Issuu on Google+

ISSN 0102-3616

RBO

V OL UM E 4 8 • Nº 1 • J AN U ARY/FEBR U ARY 2013

Revista Brasileira de Ortopedia – Janeiro/Fevereiro 2013 – Volume 48 número 1 p. 1-117

The RBO has a new publisher: a further step towards internationalization Child abuse. literature review Congenital deformities of the upper limbs. part II: failure of formation and duplications

CAPA

A simple idea for reducing cost and weight of plaster molded orthosis Clinical evaluation of patients with osteomyelitis after open fractures treated at the hospital de urgências de Goiânia, Goiás Treatment of complex acute proximal humerus fractures using hemiarthroplasty A new method for classifying distal radius fracture: the IDEAL classification Orthopedic injuries in a formation of a soccer club

Association between knee alignment, body mass index and physical fitness variables among students. a cross-sectional study Anatomical parameters in the lateral ulnar collateral ligament reconstruction: a cadaver study Tibiocalcanean arthrodesis using the Ilizarov fixator Positioning of the acetabular component in cemented protheses – radiographic calculation Videoarthroscopic treatment of Glenohumeral Osteoarthritis Knee ligament injuries: biomechanics comparative study of two suture technique in tendon – analysis “in vitro” tendon of bovine Evaluation of prognostic factors and survival of patients with Osteosarcoma treated at a charity Hospital in Teresina – PI, Brazil Quality of life of Orthopaedist of South Mato Grosso Spontaneous healing of bucket handle meniscal tears of the medial meniscus associated with LCA injury Hypothenar Hammer Syndrome: Case Report and Literature Review Acromioclavicular dislocation type vi associated with diaphyseal fracture of the clavicle Total rupture of the quadriceps muscle in an adolescent Anatomical variation of piriformis muscle as a cause of deepgluteal pain: diagnosis by mr neurography and its treatment


ISSN 0102-3616 print

ISSN 1982-4378 online

Official Publication of the Brazilian Society of Orthopedics and Traumatology Indexed in SciELO (2007), ScopusTM (2011), LILACS (1992) and associated to the Associação Brasileira de Editores Científicos (ABEC).

Editor in chief

Emeritus Editors

Gilberto Luis Camanho Departamento de Ortopedia e Traumatologia da FMUSP - DOT/ FMUSP - São Paulo, SP, Brazil

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

Associated Editors Fernando Baldy Universidade Federal de São Paulo, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil Márcio Carpi Malta Universidade Federal Fluminense, Niterói, RJ, Brazil

Marco Antonio Percope de Andrade Universidade Federal de Minas Gerais, Faculdade de Medicina, Departamento de Aparelho Locomotor, Belo Horizonte, MG, Brazil Sergio Zylbersztejn Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil

International Editors Philippe Hernigou Department of Orthopaedic Surgery, University Paris XII, Hospital Henri Mondor, 94010, France;

Michael Wagner Wilhelminenspital der Stadt Wien, Viena, Austria;

Fernando Fonseca Universidade de Coimbra, Portugal;

Rodrigo F. Pesantez Departamento de Ortopedia y Traumatologia Fundación Santa Fé de Bogotá, Colômbia;

José Neves Porto, Portugal;

Jaime Quintero Centro Médico Almirante Colon, Bogotá, Colombia;

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

Mark Vrahas Partners Chief of Orthopaedic Trauma Service, Brigham and Women´s Hospital, Massachusetts General Hospital, Boston, USA;

Norbert P Hass Center for Musculoskeletal Surgery at the Charité - University Medicine Berlin, Germany;

Marvin Tile Sunnybrook Health Sciences Centre, Canada;

Jesse B Júpiter Massachusetts General Hospital, Harvard Medical School, Boston, USA;

Facultad de Ciencias de la Salud, Colombia;

Cris Van Der Werken General Trauma Surgeon, Netherlands;

Antonio Pace Instituto Ortopedica Galeazzi, Unità Operativa di Traumatologia, Via Riccardo Galeazzi Italy;

Edgardo Ramos Hospital de Urgencias. Traumatológicas, Mexico; Sérgio Fernandez Chile;

Juan Manoel Concha Pierre Hoffmeyer Hôpital Cantonal Universitaire, Switzerland;

Rami Mosheiff Department of Orthopedic Surgery, Hadassah Medical Center, Israel; Joan Giros Spain.


Editorial Board Akira Ishida Universidade Federal de São Paulo - UNIFESP, Departamento de Ortopedia e Traumatologia, SP, Brazil; Antonio Egydio de Carvalho Junior Instituto de Ortopedia e Traumatologia do HC/FMUSP - DOT/HC/FMUSP - São Paulo, SP, Brazil; Arlindo Pardini Junior Faculdade de Medicina do Triângulo Mineiro - Belo Horizonte, MG, Brazil; Carlos Roberto Schwartsmann Fundação Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil; Cláudio Santili Departamento de Ortopedia e Traumatologia da Santa Casa de Misericórdia de São Paulo - DOT, SP, Brazil; Flávio Faloppa Universidade Federal de São Paulo - UNIFESP, Departamento de Ortopedia e Traumatologia, SP, Brazil; Geraldo Rocha Motta Filho Instituto Nacional de Traumatologia e Ortopedia - INTO-MS RJ, Brazil; Giancarlo Polesello Departamento de Ortopedia e Traumatologia da Santa Casa de Misericórdia de São Paulo - DOT, SP, Brazil;

Luiz Marczyk Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil; Luiz Mestriner Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brazil; Marcelo Tomanik Mercadante Departamento de Ortopedia e Traumatologia da Santa Casa de Misericórdia de Sao Paulo - DOT, SP, Brazil; Marcos Antonio Almeida Matos Escola Baiana de Medicina e Saúde Pública, EBMSP - Salvador, BA, Brazil; Moisés Cohen Universidade Federal de São Paulo - UNIFESP, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil; Olavo Pires de Camargo Departamento de Ortopedia e Traumatologia da FMUSP - DOT/FMUSP - São Paulo, SP, Brazil; Osmar Avanzi Departamento de Ortopedia e Traumatologia da Santa Casa de Misericórdia de Sao Paulo - DOT, SP, Brazil; Osmar Pedro Arbix Camargo Faculdade de Ciências Médicas da Santa de Misericórdia - FCMSCSP, SP, Brazil; Osvandré Lech Instituto de Ortopedia e Traumatologia de Passo Fundo, RS, Brazil;

Gildásio de Cerqueira Daltro Universidade Federal da Bahia, Brazil - Salvador, BA, Brazil;

Paulo César Schott Universidade Federal Fluminense - Rio de Janeiro, RJ, Brazil;

Helton Defino Faculdade de Medicina de Ribeirão Preto - USP, Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor (RAL). Ribeirão Preto SP, Brazil;

Paulo Couto Departamento de Engenharia Industrial da UFRJ, RJ, Brazil;

João Antonio Matheus Guimarães Instituto Nacional de Traumatologia e Ortopedia - INTO-MS RJ, Brazil;

Roberto Guarniero Departamento de Ortopedia e Traumatologia da FMUSP - DOT/FMUSP - São Paulo, SP, Brazil;

José Batista Volpon Faculdade de Medicina de Ribeirão Preto - USP, Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor (RAL). Ribeirão Preto SP, Brazil;

Roberto Santin Departamento de Ortopedia e Traumatologia da Santa Casa de Misericórdia de São Paulo - DOT, SP, Brazil;

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) - RJ, Brazil;

Roberto Sérgio Tavares Canto Centro Universitário do Triângulo, MG, Brazil;

José Sérgio Franco Faculdade de Medicina da Universidade Federal do Rio de Janeiro, RJ, Brazil; José Soares Hungria Neto Faculdade de Ciências Médicas da Santa de Misericórdia - FCMSCSP, SP, Brazil;

Sérgio Checchia Faculdade de Ciências Médicas da Santa de Misericórdia - FCMSCSP, SP, Brazil; Sérgio Nogueira Drumond Faculdade de Medicina do Triângulo Mineiro - Belo Horizonte, MG, Brazil;

Karlos Celso de Mesquita Universidade do Estado do Rio de Janeiro, RJ, Brazil;

Tarcísio Eloy P. de Barros Filho Departamento de Ortopedia e Traumatologia da FMUSP - DOT/FMUSP - São Paulo, SP, Brazil;

Luis Roberto Vialle Universidade Católica do Paraná, Curitiba, PR, Brazil;

Walter Manna Albertoni Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brazil;

Luiz Antonio M. da Cunha Universidade Federal do Paraná - UFPR- Paraná, Brazil;

Willian Dias Belangero Universidade Estadual de Campinas UNICAMPI - Campinas, SP, Brazil.

Editorial contact

Published by

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

Elsevier Editora Ltda. Rua Sete de Setembro, 111-16º andar, CEP: 20050-006 2013-2014© Elsevier Editora Ltda. EM 6725

Brazilian Society of Orthopedics and Traumatology President: Flávio Faloppa (SP); 1st Vice-President: Arnaldo José Hernandez (SP); 2nd Vice-President: Marco Antonio Percope de Andrade (MG); General Secretary: Marcelo Tomanik Mercadante (SP); 1st Secretary Glaydson Gomes Godinho (MG); 2nd Secretary Fernando A. M. Façanha Filho (CE); 1st Treasurer: Itiro Suzuki (SP); 2nd Treasurer: João Maurício Barretto (RJ) RBO Secretary - Sociedade Brasileira de Ortopedia e Traumatologia: Alamedad Lorena, 427 – 2º andar, Jd. Paulista. CEP: 01424-000, São Paulo, SP, Brazil. Phone: (11) 2137-5417 / 2137-5415. E-mail: rbo@sbot.org.br. Website: www.rbo.org.br Advertising - Gislene Lemos. Phone: (11) 5583-1980. E-mail: projetos@sbot.org.br Editorial Assistant - Diva da Silva Godoi


Publication Norms

INSTRUCTIONS FOR AUTHORS The Revista Brasileira de Ortopedia (RBO) is the scientific publication medium of the Brazilian Society of Orthopedics and Traumatology (Sociedade Brasileira de Ortopedia e Traumatologia, SBOT) and has the purpose of disseminating papers that contribute towards improving and developing the practice, research and teaching of Orthopedics and related specialties. It is published bimonthly in February, April, June, August, October and December, and has been published with absolute regularity since its first edition in 1965. The journal receives articles for publication in the following sections: Original Articles, Review Articles, Updating Articles, Case Reports, Preliminary Notes, Technical Notes and Letters to the Editor. Articles can be written in Portuguese, Spanish or English, according to their countries of origin. The journal is aimed towards orthopedists who are linked to the SBOT, healthcare professionals who are dedicated to similar activities and orthopedists in other countries. Its abbreviated title is Rev Bras Ortop., and this should be used in reference lists, footnotes and legends.

Peer-Review Peer review is one of the factors that sustain the quality of a scientific journal. In the case of the RBO, an editorial board constituted mostly by university professors has enabled discerning peer review. After receipt, articles are sent to a technical specialist in scientific research methodology and to three members of the editorial board who work within the same field. These professionals assess the studies and return them with their reports. The evaluation includes five factors: degree of priority for publication; relevance of the study; scientific quality; presentation; and recommendation. After approval by the editors, all manuscripts will be assessed by qualified reviewers, and anonymity is ensured throughout the appraisal process (blinded peer review). 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.

Copyright All declarations published in the articles are entirely under the authors’ responsibility. Nonetheless, all material published will become the RBO’s property, and the journal will become the holder of the authors’ rights. The authors must forward a declaration of transfer of authors’ rights signed by all co-authors, to the RBO by fax (+55-011-2137-5418) or post, at the time of manuscript submission. Type of article Original Review Updating Case report Technical note Letter to the editor* Editorial**

Abstract

Number of words*** References

Figures

Tables

Structured; max. 250 words Unstructured; max. 250 words Unstructured; max. 250 words Unstructured; max. 250 words Unstructured; max. 250 words 0

2,500

30

10

6

4,000

60

3

2

4,000

60

3

2

1,000

10

5

0

1,500

8

5

2

500

4

2

0

0

500

0

0

0

*publicadas à critérios dos Editores com réplica quando pertinente; **a convite dos Editores; ***excluindo resumo, referências, tabelas e figuras.

Presentation and submission of manuscripts The Revista Brasileira de Ortopedia (Rev Bras Ortop. - ISSN 0102-3616) is a bimonthly publication from the Brazilian Society of Orthopedics and Traumatology, with the purpose of publishing original studies on all the specialties of orthopedics. The concepts and declarations contained in the studies are entirely under the authors’ responsibility. Articles published in the RBO 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. Articles submitted should be accompanied by the following: Author Agreement 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. Title Page A page containing the complete identifications of the authors (affiliation, with the name of the institution, city, state and country), institution(s) from which the study originated (with the name of the institution, city, state and country) and, when applicable, any differentiated or special participation. Covering Letter A letter presenting the study that is addressed exclusively to the editor.

Manuscript A complete file containing the article with references, preferably with abstract and keywords. Figuras, Tabelas, Gráficos Individual files sent separately.

The following should be attached to the Author Agreement: Declaration of conflict of interest, when appropriate. Through this, in accordance with Federal Medical Council Resolution 1595/2000, scientific articles are prohibited from promoting or advertising any commercial products or equipment. Certificate of study approval from the Research Ethics Committee of the institution in which the study was conducted. Information on any sources of funding for the research. Declaration that the investigators have signed an informed consent document, when the article deals with clinical research on human beings. All clinical or experimental research on humans or animals should be conducted in accordance with the Declaration of Helsinki of the World Medical Association (J Bone Joint Surg Am. 1997;79(7):1089-98). Articles should be written in Portuguese, Spanish or English, according to their countries of origin.

Types of Article The Revista Brasileira de Ortopedia receives the following types of manuscripts for publication: Original Articles, Updating Articles, Review Articles, Case Reports, Technical Notes, Summaries, Abstracts, Letters and Editorials. Original Articles These describe prospective or retrospective experimental research or clinical investigations, which may be randomized or double blind. They should have a Title in Portuguese and English, an Abstract in Portuguese and English (structured as Objective, Methods, Results and Conclusion), Keywords, Introduction, Materials and Methods, Results, Discussion, Conclusions and References. Updating Articles These are reviews of the state of the art on a given topic, written by specialists on invitation from the editors. They should have an Abstract in Portuguese and English, Keywords, Title and References. Case Reports These should be informative and not contain irrelevant details. Only clinical cases that are of interest either because of their rarity as nosological entities or because of their unusual form of presentation will be accepted. They should have an Abstract in Portuguese and English, Keywords, Title and References. Review Articles These have the purpose of examining the published bibliography on a given subject, in order to make a critical and systematized assessment on a certain topic and present the important conclusions based on this literature. They will only be accepted for publication when requested by the editors. They should have an Abstract in Portuguese and English, Keywords, Title and References. Technical Notes These are destined for disseminating diagnostic methods, experimental surgical techniques, new surgical instruments, new orthopedic implants, etc. They should have an Abstract in Portuguese and English, Keywords, Title, Explanatory Introduction, Description of the Method, Material or Technique, Final Comments and References. Letters to the Editor These have the aim of commenting on or discussing studies published in the journal or reporting on original research that is in progress. They will be published at the editors’ discretion, with the respective reply, when appropriate. Editorial These are written on invitation, presenting comments on


important studies in this journal, describing important published research or presenting communications from the editors that are of interest to the specialty.

Preparation of the Manuscript

A) Cover Page (Title Page): • Title of the article, in Portuguese and English, composed of ten to twelve words (not counting articles and prepositions). The title should stimulate interest and should give an idea of the aims and content of the study; • Complete name of each author, without abbreviations; • Indication of the academic level attained and the institutional affiliation of each author, separately, with the city, state and country, with sequential numerical indication using superscript lower-case letters. If there is more than one institutional affiliation, only indicate the most relevant one; • Indication of the institution where the study was conducted, with city, state and country; • Name, address 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. Abstract and keywords: Abstract and keywords 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; Materials and 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 Preliminary Notes, the abstract does not need to be structured but keywords are required. Below the abstract, specify a minimum of three and a maximum of ten keywords that define the subject of the study. The descriptors or keywords should be based on the Health Science Descriptors (Descritores em Ciências da Saúde, DECS), which are available at the electronic address http:// www.decs.bvs.br; or on the Medical Subject Headings (MeSH), from www.nlm.nih.gov/mesh/MBrowser.html. B) Text (Manuscript) The structure for each manuscript category should be followed rigorously. In all manuscript categories, citations of authors should not be made in the text. The text should preferably have an abstract and keywords. Introduction: This should be brief and should contain and explain the objectives and reason for the study. Methods: This should contain enough information to k now what was done and how it was done. The description should be clear and sufficient for another researcher to be able to reproduce or continue with the study. The statistical methodology used should be described with sufficient detail to allow any reader with reasonable knowledge of the topic and access to the original data to verify the results presented. Use of imprecise terms such as random, normal, significant, important or acceptable without defining them should be avoided. The research results should be reported concisely in this chapter in a logical sequence. Statistical methods: These should be described in detail. Statements equivalent to “no significant difference was found between the two groups” will be rejected. Use of the word “significant” requires that the “p” value should be reported. Use of the word “correlation” should be accompanied by the respective coefficient. Information on postoperative pain management, both in humans and in animals, should be reported in the text (Resolution No. 196/96, from the Ministry of Health, and International Animal Protection Norms). Results: Whenever possible, these should be presented in tables, graphs or figures. Results with fewer than two years of follow-up will only rarely be accepted. Discussion: All the results from the study should be discussed and compared with the pertinent literature. Conclusions: These should be based on the results obtained. Acknowledgements: Collaborations from individuals or institutions or thanks for financial support or technical assistance that deserve recognition but do not justify inclusion among the authors may be mentioned. Conflicts of interest: These should be recorded objectively when present. If there are none, the following declaration should be presented: “The authors declare that there was no conflict of interests in conducting this study.”

References: These should be up to date, with preference for the most relevant studies on the topic published over the last five years. They should only contain studies referred to in the text. If pertinent, it is recommendable to include studies published in the RBO. The references should be numbered consecutively, in the order in which they are cited in the text, and should be identified using Arabic numerals in parentheses. The presentation 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. 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.” 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. 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 5 p.]. 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 2 p.]. Available from: http://bjsm.bmjjournals. com/cgi/content/full/38/4/383 C) Tables and Figures: 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. Charts and tables should be sent as individual files (preferably in Excel).. Figures: This material, with legends and respective numbering, can be presented in colors but will be printed in black and white. Figures should be sent in the form of individual files (300 dpi). Further details in: http://www.elsevier.com/author-schemas/ artwork-and-media-instructions. Each individual figure should be sent to the system. The legend(s) should be incorporated at the end of the text, in the manuscript after the reference listing. Do not include figures in the text. The term “figure” includes all illustrations, such as photographs, drawings, maps, graphs, etc, and should be numbered consecutively in 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 always 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 RBO 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://ees.elsevier.com/rbo. It is essential to send the following by fax or post: permission to reproduce the material; a 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 Author Agreement, signed by all the authors, in which they declare that the study has never been published previously (fax: +55 11 2137-5418).


Volume 48 • Number 1 • January/February 2013

CONTENTS Editorial The RBO has a new publisher: a further step towards internationalization Gilberto Luis Camanho . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Update Articles Congenital deformities of the upper limbs. part II: failure of formation and duplications Edgard Novaes França Bisneto . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Review Articles Child abuse. literature review Bernardo Barcellos Terra, Eduardo Antônio de Figueiredo, Morena Pretti Espindula de Oliveira Lima Terra, Carlos Vicente Andreoli, Benno Ejnisman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Original Articles A simple idea for reducing cost and weight of plaster molded orthosis André Esmanhotto, Guilherme Esmanhotto . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Clinical evaluation of patients with osteomyelitis after open fractures treated at the hospital de urgências de Goiânia, Goiás Pablo Erick Alves Villa, Thiago Roberto Nunes, Fernando Prudente Gonçalves, Jefferson Soares Martins, Guilhermo Sócrates Pinheiro de Lemos, Frederico Barra de Moraes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Treatment of complex acute proximal humerus fractures using hemiarthroplasty Bruno Lobo Brandão, Marcus Vinicius Galvão Amaral, Marcio Cohen, Rickson Guedes de Moraes Correia, Carlos Henrique Gazineu Abdenur, Martim Teixeira Monteiro, Geraldo Rocha Motta Filho . . . . . . . . . . . . . . . . . . . . . 29 A new method for classifying distal radius fracture: the IDEAL classification João Carlos Belloti, João Baptista Gomes Dos Santos, Marcel Jun Sugawara Tamaoki, Vinícius Ynoe Moraes, Jaime Piccaro Erazo, Leonardo Jorge Iani, Flávio Faloppao. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Orthopedic injuries in a formation of a soccer club Daniel Augusto Carvalho. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Association between knee alignment, body mass index and physical fitness variables among students: a cross-sectional study Andréia Araújo Souza, Gerson Luis de Moraes Ferrari, João Pedro da Silva Júnior, Leonardo José da Silva, Luis Carlos de Oliveira, Victor Keihan Rodrigues Matsudo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Anatomical parameters in the lateral ulnar collateral ligament reconstruction: a cadaver study Willian Nandi Stipp, Fabiano Rebouças Ribeiro, Antonio Carlos Tenor Junior, Cantídio Salvador Filardi Filho, Danilo Canesin Dal Molin, Rodrigo Souto Borges Petros, Romulo Brasil Filho . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Tibiocalcanean arthrodesis using the Ilizarov fixator Alessandro Marcondes Leite, Helder Mattos Menezes, Igor de Castro Aquino, Jefferson Soares Martins, Frederico Barra de Moraes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57


Positioning of the acetabular component in cemented protheses – radiographic calculation Pedro José Labronici, Ramon Louro Motta, Bruno Bandeira Esteves, José Sergio Franco, Rolix Hoffmann, Luiz Aurélio Costa Ferreira, Marcos Giordano, Sergio Delmonte Alves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Videoarthroscopic treatment of Glenohumeral Osteoarthritis Glaydson Gomes Godinho, Flávio Márcio Lago Santos, Flávio Oliveira França, Jose Márcio Alves Freitas, Fabrício Augusto Silva Mesquita, Thiago Serpa de Azevedo Silva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Knee ligament injuries: biomechanics comparative study of two suture technique in tendon – analysis “in vitro” tendon of bovine Elias Marcelo Batista da Silva, Mauro Batista Albano, Hermes Augusto Agottani Alberti, Francisco Assis Pereira Filho, Mario Massatomo Namba, João Luiz Viera da Silva, Luiz Antonio Munhos da Cunha . . . . . 80 Evaluation of prognostic factors and survival of patients with Osteosarcoma treated at a charity Hospital in Teresina – PI, Brazil Fernanda Râmyza de Sousa Jadão, Lailton de Sousa Lima, José Augusto Sá Lopes, Marcelo Barbosa Ribeiro . . . . . . . 87 Qualidade de Vida dos Médicos Ortopedistas do Mato Grosso do Sul Quality of life of Orthopaedist of South Mato Grosso Marcelo Henrique de Mello, José Carlos Souza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

Case Reports Spontaneous healing of bucket handle meniscal tears of the medial meniscus associated with LCA injury Neiffer Nunes Rabelo, Nícollas Nunes Rabelo, Aluísio Augusto Gonçalves Cunha, Francisco Correia Junior . . . . . . . 100 Hypothenar Hammer Syndrome: Case Report and Literature Review Lícia Pachêco Pereira, Marcia Maria Muniz de Queiroz, Clarissa Gondim Picanço, Rodrigo de Castro Luna, Fabrício da Silva Costa, Cláudio Régis Sampaio Silveira . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Acromioclavicular dislocation type vi associated with diaphyseal fracture of the clavicle Evander Azevedo Grossi, Macedo Araújo Roberto . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Total rupture of the quadriceps muscle in an adolescent Rodrigo Pires Albuquerque, José Félix dos Santos Neto, Vincenzo Giordano, Maria Isabel Pires e Albuquerque, Ney Pecegueiro do Amaral, João Maurício Barretto . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Anatomical variation of piriformis muscle as a cause of deepgluteal pain: diagnosis by MR neurography and its treatment Giancarlo Cavalli Polesello, João Paulo Tavares Linhares, Marcelo Cavalheiro Queiroz, Denise Tokechi Amaral, Nelson Keiske Ono . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114


Rev Bras Ortop. 2013;48(1):1-2

www.rbo.org.br/

Editorial

The RBO has a new publisher: a further step towards internationalization For many years, the RBO was edited by the publishers Redprint, directed by Mr. Katayama, an independent editor who brought together five or six medical journals with the common factor of the same group of sponsors, and which were published and distributed with the same periodicity. This was printing work that resembled, for example, production of a wedding invitation: the interested parties supplied data, chose the format of the invitation and the printing company printed the number of invitations that were requested. The editing work was very superficial. This form of producing the RBO was more than enough for many years, since the cost to the SBOT was zero and the members received their journal at home at a very reasonable periodicity. We supplied the material to be published, and the company found sponsorship with our material and published the RBO without cost to the SBOT. This is not criticism of this period, and there is no doubt that many of us learned much by reading studies selected by our eminent former editors and published by Mr. Katayama. However, the world of medical publishing underwent great evolution over that period. Journals became indexed through professional quality analysis systems; indexation became a required criterion in university life; sponsors started to demand higher quality from studies and publishers; and Mr. Katayama became elderly, which led the RBO to seek other directions. These problems started to become apparent at the end of Professor Giesta’s administration as Editor-in-chief and, at the beginning of our administration, we contracted a publishing company, Atha Comunicação e Editora, directed by Mr. Arthur. With Atha and with Mr. Arthur, we established a new editorial standard that met the requirements of the majority of the indexers, but we started to need greater professionalism for raising resources. We made important editorial advances, reflected in greater numbers of studies sent for publication, with higher quality. The administration sector of the SBOT became responsible for seeking the sponsorship that was necessary for paying the costs of publishing and distributing the RBO. Over the last few years, the requirements within the field of journal editing have become increasingly specific, and doi: 10.1016/j.rboe.2013.04.002

publishing medical periodicals have become a matter of some complexity. In addition to the needs for revision of the form and content, higher quality for imag es a n d g re a t e r r i g o r i n a s s e s s i n g s t u d i e s , a t t a i n m e n t o f i n t e r n a t i o n a l i z a t i o n h a s b e e n s o u g h t . T h ro u g h internationalization, studies in journals are placed in universal search systems and journals are qualified in accordance with standards established worldwide; and an impact factor is assigned according to the numbers of citations of the journal within the worldwide editorial system. This is the highest level that any journal can attain at present. To be consulted and cited internationally is a desirable objective for the most important journals within the field of medicine, so that they can be supplied with material by the best authors, who wish to see their studies displayed to the scientific world. The present moment is good for the RBO. We have a large reserve of studies already selected; we maintain a study rejection rate of around 25 to 30%; we have a constant flow of study submissions; we are read, given that we are cited; and the publishers Atha provided us with an excellent publication service. Thus, we are a good national journal, but we have not yet attained an international level. A decision to continue at this level and refine it was always borne in mind, but on the other hand, we are a Society with more than 10,000 members, with many links with international societies and an important leading position in Latin America. Hence, a proposal to set out to reach the next step, internationalization, was assessed by the boards of directors with whom I work, and all of them were unanimous in deciding to seek internationalization. President Romeu accepted and stimulated the initial contacts with international publishers; President Santilli came to the point of negotiating a contract with an important international publisher; and President Osvandré not only negotiated but also established solid contacts with major publishers. However, it became President Geraldo’s task to enter into the contract with Elsevier, one of the biggest publishers in the world, for us to start this new era. This is the first edition of this new era of the RBO. Few modifications will be noted, since our investment is for the medium to long term.


2

Rev Bras Ortop. 2013;48(1):1-2

We will be modifying some aspects of the study selection process, by creating another two analysis stages: one in the field of form and structure (librarian support) and the other in the field of content quality (medical editors). For this, we will have to select assistant editors for fields of knowledge so that, after my first evaluation as Editor-inchief, the sector editors can judge the appropriateness and originality of the study presented. We are going to head towards a rejection rate of close to 50%. In parallel with this procedure, we will have a support sector for authors, provided by the publisher and by our associate editors, so that rejections are transformed into teaching material for training good authors in accordance with the international standards for scientific production.

Our editors will have support from Elsevier’s databases for judging studies and guiding authors, through suggesting previous studies that will be made available online. We will be continuing the work of the former Editors-inchief Marcio Ibrain de Carvalho, Donato Dangelo and Carlos Giesta, who had editorial support from Mr. Katayama, and our work, which had editorial support from Mr. Arthur, in seeking to lead the RBO to an international standard compatible with the other activities of the SBOT, like our examination for obtaining the title of specialist, our continuing education program and our congresses, which have already attained this standard of excellence. Gilberto Luis Camanho Editor-in-chief, Revista Brasileira de Ortopedia


Rev Bras Ortop. 2013;48(1):3-10

www.rbo.org.br/

Updating Article

Congenital deformities of the upper limbs. Part II: failure of formation and duplications Edgard Novaes França Bisneto1* 1Attending Physician in the Hand Group, Institute of Orthopedics and Traumatology, Hospital das Clinicas, School of Medicine, Universidade de São Paulo; Care Association for Disabled Children of São Paulo (AACD), São Paulo, SP, Brazil. Work performed jointly by the Hand Group of the AACD São Paulo and the Group of the Institute of Orthopedics and Traumatology, Hospital das Clinicas, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil.

article info

a b s t r a c t

Article history:

This article, presented in three sections, review the most common upper limb malformations

Received January 31 2012

and their treatments. In this section two there’s a discussion about failure of formation and

Approved October 2012

duplication of the parts. The bibliography is continuous since section one. © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora

Keywords:

Ltda. All rights reserved.

Congenital Abnormalities Upper Extremity Upper Extremity Congenital Deformities/history

*Corresponding author at: Rua Dr. Ovídio Pires de Campos, 333, Cerqueira Cesar, São Paulo, SP, Brazil. CEP: 05403-010. Tel: (+55 11) 99631-3043. E-mail: edgard.franca@hc.fm.usp.br ISSN/$–see front matter © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved. doi: 10.1016/j.rboe.2012.10.001


4

Rev Bras Ortop. 2013;48(1):3-10

Introduction This second article of a series of three covers the guidelines for treating failure of differentiation and duplication, in accordance with the classification of the IFSSH (International Federation of Societies for Surgery of the Hand).

II Failure of differentiation of parts II.1 Synostosis This is a generic term that indicates bone union between bones that are normally separated.25 It can occur in any location, but it has greatest clinical importance when in the elbow. Radiographs may be normal at birth, but the range of motion is smaller than in normal elbows and may go unnoticed in newborns.25 Radiohumeral synostosis, which is generally associated with ulnar club hand, may form part of the multiple synostosis syndrome. In cases of stiff elbow, the functional capacity of the upper limb will depend on the position of the elbow and the functional capacity of the hand and shoulder.25 Bilateral impairment occurs most commonly. There is no specific treatment, and in most cases occupational therapy is advised. Derotation osteotomy and bone stretching can be used in wellselected cases that present large deformities.14,25 Proximal radioulnar synostosis is bilateral in 50% of the cases and may not be recognized until adolescence. 14,25 Pronation-supination is absent and the movement of the upper limb is compensated by the wrist and shoulder.25 Generally, this is an isolated deformity, but it may be associated with hypoplasia of the thumb, symphalangism, congenital clubfoot, arthrogryposis and Apert syndrome.14 Cases in mid-pronation position or small degrees of pronation or supination do not require treatment. Hyperpronation or hypersupination should be treatment by means of derotation osteotomy in synostosis, seeking a position with 30° of pronation in unilateral cases, while for bilateral cases, mid-pronation is sought in the nondominant limb and 20° of pronation in the dominant limb.14,25 II.2 Dislocation of the radial head Congenital dislocation of the radial head (Fig. 12) may occur in isolation or in association with proximal radioulnar synostosis and other syndromes, including Cornelia de Lange, Klinefelter, etc.25 The dislocation is generally posterior or posterolateral, while in one third of the cases it is anterior.14,25 There may be limitation of extreme movements, but in most cases no dysfunction is noted.14 There is great difficulty in differentiating chronic traumatic dislocation from congenital dislocation, since radiographs are in many cases

Fig. 12 - Congenital dislocation of the radial head.

produced because of trauma. 25 Congenital dislocation is generally bilateral, the radial head is flattened, associated anomalies are present, the capitellum is hypoplastic and the ulna and radius may be shortened.14,25 Treatment is rarely necessary during childhood. Resection of the radial head may be indicated during adolescence or in adulthood, always after skeletal maturity, in painful cases.14,25 II.3 Symphalangism This is characterized by stiffness or fusion of the interphalangeal joints. Surgical treatment is uniformly reported as being disappointing, although there have been descriptions of arthroplasty. At adult ages, arthrosis may occur in the distal interphalangeal or metacarpophalangeal joint due to mechanical overload.10 II.4 Syndactyly This can be defined as variable fusion between two adjacent fingers. It is one of the most common congenital deformities, occurring in 1:2,000 live births. 26,27 There are several classification systems, which will not be covered in this chapter, but classically these cases are divided into the following types:26 Simple: fusion only through the skin; Complex: when there is a bone connection. Complete: the entire commissure is involved, as far as the nail bed; Incomplete: the nail bed is not involved. Complicated: involvement of vascular tissues, tendons or nerves. It can occur separately or as a manifestation of a syndrome, such as Streeter, Apert or Poland, in which the severity of the syndactyly is greater. Practically all patients with syndactyly have surgical indications and, if possible, the surgery should be done before the age of two years,26,27 in order to avoid angular deformities between the fingers. The initial treatment consists of reconstruction of the digital commissure, with adequate skin coverage and reconstruction of the nail bed.26 Several designs for commissure flaps have been described, and planning needs to be done for each case. Skin grafting is not always necessary,26 particularly in cases of incomplete syndactyly. However, in the present author’s opinion, it should always be performed in cases of complete, complex and complicated syndactyly. There are several graft donor areas: inguinal region, hypothenar, antecubital region, feet, etc.26 (Fig. 13).

Fig. 13 - Simple/complete syndactyly (A, B). After the operation (C, D).


5

Rev Bras Ortop. 2013;48(1):3-10

It is always prudent to avoid releasing two adjacent commissures, so as to avoid vascular complications.10 The approach is surgical in most cases, and it is seen that the integration of skin grafts is significantly better, the younger the child is. In particular, the present author chooses to use larger skin flaps in cases of zigzag incisions, which also facilitates graft integration (Fig. 14). Care regarding postoperative dressings is essential for success in the operation. Apert syndrome (Fig. 15) is characterized by craniosynostosis, midfacial hypoplasia, syndactyly and visceral abnormalities. The syndactyly is complex and complicated. The initial objective of the treatment is to provide a thumb so the digital pincer movement can be made.26,27 Experiences using external fixators for detensioning of fingers with severe syndactyly, so as to avoid skin grafting (Fig. 16).28 The Poland syndrome or sequence (Fig. 17) is an abnormality of the subclavian artery, in the embryological phase, which gives rise to several types of hypoplasia in the upper limbs.

Fig. 14 - Ulnar club hand with syndactyly. Before operation (A, B); during operation with skin graft (C, D, E); after operation (F).

It is characterized by aplasia of the pectoralis major muscle, brachydactyly, hypoplasia of the hand and syndactyly. The syndactyly cases tend to be of simple type and follow the normal treatment pattern.27

II.5 Contractures II.5A Soft tissues II.5A 1 Pterygium The pterygium, or presence of a band of skin in the cubital fossa, may occur in isolation or in association with syndromes. The elbow is frequently stiff and surgical treatment to increase its range of motion is discouraged because of the lack of success in the literature.25 Plastic surgery on the skin band can be performed by means of zetaplasty for cosmetic purposes, given that cavities influence the range of motion of the elbow (Fig. 18).

II.5A 2 Congenital trigger finger There are differences between the congenital trigger condition in the thumb and in the other fingers.29 The congenital trigger condition is rare in the ulnar fingers and is associated with other malformations of the superficial and deep flexors. It generally presents with sporadic locking. Release of the A1 pulley alone tends not to produce results, and tenoplasty of the chiasm and partial opening of the A2 pulley are necessary.29 Congenital trigger thumb has been considered by some authors to be an acquired condition, given that it may not be present at birth, although abnormalities of the A1 pulley have been described. It generally presents as a contracture of the interphalangeal joint of the thumb, in fixed flexion. Its treatment is initially conservative. After one year of age, if conservative treatment fails, opening the A1 pulley is indicated.29

Fig. 15 - Apert syndrome and complex syndactyly.

Fig. 17 - Poland syndrome. Note aplasia of the pectoralis major muscle.

Fig. 16 - Use of external fixators for treating syndactyly.28

Fig. 18 - Zetaplasty of pterygium.


6

Rev Bras Ortop. 2013;48(1):3-10

II.5A 3 Hypoplastic thumb Hypoplasia of the thumb consists of a set of abnormalities that go from a thumb that is slightly smaller to its complete absence. 30 It may occur in isolation or together with longitudinal deficiencies of the radius.15 The Blauth classification modified by Manske is the one most used, as follows:15,31 Type I: slightly hypoplastic thumb with short abductor opposing the hypoplastic thumb or absent. Type II: hypoplastic thumb, with narrowing of the first commissure, absence or hypoplasia of the short abductor opposing the thumb; metacarpophalangeal joint instability through absence of the ulnar collateral ligament; and inability to perform digital pincer movement. Type III: greater instability and insufficiency of the first commissure. There are abnormalities of the extrinsic musculature through absence of the extensor and long flexor of the thumb, or abnormal connections between these, the pollex abductus and the base of the first metacarpal. Manske divided this type as follows. IIIA: presence of the base of the metacarpal, and therefore with a stable carpometacarpal joint; and IIIB: absence of the base of the metacarpal joint, with an unstable metacarpophalangeal joint. Type IV: floating thumb, without bone or tendon structures connecting the thumb to the hand. Type V: complete absence of the thumb. Conservative treatment should be recommended only for type I thumbs with pincer function and grip preserved.30,31 Type I, with functional deficits, and types II and IIIA should be reconstructed.15,30,31 The surgical procedures involved in reconstruction of the thumb include: • bone re n F 1 • o onen la y u er al le or o e our n er or abductor of the fifth finger; • e a la y o e r omm ure • re on ru on o e ulnar olla eral l amen • en on ran er e en or ro r u o e n e n er to the long extensor of the thumb; superficial flexor of the fourth finger to the long flexor of the thumb. The main surgical indication for types IIIB, IV and V consists of pollicization of the second finger.15,30-32 For type IIIB, there are surgical options consisting of creation of bone bridges between the first and second metacarpals, with the aim of stabilizing the thumb. Microsurgical transfers for reconstruction of the thumb have been described in case reports, but there is still room for discussion because of the inconstancy of the vessels and receptor structures.15,30,31,33 Pollicization is still the preferred treatment for hypoplasia of the thumb, from type IIIB onwards. This was described by Buck-Gramcko and has the aims of providing digital pincer capability, cosmetic improvement and the ability to grasp large objects.15,32 The presence of an index finger without abnormalities is fundamental for indicating pollicization, since the greater its stiffness is, the worse the digital pincer function will be.15

Fig. 19 - Stretching of first metacarpal. Type II hypoplastic thumb.

The Buck-Gramcko technique (Fig. 20) enables construction of skin flaps, resection of the diaphysis of the second metacarpal, protection of the venous drainage, release of the radial digital artery of the third finger, maximum extension and fixation of the metacarpal head on its base at 45° of abduction and 100° of pronation.30,32 The new tendon functions recommended by Buck-Gramcko are as follows: the common extensor of the fingers goes to the long extensor of the thumb; the extensor proprius of the index finger goes to the long abductor of the thumbs; the first interosseous palmar tendon goes to the adductor of the thumb; and the first interosseous dorsal tendon goes to the short abductor of the thumb (Figs. 21 and 22). There is no need for shortening of the extrinsic tendons.30

Fig. 20 - Buck-Gramcko pollicization method.31


7

Rev Bras Ortop. 2013;48(1):3-10

II.5A 4 Absence of extensors This is a rare deformity that can be presented as: Absence of extensors of one finger, generally the proximal interphalangeal; Absence of extensors from all the fingers. In these cases, tendon transfers are indicated, after the age of five years, because of the size of the tendons. So far, surgery is recommendable, with use of orthoses.10 II.5A 5 Thumb adduction contracture This is generally associated with other symptoms. Thumbs with adduction contracture are divided as follows:30 Type I: thumb is generally flexible and condition occurs through absence or hypoplasia of the extensor tendon; Type II: thumb is stiff; there are associations with joint malformations, the thenar musculature and insufficiency of the first commissure; Type III: association with arthrogryposis, without alteration of the extensor tendon. Initial use of orthoses is recommended. For type I thumbs, tendon transfers after the age of two years, with prior conservative treatment, is recommended.30 The surgical treatment for types II and III will be covered in the section on arthrogryposis. II.5A 6 Camptodactyly This is defined as a painless and progressive non-traumatic contracture of the proximal interphalangeal. 29,34 It affects

Fig. 21 - Pollicization.

Fig. 22 - Pollicization. Note interosseous repair for transfer.

around 1% of the population and the great majority of the cases are extremely mild and asymptomatic.29,34 There are three types of camptodactyly: Type I: child or congenital form; this is the classic form of camptodactyly, which affects one or both of the fifth fingers, without any difference between males and females. Type II: adolescent form; more frequent in women and generally evolves to severe contractures. Type III: the most severe form, associated with systemic syndromes. The cause of the contracture is controversial. There have been descriptions of malformations of the superficial flexor of the fingers, lumbrical muscles and the transverse and oblique retinacular ligaments.34 There may also be alterations to the configurations of the proximal interphalangeal joint. The following are differential diagnoses with camptodactyly: pterygium syndrome, arthrogryposis, symphalangism, boutonniere lesion, Marfan syndrome, absence of extensor tendons, etc.34 The treatment for type I is conservative, with orthoses and manipulation. Some authors have believed that a few degrees of flexion of the proximal interphalangeal joint are beneficial for grasping objects, particularly in the fourth and fifth fingers.29,34 For types II and III the following have been described: osteotomy of the proximal phalangeal extensor;10 tenoplasty or reconstruction of the extensor tendon;34 resection of the anomalous lumbrical;29,34 transfer of the superficial flexor of the fingers to be an extensor29,34 (Fig 23); and arthrodesis of the proximal interphalangeal joint.34 Skin flaps can be used for reconstructing severe contractures35 (Fig 24). The results are very variable, but joint stiffness of different degrees is common.29,34

Fig. 23 - Camptodactyly. Transfer of flexor digitorum superficialis to extensor and lateral flap: before operation (A); during operation (B, C); after operation, note the difference between the operated and non-operated sides (D)..

Fig. 24 - Detail of lateral flap.


8

Rev Bras Ortop. 2013;48(1):3-10

II.5A 7 Ulnar deviation of the fingers This is present from the time of birth and is characterized by progressive flexed contracture of the metacarpophalangeal joint and ulnar deviation of the fingers. There is an association with thumb adduction contracture. The initial treatment should consist of use of an orthosis until surgical treatment becomes possible. Zetaplasty, skin grafting, capsuloplasty and tendon realignment are used.10 II.5B Skeletal II.5B 1 Clinodactyly and delta phalange The term clinodactyly refers to radioulnar deformity of the phalanges, with angular deviation, distally to the metacarpophalangeal joint. 27,29 It may or may not be associated with systemic syndromes. It is more common than camptodactyly and its incidence in the population ranges from 1 to 20%.3,27,29 It typically affects the middle phalange of the fifth finger with deviation of up to 10°. 3 The physiopathology of the deformity is based on a C-shaped abnormality of the epiphysis of the middle phalange.3,27,29 Most cases of clinodactyly do not require treatment, or orthoses because of their lack of efficacy.3 In cases of severe deformity, partial epiphysiodesis or osteotomy are indicated to correct the angular deviation.27,29 The presence of abnormal phalanges of triangular shape, called delta phalanges, is associated with severe angular deformities, although delta phalanges may not produce angular deformities in some cases.27 When a delta phalange is associated with angular deformity, surgical treatment is indicated. Opening or closing-wedge osteotomy and partial epiphysiodesis are indicated27 (Fig. 25). Resection of the delta phalange is indicated in children up to the age of four years (Fig. 26). Above this age, there is a risk of finger instability.

II.5B 2 Kirner deformity This is characterized by volar-radial deviation of the distal interphalangeal joint of the fifth finger. 27 It affects between 0.15 and 0.25% of the population, and is twice as common among women. It commonly first appears during adolescence. It is attributed to non-traumatic alterations during the growth phase.27 It rarely affects hand function, and treatment is only rarely necessary. For conservative treatment, orthoses can be put in place when it is observed at an early age, before the growth spurt of puberty. Surgery is more indicated in relation to the appearance of the finger, and can be done by means of partial osteotomy of the distal phalange.27 Indications for surgical treatment are exceptional and should be exhaustively discussed with the patient. III Duplication failure III.1 Thumb Pre-axial (radial) polydactyly occurs more frequently in whites and is unilateral, sporadic and not associated with systemic syndromes in the great majority of the cases.29 It is considered to be the second most common congenital deformity, occurring in 1:3,000 live births.35 Some authors have taken the view that this deformity is not a duplication, since neither of the thumbs is normal, and have preferred to name them half-thumbs.29,36 Wassel’s classification is the best-known system.29,35,36 (Fig. 27). The principle of the treatment is to provide a single thumb of adequate volume, without nail deformities, which is mobile and stable. 40 Simple resection of the duplicate thumb is reserved solely for cases in which this duplication is a floating thumb.29,35,36 Reconstruction techniques: a) Tendon and ligament reinsertions. In duplications at the level of the joints, the collateral ligaments are inserted in different phalanges. The long abductor of the thumb and the short flexor of the thumb are inserted in the radial phalanges. The extensor tendons tend to be inserted eccentrically.35

Fig. 25 - Clinodactyly. Wedge osteotomy for closure and realignment of extensor tendon.

Fig. 26 - “Delta” phalange associated with hypoplasia of the second finger, bilaterally. Right side operated with osteotomy of the “delta” phalange.

Fig. 27 - Wassel’s classification36 and incidence of each type.35


Rev Bras Ortop. 2013;48(1):3-10

b) Osteotomy, in order to maintain the normal axis of the thumb, particularly in asymmetrical thumbs, in which the smaller one tends to cause angular deformity in the larger one36 (Fig. 28). c) Joint realignment in cases of two epiphyses.36 In thumbs in which there is clear asymmetry, the preferred treatment consists of resection of the more hypoplastic thumb, which in most cases is the radial thumb, followed by ligament and tendon reconstruction29,35,36 (Fig. 29). In situations of symmetrical thumbs, the Bilhaut-Cloquet procedure and its variations has been described. This was first described for types I and II, but can also be used for types III, IV and V29,35-37 (Figs. 30 and 31). Classically, this consists of wedge osteotomy, performed symmetrically on the two thumbs, with central resection and suturing of the lateral edges. Thumbs of adequate size and good alignment are obtained, but growth plate lesions and nail deformities are common. For this reason, variations of the technique have been described with the aim of diminishing these problems.36-39 To treat type VI thumbs and some special situations, “on-top-plasty� has been described. In this, the distal portion of one thumb is transposed to the base of the other.39,40 This procedure is done by dissecting a vascular pedicle from the distal portion that is to be transferred.

9

Type VII duplicate thumbs and triphalangism Triphalangeal thumbs may arise in isolation, or in association with duplication of the thumb (type VII), or in association with systemic syndromes.29 They are divided into two distinct group. In the first group, there is a thumb that resembles a normal one, but with an extra phalange, which may vary in shape: rectangular, trapezoid or delta. In the second group, there is a fifth finger aligned with the others, which in reality is a probably duplication of the second finger, in the absence of the thumb, without any opposing function.29 For triphalangeal thumbs in the first group, the treatment varies according to whether angular deviation is present and according to thumb length. Osteotomy, resection or shortening of anomalous phalanges (Fig. 32), reconstruction of the first commissure and tendon realignments are indicated, according to each case. For thumbs in the

Fig. 30 - Bilhaut-Cloquet: classic (A) and variations (B, C, D).36,38-43

Fig. 28 - Ligament reconstruction scheme, with or without osteotomy and joint realignment.36

Fig. 31 - Modified Bilhaut-Cloquet.

Fig. 29 - Type V duplicated thumb. Resection of hypoplastic thumb with reinsertion of ligament and long abductor of the thumb.

Fig. 32 - Triphalangeal duplicated thumb. This case underwent resection of the radial thumb, ligament realignment and partial resection of the proximal phalange.


10

Rev Bras Ortop. 2013;48(1):3-10

second group, pollicization of these fingers and possibly opponensplasty are indicated.29 In cases of duplication of type VII thumbs, the choice of which thumb to keep is not directly related to the presence of triphalangism but, rather, to assessment of which thumb is more functional. The triphalangeal thumb may indeed be retained and reconstructed.36

R

E

3.

Kozin SH. Upper-extremity congenital anomalies. J Bone Joint Surg Am. 2003;85-A(8):1564-1576. Mattar Jr, R. Deformidades congênitas do membro superior. Acta Ortop Bras. 1995;3(2):77-92. James M, Bednar M. Deformities of the wrist and forearm. In: Green DP, Pederson MD, Hotchkiss RN, Wolf SW (Eds). Green’s operative hand surgery. 5ª ed. Philadelphia: Elsevier Churchill Livingstone; 2005. p. 1469-79. Manske PR, Goldfarb CA. Congenital failure of formation of the upper limb. In: Congenital hand differences. Hand Clin. 2009;25(2):157-70. Kozin SH. Congenital differences about the elbow. In: Congenital hand differences. Hand Clin. 2009;25(2):277-91. Tonkin MA. Failure of differentiation Part I: Syndactyly. In: Congenital hand differences. Hand Clin. 2009;25(2):171-93. Kay SP, McCombe D, Kozin SH. Deformities of the hand and the fingers. In: Green DP, Pederson MD, Hotchkiss RN, Wolf SW (Eds). Green’s operative hand surgery. 5ª ed. Philadelphia: Elsevier Churchill Livingstone; 2005. p. 1381-444. Shevtsov VI, Danilkin MY. Application of external fixation for management of hand syndactyly. Intern Orthop. 2008;32(4):535-9. Kozin SH. Deformities of the thumb. In: Green DP, Pederson MD, Hotchkiss RN, Wolf SW (Eds). Green’s operative hand surgery. 5ª ed. Philadelphia: Elsevier Churchill Livingstone; 2005. p. 1445-68. Katarincic JA. Congenital disorders: hypoplastic thumb. In Berger RA, Weiss APC (Eds). Hand surgery. Philadelphia: Lippincott Williams & Williams; 2004. p. 1445-51. Buck-Gramcko D. Pollicization of the index finger. J Bone Joint Surg. 1971;53-A(8):1605-16. Shibata M, Yoshizu T, Seki T, Goto M, Saito H, Tajima T. Reconstruction of a congenital hypoplastic thumb with use of a free vascularized metatarsophalangeal Joint. J Bone Joint Surg. 1998;80-A(10):1469-76. Kozin SH, Kay SP, Griffin JR, Ezaki M. Congenital contracture. In: Green DP, Pederson MD, Hotchkiss RN, Wolf SW (Eds). Green’s operative hand surgery. 5ª ed. Philadelphia: Elsevier Churchill Livingstone; 2005. p. 1507-26. Ulkür E, Acikel C, Karagoz H, Celikoz B. Treatment of severely contracted fingers with combined use of cross-finger and side finger transposition flaps. Plast Reconstr Surg. 2005;116(6):1709-14. Watt AJ, Chung KC. Duplication. In: Congenital hand differences. Hand Clin. 2009;25(2):215-27. Dautel G, Barbary S. Duplications du pouce. Chir main. 2008;27(Suppl 1):S82-99. Epub 2008 Aug 22.:82-99. Tonkin MA, Bulstrode NW. The Bilhaut-Cloquet procedure for wassel types III, IV, and VII thumb duplication. J Hand Surg Eur Vol. 2007;32E(6):684-93. Abid A, Knorr G, Darodes P, Cahuzac JP, Sales de Gauzy J. Type IV-D thumb duplication: a new reconstruction method. Orthop Traum: Surg Res. 2010;96(5):521-4. Baek GH, Gong HS, Chung MS, Oh JH, Lee YH, Lee SK. Modified Bilhaut-Cloquet procedure for wassel type-ii and iii polydactyly of the thumb. J Bone Joint Surg. 2007;89-A(3):534-41. Carty MT, Taghinia A, Uton J. Overgrowth conditions: a diagnostic and therapeutic conundrum. In: Congenital hand differences. Hand Clin. 2009;25(2):229-45. Nguyen ML, Jones NF. Undergrowth: brachydactyly. In: Congenital hand differences. Hand Clin. 2009;25(2):247-55. Samson P, Mevio G. Symbrachydactylie. Chir Main. 2008;27(Suppl 1):S229-45. Kawamura K, Chung KC. Constriction band syndrome. In: Congenital hand differences. Hand Clin. 2009;25(2):257-63.

