vol. 45-n2-ingles

V O L U M E 4 5 • N º 2

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ISSN 0102-3616

RBODYSPLASIA OF HIP DEVELOPMENT: UPDATE

SPOrTS INjUrIES OF THE UPPEr LIMbS

FrAcTUrES OF THE DISTAL ExTrEMITY OF THE TIbIA TrEATED wITH INTrAMEDULLArY NAIL Or brIDgE PLATE: cOMPArISON OF rADIATION ExPOSUrE DUrATION bETwEEN THE TwO METHODS

EVALUATION OF THE rESULTS FrOM ArTHrOScOPIc TrEATMENT OF THE LATErAL EPIcONDYLITIS

TENDINOPATHY OF THE ANTErIOr cOMPArTMENT OF THE ANkLE

EVALUATION OF HEPATIc FUNcTION AMONg PATIENTS UNDErgOINg TOTAL HIP ArTHrOPLASTY USINg ENOxAPArIN

rADIOgrAPHIc STUDY ON THE AcrOMION INDEx AND ITS rELATIONSHIP wITH rOTATOr cUFF TEArS

TOTAL HIP ArTHrOPLASTY wITH bIOMEc PrOSTHESIS: 20-YEAr FOLLOw-UP

EVALUATION OF THE cErVIcAL SPINE AMONg PATIENTS wITH rHEUMATOID ArTHrITIS

SUrgIcAL TrEATMENT OF OSTEOcHONDrAL LESIONS OF THE kNEE bY MEANS OF MOSAIcPLASTY

EVALUATION OF ANATOMIcAL INTEgrITY USINg ULTrASOUND ExAMINATION, AND FUNcTIONAL INTEgrITY USINg THE cONSTANT & MUrLEY ScOrE, OF THE rOTATOr cUFF FOLLOwINg ArTHrOScOPIc rEPAIr

TrEATMENT OF PArALYTIc HIP DISLOcATION AMONg SPASTIc qUADrIPLEgIc cErEbrAL PALSY PATIENTS bY MEANS OF FEMOrAL AND PELVIc OSTEOTOMY, wITHOUT OPENINg THE jOINT cAPSULE (cAPSULOPLASTY)

MEcHANIcAL rESISTANcE OF THE PATELLAr LIgAMENT AFTEr rEMOVAL OF THE MIDDLE THIrD THrOUgH EITHEr ONE LONgITUDINAL INcISION Or TwO MINI-TrANSVErSE INcISIONS

INFOrMED cONSENT: THE MEDIcAL AND LEgAL cHALLENgE OF OUr TIME

TrAUMATIc POSTErIOr DISLOcATION OF THE HIP IN cHILDrEN: rEPOrT ON FIVE cASES

MONOSTOTIc PAgET’S DISEASE IN LUMbAr VErTEbrAE: AN ATYPIcAL LOcATION

Revista B

rasileira de Ortopedia – M

arço/Abril 2010 – Volum

e 45 número 2 p. 105-208

www.portaldatrombose.com.br

Contra-indicação: doença hepática associada à coagulopatia. Interação medicamentosa: antimicótico azólico de uso sistêmico. XARELTO® (RIVAROXABANA)APRESENTAÇÃO: CARTUCHO COM BLISTER CONTENDO 10 COMPRIMIDOS REVESTIDOS. COMPOSIÇÃO: CADA COMPRIMIDO REVESTIDO CONTÉM 10 MG DE RIVAROXABANA. INDICAÇÕES: XARELTO® (RIVAROXABANA) É INDICADO PARA A PREVENÇÃO DE TROMBOEMBOLIS-MO VENOSO (TEV) EM PACIENTES ADULTOS SUBMETIDOS A CIRURGIA ELETIVA DE ARTROPLASTIA DE JOELHO OU QUADRIL. CONTRA-INDICAÇÕES: XARELTO®(RIVAROXABANA) É CONTRA-INDICADO EM PACIENTES COM HIPERSENSIBILIDADE À RIVAROXABANA OU A QUALQUER OUTRO COMPONENTE DO PRODUTO, EM PACIENTES COM SANGRAMENTO ATIVO CLINICAMENTE SIGNIFICATIVO, E EM PACIENTES COM DOENÇA HEPÁTICA ASSOCIADA À COAGULOPATIA. SEU USO É CONTRA-INDICADO DURANTE TODA A GRAVIDEZ. NÃO EXISTEM DADOS DISPONÍVEIS EM MULHERES LACTANTES, PORTANTO, SÓ PODE SER ADMINISTRADA DEPOIS QUE FOR DESCONTINUADA A AMAMENTAÇÃO. PRECAUÇÕES E ADVERTÊNCIAS: RISCO DE SANGRAMENTO - A RIVAROXABANA DEVE SER UTILIZADA COM CAUTELA EM PACIENTES COM RISCO AUMENTADO DE SANGRAMENTO, TAIS COMO, DISTÚRBIOS HEMORRÁGICOS ADQUIRIDOS OU CONGÊNITOS, HIPERTENSÃO ARTERIAL GRAVE NÃO CONTROLADA, DOENÇA GASTRINTESTINAL ULCERATIVA ATIVA, ULCERAÇÕES GASTRINTESTINAIS RECENTES, RETINOPATIA VASCULAR, HEMORRAGIA INTRACRANIANA OU INTRACEREBRAL RECENTE, ANORMALIDADES VASCULARES INTRAESPINAIS OU INTRACEREBRAIS, LOGO APÓS CIRURGIA CEREBRAL, MEDULAR OU OFTALMOLÓGICA. DEVE-SE TER CUIDADO SE OS PACIENTES FOREM TRATADOS CONCOMITANTEMENTE COM FÁRMACOS QUE INTERFEREM NA HEMOSTASIA, COMO OS ANTIINFLAMATÓRIOS NÃO-ESTEROIDAIS, OS INIBIDORES DA AGREGAÇÃO PLAQUETÁRIA OU OUTROS ANTITROMBÓTICOS. QUALQUER QUEDA DE HEMOGLOBINA OU DA PRESSÃO ARTERIAL SEM EXPLICAÇÃO DEVE LEVAR À INVESTIGAÇÃO DE UM LOCAL COM HEMORRAGIA. ANESTESIA NEURAXIAL (EPIDURAL/ESPINAL) – APÓS A ANESTESIA NEURAXIAL OU UMA PUNÇÃO ESPINAL OS PACIENTES TRATADOS COM ANTITROMBÓTICOS CORREM RISCO DO DESENVOL-VIMENTO DE UM HEMATOMA EPIDURAL OU ESPINAL QUE POSSA RESULTAR EM PARALISIA A LONGO PRAZO. O RISCO DESTES EVENTOS É AINDA MAIOR COM O USO DE CATETERES EPIDURAIS DE DEMORA OU PELO USO CONCOMITANTE DE FÁRMACO QUE AFETEM A HEMOSTA-SIA. O RISCO TAMBÉM PODE AUMENTAR POR PUNÇÃO EPIDURAL OU ESPINAL TRAUMÁTICA OU REPETIDA. UM CATETER EPIDURAL NÃO DEVE SER RETIRADO ANTES DE 18 HORAS APÓS A ÚLTIMA ADMINISTRAÇÃO DE RIVAROXABANA. A RIVAROXABANA DEVE SER ADMINISTRA-DA NO MÍNIMO 6 HORAS APÓS A REMOÇÃO DO CATETER. SE OCORRER PUNÇÃO TRAUMÁTICA, A ADMINISTRAÇÃO DA RIVAROXABANA DEVERÁ SER ADIADA POR 24 HORAS. ALTERAÇÃO RENAL - A RIVAROXABANA DEVE SER UTILIZADA COM CAUTELA EM PACIENTES COM ALTERAÇÃO RENAL MODERADA (CL CR 30-49 ML/MIN) QUE ESTEJAM RECEBENDO CO-MEDICAÇÕES QUE LEVAM AO AUMENTO DA CONCENTRAÇÃO DE RIVAROXABANA NO PLASMA. EM PACIENTES COM ALTERAÇÃO RENAL GRAVE (CL CR < 30-15 ML/MIN), OS NÍVEIS PLAS-MÁTICOS DE RIVAROXABANA PODEM ELEVAR-SE SIGNIFICATIVAMENTE, O QUE PODE LEVAR A UM AUMENTO DO RISCO DE HEMORRAGIA, DEVENDO PORTANTO SER USADA COM CAUTELA. NÃO HÁ DADOS CLÍNICOS DISPONÍVEIS PARA PACIENTES COM ALTERAÇÃO RENAL GRAVE (CLCR < 15 ML/MIN), PORTANTO NÃO É RECOMENDADA NESTES PACIENTES. MEDICAÇÃO CONCOMITANTE - NÃO É RECOMENDADA A UTILIZAÇÃO DE RIVAROXABANA EM PACIENTES RECEBENDO TRATAMENTO CONCOMITANTE COM ANTIMICÓTICOS DO TIPO AZÓLI-CO OU INIBIDORES DAS PROTEASES DO HIV. INFORMAÇÃO SOBRE OS EXCIPIENTES - COMO ESTE MEDICAMENTO CONTÉM LACTOSE, OS PACIENTES COM PROBLEMAS HEREDITÁRIOS RAROS DE INTOLERÂNCIA À LACTOSE OU À GALACTOSE NÃO DEVEM TOMAR ESTE MEDICA-MENTO. GRAVIDEZ E LACTAÇÃO - É CONTRA-INDICADO O USO DE RIVAROXABANA NA GRAVIDEZ E SÓ PODE SER ADMINISTRADA DEPOIS DE DESCONTINUADA A AMAMENTAÇÃO. MULHERES EM IDADE FÉRTIL - A RIVAROXABANA DEVE SER UTILIZADA SOMENTE COM UMA CONTRACEPÇÃO EFICAZ. ALIMENTOS E LATICÍNIOS - A DOSE DE 10 MG DE RIVAROXABANA PODE SER TOMADA COM OU SEM ALIMENTOS. REAÇÕES ADVERSAS: A SEGURANÇA DE 10 MG DE RIVAROXABANA FOI AVALIADA EM TRÊS ESTUDOS FASE III QUE INCLUÍRAM 4.571 PACIENTES SUBMETIDOS A CIRURGIA DE ARTROPLASTIA TOTAL DO QUADRIL OU JOELHO, TRATADOS POR ATÉ 39 DIAS. NO TOTAL, DE CERCA DE 14% DOS PACIENTES TRATADOS APRESENTARAM REAÇÕES ADVERSAS. REAÇÕES ADVERSAS FREQUENTES ( 1% A <10%) SÃO ANEMIA, NÁUSEA, AUMENTO DA GGT, AUMENTO NAS TRANSAMINASES, E HEMORRAGIA PÓS-PROCEDIMENTO (INCLUINDO ANEMIA PÓS-OPERATÓRIA E HEMORRAGIA NA INCISÃO). REAÇÕES POUCO FREQUENTES( 0,1% A <1%) SÃO TROMBOCITOPENIA, TAQUICARDIA, CONSTIPAÇÃO, DIARRÉIA, DOR ABDOMINAL E GASTRINTESTINAL, DISPEPSIA, BOCA SECA, VÔMITOS, EDEMA LOCALIZADO, MAL-ESTAR, FEBRE, EDEMA PERIFÉRICO, SECREÇÃO NAS INCISÕES, AUMENTO DA LIPASE, AUMENTO DA AMILASE, BILIRRUBINA, DHL, FOSFATASE ALCALINA, DOR NAS EXTREMIDADES, TONTURA, CEFALÉIA, SÍNCOPE, ALTERAÇÃO RENAL (INCLUINDO AUMENTO DA CREATININA E DA URÉIA), PRURIDO, ERUPÇÃO CUTÂNEA, URTICÁRIA, HIPOTENSÃO, HEMORRAGIA (INCLUINDO HEMATOMA E CASOS RAROS DE HEMORRAGIA MUSCULAR), HEMORRAGIA NO TRATO GASTRINTESTINAL, HEMATÚRIA, HEMORRAGIA DO TRATO GENITAL E EPISTAXE. REAÇÕES RARAS ( 0,01% A <0,1%) SÃO FUNÇÃO HEPÁTICA ANORMAL, DERMATITE ALÉRGICA, AUMENTO DA BILIRRUBINA CONJUGADA, DISTÚRBIOS MÚSCULO-ESQUE-LÉTICOS, DO TECIDO CONJUNTIVO E DOS OSSOS. EM OUTROS ESTUDOS CLÍNICOS COM RIVAROXABANA, FORAM RELATADOS CASOS ISOLADOS DE HEMORRAGIA DA ADRENAL E HEMORRAGIA CONJUNTIVAL, ALÉM DE HEMORRAGIA FATAL EM ÚLCERA GASTRINTESTINAL; FORAM RAROS OS CASOS DE ICTERÍCIA E DE HIPERSENSIBILIDADE E HEMOPTISE FOI POUCO FREQÜENTE. FORAM REPORTADOS SANGRAMENTOS INTRACRANIAIS (ESPECIALMENTE EM PACIENTES COM HIPERTENSÃO ARTERIAL E/OU SOB AGENTES ANTIHEMOSTÁTICOS CONCOMITANTE-MENTE) QUE EM CASOS ISOLADOS PODEM SER POTENCIALMENTE FATAIS. INTERAÇÕES MEDICAMENTOSAS: O USO CONCOMITANTE DE RIVAROXABANA COM INIBIDORES POTENTES DO CYP 3A4 E INIBIDORES DE P-GP PODE LEVAR À REDUÇÃO DA DEPURAÇÃO HEPÁTICA E RENAL E, DESTE MODO, A AUMENTO SIGNIFICATIVO DA EXPOSIÇÃO SISTÊMICA. PORTANTO, A RIVAROXABANA NÃO É RECOMENDADA EM PACIENTES QUE ESTEJAM RECEBENDO TRATAMENTO SISTÊMICO CONCOMITANTE COM ANTIMICÓTICOS DO TIPO AZÓLICO OU INIBIDORES DE PROTEASES DO HIV. A CO-ADMINISTRAÇÃO DE RIVAROXABANA COM O INDUTOR POTENTE DE CYP 3A4 E DE P-GP, RIFAMPICINA, LEVOU A UMA DIMINUIÇÃO APROXIMADA DE 50% DA AUC MÉDIA DA RIVAROXABANA, HAVENDO DIMINUIÇÕES PARALELAS EM SEUS EFEITOS FARMACODINÂMICOS. O USO CONCOMITANTE DE RIVAROXABANA COM OUTROS INDUTORES POTENTES DO CYP 3A4, POR EXEMPLO, FENITOÍNA, CARBAMAZEPINA, FENOBARBITAL OU ERVA DE SÃO JOÃO, TAMBÉM PODE LEVAR A UMA DIMINUIÇÃO DA CONCENTRAÇÃO PLASMÁTICA DE RIVAROXABANA. A DOSE DE 10 MG DE RIVAROXABANA PODE SER TOMADA COM OU SEM ALIMENTOS. INTERAÇÕES COM TABACO E ÁLCOOL - NÃO FOI REALIZADO ESTUDO FORMAL SOBRE A INTERAÇÃO COM TABACO OU ÁCOOL, UMA VEZ QUE INTERAÇÃO FARMACOCINÉTICA NÃO É PREVISTA. PORTANTO NÃO HÁ DISPONÍVEL NENHUMA INFORMAÇÃO ADICIONAL SOBRE O USO CONCOMITANTE DE ÁLCOOL E TABACO. POSOLOGIA: A DOSE RECOMENDADA PARA PREVENÇÃO DE TEV EM CIRURGIA ORTOPÉDICA É UM COMPRIMI-DO DE 10 MG UMA VEZ AO DIA, COM OU SEM ALIMENTO. A DOSE INICIAL DEVE SER TOMADA 6 A10 HORAS APÓS A CIRURGIA, CONTANTO QUE TENHA SIDO ESTABELECIDA A HEMOSTASIA. - VENDA SOB PRESCRIÇÃO MÉDICA - ESTE TEXTO É O RESUMO DA BULA REGISTRA-DA NO MINISTÉRIO DA SAÚDE. PARA INFORMAÇÕES SOBRE PRECAUÇÕES, MOTIVOS PARA INTERRUPÇÃO, INTERAÇÕES MEDICAMENTOSAS, HIPERSENSIBILIDADE E SUPERDOSAGEM, DENTRE OUTRAS, CONSULTE A BULA DO PRODUTO, OUTROS DE NOSSOS IMPRESSOS MAIS DETALHADOS OU TELEFONE PARA O SAC (0800-7021241). REFERÊNCIA BIBLIOGRÁFICA: 1) ERIKSSON BI, BORRIS LC, FRIEDMAN RJ ET AL. RIVAROXABAN VERSUS ENOXAPARIN FOR THROMBO-PROPHYLAXIS AFTER HIP ARTHROPLASTY. N ENGL J MED 2008; 358:2765–75. 2) KAKKAR AK, BRENNER B, DAHL OE ET AL. EXTENDED DURATION RIVAROXABAN VERSUS SHORT-TERM ENOXAPARIN FOR THE PREVENTION OF VENOUS THROMBOEMBOLISM AFTER TOTAL HIP ARTHROPLASTY: A DOUBLE-BLIND, RANDOMISED CONTROLLED TRIAL. LANCET 2008; 372:31–9. 3) LASSEN MR, AGENO W, BORRIS LC ET AL. RIVAROXABAN VERSUS ENOXAPARIN FOR THROMBO-PROPHYLAXIS AFTER TOTAL KNEE ARTHROPLASTY. N ENGL J MED 2008; 358:2776–86. 4) TURPIE AGG, LASSEN MR, DAVIDSON BL ET AL. RIVAROXABAN VERSUS ENOXAPARIN FOR THROMBOPROPHYLAXIS AFTER TOTAL KNEE ARTHRO-PLASTY (RECORD4): A RANDOMISED TRIAL. LANCET 2009; 373: 1673–80. - MATERIAL PARA DISTRIBUIÇÃO EXCLUSIVA À CLASSE MÉDICA. - MS 1.7056.0048 - 31 Agosto 2009/1136/BR

XARELTO®, ORAL uma vez ao dia: Uma nova era na anticoagulação

Novo Joelho, Novo Quadril, novo nível de proteção contra os perigos do TEV1,2,3,4

, ORAL uma vez ao dia: Uma nova era na anticoagulação, ORAL uma vez ao dia: Uma nova era na anticoagulação

Novo Joelho, Novo Quadril, novo nível Novo Joelho, Novo Quadril, novo nível de proteção contra os perigos do TEVde proteção contra os perigos do TEV1,2,3,4

An_JOELHO_QUADRIL_210x280.indd 1 9/22/09 11:31:31 PM

VOLUME 45 No 2 • MarçO/abriL 2010

Órgão Oficial da Sociedade Brasileira de Ortopedia e TraumatologiaRegistrada, nos termos dos artigos 8o e 9o da Lei Federal no 5.270/67, combinados com os artigos 122 e 126 daLei Federal no 6.015/73, na lei de Imprensa, sob o no 3.015 do Livro A do 5o Registro de Títulos e Documentos de São Paulo

Indexada desde 1992 na LILACS (Literatura Latino-Americana em Ciências da Saúde).

Indexada em julho de 2007 na SciELO.

Sociedade Brasileira de Ortopedia e Traumatologia

EdiTOrES EmériTOSMárcio Ibrahim de Carvalho, MG, Brasil, Donato D´Angelo, RJ, Brasil, Carlos Giesta, RJ, Brasil

EdiTOr-ChEfEGilberto Luis Camanho, SP, Brasil

EdiTOrES ASSOCiAdOSPhilippe Hernigou, Paris, França, Fernando Fonseca, Coimbra, Portugal, José Neves, Porto, Portugal, Jacinto Monteiro, Lisboa, Portugal

COnSElhO EdiTOriAlAkira Ishida, SP, Brasil, Carlos Roberto Schwartsmann, RS, Brasil, Gildásio de Cerqueira Daltro, BA, Brasil, Helton Defino, Ribeirão Preto, SP, Brasil,

José Sérgio Franco, RJ, Brasil, Sérgio Checchia, SP, Brasil

COrpO EdiTOriAlAntonio Egydio de Carvalho Junior, SP, Brasil, Arlindo Pardini Junior, Belo Horizonte, MG, Brasil, Cláudio Santili, SP, Brasil,

Cleber A. Jansen Paccola, Ribeirão Preto, SP, Brasil, Flávio Faloppa, SP, Brasil, Geraldo Rocha Motta Filho, RJ, Brasil, Giancarlo Polesello, SP, Brasil,João Antonio Matheus Guimarães, RJ, Brasil, José Batista Volpon, Ribeirão Preto, SP, Brasil, José Maurício de Moraes Carmo, RJ, Brasil, José Soares Hungria Neto, SP, Brasil,

Karlos Celso de Mesquita, RJ, Brasil, Luis Roberto Vialle, PR, Brasil, Luiz Antonio M. da Cunha, PR, Brasil, Luiz Marczyk, RS, Brasil, Luiz Mestriner, SP, Brasil,Marcelo Tomanik Mercadante, SP, Brasil, Marco Antonio Percope de Andrade – MG, Brasil, Marcos Antonio Almeida Matos, BA, Brasil, Moisés Cohen, SP, Brasil,Olavo Pires de Camargo, SP, Brasil, Osmar Avanzi, SP, Brasil, Osmar Pedro Arbix Camargo, SP, Brasil, Osvandré Lech – RS, Brasil, Paulo César Schott, RJ, Brasil,

Paulo Couto, RJ, Brasil, Roberto Guarniero, SP, Brasil, Roberto Santin, SP, Brasil, Roberto Sérgio Tavares Canto, MG, Brasil, Sérgio Nogueira Drumond, MG, Brasil,Sergio Zylbersztejn, RS, Brasil, Tarcísio Eloy P. de Barros Filho, SP, Brasil, Walter Manna Albertoni, SP, Brasil, Willian Dias Belangero – Campinas, SP, Brasil

COrpO dE COnSulTOrESAdalberto Visco, BA, Brasil, Alberto Croci, SP, Brasil, Alberto Naoki Myasaki, SP, Brasil, Alexandre Machado, PE, Brasil, Antonio Vítor de Abreu, RJ, Brasil

Arildo E. Paim, MG, Brasil, Arnaldo Amado Ferreira Neto, SP, Brasil, Arnaldo José Hernandez, SP, Brasil, Edilson Forlin, Curitiba, PR, Brasil,Edmilson Takehiro Takata, SP, Brasil, Eduardo Benegas, SP, Brasil, Emerson Honda, SP, Brasil, Fernando Baldy dos Reis, SP, Brasil, Fernando Façanha Filho, CE, Brasil

Flávio Dorcilo Rabelo, GO, Brasil, Glaydson Godinho, MG, Brasil, Hamilton da Rosa Pereira, SP, Brasil, Henrique A. Berwanger A.Cabrita, SP, BrasilJairo de Andrade Lima, PE, Brasil, João Maurício Barretto, RJ, Brasil, José Antonio Veiga Sanhudo, RS, Brasil, José Carlos Bongiovanni, SP, Brasil

José Ricardo Pécora, SP, Brasil, José Vicente Pansini, PR, Brasil, Lindomar G. Oliveira, GO, Brasil, Luiz Carlos Sobânia, PR, Brasil,Marco Antonio de Castro Veado, MG, Brasil, Mauricio Kfuri Júnior, SP, Brasil, Ney Coutinho Pecegueiro do Amaral, RJ, Brasil, Paulo Gilberto C. de Alencar, PR, BrasilPedro Péricles R. Baptista, SP, Brasil, Raul Bolliger Neto, SP, Brasil, Rames Mattar Júnior, SP, Brasil, Renato Graça, RJ, Brasil, Reynaldo Jesus-Garcia Filho, SP, Brasil

Ricardo C. Ferreira, SP, Brasil, Sérgio Hennemann, RS, Brasil, Túlio Diniz Fernandes, SP, Brasil, Wilson Mello Alves Júnior, Campinas, SP, Brasil, Vincenzo Giordano, RJ, Brasil

EdiTOrES dE ÁrEAAndré Pedrinelli, SP, Brasil, Antonio Francisco Ruaro, PR, Brasil, Antonio Marcelo Gonçalves de Souza, PE, Brasil, Caio Nery, SP, Brasil, Edgard dos Santos Pereira, SP, Brasil

Edison Noboru Fujiki, SP, Brasil, Eduardo Frota Carrera, SP, Brasil, Eduardo Sadao Yonamine, SP, Brasil, Helio Jorge Alvachian Fernandes, SP, Brasil,Henrique Mota Neto, CE, Brasil, Idemar Monteiro da Palma, RJ, Brasil, Lucio Honório de Carvalho Junior, MG, Brasil, Luiz Koiti Kimura, SP, Brasil,

Luiz Sérgio Marcelino Gomes, SP, Brasil, Marcio Passini Gonçalves de Souza, SP, Brasil, Marcos Antonio Tebet, SP, Brasil, Mauro dos Santos Volpi, SP, Brasil,Reinaldo dos Santos Volpi, SP, Brasil, Roberto Freire da Mota e Albuquerque, SP, Brasil, Rogério Teixeira da Silva, SP, Brasil, Wagner Nogueira da Silva, MG, Brasil

Coordenação editorial, criação, diagramação e produção gráfica: Atha Comunicação e Editora Rua Machado Bittencourt, 190 - 4º andar - conj. 410 - CEP: 04044-903 - São Paulo - SP - Tel/Fax: (11) 5087-9502 / 5579-5308 - E-mail: [email protected]

Revista Brasileira de Ortopedia, é uma publicação bimestral da Sociedade Brasileira de Ortopedia e Traumatologia. A responsabilidade por conceitos emitidos nos artigos é de inteira responsabilidade de seus autores. Permitida a reprodução total ou parcial dos artigos, desde que mencionada a fonte.

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dirETOriA 2010presidente: Cláudio Santili (SP); 1o Vice- presidente: Osvandré Luiz Canfield Lech (RS); 2o Vice- presidente: Geraldo Rocha Motta Filho (RJ);

Secretário Geral: Arnaldo José Hernandez (SP); 1o Secretario: César Fontenelle (RJ); 2o Secretário: Fernando Façanha Filho (CE); 1o Tesoureiro: Moisés Cohen (SP); 2o Tesoureiro: Sandro Reginaldo (GO)

SECrETAriA GErAlSociedade Brasileira de Ortopedia e Traumatologia – Alameda Lorena, 427 14º andar Jd. Paulista - 01424-000 São Paulo/SP

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EditorialThe teaching of Orthopedics in medical schools in Brazil

Concerns regarding the teaching of medicine at undergraduate level have been the topic of many debates within academic settings. in relative terms, undergraduate medicine has been neglected by disciplines within clinical medicine, while training at levels of great specialization suitable for residents has been favored.

From a pedagogical point of view, it is not easy to pinpoint exactly what students should learn within each field.

no special care is taken by lecturers in preparing classes aimed towards the needs of generalist physi-cians. Classes given at undergraduate level are generally the same as those given to residents, with obvious disinterest among the undergraduate audience. These classes, or even the discussions on clinical cases, go deeply into topics that are aimed towards training specialists and not undergraduate students.

in Orthopedics and Traumatology, these points can be seen much more clearly, given that almost everything is aimed towards broad-based postgraduate programs, both within continuing education and within training for residents.

Excellence achieved in training orthopedists is shown by excellence in the final assessment exami-nation, which is considered to be a reference standard among all medical specialties.

nonetheless, this further deepens the abyss that exists between broad-based postgraduate pro-grams and undergraduate teaching within Orthopedics. With rare exceptions, the latter is practically nonexistent today in Brazil.

in an evaluation that we made recently, more than half of the 178 Brazilian medical schools showed very little presence of orthopedics within their teaching schedules. it appeared only within surgery as discussions on cases presented as problem-based learning (PBL). Given that the precariousness of medical education that afflicts Brazil is inversely proportional to the growing number of new schools, this situation needs to be reversed.

The situation is as if Orthopedics and Traumatology were considered to be only a specialty at postgraduate level, and as if it were unnecessary for training physicians.

However, if we were to use the basis of an epidemiological point of view to draw up a teaching cur-riculum appropriate for Brazilian realities, it can be seen that 60% of admissions at walk-in clinics are patients with musculoskeletal injuries. There is a consensus based on these statistical data that medical students who are about to graduate should be in a position to act at secondary level within orthopedics, with emphasis on multiple injuries, even if these students do not intend to practice this specialty.

it is inadmissible that internees can resuscitate a patient with cardiac arrest or control a patient in a diabetic coma, but has not had training on how to proceed when faced with a patient with an exposed fracture, given that such situations occur equally often at walk-in clinics.

However, many medical schools do not have a walk-in clinic with a daily volume of multiple-injury patients that would allow students to gain good practical training.

All this is without mentioning the outpatients for whom early diagnosis of orthopedic conditions is of fundamental importance for achieving a better prognosis, such as cases of congenital deformities and developmental deformities of the musculoskeletal system.

The nature of the undergraduate Orthopedics course, when it exists, is merely informative and does not have training value. The various diseases are shown superficially, without students having any involvement with or responsibility for patients, even if hospitalized. Knowledge-based and spe-cific skills-based training for physicians who practice orthopedics is currently restricted to orthopedics residents.

it will not be easy to turn this disheartening situation around. There are obstacles to structural modifications to the medical curriculum within the undergraduate committees, the congregation, the teaching staff and even the Ministry of Education.

Unfortunately, professors of orthopedics do not have any active presence in these collegiate bodies, since they are much more concerned with training residents than with training undergraduates.

some schools do not even have a titular professor of orthopedics who might be able to participate in and influence these changes. Few titular professors of orthopedics have achieved their positions through public competition and thus would have the pedagogical and didactic foundations to modify this situation within a university congregation.

We need to make the few titular professors of orthopedics that exist in Brazil aware of the need to establish a new generation of orthopedists with master’s and doctoral degrees who have real dedi-cation to undergraduate teaching, with research projects in which scientific initiation students can be included.

The key to restructuring Orthopedics courses is precisely to provide motivation for students at an early stage, through involving them in clinical, epidemiological and experimental studies. This will give them a solid background based on their participation in original papers that will move teaching forward and progressively increase our space within the core undergraduate curriculum.

The creation of optional disciplines also has an important role within this context, since these will attract students towards new fields of activity. The breadth of options within our specialty makes it possible for us to motivate them towards new fields, such as sports traumatology, reconstructive mi-crosurgery, orthopedic geriatrics and others.

Drawing up of a single national program for teaching Orthopedics and Traumatology, publication of an instructional book aimed at students, installation of a portal exclusively for undergraduates on the website of the Brazilian society of Orthopedics and Traumatology (sBOT) and continual monitoring of all medical schools to verify the status of the teaching of our specialty are among the measures that need to be taken urgently.

Well-structured teaching of Orthopedics at undergraduate level is the fundamental basis for us to be able to establish our specialty within the academic world and consequently within society, as one of the specialties with greatest participation in the final common objective, i.e. improvement of healthcare within Brazil.

Olavo Pires de CamargoTitular Professor and Head of the Department of Orthopedics and Traumatology

of the University of são Paulo school of Medicine

ContentsUPDaTiNG arTiCLE

DYSPLASIA OF HIP DEVELOPMENT: UPDATE .............................................................................................................................. 116Roberto Guarniero

SPORTS INjURIES OF THE UPPER LIMbS ................................................................................................................................... 122Rogerio Teixeira da Silva

OriGiNaL arTiCLE

FRAcTURES OF THE DISTAL ExTREMITY OF THE TIbIA TREATED wITH INTRAMEDULLARY NAIL OR bRIDGE PLATE: cOMPARISON OF RADIATION ExPOSURE DURATION bETwEEN THE TwO METHODS ................................................................................ 132Pedro josé Labronici, Fábio Soares Lyra, Ildeu Leite Moreira junior, Rolix Hoffmann, josé Sergio Franco, Paulo Roberto barbosa de Toledo Lourenço, Gustavo josé Labronici

EVALUATION OF THE RESULTS FROM ARTHROScOPIc TREATMENT OF THE LATERAL EPIcONDYLITIS ............................................................ 136Alberto Naoki Miyazaki, Marcelo Fregoneze, Pedro Doneux Santos, Luciana Andrade da Silva, Davi calixto Pires, jose da Mota Neto, Luis Henrique Rossato, Sergio Luis checchia

TENDINOPATHY OF THE ANTERIOR cOMPARTMENT OF THE ANkLE ................................................................................................... 141Antonio Egydio de carvalho junior, cíntia kelly bittar, Osny Salomão, joão batista Miranda, André Ninomiya, Daniel bento Silva

EVALUATION OF HEPATIc FUNcTION AMONG PATIENTS UNDERGOING TOTAL HIP ARTHROPLASTY USING ENOxAPARIN....................................... 148Felipe Vitiello wink, carlos Roberto Schwartsmann

RADIOGRAPHIc STUDY ON THE AcROMION INDEx AND ITS RELATIONSHIP wITH ROTATOR cUFF TEARS ........................................................ 151Alberto Naoki Miyazaki, Marcelo Fregoneze, Pedro Doneux Santos, Luciana Andrade da Silva, Éder Menegassi Martel, Leandro Gervazoni Debom, Manoel Loyola Andrade, Sérgio Luiz checchia

TOTAL HIP ARTHROPLASTY wITH bIOMEc PROSTHESIS: 20-YEAR FOLLOw-UP ...................................................................................... 155Rodrigo benedet Scheidt, Ricardo Rosito, carlos Alberto de Souza Macedo, carlos Roberto Galia

EVALUATION OF THE cERVIcAL SPINE AMONG PATIENTS wITH RHEUMATOID ARTHRITIS .......................................................................... 160André Luiz Passos cardoso, Nilzio Antonio da Silva, Sérgio Daher, Frederico barra de Moraes, Humberto Franco do carmo

SURGIcAL TREATMENT OF OSTEOcHONDRAL LESIONS OF THE kNEE bY MEANS OF MOSAIcPLASTY ............................................................. 166Ozório de Almeida Lira Neto, carlos Eduardo da Silveira Franciozi, Geraldo Sérgio de Mello Granata júnior, Antonio Altenor bessa de Queiroz, Mario carneiro Filho, Ricardo Dizioli Navarro

EVALUATION OF ANATOMIcAL INTEGRITY USING ULTRASOUND ExAMINATION, AND FUNcTIONAL INTEGRITY USING THE cONSTANT & MURLEY ScORE, OF THE ROTATOR cUFF FOLLOwING ARTHROScOPIc REPAIR ................................................................................... 174Glaydson Gomes Godinho, Flavio de Oliveira França, josé Marcio Alves Freitas, Fábio Nagato watanabe, Leonardo Oliveira Nobre, Manoel Augusto de Almeida Neto, Marcos André Mendes da Silva

TREATMENT OF PARALYTIc HIP DISLOcATION AMONG SPASTIc QUADRIPLEGIc cEREbRAL PALSY PATIENTS bY MEANS OF FEMORAL AND PELVIc OSTEOTOMY, wITHOUT OPENING THE jOINT cAPSULE (cAPSULOPLASTY) ........................................................................... 181Fernando Farcetta junior, Fabio Peluzo Abreu, Daniella Lins Neves, Paulo Facciola kertzman, Alexandre Zuccon, Simone de Oliveira bittencourt, Davi Moshe Leopold Lopes

MEcHANIcAL RESISTANcE OF THE PATELLAR LIGAMENT AFTER REMOVAL OF THE MIDDLE THIRD THROUGH EITHER ONE LONGITUDINAL INcISION OR TwO MINI-TRANSVERSE INcISIONS ......................................................................................................................... 186Leandro calil De Lazari, cleber Antonio jansen Paccola

INFORMED cONSENT: THE MEDIcAL AND LEGAL cHALLENGE OF OUR TIME ......................................................................................... 191Luiz carlos Séllos Simões

CaSE rEPOrT

TRAUMATIc POSTERIOR DISLOcATION OF THE HIP IN cHILDREN: REPORT ON FIVE cASES........................................................................ 196Gilberto Francisco brandão, Luiz Renato Drumond Américo, cláudio beling Gonçalves Soares, Rodrigo Galinari costa Faria, Luiz Eduardo Moreira Teixeira

MONOSTOTIc PAGET’S DISEASE IN LUMbAR VERTEbRAE: AN ATYPIcAL LOcATION ................................................................................. 200Alexandre Dias carvalho, jerúsia Oliveira Ibiapina, Lina Gomes Santos, Teresinha castelo branco carvalho, Marcelo barbosa Ribeiro

The Revista Brasileira de Ortopedia (Rev Bras Ortop.) or Brazilian Journal of Orthopedics (ISSN 0102-3616) is the scientific publication organ of the Brazi-lian Society of Orthopedics and Traumatology. Its purpose is to publish papers that contribute towards improving and developing the practice, research and teaching of Orthopedics and related specialties. All manuscripts submitted will, after receiving editorial approval, be assessed by two qualified reviewers, in a peer review process in which anonymity is ensured throughout. Papers without merit, or that 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 passed back to the authors for modifications to be made to the text or for justifications for not changing it to be provided. Only after final approval from the reviewers and editors will manuscripts be sent forward for publication. Manuscripts that have been accepted for publication will become the property of the Journal and cannot be edited in full or in part by any other means of dissemination, without prior written authorization issued by the Editor-in-Chief. The opinions and declarations contained in published papers are fully the authors’ responsibility. Papers published in the Revista Brasileira de Ortopedia follow the uniform requirements proposed by the International Com-mittee of Medical Journal Editors, as updated in October 2004 and available on the website www.icmje.org.

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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.

3) 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-estatís-tico 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 [pe-riodical on the Internet]. 2005 [cited 2005, Aug 27];13(2):[about 5p.]. Available at: 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 2p.]. Available at: http://bjsm.bmjjournals.com/cgi/content/full/38/4/383.

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level i – Randomized study with an adequate technique, with follow-up for at least 80% of the cases and a compatible statistical analysis; or meta-analysis with an adequate technique and results consistent with level I studies.level ii – Randomized study with partial randomization or randomization performed using an imperfect technique or with follow-up on less than 80% of the cases or with an imperfect statistical analysis. Comparative prospective study. Meta-analysis on level II studies or meta-analysis on level I studies with inconsistent results.level iii – Study on retrospective cases or meta-analysis on level III studies.level iV – Description of case series, with analysis on the results, without any comparative studylevel V – Description of cases, description of a surgical technique or specialist`s opinion.

lEVElS Of EVidEnCE fOr puBliCATiOn in ThE rBO

artigo 256

Associate Full Professor in the Department of Orthopedics and Traumatology, University of São Paulo School of Medicine.

Correspondence: Rua Ovídio Pires de Campos, 333, 3o andar, Cerqueira César, São Paulo, SP – E-mail: [email protected]

we declare that there is no conflict of interests in this article

UPDaTiNG arTiCLE

Rev Bras Ortop. 2010;45(2):116-21Rev Bras Ortop. 2010;45(2):116-21

iNTrODUCTiON

We have adopted the term “developmental dysplasia of the hip” (DDH) as a replacement for the previous name of “congenital hip dislocation” (CHD) and we propose to disseminate its use. This new nomenclature more precise-ly describes the spectrum of abnormalities possible for hip disorders among newborns. DDH is a generic term that describes a wide range of anatomical abnormalities of the hip, which may be congenital in nature, or may develop during children’s first months of life.

In reality, the term DDH describes the wide spec-trum of abnormalities that affect growing hips, from dysplasia to joint dislocation, and going through the different degrees of coxofemoral subluxation. This new name has been endorsed by the American Academy of Orthopedic Surgeons (AAOS), American Academy of Pediatrics (AAP), Pediatric Orthopedics Society of North America (POSNA), European Pediatric Ortho-pedics Society (EPOS) and Brazilian Society of Pediat-ric Orthopedics (SBOP)(1,2).

DYSPLASIA OF HIP DEVELOPMENT: UPDATE

Roberto Guarniero

abSTraCT

The term “developmental dysplasia of the hip” (DDH) includes a wide spectrum of abnormalities that affect the hip during its growth, ranging from dysplasia to joint dislocation and going through different degrees of coxofemoral subluxation. The inci-dence of DDH is variable, and depends on a number of factors, including geographical location. Approximately one in 1,000 newborn infants may present hip dislocation and around 10 in 1,000 present hip instability. Brazil has an incidence of five per 1,000 in terms of findings of a positive Ortolani sign, which is the early clinical sign for detecting the disorder. The risk fac-tors for DDH include: female sex, white skin color, primiparity, young mother, breech presentation at birth, family history, oli-gohydramnios, newborns with greater weight and height, and

deformities of the feet or spine. Hip examinations should be routine for newborns, and should be emphasized in maternity units. Among newborns and infants, the diagnosis of DDH is preeminently clinical and is made using the Ortolani and Bar-low maneuvers. Conventional radiography is of limited value for confirming the diagnosis of DDH among newborns, and ultra-sound of the hip is the ideal examination. The treatment of DDH is challenging, both for pediatric orthopedists and for general practitioners. The objectives of the treatment include diagnosis as early as possible, joint reduction and stabilization of the hip in a secure position. Classically, treatment options are divided according to different age groups, at the time of diagnosis.

Keywords – Hip/growth & development; Congenital hip dislo-cation; Developmental bone disease

DEfiNiTiONS

Dysplasia of the hip is a term that denotes an abnor-mality of size, morphology or anatomical orientation, in relation to the organization of either the femoral head or the acetabular cavity, or both. Acetabular dysplasia is characterized by an immature acetabulum, which may cause subluxation or luxation of the femoral head.

In cases of subluxation of the hip, the femoral head is dislocated from its normal anatomical position, but still maintains some contact with the acetabular cavity. In cases of luxation of the hip, there is no contact between the femoral head and the acetabular cavity.

Hips are described as “unstable” when the joint is reduced, in the anatomical position, but when sublux-ation or luxation of the joint can be caused.

Teratological dislocation is produced during the first months of intrauterine life. At birth, not only can dis-location be recognized, but also there are morphologi-cal abnormalities of such a degree that joint reduction will be very difficult, if not impossible. This category

117



includes dislocations associated with arthrogryposis, Larsen’s syndrome, proximal femoral deficiency (with all its variants) and neuromuscular disorders, and dislo-cations that occur in genetic syndromes. In this group, the hips are almost always dislocated: conditions of subluxation or instability do not exist and will not be discussed in this article.

EPiDEMiOLOGy aND ETiOLOGy

The incidence of DDH is variable and depends on various factors, including geographical location. Around one in every 1,000 newborns may be born with a dislo-cated hip, and around 10 in every 1,000 with a sublux-ated (unstable) hip.

In our setting, we can expect that the incidence of a positive Ortolani sign will be around five cases in every 1,000 newborns. This is the early clinical sign used for detecting DDH, as will be outlined below(3,4).

The risk factors for DDH include: female sex, white skin color, primiparity, young mothers, breech presenta-tion at birth, family history, oli go hy dramnios, newborns with greater weight and height and newborns with de-formities of the feet or spine.

The left hip is more affected (60%) and the right hip is less affected (20%) in situations of unilateral disorders, while bilateral disorders are less frequent (20%).

For unknown reasons, DDH affects individuals of black skin color less frequently.

Italians and descendents of Italians are affected more frequently, including in populations that have emigrated to other geographical regions(5).

PhySiCaL ExaMiNaTiON

The ideal situation is to perform the examination in the maternity ward, or within the first few days of life. The examination should clearly include taking the history, to assess the risk factors and antecedents, as mentioned earlier, in order to draw up the diagnosis.

The methods for diagnosing DDH were first de-scribed in the literature at least 50 years ago. In Italy, Putti started a pioneering program of early diagnosis and treatment for this disorder and published his results in 1926(6). In the United States in 1932, Howorth car-ried out a pioneering study on early diagnosis of the disorder, at the Babies Hospital of New York. Other authors then appeared in the literature, but it was in the

late 1940s, after the Second World War, that studies with greater coverage of children were reported in the United States, Sweden and England(5,7).

Early diagnosis can be regarded as relatively simple and safe, and it provides treatment that is generally ef-fective. Results obtained from early diagnosis that were classified as good or excellent have been reported both within orthopedics and within pediatrics(5,7). Early treat-ment provides good results in around 96% of the cases.

Hip examinations on newborns should therefore be performed routinely, and this practice should be empha-sized while the newborn is still in the maternity ward. It should also be part of the outpatient follow-up over children’s first weeks and months of life.

Among newborns and infants, the diagnosis of DDH is eminently clinical and is made using the Or-tolani and Barlow maneuvers. These tests take very little time within the routine physical examinations on newborns(8-11).

Ortolani’s sign is a test for hip reduction, i.e. when newborn with a dislocated coxofemoral joint is exam-ined, the femoral head is reduced into the acetabulum through the maneuver, thus demonstrating the disloca-tion. The maneuver is performed with the child in dorsal decubitus with the hips and knees in the position of 90° flexion and the thighs in adduction with slight internal rotation. One hip is examined at a time, with the other hip well stabilized, in a position of slight abduction. In making a hip abduction movement, possibly accompa-nied by slight external rotation of the thighs, there may be the feeling of a “protrusion” in joints presenting this disorder (sometimes there may even be an audible sign of this “protrusion”). Such cases are thus said to present a positive Ortolani sign (Figure 1).

Barlow’s sign is exactly the opposite, i.e. a maneuver to provoke dislocation of an unstable hip. Barlow’s test determines the potential for dislocation of the hip under examination. The patient’s thigh is kept at right angles to the trunk, in a position of adduction; force is exerted by the child’s knee vertically to the hip, in an effort to dislocate the femoral head from inside the acetabulum. The examiner looks for a sign of “pistoning” in the hip under examination, which may or may not be accom-panied by a “protrusion”. If the hip is reduced through Ortolani’s maneuver, the femoral head will be perfectly lodged in the acetabular cavity; however, with hip flex-ion and raising the thigh to the adduction position, the femoral head dislocates. This may occur posteriorly to

118

figure 1 – Illustrative photograph of the correct way to perform Ortolani’s maneuver

figure 2 – Teaching model illustrating Ortolani’s maneuver

figure 3 – Illustrative photograph of Galeazzi’s sign


the acetabulum, thus characterizing an unstable hip. In Barlow’s test, the upper part of the femur is kept be-tween the index and middle fingers, above the greater trochanter, and the thumb is kept in the inguinal region. The femoral head may be levered in and out of the joint, thereby confirming the instability.

Ortolani’s maneuver should not be performed us-ing force but, rather, with delicacy and with the child perfectly calm, since this is a procedure to reduce the dislocated hip. If the child is crying a lot and agitated, this will cause difficulties and get in the way of carrying out and concluding the examination.

After a few weeks, if the hip remains dislocated, the limitation on joint abduction will be evident, and this is an important clinical sign. The maximum abduction of the hips of newborns who are considered normal is greater than 60 degrees.

As children with dislocated hips grow, the clinical signs become more obvious. With the passage of time, it becomes more difficult or impossible to reduce the dislocation through Ortolani’s maneuver. Thus, this sign becomes negative. The limitation on abduction becomes greater.

Between three and six months of age, hip reduction in conscious children may become difficult. For this reason, it is uncommon to find children with a positive Ortolani sign in this age group. Thus, in this group, Ortolani’s maneuver loses its diagnostic value.

The examiner should also bear in mind that if chil-dren present “cracking” noises at the time of undergo-ing the physical examination, this may not be due to an unstable or dislocated hip.

The methods for examining the hips of newborns are shown to medical students or medical residents by means of audiovisual material, or by using babies in the maternity ward. The necessary experience of this clinical examination, which is fundamental for pedia-tricians, maternity ward physicians and neonatologists, will only be acquired through examining newborns with this disorder. These difficulties can be over-come through using a model for teaching and train-ing students and other healthcare professionals(12,13) (Figure 2).

Another, later sign is Galeazzi’s or Allis’s sign: with the child lying down with flexed knees, they will not be at the same height. This denotes a difference in length between the lower limbs. This sign will clearly be more evident in unilateral cases (Figure 3).

119

figure 4 – Lines on radiograph of the pelvis

Hilgenreiner


There may also be asymmetry in the gluteal skin-folds, but this is not always present.

In any event, we believe that maternity ward physi-cians or neonatologists should refer children for spe-cialist consultations with orthopedists in the following situations:

1) Clinical findings of hip instability or disloca-tion;

2) Cases of doubt; and,3) “High risk” patients, i.e. breech delivery, first

pregnancy, young mothers or family antecedents, independent of the results from the physical ex-amination that was performed.

iMaGiNG ExaMiNaTiONS

Conventional radiography has limited value for con-firming the diagnosis of DDH among newborns, since the proximal femoral epiphysis (femoral head) does not become ossified until the age of four to six months. On the other hand, ultrasonography on the hips of neonates has an obvious potential among children within this age group, since it clearly shows the cartilaginous structures that are poorly delineated by simple radiography(14-16).

Radiography of the pelvis starts to be used for con-firmation of DDH later on, after children have reached the age of four months. It needs to be emphasized that the nucleus of ossification of the femoral head will be radiographically visible from the fourth to sixth month onwards.

In radiographic evaluations for diagnosing DDH dur-ing the first months of life, indirect measurements and signs have to be used, such as: quadrant lines, Hilgen-reiner’s horizontal line, Perkins’s vertical line, Shenton’s line and the acetabular index (Figure 4).

Because of the power of resolution of axial computed tomography (ACT) for evaluating DDH, and the pos-sibility of producing transverse slices, ACT makes it possible to observe the interposition of the tendon of the iliopsoas muscle and hypertrophy of the pulvinar, even without using contrast medium in the capsule and inside the joint cavity. It also shows femoral subluxation and enables measurement of the angle of acetabular ante-version. This examination can be performed even if the child is using a plaster cast brace and is therefore useful for providing information on the exact position of the reduction. In a study carried out at Hospital das Clínicas, University of São Paulo School of Medicine that was

published in 1990, nine patients with 11 dislocated hips were studied. They underwent closed reduction with immobilization using a plaster cast brace, and this reduc-tion was monitored using ACT. It was concluded that ACT was a good method for evaluating cases of closed reduction of DDH, and that it was useful in most cases in which simple radiography left doubts. As shown by measurements made during that study, the angle of ac-etabular anteversion was not always increased in cases of DDH. Furthermore, hypertrophied pulvinar could be very well detected by ACT(17).

TrEaTMENT

Treatment for DDH is a challenge both for pediatric orthopedists and for general physicians. The objectives of this treatment include the aims of making the diag-nosis as early as possible, achieving joint reduction and stabilizing the hip in a secure position.

Classically, the treatment possibilities are divided according to the different age groups at the time of the diagnosis.

a) Treatment for newborns up to three months of age

Treatment is indicated as soon as the diagnosis has been made. For this age group, the treatment is based on the concept that if the reduced hip is kept positioned in flexion and slight abduction, the stimulus needed for normal development of the joint will be provided. Thus, once a diagnosis of hip instability or dislocation has been established, treatment will be started with the aim


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figure 5 – Illustrative photograph of Pavlik’s harness


of reducing the femoral head into the acetabular cavity and maintaining it there until joint stability has definitely been achieved.

Many types of orthopedic devices are available nowa-days for fulfilling these initial treatment objectives. To-day, the orthosis most commonly used is Pavlik’s harness (Figure 5). This orthosis provides simultaneous flexion and abduction of the coxofemoral joint through straps that join together relatively easily. According to Pavlik(18), use of the harness that he invented diminished the risk of requiring surgical reduction.

Ramsey et al(19) described the appropriate way to use Pavlik’s harness. Its action is based on the prin-ciple of reduction while in a flexed position, thereby avoiding a position of forced abduction of the joint. In their study, they showed that 89% of the dislocated hips among children aged under six months could be successfully reduced and thereafter presented nor-mal development through using this orthosis. Only one hip in their study presented slight abnormalities, consisting of osteochondritis. In two patients, failure to achieve reduction was due to not positioning the joint at flexion of 90°. These authors recommended that Pavlik’s harness should be used from the new-born period to the age of nine months. They did not report any avascular necrosis of the femoral epiph-ysis, as also reported by authors such as Kalamchi and MacFarlane(20). However, if concentric reduction is not achieved over the first two to three weeks of use of the harness, this approach is abandoned in fa-vor of traction followed by classical techniques for hip reduction.

