The influence of tourniquet use and operative time on the incidence of deep vein thrombosis in total knee arthroplasty

OBJECTIVE: To evaluate the association between tourniquet and total operative time during total knee arthroplasty and the occurrence of deep vein thrombosis. METHODS: Seventy-eight consecutive patients from our institution underwent cemented total knee arthroplasty for degenerative knee disorders. The pneumatic tourniquet time and total operative time were recorded in minutes. Four categories were established for total tourniquet time: <60, 61 to 90, 91 to 120, and >120 minutes. Three categories were defined for operative time: <120, 121 to 150, and >150 minutes. Between 7 and 12 days after surgery, the patients underwent ascending venography to evaluate the presence of distal or proximal deep vein thrombosis. We evaluated the association between the tourniquet time and total operative time and the occurrence of deep vein thrombosis after total knee arthroplasty. RESULTS: In total, 33 cases (42.3%) were positive for deep vein thrombosis; 13 (16.7%) cases involved the proximal type. We found no statistically significant difference in tourniquet time or operative time between patients with or without deep vein thrombosis. We did observe a higher frequency of proximal deep vein thrombosis in patients who underwent surgery lasting longer than 120 minutes. The mean total operative time was also higher in patients with proximal deep vein thrombosis. The tourniquet time did not significantly differ in these patients. CONCLUSION: We concluded that surgery lasting longer than 120 minutes increases the risk of proximal deep vein thrombosis.

Effectiveness of a long-term use of a minimalist footwear versus habitual shoe on pain, function and mechanical loads in knee osteoarthritis: a randomized controlled trial

Background: Recent studies have shown an important reduction of joint overload during locomotion in elderly women with knee osteoarthritis (OA) after short- term use of minimalist shoes. Our aim is to investigate the chronic effect of inexpensive and minimalist footwear on the clinical and functional aspects of OA and gait biomechanics of elderly women with knee OA. Methods/Design: Fifty-six elderly women with knee OA grade 2 or 3 (Kellgren and Lawrence) are randomized into blocks and allocated to either the intervention group, which will use flexible, non-heeled shoes-Moleca (R)-for six months for at least six hours daily, or the control group, which could not use these shoes. Neither group is undergoing physical therapy treatment throughout the intervention period. Moleca (R) is a women's double canvas, flexible, flat walking shoe without heels, with a 5-mm anti-slip rubber sole and a 3-mm internal wedge of ethylene vinyl acetate. Both groups will be followed for six months and will be assessed at baseline condition, after three months, and after six months (end of intervention). All the assessments will be performed by a physiotherapist that is blind to the group allocation. The primary outcome is the pain Western Ontario and McMaster Universities Osteoarthritis (WOMAC) score. The secondary outcomes are global WOMAC score; joint stiffness and disability WOMAC scores; knee pain with a visual analogue scale; walking distance in the six-minute walk test; Lequesne score; amount and frequency (number of days) of paracetamol (500 mg) intake over six months; knee adduction moment during gait; global medical assessment score; and global patient auto-assessment score. At baseline, all patients receive a diary to record the hours of daily use of the footwear intervention; every two weeks, the same physiotherapist makes phone calls to all patients in order to verify adherence to treatment. The statistical analysis will be based on intention to treat analysis, as well as general linear models of analysis of variance for repeated measure to detect treatment-time interactions (alpha = 5%). Discussion: This is the first randomized, clinical trial protocol to assess the chronic effect of minimalist footwear on the clinical and functional aspects and gait biomechanics of elderly women with knee osteoarthritis. We expect that the use of Moleca (R) shoes for six months will provide pain relief, reduction of the knee adduction moment when walking, and improve joint function in elderly women with knee OA, and that the treatment, thus, can be considered another inexpensive and easy-to-use option for conservative OA treatment.

