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

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

Age related changes in the elastic fiber system of the interfoveolar ligament

In order to evaluate age related changes of the elastic fiber system in the interfoveolar ligament, we studied the deep inguinal ring from 33 male cadavers aged from stillborn to 76 years. Selective and alternated staining methods for elastic fibers were performed to differentiate oxytalan, elaunin, and mature elastic fibers. We confirmed quantitative changes of the elastic fiber system with aging. There was a significant and progressive reduction of the oxytalan fibers (responsible for tissue resistance) and a significant increment in the mature elastic and elaunin fibers (responsible for tissue elasticity). Furthermore, there were structural changes in the thickness, shortness and curling of these mature elastic fibers. These changes induced loss of the elastic fiber function and loss of the interfoveolar ligament compliance. These factors predispose individuals to the development of indirect inguinal hernias that frequently emerge in adults and aged individuals, especially above the fifth decade.

Falciform ligament abscess: report of a case

Falciform ligament abscess is rare. We report a case of a 65-year-old man who presented with right upper quadrant abdominal pain, postprandial fullness, and fever. Computed tomography disclosed a cylindrical mass in the anterior abdomen that aroused suspicion of a hepatic abscess. At laparoscopic surgery, an abscess of the falciform ligament was found and drained. Two months later, the patient developed recurrence of the abscess secondary to acute calculous cholecystitis. Abscess drainage and cholecystectomy were performed. The presence of right uppper quadrant abdominal pain, epigastric tenderness, fever, leukocytosis, and a mass in the anterior abdomen should arouse suspicion of falciform ligament abscess. Its treatment consists of abscess drainage.

Allografts in posterior cruciate ligament reconstructions

Posterior cruciate ligament (PCL) injuries are often associated with other ligament lesions. Multiligament reconstructions require an important quantity of grafts and often determine the need for cadaver allografts during the surgical repair procedures. Herein, the fundamentals of allografts that have been currently used for PCL reconstructions are overviewed. The main issues to be considered when surgeons choose this therapeutic option are also discussed.

Doença periodontal como potencial fator de risco para síndromes coronarianas agudas

OBJETIVO: Detectar a existência de associação entre doença periodontal ativa (DP) e ocorrência de síndromes coronarianas agudas (SCA). MÉTODOS: Foram avaliados 361 pacientes (57,3% do sexo masculino), com idades variando de 27 a 89 (média±DP=60,5±12,2 anos) internados na Unidade de Tratamento Intensivo de um Hospital de Ensino com quadro clínico e complementar de SCA. Todos foram submetidos a exame periodontal completo, no próprio ambiente da UTI, sendo que 325 (90,0%) realizaram cinecoronariografia para confirmação diagnóstica e/ou programação de conduta terapêutica. O exame periodontal consistiu na avaliação de todos os dentes presentes na cavidade oral e dos seguintes parâmetros: profundidade clínica de sondagem, nível de inserção clinica, índice de placa e índice gengival. RESULTADOS: Dos 325 pacientes, 91 (28,0%) apresentavam artérias coronarianas isentas de obstrução ou com obstruções discretas (<= 50% de perda de diâmetro), havendo obstruções importantes nos 72,0% restantes. O teste exato de Fisher mostrou valor de P de 0,0245 e ODDS Ratio de 2,571 (IC 95% 1,192 a 5,547), ou seja, documentou-se cerca de 2,5 vezes mais possibilidade de presença de DP ativa no grupo com SCA e coronariopatia obstrutiva significante. CONCLUSÃO: Constatou-se associação significante entre presença de doença periodontal ativa e doença coronariana obstrutiva de grau importante em pacientes com síndrome coronariana aguda, reforçando a importância de prevenção e tratamento adequado da doença periodontal, que deve ser considerada como fator de risco potencial na etiologia e na instabilização da placa aterosclerótica.

Associação entre doença periodontal e síndrome coronariana aguda

OBJETIVO: Analisar a relação entre a DP e SCA e verificar a associação entre a DP e periodontite em pacientes com SCA. MÉTODOS: Foram incluídos 58 pacientes com diagnóstico de SCA e 57 controles, sem história de doença arterial coronariana (DAC). Variáveis: hipertensão arterial, diabete, dislipidemia, obesidade, história de DAC, tabagismo e polimorfismo genético do gene da interleucina-1beta. RESULTADOS: Fizeram parte do estudo 115 indivíduos. No grupo SCA, 58 pacientes foram avaliados, sendo 32 (55,2%) do sexo masculino e 26 (44,8%) do sexo feminino. No grupo controle, 57 indivíduos, sendo 32 (56,1%) do sexo masculino e 25 (43,9%) do sexo feminino. Verificou-se DP em 26 (44,8%) pacientes com SCA e em 15 (26,6%) pacientes do grupo controle (beta2 = 4,43, p = 0,04). Análise pela regressão logística, para a associação entre DP e SCA, demonstrou RC de 1,8 (IC 95%: 1,0-5,0); p = 0,24. A associação de periodontite com SCA apresentou RC: 4,5 (IC 95%: 1,3-15,6); p = 0,019. CONCLUSÃO: Não observamos associação independente entre a DP e SCA. Houve associação independente entre periodontite e SCA.

