artery disease, peripheral vascular disease and chronic pulmonary vascular disease received blood transfusions with Hb < 8 g/dL. According to transfusion criteria, we allocate the patients into two groups: Group 1 (G1) – patients who received blood transfusion; and Group 2 (G2) – patients who did not receive blood products. In this study population, the participants had a mean age of 58.5 ± 13 (G1 = 56.4 and G2 = 15 ± 59.5 ± 11.8 (p = 0.31). Weight and BMI of G1 and G2, respectively, were 71.6 ± 17.5/25.9 ± 5.5 and 73.1 ± 13.7/27.5 ± 4.5 (p > 0.05). Preoperatively, the mean arterial pressure (MAP) was 96.54 mmHg (p > 0.05) for G1 (93.11 mmHg) and G2 (98.34 mmHg) groups. Preoperative hemoglobin for G1 and G2 was 13.5 ± 1.5 and 13.6 ± 1.3 (p = 0.91), respectively (Table 1). Patients were sorted and analyzed by SPSS 17.0 software (Chicago, IL, USA). For continuous variables, descriptive statistics demonstrated performance characteristics (central tendency and dispersion). By the adherence test of Kolmogorov–Smirnov (K–S), with the Lilliefors correction of normality, the normality of data was tested. Analysis of variance (ANOVA) for hematological curves was adopted. Additional tests (post hoc) were conducted to evaluate specific differences between means, by pairs. In the analysis of risk factors, the discrete variables were assessed by Yates chi-square test, whereas for parametric and nonparametric continuous variables the Student t test and Mann–Whitney, respectively, were used. In all interpretations, the level of significance was set at p < 0.05.

Results Twenty-seven (34.6%) patients received blood transfusions: 19 (55.6%) during surgery and 12 (44.4%) post-operatively. The average intraoperative blood loss was 458.9 ± 205 mL (G1 = 540 ± 272 mL and G2 = 414.8 ± 142.3 mL [p = 0.019]). Mean post-operative bleeding was 238, 56 ± 205.27 mL (G1 = 262.4 ± 219.5 mL and G2 = 218.6 ± 175.3 mL [p = 0.09]). The curves of hemoglobin, hematocrit and platelets among transfused (G1) and not transfused (G2) patients displayed


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Table 2 – Hemoglobin, hematocrit and platelet values among transfused (G1) and not transfused (G2) patients in five visits (V1–V5). Hb (g/dL) G1 G2 Ht (%) G1 G2 Platelets (mm3 ) G1 (mm3 ) G2 (mm3 ) a

Hb (V1) (g/dL)

Hb (V2) (g/dL)

Hb (V3) (g/dL)

Hb (V4) (g/dL)

Hb (V5) (g/dL)

pa

13.57 ± 1.55 13.6 ± 1.36 Ht (V1) (%) 38.81 ± 4.48 40.08 ± 4.05 Platelets (V1) (mm3 ) 250.69 ± 43.23 245.22 ± 66.39

11.44 ± 1.73 11.45 ± 1.76 Ht (V2) (%) 32.85 ± 5.04 33.79 ± 4.75 Platelets (V2) (mm3 ) 231.92 ± 77.11 215.14 ± 77.11

9.6 ± 1.64 10.2 ± 1.52 Ht (V3) (%) 27.88 ± 4.69 30.04 ± 4.58 Platelets (V3) (mm3 ) 270.5 ± 77.4 286.93 ± 83.73

10.8 ± 1.53 11.1 ± 1.45 Ht (V4) (%) 31.78 ± 4.62 33.03 ± 4.07 Platelets (V4) (mm3 ) 466.75 ± 114.9 476.4 ± 170.48

12.55 ± 1.58 12.48 ± 1.29 Ht (V5) (%) 36.79 ± 4.4 36.93 ± 3.65 Platelets (V5) (mm3 ) 283.78 ± 67.99 266.97 ± 105.89

>0.05

>0.05

>0.05

Considering the curve analysis by ANOVA and at each respective visit (V1–V5) in the post hoc test.

15

600

14

HB (Mean values)

Transfused 12 11

Yes

10

No

Platelets (Mean values)

500 13

Transfused

400

Yes

300

No 200

9 8 N=

27

51

Visit 1

26

50

Visit 2

26

51

Visit 3

27

46

Visit 4

26

47

100

Visit 5

N=

26

49

Visit 1

Fig. 1 – Laboratory hemoglobin curve among transfused and not transfused patients.

normal distribution in their graphical representation. For all analyses of the curves between G1 and G2, p > 0.05. While the hemoglobin and hematocrit graphics data followed a parabolic normal curve, the platelet curve generated a graph with normal oscillation, represented by a curve peak during the visit 4. Their values are shown in Table 2 and Figs. 1–3. The population risk factors were separately verified. For parametric data such as age, body weight and BMI, mean arterial pressure (MAP) and preoperative hemoglobin, p > 0.05

HT (Mean values)

50

Transfused 40 Yes

No

30

20 N=

27

51

Visit 1

26

50

Visit 2

26

51

Visit 3

27

46

Visit 4

26

47

Visit 5

Fig. 2 – Laboratory hematocrit curve among transfused and not transfused patients.

26

48

Visit 2

24

49

Visit 3

24

45

Visit 4

23

45

Visit 5

Fig. 3 – Laboratory platelet curve among transfused and not transfused patients.

(Table 1). Except for ethnicity, nonparametric variables such as smoking, alcoholism, cemented or not cemented implant, hypertension and diabetes had an impact on rates of transfusion in their analysis, with p > 0.05 (Tables 1 and 3). The sum of comorbidities associated with patients in G1 had a median of 3 (95% CI 2.29–3.40), while in G2 the median was 2 (95% CI 1.90–2.61) (p = 0.09) (Table 1).

Discussion The standardization of transfusional conducts is still a challenging topic. In the first studies, dating from the 1940s,5 the hemoglobin value adopted for post-surgery control of anemia was 10 g/dL. This limit was changed in the early 1990s, with the expansion of knowledge about the behavior of acute (traumatic and surgical) shock and with detailed studies of the use of blood products in patients with severe disease. The guidelines then began to orient the new transfusional conducts,18,19 even in specific areas such as orthopedia.20 The hemoglobin thresholds were modified, from 10 g/dL to 7 g/dL in healthy patients and to 8 g/dL in patients with a comorbidity (age > 65 years, with respiratory disease and occlusive vascular disease).4 From these numbers, another argument, namely, the possible subjective criteria that could guide the conduct of every professional, regardless of laboratory numerical analysis, emerged. This can be seen in studies that generally collected and analyzed national or international multicentric


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Table 3 – Risk factors among transfused (G1) and not transfused (G2) patients (association between discrete qualitative variables). Discrete variables

Transfused (G1)

Not transfused (G2)

Total

p

a

Gender Male Female

17 (21.8%) 10 (12.8%)

26 (33.3%) 25 (32.1%)

43 (55.1%) 35 (44.9%)

0.31

Etnicitya Caucasian Black

26 (33.3%) 1 (1.3%)

40 (51.3%) 11 (14.1%)

66 (84.6%) 12 (15.4%)

0.03

Tabagisma Yes Not

9 (11.5%) 18 (23.1%)

11 (14.1%) 40 (51.3%)

20 (25.6%) 58 (74.4%)

0.25

Alcoholisma Yes Not

14 (17.9%) 13 13 (16.7%)

19 (24.4%) 32 32 (41.0%)

33 (42.3%) 45 45 (57.7%)

0.21

Hypertensiona Yes Not

13 (16.7%) 14 (17.9%)

23 (29.5%) 28 (35.9%)

36 (46.2%) 42 (53.8%)

0.79

Type of prosthesisa Cemented Not cemented

19 (24.4%) 8 (10.3%)

30 (38.5%) 21 (26.9%)

49 (62.8%) 29 (37.2%)

0.31

a

Yates chi-squared test.

conducts.2,12,20 Those studies portrayed divergent attitudes toward transfusion measures among different centers,2,21 and even among medical professionals of different subspecialties. Young et al.1 demonstrated that surgeons have a more aggressive transfusion conduct, especially when hemoglobin values ranged from 7 g/dL to 10 g/dL. In this study, from a total of 44 patients who had hemoglobin levels between 10 and 7 g/dL, 27 were not transfused with blood products. This implies that perhaps more restrict transfusional measures are adopted in the post-surgical area. We believe that objective criteria may lose its power to influence the post-operative period, by subdividing the responsibility for the recovery of the hematimetric curve with the clinic of the patients and their potential risk factors. However, this situation does not occur during intraoperative transfusions, which, although reliably quantify the necessity of blood replacement,18,19 represented 55% of transfusions in this study. This aggressive transfusional attitude is explained by the situational and dynamic medical conduct determined by intraoperative acute events. The main reasons for transfusion selected by the anesthetists were: transient hypotension unresponsive to crystalloids and trans-operatory disturbances of cardiac and respiratory rhythm caused by transitory shock. It is important to consider that the main guidelines are categorical in their conclusions. They define that the absolute numbers are not the only decisive factors exclusively for taking perioperative decisions,18,19 despite the tendency of most health professionals, toward keeping their conduct based solely on laboratory values.22 It is estimated that in the area of hip replacement surgery the rates of blood transfusions can vary between 33 and 74% of patients.4,8 These numbers reinforce the findings of this study, in which 34.6% of patients received blood products, despite the option for the more restrictive transfusion behaviors. This demonstrates that the need for improvement of these indices remains a challenge that is awaiting for better solutions.

In order to ascertain the possible variables that influence the transfusion rates, specific studies of blood transfusion in elective orthopedic procedures preferred to stick to the main transfusion criteria, risk factors and use of optional methods,4,6,12,14–16 failing to emphasize the importance of the behavior of the laboratory curve. In this study, we demonstrated an objective approach to the behavior of the curves of hemoglobin, hematocrit and platelets. As a result, we found behavioral similarity between the two analyzed groups, and this finding answered the question of the study: patients generally have similar recovery speed of the hematimetric values, regardless of blood transfusion. From this premise, some assumptions are evident. There is a significant number of individuals tolerant to surgical blood loss below the predetermined thresholds and these people present a satisfactory functional recovery without using blood products.22 In order to ascertain the possible variables influencing the transfusion rates, specific studies of blood transfusion in elective orthopedic procedures has been either complied with major transfusion criteria, risk factors and use of optional methods,4,6,12,14–16 and did not emphasize the importance of the behavior of the laboratory curve. In this study, we demonstrated an objective approach to the behavior of the curves of hemoglobin, hematocrit and platelets. As a result, we observed behavioral similarity between the two analyzed groups, and this answered the question of the study: patients generally have similar rate of recovery from hematimetric values, regardless of blood transfusion. From this premise, some assumptions are evident. There is a significant number of individuals tolerant to surgical blood loss below predetermined thresholds and that present a satisfactory functional recovery without using blood products.22 In elective orthopedic surgeries, there is a need for a minimum level of preoperative Hb, with the variant value of 11 g/dL.8 However, for the post-operative control there are no


r e v b r a s o r t o p . 2 0 1 4;4 9(1):44–50

limiting requirements. Carson et al.23,24 found that there was no benefit in functional recovery with maintaining Hb levels above 10 g/dL, even in symptomatic patients (besides vascular disease), compared with those who maintained the basal level below 8 g/dL after hip orthopedic surgeries.23 Hebert et al.25 found that early mortality has not changed in 838 critically ill patients who received aggressive transfusion (Hb < 10 g/dL), compared with those who had more restrict transfusions (Hb < 7 g/dL). Viele et al.26 analyzed patients (all of them Jehovah’s Witnesses) who tolerated Hb levels below 8 g/dL,26 with adequate recovery and presented preliminary demands only when the levels reached less than 5 g/dL (in association with increased risk of morbidity and mortality). The indices of hematocrit follow a tolerance threshold for transfusion between values of 18–25%,18 and can reach 15–20% without myocardial damage caused by lactic acid production. Cardiac failure occurs when the thresholds are close to 10%.3,18 Regarding platelets, preoperative minimum indices are relevant when they are below 50,000 mm3 , a circumstance remote from most patients undergoing elective THA – which explains the null rate specific for platelet transfusions. The behavior of hemoglobin and hematocrit curves followed a parabolic path with normal distribution of data and a downward peak was observed during the visit 3; regardless of transfusion, the peak had returned to the baseline threshold at visit 5. The graphical representation of platelets was peculiar, due to the characteristic oscillation between visits 2 and 4, and represented a normalized peak from the visit 5, not corroborated by any relevant clinical alteration. With respect to this characteristic behavior, we found no comparative analyses with other arthroplasty studies. The assessment of risk factors for transfusion is of utmost importance, since it presupposes an analysis of each individual that, possibly, be a predictor of normal variation of the hematimetric curve. Consistent with the literature, this study suggests that the risk factors are synergistic and cumulative.27 That is, the increase in the number of comorbidities of patients would probably be the variable with the greatest impact on the individual’s propensity to use blood products.27 Risk factors are invariably discussed per se. Preoperatory hemoglobin (Hb),27,28 < 12 g/dL is a predictor that influenced the Aderinto and Brenke,18 series in up to 70% of transfused patients. In our analysis, we did not give much consideration to this important predictor of risk, because the blood transfusions occurred in equal proportions in patients with Hb < 12 g/dL (36.4%) versus Hb > 12 g/dL (34.3%). It is noteworthy that, at randomization, anemic patients (Hb < 11 g/dL) were excluded. Many of these patients mentioned in Aderinto and Brenkel series,8 Salido et al.28 and Pola et al.27 showed hemoglobin values below 11 g/dL, implying that preoperative anemia is the decisive factor in the risk of transfusion. The value of 12 g/dL would be a safety number for performing arthroplasties with less risk of use of blood products.28 Other risk factors already mentioned in the literature were not correlated with the results of the present study, including advanced age, which is associated with 43% of anemia of chronic disease,4 females,4,6 comorbidities (e.g., diabetes mellitus and systemic arterial hypertension), low body mass index – lean patients (risk near 40% in patients < 70 kg), short stature, type of anesthesia and surgical technique.8,27

49

Parker et al.29 state that post-operative anemia should not be tolerated in elderly patients’ recovery, giving priority to aggressive transfusion conducts (in association with a higher rate of falls, cognitive impairment, cardiovascular risk, and decreased quality of life). Some peculiar characteristics are related to male patients who lose more blood in prosthetic procedures. Women, however, tolerate less blood loss and have a higher risk of transfusion.27 The use of post-operative closed suction,29 presents further evidence of transfusion risk in elective arthroplasties, as well as demonstrating little benefit in controlling infections and hematomata.29 Until now, no study discussed alcoholism and smoking as possible risk factors, as well as ethnicity. In our study, black people had a lower tendency to blood transfusion. Bell et al.6 associated prophylaxis for deep venous thrombosis (DVT) with unfractionated heparin to increased chances of transfusion, but with no reason established. Interestingly, Carson et al.24 and Pola et al.27 were remarkable in the establishment of transfusional conducts in patients undergoing orthopedic procedures.23,30 These authors determined that, initially, the use of blood products should precede objective parameters (laboratory indices), but that the subjective parameters (clinical and comorbidities’ analysis) rationalize the practice of transfusion. With this objective, they observed a decrease in the percentage and amount of transfusion without additional risks of mortality and myocardial infarct.30 We support this transfusion practice and, through our study, we confirm too the possibility of improving the use of blood products. Other optional methods to avoid transfusion measures with significance level still have high costs (such as recombinant erythropoietin,4 ), or gaps regarding their practicity.4,11,13,15

Conclusions The rate of blood transfusion among patients treated with hip arthroplasty was 34.6%. There is a pattern of behavior of the post-operatory hemoglobin and hematocrit curve that follows a parabola with normal distribution. However, the platelet curve follows an oscillatory path of the normal curve. The hematimetric curve has limited reliability when used as the sole and absolute parameter. The clinical and functional analysis of the patient and of its comorbidities constitutes the best parameter to influence the decision to use blood products, in association with laboratory evaluation.

Conflicts of interest The authors declare no conflicts of interest.

references

1. Young SW, Marsh DJ, Akhavani MA, Walker CG, Skinner JA. Attitudes to blood transfusion post arthroplasty surgery in the United Kingdom: a national survey. Int Orthop. 2008;32(3):325–9.


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2. Rosencher N, Kerkkamp HE, Macheras G, Munuera LM, Menichella G, Barton DM, et al. Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) study: blood management in elective knee and hip arthroplasty in Europe. Transfusion. 2003;43(4):459–69. 3. Nuttall GA, Stehling LC, Beighley CM, Faust RJ. Current transfusion practices of members of the American Society of Anesthesiologists: a survey. Anesthesiology. 2003;99(6):1433–43. 4. Munoz M, Garcia-Erce JA, Villar I, Thomas D. Blood conservation strategies in major orthopaedic surgery: efficacy, safety, and European regulations. Vox Sang. 2009;96(1):1–13. 5. Adams RC, Lundy JS. Anesthesia in cases of poor surgical risk: some suggestions for decreasing the risk. Surg Gynecol Obstet. 1942;74:1011–9. 6. Bell TH, Berta D, Ralley F, Macdonald SJ, McCalden RW, Bourne RB, et al. Factors affecting perioperative blood loss and transfusion rates in primary total joint arthroplasty: a prospective analysis of 1642 patients. Can J Surg. 2009;52(4):295–301. 7. Pedersen AB, Mehnert F, Overgaard S, Johnsen SP. Allogeneic blood transfusion and prognosis following total hip replacement: a population-based follow up study. BMC Musculoskelet Disord. 2009;10:167. 8. Aderinto J, Brenkel IJ. Pre-operative predictors of the requirement for blood transfusion following total hip replacement. J Bone Joint Surg Br. 2004;86(7):970–3. 9. Sturdee SW, Beard DJ. A strategy for reducing blood-transfusion requirements in elective orthopaedic surgery. J Bone Joint Surg Br. 2004;86(3):464. 10. Booth D, Kothmann E, Tidmarsh M. A strategy for reducing blood-transfusion requirements in elective orthopaedic surgery. J Bone Joint Surg Br. 2004;86(2):309–10. 11. Helm AT, Karski MT, Parsons SJ, Sampath JS, Bale RS. A strategy for reducing blood-transfusion requirements in elective orthopaedic surgery. Audit of an algorithm for arthroplasty of the lower limb J Bone Joint Surg Br. 2003;85(4):484–9. 12. Carless PA, Henry DA, Carson JL, Hebert PP, McClelland B, Ker K. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev. 2010;10:CD002042. 13. Couvret C, Tricoche S, Baud A, Dabo B, Buchet S, Palud M, et al. The reduction of preoperative autologous blood donation for primary total hip or knee arthroplasty: the effect on subsequent transfusion rates. Anesth Analg. 2002;94(4):815–23. 14. Feagan BG, Wong CJ, Kirkley A, Johnston DW, Smith FC, Whitsitt P, et al. Erythropoietin with iron supplementation to prevent allogeneic blood transfusion in total hip joint arthroplasty. A randomized, controlled trial. Ann Intern Med. 2000;133(11):845–54. 15. Gonzalez-Porras JR, Colado E, Conde MP, Lopez T, Nieto MJ, Corral M. An individualized pre-operative blood saving protocol can increase pre-operative haemoglobin levels and reduce the need for transfusion in elective total hip or knee arthroplasty. Transfus Med. 2009;19(1):35–42.

16. Ho KM, Ismail H. Use of intravenous tranexamic acid to reduce allogeneic blood transfusion in total hip and knee arthroplasty: a meta-analysis. Anaesth Intensive Care. 2003;31(5):529–37. 17. Yamamoto K, Imakiire A, Masaoka T, Shinmura K. Autologous blood transfusion in total hip arthroplasty. J Orthop Surg (Hong Kong). 2004;12(2):145–52. 18. Practice guidelines for blood component therapy: a report by the American Society of Anesthesiologists Task Force on Blood Component Therapy. Anesthesiology. 1996;84(3):732–47. 19. Murphy MF, Wallington TB, Kelsey P, Boulton F, Bruce M, Cohen H, et al. Guidelines for the clinical use of red cell transfusions. Br J Haematol. 2001;113(1):24–31. 20. Feagan BG, Wong CJ, Lau CY, Wheeler SL, Sue AQG, Kirkley A. Transfusion practice in elective orthopaedic surgery. Transfus Med. 2001;11(2):87–95. 21. Boralessa H, Goldhill DR, Tucker K, Mortimer AJ, Grant-Casey J. National comparative audit of blood use in elective primary unilateral total hip replacement surgery in the UK. Ann R Coll Surg Engl. 2009;91(7):599–605. 22. Vuille-Lessard E, Boudreault D, Girard F, Ruel M, Chagnon M, Hardy JF. Red blood cell transfusion practice in elective orthopedic surgery: a multicenter cohort study. Transfusion. 2010;50(10):2117–24. 23. Carson JL, Terrin ML, Barton FB, Aaron R, Greenburg AG, Heck DA, et al. A pilot randomized trial comparing symptomatic vs. hemoglobin-level-driven red blood cell transfusions following hip fracture. Transfusion. 1998;38(6):522–9. 24. Carson JL, Terrin ML, Noveck H, Sanders DW, Chaitman BR, Rhoads GG, et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med. 2011;365(26):2453–62. 25. Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999;340(6):409–17. 26. Viele MK, Weiskopf RB. What can we learn about the need for transfusion from patients who refuse blood? The experience with Jehovah’s Witnesses. Transfusion. 1994;34(5):396–401. 27. Pola E, Papaleo P, Santoliquido A, Gasparini G, Aulisa L, De Santis E. Clinical factors associated with an increased risk of perioperative blood transfusion in nonanemic patients undergoing total hip arthroplasty. J Bone Joint Surg Am. 2004;86-A(1):57–61. 28. Salido JA, Marin LA, Gomez LA, Zorrilla P, Martinez C. Preoperative hemoglobin levels and the need for transfusion after prosthetic hip and knee surgery: analysis of predictive factors. J Bone Joint Surg Am. 2002;84-A(2):216–20. 29. Parker MJ, Roberts CP, Hay D. Closed suction drainage for hip and knee arthroplasty. A meta-analysis. J Bone Joint Surg Am. 2004;86(6):1146–52. 30. Grover M, Talwalkar S, Casbard A, Boralessa H, Contreras M, Brett S, et al. Silent myocardial ischaemia and haemoglobin concentration: a randomized controlled trial of transfusion strategy in lower limb arthroplasty. Vox Sang. 2006;90(2):105–12.


r e v b r a s o r t o p . 2 0 1 4;4 9(1):51–55

www.rbo.org.br

Original Article

Clinical and radiographic medium-term evaluation on patients with developmental dysplasia of the hip, who were submitted to open reduction, capsuloplasty and Salter osteotomy夽,夽夽 Válney Luiz da Rocha, Guilherme Lima Marques, Leonardo Jorge da Silva, Tiago Augusto di Macedo Bernardes, Frederico Barra de Moraes ∗ Departamento de Ortopedia e Traumatologia, Hospital das Clínicas, Universidade Federal de Goiás, Goiânia, GO, 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 and radiographic medium-term results from surgical treat-

Received 12 October 2012

ment of developmental dysplasia through open reduction, Salter et al.’s osteotomy and

Accepted 22 March 2013

capsuloplasty. Methods: 13 patients were evaluated, 13 hips treated surgically by the proposed technique

Keywords:

between 2004 and 2011. A clinical and radiographic evaluation was conducted by Dutoit

Congenital hip dislocation/surgery

et al. and Severin et al. criteria, respectively.

