Alberto Ofenhejm Gotfryd

Functional aerobic exercise capacity limitation in adolescent idiopathic scoliosis

BACKGROUND CONTEXT Exercise limitation has been described in patients with adolescent idiopathic scoliosis (AIS); however, whether the walking performance is impaired in these patients should be elucidated. PURPOSE Thus, we aimed to evaluate the physiologic responses to the incremental shuttle walk test (ISWT) in patients with AIS. STUDY DESIGN/SETTING Cross-sectional study. PATIENT SAMPLE Twenty-nine patients with AIS and 20 healthy adolescents aged between 11 and 18 years old. OUTCOME MEASURES Oxygen uptake (VO₂), incremental shuttle walk distance (ISWD), ΔVO₂/Δwalking velocity, ΔHR/ΔVO₂, ΔVE/ΔVCO₂, and linearized Δtidal volume (VT)/ΔlnVE, forced expiratory volume in the first second of expiration (FEV1), and forced vital capacity (FVC). METHODS We performed two ISWTs, and the data used were acquired in the second test. We also evaluated the lung function and respiratory muscle strength through spirometry test and manovacuometry, respectively. All authors confirm that there are no conflicts of interest. To compare the means or medians of variables between patients and healthy subjects, we used the unpaired t test or Mann-Whitney U test, respectively. The correlations were assessed by Pearson or Spearman coefficients according to the distribution of the studied variables. The probability of alpha error was set at 5% for all analyses. RESULTS Adolescent idiopathic scoliosis patients showed significant lower values of ISWD, VO₂, and ventilation at the end of the ISWT, as well as lower FEV₁ and FVC; they also presented significantly shallower slope of ΔVT/ΔlnVE, whereas VO₂ related significantly with ISWD (r=0.80), FVC (r=0.78), FEV₁ (r=0.73), and ΔVT/ΔlnVE (r=0.58). CONCLUSIONS Adolescent idiopathic scoliosis correlated to walking limitation and was associated to reduced pulmonary function and worse breathing pattern during exercise. Our results suggest that walking-based aerobic exercises should be encouraged in these patients.

Remodelamento da matriz extracelular em degeneração experimental do disco intervertebral

OBJECTIVE: To evaluate the remodeling of the extracellular matrix in intervertebral disc degeneration through the experimental model of intervertebral disc degeneration. METHODS: The model of disc degeneration induction, using needle 20G and 360° rotation, was applied for 30 seconds between the 6th/7th, and 8th/9th coccygeal vertebrae of Wistar rats. The intermediary level, between the 7th and 8th vertebrae, was taken as control, not being subjected puncture. The distribution of the extracellular matrix components involved in the remodeling and inflammation process, such as proteoglycans (aggrecan, decorin, biglycan), growth factors (TGFβ), heparanase isoforms (HPSE1, HPSE2), metaloprotesasis-9 (MMP9) and interleukins (IL-6, IL-10) was analyzed during the post-injury period (15 to 30 days) and in the control group (discs collected immediately after the puncture, day zero). On the 15th day, acute phase of the disease, a reduced expression of extracellular matrix components had been observed, whilst there were no differences in the interleukins expression. At 30 days, the molecules followed a very similar pattern of expression in the control group (not affected by disc degeneration). RESULTS: The results show that during the acute phase significant alterations in the extracellular matrix components occur and in the late phase intervertebral disc returns to a profile similar to noninvolved tissue, probably due to extensive remodeling process of the extracellular matrix that is capable of regenerating the damaged tissue. CONCLUSION : The experimental model used demonstrated the occurrence of significant changes in the extracellular matrix during the period analyzed after induction of intervertebral disc degeneration. Laboratory investigation.OBJETIVO: Avaliar a remodelacao da matriz extracelular na degeneracao do disco intervertebral atraves do modelo experimental degeneracao do disco intervertebral. METODOS: O modelo de inducao da degeneracao discal, utilizando agulha 20G e rotacao de 360o, foi aplicado por 30 segundos entre a sexta/setima e oitava / nona vertebras coccigeas de ratos machos da linhagem Wistar. O nivel intermediario, entre a setima e oitava vertebras, foi tomado como controle, nao sendo submetido a puncao. A distribuicao de constituintes da matriz extracelular envolvidos com mecanismos de remodelamento e inflamacao, como proteoglicanos (agrecam, decorim, biglicam), fatores de crescimento (TGFβ), isoformas de heparanase (HPSE1, HPSE2), metaloprotease-9 (MMP9) e interleucinas (IL-6, IL-10) foram avaliadas no periodo pos-lesao (15 e 30 dias) e no grupo controle (discos coletados imediatamente apos a puncao, dia zero). No 15o dia, fase aguda da doenca, notou-se reducao da expressao dos constituintes da matriz extracelular, porem nao houve diferencas na expressao de interleucinas. Aos 30 dias, as moleculas seguiram um padrao de expressao muito similar ao grupo controle (nao acometido por degeneracao discal). RESULTADOS: Os resultados mostram que na fase aguda ocorrem alteracoes significativas na matriz extracelular e, na fase tardia, o disco intervertebral retorna a um perfil semelhante ao tecido nao acometido por degeneracao, provavelmente devido a um intenso processo de remodelamento da matriz extracelular que e capaz de regenerar o tecido lesionado. CONCLUSAO: O modelo experimental utilizado demonstrou a ocorrencia de alteracoes significativas da matriz extracelular durante o periodo analisado apos a inducao da degeneracao do disco intervertebral. Trabalho experimental.

