USE OF ALLOGRAFT IN LIGAMENTAR RECONSTRUCTION OF KNEE

Introduction: The use of allograft is a matter of huge interest for orthopaedic surgeons, due to the supposed advantages with its use, like decreased surgical time, larger grafts and no donator site morbidity. Objectives: The aim of this article was to review our experience with the use of allografts on ligament reconstruction. We present the technique applied for graft harvest, preparation and storage, as well as the indications for allograft use and the type of procedure in which it was applied. Methods: We revised the records of 46 patients. Results: We used 09 patellar tendons, 09 anterior tibial tendons, 08 calcaneal tendons, 06 quadriceptal tendons and 01 fibular tendon, mainly for multiple ligamentar reconstructions and ACL reviews. Conclusion: The use of allograft seems to be an interesting option for ligamentar reconstruction.

Conservative Versus Surgical Treatment for Repair of the Medial Patellofemoral Ligament in Acute Dislocations of the Patella

Purpose: The objective of this study was to analyze and compare the results obtained after 2 types of treatment, surgical and conservative, for acute patellar dislocations. Methods: We divided 33 patients with acute patellar dislocations into 2 groups. One group with 16 patients underwent conservative treatment (immobilization and subsequent physiotherapy), and the other group with 17 patients underwent surgical treatment. A radiographic examination was performed in the evaluation of the patients to verify predisposing factors for patellofemoral instability, and the Kujala questionnaire was applied with the intention of analyzing the improvement of pain and quality of life. The chi(2) test, t test, and Fisher test were used in the statistical evaluation. A significance level of P<.05 was adopted. Results: The groups were considered parametric in relation to age and sex. The conservative treatment group exhibited a higher number of recurrent dislocations (8 patients) than the surgical treatment group, which did not have any relapses. In addition, the surgical treatment group obtained a better mean score on the Kujala test (92) than the conservative treatment group (69). Conclusions: We conclude that surgical treatment afforded better results. There were no recurrences in the surgical treatment group, but there were 8 recurrences in the conservative treatment group. The mean Kujala score was 92 in the surgical treatment group and 69 in the conservative treatment group.

Evaluating Patellar Kinematics Through Magnetic Resonance Imaging During Open- and Closed-Kinetic-Chain Exercises

Purpose: To evaluate patellar kinematics of volunteers Without knee pain at rest and during isometric contraction in open- and closed-kinetic-chain exercises. Methods: Twenty individuals took part in this study. All were submitted to magnetic resonance imaging (MRI) during rest and voluntary isometric contraction (VIC) in the open anti closed kinetic chain at 15 degrees, 30 degrees, and 45 degrees of knee flexion. Through MRI and using medical e-film software, the following measurements were evaluated: sulcus angle, patellar-tilt angle, and bisect offset. The mixed-effects linear model was used for comparison between knee positions, between rest and isometric contractions, and between (he exercises. Results: Data analysis revealed that the sulcus angle decreased as knee flexion increased and revealed increases with isometric contractions in both the open and closed kinetic chain for all knee-flexion angles. The patellar-tilt angle decreased with isometric contractions in both the open and closed kinetic chain for every knee position. However, in the closed kinetic chain, patellar tilt increased significantly with the knee flexed at 15 degrees. The bisect offset increased with the knee flexed at 15 degrees during isometric contractions and decreased as knee flexion increased during both exercises. Conclusion: VIC in the last degrees of knee extension may compromise patellar dynamics. On the other hand, it is possible to favor patellar stability by performing muscle contractions with the knee flexed at 30 degrees and 45 degrees in either the open or closed kinetic chain.

Males still have limb asymmetries in multijoint movement tasks more than 2 years following anterior cruciate ligament reconstruction

More than 2 years after undergoing anterior cruciate ligament (ACL) reconstruction, women still present bilateral asymmetries during multijoint movement tasks. Given the well-known ACL-injury gender bias, the goal of this study was to investigate whether males also present such asymmetries more than 2 years after undergoing ACL reconstruction. This study involved 12 participants submitted to ACL reconstruction in the ACL group and 17 healthy participants in the control group. The mean postoperative period was 37 months. The participants executed bilateral countermovement jumps and load squat tasks. The kinematics and ground reaction forces on each lower limb and pelvis were recorded, and used to compute bilateral peak vertical ground reaction forces, peak knee and hip joint powers in the sagittal plane, and the ratio between these powers. For the jump task, the groups had the same performance in the jump height, but for the ACL group the peak knee joint power on the operated side was 13% lower than on the non-operated side (p = 0.02). For the squat task, the hip-knee joint power ratio on the operated side of the ACL group was 31% greater than on the non-operated side (p = 0.02). The ACL group presented a deficit in the operated knee that had its energy generation over time (joint power) partially substituted by the hip joint power of the same side. The fact that, even after more than 2 years following the ACL reconstruction and returning to regular activity, the ACL group still had neuromuscular asymmetries suggests a need for improvement in the ACL reconstruction surgery procedures and/or rehabilitation protocols.