Failures of reduction when using Pavlik’s harness are generally due to poor follow-up of the child by the physician at the outpatient clinic. When it is de-cided to use the harness, the child has to be exam-ined frequently in order to evaluate whether the de-vice has been applied correctly, usually once a week. Children will generally use the device for six to eight weeks; as a rule of thumb, for approximately twice the numerical value of the age at which use of Pav-lik’s harness was started. It should be borne in mind that the device can be used up to the age of four to six months(21).

In cases of failure when using the harness, our choice is to perform closed reduction and immobili-zation in a plaster cast brace (with or without an initial period of traction), for this age group.

b) Treatment between three months of age and walking age

Within this age range, most patients with DDH can be treated by means of closed reduction and immobi-lization in a plaster cast brace from the pelvis to the foot(22). During the operation, percutaneous tenotomy of the hip adductor muscles may be necessary.

When reduction through closed maneuvers cannot be achieved, open reduction is indicated. Thus, the indications for open reduction are as follows:

1) Femoral head remaining above the triradiate car-tilage in the radiographic examination;

2) Arc of reduction/luxation less than 25° after tenotomy of the adductors;

3) Femoral head not entering the acetabulum;

4) femoral head remaining lateralized in relation to the acetabulum, four weeks after partial reduc-tion; and

5) Previous failure of attempted reduction.

After the period of immobilization in the plaster cast brace, which will range from two to three months, the patient will progress to using an abduction orthosis (for example, the Milgram device) for a further two to three months.

Children with DDH require clinical and radiograph-ic evaluations, with orthopedic treatment and observa-tion when indicated, until reaching skeletal maturity.

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Guille JT, Pizzutillo PD, MacEwen GD. Development dysplasia of the hip from 1. birth to six months. J Am Acad Orthop Surg. 2000;8(4):232-42.Guarniero R, Lage LAA, Luzo CAM, Romano D. Complicações no tratamento 2. da displasia do desenvolvimento do quadril (DDQ): revisão da literatura e princípios de tratamento. Acta Ortop Bras. 1994;2(1):47-9.Guarniero R, Montenegro NB, Vieira PB, Peixinho M. Sinal de Ortolani: resulta-3. do do exame ortopédico em 9171 recém-nascidos na Associação Maternidade de São Paulo. Rev Bras Ortop. 1988;23(5):125-8.Guarniero R. Congenital dislocation of the hip. Epidemiology. Mapfre Med. 4. 1992;3(Suppl 2):11-3.Bowen JR, Kotzias-Neto A. Developmental dysplasia of the hip. Brooklandville: 5. Data Trace; 2006.Putti V. Congenital dislocation of the hip. Surg Gynecol Obstet. 1926;42:449.6. Howorth B. Development of present knowledge of congenital displacement of 7. the hip. Clin Orthop Relat Res. 1977;(125):68-87.Staheli LT. Ortopedia pediátrica na prática. 2a. Porto Alegre: Artmed; 2008.8. Skaggs DL, Flynn JM. Staying out of trouble in pediatric orthopaedics. Phila-9. delphia: Lippincott Williams & Wilkins; 2006.Storer SK, Skaggs DL. Developmental dysplasia of the hip. Am Fam Physician. 10. 2006;74(8):1310-6.Maxwell SL, Ruiz AL, Lappin KJ, Cosgrove AP. Clinical screening for deve-11. lopmental dysplasia of the hip in Northern Ireland. BMJ. 2002;27;324(7344): 1031-3.Guarniero R, Peixinho M, Montenegro NB. Avaliação do uso de um modelo 12. de ensino e treinamento para o diagnóstico precoce da luxação congênita do quadril. Rev Bras Ortop. 1988;23(5):133-5.

Cole WG. Evaluation of a teaching model for the early diagnosis of congenital 13. dislocation of the hip. J Pediatr Orthop. 1983;3(2):223-6.Sernik R. Ultrassonografia do sistema musculoesqueletico. Rio de Janeiro: 14. Revinter; 2009.Synder M, Harcke HT, Domzalski M. Role of ultrasound in the diagnosis and 15. management of developmental dysplasia of the hip: an international perspec-tive. Orthop Clin North Am. 2006;37(2):141-7.Guarniero R, Grigoletto Júnior W, Barros JC, Stump XM, Homsi C. Ultrasound 16. in the early diagnosis of congenital hip dislocation. Rev Hosp Clin Fac Med Sao Paulo. 1986;41(4):194-7.Lage LAA, Rodrigues LEA, Stump XMGRG, Guarniero R, Peixinho M. A to-17. mografia axial computadorizada na luxação congênita do quadril. Rev Bras Ortop. 1990;25(8):282-6.Pavlik A. The functional method of treatment using a harness with stirrups as 18. the primary method of conservative therapy for infants with congenital dislo-cation of the hip. 1957. Clin Orthop Relat Res. 1992;(281):4-10.Ramsey PL, Lasser S, MacEwen GD. Congenital dislocation of the hip. Use of 19. the Pavlik harness in the child during the first six months of life. J Bone Joint Surg Am. 1976;58(7):1000-4.Kalamchi A, MacFarlane R 3rd. The Pavlik harness: results in patients over 20. three months of age. J Pediatr Orthop. 1982;2(1):3-8.Kalamchi A, MacEwen GD. Avascular necrosis following treatment of congeni-21. tal dislocation of the hip. J Bone Joint Surg Am. 1980;62(6):876-88.Vitale MG, Skaggs DL. Developmental dysplasia of the hip from six months to 22. four years of age. J Am Acad Orthop Surg. 2001;9(6):401-11.Forlin E, Munhoz da Cunha LA, Figueiredo DC. Treatment of developmental 23. dysplasia of the hip after walking age with open reduction, femoral shortening, and acetabular osteotomy. Orthop Clin North Am. 2006;37(2):149-60,

rEfErENCES


c) Treatment after reaching walking ageThis requirement ought not to exist, since the ideal

is to make the diagnosis well before this age. Neverthe-less, for some children, there may be either diagnostic failure or failure of the consequent early treatment.

The approach to use and the types of treatment for children older than one and a half to two years are mat-ters of controversy.

Attempts to perform closed reduction may be indi-cated, or otherwise, open reduction will become practi-cally obligatory. For this age group, at the time of the

operation, the femoral bone shortening to enable the joint reduction has to be taken into consideration, along with the need to operations to perform complementary osteotomy in the acetabular region (Salter and Dega osteotomy, among other types)(23).

The age limit for indicating attempts to reduce the hip is around four to five years of age. After this age, so-called joint “salvage” operations are used, including pelvic osteotomy of more elaborate and difficult types (Steel, Chiari, pelvic polygon and other types). Other-wise, total hip arthroplasty might be envisaged.


artigo 267

Orthopedist and Sports Physician; MSc and PhD in Orthopedics and Sciences from Unifesp; Coordinator of the Sports and Orthopedics Study Group (NEO), São Paulo; Medical Director of the Brazilian Tennis Confederation; President of the Sports Traumatology Committee of SBOT 2009/2010.

Correspondence: Rua Botucatu, 591, 18o andar, Vila Clementino, 04023-062 São Paulo, SP – E-mail: [email protected] – Web: www.neo.org.br


UPDaTiNG arTiCLE

SPOrTS INjUrIES OF THE UPPEr LIMbS

Rogerio Teixeira da Silva


iNTrODUCTiON

Upper-limb injuries occur very frequently in sports and, in relation to many types of sports activities, or-thopedists may need to have knowledge of their phy-siopathology in greater detail in order to achieve the best possible treatment. Although some sports that frequently cause upper-limb injuries are not played much in Brazil (such as the specific case of baseball, for which a vast body of published studies exists in the medical literature), others such as tennis, volley-ball and handball also make great biomechanical de-mands on the shoulder. Such demands mean that this joint is subjected to supraphysiological forces during a good proportion of the sports movement. For exam-ple, at the time of the serve, an amateur tennis player may generate angular rotation forces of the order of 7,000 degrees per second during the acceleration phase(1).

In this article, the main focus will be on specific diagnoses and physiopathology, which are important factors for understanding the treatment strategies. Specific treatments introduced more recently will also be mentioned, focusing particularly on treatments for tendinopathy, which is a condition very frequently en-countered among athletes.

abSTraCT

Sports injuries of the upper limbs are very common in physi-cal activities and therefore, they need to be studied in detail, taking into consideration specific aspects of the types of sports practiced. Special attention should be paid to the dynamics of the shoulder girdle and the entire scapular belt, since the most appropriate treatment for athletes can only be provided in this

manner. This can also help to prevent recurrences, which can oc-cur in some cases because athletes always seek to return to their pre-injury level of sports activity. This article will focus primar-ily on the management of upper-limb tendon injuries, from the physiopathology through to the new methods of injury treatment that are more prevalent in sports practice in Brazil.

Keywords – Sports injuries; Shoulder; Elbow; Tendinopathy

principal upper-limb injuries in sports:Adolescent athletesInjuries to the distal epiphysis of the radius (gymnast’s

wrist)Injuries to the proximal epiphysis of the humerus (Little Leaguer’s shoulder)Osteochondritis of the humeral capitellum (Little Leaguer’s elbow)Os acromialeShoulder instability (minor)Shoulder instability (multidirectional)Generalized joint weaknessScapular dyskinesia

Adult athletesShoulderFracture due to stress on the distal humerusShoulder instabilityPinching syndromeRotator cuff injuries (tendinopathy/rupture)Injuries of the acromioclavicular joints (trauma and joint degeneration)Scapular dyskinesia

ElbowMedial and lateral epicondylitis

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Triceps tendinitisChondral injury of the humeral capitellumPosterior interosseous compressive syndromeSynovitis of the elbow

Wrist and handInjuries to the triangular fibrocartilageTendinitis of the ulnar extensor of the carpusOverloading of the carpal boneFracture due to stress on the ulna

ShOULDEr iNjUriES iN SPOrTSIt has been estimated that shoulder injuries account for

8% to 13% of all sports injuries(2). In addition to visits to consultation offices, these injuries are often seen at walk-in clinics, as shown by a study conducted in Germany, with support from the local ministry of health. This study showed that between 1997 and 1999, a total of 124 cases of individuals with injuries requiring medical attendance were seen(3). Out of the total number of injuries reported, 3.1% were sports injuries and the majority were reported as dislocations, torsions or ligament injuries (60%). It will be seen from the present paper that it is important to study sports injuries, even for physicians who are not specialists attending athletes alone.

This paper provides a summary of the main injuries encountered in daily practice, while taking into account that wide-ranging analysis of each specific type of in-jury would not be possible.

a) Subacromial pinching syndromeThis disorder is frequently seen among athletes,

particularly those who perform throwing mechanisms (volleyball, handball and tennis, among others). There are two types of pinching in clinical practice:

a1) Primary subacromial pinching: caused by the impact of the rotary cuff between the greater tuberosity and the coracoacromial arch or acromioclavicular joint. The causes are mainly anatomical abnormalities of the acromion (acromion type III), subacromial osteophytes and acromioclavicular arthrosis(4,5). Neer classified such pinching into three stages:

Stage 1: characterized by edema and hemorrhage in the subacromial bursa and supraspinal tendon, as a result of repeated trauma (for example, the serve move-ment in tennis);

Stage 2: at this stage, the inflammatory process pro-duces fibrosis and tendinitis in the distal insertion por-tion of the tendons;

Stage 3: characterized by partial or total rupture of the tendon (any of the components of the rotator cuff).

Even though this classification is old, it provides a very good idea of the evolution and prognosis of shoul-der pains in athletes and should always be borne in mind when dealing with sports players with shoulder pains. Depending on the stage at which the injury currently is, different treatments will be proposed, going from exclusively clinical treatment to performing corrective surgery consisting of bursectomy or acromioplasty, among other procedures(6).

a2) Secondary subacromial pinching: in sports, this type of pinching is particularly important, particularly among populations of young sports players (at the age of bone growth). Pains in the shoulder region that are attributed to primary pinching are often confounded with pain secondary to minor instability, and careful ex-amination needs to be paid to the clinical examination. The main causes that can lead to secondary pinching are minor conditions of instability(7), weakness acquired fol-lowing episodes of trauma and inappropriate movement of the scapula, also known as scapular dyskinesia(8).

From a practical point of view, for sports players, it is of interest to think of states of subacromial pinching and make a differential diagnosis with disorders that could cause secondary pinching: rotator cuff injuries, glenohumeral instability and scapular dyskinesia. It is essential to treat these disorders together, for sports play-ers who make throwing movements, in order to achieve a good result from the treatment and allow the athlete to return to an adequate and desired sports level.

b) Scapular dyskinesiaAlthough insufficient movement of the scapula dur-

ing high throwing movements in sports is not a separate disorder, it is very important to bear in mind such in-formation when thinking of pathological conditions of the shoulder. One of the authors who has studied this disorder most among sports players is Kibler(9), and many of his papers speak of the importance of assess-ing scapular movement not only for treatment but also especially for injury prevention.

The clinical examination of scapular positioning and movement must be done by watching the patient from behind, without his shirt on, in order to observe the position of the scapula at rest and also dynamically, when the patient makes frontal elevation and lateral arm movements.

SPORTS INJURIES OF THE UPPER LIMBS

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Abnormalities of scapular protraction and retrac-tion movements are important factors in generating shoulder injuries during throwing movements in sports. Loss of the complete movement of scapular retraction into the thorax causes loss of the potency from stability during the preparatory phase of the throwing action, thereby diminishing the explosive power during the acceleration phase of the action. Failure to make the complete movement of scapular protraction from the thoracic wall increases the de-celeration force of the shoulder during the throwing movement, which increases the chance of occurren-ces of pinching of the rotator cuff. This movement is especially important because these athletes usually present great tension in the posterior capsule of the shoulder(10,11).

The treatment for this pathological condition is emi-nently clinical, through appropriate rehabilitation pro-grams with the following objectives: adequate stretch-ing of the posterior capsule of the shoulder, balancing of the muscle forces from internal and external rotators of the shoulder, and specific work for strengthening and proprioception of the scapulothoracic joint.

c) rotator cuff injuriesThese are very common injuries among sports

players who make throwing movements(12,13). In Bra-zil, the main sports causing such injuries are tennis and volleyball.

Tendinopathy (going from inflammation to tissue degeneration) usually occurs more frequently in the younger population, while ruptures (partial or total) are seen more often in populations of sports players over the age of 40 years. For example, in a study by Leh-man, shoulder pains were found in 24% of young tennis players (12 to 19 years of age), while the incidence was around 50% in the population over the age of 50 years(14). This is because of the wear and dehydration that tendon structures suffer with advancing age, and this explains the importance of thinking in terms of prevention for this specific population.

Treatments for rotator cuff injuries may be compli-cated among sports players, particularly in relation to professional tennis players or amateurs who play regu-larly. The painful condition often does not correspond to what the imaging examinations say about the ana-tomical injury. From time to time, tennis players with

complete ruptures of a tendon (for example, the supras-pinal tendon) who manage to play normally, practically without reporting any pain, may be encountered. It is especially important to bear this in mind among popu-lations over the age of 50 years: such individuals may present good results from physiotherapeutic treatment, even in cases of complete rupture of a single tendon of the rotator cuff.

Good results from repair surgery on the cuff tendon have been presented in the medical literature, and such surgery can be performed both arthroscopically and as open procedures(15,16). It is preferable to perform arthroscopic repair, but the technique should be chosen on a case-by-case basis, and the surgeon needs to be comfortable with the technique chosen. A good proce-dure performed using open surgery is without doubt preferable to poor performed arthroscopy.

d) Glenohumeral instability

Instability is also a form of injury that can be found among sports players who make throwing mo-vements, and particularly cases of instability that can be considered to be long-term adaptations of throwing movements (such as previous microinstability that was caused basically by a deficit of internal rotation of the shoulder due to greater tension in the posterior capsule, which is very commonly observed among ju-venile tennis players, for example). The most impor-tant diagnosis to make here is to determine whether the athlete presents glenohumeral internal rotation de-ficit (GIRD). This abnormality is characterized by di-minished internal rotation of the shoulder, in compa-rison with the contralateral arm, and it is caused both by soft-tissue problems and by bone problems(17,18). It is important to diagnose this abnormality in athletes early on: since shoulder injuries occur frequently in competitive life, the literature recommends preventi-ve work whenever athletes presenting this deficit are encountered(19).

The present article will not go into details about the different types of treatment for these lesions, if only because such a discussion would not fit within the scope of this review article. Many other articles in this journal have focused on the surgical approach to this pathological condition, and the treatment for it does not differ greatly from the management of injuries among populations that are not sports players.

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figure 1 – Note the inflammation of the acromioclavicular joint in this 16-year-old amateur tennis player. This athlete did not report any pain in this region, despite the abnormality in the image. The examination was requested in order to evaluate the rotator cuff.

figure 2 – Note that the type II (curved) shape of the acromion does not necessarily have an impact on the tendons of the rotator cuff (the curved shape adapts to the curved shape of this region of the humeral head and the tendons that are inserted into it).

e) proximal biceps tendon injuries and superior labral (SlAp) injuries

Over recent years, increasing numbers of these injuries have been observed, even though they have recently been a focus of discussion in the worldwide literature. There has been much discussion on proximal injuries of the biceps, including their classification. Snyder et al(20) initially classified these injuries into four groups, while today up to ten types of SLAP inju-ry are envisaged. This in particular may be considered excessive, given that there should be one classification for guiding treatment(21). In the more extensive clas-sification described by Powell et al(21), some types can be considered to be variations of the types originally described by Snyder et al(20).

The clinical diagnosis is not always easy, since many pathological conditions may be associated with SLAP injuries among sports players who perform throwing movements. For this reason, magnetic resonance imag-ing should always be used when such injuries are sus-pected. With machines produced more recently (2.0, 2.5 and 3.0 Tesla), it is no longer necessary to ask for magnetic resonance imaging with intra-articular con-trast (“arthroresonance”).

Among sports players who perform throwing move-ments, it is very common to find degeneration of the insertion of the proximal biceps. Care needs to be tak-en so that a surgical view of repairing such injuries does not always have to be taken. However, when the injury is very symptomatic and the labrum is found to be stable, surgical repair should be carried out, prefer-ably using an arthroscopic route(22-24).

Another point in the literature that deserves atten-tion is the association between rotator cuff injuries and SLAP lesions. Whenever many symptoms of the latter are present together with cuff tear, the surgical result is better when two procedures are performed, to repair the injuries to both the labrum and the cuff(25,26). Although good results from these proce-dures performed in professional athletes are shown in the literature, the data may not be so encouraging and returning to the previous sports performance level may not be achieved. This is because of the extensive demands for rotation and muscle balance that profes-sional athletes routinely make, and cases in which surgery shortened the careers of these athletes are not uncommon.

f) Acromioclavicular joint injuriesIt is very common for sports players who perform

throwing movements to present worn-out acromio-clavicular joints. There is often a largely pain-free clini-cal picture in which major degeneration of this joint is seen on radiographs (Figure 1). It must always be borne in mind that such radiological abnormalities need to be correlated with the athlete’s clinical data, since the latter should prevail over the former.

One very important point that should be remem-bered relates to the morphology of the acromion. Some years ago, in relation to shoulder surgery, procedures to achieve a flat acromion were much more frequently recommended, whereas today, it is known that such procedures are not always necessary (Figure 2).


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figure 3 – Ultrasound examination to measure the distance from the acromion to the humerus. Note that when the shoulder is at rest (A), there is a good space, but when abduction at 60 degrees is performed (B), this space diminishes greatly in tennis players with scapular dyskinesia

A B

Another important point relates to the distance be-tween the acromion and the humerus and its relationship with abnormalities of scapula positioning. We recently published a study on this relationship among tennis players(27). Through clinical tests and imaging examina-tions, we observed that whenever the subacromial space diminished by more than 20% between measurements at 0 and 60 degrees of abduction, using ultrasonography, tennis players had a very great chance of presenting scapular dyskinesia (Figure 3). Although our study was not longitudinal (which would have allowed the rela-tionship between this finding and cuff injuries to be ob-served), we believe that this relationship should be borne in mind in order to think towards prevention of shoulder injuries among young competitive tennis players.

ELbOW iNjUriES iN SPOrTSThe most common elbow injury in sports is tendi-

nopathy. Traumatic injuries will not be dealt with here, but will be considered in other articles.

a) lateral epicondylitisLateral epicondylitis can be described as a specific

pathological disorder originating from the musculature of the lateral epicondyle, generally caused by overload. In this, microlesions are generated in the region of the insertions of extensor tendons of the wrist and fingers, most frequently the short radial extensor of the carpus. To a lesser degree, the long radial extensor of the carpus is affected, along with the anterior portion of the com-mon extensor of the fingers.

The pain generally starts in a mild form and progres-sively worsens in the region of the lateral epicondyle. It may radiate to the forearm, wrist, hand and shoulder. As the tendinopathy worsens, simple tasks such as picking up a milk carton or turning a door handle may become difficult to perform.

In relation to sports practices, the main topic of this review, the biomechanics of tennis must always be borne in mind, since this is the sport that most fre-quently causes such injuries. Reports in the Brazilian and worldwide literature have provided estimates that nowadays, around half of all tennis players will present such lesions, known as tennis elbow, at some time dur-ing their sporting lives(28,29). The grip and return shots in tennis require wide-ranging use of forearm extensors. The extensors become injured as the muscles reach fa-tigue through repetitive activity.

Incorrect technique in making shots is the factor that most frequently causes lateral epicondylitis(30,31). Patients who develop tennis elbow generally perform backhand shots with the “elbow in front”, without com-pleting the movement as far as the end of the swing. It is known that this causes excessive stress on the lateral epicondyle and abnormal activity of the forearm mus-culature. Another important tip for prevention is that if the tennis player can manage to perform backhand shots using both hands, this also prevents injuries. This can be explained in two ways: firstly, the player dissipates the impact forces of the shot in both arms; and sec-ondly, the player is also forced to turn the trunk more during the phase of preparing for the shot, which will

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cause the angular energy to be greater, thereby avoid-ing effort by the dominant arm alone. In our personal sample, from our consultation office, out of a total of 326 tennis players with lateral epicondylitis who were treated between 2004 and 2009, only four performed backhand shots with two hands.

Lateral epicondylitis may occur through the use of in-adequate equipment. The size of the racquet grip should be noted carefully and personalized according to each tennis player’s hand size. The cord tension of the racquet should also be measured. It can be routinely recommend-ed, whenever tennis players have no objection regard-ing decreased performance, that wide-profile racquets should be used. These have a larger head and larger area of minimum vibration (“sweet spot”), which prevents excessive vibration at the time of making the shot.

Another important tip for tennis players is that cording tensions of more than 57 pounds also increase the chance of injury. For this reason, it is now recommended that the equipment chosen should be appropriate for each player’s type of game and the shot power normally used.

General recommendations for preventing lateral epicondylitis among tennis players:a. Avoid hitting late balls.b. Learn to perform the repertoire of shots (serve, right,

left and volley) adequately.c. Seek to make contact between the ball and the racquet

head with the elbow always positioned in extension.d. Prepare the trunk rotation well, before backhand

shots, in order to be able to perform the shot with the elbow extended.

e. Avoid playing using very old balls.f. Use a maximum cording tension of 56/57 pounds.g. Give preference to synthetic or natural gut cords.h. Use racquets with a wide head profile, since these

have a larger central area of minimum vibration (sweet spot).

i. Make use of the flexion force of the knees at the time of serving.

j. Try to play backhand shots with two hands.

EtiopathogenesisThe constant overload that occurs in many sports

activities (such as tennis) generates microtraumas in the tendons and muscles of the lateral epicondyle, and the overload factor is the main mechanism generating the injury. Microtraumas promote the appearance of angiofi-

broblastic hyperplasia in the affected tendon, consequent to the chronic repetitive stimuli. These findings suggest that chronic epicondylitis is more a degenerative entity than an inflammatory entity. After the initial trauma, these areas become injured more frequently, leading to hemorrhage and the formation of deposits of granular and calcified tissue within the surrounding tissues(32).

In tennis, the classic example of a sport in which this type of pathological condition occurs very frequently, the pain is generally exacerbated through backhand shots, and it generally affects patients between 35 and 50 years of age.

Clinical pictureThe main symptom is pain, which is reported in the

external part of the elbow and may occasionally radiate from the forearm to the wrist and shoulder. Difficulty in extending the forearm may be a frequent symptom (be-cause of inflamed muscles and tendons). This pain may continue for weeks or months, and it is not uncommon for patients to seek care when they cannot even perform a handshake. The injury is considered to be chronic when the symptoms have lasted for at least three months.

Clinical diagnosisThe clinical diagnosis takes into consideration sev-

eral aspects of sports practices relating to tennis. A very detailed anamnesis regarding the development of the disorder, the length of time practicing the sport, the ways in which the pain increases and decreases and the basic movements that the sports player makes, along with specific special tests (Maudsley, Cozen and Mill tests)(33), usually confirm the diagnosis.

radiologySimple radiological examinations are performed rou-

tinely, in anteroposterior and lateral views. Ultrasound may be used, and this is an excellent imaging method for acute injuries. In chronic cases, in which several treatments may already have been undertaken, magnetic resonance imaging should be requested, since this may bring out data of greater precision regarding the patho-logical conditions that can cause pain similar to that of lateral epicondylitis (such as posterior interosseous compression syndrome)(34).

differential diagnosisThe middle finger test helps in the differential diagno-

sis between posterior interosseous nerve syndrome and


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lateral epicondylitis. This should be performed with the elbow at 90 degrees of flexion and the wrist in the neu-tral position. The third finger is pressed, while avoiding its active extension. An increase in the pain level through this maneuver suggests posterior interosseous syndrome. Another test used in the differential diagnosis between these two pathological conditions consists of infiltration of 1.0 ml of lidocaine at the level of the lateral epicon-dyle. In cases of lateral epicondylitis, the symptoms will disappear, while in cases of posterior interosseous nerve syndrome, the symptoms will persist(35).

Clinical and surgical treatmentMany treatments for diminishing the pain among

patients suffering from lateral epicondylitis have been described in the literature. However, practically all of these relate to populations that are not sports players(36), and this may bring in a conflict of data when dealing with athletes (basically tennis players, the sports popu-lation in which such injuries are most prevalent).

In dealing with acute injuries, the treatment con-sists of analgesics and non-hormonal anti-inflammatory agents. This management is always indicated together with physiotherapeutic treatment, since the aim is ad-equate muscle balance, analgesia and proprioception of the upper limb as a whole, while respecting the work of adaptation to the sports movements practiced(37).

Infiltration with corticoids may be one way to im-prove the local situation of pain, although it is made very clear in the medical literature that most of the ef-fects are fleeting and that over the long term, patients who practice sports may start to feel the pain again, given that corticoids do not cure the tissue degeneration that is often seen in chronic conditions(38,39).

Another alternative for conservative treatment that can be used is to apply shockwaves. Recently, many studies with a good level of scientific evidence have spoken in favor of the use of this therapy in cases that do not evolve well with conventional physiotherapy(40-42).

Surgery for lateral epicondylitis can only be indi-cated for chronic injuries. When the symptoms have been apparent for six months, and non-surgical medical treatment and physiotherapy have been unsuccessful, surgery is indicated. The procedure consists of removal of the degenerated fibrotic tissue that is located at the origin of the extensors. Partial release of the origin of the extensor in the lateral epicondyle of the humerus can be performed, but the release and lowering of the

tendon is avoided in sports players. In some cases, this is done in association with ostectomy of the epicondyle, or even bone perforation.

More recently, treatment with platelet-rich plasma (PRP) has been used as an alternative to surgery. We have now treated 40 such cases over the last three years, and we will shortly be publishing the results. In prin-ciple, these are promising, provided that the athlete fol-lows the recommendation to stay away from the sport for at least six to eight weeks following the infiltration. Therapy using an application of PRP seeks to improve the platelet cell support in the degenerated tissue, with the aim of repairing and regenerating the tendon cells(43). After aggregation, these platelets release platelet growth factors, among which vascular growth factors (VEGF), fibroblast-related growth factors (FGF) and insulin-re-lated growth factors (IGF), among others (Table 1).

Therapy with PRP to treat lateral epicondylitis was first described in the literature by Mishra and Pavelko(44), and it has been used routinely for cases that are re-fractory to conservative treatment, as an alternative to surgery(45). Ultrasound-guided infiltration is preferred, so that the application of PRP is only made in the in-jured area, thereby avoiding certain complications such as reactive synovitis, which could occur if the injection puts more volume into the site than is necessary(46). This is very important, because even with adequate centrifu-gation, PRP presents a small quantity of red blood cells in its composition after preparation (which may range from 2 to 4%). If these cells come into contact with the synovial lining of the elbow (which is very close to the region of the common extensor tendon), they may cause reactive synovitis, and this may compro-mise the patient’s rehabilitation. In the initial cases of our sample, some patients presented reactive synovitis: this improved after three weeks, but during the first few days, it caused a painful condition when these individu-als performed complete extension of the elbow. Through the use of an ultrasound-guided procedure, we reduced the chances of this problem occurring, since we were able to place the needle very well, exactly at the loca-tion of the injury.

Another benefit of ultrasonography is that we were able to use Doppler to observe the local vascularization. This was also very important in evaluating the tissue regeneration process that occurred up to the eighth week (Figure 4). We usually follow up the healing process by performing Doppler ultrasonography in the fourth,

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Table 1 – Summary of the most important growth factors derived from platelets, and their functions(7)

Growth factor Places where it comes from Function

TGF beta (transforming growth factor beta)

Platelets, extracellular bone matrix, cartilaginous matrix, macrophages, monocytes and neutrophils

Stimulates proliferation of undifferentiated mesenchymal cells; regulates endothelial mitogenesis of fibroblasts and osteoblasts; inhibits lymphocyte and macrophage proliferation; regulates the mitogenic effect of other growth factors; regulates collagen synthesis and collagenase secretion

bFGF (basic fibroblast growth factor)

Platelets, macrophages, mesenchymal cells, chondrocytes and osteoblasts

Promotes growth and differentiation of chondrocytes and osteoblasts; mitogenic for mesenchymal cells, chondrocytes and osteoblasts

PDGFa-b (platelet-derived growth factor)

Platelets, macrophages, monocytes, mesenchymal cells, chondrocytes, osteoblasts and muscle cells

Mitogenic for mesenchymal cells and osteoblasts; stimulates chemotaxis and mitogenesis in fibroblasts, glia cells and muscle cells; regulates collagenase secretion and collagen synthesis; stimulates chemotaxis of macrophages and neutrophils

EGF (epidermal growth factor) Platelets, macrophages and monocytes Stimulates chemotaxis and endothelial angiogenesis; regulates collagenase secretion; stimulates epithelial and mesenchymal mitogenesis

VEGF (vascular endothelial growth factor)

Platelets and endothelial cells Increases angiogenesis and vascular permeability; stimulates mitogenesis of endothelial cells


figure 4 – The use of Doppler for ultrasound evaluation of tendons is important. In such cases, it helps in controlling PRP infiltration (A) and in establishing the cure criteria, for which it shows absence of vessels in asymptomatic patients (B)

BA PRP infiltrationEight without assessment after PRP (no flow)

Elbow extensor tendon

eighth and, when necessary, twelfth week. Vasculariza-tion in the tendon usually occurs at an increased rate un-til the fourth week and is seen to have diminished in the examination in the eighth week. It should be absent in the Doppler examination in the twelfth week, at which point the patient can be released to play competitive tennis again (Table 1).

physiotherapeutic treatmentControversy still surrounds the rehabilitation for lat-

eral epicondylitis, perhaps because many techniques are used at the same time with the aim of enabling patient recovery as quickly as possible. The techniques most used for this treatment are ultrasound, shortwave, elec-trostimulation and ice(47).

When patients undergo treatment consisting of plasma-rich platelet infiltration, physiotherapy has a fundamental role in tissue recovery. Laser and ultra-

sound are used routinely in the initial phases, and light exercises for wrist and finder extension and flexion can be started early on (from the second day after applying PRP). Patients then progress to performing mild eccen-tric exercises and proprioception (from the first week onwards), always with the aim of improving all of the proprioception of the upper limb.

From the fourth week onwards, athletes are well enough to perform specific exercises for their sport, and exercises with a lighter racquet without cords, with or without elastic resistance, can also be performed in order to incorporate the work of gaining muscle strength.

Right and left movements can be made using a light-er ball in the rehabilitation clinic from the sixth week onwards and, from then on, a sports movement reeduca-tion program can be started. Athletes are released com-pletely for games and competitions between the tenth and twelfth weeks.


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b) Other tendon injuries of the elbow in sportsMedial epicondylitis and tendinopathy of the brachial

triceps are also injuries that may mess up sports players’ lives. These pathological conditions will not be dealt with in detail here, but it should be borne in mind that they may require long-term treatment, particularly in re-lation to sports in which powerful throwing movements are needed (the serve in tennis, the pitcher’s throw in baseball and attack shots in volleyball, among others).

The treatment should follow the same routes as de-scribed above for lateral epicondylitis, starting with anal-gesic physiotherapeutic measures and passing on to muscle strengthening and proprioception. In cases in which con-servative treatment does not achieve good results after a period of three to six months, even if performed correctly, other therapies may become necessary. These may include shockwave therapy, application of platelet-rich plasma and surgery in cases that are refractory to these treatments.

Rupture of the distal biceps is another tendon injury that can be found among sports players, particularly among weightlifters, because of the great force that these athletes have to exert in order to achieve good results. One important point is that whenever dealing with such injuries, it has to be ascertained whether the athlete was using anabolic steroids, since there is a di-rect relationship between the use of these substances and ruptures of this tendon in the elbow.

c) differential diagnosis for tendinopathy of the elbow in sports

uncommon shoulder and elbow injuries in sportsOther shoulder and elbow injuries that are less common

may also affect sports players who make throwing move-ments. Among these, the following can be highlighted:

a) Nerve injuries – The most common of these in sports players’ shoulders is compression of the supras-capular nerve, but the axillary and long thoracic nerves may also present abnormalities, particularly of chronic nature. In the elbow, the best known nerve compression is posterior interosseous nerve compression syndrome, which should be an obligatory differential diagnosis for chronic conditions.

b) Stress-induced bone injuries – The bone overload that is most common in the upper limbs is in the region of the distal humerus. We recently published a case se-ries reporting on this diagnosis among tennis players(48). It is important to bear this differential diagnosis in mind when sports players present subacute and chronic pain

in the distal region of the humerus of the dominant arm. The treatment should consist of temporarily stay-ing away from the sport and undergoing physiotherapy. Although rare, bone overload may also be a source of pain in the hand and wrist region(49).

c) Tumors – This diagnosis should always be borne in mind in cases of pain close to joints, particularly if the pain is insidious and in athletes who are still at the growth phase. The most commonly encountered tumors are benign, but malignant tumors may also occur, mainly affecting the proximal region of the humerus in adolescent athletes.

d) Muscle-tendon tears – In the shoulder region, one injury that is infrequent but may be found in sports is tearing of the pectoralis major muscle, which occurs among competitive weightlifters. These injuries may also be associated with the use of anabolic steroids and, within the Brazilian setting, some studies have already reported on the need for surgery to correct such cases among sports practitioners. In the elbow, as cited earlier, tears in the distal biceps may also be a problem for such athletes, and adequate correction for them generally re-quires surgical procedures.

e) Chondral injuries – These should be borne in mind when athletes present chronic pain in the shoulder and elbow joints. In certain situations, these may lead them to feel cracking or even produce crepitation during the sports movement. Especially in populations that are still at the growth stage, it should be remembered that osteo-chondritis may be the cause of pain around joints. This diagnosis needs to be borne in mind in investigating such injuries, or else they may remain unnoticed in the initial clinical examination on such athletes.

CONCLUSiONSAs can be seen, upper-limb sports injuries may form

part of the daily routine of any physician, even those who do not exclusively provide care for tennis players. Tendinopathy, which is common in the upper limbs, needs to be studied so that its chronic form can increas-ingly be avoided, given that chronic tendinopathy may lead to a requirement for treatments that are lengthier and more costly for the healthcare system.

It is hoped that this article will aid readers in manag-ing such pathological conditions, with the aim of provid-ing the best possible care, both for sports-playing and for non-sports-playing patients. The literature reviewed here was extensive, and supplementary reading of the articles referenced in this study will provide details to complete the information presented here.

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Silva RT. Lesões esportivas no tênis. In: Cohen M, Jorge RA.1. Lesões nos esportes: diagnóstico, prevenção e tratamento. Rio de Janeiro: Revinter; 2002. p. 709-32.Hill JA. Epidemiologic perspective on shoulder injuries. Clin Sports Med. 2. 1983;2(2):241-6.Schneider S, Seither B, Tönges S, Schmitt H. Sports injuries: population based 3. representative data on incidence, diagnosis, sequelae, and high risk groups. Br J Sports Med. 2006;40(4):334-9.Bigliani LU, Morrison DS, April EW. The morphology of the acromion and its 4. relation to rotator cuff tears. Orthop Trans. 1986;10:228.Zuckerman JD, Kummer FJ, Cuomo F. The influence of coracoacromial arch 5. anatomy on rotator cuff tears. J Shoulder Elbow Surg. 1992;19(1):4-13.Doneux PS, Miyazaki AN, Pinheiro Jr JA, Funchal LFZ, Checchia SL. Tratamento 6. da síndrome do impacto em tenistas. Rev Bras Ortop. 1998;33(12):939-44.Jobe CM, Pink MM, Jobe FW, Shaffer B. Anterior shoulder instability, impinge-7. ment, and rotator cuff tear: theories and concepts. In: Jobe FW, editor. Ope-rative techniques in upper extremity sports injuries. St. Louis: Mosby; 1996. p.164–76.Kibler WB. The role of the scapula in athletic shoulder function. Am J Sports 8. Med. 1998;26(2):325-37.Kibler WB, Uhl TL, Maddux JW, Brooks PV, Zeller B, McMullen J. Qualitative 9. clinical evaluation of scapular dysfunction: a reliability study. J Shoulder Elbow Surg. 2002;11(6):550-6.DiGiovine NM, Jobe FW, Pink M, Perry J. An electromyographic analysis of the 10. upper extremity in pitching. J Shoulder Elbow Surg.1992(1):15-22.Kibler WB. Biomechanical analysis of the shoulder during tennis activities. Clin 11. Sports Med. 1995;14(1):79-85.Arroyo JS, Hershon SJ, Bigliani LU. Special considerations in the athletic thro-12. wing shoulder. Orthop Clin North Am. 1997;28(1):69-78.Abrams JS. Special shoulder problems in the throwing athlete: pathology, diag-13. nosis, and nonoperative management. Clin Sports Med. 1991;10(4):839-61.Lehman RC. Shoulder pain in the competitive tennis player. Clin Sports 14. Med.1988; 7(2):309-27.Rudzki JR, Shaffer B. New approaches to diagnosis and arthroscopic manage-15. ment of partial-thickness cuff tears. Clin Sports Med. 2008;27(4):691-717.Weber SC. Arthroscopic debridement and acromioplasty versus mini-open re-16. pair in the treatment of significant partial-thickness rotator cuff tears. Arthros-copy. 1999;15(2):126-31.Ellenbecker TS, Roetert EP, Bailie DS, Davies GJ, Brown SW. Glenohumeral 17. joint total rotation range of motion in elite tennis players and baseball pitchers. Med Sci Sports Exerc. 2002;34(12):2052-6.Crockett HC, Gross LB, Wilk KE, Schwartz ML, Reed J, O’Mara J, et al. Os-18. seous adaptation and range of motion at the glenohumeral joint in professional baseball pitchers. Am J Sports Med. 2002;30(1):20-6.Lintner D, Mayol M, Uzodinma O, Jones R, Labossiere D. Glenohumeral internal 19. rotation deficits in professional pitchers enrolled in an internal rotation stretching program. Am J Sports Med. 2007;35(4):617-21.Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of 20. the shoulder. Arthroscopy. 1990;6(4):274-9.Powell SE, Nord KD, Ryu RK. The diagnosis, classification, and treatment of 21. SLAP lesions. Oper Tech Sports Med. 2004;12(1):99-110.Barber FA, Field LD, Ryu RK. Biceps tendon and superior labrum injuries: 22. decision making. Instr Course Lect. 2008;57:527-38.Paxinos A, Walton J, Rütten S, Müller M, Murrell GA. Arthroscopic stabilization 23. of superior labral (SLAP) tears with biodegradable tack: outcomes to 2 years. Arthroscopy. 2006;22(6):627-34.Rhee YG, Lee DH, Lim CT. Unstable isolated SLAP lesion: clinical presentation 24. and outcome of arthroscopic fixation. Arthroscopy. 2005;21(9):1099.Franceschi F, Longo UG, Ruzzini L, Rizzello G, Maffulli N, Denaro V. No advan-25. tages in repairing a type II superior labrum anterior and posterior (SLAP) lesion

when associated with rotator cuff repair in patients over age 50: a randomized controlled trial. Am J Sports Med. 2008;36(2):247-53.Voos JE, Pearle AD, Mattern CJ, Cordasco FA, Allen AA, Warren RF. Outco-26. mes of combined arthroscopic rotator cuff and labral repair. Am J Sports Med. 2007;35(7):1174-9.Silva RT, Hartmann LG, Laurino CF, Biló JP. Clinical and ultrasonographiccorre-27. lation between scapular dyskinesia and subacromial space measurement amon-gjunior elite tennis players. Br J Sports Med. 2008. [Epub ahead of print]RT; Santos MB. Tennis Elbow: a survey among 839 tennis players with and 28. without injury. Med Sci Tennis. 2008;13(1):36-41.Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-29. analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med. 2005;39(7):411-22.Roetert EP, Brody H, Dillman CJ, Groppel JL, Schultheis JM. The biomechanics 30. of tennis elbow. An integrated approach. Clin Sports Med. 1995;14(1):47-57.Knudson D, Blackwell J. Upper extremity angular kinematics of the one-handed 31. backhand drive in tennis players with and without tennis elbow. Int J Sports Med. 1997;18(2):79-82.Nirschl RP, Ashman ES. Elbow tendinopathy: tennis elbow. Clin Sports Med. 32. 2003;22(4):813-36.Chumbley EM, O’Connor FG, Nirschl RP. Evaluation of overuse elbow injuries. 33. Am Fam Physician. 2000;61(3):691-700.Tuite MJ, Kijowski R. Sports-related injuries of the elbow: an approach to MRI 34. interpretation. Clin Sports Med. 2006;25(3):387-408.Bencardino JT, Rosenberg ZS. Entrapment neuropathies of the shoulder and 35. elbow in the athlete. Clin Sports Med. 2006;25(3):465-87.Johnson GW, Cadwallader K, Scheffel SB, Epperly TD. Treatment of lateral 36. epicondylitis. Am Fam Physician. 2007;76(6):843-8.Stasinopoulos D, Stasinopoulou K, Johnson MI. An exercise program-37. me for the management of lateral elbow tendinopathy. Br J Sports Med. 2005;39(12):944-7.Newcomer KL, Laskowski ER, Idank DM, McLean TJ, Egan KS. Corticos-38. teroid injection in early treatment of lateral epicondylitis. Clin J Sport Med. 2001;11(4):214-22.Hay EM, Paterson SM, Lewis M, Hosie G, Croft P. Pragmatic randomized con-39. trolled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. BMJ. 1999;319(7215):964-8.Radwan YA, ElSobhi G, Badawy WS, Reda A, Khalid S. Resistant ten-40. nis elbow: shock-wave therapy versus percutaneous tenotomy. Int Orthop. 2008;32(5):671-7.Lebrun CM. Low-dose extracorporeal shock wave therapy for previously 41. untreated lateral epicondylitis. Clin J Sport Med. 2005;15(5):401-2.Chung B, Wiley JP. Effectiveness of extracorporeal shock wave therapy in the 42. treatment of previously untreated lateral epicondylitis: a randomized controlled trial. Am J Sports Med. 2004;32(7):1660-7.Mishra A, Woodall J Jr, Vieira A. Treatment of tendon and muscle using 43. platelet-rich plasma. Clin Sports Med. 2009;28(1):113-25.Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered pla-44. telet-rich plasma. Am J Sports Med. 2006;34(11):1774-8.Silva RT. Treatment of chronic tennis elbow with platelet-rich plasma. Case 45. Report. Adv Orthop. 2009;1(3):108-11.Connell DA, Ali KE, Ahmad M, Lambert S, Corbett S, Curtis M. Ultra-46. sound-guided autologous blood injection for tennis elbow. Skeletal Radiol. 2006;35(6):371-7.Perkins RH, Davis D. Musculoskeletal injuries in tennis. Phys Med Rehabil Clin 47. N Am. 2006;17(3):609-31.Silva RT, Hartmann LG, Laurino CF. Stress reaction of the humerus in tennis 48. players. Br J Sports Med. 2007;41(11):824-6.Silva RT, Cohen M, Matsumoto MH, Gracitelli GC. Avaliação das lesões ortopé-49. dicas em tenistas amadores competitivos. Rev Bras Ortop. 2005;40(5):270-9.

rEfErENCES



artigo 140

1 – PhD in Medicine from São Paulo Medical School, Federal University of São Paulo, and Head of the “Prof. Dr. Donato D’Ângelo” Orthopedics and Traumatology Service, Hospital Santa Teresa, Petrópolis, RJ, Brazil.

2 – Resident physicians in orthopedics and traumatology, “Prof. Dr. Donato D’Ângelo” Orthopedics and Traumatology Service, Hospital Santa Teresa, Petrópolis, RJ, Brazil.3 – Head of Department and Associate Professor of the Department of Orthopedics and Traumatology, School of Medicine of the Federal University of Rio de Janeiro, Brazil.4 – Physician responsible for the Trauma Group, Hospital de Ipanema, Rio de Janeiro, Brazil.5 – Physician responsible for the Shoulder Group, “Prof. Dr. Donato D’Ângelo” Orthopedics and Traumatology Service, Hospital Santa Teresa, Petrópolis, RJ, Brazil.

Work performed at the “Prof. Dr. Donato D’Ângelo” Orthopedics and Traumatology Service, Hospital Santa Teresa, Petrópolis, RJ, Brazil.Correspondence: Av. Roberto Silveira, 187, apto. 601 – 25685-040 – Petrópolis, RJ – E-mail: [email protected]


OriGiNaL arTiCLE

FrAcTUrES OF THE DISTAL ExTrEMITY OF THE TIbIA TrEATED wITH INTrAMEDULLArY NAIL Or brIDgE PLATE: cOMPArISON OF

rADIATION ExPOSUrE DUrATION bETwEEN THE TwO METHODS

Pedro José Labronici1, Fábio Soares Lyra2, Ildeu Leite Moreira Junior2, Rolix Hoffmann2, José Sergio Franco3, Paulo Roberto Barbosa de Toledo Lourenço4, Gustavo José Labronici5


iNTrODUCTiONThe radiation risks to which certain specialists are

exposed, including radiologists cardiologists and on-cologists, have already been well documented(1). How-ever, despite the increasing use of image intensifiers in orthopedic surgery, few studies have assessed the radiations risks among such surgical teams.

Over the last 20 years, with the introduction of new orthopedic procedures such as intramedullary fixation using locked nails in long bones, fixation using pedicle screws in the spine and minimally invasive procedures, the use of image intensifiers has increased. These pro-cedures may involve prolonged exposure to radiation among the orthopedic surgeons and other profession-als who work in the surgical center. Mehlman and

abSTraCTObjective: To compare the duration of exposure to radiation among patients with fractures of the distal third of the tibia treated with an intramedullary nail or with a bridge plate. Meth-ods: Intramedullary nails were used for 33 fractures, and bridge plates were used for 41 fractures. In the nail group, according to the AO classification, 14 patients had type A fractures, 15 had type B and four had type C. Twelve patients had closed fractures and 21 had open fractures. In the plate group, 10 patients had type A fractures, 22 had type B and nine had type C. Twenty-seven patients had closed fractures and 14 had open fractures. Results: There was a significant difference in the duration of exposure to radiation between the patients treated using a nail

and those treated using a plate (p = 0.0001). The group treated using a nail had significantly greater exposure to radiation than did the group treated using a plate. Comparing the type of frac-ture (A, B or C), it was observed that there was no significant difference in the duration of exposure to radiation between the nail technique (p = 0.19) and the plate technique (p = 0.80). Conclusion: Fractures of the distal third of the tibia treated with an intramedullary nail present significantly greater exposure to radiation than do fractures treated with a bridge plate, indepen-dent of the fracture type.

Keywords – Tibial fractures; Fracture fixation, intramedullary; Radiation exposure; Comparative study

DiPasquale(2) demonstrated that, depending on the dis-tance between the fluoroscopy ampoule and the surgeon, this person might receive a significant quantity of radia-tion exposure. Such exposure could occur particularly in the eyes, leading to the development of cataracts; in the thyroid, leading to the formation of sarcomas; and in the hands.

The aim of the present study was to compare simply the duration of radiation exposure during treatments for frac-tures of the distal third of the tibia, between the use of the techniques of intramedullary locked nails and bridge plates. This becomes an important matter, since the relationship with the treatment technique may, over the medium and long terms, influenced the appearance of irreversible le-sions in orthopedic surgeons.

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METhODSBetween January 2006 and December 2007, 74 cases

of fractures of the distal third of the tibia were treated at Hospital Santa Teresa, in Petrópolis, RJ. For 33 fractures, the present authors used intramedullary locked nails (non-milled Baumer® or universal AO®), and for 41 fractures, they used bridge plates for wide or narrow dynamic com-pression (AO®), depending mainly on the bone size.

The inclusion factors for this study were that the pa-tients should have fractures of the distal third of the tibia that were treated with intramedullary locked nails or bridge plates. The operations were performed in the surgical center of Hospital Santa Teresa, with the same surgical equipment and a team that had been trained in the use of two image intensifier devices (GE® model G045 and Siemens® model G5429), which supplied the radiation during the proce-dures. The procedures were performed by two surgeons, each with more than ten years of experience. Our study did not evaluate the level of radiation but just its duration.

Among the patients treated using intramedullary nails, 26 were male and seven were female. The patients’ ages ranged from 17 to 54 years (mean of 33.1 years). The AO classification (Arbeitsgemeinschaft für Osteo-synthefragen)(3) was used to divide the fractures of the tibial diaphysis into three types according to the degree of contact between the main fragment after reduction. Among these patients, 14 presented type A fractures, 15 had type B, four had type C and 12 had closed fractures. The exposed fractures were classified in accordance with Gustilo and Anderson(4), who divided the exposed fractures into three grades. There were seven grade I fractures, ten grade II and four grade III.

Among the patients treated with bridge plates, 34 were male and seven were female. The patients’ ages ranged from 14 to 76 years, with a mean of 30.8 years. With regard to the AO fracture classification, 10 were type A, 22 were type B and nine were type C. In the group of exposed fractures, three were grade I, six were grade II and five were grade III A. Twenty-seven pa-tients presented closed fractures.

Table 1 presents the frequencies and percentages from the AO classification according to the technique used (nail or plate). It was found using the chi-square test that there was no significant association (p = 0.21) between the type of fracture and the technique. It was noted that the more severe types of fracture (B and C) were treated more often using the plate technique, but without reaching statistical significance.

Table 1 – AO classification versus technique

AO typeTechnique

Nail Plate Total

A 1442.42

1024.39 24

B 1545.45

2253.66 37

C 412.12

921.95 13

Total 33 41 74

Statistical methodologyStatistical analysis was performed using the Mann-

Whitney test to investigate whether there was any dif-ference in the duration of exposure to radiation (in seconds) between the two techniques (nail and plate). To make comparisons between the three types of AO classification (A, B and C), Kruskal-Wallis analysis of variance was performed.