Surgical procedures

Results: the acetabular preoperative index for the 13 surgically treated hips ranged from 27◦

Operative/methods

to 50◦ (average of 36), and after surgical correction to 18.5◦ (10–28◦ ), so that the evaluations of

Bone diseases

preoperative and postoperative acetabular indexes showed up significant statistic reduction

Developmental

(p < 0.05). Regarding the postoperative clinical evaluation, it was found: nine excellent hips

Hip/growth and development

(69.2%), three good ones (23.1%), no fair hips (0%) and a poor one (7.7%). In radiographic evaluation, it was found: six excellent hips (46.1%), three good ones (23.1%), no fair hips (0%) and four poor ones (30.8%). Therefore, favorable results were obtained (92.3%), with grouped hips with excellent and good ratings as satisfactory and with fair and bad ratings as unsatisfactory. It is also important to notice that there was no significance among occurrence of complications, the patient’s age, the time of surgery and the preoperative acetabular index (p > 0.05). As complications occurred, it was found that three subluxations and a subluxation associated with avascular necrosis of the femoral head. Conclusion: open reduction, Salter et al.’s osteotomy and capsuloplasty are seen to be a viable option for the treatment of developmental dysplasia of the hip, according to clinical and radiological medium-term evaluations. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

夽 Please cite this article as: da Rocha VL, Marques GL, da Silva LJ, di Macedo Bernardes TA, de Moraes FB. Avaliac¸ão clínica e radiológica em médio prazo dos pacientes portadores de displasia do desenvolvimento do quadril submetidos a reduc¸ão aberta, capsuloplastia e osteotomia de Salter. Rev Bras Ortop. 2014;49:51–55. 夽夽 Study conducted at Pediatric Orthopedia Service, Department of Orthopedia and Traumatology, Hospital das Clínicas, Universidade Federal de Goiás, Goiânia, GO, Brazil. ∗ Corresponding author. E-mail: frederico barra@yahoo.com.br (F.B. de Moraes).

2255-4971/$ – see front matter © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

http://dx.doi.org/10.1016/j.rboe.2014.01.006


52

r e v b r a s o r t o p . 2 0 1 4;4 9(1):51–55

Avaliac¸ão clínica e radiológica em médio prazo dos pacientes portadores de displasia do desenvolvimento do quadril submetidos a reduc¸ão aberta, capsuloplastia e osteotomia de Salter r e s u m o Palavras-chave:

Objetivo: avaliar o resultado clínico e radiológico do tratamento cirúrgico da displasia do

Luxac¸ão congênita do

desenvolvimento do quadril em médio prazo, por meio da reduc¸ão aberta, da capsuloplastia

quadril/cirurgia

e da osteotomia de Salter et al.

Procedimentos cirúrgicos

Métodos: foram avaliados 13 pacientes, 13 quadris, entre 2004 e 2011, tratados cirurgica-

operatórios/métodos

mente pela técnica proposta. Uma avaliac¸ão clínica e radiológica foi feita pelos critérios de

Doenc¸as do desenvolvimento

Dutoit et al. e Severin et al., respectivamente.

ósseo

Resultados: nos 13 quadris acometidos o índice acetabular pré-operatório variou de 27◦ a

Quadril/crescimento e

50◦ (média de 36) e, após correc¸ão cirúrgica, para 18,5◦ em média, com variac¸ão de 10◦ a 28◦ ,

desenvolvimento

de modo que as avaliac¸ões dos índices acetabulares pré e pós-operatórios apresentaram reduc¸ão com significância estatística (p < 0,05). Quanto à avaliac¸ão clínica pós-operatória, foram encontrados: nove quadris ótimos (69,2%), três bons (23,1%), nenhum regular (0%) e um ruim (7,7%). Na avaliac¸ão radiológica, foram encontrados seis quadris ótimos (46,1%), três bons (23,1%), nenhum regular (0%) e quatro ruins (30,8%). Portanto, obtiveram-se resultados favoráveis em 92,3%, pois agrupam-se quadris com avaliac¸ão ótima e boa como satisfatórios e os com avaliac¸ão regular e ruim como insatisfatórios. Atente-se que não houve significância entre a ocorrência de complicac¸ões, a idade do paciente, o momento da cirurgia e o índice acetabular pré-operatório (p > 0,05). Como complicac¸ões ocorridas, têmse três subluxac¸ões isoladas e uma subluxac¸ão associada à necrose avascular da cabec¸a femoral. Conclusão: a reduc¸ão aberta, a capsuloplastia e a osteotomia de Salter et al. são consideradas uma opc¸ão viável do ponto de vista clínico e radiológico em médio prazo para o tratamento da displasia do desenvolvimento do quadril. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Todos os direitos reservados.

Introduction Developmental dysplasia of the hip (DDH) involves a spectrum of developmental disorders of the hip, which present in different forms and ages, from a ligament laxity to complete dislocation of the femoral head. In such cases, the acetabulum is situated in an anterosuperior position as a result of excessive anteversion, which makes it increasingly shallow, thick and oblique. DDH is classified into two types: typical (subdivided into dislocable, subluxated and dislocated hip) and teratologic. The etiology of DDH remains unknown, but ethnic and genetic factors are important. Genetic factors may determine the acetabular dysplasia, ligament laxity or both, as reported by Wynne-Davies.1 In addition to the preexisting factors, mechanical factors such as intrauterine position and postnatal habits can also interfere with the process. In several papers, the incidence of DDH ranged from 2 to 17 per 1000. In Brazil, Volpon and Carvalho Filho2 demonstrated an incidence of 2.31 per 1000. The treatment depends on the patient’s age, degree of acetabular and proximal femur dysplasia. It is considered that, after the start of the walking, a surgical option for the treatment of DDH consists of open reduction, Salter’s osteotomy, and capsuloplasty.3 This technique promotes acetabular repositioning, aiming to increase the coverage of the femoral head, which will be surgically reduced into the acetabulum.

The aim of this study was to evaluate the clinical and radiological outcome in the medium term surgical treatment of DDH by open reduction, Salter’s osteotomy, and capsuloplasty.

Materials and methods Thirteen patients who remained with DDH after they start walking, whether by failure of medical treatment in the first year of life or by referral of the child with a delayed diagnosis, were evaluated. All were treated surgically between 2004 and 2011, by the techniques of open reduction, capsuloplasty, and Salter’s osteotomy. The study was approved by the Ethics and Research Committee of the hospital, where the work was done. The age of patients ranged between one year and 11 months to six years. The group was composed of three males and 10 females, with six hips with involvement on the right side and seven on the left side. The average immobilization time with postoperative pelvi-pedal plaster was two months. The patients underwent surgical treatment with open reduction, capsuloplasty and Salter et al.’s osteotomy, as per surgical description,4 and were operated by the same orthopedic surgeon (Fig. 1). However, in only one case it was necessary to make previous traction to surgery. On average, the osteosynthesis material was removed after one year of postoperative follow-up, whose clinical and radiological evaluation occurred


r e v b r a s o r t o p . 2 0 1 4;4 9(1):51–55

53

Fig. 1 – Surgical technique: open reduction, capsuloplasty and Salter’s innominate osteotomy.

under an average outpatient follow-up of 5.3 years (1.4–14.1 years). To evaluate the results, radiographic and clinical criteria were employed. The radiographs were evaluated by the criteria of Severin,5 which take into account the Wiberg acetabular (AC) and CE angles, the sphericity of the femoral head, the dislocation and subluxation of the hip, and occurrence (or not) of arthrosis. With respect to the clinical situation, the analysis was performed in conformity to Dutoit et al. criteria,6 based on hip stability and mobility, pain, lameness and on the Trendelenburg test. The statistical analysis was performed descriptively and analytically, with the methods of McNemar, Friedman, Wilcoxon and Univariate Logistic Regression Analysis, in

order to establish statistical significance between the clinical and radiological parameters, with a significance level of 5% (p < 0.05).

Results The hips were pooled for analysis regardless of the involved side. In the 13 affected hips, the preoperative acetabular index ranged from 27◦ to 50◦ (average, 36◦ ) and after the surgical correction, the average was 18.5◦ (10–28◦ ). For this estimate, the Friedman test was used, and for pairwise comparison of the acetabular index, we used the Wilcoxon test, obtaining a statistically significant result (p < 0.05).


54

r e v b r a s o r t o p . 2 0 1 4;4 9(1):51–55

Fig. 2 – Radiological evolution of a female patient with DDH treated with Salter et al.’s osteotomy. Excellent radiologic result with 53 months’ follow-up.

According to Dutoit et al.,6 in the clinical evaluation we could observe nine very good (69.2%), three good (23.1%), 0 fair (0%), and 1 poor (7.7%) hip. Therefore, we grouped hips with good and very good evaluation as satisfactory, and those with poor and fair evaluation as unsatisfactory. Hence, we obtained 92.3% satisfactory results (Table 1). In the radiological study, six very good (46.1%) (Fig. 2), three good (23.1%), 0 fair (0%), and four poor (30.8%) hips were found. Therefore, we grouped hips with good and very good evaluation as satisfactory, and those with poor and fair evaluation as unsatisfactory. Hence, we obtained 69.2% of favorable results (Table 2). To evaluate the influence of Dutoit et al.6 and of Severin5 in relation to pre-and post-surgical treatment, considering the techniques of open reduction and capsuloplasty and Salter’s osteotomy, McNemar test and Fisher et al.’s exact test were applied, and no other correlations were observed, i.e., only the surgery interfered with the clinical and radiological outcome. With regard to complications, two isolated subluxations and one osteonecrosis of the femoral head with subluxation

Table 1 – Results of clinical evaluation according Dutoit.6 Treatment

Dutoit 1 – excellent 2 – good 3 – regular 4 – poor

Pre n

%

0 0 0 13

0.0 0.0 0.0 100.0

Post %

Nutrition

100.0

9 3 0 1

%

%

69.2 23.1 0.0 7.7

92.3 7.7

Table 2 – Results of radiological evaluation according Severin5 Treatment

Severin 1 – excellent 2 – good 3 – regular 4 – poor 5 – poor 6 – poor

Pre n

%

0 0 2 9 1 1

0.0 0.0 15.4 69.2 7.7 7.7

Post %

100.0

n

%

%

6 3 0 4 0 0

46.1 23.1 0.0 30.8 0.0 0.0

69.2 30.8

and dislocation occurred. This was one of the cases of isolated subluxation treated with another surgical procedure. There were no cases of infection, fracture, significant lower limb dysmetria, or neurovascular injury.

Discussion The surgical treatment of developmental dysplasia of the hip is becoming an increasingly less frequent challenge, thanks to current methods for early diagnosis and prevention, for example, the physical examination of the newborn and routine use of ultrasonography for suspected cases. Physical examination to identify cases of DDH should be done routinely on all newborns. The Ortolani maneuver, described in 1948 by Marino Ortolani apud Tachdjian,4 when positive, allows the diagnosis of DDH; however, the negativity does not exclude the diagnosis, because some hips are unstable, but not dislocated. The Barlow provocative maneuver allows the diagnosis of hip instability. Moreover, in children older than three months, the Ortolani maneuver may be negative, because even if the hip remains dislocated, it will be no longer possible to replace the femoral head into the acetabulum. With respect to the Barlow maneuver, it must be emphasized that many newborns tested positive in the first test become negative after two or three weeks. In the dislocated hip the treatment consists concentric and atraumatic reduction of femoral head within the acetabulum. Before the start of walking, this treatment may be conservative, however, after the child begins to walk there is a tendency of interposition of soft tissues, such as the round ligament, labrum and capsule of this joint. Hence, it is necessary an open reduction. Once achieved, this reduction can be maintained by means of procedures on the acetabulum, soft tissue, or both. Lindstrom et al.7 showed that if the concentric reduction is achieved and maintained, there will be remodeling of the acetabulum that will be more pronounced up to four years, and may occur up to eight years. Based on the joint mobility and stability in the presence of pain and/or lameness, Dutoit et al.6 developed a system of post-surgical clinical classification. Severin5 developed a system of radiological classification of the results of surgical procedures for treatment of developmental dysplasia of the hip and evaluated deformities


r e v b r a s o r t o p . 2 0 1 4;4 9(1):51–55

of the head/neck and acetabulum, with reference to the CE angle of Wiberg and presence of post-surgical subluxation/dislocation. Salter et al.3 described an innominate osteotomy for the treatment of congenital hip dislocation and subluxation and promoted acetabular repositioning with the formation of a roof to support the femoral head after reduction. In their first report, Salter et al. evaluated 25 hips after follow-up of one to three years, and reported that all their patients achieved a good or excellent result. Bohm et al.8 studied 63 hips treated with innominate osteotomy, with a median follow-up of 30.9 years; in 88.8% of cases, they achieved satisfactory radiological results, according to Severin index. Tukenmez et al.9 evaluated 61 hips treated with Salter osteotomy and obtained satisfactory clinical and radiological results in 82% (Dutoit) and 94.5% (Severin) procedures, respectively, with an incidence of 21.5% of post-operative complications. Carvalho Filho et al.10 evaluated 18 patients with DDH treated with Salter et al.’s osteotomy and obtained 72% satisfactory clinical results (Dutoit) and 81% favorable radiological outcomes (Severin); 16.6% of patients had post-operative redislocation inside the cast. Of the 13 hips included in this study, we obtained satisfactory clinical and radiological results in 92.3% (Dutoit) and 69.2% (Severin), respectively. Thus, our findings agree with the results of other series. Saleh et al.11 have demonstrated absence of pelvic remodeling after innominate osteotomy in patients with skeletal maturity. In this study, the osteotomy was performed in patients between 1.9 and 6 years (age post-march), yet there was no influence on the clinical and radiographic results in the medium term, according to that described by Carvalho and Volpon Filho.2 Frequency, degree of disability, duration of symptoms and morbidity were taken into account. However, osteonecrosis is the most feared complication of treatment of DDH, and occurs only in patients who received some form of bloody or bloodless treatment, being regarded as a common cause of hip positioning in abduction > 70◦ or in forced medial rotation. This can occur even in the normal hip opposite to that which is being treated. Therefore, hip immobilizations in an adequate position and a careful bloodless or bloody reduction in accordance with the basic principles, may decrease the risk of this serious complication. It should be borne in mind that, in this study, there were complications, such as two cases of isolated

55

subluxation, a case of osteonecrosis associated with subluxation, and one dislocation.

Conclusion The association of Salter’s osteotomy with open reduction and capsuloplasty becomes a viable option for the treatment of DDH after the child begins to walk, with satisfactory clinical and radiological results.

Conflicts of interest The authors declare no conflicts of interest.

references

1. Wynne-Davies R. Acetabular dysplasia and familial joint laxity: two etiological factors in congenital dislocation of the hip. A review of 589 patients and their families. J Bone Joint Surg Br. 1970;52(4):704–16. 2. Volpon JB, Carvalho Filho G. Luxac¸ão congênita do quadril no recém-nascido. Rev Bras Ortop. 1985;20(7):317–20. 3. Salter RB. Innominate osteotomy in treatment of congenital dislocation of the hip. J Bone Joint Surg. 1961;43:72–80. 4. Tachdjian MO. Dysplasia congenital of the hip. In: Pediatric orthopaedics. 2nd ed. Philadelphia: Saunders; 1990. 5. Severin E. Contribution to knowledge of congenital dislocation of hip joint: late results of closed reduction and arthrographic studies of recent cases. Acta Chir Scand. 1941;84:1–142. 6. Dutoit M, Moulin P, Morscher E. Salter’s innominate osteotomy. 20 years later. Chir Pediatr. 1989;30(6):277–83. 7. Lindstrom JR, Ponseti IV, Wenger DR. Acetabular development after reduction in congenital dislocation of the hip. J Bone Joint Surg Am. 1979;61(1):112–8. 8. Böhm P, Brzuske A. Salter innominate osteotomy for the treatment of developmental dysplasia of the hip in children: results of seventy-three consecutive osteotomies after twenty-six to thirty-five years of follow-up. J Bone Joint Surg Am. 2002;84(2):178–86. 9. Tukenmez M, Tezeren G. Salter innominate osteotomy for treatment of developmental dysplasia of the hip. J Orthop Surg (Hong Kong). 2007;15(3):286–90. 10. Carvalho Filho G, Chueire AG, Helencar I, Carneiro MO, Francese Neto J, Carnesin AC. Tratamento cirúrgico da luxac¸ão congênita do quadril pós-marcha: reduc¸ão aberta e osteotomia de Salter. Acta Ortop Bras. 2003;11(1):42–7. 11. Saleh JM, O’Sullivan ME, O’Brien TM. Pelvic remodeling after Salter osteotomy. J Pediatr Orthop. 1995;15(3):342–5.


r e v b r a s o r t o p . 2 0 1 4;4 9(1):56–61

www.rbo.org.br

Original Article

Tibiotalocalcaneal arthrodesis with retrograde intramedullary nailing: 29 patients’ clinical and functional evaluation夽 Thiago Barbosa Caixeta, Márcio Oliveira Calábria Júnior, Régis Vieira de Castro, Jefferson Soares Martins, Edegmar Nunes Costa, Alexandre Daher Albieri, Frederico Barra de Moraes ∗ Departamento de Ortopedia e Traumatologia, Hospital das Clínicas, Universidade Federal de Goiás, Goiânia, GO, 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 clinically and functionally the pos-operative results of patients sub-

Received 5 January 2013

mitted to tibiotalocalcaneal arthrodesis for the treatment of traumatic arthropathy and

Accepted 13 May 2013

neuropathy. Methods: Retrospective

study

of

29

patients

undergoing

ankle

arthrodesis

with

Keywords:

intramedullary retrograde nail. All patients were evaluated for fusion time, AOFAS

Osteoarthritis

and VAS scores, satisfaction, and complications of surgery. The mean follow-up was 36

Arthrodesis

months (range 6–60 months).

Ankle

Results: The union rate was 82%, and the consolidation occurred on average at 16 weeks

Fracture fixation

(10–24 weeks). The pos-operative AOFAS score improved in 65.5% (average of 57.7 on neu-

Intramedullary

rological cases and 75.7 on cases pos-traumatic) and VAS score improved 94.1% (average of 2.3 on neurological cases and 4,2 on post-traumatic cases), and 86% of patients were satisfied with the procedure performed. Complications occurred in 11 patients (38%), including pseudoarthrosis (17.24%), infection (17.24%), material failure (13.8%) and fracture (13.8%). Conclusion: Tibiotalocalcaneal arthrodesis with retrograde intramedullary nail proved to be a good option for saving the ankle joint, with improvement of clinical and functional scores (AOFAS = 65.5% and VAS = 94.1%). © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

Artrodese tibiotalocalcaneana com haste intramedular retrógrada: avaliac¸ão clínica e funcional de 29 pacientes r e s u m o Palavras-chave:

Objetivo: avaliar clínica e funcionalmente o pós-operatório de pacientes submetidos à

Osteoartrite

artrodese tibiotalocalcaneana para o tratamento das artropatias traumáticas e neurológicas

Artrodese

do tornozelo.

Please cite this article as: Caixeta TB, Júnior MOC, de Castro RV, Martins JS, Costa EN, Albieri AD, et al. Artrodese tibiotalocalcaneana com haste intramedular retrógrada: avaliac¸ão clínica e funcional de 29 pacientes. Rev Bras Ortop. 2014;49:56–61. ∗ Corresponding author. E-mail: frederico barra@yahoo.com.br (F.B. de Moraes). 2255-4971/$ – see front matter © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

http://dx.doi.org/10.1016/j.rboe.2013.12.017


57

r e v b r a s o r t o p . 2 0 1 4;4 9(1):56–61

Tornozelo

Métodos: estudo retrospectivo de 29 pacientes submetidos à artrodese do tornozelo com

Fixac¸ão intramedular de fraturas

haste intramedular retrógrada. Todos os pacientes foram avaliados em relac¸ão ao tempo de consolidac¸ão, escores Aofas e EVA e grau de satisfac¸ão, além de complicac¸ões do ato cirúrgico. O tempo de seguimento médio foi de 36 meses (variac¸ão de 6–60). Resultados: a taxa de união foi de 82% e o tempo médio de consolidac¸ão foi de 16 semanas (10-24). O critério Aofas melhorou no pós-operatório em 65,5% (média de 57,7 nos casos neurológicos e de 75,7 nos pós-traumáticos) e a EVA melhorou 94,1% (média de 2,3 nos casos neurológicos e de 4,2 nos pós-traumáticos) e 86% dos pacientes mostraram-se satisfeitos com o procedimento feito. As complicac¸ões ocorreram em 11 pacientes (38%), entre elas pseudartrose (17,24%), infecc¸ão (17,24%), falha do material (13,8%) e fratura (13,8%). Conclusão: a artrodese tibiotalocalcaneana com haste intramedular retrógrada mostrou ser uma boa opc¸ão para o salvamento da articulac¸ão do tornozelo, com melhoria dos critérios clínicos e funcionais (Aofas = 65,5% e EVA = 94,1%). © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Todos os direitos reservados.