Three-Dimensional Stress Distribution in the Human Periodontal Ligament in Masticatory, Parafunctional, and Trauma Loads: Finite Element Analysis

Background: The presence of the periodontal ligament (PDL) makes it possible to absorb and distribute loads produced during masticatory function and other tooth contacts into the alveolar process via the alveolar bone proper. However, several factors affect the integrity of periodontal structures causing the destruction of the connective matrix and cells, the loss of fibrous attachment, and the resorption of alveolar bone. Methods: The purpose of this study was to evaluate the stress distribution by finite element analysis in a PDL in three-dimensional models of the upper central incisor under three different load conditions: 100 N occlusal loading at 45 degrees (model 1: masticatory load); 500 N at the incisal edge at 45 degrees (model 2: parafunctional habit); and 800 N at the buccal surface at 90 degrees (model 3: trauma case). The models were built from computed tomography scans. Results: The stress distribution was quite different among the models. The most significant values (harmful) of tensile and compressive stresses were observed in models 2 and 3, with similarly distinct patterns of stress distributions along the PDL. Tensile stresses were observed along the internal and external aspects of the PDL, mostly at the cervical and middle thirds. Conclusions: The stress generation in these models may affect the integrity of periodontal structures. A better understanding of the biomechanical behavior of the PDL under physiologic and traumatic loading conditions might enhance the understanding of the biologic reaction of the PDL in health and disease. J Periodontol 2009;80:1859-1867.

Transurethral injection therapy with carbon-coated beads (Durasphere (R)) for treatment of recurrent pyelonephritis in kidney transplant patients with vesico-ureteral reflux to the allograft

Introduction and objectives: Recurrent transplant pyelonephritis (RTP) secondary to vesico-ureteral reflux (VUR) to the transplant kidney (KTx) remains a significant cause of infectious complications with impact on patient and graft outcomes. Our objective was to verify the safety and efficacy of transurethral injection of Durasphere (R) to relieve RTP secondary to VUR after renal transplantation. Patients and methods: Between June 2004 and July 2008, eight patients with RTP (defined as two or more episodes of pyelonephritis after transplantation) and VUR to the KTx were treated with subureteral injections of Durasphere (R). The mean age at surgery was 38.8 +/- 13.8 yr (23-65). The patients were followed regularly every six months. The mean interval between the KTx and the treatment was 76 +/- 74.1 (10-238 months). The mean follow-up was 22.3 +/- 16.1 months (8-57 months). Results: Six patients (75%) were free of pyelonephritis during a mean period of follow-up of 23.2 +/- 17.1 months (8-57 months). Two of them had no VUR and four cases presented with G II VUR (pre-operative G IV three cases and one case G III). In one case, symptomatic recurrent cystitis made a second treatment necessary. This patient remained free of infections for three yr after the first treatment and for 18 months after the second treatment. Of the remaining two patients, one had six episodes of RTP before treatment in a period of three yr and only two episodes after treatment in two yr of follow-up. The last case had a new episode of pyelonephritis five months after treatment. Conclusions: Transurethral injection therapy with Durasphere (R) is a safe and effective minimally invasive treatment option for KTx patients with recurrent RTP. A second treatment seems to be necessary in some cases.