Nonparametric methods were used, since the dura-tion of intensifier use did not present normal (Gaussian) distribution, because of data dispersion and lack of sym-metry of the distribution. The criterion used to determine significance was a level of 5%.

rESULTS

Table 2 presents the mean, standard deviation (SD), median, minimum and maximum for the duration of intensifier use (in seconds), according to the group (nail or plate). The analysis was performed using the Mann-Whitney test.

Table 2 – Statistical analysis on the duration of intensifier use (in seconds), according to the technique

Technique n Mean SD Median Minimum Maximum p

Nail 33 129.1 44.8 120 60 2700.0001

Plate 41 68.5 36.4 60 18 160Source: Hospital Santa Teresa, Petrópolis, RJ, 2007SD: standard deviation

It was observed that there was a significant differ-ence in the duration of exposure to radiation between the use of nails and plates (p = 0.0001). The group treated using nails presented significantly greater dura-tion of exposure to radiation than did the group treated using plates.

FRACTURES OF THE DISTAL ExTREMITY OF THE TIBIA TREATED WITH INTRAMEDULLARY NAIL OR BRIDGE PLATE: COMPARISON OF RADIATION ExPOSURE DURATION BETWEEN THE TWO METHODS

134


To show whether there was any relationship between the duration of exposure to radiation and the severity of the fractures, Tables 3 and 4 present the mean, standard deviation (SD), median, minimum and maximum of the duration of exposure to radiation (in seconds), accord-ing to the AO classification (A, B and C), for the nail and plate techniques, respectively. The analysis was performed using Kruskal-Wallis ANOVA.

Table 3 – Statistical analysis on the duration of intensifier use (in seconds), according to the AO classification, for the nail technique

Type n Mean SD Median Minimum Maximum p

A 14 122.2 52.1 118 60 270

0.19B 15 134.0 44.0 120 70 230

C 4 135.0 12.9 135 120 150Source: Hospital Santa Teresa, Petrópolis, RJ, 2007SD: standard deviation

Table 4 – Statistical analysis on the duration of intensifier use (in seconds), according to the AO classification, for the plate technique


A 10 62.0 40.4 60 18 160

0.80B 22 69.1 33.1 65 18 120

C 9 74.0 42.6 54 30 140Source: Hospital Santa Teresa, Petrópolis, RJ, 2007SD: standard deviation

It was observed that there was no significant differ-ence in the duration of exposure to radiation between types A, B and C (p = 0.19) when the nail technique was used.

It was observed that there was no significant differ-ence in the duration of exposure to radiation between types A, B and C (p = 0.80) when the plate technique was used.

Tables 5 and 6 present the mean, standard deviation (SD), median, minimum and maximum of the duration of exposure to radiation (in seconds), according to the AO classification (A and B + C), for the nail and plate techniques, respectively. This analysis was performed us-ing the Mann-Whitney test. The aim of this analysis was to separate the simple fractures from the more complex fractures, and for this, types B and C in the AO classifi-cation were grouped together in order to obtain greater power for the statistical test.

Although there was no significant difference at the 5% level, we were able to see a tendency (p = 0.085) for the fractures that were more severe (B + C) to present

greater duration of exposure to radiation than that of the type A fractures, with regard to the nail technique.

Table 6 – Statistical analysis on the duration of intensifier use (in seconds), according to the AO classification, for the plate technique


A 10 62.0 40.4 60 18 1600.51

B + C 31 70.5 35.4 60 18 140Source: Hospital Santa Teresa, Petrópolis, RJ, 2007SD: standard deviation

It was observed that there was no significant differ-ence in the duration of exposure to radiation between the fracture types (p = 0.51) when the plate technique was used. In this case, there was no tendency towards increased duration of exposure to radiation between the different types of fracture.

DiSCUSSiONThe risk caused by intraoperative radiation contin-

ues to be a widely discussed topic, especially with the development of orthopedic procedures that use image intensifiers(5-11). The quantity of exposure to radia-tion for patients is acceptable and remains within the safety margins(12,13). However, for surgeons and other professionals who work in surgical centers, the dura-tion of exposure may be significant and have uncertain consequences(14). The worry in relation to using im-age intensifiers is the possibility of malignancy. The areas in question include the eyes (lenses), neck re-gion (thyroid), organs (liver and spleen), gonads and hands (skin)(9).

Giachino and Cheng(15) measured the diffusion of radiation to which orthopedic surgeons were exposed during the procedure to treat fractures of the femoral neck. They found that when the surgeon was positioned at least 46 cm from the greater trochanter, the exposure to radiation was greatly reduced. Dosch et al(16) mea-sured the relationship between the radiation registered

Table 5 – Statistical analysis on the duration of intensifier use (in seconds), according to the AO classification, for the nail technique


A 14 122.2 52.1 118 60 2700.085

B + C 19 134.2 39.2 130 70 230Source: Hospital Santa Teresa, Petrópolis, RJ, 2007SD: standard deviation

135

Faulkner K, Moores BM. An assessment of the radiation dose received by staff using 1. fluoroscopic equipment. Br J Radiol. 1982;55(652):272-6.Mehlman CT, DiPasquale TG2. . Radiation exposure to the orthopaedic surgical team during fluoroscopy: “How far away is far enough?”. J Orthop Trauma. 1997;11(6):392-8.Müller ME, Allgöwer M, Schneider R, Willenegger H. Manual de osteossíntese: 3. técnicas recomendadas pelos grupos AO-ASIF. Tradução de Nelson Gomes de Oliveira. 3a ed. São Paulo: Manole; 1993. p.151-8. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand 4. and twenty-five open fractures of long bones: retrospective and prospective analy-ses. J Bone Joint Surg Am. 1976;58(4):453-8.Barry TP. Radiation exposure to an orthopedic surgeon. Clin Orthop Relat Res. 5. 1984;(182):160-4.Krettek C, Schandelmaier P, Miclau T, Tscherne H. Minimally invasive percutaneous 6. plate osteosynthesis (MIPPO) using the DCS in proximal and distal femoral fractures. Injury. 1997;28(Suppl 1):20-30.Miller ME, Davis ML, MacClean CR, Davies JG, Smith BL, Humphries JR. Radiation 7. exposure and associated risks to operating room personnel during use of fluoro-scopic guidance for selected orthopaedic surgical procedures. J Bone Joint Surg Am. 1983;65(1):1-4.Riley SA. Radiation exposure from fluoroscopy during orthopedic surgical proce-8. dures. Clin Orthop Relat Res. 1989;(248):257-60.Sanders R, Koval KJ, DiPasquale T, Schmelling G, Stenzler S, Ross E. Exposure of 9. the orthopaedic surgeon to radiation. J Bone Joint Surg Am. 1993;75(3):326-30.Skjeldal S, Backe S. Interlocking medullary nails-radiation doses in distal targeting. 10. Arch Orthop Trauma Surg. 1987(3);106:179-81.Krettek C, Könemann B, Farouk O, Miclau T, Kromm A, Tscherne H. Experimental 11.

study of distal interlocking of a solid tibial nail: radiation-independent distal aiming de-vice (DAD) versus freehand technique (FHT). J Orthop Trauma. 1998;12(6):373-8.Jones DP, Robertson PA, Lunt B, Jackson SA. Radiation exposure during fluoroscopical-12. ly assisted pedicle screw insertion in the lumbar spine. Spine. 2000;25(12):1538-41.Perisinakis K, Theocharopoulos N, Damilakis J, Katonis P, Papadokostakis G, Had-13. jipavlou A, et al. Estimation of patient dose and associated radiogenic risks from fluoroscopically guided pedicle screw insertion. Spine. 2004;29(14):1555-60.Ul Haque M, Shufflebarger HL, O’Brien M, Macagno A. Radiation exposure during 14. pedicle screw placement in adolescent idiopathic scoliosis: is fluoroscopy safe? Spine. 2006;31(21):2516-20.Giachino AA, Cheng M. Irradiation of the surgeon during pinning of femoral fractures. 15. J Bone Joint Surg Br. 1980;62(2):227-9.Dosch JC, Dupuis M, Beck G. Strahlungsmessungen bei Verriegelungsnagelungen. 16. Hefte Unfallheilk. 1983;161:36-8.Kirousis G, Delis C, Megas P, Panayiotakis G, Lampiris E. Intraoperative radiation 17. exposure during tibial intramedullary nailing procedures. J Bone Joint Surg Br. 2001;83(Suppl 2):131.Fuchs M, Schmid A, Modler H, Dumont C, Stürmer KM. How to reduce radiation ex-18. posure of the surgion during surgery. J Bone Joint Surg Br. 1999;81(Suppl 2):182.Fuchs M, Schmid A, Eiteljörge T, Modler M, Stürmer KM. Exposure of the surgeon 19. to radiation during surgery. Int Orthop. 1998;22(3):153-6.Levin PE, Schoen RW, Browner BD. Radiation exposure to the surgeon during closed 20. interlocking intramedullary nailing. J Bone Joint Surg Am. 1987;69(5):761-6.Krettek C, Konemann B, Miclau T, Schandelmaier P, Blauth M, Tscherne H. A new 21. technique for the distal locking of solid AO unreamed tibial nails. Orthop Trauma. 1997;11(6):446-51.

rEfErENCES


in the surgical room during the intramedullary locked nail procedure and the distance of the radiation ampoule from the patient. Sanders et al(9) analyzed the exposure to radiation during insertion of intramedullary nails into the femur and tibia. Because of greater muscle mass, the femur was associated with greater diffusion of ra-diation that the tibia was. This was because the tibia is smaller than the femur, the bone location is subcutane-ous and it is easier to reduce this bone and insert the locking screws. According to Sanders et al(9), insertion of intramedullary screws required significantly greater duration of fluoroscopy (mean duration of 3.6 minutes) than was required for other types of procedure (mean duration of 2.1 minutes). In our study, among the entire sample, comparing the duration of exposure to radiation between the nails and plates, the nails presented a mean duration of radiation (129.1 seconds) that was signifi-cantly greater than that of the plates (68.5 seconds).

In the present study, the tibial fractures treated were in the distal third in both groups. For the fractures treated using intramedullary locked nails, the locking consisted of two proximal screws and two distal screws, while for the plates, there were three proximal and three distal screws. We observed that there was a significant differ-ence in the duration of exposure to radiation when we treated the tibial fractures using intramedullary locked nails, as also demonstrated in the literature(9,11,17-21). It should be noted that, in comparing the duration of radia-

tion between the nails and plates used for fractures of the distal third of the tibia, the nails presented greater duration of radiation that that of the plates because of the need to find the ideal entry point for introducing them into the proximal region and for the distal blocking, which was done freehand. Krettek et al(11) diminished the duration of exposure to radiation by using a distal fixation device (DAD) for the distal region, thereby de-creasing the duration of radiation.

In using the AO fracture classification to investigate whether the type of fracture would influence the duration of exposure to radiation, there was no significant differ-ence between the nail and plate groups. In the groups that was treated using intramedullary nails, a tendency towards occurrences of greater radiation with the frac-ture types of greater severity (B and C), but this was not observed in the group of fractures that were treated using bridge plates. We did not find any studies in the literature (PubMed) that compared the duration of ex-posure between intramedullary nails and bridge plates, with regard to distal fractures of the tibia.

CONCLUSiONWe conclude that the duration of exposure to radia-

tion was significantly greater when using intramedullary locked nails than it was when using bridge plates, for treating fractures of the distal third of the tibia, inde-pendent of the type of fracture.

FRACTURES OF THE DISTAL ExTREMITY OF THE TIBIA TREATED WITH INTRAMEDULLARY NAIL OR BRIDGE PLATE: COMPARISON OF RADIATION ExPOSURE DURATION BETWEEN THE TWO METHODS

artigo 66

1 – PhD. Assistant Professor in the Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo; Head of the Shoulder and Elbow Surgery Group.

2 – Assistant Professor in the Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo; Attending Physician in the Shoulder and Elbow Surgery Group.

3 – Attending Physician in the Shoulder and Elbow Surgery Group.4 – Trainee Physician in the Shoulder and Elbow Surgery Group.5 – PhD. Adjunct Professor and Head of Clinical Medicine of the Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo;

Academic Consultant in the Shoulder and Elbow Surgery Group.

Work performed in the Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo; “Pavilhão Fernandinho Simonsen” – Director: Professor Dr. Osmar Avanzi.Correspondence: Santa Casa de Misericórdia de São Paulo, Departamento de Ortopedia e Traumatologia, “Pavilhão Fernandinho Simonsen”, Rua Dr. Cesário Mota Júnior 112, Vila Buarque, 01220-020 São Paulo, SP – E-mail: [email protected] – Site: www.ombro.med.br


OriGiNaL arTiCLE

EVALUATION OF THE rESULTS FrOM ArTHrOScOPIc TrEATMENT OF THE LATErAL EPIcONDYLITIS

Alberto Naoki Miyazaki1, Marcelo Fregoneze2, Pedro Doneux Santos3, Luciana Andrade da Silva3, Davi Calixto Pires4, Jose da Mota Neto4, Luis Henrique Rossato4, Sergio Luis Checchia5


iNTrODUCTiON

Lateral epicondylitis is the most common disorder of the elbow(1) and can be triggered by trauma or repetitive effort(2). It was first described as an occupational disease in 1880(1,3). With regard to its etiology, several theories exist, including: bursitis, synovitis, ligament inflamma-tion, periostitis and lesions of the short radial extensor tendon of the carpus(2).

In 1979, Nirschl and Pettrone(4) histologically iden-tified areas that are primarily affected by lateral epicon-dylitis in the short radial extensor tendon of the carpus and, to a lesser degree, in the anteromedial face of the common extensor of the fingers. These lesions would be the result from applying continuous and repeated trac-

abSTraCTObjective: To evaluate the results from patients with lateral epicondylitis following surgical treatment using the arthros-copy technique. Methods: Twenty patients underwent surgery using the arthroscopic technique. Their ages ranged from 19 to 54 years (average of 41 years and eight months). Twelve (60%) of them were female and eight (40%) were male. The minimum follow-up period was 12 months and the maximum was 48 months, with an average of 20 months. All the cases were refractory to conservative treatment (rest and physiotherapy), with previous clinical treatment times ranging in duration from

six to 136 months. To evaluate the results, we used the crite-ria of the American Medical Association (AMA), as modified by Bruce. Results: We obtained 13 excellent results (65%) and seven moderate results (13%), with just one complication (reflex sympathetic dystrophy). This was the only patient who reported dissatisfaction. Conclusion: Surgical treatment of the lateral epicondylitis of the elbow using arthroscopy was a good option for 65% of the cases.

Keywords – Arthroscopy; Tennis elbow; Outcome assessment (Health Care)

tion, thereby leading to microtears originating from the short radial extensor tendon of the carpus, followed by fibrosis and formation of granulation tissue. Macrosco-pically, the appearance of the tissue was friable, shiny and edematous. They also found that the tendon was not inflamed, but had degenerated. For this reason, they introduced the term angiofibroblastic hyperplasia to des-cribe the microscopic appearance of the lesion, which has been accepted up to the present day, along with their etiological theory(2-4).

Lateral epicondylitis most commonly affects indi-viduals between the ages of 35 and 60 years and gener-ally occurs among males and in the dominant limb. It also occurs more frequently in whites(1).

On physical examination, patients report localized pain

137


on palpation at the origin of the extensors, and can often precisely determine its location. The point with the great-est pain may be located in the region anterior and distal to the lateral epicondyle of the humerus(5).

Diagnostic confirmation using imaging examina-tions is unnecessary. If a magnetic resonance exami-nation is requested, signal abnormalities can be seen at the origin of the short radial extensor tendon of the carpus(1). In 25% of the patients, calcifications may ap-pear in tissues adjacent to the epicondyle, particularly if there have been previous infiltrations of steroids at this location(6).

Most patients respond to conservative treatment. Only 5 to 10% evolved with chronification of the symptoms(1,7). If the symptoms persist, surgical treat-ment may be indicated. Open, percutaneous and endo-scopic procedures have been described(5,6,8). Baker et al(8) introduced arthroscopic release of the origin of the short radial extensor tendon of the carpus.

The aim of the present study was to evaluate the results from arthroscopic surgical treatment for reliev-ing pain caused by lateral epicondylitis, among patients who were refractory to nonsurgical treatment, along with their return to their previous work and sports ac-tivities.

SaMPLE aND METhODS

Between August 1998 and March 2006, 20 patients with lateral epicondylitis underwent operations per-formed by the Shoulder and Elbow Group of the De-partment of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo, “Pavilhão Fernandinho Simonsen”.

All patients with a diagnosis of lateral epicondylitis who had not improved with clinical treatment over a minimum period of six months and had then undergone arthroscopic surgical treatment were retrospectively in-cluded in this series. Patients who did not fit within these criteria were excluded from the sample.

These patients’ ages ranged from 19 to 54 years (mean of 41 years and eight months). There were 12 female patients (60%) and eight male patients (40%). All the patients were right-handed and the dominant arm was operated in 13 cases (65%). The etiological cause of the lateral epicondylitis was repetitive effort in 14 cases (70%), non-sports injuries in five cases (25%) and mixed origins in one case (5%). The minimum follow-

up was 12 months and the maximum was 48 months, with a mean of 20 months (Table 1).

The patients were primarily treated with rest and physiotherapy. Thirteen patients (65%) underwent in-filtration of corticoids, with a minimum of one and ma-ximum of three applications (mean of two). One patient had undergone previous open surgical treatment at ano-ther service 11 years earlier, with complete remission of the symptoms. However, the condition recurred nine years later. The duration of clinical treatment had ran-ged from six months to 136 months, with a mean of 28.5 months (Table 1).

The patients underwent the operation positioned in ventral decubitus. Firstly, a posterolateral port was cre-ated between the olecranon and the lateral epicondyle, in order to position the arthroscope. Next, an inventory of the posterior compartment was made and any lesions that might be present there were treated (cases 6, 7, 14, 17 and 20). Through a proximal anteromedial port, the anterior compartment was explored and the best positioning for the anterolateral port was located under direct viewing, in order to introduce the arthroscopic blade to the soft tissues (Figure 1). Partial resection of the anterolateral capsule, identification and resection of the angiofibroblastic tissue and partial deinsertion of the extensor musculature were started through this port. In all cases, decortication of the anterior region of the lateral epicondyle was performed using an arthroscopic bit (Figure 2).

Postoperative evaluations were performed two, four and six weeks and three, six and twelve months after the operation. Analgesics were prescribed over the first two weeks and the patients’ operated arm was kept in a sling. Active movements were encouraged during the postoperative period. No specific physiotherapy was indicated.

To evaluate the results, we used the criteria of the American Medical Association (AMA), as modified by Bruce et al(9) (Box 1).

The results were compared statistically in relation to the variables of sex, profession and sports practice. For this, we used the SPSS software (Statistical Package for the Social Sciences), version 13.0, to obtain results. We applied Fisher’s exact test with the aim of investigating the degree of association between the variables of inte-rest. We took the significance level to be 5% (0.05), in order to validate the results.

EVALUATION OF THE RESULTS FROM ARTHROSCOPIC TREATMENT OF THE LATERAL EPICONDYLITIS

138

figure 1 – Arthroscopic image of the right elbow showing: Cp = ante-rolateral joint capsule, Ca = capitellum, Cr = head of radius, and angio-fibroblastic tissue (arrow).

figure 2 – Arthroscopic image of the right elbow showing: FM = muscle fascia, Ca = capitellum, angiofibroblastic tissue (arrow), and stippled area = area of debrided angiofibroblastic tissue.


rESULTS

Among the 20 patients who underwent operations us-ing the arthroscopic technique, we obtained 13 excellent results (65%) and seven moderate results (35%). Only one patient lost points regarding the criterion of range of

Table 1 – Clinical data on the patients

Age Sex Dominance Profession SportClinical

treatmentInfiltration

Previous surgery

Length of follow-up

Intra-articular lesions

BRUCEComplications

ROM ADLs Pain Anatomy Total

1 50 M + Storeman 17 m 12 m 60 20 15 5 100

2 44 F Operator 16 m 1 12 m 60 20 15 5 100

3 47 F + Accounting analyst 41 m 2 13 m 60 20 13 5 98

4 31 M + Dentist Tennis 7 m 1 18 m 60 20 15 5 100

5 46 M + Boilermaker 136 m 18 m 60 20 15 5 100

6 41 F + Housewife 17 m 26 m HSF 60 20 15 5 100

7 26 M Financial analyst Volleyball 13 m 2 18 m HSF 60 20 15 5 100

8 30 M + Engineer Tennis 11 m 18 m 60 20 15 5 100

9 53 M + Engineer Tennis 36 m 30 m 60 20 15 5 100

10 54 F + Cleaner 42 m 2 13 m 60 20 13 5 98

11 52 M + Lawyer Tennis 14 m 2 24 m 60 20 15 5 100

12 43 F Housewife 22 m 1 38 m 60 20 15 5 100

13 45 F + Systems analyst 72 m 2 13 m 60 20 15 5 100

14 37 F Nursing auxiliary 25 m 18 m HSF 54 15 10 5 84

15 44 M Driver Fishing 46 m 12 m 60 15 5 5 85

16 45 F Cleaner 7 m 3 26 m 60 10 10 5 85

17 46 F + Nursing auxiliary 24 m 3 yes 48 m HSF 60 15 5 5 85

18 38 F + Cook 10 m 2 13 m 60 10 5 5 80 RSD

19 44 F Cleaner 6 m 3 18 m 60 15 5 5 85

20 19 F + Student 12 m 2 12 m HSF 60 15 5 5 85 Source: Same-DOT ISCMSPLegend: M = male, F = female, m = months, ROM = range of motion, ADLs = activities of daily living, HSF = hypertrophy of the synovial fold, RSD = reflex sympathetic dystrophy

139

box 1 – AMA criteria, as modified by Bruce et al(8)

1)Rangeofmotion(ROM)–60points:

Number of points for ROM = 60 – (percentage incapacity of the upper limb x 0.6)

2) Activitiesofdailyliving(ADLs)andprofessionalstatus–20points:

Function of affected arm is symmetrical to contralateral arm – 20 points Independent in relation to ADLs (not more than two manual limitations) – 15 points Incapacity regarding three or more ADLs (need to change occupation) – 10 points Incapacity regarding four or more ADLs (functional incapacity) – 5 points

3) Pain–15points:

Free from pain – 15 points Slight pain without functional impairment – 13 points Pain with functional impairment – 10 points Pain with limitation regarding some ADLs – 5 points Incapacitating pain – 0 points

4) Anatomy–5points:

Acceptable cosmetic appearance – 1 point Without clinical angling – 1 point Without clinical luxation – 1 point Clinical change in carrying angle < 10º – 1 point Radiological consolidation – 1 point

Results(total:100points):Excellent: 96-100Good: 91-95Moderate: 81-90Poor: < 80

Legend: AMA: American Medical Association; ROM: range of motion; ADLs: activities of daily living


motion (Table 1). One patient presented the complica-tion of reflex sympathetic dystrophy (RSD) (case 18). When the patients were asked how satisfied they were regarding the results from the surgery, only the patient who evolved with RSD expressed dissatisfaction.

Only one patient (case 17; Table 1) had undergone previous surgery, carried out by means of the open route at another service. This patient had evolved well for nine years, but then started to present symptoms again. Despite intermittent clinical treatment for two years, there was no improvement in the symptoms. This in-dividual then underwent arthroscopic treatment with a moderate result.

The statistical results from correlating sex versus results, profession versus results and sports practice versus results were as follows, respectively: p = 0.158, p = 0.158 and p = 0.354, and these associations were therefore not statistically significant.

DiSCUSSiON

The controversies regarding surgical treatments for lateral epicondylitis continue until today. The ar-throscopic technique makes it possible to perform exci-

sion at the origin of the extensor tendons involved in this disease, and to view and treat any associated intra-articular lesions, thereby promoting an early return to habitual activities(6,10).

Good results have also been reported using the tra-ditional open techniques, but these techniques do not locate the associated intra-articular lesions. Such lesions are present in 11% to 69% of the cases(4,6,10).

In our series, we found intra-articular lesions in 25% of the patients, which was compatible with the litera-ture, and we were able to treat them immediately, during the same procedure.

We obtained excellent results in 65% of our cases, which is compatible with some studies in the literature, in which 62% of the patients were found to be relatively free from pain, while 10%, despite expressing satisfac-tion, continued to present pain in some activities of daily living(6). Cohen and Romeo(1) observed the pres-ence of moderate to severe pain in 24% of their pa-tients, one year after open and/or arthroscopic surgery. Two years after surgery, 33% presented moderate and poor results(1). From open surgery, Verhaar et al(11) also presented similar results, with 69% of their patients ex-pressing satisfaction, either without pain or with slight pain when performing activities. Likewise, Nirschil et al(4) found that 97.7% of their patients reported improve-ments in pain levels, although only 85.2% of them were able to fully return to their previous activities.

The 13 patients (65%) in our sample who were clas-sified as presenting excellent results were satisfied with their treatment. Among the seven (35%) who evolved with moderate results, six (30%) also expressed satis-faction with their evolution but did not manage to fully return to their previous activities.

We had one patient (5%) who evolved with reflex sympathetic dystrophy of the operated arm, which was considered to be a complication, and this individual was dissatisfied with the result (Table 1).

In the literature, we found some studies that showed up to 100% excellent results from the arthroscopic tech-nique, which did not occur among out sample(6,7).

Taking pain into consideration as an evaluation criterion, we noted that our results were dissimilar to those in the literature. The lack of a specific evaluation scale for the results from treating epicondylitis(7) and the differences between the evaluation criteria used in various studies may explain this result. We can take

EVALUATION OF THE RESULTS FROM ARTHROSCOPIC TREATMENT OF THE LATERAL EPICONDYLITIS

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Cohen MS, Romeo AA. Lateral epicondylitis: open and arthroscopic treatment. 1. J Hand Surg Am. 2001;3(1):172-6.

Owens BD, Murphy KP, Kuklo TR. Arthroscopic release for lateral epicondylitis. 2. Arthroscopy. 2001;17(6):582-7.

Nirschl RP. Lateral tennis elbow. Tech Shoulder Elbow Surg. 2000; 3. 1(3):192-200.

Nirschl RP, Pettrone FA. Tennis elbow: the surgical treatment of lateral epicon-4. dylitis. J Bone Joint Surg Am. 1979;61(6):832-9.

Lech O, Piluski PCF, Severo AL. Epicondilite lateral do cotovelo. Rev Bras 5. Ortop. 2003;38(8):421-35.

Baker CL Jr, Murphy KP, Gottlob CA, Curd DT. Arthroscopic classification and 6. treatment of lateral epicondylitis: two-year clinical results. J Shoulder Elbow Surg. 2000;9(6):475-82.

Zoppi Filho A, Vieira LAG, Ferreira Neto AA, Benegas E. Tratamento artroscópi-7. co da epicondilite lateral do cotovelo. Rev Bras Ortop. 2004;39(3):93-101.

Baker CL Jr, Shalvoy RM. The prone position for elbow arthroscopy. Clin Sports 8. Med. 1991;10(3):623-8.Bruce HE, Harvey JP, Wilson JC Jr. Monteggia fractures. J Bone Joint Surg 9. Am. 1974;56(8):1563-76.Smith AM, Castle JA, Ruch DS. Arthroscopic resection of the common extensor 10. origin: anatomic considerations. J Shoulder Elbow Surg. 2003;12(4):375-9.Verhaar J, Walenkamp G, Kester A, van Mamerem H, van der Linden T. Lateral 11. extensor release for tennis elbow: a prospective long-term follow-up study. J Bone Joint Surg Am. 1993;75(7):1034-43.Coonrad RW, Hooper WR. Tennis elbow: its course, natural history, conservative 12. and surgical management. J Bone Joint Surg Am. 1973;55(6):1177-82.Morrey BF. Reoperation for failed surgical treatment of refractory lateral epicon-13. dylitis. J Shoulder Elbow Surg. 1992;1(1):147-55.Kalainov DM, Cohen MS. Posterolateral rotatory instability of the elbow in as-14. sociation with lateral epicondylitis. A report of three cases. J Bone Joint Surg Am. 2005;87(5):1120-5.

rEfErENCES


the view that the moderate classification for six of our cases (30%) was ascribed to these cases because of the criteria that we adopted, which were more rigorous with regard to evaluating the activities of daily liv-ing (Table 1). Patient number 17, who had undergone previous surgery 11 years earlier, remained free from symptoms for nine years before manifesting the con-dition again, but we do not believe that the previous surgery influenced the recurrence, or the result from the present treatment.

According to the literature, patients who present le-sions that may mean taking time off work tend to have worse evolution with regard to the criteria of activities of daily living, work and/or sports, in comparison with sports players(4,6,11). In our study, in the group of seven patients with results classified as moderate, six patients were on sick leave from their jobs and were receiving sickness benefit. Even though not presenting statistical significance, we observed better results in relation to returning to work and/or sports activities among the patients whose etiology for epicondylitis was associ-ated with sports practices(7,10,12).

We agree with Morrey(13) and believe that persistence of pain may be due to erroneous selection of patients for operations (work-related causes) or initial diagnostic er-ror, or even because changes caused by the disease were

not fully corrected during the surgery. Cases in which good results are not obtained need to be reassessed.

Excluding the patients who did not obtain secondary gains with the disease, we could see that arthroscopic treatment for lateral epicondylitis offered a series of ad-vantages: intra-articular diseases could be assessed and treated; debridement of the short radial extensor tendon of the carpus could be performed without dividing the fibers of the aponeurosis of the common extensor of the fingers; the rehabilitation period was short; and, furthermore, there was the possibility of adding an open procedure, if required (although we did not have this need). This was exactly what Cohen and Romeo(1) and Baker et al(6) observed in their respective studies.

The disadvantages relating to the endoscopic method are the risks of neurovascular lesions occurring at the time of constructing the ports(14) and of posterolateral ligament lesions of the elbow. Such lesions may be one of the causes of failure of surgical treatment of this disease(10,13,14). These complications are rare and did not occur in our study.

CONCLUSiONSurgical treatment for lateral epicondylitis of the

elbow using the arthroscopic technique was a good op-tion, with satisfactory results in 65% of the cases.

artigo 161

1 – Professor of the Department of Orthopedics and Traumatology and Head of the Foot Surgery Group, State University of Campinas (Unicamp), Campinas, SP; Attending Physician at the Institute of Orthopedics and Traumatology, Hospital das Clínicas, School of Medicine, University of São Paulo (USP) São Paulo, SP, Brazil.

2 – Attending Physician in the Foot Surgery Group, State University of Campinas (Unicamp), Campinas, SP; Attending Physician in the Foot and Ankle Group, Orthopedics Service of the Celso Pierrô Hospital and Maternity Hospital, Catholic Pontificate University of Campinas (PUC), Campinas, SP, Brazil.

3 – Emeritus Professor of the Department of Orthopedics and Traumatology, Hospital das Clínicas, School of Medicine, University of São Paulo (USP), São Paulo, SP, Brazil.4 – Head of the Department of Orthopedics and Traumatology, State University of Campinas (Unicamp), Campinas, SP; Professor in the Department of Orthopedics and

Traumatology and Head of the Knee Surgery Group, State University of Campinas (Unicamp), Campinas, SP, Brazil.5 – Trainee Physician in the Foot Surgery Group, State University of Campinas (Unicamp), Campinas, SP, Brazil.6 – Trainee Physician in the Foot Surgery Group, State University of Campinas (Unicamp), Campinas, SP, Brazil.

Work developed in the Department of Orthopedics and Traumatology, School of Medicine, State University of Campinas (Unicamp), Campinas, SP, Brazil.Correspondence: Rua Guarara 261, apto. 82, Jd. Paulista, 01425-001 São Paulo, SP – E-mail: [email protected]


OriGiNaL arTiCLE

TENDINOPATHY OF THE ANTErIOr cOMPArTMENT OF THE ANkLE

Antonio Egydio de Carvalho Junior1, Cíntia Kelly Bittar2, Osny Salomão3, João Batista Miranda4, André Ninomiya5, Daniel Bento Silva6


iNTrODUCTiONThe anterior compartment of the ankle delimits a tun-

nel such that its floor corresponds to the anterior face of the metaphysis of the tibia and its roof (also inelastic) is formed by the expansion of the anterior retinacular liga-ment and its corresponding upper and lower bundles. The tendons of the anterior tibial muscle, long extensor muscle of the hallux and long extensor muscle of the toes pass through this segment in their respective synovial sheaths, along with the vasculonervous bundle. Pressure increases inside the tunnel may result from tenosynovitis, tearing, anatomical variations, capsule expansion, anterior mar-ginal osteophytes of the tibia, etc. The deep fibular nerve may be compromised and cause pain and dysfunction.

abSTraCTObjective: To carry out a retrospective analysis on the etio-pathogenesis, diagnosis and therapeutic options in cases of ten-dinopathy of the anterior compartment of the ankle. Method: 13 patients underwent surgery between September 1998 and February 2009; ten men and three women. The right side was involved in twelve patients and the left in one. The mean age was 35 years (range 15-67). The etiology was traumatic in eight patients and degenerative (non-traumatic) in five. The mean time elapsed between diagnosis and treatment was 19 months (range 1 - 60) and the mean length of follow-up was 34 months (range 4 - 127). The diagnosis was made through anamnesis and clini-cal examination. Magnetic resonance imaging was performed on nine patients, for staging and planning. The surgical treatment

was personalized in each case (synovectomy, resection of the muscle belly, consolidation with the adjacent tendon, and free grafting of the semitendinosus tendon). The following scales were used to evaluate the results: 1) subjective satisfaction scale, 2) AOFAS and 3) Maryland. Results: In relation to the subjective satisfaction scale, 12 patients were satisfied and one was dis-satisfied. The mean AOFAS score was 80 points, and the mean Maryland scale was 86 points. Conclusion: Surgical treatment is effective for restoring function. The surgical techniques need to be personalized. The option of free grafting of the semitendinosus tendon is effective for gaps larger than five centimeters.

Keywords – Anterior compartment syndrome; Tendinopathy; Orthopedic surgery; Tendon transfer

The diagnosis of tendon rupture is confirmed by the pain and by weakness in extending the ankle and toes(1).

Magnetic resonance imaging has been used in a com-plementary manner to recognize the possible lesions and their staging. In cases of rupture, the image identifies the distance between the two stumps and the intrinsic degree of tendon stretching (overstretching), which are useful pieces of information for therapeutic planning. Even though rare, occurrences of tendinopathy in this compartment may be underestimated or may be difficult to diagnose when pre-senting few symptoms. Late diagnosis should be differ-entiated from other findings such as arthrosynovial cysts, tumor syndromes of the anterior part of the ankle and com-pressions of the deep fibular nerve(2).

142

figure 1 – Clinical signs: A) Frontal appearance – loss of relief on the path of the anterior tibial tendon; B) Lateral appearance – vicariance of the undamaged tendons.

figure 2 – Magnetic resonance image: A) Sagittal projection: teno-synovitis of the long extensor tendon of the toes; B) Axial projection: inflammatory process around the extensor tendon of the toes.


The therapeutic possibilities are restricted to the symptoms and functional incapacities, without taking into consideration age, sex, level of activity, comor-bidities or delays in the diagnosis. For properly staged complete ruptures, surgical treatment is several authors’ preferred method(1,3,4). However, Markarian et al(5), Bur-man (1934) and Moskowitz (1971) apud Kashyap and Prince(2) reported good results from conservative treat-ment of tendinopathy and affirmed that nonsurgical treat-ment could be a good alternative for elderly patients with low functional demands.

The purpose of the present study was to describe the arsenal of surgical tactics used for treating tendinopathy of the anterior compartment. The surgical techniques used were tendon debridement, resection of the anoma-lous muscle belly and consolidation, along with free grafting of the semitendinosus tendon in cases of gaps greater than five centimeters.

ObjECTiVETo retrospectively analyze the etiopathogenesis, di-

agnosis and treatment options in cases of tendinopathy of the anterior compartment of the knee.

SaMPLE aND METhODSBetween September 1998 and February 2009, 14 pa-

tients were diagnosed with tendinopathy of the anterior compartment of the ankle. Surgical treatment was indi-cated for 13 patients and there was one case of conserva-tive treatment due to partial injury of the extensor tendon of the toes. In this study, the inclusion criterion limited the sample to the patients who underwent operations.

The sample therefore consisted of 10 male patients and three female patients. The right side was affected in 12 cases and the left was affected in one case. The patients’ mean age was 35 years (range 15-67).

The etiology was traumatic in eight patients, and the others were considered to be non-traumatic origin: indi-cations of degenerative in two cases and inflammatory processes in three cases.

The mean time that elapsed between making the diag-nosis and instituting the treatment was 19 months (range 1-60) and the mean length of follow-up was 34 months (range 4-127).

For both the acute and the chronic cases of rupture, the diagnosis was made through the history and clinical examination. Among the chronic cases, a trio of signs

was investigated: 1) nodulation, corresponding to hy-pertrophy of the proximal stump of the injured tendon; 2) loss of outline of the tendons under the extensor reti-naculum; and 3) vicariance of the complete tendons(1) (Figure 1).

Magnetic resonance was performed on nine pa-tients for staging of the lesion and surgical planning (Figure 2).

The distribution of the etiopathogenesis in the five non-traumatic cases was as follows: 1) one case of vil-lous-nodular synovitis and low positioning of the muscle belly in the anterior tibial tendons and long extensors of the toes; 2) one case of chronic tenosynovitis of the long extensors of the toes; 3) one case of accessory muscle of the anterior tibial tendon; and 4) two cases of degenera-tive rupture of the anterior tibial tendon.

Among the patients without ruptures (2, 3 and 5), the common factors were female gender, similar age range (young adult) and practices of strenuous physical activities. The physical examinations on these patients showed that pain was the symptom present in the ante-rior compartment, and that it radiated outwards to the

143


figure 3 – Magnetic resonance image: A) In the axial plane; B) In the sagittal plane, showing low muscle belly and intra-articular tumor.

A B

figure 4 – A) Low positioning of the muscle belly; B) Resection of the anomalous muscle.

A B

figure 5 – A) Opening of the joint capsule and resection of the villous-nodular tumor; B) Specimens removed.

A B

dorsal region of the foot along the path corresponding to the deep fibular nerve, as shown by Tinel’s sign. The functional incapacity was a consequence of the inflam-matory process and anatomical variations, which acted as compression factors due to increased content within an inelastic space.

The non-traumatic cases (6 and 7) were male patients over the age of 60 years who presented spontaneous ruptures of the anterior tibial tendon while walking. The clinical examinations showed the characteristic trio of changes to the outline, vicariance of the adjacent com-plete tendons and nodulation. The etiopathogenesis was attributed to a nonspecific degenerative factor.

In the trauma group, there was reference to cutting and bruising wounds. Functional impotence regarding dorsiflexion of the ankle or toes was the sign present. In case 13, there was loss of substance (all the skin and segments of the anterior tibial tendon and long extensor tendon of the hallux).

The topographic impairment of the affected tendons consisted of the following:

a) Three isolated ruptures of the anterior tibial tendon;b) Two isolated complete ruptures of the long exten-

sor tendon of the toes;c) Two ruptures of the anterior tibial tendon in as-

sociation with the long extensor tendon of the toes; and

d) One complete rupture of the anterior tibial ten-don in association with partial injury of the long extensor tendons of the hallux and toes.

TrEaTMENTIn the non-traumatic group, without rupture, after lack

of success with conservative treatment, surgical explora-tion was indicated. Among the individuals who presented ruptures of degenerative cause, one patient voluntarily postponed the initial surgical indication until he felt the need for it, and the other waited for a 30-day period with plaster-cast immobilization.

Delays in the operation, among the trauma cases, oc-curred because of a variety of factors, such as delay in achieving a precise diagnosis, patient negligence and late start of the symptoms.

In patient 13, the surgery was delayed because of the condition of the soft tissue. Tendon grafts and a microvascular flap were needed in order to cover the skin, concomitantly with the tendon repair.

The surgical tactic used in case 2 was resection of the belly of the anterior tibial muscle and release of the deep fibular nerve. In case 3, the decompressive surgery consisted of release of the deep fibular nerve, resection of muscle belly and synovectomy (intra-articular tumor ablation) (Figures 3, 4 and 5).

TENDINOPATHY OF THE ANTERIOR COMPARTMENT OF THE ANKLE

144


In case 5, resection of the tendon sheath and synovec-tomy of the long extensor of the toes was performed.

In all the cases of rupture due to cutting wounds or degeneration, reconstruction of the tendons was per-formed through consolidation with the adjacent tendon (cases 1, 4, 6, 8 and 9) or through free grafting of the semitendinosus (cases 7, 10, 11, 12 and 13). In these cases, the gap between the tendon stumps after debride-ment was greater than five centimeters.

The surgical technique for free grafting of the semi-tendinosus tendon consisted of the following:

1. Identification and removal of the semitendinosus tendon of the ipsilateral knee (Figure 6A).

2. Preparation of the graft (Figure 6B).3. Oblique anteromedial incision, starting six cen-

timeters proximally to the joint line and heading obliquely as far as the talonavicular joint, over the path of the anterior tibial tendon (Figure 6C).

4. Opening of the retinacula (Figure 6D).5. Debridement and preparation of the tendon stumps

(Figure 6E).6. Tendinoplasty with free grafting to join together

the stumps and tubularization (Figure 6F).7. Closure of the retinacula (Figure 6G).8. Immobilization in dorsiflexion.

To evaluate the results, three scales were used: subjective satisfaction grading, AOFAS and Maryland.

Table 1 presents the general analysis of this study.

rESULTS

In relation to the subjective satisfaction grading scale (presence or absence of pain and satisfactory or unsatis-factory functional result), 12 patients were satisfied and one was dissatisfied. The latter case presented dehis-cence of the skin and recurrence of the rupture, thereby indicating the need for a new surgery. However, the pa-tient refused to undergo this.

Patient 13 presented muscle weakness in the recon-structed anterior tibial tendon, because of the short follow-up and adherence of soft tissues. However, because of the previous severity of the condition and expectations of functional deficit, this patient felt satisfied with the result.

The mean score on the AOFAS scale after the opera-tion was 80 points, with a range from 51 to 90 points.

The mean score on the Maryland scale was 86 points, with a range from 62 to 95 points.

Table 2 correlates the results obtained with the intra-operative findings.

DiSCUSSiONIn this retrospective study, the 13 patients presented

formed a small case series. Nonetheless, this was a sig-nificant sample in the light of the sizes of other authors’ samples. Kausch and Rutt(4) reviewed 33 cases compiled from the current literature. Most of the studies consisted of case series, and the largest was by Bernstein apud Velan and Hendel(6), citing 24 cases. Results from sur-gical treatment on ruptures of the anterior tibial tendon were presented by Markarian et al(5), among a series of 16 patients, and likewise by Sammarco et al(7), among a sample of 19 patients.

The ages among the present series of patients with tendi-nopathy of the anterior compartment, of various etiologies and on different tendons, ranged from 19 to 67 years.

Taking into consideration only the degenerative factor, Pattern and Pun(8) reported in their review of the literature that the cases were predominantly among individuals in their sixth and seventh decades of life, with rupture of the anterior tibial tendon. Our sample showed that 18% of the patients fitted into this age range. Ouzonian and Anderson(1) and Markarian et al(5) considered that age was a decisive factor in selecting patients for either conserva-tive or surgical treatment. In the present sample, surgical treatment was chosen for the different age groups.

In the present study, like in previous reports, cases among males were more prevalent(1,6,9,10).

Chronic tendinopathy of the anterior compartment of the ankle results from different etiologies. The most prevalent etiopathogenesis for the tendon ruptures in the present series was traumatic, consisting of laceration due to cutting and bruising wounds. Rimoldi et al(3) reported cases of traumatic rupture due to sudden isotonic con-traction or tendon stretching due to excessive plantar flexion. The disorders of non-traumatic origin considered in this sample resulted in chronic tendinopathy through a degenerative or inflammatory process of various etiolo-gies: rubbing, repeated movements, synovial disease, an-atomical variation (elongated or accessory muscle belly), etc. Clinical investigations on systemic diseases such as diabetes, hyperparathyroidism, liver disease, rheumatic disease, gouty tophus, etc., along with the use of corti-coid therapy, have been recommended since these condi-tions have been found in other series with impairment of the tendons of the anterior compartment(5,6,10,11).

The common denominator of the spontaneous rupture of the anterior tibial tendon in two cases was weakening due to a degenerative process (antecedents of tendinopa-thy) (cases 6 and 7).

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figure 6 a – Identification of the semitendinosus tendon. b – Preparation of graft. C – Oblique anteromedial incision. D – Opening of the retinaculum. E – Debridement and preparation of the tendon stumps. f – Tendinoplasty with free grafting to join the stumps together, with tubularization. figure 6G – Closure of the retinaculum.

F G

D E

B C

A A


146


The clinical signs that showed the tendon ruptures were the following: 1) changes in gait (drop foot due to deficit of the anterior tibial tendon and painful claudica-tion); 2) loss of completeness found through palpation of the tendons; 3) change in the relief of the anterior compartment; and 4) weakness in the dorsiflexion test against resistance of the foot or toes.

According to Ouzoniam and Andreson(1), the time that elapses between the injury and its diagnosis is

greater in cases of non-traumatic etiopathogenesis, since these patients generally do not have complaints of pain and the functional incapacity is insignificant because of the low demand for activity. In the two cases of de-generative rupture in the present series, early diagno-ses were made, but the patients voluntarily delayed the indication of surgery until a time when there was both loss of function and pain complaints.

Cases 1 and 4, which were cases of traumatic rup-ture, were in young patients who despite immediate diagnosis, were only treated later on when there was interest in improvement of function.

With regard to antecedents, no systemic disease was identified. The etiopathogenesis in cases 2, 3 and 5 was related to anatomical variation (low muscle belly), presence of an intra-articular tumor (villous-nodular synovitis) and intense physical activity. The presence of Tinel’s sign was explained through the compressive effect of increased content in the anterior compartment, above the deep fibular nerve.

The routine for imaging examinations included initial radiography, which showed soft-tissue edema(2), marginal osteophytes and other bone anomalies(3). We considered magnetic resonance imaging to be the gold standard, since this enabled the diagnosis, with staging and mea-surement of the distance between the stumps. Echogra-phy has also been useful in situations in which magnetic resonance was impossible. Aboukrat(12) proposed ten-oscanography for diagnostic confirmation of tendinopa-

Table 1 – Epidemiology, etiopathogenesis, etiology, signs and symptoms, antecedents, physical examinations, complementary examinations and time elapsed from diagnosis

No. Age Sex Side Etiopathogenesis Etiology Signs and symptoms AntecedentsPhysical

examinationsComplementary

examinationsTime elapsed

from diagnosis

1 15 M D T CBW CL PF-AT CR F FI CG 482 28 F E NT AV VNS PAIN IF Running athlete CS CV PAIN TINEL MRI 363 22 F D NT AV CV PAIN Soccer player CV PAIN TINEL MRI 244 42 M D T CBW CL PF-AT CR F FI CG 605 19 F D NT CTS CV CL CR PAIN Gymnast PAIN FI TINEL MRI 126 67 M D NT DEG CL PAIN IF PAIN FI CG MRI 037 61 M D NT DEG CL PAIN IF CR PAIN F CG MRI 028 26 M D T CBW CS CL PF-LET 2º,3º,4º,5º SI PAIN FI TINEL MRI 05

9 26 M D T CBWCL PF-AT

LETLEH

SI CR F FI CG 07

10 47 M D T CBW CL PF-AT CR F FI CG MRI 0711 37 M D T CBW CS CL PF-LET 2º,3º,4º,5º PAIN FI TINEL MRI 11

12 19 M D T CBW CL PF-ATLEH CR FI CG TINEL MRI 01

13 28 M D T CBW PF- AT

LETLEH

CR FI LS 01

1) CR – change of relief; 2) CS – change of sensitivity; 3) CV – change of volume; 4) CL – claudication; 5) CR – crepitation; 6) LET – long extensor of the toes; 7) LEH – long extensor of the hallux; 8) F – failure; 9) CBW – cutting-bruising wound; 10) FI – functional impotence; 11) SI – superficial infection; 12) CG – calcaneal gait; 13) NT – non-traumatic; 14) CP – childhood paralysis; 15) MRI – magnetic resonance; 16) VNS – villous-nodular synovitis; 17) PF – loss of strength; 18) LS – loss of substance; 19) CTS – chronic tenosynovitis; 20) T – traumatic; 21) AT – anterior tibial; 22) AV – anatomical variation

Table 2 – Intraoperative findings and final results

No. Treatment Finding Follow-up (months)

Objective result

Subjective result

1 CON LEH JTS TAP F 2cm FBR AT 127 S S

2 RN MBR SY DFC AV AT LEH 79 S S

3 RN MBR DFC AV AT 67 S S4 CON LEH F 4cm AT 31 S S5 SY TSR TN LET 31 S S6 CON LEH F 4cm AT 31 S S7 FG F 8cm AT 15 S S

8 RN CON LEH F 3cm LET FBR TSR 15 S S

9 CON LEH F 4cm AT 13 U U10 FG F 6cm AT 12 S S11 FG F 6cm LET 12 S S12 FG F 7cm AT 10 S S

13 FG F 8cmAT, LEH 04 S S

1) TAP – tapering; 2) DFC – deep fibular compression; 3) FG – free grafting; 4) LET – long extensor of the toes; 5) LEH – long extensor of the hallux; 6) TSR – thickening of superior retinaculum; 7) F – failure; 8) PT – physiotherapy; 9) FBR – fibrosis; 10) I – unsatisfactory; 11) RN – release of nerve; 12) MBR – muscle belly resection; 13) S – satisfactory; 14) SY – synovectomy; 15) CON – consolidation; 16) AT – anterior tibial; 17) TN – tenosynovitis; 18) JTS – Jones tenosuspension; 19) AV – anatomical variation

147

1. Ouzonian TJ, Anderson R. Anterior tibial tendon rupture. Foot Ankle Int. 1995;16(7):406-10.

2. Kashyap S, Prince R. Spontaneous rupture of the tibialis anterior tendon: a case report. Clin Orthop Relat Res. 1987;(216):159-61.

3. Rimoldi RL, Oberlander MA, Waldrop JI, Hunter SC. Acute rupture of the tibialis anterior tendon: a case report. Foot Ankle Int. 1991;12(3):176-7.

4. Kaush T, Rutt J. Subcutaneous rupture of the tibialis anterior tendon: review of the litera-ture and a case report. Arch Orthop Trauma Surg. 1998;117(4-5):290-3.

5. Markarian GG, Kelikian AS, Brage M, Trainor T, Dias L. Anterior tibialis tendon rup-tures: an outcome analysis of operative versus nonoperative treatment. Foot Ankle Int. 1998;19(12):792-802.

6. Velan GJ, Hendel D. Degenerative tear of the tibialis anterior tendon after corticosteroid injection – augmentation with the extensor hallucis longus tendon, case report. Acta Orthop Scand. 1997;68(3):308-9.

7. Sammarco VJ, Sammarco GJ, Henning C, Chaim S. Surgical repair of acute and chronic tibialis anterior tendon ruptures. J Bone Joint Surg Am. 2009;91(2):325-32.

8. Pattern A, Pun WK. Spontaneous rupture of the tibialis anterior tendon: a case report and literature review. Foot Ankle Int. 2000;21(8):697-9.

9. Goehring M, Liakos P. Long-term outcomes following anterior tibialis tendon reconstruction with hamstring autograft in a series of 3 cases. J Foot Ankle Surg. 2009;48(2):196-202.

10. Frigg AM, Valderrabano V, Kundert HP, Hintermann B. Combined anterior tibial tendon rupture and posterior tibial tendon dysfunction in advanced flatfoot. J Foot Ankle Surg. 2006;45(6):431-5.

