Cleber Antonio Jansen Paccola

Proprioceptive and behavior impairments in individuals with anterior cruciate ligament reconstructed knees

OBJECTIVE To assess sensory deficits and their effects on proprioceptive and motor function in patients who had undergone unilateral anterior cruciate ligament (ACL) reconstruction. DESIGN Four evaluations were conducted: (1) joint position perception of the knee for predetermined angles (0 degrees, 15 degrees, 30 degrees, 45 degrees, 60 degrees ); (2) threshold for detection of passive knee motion at 0 degrees, 15 degrees, 30 degrees, 45 degrees, and 60 degrees moving into flexion and at 15 degrees, 30 degrees, 45 degrees, and 60 degrees moving into extension; (3) latency onset of hamstring muscles; and (4) postural control during upright double- and single-leg stance. SETTING Movement laboratory in Brazil. PARTICIPANTS Ten participants who had surgical reconstruction of the ACL (reconstructed group) and 10 participants without knee injury (control group). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Absolute error, angular displacement, hamstring muscles latency, and mean sway amplitude. RESULTS Individuals with a reconstructed knee showed decreased joint position perception, a higher threshold for detection of passive knee motion, longer latency of hamstring muscles, and decreased performance in postural control. CONCLUSIONS After lesion and ACL reconstruction, sensory and motor behavior changes were still observed. This may be because of the lack of proprioceptive information resulting from the ACL lesion and/or substitution of ACL by the graft.

Epidural morphine and neostigmine for postoperative analgesia after orthopedic surgery.

In this study, we examined the side effects and analgesia of the combination of epidural neostigmine and morphine in patients undergoing orthopedic surgery. Sixty patients undergoing knee surgery were divided into four groups. The intrathecal anesthetic was 15 mg of bupivacaine. The epidural test drug was diluted in saline to a final volume of 10 mL. The control group received saline as the epidural test drug. The morphine group received 0.6 mg of epidural morphine. The neostigmine group (NG) received 60 &mgr;g of epidural neostigmine. The morphine/neostigmine group received 0.6 mg of epidural morphine combined with 60 &mgr;g of epidural neostigmine. The groups were demographically the same and did not differ in intraop- erative characteristics. The visual analog scale score at first rescue analgesic and the incidence of adverse effects were similar among groups (P > 0.05). One patient from the NG complained of intraoperative nausea, closely related to spinal hypotension. Postoperatively, two patients from the NG had vomited once. The time (min) to first rescue analgesic was longer in the morphine/neostigmine group (≈11 h) compared with the other groups (P < 0.05). The analgesic consumption (number of analgesic administrations in 24 h) was larger in the control group compared with the other groups (P < 0.05).

Additional sensory information reduces body sway of individuals with anterior cruciate ligament injury

The purpose of this study was to investigate whether the additional sensory information could improve postural control in individuals with unilateral anterior cruciate ligament (ACL) injury. Twenty-eight individuals with unilateral ACL injury (mean age 23.6, 26 males, 2 females) and 28 healthy young control subjects (mean age 22.1 years, 26 males, 2 females) participated in this study. Postural control was evaluated with subjects single-leg standing on a force platform with eyes closed under two sensory conditions: normal sensory information and light touch to a stationary bar (applied force below 1N). Three trials of 30s were performed in each single-leg stance and in each sensory condition. Mean sway amplitude and predominant frequency of center of pressure were calculated for both anterior-posterior and medial-lateral directions. Individuals with ACL injury showed greater mean sway amplitude than healthy control individuals even though the predominant frequency was similar for both groups. Additional sensory information improved postural control performance in individuals with ACL injury and healthy control, with a greater effect observed for the ACL group. Based on these results, we suggest that reduction in postural control performance in individuals with ACL injury would be due to the reduction of sensory information provided by the ACL, but when sensory information is enhanced, postural control performance improves. These results have implications for novel approaches to improve stability in individuals with ACL injury.