Multifocal Renal Allograft Biopsy: Impact on Therapeutic Decisions

Objective. There are no data to support the suggestion that samples removed from one segment of the transplanted kidney are representative of the whole graft. The aim of this study was to compare the histological differences between biopsies obtained from different portions of the renal allograft and their impact on treatment recommendations. Patients and Methods. Two hundred percutaneous biopsies were performed on kidney allografts and samples were collected from the upper and lower poles (100 kidneys). All samples were randomized and blindly reviewed. We obtained the discordance rates between the poles for the grading of acute rejection and for the diagnosis of nephrotoxicity due to immunosuppression. We also checked if the differences found were sufficient to call for different clinical recommendations. These values were compared with the intrapathologist variation rates. Results. In 70 kidneys adequate sampling was obtained from both poles. The diagnosis of acute rejection were made in 1.7. The discordance rate between the upper and lower poles was 82.3% (kappa = 0.34), higher than the intrapathologist variation (P =.002). Nephrotoxicity was found in 14 kidneys. The discordance rate between the upper and lower poles was 28.6% (kappa = 0.88), with no difference compared with the intrapathologist variation. In 14 of the 70 kidneys (25.7%), discordances between poles had impact on clinical recommendations, most of these cases due to different gradings of acute rejection (78%). This number was higher than the intrapathologist variation (P =.04). Conclusions. The histopathological changes in the kidney allograft are not always homogeneous. This heterogeneity may affect the therapeutic recommendations.

Analysis of Different Staining Techniques for C4d Detection in Renal Allograft Biopsies

Capillary C4d deposition has been recognized as a marker of antibody-mediated rejection (AMR). Although the detection of capillary C4d by means of immunofluorescence (IF) in cryostat sections is well established, frozen tissue is not always available, thus limiting the diagnosis of AMR. The aim of the present study was to analyze different techniques for C4d staining and the prevalence of C4d in renal allograft biopsies. Detection of C4d was carried out using IF or immunohistochemistry (IHC) on frozen and paraffin sections of renal allograft biopsies available from the same patients. Biopsies obtained from 20 patients were classified into 3 groups: no rejection, acute rejection, and chronic allograft nephropathy (CAN). The capillary C4d deposition prevalence in frozen-IF, considered the gold standard technique for C4d detection, was 45% (9/20 cases). Compared with frozen-IF, the frozen-IHC technique presented an 85% concordance rate (17/20 cases; r =.70; P <.001; sensitivity = 77.8%; specificity = 90.9%). The paraffin-IF technique showed similar results, with an 80% concordance rate (16/20 cases; r =.64; P <.005; sensitivity = 55.6%; specificity = 100%), whereas C4d detection occurred in only 65% of paraffin-IHC cases (13/20; r =.30; not significant; sensitivity = 66.7%; specificity = 63.6%). No capillary C4d deposition was detected in cases without evidence of rejection. However, 4/7 cases (57%) of acute rejection were C4d positive. In the CAN group, 5111 cases (45%) were C4d positive. In conclusion, these results demonstrated that frozen-IHC and paraffin-IF can be considered alternative techniques to frozen-IF for C4d detection. The paraffin-IHC technique displayed the lowest concordance rate for C4d detection.

Combined glucosamine and chondroitin sulfate provides functional and structural benefit in the anterior cruciate ligament transection model

Evidence that combined glucosamine sulfate and chondroitin sulfate (Gluchon) or isolated glucosamine (Glu) modifies joint damage in osteoarthritis (OA) is still lacking. We studied joint pain and cartilage damage using the anterior cruciate ligament transection (ACLT) model. Wistar rats were subjected to ACLT of the right knee ( OA) or sham operation. Groups received either Glu (500 mg/kg), Gluchon (500 mg/kg glucosamine +400 mg/kg chondroitin) or vehicle (non-treated-NT) per os starting 7 days prior to ACLT until sacrifice at 70 days. Joint pain was evaluated daily using the rat-knee joint articular incapacitation test. Structural joint damage was assessed using histology and biochemistry as the chondroitin sulfate ( CS) content of cartilage by densitometry (microgram per milligram dried cartilage), comparing to standard CS. The molar weight (Mw) of the CS samples, used as a qualitative biochemical parameter, was obtained by comparing their relative mobility on a polyacrylamide gel electrophoresis to standard CS. Gluchon, but not Glu, significantly reduced joint pain (P<0.05) compared to NT. There was an increase in CS content in the OA group (77.7 +/- 8.3 mu g/mg) compared to sham (53.5 +/- 11.2 mu g/mg) (P<0.05). The CS from OA samples had higher Mw (4:62 +/- 0:24 x 10(4) g/mol) compared to sham (4:18 +/- 0:19 x 10(4) g/mol) (P<0.05). Gluchon administration significantly reversed both the increases in CS content (54.4 +/- 12.1 mu g/mg) and Mw (4:18 +/- 0:2 x 104 g/mol) as compared to NT. Isolated Glu decreased CS content though not reaching statistical significance. Cartilage histology alterations were also significantly prevented by Gluchon administration. Gluchon provides clinical (analgesia) and structural benefits in the ACLT model. This is the first demonstration that biochemical alterations occurring in parallel to histological damage in OA are prevented by Gluchon administration.