11. Dooley BJ, Kudelka P, Menelaus MB. Subcutaneous rupture of the tendon of tibialis anterior. J Bone Joint Surg Am. 1980; 62(4):471-2.

12. Aboukrat P. Tendonopathies du pied. Rev Prat. 1997;47(1):56-61.13. Peetrons P. Lesions du tendon tibial anterieur en echographie: rapport de deux cas.

JBR-BTR. 1999;82(4):157-8.

rEfErENCES


thy, and this was the only reference to this technique that we found. According to Peetrons(13), ultrasonography was sufficient because of its specificity and sensitivity.

Ouzonian and Anderson(1) and Frigg et al(10) used magnetic resonance not as a diagnostic method but as a verification resource, in order to identify the charac-teristics of the lesion, the details of the location and the distance between the stumps. This imaging resource was used on nine patients and contributed towards choos-ing the access route and the surgical technique, and in diagnosing the anatomical variations.

Among active patients with traumatic or degenerative etiology, with complete rupture, there is a tendency in the literature for the surgical treatment to be selectable.

When the rupture is diagnosed early, end-end anas-tomosis of the stumps can be performed. For chronic lesions, when direct suturing is not possible, “V-Y” ad-vancement, consolidation or free grafting can be per-formed. “V-Y” advancement is not indicated for tendons of the anterior compartment because of the small diam-eter, which would result in technical difficulty. Consoli-dation has become a feasible and effective resource, and this has been used on adjacent tendons such as the long extensor of the hallux, long extensor of the toes and anterior tibial tendons, when the distance between the stumps has not exceeded 4 cm.

The grafts may be autogenous or autologous. In the present series, only autogenous grafts were used, because we did not have a tissue bank available, but this might be-come an option in the future. Free grafting was used when distances greater than 5 cm between the stumps made it im-practicable to perform end-end suturing or consolidation.

The semitendinosus tendon was chosen for the cases of free grafting because of its similar thickness and resis-tance characteristics. Moreover, its size is convenient and it is easy to obtain. Use of the semitendinosus tendon has become established for knee ligament reconstructions be-cause of its low morbidity and low interference with flexor strength. The principle of not unbalancing the action of the

extrinsic musculature of the foot and ankle was maintained, since we did not use transfers that would change this dy-namic. The suturing of the free graft to the tendon stumps was done at the maximum tension possible. The ankle was immobilized in dorsiflexion at 95º and the toes at 30º. Inte-gration of the free graft was achieved in all cases.

The rupture site most commonly found by Pattern and Pun(8) was 0.5 to 3 cm proximally to the insertion of the anterior tibial tendon. The mean location found in the present study was 5 cm from this reference point, with a range from 2 to 8 cm.

The time that elapsed between diagnosis and treat-ment was long (mean of 19 months), independent of whether the case was traumatic or degenerative, for a variety of reasons. Low functional demand, low inten-sity of pain and adaptation to walking with a drop foot (compensated through the use of an orthosis) may be explanations for why it took so long for these individu-als to seek treatment.

The results from this series indicate that surgical treatment was efficient for reestablishing function and for pain relief. 92% of these individuals successfully returned to their pre-injury activities.

Surgical treatment was also seen to be necessary in cases of tendinopathy of the anterior compartment, whether of traumatic origin or not, when the aim was to reestablish functional capacity.

CONCLUSiON1 – Surgical treatment is effective for functional recovery.2 – Several techniques should be used to attend to the

spectrum of severity of tendon ruptures and deal with the possible differential diagnoses of chronic tendi-nopathy of the anterior compartment of the ankle.

3 – The choice of free grafting of the semitendinosus tendon is efficient for gaps of more than five cen-timeters and, in the same manner, consolidation is efficient at shorter distance between the stumps.


artigo 20

1 – Resident Physician in the Orthopedics and Traumatology Service, Santa Casa Hospital Complex, Porto Alegre, RS, Brazil.2 – Titular Professor of the Discipline of Orthopedics and Traumatology, Foundation of the Federal School of Medical Sciences of Porto Alegre; Head of the Orthopedics and

Traumatology Service, Santa Casa Hospital Complex, Porto Alegre, RS, Brazil.

Work performed at the Orthopedics and Traumatology Service, Santa Casa Hospital Complex (ISCMPA), Porto Alegre (RS), Brazil.Correspondence: Prof. Dr. Carlos Roberto Schwartsmann, Rua Leopoldo Bier 825, Bairro Santana, 90620-100 Porto Alegre, RS, Brazil E-mail: [email protected]


OriGiNaL arTiCLE

EVALUATION OF HEPATIc FUNcTION AMONg PATIENTS UNDErgOINg TOTAL HIP ArTHrOPLASTY USINg ENOxAPArIN

Felipe Vitiello Wink1, Carlos Roberto Schwartsmann2


iNTrODUCTiON

The thromboembolic phenomena relating to the post-operative period following orthopedic surgery are well known and greatly studied. They represent high medi-cal and hospital costs. For decades, medications with the capacity to reduce the risk of deep vein thrombosis (DVT) and its main complication, pulmonary throm-boembolism (PTE), have been studied(1).

A variety of drugs are used with the aim of preventing and treating these phenomena. Among these are prepara-tions using non-fractionated heparin and low molecular weight heparin, such as enoxaparin, cumarinic agents and new medications that are selective inhibitors of fac-tor xa(2).

Comparing these different drugs with each other, their efficacy for anticoagulation and safety in relation to the risk of hemorrhage has been well established in the medical literature(3-6). However, their safety in rela-tion to changes in liver function is not well known(7-8).

The aim of the present study was to evaluate changes in liver function among patients undergoing total hip arthroplasty with the use of enoxaparin.

abSTraCTObjective: To evaluate hepatic changes resulting from the use of enoxaparin for prophylaxis of deep vein thrombosis among patients undergoing total hip arthroplasty. Methods: Thirty-two patients underwent elective total hip arthroplasty, using enox-aparin, and were followed up for 65 days with serial hepatic enzyme assays. Results: Changes in laboratory parameters were found in up to 75% of the patients during the study, but the pa-

rameters normalized after suspension of the treatment. No clini-cal evidence of hepatic lesions was found. Conclusion: The he-patic enzyme levels increase in most patients using enoxaparin, but without clinical correlation, and the levels normalize after suspension of the treatment.

Keywords – Enoxaparin; Arthroplasty, hip; Liver failure; Ve-nous thrombosis

METhODS

Thirty-two patients who were candidates for total hip arthroplasty were selected (18 men and 14 women). They fulfilled the following inclusion criteria: a) 18 years of age or over; b) indication for elective total hip arthroplasty; c) signing of consent statement. Their indications were for the following reasons: 22 (68.75%) due to osteoarthrosis; four (12.5%) due to avascular necrosis of the femoral head; four (12.5%) due to sequelae from a proximal femoral fracture; and two (6.25%) due to sequelae from congenital luxation of the hip. The exclusion criteria were: a) schedul-ing for elective bilateral hip prosthesis surgery; b) active bleeding or high risk of bleeding, thereby contraindicating treatment with low molecular weight heparin; c) contrain-dications regarding the drug to be used or conditions that would prevent treatment with anticoagulants; d) conditions that would contraindicate bilateral phlebography; e) preg-nancy or lactation; f) among women of fertile age, nonuse of adequate contraceptive methods; g) drug or alcohol addiction; h) concomitant use of protease inhibitors for HIV treatment; i) undergoing therapy using another study product within the 30-day period preceding the start of the

149


current clinical investigation; j) use of intermittent pneu-matic compression during the period of active treatment; k) concomitant participation in another clinical investiga-tion or study; l) therapy using another type of anticoagu-lant that could not be interrupted, or another non-permitted medication; and m) significant liver disease.

The patients’ mean age was 60 years (± 14.6). The youngest patient was 20 years old and the oldest was 82 years old. None of the patients presented previous liver disease, and none of them were using medications that would alter liver function tests.

The patients followed a uniform hospital admission protocol on the day prior to surgery, with preopera-tive clinical and laboratory evaluations in accordance with medical indications. Samples were taken for the following liver enzyme assays: aspartate aminotrans-ferase (AST), alanine aminotransferase (ALT), gamma-glutamyl transpeptidase (GGT), alkaline phosphatase (ALP), lactate dehydrogenase (LDH), total bilirubin (TB) and direct bilirubin (DB).

Use of enoxaparin was started 12 hours before the surgery, with a dose of 40 mg subcutaneously, once a day. This was maintained for 35 days. Serial assays were performed on the liver function markers: after the surgery and on the 6th, 13th, 36th and 65th days after the operation.

The following reference values were used: AST 0-41 U/l, ALT 0-45 U/l, GGT 2-65 U/l, ALP 30-125 U/l, LDH 100-220 U/l, TB 0.1-1.2 mg/dl and DB 0-0.4 mg/dl, as established by the Clinical Reference Laboratory, 8433 Quivira Road, Lenexa, Kansas, USA, where the patients’ samples were analyzed.

rESULTS

In four patients (13%), one or more enzymes present elevated preoperative values (ALT and GGT). These cases were excluded from the study. During the immedi-ate postoperative period, three patients (9%) presented elevated AST levels, two (6%) ALT, three (9%) GGT and ten (31%) LDH, i.e. a total of 13 patients (41%) with abnormalities. On the 6th day after the operation, six (19%) presented elevated AST, three (9%) ALT, 12 (38%) GGT, three (9%) ALP and five (16%) LDH, i.e. a total of 15 patients (47%) with abnormalities. On the 13th day, two (6%) presented elevated AST, four (13%) ALT, twelve (38%) GGT, five (9%) ALP and seventeen (53%) LDH, i.e. a total of 24 patients (75%) with abnor-

malities. On the 36th day, two (6%) presented elevated AST, one (3%) ALT, four (13%) GGT, one (3%) ALP and seven (22%) LDH, i.e. a total of 10 patients (31%) with abnormalities. On the 65th day, one patient (3%) presented elevated ALT (9%), five (16%) GGT, three (9%) ALP and none with abnormal LDH, i.e. a total of eight patients (25%) with abnormalities (Table 1).

Table 1 – Elevated liver enzymes

Enzyme Day 0 Day 1 Day 6 Day 13 Day 36 Day 65

AST 0 3 (9%) 6 (19%) 2 (6%) 2 (6%) 1 (3%)

ALT 3 (9%) 2 (6%) 3 (9%) 4 (13%) 1 (3%) 3 (9%)

GGT 3 (9%) 3 (9%) 12 (38%) 12 (38%) 4 (13%) 5 (16%)

ALP 0 0 3 (9%) 3 (9%) 1 (3%) 3 (9%)

LDH 0 10 (31%) 5 (16%) 17 (53%) 7 (22%) 0

Total 4 (13%)* 13 (41%) 15 (47%) 24 (75%) 10 (31%) 8 (25%)AST: aspartate aminotransferase; ALT: alanine aminotransferase; GGT: gamma-glutamyl trans-peptidase; ALP: alkaline phosphatase; LDH: lactate dehydrogenase

* Patients excluded from the study

The analysis on bilirubins did not demonstrate any abnormalities in any of the patients, either before the operation or during the 65 days of follow-up. None of the patients presented any signs or symptoms relating to liver function abnormalities (Figure 1).

AST: aspartate aminotransferase; ALT: alanine aminotransferase; GGT: gamma-glutamyl trans-peptidase; ALP: alkaline phosphatase; LDH: lactate dehydrogenase

figure 1 – Mean curve for liver enzymes

0,00

50,00

100,00

150,00

200,00

250,00

ASTALTGGTFADHL

UI/L D0 D1 D6 D13 D36 D65

DiSCUSSiONIt is known that non-fractionated heparin presents a

relationship with asymptomatic elevation of transami-nases. There is no correlation between such abnormali-ties and clinical evidence of hepatic lesions. In published reports in the literature, liver enzyme values have be-come normalized after suspension of treatment with non-fractionated heparin(7).

EVALUATION OF HEPATIC FUNCTION AMONG PATIENTS UNDERGOING TOTAL HIP ARTHROPLASTY USING ENOxAPARIN

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Deitelzweig SB, McKean SC, Amin AN, Brotman DJ, Jaffer AK, Spyropoulos 1. AC. Prevention of venous thromboembolism in the orthopedic surgery patient. Cleve Clin J Med. 2008;75(Suppl 3):S27-36.Dorr LD, Gendelman V, Maheshwari AV, Boutary M, Wan Z, Long WT. Multimodal 2. thromboprophylaxis for total hip and knee arthroplasty based on risk assess-ment. J Bone Joint Surg Am. 2007;89(12):2648-57.Christiansen HM, Lassen MR, Borris LC, Sørensen JV, Rahr HB, Jorgensen PW, 3. et al. Biologic tolerance of two different low molecular weight heparins. Semin Thromb Hemost. 1991;17(4):450-4.Senaran H, Acaroğlu E, Ozdemir HM, Atilla B. Enoxaparin and heparin com-4. parison of deep vein thrombosis prophylaxis in total hip replacement patients. Arch Orthop Trauma Surg. 2006;126(1):1-5.Leclerc JR, Geerts WH, Desjardins L, Jobin F, Laroche F, Delorme F, et al. Pre-5. vention of deep vein thrombosis after major knee surgery – a ran domized, dou-

ble-blind trial comparing a low molecular weight heparin fragment (enoxaparin) to placebo. Thromb Haemost. 1992;67(4):417-23.Jensen HP, Borris LC, Lassen MR, Sørensen JV, Rahr HB, Christiansen HM, 6. et al. Low molecular heparin in prevention of thrombosis in orthopedic surgery. Ugeskr Laeger. 1993; 155(15):1109-15.Carlson MK, Gleason PP, Sen S. Elevation of hepatic transaminases after eno-7. xa parin use: case report and review of unfractionated and low-molecular-weight heparin-induced hepatotoxicity. Pharmacotherapy. 2001;21(1):108-13.Harenberg J, Jörg I, Weiss C. Observations of alanine aminotransferase and 8. aspartate aminotransferase in THRIVE studies treated orally with ximelagatran. Int J Toxicol. 2006;25(3):165-9.Agnelli G, Eriksson BI, Cohen AT, Bergqvist D, Dahl OE, Lassen MR, et al. Safety 9. assessment of new antithrombotic agents: Lessons from the EXTEND study on ximelagatran. Thromb Res. 2009;123(3):488-97.

rEfErENCES


The recently created selective inhibitors of factor xa, which are still at the clinical study phase, have been found to present significant dose-dependent abnormalities in transaminase values during the treatment, without evident clinical abnormalities. The values become normalized after suspension of the treatment(7-9).

In our study, we found abnormalities in the liver function tests on most of the patients treated with enox-aparin, reaching 75% of them on the 13th day after the operation. In addition to the transaminases, there were elevated values for the enzymes GGT, ALP and LDH. The behavior of these abnormalities corresponded to what can be seen in the literature(3,6-8), with elevation right at the start of the treatment, a peak occurring after around two weeks of medication use, and normalization after 60 days.

The values for total and direct bilirubin remained within the limits of normality throughout the study. We did not find any reports in the literature in relation to abnormalities of bilirubin metabolism among patients using enoxaparin.

Despite the abnormalities found in this study, none of the patients presented clinical signs or symptoms relating to the elevation of liver enzyme levels. These abnor-malities showed a tendency towards normalization after suspension of the treatment, with a gradual decline in the values during the follow-up.

These data resemble what can be seen in the literature(3,6-8), and it was not possible to correlate any un-favorable outcome with the elevations in the liver function tests among these patients who underwent total hip arthro-plasty using enoxaparin as prophylaxis against DVT.

CONCLUSiONMost of the patients who used enoxaparin as pro-

phylaxis against DVT/PTE presented abnormalities in laboratory tests on liver function, without clinical reper-cussions. These abnormalities became normalized with suspension of the treatment.

The greatest abnormality was in relation to LDH, which presented elevated values in 53% of the cases on the 13th day of enoxaparin administration.

artigo 11

1 – PhD. Assistant Professor in the Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo; Head of the Shoulder and Elbow Group.2 – Assistant Professor in the Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo; Attending Physician in the Shoulder and Elbow

Group.3 – Attending Physician in the Shoulder and Elbow Group.4 – Trainee Physician in the Shoulder and Elbow Group.5 – PhD. Adjunct Professor and Head of Clinical Medicine of the Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo; Academic

Consultant in the Shoulder and Elbow Group.

Work performed in the Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo, Pavilhão “Fernandinho Simonsen”. Director: Prof. Dr. Osmar Avanzi.Correspondence: Grupo de Ombro e Cotovelo, Departamento de Ortopedia e Traumatologia, Rua Dr. Cesário Mota Júnior 112, Vila Buarque, 01220-020 São Paulo, SP E-mail: [email protected]


OriGiNaL arTiCLE

rADIOgrAPHIc STUDY ON THE AcrOMION INDEx AND ITS rELATIONSHIP wITH rOTATOr cUFF TEArS

Alberto Naoki Miyazaki1, Marcelo Fregoneze2, Pedro Doneux Santos3, Luciana Andrade da Silva3, Éder Menegassi Martel4, Leandro Gervazoni Debom4, Manoel Loyola Andrade4, Sérgio Luiz Checchia5


iNTrODUCTiON

The etiology of rotator cuff tears (RCTs) is still controversial(1). However, they have been correlated with the format of the acromion(2). Bigliani et al(3) described three types of acromion and correlated type III (hooked) with greater prevalence of RCTs. Wang and Shapiro(4), along with Ikemoto et al(5), reported greater prevalence of this type of acromion among older patients.

Zuckerman et al(6) conducted a morphometric study on the shoulders of cadavers and found greater anterior projection and less inclination of the acromion in cadav-ers with RCTs, in comparison with those without such lesions. Another parameter for evaluating the format of the acromion is its lateral angulation, which was studied by Banas et al(7) using magnetic resonance images. They found smaller angles in patients with RCTs.

abSTraCTObjective: The purpose of this study was to evaluate the relation-ship between the lateral projection of the acromion and rotator cuff tears (RCTs) in the Brazilian population. Methods: The lateral projection of the acromion was measured using anteroposterior radiographs of the shoulders, carried out with the glenoid cavity in absolute profile and the humeral head in the neutral position or with internal rotation. The acromion index (AI) was defined as the ratio between the distance from the plane of the glenoid cavity to the lateral edge of the acromion and the distance from the plane of the glenoid cavity to the lateral edge of the humeral head. This

index was measured in 83 patients (mean age of 54 years) with RCTs and compared with a group of 28 individuals (mean age of 48 years) without RCTs. The presence or absence of RCTs was determined by means of magnetic resonance imaging. Results: The mean AI was 0.7194 for the patients with RCTs and 0.6677 for the individuals without RCTs, in the Brazilian population. This differ-ence was statistically significant, with P < 0.001. Conclusion: A relationship can be established between AI and rotator cuff tears in the Brazilian population.

Keywords – Rotator cuff; Acromion; Radiography

Analyzing the lateral appearance of the acromion shape, Nyffeler et al(2) and Torrens et al(8) found a di-rect relationship between lateral projection of the ac-romion and the presence of RCTs. From this relation-ship, Nyffeler et al(2) proposed a model to explain this, in which the vector of the muscle force resulting from the deltoid muscle would be influenced by the lateral projection of the acromion. Contraction of the deltoid muscle during active abduction would pull the humeral head upwards and would also put pressure on it, against the glenoid cavity. The orientation of the resultant force vector depends on the orientation of the muscle fibers of the deltoid at their origin in the acromion. The more lateral their origin is in the acromion, the greater the ascending component of the resultant force will be; and the less the lateral projection of the acromion is, the greater the compressive component of the force

152

FR – resultant force; Fa – ascendant force; Fc – compressive force

figure 1 – A) Schematic representation of the resultant force that acts on the humeral head when there is a minor lateral projection of the acromion. B) Representation of the resultant force when the insertion of the deltoid is more lateral.

figure 2 – Radiographic image of the right shoulder, in anteropos-terior view, after scanning with the millimeter ruler used to calibrate the software. From this, the acromion index (AI) is demonstrated: this is obtained as the ratio between the distance from the glenoid cavity to the lateral edge of the acromion (GA) and the distance from the glenoid cavity to the lateral edge of the humerus (GU).


* Personal communication from Professor Itoi Eiji. Búzios, 2008.

against the glenoid cavity will be (Figure 1). It might be imagined that a greater ascending force component (Fa) would favor subacromial impact and, consequently, degenerative changes to the supraspinal tendon, while a greater compressive force (Fc) would favor degenera-tive changes to the shoulder joint(2). However, there is no consensus in the literature regarding this relation-ship, given that neither Van Nüffel and Nijs(9) nor Itoi* found it in their studies, even though their work was carried out using similar methodology.

Our study had the aim of evaluating the shape of the acromion, and specifically its lateral projection, using methodology similar to that of Van Nüffel and Nijs(9)

and Itoi*, with radiographic measurements using an in-dex that was then correlated with RCT occurrences.

SaMPLE aND METhODSRadiographs from patients who undergone operations

performed by the Shoulder and Elbow Surgery Group of the Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de Misericór-dia de São Paulo, Pavilhão “Fernandinho Simonsen”, between July 1995 and December 2007.

The shoulder radiographs were standardized and only those that had been produced with correction for anteversion of the glenoid cavity were used. The arm was radiographed in a resting position alongside the body, with the proximal region of the humerus in a neu-

tral position or with internal rotation. According to the study published by Nyffeler et al(2), there is no differ-ence in measuring the acromiale index with the shoulder in neutral position of with internal rotation.

Two measurements were made on these radiographic images, taking the reference points to be the plane of the glenoid cavity, the lateral extremity of the humeral head and the lateral extremity of the acromion. The distance between the lateral extremity of the acromion and the plane of the glenoid cavity was called GA. The distance between the lateral extremity of the humerus and the plane of the glenoid cavity was called GU. The ratio be-tween the values of GA and GU forms an index known as the acromion index (AI) (Figure 2).

There was no concern regarding the distance between the ampoule of the x-ray apparatus and the radiographic film, since was an index and changes to the parameters would not interfere with the result. To check that varia-tion in the inclination of the x-ray ampoule would not alter the AI measurements, we created a control group of 10 patients. This group underwent radiography cen-tered on the glenoid cavity in anteroposterior view, at angles of 0°, 30° of caudal inclination and 30° of cranial inclination. The AI from these radiograph views was measured and subjected to statistical analysis (Friedman test). This analysis on the three views showed similar values, with a p-value of 0.999, and it was concluded that the inclination of the x-ray ampoule did not have any influence on the result (Table 1).

153


The inclusion criterion was that the patients selected should present a completely torn rotator cuff, proven by magnetic resonance images and through observation dur-ing the surgery. For the control group, patients treated for shoulder diseases who did not show RCTs on magnetic resonance images were selected. We defined the exclu-sion and non-inclusion criteria as cases of antecedents of fractures of the scapular belt, arthritis, degenerative arthrosis, osteonecrosis and sequelae from infection.

The patients selected were divided into two groups: group I, with a completely torn rotator cuff (83 cases); and group II, with an undamaged rotator cuff (28 cases) (Table 2).

The radiographs were digitized using a scanner (HP Deskjet F4180®). These images were then analyzed us-ing the Image J 1.41 software (Wayne Rasband, Re-search Services Branch, National Institute of Mental Health, Bethesda, Maryland, USA), which is available for download from the website http://rsbweb.nih.gov. This enables precise measurement of distances in fig-ures, starting from a parameter for calibration. A ruler marked out in millimeters was used as the calibration parameter (Figure 2).

The data obtained were subjected to statistical analy-sis by means of Student’s t test, which was controlled using Levene’s test for equality of variance, with a sig-nificance level of 5%. The chi-square test was also used, with the aim of investigating a possible difference in the sex distribution between the study groups.

rESULTS

In group I, the mean age was 54 years, with a range from 32 to 77 years, while in group II, the mean age was 48 years, ranging from 35 to 63 years. In group I, females predominated, accounting for 64% (53 women). This was also found in group II, in which 57% of the patients were female (16 women). However, this dif-ference in sex distribution in groups I and II was not statistically significant (p = 0.527) (Table 2).

With regard to the side affected, there was predomi-nance of the right side in both groups, accounting for 78% of the shoulders in group I and 64% of the shoul-ders in group II (Table 2).

We found a mean AI of 0.7194 among the individuals who presented RCTs (group I); and a mean AI of 0.6677 among the individuals who presented an undamaged rotator cuff (group II). The statistical analysis showed a correlation with p = 0.001, i.e. there was a statistically significant relationship between RCTs and greater lateral projection of the acromion.

DiSCUSSiONIn 1972, Neer(10) made an important study on impact

syndrome and identified that forces impacting on the low-er portion of the acromion, the coracoacromial ligament and the inferior surface of the acromioclavicular ligament were the agents responsible for the narrowing of the sub-acromial space, which led to tendon lesions. However, it is now known that the pathogenesis of RCTs is probably multifactorial(1). One of the possible causes for such le-sions is greater lateral projection of the acromion, as pro-posed by Nyffeler et al(2). However, there is no consensus in the literature in relation to this association, in the way seen for the anterior projection of the acromion(3,6,7,10).

Table 1 – Variation in the acromion index according to radiographic incidence view

Acromion index n MeanStandard deviation

Minimum Maximum Median25th

percentile75th

percentileP value

30º cranially 10 0.66309 0.09457 0.51820 0.80240 0.66585 0.59290 0.73233

0º 10 0.66489 0.09368 0.50930 0.79950 0.67545 0.59438 0.73433 >0.999

30º caudally 10 0.66434 0.09338 0.52780 0.80230 0.65980 0.59245 0.74283Source: SAME DOT-ISCMSPn = total number of patients

Table 2 – Distribution of groups I and II in relation to sex, mean age and side affected

Group I Group II

n 83 28

Mean age (years) 54 (32-77) 48 (35-63)

Sex

30 men(36%)

53 women(64%)

12 men(43%)

16 women(57%)

Side

65 right(78%)18 left(22%)

18 right(64%)10 left(36%)

Source: SAME-DOT ISCMSPn = total number of patients

RADIOGRAPHIC STUDY ON THE ACROMION INDEx AND ITS RELATIONSHIP WITH ROTATOR CUFF TEARS

154

Uhtof HK, Loehr J, Sarkar K. The pathogenesis of rotator cuff tears. The shoulder. 1. In: Proceedings of the Third International Conference on Surgery of the Shoulder, Fukuoka – Japan; 1986. p. 211-2.Nyffeler RW, Werner CM, Sukthankar A, Schmid MR, Gerber C. Association of a 2. large lateral extension of the acromion with rotator cuff tears. J Bone Joint Surg Am. 2006;88(4):800-5.Bigliani LU, Morrison DS, April EW. The morphology of the acromion and its 3. relationship to rotator cuff tears. Orthop Trans. 1986;10:216.Wang JC, Shapiro MS. Changes in acromial morphology with age. J Shoulder 4. Elbow Surg. 1997;6(1):55-9. Ikemoto RY, Bezerra AD, Monte FA, Telles RB, Fujiki EN, Porto LCK. Acrômio em 5. forma de gancho: uma variação anatômica ou um processo degenerativo? Rev Bras Ortop. 2005;40(8):454-63.Zuckerman JD, Kummer FJ, Cuomo F, Simon J, Rosenblum S, Katz N. The 6.

influence of coracoacromial arc anatomy on rotator cuff tears. J Shoulder Elbow Surg. 1992;1(1):4-14.Banas MP, Miller RJ, Totterman S. Relationship between the lateral acromion 7. angle and rotator cuff disease. J Shoulder Elbow Surg. 1995;4(6):454-61.Torrens C, López JM, Puente I, Cáceres E. The influence of the acromial coverage 8. index in rotator cuff tears. J Shoulder Elbow Surg 2007;16(3):347-51.Van Nuffel M, Nijs S. Acromial morphology, acromial index and rotator cuff problems: 9. is there a correlation? The Pellenberg Orthopaedic Yearbook. 2006-2007:37-44.Neer CS 2nd. Anterior acromioplasty for the chronic impingement syndrome in the 10. shoulder: a preliminary report. J Bone Joint Surg Am. 1972;54(1):41-50.Jerosch J, Müller T, Castro WH. The incidence of rotator cuff rupture. An anatomic 11. study. Acta Orthop Belg. 1991;57(2):124-9.Neer CS 2nd. Impingement lesions. Clin Orthop Relat Res. 1983;(173):71-7.12.

rEfErENCES


Our results support the theory of Nyffeler et al(2), since individuals with RCTs presented a greater AI, i.e. greater lateral projection of the acromion. This shape of the ac-romion causes the origin of the deltoid to be more lateral, thereby producing a resultant force with a more ascendant orientation (Fa), which probably favors subacromial im-pact. Among the patients with an undamaged rotator cuff, this index was lower, i.e. there was less lateral projection of the acromion, with a resultant force that was oriented more towards compression (Fc) against the glenoid cavity. Al-though not part of the objective of our study, we did not find any signs of arthrosis in the shoulder joint of these patients, as this theory would suppose. Our findings also in some way corroborate the results of Torrens et al(8), given that we also found a relationship between greater lateral projection of the acromion and occurrences of RCTs, even though the calculation used to determine the lateral projection of the acromion was made differently, i.e. using another index.

On the other hand, our results and those of Nyffeler et al(2) are not the same as those of Van Nüffel and Nijs(9) and Itoi*, even though we used the same way of measuring the lateral projection of the acromion and our groups were similar regarding sex and age. The only difference was that both the group with RCTs and the control group in the study by Itoi* consisted mostly of men, which could con-stitute a form of bias, given that there have been reports that RCTs are more prevalent among women, although this too is not a matter of consensus in the literature(11).

The individuals with RCTs and with undamaged ro-tator cuffs who were selected both in previous studies and in ours had mean ages between 45 and 65 years. Thus, they were in phase III of the impact syndrome, as described by Neer(12), i.e. the stage at which complete tearing of the rotator cuff occurs.

Another factor that might have influenced the results was that the radiographic images used for measuring the AI were not standardized. However, we took care to select radiographs with correction for anteversion of the glenoid cavity, and in which the humerus was in a neutral position or in internal rotation, as already demonstrated by Nyffeler et al(2), since in this way neither position would have any influence on the AI. Torrens et al(8) re-ported previously that the distance from the ampoule to the film, at the time of producing the radiograph, also did not alter the AI because it is determined as the ratio between two measurements made on the same radio-graphic image. In our study, we demonstrated that the angulation of the x-ray ampoule also did not influence the determination of the AI, thereby avoiding such bias in carrying out our study.

One factor that should be taken into consideration is that Itoi* made measurements on a Japanese population, Nyffeler et al(2) on a Swiss population and Van Nüffel and Nijs(9) on a Belgian population, while our study was conducted on a Brazilian population. Since each ethnic group has its own characteristics, it could be that the differences between the results may come from a factor relating to the biotype of each ethnic group. However, to investigate this question better, further studies should be conducted, taking into consideration other morphological parameters such as the type of acromion, lateral angle and anterior inclination of the acromion, in an attempt to find the precise etiological factor that causes RCTs.

CONCLUSiON

We conclude that RCTs may be associated with greater AI, i.e. greater lateral projection of the acromion.

artigo 209

1 – �Orthopedist R4 in the Hip Surgery Group of the Orthopedics Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS.2 – �Substitute Professor in the Department of Surgery, Federal University of Rio Grande do Sul (UFRGS); Contracted Physician at Hospital de Clínicas de Porto Alegre

(HCPA) and Preceptor of the Hip Surgery Group at HCPA.3 – �Professor in the Department of Surgery, Federal University of Rio Grande do Sul (UFRGS); Head of the Orthopedics Service, Hospital de Clínicas de Porto Alegre (HCPA)

and Head of the Hip Surgery Group at HCPA.4 – �Professor in the Postgraduate Program on Surgery, Federal University of Rio Grande do Sul (UFRGS); Contracted Physician and Preceptor of the Hip Surgery Group

at Hospital de Clínicas de Porto Alegre (HCPA).

Work performed in the Department of Surgery, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS.Correspondence: Ricardo Rosito, Rua Ramiro Barcelos 2350, Largo Eduardo Faracco, 90035-903 Porto Alegre, RS, Brazil – E-mail: [email protected]


OriGiNaL arTiCLE

TOTAL HIP ArTHrOPLASTY wITH bIOMEc PrOSTHESIS: 20-YEAr FOLLOw-UP

Rodrigo Benedet Scheidt1, Ricardo Rosito2, Carlos Alberto de Souza Macedo3, Carlos Roberto Galia4


iNTrODUCTiON

Total hip arthroplasty (THA) was popularized by Charnley in the 1960s(1). At that time, metal-on-poly-ethylene joints fixed with surgical cement (polymethyl methacrylate, PMMA) became standard. As the use of cemented THA spread, the number of complications also increased, especially cases of aseptic loosening and osteolysis. Initially, it was thought that the problem was in the cement and, at that time, the term “cement dis-ease” started to be investigated(2). The results from such studies showed that the reason for the failures was not just the cement, but rather, a set of factors. Whatever the cause, these events stimulated the search for biological solutions (without cement), as alternatives for perform-ing THA(3,4).

Thus, at the end of the 1970s, the number of indi-cations for THA using biological fixation increased. This period was marked by the emergence of a series of new types of implant based on a wide variety of con-cepts regarding materials, format, type of covering and

abSTraCT

Objective: To analyze the clinical and radiological outcomes from total hip arthroplasty using the Biomec prosthesis over a 20-year period (1988 to 2009). Methods: The patients were evaluated clinically in accordance with the Merle d’Aubigné and Postel functional classification, and underwent anteroposterior (AP) radiography of the pelvis and the operated joint in lateral view. The variables evaluated were acetabular and femoral oste-olysis, polyethylene wear, nail migration, follow-up and clinical

outcomes. Results: The mean follow-up was 10.6 years (range 4 to 21 years). The sample consisted of 84 patients (32 men and 52 women) and the mean preoperative age was 47 years. We found that 88% of the results from the clinical evaluation were good or excellent. In relation to the radiological findings, 92.5% of the results were good. The mean wear on the polyethylene was 1.4 mm. Conclusion: The use of the Biomec prosthesis in this cohort showed good clinical and radiographic results.

Keywords – Hip/surgery; Arthroplasty, hip; Biomechanics

fixation(5). Among these, the Spotorno® prosthesis, which has become established worldwide, is an example of an implant with biological fixation and a wedge-shaped quadrangular format, made of titanium (T16Al7Nb), which served as a model for developing the prosthesis examined in the present study (Biomec)(6). Analysis on the preliminary results from various designs for unce-mented implants, compared with the results achieved using adequately cemented prostheses, suggested that not all the concepts put forward could be sustained over medium-term follow-up, and this is well demonstrated by the variations in the models made by various com-panies that were formed at that time(7,8).

All of this motivated us to present our experience over 20 years of performing THA using the Biomec uncemented wedge-shaped quadrangular prosthesis.

The aim of this study was to show the clinical and radiographic results from the use of the Biomec unce-mented prosthesis, with a mean length of follow-up of 10.6 years.

156


METhODSThe present study consisted of a cohort of 84 pa-

tients (93 hips) who underwent THA using the Biomec uncemented prosthesis between 1988 and 2005, with follow-up until 2008. The clinical evaluation was per-formed before the radiographic evaluation and was done by different examiners, with the aim of dimin-ishing the measurement bias. The patients were called in for assessment; they gave responses according to a preestablished protocol; and they underwent radiogra-phy on the pelvis (anteroposterior view), and on the coxofemoral joint on the side affected (lateral view). The patients underwent operations consisting of an an-terolateral or posterolateral approach according to the decision made by the chief surgeon and the Hip Surgery Group of our hospital.

With regard to design, the femoral component of the Biomec prosthesis is made of titanium (T16Al7-Nb), with a cervical-diaphyseal angle of 145º and a wedge-shaped format in the three planes. It is fixed to the bone under pressure (pressfit) in the metaphyseal region. Proximally, the nail has anterior and posterior grooves to avoid rotational movements and favor os-seointegration. The Biomec acetabulum consists of a cupola made of titanium, of hemispherical format with six expandable fins. The interchangeable head used was made of chromium-cobalt-molybdenum (CoCrMO) of diameter 28 mm.

For the clinical evaluation, the criteria proposed by D’Aubigné and Postel(9) were used. Pain, gait and hip mobility were assessed, with a maximum score of six for each item, such that the total of 18 points represented the best result. For the purposes of statis-tical analysis, the results were considered good if the patients obtained scores graded as good or very good (greater than or equal to 15 points), and other results were considered unsatisfactory.

The radiographic evaluation on acetabular osteolysis was based on the criteria of Zicat et al(10), regarding expansive or linear type, and on De Lee and Charnley zones(11) regarding localization. For evaluations on fem-oral osteolysis, the criteria of Turíbio were used(12).

Other variables were also assessed radiographically, such as the wear on the polyethylene, migration of the femoral component (subsidence) and femoral morphoc-ortical index. All these were measured with a transpar-ent plastic ruler divided into millimeters.

To describe the variables, we took into considera-tion the arithmetic mean, standard deviation (SD), me-dian and maximum and minimum values. In the statis-tical analysis on non-parametric variables, Spearman’s correlation test was use, while the Mann-Whitney test was used for parametric variables. Both of these were calculated using the SPSS software for Windows, ver-sion 14.0 (SPSS Inc, Chicago, IL, USA). We took P values less than 0.05 to be significant.

Statistical correlations were investigated in rela-tion to the following outcomes: acetabular osteoly-sis versus clinical outcome; clinical outcome versus follow-up, femoral migration, polyethylene wear, fe-moral osteolysis and acetabular osteolysis; acetabular osteolysis versus follow-up, polyethylene wear and follow-up.

rESULTS

The Biomec prosthesis was used for 100 patients between 1988 and 2001. Of these, seven died during the later postoperative period for reasons unrelated to the surgical procedure. Because there was no recent assessment for these patients, they were excluded from the study. Another nine patients could not be located for reassessment. Thus, 84 patients and 93 hips were evaluated, i.e. there were nine cases of bilateral ar-throplasty. Thirty-two of the patients (38%) were men and 52 (62%) were women. The mean age before the operation was 47 years (range 19 to 77 years). The right side was operated in 49 cases (58%) and the left side in 35 cases (42%).

The mean duration of follow-up was 10 years and six months. The shortest follow-up was four months and the longest was 20 years, with a median of nine years and SD of 4.8 years.

There were three cases of failure of both compo-nents (3.2%) and four cases of failure of the acetabular component alone (4.3%).

From analysis on the clinical results in accordance with the classification of D’Aubigné and Postel(9), 82 hips (88%) presented good or very good results, as il-lustrated in Figure 1.

Osteolysis was present in 66 acetabula (75%) and was most frequently seen in the DeLee and Charnley zones two and three(11), as presented in Figure 2, ac-cording to their location.

157

010203040506070

Verygood

Good Medium Fair Poor

2 (2%)

62 (67%)

20 (21%)

5 (6%) 4 (4%)

No.

of c

ases

(%)

figure 1 – Sample distribution in accordance with the functional evaluation proposed by D’Aubigné and Postel(9)

figure 2 – Sample distribution according to the presence of osteolysis and location in accordance with the DeLee and Char-nley zones(11). In this case, we considered that osteopenia was present in area II.

figure 3 – Anteroposterior radiograph of the pelvis on a patient with 17 years of follow-up on the right side and 16 years on the left side.

figure 4 – Radiograph on the left hip demonstrating femoral osteopenia affecting the regions of the greater and lesser tro-chanters, without compromising the stability and fixation of the femoral implant.


Femoral osteolysis was present in 83 cases (98.8%), and it was classified in accordance with the criteria of Turíbio, as illustrated in Table 1 according to its location:

Table 1 – Sample distribution in relation to femoral osteolysis, in accordance with the criteria of Turíbio

Turíbio grade Cases Percentage (%)

01234

12942102

1.2034.5050.0011.902.40

0 – �absence of osteolysis1 – �osteolysis restricted to the region of the greater trochanter2 – �osteolysis extending from the region of the greater trochanter towards the lesser trochanter3 – �osteolysis affecting both the greater and the lesser trochanter and extending to the middle third

of the diaphysis4 – �osteolysis throughout the region of the femoral implant.

In Figure 4, we present an example of femoral os-teolysis affecting the regions of the greater and lesser trochanter (Turíbio 2), without compromising the stabil-ity of the femoral component.

Polyethylene wear was present in 69 cases (82%), with a mean of 1.4 mm (range 0 to 5). Taking the mean duration of follow-up of 10 years and six months, the mean rate of polyethylene wear was 0.13 mm per year. The statistical analysis demonstrated that the occurrences of acetabular osteolysis were related to polyethylene wear

In Figure 3, we present a radiograph from a case with 17 years of follow-up on the right side and 16 years on the left side, without any signs of loosening of the implants. It shows signs of acetabular osteolysis, but without clinical repercussions.

TOTAL HIP ARTHROPLASTY WITH BIOMEC PROSTHESIS: 20-YEAR FOLLOW-UP

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13 2124

85 3 8

0

5

10

15

20

25

Absent 1mm 2mm 3mm 4mm 5mm 6 a11mm

N° of cases

figure 5 – Sample distribution according to the frequency and magnitude of migration of the femoral nail.


(P = 0.04). The wear on the polyethylene was also cor-related with worsened clinical outcomes (P = 0.036).

Femoral nail migration or “subsidence” was present in 67 cases (79.7%) and absent in 17 cases (20.3%), with a mean migration distance of 2.33 mm and median of 2 mm. Figure 5 provides a better illustration of the frequency of migration. The statistical analysis did not show any worsening of the clinical outcome through femoral migration (P = 0.009).

DiSCUSSiONThe sex distribution in our sample (38% men and

62% women) was in accordance with other reports in the literature(13-15). The mean age in our study (47 years) was also similar to reports in the literature, which de-scribe mean ages ranging from 51 to 53 years(13-18).

The clinical assessment showing that 80% of the re-sults were good and very good was similar to what was found in a study using the Spotorno® prosthesis, a foreign model that formed the basis for the development of the prosthesis under examination here(13,14,18,19). In the statis-tical analysis on the clinical outcome over the follow-up period, it was observed that there was a gradual decrease in functional grade as the length of follow-up increased, with P = 0.008. This can be explained in terms of wear on the implant with the passage of the years, thereby leading to a gradual decrease in the clinical score.

We did not find any statistical significance with re-gard to analyzing the prevalence of acetabular osteolysis (75%) in relation to the clinical outcome (P = 0.001). This explains the finding of very good functional results despite the high prevalence of acetabular osteolysis. It is in line with what was reported by other authors, who did

not find any relationship between acetabular osteolysis and the clinical outcome(15,18).

Femoral osteolysis presented even greater preva-lence, such that it was observed in 98.8% of the cases. However, in around 85% of the cases, it only affected the regions of the greater and lesser trochanters and did not compromise the fixation and/or stability of the implant. This was demonstrated in a prospective study with evaluation of the bone mineral density around the prosthesis following Spotorno® arthroplasty, in which a significant decline in bone mass (21%) was found in the region of the trochanters over the first two years after the operation(20). In the statistical analysis between femoral osteolysis and the clinical outcome, we also did not find any statistical significance (P = 0.124).

Acetabular osteolysis presented a correlation with femoral osteolysis, with greater prevalence as the femo-ral osteolysis became more marked (P = 0.014). This was very likely due to the accumulation of debris and penetration at the bone-implant interface.

The correlation between wear on the polyethylene and greater prevalence of acetabular osteolysis found in our study was statistically significant (P = 0.04), and this had already been demonstrated by previous studies(21,22).

The mean wear of 1.4 mm found in our series and the wear rate of 0.13 mm/year considering the mean follow-up of ten years and six months overlapped with the mean wear reported in the literature for cemented prostheses and was a smaller amount than shown in studies on uncement-ed (non-expansive) acetabula with shorter follow-up(23).

The migration and accommodation of the femoral nail (subsidence) in 67 cases (80%), with a mean of 2.33 mm, was in line with the biomechanical theory put forward many years ago by Spotorno for wedge-shaped nails, which is now greatly valued by advocates of cemented and polished wedge-shaped nails without collars(24). This makes us believe that until secondary fixation through osseointegration has been established, adjustments to the wedge-shaped quadrangular nail within the bone case.

CONCLUSiONTHA using the Biomec uncemented prosthesis present-

ed good results in 88.2% of the cases, over a mean follow-up of ten years and six months among this cohort.

Although we found significant numbers of cases of femoral and acetabular osteolysis among our sample, these did not have any significance regarding modifica-tion of the clinical outcome.

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Charnley J. The long-term results of low-friction arthroplasty of the hip performed 1. as a primary intervention. J Bone Joint Surg Br. 1972;54(1):61-76.Jones LC, Hungerford DS. Cement disease. Clin Orthop Relat Res. 1987;(225): 2. 192-206.Chandler HP, Reineck FT, Wixson RL, McCarthy JC. Total hip replacement in 3. patients younger than thirty years old. A five-year follow-up study. J Bone Joint Surg Am. 1981;63(9):1426-34.Judet R, Siguier M, Brumpt B, Judet T. A noncemented total hip prosthesis. Clin 4. Orthop Relat Res. 1978;(137):76-84.Spotorno L, Romagnoli S, Ivaldo N, Grappiolo G, Bibbiani E, Blaha DJ, Guen 5. TA.The CLS system. Theoretical concept and results. Acta Orthop Belg. 1993;59(Suppl 1):144-8.Macedo CAS, Scheidt RB, Palma HM, Rosito R, Weissheimer W, Galia CR. 6. Artroplastia total de quadril de spotorno: resultados clínicos e radiográficos. Acta Ortop Bras. 2008;16(1):17-22.Zweymüller K, Semlitsch M. Concept and material properties of a cementless hip 7. prosthesis system with Al2O3 ceramic ball heads and wrought Ti-6Al-4V stems. Arch Orthop Trauma Surg. 1982;100(4):229-36.Zweymüller K. A cementless titanium hip endoprosthesis system based on press-fit 8. fixation: basic research and clinical results. Instr Course Lect. 1986;35:203-25.D’Aubigné RM, Postel M. Function al results of hip arthroplasty with acrylic pros-9. thesis. J Bone Joint Surg Am. 1954;36(3):451-75.Zicat B, Engh CA, Gokcen E. Patterns of osteolysis around total hip components 10. inserted with and without cement. J Bone Joint Surg Am. 1995;77(3):432-9.DeLee JG, Charnley J. Radiological demarcation of cemented sockets in total hip 11. replacement. Clin Orthop Relat Res. 1976;(121):20-32.Turíbio FM. Alterações radiográficas do fêmur nas artroplastias totais do quadril 12. com prótese não cimentada de Parhofer-Monch [tese]. São Paulo: Escola Paulista de Medicina, Universidade Federal de São Paulo; 1996.Spotorno L, Schenk RK, Dietschi C, Romagnoli S, Mumenthaler A. [Personal 13. experiences with uncemented prostheses]. Orthopade. 1987;16(3):225-38.

Bulow JU, Scheller G, Arnold P, Synatschke M, Jani L. Follow-up (6-9 years) 14. results of the uncemented CLS Spotorno stem. Arch Orthop Trauma Surg. 1996;115(3-4):190-4.

Aldinger PR, Breusch SJ, Lukoschek M, Mau H, Ewerbeck V, Thomsen M. A 15. ten- to 15-year follow-up of the cementless spotorno stem. J Bone Joint Surg Br. 2003;85(2):209-14.

Schramm M, Keck F, Hohmann D, Pitto RP. Total hip arthroplasty using an un-16. cemented femoral component with taper design: outcome at 10-year follow-up. Arch Orthop Trauma Surg. 2000;120(7-8):407-12.

Vidyadhara S, Rao SK. Uncemented primary press-fit total hip arthroplasty: a 3 to 17. 6 years of experience. J Orthop Surg (Hong Kong). 2007;15(1):50-5.

Tauber C, Kidron A. Total hip arthroplasty revision using the press-fit CLS Spotorno 18. cementless stem. Twenty-four hips followed between 1987 and 1998. Arch Orthop Trauma Surg. 2000;120(3-4):209-11.

Macedo CAS, Scheidt RB, Palma HM, Rosito R, Weissheimer W, Galia CR. Artro-19. plastia total do quadril de Spotorno. Acta Ortop Bras. 2008;16(4):217-22.

Zerahn B, Lausten GS, Kanstrup IL. Prospective comparison of differences in 20. bone mineral density adjacent to two biomechanically different types of cementless femoral stems. Int Orthop. 2004;28(3):146-50.

Mallory TH, Head WC, Lombardi AV Jr. Tapered design for the cementless total hip 21. arthroplasty femoral component. Clin Orthop Relat Res. 1997;(344):172-8.

Robinson RP, Deysine GR, Green TM. Uncemented total hip arthroplasty using 22. the CLS stem: a titanium alloy implant with a corundum blast finish. Results at a mean 6 years in a prospective study. J Arthroplasty. 1996;11(3):286-92.

Joshi RP, Eftekhar NS, McMahon DJ, Nercessian OA. Osteolysis after Charnley 23. primary low-friction arthroplasty. A comparison of two matched paired groups. J Bone Joint Surg Br. 1998;80(4):585-90.

Engh CA, Massin P, Suthers KE. Roentgenographic assessment of the bio-24. logic fixation of porous-surfaced femoral components. Clin Orthop Relat Res. 1990;(257):107-28.

rEfErENCES


TOTAL HIP ARTHROPLASTY WITH BIOMEC PROSTHESIS: 20-YEAR FOLLOW-UP

artigo 195

1 – �MSc from UnB. Attending Physician in the Spinal Surgery Service, DOT-HC, Federal University of Goiás (UFG).2 – �PhD from USP. Titular Professor of Rheumatology in the Department of Clinical Medicine, School of Medicine, Federal University of Goiás (UFG).3 – �Auxiliary Professor and Head of the Spinal Surgery Service, DOT-HC, Federal University of Goiás (UFG).4 – �MSc from UnB. Auxiliary Professor, DOT-HC, Federal University of Goiás (UFG).5 – �Attending Physician in the Rheumatology Service, Department of Clinical Medicine, School of Medicine, Federal University of Goiás (UFG).

Work performed in the Rheumatology Service and Spinal Surgery Service, School of Medicine, Federal University of Goiás (UFG).Correspondence: Frederico Barra de Mores, Departamento de Ortopedia e Traumatologia, 3º andar, Hospital das Clínicas, Setor Universitário, Av. Universitária s/nº, 74000-000 Goiânia, GO, Brazil – E-mail: [email protected]


OriGiNaL arTiCLE

EVALUATION OF THE cErVIcAL SPINE AMONg PATIENTS wITH rHEUMATOID ArTHrITIS

André Luiz Passos Cardoso1, Nilzio Antonio da Silva2, Sérgio Daher3, Frederico Barra de Moraes4, Humberto Franco do Carmo5


iNTrODUCTiONRheumatoid arthritis is a chronic systemic inflammatory

disease of unknown cause that mainly affects the synovial membrane of many joints(1,2). Its prevalence in Brazilian populations ranges from 0.2 to 1%(3).

Although it may affect the entire vertebral axis, its main involvement is in the cervical spine and especially at the craniocervical junction, which can be explained by the fact that the occipital-C1 and C1-C2 joints are purely synovial(4,5).

