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ISSN 0102-3616 VOLUME 46 • Nº 6 N ovemb e r / D e c ember 2011

PERIPHERAL NERVE REGENERATION: CELL THERAPY AND NEUROTROPHIC FACTORS

630 634 643

CLINICAL AND RADIOLOGICAL EVALUATION ON DEVELOPMENTAL HIP DYSPLASIA AFTER SALTER AND OMBRÉDANNE PROCEDURE

650

MECHANICAL STUDY ON DORSAL STABILITY OF INTRAMEDULLARY OSTEOSYNTHESIS ASSOCIATED WITH EXTERNAL FIXATION (ULSON’S METHOD)

656

EPIDEMIOLOGICAL CHARACTERISTICS AND CAUSES OF PROXIMAL FEMORAL FRACTURES AMONG THE ELDERLY

660

ANALYSIS ON THE MODIFIED LYSHOLM FUNCTIONAL PROTOCOL AMONG PATIENTS WITH NORMAL KNEES

668

BAKER’S CYST PROPOSAL FOR STANDARDIZATION OF RADIOGRAPHIC STUDIES ON THE HIP AND PELVIS

RANDOMIZED PROSPECTIVE STUDY ON TRAUMATIC PATELLAR DISLOCATION: CONSERVATIVE TREATMENT VERSUS RECONSTRUCTION OF THE MEDIAL PATELLOFEMORAL LIGAMENT USING THE PATELLAR 675 TENDON, WITH A MINIMUM OF TWO YEARS OF FOLLOW-UP RESULTS FROM FILLING “REMPLISSAGE” ARTHROSCOPIC TECHNIQUE FOR RECURRENT ANTERIOR SHOULDER DISLOCATION “ROCAMBOLE-LIKE” BICEPS TENODESIS: TECHNIQUE AND RESULTS LOW-LEVEL LASER THERAPY AFTER CARPAL TUNNEL RELEAS

684 691 697

TREATMENT OF OSTEOCHONDRAL LESIONS OF THE TALUS BY MEANS OF THEARTHROSCOPY-ASSISTED 702 MICROPERFORATION TECHNIQUE SCHEUERMANN’S KYPHOSIS: COMPARISON BETWEEN THE POSTERIOR APPROACH ASSOCIATED WITH SMITH-PETERSEN OSTEOTOMY AND COMBINED ANTERIOR-POSTERIOR FUSION

709

EFFECT OF USE OF BONE-MARROW CENTRIFUGATE ON MUSCLE INJURY TREATMENT: EXPERIMENTAL STUDY ON RABBITS

718

PHYSICAL EXAMINATIONS FOR DIAGNOSING MENISCAL INJURIES: CORRELATION WITH SURGICAL FINDINGS

726

LEG’S COMPARTiMENTal SYNDROME AFTER RECONSTRUCTION OF THE ANTERIOR CRUCIATE LIGAMENT: CASE REPORT SEGMENTAL CLAVICLE FRACTURE

730 733

PROGRESSIVE OSSIFYING FIBRODYSPLASIA: CASE REPORT

736

ACUTE LESION OF THE MOTOR BRANCH OF THE ULNAR NERVE IN THE WRIST AFTER TUG-OF-WAR TRAINING

741

TIBIAL PERIPROSTHETIC FRACTURE COMBINED WITH TIBIAL STEM STRESS FRACTURE FROM TOTAL KNEE ARTHROPLASTY

745


VOLUME 46 No 6 • NOVEMBER/DECEMBER 2011

issn 0102-3616

Official organ of the Brazilian Society of Orthopedics and Traumatology Registered under the terms of Articles 8 and 9 of Federal Law No. 5270/67, combined with Articles 122 and 126 of Federal Law No. 6015/73, in the Press Law, under No 3015 of Book A of the 5th Register of Titles and Documents of São Paulo

Indexed in SciELO since July 2007.

Indexed in LILACS (Literatura Latino-Americana em Ciências da Saúde) since 1992.

Affiliated to the Brazilian Association of Scientific Editors

Editors EmERITI Márcio Ibrahim de Carvalho, MG, Brasil, Donato D´Angelo, RJ, Brasil, Carlos Giesta, RJ, Brasil

Editor-IN-CHIEF Gilberto Luis Camanho - Departamento de Ortopedia e Traumatologia da FMUSP, São Paulo, SP, Brasil

ASSOCIATE EDITORS Philippe Hernigou – Department of Orthopaedic Surgery, University Paris XII, Hospital Henri Mondor, Fernando Fonseca – Universidade de Coimbra, Portugal, José Neves – Porto, Portugal, Jacinto Monteiro – Serviço de Urgência de Ortopedia do Hospital Distrital do Barreiro, EPE, Lisboa, Portugal, Norbert P Hass – Center for Musculoskeletal Surgery at the Charité – University Medicine Berlin, Alemanha, Jesse B Júpiter – Massachusetts General Hospital, Harvard Medical School, Boston, USA , Cris Van Der Werken – General Trauma Surgeon, Holanda, Edgardo Ramos – Hospital de Urgencias. Traumatológicas, México, Sérgio Fernandez, Chile, Michael Wagner – Wilhelminenspital der Stadt Wien, Wien, Austria, Rodrigo Pesantez – Departamento de Ortopedia y Traumatologia Fundación Santa Fé de Bogotá, Colômbia, Jaime Quintero – Centro Médico Almirante Colon, Bogotà, Colombia, Mark Vrahas – Partners Chief of Orthopaedic Trauma Service, Brigham and Women´s Hospital, Massachusetts General Hospital, Boston, USA, Marvin Tile – Sunnybrook Health Sciences Centre, Canadá, Juan Manoel Concha – Facultad de Ciencias de la Salud, Colômbia, Pierre Hoffmeyer - Hôpital Cantonal Universitaire, Suiça, Antonio Pace - Instituto Ortopedica Galeazzi, Unità Operativa di Traumatologia, Via Riccardo Galeazzi, Itália, Rami Mosheiff – Department of Orthopedic Surgery, Hadassah Medical Center, Israel, Joan Giros – Espanha

Editorial BOARD Akira Ishida - Universidade Federal de São Paulo, Departamento de Ortopedia e Traumatologia, SP, Brasil, Helton Defino - Faculdade de Medicina de Ribeirão Preto - USP, Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor (RAL). Ribeirão Preto SP, Brasil, José Sérgio Franco - Faculdade de Medicina da Universidade Federal do Rio de Janeiro, RJ, Brasil, Marco Antonio Percope de Andrade – Universidade Federal de Minas Gerias, Faculdade de Medicina, Departamento de Aparelho Locomotor, MG, Brasil, Sérgio Checchia - Faculdade de Ciências Médicas da Santa de Misericórdia - FCMSCSP, SP, Brasil, Sergio Zylbersztejn - Fundação Faculdade Federal de Ciências Médicas de Porto Alegre, Porto Alegre, RS, Brasil

Editorial advisory board Antonio Egydio de Carvalho Junior - Instituto de Ortopedia e Traumatologia do HC/FMUSP, São Paulo, SP, Brasil, Arlindo Pardini Junior - Faculdade de Medicina do Triângulo Mineiro, Belo Horizonte, MG, Brasil, Carlos Roberto Schwartsmann -Fundação Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brasil, Cláudio Santili - Departamento de Ortopedia e Traumatologia da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil, Cleber A. Jansen Paccola - Faculdade de Medicina de Ribeirão Preto - USP, Ribeirão Preto, SP, Brasil, Flávio Faloppa - Universidade Federal de São Paulo - UNIFESP, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brasil, Geraldo Rocha Motta Filho – Instituto Nacional de Traumatologia e Ortopedia - INTO-MS, Rio de Janeiro, RJ, Brasil, Giancarlo Polesello - Departamento de Ortopedia e Traumatologia da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil, Gildásio de Cerqueira Daltro - Universidade Federal da Bahia, Salvador, BA, Brasil, João Antonio Matheus Guimarães - Instituto Nacional de Traumatologia e Ortopedia - INTO-MS, Rio de Janeiro, RJ, Brasil, José Batista Volpon - Faculdade de Medicina de Ribeirão Preto - USP, Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor (RAL), Ribeirão Preto, SP, Brasil, José Maurício de Moraes Carmo - Setor de Cirurgia de Mão e Microcirurgia do Hospital Universitário Pedro Ernesto da Universidade do Estado do Rio de Janeiro (HUPE-UERJ), Rio de Janeiro, RJ, Brasil, José Soares Hungria Neto - Faculdade de Ciências Médicas da Santa de Misericórdia, São Paulo, SP, Brasil, Karlos Celso de Mesquita - Universidade do Estado do Rio de Janeiro, RJ, Brasil, Luis Roberto Vialle - Universidade Católica do Paraná, Curitiba, PR, Brasil, Luiz Antonio M. da Cunha - Universidade Federal do Paraná, Curitiba, PR, Brasil, Luiz Marczyk - Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil, Luiz Mestriner - Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brasil, Marcelo Tomanik Mercadante - Departamento de Ortopedia e Traumatologia da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil, Marcos Antonio Almeida Matos - Escola Baiana de Medicina e Saúde Pública, Salvador, BA, Brasil, Moisés Cohen - Universidade Federal de São Paulo - UNIFESP, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brasil, Olavo Pires de Camargo - Departamento de Ortopedia e Traumatologia da FMUSP - DOT/FMUSP - São Paulo, SP, Brasil, Osmar Avanzi - Departamento de Ortopedia e Traumatologia da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil, Osmar Pedro Arbix Camargo - Faculdade de Ciências Médicas da Santa de Misericórdia, São Paulo, SP, Brasil, Osvandré Lech - Instituto de Ortopedia e Traumatologia de Passo Fundo, RS, Brasil, Paulo César Schott - Universidade Federal Fluminense - Rio de Janeiro, RJ, Brasil, Paulo Couto - Departamento de Engenharia Industrial da UFRJ, Rio de Janeiro, RJ, Brasil, Roberto Guarniero - Departamento de Ortopedia e Traumatologia da FMUSP - DOT/FMUSP - São Paulo, SP, Brasil, Roberto Santin - Departamento de Ortopedia e Traumatologia da Santa Casa de Misericórdia de São Paulo - DOT, SP, Brasil, Roberto Sérgio Tavares Canto - Centro Universitário do Triângulo, MG, Brasil, Sérgio Nogueira Drumond - Faculdade de Medicina do Triângulo Mineiro - Belo Horizonte, MG, Brasil, Tarcísio Eloy P. de Barros Filho - Departamento de Ortopedia e Traumatologia da FMUSP - DOT/FMUSP - São Paulo, SP, Brasil, Walter Manna Albertoni - Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brasil, Willian Dias Belangero - Universidade Estadual de Campinas- UNICAMPI - Campinas, SP, Brasil


consultative body Adalberto Visco – Clinica de Fraturas Ortoped – Salvador, BA, Brasil, Alberto Croci – Departamento de Ortopedia e Traumatologia da FMUSP – São Paulo, SP, Brasil, Alberto Naoki Myasaki - Departamento de Ortopedia e Traumatologia da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil, Alexandre Adolfo R. Machado – Faculdade de Ciência de Pernambuco, Departamento de Ortopedia e Traumatologia – Fortaleza, PE, Brasil, Antonio Vítor de Abreu – Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil, Arildo E. Paim – Santa Casa de Belo Horizonte – Departamento de Ortopedia – Belo Horizonte, MG, Brasil, Arnaldo Amado Ferreira Neto - Instituto de Ortopedia e Traumatologia da FMUSP – São Paulo, SP, Brasil, Caio Nery - Universidade Federal de São Paulo- Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brasil, Edilson Forlin - Hospital Infantil Pequeno Príncipe, Curitiba, PR, Brasil, Edmilson Takehiro Takata – Departamento de Ortopedia e Traumatologia da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil, Eduardo Benegas – Instituto de Ortopedia e Traumatologia da FMUSP – São Paulo, SP, Brasil, Emerson Honda – Faculdade de Ciências Médicas Departamento de Ortopedia e Traumatologia da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil, Fernando Baldy dos Reis - Universidade Federal de São Paulo - UNIFESP, São Paulo, SP Brasil, Fernando Façanha Filho –Instituto Dr. José Frota- Departamento de Ortopedia, Fortaleza, CE, Brasil, Flávio Dorcilo Rabelo– Hospital Ortopédico de Goiânia- GO- Brasil, Glaydson Godinho - Hospital Belo Horizonte, Belo Horizonte, MG, Brasil, Hamilton da Rosa Pereira – Universidade Estadual Paulista Júlio de Mesquita Filho, São Paulo, SP, Brasil, Henrique A. Berwanger Cabrita - Instituto de Ortopedia e Traumatologia da FMUSP – São Paulo, SP, Brasil, Jairo de Andrade Lima – Universidade Federal de Pernambuco-PE, Brasil, João Maurício Barretto – Santa Casa de Misericórdia do Rio de Janeiro, Departamento de Ortopedia e Traumatologia, Rio de Janeiro, RJ, Brasil, José Antonio Veiga Sanhudo - Clínica de Especialidades em Ortopedia e Traumatologia, Porto Alegre, RS, Brasil, José Carlos Bongiovanni – Universidade Federal de São Paulo- Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brasil, José Ricardo Pécora – Instituto de Ortopedia e Traumatologia da FMUSP, São Paulo, SP, Brasil, José Vicente Pansini – Faculdade de Ciências Médicas da Santa Casa de São Paulo- Departamento de Ortopedia e Traumatologia, Curitiba, PR, Brasil, Lindomar Guimarães Oliveira – Universidade Federal de Goiás, Goiás, Brasil, Luiz Carlos Sobânia – Universidade Federal do Paraná, Curitiba, PR, Brasil, Marco Antonio de Castro Veado –Faculdade de Ciências Médica de Minas Gerais- Departamento de Ortopedia, Belo Horizonte, MG, Brasil, Mauricio Kfuri Júnior - Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brasil, Ney Coutinho Pecegueiro do Amaral – Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil, Paulo Gilberto C. de Alencar – Hospital das Clinicas da Universidade Federal do Paraná, Curitiba, PR, Brasil, Paulo Roberto Barbosa T. Lourenço – Grupo de Trauma do Hospital de Ipanema, Rio de Janeiro, RJ, Brasil, Pedro Péricles R. Baptista – Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brasil, Raul Bolliger Neto – Instituto de Ortopedia e Traumatologia da FMUSP – São Paulo, SP, Brasil, Rames Mattar Júnior - Departamento de Ortopedia e Traumatologia da FMUSP, São Paulo, SP, Brasil, Renato Graça - Universidade Federal Fluminense, Rio de Janeiro, RJ, Brasil, Reynaldo JesusGarcia Filho – Universidade Federal de São Paulo, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brasil, Ricardo Cardenuto Ferreira – Faculdade de Ciências Médica da Santa Casa de São Paulo, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brasil, Sérgio Hennemann – Clinica da Coluna Hennemann Schumacher, Porto Alegre, RS, Brasil, Túlio Diniz Fernandes – Departamento de Ortopedia e Traumatologia da FMUSP, São Paulo, SP, Brasil, Wilson Mello Alves Júnior – Pontifícia Universidade Católica de Campinas – PUCC, Campinas, SP- Brasil,Vincenzo Giordano Neto – Hospital Municipal Miguel Couto Serviço de Ortopedia e Traumatologia, Rio de Janeiro, RJ, Brasil

SPECIALIST Editors Alexandre Fogaça Cristante - Instituto de Ortopedia e Traumatologia da FMUSP – São Paulo, SP, Brasil, André Pedrinelli – Instituto de Ortopedia e Traumatologia da FMUSP – São Paulo, SP, Brasil, Antonio Francisco Ruaro – Universidade Paranaense, Paraná, Brasil, Antonio Marcelo Gonçalves de Souza – Universidade Federal de Pernambuco, Recife, PE, Brasil, Carlos Henrique Ramos – Santa Casa de Misericórdia de Curitiba, Hospital de Clínicas da UFPR, Curitiba, PR, Brasil, Edgard dos Santos Pereira – Universidade de Santo Amaro, São Paulo, SP, Brasil, Edison Noboru Fujiki – Departamento de Ortopedia e Traumatologia da Faculdade de Medicina do ABC, São Paulo, SP Brasil, Edilson Schwansee Thiele – Universidade Tuiuti do Paraná, Curitiba, PR, Brasil, Eduardo Frota Carrera - Universidade Federal de São Paulo - UNIFESP, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brasil, Eduardo Sadao Yonamine – Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brasil, Gilberto Hiroshi Ohara – Universidade Federal de São Paulo - UNIFESP, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brasil, Helio Jorge Alvachian Fernandes – Universidade Federal de São Paulo - UNIFESP, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brasil, Henrique Mota Neto – Universidade Federal do Ceará, Faculdade de Medicina, Departamento de Cirurgia Serviço de Traumatologia e Ortopedia. Fortaleza, CE, Brasil, Idemar Monteiro da Palma – Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, RJ, Brasil, Ildeu Almeida – Hospital Felício Rocho, Belo Horizonte, MG, Brasil, Kodi Kojima – Instituto de Ortopedia e Traumatologia da FMUSP – São Paulo, SP, Brasil, Luiz Koiti Kimura – Instituto de Ortopedia e Traumatologia da FMUSP – São Paulo, SP, Brasil, Luiz Sérgio Marcelino Gomes – Grupo de Quadril do Hospital e Maternidade Celso Pierro da Pontifícia Universidade Católica de Campinas (PUCCAMP) – Campinas, SP, Brasil, Marcelo Wajchenberg – Universidade Federal de São Paulo, Departamento de Ortopedia e Traumatologia, SP, Brasil, Marcio Passini Gonçalves de Souza – Instituto de Ortopedia e Traumatologia da FMUSP – São Paulo, SP, Brasil, Marcos Antonio Tebet – Faculdade de Medicina de Jundiaí, São Paulo, SP, Brasil, Mário Carneiro – Universidade Federal de São Paulo, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brasil, Mauro dos Santos Volpi – Universidade Estadual Paulista Júlio de Mesquita Filho, Faculdade de Medicina de Botucatu, Departamento de Cirurgia e Ortopedia, Botucatu, SP, Brasil, Nilson Roberto Severino – Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento Ortopedia, São Paulo, SP, Brasil, Reinaldo dos Santos Volpi – Universidade Estadual Paulista Júlio de Mesquita Filho, Faculdade de Medicina de Botucatu, Departamento de Cirurgia e Ortopedia, Botucatu, SP, Brasil, Rogério Teixeira da Silva - Universidade Federal de São Paulo, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brasil, Wagner Nogueira da Silva – Serviço de Ortopedia Prof. Matta Machado - Hospital da Baleia – FBG - Belo Horizonte, MG, Brasil

Brazilian Society of Orthopedics and Traumatology SBOT Board of Directors – 2011 Administration

President: Dr. Osvandré Luiz Canfield Lech (RS); 1st Vice-President: Dr.Geraldo da Rocha Motta Filho (RJ); 2nd Vice-President: Dr. Flávio Faloppa (SP); Secretary-General: Jorge dos Santos Silva (SP); 1st Secretary: Marcelo Tomanik Mercadante (SP); 2nd Secretary: Ney C. Pecegueiro do Amaral (RJ); 1st Treasurer: Adalberto Visco (BA); 2nd Treasurer: Reynaldo Jesus Garcia Filho (SP)

GENERAL SECRETARIAT Sociedade Brasileira de Ortopedia e Traumatologia – Alameda Lorena, 427 14º andar Jd. Paulista - 01424-000 São Paulo/SP Tel. (11) 2137-5417 – Site: www.rbo.org.br

ADVERTISING Dr. Rogerio Teixeira da Silva – Tel. (11) 5549-5581 – E-mail: rgtsilva@uol.com.br

TECHNICAL AIDE Diva da Silva Godoi Revista Brasileira de Ortopedia (Brazilian Journal of Orthopedics) is a bimonthly publication from the Brazilian Society of Orthopedics and Traumatology. The responsibility for opinions put forward in articles published in this journal lies entirely with their authors. Full or partial reproduction of articles is permitted, provided that the source is mentioned.

Coordenação editorial, criação, diagramação e produção gráfica:

Atha Comunicação e Editora

Rua Machado Bittencourt, 190 - 4º andar - conj. 410 - CEP: 04044-903 - São Paulo - SP - Tel/Fax: (11) 5087-9502 / 5579-5308 - E-mail: 1atha@uol.com.br


Contents EDITORIAL What is your opinion?.................................................................................................................................... 628 Gilberto Luis Camanho

UPDATING ARTICLE BAKER’S CYST................................................................................................................................................ 630 Marco Kawamura Demange

PROPOSAL FOR STANDARDIZATION OF RADIOGRAPHIC STUDIES ON THE HIP AND PELVIS......................................................... 634 Giancarlo Cavalli Polesello, Tarsila Sato Nakao, Marcelo Cavalheiro de Queiroz, Daniel Daniachi, Walter Ricioli Junior, Rodrigo Pereira Guimarães, Emerson Kiyoshi Honda, Nelson keiske Ono

REVIEW ARTICLE PERIPHERAL NERVE REGENERATION: CELL THERAPY AND NEUROTROPHIC FACTORS.............................................................. 643 Alessandra Deise Sebben, Martina Lichtenfels, Jefferson Luis Braga da Silva

ORIGINAL ARTICLE CLINICAL AND RADIOLOGICAL EVALUATION ON DEVELOPMENTAL HIP DYSPLASIA AFTER SALTER AND OMBRÉDANNE PROCEDURE.......... 650 Válney Luiz da Rocha, André Luiz Coelho Thomé, Daniel Labres da Silva Castro, Leandro Zica de Oliveira, Frederico Barra de Moraes

MECHANICAL STUDY ON DORSAL STABILITY OF INTRAMEDULLARY OSTEOSYNTHESIS ASSOCIATED WITH EXTERNAL FIXATION (ULSON’S METHOD) ............................................................................................................................. 656 Trajano Sardenberg, Sérgio Swain Muller, Daniel Ricardo Medeiros, Pablo Luiz Baptistão

EPIDEMIOLOGICAL CHARACTERISTICS AND CAUSES OF PROXIMAL FEMORAL FRACTURES AMONG THE ELDERLY .............................. 660 José Soares Hungria Neto, Caio Roncon Dias, José Daniel Bula de Almeida

ANALYSIS ON THE MODIFIED LYSHOLM FUNCTIONAL PROTOCOL AMONG PATIENTS WITH NORMAL KNEES...................................... 668 Rodrigo Pires e Albuquerque, Vincenzo Giordano, Alexandre Calixto, Felipe Malzac, Carlomã Aguiar, Ney Pecegueiro do Amaral, Antônio Carlos Pires Carvalho

RANDOMIZED PROSPECTIVE STUDY ON TRAUMATIC PATELLAR DISLOCATION: CONSERVATIVE TREATMENT VERSUS RECONSTRUCTION OF THE MEDIAL PATELLOFEMORAL LIGAMENT USING THE PATELLAR TENDON, WITH A MINIMUM OF TWO YEARS OF FOLLOW-UP.............. 675 Alexandre Carneiro Bitar, Caio Oliveira D’Elia, Marco Kawamura Demange, Alexandre Christo Viegas, Gilberto Luis Camanho

RESULTS FROM FILLING “REMPLISSAGE” ARTHROSCOPIC TECHNIQUE FOR RECURRENT ANTERIOR SHOULDER DISLOCATION............... 684 Mauro Emilio Conforto Gracitelli, Camilo Partezani Helito, Eduardo Angeli Malavolta, Arnaldo Amado Ferreira Neto, Eduardo Benegas, Flávia de Santis Prada, Augusto Tadeu Barros de Sousa, Jorge Henrique Assunção, Edwin Eiji Sunada


T“ROCAMBOLE-LIKE” BICEPS TENODESIS: TECHNIQUE AND RESULTS................................................................................ 691 Glaydson Gomes Godinho, Fabrício Augusto Silva Mesquita, Flávio de Oliveira França, José Márcio Alves Freitas

LOW-LEVEL LASER THERAPY AFTER CARPAL TUNNEL RELEASE........................................................................................ 697 Marcelo de Pinho Teixeira Alves, Gabriel Costa Serrão de Araújo

TREATMENT OF OSTEOCHONDRAL LESIONS OF THE TALUS BY MEANS OF THE ARTHROSCOPY-ASSISTED MICROPERFORATION TECHNIQUE ....702 Everton de Lima, Felipe de Queiroz, Osmar Valadão Lopes Júnior, Leandro de Freitas Spinelli

SCHEUERMANN’S KYPHOSIS: COMPARISON BETWEEN THE POSTERIOR APPROACH ASSOCIATED WITH SMITH-PETERSEN OSTEOTOMY AND COMBINED ANTERIOR-POSTERIOR FUSION ............................................................................................................... 709 Eduardo Frois Temponi, Rodrigo D’Alessandro de Macedo, Luiz Olímpio Garcia Pedrosa, Bruno Pinto Coelho Fontes

EFFECT OF USE OF BONE-MARROW CENTRIFUGATE ON MUSCLE INJURY TREATMENT: EXPERIMENTAL STUDY ON RABBITS ................. 718 Daniel Ferreira Fernandes Vieira, Roberto Guarniero, Carlos Eduardo Sanches Vaz, Paulo José de Santana

PHYSICAL EXAMINATIONS FOR DIAGNOSING MENISCAL INJURIES: CORRELATION WITH SURGICAL FINDINGS................................... 726 Ricardo da Rocha Gobbo, Victor de Oliveira Rangel, Francisco Consoli Karam, Luiz Antônio Simões Pires

CASE REPORT LEG’S COMPARTiMENTal SYNDROME AFTER RECONSTRUCTION OF THE ANTERIOR CRUCIATE LIGAMENT: CASE REPORT ................... 730 Jorge Sayum Filho, Leonardo Adeo Ramos, Jorge Sayum, Rogério Teixeira de Carvalho, Benno Ejnisman, Marcelo Mitsuro Matsuda, Alexandre Nicolini, Moisés Cohen

SEGMENTAL CLAVICLE FRACTURE.......................................................................................................................... 733 Evander Azevedo Grossi

PROGRESSIVE OSSIFYING FIBRODYSPLASIA: CASE REPORT ........................................................................................... 736 Fabiana Romani, Simone de Menezes Karam

ACUTE LESION OF THE MOTOR BRANCH OF THE ULNAR NERVE IN THE WRIST AFTER TUG-OF-WAR TRAINING ............................... 741 Vladimir Ferreira Seguti, Aloísio Fernandes Bonavides Júnior, Leandro Pretto Flores, Lisiane Seguti Ferreira

TIBIAL PERIPROSTHETIC FRACTURE COMBINED WITH TIBIAL STEM STRESS FRACTURE FROM TOTAL KNEE ARTHROPLASTY................. 745 Fernando Fonseca, Edgar Rebelo, António Completo

The articles published in this journal are available online in Portuguese and English, at the websites: www.rbo.org.br and www.scielo.br/rbort


Publication Norms Instructions for Authors STUDY COMPILATION AND PRESENTATION CRITERIA The Revista Brasileira de Ortopedia (Rev Bras Ortop.) (ISSN 0102-3616) is the scientific publication medium of the Brazilian Society of Orthopedics and Traumatology (Sociedade Brasileira de Ortopedia e Traumatologia) and has the purpose of disseminating papers that contribute towards improving and developing the practice, research and teaching of Orthopedics and related specialties. After approval by the Editors, all manuscripts will be assessed by two qualified reviewers (peer review), and anonymity is ensured throughout the appraisal process. Articles that do not have merit, contain significant methodological errors or do not fit within the journal’s editorial policy will be rejected without any appeal rights. The reviewers’ comments will be returned to the authors, so that the authors can make modifications to the text or justify why the text should be maintained. Only after final approval from the reviewers and editors will manuscripts be sent for publication. Manuscripts accepted for publication will become the journal’s property and cannot be edited, either wholly or partially, by any other communications medium without prior written authorization issued by the Editor-inChief. The concepts and declarations contained in the studies are entirely under the authors’ responsibility. Articles published in the Revista Brasileira de Ortopedia follow the uniform requirements proposed by the International Committee of Medical Journal Editors, as updated in October 2004 and available at the electronic address www.icmje.org For studies involving investigations on human beings or laboratory animals, their compliance with the appropriate guidelines and the institutional committee’s approval of the study protocol should be clearly presented. Recommendations for articles submitted to the Revista Brasileira de Ortopedia Number Number of figures of tables

Type of article

Abstract

Number of words

Number of references

Original Article

Structured, with up to 250 words

2,500, not including the abstract, references, tables and figures

30

10

6

Review Article

Unstructured, with up to 250 words

4,000, not including the abstract, references, tables and figures

60

3

2

Updating Article

Unstructured, with up to 250 words

4,000, not including the abstract, references, tables and figures

60

3

2

Case Report

Unstructured, with up to 250 words

1,000, not including the abstract, references, tables and figures

10

5

0

Technical Note

Unstructured, with up to 250 words

1,500, not including the abstract, references, tables and figures

8

5

2

0

500

4

2

0

0

500

0

0

0

Letter to the Editor* Editorial**

* These will be published at the Editors’ discretion, with the respective reply, when appropriate. ** Written on invitation from the Editor-in-Chief.

PRESENTATION AND SUBMISSION OF MANUSCRIPTS Articles submitted should be accompanied by a letter signed by all the authors that authorizes publication of the article and declares that it is unpublished and that it has not been and is not being submitted for publication in another journal. The following should be attached to this letter:

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• Indication of the institution where the study was conducted; • Name, address, fax number and e-mail address of the author for correspondence; • Sources of funding for the research, if there were any; • Declaration that there were no conflicts of interest. B) Abstract and Descriptors: Abstract in Portuguese and English, with a maximum of 250 words. In original articles, the abstract should be structured, emphasizing the most significant data from the study (Objective: state why the study was conducted, emphasizing the motivation; Methods: succinctly describe the material evaluated and the method used to do so; Results: describe the important findings with statistical data and the respective significance; Conclusions: only report the main conclusions; Descriptors: also known as Keywords – consult the list at BIREME: www.bireme.com. br). For Case Reports, Review Articles, Updating Articles and Technical Notes, the abstract does not need to be structured. Below the abstract, specify between a minimum of three and a maximum of ten descriptors or keywords that define the subject of the study. The descriptors or keywords should be based on the Medical Science Descriptors (DECS) that are available at the electronic address http://www.decs.bvs.br C) Text The structure for each manuscript category should be followed rigorously. For all manuscript categories, the citations of authors in the text should be numerical and sequential, using Arabic numerals between parentheses, in superscript format. Introduction The authors should justify why the study was conducted, and should describe the relevance and interest of the study. A few (two or three) bibliographic references may be used when this is judged to be important for clarifying the importance of the study. The aim of the study should be made explicit at the end of the introduction, and the authors may also place this as a separate section. Material This is the substance of the study and therefore should be described in detail. The origin of the patients, their identification, their qualification and the inclusion and exclusion criteria should be indicated in this item. Thus, the authors should clearly define the group that has been studied. Method The authors should describe the procedure or analysis that was applied to the material, in detail. The description should be detailed so that it can be reproduced. Illustrations clarifying the method may be appropriate in this item. The way in which the results were measured should be described in terms of parameters in the literature or the authors’ own parameters, along with what is good and what is regular, etc., in the concept proposed by the authors. The statistical analysis used should be cited in this item. Results The results should be cited objectively, without comments, containing only the clarifications or highlighting that can accompany the citation of the results. Graphs or tables should be used whenever necessary, following the journal’s parameters. Discussion In this item, the authors should discuss the opportuneness of their study, material, method and results, making comparisons with the pertinent literature. The literature to be cited should mainly consist of studies from the last ten years. Only in exceptional cases should studies from before this period be cited, for example the classic studies on the topic. The conclusions, as part of the discussion, should be based on the results and should indicate whether aims cited in the introduction were achieved. Complementary comments may be appropriate. Conclusions: These should be based on the results obtained. Acknowledgements: Collaborations from individuals or institutions, or acknowledgements of financial support or technical assistance, which deserve recognition but do not justify inclusion among the authors, can be mentioned. References: Cite up to around 30 references for original articles. For the other categories, see the table of recommendations above. The references should be up to date, with preference for the most relevant studies on the topic published over the last five years. No studies that are not referred to in the text should be cited. If pertinent, it is recommendable to include studies published in the Revista Brasileira de Ortopedia. The references should be numbered consecutively, in the order in which they are mentioned in the text, and should be identified using Arabic numerals in parentheses, in superscript format. The references should follow the “Vancouver Style” format, as shown in the models below. Journal titles should be abbreviated in accordance with the style presented by the National Library of Medicine, as available in the “List of Journals Indexed in Index Medicus”, at the electronic address: http://www.ncbi.nlm.nih.gov/entrez/query. fcgi?db=journals

2) Bridwell KH, Anderson PA, Boden SD, Vaccaro AR, Wang JC. What’s new in spine surgery. J Bone Joint Surg Am. 2005;87(8):1892-901. Schreurs BW, Zengerink M, Welten ML, van Kampen A, Slooff TJ. Bone impaction grafting and a cemented cup after acetabular fracture at 3-18 years. Clin Orthop Relat Res. 2005;(437):145-51. Books: Baxter D. The foot and ankle in sport. St Louis: Mosby; 1995. Chapters in books: Johnson KA. Posterior tibial tendon. In: Baxter D. The foot and ankle in sport. St Louis: Mosby; 1995. p. 43-51. Dissertations and theses: Laredo Filho J. Contribuição ao estudo clínico-estatístico e genealógico-estatístico do pé torto congênito equinovaro [thesis]. São Paulo: Universidade Federal de São Paulo. Escola Paulista de Medicina; 1968. Electronic publications: 1) Lino Junior W, Belangero WD. Efeito do Hólmio YAG laser (Ho: YAG) sobre o tendão patelar de ratos após 12 e 24 semanas de seguimento. Acta Ortop Bras [periodical on the Internet]. 2005 [cited 2005, Aug 27];13(2):[about 5p.]. Available from: http://www. scielo.br/scielo. 2) Feller J. Anterior cruciate ligament rupture: is osteoarthritis inevitable? Br J Sports Med [serial on the Internet]. 2004 [cited 2005, Aug 27]; 38(4): [about 2p.]. Available from: http://bjsm.bmjjournals.com/cgi/content/full/38/4/383

For all the references, cite all the authors up to six. When there are more than six authors, cite the first six authors, followed by the expression “et al.”

Leve III - Comparative study on retrospective cases or meta-analysis on level III studies.

Articles in journals: 1) Borges JLP, Milani C, Kuwajima SS, Laredo Filho J. Tratamento da luxação congênita de quadril com suspensório de Pavlik e monitorização ultra-sonográfica. Rev Bras Ortop. 2002; 37(1/2):5-12.

Tables and Figures: Tables: Tables should be numbered in their order of appearance in the text, using Arabic numerals. Each table should have a title and, if necessary, an explanatory legend. Boxes and tables should be sent as their original files (Excel). Figures: This material should be presented in black and white, with legends and the respective numbering printed at the bottom of each illustration. Figures should be sent as their original files (Jpeg or Tif: 300 dpi). Each figure should be sent separately to the system. The legend(s) should be incorporated at the end of the text, before the reference list. Do not include figures in the text. The term “figures” includes all the illustrations, such as photographs, drawings, maps, graphs, etc. All the figures should be numbered consecutively using Arabic numerals. Photographs in black and white will be reproduced free of charge, but the Editor reserves the right to establish a reasonable limit regarding the number of such photographs, or to charge the authors for the expenses resulting from the excess. Colored photographs will be charged to the authors. Abbreviations: These should be preceded by the name in full, when cited for the first time in the text. In figures and tables, the meanings of abbreviations, symbols and other signs should be given as footnotes. The footnotes should also give information on the source: the place where the research was conducted. If the illustrations have already been published, their submission should be accompanied by written authorization from the author or editor, and the reference source where they were published should be declared. The Revista Brasileira de Ortopedia reserves the right not to accept for assessment any articles that do not fulfill the criteria laid out above. Sending the manuscript Submissions should be made online, through the link http://submission.scielo. br/index.php/rbo/login. It is essential to also send the following as supplementary documents, together with the manuscript: the letter giving permission to reproduce the material; the letter giving approval from the Ethics Committee of the institution where the work was carried out, when it related to therapeutic or diagnostic interventions in human beings; and the letter signed by all the authors in which they declare that the study has never been published previously. LEVELS OF EVIDENCE FOR PUBLICATION IN THE RBO Level I - Randomized study conducted using an appropriate technique, with follow-up of at least 80% of the cases and a compatible statistical analysis; or meta-analysis on level I studies with an appropriate technique and consistent results. Leve lII - Randomized study with partial randomization or conducted using a flawed technique or with follow-up of less than 80% of the cases, or with a flawed statistical analysis. Comparative prospective study. Meta-analysis on level II studies or metaanalysis on level I studies with inconsistent results.

Leve IV - Description of a case series with analysis on the results, without any comparative study. Leve V - Case description, description of a surgical technique or specialist’s opinion.


Editorial What is your opinion? We have commented several times in this editorial on the need for us to view the Internet as a means of disclosure and distribution of scientific journals, especially the Brazilian Journal of Orthopaedics, or RBO. Several publications are already presented exclusively online, and we are reluctant to let our RBO be handled, transported and filed almost as a plaything – to have it in a tablet. We cannot deny that the electronic form is much cheaper, allows greatly superior image quality and enables more direct and objective search and retrieval of articles. We discussed the various options with the publishers at the 43rd CBOT conference and decided to hear the readers' opinion. The number of articles, which is progressively increasing, to the point where we are seeing a delay of almost a year in the pace of publications, obliges us to think about three possible options:


• We could increase the number of articles per journal, an attitude that would result in an increase in the journal's cost and in the cost of delivery by mail, and would solve the problem temporarily; • We could increase the number of journals per year, which would basically produce the same difficulties; • We could publish part of the journal in printed form, as we already do, and cite a number of articles that would be available online in full. Thus, we could satisfy the demand for publications and would use our electronic form, which has existed since 1993, to update the flow of publications. Articles published in electronic form would have the same citation value, as they would be listed in the printed form. Some journals, such as Arthroscopy, already use this publication method for papers on surgical techniques, papers that require more precise images and case reports. I would like to know your opinion. In this manner, we will be able to test the Internet as a form of communication and discover your view of the subject. Please reply by choosing one of the options and send it to: rbo@sbot.org.br We will inform the result at a convenient time.

Thank you, Gilberto Luis Camanho


UPDATING ARTICLE

Baker’s Cyst

Marco Kawamura Demange1

Abstract Baker’s cysts are located in the posteromedial region of the knee between the medial belly of the gastrocnemius muscle and semimembranosus tendon. In adults, these cysts are related to intra-articular lesions, which may consist of meniscal lesions or arthrosis. In children, these cysts are usually found on physical examination or imaging studies, and they generally do not have any clinical relevance. Ultrasound examination is appropriate for identifying and measuring the popliteal cyst. The main treatment approach

INTRODUCTION The Baker’s cyst, or popliteal cyst, manifests itself as an increase of volume in the posterior region of the knee. These cysts were described for the first time by Adams in 1840, but were popularized by Baker’s description in 1877. In his description, Baker postulated that the formation of this cyst results from a buildup of fluid in the bursa of the semimembranosus tendon, with communication between here and the joint, yet with a one-way flow of fluid in the direction of the cyst, limited by a valve(1). After Baker’s description, several papers described popliteal cysts and noted that Baker’s cyst corresponds to a cyst located between the medial head of the gastrocnemius muscle and semimembranosus tendon. Baker’s cyst presents bimodal epidemiologic distribution, with peaks in childhood and in adulthood(2). Baker’s cyst in childhood is rare and generally discovered by chance. There is usually no precedent trauma for the appearance of popliteal cysts in children. In the case of adults, in turn, there is generally an association between these cysts and intra-articular lesions. The most frequent associated pathologies are meniscal le-

should focus on the joint lesions, and in most cases there is no need to address the cyst directly. Although almost all knee cysts are benign (Baker’s cysts and parameniscal cysts), presence of some signs makes it necessary to suspect malignancy: symptoms disproportionate to the size of the cyst, absence of joint damage (e.g. meniscal tears) that might explain the existence of the cyst, unusual cyst topography, bone erosion, cyst size greater than 5 cm and tissue invasion (joint capsule). Keywords – Knee; Popliteal Cyst; Adult; Child

sions (lesions of the medial meniscus in 82% of the cases and of lesions of the lateral meniscus in 38%) and osteoarthritis(3). Studies with magnetic resonance describe that the prevalence of popliteal cysts is 5% of the adult population, and higher in older patients(4). Patients with rheumatoid arthritis and patients with gout frequently present popliteal cysts(5). From the anatomopathological point of view, it is a ganglion cyst covered by mesothelial cells and fibroblasts. The fluid in its interior is viscous and with a high concentration of fibrin. The interior of the cyst may present lobulations with walls ranging from 2 to 8 mm. In the 1950s, Bickel et al(6) actually classified Baker’s cysts in three types, from the anatomopathological point of view, according to wall thickness and cyst content. The clinical relevance of this classification is limited. The pathogenesis of Baker’s cyst is explained by the presence of a connection between the knee joint and a bursa between the gastrocnemius muscle and the semitendinosus tendon, allowing the flow of fluid. There is a valve effect between the cyst and the joint, due to the action of the semitendinosus and gastrocnemius muscles. During flexion the “valve” opens and

1 - Master’s degree and Doctor’s degree from Universidade de São Paulo; Assistant Physician of the Knee Group of the Institute of Orthopedics and Traumatology of HC/FMUSP. Mailing address: Rua Ovídio Pires de Campos, 333, 3º andar, Cerqueira Cesar - 05403-010 - São Paulo, SP. Email: demange@usp.br Study received for publication: 03/03/2011, accepted for publication: 10/19/2011. The authors declare that there was no conflict of interest in conducting this work This article is available online in Portuguese and English at the websites: www.rbo.org.br and www.scielo.br/rbort

Rev Bras Ortop. 2011;46(6):630-33


BAKER’S CYST

during extension the “valve” closes due to the tension of these muscles. Moreover, the intra-articular pressure of the knee interferes in the formation and in the filling of the popliteal cysts. The intra-articular pressure during partial knee flexion is negative (-6 mmHg), becoming positive with knee extension (16 mmHg). Hence, these three factors – presence of communication between joint and bursa, “valve” effect and variation of intra-articular pressure in the knee – correspond to the pathophysiologic explanation of the formation of Baker’s cysts(2).

CLINICAL PICTURE Patients with Baker’s cyst may refer to the presence of a mass or growth in the posterior region of the knee. In children, these cysts are asymptomatic, and are mostly found in physical examinations. In adults, these cysts can cause pain and a feeling of pressure in the posterior region of the knee. The symptoms are more intense when extending the joint or during physical activities. Most of the time, the clinical complaints are not related to the cyst, but refer to the problem associated with the condition. Therefore, complaints relating to osteoarthritis or to meniscal lesion are more frequent(2). When a Baker’s cyst ruptures, the clinical picture consists of abrupt and intense pain in the posterior region of the knee and of the calf. This picture is often confused with the diagnosis of deep vein thrombosis. In both clinical situations there can be an increase of volume and clubbing of the calf(7). In Baker’s cysts of significant volume there can be compression of associated structures and clinical symptoms arising from the latter. This profile is rare, yet should be suspected when there is correlation between compressive symptoms and the location of the cyst(8-11). For the physical examination, we should assess the patient in prone position and perform knee palpation in extension and in flexion of 90 degrees. We palpate a rounded, mobile mass, with sensation of fluid content and of well-defined edges. The cyst tends to disappear or to decrease with 45 degrees of knee flexion (Foucher’s sign). This test is useful to distinguish Baker’s cysts from fixed, solid masses that do not change position.

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IMAGING DIAGNOSIS Ultrasonography allows us to define the size and location of the Baker’s cyst. Additional subsidiary examination is not usually necessary. Ultrasonography allows us to evaluate the tumor content, and to distinguish cysts with liquid contents from solid masses. Complementarily, we can perform magnetic resonance imaging, which is especially useful in case of suspicion of lesions associated with the popliteal cyst. In the MR imaging exam, the popliteal cyst presents low-signal intensity in the T1weighted images and high-signal intensity in the T2-weighted images, due to its fluid content (Figures 1, 2 and 3). Baker’s cyst consists of an ovular, well-defined image of fluid content. Magnetic resonance imaging allows us to differentiate popliteal cysts from parameniscal cysts, since the latter are generally located on the outer edges of the meniscuses (medial or lateral) and present communication with the meniscal lesion(12). The radiographic exam of the knee is useful in the diagnosis of osteoarthritis and not of the actual cyst. Arthrography was used as a diagnostic method in the past, demonstrating communication between the joint and the cyst in 30 to 40% of patients. Arthrography is not used as a routine diagnostic method nowadays.

Figure 1 – Sagittal T1-weighted magnetic resonance image of the knee depicts the presence of Baker's cyst. Rev Bras Ortop. 2011;46(6):630-33


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Figure 2 –Sagittal T2-weighted magnetic resonance image of the knee depicts the presence of Baker's cyst.

Figure 3 – Axial T2-weighted magnetic resonance image of the knee depicts the presence of Baker's cyst.

TREATMENT In the vast majority of cases, the popliteal cyst does not require treatment(13). In childhood it is necessary to explain the condition to the child’s parents, in order to assuage their anxiety in relation to the presence of the cyst. It is known that, in spite of surgical treatRev Bras Ortop. 2011;46(6):630-33

ment, the recurrence of popliteal cysts in children is approximately 40%(14). Moreover, in children treated conservatively, there is partial or total remission of the growth in approximately half of the patients(13). In children with persistent painful symptoms we indicate surgical excision. In this case, the procedure is carried out with the patient in prone position, through a transverse access route in the popliteal fold, following the skin lines, dissecting around the cyst. After we identified the base of the cyst, we performed the excision and closed the residual orifice with circular stitches using non-absorbable thread(14). Surgical excision is not usually required in the treatment of Baker’s cysts in adults. The surgical treatment of Baker’s cysts calls for prioritization of the approach to the associated intra-articular lesion. The isolated resection of Baker’s cysts generally leads to recurrence of the growth. On the same line, the aspiration and local injection of corticosteroids consists of a temporary measure, as it presents a high rate of recurrence of the cyst. Thus, when we opt for the conservative treatment of the associated lesion, Baker’s cyst is only observed. In these cases, it is also possible to perform aspiration and infiltration of corticosteroids as a relief measure. The treatment of the associated lesion is usually performed by arthroscopy, since many patients with popliteal cysts present meniscal lesions. In most cases, we perform only the treatment of the intra-articular lesion, as Baker’s cyst frequently presents reduction of volume or remission after the arthroscopic procedure. In selected cases, when a Baker’s cyst does not recede and continues to cause discomfort, we consider open resection. In this case, we create a local route of access, performing dissection of the cyst and removal from its base. We place a closing suture at the base to prevent its recurrence. Some authors have described the possibility of executing the approach to the Baker’s cyst by arthroscopic route(15). In relation to parameniscal cysts, the treatment should also emphasize the meniscal lesion. In most cases, the isolated treatment of the meniscal lesion is sufficient. During the arthroscopy procedure, it is possible to use the probe, arthroscopic rasps or the shaver blade to break open the parameniscal cyst(16,17). When the cyst cannot be decompressed arthroscopically, surgical excision can be considered when the presence of the cyst consists of an important complaint of the patient(17).


BAKER’S CYST

DIFFERENTIAL DIAGNOSES Parameniscal cysts generally appear on the outer edge of the meniscuses and communicate with meniscal lesions. There are malignant tumors that can appear in cystic form, comprising differential diagnoses to Baker’s cysts. The most common are the fibrosarcoma, synovial sarcoma and malignant fibrous histiocytoma. We suggest sending all resected synovial cysts for anatomopathological examination. The level of suspicion of malignant tumors should be stronger when the cyst is not in its typical location (between the medial gastrocnemius and the semimembranosus tendon), when there is recurrence of the cyst in spite of surgical treatment, in the case of fast growth of the tumor or disproportion between the lesion size and the symptoms(18). Benign cysts do not present tissue invasion, having well-defined outlines, dissecting between the musculotendinous structures. The differentiation between solid masses and cystic masses can be performed using transilummination. Nerve sheath tumors are rare and can present positive Tinel’s sign upon local percussion. In imaging examinations, the presence of calcification or of areas of bone erosion arouses suspicion of malignant lesions. Moreover, the heterogeneous aspect of the cyst content and the absence of intra-articular lesions that justify the presence of the cysts in adults should

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alert the orthopedist(19). Anyhow, they are rare and infrequent lesions. Aneurysms of the popliteal region can be differentiated by palpation and auscultation. Another pathology, cystic adventitial disease of the popliteal artery, can cause pain and claudication. It generally affects young adults, but can affect elderly patients with chronic vascular problems. It ideally requires early diagnosis as it can evolve to occlusion of popliteal artery. The diagnosis can be performed with the use of resonance imaging of the knee with contrast(20,21). In ruptured Baker’s cysts, the differential diagnosis is performed with thrombophlebitis and with deep vein thrombosis(8). In the case of thrombophlebitis, the differential diagnosis can be performed by palpation of a rope that corresponds to the thrombosed vein(22). In the case of deep vein thrombosis, we should appreciate the importance of the clinical history and, when necessary, use lower extremity venous Doppler(23).

FINAL CONSIDERATIONS Baker’s cyst consists of a frequent finding, and is highly prevalent in adult patients with meniscal lesions or arthrosis of the knee. The treatment should generally target intra-articular pathology. The cyst itself does not usually require treatment and can recede after treatment of the associated lesion.

ReferEncEs 1. Wigley RD. Popliteal cysts: variations on a theme of Baker. Semin Arthritis Rheum. 1982;12(1):1-10. 2. Handy JR. Popliteal cysts in adults: a review. Semin Arthritis Rheum. 2001;31(2):108-18. 3. Kornaat PR, Bloem JL, Ceulemans RY, Riyazi N, Rosendaal FR, Nelissen RG, et al. Osteoarthritis of the knee: association between clinical features and MR imaging findings. Radiology. 2006;239(3):811-7. 4. Fielding JR, Franklin PD, Kustan J. Popliteal cysts: a reassessment using magnetic resonance imaging. Skeletal Radiol. 1991;20(6):433-5. 5. Liao ST, Chiou CS, Chang CC. Pathology associated to the Baker’s cysts: a musculoskeletal ultrasound study. Clin Rheumatol. 2010;29(9):1043-7. 6. Bickel WH, Burleson RJ, Dahlin DC. Popliteal cyst; a clinicopathological survey. J Bone Joint Surg Am. 1956;38(6):1265-74. 7. Arumilli BR, Lenin Babu V, Paul AS. Painful swollen leg--think beyond deep vein thrombosis or Baker’s cyst. World J Surg Oncol. 2008;6:6. 8. Kabeya Y, Tomita M, Katsuki T, Meguro S, Atsumi Y. Pseudothrombophlebitis. Intern Med. 2009;48(21):1927. 9. Shiver SA, Blaivas M. Acute lower extremity pain in an adult patient secondary to bilateral popliteal cysts. J Emerg Med.9. Shiver SA, Blaivas M. Acute lower extremity pain in an adult patient secondary to bilateral popliteal cysts. J Emerg Med.9. Shiver SA, Blaivas M. Acute lower extremity pain in an adult patient secondary to bilateral popliteal cysts. J Emerg Med. 10. Dressler F, Wermes C, Schirg E, Thon A. Popliteal venous thrombosis in juvenile arthritis with Baker cysts: report of 3 cases. Pediatr Rheumatol Online J. 2008;6:12. 11. Ji JH, Shafi M, Kim WY, Park SH, Cheon JO. Compressive neuropathy of the tibial nerve and peroneal nerve by a Baker’s cyst: case report. Knee. 2007;14(3):249-52.

