Michel Kanas

Lesão do ligamento cruzado anterior: tratamento e reabilitação. Perspectivas e tendências atuais

Universidade Federal de Sao Paulo (UNIFESP) Departamento de Ortopedia e Traumatologia Centro de Traumatologia do Esporte

Adolescent idiopathic scoliosis: current concepts on neurological and muscular etiologies

Adolescent idiopathic scoliosis (AIS) is a frequent disease but its etiology remains unknown. Gender prevalence in females is already known and there are many suggested hypotheses to explain its origin and manifestation, like associated neurologic, muscular and connective tissue disorders. Literature reports have tried to analyze disease prevalence in selected populations, possible ways of inheritance, related genes location and their polymorphisms, which may play a role in the development of the deformity. The purpose of this paper is to review and update concepts on the origin and genetic influence on AIS.

Anterior cruciate ligament injury: treatment and rehabilitation. Current perspectives and trends

Objective: The aim of this study was to evaluate the procedures used by knee surgeons in Brazil for treating and rehabilitating anterior cruciate ligament injuries. Methods: A questionnaire consisting of 21 closed questions was developed, addressing topics relating to treatment and rehabilitation after anterior cruciate ligament reconstruction. The questionnaire was applied to Brazilian knee surgeons during the three days of the 42nd Brazilian Congress of Orthopedics and Traumatology in 2010. Results: A total of 226 surgeons filled out the questionnaire completely. The most commonly used types of graft were hamstrings tendons and the central third of the ipsilateral patellar tendon, which were used by 82.3% and 53.5% of the sample, respectively. The technique of reconstruction with a single transtibial band was the first preference and was used by 66.4% of the participants. A period of 1 to 4 weeks between injury and surgical procedure was considered ideal by most participants (52.65%). Complaints from patients that the knee was ‘giving way’ or unstable and presence of a positive pivot shift maneuver were the most decisive factors considered in making the decision to operate the patient. Patient satisfaction and absence of complaints of instability during the postoperative period were the criteria deemed to be most important for the surgery to be considered a success. Conclusions: There are clearly evolving trends in treating and rehabilitating the anterior cruciate ligament in Brazil. However, more prospective controlled studies are needed in order to evaluate the clinical and scientific benefits of these trends.

Diskectomy during Pregnancy: Case Report and Review of the Literature.

Study Design Case report. Objective The purpose of this report is to discuss the management of a disk herniation during pregnancy and the indication and particularities of surgery in this situation. Methods We describe a case of diskectomy performed in a 35-year-old woman at 18 weeks of gestation. After 4 weeks of trying to manage the disk herniation with rest and medications without success, the muscle strength of the L5 right root decreased to grade 4, and the patient was not responding to intravenous analgesia. After discussion with the patient and family, a decision was made to perform the diskectomy. Results After surgery, the patients pain lessened, and the Lasegue test became negative. Two weeks after the procedure, the patients muscle strength was normal. In the 40th week of pregnancy, the patient gave birth without any complications. Conclusion When necessary, diskectomy can be indicated and performed during pregnancy. However, appropriate precautions must be taken. Awareness of these precautions is important for the success of the procedure and for the well-being of the mother and the newborn.

Paracoccidioidomycosis in the spine: case report and review of the literature

CONTEXT: Paracoccidioidomycosis is a systemic form of mycosis that spreads hematogenously, secondarily to reactivation of lung infection or infection at another site or to new exposure to the causative agent. Few cases of bone involvement have been reported in the literature and involvement of the spine is extremely rare. CASE REPORT: We describe a case of a 68-year-old male patient with spondylodiscitis at the levels L4-L5 caused by presence of the fungus Paracoccidioides brasiliensis, which was diagnosed through percutaneous biopsy. The patient was treated with sulfamethoxazole and trimethoprim for 36 months, with complete resolution of the symptoms. CONCLUSION: Spondylodiscitis caused by the fungus Paracoccidioides brasiliensis is uncommon. However, in patients with chronic low-back pain who live or used to live in endemic regions, this infection should be considered as a possible differential diagnosis.

CROSS-SECTIONAL STUDY ON DIFFERENT ENTRY POINTS FOR ANTEROGRADE FEMORAL INTRAMEDULLARY OSTEOSYNTHESIS

Objective: To analyze the degree of knowledge among professionals who treat fractures using the recommended technique, with regard to correlating the nail with the entry point that is considered appropriate. Methods: A questionnaire that presented five types of nail and simulated a transverse diaphyseal fracture of the femur was developed. Results: Responses regarding the entry points corresponding to choosing the type of nail were obtained from 370 orthopedists who were participating in the 41st Brazilian Congress of Orthopedics and Traumatology. It was observed that only 20% correctly identified the entry point and that there was no difference between the professionals within the specialty of Traumatology and the others. Conclusion: It was concluded that the majority of the physicians attending the congress were unaware of the entry points.

Estudo transversal sobre os diferentes pontos de entrada na osteossíntese intramedular femoral anterógrada

OBJECTIVE: To analyze the degree of knowledge among professionals who treat fractures using the recommended technique, with regard to correlating the nail with the entry point that is considered appropriate. METHODS: A questionnaire that presented five types of nail and simulated a transverse diaphyseal fracture of the femur was developed. RESULTS: Responses regarding the entry points corresponding to choosing the type of nail were obtained from 370 orthopedists who were participating in the 41st Brazilian Congress of Orthopedics and Traumatology. It was observed that only 20% correctly identified the entry point and that there was no difference between the professionals within the specialty of Traumatology and the others. CONCLUSION: It was concluded that the majority of the physicians attending the congress were unaware of the entry points.