10. 14

III.2 Ulnar Postaxial duplications are more common in blacks and generally consist of isolated congenital deformities.35 They can be divided into two groups: in the first, there is true duplication; and in the second, there is a rudimentary bud of a finger, which can even be tied off after birth, so that it undergoes necrosis and falls off, painlessly for the patient.3 In the great majority of cases, simple resection of the extranumerary finger is sufficient (Fig. 33).

15.

25. 26. 27.

28. 29.

30.

31.

Fig. 33 - Ulnar duplication.

III.4 Central duplications

32.

These are duplications of the second, third and fourth fingers and are very rare in comparison with radial and ulnar duplications.35 Their treatment varies greatly, from reconstructions to amputations of the radius. Individual assessment of each case is required.35

33.

III.5 Mirror hand

35.

This is perhaps the greatest example of duplication and is characterized by ulnar dimyelia, in which there is duplication of the ulna, absence of the radius and thumb and duplication of the ulnar fingers. It has variations that may reach duplication of the hand.35 It is extremely rare and its treatment consists of creating a hand of acceptable and functional esthetic appearance. Resection of the fingers and reconstruction of the thumb are the initial guidelines.35

34.

36. 37.

38.

39.

Conflicts of interest

40.

The authors declare that there was no conflict of interests in conducting this study.

41. 42. 43.

F

E

R

E

N

C

E

S


Rev Bras Ortop. 2013;48(1):11-16

www.rbo.org.br/

Review Article

Child abuse: review of the literature Bernardo Barcellos Terra,1* Eduardo Antônio de Figueiredo,2 Morena Pretti Espindula de Oliveira Lima Terra,3 Carlos Vicente Andreoli,4 Benno Ejnisman5 1Physician

and Titular Member of the Shoulder and Elbow Society, Shoulder and Elbow Group, Medical School, Santa Casa de Misericórdia de Vitória ES (EMESCAM), Vitória, ES, Brazil. 2Physician and Titular Member of the Brazilian Shoulder and Elbow Society, Shoulder and Elbow Group, Sports Traumatology Center, Universidade Federal de São Paulo, São Paulo, SP, Brazil. 3 Titular Member of the Brazilian Pediatric Society. 4 PhD in Orthopedics. Head of the Sports Traumatology Center, Universidade Federal de São Paulo, São Paulo, SP, Brazil. 5PhD in Orthopedics. Head of the Shoulder and Elbow Group, Sports Traumatology Center, Universidade Federal de São Paulo, São Paulo, SP, Brazil. Work performed in the Department of Orthopedics and Traumatology, Universidade Federal de São Paulo (DOT-Unifesp/EPM), São Paulo, SP, Brazil.

article info

a b s t r a c t

Article history:

Non-accidental injuries in children are an important cause of morbidity and mortality in

Received December 03 de 2011

this population. Fractures are the second most common clinical manifestation of child

Approved March 12 2012

abuse. The fracture of the femur is associated in more than 60% of child abuse in children younger than 3 years. The objective was to review the literature on child abuse in the major

Keywords:

databases and report a rare case of bilateral subtrochanteric femur fractures associated

Femoral fractures

with unilaterall humeral fracture in a 28-day newborn. The orthopedic surgeon is often

Humeral fracture

the first physician to evaluate these children, so a high degree of suspicion, and a physical

Child abuse

examination and a detailed clinical history is mandatory when evaluating a newborn with musculoskeletal injuries. © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

* Corresponding author at: Rua Borges Lagoa, 783, 5. andar, Vila Clementino, São Paulo, SP, CEP: 04038-032. Univerdade Federal de São Paulo. E-mail: bernardomed@hotmail.com ISSN/$–see front matte © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved. doi: 10.1016/j.rboe.2012.03.001


12

Rev Bras Ortop. 2013;48(1):11-16

Introduction

Case report

Greater raising of awareness of child abuse has contributed towards better understanding of this complex problem. It has been estimated that the annual incidence of abuse is between 15 and 40 cases per 1,000 children. Thus, approximately one million children become victims every year and more than 1,200 die as a result of abuse.1 Despite the severity of the problem, it is highly prevalent. In a systematic review on 32 studies, Kemp et al.2,3 concluded that abuse was more common among children under the age of three years, and that multiple fractures were also more common among children who suffered abuse. In Brazil, no data on the incidence of child abuse has been established. However, according to Ruaro et al.,4 recent studies show that among every 1,000 children, ten are victims of abuse and that of these, 2% to 3% die. Thus, the incidence of mortality is similar to that due to leukemia. The literature on abuse among newborns is sparse and there are few studies on children under the age of one year. Fractures are the second commonest presentation of this condition and orthopedists are often the first physician to evaluate these children.5 The objectives of this study were to conduct a review of the literature on this topic and report on a case, never previously reported in the literature, of a 27-day-old newborn who was a victim of abuse, with bilateral subtrochanteric femoral fractures and a unilateral humeral fracture, and to conduct a review of the literature on this topic.

A 27-day-old newborn was admitted to hospital accompanied by a young mother of 16 years of age, with a history of fever associated with productive coughing, and without any other disorders, according to the mother’s report. The case was initially attended by the pediatrics team, who diagnosed pneumonia with criteria of respiratory insufficiency. The newborn was hospitalized and received antibiotic therapy in association with noninvasive ventilatory support. In talking with the mother, it could be seen that she was giving a confused story, without causal links and inconsistent with the patient’s clinical condition. At this time during the consultation, the mother denied that the child had suffered any traumatic event, alleging that she had been close to the child at all times. The hospital’s social assistance team was put into action and, concomitantly, the guardianship council. On the fourth day of hospitalization, the orthopedic team was asked to provide an interdisciplinary consultation regarding the child’s case, because of bilateral edema on the thighs and because the child was crying a lot if its legs were manipulated. After detailed orthopedic examination, with imaging examinations, it was determined that the child presented bilateral subtrochanteric femoral fractures associated with a unilateral humeral fracture in the left arm (Figs. 1 and 2), without any neurological and vascular deficits in the limbs. There were no cutaneous and/or ocular lesions. On this day, the mother reported that the child had fallen to the floor in the bathroom and its legs had hit the edge of the bath, thus contradicting her story at the time of hospital admission. The father had not been located. A small plaster-cast splint was immediately applied to the left arm, extending from the axilla to the palm, and bilateral skin traction was applied to the legs, since the pediatric team asked for any procedure under anesthesia at that moment

Method An investigation was conducted in the main databases (Lilacs, Pubmed and Embase) using the following descriptors: nonaccidental injury, child abuse, child neglect, femoral fractures and humeral fractures. The inclusion criteria were that the article needed to have been published within the last 12 years, in the Portuguese, English or Spanish languages, or that they were regarded as classic studies on the topic. Systematic reviews with and without meta-analyses were also included. Studies that did not fulfill these criteria were automatically excluded.

Results The initial search found 70 studies, which were selected according to their title, in order to read the abstracts. From this reading, 23 studies that met the inclusion criteria were selected for reading in full and for discussion of the proposed objective.

Fig. 1 - Radiograph at the time of admission.


Rev Bras Ortop. 2013;48(1):11-16

Fig. 2 - Humeral fracture at the time of admission.

to be postponed until the child’s infectious and respiratory conditions had stabilized. Over this period, serum samples were collected for tests and metabolic and congenital diseases were investigated. All pathological conditions that form differential diagnoses with child abuse, such as osteogenesis imperfecta, were ruled out. On the seventh day of hospital stay, the child was subjected to bilateral plaster-cast immobilization from the chest to the malleolus, under sedation and analgesia, in the surgical center. The child was kept immobilized in the plaster cast for three weeks. The femoral and humeral immobilizations were removed when it was seen that there was no longer any crepitation at the foci of the fractures and a voluminous bone callus had formed bilaterally in the femurs and in the humerus (Figs. 3 and 4). At this time, the patient was no longer on antibiotic therapy and presented normal pulmonary functions. The child remained hospitalized for a further week, because of the social problems and then, after release, was taken to a shelter institution for children abandoned by their parents. The child was brought to the outpatient clinic in the second, fourth and sixth months (Figs. 5, 6, 7 and 8), for follow-up

Fig. 3 - Radiograph of the arm at the age of three weeks.

13

Fig. 4 - Radiograph of the femurs at the age of three weeks.

Fig. 5 - Radiograph at the age of two months.

Fig. 6 - Radiograph at the age of four months.


14

Rev Bras Ortop. 2013;48(1):11-16

consultations, through which it could be seen that the child was completely healthy, without anisomelia and/or associated deformities (Fig. 9). From control radiographs, satisfactory evolution of both the femoral and humeral bone consolidation was observed. Currently, the legal procedures for guardianship of the child are underway and a court hearing to decide on guardianship is awaited.

Discussion

Fig. 7 - Radiograph of the proximal femur at the age of six months.

Fig. 8 - Radiograph of the humerus at the age of six months.

Fig. 9 - Photograph at the age of six months, showing absence of anisomelia or significant deformities.

In 1946, Caffey6,7 described an association between subdural hematomas and fractures of long bones in infants. In a subsequent report, he confirmed that this process was due to physical abuse. In 1961, the American Academy of Pediatrics established the expression “battered child�, defined as a child who had suffered non-accidental injuries as a result of attitudes or omissions by its parents or other adults responsible for the child.8 Legally, children are considered to be individuals up to but not completing 12 years of age and adolescents are considered to be between 12 and 18 years of age.9 Child abuse can be defined as any action or omission by the adult caregiver or older adolescent that might result in damage to the child’s physical, emotional, intellectual, moral or social development of the child or adolescent. It can be classified into four types: physical, emotional (psychological), sexual and neglectful (negligence through omission or abandonment).10 In 2001, the Brazilian Ministry of Health determined that notification of any form of violence against children and adolescents would be mandatory for all healthcare professionals, and that failure to do so would render the healthcare professional liable to a fine of three to twenty reference salaries, with doubling of the fine in the event of recurrence.9 It should be emphasized that in these cases the defense of violation of the duty of confidentiality resulting from professional practice would be inapplicable, since this would be communication required by law.4 Fractures are the second largest form of presentation after skin lesions, and approximately one third of these presentations are seen by orthopedists at the initial consultation.11 The pattern of non-accidental injuries consists mainly of metaphyseal lesions, multiple fractures at different stages of consolidation, fractures of posterior ribs and fractures of long bones in children under the age of two years.12 Fractures of the long bones in very young children may represent one of the main pieces of evidence of physical abuse. 13 Femoral fractures are associated with abuse syndrome in 60% of the cases affected children under the age of three years11 and up to 85% among children under the age of one year. 14,15 Bergamaschi et al. 16 studied 35 cases of children under the age of three years who had suffered diaphyseal fractures of the femur. In 50% of the children reassessed, there were indications of physical abuse and negligence, such as triggering of femoral fractures. Anderson reported rates of suspected abuse of 79% and 83% among children under the ages of two years and 13 months, respectively, when femoral fractures were present. 17 In the present case, the infant was 27 days of age on admission to


Rev Bras Ortop. 2013;48(1):11-16

hospital, which led us to have a high degree of suspicion and diagnostic certainty of close to 100%. The signs suggestive of child abuse include the presence of multiple acute lesions (ecchymosis, hematoma, excoriation, bites, burns and edema of soft tissues), previous history of abuse, subdural hematoma, behavioral alterations, presence of multiple fractures (especially in the femur, tibia and humerus) and/or fractures at various stages of healing. However, fractures alone frequently occur. 18 In the case reported here, the newborn presented multiple fractures, but all of them were in the acute phase and there were no skin lesions or subdural hematomas. According to Pfeiffer, a clinical history or physical examination demonstrating signs of frequent lesions that are said to be accidental and an unexplainable delay between the “accident” and seeking medical care are general signs suggestive of physical abuse. 19 In our case, the mother only sought medical care because of the condition of respiratory insufficiency and fever that the child presented, which led us to believe that the trauma had occurred some days before the time of hospital admission. Dalton et al. 11 showed that orthopedists are the main investigators (in absolute numbers) of physical abuse among children with femoral fractures, followed by pediatricians. In the present case, the newborn was initially attended by a pediatrician because of the respiratory condition and secondarily by an orthopedist, who diagnosed the fractures that led to the suspicion of abuse. Pandya et al.5,10 studied 1,485 children who were victims of abuse or accidental trauma. They came to the conclusion that patients under the age of 18 months who presented fractures of the ribs, tibia, humerus or femur were more likely to have suffered abuse, while those over the age of 18 months with fractures of the long bones (femur and humerus) presented greater likelihood of having suffered accidental trauma. Lane et al.20 reported that black children had higher rates of non-accidental lesions than did white children of the same age group, but also reported that those children were more likely to the evaluated and registered due to suspicion of abuse, thus showing that ethnic difference exist in assessment and communication of pediatric fractures due to child abuse.20 In the case presented here, the mother and the newborn were not black. In a systematic review on 32 studies, Kemp et al. 21 concluded that fractures resulting from abuse were more common among children under the age of three years, and that multiple fractures were also more common in the group of children who had suffered abuse. They reported that fractured ribs were most likely to result from child abuse (0.71, with 95% CI of 0.42 to 0.91), and that the likelihood of humeral fractures resulting from abuse was 0.54 (0.20 to 0.88) and that of femoral fractures was 0.43 (0.32 to 0.54). They came to the conclusion that during evaluations on individual fractures, the site, the type of fracture and the child’s developmental stage could help in diagnosing abuse. Gholve et al. 22 reported on a rare case of femoral neck fracture in a three-year-old girl. They stated that these fractures account for 46% of the fractures of the proximal femur, but

15

that they account for only 1% of the fractures in children. Jones et al.12 reported on two cases of growth plate lesions in the proximal femur, in children who had been victims of abuse, and they drew attention to the need to think of the possibility that these lesions could be a consequence of abuse, despite the diagnostic difficulties, given that the center of ossification of the femoral head appears at the age of four months. Thus, this type of fracture in this age group should signal that this lesion is not accidental, as in our case. In diagnosing battered child syndrome, physicians need to be cautious and make differential diagnoses, particularly with the following pathological conditions: osteogenesis imperfecta, congenital insensitivity to pain, scurvy, congenital syphilis, Caffey’s disease, multiple fractures of severe rickets, hypophosphatemia, leukemia, metatarsal neuroblastoma, sequelae of osteomyelitis and septic arthritis.3,18,23-25 In the case presented here, all of the abovementioned possibilities were ruled out. Prasad et al.26 demonstrated that children who were victims of abuse presented worse cognitive function and deficits in motor skills, expression and language reception during their growth. Healthcare professionals therefore have a social commitment towards detecting and notifying suspected cases of child abuse, and should be prepared to identify it. The case presented here has only evolved for 18 months, but apparently does not present any developmental deficit. Puerperal psychosis is a state of delirium that is frequently hallucinatory, severe and acute. It appears between the second day after delivery and three months afterwards, at the frequency of one or two deliveries in every 1,000, and more often affects primiparous and single mothers. This psychosis does not present any relationship with the mother’s age or with her color.27 In the present case, the mother was within the period of occurrence of puerperal psychosis; the child was her first and the father was not present. The mother was sent to the hospital’s psychiatry department for investigation and possible treatment. It is known that approximately 50% of the children who are victims of physical abuse who return home are subsequently beaten again. Of these, 20% end up dying. Therefore, there needs to be a high degree of suspicion in attending children with fractures or skin lesions that are poorly explained by the trauma mechanism, like in the present case report, given than there is no pathognomonic fracture in child abuse cases.20 Physicians who suspect that a case is one of child abuse should immediately communicate this to one of the following three bodies: the guardianship council, a police station or the public attorney’s office. All of these institutions have the duty to safeguard and defend the rights of children and juveniles.

Conclusion Child abuse should always be borne in mind as a differential diagnosis among children who present fractures that are poorly explained by trauma mechanisms, particularly femoral fractures in children who cannot yet walk. The present article reported a rare presentation of this condition; around 30% of such cases are presented to orthopedists initially. These cases


16

Rev Bras Ortop. 2013;48(1):11-16

need to be managed by a multidisciplinary team because of the high risk of recurrence of possible death among these children.

Conflicts of interest The authors declare that there was no conflict of interests in conducting this study.

R

1.

E

F

E

R

E

N

C

E

S

Kocher MS, Kasser JR. Orthopaedic aspects of child abuse. J Am Acad Orthop Surg. 2000;8(1):10-20. 2. Kempe CH, Silverman FN, Steele BF, Droegemueller W, Silver HK. Landmark article July 7, 1962: The battered-child syndrome. By C. Henry Kempe, Frederic N. Silverman, Brandt F. Steele, William Droegemueller, and Henry K. Silver. JAMA. 1984;251(24):3288-94. 3. Kempe CH. Uncommon manifestations of the battered child syndrome. Am J Dis Child. 1975;129(11):1265. 4. Ruaro AF MT, Aguilar JAG, Hellu JJ, Custódio MD. Síndrome da criança espancada. Aspectos legais e cínicos – Relato de um caso. Rev Bras Ortop. 1997;32(10):835-8. 5. Pandya NK, Baldwin K, Kamath AF, Wenger DR, Hosalkar HS. Unexplained fractures: child abuse or bone disease? A systematic review. Clin Orthop Relat Res. 2011;469(3):805-12. 6. Caffey J. Multiple fractures in the long bones of infants suffering from chronic subdural hematoma. Am J Roentgenol Radium Ther. 1946;56(2):163-73. 7. Caffey J. The classic: multiple fractures in the long bones of infants suffering from chronic subdural hematoma. Clin Orthop Relat Res. 2011;469(3):755-8. 8. Schleberger R, Schulze H, Kemperdick F. [The battered child syndrome from the orthopedic point of view]. Z Orthop Ihre Grenzgeb. 1983;121(1):23-4. 9. Estatuto da Criança e do Adolescente. Ministério da Saúde. 3ª ed., 2008 (Série E). 10. Pandya NK, Baldwin K, Wolfgruber H, Christian CW, Drummond DS, Hosalkar HS. Child abuse and orthopaedic injury patterns: analysis at a level I pediatric trauma center. J Pediatr Orthop. 2009;29(6):618-25. 11. Dalton HJ, Slovis T, Helfer RE, Comstock J, Scheurer S, Riolo S. Undiagnosed abuse in children younger than 3 years with femoral fracture. Am J Dis Child. 1990;144(8):875-8.

12. Jones JC, Feldman KW, Bruckner JD. Child abuse in infants with proximal physeal injuries of the femur. Pediatr Emerg Care. 2004;20(3):157-61. 13. Rex C, Kay PR. Features of femoral fractures in nonaccidental injury. J Pediatr Orthop. 2000;20(3):411-3. 14. Schwend RM, Werth C, Johnston A. Femur shaft fractures in toddlers and young children: rarely from child abuse. J Pediatr Orthop. 2000;20(4):475-81. 15. Forlin E. Maus-tratos na infância e adolescência. Programa de Atualização em Traumatologia e Ortopedia (Proato) Porto Alegre: Artmed/Panamericana Editora; 2004. 16. Bergamaschi J, Alcântara T, Santili C, Braga S, Waisberg G, Akkar M. Femoral diaphyseal fractures: an assesmente in children younger than 3 years old. Rev Bras Ortop. 2006;15(2):72-5. 17. Anderson WA. The significance of femoral fractures in children. Ann Emerg Med. 1982;11(4):174-7. 18. Dos Santos LM, Stewart G, Meert K, Rosenberg NM. Soft tissue swelling with fractures: abuse versus nonintentional. Pediatr Emerg Care. 1995;11(4):215-6. 19. Pfeiffer L. Maus-tratos – Crianças sem vínculos, adolescentes sem rumo [monogragia]. Curitiba: PUC-PR; 2000. 20. Lane WG, Rubin DM, Monteith R, Christian CW. Racial differences in the evaluation of pediatric fractures for physical abuse. JAMA. 2002;288(13):1603-9. 21. Kemp AM, Dunstan F, Harrison S, Morris S, Mann M, Rolfe K, et al. Patterns of skeletal fractures in child abuse: systematic review. BMJ. 2008;337:a1518. Epub Oct 2008. 22. Gholve P, Arkader A, Gaugler R, Wells L. Femoral neck fracture as an atypical presentation of child abuse. Orthopedics. 2008;31(3):271. 23. Paterson CR, Burns J, McAllion SJ. Osteogenesis imperfecta: the distinction from child abuse and the recognition of a variant form. Am J Med Genet. 1993;45(2):187-92. 24. Paterson CR, McAllion SJ. Osteogenesis imperfecta in the differential diagnosis of child abuse. BMJ. 1989;299(6713):1451-4. 25. Kratz CP, Schweiger B, Kemperdick H, Gobel U. Childhood multifocal skeletal non-Hodgkin lymphoma is a differential diagnosis of battered child syndrome. Pediatr Hematol Oncol. 2003;20(8):575-7. 26. Prasad MR, Kramer LA, Ewing-Cobbs L. Cognitive and neuroimaging findings in physically abused preschoolers. Arch Dis Child. 2005;90(1):82-5. 27. Maldonado MT. Psicologia da gravidez. São Paulo: Saraiva; 2000.


Rev Bras Ortop. 2013;48(1):17-21

www.rbo.org.br/

Original Article

A simple idea for reducing the cost and weight of plaster-cast orthoses André Esmanhotto1*, Guilherme Esmanhotto2 1Resident

Physician in Orthopedics and Traumatology, Cajuru University Hospital, Curitiba, PR, Brazil. Medical Student, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brazil. Work performed in the Mechanical Engineering Laboratory, PUC-PR, Curitiba, PR, Brazil.

2Sixth-year

article info

a b s t r a c t

Article history:

Objective: To reduce the cost and weight of plaster molded orthosis (increasing patient

Received April 02 2012

comfort), keeping the same resistance. Methods: 22 plaster orthosis were analysed, 11

Approved June 06 2012

with conventional shape and 11 with pyramidal shape. It was compared, in theory (mathematcally) and practice, the change of weight (and consequently cost) and flexion

Keywords:

resistance between conventional shape and pyramidal shape. Results: Theorical analysis:

Orthotic devices

weight and cost decrease of 26.7%-38.9%, according to the layers disposition of the cast.

Cost

Laboratorial analysis: cast´s weight decrease of 34.5% (p = 0.000005) and resistance

Immobilization

increase of 26.7% (p = 0.03). Conclusion: plaster molded orthosis made in a pyramidal shape,

Cast, surgical

have a statistically significant decrease of weight (and consequently cost) and statistically

Material resistance

significant increase of resistance if compared with traditional shape.

Calcium sulfate

© 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

*Corresponding author at: Hospital Universitário Cajuru, Avenida São José, 300, Cristo Rei, Curitiba, PR, CEP: 80050-350. E-mail: a.esmanhotto@hotmail.com ISSN/$–see front matter © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved. doi: 10.1016/j.rboe.2012.06.001


18

Rev Bras Ortop. 2013;48(1):17-21

Introduction Plaster-cast orthoses do not need to have the same thickness throughout their length, given that the deforming forces to which they are subjected are not the same over the entire length. They are subjected to greater plaster fracture forces in the regions over joints, since the stress on the material is greater at the fulcrum of the potential movement. This can be seen to be true in practice, given that plaster-cast orthoses generally break over joint areas (wrist, elbow, ankle or knee). Thus, a plaster cast covering the lower leg and foot tends to break in the ankle region and a plaster cast covering the forearm and palm of the hand tends to break at the wrist, and so on. This experimental study was started with the idea of improving the way in which plaster-cast orthoses are constructed. No similar studies were found in the Bireme (Lilacs and SciELO), PubMed and RBO databases.

Objective

A

B

Figs. 1A and 1B - Progressive increase in the number of layers, going towards the fulcrum of movement, in the form of “steps”, to accompany the flexion deformation forces on the plaster-cast orthosis. The first step should have four layers. The side on which unrolling the bandage starts has one layer more, but the apex has the same number of layers on both sides.

To diminish the cost and weight of plaster casts, while maintaining similar resistance.

Practice – weighing and flexion testing

Methods Theoretical foundation The flexion strength of the material is the main factor causing plaster casts to break. The stress on the material becomes greater with increasing proximity to the fulcrum of movement and thus, the cast thickness also needs to increase. In this experiment, the arrangement of the layers of plaster was reorganized, with a greater number of layers in the region of the fulcrum of movement. This increase in the number of layers needs to be progressive, just as the tendency for plaster-cast orthoses to fracture progressively increases towards this location. With this in mind, we decided to progressively increase the number of layers, in the form of “steps”, towards the region of the fulcrum of movement (Figs. 1A and 1B). However, two layers in the most peripheral steps were seen to break very easily. We therefore decided to use four layers in the peripheral steps. Furthermore, during the construction of the plaster cast, the side on which we started to unroll the plaster-covered bandage had one additional layer. However, the apex of the pyramid ended up with the same numbers of layers on both sides of the fulcrum if we finished unrolling the bandage on the same side on which we started. After defining the format of the plaster-cast orthosis, it was then possible to mathematically predict the weight decrease (and therefore the cost) of plaster casts constructed in this manner, through calculating the area. This is presented in the Results and Discussion sections.

Twenty-six plaster-cast orthoses were then constructed: 13 with the conventional format and 13 with the pyramidal format. They were all 30 cm in length, had a central fulcrum and 12 layers (five steps on each side). Two boxes each containing 20 plaster-covered bandages (measuring 8 cm x 2 m), of a brand that is well-regarded in the market, were used (Figs. 2A and 2B).

A

B

Figs. 2A and 2B - The cast acquires a pyramidal format, with the apex of the pyramid in the region over the joint.


Rev Bras Ortop. 2013;48(1):17-21

Five days later (the time taken for the casts to dry out), they were taken to the Mechanical Engineering Laboratory of the Pontifícia Universidade Católica - Paraná, where they were weighted that then subjected to flexion testing at three points , with spans of 26 cm between the supports. An EMIC DL500 test machine was used, with a load cell of capacity 200 kg and advancing velocity of 50 mm/min. The machine was activated until reaching plaster cast deformation of 30 mm, in a manner very similar to a flexion test that was performed to test the quality of three different brands of plaster, which was published in Ata Ortopédica Brasileira in 20061 (Fig. 3). Two plaster-cast orthoses in each group were excluded, due to errors in cast construction or in the flexion test.

19

2) Calculation of the area of a pyramidal plaster-cast orthosis consisting of 12 layers and a fulcrum between the first and second quarters, in comparison with a conventional plaster cast (Fig. 5). 3) Calculation of the area of a pyramidal plaster-cast orthosis consisting of 22 layers and a central fulcrum, in comparison with a conventional plaster cast (Fig. 6).

Fig. 4 - Graphical representation of the area occupied by a pyramidal plaster-cast orthosis with 12 layers and a central fulcrum. While the conventional cast occupies an area of 12c, the pyramidal cast occupies an area of 8.4c.

Fig. 3 - Flexion test at three points.

Fig. 5 - Graphical representation and mathematical calculation of the area. While the conventional cast occupies an area of 12c, the pyramidal cast with 12 layers and a peripheral fulcrum occupies an area of 8.8c.

Results Theoretical foundation The areas of three types of pyramidal plaster-cast orthoses that differed in numbers of layers and position of the pyramidal apex were calculated. These were compared with the equivalent area of a plaster cast of conventional format: 1) Calculation of the area of a pyramidal plaster-cast orthosis consisting of 12 layers and a central fulcrum, in comparison with a conventional plaster cast (Fig. 4).

Fig. 6 - Cast with 22 layers and a central fulcrum. While the conventional cast occupies an area of 22c, the pyramidal cast occupies an area of 13.45c.


20

Rev Bras Ortop. 2013;48(1):17-21

Weighing and flexion testing The plaster-cast orthoses were then taken to the Mechanical Engineering Laboratory of “University X�, where the plastercast orthoses were weighed and the flexion test at three points was performed, as described above. The results were expressed as the force in newtons that would be needed to deform the cast by 3 cm, and as the respective weight of each cast, in grams, and these are presented in Table 1. The mean weight of the conventional plaster-cast orthosis was 152.70 g and that of the pyramidal cast was 100.06 g, i.e. 34.5% lower (p = 0.000005). The mean force in newtons that was needed to flex the plaster cast was 1.62 N in the conventional casts and 2.05 N in the pyramidal casts, i.e. 26.7% greater (p = 0.03). Table 1 - Results from weight analysis and flexion testing at three points. Conventional plaster-cast orthosis Weight(g)

Strength(N)

Pyramidal plaster-cast orthosisl Weight(g)

Strength(N)

1

148.6

1.49

93.4

1.17

2

150.2

1.82

93.8

2.16

3

154.1

1.47

95.1

2.21

4

156.3

1.11

99.8

2.19

5

152.1

1.35

96.7

1.83

6

144.7

1.32

94.2

1.6

7

156.1

1.55

108.3

2.58

8

151.8

2.53

96.5

2.39

9

154.5

1.6

108.8

2.53

10

157.4

1.18

105.8

1.96

11

154

2,39

108,3

1,96

Discussion Theoretical matters It is important to progressively increase the number of layers in the plaster-cast orthosis, so that the resistance increases harmoniously as the fulcrum is approached, and to avoid the presence of layers within the cast, which could cause discomfort for the patient. The number of steps should be calculated according to the length of the plaster cast and the number of layers. With five steps on each side, 12 layers are achieved; with six steps, 14 layers; with seven steps, 16 layers; and so on progressively, adding two layers for each step added, as shown in Table 2. For example, a plaster cast covering the forearm and palm of the hand could be constructed with four steps, which would result in 10 layers, a thickness that is generally enough for this type of plaster cast. A plaster cast extending from the inguinal region to the malleolus could be constructed using eight steps, thus resulting in 18 layers.

Table 2 - Number of steps and resultant plaster-cast orthosis thickness. Degrees

Layers

3

8

4

10

5

12

6

14

7

16

8

18

9

20

10

22

Through the mathematical calculation on the area occupied by the plaster-cast orthosis, it can be seen that the saving varies according to the position of the fulcrum in relation to the plaster cast, and is greatest when the fulcrum is central. It also varies according to the number of steps, and becomes slightly greater as the number of steps increases. It varies in another manner with the number of layers used, since the greater the number of layers is, the greater the saving is in relation to plaster casts constructed conventionally. Another point that needs to be made is that this format of plaster cast is only possible when there is only one fulcrum, such as in casts extending from the forearm to palm of the hand, from the upper arm to the forearm, from the inguinal region to the malleolar region and from the sural region to the foot. In practice, it is not technically possible to calculate two pyramidal apexes in plaster casts with two fulcrums, such as those extending from the upper arm to the palm and from the inguinal region to the foot.

Practical matters There is greater technical difficulty in constructing plastercast orthoses of pyramidal format: marking out the fulcrum, dividing the steps and submersing the cast in a basin of water without the steps sliding. Regarding this last point, surgical forceps or ordinary clothes pegs can be used, attached to the fulcrum so that the layers do not slide over each other. Thought should also be given to the applicability of this concept in small plaster casts versus large casts. In large casts, the advantage is greater, both economically and in terms of diminished weight. Regarding the results from diminishing the weight of plaster casts, it is more reasonable to analyze this based on the weight reduction seen in the practical test (weighing), and not in the theory (mathematical calculation on the area), considering that the plaster was totally dry at the time of weighing it, i.e. five days after constructing the cast. It should be emphasized that this decrease in weight is directly proportional to the cost reduction. Thus, a plaster-cast orthosis extending from the forearm to the palm of the hand, with 12 layers would give rise to a weight reduction from around 150 g to 105 g and a cost


21

Rev Bras Ortop. 2013;48(1):17-21

reduction from around R$ 2.00 to R$ 1.40 (considering that the saving is 30% and that two bandages measuring 8 cm x 2 m are used, each costing US$ 1.00). Even better, with a plaster cast of 22 layers extending from the inguinal region to the malleolar region, the weight would reduce from around 1500 g to 915 g and the cost from around R$ 20.00 to R$ 12.00 (considering that

Conclusion The plaster-cast orthosis with pyramidal shape presented a statistically significant decrease in weight, and consequently in cost, with increased resistance in comparison with plaster casts with the conventional format.

the saving is 38.9% and using four bandages measuring 20 cm x 4 m, each costing R$ 5.00). Regarding the resistance results, although the objective of this study was to achieve similar resistance, the resistance to flexion achieved with the pyramidal format was even greater.

Conflicts of interest The authors declare that there was no conflict of interests in conducting this study.

At this initial stage, we have not been able to explain this. The importance of this study when scaled up to apply these concepts to the magnitude of hospital expenditure on plastercovered bandages should be emphasized. Moreover, finally and just as importantly, diminishing the weight of the plaster cast is beneficial for the patient.

R

E

F

E

R

E

N

C

E

S

1.

Vieira GC, Fonseca MCR, Shimano AC, Mazzer M, Barbieri CH, Elui VCM. Avaliação das propriedades mecânicas de atadura gessada de três diferentes fabricantes, usada para confecção de órtese. Acta Ortop Bras. 2006;14(3):122-5.


Rev Bras Ortop. 2013;48(1):22-28

www.rbo.org.br/

Original Article

Clinical evaluation of patients with osteomyelitis after open fractures treated at the Hospital de Urgências de Goiânia, Goiás Pablo Erick Alves Villa,1 Thiago Roberto Nunes,1 Fernando Prudente Gonçalves,1 Jefferson Soares Martins,2 Guilhermo Sócrates Pinheiro de Lemos,3 Frederico Barra de Moraes4* 1Resident

Physician in Orthopedics and Traumatology, Emergency Hospital of Goiânia, State Health Department, Goiânia, GO, Brazil. and Head of Residence in Orthopedics and Traumatology, Emergency Hospital of Goiânia, State Health Department, Goiânia, GO, Brazil. 3Infectologist and Head of the Hospital Infection Control Committee, Emergency Hospital of Goiânia, State Health Department, Goiânia, GO, Brazil. 4Orthopedist; MSc in Health Sciences from UFG/UnB; Doctoral Student and Preceptor of Residence in Orthopedics and Traumatology, Emergency Hospital of Goiânia, State Health Department, Goiânia, GO, Brazil. Work performed in the Emergency Hospital of Goiânia, State Health Department, Goiânia, GO, Brazil. 2Orthopedist

A RT I C L E I N F O

a b s t r a c t

Article history:

Objective: To evaluate clinically patients with chronic osteomyelitis after open fractures, treated

Received December 26 2011

in the Hospital of urgencies in Goiania. Methods: A cross-sectional study, with data collection

Approved March 8 2012

through questionnaire, from a review of medical records. We collected data on the type of trauma and the clinical characteristics of the patient. The hour of attendance and the injuries

Keywords:

on the patients were collected, and then classified according to Gustilo and Anderson (1976).

Osteomyelitis

Samples of the lesion during the surgical procedure were collected for culture of pathogenic

Fractures, Open

microorganisms. The analyzes were performed using STATA/SE version 8.0. Descriptive analysis

Orthopedics

was performed (absolute and relative frequencies) and to verify existence of association between variables was performed using thur-square or Fisher’s Exact Test. This study was approved by the Research Ethics Committee of the Hospital and Emergency in Goiania. Results: There was predominance of male adult, presenting open fractures with increased involvement of the leg bones or in two or more bones (polytrauma). The majority of patients presented with a lesion type III (high-energy trauma). There was loss of excessive time since the time of the accident until the initial surgical care. We detected the presence of gram-positive cultures of material obtained after the diagnosis of osteomyelitis. Conclusions: The control of factors such as antibiotics, exposure time, bacterial resistance to the antimicrobial used, extensive tissue damage and location of the fracture are extremely important to the predictive effect of infection in open fractures. © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

*Corresponding author at: Rua Teresina, 30/1202, Edificio Spazio Gran Ville, Goiania, GO. CEP: 74.815-715. E-mail: frederico_barra@yahoo.com.br ISSN/$–see front matter © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved. doi: 10.1016/j.rboe.2012.03.002


Rev Bras Ortop. 2013;48(1):22-28

Introduction Increasing popularization of means of transport, with increasing numbers of vehicles of ever greater power, has led to higher incidence of exposed fractures. These are severe injuries with a high socioeconomic impact.1 These fractures involve high energy in their mechanism of occurrence, which causes greater devitalization of the bone tissue and its protective sheath. This favors infection by germs, as well as making their consolidation more difficult. In this type of fracture, there is communication between the bone or hematoma and the external environment, which is generally contaminated by bacteria.2 Evolution to complete consolidation, without infection of the exposed fracture depends on various factors, such as the degree of contamination of the fracture, the individual’s nutritional state, the time that elapsed between the traumatic event and correct attendance, and especially, the soft-tissue sheath around the fracture. These soft tissues are the conduit through which an adequate blood supply arrives at the bone, containing repair and defense cells.3 Adequate classification and documentation at the time of the trauma are essential steps in establishing approaches that will be decisive in achieving good evolution of the condition. Another important aspect of this classification is that it enables comparison between different samples.2 The treatment begins with correct pre-hospital attendance, followed by use of antibiotics as early as possible (which should be started at the hospital’s emergency reception), surgical debridement, exhaustive surgical-mechanical cleaning, abundant irrigation, initial stabilization, definitive stabilization and skin coverage.4 Thus, although exposed fractures are very common within orthopedic settings, understanding them goes beyond the bone-trauma binomial to involve intrinsic and extrinsic characteristics that have a high relationship with the time of the traumatic event and the initial attendance after the event. Therefore, this study had the aim of clinically evaluating patients with chronic osteomyelitis after exposed fractures who were treated at the Emergency Hospital of Goiania, Goiás.

Methods This was a cross-sectional study conducted among 95 patients with chronic osteomyelitis after exposed fractures who were hospitalized for surgical treatment at the Emergency Hospital of Goiania. These patients were attended between January 2006 and January 2010, among a total of 9,500 patients. In the present study, the need for hospitalization for surgical treatment of exposed fractures that evolved with osteomyelitis was evaluated as the inclusion criterion. Other cases that were treated in this hospital’s emergency clinic by means of regional anesthetic blockade, mainly those with wounds to the extremities of the hands and feet, were excluded.

23

The sample was formed by convenience, and the data were gathered in 2011, through filling out a questionnaire, from reviewing the medical records held by the Hospital Infection Control Committee (HICC) of this hospital. Personal data on the patients were gathered, along with data relating to the type of trauma and the patients’ clinical characteristics (preoperative bath, time elapsed between the trauma and the surgery, data on the operation, presence or absence of microorganisms and antibiotic therapy used). The time of attendance and lesions encountered in the patient were described, and the case was then classified in accordance with Gustilo and Anderson,5 namely: Type I: wound of 1 cm (or less) on the skin, with minimal detachment of periosteum or soft tissues. Minimal comminution. Inside out. Type II: wound of between 1 cm and 10 cm on the skin with moderate detachment of periosteum or soft tissues and comminution of the fracture. Type III: wound larger than 10 cm, with high energy associated with it. Extensive injury to soft tissues and periosteal detachment and/or crushing. IIIA: significant contamination. Adequate coverage of soft tissues, despite presence of lacerations and flaps. IIIB: significant contamination. Extensive injuries with major periosteal detachment, but with external loss of soft tissues that does not allow skin coverage, generally requiring reconstruction procedures later on. IIIC: fracture with arterial injuries requiring repair. In relation to the diagnostic criteria for infection, samples were collected from the lesion during the surgical procedure, for culturing microorganisms in the patients with diagnoses of osteomyelitis. These were obtained by means swab smears, along with collection of a small part of the affected bone, which was deposited in a test tube with 1 mL of 0.9% physiological serum. The sample was sent to the laboratory for analysis. To isolate the microorganisms, BHI (brain-heart infusion) broth and plates containing blood agar and MacConkey agar were used. The material collected using swabs and the sediment from the aspirated material were sown in these culturing media, which were centrifuged at 3,500 rpm for 15 minutes. The plates and the tubes with sown material were incubated at 36 degrees Celsius for up to 48 hours, and the growth in the BHI broth was subcultured on blood agar and MacConkey agar plates. The microorganisms isolated were identified using conventional methods.6 A database was constructed using the Excel software. The data analyses were processed using the STATA/SE software, version 8.0. Descriptive analysis was performed (absolute and relative frequencies) in order to identify the behavior of the variables studied. To investigate whether there were any associations between the variables, Pearson’s chi-square or Fisher’s exact test was used. In all the tests, a significance level of 5% was used (alpha = 0.05), and tests were taken to be statistically significant when p < 0.05. This study was approved by the Research Ethics Committee of the Emergency Hospital of Goiania (protocol no. 025/11).


24

Rev Bras Ortop. 2013;48(1):22-28

Results

40.0 30.0

32.0

26.7

Ninety-five patients with exposed fractures who evolved with

26.7

25.0

chronic osteomyelitis were studied. Their mean age was 33 years (range: 15 to 76).

Male

The majority of the patients were male: 75 (78.95%). The age group most affected was between 30 and 59 years

us

er

(44.21%), followed by the age group from 20 to 29 years (37.89%). Regarding origin, 52 patients (54.74%) were from cities in the state of Goiás other than the state capital (Table 1). After

Female

5.3 5.0 4.0

um

H

rm

a re Fi

2.7

ur m Fe

er w Lo

g le H

t

oo

/f

d an

2.7

i av

Cl

Part of body affected

s

ne

s

vi

el

/p

e cl

o Tw

or

e or

bo

m

stratification by sex, the age group from 30 to 59 was also the one most affected, both in females and in males (Fig. 1). Among the men, the body segments that most frequently presented osteomyelitis after exposed fractures were the lower leg bones (32%) and the femur (26.7%). Among the women, there

Fig. 2 - Part of the body affected according to the sex of the patients with chronic osteomyelitis after exposed fractures who were treated at the Emergency Hospital of Goiânia, Goiás, in 2011 (n = 95).

was a higher percentage (40%) of osteomyelitis after exposed fractures in two or more bones (femur and/or tibia), while in 30% of the patients, only the femur was affected (Figure 2).

Table 1 - Characterization according to sex, age and origin among patients with chronic osteomyelitis after exposed fractures who were treated at the Emergency Hospital of Goiânia, Goiás, in 2011 (n = 95). Variables

N

%

Sex Male

75

78.95

Female

20

21.05

< 20

11

11.58

20 to 29

36

37.89

30 to 59

42

44.21

≥ 60

6

6.32

Goiânia

43

45.26

Other cities

52

54.74

Age group (years)

Origin*

Male Female

< 20

20 to 29

30 to 59

≥ 60

Age Group

Fig. 1 - Age distribution according to the sex of the patients with chronic osteomyelitis after exposed fractures who were treated at the Emergency Hospital of Goiânia, Goiás, in 2011 (n = 95).

From analysis on some of the patients’ characteristics according to the type of exposed fracture among the patients with a diagnosis of osteomyelitis, it was observed that individuals in the age group from 30 to 59 years presented greater frequency of type III lesions (51.9%). It was also seen that in patients with type III exposed fractures, the part of the body most affected was the lower leg (36.5%), followed by fractures in two or more bones (28.5%) and then the femur (26.9%). In patients with type II exposed fractures, the femur was more affected (33.3%), while in patients with type I exposed fractures, there were more injuries to the lower leg (50%). There was a statistically significant difference between the exposed fractures of the femur and the other injuries (p = 0.036) (Table 2). Regarding preoperative baths, it was observed that 90% of the patients with osteomyelitis after type III exposed fractures did not have one. Regarding the time spent waiting for surgery, it was seen that 30.4% of the patients with type III lesions waited for the procedure for 12 to 24 hours (Table 3). In the 43 cases in which a sample was collected for culturing during the surgical procedure, growth of Staphylococcus aureus and two or more other etiological agents (multiple microbial agents) was observed in fractures of types I, II and III. However, attention was drawn to the presence of multiresistant Staphylococcus aureus in type III exposed fractures. Regarding the length of antibiotic use from the time of diagnosis to the clinical cure from osteomyelitis, it was observed that the patients with type III lesions presented greater lengths of antibiotic use (more than six months) (Table 4). Among the antibiotics used at the time of the patient’s admission, it was observed that, independent of the type of exposed fracture, the majority of the patients used firstgeneration cephalosporin, followed by a double regimen (firstgeneration cephalosporin + gentamicin). Among the patients with type III exposed fractures, 50% used first-generation cephalosporin alone. Regarding the definitive antibiotic therapy, it was seen that antibiotics were most used on the fractures alone. However, it was observed that for 10.4% of the patients with type III fractures, it was necessary to use antibiotic regimens, consisting of vancomycin and ciprofloxacin in association (Table 4).


25

Rev Bras Ortop. 2013;48(1):22-28

Table 2 - Age group and part of body affected among patients with chronic osteomyelitis, according to type of exposed fracture treated at the Emergency Hospital of Goiânia, Goiás, in 2011 (n = 67). Type of Fracture Variables

I

II

N(%)

III

N(%)

p value*

N(%)

Age group (years) <20

2 (33,3)

1 (11,1)

5 (9,6)

20 a 29

2 (33,3)

5 (55,6)

17 (32,7)

30 a 59

2 (33,3)

2 (22,2)

27 (51,9)

0 (0,0)

1 (11,1)

3 (5,8)

Humerus

0 (0,0)

2 (22,2)

2 (3,8)

Forearm

1 (16,7)

1 (11,1)

1 (1,9)

Femur

1 (16,7)

3 (33,3)

14 (26,9)

Lower leg

3 (50,0)

0 (0,0)

19 (36,5)

Hand/foot

0 (0,0)

0 (0,0)

1 (1,9)

Clavicle/pelvis

0 (0,0)

1 (11,1)

0 (0,0)

Two or more bones

1 (16,7)

2 (22,2)

15 (28,5)

≥ 60

0,304

Part of body affected

0,036

* Fisher’s exact test..

Table 3 - Preoperative bath and time spent waiting for surgery among patients with chronic osteomyelitis, according to type of exposed fracture treated at the Emergency Hospital of Goiânia, Goiás, in 2011 (n = 67). Type of fracture Variables

I

II

III

N(%)

N(%)

N(%)

p value*

Preoperative batha Yes

1 (16,7)

2 (25,0)

4 (10,0)

No

5 (83,3)

6 (75,0)

36 (90,0)

Up to 6 hours

1 (20,0)

2 (25,0)

11 (23,9)

6 to 12 hours

1 (20,0)

3 (37,5)

19 (41,3)

12 to 24 hours

1 (20,0)

2 (25,0)

14 (30,4)

> 1 day

2 (40,0)

1 (12,5)

2 (4,3)

0,494

Waiting time for surgeryb

a

Data missing in relation to 13 participants; b Data missing in relation to 8 participants; * Pearson’s chi-square test.

0,252


26

Rev Bras Ortop. 2013;48(1):22-28

Table 4 - Etiological agent, length of use of antibiotic and drug treatment among patients with chronic osteomyelitis, according to type of exposed fracture treated at the Emergency Hospital of Goiânia, Goiás, in 2011 (n = 67). Type of fracture Variables

I

II

N(%)

N(%)

III

p value

N(%)

Etiological agenta Staphylococcus aureus

2 (50,0)

1 (20,0)

3 (8,8)

Staphylococcus aureus (multiresistant)

0 (0,0)

1 (20,0)

21 (61,8)

Enterobacter sp.

0 (0,0)

1 (20,0)

1 (2,9)

Klebsiella sp

1 (25,0)

0 (0,0)

2 (5,9)

Acinectobacter sp.

0 (0,0)

0 (0,0)

1 (2,9)

Pseudomonas sp.

0 (0,0)

0 (0,0)

2 (5,9)

Multiple microbial agents

1 (25,0)

2 (40,0)

4 (11,8)

Ciprofloxacin + clindamycin

1 (33,3)

0 (0,0)

1 (4,2)

0,042

Initial antibiotic useb

First-generation cephalosporin

1 (33,3)

5 (71,4)

12 (50,0)

Clindamycin + gentamicin

0 (0,0)

1 (14,3)

3 (12,5)

First-generation cephalosporin + gentamicin

1 (33,3)

1 (14,3)

3 (12,5)

Others (antibiotic regimens)

0 (0,0)

0 (0,0)

5 (20,8)

1 (0,0)

2 (28,6)

19 (39,6)

Ciprofloxacin

0 (0,0)

2 (28,6)

8 (16,7)

Teicoplanin

1 (25,0)

0 (0,0)

5 (10,4)

Definitive antibiotic

0,474

usec

Vancomycin

Vancomycin + teicoplanin

0 (0,0)

0 (0,0)

6 (12,5)

Ciprofloxacin + rifampicin

1 (25,0)

1 (14,3)

0 (0,0)

Amikacin

0 (0,0)

0 (0,0)

2 (4,2)

Imipenem

1 (25,0)

1 (14,3)

1 (2,1)

Ciprofloxacin + clindamycin

0 (0,0)

0 (0,0)

3 (4,2)

Others (antibiotic regimens)

1 (25,0)

1 (14,3)

5 (10,4)

0,053

Length of antibiotic use (months)d <1

2 (50,0)

0 (0,0)

11 (34,4)

1 a 2,9

2 (50,0)

1 (33,3)

4 (12,5)

3 a 5,9

0 (0,0)

1 (33,3)

6 (18,7)

≥6

0 (0,0)

1 (33,3)

11 (34,4)

0,192

a

Data missing in relation to 24 participants; b Data missing in relation to 33 participants; c Data missing in relation to 8 participants; d Data missing in relation to 28 participants; * Fisher’s exact test.