Induction of Indoleamine 2,3-Dioxygenase by Gene Delivery in Allogeneic Islets Prolongs Allograft Survival

Indoleamine 2,3-dioxygenase (IDO), an enzyme that plays a critical role in fetomaternal tolerance, exerts immunoregulatory functions suppressing T-cell responses. The aims of this study were to promote IDO expression in rat islets using a nonviral gene transfer approach, and to analyze the effect of the in vivo induction of IDO in a model of allogeneic islet transplantation. The IDO cDNA was isolated from rat placenta, subcloned into a plasmid and transfected into rat islets using Lipofectamine. The efficiency of transfection was confirmed by qRT-PCR and functional analysis. The in vivo effect of IDO expression was analyzed in streptozotocin-induced diabetic Lewis rats transplanted with allogeneic islets under the renal capsule. Transplantation of IDO-allogeneic islets reversed diabetes and maintained metabolic control, in contrast to transplantation of allogeneic nontransfected islets, which failed shortly after transplantation in all animals. Graft survival of allograft islets transfected with IDO transplanted without any immunosuppression was superior to that observed in diabetic rats receiving nontransfected islets. These data demonstrated that IDO expression induced in islets by lipofection improved metabolic control of streptozotocin-diabetic rats and prolonged allograft survival.

The presence of a vocal ligament in fetuses: a histochemical and ultrastructural study

Although it is currently believed that the vocal ligament of humans undergoes considerable development postnatally, there is no consensus as to the age at which it first emerges. In the newborn infant, the lamina propria has been described as containing a sparse collection of relatively unorganized fibres. In this study we obtained larynges from autopsy of human fetuses aged 7-9 months and used light and electron microscopy to study the collagenous and elastic system fibres in the lamina propria of the vocal fold. Collagen fibres were viewed using the Picrosirius polarization method and elastic system fibres were stained using Weigert`s resorcin-fuchsin after oxidation with oxone. The histochemical and electron microscopic observations were consistent, showing collagen populations with an asymmetric distribution across different compartments of the lamina propria. In the central region, the collagen appeared as thin, weakly birefringent, greenish fibres when viewed using the Picrosirius polarization method, whereas the superficial and deep regions contained thick collagen fibres that displayed a strong red or yellow birefringence. These findings suggest that the thin fibres in the central region consist mainly of type III collagen, whereas type I collagen predominates in the superficial and deep regions, as has been reported in studies of adult vocal folds. Similarly, elastic system fibres showed a differential distribution throughout the lamina propria. Their distribution pattern was complementary to that of collagen fibres, with a much greater density of elastic fibres apparent in the central region than in the superficial and deep regions. This distribution of collagen and elastic fibres in the fetal vocal fold mirrors that classically described for the adult vocal ligament, suggesting that a vocal ligament has already begun to develop by the time of birth. The apparently high level of organization of connective tissue components in the newborn is in contrast to current hypotheses that argue that the mechanical stimuli of phonation are essential to the determination of the layered structure of the lamina propria and suggests that genetic factors may play a more significant role in the development of the vocal ligament than previously believed.

Inter- and intra-tester reliability of clinical measurement to determine medio-lateral patellar position using a pachymeter or visual assessment

The aim was to investigate inter-tester and intra-tester reliability and parallel reliability between a visual assessment method and a method using a pachymeter for locating the mid-point of the patella in determining the medial/lateral patella orientation. Fifteen asymptomatic subjects were assessed and the mid-point of the patella was determined by both methods on two separate occasions two weeks apart. Inter-tester reliability was obtained by ANOVA and by intraclass correlation coefficient (ICC); intra-tester reliability was obtained by a paired t-test and ICC; and parallel reliability was obtained by Pearson`s Correlation and ICC, for the measurement on the first and second evaluations. There was acceptable inter-tester agreement (p = 0.490) and reliability for the visual inspection (ICC = 0.747) and for the pachymeter (ICC = 0.716) at the second evaluation. The inter-tester reliability in the first evaluation was unacceptable (visual ICC = 0.604; pachymeter ICC = 0.612). Although there was statistical similarity between measurements for the first and second evaluations for all testers, intra-tester reliability was not acceptable for both methods: visual (examiner 1 ICC = 0.175; examiner 2 ICC = 0.189; examiner 3 ICC = 0.155) and pachymeter (examiner 1 ICC = 0.214; examiner 2 ICC = 0.246; examiner 3 ICC = 0.069). Parallel reliability gave a perfect correlation at the first evaluation (r=0.828; p<0.001) and at the second (r=0.756; p<0.001) and reliability was between acceptable and very good (ICC = [0.748-0.813]). Both visual and pachymeter methods provide reliable and similar medial/lateral patella orientation and are reliable between different examiners, but the results between the two assessments at 2 weeks` interval demonstrated an unacceptable reliability. (C) 2009 Elsevier B.V. All rights reserved.