12. Papp DF, Khanna AJ, McCarthy EF, Carrino JA, Farber AJ, Frassica FJ. Magnetic resonance imaging of soft-tissue tumors: determinate and indeterminate lesions. J Bone Joint Surg Am. 2007;89(Suppl 3):103-15. 13. Van Rhijn LW, Jansen EJ, Pruijs HE. Long-term follow-up of conservatively treated popliteal cysts in children. J Pediatr Orthop B. 2000;9(1):62-4. 14. Chen JC, Lu CC, Lu YM, Chen CH, Fu YC, Hunag PJ, et al. A modified surgical method for treating Baker’s cyst in children. Knee. 2008;15(1):9-14. 15. Ahn JH, Lee SH, Yoo JC, Chang MJ, Park YS. Arthroscopic treatment of popliteal cysts: clinical and magnetic resonance imaging results. Arthroscopy. 2010;26(10):1340-7. 16. Goldstein R, Andrade Júnior A. Lesão cística de menisco: abordagem por via artroscópica. Rev Bras Ortop. 1998;33(5):371-6. 17. Greis PE, Holmstrom MC, Bardana DD, Burks RT. Meniscal injury: II. Management. J Am Acad Orthop Surg. 2002;10(3):177-87. 18. Damron TA, Sim FH. Soft-Tissue Tumors About the Knee. J Am Acad Orthop Surg. 1997;5(3):141-52. 19. Mountney J, Thomas NP. When is a meniscal cyst not a meniscal cyst? Knee. 2004;11(2):133-6. 20. Chung CB, Isaza IL, Angulo M, Boucher R, Hughes T. MR arthrography of the knee: how, why, when. Radiol Clin North Am. 2005;43(4):733-46. 21. Cassar K, Engeset J. Cystic adventitial disease: a trap for the unwary. Eur J Vasc Endovasc Surg. 2005;29(1):93-6. 22. Gordon GV, Edell S, Brogadir SP, Schumacher HR, Schimmer BM, Dalinka M. Baker’s cysts and true thrombophlebitis. Report of two cases and review of the literature. Arch Intern Med. 1979;139(1):40-2. 23. Useche JN, de Castro AM, Galvis GE, Mantilla RA, Ariza A. Use of US in the evaluation of patients with symptoms of deep venous thrombosis of the lower extremities. Radiographics. 2008;28(6):1785-97. Rev Bras Ortop. 2011;46(6):630-33


UPDATING ARTICLE

PROPOSAL FOR STANDARDIZATION OF RADIOGRAPHIC STUDIES ON THE HIP AND PELVIS

Giancarlo Cavalli Polesello1, Tarsila Sato Nakao2, Marcelo Cavalheiro de Queiroz3, Daniel Daniachi3, Walter Ricioli Junior3, Rodrigo Pereira Guimarães4, Emerson Kiyoshi Honda5, Nelson keiske Ono6

Abstract Diagnoses of hip and pelvis disorders are based on the detailed medical history, physical examination and laboratory tests, as appropriate for each condition. Plain radiography is still the initial examination of choice and, because of its importance, there is a need to standardize radiographic studies, both in relation to execution and in radiographic series,

INTRODUCTION The diagnosis of hip and pelvic disorders is based on detailed clinical history, physical examination and laboratory tests, as appropriate for each condition. Plain radiography is still the initial examination of choice, although computed tomography and nuclear magnetic resonance are useful for diagnostic confirmation(1,2). In view of the importance of radiography, there is a need to standardized radiographic studies, both in relation to execution and in radiographic series, according to the different pathological conditions. The aim of this article is to propose standardization for the main radiographic views of the hip and pelvis, and with regard to performing specific series for different pathological conditions, providing technical guidance for achieving these aims.

RADIOGRAPHIC VIEWS A) Non-traumatic series 1) Anteroposterior (AP) pelvic radiograph:

according to the different pathological conditions. The aim of this paper was to propose standardization for the main radiographic views of the hip and pelvis, and with regard to performing specific series for different pathological conditions, and to provide technical guidance for achieving these aims. Keywords - Hip/pathogy; Hip/radiography; Pelvis/pathogy; Pelvis/radiography

- Patient in supine or orthostatic position; - Beam incident on median line just above the pubic symphysis, feet rotated internally from 15 to 20° (for correction of the neck anteversion angle), so that the greater trochanter does not overlap the femoral neck (Figure 1); - It should be possible to visualize the coccyx aligned with the pubic symphysis, 2.5 cm cranial in the female sex and 1.5 cm in the male sex. The obturator foramens should be symmetrical(3) (Figure 2); - The iliopectineal line, ilioischial or Köehler’s line(4), teardrop (lower limit of the acetabulum), acetabular roof and edges of the anterior and posterior walls can be observed (Figure 3); and - The AP pelvic radiograph is the main view in the radiographic series of the hip and of the pelvis; however, their performance with stress is controversial in literature. Conrozier et al(5) and Vanni et al(6) demonstrated that there is only a decrease of the articular space in patients with coxarthrosis, in a

1 – Assistant Professor with Doctoral Degree; Assistant of the Hip Group of the School of Medical Sciences, Santa Casa de São Paulo – São Paulo, SP, Brazil. 2 – Orthopedist; Former Intern of the Hip Group of the School of Medical Sciences, Santa Casa de São Paulo – São Paulo, SP, Brazil. 3 – Orthopedist; Assistant of the Hip Group of the School of Medical Sciences, Santa Casa de São Paulo – São Paulo, SP, Brazil. 4 – Teaching Instructor with Master’s Degree; Assistant of the Hip Group of the School of Medical Sciences, Santa Casa de São Paulo – São Paulo, SP, Brazil. 5 – Teaching Instructor with Doctoral Degree; Senior Member of the Hip Group of the School of Medical Sciences, Santa Casa de São Paulo – São Paulo, SP, Brazil. 6 – Assistant Professor with Doctoral Degree; Head of the Hip Group of the School of Medical Sciences, Santa Casa de São Paulo – São Paulo, SP, Brazil. Study conducted at the Department of Orthopedics and Traumatology of the School of Medical Sciences, Santa Casa de São Paulo – Director: Prof. Dr. Osmar Avanzi. Mailing address: Rua Dr. Cesário Motta Júnior, 112, Prédio Ortopedia, 2º andar, Sala Quadril – 01221-020 – São Paulo, SP, Brazil. Email: dot.quadril@hotmail.com Study received for publication: 1/11/2011, accepted for publication: 3/25/2011. The authors declare that there was no conflict of interest in conducting this work This article is available online in Portuguese and English at the websites: www.rbo.org.br and www.scielo.br/rbort

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PROPOSAL FOR STANDARDIZATION OF RADIOGRAPHIC STUDIES ON THE HIP AND PELVIS

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Figure 3 – Anteroposterior pelvic radiograph and the main structures identified.

Figure 1 – Anteroposterior pelvic radiograph: positioning of patient supine with the lower limbs rotated internally from 15 to 20 degrees; beam incident on the median line, just above the pubic symphysis.

Figure 2 – Anteroposterior pelvic radiograph executed with correct technique. Observe the alignment of the coccyx with the pubic symphysis. The coccyx should be located cranially, no further than 2.5cm from the pubic symphysis.

comparison with unstressed radiography. However, in patients with normal hips or in cases of initial arthrosis, the use of stressed radiography is not necessary(6-8). 2) Lequesne’s false profile(9): - It is a false profile, as it corresponds to the profile of the head and of the proximal femur, and not of the acetabulum (Figure 4); - Patient in orthostatic position, with the back tilted 65° anteriorly in relation to the film chassis, both lower limbs in external rotation, with the affected limb (limb furthest from the chassis) perpendicular to the chassis and the contralateral limb parallel to the chassis (Figure 5); - When properly executed, observe between the femoral heads the distance corresponding to the diameter of a femoral head (Figure 6); and - It is a useful view for the visibility of the medial and anterosuperior impingement of the coxofemoral joint. Therefore, it is important for the evaluation of coxarthrosis and acetabular dysplasia(2,10,11). 3) Ducroquet’s profile: - Patient positioned supine, affected hip with flexion of 90° and abduction of 45° (this radiograph therefore requires good hip mobility) (Figure 7); - Beam centered vertically on the coxofemoral joint; - We can observe the profile of the femoral neck, with good visibility of the anterosuperior region of the femoral head-neck transition, the most frequent site of CAME type femoroacetabular impingement. Besides the neck, we can visualize the acetabular roof Rev Bras Ortop. 2011;46(6):634-42


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Figure 4 – Lequesne's false profile radiograph, called falseprofile as it corresponds to the profile of the head and of the proximal femur, and not of the acetabulum.

Figure 6 – Lequesne's false profile radiograph executed with correct technique. Observe the distance between the two heads corresponding to the diameter of one of them.

Figure 5 – Lequesne's false profile radiograph. Observe patient's positioning with the affected left lower limb further from the chassis. Patient in orthostatic position, with the back tilted 65° anteriorly in relation to the film chassis, both lower limbs in external rotation, with the affected limb perpendicular to the chassis and the contralateral limb parallel to the chassis.

Figure 7 – Ducroquet profile view. Patient in supine position, affected hip with flexion of 90° and abduction of 45°. Beam centered vertically on the coxofemoral joint.

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PROPOSAL FOR STANDARDIZATION OF RADIOGRAPHIC STUDIES ON THE HIP AND PELVIS

and identify the presence of an intra-articular foreign body (Figure 8); - The Dunn view is a similar profile, performed with hip flexion of 45° and abduction of 20°. In this view we can also clearly observe the anterosuperior segment of the femoral head-neck transition; and - It is also possible to measure the alpha angle in both views (angle formed between the longitudinal axis of the femoral neck and a line passing through the center of rotation of the femoral head and through the point of the head-neck junction from where the distance to the center of the head exceeds the radius, i.e., loses sphericity. Its normal value should not exceed 55°)(3,12,13) (Figure 9). 4) Arcelin’s surgical profile or cross table view: - Patient in supine position with flexion of 90 degrees of the contralateral hip; - The X-ray tube should be angled 45° cranially in the horizontal plan, towards the thigh root (does not require mobilization of the affected hip, and is ideal for traumatized patients) (Figure 10); and - Observe the femoral neck in profile and the headneck transition. 5) Lauenstein pelvic radiograph (frog position): - Patient in supine position with double abduction of the lower limbs; beam incident on median line, just above the pubic symphysis, oriented vertically (Figure 11). Given the superimposition of images on the femoral side and on the acetabular side, it is the same as a frontal pelvic radiograph, and its usefulness in adults is questionable.

Figure 8 – Radiograph in Ducroquet profile view.

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Figure 9 – Measurement of the alpha angle (in the Ducroquet profile view: angle formed by the longitudinal axis of the femoral neck and line AC (A – point of loss of sphericity of the head-neck junction, C – center of the head, r – radius of the femoral head).

B) Traumatic series 1) Alar(14): - Patient in supine position with rotation of 45° over the affected side; beam centered vertically on the thigh root (Figure 12); - It evidences the iliac wing, sacroiliac joint, posterior column and anterior acetabular wall (Figure 13); - Indicated mainly for physical trauma, especially acetabular fractures(15,16). 2) Protrusive or foraminal view(14): - Patient in supine position rotated 45° over the unaffected side; beam centered vertically on the thigh root (Figure 14); - It evidences anterior column and posterior acetabular wall (Figure 15); and - Indicated mainly for physical trauma, especially acetabular fractures(15,16). Rev Bras Ortop. 2011;46(6):634-42


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A

B

Figure 10 – A) Surgical profile view. Patient supine, the X-ray tube should be angled 45° cranially in the horizontal plane, towards the thigh root. B) Radiograph in surgical profile view.

A

B

Figure 11 – A) Lauenstein pelvic radiograph. Patient in supine position with double abduction of the lower limbs; beam incident on the median line, just below the pubic symphysis, oriented vertically. B) Lauenstein pelvic radiograph. Rev Bras Ortop. 2011;46(6):634-42

Figure 12 – Alar oblique view of pelvis. Patient in supine position with rotation of 45° over the affected side; beam centered vertically on the thigh root.


PROPOSAL FOR STANDARDIZATION OF RADIOGRAPHIC STUDIES ON THE HIP AND PELVIS

Figure 13 – Alar pelvic radiograph of the left hip.

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Figure 15 – Foraminal pelvic radiograph ofthe left hip.

3) Pelvic inlet(17); - Patient in horizontal supine position, with beam incident in the craniocaudal direction with angulation of 60° (Figure 16); - When properly executed, observe the promontory overlapping the anterior cortex of the S1 vertebral body(17); - Indicated mainly for physical trauma (pelvic fracture); and - It allows us to evaluate the integrity of the pelvic ring, as well as anteroposterior and rotational deviations. 4) Pelvic outlet(17): - Patient in horizontal supine position, with beam incident in the caudocranial direction with angulation of 45° (Figure 17); - Technique properly executed when the upper part of the pubic symphysis is at the same level as the second sacral body; - Indicated mainly for physical trauma (pelvic fracture); - It allows us to evaluate sacral fractures (to observe the wedge format when intact and to evaluate the outline of the foramens), as well as fractures of the posterior portion of the iliac wing and of the pubic ramus, sacroiliac disjunction and vertical deviations(17). C) Suggestions of views by condition

Figure 14 – Foraminal oblique view of the pelvis. Patient in supine position with rotation of 45° over the unaffected side; beam centered vertically on the thigh root.

1) Coxarthrosis: The AP pelvic radiograph is still the main examination, where it is possible to classify the degree of arthrosis. Rev Bras Ortop. 2011;46(6):634-42


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A

B

A

B

Figure 16 – Inlet view of pelvis. A) Patient in horizontal supine position, with beam incident in the craniocaudal direction with angulation of 60°. B) Inlet pelvic radiograph executed with correct technique. Observe the promontory overlapping the anterior cortex of the S1 vertebral body.

Figure 17 – Outlet view of the pelvis. A) Patient in horizontal supine position, with beam incident in the caudocranial direction with angulation of 45°. B) Outlet pelvic radiograph.

Another very useful view, particularly for initial cases of arthrosis, is Lequesne’s false profile, as it evidences anterosuperior and medial impingement, often not clearly observed in the AP view (Figure 18), which can lead to inappropriate indications and surgeries. 2) Alterations in the acetabular morphology and depth: The AP pelvic radiograph allows us to visualize alterations in the acetabular version, dysplasia, acetabular protrusion and coxa profunda. Alterations in the acetabular depth should be based on the ilioischial line, and are called coxa profunda when the floor of the acetabulum touches the line and acetabular protrusion when the femoral head surpasses such line (Figure 19).

Lequesne’s view is also useful in the evaluation of acetabular dysplasia, measuring the angle of anterior coverage of the femoral head, whose normal value is 25° or higher(2) (Figure 20). 3) Femoroacetabular impingement: With the AP radiograph we can evaluate the presence of deformity in the proximal portion of the femur, alterations in the acetabular version and dysplasia. The Lequesne, Ducroquet and Dunn views are used to evaluate the sphericity of the cervicocephalic junction, mainly in the anterolateral portion, as well as the acetabular coverage of the femoral head. Through Lequesne’s false profile view we can visualize potential excessive acetabular coverage (Pincer impingement)(18).

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Figure 18 – AP view of left hip with slight anterosuperior impingement. Lequesne's false profileview of the same patient with more evident anterosuperior impingement.

Figure 19 – AP pelvic radiograph with coxaprofunda of the right hip and protrusion of the left hip.

As described previously, the Dunn and Ducroquet views are useful to measure the alpha angle, important in the study of CAME impingement. 4) Fractures: a) Pelvis – AP, inlet and outlet; b) Acetabulum – AP, alar and foraminal; and c) Fractures of the proximal third of the femur – AP, AP with traction and internal rotation (aiming to predict the degree of instability, and consequently, the surgical technical difficulty), cross table (an advantage in traumatized patients, since the affected hip is not mobilized).

Figure 20 – Lequesne's false profile radiograph. Visibility of the angle of anterior coverage of the femoral head. The lines are drawn passing through the center of rotation of the femoral head, with one vertical and the other passing across the more ossified edge of the acetabular portion. Rev Bras Ortop. 2011;46(6):634-42


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REFERENCES 1. Clohisy JC, Carlisle JC, Trousdale R, Kim YJ, Beaule PE, Morgan P, StegerMay K, Schoenecker PL, Millis M. Radiographic evaluation of the hip has limited reliability. Clin Orthop Relat Res. 2009;467(3):666-75.

10. Lequesne M, Laredo JD. The faux profil view of the hip may detect joint space narrowing when lacking on the anteroposterior radiograph in incipient osteoarthritis. Arthritis Rheum. 1998;41(Suppl):145.

2. Godefroy D, Chevrot A, Morvan G, Rousselin B, Sarazin L. [Plain films of pelvis]. J Radiol. 2008;89(5 Pt 2):679-90.

11. Conrozier T, Bochu M, Gratacos J, Piperno M, Mathieu P, Vignon E. Evaluation of the ‘Lequesne’s false profile’ of the hip in patients with hip osteoarthritis. Osteoarthritis Cartilage. 1999;7(3):295-300.

3. Tannast M, Siebenrock KA, Anderson SE. Femoroacetabular impingement: radiographic diagnosis--what the radiologist should know. AJR Am J Roentgenol. 2007;188(6):1540-52. 4. Armbuster TG, Guerra J Jr, Resnick D, Goergen TG, Feingold ML, Niwayama G, Danzig LA. The adult hip: an anatomic study. Part I: the bony landmarks. Radiology. 1978;128(1):1-10. 5. Conrozier T, Lequesne MG, Tron AM, Mathieu P, Berdah L, Vignon E. The effects of position on the radiographic joint space in osteoarthritis of the hip. Osteoarthritis Cartilage. 1997;5(1):17-22. 6. Vanni GF, Stucky JM, Schwarstmann CR. Avaliação radiológica do espaço articular na artrose do quadril: estudo comparativo em decúbito e ortostatismo. Rev Bras Ortop. 2008;43(10):460-4. 7. Auleley GR, Duche A, Drape JL, Dougados M, Ravaud P. Measurement of joint space width in hip osteoarthritis: influence of joint positioning and radiographic procedure. Rheumatology (Oxford). 2001;40(4):414-9

12. Meyer DC, Beck M, Ellis T, Ganz R, Leunig M. Comparison of six radiographic projections to assess femoral head/neck asphericity. Clin Orthop Relat Res. 2006;445:181-5. 13. Polesello GC, Queiroz MC, Ono NK, Honda EK, Guimarães RP, Ricioli W. Tratamento artroscópico do impacto femoroacetabular. Rev Bras Ortop. 2009;44(3):230-38. 14. Reilly MC. Fractures of the acetabulum. In: Bucholz RW, Heckman JD, CourtBrown CM, editors. Rockwood & Green’s fractures in adults. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2006. p.1666- 714. 15. Judet R, Judet J, Letournel E. Fractures of the acetabulum: classification and surgical approaches for open reduction. Preliminary report. J Bone Joint Surg Am. 1964;46:1615-46. 16. Letournel E. Acetabulum fractures: classification and management. Clin Orthop Relat Res. 1980;(151):81-106.

8. Vignon E, Conrozier T, Piperno M, Richard S, Carrillon Y, Fantino O. Radiographic assessment of hip and knee osteoarthritis. Recommendations: recommended guidelines. Osteoarthritis Cartilage. 1999;7(4):434-6.

17. Starr AJ, Malekzadeh AS. Fractures of the pelvic ring. Bucholz RW, Heckman JD, Court-Brown CM, editors. Rockwood & Green’s fractures in adults. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2006. p. 1585-664.

9. Lequesne MG, Laredo JD. The faux profil (oblique view) of the hip in the standing position. Contribution to the evaluation of osteoarthritis of the adult hip. Ann Rheum Dis. 1998;57(11):676-81

18. Crestani MV, Teloken MA, Gusmão PDF. Impacto femoroacetabular: uma das condições precursoras da osteoartrose do quadril. Rev Bras Ortop. 2006;41(8):285-93.

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REVIEW ARTICLE

Peripheral nerve regeneration: cell therapy and neurotrophic factors

Alessandra Deise Sebben1, Martina Lichtenfels2, Jefferson Luis Braga da Silva3

Abstract Peripheral nerve trauma results in functional loss in the innervated organ, and recovery without surgical intervention is rare. Many surgical techniques can be used for nerve repair. Among these, the tubulization technique can be highlighted: this allows regenerative factors to be introduced into the chamber. Cell therapy and tissue engineering have arisen as an alternative for stimulating and aiding peripheral nerve regeneration. Therefore, the aim of this review was to provide a survey and analysis on the results from experimental and clinical studies that used cell therapy and tissue engineering as tools for optimizing the regeneration process. The articles used came from the LILACS, Medline and SciELO scientific databases. Articles on the use of stem cells, Schwann cells, growth factors, collagen, laminin and platelet-rich plasma for peripheral nerve repair were summarized over the course

INTRODUCTION Peripheral nerve transection traumas are extremely common in clinical practice and recovery without surgical intervention is rare. Lesions with loss of nerve substance produce serious problems for the patient. Besides causing pain and morbidity, these injuries usually generate permanent sequelae, such as sensory deficit and functional dysfunction. These lesions cause damages that substantially diminish the quality of life of these patients, including physical disability and total or partial loss of their productive activities, which gives rise to important social and economic consequences(1). The current repair techniques offer random and frequently unsatisfactory results. In view

of the review. Based on these studies, it could be concluded that the use of stem cells derived from different sources presents promising results relating to nerve regeneration, because these cells have a capacity for neuronal differentiation, thus demonstrating effective functional results. The use of tubes containing bioactive elements with controlled release also optimizes the nerve repair, thus promoting greater myelination and axonal growth of peripheral nerves. Another promising treatment is the use of platelet-rich plasma, which not only releases growth factors that are important in nerve repair, but also serves as a carrier for exogenous factors, thereby stimulating the proliferation of specific cells for peripheral nerve repair. Keywords - Peripheral Nerve System/injuries; Regenerative Medicine; Nerve Regeneration

of these limitations, many researchers seek therapeutic options to improve the repair of lesions with peripheral nerve transections(2). Nowadays autologous peripheral nerve transplantation represents the gold standard of repair when there is loss of substance that precludes neurorrhaphy. However, it presents some limitations, such as the need to perform two surgical procedures at different sites, the consequent greater morbidity and the shortage of nerve donor sites, besides the resulting sensory deficit in the area from which it was removed(2,3). In cases where the extent of the lesion precludes the simple joining of the stumps, an available and widely used repair technique is tubulization. This technique,

1 – Biologist, Studying towards Doctoral Degree in Medicine and Health Sciences (PUCRS) – Porto Alegre, RS, Brazil. 2 – Biologist, Studying towards Master’s Degree in Medicine and Health Sciences (PUCRS) – Porto Alegre, RS, Brazil. 3 – Physician; Full Professor of the School of Medicine (PUCRS) – Porto Alegre, RS, Brazil. Study conducted at the Laboratory of Medical Abilities and Surgical Research, Pontifícia Universidade Católica do Rio Grande do Sul – PUCRS. Mailing address: Avenida Ipiranga, 6.690 / 64, Partenon – 90610-000 – Porto Alegre, RS. Email: adsebben@gmail.com Study received for publication: 2/11/2011, accepted for publication: 6/16/2011. The authors declare that there was no conflict of interest in conducting this work This article is available online in Portuguese and English at the websites: www.rbo.org.br and www.scielo.br/rbort

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also called entubulation, is a surgical procedure in which the sectioned nerve stumps are introduced and fastened inside a tubular prosthesis, aiming to provide a favorable environment for regeneration. It also serves as a guide for the nerve growth of the broken or sectioned ends(2,4), protecting the nerve fibers of the scar tissue and avoiding neuroma formation(5). Tubulization presents another interesting characteristic: it can be optimized with the addition of regenerative factors(6-8). It is known that tissue repair requires a complex interaction between cells, extracellular matrix and trophic factors, which are all important elements involved in nerve regeneration(9). Consequently, cell therapy and tissue engineering have been receiving a great deal of attention in recent decades, and are widely used in different areas(7,10-13). Although the complexity of molecular and cellular events of tissue repair is not yet completely clarified, existing knowledge of the mechanisms of the cascade that induces regeneration after peripheral nerve lesions is vast, and provides important information for a better conception of nerve repair. Therefore, the aim of this review is to provide a survey and analysis of experimental and clinical studies regarding the results obtained from peripheral nerve repair techniques, which use cell therapy and tissue engineering as tools to optimize the regeneration process. The articles used are from scientific databases LILACS, Medline and SciELO.

REVIEW OF LITERATURE Cell therapy and peripheral nerve repair Cell transplantation is one of the cell therapy and tissue engineering strategies aimed at the creation of a favorable microenvironment for tissue regeneration. Stem cells have important characteristics that differentiate them from other cell types, are undifferentiated precursor cells that have self-renewal ability and can differentiate into multiple lineages(14). They are present in several tissues and are responsible for their regeneration in the event of injuries or lesions(15). Bone marrow, adipose tissue, umbilical cord blood and peripheral blood are some sources of stem cells; however, these cells can be tissuespecific, i.e., originating directly from specialized tissues(6,14,16-18). In nerve repair, the most widely used Rev Bras Ortop. 2011;46(6):643-49

cells include the mesenchymal cells of the bone marrow and of the adipose tissue, as well as the actual Schwann cells(6,7,19-33) (Table 1). These cells can be applied directly after density gradient separation (Ficoll-PaqueŽ) or be cultivated and differentiated in vitro for subsequent application, as is the case of stem cell differentiation into Schwann cells. We present below a description of some of the cell types used most often in nerve repair surveys. Table 1 – Types of cells used as cell therapy in nerve repair. Cell

Study model

Reference

Bonemarrow-derived mesenchymal

Clinical

7

Bonemarrow-derived mesenchymal

Experimental

6, 19, 20, 21, 22, 23, 24

Adipose-derived mesenchymal

Experimental

Schwann cells

Experimental

25, 26 27, 28, 29, 30, 31, 32, 33

Schwann cells in nerve repair The cells most commonly used in nerve regeneration are autologous Schwann cells (SC). These represent glial cells in the peripheral nervous system, and their main function is to provide support to the axons through the release of growth factors and isolation of the axon through formation of the myelin sheath(34). The addition of SCs in synthetic tubes assists regeneration in nerve defects, although repair with autologous graft, in most studies, still presents superior recovery(27,29,33,35-37). Besides synthesizing growth factors, SCs also are able to produce extracellular molecules, such as laminin and type IV collagen. The extracellular matrix can serve as a reservoir of growth factors that are secreted by SCs(38). Experimental studies based on the use of SCs as a therapeutic option for the recovery of nerves with loss of substance proved the efficacy of these cells(28,32,39). SCs play an important role in the maintenance, nutrition and in the repair of peripheral nerves. Although there are still limiting factors in the use of SCs, these have promising results in tissue, physiological and functional improvement in


PERIPHERAL NERVE REGENERATION: CELL THERAPY AND NEUROTROPHIC FACTORS

lesions caused by trauma or pathologies in peripheral nerves. Bone marrow mesenchymal cells and nerve regeneration Many researchers have developed studies on stem cells(19,25,27,40). Embryonic stem cells, as well as those obtained from adult cerebral tissue, are able to undergo expansion and neuronal differentiation in vitro and in vivo. However, the inaccessibility of these cells limits their clinical use, which stimulated the search for cells that are capable of differentiating into neuronal lineages(28,41). Moreover, there is controversy involving research with the use of stem cells concerning the sources from which these are obtained. In particular, the use of embryonic stem cells, although legally regulated in Brazil, allowing research into and the manipulation of these cells obtained through “unviable embryos�, is still a subject of ethical and political discussions(29,30,42,43). An alternative and viable source of mesenchymal stem cells is bone marrow. Adult bone marrow-derived cells are characterized as multipotent, as they are able to differentiate into cell lineages of mesodermal origin(44,45). Several surveys on transplantation of bone marrow-derived mesenchymal stem cells (BMDMSC) have reported that these cells also present in vitro neuronal differentiation ability, which means they can be used in peripheral nerve repair(46-52). Additionally, Montzka et al(53) demonstrated the ability of human BMDMSCs to express different neuronal and glial cell markers. Experimental studies in rodents(20,21,23), rabbits(22,54) and primates(55) prove the efficiency of these cells, presenting positive functional outcomes in peripheral nerve repair. The combination of bone marrow mesenchymal cells with bioabsorbable tube increases nerve regeneration and sciatic nerve functional recovery in mice(56). BMDMSCs can positively influence the regeneration of peripheral nerves not only through the direct release of neurotrophic factors, but also through indirect modulation of the behavior of SCs(24,46). There is clinical evidence indicating BMDMSCs as an effective treatment in peripheral nerve repair. In comparing the tubulization technique with and without the addition of bone marrow mononuclear cells (this group of cells contains a fraction of stem cells) in 44 patients with damage to the median or ulnar nerve, it was verified that lesions treated with these cells

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presented better results in the regeneration process than conventional tubulization(7). However, BMDMSCs present some limitations. Besides the fact that these cells are obtained with the application of epidural or general anesthesia, since harvesting occurs through a very painful procedure, the quantity of cells acquired often fails to reach the necessary number(57). Adipose tissue-derived mesenchymal cells and nerve regeneration Mesenchymal stem cells are not only present in the bone marrow, but also in other tissues including the adipose tissue(18). Most authors call them adipose-derived stem cells, or ADSCs. There is a strong resemblance between ADSCs and BMDMSCs, since both present a similar immunophenotypical profile, as well as the ability to differentiate into osteogenic, chondrogenic, myogenous and adipogenic lineages(58,59). The advantage of using ADSCs is their widespread availability, as human subcutaneous fat is abundant, and can be harvested easily through the liposuction procedure, besides the fact that it appears much more frequently in the adipose tissue than mesenchymal cells in the bone marrow(60). The ability of mesenchymal cells originating from the adipose tissue to differentiate into cells with neuronal features was proved in vitro. Kingham et al(61) reported that ADSCs are able to differentiate into cells similar to the genuine SC, when cultivated together with a combination of glial trophic factors. Cells derived from adipose tissue of murinae and humans, after neuronal induction, presented morphology typical of nerve cells, which were positive for immunocytochemical expression of GFAP, nestin and neuron-specific nuclear protein (Neu-N). Pre-treatment with epidermal growth factor (EGF) and basic fibroblast growth factor (FGF) increases the neuronal differentiation of adipose-derived human stem cells, whose use has important biological and clinical implications(41). However, the adipose-derived mesenchymal stem cell should have the ability to produce myelin sheath, the main function of SCs. This characteristic was confirmed in in vitro studies, thus becoming another option for the treatment of peripheral nerve injuries(57). The adipose-derived mesenchymal stem cells present results similar to bone marrow-derived cells in vivo(25,26). However, due to the ease of their harvesting Rev Bras Ortop. 2011;46(6):643-49


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and abundant quantity of cells available in subcutaneous deposits, ADSCs are indicated as a better alternative for clinical application(25). Growth factors in nerve repair The complexity of nerve regeneration involves a range of elements that interact with one another, and are all essential to the process; among them, the growth factors (GF) aroused a great deal of interest in the scientific community(62), due to their performance as important cell modulators(62-78) (Table 2). Degenerated peripheral nerves are an important source of these factors, as are the SCs. These proteins are basically a set of three families of molecules and their receptors, responsible for maintaining the growth and survival of the sensory and motor axons and neurons after tissue damage(62). The local presence of GFs is important in the control of the survival, migration, proliferation and differentiation of various types of cells that are engaged in nerve repair(9,62). For these reasons, the use of therapies based on GFs has increased in the last few decades. Growth factors should be administered locally to achieve a more adequate therapeutic effect with few adverse reactions. Therefore, the delivery of growth factors for nerve regeneration can be ideally combined with nerve conduits(34). Among neurotrophic factors, the nerve growth factor (NGF) is the most researched factor, due to its action in the proliferation and differentiation of neurons(64) and as it assists in the repair and functional recovery of injured nerves(63). When combined with biomaterials and with controlled release, its effect can Table 2 – Main neurotrophic factors used in peripheral nerve repair. Growth factor

Main target

Reference

NGF

Sensory neurons and small axons

63, 64, 65

BDNF

Sensory neurons and large axons

66, 67, 68

NT-3

Sensory and motor neurons

69

NT-4/5

Motor neurons

62

GDNF

Motor neurons

70

CNTF

Sciatic nerve

71

IGF VEGF

Inflammatory (anti-inflammatory) cells; sensory and motor neurons Vascular endothelial cells

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72, 73, 74, 75 76, 77, 78

be strengthened(79-81). The ability of the NGF to promote functional recovery after lesions was confirmed in experimental studies(65,81). The endogenous brain-derived neurotrophic factor (BDNF) demonstrates an important role in the induction of the cell body response in injured rat neurons. When exposed to mitogens such as BDNF, stem cells differentiate into neuronal lineages in vitro(68). The glial cell line-derived neurotrophic factor (GDNF) is considered the most protective factor for motor neurons(70), and is essential in their formation, as well as that of sensory neurons during the regeneration process(82). GDNF has its expression elevated in experimental models of motor neuropathies in rats, several human neuropathies and in traumatized human nerves(82). In a model of peripheral nerve lesion in rats, it was demonstrated that the combination of nerve conduits composed of chitosan, GDNF and laminin was significantly more efficient during the initial stages of nerve repair, promoting greater axonal growth and myelination in six weeks after the animals’ nerve transection(83). The ciliar neurotrophic factor (CNTF) assists in the differentiation and in the survival of a variety of neurons, and the mRNA expression levels of CNTF decrease significantly and continue low for a long time after peripheral nerve transection(71). Similarly, the insulin-like growth factor (IGF) also assists in nerve regeneration. IGF-1 is present in several stages of development of the peripheral nerve system, performing a wide range of functions, including the promotion of the regeneration of motor and sensory axons(72-75). Evidence suggests that high levels of IGF in denervated muscle can stimulate regeneration with nerve sprouting(84). Besides acting essentially in the vascular tissue, the vascular endothelial growth factor (VEGF) also assists nerve regeneration, due to the close relationship existing between the nerve fibers and the blood vessels during this process. The addition of VEGF significantly increases the infiltration of blood vessels in nerve conduction chambers, and is related to the increase of axonal regeneration and migration of SCs(76,77). Moreover, the VEGF acts as a neuroprotective agent in neurons in vitro after ischemic lesion(78). In an experimental study,


PERIPHERAL NERVE REGENERATION: CELL THERAPY AND NEUROTROPHIC FACTORS

the use of VEGF demonstrated an effect on vascular blood supply, with a significant increase of axonal regeneration and of SCs, stimulating nerve regeneration(85). Collagen and laminin as carriers Components of the extracellular matrix are collagen and laminin, essential for guidance and axonal growth during the nerve regeneration process. Collagen and laminin are involved in the regeneration process through the formation of a substrate for the migration of non-neuronal cells. The filling of silicone tubes with these components presents an increase in the regeneration rate(86) and in the connection of extensive defects(87). This effect, however, depends on some factors such as the concentration and permeability of the tube(87,88). Nowadays, different gels containing collagen or laminin (Matrigel®) are being used as a support for cells and growth factors(27,35,37). Collagen, as the main component of the extracellular matrix, is used in various surgical prostheses. A study on an animal model demonstrated the efficacy of a biological matrix composed of collagen (Tissudura™ ) when used in nerve regeneration(89). As is the case of collagen, laminin also plays an important role in in vivo axonal growth. Surveys include this component of the extracellular matrix in animal models to repair injured sciatic nerves and to obtain an improvement in some areas of axonal regeneration. The application of tubes composed of chitosan combined with laminin demonstrates that the tube optimizes the nerve regeneration process during the initial phases of repair(83). Use of platelet-rich plasma in peripheral nerve repair Autologous blood-derived platelet-rich plasma (PRP) is defined as a volume of plasma with platelet concentration around five times above the physiologic levels(90). The platelets that constitute PRP are able to release various growth factors that are essential for the healing of lesions, such as the three platelet growth factor isomers (PDGF αα, ββ and αβ), VEGF, transforming growth factor (TGF-β 1 β2) and epithelial growth factor (EGF)(91,92). The platelets are also responsible for the synthesis and storage of BDNF(93). PRP has been used by areas such as oral and bu-

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comaxillofacial surgery for some time(94-96), and it has aroused considerable interest in cosmetic(97,98) and orthopedic(99,100) surgery. In experimental studies, PRP was used in peripheral nerve lesions, promoting remyelination in the facial(91) and sciatic nerve of rats(8). The application of PRP increases the number of nerve fibers after peripheral nerve lesions, and can produce a neurotrophic effect, stimulating the proliferation of Schwann cells and myelination, important components during peripheral nerve repair(6,101). Data in literature on the effect of PRP on peripheral nerve regeneration are scarce, which stimulates the search for more precise information about its performance. Therefore, this treatment should receive attention and be expanded, as it has the potential to become another safe option of low associated cost for the treatment of a wide variety of lesions and neuropathies in peripheral nerves.

CONCLUSION The concept of an ideal treatment to assist in nerve repair is based on the creation of synthetic tubes, preferentially bioabsorbable, covered by components of the extracellular matrix and that are appropriate for controlled release of one or more neurotrophic factors, bioactive elements or cells. The combination of two or more growth factors probably has a synergic effect on nerve regeneration, especially when they belong to different families and act by distinct mechanisms. In spite of the vast knowledge already acquired about these proteins in the improvement of nerve regeneration, more experimental studies are necessary before their use in clinical practice. The use of cells, whether actual Schwann cells or the stem cells obtained from varied sources, demonstrates considerable benefits in the repair of peripheral nerves, with great potential to become one of the most promising options at the clinic. Another interesting technique that has not yet been fully explored is the use of PRP, which releases autologous growth factors and serves as a carrier for other exogenous factors in nerve regeneration. Considering the evidence found, it was observed that a promising treatment is based on the combination of biological and synthetic elements for regeneration to be optimized and to provide better results. Rev Bras Ortop. 2011;46(6):643-49


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Rev Bras Ortop. 2011;46(6):643-49


ORIGINAL ARTICLE

CLINICAL AND RADIOLOGICAL EVALUATION ON DEVELOPMENTAL HIP DYSPLASIA AFTER SALTER AND OMBRÉDANNE PROCEDURE Válney Luiz da Rocha1, André Luiz Coelho Thomé2, Daniel Labres da Silva Castro2, Leandro Zica de Oliveira2, Frederico Barra de Moraes3

Abstract Objective: To evaluate the clinical and radiological mediumterm results from surgical treatment of developmental hip dysplasia through Salter innominate bone osteotomy and Ombrédanne femoral shortening. Methods: Fourteen patients were evaluated, with surgical treatment on 18 hips (seven right-side hips and eleven left-side hips) using the proposal technique, performed between 1998 and 2008. The Dutoit and Severin criteria were used respectively for clinical and radiographic evaluations. Results: The average preoperative index for the seven right-side hips was 43.3º (40º to 50º), and this was corrected through surgery to an average of 31.57º (24º to 42º). The average preoperative index for the eleven left-side hips was 42.1º (36º to 56º), and this was corrected through surgery to an average of 30.36º (20º to 44º). There was a statistically significant difference between the preoperative and postoperative acetabular indexes, with P < 0.05.

INTRODUCTION Developmental hip dysplasia (DHD) involves several abnormalities, which range from hip ligament laxity, leading to instability, to dislocation with loss of the anatomical relationship between the femoral head and the acetabulum. The femoral head can remain spherical or appear posteromedially flattened, and the acetabulum progressively becomes thick, shallow and oblique. It can be classified as teratologic and typical, and the latter is subdivided into dislocatable, subluxated and dislocated hip.

The clinical evaluation showed that there were seven excellent hips (38.9%), eight good ones (44.4%), three fair hips (16.7%) and no poor ones (0%). By grouping the hips rated good and excellent as satisfactory and those rated poor and fair as unsatisfactory, 83.3% of the results were seen to be favorable. There were no statistically significant correlations between occurrences of complications and patient age at the time of surgery or between complications and the preoperative acetabular index (p > 0.05). The complications observed consisted of one case each of subluxation, osteonecrosis and osteonecrosis together with subluxation. Conclusion: The combined procedure of Salter and Ombrédanne is a viable option for treating developmental hip dysplasia after patients have started to walk. Keywords - Hip Dislocation, Congenital/surgery; Surgical Procedures, Operative/methods; Bone Diseases, Developmental; Hip/growth & development

The etiology of DHD remains unknown. Ethnic and genetic factors are important. The genetic factors can determine acetabular dysplasia, ligament laxity, or both, as reported by Wynne-Davies(1). Mechanical factors, such as the intrauterine position and postnatal habits, are added to the preexisting factors. In several studies in scientific literature, the incidence of DHD has varied from 2 to 17 per 1,000(3). In Brazil, Volpon and Carvalho Filho(2) demonstrated an incidence of 2.31 per 1,000. The treatment depends on the patient’s age, on the

1 – Head of the Pediatric Orthopedics Clinic of Hospital de Acidentados – Goiânia and of the Pediatric Orthopedics Clinic of Hospital das Clínicas da Universidade Federal de Goiás (UFG) – Goiânia, GO, Brazil. 2 – Resident of the Orthopedics and Traumatology Department of Hospital das Clínicas da Universidade Federal de Goiás (UFG) – Goiânia, GO, Brazil. 3 – Master’s Degree, Assistant Professor of the Department of Orthopedics and Traumatology of Hospital das Clínicas da Universidade Federal de Goiás (UFG) – Goiânia, GO, Brazil. Study conducted at the Pediatric Orthopedics Clinic of the Department of Orthopedics and Traumatology of Hospital das Clínicas da Universidade Federal de Goiás (UFG) – Goiânia, GO. Mailing address: Dr. Frederico Barra de Moraes, Departamento de Ortopedia e Traumatologia e Cirurgia Plástica do HC-FMUFG, Primeira Avenida, Sem Número, 3° andar, Setor Universitário – 74605-085 – Goiânia, GO. Email: frederico_barra@yahoo.com.br Study received for publication: 5/31/2010, accepted for publication: 6/22/2011. The authors declare that there was no conflict of interest in conducting this work This article is available online in Portuguese and English at the websites: www.rbo.org.br and www.scielo.br/rbort

Rev Bras Ortop. 2011;46(6):650-55


CLINICAL AND RADIOLOGICAL EVALUATION ON DEVELOPMENTAL HIP DYSPLASIA AFTER SALTER AND OMBRÉDANNE PROCEDURE

degree of acetabular dysplasia and proximal femoral dysplasia. A surgical option for the treatment of DHD, after walking has started, is the association between Salter innominate bone osteotomy and Ombrédanne femoral shortening. This association is geared towards decreasing pressure in the femoral head that will be reduced surgically into the acetabulum, compensating the contracture of soft parts. The aim of this study is to evaluate the clinical and radiological medium-term result of the surgical treatment of DHD through the Salter procedure and Ombrédanne femoral shortening osteotomy.

MATERIALS AND METHODS Fourteen patients were evaluated, with surgical treatment on 18 hips between 1998 and 2008 by the Salter and Ombrédanne technique. None of the patients had received previous treatment for DHD, and they did not undergo postoperative physiotherapy or rehabilitation. The study was approved by the Research and Ethics Committee of the hospital where the trial was carried out. The age of the patients, who were all female, ranged from two to eight years, and four presented bilateral DHD. Seven right-side hips and 11 left-side hips were affected. The ideal acetabular index has an acceptable maximum value of 30°(3). The average postoperative immobilization time with pelvic-podalic plaster cast was 2.5 months. In the bilateral cases there was an average interval of six months between the two procedures. All the cases were operated by the same orthopedic surgeon (Figure 1). No preoperative traction was performed in any case. The osteosynthesis material used in the procedures was removed, on average, after one year of postoperative follow-up. The clinical and radiological evaluation occurred with average outpatient follow-up of 56 months (26 to 132 months). Clinical and radiographic criteria were used to evaluate the results. The radiographs were evaluated by the Severin criteria(3), which take into account the acetabular (AC) and Wiberg’s(4) CE angles, sphericity of the femoral head, dislocation or subluxation of the hip and the presence or absence of arthrosis. The clinical profile was analyzed by the criteria of Dutoit et al(5) based on hip stability and mobility, pain, lameness and the Trendelenburg test. The statistical analysis was conducted in a descrip-

651

tive and analytical manner, using the Student’s t, paired Student’s t, chi-square, ANOVA and Pearson methods, with the intention of establishing statistical significance between the clinical and radiological parameters.

RESULTS The hips were grouped for analysis according to the affected side. In the seven right-side hips, the preoperative index ranged from 40° to 50° (average of 43.3°), and was corrected through surgery to an average of 31.57° (24° to 42°), while the 11 left-sided hips had preoperative mean of 42.1° (36° to 56°), evolving to 30.36° (20° to 44°). The paired Student›s t-test was used to analyze these data, obtaining a statistically significant result (p < 0.001) (Figure 2). The clinical evaluation, according to Dutoit et al(5), showed seven excellent hips (38,9%), eight good hips (44.4%), three fair ones (16.7%) and no poor ones (0%). By grouping the hips rated good and excellent as satisfactory and those rated poor and fair as unsatisfactory, 83.3% of the results were seen to be favorable (Table 1). The radiological evaluation showed six excellent hips (33.3%) (Figure 3), 10 good hips (55.6%), no fair ones (0%) and two poor ones (11.2%). By grouping the hips rated good and excellent as satisfactory and those rated poor and fair as unsatisfactory, 88.9% of the results were seen to be favorable (Table 2). The complications observed consisted of one case each of subluxation, osteonecrosis and osteonecrosis together with subluxation, while the case of isolated subluxation was treated with another surgical procedure. There were no cases of infection, fracture, significant lower limb dysmetria or neurovascular lesion. Both the clinical picture, based on the criteria of Dutoit et al(5), and the radiological picture, according to Severin(3), were associated with the preoperative acetabular index. However, statistical relevance was not achieved. The clinical and radiological pictures were associated with one another by the chi-square test, yet no results with statistical value were obtained. After the data analysis, it was observed that the evaluation of pre- and postoperative acetabular indices presented statistical significance with p < 0.05. In applying the Student’s t-test, no statistical significance was obtained between the occurrence of complications and the patient’s age at the time of surgery, and the preoperative acetabular index (p > 0.05). Rev Bras Ortop. 2011;46(6):650-55


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Figure 1 â&#x20AC;&#x201C; Surgical technique: Salter innominate bone osteotomy and OmbrĂŠdanne femoral shortening. Rev Bras Ortop. 2011;46(6):650-55


CLINICAL AND RADIOLOGICAL EVALUATION ON DEVELOPMENTAL HIP DYSPLASIA AFTER SALTER AND OMBRÉDANNE PROCEDURE

653

Table 2 – Result of the radiological evaluation according to Severin(3).

45 40 35 30 25 20 15 10 5 0

Severin 1 – Excellent 2 – Good 3 – Fair 4 – Poor 5 – Poor 6 – Poor Total

6 10 0 1 1 0 18

% 33.34% 55.56% 0% 5.55% 5.55% 0% 100%

% 88.90 %

11.10 % 100 %

DISCUSSION Right Side

Left Side

Total

Preop Postop

Figure 2 – Distribution of the pre- and postoperative acetabular index according to the affected side of the hip. Table 1 – Result of the clinical evaluation according to Dutoit(5). Dutoit Excellent Good Fair Poor Total

7 8 3 0 18

% 38.90% 44.44% 16.66% 0.00 100%

% 83.34 % 16.66 % 100 %

The physical examination to identify cases of DHD should be carried out on a routine basis on all newborns. The Ortolani maneuver, described in 1948 by Marino Ortolani, when positive, allows the diagnosis of DHD; however, a negative result does not rule out the diagnosis, since some hips are unstable, yet not dislocated. The Barlow provocative maneuver allows the diagnosis of hip instability. On the other hand, in children over three months of age, the Ortolani maneuver can be negative, since even if the hip remains dislocated, it is no longer possible to place the femoral head in the acetabulum. As regards the Barlow maneuver, it should be emphasized that many newborns

Figure 3 – Radiological evolution of a female patient with DHD submitted to Salter and Ombrédanne osteotomy. Note the excellent radiological result after 41 months of postoperative follow-up. Rev Bras Ortop. 2011;46(6):650-55


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testing positive in the first examination become negative after two or three weeks. In the dislocated hip, the treatment consists of concentric and atraumatic reduction of the femoral head inside the acetabulum. Before the walking phase, this treatment can be conservative; however, as the infant starts to walk, there is a tendency for interposition of soft tissues (round ligament, labrum and capsule) in this joint and open reduction is necessary. Once reduction is obtained, this can be maintained through procedures in the acetabulum, in the femur, in the soft parts or in both. Lindstrom et al(6) demonstrated that, if concentric reduction is obtained and maintained, there will be remodeling of the acetabulum, which is more accentuated up to the age of four years and can occur up to the age of eight years. Severin(3) developed a system for radiological classification of the results of surgical procedures for the treatment of developmental hip dysplasia, evaluating deformities both of the head and of the neck and acetabulum, using Wibergâ&#x20AC;&#x2122;s CE angle and the presence of subluxation/dislocation in the postoperative period as a reference. Dutoit et al(5) developed a postsurgical clinical rating system based on joint mobility and stability and the presence of pain and/or lameness. Salter(7) described innominate bone osteotomy for the treatment of congenital dislocation and subluxation of the hip, promoting acetabular repositioning with the formation of a roof to support the femoral head after the reduction. Salter et al(8) reported that a reduction in which it is necessary to adopt an extreme position, with hyperflexion/abduction of the hip, tended to provoke avascular necrosis of the femoral head due to hyperpressure between the femoral head and acetabulum resulting from the action of the strong abductor muscles of the hip, promoting interruption of the blood supply to the proximal portion of the femur. They also concluded that this alteration evolved with severe complications for the patients affected, with significant worsening of their prognosis. Based on this finding, Klisic proposed the association of innominate bone osteotomy with femoral shortening. Klisic and Jankovic(9) analyzed, over a minimum period of five years, 60 hips of children aged between five and 15 years, submitted to the Salter procedure associated with femoral shortening, obtaining 3% of Rev Bras Ortop. 2011;46(6):650-55

excellent results (clinical and radiological) and 60% of good results. Klisic et al(10) monitored 225 hips submitted to innominate bone osteotomy (procedures of Salter, Pemberton or Chiari) associated with femoral shortening in children between seven and 15 years of age, with long follow-up, obtaining satisfactory general results, with good function and absence of pain. Santili(11), in a study of 42 hips, treated between two years and one month and 10 years and three months of age, with open reduction and Salterâ&#x20AC;&#x2122;s osteotomy associated with femoral shortening, referred to 47.6% of excellent results and 40.5% of good results. In this study, the satisfactory results (good and excellent) achieved clinically and radiologically were, respectively, 83.33% and 88.88%. Of the 18 hips included in this study, satisfactory clinical and radiological results were obtained in 83.33% and 88.9%, respectively; therefore there is concordance with the results of the other series. Taking into account the frequency, the degree of disability, the duration of the symptoms and morbidity, osteonecrosis is the most formidable complication of the treatment of DHD. Osteonecrosis occurs only in patients who have received some form of closed or open treatment. The positioning of the hip in abduction of more than 70° or forced medial rotation is a frequent cause of osteonecrosis. This can occur even in the normal hip, opposite to the one that is being treated. Therefore, hip immobilizations in an appropriate position and a careful open or closed reduction technique, observing the basic principles, can reduce the risk of this serious complication. Based on scientific literature(12), it is known that the Salter osteotomy is not exempt from complications, such as: superficial and deep infection, osteochondritis, subluxation, re-dislocation, chondrolysis, sciatic nerve praxis and avascular necrosis. With the intention of reducing the isolated complications related to acetabular osteotomy, mentioned above, the preferred procedure has been to associate the Salter osteotomy with femoral shortening. In this study, the complications were one case each of subluxation, osteonecrosis and osteonecrosis together with subluxation, where the isolated subluxation case was treated with another surgical procedure. There were no cases of infection, fracture, significant lower limb dysmetria or neurovascular lesion.


CLINICAL AND RADIOLOGICAL EVALUATION ON DEVELOPMENTAL HIP DYSPLASIA AFTER SALTER AND OMBRÉDANNE PROCEDURE

Some authors such as Galpin et al(13), Browne(14) and Gibson and Benson(15) prefer femoral osteotomy as a complement of open reduction. Other authors such as Karakas et al(16) and Williamson et al(17) associate femoral osteotomy with the Salter osteotomy after open reduction. Saleh et al(18) demonstrated that pelvic remodeling after innominate bone osteotomy was not observed in patients with skeletal maturity. In this study, the osteotomy was performed on patients between 2.23 and 7.78 years of age (post-walking age); neverthe-

655

less, there was no influence on the clinical and radiographic results in the medium term, according to the description provided by Volpon and Carvalho Filho(2).

CONCLUSION It is concluded that the Salter procedure in association with the femoral shortening osteotomy is a viable option for DHD treatment after the patient has started to walk, with satisfactory results both clinically and radiologically, presenting a low rate of complications.

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. Luxação congênita do quadril no recém nascido. Rev Bras Ortop. 1985;20(7):317-20. 3. 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(63):1-142. 4. Wiberg G. Studies on dysplastic acetabula and congenital subluxation of the hipjoint: with special reference to the complication of osteoarthritis. Acta Chir Scand. 1939;83:1-135. 5. Dutoit M, Moulin P, Morscher E. [Salter’s innominate osteotomy. 20 years later...]. Chir Pediatr. 1989;30(6):277-83. 6. 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. 7. Salter RB. Innominate osteotomy in treatment of congenital dislocation of the hip. J Bone Joint Surg. 1961;43:72-80. 8. Salter RB, Kostuik J, Dallas S. Avascular necrosis of the femoral head as a complication of treatment for congenital dislocation of the hip in young children: a clinical and experimental investigation. Can J Surg. 1969;12(1):44-61. 9. Klisic P, Jankovic L. Combined procedure of open reduction and shortening of the femur in treatment of congenital dislocation of the hips in older children. Clin Orthop Relat Res. 1976;(119):60-9.