The various studies available show that 5% to 73% of the patients with rheumatoid arthritis will develop atlantoaxial subluxation between two and ten years after receiving their diagnosis. Of these, 20% will present

abSTraCT

Objective: To evaluate the prevalence of cervical spine abnor-malities among patients with rheumatoid arthritis and correlate the imaging findings with the clinical state. Methods: A cross-sectional study on 35 patients was carried out at the School of Medicine of the Federal University of Goiás (UFG) in 2004. The following were evaluated: age, use of medications and the clinical picture of pain and neurological characteristics. The erythrocyte sedimentation rate (ESR) and rheumatoid factor were tested, and radiographs of the cervical spine were produced in anteroposte-rior, lateral and dynamic views. To evaluate the influence of the variables on the emergence of instabilities, univariate and mul-tivariate logistic regression tests were used (p < 0.05). Results: Among the 35 patients evaluated, 13 (37.1%) presented a stable cervical spine. Out of the 22 patients with instability, six presented more than one type. Atlantoaxial instability was found in 15 pa-

tients, with a mean anterior atlantodental distance of 3.40 mm in the neutral lateral radiographic view and 6.54 mm in the lateral view with flexion. Basilar invagination was found in five patients and subaxial subluxation in seven patients. Two thirds of the asymptomatic patients had instabilities. Bicipital hyperreflexia presented statistically significant correlations with atlantoaxial instability (p = 0.024) and subaxial instability (p = 0.01). Age at diagnosis correlated with subaxial instability (p = 0.02). Conclu-sions: The prevalence of cervical instability was 62.9 % (22/35). The most frequent instabilities were: atlantoaxial subluxation (42.9 %), subaxial subluxation (20%) and basilar invagination (14.3%). The correlation between instabilities and clinical signs and symptoms was poor. The patients with subaxial subluxation presented disease onset at a younger age. Dynamic radiography was important for diagnosing atlantoaxial subluxation.

Keywords – Spine; Cervical vertebrae; Rheumatoid arthritis

significant abnormalities in the subaxial cervical spine. Around 17% of all patients with rheumatoid arthritis will develop neurological signs and symptoms (ranging from 5 to 67%) and, among those who develop myel-opathy, half of them will only survive for one year(6-9).

There are several reports on the prevalence of cervi-cal lesions and rheumatoid arthritis in European and North American populations, but the extent of this prob-lem remains little known within the Brazilian setting.

The aims of this study were to evaluate the prevalence of abnormalities of the cervical spine among patients with rheumatoid arthritis and to establish which types are most frequent, with correlations between imaging findings and the clinical picture.

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METhODS

This study was approved in July 2003 by the Ethics Committee for Human and Animal Research of Hospital das Clínicas, Federal University of Goiás (UFG). All the patients were evaluated and included in the study after they had signed an informed consent statement.

A cross-sectional investigation was then carried out in 2004, with a sample obtained from among patients at the outpatient clinic of the Rheumatology Service of the Department of Clinical Medicine, School of Medicine, UFG. Cases of rheumatoid arthritis were diagnosed in accordance with the criteria of the American College of Rheumatology (ACR), and patients were included in this study consecutively as they were attended.

Patients were excluded from the study if they started to present the disease before reaching 18 years of age; if they had a history of trauma to the cervical spine; if they had previously undergone surgery on the cervical spine; if they did not accept the informed consent statement; if they abandoned the study; or if they did not undergo the examinations that they were asked to have.

The following variables were evaluated: age at diag-nosis, duration of the disease, use of and duration of use of corticoids, use of disease-modifying antirheumatic drugs (DMARDs) and neurological state.

The presence of occipital headache, cervicalgia or paresthesia, and the subjective assessment of strength, were evaluated and correlated with the presence of cervical instability. The presence of abnormal reflexes, presence of Babinsky and L’Hermitté signs and presence of clonus were evaluated in the physical examination. Objective evaluation of strength was excluded because of interference from the disease activity, which made interpretation difficult. The classification of Ranawat et al(10) was used to objectively assess the painful symp-toms and neurological involvement (Boxes 1 and 2).

The erythrocyte sedimentation rate (ESR) and rheu-matoid factor were tested in the laboratory.

The imaging examinations consisted of simple ra-diography of the spine, using the anteroposterior and lateral views. The latter was performed in neutral posi-tion and dynamic (flexion and extension) positions. The tube-film distance was standardized as 1.50 m.

Atlantoaxial instability was diagnosed when the an-terior atlantodental distance was greater than 3 mm, as measured between the anterior arch of the atlas and the odontoid process. Basilar invagination (upwards migra-tion of the odontoid) was evaluated using the methods of Ranawat et al(10) (the normal value was taken to be 15 mm or more for men and 13 mm or more for wom-en) (Figure 1) and the methods of Redlund-Johnell and Pettersson(11) (the normal value was taken to be 34 mm or more for men and 29 mm or more for women) (Figure 2). It was diagnosed when it was found to be positive using either of these two criteria. Subaxial subluxation was di-agnosed when there was slippage of more than 3.5 mm.

The patients were asked whether they had previously undergone radiography on the spine and whether the physician attending them had informed them that they presented spinal abnormalities.

box 1 – Ranawat pain classification

CLASS

0 Free from pain

I Intermittent pain, responsive to ordinary analgesics

II Intermittent pain, responsive ordinary analgesics, with need for immobilization using a cervical collar

III Continuous and incapacitating pain that does not respond to analgesics

Adapted from Ranawat et al(10)

box 2 – Ranawat classification for neurological involvement

CLASS Neurological abnormality

I No neurological abnormalities

II Subjective weakness, hyperreflexia, dysesthesia

IIIObjective weakness, long tract signsA – Able to walkB – Unable to walk, quadriparetic

Adapted from Ranawat et al(10)

figure 1 – A) Illustration demonstrating Ranawat’s method (mea-surement of the distance between the center of the pedicle of C2 and the transverse line on the C1 arch), as modified by Riew et al(12) (reproduced with permission from the Journal of Bone and Joint Surgery, Inc.). B) Lateral radiograph of the spine, demon-strating how the Ranawat index was measured.

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figure 2 – A) Illustration demonstrating Redlund-Johnell’s meth-od (measurement of the distance between McGregor’s line and the midpoint of the lower margin of C2), as modified by Riew et al(12) (reproduced with permission from the Journal of Bone and Joint Surgery, Inc.). B) Lateral radiograph of the spine, demon-strating how the Redlund-Johnell index was measured.

figure 3 – 53-year-old female patient with the disease for the past 33 years. She did not present any complaint and, on Ranawat’s scale, she was grade 0. Lateral radiograph showing anterior atlantoaxial distance of 3.2 mm, viewed in the neutral position (A) and anterior atlantoaxial distance of 9.9 mm, viewed laterally, in flexion (B). A pos-terior atlantoaxial distance of 11.6 mm can also been seen on the ra-diograph in flexion: this is a sign of high risk of irreversible paralysis.


The Microsoft® Excel 2000 software was used to tabulate the data, and the statistical analysis was per-formed using the SPSS® software (Statistical Package for the Social Sciences) for Windows®, version 11.5. To evaluate the influence of the variables on the emergence of instabilities, univariate and multivariate logistic re-gression tests were used. The significance level was taken to be values less than 0.05 (p < 0.05).

rESULTSAmong the 35 patients evaluated, there were 31 women

(88.6%) and four men (11.4%), with a mean age of 51.6 years (ranging from 32 to 68 years). The mean age at which rheumatoid arthritis was diagnosed was 36.6 years (rang-ing from 20 to 62 years). The patients had had the disease for a mean of 15 years (ranging from 4 to 33 years).

One patient was not using any medication.With regard to corticoid use, only one patient was

not doing so, while the other 34 patients had been us-ing corticoids for a mean of 11.8 years (ranging from 5 to 32 years).

Two patients were not using disease-modifying anti-rheumatic drugs (DMARDs). Twenty-nine patients were using only one DMARD, while nine were using a double regimen and one was using a triple regimen.

Twenty-six patients had at least one of the clinical manifestations under evaluation: 14 patients with oc-cipital headache, 19 with cervicalgia, 12 with paresthe-sia and nine with subjective loss of strength. Among the nine patients who did not have any complaints of headache, cervicalgia, paresthesia and loss of strength, or any complaints of pain in the Ranawat classification

(class 0), six presented cervical instability (three cases of atlantoaxial subluxation, two of subaxial subluxation and one of atlantoaxial subluxation in association with basilar invagination) (Figure 3).

Eleven patients did not present any abnormalities of reflexes. Two patients were positive for Babinsky’s sign, four were positive for L’Hermitté’s sign and two presented clonus.

The pain presented by the patients was classified as follows on the Ranawat scale: 13 in class 0, 20 in class I and two in class III. The functional evaluation showed that there were 24 cases in class I, nine cases in class II and two cases in class III-A.

The erythrocyte sedimentation rate (ESR) was high in 16 patients, with a mean of 52.5 mm/h. Twenty-seven patients were positive for rheumatoid factor.

Only two patients had previously undergone radiog-raphy on the spine. One of them presented atlantoaxial instability and did not know about it, while the other was aware of having a spinal abnormality but did not know which one it was.

Among the patients evaluated, 13 (37.1%) presented spinal stability. Among the 22 patients (62.9%) with a radiographic picture of instability, six had more than one type of instability (one case of invagination and subaxial subluxation, two cases of invagination and at-lantoaxial subluxation and three cases of atlantoaxial subluxation and subaxial subluxation).

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Atlantoaxial instability was found in 15 patients (42.9%), with a mean anterior atlantodental distance of 3.4 mm (ranging from 1.5 to 9.4 mm) on lateral radiographs in neutral position and 6.5 mm (ranging from 3.1 to 10.1 mm) on lateral radiographs in flexion. Among these 15 patients, the anterior atlantodental distance was normal on lateral radiographs in neutral position. Measurements of the posterior atlantodental distance showed that two patients presented an interval of less than 14 mm.

Basilar invagination was found in five patients (14.3%), among whom four were diagnosed using the Ranawat method, three were diagnosed using the Redlund-Johnell method and two were diagnosed using both methods.

Subaxial subluxation was observed in seven patients (20%).

The statistical analysis demonstrated significant correlations between the following variables: bicipital hyperreflexia and atlantoaxial instability (p = 0.024); bicipital hyperreflexia and subaxial instability (p = 0.01); and age at diagnosis and subaxial instability (p = 0.02). The mean age at diagnosis among the patients with subaxial instability was 34.9 years (± 10), while the mean age of the patients without subaxial instabil-ity was 42.5 years (± 12.7). There was no significant correlation between the other variables and the differ-ent types of instability (atlantoaxial subluxation, basilar invagination and subaxial subluxation).

DiSCUSSiON

Studies on the involvement of the cervical spine in pa-tients with rheumatoid arthritis have not been prominent within the Brazilian setting. Systematic periodic evalua-tion of the cervical spine among patients with rheumatoid arthritis should be performed routinely in rheumatology and orthopedics services, but it is not even done preop-eratively for a significant proportion of the patients(13).

Despite the advances due to new types of imaging examinations (computed tomography and magnetic reso-nance), investigations using simple radiography form the ideal method for screening for instabilities of the cervical spine because of their low cost (less than 10% of the cost of magnetic resonance) and easy access (practi-cally universal availability in clinics and hospital, even in those of small size)(14-18).

In our sample, we did not find any statistical correla-tion between the use of DMARDs and the development of cervical abnormalities, but it is important to emphasize

that the study model used (cross-sectional) had a major influence on this finding, given that this methodology is not ideal for making this specific investigation.

The prevalence of instability found in our se-ries (62.9%) was within the range reported in the literature(1,15,17-22).

Atlantoaxial subluxation is the type of instability that most frequently affects the cervical spine of patients with rheumatoid arthritis(14,18,19,21,23,24). The anterior atlanto-dental distance measurement is the reference for diagnos-ing anterior atlantoaxial subluxation, although Boden et al(21) observed in a study on factors predicting paralysis that the posterior atlantodental distance is the main pa-rameter to be evaluated. In their study, they observed that patients with a posterior atlantodental distance small-er than 10 mm did not achieve neurological recovery through surgical treatment, and that when there was an association with basilar invagination, the minimum pos-terior atlantodental distance should be 13 mm, for there to be neurological recovery. However, all the patients with paralysis and a posterior atlantodental distance of at least 14 mm achieved complete neurological recovery. The authors concluded that surgical treatment, whether in cases of neurological deficit or not, was indicated for all patients with atlantoaxial subluxation and a posterior atlantodental distance of 14 mm or less. This approach was reinforced by the study by Zeidman and Ducker(7) who, in studying the craniocervical junction, observed that the minimum space for the neural structures was 13 to 14 mm. In our sample, two of the 15 patients with at-lantoaxial subluxation presented a posterior atlantodental distance smaller than 14 mm on the radiograph in flexion, and one of these cases was asymptomatic (Figure 4).

figure 4 – Case demonstrating the importance of producing dy-namic radiographs. Lateral radiographic views showing a normal anterior atlantodental distance in the neutral position (1.6 mm) and a significant increase in the anterior atlantodental distance in the flexed position (7.2 mm)


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One point to be emphasized in studying atlantoaxial instability is the use of dynamic radiographs. We ob-served in our study that 60% (9/15) of the patients with atlantoaxial subluxation presented a normal anterior atlantodental distance (less than 3 mm) on the lateral radiograph in neutral position (Figure 4). Kwek et al(13) demonstrated that the difference in the detection rate for instabilities of the cervical spine between radiographic views in a stressed position (dynamic) and non-stressed position (neutral) was statistically significant (p < 0.05). Basilar invagination may be difficult to diagnose on sim-ple radiographs, to such an extent that several techniques for diagnosing it exist. Riew et al(12) conducted a study to evaluate the radiographic criteria that are most accepted for diagnosing basilar invagination among patients with rheumatoid arthritis (Clark’s stages, Chamberlain’s line, McRae’s line, McGregor’s line, Redlund-Johnell’s crite-rion, Ranawat’s criterion, Fischgold-Metzger’s line and Wackenheim’s line). The study demonstrated that no test alone had sensitivity or negative predictive value greater than 90%. These authors suggested that a combination of tests should be used (Clark’s stages, Redlund-Johnell’s criterion and Ranawat’s criterion), in order to attain higher sensitivity and negative predictive value, and that if any of these tests were to suggest the presence of basilar invagination, computed tomography or magnetic resonance examinations should be performed. Even with a combined approach, the authors reported that around 6% of the basilar invagination would pass by unnoticed, and they concluded that whenever there was any diag-nostic doubt based on simple radiograph examinations, computed tomography or magnetic resonance examina-tions should be performed. In our study, we chose to use the methods of Redlund-Johnell and Ranawat, and this standard was also used by Souza and Defino(20). These authors found prevalences of basilar invagina-tion of 11% and 13.5% among their patients, using the criteria of Ranawat and Redlund-Johnell respectively, but they did not comment on the simultaneous findings. The advantage of these techniques is that the diagnosis is made independent of viewing the tip of the odontoid, which is difficult to see in rheumatic patients because of osteoporosis. Riew et al(12) were able to identify the tip of the odontoid in only 34% of their cases and, for this reason, they did not recommend the use of techniques for direct measurement of the migration of the odontoid (McRae’s, Chamberlain’s and McGregor’s lines). This opinion has also been shared by other authors(9-24). We observed a prevalence of basilar invagination of 14.3%

(five patients) in our group of patients, with diagnoses using Ranawat’s method in four cases and using Red-lund-Johnell’s method in three cases, and simultaneous diagnosis using both methods in two cases.

Involvement of the subaxial cervical spine occurs in 7 to 29% of patients with rheumatoid arthritis(8,25), and this considered to be the second most frequently occurring type of cervical subluxation(9,18,24). In our sample, we found subaxial subluxation in 20% of our patients, and this was the second most frequent instability. The pa-tients with subaxial subluxation started to present rheu-matoid arthritis at a younger age, which was a statisti-cally significant difference (34.8 years versus 42.5 years; p = 0.02). According to Bouchard-Chabot and Lioté(8), the subaxial cervical spine is more affected among older patients, but they did not make any comments regarding the onset of rheumatoid arthritis at younger ages. The mean age among the group of patients with subaxial subluxation in our sample was 56.1 years (ranging from 43 to 68 year), while the mean age among the patients without subaxial subluxation was 50.5 years (ranging from 32 to 65 years), which was a difference without statistical significance.

Castro et al(19) evaluated 50 patients with a diagno-sis of rheumatoid arthritis and observed that the cor-relation between the neurological clinical signs and the severity of the radiographic findings was low. Souza and Defino(20) concluded that there was no statistically significant correlation between cervical instabilities and complaints of cervicalgia or signs of neurological com-pression, and they commented that this is a fact of great practical value, since it shows that even in the absence of symptoms, the cervical spine should be investigated. In our series, we observed that 66% (6/9) of the patients who did not have any complaints presented instabilities of the cervical spine. Moreover, one of these patients had a posterior atlantodental distance of less than 14 mm (11.65 mm) (Figure 3), which would be an absolute indication for investigation using magnetic resonance,(18) in order to evaluate a likely indication for surgical treat-ment because of the risk of irreversible paralysis(21). In the present sample, it could be seen that there was a lack of correlation between instabilities of the cervical spine and clinical signs and symptoms.

Kauppi et al(26) carried out a study to evaluate risk factors for anterior atlantoaxial subluxation and conclud-ed that the erythrocyte sedimentation rate did not have any correlation with the development of the instability. According to these authors, the rapid relative changes

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Alberstone CD, Benzel EC. Cervical spine complications in rheumatoid arthritis 1. patients. Awareness is the key to averting serious consequences. Postgrad Med. 2000;107(1):199-200, 205-8.Hellmann DB, Stone JH. Arthritis & musculoskeletal disorders. In: Tierney Jr 2. LM, McPhee SJ, Papadakis MA. Current medical diagnosis & treatment 2000. 39th ed. New York: Lange Medical Books; 2000. p.826-33.Marques Neto JF, Gonçalves NT, Langen LFOB, Cunha MFL, Radominski S, 3. Oliveira SM, et al. Estudo multicêntrico da prevalência da AR no adulto em amostras da população brasileira. Rev Bras Reumatol. 1993;33:169-73.Crockard HA. Surgical management of cervical rheumatoid problems. Spine 4. (Phila Pa 1976). 1995; 20(23):2584-90.Reiter MF, Boden SD. Inflammatory disorders of the cervical spine. Spine (Phila 5. Pa 1976). 1998;23(24):2755-66.Casey AT, Crockard HA, Pringle J, O’Brien MF, Stevens JM. Rheumatoid arthritis 6. of the cervical spine: current techniques for management. Orthop Clin North Am. 2002;33(2):291-309.Zeidman SM, Ducker TB. Rheumatoid arthritis. Neuroanatomy, compression, 7. and grading of deficits. Spine (Phila Pa 1976). 1994;19(20):2259-66.Bouchaud-Chabot A, Lioté F. Cervical spine involvement in rheumatoid arthritis. 8. A review. Joint Bone Spine. 2002;69(2):141-54.Gurley JP, Bell GR. The surgical management of patients with rheumatoid cervi-9. cal spine disease. Rheum Dis Clin North Am. 1997;23(2):317-32.Ranawat CS, O’Leary P, Pellicci P, Tsairis P, Marchisello P, Dorr L. Cervical spine 10. fusion in rheumatoid arthritis. J Bone Joint Surg Am. 1979;61(7):1003-10.Redlund-Johnell I, Pettersson H. Radiographic measurements of the cranio-11. vertebral region. Designed for evaluation of abnormalities in rheumatoid arthritis. Acta Radiol Diagn (Stockh). 1984;25(1):23-8.Riew KD, Hilibrand AS, Palumbo MA, Sethi N, Bohlman HH. Diagnosing basilar 12. invagination in the rheumatoid patient. The reliability of radiographic criteria. J Bone Joint Surg Am. 2001;83(2):194-200.Kwek TK, Lew TW, Thoo FL. The role of preoperative cervical spine X-rays in 13. rheumatoid arthritis. Anaesth Intensive Care. 1998;26(6):636-41.Chang DJ, Paget SA. Neurologic complications of rheumatoid arthritis. Rheum 14. Dis Clin North Am. 1993;19(4):955-73.Kramer J, Jolesz F, Kleefield J. Rheumatoid arthritis of the cervical spine. 15. Rheum Dis Clin North Am. 1991;17(3):757-72.

Boden SD. Rheumatoid arthritis of the cervical spine. Surgical decision mak-16. ing based on predictors of paralysis and recovery. Spine (Phila Pa 1976). 1994;19(20):2275-80.Rawlins BA, Girardi FP, Boachie-Adjei O. Rheumatoid arthritis of the cervical 17. spine. Rheum Dis Clin North Am. 1998;24(1):55-65.Dreyer SJ, Boden SD. Natural history of rheumatoid arthritis of the cervical 18. spine. Clin Orthop Relat Res. 1999;(366):98-106.Castro S, Verstraete K, Mielants H, Vanderstraeten G, de Reuck J, Veys 19. EM.Cervical spine involvement in rheumatoid arthritis: a clinical, neurological and radiological evaluation. Clin Exp Rheumatol. 1994;12(4):369-74.Souza CP, Defino HLA. Estudo radiográfico das alterações da coluna cervical 20. na artrite reumatoide e sua associação com sinais e sintomas da doença. Acta Ortop Bras. 2005;13(1):38-41.Boden SD, Dodge LD, Bohlman HH, Rechtine GR. Rheumatoid arthritis of the 21. cervical spine. A long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg Am. 1993;75(9):1282-97.Collins DN, Barnes CL, FitzRandolph RL. Cervical spine instability in rheu-22. matoid patients having total hip or knee arthroplasty. Clin Orthop Relat Res. 1991;(272):127-35.Kauppi M, Konttinen YT, Honkanen V, Sakaguchi M, Hamalainen M, Santavirta 23. S. A multivariate analysis of risk factors for anterior atlantoaxial subluxation and an evaluation of the effect of glucocorticoid treatment on the upper rheumatoid cervical spine. Clin Rheumatol. 1991;10(4):413-8.Roche CJ, Eyes BE, Whitehouse GH. The rheumatoid cervical spine: signs of 24. instability on plain cervical radiographs. Clin Radiol. 2002;57(4):241-9.Oostveen JC, van de Laar MA, Geelen JA, de Graaff R. Successful conserva-25. tive treatment of rheumatoid subaxial subluxation resulting in improvement of myelopathy, reduction of subluxation, and stabilisation of the cervical spine. A report of two cases. Ann Rheum Dis. 1999;58(2):126-9.Kauppi M, Hakala M. Prevalence of cervical spine subluxations and dislo-26. cations in a community-based rheumatoid arthritis population. Scand J Rheumatol.1994;23(3):133-6.Paimela L, Laasonen L, Kankaanpää E, Leirisalo-Repo M. Progression of cer-27. vical spine changes in patients with early rheumatoid arthritis. J Rheumatol. 1997;24(7):1280-4.

rEfErENCES


in inflammatory parameters were not reflected in the slowly progressive changes that occur in the rheumatic cervical spine.

Positive findings of rheumatoid factor (seropositiv-ity) have been implicated as a risk factor for cervical involvement(5,15,17). Paimela et al(27) observed that pa-tients with cervical involvement were more frequently positive for rheumatoid factor than were patients with a normal cervical spine (85% versus 57%; p < 0.05).

In the laboratory evaluation on our patients, no statis-tical correlation was found between the instabilities and positive findings of VHS or rheumatoid factor.

The prevalence of instabilities of the cervical spine found in our patients reflects the data in the worldwide literature. The high frequency of instabilities in asymp-tomatic patients reinforces the need for routine investi-gation of the cervical spine in patients with rheumatoid arthritis. The possibility of severe and even fatal neuro-logical complications should serve as a warning to medi-cal teams involved in treating patients with rheumatoid arthritis, so that they maintain a high level of alertness regarding involvement of the cervical spine.

CONCLUSiONS

The prevalence of cervical instability in the present sample was 62.9 % (22/35).

The most frequent instabilities, in decreasing order, were: atlantoaxial subluxation, affecting 42.9% (15/35); subaxial subluxation, affecting 20% (7/35); and basilar invagination, affecting 14.3% (5/35).

The correlation between the instabilities of the cer-vical spine and the clinical signs and symptoms was poor. Only bicipital hyperreflexia showed a significant correlation with atlantoaxial subluxation (p = 0.024) and subaxial instability (p = 0.01). Among the asymptomatic patients, 66% presented cervical instabilities.

The patients with subaxial subluxation started to present rheumatoid arthritis at a younger age (34.8 years versus 42.5 years; p = 0.02).

Dynamic radiography was important for diagnosing atlantoaxial instability, since 60% (9/15) of the patients with atlantoaxial subluxation presented a normal anterior atlantodental distance (< 3 mm) on the lateral radio-graphic view in the neutral position.


artigo 146

1 – �Physician in the Knee Group of the Discipline of Orthopedics, Department of Orthopedics and Traumatology, Federal University of São Paulo (Unifesp).2 – �PhD from the Federal University of São Paulo. Physician in the Knee Group of the Discipline of Orthopedics, Department of Orthopedics and Traumatology, Federal

University of São Paulo (Unifesp).3 – �MSc in Sciences from Unifesp. Physician in the Knee Group of the Discipline of Orthopedics, Department of Orthopedics and Traumatology, Federal University of São

Paulo (Unifesp).4 – �PhD in Sciences from Unifesp. Affiliated Professor, Federal University of São Paulo (Unifesp).5 – �Full Associate Professor and Head of the Knee Group of the Discipline of Orthopedics, Department of Orthopedics and Traumatology, Federal University of São Paulo

(Unifesp).

Work performed within the Knee Group of the Discipline of Orthopedics, Department of Orthopedics and Traumatology, Federal University of São Paulo (Unifesp) – São Paulo Medical School.Correspondence: Rua Visconde de Inhaúma 81, apto. 94, 04145-030 São Paulo, SP, Brazil – E-mail:[email protected]


OriGiNaL arTiCLE

SUrgIcAL TrEATMENT OF OSTEOcHONDrAL LESIONS OF THE kNEE bY MEANS OF MOSAIcPLASTY

Ozório de Almeida Lira Neto1, Carlos Eduardo da Silveira Franciozi1, Geraldo Sérgio de Mello Granata Júnior2, Antonio Altenor Bessa de Queiroz3, Mario Carneiro Filho4, Ricardo Dizioli Navarro5


abSTraCT

Objective: To evaluate the functional results from the technique of mosaicplasty, in the knees of patients with osteochondral lesions. Methods: Between August 1999 and March 2005, 27 patients un-derwent mosaicplasty on their knees. Twenty-one were male and six were female. The patients’ ages ranged from 16 to 64 years (mean of 38.1 years). Seventeen lesions were located on the right knee and ten on the left knee. The lesion was located on the lateral femoral condyle in four patients (15%), on the medial femoral condyle in 18 patients (66.5%) and on the patella in five patients (18.5%). The lesion sizes ranged from 1 to 8 cm² (mean of 2.7 cm²). The patients were evaluated before and after the operation using Lysholm’s functional scale, with a mean follow-up of 2.5 years. Results: Before the operation, the mean was 62.7 points, and

after the operation, the mean was 95.4 points. The patients who underwent mosaicplasty on the lateral femoral condyle presented a mean of 51.5 points before the operation, and a mean of 100 points after the operation. In relation to the medial femoral condyle, the mean before the operation was 64.1 points, and it was 95.4 points after the operation. In relation to the patella, the mean before the operation was 66.4 points, and it was 92 points after the operation. Conclusion: Mosaicplasty proved to be a good alternative for treat-ing osteochondral lesions of the knee. It presented better evolution in relation to lesions of the femoral condyles than in relation to lesions located on the patella.

Keywords – Cartilage diseases/surgery; Joint cartilage/trans-plantation; Knee joint/surgery; Arthroscopy; Autologous trans-plantation

iNTrODUCTiON

Chondral and osteochondral lesions in the knee are still one of the biggest problems for knee surgeons, espe-cially when they occur in young individuals and athletes. Preservation of the anatomical structure and physiologi-cal properties of the cartilage is a basic requisite for good functioning of the joint.

The capacity for cartilage regeneration is limited be-cause chondrocytes do not have the capability to differ-entiate and multiply.

These lesions can cause pain, edema and joint blockage. If they are not properly treated, they can cause osteoarthro-sis, particularly if they are located in load-bearing areas.

Several types of surgical treatment for these lesions exist. They are basically divided into reparative meth-ods, which stimulate and enable the formation of chon-drogenic or fibrochondrogenic tissue, and reconstruc-tive methods, which treat the defect with autologous or homologous chondral or osteochondral grafts(1).

The reparative techniques, such as debridement of the lesion, chondroplasty to treat abrasion, subchondral perforations and, more recently, treatment for microfrac-tures have the aim of forming fibrocartilaginous tissue with has a structure and biomechanical properties that are similar but inferior to those of normal cartilage(2). However, over the long term, this does not stop the pro-

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gression of the degeneration and, one year afterwards, the lesions already show new fiber degeneration and cell death(3,4).

Other, alternative methods exist, such as periosteal grafting, synthetic osteochondral grafting, autologous osteochondral grafting (mosaicplasty) and chondrocyte transplantation(2).

Macroscopic and microscopic evaluations on the technique of mosaicplasty, which was described by Hangody in 1992 and published in 1997, demonstrated that transplanted hyaline cartilage survived well. Eight weeks after grafting, a bed composed of 80% cartilage and 20% fibrocartilage had formed at the base of the bone defect, the graft had become integrated with the bone matrix of the recipient area, and the donor sites had become filled with spongy bone and covered with a cap of fibrocartilage(5,6).

The technique consists of removing small bone cyl-inders from the periphery of the femoral condyle and intercondylar region and transplanting them to areas where there are chondral and osteochondral lesions, with the aim of maintaining the quality and structure of the cartilage that makes up this region(7).

According to Hangody et al(5-8), the literature pro-vides both indications and contraindications for this type of surgery (Box 1).

The present had the aim of making functional evalu-ations on patients who underwent mosaicplasty to treat osteochondral lesions of the knee.

METhODSBetween August 1999 and March 2005, 27 patients

with osteochondral lesions in their knees underwent mo-saicplasty. The patients’ mean age was 31.1 years (range: 16-64 years). Among these patients, 21 were male and six were female. Sixteen patients underwent operations on the right knee and ten on the left knee.

The mean size of the defect was 2.7 cm² (range: 1-8 cm²). Regarding the lesion site, four were located on the lateral femoral condyle, 18 on the medial femoral condyle and five on the patella (Table 1).

box 1 – Indications and contraindications

INDICATIONSABSOLUTE

CONTRAINDICATIONSRELATIVE

CONTRAINDICATIONS

Focal chondral and osteochondral lesions on the joint surface in loaded areas

Tumors, infections, rheumatoid arthritis, advanced osteoarthrosis

Age between 40 and 50 years

Age less than 50 years Lack of donor area available

Defects between 4 and 8 cm²

Lesion area between 1 and 4 cm²; it may be up to 8 cm² in particular cases as a salvage procedure

Age greater than 50 years Intermediate arthrosis

Concomitant or previous treatment for instability, misalignment or meniscal lesions

Lesions greater than 8 cm²

Patient’s acceptance of cooperation in postoperative loading of weight

Table 1 – Characterization of the sample

Variables n = 27

Age (years) – mean (sd) 38.1 (13.1)

minimum – maximum 16 – 64

Sex – n (%)

Female 6 (22.2)

Male 21 (77.8)

Side operated n (%)

Right 17 (63.0)

Left 10 (37.0)

Lesion location n (%)

Medial femoral condyle 18 (66.7)

Lateral femoral condyle 4 (14.8)

Patella 5 (18.5)

Lesion size (cm²) – mean (sd) 2.7 (1.8)

minimum – maximum 1 – 8

Time elapsed since operation (years) – mean (sd) 2.3 (1.5)

minimum – maximum 0.3 – 6.0Source: Department of Orthopedics and Traumatology, Federal University of São Paulo

The patients were evaluated before and after the op-eration using Lysholm’s functional scale, with a mean follow-up of 2.5 years.

The simplified scoring scale used in Lysholm’s func-tional questionnaire was as follows: excellent, if the total score was between 95 and 100; good, between 84 and 94; moderate, between 65 and 83; and poor, if lower than 64.

Among the 27 patients, five had undergone previous surgery. One of these had undergone three procedures: removal of the Hoffa fat, chondroplasty and lateral re-lease by means of drilling the patella. The other four

SURGICAL TREATMENT OF OSTEOCHONDRAL LESIONS OF THE KNEE BY MEANS OF MOSAICPLASTY

168

Mosaicplasty aloneConcomitant surgeryPrevious surgery

5 11

11

Source: Department of Orthopedics and Traumatology, Federal University of São Paulo

figure 1 – Procedures


figure 2 – Mosaicplasty

Joint portion of the femoral condyles

Osteochondral cylinders

Osteochondral lesion

figure 3 – Open surgery


figure 4 – Arthroscopic route


had respectively undergone free-body removal, drilling of the medial femoral condyle, partial meniscectomy of the medial meniscus and partial meniscectomy with excision of a meniscal cyst (Figure 1).

Eleven patients underwent treatment concomitantly with treatment of other lesions. Among these, there were four procedures of meniscectomy, three procedures of valgizing osteotomy with fixation using Puddu plates, two reconstructions of the anterior cruciate ligament and two reconstructions of the anterior cruciate ligament in association with valgizing osteotomy, with fixation using Puddu plates (Figure 1).

The mosaicplasty technique consists of obtaining small osteochondral cylinders from an area subjected to minimal load bearing, and transplanting these to defec-tive areas of load-bearing regions. By using different combinations of graft sizes, 90 to 100% of the defect can be filled (Figure 2).

The technique can be carried out as open surgery, through miniarthrotomy (Figure 3), or arthroscopically (Figure 4), with similar procedures that differ only in certain steps(7).

Among the 22 cases of osteochondral lesions without previous surgery, six were treated using the technique of miniarthrotomy and 16 using arthroscopy. The other five cases were of patients who had undergone previ-ous operations.

In the arthroscopic procedure, the siting of the ports is an extremely important matter. The patient was po-sitioned supinely, with the knee free to flex up to 120 degrees. We used a needle to find the best position for the port, such that the lesion would be reached through the port perpendicularly to the instrument that would be used to remove the osteochondral cylinders and then transplant them(7).

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figure 5 – Test guides


figure 6 – Determining the number of cylinders


These ports are usually more medial than the normal ports. Lesions in the medial femoral condyle caused by osteocondritis dissecans, in their most common loca-tions, are dealt with better through a lateral port. On the other hand, a central port crossing the patellar tendon enables good access to the internal regions of the medial and lateral femoral condyles.

Once the lesion has been identified, it is debrided un-til viable subchondral bone below it has been exposed. Using a test guide, the size of the lesion is measured and the quantity and size of the cylinders to use are calculated (Figures 5 and 6).

when the joint is insufflated, as described by Hangody et al(7). For the larger lesions, grafts had to be taken from both condyles.

Using an instrument suitable for resection, we re-moved cylinders of different diameters, all of 15 mm in length, until reaching the quantity needed to fill the lesion. We took the final sulcus as the lower anatomical limit for resection of the grafts from the lateral femoral condyle (Figures 7, 8 and 9).

Turning to the receptor area, the lesion was perfo-rated using a trephine, down to the desired depth, and then a dilator of the size of the graft was used under pressure to regularize the tunnel, always perpendicu-larly to the defect that existed. Using an appropriate instrument, the graft was gently placed in the defect, with the aim of avoiding damage to the osteochondral cylinder. This procedure of milling, dilation and place-ment was performed as many times as needed, until completely filling the location of the lesion with osteo-chondral cylinders (Figures 10, 11 and 12).

For lesions of the patella, we always performed open procedures. Using lateral arthrotomy, the patella was tilted to view the lesion and the procedure described earlier was performed. In these cases, we always used the lateral femoral condyle as the donor area.

Independent of the route, after placement of the osteo-chondral cylinders, the knee was flexed and extended to verify the excursion of the structures in the grafted area, with subsequent layer-by-layer closure up to the skin.

We used drains in all the patients and removed them 24 hours after the end of the operation.

With regard to rehabilitation, the patients were re-leased for performing a passive arc of movement after removal of the drain on the second day after the opera-tion. They were allowed to flex the knee freely, as much as they could tolerate, but did not place any load on it for six weeks. Over the subsequent two weeks, we released the patients to place partial loading on the knee, attaining full loading in the eighth week. The patients returned to sports activities four to six months after the operation.

The values obtained were subjected to statistical analysis, using the Wilcoxon and Mann-Whitney tests.

rESULTSThe patients underwent pre and postoperative func-

tional evaluations and were classified according to Ly-sholm’s questionnaire. They were followed up for a

Next, with the knee in extension, we approached the donor area. In the open procedure, we used the medial or lateral femoral condyle. In the arthroscopic procedure, we used the medial femoral condyle as the first choice, since the patella become displaced laterally


170


figures 7, 8 and 9 – Removing the graft material

7 8 9


figures 10, 11 and 12 – Placement of the graft material

10 11 12


mean of 2.5 years. The most recent assessment avail-able for each patient was taken to be the definitive final result.

The mean preoperative value for the 27 patients was 63 points (poor) and the mean postoperative value was 95 points (excellent).

Comparison between the pre and postoperative ap-plications of Lysholm’s scale showed that there was a statistically significant difference (p < 0.001). All the patients presented higher scores on the scale after the operation than they did before it, with a mean increase of 59.9% (SD = 40.6%), with a range from 11.3% to 135.7% (Table 2).

Evaluation of the patients according to the location of the lesion (patella, lateral femoral condyle or medial femoral condyle) showed slight variation. For lesions in the patella, the patients presented a preoperative score of 66 points (moderate) and a postoperative score of 92 points (good). The patients with lesions in the lateral femoral condyle had a preoperative score of 51 points

Table 2 – Lysholm’s scale

Application Lysholm’s scale (n = 27)

Mean sd Median Minimum Maximum

Before the operation 62.7 12.8 65 42 83

After the operation 95.4 6.7 99 78 100

∆% 59.9 40.6 47.7 11.3 135.7Wilcoxon Test: p < 0.001*Source: Department of Orthopedics and Traumatology, Federal University of São Paulo

(poor) and a postoperative score of 100 points (excel-lent). For the patients with lesions in the medial femoral condyle, the preoperative score was 66 points (moderate) and the postoperative score was 95 points (excellent).

Analysis on these values in relation to location, there was no statistically significant difference between the groups regarding scores on Lysholm’s scale for preoper-ative applications (p = 0.147), postoperative applications (p = 0.060) or the ∆% change (p = 0.125) (Table 3).

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figure 13 – Procedures

Before theoperation

After theoperation

Lysholm versus Procedures

MosaicplastyalonePrevious surgery

Concomitantsurgery


Division of the sample according to lesion size did not show any statistically significant difference between the groups regarding scores on Lysholm’s scale for preopera-tive applications (p = 0.693), postoperative applications (p = 0.066) or the ∆% change (p = 0.657) (Table 4).

Finally, we divided the patients into three groups: individuals who underwent mosaicplasty alone (group 1), individuals who underwent mosaicplasty with other concomitant procedures (group 2) and individuals who had already undergone other procedures prior to mosa-icplasty (group 3). From this, we obtained the following result: group 1 presented a mean preoperative score of 62 points, which became 97 points after the operation; group 2 had 59 points before the operation and 95 points after the operation; and group 3 had 71 points before the operation and 91 points after the operation. There were no statistically significant differences between these three groups (Figure 13).

With regard to complications, two patients presented infectious conditions during the immediate postopera-tive period. Both of these patients had undergone val-gizing osteotomy using the Puddu plate technique. One patient presented superficial infection and was treated with antibiotic therapy and local cleaning. The other patient, with deep infection at the osteotomy site, was treated with removal of the lyophilized graft, surgical cleaning and antibiotic therapy. Both of these patients evolved well, and the infection was cured.

DiSCUSSiON

The technique of mosaicplasty was chosen for treat-ing these cartilage lesions on the basis of findings in the literature. A multicenter randomized study carried out by Hangody et al(9) compared four different techniques

Table 3 – Lysholm’s scale according to lesion location

Lesion location

Lysholm’s scale

Before the operation

After the operation

∆%

Medial femoral condyle n = 18

64.1 (11.9)42 – 83

95.4 (6.4)79 – 100

54.7 (35.4)11.3 – 126.2

Lateral femoral condyle n = 4

51.5 (11.0)45 – 68

100.0 (0.0)100 – 100

99.9 (35.4)47.1 – 122.2

Patella (n = 5) 66.4 (14.7)42 – 80

92.0 (8.8)78 – 99

46.6 (49.9)20.0 – 135.7

Mann-Whitney test p = 0.147 P = 0.060 p = 0.125Values expressed as mean (sd), minimum – maximumSource: Department of Orthopedics and Traumatology, Federal University of São Paulo

Table 5 – Lysholm’s scale according to patients’ ages

AgeLysholm’s scale

Before the operation After the operation ∆%

< 40 years (n = 15) 64.1 (13.4)42 – 83

93.8 (8.2)78 – 100

54.4 (43.7)13.7 – 126.2

≥ 40 years (n = 12) 60.9 (12.2)42 – 81

97.5 (3.4)89 – 100

66.8 (36.9)11.3 – 135.7

Mann-Whitney test p = 0.464 p = 0.392 p = 0.367Values expressed as mean (sd), minimum – maximumSource: Department of Orthopedics and Traumatology, Federal University of São Paulo

Table 4 – Lysholm’s scale according to lesion size

Lesion size

Lysholm’s scale

Before the operation

After the operation

∆%

≤ 2 cm² (n = 16) 62.0 (12.0)42 – 80

93.3 (7.8)78 – 100

57.8 (42.6)11.3 – 135.7

> 2 cm² (n = 11) 63.6 (14.3)46 – 83

98.6 (2.2)95 – 100

62.9 (39.2)17.3 – 117.4

Mann-Whitney test p = 0.693 p = 0.066 p = 0.657Values expressed as mean (sd), minimum – maximumSource: Department of Orthopedics and Traumatology, Federal University of São Paulo

Analysis according to age showed that the patients under 40 years of age presented a preoperative score of 64 points and a postoperative score of 94 points, while the patients aged 40 years or over presented a preoperative score of 60 points and a postoperative score of 92 points. There was no statistically significant difference between the age groups regard the scores on Lysholm’s scale for preoperative applications (p = 0.464), postoperative appli-cations (p = 0.392) or the ∆% change (p = 0.367) (Table 5).


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for treating cartilage lesions (drilling, abrasion arthro-plasty, microfracture and mosaicplasty) and showed that there was a substantial clinical and functional improve-ment among the patients who underwent mosaicplasty, in relation to other reparative techniques, especially after three, four and five years.

From a multicenter randomized study comparing mo-saicplasty and the reconstructive technique of chondro-cyte transplantation, Dozin et al(10) concluded that the two techniques were functionally and clinically similar, with full recovery for 85% and 68% of the patients who underwent mosaicplasty and chondrocyte transplantation, respectively. In another randomized prospective study on 100 patients, Bentley et al(11) achieved good results for 78% and 69% of the patients who underwent chondro-cyte transplantation and mosaicplasty, respectively.

We used mosaicplasty because we believe that this technique is superior to the reparative techniques cited above, while presenting results that are similar results to those from chondrocyte transplantation, which has the main drawbacks of the difficult access and high cost of the procedure.

The follow-up achieved in this study (2.5 years) was not long enough for us to definitively assess the durabil-ity of the results and the survival of the grafts, but the results showed that this is a safe and effective technique over the short and medium terms.

The results from the evaluations using Lysholm’s scale showed that the patients presented a statistically significant functional improvement, from a mean of 62.7 points (poor) to 95.4 points (excellent).

These results are in line with reports in the literature by several authors such as Marcacci et al(1), who found good results in 78.3% of their cases, Jakob et al(2), with 100% improvement in function and 93% with good results, Hangody et al(7) with good results from around 90% of their 831 procedures, and Koulalis et al(12), with good results in 90% of their cases three to six months after the operation.

With regard to the access route, Hangody et al(5) rec-ommended the arthroscopic route only for lesions of up to 2 cm², with a maximum of four to six osteochondral cylinders to be grafted, in their initial description of the technique. For larger lesions, they indicated open surgery (miniarthrotomy). In more recent papers, they indicated open surgery only in cases in which the le-sion site was difficult to access because of its location or because of limitations on knee flexion.

There are reports in the literature showing good re-sults from the use of open surgery alone, such as Jakob et al(2), and from the use of the arthroscopic route alone, such as Marcacci et al(1). We used the arthroscopic ap-proach or miniarthrotomy for condylar lesions, while we always used lateral miniarthrotomy for lesions of the patella.

The results were divided into two groups according to the patients’ ages: one group under 40 years of age and the other, 40 years and over. On the other hand, Hangody et al(7) only recommended treatment for in-dividuals up to the age of 40 years. They considered that ages between 40 and 50 years constituted a rela-tive contraindication and they contraindicated treatment for patients over the age of 50 years. We did not find any statistical difference in the results between the two groups that we evaluated, although the literature shows better results from younger patients(1,7,8).

With regard to the size of the lesion, Hangody et al(7) indicated the procedure preferentially for lesions of 1 to 4 cm², while it could also be performed in some salvage cases with an area of up to 8 cm². In our study, we car-ried out procedures on lesions of 1 to 8 cm² in area and, to evaluate the results, we divided the lesions into two groups, with lesions of up to 2 cm² and lesions greater than 2 cm². We did not find any statistically significant difference between these two groups, although there was a tendency towards better results from lesions greater than 2 cm² in area. In this respect, the literature does not provide any clear definition. Some authors like Marcacci et al(1) reported that the smaller the lesion was, the bet-ter the result was, and Hangody et al(7) had better results from lesions between 1 and 4 cm². On the other hand, other authors such as Jakob et al(2) reported that there was no difference in the results in relation to lesion size.

With regard to the location of the lesion, our results did not show any statistically significant difference, al-though they tended to be better from condylar lesions than from patellar lesions. Condylar lesions located in the lateral condyle evolved better than did those in the medial condyle, thus confirming the reports in the literature(1,6).

We also analyzed the results by dividing the sample into three groups: one with patients who underwent mo-saicplasty alone; another with patients who underwent mosaicplasty with another procedure concomitantly; and a third group of patients who underwent mosaicplasty but had already undergone previous procedures on the same knee. We did not find any statistically significant differ-

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Marcacci M, Kon E, Zaffagnini S, Iacono F, Neri MP, Vascellari A, et al. 1. Multiple osteochondral arthroscopic grafting (mosaicplasty) for cartilage de-fects of the knee: prospective study results at 2-year follow-up. Arthroscopy. 2005;21(4):462-70.Jakob RP, Franz T, Gautier E, Mainil-Varlet P. Autologous osteochondral graft-2. ing in the knee: indication, results, and reflections. Clin Orthop Relat Res. 2002;(401):170-84.Buckwalter JA. Chondral and osteochondral injuries. Mecanism of injury and 3. repair responses. Oper Tech Orthop. 1997;7(4):263-9.Suh JK, Aroen A, Muzzonigro TS, Disilvestro M, Fu FH. Injury and repair of 4. articular cartilage. Operative Techniques in Orthopaedics 1997;7(4):270-8.Hangody L, Kish G, Kárpáti Z, Szerb I, Udvarhelyi I. Arthroscopic autogenous os-5. teochondral mosaicplasty for the treatment of femoral condylar articular defects. A preliminary report. Knee Surg Sports Traumatol Arthrosc. 1997;5(4):262-7.Hangody L, Feczkó P, Bartha L, Bodó G, Kish G. Mosaicplasty for the treatment 6. of articular defects of the knee and ankle. Clin Orthop Relat Res. 2001;(391 Suppl):S328-36.Hangody L, Ráthonyi GK, Duska Z, Vásárhelyi G, Füles P, Módis L. Autolo-7.

gous osteochondral mosaicplasty. Surgical technique. J Bone Joint Surg Am. 2004;86(Suppl 1):65-72.

Hangody L, Füles P. Autologous osteochondral mosaicplasty for the treatment 8. of full-thickness defects of weight-bearing joints: ten years of experimental and clinical experience. J Bone Joint Surg Am. 2003;85-A(Suppl 2):25-32.

Hangody L, Kish G, Kárpáti Z. Arthroscopic autogenous osteochondral mo-9. saicplasty – a multicentric, comparative, prospective study. Index Traumatol Sport. 1998;5(1):3-9.

Dozin B, Malpeli M, Cancedda R, Bruzzi P, Calcagno S, Molfetta L, et al. Com-10. parative evaluation of autologous chondrocyte implantation and mosaicplasty: a multicentered randomized clinical trial. Clin J Sport Med. 2005;15(4):220-6.

Bentley G, Biant LC, Carrington RW, Akmal M, Goldberg A, Williams AM, Skin-11. ner JA, et al. A prospective, randomised comparison of autologous chondrocyte implantation versus mosaicplasty for osteochondral defects in the knee. J Bone Joint Surg Br. 2003;85(2):223-30.

Koulalis D, Schultz W, Heyden M, König F. Autologous osteochondral grafts in 12. the treatment of cartilage defects of the knee joint. Knee Surg Sports Traumatol Arthrosc. 2004;12(4):329-34.

rEfErENCES


ence between the three groups, but we observed that the results were better among the patients who underwent mosaicplasty alone. There was a significant improve-ment among the patients who underwent other concomi-tant procedures, while the results were worse among the patients who had undergone previous surgery. These trends in our results are in agreement with the literature, in which Jakob et al(2) reported better results among pa-tients who underwent mosaicplasty alone. Marcacci et al(1) also reported greater functional improvement among patients who underwent concomitant procedures, in rela-tion to those who underwent mosaicplasty alone, while they had worse results among the group of patients who had undergone surgery previously.

We believe that the functional improvement among the patients who underwent concomitant procedures was due not only to the mosaicplasty, but also to the treat-ment provided for associated lesions. On the other hand, the worse results from cases with previous surgery may have occurred because the lesions were more severe in these cases and were sometimes unsuccessfully treated, which may have compromised the joint in other ways. In addition, such patients may have been skeptical about obtaining good results, which would have altered their subjective assessment on the functional scale.

With regard to rehabilitation, we based our protocol on personal experience with other procedures for treat-ing cartilage lesions, along with protocols for treating concomitant lesions. Comparing the protocols in the literature, we observed that they are very similar. Hang-

ody et al(8) recommended completely passive movement without loading for three weeks, followed by partial loading for another two to three weeks. Jakob et al(2) advised passive movement of up to 100° until the third week and full movement thereafter, with partial loading for four to eight weeks, depending on the size of the lesion, and a return to sports activities or heavy work after four to six months. We agree with early passive mobilization, but we prefer to keep the patient without loading for six weeks, because we think that it is dif-ficult for patients to establish what partial early loading should consist of, and for them to control this. In this manner, we eliminate the risk of applying full loading before the appropriate moment.

CONCLUSiONMosaicplasty was shown to be a good alternative

for treating osteochondral lesions of the knee. Age up to 65 years and lesion size were not limiting factors. There was better evolution of lesions of the femoral condyles, in relation to patellar lesions, although we did not find any statistically significant difference in this respect. Other surgery performed concomitantly or previous operations did not make it impossible to perform the procedure that we studied.

aCkNOWLEDGEMENTSOur thanks go to Dr. Marcel Jun Sugawara Tamaoki,

without whom it would not have been possible to ac-complish this work.


artigo 28

1 – �MSc and PhD in Orthopedics. Head of the Shoulder Group at the Orthopedic Hospital and Belo Horizonte Hospital, Belo Horizonte, MG.2 – �Attending Surgeon in the Shoulder Group at the Orthopedic Hospital and Military Police Hospital of Minas Gerais, Belo Horizonte, MG.3 – �Attending Surgeon in the Shoulder Group at the Orthopedic Hospital and Belo Horizonte Hospital, Belo Horizonte, MG.4 – �Residents in the Shoulder Group at the Orthopedic Hospital and Belo Horizonte Hospital, Belo Horizonte, MG.