Radiografias em inclinação lateral como fator preditivo da correção cirúrgica na escoliose idiopática do adolescente

OBJECTIVE: To evaluate the use of x-rays in dorsal decubitus, as a predictive factor for surgical correction of the main thoracic curve using pedicle screws, on patients with idiopathic adolescent scoliosis. METHOD: Twenty patients with idiopathic adolescent scoliosis of Lenke types 1A and 1B who were operated using a technique only involving pedicle screws by means of the posterior route were evaluated clinically and radiographically. The curve flexibility was calculated by means of active supine lateral oblique radiographs. The postoperative values for the main thoracic curve were included in a mathematical equation proposed by Cheung et al., with the aim of predicting the expected angular result from the surgical correction. The difference between the expected and actual postoperative results was then investigated regarding its statistical significance. RESULTS: There was statistical significance for all the cases studied, between the values predicted before the operation and the radiographic findings immediately after the operation (p < 0.005). CONCLUSIONS: It is possible to predict the percentage surgical correction of the main thoracic curve that will be achieved using pedicle screws in patients with idiopathic adolescent scoliosis of Lenke types 1A and 1B, by means of preoperative supine oblique radiographs.

Avaliação postural por fotogrametria em pacientes com escoliose idiopática submetidos à artrodese: estudo piloto

INTRODUCTION: Scoliosis is a structural change of the vertebrae three-dimensiona. Quantification of lateral deviation after surgical correction could assist about the prognosis for the evolution of curvature and better direction in rehabilitation. OBJECTIVES: To evaluate and quantify the changes of posture in idiopathic scoliosis patients in the preoperative and postoperative surgical treatment. MATERIALS AND METHODS: Nine patients with idiopathic scoliosis between 11 and 18 years of age were evaluated. The participants were photographed preoperatively and after four weeks of postoperatively. The anatomical points were marked on the skin. For analysis of the photographs, they were transferred to a computer that has installed the SAPO. Statistical analysis was performed using test t pareado. RESULTS: We observed a significant decrease in left axillary angle (EACE) and left angle Q (AQE), an increase in the angle of inclination of the trunk in anterior view (ITA), the angle between the highest point of the manubrium and left trapezius ( TAME), thoracic kyphosis angle of the right (CTD) and lumbar lordosis right and left (LLD and LLE) and the left tibiotarsal angle (ATTE). There was an increase in the distances between C7, T3 and T7 posterior superior iliac spine to the right (DC7, DT3 and T7) and C7, T3 and L4 posterior superior iliac spine to the left (EC7, ET3 and EL4). CONCLUSION: It was observed significant changes in the angles ECAA, AQE, ITA, TAME, CTD, LLD, LLE, and the distances ATTE DC7, DT3, DT7, EC7, and EL4 ET3 four weeks after arthrodesis.