10. Klisić P, Janković L, Basara V. Long-term results of combined operative reduction of the hip in older children. J Pediatr Orthop. 1988;8(5):532-4. 11. Santili C. Tratamento da subluxação e luxação congênita do quadril pelo método associado da operação de Salter com o encurtamento ósseo femoral. Análise dos resultados a longo prazo [tese]. São Paulo: Faculdade de Ciências Médicas, Santa Casa de São Paulo; 1996. 12. Haidar RK, Jones RS, Vergroesen DA, Evans GA. Simultaneous open reduction and Salter innominate osteotomy for developmental dysplasia of the hip. J Bone Joint Surg Br. 1996;78(3):471-6. 13. Galpin RD, Roach JW, Wenger DR, Herring JA, Birch JG. One-stage treatment of congenital dislocation of the hip in older children, including femoral shortening. J Bone Joint Surg Am. 1989;71(5):734-41. 14. Browne RS. The management of late diagnosed congenital dislocation and subluxation of the hip-with special reference to femoral shortening. J Bone Joint Surg Br. 1979;61(1):7-12. 15. Gibson PH, Benson MK. Congenital dislocation of the hip. Review at maturity of 147 hips treated by excision of the limbus and derotation osteotomy. J Bone Joint Surg Br. 1982;64(2):169-75. 16. Karakaş ES, Baktir A, Argün M, Türk CY. One-stage treatment of congenital dislocation of the hip in older children. J Pediatr Orthop. 1995;15(3):330-6. 17. Williamson DM, Glover SD, Benson MK. Congenital dislocation of the hip presenting after the age of three years. A long-term review. J Bone Joint Surg Br. 1989;71(5):745-51. 18. Saleh JM, O’Sullivan ME, O’Brien TM. Pelvic remodeling after Salter osteotomy. J Pediatr Orthop. 1995;15(3):342-5. Rev Bras Ortop. 2011;46(6):650-55


ORIGINAL ARTICLE

MECHANICAL STUDY ON DORSAL STABILITY OF INTRAMEDULLARY OSTEOSYNTHESIS ASSOCIATED WITH EXTERNAL FIXATION (ULSON’S METHOD)

Trajano Sardenberg1, Sérgio Swain Muller1, Daniel Ricardo Medeiros2, Pablo Luiz Baptistão2

Abstract Objective: To evaluate the Ulson intramedullary fixation method, with external fixation in which the level of the external locking of the Kirschner wires is varied, and without external fixation. Methods: Eighteen porcine tibias were used. Transverse osteotomy was performed in the region of the tuberosity, and two intramedullary Kirschner wires were inserted into each specimen, using three different assembly patterns: Group I: locking with external minifixator at a height of 3.0 cm; Group II: locking at a height of 4.5 cm;

INTRODUCTION Unstable and reducible extra-articular distal radius fractures can be treated with percutaneous pinning and the use of antebrachial-palmar plaster(1,2). The method proposed by Ulson combines intramedullary percutaneous pinning with two Kirschner wires, with external locking of these wires using an external minifixator(3). Severo et al(4) proposed modifications to the folding of the Kirschner wires, characterized by greater height of the site at which the wires are locked by the external mini-fixator, with the aim of facilitating flexion and extension movements of the wrist in the third week after surgery, and double folding of the medial wire, to facilitate its removal. However, increasing the distance between the connection with the bone and the external fixation can result in loss of stability of the assembly(5). The objective of this study was to mechanically

Group III: without external locking. Mechanical shear tests were then conducted, to determine the maximum load, proportionality limit and coefficient of rigidity. Results: There were no significant differences in maximum load or proportionality limit between the groups. The coefficient of rigidity was higher in Group II. Conclusion: The locking height for the Kirschner wires in Ulson’s method, within the limits evaluated, did not harm the stability of the fracture fixation system. Keywords - Radius Fractures; External Fixators; Biomechanics

evaluate the Ulson intramedullary fixation method associated with external fixation(3), varying the height of the external locking of the Kirschner wires.

METHODs Eighteen porcine tibias were used, from animals with an average age of six months, obtained from a slaughterhouse and preserved in a domestic freezer at -20°C for four to seven days. On the day of the mechanical tests, the anatomical pieces were defrosted at room temperature, the soft parts were removed, and transversal osteotomy was carried out in the region of the anterior tuberosity, with a manual saw. The orifice for insertion of the Kirschner wires (2 mm in diameter) was started off with an electric drill and completed manually. The Kirschner wires were locked with an external mini-fixator under manually applied tension.

1 – Professor, Botucatu School of Medicine – UNESP – Botucatu, SP, Brazil. 2 – Physician; Former Resident in Orthopedics and Traumatology of the Botucatu School of Medicine – UNESP – Botucatu, SP, Brazil. Study conducted at the Department of Surgery and Orthopedics of the Botucatu School of Medicine - UNESP. Mailing address: Departamento de Cirurgia e Ortopedia da Faculdade de Medicina de Botucatu – UNESP, Distrito de Rubião Junior s/n – 18603-970 – Botucatu, SP. Email: tsarden@uol.com.br Study received for publication: 5/31/2010, accepted for publication: 6/16/2011. The authors declare that there was no conflict of interest in conducting this work This article is available online in Portuguese and English at the websites: www.rbo.org.br and www.scielo.br/rbort

Rev Bras Ortop. 2011;46(6):656-59


MECHANICAL STUDY ON DORSAL STABILITY OF INTRAMEDULLARY OSTEOSYNTHESIS ASSOCIATED WITH EXTERNAL FIXATION (ULSON’S METHOD)

The intramedullary positioning of the wires was controlled by means of radiographic image. The test samples were divided into three groups, according to the type of assembly: Group I – intramedullary fixation with two Kirschner wires of 2 mm in diameter and locking with an external mini-fixator at a height of 3.0 cm (Figure 1A); Group II – intramedullary fixation with two Kirschner wires of 2 mm in diameter and locking with an external mini-fixator at a height of 4.5 cm; in this group, the medial wire was folded, as proposed by Severo et al(4) (Figure 1B); and Group III – intramedullary fixation with two Kirschner wires of 2 mm in diameter, folded and cut, maintained without external locking (Figure 1C). Figure 1 demonstrates the assemblies of groups I, II and III. The test samples were submitted to the mechanical shear test in a mechanical universal testing machine, with load cell of 1000 N and load application speed of 30mm/min. Figure 2 shows the system of fixation of the test sample and application of the load. After the test, the program of the machine coupled to a computer gave the values for mechanical maximum load (N), limit of proportionality (N), and coefficient of rigidity (N/mm). The values were submitted to statistical analysis by means of analysis of variance for one-factor model, complemented by Tukey’s test(6) (comparisons between mean pairs of groups). All the conclusions were described at a level of 5% significance (p < 0.05).

group I

RESULTS Tables 1 and 2 and Figures 3, 4 and 5 show the results. The statistical analysis indicated that in relation to maximum load and limit of proportionality, the behavior of experimental groups I, II and III was similar. On the other hand, for the coefficient of rigidity, the statistical analysis indicated that group II presented higher values than group I, which in turn, presented higher values than group III.

DISCUSSION The study carried out presents limitations in relation to the mechanical test method and material used. The shear test only tested the dorsal stability of the distal fragment of the fracture, and did not evaluate deviations in laterality, rotation and shortening. Tests to evaluate stability in relation to shortening would certainly enrich the study, since for the treatment of the distal radius fractures, this parameter is important for analyzing the results obtained. However, shortening of the radius is associated principally with osteoporosis, which was absent in the present study as it used bones from young pigs without osteoporosis. Porcine tibia, the material used for the fracture model, proved to be adequate, particularly for the measurements of the corticals of the metaphysiary and diaphysiary bones and the intramedullary canal. Therefore, the conclusions of the present study can only be considered in relation to stabilization of the extra-articular metaphysiary fracture in bone without osteoporosis, and in relation to dorsal deviation. Oliveira Filho et al(7), Saeki et al(8) and Pehlivan et al(9) performed experimental studies with methodological

group II

group III

4.5cm

3cm A

657

B

C

Figure 1 – Intramedullary fixation assemblies associated with external fixation of the test samples used in groups I, II and III. Rev Bras Ortop. 2011;46(6):656-59


Maximum load (N)

658

A

Group

Limit of proportionality (N)

Figure 3 – Mean and standard deviation of the values obtained for maximum load (N) in each experimental group.

B

Figure 2 – A) Test sample fixed in the mechanical universal testing machine for the shear test; B) Test sample at the end of the mechanical test.

Group

Variable Group I

Group II

Group III

Statistical result (p-value)

Maximum load (N)

337 ± 117a 396 ± 142a 245 ± 45a

p> 0.05 (p = 0.085)

Limit of proportionality (N)

285 ± 64a

269 ± 72a

207 ± 27a

p >0.05 (p = 0.105)

Coefficient of rigidity (N/mm)

38 ± 16ab

47 ± 17a

26 ± 6 b

p <0.05 (p = 0.031)

Table 2 – Statistical analysis of the results. Variable Maximum load (N) Limit of proportionality (N) Coefficient of rigidity (N/mm)

Rev Bras Ortop. 2011;46(6):656-59

Figure 4 – Mean and standard deviation of the values obtained for the limit of proportionality (N) in each experimental group.

Coefficient of rigidity (N/mm)

Table 1 – Mean and standard deviation of the variables by group.

Group

p = 0.031

Analysis of the results Group I ≅ group II ≅ group III Group I ≅ group II ≅ group III Group II > group I > group III

Group Figure 5 – Mean and standard deviation of the values obtained for the coefficient of rigidity (N/mm) in each experimental group.


MECHANICAL STUDY ON DORSAL STABILITY OF INTRAMEDULLARY OSTEOSYNTHESIS ASSOCIATED WITH EXTERNAL FIXATION (ULSON’S METHOD)

differences, in relation to the mechanical tests and the materials used, similar to the present study, which reveal the difficulties involved in performing the tests, and in comparing the results of biomechanical studies. The central idea of this study was to evaluate whether changes to the folding of the Kirschner wires in the Ulson method, used in the treatment of distal radius fractures, proposed by Severo et al(4), with the objective of facilitating the movement of the wrist and removal of the wire placed in the medial side of the radius, would be harmful to the stability of the fixation system. The results obtained indicated that there were no statistical differences in the mechanical parameters for maximum load and limit of proportionality evaluated in groups I, II and III. However, in relation to the mechanical property coefficient of rigidity, the results indicate that group II, with higher locking of the Kirschner wires and simpler folding of the medial wire, presented higher values than group I, which in turn, presented higher values than group III, in which the Kirschner wires were not locked. These results demonstrated that increasing the height of the locking site, and altering the fold of the medial wire, did not totally alter the stability of the system. The results obtained contradict the concept that the greater the distance between the connection with the bone and the fixation, the lower the stability of the assembly of the external fixators, as explained by Dell’Oca(5). These results indicate that within determined limits, it is possible to increase the height of the fixation site in the assembly without diminishing the stability of the system. Determining these limits will require mechanical tests with greater variations in fixation heights, or studies of theoretical engineering models, which did not form part of the present study. The mechanical property rigidity, evaluated in the present study by means of the coefficient of rigidity, indicates the capacity of the test sample to undergo deformation in response to the load applied, and that the more rigid the material, the smaller the resulting

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deformation caused by a determined load(10). The results obtained indicate that the most rigid system, i.e., that which deformed less in response to the applied load, was group II, with higher locking of the Kirschner wire and modification of the folding of the medial wire. However, it should be remembered that the values of group II were slightly higher than those of group I. In any case, these results contradict the mechanical concepts explained by Dell’Oca(5) in relation to the distance between the connection with the bone and the fixation in the external fixators. The model used in the present study, which is a combination of intramedullary fixation and external fixation, as well as the simpler and more direct folding of the medial wire in group II could, in theory, explain this apparent paradox, i.e., locking of the system further from the bone, and yet, greater rigidity. Experimental studies of intramedullary fixation with Kirschner wires in tubular bones of animals or artificial models presented controversial results, depending on variables such as diameter, number and angle of the wires, and diameter of the medullary canal of the test sample used in the tests(7-9), which makes comparison with the results obtained in the present study inappropriate. Comparing the conventional fixation by the Ulson method versus the fixation proposed by Severo et al(4) it is noted that there was no significant difference in any of the parameters studied. To obtain better mobility in flexion and extension movements of the wrist, and facilitate the removal of the wire placed in the medial side of the radius, it can be concluded that the assembly performed in group II (locking at a height of 4.5 cm) is clinically preferable.

CONCLUSION In the conditions of the present study, the height of the locking of the Kirschner wires using the Ulson method, within the limits evaluated, did not diminish the stability of the system.

REFERENCES 1. Albertoni WA, Faloppa F, Belotti JC. Tratamento das fraturas da extremidade distal do rádio. Rev Bras Ortop. 2002; 37(1/2):1-4. 2. Fernandez DL. Rádio distal / punho. In: Rüedi TP, Murphy WM. Princípios AO do tratamento de fraturas. São Paulo: Art Méd; 2002. p. 357-77. 3. Ulson HJR. Fraturas da extremidade distal do rádio e ulna. In: Pardini Jr AG. Traumatismo da mão. Rio de Janeiro: Medsi; 1985. p. 199-246. 4. Severo AL, Mentz L, Busetto MA, Lech O, Pinto S. Fraturas da extremidade distal do rádio tratadas pela técnica de Ulson. Rev Bras Ortop. 2003; 38(8):437-45. 5. Dell’Oca AF. Fixação externa. In: Rüedi TP, Murphy WM. Princípios AO do tratamento de fraturas. São Paulo: Art Méd; 2002. p. 233-47. 6. Zar JH. Biostatistical analysis. New Jersey: Prentice Hall; 1999.

7. Oliveira Filho OM, Mazer N, Barbieri CH, Moro CA. Avaliação mecânica de diferentes métodos de osteossíntese de ossos longos pequenos. Estudo “in vitro” em metacárpicos de porcos. Rev Bras Ortop. 1995; 30(1/2):69-74. 8. Saeki Y, Hashizume H, Nagoshi M, Tanaka H, Inoue H. Mechanical strength of intramedullary pinning and transfragmental Kirschner wire fixation for Colles’ fractures. J Hand Surg Br. 2001;26(6):550-5. 9. Pehlivan O, Kiral A, Mahirogullari M, Koksal O, Kaplan H. Four-point bending strength of transverse osteotomies stabilized with various Kirschner wire and tension band configurations. J Hand Surg Br. 2005;30(4):428-31. 10. Cozaciuc I, Silva LR, Togni MA. Telecurso 2000 profissionalizante, mecânica, ensaio de materiais. São Paulo: Globo; 2000. Rev Bras Ortop. 2011;46(6):656-59


ORIGINAL ARTICLE

Epidemiological Characteristics and Causes of Proximal Femoral Fractures among the Elderly

José Soares Hungria Neto1, Caio Roncon Dias2, José Daniel Bula de Almeida2

Abstract Objective: The social and economic cost of proximal femoral fractures is high, due the morbidity and mortality relating to the fracture itself, among other factors. Despite the importance of this issue, studies on this topic are still scarce in Brazil. This was a retrospective, observational and cross-sectional (ecological) study with the aims of outlining an epidemiological profile for proximal femoral fractures among the elderly and analyzing the causes of these fractures and the physical characteristics of patients admitted to a single university hospital in São Paulo. Methods: This was a study on medical records over a oneyear period, with group comparisons using the chi-square test; p < 0.05 was considered significant. Results: Ninety-four individuals were evaluated: predominantly female (2:1); 81-85 years of age; body mass index within normal limits; white and

IntroduCTION The number of elderly individuals aged 60 years or over (Brazilian legislation), has been increasing year by year, both in the world population and in Brazil. According to the Brazilian Institute of Geography and Statistics (IBGE), in 1950 there were about 204 million elderly individuals in the world; while in 1998, this group reached 579 million. The projections indicate that, in 2050, the elderly population will amount to 1.9 billion people. Nowadays, one in every 10 people is aged 60 years or over, and it is estimated that the worldwide ratio will be one to five in 2050. In Brazil, elderly people corresponded to 4.2% of the population in 1950, while in the year 2000, they

Asian patients (p < 0.05). The vast majority of the fractures occurred through low-energy trauma and inside the patients’ homes (p < 0.05). After excluding the trauma resulting from high-energy events, over 39% occurred as the patients were moving from sitting to standing up or were using stairs, and approximately 40% occurred while they were standing still or walking. A greater number of cases corresponded to the cold seasons of the year (p < 0.05); Conclusion: Most injuries occurred inside the patients’ own homes and had low-energy causes. Thus, some accidents might be avoided through simple low-cost measures that guide the elderly regarding situations of risk, which would bring major quality-of-life benefits and significant decreases in morbidity, mortality and the socioeconomic costs of this increasingly frequent problem. Keywords - Femoral Fractures; Aged; Epidemiology

represented 8.6% and, in 2020, are expected to correspond to 14%, or about 31 million people. This increase is mainly due to the better living conditions and to the constant advance of medicine, increasing the population’s life expectancy. However, this aging accompanies the problems of old age, such as proximal femoral fractures, a common and important cause of morbidity and mortality in this age bracket. Proximal femoral fractures in elderly individuals generally result from low-energy trauma, such as falls, and are related to various factors, such as: advanced age, osteoporosis, diminishing muscle strength, hip geometry, ingestion of calcium and vitamin D and ge-

1 – Adjunct Professor of the Santa Casa de São Paulo; Vice Dean of the Faculdade de Ciências Médicas da Santa Casa de São Paulo – São Paulo, SP, Brazil. 2 – Sixth-year Medical Student of the Faculdade de Ciências Médicas da Santa Casa de São Paulo – São Paulo, SP, Brazil. Study conducted at the Department of Orthopedics and Traumatology of the Faculdade de Ciências Médicas da Santa Casa de São Paulo, Pavilhão Fernandinho Simonsen da Irmandade da Santa Casa de Misericórdia de São Paulo. Mailing address: Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Ortopedia e Traumatologia, Rua Dr. Cesário Motta Jr., 112, Santa Cecília – 01221-020 – São Paulo, SP, Brazil. Email: jose.hungria@fcmscsp.edu.br Study received for publication: 10/12/2010, accepted for publication: 12/23/2011. The authors declare that there was no conflict of interest in conducting this work This article is available online in Portuguese and English at the websites: www.rbo.org.br and www.scielo.br/rbort

Rev Bras Ortop. 2011;46(6):660-67


EPIDEMIOLOGICAL CHARACTERISTICS AND CAUSES OF PROXIMAL FEMORAL FRACTURES AMONG THE ELDERLY

netic predisposition(1-11). Porter et al(12) demonstrated that the main factor that leads to an increase in the incidence of these fractures in the over-60 age bracket is the presence of osteoporosis, as well as the higher incidence of falls. Approximately one third of white women over 65 years of age have osteoporosis(13), and 30% of elderly women fall at least once a year(1). It is estimated that 6,000,000 individuals in the world will suffer a proximal femoral fracture in the year 2050(12). Sakaki et al(14) showed that 5.5% of patients with proximal femoral fracture die during their hospital stay; 4.6%, at the end of one month of follow-up; 11.9%, after three months; 10.8%, after six months; 19.2%, after a year; and 24.9%, after two years. Cunha and Veado(15) showed mortality of 25% in one year. Four factors are closely related to mortality: advanced age, number of comorbidities, male sex and presence of cognitive deficiencies(14). The social and economic cost of femoral fractures is high, and results, among other factors, from the morbimortality of the fracture itself and from the associated diseases, from a variable period of hospitalization, often in an intensive care unit, clinical and surgical care, besides rehabilitation programs over prolonged periods of time(16). And, in the period of one year, just 40.5% of the patients are totally independent in their activities of daily living(15). In spite of the importance of proximal femoral fractures, epidemiological studies involving this topic are still scarce in Brazil. The aim of this study is to outline an epidemiological profile of this type of fracture in elderly individuals, and to analyze its causes, studying the physical characteristics of the patients with this type of injury admitted to the Department of Orthopedics and Traumatology “Pavilhão Fernandinho Simonsen”, Irmandade Santa Casa de Misericórdia de São Paulo.

years of age, were excluded from the study. We gathered information on this group of patients through a study of their medical records, obtaining anthropometric data, age, sex and ethnicity, associated diseases and use of medications (Chart 1). The year was divided into four seasons, by quarter: fall (April, May and June 2004); winter (July, August and September 2004); spring (October, November and December 2004); and summer (January, February and March 2005). The number of fractures by season was added up in search of a possible seasonal variation. The analyses by age bracket were divided into five-year intervals for better processing of the gathered data and in order to facilitate the comparison with previous studies. The body mass index (BMI) was calculated in all the patients to analyze the possible existence of a more susceptible group, as well as ethnicity, the place where the fracture occurred, its cause, previous use of medications and other associated comorbidities. To analyze cause, the patients were divided into those with high and low-energy trauma. Accidents involving an external factor of impact, such as run over victims and falls from considerable heights (such as the roof), were considered high-energy traumas, while falls from own height or from stairs and patients who did not remember the occasion of the fracture (sought medical care due to pain with the verification of a fracture) were considered low- energy traumas. Chart 1– Data collection. Date of collection Hospital bed Name Age Sex

PATIENTS AND METHODS This was a retrospective, observational and cross- sectional (ecological) study. The inclusion criterion gathered all the patients with proximal femoral fractures over 59 years of age, who were hospitalized in the Department of Orthopedics and Traumatology “Pavilhão Fernandinho Simonsen”, Irmandade Santa Casa de Misericórdia de São Paulo, in the period between April 1, 2004 and March 31, 2005. Patients with this type of fracture, yet under 60

661

Color Weight Height Leg Date of accident Time of accident Date of hospitalization Time of hospitalization

 

Cause

       

Diseases

         

Medications

      Rev Bras Ortop. 2011;46(6):660-67


662

For statistical analysis we used the chi-square test, which compared the actual interval obtained with the expected interval, i.e., the expected value at which the cases are distributed mathematically equal to one another.

ResultS We reviewed the medical records of 94 patients, of whom 31 were men (33%) and 63 women (67%), demonstrating female predominance of 2:1 (Table 1). The mean age found was 78.2 years, with a standard deviation (SD) of 9.18. The calculated median resulted in 79 years (ranging from 60 to 101 years). We observed a statistical difference in terms of the patient’s age (p < 0.05), showing that the number of cases per age bracket did not exhibit homogeneous distribution. The highest number of proximal femoral fractures occurred in women between 81-85 years of age. As regards the men, fractures also predominated in the age bracket between 81-85 years (Figure 1), taking into account that in the bracket between 60-64 years, 50% of the cases were caused by high-energy trauma. Analyzing each one of the sexes individually, the age of the male patients averaged 75.5 years (SD of 10.1 and median of 77 years) while that of the female patients averaged 79.6 years (SD of 8.4 and median of 80 years). The patients’ mean body mass index (BMI = weight/ height2) was 22.6 kg/m2 (with 21.8 in the men and 22.9 in the women), keeping in mind that the range considered normal is 19 to 25 kg/m2. As regards ethnicity, it was observed that approximately 93.6% of the patients were white or Asian, against only 6.4% of blacks or individuals of mixed race (p < 0.05). Woman

Cases

Man

Age bracket

Figure 1 – Distribution of the number of cases according to sex and age bracket(years). Rev Bras Ortop. 2011;46(6):660-67

As regards comorbidities, 84% of the medical records contained personal history in the anamnesis; of these, 72% presented some comorbidity (p < 0.05), with 31.7% hypertensive and 16.5% diabetic patients, 8.9% with some neurological disease (Parkinson’s or Alzheimer’s, for example) and 13.9% presented a previous diagnosis of osteoporosis. In 79 medical records there is a description of the place where the fracture occurred. Of these, 73.4% suffered the trauma inside their own home (p < 0.05). There was a statistically significant difference (p = 0.026) between the patients’ location at the time of the trauma when separated by sex (42% of the men were outside the home, against 19% of the women) (Figure 2). Of the patients that suffered fractures in external environments, 73% of the cases in men occurred due to high-energy trauma, such as being run over by a vehicle or a fall from the roof, against just 20% of high-energy trauma among the women who were outside their own homes. A difference was observed in relation to the number of cases according to the month of the year (p < 0.05), with fractures predominating in June, July and August (Figure 3). As regards the seasonality of the proximal femoral fracture, grouping the months according to the respective seasons of the year, note the predominance of cases of proximal femoral fracture in the period corresponding to fall and to winter, recording 28 and 29 cases, respectively; during spring, we observed 17, and in summer there were 20 (Figure 4). These values did not demonstrate statistical significance (p = 0.215); yet when we associate the two coldest seasons (fall and winter) and compare them with the combination of the warmest seasons (spring and summer), we obtain statistical significance (p < 0.05). Evaluating just the cause of the fracture, of the 79 medical records that included this information, 87% had their trauma resulting from low energy (p < 0.05). Of these, 40.6% were due to falls when walking or even with the patient standing still, 27.5% of the fractures occurred while getting up (from bed, or from a chair or sofa), 11.6% were due to falls on staircases and 4.3% were caused by stumbling while walking (due to some kind of obstacle). It was also observed that of this group of patients, 26% of them experienced a sensation of dizziness or vertigo at the time of the accident (Figure 5).


EPIDEMIOLOGICAL CHARACTERISTICS AND CAUSES OF PROXIMAL FEMORAL FRACTURES AMONG THE ELDERLY

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Table 1 â&#x20AC;&#x201C; Results. Variable

Category

Man

Total

p

Age

Mean Standard deviation Median

Age bracket

60-64 65-70 71-75 76-80 81-85 86-90 > 90 Total

6 5 4 5 6 3 2 31

6.3 5.3 4.2 5.3 6.3 3.2 2.1 33

2 6 12 13 18 4 8 63

2.1 6.3 12.7 13.8 19.1 4.2 8.5 67

8 11 16 18 24 7 10 94

8.5 11.7 17 19.1 25.5 7.4 10.6 100

0.009

April May June July August September October November December January February March

2 4 5 5 3 3 1 0 2 1 3 2

2.1 4.2 5.3 5.3 3.2 3.2 1 0 2.1 1 3.2 2.1

5 5 7 9 9 0 4 4 6 1 8 5

5.3 5.3 7.4 9,5 9.5 0 4.2 4.2 6.3 1 8.5 5.3

7 9 12 14 12 3 5 4 8 2 11 7

7.4 9.5 12.7 14,8 12.7 3.2 5.3 4.2 8.5 2.1 11.7 7.4

0.031

Fall Winter Spring Summer

11 11 3 6

11.7 11.7 3.2 6.3

17 18 14 14

18 19.1 14.9 14.9

28 29 17 20

29.8 30.8 18.1 21.3

0.215

Fall + winter Spring + summer

22 9

23.4 9.8

35 28

37.2 29.8

57 37

60.6 39.4

0.039

Whites Blacks

29 2

30.8 2.1

59 4

62.8 4.3

88 6

93.6 6.4

< 0.05

73.4 26.6 100

< 0.05

Month

Season

Season

Ethnicity

Mean BMI Place*

%

Woman no. % 79. 6 8.4 80

no. 75.5 10.1 77

21.8

22.9

15 11 26

19 13.9 32.9

43 10 53

54.4 12.6 67.1

Place individualized by sex

At home On the street

15 11

57.7 42.3

43 10

81.1 18.9

Trauma*

High energy Low energy Total

8 18 26

10.1 22.7 32.9

2 51 53

2.5 64.5 67

Trauma individualized by sex*

High energy Low energy

8 18

30.7 69.2

2 51

3.7 96.2

Low-energy trauma

With dizziness or vertigo Without

Trauma + place*

High-energy at home

0

0

%

22.6

At home On the street Total

0

no. 78.2 9.18 79

0

58 21 79

0.026 10 69 79

12.6 87.3 100

< 0.05

< 0.05 18 51

26 73.9

0

0 Rev Bras Ortop. 2011;46(6):660-67


664 Variable

Category High-energy on the street Low-energy at home Low-energy on the street Total

8 15 3 26

10.1 19 3.8 32.9

Woman 2 2.5 43 54.4 8 10.1 53 67.1

10 58 11 79

High-energy at home High-energy on the street Low-energy at home Low-energy on the street

0 8 15 3

0 30.8 57.7 11.5

0 2 43 8

0 3.7 81.1 15.1

 

 

Low energy + place individualized by sex*

Low-energy at home Low-energy on the street Total

15 3 18

83.3 16.7 100

43 8 51

84.3 15.7 100

 

 

Low-energy trauma + cause*

Fall walking or standing still Fall in rising Fall from stairs Slipping Stumbling Others Total

 

Associated morbidities*

Without With

 

Associated morbidities*

Hypertension Diabetes Osteoporosis** Alzheimer's Parkinson's

4 1 1 3 1

Trauma + place individualized by sex*

Man

5.1 1.3 1.3 3.8 1.3

Total 12.6 73.4 13.9 100

p

 

 

28 19 8 8 3 3 69

40.6 27.5 11.6 11.6 4.3 4.3 100

 

 

22 57

27.8 72.1

< 0.05

25 13 11 4 3

31.7 16.5 13.9 5.1 3.8

 

21 12 10 1 2

26.6 15.2 12.7 1.3 2.5

* 79 of the 94 (84%) medical records contained the situation in which the trauma occurred ** Patients diagnosed with osteoporosis prior to the trauma

Men

On the street

On the street

Women

On the street

At home

At home

At home

Figure 2 – Location of the patients at the time of trauma: total and divided by sex.

DiscussION In this study we verified a mean body mass index (BMI) of 22.6 (without significant difference between men and women), i.e., the fractures occurred in people with BMI within the normal range (19-25) and not in overweight or obese people. This fact was also Rev Bras Ortop. 2011;46(6):660-67

observed by other authors(17-19). There are different hypotheses for this phenomenon: elderly individuals with a higher BMI generally present a larger quantity of muscle and fat tissue, with an increase of stress on the bone, leading to less mineral loss(18); moreover, the excess fat and greater musculature, present due to


EPIDEMIOLOGICAL CHARACTERISTICS AND CAUSES OF PROXIMAL FEMORAL FRACTURES AMONG THE ELDERLY

Cases Men

April

June

August

665

Cases Women

October

December

February

Figure 3 – Distribution of the number of cases according to sex and month.

Fall

Man

Woman

Winter

Spring

Summer

Figure 4 – Distribution of the number of cases according to sex and seasons.

Others Stumbling Slipped Fall walking or standing still Fall from stairs

Fall when rising Figure 5 – Cause of the low-energy fractures.

excess load, can act as a cushion for the hip, absorbing trauma in the region. In this study we observed predominance of proximal femoral fractures in the female population (2:1). Although similar studies always show a greater incidence among female subjects, the ratio differs quantitatively among them: a study also conducted in São Paulo showed a ratio of 3.3:1(17); in Uberaba, 1.3:1(2); another, in La Plata, Argentina, of 3.8:1(5); while in Oxford, England, the authors observed 3:1(20); and, in Rome, Italy, 4.5:1(21). The difference encountered between the sexes is partly explained by the reduced bone density in postmenopausal females(3). The mean age found was 78.2, similar to that found in the study also conducted in the city of São Paulo, where the age averaged 78.5(17) and in Belo Horizonte, averaging 79 years(15) and scarcely different from that conducted in Uberaba with mean age of 68 years(2). The female median of 80 years was also similar(2,17). The mean age in the males was lower (77 years), also similar to the abovementioned studies(5,17). Unlike other studies, in relation to the male sex, the authors did not find a considerable variation in the percentage of cases in the different age brackets, in fact there was a decrease in the incidence of fractures above the age of 85 years. But it is worth noting that the percentage of the male population decreases faster than the female population with age, and that, of the cases of younger male patients studied in this article (11 patients aged between 60 and 69 years, 35%), 56% had suffered high-energy trauma (such as falling from a roof). Rev Bras Ortop. 2011;46(6):660-67


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A low rate of fractures was observed in black patients (6.4% against 93.6% in the white population), similar to the value found in literature of 6.2%(2). An explanation for this occurrence is that blacks present greater bone mass accumulation, which must be related to the greater renal calcium reabsorption and resistance to the action of parathormone (PTH) on bone(22); in addition, according to some studies, black individuals exhibit lower levels of osteocalcin, of the bone fraction of alkaline phosphatase and of urinary hydroxyproline(23,24). A significant difference was observed between the sexes as regards the place where the patient suffered the facture: while 81% of the women were at home, only 58% of the men were also inside the home. But, considering only the cases of low-energy trauma, it is verified that 84% of the total patients experienced a fracture inside the home, with 83% of the cases involving male and 84% female patients, a very similar result between the sexes. This fact demonstrates that, if we remove high-energy trauma from the equation, most of the patients suffered the fracture inside their own homes (p < 0.05). Of the patients whose fractures occurred in external environments, 73% of the cases in men occurred due to high-energy trauma (patients run over by vehicles, falls from a roof, etc.) against just 19% of the women. All told, 87.3% of the fractures resulted from low- energy trauma, a result higher than the 73.5% found in literature(2). Analyzing just these fractures, it is verified that most of the patients fell while standing, either walking or standing still. This fall can often be associated with an episode of weakness or sensation of dizziness. It was also noticed that most of the patients fell while rising from a seated or lying position, connecting a lower percentage of fractures to minor accidents, such as falling from the stairs or stumbling. As regards the presence of comorbidities, it is known that individuals within the age bracket of this study, in general, already have some kind of disease and pharmacological dependence. This study showed that the patients already presented some associated disease, with hypertension, diabetes mellitus and osteoporosis predominating; it is also important to keep in mind that the same patient Rev Bras Ortop. 2011;46(6):660-67

can present more than one associated pathology, which is not uncommon. The seasonal variation in the incidence of femoral fractures is implied by the greater quantity of cases occurring in the period corresponding to winter (more specifically end of fall and winter). Some studies did not find this seasonal variation(25-28), but the result obtained was similar to that found in other studies(29-32). Although the cause of this variation is still uncertain, some explanations include a decrease in neuromuscular coordination and vitamin D deficiency in winter periods(33). This is due to the essential effect that vitamin D produces in calcium absorption, increasing it in the intestinal tract; moreover, there is an influence on bone deposition and resorption. Although this study did not feature an evaluation of daily physical activity, including a control group, it is important to emphasize that literature(18,34,35,36) shows a retrospective history of low daily physical activity in individuals with proximal femoral fracture in comparison to individuals from the group without the same fracture. Cooper et al(35) verified that, in both sexes, an increase in activity, including walks, climbing stairs, working in the house and in the garden, protects against these fractures. This is due to the increase of strength resulting from muscular demands above the basal level, resulting in a greater load on the bones and, consequently, an increase of bone mineral density, besides the fact that the actual muscle mass acts as local protection against trauma.

ConclusION In this study we observed a female predominance of 2:1 in patients with mean age of 78.2 years, with a greater risk especially for the age bracket of 81-85 years. The mean body mass index (BMI) observed was 22.6 kg/m2. We also verified the prevalence of fractures in white individuals and in patients with one or more associated comorbidities. There was a predominance of fractures in colder periods of the year (fall and winter). Most fractures occurred inside the patientsâ&#x20AC;&#x2122; own homes and were due to low-energy trauma. Of the patients whose fractures occurred due to low-energy trauma, note that more than 38%


EPIDEMIOLOGICAL CHARACTERISTICS AND CAUSES OF PROXIMAL FEMORAL FRACTURES AMONG THE ELDERLY

of the accidents could have been avoided, as they occurred when the patient was rising from a seated or lying position or was using the stairs. To this end, simple and economical epidemiological measures that counsel and instruct the elderly population to rise cautiously (from bed in the morning, or from a chair, or while getting out of the car), and to be

667

more careful while descending stairs, can reduce the incidence of proximal femoral fractures by approximately 40%, bringing substantial benefits in the quality of life of the elderly population, besides producing an enormous decrease of morbimortality and of the socioeconomic costs of this increasingly frequent problem.

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ORIGINAL ARTICLE

Analysis on the modified Lysholm functional protocol among patients with normal knees

Rodrigo Pires e Albuquerque1, Vincenzo Giordano2, Alexandre Calixto3, Felipe Malzac3, Carlomã Aguiar3, Ney Pecegueiro do Amaral4, Antônio Carlos Pires Carvalho5

Abstract Objective: To evaluate the modified Lysholm protocol among patients with knees that were considered to be normal (without previous complaints or pathological conditions in this region). Method: Between January 2010 and March 2010, a prospective study was conducted on 300 patients with orthopedic complaints in other regions of the body who came to the emergency service of our hospital. The inclusion criterion among these patients was the absence of complaints or previous surgery in the knee that was considered to be dominant. The age range was from 16 to 40 years, with an average of 28.8 years. Our study group consisted of 153 males and 147 females. In the modified Lysholm system, the maximum score is 100 points and this includes functional and objective

IntroduCTION Numerous systems have been developed recently to evaluate the pre- and postoperative condition of patients who are submitted to surgical procedures in the knee region. The protocol format can vary, but is usually based on functional and clinical evaluations. O’Donoghue was the first to apply a metric scale system for the evaluation of postoperative results(1). The concern about documenting results and being able to compare them validly with those obtained by

criteria. Altogether, 50% of the total score is based on symptoms of pain and instability. Results: The average score using the Lysholm protocol was 95 points in the knees that were considered normal. Males had higher scores than females. Conclusion: These patients with knees that were considered normal did not achieve the maximum score when evaluated using the modified Lysholm protocol. This study suggests that this line of research on functional evaluation systems for the knee is open for further evaluations. Moreover, creation and development of new forms of functional assessment for the knee should be investigated in order to achieve a worldwide consensus. Keywords - Knee; Follow-Up Studies; Evaluation 

other colleagues appears to us to be the major motivation for the use of formal evaluation systems. Thus, we observed a wide variety of possible methods of evaluation of surgical procedures at the level of the knee in the literature investigated. Among which we proposed an evaluation of the modified Lysholm score(2) (Attachment 1). The choice of this scoring system was based on the modified Lysholm protocol as it is one of the protocols used most often in literature, and, until the start of the survey, the only one validated in Brazil(3). The authors’ goal was

1 – Master’s and Doctor’s degree in Medicine; Orthopedist and Coordinator of the Knee Surgery Division of the Serviço de Ortopedia e Traumatologia Professor Nova Monteiro – Hospital Municipal Miguel Couto (SOT-HMMC) – Rio de Janeiro, RJ, Brazil. 2 – Master’s degree in Medicine; Orthopedist and Coordinator of the Medical Residency Program of the Serviço de Ortopedia e Traumatologia Professor Nova Monteiro – Hospital Municipal Miguel Couto (SOT-HMMC) – Rio de Janeiro, RJ, Brazil. 3 – Master’s degree in Medicine; Orthopedist, Collaborator of the Serviço de Ortopedia e Traumatologia Professor Nova Monteiro – Hospital Municipal Miguel Couto (SOT-HMMC) – Rio de Janeiro, RJ, Brazil. 4 – Head of the Serviço de Ortopedia e Traumatologia Professor Nova Monteiro – Hospital Municipal Miguel Couto (SOT-HMMC) – Rio de Janeiro, RJ, Brazil. 5 – Master’s degree and Doctor’s degree in Medicine; Associate Professor of the Department of Radiology of Universidade Federal do Rio de Janeiro – Rio de Janeiro, RJ, Brazil. Study conducted at the Serviço de Ortopedia e Traumatologia Professor Nova Monteiro – Hospital Municipal Miguel Couto (SOT-HMMC) – Rio de Janeiro, RJ, Brazil. Mailing address: Av. Henrique Dodsworth, 83, ap. 105, Copacabana – 22061-030 – Rio de Janeiro, RJ, Brazil. Email: rodalbuquerque@ibest.com.br Study received for publication: 12/29/2010, accepted for publication: 3/25/2011. The authors declare that there was no conflict of interest in conducting this work This article is available online in Portuguese and English at the websites: www.rbo.org.br and www.scielo.br/rbort

Rev Bras Ortop. 2011;46(6):668-74


ANALYSIS ON THE MODIFIED LYSHOLM FUNCTIONAL PROTOCOL among patients with normal knees

to evaluate the modified Lysholm scoring system in patients with knees considered normal, i.e., without complaints or previous pathologies in this region.

METHOD To apply the modified Lysholm scoring system, we prospectively evaluated 300 patients who appeared at the emergency department of our hospital with orthopedic complaints in other body regions. Of these, 153 were men and 147 women with a mean age of 28.8 years (16 to 40 years), involving 248 right knees and 52 left knees. The age criterion was imposed as we know that patients over 40 years of age present a greater risk of knee osteoarthritis, which could mask our functional evaluation. The criterion of inclusion

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of the patients was absence of complaints or previous surgery on the knee considered dominant. The group was evaluated by a single physician, member of the Brazilian Society of Knee Surgery and with a postgraduate degree (master’s), performing bilateral radiographic exam and exhaustive clinical examination, searching for meniscal, ligament and patellofemoral pathologies. In the modified Lysholm system the maximum score is 100 points, in which: 91 to 100 points is considered excellent; 84 to 90, good; 65 to 83, fair; and 64 or less, unsatisfactory. Lysholm’s system is an evaluation system that includes three functional criteria and five subjective criteria. All told, 50% of the total score is based on the symptoms of pain and instability(2). The descriptive analysis presented the

Attachment 1 – Modified Lysholm.

Modified Lysholm limp (5 points)

None = 5 Slightly or periodically = 3 Severe or constant = 0

Support (5 points)

None= 5 Limp = 2 Weight-bearing impossible = 0

Locking (15 points)

No locking or crepitation sensation = 15 “Catching” sensation but no locking sensation = 10 Occasional locking = 6 Frequently = 2 Locked joint on examination = 0

Instability (25 points)

Has never presented buckling = 25 Rarely during sports activities or other exertion = 20 Frequently during sports activities or other exertion = 15 Occasionally in daily living activities = 10 Frequently in daily living activities = 5 With every step = 0

Pain (25 points)

None = 25 Inconstant and slight during severe exertion = 20 Marked during severe exertion = 15 Marked on or after walking 2 km or more = 10 Marked on or after walking less than 2 km = 5 Constant = 0

Joint effusion/swelling (10 points)

None = 10 On severe exertion = 6 On slight exertion = 2 Constant = 0

Stair climbing (10 points)

No problem = 10 Slightly impaired = 6 Step by step (one stair at a time) = 2 Impossible = 0

Squatting (5 points)

No problem = 5 Slightly impaired = 4 Up to 90 degrees = 2 Impossible = 0

TOTAL COUNT Result (first letter) Excellent: 91-100

Good: 84-90

Fair: 65-83

Poor: < or = 64

Source: Tegner Y, Lysholm J. Rating systems in the evaluation of the knee ligament injuries. Clin Orthop 1985;198:43-9. Rev Bras Ortop. 2011;46(6):668-74


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observed data in table form, expressed in the form of frequency (n) and percentage (%) for the individual aspects and general classification of the modified Lysholm system, and of mean ± standard deviation and median for age (in years) and total score (in points), together with illustrative graphs. Aiming to verify whether there is a significant difference in the individual aspects, general classification and total score of the modified Lysholm system between sexes, we considered the following tests: χ2 or Fisher’s exact test for categorical factors and the Student’s t-test for independent samples or the Mann-Whitney test (total score) for numerical variables. The homogeneity of variance was verified by Levene’s test. The significance determination criterion adopted was the level of 5%. The statistical analysis was processed by the statistical software SAS® System, version 6.11.

Table 2 – Distribution of aspects and general classification of the modified Lysholm system. Modified Lysholm

Limp

Support

Squatting

Stair climbing Joint effusion/ swelling

Locking

RESULTS Tables 1 and 2 provide the frequency (n) and the percentage (%) of the clinical characteristics and of the individual aspects and the general classification of the modified Lysholm score, respectively. The age and the total modified Lysholm score (in points) were expressed through mean ± standard deviation and median. The analysis observed that 26% of the individuals exhibited some type of impairment, i.e., did not reach the maximum score, whereas 9.3% obtained a fair or poor result (Figure 1). The survey verified that 42.7% of the individuals exhibited some type of symptom related to the lock-

Pain

Instability

General classification

Table 1 – Description of the characteristics of the general sample. Variable

Category

n

%

Male

153

51.0

Female

147

49.0

Right

248

82.7

Left

52

17.3

Sex

Knee (side)

Age (years)* * Expressed in mean ± SD – median. Source: SOT-HMMC, 2010. Rev Bras Ortop. 2011;46(6):668-74

29.3 ± 6.1 – 29

General classification (grouped)

Category

n

%

Severe or constant

1

0.3

Slightly

7

2.3

None

292

97.4

Limp

14

4.7

None

286

95.3

Impossible

1

0.3

Up to 90 degrees

1

0.3

Slightly impaired

24

8.0

No problem

274

91.4

Slightly impaired

39

13.0

No problem

261

87.0

On severe exertion

39

13.0

None

261

87.0

Occasional

8

2.7

“Catching” sensation

120

40.0

None

172

57.3

On walking 2 km or more

8

2.7

On severe exertion

26

8.7

Inconstant or slight

88

29.3

None

178

59.3

Occasionally in daily activities

5

1.7

Rarely during sports activities

16

5.3

Has never presented buckling

279

93.0

Excellent

222

74.0

Good

50

16.7

Fair

27

9.0

Poor

1

0.3

Excellent

222

74.0

Not excellent

78

26.0

Total score (points)*

93.2 ± 6.9 – 95

* Expressed in mean ± SD – med ian.

ing aspect; followed by the pain aspect, with 40.7%; and climbing stairs, with 13%. The analysis suggests that, although the individuals do not have a diagnosed prior or current pathology, they already present some symptomatology, not obtaining the maximum concept of the score (Figure 2).


ANALYSIS ON THE MODIFIED LYSHOLM FUNCTIONAL PROTOCOL among patients with normal knees

Table 3 provides the frequency (n) and the percentage (%) of the individual aspects and the general classification of the modified Lysholm according to sex (male and female) and the corresponding descriptive level (p value) of the statistical test. The statistical analysis was composed of the χ2 or Fisher’s exact tests for the individual aspects and general classification and by the Student’s t-test for independent samples and the Mann-Whitney test (total score). The study observed that there is no significant difference in the individual aspects, in the general classification and in the total score of the modified Lysholm between the sexes, at the level of 5%.

Table 3 – Analysis of the individual aspects and general classification of the modified Lysholm system according to sex. Modified Lysholm

%

Severe or constant

0

0.0

1

0.7

Slightly

3

2.0

4

2.7

None

150

98.0

Limp

8

5.2

None

145

94.8

Impossible

1

0.7

0

0.0

Up to 90 degrees

0

0.0

1

0.7

Slightly impaired

11

7.2

13

8.8

No problem

141

92.2

133 90.5

Slightly impaired

18

11.8

21

No problem

135

88.2

126 85.7

Joint effusion/ On severe exertion 24 swelling None 129

15.7

15

84.3

132 89.8

Limp

Support

Squatting

64

41.8

56

38.1

None

83

54.3

89

60.5

On walking 2 km or more

3

2.0

5

3.4

On severe exertion

15

9.8

11

7.5

Inconstant or slight

44

28.8

44

29.9

None

91

59.5

87

59.2

Occasionally in daily activities

3

2.0

2

1.4

Rarely during sports activities

7

4.6

9

6.1

Has never presented buckling

143

93.5

136 92.5

Excellent

110

71.9

112 76.2

General classification

Good

26

17.0

24

16.3

Fair

17

11.1

10

6.8

Poor

0

0.0

1

0.7

General classification (grouped)

Excellent

110

71.9

112 76.2

Not excellent

43

28.1

35

Age (years)

Mean ± SD – Median

29.6 ± 5.8 – 29

Total score (points)

Mean ± SD – Median

7.0

13.0 13.0

Pain

40.7

Locking

42.7 0

5

10

15

20

25

30

35

40

45

50

% of individuals with symptoms

Figure 2 – Decreasing distribution of individuals with some type of symptom related to the aspects of the modified Lysholm protocol (%).

10.2

“Catching” sensation

4.7

Effusion/ swelling Stair climbing

14.3

1.4

Instability

8.6

141 95.9

2

2.6

Agachamento

4.1

3.9

Figure 1 – Distribution of the general classification of the modified Lysholm protocol.

Instability

6

6

Pain

0.58

142 96.6

Occasional Locking

Support

a

n

Poor

Limp

Female (n = 147) p value

%

Excellent

Fair

Category

Male (n = 153) n

Stair climbing

Good

671

23.8

0.63

0.63

0.51

0.15

0.27

0.78

0.75

0.41

0.39

29.1 ± 6.4 – 28

0.47 b

92.9 ± 6.7 – 92.4 ± 7.0 95 – 95

0.42 c

a 2

χ test or Fisher’s exact test. Student’s t-test for independent samples. c Mann-Whitney test. b

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DISCUSSION There is a vast amount of scientific production relating to surgical procedures on the knee; nevertheless, it is difficult to compare results between different students. When we specifically compare the knee evaluation systems, we observe various studies with results of non-concordance between systems(4-6). However, we can still find some authors today who do not use knee scoring systems to evaluate the clinical follow-up of their patients(7). We believe that such a difficulty is due to the fact that the available evaluation systems are not completely satisfactory. The IKDC presents very interesting characteristics, as it aims to perform a subjective, objective and functional assessment(8). Although it initially appears to be a perfect system, we observed some deficiencies in its use. Its final result is represented by the worst result of all the sub-items investigated. Thus the patient’s overall evaluation is very radically penalized, often not reflecting their functional level. Abdalla et al(9) concluded that the Cincinnati system was superior to the other two studied, namely, Lysholm and IKDC. They compared two groups: one group six months after ACL reconstruction surgery and the other composed of volunteers without previous knee injuries. In the evaluation of the Lysholm and Cincinnati questionnaires, they observed similar results between both groups. The evaluation of the IKDC protocol presented inferior rating results in comparison to the other two questionnaires. Moreover, it rated 46.6% of the group without previous injury as subnormal and abnormal, corroborating our opinion that the IKDC protocol evidencing a poor result in a subgroup penalizes the final evaluation. Brinker et al(10) conducted a study with 91 athletes without previous knee injuries and compared four systems: IKDC, Lysholm, Feagin & Blake and HSS. The IKDC presented non-concordant results that were of inferior value when compared to the other three protocols, and only 60% of these athletes without previous knee injuries were rated normal. Our survey is consistent with this affirmation and observes that so-called normal patients do not reach the maximum rating in the Lysholm score. Sernert et al(11) evaluated 527 patients submitted to ACL reconstruction with the IKDC protocol. They Rev Bras Ortop. 2011;46(6):668-74

concluded that the IKDC protocol is valid and useful for evaluating ACL reconstructions. However, when we observed the outcome of the survey, just 33.6% of the patients were considered with a normal score, evidencing the stringent evaluation criterion of the IKDC. In the middle of the preparation of our study, the IKDC was validated in Brazil; however, due to its stringent final evaluation system, we decided not to use it(12). McAllister et al(13) compared elite university athletes with and without ACL injury with the Lysholm and Tegner systems, two subjective items of the IKDC and the SF-36 protocol. There was no statistically significant difference, except for the IKDC. Our opinion is based on the fact that patients with ACL injury present repeated buckling, generating a lower functional assessment score. Consequently, we decided to evaluate only patients with normal knees. Lysholm and Gillquist(14), when comparing their evaluation system with that of Larson, emphasized its specificity in measuring the functional level more adequately, as it expresses the patient’s opinion about their own knee. In the use of this system, they concluded that, besides adequately assessing functional level, it was easy for patients to understand and apply, confirming what we observed in our study on Lysholm’s modified protocol. Tegner and Lysholm(2) assessed 76 patients with ACL injury and compared the modified Lysholm protocol with the Hospital for Special Surgery’s first form. Binary questions, requiring answers such as “yes” or “no”, provided less detail than the modified Lysholm scale. They concluded that the stability test, performance test, functional score and activity level should not be included in the same scoring scale. They believe that each assessment was important at different times during the treatment of the ligament injury, and that they should therefore be analyzed separately. When we compared this with our study, we observed that the modified Lysholm system appropriately classifies patients without previous knee injury as “excellent”, yet we did not verify the maximum score obtained. Sgaglione et al(15) compared four knee rating systems: score of the Hospital for Special Surgery, Lysholm, Tegner and Cincinnati. They concluded, in comparing the Lysholm test with other methods, that it is of a subjective nature as regards functional as-


ANALYSIS ON THE MODIFIED LYSHOLM FUNCTIONAL PROTOCOL among patients with normal knees

sessment of the knee, and that when in use it should be associated with another method. They support the use of a protocol with subjective, objective and functional assessment, with individualized rather than general results. We agree with this conclusion, as we believe that a subjective, objective and functional assessment creates a more complete scoring system and a more precise evaluation. We used the modified Lysholm system as it is one of the knee evaluation systems used most often in literature and the only one validated in Brazil when we started our survey. HĂśher et al(16), in their study, assessed 61 patients one year after ACL reconstruction and compared the result of the Lysholm protocol self-administered by the patient compared to that applied by the examiner, and also draw our attention to the fact that the examiner could influence the functional assessment result, since they are usually involved in the survey in question. They confirm our opinion that the knee assessment protocol should be composed of a subjective, objective and functional component to reduce examiner interference. We believe that the examiner should be the one to conduct the survey, as a layman would not know how to distinguish between buckling or locking investigated in the modified Lysholm protocol. There are scoring systems in which the method of assessment is visual analogue. This method of evaluating subjective findings has proven efficacy(17); however, we observed some difficulties in its application. As it is a scale, the patientâ&#x20AC;&#x2122;s understanding of the test requires notions of mathematics and proportion, skills usually acquired at school. In our group we found a large number of patients with a low level of education, to whom the understanding of the test would require several explanations by the examiner. In these eventualities it was clear how the final score can be influenced by external interferences(16,18), which, in our opinion, is the main disadvantage of this kind of system. Labs and Paul(5), in a prospective study of 56 patients with ACL reconstruction, compared eight knee rating systems. In analyzing the results of the knee rating systems, they concluded that they are incomparable, since there are individual variations of the subjective, objective and functional parameters. They observed that there is frequently disagreement betwe-

673

en subjective satisfaction and objective results. As regards sex, we perceived that the functional assessment score of the women was lower than that of the men, probably due to the greater patellofemoral complaint and more accentuated genus valgum. Aiming to decrease the bias(19), our survey was conducted by only one examiner experienced in the use of this scoring system. On the other hand, Demirdjian et al(20) carried out a semiological evaluation using some colleague or another with a different degree of experience. We believe that this study loses its credibility and that the likelihood of errors increases. The inclusion criteria used in our survey were: absence of complaints or previous surgery on the knee considered dominant. As regards possible knee symptoms, anything that could limit the functional assessment was considered relevant. We emphasize that crepitation in the patellofemoral joint, or pain at the femorotibial interline, were not exclusion criteria, as in our understanding, they are hardly trustworthy findings for defining a knee as abnormal. In our study, no patient was excluded due to symptoms in the knee. Moreover, we executed a bilateral radiographic evaluation in which we compared the knees for better functional analysis. Complaints of pain, locking and climbing stairs were mentioned the most often, respectively. Previous pain in the knee was the main cause of these findings, since it is the main complaint of the population in general(21). Briggs et al(22) conclude that even a high level athlete might not achieve the score of excellent, an opinion corroborated by us. The study suggests that this line of research on knee rating systems is open for new studies. Furthermore, we should investigate the creation and the preparation of new knee assessment forms to obtain a consensus on a better knee assessment scoring system.

