Marco Martins Amatuzzi

Pathologic synovial plica of the knee Results of conservative treatment

Observations of 136 cases of pathologic synovial plica of the knee were analyzed with regard to etiology, symptoms, and the results of conservative treatment. The results obtained with conservative treatment were good in 40% of cases, average in 20%, and poor in 40%. In our opinion, these results justify the treatment of this condition with physical therapy before proceed ing with surgical correction. The objective of physical therapy was to decrease the compressive forces in the anterior compartment of the knee by increasing the structural flexibility of the flexor and extensor muscles. This increase in flexibility was obtained by instituting stretching exercises for the hamstrings, gastrocnemius, and quadriceps.

Study of the proximal femoral fractures mortatlity in elderly patients

Foi feito um estudo de revisao sobre a mortalidade na fratura do femur proximal em idosos com base nas publicacoes mais relevantes do periodo de 1998 a 2002. Foram incluidos 25 artigos relacionados ao assunto, selecionados com base nos bancos de dados Medline e Cochrane, totalizando 24.062 pacientes com mais de 60 anos de idade, que tiveram fratura do femur proximal. Quatorze estudos foram prospectivos, oito retrospectivos e tres revisoes sistematicas. As taxas medias de mortalidade foram de 5,5% durante a internacao hospitalar, 4,7% ao fim de um mes de seguimento, 11,9% com tres meses, 10,8% com seis meses, 19,2% com um ano e 24,9% com dois anos. Foram identificados quatro fatores intimamente relacionados com uma maior mortalidade nestes pacientes: idade avancada, grande numero de doencas associadas, sexo masculino e presenca de deficiencias cognitivas. Outros fatores mostraram uma fraca correlacao com a mortalidade como capacidade deambulatoria previa, indice de risco anestesico da Sociedade Americana de Anestesia (ASA), anemia, hipoalbuminemia, linfopenia e existencia de AVC previo. Os fatores como tempo previo a cirurgia, tipo de anestesia utilizada e tipo de osteossintese empregada nao mostraram ter interferencia.

Avaliaçåo isocinética no joelho do atleta

ABSTRACTIsokinetic evaluation of athletes’ kneeThe isokinetic evaluation has been used in the last threedecades as a method to determine both the strength func-tional pattern and the muscle balance. In our environment,this evaluation has been spread over the last 10 years. It ispossible to quantify absolute values of torque, effort, andpower of muscle groups, and to determine relative values,that is, the agonist/antagonist proportion of such groups.Another valuable resource of this evaluation may be usedas an auxiliary method in the rehabilitation of sports le-sions. The examination is performed with a constant andpreset angular speed, that is, low, intermediate, and/or highspeed. Most isokinetic studies are applied to the knee. Inthe sports practice, the agonist/antagonist muscle balance,that is, the flexor/extensor balance represented, respective-ly, by the ischiotibial muscle/quadriceps plays an impor-tant role. On the other hand, the comparison between theabsolute values of the muscle function for the left and rightsides is also relevant. Changed results usually relate tosports lesions or their sequels. The development of an ob-jective and safe method to evaluate the muscle functional-ity which provides for reliable and reproducible results isof utmost importance to athletes and to multidisciplinaryteams. Also significant are the results obtained from isoki-netic tests, which may be useful to establish criteria forathletes to resume and practice sports activities after le-sions. This review aims at addressing some practical as-pects of the isokinetic evaluation in the knee and its use inindividuals performing sports activities.

Cartilagem Articular e Osteoartrose

Currently, the mechanical degenerative changes of the articularcartilage are one of the primary concerns among orthopedicexperts.Both the difficulty in establishing experimental models of arthrosisand the regular observation of secondary arthritic phenomena intypically orthopedic diseases - like sequelae from fractures andarticular instability - are aspects which close the orthopedist to thestudy of the cartilage and its physiology.The objectivity of orthopedics becomes this interest andproximity hard. The study of either the cartilage biology or itsstructure and degeneration is based on concepts few common toour literature. However, the knowledge of the pathophysiology ofthe osteoarthrosis has demonstrated that a biological solution isvery close, especially in the initial cases. The use of eithertherapeutically or preventively systemic or intra-articular drugs isalready incorporated in our arsenal.The aim of this review article is to offer briefly to the orthopedistthe study of the cartilage physiology and the osteoarthrosispathophysiology.THE NORMAL ARTICULAR CARTILAGEIt is known that the articular cartilage is an avascular and poorlycellular tissue, whose biochemical characteristics reflect mainlythe composition of the extracellular matrix (Lanzer & Komenda,1990). The extracellular matrix is hyperhydrated (the water contentranges from 66% to 80%), with 20%-34% of solid components,5%-6% of which is inorganic components (hydroxyapatite). Amongthe remaining organic content, 48%-62% is formed by type-IIcollagen and 22%-38% is formed by proteoglycan. The rigidityand elasticity of the tissue are consequence of the relativedecompressibility of the proteoglycan molecules. The thick bundleof collagen fibers underlying and paralleled to the articular surfaceform a “skin” and probably serve not only as a restrictive layer butalso as a distributor of compression strengths. The fibers of thecartilage basal layer are perpendicular to the surface and theyserve as an anchor, which fasten the decalcificated cartilage tothe calcified zone and perhaps to the subchondral bone. In theintermediate zones, the fibers are randomly disposed. The oblique