Discussion The majority of the patients were male (78.95%), and this result was similar to what was reported by Muller et al.,7 who found that 86.3% of their sample were male. Regarding age, the mean age in the present study was 33 years (range: 15 to 76), while Moore et al.8 found a mean age of 31 years. In a study conducted by Arruda et al.,9 the majority of the patients were

also male, in the proportions of 6.6 men for each woman, and most of them were in an economically active age group (from 21 to 30). The type of trauma causing the fracture is often related to the severity of the injury caused, and often to the severity of the patient’s condition. In the present study, 26.7% of the men and 40% of the women presented injuries to twp or more bones (multiple trauma). Moore et al.,8 found that 67.3% presented


Rev Bras Ortop. 2013;48(1):22-28

multiple trauma, while Gustilo10 found this in 30%, probably because they studied samples at hospitals located close to very busy highways with greater incidence of high-speed accidents. In recent studies, high-speed accidents have been correlated as the biggest causes of severe exposed fractures. These more recent citations denote changes in the types of accident that generate fractures, in line with changes to modern life and advances in technology. This often limits the comparisons that might be made between older and more recent studies, taking into consideration the progressive changes in aggressiveness of the trauma and consequently in the severity of the fractures and the patientsâ&#x20AC;&#x2122; conditions.11,12 In relation to the classification of the exposed fractures, 51.9% of the patients aged 30 to 59 years in the present study had type III lesions, and this was similar to what was observed by Moore et al.,8 who found that 50.9% had type III lesions, with a likely influence on the incidence of infection. On the other hand, in a study conducted by Gustilo,10 only 25.5% of the patients presented type III exposed fractures. This discrepancy occurred through the effect of variables such as the location of the healthcare clinics, degree of urbanization, risk factors and time of conducting the studies. In the present study, the most severe fractures (type III) occurred mainly in the lower-leg bones, probably through the commonest trauma mechanism, i.e. falling from a motorbike, thus corroborating the findings of Arruda et al.9 It is known and also formed part of our findings that fractures of the lower leg and femur that occur as type III injuries, are in themselves a major set of predictive factors for infection over the course of the treatment. These fractures require specific care from the time that the patient arrives at the hospital onwards, so that all approaches are designed such that complications, including infections, are prevented. The exposure duration, i.e. the length of time between the occurrence of the accident and the start of surgical treatment, may be a factor predictive of infection. In the present study, for 30.4% of the patients with type III lesions, this exposure duration was between 12 and 24 hours. In a study by Muller et al., 7 the mean exposure duration was 5 hours and 39 minutes, and an average of 3 hours and 11 minute of precious times were probably consumed by bureaucracy and other measures, such as waiting for X-rays and preparation of the surgical theater, among other matters, which could have been dealt with more speedily and have led to possible diminution of the incidence of infections. Gustillo13 found that the mean time was 4 hours and 24 minutes between the occurrence of the trauma and the start of the surgical treatment, and that 21.15% were attended after waiting for more than six hours. In our sample, 41.38% of the patients with type III exposed fractures began their treatment between 6 and 12 hours after the accident. The reasons for greater occurrence of osteomyelitis in exposed fractures, particularly in those of type III, are likely to be connected with the time wasted between the time of the accident and the start of the initial operation (as mentioned above), or to the other particular characteristics of the wounds (high degree of contamination, accident in a rural area, first attendance, etc.) and the removal and transportation conditions.7

27

In the present study, growth by some pathogenic microorganisms in the different types of exposed fracture was observed. There was growth by Staphylococcus aureus and two or more etiological agents (multiple microbial agents) in exposed fractures of types I, II and III, and predominance of multiresistant Staphylococcus aureus (commonly present in the skin) in type III exposed fractures. These results did not differ much from those presented by Gustilo,10 who found that Staphylococcus aureus (Gram-positive) predominated, with 60% Gram-positive agents overall. Clifford14 stated that 60% to 70% of the entry cultures were positive, with predominance of Staphylococcus aureus and Enterococcus sp. (Gram-negative). Moore et al.8 reported having found that 71% of the germs were Gram-positive. In the present study, it was seen that, independent of the type of exposed fracture, the majority of the patients used first-generation cephalosporin, followed by a double regimen (first-generation cephalosporin + gentamicin), as the initial antibiotic therapy. A study conducted by Muller et al.7 showed that cefalotin was preferred in 59.8% of the cases, and was well indicated for coverage of Gram-positive germs; the combination of crystalline penicillin + amikacin, which was used on 16.2% of the occasions, may cover Gram-positive and Gramnegative germs, but with the disadvantage that crystalline penicillin is generally not a good choice for Staphylococcus. Another, more expensive option would be to use an association of clindamycin + amikacin, with the advantage of coverage against Gram-positive and anaerobic bacteria s (clindamycin) and Gram-negative bacteria (amikacin). Another option would be to choose a single antibiotic in cases of contaminations in urban areas, with preference for cefalotin or cefazolin, while saving the cited associations for cases of contamination in rural areas, in which Gram-negative and anaerobic germs occur more frequently. In the present study, regarding the definitive antibiotic therapy, it was observed that the antibiotics most used in cases of type II fractures were vancomycin alone, followed by ciprofloxacin alone. However, it was seen that 10.4% of the patients with type III fractures needed to use antibiotic regimens consisting of vancomycin and ciprofloxacin in association.

Conclusions According to the results from this study, the patients were predominantly male adults presenting exposed fractures. The leg bones were more affected, or two or more bones (multiple trauma). The majority of the patients presented type III injuries (high-energy trauma). It was noted that excessive time elapsed between the accident and the start of emergency surgical treatment, and that Gram-positive germs predominated in the cultures from the material obtained. It is known that post-traumatic osteomyelitis presents elevated morbidity, which often leads such patients to permanently incapacitating lesions, from a physical and/or psychological point of view, and/or may lead to burdensome and prolonged treatments, with results that sometimes are discouraging. Therefore, control over factors such as


28

Rev Bras Ortop. 2013;48(1):22-28

antibiotic therapy, exposure duration, bacterial resistance to the antimicrobial agent used, major tissue damage and facture location are extremely important for annulling the predicted effect of infections in exposed fractures.

4.

Enninghorst N, McDougall D, Hunt JJ, Balogh ZJ. Open tibia fractures: timely debridement leaves injury severity as the only determinant of poor outcome. J Trauma. 2011;70(2):352-7.

5.

Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J. Bone

Acknowledgements

Joint Surg Am. 1976;58(4):453-8.

To the Emergency Hospital of Goiania for making it viable to conduct the study; and to the patients who were the study subjects.

6.

Koneman EW, Allen SD, Janda WM, Shreckenberg PC, Winn Jr.

7.

Muller SS, Sadenberg T, Pereira GJC, Sadatsune T, Kimura

WC. Diagnostico microbiologico. Rio de Janeiro: MEDSI; 2001. EE, Novelli Filho JLV. Estudo epidemiologico, clinico e microbiologico prospectivo de pacientes portadores de

Conflicts of interest

fraturas expostas atendidos em hospital universitario. Acta

The authors declare that there was no conflict of interests in conducting this study.

Ortop Bras. 2003;11(3):158-69. 8

Moore TJ, Mauney C, Barron J. The use of quantitative bacterial counts in opens fractures. Clin Orthop. 1989;(248):227-30.

R

E

1.

Imran Y, Vishvanathan T. Does the right leg require extra protection? Five-year review of type 3 open fractures of the tibia. Singapore Med J. 2004;45(6):280-2. Paccola CAJ. Fraturas expostas. Rev Bras Ortop. 2001;36(8):283-91. Kinik H, Karaduman M. Cierny-Mader Type III chronic osteomyelitis: the results of patients treated with debridement, irrigation, vancomycin beads and systemic antibiotics. Int Orthop. 2008;32(4):551-8.

2. 3.

F

E

R

E

N

C

E

S

9.

Arruda LRP, Silva MAC, Malerba FG, Fernandes MC, Turibio FM, Matsumoto MH. Fraturas expostas: estudo epidemiologico e prospectivo. Acta Ortop Bras. 2009;17(6):326-30.

10. Gustilo RB. Management of open fractures in orthopaedic infection: diagnosis and treatment. Philadelphia: Saunders; 1989. p. 87-117. 11. Merritt K. Factors increasing the risk of infection in patients with open fractures. J Trauma. 1988;28(6):823-7.


Rev Bras Ortop. 2013;48(1):29-35

www.rbo.org.br/

Original Article

Treatment of complex acute proximal humerus fractures using hemiarthroplasty Bruno Lobo Brandão,1* Marcus Vinicius Galvão Amaral,2 Marcio Cohen,2 Rickson Guedes de Moraes Correia,2 Carlos Henrique Gazineu Abdenur,3 Martim Teixeira Monteiro,4 Geraldo Rocha Motta Filho5 1MSc in Medicine from the Department of Orthopedics and Traumatology, Universidade Federal do Rio de Janeiro (UFRJ). Attending Physician, Shoulder and Elbow Surgery Center, National Institute for Traumatology and Orthopedics (INTO), Rio de Janeiro, RJ, Brazil. 2Attending Physician, Shoulder and Elbow Surgery Center, National Institute for Traumatology and Orthopedics (INTO), Rio de Janeiro, RJ, Brazil. 3Trainee (2010-2011), Shoulder and Elbow Surgery Center, National Institute for Traumatology and Orthopedics (INTO), Rio de Janeiro, RJ, Brazil. 4Head of the Shoulder and Elbow Surgery Center, National Institute for Traumatology and Orthopedics (INTO), Rio de Janeiro, RJ, Brazil. 5MSc in Medicine from the Department of Orthopedics and Traumatology, Universidade Federal de São Paulo (UNIFESP/EPM), São Paulo, SP. Attending Physician, Shoulder and Elbow Surgery Center, National Institute for Traumatology and Orthopedics (INTO), Rio de Janeiro, RJ, Brazil. Work performed at the National Institute for Traumatology and Orthopedics (INTO), Rio de Janeiro, RJ, Brazil.

article info

a b s t r a c t

Article history:

Objective: Evaluate the clinical and radiological results of hemiarthroplasty for treatment

Received April 22 2012

of complex proximal humerus fractures. Methods: Sixty-seven patients were included, with

Approved July 23 2012

follow-up of 12 to 62 months. Mean age was 65 years (44 to 88), and 47 patients were female (70%). Clinical assessment was performed using the University of California Los Angeles

Keywords:

score (UCLA) and measurement of range of motion (ROM) according to the American Academy

Shoulder

of Orthopaedic Surgeons criteria. A standardized radiological evaluation was conducted,

Arthroplasty

with special attention to healing and position of tuberosities. Patients were divided into

Humeral fractures

two groups: A (anatomical healing of tuberosities) and B (without anatomical healing of tuberosities). Statistical analyses were performed using the t test. Level of significance was set at p < 0.05. Results: Considering the entire sample, the mean UCLA score was 26 points, with 8 points for pain and 64 patients subjectively satisfied (96%). The mean values for active ROM were 104º of forward flexion and 36° of external rotation. In group A, with 33 patients, we found a mean of 122º forward flexion and 29.5 points on UCLA. In group B the mean forward flexion were 87º and 22.7 points for UCLA. Comparing these parameters in the two groups, we found statistically significant differences for both forward flexion (p < 0.0001) and UCLA. (p < 0.0001). Conclusion: We conclude that hemiarthroplasty for treatment of complex proximal humerus fractures has a low incidence of complications and a high subjective satisfaction rate, with favorable results related to pain. A good functional result is less predictable and depends on anatomical reestablishment of proximal humerus anatomy, particularly healing of the greater tuberosity. © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

*Corresponding author at: Rua Maria Angélica 146/802, Lagoa, Rio de Janeiro, Brazil. CEP: 22470-202. E-mail: brunolobobrandao@yahoo.com.br. ISSN/$–see front matter © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

doi: 10.1016/j.rboe.2013.04.003


30

Rev Bras Ortop. 2013;48(1):29-35

Introduction Fractures of the proximal extremity of the humerus in adults account for approximately 5% of all fractures. 1 They are more frequent in elderly people, resulting from low-energy trauma, and are especially common in postmenopausal

The aim of the present study was the evaluate the clinical and radiographic results from patients who underwent hemiarthroplasty of the shoulder for treatment of complex acute fractures of the proximal extremity of the humerus, with operations performed at the Shoulder and Elbow Surgery Center of the National Institute for Traumatology and Orthopedics (INTO).

women because of osteoporosis, in proportions of 2:1.1,2 The main mechanism consists of falling from a standing position, onto the extended hand. These fractures may also occur in a younger population when associated with high-energy trauma, such as in a car accident.2 Most of these fractures are classified as minimally displaced or in two parts, and nonoperative treatment or osteosynthesis (when there is significant deviation of the fragments) presents a very favorable prognosis.3 On the other hand, these satisfactory results are not so easily obtained in cases of injuries of greater severity, i.e. complex fractures of the proximal extremity of the humerus. This group can include fractures in three or four parts, fractures affecting the joint surface of the humeral head (of â&#x20AC;&#x153;head splitâ&#x20AC;? type) and fractures with dislocation.3 In these cases, osteosynthesis is not always possible, due to bone fragmentation and osteopenia, as well as the risk of avascular necrosis caused by impairment of the vascular supply to the humeral head.3,4 Depending on the severity of the lesion and the patientâ&#x20AC;&#x2122;s age, arthroplastic treatment may be the best indication. Use of hemiarthroplasty for treating complex fractures of the proximal humerus was popularized in the 1970s by Neer, who reported excellent results in around 90% of the patients.5 Since then, this technique has been widely used around the world, but most of the results published by Neer could not be reproduced in subsequent studies.6-10 In a general manner, the reports in the literature show that the patients are satisfied, with a pain-free shoulder, but that they do not present adequate functional recovery, especially because of their limited active elevation6-23 (Figure 1).

Compito et al.12

Goldman et al.20

Zyto et al.21

Boileau et al.7

Prakash et al.22

Mighell et al.16

Checchia et al.1

~ Antuna et al.8

Fig.1 - Variation in active anterior flexion according to different authors.

Material and methods This study consisted of a retrospective analysis that used the accumulated data in our register of shoulder arthroplasty cases. We analyzed all the patients who consecutively underwent hemiarthroplasty at the Shoulder and Elbow Surgery Center of the National Institute for Traumatology and Orthopedics (INTO) for treatment of acute fractures of the proximal extremity of the humerus, between July 2004 and March 2009. All the fractures were evaluated in accordance with the classification of Neer4 and only complex fractures were found, i.e. fractures in three or four parts, dislocated fractures or fractures that affected the joint surface (head split type). The exclusion criteria were that the fractures should not have evolved for more than six weeks and the patients should not present previous disease in the shoulder operated or outpatient follow-up of less than 12 months. Cases were also excluded if the data available regarding the clinical or radiographic evaluations of the postoperative follow-up were insufficient. Out of the 97 patients, 67 fulfilled the inclusion criteria. The mean length of follow-up was 38 months, with a range from 12 to 62 months. The mean age was 65 years (range: 44 to 88), and 47 patients were female (70%). The right side was affected in 39 patients (58%) and the left side in 28 (42%). In accordance with Neer, 46 fractures were classified as being in four parts, 18 as being in three parts, 19 as associated with anterior dislocation and three as associated with posterior dislocation. The commonest trauma mechanism consisted of falling from a standing position, which affected 59 patients (88%). The remainder of the fractures were related to higherenergy trauma, such as car accidents and convulsive crises. The mean interval between the trauma and the surgical treatment was 18 days, with a range from three to 40 days. All the patients were operated in the deckchair position, through a deltopectoral access, without deinsertion of the deltoid. Tenodesis of the tendon of the long head of the biceps was performed routinely at the humeral insertion of the pectoralis major muscle. The Global FX prosthesis (DePuy, Warsaw, Indiana, USA) was used in all the cases, with use of bone cement on the diaphysis and placement of a cemented plastic restrictor in the humeral canal. To position the humeral component, we used an instrument called a positioning jig, which maintained provisional fixation of the test prosthesis on the diaphysis and thus enabled greater precision and security with regard to assessing the height and retroversion established by the surgeon (Fig. 2). This guide also allowed reproduction of these parameters during cementation of the definitive prosthesis.


Rev Bras Ortop. 2013;48(1):29-35

31

After cementation, the tubercles were fixed using No. 5 non-absorbable polyester thread, by means of orifices in the diaphysis, with fixation to the fins of the prosthesis, fixation between the tubercles and circumferential fixation around the neck of the prosthesis and circumferential fixation around the neck of the prosthesis (“around the world”). In this manner, approximately six threads were used for fixation in the horizontal and vertical planes (Fig. 3). In all cases, an autologous bone graft from the humeral head was used, between the tubercles and the diaphysis. Perioperative control radiographs were performed routinely, with the aim of confirming the positioning of the prosthesis and the tubercles.

For this reason, monitoring the protocol that was used for the rehabilitation was more difficult. The patients underwent postoperative clinical-functional and radiographic evaluations at the Shoulder and Elbow Center of INTO. The active and passive ranges of motion were measured using a goniometer, in accordance with the criteria of the American Academy of Orthopaedic Surgeons (AAOS).24 The functional assessment was performed by means of the UCLA score.25 Patients with scores greater than 33 points were considered to present excellent results; scores between 28 and 33 were good; scores between 21 and 27 were fair; and scores of 20 or below were poor. The radiographic evaluation was performed by means of the true AP view, scapular lateral view and axillary lateral view. The positioning and consolidation of the tubercles were observed, along with the positioning of the prosthesis and the quality of cementation. To evaluate the position of the greater tubercle on the AP radiograph, we used the method described by Boileau et al.7 A line was traced out perpendicularly to the longitudinal axis of the humeral shaft, tangential to the apex of the cephalic component of the prosthesis, and another line tangential to the uppermost region of the greater tubercle. The distance between these two parallel lines was then measured (Fig. 4). Taking into consideration the parameters determined in previous anatomical studies,26 we defined that the greater tubercle was correctly positioned when its apex was located between 5 and 10 mm below the apex of the prosthesis. In accordance with this radiographic evaluation, the patients were divided into two groups. Group A included the patients who presented anatomical consolidation of the tubercles and group B included the patients who could not be included in group A, i.e. those with pseudarthrosis or skewed consolidation, or cases in which reabsorption of the tubercles occurred.

Fig. 3 - Sequence showing the binding of the tubercles, associated with bone grafting.

Fig. 4 - Technique for measuring the height of the greater tubercle.

After the operation, the patients were kept using slings for six weeks. After the first week, pendular exercises and passive anterior flexion exercises were started. Active exercises were started after the sixth week, while strengthening exercises were started after 12 weeks. It has to be noted that, unfortunately, because many patients lived far from our hospital and had transportation difficulties, they were unable to do the physiotherapy treatment at our hospital.

The data on the patients who fulfilled the inclusion criteria were entered into an electronic spreadsheet (Microsoft Office Excel 2007) and were subjected to statistical analysis by means of the Stata v10.0 software. After our samples had been shown to present normal characteristics (skewness and kurtosis tests), these data were analyzed by means of Student’s t test (comparison between means) and Pearson’s test (correlation), and findings with p < 0.05 were considered to be significant.

Fig. 2 - Positioning of the test prosthesis using the positioning jig.


32

Rev Bras Ortop. 2013;48(1):29-35

Results In evaluating the active range of motion, we found the following means: anterior flexion of 104º (range: 20º to 160º); external rotation of 36º (range: -5º to 60º); and internal rotation to L1 (range: gluteus to T7). In evaluating the UCLA score, we found a mean of 26 points, with six excellent results, 24 good, 26 fair and 11 poor (Fig. 5). In analyzing the score parameters separately, we found a mean of 8.25 for pain; 6 for function; 3 for elevation and 3.75 for elevation strength. We found a high rate of subjective satisfaction, such that 64 patients (96%) were satisfied with the procedure. Excellent

Fig. 6 - Comparison of UCLA score between groups A and B.

Active Anterior Flexion

Fig. 5 - Results according to UCLA score.

From the radiographic evaluation, we identified 33 patients who presented tubercles consolidated in the anatomical position, and these were included in group A. Thus, the other 34 patients were included in group B. In group A, we found a mean UCLA score of 29.5 and active anterior flexion of 122º. In group B, we found a mean UCLA score of 22.7 points and mean active anterior flexion of 87º (Table 1). Using Student’s t test, we comparatively analyzed the mean active elevation and UCLA scores between groups A and B (Figs. 6 and 7). We found statistically significant differences both for anterior flexion (p < 0.0001) and for UCLA score (p < 0.0001). The male individuals had functional results that were better than those of the females. This result was statistically significant according to Student’s t test. The mean active

Fig. 7 - Comparison of active anterior flexion between groups A and B.

elevation was 119° for the men and 98° for the women (p = 0.0268). The UCLA score was 29.7 for the men and 24.5 for the women (p = 0.0005). Through Pearson’s test, we did not find any statistically significant correlation between the patients’ ages and functional results.

Table 1 - UCLA and active anterior flexion results, stratified into groups A and B. #

UCLA

Active anterior flexion

Total

67

26,0

104o

A

33

29,5

122o

B

34

22,7

87o

The complications encountered included two cases of periprosthetic fracture, which were treated by means of osteosynthesis, using a plate and screws. One of these was a case of perioperative fracture and the other was a diaphyseal fracture that occurred 11 months after hemiarthroplasty. Two patients presented neuropraxia as a surgical complication: one in the median nerve and the other in the axillary nerve. Both of these presented complete resolution. There was only one case of infection, which was treated by means of surgical debridement and venous antibiotic therapy, with complete resolution.


Rev Bras Ortop. 2013;48(1):29-35

Discussion Since the 1970s, when hemiarthroplasty was popularized by Neer, it has been widely used around the world for treatment of complex fractures of the proximal extremity of the humerus,5-23 particularly among elderly patients. However, differing from the excellent results reported by Neer, most of the studies in the literature have reported disappointing results. The results generally show high incidence of subjective satisfaction and absence of complaints of pain, but with disappointing functional results, particularly because of limitations of active elevation.6-23 In a systematic review published in 2008, Kontakis et al.9 included 16 studies with 810 patients who underwent hemiarthroplasty for treatment of acute fractures of the proximal extremity of the humerus. The means for anterior flexion and the Constant functional score were 105° and 56 points, respectively, from which it can be concluded that most of the patients presented functional limitation in the final evaluation. In our study, we found results that were similar to those described in the literature, and we also identified high incidence of satisfaction among the patients, particularly in relation to pain, even when they did not present satisfactory active mobility. In our series, it was possible to demonstrate that consolidation of the tubercles in the anatomical position had a large influence on the functional result. Several studies in the literature have emphasized the importance of reestablishing the anatomy of the tubercles, in order to obtain satisfactory functional results.7-21 Bono et al.27 demonstrated that changes to the height of the greater tubercle that were more than 5 mm modified the lever arm of the shoulder operated, thereby diminishing the deltoid abduction strength. In 2008, Antuña et al. 8 stated that the commonest complication following hemiarthroplasty is displacement of the greater tubercle, and correlated this with worse functional scores. Compito et al.12 also identified displacement of the greater tubercle as the main factor responsible for poor results in this type of procedure. These authors found that 43% of the results were excellent, such that all the tuberosities became consolidated with displacements of less than 5 mm. Mighell et al.16 reported that their worst results were related to excessive lowering of the greater tubercle. Because of the importance of anatomical consolidation of the tubercles, we believe that the surgical technique should include special attention to measures that might influence this objective. Since these cases present fragile and osteopenic bone tissue, handling the tubercles should be done carefully, thus avoiding rough or excessive manipulation that might increase their fragmentation. Binding the tubercles is extremely important and should be done meticulously, using strong thread that can function in both the horizontal and the vertical plane. Extra attention is needed so that the greater tubercle is not lowered too much during the binding process. This is a frequent mistake, with undesirable consequences. Boileau et al.7 reported that the worst results from this surgery were related to the presence of an unfortunate trio of factors: high prosthesis, excessive retroversion and lowered greater tubercle.

33

Although tubercle fixation is traditionally done by means of binding with non-absorbable threads, other methods have been proposed. Krause et al. 19 compared traditional binding of the tubercles with fixation by means of steel wires, thereby obtaining superior results in this group. Another measure than may be very useful is to perform perioperative control radiographs, which enable timely correction of possible imperfections regarding the tubercle height, given that the presence of the rotator cuff makes it difficult to directly view the relationship between the tubercle and the prosthesis. Lastly, the importance of bone grafts for facilitating consolidation between the diaphysis and the tubercles should be borne in mind. Another of the great challenges in conducting this surgery is to correctly establish the height of the prosthesis, which is one of the crucial points regarding reestablishment of the anatomical functioning of the shoulder. Loss of the anatomical reference points of the upper region of the humerus makes it much more difficult to identify the precise position of the implant. Furthermore, there is difficulty in maintaining the positioning of the prosthesis during its testing, and even more so in reproducing this position at the time of cementation. In the system that we use, there is a very useful guide that enables provisional fixation of the prosthesis so that its height and version can be tested, and enables reproduction of this position at the time of placing the definitive implant. Other ways of correctly establishing the height of the prosthesis have been described, such as measurement of the distance between the cephalic component and the upper edge of the pectoralis major.28 The most serious mistake is excessive stretching of the humerus, since this causes upward migration of the prosthesis and elevated pressure on the rotator cuff, and creates difficulty regarding consolidation. Shortening of the humerus tends to be better tolerated, even though this may alter the tension and power of the deltoid if it is greater than 20 mm.29 In addition to the heights of the humeral shaft and tubercles, precise determination of the retroversion of the prosthesis is extremely important for correct functioning of the system. Retroversion is important not only for prosthesis stability but also in influencing the position of the tubercles and, fundamentally, for their consolidation. Boileau et al. 7 found an association between retroversion greater than 40º and posterior migration of the greater tubercle, with consequent compromising of the functional result. Excessive retroversion leads to elevated tension upon fixation of the greater tubercle, which is subject to traction caused by the tendons of the infraspinatus and teres minor, especially when the arm is placed in internal rotation. For this reason, Boileau et al.7 avoided placing a sling in internal rotation during the period of tubercle consolidation and preferred immobilization in neutral rotation. Another factor of great importance is the postoperative management. In a general manner, there is a current tendency to implement rehabilitation more slowly and to keep the patient using a sling for a longer time, 7,30 so that consolidation of the greater tubercle is achieved, which is defined as fundamental for the quality of the functional result. In addition, the patient’s motivation during the postoperative period, along with a good team of physiotherapists, plays an important role in the final result.


34

Rev Bras Ortop. 2013;48(1):29-35

As also described by Boileau et al., 7 we found that the functional result among female patients was inferior to the result among males, probably due to osteopenia and the

R

E

1.

Lind T, Kroner K, Jensen J. The epidemiology of fractures of proximal humerus. Arch Orthop Trauma Surg. 1989;108(5):285-7. Habermeyer P, Schweiberer L. Fractures of the proximal humerus. Orthopade. 1989;18(3):200-7. Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004;13(4):427-33. Neer CS 2nd. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am. 1970;52(6):1077-89. Neer CS 2nd. Displaced proximal humeral fractures. II. Treatment of three part and four-part displacement. J Bone Joint Surg Am. 1970;52(6):1090-103. Movin T, Sjödén GO, Ahrengart L. Poor function after shoulder replacement in fracture patients. A retrospective evaluation of 29 patients followed for 2-12 years. Acta Orthop Scand. 1998;69(4):392-6. Boileau P, Krishnan SG, Tinsi L, Walch G, Coste S, Molé D. Tuberosity malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus. J Shoulder Elbow Surg. 2002;11(5):401-12. Antuña SA, Sperling JW, Cofield RH. Shoulder hemiarthroplasty for acute fractures of the proximal humerus: a minimum fiveyear follow-up. J Shoulder Elbow Surg. 2008;17(2):202-9. Kontakis G, Koutras C, Tosounidis T, Giannoudis P. Early management of proximal humeral fractures with hemiarthroplasty: a systematic review. J Bone Joint Surg Br. 2008;90(11):1407-13. Kralinger F, Schwaiger R, Wambacher M, Farrell E, Menth-Chiari W, Lajtai G, et al. Outcome after primary hemiarthroplasty for fracture of the head of the humerus. A retrospective multicentre study of 167 patients. J Bone Joint Surg Br. 2004;86(2):217-9. Hawkins RJ, Switlyk P. Acute prosthetic replacement for severe fractures of the proximal humerus. Clin Orthop Relat Res. 1993;(289):156-60. Compito CA, Self EB, Bigliani LU. Arthroplasty and acute shoulder trauma. Reasons for success and failure. Clin Orthop Relat Res. 1994;(307):27-36. Checchia SL, Doneux PS, Miyazaki AN, Fregoneze M, Silva LA, Faria FN, et al. Tratamento das fraturas do terço proximal do úmero com a prótese parcial Eccentra. Rev Bras Ortop. 2005;40(3):130-40. Veado MAC, Machado LP, Soares CGN, Souza SVS. Avaliação da função do ombro pós-hemiartroplastias em fraturas em três e quatro partes do úmero proximal. Rev Bras Ortop. 2001;36(5):710-7. Santos PS, Bonamin C, Sobania LC, Otsuka N, Sobania RL, Lucio SRE, et al. Hemiartroplastias em fraturas e fraturasluxações do ombro. Rev Bras Ortop. 1994;29:651-5. Mighell MA, Kolm GP, Collinge CA, Frankle MA. Outcomes of hemiarthoplasty for fractures of the proximal humerus. J Shoulder Elbow Surg. 2003;12(6):569-77. Tanner MW, Cofield RH. Prosthetic arthroplasty for fractures and fracture-dislocations of the proximal humerus. Clin Orthop Relat Res. 1983;(179):116-28. Robinson CM, Page RS, Hill RM, Sanders DL, Court-Brown CM, Wakefield AE. Primary arthroplasty for treatment of proximal humeral fractures. J Bone Joint Surg Am. 2003;85(A):1215-23.

fragility of the tubercles. Moreover, may studies have suggested that there is a progressive worsening of the results with

2.

advancing age.7,10,18,22 However, in our case series, we were unable to demonstrate any statistically significant correlation

3.

between age and the functional results. Because of the many technical details described previously,

4.

it can be expected that the team’s experience and training will have a large influence on the results from a surgical procedure of such complexity. This can be proven from a multicenter

5.

study that was conducted by Kralinger et al.10 Even when the surgical technique is implemented adequately, the result is not

6.

as predictable as the functional result.7 Thus, we believe that this surgical procedure should continue to be refined through technical innovations and technologies, so that satisfactory functional results can be achieved more frequently (Fig. 8).

7.

8.

9.

10.

11.

Fig. 8 - Example of patient with good radiological and clinical results.

12.

13.

Conclusion Hemiarthroplasty for treatment of complex fractures of the proximal extremity of the humerus among elderly people presented a low complication rate and high subjective satisfaction rate, with absence of pain. Satisfactory functional results are not readily predictable and fundamentally depend on precise reestablishment of the anatomy of the proximal extremity of the humerus, especially anatomical consolidation of the greater tubercle.

14.

15.

16.

17.

Conflicts of interest The authors declare that there was no conflict of interests in conducting this study.

18.

F

E

R

E

N

C

E

S


Rev Bras Ortop. 2013;48(1):29-35

19. Krause FG, Huebschle L, Hertel R. Reattachment of the tuberosities with cable wires and bone graft in hemiarthroplasties done for proximal humeral fractures with cable wire and bone graft: 58 patients with a 22-month minimum follow-up. J Orthop Trauma. 2007;21(10):682-6. 20. Goldman RT, Koval KJ, Cuomo F, Gallagher MA, Zuckerman JD. Functional outcome after humeral head replacement for acute three- and four-part proximal humeral fractures. J Shoulder Elbow Surg. 1995;4(2):81-6. 21. Zyto K, Wallace WA, Frostick SP, Preston BJ. Outcome after hemiarthroplasty for three- and four-part fractures of the proximal humerus. J Shoulder Elbow Surg. 1998;7(2):85-9. 22. Prakash U, McGurty DW, Dent JA. Hemiarthroplasty for severe fractures of the proximal humerus. J Shoulder Elbow Surg. 2002;11(5):428-30. 23. Grönhagen CM, Abbaszadegan H, Révay SA, Adolphson PY. Medium-term results after primary hemiarthroplasty for comminute proximal humerus fractures: a study of 46 patients followed up for an average of 4.4 years. J Shoulder Elbow Surg. 2007;16(6):766-73. 24. AAOS – American Academy of Orthopedic Surgeons: Joint Motion: Method of Measuring and Recording. Chicago: American Academy of Orthopedics; 1965.

35

25. Ellman H, Hanker G, Bayer M. Repair of the rotator cuff: endresult study of factors influencing reconstruction. J Bone Joint Surg Am. 1986;68(8):1136-44. 26. Iannotti JP, Gabriel JP, Schneck SL, Evans BG, Misra S. The normal glenohumeral relationships. An anatomical study of one hundred and forty shoulders. J Bone Joint Surg Am. 1992;74(4):491-500. 27. Bono CM, Renard R, Levine RG, Levy AS. Effect of displacement of fractures of the greater tuberosity on the mechanics of the shoulder. J Bone Joint Surg Br. 2001;83(7):1056-62. 28. Murachovsky J, Ikemoto RY, Nascimento LG, Fujiki EN, Milani C, Warner JJ. Pectoralis major tendon reference (PMT): a new method for accurate restoration of humeral length with hemiarthroplasty for fracture. J Shoulder Elbow Surg. 2006;15(6):675-8. 29. Neer CS, Kirby RM. Revision of humeral head and total shoulder arthroplasties. Clin Orthop. 1982;(172):189-95. 30. Amirfeyz R, Sarangi P. Shoulder hemiarthroplasty for fracture with a conservative rehabilitation regime. Arch Orthop Trauma Surg. 2008;128(9):985-8.


Rev Bras Ortop. 2013;48(1):36-40

www.rbo.org.br/

Original Article

A new method for classifying distal radius fracture: the IDEAL classification João Carlos Belloti,1* João Baptista Gomes dos Santos,1 Jaime Picaro Erazo ,2 Leonardo Jorge Iani,2 Marcel Jun Sugawara Tamaoki,3 Vinícius Ynoe de Moraes,4 Flávio Faloppa5 1PhD. Adjunct

Professor in the Discipline of Hand and Arm Surgery, Universidade Federal de São Paulo Medical School (UNIFESP-EPM), São Paulo, SP, Brazil. 2Student, UNIFESP-EPM, São Paulo, SP, Brazil. 3Doctoral Student, Discipline of Hand and Arm Surgery, UNIFESP-EPM, São Paulo, SP, Brazil. 4R5 in the Discipline of Hand and Arm Surgery, UNIFESP-EPM, São Paulo, SP, Brazil. 5Titular Professor and Full Professor, Discipline of Hand and Arm Surgery, UNIFESP-EPM, São Paulo, SP, Brazil. Work performed in the Discipline of Hand and Arm Surgery, Universidade Federal de São Paulo Medical School, São Paulo, SP, Brazil.

article info

a b s t r a c t

Article history:

Objectives: To describe the new IDEAL method from classifying distal radius fractures.

Received March 30 2012

Methods: IDEAL classification system is based on the most important literature evidences

Approved June 6 2012

about clinical and radiographic characteristics that influence in the treatment and prognosis for patients that suffered from a distal radius fractures. In this method, we

Keywords:

classify the fracture in patients first consultation, in which we collect demographical

Distal Radius Fractures

(age and trauma energy) and radiographic characteristics ( fracture deviation, articular

Classification Systems

fracture, and associated lesions). For each feature a score is attributed for grouping

Description

purposes. Group I – Stable fractures, good prognosis; Group II – potentially unstable fractures, commonly treated by surgical methods. Prognosis depends on surgeons’ success after method choice. Group III – complex and instable fractures, poor outcome is expected. Conclusion: IDEAL classification staging rationale was presented, which is based on the best available evidence. The evidence of its scientific plausibility will be settled with the assessment of the classification reliability and its capacity to aid in therapeutical decisions and as a tool to predict prognosis. Further studies are under development to support these properties. © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

*Corresponding author at: Discipline of Hand and Arm Surgery, Universidade Federal de São Paulo Medical School, Rua Borges Lagoa, 778, São Paulo, SP, Brazil. E-mail: jcbelloti@gmail.com ISSN/$–see front matter © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved. doi: 10.1016/j.rboe.2012.06.002


Rev Bras Ortop. 2013;48(1):36-40

Introduction Distal radius fractures have an incidence of approximately 1:10,000 individuals and represent 16% of skeletal fractures and 74% of forearm fractures. 1 The most common trauma mechanism is a fall onto the hand, in hyperextension. The characteristics of the fracture (location of the fracture line, presence or absence of joint impairment, degree of comminution and degree of injury to soft tissues) are directly related to the trauma energy, angle of the wrist at the moment of the trauma and bone quality. These are essential for the fracture classification and treatment plan. Classification systems have been developed with the aim of allowing surgeons to classify fractures into different and clinically useful groupings. During the past century, Colles, Smith, Barton, Pouteau, Goyrand and others started to establish descriptions for fracture morphology with the aim of treating these fractures,2-3 even using cadavers.4-7 With the advent of radiology, descriptions of greater accuracy became possible, including both the degree of displacement and the presence of joint lesions. NissenLie 8 (1939) and Gartland and Werley 9 (1951) based their classifications on the presence or absence of intra-articular involvement, metaphyseal comminution and/or singular deformity. Fragment displacement was not evaluated in any of the systems. In 1959, Lindstrom expanded these criteria into six groups and described the displacement of the fragments in greater detail, along with joint impairment.10 In 1967, Frykman established a classification system that took into account the impairment of the radiocarpal and/or distal radioulnar joints, along with the presence or absence of fracturing of the ulnar styloid.11 Nonetheless, this classification system was limited, since it did not take into account factors such as the magnitude of the fragment displacement, presence or absence of comminution and instability factors. In 1984, Melone 12 published a classification system for intra-articular fractures of the distal radius based on four parts: radial styloid, radial diaphysis, medial dorsal fragment and medial palmar fragment of the radius. This classification is used to define surgical fixation methods, but its accuracy and reproducibility for identifying the four fragments on conventional radiographs have still not been validated in clinical studies, and discrepancies remain.13 The AO classification was created in 1986 and revised in 2007.14,15 It takes into consideration the severity of the bone lesion and serves as the basis for the treatment and for evaluating the results. There are three basic types: extraarticular, partial articular and complete articular. The three groups are organized in increasing order of severity, in relation to morphological complexity, treatment difficulty and prognosis. This is one of the most complete classification systems, but its intra and inter-observed reproducibility has been a problem when groups and subgroups are being evaluated.15,16 The universal classification, described by Rayhack and Cooney in 1990,17 is characterized by its simplicity. It classifies fractures as intra or extra-articular, with presence

37

or absence of displacement, in relation to stability and the possibility of reduction, thus functioning as a guide for approaches towards treatment. The classification proposed by Fernandez and Jupiter is based on the trauma mechanism.18,19 This classification was produced to be practical, predict stability, identify equivalent lesions in children and provide general recommendations for treatments. An efficient classification system should be valid, re l i abl e a n d rep ro d u c i bl e. F u r t h e r m o re, i t s h o u l d standardize reliable communication language, provide guidelines for treatment, indicate the possibilities of complications and fracture stability and allow a reasonable prognosis to be obtained in relation to each fracture. This system should also provide a mechanism that makes it possible to assess and compare the results obtained with treatments implemented on similar fractures in different centers that have been reported at different times in the literature.20 Currently, there is no classification system in the literature with adequate reproducibility that would be able to provide elements for the treatment and prognosis. The aim of the present study was to describe a new classification method.

Material and methods This new classification system for fractures at the distal extremity of the radius (IDEAL) is based on the main evidence in the literature regarding the clinical and radiographic factors that might influence the treatment and prognosis of these fractures. In this method, we classify the fracture at the time of the patient’s first consultation, by means of ascertaining two epidemiolog ical parameters (the patient’s ag e and the energy of the trauma that caused the fracture) and three radiographic parameters, assessed from the initial radiograph on the fracture, in PA and lateral views (displacement of the fragments, joint incongruence and associated lesions), which are the elements that are considered fundamental for grading fracture types. For each of the five fundamental elements, a score of zero or one is given, according to the absence or presence of these factors. Thus, factors can have gradings from zero to five points and are grouped into three possible types, with increasing severity and complexity: Grade I – zero to one point; Grade II – two to three points; Grade III – more than three points. The criteria used for ascertaining the presence (one point) or absence (zero) of the elemental classification factors are defined in the following manner. For all patients aged over 60 years, one point will be credited and zero will be given to those aged up to 60 years. Fractures with displacement, defined as those that need to be reduced (shortening of the radius greater than 3 mm and/or loss of volar inclination greater than 10 degrees and/or loss of radial inclination greater than five degrees), will be credited with one point, while zero will


38

Rev Bras Ortop. 2013;48(1):36-40

be given to fractures without displacement. Fractures will be considered to be of high-energy type and will receive one point if they were caused by a fall from a height, traffic accidents, crushing or firearm projectiles. All fractures resulting from falling from a standing position will be considered to be of lowenergy type and will receive zero. When a joint is involved with incongruence greater than or equal to 2 mm, one point will be credited, while fractures that do not involve a joint or have incongruence of less than 2 mm will receive zero. Fractures with the following associated lesions will receive one point: radiocarpal dislocation or subluxation, fractures of the carpal bones, carpal instability, ulnar fractures, neurovascular lesions and exposed fractures. After verification of whether the elemental factors of the score classification (zero to five) are present or not, the fractures will be classified into three types (Figs. 1 and 2):

Characteristic

0 point

Fig. 3 - Fracture grouped into type I of the IDEAL method: age 52 years (0 point); displacement (absent: 0 point); energy – fall from standing position (low energy: 0 point); joint involvement (absent: 0 point); associated lesions (absent: 0 point).

1 point

Age

< 60 years

> 60 years

Deviation

No

Trauma energy1

Low

High

Articular fracture

No

Fracture or gap > 2 mm

Associated lesions2

Absent

Present

Deviation needing reduction

1. Low: falling from a standing position/ High - Others. 2. Exposed fracture/ Fractures of the carpal bones, carpal instability/ Ulnar fractures

Fig. 1 - IDEAL classification: epidemiological and radiographic criteria.

Classification

Score

0-1 point 2-3 points

4-5 points

Description

Treatment

Stable

Conservative

Type II – scores of 2 to 3 points (Fig. 4). These correspond to fractures with displacement and are potentially unstable. They are fractures with a high potential for loss of reduction and skewed consolidation, caused by poor bone quality (in elderly patients), high-energy trauma (in younger patients) or joint incongruence or associated lesions (both young and old patients). They generally require surgical stabilization using percutaneous pinning methods, external fixation or internal osteosynthesis with plates. These are fractures that present greater potential for complications inherent to the surgical procedure, and their prognosis is dependent on the success of the surgical technique used.

Prognostic Good

External fixation, percuPotentially taneous pinning, internal Intermidiate Potentially unstable unstable osteosynthesis with plates Complex

Associatedmethods, bone grafts

Bad

Fig. 2 - IDEAL classification: stratification according to scoring.

Type I – scores of 0 to 1 point (Fig. 3). These are stable fractures. They correspond to fractures in elderly people without displacement, or to displaced fractures in younger patients caused by low-energy trauma, without joint incongruence or associated lesions. They are usually treated conservatively, with plaster casts, and have a good prognosis.

Fig. 4 - Fracture grouped into type II of the IDEAL method: age 39 years (0 point); displacement (present: 1 point); energy – fall from height (high energy: 1 point); joint involvement (1 point); associated lesions (0 point).


39

Rev Bras Ortop. 2013;48(1):36-40

Type III – scores of 4 to 5 points (Fig. 5). These correspond to complex displaced fractures. They are generally caused by high-energy trauma, and they present joint incongruence and associated lesions. Because of their patent instability and potential irreducibility, they require open reduction, associated fixation methods and bone grafts. They present high potential for complications and a guarded prognosis, regardless of the treatment method used.

Fig. 5 - Fracture grouped into type III of the IDEAL method: age 25 years (0 point); displacement (present: 1 point); energy – motorbike accident (high energy: 1 point); joint involvement (present: 1 point); associated lesions (present: 1 point).

Results Although fractures of the distal extremity of the radius are very frequent, there is currently no classification system in the literature with adequate reproducibility that could provide elements for treatment planning and prognosis. The aim

prognoses and treatments for fractures of the distal extremity of the radius.14,19 The great virtue of the IDEAL classification is that it has objective parameters, of which two are epidemiological but are not liable to be subjectively evaluated or interpreted. Likewise, the radiographic parameters are clear and described binomially, which provides greater robustness and precision for the fracture classification process. The classification system that we have developed is based on a mnemonic method and summarizes the fractures into three types, with the aim of providing a reproducible and useful form of classification. Thus, the objective now is to evaluate the reproducibility of this classification, along with its ability to assist in treatment and making the prognosis. These are the next phases, which are being conducted at present. Through this, we believe that we will ratify the propositions that we presented in describing this classification. The most important reason for proposing a new classification model comes from our experience with clinical studies involving this condition. In these, there is no consensus regarding the fracture classification process, and classifications characterized by low reproducibility are used.13-15 These factors are due to excessive grouping into subgroups15 and/or inclusion of fractures in groups that are too heterogenous.17,18

Conclusion We have presented a description of the IDEAL classification method. The parameters for creating it are grounded in the best scientific evidence available. Proof of its scientific and clinical plausibility will be established through analysis on the results from clinical studies that measure its reproducibility and its capacity to determine treatments and infer prognoses for these very frequent fractures. These studies that validate the properties of this classification are currently under development and will be the subject of future papers on this important topic.

of this study was to describe a new classification method and test its validity and reproducibility in comparison with the classification methods most used in the literature. Because the IDEAL classification is a mnemonic method and evaluates radiographic and clinical criteria summarized into three possible types of fracture, it is expected to present

Conflicts of interest The authors declare that there was no conflict of interests in conducting this study.

adequate inter and intra-observer reproducibility rates that are superior to those of other systems currently used. Thus, it may become a tool that enables adequate guidance for planning treatments for these fractures, and may be widely used.

Discussion

R

E

1.

Pires PR. Fraturas do rádio distal. In Traumatologia Ortopédica. Rio de Janeiro: Revinter; 2004. Falch JA.. Epidemiology of fractures of the distal forearm in Oslo, Norway. Acta Orthop Scand. 1983;54(2):291-5. Colles A. On the fracture of the carpal extremity of the radius. Edinb Med Surg J. 1814;10:182-6. Barton JR. Views and treatment of an important injury of wrist. Med Exam. 1838;1:365-8. Smith RW. Atreatise on fractures in the vicinity of the joints and on cetain forms of accidental and congenital dislocations. Dublin: Hodges & Smith; 1847.

2. 3.

The main scientific challenge of this study was to develop and test a classification method that would be useful and reproducible at all levels of medical knowledge, from the physician responsible for the first consultation to the hand surgery specialist, such that it is easy to apply and guides

4. 5.

F

E

R

E

N

C

E

S


40

6.

7.

8. 9. 10.

11.

12. 13.

Rev Bras Ortop. 2013;48(1):36-40

Pouteau C. Ocurrés posthumes de M. Pouteau. Memóire, contenant quelques reflexions sur quelques fractures de l’avant-bras sûr lês luxations incomplèttes du poignet et sûr lateral epicondylitis diastasis. Paris: Ph. Pierres; 1783. Goyrand G. Mémoire sûr lês fractures de l’extremité inférieure du radius qui simulnt lês luxations du poignet. Gaz Med. 1832;3:664-7. Nissen-Lie HS. Fracture radii “typica”. Nord Med. 1939;1:293- 303. Gartland JJ, Werley CW. Evaluation of healed Colles’ fractures. J Bone Joint Surg Am. 1951;33A:895-907. Lidstrom A. Fractures of the distal end of radius: a clinical and statistical study of end results. Acta Orthop Scand. 1959;30(Suppl.41):1-118. Frykman G. Fractures of distal radius, including squelaeshouder-and finger-syndrome, disturbance in the distal radioulnar joint and impairment of nerve function: a clinical and experimental study. Acta Orthop Scand. 1967;108(Suppl):1-153. Melone CP Jr. Articular fractures of the distal radius. Orthop Clin North Am. 1984;15(2):217-36. Andersen DJ, Blair WR, Steyers CM, Adams BD, El-Khouri GY, Brandser EA. Classification of distal radius fractures: an analysis of interobserver reliability andintraobserver reproducibility. J Hand Surg. 1996;21(4):574-82.

14. Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, et al. Fracture and dislocation compendium – 2007: Orthopaedic Trauma Association classifications, database and outcomes comittee. J Orthop Trauma. 2007;21(10 Suppl):S1-S133. 15. Belloti JC, Tamaoki MJ, Franciozi CE, Santos JB, Balbachevsky D, Chap E, et al. Are distal radius fracture classifications reproducible? Intra and interobserver agreement. Sao Paulo Med J. 2008;126(3):180-5. 16. Kreder HJ, Hanel DP, Mckee M, Jupiter J, Mcgillivary G, Swiontkowski MF. Consistency of AO fracture classification for the distal radius. J. Bone Joint Surg. 1996;78(5):726-31. 17. Rayhack J. Symposium: management of intraarticular fractures of distal radius. Contemp Orthop. 1990;21:71-104. 18. Fernandez D, Jupiter J. Fractures of distal radius. New York: Springer-Verlag; 1996. p. 26-52. 19. Fernandez DL. Fractures of distal radius: operative treatment. Instr Course Lect. 1993;42:73-88. 20. Martin JS, Marsh JL. Current classification of fractures. Rationale and utility. Radiol Clin North Am. 1997;35(3):491-506.


Rev Bras Ortop. 2013;48(1):41-45

www.rbo.org.br/

Original Article

Orthopedic injuries in a formation of a soccer club Daniel Augusto de Carvalho1* 1Orthopedist and Traumatologist at the “Ninho da Gralha” Player Training Center, Paraná Club, Quatro Barras, Paraná, Brazil. Work performed at the “Ninho da Gralha” Player Training Center, Paraná Club, Quatro Barras, Paraná, Brazil.

article info

a b s t r a c t

Article history:

Introduction: Football is one of the most popular sports in the world with approximately

Received August 25 2011

400 million practitioners. All physical activity generates an overload somewhere in the

Approved December 21 2011

locomotor system, above all, in young athletes. Objective: To conduct the epidemiological survey of orthopedic injuries in a medical department of the categories of junior soccer

Keywords:

a football club in Curitiba. Methods: Epidemiological survey of injuries in 310 different

Football

athletes during the 2009 and 2010 seasons. Results: The number of recorded visits was

Wounds and Injuries

3.64 per athlete orthopedic complaints in two years. Furthermore, we find 2.88 injuries

Training

/ 1,000 hours of play, and the junior (under 20 and under 18) with the highest rate (3.05).

Categories

The most frequent injury was contusion (32.15%), lower limbs, especially the thigh (3.94%). The higher incidence of injuries occurred in the Middle - campers (30.65%), being the training responsible for 88.31% of the complaints. Conclusion: The epidemiological survey of medical care is a medical department is an important tool for analysis of the main complaints, as well as the primary means of prevention and maintaining the health of athletes. © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

*Corresponding author at: Rua Rio Grande do Sul 116, apto 133, Curitiba, PR, Brazil. CEP: 80620-080. E-mail: decarvalho78@hotmail.com; ortopedia.esporte@hotmail.com ISSN/$–see front matter © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved. doi: 10.1016/j.rboe.2011.12.001


42

Rev Bras Ortop. 2013;48(1):41-45

Introduction Football (soccer) is the most widely practiced and most popular sport in the world, with more than 400 practitioners in approximately 186 countries, according to FIFA (Fédération Internationale de Football Association).1,2 Practicing this sport depends on adequate development of tactical, technical, nutritional, psychological and physical factors,3 and the team is divided into: goalkeepers, full-backs, wingers, midfielders and strikers, who cover different distances with differentiated intensities and movements.4 All physical activity generates an overload at some point of the locomotor system5 and increased levels of sports practice also cause considerable increases in the incidence of injuries.2 Moreover, in striving to make a mark and achieve success, players inevitably need to subject themselves to physical and mental efforts that are very close to their physiological limits, which exposes them to a potentially pathological level of

These categories had different training periods and games, which were divided into preparatory and competitive periods. The total duration was 79 weeks for the child category (1016 hours), 77 weeks for the juvenile category (1254 hours) and 87 weeks for the junior category (1520 hours). The players’ complaints reached a total of 1548 records (clinical = 419; traumatic = 1129), and the following points were highlighted: location and type of injury per body segment; distribution according to the players’ tactical positions; and time of occurrence of the injury (training or game). The data were tabulated using the Excel® software (Microsoft Office 2007). The definition of injury that was used was any event that occurred during games or training at the club that caused reduction or complete withdrawal of the player’s participation in the sports activities.12 The prevalence of injuries was expressed as the number of injuries per 1000 hours of games/training per player. In addition, the player’s position and the time at which the injury occurred (training or official game) were analyzed.

activity and results in a high number of sports injuries.6 Football is a major cause of injuries among sports players worldwide and is responsible for 50% to 60% of all sports injuries in Europe.7,8 Among all the cases of physical trauma treated in European hospitals, between 3.5% and 10% are caused by football. Furthermore, age has been found to be an important factor in studies on exposure to injury risk factors, given that greater numbers of injuries are seen in adults than in young players.7,9-11 It is rare for player training teams to have healthcare professions acting directly in relation to assessment of risk factors and injury rehabilitation. Likewise, few studies have investigated the incidence of injuries among these players.

Objective To conduct an epidemiological survey on orthopedic injuries among the training categories of a football (soccer) club in Curitiba, seen at its medical department.

Materials and methods An epidemiological survey was conducted on the injuries that

Results There were 1548 reported complaints, of which 419 (27.07%) were clinical and 1129 (72.93%) were orthopedic. In relation to the total number of orthopedic complaints, there were 3.64 complaints per player, among which the junior category accounted for 36.49% of the injuries, followed by the child category (34.63%) and the juvenile category (28.88%) (Table 1). In relation to the type of injury, we found the following results, in decreasing order: contusion (32.15%), muscle pain (28.70%), sprains (19,22%), bursitis/tenosynovitis and tendinopathy (8.41%), joint pain (3.37%), wounds (2.48%), contractions (1.15%) and fractures (0.71%) (Table 2). There were 2.8 complaints per 1000 hours of games/training per player, and the highest incidence was for the junior category (3.05) (Table 3). In correlating injury incidence with the players’ positions on the pitch, we found that midfielders accounted for 30.65% of the complaints (Fig. 1). Moreover, the most frequent time for injuries was during training sessions, which accounted for 88.31% (Fig. 2). There was no significant difference in this percentage between the different categories.

Discussion

occurred and clinical care that was provided over the course of two seasons (24 months), from January 2009 to December 2010, at a football player training club (Paraná Club), in the city of Curitiba, state of Paraná. The study participants comprised 310 players who were enrolled during the seasons analyzed. Those who continued at the club for the 2010 season were excluded from the total calculation, given that they had already been included in the total for the 2009 season. According to their ages, they were divided into three categories: child (under 15 years; 116 players), juvenile (under 16 and 17 years; 105 players) and junior (under 18 and 20 years; 89 players).