Doença periodontal em portadoras de valvopatia durante a gravidez: estudo clínico e microbiológico

FUNDAMENTO: A doença periodontal representa risco à gestante portadora de valvopatia reumática, seja para contrair endocardite infecciosa, seja por propiciar complicações obstétricas. OBJETIVO: Estudar a frequência da doença periodontal em portadoras de valvopatia reumática durante a gravidez. MÉTODOS: Foram estudadas 140 gestantes, comparáveis quanto a idade e o nível socioeconômico, divididas em: 70 portadoras de doença valvar reumática e 70 mulheres saudáveis. Todas se submeteram a: 1) avaliação clínica odontológica que incluiu a análise dos seguintes parâmetros: 1.1) profundidade à sondagem, 1.2) distância da linha esmalte-cemento à margem gengival, 1.3) nível clínico de inserção, 1.4) índice de sangramento, 1.5) índice de placa bacteriana, e, 1.6) comprometimento de furca; e, 2) exame microbiológico nas amostras de saliva e do cone que considerou o controle positivo para as cepas das bactérias Porphyromonas gingivalis, Tannerella forsithia e Aggregobacter actinomycetemcomitans. RESULTADOS: A lesão valvar mitral foi prevalente (65 casos = 92,8%) dentre as gestantes cardiopatas. A comparação entre os grupos mostrou não haver diferenças entre idade e a paridade, e embora tenham sido verificadas diferenças entre as medidas da distância da linha esmalte-cemento à margem gengival (p = 0,01) e o índice de placa (p=0,04), a frequência da doença periodontal identificada em 20 (14,3%) gestantes, não foi diferente entre os grupos (p = 0,147). O exame microbiológico mostrou uma proporção maior da bactéria P. gingivalis na saliva de gestantes saudáveis (p = 0,004). CONCLUSÃO: O estudo clínico e microbiológico periodontal durante a gravidez demonstrou igual frequência da doença periodontal em portadoras de valvopatia reumática quando comparada às mulheres saudáveis.

Subclinical femoral neuropathy after anterior cruciate ligament reconstruction

Background and aim of the study: Patients with anterior cruciate ligament (ACL) reconstruction and femoral catheter analgesia may develop quadriceps amyotrophy. We aimed to determine whether this amyotrophy might be related to a femoral neuropathy. Material and method: After Ethical Committee approval and patients' written informed consent, 17 patients ASA I and II scheduled to undergo ACL reconstruction were recruited. An electromyography (EMG) was performed before the operation in order to exclude a femoral neuropathy. A femoral nerve catheter was inserted before the surgery with the aid of a nerve stimulator, and 20 ml of 0.5% ropivacaine was injected. The operation was done under spinal or general anaesthesia. Postoperative analgesia was provided with 0.2% ropivacaine for 72 hours, in association with oxycodone, paracetamol and ibuprofen. A second EMG was performed 4 weeks after the ACL repair. A femoral neuropathy was defined as a reduction of the surface of the motor response of more than 20%, compared to the first EMG. A third EMG was performed at 6 months if a neuropathy was present. Results: Mean age of this group of patients was 27 years old (range 18-38 y.). Among the 17 patients, 4 developed a transient femoral neuropathy (incidence of 24%) without clinical complain. Conclusion: In this study, the incidence of subclinical femoral neuropathy after ACL reconstruction is high. This lesion may be caused by the femoral catheter (mechanical damage, toxicity of local anaesthesia) or by the Tourniquet. Further studies are needed to investigate the incidence of subclinical neuropathy, according to the type of analgesia (epidural analgesia, PCA) and surgery.

3-T direct MR arthrography of the wrist: value of finger trap distraction to assess intrinsic ligament and triangular fibrocartilage complex tears.

PURPOSE: To determine the value of applying finger trap distraction during direct MR arthrography of the wrist to assess intrinsic ligament and triangular fibrocartilage complex (TFCC) tears. MATERIALS AND METHODS: Twenty consecutive patients were prospectively investigated by three-compartment wrist MR arthrography. Imaging was performed with 3-T scanners using a three-dimensional isotropic (0.4 mm) T1-weighted gradient-recalled echo sequence, with and without finger trap distraction (4 kg). In a blind and independent fashion, two musculoskeletal radiologists measured the width of the scapholunate (SL), lunotriquetral (LT) and ulna-TFC (UTFC) joint spaces. They evaluated the amount of contrast medium within these spaces using a four-point scale, and assessed SL, LT and TFCC tears, as well as the disruption of Gilula's carpal arcs. RESULTS: With finger trap distraction, both readers found a significant increase in width of the SL space (mean Δ = +0.1mm, p ≤ 0.040), and noticed more contrast medium therein (p ≤ 0.035). In contrast, the differences in width of the LT (mean Δ = +0.1 mm, p ≥ 0.057) and UTFC (mean Δ = 0mm, p ≥ 0.728) spaces, as well as the amount of contrast material within these spaces were not statistically significant (p = 0.607 and ≥ 0.157, respectively). Both readers detected more SL (Δ = +1, p = 0.157) and LT (Δ = +2, p = 0.223) tears, although statistical significance was not reached, and Gilula's carpal arcs were more frequently disrupted during finger trap distraction (Δ = +5, p = 0.025). CONCLUSION: The application of finger trap distraction during direct wrist MR arthrography may enhance both detection and characterisation of SL and LT ligament tears by widening the SL space and increasing the amount of contrast within the SL and LT joint spaces.