Postoperative analgesia by intraarticular and epidural neostigmine following knee surgery

Abstract Study Objectives: To define the analgesic efficacy, and to identify a possible site of action, of epidural and intraarticular neostigmine. Design: Randomized, double-blind study. Setting: Postoperative analgesia, teaching hospital. Patients: 58 ASA physical status I and II patients undergoing knee surgery. Interventions: All patients were premedicated with 0.05 to 0.1 mg/kg intravenous midazolam and received combined epidural/intrathecal technique. Intrathecal anesthesia consisted of 20 mg bupivacaine. A 10 mL epidural and intraarticular injection was administered to all patients; this consisted of either the study drug or normal saline. Postoperatively, pain was assessed using the 10 cm Visual Analog Scale (VAS), and intramuscular (IM) 75 mg diclofenac was available at patient request. The control group (CG) received both epidural and intraarticular saline. The 1 μg/kg epidural group (1 μg/kg EG) received epidural neostigmine and intraarticular saline. The 1 μg/kg intraarticular group (1 μg/kg AG) received epidural saline and intraarticular neostigmine. Finally, the 500 μg intraarticular group (500 μg AG) received epidural saline and intraarticular neostigmine. Measurements and Main Results: 56 patients were evaluated. Groups were demographically the same and did not differ in intraoperative characteristics. The VAS score at first rescue analgesic and the incidence of adverse effects were similar among groups ( p p th –75 th percentile]) in 24 hours was higher in the CG group than both the 1 μg/kg EG and 500 μg AG groups ( p p Conclusion: Although peripheral neostigmine 1 μg/kg did not result in postoperative analgesia, the same dose applied epidurally resulted in over 5 hours of analgesia, similar to a fivefold dose applied peripherally. The results suggest that epidural neostigmine has a greater analgesic efficacy than peripherally applied neostigmine.

The Effect of Transdermal Nitroglycerin on Spinal S(+)-Ketamine Antinociception Following Orthopedic Surgery

STUDY OBJECTIVES To determine whether combination of transdermal nitroglycerine (a nitric oxide generator) would enhance analgesia from epidural S(+)-ketamine (a N-methyl-D-aspartate antagonist) in patients undergoing orthopedic surgery with combined spinal anesthesia. DESIGN Randomized, double-blind study. SETTING Orthopedic surgery unit of a teaching hospital. PATIENTS 60 ASA physical status I and II patients scheduled for minor orthopedic knee surgery. INTERVENTIONS Patients were randomized to one of five groups (n = 12) to receive combined epidural/intrathecal anesthesia. A 10-mL epidural injection was first administered to all patients (study drug or normal saline). Intrathecal anesthesia consisted of 15 mg bupivacaine. Twenty to 30 minutes after the spinal puncture, a transdermal patch of either nitroglycerin 5 mg or placebo was applied. The control group (CG) received epidural saline and transdermal placebo. The nitroglycerin group (NG) received epidural saline and transdermal nitroglycerine patch. The 0.1 mg/kg S(+)-ketamine epidural group (1 KG) received 0.1 mg/kg epidural S(+)-ketamine and transdermal placebo. The 0.2 mg/kg S(+)-ketamine epidural group (2 KG) received 0.2 mg/kg epidural S(+)-ketamine and transdermal placebo. Finally, the nitroglycerin/0.1 mg/kg S(+)-ketamine epidural group (1 NKG) received 0.1 mg/kg epidural S(+)-ketamine and transdermal nitroglycerin. Pain and adverse effects were evaluated using a 10-cm visual analog scale (VAS). MEASUREMENTS AND MAIN RESULTS The groups were demographically the same. Sensory anesthetic level and VAS score for pain at the time of first rescue medication were similar among groups. The time to first rescue analgesic (min) was less in both the CG and the NG groups compared with the other groups (p < 0.05). Epidural S(+)-ketamine resulted in analgesia to both groups (1 KG < 2 KG; p < 0.05). The 1 NKG and the 2 KG displayed similar analgesia (p > 0.05). The CG required more rescue analgesics in 24 hours compared with the patients who received epidural S(+)-ketamine (p < 0.02). CONCLUSIONS Epidural S(+)-ketamine resulted in antinociception, which was enhanced by transdermal nitroglycerin.