STUDY ON IMPLANT STABILITY IN CEMENTLESS TOTAL KNEE ARTHROPLASTY

Objetives: Determine the stability of tibial and femoral components of 20 cementless knee arthroplasties with rotating platform. Methods: The 20 patients (20 knees) underwent an analysis of dynamic radiographs with an image amplifier and maneuvers of varus and valgus which were compared to static frontal and lateral radiographs of the knees and analyzed by two experienced surgeons in a double-blind way. Results: We could observe in this study that both methods showed very similar results for the stability of the tibial and femoral components (p<0.001) using the Kappa method for comparison. Conclusion: The tibial component was more unstable in relation to the femoral component in both static and dynamic studies. Level of Evidence IV, Case Series.

Judet quadricepsplasty in the treatment of posttraumatic knee rigidity: Long-term outcomes of 45 cases

BACKGROUND: Posttraumatic knee stiffness is a very debilitating condition. Judet's quadricepsplasty technique has been used for more than 50 years. However, few reports of quadricepsplasty results exist in the literature. METHODS: We report the results of 45 cases of posttraumatic arthrofibrosis of the knee treated with Judet's quadricepsplasty. The results of the procedure were analyzed by measuring the degrees of flexion of the operated knees at different time points (before, immediately after, and late postoperatively). RESULTS: The degree of flexion increased from 33.6 degrees (range, 5-80 degrees) preoperatively to 105 degrees (range, 45-160 degrees) immediately after surgery, followed by a slight fall in the range of motion (ROM) in the late postoperative period, which reached an average of 84.8 degrees. There was no significant correlation between knee strength and the patient's gender, but there was a slight trend of lower strength with age. Although Judet's quadricepsplasty technique dates from more than 50 years ago, it still provides good outcomes in the treatment of rigid knees of various etiologies. In general, all cases showed the same pattern of a small decrease in the ROM in the late postoperative period. CONCLUSION: Judet's quadricepsplasty can increase the ROM of rigid knees. The ROM obtained with the surgery persists long term. (J Trauma. 2012; 72: E77-E80. Copyright (C) 2012 by Lippincott Williams & Wilkins)

Short-term efficacy of physical interventions in osteoarthritic knee pain. A systematic review and meta-analysis of randomised placebo-controlled trials

Abstract Background Treatment efficacy of physical agents in osteoarthritis of the knee (OAK) pain has been largely unknown, and this systematic review was aimed at assessing their short-term efficacies for pain relief. Methods Systematic review with meta-analysis of efficacy within 1–4 weeks and at follow up at 1–12 weeks after the end of treament. Results 36 randomised placebo-controlled trials (RCTs) were identified with 2434 patients where 1391 patients received active treatment. 33 trials satisfied three or more out of five methodological criteria (Jadad scale). The patient sample had a mean age of 65.1 years and mean baseline pain of 62.9 mm on a 100 mm visual analogue scale (VAS). Within 4 weeks of the commencement of treatment manual acupuncture, static magnets and ultrasound therapies did not offer statistically significant short-term pain relief over placebo. Pulsed electromagnetic fields offered a small reduction in pain of 6.9 mm [95% CI: 2.2 to 11.6] (n = 487). Transcutaneous electrical nerve stimulation (TENS, including interferential currents), electro-acupuncture (EA) and low level laser therapy (LLLT) offered clinically relevant pain relieving effects of 18.8 mm [95% CI: 9.6 to 28.1] (n = 414), 21.9 mm [95% CI: 17.3 to 26.5] (n = 73) and 17.7 mm [95% CI: 8.1 to 27.3] (n = 343) on VAS respectively versus placebo control. In a subgroup analysis of trials with assumed optimal doses, short-term efficacy increased to 22.2 mm [95% CI: 18.1 to 26.3] for TENS, and 24.2 mm [95% CI: 17.3 to 31.3] for LLLT on VAS. Follow-up data up to 12 weeks were sparse, but positive effects seemed to persist for at least 4 weeks after the course of LLLT, EA and TENS treatment was stopped. Conclusion TENS, EA and LLLT administered with optimal doses in an intensive 2–4 week treatment regimen, seem to offer clinically relevant short-term pain relief for OAK.