Critical evaluation of outcome scales to assess outcome after lateral ankle ligament repair

Introduction: Several scores are commonly used to evaluate patients' postoperative satisfaction after lateral ankle ligament repair, including: AOFAS, FAAM, CAIT and CAIS. Comparing published studies in the literature is difficult, as the same patient can have markedly different results depending on which scoring system is used. The current study aims to address this gap in the literature by developing a system to compare these tests, to allow better analysis and comparison of published studies. Patients and methods: This is a retrospective cohort study of 47 patients following lateral ankle ligament repair using a modified Broström-Gould technique. All patients were operated between 2005 and 2010 by a single surgeon and followed the same post operative rehabilitation protocol. Six patients were excluded from the study because of concomitant surgery. Patients were assessed by an independent observer. We used the Pearson correlation coefficient to analyse the concordance of the scores, as well as scatter plots to assess the linear relationship between them. Results: A linear distribution between the scores was found when the results were analysed using scatter plots. We were thus able to use the Pearson correlation coefficient to evaluate the relationship between each of the different postoperative scores. The correlation was found to be above 0.5 in all cases except for the comparison between the CAIT and the FAAM for the activities of daily living (0.39). We were, therefore, able to compare the results obtained and assess the relative concordance of the scoring systems. The results showed that the more specific the scale is, the worst the score is and inversely. So the CAIT and the CAIS appeared to be more severe than the AOFAS and the FAAM measuring the activities of daily living. The sports subscale of the FAAM demonstrated intermediate results. Conclusion: This study outlines a system to compare different postoperative scores commonly used to evaluate outcome after ankle stabilization surgery. The impact of this study is that it makes comparison of published studies easier, even though they use a variety of different clinical scores, thus facilitating better outcome analysis of operative techniques.

Critical evaluation of outcome scales assessment of lateral ankle ligament reconstruction

Introduction: Les résultats d'une chirurgie du pied et de la cheville peuvent être évalués par des scores spécifiques à la région anatomique ainsi que par des scores spécifiques à la pathologie. Beaucoup de scores existent rendant la comparaison entre les études difficile. La présente étude se focalise sur une pathologie fréquente du pied et de la cheville et compare les résultats obtenu par deux scores spécifiques à la région et deux scores spécifiques à la pathologie. Méthode: Nous avons revu 41 patients ayant bénéficié d'une plastie ligamentaire externe de la cheville. Quatre scores ont été administrés simultanément: the Cumberland Ankle Instability Tool (CAIT) et the Chronic Ankle Instability Scale (CAIS), spécifiques à la pathologie, the American Orthopedic Foot & Ankle Society (AOFAS) hindfoot scale et the Foot and Ankle Ability Measure comprenant deux parties (FAAM1 et FAAM2), spécifiques à la région anatomique. Le degré de corrélation entre les scores a été évalué par le coefficient de corrélation de Pearson. L'analyse graphique des variances a été utilisée pour le choix de tests paramétriques versus non paramétriques. Des tests non paramétriques, le Kruskal-Wallis pour éliminer l'hypothèse nulle et le Mann-Whitney pour la comparaison entre les scores deux à deux, ont été utilisés. Résultats: Une différence significative (p<.005) a été démontrée entre le CAIS et l'AOFAS (p=.0002), entre le CAIS et le FAAM1 (p=.0001) et entre le CAIT et l'AOFAS (p=.0003) Conclusions: Cette étude compare les performances de quatre scores dont deux spécifiques à la région anatomique et deux spécifiques à la pathologie. Nous avons démontré une bonne corrélation entre les scores ainsi que des différences significatives entre les résultats obtenus par chacun d'eux. Les résultats obtenus par les scores spécifiques à la pathologie semblent être plus précis que ceux obtenus par les scores spécifiques à la région anatomique. De plus, nous avons mis en évidence une forte corrélation entre l'AOFAS et les autres scores. Le FAAM semble être un bon compromis car il offre la possibilité, du fait de ses deux parties, d'évaluer le résultat en fonction de la demande fonctionnelle du patient. Perspectives: Un algorithme est proposé qui permet d'évaluer la littérature spécifique de manière plus critique et peut s'adapter également à la recherche et à la clinique relative à d'autres pathologies du pied et de la cheville