Reconstruction of Mandibular Segmental Defects Using the Guided-Bone Regeneration Technique With Polylactide Membranes and/or Autogenous Bone Graft: A Preliminary Study on the Influence of Membrane Permeability

PURPOSE Bone maintenance after mandibular reconstruction with autogenous iliac crest may be disappointing due to extensive resorption in the long term. The potential of the guided-bone regeneration (GBR) technique to enhance the healing process in segmental defects lacks comprehensive scientific documentation. This study aimed to investigate the influence of polylactide membrane permeability on the fate of iliac bone graft (BG) used to treat mandibular segmental defects. MATERIALS AND METHODS Unilateral 10-mm-wide segmental defects were created through the mandibles of 34 mongrel dogs. All defects were mechanically stabilized, and the animals were divided into 6 treatment groups: control, BG alone, microporous membrane (poly L/DL-lactide 80/20%) (Mi); Mi plus BG; microporous laser-perforated (15 cm(2) ratio) membrane (Mip), and Mip plus BG. Calcein fluorochrome was injected intravenously at 3 months, and animal euthanasia was carried out at 6 months postoperatively. RESULTS Histomorphometry showed that BG protected by Mip was consistently related to larger amounts of bone compared with other groups (P <or= .0001). No difference was found between defects treated with Mip alone and BG alone. Mi alone rendered the least bone area and reduced the amount of grafted bone to control levels. Data from bone labeling indicated that the bone formation process was incipient in the BG group at 3 months postoperatively regardless of whether or not it was covered by membrane. In contrast, GBR with Mip tended to enhance bone formation activity at 3 months. CONCLUSIONS The use of Mip alone could be a useful alternative to BG. The combination of Mip membrane and BG efficiently delivered increased bone amounts in segmental defects compared with other treatment modalities.

Efeito de informação sensorial adicional na propriocepção e equilíbrio de indivíduos com lesão do LCA

OBJECTIVE: The purpose of this study was to examine the effect of additional sensory information in proprioception and postural balance of individuals with ACL lesion. METHODS: Participated in this study 28 individuals with ACL unilateral lesion and 28 individuals with healthy knee. Proprioception was evaluated through the threshold to detection of passive knee motion from 15 and 45 degrees, for flexion and extension directions. Postural balance was evaluated in single leg stance without vision, on a plate force and investigated through the mean sway amplitude, mean sway velocity of the center of pressure. The conditions of sensory information used were: normal information, infrapatellar adhesive tape and infrapatellar strap. RESULTS: Individuals with ACL lesion show a deficit in proprioception and postural balance when compared with individuals with healthy knee (p 0.05). CONCLUSION: ACL lesion causes damage in the proprioception and postural control system. However, these effects are minimized with the use of additional sensory information.

Fraturas do planalto tibial

As fraturas do planalto tibial sao lesoes articulares cujos principios de tratamento envolvem a reducao anatomica da superficie articular e a restauracao funcional do eixo mecânico do membro inferior. Contribuem para a tomada de decisoes no tratamento dessas fraturas o perfil do paciente, as condicoes do envelope de tecidos moles, a existencia de outros traumatismos associados e a infraestrutura disponivel para abordagens cirurgicas. Para as fraturas de alta energia, o tratamento estagiado, seguindo o principio do controle de danos, tem como prioridade a manutencao do alinhamento do membro enquanto se aguarda a resolucao das mas condicoes de tecidos moles. Ja nos traumas de baixa energia, desde que os tecidos moles nao sejam um fator adverso, o tratamento deve ser realizado em tempo unico, com osteossintese definitiva. Fixacao estavel e movimento precoce sao variaveis diretamente relacionadas com os melhores prognosticos. Desenvolvimentos recentes, como os implantes com estabilidade angular, substitutos osseos e imagens tridimensionais para controle intraoperatorio, deverao contribuir para cirurgias menos invasivas e melhores resultados.