Tradução e validação da escala Knee Society Score: KSS para a Língua Portuguesa

OBJETIVO: Traduzir, adaptar culturalmente e validar o "Knee Society Score" (KSS) para a língua portuguesa e verificar suas propriedades de medida, reprodutibilidade e validade. MÉTODO: Avaliados 70 pacientes de ambos os sexos, em estudo clínico transversal, idade entre 55 e 85 anos, osteoartrose primária submetidos a artroplastia total de joelho, com o questionário KSS pelo avaliador 1 (inglês) e após 30 minutos pelo avaliador 2 (português) no pré- operatório e após três e seis meses de pós-operatório. RESULTADOS: O índice alfa de Cronbach e a diagramação de Bland-Altman não detectaram diferença entre as médias das duas avaliações no pré-operatório (p=1,000), com três meses (p=0,991) e seis meses de pós-operatório (p=0,985) na pontuação do joelho e na nota da função do joelho, p=1,000 nos três períodos. CONCLUSÃO: A versão brasileira do Knee Society Score, o Escore da Sociedade do Joelho, mostrou ser um instrumento de fácil compreensão e aplicação; válido e confiável para medir a pontuação e função do joelho de pacientes brasileiros submetidos a ATJ. Nível de Evidências: Estudos diagnósticos - Nivel de Evidência I, Teste de critérios diagnósticos desenvolvidos anteriormente em pacientes consecutivos (com padrão de referência "ouro" aplicado).

Clinical rearfoot and knee static alignment measurements are not associated with patellofemoral pain syndrome

The aim of the present study was to investigate the association between the patellofemoral pain syndrome and the clinical static measurements: the rearfoot and the Q angles. The design was a cross-sectional, observational, case-control study. We evaluated 77 adults (both genders), 30 participants with patellofemoral pain syndrome, and 47 controls. We measured the rearfoot and Q angles by photogrammetry. Independent t-tests were used to compare outcome continuous measures between groups. Outcome continuous data were also transformed into categorical clinical classifications, in order to verify their statistical association with the dysfunction, and χ2 tests for multiple responses were used. There were no differences between groups for rearfoot angle [mean differences: 0.2º (95%CI -1.4-1.8)] and Q angle [mean differences: -0.3º (95%CI -3.0-2.4). No associations were found between increased rearfoot valgus [Odds Ratio: 1.29 (95%CI 0.51-3.25)], as well as increased Q angle [Odds Ratio: 0.77 (95%CI 0.31-1.93)] and the patellofemoral pain syndrome occurrence. Although widely used in clinical practice and theoretically thought, it cannot be affirmed that increased rearfoot valgus and increased Q angle, when statically measured in relaxed stance, are associated with patellofemoral pain syndrome (PFPS). These measures may have limited applicability in screening of the PFPS development.

Molecular gas in the galaxy M83 : Its distribution, kinematics, and relation to star formation

The barred spiral galaxy M83 (NGC5236) has been observed in the 12CO J=1–0 and J=2–1 millimetre lines with the Swedish-ESO Submillimetre Telescope (SEST). The sizes of the CO maps are 100×100, and they cover the entire optical disk. The CO emission is strongly peaked toward the nucleus. The molecular spiral arms are clearly resolved and can be traced for about 360º. The total molecular gas mass is comparable to the total Hi mass, but H2 dominates in the optical disk. Iso-velocity maps show the signature of an inclined, rotating disk, but also the effects of streaming motions along the spiral arms. The dynamical mass is determined and compared to the gas mass. The pattern speed is determined from the residual velocity pattern, and the locations of various resonances are discussed. The molecular gas velocity dispersion is determined, and a trend of decreasing dispersion with increasing galactocentric radius is found. A total gas (H2+Hi+He) mass surface density map is presented, and compared to the critical density for star formation of an isothermal gaseous disk. The star formation rate (SFR) in the disk is estimated using data from various star formation tracers. The different SFR estimates agree well when corrections for extinctions, based on the total gas mass map, are made. The radial SFR distribution shows features that can be associated with kinematic resonances. We also find an increased star formation efficiency in the spiral arms. Different Schmidt laws are fitted to the data. The star formation properties of the nuclear region, based on high angular resolution HST data, are also discussed.