CONCLUSION The patients with knee considered normal did not obtain the maximum score in the assessment by the modified Lysholm protocol. The study suggests that this line of research on systems for functional knee assessment is open to further evaluation. In addition, we should investigate the creation and the preparation of new functional knee assessment forms to obtain a worldwide consensus. Rev Bras Ortop. 2011;46(6):668-74


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ReferEncEs 1. O’ Donoghue DH. An analysis of end results of surgical treatment of major injuries to the ligaments of the knee. J Bone Joint Surg Am. 1955;37 A(1):1-13. 2. Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. 1985;(198):43-9. 3. Peccin MN, Ciconelli R, Cohen M. Specific questionnaire for knee symptomsThe Lysholm knee scoring scale- Translation and validation into Portuguese. Acta Ortop Bras. 2006;14(5): 268-72. 4. Hrubesch R, Rangger C, Reichkendler M, Sailer RF, Gloetzer W, Eibl G. Comparison of score evaluations and instrumented measurement after anterior cruciate ligament reconstruction. Am J Sports Med. 2000;28(6):850-6. 5. Labs K, Paul B. To compare and contrast the various evaluation scoring systems after anterior cruciate ligament reconstruction. Arch Orthop Trauma Surg. 1997;116(1-2):92-6. 6. Bollen S, Seedhom BB. A comparison of the Lysholm and Cincinnati knee scoring questionnaires. Am J Sports Med. 1991;19(2):189-90. 7. Johnson DS, Smith RB. Outcome measurement in the ACL deficient knee-what’s the score? Knee. 2001;8(1):51-7. 8. Hefti F, Müller W. [Current state of evaluation of knee ligament lesions. The new IKDC knee evaluation form ]. Orthopade. 1993;22(6):351-62. 9. Abdalla RJ, Camanho GL, Cohen M, Forgas CR, Monteiro CG, Jeremias SL, Mosconi FV. Estudo comparativo entre os questionários de avaliação funcional do joelho: IKDC, Cincinnati e Lysholm. Rev Joelho. 2001;1(1): 11-4. 10. Brinker MR, Garcia R, Barrack RL, Timon S, Guinn S, Fong B. An analysis of sports knee evaluation instruments. Am J Knee Surg. 1999 Winter;12(1):15-24. 11. Sernert N, Kartus J, Köhler K, Stener S, Larsson J, Eriksson BI, Karlsson J. Analysis of subjective, objective and functional examination tests after anterior cruciate ligament reconstruction. A follow-up of 527 patients. Knee Surg Sports Traumatol Arthrosc. 1999;7(3):160-5.

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12. Metsavaht L, Leporace G, Riberto M, de Mello Sposito MM, Batista LA. Translation and cross-cultural adaptation of the Brazilian version of the International Knee Documentation Committee Subjective Knee Form: validity and reproducibility. Am J Sports Med. 2010;38(9):1894-9. 13. McAllister DR, Tsai AM, Dragoo JL, McWilliams J, Dorey FJ, Hame SL, et al. Knee function after anterior cruciate ligament injury in elite collegiate athletes. Am J Sports Med. 2003;31(4):560-3. 14. Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med. 1982;10(3):150-4. 15. Sgaglione NA, Del Pizzo W, Fox JM, Friedman MJ. Critical analysis of knee ligament rating systems. Am J Sports Med. 1995;23(6):660-7. 16. Höher J, Bach T, Münster A, Bouillon B, Tiling T. Does the mode of data collection change results in a subjective knee score? Self-administration versus interview. Am J Sports Med. 1997;25(5):642-7. 17. Flandry F, Hunt JP, Terry GC, Hughston JC. Analysis of subjective knee complaints using visual analog scales. Am J Sports Med. 1991;19(2):112-8. 18. Roos EM. Outcome after anterior cruciate ligament reconstruction—a comparison of patients’ and surgeons’ assessments. Scand J Med Sci Sports. 2001;11(5):287-91. 19. Galli M, De Santis V, Tafuro L. Reliability of the Ahlbäck classification of knee osteoarthritis. Osteoarthritis Cartilage. 2003;11(8):580-4. 20. Demirdjian AM, Petrie SG, Guanche CA, Thomas KA. The outcomes of two knee scoring questionnaires in a normal population. Am J Sports Med. 1998;26(1):46-51. 21. Lubowitz JH, Bernardini BJ, Reid JB 3rd. Current concepts review: comprehensive physical examination for instability of the knee. Am J Sports Med. 2008;36(3):577-94. 22. Briggs KK, Steadman JR, Hay CJ, Hines SL. Lysholm score and Tegner activity level in individuals with normal knees. Am J Sports Med. 2009;37(5):898-901.


ORIGINAL ARTICLE

Randomized prospective study on traumatic patellar dislocation: conservative treatment versus reconstruction of the medial patellofemoral ligament using the patellar tendon, with a minimum of two years of follow-up Alexandre Carneiro Bitar1, Caio Oliveira D’Elia1, Marco Kawamura Demange2, Alexandre Christo Viegas3, Gilberto Luis Camanho4

Abstract Objective: The aim of this study was to compare the surgical results from reconstruction of the medial patellofemoral ligament (MPFL) with non-operative treatment of primary patellar dislocation. Methods: Thirty-nine patients (41 knees) with patellar dislocation were randomized into two groups. One group was treated conservatively (immobilization and physiotherapy) and other was treated surgically with reconstruction of the MPFL, and the results were evaluated with a minimum follow-up of two years. The Kujala questionnaire was applied to assess pain and quality of life, and recurrences were evaluated. Pearson’s chi-square test and Fisher’s exact test were used in the statistical evaluation. Results: The statistical analysis showed that the mean Kujala score was significantly lower in the conservative group (70.8),

INTRODUCTION Acute patellar dislocation represents 2% to 3% of knee injuries, and is the second most common cause of traumatic hemarthrosis of the knee(1). Acute patellar dislocations can result in patellar instability in the long term, with recurrence rates of 15% to 44% after conservative treatment, pain, inability to return to sports (reported by up to 55% of patients) and patellofemoral arthrosis(2).

compared with the mean value in the surgical group (88.9), with p = 0.001. The surgical group presented a higher percentage of “good/excellent” Kujala score results (71.43%) than in the conservative group (25.0%), with p = 0.003. The conservative group presented a greater number of recurrences (35% of the cases), while in the surgical group there were no reports of recurrences and/or subluxation. Conclusions: Treatment with reconstruction of the medial patellofemoral ligament using the patellar tendon produced better results, based on the analysis of post-treatment recurrences and the better final results from the Kujala questionnaire after a minimum follow-up period of two years. Keywords – Patellar Ligament; Knee; Reconstruction; Patellar Dislocation

Most first-time traumatic patellar dislocations were treated conservatively, except when there was associated patellar dislocation or osteochondral fractures of the lateral femoral condyle. However, studies that observed a recurrence rate of up to 44%, findings of late symptoms such as previous knee pain and a recurrent instability rate above 50% after conservative treatment led to an increase in the initial treatment with surgical repair and reconstruction of the medial patellar stabilizers (medial patellofemoral ligament,

1 –Master’s degree in Science from the Department of Orthopedics of the School of Medicine of Universidade de São Paulo; Orthopedist at Instituto Vita – São Paulo, SP, Brazil. 2 – Master’s and Doctor’s degree in Science from the Department of Orthopedics of the School of Medicine of Universidade de São Paulo; Assistant Physician of the Institute of Orthopedics and Traumatology of HC-FMUSP – São Paulo, SP, Brazil. 3 – Master’s degree in Science from the Department of Orthopedics of the School of Medicine of Universidade de São Paulo; Orthopedist at Instituto Camanho and at Hospital do Coração – São Paulo, SP, Brazil. 4 – Full Professor of the Department of Orthopedics and Traumatology of the School of Medicine of Universidade de São Paulo – São Paulo, SP, Brazil. Study conducted at Vita Care and LIM 41 – Laboratory of Medical Investigation of the Musculoskeletal System of the Department of Orthopedics and Traumatology of the School of Medicine of Universidade de São Paulo. Mailing address: Rua Mato Grosso, 306, 1º andar, Higienópolis – 01239-040 – São Paulo, SP. Email: bitar@vita.org.br Study received for publication: 12/22/2010, accepted for publication: 3/25/2011. .

The authors declare that there was no conflict of interest in conducting this work This article is available online in Portuguese and English at the websites: www.rbo.org.br and www.scielo.br/rbort

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vastus medialis obliquus and medial retinaculum)(1,3-5). Our understanding of the natural history of acute patellar dislocations has undergone significant changes recently, although the literature on this subject is still scarce. There are few randomized controlled studies(6-8) and only one systematic review(1). Conclusions based on results of existing studies should be reached with care due to the vast diversity of methodologies(1,7,9). As a result, there is a great deal of controversy regarding the ideal conduct in primary patellar dislocations. The aim of this study was to analyze and to compare, prospectively and randomly, results obtained from two types of approach (reconstruction of the medial patellofemoral ligament with patellar tendon versus conservative approach) in the treatment of traumatic patellar dislocations, in relation to the Kujala score and to recurrence.

MATERIAL AND METHODS The diagnosis of primary patellar dislocation was patellar displacement or was based on findings of a physical examination carried out by an experienced orthopedic surgeon (history of acute knee trauma, intra-articular hematoma, softening in the medial epicondyle and positive lateral patellar apprehension). All the patients had radiographies of the affected knee and the NMR scan was taken to detect potential chondral or osteochondral fragments and to confirm the ligament injury.

Inclusion/exclusion criteria The inclusion criteria for this prospective study were: 1) Occurrence of acute lateral patellar dislocation up to three weeks before the treatment; 2) Absence of history of previous knee surgery or severe lesion in the affected knee; 3) Absence of coexisting severe tibiofemoral ligament lesion that requires repair; 4) Absence of large osteochondral fragments (diameter > 15 mm) that require fixation; and 5) Patientâ&#x20AC;&#x2122;s authorization for participation in the study. Exclusion criteria 1) Previous surgery on the injured knee; 2) Conditions associated with severe neuromuscular or congenital diseases; Rev Bras Ortop. 2011;46(6):675-83

3) Patients under 18 years of age; 4) Follow-up time under two years; 5) Patients with patellar dislocation or symptoms of patellar instability in the affected knee; 6) Non-traumatic patellar dislocation (e.g.: dislocation during gait or squatting with moderate stress on the knee, resulting in dislocation without acute pain in the knee); 7) Patients unable to following the treatment protocol. From 2003 to 2006 we assessed 44 patients diagnosed with primary patellar dislocation. Two patients were excluded, as they presented osteochondral fragments (diameter > 15 mm) that required fixation and three patients were lost in the follow-up (11.3%). Thirty-nine patients (41 knees) with acute patellar dislocation were randomized into two groups (conservative group and reconstruction group), and evaluated with minimum follow-up of two years (Figure 1). One group (18 patients; 20 knees) received conservative treatment (physiotherapy) only, while the other group (21 patients; 21 knees) was treated surgically with reconstruction of the medial patellofemoral ligament (MPFL) with patellar tendon(10). In the conservative treatment group, the patients used an extension brace for three weeks followed by physiotherapy focusing on range of motion and quadriceps strengthening. During this period, the patients were started on isometric quadriceps exercises, as well as analgesia, cryotherapy and electrostimulation. The orthopedist executed passive mobilization of the knee during the patientsâ&#x20AC;&#x2122; fortnightly visit. Weight bearing was allowed after three weeks. The exercises for gain of range of motion were increased in the third week, with the introduction of the stationary bicycle without load. Initial proprioception and closed kinetic chain exercises were executed and gradually evolved into open chain exercises. The objective was to enable the patient to resume previous sports activities in approximately 16 to 24 weeks. In the reconstruction group, we initiated the procedure arthroscopically to diagnose and treat possible cartilage lesions in all the patients(10). The surgical incision started proximally at the level of the upper patellar margin and centrally between the medial patellar margin and the medial epicondyle. A descending incision was then made, directed toward the superomedial margin of the tibial tubercle. We separated the


RANDOMIZED PROSPECTIVE STUDY ON TRAUMATIC PATELLAR DISLOCATION: CONSERVATIVE TREATMENT VERSUS RECONSTRUCTION OF THE MEDIAL PATELLOFEMORAL LIGAMENT USING THE PATELLAR TENDON, WITH A MINIMUM OF TWO YEARS OF FOLLOW-UP

medial third of the patellar ligament (PL) from the rest of the ligament with dissection up to the patella. The PL was carefully detached from the patella up to the transition between the proximal third and medial third of the patella (Figure 2). We placed the stitches between the periosteum and the ligament using FiberWire absorbable threads (Arthrex, Naples, FL) to safely rotate the graft (Figure 3). The femoral insertion of the MPFL covered an area more posterior and proximal to the medial epicondyle (Figure 4). A tunnel was then drilled using a bit of the same diameter as the graft, and this was secured with an absorbable interference screw (Figure 4) or with anchors (also absorbable or nonabsorbable). At the end, we sutured the distal edge of the vastus medialis muscle to the graft, which bestowed a dynamic component upon the reconstruction. No lateral release procedure was performed. Rehabilitation started on the day of the patient’s first return visit and the subject used an immobilizer for three weeks; isometric quadriceps exercises as well as analgesia, cryotherapy and electrostimulation were started during this period. The surgeon performed passive mobilization of the knee during the fortnightly visits and weight bearing was permitted immediately after surgery. The exercises for gain

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Figure 2 – A 2 cm bone fragment is removed in order to detach the medial third of the patellar ligament from the rest of the ligament and to insert it in the patella.

Primary acute patellar dislocation (n = 44 patients)

Patients with inclusion and exclusion criteria (n = 39 patients/n = 41 knees)

Allocation to the conservative group or reconstruction group

Conservative group Physiotherapy (n = 20 knees)

Conservative group Analyzed (n = 20)

Reconstruction group Reconstruction of the medial patellofemoral ligament – MPFL (n = 21 knees)

Reconstruction group Analyzed (n = 21)

Figure 1 – Flowchart of the studied patients.

Figure 3 – Technique without the use of the bone fragment. Desinsertion is performed by planes up to the peritendon of the patellar ligament.

of range of motion were increased in the third week, with introduction of the stationary bicycle without load. Initial proprioception and closed kinetic chain exercises were executed and gradually evolved into open chain exercises. The objective was to enable the patient to resume previous sports activities in approximately 10 to 12 weeks. Rev Bras Ortop. 2011;46(6):675-83


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univariate manner and controlled by the covariables age, sex and side. The need for the sample size to be 16 patients per study group was calculated with power of 90% and type I error (a) of 0.05.

RESULTS

Figure 4 – Diagrammatic view of post-fixation of the medial structures, showing the site between the epicondyle and the adductor tubercles.

The Kujala questionnaire was applied to assess the patient’s evolution in terms of pain and quality of life(11). Recurrence was defined as a recurrent patellar dislocation that required a further visit to the physician or hospital. Patellar instability was defined as redislocation or subjective sensation of subluxation(7). The mean values of the Kujala score in the conservative and surgical groups were initially compared by means of a single factor (ANOVA). After this, still aiming to compare these mean values, we used the score adjusted to age, sex and side of knee (ANCOVA), since these factors can influence the comparison of interest. The necessary assumptions for use of the proposed models were evaluated and proved appropriate for the data. Besides the analysis of Kujala scores in their original form (continuous variable), we also conducted an analysis of this variable after being qualitatively categorized as: poor (Kujala ≤ 64), fair (Kujala between 65 and 84) and good/excellent (Kujala ≥ 85), as proposed by Sillanpaa et al (2008)(12). The associations between the Kujala categories and the variables group, sex and side were evaluated by means of Pearson’s chi-square test or Fisher’s exact test, when the latter proved more adequate. A logistic regression model was used to estimate the odds ratio between Kujala (considering two categories – poor/fair and good/excellent) and group, both in a Rev Bras Ortop. 2011;46(6):675-83

Kujala Score Table 1 presents descriptive measures of the Kujala score for each study group and also according to sex and affected side of knee. In general, the surgical group presented higher mean values in both knees and in both sexes. The scatter graph between the measures of the Kujala score and of the age of the patients in each group (Figure 5) did not indicate an association between these quantities, and Pearson’s correlation coefficient was equal to 0.07 for the surgical group and -0.12 for the conservative group. We highlight the result of a low extreme value for the Kujala score (equal to 16), which corresponds to a measure of the conservative group, observed in a 25-year-old woman. The statistical analysis showed that the mean Kujala score was significantly lower in the conservative group (70.8) when compared to the mean value of the surgical group (88.9), with p = 0.001. This conclusion is maintained (with p = 0.002) even after considering control by sex, age and side of the operated knee. Note that if we disregard the extreme observation emphasized earlier (Kujala = 16), the mean value of the conservative group rises from 70.8, with standard deviation (s.d.) of 19.2, to 73.7, with s.d. of 14.6. However, the removal of this value does not change the conclusions described previously, as the mean value of this group still appears significantly lower than that of the surgical group (p < 0.001), even after control by the covariables considered (p = 0.001). Table 2 presents the percentages of the Kujala score according to group, sex and side, considering the score divided into three or two categories (in this case, grouping poor and fair). The analysis indicates association between group and Kujala score, while the surgical group presented a higher percentage of good/excellent results (71.5%) when compared with the conservative group (25.0%), with p = 0.003. It can also be seen that only 9.5% of the patients from the surgical group were classified as poor; while among those from the conservative group, this percentage was equal to 35.0%.


RANDOMIZED PROSPECTIVE STUDY ON TRAUMATIC PATELLAR DISLOCATION: CONSERVATIVE TREATMENT VERSUS RECONSTRUCTION OF THE MEDIAL PATELLOFEMORAL LIGAMENT USING THE PATELLAR TENDON, WITH A MINIMUM OF TWO YEARS OF FOLLOW-UP

Table 1 – Descriptive measures of the Kujala score for each study group according to sex and knee involved.  

Side of knee

 

 

 

Poor

Fair

Good/ excellent

Total

Group

Reconstruction

2

4

15

21

9.5%

19.0%

71.4%

100%

7

8

5

20

35.0%

40.0%

25.0%

100%

7

5

8

20

35.0

25.0

40.0%

100%

Male

2

7

12

21

 

 

9.5

33.3

57.1%

100%

Right

2

4

8

14

14.30%

28.60%

57.10%

100%

7

8

12

27

25.90%

29.60%

44.40%

100%

N

9

12

9

12

21

Mean

92

86.5

85.2

91.6

88.9

Standard Deviation

6.8

12.2

13.5

6.7

10.4

Median

94

91

91

92

92

Minimum

82

62

62

82

62

Maximum

100

100

100

100

100

N

5

15

11

9

20

Mean

74

69.8

66.5

76.1

70.8

Sex

Standard Deviation

18.5

20

20.5

17.2

19.2

p1=0.182 p2=0.272

 

Female Total

Median

83

71

71

83

73.5

Minimum

51

16

16

51

16

Maximum

94

96

87

96

96

p2=0.003

16

27

20

21

41

85.6

77.2

75

84.9

80.1

Side of knee

Standard Deviation

14.6

18.7

19.7

14.3

17.7

p1=0.701

Median

88.5

82

81

90

84

p2=0.440

Minimum

51

16

16

51

16

Maximum

100

100

100

100

100

Conservative

Left

 

TOTAL

9

12

20

41

 

 

22.00%

29.30%

48.80%

100%

1

p-value referring to Fisher’s exact test, with Kujala in three categories. p-value referring to Pearson’s chi-square test, with Kujala in two categories: poor/ fair and good/excellent. 2

90

Table 3 – Descriptive measures of the patients’ age according to the categories of the Kujala score.

70 50

Kujala

30

Poor/ Fair

10

Conservative

Female

N

110

Kujala

p1=0.008

Mean

Reconstruction

 

 

Reconstruction

Total

Kujala

 

 

 

Male

Table 2 – Distribution of the Kujala categories according to group, side involved and sex.

Group

Conservative

Right Left

Sex

679

10

15

20

25 Age (years)

30

35

In relation to the patients’ age, Table 3 presents descriptive measures of this variable according to the categories of the Kujala score. In general, the distributions of ages do not present major differences, especially when the poor and fair categories are grouped. Considering the division of the score into two categories, it is concluded that the odds of a patient

N

23

18

38

21.5

4.1

22

14

26

21 23.7

5.1

23

14

38

5

22.2

2.2

23

19

24

Reconstruction 15 24.9

7.6

25

12

37

6.7

24

12

37

4.8

23

18

38

6.8

24

12

37

5.8

23

12

38

Good/ Conservative excellent

Total

Total

20 24.2

Conservative 20

24

Reconstruction 21 23.9  

Standard Median Minimum Maximum Deviation

5.3

Total

 

Mean

Conservative 15 24.5 Reconstruction 6

40

Figure 5 – Scatter graph between Kujala score and age of the patients, according to group.

Groups

Total

41 23.9

Rev Bras Ortop. 2011;46(6):675-83


680

being classified as Kujala good/excellent are greater for those operated with the surgical method. The odds of a patient being classified as Kujala excellent/good in relation to fair/poor for those operated with the surgical method are 7.5 times the same odds for those operated with the conservative method, with a confidence interval of 95% ranging from 1.9 to 30.0. This odds ratio also appears significantly different from 1 after control by the variables sex, side of knee affected and age of the patient (OR: 7.2; CI 95%: 1.7 to 29.6).

Recurrence and/or subluxation in the conservative group In relation to cases of recurrence and/or subluxation in the conservative group, it was observed that of the 20 procedures evaluated, 35.0% (with confidence interval of 95% ranging from 14.1% to 55.9%) exhibited recurrence or subluxation. It is also worth noting that of the two patients who had both sides affected, one of them presented recurrence on the right side and subluxation on the left side, and the other did not present any occurrence on either one of the sides.

DISCUSSION There are many studies in relation to the surgical treatment of patellar dislocations with more than 100 surgical techniques, open or arthroscopic(1). There are few randomized controlled studies(6-8) and only one systematic review(1) comparing the conservative and surgical treatments. In these studies, the authors recommend non-surgical treatment for primary patellar dislocations, except in cases where there is evidence of an osteochondral fragment. In case of the presence of an osteochondral fracture, arthroscopy is recommended for removal of the fragment or open repair according to its size. More specifically, the well-designed prospective, randomized study of Nikku et al (1997)(8) compared surgical treatment with conservative treatment in 125 patients with two years of follow-up. The results were evaluated subjectively by the patientsâ&#x20AC;&#x2122; general opinion (excellent, good, reasonable and poor), by the Lysholm II score and by the visual analogue scale (VAS). The authors concluded that the surgical and conservative treatments produced almost identical results after two years in relation to the subjective scores, recurrence of instability and function. However, greater complicaRev Bras Ortop. 2011;46(6):675-83

tions only occurred after surgical treatment. Conclusions based on this study are hard to reach due to the reports of conservative treatment presented by Maenpaa and Lehto (1997)(13), which showed that more than half of the recurrences took place two years or more after the first dislocation. In 2005, Nikku et al(7) published their randomized, prospective study over a mean period of seven years with 125 patients. The study compared the conservative treatment, with immobilization and functional rehabilitation, with proximal realignment surgery (extensor mechanism realignment, repair of the medial patellar ligaments and/or lateral release). Their clinical results were very similar between the conservative and surgical groups. For this reason, Nikku et al(7) do not recommend proximal realignment surgery for the treatment of primary patellar dislocations. This case series is a randomized, prospective, level I study, with long-term follow-up that compares the surgical conduct with the closed treatment of primary patellar dislocations. Moreover, episodes of redislocation and recurrent subluxation were included in a group together, and called episodes of instability, which contributed to the slightly higher recurrence rate in our series. We believe, like Stefancin and Parker (2007)(1), that the difference in surgical procedures makes it impossible to compare the two studies of Nikku et al(7) and our study. As observed in many other surgical procedures, the results of the series of cases of MPFL repair appear to overestimate the success rates when compared with those of the randomized trials. Moreover, a wide range of different surgical procedures was carried out in the surgical group in the study conducted by Nikku et al(7). Surgical intervention in 10% of the patients consisted of isolated lateral release. In an additional 81% of the patients, the medial retinaculum was repaired or duplicated, but the MPFL was not specifically used. Consequently, these results should not be extrapolated for procedures that involve repair or reconstruction of the MPFL. Finally, the trial of Nikku et al(7) included both adults and children. Another prospective and comparative, yet nonrandomized study, was that of Sillanpaa et al(12). Our criticism consists of the fact that the magnetic resonance scan was only performed in the conservative group and the fixation of the surgical group was only performed in the patella. Another two comparative


RANDOMIZED PROSPECTIVE STUDY ON TRAUMATIC PATELLAR DISLOCATION: CONSERVATIVE TREATMENT VERSUS RECONSTRUCTION OF THE MEDIAL PATELLOFEMORAL LIGAMENT USING THE PATELLAR TENDON, WITH A MINIMUM OF TWO YEARS OF FOLLOW-UP

studies were those of Palmu et al(14) and Buchner et al(9). However, the first only studied patellofemoral dislocation in children and adolescents and the second is a retrospective study in which the authors excluded the patients with predisposing factors shown in the radiographies. Finally, a recent randomized, prospective study was that of Christiansen et al(6). The main criticism of the study is that the patients from the surgical group were submitted to ligament repair on average 50 days after the traumatic episode and the lesion was fixed only at the femoral site. We recently presented a nonrandomized prospective study comparing conservative treatment with MPFL repair(15). In spite of the better rates of subjective scores and the lower number of recurrences of the surgical group in comparison to the conservative group, two patients presented subluxations with the same minimum follow-up time as our study on MPFL reconstruction. Our study is the first randomized, prospective study comparing conservative treatment with a technique for reconstruction (and not repair) of the medial patellofemoral ligament (MPFL) described previously by Camanho et al(10). We believe that MPFL reconstruction is the most appropriate form of surgical intervention for treating an acute traumatic patellar dislocation, since despite the controversy involving the site where the MPFL lesion occurs(5,12,16), there are studies showing that intrasubstance injury of the MPFL is not infrequent(17). In his article, Nomura(18) showed the site of the MPFL injury through open exploration carried out on 27 knees after acute patellar dislocation. The MPFL suffered avulsion of its femoral origin in 10 knees, and one intrasubstance tear of the ligament was identified in another 16 knees. Sillanpaa et al(12) observed an internal tear in the substance of the MPFL in 10 patients (23%) in their study. In our clinical practice, the NMR often evidences a focal lesion on the femur or patella; however, we also observe signal alteration in the ligament in many cases, either due to a partial or total lesion, or just distension of the MPFL. This could indicate that repair and reinsertion of the MPFL at the AT, which is the insertion site of the MPFL, or failure in the identification and correction of the incompetence of the MPFL at the rupture site would compromise reasonable surgical treatment,

681

which is also proposed by Christiansen et al(6) and Hautamaa et al(19), respectively. Another aspect that we view as yet another advantage of reconstruction in relation to MPFL repair is the fact that it heals in an elongated manner, as proposed by Arendt et al(20) in a review article of 2002. Some case series present results that are also encouraging with the reconstruction of MPFL in the treatment of acute patellar dislocation(16). The importance of associating techniques that recreate the anatomy and biomechanics of the MPFL is essential in surgery. Boden et al(21) and Feller et al(22) refer to the importance of the MPFL in the proprioception of the surrounding musculature. Through biomechanical studies, Amis et al(23), Conlan et al(24), Desio et al(25), Sandmeier et al(26) and Tuxoe et al(27) conclude that the MPFL is responsible for approximately 50 to 70% of the total lateral restriction, and is therefore, the primary medial stabilizer of the patella. Another important aspect in our technique is that we also sewed the graft to the vastus medialis, introducing a dynamic component into the reconstruction. The direction of the fibers of the vastus medialis obliquus (VMO) and its anatomic relationship with the intramuscular septum proximally, and with the adductor magnus tendon distally, allow the VMO to traction the patella in oblique direction and thus to work as a dynamic medial stabilizer of the patella. In relation to our technique, we believe that lateral release should never be executed in acute cases. According to literature, the role of lateral release is not clear when combined with surgery of medial patellar structures(3,12,24). It was concluded that the performance of the lateral release in unstable patellae does not improve the clinical results, while this procedure can be beneficial for unstable and painful patellae. The role of lateral release is not clear, but Desio et (25) al suggested that lateral release may even increase lateral patellar instability, since their biomechanical study found that the lateral retinaculum contributes 10% to the retention strength. It is not known whether the lateral release performed in this study caused any effect on patellar instability. It was presumed that lateral release could cause additional instability in the hypermobile patellar joint. In this study, however, the dislocations were primary traumatic lesions and no hypermobile patellar joint was found(25,28-31). Rev Bras Ortop. 2011;46(6):675-83


682

Although recent review studies still consider conservative treatment the first option, some studies associate this treatment with evolution to recurrences(1,16). In 1979, McManus et al(32) published a study on the natural history of acute patellar dislocation. Recurrent dislocations occurred in 15% of the patients, with an additional 33% of patients experiencing sensations of instability or apprehension. Hawkins et al(33) also gave an account of the natural history of acute patellar dislocation. Redislocation occurred in 15% of the patients, and a sensation of insecurity or knee instability persisted in another 20% of the patients. Maenpaa and Lehto(13) monitored 100 patients treated nonoperatively after patellar dislocation for 13 years on average. Forty-four percent of the patients presented recurrence, and another 19% presented recurrence of subluxation and patellofemoral pain. Surprisingly, there is little evidence in relation to the conservative treatment of primary patellar dislocation(2). Treatment protocols range from immediate mobilization without the use of a brace to plaster cast immobilization in extension for six weeks. Immobilization in extension could provide the medial structures, particularly the MPFL, with a better means of achieving their healing. However, this entails the stiffness that frequently accompanies prolonged immobilization. The patientâ&#x20AC;&#x2122;s adhesion can also be a factor in the decision for conservative treatment. For these reasons, many clinicians decide on a short period of immobilization followed by knee rehabilitation with or without a brace. In our study, in the conservative treatment group, the patients remained in extension with the brace for three weeks followed by physiotherapy focused on range of motion and quadriceps strengthening. Articular cartilage lesions are more common than previously believed and were reported in about 10% to 40% of the cases(9); however, according to Nomura(18), this incidence can be as high as 95% of primary patellar dislocations. What we take into account is the fragment size and the intraoperative evaluation of the need to fix the lesion. In our study, we excluded two patients with osteochondral fragments (diameter > 15 mm) that required fixation. As regards our results, we consider the superiority of the results of the reconstruction group plainly obvious in comparison to the conservative Rev Bras Ortop. 2011;46(6):675-83

group, both in relation to recurrence (and consequently instability) and in relation to the specific Kujala patellofemoral score. As regards the Kujala score, our results upon quantitative analysis showed a clear advantage of the reconstruction group. According to a study by Sillanpaa et al(12), the Kujala score can be analyzed qualitatively: with a maximum possible score of 100 points (without symptoms), a rating of 95 points or more is excellent; 94 to 85, good; 84 to 65, reasonable; and 64 or less, poor. Analyzing our sample this way, we still evidenced superiority of the surgical group in the results of this score. Our study presents some points to be criticized: firstly due to the short follow-up time (in spite of the minimum period of two years) for us to evaluate mainly the recurrence rate. There is a tendency for redislocation with a longer follow-up time, both in the conservative and in the surgical series(13,34). The short follow-up of the surgical series can explain the better results obtained after primary surgery. The second criticism is our failure to separate the cases of patients with predisposing factors considered in literature. In this study we really did not analyze the predisposing factors. However, a recent study by our service clearly demonstrates that the predisposing factors did not influence the results(15). As the reconstruction study followed the repair study we did not consider predisposing factors. Finally, another criticism concerns the number of patients studied when compared with other studies in literature(6-8). However, we believe that our statistical analysis presented power of comparison in relation to the score used since it was necessary for the sample size to be at least 16 patients per study group and for this to have been calculated with power of 90%, and type I error (a) of 0.05.

CONCLUSION We were able to conclude that the treatment with reconstruction of the medial patellofemoral ligament with the patellar tendon produced better results, based on the analyses of post-treatment recurrences and on the better end results of the Kujala questionnaire after a minimum follow-up of two years.


RANDOMIZED PROSPECTIVE STUDY ON TRAUMATIC PATELLAR DISLOCATION: CONSERVATIVE TREATMENT VERSUS RECONSTRUCTION OF THE MEDIAL PATELLOFEMORAL LIGAMENT USING THE PATELLAR TENDON, WITH A MINIMUM OF TWO YEARS OF FOLLOW-UP

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23. Amis AA, Firer P, Mountney J, Senavongse W, Thomas NP. Anatomy and biomechanics of the medial patellofemoral ligament. Knee. 2003;10(3):215-220.

8. Nikku R, Nietosvaara Y, Kallio PE, Aalto K, Michelsson JE. Operative versus closed treatment of primary dislocation of the patella. Similar 2-year results in 125 randomized patients. Acta Orthop Scand. 1997;68(5):419-23. 9. Buchner M, Baudendistel B, Sabo D, Schmitt H. Acute traumatic primary patellar dislocation: long-term results comparing conservative and surgical treatment. Clin J Sport Med. 2005;15(2):62-6. 10. Camanho GL, Bitar AC, Hernandez AJ, Olivi R. Medial patellofemoral ligament reconstruction: a novel technique using the patellar ligament. Arthroscopy. 2007;23(1):108 e101-4. 11. Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka O. Scoring of patellofemoral disorders. Arthroscopy. 1993;9(2):159-63. 12. Sillanpaa PJ, Maenpaa HM, Mattila VM, Visuri T, Pihlajamaki H. Arthroscopic surgery for primary traumatic patellar dislocation: a prospective, nonrandomized study comparing patients treated with and without acute arthroscopic stabilization with a median 7-year follow-up. Am J Sports Med. 2008;36(12):2301-9. 13. Maenpaa H, Lehto MU. Patellar dislocation. The long-term results of nonoperative management in 100 patients. Am J Sports Med. 1997;25(2):213-7. 14. Palmu S, Kallio PE, Donell ST, Helenius I, Nietosvaara Y. Acute patellar dislocation in children and adolescents: a randomized clinical trial. J Bone Joint Surg Am. 2008;90(3):463-70. 15. Camanho GL, Viegas Ade C, Bitar AC, Demange MK, Hernandez AJ. Conservative versus surgical treatment for repair of the medial patellofemoral ligament in acute dislocations of the patella. Arthroscopy. 2009;25(6):620-5. 16. Dopirak RM, Steensen RN, Maurus PB. The medial patellofemoral ligament. Orthopedics. 2008;31(4):331-8.

24. Conlan T, Garth WP Jr, Lemons JE. Evaluation of the medial soft-tissue restraints of the extensor mechanism of the knee. J Bone Joint Surg Am. 1993;75(5):682-93. 25. Desio SM, Burks RT, Bachus KN. Soft tissue restraints to lateral patellar translation in the human knee. Am J Sports Med. 1998;26(1):59-65. 26. Sandmeier RH, Burks RT, Bachus KN, Billings A. The effect of reconstruction of the medial patellofemoral ligament on patellar tracking. Am J Sports Med. May- 2000;28(3):345-9. 27. Tuxoe JI, Teir M, Winge S, Nielsen PL. The medial patellofemoral ligament: a dissection study. Knee Surg Sports Traumatol Arthrosc. 2002;10(3):138-40. 28. Fithian DC, Paxton EW, Post WR, Panni AS. Lateral retinacular release: a survey of the International Patellofemoral Study Group. Arthroscopy. 2004;20(5):463-8. 29. Jensen CM, Roosen JU. Acute traumatic dislocations of the patella. J Trauma. 1985;25(2):160-2. 30. Rosner B. Fundamentals of biostatistics. 6th ed. Belmont, CA: ThomsonBrooks/Cole; 2006. 31. Sherman OH, Fox JM, Sperling H, Del Pizzo W, Friedman MJ, Snyder SJ, et al. Patellar instability: treatment by arthroscopic electrosurgical lateral release. Arthroscopy. 1987;3(3):152-60. 32. McManus F, Rang M, Heslin DJ. Acute dislocation of the patella in children. The natural history. Clin Orthop Relat Res. 1979(139):88-91. 33. Hawkins RJ, Bell RH, Anisette G. Acute patellar dislocations. The natural history. Am J Sports Med. 1986;14(2):117-20. 34. Harilainen A, Sandelin J. Prospective long-term results of operative treatment in primary dislocation of the patella. Knee Surg Sports Traumatol Arthrosc. 1993;1(2):100-3.

Rev Bras Ortop. 2011;46(6):675-83


ORIGINAL ARTICLE

Results from filling “remplissage” arthroscopic technique for recurrent anterior shoulder dislocation

Mauro Emilio Conforto Gracitelli1, Camilo Partezani Helito2, Eduardo Angeli Malavolta1, Arnaldo Amado Ferreira Neto3, Eduardo Benegas1, Flávia de Santis Prada1, Augusto Tadeu Barros de Sousa4, Jorge Henrique Assunção5, Edwin Eiji Sunada5

Abstract Objective: To evaluate the clinical result from the filling (“remplissage”) technique in association with Bankart lesion repair for treating recurrent anterior shoulder dislocation. Methods: Nine patients (10 shoulders), with a mean follow-up of 13.7 months, presented traumatic recurrent anterior shoulder dislocation. All of them had a Bankart lesion, associated with a Hill-Sachs lesion showing the “engaging” sign. The Hill-Sachs lesion defect was measured and showed an average bone loss of 17.3% (7.7% to 26.7%) in relation to the diameter of the humeral head. All the cases underwent arthroscopic repair of the Bankart lesion, together with filling of the Hill-Sachs lesion by means of tenodesis of the infraspinatus. Results: The Rowe score ranged from 22.5 (10 to 45) before the operation to 80.5 (5 to 100) after the operation

IntroduCTION The treatment of recurrent anterior shoulder dislocation through arthroscopic repair of the Bankart (BK) lesion presents variable results in literature(1,2). Recent studies demonstrate multifactorial causes for recurrence. Non-healing of the glenoid lip, erosion of the glenoid cavity and the Hill-Sachs (HS) lesion have an important role in this origin(2,3). In these studies, about 70% of the patients with postoperative recurrence presented some type of important bone lesion(4).

(p < 0.001). The UCLA score ranged from 18.0 (8 to 29) to 31.1 (21 to 31) (p < 0.001). The measurements of external and internal rotation at abduction of 90º after the operation were 63.5º (45º to 90º) and 73º (50º to 92º) respectively. Two patients presented recurrence (one with dislocation and the other with subluxation). None of the patients presented pain in the region of the infraspinatus tendon after the operation. Conclusion: Over the short term, the filling (“remplissage”) arthroscopic technique produced improvements in functional scores and a low complication rate when used for treating glenohumeral instability associated with Hill-Sachs lesions. Keywords – Joint Instability; Shoulder Dislocation/epidemiology; Shoulder Dislocation/surgery; Arthroscopy; Recurrence

The HS lesion is a compression fracture in the posterosuperior lateral region of the humeral head(5). Its incidence in acute anterior dislocation is estimated as 47% to 80% and, in recurrent dislocation, it is present in up to 93% of the cases(1,4,6). This lesion changes the spherical format of the humeral head, and, depending on its format and extension, can decrease the articular arc of excursion of the humeral head in relation to the glenoid cavity in the position of abduction and lateral rotation. In this situation it engages easily on its anterior edge, leading to the dislocation(7,8).

1 – Assistant Physician of the Shoulder and Elbow Group of the Institute of Orthopedics and Traumatology of HC/FMUSP – São Paulo, SP. 2 – Resident Physician of the Shoulder and Elbow Group of the Institute of Orthopedics and Traumatology of HC/FMUSP – São Paulo, SP. 3 – Assistant Physician and Head of the Shoulder and Elbow Group of the Institute of Orthopedics and Traumatology of HC/FMUSP – São Paulo, SP. 4 – Orthopedist in Training of the Shoulder and Elbow Group of the Institute of Orthopedics and Traumatology of HC/FMUSP – São Paulo, SP. 5 – Orthopedists and Preceptors of the Shoulder and Elbow Group of the Institute of Orthopedics and Traumatology of HC/FMUSP – São Paulo, SP. Study conducted at LIM 41 – Laboratory of Medical Investigation of the Musculoskeletal System of the Department of Orthopedics and Traumatology of the School of Medicine of Universidade de São Paulo. Mailing address: Rua Dr. Ovídio Pires de Campos, 333, Cerqueira Cesar – 05403-010 – São Paulo, SP. Email: mgracitelli@gmail.com. Study received for publication: 2/2/2011, accepted for publication: 5/25/2011. The authors declare that there was no conflict of interest in conducting this work This article is available online in Portuguese and English at the websites: www.rbo.org.br and www.scielo.br/rbort

Rev Bras Ortop. 2011;46(6):684-90


RESULTS FROM FILLING “REMPLISSAGE” ARTHROSCOPIC TECHNIQUE for recurrent anterior shoulder dislocation

These lesions, particularly those considered large (involving more than 20% of the humeral head surface), when not treated, increase the risk of postoperative recurrence after the isolated repair of the BK lesion(2). This also occurs in the presence of bone lesions of the anterior edge of the glenoid cavity, surpassing 25% of its diameter(2,9). The treatment of the HS lesion has always been a challenge due to its location, which hinders less aggressive surgical access, and due to the technical difficulties of filling the lesion (use of bone, autologous osteocartilaginous or tissue bank graft). In 1972, Connoly(10) proposed the open surgical treatment of the HS lesion, performing tenotomy of the infraspinatus tendon and suturing it on the bone defect of the HS lesion, like McLaughlin’s surgery in the treatment of posterior shoulder dislocation. Based on this technique, Purchase et al(11) idealized a procedure, called “remplissage”, for the arthroscopic treatment of the HS lesion. This French term, which means filling, or padding, was used to define this technique that consists of suturing the tendon of the infraspinatus muscle (tenodesis) at the site of the defect together with the arthroscopic repair of the BK lesion. The objective of this suturing is to prevent the HS from engaging onto the anterior edge of the glenoid cavity in the abduction and external rotation movement(11). The aim of this study was to retrospectively evaluate the clinical result of the “remplissage” technique associated with repair of the BK lesion for treatment of recurrent anterior shoulder dislocation.

MateriaL AND METHODS Methods Nine patients (10 shoulders) diagnosed with recurrent anterior shoulder dislocation of traumatic origin, submitted to the “remplissage” procedure in association with repair of the BK lesion, were evaluated retrospectively. They were all operated at the Orthopedics Institute of Hospital das Clínicas, in the period from January 2006 to December 2009. The mean follow-up time was 13.7 months (six to 28 months). Seven patients were male and two female. An operation was performed on five right shoulders, and five left shoulders, of which four were of the dominant limb. The patients’ age averaged 33.4 years (23 to 56 years). The patients presented an average

685

of 19.5 dislocation episodes (two to 55). Preoperative computed arthrotomography scans were performed in eight cases, and nuclear magnetic resonance imaging in two cases. All the lesions (BK and HS) were diagnosed by magnetic resonance (MR) or computed arthrotomography. We evaluated the size of the HS lesion in the axial sections of the arthrotomography or MR, as follows: we based our evaluation on the axial section that presented the longest extension of HS lesion; in the same section, we traced the total circumference of the humeral head, using its uninjured portion as a reference; we measured the diameter of the head – segment AB and the depth of the defect – segment BC; the percentage of bone defect was calculated by the formula BC/ AB x 100 (Figure 1). The articular arc of the humeral head can be defined as the angle formed between the limits of the anterior and posterior articular cartilage of the humeral head in an axial section of the arthrotomography or MR, considering the center of the humeral head as the axis. The axial section was chosen in the area with largest lesion, limited to 25 mm from the top of the head. As demonstrated in Figure 2, the first step consists of marking the center of the humeral head. For this purpose, a circle is superimposed on the humeral head, and its center is marked. After this, the anterior and posterior limits of the cartilage are marked. Two lines are drawn between the anterior and posterior limits of the cartilage and the center of the head, and the angle formed here is measured. The “engaging” HS lesion was evaluated under direct view at the start of the arthroscopic treatment, through the engagement maneuver that consists of positioning the shoulder in abduction of 90° and external rotation of 90°, observing the easy engagement of the HS on the anterior edge of the glenoid cavity (Figure 3). All the patients presented bone lesion of the anterior edge of the glenoid cavity below 20% in relation to its anteroposterior diameter. This measurement was performed in the intraoperative stage with a probe marked in millimeters using the technique described by Burkhart(12). Cases with rotator cuff lesions, fractures of the proximal third of the humerus and bone lesions of the glenoid cavity above 20% were not included. Rev Bras Ortop. 2011;46(6):684-90


686

B

A

Figure 1 – Measurement of the depth of the HS lesion. Segment AB: diameter of the humeral head; segment BC: depth of the defect. (A) BC = 20.9; AB = 128.2; defect = 16.3%. (B) BC = 25.5; AB = 125.2; defect = 20.4%.

A

Figure 2 – Articular arc of humeral head.

The patients were clinically evaluated in the pre- and postoperative stages, using the ROWE and UCLA scores. Healing of the infraspinatus tenodesis (“remplissage” procedure) was evaluated by MR. Surgical technique The surgical technique performed was the same described by Purchase et al(11). The surgery begins with an articular inspection, confirming the engagement of the HS lesion on the anterior edge of the glenoid cavity after maximum external rotation with Rev Bras Ortop. 2011;46(6):684-90

B

Figure 3 – Engaging HS maneuver, performed with abduction and external rotation of 90°, demonstrated with visualization through the posterior (A) or anterosuperior (B) portal.

the arm at 90° of abduction. The degree of bone lesion of the glenoid cavity was measured using Burkhart’s technique, followed by the repair of the BK lesion


RESULTS FROM FILLING “REMPLISSAGE” ARTHROSCOPIC TECHNIQUE for recurrent anterior shoulder dislocation

using a standard technique with anchors. After this stage, infraspinatus tenodesis was performed in the humeral head defect as follows: visualization through the anterolateral portal and measurement of the size of the HS lesion for calculation of the number of anchors to be used; debridement of the lesion, through the standard posterior portal, with a bone shaver, obtaining a bleeding bone surface (be careful not to deepen the lesion); through the same portal, placement of the 5.5 mm anchor(s) around 3 mm from the edge of the articular surface, vertically in relation to the HS lesion and according to its size. Two anchors were used on average. Then, the posterior cannula is backed out of the joint, with juxtaposition on the surface of the infraspinatus tendon; passage of straight bird-beak arthroscopic suture passers through the tendon and capturing of the suture threads making a “U” shaped stitch (the quantity of tissue from the tendon to be sutured should be as large as possible); making of slipknots observing the filling of the lesion (Figure 4). The physiotherapy protocol consisted of keeping the shoulder immobilized with a Velpeau sling for four weeks, allowing active movements of the elbow, wrist and fingers. Passive and passive-assisted exercises were introduced after this period for gain of movement. Muscle strengthening was only started after the eighth week.

Statistical analysis After the performance of the normality test (Shapiro-Wilk), it was verified that there were data whose distribution did not allow approximation for Gaussian distribution, and the organizers decided to use nonparametric tests. The comparison between the values of the UCLA and ROWE scales between the pre- and

A

687

postoperative periods was performed by the Wilcoxon test. The correlations between the pre- and postoperative values of ROWE and UCLA and the values of the residual articular angle of the head and of the percentage loss of the head diameter were performed by the Spearman test. The significance level of 5% (α = 0.05) was adopted in all the cases.

ResultS We analyzed 10 shoulders of nine patients submitted to the “remplissage” procedure. In the evaluation of the bone defect of the glenoid cavity, all the individuals presented lesion of the lower anterior edge at 20% of the diameter. The mean residual articular arc of the humeral head was 150.9° (119 to 169°). The percentage of loss of the diameter of the humeral head averaged 17.3% (7.7 to 26.8%). The mean depth of the HS lesion was 20.4 mm (5.6 mm to 35.7 mm) (Table 1). Two anchors were used in four cases and one in six cases for posterior capsule and infraspinatus tendon fixation in the HS defect. The patients presented a mean preoperative ROWE score of 22.5 points (10 to 45) and a mean preoperative UCLA score of 18 points (8-29). The mean postoperative ROWE score was 80.5 points (5 to 100) and the UCLA score was 31.1 points (21-35) (Table 2). The improvement after the surgical procedure was statistically significant for both scores, through the Wilcoxon test (p < 0.001). The pre- and postoperative clinical scores (ROWE and UCLA) were correlated with the different preope-

B

Figure 4 – Arthroscopic visualization through the anterosuperior portal. (A) Passage of the stitches through the posterior capsule and infraspinatus tendon; (B) Suturing and filling of the HS. Rev Bras Ortop. 2011;46(6):684-90


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rative HS measurements (residual articular angle and percentage of loss of the head diameter) through the Spearman test. There was statistically significant correlation between the preoperative UCLA score and the residual articular angle and between the postoperative ROWE score and the percentage of loss of the head diameter (p = 0.0021 and p = 0.0201 respectively). The other correlations were not significant. As regards the postoperative range of motion, the mean external rotation at 90° of abduction was 64° (45° to 90°) and the internal rotation at 90° of abduction was 73° (50° to 90°). No patient presented pain on the posterior side of the shoulder and in the infraspinatus topography or neurovascular complications. Two patients presented recurrence of the instability. In one case, subluxation symptoms started nine months after surgery, while the patient was performing abduction and external rotation activities, without a history of trauma. In this individual, the loss of head diameter was 18.9%. Only one patient presented Table 1 – Measurement of the Hill-Sachs lesion. Residual articular Loss of head diamarc (degrees) eter (%)

Case

Depth of the HS (mm)

1

156

0.6

18.7

2

169

1.2

15.4

3

146.7

2.0

20.9

4

159

2.5

25.5

5

162

3.1

20.4

6

148

4.1

5.6

7

151

4.6

16.4

8

160

5.0

35.7

9

138

6.5

15.1

10

119

8.4

30.5

Table 2 – Pre- and postoperative scores and recurrence. Case

Follow-up Preop (months) ROWE

Postop ROWE

Preop UCLA

Postop Recurrence UCLA

1

12

10

70

19

26

3

19

20

95

13

33

No Yes (subluxation) No

2

12

45

80

27

34

4

12

25

95

19

35

No

5

9

45

95

29

35

No

6

6

10

100

8

35

No

7

9

15

90

19

29

No

8

21

15

80

19

30

No

9

9

15

95

11

33

No

10

28

25

5

16

21

Yes

Rev Bras Ortop. 2011;46(6):684-90

new episodes of dislocation. Recurrence started 10 months after surgery, during a seizure, despite the healing of the “remplissage”. This patient presented 26.8% of loss of head diameter and residual articular arc of 119°. The patient was submitted to the Latarjet procedure, evolving without complications and without recurrence. Of the five patients who performed postoperative MR, three (60%) presented clear signs of healing of the tenodesis in the HS defect. Two of these patients presented recurrence (66%) after the NMR. Two patients (40%) did not present clear signs of tenodesis healing, yet did not present recurrence of the dislocation (Figure 5).