Functional exercise capacity, lung function and chest wall deformity in patients with adolescent idiopathic scoliosis

Introduction The adolescent idiopathic scoliosis (AIS) causes changes on the compliance of the chest. These changes may be associated with impaired lung function and reduced functional exercise capacity of these adolescents. We aimed to evaluate the correlation between functional exercise capacity, lung function and geometry of the chest at different stages of AIS.Materials and methods The study was carried out in a cross-sectional design which were evaluated 27 AIS patients at different stages of the disease. For chest wall evaluation, were created geometry angles/distances (A/D), which were quantified by Software Postural Assessment. The functional exercise capacity was assessed by a portable gas analyzer during the incremental shuttle walk test (ISWT). Besides that, manovacuometry and spirometry were also performed.Results Linear regressions showed that oxygen uptake (peak VO2) was correlated with distance travelled in the ISWT (R2 = 0.52), maximal respiratory pressures, cough peak flow (R2 = 0.59) and some thoracic deformity markers (D1, D2 and A6).Discussion We observed that the chest wall alterations, lung function and respiratory muscle strength are related to the functional exercise capacity and may impair the physical activity performance in AIS patients.Final considerations There is correlation between functional exercise capacity, lung function and geometry of the chest in AIS patients. Our results point to the possible impact of the AIS in the physical activities of these adolescents. Therefore, efforts to prevent the disease progression are extremely important.

Radiographic and functional evaluation of the iliac bone graft in the treatment of adolescent idiopathic scoliosis.

This study aimed to assess the impact of the use of an additional iliac bone graft on functional and radiographic results after thoracic spine arthrodesis with pedicle screws in patients with adolescent idiopathic scoliosis. Participants were divided into two groups: a control group that received only local bone (n=19) and a second group that, in addition to this procedure, received an iliac graft (n=22). The evaluations were performed on preoperative, immediate postoperative, and last follow-up (mean 29.7 months; minimum 12 months). Radiographic evaluations included the loss of correction and the presence of nonunion. The functional outcome was evaluated using the Scoliosis Research Society-30 questionnaire. Surgical complications and the presence of iliac donor site pain were also described. There were no significant differences between groups in the pseudoarthrosis rate, loss of correction over time, and quality of life. We concluded that the addition of bone graft from the iliac yielded no benefit in terms of the fusion rate and functional outcomes. The appropriate facetectomy, bed preparation, and filling with a local bone graft must be adequate to achieve an adequate fusion on surgical treatment of adolescent idiopathic scoliosis.

Reliability analysis of radiographic methods for determination of posterolateral lumbossacral fusion

ABSTRACT Objective To analyze intra and interobserver agreement of two radiographic methods for evaluation of posterolateral lumbar arthrodesis. Methods Twenty patients undergoing instrumented posterolateral fusion were evaluated by anteroposterior and dynamic lateral radiographs in maximal flexion and extension. The images were evaluated initially by 6 orthopedic surgeons, and after 8 weeks, reassessed by 4 of them, totaling 400 radiographic measurements. Intra and interobserver reliability were analyzed using the Kappa coefficient and Landis and Koch criteria. Results Intra and interobserver agreement regarding anteroposterior radiographs were, respectively, 76 and 63%. On lateral views, these values were 78 and 84%, respectively. However, the Kappa analysis showed poor intra and interobserver agreement in most cases, regardless of the radiographic method used. Conclusion There was poor intra and interobserver agreement in the evaluation of lumbosacral fusion by plain film in anteroposterior and dynamic lateral views, with no statistical superiority between the methods.