Work performed by the Shoulder Group at the Orthopedic Hospital and Belo Horizonte Hospital, Belo Horizonte, MG.Correspondence: Rua Prof. Otávio Coelho de Magalhães 111, Mangabeiras, 30210-300 Belo Horizonte, MG – E-mail: [email protected]


OriGiNaL arTiCLE

EVALUATION OF ANATOMIcAL INTEgrITY USINg ULTrASOUND ExAMINATION, AND FUNcTIONAL

INTEgrITY USINg THE cONSTANT & MUrLEY ScOrE, OF THE rOTATOr cUFF FOLLOwINg ArTHrOScOPIc rEPAIr

Glaydson Gomes Godinho1, Flavio de Oliveira França2, José Marcio Alves Freitas3, Fábio Nagato Watanabe4, Leonardo Oliveira Nobre4, Manoel Augusto de Almeida Neto4, Marcos André Mendes da Silva4


abSTraCT

Objective: To evaluate the functional and anatomical results from surgical treatment via arthroscopy in cases of complete rupture of the rotator cuff, using ultrasound images and the Constant and Murley functional index to investigate the cor-relation between them. Methods: 100 patients (110 shoulders) were evaluated. The mean follow-up was 48.8 ± 33.28 months (12 to 141 months). The mean age was 60.25 ± 10.09 (36 to 81 years). Rupture of the supraspinal tendon alone occurred in 85 cases (77%), and in association with the infraspinatus in 20 cases (18%) and subscapularis in four shoulders (4%). An association of supraspinatus, infraspinatus and subscapularis lesions was found in one shoulder (1%). The lesions were clas-sified according to DeOrio and Cofield scores as small/medium in 85 shoulders (77%) and large/extensive in 25 (23%). The clinical results were assessed in accordance with the Constant and Murley criteria. The ultrasound results relate to reports is-sued by different radiologists. Statistical analysis was carried out using the chi-square test, Fisher’s exact test, Student’s t test, Pearson’s correlation, Kruskal-Wallis correlation and logistic regression (significance: p < 0.05). Results: The mean Constant

evaluation was 85.3 ± 10.06 in the normal shoulders and 83.96 ± 8.67 in the operated shoulders (p = 0.224). Excellent and good results were found in 74 shoulders (67%), satisfactory and moderate results in 32 (29%) and poor results in four (4%). The ultrasound evaluation showed 38 shoulders with re-rupture (35%) and absence of rupture in 71 (65%). Among the 74 shoul-ders (67%) with excellent/good results, 22 (30%) presented re-rupture in the ultrasound report (p = 0.294). Among the four shoulders (4%) with poor results, two (50%) presented reports of intact tendons (p = 0.294). Conclusion: There was no statis-tically valid correlation between the ultrasound diagnosis and the clinical evaluation of results among the patients who under-went arthroscopic repair to treat full tear lesions of the rotator cuff. The clinical results from the complete rotator cuff repairs via arthroscopy presented a high level of functional recovery (Constant 83.96), compared with the contralateral shoulder. The postoperative ultrasound reports presented a high percentage of re-rupture (35%). Postoperative strength was greater among the patients aged under 60 years (p = 0.002) and in cases of lesions less than or equal to 3 cm (p = 0.003).

Keywords – Rotator cuff; Arthroscopy; Ultrasonography

iNTrODUCTiON

Rotator cuff tears occur frequently in the population over 50 years of age. This is a condition of multifacto-rial etiology, with the characteristics of degenerative lesions in most cases, and it affects 10 to 90% of the population(1,2). The diagnosis is based on clinical evalu-ation and imaging methods. Factors such physiological

age and functional demand will determine whether the treatment should be conservative or surgical (open or arthroscopic repair). The functional and structural evalu-ation has been a subject of discussion(3,4), since most studies have had short follow-ups and small samples. Many difficulties are found in postoperative evaluations on the rotator cuff by means of ultrasonography, and understanding the anatomical variations is among these.

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Although this imaging examination has high preopera-tive sensitivity and specificity rates, this is not the case in postoperative evaluations. Despite such imprecision(5-7), it is often used as an imaging examination for diagnosing re-rupture of the rotator cuff because it is a low-cost and noninvasive examination that is easily accessible for the population and, in addition, it enables evaluation of the contralateral shoulder(8). This method may identify the tendons involved and the extent of the lesion(6), but the quality of the image is fundamental for the diagnosis(9).

Arthroscopic repair of lesions of the rotator cuff presents high rates of good and excellent clinical results(1,4,5,10,11), even though adequate healing of the tendon does not oc-cur in many cases(3). Re-rupture is one of the complica-tions encountered. Studies using functional scores and imaging examinations have demonstrated incoherent cor-relations between function and reports of re-rupture. For this reason, there is no well-defined standard that would correlate functional capacity and anatomical integrity of the tendons(3). Images of re-rupture remain a challenge for radiologists. There is a need to standardize what an image of re-rupture consists of, because the definitions of this lesion and its extent vary significantly in the literature(3). Nevertheless, the high cost of nuclear magnetic resonance (NMR), the degree of difficulty in understanding the post-surgical anatomy of the rotator cuff through this exami-nation and the impossibility of performing arthroscopy (gold standard) on all patients undergoing postoperative follow-up make ultrasonography a viable option. Because ultrasonography is an examiner-dependent examination, it ought to be performed by a single radiologist. Unfortu-nately, this is not the real situation in Brazil and, often for reasons outside of physicians’ requirements, the examina-tions are performed randomly.

The aim of the present study was to evaluate the ana-tomical and functional integrity of arthroscopic repairs on cases of complete tearing of the rotator cuff, using ultrasound images and Constant and Murley functional scores(12), and to investigate the degree of concordance between them.

SaMPLE aND METhODS

A prospective study with functional and ultrasound evaluations was conducted in relation to 1,531 operations that were carried out between September 1996 and May 2007, at the Orthopedic Hospital and Belo Horizonte Hospital, in the city of Belo Horizonte, Minas Gerais.

Patients who had undergone arthroscopic repair of complete tearing of the rotator cuff, with a minimum follow-up of one year, were included in this study. All the patients were assessed using Constant and Murley functional scores and ultrasound following their opera-tions (Figures 1A and 1B).

figure 1 – A) Ultrasound image demonstrating an anatomical abnormality consequent to an area of scarring on the supraspinal tendon. B) Ultrasound image showing anatomical integrity

A B

The exclusion criteria consisted of less than one years of follow-up, glenohumeral arthrosis with advanced joint degeneration, calcaneal tendinitis, rheumatoid arthritis, adhesive capsulitis, sequelae from fractures, failure to locate patients or insufficient documentation.

A sample of 147 patients (159 shoulders) was se-lected, from whom 47 patients (49 shoulders) were ex-cluded because of a lack of postoperative ultrasound examination, incomplete functional assessment, or both. Thus, 100 patients (110 shoulders) remained in the sam-ple, consisting of 36 men (33%) and 74 women (67%). The mean follow-up was 48.8 ± 33.28 months (ranging from 12 to 141 months). The mean age of the study group was 60.25 ± 10.09 years (ranging from 36 to 81 years) (Figure 2). The right shoulder was affected in 86 cases (78%) and the left shoulder in 24 cases (22%). Ten patients (10%) had bilateral lesions. The affected shoulder was on the dominant side in 88 cases (80%) and the non-dominant side in 22 cases (20%). Thirty-four percent of the patients were sports practitioners and 66 (66%) were not.

Before the operation, it was observed that in the to-pography of the tendons involves, the supraspinatus was present in 110 shoulders (100% of the cases). Rupture of the supraspinatus tendon alone was present in 85 shoulders (77%), while it was present in association with the infraspinatus (posterosuperior lesion) in 20 shoulders (18%) and in association with the subscapu-laris (anterosuperior lesion) in four shoulders (4%). An

EVALUATION OF ANATOMICAL INTEGRITY USING ULTRASOUND ExAMINATION, AND FUNCTIONAL INTEGRITY USING THE CONSTANT & MURLEY SCORE, OF THE ROTATOR CUFF FOLLOWING ARTHROSCOPIC REPAIR

176Fr

eque

ncy

18

16

14

12

10

8

6

4

2

037.5 45.0 52.5 60.0 67.5 75.0 82.5

figure 2 – A) Population distribution according to age. B) Popula-tion characterization according to age

N 110.00Mean 60.25

Standard deviation

10.09

Minimum 36.00Median 61.00Maximum 81.00

A B

1

50

100

77%

18%

4% 1%

Supraspinatus (85)Supraspinatus + infraspinatus (20)Supraspinatus + subscapularis (4)Supraspinatus + infraspinatus + subscapularis (1)

figure 3 – Tendons affected

77%

33%

� 3 cm � 3 cm

figure 4 – Extent of the lesion in the anteroposterior orientation following tendon debridement


association involving lesions of the supraspinatus, in-fraspinatus and subscapularis was found in one shoulder (1%) (Figure 3).

The length of the lesions in the anteroposterior orien-tation, as measured during the arthroscopic procedure, after debridement, ranged from 0.5 cm to 5.4 cm. In ac-cordance with DeOrio and Cofield(13), the lesions were classified as small (≤ 1 cm), present in 14 shoulders (13%); medium (1-3 cm) in 71 shoulders (65%); large (3-5 cm) in 23 shoulders (21%); and extensive (> 5 cm) in two shoulders (2%) (Figure 4).

Evaluation of the tendon of the long head of the biceps during the operation showed that there were 63 normal tendons (57%) and five ruptured tendons (5%). The remainder presented some degree of degeneration: tenolysis was performed on two (2%), tenotomy on 31 (28%) and tenodesis on nine (8%).

Subacromial decompression (anteroinferior acromio-plasty) was performed on 108 shoulders (98%).

The clinical evaluation on the results was per-formed in accordance with the criteria of Constant and Murley(12), who used two subjective parameters (pain and activities of daily living) and two objective param-eters (range of motion and strength). The maximum score of 100 points would correspond to an asymptom-atic shoulder with complete function and strength of approximately 11 kg). Pain could be absent (15 points), mild (10 points), moderate (5 points) or intense (0). The activities of daily living could total 20 points: full-time work without limitations (4 points), recreational activity without limitations (4 points), lack of sleep disturbance due to pain (2 points) and positioning of the hand in space (10 points when the hand reached the level of above the head). Function was evaluated according to range of motion (ROM), with 10 points for each integral evaluation (medial rotation, lateral rotation, abduction and flexion), thus totaling 40 points. Strength was mea-sured in pounds (kg multiplied by a constant of 2.2). Thus, the normal pattern referred to an asymptomatic 25-year-old individual with a strength of 25 pounds (approximately 11 kg). For this, a fixed-point domestic balance was used (Figures 5A and 5B), with marking limited to 12 kg, for recording the values measured

177

figure 5 – A) Positioning for strength measurements in accor-dance with Constant and Fisher. B) Device with fixed-point con-ventional dynamometer, limited to 12 kg

A B

figure 6 – Descriptive statistics showing the non-significant difference in postoperative strength measurements between tendons with and without re-rupture, as shown by ultrasonog-raphy. (p = 0.256). No: absence of re-rupture; Yes: presence of re-rupture

12

10

8

6

4

2

0

No

Hom

olat

eral

str

engt

h

Yes

Boxplot of homolateral strength

Separates by: RUPTURE


through the Jobe test(12,14). According to Boehm(15), the results encountered through Constant’s method may be excellent (91-100), good (81-90), satisfactory (71-80), moderate (61-70) or poor (< 60).

The results from ultrasonography related to reports issued by different radiologists, using equipment with transducers of varying power (7.5 to 15 MHz). The examinations were performed postoperatively, after an interval of one to two years in the cases of 52 shoul-ders (47%); two to five years in the cases of 31 shoul-ders (28%); and more than five years in the cases of 27 shoulders (25%).

The statistical analysis was performed in accordance with the methods of the chi-square test, Fisher’s exact test, Student’s t test, Pearson’s correlation, Kruskal-Wallis test and logistic regression, with the significance level set at p < 0.05.

rESULTS

The mean from the Constant evaluation was found to be 85.3 ± 10.06 (range 46 to 99) for the normal shoul-ders and 83.96 ± 8.67 (range 59 to 99) for the oper-ated shoulders (p = 0.224). There were excellent and good results from 74 shoulders (67%), satisfactory and moderate results from 32 (29%) and poor results from four (4%).

Excluding the bilateral cases, the mean ipsilateral postoperative strength was 5.53 kg ± 2.34 (range 2 to 11) and the contralateral strength was 5.88 kg ± 2.45 (range 0.6 to 11) (p = 0.091). The mean postoperative strength was 6.38 kg ± 2.53 among the patients in the age group between 41 and 60 years, and 4.78 kg ± 2.23 among the patients over the age of 60 years (p = 0.002). Among the lesions that were less than or equal to 3

cm, 85 shoulders (77%) presented a mean postoperative strength of 5.64 kg ± 2.41. Among the lesions that were greater than 3 cm, 25 shoulders (23%) demonstrated strength of 4.00 kg ± 2.03 (p = 0.003).

There was no statistically significant difference in the mean postoperative strength between the patients who presented ultrasound reports showing re-rupture and those showing anatomical integrity (p = 0.256) (Figure 6).

The mean score on Constant’s scale among the pa-tients who had undergone tenodesis of the long head of the biceps was 86.73 ± 9.42, versus 78.10 ± 10.60 in the cases with tenotomy (p = 0.035).

Eighty-one of the patients evaluated (74%) did not have any complaint of pain, while 29 (26%) presented some degree of residual pain. Of the latter, 20 (17%) complained of mild pain, five (5%) of moderate pain and four (4%) of severe pain. Among the patients with excellent and good results, eight (11%) presented com-plaints of pain.

The ultrasound evaluation showed that 38 shoulders (35%) presented re-rupture, while there was absence of rupture in 71 shoulders (65%). One diagnosis was inconclusive and was therefore excluded.

Simultaneous occurrences of results according to Constant’s classification and the ultrasound reports are represented in Box 1 (P = 0.294) (Box 1).


178


box 1 – Correlation between Constant’s functional assessment (categorized by Boehm)(15) and the ultrasound results

Constant

Ultrasound

Total

Re-rupture Integral

Excellent and good 22 51 73

Satisfactory and moderate 14 18 32

Poor 2 2 4

Total 38 71 109

The correlation between the ultrasound findings

and the length of follow-up is represented in Box 2 (P = 0.133).

Occurrences of re-rupture (ultrasound) according to the extent of the lesions is represented in Box 3 (P = 0.531).

box 2 – Correlation between length of follow-up and the ultra-sound results

Follow-up

Ultrasound

Total

Re-rupture Integral

1 to 2 years 14 (27%) 38 (73%) 52 (100%)

2 to 5 years 11 (35%) 20 (65%) 31 (100%)

> 5 years 13 (50%) 13 (50%) 26 (100%)

box 3 – Correlation between the extent of the lesion of the rota-tor cuff and the ultrasound results

Extent of lesion

Ultrasound

Total

Re-rupture Integral

≤ 3 cm 30 (35%) 55 (65%) 85 (100%)

> 3 cm 8 (33%) 16 (67%) 24 (100%)

DiSCUSSiON

Ultrasonography is widely used for diagnosing rotator cuff injuries(9,16). However, the results from analysis on operated shoulders are compromised(16,17). Some authors have stated that this diagnostic method

may present high rates of sensitivity, specificity and precision, even under such conditions, when they are performed by experienced professionals(5-7,18,19). Through the present study, we did not find any co-herent correlation between the structural analysis on the tendons (ultrasound) and the functional result (Constant). We observed re-rupture rates of up to 20% among patients with excellent and good func-tional results, and this has also been cited in the literature(1,3,4,17). Postoperative functional and structur-al evaluations have been a subject of discussion(3,4,17). It can be seen that the studies on repairs performed arthroscopically present results from short follow-ups on small samples(3,6,7,20). Inadequate understanding and lack of standardization of postoperative ultra-sound findings(21) may at least partially explain our incoherent findings. Crass et al(21) described anatomi-cal distortion consequent to adherence between the deltoid muscle and the rotator cuff, presence of gran-ulation tissue and changes in the direction of fibers as veritable obstacles hindering precise diagnosis (i.e. diagnosis of what re-rupture really represents). This suggests that there is a need for a more effective method for image evaluation. Similar characteristics have been cited in other studies(16,20). In the light of such limitations, Furtschegger and Resch(16) designed a study that attempted to define postoperative ultra-sound criteria for rotator cuff injuries. They high-lighted inability to view the tendon and its echogenic discontinuity as determining factors for diagnosing such injuries.

Standardization of the equipment and of the ul-trasonography technique has been recommended by several authors(3,5,6). Nevertheless, this academic prac-tice does not reflect the realities of clinical practice. Patients and physicians cannot always entrust their examinations to the few highly experienced profes-sionals, or to centers of excellence with latest-genera-tion equipment. Thus, studies conducted under special conditions overvalue the method, in a generic manner that is distant from the realities. Diagnostic ultrasonog-raphy has undergone significant advances that should be reconsidered.

We used the functional protocol of Constant and Murley(12) and grouped our results as suggested by Boehm(15), contrary to some authors who used

179


protocols that emphasized criteria that were more subjective(3,8,17,22). In the total scores possible ac-cording to this protocol, 25 points were attributed to strength, which corresponds to a direct correlation with the anatomical integrity of the tendon(4,23). In the present series, we found that the absolute mean score using the protocol of Constant e Murley(12) on the operated shoulders was 83.96 ± 8.67. Gartsman et al(23) found a similar value (83.6) from their evalu-ation on 73 patients with a two-year follow-up. They also compared the mean preoperative strength with the mean postoperative strength and found that the mean increase was 2.9 kg, which was statistically significant.

In the present study, we compared the mean ipsi-lateral postoperative strength (5.53 kg ± 2.34) with the contralateral strength (5.88 kg ± 2.45) and did not find any statistical significant difference (p = 0.091), thus demonstrating that the strengths were equivalent to each other. We also did not find any significant dif-ference in mean postoperative strength between the patients who presented ultrasound reports showing re-rupture (4.77 kg ± 2.45) and those showing integral tendons (5.50 kg ± 2.39) (p = 0.126).

We evaluated the correlation between the extent of the lesions and the postoperative strength and found better results in relation to the lesions that were less than or equal to 3 cm. The mean strength observed among these patients was 5.64 kg ± 2.03, versus 4.0 kg ± 2.41 for those with lesions larger than 3 cm (p = 0.003).

For 39 patients (41 shoulders), we documented the preoperative strength with the aim of carrying out a prospective study. Among this group, the change in mean strength from before to after the operation was from 3.82 kg to 5.05 kg (p < 0.0001), respectively.

Mack et al(20) found that pain was a residual symp-tom among 26% of their patients with excellent and good results who had undergone open surgery. We observed the presence of pain of different intensities in 26% of the cases that we studied. Among the 74 shoulders (67%) with excellent and good functional results, eight shoulders (11%) presented pain, although its intensity was mild.

Arthroscopy for rotator cuff injuries presents high rates of good and excellent results(1,4,5,10,11). Re-rup-

ture is one of the complications reported, at a fre-quency ranging from 20 to 65% of the cases(1,4,17). Through an evaluation using ultrasonography two years after open surgery to repair large and exten-sive injuries of the rotator cuff, Galatz et al(17) found new lesions in 94% of the cases. DeFranco et al(3) found a re-rupture rate of 40% from a three-year follow-up on arthroscopic repairs to lesions smaller than 3 cm, using ultrasound. Harryman et al(8) stated that ultrasound was capable of diagnosing 65% of the tendons that were unbroken, five years after the operation. Sugaya et al(22) found a re-rupture rate of 13% among medial lesion and 44% among large and extensive lesions, using NMR for postoperative structural analysis.

We found that re-rupture was shown in 35% of the ultrasound reports among our sample.

There are studies in the literature that show that there is no relationship between function and integrity of repair following surgery on the rota-tor cuff(3,24). Harryman et al(8) reported increases in strength, function and activity with the arm above head height, among the patients who presented structural integrity of the repaired tendons. They also reported that for 87% of the patients who pre-sented re-rupture on ultrasound images, it was not possible to observe any abnormality in the clinical examination, thus affirming that ultrasound is im-precise in relation to evaluating re-rupture alone. DeFranco et al(3) stated that the functional improve-ment was more significant when the anatomical in-tegrity was fully restored, but that partial lesions or re-ruptures did not necessarily imply unsatisfactory functional results. We did not find any statistical significance in relation to simultaneous occurrence of excellent/good functional results and ultrasound reports showing structural integrity (p = 0.294). Nor was there any statistical significance regarding the incoherent occurrences of excellent/good functional results with ultrasound reports showing re-rupture (p = 0.294).

DeFranco et al(3) reported that age was the main predictive factor for structural integrity following arthroscopic repair. In our study, age did not show any statistical significance in relation to postoperative integrity of the rotator cuff, as assessed using ultra-


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Williams GR Jr, Rockwood CA Jr, Bigliani LU, Iannotti JP, Stanwoo W. Rotator cuff 1. tears: Why do we repair them? J Bone Joint Surg Am. 2004;86(12):2764-76.

Veado MAC, Gomes TPO, Pinto RZA. Análise funcional e estrutural do reparo das 2. lesões extensas do manguito rotador. Rev Bras Ortop. 2006;41(8):294-301.

DeFranco MJ, Bershadsky B, Ciccone J, Yum J, Iannotti JP. Functional outcome 3. of arthroscopic rotator cuff repairs: A correlation of anatomic and clinical results. J Shoulder Elbow Surg. 2007;16(6):759-65.

Gazielly DF, Gleyze P, Montagnon C. Functional and anatomical results after 4. rotator cuff repair. Clin Orthop Relat Res. 1994;(304):43-53.

Iannotti JP, Ciccone J, Buss DD, Visotsky JL, Mascha E, Cotman K, et al. 5. Accuracy of office-based ultrasonography of the shoulder for the diagnosis of rotator cuff tears. J Bone Joint Surg Am. 2005;87(6):1305-11.

Teefey SA, Hasan A, Middleton WD, Patel M, Wright RW, Yamaguchi K. Ul-6. trasonography of the rotator cuff: A comparison of ultrasonographic and ar-throscopic findings in one hundred consecutive cases. J Bone Joint Surg Am. 2000;82(4):498-504.

Teefey SA, Rubin DA, Middleton WD, Hildebolt CF, Leibold RA, Yamaguchi K. 7. Detection and quantification of rotator cuff tears: comparison of ultrasonographic, magnetic resonance imaging, and arthroscopic findings in seventy-one consecu-tive cases. J Bone Joint Surg Am. 2004;86(4):708-16.

Harryman DT 2nd, Mack LA, Wang KY, Jackins SE, Richardson ML, Matsen FA 8. 3rd. Repairs of the rotator cuff: correlation of functional results with integrity of the cuff. J Bone Joint Surg Am. 1991;73(7):982-9.

Brandt TD, Cardone BW, Grant TH, Post M, Weiss CA. Rotator cuff sonography: 9. a reassessment. Radiology. 1989;173(2):323-7.

Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG. 10. Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal? J Bone Joint Surg Am. 2005;87(6):1229-40.

Godinho GG. Reparação artroscópica do manguito rotador do ombro: avalia-11. ção funcional dos resultados de 87 pacientes [tese]. São Paulo: Universidade Federal de São Paulo. Escola Paulista de Medicina; 2002.

Constant CR, Murley AHG. A clinical method of functional assessment of the 12. shoulder. Clin Orthop Relat Res. 1987;(214):160-4.DeOrio JK, Cofield RH. Results of a second attempt at surgical repair of a failed 13. initial rotator-cuff repair. J Bone Joint Surg Am. 1984;66(4):563-567.Fischer BW, Gross MR, McCarthy JA, Arroyo JS. Incidence of acromioclavicular 14. joint complications after athroscopic subacromial descompression. Arthroscopy. 1999;15(3):241-8.Boehm D. Valuation of the Constant score. In: Habermeyer P, Magosch P, 15. Lichtenberg S. Classifications and scores of the shoulder. Heidelberg: Springer; 2006. p. 204.Furtschegger A, Resch H. Value of ultrasonography in preoperative diagnosis of ro-16. tator cuff tears and postoperative follow-up. Europ J Radiology. 1988;8(2):69-75.Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and 17. repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am. 2004;86(2):219-24.Prickett WD, Teefey SA, Galatz LM, Calfee RP, Middleton WD, Yamaguchi K. 18. Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively. J Bone Joint Surg Am. 2003;85(6):1084-9.Crass JR, Craig EV, Feinberg SB. Ultrasonography of rotator cuff tears: a review 19. of 500 diagnostic studies. J Clin Ultrasound. 1988;16(5):313-27.Mack LA, Nyberg DA, Matsen FR 3rd, Kilcoyne RF, Harvey D. Sonography of 20. the postoperative shoulder. Am J Roentgenol. 1988;150(5):1089-93.Crass JR, Craig EV, Feinberg SB. Sonography of the postoperative rotator cuff. 21. Am J Roentgenol. 1986;146(3):561-4.Sugaya H, Maeda K, Matsuki K, Moriishi J, Functional and structural otcome 22. after arthroscopic full-thickness rotator cuff repair: single-row versus dual-row fixation. Arthroscopy. 2005;21(11):1307-16.Gartsman GM, Khan M, Hammerman SM. Arthroscopic repair of full-thickness 23. tears of the rotator cuff. J Bone Joint Surg Am. 1998;80(6):832-40.Anderson K, Boothby M, Aschenbrener D, Holsbeeck MV. Outcome and struc-24. tural integrity after arthroscopic rotator cuff repair using 2 rows of fixation: mini-mum 2-year follow-up. Am J Sports Med. 2006;34(12):1899-905.

rEfErENCES


sonography (p = 0.767). However, age was a negative predictive factor regarding excellent/good functional results (p = 0.008).

A significant difference was observed in the rela-tionship between postoperative strength and age, such that it was observed that the patients under 60 years of age presented greater mean strength (5.90 kg ± 2.49) than those over the age of 60 years (4.70 kg ± 2.23) (p = 0.009).

It was observed that the patients whose mean post-operative follow-ups were longer (4.29 years ± 2.77) presented greater incidence of ultrasound reports of re-rupture than did the patients with shorter follow-ups (3.13 years ± 2.48) (p = 0.034).

CONCLUSiONS1 – �There was no statistically valid correlation between

the functional result and the ultrasound image (p = 0.294).

2 – �The clinical result from the repairs on the complete ruptures of the rotator cuff using arthroscopy pre-sented a high percentage of functional recovery (Constant 83.96), in comparison with the contral-ateral side.

3 – �The evaluation using ultrasound images presented high rates of re-rupture (35%).

4 – �The postoperative strength was greater among patients younger than 60 years (p = 0.002) and among cases of lesions of less than or equal to 3 cm (p = 0.003).

artigo 236

1 – Orthopedic Pediatrician at the Disabled Children’s Care Association of São Paulo (AACD-SP).2 – Resident Physician at the Disabled Children’s Care Association of São Paulo (AACD-SP).

Work performed at the Department of Orthopedic Pediatrics of the Disabled Children’s Care Association of São Paulo.Correspondence: Dr. Fabio Peluzo Abreu, Av. Bernardino de Campos 542, apto. 52, 11065-002 Santos, SP – E-mail: [email protected]


OriGiNaL arTiCLE

TrEATMENT OF PArALYTIc HIP DISLOcATION AMONg SPASTIc qUADrIPLEgIc cErEbrAL PALSY PATIENTS bY MEANS OF FEMOrAL AND PELVIc OSTEOTOMY,

wITHOUT OPENINg THE jOINT cAPSULE (cAPSULOPLASTY)

Fernando Farcetta Junior1, Fabio Peluzo Abreu1, Daniella Lins Neves1, Paulo Facciola Kertzman1, Alexandre Zuccon1, Simone de Oliveira Bittencourt1, Davi Moshe Leopold Lopes2


iNTrODUCTiONCerebral palsy is a syndrome cause by lesions in the

immature brain. It is characterized by abnormal control over motor function, which may interfere with sensory function and cerebral development(1). Cerebral palsy has various causes and, among these, cerebral malfor-mation, vascular lesions, traumatic lesions, infections, metabolic disorders and toxic substances can be cited, among others. The lesions usually appear prenatally or perinatally, and the cause is postnatal in only 10% of such patients(2).

It is characterized by anatomical and physiopathologi-cal impairment(2). The greatest anatomical deformities are found in quadriplegic patients with the four extremities involved. Spasticity is the most common type of phys-iopathological impairment. Among the anatomical prob-

abSTraCTObjectives: To show the preoperative planning and results from surgical treatment for paralytic hip dislocation among patients with cerebral palsy. The techniques used were proximal femo-ral varus derotation osteotomy in association with Dega iliac osteotomy, without opening the joint capsule. Methods: We performed a retrospective review of ten hips in eight patients with spastic quadriplegic cerebral palsy who underwent surgi-cal treatment between 2003 and 2005, with the same surgical technique. The pre and postoperative clinical and radiological parameters, and the preoperative planning using an image in-tensifier, were assessed. The clinical parameters analyzed were: pain, hygiene-related difficulties and positioning difficulties. The

radiological parameters were Reimer’s index, the acetabular index and the neck-shaft angle. These results were subjected to statistical analysis. Results: We obtained good results with this technique. After a mean follow-up of three years, all the hips were observed to be stable at the last assessment, and there was a high degree of satisfaction among the families in relation to the treatment. We also showed that preoperative planning using an image intensifier allowed us to reduce and stabilize these hips without the need for capsuloplasty. Conclusion: The authors conclude that in treating hip dislocation among spastic quadriplegic cerebral palsy patients, capsuloplasty is unneces-sary for stabilizing the coxofemoral joint.

Keywords – Cerebral palsy; Hip dislocation; Osteotomy; Femur

lems, the hips may very frequently be involved in this pathological condition.

The abnormalities of the hips of patients with ce-rebral palsy merit special attention because they may bring serious problems for patients and their families. Among the problems triggered by hip dislocation, there may be high incidence of morbid conditions, in terms of pain, muscle contractions, hygiene-related difficulties, difficulties in positioning, pelvic tilting, scoliosis, skin ulceration and fractures, among others(1,2). The preva-lence of hip dislocation or subluxation among patients with cerebral palsy has been reported as 3 to 60%(2,3). In most cases, the dislocation is posterior. Anterior disloca-tion is rare, accounting for 1.5% of the cases, according to the literature(3,4), because of the characteristics of the musculature involved in this pathological condition.

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We believe that surgical treatment brings benefits for patients, through improving their seated position, their hygiene and, especially, the pain relating to the dislocated hip(2,3).

The good results from surgical treatment for this pathological condition are very well documented in the literature. Such treatment has the aim of ensuring that the hip is in the anatomically correct position, without presenting pain, by means of proximal femoral varus osteotomy and pelvic osteotomy(5-8). However, little has been written about whether the joint capsule needs to be opened in order to improve the stabilization of this hip.

The aim of our study, in addition to seeking to confirm the good results achieved through osteotomy in the femur and pelvis, was to show that with preoperative planning through using an image intensifier, a stable hip can be achieved without opening the joint capsule, in the belief that this would not influence the stabilization of the hip.

METhODSA retrospective study was conducted at the Disabled

Children’s Care Association of São Paulo (AACD-SP) between January 2003 and December 2005, in which ten cases of patients with spastic quadriplegic cerebral palsy presenting dislocated and subluxated hips were treated at this institution with hip reconstruction using the same surgical technique and without the need for capsuloplasty. Out of the ten patients studied, two sub-sequently died and therefore this analysis was conducted on eight patients.

One patient was female and seven were male. The mean age at the time of the surgery was eight years and six months (range 5 to 13 years). Ten hips were recon-structed (two patients were operated bilaterally): four on the left side and six on the right side.

The preoperative data were obtained from these pa-tients’ medical files, in order to check the clinical and radiographic parameters. The postoperative evaluation was performed by inviting the patient to come for a new clinical and radiographic assessment.

The clinical parameters analyzed, both before and after the operation, were the patients’ complaints that were expressed through their families, such as pain, hygiene-related difficulties and difficulties in position-ing. The radiological parameters used were Reimer’s index(9), the acetabular index and the neck-shaft angle. The radiological parameters were subjected to statistical analysis using the Wilcoxon test.

The hip reconstructions on these patients were per-formed by means of a lateral incision in the femur in order to perform varus osteotomy on this femur at the level of the lesser trochanter, with removal of a small wedge of medial base and fixation using an AO angled plate with a fixed angle of 90 degrees. Another inci-sion of bikini type was made in the iliac in order to perform osteotomy in this bone through the Dega tech-nique, without approaching the joint capsule or opening it. Tenotomy of the psoas and release of the adductors medially were also performed(1).

The decision not to open the joint capsule was made at the surgical center before undertaking the asepsis and antisepsis measures, with the patient on the surgical table, under general anesthesia. We studied these patients’ hips and noted the degree to which the hip dislocation or sub-luxation could be reduced through maneuvers of abduc-tion and internal rotation of the hip, viewed by means of an image intensifier (Figures 1, 2, 3 and 4). For the patients for whom we were able to reduce the hip through this method, we chose not to open the joint capsule. Our parameter was the normalization of Wiberg’s center-edge (CE) angle, as observed through the image intensifier dur-ing this maneuver (reducibility test; Figure 4).

The mean duration of the follow-up on these patients (defined as the time elapsed from the operation to the last consultation conducted) was three years (range, one to five years).

A plaster cast extending from the pelvis to the foot was applied after the operation, and this remained in place for an average of six weeks.

rESULTSAt the start of our study, ten patients underwent the op-

eration. Two patients subsequently died because of compli-cations inherent to their pathological condition but without any relationship to complications from the surgical treat-ment. These two patients were therefore not evaluated.

Before the operation, two patients did not present any complaints, while six presented pain and their families said that they had difficulties with personal hygiene. At the last postoperative consultation, five patients were without complaints; two said that the plate was sticking out but that they were free from pain, and one reported leg pain. After the operation, three patients started to practice standing up (using a parapodium), which they had not been doing before the operation.

All the patients’ families were satisfied with the surgery and said that they would be willing to go through it again.

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figure 1 – Preoperative radiograph; preoperative planning using an image intensifier; immediate postoperative period

figure 2 – Preoperative radiograph; preoperative planning using an image intensifier; immediate postoperative period

figure 3 – Reducibility test (preoperative planning with normalization of Wiberg’s CE angle, after maneuver of internal rotation and abduction of the hip); postoperative period


With regard to personal hygiene, the families reported improvements in all cases. The positioning of these patients improved, both in the seated position and when standing.

In relation to the radiographic appearance, the mean for Reimer’s index went from 76% before the operation to 2.2% (p = 0.0026) at the last postoperative assessment. The mean acetabular index went from 30 degrees to 19 degrees (p = 0.0038) and the mean neck-shaft angle went from 155 degrees to 118 degrees (p = 0.0026) at the last postoperative assessment. All these parameters were sta-tistically significant (Table 1).

With regard to complications, two patients presented eschars after the operation: one in the sacral region and the other in the heel region because of using a plaster cast. They were treated with local dressings until the wounds had healed, without further complications. One patient presented an episode of convulsive crisis during

the immediate postoperative period, which responded to medication. One patient had to have the plaster cast changes at the surgical center, 15 days after the opera-tion, because of hygiene problems. There was no loss of reduction in any of the cases studied, and all the hips that were operated remained in the correct location and centered within the standards of normality (taking subluxation of the hip to be shown by Reimer’s index greater than 30%).

Table 1 – Radiographic parameters of the patients before and after the operation

Reimer’s index Acetabular index Neck-shaft angle

Before op. After op. Before op. After op. Before op. After op.

Mean 76.00 2.1 30.1 19.5 155 118.5

Median 78.00 0.0 30.0 17.5 155 117.5 Values in degreesSource: medical files at AACD

TREATMENT OF PARALYTIC HIP DISLOCATION AMONG SPASTIC QUADRIPLEGIC CEREBRAL PALSY PATIENTS BY MEANS OF FEMORAL AND PELVIC OSTEOTOMY,WITHOUT OPENING THE JOINT CAPSULE (CAPSULOPLASTY)

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figure 4 – Reducibility test: patient positioned on the surgical table and undergo-ing the test. Note the reducibility of the hip through the maneuver of abduction and internal rotation, with the aid of an image intensifier

DiSCUSSiONHip reconstruction in cases of cerebral palsy is a con-

troversial subject in relation to patients without a prog-nosis of being able to walk. In our opinion, hips should be reconstructed in children who are in a good clinical condition, since this avoids joint deterioration and the possible development of difficult-to-treat pain.

We believe that hip reduction stabilizes the pelvis and prevents pelvic tilt and posterior scoliosis.

In cases of cerebral palsy, the dislocation is progres-sive because of muscle imbalance, in which the adduc-tor and flexor musculature is strong and the abductor and extensor musculature is weak(6). These patients’ hips are correctly centered at birth and they evolve to progressive dislocation with acetabular dysplasia, femo-ral anteversion and valgus of the femoral neck.

Nonsurgical therapeutic options for pathological conditions of the hip among these patients, such as or-thoses and physiotherapy, do not show good results. Hence, surgical treatment is the best option(2). The surgi-cal treatment should promote better muscle balance and reduce the dislocation, thereby making the joint close to normal and pain-free for the patient.

There is no doubt that proximal femoral osteotomy

corrects valgus and large anteversion of the femoral neck. The technique of periacetabular osteotomy of the iliac that was described by Dega(10) corrects anterior, lateral and posterior acetabu-lar dysplasia and is a good treatment option used around the world. How-ever, there is some doubt in relation to whether or not the joint capsule has to be opened in order to ensure that the hip is stable after the operation.

Fucs et al(5) achieved good results in 86% of their cases, with reduction or dis-appearance of the pain and improvements in hygiene and positioning, in operations on 43 hips of patients with cerebral pal-sy in which the same surgical technique was used, but with opening and clean-ing of the joint cavity. The length of the follow-up was two years and six months, i.e. close to the mean follow-up of three years that was used in our study.

Sankar et al(11) showed good results with 16 years of follow-up, among

patients with cerebral palsy presenting dislocated hips, through hip reconstruction involving opening of the joint capsule. In their paper, they reported that there were few complications and that their procedure promoted pain-free hip stability, improved hygiene, absence of pressure ulcer formation, better positioning and better walking ability among the patients who could walk.

Mubarak and Wenger(12) treated 18 dislocated or sub-luxated spastic hips with a mean follow-up of six years. Among these, 17 hips remained anatomically reduced at the last follow-up assessment. In their study, the joint capsule was opened in all the cases and obstacles that might have impede the reduction were removed (round-ed ligament, transversal acetabulum or pulvinar) and the capsule was then repaired. In our study, we chose not to open the joint capsule, since we believed that the hip would not be stabilized by the joint capsule in cerebral palsy cases. Thus, with preoperative planning, hip reduction without opening the capsule would be pos-sible in some cases. At the last follow-up assessment in our study, all the hips were seen to present anatomical reduction. McNerney et al(13) performed capsuloplasty if the head migration rate was greater than 70% or if the femoral head did not reduce completely within the acetabulum. Those authors believed that there could be

185

1. �Tachdjan MO. Ortopedia pediátrica. São Paulo: Manole; 1995. 2. �Renshaw TS, Green NE, Griffin PP, Root L. Cerebral palsy: ortophaedics manage-

ment. J Bone Joint Surg Am. 1995;77(10):1590-606. 3. �Samilson R, Tsou P, Aamoth GH, Green WM. Dislocation and subluxation of the

hip in cerebral palsy. J Bone Joint Surg Am. 1972;54(4):863-73. 4. �Selva G, Miller F, Dabney KW. Anterior hip dislocation in children with cerebral

palsy. J Pediatr Orthop. 1998;18(1):54-61. 5. �Fucs P, Svartman C, Assumpção MCR, Virgulino CC, Gomi FH, Silber MF. Re-

sultados da reconstrução do quadril subluxado e luxado da paralisia cerebral. Rev Bras Ortop Pediatr. 2002;3(1):9-17.

6. �Settecerri JJ, Karol LA. Effectiveness of femoral varus osteotomy in patients with cerebral palsy. J Pediatr Orthop. 2000;20(6):776-80.

7. �Owers KL, Pyman J, Gargan MF, Witherow PJ, Portinaro NMA. Bilateral hip surgery in severe cerebral palsy a preliminary review. J Bone Joint Surg Br. 2001;83(8):1161-7.

8. �Root L, Laplaza FJ, Brourman SN, Angel DH. The severely unstable hip in ce-

rebral palsy. Treatment with open reduction, pelvic osteotomy, and femoral os-teotomy with shortening. J Bone Joint Surg. 1995;77(5):703-12.

9. �Reimers J. The stability of the hip in children. A radiological study of the results of muscle surgery in cerebral palsy. Acta Orthop Scand. 1980;(Suppl 184):1-97.

10. �Sharp IK. Acetabular dysplasia. The acetabular angle. J Bone Joint Surg Br. 1961;43:268-72.

11. �Dega W. Osteomia trans iliakalna w leczeniu wrodzonej dysplazji biodra. Chir Narzadow Ruchu Ortop Pol. 1974;39(5):601-13.

11. �Sankar WN, Spiegel DA, Gregg JR, Sennett BJ. Long term follow –up after one –stage reconstruction of dislocated hips in pacients with cerebral palsy. J Pediatr Orthop.2006;26(1):1-7.

12. �Mubarak GF, Wenger DR. One Stage correction of the spastic dislocated hip. J Bone Joint Surg Am. 1992;74(9):1347-57.

13. �McNerney NP, Mubarak SJ, Wenger DR. One-stage correction of the dysplastic hip in cerebral palsy with the San Diego acetabuloplasty: results and complications in 104 hips. J Pediatr Orthop. 2000;20(1):93-103.

rEfErENCES


recurrence of dislocation in 60% of the cases if capsulo-plasty were not performed, compared with a recurrence rate of 3% among patients with Reimer’s index greater than 70% who underwent capsuloplasty. We had six hips with Reimer’s index greater than 70%, and the preoperative planning using the reducibility test showed that Wiberg’s CE angle became normalized. Thus, we were able to reduce the hip and did not need to perform capsuloplasty. We did not have any cases of recurrence of dislocation, even though our follow-up was shorter than the six years of follow-up by those authors.

In all our cases, the dislocation was posterior, which is in line with the literature. Cases of anterior disloca-tion among patients with cerebral palsy are rare(3,4).

We agree with Settecerri et al(6), who stated that the best postoperative results are obtained among patients presenting subluxation of the hip instead of dislocation. Thus, orthopedists’ role should be to avoid complete coxofemoral dislocation through taking measures before it occurs, in order to attain better results.

We preferred to treat the hips separately, such that in cases of bilateral dislocation, we would wait for full surgical recovery on one side before scheduling the other side. Owers et al(7) treated these hips simultane-ously and with good results, although their paper did not state whether the joint capsule was opened or not, for reducing the hips.

Out of the ten hips that were operated, four present-ed complete dislocation with Reimer’s index of 100%, while six were subluxated. Even though 40% of the pa-tients presented dislocated hips, we achieved anatomi-cal reduction of these cases without opening the joint capsule, and these hips were reduced at the preoperative planning stage, shortly before the surgery. Despite the dislocation, the femoral head was at the same level as the acetabulum, regarding the height, and thus we were able to normalize Wiberg’s CE angle.

None of the patients that we operated presented complaints of pain after the operation, and their fam-ilies were very satisfied, which was in line with the literature(3,6,8,11,12). We agree with Root et al(8), who re-ported that after the surgical procedure for hip recon-struction, all the patients presented better positioning with regard to sitting and no longer had any pain. Even though this surgical procedure may present complica-tions, the good results justify the care, treatment and attention given to these patients.

In this group of patients, we found few complica-tions. This differed from the literature, in which there have been reports of delayed consolidation, infection of the operative wound, avascular necrosis of the femoral head and fractures of the proximal femur, among other complications. We believe that the absence of complica-tions in this study was due mainly to the small number of patients, compared with the numbers in the literature(3,12), considering that this is a major procedure carried out on patients who often present clinical complications.

CONCLUSiON

Thus, with preoperative planning through using an image intensifier, we were able to plan the hip recon-struction without the need to open the joint capsule, thereby diminishing one stage of the surgical proce-dure and avoiding exposure of these patients’ joints. The reducibility test at the surgical center showed that Wiberg’s CE angle became normalized through the ma-neuver of abduction and internal rotation of the femur, and is thus a good parameter for making decisions re-garding the need to open the joint capsule in order to achieve femoroacetabular reduction. We believe that the joint capsule is not a factor in the stabilization of these patients’ hips, although a study with a greater number of patients and longer follow-up is necessary.

TREATMENT OF PARALYTIC HIP DISLOCATION AMONG SPASTIC QUADRIPLEGIC CEREBRAL PALSY PATIENTS BY MEANS OF FEMORAL AND PELVIC OSTEOTOMY,WITHOUT OPENING THE JOINT CAPSULE (CAPSULOPLASTY)

artigo 240

1 – �Orthopedist. PhD student at the Ribeirão Preto School of Medicine, University of São Paulo (USP).2 – �Professor Titular of the Department of Biomechanics, Medicine and Rehabilitation of the Locomotor Apparatus, Ribeirão Preto School of Medicine, University of São

Paulo (USP).

Work performed in the Department of Biomechanics, Medicine and Rehabilitation of the Locomotor Apparatus, Ribeirão Preto School of Medicine, University of São Paulo (USP).Correspondence: Leandro Calil De Lazari, Rua Dr. Álvaro Costa Couto 50, apto. 1201, 14015-140 Ribeirão Preto, SP – E-mail: [email protected]


OriGiNaL arTiCLE

MEcHANIcAL rESISTANcE OF THE PATELLAr LIgAMENT AFTEr rEMOVAL OF THE MIDDLE THIrD THrOUgH EITHEr ONE

LONgITUDINAL INcISION Or TwO MINI-TrANSVErSE INcISIONS

Leandro Calil De Lazari1, Cleber Antonio Jansen Paccola2


iNTrODUCTiON

Reconstructions of the anterior cruciate ligament (ACL) using the middle third of the patellar ligament as a graft have produced good functional results. However, persistent pain at the graft harvesting site, anterior sen-sitivity disorders in the knee and difficulty in kneeling down are problems encountered by 40 to 60% of pa-tients who undergo ACL reconstruction when the tradi-tional technique for harvesting a patellar graft, through a single longitudinal incision, is used(1).

Minimally invasive techniques are being developed in many areas of surgery, with the aims of diminishing the aggression to soft tissues and enabling rehabilita-tion as early and as painlessly as possible, along with improving the esthetic appearance of the scar.

Two less invasive techniques for harvesting grafts from the patellar ligament for ACL reconstruction can be seen in the literature: one described by Kartus et al(1)

abSTraCT

Objective: To evaluate the resistance and regeneration of the patellar ligament after harvesting a graft for reconstruction of the anterior cruciate ligament, using the traditional technique of a single longitudinal skin incision or a technique of two transverse mini-incisions, in sheep. Methods: Ten sheep were used. In the right knee, we removed the graft using the traditional method, and in the left knee, using the two-incision method. The animals were observed for six months. The specimens (patellar ligament, tibia and patella) were adapted to the mechanical test machine for ligament resistance tests. Results: No difference was found be-

tween the two proposed techniques in relation to the regeneration and resistance of the patellar ligament. However, we observed that shortening of the patellar ligament occurred in both groups, and that suturing of the superficial fascia of the patellar liga-ment did not influence the regeneration of the patellar ligament, according to the histology. Conclusion: The technique using two incisions in the skin presents the same patterns of regeneration and resistance of the remaining patellar ligament as shown by the traditional technique of a single, longitudinal incision.

Keywords – Anterior cruciate ligament; Patellar ligament; Sheep

through two longitudinal mini-incisions and the other, described by Carneiro et al(2) and Tsuda et al(3), through two transverse mini-incisions. Both of them have the aim of diminishing the aggression to soft tissues and avoiding injury to the infrapatellar branch of the saphen-ous nerve and anterior pain in the knee.

There has been some concern regarding the effect of suturing the superficial fascia for regeneration of the remaining ligament. Shortening of the tendon has been reported by several authors.

Adam et al(4) harvested a graft from the patellar ligament and did not close up the flaw left by its re-moval, but sutured the superficial fascia. They report-ed that shortening of the patellar ligament occurred in all their cases.

Krosser et al(5) analyzed two groups: one in which the flaw left by harvesting the graft from the patellar ligament was closed up; and another in which the flaw was not closed. They concluded that there was no sig-

187

figure 2 – Anterior view of the knee during the operation. A) Traditional incision, with graft already individualized and tibial bone block already raised. B) Two incisions. The harvesting went from distal to proximal.

figure 1 – Anterior view of the knee. The dotted line repre-sents the planned incisions. A) Single longitudinal incision. B) Two transverse mini-incisions.


nificant difference between the two groups. They also reported that shortening of the patellar ligament oc-curred in both groups.

There are few reports in the literature regarding le-sions of the patellar ligament after harvesting a graft. Lee et al(6) reported some cases of postoperative com-plications in the patellar ligament, with rupture of the ligament after removal of the graft. However, it can be asked whether the viewing difficulties that are inherent to the technique of two mini-incisions for harvesting the patellar graft might cause removal beyond what would be desired, thereby weakening the remaining part of the ligament. There is also the question of whether suturing of the superficial fascia (which is only possible when using the classic technique of a single longitudinal incision) has any influence on the regeneration of the ligament(1,7,8).

Our aim in this study was to analyze the mechani-cal resistance of the remaining patellar ligament, af-ter harvesting a graft from its middle third for ACL reconstruction, either using the traditional technique (single longitudinal incision) or two transverse mini-incisions.

METhODS

Ten shorn adult ewes of undefined breed, weighing 45 to 55 kg, were used.

From the right knee, a bone-tendon-bone graft was harvested in the traditional manner, by means of a lon-gitudinal incision from the lower pole of the patella to the anterior tuberosity of the tibia. The superficial fascia was sutured and the remaining thirds of the liga-ment were brought together using separate stitches. The incision in the left knee consisted of two mini-incisions that followed the width of the patella and the anterior tuberosity of the tibia (Figures 1 and 2).

In both techniques, the lateral and medial extremi-ties of the patellar ligament were marked out using stitches of 3-0 nylon thread, so that these points could be located more easily later on. All the ligaments were measured, noting the length and the proximal, medial and distal circumferences, using a special device that was specially developed for this purpose. An example of this measurement model is shown in Figure 3 and the values are shown in Table 1.

In the two-incision technique (surgery), the circum-ference of the medial region of the patellar ligament was considered to be equal to the same circumference on the contralateral side, given that these measurements were on the same animal. The animals remained free to move and support their own full weight.

Six months later, the animals were sacrificed (this length of time was suggested by Picado et al(7)). The scars were photographed and the patellar ligaments were isolated and measured, following the markings of the nylon stitches. The patella, patellar ligament and tibia were removed from the animals as a single block, for mechanical tests and histological analysis.

In an alternate manner, five animals were chosen sequentially for histological analysis and five for the mechanical tests.

The mechanical traction test was performed using a test machine*. The tests used were the following: trac-tion of the patellar ligament until is rupture, maximum force for breaking the ligament and maximum tension in the ligament at the time of rupture (Figure 4).

The histological analysis was performed by analyz-ing the portion halfway between the patella and tibia. The sections were stained using hematoxylin-eosin and were examined at a magnification of 25 times.

MECHANICAL RESISTANCE OF THE PATELLAR LIGAMENT AFTER REMOVAL OF THE MIDDLE THIRD THROUGH EITHER ONE LONGITUDINAL INCISION OR TWO MINI-TRANSVERSE INCISIONS

188

figure 4 – View of the extracted block of the patella, patellar ligament and tibia in the test machine (*Model EMIC DL 10000, São José dos Pinhais, Curitiba, PR, Brazil.


figure 3 – View of the instrument for measuring the circumference and the corresponding measurement during the operation.

than 5% in all of the analyses, which indicates that there was no significant difference between the two groups (Table 2).