In the present study, we observed that the number of records of orthopedic injuries was 3.64 per players over the two-year period, with a mean of 2.88 injuries/1000 hours of games/ training, and that the junior category (under 18 and under 20) had the highest rate (3.05). These data are similar to those of studies on young individuals found in the literature.11-15 Concordant with the findings of Nilsson & Roaas16 and Pedrinelli,17 the injury most often encountered was contusion (32.15%), with greatest frequency on the lower limbs, especially on the thighs (3.94%). Muscle pain without anatomical injury was the second most frequent complaint (28.70%), particularly in the lower limbs


43

Rev Bras Ortop. 2013;48(1):41-45

Table 1 - Incidence of complaints according to category. Junior

Juvenile

Child

Number of players

28.70%

33.87%

37.41%

310

Total number of complaints

Total number

36.30%

28.35%

35.33%

1,548

Traumatic

26.61%

21.06%

25.26%

1,129

Clinical

9.69%

7.30%

10.08%

419

6.31

4.18

4.72

4.99

Complaints/player

Table 2 - Incidence of traumatic injuries. Type of injury

% of total complaints

% of traumatic complaints

Contusion

23.46%

32.15%

Muscle pain

20.93%

28.70%

Sprains

14.02%

19.22%

Tendinopathy/bursitis

6.14%

8.41%

Muscle injury

2.78%

3.81%

Joint pain

2.45%

3.37%

Wounds

1.81%

2.48%

Contractions

0.84%

1.15%

Fractures

0.52%

0.71%

Injury per playerâ&#x20AC;&#x2122;s position

GOL: Goalkeeper; ZAG: Full-back; LAT: Winger; MEIO: Midfielder; ATAC: Striker.

Table 3 - Traumatic complaints per 1,000 hours of games and training. Junior Juvenile

Child

Total

Number of players

89

105

116

310

Total number of traumatic complaints

412

326

391

1,129

Traumatic complaints/ player

4.63

3.10

3.27

3.64

Traumatic complaints/1000 hours of games and training

3.05

2.48

3.32

2.88

Fig. 1 - Incidence of injuries according to position.

Time for injuries

Training Game

and lumbar spine. Most previous studies did not cover this complaint in a detailed manner, given that they put the reports on muscle pain (late muscle pain, post-effort myalgia and contractions) together with complaints of muscle injuries (fiber injury). However, we believe that this information is important and that the result may be influenced by the physiological muscle condition under the training found among the younger players, in association with greater volume and intensity of training aimed at improving the yield. In addition, there was a lack of diagnoses through imaging examinations, given that

Fig. 2 - Time of injury.


44

Rev Bras Ortop. 2013;48(1):41-45

the structure for the training categories has certain restrictions on performing these examinations. Sprains are frequent injuries in football practice, especially involving ankles and knees.10,11,13,14 Sprained ankles (13.72%) and sprained knees (3.45%) were the most frequent complaints, and in total, sprains accounted for 19.22% of the complaints over the period. Most of the sprained ankles were grade I, of low severity (13.37%), while for the knees, sprains without injury (1.77%) were most frequent. Ligament injuries to the knees, and especially those that evolve into an unstable condition, are worrying events and modify sports players’ performance.18 In our setting, Carazzato et al.19 found that the rate of ligament and meniscus injuries among male footballers was 13%, over 20 years of activity at a multisport club. In the present study, four cases of cruciate ligament injury (0.35%) and one case of meniscus injury (0.09%) were diagnosed over the two-year period. We observed that there was a difference in relation to data in the literature, such as in an epidemiological study on football injuries among American students, which showed that the incidence of ligament injuries requiring reconstruction was 12.9%. 20 We believe that the significant difference in ligament injuries in relation to the literature occurred due to difficulty in comparing different populations of sports players with regard to preparation. In our study, all the sports players were young and were undergoing preparation similar to that of professional athletes, and thus differed from student sports players, who have less specific preparation with regard to injury prevention. Furthermore, most studies have made analyses on injuries among professional sports players, thus leading to a lack of specific data for training categories, which despite the similarity of their preparation in relation to professional, have intensities and volumes that are clearly lower. Differing from some studies,21-23 in which muscle injuries have appeared in first place, we found in our study that only 3.81% were diagnosed with such injuries. This can be explained in terms of the large differences in injury incidence rates recorded in football that several studies have demonstrated,7,9,11,13 considering that there are many conceptual controversies and errors in data gathering methods, lengths of observation, study designs and study types. Moreover, as mentioned earlier, we found some restrictions in relation to confirmation through imaging examinations, which is common in medical departments dealing with training categories. Bone injuries need to be regarded with caution, given that we did not find any sports players who presented severe fractures. Cohen21 reported a fracture and dislocation rate of 5.4% among professional sports players. On the other hand, over the two-year period, we only found eight fracture cases (0.71%). Of these, one was a maxillary facture and one was a fracture of the medial malleolus that required surgical fixation. The greatest incidence of injuries was among midfielders (30.65%), followed by strikers (19.84%) and full backs (19.84%), and this was concordant with the findings from a study on professional sports players conducted by Pedrinelli.17 These data may confirm that the change to a more competitive style of game among the training categories, with the aim of better professional projection, has had a direct influence on the increasing numbers of injuries that are appearing. These sports

players make greater physical demands than the others do (goalkeepers and wingers), since they make excessive numbers of rotational movements and run greater distances at full speed, which increases the injury rate.17,21-24 The level of competitiveness in technical-tactical training sessions resembles that of games, in which competing for possession of the ball and for a place in the first team may favor the incidence of some injuries.25,26 Moreover, striving for high muscle yield through physical training has increased the number of injuries. In the present study, 88.31% of the orthopedic complaints occurred during or after training, and only 11.69% during or after games. In a prospective study among professional sports players, Chomiak et al.9 observed that trauma was responsible for 81.5% of the injuries that occurred. Few studies have presented comparative results between injuries occurring during training and in games. In this regard, we observed that there was lower incidence in games, among the training categories. This can be explained in terms of the lower burden of games on these sports players than on professional players, while the training load is slightly higher. In addition, the young players present markedly weaker technical and tactical skills, along with lower muscle strength, resistance, coordination and experience.

Conclusion The type of injury most found was contusion, with greatest frequency in the lower limbs, especially in the thighs. The incidence of injuries was highest among midfielders, during training sessions especially and among players in the junior category. Epidemiological surveys of attendance provided at medical departments are an important tool for analyzing the main complaints, as well as the main means for preventive measures and maintenance of the sports players’ health. Furthermore, structuring and standardization of the medical structure for training categories in Brazilian clubs is becoming increasingly necessary, in order to avoid early incapacitating injures within professional football practice.

Conflicts of interest The authors declare that there was no conflict of interests in conducting this study.

R

E

1.

Inklaar H, Bol E, Schmikli SL, Mosterd WL. Injuries in male soccer players: team risk analysis. Int J Sports Med. 1996;17(3):229-34. Cohen M, Abdala RJ. Lesões no esporte: diagnóstico, prevenção e tratamento. Rio de Janeiro: Revinter; 2003. Cohen M, Abdalla RJ, Ejnisman B, Amaro JT. Lesões ortopédicas no futebol. Rev Bras Ortop. 1997;32(12):940-4. Bangsbo J, Norregaard L, Thorsoe F. Activity profile of competition soccer. Can J Sport Sci. 1991;16(2):110-6.

2. 3. 4.

F

E

R

E

N

C

E

S


Rev Bras Ortop. 2013;48(1):41-45

5.

6.

7. 8.

9. 10. 11. 12. 13. 14. 15.

16.

Torres SF. Perfil epidemiológico das lesões no esporte. [dissertation] Florianópolis. – Universidade Federal de Santa Catarina; 2004. Carazzato JG. Manual de medicina do esporte. São Paulo: Sociedade Brasileira de Medicina Esportiva/Laboratório Pfizer, 1993. Keller CS, Noyes FR, Buncher CR. The medical aspects of soccer injury epidemiology. Am J Sports Med. 1987;15(3):230-7. Silva AA, Dória DD, Morais GA, Prota RVM, Mendes VB, Lacerda AC, et al. Fisioterapia esportiva: prevenção e reabilitação de lesões em atletas do América Futebol Clube. Belo Horizonte: Anais do 8º Encontro de Extensão da UFMG; 2005. Chomiak J, Junge A, Peterson L, Dvorak J. Severe injuries in football players. Am J Sports Med. 2000;28(5):58-68. Inklaar H. Soccer injuries I: incidence and severity. Sports Med. 1994;18(1):55-73. Kakavelakis KN, Vlazakis S, Vlazakis I, Charissis G. Soccer injuries in childhood. Scand J Med Sci Sports. 2003;13(3)175-8. Schimidt OS, Jorgensen U, Kaalund S, Sorensen J. Injuries among young soccer players. Am J Sports Med. 1991;19(3):273-5. Junge A, Chomiak J, Dvorak J. Incidence of football injuries in youth players. Am J Sports Med. 2000;28(5):47-50. Kibler WB. Injuries in adolescent and preadolescent soccer players. Med Sci Sports Exerc. 1993;25(12):1330-32. Peterson L, Junge A, Chomiak J, Graff BT, Dvorak J. Incidence of football injuries and complaints in different age groups and skill-level groups. Sports Med. 2000;28(5):51-7. Nilsson S, Roaas A. Soccer injuries in adolescents. Am J Sports Med. 1978;6:358-61.

45

17. Pedrinelli A. Incidência de lesões traumáticas em atletas de futebol [thesis]. São Paulo: Universidade de São Paulo; 1994. 18. Rezende UM, Camanho GL, Hernandez AJ. Alteração da atividade esportiva nas instabilidades crônicas do joelho. Rev Bras Ortop. 1993;28(10):725-30. 19. Carazzato JG, Campos LAN, Carazzato SG. Incidência de lesões traumáticas em atletas competitivos de dez tipos de modalidade esportiva. Trabalho individual de duas décadas de especialista em Medicina Esportiva. Rev Bras Ortop. 1992;27(10):745-58. 20. Yard E, Schroeder MJ, Fields SK, Collins CL, Comstock D. The Epidemiology of United States High School Soccer Injuries, 2005-2007. Am J Sports Med. 2008;36(10):1930-7. 21. Cohen M, Abdalla RJ, Ejnisman B, Amaro JT. Lesões ortopédicas no futebol. Rev Bras Ortop. 1997;32(12):940-4. 22. Stewien ETM, Camargo OPA. Ocorrência de entorse e lesões do joelho em jogadores de futebol da cidade de Manaus, Amazonas. Acta Ortop Bras. 2005;13(3):141-6. 23. Raymundo JLP, Reckers LJ, Locks R, Silva L, Hallal PC. Perfil das lesões e evolução da capacidade física em atletas profissionais de futebol durante uma temporada. Rev Bras Ortop. 2005;40(6):341-8. 24. Gould III JA. Fisioterapia na ortopedia e na medicina do esporte. São Paulo: Manole; 1993. 25. Mannrich G. Epidemiologia das lesões ocorridas na prática diária (jogo e treino) de uma equipe de futebol profissional no período de janeiro a setembro de 2001. Florianópolis, 2001. 26. Arnason A, Gudmundsson A, Dahl HA, Johannsson E. Soccer injuries in Iceland. Scand J Med Sci Sports. 1996;6(1):40-5.


Rev Bras Ortop. 2013;48(1):46-51

www.rbo.org.br/

Original Article

Association between knee alignment, body mass index and physical fitness variables among students: a cross-sectional study Andréia Araújo Souza,1* Gerson Luis de Moraes Ferrari,2 João Pedro da Silva Júnior,3 Leonardo José da Silva,4 Luis Carlos de Oliveira,5 Victor Keihan Rodrigues Matsudo6 1Specialist

in Adolescence for Multidisciplinary Teams. Member of the Study Center of the Physical Fitness Laboratory of São Caetano do Sul (CELAFISCS), São Caetano do Sul, SP, Brazil. 2MSc in Pediatrics and Sciences Applied to Pediatrics from the Universidade Federal de São Paulo (2012). Member of the Study Center of the Physical Fitness Laboratory of São Caetano do Sul (CELAFISCS), São Caetano do Sul, SP, Brazil. 3BSc in Physical Education from the Universidade Camilo Castelo Branco, Brazil (2006). Member of the Study Center of the Physical Fitness Laboratory of São Caetano do Sul (CELAFISCS), São Caetano do Sul, SP, Brazil. 4MSc in Health Sciences from the Universidade Federal de São Paulo (2011). Physical Education Instructor at the Israelite Institute for Social Responsibility (Hospital Albert Einstein), São Paulo, SP, Brazil. 5MSc in Physical Education from the Universidade São Judas Tadeu (2006). Titular Professor at the Universidade São Judas Tadeu and Member of the Study Center of the Physical Fitness Laboratory of São Caetano do Sul (CELAFISCS), São Caetano do Sul, SP, Brazil. 6Specialization in Sports Medicine from the Universidade de São Paulo, Brazil (1976). Full Professor at the Universidade Gama Filho, Rio de Janeiro, RJ, Brazil. Work performed at the Study Center of the Physical Fitness Laboratory of São Caetano do Sul (CELAFISCS), São Caetano do Sul, SP, Brazil. All the authors are members of the Study Center of the Physical Fitness Laboratory of São Caetano do Sul (CELAFISCS).

article info

a b s t r a c t

Article history:

Objective: To assess the association between malalignment of the knees (genu valgum) and

Received September 15, 2011

variables of physical fitness among schoolchildren. Methods: We analyzed data collected bet-

Approved October 25, 2011

ween the years 2000 to 2009. The sample comprised 1,141 schoolchildren of both sexes aged 06 to 18 years. To participate in the research, the students must meet the following criteria:

Keywords:

age between 6 and 18 years and a full assessment of physical fitness, including measurement

Genu Valgum

of genu valgus in at least one of the semester assessments. Postural evaluation (valgus) was

Physical Fitness

determined by the intermalleolar distance, in centimeter. Body Mass Index (BMI) determi-

Child

ned through the growth curves of the World Health Organization. Physical fitness variables (strength of upper and lower limbs, agility, speed and flexibility), were taken according to CELAFISCS standardization. Results: Among male students it was found a prevalence of 23.2% obese, 44.4% overweight and 32.4% eutrophic. Among females, the values were: 30.9% obese, overweight 39.5% and 20.6% eutrophic. When analyzing the prevalence of valgus according to the BMI classifications it was, found a significant positive association in both sexes. Associa-

*Corresponding author at: Rua Heloisa Pamplona, 269, sala 31, CEP 09520-320, Bairro Fundacao, São Caetano do Sul, São Paulo, Brazil. Tel: (55-11) 4229-8980 and 4229-9643 E-mail: celafiscs@celafiscs.org.br ISSN/$–see front matter © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved. doi: 10.1016/j.rboe.2013.04.004


Rev Bras Ortop. 2013;48(1):46-51

47

tion was found between genu valgum and upper limbs strength only in crude analysis. The other variables, agility, speed and flexibility were not associated even when the analysis was adjusted. Conclusion: there was a positive association between malalignment of the knees, body mass index and physical fitness among schoolchildren. © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

Introduction Data from around the world have demonstrated increasing prevalence of obesity, not only among the adult population but also among young adults and adolescents.1 This increase is strongly associated with two main factors, among other causes: low levels of physical activity and increased intake of highly calorific foods.2,3 Regular practicing of physical activity may positively influence the levels of physical fitness. 4 However, biomechanical and/or postural abnormalities such as knee misalignment seem to be one of the possible causes that may limit individuals’ engagement in physical activities, given that in addition to the specific local alterations, these may affect other joints and limit the capacity for exercise.5 One of the deviations that most affect children and young adults is genu valgum. This knee misalignment is defined as displacement of the knees in relation to the proximal axis of the body, and it is more prevalent among girls. In cases of high degrees of valgus, this may directly influence performance relating to neuromotor variables of physical fitness, such as speed and agility, and also anthropometric variables like body adiposity.6 Some hypotheses have suggested that overweight and obese individuals would have greater likelihood of presenting postural deviation (genu valgum).7,8 On the other hand, other authors have suggested that higher degrees of genu valgum may have implications for maintaining a physically active lifestyle, thereby increasing the chances of presented greaterthan-expected weight.9 The objective of the present study was to analyze the association between genu valgum, body mass index and physical fitness among students at public schools.

Methods The present study forms part of the Mixed Longitudinal Growth and Development Project of Ilhabela, which has been developed by CELAFISCS since 1978. In this, the impact of the growth and development process on physical fitness variables among children in the municipality of Ilhabela (São Paulo, Brazil) is studied. This project makes semestral assessments, always in April and October, and includes anthropometric, metabolic, neuromotor, nutritional and, more recently, physical activity level measurements. To make up the sample for the present

study, a database of more than 3,500 children and adolescents of both sexes who participated in evaluations between 2000 and 2009 was analyzed. Among these subjects, 1,141 met the inclusion criteria used, i.e. they were between 6 and 18 years of age and a complete assessment of physical fitness, including measurements of genu valgum, were available. This project was approved by the Ethics Committee of the Universidade Federal de São Paulo, under protocol n# 0056/10. Knee misalignment (genu valgum) was assessed with the students in an upright standing position, with observation in the posteroanterior direction, using a rule marked out in centimeters (cm). The intermalleolar distance was measured in cm as recommended by Heath and Staheli.10 Body mass measurements were obtained using a digital scale with precision of 100 grams, with the individual wearing as little clothing as possible. Height was measured using a stadiometer, in cm, and was calculated as the average of three measurements. To calculate the body mass index (BMI), the above two measurements were used and the subjects were classified as eutrophic, overweight or obese, in accordance with the criteria proposed by the World Health Organization.11 Lower-limb strength was measured by means of the vertical impulse test, without aid from the upper limbs (cm), and three attempts were made. To measure upper-limb strength, the hand grip test was used with a dynamometer (kg). The variable of agility was measured using the “shuttle run” test (seconds), with two attempts. For the speed test, running over a distance of 50 meters (seconds) was used, with a single attempt. Flexibility was estimated (cm) using the “sit and reach” test.12 All the measurements and tests followed the standardization of CELAFISCS13 and took into consideration the best result from each test. The reproducibility and objectivity values for each measurement made between the years ranged from 0.96 to 0.99 for body mass, 0.97 to 0.99 for height, 0.51 to 0.97 for upper-limb strength, 0.62 to 0.92 for lower-limb strength, 0.58 to 0.89 for agility, 0.61 to 0.91 for flexibility and 0.58 to 0.92 for speed, respectively.

Statistical analysis The descriptive analyses were detailed by means of absolute numbers and proportions for categorical data. Bivariate analyses between the physical activity level and independent variables were conducted using chi-square tests for heterogeneity (categorical variables) and for linear trend (ordinal variables). To analyze the physical fitness variables, increasing terciles were created because classification criteria existed for the variables used in the present study.


48

Rev Bras Ortop. 2013;48(1):46-51

Analyses adjusted for possible confounding factors were performed by means of Poisson regression with robust adjustment of variance.14 The variables were selected by means of the “bottom-down” method.15 Variables with p values < 0.20 were retained in the final analysis model. The significance level used was p < 0.05. All the analyses were conducted by means of the Stata version 10.0 statistical package.

Results The data for the present study was supplied by 1141 individuals who fulfilled the inclusion criteria. The mean age of the sample was 11.16 ± 2.65 years (boys 11.25 ± 2.74 and girls 11.09 ± 2.57). The mean BMI was 18.17 ± 3.27 kg/m2 (boys 17.92 ± 3.19 kg/m2 and girls 18.37 ± 3.31 kg/m2). After adjusting for age and sex, the prevalence of obesity among the girls was 45% (95% CI: 1.21 – 1.74) greater than the prevalence of eutrophic individuals, while the prevalence among the boys was 34% greater (95% CI: 1.08 – 1.66) (Table 1).

Table 1 - Multivariate analysis on the association between genu valgum and body mass index, among students in the municipality of Ilhabela, stratified by sex. Variables

Crude PR (95% CI)

Boys BMI

p

Ajusted PR** (95% CI)

< 0.002 * Eutrophic

p

Table 2 - Knee alignment according to the independent variables of students at public schools in the municipality of Ilhabela, São Paulo. Variables

N (%)

Genu valgum ( %)

6 to 10

425 (37.2)

262 (40.6)

11 to 14

577 (50.6)

317 (49.1)

15 to 18

139 (12.2)

139 (12.2)

Age

0.007 *

<0.001 *

BMI Normal

349 (30.9)

164 (25.59)

Overweight

473 (41.8)

266 (41.50)

Obese

309 (27.3)

211 (32.9)

Sex

0.05

Female

613 (53.7)

363 (56.2)

Male

528 (46.3)

283 (43.8)

Lower-limb strength 1st

tercile

2nd 3rd

376 (33.8)

231 (37.0)

tercile

408 (36.7)

236 (37.8)

tercile

327 (29.4)

158 (25.3)

382 (33.9)

226 (35.5)

2nd tercile

371 (33.01)

218 (34.2)

371 (33.01)

193 (33)

1.0

Overweight

1.17 (0.95 – 1.43)

1.15 (0.94 – 1.45)

3rd

Obese

1.40 (1.13 – 1.17)

1.34 (1.08 – 1.66)

Flexibility

< 0.001 * Eutrophic

1.0

Overweight

1.22 (1.02 – 1.47)

Obese

1.48 (1.24 – 1.77)

< 0.001 * 1.0 1.21 (1.01 – 1.46) 1.45 (1.21 – 1.74)

* Wald test for heterogeneity; **adjusted for age and sex.

Table 2 presents a description of the sample for all the independent variables and their associations with genu valgum. The prevalence of genu valgum encountered was 56.6% (95% CI: 53.7 – 59.4). Among females, the prevalence was 59.2% and among males, 53.6%. Among the girls, 20.6% were classified as eutrophic, 39.5% as overweight and 30.9% as obese. Among the boys, the values were 32.4% eutrophic, 44.4% overweight and 23.2% obese. Analysis on associations with the degree of genu valgum showed that individuals with better performance in the lower-limb strength test presented lower prevalence of knee misalignment (p ≤ 0.001). Table 3 shows the crude and adjusted analyses on the association between genu valgum and the independent

0.08

1st tercile

1.0

Girls BMI

<0.001

Upper-limb strength 0.007 *

1st

tercile

tercile

0.85 375 (33.4)

213 (35)

2nd tercile

422 (37.5)

242 (30)

3rd tercile

327 (29.1)

181 (28.46)

Agility

0.44

1st tercile

377 (33.9)

209 (33.2)

2nd tercile

388 (34.9)

230 (36.5)

3rd

346 (31.1)

191 (30.32)

tercile

Speed 1st

P

0.12 tercile

384 (35.7)

202 (33.5)

2nd tercile

347 (32.3)

195 (32.3)

3rd tercile

343 (31.9)

206 (34.2)

*p < 0.05.

variables. After adjustment for confounding variables, genu valgum was seen to be associated with age and BMI, with prevalence in the obese group that was 40% (95% CI: 1.22 -1.60) greater than among the eutrophic individuals.


Rev Bras Ortop. 2013;48(1):46-51

49

Table 3 - Multivariate analysis on the association between genu valgum and the independent variables of students in the municipality of Ilhabela, SĂŁo Paulo. Crude PR (95% CI) Variables Age***

Ajusted (95% CI)

P

P

<0.001 *

0.007 *

6 to 10

1.0

1.0

11 to 14

0.89 (0.80-0.99)

0.89 (0.80-0.99)

15 to 17

0.78 (0.65-0.94)

0.78 (0.65-095)

BMI**

<0.001 *

Eutrophic

<0.001 *

1.0

1.0

Overweight

1.20 (1.04-1.37)

1.18 (1.03-1.36)

Obese

1.45 (1.27-1.66)

1.40 (1.22-1.60)

Sex ****

0.06*

Female Male

0.06*

1.0

1.0

0.90 (0.81-1.00)

0.91 (0.82-1.00)

Lower-limb strength**

0.09* 1.0

1.0

2nd tercile

1.00 (0.85-1.17)

1.03 (0.87-1.21)

3rd

0.84 (0.76-0.94)

0.90 (0.79-1.01)

tercile

0.05*

0.70*

1st tercile

1.0

1.0

2nd tercile

0.99 (0.88-1.12)

1.08 (0.95-1.24)

3rd tercile

0.88 (0.77-0.99)

1.03 (0.87-1.23)

Speed** 1st

tercile

2nd 3rd

Discussion 0.07*

1st tercile

Upper-limb strength**

Fig.1 - Association between degree of genu valgum and body mass index among students in Ilhabela, SP.

0.04*

0.84*

1,0

1,0

tercile

1.07 (0.93-1.22)

0.98 (0.86-1.15)

tercile

1.14 (1.01-1.30)

1.01 (0.87-1.18)

* Wald test for heterogeneity; ** adjusted for age and sex; *** adjusted for sex; **** adjusted for age. **** ajustado para idade.

An association was found between genu valgum and upperlimb strength was only found in the crude analysis. The other variables (agility, speed, lower-limb strength and flexibility) did not present any association even when the analysis was adjusted (Table 3). Fig. 1 presents a correlation between the degree of genu valgum (percentiles) and BMI. The proportion of the individuals classified in the percentile â&#x2030;Ľ 75 was greatest among the obese subjects (p < 0.001). The lowest BMI (eutrophic individuals) presented a significant association with lower degree of genu valgum, i.e. the greater the degree of valgus was, the greater the obesity was; and reciprocally, the lower the degree of valgus was, the lower the degree of adiposity was.

The Longitudinal Growth, Development and Physical Fitness Project among students in Ilhabela has provided an important original line of approach on posture that has sought to correlate postural deviation with motor performance and anthropometric, neuromotor, metabolic and physical activity characteristics. The results found in the present study showed that there was a significant association between genu valgum and physical fitness variables among students of both sexes in Ilhabela. In addition to the present study, other authors9,16,17 have also undertaken research projects among students in Ilhabela, showing correlations between physical fitness and the intermalleolar and intercondylar distances among students in Ilhabela. A study that analyzed 274 students of both sexes aged 7 to 18 years found a significant association between the degrees of genu valgum and the physical fitness variables (body mass, agility and speed).9 In the same study, the prevalence of genu valgum found was 68.6%, and the authors observed that the young people who presented greater degrees of valgus had deficits of 10% in speed tests. Martinelli et al.18 found that the prevalence of genu valgum was 87% among overweight children of both sexes aged 5 to 9 years. These authors did not find any statistical difference between the sexes. According to Gomes et al.,19 the prevalence of genu valgum varied over the years, with a relationship with different developmental stages. According to Cardoso et al.,5 Gomes et al.,19 MacMahon et al.20 and Arazi et al.,21 in addition to knee alignment variations (valgus, varus or neutral)with age among normal children, the prevalence of genu valgum is greater during infancy, especially between the ages of 2 to 6 years. These authors stated that high degrees of genu valgum might have implications for maintaining a physically active lifestyle among children and adolescents. Through this, the chances that such children would present greater-than-expected weight would be higher. This hypothesis was supported by the findings from the present study.


50

Rev Bras Ortop. 2013;48(1):46-51

Joao et al. 22 measured the angling of the knees using a goniometer and the distance between the malleoli using a measuring tape, in a study on 79 children aged 7 to 10 years. These authors observed that the group of obese subjects presented greater prevalence of valgus knee in the two methods of evaluation. A literature review study demonstrated that valgus and varus knee deformities may give rise to lower-limb dysfunction that has important consequences for activities of daily living, such as walking, sitting down and getting up, and going up and down stairs.23,24 It is extremely important to emphasize that the results from the present study and from other studies conducted so far9,16,24,25 only show a relationship between the intermalleolar and intercondylar distances and the obesity and physical fitness variables in children and adolescents. According to some authors,23,26 obese adolescents have been shown to present localized orthopedic alterations, particularly in the lower limbs, such as genu valgum. Jannini et al.23 conducted a cross-sectional study among eutrophic and obese adolescents. They concluded that obesity may cause damage to the osteoarticular system at the beginning of adolescence. According to Calvete,27 obesity causes mechanical overload on the locomotor apparatus and postural misalignment with anteriorization of the center of mass, thus leading to functional alterations in the lower limbs and increased mechanical need for adaptation to the new corporal regime. Yaniv et al.28 conducted a study among young athletes and found that there were greater postural alterations among older athletes than among younger ones, which may have indicated that the occurrences of changes to the alignment of the lower limbs resulted from sports practice. However, these authors made it clear that further studies using different methods would be needed in order to obtain a broader view regarding the causes of axial deformity. According to Matsudo6 and Garcia et al.,9 genu valgum was more prevalent among girls, which could be in physiologically lighter cases, but in cases of greater intensity and during adolescence there would be greater implications regarding anthropometric and neuromotor fitness, and particularly in relation to adiposity and running for 50 m. We consider that the present study has certain limitations: there was a lack of criteria for classifying genu valgum; this was a cross-sectional cohort study that did not allow a causeeffect relationship to be established; and no control was made for biological maturity and age, which is an important factor given that postural deviations of the lower limbs undergo modifications with the passing of the years.

Conclusion Within the limitations of a cross-sectional study, the present findings confirm the hypothesis of a positive association between knee misalignment, body mass index and physical fitness among students. Further studies with appropriate designs that might show a possible cause-effect relationship between the variables analyzed in the present study are needed.

Conflicts of interest The authors declare that there was no conflict of interests in conducting this study.

R

E

1.

Wang Y, Lobstein T. Worldwide trends in childhood overweight and obesity. Int J Pediatr Obes. 2006;1(1):11-25. He Q, Wong T, Du L, Jiang Z, Yu TI, Qiu H, et al. Physical activity, cardiorespiratory fitness, and obesity among Chinese children. Prev Med. 2011;52(2)109-13. Singhal A, Kennedy K, Lanigan J, Fewtrell M, Cole TJ, Stephenson T, et al. Nutrition in infancy and long-term risk of obesity: evidence from 2 randomized controlled trials1–3. Am J Clin Nutr. 2010;92(5)1133-44. Kristensen PL, Moeller NC, Korsholm L, Kolle E, Wedderkopp N, Froberg K, et al. The association between aerobic fitness and physical activity in children and adolescents: the European youth heart study. Eur J Appl Physiol. 2010;110(2):267-75. Cardoso ALS, Tavares A e Plavnik FL. Aptidao fisica em uma populacao de pacientes hipertensos: avaliacao das condições osteoarticulares visando a beneficio cardiovascular. Rev Bras Hipertens. 2008;15(3):125-32. Matsudo V. Lesoes e alteracoes osteomusculares na criança e no adolescente atleta. In: De Rose Junior D. Esporte e atividade fisica na infancia e na adolescencia. Porto Alegre: Artmed; 2a ed, 2009. p. 197-209. Cicca LO, Joao SMA e Sacco ICN. Caracterizacao postural dos membros inferiores de criancas obesas de 7-10 anos. Fisioter Pesqui. 2007;14(2):40-6. Wearing SC, Hennig EM, Byrne NM, Steele Jr, Hills AP. The impact of childhood obesity on musculoskeletal form. Obes Rev. 2006;7(2):209-18. Garcia N, Matsudo SM, Matsudo VKR. Relacao entre aptidao fisica e geno valgo em criancas e adolescentes. In: Anais XXIII Simposio Internacional de Ciencias do Esporte. São Paulo, Brasil, 2000, p.142. Heath CH, Staheli LT. Normal limits of knee angle in white children-genu varum and genu valgum. J Pediatr Orthop. 1993;13(2):259-62. De Onis M, Onyango AW, Borghi E, Siyam A, Nishida C, Siekmann J. Development of a WHO growth reference for school-aged children and adolescents. B World Health Organ. 2007;85(9):660-7. Wells KF, Dillon EK. The sit and reach a test of back and leg flexibility. Res Q Exerc Sport. 1952;23(1):115-8. Matsudo VKR. Testes em Ciencias do Esporte. São Paulo: Centro de Estudos do Laboratorio de Aptidao Fisica de São Caetano do Sul; 7a ed, 2005. Barros AJ, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol. 2003;3(1):21. Dumith SC. Proposta de um modelo teorico para a adocao da pratica de atividade fisica. Rev Bras Ativ Saude. 2008;13(2):110-20. Oliveira AC, Andrade DR, Matsudo VKR, Oliveira LC. Relacao entre geno varo e aptidao fisica em estudantes de baixo nível socioeconomico. R Bras Ci e Mov. 2009;17(1):7-14.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12. 13.

14.

15.

16.

F

E

R

E

N

C

E

S


Rev Bras Ortop. 2013;48(1):46-51

17. Rezende LFM, Araujo TL, Santos M, Matsudo VKR. Does soccer lead to genu varum? In: American College of Sports Medicine. 57th Annual Meeting. Baltimore: Med Sci Sports Exerc; 2010. 18. Martinelli AR, Purga MO, Mantovani AM, Camargo MR, Rosell AB, Fregonesi CEPT, et al. Analise do alinhamento dos membros inferiores em criancas com excesso de peso. Rev Bras Cineantropom Desempenho Hum. 2011;13(2):124-30. 19. Gomes CTS, Keiserman LS, Kroeff MAH, Crestani MV. Variacao das distancias intermaleolar e intercondiliana nos jovens. Rev Bras Ortop. 1997;32(12):963-6. 20. MacMahon EB, Carmines DV, Irani RN. Physiologic bowing in children: an analysis of the pendulum mechanism. J Pediatr Orthop B. 1995;4(1):100-5. 21. Arazi M, Ogun TC, Memik R. Normal development of the tibiofemoral angle in children: a clinical study of 590 normal subjects from 3 to 17 years of age. J Pediatr Orthop. 2001;21(2)264-7. 22. Jo찾o SMA, Cicca LO, Cunha ACP. Avaliacao postural do joelho de criancas obesas de 7 a 10 anos. In: Anais 13o Simposio Internacional da Iniciacao Cientifica da Universidade de S찾o Paulo. Ribeirao Preto; 2005, p. 2090.

51

23. Jannini SN, Doria-Filho U, Damiani D, Silva CAA. Dor musculo-esqueletica em adolescentes obesos. J Pediatr. 2011;87(4):329-35. 24. Gama AEF, Lucena LC, Andrade MM, Alves SB. Deformidades em valgo e varo de joelhos alteram a cinesiologia dos membros inferiores. In: X Encontro de Iniciacao a Docencia da Universidade Federal da Paraiba, Paraiba; 2007. 25. Neves MC, Campagnolo JL. Desvios axiais dos membros inferiores. Rev Port Clin Geral. 2009;25:464-70. 26. Gettys FK, Jackson JB, Frick SL. Obesity in pediatric orthopaedics. Orthop Clin North Am. 2011;42(1):95-105. 27. Calvete AS. A relacao entre alteracao postural e les천es esportivas em criancas e adolescentes obesos. Motriz. 2004;10(2):67-72. 28. Yaniv M, Becker T, Goldwirt M, Khamis S, Steinberg D, Weintroub S. Prevalence of bowlegs among child and adolescent soccer players. Clin J Sport Med. 2006;16(5):392-6.


Rev Bras Ortop. 2013;48(1):52-56

www.rbo.org.br/

Original Article

Anatomical parameters in the lateral ulnar collateral ligament reconstruction: a cadaver study Willian Nandi Stipp,1* Fabiano Rebouças Ribeiro,2 Antonio Carlos Tenor Junior,3 Cantídio Salvador Filardi Filho,3 Danilo Canesin Dal Molin,1 Rodrigo Souto Borges Petros,1 Romulo Brasil Filho4 1Trainee

(2012) in the Shoulder and Elbow Group, Orthopedics and Traumatology Service, State of São Public Servants’ Hospital (HSPE), São Paulo, SP, Brazil. 2MSc in Medicine/Orthopedics. Head Physician of the Shoulder and Elbow Group, Orthopedics and Traumatology Service, State of São Public Servants’ Hospital (HSPE), São Paulo, SP, Brazil. 3Attending Physician in the Shoulder and Elbow Group, Orthopedics and Traumatology Service, State of São Public Servants’ Hospital (HSPE), São Paulo, SP, Brazil. 4MSc in Medicine/Orthopedics. Attending Physician in the Shoulder and Elbow Group, Orthopedics and Traumatology Service, State of São Public Servants’ Hospital (HSPE), São Paulo, SP, Brazil. Work performed in the Orthopedics and Traumatology Service, State of São Public Servants’ Hospital (HSPE), São Paulo, SP, Brazil.

article info

a b s t r a c t

Article history:

Introduction: The purpose of this study was to indentify the ulnar insertion of the LUCL using

Received January 26 2012

the olecranon tip and the radial head as parameters to guide the ligament reconstruction

Approved May 8 2012

surgery. Methods: Thirteen elbows of eight fresh cadavers were dissected for the study of the LUCL. The distances between the proximal and distal insertion of the LUCL (footprint),

Keywords:

between the radial head and the footprint and between the olecranon tip and the footprint

Elbow/anatomy&histology

were measure with a digital pachimeter. Results: The average distance from the radial head

Elbow/surgery

to the proximal and distal ulnar insertion of the LUCL was 13.6 and 22.99 mm, respectively.

Elbow Joint

The average distance between the olecranon tip and the proximal and distal ulnar insertion

Cadaver

of the LUCL was 38.25 and 47.6 respectively. The mean length of the LUCL footprint was 9.35 mm. Conclusions: The LUCL insertion has a wide footprint with average 9.3 mm (7.5-11 mm). Ulnar insertion half point be located at 18.2 mm of the radial head and at 42.9 mm of olecranon tip. © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

Corresponding author at: Rua José Evaristo Fogaça, 738, Vila Moema, Tubarão, SC, Brazil. E-mail: willstipp@yahoo.com.br ISSN/$–see front matter © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved. doi: 10.1016/j.rboe.2012.05.001


Rev Bras Ortop. 2013;48(1):52-56

53

Introduction

Methodology

The elbow has inherent bone stability due to its anatomical

Fourteen elbows from seven chilled recent adult cadavers were studied. The cadavers did not have any congenital abnormalities, advanced arthrosis or signs of trauma or previous surgery. One of the elbows was rejected because it presented signs of an old fracture in the olecranon, thus resulting in 13 elbows, from six men and one woman, with a mean age of 66.4 years, ranging from 55 to 92 years. There were seven right elbows and six left elbows. The dissections were performed by a single researcher. A pilot study had previously been conducted on four elbows from two cadavers, before any data-gathering, so as to gain better knowledge of the local anatomy and to study it. An incision was made in the skin of the lateral face of the elbow, to reveal tissues down to the muscle fascia. The interval between the anconeus muscle (which was released from its ulnar insertion and subsequently folded back) and the ulnar extensor muscle of the carpus was accessed. The conjoined tendon, composed of the origin of the supinating extensor musculature, was dissected until the lateral ligament complex and the joint capsule had been revealed proximally, along with the supinator muscle distally. Following this, the origin of the supinator muscle was released in order to isolate the insertion of the LUCL (Fig. 1).

characteristics, but the structures of the adjacent soft tissues also contribute. The statistic stabilizers are the anterior and posterior capsules and the medial and lateral collateral ligaments, while the dynamic stabilizers are the muscles that cross the joint and compress the bone surfaces.1 Although acute dislocation of the elbow occurs frequently and is the second commonest among the major joints, chronic instability and recurrent dislocation have been less reported.1,2 The commonest form of symptomatic chronic instability of the elbow is posterolateral rotatory instability (PLRI), in which the radius and ulnar rotate externally in relation to the distal humerus, leading to posterior dislocation of the radial head in relation to the capitellum.3 According to Oâ&#x20AC;&#x2122;Driscoll et al.,4 the main factor responsible for this displacement is injury to the lateral ulnar collateral ligament (LUCL). The lateral ligament complex may become injured consequent to trauma, iatrogenically or through chronic mechanical overload. Acute dislocation of the elbow is the main traumatic cause, through the axial overload mechanism and through supination and valgus, in which the capsuleligament lesion progresses from lateral to medial locations.5 Lesions of the lateral complex may occur iatrogenically following open or arthroscopic surgical release for lateral epicondylitis, through approaches to the radial head and even through serial infiltrations into the lateral compartment.3,6,7 Chronic overloading of the elbow may also cause instability, such as in cases of cubitus varus and in patients who use crutches.3,8 In most cases, the symptoms of posterolateral chronic rotatory instability do not improve with conservative treatment and require surgical treatment involving repair, retensioning or reconstruction.3,9 Contrary to the medial complex, for which observations regarding its anatomical description have been concordant, there have been divergences in descriptions of the lateral complex, with regard to: the ligaments that form it, the types of insertion of the LUCL, its annular ligament (conjoined or separated) and the exact location of its

Fig. 1 - (1) Lateral ulnar collateral ligament, (2) radial collateral ligament, (3) accessory ligament, (4) annular ligament.

insertion. 1,2,10-12 The lack of published studies and the low degree of unanimity regarding the location the ulnar insertion in reconstructions of the LUCL create difficulties in conducting procedures aimed towards achieving anatomical positioning.9,13-16 This study had the aim of identifying the ulnar insertion of the LUCL through using the olecranon tip and radial head as fixed parameters, thereby aiming to guide the positioning of the ulnar tunnel in ligament reconstruction surgical procedures.

Measurements were made using a MistainlessÂŽ digital pachymeter, with the elbow on the dissection table at 90 degrees of flexion and without varus and valgus stress. To demarcate the limits of the segments measured, 40 x 1.2 mm needles were used. The following measurements of the elbows studied were recorded: the insertion footprint of the LUCL; the distance from the proximal edge of the cartilage of the radial head to the proximal and distal insertion of the LUCL; the distance from


54

Rev Bras Ortop. 2013;48(1):52-56

the proximal edge of the olecranon to the proximal and distal insertion of the LUCL; and the distance from the proximal edge of the cartilage of the radial head to the distal edge of the annular ligament (Fig. 2). The gender, side, age and height of the cadavers were also recorded. The ligaments forming the lateral ligament complex were identified, along with observing whether the insertion patterns of the LUCL and the annular ligament were conjoined or separated.

Fig. 3 - Conjoined insertion of the LUCL and annular ligament.

Fig. 2 - The white arrow shows the footprint of the LUCL. The black arrow shows the distance from the radial head to the start of the footprint, and the grey arrow shows the olecranon tip at the start of the footprint.

Result In 10 cases, the lateral ligament complex was composed of four ligaments (annular, lateral ulnar collateral, lateral radial collateral and accessory), while in three cases the accessory ligament was not observed. The insertion of the LUCL was conjoined with the annular ligament in two elbows, while in 11 of them it was possible to differentiate the insertion of the LUCL through the presence of a foramen filled with adipose tissue (Figs. 3 and 4). The mean distance between the edge of the radial head and the proximal insertion of the LUCL was 13.6 mm (11.7-16.2 mm); the mean distance between the edge of the radial head and the distal insertion of the LUCL was 22.9 mm (20.2-26.4 mm); and the midpoint between the proximal and distal insertions was 18.2 mm from the radial head. The mean distance between the olecranon tip and the proximal insertion of the LUCL was 38.2 mm (33.6-43.9 mm) and the mean distance between the olecranon tip and the distance between the olecranon tip and the distal insertion of the LUCL was 47.6 mm (42.6-55 mm). The midpoint was 42.9 mm from the olecranon tip (Fig. 5). In the two cases in which the insertion of the LUCL was conjoined with the annular ligament, the distance between

Fig. 4 - Single insertion of the LUCL: the arrow shows the foramen that separates the ligaments.

Fig. 5 - Distance between the olecranon tip and the distal insertion of the LUCL.


Rev Bras Ortop. 2013;48(1):52-56

the edge of the radial head and the distal edge of the annular ligament was measured in the anterior region of the radius, where the LUCL was not present. By subtracting the length of the insertion of the annular ligament from the total value for the conjoined insertion, we obtained the footprint. The measurement of the footprint of the LUCL in the ulna ranged from 7.5 to 11 mm (mean length of 9.3 mm).

55

resulted in 15% of the total displacement. Thus, they suggested that more than one structure must have been comprised for a substantial displacement of the radial head to have been caused.19 Likewise, Dunning et al.20 observed that the pivot shift test was negative and there was no difference in the magnitude of the pronation-supination and varus-valgus lassitude when only the LUCL was sectioned, in comparison with the intact elbow. This evidence was confirmed by the studies of

Discussion

McAdams et al.21 and Olsen et al.2

In 1985, Morrey and An10 conducted an anatomical study in which they gave the name lateral ulnar collateral ligament to a structure posterior to the radial collateral ligament that extended to the annular ligament and was inserted into the crest of the supinator. This structure was observed in five of the ten elbows dissected and, at that time, no importance was attributed to this structure with regard to elbow stabilization. Beckett et al.10 studied 39 elbows from cadavers in order to describe the anatomical variations of the lateral ligament complex and found that the LUCL was present in only 50% of the cases. Olsen et al.17 observed that the LUCL was present in all the cases in their study, like in our study, in which this ligament was identified in 100% of the elbows dissected (Fig. 3). A histological and anatomical analysis conducted by Imatani et al.12 also recognized the LUCL in 100% of the elbows studied. Furthermore, they showed that this ligament was related to the fascia of the ulnar extensor muscles of the carpus and supinator in their medial portion and with the lateral radial collateral ligament in its proximal portion. This would cause difficulty in identifying it macroscopically in anatomical studies, thereby causing the mistaken belief that it did not exist. In 1999, Vieira and Caetano18 published an anatomical study in which they described the lateral ligament complex in detail, such that it was composed of the lateral ulnar collateral ligament, radial collateral ligament, accessory ligament and annular ligament. In our dissection, we observed that there was a close relationship between the conjoined tendon of the extensorsupinator muscles, the origin of the lateral ligament complex and the joint capsule, which made it difficult to separate these elements. At the origin of the lateral ligament complex, the ulnar and radial bands could not be differentiated from the lateral collateral ligament, which is concordant with the literature.10,12,17,18 At the insertion of the lateral ligament complex, it was possible to identify the LUCL separated from the annular ligament in 11 elbows. This type of insertion of the LUCL alone was observed by Olsen et al.17 in 100% of the cases and by Cohen and Hastings 2nd 19 in 22 of the 40 elbows studied. Since posterolateral rotatory instability was described by Oâ&#x20AC;&#x2122;Driscoll et al.,4 the LUCL has been indicated as the main restrictor for this displacement. However, the importance of the entire lateral ligament complex, septa, fasciae and extensor-supinator has been emphasized,2,19-21 thus showing that the LUCL is not the only factor responsible. Cohen and Hastings 2nd 19 conducted an anatomical study in which they serially sectioned the lateral stabilizing structures of the elbow and observed that injury to the fibers of the LUCL only

aim of reconstructing the LUCL. On the other hand, there is a

Nevertheless, surgery to correct the PLRI still has the sole lack of precision in the literature regarding the insertion site for the ulnar tunnel.9,13-16 In 1992, Nestor et al.13 published an article in which they described the region just posteriorly to the tubercle of the supinator as the point for the ulnar tunnel. Lee and Teo9 described the location of the ulnar tunnel as posterior to the crest of the supinator. Rizzio14 reported on a case of reconstruction in a patient with an immature skeleton and also only cited the crest of the supinator, as also seen in the biomechanical study by King et al.15 and the study by Olsen and SĂśjbjerg.16 The ulnar insertion point should reproduce the original anatomy of the lateral ligament complex for the best result.22 However, the conjoined insertion of the annular ligament and LUCL into the ulna measures 2 cm on average and there have not been any reports on the length of the LUCL insertion alone.1,15,23 In our study, we were able to measure this footprint (mean value of 9.3 mm), thereby facilitating the measurement of the site of LUCL insertion. Goren et al.23 conducted a biomechanical study with the aim of identifying the best location for the humeral and ulnar tunnels, by means of a software program that measured the variations in distances between the points chosen during flexion-extension. At the end of the study, they found that there was no true universal isometric point for the LUCL and that the individual variation in tunnel insertion was statistically significant. However, the point of greatest isometry would be 16-20 mm distally to the joint face of the radial head. This information is concordant with the results from our study, in which we found that the midpoint of LUCL insertion was 18.2 mm from the radial head. On the other hand, Moritomo et al.24 investigated the isometric point of the LUCL in vivo and established three insertion points for testing in the ulna, at 5, 15 and 25 mm distally to the joint face of the radial head, and were unable to identify it, thus showing that the LUCL is not isometric. In addition to using the radial head, as described in the literature,23,24 the present study added the olecranon tip as a reference point and fixed parameter, since it is located in the same bone, in order to increase the precision of the correct location for LUCL insertion (mean of 42.9 mm). No similar studies with measurements made from the olecranon tip (of the same bone) to the insertion zone of the LUCL were found in the literature that we consulted LUCL (Fig. 4).


56

Rev Bras Ortop. 2013;48(1):52-56

Conclusion We conclude that the insertion of the LUCL has a wide footprint, of 9.3 mm on average (range: 7.5-11 mm). The midpoint of the ulnar insertion is located 18.2 mm from the radial head and 42.9 mm from the olecranon tip.

Conflicts of interest The authors declare that there was no conflict of interests in conducting this study.

R

1.

E

F

E

R

E

N

C

E

S

Safran MR, Baillargeon D. Soft-tissue stabilizers of the elbow. J Shoulder Elbow Surg. 2005;14(1 Suppl):179S-185S. 2. Olsen BS, Söjbjerg JO, Dalstra M, Sneppen O. Kinematics of the lateral ligamentous constraints of the elbow joint. J Shoulder Elbow Surg. 1996;5(5):333-41. 3. Charalambous CP, Stanley JK. Posterolateral rotator instability of the elbow. J Bone Joint Surg Br. 2008;90(3)-B:272-9. 4. O’Driscoll SW, Bell DF, Morrey BF. Postero-lateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73-A:440-6. 5. O’Driscoll SW, Jupiter JB, King GJW, Hotchkiss RN, Morrey BF. The unstable elbow. J Bone Joint Surg Am. 2000;82:724-37. 6. Charalambous CP, Stanley JK, Siddique I, Aster A, Gagey O. Posterolateral rotator laxity following surgery to the read of the radius: biomechanical comparison of two surgical approaches. J Bone Joint Surg Br. 2009;91:82-7. 7. Kalainov DM, Cohen MS. Postero-lateral rotatory instability of the elbow in association with lateral epicondylitis: a report of three cases. J Bone Joint Surg Am. 2005;87(5):1120-5. 8. O’Driscoll SW, Spinner RJ, McKee MD, Kibler WB, Hastings II H, Morrey BF et al. Tardy postero-lateral rotatory instability of the elbow due to cubitus varus. J Bone Joint Surg Am. 2001;83A:1358-69. 9. Lee BPH, Teo LHY. Surgical reconstrution for posterolateral rotatory instability of the elbow. J Shoulder Elbow Surg. 2003;12(5):476-9. 10. Morrey BF, An KN. Functional anatomy of the ligaments of the elbow. Clin Orthop Relat Res. 1985;201:84-90.

11. Beckett KS, McConnell P, Lagopoulos M, Newman RJ. Variations in the normal anatomy of the collateral ligaments of the human elbow joint. J Anat. 2000;197(Pt3)507-11. 12. Imatani J, Ogura T, Morito Y, Hashizume H, Inoue H. Anatomic and histologic studies of the lateral collateral ligament complex of the elbow joint. J Shoulder Elbow Surg. 1999;8(6):625-7. 13. Nestor BJ, O’Driscoll SW, Morrey BF. Ligamentous reconstruction for posterolateral rotator instability of the elbow. J Bone Joint Surg Am. 1992;74(8):1235-41. 14. Rizzio L. Lateral Ulnar collateral ligament reconstruction in a skeletally immature patient. Am J Sports Med. 2005;33(3):439-42. 15. King GJW, Dunning CE, Zarzour ZDS, Patterson SD, Johnson JA. Single-strand reconstruction of the lateral ulnar collateral ligament restores varus and posterolateral rotatory stability of the elbow. J Shoulder Elbow Surg. 2001;11(1):60-4. 16. Olsen BS, Söjbjerg JO. The treatment of recurrent posterolateral instability of the elbow. J Bone Joint Surg Br. 2003;85(3):342-6. 17. Olsen BS, Vaesel MT, Söjbjerg JO, Helmig P, Sneppen O. Lateral collateral ligament of the elbow joint: anatomy and kinematics. J Shoulder Elbow Surg. 1996;5(2Pt1):103-12. 18. Vieira EA, Caetano EB. Bases anátomo-funcionais da articulação do cotovelo: contribuição ao estudo das estruturas estabilizadoras dos compartimentos medial e lateral. Rev Bras Ortop. 1999;34(8):481-8. 19. Cohen MS, Hastings H 2nd. Rotatory instability of the elbow. The anatomy and role of the lateral stabilizers. J Bone Joint Surg Am. 199779(2):225-33. 20. Dunning CE, Zarzour ZDS, Patterson SD, Johnson JA, King GJW. Ligamentous stabilizers against posterolateral rotatory instability of the elbow. J Bone Joint Surg Am. 2001;83A(12):1823-8. 21. McAdams TR, Masters GW, Srivastava S. The effect of arthroscopic sectioning of the lateral ligament complex of the elbow on posterolateral rotatory stability. J Shoulder Elbow Surg. 2005;14(3):298-301. 22. Cohen MS, Bruno JR. The collateral ligaments of the elbow: anatomy and clinical correlation. Clin Orthop Relat Res. 2001;383:123-30. 23. Goren D, Budoff JE, Hipp JA. Isometric placement of lateral ulnar collateral ligament reconstruction. Am J Sports Med. 2010;38(1):153-159. 24. Moritomo H, Murase T, Arimitsu S, Oka K, Yoshikawa H, Sugamoto K. The in vivo isometric point of the lateral ligament of the elbow. J Bone Joint Surg Am 2007;89(9):2011-7.