Muscular and pulmonary O2 uptake kinetics during moderate- and high-intensity sub-maximal knee-extensor exercise in humans

[EN] The purpose of this investigation was to determine the contribution of muscle O(2) consumption (mVO2) to pulmonary O(2) uptake (pVO2) during both low-intensity (LI) and high-intensity (HI) knee-extension exercise, and during subsequent recovery, in humans. Seven healthy male subjects (age 20-25 years) completed a series of LI and HI square-wave exercise tests in which mVO2 (direct Fick technique) and pVO2 (indirect calorimetry) were measured simultaneously. The mean blood transit time from the muscle capillaries to the lung (MTTc-l) was also estimated (based on measured blood transit times from femoral artery to vein and vein to artery). The kinetics of mVO2 and pVO2 were modelled using non-linear regression. The time constant (tau) describing the phase II pVO2 kinetics following the onset of exercise was not significantly different from the mean response time (initial time delay + tau) for mVO2 kinetics for LI (30 +/- 3 vs 30 +/- 3 s) but was slightly higher (P < 0.05) for HI (32 +/- 3 vs 29 +/- 4 s); the responses were closely correlated (r = 0.95 and r = 0.95; P < 0.01) for both intensities. In recovery, agreement between the responses was more limited both for LI (36 +/- 4 vs 18 +/- 4 s, P < 0.05; r = -0.01) and HI (33 +/- 3 vs 27 +/- 3 s, P > 0.05; r = -0.40). MTTc-l was approximately 17 s just before exercise and decreased to 12 and 10 s after 5 s of exercise for LI and HI, respectively. These data indicate that the phase II pVO2 kinetics reflect mVO2 kinetics during exercise but not during recovery where caution in data interpretation is advised. Increased mVO2 probably makes a small contribution to during the first 15-20 s of exercise.

Hypoxia and the cardiovascular response to dynamic knee-extensor exercise

[EN] Hypoxia affects O2 transport and aerobic exercise capacity. In two previous studies, conflicting results have been reported regarding whether O2 delivery to the muscle is increased with hypoxia or whether there is a more efficient O2 extraction to allow for compensation of the decreased O2 availability at submaximal and maximal exercise. To reconcile this discrepancy, we measured limb blood flow (LBF), cardiac output, and O2 uptake during two-legged knee-extensor exercise in eight healthy young men. They completed studies at rest, at two submaximal workloads, and at peak effort under normoxia (inspired O2 fraction 0.21) and two levels of hypoxia (inspired O2 fractions 0.16 and 0.11). During submaximal exercise, LBF increased in hypoxia and compensated for the decrement in arterial O2 content. At peak effort, however, our subjects did not achieve a higher cardiac output or LBF. Thus O2 delivery was not maintained and peak power output and leg O2 uptake were reduced proportionately. These data are consistent then with the findings of an increased LBF to compensate for hypoxemia at submaximal exercise, but no such increase occurs at peak effort despite substantial cardiac capacity for an elevation in LBF.