Introduction The tibiotalocalcaneal arthrodesis is used as a salvage procedure for the ankle joint in patients with changes in the subtalar junction of the tibiotarsal joint.1–4 The indications for this procedure are mostly post-traumatic arthrodesis, rheumatoid arthritis, sequelae of infection, neuromuscular conditions, and failures of total ankle arthroplasty.2,5–11 In 1906, Lexer described for the first time the tibiotalocalcaneal arthrodesis with intramedullary fixation using cadaveric bone graft among the calcaneus, talus and tibia.12 Since the introduction of the concept of ankle arthrodesis by compression by Charnley in 1951, more than 30 techniques and a number of technical modifications have been described.8 Patients with ankle arthropathy often present with bone loss, osteopenia or severe deformities (Figs. 1 and 2A/B), which hinders the arthrodesis fixation.2,11,13,14 The literature has pointed to high infection rates (10–20%) and pseudoarthrosis6,12,15 (10–20%)8 associated with arthrodesis, especially for the treatment of neuromuscular arthropathies.5,12,13 Intramedullary fixation in tibiotalocalcaneal arthrodesis represents a modern approach, with the advantage of promoting rigid internal fixation with minimal periosteal aggression and vascular damage.6,7,15 In addition, the procedure promotes compression in the focus of the arthrodesis, with high consolidation ratios (85%) and an average arthrodesis fusion time of approximately three months.14,15 However, the procedure is not free of complications (30–80% in most series).7,14 The present study aimed to evaluate clinically and functionally patients undergoing tibiotalocalcaneal arthrodesis using a locked retrograde intramedullary nail for the treatment of neurological and traumatic arthropathy of the ankle and subtalar joint.

Materials and methods This is a retrospective study with a convenience sample of 29 patients with arthrosis of ankle and subtalar joints by traumatic and neurological causes. The mean age was 41.3 years (13–72), and 15 patients (51.7%) were male and 14 (48.3%)

females. Regarding etiology, 16 patients had post-traumatic arthropathy (55.2%), and in 13 (44.8%) the lesion had neurologic causes (Charcot arthropathy, sequelae of cerebral palsy and polio). The average follow-up time was 36 months (6–60) after the arthrodesis. The surgical technique employed, from January 2005 to January 2011, was tibiotalocalcaneal arthrodesis with retrograde intramedullary nailing of the ankle. The surgical technique follows a protocol with the patient in the lateral position. By a lateral access port of 10 cm, an osteotomy is made at right angles to the resection of distal fibula. The joint surfaces of the talus and distal tibia are decorticated by this access. A medial access is used to facilitate joint debridement and placement of the talus and the medial malleolus. The surgeon removes minimal amounts of bone to prevent shortening of the limb. A medial access is used to facilitate joint debridement and placement of the talus, with the medial malleolus. To make the fixation with the intramedullary nail, the surgeon makes an incision at the junction of middle and distal thirds of the fat pad of the heel. The foot is held in the desired position; then the surgeon passes a guide wire through the calcaneus and the talus to reach the center of the tibia. The position is checked in the image intensifier and then the surgeon proceeds with the milling. Usually, we use the 12 mm-nail and the milling is done up to 11 mm. After the removal of the intramedullary guide wire, the locking screws are inserted percutaneously with the drill guide. We use two medial screws into the tibia for the proximal locking, and one screw into the talus and calcaneus for the distal locking. This procedure does not allow the shank’s dynamisation, because it results only in static locking. The procedures were performed by the surgery of the foot and ankle staff, who are members of the Department of Orthopedics and Traumatology, Hospital das Clínicas, Federal University of Goiás (UFG-DOT-HC). The study was approved by the ethics committee of the HC-UFG. The patients were requested to fill the questionnaires of the American Orthopedic Foot & Ankle Society (AOFAS) and to a Visual Analog Scale (VAS) preoperatively. According to the AOFAS criteria, the patient can be classified with a poor (0–69), fair (70–80), good (80–90) or excellent (90–100) function. The VAS criterion classifies pain as absent (0), mild (1–3), moderate (4–6), high intensity (7–9) and intolerable (10). Patients classified as AOFAS’ poor function (less than 69) and severe


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Fig. 1 – Clinical appearance of sequelae of right tibial pylon fracture, and evolution with infection. Attempted arthrodesis was performed with an external fixator, without success. The lesion evolved to infection healing with pain, however with mobility in the focus of arthrodesis, valgus deformity of ankle, and inability to march.

VAS (between eight and 10) were selected preoperatively for the arthrodesis procedure. After surgery and after six months of evolution, the same patients answered again to the questionnaires (AOFAS and VAS). Later, we divided the cases into two groups, according to the etiology of the arthrosis (traumatic or neurological) and evaluated the following variables: time for the consolidation, smoking habits (more than 20 cigarettes/day), patient satisfaction and post-operative complications. The joint fusion was assessed by radiographs of the ankle (anteroposterior [AP] and lateral views) (Fig. 3A and B) and have been considered as a pseudoarthrosis in cases in which there were no signs of bone healing and osseous trabeculation in the AP and lateral views up to six months (24 weeks) after surgery. The statistical analysis was descriptive and analytical, using Fischer’s exact and chi-squared tests and comparing

Fig. 2 – Anteroposterior (A) and lateral (B) ankle radiographs, depicting non-consolidation of the previous arthrodesis, valgus deformity and joint degeneration.

qualitative variables by frequency. The database is stored in the Microsoft Excel program and analyzed using SPSS version 15.0.

Results In the evaluation of the AOFAS questionnaire in the postoperative period, we noted improved scores, when compared with the values in the preoperative period, since our findings were 34.5% poor (10 cases), 20.7% fair (six cases), 34.5% good (10 cases), and 10.3% excellent (three cases) (Table 1). When analyzed by etiology, the post-operative AOFAS for traumatic cases (mean 75.7) was 21.2% better vs. neurological cases (57.7) (Fig. 4). Regarding the VAS questionnaire (Table 2), in the postoperative period we found 48.3% mild (14 cases), 44.8%

Fig. 3 – Radiological consolidation observed at six months post-operatively on anteroposterior (A) and lateral (B) radiographs.


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Table 1 – Comparison between AOFAS criteria in preand post-operative period.

5

AOFAS

4

Preoperative

Poor Fair Good Excellent

Post-operative

29 0 0 0

10 6 10 3

34.5% 20.5 34.5% 10.5

Infection 65.5%

3

Pseudoarthrosis Fracture

2

Material failure

7 1

6 5

0 17.2% 17.2% 13.7% 13.7%

4

Fig. 5 – Post-operative complications of tibiotalocalcaneal arthrodesis.

3 2

(17.2%) nonunions, 5 (17.2%) infections, 4 (13.7%) tibial fractures and 4 (13.7%) material failures (Fig. 5).

1 0

AOFAS post (0-69 points)

AOFAS AOFAS AOFAS post (70-80 points) post (80-90 points) post (90-100 points)

Traumatic

Neurological

Fig. 4 – Comparison between AOFAS criteria post-operatively according to etiology (traumatic vs. neurological).

moderate (13 cases), and 6.9% severe (two cases) – an improvement of 94.1% (average of 2.3 in neurological cases and 4.2 in post-traumatic cases). The rate of satisfaction with the procedure was 86% (25 of 29 patients). Of the 29 patients, 12 were smokers (41.4%). Of the 29 patients, the arthrodesis consolidation was radiographically confirmed in 24 (82%), and five (17.2%) had nonunions. The average healing time was 16 weeks (10–24). Although we observed a trend toward an association between smoking and nonunion (pseudoarthrosis more frequent in smokers) and between nonunion and neurological etiology, no statistical significance was observed, probably because of the small sample size. Regarding complications, 11 patients (38%) developed some kind of complication. Of those, five had more than one type of complication. So, in 29 patients, 18 complications occurred: 5

Table 2 – Comparison of Visual Analog Scale for pain in pre- and post-operative period. VAS Mild Moderate Severe

Preoperative 0 0 29

VAS, Visual Analog Scale.

Post-operative 14 13 2

48.3% 44.8% 5.9%

94.1%

Discussion The treatment of patients with arthritis, pain and deformity of the ankle and subtalar junction is still a challenge and is extremely difficult to get excellent results. The main surgical goals of the tibiotalocalcaneal arthrodesis are to reduce pain and promote a stable and plantigrade foot with good function for deambulation.1,4,9 This is a procedure with high risk of complications. However, in recent years the procedure has gained acceptance as an option for saving the tibiotarsal and subtalar joints.2,6,12–15 (Table 3). In the last decade, a number of studies reporting complications and high rates of nonunion (4–24%) was published.13,15,16 Nonunion is not uncommon, mainly in cases of surgical reapproaches, as previously reported by Kim et al.14 Chou et al.17 reported union in 86% of their patients with a mean of 19 weeks (12–65). Boer et al.2 published a minimum consolidation period of 12 weeks, with a mean of 20.4 weeks (12–72). Mendicino et al.12 obtained 95% of fusions at approximately 4.1 months (17 weeks). Niinimäki et al.15 reported radiographic signals of fusion in 26 (76%) of 34 patients after 16 weeks. Pelton et al.6 reported 88% of fusion at a mean period of 3.7 months (16 weeks). Hammett et al.13 achieved complete fusion of the arthrodesis in 88.46% of their series of 52 patients in about four months (17 weeks). We obtained a fusion rate of 82.7% in our 29 patients at a mean time of 3.6 months (16 weeks) – findings similar to the average observed in the literature. In 2007, Smith et al.16 prospectively analyzed AOFAS and VAS criteria in 10 patients. These authors found a significant increase of these criteria, with a preoperative AOFAS of 39 (range 14–51) that increased to 69 (range 51–91) postoperatively.16 VAS was also evaluated prospectively and ranged from 8.3 points in the preoperative period to 2 points after the operation.16 in our series of 29 cases, we also observed a favorable evolution for AOFAS and VAS criteria. The AOFAS of


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Table 3 – Comparison of results among studies in the literature. Study

Chou et al.17 Hammett et al.13 Pelton et al.6 Boer et al.2 Niinimäki et al.15 Smith et al.16 Mendicino et al.12 This study

Pat. Nr.

37 47 33 50 34 10 19 29

Age

53 (19–79) 57.1 (25–81) 54 (32–88) 57.6 (22–82) 57 (25–77) 60.6 (48–78) 56 (33–81) 41 (13–72)

Follow-up (months)

Union rate

Time for consolidation (weeks)

AOFAS

26 (12–168) 34 (8–37) 14 51 (12–84) 24 (6–43) 14.7 (12–18) 19.8 (8–42) 36 (6–60)

86% 87% 88% 96% 76% 80% 95% 82%

19 (12–65) 17 (13–39) 16 20.4 (12–72) 16 (6–45) – 17 16 (10–24)

66 63 (13–84) – 70 (32–86) – 69 (14–51) – 69 (16–96)

VAS

Satisfaction

– – – – 1.9 2 (0–7) – 3.5 (0–6)

87% 82% – 92% 90% – – 86%

VAS, Visual Analog Scale.

all our cases evaluated was poor preoperatively; after surgery, the mean was 69 points (range 12–96 points). VAS has also evolved considerably, from a severe pain preoperatively in 100% of cases, to a mean of 3.5 points. Only two patients (6.9%) remained with severe pain post-operatively. Other authors also used in their series the AOFAS criteria, but only after the surgery. This was the case of Boer et al.,2 with a mean of 70 points in this regard. Hamett et al.13 obtained an average of 63 points. Chou et al.17 found a mean of 66 points. In our study, the mean score by AOFAS’ criteria was 69 points (range 12–96). In the series of Boer et al.2 there was only one complication. The patient had sensory loss on the dorsum of the foot and radiolucency at the nail entry point. Niinimäki et al.15 reported 15% of complications in 34 patients, four post-operative infections (two patients in need of implant removal) and one case of venous thromboembolism. Smith et al.16 reported 20% of complications (nonunions) and related this occurrence to smoking. Patient satisfaction with the procedure was also one criterion assessed in our study; when compared with data in the literature, there was discordance of findings. Chou et al.17 found 87% satisfaction with the post-operative result. In their series, Hammett et al.13 reported 82% satisfaction. Boer et al.2 reported 92% satisfaction of their patients. Niinimäki et al.15 obtained 90% satisfaction. In our study, 25 of 29 patients (86.2%) were satisfied with the treatment.

Conclusion In our study we found a favorable evolution of AOFAS criteria, of 65.5% (mean of 57.7 in neurological and 75.7 in post-traumatic cases) and of VAS, of 94.1% (mean of 2.3 in neurological and 4.2 in post-traumatic cases) in the patients assessed. Despite the incomplete improvement of pain, most patients (86%) were satisfied with the end result.

Conflicts of interest The authors declare no conflicts of interest.

references

1. O’Neill PJ, Logel KJ, Parks BG, Schon LC. Rigidity comparison of locking plate and intramedullary fixation for tibiotalocalcaneal arthrodesis. Foot Ankle Int. 2008;29(6):581–6. 2. Boer R, Mader K, Pennig D, Verheyen CC. Tibiotalocalcaneal arthrodesis using a reamed retrograde locking nail. Clin Orthop Relat Res. 2007;(463):151–6. 3. Lowery NJ, Joseph AM, Burns PR. Tibiotalocalcaneal arthrodesis with the use of a humeral locking plate. Clin Podiatr Med Surg. 2009;26(3):485–92. 4. Noonan T, Pinzur M, Paxinos O, Havey R, Patwardhin A. Tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail: a biomechanical analysis of the effect of nail length. Foot Ankle Int. 2005;26(4):304–8. 5. Ahmad J, Pour AE, Raikin SM. The modified use of a proximal humeral locking plate for tibiotalocalcaneal arthrodesis. Foot Ankle Int. 2007;28(9):977–83. 6. Pelton K, Hofer JK, Thordarson DB. Tibiotalocalcaneal arthrodesis using a dynamically locked retrograde intramedullary nail. Foot Ankle Int. 2006;27(10):759–63. 7. Alfahd U, Roth SE, Stephen D, Whyne CM. Biomechanical comparison of intramedullary nail and blade plate fixation for tibiotalocalcaneal arthrodesis. J Orthop Trauma. 2005;19(10):703–8. 8. Pickering RM. Artrodese de tornozelo, joelho e quadril. In: Canale ST, editor. Cirurgia ortopédica de Campbell. 10a ed. Barueri: Manole; 2006. p. 155–78. 9. Means KR, Parks BG, Nguyen A, Schon LC. Intramedullary nail fixation with posterior-to-anterior compared to transverse distal screw placement for tibiotalocalcaneal arthrodesis: a biomechanical investigation. Foot Ankle Int. 2006;27(12):1137–42. 10. Bennett GL, Cameron B, Njus G, Saunders M, Kay DB. Tibiotalocalcaneal arthrodesis: a biomechanical assessment of stability. Foot Ankle Int. 2005;26(7): 530–6. 11. Santangelo JR, Glisson RR, Garras DN, Easley ME. Tibiotalocalcaneal arthrodesis: a biomechanical comparison of multiplanar external fixation with intramedullary fixation. Foot Ankle Int. 2008;29(9):936–41. 12. Mendicino RW, Catanzariti AR, Saltrick KR, Dombek MF, Tullis BL, Statler TK, et al. Tibiotalocalcaneal arthrodesis with retrograde intramedullary nailing. J Foot Ankle Surg. 2004;43(2):82–6. 13. Hammett R, Hepple S, Forster B, Winson I. Tibiotalocalcaneal (hindfoot) arthrodesis by retrograde intramedullary nailing using a curved locking nail. The results of 52 procedures. Foot Ankle Int. 2005;26(10):810–5.


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14. Kim C, Catanzariti AR, Mendicino RW. Tibiotalocalcaneal arthrodesis for salvage of severe ankle degeneration. Clin Podiatr Med Surg. 2009;26(2):283–302. 15. Niinimäki TT, Klemola TM, Leppilahti JI. Tibiotalocalcaneal arthrodesis with a compressive retrograde intramedullary nail: a report of 34 consecutive patients. Foot Ankle Int. 2007;28(4):431–4.

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16. Smith JW, Moore TJ, Fleming S, Pochatko D, Principe R. Tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail. Foot Ankle Int. 2007;19(16): 433–6. 17. Chou LB, Mann RA, Yaszay B, Graves SC, McPeake 3rd WT, Dreeben SM, et al. Tibiotalocalcaneal arthrodesis. Foot Ankle Int. 2000;21(10):804–8.


r e v b r a s o r t o p . 2 0 1 4;4 9(1):62–68

www.rbo.org.br

Original article

Effect of hyaluronic acids as chondroprotective in experimental model of osteoarthrosis夽,夽夽 Marcello Zaia Oliveira ∗ , Mauro Batista Albano, Mario Massatomo Namba, Luiz Antônio Munhoz da Cunha, Renan Rodrigues de Lima Gonc¸alves, Edvaldo Silva Trindade, Lucas Ferrari Andrade, Leandro Vidigal 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 analyze the effects of hyaluronic acid of different molecular weights in an

Received 3 February 2013

experimental model of osteoarthritis in rabbits.

Accepted 9 April 2013

Methods: forty-four male California rabbits were divided randomly into three groups and underwent resection of the anterior cruciate ligament in his right knee. After three weeks

Keywords:

of the surgical procedure began three weekly intra-articular injections of hyaluronic acid

Osteoarthritis

native (Polireumin® )-PR, hyaluronic acid branched chain (Synvisc® )-S and 0.9% saline-P. All

Hyaluronic acid

animals were sacrificed after twelve weeks of surgery and tibial plateau infiltrated the knees

Anterior cruciate ligament

were dissected. Histological cartilage of the support areas of the tibial plateaus were stained

Knee

with Alcian Blue pH 1.0, Alcian Blue pH = 2.5 and toluidine blue for research on the amount

Rabbits

of proteoglycans. The intensity of staining was quantified on a Zeiss microscope apparatus Imager Z2 MetaSystems and analyzed by software MetaferMsearch. Results: the effect of chondroprotetor hyaluronic acids used in the study was confirmed when compared to the control group, but the comparison made between them, there was no statistically significant difference regarding chondroprotetion. Conclusion: the hyaluronic acids tested had chondroprotective effect, with no statistical difference with regard to the different molecular weights. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

Efeito dos ácidos hialurônicos como condroprotetores em modelo experimental de osteoartrose r e s u m o Palavras chave:

Objetivo: analisar os efeitos do ácido hialurônico de diferentes pesos moleculares em modelo

Osteoartrose

experimental de osteoartrose em coelhos.

Ácido hialurônico

Métodos: foram alojados de modo aleatório 44 coelhos da rac¸a California, machos, em três

Ligamento cruzado anterior

grupos (PR, S e P) e submetidos a ressecc¸ão do ligamento cruzado anterior do joelho direito.

夽 Please cite this article as: Oliveira MZ, Albano MB, Namba MM, da Cunha LAM, de Lima Gonc¸alves RR, Trindade ES, Andrade LF, Vidigal L. Efeito dos ácidos hialurônicos como condroprotetores em modelo experimental de osteoartrose. Rev Bras Ortop. 2014;49:62–68. 夽夽 Study conducted at Department of Orthopedy and Traumatology, Universidade Federal do Paraná, Curitiba, PR, Brazil. ∗ Corresponding author. E-mail: marcellozaia@yahoo.com.br (M.Z. Oliveira).

2255-4971/$ – see front matter © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

http://dx.doi.org/10.1016/j.rboe.2014.01.007


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Joelho

Decorridas três semanas do procedimento cirúrgico iniciaram-se as três injec¸ões intra-

Coelhos

articulares semanais de ácido hialurônico nativo (Polireumin® )-PR, ácido hialurônico de cadeia ramificada (Synvisc® )-S e soro fisiológico 0,9%-P. Todos os animais foram sacrificados após 12 semanas do ato cirúrgico e os platôs tibiais dos joelhos infiltrados foram dissecados. Cortes histológicos da cartilagem das áreas de apoio com maior espessura dos platôs tibiais foram corados com Alcian Blue pH = 1,0, Alcian Blue Ph = 2,5 e Azul de Toluidina para pesquisa da quantidade de proteoglicanos. A intensidade de colorac¸ão foi quantificada em um aparelho de microscopia ZeissImager Z2 Metasystems e analisada pelo software MetaferMsearch. A análise estatística consistiu no uso dos testes Kolmorogov–Smirnov, análise de variância (Anova), t de Student e qui-quadrado. O nível de significância usado foi de 5%. Resultado: o efeito condroprotetor dos ácidos hialurônicos usados no estudo foi demonstrado quando comparado ao do grupo controle, porém, feita a comparac¸ão entre si, não houve diferenc¸a estatística quanto à condroprotec¸ão. Conclusão: os ácidos hialurônicos testados obtiveram efeito condroprotetor, sem diferenc¸a estatística com relac¸ão aos diferentes pesos moleculares. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Todos os direitos reservados.