Tratamento cirúrgico da escoliose idiopática do adolescente utilizando parafusos pediculares: análise dos resultados clínicos e radiográficos

Objective: To evaluate clinically and radiographically patients with adolescent idiopathic scoliosis (AIS) submitted to posterior arthrodesis using pedicle screws-only constructs and correlate image results with SRS-24 scores. Methods: Twenty five patients with AIS submitted to posterior arthrodesis were evaluated. The follow-up was 23.7 months ranging from 12 to 35. Radiographic criteria were reviewed regarding the deformity correction and a specific questionnaire developed by Scoliosis Research Society (SRS-24) was applied. Results: The sample was composed by 92% females and 8% males. The average age was 14.2 years. The Cobb angle average measured by anterior-posterior roentnogegram was 24.4° at proximal thoracic curve, 54.9° at principal thoracic and 38.5° at the lumbar curve. The mean angular values obtained after the surgery were 11.0°; 16.7° and 12.2° respectively and the average correction of the principal thoracic curve was 69.9%. The mean SRS-24 scores were 98.1 points. Two patients had post-operative complications; however, there were no neurological complications. Conclusions: The technique showed to be effective on surgical treatment of AIS, with high percentage of deformity correction, low risk of complications and satisfactory clinical results. There was no correlation between the percentage of correction (thoracic or lumbar) and/or the post-operative value of angular deformity and the SRS-24 results, neither with “satisfaction” or “self-image after surgery” domains.

Predictors for Postoperative Shoulder Balance in Lenke 1 Adolescent Idiopathic Scoliosis: A Prospective Cohort Study.

STUDY DESIGN Prospective cohort. OBJECTIVES To determine the predictors of the shoulder balance after main thoracic (MT) fusion in patients with Lenke 1 adolescent idiopathic scoliosis (AIS). Imbalanced shoulders are a major cause of dissatisfaction in AIS patients. In Lenke 1 curves, MT curve fusion is supposed to lead to spontaneous correction of the proximal thoracic (PT) curve and thereby promote shoulder balance. However, this is not always observed. METHODS Fifty-two Lenke 1 AIS patients who underwent MT fusion by a posterior approach were prospectively evaluated preoperatively, immediately postoperatively and two years after the surgical procedure. The shoulder balance was determined using the biacromial angle. The clinical results were examined for their correlation with several radiographic measurements. RESULTS Spontaneous correction of the PT Cobb angle after MT fusion was noted in 52% of cases, similar to that observed on preoperative bending films. A total of 51% of patients had unbalanced shoulders before surgery (right side higher). Two years after surgery, 30.77% showed unbalanced shoulders (p <.001). However, 17.1% of patients presented with a higher left shoulder, a reversion of the initial deformity. This phenomenon was more common among the patients with mild or no shoulder asymmetry (biacromial angle inferior to 1°) before surgery (p < .001). It was also determined that for each degree measured for the clavicle angle, there was an elevation of 0.14° for the ipsilateral shoulder. CONCLUSIONS In Lenke 1 cases with higher right shoulder and absence of abnormalities in the sagittal plane view, the correction of the main right thoracic curve could be enough to balance the shoulders. No correlation was found between shoulder balance and the amount of correction of the PT and MT curves.

Assessment of spontaneous correction of lumbar curve after fusion of the main thoracic in Lenke 1 adolescent idiopathic scoliosis

Objective To evaluate the clinical and radiographic response of the lumbar curve after fusion of the main thoracic, in patients with adolescent idiopathic scoliosis of Lenke type 1. Methods Forty-two patients with Lenke 1 adolescent idiopathic scoliosis who underwent operations via the posterior route with pedicle screws were prospectively evaluated. Clinical measurements (size of the hump and translation of the trunk in the coronal plane, by means of a plumb line) and radiographic measurements (Cobb angle, distal level of arthrodesis, translation of the lumbar apical vertebral and Risser) were made. The evaluations were performed preoperatively, immediately postoperatively and two years after surgery. Results The mean Cobb angle of the main thoracic curve was found to have been corrected by 68.9% and the lumbar curve by 57.1%. Eighty percent of the patients presented improved coronal trunk balance two years after surgery. In four patients, worsening of the plumb line measurements was observed, but there was no need for surgical intervention. Less satisfactory results were observed in patients with lumbar modifier B. Conclusions In Lenke 1 patients, fusion of the thoracic curve alone provided spontaneous correction of the lumbar curve and led to trunk balance. Less satisfactory results were observed in curves with lumbar modifier B, and this may be related to overcorrection of the main thoracic curve.