Rev Bras Ortop. 2013;48(1):57-61

www.rbo.org.br/

Original Article

Tibiocalcaneal arthrodesis using an Ilizarov fixator Alessandro Marcondes Leite,1 Helder Mattos Menezes,1 Igor e Castro Aquino,1 Jefferson Soares Martins,2 Frederico Barra de Moraes3* 1Resident

Physician in Orthopedics and Traumatology, Emergency Hospital of Goiânia, Goiânia, Goiás, Brazil. and Head of Residence in Orthopedics and Traumatology, Emergency Hospital of Goiânia, Goiânia, Goiás, Brazil. 3Orthopedist; MSc in Health Science from UFG/UnB; Doctoral Student and Preceptor of Residence in Orthopedics and Traumatology, Emergency Hospital of Goiânia, Goiânia, Goiás, Brazil. Work performed in the Foot and Ankle Group, Emergency Hospital of Goiânia, Goiânia, Goiás, Brazil. 2Orthopedist

article info

a b s t r a c t

Article history:

Objective: To evaluate the results of arthrodesis with Ilizarov fixator with tibiocalcaneana.

Received March 1 2012

Methods: We studied 12 patients with a mean age of 35 years, and 9 (75%) men and 3 (25%)

Approved September 14 2012

women, underwent arthrodesis tibiocalcaneana. The diagnosis in the preoperative talus infection. We used a modified surgical technique Reckling (6 patients) and the Ilizarov

Keywords:

technique, modified by Catagni (6 patients). Patients were evaluated by the AOFAS scale

Artrodese

research and patient satisfaction. Results: Union was achieved in 100% of cases. The mean

Ankle

time to healing was 6 months (range 4-12 months) and mean duration of external fixator

Ilizarov Technique

removal was 9 months (range 4-13 months). Stretching was performed in 6 patients with an average of 4 cm. The follow-up with Vancomycin lasted around 6 months. The average AOFAS score was 72.5 points (range 57 to 89 points). All patients were satisfied with the result. Conclusion: Despite the small number of cases, arthrodesis tibiocalcaneana seemed to be a good solution for cases of complex pathologies of the talus, such as infection, resulting in bone healing, pain relief and patient satisfaction. © 2013 Sociedade Brasileira de Ortopedia e Traumatologia.Published by Elsevier Editora Ltda. All rights reserved.

*Corresponding author at: Setor Universitário, Departamento de Ortopedia, Hospital das Clínicas, Primeira Avenida, sem número, CEP: 74000-000, Goiânia, Goiás, Brazil. E-mail: frederico_barra@yahoo.com.br ISSN/$–see front matter © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

doi: 10.1016/j.rboe.2013.04.005


58

Rev Bras Ortop. 2013;48(1):57-61

Introduction Arthrodesis is a surgical procedure that induces fusion of two or more joints with the objective of improving pain, stopping disease evolution or providing local stability. The main indications for arthrodesis of the ankle are in cases of posttraumatic arthrosis, after infection, rheumatoid arthritis and sequelae from non-reducible equinus deformity.1 The first case of arthrodesis of the ankle was described by Albert in 18822 and, since then, it has been shown to be the best therapeutic option for painful or unstable conditions of the ankle, if other means of treatment are insufficient. Because of increasing numbers of traffic accidents, particularly involving motorbikes, fractures and dislocations of the talus have been occurring more frequently. These are one of the main indications for tibiocalcaneal arthrodesis, because of the high rate of long-term complications. In most cases, talar infection is resistant to surgical debridement and broad regimens of antibiotic therapy, and conventional talectomy alone presents a high complication rate with unsatisfactory results.3,4 Many authors have therefore chosen to perform tibiocalcaneal arthrodesis in this situation, using an external Ilizarov fixator, because this not only allows stability for consolidation but also makes it possible to correct the limb shortening that results from talectomy.5 The objective of this study was to evaluate the clinical, radiographic and functional results among patients who underwent tibiocalcaneal arthrodesis using an Ilizarov fixator.

with compression of the osteotomized surfaces by means of an Ilizarov fixator4 (Figs. 4 and 5). In the other six patients, we used the same surgical procedure, but we created the assembly using the Ilizarov technique as modified by Catagni, with arthrodesis of the ankle using wires and Schanz pins, without ankle stretching using Schanz wires and pins and without associated stretching of the tibia6 (Fig. 6). In all the patients, the assembly encompassed both the hindfoot and the forefoot, with two Schanz pins in the calcaneus, one Schanz pin in the first metatarsal and one Schanz pin in the cuboid. The patients underwent functional clinical evaluation by means of the protocols of the American Orthopaedic Foot & Ankle Society (AOFAS)7 and measurement of the degree of satisfaction.

Material and methods Between February 2007 and October 2009, 12 patients underwent tibiocalcaneal arthrodesis performed by the Foot and Ankle Group at the Emergency Hospital of Goi창nia. A retrospective study was conducted by means of analysis of medical records and questionnaires applied to the patients, which enabled descriptive statistical analysis on the data gathered. This was a convenience sample composed of nine male patients and three female patients, with a mean age of 35 years (minimum of 18 and maximum of 60). In eight patients, the surgical procedure was performed on the right lower limb and in four patients, on the left lower limb. On admission, all the patients presented an exposed fracture of the ankle, classified as Gustilo III B, and evolved with locoregional infections, a few days after hospital admission (Figs. 1 and 2). The inclusion criterion was thus that these should be patients with talar infection due to traffic accidents, with local exposure. The exclusion criteria were that these should not be patients with diabetes mellitus or Charcot arthropathy. Each patient underwent an average of three surgical procedures during the treatment. Half of the sample (six patients) underwent stretching concomitantly with tibiocalcaneal arthrodesis, by means of osteotomy in the proximal third of the tibia, as elected by the patient (Fig. 3). For these patients, we used the modified Reckling technique, in which we created medial and lateral access routes and performed ostectomy on the fibula, resection of the medial malleolus and talectomy,

Fig. 1 - Preoperative clinical appearance.

Fig. 2 - Preoperative radiographic appearance.


Rev Bras Ortop. 2013;48(1):57-61

Fig. 3 - Osteotomy for stretching concomitantly with arthrodesis.

59

Fig. 6 - Ilizarov arthrodesis, as modified by Catagni.

Results Consolidation of the arthrodesis occurred in 100% of the cases, and was reached between 5 and 12 months after the operation (mean of six months) (Fig. 7). The mean time until removal of the external fixator was nine months. This difference regarding the time taken for the external fixator to be removed occurred because of the characteristics of our clinic, in which there is some difficulty in scheduling outpatient removal of fixators. The stretching was performed concomitantly with the arthrodesis in six patients, with a mean of 4 cm. The scale used (AOFAS, Graph 1) defines excellent results as between 90 and 100 points, good between 80 and 89, fair between 70 and 79 and poor below this. The mean score

Fig. 4 - Distal osteotomy of the tibia and fibula, with talectomy.

Fig. 5 - Assembly with Ilizarov and proximal tibial osteotomy.

Fig. 7 - Lateral X-ray showing consolidation of the arthrodesis.


60

Rev Bras Ortop. 2013;48(1):57-61

achieved was 72.5 points (fair), with a range from 57 to 89 points. There was no statistically significant difference between the patients who underwent stretching in the same procedure and those who elected not to do so. The infection was treated using vancomycin on an outpatient basis for six months after the surgery. This antibiotic therapy was used on an outpatient basis with follow-up by an infectologist, based on bone cultures with methicillin-resistant Staphylococcus aureus. The sample and the study results are presented in Table 1.

Post-op AOFAS

Graphic 1 - American Orthopaedic Foot & Ankle Society (AOFAS).

Discussion Since the first use of surgical arthrodesis on the ankle, several techniques have been proposed, albeit without any worldwide consensus. The possibilities for arthroplasty of the ankle still present unsatisfactory results and become particularly unviable in cases of infection. In situations without current infection, tibiotarsal arthrodesis can therefore be chosen, thereby preserving the talus and using internal synthesis materials, such as plates, screws and intramedullary nails. In the literature, these techniques have been shown to produce good results, with consolidation rates ranging from 77% to 100%. Complications consisting of infection (5% to 20%) and pseudarthrosis (20%) have been described.8 One of the indications for tibiocalcaneal arthrodesis is precisely the failure of previous tibiotalar arthrodesis. Other indications for this type of arthrodesis would include avascular necrosis of the talus, osteoarthritic involvement of these joints, sequelae from trauma, sever deformities due to neuromuscular diseases, Charcot arthropathy and presentation of bone failure or skeletal deformities following tumor resection.9 Arthrodesis of the ankle has been shown to be a viable procedure that can be indicated in selected cases for which all other therapeutic options have run out. Syme described 11 cases of death due to complications resulting from talar infection, 10 thus demonstrating the severity of these lesions. In the literature, a low success rate in cases of tibiotarsal arthrodesis with maintenance of the talus has also been described. This would be due to perpetuation of talar infection and occurrences of pseudarthrosis and delayed consolidation.11

Table 1 - Sample and results. Case no

Age

Sex

Number of procedures

Stretching

Consolidation Time until (months) removal of fixator

AOFAS

1

18

Male

Three

No

5 months

9 months

89

2

24

Male

Two

3 cm

4 months

4 months

80

3

26

Male

Three

4 cm

6 months

10 months

68

4

26

Male

Three

No

6 months

9 months

72

5

34

Female

Two

4 cm

6 months

10 months

70

6

35

Male

Three

4 cm

5 months

9 months

70

7

35

Male

Three

4 cm

7 months

10 months

72

8

38

Male

Four

No

5 months

9 months

70

9

40

Female

Two

No

6 months

8 months

80

10

41

Male

Five

5 cm

12 months

13 months

57

11

43

Male

Three

No

5 months

9 months

62

12

60

Female

Three

No

5 months

8 months

80

AOFAS: American Orthopaedic Foot & Ankle Society.


61

Rev Bras Ortop. 2013;48(1):57-61

Another treatment option that has been put forward in the literature is talectomy alone. However, studies on this have reported occurrences of pain and instability as considerable complications. In fact, amputation is not accepted by the vast majority of the patients12 and, moreover, it presents a high treatment cost, including hospitalization, fitting of a prosthesis and rehabilitation.13 In this light, one good therapeutic option for severe cases of infection of the talus would be talectomy and subsequent tibiocalcaneal arthrodesis, with external fixation. Some types of external fixators for performing tibiocalcaneal arthrodesis have been described, and among these, the Ilizarov fixator has been used with good results, because it provides the possibility of compression at the site of the arthrodesis, associated stretching and correction of deformities. In all of our patients, the clinical symptoms disappeared or diminished. The patients showed themselves to be satisfied with the treatment, with a good gait pattern and the ability to walk unaided. The patients who elected not to undergo the stretching adapted to using insoles and tennis shoes with rigid soles, and they did not present any statistical difference regarding the AOFAS score, in comparison with the group that underwent stretching. In the literature, there are results similar to those presented in this study, regarding arthrodesis of the ankle. Vianna14 achieved a long-term mean AOFAS score of 72.8 points, which was very similar to the result from our study, which was 72.5 points. However, 75% of the patients who we evaluated had scores of over 70 points, thus differing from the 60% found in the literature. The time taken for consolidation of the arthrodesis was similar to the results from other studies, which showed mean times until consolidation ranging from 4.5 to eight months, while our mean time until consolidation was six months. Some authors have described postoperative infection and pseudarthrosis as the main complications.15,16 In our study, we achieved consolidation in 100% of the cases and the infections resolved after six months of outpatient treatment with vancomycin.

R

E

1.

Conclusion

16.

Salomão O, Carvalho Jr AE, Fernandes TD, Marques J, Montenegro NB. Artrodese tibiotársica via transfibular. Rev Bras Ortop. 1991;26(10):369-72. Albert, Eduard: Einige Fälle von künstlicher Ankylosen bildung an paralytischen Gleidmassen. Viena: Wiener Medizinische Press; 1882. Canale ST, Kelly FB Jr. Fractures of the neck of the talus: Longterm evaluation of seventy-one cases. J Bone Joint Surg Am. 1978;60(2):143-56. Dennison MG, Pool RD, Simonis RB, Singh BS. Tibiocalcaneal fusion for avascular necrosis of the talus. J Bone Joint Surg Br. 2001;83(2):199-203. Johnson EE, Weltemer MD, Lian GJ, Cracchiolo A 3rd. – Ilizarov ankle arthrodesis. Clin Orthop. 1992;(280):161-9. Catagni MA. Fratture e pseudoartrosi – Trattamento con fissatore esternocircolare di Ilizarov. Studio CA, 1997. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 1994;15(7):349-53. Priano F, Molfetta L, Russo A. et al. Arthroscopic ankle arthrodesis: indications, technique and short-term results. J Sports Traumatol. 1996;18:143-8. Papa JA, Myerson MS. Pantalar and tibiotalocalcaneal arthrodesis for post-traumatic osteoarthrosis of the ankle and hindfoot. J Bone Joint Surg; 1992;74(7):1042-9. Syme J. Contributions to the pathology and practice of surgery. Edinburgh, Scotland: Sutherland and Knox;, 1848. Heckman JD. Fractures and dislocations of the foot. In: Rockwood CA, Green DP, Bucholz RW, Heckman, JD (Eds). Rockwood and Green’s Fractures in Adults. Philadelphia: Lippincott-Raven; 1996. p. 2226-405. Williams MO. Long-term cost comparison of major limb salvage using the Ilizarov method versus amputation. Clin Orthop Relat Res. 1994;(301):156-8. Huang CT, Jackson JR, Moore NB, Fine PR, Kuhlemeier KV, Traugh GH, et al. Amputation: energy cost of ambulation. Arch Phys Med Rehabil. 1979;60(1):18-24. Vianna S. Artrodese tibiotársica: resultado a longo prazo. R. Into. 2006;4(1):5-17. Gulan G, Sestan B, Jotanovic Z, Madarevic T, Mikacevic M, Ravlic-Gulan J, et al. Open total talar dislocation with extrusion (missing talus). Coll Antropol. 2009;33(2):669-72. Oboerien M, Ankle arthrodesis following trauma, a useful salvage procedure – A report on three cases. J Surg Tech Case Rep. 2011;3(2):102-5.

We therefore consider that tibiocalcaneal arthrodesis using an Ilizarov fixator is a good option for treating severe fractures and dislocations of the ankle associated with talar infection, with AOFAS scores greater than 70 points, and with a good degree of final satisfaction among the patients.

Conflicts of interest The authors declare that there was no conflict of interests in conducting this study.

2.

3.

4.

5. 6. 7.

8.

9.

10. 11.

12.

13.

14. 15.

F

E

R

E

N

C

E

S


Rev Bras Ortop. 2013;48(1):62-68

www.rbo.org.br/

Original Article

Positioning of the acetabular component in cemented prostheses – radiographic calculation Pedro José Labronici,1* Ramon Louro Motta,2 Bruno Bandeira Esteves,2 José Sergio Franco,3 Rolix Hoffmann,4 Luiz Aurélio Costa Ferreira,5 Marcos Giordano,6 Sergio Delmonte Alves7 1PhD

in Medicine from the Universidade Federal de São Paulo – Escola Paulista de Medicina. Head of the “Prof. Dr. Donato D’Ângelo” Orthopedics and Traumatology Service, Hospital Santa Teresa, Petrópolis, Rio de Janeiro, Brazil. 2Resident Physician in Orthopedics and Traumatology, “Prof. Dr. Donato D’Ângelo” Orthopedics and Traumatology Service, Hospital Santa Teresa, Petrópolis, Rio de Janeiro, Brazil. 3PhD. Head of Department and Associate Professor of the Department of Orthopedics and Traumatology, School of Medicine, universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Rio de Janeiro, Brazil. 4Physician in the “Prof. Dr. Donato D’Ângelo” Orthopedics and Traumatology Service, Hospital Santa Teresa, Petrópolis, Rio de Janeiro, Brazil. 5Resident Physician (R4) in the Hip Group, “Prof. Dr. Donato D’Ângelo” Orthopedics and Traumatology Service, Hospital Santa Teresa, Petrópolis, Rio de Janeiro, Brazil. 6Head of the Orthopedics and Traumatology Service, Galeão Air Force Hospital, Rio de Janeiro; MSc in Medicine Focusing on Orthopedics and Traumatology, Petrópolis, Rio de Janeiro, Brazil. 7Physician Responsible for the Hip Group, “Prof. Dr. Donato D’Ângelo” Orthopedics and Traumatology Service, Hospital Santa Teresa, Petrópolis, Rio de Janeiro, Brazil. Work performed at the “Prof. Dr. Donato D’Ângelo” Orthopedics and Traumatology Service, Hospital Santa Teresa, Petrópolis, Rio de Janeiro, and at the School of Medicine of Petrópolis, Petrópolis, Rio de Janeiro, Brazil. A RT I C L E I N F O

a b s t r a c t

Article history:

Objective: to assess the reliability of the inclination angle and anteversion of acetabular

Received January 18 2012

cup component in patients with idiopatic osteoarthritis of the hip, aseptic necrosis and

Approved April 27 2012

hip neck fracture using trigonometric formula and plain radiographs. Methods: 66 patients underwent cemented total arthroplasty of 72 hips. The inclination of acetabular component

Keywords:

was measured using plain radiograph. The acetabular component anteversion was

Mycobacteria, atypical

measured using trigonometric formula. Results: it was observed that, in the osteoarthritic

Keratitis

hips, hip neck fracture and aseptic necrosis, the degree of agreement was highly significant

Corneal transplantation

(p < 0.0001), in the measurements of anteversion and inclination angles, among the three assessments, from intra as well as inter-observers. All the agreement pairs were of excellent degree (ICC > 0.80). Conclusion: using plain radiographs and trigonometric formula, the method resulted to be highly accurate and reliable. Besides being easy to be calculated. No significant variation was found in the anteversion and inclination angles when compared with osteoarthritis of the hip, aseptic necrosis and hip neck fracture. © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

*Corresponding author at: Av. Roberto Silveira, 187/601, Petropolis, RJ, Brazil. CEP: 25685-040. Phone: (+55 24) 2242 5571. E-mail: plabronici@globo.com ISSN/$–see front matter © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved. doi: 10.1016/j.rboe.2012.04.001


Rev Bras Ortop. 2013;48(1):62-68

Introduction The positions of the components in total hip arthroplasty in relation to the femur and pelvis is important with regard to the prognosis for the surgery.1 The inclination and anteversion of the acetabular component were defined by Murray,2 in relation to three different perspectives: radiographic, surgical and anatomical. The present study analyzed only the radiographic angle, which is the inclination between the longitudinal and acetabular axes that is projected onto the coronal plane. Several studies in the literature have demonstrated the importance of achieving appropriate inclination and anteversion, and of making measurements on these.2-10 A variety of mathematical, trigonometric and fluoroscopic methods have been described for determining the position of the acetabular component on conventional radiographs.2,3,7,9,11,12 Lewinnek et al.13 proposed that the ideal radiographic image would be an acetabular component with anteversion of 15° (SD 10°) and abduction of 40° (SD 10°) with the aim of preventing impact and dislocation. The aim of the present study was to measure the reliability of the inclination and anteversion angles of the acetabular component in patients with idiopathic hip osteoarthrosis, aseptic necrosis and femoral neck fracture who underwent cemented total hip arthroplasty, through using a trigonometric formula for measuring the anteversion and through using direct measurement of the acetabular inclination angle on conventional radiographs.

63

measured using the angle between a line joining the ischial tuberosities and a line crossing the long axis of the acetabular component, determined by means of the axis of the major diameter that is formed by the projection of the metal rim on the radiograph (Fig. 1). The anteversion of the acetabular component was measured using Pradhan’s technique.11 A point M was marked at one-fifth of the distance along the maximum length of the diameter (D) of the ellipse projected on the ring of the acetabular dome (Fig 2). The perpendicular distance (p) was measured from the point M to the rim. Thus, the formula was: Planar anteversion = arc sin* (p/0.4D) *arc sin = trigonometric function involving operations with radian degrees.

Methods

Fig. 1 - Measurement of the inclination angle of the acetabular component. (a) – line tangential to the ischial tuberosities; (b) – line through the axis of the major diameter formed by the projection of the metal rim on the radiograph; (c) – acetabular inclination angle.

Between March 2009 and January 2011, 66 patients were treated with total hip arthroplasty, among which there were 12 bilateral and 60 unilateral cases, thus totaling 72 hips. Forty-eight patients of mean age 67.6 years presented hip osteoarthrosis. Sixteen patients of mean age 72.7 years presented femoral neck fractures, and eight patients of mean age 52.5 years presented aseptic necrosis. All the patients were treated with cemented total arthroplasty, both for the acetabular and for the femoral component, with use of the Hardinge direct lateral access. The inclusion factors were that these should be patients presenting idiopathic hip osteoarthrosis, aseptic necrosis and femoral neck fractures who were treated with total hip arthroplasty using a cemented acetabular component that had a circumferential metal rim around the entire edge of the acetabular polyethylene (BaumerR). The exclusion factors were that these should not be patients who presented acetabular revision components, hip dysplasia, previous acetabular fractures or osteometabolic diseases. The first postoperative radiograph was selected and the position of the acetabular component was measured in accordance with Murray’s technique.2 All the patients were positioned in dorsal decubitus with the radius centered over the public symphysis, to show both hips (foramen obturatum the same on both sides) and including the proximal third of the femur. The inclination of the acetabular component was

Fig. 2 - Measurement of the acetabular component by means of a trigonometric formula. Line D – distance of the maximum length of the diameter of the ellipse projected on the ring of the acetabular dome; point M – point marked at one-fifth of the distance of the maximum length of the diameter (D) of the ellipse projected on the ring of the acetabular dome; perpendicular distance (p) – perpendicular measurement from the point M to the metal ring.


64

Rev Bras Ortop. 2013;48(1):62-68

To analyze the inter and intra-observer reproducibility, each acetabulum was measured in random order by three orthopedic surgeons at different times while the result was kept concealed. Table 1 provides a general description of the sample of 72 hips that were studied. Tables 2 and 3 show the mean ± standard deviation, minimum and maximum for the anteversion and inclination angles, respectively, for each observer (Observer 1, Observer 2 and Observer 3) and the first and second measurements.

Table 1 - General description of the sample. Variable

Category

Age (years)

n

%

67.1 ± 14.2 (30 - 91)

Etiology

Arthrosis

48

66.7

Hip fracture

16

22.2

Aseptic necrosis

8

11.1

Right

38

52.8

Left

34

47.2

Side

Source: Hospital Santa Teresa. SD: standard deviation; age is expressed as the mean ± SD (minimum - maximum).

Table 2 - General description of the anteversion angle (degrees). Observer Measurement Mean ± SD Minimum Maximum Observer 1

Observer 2

Observer 3

AA 1

13.2

±

7.4

0

34.9

AA 2

13.0

±

7.4

2.7

32.6

AA 1

13.2

±

7.5

0

33.3

AA 2

12.2

±

7.0

0

29.2

AA 1

14.2

±

7.4

2.6

31.9

11.4

±

6.6

0

30.0

Source: Hospital Santa Teresa. AA1 – Anteversion angle of the first measurement; AA2 – Anteversion angle of the second measurement.

Table 3 - General description of the inclination angle (degrees). Observer Measurement Mean ± SD Minimum Maximum Observer 1

Observer 2

Observer 3

AI 1

42.6

± 9.0

22

64

AI 2

42.8

± 9.1

24

62

AI 1

42.6

± 8.6

24

62

AI 2

43.8

± 8.2

24

64

AI 1

42.5

± 8.8

22

64

AI 2

42.3

± 8.7

22

60

Source: Hospital Santa Teresa. AI1 – Inclination angle of the first measurement; AI2 – Inclination angle of the second measurement.

Methodology The statistical analysis comprised the intraclass correlation coefficient (ICC) for evaluating the intra and inter-observer agreement of the measurements of the anteversion and inclination angles, and one-way ANOVA 14 to investigate whether there was any significant difference in angles between the three types of etiology. The criterion for determining significance was taken to be the level of 5%. The statistical analysis was processed using the SPSS version 17.0 statistical software.

Result The intra and inter-observer reliability was assessed using the intraclass correlation coefficient (ICC), which ascertained whether there was any significant agreement in the measurements on the anteversion angle (AA) and inclination angle (AI) between the three evaluators (Obs 1, Obs 2 and Obs 3). It is known that the closer the ICC is to one, the stronger (or more perfect) the agreement is between the observers. In this case, the observers would be similar regarding numerical (quantitative) values. On the other hand, the closer to zero (0) the ICC is, the greater the disagreement is, i.e. the values are not reproduced and the differences are not random. Through a variety of studies and simulations, it can be said that: ICC ≤ 0.20 → no agreement 0.20 < ICC ≤ 0.40 → weak agreement 0.40 < ICC ≤ 0.60 → moderate agreement 0.60 < ICC ≤ 0.80 → good agreement ICC > 0.80 ≤ very good agreement (excellent) When strong agreement (ICC > 0.80) predominates in a study, the 95% confidence interval (95% CI) of the ICC is used as a differential, i.e. a narrow interval expresses greater precision. On the other hand, a wide interval expresses low precision, which is thus less reliable. Tables 4 to 6 show the ICC with its respective 95% CI and the descriptive level (p value) for each pair of observers. The anteversion and inclination angles were studied for the whole sample (n = 72) and separately according to the pathological condition: arthrosis (n = 48), hip fracture (n = 16) and aseptic necrosis (n = 8), respectively. Among the 74 hips studied, there was highly significant intra and inter-observer agreement (p < 0.0001) in the measurements of the anteversion and inclination angles between the three evaluators. All the pairs of agreement were of excellent degree (ICC > 0.80). It was observed that, in relation to the hips with arthrosis, there was highly significant intra and inter-observer agreement (p < 0.0001) in the measurements on the anteversion and inclination angles between the three evaluators. All the pairs of agreement were of excellent degree (ICC > 0.80). Among the hips with fractures, there was highly significant intra and inter-observer agreement (p < 0.0001) in the measurements of the anteversion and inclination


65

Rev Bras Ortop. 2013;48(1):62-68

Table 4 - Agreement analysis for the anteversion and inclination angles, for the total sample (n = 72). Measurement

Analysis

Observers

ICC

95% CI

p value

Obs1 x Obs1

0.951

0.92 - 0.97

< 0.0001

Intra-observer

Obs2 x Obs2

0.842

0.76 - 0.90

< 0.0001

Obs3 x Obs3

0.860

0.79 - 0.91

< 0.0001

Anteversion angle (AA)

Inter-observer (measurement 1)

Inter-observer (measurement 2)

Obs1 x Obs2

0.932

0.89 - 0.96

< 0.0001

Obs1 x Obs3

0.944

0.91 - 0.97

< 0.0001

Obs2 x Obs3

0.917

0.87 - 0.95

< 0.0001

Obs1 x Obs2

0.901

0.85 - 0.94

< 0.0001

Obs1 x Obs3

0.919

0.88 - 0.95

< 0.0001

0.900

0.85 - 0.94

< 0.0001

Obs1 x Obs1

0.956

0.93 - 0.97

< 0.0001

Obs2 x Obs2

0.917

0.87 - 0.95

< 0.0001

Obs3 x Obs3

0.942

0.91 - 0.96

< 0.0001

Obs1 x Obs2

0.942

0.91 - 0.96

< 0.0001

Obs1 x Obs3

0.958

0.93 - 0.97

< 0.0001

Obs2 x Obs3

0.936

0.90 - 0.96

< 0.0001

Obs1 x Obs2

0.921

0.88 - 0.95

< 0.0001

Obs1 x Obs3

0.946

0.92 - 0.97

< 0.0001

0.911

0.86 - 0.94

< 0.0001

Inclination angle (AI)

Intra-observer

Inter-observer (measurement 1)

Inter-observer (measurement 2)

Source: Hospital Santa Teresa. ICC: intraclass correlation coefficient; 95% CI: 95% confidence interval for the ICC; Obs: Observer.

Table 5 - Agreement analysis for the anteversion and inclination angles in the hips with arthrosis (n = 48). Measurement

Analysis

Observers

ICC

95% CI

p value

Obs1 x Obs1 Obs2 x Obs2

0.963

0.94 - 0.98

< 0.0001

0.864

0.77 - 0.92

< 0.0001

Anteversion angle (AA)

Intra-observer

Inter-observer (measurement 1)

Inter-observer (measurement 2) Inclination angle (AI) Intra-observer

Inter-observer (measurement 1)

Inter-observer (measurement 2)

Obs3 x Obs3

0.860

0.76 - 0.92

< 0.0001

Obs1 x Obs2

0.934

0.89 - 0.96

< 0.0001

Obs1 x Obs3

0.946

0.91 - 0.97

< 0.0001

Obs2 x Obs3

0.923

0.87 - 0.96

< 0.0001

Obs1 x Obs2

0.902

0.83 - 0.94

< 0.0001

Obs1 x Obs3

0.918

0.86 - 0.95

< 0.0001

0.897

0.82 - 0.94

< 0.0001

Obs1 x Obs1

0.946

0.91 - 0.97

< 0.0001

Obs2 x Obs2

0.900

0.83 - 0.94

< 0.0001

Obs3 x Obs3

0.940

0.90 - 0.97

< 0.0001

Obs1 x Obs2

0.929

0.88 - 0.96

< 0.0001

Obs1 x Obs3

0.945

0.90 - 0.97

< 0.0001

Obs2 x Obs3

0.928

0.88 - 0.96

< 0.0001

Obs1 x Obs2

0.909

0.84 - 0.95

< 0.0001

Obs1 x Obs3

0.937

0.89 - 0.96

< 0.0001

0.898

0.83 - 0.94

< 0.0001

Source: Hospital Santa Teresa. ICC: intraclass correlation coefficient; 95% CI: 95% confidence interval for the ICC; Obs: Observer.


66

Rev Bras Ortop. 2013;48(1):62-68

Table 6 - Agreement analysis for the anteversion and inclination angles in the fractured hips (n = 16). Measurement

Analysis

Observers

ICC

95% CI

p value

Obs1 x Obs1

0.903

0.75 - 0.97

< 0.0001

Obs2 x Obs2

0.709

0.36 - 0.89

0.001

Obs3 x Obs3

0.837

0.60 - 0.94

< 0.0001

Obs1 x Obs2

0.915

0.78 - 0.97

< 0.0001

Obs1 x Obs3

0.930

0.82 - 0.98

< 0.0001

Obs2 x Obs3

0.863

0.66 - 0.95

< 0.0001

Obs1 x Obs2

0.848

0.63 - 0.94

< 0.0001

Obs1 x Obs3

0.902

0.75 - 0.96

< 0.0001

0.882

0.70 - 0.96

< 0.0001

Obs1 x Obs1

0.957

0.88 - 0.99

< 0.0001

Obs2 x Obs2

0.943

0.85 - 0.98

< 0.0001

Obs3 x Obs3

0.946

0.86 - 0.98

< 0.0001

Obs1 x Obs2

0.957

0.89 - 0.99

< 0.0001

Obs1 x Obs3

0.981

0.95 - 0.99

< 0.0001

Obs2 x Obs3

0.934

0.83 - 0.98

< 0.0001

Obs1 x Obs2

0.935

0.83 - 0.98

< 0.0001

Obs1 x Obs3

0.969

0.92 - 0.99

< 0.0001

0.942

0.85 - 0.98

< 0.0001

Anteversion angle (AA)

Intra-observer

Inter-observer (measurement 1)

Inter-observer (measurement 2) Inclination angle (AI)

Intra-observer

Inter-observer (measurement 1)

Inter-observer (measurement 2)

Source: Hospital Santa Teresa. ICC: intraclass correlation coefficient; 95% CI: 95% confidence interval for the ICC; Obs: Observer.

angles between the three evaluators, except for the intraobserver agreement of Observer 2 for the anteversion angle (ICC = 0.709; p = 0.001). All the pairs of agreement were of excellent degree (ICC > 0.80), except for the intra-observer agreement of Observer 2. In addition, it was seen that the confidence intervals of the ICC for the measurements on the anteversion angle were wider (less precise) than those of the inclination angle. We investigated whether there were any differences in the anteversion and inclination angles between the three

Table 7 - Anteversion angle (in degrees) according to etiology. Etiology

n

Mean ± SD

Median

Arthrosis

48

13.9 ± 7.5

12.9

Fracture

16

11.7 ± 5.5

11.2

Necrosis

8

8.8 ± 4.6

9.0

Total

72

12.9 ± 7.0

12.0

p value a

0.12

Source: Hospital Santa Teresa. SD: standard deviation; a one-way ANOVA.

etiologies (arthrosis, neck fracture and necrosis). Tables 7 and 8 show the mean, standard deviation (SD) and median of the anteversion and inclination angles, respectively, according to the etiology and the corresponding descriptive level (p value) for one-way ANOVA. 14 In this analysis, the mean from six evaluations on each angle was used as the comparison measurement. It was observed that there was no significant difference at the 5% level, in the anteversion angle (p = 0.12) and inclination angle (p = 0.16), between the etiologies in this study sample.

Table 8 - Inclination angle (in degrees) according to etiology. Etiology

n

Mean ± SD

Median

Arthrosis

48

44,1 ± 8,5

43,9

Fracture

16

40,0 ± 7,6

39,8

Necrosis

8

40,2 ± 9,4

38,4

Total

72

42,8 ± 8,5

41,8

Source: Hospital Santa Teresa. SD: standard deviation; a one-way ANOVA.

p value a

0,16


Rev Bras Ortop. 2013;48(1):62-68

Discussion Radiography is the most important means for making diagnoses after total hip arthroplasty. It is a low-cost examination and can be done in any hospital. While the inclination of the acetabulum can be measured by means of conventional radiographs, calculation of the anteversion still presents problems, and even more so when done in cases of different pathological conditions. The methods described for evaluating anteversion involve complex mathematical and trigonometric equations for ellipses. McLaren15 described anteversion as a function of a coefficient with minimum and maximum diameters of an ellipse. He prepared a reference table for each degree of anteversion. Visser et al.7 described a complex trigonometric formula using a system of Cartesian coordinates on a projected ellipse. They did not record the efficiency of their methods. Ghelman 16 used fluoroscopy by changing the direction of the X=ray ampulla from cephalic to caudal and observed the angle of the tube in the sagittal plane when the two halves of the ellipse were superimposed, which was when the X-rays were tangential to the opening of the acetabular dome. This author defined this process as the version angle. Schneider et al. 17 used a similar technique, but obtained several images until the wire circle of the acetabulum became tangential. These methods involved repeated irradiation, with greater cost and time. Lewinnek et al.13 proposed a safe radiographic range for the position of the acetabular dome with an anteversion of 15° (SD 10°) and abduction of 40° (SD 10°), but based only on nine dislocations. In order to prevent impact and dislocation, McCollum and Gray18 determined that the safe range for the position of the dome was from 30° to 50° of abduction and 20° to 40° of horizontal flexion. Dorr and Wan19 considered that poor positioning of the dome would be an anteversion of less than 15° or greater than 30° and an abduction angle greater than 55°. To obtain true anteversion values, they added 5° to the angle measured on the anteroposterior radiograph of the pelvis. Khan 20 radiographically graded the anteversion of acetabular components that exceeded 15° and considered that they were too vertical if the abduction angle exceeded 50°. Biedermann et al. 21 demonstrated that there was no safe range for the position of the acetabular component and that anteversion of 15° and inclination of 45° presented the least risk of dislocation when an anterolateral access was used. Paterno et al. 22 were unable to establish any association between the anteversion or inclination angle of the acetabular component and the risk of dislocation. Thus, they concluded that the importance of the inclination angle as a risk factor for dislocation might have been exaggerated in preliminary studies. Ackland et al.9 described a method using a mathematical formula for calculating the minor axis of the ellipse in order to avoid “unacceptable subjective human errors.” They considered that it was too laborious to calculate each case through this formula and therefore used a computer program to make future estimates. They drew up a table to read the degrees of anteversion. However, the formula used was not

67

shown. Hassan et al.23 described a complex mathematical formula for evaluating planar anteversion and attested it through the intra-observer reliability. Pradhan 11 described a method based on the elementary geometry of circles and triangles, and developed a simple formula that could be used to determine the planar anteversion using a pocket calculator. The results from different studies cannot be compared with each other because of the various definitions of anteversion that are used. Some authors have not used standard measurements or well-documented radiographic measurements, thus preventing precise measurement of the angling of the acetabular component.21 I t w a s d e m o n s t ra t e d i n t h e p re s e n t s t u dy t h a t measurement of the anteversion and of the acetabular inclination angle, when the X-ray ampulla was correctly centered over the hip, and with use of the trigonometric formula, was highly accurate and easy to calculate and presented high reliability. According to the literature, the inclination angle ranges from 33° to 50° and the anteversion angle from 15° to 30°. In this study, the mean inclination angle of the total sample was 43° and the mean anteversion angle was 13°. The mean anteversion angle in the hip arthrosis cases was 14°, in the hip fracture cases 12° and in the aseptic necrosis cases 9°. The mean inclination angle in the hip arthrosis cases was 43°, in the hip fracture cases 41° and in the aseptic necrosis cases 41°. Therefore, as demonstrated in the results, there was no significant variation in the inclination angle. However, regarding the anteversion angle, there was a tendency towards differences in angle between the different pathological conditions. It was observed that the degree of agreement of measurements of anteversion and inclination angles between the three evaluators in the intra and interobserver assessments was highly significant (p < 0.0001), in all three pathological conditions (hip arthrosis, femoral neck fracture and aseptic necrosis). All the agreement pairs were of excellent degree (ICC > 0.80), except for the intraobserver agreement for Observer 2 regarding the anteversion angle in hip fractures (ICC = 0.709; p = 0.001). In the present sample, there was no significant difference in anteversion angle (p = 0.12) and inclination angle (p = 0.16) between the etiologies. However, the major limitation of this study was the presence of only small numbers of patients with femoral neck fracture and aseptic necrosis. It is worth emphasizing that this method cannot be used in arthroplasty cases that use a metal back or surfaces other than polyethylene, and when the latter is used, it needs to be cemented and have a metal rim along the entire acetabular edge, in order to enable measurement.

Conclusion Using conventional radiographs and a trigonometric formula, the method was shown to be highly accurate, easy to calculate and very reliable. There was no significant variation in the anteversion and inclination angles when compared with regard to hip arthrosis, aseptic necrosis and femoral neck fracture.


68

Rev Bras Ortop. 2013;48(1):62-68

Conflicts of interest The authors declare that there was no conflict of interests in conducting this study.

R

1.

E

F

E

R

E

N

C

E

S

Charnley J. The long-term results of Low-friction arthroplasty of the hip performed as a primary Intervention. J Bone Joint Surg Br. 1972;54(1)-B:61-76. 2. Murray D. The definition and measurement of acetabular orientation. J Bone JointSurg Br. 1993;75(2):228-32. 3. Hassan DM, Johnston GH, Dust WN, Watson G, Dolovich AT. Accuracy of intraoperative assessment of acetabular prosthesis placement. J Arthroplasty. 1998;13(1):80-4. 4. Muller O, Reize P, Trappmann D, Wulker N. Measuring anatomical acetabular cup orientation with a new X-ray technique. Comput Aided Surg. 2006;11(2):69-75. 5. Wan Z, Malik A, Jaramaz B, Chao L, Dorr LD. Imaging and navigation measurement of acetabular component position in THA. Clin Orthop Relat Res. 2009;467(1):32-42. 6. Derbyshire B. Correction of acetabular cup orientation measurements for X-ray beam offset. Med Eng Phys. 2008;30(9):1119-26. 7. Visser JD, Konings JG. A new method for measuring angles after total hip arthroplasty: a study of the acetabular cup and femoral component. J Bone Joint Surg Br. 1981;63-B:556-9. 8. Amuwa C, Dorr LD. The combined anteversion technique for acetabular component anteversion. J Arthroplasty. 2008;23(7):1068-70. 9. Ackland MK, Bourne WB, Uhthoff HK. Anteversion of the acetabular cup: measurementof angle after total hip replacement. J Bone Joint Surg [Br]. 1986;68(3):409-13. 10. Hill JC, Gibson DP, Pagoti R, Beverland DE. Photographic measurement of the inclination of the acetabular component in total hip replacement using the posterior approach. J Bone Joint Surg Br. 2010;92(9):1209-14.

11. Pradhan R. Planar anteversion of the acetabular cup as determined from plain anteroposterior radiographs. J Bone Joint Surg Br. 1999;81(3):431-5. 12. Widner KH. A simplified method to determine acetabular cup anteversion from plain radiographs. J. Artroplast. 2004;19(3):387-90. 13. Lewinnek GE, Lewis JL, Tarr R, Compere CL, Zimmerman JR. Dislocations after total hip-replacement arthroplasties. J Bone Joint Surg Am. 1978;60(2):217-20. 14. Bartko, JJ, Carpenter WT. On the methods and theory of reliability. The J Nerv Ment Dis. 1976;163(5):307-16. 15. McLaren RH. Prosthetic hip angulation. Radiology 1973;107(3):705-6. 16. Ghelman B. Radiographic localization of the acetabular component of a hip prosthesis. Radiology. 1979;130(2):540-2. 17. Schneider R, Freiberger RH, Ghelman B, Ranawat CS. Radiologic evaluation of painful joint prostheses. Clin Orthop Relat Res. 1982;(170):156-68. 18. McCollum DE, Gray WJ. Dislocation after total hip arthroplasty: causes and prevention. Clin Orthop Relat Res 1990;(261):159-70. 19. Dorr LD, Wan Z. Causes of and treatment protocol for instability of total hip replacement. Clin Orthop Relat Res. 1998;(355):144-51. 20. Ali Khan MA, Brakenbury PH, Reynolds IS. Dislocation following total hipreplacement. J Bone Joint Surg Br. 1981;63B(2):214-18. 21. Biedermann R, Tonin A, Krismer M, Rachbauer F, Eibl G, Stockl B. Reducing the risk of dislocation after total hip arthroplasty. The effect of orientation of the acetabular component. J Bone Joint Surg Br. 2005;87(6):762-9. 22. Paterno SA, Lachiewicz PF, Kelley SS. The influence of patientrelated factors and the position of the acetabular component on the rate of dislocation after total hip replacement. J Bone Joint Surg Am. 1997;79(8):1202-10. 23. Hassan DM, Johnston GHF, Dust WNC, Watson LG, Cassidy D. Radiographic calculation of anteversion in acetabular prostheses. J Arthroplasty. 1995;10(3):369-72.


Rev Bras Ortop. 2013;48(1):69-79

www.rbo.org.br/

Original Article

Videoarthroscopic treatment of glenohumeral osteoarthritis Glaydson Gomes Godinho1*, Flavio Marcio Lago Santos2, Flavio Oliveira França3, José Márcio Alves Freitas4, Fabrício Augusto Silva Mesquita5, Thiago Serpa de Azevedo Silva5 1Head

of the Shoulder Surgery and Rehabilitation Service, Orthopedic Hospital (HO), Hospital Belo Horizonte (HBH) and Lifecenter Hospital (HLC), Belo Horizonte, MG, Brazil. 2Surgeon in the Shoulder Surgery and Rehabilitation Service, HLC, Belo Horizonte, MG, Brazil. 3Surgeon in the Shoulder Surgery and Rehabilitation Service, HO and HLC, Belo Horizonte, MG, Brazil. 4Surgeon in the Shoulder Surgery and Rehabilitation Service, HO and HBH, Belo Horizonte, MG, Brazil. 5Resident Physician (R4) in the Shoulder Surgery and Rehabilitation Service, HO, HBH and HLC, Belo Horizonte, MG, Brazil. Work performed at the Shoulder Surgery and Rehabilitation Service, Orthopedic Hospital and Hospital Belo Horizonte, MG, Brazil.

article info

a b s t r a c t

Article history:

Objetive: To evaluate possible benefits obtained through the use of surgical videoarthrosco-

Received January 24 2011

py in the management of glenohumeral osteoarthritis.

Approved May 28 2011

Methods: We evaluated 37 patients (38 shoulders) who underwent through surgical videoarthroscopy in the period between November 1999 and May 2009 (minimum follow-up of

Keywords:

two years). Twenty five patients attend for revaluation and thirteen were interviewed by

Shoulder

telephonic contact. Functional assessments were performed (UCLA, Constant, and measu-

Arthroscopy

rement of range of motion –ROM-), as well as pre and post surgical radiographics. We eva-

Osteoarthritis

luated the influence of the following factors in the final results: the presence of chondral lesions, joint space narrowing, osteophyte presence, associated injuries (rotator cuff torn or instability), and follow-up. Among those patients interviewed by phone we evaluated the satisfaction level and if they would submit themselves again to the surgical procedure. Results: It was observed significant gain towards to the function (UCLA) and the internal rotation, as well as the association between dissatisfaction and pre surgical joint space reduced. Among the operated patients, 84% were satisfied with the results and 86.6% would repeat the procedure. Conclusion: Surgical videoarthroscopy presents a relevant role in management of the glenohumeral osteoarthritis, providing improvement of functional results and high levels of satisfaction. © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved

*Corresponding author at: Rua Prof. Otávio Coelho de Magalhães, 111, bl. C, 2º piso, Mangabeiras, CEP: 30210-300, Belo Horizonte, MG, Brazil. E-mail: glaydsongg@gmail.com ISSN/$–see front matter © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved. doi: 10.1016/j.rboe.2011.05.001


70

Rev Bras Ortop. 2013;48(1):69-79

Introduction Osteoarthritis of the glenohumeral joint is not uncommon and may affect more than 20% of the elderly population. Its therapeutic management begins with conservative methods, with the aims of alleviating painful symptoms and improving range of motion. Lifestyle changes, analgesic and anti-inflammatory medication, physiotherapy, joint infiltrations with corticoids and viscosupplementation have been mentioned in the literature.1-5 When conservative methods fail, total arthroplasty or hemiarthroplasty provide significant relief of painful symptoms and functional improvement, particularly in more elderly populations (over the age of 60 years). However, in younger populations (under the age of 50 years) that are active, these procedures do not present the same results, due mainly to the high functional demands made by this age group, their functional expectations and the length of survival of the implants, especially the glenoid component. 1,4,6,7 Among patients with this profile, arthroscopic management may provide relief for painful symptoms and functional improvements. However, it is incapable of restoring joint cartilage that presents lesions.8,9 The arthroscopic procedures of lavage and debridement provide satisfactory short-term results for 70 to 88% of these patients.8-10 The aim of the present study was to evaluate the results from videoarthroscopic treatment among patients with glenohumeral osteoarthritis.

with the arm abducted at 90° (RL II) and internal rotation (RM) with a mean limitation of five vertebral levels. Out of the total, 33 shoulders presented associated diseases: 22 rotator cuff injuries, 10 Bankart lesions, three Slap lesions and one case dysplasia of the proximal humerus. The patients selected were evaluated before and after the operation. The preoperative evaluations were done by reviewing the medical files and the initial radiographs, and the following data were gathered: age, gender, dominance, side affected, ranges of motion (EAA, EAP, ER I, ER II and IR), radiographic evaluation of the joint space (in the true anteroposterior and simple axillary lateral views),11 radiographic classification according to Samilson and Prieto12 (Fig. 1), function evaluation using the University of California

Methodology A retrospective survey was conducted among the patients with conditions of glenohumeral osteoarthritis (primary or secondary) who underwent operations arthroscopically, performed by the orthopedic shoulder group of Belo Horizonte between November 1999 and May 2009, with a minimum follow-up of two years. We identified 65 patients and 70 shoulders operated. Five patients (seven shoulders) were excluded from the study due to death; three patients were excluded because their cases evolved to arthroplasty; 18 patients (20 shoulders) were excluded because they could not be contacted; and two patients (two shoulders) were excluded because they refused to supply data for the investigation. Thirteen patients (14 shoulders) were unable to come for a physical examination and were interviewed by means of the telephone. Out of the 37 patients (38 shoulders), 23 were male and 14 were female, with a mean age of 58.3 years (range: 33 to 80 years). The mean length of follow up was 5.13 years (range: 2 to 11 years). There were 28 operations on right shoulders and 10 on left shoulders; 26 cases involved the dominant arm and 12 were on the non-dominant arm. The initial mean range of motion was: 143.5° of active anterior elevation (EAA), 155° of passive anterior elevation (EAP), 50.13° of external rotation with the arm beside the body (RL I), 72.3° of external rotation

Fig. 1 - Samilson and Prieto classification:12 A) Mild arthrosis – lower osteophyte of the humeral head and/or glenoid smaller than 3 mm; B) Moderate arthrosis – lower osteophyte of the humeral head and/or glenoid measuring 3 to 7 mm, with gentle irregularity of the joint surface; C) Advanced arthrosis – lower osteophyte of the humeral head and/or glenoid larger than 7 mm, reduction of the joint space and bone sclerosis.

at Los Angeles (UCLA) score and presence of associated lesions. We reviewed the operative records of each patient, thus obtaining the classification of the chondral lesion as described by Outerbridge13 (Fig. 2), and the surgical procedures performed (debridement, resection or non-resection of osteophytes or microfractures and treatment of associated lesions). The results from capsulotomy and microfractures


Rev Bras Ortop. 2013;48(1):69-79

GRADE 1

Softening of the cartilage

GRADE 2

Fragmentation and fissures covering an area less than or

GRADE 3

Fragmentation and fissures covering an area greater than

GRADE 4

Erosion of the subchondral bone

equal to 1.5 cm in diameter 1.5 cm in diameter

Fig. 2 - Outerbridge classification13 developed for patellar chondromalacia. were not assessed separately, since these were performed on limited numbers of patients (four and three, respectively). The postoperative evaluations were made by two independent examiners who had not participated in the surgical procedures. Twenty-four patients came for the examination (24 shoulders), at which they underwent assessments of range of motion (EAA, EAP, ER I and ER II by means of a goniometer and IR by means of the difference in vertebral level achieved, between the operated and contralateral sides) and the length of postoperative follow-up, with radiographic evaluation (preservation or non-preservation of the joint space and the Samilson and Prieto classification) and functional evaluation by means of the Constant and UCLA scores. The patients were also asked whether they would go through the same surgical procedure again if necessary. The 13 patients (14 shoulders) who were unable to come for the physical examination were interviewed over the telephone and were evaluated regarding their current degree of satisfaction (satisfied or dissatisfied, in accordance with the UCLA score) and whether they would go through the same surgical procedure again. One patient in this group had undergone treatment in both shoulders: we considered evaluating each shoulder separately, since we judged that the subjective evaluation on one would not influence that of the other. The preoperative and postoperative ranges of motion and functional evaluations were compared. We investigated the influence of the degree of chondral degeneration, the size of the humeral or glenoid osteophyte (in accordance with the Samilson and Prieto classification), degree of preservation of the preoperative joint space, the length of postoperative follow-up and the presence of rotator cuff injuries or instability associated with glenohumeral osteoarthritis in postoperative functional assessments (Constant and UCLA). We divided the occurrences of chondral degeneration into two groups: one with Outerbridge grades 1, 2 and 3 (mild to moderate chondral degenerations) and the other with Outerbridge grade 4 (advanced chondral degenerations). In relation to the size of the osteophyte, one group included patients with osteophytes smaller than 8 mm (mild and moderate arthrosis; Samilson and Prieto stages 1 and 2) and the other group included patients with osteophytes larger than or equal to 8 mm (advanced arthrosis; Samilson and Prieto stage 3). Among the patients in the second group (osteophytes larger than 8 mm), the influence of resection of the osteophyte on the postoperative functional result was analyzed. The length of postoperative follow-up among the patients evaluated ranged from 2 to 11 years. To analyze its importance regarding the postoperative functional evaluations, we compared the results between the patients with up to five

71

years of follow-up with those with less than five years of follow-up. We also evaluated the influence of the length of follow-up on the functional results, in comparing the groups of chondral lesions (mild to moderate versus advanced), size of osteophyte (Samilson 1 and 2 versus Samilson 3) and joint space (preserved versus reduced), since a difference in length of follow-up between the groups compared might directly influence the results. In relation to the associated lesions, we identified two groups of patients: one with rotator cuff injuries and the other with instability (Bankart or Slap). Two patients (two shoulders) who presented both instability and rotator cuff injury in association were taken to belong to the group of rotator cuff injuries. Among the patients who said that they were dissatisfied in the postoperative subjective UCLA evaluation, we analyzed which preoperative factors (degree of chondral degeneration, Samilson classification stage and joint space) contributed towards that level of satisfaction, along with the influence of the length of follow-up. The statistical analysis was done using the resources of the PASW statistical software, version 18. The results were described in terms of descriptive measurements for quantitative variables and frequency tables for the qualitative variables analyzed. The significance of the chondral degeneration, Samilson and Prieto stage, joint space, length of follow-up and resection of the osteophyte among the patients with Samilson and Prieto stage 3, in relation to the functional result, along with the influence of the length of follow-up on the patients level of satisfaction, was evaluated using nonparametric MannWhitney tests. The differences between the preoperative and postoperative ranges of motion and UCLA scores were assessed using the nonparametric Wilcoxon test. Contingency tables were used to correlate the patientsâ&#x20AC;&#x2122; degree of satisfaction with the preoperative factors of chondral degeneration, Samilson and Prieto stage and joint space. Fisherâ&#x20AC;&#x2122;s chi-square test was used to investigate the statistical significance of associations between these variables. To compare the means of the Constant and UCLA variables of the group of patients with associated pathological conditions present (rotator cuff injury or instability) with those of the patients in the full sample, the t test for one sample was used. In this study, the specific value to be tested was the calculation of the general mean of 24 patients for the Constant and UCLA variables. In all the statistical tests used, the significance level was taken to be 5%. Thus, associations were considered to be statistically significant if the p value was less than 0.05.