Introduction Osteoarthrosis (OA) is the most common joint disease worldwide, with prevalence greater than 10% after the age of 50. This condition exhibits cartilaginous histological changes, and can result in significant functional limitation.1,2 OA is the result of several factors in joint dysfunction and is characterized by cartilaginous degeneration and simultaneous bone, cartilage and connective tissue proliferation.3 Among various treatment modalities currently available, the treatment with intra-articular injections of hyaluronic acid (HA) has shown beneficial effects in controlling the symptoms of knee OA.4 HA, a polysaccharide of the glycosaminoglycan family, contributes to the homeostasis of the normal articulation, showing lower concentration and decreased molecular weight in the synovial fluid in joints with osteoarthrosis.5,6 HA administered in the form of intra-articular injections may enhance the regenerative effects of endogenous HA on joint cartilage, restore the viscoelasticity of the synovial fluid, contributing to the synthesis of HA by synoviocytes, and prevent the degradation of proteoglycans and collagen fibers present in the extracellular matrix. HA stimulates the metabolism, prevents apoptosis of chondrocytes, and inhibits chondral degradation and articular inflammatory responses.6 These effects of therapy with the use of HA are attributed not only to its ability to alleviate the symptoms related to osteoarthrosis, but also to its interference in the progression of joint degeneration.5–7 Considering the scope and implications of the knee OA, nowadays we understand the importance of diagnosis and treatment in its early stages, so that its consequences are minimized.8 So far, there is no interventions capable of inhibiting its evolution; hence, are essential options that allow reducing its progression. Intra-articular injections of different types of HA could be used for this purpose. To evaluate the effects of these substances in gonarthrosis, in this research we proposed the use of an experimental OA model that resembles that mimics the condition in humans. The section of the anterior cruciate ligament (ACL) of the rabbit knee, the “stifle joint” (term used in veterinary anatomy

for the joint similar to human knee in small animals, such as rabbits and dogs), mimics the morphological and biochemical changes observed in human osteoarthrosis, which allows the accurate reproduction of the results.9,10 The aim of this study was to evaluate the effect of intraarticular injections of native HA (Polireumin® , TRB Pharma, São Paulo, Brazil) and of branched-chain HA (Synvisc® , Novartis, São Paulo, Brazil), separately and comparatively between themselves, in OA induced by ACL section of rabbit knees.

Materials and methods This experiment was conducted at the bioterium of the postgraduate course of Federal University of Paraná (UFPR). The Research Ethics Committee of the Department of Health Sciences, UFPR, evaluated and approved the research protocol of this study (registry CEP/SD: 001.004 SI 06-06). Forty-four male California rabbits, which were kept before and during the procedures in cages (two animals per cage) in the unit bioterium, were used. The ration was standardized and the animals received water ad libitum. The rabbits were kept under controlled light (light–dark cycle of 12 h), with temperature (22 ± 1 ◦ C), humidity and noise level kept stable, with an average weight of 3.5 kg. Initially, all animals underwent resection of the ACL. The right knee has been chosen just to standardize the experiment. The surgical procedure consisted of a pre-operative anesthesia with 10 mg/kg of ketamine hydrochloride (Dopalen® ) and 50 mg/kg of xylazine hydrochloride (Anasedan® ), administered in the same syringe by intramuscular (IM) injection in the semimembranosus and semitendinosus muscle bellies of the right hind limb. On the same occasion, the rabbits were treated with an injection of penicillin 14,400 IU and streptomycin 6 mg (Pentabiotic Veterinary Reinforced® – Eurofarma) as antibiotic prophylaxis, and Flunamine® (Bayer) 2.2 mg/kg IM, as post-operative analgesia. The right knee was subjected to trichotomy and antisepsis with polyvinylpyrrolidone (Povidini® ). After application of sterile fields, a medial parapatellar incision was made in the


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Fig. 1 – Photo of the skin incision and ACL capsulotomy.

skin and subcutaneous tissue, followed by capsulotomy and lateral dislocation of the patella (Fig. 1). Then, the knee was placed in maximum flexion, allowing visualization of the anterior cruciate ligament. This structure was sectioned with an scalpel blade nr. 15 (Fig. 2), the joint was irrigated with normal saline; and a capsulorrhaphy and skin suture with 4.0 monofilament nylon completed the operation (Fig. 3). One rabbit in Group 2 and one in Group 3 developed infection of the surgical site with articular extension and were excluded from the study. After surgery, the rabbits were kept in their cages without restricting the support to operated members. The animals were randomized into three groups, with 14 animals in each group. After three weeks of the surgical procedure, the animals were initiated in their intra-articular injections. The amount of hyaluronic acid was 0.3 ml, similar to the volume used in small joints of humans. Group P: control group, three injections (at weekly intervals) of 0.9% isotonic saline; Group PR: three injections (at weekly intervals) of native hyaluronic acid (Polireumin® ); Group S: three injections at weekly intervals of branched-chain hyaluronic acid (Synvisc® ).

Fig. 2 – Photo of ACL exposure.

Fig. 3 – Photo of skin suture.

The rabbits were euthanized after 12 weeks of surgery; the animals were anesthetized as described previously and subjected to intracardiac injection of thiopental (5 mL) and potassium chloride (10 mL). The tibial plateaus were resected aseptically and immersed in a flask containing 10% formaldehyde. The vials were labeled for identification of groups and sent to the Clinical Pathology Service, Hospital de Clínicas. The tibial plateaus were decalcified. The medials in the area of greater cartilage thickness were subjected to microtomy in the sagittal plane; then, three slides were prepared by tibial plateau, with the use of stains Alcian Blue pH 1.0, Alcian Blue pH 2.5, and Toluidine Blue and included in paraffin. The stained slides were sent to the Polytechnic Center of the Life Sciences Sector, Federal University of Paraná. The histological slides were automatically scanned into a ZeissImager Metasystems Z2 microscope, using the software MetaferMSearch with post-assembly with VSlide. Then, the cartilaginous regions were selected with the MetaViewer software snapshot tool. The pictures were analyzed by ImageJ software, using the RGB Stack tool for Alcian Blue pH 1.0, Alcian Blue pH 2.5 and the Color Deconvolution “RGB” for Toluidine Blue stains. Subsequently, the percentage of marked area was calculated after a threshold, followed by quantification.11 All study substances were acquired with own resources of researchers, without external financial support. Data obtained were statistically analyzed by analysis of variance for single factor (ANOVA), followed by F and T unpaired tests, with significance when p < 0.05. Graphs were plotted with the mean standard deviation, using the software Microsoft Excel 2007. The data evaluation was objective (standardized by computer), and subjective, by scores given by the biologist responsible for the quantification of the staining in chi-square test. The scores 1, 2 and 3 were classified as poor, intermediate and excellent.


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Table 1 – Numbers of quantification of Toluidine Blue. Slides

1 2 3 4 5 6 7 8

Treatment groups P

PR

S

66.81098 15.6544 48.30333 72.81427 76.35281 83.84236 30.08729 37.47977

72.71096 50.25438 93.63707 98.97833 90.30573 73.03511 96.62571 73.87755

96.52204 97.83475 73.56667 64.13119 49.14048 56.87234 66.2721 46.77349

Results The decalcified slides, stained with Alcian Blue pH 1.0, Alcian Blue pH 2.5, and Toluidine Blue, showed the presence of glycosaminoglycans in larger quantities in the groups PR (Polireumin® ) and S (Synvisc® ) versus control group P (placebo). The significance level for all analyzes was 5%. The evaluation of the staining intensity of histological sections stained with Alcian Blue pH 1.0, Alcian Blue pH 2.5 and Toluidine Blue with ZeissImager Z2 Metasystems microscopy generated results that were shown in tables and graphs. Below are graphs provided by the program, representative of the actual staining intensity measured in each group of the abovementioned dyes. Through the analysis conducted, each slide generated a datum in the set of data for each group: “P”, “PR”, or “S”, totaling 24 slides/analyzed individuals (eight for each group). For the statistical analysis, the null hypothesis (H0 ) was: there is no difference between the independent variables, and the alternative hypothesis (H1 ) was: There is difference between the independent variables. An alpha value of 0.05 was used. The values for each coloration are presented in Tables 1–4. The Kolmorogov–Smirnov test found a normal distribution of data (not shown). Thus, parametric tests were used: an analysis of variance (ANOVA) for single factor and unpaired Student t-test assumed equal variances. In the F-test, it was found that the variances of the groups did not differ within the same stain. In Toluidine Blue and Alcian Blue pH 2.5 (but not for pH 1.0) stains, ANOVA indicated a statistically significant

Table 3 – Numbers of quantification of Alcian Blue pH 1.0. Slides

1 2 3 4 5 6 7 8

Treatment groups P

PR

S

34.34797 89.68194 50.03834 41.21177 30.09164 38.7721 10.06779 32.54817

68.02167 29.72821 81.88278 35.19409 34.54938 55.28347 43.21785 40.86236

95.38368 97.26896 41.70293 68.65967 99.88211 44.2001 36.21376 29.08637

Table 4 – Numbers of quantification of Alcian Blue pH 2.5. Slides

1 2 3 4 5 6 7 8

Treatment groups P

PR

S

49.86103 37.0048 90.00677 39.21933 41.19301 35.90056 12.16039 28.92869

61.96043 99.59628 89.87066 38.10635 99.1222 62.46105 72.56529 53.91113

36.31462 96.2119 94.47586 63.63671 64.21882 60.2876 64.85414 29.84288

difference (p < 0.05) (data not shown). Thus, for these two dyes with difference in ANOVA, Student’s t-tests were performed. For Toluidine Blue staining, a difference was noted only between P versus PR groups (Table 2). For Alcian Blue pH 2.5, a difference was observed between P versus PR and P versus S groups, but the latter divergence was perceived only in the one-tailed analysis (Table 5). In order to verify whether there were a difference between the values of P and S groups, nonparametric analysis for categorical variables was performed. For this purpose, instead of analyzing the slides using the ImageJ software, scores from 1 to 3 for staining intensity were attributed, that is, the higher the score, the more intense the staining with Alcian Blue pH 2.5, as described above.12 The statistical test used was the contingency chi-square (2 ) test. For this test, H0 is: P and S groups did not differ in the pattern of staining intensity, while in H1 P and S groups

Table 2 – Analyses of Table 1 data with Student’s t-test. Comparisons 2 × 2

Information P Mean Variance Observations Pooled variance H0 difference Df t-Calculated P (T ≤ t) tailed t-Tailed critical P (T ≤ t) two-tailed t-Two-tailed critical

53.9 607 8 442.7 0 14 −2.6 0.01 1.8 0.02 2.1

PR 81.2 277.4 8

P

S

PR

53.9 608 8 495.1 0 14 −1.3 0.10 1.8 0.20 2.1

68.9 382.3 8

81.2 277.4 8 329.8 0 14 1.3 0.10 1.76131 0.20 2.1

S 68.9 382.3 8


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Table 5 – Analyses of Table 4 data with Student t test. Comparisons 2 × 2

Information P Mean Variance Observations Pooled variance H0 difference Df t-Calculated P (T ≤ t) tailed t-Tailed critical P (T ≤ t) two-tailed t-Two-tailed critical

PR

41.8 499.7 8 498.7 0 14 −2.7 0.01 1.8 0.02 2.1

72.2 497.8 8

Table 6 – Analysis of categorical data of Alcian Blue pH 2.5. Treatment groups

Notes 1

P (n = 8) S (n = 8)

62.5% (5) 25% (2)

2

3

12.5% (1) 12.5% (1)

25% (2) 62.5% (5)

Note: 2 calculated = 32.14286.

differ in the pattern of staining intensity. N = 16 (eight for each treatment group), alpha = 0.05, degree of freedom = 2, and tabulated 2 = 5.991. 2 calculated was = 32.14286 (Table 6). As the calculated value of 2 is greater than the tabulated value, we reject H0 and accept the alternative hypothesis.

Discussion In recent decades, studies comparing the effectiveness of hyaluronic acids of different molecular weights have been published. The data are discrepant because of its results and methods of evaluation.13 In clinical practice, the orthopedic surgeons have preferred the hyaluronic acid of high molecular weight for the treatment of osteoarthrosis, based on studies such as Atamaz et al.14 and Wobig et al.15 who used the model of osteoarthrosis in humans, compared hyaluronic acids of different molecular weights with saline intra-articularly infiltrated, and obtained better results with the use of hyaluronic acid of higher molecular weight by clinical and non-histological criteria. However, according to Karlsson et al.16 who studied hyaluronic acids of different molecular weights injected by intra-articular infiltrations in humans with osteoarthrosis, there was no significant difference among hyaluronic acids of different molecular weights, concerning clinical and nonhistological criteria. These controversies have led to the realization of this study, that compared the effect of a high molecular weight (Synvisc® ) with a low weight (Polireumin® ) hyaluronate. For its realization, we used an experimental model of osteoarthrosis.

P

S

PR

41.8 499.7 8 529.4 0 14 −1.9 0.04 1.8 0.08 2.1

63.7 559.1 8

72.2 497.8 8 528.4 0 14 0.7 0.2 1.8 0.5 2.1

S 63.7 559.1 8

The experimental model in small animals which most closely resembles the osteoarthrosis present in human beings is the transection of the anterior cruciate ligament in rabbit knee. This model mimics the morphological and biochemical changes observed in humans with osteoarthrosis.5 The rabbit was the animal chosen because of its easy handling, lower cost, and the vast literature that confirms its use for the purposes of obtaining induced osteoarthrosis. The study period of 12 weeks is relatively short for obtaining AO, but this average time is used in most published studies in the literature. The anatomy of the rabbit knee is easy to dissect and allows visualization of the anterior cruciate ligament, which facilitates the surgical procedure of its transection.9,10,17,18 In the present study, the handling of the animals and the surgical dissection of the rabbit knees were easy to perform. The skin incision, the medial capsulotomy with visualization of the anterior cruciate ligament, and its transection had been done quickly and in a practical way. The knee plateaus undergoing this procedure showed signs of obvious macroscopic lesions, especially those in the control group P (placebo – 0.9% saline).19 Specific histological colorations for glycosaminoglycans were chosen to assess joint cartilage, because of their high sensitivity for detection of proteoglycans. Alcian Blue pH 1.0, Alcian Blue pH 2.5 and Toluidine Blue have great ability to stain glycosaminoglycans and proteoglycans, having been used successfully in several histological studies of cartilage.20–23 The Alcian Blue pH 1.0 stains generally glycosaminoglycans in different tissues, whereas Alcian Blue pH 2.5 and Toluidine Blue specifically stain proteoglycans. The use of the ZeissImager Z2 Metasystems microscope and of the MetaferMsearch software allowed the measurement of the staining intensity in the slides of cartilaginous tissue. Greater staining intensity was obtained In S (Synvisc® ) and PR (Polireumin® ) groups versus control group P (placebo – 0.9% saline); hence, the decalcified and stained slides with Alcian Blue pH 1.0, Alcian Blue pH 2.5 and Toluidine Blue showed the presence of glycosaminoglycans in greater amounts, when compared with the control group P (placebo). This finding confirms the hypothesis that the hyaluronic acids tested act as chondroprotective factors, as they preserved a greater amount


r e v b r a s o r t o p . 2 0 1 4;4 9(1):62–68

of proteoglycans in the cartilaginous tissue of the knees infiltrated with hyaluronates. There were no statistical differences in the intensity of staining of slides of knees treated with infiltration with high molecular weight versus low molecular weight hyaluronic acid. The transposition of the data found in rabbits in this study may not reflect the same findings in humans. At the same time, an evaluation of the staining intensity by direct vision of the slides, that is, dependent on the examiner, was done. In this sense, we asked a biologist to assess the slides, ascribing scores. This professional rated with 1, 2, and 3 points the slides stained with Alcian Blue pH 2.5 as poor, intermediate and excellent, respectively. The results by direct vision confirmed the results conferred by the instrument, i.e., there was no statistical difference between the groups treated with hyaluronates when compared with the placebo group, and there was no statistical difference between the groups infiltrated with hyaluronates, regardless of molecular weight. Subjective data were evaluated by chi-square test. The literature that compares the different molecular weights of hyaluronates in this experimental model is scarce. Shimizu et al.24 in a study in rabbits, concluded that hyaluronic acids of low molecular weight were superior versus those of higher molecular weight. Their study did not mention the dose used in the infiltration; hence we could not make a more appropriate comparison with our study. In our study, the rabbits were treated with intra-articular applications for three weeks (as is usually done in humans) and the volume used was 0.3 mL for the three substances tested (native hyaluronic acid, branched-chain hyaluronic acid, and normal saline). The half-life of native hyaluronic acid is 13 h, while branchedchain hyaluronic acid is 36 h. We chose a volume of 0.3 mL, because this is the recommended dose for use in small joints of humans.25 Ghosh and Guidolin26 using an experimental model of transection of the anterior cruciate ligament in dogs, obtained better results with hyaluronic acids of lower molecular weight. The same authors, in an in vitro study, found better results with the use of hyaluronic acid of higher molecular weight, which contradicted their studies in animals. This substance would be a better stimulator of the production of extracellular matrix components. This could be partly explained, because the hyaluronic acid of lower molecular weight would penetrate the extracellular matrix more easily, maximize its concentration, and promote its interaction with target cells in the synovium. Furthermore, there is evidence that the binding of molecules of hyaluronic acid with cellular receptors is dependent on the molecular weight.12,13 There are several hypotheses trying to explain the mechanism of action of hyaluronic acids in non-pathological articulations of humans. In one of them, hyaluronic acid would act as modulator, through the interaction with CD44 receptors present in synoviocytes, and would act biochemically in the joint and decrease the production of cytokines, prostaglandins and metalloproteinases.27–30 Arguably, hyaluronic acid also retrieves the physiological properties of synovial fluid, decreases the pressure of the strength/weight, and improves the distribution of the weight incident on the joint. Therefore, hyaluronic acids play an important role in the mechanical effects of the joints.31

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In summary, in this study the data confirm the findings of Karlsson et al.16 who studied the effects of hyaluronates of different molecular weights in intra-articular infiltrations in humans with osteoarthrosis, and suggest no differences in the molecular weight of hyaluronic acids, with respect to chondroprotection.

Conclusion The analysis of the effects of native and branched-chain hyaluronic acids in an experimental model of osteoarthrosis in rabbits demonstrated chondroprotective proprieties, when compared to the control group (0.9% saline). When native chain and branched-chain hyaluronic acids were compared, no statistically significant difference was perceived.

Conflicts of interest The authors declare that there were no conflicts of interest.

references

1. Wang CT, Lin YT, Chiang BL, Lin YH, Hou SM. High molecular weight hyaluronic acid down-regulates the gene expression of osteoarthritis-associated cytokines and enzymes in fibroblast-like synoviocytes from patients with early osteoarthritis. Osteoarthr Cartil. 2006;14(12):1237–47. 2. Bedson J, Jordan K, Croft P. The prevalence and history of knee osteoarthritis in general practice: a case–control study. Fam Pract. 2005;22(1):103–8. 3. Lotz M. Osteoarthritis year 2011 in review: biology. Osteoarthr Cartil. 2012;20(3):192–6. 4. Altman RD, Moskowitz R. Intraarticular sodium hyaluronate (Hyalgan) in the reatment of patients with osteoarthritis of the knee: a randomized clinical trial. Hyalgan Study Group. J Rheumatol. 1998;25(11):2203–12. 5. Yoshimi T, Kikuchi T, Obara T, Yamaguchi T, Sakakibara Y, Itoh H, et al. Effects of high-molecular-weight sodium hyaluronate on experimental osteoarthrosis induced by the resection of rabbit anterior cruciate ligament. Clin Orthop Relat Res. 1994;(298):296–304. 6. Schiavinato A, Finesso M, Cortivo R, Abatangelo G. Comparison of the effects of intra-articular injections of Hyaluronan and its chemically cross-linked derivative (Hylan G-F20) in normal rabbit knee joints. Clin Exp Rheumatol. 2002;20(4):445–54. 7. Hulmes DJ, Marsden ME, Strachan RK, Harvey RE, McInnes N, Gardner DL. Intra-articular hyaluronate in experimental rabbit osteoarthritis can prevent changes in cartilage proteoglycan content. Osteoarthr Cartil. 2004;12(3):232–8. 8. Cooper C, Snow S, McAlindon TE, Kellingray S, Stuart B, Coggon D, et al. Risk factors for the incidence and progression of radiographic knee osteoarthritis. Arthritis Rheum. 2000;43(5):995–1000. 9. Moskowitz RW. Experimental models of osteoarthritis. In: Moskovitz RW, Altman RD, Buckwalter JA, Goldberg VM, Hochberg MC, editors. Osteoarthritis: diagnosis and medical/surgical management. 2nd ed. Philadelphia: Saunders; 1992. p. 213–52. 10. Sah RL, Yang AS, Chen AC, Hant JJ, Halili RB, Yoshioka M, et al. Physical properties of rabbit articular cartilage after transection of the anterior cruciate ligament. J Orthop Res. 1997;15(2):197–203.