DiscussION Defects of the articular surface of the humeral head and their relationship with shoulder dislocation were described in literature even before Hill and Sachs(5). However, the influence of HS lesions on the recurrence of anterior shoulder dislocation is controversial. Classically, authors such as Bankart(13) did not consider the HS lesion a significant factor for the recurrence of dislocation. Burkhart and De Beer(2), however, demonstrated that bone lesions of the humerus or of the glenoid cavity can contribute towards recurrence, in spite of the adequate arthroscopic repair of the labrum lesion. These authors demonstrated that, in cases in which there is bone lesion of the glenoid cavity above 25% or engaging sign during arthroscopic visualization, the isolated repair of the BK lesion presents a high rate of recurrence, as high as 67% against 4% of recurrence in cases without bone lesion(2). The evaluation of the degree of humeral bone lesion is controversial. The HS lesion can also be classified according to the percentage of bone loss of the humeral head diameter: slight (20%), moderate (20 to 45%) and severe (> 45%)(14). In our study, we evaluated the percentage of loss of the humeral head diameter, the depth of the HS lesion and the residual articular arc through the axial section with the largest lesion (limited to 25 mm from the top of the head). We obtained a mean percentage of 17.3% (7.7 to 26.8%) of bone loss from the head. Three cases would be classified as moderate and the other cases (seven cases) as slight. Of the three cases with moderate HS, one case presented recurrence after a seizure after


RESULTS FROM FILLING “REMPLISSAGE” ARTHROSCOPIC TECHNIQUE for recurrent anterior shoulder dislocation

A

689

B

Figure 5 – Pre- (A) and postoperative (B) magnetic resonance scan of patient submitted to the “remplissage” procedure, with signs of healing of the infraspinatus tendon in the HS defec.

10 months of follow-up. However, all the cases presented the engaging HS sign in the absence of the inverted-pear sign and with bone lesions of the glenoid cavity below 25%. The correlations appeared statistically significant only between the preoperative UCLA score and the residual articular arc (p = 0.0021), and between the postoperative ROWE score and the percentage loss of head diameter (p = 0.0201). These correlations demonstrate the importance of the size of the HS lesion, whether it is measured through the residual articular arc or through the head diameter, in the preoperative clinical picture, which is an important criterion of severity. The lack of correlation in the other analyses may perhaps be due to the small study sample. In our opinion, the different measurements of HS, the existing classifications and their correlation with the intraoperative evaluation are still controversial and should be studied in more depth. Humeral head reconstruction or approach indications are also controversial. HS lesions have historically been approached only after the failure of the previous repair of soft parts. Primary approaches to HS lesion have been implemented recently with the objective of decreasing the recurrence of cases with bone lesions. The size of the HS lesion, considered borderline for the performance of the BK lesion repair separately, is variable in literature. Most authors consider the limit for non-approach to the HS lesion to be 20%, but values between 12.5% and 30% of head diameter loss are mentioned(3,9,15). Other authors, such as Balg and Boileau(16), use a combination of clinical and radiographic criteria

as an indication for the approach to bone lesions both of the humerus and of the glenoid cavity. In our sample, we considered the following criteria for performance of the “remplissage” procedure: lesions of the glenoid cavity below 25% of the diameter (by arthrotomography, MR or arthroscopic evaluation); HS lesions present in the arthrotomography or in the MR; engaging sign during the arthroscopic evaluation. Several techniques are described in literature for approach to the HS lesion, such as: external derotation humeral osteotomy(17), anterior capsuloplasty creating limitation of external rotation(2), humeroplasty(18), filling of the HS lesion, with soft parts or bone graft(15,19), partial humeral head prostheses or the Bristow procedure(20,21). However, most of the abovementioned procedures are technically difficult and some may require a posterior approach. Moreover, it may be necessary to have a simultaneous or sequential anterior approach for the treatment of labrum and ligament lesions. Potential setbacks can occur in the postoperative period, prolonging rehabilitation and generating possible limitations in the range of motion(2,15,17,18). Other complications, such as postoperative infection, synthesis material working loose and secondary rigidity are described with these techniques(2,15,17,18). Toro et al(22) described the method for performing tenodesis by intra-articular visualization, without the need for subacromial visualization. The authors reported a good clinical result, without complications related to the procedure. Koo et al(23) described a similar technique, in which the tendon was sutured with two anchors, with stitches that were further apart in the infraRev Bras Ortop. 2011;46(6):684-90


690

spinatus tendon, using the double-pulley suture-bridge technique. The author visualized the suture through the extra-articular space, to allow a safer knot. The same author reports a low rate of complications with this procedure. In our cases, we did not routinely visualize the stitches through the subacromial space, without noticing problems during their performance. As advantages of the “remplissage” technique, we can say that the procedure adds little operative time to the arthroscopic repair of BK, and does not change the standard technique, without important technical difficulties. As the procedure is entirely arthroscopic, it has the advantage of less surgical invasiveness and, consequently, a lower rate of infection, allowing early rehabilitation. Some authors reported a decrease of joint mobility, mainly limitations of internal and external rotation(24). On the other hand, other authors did not encounter internal rotation limitations(23). In our sample, we demonstrated a low incidence of internal and external rotation limitation. As regards the healing of the tendon and the head defect, we did not find any postoperative evaluation through any imaging method in literature. In our

study we used the MR examination for this purpose; however, it was not possible to conduct the statistical analysis due to the small number of cases submitted to postoperative MR. We had a case of recurrence whose MR examination showed healing of the “remplissage”. We believe that this occurred due to the new seizure episodes and also due to the severity of the HS lesion (26.7%). The main weak points of our study were short follow-up time, small sample and absence of control group. The definitive indication of the “remplissage” procedure, in association with the repair of the BK lesion, is still under discussion. Prospective, randomized studies will be necessary to analyze the efficacy and the long-term safety of this procedure in the treatment of recurrent anterior shoulder dislocation.

ConclusIONS The arthroscopic “remplissage” technique demonstrated improvement of functional scores and a low rate of complications in the treatment of glenohumoral instability associated with Hill-Sachs lesions in the short term.

ReferEncEs 1. Tauber M, Resch H, Forstner R, Raffl M, Schauer J. Reasons for failure after surgical repair of anterior shoulder instability. J Shoulder Elbow Surg. 2004;13(3):279-85. 2. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy. 2000;16(7):677-94. 3. Kropf EJ, Tjoumakaris FP, Sekiya JK. Arthroscopic shoulder stabilization: is there ever a need to open? Arthroscopy. 2007;23(7):779-84. 4. Bushnell BD, Creighton RA, Herring MM. The bony apprehension test for instability of the shoulder: a prospective pilot analysis. Arthroscopy. 2008;24(9):1061-73. 5. Hill HA, Sachs MD. The groove defect of the humeral head. A frequently unrecognized complication of dislocations of the shoulder joint. Radiology. 1940;35:690-700. 6. Chen AL, Hunt SA, Hawkins RJ, Zuckerman JD. Management of bone loss associated with recurrent anterior glenohumeral instability. Am J Sports Med. 2005;33(6):912-25. 7. Burkhart SS, Danaceau SM. Articular arc length mismatch as a cause of failed bankart repair. Arthroscopy. 2000;16(7):740-4. 8. Itoi E, Lee S, Berglund L, Berge L, An K. The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair. A Cadaveric Study. J Bone Joint Surg Am. 2000;82(1):35-46. 9. Boileau P, Villalba M, Héry JY, Balg F, Ahrens P, Neyton L. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am. 2006;88(8):1755-63. 10. Connoly JF. Humeral head defects associated with shoulder dislocation-Their diagnostic and surgical significance. Instr Course Lect. 1972;21:42-54 11. Purchase RJ, Wolf EM, Hobgood ER, Pollock ME, Smalley CC. Hill-sachs “remplissage”: an arthroscopic solution for the engaging hill-sachs lesion. Arthroscopy. 2008;24(6):723-6.

14. Bigliani LU, Flatow EL,Pollock RG. Fractures of the proximal humerus. In: Rockwood CA, Green DP, Bucholz RW, editors. Fractures in adults. 4th ed. Philadelphia: Lippincott-Raven; 1996. p. 1055-107. 15. Kropf EJ, Sekiya JK. Osteoarticular allograft transplantation for large humeral head defects in glenohumeral instability. Arthroscopy. 2007;23(3):322.e1-5. 16. Balg F, Boileau P. The instability severity index score. A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br. 2007;89(11):1470-7. 17. Weber BG, Simpson LA, Hardegger F. Rotational humeral osteotomy for recurrent anterior dislocation of the shoulder associated with a large Hill-Sachs lesion. J Bone Joint Surg Am. 1984;66(9):1443-50. 18. Kazel MD, Sekiya JK, Greene JA, Bruker CT. Percutaneous correction (humeroplasty) of humeral head defects (Hill-Sachs) associated with anterior shoulder instability: a cadaveric study. Arthroscopy. 2005;21(12):1473-8. 19. Doneux PS, Miyazaki AN, Lemos PEG, Souza AS, Checchia SL. Tratamento da luxacao recidivante anterior de ombro: uso de enxerto osseo na deficiencia da glenoide. Rev Bras Ortop. 1997;32(9):675-82. 20. Oliveira C, Finelli CA, Santos MAM, Moretto RTS, Monteiro AC. Tratamento da luxacao anterior recidivante do ombro pela tecnica de Bristow-Latarjet. Rev Bras Ortop. 2001;36(10):375-80. 21. Helfet AJ. Coracoid transplantation for recurring dislocation of the shoulder. J Bone Joint Surg Br. 1958;40(2);198-202. 22. Toro F, Meleán P, Moraga C, Ruiz F, González F, Vaisman A. Remplissage: infraspinatus tenodesis and posterior capsulodesis for the treatment of Hill Sachs lesions: an all intraarticular technique. Techn Shoulder Elbow Surg. 2008;9(4):188-92.

12. Burkhart SS, Debeer JF, Tehrany AM, Parten PM. Quantifying glenoid bone loss arthroscopically in shouldert instability. Arthroscopy. 2002;18(5):488-491.

23. Koo SS, Burkhart SS, Ochoa E. Arthroscopic double-pulley remplissage technique for engaging Hill-Sachs lesions in anterior shoulder instability repairs. Arthroscopy. 2009;25(11):1343-8.

13. Bankart BA. Discussion on recurrent dislocation of the shoulder. J Bone Joint Surg Br. 1948;30(1):46-8.

24. Deutsch AA, Kroll DG. Decreased range of motion following arthroscopic remplissage. Orthopedics. 2008;31(5):492.

Rev Bras Ortop. 2011;46(6):684-90


ORIGINAL ARTICLE

“ROCAMBOLE-LIKE” BICEPS TENODESIS: TECHNIQUE AND RESULTS Glaydson Gomes Godinho1, Fabrício Augusto Silva Mesquita2, Flávio de Oliveira França3, José Márcio Alves Freitas3

Abstract Objective: To present a new technique for bicipital tenodesis and its results: accomplished partially via arthroscopy and grounded in concepts of the normal and pathological anatomy of the tendon of the biceps long head. It is based on the predisposition of this tendon towards becoming attached to the intertubercular sulcus after rupture or tenotomy (auto-tenodesis). Methods: Evaluations were conducted on 63 patients (63 shoulders), aged from 32 to 77 years (average 55), consisting of 32 females (51%) and 31 males (49%). Thirty-five of the patients (55.6%) were over 60 years of age and 28 patients (44.4%) were under 60 years of age. Eighteen were sports participants (28.6%). Fourteen had injuries associated with the subscapularis (22.2%). The average follow up was 43 months (ranging from 12 to 74 months). The right shoulder accounted for 48 cases (76.2%), of which one was a left-handed individual and 47 were right-handed. The left shoulder accounted for 15 (23%) of the patients, of whom two were left-handed and 13 were right-handed. There were no bilateral occurrences. The statistical analysis were

INTRODUCTION The origin of the biceps tendon is located in the supraglenoid tubercle in 30% of cases; in the labrum, in 45%; and mixed in the labrum and tubercle, in 25%. Its course is oblique in the joint, emerges under the transverse humeral ligament inside the intertubercular groove, is intra-articular and extrasynovial. The average length is 102 mm (89-146 mm). The proximal area of the glenoid (articular) averages 8.4 x 3.4 mm. At the exit point of the intertubercular groove (extra-articular) it measures 4.5 x 2.1 mm(1).

done using SPSS version 18. Pearson’s chi-square test and continuity corrections were used to investigate the statistical significance of associations between variables. Associations were taken to be statistically significant when p was less than 0.05. Results: Residual Popeye deformity was perceived by seven patients (11.1%); it was only observed by the examiner in 15 cases (23.8%); and neither the patient nor the examiner observed it in 41 cases (65%). There were no statistically valid influences from age, participation in contact or throwing sports, subscapularis tendon-associated injury or Popeye deformity. Fifty-eight patients (92.06%) were satisfied, two patients were dissatisfied (3.17%) and three patients were indifferent (4.76%). Conclusion: The technique presented high patient satisfaction rates (92.06%) and residual deformity was perceived by 11.1% of the patients. The appearance did not have any statistically valid correlation with ages over or under 60 years (p = 0.883), sports practice (p = 0.195) or subscapularis-associated injury (p = 0.958). Keywords – Arthroscopy; Shoulder/injuries; Shoulder/surgery

The long head of biceps tendon is a frequent cause of pain in the shoulder. The pathology of the long head of biceps tendon can be a result of trauma or micro-instability, or a consequence of a chronic inflammatory process due to excessive or degenerative use. Due to the close relationship with the rotator cuff, mechanical impact against the coracohumeral arch has been reported as the main cause of bicipital degeneration, whose inflammatory response leads to a hypertrophy of the tendon, with pain and dysfunction(2).

1 – Head Surgeon of the Shoulder Group of the Lifecenter, Belo Horizonte and Clínica Ortopédico-BH hospitals – Belo Horizonte, MG, Brazil. 2 – Third-year Resident of Hospital Belo Horizonte – Belo Horizonte, MG, Brazil. 3 – Surgeon of the Shoulder Group, Hospital Lifecenter and Clínica Ortopédico-BH – Belo Horizonte, MG, Brazil. Study conducted at the Lifecenter, Belo Horizonte and Clínica Ortopédico-BH hospitals– Belo Horizonte, MG. Mailing address: Rua Vicente Guimarães, 35/1.002, Belvedere – 30320-640 – Belo Horizonte, MG. Email: ggodinho@terra.com.br Study received for publication: 2/13/2011, accepted for publication: 5/25/2011.. The authors declare that there was no conflict of interest in conducting this work This article is available online in Portuguese and English at the websites: www.rbo.org.br and www.scielo.br/rbort

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Lesions vary in degree from tendinitis, delamination and subluxation on the medial border of the intertubercular groove, to its full dislocation, which can also cause a glenohumeral articular block(3). It was demonstrated that the diameter of unhealthy tendons is significantly larger than in normal tendons, and that the force required to cause the distal migration of the biceps is also significantly greater than that necessary in normal tendons(1,2). Multiple surgical techniques were described for the treatment of bicipital degeneration with the performance of tenodesis(4,5). Tenodesis was proposed by several authors as an alternative to avoid the cosmetic alteration caused by residual deformity (“Popeye”) and possible muscle discomfort after tenotomy(4). Some techniques use the fixation of the tendon in the intertubercular groove, while others use fixation in soft parts, partially or totally by arthroscopic route. Interference anchors are generally used in these cases(5). The aim of this study is the presentation of a tenodesis technique developed by the institution’s group of shoulder specialists, based on the normal and pathological anatomy of the long biceps tendon. The shape formed by suturing the stump on itself suggests the figure of a “Swiss roll”, exacerbating the diameter of the articular extremity of the tendon, which is normally larger than the extra-articular diameter. Consequently, there is an even more pronounced block of its distal migration, performed in a simple, low-cost manner.

Surgical technique Patient positioned in lateral decubitus with vertical and longitudinal traction mechanisms on the arm to be operated. General anesthesia associated with brachial plexus block. Classic arthroscopic posterior, lateral, anterior superior and anterior inferior portals. Joint inspection and identification of the bicipital lesion and its extension, besides that of the associated lesions(7). The biceps tendon is initially transfixed with double-row repair sutures, approximately 1.0 cm from its origin in the supraglenoid tubercle and upper labrum. Number 1, monofilament suture thread is used for this purpose, replaced after the passage of number 2 nonabsorbable thread (Figure 1). The tendon is sectioned close to the upper labrum, taking care to preserve its length as much as possible (Figure 2). After the tenotomy, the arm is removed from the longitudinal traction mechanism, the elbow is flexed to relax the biceps and the tendon is pulled outside through the anterior superior portal and maintained with maximum exposure while being fixed with a pair of forceps. At this time, the extremity is rolled around itself and transfixed with number 2 nonabsorbable thread, producing a configuration that resembles a “Swiss roll”, after which the technique was named (Figures 3A and 3B). After this, the elbow is once again placed in extension and the arm repositioned in the traction mechanism on the arthroscopy table. When it is distended,

METHODS A retrospective study was conducted with 81 patients (81 shoulders), operated in the period between 4/23/03 and 7/15/09, on whom we performed biceps tenodesis, according to the technique to be presented. The study was authorized by the medical ethics committees of the institutions involved. The criteria of indication of the bicipital tenodesis were: 1) patients submitted to the treatment of degenerative lesions involving approximately 50% of the diameter of the long head of biceps tendon, associated with rotator cuff lesions or separate; 2) subluxations and dislocations of this tendon(6). Rev Bras Ortop. 2011;46(6):691-96

Figure 1 – Transfixation of the biceps tendon with double-row repair suture approximately 1.0 cm from its origin.


“ROCAMBOLE-LIKE” BICEPS TENODESIS: TECHNIQUE AND RESULTS

Figure 2 – Biceps tenotomy.

Figure 3A – Externalization and suturing of the tendon stump on itself.

Figure 3B – Swiss roll: the dish whose appearance inspired the name of the technique.

693

the tendon stump migrates to the entrance of the intertubercular groove, where it is blocked. This is followed by the performance of the rotator cuff repair procedure, when necessary. In the case of deinsertion of the subscapularis tendon, this tendon is reinserted prior to the bicipital tenodesis. The immobilization time, when dealing with an isolated procedure of the biceps, is three weeks with the use of a velpeau sling. Flexion/extension exercises are allowed once a day, with restriction of the last 30 degrees of extension to avoid forcing the distal migration of the biceps. When isolated, tenodesis allows patients to resume contact and throwing sports 90 days after surgery. When associated with rotator cuff repair procedures, this resumption will depend on the extension of the cuff lesion, whose protocol is resumption of sports six months after surgery. The exclusion criteria were: patients with follow-up time of less than 12 months after surgery, those who did not attend the clinical revision and did not present complete medical records. A total of 63 patients (77.8%), with 31 (49%) males and 32 (51%) females, were evaluated. Age ranged from 32 to 77 years, averaging 55 years. Thirty-five patients (55.0%) were aged 60 years or over. The minimum follow-up was 12 months, averaging 43 months, with a maximum of 74. The right shoulder corresponded to 48 cases (76.2%), with one left-handed patient and 47 right-handed patients. The left shoulder represented 15 (23.8%), with two left-handed patients and 13 right-handed patients. There was no bilateral occurrence. Eighteen patients (28.6%) played sports with direct involvement of the arms. In 14 patients (22.2%) there was concomitant deinsertion of the subscapularis tendon. All the patients were evaluated by an independent examiner who did not take part in the surgery and the evaluations were carried out in the absence of the surgeons, avoiding the interference of their subjectivity. The cosmetic perception of the deformity caused by distal migration of the biceps (“Popeye sign”) was evaluated based on observations made by the examiner and the patient, as was the latter’s degree of satisfaction. Alteration of strength of elbow flexion and forearm supination, presence of pain or muscle Rev Bras Ortop. 2011;46(6):691-96


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fatigue and influence of the associated subscapularis tendon lesion and of playing sports involving direct action of the arms on the results were also evaluated. The patients were asked the following question: “Do you notice any modification in the contour of your operated arm in comparison to the non-operated arm? Are you satisfied, dissatisfied or indifferent in relation to your arm’s appearance?” The examiner was expected to verify the presence or absence of residual deformity in the arm, as well as pain and/or muscle fatigue, and to perform the clinical evaluation of elbow and forearm flexion strength.

STATISTICAL ANALYSIS The statistical analysis was carried out according to the resources of version 18 of the SPSS statistical program. Descriptive measures (mean and standard deviation, minimum and maximum) were used for the quantitative variables with frequency distributions for the qualitative variables(8,9). Contingency tables were used to associate the observer’s objective evaluation with the following variables: age bracket, physical activity, presence of lesions of the subscapularis tendon in the operated patients and objective evaluation of the patients. Pearson’s chi-square test, with continuity correction, was adopted to test the statistical significance of the association between and among such variables. A significance level of 5% was considered in all the statistical tests used. Therefore associations whose p value was below 0.05 are considered statistically significant(8,9).

RESULTS The results indicated that there is correlation between the evaluation of Popeye deformity carried out by the observer (examiner) and the patient. However, the observer’s evaluation to identify the presence of Popeye is more concise than that of the patient (p = 0.001) (Table 1). We were able to observe that the variable age of patients did not have statistical significance in the cross-evaluation with the occurrence of Popeye deformity (p = 0.883) (Table 2 and Figure 4). The statistical analysis showed absence of valid correlation between the practice of sports and the occurrence of Popeye deformity (p = 0.195) (Table 3 and Figure 5). Rev Bras Ortop. 2011;46(6):691-96

No statistically valid correlation was observed between the subscapularis tendon lesion and its corresponding repair with the occurrence of residual Popeye deformity (p = 0.958) (Table 4). Fifty-eight patients (92%) declared themselves satisfied; two (3.2%) dissatisfied; and three (4.8%) indifferent. No difference of strength of elbow flexion or forearm supination was observed during the physical evaluation in any patient. Weak residual pain was reported by two patients, which correspond to the unsatisfactory results (3.2%) (Figure 6). Table 1 – Analysis of the correlation between the objective evaluation of the patient and of the examiner with regards to the presence of Popeye deformity. Objective evaluation of Objective evaluation of the patient the examiner Total Without Without Popeye Popeye Popeye Cases 41 0 41 Without Popeye % 100.0% 0.0% 100.0% Cases 15 7 22 Popeye % 68.2% 31.8% 100.0% Total Cases 56 7 63   % 88.9% 11.1% 100.0%

P-value 0.001**

 

Pearson’s chi-square test, with continuity correction, of the association between the objective evaluation of the examiner and the objective evaluation of the patients from the sample.

.

Table 2 – Occurrence of Popeye deformity according to the examiner, related to the variable age, over or under 60 years. Objective evaluation of the examiner under 60 years Without Cases Popeye % Popeye Cases % Total Cases   %

Age bracket under 60 over 60 years years

Total

P-value

19

22

41

0.883

46.3% 9 40.9% 28 44.4%

53.7% 13 59.1% 35 55.6%

100.0% 22 100.0% 63 100.0%

 

Pearson’s chi-square test, with continuity correction, of the association between the objective evaluation of the examiner and the age bracket of the patients from the sample.

Table 3 – Analysis of the correlation between physical activity and Popeye deformity, according to the examiner. Objective evaluation of the observer Without Cases Popeye % Popeye Cases % Total Cases  

%

Physical activity No Yes

Total

P-value 0.195

32

9

41

78.0% 13 59.1% 45

22.0% 9 40.9% 18

100.0% 22 100.0% 63

71.4%

28.6%

100.0%

 

Pearson’s chi-square test, with continuity correction, of the association between the objective evaluation of the observer and the physical activity of the patients from the sample.


“ROCAMBOLE-LIKE” BICEPS TENODESIS: TECHNIQUE AND RESULTS

695

Satisfied Dissatisfied Indifferent

Popeye deformity Popeye deformity observed by the observed only by patient the observer Age 60 years or over

Age under 60 years

Absence of deformity observed by the patient and observer

Figure 4 – Occurrence of Popeye deformity according to the evaluation of the patient and of the examiner, relating to the variable age, over or under 60 years (p = 0.883).

Deformity Absence of Popeye deformity observed only by deformity observed observed by the patient the observer by the patient and Practicing sports observe Not practicing sports

Figure 5 – Analysis of the correlation between physical activity and Popeye deformity according to the examiner and the patient. (p = 0.195).

Table 4 – Analysis of the correlation between Popeye deformity and lesion of the subscapularis tendon. Objective evaluation of Subscapularis lesion the observer Yes No Without Popeye Cases % Popeye

Total

P-value 0.958

30

11

41

73.2%

26.8%

100.0%

Cases

17

5

22

%

77.3%

22.7%

100.0%

Total

Cases

47

16

63

 

%

74.6%

25.4%

100.0%

 

Pearson’s chi-square test, with continuity correction, of the association between the objective evaluation of the observer and the subscapularis lesion in the patients from the sample.

Figure 6 – Degree of satisfaction of the patients according to the esthetic and functional result.

DISCUSSION The long head of biceps tendon is a frequent cause of pain in the shoulder. Gilcreest(10) was the first author to describe tenodesis of the long head of the biceps, fixing it in the coracoid process. Since then, multiple techniques have been described, some with fixation of the tendon in the intertubercular groove(11,12) and others with fixation in soft parts, partially or totally by arthroscopic approach(13). Almeida et al(14), in analyzing a group of 77 patients submitted to arthroscopic tenotomy of the long head of biceps tendon, noted that there were no complaints of esthetic deformity in 50 (64.9%) patients, while 27 (35.1%) expressed some complaint. In our sample, we observed that the patient perceived residual Popeye deformity after tenodesis in 11.1% of the cases (seven patients). The complete absence of residual deformity was observed in 65% (41 patients). The results indicated that there is a relationship between the evaluation of the observer and that of the patient; however, the observer’s evaluation to identify the presence of Popeye is more concise than that of the patient (p = 0.001) (Table 1). Szabó et al(3) used the criterion of age to indicate tenotomy or tenodesis, preferring tenodesis for more active patients under 60 years of age. The same authors noted that patients aged between 45 and 55 years appear more concerned about the cosmetic aspect of the residual deformity after spontaneous rupture of the biceps long head, which is not the case in patients over 65 years of age, partly due to the atrophy and loss of muscle tone related to age(3). Rev Bras Ortop. 2011;46(6):691-96


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Besides the concern with the cosmetic aspect, the possible deficit of strength at the level of the elbow and forearm is a recommendation for tenodesis instead of tenotomy, in patients under 55 years of age(3). Almeida et al(14) did not find statistical significance when they performed the cross-evaluation between the patients’ ages and the esthetic complaint of residual deformity. The mean age of the patients in our sample was 55 years, ranging between 32 and 77 years. When we divided the study group into two subgroups, over and under 60 years of age, respectively, we were able to note that the patients’ age did not have statistical significance in the cross-evaluation with the occurrence of Popeye deformity (p = 0.883) (Table 2 and Figure 4). Tenodesis is recommended in physiologically young, active patients under 50 years of age, either in association with or without arthroscopic subacromial decompression(15). Eighteen patients played contact or throwing sports in our study group, corresponding to 28.6%. The statistical analysis showed absence of valid correlation between these sports and the occurrence of Popeye deformity (p = 0.195) (Table 3 and Figure 5). A question that is always raised in relation to the type of technique described concerns its safety when there is deinsertion of the subscapularis tendon, reinserting this tendon in the lesser tubercle in the same surgery. This condition typically occurs in throwing athletes,

requiring the correction of both deformities(15). In our sample, we observed the association of lesion caused by complete deinsertion of the subscapularis tendon and bicipital lesion, with performance of tenodesis in 14 patients (22.2%). No statistically valid correlation was observed between the subscapularis tendon lesion and its corresponding repair, with the occurrence of residual Popeye deformity (p = 0.958) (Table 4). Walch et al(16) observed the presence of Popeye deformity in 50% of the patients submitted to arthroscopic tenotomy. However, it was observed that the cosmetic deformity of the arm does not usually cause the patient discomfort. Furthermore, no patient characterized its result as fair or poor with a basis on the cosmesis. The degree of satisfaction of the patients showed 58 satisfied (92.06%), two dissatisfied (3.17%) and three patients (4.76%) who declared themselves indifferent with regards to the residual deformity (Popeye) observed (Figure 6).

CONCLUSION “Swiss roll” biceps tenodesis presents high percentages of satisfaction (92.06%); residual Popeye deformity is perceived by 11.1% of the patients. Its appearance has no statistically valid correlation with the age bracket over or under 60 years (p = 0.883), with sports (p = 0.195) or with the associated lesion of the subscapularis tendon and its repair (p = 0.958).

REFERENCES 1. Yamaguchi K, Bindra R. Disorders of the bíceps tendon. In: Ianotti JP, Willians GR Jr, editors. Disorders of the shoulder: diagnosis and management. Philadelphia: Lippincott Williams and Wilkins; 1999. p. 159-90. 2. Ahmad SC, DiSipio C, Lester J, Gardner RT, Levine NW, Bigliani L. Factors affecting dropped biceps deformity after tenotomy of the long head of the biceps tendon. Arthroscopy. 2007;23(5):537-41. 3. Szabó I, Boileau P, Walch G. The proximal biceps as a pain generator and results of tenotomy. Sports Med Arthrosc Rev. 2008;16(3):180-6. 4. Boileau P, Krishnan SG, Coste JS, Walch G. Arthroscopic biceps tenodesis:a new technique using bioabsorbable interference screw fixation. Arthroscopy. 2002;18(9):1002-12. 5. Mazzoca DA, Bicos J, Santangelo S, Romeo AA, Arciero AR. The biomechanical evaluation of four fixation techniques for proximal bíceps tenodesis. Arthroscopy. 2005;21(11):1296-306. 6. Crenshaw AH, Kilgore WE. Surgical treatment of bicipital tenosynovites. J Bone Joint Surg Am.1966;48(8):1496-502. 7. Godinho GG, Souza JMG, Bicalho LA. Reparo das rupturas do manguito rotador do ombro pela videoartroscopia cirúrgica: técnica. Rev Bras Ortop. 1996;31(4):284-8. 8. Cohen J. Statistical power analysis for the behavioral sciences. 2nd. ed. New Jersey: Editora Lawrence Erlbaum Associates; 1988. Rev Bras Ortop. 2011;46(6):691-96

9. Triola MF. Introdução à estatística. 7a. ed. Rio de Janeiro: LTC Editora; 1998. 10. Gilcreest EL. Two cases of spontaneous rupture of the long head of the bíceps flexor cubiti. Surg Clin North Am. 1926;6:539-54. 11. Lippman RK. Frozen shoulder, periarthritis, bicipital tenosynovitis. Arch Surg. 1943;47:283-96. 12. Hitchcock HH, Bechtol CO. Painful shoulder; observations on the role of the tendon of the long head of the biceps brachii in its causation. J Bone Joint Surg Am. 1948;30(2):263-73. 13. Mazzoca DA, Bicos J, Santangelo S, Romeo AA, Arciero AR. The biomechanical evaluation of four fixation techniques for proximal biceps tenodesis. Arthroscopy. 2005;21(11):1296-306. 14. Almeida A, Roveda G, Scheifler C. Avaliação da deformidade estética após a tenotomia da cabeça longa do bíceps na artroscopia do ombro. Rev Bras Ortop. 2008;43(7):271-8. 15. Busconi BB, DeAngelis N, Guerrero EP. The proximal bíceps tendon:Tricks and pearls. Sports Med Arthrosc Rev. 2008;16(3):187-94. 16. Walch G, Edwards TB, Boulahia A, Nové-Josserand L, Neyton L, Szabo I. Arthroscopic tenotomy of the long head of the biceps in the treatment of rotator cuff tears: clinical and radiographic results of 307 cases. J Shoulder Elbow Surg. 2005;14(3):238-46.


ORIGINAL ARTICLE

LOW-LEVEL LASER THERAPY AFTER CARPAL TUNNEL RELEASE

Marcelo de Pinho Teixeira Alves1, Gabriel Costa Serrão de Araújo2

Abstract Objective: Evaluate the post-operative treatment of CTS, using the LLLT. Method: We prospectively evaluated 58 patients with CTS, randomly divided into two groups: treatment with LLLT (Group 1) and placebo (Group 2). A 830 nm gallium-aluminum-arsenic laser was used, with a power of 30 mW. Results: There was female predominance in both groups. The mean age of the patients in Group 1 was 44.3 years and in Group 2, 51.9 years. The average duration of disease progression was around two years in both groups. The average time elapsed since discharge from treatment was 3.6 months in both groups, and fewer patients had postoperative complaints in Group 1 than in Group 2. At the end of the treatment, in

IntroduCTION Carpal tunnel syndrome (CTS) is a disease characterized by compression of the median nerve when this passes below the flexor retinaculum of the wrist, and is associated with functional alterations of the nerve(1). Individuals with the disease in an advanced stage present the median nerve extended in the region proximal to the carpal tunnel and stenosed inside the tunnel, with a bluish coloration, typical of chronic ischemia. Atrophy of the thenar region may be present in these cases(1). Patients usually complain about progressive loss of strength in the hand, especially in thumb opponency, paresthesia in median nerve sensory distribution and pain in the palmar region, with characteristic nighttime pain that causes awakening from sleep. Both hands can be affected, yet the symptoms are

Group 1, 29.41% of the patients presented electromyographic abnormalities, while in Group 2, 63.64% of the patients had abnormalities, after six months. Conclusion: This was an initial study on adjuvant therapy using postoperative LLLT on CTS. The method presented was sufficient for postoperative evaluation of the patients in this study. Patients undergoing LLLT after surgery for CTS were benefited and had better functional outcomes than shown by the control group. The technique was effective and did not have any adverse effects on the patients studied. Keywords - Carpal Tunnel Syndrome; Median Neuropathy; Laser Therapy, Low-Level; Postoperative Period

generally worse in the dominant hand. Middle-aged women constitute the majority of patients(1). The clinical diagnosis is based on the history of the disease and physical examination, especially Tinel’s sign and the Phalen and Durkan tests. Tinel’s sign is verified with digital percussion along the course of the median nerve through the carpal tunnel, which causes an electric shock sensation in the nerve distribution territory. Phalen’s test consists of flexion of the wrists with the elbows flexed at 90° and shoulders in abduction in the scapular plane of 90°, for approximately one minute, causing exacerbation of the sensory alterations perceived by the patient(1). Compression of the wrist caused by the examiner induces pain and also exacerbates the symptoms, and is called the Durkan test; it is the most sensitive of clinical tests for the disease(2). Factors associated with the disease include obe-

1 – Full Member of the Brazilian Association of Hand Surgery; Studying towards Master’s Degree in Medical Sciences from Universidade Federal Fluminense; Physician of the Hand Surgery Outpatient Clinic of Hospital Universitário Antônio Pedro – Universidade Federal Fluminense – Niterói, RJ, Brazil. 2 – Third-year Orthopedics and Traumatology Resident of Hospital Universitário Antônio Pedro – Universidade Federal Fluminense – Niterói, RJ, Brazil. Study conducted at the Orthopedics and Traumatology Clinic of Hospital Universitário Antonio Pedro of the Universidade Federal Fluminense – UFF. Mailing address: Serviço de Ortopedia do HUAP/UFF, Av. Marques de Paraná, 303 – 24033-090 – Niterói, RJ. Email: marceloptalves@hotmail.com Study received for publication: 7/7/2010, accepted for publication: 7/4/2011. The authors declare that there was no conflict of interest in conducting this work This article is available online in Portuguese and English at the websites: www.rbo.org.br and www.scielo.br/rbort

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sity, hypothyroidism, diabetes mellitus, pregnancy, kidney disease, inflammatory arthritis, acromegaly, mucopolysaccharidosis, advanced age, smoking and extreme, repetitive flexion of the wrist(2). It is necessary to investigate other diseases that cause similar symptoms, such as: cervical radiculopathy, lesions of the brachial plexus, thoracic outlet syndrome, neoplasias of the pulmonary apex, pronator syndrome, cubital and ulnar tunnel syndromes and secondary peripheral neuropathies. Electrophysiological evaluations of the median nerve, such as nerve conduction velocity and electromyography, are used to confirm the clinical diagnosis. The decrease in amplitude of the action potential, the increase of distal latency and the reduction of nerve conduction velocity are findings considered abnormal. Distal motor and sensory latencies above 4.2ms and 3.5ms, respectively, are generally considered parameters of abnormality(3). There are recent studies suggesting the complementary use of wrist ultrasonography, with measurement of the cross-sectional area of the median nerve, as an aid in the diagnosis and supervision of CTS treatment(4). Some authors relate the diseaseâ&#x20AC;&#x2122;s diagnosis and its severity to the results obtained after evaluation of the self-administered Boston questionnaire(5). Therapeutic methods range from observation of disease evolution alone, wrist immobilization and local injection of corticosteroids, to surgery(6). Conservative treatments have satisfactory results in most cases, when the symptoms have been present for less than a year(2). Surgery is reserved for cases that are refractory to conservative treatment and for those in advanced stages of the condition, with atrophy of the thenar region or electrophysiological evidence of denervation. The complications of surgery are well documented in literature and include the persistence of symptoms, which is closely related to the surgeonâ&#x20AC;&#x2122;s experience for complete release of the carpal tunnel(2). Common concerns in the postoperative period are pain, relief of nerve compression symptoms, sensitivity of the scar and time taken to return to work(7). As an alternative to the conservative treatments described for CTS, many studies have investigated the results of low-level laser therapy (LLLT) in the relief of symptoms and in the functional recovery of the median nerve. In patients with slight and moderate CTS, Chang verified that laser therapy was effective in the relief of pain and symptoms, and improved the Rev Bras Ortop. 2011;46(6):697-701

functional ability of the fingers and strength of the hand, not observing side effects(8). Yagci et al(9) compared the treatment using immobilization of the wrist and immobilization associated with sessions of lowlevel laser therapy in patients with CTS, concluding that the electrophysiological parameters were better after the associated treatment. A randomized, doubleblind, placebo-controlled Canadian trial, conducted with 16 patients with CTS, demonstrated a placebo effect of LLLT, and the inefficacy of the therapeutic method(10); Bakhtiary and Rashidy-Pour concluded that ultrasound is superior to laser therapy in the conservative treatment of CTS(11). In the comparison between LLLT and surgical release of the carpal tunnel for the treatment of CTS, it was concluded that laser therapy is effective in initial cases with slight to moderate symptoms, when pain is the main symptom present, while surgery is reserved for advanced and chronic cases of the disease. These authors also suggest using LLLT to relieve residual pain after surgical treatment(12). It is believed that low-level laser radiation stimulates cell proliferation, by a photochemical reaction that changes the permeability of the cell membrane. Laser therapy has been used to stimulate the healing of wounds, for neuronal regeneration and in pain control. Rochkind et al(13) demonstrated the presence of stimulation of cell growth of rat embryo neurons that received laser therapy radiation in comparison to a control group of non-radiated rats. Gigo-Benato et al(14) and Rochkind et al(15) published an extensive bibliographic review of experimental basic studies that demonstrate the stimulation of laser therapy in neuronal growth and in the functional recovery of injured peripheral nerves. A controlled experiment on rats assessed the functional recovery of the ischiatic nerve and the histology of the nerve after three weeks of LLLT for the treatment of surgical crushing of the nerves, concluding that the laser effectively accelerated neuronal regeneration(16). This study aims to compare the postoperative results of the patients treated with low-level laser therapy with those of the patients treated with placebo laser, in relation to the parameters of pain, persistence of symptoms, return to work or to daily activities and neurophysiological recovery, observed by electroneuromyography.


LOW-LEVEL LASER THERAPY AFTER CARPAL TUNNEL RELEASE

CasuISTRY AND METHOD The study was composed of 58 patients with carpal tunnel syndrome treated at the Hand Surgery Outpatient Clinic, assessed between May 2009 and January 2011. The patients confirmed their agreement to participate in the study by signing an informed consent form. The eligibility criteria of this study included patients with a clinical and electroneuromyographic diagnosis of carpal tunnel syndrome, with normal laboratory tests (leukogram, erythrogram, coagulogram, glucose, urea, creatinine, sodium, potassium), and wrist radiographs without osteoarticular lesions. Individuals already submitted to surgical procedures involving the wrist, those who received infiltration at the site, pregnant or breastfeeding women, those using an experimental drug, patients with active infection, or myocardial infarct less than six months earlier or other diseases without adequate clinical control were excluded from the study. The surgical technique was the same for all the patients from the study, with the classic, longitudinal access route, anterior to the flexor retinaculum, with release of the flexor retinaculum of the wrist, without the performance of median nerve microneurolysis in any patient. The patients were randomly and sequentially divided into two groups: group 1 – low-level laser therapy (LLLT); group 2 – placebo laser therapy (PLT). The treatment was performed in 10 daily, consecutive sessions, with an interval of two days (weekend), using a total of three Joules, at three points of the carpal tunnel (in the topography of the pisiform bone, in the middle of the carpal tunnel and at the distal limit of the carpal tunnel). Neither group of patients knew the identity of the members of the placebo group or treatment group. The equipment used was the aluminum gallium arsenide Ibramed® laser pen, with a wavelength of 830nm, and power of 30mW. Both groups were assessed regularly by the surgeon after the procedure, in visits two weeks after surgery, and in the first, second, third and sixth postoperative months, or until the patients were asymptomatic and capable of returning to work or to their activities of daily living. During the visits, they were evaluated in terms of symptoms of palmar pain, pillar pain, paresthesia, nighttime pain, pain or discomfort at the site of the scar and Tinel›s test, as well as time taken to return to activities of daily living or to work.

699

Electroneuromyography was performed in the sixth postoperative month, or when the patient was asymptomatic (if this occurred earlier). The univariate analysis was conducted using Fisher›s exact test to indicate the statistical difference between the groups.

Results The patients from group 1 totaled 29. They were all treated surgically and submitted to low-level laser therapy in the wrist during the postoperative period; of these, eight were male and 21 female, with ages ranging between 25 and 80 years (mean age 44.3 years), with 17 right wrists and 12 left; the disease evolution time ranged between six months and 10 years (mean time 1.97 years). Group 2 was formed by 29 patients, four of whom were male and 25 female, with ages between 24 and 89 years (mean age 51.9 years); 19 right wrists and 10 left; the disease evolution time ranged between six months and 10 years (mean time of two years and two months). The patients were monitored by the surgeon after the procedure until the symptom complaints ceased and the patients were discharged from the treatment program. Thus in both groups the mean time to discharge was 3.6 months, whereas in group 1 it ranged from one to six months to discharge, and in group 2 from one to eight months. The electroneuromyographic examinations were performed before surgery and six months after surgery, except in cases in which the patient had been discharged from the treatment program before the six months. In group 1, the examination showed abnormalities in 100% of the patients at the beginning of the treatment and in 29.41% at the end. In group 2, we had 92.60% of the patients with neurofunctional alterations at the beginning of the treatment and 63.64% at the end of the study. The evaluation of the patients performed at one, two, three and six months considered the complaints of symptoms and the clinical signs of the disease. The results are demonstrated in Table 1, which lists the number of patients and the clinical findings over time. Figure 1 records the total number of patients from both groups with clinical alterations in each evaluation. Figures 2 and 3 individualize the groups and the postoperative complaints. No patient abandoned the study, or declared themselves dissatisfied with the treatment. They all reRev Bras Ortop. 2011;46(6):697-701


turned to their daily activities and were asymptomatic upon medical discharge. No complications were observed in relation to the surgical procedure, nor did any of the patients from the study groups require further surgery.

Gráfico do Grupo 1 (Figura 3)  Gráfico do Grupo 1 (Figura 3) 

Table 1 – Postoperative clinical evaluation.  

 

Painful scar

 

 

 

 

 

Pillar Nighttime Palmar Clinical Numbness pain pain pain signs

Group 1 – number of patients Group 2 – number of patients Second month

9

8

3

0

8

3

16

6

8

0

11

1

 

 

 

 

 

 

 

Painful scar

Group 1 – number of patients Group 2 – number of patients Third month   Group 1 – number of patients Group 2 – number of patients Sixth month  

3

0

1

6

0

6

3

 

 

 

 

 

 

almar pain Clinical signs

First month Second month Third month Sixth month

 

Figure 2 – Evolution of complaints of group 1. Gráfico do Grupo 2 (Figura 4) 

 

Gráfico do Grupo 2 (Figura 4) 

Pillar Nighttime Palmar Clinical Numbness pain pain pain signs

1

4

0

0

0

0

3

6

3

0

1

0

 

 

 

 

 

Pillar Nighttime Palmar Clinical Numbness pain pain pain signs

0

0

0

0

1

0

1

1

2

0

1

0

Source: SOT/HUAP

Group Grupo 2

Número Numberde of pacientes patients

Grupo Group11

Preoperative

Nighttime pain

0

7

Painful scar

Group 1 – number of patients Group 2 – number of patients

0

6

 

Numbness

Nighttime Palmar Clinical Pillar Numbness pain pain pain signs 4

Painful scar

Pillar pain

st

1 month

2

nd

month

rd

3 month

th

6 month

Figure 1 – Total number of patients with complaints, from both groups. Rev Bras Ortop. 2011;46(6):697-701

Painful scar

Number of patients

First month

Painful scar

Number of patients

700

Pillar pain Numbness Nighttime pain Palmar pain Clinical signs

First month Second month Third month Sixth month

 

 

 Figure 3 – Evolution of complaints of group 2.

DiscussION Carpal tunnel syndrome is a frequent disease at orthopedic and hand surgery outpatient clinics, with high prevalence in the general population. It is the most common and most extensively studied compressive neuropathy in humans. Failures in conservative treatment lead to a large number of patients submitted to surgery. The experimental model presented in this trial was established to propose a method that accelerates the functional recovery of patients submitted to surgery for the treatment of carpal tunnel syndrome, testing its efficacy. The search in medical literature did not produce any trial that could test the efficacy of lowlevel laser therapy in the postoperative state of carpal tunnel syndrome; therefore, the unprecedented nature of this study hinders the comparison of our results. There are several studies that evaluate the postoperative results of release of the flexor retinaculum of the wrist for the treatment of carpal tunnel syndrome,

 


LOW-LEVEL LASER THERAPY AFTER CARPAL TUNNEL RELEASE

with high rates of satisfactory results(1,2,7,17). Our sample coincides with literature in terms of the predominance of female patients, mean age, preoperative symptoms and diversity of postoperative complaints. The analysis of results evidences that patients treated with adjuvant laser therapy in the postoperative stage had fewer complaints in this period. Literature lists a painful scar as the main complaint of operated patients. This also occurred in our study; however, in the first month, 31.03% of the patients from group 1 had such a complaint, against 55.17% from group 2. In the following months, references to the painful scar symptom were constantly less common in group 1 than in group 2. Pillar pain is also frequently associated with surgical failure, and it was present in our patients’ complaints, yet progressively decreased during postoperative follow-up, and was nonexistent in group 1 after the sixth month. Numbness (paresthesia) was also a frequent complaint, with incidence in 18.96% of the individuals in the first month, but in the second month none of them noticed such a symptom. Nighttime pain was not experienced by any of the patients from either one of the groups in the postoperative period. Pain in the palmar region was experienced by 32.76% of the patients in the first month, and to a lesser extent in those submitted to phototherapy. The clinical signs of the disease were still present in 10.34% of the patients from group 1 in the first month and ceased in the following evaluations. The neurofunctional evaluations demonstrated better results in the patients submitted to LLLT. The various studies demonstrating the results of LLLT in neuronal regeneration and in the conservative

701

treatment of CTS led us to believe that laser therapy could be useful in the functional recovery process of the median nerve and could alleviate the symptoms perceived after the surgical procedure. Although it is an intuitive process at first, we sought an analytical method to test the hypothesis. The study design was aimed at controlling treatment with the placebo and there was randomization to distribute the participants. We did not achieve the necessary structure to exclude the surgeon’s awareness of the group to which the patients belonged. But we believe that the fact that only the evaluator knew whether the patients were being treated with laser or placebo led to slight distortion of results, since the evaluated complaints originated from the patients and not from subjective evaluations by the examiner. The electroneuromyographies were executed by examiners who did not come into contact with the study data, and thus produced objective results.

ConclusIONS We consider this an initial study on the adjuvant therapeutic approach using low-level laser therapy in the postoperative period of carpal tunnel syndrome. Other studies will be necessary to validate the technique. We concluded that the methodology presented was sufficient for the postoperative evaluation of the patients from the study. The patients submitted to low-level laser therapy after surgical release of the flexor retinaculum in the wrist benefited from the treatment and obtained better functional results than those from the control group. The technique was effective and without adverse effects among our patients.