Results Among the 24 patients (24 shoulders) on whom the functional results were analyzed, the preoperative mean UCLA score was 16 and the postoperative score was 28, with a significant difference between them (p = 0,000) (Fig. 3). The mean postoperative Constant score was 71.8.


72

Rev Bras Ortop. 2013;48(1):69-79

the patients with advanced degeneration, 4.53 years; this difference was not significant (p = 0.402) (Fig. 4). Thirteen of the 24 patients presented reduced joint space (less than 2 mm) and 11, preserved joint space in the preoperative radiographic evaluation. In the preoperative functional evaluation, the UCLA of the first group was 15 and of the second group, 21, without any significant difference between these values (p = 0.081). After the operation, the patients with reduced joint space presented UCLA of 26

Preoperative

Postoperative

Fig. 3 - Difference in UCLA score between pre and postoperative evaluations. *p < 0.05.

These 24 patients presented the following mean preoperative ranges of motion: active anterior elevation = 160°, passive anterior elevation = 160°, external rotation with arm beside the body = 50°, external rotation with the arm abducted at 90° = 70° and medial rotation limited to six vertebral levels. The postoperative values were as follows: active anterior elevation =155°, passive anterior elevation = 160°, external rotation with arm beside body = 45°, external rotation with arm abducted at 90° = 78° and internal rotation limited to three vertebral levels. With the exception of the internal rotation (p = 0.043), there were no difference between the preoperative and postoperative range of motion measurements (Table 1). Among the 24 patients, 12 presented mild to moderate chondral degeneration (Outerbridge 1, 2 and 3) and the other 12 presented advanced chondral degeneration (Outerbridge 4). In the preoperative functional evaluation, the UCLA score of the first group was 18.5 and of the second group, 17, and there was no significant difference between these values (p = 0.706). After the operation, the patients with mild to moderate abnormalities presented UCLA of 29.5 and Constant of 75. The patients with advanced abnormalities presented UCLA of 27 and Constant of 78. The differences between the two groups were not significant (p = 0.367 and p = 0.862). The mean length of follow-up for the patients with mild to moderate degeneration was five years and for

Preoperative UCLA*

Postoperative UCLA**

Postoperative Constant***

Follow-up (years)****

Fig. 4 - Influence of the degree of chondral degeneration on the functional results. *p = 0.706; **p = 0.367; ***p = 0.862; ****p = 0.402.

and Constant of 79, while the patients with preserved joint space presented UCLA of 31 and Constant of 74. The differences between the two groups were not significant (p = 0.155 and p = 0.663). The mean length of follow-up among the patients with reduced joint space was 3.8 years and it was five years among the patients with preserved joint space. This difference was not significant (p = 0.522) (Fig. 5). Among the 24 patients, 12 presented lower osteophytes smaller than 8 mm (Samilson and Prieto stages 1 and 2), while the other 12 had osteophytes larger than or equal to 8 mm (Samilson and Prieto stage 3). In the preoperative functional evaluation, the UCLA of the first

Table 1 - Pre and postoperative ranges of motion. EAA

EAP

ER I

ER II

IR (NV)

Preoperative

160° (38.098)

160° (31.021)

50° (21.110)

70° (27.544)

6 (2.64)

Postoperative

155° (36.235)

160° (23.175)

45° (29.167)

78° (28.746)

3.5 (3.09)

p = 0.455

p = 0.836

p = 0.178

p = 0.454

p = 0.043

The values in parentheses are the standard deviations of the means for each range of motion. The p values in bold indicate significant differences. EAA: active anterior elevation; EAP: passive anterior elevation; ER I: external rotation with arm beside body; ER II: external rotation with arm at 90° of abduction; IR: internal rotation; NV: difference in vertebral levels.


73

Rev Bras Ortop. 2013;48(1):69-79

Preserved joint space Reduced joint space

Preoperative UCLA*

Postoperative UCLA**

Postoperative Constant***

Follow-up (years)****

Fig. 5 - Influence of the joint space on the functional results from the preoperative radiographic evaluation. *p = 0.081; **p = 0.153; ***p = 0.663;****p = 0.523.

group was 19.5 and of the second group, 14.5, without a significant difference between these values (p = 0.582). After the operation, the patients with osteophytes smaller than 8 mm presented UCLA of 29.5 and Constant of 75.5, while the patients with osteophytes larger than or equal to 8 mm had UCLA of 28 and Constant of 76.5. The differences between the two groups were not significant (p = 0.727 and p = 0.772). The mean length of follow-up among the patients with osteophytes smaller than 8 mm was 5.7 years and, among the patients with osteophytes larger than 8 mm, 3.3 years. This difference was not significant (p = 0.236) (Fig. 6). Among the 12 patients with osteophytes larger than or equal to 8 mm (Samilson and Prieto stage 3), eight underwent resection of the osteophyte and four did not undergo this procedure. The preoperative UCLA scores (15.5 and 15.5), postoperative UCLA scores (25 and 26.5) and postoperative Constant scores (69 and 70.5) did not present any significant differences (p = 0.798, 0.730 and 0.864) (Fig. 7). Among the 24 patients, 13 presented lengths of follow-up less than or equal to five years and 11 presented follow-ups longer than five years. The preoperative UCLA scores (15 and 15), postoperative UCLA scores (28 and 28) and postoperative Constant scores (77 and 74) did not present any significant differences (p = 0.931, 0.907 and 0.642). For these 24 patients, the mean preoperative UCLA and postoperative Constant were respectively, 16.6, 25.6 and 71.9; the mean length of follow-up among this population was 5.3 years. Of these patients, 16 presented rotator cuff injuries associated with osteoarthritis and had preoperative UCLA = 17.5, postoperative UCLA = 24.3 and postoperative Constant = 70.6; the mean length of follow-up among these patients was 5.25 years. There was no significant difference between these values and those of the compete group (p = 0.503, 0.540, 0.740 and 0.929) (Table 2). The five patients in whom the associated pathological condition was instability presented preoperative UCLA = 14.8, postoperative UCLA = 25 and postoperative Constant = 74.4. The mean length of follow-up among these patients was 4.84 years. There was no significant difference in these values in comparison with the complete group (p = 0.403, 0.860, 0.647 and 0.413) (Table 3).

Preoperative UCLA*

Postoperative UCLA**

Postoperative Constant***

Follow-up (years)****

Fig. 6 - Influence of the stage of the Samilson classification on the functional results. *p = 0.582; **p = 0.727; ***p = 0.772;****p = 0.236.

Osteophyte not resected Osteophyte resected

Preoperative UCLA*

Postoperative UCLA**

Postoperative Constant***

Fig. 7 - Influence of the resection of osteophytes on the functional results of patients with Samilson stage 3. *p = 0.798; **p = 0.730; ***p = 0.864.

Out of the 38 shoulders included in this study (24 shoulders among the patients examined and 14 shoulders among the 13 patients interviewed over the telephone), 32 (84%) presented satisfactory results in the subjective assessment. Also in this evaluation, there were no significant differences regarding the degree of chondral degeneration (p = 0.645), Samilson classification stage (p = 1.000) or length of follow-up (p = 0.542) between the shoulders with satisfactory and unsatisfactory results (Tables 4 and 5). The mean length of follow-up among the shoulders with satisfactory results in the subjective assessment was 4.75 years and among the unsatisfactory ones, 5.63 years, without any significant difference (p = 0.542). There was an association between unsatisfactory results in the subjective assessment and the presence of reduced preoperative joint space (p = 0.024) (Table 6). Among the 37 patients included in the study, 33 (89%) would go through the surgical procedure again.


74

Rev Bras Ortop. 2013;48(1):69-79

Table 2 - Functional results among the patients with rotator cuff injury and in the complete group (t test). UCLA preop

UCLA postop

Constant postop

Follow-up (years)

24 patients

16

28

71.8

5.31

Rotator cuff injury (16 patients)

17.5 (5.73)

24.31 (8.4)

70.06 (20.45)

5.25 (2.64)

p = 0.530

p = 0.540

p = 0.740

p = 0.929

The values in parentheses are the standard deviations of the means for each value.

Table 3 - Functional results among the patients with instability and in the complete group (t test). UCLA preop

UCLA postop

Constant postop

Follow-up (years)

24 patients

16

28

71.8

5.31

Instability (5 patients)

14.8 (7.05)

25 (7.52)

74.4 (11.8)

4.84 (1.15)

p = 0.603

p = 0.860

p = 0.647

p = 0.413

The values in parentheses are the standard deviations of the means for each value.

Table 4 - Association between degree of satisfaction and degree of chondral degeneration (Fisher chi-square test). Outerbridge Satisfaction

Dissatisfied Satisfied Total

1,2,3

4

Total

p-value 0.645

Cases

2

4

6

%

33.3%

66.7%

100.00%

Cases

11

9

20

%

55.0%

45.0%

100.0%

Cases

13

13

26

%

50.0%

50.0%

100.0%

Table 5 - Association between degree of satisfaction and the preoperative Samilson stage (Fisher chi-square test). Samilson preop Satisfaction

Dissatisfied Satisfied Total

1,2

3

Total

p-value 1,000

Cases

3

3

6 100.0%

%

50.0%

50.0%

Cases

9

11

20

%

45.0%

55.0%

100.0%

Cases

12

14

26

%

46.2%

53.8%

100.0%

Table 6 â&#x20AC;&#x201C; Association between degree of satisfaction and the preoperative joint space. Preop joint space Satisfaction

Dissatisfied Satisfied Total

Preserved

Reduced

Total

p-value 0.024

Cases

0

6

6

%

0%

100.0%

100.0%

Cases

11

9

20

%

55.0%

45.0%

100.0%

Cases

11

15

26

%

42.3%

57.7%

100.0%


Rev Bras Ortop. 2013;48(1):69-79

Discussion Glenohumeral osteoarthritis may result in significant functional incapacity. From the patientâ&#x20AC;&#x2122;s perspective, the impact from this pathological condition is comparable to that of chronic comorbidities such as congestive heart failure, diabetes and coronary diseases.1 Clinically, such patients present with pain, which may interfere with their nighttime rest; and also with overall loss of range of motion with occasional blockade, which may be due to free intra-articular bodies. 2 Pain at the extremities of movements may result from impact syndrome, whereas pain in the middle of the range, particularly below shoulder level is associated with mechanical symptoms.14 In physical examinations, the symptoms of chondral lesions may resemble those of other intra-articular or extra-articular diseases, such as subacromial impact, tenosynovitis of the biceps and labral lesions. 3,14,15 On inspection, muscle hypotrophy and bone prominences are searched for, and the scapular-thoracic rhythm is assessed. The range of motion, both passive and active, generally presents limitations.3,14,15 Ellman described a compressionrotation test that helps to differentiate chondral lesions from impact syndrome: a internal and external rotation maneuver with the arm beside the body, at the same time as performing compression of the humeral head in the direction of the glenoid, which is done before and after bursal infiltration using lidocaine. The symptoms that are alleviated on the second occasion are related to impact syndrome. 14 In radiographic evaluations, glenohumeral osteoarthritis is classically characterized by asymmetrical reduction of the joint space, subchondral sclerosis, cyst formation and osteophyte formation (in the humeral head or glenoid). Free bodies can be seen inside the joint. 2 Samilson and Prieto developed a classification system that was originally described for degenerative joint alterations resulting from arthropathy due to instability, which today is applied to arthrosis of other etiologies. The classification takes into consideration the size of the osteophyte, whether it is located inferiorly on the humeral head or on the glenoid, and any presence of irregularities on the joint surface, observed in anteroposterior radiographic view of the glenohumeral joint. The arthrosis is mild if the osteophyte is smaller than 3 mm, moderate if between 3 and 7 mm, in association with mild irregularity of the joint surface, and severe if greater than 7 mm, in association with diminished joint space and bone sclerosis. 12 The size of the osteophyte is correlated negatively with range of motion. 16 In arthroscopic evaluations, chondral lesions are classified in accordance with the system proposed by Outerbridge.13 Grade 1 represents softening of the cartilage. Grade 2 presents fragmentation and fissures covering an area less than or equal to 1.5 cm in diameter. Grade 3 presents fragmentation and fissures covering an area greater than 1.5 cm in diameter. Grade 4 presents erosion of the subchondral bone. These chondral lesions can be found in 5% to 17% of routine arthroscopic evaluations.3,4

75

To t a l a r t h ro p l a s t y o r h e m i a r t h ro p l a s t y p rov i d e s significant pain relief and functional improvement, especially in more elderly populations (over the age of 60 years). 1,4,6,7 On the other hand, Sperling et al. 17 observed that among patients under the age of 50 years who underwent hemiarthroplasty or total arthroplasty of the shoulder, the rate of unsatisfactory results was approximately 56%, thus suggesting that for this group of patients, another therapeutic approach should be used. Several studies in the literature have demonstrated good results from arthroscopic approaches for treating glenohumeral osteoarthritis. Ogilvie-Harris and Wiley 15 conducted a retrospective analysis on 439 patients who underwent arthroscopic shoulder surgery and found 54 cases of glenohumeral osteoarthritis. Of these, 29 presented associated diseases. These patients underwent removal of the arthroscopic debris and chondral fragments, and synovectomy. Satisfactory results were achieved in twothirds of the patients with slight degenerative alterations (superficial lesions in the joint cartilage) and on one-third of the patients with severe degenerative alterations (with exposure of the subchondral bone). Ellman et al. 14 reported on a group of 18 patients with degenerative joint diseases the clinically resembled impact syndrome. Among these 18, ten came to a diagnosis of glenohumeral osteoarthritis even before the operation. During the operation, no cases of complete rotator cuff injury were found, but partial joint lesions were found in five shoulders (three A1 and two A3). The arthroscopic procedures consisted of debridement of the unstable cartilaginous fragments, removal of free bodies and partial synovectomy, Subacromial decompression was performed in 15 patients. Among the 18 patients, ten presented a minimum duration of symptom relief greater than six months. Richards and Burkart 18 presented preliminary results from arthroscopic debridement associated with release of the rotator interval and capsulotomy, for treating glenohumeral osteoarthritis. In addition to pain reduction, there were increases in anterior elevation, external rotation and internal rotation. The alleviation of the painful symptoms was due to elimination of the joint debris and diminution of the joint contact pressure. Weinstein et al. 10 followed up 25 patients for 12 months, who had undergone arthroscopic debridement of glenohumeral osteoarthritis. Nine of these patients presented an associated disease. The procedures for treating the osteoarthritis consisted of arthroscopic lavage, debridement of labral and cartilaginous lesions, removal of free bodies, partial synovectomy and resection of the osteophyte, in addition to treatment for the associated diseases. At the end of the follow-up, it was observed that 8% of the results were excellent, 72% good and 20% unsatisfactory. There was no statistical correlation between good results and the degree of radiographic alterations and degenerative joint alterations. Pain was the most important factor in evaluating the patients. Cameron et al. 9 retrospectively analyzed 61 patients who underwent debridement, with or without associated capsulotomy, for treating grade IV chondral lesions. The


76

Rev Bras Ortop. 2013;48(1):69-79

patients were divided according to the location of the lesion (humeral, glenoid or bipolar) and the size of the osteochondral defect (greater than or less than 2 cm2). The indication for capsulotomy was a restriction of more than 15째 in any plane of the range of motion. Improvements in painful symptoms were observed in 88% of the patients, based on a visual analogue pain scale and on the increase in the score of the American Shoulder and Elbow Surgeons (ASES). Among the patients, 87% stated that they would undergo this surgical procedure again, if necessary. The location and size of the lesions did not have any influence on the improvements in pain and functional scores. Kerr and McCarty 19 analyzed 19 patients (20 shoulders) w h o u n d e r we n t a r t h ro s c o p i c d eb r i d e m e n t t o t re a t glenohumeral osteoarthritis. No difference in functional results was found between the patients with mild-tomoderate degenerative alterations (Outerbridge 2 and 3) and those with advances degenerative alterations (Outerbridge 4). However, patients with unipolar impairment presented better results than did those with bipolar impairment. Va n T h i e l e t a l . 2 0 f o l l owe d u p 7 1 p a t i e n t s w i t h glenohumeral osteoarthritis who underwent arthroscopic debridement. Of these, 22% evolved to arthroplastic procedures after a mean of 10 months of follow-up, w h i l e 7 8 % c o n t i n u e d w i t h o u t a r t h r o p l a s t y ov e r a follow-up of 27 months. The group of patients who did not evolve to arthroplasty presented larger joint spaces and lower stages in the Samilson classification from preoperative radiographs and, at the end of the follow-up, better functional results and fewer painful symptoms. In this group of patients, 87% said that they would undergo this procedure again. In our series of patients, we obtained a significant difference in UCLA scores from before to after the operation (p = 0.000), and this was concordant with previous studies in relation to functional improvement. The mean postoperative Constant score was 71.8, which was considered satisfactory. We did not find any relationship between the functional results and the degree of chondral degeneration (p = 0.367 and 0.862 for the postoperative UCLA and Constant scores), and this was concordant with what had previously been reported by Weinstein et al., 10 Kerr and McCarty 19 and Cameron et al. 9 The reduction in joint space also did not influence the functional results (p = 0.153 and 0.663 for the postoperative UCLA and Constant scores), thus resembling the findings of Van Thiel et al.20 There was a tendency (p = 0.081) for the preoperative UCLA to be greater in the patients with preserved joint space. We did not find any correlation between the Samilson classification stages (osteophyte size) and the functional results (p = 0.727 for the postoperative UCLA and Constant scores), which was concordant with the reports of Weinstein et al.10 Although the radiographic classification used in that study had been drawn up at their own clinic, it resembled the Samilson classification with regard to progression of the osteophyte. On the other hand, Van Thiel et al.20 presented better functional results among patients with lower Samilson stages in the preoperative radiographic evaluation. Among our patients with osteophytes larger

than 8 mm, there was no influence on the functional results caused by resecting the osteophyte (p = 0.730 and 0.864 for the postoperative UCLA and Constant scores). Neither Van Thiel et al.20 nor Weinstein et al.10 mentioned any influence from resecting the osteophytes on their results. Our sample presented a mean follow-up of 5.13 years, with a range from 2 to 11 years. There was no difference in the functional results between the group of patients with less than five years of follow-up and those with more than five years of follow-up (p = 0.907 and 0.642 for the postoperative UCLA and Constant scores), thus suggesting that the improvement in functional results could be long-lasting. The length of follow-up also did not interfere with the functional evaluation when we took into account the degree of chondral degeneration, Samilson classification stage or joint space. In relation to the length of follow-up, our study differs from the remainder of the literature, in which the length of follow-up was a maximum of two years.20 We found high incidence of rotator cuff injuries and instability associated with glenohumeral arthrosis. An association between glenohumeral arthrosis and both intra and extra-articular disease had already been mentioned in the studies by Ogilvie-Harris and Wiley15 and Ellman et al.14 Although our sample was of limited size, we did not find any influence from these diseases on the functional result (postoperative UCLA and Constant, with p = 0.540 and 0,740 in patients with rotator cuff injuries, and p = 0.860 and 0.647 in patients with associated instability). In relation to the influence of rotator cuff lesions on treatments for glenohumeral osteoarthritis, Wirth et al. 21 observed that small lesions, independent of whether they had been repaired concomitantly with the arthroplastic procedure, did not interfere with the final result from hemiarthroplasty. Iannotti and Norris 22 analyzed the influence of preoperative factors on the results from shoulder arthroplasty for treating glenohumeral arthrosis, and found that small repairable rotator cuff injuries that were limited to the supraspinatus did not affect the postoperative score of the American Shoulder and Elbow Surgeons (ASES). In our series of patients, all the associated rotator cuff lesions were successfully repaired and, although the treatment type was different, the results were concordant with what had been proposed by Iannotti and Norris22 and Wirth et al.,21 regarding the presence of repairable lesions of the rotator cuff associated with glenohumeral osteoarthritis. Millett and Gaskill23 presented their preliminary results. They suggested that the lower osteophyte might compress the axillary nerve close to the lower capsule, thereby causing symptoms similar to those of quadrilateral space syndrome. In addition to extensive joint debridement, capsulotomy and resection of the lower osteophyte, decompression of the axillary nerve was performed. Among their 26 patients (27 shoulders) with a mean follow-up of 20 months, there was an increase in the satisfaction rate, diminution of pain, increase in mean range of motion and improvement of the ASES score. One of the patients in our sample (M.A.B.N) underwent arthroscopic debridement at the age of 29 years. Radiographically, he had a lower osteophyte in the humeral head that was larger than 8 mm (Fig. 8); and clinically, he


Rev Bras Ortop. 2013;48(1):69-79

77

Fig. 8 - A) Radiograph in true AP view on the right shoulder, showing large lower osteophyte in the humeral head, preservation of the joint space and presence of metal anchors from previous surgery on the glenoid; B) NMR T2 image with fat suppression – presence of large lower osteophyte and subchondral cysts in the humeral head; tendon of supraspinatus preserved in its insertion.

Fig. 9 - Radiograph in true AP view on the right shoulder. Postoperative control demonstration complete resection of the lower osteophyte of the humeral head and preservation of the joint space.

presented painful limitation of the range of motion, along with pain on the posterior face of the shoulder, thus suggesting axillary nerve compression. After arthroscopic debridement and complete resection of the osteophyte (Fig. 9), this patient evolved with improvement of the range of motion and painful symptoms. Differently to what was proposed by Millet, we did not do any intraoperative controls using fluoroscopy. At the end of the surgical procedure, radiography was performed in true anteroposterior view, in order to verify the resection of the lower osteophyte. We also did not perform additional decompression of the axillary nerve, and resection of the osteophyte was sufficient for improving the compressive symptoms. After five years of follow-up, the patient is satisfied with the procedure that was performed, with few painful symptoms and the following range of motion: EAA = 170°, ER I = 30°, ER II = 70° and IR = 5th lumbar vertebra (Fig. 10).

Fig. 10 - After five years of follow-up, the patient still presented good range of motion; A) External rotation I, B) External rotation II and C) Internal rotation.

In assessing the level of satisfaction, in addition to the 24 patients (24 shoulders) examined, we also analyzed the 13 patients (14 shoulders) who were contacted by telephone. Out of these 38 shoulders, 32 (84%) presented satisfactory results in the subjective UCLA evaluation. Among the unsatisfactory results, we did not find any correlations with the degree chondral degeneration (p = 0.645), preoperative Samilson classification stage (p =


78

Rev Bras Ortop. 2013;48(1):69-79

1.000) or length of follow-up (p = 0.542). On the other hand, there was a significant association between shoulders with unsatisfactory results from the subjective assessment and reduced joint space in the preoperative radiographic evaluation (p = 0.024). Although this association was from a subjective assessment, it followed the trend of the results of Van Thiel et al., 20 in which the patients with preserved joint space before the operation presented better functional evaluations and fewer painful symptoms at the end of the follow-up. In the same way, these authors reported that 87% of the patients would go through the same surgical procedure again, which did not differ from our results, in which 89% would go through the procedure again. This is directly related to the patients’ level of satisfaction. In our sample, we had a significant loss of patients from the follow-up. Out of the 65, five died for reasons unrelated to the surgical procedure, 18 could not be found because of changes of address and two refused both to come for the examination and to undergo subjective assessment over the telephone. Three patients evolved to total arthroplasty within two years after arthroplastic debridement and were therefore excluded from the data analysis. Out of the 37 patients (38 shoulders) that remained, 13 (14 shoulders) were unable to come for a physical examination (eight of them were living in other cities, which made it impossible to come for the examination). Among these patients, the assessment was made by means of telephone contact. Functional results from 24 patients were analyzed. We did not find any significant difference in the functional results when we took into account the degree of chondral degeneration, size of the osteophyte, preservation of the joint space, length of postoperative follow-up and presence of rotator cuff injuries. This may have been due to the limited number of patients, which might have interfered with the statistical analysis. Although the postoperative Constant score presented a mean of 71.8, which was considered satisfactory, we did not have a preoperative value for evaluating the functional gain and for adding value to the functional gain obtained through the UCLA score. Other limitations of our study included the retrospective study model and the lack of a control group. Future studies using a prospective model, with a control group and with fewer losses from the follow-up are needed in order to consolidate our results.

R

E

1.

Conclusion

17.

Arthroscopic management of the arthrotic shoulder provided improvement of the functional results and high satisfaction levels. The reduced joint space in the preoperative radiographic assessment negatively influenced the satisfaction level in the final evaluation.

18.

Denard PJ, Wirth MA, Orfaly RM. Management of glenohumeral arthritis in the young adult. J Bone Joint Surg Am. 2011;93(9):885-92. Chong PY, Srikumaran U, Kuye IO, Warner JJP. Glenohumeral arthritis in the young patient. J Shoulder Elbow Sur. 2011;20(2 Suppl):S30-40. Boselli KJ, Ahmad CS, Levine WN. Treatment of glenohumeral arthrosis. Am J Sports Med. 2010;38(12):2558-72. McCarty LP 3rd., Cole BJ. Nonarthroplasty treatment of glenohumeral cartilage lesions. Arthroscopy. 2005;21(9):1131-48. Strauss EJ, Hart JA, Miller MD, Altman RD, Rosen JE. Hyaluronic acid viscosupplementation and osteoarthritis: current uses and future directions. Am J Sports Med. 2009;37(8):1636-44. Savoie FH 3rd., Brislin KJ, Argo D. Arthroscopic glenoid resurfacing as a surgical treatment for glenohumeral arthritis in the young patient: midterm results. Arthroscopy. 2009;25(8):864-71. Millet PJ, Huffard BH, Horan MP, Hawkins RJ, Steadman JR. Outcomes of full-thickness articular cartilage injures of the shoulder treated with microfrature. Arthroscopy. 2009;25(2):856-63. Cole BJ, Yanke A, Provencher MT. Nonarthroplasty alternatives for the treatment of glenohumeral arthrititis. J Shoulder Elbow Surg. 2007;16(5 Suppl):S231-40. Cameron BD, Galatz LM, Ramsey ML, Williams GR, Iannotti JP. Non-prosthetic management of grade IV ostechondral lesions of the glenohumeral joint. J Shoulder Elbow Surg. 2002;11(1):25-32. Weinstein DM, Bucchieri JS, Pollock RG, Flatow EL, Bigliani LU. Arthroscopic debridement of the shoulder for osteoarthritis. Arthroscopy. 2000;16(5):471-6. Rockwood CA, Jensen KL. Avaliação radiográfica dos problemas do ombro. In: Rockwood e Matsen. Ombro. 2ª ed. Rio de Janeiro: Revinter; 2002. p. 200-2. Samilson RL, Prieto V. Dislocation arthropathy of the shoulder. J Bone Joint Surg Am. 1983;65(4):456-60. Outerbridge RE. The etiology of chondromalacia patellae. J Bone Joint Surg Br. 1961;43B(4):752-7. Ellman H, Harris E, Kay SP. Early degenerative joint disease simulating impingement syndrome: arthroscopic findings. Arthroscopy. 1992;8(4):482-7. Ogilvie-Harris DJ, Wiley AM. Arthroscopic surgery of the shoulder. J Bone Joint Surg Br. 1986;68(2):201-7. Kircher J, Murhard M, Magosch P, Ebinger N, Lichtender S, Habermeyer P. How much are radiological parameters related to clinical symptoms and function in osteoarthritis of the shoulder? Int Orthop. 2010;34:677-81. Sperling JW, Cofield RH, Rowland CH. Minimum fifteenyears follow-up of Neer hemiarthroplasty and total shoulder arthroplasty in patients aged fifty years or younger. J Shoulder Elbow Surg. 2004; 13(6):604-13. Richards DP, Burkart SS. Arthroscopic debridement and capsular release for glenoumeral osteoarthritis. Arthroscopy. 2007;23(9):1019-22. Kerr BJ, McCarty EC. Outcomes of arthroscopic debridement is worse for patients with glenohumeral arthritis of both sides of the joint. Clin Orthop Relat Res. 2008;466(8):634-8. Van Thiel GS, Sheehan S, Frank RM, Slabaugh M, Cole BJ, Nicholson GP, et al. Retrospective analysis of arthroscopic management of glenohumeral degenerative disease. Arthroscopy. 2010;26(110):1451-5.

Conflicts of interest The authors declare that there was no conflict of interests in conducting this study.

2.

3. 4. 5.

6.

7.

8.

9.

10.

11.

12. 13. 14.

15. 16.

19.

20.

F

E

R

E

N

C

E

S


Rev Bras Ortop. 2013;48(1):69-79

21. Wirth MA, Tapscott RS, Southworth C, Rockwood Jr CH. Treatment of glenohumeral arthritis with a hemiarthroplasty: minimum five-year follow-up outcome study. J Bone Joint Surg Am. 2006;88(5):964-73. 22. Iannotti JP, Norris TR. Influence of preoperative factor on outcome of shoulder arthroplasty for glenohumeral osteoarthritis. J Shoulder Elbow Surg. 2003;85-A(2):251-8.

79

23. Millett PJ, Gaskill TR. Arthroscopic management of glenohumeral arthrosis: humeral osteoplasty, capsular release, and arthroscopic axillary nerve release as a jointpreserving approach. Arthroscopy. 2011;27(9):1296-303.


Rev Bras Ortop. 2013;48(1):80-86

www.rbo.org.br/

Original Article

Knee ligament injuries: biomechanics comparative study of two suturetechnique in tendon – analysis “in vitro” tendon of bovine Elias Marcelo Batista da Silva,1* Mauro Batista Albano,2 Hermes Augusto Agottani Alberti,3 Francisco Assis Pereira Filho,4 Mario Massatomo Namba,5 João Luiz Viera da Silva,6 Luiz Antônio Munhoz da Cunha7 1Master’s

Student on Surgical Clinical Medicine, Universidade Federal do Paraná (UFPR). Professor of the Specialization Course on Sports Traumatology and Arthroscopy at UFPR and at the Workers’ Hospital (HT), Curitiba, PR, Brazil. 2Doctoral Student on Surgical Clinical Medicine, UFPR. Professor of the Specialization Course on Sports Traumatology and Arthroscopy at UFPR/HT, Curitiba, PR, Brazil. 3Master’s Student on Biomedicine, Universidade Tecnológica Federal do Paraná (UTFPR). Professor of the Specialization Course on Sports Traumatology and Arthroscopy at UFPR/HT, Curitiba, PR, Brazil. 4Professor of the Specialization Course on Sports Traumatology and Arthroscopy at UFPR/HT, Curitiba, PR, Brazil. 5MSc on Surgical Clinical Medicine, UFPR; Professor and Coordinator of the Specialization Course on Sports Traumatology and Arthroscopy at UFPR/HT, Curitiba, PR, Brazil. 6Titular Professor of Orthopedics and Traumatology, Universidade Positive (UP), and Professor of the Specialization Course on Sports Traumatology and Arthroscopy at UFPR/HT, Curitiba, PR, Brazil. 7Titular Professor of Orthopedics and Traumatology, UFPR, and Head of the Orthopedics and Traumatology Service, UFPR, Curitiba, PR, Brazil. Work performed within the Stricto Sensu Postgraduate Course on Surgical Clinical Medicine, Health Sciences Sector, UFPR.

article info

a b s t r a c t

Article history:

Objective: To evaluate and compare the biomechanical behavior of two different suture

Received December 4 2011

configurations: “X” and “Loop” in the preparation of tendons for knee ligament reconstruction.

Approved July 17 2012

Methods: We used common digital extensor tendons of bovine that can replace the human flexor tendons in experimental studies of traction. In the first group, point “X” suture with

Keywords:

Ethibond ® No. 5 began in the distal graft points transfixing, with spacing of 7.5 mm points

Biomechanics

to reach 03 cm distal to the beginning of the suture, returning suture in the same manner,

Transplants

transfixing the tendon in open spaces across the suture configuration “X”. The second

Anterior cruciate ligament

group, the point “Loop” was prepared with the same type Ethibond ® No. 5 of the needle wire

Suture techniques

was removed for use only of the wire was mounted in a twofold manner in a single piece forming a needle loop. Started the suture 3 cm from the end of the graft through loops and transfixing points throughout the tendon substance, with spacing between dots of 7.5 mm.

*Corresponding author at: Rua Herculano Carlos Franco de Souza, 438, Água Verde, Curitiba, PR, Brazil. CEP 80240-290. Phone: (+55 41) 3044-2940. Fax: (+55 41) 3044-2941 E-mail: eliasmbsilva@gmail.com ISSN/$–see front matte © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved. doi: 10.1016/j.rboe.2012.07.001


Rev Bras Ortop. 2013;48(1):80-86

81

Result: The Maximum Force of Rupture suture in “Loop” was 444.45 N and the suture in “X” was 407.59 N with statistical significance (p = 0.030). The average Tension obtained at the suture in “Loop” was 27.67 MPa and at the suture in “X” was 25.73 MPa with a statistically significant difference (p = 0.036). The stiffness showed no statistical differences (p = 0.350) at 11.804 N / mm at the point where “Loop” and 11.570 N / mm at the suture “X”. Conclusion: The suture in “Loop” had a higher biomechanical behavior to the suture “X”, considering the Maximum Force and Tension. © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

Introduction Ligament injuries occur very commonly in humans, particularly at knee level, where the anterior cruciate ligament (ACL) is one of the most frequently injured ligaments.1 Cruciate ligament reconstruction surgery is based on two well-established concepts: a) use of biological grafts with biomechanical characteristics similar to those of the ACL; b) graft fixation as rigidly as possible and as close as possible to the ligament exit point in the joint. The grafts most used for reconstructing knee ligaments come from the central third of the patellar tendon, with its bone insertions, and the tendons of the hamstring muscles or the flexor tendons in a quadruple configuration. 2 Independent of the type of tendon graft obtained, one of the problems for surgeons consists of adequate preparation of the tendon. Suitably resistant suturing at the time of fixation enables tension levels that are sufficient for promoting the best conditions for graft incorporation to the host bone.

the cattle was obtained for extraction. The animals’ mean age was two years. Each tendon was divided, thus forming a total of 20 paired tendons that simulated the flexor, gracilis and semitendinosus tendons of the human knee. 5 The pairs were divided into two groups of ten tendons and were all cut to the length of 20 cm. The first group, defined as the “X” configuration, was prepared using synthetic polyester Ethibond® No. 5 braided thread on a needle. The suturing was started in the distal portion of the graft, on one of the margins, using transfixing stitches across the entire substance of the tendon, with spacing of 7.5 mm between the stitches, until reaching 3 cm distally to the start of the suture. The suturing then returned along the line in the same manner, from the same margin as at the start of the suture, transfixing the tendon in the open spaces, intercalating the stitches and crossing the suture line in an “X” configuration. The same procedure was followed at the other end of the tendon (Figs. 1 and 2). The second group, defined as stitches in a “loop” configuration, was prepared with the same type of synthetic

However, there is no standard preparation method, or any consensus regarding the best technique. There are probably as many techniques for graft preparation as there are surgeons performing ACL reconstruction surgery.3 Stitches such as the whipstitch, whipknot, Prusik knot, Kessler, crisscross, Bunnell, baseball stitch, prefabricated “loop” stitch (Fiber loop) with and without locking and Krackow have been used and described as techniques.3,4 The aim of the present study was to evaluate and compare the biomechanical behavior of two different suture configurations that were subjected to tests on a traction machine: 1) “X” stitches; 2) “loop” stitches. These were prepared on bovine common digital extensor tendons, which can replace the human flexor tendons in experimental traction-test studies.5

Material and method Ten common digital extensor tendons from cattle of Nellore breed were acquired fresh from a specialist beef slaughter and trading company. The distal part of the anterior limb of

Fig. 1 - (A) Start of preparation of stitches in “X” configuration in the distal portion of the tendon, with transfixing stitches along the entire substance, with spacing between stitches of 7.5 mm. (B) Returning along the suture line in the same manner, transfixing the tendon in the open spaces. (C) Stitch in “X” configuration completed.


82

Rev Bras Ortop. 2013;48(1):80-86

Fig. 2 - Tendons prepared using “X” stitches”.

polyester Ethibond® No. 5 braided thread on a needle. However, the needle was removed to use only the thread, which was mounted in a double manner on a single needle, to form a loop (Fig. 3). The end of the graft was introduced into the loop, with the needle positioned superiorly. The stitches were started by transfixing the graft from the upper face to the lower face in each stitch. The suturing was started 3 cm from the end of the graft, by means of loops and transfixing stitches across the entire substance of the tendon, with spacing between the stitches of 7.5 mm (Figs. 4 and 5). This was also done at the other end. All the tendons that had previously been prepared (Fig. 6) were folded over in the middle, over an Ethibond® No. 5 thread, in horse-rider style. In this double configuration, the

Fig. 3 - (A) Synthetic polyester No. 5 braided thread on needle. (B) Needle separated from the thread. (C) Synthetic polyester No. 5 braided thread, threaded doubly on a single needle.

Fig. 4 - (A) Start of preparation of stitches in “loop” configuration, looping around the tendon 3 cm proximally to the end of the graft. (B) First stitch transfixing the graft in this region (C, D, E, F, G), looping around the tendon, and stitch transfixing the tendon with spacing of 7.5 mm. (F) Stitch in “loop” configuration completed.

Fig. 5 - Tendon prepared with “loop” stitches.

tendons were named “test bodies”, which were of length 10 cm and were kept under tension of 20 N (Fig. 7). Each test body was coated with an alginate paste (Jeltrade alginate type II, regular set), which developed the consistency of rubber after a few seconds. The tendon was then removed, leaving an impression of the test body in the alginate, like in a mold. This mold was then sectioned transversally. The sections generated from the alginate mold were then digitized with a resolution of 600 dpi, by means of an HP J5780® digitizer. The cross-sectional areas of the molds were measured with the aid of the Image-Pro Plus® software, which had the capacity to supply measurements of the cross-sectional area from the digitized images.6 The group of tendons with “X” sutures and the group of tendons with “loop” sutures were coated separately and labeled to distinguish the suturing method and, on the same day, were taken to the Mechanics Department of the Universidade Tecnológica Federal do Paraná (UTFPR), where they were adapted to an MTS 810 universal hydraulic traction machine.


Rev Bras Ortop. 2013;48(1):80-86

83

Fig. 6 - “X” and “loop” stitches.

Fig. 9 - Test body positioned in traction machine, with threads for suturing the ends held in surgical hemostatic forceps. Fig. 7 - Test body.

The maximum strength and the force-versus-displacement results were obtained using a load cell (model 661.19 F-02; MTS Systems Corporation) with a capacity of 10 KN and test velocity of 20 mm/min. East test body was installed in the machine in horse-rider style, on a steel bar of diameter 6.35 mm at the top of the machine. The thread used for suturing the ends of each test body were fixed at the base of the machine with the aid of surgical hemostatic forceps, in the same way as done in ACL reconstruction surgery to maintain the tension when the graft is fixed in the tibial tunnel. The same length of thread (15 cm) was left between the end of the tendon and the forceps, in all the tests (Figs. 8 and 9).

Fig. 8 - Test body positioned in traction machine, in horserider position.

In the statistical analysis, the normality of the data was tested using the Shapiro-Wilk test. Discrepant values or outliers were identified using a boxplot graph and then the t test for independent samples was performed, taking p < 0.05. The statistical analyses were performed using the SPSS 17 software for Windows.

Results The “loop” stitches presented mean maximum strength of 444.45 N. The “X” stitches presented mean maximum strength of 407.59 N. The Shapiro-Wilk normality test demonstrated that the groups of “loop” and “X” stitches had distributions compatible with normal in relation to maximum strength. The t test for independent samples showed that after three outliers had been removed, the difference in maximum strength between the groups presented a statistically significant difference, with p = 0.030. The mean cross-sectional area was 16.2 mm2 in the “loop” stitches and 16.08 mm 2 in the “X” stitches. There was no statistically significant difference between the two groups, with p = 0.283. The mean rigidity of the “loop” stitches was 11.570 N/mm and of the “X” stitches, 11.804 N/mm. The difference between the two groups was not significant, with p = 0.350. The Shapiro-Wilk normality test demonstrated that the groups with “loop” stitches and with “X” stitches had distribution compatible with normal in relation to tension. The mean tension obtained in the “loop” stitches was 27.67 MPa and in the “X” stitches, 25.73 MPa. The statistical difference between the two groups after removal of an outlier was significant, with p = 0.036. The data obtained from the test bodies with “X” stitches are in Table 1. The data obtained from the test bodies with “loop” stitches are in Table 2.


84

Rev Bras Ortop. 2013;48(1):80-86

The failures in the maximum strength test occurred in the proximal portion of the tendon-thread complex (Fig. 10).

Table 1 - Test body results from stitches in “X” configuration (N = 10). Area (mm2) Strength (N) Stiffness (N/mm) σ (MPa) Medium

16.08

407.59

11.804

25.73

SD

3.25

63.37

3.631

3.62

Minimum

11.7

295.52

3.087

18.59

Maximum

23.4

517.24

16.476

30.4

N: # tests, σ: tension.

Table 2 - Test body results from stitches in “loop” configuration (N = 10). Area (mm2) Strength (N) Stiffness (N/mm) σ (MPa) Medium

16.2

444.45

11.57

SD

2.69

94.06

3.287

27.67 5.17

Minimum

13.5

257.94

7.341

14.82

Maximum

22.3

600.68

18.372

33.47

N: # tests, σ: tension.

Fig. 10 - Region of suture failure in traction test

Discussion ACL reconstruction is one of the surgical procedures most performed on the knee. Over recent decades, there have been advances in knowledge and refinement of the techniques and materials. The great majority of studies on refinements have been based on improvements to the methods for fixing grafts, choosing grafts and developing reconstruction techniques that allow restructuring of the biomechanics prior to the ACL injury in the knee. Many details within the reconstruction still need to be evaluated and refined. Little is known about the best way of preparing grafts and how this preparation might influence the final results from the reconstruction. Preparation of grafts from flexor tendons using “X” and “loop” stitches is very frequently done. However, there is little in the worldwide literature on which this practice can be based. Some authors have advocated Krackow stitches and prefabricated “loop” stitches (fiber loop) with locking. 4 Others have preferred the Whipstitch and crisscross suturing.7 “X” stitches resemble crisscross stitches but suture the graft without joining the stitches. Each graft stitch is prepared individually, thus differing from crisscross suturing. “X” stitches suture the graft in a manner that is easy to perform and reproduce and which rarely produces cuts in the region where applied or divisions at the edge of the graft. “Loop” stitches, which were developed to simulate a prefabricated loop stitch (fiber loop), are used because they are economical, use materials that are easy to obtain and acquire, both in public and in private healthcare clinics, and enable use of the same principles as in fiber loops, i.e. easy and fast application in graft preparation. We chose to use bovine common digital extensor tendons for this experiment based on studies that compared properties between these and the flexor tendons of the human knee.5 These demonstrated that grafts using bovine common digital extensor tendons can replace the flexor tendons in traction tests. Another factor in making this choice was the possibility of obtaining fresh tendons and performing the traction tests in the same period of the day of their extraction, thereby avoiding changes such as those that occur to the modulus of elasticity of the tendons when they are stored in frozen condition 8 or in formalin, which harden the tissue.9 The data on maximum rupture strength and tension obtained from the test bodies were displayed on boxplot graphs to show the presence of any outlying discrepant values, which were then eliminated in accordance with the statistical analysis. The boxplot method for determining discrepant data was used because it is greatly used, easy to use and has great precision for detecting truly atypical observations. The “loop” stitches presented a mean maximum rupture strength that was greater than that of the “X” stitches, with


85

Rev Bras Ortop. 2013;48(1):80-86

a statistically significant difference (p = 0.030). When the choice for preparing grafts using Ethibond® No. 5 thread is between using “loop” or “X” stitches, taking only the mean maximum rupture strength into consideration, use of “loop” stitches is more recommended. However, taking only the tension strength of 60 to 140 N that is needed in the graft at the time of its fixation, 10 both types of preparation are adequate, even considering the minimum value for the maximum rupture strength, which was 295.92 N for the “X” stitches and 257.94 N for the “loop” stitches. Both stitch types are sufficient for supporting the recommended tension forces during graft fixation in the receptor regions of the femur and tibia. Wit h advances i n t he t echni q u e of d ou bl e -ba n d reconstruction, the preparation of flexor tendons has gained an important mechanical characteristic. When reconstruction is done using a single band, flexor grafts are used in double form for the semitendinosus and gracilis, which together form a quadruple arrangement in which they are positioned in a single tunnel in the femur and tibia. In addition, they are fixed in this position as a single structure, and not separately for each tendon. However, when the double-band technique is performed, grafts from the semitendinosus are used in double form to simulate one of the bands and the gracilis is used in double form to simulate the other band, such that two tunnels are needed in the femur and two in the tibia, with independent fixation for each graft in each tunnel. Through using the test body configuration in double form in the present study, we were able to show that separately, the mean maximum rupture strengths of the two types of stitches in preparing the tendons (444.45 N for the “loop” and 407.59 N for the “X”) were insufficient to enable modern rehabilitation protocols subsequent to ACL surgical reconstruction, when only indirect or post fixation is used, i.e. in which the preparation suture threads are used to fix the graft. It has to be borne in mind that during the first six weeks after the operation, the graft fixation has to withstand mechanical loads from day-to-day activities that are estimated to be up to 454 N.11 The mean values for the cross-sectional area in the test body groups with “loop” and “X” stitches did not present statistical differences, which enabled better comparison between the two groups. The mean maximum tension obtained before the r u p t u re a c c o m p a n i e d t h e m e a n m a x i mu m r u p t u re strength. The mean tension values for the “loop” stitches before the rupture were 7.01% greater than those for the “X” stitches, with a statistically significant difference (p = 0.036). In reconstructing the ACL, choosing the quadruple configuration for flexor grafts increases the cross-sectional area of the test bodies and the capacity to withstand the tension. The stiffness obtained in the two types of graft preparation did not show any statistical difference, with 11.804 N/mm for the “X” stitches and 11.57 N/mm for the “loop” stitches, in comparison with the stiffness of the ACL of 242 N/mm. Both preparations were well below the stiffness of this structure. Compared with the stiffness of a system configured as a single fold of the gracilis (336 N/mm) and a

single fold of the semitendinosus (469 N/m), the stiffness of the test bodies was 30 to 40 times lower. This demonstrates that the preparation or the thread, suture and graft complex is the link that weakens the graft stiffness, as also observed by Hamner et al.12

Conclusion Based on the experimental model used, the “loop” suture configuration presented biomechanical behavior that was superior to that of the “X” configuration, taking the maximum strength and tension into consideration. Both configurations were valid for supporting the recommended graft tensions at the time of fixation in ACL ligament reconstruction.

Conflicts of interest The authors declare that there was no conflict of interests in conducting this study.

R

E

1.

Beynnon BD, Johnson RJ, Abate JA, Fleming BC, Nichols CE. Treatment of anterior cruciate ligament injuries. Part I. Am J Sports Medi. 2005;33(10):1579-602. Fu FH, Bennett CH, Ma CB, Menetrey J, Lattermann C. Current trends in anterior cruciate ligament reconstruction. Part II. Operative procedures and clinical correlations. Am J Sports Med. 2000;28(1):124-30. Charlick DA, Caborn DN. Technical note: alternative softtissue graft preparation technique for cruciate ligament reconstruction. Arthroscopy. 2000;16(8):E20. White KL, Camire LM, Parks BG, Corey WS, Hinton RY. Krackow locking stitch versus locking premanufactured loop stitch for soft-tissue fixation: a biomechanical study. Arthroscopy. 2010;26(12):1662-6. Donahue TLH, Gregersen C, Hull ML, Howell SM. Comparison of viscoelastic, structural, and material properties of doublelooped anterior cruciate ligament grafts made from bovine digital extensor and human hamstring tendons. J Biomech Eng. 2001;123(2):162. Stieven Filho E, Malafaia O, Ribas-Filho JM, Diniz OE dos S, Borges PC, Albano M, et al. Análise biomecânica da solidarização de tendões para reconstrução do ligamento cruzado anterior. Rev Col Bras Cir. 2010;37(1):52-7. Howell SM, Goi-flieb JE. Endoscopic fixation of a doublelooped semitendinosus and gracilis anterior cruciate ligament graft using bone mulch screw. Oper Tech Orthop. 1996;6(3):152-160. Matthews LS, Ellis D. Viscoelastic properties of cat tendon: effects of time after death and preservation by freezing. J Biomech. 1968;1(2):65-71. Krappinger D, Kralinger FS, El Attal R, Hackl W, Haid C. Modified Prusik knot versus whipstitch technique for soft tissue fixation in anterior cruciate ligament reconstruction: a biomechanical analysis. Knee Surg Sports Traumatol Arthrosc. 2007;15(4):418-23.

2.

3.

4.

5.

6.

7.

8.

9.

F

E

R

E

N

C

E

S


86

Rev Bras Ortop. 2013;48(1):80-86

10. Fleming BC, Abate JA, Peura GD, Beynnon BD. The relationship between graft tensioning and the anteriorposterior laxity in the anterior cruciate ligament reconstructed goat knee. J Orthop Res. 2001;19(5):841-4. 11. Noyes FR, Butler DL, Grood ES, Zernicke RF, Hefzy MS. Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions. J Bone Joint Surg Am. 1984;66(3):344-52.

12. Hamner DL, Brown CH, Steiner ME, Hecker AT, Hayes WC. Hamstring tendon grafts for reconstruction of the anterior cruciate ligament: biomechanical evaluation of the use of multiple strands and tensioning techniques. J Bone Joint Surg Am. 1999;81(4):549-57.