Isokinetic assessment of knee flexor/extensor muscular strength in elderly women

OBJECTIVE To assess knee flexor-extensor muscular strength in elderly women with no previous history of musculoskeletal disorders on the lower limbs using an isokinetic dynamometer, in order to obtain data that could be used as a comparative parameter in the evaluation of elderly women with knee disorders, thus facilitating a better rehabilitation of these patients. METHODS Twenty-six volunteers aged 75 to 83 years were studied using a Cybex 6000 isokinetic dynamometer. The chosen angular velocity was 60 degrees /s, and concentric exercise was used for either flexion or extension. The studied parameters were: peak torque, angle of peak torque, and flexor-extensor torque rate. RESULTS There were no differences between dominant (D) and nondominant (ND) knee peak torque values. This was true for both flexor (D = 42.46 +/- 9.09 Nm / ND = 40.65 +/- 9.38 Nm) and extensor (D = 76.92 +/- 13.97 Nm / ND = 77.65 +/- 15.21 Nm) movements. The descriptive statistical analysis of the values obtained for the flexor-extensor peak torque rate and for the angle of occurrence of peak torque was the same for the dominant and nondominant sides. CONCLUSIONS The values of peak torque for the contralateral side can be used as a reference during rehabilitation of elderly women with acute disease of the knee, and the angular velocity of 60 degrees /s is proper and safe for isokinetic assessment of elderly people.

Anterior cruciate ligament reconstruction with double bundle versus single bundle: experimental study

OBJECTIVE To test an intra-articular reconstruction of the anterior cruciate ligament of the knee in 10 human cadavers by replacing 2 anterior cruciate ligament bundles, with the purpose of producing a surrogate that would be structurally more similar to the anatomy of the anterior cruciate ligament and would provide the knee with more stability. METHODS We reconstructed the anteromedial and posterolateral bundles using a quadriceps muscle tendon graft that included a patellar bone segment. The anteromedial bundle was replaced in 10 knees (5 right and 5 left knees from different cadavers) by a quadriceps-bone tendon graft, and the anteromedial and posterolateral bundles were replaced in the matching pairs of these knees. In the latter, the bone segment was fixed to the tibia, and the tendinous portion of the graft was divided longitudinally creating two 5-mm wide bundles that were inserted individually into the femur through 2 independent bone tunnels. Then, the knees were tested mechanically to evaluate the tibial anterior dislocation in relation to the femur, as well as the rigidity of the graft. The control group was formed by the knees with intact anterior cruciate ligaments, before being resected to be reconstructed. RESULTS The results obtained did not show superiority of double-bundle reconstruction over single-bundle reconstruction, and neither technique provided the knee with the same stability and rigidity of the intact anterior cruciate ligament. CONCLUSION Our hypothesis, based on the anatomy and biomechanics of the knee, that reconstruction of the anterior cruciate ligament using 2 bundles would result in a more anatomic reconstruction and provide better containment of the anterior tibial translation was not supported by the results of this study.

Positioning of the femoral tunnel for arthroscopic reconstruction of the anterior cruciate ligament: comparative study of 2 techniques

OBJECTIVE To compare the accuracy of positioning of the femoral tunnel in reconstructing the anterior cruciate ligament by means of 2 techniques: tibial tunnel and anteromedial portal. METHOD Femoral tunnels were drilled in 20 knees from human cadavers by means of arthroscopy. Group I had the femoral tunnel drilled via a trans-tibial tunnel, and Group II via the anteromedial portal. Four variables were measured: A) posterior wall thickness; B) tunnel positioning at the notch; C) tunnel inclination in relation to the femoral axis; and D) distance between the wire guide exit and the lateral epicondyle. RESULTS As above, respectively, A) 2.23 mm for group I and 2.36 mm for group II (P =.54); B) 25.5 degrees for group I and 30.0 degrees for group II (P =.23); C) 23.9 degrees for group I and 32.0 degrees for group II (P =.02); D) 7.8 cm for group I and 3.9 cm for group II (P <.001). CONCLUSIONS Both techniques achieved the desired positioning for the femoral tunnel entrance and satisfactory thickness for the posterior cortex. Drilling via the anteromedial portal may provide greater protection against rupture of the posterior wall.