ReferEncEs 1. Phalen GS. The carpal-tunnel syndrome. Seventeen years’ experience in diagnosis and treatment of six hundred fifty-four hands. J Bone Joint Surg Am. 1966;48(2):211-28. 2. Howard RF. Hand and microsurgery. In: Miller M, editors. Review of orthopaedics. Philadelphia: Saunders; 2004. p. 308-312. 3. Pardini Júnior A, Freitas A, Tavares K. Antebraço, punho e mão. In: Hebert S, Barros Filho T, Xavier R, Pardini Júnior A, editores. Ortopedia e traumatologia – princípios e prática. Porto Alegre: Editora Artmed; 2009. p. 231-253. 4. Seror P. Sonography and electrodiagnosis in carpal tunnel syndrome diagnosis, an analysis of the literature. Eur J Radiol. 2008;67(1):146-52. 5. Heybeli N, Kutluhan S, Demirci S, Kerman M, Mumcu EF. Assessment of outcome of carpal tunnel syndrome: a comparison of electrophysiological findings and a self-administered Boston questionnaire. J Hand Surg Br. 2002;27(3):259-64. 6. Cranford CS, Ho JY, Kalainov DM, Hartigan BJ. Carpal tunnel syndrome. J Am Acad Orthop Surg. 2007;15(9):537-48. 7. Henrique A. Avaliação pós-operatória de 237 liberações cirúrgicas abertas para o tratamento de síndrome do túnel do carpo. Rev Bras Ortop. 2003;38(7):381-90. 8. Chang WD, Wu JH, Jiang JA, Yeh CY, Tsai CT. Carpal tunnel syndrome treated with a diode laser: a controlled treatment of the transverse carpal ligament. Photomed Laser Surg. 2008;26(6):551-7. 9. Yagci I, Elmas O, Akcan E, Ustun I, Gunduz OH, Guven Z. Comparison of splint-

ing and splinting plus low-level laser therapy in idiopathic carpal tunnel syndrome. Clin Rheumatol. 2009;28(9):1059-65. 10. Irvine J, Chong SL, Amirjani N, Chan KM. Double-blind randomized controlled trial of low-level laser therapy in carpal tunnel syndrome. Muscle Nerve. 2004;30(2):182-7. 11. Bakhtiary AH, Rashidy-Pour A. Ultrasound and laser therapy in the treatment of carpal tunnel syndrome. Aust J Physiother. 2004;50(3):147-51. 12. Elwakil TF, Elazzazi A, Shokeir H. Treatment of carpal tunnel syndrome by lowlevel laser versus open carpal tunnel release. Lasers Med Sci. 2007;22(4):265-70. 13. Rochkind S, El-Ani D, Nevo Z, Shahar A. Increase of neuronal sprouting and migration using 780 nm laser phototherapy as procedure for cell therapy. Lasers Surg Med. 2009;41(4):277-81. 14. Gigo-Benato D, Geuna S, Rochkind S. Phototherapy for enhancing peripheral nerve repair: a review of the literature. Muscle Nerve. 2005;31(6):694-701. 15. Rochkind S, Geuna S, Shainberg A. Phototherapy in peripheral nerve injury: effects on muscle preservation and nerve regeneration. Int Rev Neurobiol. 2009;87:445-64. 16. Endo C, Barbieri CH, Mazzer N, Fasan VS. A Laserterapia de baixa intensidade acelera a regeneração de nervos periféricos. Acta Ortop Bras. 2008;16(5):305-310. 17. Alves MPT. Estudo prospectivo comparativo entre a descompressão do canal do carpo pela mini-incisão transversa proximal e a incisão palmar longitudinal convencional. Rev Bras Ortop. 2010; 45(5):437-444. Rev Bras Ortop. 2011;46(6):697-701


ORIGINAL ARTICLE

Treatment of osteochondral lesions of the talus by means of thearthroscopy-assisted microperforation technique

Everton de Lima1, Felipe de Queiroz2, Osmar Valadão Lopes Júnior3, Leandro de Freitas Spinelli4

Abstract Objective: To evaluate patients affected by osteochondral fractures of the talus who were treated surgically by means of arthroscopy-assisted microperforation. Methods: A retrospective study was carried out on 24 patients with osteochondral lesions of the talus who underwent microperforation assisted by videoarthroscopy of the ankle. They were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) score system before and after the operation. Results: There were 19 men and 5 women, with a

INTRODUCTION The evolution of orthopedics produced the development of minimally invasive surgical techniques for the diagnosis and treatment of orthopedic pathologies. Arthroscopic surgery of the ankle allows the approach to intra-articular structures without extensive incisions, increasing the diagnostic capacity and allowing the execution of less aggressive surgical correction techniques. Munro(1), in 1856, was the first author to describe the existence of free bodies in the ankle joint. Barth(2), in 1898, considered the osteochondral lesion of the talus as being an intra-articular fracture. Kappis(3) used the term “osteochondritis dissecans of the talus” for

mean age of 35.3 years (minimum of 17 years and maximum of 54 years). The minimum follow-up was two years (maximum of 39 months). All the patients showed an improvement in AOFAS score after surgery, with an average improvement of around 22.5 points. Conclusion: Videoarthroscopy-assisted microperforation is a good option for treating osteochondral lesions of the talus and provides good functional results. Keywords - Osteochondral; Talus/injuries; Talus/surgery; Arthroscopy; Ankle

the first time in 1922. Berndt and Harty(4) suggested that the name “transchondral fracture” would be the best definition, both from the etiological and from the pathophysiological point of view. Ferkel et al(5) introduced the term “osteochondral lesions of the talus” (OLT) as the most appropriate for describing chondral lesions that involve the articular surface of the talus. There is a difference of opinion among the authors regarding the location and frequency of chondral lesions of the talus. Berndt and Harty(4) and Roach and Frost(6) suggest that osteochondral lesions of the talus occur in two areas of the talar dome: the anterolateral region and the posteromedial region. Elias et al(7) divided the talar dome into nine zones and suggested

1 – Orthopedist and Traumatologist; Head of the Foot and Ankle Surgery Clinic of the Instituto de Ortopedia e Traumatologia de Passo Fundo, RS; Member of the Sociedade Brasileira de Ortopedia e Traumatologia (Brazilian Society of Orthopedics and Traumatology) and of the Sociedade Brasileira de Cirurgia do Pé e Tornozelo (Brazilian Society of Foot and Ankle Surgery). 2 – Orthopedist and Traumatologist of the Vitória Apart Hospital – Vitória, ES; Specialist in Foot and Ankle Surgery; Member of the Sociedade Brasileira de Ortopedia e Traumatologia. 3 – Orthopedist and Traumatologist; Preceptor of the Instituto de Ortopedia e Traumatologia de Passo Fundo, RS; Member of the Sociedade Brasileira de Ortopedia e Traumatologia and of the Sociedade Brasileira de Cirurgia do Joelho (Brazilian Society of Knee Surgery). 4 – Orthopedist and Traumatologist, Instituto de Ortopedia e Traumatologia de Passo Fundo, RS; Master’s and Doctoral Degree from the Universidade Federal do Rio Grande do Sul. Study conducted at the Instituto de Ortopedia e Traumatologia de Passo Fundo, RS. Mailing address: Instituto de Ortopedia e Traumatologia de Passo Fundo, Rua Uruguai 2.050 – 99010-220 – Passo Fundo, RS, Brazil. Email: evelimany@hotmail.com / scjp@iotrs.com.br Study received for publication: 8/18/2010, accepted for publication: 5/25/2011. The authors declare that there was no conflict of interest in conducting this work This article is available online in Portuguese and English at the websites: www.rbo.org.br and www.scielo.br/rbort

Rev Bras Ortop. 2011;46(6):702-08


TREATMENT OF OSTEOCHONDRAL LESIONS OF THE TALUS BY MEANS OF THEARTHROSCOPY-ASSISTED microperforation technique

that the most severely affected zones would be zone 4 (medial and central) and, in second place, zone 6 (mid-lateral). Medial lesions, besides being more frequent, are also larger and deeper than lateral lesions. Fractures of the lateral portion of the talar dome occur when inversion force affects the foot in dorsiflexion, while fractures of the medial portion are produced upon inversion on the foot in equinus(4). Clinically, patients with osteochondral lesions of the talus refer to nonspecific pains of low intensity involving the ankle joint. They also report edema, clicking, blocks and a buckling sensation in the affected ankle. A previous history of traumatism involving the ankle joint is common in most cases. Regarding the physical examination, patients generally present medial or lateral hypersensitivity in the ankle accompanied by limitation of range of motion and edema, and may present signs of ankle instability(8). The diagnosis of osteochondral lesions of the talus requires a high suspicion rate. The period between the onset of symptoms and the definitive diagnosis can range from four months to up to two years(9,10). In many cases, the radiological alterations are slight and only appear some months after the onset of the symptoms. Nowadays, computed tomography and particularly nuclear magnetic resonance of the ankle are essential in the early diagnosis of osteochondral lesions of the talus(8,11,12). The osteochondral lesion is classified radiologically, according to Berndt and Harty(4), in four stages: I – small area of compression of subchondral bone; II – partially detached osteochondral fragment; III – completely detached osteochondral fragment; IV – displaced osteochondral fragment(4). The treatment of osteochondral lesion of the talus can be a major challenge due to the low intrinsic reparability of the articular damage(13). Most authors defend surgical treatment as the most appropriate means of treatment of osteochondral lesions of the talus(9,14-16), while some still believe that the conservative treatment is the best conduct to be employed(17). In this context, videoarthroscopy of the ankle offers an adequate treatment with lower morbidity and an accelerated return to sports and daily activities(8), besides offering the chance of a careful articular inspection and lavage after the procedure for removal of loose debris(18). During the videoarthroscopy procedure, Van Bergen et al(18) suggest that the treatment of osteochon-

703

dral lesion defects smaller than 15 mm be executed by debridement and stimulation of the spongy bone. For cystic lesions, retrograde drilling associated with bone graft is a good alternative. Osteochondral autograft or autologous chondrocyte implantation are recommended for secondary cases, as well as for larger lesions. Takao et al(19) propose the same procedure. Giza et al(13) also use the autologous chondrocyte graft, but in the treatment of patients who do not respond to curettage of the cyst and subsequent microperforations. Nery and Carneiro(15) carry out the same procedure as an alternative method in cases in which the patient continues with complaints after the conservative or surgical treatment, also with good results. More recently, Nery et al(20) analyzed the results of autologous chondrocyte implantation in patients submitted to previous surgical treatment without the obtainment of satisfactory results in terms of healing of the lesion and the remission of symptoms. The authors noted that autologous chondrocyte implantation is a safe and effective method for the treatment of osteochondral lesions of the talus. Cohen et al(21) also present autologous chondrocyte implantation as a promising technique for chondral lesions of the knee and of the talus. Other authors still advocate the use of mosaicplasty(22) or fresh talus allograft(23). Gras et al(24) propose the use of navigation in association with arthroscopy aiming to improve the accuracy of the retrograde perforation of cystic osteochondral lesions. The objective of this study is to evaluate patients with osteochondral lesion of the talus treated with videoarthroscopy-guided microperforations.

MATERIALS AND METHODS A retrospective study was conducted with 24 patients affected by osteochondral lesion of the talus submitted to ankle arthroscopy-assisted microperforations between August 2007 and December 2009. All the patients were operated by the same surgeon at the Instituto de Ortopedia e Traumatologia de Passo Fundo, Rio Grande do Sul. The preoperative evaluation was based on the review of medical records and on interviews with the patients in routine reviews in the postoperative period. All the patients presented a profile of pain in the ankle and limitation of their daily and sports activities for more than three months, prior to the surgical treatment, and they all reported previous trauma. Rev Bras Ortop. 2011;46(6):702-08


704

All the patients were evaluated through anteroposterior, lateral and oblique radiographies (Figure 1) and by nuclear magnetic resonance (NMR) (Figure 2). The scoring system of the American Orthopaedic Foot & Ankle Society (AOFAS)(25)was used for the functional evaluation of results.

SURGICAL TECHNIQUE As regards anesthesia, the patients were submitted to epidural block or general anesthesia. A tourniquet was applied in the proximal region of the thigh and the lower limb was positioned in a leg holder. The ankle arthroscopy was executed through the anteromedial and anterolateral portals (Figure 3)(14). The surgeon used a scope with a diameter of 2.9 mm and

30° of angulation, accompanied by a compatible cannula for visualization of the articular compartment. The evaluation of the cartilage condition was performed by direct visualization and through the use of a probe for palpation and evaluation of its integrity. A grasper is used to remove fragments and articular debris. The procedure was executed with cutaneous traction, without a distractor, performed by manual traction. Introduction of the arthroscopy instruments was followed by an inspection of the ankle joint and an analysis of the conditions of the articular cartilage adjoining the lesion (Figure 4). After drying all the loose cartilage fragments, the surgeon performed the curettage of the lesion (Figure 5). The microperforations were made with the help of a Kirschner wire or

Figure 1 – Anteroposterior, lateral and oblique radiographies showing minimum alteration of the medial portion of the talus.

Figure 2 – Magnetic resonance imaging in coronal and sagittal to axial cross sections showing the osteochondral lesion in the mid-medial aspect of the talus. Rev Bras Ortop. 2011;46(6):702-08


TREATMENT OF OSTEOCHONDRAL LESIONS OF THE TALUS BY MEANS OF THEARTHROSCOPY-ASSISTED microperforation technique

705

Figure 4 – Osteochondral lesion.

Figure 3 – Positioning of the anteromedial and anterolateral portals.

1.5 mm drill at low rotation (Figure 6). The tourniquet was released after the complete performance of perforations to visualize whether the bleeding at the lesion site was satisfactory (Figure 7). After closing the portals, an occlusive dressing was applied in all the cases. The patients were kept without load for 45 days, but with early mobility through passive and active exercises since the immediate postoperative period.

RESULTS The study group consisted of 19 men and five women, with mean age of 35.3 years (minimum of

Figure 5 – Osteochondral lesion after debridement.

17 and maximum of 54), with minimum follow-up of two years (maximum of 39 months). Nineteen patients (79.2%) reported ankle sprain, but were unable to define the sprain mechanism. The right side was the most affected (70.8%) (Table 1). None of the patients presented type I lesion according to the classification of Berndt and Harty(4), while 50.0% presented type II, 41.7% type III and 8.3% type IV. Considering the matrix described by Elias et el(7), we observed 14 patient (58.4%) with lesions in zone 4 (mid-medial), six patients (25.0%) in zone 6 (midlateral), two patients (8.3%) in zone 3 (anterolateral) Rev Bras Ortop. 2011;46(6):702-08


706 Table 1 – Distribution of the analyzed patients.

Figure 6 – Perforations of the lesion.

Lesion mechanism

Lesion Follow-up site Classification (months) (zone)

Nº Sex Age

Side

1

M

38

Right

Sprain

4

II

38

2

M

33

Left

Sprain

4

III

24

3

F

35

Right

Sprain

3

II

39

4

M

26

Right

Sprain

7

III

24

5

M

47

Left

Sprain

4

III

30

6

M

28

Left

Sprain

6

IV

25

7

M

36

Right

Sprain

4

II

38

8

M

34

Right

Sprain

6

III

24

9

M

42

Right

Fracture

6

II

24

10

M

47

Right

Sprain

4

II

24

11

M

24

Right

Sprain

4

III

24

12

M

39

Right

Sprain

7

II

20

13

M

56

Left

Sprain

4

II

24

14

F

20

Right

Sprain

4

II

24

15

F

54

Right

Sprain

4

III

24

16

M

38

Right

Sprain

4

II

29

17

F

35

Left

Sprain

3

III

33

18

F

20

Left

Sprain

4

III

24

19

M

38

Right

Sprain

4

IV

26

20

M

17

Right

Fracture

6

III

24

21

M

29

Left

Sprain

4

III

24

22

M

36

Right

Fracture

6

II

32

23

M

40

Right

Sprain

6

II

24

24

M

36

Right

Sprain

4

II

24

Mean follow-up – 27 months; Mean age – 35 years; Women – 20.8%, Men – 79.2% Right side – 70.8%; Left side – 29.2% Lesion: zone 3 (8.3%), 4 (58.4%), 6 (25.0%), 7 (8.3%) Classification: II (50.0%), III (41.7%), IV (8.3%)

Figure 7 – Final appearance after perforations.

and two patients (8.3%) in zone 7 (posteromedial). The affected surface was never larger than 1.2 mm. Table 2 contains the data referring to the results through an evaluation of the AOFAS score, obtained in the pre- and postoperative period of the osteochondral lesion of the talus. All 24 patients evaluated in the study presented a rise in the AOFAS score, averaging 22.4 points (± 11.4 standard deviation), changing the mean preoperative score from 73.6 (± 12.5) (minimum: 44/maximum: 87 points) to 96.1 points (± 5.96) (minimum: 81/maximum: 100). In the patients free Rev Bras Ortop. 2011;46(6):702-08

from complications (22 patients), there was a rise in the AOFAS score of 23.9 (± 10.6) points. Two patients exhibited superficial infection in one of the surgical portals. The diagnosis was made two weeks after surgery and resolved with the used of oral antibiotics for seven days. No patient required an additional surgical procedure.

DISCUSSION Osteochondral lesions of the talus are hard to diagnose and treat(6). The symptoms are usually nonspecific with late radiological findings. The use of computed tomography (CT) and of nuclear magnetic resonance (NMR) for the investigation of cases of pain in the ankle without a defined cause is essential for the diagnosis and early treatment of lesions. In the


TREATMENT OF OSTEOCHONDRAL LESIONS OF THE TALUS BY MEANS OF THEARTHROSCOPY-ASSISTED microperforation technique

Table 2 â&#x20AC;&#x201C; Table for evaluation of patients by the AOFAS system. Patient no.

Preoperative score

Postoperative score

Rise in score

1

87

90

3

2

84

100

16

3

86

100

14

4

52

90

38

5

61

87

26

6

85

100

15

7

86

100

14

8

69

100

31

9

73

87

14

10

81

90

9

11

44

100

56

12

73

100

27

13

81

100

19

14

85

100

15

15

70

100

30

16

65

97

32

17

48

81

33

18

84

100

16

19

82

100

18

20

74

100

26

21

84

100

16

22

65

97

32

23

75

100

25

24

74

87

13

Mean

73.6

96.1

22.4

Standard deviation

12.5

5.96

11.4

usual radiological views it is often difficult to locate a lateral or medial lesion, and to determine whether it is anterior, medial or posterior. NMR allows multiplanar evaluation and offers the advantage of visualizing the articular cartilage and the subchondral bone of the talus, besides evaluating the edema and the surrounding soft tissues(8). The analysis of age bracket, distribution between left and right sides, sex and the greater incidence in the medial talar dome in our sample coincide with the observations of other authors(14,17,26,27). A clinical history involving ankle inversion followed by persistent chronic pain in the tibiotalar joint is the classical presentation of osteochondral lesions of the talus. Ferkel et al(8) found a previous history of trauma involving the ankle joint in 37 of the 50 patients reported in

707

their study. Anderson et al(26) reported osteochondral fractures of the talus in 57% of the patients with ankle sprain. In our study, all the patients referred to a history of trauma in the origin of the osteochondral fracture of the talus. Intra-articular lesions of the talus of any origin present a reserved prognosis(14,17). Invariably they cause pain, functional limitation and deterioration in the quality of life of patients. The option for arthroscopic treatment for osteochondral lesions of the talus is due to the relative ease and low morbidity of this procedure. Although having imaging resources, at present there are not criteria able to predict the development of each case. It is known that there is progression of fractures from the less severe to the most severe stages(28,29) and strong correlation between the size of the lesion and its prognosis(30,31). In this survey there was homogeneity in relation to the size of the lesions, which ranged between 0.8 and 1.2 mm. Most patients presented an improvement of symptoms, seen on the AOFAS scale. Parisien(32) obtained 88% of good results after arthroscopic treatment in 18 patients with osteochondral lesions of the talus. The treatment consisted of partial synovectomy, debridement of the osteochondral lesion and microperforations. Even after the short follow-up period, which varied from three months to three years, Parisien recommends arthroscopic excision due to the reduced morbidity, short hospitalization period and faster recovery. In another study, Ogilvie-Harris and Sarrosa(27) described significant improvement of pain, edema and claudication after arthroscopic treatment in 33 patients, consisting of the removal of the cartilaginous fragments, debridement and abrasion of the base until bleeding occurs in the subchondral bone. Nevertheless, the study reports persistence of pain in 24% of the patients due to loose chondral and osteochondral residual dendrites at the lesion site(27). Various studies demonstrate good and excellent results after arthroscopic treatment of osteochondral lesions of the talus. However, it was observed that most studies present a short postoperative follow-up period(10,29,33-37). The importance of the follow-up period after the arthroscopic treatment of osteochondral lesions of the talus is emphasized in the study by Hunt and Sherman(35), in which 54% of the patients presented unsatisfactory results after 66 months of follow-up. Rev Bras Ortop. 2011;46(6):702-08


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The increase of the mean AOFAS score obtained in this study is equivalent to most of the results encountered in literature. The choice of the AOFAS table for evaluation allows us to evaluate the evolution of pain and of functions (distance walked, gait abnormalities, limitation of activities and need for support etc.)(25). As regards the postoperative period, there is no consensus concerning the turnaround time required for the complete reestablishment of the osteochondral lesion. The information obtained through the simple radiological study during the clinical reviews is questionable, since full repair of the bone defect is very slow and often fails to occur(17,32). Hyer et al(38) men-

tion that rehabilitation should be individualized by patient according to the physiotherapist, and can start after healing, which occurs between six and seven weeks for microperforation or internal fixation procedures, and the patient should remain without support in this period. The physiotherapy includes active and passive exercises for gain of mobility, control of edema, stretching and proprioceptive training.

CONCLUSION The videoarthroscopy-assisted microperforation technique consists of a good option for the treatment of osteochondral lesions of the talus and provides good functional results with an increase in the mean AOFAS score.

ReferEncEs 1. Munro A. Microgeologie. Berlin, Germany: The Billroth; 1856. 2. Barth A. Die Enstenhung und das Wachsthum der freien Gelenkkorper. Arch Klin Chir. 1898;56:507-73. 3. Kappis M. WeitereBeitrage zu tramatish-mechanischen Enstenhung der “spontanen” Knorpelalblosungen (sogen. Osteochondritis dissecans). Dtsch Z Chir. 1922;171:13-29. 4. Berndt AL, Harty M. Transchondral fractures of the talus. J Bone Joint Surg Am. 1959;41:988-1020. 5. Ferkel RD, Sgaglione NA, Del Pizzo W. Arthroscopic treatment of osteochondral lesions of the talus: techinque and results. Orthop Trans. 1990; 14:172-3. 6. Roach R, Frost A. Osteochondral injuries of the foot and ankle. Sports Med Arthrosc. 2009;17(2):87-93. 7. Elias I, Zoga AC, Morrison WB, Besser MP, Schweitzer ME, Raikin SM. Osteochondral lesions of the talus: localization and morphologic data from 424 patients using a novel anatomical grid scheme. Foot Ankle Int. 2007;28(2):154-61. 8. Ferkel DR, Zanotti MR, Komenda AG. Arthoscopic Treatment of chronic osteochondral lesions of the talus: long-term results. Am J Sports Med. 2008;36(9):1750-62. 9. Loomer R, Fischer C, Loyd-Smith R, Sisler J, Cooney T. Osteochondral Lesions of the talus. Am J Sports Med 1993;21(1):13-9. 10. Pritsch M, Horoshovski H, Farine I. Arthroscopic treatment of osteochondral lesions of the talus. J Bone Joint Surg Am. 1986;68(6):862-5. 11. Van Bergen CJA, De Leeuw PAJ, Van Dijk CN. Treatment of osteochondral defects of the talus. Rev Chir Orthop Reparatrice Appar Mot. 2008;94(8 Suppl):398-408. 12. Amendola A, Panarella L. Osteochondral lesions: medial versus lateral, persistent pain, cartilage restoration options and indications. Foot & Ankle Clin North Am. 2009;14(2):215-27. 13. Giza E, Sullivan M, Ocel D, Lundeen G, Mitchell ME, Veris L, Walton J. Matrixinduced autologous chondrocyte implantation of talus articular defects. Foot Ankle Int. 2010;31(9):747-53.

20. Nery C, Lambello C, Réssio C, Asaumi I. Implante autólogo de condrócitos no tratamento das lesões osteocondrais do talo. Rev ABTPe. 2010;4(2):113-23. 21. Cohen M, Nery C, Pecin MS, Réssio CR, Asaumi ID, Lombello CB. Implante autólogo de condrócitos para o tratamento de lesão do côndilo femoral e talo. Einstein. 2008;6(1):37-41. 22. Kiliç A, Kabukçuoglu Y, Gül M, Ozkaya U, Sökücü S. Early results of open mosaicoplasty in osteochondral lesions of the talus. Acta Orthop. Traumatol. Turc. 2009;43(3):235-42. 23. Hahn DB, Aanstoos ME, Wilkins RM. Osteochondral lesions of the talus treated with fresh talar allografts. Foot Ankle Int. 2010;31(4):277-82. 24. Gras F, Marintschev I, Müller M, Klos K, Lindner R, Mückley T, Hofmann GO. Arthroscopic-controlled navigation for the retrograde drilling of osteochondral lesions of the talus. Foot Ankle Int. 2010;31(10):897-904. 25. Kitaoka HB, Alexander IJ, Adelar RS. AOFAS Clinical Rating Systems for the ankle-hindfoot, hallux and lesser toes. Foot Ankle Int. 1994;15(7):135-49. 26. Anderson LF, Crichton MB, Grattan-Smith MB, Cooper RA, Brazie D. Osteochondral Fractures of the dome of the talus. J Bone Joint Surg Am. 1989;71(8):1143-52. 27. Ogilvie-Harris DJ, Sarrosa EA. Arthroscopic Treatment of Osteochondritis dissecans of the talus. Arthroscopy 1999;15(8):805-8. 28. O`Farrell TA, Costello BG. Osteochondritis dissecans of the talus. J Bone Joint Surg Br. 1982;64(4):494-7. 29. Robinson DE, Wilson IG, Harris WJ, Kelly AJ. Arthroscopic treatment of osteochondral lesions of the talus. J Bone Joint Surg Br. 2003;85(7):989-93. 30. Chuckpaiwong B, Berkson EM, Theodore GH. Microfracture for osteochondral lesions of the ankle: outcome analysis and outcome predictors of 105 cases. Arthroscopy 2008;24(1):106-12. 31. Choi WJ, Park KK, Kim BS, Lee JW. Osteochondral lesion of the talus. Is there a critical defect size for poor outcome? Am J Sports Med. 2009;37(10):1974-80.

14. Ferkel RD. Artroscopy of the ankle and foot. In: Mann RA, Coughlim MJ. Sugery of the foot and ankle. 8th ed. Philadelphia: Mosby/Elsevier; 2007. p.1643-83.

32. Parisien JS. Arthroscopic treatment of osteochondral lesions of the talus. J Sports Med Am. 1986;14(3):211-7.

15. Nery CAS, Carneiro MF. Tratamento artroscópico das fraturas osteocondrais do talo. Rev Bras Ortop. 1995;30(8):567-74.

33. Baker CL, Andrews JR, Ryan JB. Arthroscopic treatment of transchondral talar dome fractures. Arthroscopy. 1986;2(2):82-7.

16. White KS, Sands AK. Osteochondral lesions of the talus. Cur Orthop Pract. 2009;20(2):123-9.

34. Frank A, Cohen P, Beaufils P, Lamare J. Atrhroscopic treatment of osteochondral talar dome. Arthroscopy. 1989;5(1):57-61.

17. Mukherjee SK, Young AB. Dome fractures of the talus a report of ten cases. J Bone Joint Surg Br. 1973;55(2):319-26.

35. Hunt SA, Sherman O. Arthroscopic treatment of osteochondral lesions of the talus with corelation of outcome scoring systems. Arthroscopy. 2003;19(4):360-7.

18. Van Bergen CJA, Leeuw PAJ, Van Dijk CN. Potential pitfall in the microfracturing technique during the arthroscopic treatment of an osteochondral lesion. Knee Surg. Sports Traumat Arthrosc. 2009;17(2):184-7.

36. Kumai T, Takakura Y, Higashiyama I, Tami S. Arthroscopic drilling for the treatment of osteochondral lesions of the talus. J Bone Joint Surg Am. 1999;81(9):1229-35.

19. Takao M, Innami K, Komatsu F, Matsushita T. Retrograde cancellous bone plug transplantation for the treatment of advanced osteochondral lesions with large subchondral lesions of the ankle. Am J Sports Med. 2010;38(8):1653-60. Rev Bras Ortop. 2011;46(6):702-08

37. Van Buecken K, Barrack RL, Alexander AH, Ertl JP. Arthroscopic treatment of transchondral talar dome fratctures. Am J Sports Med. 1989;17(3):350-6. 38. Hyer CF, Berlet GC, Philloin TM, Lee TH. Retrograde drilling of osteochondral lesions of the talus. Foot Ankle Spec. 2008;1(4):207-9.


ORIGINAL ARTICLE

SCHEUERMANN’S KYPHOSIS: COMPARISON BETWEEN THE POSTERIOR APPROACH ASSOCIATED WITH SMITH-PETERSEN OSTEOTOMY AND COMBINED ANTERIOR-POSTERIOR FUSION Eduardo Frois Temponi1, Rodrigo D’Alessandro de Macedo2, Luiz Olímpio Garcia Pedrosa3, Bruno Pinto Coelho Fontes4

Abstract Objective: Surgical treatment of Scheuermann’s kyphosis (SK) remains a subject under discussion. In view of the controversy over the best form of surgical tr otomy. Methods: This was a descriptive case-control study with cross-sectional analysis. Twenty-eight patients, split into two groups conducted at different times, were evaluated. Results: The first group comprised patients treated using the double approach, with an average age of 19 years, preoperative kyphosis of 77.6°, postoperative kyphosis of 35.8° and average correction of 53.2%. The second group comprised patients treated using the posterior route associated with Smith-Petersen osteotomy, with a mean age of 27.3 years, preoperative kyphosis of 72.9°, postoperative kyphosis of 44.3° and average correction of 39.3%. Analysis between the two groups showed statistically signi-

INTRODUCTION In 1921, Holger Scheuermann described a kyphotic juvenile vertebral alteration that could be distinguished from postural kyphosis based on its peculiar rigidity(1). He observed that the kyphotic deformity was rigid, and associated with wedging of vertebral bodies(2). Diagnostic criteria were established in 1964 by Sorensen, who came up with a definition of Scheuermann’s kyphosis (SK) as a rigid kyphosis that includes three adjacent vertebrae, with wedging

ficant differences in the following variables: age (p = 0.02), postoperative kyphosis (p = 0.04) and degree and percentage of kyphosis correction (p = 0.001). There was no difference concerning preoperative kyphosis (p = 0.33). In the assessment of postoperative pain (VAS), the first group presented an average of 0.6, versus 0.5 in the second group. There were only minor complications: seven in the first group and two in the second. Conclusion: The two surgical techniques studied proved to be adequate for treating SK. In the present study, the deformity correction was greater in the first group, while the pain VAS results were better in the second group, with lower incidence of complications. Keywords - Kyphosis; Spine; Scheuermann Disease; Osteotomy; Spinal Fusion

of five or more degrees(2). Other criteria were also used, such as an increase in thoracic kyphosis, irregularity of the endplates, increase in disc space and/or characteristic radiographic signs (kyphosis, vertebral wedging, Schmorl’s nodes)(3,4). In 1987, Drummond suggested that the diagnosis of the disease be based on adjacent wedging of two or more vertebrae(5). More recently, Bradford modified the previous diagnostic criteria, defining SK as thoracic kyphosis of more than 45° and at least one wedged vertebra(6) (Figure 1).

1 – Third-year Orthopedics and Traumatology Resident at the Professor Matta Machado Clinic of Hospital Baleia/Fundação Benjamin Guimarães – Belo Horizonte, MG, Brazil. 2 – Coordinator of the Spine Group of Instituto de Previdência dos Servidores de Minas Gerais – IPSEMG. Preceptor of the Spine Group of the Professor Matta Machado Clinic of Hospital da Baleia/Fundação Benjamin Guimarães; Master’s Degree in Nuclear Sciences and Techniques from the Department of Nuclear Engineering of Universidade Federal de Minas Gerais – UFMG – Belo Horizonte, MG, Brazil. 3 – Third-year Orthopedics and Traumatology Resident at the Professor Matta Machado Clinic of Hospital Baleia/Fundação Benjamin Guimarães – Belo Horizonte, MG, Brazil. 4 – Preceptor of the Spine Group of the Professor Matta Machado Clinic of Hospital da Baleia/Fundação Benjamin Guimarães – Belo Horizonte, MG, Brazil. Study conducted at Professor Matta Machado Orthopedic Clinic of Hospital da Baleia/Fundação Benjamin Guimarães and at Hospital Governador Israel Pinheiro/IPSEMG – Belo Horizonte, MG. Mailing address: Rua Santa Apolônia, 349, Fernão Dias – 31920-360 – Belo Horizonte, MG. Email: dufrois@gotimail.com Study received for publication: 3/24/2011, accepted for publication: 7/1/2011. The authors declare that there was no conflict of interest in conducting this work This article is available online in Portuguese and English at the websites: www.rbo.org.br and www.scielo.br/rbort

Rev Bras Ortop. 2011;46(6):709-17


710

The etiology of SK remains undefined, but is apparently multifactorial in nature, with a dominant autosomal genetic component of high penetrance and variable expressivity, with 74% heredity(7). Its origin has been associated with avascular necrosis of the epiphyseal rings(1), juvenile osteoporosis(8,9) and cartilaginous matrix disorder, all still with conflicting results. Other etiologies reported include shortening of the ischiotibial musculature(9) and mechanical factors that would trigger secondary remodelling responses, such as reduction of sternal size(2,9-12). According to literature, the incidence of SK ranges from 0.04 to 8.3% of the population(2,13). It is a deformity that typically occurs at the end of juvenile age, more commonly between eight and 12 years, and occurs in its most rigid form between 12 and 16 years of age. The majority of studies do not show any difference between the sexes, and the incidence in men and women is similar, varying only in terms of the criteria for inclusion of each trial(14,15). The treatment for SK is still controversial. The tendency is to consider surgical treatment for patients with kyphotic curves of over 75°, with refractory pains on conservative treatment, unacceptable deformities, neurological deficits, and cardiopulmonary impairment(16).

Isolated posterior arthrodesis presented significant failures, perhaps due to the lack of anterior support, inadequate initial correction, failure of the implant, fixation on the side of the tension, or due to insufficient length of the fixation(12,17). To resolve these problems, dual approach arthrodesis was proposed, with discectomy, release of the anterior-posterior longitudinal ligament, and intersomatic arthrodesis in the first phase of surgery, and arthrodesis and instrumentation in the second phase. Due to the morbidity associated with the dual access, the development of third-generation implants, and materials for their application, associated with average corrections of 59% of the curves without significant loss, the exclusively posterior approach associated with Smith-Petersen osteotomies has been considered a therapeutic option, already with good results in literature(17-19). Considering the controversy surrounding the best form of surgical treatment, a study was proposed involving patients diagnosed with SK, to compare the results of treatment using the dual approach (AA + PA) with treatment using posterior approach associated with Smith-Petersen osteotomies (PA + SPO). The aim of this study is to compare the characteristics of the sample in question, the results of the treatment in terms of the improvement in pain using the VAS, the degree of correction of the deformity, and the patient›s satisfaction with the procedure.

MATERIALS AND METHODS

A

B

Figure 1 – A) Clinical presentation; and B) Radiographic presentation of Scheuermann’s kyphosis. Rev Bras Ortop. 2011;46(6):709-17

The survey was carried out at the Professor Matta Machado Orthopedic Clinic of Hospital da Baleia/ Fundação Benjamin Guimarães and at Hospital Governador Israel Pinheiro of the Instituto de Previdência dos Servidores do Estado de Minas Gerais (IPSEMG). All the patients were submitted to surgical treatment by the same team of surgeons. The proposed study was submitted to, and accepted by the Research Ethics Committee (protocol no. 13/2009). The patients were given instructions and signed a term of consent before taking part in the study. The diagnostic criteria of SK used were: patients with rigid radiological thoracic kyphosis of over 45° and at least one wedged vertebra(6). The indications for surgery were: patients with rigid curves of more than 75°, curves of more than 55° with refractory pain to conservative treatment, and/or major aesthe-


SCHEUERMANN’S KYPHOSIS: COMPARISON BETWEEN THE POSTERIOR APPROACH ASSOCIATED WITH SMITH-PETERSEN OSTEOTOMY AND COMBINED ANTERIOR-POSTERIOR FUSION

tic deformity reported by the patient. Patients with flexible thoracic kyphoses, evaluated by means of physical examination and radiography in hyperextension, were excluded, as were patients with kyphosis of other causes. Due to the wide variation in prevalence of the deformity between populations, and the lack of studies comparing forms of treatment, sample calculation was not possible. Therefore, we opted to use a sample projected to a work of greater international importance, involving 39 patients, which was conducted partly retrospectively and partly prospectively, and published in 2006 by Lee et al(20). Our sample consisted of 28 patients, divided into two groups, and operated at different times. At the end, the two groups were compared, adopting a comparative, case control methodology with transversal analysis. The first group consisted of patients diagnosed with SK treated with AA + PA, evaluated retrospectively, and the second group consisted of patients treated exclusively with PA + SPO, and operated prospectively. The first group consisted of a total of 19 patients submitted to surgical treatment with AA + PA for SK in the period from February 2001 to May 2007. The age bracket in this group was 13 to 35 years, with a mean age of 19 years; 19.6 years for the male patients and 17.4 for the female patients. Follow-up time ranged from 12.6 to 61.7 months, with a mean of 37.5 months. The second group consisted of nine patients submitted to surgical treatment with PA + SPO with follow-up from October 2007 to May 2010. The ages ranged from 16 to 51 years, with a mean age of 27.3; 24.4 years for the males and 51 for the female patients. The follow-up time ranged from 13 to 31 months, with a mean of 22.8 months. The distribution of the groups by sex and age is shown in Table 1. In the selection of the levels of instrumentation, we considered the proximal level as the vertebra that represented the thoracic kyphosis transition with the cervical lordosis, generally T2 or T3, and the distal level of fusion as the most proximal vertebra that touched the posterior sacral vertebral line, generally from L1 to L3. The patients in the first group were submitted to anterior release by conventional thoracotomy and intersomatic fusion, followed by posterior arthrodesis with posterior instrumentation using the system of

711

Table 1 – Distribution of patients by sex – group I and II.

Sex

No. of patients group I

No. of patients group II

Mean age group I (years)

Mean age group II (years)

Male

14.0

8.0

19.6

24.4

Female

5.0

1.0

17.4

51.0

pedicle screws. The anterior approach was performed by means of left thoracotomy with the patient positioned in right lateral decubitus with costectomy, anterior release (anterior and posterior longitudinal ligament), complete discectomy at the maximum levels necessary and intersomatic arthrodesis without instrumentation of an average of seven discs at the site of the deformity. Only resected rib grafts were placed in the disc spaces. In the period between the two procedures, the patients were kept hospitalized and at rest, without any orthopedic brace and/or traction. After an average of seven days, the patients were submitted to the second surgery, when third generation posterior instrumentation was performed with autologous graft from spinous, transverse and laminous processes. With the patient in ventral decubitus, after a posterior access and subperiosteal dissection, resection of the lower facets was performed at all the levels of arthrodesis (Figure 2). The intersection of the upper border of the transverse process and the lateral vertical line of the upper articular facet was used as the point of insertion of the pedicle screw(21). Using a 3.2 mm low-rotation trepan drill, and by manual perception of bone resistance, the drill was advanced slowly, always checking, by small incursions, for the presence of bone at the end of the orifice. A flexible probe was used to confirm the presence of bone in the upper, lower, medial, lateral walls and at the end of the access route(22). The screws were then introduced using the freehand technique – unlike the method reported by Kim et al(23) in which a drill was used to make the access route(21). Screws were placed bilaterally or unilaterally at each level. The position of the screws was checked by radiographic study in lateral and anterior-posterior views. The stems were moulded and then fixed in the proxiRev Bras Ortop. 2011;46(6):709-17


712

A

B

Figure 2 – Dual approach AA + PA: a) Anterior approach with discectomy and arthrodesis without instrumentation; b) Posterior approach with correction of the deformity, instrumentation and arthrodesis. Rev Bras Ortop. 2011;46(6):709-17

mal segments. Using the “cantilever” manoeuvre, the deformity was reduced and the stems were fixed in the distal segments. Compression manoeuvres were used in the apex of the curve. The number of transversal devices varied as necessary during surgery. In the second group, the instrumentation was performed with posterior arthrodesis, where the difference was due to the osteotomies performed at the apex of the deformity of an average of five segments. After performing the posterior closing-wedge (Smith-Petersen) osteotomies in the segments of the apex of the deformity, the stems were moulded and the deformity was corrected by the same “cantilever” manoeuvre, with compression at the level of the apex (Figure 3). No somatosensitive monitoring studies or evoked medullary potential studies were carried out in any of the cases due to the lack of available conditions for their performance. All the patients who did not have access to monitoring were submitted to the Stagnara wake-up test, after reduction of the deformity. No orthopedic brace was used on the patients in the postoperative period. The patients were followed up every 15 days in the first month after surgery. New evaluations were carried out at three, six, and twelve months after surgery. The evaluations were carried out by members of the team, and consisted of a medical examination and questionnaires to evaluate pain, by the visual analogue scale (VAS), the patients’ satisfaction with the procedure, and any complications. The radiological exams were executed for each outpatient control follow-up visit, according to indication. For the decision as to which statistical tests to perform, the normality of the variables was tested, i.e., whether they followed a normal distribution. With an error of five percent, the variables sex, initial kyphosis, final kyphosis, correction (degrees) and follow-up (months) followed a normal distribution. The variables age, level of posterior fusion, and number of screws did not follow this behaviour. Thus, for the variables that were considered normal, a parametric test will be used, in this case, the T-test, to test whether there is any difference between the means of the variables. For the non-normal variables, a nonparametric test will be used, the Mann-Whitney test. The purpose of this treatment is to level out the sample and avoid any statistical bias.


SCHEUERMANN’S KYPHOSIS: COMPARISON BETWEEN THE POSTERIOR APPROACH ASSOCIATED WITH SMITH-PETERSEN OSTEOTOMY AND COMBINED ANTERIOR-POSTERIOR FUSION

A

B

C

D

713

Figure 3 – Exclusively posterior approach associated with Smith-Petersen osteotomies (PA + SPO): a) Radiographic presentation of the deformity; b) Posterior approach with introduction of screws under fluoroscopic guidance; c) Smith-Petersen osteotomies at the apex of the deformity; d) Introduction of the stem and correction of the deformity. Rev Bras Ortop. 2011;46(6):709-17


714

RESULTS There was no statistical difference between the sexes of both groups (p = 0.2). Comparing the ages of both groups, a statistical difference was noted (p = 0.02). The comparison between the degree of initial and final average kyphosis between the sexes of both groups is shown in table 2. In the preoperative evaluation of the patients in the first group, the degree of thoracic kyphosis ranged from 66° to 94° with an average of 77.6°. After the postoperative follow-up, the degree of kyphosis found in the patients was 23° to 50°, with an average of 35.8° (Table 3). In the evaluation of the second group, the degree of kyphosis in the preoperative period ranged from

57° to 90°, with an average of 77.58°. After the posterior approach, an average correction of 28.56° was obtained, with a degree of final kyphosis ranging from 33° to 60°, and an average of 44.3° (Table 4). In the comparative analysis between the two groups (Table 5), there was statistical significance for the variables age (p = 0.02), postoperative kyphosis (p = 0.04), and the degree and percentage of correction of the kyphosis (p = 0.001), but there were no differences for preoperative kyphosis (p = 0.33). Of the patients in the first group, 17 had preoperative pain. The average score obtained in the preoperative evaluation was 6.6. After follow-up, the patients were evaluated by the same VAS method; only three

Table 2 – Comparison between the sexes in the evolution of degree of kyphosis. Mean final Mean initial kyphosis Mean initial kyphosis Mean final kyphosis Mean % correction Mean % correction kyphosis group II group I (degree) group II (degree) group I (degree) group I group II (degree)

Sex Male

75.4°

70.8°

37.5°

43.4°

50.3°

38.7°

Female

83.8°

90°

31.2°

52°

62.8°

38°

Table 3 – Results of the treatment – group I.

Table 4 – Results of the treatment – group II.

Level of Final Initial Follow-up No. of Age Sex kyphosis kyphosis posterior Patient (months) screws (years) (degree) (degree) fusion

Patient

Level of Final Initial Follow-up No. of Age Sex kyphosis kyphosis posterior (months) screws (years) (degree) (degree) fusion

1

15

M

86

40

T2-L2

61.7

12

1

19

M

58

38

T4-L1

31

20

2

21

M

82

48

T3-L3

55.1

16

2

30

M

78

45

T3-L2

29

20

28

M

72

48

T2-L2

26

26

3

33

M

80

50

T2-L2

48.8

20

3

4

22

F

72

23

T2-L3

48.4

20

4

20

M

66

35

T3-L3

18

16

5

16

M

72

28

T4-L2

51.9

13

5

20

M

75

54

T3-T12

21

16

6

43

M

90

60

T2-L3

28

28

6

16

M

66

30

T2-L1

51.6

11

7

51

F

90

52

T3-L2

25

22

7

18

M

90

30

T3-L3

46.5

18

8

19

M

70

33

T4-L3

15

16

8

13

M

60

40

T4-L2

43.9

14

9

16

M

57

34

T3-L1

13

15

Mean

27.3

NA

72.8

44.3

NA

22.8

179

9

16

F

90

30

T3-L2

47.6

15

10

20

M

82

40

T3-L3

45.1

14

11

17

F

78

32

T4-L2

26.7

15

12

15

M

65

30

T3-L2

36.6

16

 

Dual access

Posterior approach

P value

13

21

M

60

45

T2-L2

36.2

16

Mean age* (SD)

19.0 years (± 5.8)

27.33 years (± 12.2)

0.02*

14

35

M

86

48

T3-L2

21.5

15

Maximum kyphosis

15

16

M

69

28

T3-L2

18.5

19

Preoperative (SD)

77.6 (± 10.4)

72.9 (± 12.0)

0.33

16

16

F

94

35

T2-L2

25.4

16

Postoperative (SD)

35.8 (± 8.0)

44.3 (± 9.8)

0.04*

17

16

F

85

36

T2-L2

14.2

16

Correction

 

18

16

M

72

28

T2-L2

12.6

19

 

 

° Postoperative (SD)

41.7 (± 12)

28.6 (± 6)

0.001*

19

19

M

85

40

T2-L2

19.7

16

% Postoperative (SD)

53.2 (± 11.9)

39.3 (± 7.8)

0.001*

Mean

19

NA

77.6

35.8

NA

37.5

15.8

Caption: NA – not applicable; M – male; F – Female. Rev Bras Ortop. 2011;46(6):709-17

Table 5 – Comparative analysis of surgical approaches.

* Indicates that the variables are considered significant, with 95% confidence, i.e., there is a difference between the groups (p < 0.05).


SCHEUERMANN’S KYPHOSIS: COMPARISON BETWEEN THE POSTERIOR APPROACH ASSOCIATED WITH SMITH-PETERSEN OSTEOTOMY AND COMBINED ANTERIOR-POSTERIOR FUSION

patients complained of residual pain, and the average postoperative score was 0.6. In the second group, eight patients presented preoperative pain, with an average score of 5.6. After the follow-up, only one patient complained of residual pain, and the final average score was 0.5. In terms of patient satisfaction with the surgical procedure, 94.7% of those in the first group were satisfied, and just one was dissatisfied, reporting that they would not submit again to the surgical intervention if indicated to do so. In the second group, patient satisfaction was 100%. In terms of complications associated with the procedures, the following were identified for the first group: one case of early surface infection of the surgery wound, treated with oral antibiotic in outpatient regimen; one case of asymptomatic breaking of two screws; one case of late infection at 24 months after surgery, which was resolved with the removal of the implant without losing the correction of the deformity; one case of loosening of the distal implant, requiring a new surgical intervention with extension of the level of the arthrodesis; three patients with complaint of residual pain, and two of these patients reported sporadic pain, which did not require any treatment. The second group presented a case of residual pain of lesser intensity than in the preoperative period, one case of seroma in the postoperative period, improving with local measures, and one case of discomfort at the site of the implants, opting to remove them two years after the procedure, with resolution of the pain.

DISCUSSION The treatment of SK remains controversial. Since Bradford et al(24) carried out the first report on posterior fusion in the treatment of SK, the surgical indications, as well as the operating techniques, have altered significantly. In various case series, pain and deformity are adopted as the criteria for surgical indication(4,22,24). Some studies indicate surgery for cases of pain that is refractory to conservative treatment(25,26). Lowe recommends surgery in SK in adults with kyphosis greater than or equal to 75°, where there is persistent pain, despite conservative treatment, and in those with deformities affecting the patient’s aesthetic appearance(25). Murray et al(15) reserve the surgical option only for cases of unacceptable pain and deformity. The criteria used in this study were in keeping with literature.

715

The efficacy of combined treatment of SK by the anterior and posterior route is well documented in literature. Bradford et al(24), in 1980, described average correction of 77° to 41° at the end of the procedure, and 47° at the end of the follow-up of 24 patients. Herndon et al(27) evaluated the results of dual access in 13 patients with release and anterior arthrodesis followed by posterior fusion, obtaining average correction of 51° and satisfactory pain relief in 12 patients. Lowe(25) analyzed 24 patients submitted to the anterior approach with posterior fusion, and obtained good results without significant loss of correction or complications at the end of the 19-month follow-up. Lim et al(28), evaluating 23 patients, described correction of 37° at the end of the procedure, and 32° at the end of the follow-up. In our study, we retrospectively operated on 19 patients with initial average kyphosis of 77.6° through the dual approach, over a period of 37.5 months, obtaining 53.2% correction at the end of the treatment (average 41.7°). In relation to the posterior approach in isolation, the debate still continues, as the results of literature are conflicting. The first reports came from Bradford et al(14); but with loss of good results of correction in 16 of the 22 patients. Papagelopoulos et al(29) compared the treatment in 13 patients submitted to posterior instrumentation versus eight patients treated by the dual approach route, obtaining a correction rate of 42% (68.5° to 40°) with loss of correction in this group of 5.8° over 4.5 years of follow-up. Otsuka et al(26), with the posterior approach using the system of Harrington, obtained average correction of 45% (71.4° to 39.3°) with a loss rate of 7.8%. Johnston et al(30), in a retrospective study, evaluated 27 patients divided into two groups based on the dual approach, and the posterior approach (46% x 53%). There was no difference in the correction obtained after surgery or after end of the follow-up. Lee et al(20) compared 18 patients with SK submitted to posterior spinal fusion using a pedicle screw with 21 patients in whom anterior-posterior fusion was carried out through the use of combined constructions using hooks or screws/ hooks. In the first group, the average degree of correction was 52% after a mean follow-up time of 31.7 months, while in the second group of patients, the average correction was 54.6%, after a mean follow-up of 67.5 months(20). In the present study, the patients Rev Bras Ortop. 2011;46(6):709-17


716

in whom the posterior approach was used had a mean follow-up of 22.8 months, with initial kyphosis of 72.9° and a final average of 44.3°, obtaining 39.3% of correction (28.6° average correction). Lim et al(28), in a retrospective follow-up of 23 patients, 20 treated by the dual route and three by the posterior route, obtained 43% of minor complications, 17% of major complications, and 0% of life-threatening complications. Two other studies evaluating the posterior approach using the hook system showed loosening of the hooks in three cases out of 27, requiring two subsequent surgeries(4); in the other study, there was breaking of the stem in one case out of 30, requiring revision surgery and resulting in one patient with loss of correction, and pain(31). In the series of Lee et al(20) there were no complications related to the instrumentation. In our series, we demonstrated seven complications in the group in which the double approach was used (one case of early surface infection of the surgery wound; one case of asymptomatic breaking of two screws; on case of late infection 24 months after surgery; one case of loosening of the distal implant; and three patients with complaints of residual pain), and only three in the group in which the posterior route was used (one case of residual pain, another of discomfort around the implants, and another with a wound seroma after surgery). The frequency of complications varies depending on the criteria adopted by the researchers, but this has not been validated. In the comparative evaluation of the two groups in this study, better correction of the deformity was found in the cases operated by the traditional technique (AA + PA), with statistical difference in the postoperative curves, and in the degree and percentage of correction of the deformity (p = 0.01). This may be explained by the learning curve required for the new technique, the incipient number of patients in which the second technique was used, and perhaps, the presence of older patients, with more rigid curves, in the posterior approach group. There were no differences between the sexes in the comparison between the two groups; however, there was a distinction for the variable age, with group II (PA + SPO) being, on average, eight years older, a fact that was also demonstrated in the work of Lee et al(20). Although not tested statistically, there was a higher absoluRev Bras Ortop. 2011;46(6):709-17

te number of complications, though less severe, in group I, with higher levels of satisfaction achieved in group II. No valid questionnaire of satisfaction and improvement in quality of life was applied in this study; however, for the next follow-up, the SRS-22 questionnaire will be applied. The results of this study demonstrate the importance of study with randomized, prospective follow-up with greater homogenization of the samples, to adequately determine which is the best choice in terms of approach. However, these choices are hampered by the minor prevalence of the disease, and the restricted criteria for surgical indication. The posterior approach associated with osteotomies has been a recent option, given the association between technical improvements (osteotomies) and the development of fixation systems, resulting in shorter surgery times, and fewer comorbidities and associated complications (blood transfusion, decrease in pulmonary capacitance, hospitalization times, and recovery times). The objective of any correction is to offer the patient an improvement in sagittal and coronal balance, centralizing the whole segment above the pelvis, and this has been achieved by means of a single approach. Although there was no objective control in this study, it was noted that there were less systemic repercussions in patients when this approach route was used, with faster, less painful rehabilitation. We highlight the fact that the sample is still small, and the need for longer follow-up of cases, following surgery, as well as better training in the practice of osteotomies, and new studies to evaluate the real role of posterior instrumentation associated with SmithPetersen osteotomy as a method of treating SK.

CONCLUSION The two surgical techniques studied proved to be adequate for the treatment of Scheuermann’s kyphosis. In the present study, we observed greater correction of the deformity with the double approach, while in the second group there were better results in the VAS pain scale, and a lower percentage of complications. For a more viable result, a program of prospective, randomized work is needed, to homogenize the groups and eliminate differences in the sample.