Fresh immature articular cartilage allografts

SummaryThe integration of immature cartilage allografts to knee joints of both normal rabbits and those submitted to arthritis through papain was studied for a period of up to 9 months.Two types of grafts were compared: chondral—constituted only by cartilage, and osteochondral—cartilage plus a thin layer of subchondral bone.The integration of the grafts was analyzed through inspection of the articular surface and histologic sections.The viability of the grafts was checked through the incorporation of 35SO4 on the chondral matrix.The following conclusions were drawn:(1)A large member of the grafted cartilages were well accepted without histological evidence of immunological rejection, and metabolically active 9 months after transplantation.(2)The chondral graft was found to be superior to the osteochondral one regarding the integration, but both showed tendency to degeneration with time.(3)The presence of arthritis previously induced by papain affected the integration of the grafts causing a higher percentage of degeneration on the grafted cartilage.ZusammenfassungÜber einen Zeitraum bis zu 9 Monaten wurde die Integration unreifer Knorpel-Allotransplantate in den Kniegelenken normaler Ratten und solcher, bei denen mittels Papain Arthritis hervorgerufen wurde, beobachtet.Es wurde ein Vergleich zwischen zwei Transplantatarten aufgestellt: 1. chondralen — bestehend aus nur einem Knorpel und 2. osteochondralen — bestehend aus einem Knorpel plus einer dünnen Schicht aus subchondralem Knochen.Die Integration der Transplantate wurde analysiert durch Inspektion der Gelenkoberfläche und der histologischen Abschnitte.Die Lebensdauer der Transplantate wurde durch Eingeben von 35SO4 in die Knorpelmatrize getestet.Folgende Schlußfolgerungen wurden gezogen:1.Ein Großteil der Knorpeltransplantate wurde gut aufgenommen, ohne histologischen Beweis für immunologische Abwehr, und war metabolisch noch nach 9 Monaten aktiv.2.Das chondrale Transplantat integrierte sich besser als das osteochondrale, beide neigten jedoch mit der Zeit zu Degenerationserscheinungen.3.Die zuvor mittels Papain hervorgerufene Arthritis beeinträchtigte die Integration der Transplantate und rief einen größeren Prozentsatz an degenerierten Knorpeltransplantaten hervor.

Osteotomia alta da tíbia com cunha de abertura medial: relevância biomecânica da cortical oposta

OBJETIVO: Avaliar o impacto da integridade da cortical lateral osteo-tomia alta de tibia (OAT) com cunha de abertura. METODOS: Modelos experimentais artificiais em poliuretano foram fixados com placa DCP® 4,5mm. Cunhas de abertura foram confeccionadas para simular a distracao da osteotomia alta da tibia. Realizadas falhas na cortical lateral para simular fraturas e fixadas com diferentes tipos de parafusos. Ensaios de torcao e compressao axial foram realizados. 04 diferentes grupos foram constituidos. RESULTADOS: As medidas de torcao registradas no grupo com cortical integra foram superiores aquelas obtidas no grupo com cortical rompida (p 0,05). As medidas de compressao obtidas no grupo com cortical integra foram superiores aos demais grupos (p 0,05). CONCLUSAO: A cortical lateral integra agrega estabilidade as osteotomias com cunha de abertura medial. Modelo com cortical integra evidenciou superioridade biomecânica em rigidez nos ensaios de torcao e compressao. Nos ensaios torcionais, os modelos com falha de continuidade cortical com parafusos de estabilizacao lateral de compressao ou de posicao apresentaram equivalencia aos modelos com cortical integra.