In the analysis on the area and longitudinal length of the patellar ligament at the times of the surgery and sacrifice, the p-value was greater than 5%, which indi-cated that there was no significant difference between the groups.

Table 1 – Means for the circumference, area and length of the patellar ligament

Traditional technique, mean value Surgery Sacrifice

Upper circumference (mm) 20.18 30.36

Middle circumference (mm) 19.55 29.45

Lower circumference (mm) 20.23 29.55

Longitudinal length (mm) 54.64 35.27

Upper area (mm²) 32.60 74.40

Middle area (mm²) 30.49 69.91

Lower area (mm²) 32.74 70.25

Two-incision technique, mean value Surgery Sacrifice

Upper circumference (mm) 19.77 29.09

Middle circumference (mm) 19.55 29.45

Lower circumference (mm) 19.55 28.00

Longitudinal length (mm) 55.27 34.73

Upper area (mm²) 31.18 68.36

Middle area (mm²) 30.49 69.91

Lower area (mm²) 30.46 63.49

rESULTS

The statistical analysis was performed using the non-parametric Wilcoxon test, with analysis on the deforma-tion, maximum force and the maximum tension at the moment of graft rupture. We obtained p-values greater

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figure 5 – Mean longitudinal length of the patellar ligament dur-ing the operation and at the time of sacrifice. Significant shorten-ing of the ligament occurred similarly in both techniques


DiSCUSSiON

The discomfort of lesions of the infrapatellar branch of the saphenous nerve, which occurs in many patients who undergo harvesting of a graft from the patellar ligament by means of the traditional technique, justifies the attempts to find an alternative technique. The pos-sibility of improvements in the scar esthetics and fewer vascular lesions are other points that motivated us to develop and study a new and less invasive technique.

Some techniques of a less invasive nature for har-vesting grafts from the patellar ligament have been published in the literature(1,2,3,9), and these have shown good results in relation to their objectives.

The technique of a single horizontal lesion, as de-scribed by Portland et al(10), has the aim of avoiding in-jury to the infrapatellar branch of the saphenous nerve. However, this is a single long incision that is relatively aggressive, with the need for extensive detachment of subcutaneous tissue and stretching of the skin in order to achieve graft harvesting.

Kartus et al(1), Carneiro et al(2), Tsuda et al(3) and Garofalo et al(11) demonstrated the way in which less invasive techniques for graft harvesting, with two mini-incisions, could result in benefits for patients. They showed encouraging results.

However, these techniques raise doubts regarding the possibility that the remainder of the ligament might become weakened. Because of viewing difficulties, sur-geons might harvest grafts that are excessively robust or, on the other hand, very thin, thereby affecting the mechanical properties of the remaining ligament.

Rupture of the patellar ligament following graft har-vesting is a rare complication but it has been reported in the literature(12). The fact that we were proposing a new technique without a precise harvesting control, along with the lack of suturing around the tendon, was a matter of concern for us and motivated us to conduct this study.

Thus, the present study is pertinent, given that in investigating in PubMed, we did not find any articles analyzing the repercussions on the resistance of the remaining patellar ligament, from the use of a less in-vasive technique. Even so, since this is a little used technique, the lack of reports on occurrences of com-plications does not constitute proof that there is no excessive weakening associated with this technique for graft harvesting.

Table 2 – Statistical analysis on deformation, maximum force and maximum tension

Mean Standard deviation

Coefficient of variation

Median p value

Deformation (%) (%) (%) (%)

Traditional 51.19 19.48 38.05 42.95 0.06

Two incisions 60.23 15.78 26.20 57.06

Maximum force (Newton) (Newton) (Newton) (Newton)

Traditional 2221 843 37.99 2058 0.59

Two incisions 2415 450 18.64 2232

Maximum tension (Pascal) (Pascal) (Pascal) (Pascal)

Traditional 34532118 15256297 44.18 30744388 0.59

Two incisions 42082416 12939589 30,75 41500008

In the length measurements, we observed shortening of the patellar ligament and lowering of the patella in all of our cases (Figure 5 and Table 1).

Comparing the lengths of the patellar ligaments as seen during the operation and at the time of sacrifice, we concluded that there was significant shortening and increases in the circumference of the patellar ligament, for the same ligament. However, there was no difference between the two techniques (Figure 5).

In the histological evaluation, we observed that the fibers lost their parallel orientation, collagen was in-terspersed, there were small numbers of blood vessels and the ligament had a chondroid appearance. However, there was no perceptible difference between the two techniques.

MECHANICAL RESISTANCE OF THE PATELLAR LIGAMENT AFTER REMOVAL OF THE MIDDLE THIRD THROUGH EITHER ONE LONGITUDINAL INCISION OR TWO MINI-TRANSVERSE INCISIONS

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1. �Kartus J, Ejerhed L, Sernert N, Brandsson S, Karlsson J. Comparison of tradi-tional and subcutaneous patellar tendon harvest. A prospective study of donor site-related problems after anterior cruciate ligament reconstruction using dif-ferent graft harvesting techniques. Am J Sports Med. 2000;28(3):328-35.

2. �Carneiro Filho M, Navarro RD, Cortelazo MJ. Reconstrução artroscópica do ligamento cruzado anterior com tendão patelar utilizando dupla incisão anterior transversa. Rev Bras Ortop. 1997;32(4):279-82.

3. �Tsuda E, Okamura Y, Ishibashi Y, Otsuka H, Toh S. Techniques for reducing anterior knee symptoms after anterior cruciate ligament reconstruction using a bone-patellar tendon-bone autograft. Am J Sports Med. 2001;29(4):450-6.

4. �Adam F, Pape D, Kohn D, Seil R. Length of the patellar tendon after anterior cru-ciate ligament reconstruction with patellar tendon autograft: a prospective clinical study using Roentgen stereometric analysis. Arthroscopy. 2002;18(8):859-64.

5. �Krosser BI, Bonamo JJ, Sherman OH. Patellar tendon length after ante-rior cruciate ligament reconstruction. A prospective study. Am J Knee Surg. 1996;9(4):158-60.

6. �Lee GH, McCulloch P, Cole BJ, Bush-Joseph CA, Bach BR Jr. The incidence of acute patellar tendon harvest complications for anterior cruciate ligament reconstruction. Arthroscopy. 2008;24(2):162-6.

7. �Picado CHF, Paccola CAJ. Efeitos do enfraquecimento e da desvitalização do ligamento patelar de ovinos sobre sua resistência à tração. Rev Bras Ortop. 1996;31(9):759-70.

8. �Rogers GJ, Milthorpe BK, Muratore A, Schindhelm K. Measurement of the me-chanical properties of the ovine anterior cruciate ligament bone-ligament-bone complex: a basis for prosthetic evaluation. Biomaterials. 1990;11(2):89-96.

9. �Drain O, Beaufils P, Thevenin LC, Boggione C, Katabi M, Charrois O et al. [Mini-invasive double-incision for patellar tendon harvesting in anterior cruciate ligament reconstruction]. Rev Chir Orthop Reparatrice Appar Mot. 2007;93(8):836-41.

10. �Portland GH, Martin D, Keene G, Menz T. Injury to the infrapatellar branch of the saphenous nerve in anterior cruciate ligament reconstruction: comparison of hor-izontal versus vertical harvest site incisions. Arthroscopy. 2005;21(3):281-5.

11. �Garofalo R, Mouhsine E, Chambat P, Siegrist O. Anatomic anterior cruciate liga-ment reconstruction: the two-incision technique. Knee Surg Sports Traumatol Arthrosc. 2006;14(6):510-6.

12. �Marumoto JM, Mitsunaga MM, Richardson AB, Medoff RJ, Mayfield GW. Late pa-tellar tendon ruptures after removal of the central third for anterior cruciate ligament reconstruction. A report of two cases. Am J Sports Med. 1996;24(5):698-701.

13. �Levy HJ, Byck DC. Patellar tendon autograft harvesting using a mini vertical incision. Arthroscopy. 2000;16(5):558-62.

14. �Muellner T, Kaltenbrunner W, Nikolic A, Mittlboeck M, Schabus R, Vecsei V. Shortening of the patellar tendon after anterior cruciate ligament reconstruction. Arthroscopy. 1998;14(6):592-6.

15. �Busfield BT, Safran MR, Cannon WD. Extensor mechanism disruption after contralateral middle third patellar tendon harvest for anterior cruciate ligament revision reconstruction. Arthroscopy. 2005;21(10):1268.

rEfErENCES


In our clinical cases, we observed that harvesting the graft from the patellar ligament by means of two mini-incisions was easier to perform from distal to proxi-mal, because at the insertion of the patellar ligament in the tibia, delimitation and viewing are both easier. The middle third of the ligament can be isolated using a blunt instrument of Kelly hemostatic type, or a Smil-lie knife for menisci. In the beginning, it may even be somewhat difficult to perform the technique, but after a few cases, it becomes easy and safe.

The non-closure of the superficial fascia in the mini-mally invasive technique was another factor that was of concern to us in relation to regeneration of the patellar ligament. However, we observed that there was no dif-ference in tissue regeneration, either from a mechanical or from a histological point of view, thus showing that apparently, suturing the superficial fascia does not in-fluence the repair process on the flaw that was created in the ligament.

Increases in the circumference of the patellar liga-ment were observed in both groups (Table 1). This may have been due to the shortening of the patellar ligament, but there was no doubt that it was not associated with the technique used for harvesting the graft.

Esthetic factors have also been of concern in ACL reconstruction(13). From observing the scares from the two surgical techniques that we performed, it was clear that the two-incision technique was much more estheti-cally pleasing than the traditional technique. This was

probably because in the two-incision technique, the in-cisions were parallel to the skin crease lines, thus mak-ing them less evident and more esthetic.

Muellner et al(14) reported lowering of the patella in 30% of their cases. In our study, the shortening of the patellar ligament was very significant (Table 1) and occurred in all cases. The reason for the shortening is a matter for debate, but it was undoubtedly not due to resting during the postoperative period, given that the animals were not restrained and were walking around soon after the surgery.

From a mechanical point of view, we observed that the rupture in the ligament tests occurred in the proxi-mal third in most cases, and next to the patella. This occurred similarly in the two groups. In a study on pa-tients who underwent revision of the ACL, Busfield et al(15) reported one case of rupture next to the patella when a graft was harvested from the contralateral patel-lar ligament. This may suggest that the weakest point after harvesting the graft from the patellar ligament is the proximal insertion in the patella, and this is in line with our observations.

CONCLUSiONThere was no significant difference in patellar liga-

ment resistance between the two techniques analyzed. We did not observe any histological differences in the regeneration of the patellar ligament between the two techniques analyzed.

artigo 223

Lawyer (OAB-RJ 70.640) and Medical Internee at Unigranrio (4599064)

Teaching institution: UNIGRANRIO (University of Greater Rio), Rio de Janeiro, RJCorrespondence: Rua Barata Ribeiro 463, apto. 803, Copacabana, 22040-001 Rio de Janeiro, RJ, Brazil. E-mails: [email protected], [email protected] and [email protected]


OriGiNaL arTiCLE

INFOrMED cONSENT: THE MEDIcAL AND LEgAL cHALLENgE OF OUr TIME

Luiz Carlos Séllos Simões


iNTrODUCTiON

Back in 1767, in England, with the aim of continuing with treatment for a leg fracture, a certain Mr. Slater went to Dr. Baker, who worked together with Dr. Stapleton, to find a solution for his pathological condition. However, completely without their patient’s knowledge, at a time when anesthesia did not even exist, the two physicians deliberately refractured the limb in order to test a new and unconventional surgical technique that would cause traction throughout the consolidation process.

This action caused sequelae in the patient that were not even dealt with as inherent risks of the procedure used, in the same way that no authorization to perform the procedure had been sought. In view of these events, the patient took the matter to the courts under the allegation of medical damage caused by ignorance and ineptness. The court-appointed experts gave full backing to the patient, and the physicians were found guilty(1).

In 1894, in Germany, and more precisely in the “Re-ichsgericht” (state court), it was expressly ruled that a lack of authorization from the patient was an absolute impedi-ment on carrying out any medical action, and that profes-sionals who defied this ruling could be sent to prison.

abSTraCT

Objective: To assess the real importance of obtaining informed consent, through an appropriate form, and its role in the outcome from civil liability claims. Methods: The wordings of the current Brazilian law and jurisprudence were compared with rulings from the State Court of the State of Rio de Janeiro, in 269 civil liability claims against healthcare professionals and hospitals. Results: Favorable and unfavorable outcomes (i.e. acquittals and con-

victions) were compared, and possible variations in the verdicts were discussed in relation to whether informed consent forms had been filled out or not. Conclusions: Obtaining informed consent, by means of appropriate forms, is still not a widespread practice in the Brazilian healthcare or judicial systems. It is recommended that this practice be adopted in the manner described in this paper, since this is prescribed in Brazilian law.

Keywords – Informed consent; Bioethics; Evaluation

In 1914, in New York, United States, a legal ruling that was fundamental to patients’ rights was made, with the recognition that patients could reject the treatment that had been proposed to them. This was the first case involving a patient and a hospital unit(2).

The term Informed Consent was used for the first time in a verdict in the United States, in California in 1957. Two years earlier, the Supreme Court of the State of North Carolina, United States, had defined that fail-ure by a physician to provide information regarding the risks of a surgical procedure constituted negligent conduct(3).

CONCEPT

Today, in Brazil, informed consent is defined as: “a voluntary verbal or written decision by an autonomous and capable person that is made after a process of infor-mation provision, in which this person accepts a specific treatment or experimental procedure while aware of its risks, benefits and possible consequences”(4).

Thus, obtaining a patient’s consent to perform a given medical action translates into an agreement that can be revoked at any time, preceded by provision of

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clear information that relates to a particular time and is wide-ranging and satisfactory such that the patient can understand his real state of health.

This informed consent is a right of the patient and is included among the rights of personality. It expresses the patient’s autonomy regarding his physical and psy-chological integrity, and is the opposite of heteronomy, in which the physician’s will prevails. Informed consent is manifested as the patient’s power to make informed decisions regarding agreement with treatment or medical diagnoses.

In situations such as severe diseases or in cases of di-agnoses and treatments that might take a long time, con-tact between the physician and the patient, or the adult responsible for that patient, with the aim of communi-cating information and providing explanations about the patient’s clinical situation, should not be restricted to an interview. The information supplied also needs to be adapted to the psychological state that patients may present at that particular time.

When patients are making decisions about the lines of their treatment, it cannot be said that the decision is made on the basis of awareness and voluntary action if the patient’s will is contaminated with ignorance. In such cases, the patient lacks knowledge about the subject of the decision that he will make. The consent may be deemed invalid because of the existence of this substantial error (i.e. lack of knowledge about what is to be decided). Such consent would consist of a prefor-mulated and incorrect declaration of wishes, without precise notions regarding the investigative, diagnostic, treatment-related and prognostic characteristics of the patient’s disease(5).

CUrrENT LEGiSLaTiON iN braziL

The legal doctrine of informed consent refers to the Consumer Defense Code (CDC), which was created through Law no. 8,078 of September 11, 1990, with its fulcrum in article 5, xxxII, of the Federal Constitution, as applicable to consumer relations.

According to the CDC, patients are consumers to whom services are provided; physicians are suppliers who carry out service provision activities; and medical actions are activities provided for individuals or entities through remuneration without employment linkage(6).

The Brazilian Federal Constitution, which has been in force since 1988, attributes the characteristic of pub-

lic service to service providers, in the light of what is expressed in the “caput” of article 6: “Health, work, leisure, safety, social security, protection of maternity and childhood and assistance for the destitute are social rights, in the form of this Constitution”.

In addition, article 196 of the Federal Constitution is categorical: “Health is the right of everyone and a duty of the State, ensured through social and economic policies that aim to reduce the risk of disease and other threats to health, and to provide equal and universal access to actions and services for health promotion, protection and recovery”. It does not leave any doubt regarding the pub-lic service nature of the activity of hospital service provi-sion, even if conceded to private entities.

Civil liability consists of the way in which repara-tions for losses caused to others are imposed on a given individual, through indemnificatory action, relating to the event itself or to people or things that depend on it(7). Therefore, it should be understood as a successive legal duty that arises to make good the damage resulting from an original legal duty(8), i.e. it is subjective and the burden of proof falls on those who make the allegations, unless the inversion foreseen in the CDC is required.

Physicians’ personal liability is subjective, but the bur-den of fixed proof is in favor of the consumer(6). Prior to the Consumer Defense Code (CDC), the principle established in law was that the burden of proof fell to those who made allegations. However, today, this has been inverted and the current interpretation from articles 6, VIII and 14 of the CDC is the following: “Suppliers of services are responsible, independent of the exis-tence of culpability, for reparation of damage caused to consumers through defects in the services provided, and for insufficiencies or inadequacies of the informa-tion relating to usage and risks. Paragraph 4 lays down that the personal liability of liberal professionals will be ascertained through verification of the culpability”. Hence, informed consent becomes an important weapon in physicians’ defense.

Predictability consists of a psychological link between the agent and the result, expressed by foreseen absence of predictions (informed consent). It places a limit on the liability of the agent (physician) for the results coming from his initial lack of diligence. The agent is only liable for the predictable results, while others that do not come from ineptness, imprudence or negligence are deemed to be professional misfortune.

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If the criterion of predictability is eliminated, simple culpability becomes a hypothesis of obligatory con-demnation, which is the opposite of the principle of culpability in the modern subjective sense(9).

For civil liability to be demandable, it is insufficient for the patient to have suffered a loss or for the physi-cian to have acted culpably. A third and final requisite also needs to be present: the existence of a cause-effect link between the culpability and the loss, i.e. the loss suffered has to be a consequence of the culpable action (causal nexus).

Even in cases of objective liability, the causal nex-us between conduct and result is essential. Among the causes that exclude the physician’s liability is proof that when the service was provided, the defect did not exist. It is enough to prove that the event did not result from a defect in the service but, rather, from the patient’s own conditions or other unforeseeable factors. In this, a de-tailed and cautious informed consent statement may be of assistance(10).

Since physicians’ personal liability is subjective, as in reality it is, it will not be enough for the clinical or surgical treatment merely to be unsuccessful, for a duty to indemnify to be caused. The victim will have to prove not only the loss, causal nexus and objective liability, but also the physician’s culpability. This would occur if, for example, through using the normal knowledge of medicine, a physician were to arrive at an erroneous conclusion regarding a diagnosis or a surgical interven-tion: however, only a gross error by such professionals would constitute penal culpability(11).

In objective liability, culpability will be proven or presumed. This may consist of lack of informed consent in cases of elective surgery that result, for example in orthopedics, in limitations on the movements of a given limb or diminution of its functioning. In Brazil, individu-als can only be sentenced to provide indemnification if there is culpability.

Today, with the inversion of the burden of proof en-abled through the Consumer Defense Code, it falls to physicians to prove their own innocence, and no longer to patients to prove that the professional was culpable.

For rights to be exercised in a regular manner, it is essential to obtain patients’ consent or the consent of their legal representative, as expressed in the “caput” of article 46 of the Medical Ethics Code,. Thus, physi-cians have the duty to give information to patients and,

except in emergencies, patients have to be consulted regarding the medical options, so that they can make choices. They need to be informed about procedures and, whenever possible, give their consent, with full explanations about the possible risks of medical inter-vention and everything that will be done(12).

Despite the use of the term informed consent, the medical or surgical intervention does not exclude crimi-nal charges when there is ineptness, imprudence or neg-ligence by the agent. This agent will be answerable for a culpable crime if it not a case of simple professional error(13).

The following dictionary definitions should be borne in mind. Ineptness is incompetence or lack of expertise; imprudence is action without due care; and negligence is slothfulness, disregard or laxness(13,14).

If patients allege medical errors, the responsibility for defensive proof may be optional, if it is considered difficult for users to assemble proof regarding their sup-posed rights, if only because at the time of the relation-ship, users were acting in good faith, in addition to the foreseeable obstacles against obtaining material proof (medical files).

The sanctions applied by the Consumer Defense Code in addition to fines are set forth in article 56: “Infractions of the consumer defense norms are subject to the following administrative sanctions, according to the case, without prejudice to those of civil or penal nature or those defined in specific rules: I – fine; IV – suspension of supply of services; Ix – revocation of the license for the establishment or activity. The sanctions listed shall be applied by the administrative authority, within the scope of their attributed powers (Regional Medical Council), while full defense is assured”.

In article 951 of the Civil Code, the liability for in-demnification is expanded, particularly in relation to the hypotheses of death, incapacitation for work and wounds, and brings in the new situation of aggravation of the patient’s ailments. In the case of wounds, greater cover-age of the liability can also be accepted by studying the cause of the patient’s injury, which is more wide-ranging than wounds and also covers psychological disorders, for example, among other causes. These can be of any order (for example: family, social, professional, etc), given that the text does not mention any restriction.

Article 206 of the new Civil Code of January 10, 2003, states the following: “Art. 206. Prescription: § 3: for three years: V – intention of civil reparation”.

INFORMED CONSENT: THE MEDICAL AND LEGAL CHALLENGE OF OUR TIME

194


The Civil Code of 2003 corroborates this liability in article 927, sole paragraph: “Art. 927. (...) Sole Para-graph. There will be an obligation to provide reparation for the loss, independent of culpability, in the cases specified in laws, when the activity developed by the perpetrator implies risks to the rights of others through its nature.”

For the importance of informed consent in the legal doctrine applicable to physicians to be comprehended, the damage needs to be understood conceptually.

Material damage is defined as damage that affects the individual physically in terms of the body or economic interests (for example, assets), whereas moral damage af-fects legal issues of a moral or subjective nature such as honor, dignity or social standing, for which pecuniary estimation is difficult.

PrEParaTiON Of a COrrECT iNfOrMED CONSENT fOrM

In the light of the above, the following are the mini-mum requisites to be considered in an informed consent document:– �Name and surname of the patient and of the physician

providing the information;– �Explanation of the nature of the ailment and its natural

evolution;– �Name of the procedure to be performed and its constit-

uent specifications, and how it will be carried out;– �Explanation of the benefits and risks that can reasonably

be expected from the intervention and the consequences of denial;

– �Information on the risks from the intervention, likely complications, mortality and sequelae;

– �Alternative treatments, compared with the proposed treatment;

– �Explanation regarding the type of medication required for the intervention and its risks;

– �Authorization to obtain photographs, videos and graph-ic recordings before, during and after the intervention, in order to disseminate the results or for image analy-sis in medical journals and/or in scientific circles;

– �Possibility of revocation of the consent at any time before the intervention;

– �Patient’s satisfaction regarding the information re-ceived and dealing with all the patient’s queries;

– �All of this in simple and easily accessible language, for full comprehension by the patient and/or his family;

– �Signatures of the physician, patient and witnesses, if possible with the addition of the respective civil identi-fication numbers (for example: identity card, tax num-ber, address, etc)(15).

METhODS

The dialectic method was applied, starting from analysis of the current Brazilian legislation covering the topic of obligation or lack of obligation regarding the use of informed consent statements and then making extensive direct observation of jurisprudence issued by the State Court of the State of Rio de Janeiro, solely during the year 2008.

Quantitative investigations were conducted on 269 civil liability claims that were motivated by supposed medical errors. The parameters highlighted were the numbers of acquittals and convictions of physicians and/or the institutions in which they worked(16).

The use or nonuse of informed consent by the phy-sicians and magistrates was taken into consideration in the investigation: either as a source of defense or for drawing up sentences in which the grounds for the conviction consisted of alleged lack of knowledge of disagreeable results obtained after carrying out a certain medical procedure.

The specific realties of orthopedists were also high-lighted within this set of cases, giving them special treat-ment and attention in the present study. These sentences were grounded in the laws and protocols described in the introduction.

This investigation was conducted using the internet, in the website of the abovementioned court, in scien-tific articles and in the current Brazilian and foreign technical literature relating to important studies of our time.

rESULTS

Contrary to what most physicians think, the judiciary is not so severe or impositional towards them. Rather, it seeks the version closest to the medical truth, with per-fect comprehension of the profession, its anxieties and its aspirations, and with clear understanding of its diffi-culties and professional intercurrences, while expecting that physicians always seek the best rehabilitation for their patients, whenever possible, within appropriate therapies of good academic standard.

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1. �Goldim JR. Primeira sentença judicial sobre a necessidade do uso de consen-timento. Núcleo Interinstitucional de Bioética da Universidade do Rio Grande do Sul / Hospital das Clínicas de Porto Alegre. Disponível em: http://www.ufrgs.br/bioetica/conslate.htm. Acesso em 15 mai 2009.

2. �Silva CA. O consentimento informado e a responsabilidade civil do médico, Jus Navigandi, Terezina, a. 7, n.º 63 mar 2003. Disponível em: http://jus2.uol.com.br/doutrina/texto.asp?id=5311. Acesso em 25 abr 2009.

3. �Clotet J. O consentimento informado: uma questão de interesse de todos. Jornal de Medicina, do Conselho Federal, (10/11); 2000. p. 9.

4. �Souza NTC. Erro médico e consentimento informado, Jus Navigandi, Terezina, ano 8. n.º 337, 9 jun 2004. Disponível em: http://jus2.uol.com.br/doutrina/texto.asp?id=5311. Acesso em 26 abr 2009.

5. �Biondo-Simões MLP, Martynetz J, Ueda FMK, Olandoski M. Compreensão do termo de consentimento informado. Rev Col Bras Cir. 2007:34(3):183-8.

6. �Código de defesa do consumidor. 9a. edição. Rio de Janeiro: Forense; 2007. p. 21;193.

7. �Cavallieri S. Programa de responsabilidade civil. 6a. edição. São Paulo: Mal-heiros; 2005. p. 25.

8. �Coutinho LM. Código de ética médica comentado. 3a. edição. Florianópolis: Editora OAB/SC; 2003. p.153.

9. �Anibal B. Direito penal: parte geral. 4a. edição. Rio de Janeiro: Forense; 1984. p.138.

10. �Foster N. Erro médico. São Leopoldo: Editora Unisinos; 2002. p. 39.11. �Udesmann A. Responsabilidade civil, penal e ética dos médicos. Rev Assoc

Med Bras. 2002;48(2):172-82.12. �Mirabete JF. Manual de direito penal. 20a edição. São Paulo: Editora Atlas; 2003.

p. 192.13. �Ferreira, ABH. Mini Aurélio séc. XXI – Minidicionário da Língua Portuguesa –

4a Edição especial para o FNDE/PNLD-Editora Nova Fronteira-2002.14. �Neves LB. Vocabulário prático de tecnologia jurídica e de brocados latinos.

2ª edição. Rio de Janeiro: Edições Fase; 1988.15. �Navarro-Reynoso FP, et al. Derechos humanos y consentimiento informado.

Cirurgia y Cirurjanos, México. 2004;72(3):243. Disponível em: http://medigraph-ic.com/espanol/e-htms/e-circir/e-cc2004/e-cc04-3/em-cc043n.htm. Acesso em 27 mai 2009.

16. �Tribunal de Justiça do Estado do Rio de Janeiro. Consultas a jurisprudências – ano início: 2008 – ano término: 2008, tema: Erro Médico. Disponível em: http://www.tj.rj.gov.br. Acesso 01 mai 2009.

17. �Código Civil Brasileiro. 54a edição. São Paulo: Editora Saraiva; 2003. p.69.

rEfErENCES


DiSCUSSiON

The proof of this is that, including cases that were shelved without determining their merit, there were 194 acquittals out of the total of 269 civil claims judged by the State Court of the State of Rio de Janeiro. The vast majority of the cases were dismissed under the argument of lack of the causal nexus proposed in the initial petition, in the light of the real medical conduct ascertained by the court’s expert witness.

As an example of causal nexus, taking a simple form, there might be a man with cerebral aneurism who died in a plane crash in which he was a passenger making a business trip. It would be concluded that there was no causal nexus between the aneurysm (his disease) and the cause of death (the plane crash).

It should be noted that two of these acquittals were due to good and reasonable use of an informed consent statement, preceding the medical procedure, in line with the dispositions presented in the introduction.

The convictions, totaling 24, were mostly due to deaths of patients in which the minimum medical pro-tocols had not been followed. This was to a large extent seen through the lack of precise description of all of the medical actions in the medical files(17). There were also five cases that were generated specifically by pa-tients who alleged that they did not know the future consequences of the medical acts to which they were subjected. In other words, an informed consent state-ment made prior to the procedure might have avoided the civil conviction.

Among the set of cases mentioned above, there were 13 cases specifically against orthopedists, which re-sulted in nine acquittals and four convictions. However,

none of these could be linked with use or nonuse of informed consent statements.

The remainder of the cases due to medical error did not fit within the criteria for the present study, given that they were directed against health insurance plans, life insurance and others (total of 51 cases).

Looking at the indemnifications achieved in the cas-es of conviction, the minimum level was one minimum monthly salary, the maximum was R$ 200,000, and the mean ranged from R$ 30,000 and R$ 40,000. The physicians and the institutions in which they worked (public, private and/or philanthropic institutions) were jointly liable for these amounts(17).

CONCLUSiONAlthough informed consent is still at the embryonic

stage within the Brazilian medical-legal setting, it is fully supported by legislation and already has backing from many physicians and jurists. Through the laws that already exist, it should become a standard medical-legal practice and a component of the training for the values held by magistrates in drawing up their rulings.

The mere use of this term does not provide exemption in relation to application of the law in cases of error due to ineptness, imprudence or negligence by professionals, nor in relation to medical processes caused by such acts. However, their supposed errors can be dismissed with reasonable confidence when the academic means appro-priate for the case of each patient are used, in associa-tion with full information for the patient. This becomes unquestionable through drawing up an informed consent statement that is written in an honest, clear, simple and transparent manner, thereby protecting physicians from heavy indemnifications applied by the courts.

INFORMED CONSENT: THE MEDICAL AND LEGAL CHALLENGE OF OUR TIME

artigo 101

1 – �MSc student of Nuclear Science Techniques at the Federal University of Minas Gerais (UFMG). Pediatric Orthopedist at Hospital da Baleia and Hospital das Clínicas, UFMG.2 – �Orthopedist at Hospital da Baleia.3 – �Pediatric Orthopedist at Hospital da Baleia.4 – �Orthopedist at Hospital Infantil São Camilo.5 – �PhD student of Surgery. Professor in the Department of the Locomotor Apparatus, Federal University of Minas Gerais.

Work performed in the Pediatric Orthopedics Group of Belo Horizonte, at Hospital da Baleia (Prof. Matta Machado service), Hospital das Clínicas (UFMG) and Hospital São Camilo, Belo Horizonte, and at the Minas Gerais Institute of Orthopedics and Traumatology, Belo Horizonte.Correspondence: Instituto Mineiro de Ortopedia e Traumatologia, Avenida do Contorno 7485, 30110-120 Belo Horizonte, MG – E-mail: [email protected]


CaSE rEPOrT

TrAUMATIc POSTErIOr DISLOcATION OF THE HIP IN cHILDrEN: rEPOrT ON FIVE cASES

Gilberto Francisco Brandão1, Luiz Renato Drumond Américo2, Cláudio Beling Gonçalves Soares3, Rodrigo Galinari Costa Faria4, Luiz Eduardo Moreira Teixeira5


iNTrODUCTiON

Posterior traumatic dislocation of the hip in children is a rarely seen injury and constitutes an orthopedic emergency(1). During childhood, it may result from low-energy trauma caused by acetabular plasticity and liga-ment weakness(1).

The treatment should be performed as early as pos-sible. Closed reduction under anesthesia is the method of choice for the initial approach towards these lesions, in order to minimize the complications. However, there continues to be no consensus regarding the treatment after achieving reduction(1).

The most common early complications are associated fractures and neurological lesions. The late complications include episodes of renewed dislocation, chondrolysis, avas-cular necrosis and degenerative arthritis, usually secondary to delayed reduction. The following factors are related to worse prognosis: dislocation that is not corrected for more than six hours, advanced skeletal maturity, severe joint le-sions and the presence of multiple associated trauma(1).

abSTraCT

Objective: To evaluate a series of cases of traumatic posterior dis-locations in children, with the treatment and results, and to review issues relating to the epidemiology, clinical and radiographic diag-nosis, treatment, complications and prognosis of such cases. Meth-ods: Five patients with traumatic hip dislocation, with a mean age of 4.6 ± 0.9 years and a follow-up period of 19.8 ± 7.0 months, were evaluated retrospectively. The time elapsed between dislocation and reduction, the type of treatment, the associated injuries and the subsequent complications were evaluated. Results: The initial treat-ment was closed reduction, which was performed on average 5.2

± 3.6 hours after the initial trauma. All the patients underwent the reduction under anesthesia. The complementary treatment included plaster cast immobilization and traction. No need for additional surgery was observed and there were no long-term side effects. Conclusion: Traumatic dislocation of the hip should be treated quickly by means of closed reduction, with appropriate control over the reduction and rigorous observation in order to diagnose and treat late complications.

Keywords: Hip dislocation/epidemiology; Hip dislocation/diag-nosis; Hip dislocation/radiography; Hip dislocation/complica-tions; Child

The aim of the present study was to evaluate a series of cases of posterior traumatic dislocation in children, with the treatment and results, and to review the is-sues relating to the epidemiology, clinical diagnosis, radiographic diagnosis, treatment, complications and prognosis of such cases.

PaTiENTS aND METhOD

Five cases of posterior traumatic dislocation of the hip in patients with immature skeletons were evaluated between September 1999 and December 2003. The pa-tients were attended at Hospital da Baleia, Hospital São Camilo and the Minas Gerais Institute of Orthopedics. The mean age was 4.6 ± 0.9 years (ranging from 3.9 to 6 years). Four children (80%) were male and one (20%) was female. The injury mechanism was direct trauma in one case (20%), fall from the patients’ own height in three cases (60%) and fall from a high platform in one case (20%). The left side was affected in four cases (80%) and the right side in one case (20%).

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figure 1 – Clinical appearance characteristic of posterior dis-location of the hip

figure 2a – Radiographic appearance of traumatic posterior dislocation of the hip

figure 2b – After reduction of the dislocation and without signs of necrosis, seven months later


In all the cases, the diagnosis was based on physical examinations and radiographic findings from anteropos-terior views of the hip. On examination, all five children were unable to walk and presented typical deformities regarding flexion, adduction and medial rotation of the hip that was affected (Figures 1 and 2A). All the patients underwent closed reduction under venous anesthesia, and monitoring after the reduction was performed us-ing conventional radiographs (Figure 2B), Computed tomography was used if joint incongruence or the possi-bility of occult lesions was suspected. The patients were followed up every week for the first two months, every month over the first two years and every six months from the third year onwards. The control examinations consisted of clinical assessment of the range of motion, gait pattern, discrepancy between the limbs and radio-graphic evaluations in anteroposterior and batráquio views. The mean length of follow-up was 19.8 ± 7.0 months. The following were evaluated: severity of the trauma, initial time elapsed between the trauma and the reduction, the associated lesions, the functional result in terms of the limitation on joint mobility and residual claudication, the radiographic result in terms of analysis on the sphericity of the femoral head and abnormali-ties of acetabular development, and new episodes of dislocation. The data were analyzed with the aid of the Epi-Info software, version 6.04.

This study was approved by the Ethics Committees of the respective hospitals, and the parents responsible for these children gave their consent through a free and informed consent statement.

rESULTSThe trauma that resulted in the dislocation was

low-energy in four cases (80%). Only one case was high-energy, caused by a fall from a high platform (ap-proximately 2.5 m) (Table 1). The initial treatment con-sisted of closed reduction under anesthesia, which was performed on average 5.2 ± 3.6 hours after the initial trauma (median of 3.5 hours). Epiphysiolysis of the proximal femur was observed in one case, but after the reduction, the radiographic and tomographic examina-tions showed spontaneous reduction that remained sta-ble in radioscopic control examinations. It was decided to treat it conservatively, with a plaster cast from the pelvis to the foot. None of the cases presented neuro-logical abnormalities as complications. In the evaluation after the reduction, joint congruence was observed in all the cases, and there were no interpositions or occult associated lesions in the radiographic examinations.

After the complementary treatment, all the children were released for walking without restrictions. Dur-

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ing the follow-up, no clinical abnormalities or episodes of renewed dislocation were observed. All the patients presented symmetrical ranges of motion in relation to the contralateral hip, three months after the trauma, and none of them presented residual claudication. The radio-graphic evolution was satisfactory, with maintenance of the sphericity of the femoral head, acetabular orienta-tion and joint congruence. No cases of chondrolysis, avascular necrosis or joint degeneration were observed during the follow-up. In none of the cases was comple-mentary surgical treatment necessary.

DiSCUSSiONTraumatic dislocation of normal hips in children under

the age of 16 years(2) is a rare injury, with an incidence of 0.8 cases per million/year, and posterior dislocation ac-counts for 80% of such cases(2-11). It is more common in boys (4:1)(8,9) and may occur at any age among children, although the peak incidence occurs between four and sev-en years of age and between 11 and 15 years of age(3,8,9).

In younger children, the acetabulum is very flex-ible, loose and cartilaginous(1-4), thus allowing trivial trauma to result in dislocation(1,3-5,7-10,12). With growth, the cartilage calcifies and the ligament weakness dimin-ishes, such that greater energy is required to dislocate the hip(1,2,10-12). Thus, associations between traumatic dislocation of the hip and femoral fractures in children should always be borne in mind(11), especially among older children and adolescents(1-4,10).

The cases described here presented characteristics similar to those in the literature. We observed that male patients and a mean age of 4.6 years predominated, with lower-energy trauma in most cases, with the exception of one patient who suffered a fall from a height and pre-sented associated proximal epiphysiolysis of the femur.

The clinical diagnosis for this lesion is based on the history of trauma, pain in the hip and inability to

walk(2). The typical deformity varied according to the type of dislocation. In posterior dislocation, the leg will be flexed, adducted and internally rotated(1-4,9). The functioning of the sciatic nerve should be registered before and after the hip reduction(3,4). There is also the possibility of spontaneous but partial reduction of the dislocation, through interposition of soft tissues(13). This situation may not be recognized, thus leading to perma-nent joint damage(1,12,14,15).

Good-quality radiographic evaluation is essential for confirming the diagnosis, revealing the type of dis-location and discarding the hypothesis of associated fractures(2). Fragments from acetabular or femoral frac-tures are often seen better on radiographs produced be-fore the reduction(3,4). In our case of femoral fracture, the lesion was only evident on the initial radiograph, in agreement with Canale(3).

Traumatic dislocation of the hip in children is an orthopedic emergency(7,11). There is a consensus that the reduction should be performed immediately, pref-erably using a closed procedure and under general anesthesia(9,16,17) or with relaxants(3,11), using the same maneuvers as used for reductions in adults (Stimson, Allis and Bigelow)(2,3,9,10). After the reduction, the joint congruence should be evaluated, comparing the joint space, lateralization of the head(14) and breakage of Shenton’s line(9) with the contralateral side.

In cases of incongruent reduction, computed tomog-raphy (CT) and magnetic resonance imaging (MRI) are useful for determining any presence of fragments or interposed tissue(14). If the presence of interposition is confirmed, a second attempt at reduction is made(3,4), or open reduction using a posterior approach is performed(3,4,10). The indications for open reduction are weakness of the closed reduction, injury to the sciatic nerve with indication for exploration(2,3) and fractures of the acetabulum, femoral neck or femoral head that require surgical treatment(2).

There continues to be no consensus regarding the treat-ment to be followed after achieving reduction(1). Price et al(12) and Tachdjian(9) recommended using a plaster cast from the pelvis to the foot (PCPF) for four to six weeks, in order to allow the capsule to heal. Gianom et al(6) indicated resting in bed until achieving pain relief, following by walk-ing using crutches and protection of the support for four weeks. Blaster and Hughes(10) proposed resting until the pain improved, followed by a return to walking. Canale(3) and Hebert(2) used cutaneous traction for one week, fol-lowed by protection of the support for four to six weeks.

Table 1 – Complementary treatment following closed reduction, among the patients with posterior dislocation of the hip

Patient Gender Complementary treatment

Duration of immobilization

(weeks)

Time taken to restore weight loading(weeks)

DBL M PCPT 3 4FFL F PCPT 4 8ASR F ST + PCPT 4 4

BCMM F ST + PCPT 4 4EML F PCPT 4 4

Source: SAME – Hospital da Baleia, Hospital São Camilo and IMOTLegend: PCPT – plaster cast from pelvis to foot, ST – skeletal traction, M – male, F – female

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Kutty S, Thornes B, Curtin WA, Gilmore MF. Traumatic posterior dislocation of hip in 1. children. Pediatr Emerg Care. 2001;17(1):32-5.Hebert S. Fraturas e luxações do quadril na criança e no adolescente. In: Hebert S, Xavier 2. R, Pardini Júnior AG, Barros Filho TEP. Ortopedia e Traumatologia – Princípios e Prática. 3a. ed., Porto Alegre: Artmed; 2003. P.1231-7. Canale ST. Luxações traumáticas do quadril em crianças. In: Crenshaw AH. Cirurgia 3. Ortopédica de Campbell. 8a. ed. São Paulo: Manole; 1996. p.1222-5.Canale ST, King RE. Luxações traumáticas do quadril. In: Rockwood CA Jr, Wilkins KE, 4. King RE. Fraturas em crianças. Tradução de Vilma Ribeiro de Souza Varga. 3a. ed. São Paulo: Manole; 1993. p.1061-89.Guarniero R, Peixinho M. Luxação traumática do quadril na criança. Rev Bras Ortop. 5. 1990; 25(4):93-6.Gianom D, Kronberger G, Sacher P. Long-term follow-up of traumatic hip dislocation in 6. childhood. Helv Chir Acta.1994;60(4):623-7.Hughes MJ, D’Agostino J. Posterior hip dislocation in a five-year-old boy: a case report, re-7. view of the literature and current recommendations. J Emerg Med. 1996; 14(5):585-90.Petrie SG, Harris MB, Willis RB. Traumatic hip dislocation during childhood. A case report 8. and review of the literature. Am J Orthop. 1996;25(9):645-9.Tachdjian MO. Luxação traumática do quadril. In: Tachdjian MO. Ortopedia pediátrica. 9. Tradução de José Aparecido Lopes. 2a. ed. São Paulo: Manole; 1995. p. 3222-40.Blaster RD, Hughes LO. Fractures and traumatic dislocation of the hip in children. In: 10. Beaty JH, Kasser JR. Rockwood & Wilkins Fractures in children. 5th edition. Philadelphia: Lippincott Willians & Wilkins; 2001. p. 930-8.

Macnicol MF. The Scottish incidence of traumatic dislocation of the hip in childhood. J 11. Pediatr Orthop B. 2000;9(2):122-4.Price CT, Phillips JH, Devito DP. Management of fractures. In: Morrisy RT, Weinstein SL. 12. Lovell & Winter’s pediatric orthopaedics. 5th edition. Philadelphia: Lippincott Willians & Wilkins; 2001. p. 1372-3.Price CT, Pyevich MT, Knapp DR, Phillips JH, Hawker JJ. Traumatic hip dislocation with 13. spontaneous incomplete reduction: a diagnostic trap. J Orthop Trauma. 2002;16(10):730-5.Banskota AK, Spiegel DA, Shrestha S, Shrestha OP, Rajbhandary T. Open reduction 14. for neglected traumatic hip dislocation in children and adolescents. X-ray transparency interpositions after reduction of traumatic dislocations of the hip in children. J Pediatr Orthop. 2007;27(2):187-91.Olsson O, Landin LA, Johansson A. Traumatic hip dislocation with spontaneous reduction 15. and capsular interposition. A report of 2 cases. Acta Orthop Scand. 1994;65(4):476-9.Burgos J, Gonzales-Herrans P, Ocete G. Traumatic hip dislocation with incomplete 16. reduction due to soft tissue interposition in a 4-year-old boy. J Pediatr Orthop B. 1995;4(2):216-8.Rieger H, Pennig D, Klein W, Grunert J. Traumatic dislocation of the hip in young children. 17. Arch Orthop Trauma Surg. 1991;110(2):114-7.Mehlman CT, Hubbard GW, Crawford AH, Roy DR, Wall EJ. Traumatic hip dislocation in 18. children. Long-term followup of 42 patients. Clin Orthop Relat Res. 2000;(376):68-79.Pinheiro PCMS. Uma lesão traumática no quadril da criança. Relato de um caso. Rev 19. Bras Ortop. 1994;29(1/2):44-6.Salisbury RD, Eastwood DM. Traumatic dislocation of the hip in chlidren. Clin Orthop 20. Relat Res. 2000;(377):106-11.

rEfErENCES

When there is a need for open reduction, skeletal traction (ST) or PCPF is recommended for up to six weeks(2,3,10). For cases of dislocation that evolved over more than 24 hours, ST prior to reduction is recommended, followed by traction for two to three weeks after the reduction(2,3).

The five cases analyzed here were subjected to closed reduction under anesthesia. Radiographic evaluation to verify joint congruence was performed on all of them. In cases of dislocation associated with femoral fracture, the congruence is confirmed using CT.

Many complications are associated with traumatic dis-location of the hip in children. Nerve injuries occur in around 5% of such children(2,9), and the fibular branch of the sciatic nerve is the one most affected in cases of poste-rior dislocation due to direct compression(13). Absence of improvement after four to six weeks is an indication for surgical exploration following neurodiagnostic studies(9). If there is loss of function of the sciatic nerve after the reduction, the nerve should be explored surgically(10). Avas-cular necrosis has an incidence of 8% to 10%, and delays in performing the reduction, high-energy trauma and age greater than five years are factors associated with higher frequency of this complication(1-3,7). The main risk factor seems to be the time elapsed since the dislocation. Reduc-tion performed after more than six hours of evolution pres-ents a risk of avascular necrosis that is 20 times greater(18). According to Mehlman et al(18), scintigraphic evaluation is unnecessary as routine follow-up. According to Blaster and Hughes(10), it is recommendable for the hip to be evaluated using serial radiographs, at least two years after the disloca-tion. These authors also did not recommend scintigraphic

evaluation or MRI as routine control examinations until reaching skeletal maturity(19). Renewed dislocation is rare and is associated with children younger than eight years of age(10) and children with ligament looseness, especially those with Down syndrome(3,10). Its treatment consists of a new reduction, followed by PCPF for six weeks or capsuloplasty(2,10). Among older children, it may be neces-sary to associate this with bone procedures such as Salter’s operation(3,10) or varus osteotomy(3). Chondrolysis has been reported following traumatic dislocation of the hip, in 6% of the children. It probably results from the joint lesion at the time of dislocation. The treatment should be symp-tomatic. If joint reconstitution does not occur, arthrodesis or reconstruction should be considered(10). Coxa magna seems to occur as a result of post-traumatic hyperemia. In most of these children, this condition is asymptomatic and does not require any treatment. Ossifying myositis(3) and degenerative arthritis(1,7-9) are potential sequelae.

The five cases reported here did not present any com-plications up to the time of the last orthopedic evalua-tion. Most of the children had good long-term evolution and better results than shown by adults(10,20). A large proportion of such patients (78%) can undertake high-demand activities such as soccer or basketball(18).

CONCLUSiONTraumatic dislocation of the hip occurred in younger

children in our case series, with lower-energy trauma and good late evaluation. Despite the satisfactory evolution of our five patients, long-term follow-up needs to be maintained.

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artigo 192

1 – �Orthopedist at Hospital São Marcos (HSM) and the Piauí Association for Combating Cancer (APCC), Teresina, PI. Member of the Brazilian Society of Orthopedics and Traumatology.

2 – �Professor in the Discipline of General Pathology, State University of Piauí, and Pathologist in the Pathological Anatomy Laboratory, HSM/APCC.3 – �Professor in the Discipline of General Pathology, Federal University of Piauí (UFPI), and Pathologist in the Pathological Anatomy Laboratory, HSM/APCC.4 – �Retired Professor of the Discipline of General Pathology, Federal University of Piauí (UFPI), and Pathologist in the Pathological Anatomy Laboratory, HSM/APCC.5 – �Orthopedist at HSM/APCC, Member of the Brazilian Society of Orthopedics and Traumatology and of the Brazilian Association of Orthopedic Oncology. Professor of the

Medical Course of the Federal University of Piauí and MSc from FMUSP.

Work performed at the Orthopedics and Traumatology Service of Hospital São Marcos (HSM) and the Piauí Association for Combating Cancer (APCC), Teresina, PI.Correspondence: Marcelo Barbosa Ribeiro, Rua Porto 1186, Bloco Tulipas, apto. 103, Bairro Pio xII, 64019-900 Teresina, PI – E-mail: [email protected]


CaSE rEPOrT

MONOSTOTIc PAgET’S DISEASE IN LUMbAr VErTEbrAE: AN ATYPIcAL LOcATION

Alexandre Dias Carvalho1, Jerúsia Oliveira Ibiapina2, Lina Gomes Santos3, Teresinha Castelo Branco Carvalho4, Marcelo Barbosa Ribeiro5


iNTrODUCTiON

Paget’s disease was first described by Sir James Paget in 1877, under the name osteitis deformans. It consists of a bone remodeling disorder. There are etiological hypoth-eses involving viruses, mutations and/or genetic heredity. It is more common among white individuals, in the age group over 60 years and among men, in the proportions of 3:2. In most cases, it can be diagnosed using simple radiography. The alkaline phosphatase concentration is an important marker for controlling systemic forms. The current treatment consists of using bisphosphonates and analgesics. Zoledronic acid has been used with a good response(1-3).

The monostotic form is rare and is most common in the long bones and pelvis. In the spine, it represents 10 to 15% of this form of presentation(4).

The aim of this study was to report on the case of a patient with monostotic Paget’s disease in the spine.

CLiNiCaL CaSE

The patient was a 41-year-old white woman with a complaint of lumbar pain for more than three years. She underwent clinical treatment of the symptoms and

abSTraCT

A 41-year-old white female patient with complaints of lumbar pain for more than three years, without irradiation, underwent several radiological examinations. Her condition was diagnosed

by means of biopsy, as monostotic Paget’s disease in the third lumbar vertebra. This is an uncommon location.

Keywords – Paget’s disease; Monostotic fibrous dysplasia; Spine

physiotherapy at that time. In the physical examination, she presented limitations regarding trunk flexion, pain upon local mobilization, rectification of lumbar lordosis, paravertebral contracture and normal muscle strength and sensitivity. She did not have any other signs or symptoms. There were no significant personal and/or family anteced-ents. Simple radiography showed a blastic lesion on the L3 vertebral body in the anteroposterior and profile views. Magnetic resonance imaging (MRI) (Figure 1) showed a lesion with a fracture, without compromising the medul-lary canal. Bone scintigraphy indicated a single lesion (Figure 2). The case was discussed with the Orthopedic Oncology group, and screening was applied because of a hypothesis of metastatic bone lesion. All the examina-tions were shown to be normal, including mammography, chest and abdominal tomography, laboratory tests and myelogram. It was decided to perform a biopsy guided by tomography, and this produced an inconclusive result. A transpedicular biopsy using a 4 mm trephine was then performed. The histopathological evaluation on the surgi-cal specimen, under a conventional optical microscope, showed the presence of bone trabeculae of irregular shape and disorganized structure, with the formation of cement lines compatible with Paget’s disease (Figure 3). The team

201

figure 4 – Surgical treatment with pedicle screws and longitu-dinal nails

figure 1 – T1 and T2-weighted nuclear magnetic resonance images showing lesion in the third lumbar vertebra

figure 2 – Bone scintigraphy using technetium 99, with abnor-mally high uptake in L3

figure 3 – Photomicrograph (HE; 100x) showing histological appearance of Paget’s disease


decided to carry out internal stabilization using pedicle screws and nails because of fear of fractures, both of the pedicle and due to vertebral failure in the future, with the aim of avoiding new surgical procedures (Figure 4). The patient evolved well with the use of sodium alendronate, and with outpatient return visits.