Rev Bras Ortop. 2013;48(1):87-91

www.rbo.org.br/

Original Article

Evaluation of prognostic factors and survival among patients with osteosarcoma attended at a philanthropic hospital in Teresina, Piauí, Brazil Fernanda Râmyza de Sousa Jadão,1 Lailton de Sousa Lima,2 José Augusto Sá Lopes,3 Marcelo Barbosa Ribeiro4* 1Undergraduate

Medical Student, Universidade Federal do Piauí (UFPI), Teresina, PI, Brazil. Medical Student, Universidade Estadual do Maranhão (UEMA), Caxias, MA, Brazil. 3Oncological Orthopedist at Hospital São Marcos (HSM), Piauí Anti-Cancer Association (APCC), Teresina, PI, Brazil. 4MSc from the School of Medicine, Universidade de São Paulo (FMUSP). Professor of the Discipline of Orthopedics, UFPI, and Oncological Orthopedist at HSM/APCC, Teresina, PI, Brazil. Work performed at the Oncological orthopedics Service, Hospital São Marcos, Piauí Anti-Cancer Association. 2Undergraduate

article info

a b s t r a c t

Article history:

Objective: Make an analysis of the factors that influence their survival and prognosis of

Received March 6 2012

patients with osteosarcoma treated at a Charity Hospital in Teresina-PI. Methods: We

Approved May 23 2012

analyzed medical records of 32 patients diagnosed with osteosarcoma in the period January 2005 to December 2010. Results: Patients were aged between 6 and 73 years, with 56.2%

Keywords:

men and 43.7% women. The prevailing color was black, with 62.5% of cases. With regard to

Osteosarcoma

histological subtype, the majority were osteoblastic type (71.8%). The anatomical location

Prognosis

of the tumor was prevalent region of the knee (distal femur and proximal tibia). Regarding

Survival Analysis

the size of the tumor, tumors were 43.8% bigger than 15 cm. Degree of necrosis Huvos concentrated primarily among the types I and II, 53.1% and 25% respectively. The overall survival at two and four years was 45.5% and 39% respectively and event- free survival at two and four years was 39.8% and 19.9% respectively. Conclusion: We considered the worst prognosis, the presence of metastases at diagnosis and tumors larger than 15 cm. And the criteria of Huvos did not reach statistical significance for the prognosis of patients. © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

*Corresponding author at: Rua Porto, 1186/103, Tulipas, Bairro São Pedro, Teresina, PI, Brazil. CEP: 64019-500. E-mail: mbribeiro@hotmail.com ISSN/$–see front matter © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved. doi: 10.1016/j.rboe.2012.05.002


88

Rev Bras Ortop. 2013;48(1):87-91

Introduction

Table 1 - Incidence of complaints per category. Types

Neoplasia occupies second place among Brazilian mortality rates, only behind circulatory diseases, which therefore makes cancer a public health problem.1 Among all forms of neoplasia in general, primary bone tumors constitute 3% to 4%. Furthermore, in the Brazilian setting, the definitive diagnoses for cases of primary bone tumors tend to be delayed. Early diagnosis for these forms of neoplasia is fundamentally important, especially in relation to malignant tumors, for which local control and therapeutic management aimed at increasing these patients’ survival are needed.1 Osteosarcoma is the commonest type of bone tumor with a primary malignant bone matrix, accounting for 0.2% of human malignant neoplasia. It was first described by Dupuytren in 1805, and its main characteristic consists of production of osteoid matrix by neoplastic cells. It mainly affects children and adolescents during their first two decades of life and its favored anatomical position is the metaphyses of long bones. The distal femur and proximal tibia are the locations most frequently affected by osteosarcoma, followed by the proximal humerus.1 Today, it can be said that the prognosis for patients with osteosarcoma depends on the size of the tumor, the surgical margins achieved during the operation and any presence of pulmonary metastases.2 It is also known that factors such as sex and anatomical location of the lesion are not associated with local recurrence or with the prognosis, while the percentage induction of necrosis by chemotherapy and the surgical margins are factors associated with local control.2 This study had the aims of analyzing the factors that were influencing prognosis and survival among patients attended at a philanthropic hospital in Teresina, Piauí, and epidemiologically and clinically characterizing the sample. Each factor was evaluated separately and together, with the aim of finding a better diagnostic and therapeutic approach for the patients affected by this disease.

Sample and methods After gaining approval from the Research Ethics Committee of UFPI, with CAAE registration no. 0399.0.045.000-11, and approval from the National Research Ethics Commission (CONEP), with registration number 045, a descriptive-analytical quantitative retrospective cross-sectional study was begun, covering the period from January 2005 to December 2010. The medical files of 32 patients who had been diagnosed with osteosarcoma at a philanthropic hospital in Teresina, Piauí, were analyzed. In evaluating the medical files, the following data were gathered: age, sex, color, occupation, date of diagnosis of osteosarcoma, Huvos criterion (Table 1), size and anatomical location of the tumor, histological subtype, presence of lymph fluid and/or blood invasion, surgical treatment used, surgical limits found from histopathological evaluation, presence or

Huvos criteria

Grade I

No effect from chemotherapy

Grade II

Partial response with necrosis of more than 50%

Grade III

Necrosis of more than 90%, with viable tumor present

Grade IV

No viable tumor

absence of metastasis over the course of the study, location of the metastasis and data of appearance, tumor staging at the time of diagnosis, presence or absence of local recurrence after the surgical treatment, and date of the patient’s death, if this occurred during the period of the study. The patients of the present study were treated based on the Brazilian protocols for chemotherapy treatment for osteosarcomas (both metastatic and non-metastatic). The statistical analyses were performed using the SPSS statistical software (version 9.0). Initially, the simple frequencies of all the variables studied were calculated. Subsequently, the accumulated survival probabilities were calculated by means of the Kaplan-Meier technique. All the variables were analyzed regarding their importance in relation to the prognosis, for event-free survival (percentage of patients who up to a given date, remained free from local and/or systemic manifestations) and for overall survival (percentage of patients who were still alive up to a given date). The Huvos grade (I, II, III or IV), tumor size (< 15 or > 15 cm), presence of metastasis at diagnosis and surgical treatment used (radical or salvage) were evaluated as variables to determine their prognostic value, in relation to survival, using the log-rank test.

Results The patients’ ages ranged from 6 to 73 years, with a median of 15 years; 56.2% were aged less than or equal to 15 years and 43.7% were over 15 years of age. In relation to sex, 56.2% were men and 43.7% were women. The most prevalent color was black, accounting for 62.5% of the cases, followed by mixed (21.8%) and white (15.6%). Regarding the variable of occupation, 90.6% of the patients were students. In relation to histological subtype, 71.8% were osteoblastic, 21.8% were chondroblastic and 6.2% were rich in giant cells. The anatomical location of the tumor had the following distribution: 50% distal femur, 21.8% proximal tibia, 9.4% proximal femur and 9.4% proximal humerus. The distal tibia, proximal fibula and distal fibula presented one case each (percentage of 3.1%). The tumor sizes were divided into less than or equal to 15 cm (56.2%) and greater than 15 cm (43.8%). In relation to the Huvos necrosis grade, 17 patients (53.1%) presented Huvos I, 8 (25%) had Huvos II, 7 (21.8%) had Huvos III and none had Huvos IV. Regarding metastasis, 20 patients (62.5%) developed this at some time over the course of the disease. Of these, seven (21.8%) already had a metastasis at the time of the diagnosis.


89

Rev Bras Ortop. 2013;48(1):87-91

Among the metastasis sites were the following: lung (100%), bone (25%), liver (5%) and others (15%). In relation to the surgical treatment, 65.6% of the patients underwent radical surgery (amputation), while 34.4% were able to benefit from salvage surgery on the limb. Among the patients with larger-sized tumors (> 15 cm), 85.7% underwent radical surgery. Two cases of local recurrence were observed (6.2%) and 62.5% of the patients died due to osteosarcoma. The overall survival curve is shown in Fig. 1 and the two and four-year rates were 45.5% and 39%, respectively. The event-free survival curve is shown in Fig. 2 and the two and four-year rates were 39.8% and 19.9%, respectively. The factor that significantly influenced overall survival in the univariate analysis was the surgical treatment (p = 0.0002), as illustrated in Fig. 3. Radical surgical treatment was considered to be an adverse factor, in comparison with salvage treatment, since it presented a higher mortality rate. Other factors such as sex, age, tumor location, histological subtype, tumor size, metastasis at the time of diagnosis and surgical limits, did not reach statistically significant limits, for p-values < 0.05. The factors that had an influence on the risk of an event (metastasis and/or local recurrence) in the univariate analysis were the following: surgical treatment (p = 0.0037; Fig. 4), metastasis at the time of diagnosis (p = 0.0016; Fig. 5) and tumor size (p = 0.0502; Fig. 6). Radical surgical treatment was considered to be an adverse factor for events to appear (metastasis and/ or local recurrence), in comparison with salvage treatment. Presence of metastasis at the time of diagnosis showed a greater rate of events (metastasis and/or local recurrence), in comparison with its absence, and tumor size greater than 15 cm along its major axis was considered to be an adverse factor for event-free survival. The other factors studied did not present significance levels for p-values < 0.05 (sex, age, tumor location, histological subtype and surgical limits). The degrees of tumor necrosis following chemotherapy (Huvos) did not reach statistical significance levels for the two survival types: overall (p = 0.2903) and event-free (0.5327), as shown in Figs. 7 and 8. Huvos grades were not considered to be prognostic factors for either overall or event-free survival.

1.2

1.2 1.0 .8 .6 .4 .2 0.0 -2 Event-free survival curve in months

Fig. 2 - Event-free survival curve.

1.2 1.0 .8 .6 Surgical treatment

.4

Salvage .2

Salvage - censored

0.0

Radical Radical - censored

-2

Overall survival curve and surgical treatment in months

Fig. 3 - Overall survival curve according to surgical treatment.

1.2

1.0

1.0 .8

.8

.6 .6

.4 .2

.4

0.0 .2

-2

0.0

Surgical treatment Salvage Salvage - censored Radical Radical - censored

Event-free survival curve and surgical treatment in months Overall survival curve in months

Fig. 1 - Overall survival curve.

Fig. 4 - Event-free survival curve according to surgical treatment.


90

Rev Bras Ortop. 2013;48(1):87-91

1.2

Discussion

1.0 .8 .6 Metastasis at time of diagnosis

.4

No

.2

Non-censored

0.0

Yes

-2

Yes-censored

Event-free survival curve and metastasis at time of diagnosis

Fig. 5 - Event-free survival curve according to metastasis at the time of diagnosis. 1.2 1.0 .8 .6 .4

Tumor size

.2 0.0 -2 Event-free survival curve and tumor size in months

Fig. 6 - Event-free survival curve according to tumor size

1.2 1.0 .8

Huvos grade

.6 .4 .2 0.0 -2 Overall survival curve and Huvos necrosis grade in months

Fig. 7 - Overall survival curve according to Huvos necrosis grade. 1.2 1.0 .8

Degree of necrosis

.6 .4 .2 0.0 -2 Event-free survival curve and Huvos necrosis grade in months

Fig. 8 - Event-free survival curve according to Huvos necrosis grade.

The epidemiological and clinical characterization in the present study was concordant with the literature.1-3 The unfavorable prognostic factors were metastasis at the time of diagnosis, tumor size larger than 15 cm and radical surgical treatment. During the follow-up among these patients, metastases were identified in 62.5% of them, among whom 21.8% had already presented metastasis at the time of diagnosis. This percentage was, in turn, higher than values reported from other countries (15% to 20%), but it was within the range reported in Brazil, which has been as high as 38%.4 In evaluating its significance for event-free survival, we found that it was related to worse prognosis. Rech et al.5 also came to this conclusion, through demonstrating that less than 20% of these patients present five-year disease-free survival. 5 These patients probably demonstrated worse survival results because they had larger-sized tumors during the initial stages of the disease and because these cases were diagnosed at a late stage.4,5 In our study, 43.8% of the patients presented tumor sizes larger than 15 cm, and these patients had worse event-free survival results. This corroborates the data of Bispo Júnior,6 in a doctoral thesis, and the findings of Castro et al.4 The patients’ overall survival after two and four years was 45.5% and 39%, respectively. Other studies4,6 have reported overall survival rates higher than those found in our study. In evaluating event-free survival, we observed two and four-year rates of 39.8% and 19.9%, respectively. Similar studies have revealed higher rates.4-6 The type of surgical treatment (amputation or limb preservation) was chosen for the patients in accordance with the concomitant conditions presented. In other words, the decision was made according to the degree to which the disease had already evolved. Patients whose diagnoses were made at a late stage, with metastatic disease and/or largevolume tumors, almost always underwent radical surgery. In this manner, 65.6% of the patients underwent amputation. Although the patients with an indication for salvage surgery on the limb had a greater chance of presenting local recurrence, depending on the surgical technique and the learning curve, they presented overall and event-free survival rates greater than those of patients who underwent amputation.7,8 This was because the patients with voluminous tumors (with the implication of impossibility of limb preservation) presented worse prognosis even at the time of diagnosis.8,9 We evaluated the Huvos criteria but found that they did not present any significance in relation to the patients’ prognoses. In a doctoral thesis, Bispo Júnior6 reported that the stratification into groups I and II was unnecessary because of the similar behavior presented by these two groups, and also demonstrated that the prognostic behavior was similar between the groups. Other criteria for prognostic evaluation and staging have already been proposed in the worldwide literature. 10,11 Magnetic resonance imaging may in the future be used for assessing the degree of tumor necrosis following neoadjuvant chemotherapy.


Rev Bras Ortop. 2013;48(1):87-91

5.

Conclusion According to this study, presence of metastasis at the time of diagnosis and tumor size larger than 15 cm were factors for worse prognosis. On the other hand, the Huvos criteria did not reach statistical significance for the patients’ prognoses.

Conflicts of interest The authors declare that there was no conflict of interests in conducting this study.

R

E

F

E

R

E

N

C

E

S

1.

Camargo OP, Baptista AM, Caiero MT, Camargo AFF. Afecções tumorais: avaliação, epidemiologia e diagnóstico. In: Barros Filho TEP, Camargo OP, Camanho GL. Clínica ortopédica – Medicina USP. Barueri: Manole; 2012. p. 506-10.

91

Rech A, Castro CG Jr, Mattei J, Gregianin L, Di Leone L, David A, et al. Características clínicas do osteossarcoma na infância e sua influência no prognóstico. J Pediatr. 2004;80(1):65-70. 6. Bispo Júnior RZ. Fatores prognósticos da sobrevida no osteossarcoma primário: grau I versus II de Huvos [tesse]. São Paulo: Faculdade de Medicina da Universidade de São Paulo; 2009. 7. Simon MA. Current concepts review: limb salvage for osteosarcoma. J Bone Joint Surg Am. 1988;70(2):307-10. 8. Rougraff BT, Simon MA, Kneisl JS, Greenberg DB, Mankin HJ. Limb salvage compared with amputation for osteosarcoma of the distal end of the femur. J Bone Joint Surg Am. 1994;76(5):649-56. 9. Curcelli EC. Prognóstico em osteossarcoma: análise clínica, epidemiológica, histopatológica e imuno-histoquímica [tese]. Botucatu: Universidade Estadual Paulista; 2008. 10. Wuisman P, Enneking WF. Prognosis for patients who have osteosarcoma with skip metastasis. J Bone Joint Surg Am. 1990;72(1):60-8. 11. Peabody TD, Gibbs CP, Simon MA. Current concepts review: evaluation and staging of musculoskeletal neoplasms. J Bone Joint Surg Am. 1998;80(8):1204-18.


Rev Bras Ortop. 2013;48(1):92-99

www.rbo.org.br/

Original Article

Quality of life of orthopedists in Mato Grosso do Sul Marcelo Henrique de Mello1, José Carlos Souza2* 1Orthopedist;

MSc in Psychology from the Universidade Católica Dom Bosco (UCDB), Campo Grande, Mato Grosso do Sul, Brazil. PhD in Mental Health, Universidade de Campinas (Unicamp), Campinas, São Paulo, Brazil; PhD from Lisbon Medical School, Lisbon, Portugal. Professor at the Universidade Católica Dom Bosco (UCDB), Campo Grande, Mato Grosso do Sul, Brazil. Work performed at the Department of Postgraduate Studies on Psychology, Healthcare Practices Sector, Universidade Católica Dom Bosco, Campo Grande, Mato Grosso do Sul, Brazil. 2Psychiatrist;

A RT I C L E I N F O

a b s t r a c t

Article history:

Objective: Evaluate QOL and its implications for health care providers specialized in orthopedics.

Received December 21 2011 Accepted April 12 2012 Keywords: Quality of Life Orthopedics Questionnaires

Methods: In this quantitative, descriptive, cross-sectional study two questionnaires, World Health Organization Quality of Life (WHOQOL-100) and sociodemographic, were sent to 117 orthopedic surgeons, with 29 doctor’s response. Statistical analysis was performed using three different tests: Analysis of Variance (ANOVA), Student t-test, and Pearson’s linear correlation. The tests were applied with a reliability of 95%. Results: Twenty-nine orthopedic surgeons responded to the questionnaire. The studied variables regarding domains were age and employment duration, which have a positive relationship with the environment and social relationships domains; income, which positively influences the level of independence and environment domains; and workload, which negatively influences the psychological domain. Conclusion: Orthopedic physicians had high scores in the WHOQOL-100 domains and, in their perception, good quality of life had higher scores compared to other professions. © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

*Corresponding author at: Rua Theotônio Rosa Pires, 88, Campo Grande, MS, Brazil. CEP: 79004-340, Phone: (+55 67) 9981-6271. E-mail: josecarlossouza@uol.com.br ISSN/$–see front matter © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved. doi: 10.1016/j.rboe.2012.04.002


Rev Bras Ortop. 2013;48(1):92-99

Introduction Since the time when humans became recognizable, they have suffered health problems and have sought solutions for them. There have been very many reports on such actions. In modern times, humans have become institutionalized, and their knowledge has become grouped into so-called “schools”. Medicine is no different in this regard: while it was solitary in the early days of the physician-philosophers, and mostly empirical, today it is organized into schools that make it possible for thousands of young people in Brazil and around the world to become physicians and deal with life, death and all possible diseases on a daily basis. Society’s facilitated access to medicine, and to physicians in general, is one of the great advances of medicine. It is probably also one of the motives for concern among physicians, given that with this proximity, they have become more vulnerable than ever to the increasing demands that they should get things right, with ever fewer errors. It is impossible to practice medicine without an awareness of benefit and harm, without a desire to serve and be useful, or without love for human beings. Medicine is a science when the biological aspects of human beings are studied and an art when its knowledge is applied to benefit mankind.1 In Brazil today, there are 180 medical schools from which around 15,500 physicians graduate every year. These will spread across Brazil, many without doing any other specialization. In many cases, they will be seeking economic stability, which is one of the main advantages of the profession, or at least one of the most celebrated advantages.2 For many years, people who sought to study medicine were almost always attracted by the independence provided by the profession. Physicians, as liberal professionals, could develop their best abilities and adapt their work according to their individual lives and needs, lifestyles and personalities. However, today, physicians as liberal professionals are almost extinct and they act defensively, with preoccupations relating to being sued for possible mistakes. The profession is now dominated by health insurers.3 It has been shown that today, the financial stability that previously was guaranteed to individuals graduating in medicine is not longer accompanied by a satisfactory return in terms of salary. To achieve a reasonable financial condition, professionals end up becoming overloaded, through subjecting themselves to a variety of jobs and on-call duties, thereby leading to technical deterioration of their practice.4 Specifically in the case of physicians who specialize in orthopedics and traumatology, for them to obtain the title of specialist in orthopedics and traumatology after their basic training of six years of medical school, they have the obligation to undergo specialization training for a minimum of three years, at healthcare services recognized by the Brazilian Society of Orthopedics and Traumatology (SBOT). Currently, there are around 155 of these services, which produce approximately 400 trained orthopedists every year. After these three years of accredited medical residence, these physicians also need to go through a theoretical-practical test applied by the society.

93

After approval, they can be enrolled as “specialists”.5 Thus, in addition to all the waiting and anxieties of becoming physicians, prospective orthopedists still have to undergo tests to be considered suitable and finally achieve economic stabilization and the satisfaction of practicing their profession. In the state of Mato Grosso do Sul, there are 117 physicians who are specialists in orthopedics and traumatology6 and, of these, 74 live in the state capital and 43 elsewhere in the state. They are composed of 113 men and four women. After receiving the title of specialist in orthopedics and traumatology, many of these professionals still continue studying and improving their skills, given that the SBOT not only recognizes general orthopedics but also today recognizes 12 subspecialties: hand surgery, spinal surgery, knee surgery, foot and ankle surgery, pediatric orthopedics, oncological orthopedics, shoulder and elbow surgery, osteoporosis and metabolic disease, orthopedic trauma, arthroscopy, hip surgery, reconstruction and bone lengthening. The need for professionals to care for themselves is fundamental for professionals to be able to practice their profession, since care is a condition that results in physical and mental wellbeing, and these conditions make it possible to provide better care for others. This concern for physical and emotional wellbeing has increasingly become part of the dayto-day routine, which takes the name of quality of life (QOL). Such concerns are not restricted to physicians, given that all professions and strata of society today have the same thinking with regard to improving their “quality of life”.7 When physicians present emotional disorders, they do not seek help, but self-medicate. Moreover, they neglect their general needs regarding health. Most physicians (70%) do not undergo regular check-ups and 60% of family physicians do not consult another physician. When they are actually diagnosed as presenting an illness, they aggregate multiple diagnoses. The rate of surgery among physicians is three times greater than that of the general population.8 Physicians’ adherence to treatments prescribed by their colleagues is extremely poor. They refuse, ignore or deprecate their own treatment and are therefore mandatory targets for better assessment and actions in relation to QOL. In order to think about improving the general QOL of orthopedists, it firstly needs to be understood what QOL is and what its implications are, and it needs to be quantified, so that it becomes possible with this information at hand to introduce positions and initiatives that might increase and improve QOL. This was the aim of the present study: to bring the concept of QOL to the eyes of orthopedists, through conceptualizing and exemplifying it, so that through recognizing it, they might concern themselves more with it and act towards improving it. Thus, the objectives of the present study were to evaluate the general QOL of orthopedists in the state of Mato Grosso do Sul and to characterize the sample by means of the following sociodemographic variables: age; sex; time since graduation; marital status; specialization held, if any; timetabled workload; number of days worked per week; monthly family income; any other sources of income; home location; and perception of work in relation to other orthopedists. In addition, the aim was to evaluate QOL according to the domains of the WHOQOL-100 questionnaire: physical aspects, psychological aspects, level


94

Rev Bras Ortop. 2013;48(1):92-99

of independence, social relationships, environment and spirituality/beliefs/religion; and to compare the QOL domains of WHOQOL-100 with the sociodemographic variables.

Material All the professional orthopedists of the state of Mato Grosso do Sul who had the title of specialist in orthopedics and traumatology, as recognized by the Brazilian medical Association, and who were associates of the SBOT, were invited to participate in the study and received the questionnaires. These totaled 117 physicians (N = 117), of whom four were women and 113 were men, distributed between the state capital (74) and elsewhere (43), in 18 municipalities: Amambai, Aparecida do Taboado, Aquidauana, Bonito, Cassilândia, Chapadão do Sul, Corumbá, Coxim, Costa Rica, Dourados, Eldorado, Jardim, Naviraí, Nova Andradina, Paranaíba, Ponta Porã, São Gabriel and Três Lagoas. Twenty-nine orthopedists (all male) provided responses to the questionnaires. The inclusion criteria for the study were that the subjects should have the title of specialist in orthopedics and traumatology and should agree to participate in the study.

Methods The project for this dissertation was presented to the Research Ethics Committee of UCDB, for authorization of this study on human beings, as established through Resolution No. 196, of October 10, 1996, from the National Health Board. This approval was granted.9 Authorization from the SBOT in the state of Mato Grosso do Sul for conducting a survey among its members was also sought and granted. After obtaining approval for the project from the Research Ethics Committee of UCDB, a pilot study was then conducted among three orthopedists in a clinic in Campo Grande, MS, was then conducted with the aim of ascertaining the suitability of the instrument. The period for this cross-sectional survey was determined by the researcher to be from September 2009 to the end of December 2009 (four months). The questionnaires were all sent out or delivered in the same week of September and the period for participants to return them was prolonged until the end of December 2009. There were no other returns after this period. So that anonymity was achieved, each of the invited participants was sent an envelope containing the following, at the private clinic or the hospital where they were known to work: letter from the SBOT signed by its president, giving the society’s endorsement of the survey; informed consent statement, which needed to be signed or otherwise the filled-out questionnaire would be excluded; WHOQOL-100 questionnaire consisting of 100 self-explanatory questions. Some physicians received the envelope directly at their workplaces (private clinics), particularly those living in the state capital (Campo Grande). The remainder (i.e. the majority) received it through the post. Each participant signed the free and informed consent statement. Since the WHOQOL-100 questionnaire is self-explanatory, each participant filled it

out alone, without the presence of the researcher. After the questionnaires had been filled out, they were sent or taken personally in an envelope to the main office of the SBOT in Mato Grosso do Sul (when posted, the cost was borne by the participant, sent in an envelope without identification), located at the same office as the Medical Association of Mato Grosso do Sul, in Parque dos Poderes, Campo Grande, MS. After the questionnaires had been received at the main office of the SBOT, the author separated out the consent statements from the questionnaire forms, so as to preserve anonymity. After this, the data were surveyed, the results were tabulated and the latter were analyzed. Because most of the municipalities in the state only have one orthopedist working there (except for Campo Grande, Dourados, Três Lagoas, Aquidauana, Corumbá, Nova Andradina and Ponta Porã), the home locations of the physicians who answered the questionnaire will not be described, in order to maintain confidentiality. Two research instruments were used: WHOQOL-100 (World Health Organization Quality of Life – 100); and a sociodemographic questionnaire drawn up by the researcher, in which the following characteristics were investigated for subsequent correlation: age, sex, marital status, time since graduation, monthly family income, weekly timetabled workload in different settings, home location (capital or elsewhere), subspecialization held (if any), income sources other than medicine (if any) and each physician’s perception regarding the volume of work, in relation to other orthopedists in the state. WHOQOL-100 is just one of the questionnaires that exist in the arsenal of QOL surveys. A review study on QOL found that certain methodological difficulties exist because of the subjectivity of this topic, although these may be resolved through the large number of questionnaires that have already been validated in Brazil. 10 The study mentioned 126 instruments for measuring different populations, and highlighted three of them: the Medical Outcomes Study (MOS) Short Form-36 Health SurvWey (SF-36); the World Health Organization Quality Of Life questionnaire (WHOQOL-100); and the Quality Of Life (QOL) questionnaire. WHOQOL-100 is an instrument for evaluating QOL that can be used both for healthy populations and for populations affected by illnesses and/or chronic diseases.11 WHOQOL-100 was conceptualized by the Quality of Life Group of the Mental Health Division of the World Health Organization (WHO).12 It initially contained 2000 questions and was then reduced first to 300 and later on to its final form of 100 questions. It was subsequently translated and validated by the Department of Psychiatry and Legal Medicine of the Universidade Federal do Rio Grande do Sul, Porto Alegre, in 1996. Brazil is one of more than 20 countries that apply this questionnaire, which demonstrates its transcultural applicability, with six distinct aspects: physical domain, psychological domain, level of independence, social relationships, environment and spirituality/beliefs/religion.13 Development of QOL measurement instruments is a complex and systematic concern within several fields of scientific knowledge, for investigating healthcare measures in a broader manner that goes beyond the traditional and insufficient parameters of morbidity and mortality.13


Rev Bras Ortop. 2013;48(1):92-99

Starting from these premises, WHO proposed to develop an instrument that would fill this gap. Firstly, the fundamental characteristics that the construct would need to have were established: subjectivity; multidimensionality; bipolarity. Within this context, the Group drew up WHO’s definition of QOL: it is the individual’s perception of his position in life, within the context of his culture and the value system in which he lives, and in relation to his expectations, standards and preoccupations.12 The domains of WHOQOL include six aspects, subdivided into 24 facets to be investigated. The WHOQOL questions were formulated for a scale of Likert-like responses, in relation to intensity (nothing – extremely), capacity (nothing – completely), frequency (never – always) and assessment (very dissatisfied – very satisfied; very poor – very good). Although these anchor points are easy to translate into different languages, the choice of intermediate terms presents certain difficulties of semantic equivalence in different languages. For example, between the anchors “never” and “always”, there may be “sometimes”, “frequently”, “very frequently”, “often”, etc.). After the facets had been developed, the translation was done, followed by discussion of the translated version in Portuguese, in focus groups. The focus groups suggested that small modifications should be made in the way of formulating the questions. These suggestions were then discussed in a second bilingual panel, and thereafter incorporated into the final version of the instrument. The panel decided to maintain the suggestions that would furnish the simplest and most commonly used synonym, in order to facilitate understanding by the largest number of people. The Portuguese version of WHOQOL-100 was discussed in four focus groups in the city of Porto Alegre, southern Brazil. The focal groups were composed by individuals who were representative of the demographic characteristics of the population that seeks Hospital de Clínicas, in Porto Alegre, in relation to sex, age, educational level and socioeconomic level. The aims of the focus groups were: 1) to review the formulation and comprehension of the 100 questions of the questionnaire; 2) to discuss the extent to which each of the facets affected people’s quality of life; and 3) to investigate whether there might be other uninvestigated facets that would be important specifically for Brazil. The list of facets was considered to be valid by the great majority of the participants. People from the community, patients (both inpatients and outpatients) and healthcare professionals all emphasized that the facets described in detail what each of the participants understood by quality of life within their settings. The 24 facets (below) were considered to be relevant by all the groups. Patients and people from the community considered that the instrument also provided an opportunity for thinking about important aspects of their own lives in a systematic manner: an opportunity to “stop and think”. Some patients reported that the instrument brought out questioning that had the capacity to motivate them to seek deeper analysis with a psychologist, psychiatrist or their own physician. One patient with leukemia reported feeling anxious about some questions. At the end of this process, the following relationships between the facets and the domains were found:

95

Domain I Physical: 1. Pain and discomfort; 2. Energy and fatigue; 3. Sleep and rest; Domain II Psychological: 4. Positive feelings; 5. Thinking, learning, memory and concentration; 6. Self-esteem; 7. Body image and appearance; 8. Negative feelings; Domain III Level of independence: 9. Mobility; 10. Activities of daily living; 11. Dependence on medication and treatments; 12. Capacity for work; Domain IV Social relationships: 13. Personal relationships; 14. Social support; 15. Sexual activity; Domain V Environment: 16. Physical security and protection; 17. Home environment; 18. Financial resources; 19. Healthcare and social care: availability and quality; 20. Opportunities to acquire information and skills; 21. Participation in recreation/leisure opportunities; 22. Physical environment (pollution, noise, traffic, weather); 23. Transportation; Domain VI Spiritual factors/religion/personal beliefs: 24. Spirituality/religion/personal beliefs. The scores would be obtained using the SPSS statistical software (SPSS syntax), and manual scoring was not recommended, since this would increase the margin of error in calculating the scores. So far, there is no normative population-based data for WHOQOL scores.12 For the statistical analysis on the data, three different statistical tests were applied: analysis of variance (ANOVA) to assess the orthopedists’ general QOL; Student’s t test for the orthopedists’ sociodemographic variables in relation to the dimensions of the WHOQOL-100 questionnaire; and Pearson’s linear correlation test in relation to the continuous variables. The tests were applied with a 95% confidence interval, which was equivalent to saying that all the results presenting values less than 0.05 (p < 0.05) were significant. This study was divided into three parts: firstly, presentation of the orthopedists’ general QOL, secondly, presentation and analysis of the sociodemographic variables; and thirdly and lastly, presentation of the basic statistics and analyses on the continuous variables in relation to the WHOQOL-100 domains.


96

Rev Bras Ortop. 2013;48(1):92-99

Results

Pain and discomfort Energy and fatigue

Twenty-nine male orthopedists provided responses for the sociodemographic and WHOQOL-100 questionnaires, during the period from September to December 2009. The majority of them had a subspecialization (65.5%) and worked on more than five days a week (53.6%). There was a balance between the work locations (consultation office 54.2%, hospital 45.8%); most of them lived exclusively from the income earned through medicine (58.6%); and the great majority had a perception that their workload was greater than the average among their orthopedist colleagues (69%). In the present study, it was observed that the orthopedists had lower scores in the physical dimension (mean = 63.89) and environment (mean = 65.77) and higher scores in the dimension of level of independence (mean = 80.41) (Fig. 1).

Sleep and rest Positive feelings Thinking, learning, memory and concentration Self-esteem Body image and appearance Negative feelings Mobility Activities of daily living Dependence on medication or treatments Capacity for work Personal relationships Social support Sexual activity Physical security and protection

Health and social care: availability and.. Opportunities to acquire new information

63.89

71.59

80.41

Participation in, and opportunity for...

72.07

65.77

72.10

Physical environment (pollution, noise, traffic and climate)

Transportation Spirituality, religion and personal beliefs Quality of life from the point of view of the person evaluated

Physical

Psychological

Level of Social independence relationships

Environment

Spiritual

Fig. 2 - General score for WHOQOL-100 among the orthopedists sampled, per facet.

Mean

Fig. 1 - General mean for WHOQOL-100 among the orthopedists sampled, per dimension.

For better understanding of the domain scores, a graph is presented discriminating all the facets involved in the six domains of WHOQOL-100, with their respective scores, thereby expanding the view of these domains. The physical aspect dimension was the one that showed the lowest values and, from analysis on Fig. 2, it can be seen that the mean was influenced by the facet of “pain”, probably related to the mean age of the sample (46.70 years, with a minimum of 27 and maximum of 78), but did not go as far as influencing “energy” or “rest”. The individuals surveyed presented good capacity and energy for work. It is important to highlight that there have been studies that indicated that changes to sleep and rest were the main agents for low QOL.14,15 A study among physicians and nurses at a neonatal ICU found much worse results than in the present study, with regard to the physical domain and environment, although the population observed in that study was predominantly female and was younger (mean age of 34.7 years).16 Contrary to the findings in the present study, it was found that the physical domain presented higher scores among community health agents (73.8) in a municipality in the western part of the state of São Paulo.17 There was a

similar result among community health agents in the state of Minas Gerais (82.8).18 A higher score was found in the physical score among psychologists (71.32).19,20 Regarding the environment dimension, low scores were found in the facets of security and recreation, which possibly reflected a delicate time in medicine in Mato Grosso do Sul, when physicians were often being assaulted at health clinics and hospitals, with wide coverage in the press, which even gave rise to movements among professional associations against this growing practice. The presence or absence of security and access to recreation and leisure may have been related to fatigue after exhausting working days, sometimes not so long, but with demanding work (surgery, for example). These data also appear for different reasons, given that in this study insecurity came from the precariousness and quantity of employment linkages, as well as the perceived low salary.21 On the other hand, the orthopedists presented high values regarding opportunities to acquire new knowledge, good levels of concentration, memory, reasoning and learning, good self-esteem and good perceptions of their body image. These factors may make the service provided more efficient and of better quality.22-24 Despite the vast amount of material on the construct of QOL, there is a scarcity of material in relation to WHOQOL-100 among physicians, both nationally and worldwide. After investigating in the websites of Scielo, Bireme, Universidade de São Paulo library, State Universidade de Campinas library, Google Academic and others, using the keywords “quality of life”, “orthopedics” and “WHOQOL-100” (both in English and


97

Rev Bras Ortop. 2013;48(1):92-99

in Portuguese), only a few texts relating to studies conducted using the WHOQOL-100 questionnaire were found, and none among orthopedists. Comparatively, most of the orthopedists presented higher values than those of other professions, despite all the difficulties of practicing medicine nowadays. A study conducted among metalworkers was found, in which lower scores were seen in all the domains, including the general perception of QOL, with similarities only in the construct of level of independence.25 The high scores among the orthopedists in the dimension of level of independence were based mainly on the orthopedists’ high capacity for work and possibility of performing their daily tasks, although this same dimension presented a paradoxical low score regarding the participants’ need for or dependence on medicines. This dependence may be explained by the orthopedists’ high mean age, but the high workloads with physical and psychological demands, often with sleep deprivation, have to be mentioned. These situations have already been discussed in other studies, in which high rates of absenteeism, legal cases and irregular practices among physicians have been observed.26 In other documents, on health agents for example, professional exhaustion and mental disorders have been cited as causes of use of medications like calmants, tranquillizers or antidepressants at rates of up to 17% of the population.27 Using the WHOQOL-100 questionnaire, a study was conducted in which a group of patients with depressive symptoms was compared with a control group without any detectable abnormalities.28 Comparison between the scores obtained by this control group and those of the group of orthopedists showed that the values were very similar. There were slight differences only in the spirituality domain, with advantage for the orthopedists, and in the physical domain, with advantage for the control group individuals. Comparison with the scores of the group with depressive symptoms showed that the orthopedists presented higher values in all the domains. A survey using the WHOQOL-100 questionnaire applied to bank workers in the city of Ponta Grossa, in Paraná, with practically the same number of participants as in the present study, measured much lower scores in almost all the domains. Once again, only the construct of spirituality presented higher scores than those of the group of orthopedists.29 Comparison with another study that was conducted among physicians of various specialties who were doing medical residence or improvement or refresher courses also showed that the orthopedists presented better scores in practically all the domains, with a difference again in the spiritual domain, such that improvement students had higher scores, in the range of 83.59, versus 72.10 for the orthopedists.20 Here, it can be emphasized that the score obtained in the spiritual domain was at the average for the WHOQOL-100 domains for this group, i.e. not lower and not higher than the others, without statistical significance. Despite the divergence, this subject merits greater attention. Citing Hippocrates, “Some patients, sensing that their illness is very severe and believing in the humanism of the physician, recover their health” (Decorum; Corpus hippocraticum, second century BC).30 This observation relates to the importance of spirituality among physicians and consequently among

orthopedists. Providing comprehension, compassion and hope is the ancient basis of the medical profession and does not necessarily depend on the professional’s faith. No effort should be spared in surmounting the conflicts that might come from differences in convictions and beliefs in the physician-patient relationship. Although this matter is still controversial, some authors have indicated that spirituality and religiousness may have a positive role (especially in prayers for intercession) in relation to coronary diseases, arterial hypertension, anxiety, depression, immune function and mortality in general.31-33 There is evidence that people with some type of spirituality present lower incidence of these diseases, live longer, recover faster when they are ill and present fewer complications during treatments. Reflecting on this, despite scientific controversy regarding the effects of spirituality on health: 31 “It should remain clear that if these benefits come from an intervention or response by God to the appeals of prayer and spirituality, this is always going to be beyond what science can or cannot prove.” Returning to the results under discussion, it was observed that the group of orthopedists had higher scores than what was found in direct comparisons with other professions. From Table 1, it can be seen that most of the group was formed by physicians with subspecializations (65.5%), who worked for more than five days per week (53.6%). There was a balance between workplaces (consultation office, 54.2%; hospital, 45.8%); the physicians mostly lived solely on income earned through medicine (58.6%); and the great majority had a perception that their workload was greater than the average for their colleagues (69.0%).

Table 1 - Sociodemographic characteristics of the orthopedists. Variable Subspecialization

Days worked

Main work location

Other income

Perception of work (h/day), in relation to other orthopedists

Values n % No

10

34.5

Yes

19

65.5 46.4

Up to 5 days

13

More than 5 days

15

53.6

Consultation office

13

54.2

Hospital/outpatient clinic

11

45.8

No

17

58.6

Yes

12

41.4

Less/little

9

31.0

More/a lot

20

69.0

Having or not having a subspecialization did not interfere significantly in QOL, with regard to any of the dimensions of WHOQOL-100 among the orthopedists sampled. In other words, the means for the domains were equal. Being specialists, and doing a subspecialization on the knee, hand, spine or any other specialty, did not make any difference. This leads


98

Rev Bras Ortop. 2013;48(1):92-99

to the belief that, hypothetically, the greatest demand is for orthopedists, and this would probably be related to the low number of orthopedists in the state and the high demand for their services, especially in emergency and high complexity settings, which in this state is mainly limited to the Santa Casa hospital of Campo Grande, the University Hospital and the Rosa Pedrossian Regional Hospital. With the high demand for services in these hospitals, it is essential for on-call rosters to be correctly filled, and for this it is unimportant whether the orthopedist has or does not have a subspecialization. This gives rise to the possibility that even those who do not have a subspecialization may have earnings proportional to those who do. For the analysis on the orthopedists in relation to the number of days of the week worked, two groups were formed: up to five days a week; and more than five days a week. No significant difference was detected in any of the WHOQOL-100 domains, i.e. the orthopedists’ QOL did not depend on the number of days worked. One of the hypotheses for this might be that those who were working for more than five days a week were doing so on an on-call basis, with a salary addition in line with or proportional to the effort required. Another hypothesis is that this work yields pleasure and satisfaction among the orthopedists. Benevolence has great value in all cultures because of the primary need for human beings to live in groups and help each other, so as to ensure the survival and wellbeing of the community.34 This result confirms previous studies that demonstrated that healthcare professionals were motivated through the influence of the factors of need for contact with patients and interest in helping one’s fellows.35

5. 6.

7. 8. 9. 10. 11.

12. 13.

14. 15.

16.

17.

Conclusion The orthopedists presented high scores in the WHOQOL-100 domains and, in their perception, good quality of life. Their scores were higher than in other professions.

18.

19.

Conflicts of interest The authors declare that there was no conflict of interests in conducting this study.

R

E

F

E

R

E

N

C

E

1.

Rezende JM. Vertentes da medicina. São Paulo: Giordano; 2001. Dados Estatísticos sobre as Escolas Médicas do Brasil. Brasília: Associação Médica Brasileira; 2010. Millan LR, Marco OLN, Rossi E, Arruda PCV. O curso médico no Brasil. In: Millan LR. O universo psicológico do futuro médico: vocação, vicissitudes e perspectivas. São Paulo: Casa do Psicólogo; 1999, p. 31-42. Benevides-Pereira AMT. O adoecer dos que se dedicam à cura das doenças: o burnout em um grupo de médicos. In: ______ (Org.). Burnout: quando o trabalho ameaça o bem-estar do trabalhador. São Paulo: Casa do Psicólogo; 2002, p. 105-32.

20.

S

21.

2. 3.

4.

22.

23.

24.

Sociedade Brasileira de Ortopedia e Traumatologia. Exame de especialista. São Paulo; 2010a. Sociedade Brasileira de Ortopedia e Traumatologia. História da SBOT. São Paulo, 2010b. Disponível em: [http://www.sbot. org.br/?acao=institucional/historia]. Waldow VR. O cuidado na saúde: as relações entre o eu, o outro e os cosmos. Petrópolis: Vozes; 2004. Frasquilho MA. Medicina, médicos e pessoas: compreender o stress para prevenir o burnout. Acta Med Port. 2005;18(6):433-44. Brasil. Conselho Nacional de Saúde (1996). Resolução nº. 196. Brasília: Senado Federal; 1996. Velarde-Jurado E, Avila-Figueroa C. Evaluación de la calidad de vida. Salud Publica Mex. 2002;44(4):349-61. Vilarta R, Gonçalves, A. Qualidade de vida: identidade e indicadores. In: _____ (Orgs.). Qualidade de vida e atividade física: explorando teoria e prática. Barueri: Manole; 2004. p. 3-25. Whoqol Group. Development of the Whoqol: rationale and current status. Int J Mental Health. 1994;23(3):24-56. Fleck MPA, Leal OF, Louzada S, Xavier M, Chachamovich E, Vieira G et al. Desenvolvimento da versão em português do instrumento de avaliação de qualidade de vida da Organização Mundial de Saúde (WHOQOL-100). Rev Bras Psiquiatr. 1999;21(1):19-28. Reimer MA, Flemons WW. Quality of life in sleep disorders. Sleep Med Rev. 2003;7(4):335-49. Papp KK, Stoller EP, Sage P, Aikens JE, Owens J, Avidan A, et al. The effects of sleep loss and fatigue on residentphysicians: a multiinstitutional, mixed-method study. Acad Med. 2004;79(5):394-406. Fogaça MC, Carvalho WB, Nogueira PCK, Martins LAN. Estresse ocupacional e suas repercussões na qualidade de vida de médicos e enfermeiros intensivistas pediátricos e neonatais. Rev Bras Ter Intens. 2009;21(3):299-305. Bernardes KAG. Qualidade de vida de agentes comunitários de saúde de um município da região oeste do Estado de São Paulo [dissertação]. São Paulo; Universidade de São Paulo; 2008. Disponível em: [http://www.teses.usp.br/teses/ disponiveis/22/22133/tde-31102008-150058/pt-br.php]. Vasconcellos NPC, Costa-val R. Avaliação da qualidade de vida dos agentes comunitários de Lagoa Santa-MG. Rev APS. 2008;11(1):17-28. Costa CC, Bastiani M, Geyer JG, Calvetti PU, Muller MC, Moraes MLA. Qualidade de vida e bem-estar espiritual em universitários de psicologia. Psicologia em Estudo. 2008;13(2):249-55. Lourenção LG. Qualidade de vida de médicos residentes, aprimorandos e aperfeiçoandos da Faculdade de Medicina de São José do Rio Preto/SP [tese]. São José do Rio Preto: Faculdade de Medicina; 2009. Disponível em: [http://bdtd. famerp.br//tde_busca/arquivo.php?codArquivo=250]. Miranzi SSC, Mendes CA, Nunes AA, Iwamoto HH, Miranzi MAS, Tavares DMS. Qualidade de vida e perfil sociodemográfico de médicos da estratégia de saúde da família. Rev Med Minas Gerais. 2010;20(2):189-97. Schwartzmann L. Health related quality of life in medical doctors: study of a sample of Uruguayan professionals. Vertex: Rev Arg Psiquiatr. 2007;18(72):103-10. Seidl EMF, Zannon CMLC. Qualidade de vida e saúde: aspectos conceituais e metodológicos. Cad Saude Publica. 2004;20(2):580-8. Shearer S, Toedt M. Family physicians’ observations of their practice, well being, and health care in the United States. J Family Pract. 2001;50(9):751-6.


Rev Bras Ortop. 2013;48(1):92-99

25. Rosa MAS, Pilatti LA. Qualidade de vida no trabalho: análise do caso de colaboradores de uma empresa do ramo de metalurgia de Ponta Grossa-PR. Revista Digital. 2007;12(108). 26. Alves HNP, Surjan JC, Nogueira-Martins LA, Marques ACPR, Ramos SP, Laranjeira RR. Perfil clínico e demográfico de médicos com dependência química. Rev Assoc Med Bras. 2005;51(3):139-43. 27. Silva NAC, Menezes PR. Esgotamento profissional e transtornos mentais comuns em agentes comunitários de saúde. Rev Saude Publica. 2008;42(5):921-9. 28. Gameiro S, Carona C, Pereira M, Canavarro MC, Simões M, Rijo D, et al. Sintomatologia depressiva e qualidade de vida na população geral. Psic, Saude & Doenças. 2008;9(1):103-11. 29. Maier RC, Santos Santos G Jr. Análise da qualidade de vida: um estudo com colaboradores bancários da cidade de Ponta Grossa – PR. In: Congresso Internacional de Administração, 7, Anais do Enegep. Ponta Grossa, PR; 2010. Disponível em:[www.admpg.com.br/2010/down.php?id=1251&q=1].

99

30. Milnitsky-Sapiro C. Teorias em desenvolvimento sociomoral: Piaget, Kohlberg e Turiel – Possíveis implicações para a educação moral na educação médica. Rev Bras Educ Med. 2000;24(3):7-15. 31. Sá FC. O ensino de bioética e ética médica na FCM. Boletim da FCM. 2005;1(6):6. 32 . Townsend M, Kladder V, Ayele H, Mulligan T. Systematic review of clinical trials examining the effects of religion on health. South Med J. 2002;95(12):1429-34. 33. Coruh B, Ayele H, Pugh M, Mulligan T. Does religious activity improve health outcomes? A critical review of the recent literature. Explore (NY). 2005;1(3):186-91. 34. Schwatz SH, Bardi A. Value hierarchies across cultures: taking a similarities perspective. J Cross-Cult Psychol. 2001;32(3):26890. 35. Sobral DT. Alvos de carreira de alunos de medicina em Brasília. Rev Bras Pesqui Med Biol. 1977;10(4):265-70.


Rev Bras Ortop. 2013;48(1):100-103

www.rbo.org.br/

Case Report

Spontaneous healing of bucket handle tear of the medial meniscus associated with ACL tear Neiffer Nunes Rabelo,1 Nícollas Nunes Rabelo,2,* Aluísio Augusto Gonçalves Cunha,2 Francisco Correia Junior3 1First-year

Student at Paracatu Medical School, Paracatu, MG, Brazil. Student at Paracatu Medical School, Paracatu, MG, Brazil. 3Supervising Teacher and Professor of the Discipline of Orthopedics, Paracatu Atenas School, Paracatu, MG, Brazil. Work performed at the Orthopedics Service of Paracatu Atenas School, Paracatu, MG, Brazil. 2Sixth-year

article info

a b s t r a c t

Article history:

We report a case of injury of the medial bucket handle meniscal tears (BH), which resolved

Received March 14 2012

spontaneously, in association with anterior cruciate ligament (ACL) injury. The patient

Approved May 23 2012

twisted his left knee during a fight in martial arts, progressing to pain and joint locking and a sense of distortion. In NMR it could be seen bucket-handle tear of the medial meniscus with

Keywords:

displacement of the fragment to the intercondylar region, rupture of the lateral meniscus

Anterior cruciate ligament injury

and ACL tear. After conservative treatment and physiotherapy, in an interval of one year, later

bucket handle

examinations showed that there was spontaneous healing of AB.

Spontaneous resolution of bucket

© 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora

handle

Ltda. All rights reserved.

Knee injury in trauma sports

*Corresponding author at: Rua Rio Grande do Sul, Paracatu, MG, Brazil. Tel: (+55 38) 91383109. E-mail: nicollasrabelo@hotmail.com ISSN/$–see front matter © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

doi: 10.1016/j.rboe.2012.05.004


Rev Bras Ortop. 2013;48(1):100-103

Introduction Meniscal lesions can occur separately or in association with bone or ligament injuries. One of the less frequent meniscal lesions is the bucket handle tear, which consists of a vertical or oblique tear that extends longitudinally, with medial displacement of the fragment, usually from the central part of the meniscus. The incidence of this condition ranges from 9% to 24% of the cases. Bucket handle tears have great clinical importance, since displacement of the fragment from the meniscus may cause joint locking, thus requiring surgical treatment. In the literature, there is only one description of a bucket handle tear with spontaneous resolution, but without any association with the anterior cruciate ligament (ACL). The diagnosis is made with the aid of NMR. The incidence of meniscal lesions in patients with ACL instability has been described in the literature as ranging from 35% to 97%. It is seen that 82% of the patients present associated meniscal lesions, and it is believed that the length of time between the initial injury and the reconstruction surgery is the main factor contributing towards this high rate of association.1-4 The ACL acts as a mechanical stabilizer, thereby restricting anteriorization and rotation of the tibia in relation to the femur. Its main function is to prevent anterior displacement of the tibia in relation to the femur, in the mechanism for internal and external rotation, and to restrict valgus and varus stress. Functionally, the greatest vulnerability of the ACL occurs in rotational mechanisms, given that 70% of ACL tears are related to this mechanism. The incidence of ACL injury is 0.24 cases per 1,000 healthy individuals per year. Tearing of the ligament results from maximum overload, despite its resistance, especially during sports activities. It usually limits or impedes sports practice; nonetheless, depending on the patient’s response to the injury, it may not have any influence on the patient’s previous sports activites.5-6

101

Lachman test (grade III) and subluxation with crackling in the pivot shift test. NMR showed a bucket handle tear of the medial meniscus, with displacement of the fragment into the intercondylar region, tearing of the lateral meniscus, joint effusion, grade II femoropatellar chondropathy and ACL tearing (Figs. 1 and 2).

Fig. 1 - NMR on the right knee, showing the bucket handle tear in a longitudinal slice.

Case report The patient (NNR) was a 17-year-old male (85 kg; 1.75 cm; mixed skin color). His complaint was that a year and a half earlier he had twisted his right knee when placing his leg on the floor during a karate match, without direct trauma. He developed pain and edema immediately after the trauma, with intensely incapacitating medial pain in the right knee. He used NSAIDs until the pain improved, with cold compresses on the site. One week later, he returned to karate training, doing only part of the activities, because he then presented joint instability, with uncertainty in flexing the joint on his own weight. He also presented difficulty in rotating the knee and in squatting, with a feeling that the joint had “gone out of its place”. He presented improvement of the pain after stretching the joint, whenever there was this sensation of pain followed by instability and subluxation of the joint. On clinical examination, the patient presented medial pain on mobilization, locking in extension at 45°, a positive anterior drawer sign (grade III), a positive

Fig. 2 - NMR on the right knee, showing the bucket handle tear in a transverse slice.