Chordoma of the Cervical Spine in a Competition Athlete: Case Report and Long-term Follow Up

Introduction: Chordoma is a rare type of low-grade malignant neoplasm that arised from the remnants of the embryonic notochord. Observed mainly in the clivus and sacrum but can occur anywhere along the spine. Several treatment approaches are described. Treatment outcomes are significantly influenced by the size and location of the tumor. Clinical presentation and follow up: We report a 19-year-old female professional athlete with a cervical chordoma, involving C2, C3 and C4 vertebrae with spinal cord compression. Diagnosis was established by open biopsy. The patient was surgically treated in three steps: one anterior resection of the lesion was carried out, followed by a posterior resection and finally an arthrodesis and anterior fixation. The patient was referred to rehabilitation and one year after the first surgery she resumed competitive sport activities. No recurrences were observed within fifteen years of follow-up.

Are Systematic Reviews and Meta-Analysis for Lumbar Spine Disorders Treatment Really Conclusive? A Systematic Review of Systematic Reviews

Introduction Low back pain is among the most frequent causes for medical appointments and increased health cost every year. Treatment for this disorder should be evidence-based through systematic reviews (SR) and meta-analysis (MA). However, methodological mistakes frequently seen in those studies put their credibility into question. Materials and Methods A literature search was conducted using established databases and gray literature for systematic reviews only, involving low back pain as population and surgical treatment as intervention. A previous protocol has been registered in the local research committee. SR for cervical or thoracic spine disorders were excluded. Four certified spine surgeons independently extracted data. Study quality was assessed through measurement tools specific for SR (PRISMA and AMSTAR). For both questionnaires, studies were rated as poor, fair, good, very good, and excellent according to their quality percentage (0–30, 30–50, 50–70, 70–90, > 90%, respectively). For each SR, data were extracted for population, intervention, primary outcomes (VAS, Oswestry disability index, SF-36 questionnaire) and secondary outcomes (fusion, complications, return to work). When a meta-analysis was performed, the outcomes were considered as conclusive or inconclusive. Similar studied diseases, interventions, and outcomes were grouped and analyzed independently. Results A total of 40 SR of low back pain with at least one surgical treatment were included. After a throughout analysis of the studies, most popular search database was Medline, followed by Cochrane and EMBASE. Majority of the SR were published within the last 10 years (90%). Average number of included studies was 17.7 per systematic review. According to the PRISMA quality tool, 7.5% of the SR were rated as poor, 30% fair, 37.5% good, 20% very good, and 5% excellent. AMSTAR rated 22.5% of the SR as poor, 15% as fair, 30% good, 25% very good, and 7.5% excellent. Most frequent mistakes identified by the PRISMA questionnaire was the lack of a review protocol followed by absent analysis of risk of bias within studies. AMSTAR indicated unreported conflict of interest as major error, followed by the lack of a previously reported protocol. Six analyzed lumbar spine diseases were identified and grouped as degenerative disk disease (DDD) (32.5%), spondylolisthesis (SL) (15%), lumbar stenosis (LS) (12.5%), lumbar disk herniation (LDH) (7.5%), spondylosis (S) (27.5%), and painful facet disease (PFD) (5%). Three SR presenting same population (DDD), intervention (arthroplasty vs. fusion) and outcome (Oswestry disability index) had a positive meta-analysis favoring the total disk replacement technique. Two SR analyzing fusion techniques for spondylolisthesis (posterolateral fusion vs. posterior lumbar interbody fusion) had positive meta-analysis for higher fusion rates with the interbody fusion technique. Conclusion Systematic reviews for lumbar spine diseases are still not effective to determine conclusive optimal treatment mostly due to methodological mistakes and lack of scientific evidence.

Comparación de los métodos de Farfan modificado e de Frobin para la medición de la altura del disco intervertebral

OBJETIVO: Evaluar la confiabilidad y reproducibilidad de los metodos de Farfan modificado y Frobin para medicion de la altura radiografica de los discos intervertebrales lumbares por comparacion inter e intraobservadores. METODO: Imagenes radiograficas fueron recogidas y digitalizadas de 6 pacientes con queja de dolor lumbar; fueron evaluados cinco discos lumbares de cada paciente. Las mediciones fueron realizadas en el software Image Pro Plus version 6.0, por seis examinadores con diferentes niveles de experiencia. RESULTADOS: Al ser comparados entre si, los metodos demostraron concordancia superior a 95%. En el analisis intraexaminador, ambos metodos tambien se demostraron reproductibles y confiables con alta concordancia. Al comparar la concordancia entre las clases de los examinadores, cuanto mayor el nivel de experiencia mayor fue la concordancia entre ambos metodos. CONCLUSION: Tanto el metodo de Farfan modificado como el de Frobin, pueden ser utilizados de forma confiable para evaluar la altura discal en las radiografias en perfil. Cuanto mayor el nivel de experiencia del examinador, mayor la concordancia entre ambas mediciones.