DiSCUSSiON

Vukasinović et al(5) reported the case of a patient with a hypothesis of disease in the parathyroids, for whom biopsy confirmed that it was a case of monos-

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Avramidis A, Polyzos SA, Moralidis E, Arsos G, Efstathiadou Z, Karakatsanis 1. K et al. Scintigrafic, biochemical and clinical response to zolendronic acid treatment in patients with Paget’s disease of bone. J Bone Miner Metab. 2008;26(6):635-41.

Sheane BJ, Delaney H, Doran MF, Cunnane G. A classical presentation of Paget 2. disease of bone. J Clin Rheumatol. 2008;14(6):373.

Seton M. Paget’s disease: epidemiology and pathophysiology. 3. Curr Osteoporos Rep. 2008;6(4):125-9.

Wu LC, Tseng CH, Chiang YF, Tsuang YH. Monostotic Vertebral Paget’s Disease 4. of the Lumbar Spine. J Chin Med Assoc. 2009;72(1):52-5.

Vukasinović Z, Slavković N, Spasovski D, Slavković S. Spinal localization of 5. Paget disease – case report. Srp Arh Celok Lek. 2008;136(7-8):419-22.

Reyes R, Peris P, Monegal A, Fuster D, Guañabens N. Vertebral “clover” scin-6. tigraphic image in a vertebral metastasis misdiagnosed with Paget’s disease. Clin Rheumatol. 2008; 27(12):1585-6.

Lewis RJ, Jacoes B, Marchisello PJ, Bulolough PG. Monostotic Paget’s disease 7. of the spine. Clin Orthop Relat Res. 1977;(127):208-11.Rosen MA, Matasar KW, Irwin RB, Rosenberg BF, Herlowitz HN. Osteolytic 8. monostotic Paget’s disease of the fifth lumbar vertebra. A case report. Clin Orthop Relat Res. 1991;(262):119-23.Rosen MA, Wesolowski DP, Herkowitz HN. Osteolytic monostotic Paget’s dis-9. ease of the axis. A case report. Spine. 1988;13(1):125-7.Dinneen SF, Buckley TF. Spinal nerve root compression due to monostotic 10. Paget’s disease of a lumbar vertebra. Spine. 1987;12(9):948-50.Harris DJ, Fornasier VL. An ivory vertebra: monostotic Paget’s disease of bone. 11. Clin Orthop Relat Res. 1978;(136):173-5.Herter M, Steudel H, Steudel A12. . Histological confirmation of monostotic Paget’s disease in the sacrum by CT-guided bone puncture biopsy. Rofo. 1986;145(5):608-10.Guyer PB, Clough PW. Paget’s diseases of bone: some observations on the rela-13. tion of the skeletal distribution to pathogenesis. Clin Radiol. 1978;29(4):421-6.

rEfErENCES

Rev Bras Ortop. 2010;45(2):200-2

totic Paget’s disease. In their paper, they recognized the benefits of early surgical stabilization, given that one of their patients who did not undergo an operation subsequently evolved to kyphosis. After receiving the diagnosis, our patient was given information about the natural history of the disease, its risk factors and its orthopedic management with corsets and surgery using screws or nails. Together with the medical team, our patient chose a surgical approach because of the greater stability possible, given that the pagetoid bone could in the future evolve to fracturing.

All patients with suspected Paget’s disease should be evaluated by an oncological orthopedist, given that the hypothesis of neoplasia should thus be discarded. Reyes et al(6) drew attention to the risks of diagnoses made from images suggestive of Paget’s disease, and they reported the case of a patient with metastasis from hepatocellular carcinoma that simulated typical Paget vertebrae. There are other reports in the literature that confirm our opin-ion, in which the differential diagnosis between Paget’s disease and bone neoplasia often becomes difficult(7).

The vertebral lesions of Paget’s disease may appear in different forms: lytic, blastic and/or mixed. Detailed studies need to be made, including biopsy whenever possible. The vertebral locations ranged from the axis

to the sacrum. Cases from outside of the standard age range are increasingly being found. Such cases may be diagnosed late, with neurological lesions already established(8-11).

Tomography-guided biopsy is the gold standard to-day for diagnosing vertebral lesions, but pathologists sometimes need large samples of material in order to reach a diagnostic conclusion(12). In our case, we had to perform a biopsy using a 4 mm trephine, by means of the posterior transpedicular route, with an oncological orthopedist analyzing the macroscopic appearance of the sample during the operation.

In an interesting survey conducted in the United Kingdom among 1225 patients with Paget’s disease, the most frequently found locations were the pelvis, lumbar spine, sacrum, femur, cranium and dorsal spine. It was found that 30% of the cases were of the monos-totic form(13). This percentage was much greater than found by most other authors. This finding raises ques-tions relating to whether racial or genetic characteristics might be the causes.

Monostotic forms of Paget’s disease should form part of the differential diagnosis for bone lesions, given that ever greater numbers of very atypical cases such as the case in the present report are appearing.

Miosan CAF® – cloridrato de ciclobenzaprina + cafeína. FORMA FARMACÊUTICA, VIA DE ADMINISTRAÇÃO E APRESENTAÇÕES: Uso oral. Comprimidos de 5 mg de cloridrato de ciclobenzaprina e 30 mg de cafeína: Caixas com 15 comprimidos revestidos. Com-primidos de 10 mg de cloridrato de ciclobenzaprina e 60 mg de cafeína: Caixas com 15 comprimidos revestidos. USO ADULTO. INDICAÇÕES DO MEDICAMENTO: Miosan CAF®, cujos princípios ativos são o cloridrato de ciclobenzaprina e a cafeína, é indicado: No tratamento dos espasmos musculares associados com dor aguda e de etiologia músculo-esquelética, como nas lombalgias, torcicolos, fibromialgia, periartrite escapuloumeral, cervicobraquialgias. O produto é indicado como coadjuvante de outras medidas para o alívio dos sintomas, tais como fisioterapia e repouso. CONTRA-INDICAÇÕES: Hipersensibilidade a ciclobenzaprina e/ou cafeína ou a qualquer outro componente da fórmula do produto. Miosan CAF® é contra-indicado para pacientes que apresentam glaucoma ou retenção urinária. Uso simultâneo de IMAO (inibidores da monoaminoxidase). Fase aguda pós-infarto do miocárdio. Pacientes com arritmia cardíaca, bloqueio, alteração da conduta, insuficiência cardíaca congestiva ou hipertireoidismo. PRECAUÇÕES E ADVERTÊNCIAS: A utilização de Miosan CAF® por períodos superiores a duas ou três semanas deve ser feita com o devido acompanhamento médico. Doses acima de 250 mg de cafeína ao dia aumentam a freqüência e severidade dos efeitos adversos. Gravidez: Não há estudos adequados e bem controlados sobre a segurança do uso de ciclobenzaprina em mulheres grávidas. Como os estudos em animais nem sempre reproduzem a resposta em humanos, não se recomenda a administração de Miosan CAF® (cloridrato de ciclobenzaprina) durante a gravidez. A cafeína atravessa a barreira placentária, e durante a gestação seu metabolismo encontra-se reduzido. A cafeína pode potencializar os efeitos teratogênicos do tabaco, álcool, ergotamina e propranolol. Lactação: Não é conhecido se a droga é excretada no leite materno. Como a ciclobenzaprina é quimicamente relacionada aos antidepressivos tricíclicos, alguns dos quais são excretados no leite materno, cuidados especiais devem ser tomados quando o produto for prescrito a mulheres que estejam amamentando. Cerca de 1% do total da cafeína sérica pode ser encontrada no leite materno, mas segundo avaliação da American Academy of Pediatrics e da World Health Organization (WHO), o uso da cafeína em baixas doses é compatível com a amamentação. O consumo de cafeína pela mãe não é associado a efeitos adversos no lactente, entretanto o consumo excessivo pode ser associado à irritabilidade e alterações do padrão de sono da criança. Pediatria: Não foi estabelecida a segurança e a eficácia de ciclobenzaprina em crianças menores de 15 anos. INTERAÇÕES MEDICAMENTOSAS: A ciclobenzaprina pode aumentar os efeitos do álcool, dos barbituratos e dos outros depressores do SNC. Os antidepressivos tricíclicos podem bloquear a ação anti-hipertensiva da guantidina e de compostos semelhantes. Antidiscinéticos e antimuscarínicos podem ter aumentada a sua ação, levando a problemas gastrintestinais e a íleo paralítico. Com inibidores da monoaminoxidase é necessário um intervalo mínimo de 14 dias entre a administração dos mesmos e da ciclobenzaprina, para evitar as possíveis reações. A cafeína reduz os efeitos sedativos e ansiolíticos (por efeito antagonista no SNC) do clonazepam, midazolam, diazepam, lorazepam, alprazolam, bromazepam, clordiazepóxido, nitrazepam, prazepam, flurazepam, halazepam, clobazam e triazolam. A cafeína aumenta a concentração e toxicidade da teofilina, podendo gerar náuseas, vômitos, palpitação e convulsões. A ciprofloxacina e outras quinolonas interferem com o metabolismo da cafeína, reduzindo seu clerance e aumentando sua meia-vida. A cafeína interage farmacodinamicamente com medicamentos sedativos (benzodiazepínicos), reduzindo estes efeitos o que, em alguns casos pode ser um resultado desejado. REAÇÕES ADVERSAS: As reações adversas que podem ocorrer com maior freqüência são: sonolência, secura de boca e vertigem. As reações relatadas em 1 a 3% dos pacientes foram: fadiga, debilidade, astenia, náuseas, constipação, dispepsia, sabor desagradável, visão borrosa, cefaléia, nervosismo e confusão. Estas reações somente requerem atenção médica se forem persistentes. Com incidência em menos de 1% dos pacientes foram relatadas as seguintes reações: síncope e mal-estar. Cardiovasculares: taquicardia, arritmias, vasodilatação, palpitação, hipotensão. Digestivas: vômitos, anorexia, diarréia, dor gastrintestinal, gastrite, flatulência, edema de língua, alteração das funções hepáticas, raramente hepatite, icterícia e colestase. Hipersensiblidade: anafilaxia, angioedema, prurido, edema facial, urticária e “rash”. Músculo-esqueléticas: rigidez muscular. Sistema nervoso e psiquiátrico: ataxia, vertigem, disartria, tremores, hipertonia, convulsões, alucinações, insônia, depressão, ansiedade, agitação, parestesia, diplopia. Pele: sudorese. Sentidos especiais: ageusia, tinitus. Urogenitais: Freqüência urinária e/ou retenção. Estas reações, embora raras, requerem supervisão médica. A cafeína em doses maiores que 250mg/dia pode desencadear: - no sistema cardiovascular: arritmias, palpitação e hiperemia; - no SNC: nervosismo, agitação, insônia, agitação psico-motora, irritabilidade e tremor. Distúrbios gastrintestinais também podem ser observados. Gastrites e intolerâncias alimentares podem ser observadas. Os resultados dos estudos a respeito da influência da cafeína na densidade mineral óssea são conflitantes, mas acredita-se que o seu consumo não seja um importante fator de risco para baixa massa óssea. Já foram relatadas alterações psiquiátricas como alucinações e psicose após uso de cafeína. Diversos estudos têm demonstrado que a retirada ou redução abrupta da cafeína em indivíduos com consumo regular por longo período de tempo, pode desencadear sintomas como cefaléia, letargia e dificuldade de concentração, que normalmente têm início em 12-24 horas, pico em 20 a 48 horas e duração em torno de uma semana. POSOLOGIA: Adultos: A dose usual é de 20 a 40 mg de cloridrato de ciclobenzaprina ao dia, em duas a quatro administrações. A dose máxima diária é de 60 mg de cloridrato de ciclobenzaprina. O uso do produto por períodos superiores a duas ou três semanas, deve ser feita com o devido acompanhamento médico. VENDA SOB PRESCRIÇÃO MÉDICA. Reg. MS nº 1.0118.0611. APSEN FARMACÊUTICA S/A.

Contra-indicações: Hipersensibilidade a ciclobenzaprina e/ou cafeína ou a qualquer outro componente da fórmula do produto. Interações medicamentosas: A ciclobenzaprina pode aumentar os efeitos do álcool, dos barbituratos e dos outros depressores do SNC.

Miosan CAF (cloridrato de ciclobenzaprina + cafeína) é um medicamento. Durante seu uso, não dirija veículos ou opere máquinas, pois sua agilidade e atenção podem estar prejudicadas.

JAN/

10

Referências Bibliográficas: 1. Suplemento do D.O.U. nº 102, 01 de Junho de 2009. 2. Toth PP, Urtis J. Commonly used muscle relaxant therapies for acute low back pain: a review of carisoprodol, cyclobenzaprine hydrochloride, and metaxalone. Clin Ther. 2004 Sep;26(9):1355-67. 3. Paluska SA. Caffeine and exercise. Curr Sports Med Rep. 2003 Aug;2(4):213-9. 4. Sökmen B, Armstrong LE, Kraemer WJ, Casa DJ, Dias JC, Judelson DA, Maresh CM. Caffeine use in sports: considerations for the athlete. J Strength Cond Res. 2008 May;22(3):978-86. 5. Dórea JG, da Costa TH. Is coffee a functional food? Br J Nutr. 2005 Jun;93(6):773-82. 6. Elenbaas JK. Centrally acting oral skeletal muscle relaxants. Am J Hosp Pharm. 1980 Oct;37(10):1313-23. 7. C Jones G. Caffeine and other sympathomimetic stimulants: modes of action and effects on sports performance. Essays Biochem. 2008;44:109-23. 8. Shapiro RE .Caffeine and headaches. Neurol Sci. 2007 May;28 Suppl 2:S179-83. 9. Pandi-Perumal SR, Verster JC, Kayumov L, Lowe AD, Santana MG, Pires ML, Tufik S, Mello MT. Sleep disorders, sleepiness and traffic safety: a public health menace.Braz J Med Biol Res. 2006 Jul;39(7):863-71. 10. Moreno RA, Sverdloff CE, Oliveira RA, Oliveira SE, Borges DC, et al. Comparative bioavailability and pharmacodynamic aspects of cyclobenzaprine and caffeine in healthy subjects and the effect on drowsiness intensity. Journal of Bioequivalence & Bioavailability 2009; 1(3):86-92. 11. Rosenthal TC, Majeroni BA, Pretorius R, Malik K. Fatigue: an overview. Am Fam Physician. 2008 Nov 15;78(10):1173-9. 12. Kallus KW, Schmitt JA, Benton D. Attention, psychomotor functions and age. Eur J Nutr. 2005 Dec;44(8):465-84. 13. Srinivas G. Rao, MD, PhD; Judith F. Gendreau, MD; Jay D. Kranzler, MD, PhD.Understanding the Fibromyalgia Syndrome. Psychopharmacol Bull. 2008;40(4):24-56.

Anúncio Miosan Caf 21 x 28_ORTO.indd 1 22/01/2010 16:00:12

Seu pacientepegou pesado?

Você prescreve,o paciente “miorrelaxa”.

MIOFLEX-A (diclofenaco sódico, carisoprodol, paracetamol, cafeína). Indicações: reumatismo nas suas formas inflamatório-degenerativas agudas e crônicas; crises agudas de gota; estados in-flamatórios agudos, pós-traumáticos e pós-cirúrgicos. Exacerbações agudas de artrite reumatoide e osteoartrose e estados agudos de reumatismo nos tecidos extra-articulares. Coadjuvante em processos inflamatórios graves decorrentes de quadros infecciosos. Contraindicações: hipersensibilidade conhecida a qualquer componente da fórmula; úlcera péptica em atividade; discrasias sanguíneas; diáteses hemorrágicas (trombocitopenia, distúrbios da coagulação); porfiria; insuficiências cardíaca, hepática ou renal graves; hipertensão arterial grave. pacientes asmáticos nos quais o ácido acetilsalicílico e demais inibidores da síntese de prostaglandinas via ciclooxigenase precipitam acessos de asma, urticária ou rinite aguda. o produto não é indicado para crianças abaixo de 14 anos com exceção de casos de artrite juvenil crônica. Advertências: este medicamento deverá ser usado sob prescrição médica. Não use outro produto que contenha paracetamol. A possibilidade de reativação de úlceras pépticas requer cuidadosa anamnese quando houver história pregressa de dispepsia, hemorragia gastrointestinal ou úlcera péptica. Nas indicações do produto por períodos superiores a 10 dias deverão ser realizados hemograma e provas da função hepática antes do início, periodicamente e após o tratamento. a diminuição na contagem de leucócitos e/ou plaquetas ou do hematócrito requer a suspensão do tratamento. Em pacientes portadores de doenças cardiovasculares, deve-se considerar a possibilidade de ocorrer retenção de sódio e edema. A medicação deverá ser imediatamente suspensa caso ocorram reações alérgicas pruriginosas ou eritematosas, febre, icterícia, cianose ou sangue nas fezes. Gravidez e lactação: embora os estudos realizados não tenham evidenciado efeitos teratogênicos, o uso do medicamento nesses períodos não é recomendado. Uso pediátrico: a segurança e a eficácia do diclofenaco – independentemente da formu-lação farmacêutica - não foram estabelecidas em crianças. Assim sendo, com exceção de casos de artrite juvenil crônica, o uso do diclofenaco não é recomendado em crianças com idade inferior a 14 anos. Interações medicamentosas: o diclofenaco sódico pode elevar a concentração plasmática de lítio ou digoxina, quando administrados concomitantemente. Alguns agentes antiinflamatórios não esteróides são responsáveis pela inibição da ação de diuréticos da classe da furosemida e pela potencialização de diuréticos poupadores de potássio, sendo necessário o controle periódico dos níveis séricos de potássio. A administração concomitante de glicocorticoides e outros agentes anti-inflamatórios não esteroides pode levar ao agravamento de reações adversas gastrointestinais. A biodisponibilidade do produto é alterada pelo ácido acetilsalicílico quando esses compostos são administrados conjuntamente. Recomenda-se a realização de exames laboratoriais periódicos quando anticoagulantes forem administrados juntamente com o medicamento para verificar se o efeito anticoagulante desejado está sendo mantido. Estudos clínicos realizados com pacientes diabéticos mostram que o produto não interage com hipoglicemiantes orais. Pacientes em tratamento com metotrexato não devem usar o produto 24 horas antes ou após a administração do metotrexato, uma vez que sua concentração sérica pode elevar-se aumentando a toxicidade desse quimioterápico. Reações adversas: podem ocorrer distúrbios gastrointestinais como dispepsia, dor epigástrica, recor-rência de úlcera péptica, náuseas, vômito e diarréia. Ocasionalmente, podem ocorrer cefaléia, confusão mental, tonturas, distúrbios da visão, edema por retenção de eletrólitos, hepatite, pancreatite, nefrite intersticial. Foram relatadas raras reações anafilactoides urticariformes ou asmatiformes, bem como síndrome de Stevens-Johnson e síndrome de Lyell, além de leucopenia, trombocitopenia, pancitopenia, agranulocitose e anemia aplástica. O uso prolongado pode provocar necrose papilar renal. Posologia: a dose mínima diária recomendada é de 1 comprimido a cada 12 horas. Entretanto, aconselha-se, individualizar a posologia, adaptando-a ao quadro clínico, idade do paciente e condições gerais. A duração do tratamento, sempre que possível, não deverá ultrapassar 10 dias. Trata-mentos mais prolongados requerem observações especiais (vide advertências). Os comprimidos devem ser ingeridos inteiros (sem mastigar) junto com líquidos, às refeições. Venda sob prescrição médica. Farmacêutico responsável: Dr. J. G. Rocha - CRF-SP nº 4067. Reg. MS:1.0394.0469.

Contra indicações: hipersensibilidade conhecida a qualquer componente da fórmula; úlcera péptica em atividade. Interações medicamentosas: a administração concomitante de glicocorticoides e outros agentes anti-inflamatórios não esteroides pode levar ao agravamento de reações adversas gastrointestinais.

Anuncio_mioflex_2.indd 1 21/12/09 15:18

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Referências Bibliográficas: 1. Frampton JE; Keating GM. Celecoxib: A Review of its Use in the Management of Arthritis and Acute Pain. Drugs 2007; 67 (16): 2433-2472. 2. Calin A. Celecoxib and ankylosing spondylitis. Expert Review Clin Immunol 2008; 4(3): 339-349 3.Will OCC, Man RF, Phillips RKS et al. Familial adenomatous polyposis and the small bowel: A loco-regional review and current management strategies. Pathol Res Pract 2008; 204(7): 449-458. 4.White WB, West CR, Borer JS et al. Risk of Cardiovascular Events in Patients Receiving Celecoxib:A Meta-Analysis of Randomized Clinical Trials. Am J Cardiol 2007;99:91–98. 5. Moore RA, Derry S, McQuay HJ. Cyclo-oxygenase-2 selective inhibitors and nonsteroidal anti-inflammatory drugs: balancing gastrointestinal and cardiovascular risk. BMC Musculoskelet Disord. 2007; 8: 73. Publicado online em 3 de agosto de 2007 doi: 10.1186/1471-2474-8-73. 6. Moore RA, Derry S, McQuay HJ. Cyclo-oxygenase-2 selective inhibitors and nonsteroidal anti-inflammatory drugs: balancing gastrointestinal and cardiovascular risk. BMC Musculoskelet Disord. 2007; 8: 73. Publicado online em 3 de agosto de 2007 doi: 10.1186/1471-2474-8-73, disponível em: http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=17683540 Acessado em 08 de dezembro de 2009.

Celebra® (celecoxibe) é um antiinflamatório e analgésico pertencente ao grupo de medicamentos denominados inibidores específicos da enzima ciclooxigenase 2 (COX-2). Indicações: tratamento dos sinais e sinto-mas da osteoartrite e artrite reumatoide; alívios dos sinais e sintomas da espondilite anquilosante; alívio da dor aguda (principalmente no pós-operatório de cirurgia ortopédica ou dental e em afecções músculo-esque-léticas); alívio dos sintomas de dismenorréia primária (cólica menstrual); redução do número de pólipos adenomatosos colorretais em poliposes adenomatosas familiares (PAF) como um adjunto aos cuidados usuais (por ex., vigilância endoscópica e cirurgia). Contra-indicações: hipersensibilidade ao celecoxibe ou a qualquer componente da fórmula ou às sulfonamidas; pacientes que tenham apresentado asma, urticária ou re-ações alérgicas após uso de ácido acetilsalicílico (Aspirina) ou outros antiinflamatórios não-esteróides (AINEs), incluindo outros inibidores específicos da COX-2. Reações graves, raramente fatais, tipo anafiláticas a AINES foram descritas em tais pacientes; pacientes com doenças hepáticas (albumina sérica abaixo de 25 g/L) e com insuficiência renal grave (clearance de creatinina abaixo de 30 mL/min); no tratamento da dor peri-operatória em pacientes submetidos à cirurgia de revascularização do miocárdio. Advertências e precauções: Celebra® pode causar um aumento no risco de eventos cardiovasculares trombóticos graves, infarto do miocárdio e derrame, que pode ser fatal. Todos os antiinflamatórios não-esteróides podem ter um risco similar. Este risco pode aumentar com a dose, duração do tratamento e fator de risco cardiovascular basal. Perfurações, úlceras ou hemorragias gastrintestinais altas ocorreram em pacientes tratados com Celebra®. Para se reduzir o risco potencial de um efeito adverso cardiovascular e GI, deve ser utilizada a menor dose eficaz durante o menor período possível. Em pacientes em terapia concomitante com varfarina ou agentes similares, foram relatados eventos hemorrágicos sérios, alguns deles fatais. A atividade anticoagulante deve ser monitorada após o início do tratamento com Celebra® ou após mudança de dose. Assim como todos os AINEs, Celebra® pode levar ao início de uma nova hipertensão ou piora da hipertensão pré-existente, podendo contribuir para uma aumento na incidência de eventos cardiovasculares. A pressão sangüínea deve ser cuidadosamente monitorada nesses pacientes. Deve-se usar Celebra® com cautela em pacientes com com-prometimento da função cardíaca, como insuficiência cardíaca congestiva, e outras condições que predisponham ou piorem a retenção hídrica. O celecoxibe deve ser usado com cautela em pacientes com funções cardíacas comprometidas, edema préexistente, ou outras condições de pré-disposição, ou que possam piorar pela retenção hídrica, incluindo aqueles que fazem uso de diuréticos, ou por outro lado, o risco de hipo-volemia. AINEs incluindo Celebra® podem causar toxicidade renal. Pacientes com insuficiência renal, insuficiência cardíaca, disfunção hepática e idosos devem ser cuidadosamente monitorados durante a terapia com Celebra® e deve-se ter cuidado ao iniciar o tratamento em pacientes com desidratação. Celebra® deve ser utilizado com cuidado em pacientes com insuficiência hepática moderada (classe B de Child-Pugh). Deve-se interromper o uso de Celebra® caso apareçam sinais e sintomas clínicos compatíveis com doença hepática, ou suas manifestações sistêmicas (por ex., eosinofilia, erupção, etc.). Por reduzir a inflamação, Celebra® pode reduzir a utilidade de sinais diagnósticos, como febre, na detecção de infecções. Reações graves na pele, algumas delas fatais, incluindo dermatite esfoliativa, síndrome de Stevens-Johnson e necrólise epidérmica tóxica, foram relatadas muito raramente em associação ao uso de celecoxibe. Celebra® deve ser descontinuado ao primeiro aparecimento de rash cutâneo, lesões nas mucosas ou qualquer outro sinal de hipersensi-bilidade. O tratamento da PAF com Celebra® não demonstrou reduzir o risco de câncer gastrintestinal ou a necessidade de colectomia profilática ou outras cirurgias relacionadas à PAF. Pode ocorrer anemia em pa-cientes recebendo Celebra®. Pacientes com asma podem apresentar broncoespasmo induzido por ácido acetilsalicílico (AAS). Não foram avaliadas a segurança e a eficácia em indivíduos abaixo de 18 amos de idade. Celebra® pode causar inércia uterina e fechamento prematuro do ducto arterioso e deve ser evitado durante o terceiro trimestre da gravidez. Celebra® deve ser usado durante a gravidez apenas se, a critério médico, o potencial benefício justificar o risco potencial para o feto (vide bula completa do produto). Celebra® é um medicamento classificado na categoria C de risco de gravidez. Portanto, este medicamento não deve ser utilizado por mulheres grávidas sem orientação médica ou do cirurgiãodentista. O médico deve tomar uma decisão quanto a interromper o aleitamento ou suspender o uso do medicamento, considerando a importância do medicamento para a mãe. Interações medicamentosas: pacientes com deficiência ou suspeita de deficiência de metabolizadores CYP2C9 devem utilizar Celebra® com cautela, uma vez que podem apresentar níveis plasmáticos altos anormais devido à redução do clearance metabólico. Existe um potencial para interação medicamentosa in vivo com fármacos metabolizados pela CYP2D6. Celebra® deve ser introduzido na menor dose recomendada em pacientes recebendo o inibidor da CYP2C9, fluconazol. A inibição das prostaglandinas pode reduzir o efeito antihipertensivo dos inibidores da enzima conversora de an-giotensina (ECA) e/ou antagonistas da angiotensina II. Esta interação deve ser considerada em pacientes que recebem Celebra® juntamente com inibidores da ECA e/ou antagonistas da angiotensina II. Estudos clí-nicos mostraram que os AINEs podem reduzir o efeito natriurético da furosemida e tiazídicos em alguns pacientes através da inibição da síntese de prostaglandinas renais. Celebra® não demonstrou efeitos clínicamente relevantes na farmacocinética de um protótipo de um contraceptivo oral combinado (1 mg noretindrona/ 0,035 mg etinilestradiol). Pacientes sob tratamento com lítio devem ser monitorados cuidadosamente quando Celebra® for introduzido ou retirado. Celebra® não é um substituto para o AAS na profilaxia de doença cardiovascular (vide bula completa do produto). Reações adversas: comuns (≥ 1% e < 10%): piora da alergia, insônia, tontura, hipertonia, edema periférico, bronquite, tosse, faringite, rinite, sinusite, infecção do trato respiratório superior, dor abdominal, diarréia, dispepsia, flatulência, problemas dentários, prurido, rash, infecção do trato urinário, sintomas da gripe, lesões acidentais. Reações adversas relatadas nos estudos prolongados de prevenção de pólipos: muito comuns (≥ 10%): hipertensão, diarréia. Reações observadas na experiên-cia pós-comercialização: anafilaxia, alucinação, meningite asséptica, ageusia, anosmia, vasculite, hemorragia gastrintestinal, hepatite, insuficiência hepática, insuficiência renal aguda, nefrite intersticial, dermatite esfo-liativa, eritema multiforme, síndrome de Stevens-Johnson, necrólise epidérmica tóxica, reação de fotossensibilidade, distúrbios menstruais (vide bula completa do produto). Posologia: nas doses de até 200 mg 2 vezes ao dia pode ser administrado com ou sem alimentos. Osteoartrite: 200 mg em dose única ou 100 mg 2 vezes ao dia por via oral. Foi demonstrada segurança para doses de até 400 mg 2 vezes ao dia Artrite Reumatoide: 100 ou 200 mg 2 vezes ao dia por via oral. Foi demonstrada segurança para doses de até 400 mg 2 vezes ao dia. Espondilite anquilosante: 200 mg em dose única ou 100 mg 2 vezes ao dia por via oral. Alguns pa-cientes apresentaram benefícios com uma dose diária total de 400 mg. Analgesia aguda e tratamento da dismenorréia primária: 400 mg, inicialmente, seguidos de uma dose de 200 mg por via oral, se necessário, no 1º dia do tratamento. Nos dias subseqüentes, administrar 200 mg 2 vezes ao dia, conforme necessário. Polipose adenomatosa familiar (PAF): os cuidados médicos para pacientes com PAF devem continuar mesmo durante o tratamento com Celebra®. A dose recomendada é de 400 mg (2 cápsulas de 200 mg), por via oral, 2 vezes ao dia junto com as refeições para melhorar a absorção. Tratamento da Dor Crônica: todo antiin-flamatório deve ser usado na sua menor dose diária eficaz durante o menor período possível, inclusive no manejo de doenças crônicas. O tempo adequado deve ser decisão do médico. Celebra® deve ser administrado na menor dose recomendada em pacientes com artrite ou dor com insuficiência hepática moderada (classe B de Child Pugh). O uso de Celebra em pacientes com insuficiência hepática grave não é recomendado. A dose de Celebra® deve ser reduzida aproximadamente à metade em pacientes com PAF com insuficiência hepática moderada (classe B de Child Pugh). Idosos: em pacientes com menos de 50 kg deve-se iniciar o tratamento com a menor dose recomendada. Celebra® deve ser administrado na menor dose recomendada a pacientes sob tratamento com fluconazol, um inibidor da CYP2C9. Deve-se ter cautela ao administar outros inibidores da CYP2C9 com Celebra®. Deficiência de metabolizadores CYP2C9: considerar o início do tratamento com a metade da menor dose recomendada. Superdosagem: nos casos suspeitos de super-dosagem, cuidados médicos de suporte devem ser instituídos. Emese e/ou carvão ativado 60 a 100 g em adultos, 1 a 2 g/kg em crianças e/ou catárticos osmóticos podem estar indicados em pacientes examinados no prazo de 4 horas da ingestão com sintomas ou depois de grande superdosagem. Diurese forçada, alcalinização da urina, hemodiálise ou hemoperfusão podem não ter utilidade por causa da alta ligação protéica. Apresentações: cápsulas de 100 mg em embalagem com 20 unidades e 200 mg em embalagens com 10 ou 30 unidades. USO ADULTO. USO ORAL. VENDA SOB PRESCRIÇÃO MÉDICA. SÓ PODE SER VENDIDO COM RETENÇÃO DA RECEITA. A persistirem os sintomas, o médico deverá ser consultado. Para maiores informações, consulte a bula completa do produto (cel16). Documentação científica e in-formações adicionais estão à disposição da classe médica mediante solicitação. Laboratórios Pfizer Ltda., Rua Alexandre Dumas, 1860 – Chácara Santo Antônio, São Paulo, SP – CEP 04717-904. Tel.: 0800-16-7575. Internet: www.pfizer.com.br Celebra®. MS – 1.0216. 0135. USO ADULTO. VENDA SOB PRESCRIÇÃO MÉDICA. SÓ PODE SER VENDIDO COM RETENÇÃO DA RECEITA.

CONTRAINDICAÇÃO: CELEBRA® É CONTRAINDICADO PARA O TRATAMENTO DA DOR PERIOPERATÓRIA RELACIONADA À CIRURGIA DE REVASCULARIZAÇÃO DO MIOCÁRDIO. INTERAÇÃO MEDICAMENTOSA: PACIENTES COM DEFICIÊNCIA OU SUSPEITA DE DEFICIÊNCIA DE METABOLIZADORES CYP2C9 DEVEM UTILIZAR CELEBRA® COM CAUTELA, UMA VEZ QUE PODEM APRESENTAR NÍVEIS PLASMÁTICOS ALTOS ANORMAIS DEVIDO À REDUÇÃO DO CLEARANCE METABÓLICO.

CELEBRA004_10 ANÚNCIO-minibula_verso_AF.indd 2 02/02/2010 17:39:20

UMA ESCOLHA COM BASE EM EVIDÊNCIAS1-5

FORTE poder ANALGÉSICO e anti-inflamatório, com melhor perfil de TOLERABILIDADE GI, CV e hepática entre os anti-inflamatórios1-6

EFICÁCIA SUSTENTADA POR EVIDÊNCIAS1-5

SE PERSISTIREM OS SINTOMAS, O MÉDICO DEVERÁ SER CONSULTADO

Laboratórios Pfizer Ltda.Rua Alexandre Dumas, 1860 - São Paulo - SP - CEP 04717-904CNPJ 46.070.868/0019-98 - © Copyright Pfizer Ltda. 2010Todos os direitos reservados. www.pfizer.com.br. Produzido em fevereiro/2010.

A minibula encontra-se na penúltima página desta publicação

USO ADULTO. VENDA SOB PRESCRIÇÃO MÉDICA. SÓ PODE SER VENDIDO COM RETENÇÃO DA RECEITA.

CELEBRA004_10 ANÚNCIO-minibula_verso_AF.indd 1 02/02/2010 17:39:19

PosologiaUso Adulto1 comprimido de 400 mg3 x ao dia, após as refeições.

ApresentaçãoComprimidos revestidos gastro-resistentes contendo 400 mg de extrato seco padronizado a 5% de Harpagophytum procumbens, correspondente a 20 mg de harpagosídeo.

Reduz a intensidade da dor na Artrose; 1-5

Melhora a fl exibilidade articular; 1-5

Tolerabilidade superior quando comparado aos AINEs; 1,3-4

Reduz a necessidade de AINEs e analgésicos no tratamento da Osteoartrose1,3 w

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ARPADOL – Harpagophytum procumbens 400 mg Extrato seco 5%. FORMA FARMACÊUTICA, VIA DE ADMINISTRAÇÃO E APRESENTAÇÕES: USO ORAL. Comprimidos revestidos gastro-resistentes de 400 mg. Caixas com 30 comprimidos. USO ADULTO. COMPOSIÇÃO: Cada comprimido revestido gastro-resistente contém: 400 mg; Harpagophytum procumbens extrato seco 5%... 400 mg; Excipientes* qsp... 1 cpr; *Excipientes: Celulose microcristalina, polivinilpirrolidona, croscarmelose sódica, estearato de magnésio, dióxido de silício coloidal, hidroxipropilmetilcelulose, polietilenoglicol, óxido de ferro amarelo e dióxido de titânio. Correspondência em marcador: 400 mg de Harpagophytum procumbens extrato seco 5% corresponde a 20 mg de harpagosídeo. Indicações: O medicamento Arpadol, extrato seco de Harpagophytum procumbens, está indicado como antiinflamatório e analgésico para quadros reumáticos tais como artrites e artroses, assim como lombalgias, mialgias e demais quadros ósteo-mio-articulares. Contra-indicações: Nos casos de hipersensibilidade ao Harpagophytum procumbens ou aos componentes da formulação do produto. O medicamento não deve ser usado em pacientes que apresentam úlceras gástricas e duodenais, intestino irritável e litíase vesicular. Posologia: O produto ARPADOL é apresentado na forma de comprimidos revestidos gastro-resistentes de 400 mg. ARPADOL deve ser ingerido depois das refeições e a via de administração proposta é a via oral, com o auxílio de quantidade suficiente de líquido. Adultos: A posologia recomendada de extrato seco de Harpagophytum procumbens 400 mg (com 5% de harpagosídeo) é de um comprimido três vezes ao dia. Advertências: Pacientes portadores de doenças cardíacas e que fazem uso de terapias hipo/hipertensivas devem ter cuidado com a ingestão de doses excessivas devido a possível cardioatividade. Pacientes com obstrução nas vias biliares devem ter aconselhamento médico. Pacientes diabéticos, apesar de não haver relatos específicos na literatura científica, devem evitar o seu uso devido a uma possível ação hipoglicemiante. Portanto, doses excessivas podem interferir com terapias cardíacas ou antidiabéticas. Gravidez: Devido a evidências de atividade ocitócica em animais, o medicamento não deve ser utilizado durante a gravidez e lactação sem acompanhamento médico. Também está contra indicado para gestantes, visto que pode estimular as contrações uterinas. Amamentação: O médico deve avaliar o risco/benefício do uso de ARPADOL. Não se sabe se a droga é excretada no leite materno. Interações medicamentosas: Possíveis interações com drogas antiarrítmicas e anti-hipertensivas não devem ser excluídas. Podem ocorrer também interações com drogas antidiabéticas, por causa do seu efeito hipoglicemiante. Devido à citação de que o Harpagophytum procumbens pode aumentar a acidez estomacal, existe a possibilidade da diminuição da efetividade de antiácidos, inibidores da bomba de prótons e bloqueadores H2; púrpura foi relatada em um paciente com administração conjunta de warfarina e Harpagophytum procumbens, sugerindo potencialização do efeito anticoagulante e remetendo a avaliação cuidadosa dessa associação e mesmo ajuste de dose da warfarina. Reações Adversas: Riscos a saúde e efeitos colaterais nas doses terapêuticas não têm sido relatados com freqüência. Efeitos adversos como diarréia, dores abdominais, vômito, flatulência, perda do paladar, dor de cabeça frontal, dispepsia e zumbidos foram relatados em poucos casos. Um estudo demonstrou que o efeito adverso mais comum foi a diarréia, que diminui espontaneamente após o 2-3º dia de tratamento. VENDA SOB PRESCRIÇÃO MÉDICA. Reg. MS nº1.0118.0606. APSEN FARMACÊUTICA S/A.Contra-indicações: Nos casos de hipersensibilidade ao Harpagophytum procumbens ou aos componentes da formulação do produto. O medicamento não deve ser usado em pacientes que apresentam úlceras gástricas e duodenais, intestino irritável e litíase vesicular. Interações medicamentosas: Possíveis interações com drogas antiarrítmicas e anti-hipertensivas não devem ser excluídas. Podem ocorrer também interações com drogas antidiabéticas, por causa do seu efeito hipoglicemiante.Referências Bibliográficas: 1. Chantre P, Cappelaere A, Leblan D, et al. Efficacy and tolerance of Harpagophytum procumbens versus diacerhein in treatment of osteoarthritis. Phytomedicine 2000 7(3): 177-83. 2. Brendler T, Gruenwald J, Ulbricht C, Basch E Devil´s Claw (Harpagophytum procumbens DC): an evidence-based systematic review by the Natural Standard Research Collaboration. Journal of Herbal Pharmacotherapy 2006 6(1): 89-126. 3. Lieblan D, Chantre P, Fournié B Harpagophytum procumbens in the treatment of knee and hip osteoarthritis. Four-month results of a prospective, multicenter, double-blind trial versus diacerhein. Joint Bone Spine 2000 67: 462-7. 4. Chrubasik JE, Roufogalis BD, Chrubasik S Evidence of effectiveness of Herbal Antiinflammatory drugs in the treatment of painful Osteoarthritis and chronic low back pain. Phytotherapy Research 2007 21: 675-83. 5. Stewart KM, Cole D The commercial harvest of devil´s claw (Harpagophytum spp.) in southern Africa: The devil´s in the details. Journal of Ethnopharmacology 2005 100: 225-36. 6. Chrubasik S, Eisenberg E Treatment of rheumatic pain with kampo medicine in Europe. Part 1. Harpagophytum procumbens. The Pain Clinic 1999 11(3): 171-8. 7. Grant L, McBean DE, Fyfe L, Warnock AM A review of the biological and potential therapeutic actions of Harpagophytum procumbens. Phytotherapy Research 2007 21: 199-209. 8. Warnock M, McBean D, Suter A, et al. Effectiveness and safety of Devil´s Claw tablets in patients with general Rheumatic Disorders. Phytotherapy Research 2007 21: 1228-33. 9. Gagnier JJ, Chrubasik S, Manheimer E Harpagophytum procumbens for osteoarthritis and low back pain: A systematic review. BMC Complementary and Alternative Medicine 2004 4(13): 1-10.

Nível de Evidência Científi ca 9

Grau de Recomendação 9

Harpagophytum procumbens 400 mg Extrato seco 5%. FARMACÊUTICA, VIA DE ADMINISTRAÇÃO E APRESENTAÇÕES:FARMACÊUTICA, VIA DE ADMINISTRAÇÃO E APRESENTAÇÕES:

Harpagophytum procumbensFARMACÊUTICA, VIA DE ADMINISTRAÇÃO E APRESENTAÇÕES:

Harpagophytum procumbens 400 mg Extrato seco 5%. FARMACÊUTICA, VIA DE ADMINISTRAÇÃO E APRESENTAÇÕES:

400 mg Extrato seco 5%.

Comprimidos revestidos gastro-resistentes de 400 mg. Caixas com 30 comprimidos. FARMACÊUTICA, VIA DE ADMINISTRAÇÃO E APRESENTAÇÕES:Comprimidos revestidos gastro-resistentes de 400 mg. Caixas com 30 comprimidos. FARMACÊUTICA, VIA DE ADMINISTRAÇÃO E APRESENTAÇÕES:FARMACÊUTICA, VIA DE ADMINISTRAÇÃO E APRESENTAÇÕES:Comprimidos revestidos gastro-resistentes de 400 mg. Caixas com 30 comprimidos. FARMACÊUTICA, VIA DE ADMINISTRAÇÃO E APRESENTAÇÕES:

COMPOSIÇÃO:COMPOSIÇÃO:Comprimidos revestidos gastro-resistentes de 400 mg. Caixas com 30 comprimidos.

COMPOSIÇÃO:Comprimidos revestidos gastro-resistentes de 400 mg. Caixas com 30 comprimidos.

Cada comprimido revestido gastro-resistente contém:Comprimidos revestidos gastro-resistentes de 400 mg. Caixas com 30 comprimidos.


Harpagophytum procumbensHarpagophytum procumbensCOMPOSIÇÃO:

Harpagophytum procumbensCOMPOSIÇÃO:COMPOSIÇÃO:

Harpagophytum procumbensCOMPOSIÇÃO: Cada comprimido revestido gastro-resistente contém:

Harpagophytum procumbens Cada comprimido revestido gastro-resistente contém:

extrato seco 5%... 400 mg; Excipientes* qsp... 1 cpr; *Excipientes: Cada comprimido revestido gastro-resistente contém:


Celulose microcristalina, polivinilpirrolidona, croscarmelose sódica, estearato de magnésio, dióxido Harpagophytum procumbensCelulose microcristalina, polivinilpirrolidona, croscarmelose sódica, estearato de magnésio, dióxido Harpagophytum procumbens extrato seco 5%... 400 mg; Excipientes* qsp... 1 cpr; *Excipientes: Celulose microcristalina, polivinilpirrolidona, croscarmelose sódica, estearato de magnésio, dióxido

extrato seco 5%... 400 mg; Excipientes* qsp... 1 cpr; *Excipientes:

1 400 mg Extrato seco 5%. FORMA

FARMACÊUTICA, VIA DE ADMINISTRAÇÃO E APRESENTAÇÕES:FARMACÊUTICA, VIA DE ADMINISTRAÇÃO E APRESENTAÇÕES: 400 mg Extrato seco 5%.

FARMACÊUTICA, VIA DE ADMINISTRAÇÃO E APRESENTAÇÕES: 400 mg Extrato seco 5%.

USO ORAL. USO ORAL. 400 mg Extrato seco 5%.

USO ORAL. 400 mg Extrato seco 5%.

Comprimidos revestidos gastro-resistentes de 400 mg. Caixas com 30 comprimidos. Comprimidos revestidos gastro-resistentes de 400 mg. Caixas com 30 comprimidos. FARMACÊUTICA, VIA DE ADMINISTRAÇÃO E APRESENTAÇÕES:Comprimidos revestidos gastro-resistentes de 400 mg. Caixas com 30 comprimidos. FARMACÊUTICA, VIA DE ADMINISTRAÇÃO E APRESENTAÇÕES:FARMACÊUTICA, VIA DE ADMINISTRAÇÃO E APRESENTAÇÕES:Comprimidos revestidos gastro-resistentes de 400 mg. Caixas com 30 comprimidos. FARMACÊUTICA, VIA DE ADMINISTRAÇÃO E APRESENTAÇÕES:

USO Cada comprimido revestido gastro-resistente contém:

Comprimidos revestidos gastro-resistentes de 400 mg. Caixas com 30 comprimidos. Cada comprimido revestido gastro-resistente contém:

Comprimidos revestidos gastro-resistentes de 400 mg. Caixas com 30 comprimidos. 400 mg

Comprimidos revestidos gastro-resistentes de 400 mg. Caixas com 30 comprimidos. 400 mg

Comprimidos revestidos gastro-resistentes de 400 mg. Caixas com 30 comprimidos. ;


extrato seco 5%... 400 mg; Excipientes* qsp... 1 cpr; *Excipientes: Cada comprimido revestido gastro-resistente contém: 400 mg

extrato seco 5%... 400 mg; Excipientes* qsp... 1 cpr; *Excipientes: 400 mg;

extrato seco 5%... 400 mg; Excipientes* qsp... 1 cpr; *Excipientes: ;

Celulose microcristalina, polivinilpirrolidona, croscarmelose sódica, estearato de magnésio, dióxido extrato seco 5%... 400 mg; Excipientes* qsp... 1 cpr; *Excipientes:


400 mg Extrato seco 5%. FARMACÊUTICA, VIA DE ADMINISTRAÇÃO E APRESENTAÇÕES:FARMACÊUTICA, VIA DE ADMINISTRAÇÃO E APRESENTAÇÕES:

400 mg Extrato seco 5%. FARMACÊUTICA, VIA DE ADMINISTRAÇÃO E APRESENTAÇÕES:

400 mg Extrato seco 5%.

Comprimidos revestidos gastro-resistentes de 400 mg. Caixas com 30 comprimidos. FARMACÊUTICA, VIA DE ADMINISTRAÇÃO E APRESENTAÇÕES:Comprimidos revestidos gastro-resistentes de 400 mg. Caixas com 30 comprimidos. FARMACÊUTICA, VIA DE ADMINISTRAÇÃO E APRESENTAÇÕES:FARMACÊUTICA, VIA DE ADMINISTRAÇÃO E APRESENTAÇÕES:Comprimidos revestidos gastro-resistentes de 400 mg. Caixas com 30 comprimidos. FARMACÊUTICA, VIA DE ADMINISTRAÇÃO E APRESENTAÇÕES:







A

Material científico destinado exclusivamente à Classe Médica

Anti-infl amatório e analgésico com ação inibidora das metaloproteinases no tratamento crônico da Osteoartrose1-8

ós as refeições.

gastro-resistentes contendo

inibidores da bomba de prótons e bloqueadores H2; púrpura foi relatada em um paciente com administração conjunta de warfarina e inibidores da bomba de prótons e bloqueadores H2; púrpura foi relatada em um paciente com administração conjunta de warfarina e inibidores da bomba de prótons e bloqueadores H2; púrpura foi relatada em um paciente com

efeito anticoagulante e remetendo a avaliação cuidadosa dessa associação e mesmo ajuste de administração conjunta de warfarina e efeito anticoagulante e remetendo a avaliação cuidadosa dessa associação e mesmo ajuste de administração conjunta de warfarina e

dose da warfarina. efeito anticoagulante e remetendo a avaliação cuidadosa dessa associação e mesmo ajuste de dose da warfarina. efeito anticoagulante e remetendo a avaliação cuidadosa dessa associação e mesmo ajuste de

não têm sido relatados com freqüência. Efeitos adversos como diarréia, dores abdominais, vômito, flatulência, perda do paladar, dor de cabeça frontal, dispepsia e zumbidos foram relatados em não têm sido relatados com freqüência. Efeitos adversos como diarréia, dores abdominais, vômito, flatulência, perda do paladar, dor de cabeça frontal, dispepsia e zumbidos foram relatados em não têm sido relatados com freqüência. Efeitos adversos como diarréia, dores abdominais, vômito,

poucos casos. Um estudo demonstrou que o efeito adverso mais comum foi a diarréia, que diminui flatulência, perda do paladar, dor de cabeça frontal, dispepsia e zumbidos foram relatados em poucos casos. Um estudo demonstrou que o efeito adverso mais comum foi a diarréia, que diminui flatulência, perda do paladar, dor de cabeça frontal, dispepsia e zumbidos foram relatados em

espontaneamente após o 2-3º dia de tratamento. poucos casos. Um estudo demonstrou que o efeito adverso mais comum foi a diarréia, que diminui espontaneamente após o 2-3º dia de tratamento. poucos casos. Um estudo demonstrou que o efeito adverso mais comum foi a diarréia, que diminui

MS nº1.0118.0606. APSEN FARMACÊUTICA S/A.espontaneamente após o 2-3º dia de tratamento. MS nº1.0118.0606. APSEN FARMACÊUTICA S/A.espontaneamente após o 2-3º dia de tratamento.

Contra-indicações: Nos casos de hipersensibilidade ao procumbensContra-indicações: Nos casos de hipersensibilidade ao procumbensContra-indicações: Nos casos de hipersensibilidade ao

não deve ser usado em pacientes que apresentam úlceras gástricas e procumbensnão deve ser usado em pacientes que apresentam úlceras gástricas e procumbens

duodenais, intestino irritável e litíase vesicular. Interações medicamentosas: não deve ser usado em pacientes que apresentam úlceras gástricas e duodenais, intestino irritável e litíase vesicular. Interações medicamentosas: não deve ser usado em pacientes que apresentam úlceras gástricas e

Possíveis interações com drogas antiarrítmicas e anti-hipertensivas não devem duodenais, intestino irritável e litíase vesicular. Interações medicamentosas: Possíveis interações com drogas antiarrítmicas e anti-hipertensivas não devem duodenais, intestino irritável e litíase vesicular. Interações medicamentosas:

ser excluídas. Podem ocorrer também interações com drogas antidiabéticas, Possíveis interações com drogas antiarrítmicas e anti-hipertensivas não devem ser excluídas. Podem ocorrer também interações com drogas antidiabéticas, Possíveis interações com drogas antiarrítmicas e anti-hipertensivas não devem

por causa do seu efeito hipoglicemiante.ser excluídas. Podem ocorrer também interações com drogas antidiabéticas, por causa do seu efeito hipoglicemiante.ser excluídas. Podem ocorrer também interações com drogas antidiabéticas,

Referências Bibliográficas: 1.in treatment of osteoarthritis. procumbens2006 6(1): 89-126. results of a prospective, multicenter, double-blind trial versus diacerhein. Chrubasik S Evidence of effectiveness of Herbal Antiinflammatory drugs in the treatment of painful Osteoarthritis and chronic low back pain. Phytotherapy ResearchAfrica: The devil´s in the details. with kampo medicine in Europe. Part 1. AM A review of the biological and potential therapeutic actions of 8. Research

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embalagem

Fórmula

inalterada

Anúncio Arpadol 21 x 28.indd 1 22/03/2010 19:46:59

vol. 45-n2-ingles

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