INTERDISCIPLINARY CARE IN ORTHOGERIATRICS: A GOOD COST‐BENEFIT MODEL OF CARE

Even more eye catching is the assertion that, “at the very least, the data in this trial demonstrate that cognition and overall dementia severity are maintained for 6 months.” At 6 months, the cognitive measure, the main outcome measure, and the ADL measure were not significantly different from placebo. There is no evidence of stabilization. The drug makers supported four of the seven authors in this study and have paid them consulting fees and honoraria. The other three authors are full-time employees of the drug company. This article represents a failure of peer review.

Isokinetic assessment of the flexor-extensor balance of the knee in athletes with total rupture of the anterior cruciate ligament

The purpose of this study was to assess the flexor-extensor group of muscles of the knee in young athletes diagnosed with a total rupture of the anterior cruciate ligament (ACL). Eighteen knees of 18 athletes (14 men and 4 women) with an average age of 21.6 years (range 16-32 years) were assessed with a Cybex 6000 model isokinetic apparatus. The average internal between occurrence of the injury and assessment was 10.2 months (range 2-48 months). There was an associated meniscal injury in eight of the knees. Athletes with any other kind of associated injury, limitation, or blockage of the movement of the joint, significant pain during the exam, or interval between injury and exam of less than two months were excluded from the study. The parameters studied were the peak torque-velocity and flexor-extensor relationships at the constant angular velocities of 60 degrees/sec and 240 degrees/sec. Previous warming-up was done by means of an ergometric bicycle and adaptation with 3 submaximal repetitions. The contra-lateral side, which presented no injury, was used as control. Peak torque (PT) at the constant velocity of 60 degrees/sec was greater than that at 240 degrees/sec for knees with and without injuries. However, there was no significant difference between the injured and uninjured sides at 60 degrees/sec or at 240 degrees/sec. The average value for the flexor-extensor relationship at 60 degrees/sec on the injured was 60% ((6), compared to 57% ((10) on the contra-lateral side. At 240 degrees/sec, the average value was 75% ((10) on the injured side, and 65% ((12) on the contra-lateral side. In conclusion, despite the complete rupture of the ACL of one knee, the average values for the flexor-extensor relationship were similar on the injured and uninjured sides at the velocity of 60 degrees/sec. As the velocity increased, an increase in the values for the flexor-extensor relationship of the knee also occurred, indicating a tendency of the performance of the flexor muscle group to approach that of the extensor muscle group, and this tendency was more pronounced on the side of the injury.

O uso da matriz óssea desmineralizada na reparação de lesões osteocondrais: estudo experimental em coelhos

This study evaluated the use of the demineralized bone matrix in the repair of osteochondral lesions. The articular cartilage has little regeneration capacity because of its histological features and the absence of blood vessels. Implants of tissues and culture of chondrogenic cells have been used for the treatment of osteochondral lesions, but show technical difficulties of fixation and mechanical support of the subchondral region. The demineralized bone matrix can technically facilitate the fixation of these implants because it is a firm material with elastic features. Besides having osteogenic capacity and producing subchondral bone tissue and then working as mechanical support, it also has inductor factors of chondrogenesis. Osteochondral lesions were produced in the knees of 15 rabbits and the left knees were treated with the demineralized bone matrix, and the right knees were used like control of the study. Macroscopic and histological evaluations were made with 02, 04 and 06 weeks. In the lesions treated with the demineralized bone matrix it was obtained 100% of viability of the graft and the formation of a plain regular repair tissue which filled the lesion completely with DBM. The histological analysis revealed bone neoformation and integration of the graft with the bone tissue in the subchondral region, and in superficial region of the lesion occurred the induction of the formation of chondrogenic tissue. The conclusion of this study is that the demineralized bone matrix is useful in the repair of osteochondral lesions because of its capacity of bone induction, integration to the subchondral bone tissue and induction of the formation of chondrogenic tissue. It can be used as a component of a composite graft with chondrogenic tissue or culture of chondrogenic cells for the treatment of osteochondral lesions, and can decrease the technical difficulties of fixation and support of these implants.