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11. Andrade LF. Avaliac¸ão da ac¸ão do medicamento M1 sobre o melanoma murino “in vivo”. Curitiba: Universidade Federal do Paraná; 2011 [dissertac¸ão]. 12. Chow MT, Tschopp J, Möller A, Smyth MJ. NLRP3 promotes inflammation-induced skin cancer but is dispensable for asbestos-induced mesothelioma. Immunol Cell Biol. 2012;90(10):983–6. 13. Jüni P, Reichenbach S, Trelle S, Tschannen B, Wandel S, Jordi B, et al., Viscosupplementation Trial Group. Efficacy and safety of intraarticular hylan or hyaluronic acids for osteoarthritis of the knee: a randomized controlled trial. Arthritis Rheum. 2007;56(11):3610–9. 14. Atamaz F, Kirazli Y, Akkoc Y. A comparison of two different intra-articular hyaluronan drugs and physical therapy in the management of knee osteoarthritis. Rheumatol Int. 2006;26(10):873–8. 15. Wobig M, Bach G, Beks P, Dickhut A, Runzheimer J, Schwieger G, et al. The role of elastoviscosity in the efficacy of viscosupplementation for osteoarthritis of the knee: a comparison of hylan G-F 20 and a lower-molecular-weight hyaluronan. Clin Ther. 1999;21(9):1549–62. 16. Karlsson J, Sjögren LS, Lohmander LS. Comparison of two hyaluronan drugs and placebo in patients with knee osteoarthritis. A controlled, randomized, double-blind, parallel-design multicentre study. Rheumatology (Oxford). 2002;41(11):1240–8. 17. Yoshioka M, Coutts RD, Amiel D, Hacker SA. Characterization of a model of osteoarthritis in the rabbit knee. Osteoarthr Cartil. 1996;4(2):87–98. 18. Laverty S, Girard CA, Williams JM, Hunziker EB, Pritzker KP. The OARSI histopathology initiative – recommendations for histological assessments of osteoarthritis in the rabbit. Osteoarthr Cartil. 2010;18 Suppl. 3:S53–65. 19. Albano MB, Vidigal L, Oliveira MZ, Namba N, Silva JL, Pereira Filho FA, et al. Análise macroscópica dos efeitos dos hialuronatos e do corticoesteroide no tratamento da osteoartrose induzida em coelhos de coelhos. Rev Bras Ortop. 2010;45(3):273–8. 20. Naito K, Watari T, Furuhata A, Yomogida S, Sakamoto K, Kurosawa H, et al. Evaluation of the effect of glucosamine on

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an experimental rat osteoarthritis model. Life Sci. 2010;86(13–14):538–43. Schmitz N, Laverty S, Kraus VB, Aigner T. Basic methods in histopathology of joint tissues. Osteoarthr Cartil. 2010;18 Suppl. 3:S113–6. Kuroda T, Matsumoto T, Mifune Y, Fukui T, Kubo S, Matsushita T, et al. Therapeutic strategy of third-generation autologous chondrocyte implantation for osteoarthritis. Ups J Med Sci. 2011;116(2):107–14. Lin W, Shuster S, Maibach HI, Stern R. Patterns of hyaluronan staining are modified by fixation techniques. J Histochem Cytochem. 1997;45(8):1157–63. Shimizu C, Kubo T, Hirasawa Y, Coutts RD, Amiel D. Histomorphometric and biochemical effect of various hyaluronans on early osteoarthritis. J Rheumatol. 1998;25(9):1813–9. Furtado R, Natour J. Infiltrac¸ões no aparelho locomotor: técnicas para realizac¸ão com e sem o auxílio de imagem. Artmed: Porto Alegre; 2011. Ghosh P, Guidolin D. Potential mechanism of action of intra-articular hyaluronan therapy in osteoarthritis: are the effects molecular weight dependent? Semin Arthritis Rheum. 2002;32(1):10–37. Prieto JG, Pulido MM, Zapico J, Molina AJ, Gimeno M, Coronel P, et al. Comparative study of hyaluronic derivatives: rheological behaviour, mechanical and chemical degradation. Int J Biol Macromol. 2005;35(1–2):63–9. Takeshita S, Mizuno S, Kikuchi T, Yamada H, Nakimi O, Kumagai K. The in vitro effect of hyaluronic acid on Il-1␤ production in cultured rheumatoid synovial cells. Biomed Res. 1997;18(3):187–94. Tanaka S, Hamanishi C, Kikuchi H, Fukuda K. Factors related to degradation of articular cartilage in osteoarthritis: a review. Semin Arthritis Rheum. 1998;27(6):392–9. Pelletier JP, Martel-Pelletier J, Malemud CJ. Canine osteoarthritis: effects of endogenous neutral metalloproteoglycanases on articular cartilage proteoglycans. J Orthop Res. 1988;6(3):379–88. Peyron JG. Intraarticularhyaluronan injections in the treatment of osteoarthritis: state-of-the-art review. J Rheumatol Suppl. 1993;39:10–5.


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www.rbo.org.br

Technical Note

Total arthroplasty in displaced dysplastic hips with acetabular reconstruction and femoral shortening – technical note夽,夽夽 Paulo Silva a , Leandro Alves de Oliveira a , Danilo Lopes Coelho a , Rogério Andrade do Amaral a , Percival Rosa Rebello a , Frederico Barra de Moraes b,∗ a b

Hospital Geral de Goiânia, Goiânia, GO, Brazil Clínica de Ortopedia e Traumatologia, Goiânia, GO, Brazil

a r t i c l e

i n f o

a b s t r a c t

Article history:

To describe a new procedure of total hip replacement in patient with severe developmen-

Received 3 April 2013

tal dysplasia of the left hip, using technique of acetabular reconstruction with autogenous

Accepted 13 May 2013

bone grafts and subtrochanteric shortening femoral osteotomy. Total hip replacement done in January of 2003. The Eftekhar’s classification was used and included type D, neglected

Keywords:

dislocations. Bone graft incorporated in acetabular shelf and femoral osteotomy. Our con-

Arthroplasty, replacement, hip

tribution is the use of an Allis plate to better fix acetabular grafts, avoiding loosening, and

Bone diseases, developmental

cerclage around bone graft in femoral osteotomy site, which diminish pseudoarthrosis risk.

Osteotomy

This technique shows efficiency, allowing immediately resolution for this case with pain and

Transplantation, autologous

range of motion of hip improvement. It also allows the acetabular dysplasia reconstruction, equalization of the limb length (without elevated risk of neurovascular lesion) and repairs the normal hip biomechanics due to the correction of the hip’s center of rotation. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

Artroplastia total em quadris displásicos luxados com reconstruc¸ão acetabular e encurtamento femoral r e s u m o Palavras-chave:

Descrever contribuic¸ões à técnica da cirurgia de artroplastia total em displasias do desen-

Artroplastia de quadril

volvimento do quadril grave, por meio da reconstruc¸ão acetabular com o uso de enxerto

Doenc¸as do desenvolvimento ósseo

autólogo e encurtamento femoral feito com osteotomia subtrocantérica em V invertido.

Osteotomia

Paciente submetido a artroplastia total do quadril esquerdo em janeiro de 2003. Foi usada a

Transplante autólogo

classificac¸ão de Eftekhar e o paciente era do tipo D, luxac¸ão inveterada. Incorporac¸ão do enxerto no teto acetabular e osteotomia femoral. Acrescentamos a fixac¸ão do enxerto da cabec¸a femoral no acetábulo com placa do tipo Allis, que contribui para maior resistência do sistema, e a cerclagem com fio de ac¸o no enxerto ósseo junto à osteotomia subtrocantérica, que

夽 Please cite this article as: Silva P, de Oliveira LA, Coelho DL, do Amaral RA, Rebello PR, de Moraes FB. Artroplastia total em quadris displ´sicos luxados com reconstruc¸ão acetabular e encurtamento femoral. Rev Bras Ortop. 2014;49:69–73. 夽夽 Study conducted at Department of Hip Surgery, Hospital Geral de Goiânia, Clínica de Ortopedia e Traumatologia de Goiânia, GO, Brazil. ∗ Corresponding author. E-mail: frederico barra@yahoo.com.br (F.B. de Moraes).

2255-4971/$ – see front matter © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

http://dx.doi.org/10.1016/j.rboe.2014.01.013


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r e v b r a s o r t o p . 2 0 1 4;4 9(1):69–73

diminui o risco de pseudoartrose. Essa técnica demonstrou eficácia e permitiu a resoluc¸ão imediata do caso com melhoria da dor e da amplitude de movimento do quadril. Permitiu também a reconstruc¸ão do déficit ósseo acetabular, a recomposic¸ão do comprimento do membro (sem risco aumentado de lesão neurovascular) e a recuperac¸ão da biomecânica do quadril com a reparac¸ão do centro de rotac¸ão normal. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Todos os direitos reservados.

Introduction

Technical note

Since the emergence of the modern techniques of prosthetic reconstruction of the hip using the principles of Charnley et al,1 a disease continues to challenge hip orthopedic surgeons: developmental dysplasia of the hip (DDH). In DDH the anatomy is altered. The dysplastic acetabulum is vertical, shallow and with proximal migration, and has poor bone quality and superolateral coverage deficit. The proximal femur is narrow, with small femoral head; and the short neck and trochanter are located posteriorly. Changes in the soft parts also occur, with flattening of the abductor muscles, joint capsule thickening and redundant, hypertrophy of iliopsoas muscle and shortening of the sciatic nerve.2 Because of these changes, Charnley et al. and Feagin et al. discouraged the practice of total hip arthroplasty (THA) in patients with DDH.3 Subsequently, other authors have published studies using bone graft, with the goal of reconstructing the acetabulum and promoting an increase in the coverage of the prosthetic component. Hasting et al. and Parker et al.,4 in 1975, were the first to use autograft of the femoral head, with good results. Harris, in 1977, demonstrated the incorporation of cortico-cancellous grafts,5 and Azuma et al.,6 in 1994, reviewed the graft incorporation by radiographic studies. These studies encouraged the practice of acetabular reconstruction and adopted the incorporation of the graft into the acetabular bed with increased bone stock, which results in increased survival of the hip arthroplasty. Apart from the difficulties imposed by acetabular dysplasia, other important obstacles are the changes of the proximal femur and the lower limb dysmetria. In these patients, the ectopy of the femoral head, more proximally located, leads to the formation of a false acetabulum and to the soft tissue changes already mentioned. In patients with bilateral involvement, the two surgeries should be made with little delay between the procedures, so there is no detrimental effect on the patient’s gait rehabilitation.2 In those people in whom the affection is unilateral, one should try to restore the limb length. The femoral shortening should be made to avoid an exaggerated limb lengthening and to protect the sciatic nerve. The aim of this study was to describe the surgical steps of a total hip arthroplasty in patients with DDH with dislocated hip, through an acetabular reconstruction with bone grafting of the femoral head and fixation with plate for added strength, and femoral shortening with osteotomy in inverted-V, with addition of bone graft cerclage into the osteotomy, to prevent nonunion.

Female patient, 44 years old, submitted to THA in January 2003, with clinical presentation of DDH and stubborn dislocation of left hip. The patient was operated by a group of hip surgeons in the General Hospital of Goiânia (GO). The classification of DDH of Eftekhar7 was used: type D (stubborn dislocation), in which, besides the need for acetabular reconstruction, femoral shortening osteotomy was also made. In the preoperative planning, we requested AP radiographs of the pelvis, including the proximal third of femur, hip profile, and orthoradiographic profile of the lower limbs. An assessment with the use of templates was performed. The goal was the normal biomechanics of the hip to be operated (Fig. 1). The patient underwent spinal anesthesia and was positioned in lateral recumbency. The procedure started with an extensive posterolateral approach and posterior capsulectomy (via Kocher-Langenbeck). Following the osteotomy of the femoral neck, the femoral head is reserved to be used as a graft to the acetabulum. After locating the true acetabulum (to restore the biomechanics of the hip and give durability to the implant; one must be careful not to put the implant into the false acetabulum), this structure was prepared to receive the graft of femoral head fragment, and an osteotomy of the femoral neck was performed. The femoral head is kept to be used as graft of the acetabulum, which is positioned so as to increase the superolateral coverage of acetabulum, and for correction of dysplasia. To obtain a good integration, the recipient bed was scarified till bleeding and the graft is fixed with an Allis plate and screws for small fragments,

Fig. 1 – Radiography of pelvis in the anteroposterior view in the preoperative planning that highlights the developmental dysplasia of the left hip with stubborn dislocation.


r e v b r a s o r t o p . 2 0 1 4;4 9(1):69–73

71

Fig. 2 – Rigid fixation of the autograft for acetabular reconstruction with Allis plate, showing intraoperative image (A) and pelvic X-ray in post-operative anteroposterior view, showing acetabular reconstruction (B).

providing rigid stability to the system. Following that, the reaming of the acetabular bed was made, and the prosthetic component was applied, now under an appropriate coverage (Fig. 2). The next step is to prepare the femoral canal. We must be careful with the femoral anteversion and anterior angulation of the femur. After the reaming of the femoral canal, the subtrochanteric osteotomy of the femur in an invertedV was made, with shortening of the bone. The osteotomy in V facilitates the reduction, increases the contact surface of the osteotomy and decreases the percentage of pseudoarthrosis (Fig. 3). With the osteotomy reduction done, we applied an implant -test into the femoral canal and did the fixation with DCP for little fragments, avoiding the femoral canal. After this, an autograft with steel wire cerclage at the osteotomy site with the osteotomized bone itself was done, also to prevent nonunion. Then, definitive implant and interchangeable femoral head were applied, and the hip reduction was done (Fig. 4). After stability testing of the hip and lower limb length has been made, we proceeded with the percutaneous adductor tenotomy. In the post-operative follow-up, orthoradiography or teleradiography of lower limbs was taken, to assess limb length discrepancy. AP and lateral radiographs of the operated hips were also obtained, to assess the osteointegration of the graft in the acetabular bed and the consolidation of femoral osteotomy (Fig. 5).

A gain in length of the operated limb was obtained, in spite of the femoral shortening, because the acetabular implant is always positioned in the true acetabulum, to the restoration of the proper center of rotation and its hip biomechanics. Thus, femoral shortening was essential for the non-occurrence of vascular complications and especially of any neurological injury postoperatively. The consolidation of the osteotomy occurred in six months after surgery. The results of post-operative orthoradiography or teleradiography also showed equalization of the lower limbs. This fact, together with the retensioning of the abductor muscles caused by the correction of the hip center of rotation, was responsible for improving gait and quality of life of the patient. There was also improvement in pain and in range of motion in the operated hip.

Discussion Patients with sequelae of DDH have, as an option in adulthood, the prosthetic hip reconstruction to improve gait and quality of life. We must remember that these are young and autonomous patients. The arthroplasty for hips with stubborn dislocation presents a special problem, because of the peculiar surgical technique; its practice was even discouraged by Charnley and Feagin3 More recently, studies have demonstrated the effective incorporation of the bone graft in the

Fig. 3 – Shortening femoral osteotomy in inverted-V showing (A) the removal of the bone fragment (B) and the 2-cm fragment (C).


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Fig. 4 – Intraoperative image in which femoral osteotomy in inverted-V and rigid fixation with DCP plate (A) were performed and pelvic X-ray in anteroposterior view showing the attachment after shortening and application of graft cerclage into the osteotomy (B).

Fig. 5 – Radiographic control in the postoperative period of length discrepancy through orthoradiography of the lower limbs (A); X-ray showing autologous bone graft taken from the osteotomy fragment placed in the subtrochanteric region with cerclage by steel wire (arrow) (B).

acetabular roof, with midterm results that encouraged the procedure.4–8 The first obstacle to good functional outcome of THA in cases of DDH is: lowering of the center of rotation, remaking of the acetabular coverage and correction of the dysplasia. The implantation of the acetabular dome into the false acetabulum is associated with shorter survival of the implant. Linde et al.9 reported 42% of loosening when the dome was placed in the false acetabulum; and Stans et al.10 demonstrated an index of acetabular loosening of 83% in a follow-up of 16 years. For the reconstruction of the acetabular roof the use of autologous femoral head is recommended, as described by

Harris et al.5 in 1977. In their study, these authors guide the graft fixation on the acetabular roof with screws. But they had 20% of loosening in seven years.5 We believe that, to get a good result in the consolidation of the graft so there’s no reabsorption, there is need for a proper preparation of the host bed (which is critical), as described by Chandler and Pennenberg,11 and a stable fixation. To the techniques available, we added the use of a plate for graft fixation in the acetabulum, which makes the system more stable and less prone to loosening. For the assessment of graft incorporation onto the acetabular roof, we used radiography, as advocated by Azuma et al.6 Gonc¸alves et al.12


r e v b r a s o r t o p . 2 0 1 4;4 9(1):69–73

concluded that the best method for the evaluation of this incorporation is the histological one; however, the procedure is difficult and causes morbidity for the patient. Hence, radiography is the technique most used. The second obstacle is the shortening of the limb to be operated. In cases of stubborn dislocation and high position, correction of lower limb dysmetria is the goal to be achieved, since its correction will benefit the gait and quality of life of the patient. As in these cases the center of rotation of the hip is high, the femoral reduction in the true acetabulum may cause excessive prolongation of the member, and hence, possible neurological damage. Thus, we made a femoral shortening subtrochanteric osteotomy in inverted-V, as described by Becker and Gustilo,13 with fixation with DCP for small fragments. This osteotomy facilitates reduction, promotes rotational stability and increases the contact surface. Our contribution to the existing techniques is the use of bone graft generated by the osteotomy itself around the inverted-V, with a steel wire cerclage, which reduces the risk of femur nonunion.

Conclusion The technique of acetabular reconstruction and femoral shortening in patients with DDH classified as Eftekhar type D was very efficient, with immediate resolution of the defect and pain. Fixation of the femoral head graft into the acetabulum with plate Allis was done, which contributes to greater resistance of the system, and cerclage with steel wire in the bone graft next to the subtrochanteric osteotomy, which reduces the risk of nonunion.

Conflicts of interest The authors declare no conflicts of interest.

73

references

1. Charnley J. Low friction arthroplasty of the hip: theory and practice. New York: Springer-Verlag; 1979. 2. Canale ST. Cirurgia ortopédica de Campbell. 10a ed. São Paulo: Manole; 2006. 3. Charnley J, Feagin JA. Low-friction arthroplasty in congenital subluxation of the hip. Clin Orthop Relat Res. 1973;(91):98–113. 4. Hastings DE, Parker SM. Protrusio acetabuli in rheumatoid arthritis. Clin Orthop Relat Res. 1975;(108):76–83. 5. Harris WH, Crothers O, Oh I. Total hip replacement and femoral-head bone-grafting for severe acetabular deficiency in adults. J Bone Joint Surg Am. 1977;59(6):752–9. 6. Azuma T, Yasuda H, Okagaki K, Sakai K. Compressed allograft chips for acetabular reconstruction in revision hip arthroplasty. J Bone Joint Surg Br. 1994;76(5):740–4. 7. Eftekhar N. Principles of total hip arthroplasty. St Louis: CV Mosby; 1978. 8. Sponseller PD, McBeath AA. Subtrochanteric osteotomy with intramedullary fixation for arthroplasty of the dysplastic hip. A case report. J Arthroplasty. 1988;3(4):351–4. 9. Linde F, Jensen J. Socket loosening in arthroplasty for congenital dislocation of the hip. Acta Orthop Scand. 1988;59(3):254–7. 10. Stans AA, Pagnano MW, Shaughnessy WJ, Hanssen AD. Results of total hip arthroplasty for Crowe Type III developmental hip dysplasia. Clin Orthop Relat Res. 1998;(348):149–57. 11. Chandler HP, Penenberg BL. Bone stock deficiency in total hip replacement: classification and management. Thorofare, NJ: Slack; 1989. 12. Gonc¸alves HR, Honda EK, Ono NK. Análise da incorporac¸ão do enxerto ósseo acetabular. Rev Bras Ortop. 2003;38(4):139–60. 13. Becker DA, Gustilo RB. Double-chevron subtrochanteric shortening derotational femoral osteotomy combined with total hip arthroplasty for the treatment of complete congenital dislocation of the hip in the adult Preliminary report and description of a new surgical technique. J Arthroplasty. 1995;10(3):313–8.


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Case Report

Lipoma arborescens of the knee: a case report夽,夽夽 Daniel Rodrigo Klein Servic¸o de Ortopedia e Traumatologia, Hospital Arquidiocesano Cônsul Carlos Renaux, Brusque, SC, Brazil

a r t i c l e

i n f o

a b s t r a c t

Article history:

Case report of a female patient of 26 years who complained of pain and recurrent episodes

Received 2 December 2012

of joint swelling in his left knee about 10 years ago. After anamnesis, physical examina-

Accepted 22 March 2013

tion and radiographic imaging and magnetic resonance were diagnosed with arborescent lipoma of the knee, and the patient underwent arthroscopic treatment for resection of the

Keywords:

lesion. Postoperatively the patient was referred to physical therapy rehabilitation with good

Knee

evolution. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora

Lipoma arborescens

Ltda. All rights reserved.

Synovial membrane

Lipoma arborescente de joelho: relato de caso r e s u m o Palavras-chave:

Relato de caso de um paciente do sexo feminino de 26 anos que apresentava queixas de

Joelho

dores eventuais e episódios recorrentes de derrame articular no joelho esquerdo havia

Lipoma arborescente

aproximadamente 10 anos. Após anamnese, exame físico, exames radiográficos e exames

Membrana sinovial

de imagem por ressonância magnética foi firmado o diagnóstico de lipoma arborescente de joelho. A paciente foi submetida a tratamento artroscópico para ressecc¸ão da lesão. No pós-operatório foi encaminhada para reabilitac¸ão fisioterápica, com boa evoluc¸ão. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Todos os direitos reservados.

Introduction Arborescent lipoma is a rare benign intra-articular lesion characterized by diffuse replacement of synovial tissue by mature adipocytes, causing a villous lipomatous proliferation of the sinovial membrane.1 Typically, this is a monoarticular condition. The knee is the most commonly affected joint. The highest incidence of

夽 夽夽

presentation occurs in the fourth and fifth decades of life, with no predilection for gender.2 The typical clinical presentation consists of repetition effusions, often with large volume, accompanied by a diffuse and intermittent pain. In the knee the condition commonly affects the suprapatellar pouch, with a soft consistency on palpation. We should suspect the diagnosis in a patient whose clinical history is of frequent joint effusions, occasional pain and increased volume in the suprapatellar aspect. Radiographic studies may be normal or show

Please cite this article as: Klein DR. Lipoma arborescente de joelho: relato de caso. Rev Bras Ortop. 2014;49:74–77. Study conducted at Orthopedy and Traumatology Service, Hospital Arquidiocesano Cônsul Carlos Renaux, Brusque, SC, Brazil. E-mail: drdanielklein@hotmail.com

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http://dx.doi.org/10.1016/j.rboe.2014.01.008


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75

Fig. 1 – Increased volume in the left knee.

nonspecific changes, such as increased soft tissue or even degenerative changes.2 Magnetic resonance imaging (MRI) is the primary diagnostic test. The image of a mass of synovial villous architecture, with isointensity with subcutaneous fat, is considered by some authors as pathognomonic for arborescent lipoma, which enables the establishment of diagnosis even before the results of the anatomopathological examination. The recommended treatment is open or arthroscopic synovectomy, with very rare cases of recurrence of patology.3

Case report Female, 26 years old. The patient reported that, since adolescence, had episodes of swelling and occasional pain in the left knee without any triggering traumatic event. Denied a history of giving way or locking of the joint, having seen several doctors; sometimes, she underwent arthrocentesis without diagnosis. Her symptoms were reasonably well controlled with physical therapy to maintain muscle control and range of motion. On physical examination, she had bilateral genu valgus, with swelling in the left knee (Fig. 1). She also presented a palpable mass of soft and painless consistency in the lateral aspect, and a positive key sign inferring moderate joint effusion, range of motion with audible crackling in flexion-extension arc and pain with compression of the patellofemoral joint. The maneuvers in search of ligament and meniscal lesions were negative, with no other relevant signs or symptoms. The patient had no family or personal history worthy of note. Plain radiographs of the knee showed reduced medial joint space, subchondral sclerosis, and reactional osteophytes (Fig. 2). MRI demonstrated a large joint effusion, thickening of synovial membranes with enhancement after contrast medium with finger-like aspect and lipomatous content on the lateral aspect of the joint, besides degenerative chondral compartmental changes and degeneration in the body of the medial meniscus (Fig. 3). After evaluation of the physical examination and laboratory tests, the patient underwent videoarthroscopy with use of anterior-inferior and anteriorsuperior portals to resect the lesion and to obtain material for anatomopathological examination, with confirmation of

Fig. 2 – Radiographs of the left knee in AP (A) and lateral views showing degenerative changes (B).

the diagnosis of lipoma arborescens. Besides compartmental degenerative lesions, the arthroscopic examination revealed synovitis of pedunculated appearance and a reddish, diffuse color, with predominance in the lateral gutter (Fig. 4). A drain suction was applied for 24 h, collecting a volume of approximately 350 mL of blood. The patient was discharged without complaints the next day after the procedure. The physical therapy was initiated immediately after discharge, aiming to maintain the range of motion and muscle control, and the patient was allowed to support the weight as tolerated. Thirty days after surgery, the patient was allowed to return to her usual activities. In her latest revision (approximately three months postoperatively), the patient was asymptomatic with minimal joint effusion. In the first year, the follow-up will be semiannual; subsequently, the patient will be annually accompanied for two years.