102

Rev Bras Ortop. 2013;48(1):100-103

The orthopedic surgeon decided to perform ligament reconstruction by means of the tendon of the semitendinosus muscle, using arthroscopy, with restoration of the meniscus. However, the patient opted to undergo conservative treatment with regard to muscle strengthening through proprioceptive exercises, with strengthening of the extensor musculature and impactfree aerobic exercises such as swimming and cycling. Over one-year period, the patient gave up his karate training and dedicated himself solely to the rehabilitation and doing an educational course on sports habits. During this period, he repeated the NMR examination on his right knee, which presented slight signal abnormalities, with irregularity of the outlines of the lower surface of the lateral meniscus. This was thought to be related to an old tear, a radial tear at the root of the posterior body of the medial meniscus, complete tearing at the origin of the ACL and slight trochlear chondroplasty. Over this one-year period, the bucket handle tear completely regenerated, although a healed ACL tear remained, without impairing the patientâ&#x20AC;&#x2122;s daily activities after restructuring of his sports habits. He did not present any joint pain or locking, but only some instability due to the old tearing of the ACL (Figs. 3 and 4).

Fig. 4 - NMR on the right knee, one year after conservative treatment, with spontaneous resolution of the bucket handle tear seen in a transverse slice.

Discussion

Fig. 3 - NMR on the right knee, one year after conservative treatment, with spontaneous resolution of the bucket handle tear seen in a longitudinal slice.

Bucket handle tears of the medial meniscus are three to six times more common than similar tears in the lateral meniscus. These tears effectively reduce the width of the meniscus, and peripheral sagittal images do not demonstrate the normal bow-tie configuration of the meniscal body. The sensitivity of NMR for diagnosing bucket handle tears, if one or more of the four signs described is observed, is up to 97%, i.e. comparable with arthroscopy. It ranges from 27% to 44% for the posterior double cruciate sign, from 33% to 40% for the anterior double cornu sign, from 60% to 94% for the fragment displaced to the intercondylar incisure, and from 71% to 97% for absence of the bow-tie configuration. Identification of the displaced meniscal fragment is very important for surgical treatment, and this can be done via arthroscopy or conventional means. Bucket handle tears are often associated with ACL injuries (10% to 60%). Meniscal lesions are the biggest cause of knee locking in clinical practice. The differential diagnosis includes, among other conditions, cruciate ligament tears, cysts in the cruciate ligaments, intra-articular free bodies (osteochondritis dissecans, acute osteochondral lesions, synovial osteochondromatosis and penetrating injuries), pigmented nodular synovitis and plica syndrome.1,2,7,8,9


103

Rev Bras Ortop. 2013;48(1):100-103

Functionally, two groups of individuals with ACL injuries can be identified. The first presents clinical symptoms such as edema, pain and instability during knee movements, with difficulty in performing some activities of daily living. For individuals in this group, surgical reconstruction of the ACL is often recommended. On the other hand, there is a group of individuals presenting ACL injuries but without reporting clinical symptoms such as edema and pain. The individuals in this group are able to perform motor tasks involving the knee joint, without any apparent functional deficit, and are considered to have adapted to the lesion.5 It is believed that a lack of proprioceptive information originating from the ACL causes static and dynamic alterations, along with two distinct responses. Firstly, there is an inhibitory reflex in the quadriceps, thereby diminishing the mass of this musculature, which is also observed clinically. This inhibition also diminishes the capacity of the quadriceps to generate extensor torque, which provokes excessive anteriorization of the tibia. Secondly, this facilitates activation of the hamstrings, which promotes strengthening of this musculature. Chronic ACL injury generates isometric weakness of the musculature, which performs internal rotation or strengthening of the external rotators, thereby increasing the activity of the vastus lateralis and biceps femoris during gait. Ligament injury in a knee may also interfere with the functionality of the contralateral limb, due to the complex circuitry, and activate a polysynaptic route in the contralateral neurons. In a general manner, individuals with ACL injuries present increased hip and knee flexion angles during gait.5 There is a need for proprioceptive reeducation of the knee, also known as sensory-motor reeducation. This aims to develop and/or improve the joint protection by means of conditioning and reflexive training. Exercises with special imbalance stimuli have been adapted to be performed in a closed kinetic chain, in which there is always a concentration on the quadriceps and hamstrings, thereby minimizing the anterior translation of the tibia and providing synchronism for hip, knee and ankle movements. We have also introduced exercises with variable resistance into the method, using rubber tubes and elastic bands, in order to seek a greater response regarding strength and muscle mass. The method also favors high-level sports players by adding special training with advanced proprioception and muscle explosion exercises, known as plyometric exercises. The length of time for applying the method is three months, with variation according to the patient’s condition.10 In the present study, the case of a patient who had a bucket handle tear of the medial meniscus on NMR, with ACL tearing, is described. After the clinical treatment, a control examination showed that the tear had spontaneously resolved, since the meniscal fragment could no longer be seen and the meniscus was of normal volume, in relation to the previous examination.

The patient only presented a slight signal irregularity in the posterior cornu. Therefore, this spontaneous resolution occurred without surgical intervention, even though an ACL lesion was still present, without impairing the patient’s dayto-day joint movements and impact-free sports activities, and without flexing the knee for squat movements. As shown on the control NMR examination, we conclude that spontaneous resolution of the lesion occurred.

Conflicts of interest The authors declare that there was no conflict of interests in conducting this study.

R

1.

E

F

E

R

E

N

C

E

S

Vianna EM, Mattos AC, Domingues RC, Marchiori E. Resolução espontânea de lesão em alça de balde do menisco medial: relato de caso e revisão da literatura. Radiol Bras. 2004;37(3):219-21. 2. Helms CA, Laorr A, Cannon WD Jr. The absent bow tie sign in bucket-handlle tears of the menisci in the knee. AJR Am J Roentgenol. 1998;170(1):57-61. 3. Wright DH, De Smet AA, Noris M. Bucket-handle tears of the medial and lateral me-nisci of the knee: value of MR imaging in detecting displaced fragments. AJR Am J Roentgenol. 1995;165(3):621-5. 4. Singson RD, Feldman F, Staron R, Kierman H. MR imaging of displaced bucket-handle tear of the medial meniscus. AJR Am J Roentgenol. 1991;156(1):121-4. 5. Fatarelli IF, Almeida GL, Nascimento BG. Lesão e reconstrução do LCA: uma revisão biomecânica e do controle motor. Rev Bras Fisioter. 2004;8(3):197-206. 6. Rezende UM, Camanho GL, Hernandez AJ. Alteração da atividade esportiva nas instabilidades crônicas do joelho. Rev Bras Ortop. 1993;28(10):725-30. 7. Karam FC, Silva JLB, Fridman MW, Abreu A, Arbo RM, Abreu M, et al. A ressonância magnética para o diagnóstico das lesões condrais, meniscais e dos ligamentos cruzados do joelho. Radiol Bras. 2007;40(3):179-82. 8. Brammer H, Sover E, Erickson S, Stone J. Simultaneous identification of medial and lateral buckethandle tears: the Jack and Jill lesion. AJR Am J Roentgenol. 1999;173(3):860-1. 9. McAllister DR, Motamedi AR. Spontaneous healing of a bucket-handle lateral meniscal tear in an anterior cruciate ligament-deficient knee. A case report. Am J Sports Med. 2001;29(5):660-2. 10. Sampaio TC, Souza JMG. Reeducação proprioceptiva nas lesões do ligamento cruzado anterior do joelho. Rev Bras Ortop. 1994;29(5):303-9.


Rev Bras Ortop. 2013;48(1):104-107

www.rbo.org.br/

Case Report

Hypothenar hammer syndrome: case report and literature review Márcia Maria Muniz de Queiroz,1 Lícia Pachêco Pereira,2* Clarissa Gondim Picanço,3 Rodrigo de Castro Luna,2 Fabrício da Silva Costa,4 Cláudio Régis Sampaio Silveira2 1Resident

Physician (R2) in Nephrology, University Hospital of Brasília, Brasília, DF, Brazil. in the Radiology Service, General Hospital of Fortaleza, and Titular Member of the Brazilian College of Radiology, Fortaleza,CE, Brazil. 3Resident Physician (R1) in Medical Genetics, University of São Paulo, Ribeirão Preto, SP, Brazil. 4PhD in Gynecology and Obstetrics from the University of São Paulo (USP); Postdoctoral Attending Physician in the Royal Women’s Hospital, Melbourne, Australia. Work performed in the Imaging Diagnostics Service, General Hospital of Fortaleza, Fortaleza, CE, Brazil. 2Radiologist

A RT I C L E I N F O

a b s t r a c t

Article history:

Case report of a 69 year-old patient, with history of repetitive trauma events in the wrist,

Received September 19 2009

clinically simulating tenosynovitis, being held with Doppler Ultrasound and Magnetic

Approved October 5 2012

Nuclear Resonance, which showed ulnar artery thrombosis. The accurate diagnosis of the hammer hypothenar disease through those tests enable an early intervention, improving

Keywords: Syndrome Hand Injuries

the prognosis of patients affected by this rare disease. © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

Ultrasonography Magnetic Resonance Imaging

*Corresponding author at: Hospital Geral de Fortaleza, Serviço de Radiologia e Diagnóstico por Imagem, Rua Ávila Goulart, 900, Papicu, Fortaleza, CE, Brazil. CEP: 60115-290. E-mail: pacheco.licia@gmail.com ISSN/$–see front matter © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.

doi: 10.1016/j.rboe.2012.05.003


Rev Bras Ortop. 2013;48(1):104-107

Introduction Thrombosis of the ulnar artery, a rare condition that is often secondary to trauma at the hypothenar eminence, may be attributable to a single traumatic event or to repeated trauma in this region. In the latter case, it is named hypothenar hammer syndrome,1,2 and it results in degeneration and thrombosis of the ulnar artery at the level of the hamate.3 It was first described by Von Rosen in 1934, and has been reported in cyclists, tennis players, golf players and practitioners of a variety of other sports. 2 It may also be associated with fractures of the hamate, arteritis, use of walking sticks and anomalous muscles.4,5 Because of the trauma mechanism, the cases reported in the literature have predominantly occurred in males 4 and in smokers.6 The signs and symptoms are very variable. There may be intolerance of cold, cyanosis, hyperalgesia, Raynaudâ&#x20AC;&#x2122;s phenomenon, ulnar neuropathy, a mass in the hypothenar region or even necrosis of the fingers.4 Demonstration of a positive Allen test for occlusion of the ulnar artery is highly suggestive of this condition.4 It is fundamentally important to make a differential diagnosis in relation to Raynaudâ&#x20AC;&#x2122;s disease, thromboangiitis obliterans, scleroderma, giant cell arteritis, thoracic outlet syndrome, ulnar neuropathy and thromboembolic phenomena.4 The preferred examination for confirming a clinical suspicion is arteriography, although Doppler ultrasonography (US) and nuclear magnetic resonance (NMR) may be useful in making the diagnosis. To avoid traumatic etiological factors, anticoagulants, vasodilators and thrombolytic agents have been used in therapy for this condition. Blockade of the sympathetic nerves, sympathectomy and, in acute and severe cases, embolectomy with a catheter have been reported. Surgical treatment can be performed, consisting of resection and vein grafting using a microsurgical technique.

105

region. Distally to the thrombus in the palmar region, flow in the caudal-cranial direction was noted, probably relating to collateral circulation (Fig. 1). NMR showed that the ulnar artery presented increased caliber and thickened walls. There was a heterogenous signal with predominance of hypersignal in T1, hypersignal in T2 and parietal highlighting after injection of paramagnetic contrast medium. The ulnar artery was around 5 cm long, with a diameter of 1 cm (Fig. 2). The patient underwent conservative treatment, with recommendations to stop smoking, avoid further local trauma, control the hypertension and use anticoagulants. At a control echographic examination performed around three months after the diagnosis, on an occasion when the patient was asymptomatic, chronic thrombosis was also seen, and the vascularization of the palmar arch remained collateral. The patient refused to undergo any further control imaging examinations, but in a telephone contact 12 months later, he said that the symptoms had resolved spontaneously, without recurrences during this period.

Fig. 1 - Doppler ultrasound on the ulnar artery. It was found to be dilated, with thickened walls, although with flow present, in the middle third of the forearm (A), while in the distal third (B) there was echogenic material inside the vessel (thrombus) and absence of flow.

Case report The patient was a 66-year-old man who was a smoker and hypertensive, with a history of regularly suffering small traumatic events. In particular, 15 days before the current symptoms appeared, he had suffered bruising trauma on the distal third of the right forearm, and started to present increased volume and pain in this region. His condition was clinically diagnosed as post-traumatic tenosynovitis, but even after clinical treatment, physiotherapy and anti-inflammatory drug administration, he did not present any improvement. He was then referred to our service for NMR and Doppler US to be performed on his wrist. Doppler US showed that the ulnar artery presented significant parietal thickening, starting in the middle third of the forearm. In the distal third, echogenic content was observed inside the forearm, and no flow was seen in this

Fig. 2 - T1-weighted NMR sequences (A), T2 sequences with fat suppression (B), and after injection of contrast medium (C), showing a dilated ulnar artery with high T1 and T2 signal, representing thrombus, and parietal highlighting by means of the contrast, relating to the post-traumatic inflammatory process.


106

Rev Bras Ortop. 2013;48(1):104-107

Discussion

professional sports players can also return to their activities sooner through surgical treatment.12 Previous studies have also described nonsurgical approaches for patients with

Approximately 50% of the cases of ulnar thrombosis are not diagnosed initially, as was also the case with our patient. This restricts the therapeutic arsenal and worsens the prognosis for these patients.7 The clinical condition varies greatly in intensity and form,4 and Raynaud’s phenomenon may be presented, in which pallor and cyanosis may appear, while hyperemia has not yet been described.8 There may be intolerance of cold conditions, cyanosis, pain, ischemia of the fingers, symptoms of ulnar neuropathy4 and a mass or heat in the hypothenar region,4 and the condition my reach irreversible gangrene in the fingers.9 The Allen test should be used for clinically confirming the diagnosis,4 which may be negative in 17% of the cases.2 This consists of simultaneously occluding the radial and ulnar arteries and subsequently releasing the pressure on either of the two arteries, which should cause immediate filling of this artery and return of coloration to the hand. The test is said to be positive when the color does not return to the whitened hand. The imaging diagnosis is generally done by means of arteriography, Doppler US or NMR. The preferred examination for confirming the diagnosis is arteriography, which shows occlusion or aneurysm of the distal ulnar artery.2,4 Doppler US has been shown to provide excellent diagnostic sensitivity, and to enable perfect viewing of the radial and ulnar arteries and the palmar arch, thus making it possible to identify aneurysms,10 Doppler US is capable of distinguishing hypothenar hammer syndrome from other causes of ischemia of the fingers. 2 This examination is useful for evaluating reperfusion after surgical reconstitution6 and for following up these patients. Furthermore, it has many advantages due to its easy accessibility, relatively low cost, safety and noninvasiveness. 3 NMR is also a noninvasive examination, which uses relatively safe paramagnetic contrast without irradiation, in a multiplanar manner with high resolution for soft tissues. This enables detailed viewing of the vascular structures and their alterations, such as intraluminal thrombi, and it is also very useful for detecting anatomical variations in the small palmar muscles. However, because of its high cost, it is not used routinely. Histopathological examination generally hyperplasia of the tunica intima, with fragmentation along the internal elastic lamina and luminal occlusion with organized thrombi, with or without formation of aneurysms.10 The therapeutic strategy remains a matter of controversy, because of the wide spectrum of symptoms and severity of clinical presentation. Given its rarity, there are still no randomized prospective studies comparing treatments with drugs, surgery or interventions. For most patients, conservative therapy is sufficient, especially in cases in which adequate collateral circulation exists.11 The conservative measures include use of acetylsalicylic acid, anticoagulants, thrombolytics and vasodilators, and patients are always advised to avoid traumatic factors and smoking, if this is the case. 4,12 Most authors suggest that invasive therapy should be implemented in cases of ischemia with risk to the limb or inadequate response to drug treatment, and in cases of aneurysm of the ulnar artery. Patients who are

ischemia of the fingers, consisting of combined conservative treatments with intra-arterial infusion of vasodilators, 13 distal microcatheterization and embolization. 14,15 Surgical treatments include excision of the segment of the ulnar artery with venous grafting,16 resection of the aneurysm with endto-end anastomosis, thoracic sympathectomy and, if this is the case, amputation of fingers presenting necrotic ulcers.11 Temming et al.17 recently described autologous use of the descending branch of the lateral femoral circumflex artery as an option for venous grafting in reconstruction of the ulnar artery, with positive results. Marie et al.18 reported that the rate of symptom recurrence within 12 months (mean of 11 months) was 27.7% in a retrospective study on 47 patients, among whom the majority underwent conservative treatment, thus emphasizing the importance of adequate medium and long-term control among these patients.

Conclusion Thrombosis of the ulnar artery, which is a condition that is difficult to clinically diagnose in isolation because of its nonspecific clinical characteristics, is associated with intense morbidity in the patients affected, when not adequately diagnosed and not treated early on. Demonstration of thrombosis in the distal ulnar artery by means of ultrasonography or NMR enables precise diagnosis of hypothenar hammer disease, when considered in combination with the frequent clinical manifestations of this affection, thereby enabling early intervention and improving the prognosis for patients affected by this rare condition.

Conflicts of interest The authors declare that there was no conflict of interests in conducting this study.

R

E

1.

Troum SJ, Floyd WE 3rd, Saap J. Ulnar artery thrombosis: a 6-year experience. J South Orthop Assoc. 2001;10(3):147-54. Cooke RA. Hypothenar hammer syndrome: a discrete syndrome to be distinguished from hand-arm vibration syndrome. Occup Med (Lond). 2003;53(5):320-4. Okereke CD, Knight S, McGowan A, Coral A. Hypothenar hammer syndrome diagnosed by ultrasound – case report. Injury. 1999;30(6):448-9. Fernandes CH, Tinós MS, Meirelles LM. Trombose da artéria ulnar por digitação: relato de caso. Rev Bras Ortop. 1998;33(11):911-3. Mueller LP, Mueller LA, Degreif J, Rommens PM. Hypothenar hammer syndrome in a golf player – a case report. Am J Sport Med. 2000;28(5):741-5.

2.

3.

4.

5.

F

E

R

E

N

C

E

S


Rev Bras Ortop. 2013;48(1):104-107

6.

7.

8.

9. 10.

11.

12.

13.

De Monaco D. de, Fritsche E, Rigoni G, Schlunke S, von Wartburg U. Hypothenar hammer syndrome – retrospective study os nine cases. J Hand Surg Br. 1999;24(6):731-4. Mehlhoff TL, Wood MB. Ulnar artery thrombosis and the role of interposition vein grafting: patency with microsurgical technique. J Hand Surg Am. 1991;16(2):274-8. Pineda CJ, Weisman MH, Bookstein JJ, Saltzstein SL. Hypothenar hammer syndrome: from of reversible Raynaud’s phenomenon. Am F Med. 1985;79(5):561-70. Conn J Jr, Bergan J, Bell J. Hypothenar hammer syndrome: posttraumatic digital ischemia. Surgery. 1970;68:1122-8. Dethmers RS, Houpt P. Surgical management of hypothenar and thenar hammer syndromes: a retrospective study of 31 instances in 28 patients. J Hand Surg Br. 2005;30(4):419-23. Yuen JC, Wright E, Johnson LA, Culp WC. Hypothenar hammer syndrome: an update with algorithms for diagnosis and treatment. Ann Plast Surg. 2011;67(4):429-38. Swanson KE, Bartholomew JR, Paulson R. Hypothenar hammer syndrome: a case and brief review. Vasc Med. 2012;17(2):108-15. Sharma R, Ladd W, Chaisson G, et al. Images in cardiovascular medicine: hypothenar hammer syndrome. Circulation. 2002;105(13):1615-6.

107

14. Bakhach J, Chahide N, Conde A. Hypothenar hammer syndrome: management of distal embolization by intraarterial fibrinolytics. Chir Main. 1998;17(3):215-20. 15. Abdel-Gawad EA, Bonatti H, Housseini AM, Maged IM, Morgan RF, Hagspiel KD. Hypothenar hammer syndrome in a computer programmer: CTA diagnosis and surgical and endovascular treatment. Vasc Endovascular Surg. 2009;43(5):509-12. 16. Lifchez SD, Higgins JP. Long-term results of surgical treatment for hypothenar hammer syndrome. Plast Reconstr Surg. 2009;124(1):210-6. 17. Temming JF, van Uchelen JH, Tellier MA. Hypothenar hammer syndrome: distal ulnar artery reconstruction with autologous descending branch of the lateral circumflex femoral artery. Tech Hand Up Extrem Surg. 2011;15(1):24-7. 18. Marie I, Hervé F, Primard E, Cailleux N, Levesque H. Long-term follow-up of hypothenar hammer syndrome: a series of 47 patients. Medicine (Baltimore). 2007;86(6):334-43.


Rev Bras Ortop. 2013;48(1):108-110

www.rbo.org.br/

Case Report

Acromioclavicular dislocation type VI associated with diaphyseal fracture of the clavicle Evander Azevedo Grossi,1* Roberto Araújo Macedo2 1Orthopedist

and Shoulder Surgeon at Hospital Márcio Cunha and Hospital Unimed Vale do Aço, Ipatinga, MG, Brazil. and Shoulder/Elbow Surgeon at Hospital Márcio Cunha and Hospital Unimed Vale do Aço, Ipatinga, MG, Brazil. Work performed at the São Francisco Xavier Foundation, Hospital Márcio Cunha, Ipatinga, MG, Brazil. 2Orthopedist

article info

a b s t r a c t

Article history:

The purpose is to present a very unusual case of the acromioclavicular joint inferior

Received August 25 2011

dislocation associated with the clavicle fracture. It concerns to a young patient who had

Approved December 21 2011

a bike fall and had this type of pathology, had been operated and obtained excellent clinic result. The literature mentions many cases of subcoracoide dislocation, but there are only two

Keywords:

subacromial similar to ours. The case is described, a literary revision is done and discussed

Acromioclavicular articulation

and the treatment is discussed.

/surgery

© 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora

Clavicle/injuries

Ltda. All rights reserved.

Dislocations

Introduction Acromioclavicular dislocation is one of the most ancient traumatic pathological conditions recorded in the literature, and its frequency is 5 to 10 times greater among males.1 The most common cause of its occurrence is a fall on the shoulder with the arm adducted, but indirect trauma may also injure this joint. 1 Acromioclavicular dislocations are classified into six types, according to Rockwood et al.,2 and type VI is divided into subacromial and subcoracoid. The first case of inferior dislocation of the clavicle (subcoracoid) was described by Patterson in 1967.3 In this, the

mechanism for subcoracoid dislocation comes from forced hyperabduction of the arm in association with retraction of the scapula. This mechanism may injure the accessory nerve. Injuries of this type generally occur in multiple trauma cases, and may also be associated with fractures of the acromion, clavicle, scapula and/or ribs.4 For subacromial dislocation, there is no specific description of a trauma mechanism, but from the characteristics of lesions that occur in fractures of the clavicular diaphysis, associated with inferior dislocation of the acromioclavicular joint, it can be suggested that subacromial dislocations are caused by segmental fractures, in which there would be several traumatic events affecting the clavicle.5

*Corresponding author at: Av. Itália, 2556, Bairro Cariru, Ipating, MG, Brazil. Phone/fax: (+55 31) 38252529. CEP: 35160-115. E-mail: ovazadao@yahoo.com.br; evander.grossi@usiminas.com ISSN/$–see front matter © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved. doi: 10.1016/j.rboe.2011.12.002


Rev Bras Ortop. 2013;48(1):108-110

We report a rare case of a young adult who presented subacromial acromioclavicular dislocation in association with an incomplete diaphyseal fracture, with deviation of the clavicle, which was treated surgically with a satisfactory result.

Case report The patient was a 19-year-old male who suffered a fall from a bicycle and was taken to an emergency service with a single complaint of pain in the right clavicle. Clinical examination did not show any local neurovascular deficit or associated pathological conditions. Digital radiographic examination of the clavicle showed an incomplete fracture of the diaphysis with posteroinferior deviation and consequent dislocation of the lateral extremity of the clavicle to the subacromial space and posteriorly (Figs. 1A and 1B). Clinically, there was a prominence in the medial

Fig. 1A - Incomplete diaphyseal fracture of the right clavicle and inferior acromioclavicular dislocation.

Fig. 1B - Image obtained via radioscopy, showing the deviation.

109

region of the acromion and an inferior deviation of the distal extremity of the clavicle. The patient complained about a lot of local pain and significant limitation of movements. Surgical treatment was chosen, and surgical reduction was performed on the acromioclavicular dislocation and on the clavicular fracture, with a manual maneuver. Since the diaphyseal fracture was of greenstick type, the reduction was easy and stable. The coracoclavicular ligaments were complete, while the acromioclavicular ligament was injured. The acromioclavicular ligament was sutured and this joint was then fixed using two Steinmann wires (Fig. 2). These wires were subsequently removed, seven weeks later, and the patient was referred for physiotherapy. The digital radiological examination facilitated the evaluation of the two pathological conditions, and there was no need for a different examination for each condition. 5 An excellent clinical and radiographic result was presented after 12 months (Fig. 3).

Fig. 2 - Reduction of the acromioclavicular dislocation and

Fig. 3 - Final result from the fracture and acromioclavicular dislocation.


110

Rev Bras Ortop. 2013;48(1):108-110

Discussion

R

E

1.

Singh B, Singh S, Saraf N, Farooque K , Sharma V. Unusual mechanism of injury with segmental fracture clavicle. J Orthop Surg. 2007;6(1):7. Rockwood Jr CA, Williams GR, Young DC. Disorders of the acromioclavicular joint. In: Rockwood Jr CA, Matsen FA. The shoulder. Philadelphia: Saunders; 1998. p. 483-553. Patterson WR. Inferior dislocation of the distal end of the clavicle: a case report. J Bone Joint Surg.1967;49(6):1184-6. McPhee IB. Inferior dislocation of the outer end of the clavicle. J Trauma. 1980;20(8):709-10. Grossi EA. Fratura segmentar da clavícula. Rev Bras Ortop. 2011;46(6):733-5. Torrens C, Mestre C, Perez P, Marin M. Subcoracoid dislocation of the distal end of the clavicle. Clin Orthop. 1998;(348)121-3. Schwarz N, Kuderna H. Inferior acromioclavicular separation report of an unusual case. Clin Orthop Relat Res. 1988;(234):28-30. Sage J. Recurrent inferior dislocation of the clavicle at the acromioclavicular joint: a case report. Am J Sports Med. 1982;10(8)145-6. Naumann T. Der seltene Fall einer habituellen lateralen Claviculaluxation nach dorsal subacromial (Fallbericht). Z Orthop. 1986;124(1):34-5. Leppilahti J, Jalovaara P. Recurrent inferior dislocation of the acromioclavicular joint: a report of two cases. J Shoulder Elbow Surg. 2001;10(4):387-8. Koka SR, D’Arcy JC. Inferior (subacromial) dislocation of the outer end of the clavicle. Injury. 1993; 24(3)210-1. Juhn MS, Simonian PT. Type VI acromioclavicular separation with middle-third clavicle fracture in an ice hockey player. Clin J Sport Med. 2002;12(5):315-7. Namkoong S, Zuckerman JD, Rose DJ. Traumatic subacromial dislocation of the acromioclavicular joint: a case report. J Shoulder Elbow Surg. 2007;16(1):e8-10.

In reviewing the bibliography, we found 11 articles reporting on acromioclavicular dislocation type VI, of which five cases presented dislocation inferior to the coracoid3,4,6-8 and six were

2.

subacromial. Of the latter, three articles related to recurrent acromioclavicular dislocation,8-10 two presented associations with diaphyseal fractures of the clavicle11,12 and one showed an association with incarcerated subacromial dislocation.1 Koka and D’Arcy11 described the presence of subacromial acromioclavicular dislocation associated with complete diaphyseal fracture, with deviation. Surgical treatment similar

3. 4. 5. 6.

to what is described in our report was performed, with an excellent functional result. Juhn and

Simonian 12

7.

described a case of a greenstick

diaphyseal fracture of the clavicle with good evolution after clinical treatment. On the day after the trauma, the patient

8.

already presented good range of motion, and for this reason conservative treatment was chosen.

9.

Like Juhn and Simonian,12 we agree that acromioclavicular dislocations should be classified as type VI-A for subacromial and type VI-B for subcoracoid.

10.

Therefore, like some authors,1,2,4,8,10,11 we believe that surgical treatment for inferior lesions of the acromioclavicular

11.

joint ensures a satisfactory functional result. 12.

Conflicts of interest The authors declare that there was no conflict of interests in conducting this study.

13.

F

E

R

E

N

C

E

S


Rev Bras Ortop. 2013;48(1):111-113

www.rbo.org.br/

Case Report

Total rupture of the quadriceps muscle in an adolescent Rodrigo Pires e Albuquerque,1* José Felix dos Santos Neto,2 Vincenzo Giordano,3 Maria Isabel Pires e Albuquerque,4 Ney Pecegueiro do Amaral,5 João Maurício Barretto6 1PhD

in Medicine. Coordinator of the Knee Surgery Sector, “Professor Nova Monteiro” Orthopedics and Traumatology Service, “Miguel Couto” Municipal Hospital (SOT-HMMC), Rio de Janeiro, RJ, Brazil. 2Attending Physician at SOT-HMMC, Rio de Janeiro, RJ, Brazil. 3MSc in Medicine. Coordinator of the Medical Residence Program at SOT-HMMC, Rio de Janeiro, RJ, Brazil. 4Pediatrician at the National Cancer Institute, Rio de Janeiro, RJ, Brazil. 5MSc in Medicine. Head of the Orthopedics and Traumatology Service, SOT-HMMC, Rio de Janeiro, RJ, Brazil. 6PhD in Medicine. Head of the Orthopedics Service, Santa Casa do RJ, Rio de Janeiro, RJ, Brazil. Work performed at the Professor Nova Monteiro” Orthopedics and Traumatology Service, “Miguel Couto” Municipal Hospital (SOT-HMMC), Rio de Janeiro, RJ, Brazil.

article info

a b s t r a c t

Article history:

The total rupture of the quadriceps muscle in an adolescent is a rare lesion. We report a case

Received October 20 2011

of a 13 year old boy who suffered a direct trauma to the left knee. No predisposing factors

Approved September 2 2012

have been diagnosed. The lesion was treated with surgical repair and transosseus sutures. The aim of this study was to present a rare case of rupture of the quadriceps muscle in an

Keywords: Quadriceps Muscle

adolescent and the therapy used. © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora

Rupture

Ltda. All rights reserved.

Adolescent

*Corresponding author at: Av. Henrique Dodsworth 83/105, Copacabana, RJ, Brazil. E-mail: rodalbuquerque@ibest.com.br ISSN/$–see front matter © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved. doi: 10.1016/j.rboe.2012.09.002


112

Rev Bras Ortop. 2013;48(1):111-113

Introduction Rupture of the quadriceps muscle is a well-known injury in the orthopedic literature and it generally affects males after the age of 40 years. The age group of our patient was unusual and rarely reported. This rupture is generally related to comorbidities coming from rheumatic or systemic diseases. Excessive sports activity and chronic use of certain medications also facilitate this type of lesion. In this study, we report a case of total rupture of the quadriceps muscle in a healthy adolescent, along with the therapy used.

Fig. 1 - Preoperative radiograph of the left knee.

Case report A healthy 13-year-old boy suffered direct trauma to his left knee and immediately presented pain, hemarthrosis and incapacity to walk. The patient was sent to the emergency service of our hospital. Physical examination revealed edema in the left knee, low patella and a gap at the upper center of the patella. The patient was also incapable of actively extending his leg. At the time of the trauma, the patient weighed 61 kg and his height was 1.75 m. Radiography on the knee showed the low patella and dislocation of the patella, and confirmed the diagnosis of total rupture of the quadriceps muscle of the left knee (Fig. 1). The patientâ&#x20AC;&#x2122;s clinical history was investigated and blood tests were performed, for all markers for rheumatic and renal diseases. From this, relationships with any systemic disease or steroid use were rejected. Surgery was performed one day after hospital admission, using a tourniquet and a straight anterior incision in the knee (Fig. 2). The surgical technique used consisted of suturing of the quadriceps muscle by means of transosseous holes, together with repairs to the retinaculum. The suture repair was tested by means of careful flexing of the knee joint. After the operation, the knee was immobilized for six weeks, using a long splint, which was removed for active rehabilitation exercises, in order to avoid atrophy of the quadriceps. The program consisted of isometric exercises for the quadriceps during the immobilization period, and active exercises for the quadriceps with progressive increases of the range of motion. The complete range of motion and full functioning of the knee were achieved within six months. Our patient was evaluated after one week, 15 days, one month, 45 days, two months and monthly thereafter until the sixth month, when the consultations became every three months. We have now been following up this patient for two years, and he had gone back to his habitual activities. The follow-ups consist of a radiological control examination, in which we evaluate the height of the patella and the functional knee score (modified Lysholm classification)1 (Fig. 3). The mean score is now 90 points, which is considered to be a good result according to this evaluation system (Figs. 4 and 5). The range of motion of the left knee is now from zero to 120 degrees,

Fig. 2 - Intraoperative evaluation of the left knee.

Fig. 3 - Postoperative radiograph of the left knee.

Fig. 4 - Functional evaluation of the left knee.


113

Rev Bras Ortop. 2013;48(1):111-113

Fig. 5 - Functional evaluation of the left knee.

and is equal to that of the contralateral knee. The thigh circumference is now 32 cm on the left side and 36 cm on the non-operated side.

Diagnosing lesions due to quadriceps rupture is basically clinical, and is performed by means of palpation of the gap and observing whether the extensor mechanism has failed. With regard to complementary examinations, radiography on the knee (trauma series) enables good accuracy for the diagnostic confirmation, as well as being inexpensive. We did not use ultrasonography because this is a dependent examination. Magnetic resonance is the gold-standard complementary examination for diagnosing this type of injury. Unfortunately, because of its high cost, it is still not available in all Brazilian hospitals. In the future, as this examination becomes more popular, it will start to contribute greatly towards analysis on the condition of the tendon and the structures around the knee. Diagnosing the lesion and early repair are the secret to success. We did not use reinforcement from the semitendinosus, or any V-Y flap techniques. We prefer to use these techniques when dealing with chronic lesions of the quadriceps tendon. Use of anchors for repairing the quadriceps tendon is another option, and this generates less surgical aggression with this technique, compared with the traditional method.10 In the literature, in comparatively analyzing biomechanical studies between these two surgical techniques, we did not observe any diference in repair failure, with up to 1,000 cycles.10

Discussion In the immature skeleton, the muscles, ligaments and tendons are generally stronger than the growth plates.2 In our patient, a lesion was observed in the upper center of the patella, with hemarthrosis of the knee, thus demonstrating the traumatic and acute nature of the injury. From reviewing the literature for papers published in English on total rupture of the quadriceps muscle in individuals with an immature skeleton, only five articles were found, thus showing the rarity of this lesion and the importance of case reports.3-7 Siwek and Rao reviewed the literature on ruptures in the quadriceps between 1880 and 1978. In their study, only two patients under the age of 20 years were seen, out of a total of 69 cases.3 Our patient was only 13 years of age, thus showing the infrequent nature of such lesions and relevance of our case. There is some controversy regarding whether patients should be kept immobilized during the postoperative period, and how long this immobilization should last.8 It needs to be borne in mind that this injury occurred in an adolescent, given that in this population group, medical orders are at greater risk of being disrespected. On the other hand, in the immature skeleton, there is less risk of joint stiffness that in the adult population. For this reason, brace use was maintained for six weeks, with daily removal for exercises aimed at achieving gains in range of motion and muscle development. Research has been conducted on structural alterations to the tendon resulting from microtraumas or degeneration, which give rise to traumatic ruptures. 9 On the other hand, other researchers have maintained that direct trauma to the knee is the cause of injury to the knee extensor mechanism in healthy patients.4 In our study, because this was an adolescent without previous complaints or systemic diseases, we believe that direct trauma was the mechanism for the injury. Nonetheless, we agree that structural abnormalities increase the risk of injury to the knee extensor apparatus.

Conflicts of interest The authors declare that there was no conflict of interests in conducting this study.

R

1.

E

F

E

R

E

N

C

E

S

Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. 1985;(198):43-9. 2. Aydemir G, Cakmak S, Aydinoz S. Partial rupture of the quadriceps muscle in a child. BMC Musculoskelet Disord. 2010;11:214. 3. Siwek CW, Rao JP. Ruptures of the extensor mechanism of the knee joint. J Bone Joint Surg Am. 1981;63(6):932-7. 4. Adolphson P. Traumatic rupture of the quadriceps tendon in a 16-year-old girl. A case report. Arch Orthop Trauma Surg. 1992;112(1):45-6. 5. Omololu B, Ogunlade SO, Alonge TO. Quadriceps tendon rupture in an adolescent. West Afr J Med. 2001;20(3):272-3. 6. Naver L, Aalberg JR. Rupture of the quadriceps tendon following dislocation of the patella. Case report. J Bone Joint Surg Am. 1985;67(2):324-5. 7. Alexander VA, Keilin S, Cohn BT. Adolescent quadriceps mechanism disruption. Orthopedics. 2001;24(6):591-3. 8. West JL, Keene JS, Kaplan LD. Early motion after quadriceps and patellar tendon repairs: outcomes with single-suture augmentation. Am J Sports Med. 2008;36(2):316-23. 9. Matsumoto K, Hukuda S, Ishizawa M, Kawasaki T, Okabe H.Partial rupture of the quadriceps tendon (jumperâ&#x20AC;&#x2122;s knee) in a ten-year-old boy. A case report. Am J Sports Med. 1999;27(4):521-5. 10. Lighthart WA, Cohen DA, Levine RG, Parks BG, Boucher HR Suture anchor versus suture through tunnel fixation for quadriceps tendon rupture: a biomechanical study. Orthopedics. 2008;31(5):441.


Rev Bras Ortop. 2013;48(1):114-117

www.rbo.org.br/

Case Report

Anatomical variation of piriformis muscle as a cause of deep gluteal pain: diagnosis using MR neurography and treatment Giancarlo Cavalli Polesello,1* Marcelo Cavalheiro Queiroz,2 João Paulo Tavares Linhares,3 Denise Tokechi Amaral,4 Nelson Keiske Ono5 1PhD. Assistant

Professor and Head of the Hip Group, School of Medical Sciences, Santa Casa de São Paulo, São Paulo, SP, Brazil. and Attending Physician in the Hip Group, School of Medical Sciences, Santa Casa de São Paulo, São Paulo, SP, Brazil. 3Orthopedist and Trainee in the Hip Group, School of Medical Sciences, Santa Casa de São Paulo, São Paulo, SP, Brazil. 4Radiologist at the Syrian-Lebanese Hospital, São Paulo, SP, Brazil. 5PhD. Adjunct P and Attending Physician in the Hip Group, School of Medical Sciences, Santa Casa de São Paulo, São Paulo, SP, Brazil. Work performed in the Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo, São Paulo, SP, Brazil. 2Orthopedist

article info

a b s t r a c t

Article history:

Female patient, 42 years old with a history of low back pain on the left for seventeen years

Received November 28 2011

in which the definitive diagnosis of the etiology of pain was evident after the completion of

Approved December 4 2012

neurography magnetic resonance imaging of the sciatic nerve. In this test it was identified the presence of an anatomical variation in the relationship between the piriformis muscle

Keywords:

and sciatic nerve. We discuss details of this imaging technique and its importance in

Piriformis Muscle Syndrome

the frames of refractory low back pain. We also describe the treatment given to the case.

Diagnosis

© 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora

Magnetic Resonance Imaging

Ltda. All rights reserved.

Endoscopy

*Corresponding author at: Rua Dr. Cesário Motta Júnior, 112, Prédio Ortopedia, 2° andar, Sala Quadril, CEP: 01221-020, São Paulo, SP, Brazil. E-mail: giancarlopolesello@hotmail.com ISSN/$–see front matter © 2013 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved. doi: 10.1016/j.rboe.2012.09.001


Rev Bras Ortop. 2013;48(1):114-117

115

Introduction In 1928, Yeoman was the first to describe the piriformis muscle as an etiological factor in sciatic pain and low back pain.1 Between the sciatic nerve and the piriformis muscle, there are many anatomical variations and some authors have correlated this condition with piriformis syndrome2 and deep gluteal pain syndrome.3 Because of the similarity between this condition and disorders of the lumbar region, there is no consensus regarding its diagnosis and no specific criteria for this.4 In this context, in addition to clinical criteria and a directed physical examination, magnetic resonance can be used for most patients, especially for evaluating the lumbosacral spine. However, when performed using traditional techniques, this diagnostic method is not always capable of identifying the origin of the problem, particularly when there is involvement of the lumbosacral plexus or the sciatic nerve. In these cases, magnetic resonance neurography is the preferred examination for defining the intrinsic abnormalities of the sciatic nerve and the possible anatomical variations, and for

Fig. 1 - Magnetic resonance diagnosed as normal. T1 in axial plane (a) and FSE T2 with fat saturation in the axial plane (b) and coronal plane (c) of thickness 5 mm. The piriform muscles (*) are symmetrical, without alterations to the T2 signal. The sciatic nerves (arrows) present preserved thickness and signal intensity, without obliteration of the perineural fat. The accessory muscle belly of the left piriformis muscle (arrowhead) is best seen on magnetic resonance neurography (d) of thickness 1 mm.

characterizing the extrinsic compression of the nerve bundle, thereby enabling better surgical planning.5 In this patient, with a history of left-side low back pain for 17 years, the definitive diagnosis of the etiology of the pain was only achieved through magnetic resonance neurography. Subsequently, endoscopic treatment of the abnormalities found was performed.

Case report T h e p a t i e n t wa s a 4 2 - ye a r- o l d wo m a n w h o wa s a physiotherapist. At the age of 25 years, she started to present a condition of left-side low back pain that, at that time, was diagnosed as L5-S1 spondylolisthesis, with an associated disc hernia. After six months of treatment with analgesics and physiotherapy, she evolved with a deficit of hallux extension strength and then underwent L5-S1 arthrodesis without instrumentation. Even with this treatment, she often felt recurrent pain in the left gluteal region. Two years before she came to our clinic (end of 2009), her condition evolved with worsening of the pain, without any factor that would improve it, which prevented her from continuing to work. The pain worsened when she was seated or was standing upright for a long time. Over the latter two years, she underwent treatment with cortisone infiltration into the gluteal region, with fleeting improvements. Also over that period, she underwent five magnetic resonance examinations on the lumbosacral spine and left hip, without any diagnostic elucidation (Fig. 1). In February 2010, she underwent botulinum toxin application to the piriformis muscle and thereafter remained asymptomatic for four months. In May 2011, with recurrence of the symptoms, she sought our clinic for diagnostic investigation and treatment.

Diagnosis The Friberg test 4 (adduction and forced passive internal rotation of the lower limb affected) and Pace test4 (abduction and external rotation against resistance) were positive. The patient presented pain in the gluteal region, which worsened with palpation in the region of the external hip rotators, at approximately 1 cm laterally to the ischium. Taking together the physical examination with the report of temporary improvement of the symptoms through application of botulinum toxin to the piriformis muscle, a diagnosis of deep gluteal pain syndrome was suspected. After analysis on magnetic resonance imaging of the hips and lumbosacral spine, which showed normal results (Fig. 1), magnetic resonance neurography was performed over the left hip region. The equipment used was the Philips Achieva, with the following specifications: 1.5 Tesla, phased array coil, an isotropic volumetric sequence named Vista, T2 with TR/TE of 4500/90 ms, thickness of 1 mm and FOV of 28 cm. Following this, multiplanar reformatting was done along the major axis of the sciatic nerve (Fig. 2). An accessory muscle belly of the left piriformis was identified (anatomical variation), and the fibular branch of the sciatic nerve passed between the fibers of this accessory belly and the standard piriformis muscle (Fig. 2). This corresponded to a type B variation (Fig. 3), according to the classification of Beaton and Anson. 5 Because of this, compression and tensioning of the sciatic nerve was occurring, with consequent pain that was refractory to the treatments previously instituted. The tendon of the piriform muscle was in reality acting as a dart, transfixing the nerve.


116

Rev Bras Ortop. 2013;48(1):114-117

Fig. 2 - Magnetic resonance neurography: reformatting to the major axis of the sciatic nerve (arrow) on the right side (a) which passes anteriorly to the piriformis muscle. On the left side (b), the accessory muscle belly of the piriformis (*) passes between the common fibular and tibial bands of the sciatic nerve.

Fig. 4 - (a) Transoperative image of the anatomical variation of the piriformis muscle and (b) correlation with the image from magnetic resonance neurography (arrow). Postoperative image (c) after surgical release of the piriformis muscle.

Fig. 3 - Beaton and Anson classification for the anatomical variations between the piriformis muscle and the sciatic nerve.

Treatment In July 2011, using anterior and posterior peritrochanteric portals and an auxiliary portal (Fig. 5), endoscopic release of the piriformis was performed by means of its muscle mass, in association with tenotomy (Fig. 4).

Fig. 5 - Anterior paratrochanteric arthroscopic portal (PTA), posterior paratrochanteric arthroscopic portal (PTP) and auxiliary portal (PAX).

After the operation, a specific rehabilitation protocol for such cases was used, consisting of stretching exercises, cryotherapy and muscle reinforcement. Nine months after the surgery, the patient was asymptomatic.

Discussion The first descriptions of the piriformis muscle acting as an etiological factor on sciatic pain and low back pain date from 1928, published by Yeoman. 1 The presence of anatomical variations between the sciatic nerve and the piriformis muscle have been reported with the appearance of the piriformis syndrome, 2 characterized by sensory, motor and trophic disorders in the area of innervation of the sciatic nerve. The incidence of this syndrome in the population is only 6%, and it is more common among females than among males.6 In around 83% of the population, the sciatic nerve leaves the pelvis in a single stem and passes below the piriformis muscle, maintaining a descending path towards the popliteal fossa, where it divides into two terminal branches: the common fibular nerve and the tibial nerve.5 Among patients who present anatomical variations, 81% have an appearance similar to what was presented by our patient, in whom the sciatic nerve emerged already divided, with the common fibular part crossing the middle of the belly of the piriformis muscle and the tibial part passing below the lower margin of this muscle.5 Pecina8 emphasized that anatomical variations of this type could lead to development of the piriformis syndrome, in which stretching of the piriformis muscle might compress the common fibular branch between the tendinous parts of this muscle. Because of the frequency of anatomical variations between the piriformis muscle and the sciatic nerve, it is necessary to always remain alert to this possible diagnosis, particularly in


117

Rev Bras Ortop. 2013;48(1):114-117

patients with complaints of refractory sciatic pain and low back that remain unexplained through subsidiary examinations such as magnetic resonance, given that the latter examination does not have the capacity to evaluate pain originating in the lumbosacral plexus or sciatic nerve.5 Clinical tests such as the Friberg, Pace and FADIR tests4 (flexion, adduction and internal rotation of the affected hip) that show deep gluteal pain irradiating through the region of the sciatic nerve reinforce the hypothesis of compression of this nerve in the deep gluteal region. However, this diagnosis is controversial and it has been difficult to obtain objective evidence for the existence of this entity. 9 In this context, magnetic resonance neurography is an important diagnostic option. In this technique, high-resolution 1 mm slices are used, with T1 and T2-weighted sequences and fat suppression.5 The T1 sequence enables anatomical evaluation of the muscle layers and better definition of the peripheral nerves, which present a fascicular pattern with an intermediate signal, surrounded by perineural fat with hypersignal. With the T2 sequence with fat saturation, the objective is to define whether there is any thickening and hypersignal of the sciatic nerve, along with signs of denervation of the piriformis muscle characterized by increased signal.9 Isotropic volumetric data acquisition enables postprocessing of the images on a workstation with distortion of the images, thus making it possible to reformat the data along the major axis of the sciatic nerve in the sagittal and oblique coronal planes.10 Lewis et al.11 evaluated 14 patients with low back pain and normal results from magnetic resonance who underwent magnetic resonance neurography of the lumbosacral plexus and sciatic nerve. Of these, 12 presented signal abnormalities relating to the sciatic nerve, and in eight cases these alterations were located at the ischial incisure or in the piriformis muscle. The patient of the present case underwent five magnetic resonance examinations on the left hip and lumbosacral spine, all with normal results. The definitive diagnosis, made following clinical suspicion, was only achieved through magnetic resonance neurography, from which a Beaton and Anson type B variation was identified. The initial treatment for these cases is eminently clinical, with use of nonsteroidal anti-inflammatory drugs, physiotherapy, stretching and strengthening exercises, massage, local application of heat, cryotherapy, muscle relaxants, perisciatic injection of corticoids and injection of botulinum toxin guided by computed tomography.12 Fanucci et al.13 evaluated 30 patients with 12 months of follow-up after injection of intramuscular botulinum toxin into the piriformis guided by means of computed tomography, which was found to provide symptom relief in all the patients. Despite the good results presented in the literature, the patient of the present case only achieved an improvement for a period of approximately four months, with subsequent recurrence of the symptoms. After failure of conservative treatment, surgical treatment is indicated. Reports on open exploration have shown good results, although the endoscopic method has shown lower morbidity and achieved extensive exploration of the path of

the nerve, along with identifying anatomical abnormalities.13 Martin et al.3 reported good results from endoscopic treatment on a series of 35 patients with deep gluteal pain, mean follow-up of 23 months and use of a technique similar to that of the present case. Therefore, it seems to us that it is important to perform magnetic resonance neurography on the sciatic nerve, in cases in which the etiology of the pain has not been elucidated through conventional magnetic resonance, in order to obtain diagnostic clarification of deep gluteal pain and identify anatomical variations that give rise to compressive effects on the sciatic nerve.

Conflicts of interest The authors declare that there was no conflict of interests in conducting this study.

R

E

1.

Yeoman W. The relation of arthritis of the sacro-iliac joint to sciatica: with one analysis of 100 Cases. Lancet. 1928;2:1119-23. Fishman LM, Dombi GW, Michaelsen C, Ringel S, Rozbruch J, Rosner B, et al. Piriformis syndrome diagnosis, treatment and outcome a 10 years study. Arch Phys Med Rehabil. 2002;83(3):295-301. Martin HD, Shears SA, Johnson JC, Smathers AM, Palmer IJ. The endoscopic treatment of sciatic nerve entrapment deep gluteal syndrome. Arthroscopy. 2011;27(2):172-81. Parziale JR, Hudgins TH, Fishman LM. The piriformis syndrome. Am J Orthop. 1996;25(12):819-23. Beaton LE, Anson BJ. The relation of the sciatic nerve and of its subdivisions to the piriformis muscle. Anat Rec. 1937;70(1):1-5. Smoll NR. Variations of the piriformis and sciatic nerve with clinical consequence: a review. Clin Anat. 2010;23(1):8-17. Pace JB, Nagle D. Piriformis syndrome. West J Med. 1976;124(6):435-9. Pecina M. Contribution to the ethiological explanation of the piriformis syndrome. Acta Anat. 1979;105(2):181-7. Petchprapa CN, Rosenberg ZS, Sconfienza LM, Cavalcanti CF, Vieira RL, Zember JS. MR imaging of entrapment neuropathies of the lower extremity. Part I. The pelvis and hip. Radiographics. 2010;30(4):983-1000. Chhabra A, Williams EH, Wang KC, Dellon AL, Carrino JA. MR neurography of neuromas related to nerve injury and entrapment with surgical correlation. AJNR 2010;38(1):1363-8. Lewis AM, Layzer R, Engstrom JW, Barbaro NM, Chin CT. Magnetic resonance neurography in extraspinal ciatica. Arch Neurol. 2006;63(10):1469-72. Polesello GC, Rosa JM, Queiroz MC, Honda EK, Guimarães RP, Junior WR, et al. Dor glútea profunda: problema comum no consultório – revisão da literatura e relato do tratamento endoscópico de 3 casos. Rev Bras Ortop. 2011;46(Suppl 2):56-63. Fanucci E, Masala S, Sodani G, Varrucciu V, Romagnoli A, Squillaci E, et al. CT guided injection of botulinic toxin for percutaneous therapy of piriformis muscle syndrome with preliminary MRI results about denervatite process. Eur Radiol. 2001;11(12):2543-8.

2.

3.

4. 5.

6. 7. 8. 9.

10.

11.

12.

13.

F

E

R

E

N

C

E

S


rbo-48-1 ingles