SCHEUERMANN’S KYPHOSIS: COMPARISON BETWEEN THE POSTERIOR APPROACH ASSOCIATED WITH SMITH-PETERSEN OSTEOTOMY AND COMBINED ANTERIOR-POSTERIOR FUSION

717

REFERENCES 1. Scheuermann HW. Kyphosis dorsalis juvenilis. Orthop Chir. 1921;41:305-17. 2. Sorensen KH. Scheuermann’s Juvenile Kyphosis: clinical appearances, radiography, aetiology and prognosis. Copenhagen: Munksgaard; 1964. 3. Stoddasd A, Osborn JF. Scheuermann’s disease or spinal osteochondrosis: its frequency and relationship with spondylosis. J Bone Joint Surg Br. 1979;61(1):56-8. 4. Taylor TC, Wenger DR, Stephen J, Gillespie R, Bobechko WP. Surgical management of thoracic kyphosis in adolescents. J Bone Joint Surg Am. 1979;61(4):496-503. 5. Ali RM, Green DW, Patel TC. Scheuermann’s kyphosis. Curr Opin Pediatr. 1999;11(1):70-5. 6. Bradford DS. Juvenile kyphosis. In: Lonstein JE, Bradford DS, Winter RB, Ogilvie J. Moe’s textbook of scoliosis and other spinal deformities. 3rd ed. Philadelphia: Saunders; 1995. p. 349-67. 7. Damborg F, Engell V, Andersen M, Kyvik KO, Thomsen K. Prevalence, concordance, and heritability of Scheuermann kyphosis based on a study of twins. J Bone Joint Surg Am. 2006;88(10):2133-6. 8. Gilsanz V, Gibbens DT, Carlson M, King J. Vertebral bone density in Scheuermann disease. J Bone Joint Surg Am. 1989;71(6):894-7. 9. Lopez RA, Burke SW, Levine DB, Schneider R. Osteoporosis in Scheuermann’s disease. Spine. 1988;13(10):1099-103. 10. Lowe TG. Scheuermann disease. J Bone Joint Surg Am. 1990;72(6):940-5. 11. Aufdermaur M. Juvenile kyphosis (Scheuermann’s disease): radiography, histology, and pathogenesis. Clin Orthop Relat Res. 1981;(154):166-74. 12. Ferguson AB Jr. The etiology of preadolescent kyphosis. J Bone Joint Surg Am. 1956;38(1):149-57. 13. Scoles PV, Latimer BM, DigIovanni BF, Vargo E, Bauza S, Jellema LM. Vertebral alterations in Scheuermann’s kyphosis. Spine. 1991;16(5):509-15. 14. Bradford DS, Moe JH, Montalvo FJ, Winter RB. Scheuermann’s kyphosis. Results of surgical treatment by posterior spine arthrodesis in twenty-two patients. J Bone Joint Surg Am. 1975;57(4):439-48. 15. Murray PM, Weinstein SL, Spratt KF. The natural history and long-term follow-up of Scheuermann kyphosis. J Bone Joint Surg Am. 1993;75(2):236-48. 16. Tribus CB. Scheuermann’s kyphosis in adolescents and adults: diagnosis and management. J Am Acad Orthop Surg. 1998;6(1):36-43. 17. Gill JB, Levin A, Burd T, Longley M. Corrective osteotomies in spine surgery. J Bone Joint Surg Am. 2008;90(11):2509-20. 18. Berven SH, Deviren V, Smith JA, Hu SA, Bradford DS. Management of fixed sagittal plane deformity: outcome of combined anterior and posterior surgery. Spine (Phila Pa 1976). 2003;28:1710-16.

19. Bridwell KH. Decision making regarding Smith-Petersen vs. pedicle subtraction osteotomy vs. vertebral column resection for spinal deformity. Spine (Phila Pa 1976). 2006;31(19 Suppl):S171-8. 20. Lee SS, Lenke LG, Kuklo TR, Valenté L, Bridwell KH, Sides B, Blanke KM. Comparison of Scheuermann kyphosis correction by posterior-only thoracic pedicle screw fixation versus combined anterior/posterior fusion. Spine (Phila Pa 1976). 2006;31(20):2316-21. 21. Macedo RD, Fontes BPC, Cunha FM, Werlang PM. Sistema de parafusos pediculares no tratamento de deformidades vertebrais: analise da correção e das complicações imediatas. Rev Bras Ortop. 2006;41(10):417-24. 22. Suk SI, Kim WJ, Lee SM, Kim JH, Chung ER. Thoracic pedicle screw fixation in spinal deformities: are they really safe? Spine (Phila Pa 1976). 2001;26(18):2049-57. 23. Kim YJ, Lenke LG, Bridwell KH, Cho YS, Riew KD. Free hand pedicle screw placement in the thoracic spine: is it safe? Spine (Phila Pa 1976). 2004;29(3):333-42. 24. Bradford DS, Ahmed KB, Moe JH, Winter RB, Lonstein JE. The surgical management of patients with Scheuermann’s disease: a review of twenty-four cases managed by combined anterior and posterior spine fusion. J Bone Joint Surg Am. 1980;62(5):705-12. 25. Lowe TG. Double L-rod instrumentation in the treatment of severe kyphosis secondary to Scheuermann’s disease. Spine (Phila Pa 1976). 1987;12(4):336-41. 26. Otsuka NY, Hall JE, Mah JY. Posterior fusion for Scheuermann’s kyphosis. Clin Orthop Relat Res. 1990;(251):134-9. 27. Herndon WA, Emans JB, Micheli LJ, Hall JE. Combined anterior and posterior fusion for Scheuermann’s kyphosis. Spine (Phila Pa 1976). 1981;6(2):125-30. 28. Lim M, Green DW, Billinghurst JE, Huang RC, Rawlins BA, Widmann RF, Burke SW, Boachie-Adjei O. Scheuermann kyphosis: safe and effective surgical treatment using multisegmental instrumentation. Spine (Phila Pa 1976). 2004;29(16):1789-94. 29. Papagelopoulos PJ, Klassen RA, Peterson HA, Dekutoski MB. Surgical treatment of Scheuermann’s disease with segmental compression instrumentation. Clin Orthop Relat Res. 2001;(386):139-49. 30. Johnston CE 2nd, Elerson E, Dagher G. Correction of adolescent hyperkyphosis with posterior-only threaded rod compression instrumentation: is anterior spinal fusion still necessary? Spine (Phila Pa 1976). 2005;30(13):1528-34. 31. Sturm PF, Dobson JC, Armstrong GW. The surgical management of Scheuermann’s disease. Spine (Phila Pa 1976). 1993;18:685-91.

Rev Bras Ortop. 2011;46(6):709-17


ORIGINAL ARTICLE

Effect of use of bone-marrow centrifugate on muscle injury treatment: experimental study on rabbits

Daniel Ferreira Fernandes Vieira1, Roberto Guarniero2, Carlos Eduardo Sanches Vaz3, Paulo José de Santana4

Abstract Objective: The objective of this study was to evaluate the effect of bone-marrow centrifugate on the healing of muscle injuries in rabbits. Methods: This experimental study involved use of fifteen adult male New Zealand White rabbits. Each animal received a transverse lesion in the middle of the right tibialis anterior muscle, to which an absorbable collagen sponge, soaked in a centrifugate of bone marrow aspirate from the ipsilateral iliac bone, was added. The left hind limb was used as a control and underwent the same injury, but in this case only the absorbable collagen sponge. Thirty days later, the animals were sacrificed to study the muscle healing. These muscle areas were subjected to histological analysis with histomorphometry, with the aim of measuring the number of

INTRODUCTION Muscle injuries constitute one of the most challenging problems of sports traumatology, since although common, their treatment is still controversial, and often inefficient(1). Long periods of leave of absence are habitually necessary for athletes to fully resume their activities and sequelae can be part of the end result(2). The muscle tissue healing process usually starts promptly as soon as a trauma occurs; however, it can evolve slowly and irregularly, hindered by an excessive formation of connective scar tissue (fibrosis)(3).

muscle cells per square micrometer undergoing regeneration and the proportion of resultant fibrosis. Results: The centrifugation method used in this study resulted in an average concentration of nucleated cells greater than the number of these cells in original aspirates, without causing significant cell destruction. Addition of the bone marrow centrifugate did not result in any significant increase in the number of muscle cells undergoing regeneration, in relation to the control group. There was also no significant difference in the proportion of resultant fibrosis, compared with the control group. Conclusion: Administration of the bone marrow centrifugate used in this study did not favor healing of muscle injuries in rabbits. Keywords - Bone Marrow; Stem Cells; Regeneration; Skeletal Muscle; Animals Models; Rabbits

This scar tissue in excess inhibits the complete regeneration of the preexisting muscle structure, and, as it is more fragile and anomalous, contributes towards the local recurrence of the lesion, preventing the complete recovery of muscle function(4). The treatment employed most often in muscle injuries is conservative, involving measures such as rest, immobilization of the affected limb for a variable time, local application of ice and physiotherapeutic monitoring. In some cases, depending on the severity of the lesion, its surgical repair may be indicated. Although these treatments frequently lead to good clinical results, they appear to have a limited effect

1 – Orthopedics and Traumatology, Master’s degree in Medicine and Health Sciences at the Universidade Estadual de Londrina – Londrina, PR, Brazil. 2 – Associate Professor of the School of Medicine of Universidade de São Paulo – São Paulo, SP, Brazil. 3 – Doctor and Adjunct Professor of the Orthopedics and Traumatology Discipline of Universidade Estadual de Londrina – Londrina, PR, Brazil. 4 – Doctor and Adjunct Professor of the Orthopedics and Traumatology Discipline of Universidade Estadual de Londrina – Londrina, PR, Brazil. Study conducted at the LIM 41 – Laboratory of Medical Investigation of the Musculoskeletal System of the Department of Orthopedics and Traumatology of the School of Medicine of Universidade de São Paulo and in the Orthopedics and Traumatology Discipline of Universidade Estadual de Londrina. Mailing address: Carlos Eduardo Sanches Vaz, Rua Borba Gato, 1.078, ap. 1.202, Jardim das Américas – 86010-630 – Londrina, PR. Email: carlos.vaz@sercomtel.com.br Study received for publication: 11/30/2010, accepted for publication: 05/26/2011.. The authors declare that there was no conflict of interest in conducting this work This article is available online in Portuguese and English at the websites: www.rbo.org.br and www.scielo.br/rbort

Rev Bras Ortop. 2011;46(6):718-25


EFFECT OF USE OF BONE-MARROW CENTRIFUGATE ON MUSCLEinjury treatment: experimental study on rabbits

on functional recovery and the risk of recurrence(2). The limitations described gave rise to surveys investigating biological measures capable of stimulating the muscle regeneration process and of preventing fibrosis formation(5). This resulted in a better identification of the cellular and molecular pathways involved in muscle regeneration and in a more complete understanding of the activity of satellite cells and pluripotent cells, capable of myogenic differentiation during muscle healing(6,7). This better understanding of the muscle repair process made room for favorable prospects in the appearance of new therapies(8). Tissue repair, replacement and regeneration techniques, employing tissue engineering knowledge have recently achieved promising results, which include the capturing and transplantation of precursor cells and the use of bioactive matrices, peptide hormones and growth factors(9). Among these new techniques, two lines of research have been studied extensively: 1) the local application of platelet-rich plasma, due to its supposed healing properties, attributed to the ability to recruit, proliferate and differentiate cells involved in tissue repair; and 2) therapies based on the direct local addition of embryonic stem cell cultures, in the hope that the latter will differentiate in the cells of the target tissue. Although therapies based on the local addition of embryonic stem cell cultures produced in vitro have demonstrated the ability to differentiate into muscle cells (myocytes)(10,11), the culturing and the transplantation of undifferentiated bone marrow cells are complex, costly procedures with technology restricted to large research centers(12). Consequently, the local application of bone marrow aspirates containing adult stem cells has been researched clinically and experimentally(13). The latter have limited tissue differentiation potential in comparison to embryonic stem cells, yet they are able to produce bone, cartilaginous and muscle cells(14). Since the local addition of myocytes is related to an increase of muscle regeneration at the lesion site, the local application of a sufficient number of their precursor cells constitutes a promising approach in the attempt to improve muscle healing(15,16).

719

The aim of this study was to evaluate the positive effect of the addition of bone-marrow centrifugate in the healing of muscle injuries in rabbits.

METHODS This experimental study was evaluated and approved, on March 13, 2007, by the Animal Research Ethics Committee of Universidade Estadual de Londrina. The study subjects were 15 adult male New Zealand White (Orytolagus cuniculus) rabbits with mean weight of 3 kg and approximate age of four months, from the Experimental Farm of Iguatemi, of Universidade Estadual de Maringรก, and bred in the Vivarium of the Health Sciences Center, of Universidade Estadual de Londrina. As there is no consensus in literature regarding the appropriate method for calculating the size of the ideal sample for the study in question, we opted to use a number of animals similar to that used in the reference studies. Moreover, the current ethical guidelines for animal research recommend the use of the lowest possible number of animals, as long as they provide significant statistical results. The animals were evaluated previously by a veterinarian and were accommodated in individual metal cages, with 12 continuous hours of daily light, and with room temperature, humidity and noise kept stable. Their diet consisted of water ad libitum and appropriate balanced and pelleted industrial feed.

Preparation of the bone marrow centrifugate The anesthetic procedure was based on the anesthesia protocol advocated by the Canadian Council on Animal Care, in the Guide to the Care and Uses of Experimental Animals(17). One mg/kg of atropine sulfate was applied in each animal by intramuscular route as a preanesthetic medication. The anesthesia started with the intramuscular application, in the proximal region of the pelvic limb, of a solution containing 40 mg/kg of 10% ketamine chlorhydrate, associated with 5 mg/kg of xylazine chlorhydrate. Soon after the anesthesia induction, the animals were identified with numbers ranging from 1 to 15, tattooed in the left ear. The fractionated administration of 1 mg/kg xylazine chlorhydrate was performed when it was necessary to prolong the anesthesia. Rev Bras Ortop. 2011;46(6):718-25


720

The skin of the right iliac crest region was trichotomized, and after appropriate asepsis and antisepsis, the surgeon performed the puncture of the bone marrow from the posterior iliac crest, using a 16G needle with trocar. The medullary cavity was reached with delicate rotation movements. After this, the trocar was removed, connecting to the needle a 10 ml disposable plastic syringe, the inside of which had been previously soaked in a heparin solution at 1:1.000. Approximately 5 ml of bone marrow were aspirated with firm traction of the syringe piston. The material was processed in a laminar flow chamber under sterile conditions. To disperse the cellular aggregates, the 5 ml sample from the plastic syringe was transferred to a sterile graduated tube, initially through a 19 gauge needle, then using a 22 gauge needle. The material was centrifuged at 400G and at 20°C, for 10 minutes. After centrifugation, the aspirate split into three distinct levels: an upper layer containing the blood plasma, an intermediate layer known as the buffy-coat, where we can find the nucleated cells (due to their greater density), which include hematopoietic precursor cells and marrow stromal cells, the site where it is possible to find the mesenchymal and progenitor cells (bone, cartilaginous and muscle cell precursors). Finally, the last layer is composed of the red cells sedimented at the bottom of the tube. The buffy-coat material was then homogenized, and a sample of 50 microliters was separated to count the cells and to carry out a cell viability test, to avoid the administration of dead cells that could result from the centrifugation process.

mately 60% of its length, starting from its proximal origin, according to the model of Menetrey et al(18). This is done to avoid the total crosswise section of the muscular venter, enabling more uniform healing between the muscle portions separated by the incision and sparing the motor nerve at its point of penetration in the muscle(6). After this, the surgeon placed proximal and distal repair stitches at a distance of 5 mm from the edges of the muscle injury, using 4.0 mononylon suture thread, according to the procedure recommended by Marlow et al(19). A sample of absorbable gelatin sponge (GelfoamÂŽ) measuring 1.0 x 0.5 cm was soaked in the bone marrow centrifugate and placed over the lesion (Figure 1). The surgical wound was sutured by planes using 4.0 mononylon suture thread and occluded with a sterile impermeable dressing. The same procedure was carried out in the left tibialis anterior muscle;

Surgical technique The anesthetized animal was positioned in dorsal decubitus on the operating table, performing trichotomy of the anterior surfaces of the right and left legs, and appropriate asepsis and antisepsis. A longitudinal, anteromedial access route was made in the middle third of the hind limb, approximately 3 cm in length. This was followed by dissection by planes, approaching skin, subcutaneous tissue and fascia, which were pulled aside, exposing the body of the tibialis anterior muscle. Using a no. 15 scalpel blade, a crosswise incision was made in the body of the tibialis anterior muscle, covering 75% of its width, 50% of its thickness and approxiRev Bras Ortop. 2011;46(6):718-25

Figure 1 â&#x20AC;&#x201C; Muscle repair and absorbable gelatin sponge soaked in bone marrow centrifugate on the lesion of the right tibialis anterior muscle.


EFFECT OF USE OF BONE-MARROW CENTRIFUGATE ON MUSCLEinjury treatment: experimental study on rabbits

yet only the absorbable gelatin sponge was applied at the site. At the end of surgery, the animal was isolated from the other animals, placed in an appropriate box and heated. An intramuscular dose of antibacterial and anti-inflammatory drug containing penicillin G benzathine, penicillin G procaine, dihydrostreptomycin sulfate and piroxicam was administered. After total recovery from anesthesia, the rabbit was returned to its cage, receiving water and feed ad libitum. Full weight-bearing on the operated limbs was authorized and allowed immediately, without any type of restriction or immobilization. According to Järvinen et al(1), early mobilization induces faster and more intense capillary growth into the injured area, better regeneration and more parallel muscle fiber orientation, while inactivity is associated with significant atrophy of the muscle fibers and excessive fibrosis deposition. Thirty days after the surgery date, the animals were sacrificed. The right and left tibialis anterior muscles of each animal were carefully dissected from their proximal to their distal insertion and removed. The proximal and distal surgical repair stitches were located, 5 mm from the lesion site, and the muscle was sectioned between these stitches, according to the experimental model described by Menetrey et al(18). After this, the proximal and distal halves of the muscles were placed in appropriate containers, fixed in a 10% formalin solution, and identified with the rabbit’s number and corresponding hind limb (right or left). The muscle tissue samples were then dehydrated and soaked in paraffin for the histological study, positioned in such a way that the location of the surface of the middle line would allow cross sections from the middle point of the injury. Histological sections with a thickness of 4µm were obtained from the paraffin blocks, and followed the histological routine for staining with hematoxylin-eosin, for histopathological and histomorphometric evaluation. The evaluation of results was performed by the quantitative histological measurement (number of muscle cells per µm2 and proportion of fibrosis) of healing of the muscle injury, comparing the right tibialis anterior muscle with the left from the surface of the middle line of their segments, in the intermediate region of the muscle injury, which is the ideal region for quantification of muscle regeneration, as it occurs

721

regardless of vascular supply and in an environment not influenced by fibrous repair, reflecting only the myogenic potential. The findings were then documented in scanned images captured with the assistance of the Kontron Electronic 300 (Zeiss®) image analysis system, for the quantitative evaluation. This semi-automated routine was carried out in each field of the slide under analysis, with 10 fields per slide. The results obtained in each field, corresponding to the analyzed area (number of muscle cells per µm2 and proportion of fibrosis), were filed in a Microsoft Excel® spreadsheet for subsequent statistical analysis. The statistical analysis was performed in the Department of Statistics of the Center of Exact Sciences of Universidade Estadual de Londrina. The mean, the standard deviation, the median and the interquartile amplitude of the continuous quantitative variables were all measured. Statistical tables and column charts (mean ± standard deviation) presented the descriptive statistics of the variables: number of muscle cells/µm2 and proportion of fibrosis. Wilcoxon’s test was used for inference on the difference between the observations of the paired and nonparametric samples. The significance level adopted was 5% (α = 0.05).

RESULTS Table 1 contains the results of the cell count and of the cell viability test, carried out after the bone marrow aspirate centrifugation. Table 2 and Figure 2 demonstrate the number of muscle cells per square micrometer formed at the site of the muscle injury, treated with bone marrow centrifugate, in comparison to the control group. Table 3 and Figure 3 demonstrate the percentage of fibrosis formed at the site of the muscle injury, treated with bone marrow centrifugate, in comparison to the control group.

DISCUSSION Muscle injuries are extremely common, constituting around 35-55% of all sports-related injuries. The associated morbidity is significant since these injuries can lead to painful muscle contractures and atrophies, Rev Bras Ortop. 2011;46(6):718-25


722 Table 1 – Descriptive statistics of the nucleated cell count in each sample of bone marrow aspirate and determination of their cell viability. Nucleated cell Rabbit

Puncture Mean count volume (107 cells/ (ml) ml)

Viable

Cell viability (%)

Non-viable

1st

2nd

M

1st

2nd

M

M

97.0

1

5.0

10.2

97

100

99

2

4

3

#

3

97.0

2

5.0

3.4

32

34

33

1

1

1

#

1

97.9

3

4.0

4.9

51

44

48

1

1

1

#

1

95.6

4

5.0

4.6

40

47

44

1

2

2

#

2

97.4

5

3.0

7.8

73

78

76

1

3

2

#

2

95.5

6

3.0

6.7

65

62

64

3

3

3

#

3

96.0

7

5.0

5.0

53

43

48

3

1

2

#

2

90.6

8

6.0

7.5

66

69

68

6

8

7

#

7

96.8

9

7.0

9.5

94

90

92

2

4

3

#

3

96.3

10

4.5

13.6

130

132

131

4

5

5

#

5

94.9

11

5.5

5.9

56

55

56

2

4

3

#

3

92.5

12

6.0

8.1

78

71

75

6

5

6

#

6

93.6

13

5.0

4.7

47

40

44

3

3

3

#

3

94.9

14

5.5

7.9

72

77

75

2

6

4

#

4

92.5

15

5.5

4.0

31

42

37

2

4

3

#

3

1st – First count – 2nd – Second count – M – Mean count

Table 2 – Descriptive statistics of the number of muscle cells formed at the site of the muscle injury, comparing the side where the bone marrow centrifugate was applied with the control side. Rabbit

Bone marrow centrifugate (BMC)

Control (C)

1

0.000202916

0.000202135

2

0.000754903

0.000339927

3

0.000522031

0.000297436

4

0.000156089

0.000417183

5

0.000364207

0.000569724

6

0.000376955

0.000339927

7

0.000587284

0.000400628

8

0.000366809

0.000348273

9

0.000422149

0.000417183

10

0.000304373

0.000207598

11

0.000476781

0.000147504

12

0.000242805

0.000182104

13

0.000327787

0.000195111

14

0.000143407

0.000176034

15

0.000392351

0.000196672

Mean ± standard deviation

0.000376 ± 0.0001647

0.000296 ± 0.0001219

Difference (BMC-C)

0.000080 ± 0.0001796

 

Median (interquartile 0.000367 (0.0002340) amplitude)

Bone marrow centrifugate

Control

0.000297 (0.0002055)

Difference (BMC-C)

0.000061 (0.0001949)

 

Wilcoxon

S = 32

p = 0.0730

Rev Bras Ortop. 2011;46(6):718-25

Number of cells/µm2

Number of muscle cells/µm2

Figure 2 – Number of muscle cells by square micrometer in the intermediate region of the injury of the tibialis anterior muscle treated with bone marrow centrifugate and control.


EFFECT OF USE OF BONE-MARROW CENTRIFUGATE ON MUSCLEinjury treatment: experimental study on rabbits

Table 3 – Comparative descriptive statistics of the percentage of fibrosis formed at the muscle injury sites. Proportion of fibrosis Rabbit

Bone marrow centrifugate (BMC)

Control (C)

1

0.601304503

0.469212643

2

0.525683356

0.642372385

3

0.361749355

0.445195018

4

0.666412294

0.377530994

5

0.676205576

0.593659394

6

0.343374895

0.699801392

7

0.555734885

0.500963831

8

0.500546007

0.583348253

9

0.387811732

0.379854791

10

0.567422834

0.491287125

11

0.646452016

0.37336342

12

0.663838047

0.543644596

13

0.630006334

0.513283371

14

0.302357471

0.672787984

15

0.59545864

0.448178945

Mean ± standard deviation

0.534957 ± 0.12778

0.515632 ± 0.10568

0.019325 ± 0.19402

 

0.567423 (0.25864)

0.500964 (0.14846)

Difference (BMC-C)

0.076136 (0.21554)

 

Wilcoxon

S = 13

p = 0.4887

Percentage of fibrosis

Difference (BMC-C) Median (interquartile amplitude)

Bone marrow centrifugate

Control

Figure 3 – Proportion of fibrosis in the intermediate region of the injury of the tibialis anterior muscle treated with bone marrow centrifugate and control.

723

require long periods of recovery, increase the risk of recurrence and, in some cases, make it difficult for athletes to return to their pre-injury activity level. In recent years, the development of cell and tissue engineering therapies has stimulated research employing these techniques in the treatment of muscle injuries. The purpose of these therapies is to stimulate an increase in the formation of muscle cells in the affected region, and, at the same time, to reduce the formation of excess connective scar tissue (fibrosis). The latter is directly related to the rate of recurrent injuries and has been shown capable of preventing athletes from returning to their pre-injury state, partly as it prevents the formation of new myofibrils, contributing towards the decline of muscle contractility and of range of motion(20). The pain resulting from the formation of fibrosis is also a limiting factor for total functional recovery during physiotherapy and in the long-term. Although studies evidence the ability of embryonic progenitor cell (embryonic stem cell) cultures to form bone, cartilaginous and muscle tissues, this technology is expensive and complex, and, therefore, still far from the daily clinical practice. Because of this, the initiative of our using in our survey aspirates from bone marrow, which demonstrably contains, in its stroma, adult mesenchymal tissue precursor cells. These cells also present the potential, although more limited than the embryonic precursory cells, to differentiate into muscle cells. We use the muscle injury model described by Menetrey et al(18), which impedes the total separation of the muscle fibers, favoring the study of healing. On the lesion site, we apply absorbable collagen foam, soaked in the bone marrow centrifugate, to prevent the dispersion of the cells and to allow their more prolonged contact with the lesion, since the foam remains at the site for approximately fifteen days before being absorbed completely. The samples of bone marrow aspirate were centrifuged with the objective of separating the nucleated cells, of which both hematopoietic precursor cells and stromal cells form part. After the centrifugation process is complete, these cells are concentrated in the intermediate layer of the tubes (buffy-coat). Although the model used does not faithfully reproduce the muscle injuries most frequently encountered Rev Bras Ortop. 2011;46(6):718-25


724

in the clinical practice, which are those caused by contusion or laceration mechanism, we opted for the model proposed by the cited authors as it allows a better standardization of the injury in each animal. According to these authors, this model is easy to execute and eliminates variables such as extension, depth and intensity of the force applied when attempting to cause the injury by contusion or laceration, allowing a better characterization of the muscle healing. Another conflicting factor in our study was the option to sacrifice the animals with a single time interval of four weeks. Ideally, we should evaluate the healing in several periods, which would allow a more uniform and linear follow-up. However, this would require a much larger sample group of animals, which has been discouraged by animal protection societies and animal welfare boards. Nowadays they advocate the use of the lowest possible quantity of animals, and uphold that people should preferably work at tissue level (histology). Moreover, there is no standardization, in literature, of the calculation of the most appropriate number of animals for this type of study. In spite of all these precautions, our results demonstrated that there was no significant difference in the number of muscle cells formed at the site of the muscle lesions where the bone marrow centrifugate was applied, in comparison with the control side. Neither was there any difference in the percentage of fibrosis formed, which allows us to conclude that the bone marrow concentrate was not able to improve the quality of the muscle scar. Although literature frequently refers to mesenchymal progenitor cells of the bone marrow as a homogeneous population, these cells are actually very heterogeneous, differing greatly in their ability to differentiate into adult muscle cells. Therefore, even when the same technique is employed for their obtainment, bone marrow aspirates can be very different in relation to the quantity of truly precursor cells present in each collected sample. This may be one of the causes of failure in our study. According to Matziolis et al(21), the inflammatory process triggered by a muscle injury can lead to the death of the myogenic precursor cells implanted immediately, which may result in cell survival below 10% on the Rev Bras Ortop. 2011;46(6):718-25

fifth day after the trauma. This is apparently caused by the cellular and humoral factors that form part of the physiological inflammation processes during the first days after the injury. Moreover, the damage to microvascularization results in poor regenerative response in this phase. Together, these factors create a hostile environment that hinders the survival, the proliferation and the differentiation of transplanted cells, contributing to justify the negative results found in our study. Although tissue regeneration mediated by embryonic stem cells in vitro has promising therapeutic potential, Musarò et al(10) believe that the differentiation in the skeletal muscle of adult stem cells originating from the bone marrow has hardly any clinical import. In this study, the greater proportion of fibrosis in the treatment group, although not significant, came as a surprise, demonstrating that the excessive formation of connective scar tissue, in the opinion of other authors, is a problem yet to be resolved. The results obtained in this study demonstrate that the bone marrow centrifugate was not able to induce a better quality of muscle healing, increasing the number of muscle fibers and reducing fibrosis formation. One alterative that has been the focus of recent surveys seeking to repair and/or to regenerate the muscle tissue is the use of platelet concentrate, also known as platelet-rich plasma (PRP)(22). The platelets are the first cells to reach the site of the injury and are very active in the initial inflammatory phase of tissue repair. They act in tissue homeostasis, by means of adherence, aggregation, formation of clots and release of substances (growth factors) that promote tissue repair and that influence local neovascularization(23). Platelets release growth factors through degranulation, and the interest in their local application at lesion sites is due precisely to the possibility of enhancing tissue healing potential through the direct administration of these factors. These factors are concentrated by means of techniques of centrifugation of autologous blood from the actual patient, producing a platelet-rich substance that can be applied in liquid or gelatinous form on the injured tissue(23).


EFFECT OF USE OF BONE-MARROW CENTRIFUGATE ON MUSCLEinjury treatment: experimental study on rabbits

In spite of its considerable appeal, recent studies have demonstrated that there is still a great deal of controversy regarding the true efficacy of PRP, mainly due to the non-standardization of variables such as quantity to be applied, concentration, time interval etc. Most surveys appear to demonstrate a favorable effect in the treatment of chronic tendinosis, but conflicting results in bone and muscle application(24). Further studies should be conducted, perhaps using

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homogeneous populations of mesenchymal progenitor cells, in an attempt to regenerate the muscle fibers, resulting in more adequate muscle healing and in the complete recovery of pre-injury muscle function.

CONCLUSION The administration of the bone marrow centrifugate used in this study did not favor the healing of muscle injuries in rabbits.

REFERENCES 1. Järvinen TA, Järvinen TL, Kääriäinen M, Kalimo H, Järvinen M. Muscle injuries:biology and treatment. Am J Sports Med. 2005;33(5):745-64.

13. Connolly JF. Injectable bone marrow preparations to stimulate osteogenic repair. Clin Orthop Relat Res. 1995;(313):8-18.

2. Armfield DR, Kim DH, Towers JD, Bradley JP, Robertson DD. Sports-related muscle injury in the lower extremity. Clin Sports Med. 2006;25(4):803-42.

14. Bianco P, Riminucci M, Gronthos S, Robey PG. Bone marrow stromal stem cells: nature, biology, and potential applications. Stem Cells. 2001;19(3):180-92.

3. Buckwalter JA, Cruess RL. A cura dos tecidos musculoesqueléticos. In: Rockwood CA, Green DP, Bucholz RW, editores. Fraturas em adultos. 3a. ed.. São Paulo: Manole; 1993. p. 179-219.

15. Ferrari G, Cusella-De Angelis G, Coletta M, Paolucci E, Stornaiuolo A, Cossu G, et al. Muscle regeneration by bone marrow-derived myogenic progenitors. Science. 1998;279(5356):1528-30.

4. Garrett WE Jr, Seaber AV, Boswick J, Urbaniak JR, Goldner JL. Recovery of skeletal muscle after laceration and repair. J Hand Surg Am. 1984;9(5):683-92. 5. Huard J, Li Y, Fu FH. Muscle injuries and repair: current trends in research. J Bone Joint Surg Am. 2002;84 A(5):822-32. 6. Chargé SB, Rudnicki MA. Cellular and molecular regulation of muscle regeneration. Physiol Rev. 2004;84(1):209-38. 7. Shefer G, Wleklinski-Lee M, Yablonka-Reuveni Z. Skeletal muscle satellite cells can spontaneously enter an alternative mesenchymal pathway. J Cell Sci. 2004;117(Pt 22):5393-404. 8. Griffith LG, Naughton G. Tissue engineering--current challenges and expanding opportunities. Science. 2002;295(5557):1009-14. 9. Muschler GF, Nakamoto C, Griffith LG. Engineering principles of clinical cellbased tissue engineering. J Bone Joint Surg Am. 2004;86(7):1541-58. 10. Musarò A, Giacinti C, Borsellino G, Dobrowolny G, Pelosi L, Cairns L, et al. Stem cell-mediated muscle regeneration is enhanced by local isoform of insulinlike growth factor 1. Proc Natl Acad Sci U S A. 2004;101(5):1206-10. 11. Fukada S, Miyagoe-Suzuki Y, Tsukihara H, Yuasa K, Higuchi S, Ono S, et al. Muscle regeneration by reconstitution with bone marrow or fetal liver cells from green fluorescent protein-gene transgenic mice. J Cell Sci. 2002;115(Pt 6):1285-93. 12. Vaz CES. Avaliação do efeito de centrifugado osteogênico de medula óssea na consolidação de fratura: estudo experimental em coelhos [tese]. São Paulo: Universidade de São Paulo; 2006.

16. Muschler GF, Midura RJ. Connective tissue progenitors: practical concepts for clinical applications. Clin Orthop Relat Res. 2002;(395):66-80. 17. Olfert ED, Cross BM, McWilliam AA. editors. (1993). Guide to the Care and Use of Experimental Animals. 2nd ed. Ottawa: Canadian Council on Animal Care; 1993. 18. Menetrey J, Kasemkijwattana C, Fu FH, Moreland MS, Huard J. Suturing versus immobilization of a muscle laceration. A morphological and functional study in a mouse model. Am J Sports Med. 1999;27(2):222-9. 19. Marlow SA, McGeachie JK, Tennant M, Papadimitriou JM. A morphometric technique for the histological quantification of skeletal muscle regeneration. J Anat. 1996;189 ( Pt 1):151-8. 20. Kääriäinen M, Järvinen T, Järvinen M, Rantanen J, Kalimo H. Relation between myofibers and connective tissue during muscle injury repair. Scand J Med Sci Sports. 2000 Dec;10(6):332-7. Review. PubMed PMID: 11085560. 21. Matziolis G, Winkler T, Schaser K, Wiemann M, Krocker D, Tuischer J, Perka C,Duda GN. Autologous bone marrow-derived cells enhance muscle strength following skeletal muscle crush injury in rats. Tissue Eng. 2006;12(2):361-7. 22. Cole BJ, Seroyer ST, Filardo G, Bajaj S, Fortier LA. Platelet-Rich Plasma:Where are we now and where are we going?. Sports Health. 2010;2:203-10. 23. Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA. Plateletrich plasma: from basic science to clinical applications. Am J Sports Med. 2009;37(11):2259-72. 24. Hall MP, Band PA, Meislin RJ, Jazrawi LM, Cardone DA. Platelet-rich plasma: current concepts and application in sports medicine. J Am Acad Orthop Surg. 2009;17(10):602-8. Rev Bras Ortop. 2011;46(6):718-25


ORIGINAL ARTICLE

Physical examinations for diagnosing meniscal injuries: correlation with surgical findings

Ricardo da Rocha Gobbo1, Victor de Oliveira Rangel2, Francisco Consoli Karam3, Luiz Antônio Simões Pires4

Abstract Objective: A set of five maneuvers for meniscal injuries (McMurray, Apley, Childress and Steinmann 1 and 2) was evaluated and their sensitivity, specificity, accuracy and likelihood were calculated. The same methods were applied to each test individually. Methods: One hundred and fifty-two patients of both sexes who were going to undergo videoarthroscopy on the knee were examined blindly by one of five residents at this hospital, without knowledge of the clinical data and why the patient was going to undergo an operation. This examination was conducted immediately before the videoarthroscopy and its results were recorded in an electronic spreadsheet. The set of maneuvers was considered

INTRODUCTION Meniscal injuries (MI) habitually occur in patients who suffer rotational trauma to the knee under compression. They can occur separately or in association with ligament ruptures and chondral pathologies. They are quite often found in the orthopedic practice(1) and MIs usually occur during sports(1). In a recent case, the findings of the physical examination may be limited, insofar as the patient may present a painful knee, restricted range of motion (ROM) and joint effusion(2). When it is a long-standing injury, the efficacy of the tests for detection of MI will be compromised(3). The posterior horn of the medial meniscus is the most common site of meniscal

positive when one was positive. In the individual analysis, it was enough for the test to be positive. Results: The analysis showed that the set of five meniscal tests presented sensitivity of 89%, specificity of 42%, accuracy of 75%, positive likelihood of 1.53 and negative likelihood of 0.26. Individually, the tests presented accuracy of between 48% and 53%. Conclusion: The set of maneuvers for meniscal injuries presented a good accuracy and significant value, especially for ruling out injury. Individually, the tests had less diagnostic value, although the Apley test had better specificity. Keywords – Knee; Arthroscopy; Physical Examination; Video-Assisted Surgery; Comparative Study

conditions, while longitudinal ruptures represent the most frequent injuries(4). With the advance of modern imaging exams, the diagnosis of MIs has become more precise. Magnetic resonance imaging has become the exam of choice for the imaging study of these injuries(5,6), and it is indicated as a highly accurate diagnostic tool(7-10). Accompanying this evolution, arthroscopic therapeutic methods have provided a new scenario for the treatment of meniscal conditions(11,12). In spite of these facts, it is firmly established in the current literature that anamnesis and the physical examination are directly related to the diagnosis of MIs(13-17), and are pointed out, by Wagemakers et al(3), as having a slightly su-

1 – Member of the Brazilian Society of Knee Surgery (Sociedade Brasileira de Cirurgia do Joelho); Member of the Brazilian Society of Orthopedics and Traumatology (Sociedade Brasileira de Ortopedia e Traumatologia); Former Resident of the Knee Group of the Orthopedics and Traumatology Clinic of Hospital São Lucas, PUCRS – Porto Alegre, RS, Brazil. 2 – Member of the Brazilian Society of Orthopedics and Traumatology; Former Resident Physician of the Orthopedics and Traumatology Clinic of Hospital São Lucas, PUCRS – Porto Alegre, RS, Brazil. 3 – Master’s degree in Human Movement Sciences; Doctor’s degree in Medicine; Member of the Knee Group of the Orthopedics Clinic of Hospital São Lucas, PUCRS – Porto Alegre, RS, Brazil. 4 – Master’s degree in Human Movement Sciences; Head of the Orthopedics and Traumatology Clinic of Hospital São Lucas, PUCRS – Porto Alegre, RS, Brazil. Study conducted at the Knee Surgery Group of the Orthopedics and Traumatology Clinic of Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul. Mailing address: Avenida Ipiranga, 6.690 – 90610-000 – Porto Alegre, RS. Email: ricgobbo@hotmail.com Study received for publication: 10/21/2010, accepted for publication: 12/23/2011 The authors declare that there was no conflict of interest in conducting this work This article is available online in Portuguese and English at the websites: www.rbo.org.br and www.scielo.br/rbort

Rev Bras Ortop. 2011;46(6):726-29


PHYSICAL EXAMINATIONS FOR DIAGNOSING MENISCAL INJURIES: correlation with surgical findings

perior value to magnetic resonance imaging. Kocabey et al(18) evaluated the painful joint line, McMurray, Steinmann and modified Apley tests. This set of tests presented accuracy of 80% for the medial meniscus and 92% for the lateral meniscus(18). The aim of our study is to calculate the sensitivity, specificity, accuracy, positive and negative likelihood of the McMurray, Steinmann, Apley and Childress (duck waddle) tests both separately and jointly.

MATERIAL AND METHODS A cross-sectional study, with prospective data collection performed between January 2008 and June 2009. Two of the five Orthopedics and Traumatology residents of Hospital São Lucas, PUCRS, examined 162 patients (163 knees) with meniscal and/or ACL injury who were going to undergo knee videoarthoscopy afterwards. The examiners, who received specific training to perform meniscal maneuvers, were not familiar with the patients’ clinical data, or the reason for surgery. The physical examination was performed prior to surgery and its results were compared with the surgical findings. The residents selected 117 male patients and 45 female patients over 18 years of age (mean age of 39.03 years) with traumatic or degenerative knee injuries. The set of maneuvers performed for the MI diagnosis was composed of the McMurray apud Tria(19), Apley(20), Childress, Steinmann I and II tests(19). The physical examination was conducted by two residents; in the event of a tie, a third resident was recruited to examine the patient. The result was written down by this examiner, who marked the test positive or negative. For the set of maneuvers, it was considered a positive physical examination when one of them was positive. The maneuvers were also considered positive or negative in separate form. The arthroscopic assessment of the knee was performed at the surgical center, always by one of the two orthopedists specialized in the knee, on patients who presented previous surgical indication, but did not present exams and clinical data reported to the three orthopedic residents who were performing the physical examination proposed in the study. Arthroscopies were performed through the classic parapatellar, anterolateral and anteromedial portals. After insertion of the arthroscope through the lateral parapatellar portal, a routine inspection was carried

727

out on the whole joint in all the cases, analyzing the medial and lateral compartments (condyles, plateaus and menisci), intercondyle (cruciate ligaments), and finally the femoropatellar joint (patellar and synovial cartilages). Investigation through medial and lateral suprapatellar portals was performed as necessary. The injuries were identified and recorded for comparison with the physical examination. After the inspection, the lesions were surgically corrected as necessary. Videoarthroscopies were not performed in patients without indication for surgical treatment (videosurgery) for their disease. Any type of meniscal injury found in the transoperative period was considered a positive finding, regardless of whether it was radial or longitudinal, simple or complex, traumatic or degenerative. The study was submitted and approved by the research ethics committee of the institution where it was conducted, and all the patients read and signed the informed consent form. The data were filed in a MS Office-Excel 2007 spreadsheet and evaluated by BioEstat 5.0 software. The accuracy, sensitivity and specificity of the tests were evaluated jointly.

RESULTS Of the 162 patients included in the study, 124 presented meniscal injury, while 82 (66.12%) had an injury involving the medial meniscus (MM), 42 (33.87%) the lateral meniscus (LM) and 10 (8.06%) had both menisci injured (Table 1). Table 1 – Results relating to the distribution of medial and lateral meniscal injuries. MI

MM

LM

Both M

TOTAL

82 (66.12%)

42 (33.87%)

10 (8.06%)

124 (100%)

As observed in the Table 2, the analysis showed that the set of the five meniscal tests presented 89% of sensitivity for the MM and 85% of sensitivity for the LM. As regards specificity, the values were 31% for the MM and 24% for the LM, which led us to a calculation of 60% of accuracy for the MM and 40% for the LM. The positive likelihood was 1.29 in the MM and 1.13 in the LM. The negative likelihood was 0.35 for the MM and 0.59 for the LM. In Table 3 we analyzed each test separately, with their respective values of accuracy, likelihoods, sensitivity and specificity. The Apley test presented Rev Bras Ortop. 2011;46(6):726-29


728 Table 2 – Sensitivity, specificity, positive likelihood, negative likelihood of the set of tests. MM Set

LM Set

Sensitivity

89.02%

Sensitivity

85.71%

Specificity

31.25%

Specificity

24.17%

Positive Likelihood

1.29

Positive Likelihood

1.13

Negative Likelihood

0.35

Negative Likelihood

0.59

Accuracy

60.49%

Accuracy

40.00%

MM: medial meniscus; LM: lateral meniscus.

specificity of 65% for the MM and 60% for the LM; therefore these values are higher than those of the other tests. As regards accuracy, Steinmann I and II tests presented values of around 62% for the detection of MM injury. The accuracy of the isolated tests was greater in the MM examination, with the exception of the Apley test in which it was the same.

DISCUSSION To verify the value of the physical examination in the detection of meniscal injuries of the knee, we used arthroscopy as the standard method, like in the vast majority of similar studies(18,20-23). Some provocative tests are described with the intention of identifying symptoms involving the menisci. The tests used in this study can be divided into two groups. The first group includes the tests that depend on palpation or clicking sensation at the joint line, such as the McMurray and Steinmann II tests. The positive McMurray test for medial meniscus is

demonstrated with external rotation of the tibia and passive movement from flexion to extension. For lateral meniscus, it is demonstrated with internal rotation of the tibia and passive movement from flexion to extension. The Steinmann II test demonstrates pain at the interline that moves posteriorly when the knee is flexed and anteriorly when the knee is extended. The second group contains the tests that depend on pain with rotation. The Apley test is carried out through compression and distraction between the tibiofemoral joint surface in flexion. If the distraction promotes less discomfort than the compression, it indicates meniscal pain instead of a joint disorder. The Childress (duck waddle) test provokes compressive force on the posterior horn of the meniscus causing pain. The Steinmann I test is carried out with the knee flexed at 90 degrees and a sudden external rotatory force is applied on the tibia to test the medial meniscus. The result is pain along the medial joint line. Internal tibial rotation is used for lateral meniscal pain(19). Manzotti et al(23) demonstrated in their study that the McMurray’s maneuver presents greater sensitivity for medial meniscus injuries when compared to the lateral meniscus, a fact that was confirmed in our study. Evans et al(21), taking into account just joint snapping for the positivity of the McMurray test, concluded that this has specificity of 98% and sensitivity of 16%. Our study showed a lower specificity, yet a

Table 3 – Sensitivity, specificity, positive likelihood, negative likelihood of the tests separately. MC MM

MC LM

STI MM

STI LM

Sensitivity

64.63%

Sensitivity

61.90%

Sensitivity

69.51%

Sensitivity

59.52%

Specificity

57.50%

Specificity

49.17%

Specificity

56.25%

Specificity

44.17%

Positive Likelihood

1.52

Positive Likelihood

1.22

Positive Likelihood

1.59

Positive Likelihood

1.07

Negative Likelihood

0.62

Negative Likelihood

0.77

Negative Likelihood

0.54

Negative Likelihood

0.92

Accuracy

61.10%

Accuracy

52.46%

Accuracy

62.96%

Accuracy

48.14%

STII MM

STII LM

CH MM

CH LM

Sensitivity

68.29%

Sensitivity

59.52%

Sensitivity

63.41%

Sensitivity

73.81%

Specificity

56.25%

Specificity

45.00%

Specificity

45.00%

Specificity

45.83%

Positive Likelihood

1.56

Positive Likelihood

1.08

Positive Likelihood

1.15

Positive Likelihood

1.36

Negative Likelihood

0.56

Negative Likelihood

0.9

Negative Likelihood

0.81

Negative Likelihood

0.57

Accuracy

62.34%

Accuracy

48.76%

Accuracy

54.32%

Accuracy

53.00%

AP MM

AP LM

Sensitivity

50.00%

Sensitivity

50.00%

Specificity

65.00%

Specificity

60.00%

Positive Likelihood

1.43

Positive Likelihood

1.25

Negative Likelihood

0.77

Negative Likelihood

0.83

Accuracy

57.40%

Accuracy

57.40%

MC: McMurray; STI – STII: Steinmann I – II; CH: Childress; AP: Apley; MM: menial meniscus; LM: lateral meniscus. Rev Bras Ortop. 2011;46(6):726-29


PHYSICAL EXAMINATIONS FOR DIAGNOSING MENISCAL INJURIES: correlation with surgical findings

higher sensitivity in relation to Evans’ study for this test. Meserve et al(24), in their meta-analysis, showed that the Apley test presents superior specificity when compared to McMurray’s maneuvers and painful palpation of the joint line. However, as regards sensitivity, the Apley test presented much lower values. These data were similar to those of our study when the Apley test was compared to another four maneuvers. Steinmann I and II tests are not often used to test the accuracy of the physical examination in studies of greater relevance. Kocabey et al(18) cited Steinmann’s maneuver in their study, yet did not specify whether it was Steinmann I or II, showing the data together with other maneuvers. Through our results it is possible to notice that both Steinmann I and II have superior accuracy over the other tests in relation to the medial meniscus. Fowler and Lubliner(17) stressed that no meniscal test is predictive for the diagnosis, and that the set of maneuvers should be used. Kocabey et al(18)

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compared the accuracy of the set of maneuvers with that of nuclear magnetic resonance (NMR) in their study. Through their data, they concluded that the physical examination has superior accuracy to that of NMR with sensitivity results that resemble ours (MM 87% – LM 75%). Accordingly, in patients with strong suspicion of injury, the set of maneuvers can be very useful for ruling out this suspicion. All the isolated tests, except for the Apley test, presented greater sensitivity than specificity. A test with high sensitivity is used mainly to exclude the presence of a pathology.

CONCLUSION The set of maneuvers for meniscal injuries has good accuracy and significant value, particularly to exclude injuries. The isolated tests have lower diagnostic value, while the Apley test is that with the best specificity.

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2. DeHaven KE. Diagnostic of acute knee injuries with hemarthrosis. Am J Sports Med. 1980;8(1):9-14.

13. Calmbach WL, Hutchens M. Evaluation of patients presenting with knee pain: Part I. History, physical examination, radiographs, and laboratory tests. Am Fam Physician. 2003;68(5):907-12.

3. Wagemakers HP, Heintjes EM, Boks SS, Berger MY, Verhaar JA, Koes BW et al. Diagnostic value of history-taking and physical examination for assessing meniscal tears of the knee in general practice. Clin J Sports Med. 2008;18(1):24-30. 4. Miller RH. Knee injuries. In: Canale ST, editor. Campbell’s orthopaedics surgery. 10th ed. Philadelphia: Mosby,2003. p. 2165-337. 5. Karam FC, Silva JLB, Fridman MW, Abreu A, Arbo RDM, Abreu M et al. A ressonância magnética para lesões condrais, meniscais e dos ligamentos cruzados dos joelhos. Radiol Bras. 2007;40(3):179-82. 6. Schneider I, Schueda MA, Demore AB. Análise comparativa da ressonância nuclear magnética com a artroscopia no diagnóstico das lesões intra-articulares do joelho. Rev Bras Ortop. 1996;31(5):373-6. 7. Oei EH, Nikken JJ, Verstijnen AC, Ginai AZ, Myriam Hunink MG. MR imaging of the menisci and cruciate ligaments: a systematic review. Radiology. 2003;226(3):837-48. 8. Vincken PW, ter Braak BP, van Erkell AR, de Rooy TP, Mallens WM, Post W, et al. Effectiveness of MR imaging in selection of patients for arthroscopy of the knee. Radiology. 2002;223(3):739-46. 9. Severino NR, Camargo OPA, Aihara T, Cury RPL, Oliveira VM, Vaz CES et al. Comparação entre a ressonância magnética e a artroscopia no diagnóstico das lesões do joelho Rev Bras Ortop. 1997;32(4):275-8.

14. Smith BW, Green GA. Acute knee injuries: Part I. History and physical examination. Am Fam Physician. 1995;51(3):615-21. 15. Jackson JL, O’Malley PG, Kroenke K. Evaluation of acute knee pain in primary care. Ann Intern Med. 2003; 139(7):575-88. 16. Heintjes EM, Bierma SM, Bernsen RM. Physical examination of knee injuries. JAMA. 2002;287(1):40; author reply 41. 17. Fowler PJ, Lubliner JA. The predictive value of five clinical signs in the evaluation of meniscal pathology. Arthroscopy. 1989;5(3):184-6. 18. Kocabey Y, Tetik O, Isbell WM, Atay A, Johnson DL. The value of clinical examination versus magnetic resonance imaging in the diagnosis of meniscal tears and anterior cruciate ligament rupture. Arthroscopy. 2004;20(7):696-700. 19. Tria AJ Jr. Clinical examination of the knee. In: Insaii JN, Scott WN, editors. Surgery of the knee. 3rd ed. New York: Churchill Livingstone; 2001. p 161 74. 20. Apley G. The diagnosis of meniscus injuries. Bone Joint Surg Am. 1947;29(1):78-84. 21. Evans PJ, Bell GD, Frank C. Prospective evaluation of the McMurray test. Am J Sports Med.1993;21(4):604-8. 22. Anderson AF, Lipscomb AB. Clinical diagnosis of meniscal tears: description of a new manipulative test. Am J Sports Med 1986;14(4):291-3.

10. Yousef JW, Thiele ES, Scuisato DL. Correlação diagnóstica da ressonância magnética com artroscopia nas lesões intra-articulares do joelho. Rev Bras Ortop. 1999;34;(6):375-80.

23. Manzotti A, Baiguini P, Locatelli A. Statistical evaluation of McMurray’s test in the clinical diagnosis of meniscus injuries. J Sports Traumatol Relat Res. 1997;19:83–9.

11. Barretto JM, Couto P. Artroscopia do joelho sob anestesia local e sedação: possibilidades diagnóstica e terapêutica. Rev Bras Ortop. 1997;32(4):289-92.

24. Meserve BB, Cleland JA, Boucher TR. A meta-analysis examining clinical test utilities for assessing meniscal injury. Clin Rehabil. 2008;22(2):143-61. Rev Bras Ortop. 2011;46(6):726-29


CASE REPORT

LEG’S COMPARTMENT SYNDROME AFTER RECONSTRUCTION OF THE ANTERIOR CRUCIATE LIGAMENT: CASE REPORT Jorge Sayum Filho1, Leonardo Adeo Ramos1, Jorge Sayum2, Rogério Teixeira de Carvalho1, Benno Ejnisman1, Marcelo Mitsuro Matsuda1, Alexandre Nicolini1, Moisés Cohen3

Abstract

left knee that complicated to a compartment syndrome.

The authors report a case of a patient that was submitted to a surgery of reconstruction of anterior cruciate ligament and collateral medial ligament repair of the

Keywords – Compartment Syndromes, Anterior Cruciate

INTRODUCTION Despite its evolution, anterior cruciate ligament (ACL) reconstruction surgery still presents some potential complications. Although the compartment syndrome is a rare complication, this is perhaps one of the most devastating. The authors report on a case of compartment syndrome after surgery for reconstruction of the anterior cruciate ligament and repair of the medial collateral ligament.