Discussion Arborescent lipoma is a condition characterized by diffuse replacement of subsynovial tissue by mature adipocytes, with


76

r e v b r a s o r t o p . 2 0 1 4;4 9(1):74–77

Fig. 4 – Intraoperative macroscopic appearance of the lesion (A and B): diffuse villous projections with reddish color, located predominantly in the lateral gutter.

Fig. 3 – Magnetic resonance imaging in sagittal (A), coronal (B) and axial (C) slices, depicting the villous and lipomatous appearance of the synovial membrane.

prominent villous transformation.4 Its etiology is unknown, although in some cases this problem is associated with certain conditions, such as degenerative joint disease, diabetes mellitus, rheumatoid arthritis, and psoriatic arthritis, suggesting the possibility of a reaction process.1 Popliteal cysts were noted in approximately 20% of reported cases.4 Although the knee is the most commonly affected joint, there are also reports of involvement in the wrist,4,5 elbow,4,6 shoulder,4,7 ankle,4,8 and hip.4,9 The differential diagnosis of arborescent lipoma of the knee includes pigmented villonodular synovitis, intra-articular lipoma of the knee, synovial chondromatosis, synovial hemangioma, and rheumatoid arthritis.1,4 Its insidious clinical course, supplemented by tests such as radiography and mainly MRI, virtually confirms the diagnosis. A synovial mass of villous architecture depicting isointensity with subcutaneous fat (hyperintense on T1, which is abolished in the sequences with fat saturation) can be seen on MRI. There is no contrast uptake by the lesion, which

excludes other inflammatory or neoplastic processes of the synovia. However, some intra-articular diffusion of the contrast into the joint fluid, with insinuation between the sinovial lipomatous villous projections, can be seen, giving rise to small areas of uptake.1 Nowadays, with the more widespread use of MRI, it has become more easier to diagnose this pathology. The open or arthroscopic synovectomy is considered curative by most authors. Although there are few published cases of arthroscopic synovectomy, these showed good progress during a follow-up period of up to two years,2 with lower morbidity when compared to cases where open conventional treatment was done.1 We found no major technical difficulties for the arthroscopic procedure, perhaps because the specific localization of the pathology in the anterior aspect of the knee. The use of the anterior- superior accessory portals greatly facilitated the procedure, with little increase in morbidity for the patient. A drain suction should be applied for a period of approximately 24 h after the surgery, in view of the bleeding that occurs after the procedure. In the case described, the location of the pathology and its monoarticular feature, as well as the description of symptoms, coincide with the literature, despite the young age of the patient. With a follow-up of about three months, it can be concluded so far that the proposed treatment was appropriate, since it was possible to do the synovectomy of the entire lesion without adding the usual damage of an open surgery.


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Conflicts of interest The author declares no conflicts of interest.

references

1. Bernardo A, Bernardes M, Brito I, Vieira A, Ventura F. Lipoma arborescente da sinovial. Acta Med Port. 2004;17:325–8. 2. Sailhan F, Hautefort P, Coulomb A, Mary P, Damsin JP. Bilateral lipoma arborescens of the knee: a case report. J Bone Joint Surg Am. 2011;93(2):195–8. 3. Sumathi S, Khan DM, Annam V, Mrinalini VR. Secondary unilateral monoarticular lipoma arborescens of the knee. A case report with review of literature. Int J Biol Med Res. 2012;3(1):1456–8.

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4. Kloen P, Keel SB, Chandler HP, Geiger RH, Zarins B, Rosenberg AE. Lipoma arborescens of the knee. J Bone Joint Surg Br. 1998;80(2):298–301. 5. Gaede EA. Ein fall von synovitis chronicavillosageneralisata. Arch Orthop Unfallchir. 1961;53:315–9. 6. Levadoux M, Gadea J, Flandrin P, Carlos E, Aswad R, Panuel M. Lipoma arborescens of the elbow: a case report. J Hand Surg Am. 2000;25(3):580–4. 7. Laorr A, Peterfy CG, Tirman PF, Rabassa AE. Lipoma arborescens of the shoulder: magnetic resonance imaging findings. Can Assoc Radiol J. 1995;46(4):311–3. 8. Napolitano A. Lipoma arborescens of the synovial fluid; clinical contribution to a case located at the synovia of the wrist. Prog Med (Napoli). 1957;13(4): 109–18. 9. Hubscher O, Costanza E, Elsner B. Chronic monoarthritis due to lipoma arborescens. J Rheumatol. 1990;17(6):861–2.


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Case Report

Necrotizing fasciitis after internal fixation of fracture of femoral trochanteric夽,夽夽 Leandro Emílio Nascimento Santos a,∗ , Robinson Esteves Santos Pires a,b , Leonardo Brandão Figueiredo a , Eduardo Augusto Marques Soares a a b

Hospital Felício Rocho, Belo Horizonte, MG, Brazil Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil

a r t i c l e

i n f o

a b s t r a c t

Article history:

Necrotizing fasciitis is a rare and potentially lethal soft tissue infection. We report a case

Received 6 December 2012

of trochanteric femur fracture in a patient who underwent fracture fixation and developed

Accepted 22 March 2013

necrotizing fasciitis. A literature review on the topic will be addressed. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

Keywords: Necrotizing fasciitis Infection Hip fractures Femoral fractures

Fasciíte necrosante pós-osteossíntese de fratura transtrocantérica do fêmur r e s u m o Palavras-chave:

A fasciíte necrosante é uma rara e potencialmente letal infecc¸ão de partes moles. A seguir,

Fasciíte necrosante

descreveremos o caso de uma paciente portadora de fratura transtrocantérica do fêmur que

Infecc¸ão

evoluiu com fasciíte necrosante após a osteossíntese da fratura. Uma revisão da literatura

Fraturas do quadril

acerca do tema será abordada. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora

Fraturas do fêmur

Ltda. Todos os direitos reservados.

Introduction Necrotizing fasciitis is a rare infection, misdiagnosed as a benign infection. The physician must have a high degree

of clinical suspicion for the establishment of an immediate diagnosis/treatment. The most important variable influencing mortality is the time of surgical debridement. Orthopedic surgeons are often the first to evaluate patients with necrotizing fasciitis and therefore must be

夽 Please cite this article as: Santos LEN, Pires RES, Figueiredo LB, Soares EAM. Fasciíte necrosante pós-osteossíntese de fratura transtrocantérica do fêmur. Rev Bras Ortop. 2014;49:78–81. 夽夽 Study conducted at Hospital Felício Rocho, Belo Horizonte, MG, Brazil. ∗ Corresponding author. E-mail: leandroens@hotmail.com (L.E.N. Santos).

2255-4971/$ – see front matter © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

http://dx.doi.org/10.1016/j.rboe.2014.01.009


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79

knowledgeable of the clinical presentation and treatment. Timely diagnosis, surgical debridement and broad-spectrum parenteral antibiotic therapy are the keys to proper treatment. The objective of this study was to describe the fatal course of a patient who developed necrotizing fasciitis after osteosynthesis of transtrochanteric fracture and to review the literature of this serious infection.

Case report Seventy-one year old female with a history of falling in the bathroom. The patient was in pain, unable to walk, with shortening, external rotation and limited range of motion of the left leg. Presented with arterial hypertension, diabetes, congestive heart failure, liver cirrhosis, schistosomiasis with portal hypertension and thrombocytopenia. Radiographs of the pelvis and left hip showed an unstable transtrochanteric fracture (31-A2.2/AO-ASIF). The patient was operated on the fourth day of hospitalization after her release of the medical clinic. Relative stability of the fracture (osteosynthesis with DHS screw) and postoperative control in the ICU were obtained. On the second day postoperatively, the patient was discharged from the ICU and started motor physical therapy with progressive partial load with walker. She was discharged on the eighth hospital day. Six days after discharge, the patient returned to the hospital complaining of pain in her left leg, with edema, ecchymosis and swelling of the left calf. The duplex scan of the lower limbs depicted deep vein thrombosis (DVT) in the left lower limb. Anticoagulation with enoxaparin SC, followed by warfarin PO, was initiated. After two days, the patient reported persistent pain in the medial aspect of her left thigh, with fever (38 ◦ C). Absence of skin changes in the wound. Laboratory tests were requested: hemoglobin: 7.5 g/dL, total leukocyte: 2400 mm–3 (bands: 7%, segmented: 82%); platelets: 46,000 mm−3 , RNI 1.94; APTT: 41/26, PCR: 28.7 mg/dL. Progression the next day with hypotension (BP: 80 × 40 mmHg), prostration and appearance of blisters on the medial aspect of the left thigh. Absence of pain relief with the use of opioids. Started empirical antibiotic therapy (meropenem), with no improvement. Suspicion of necrotizing fasciitis because of severe pain, rapid appearance of bullous lesions in her left thigh and refractoriness to analgesia. Indication of debridement of the left leg, but the patient had blood dyscrasia (INR 7.36 and PTTA 73/26). Changing antibiotics to intravenous tigecycline. The patient was referred on an emergency basis to the operating room for wide left leg fasciotomy, surgical debridement and collection of material for analysis (Figs. 1–3). Occurrence of severe septic shock refractory to the use of amines. The patient eventually died. The results of blood cultures and samples collected during surgery identified multiresistant A. baumannii/haemolyticus. germ was only sensitive to trimethoprimThe sulfamethoxazole, tetracycline and tigecycline.

Fig. 1 – Necrotizing fasciitis in left leg.

Fig. 2 – Anterior aspect of the left leg. Extensive necrosis and presence of blisters.

Fig. 3 – Extensive necrosis in the anteromedial aspect of left thigh.


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Discussion Necrotizing fasciitis was described in 1871 by the U.S. Army surgeon Joseph Jones. In 1883, Fournier identified necrotizing fasciitis that affects the perineum and external genitalia. But it was Ben Wilson, in 1952, who described the superficial fascia and subcutaneous necrosis. Necrotizing fasciitis follows an injury to the epidermis. In 45% of cases, it is not possible identify the site of the initial injury.1–3 The extremities are the most commonly affected local, but the involvement of the trunk and perineum is related to the high mortality rate.4,5 Patients over 65 years old have the highest incidence of the disease.1 Initially, the disease presents with a local edema. However, with the involvement of the surrounding tissues, local toxicity is triggered and simulates a cellulitis. But the patient presents with severe pain, disproportionate to the skin lesion. The progression of the margins of erythema at greater than 1 cm/h speed is an important signal to the diagnosis in the early stages of necrotizing fasciitis.6 With the evolution of the underlying necrotic process, serous blisters possibly becoming hemorrhagic can be observed. Usually, fever, chills, hypotension, tachycardia, and altered level of consciousness are present.2,6 Acute renal failure is present in 35% of patients, coagulopathy in 29%, acute respiratory failure in 14%, and bacteremia in 46%.7 The burning pain is the most prominent symptom, that can be observed in almost 100% of patients with necrotizing fasciitis.8 The diagnosis is mainly clinical; it is essential that the physician has a high degree of suspicion. The average time between onset of symptoms and diagnosis is 2-4 days.9 WBC count > 15,400 cells/mm3 and serum level of sodium < 135 mmol/L have a sensitivity of 90% for necrotizing fasciitis. The specificity is 76% and the positive predictive value is 26%, and that only serves to exclude the disease.10 Phosphocreatin levels > 600 IU/L have 58% sensitivity and 95% specificity.11 MRI has high sensitivity (93–100%) for diagnosis. Liquefied tissue inflammation and edema around the fascia are detected by an increased signal on T2-weighted images and absence of attenuation of gadolinium in T1. “The finger test” is a simple procedure, done under local anesthesia. The surgeon makes an incision of 2 cm to the deep fascia, and his/her gloved finger is inserted. The presence of liquefied subcutaneous tissue, absence of bleeding and poor adherence of subcutaneous tissue during blunt dissection define a positive test. A sample of tissue must be resected and sent to bacterioscopy, culture and anatomopathological examination. Histologically, necrotizing fasciitis is characterized by suppurative focal necrosis of fascia, fat and nerves, edema of the fibrous septa and infiltration by polymorphonuclear cells. The parenteral empirical antibiotic therapy can be initiated with imipenem, meropenem, ampicillin/sulbactam or piperacillin/tazobactam associated with clindamycin. The antibiotic is complementary to debridement.

In patients allergic to penicillin, ceftazidime, associated with clindamycin, is an option.12 The mortality of necrotizing fasciitis ranges from 6% to 76%.13 Patients over 60 years old have a high mortality rate. Thrombocytopenia, abnormal liver function, hypoalbuminemia, acute renal failure, and increased serum lactate are associated with mortality.14 The mortality can reach 100% in non-operated cases and in the case of myonecrosis.7 However, the mortality rate drops to 12% if the diagnosis and treatment are made in the first four days after the onset of symptoms.15

Conclusion Necrotizing fasciitis is a severe infectious disease. It requires a high index of suspicion to initiate antibiotic therapy and debridement. Despite the diagnosis of necrotizing fasciitis and the indication of debridement, blood dyscrasias precluded surgery in a timely manner, so there was no reversal of the clinical picture.

Conflicts of interest The authors declare no conflicts of interest.

references

1. Dufel S, Martino M. Simple cellulitis or a more serious infection? J Fam Pract. 2006;55(5):396–400. 2. Bisno AL, Stevens DL. Streptococcal infections of skin and soft tissues. N Engl J Med. 1996;334(4):240–5. 3. Mulla ZD. Treatment options in the management of necrotising fasciitis caused by Gro*up A treptococcus. Expert Opin Pharmacother. 2004;5(8):1695–700. 4. Levine EG, Manders SM. Life-threatening necrotizing fasciitis. Clin Dermatol. 2005;23(2):144–7. 5. Carter PS, Banwell PE. Necrotising fasciitis: a new management algorithm based on clinical classification. Int Wound J. 2004;1(3):189–98. 6. Wong CH, Chang HC, Pasupathy S, Khin LW, Tan JL, Low CO. Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality. J Bone Joint Surg Am. 2003;85(8):1454–60. 7. Kaul R, McGeer A, Low DE, Green K, Schwartz B. Population-based surveillance for Group A streptococcal necrotizing fasciitis: clinical features, prognostic indicators, and microbiologic analysis of seventy-seven cases. Ontario Group A Streptococcal Study. Am J Med. 1997;103(1):18–24. 8. Young MH, Aronoff DM, Engleberg NC. Necrotizing fasciitis: pathogenesis and treatment. Expert Rev Anti Infect Ther. 2005;3(2):279–94. 9. Wysoki MG, Santora TA, Shah RM, Friedman AC. Necrotizing fasciitis: CT characteristics. Radiology. 1997;203(3):859–63. 10. Wall DB, Klein SR, Black S, de Virgilio C. A simple model to help distinguish necrotizing fasciitis from nonnecrotizing soft tissue infection. J Am Coll Surg. 2000;191(3):227–31. 11. Simonart T. Group a beta-hemolytic streptococcal necrotising fasciitis: early diagnosis and clinical features. Dermatology. 2004;208(1):5–9. 12. Smith RJ, Berk SL. Necrotizing fasciitis and nonsteroidal anti-inflammatory drugs. South Med J. 1991;84(6):785–7.


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13. Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32(7): 1535–41.

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14. Golger A, Ching S, Goldsmith CH, Pennie RA, Bain JR. Mortality in patients with necrotizing fasciitis. Plast Reconstr Surg. 2007;119(6):1803–7. 15. Morantes MC, Lipsky BA. “Flesh-eating bacteria”: return of an old nemesis. Int J Dermatol. 1995;34(7):461–3.


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Case Report

Osteoid osteoma of the acromion simulating acromioclavicular pain夽,夽夽 Alberto Naoki Miyazaki ∗ , Marcelo Fregoneze, Pedro Doneux Santos, Luciana Andrade da Silva, Guilherme do Val Sella, Douglas Lobato Lopes Neto, Melvis Muchiuti Junior, Sergio Luiz Checchia Departamento de Ortopedia e Traumatologia, Faculdade de Ciências Médicas da Santa Casa de São Paulo, 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:

The osteoid osteoma is a benign bone tumour that usually presents with nocturnal pain in

Received 17 March 2013

young adults, relieved by rest and anti-inflammatories. It can affect any bone; however, their

Accepted 9 April 2013

occurrence is rare in the acromion. The authors describe a case of osteoid osteoma located in the acromion, with symptoms that simulated acromion claviculararthrosis. The diagnosis

Keywords:

was made by CT scan and treatment was excision of the nidus through arthroscopy. The

Osteoid osteoma

diagnosis was confirmed by histopathology. In the outpatient segment, the patient remained

Bone neoplasms

asymptomatic, with complete recovery of function of the affected limb.

Acromion

© 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

Osteoma osteóide de acrômio que simula dor acrômio-clavicular r e s u m o Palavras-chave:

O osteoma osteóide é um tumor ósseo benigno que se apresenta geralmente em adultos

Osteoma osteóide

jovens com dor noturna, aliviada por repouso e anti-inflamatórios. Pode acometer qual-

Neoplasias ósseas

quer osso. Entretanto, sua ocorrência no acrômio é rara. Os autores descrevem um caso de

Acrômio

osteoma osteóide localizado no acrômio, com sintomas que simulavam artrose acrômio-clavicular. O diagnóstico foi feito por meio de tomografia computadorizada e o tratamento proposto foi a exérese do nidus por meio de artroscopia. O diagnóstico definitivo foi confirmado por exame histopatológico. No segmento ambulatorial, a paciente permaneceu assintomática e com recuperac¸ão completa da func¸ão do membro acometido. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Todos os direitos reservados.

Please cite this article as: Miyazaki AN, Fregoneze M, Santos PD, da Silva LA, do Val Sella G, Neto DLL, Muchiuti Junior M, Checchia SL. Osteoma osteóide de acrômio que simula dor acrômio-clavicular. Rev Bras Ortop. 2014;49:82–85. 夽夽 Work conducted at Shoulder and Elbow Group, Department de Orthopaedics and Traumatology, Medical Sciences School, Santa Casa de São Paulo, São Paulo, SP, Brazil. ∗ Corresponding author. E-mail: ombro@ombro.med.br (A.N. Miyazaki). 2255-4971/$ – see front matter © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

http://dx.doi.org/10.1016/j.rboe.2014.02.001


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Introduction Osteoid osteoma is a benign osteoblastic lesion, and constitutes approximately 11% of all benign bone tumours that usually occur in young men. This neoplasm is found in the second or third decade of life. However, it can be seen in other age groups.1 Any bone can be involved. However, there is a predilection for lower extremities: half of the cases involve the femur or tibia.2 The scapula is a bone rarely affected and few cases have been reported in the literature. Mosheiff et al.,3 in a review of the literature, reported the involvement of 12 scapulae in 1236 cases of osteoid osteoma.

Case report A female patient, aged 46 years, right-handed, complained of right shoulder pain for three months, especially at night, with worsening during physical activities, and improved with the use of NSAIDs. She denied any history of trauma or previous disease in the joint. She has been diagnosed previously as having impingement syndrome and treated with two subacromial corticosteroid injections and physical therapy, with partial improvement of symptoms. On physical examination, her shoulders had no deformities, tumours or skin lesions, and muscle tropism was preserved. The range of active movement of the affected limb was slightly limited by pain and the passive movement was normal. Provocative manoeuvres for acromioclavicular joint (O’Brien, forced adduction and pain on palpation) were strongly positive and the other tests to evaluate the rotator cuff and instability of the shoulder joint resulted negative. The Zanca view radiographs revealed changes in the acromioclavicular joint (Fig. 1). A magnetic resonance imaging study showed an acromioclavicular arthrosis with intense inflammatory process in the joint region with a cyst on the acromion, initially interpreted as a geode. However, our attention was drawn by the fact that there was an intense inflammatory process around the lesion, which was very regular and larger than usual; in addition, the images

Fig. 1 – Radiograph of the right shoulder, Zanca view, showing arthrosis of acromioclavicular joint.

suggested the existence of some solid content inside it (Fig. 2A and B). The diagnosis hypothesis of osteoid osteoma was proposed and then we requested a CT scan for confirmation; the nidus inside the cyst could be easily evidenced (Fig. 3). All the complementary laboratory tests were normal. We chose arthroscopic surgery and resection of the nidus (Fig. 4), complemented with a broader than usual acromioplasty, until the removal of the entire tumour, and resection of the distal end of the clavicle (Mumford procedure) was taken (Fig. 5). The diagnosis was confirmed by pathological study. The patient had rapid regression of symptoms, with complete recovery of the functional range of motion of the affected limb, and remained asymptomatic until her last return, by occasion of the postoperative examination of seven years.