A new approach for the dynamic modelling of the human knee

Mathematical models of the knee joint are important tools which have both theoretical and practical applications. They are used by researchers to fully understand the stabilizing role of the components of the joint, by engineers as an aid for prosthetic design, by surgeons during the planning of an operation or during the operation itself, and by orthopedists for diagnosis and rehabilitation purposes. The principal aims of knee models are to reproduce the restraining function of each structure of the joint and to replicate the relative motion of the bones which constitute the joint itself. It is clear that the first point is functional to the second one. However, the standard procedures for the dynamic modelling of the knee tend to be more focused on the second aspect: the motion of the joint is correctly replicated, but the stabilizing role of the articular components is somehow lost. A first contribution of this dissertation is the definition of a novel approach — called sequential approach — for the dynamic modelling of the knee. The procedure makes it possible to develop more and more sophisticated models of the joint by a succession of steps, starting from a first simple model of its passive motion. The fundamental characteristic of the proposed procedure is that the results obtained at each step do not worsen those already obtained at previous steps, thus preserving the restraining function of the knee structures. The models which stem from the first two steps of the sequential approach are then presented. The result of the first step is a model of the passive motion of the knee, comprehensive of the patello-femoral joint. Kinematical and anatomical considerations lead to define a one degree of freedom rigid link mechanism, whose members represent determinate components of the joint. The result of the second step is a stiffness model of the knee. This model is obtained from the first one, by following the rules of the proposed procedure. Both models have been identified from experimental data by means of an optimization procedure. The simulated motions of the models then have been compared to the experimental ones. Both models accurately reproduce the motion of the joint under the corresponding loading conditions. Moreover, the sequential approach makes sure the results obtained at the first step are not worsened at the second step: the stiffness model can also reproduce the passive motion of the knee with the same accuracy than the previous simpler model. The procedure proved to be successful and thus promising for the definition of more complex models which could also involve the effect of muscular forces.

Tectonics and kinematics of curved mountain belts: examples from the Andes and the Alps

Curved mountain belts have always fascinated geologists and geophysicists because of their peculiar structural setting and geodynamic mechanisms of formation. The need of studying orogenic bends arises from the numerous questions to which geologists and geophysicists have tried to answer to during the last two decades, such as: what are the mechanisms governing orogenic bends formation? Why do they form? Do they develop in particular geological conditions? And if so, what are the most favorable conditions? What are their relationships with the deformational history of the belt? Why is the shape of arcuate orogens in many parts of the Earth so different? What are the factors controlling the shape of orogenic bends? Paleomagnetism demonstrated to be one of the most effective techniques in order to document the deformation of a curved belt through the determination of vertical axis rotations. In fact, the pattern of rotations within a curved belt can reveal the occurrence of a bending, and its timing. Nevertheless, paleomagnetic data alone are not sufficient to constrain the tectonic evolution of a curved belt. Usually, structural analysis integrates paleomagnetic data, in defining the kinematics of a belt through kinematic indicators on brittle fault planes (i.e., slickensides, mineral fibers growth, SC-structures). My research program has been focused on the study of curved mountain belts through paleomagnetism, in order to define their kinematics, timing, and mechanisms of formation. Structural analysis, performed only in some regions, supported and integrated paleomagnetic data. In particular, three arcuate orogenic systems have been investigated: the Western Alpine Arc (NW Italy), the Bolivian Orocline (Central Andes, NW Argentina), and the Patagonian Orocline (Tierra del Fuego, southern Argentina). The bending of the Western Alpine Arc has been investigated so far using different approaches, though few based on reliable paleomagnetic data. Results from our paleomagnetic study carried out in the Tertiary Piedmont Basin, located on top of Alpine nappes, indicate that the Western Alpine Arc is a primary bend that has been subsequently tightened by further ~50° during Aquitanian-Serravallian times (23-12 Ma). This mid-Miocene oroclinal bending, superimposing onto a pre-existing Eocene nonrotational arc, is the result of a composite geodynamic mechanism, where slab rollback, mantle flows, and rotating thrust emplacement are intimately linked. Relying on our paleomagnetic and structural evidence, the Bolivian Orocline can be considered as a progressive bend, whose formation has been driven by the along-strike gradient of crustal shortening. The documented clockwise rotations up to 45° are compatible with a secondary-bending type mechanism occurring after Eocene-Oligocene times (30-40 Ma), and their nature is probably related to the widespread shearing taking place between zones of differential shortening. Since ~15 Ma ago, the activity of N-S left-lateral strike-slip faults in the Eastern Cordillera at the border with the Altiplano-Puna plateau induced up to ~40° counterclockwise rotations along the fault zone, locally annulling the regional clockwise rotation. We proposed that mid-Miocene strike-slip activity developed in response of a compressive stress (related to body forces) at the plateau margins, caused by the progressive lateral (southward) growth of the Altiplano-Puna plateau, laterally spreading from the overthickened crustal region of the salient apex. The growth of plateaux by lateral spreading seems to be a mechanism common to other major plateaux in the Earth (i.e., Tibetan plateau). Results from the Patagonian Orocline represent the first reliable constraint to the timing of bending in the southern tip of South America. They indicate that the Patagonian Orocline did not undergo any significant rotation since early Eocene times (~50 Ma), implying that it may be considered either a primary bend, or an orocline formed during the late Cretaceous-early Eocene deformation phase. This result has important implications on the opening of the Drake Passage at ~32 Ma, since it is definitely not related to the formation of the Patagonian orocline, but the sole consequence of the Scotia plate spreading. Finally, relying on the results and implications from the study of the Western Alpine Arc, the Bolivian Orocline, and the Patagonian Orocline, general conclusions on curved mountain belt formation have been inferred.