Analysis of patellar stabilizers muscles and patellar kinematics in anterior knee pain subjects

Patella stabilizer muscle response and patellar kinematics were evaluated in 19 women with anterior knee pain (AKP) and 20 healthy women during maximum voluntary isometric contraction (MVIC) with the knee positioned at 15 degrees, 30 degrees and 45 degrees flexion during open (OKC) and closed (CKC) kinetic chain exercises. Patellar kinematics was evaluated through patellar tilt and displacement, and the electrical activity of patellar stabilizers through the root mean square normalized during MVIC and OKC with the knee at 90 degrees flexion. Data revealed that the vastus medialis oblique muscle (VMO) was more active in the control group compared to the AKP group during OKC exercises with the knee at 45 degrees flexion. However, no difference in the patellar kinematics was observed between these groups; nevertheless, the correlation between these parameters also showed, with the knee at 45 degrees flexion, that lateral patellar tilt increase was associated with a reduction in the activity of lateral patellar stabilizers in the control group and with an increase in the VMO activity in the AKP group. In conclusion, electrical activity is an important factor in evaluating AKP and in AKP treatment evolution. (C) 2010 Elsevier Ltd. All rights reserved.

ONSET OF ELECTRICAL ACTIVITY OF PATELLAR STABILIZER MUSCLES IN SUBJECTS WITH PATELLOFEMORAL PAIN

Objective: To asses the onset (%) of patella stabilizer muscles during maximal isometric contraction exercises (MIC) in individuals with and without signs of patellofemoral pain syndrome (PFPS) in open (OKC) and closed (CKC) kinetic chain exercises, Method: Assessments were carried out on 22 women; ten with no complains of anterior knee pain, and 12 with PFPS signs during MIC in OKC and CKC with the knee flexed at 90 degrees. The onset of the electromyographic activity of the vastus mediallis obliquus (VMO), vastus lateralis obliquus (VLO) and vastus lateralis longus (VLL) was identified by means of an algorithm in the Myosystem Br 1 software. The statistical analysis used was Chi-Square test and student`s t test, which are both tests with a level of significance at 5%. Results: The VMO and VLO muscles presented a greater onset compared to the VLL during OKC exercises for both groups and for the PFPS group without CCF No differences were observed between the groups. Conclusion: CKC and OKC exercises seem to benefit the synchronism of the musculature that supposedly benefits the patella stabilizer musculature, and can be recommended in physiotherapeutic treatment programs.

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

The purpose of this study was to investigate whether the additional sensory information could improve postural control in individuals with unilateral anterior cruciate ligament (ACL) injury. Twenty-eight individuals with unilateral ACL injury (mean age 23.6, 26 males, 2 females) and 28 healthy young control subjects (mean age 22.1 years, 26 males, 2 females) participated in this study. Postural control was evaluated with subjects single-leg standing on a force platform with eyes closed under two sensory conditions: normal sensory information and light touch to a stationary bar (applied force below 1 N). Three trials of 30 5 were performed in each single-leg stance and in each sensory condition. Mean sway amplitude and predominant frequency of center of pressure were calculated for both anterior-posterior and medial-lateral directions. Individuals with ACL injury showed greater mean sway amplitude than healthy control individuals even though the predominant frequency was similar for both groups. Additional sensory information improved postural control performance in individuals with ACL injury and healthy control, with a greater effect observed for the ACL group. Based on these results, we suggest that reduction in postural control performance in individuals with ACL injury would be due to the reduction of sensory information provided by the ACL, but when sensory information is enhanced, postural control performance improves. These results have implications for novel approaches to improve stability in individuals with ACL injury. (c) 2008 Elsevier Ireland Ltd. All rights reserved.