Discussion The scapula is a rare site of osteoid osteoma location and, therefore, is often failed to be included in the differential

Fig. 2 – Magnetic resonance images of the right shoulder, coronal (a) and axial (b) section, showing acromioclavicular arthrosis with severe swelling in the joint and a cyst (nidus) into the acromion, next to the joint.


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Fig. 3 – Axial CT image of the right shoulder showing osteoid osteoma in the acromion, next to the acromioclavicular joint.

Fig. 4 – Surgical arthroscopic image, subacromial view, showing the resection of the tumour with a curette.

diagnosis of chronic shoulder pain.4 The patient with an osteoid osteoma is characterized by pain that occurs predominantly at night and is relieved by aspirin or anti-inflammatory drugs.5 Often the nocturnal pain is attributed to rotator cuff disease. However, the age range of patients with osteoid osteoma would imply in lower probability of a rotator cuff disease. Multiple treatment options for this tumour are available: drug therapy, percutaneous ablation by radiofrequency and

Fig. 5 – Magnetic resonance imaging, right shoulder, sagittal view, showing complete resection of the lesion (acromioplasty) and resection of the lateral end of the clavicle.

surgical procedures involving the complete removal of the nidus, which can be achieved by curettage, en bloc resection and, more recently, by arthroscopic route, with good results.6,7 If the patient’s symptoms are adequately controlled, anti-inflammatory medication can be used as a final treatment. Patients treated in this manner usually experience spontaneous healing of the lesion in three to four years.8 Degreef et al.7 first described the occurrence of an osteoid osteoma in the acromion in a female patient aged 56, whose treatment was open resection of the lesion. Kelly et al.6 described a case of arthroscopic resection of an osteoid osteoma located at the anterior border of the glenoid of a male patient aged 30 years, who had undergone two surgeries for treatment of a SLAP lesion. The authors also reported an arthroscopic resection of an osteoid osteoma located at the base of the coracoid process of a male patient aged 12 years. Our choice was the arthroscopic treatment, as in the cases described above, because the patient’s was a benign lesion and we had a possibility to resect the entire lesion with minimal tissue damage. This option proved to be effective, and can be applied in similar cases.

Conflicts of interest The authors declare no conflicts of interest.


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references 1. Lee BG, Cho NS, Rhee YG. Unusual shoulder synovitis secondary to an osteoid osteoma without a nidus in the coracoid process: delayed appearance of a nidus. J Orthop Sci. 2010;15(6):825–8. 2. Mitsui Y, Gotoh M, Yoshida T, Hirai Y, Shinozaki T, Nakama K, et al. Osteoid osteoma of the proximal humerus: a misleading case. J Shoulder Elbow Surg. 2008;17(1):e13–5. 3. Mosheiff R, Liebergall M, Ziv I, Amir G, Segal D. Osteoid osteoma of the scapula. A case report and review of the literature. Clin Orthop Relat Res. 1991;262:129–31. 4. Glanzmann MC, Hinterwimmer S, Woertler K, Imhoff AB. Osteoid osteoma of the coracoid masked as localized capsulitis of the shoulder. J Shoulder Elbow Surg. 2011;20(8):e4–7.

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5. Gracia IA, Itarte JI, Majo JB, Salo GB, Proubasta IR. Osteoid osteoma of the coracoid process. J Southern Orthop Assoc. 2001;10(1):49–52. 6. Kelly AM, Selby RM, Lumsden E, O’Brien SJ, Drakos MC. Arthroscopic removal of an osteoid osteoma of the shoulder. Arthroscopy. 2002;18(7):801–6. 7. Degreef I, Verduyckt J, Debeer P, De Smet L. An unusual cause of shoulder pain: osteoid osteoma of the acromion – a case report. J Shoulder Elbow Surg. 2005;14(6): 643–4. 8. Heck Jr RK. Bone-forming tumors. In: Canale T, Beaty JH, editors. Campbell’s operative orthopaedics. 11th ed. Philadelphia: Saunders Elsevier; 2007. p. 855–7.


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www.rbo.org.br

Case report

Compartment syndrome after tibial plateau fracture夽 Guilherme Benjamin Brandão Pitta ∗ , Thays Fernanda Avelino dos Santos, Fernanda Thaysa Avelino dos Santos, Edelson Moreira da Costa Filho Universidade Estadual de Ciências da Saúde de Alagoas, Maceió, AL, Brazil

a r t i c l e

i n f o

a b s t r a c t

Article history:

Fractures of the tibial plateau are relatively rare, representing around 1.2% of all fractures.

Received 6 February 2013

The tibia, due to its subcutaneous location and poor muscle coverage, is exposed and suffers

Accepted 9 April 2013

large numbers of traumas, not only fractures, but also crush injuries and severe bruis-

Keywords:

patient. The case is reported of a 58-year-old patient who, following a tibial plateau frac-

Tibial fractures

ture, presented compartment syndrome of the leg and was submitted to decompressive

ing, among others, which at any given moment, could lead compartment syndrome in the

Bone wires

fasciotomy of the four right compartments. After osteosynthesis with internal fixation of

Fracture fixation internal

the tibial plateau using an L-plate, the patient again developed compartment syndrome. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

Síndrome compartimental pós-fratura de platô tibial r e s u m o Palavras-chave:

As fraturas de platô tibial são relativamente raras e representam, aproximadamente, 1,2%

Fraturas da tíbia

de todas as fraturas. A tíbia, por sua localizac¸ão subcutânea e pobre cobertura muscular, está

Fios ortopédicos

exposta a sofrer grandes quantidades de traumatismos, que não são somente fraturas, mas

Fixac¸ão interna de fraturas

também lesões por achatamento, contusões severas, entre outras que, em um determinado momento, podem causar no enfermo a síndrome compartimental. É relatado o caso de um paciente de 58 anos que, após fratura de platô tibial, apresentou síndrome compartimental de perna e foi submetido à fasciotomia descompressiva dos quatro compartimentos direitos. Após osteossíntese com fixac¸ão interna de platô tibial com placa em L, evoluiu com nova síndrome compartimental. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Todos os direitos reservados.

Please cite this article as: Pitta GBB, dos Santos TFA, dos Santos FTA, da Costa Filho EM. Síndrome compartimental pós-fratura de platô tibial. Rev Bras Ortop. 2014;49:86–88. ∗ Corresponding author. E-mail: guilherme@guilhermepitta.com (G.B.B. Pitta). 2255-4971/$ – see front matter © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

http://dx.doi.org/10.1016/j.rboe.2014.02.002


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87

Introduction Tibial plateau fractures are relatively rare and represent 1.2% of all fractures.1 The tibia is exposed to a lot of traumas, that can cause compartment syndrome (CS).2 With a diagnosis of SC, fasciotomy is indicated for the opening of the four compartments.3 The aim of this study is to report a case of compartment syndrome after tibial plateau fracture treated with fasciotomy prior to osteosynthesis of tibial metaphysis and which developed into a compartment syndrome postoperatively.

Case report Patient, male, 58 years old, fell from height, developed pain in the right lower limb (RLL), associated with swelling and difficult walking. The radiograph of RLL revealed fracture of proximal tibial metaphysis and proximal fibular epiphysis with involvement of the knee joint. Computed tomography of joints revealed comminuted fractures of the tibial plateau and fibular head. In the biochemical tests, it was found that total CK = 637 U/L. As the patient developed progressive and severe pain, paresthesia, paresis, pallor and tense and shiny skin, he was referred to the vascular surgery service, where a Doppler vascular ultrasonography was requested, excluding venous thrombosis. The indication for decompressive fasciotomy was based on the leg nerve paresthesia, associated with the limb volume, when compared to the contralateral limb. The patient was referred for decompressive fasciotomy of urgency in other surgical service. The surgery was performed under peridural anesthesia and medial and lateral fasciotomies were made, to release the four compartments of the leg. Finally, the surgeon proceeded with haemostasis, partial synthesis of fasciotomy and surgical wound dressing. In that service, 48 h later, the osteosynthesis was performed under spinal anesthesia. Fracture reduction, internal fixation of the tibial plateau fracture in the medial and lateral sides with L-plate and closure of fasciotomy were performed. During the fracture manipulation for its fixation with the Lplate, the right leg developed progressive swelling and pain in a localized compartment, and this complication has made the patient seek our service, when we identified the need to reopen the incision (a new decompressive fasciotomy), being possible to visualize the plate stem (Fig. 1), which had not been previously removed. A wound dressing was made and, after 15 days postoperatively, a free skin graft in the lateral region of the affected leg was applied, with exposition of the plate and of the internal fixator screw (Fig. 2). After six weeks, the lateral stem was retired; then, total closure of the wound was made, with a good progress so far and without associated comorbidities.

Fig. 1 – Reopening of surgical incision (new decompressive fasciotomy).

complexity of the bone lesion, as for the associated soft tissue injury.5 Important factors for the diagnosis of this lesion are a detailed clinical history and the use of imaging studies.6 In this case report, the patient first sought another surgical service with pain associated with swelling and difficult walking; a tibial plateau fracture was diagnosed with the aid of radiography and computed tomography. In several studies of fractures associated with vascular trauma, the likelihood of compartment syndrome (CS) increases; therefore, also increases the possibility of fasciotomies. A study was published exploring the association between the site of trauma penetration to the lower extremity and the need for fasciotomies. Its authors concluded that proximal lesions below the knee confer a substantially increased risk of “compartment” and that the risk increases with an association with a proximal tibial fracture.7 In our study, we showed radiographically a fracture of proximal tibial metaphysis and of proximal fibular epiphysis with involvement of the knee joint.

Discussion Tibial plateau fractures account for 1% of all fractures; in elderly subjects they represent about 8% of their fractures.4 These lesions are a challenge for surgeons, both for the

Fig. 2 – Free skin grafting in anterolateral fasciotomy of the right leg with exposure of plate and internal fixation screw.


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CS is defined as the increase in pressure within the compartment enclosed by fascia and which affects the viability of the tissues. Acute CS is a severe condition and occurs as a result of trauma which, in many cases, require decompression fasciotomies to prevent muscle necrosis.2 The degree of damage will depend on how fast the pressure rise is established and how long it lasts. The pathogenesis is explained by the high intracompartmental pressure, at levels sufficient to compromise the microcirculation of tissues.8 Classically there are six clinical findings in the diagnosis of compartment syndrome: (1) pain in the affected extremity, disproportionate to the injury; (2) pain induced by the stretching of the compartment muscles; (3) paresis of the muscles of the compartment; (4) hypoesthesia or paresthesia in the topography of the nerves that run through the affected segment; (5) hardening or inflammation, or both, of the affected site; and (6) reduced or absent distal pulses.9 The most important clinical finding is hardening, strain in the affected segment (if accompanied by pain), swelling, decreased sensitivity and difficulty in moving the limb.10 In the laboratory workup, an increased creatine kinase (CK) to 1000–5000 U/ml is possible, which demonstrates a myoglobinuria that may suggest the diagnosis.9 The patient came to our service after fracture manipulation for fixation with L-plate, because the right leg developed swelling and progressive pain in a localized compartment, and a decompressive fasciotomy was indicated, based on leg nerve paresthesia associated with limb volume, when compared to the contralateral limb. Furthermore, a total CK = 637 U/L was obtained, which confirmed the diagnosis. Absolute indications for surgical treatment are open fractures and fractures associated with CS or vascular injury. In these situations, the treatment should be conducted on an emergency basis. In other cases, the time of surgery is dictated by the general clinical condition of the patient.6

Conclusion The fracture of the tibial plateau is a major trauma, which may be associated with poor prognosis. Thus, because of the importance of the association between bone fractures and the development of compartment syndrome, the establishment

of the differential diagnosis is essential, based on the early recognition of the signs and symptoms of the syndrome for the institution of an appropriate therapy, which improves the prognosis and decreases the morbidity.

Conflicts of interest The authors declare no conflicts of interest.

references

1. Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury. 2006;37(8):691–7. 2. Blanco MG, López AA, Lorenzo YG. Síndrome compartimental agudo en lesiones de la tibial. Arq Med Camagüey. 2008;4(12):1–10. 3. Kojima KE, Ferreira RV. Fraturas da diáfise da tíbia. Rev Bras Ortop. 2011;46(2):130–5. 4. Mandarino M, Pessoa A, Guimarães JAM. Avaliac¸ão da reprodutibilidade da classificac¸ão de Schatzker para as fraturas do planalto tibial. Rev Into. 2004;2(2):1–60. 5. Faustino CAC, Góes CEG, Godoy FAC, Nishi ST, Bicudo LAR. A importância da ressonância magnética pré-operatória nas fraturas do planalto tibial. Rev Bras Ortop. 2011;46(Suppl 1): 13–7. 6. Kfuri Júnior M, Fogagnolo F, Bitar RC, Freitas RL, Salim R, Paccola CAJ. Fraturas do planalto tibial. Rev Bras Ortop. 2009;44(6):468–74. 7. 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. 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. 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. 4th ed. São Paulo: Di-Livros; 2000. p. 1290–8. 10. Pitta GBB. Lesiones de la arteria poplitea por traumatismo en la vida civil. In: Anais do XVIII Congresso Del Capitulo Latino Americano. II Congresso Nacional de Angiologia. 1986. p. 76.


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www.rbo.org.br

Case Report

Nodular fasciitis in finger simulating soft tissue malignancy夽,夽夽 Soraya Silveira Monteiro, Diva Helena Ribeiro, Tatiane Cantarelli Rodrigues ∗ , Gerson Ferreira Gontijo Junior, Kylza Arruda, Eloy De Avila Fernandes Hospital do Servidor Público Estadual, 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:

Nodular fasciitis (NF) is a rare fibroblastic proliferative lesion, characterized clinically as a

Received 4 February 2013

solitary mass of hardened and slightly painful on palpation, fast growing and no gender

Accepted 9 April 2013

preference. The objective of this study is to report the case of a patient with NF in third finger of left hand, describe the findings of plain radiography, computed tomography and

Keywords:

magnetic resonance imaging and correlate with the literature. Since the diagnosis of NF is

Fasciitis/radiography

a challenge, being necessary to conciliate the clinical, radiological and pathological.

Computed tomography

© 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

Magnetic resonance spectroscopy Soft tissue neoplasms

Fasciíte nodular em quirodáctilo que simula neoplasia maligna de partes moles r e s u m o Palavras-chave:

Fasciíte nodular (FN) é uma lesão proliferativa fibroblástica rara, caracterizada clinicamente

Fasciíte/radiografia

como uma massa solitária de consistência endurecida, pouco dolorosa à palpac¸ão, de cresci-

Tomografia computadorizada

mento rápido e sem predilec¸ão por sexo. O objetivo deste trabalho é relatar o caso de uma

Espectroscopia de ressonância

paciente com FN no terceiro quirodáctilo da mão esquerda, descrever os achados da radio-

magnética

grafia simples, tomografia computadorizada e ressonância magnética e correlacionar com

Neoplasias de tecidos moles

a literatura. Visto que o diagnóstico de FN é um desafio, é necessário conciliar os achados clínicos, radiológicos e patológicos. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Todos os direitos reservados.

夽 Please cite this article as: Monteiro SS, Ribeiro DH, Rodrigues TC, Junior FGK, Arruda G, Fernandes EDeA. Fasciíte nodular em quirodáctilo que simula neoplasia maligna de partes moles. Rev Bras Ortop. 2014;49:89–93. 夽夽 Study conducted at Hospital do Servidor Público Estadual, São Paulo, SP, Brazil. ∗ Corresponding author. E-mail: tcantarelli@gmail.com (T.C. Rodrigues).

2255-4971/$ – see front matter © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

http://dx.doi.org/10.1016/j.rboe.2014.01.010


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Introduction Nodular fasciitis (NF) is a benign soft tissue injury of unknown etiology,1–4 characterized by proliferation of fibroblasts and often confused histologically with sarcomas, because of its rapid growth, high cellularity and increased mitotic activity.1,3,4 The lesions are commonly solitary, occur in adults between 20 and 40 years old,1–4 and affect any region of the body.1,5 This is a self-limiting disease.2,3 Patients usually have a history of rapid growth and nodulation, and may develop numbness or paresthesia.1–3,6 Its diagnosis is challenging and can be confused with malignant tumors, because of the aggressive clinical behavior associated with imaging and histology findings.1–3 Multiple lesions are rare,1,7 as well as lesions in hands and feet, and very rare in the fingers.8 Given this fact, we report a case of FN on the finger, since the knowledge of the appearance of the imaging studies can avoid aggressive invasive procedures, since the histological study without image may lead to suspicion of a lesion with high aggressiveness.

Case report Patient, female, 45 years old, teacher, referring appearance of nodulation of rapid growth in the third left finger for two years; painless, but with local discomfort. She denied trauma or previous surgery. The physical examination showed volar nodulation in the proximal phalanx of the third chirodactyl, adhered to the skin without retraction or phlogistic signs, and measuring approximately 2 cm. Plain radiography (RX) revealed ossification of soft tissues of the radial and flexor diaphyseal faces of the proximal phalanx of the finger, with irregular and partially defined contours, cortical erosion and lamellar periosteal reaction proximal and distal to the nodule, and increased volume and density of parts of the adjacent soft tissue (Fig. 1). Computed

tomography (CT) ratified these findings and demonstrated more clearly the ossification, extending from the bone and externally involving the cortical flexor contiguous with the radial and flexor aspect nodulation (Fig. 2). MRI revealed expansive formation on soft parts of the radial face of the proximal phalanx, which promoted slight thinning of the cortical bone with intimate contact, and superiorly displaced the extensor hood. The lesion depicted the iso/hypersignal relative to muscle on T1, heterogeneous signal with mild hypersignal on T2, and significant heterogeneous enhancement to paramagnetic contrast medium, associated with a bone marrow edema pattern (Fig. 3). The patient underwent surgical exeresis, and the histopathological examination revealed fibrous connective tissue with neoformation and trabeculation, favoring the diagnosis of NF. Five months later, MRI depicted only fibrocicatricial changes in soft tissues, without significant enhancement in the contrast medium (Fig. 4).

Discussion FN is a benign lesion of unknown etiology,1,5 but with possible association with trauma.1,3,7 FN affects every body part, and most commonly1,5 the upper extremity (48%), besides the trunk (20%), head and neck (17%), and lower extremity (15%).1,2 Its occurrence is rare in hands and feet, and very rare in fingers.8 The most affected age group is 20–40 years; FN also affects both genders.1,3 Symptoms such as numbness, paraesthesia and pain are infrequent, implying nervous compression.2,3 Multiple lesions are rare.1,7 The average diameter of the lesion is about 2 cm, and larger lesions are exceptional.1,3,7 Based on the anatomical location, FN can be divided into three types: subcutaneous, intramuscular, and fascial. Subcutaneous FN is three to 10 times more frequent.1,2,4 The intramuscular type more perfectly simulates a neoplasm of soft tissues.1 Intravascular and intradermal forms are rare subtypes.2

Fig. 1 – RX AP (A) and oblique (B), showing ossification of soft tissues of the radial and flexor diaphyseal faces of the proximal phalanx of the third chirodactyl, with irregular and partially defined contours (arrows), cortical erosion (open arrows) and lamellar periosteal reaction (arrowheads) proximal and distal to the node, and increased volume and density of the adjacent soft tissue (open arrowheads).


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Fig. 2 – Axial slice CT scan reveals the ossification (arrows) advancing from the bone and that externally involved the cortical flexor (open arrows) contiguous to the radial and flexor aspect nodulation. The reconstruction in the coronal plane (D) depicts continuity of nodular lesion with periosteal reaction (arrowheads) extending to the flexor side.

According to the predominant histologic composition, FN can be fibrous, myxoid or cellular.1,3,4 Histologically, this lesion consists of fibroblasts arranged in short bundles and fascicles scattered within a myxoid stroma, and may simulate sarcoma.1,2,8 Some authors believe that the amount and type of extracellular matrix reflect the age of the lesion: in early FN, predominates the myxoid component; in mature FN, the fibrous component is more abundant.1,2,4 The various components can coexist in the same lesion, with combinations of myxoid-cellular, and of cellular-fibrous types, that are more common than combinations of myxoid-fibrous types, suggesting histological transition from myxoid to cellular and, later, to fibrous type.1 Imaging studies may be used to evaluate patients with FN. The present study shows some of the image changes to be characterized and recognized. RX shows increased soft tissue. To our knowledge, there is only one case in the literature that depicts the radiographic appearance of the lesion, considering it as nonspecific.8 On CT, lesions of FN usually appear as a superficial mass of soft tissue, with density similar to other lesions,1 well-defined, and that can invade and destroy adjacent bone.7 At MRI, the appearance is nonspecific,1,2,7,8 most commonly iso/hyperintense on T1 and hyperintense on T2, with varied enhancement by paramagnetic contrast because of the different histological types.3,4 It is unknown which influences more decisively in signal intensity: the cellularity or collagen.