CASE REPORT A male patient, age 30, of mixed race, bank employee, born in and originating from São Paulo, visited the clinic of the Sports Traumatology Center (CETE) of the Department of Orthopedics and Traumatology (DOT) of Universidade Federal de São Paulo (Unifesp) with complaints of pain in the left knee starting more or less one day before, after suffering a sprain of the left knee. The patient reported that his left knee had begun to hurt on the previous day, after a soccer game where

Ligament; Knee; Postoperative Complications

he had experienced a sprain. The patient was seen by a physician and examined. A knee resonance was requested that resulted in a diagnosis of total rupture of the anterior cruciate ligament and of the medial collateral ligament. Two weeks later, the patient underwent surgery for reconstruction of the anterior cruciate ligament and repair of the medial collateral ligament. The surgery lasted for two hours and was performed under rachianesthesia; an infusion pump was used for the arthroscopy, and the graft donor site was the flexor tendons. Ten hours after surgery, the patient evolved with progressive and intense pain, paresthesia, paresis, with a pallid aspect and tense and shiny skin. A Doppler ultrasound was requested to rule out venous thrombosis; thus measurement of the intracompartmental pressure of the right leg was requested and performed with the Whitesides’ apparatus, which verified intracompartmental pressure of 85mmHg. The patient was immediately referred to the surgical center to perform an urgent decompression fas-

1 – Assistant Physician of the Sports Traumatology Center (CETE) of the Department of Orthopedics and Traumatology (DOT) of Universidade Federal de São Paulo (Unifesp) São Paulo, SP, Brazil. 2 – Head of the Department of Orthopedics and Traumatology of Hospital e Maternidade Assunção (HMA) – São Bernardo do Campo, SP, Brazil. 3 – Lecturer of the Department of Orthopedics and Traumatology (DOT) of Universidade Federal de São Paulo (Unifesp) and Head of the Sports Traumatology Center (CETE) – São Paulo, SP, Brazil. Study conducted at the Sports Traumatology Center (CETE) of the Department of Orthopedics and Traumatology (DOT) of Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil. Mailing address: Rua França Pinto, 186, ap. 61, Vila Mariana – 04016-001 – São Paulo, SP. Email: jorgesayumfilho@hotmail.com Study received for publication: 8/20/2010, accepted for publication: 3/25/2011. The authors declare that there was no conflict of interest in conducting this work This article is available online in Portuguese and English at the websites: www.rbo.org.br and www.scielo.br/rbort

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ciotomy. Two fasciotomies (medial and lateral) were carried out to release the four leg compartments. The patient was discharged from hospital 10 days after surgery. Twenty-one days after surgery, a skin graft was performed by the plastic surgery clinic in the lateral region of the leg, since the only fasciotomy that healed by secondary intention was the medial fasciotomy. Today, two months after surgery, the patient is having physiotherapy, has a sensitivity deficit of the superficial and profound fibular nerve, reduction of range of motion and muscle strength, but manages to walk with a plantigrade foot, and therefore continues under outpatient supervision (Figures 1 and 2). Figure 2 – Medial fasciotomy.

Figure 1 – Left knee in the immediate postoperative period.

DISCUSSION Anatomical compartments are very limited spaces existing in the musculoskeletal system , whose walls are formed by bones and by osteofascial structures, which are relatively inelastic elements. The compartment syndrome develops when there is a pressure increase in the compartment space, which impairs tissue perfusion and jeopardizes the viability of the structures existing there (muscles, tendons, vessels and nerves)(1,2).

The intracompartmental pressure can be increased on account of internal or external causes and can reach levels above 100mmHg. The degree of injury will depend on the speed at which the pressure increase is established and its duration. The pathogenesis is explained by the increase of intracompartmental pressure at sufficient levels to impair tissue microcirculation, while the final substratum is represented by interstitial and intracellular edema. There is a buildup of fluids and of intracompartmental pressure that leads to acute ischemia, which in turn leads to an increase in capillary permeability, which increases the interstitial edema, thus producing the installation of a vicious cycle that if maintained, leads to the complete destruction of the musculature, vessels and nerves(2-4). If many compartments are affected the crush syndrome develops with renal failure, shock and even death. A varied spectrum of lesions of the soft parts, bones and vessels can trigger a compartment syndrome(3,5). The clinical profile consists of: increase of intracompartmental pressure, progressive pain in the compartment, paresthesia, paresis and dark coloration of the skin in the distal region. The most important differential diagnoses are obstructive or semi-obstructive arterial disorders that, leading to ischemia, can cause similar complaints(5-7). Acute compartment syndrome has only one form of treatment: urgent decompression fasciotomy, which will allow the expansion of tissues, the normalization of pressure, and consequently, reperfusion(6,7). Rev Bras Ortop. 2011;46(6):730-32


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On account of the foregoing, we presented the case of a patient submitted to anterior ligament reconstruction (arthroscopic route) and repair of the medial collateral ligament of the right knee, who was treated according to orthopedic literature. It is a rare case and

seldom reported in literature, since surgeons are generally unwilling to publish their complications. But it is a good idea to stress that the compartment syndrome exists and every medical surgeon should know how to diagnose and treat it (Figures 3 and 4).

Figure 3 â&#x20AC;&#x201C; Lateral fasciotomy.

Figure 4 â&#x20AC;&#x201C; Twenty-one days after surgery. Note that there is closing by secondary intention only of the medial fasciotomy and the need for a skin graft in the lateral fasciotomy.

REFERENCES 1. Clarke HD. Anatomy.. In; Scott WN. Insall & Scott surgery of the knee. 4th ed. New York: Churchill Livingstone; 2006. p. 3-67. 2. Edwards PD, Miles KA, Owens SJ, Kemp PM, Jenner JR. A new non invasive test for the detection of compartment syndromes. Nucl Med Commun. 1999;20(3):215-8.

5. Whitesides TE, Haney TC, Morimoto K, Harada H. Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop Relat Res. 1975;(113):43-51.

3. Hallock GG. An endoscopic technique for descompressive fasciotomy. Ann Plast Surg. 1999;43(6):668-70.

6. Turnbull D, Mills GH. Compartment syndrome associated with the Lloyd Davies position. Three case reports and review of the literature. Anaesthesia. 2001;56(10):980-7.

4. Tollens T, Janzing H, Broos P. The pathophysiology of the acute compartment syndrome. Acta Chir Belg. 1998;98(4):171-5.

7. Hughston JC. Complications of anterior cruciate ligament surgery. Orthop Clin North Am. 1985;16(2):237-40.

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CASE REPORT

SEGMENTAL CLAVICLE FRACTURE

Evander Azevedo Grossi1

Abstract The aim here was to present an unusual case of segmen-

multiple trauma. The case of a patient with a fracture of the diaphysis and lateral extremity of the clavicle is described: the patient was treated surgically and an excellent result was achieved. Similar cases in the literature are reviewed and their management is discussed.

tal clavicle fracture associated with ipsilateral rib fracture. Although the clavicle is very superficial, undetected cases of both types of fracture may occur, because these patients usually suffer

Keywords - Clavicle; Fractures Fixation; Orthopedic Surgery

INTRODUCTION

CASE REPORT

Among clavicle fractures, 69% occur in the diaphysis, 28% in the lateral extremity and 3% in the medial portion(1). Meanwhile, segmental fractures are very rare, with few articles described in English literature. Clavicle fractures usually have a very easy diagnosis as their anatomical position is very superficial, and their consolidation is achieved even without treatment in most cases. But in spite of this characteristic, many complications can occur, including ipsilateral rib fracture(2). They occur less often after direct trauma, and this has been the mechanism described in segmental fractures in which there is generally multiple trauma in the clavicle(3). In segmental fractures, the fractured segment suffers the action of muscular forces and may evolve with blood supply failure, for which reason fixation should be performed early(3,4). Allman(5), in 1967, was the first to classify fractures dividing the clavicle anatomically into three segments. Other modifications were made, and finally with more details, by Craig(6) in 1991. The purpose of this study is to present a rare fracture of the clavicle not yet published in indexed Brazilian literature.

Male patient, age 41, who fell from a roof and was treated for vomiting, left otorrhagia, cranioencephalic trauma, nosebleed, segmental fracture of the left clavicle and fracture of the third left posterior rib. He required treatment in an intensive care unit, and after clinical and neurological improvement was released to the orthopedic department. He did not present neurovascular deficit in the shoulder girdle due to the clavicle fractures, or pneumothorax due to the rib fracture, but evolved with left anacusis. Clinically, there was gross deformity in the middle third of the clavicle (Figure 1), the only site about which the patient complained; and, radiologically, there was deviation of the lateral extremity and greater than 2 cm of the diaphyseal fracture (Figures 2A and 2B). The fractures were classified in group I (diaphysis), and the lateral fracture in group II, as Craig type II B fractures (Figure 3). Radiographs were taken in two views in plain neutral AP and with 45° cephalic tilt to classify and decide on the treatment. Osteosynthesis of the diaphyseal fracture was executed after clinical clearance using a reconstruction plate molded above the clavicle and two Kirschner wires crossed at the distal extremity (Figure 3). The wires were removed after seven weeks and the patient

1 – Orthopedist and Traumatologist of Fundação São Francisco Xavier/Hospital Márcio Cunha – Ipatinga, MG. Study conducted at Fundação São Francisco Xavier/Hospital Márcio Cunha – Ipatinga, MG. Mailing address: Av. Itália, 2.556, Bairro Cariru – 35160 115 – Ipatinga, MG. Emails: ovazadao@yahoo.com.br and evander.grossi@usiminas.com Study received for publication: 3/15/2011, accepted for publication: 6/16/2011 The authors declare that there was no conflict of interest in conducting this work This article is available online in Portuguese and English at the websites: www.rbo.org.br and www.scielo.br/rbort

Rev Bras Ortop. 2011;46(6):733-35


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was referred to physiotherapy. After 14 weeks, he returned with the fractures consolidated (Figures 4A and 4B), asymptomatic, and with mobility preserved. The plate was removed after seven months due to protrusion and discomfort.

Osman et al(2) treated a similar case of fracture of the diaphysis and lateral third of the clavicle, which was associated with ipsilateral rib fractures and consequent pneumothorax. The patient underwent plate

Figure 1 – Clinical aspect of the gross deformity of the diaphyseal fracture of the left clavicle.

Figure 3 – Immediate postoperative period showing the osteosyntheses with plate and wires.

DISCUSSION

A A

B

Figure 2 – (A) Segmental clavicle fracture showing deviation of the diaphyseal fracture and alignment of the lateral fracture. Arrow showing the rib fracture. (B) Aligned fracture of the diaphysis and with deviation of the lateral extremity. Rev Bras Ortop. 2011;46(6):733-35

B

Figure 4 – (A) Conventional radiography for evaluation of the diaphyseal fracture. (B) Conventional radiography for evaluation of the lateral fracture.


SEGMENTAL CLAVICLE FRACTURE

osteosynthesis with subsequent removal of the plates since one of the screws caused an impact in the coracoid process, and also due to the risk of fracture between the plates. Our patient’s second-rib fracture did not cause pneumopathy. Miller et al(7) presented a report of fracture of the medial and lateral extremity of the clavicle with the use of a reconstruction plate and another with locking T-plate, and Karimi et al(8) had a case similar to ours that was also treated by the same method; both authors emphasized that due to the rarity of the case, there is no routine surgical technique described for the treatment of this type of fracture. Osteosynthesis of diaphyseal clavicle fractures with locked plates is an excellent treatment option, and some authors(2,4) have treated segmental fractures similar to this one using this method. But in our case, such an implant is not available for use in patients of the public health network. We agree with the indication of osteosynthesis in this type of fracture due to the risk of pseudarthrosis, according to Heywood and Clasper(4), who treated segmental clavicle fracture with a superior plate and use of the hook plate, but the latter is seldom used in our circles. The choice of plates as diaphyseal clavicle fracture synthesis material is more common, and their anterior placement is more aesthetic, while the superior placement has the advantage of greater rigidity(9,10), yet they increase the risks of neurovascular lesion and prominence of the plate, a fact that was observed in our patient. The intramedullary method has also been used in diaphyseal fractures, through threaded, smooth wires, locked mobile nails and cannulated screws; but in the case of segmental fracture, the “S”

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Figure 5 – Digital radiography showing consolidation of fractures after seven months.

shape of the clavicle prevents the same nail from fixing the two fractures with rigidity. Since many conventional radiographic examinations carried out to diagnose clavicle fracture have good visualization in the diaphysis and to a lesser degree in the lateral extremity, we noticed, during the treatment, that it was necessary to take separate radiographs of these segments to monitor fracture consolidation; yet with digital radiography, it was possible to analyze both fractures in just one view (Figure 5).

CONCLUSION Segmental clavicle fractures are rare, but need a good radiological examination of the whole bone in more than one view for diagnosis and treatment, whereas surgical indication ensures a satisfactory result.

REFERENCES 1. Robinson CM. Fractures of the clavicle in the adult. Epidemiology and classification. J Bone Joint Surg Br. 1998;80(3):476-84.

5. Allman FL Jr. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg Am. 1967;49(4):774-84.

2. Osman N, Sinopidis C, Gibson L Unusual segmental fracture of clavicle associated with rib fractures and pneumothorax. J Orthop Surg. 2010;15(2). Disponível em: http://www.ispub.com/journal/the_internet_journal_of_orthopedic_surgery/volume_15_number_2_2/article/unusual-segmental-fracture-of-theclavicle-associated-with-rib-fractures-and-pneumothorax.html

6. Craig EV. Fractures of the clavicle. In: Rockwood CA Jr, Matsen FA 3rd, editors. The shoulder. Philadelphia: Saunders; 1990. p. 367-412.

3. Singh B, Singh S, Saraf N, Farooque K, Sharma V. Unusual Mechanism of Injury with Segmental Fracture Clavicle. J Orthop Surg. 2007;6(1). Disponível em: http://www.ispub.com/journal/the_internet_journal_of_orthopedic_surgery/ volume_15_number_2_2/article/unusual-segmental-fracture-of-the-clavicleassociated-with-rib-fractures-and-pneumothorax.html 4. Heywood R, Clasper J. An unusual case of segmental clavicle fracture. J R Army Med Corps. 2005;151(2):93-4.

7. Miller D, Smith K, Mc Clelland D. Bipolar segmental clavicle fracture. Eur J Orthop Traumatol. 2009;19:337-9. 8. Karimi A, Ettehad H, Akbar MH. Segmental fracture of the clavicle (a very rare case in trauma surgery) Shiraz E-Medical J. 2007;8(2):90-5. 9. Iannotti MR, Crosby LA, Stafford P, Grayson G, Goulet R. Effects of plate location and selection on the stability of midshaft clavicle osteotomies: a biomechanical study. J Shoulder Elbow Surg. 2002;11(5):457-62. 10. Celestre P, Roberston C, Mahar A, Oka R, Meunier M, Schwartz A. Biomechanical evaluation of clavicle fracture plating techniques: does a locking plate provide improved stability? J Orthop Trauma. 2008;22(4):241-7. Rev Bras Ortop. 2011;46(6):733-35


CASE REPORT

PROGRESSIVE OSSIFYING FIBRODYSPLASIA: CASE REPORT

Fabiana Romani1, Simone de Menezes Karam2

Abstract Progressive ossifying fibrodysplasia is a rare genetic disease that affects one individual in every two million births. Its main consequence is heterotopic ossification, i.e. formation of additional bone in abnormal locations. It is an autosomal dominant disease, usually caused by a new mutation in the ACVR1 receptor gene, which is in the signaling pathway for bone morphogenic protein. This abnormality is not related to

INTRODUCTION Individuals suffering from FOP can be recognized as people who form two skeletons: one in the normal place, which develops during the embryo formation phase; and another at an abnormal site, which develops after birth(1). At birth, the child’s skeleton is apparently normal; however, it already usually exhibits the first signs of the disease, which are varied skeletal malformations, the main one being malformation of the halluces(2). This characteristic is present in 95% of patients with FOP. It is also possible to find other skeletal malformations such as defects in the cervical spine, short thumbs and osteochondromas in the proximal part of the tibia. The disease usually starts in the neck and shoulders and progresses to the back, trunk and limbs. The symptoms start to appear before the age of 20 years, and frequently before the age of 10. They are characterized by reddish swellings in the shoulders and back that disappear with time, but that leave a bone in the place where there was inflammation. The knees and hip are commonly affected in adolescence and in early adulthood.

gender, ethnicity or consanguinity. The present study reports the case of A.C., a 17-year-old girl. Her clinical investigation began at the age of four years, but she was only diagnosed with FOP at the age of 15 years, after being evaluated by several specialists in different centers. The patient has two siblings, but her family history did not reveal any similar cases. Keywords - Myositis Ossificans; Ossification, Heterotopic; ACVR1 Protein; Genetics

The bones formed by FOP are a result of the progressive transformation of soft tissues in cartilage and bone. It is a process identical to that of post-fracture bone regeneration. The body can go for months without forming new bones, as if the disease were dormant; however, without prior notice and without any injury or trauma, bones can appear in unexpected places (ligaments, muscles, tendons). As a consequence, movement in the affected areas becomes difficult or impossible. Bone neoformation is designated as a flare-up. This process is generally painful, accompanied by low fever, and there is no medication that can prevent it, once it has already started. The local edema can have various causal factors: Occurrence of flare-ups; Restriction of movements hindering the pumping of blood inside the ossified muscles; Compression of veins and lymphatic vessels by the new bones; Formation of blood clot. According to studies, the extra bones can generate cardiopulmonary complications, especially when in association with a state of flu or infection. For this

1 – Sixth-year Medical Student at the School of Medicine of Universidade Federal do Rio Grande (FURG) – Rio Grande, RS, Brazil. 2 – Professor of the Maternity and Children’s Area of the School of Medicine of Universidade Federal de Rio Grande (FURG) – Rio Grande, RS, Brazil. Study conducted in the Academic Area of Hospital Universitário Dr. Miguel Riet Corrêa Júnior, Universidade Federal de Rio Grande (FURG). Address: Rua Visconde de Paranaguá, 102, Centro 96200-190 – Rio Grande, RS. Mailing address: Rua Dom Bosco, 1.017, bloco 4, ap. 215, bairro Hidráulica – 96211-092 – Rio Grande, RS. Email: fabyromani@yahoo.com.br Study received for publication: 10/5/2010, accepted for publication: 11/26/2010. The authors declare that there was no conflict of interest in conducting this work This article is available online in Portuguese and English at the websites: www.rbo.org.br and www.scielo.br/rbort

Rev Bras Ortop. 2011;46(6):736-40


PROGRESSIVE OSSIFYING FIBRODYSPLASIA: CASE REPORT

reason, all infections must be treated aggressively in these patients. Some patients may present right ventricular overload on account of the pulmonary hypertension that they develop, the so-called Cor Pulmonale(3). The evident radiological signs of FOP are abnormal calcifications both in fingers and in toes, generating bone malformations and trabeculae. The presence of hallux valgus and other alterations of this toe is also relevant. Moreover, there have been reports of spinal fusion and the presence of osteochondromas in these patients(4). Generally speaking, this “newly-formed skeleton” produces dental and morphological complications, mobility limitations, cardiopulmonary impairment and right ventricular overload.

CASE REPORT A four-year-old patient referred by the orthopedist to the Medical Genetics Clinic of HCPA in 1998 for investigation. This patient was having increasing difficulty moving her limbs and neck, and presented small “bone tumors” on her back. Such clinical manifestations were associated with the rigid spine profile, and the patient remained under outpatient supervision. After seeing several specialists at different centers, she was reassessed and a full skeleton radiography was requested. Hence the diagnosis of fibrodysplasia ossificans progressiva (FOP) was confirmed six years after the first diagnostic hypothesis, and 10 years after the onset of symptoms. However, before the diagnostic conclusion, the patient underwent physiotherapy, dental and anesthetic procedures that instead of producing benefits, promoted some ossifications. As regards family history, no similar cases or cases that could be related to the abovementioned disease were observed. The patient comes from a family of three healthy siblings (Figure 1). The diagnosis was based on the characteristic findings evidenced in the clinical examination and in the imaging tests. In the physical examination, the patient presented malformed hallux, a classic characteristic of FOP, and the formation of “protuberances” in regions of more superficial soft tissues around the body (Figure 2), important alterations of mobility (gait, elevation and extension of the upper limbs) and of speech as well.

737

Some degree of breathing difficulty is also present, due mainly to the decrease of lung expandability. The radiography of chest and of upper limbs showed ossifications in regions of soft tissues (in the scapulae, shoulders and tibia), with formation of bone bridges (Figures 3, 4 and 5). The foot radiography produced findings characteristic of shortening of the halluces (Figure 6), while an important decrease of the range of mandibular motion could be visualized in the cranial computed tomography scan (Figure 7). Besides the abovementioned findings, the patient was submitted to the collection of material for molecular analysis of DNA and is currently under outpatient clinical supervision.

DISCUSSION It is vitally important to understand that FOP must be promptly identified, based exclusively on the clinical history, physical examination and radiographic findings, as no invasive procedures should be executed for diagnostic determination, such as excisional or non-excisional biopsies and the use of anesthetics. Moreover, dental treatments are contraindicated, since they frequently bring about ossifications in the region. Recent data revealed that 67% of patients with FOP were submitted to invasive procedures and 68% received unnecessary treatments(5), as in the case of the patient in question. Hallux shortening was not

Figure 1 – A.C.’s family heredogram. Rev Bras Ortop. 2011;46(6):736-40


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Figure 4 – Ossifications in the scapulae, shoulders and chest.

Figure 2 – Image of A.C’s back, revealing scoliosis and bulging points resulting from heterotopic ossification.

Figure 3 – Ossifications in soft parts. Rev Bras Ortop. 2011;46(6):736-40

Figure 5 – Shortening of the halluces.


PROGRESSIVE OSSIFYING FIBRODYSPLASIA: CASE REPORT

739

CLOSED MOUTH

OPEN MOUTH Figure 6 – Shortening of the halluces.

observed in some of the evaluations performed, while in others it was observed, but was not related to FOP. Although this type of malformation may occur in other genetic conditions or as an isolated congenital malformation, it should always refer to the diagnostic possibility of FOP(4). There is, as yet, no cure for this disease, and its prognosis is poor, since current treatments are still only symptomatic. However, the life expectancy of these patients is usually long, as many do not develop major comorbidities. Respiratory complications due to the formation of strips of bone that surround and immobilize the chest (restrictive syndrome), or severe malnutrition caused by difficulties in self-feeding, can limit the life expectancy of patients with FOP. At any rate, these people attain adulthood, and can reach the age of 70, when flare-ups are infrequent. However, the pace of the disease varies from patient to patient. Unfortunately, most affected individuals are confined to a wheelchair or become bedridden around the second decade of life, since the extra bones progressively create bridges between the joints, causing immobility. Another important precaution is to maintain standards of hygiene, especially dental hygiene, as in this

Figure 7 – Alterations in mandibular mobility seen in computed tomography.

manner we will avoid future dental problems, whose treatments are great villains for these patients, as they are potential causers of flare-ups and consequent heterotopic ossifications(3). Despite all the limitations to which these individuals are subject, we should encourage socializing activities such as leisure, work and family and social conviviality, obviously taking into account the appropriate care with traumatism, thus prolonging the patient’s well-being. In this context, it is essential to cite meritorious initiatives such as that of the International Fibrodysplasia Ossificans Progressiva Association (IFOPA), whose foundations are the inclusion of these patients in society and the fact that it publicizes the existence of this disorder, so that the population Rev Bras Ortop. 2011;46(6):736-40


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in general and the family members of those affected will understand the limitations, but more important still, the need for patients with FOP to have a less restricted, happier life(6). Finally, the discovery of the gene responsible for the development of the disease brought prospects of

long-term treatment, and not just palliative such as those used at present(4).

ACKNOWLEDGEMENTS The authors are grateful to Dr. Renato Barbosa Xavier, responsible for the referral of the patient to our clinic.

ReferEncEs 1. Shafritz AB, Shore EM, Gannon FH, Zasloff MA, Taub R, Muenke M, et al. Overexpression of an osteogenic morphogen in fibrodysplasia ossificans progressiva. N Engl J Med. 1996;335(8):555-61.

4. Kaplan FS, Xu M, Glaser DL, Collins F, Connor M, Kitterman J, et al. Early diagnosis of fibrodysplasia ossificans progressiva. Pediatrics. 2008;121(5):e1295-300.

2. Gonçalves AL, Masruhsa MR, Campos CC, Delai PLR; Vilanova LCP. Fibrodysplasia ossificans progressiva. Arq Neuropsiquiatr. 2005; 63(4):1090-3.

5. Kitterman JA, Kantanie S, Rocke DM, Kaplan FS. Iatrogenic harm caused by diagnostic errors in fibrodysplasia ossificans progressiva. Pediatrics. 2005;116(5):e654-61.

3. Wagman RB, Kantanie SL, Kaplan FS. O q é FOP? Um guia para famílias. 2003.

6. International Fibrodysplasia Ossificans Progressiva Association (IFOPA). FOP Conection; 2004.

Rev Bras Ortop. 2011;46(6):736-40


CASE REPORT

Acute lesion of the motor branch of the ulnar nerve in the wrist after tug-of-war training Vladimir Ferreira Seguti1, Aloísio Fernandes Bonavides Júnior2, Leandro Pretto Flores3, Lisiane Seguti Ferreira4

Abstract Papers correlating clinical and electrophysiological findings relating to ulnar nerve lesions in the wrist are uncommon in the literature, if compared with elbow injuries. We present the case of a patient with atrophy of the intrinsic musculature of the hand, secondary to injury only of the motor branch of the ulnar nerve, which is located in Guyon’s canal close to the hamate hook. We review the anatomical, clinical and neu-

INTRODUCTION Ulnar nerve entrapment is the second most common entrapment in the upper extremity; however, acute ulnar neuropathy, located distally, is an unusual condition(1). The correlation between electrophysiological and surgical findings of ulnar nerve lesions in the wrist is not frequent in literature, when compared to the description of elbow injuries(2). The aim of this study is to present the case of ulnar nerve lesion, located distally, and to make a brief review of the main anatomical, clinical and neurophysiological aspects of the distal lesion of this nerve, besides warning of the risks of injury during military physical training.

CLINICAL CASE Male, age 42, soldier, serving in the National Force of Luziânia, Goiás. He was in physical training for three months, when he suffered trauma in the right hand, while participating in a tug of war competition. The patient did not hit or fall with his wei-

rophysiological aspects of distal ulnar nerve injuries and we emphasize the importance of multidisciplinary approaches. Specifically in relation to the mechanism of injury of this patient (tug-of-war), we did not find any similar cases in the literature. We issue an alert regarding the risks during military physical training. Keywords – Ulnar Nerve/anatomy & histology; Ulnar Nerve/ injuries; Military

ght on his hand, but merely exerted compression and drag force on the rope. He presented sudden pain and weakness in the palm of the right hand, discontinuing the training. He sought medical advice, three days after the trauma, and was medicated with non-hormonal anti-inflammatory drugs. The pain improved, yet the patient evolved with inability to move the fingers, as well as loss of muscle trophism in the dorsal region of the right hand. There was no report of local edema. He denied sensory complaints in the hand and forearm. The orthopedist requested a radiograph and ultrasonography of the hand, which were normal, besides electroneuromyography (ENMG). There was no evidence of fracture. The ENMG showed a normal sensory nerve conduction study and the motor nerve conduction study with important reduction in compound muscle action potential amplitude (difference of over 90% in relation to the contralateral homologous muscle), exclusively when captured in the first dorsal interosseous muscle (Figure 1). The needle

1 – Orthopedist of the Federal District Health Department – Brasília, DF, Brazil. 2 – Orthopedist of the Federal District Health Department; Professor of the Medical Course of Escola Superior de Ciências da Saúde do Distrito Federal – Brasília, DF, Brazil. 3 – Neurosurgeon of the Federal District Health Department – Brasília, DF, Brazil. 4 – Clinical Neurophysiologist of the Federal District Health Department; Professor of the Medical Course of Universidade de Brasília – Brasília, DF, Brazil. Mailing address: Aloísio Fernandes Bonavides Júnior – SEPS 712/912. Edifício Pasteur, Bloco I, Sala 111 – 70390-125 – Brasília, DF. Email: aloisiobonavides@hotmail.com Study received for publication: 1/14/2011, accepted for publication: 3/22/2011. The authors declare that there was no conflict of interest in conducting this work This article is available online in Portuguese and English at the websites: www.rbo.org.br and www.scielo.br/rbort Rev Bras Ortop. 2011;46(6):741-44


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examination evidenced signs of active denervation and recruitment of just two motor unit potentials in the first dorsal interosseous muscle (Figure 2). The other muscles evaluated were normal. These findings were compatible with ulnar neuropathy, of axonal impairment, involving exclusively the motor branch, located close to the pisi-unciform hiatus. With the electrophysiological alterations described and according to the classification proposed by Wu et al(3) (Chart 1), the patient was categorized as a type IV lesion. The ENMG, performed 30 days later, remained unchanged. In the orthopedic revaluation, the health professionals opted for expectant manage-

Figure 1 â&#x20AC;&#x201C; Observe the compound muscle action potential (CMAP) captured in the first dorsal interosseous muscle â&#x20AC;&#x201C; upper line (green) with amplitude of 1.9 and compare with the contralateral CMAP (third line in yellow), corresponding to a decrease close to 90%.

Figure 2 â&#x20AC;&#x201C; Recruitment significantly reduced upon exertion. Only two motor unit potentials were recorded here. Rev Bras Ortop. 2011;46(6):736-40

ment and suggested neurological evaluation. The neurological examination evidenced muscle atrophy, degree IV strength of the intrinsic muscles of the hand, with degree V strength of the abductor muscle of the little finger and normal hand sensitivity. The patient was questioned about the existence of a narrow band of hypoesthesia in the territory of C5 in the right upper limb and debatable difficulty in abducting the right arm. The patient had an MRI scan of the cervical spine and brachial plexus, which were normal. There was a third ENMG with a study of more than three segments, in order to rule out the possibility of involvement of the anterior horn of the spinal cord. The ENMG confirmed the selective involvement of the motor branch of the ulnar nerve. The patient was referred for neurosurgical evaluation due to the absence of improvement. The professionals then opted for the surgical procedure, performed six months after the trauma. The initial intention was to verify the lesion site in situ, and to carry out the necessary decompression and/or correction procedures to reestablish ulnar nerve integrity. After the application of the pneumatic tourniquet, an incision was made in the wrist, between the pisiform bone and the hamate hook (Figure 3). The palmar carpal ligament was dissected, providing a view of the pisohamate ligament that was thickened, followed by the complete sectioning of this ligament, with the surgeon observing an area of probable compression (pseudoneuroma) with increase in the nerve thickness (Figures 4 and 5). No deformities such as bone calluses, poor alignment of possible pisiform or hamate fractures, cysts or tumors were verified after decompression further forward in the deep branch of the ulnar nerve. It was decided not to perform epineurolysis due to the fact that the compression was caused by alterations in the surrounding ligaments and tissues. The patient was reassessed 12 months subsequent to the surgical procedure and after physiotherapy, with almost complete recovery of muscle strength and absence of hypotrophy (Figure 6).


ACUTE LESION OF THE MOTOR BRANCH OF THE ULNAR NERVE in the wrist after tug-of-war training

Figure 3 – Planning of surgery.

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Figure 5 – Performance of decompression in the deep branch of the ulnar nerve, followed by complete sectioning of the pisohamate ligament.

Figure 6 – There are no signs of hypotrophy one year after the surgical procedure.

Figure 4 – The ulnar nerve was dissected at the wrist and the deep branch was followed up to the point of entry of the pisohamate hiatus, where proximal ingurgitation of the nerve was observed (pseudoneuroma).

DISCUSSION The ulnar nerve is the second most severely impaired nerve in compression syndromes of the upper limb, and proximal involvement in the elbow is much more common(2,4,5).

We documented the patient’s clinical and electrophysiological findings, without evidence of fracture, presenting acute lesion of the ulnar nerve, of distal location, involving only its motor branch. Besides being uncommon in this topography, we stress that there is no record of similar cases in literature, specifically with this mechanism of injury (tug of war). The tug of war or rope pulling is a sport in which two teams compete against each other in a test of strength, pulling a rope. The sport was part of the Rev Bras Ortop. 2011;46(6):741-44


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Olympic Games from 1900 to 1920 and is regulated by the Tug of War International Federation – TWIF(6). However, as is the case of other sports, tug of war training can entail dislocations, sprains and fractures(7). Studies have been conducted on the occurrence of injuries during military physical training, which mainly involve the knee and the ankle and are more often related to running. The occurrence of these injuries has served as a warning as regards choice, correct method and intensity in the execution of exercises(8). The risk of the patient under analysis evolving to claw hand on the right side (dominant hand) as a sequela could not be disregarded in this context. In dealing with a patient with claw hand, the investigation should include the following possibilities: brachial plexopathy, C8/T1 radiculopathy, cervical syringomyelia, thoracic outlet syndrome, Hirayama syndrome, multifocal neuropathy, Hansen’s disease leading to amyotrophic lateral sclerosis, among others(9). The patient’s diagnosis was facilitated by the thorough electrophysiological study, which identified injury of the ulnar nerve with exclusive involvement of the motor branch. NMRs of the cervical spine and brachial plexus were requested in addition to the ENMG of the four limbs, as the patient also presented complaints of weakness in the arm. The clinical presentation of ulnar nerve lesions shows variation due to the complex anatomical course of the nerve at its most distal sites, which hinders semiological and electrophysiological interpretation, resulting in diagnostic challenge(4,5). In Guyon’s canal, the ulnar nerve can be com-

pressed along its course, producing sensory, motor or mixed deficits. The deep branch innervates the hypothenar muscles, including the abductor of the fifth finger, and travels through the palm to the dorsal and palmar interossei, the third and fourth lumbricals, the thumb adductor muscle and part of the short flexor of the thumb. The short flexor of the fifth finger, hypothenar muscle, has two separate fixations, in the unciform bone and in the pisiform bone. These musculocutaneous fixations form a fibrous arch and create the superficial limits of the pisi-unciform hiatus, site of the patient’s lesion(9,10). Almost half of the injuries occur secondarily to acute or chronic trauma, mainly related to the type of occupation(10,11). Ganglion cysts are the second most common cause; but, in these cases, the isolated compression of the deep motor branch alone is uncommon, particularly in those that present fast evolution, severe and progressive nature of the compression signs and symptoms(12). The conduct indicated in patients with fractures, cysts or expansive processes is surgery. Clinical and electrophysiological control is performed in the other cases. The absence of improvement after conservative treatment and clinical deterioration is indicative of surgical intervention(13). After decompression, the prognosis is usually good, as the lesion is distal and targeted hand muscle reinnervation is efficient(14). Finally, the favorable evolution of the case described here illustrates the importance of follow-up by different specialists, since the patient could have evolved with permanent ulnar claw. It also serves as a warning with regards to the risks during the physical training of soldiers, which emphasizes the criterion in the selection and intensity of the exercises applied.

REFERENCES 1. Elhassan B. Entrapment neuropathy of the ulnar nerve. J Am Acad Orthop Surg. 2007;15(11):672-81. 2. Papathanasiou ES, Loizides A, Panayiotou P, Papacostas SS, Kleopa KA. Ulnar neuropathy at Guyon’s canal: electrophysiological and surgical findings. Electromyogr Clin Neurophysiol. 2005;45(2):87-92. 3. Wu JS, Morris JD, Hogan GR. Ulnar neuropathy at the wrist: case report and review of literature. Arch Phys Med Rehabil. 1985;66(11):785-8. 4. Erkin G, Uysal H, Keles I, Aybay C, Ozel S. Acute ulnar neuropathy at the wrist: a case report and review of the literature. Rheumatol Int. 2006;27(2):191-6. 5. Pearce C, Feinberg J, Wolfe SW Ulnar neuropathy at the wrist. HSS J. 2009; 5(2):180-3. 6. TWIF rules manual 2009/2010. Twif Tug of War International Federation. Disponível em: http://www.tugofwar-twif.org 7. Rettig AC. Athletic injuries of the wrist and hand. Part I: traumatic injuries of the wrist. Am J Sports Med. 2003;31(6):1038-48. 8. Gonçalves EM, Silva RR. Principais lesões decorrentes do treinamento físico Rev Bras Ortop. 2011;46(6):736-40

militar no Centro Integrado de Guerra Eletrônica – Departamento de Ciência e Tecnologia do Exército Brasileiro. Rev Educ Física. 2008;2(3):1-11. 9. Dumitri D, Amato A, Zwarts, M. Eletrodiagnostic medicine. 2nd ed. Philadelphia: Hanley & Belfus; 2004. 10. Monein MS: Ulnar nerve compression at the wrist: ulnar tunnel syndrome. Hand Clinics. 1992;8:337-44. 11. Haferkamp H. Ulnar nerve compression in the area of the wrist. Langenbecks Arch Chir Suppl Kongressbd. 1998;115:635-40. 12. Inaparthy PK, Anwar F, Botchu R, Jähnich H, Katchburian MV. Compression of the deep branch of the ulnar nerve in Guyon’s canal by a ganglion: two cases. Arch Orthop Trauma Surg. 2008;128 (7): 641-3. 13. Blecher R, Loebenberg M, Oron A. Ulnar Entrapment Neuropathy. Hareafuah. 2010;149(2):104-7. 14. Zöch G, Meissl G, Millesi H. Results of decompression of the ulnar nerve in Guyon’s canal] Handchir Mikrochir Plast Chir. 1990;22(3):125-9.


CASE REPORT

Tibial periprosthetic fracture combined with tibial stem stress fracture from total knee arthroplasty

Fernando Fonseca1, Edgar Rebelo2, António Completo3

Abstract Total knee arthroplasty complications related to the prosthetic material are very rare, except for polyethylene wear. We report the case of a 58-year-old woman who came to the emergency service of our hospital with a periprosthetic tibial fracture (Mayo Clinic type I). Careful examination showed that this fracture was concomitantly associated with a tibial stem fatigue fracture. The prosthesis and the stem were sent to an independent biomechanics laboratory for evaluation. A finite-element CAD system was used to make a reconstruction, so as to as-

certain whether there had been any manufacturing defect and what the causes of the event might have been. After evaluation of several hypotheses, it was concluded that the fracture in the prosthetic material had been caused by overloading at the plate/stem transition zone secondary to previous bone failure (fracture). From the evaluation of this case, the need to make appropriate assessment of bone mineralization can again be emphasized. In cases of doubt, a longer stem should be used. Keywords – Arthroplasty, Replacement, Knee; Fractures, Stress; Reoperation

IntroduCTION

CLINICAL FACT

In 1984, Mendes et al described a baseplate fracture of the tibial component of total knee arthroplasty(1), a case that is not unique in literature(2-4), although in monoblock tibial components (base and single stem). However, due to market requirements, many companies sell modular tibial components with the base and tibial stem separate, with assembly executed upon deployment. These solutions produce an increase in the concentration of loads(5) in the transition zone, which, according to manufacturers, is below the resistance limit of the material. Among periprosthetic bone fractures of the knee, the tibial fracture is equally rare(6). This case reports a phenomenon of association of two different fractures (bone and metal) simultaneously in the same patient, a fact that to the best of our knowledge does not appear reported in literature.

A 58-year-old female patient, active agricultural laborer, was referred to the emergency service of our hospital. She had a history of varus deformity of the right knee, which had been progressing for about six months. She denied the presence of associated pain or any previous trauma. She walked with the aid of a Canadian crutch, as she understood that there was slackening of knee resistance force. In her medical history she referred to osteoarthrosis of the right knee and menopause at 45 years of age without the use of hormone replacement therapy. Total knee replacement had been performed two years previously at another hospital institution (Performance type total knee replacement, Biomet Europe) because of the knee arthrosis. Reducible varus of the right knee of 20° and a range of motion of 100° (100°-0°-0°) were reported in the physical examination.

1 – Head of Clinic; Director of the Integrated Surgical Management Area 2 of HUC; In charge of the Knee Surgery Unit of HUC; Assistant Professor of the School of Medicine of Coimbra, Portugal. 2 – Orthopedic Resident at HUC – Coimbra, Portugal. 3 – Assistant Professor of Universidade de Aveiro, Department of Mechanical Engineering Biomechanics Investigation Group – Coimbra, Portugal. Study conducted at the Orthopedic Clinic of HUC – Coimbra, Portugal Mailing Address: Rua Larga – 3004-504 – Coimbra, Portugal. Email: pereirafonseca@gmail.com Study received for publication: 9/22/2010, accepted for publication: 5/25/2011. The authors declare that there was no conflict of interest in conducting this work This article is available online in Portuguese and English at the websites: www.rbo.org.br and www.scielo.br/rbort

Rev Bras Ortop. 2011;46(6):745-50


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A knee radiograph was taken at the same time (Figure 1) and the patient was admitted to our clinic with a diagnosis of Mayo Clinic type IB tibial periprosthetic fracture(3). During surgical preparation and planning there was a more careful observation of the images, with detection of a tibial stem fracture at the tibial stem/baseplate transition (Figure 1). In view of these new data, the decision was made to conduct a review with deployment of total knee arthroplasty. In the perioperative period and after extraction of the tibial component the stem fracture was confirmed unequivocally (Figure 2). Both components and stems were replaced, and a tibial wedge (P.F.C. Sigma TC3 – Depuy Orthopaedics – Warsaw-IN) was included (Figure 3). The postoperative period elapsed without incidents.

Analysis by the finite element method Various questions were brought up after the patient was treated: - Was the stem fracture secondary to the bone fracture? - Can the stem fracture have caused instability responsible for the bone fracture? The extracted total knee replacement implant was sent to a biomechanics laboratory in an attempt to answer these questions. Two finite element models were then developed in order to quantify the tension forces in the stem in a model of the normal knee without deformity and in a model with varus deformity resembling that found in the patient, with the end of the stem in contact with the lateral tibial cortex, as observed in the radiograph (Figure 1). These models were planned taking into account the patient’s weight (80 kg), the tibial geometry and the geometry of the implants before the fracture as well. The stress level observed in each one of the models was compared with the fatigue limit of the material that forms the stem and is supplied by the manufacturer. To build the finite element model according to the patient’s specificity, she underwent frontal and lateral radiographs and a computed tomography, with the presumptive model of the tibia before (Figure 4) and after the varus deformity having been built in a CAD model (Catia, Dassault Systèmes, France). Two volumes are distinguished in the bone model, representing a cortical bone and the other spongy bone of the tibia. The limit of the transition between the cortical and Rev Bras Ortop. 2011;46(6):736-40

Figure 1 – X-ray upon admission.

spongy bones was calculated in the computed tomography. This was followed by a scan of the tibial baseplate of their stem in a 3D laser scanner (Roland LPX 250) with a precision of 0.2 mm (Figure 4). The finite elements relating to the arthroplasty were also built in a CAD model (Catia, Dassault Systèmes, France). As the arthroplasty was cemented, a cement mantle model was created. The set of 3D models created (bone, tibial component, cement) was converted automatically into a model of finite elements using CATIA software (Catia, Dassault Systèmes, France). The finite element mesh was built with 4-node elements. The properties of the cortical and spongy bone were calculated by means of tomography(7). The properties of the arthroplasty and bone cement materials considered were provided by the manufacturers (Table 1), assuming that they are homogeneous, isotropic and with linear elasticity. The number of elements of the evaluated set was 134,952 for the “normal alignment model” and 128,410 elements in the “model with varus deformity” (Figure 5). The nonlinear finite element analysis was carried out using the ABAQUS program (6.7-1) for


TIBIAL PERIPROSTHETIC FRACTURE COMBINED WITH TIBIAL STEM stress fracture from total knee arthroplasty

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Figure 2 – Total knee replacement with tibial stem fracture.

Figure 3 – Total knee replacement implanted. Rev Bras Ortop. 2011;46(6):745-50


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A

B

C

Figure 4 – (A) Total knee replacement with tibial stem fracture – (B) Perioperative – (C) At the laboratory. Table 1 – Characteristics of materials. Material

Table 2 – Times considered.

Modulus of elasticity (GPa)

Poisson’s coefficient

Tibial baseplate and stem

Titanium

Polyethylene insert

Polyethylene

0.5

0.3

Cement

PMMA

2.28

0.3

110

Designation

Value

Axial

(MF) + (LF) (60% medial + 40% lateral)

2,100 N

Internal-external time

IE

7 N.m

Patellar tendon

PL

670 N

0.3

CATIA V5 (Providence, USA). The cement-implant, implant-bone and implant-polyethylene insert interface zones were considered with a specific algorithm. Two load simulations were executed to evaluate forces at the stem level. The first case was a load corresponding to 45% of the gait cycle on the load side just before impulsion by the hallux, with an axial force corresponding to three times the patient’s body weight (3 x 80 kg)(6), distributed over the tibial plate asymmetrically (60% medial and 40% lateral), also considering in this configuration the forces exerted by the patellar tendon (Table 2) according to the patient’s weight (80 kg). The second case was identical to the first, but with application of axial load only on the medial plate (simulation of severe case of varus deformity). The von Mises stress forces (Figure 6) were evaluated in both cases. The applied stress forces can be observed in Figure 7, in both situations tested (before and after varus deformity observed upon admission to the emergency department). The maximum value of the von Mises stress forces before the varus deformity was 27.2MPa, having risen to 54.3MPa in the simulation of varus deformity. In both cases, the maximum value was Rev Bras Ortop. 2011;46(6):736-40

Force/time

found in the medial transition zone between the tibial baseplate and the stem. The location found in the finite element model in the tibial stem corresponds to the fatigue fracture zone found in the arthroplasty stem implanted in the patient in question. However, in any of the simulations, the values reached were below the stress force limit of the titanium alloy used in the arthroplasty (160MPa in 10 million cycles). However, it should be stressed that simple varus alignment did not alter the maximum tension zones, but doubled them instead. In addition, we should keep it in mind that the simulation did not consider, due to technical impossibility, loads in more extreme values with the varus deformity, namely in agricultural labor.

DISCUSSION Tibial component stress fractures from total knee arthroplasty are very rare, as demonstrated by Chatterji et al(8), who described several possible causes. The same can be said of tibial periprosthetic bone fractures(9). Scott et al(4) postulated that the varus implantation of the tibial component of a total knee arthroplasty increases the concentration of loads with their asymmetric distribution, and can cause a metal fatigue frac-


TIBIAL PERIPROSTHETIC FRACTURE COMBINED WITH TIBIAL STEM stress fracture from total knee arthroplasty

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Figure 6 – Finite element model of prosthesis showing a high concentration of forces in the transition zone of the tibial baseplatestem modular system.

Figure 5 – “Normal” model built in finite elements.

ture. Also the implantation of the tibial component in external rotation was identified as responsible for excessive loads in tibial components, specifically in total condylar III knee(10) arthroplasties, as well as in the polyethylene fitting zone(5,11,12). The work of Maquet(13) demonstrated that, in the static position, varus knee deformity produces the exponential growth of loads transmitted to the medial tibial plate, not only through the increase of the lever arm but also through the decrease of the load-bearing surface. However, Johnson et al(14) and Harrington(15) report that this increase is mainly in the orthostatic position, since during gait, there is a passage of the load-bearing surface to the medial zone, and, as such,

Figure 7 – Detail in the stress forces applied in the “normal model (load case 1)” and in the “varus model (load case 2)”.

the load increase is not as intense. The simulations with finite element models showed that a varus deformity increases stress values in the medial tibial plate 1.7 times below the fatigue resistance value of the bone structure involved, and can justify the strong association between tibial periprosthetic fracture and poor axial alignment(16). From the biomechanical point of view, the transition zone between the tibial stem/keel and the tibial baseplate constitutes a weak point with potential risk of fatigue fracture due to the concentration in this zone of all the load forces transmitted by the prosRev Bras Ortop. 2011;46(6):745-50


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thesis, a situation exacerbated in cases of modular tibial components such as in applied arthroplasty. In this case, we went on to study the patient’s local conditions, paying attention to bone mass, weight and height of the patient as well as the type of arthroplasty implanted through the finite element method. Analysis by the finite element method is an engineering tool whose use is becoming increasingly frequent in the calculation and design of implants and that can become important in cases such as the one described here, as it allows us to simulate the local conditions of implantation of an arthroplasty, contributing to the understanding of possible causes of failure or mistakes committed. The tests showed that the zones of greatest stress are concordant with the alterations observed in the prosthesis removed from the patient, although the maximum load peak was lower than the fatigue limits of the material indicated by the manufacturer, both in the correct position and in the position presented in the patient’s initial assessment. However, it should be noted that the maximum peak of stress doubled from one position to the other, which leaves open the possibility that the patient may have reached the fatigue limits, since she was an agricultural laborer and this work entails intense efforts, and above all, very heavy loads and objects for transportation (sometimes between 50 and 100 kg). In the radiograph obtained

upon admission to our hospital, it is not possible to identify poor initial alignment, and we were unable to obtain the immediate postoperative radiograph, but we believe that the varus positioning of the tibial component is secondary to the fracture that will have occurred first and was not identified. Since the patient continued to work and only noticed progressive varus deformity, the bone collapse may have permitted the varus positioning found on the date of admission to our unit, and, taking into account the patient’s type of work, the repeated loads changed significantly, having possibly arrived at or even surpassed the fatigue limit of the titanium alloy, secondarily provoking a fatigue fracture of the material. Although the cause of a potential fracture risk cannot be attributed to the design of the arthroplasty, this case alerted our attention to this possibility in extreme situations such as the one described here, and was the basis of our decision not to use monoblock tibial plate having abandoned the modular option.

conclusION This type of case shows the need for clinical and radiographic control of patients for early detection of alterations such as that described.

ReferEncEs 1. Mendes DG, Brandon D, Galor L, Roffman M. Breakage of the metal tray in total knee replacement. Orthopedics. 1984;7: 860-2.

baseplate fracture after total knee arthroplasty. J Arthroplasty. 2005;20(1):101-7. 9. Rand JA, Coventry MB. Stress fractures after total knee arthroplasty. J Bone Joint Surg Am. 1980;62(2):226-33.

2. Abernethy PJ, Robinson CM, Fowler RM. Fracture of the metal tibial tray after Kinematic total knee replacement. A common cause of early aseptic failure. J Bone Joint Surg Br. 1996;78(2):220-5.

10. McPherson EJ, Vince KG. Breakage of a Total Condylar III knee prosthesis. A case report. J Arthroplasty. 1993;8(5):561-3.

3. Hanssen AD, Stuart MJ, Felix NA. Classification of periprosthetic tibial fractures. In: Scuderi GR, Tria AJ, editors. Surgical techniques in total knee arthroplasty. New York: Springer-Verlag; 2002. p. 576.

11. Maruyama M, Terayama K, Sunohara H, Adachi T, Suzuki S, Fukuzawa T. Fracture of the tibial tray following PCA knee replacement. A report of two cases. Arch Orthop Trauma Surg. 1994;113(6):330-3.

4. Scott RD, Ewald FC, Walker PS. Fracture of the metallic tibial tray following total knee replacement. Report of two cases. J Bone Joint Surg Am. 1984;66(5):780-2.

12. Skinner HB, Mabey MF, Paganelli JV, Meagher JM. Failure analysis of PCA revision total knee replacement tibial component. A preliminary study using the finite element method. Orthopedics. 1987;10(4):581-4.

5. Flivik G, Ljung P, Rydholm U. Fracture of the tibial tray of the PCA knee. A case report of early failure caused by improper design. Acta Orthop Scand. 1990;61(1):26-8. 6. Taylor SJ, Walker PS, Perry JS, Cannon SR, Woledge R. The forces in the distal femur and the knee during walking and other activities measured by telemetry. J Arthroplasty. 1998;13(4):428-37. 7. Les CM, Keyak JH, Stover SM, Taylor KT, Kaneps AJ. Estimation of material properties in the equine metacarpus with use of quantitative computed tomography. J Orthop Res. 1994;12(6):822-33. 8. Chatterji U, Ashworth MJ, Smith AL, Brewster N, Lewis PL. Retrieval study of tibial Rev Bras Ortop. 2011;46(6):736-40

13. Maquet PGJ. Biomechanics of the Knee: With Applications to the Pathogenesis and the Surgical Treatment of Osteoarthritis. Berlin:Springer-Verlag; 1984. 14. Johnson F, Leitl S, Waugh W. The distribution of load across the knee. A comparison of static and dynamic measurements. J Bone Joint Surg Br. 1980;62(3):346-9. 15. Harrington IJ. Static and dynamic loading patterns in knee joints with deformities. J Bone Joint Surg Am. 1983;65(2):247-59. 16. Cordeiro EN, Costa RC, Carazzato JC, Silva J. Periprosthetic fractures in patients with total knee arthroplasties. Clin Orthop Relat Res. 1990;(252):182-9.


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