Kinematics of fibrous aggregates

This thesis reports on a research into the progressive development of fibrous aggregates, e.g. calcite, quartz and mica crystals in veins and strain fringes. The study is based on microstructural analysis of natural examples and on computer experiments. Investigation of fibrous looking elongate crystals in striped bedding-veins from the Orobic Alps, Italy indicate that these crystals do not track the opening trajectory of the veins but are oriented at an angle of up to 80° to the opening direction. Microstructural analysis of quartz, calcite and chlorite fibres in antitaxial strain fringes indicate that most strain fringes contain complex intergrowth of tracking (displacement-controlled) and non-tracking (face-controlled) fibres. To explain these growth features the computer program

Kinematics of the Sicily and Calabria Subduction System from Elastic Block Modeling of GPS Data

We use data from about 700 GPS stations in the EuroMediterranen region to investigate the present-day behavior of the the Calabrian subduction zone within the Mediterranean-scale plates kinematics and to perform local scale studies about the strain accumulation on active structures. We focus attenction on the Messina Straits and Crati Valley faults where GPS data show extentional velocity gradients of ∼3 mm/yr and ∼2 mm/yr, respectively. We use dislocation model and a non-linear constrained optimization algorithm to invert for fault geometric parameters and slip-rates and evaluate the associated uncertainties adopting a bootstrap approach. Our analysis suggest the presence of two partially locked normal faults. To investigate the impact of elastic strain contributes from other nearby active faults onto the observed velocity gradient we use a block modeling approach. Our models show that the inferred slip-rates on the two analyzed structures are strongly impacted by the assumed locking width of the Calabrian subduction thrust. In order to frame the observed local deformation features within the present- day central Mediterranean kinematics we realyze a statistical analysis testing the indipendent motion (w.r.t. the African and Eurasias plates) of the Adriatic, Cal- abrian and Sicilian blocks. Our preferred model confirms a microplate like behaviour for all the investigated blocks. Within these kinematic boundary conditions we fur- ther investigate the Calabrian Slab interface geometry using a combined approach of block modeling and χ2ν statistic. Almost no information is obtained using only the horizontal GPS velocities that prove to be a not sufficient dataset for a multi-parametric inversion approach. Trying to stronger constrain the slab geometry we estimate the predicted vertical velocities performing suites of forward models of elastic dislocations varying the fault locking depth. Comparison with the observed field suggest a maximum resolved locking depth of 25 km.