Some authors advocate that myxoid forms present hyperintensivity relative to muscle on T1, and to subcutaneous fat on T2; and that fibrous forms are hypointense to the muscle in all sequences. Other authors state that the lesion is isointense to muscle on T1, and to venous structures on T2.1 The hypercellular lesions present isointense signal to muscle on T1, and are hyperintense to fat on T2.4 Because of the nonspecific findings, many differential diagnoses can be proposed, including neuroma, neurofibroma, sarcoidosis, aggressive fibromatosis, dermatofibroma, fibrosarcoma, and malignant fibrous histiocytoma.2,3,7 In the intramuscular lesions, one can think of myositis ossificans in early stage.4 Giant cell tumors of the tendon sheath can be differentiated from FN by its slow growth and by the fixation of the tumor to the tendon.8 In some cases, the similarity in clinical and microscopic presentation between FN and sarcoma makes difficult the establishment of a diagnosis, but some clinical and radiological features make the diagnosis of NF less likely, including lesions in patients over 70 years old, lesions located in the hands and feet, or simultaneous, multiple, recurrent lesions, with perilesional tissue edema or intralesional deposition of hemosiderin in MRI studies.2 The physician must obtain a biopsy to establish a definitive diagnosis.2,8 The excision, usually curative, is the mainstay of treatment,5 although intralesional infusion of corticosteroids has been suggested by some authors.2,6 There may be spontaneous remission.6 Relapses are rare, occurring in 1–2%


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Fig. 3 – MRI reveals expansive formation on soft parts of the radial face of the proximal phalanx with iso/hypersignal relative to muscle on T1 (A and C), mild hypersignal on T2 (B), and significant heterogeneous enhancement to paramagnetic contrast medium (D); slight thinning of the cortical bone (arrows), which superiorly displaces the extensor hood (arrowheads), associated with bone marrow edema pattern.

Fig. 4 – Five months after surgery, MRI scan in the coronal and axial plans (A, B) demonstrating absence of nodulation, and fibrocicatricial change (arrows) in the soft tissues, and after the administration of paramagnetic contrast (C), without areas of significant enhancement.


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of patients and being usually observed immediately after excision.2,8 In summary, FN can be interpreted as a malignant lesion because of its rapid growth and aggressive histological nature. However, the correct diagnosis can be established by combining the characteristics of the image, localization and histology.1

Conflicts of interest The authors declare no conflicts of interest.

references

1. Wang XL, De Schepper AM, Vanhoenacker F, De Raeve H, Gielen J, Aparisi F, et al. Nodular fasciitis: correlation of MRI findings and histopathology. Skeletal Radiol. 2002;31(3):155–61.

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2. Leung LY, Shu SJ, Chan AC, Chan MK, Chan CH. Nodular fasciitis: MRI appearance and literature review. Skeletal Radiol. 2002;31(1):9–13. 3. Duncan SFM, Athanasian EA, Antonescu CR, Roberts CC. Resolution of nodular fasciitis in the upper arm. Radiology Case Reports [Online]. 2006;1:3. 4. Dinauer PA, Brixey CJ, Moncur JT, Fanburg-Smith JC, Murphey MD. Pathologic and MR imaging features of benign fibrous soft-tissue tumors in adults. Radiographics. 2007;27(1): 173–87. 5. Souza LS, Almeida WL, Costa ALD, Silva OS, Souza LL. Fasceíte nodular. Rev Bras Cir Cab Pesc. 2009;38:274–5. 6. Graham BS, Barrett TL, Goltz RW. Nodular fasciitis: response to intralesional corticosteroids. J Am Acad Dermatol. 1999;40(3):490–2. 7. Kim ST, Kim HJ, Park SW, Baek CH, Byun HS, Kim YM. Nodular fasciitis in the head and neck: CT and MR imaging findings. AJNR Am J Neuroradiol. 2005;26(10):2617–23. 8. Park JS, Park HB, Lee JS, Na JB. Nodular fasciitis with cortical erosion of the hand. Clin Orthop Surg. 2012;4(1): 98–101.


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Case Report

Open anterior dislocation of the hip in an adult: a case report and review of literature夽,夽夽 Anderson Luiz de Oliveira ∗ , Eduardo Gomes Machado Instituto Jundiaiense de Ortopedia e Traumatologia, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brazil

a r t i c l e

i n f o

a b s t r a c t

Article history:

Open anterior hip dislocation is a rare condition and results from high-energy trauma. Ten

Received 3 April 2013

cases of open anterior dislocation have been described in the literature so far. Its rarity is due

Accepted 23 April 2013

to the inherent stability of the joint, its deep position in the pelvis, with strong ligaments and bulky muscles around the articulation. Several factors influence the prognosis, such as the

Keywords:

degree of compounding, the associated soft tissue injuries, the age of the patient and, mainly,

Hip

the delay in reduction. The main complications are: arthrosis of the hip, with incidence of

Hip dislocation

50% of cases, when associated with fractures of the femoral head; and osteonecrosis of the

Hip fractures

femoral head, with incidence between 1.7 and 40% (in closed anterior dislocation). Because

Open fractures

of the rarity and the potential disability of this lesion, we report a case in a 46-year-old man, involved in an automobile accident. The hip was reduced (anterior superior dislocation) in the first three hours of the trauma. The patient was kept non-weight bearing until sixth week, with complete weight bearing after 10th week. After one year follow-up, the functional result was poor (Harris Hip Score: 52), probably because of the associated labral tear, but without signs of osteonecrosis of the femoral head in magnetic resonance imaging. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

Luxac¸ão anterior exposta do quadril em um adulto: relato de caso e revisão da literatura r e s u m o Palavras-chave:

A luxac¸ão anterior exposta do quadril é condic¸ão rara e resulta de trauma de alta energia.

Quadril

Até o momento, foram descritos na literatura 10 casos. Sua raridade deve-se à estabilidade

Luxac¸ão do quadril

inerente da articulac¸ão e à posic¸ão profunda na pelve, com fortes ligamentos e musculatura

Fraturas do quadril

volumosa ao seu redor. Influenciam o prognóstico dessa lesão diversos fatores, tais como

Fraturas expostas

grau de contaminac¸ão, lesões de partes moles, idade do paciente e, principalmente, atraso na reduc¸ão. As principais complicac¸ões são: artrose do quadril, com incidência que pode chegar a 50% dos casos, quando associada a fraturas da cabec¸a femoral; e osteonecrose da cabec¸a

夽 Please cite this article as: de Oliveira AL, Machado EG. Luxac¸ão anterior exposta do quadril em um adulto: relato de caso e revisão da literatura. Rev Bras Ortop. 2014;49:94–97. 夽夽 Study conducted at Hospital de Caridade São Vicente de Paulo, Jundiaí, SP, Brazil. ∗ Corresponding author. E-mail: anderson luizoliveira@hotmail.com (A.L. de Oliveira).

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do fêmur, com incidência entre 1,7% e 40% (nos casos de luxac¸ão anterior fechada). Por causa da raridade e da potencial incapacidade funcional decorrente dessa lesão, relatamos o caso de um homem de 46 anos vítima de acidente automobilístico. Foi feita reduc¸ão do quadril (luxac¸ão do tipo anterior alta) nas primeiras três horas pós-trauma. O paciente foi mantido sem carga até a sexta semana, com carga total após a 10a semana. Após um ano de seguimento, observou-se resultado funcional pobre (Harris Hip Score: 52), provavelmente por causa de lesão labral associada, porém sem sinais na ressonância nuclear magnética de osteonecrose da cabec¸a femoral. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Todos os direitos reservados.

Introduction The hip joint is inherently stable, which requires significant force to promote its dislocation.1 Thus, hip dislocations usually result from high-energy trauma. Cranio-cerebral, thoracic and abdominal injuries are commonly associated. Skeletal injuries often associated include fractures of head or femoral neck, femoral shaft, acetabulum and pelvis, as well as knee, ankle and foot injuries and neurological lesions.1,2 Previous hip dislocations are uncommon and constitute 12% of traumatic hip dislocations. These injuries may occur in accidents by deceleration, in that the vehicle occupant is with his (her) legs bent, abducted, and externally rotated during impact, as well as in motorcycle accidents in which the legs are often in hyperabduction. The hip position determines the type of anterior dislocation: pubic/superior type when the hip is extended, and obturator/lower type when it is in flexion.1–3 So far, research in databases (Lilacs, Medline, SciELO and Cochrane) revealed ten cases of open anterior hip dislocation reported in the literature,4–13 six of them in children between five and 11 years, one in a teenager aged 15 years, and three in adults. Because of the rarity and the potential incapacity resulting from that injury, we describe this case.

Case report Male patient, 46 years old, victim of an automobile accident, was ejected from the vehicle. He was admitted in our hospital about an hour after the injury, brought by the rescue team. On examination, the following were observed: he was conscious and hemodynamically stable; with a wound of about 10 cm on the left inguinal region, cross position, with exposure of the left femoral head; hip in extension, abduction and external rotation (Fig. 1); distal pulses present and, apparently, no signs of neurological impairment in the affected limb. The initial radiographs revealed high anterior dislocation of left hip (Fig. 2) and fracture of the left clavicle; no visceral injury was detected. The patient was sent to the operating room two hours after admission. A lesion of the proximal rectus femoris muscle was viewed. Cleaning and debridement of the wound were made; the joint reduction was done by traction and internal rotation, without difficulties. Clinical and radiographic evaluation revealed a stable reduction (Fig. 3). The wound was

Fig. 1 – Appearance of wound at the root of the left thigh, exposing the femoral head.

closed with introduction of broad-spectrum antibiotics for 72 h. Wound healing without need for further debridement occurred. The post-reduction computed tomography (CT) demonstrated joint congruence and great trochanter fracture without deviation, treated conservatively (Fig. 4). The patient was kept without loading for six weeks, followed by progressive load, with full load after 10 weeks. After one year of follow-up, the functional outcome was poor (Harris Hip Score: 52 points) with limited range of motion of the hip (flexion 90◦ , extension 20◦ , abduction 20◦ , adduction 10◦ , internal rotation 10◦ , external rotation 30◦ ) and without neurological deficit. Radiographs and magnetic resonance imaging (MRI) showed no signs of necrosis of the femoral head until the last follow-up. MRI showed a lesion of the


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Fig. 2 – AP radiograph of the pelvis demonstrating anterosuperior dislocation of the left hip, with prominence of the lesser trochanter.

Fig. 4 – Postreduction CT showing fracture of left greater trochanter. anterosuperior portion of the labrum, associated with thickening of the tendon of the rectus femoris muscle (Fig. 5).

Discussion

Fig. 3 – Postreduction radiograph showing left hip joint congruency.

Anterior traumatic hip dislocation is a rare injury. The injury is classified according to the position taken by the femoral head: pubic (high) and obturator (low).2 Biomechanical studies on cadavers have shown that extension, abduction and external rotation of the hip produces pubic dislocation with the femoral head positioned in front of the horizontal ramus of the pubis, with possibility of laceration of pectineus and iliopsoas muscles and of injury to the neurovascular bundle. On the other hand, flexion, abduction and external rotation of the hip produce dislocation of obturator type, in which the femoral head is held against the anterolateral margin of the obturator foramen, causing an indentation fracture in the anterosuperior aspect of the femoral head, without injury to the iliofemoral ligament.1,3,14 Radiographically, the high dislocation can be confused with posterior displacement in the AP view of the pelvis, as the femoral head is located above the acetabulum. The

Fig. 5 – MRI showed no signs of osteonecrosis of femoral head; visualization of lesion of the anterior superior portion of the acetabular labrum.


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observation of the lesser trochanter helps to distinguish between these two types. In anterosuperior dislocation, the hip is in external rotation and the lesser trochanter is prominent; in posterior dislocation, the femur is internally rotated, with the trochanter less prominent or obscured.3 The reduction is accomplished by traction and countertraction. In the case of superior displacement, the traction is done till the femoral head is leveled with the acetabulum, and then a smooth internal rotation is applied.1 CT is useful in operative planning, required in cases of concomitant fractures, irreducible dislocation or incongruent reduction. Location, size and number of free intra-articular fragments are outlined, which allows an accurate preoperative planning.1 Studies indicate that MRI is not consistent in predicting the occurrence of avascular necrosis and, therefore, in determining whether the early liberation of weight is a risk factor for femoral head collapse. In reduced hips, the rate of osteonecrosis of the femoral head is higher after six hours of injury. So, in these cases it may be reasonable to delay the liberation of total weight for eight to 12 weeks. In cases with reduction in the first six hours, the treatment includes a short rest period (two weeks), followed by progressive mobilization and loading. Continuous passive motion is desirable, to avoid intra-articular formation of adhesions and arthrosis. Extremes of motion must be avoided for six to eight weeks, to allow capsular healing.1 Arthrosis is one of the most common complications, most frequently in cases of posterior versus anterior dislocation. The association with fractures of the femoral head can cause arthritis in 50% of patients.1 In cases of closed anterior dislocation, the risk of avascular necrosis varies from 1.7% to 40% in different series.1 In the case of open dislocations, there was osteonecrosis of femoral head in five of nine cases (of the ten cases previously described in the literature, one case of death in the immediate postoperative period was excluded). Of these five cases, three were associated with deep infection.4–13 Despite the absence of osteonecrosis of the femoral head and infection, the related case evolved to a poor clinical outcome, probably because of the associated labral lesion. Therefore, the degree of contamination, the delay in reducing the lesion and the associated soft tissue injuries are key factors in the treatment and prognosis of open anterior dislocations of the hip.4,5,7,8,11,12

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Conflicts of interest The authors declare no conflicts of interest.

references

1. Tornetta 3rd P. Hip dislocations and fractures of the femoral head. In: Bucholz RW, Heckman JD, Court-Brown CM, editors. Rockwood & Green’s fractures in adults. 6th ed. Philadelphia: Lippincott, Williams and Wilkins; 2006. p. 1716–52. 2. Epstein HC, Harvey JP. Traumatic anterior dislocation of the hip: management and results. J Bone Joint Surg Am. 1972;54:1561–70. 3. Erb RE, Steele JR, Nance Jr EP, Edwards JR. Traumatic anterior dislocation of the hip: spectrum of plain film and CT findings. Am J Roentgenol. 1995;165(5):1215–9. 4. Muzaffar N, Ahmad N, Bhat A, Shah N. Open anterior hip fracture dislocation in a young adult with exposed femoral head: a case report. Webmed Central Orthopaedics [serial on the internet] 2011;2(9): [about 7 p.]. Available from: http://www.webmedcentral.com/articleview/21705 [cited 28.09.11]. 5. Schwartz DL, Haller JA Jr. Open anterior hip dislocation with femoral vessel transection in a child. J Trauma. 1974;14(12):1054–9. 6. García Mata S, Hidalgo Ovejero A, Martinez Grande M. Open anterior dislocation of the hip in a child. J Pediatr Orthop B. 1998;7(3):232–4. 7. Khan SA, Sadiq SA, Abbas M, Asif N, Gogi N. Open anterior dislocation of the hip in a child. J Trauma. 2001;51(4):773–6. 8. Rafai M, Ouarab M, Largab A, Guerch A, Rahmi M, Trafeh M. Open post-traumatic anterior luxation of the hip in children. Apropos of a case and review of the literature. Rev Chir Orthop Reparatrice Appar Mot. 1995;81(2):178–81. 9. Renato L. Open anterior dislocation of the hip in a child. Acta Orthop Scand. 1987;58(6):669–70. 10. Grundy M, Kumar N. Open anterior dislocation of the hip. Injury. 1982;13(4):315–6. 11. Lamberti PM, Rabin SI. Open anterior–inferior hip dislocation. J Orthop Trauma. 2003;17(1):65–6. 12. Sadhoo UK, Tucker GS, Maheshwari AV, Kaul A. Open anterior fracture dislocation of the hip: a case report and review of literature. Arch Orthop Trauma Surg. 2005;125(8):550–4. 13. Sabat D, Singh D, Kumar V, Gupta A. Open perineal dislocation of hip in a child. Eur J Orthop Surg Traumatol. 2009;19: 277–9. 14. Amihood S. Anterior dislocation of the hip. Injury. 1975;7(2):107–10.


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Letter to the Editor

The anterolateral ligament of the knee – Visibility on magnetic resonance imaging夽 Ligamento anterolateral do joelho – visibilidade na ressonância nuclear magnética Dear Editor, With great interest I have read the article “Anatomical study on the anterolateral ligament of the knee” in your journal.1 Meanwhile another morphological study by Claes et al.2 also reported regular occurrence of the anterolateral ligament of the knee. Together with the data of Vincent et al., these three studies have examined 57 anatomical specimen and found the anterolateral ligament in 56 of them (98.2%).1–3 Given the probable clinical impact on outcome after surgery of the anterior cruciate ligament preoperative judgment of its integrity would be desirable. To study the visibility on standard magnetic resonance imaging (MRI) of the knee 30 randomly selected knee MRIs from the departmental PACS were reviewed (5 women, 25 men, mean age 38.9 years). Imaging was performed on an outpatient basis using different scanners with a field strength of 1.0 or 1.5 T. According to the reported localization of the anatomic studies coronal images seemed most appropriate

for depiction. All patients received coronal proton-density weighted or fat-suppressed T2-weighted images with a slice thickness of 3–4 mm. The images were reviewed using the departmental PACS (synedra view® , Synedra, Innsbruck, Austria). The anterolateral ligament could be identified in 22 of the 30 patients (73.3%). As shown in the figure it could be found dorsal to the ilitibial tract and vetral to the lateral collateral ligament (Fig. 1). In most patients the anterolateral ligament could only be seen as a very thin ligamentous structure, in some patients only the part inserting at the lateral meniscus could be identified. Given the small number of cases no significant differences between the different scanners/sequences could be observed. Other orientations of the sequences (sagittal/axial) were found to be unreliable for the depiction of the anterolateral ligament. Until now the depiction of this ligament has not been discussed in the radiological literature. In an abstract of their work Claes et al.4 reported about a visibility of the anterolateral ligament in 95.7% on MRI of cases with

Trato iliotibial

Ligament an terolateral

Ligament colateral lateral

Fig. 1 – Coronal fat-suppressed T2-weighted imaging of a 38-year-old male after trauma. The anterolateral ligament is arising from the femur with two insertions, the lateral meniscus and the tibia. It is located dorsal to the iliotibial tract and ventral to the lateral collateral ligament.

Please cite this article as: Gossner J. Ligamento anterolateral do joelho – visibilidade na ressonância nuclear magnética. Rev Bras Ortop. 2014;49:98–99.


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ruptured anterior cruciate ligament. The difference may be explained by the fact that the depiction of ligamentous injury is facilitated by joint effusion and edematous soft tissues separating the anatomical structures. In contrast, our approach also included exams without acute pathology, but they did not report the scanners or sequences used. In these patients a high frequency of torn anterolateral ligaments was reported. In conclusion, the recently reported anterolateral ligament can be depicted in the majority of patients undergoing standard MRI of the knee. With a reduction of slice thickness or higher field strengths (3 T) visibility will probably further increase. Orthopedic surgeons and radiologists should be aware of the importance of this structure and report about it when reviewing MRI scans of the knee.

references 1. Helito CP, Miyahare HS, Bonadio MB, Tirico LE, Gobbi RG, Demange MK, et al. Anatomical study on the anterolateral ligament of the knee. Rev Bras Ortop. 2013;48(4):368–73. 2. Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J. Anatomy of the anterolateral ligament of the knee. J Anat. 2013;223(4):321–8.

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3. Vincent JP, Magnussen RA, Gezmez F, Uguen A, Jacobi M, Weppe F, et al. The anterolateral ligament of the human knee: an anatomic and histologic study. Knee Surg Sports Traumatol Arthrosc. 2012;20(1):147–52. 4. Claes SA, Bartholomeeusssen S, Vereecke EE, Victor JM, Verdonk P, Bellemans J. The anterolateral ligament of the knee: anatomy, radiology, biomechanics and clinical implications. Presented at the 2013 AAOS annual meeting; 2014. Available from www.abstractsonline.com

Johannes Gossner Departamento de Radiologia Clínica, Hospital Göttingen-Weende, Göttingen, Germany E-mail: johannesgossner@gmx.de 14 November 2013 20 November 2013 2255-4971/$ – see front matter © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved. http://dx.doi.org/10.1016/j.rboe.2014.01.004


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Erratum

Erratum on “Meniscal repair by all-inside technique with Fast-Fix device” [Rev. Bras. Ortop. 48 (5) (2013) 448–454]夽 Errata em “Sutura do menisco pela técnica all-inside com o dispositivo Fast-Fix” [Rev. Bras. Ortop. 48 (5) (2013) 448–454] Leonardo José Bernardes Albertoni a , Felipe Conrado Schumacher b , Matheus Henrique Araújo Ventura b , Carlos Eduardo da Silveira Franciozi c,∗ , Pedro Debieux d , Marcelo Seiji Kubota a , Geraldo Sérgio de Mello Granata Júnior c , Marcus Vinícius Malheiros Luzo e , Antônio Altenor Bessa de Queiroz a Mario Carneiro Filho f a

MSc, Physician in the Knee Group, Department of Orthopedics and Traumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil b Third-year Resident Physician in the Department of Orthopedics and Traumatology, EPM-UNIFESP, São Paulo, SP, Brazil c PhD, Physician in the Knee Group, Department of Orthopedics and Traumatology, EPM-UNIFESP, São Paulo, SP, Brazil d Physician in the Knee Group, Department of Orthopedics and Traumatology, EPM-UNIFESP, São Paulo, SP, Brazil e PhD, Affiliated Professor and Physician in the Knee Group, Department of Orthopedics and Traumatology, EPM-UNIFESP, São Paulo, SP, Brazil f PhD, Affiliated Professor and Head of the Knee Group, Department of Orthopedics and Traumatology, EPM-UNIFESP, São Paulo, SP, Brazil

The article “Meniscal repair by all-inside technique with Fast-Fix device”, published in Rev Bras Ortop. 2013;48(5):448–54, should be considered an original article rather than a case report.

DOI of original article: http://dx.doi.org/10.1016/j.rboe.2012.08.010. Please cite this article as: Albertoni LJB, Schumacher FC, Ventura MHA, da Silveira Franciozi CE, Debieux P, Kubota MS, Granata GSM, Luzo MVM, de Queiroz AAB, Filho MC, Errata em “Sutura do menisco pela técnica all-inside com o dispositivo Fast-Fix” [Rev. Bras. Ortop. 48 (5) (2013) 448–454]. Rev Bras Ortop. 2014;49:100. ∗ Corresponding author at: Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Ortopedia e Traumatologia, Rua Borges Lagoa, 783, 5◦. andar, Vila Clementino, São Paulo, SP, CEP 04038-032, Brazil. Tel.: +55 11 5571 6621. E-mail: cacarlos66@hotmail.com (C.E. da Silveira Franciozi). 夽

2255-4971/$ – see front matter © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

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