Comparison of extramedullary versus intramedullary referencing for tibial component alignment in total ankle arthroplasty.

BACKGROUND: The majority of total ankle arthroplasty (TAA) systems use extramedullary alignment guides for tibial component placement. However, at least 1 system offers intramedullary referencing. In total knee arthroplasty, studies suggest that tibial component placement is more accurate with intramedullary referencing. The purpose of this study was to compare the accuracy of extramedullary referencing with intramedullary referencing for tibial component placement in total ankle arthroplasty. METHODS: The coronal and sagittal tibial component alignment was evaluated on the postoperative weight-bearing anteroposterior (AP) and lateral radiographs of 236 consecutive fixed-bearing TAAs. Radiographs were measured blindly by 2 investigators. The postoperative alignment of the prosthesis was compared with the surgeon's intended alignment in both planes. The accuracy of tibial component alignment was compared between the extramedullary and intramedullary referencing techniques using unpaired t tests. Interrater and intrarater reliabilities were assessed with intraclass correlation coefficients (ICCs). RESULTS: Eighty-three tibial components placed with an extramedullary referencing technique were compared with 153 implants placed with an intramedullary referencing technique. The accuracy of the extramedullary referencing was within a mean of 1.5 ± 1.4 degrees and 4.1 ± 2.9 degrees in the coronal and sagittal planes, respectively. The accuracy of intramedullary referencing was within a mean of 1.4 ± 1.1 degrees and 2.5 ± 1.8 degrees in the coronal and sagittal planes, respectively. There was a significant difference (P < .001) between the 2 techniques with respect to the sagittal plane alignment. Interrater ICCs for coronal and sagittal alignment were high (0.81 and 0.94, respectively). Intrarater ICCs for coronal and sagittal alignment were high for both investigators. CONCLUSIONS: Initial sagittal plane tibial component alignment was notably more accurate when intramedullary referencing was used. Further studies are needed to determine the effect of this difference on clinical outcomes and long-term survivability of the implants. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Reorganização dos ajustes posturais antecipatórios do tibial anterior e do solear no início da marcha, em pacientes com AVE, face a uma intervenção de fisioterapia baseada no conceito de Bobath

Introdução: os APA´s ocorrem imediatamente antes do movimento e preparam-no tornando-o mais harmonioso e eficiente. Os pacientes com lesão do SNC apresentam frequentemente alterações no sistema de controlo postural interferindo significativamente nas suas AVD´s, como no início da marcha. Objetivo: descrever as alterações no tempo de ativação e sequência de ativação muscular do TA e do SOL no início da marcha em pacientes com AVE, face a uma intervenção em fisioterapia. Metodologia: A avaliação realizou-se antes e após um programa de intervenção, segundo a abordagem do Conceito de Bobath, através da electromiografia, plataforma de forças e máquina fotográfica para a avaliação do tempo de ativação muscular do tibial anterior e do solear no início da marcha. Recorreu-se também à Classificação Internacional de Funcionalidade e à Fulg-Mayer Assessment of Motor Recovery after Stroke. Resultados: Obteve-se uma diminuição dos valores registados pela EMG nos tempos de ativação muscular do TA e do SOL bilateralmente, e alterações na sequência de ativação. Verificaram-se modificações nos resultados da Classificação Internacional de Funcionalidade e da Fulg-Mayer Assessment of Motor Recovery after Stroke. Conclusão: O programa de intervenção segundo o Conceito de Bobath, induziu mudanças nos tempos de ativação muscular e na sequência de ativação dos músculos TA e SOL no início da marcha em pacientes com AVE.

A novel locus for split-hand/foot malformation associated with tibial hemimelia (SHFLD syndrome) maps to chromosome region 17p13.1-17p13.3

Split-hand/foot malformation (SHFM) associated with aplasia of long bones, SHFLD syndrome or Tibial hemimelia-ectrodactyly syndrome is a rare condition with autosomal dominant inheritance, reduced penetrance and an incidence estimated to be about 1 in 1,000,000 liveborns. To date, three chromosomal regions have been reported as strong candidates for harboring SHFLD syndrome genes: 1q42.2-q43, 6q14.1 and 2q14.2. We characterized the phenotype of nine affected individuals from a large family with the aim of mapping the causative gene. Among the nine affected patients, four had only SHFM of the hands and no tibial defects, three had both defects and two had only unilateral tibial hemimelia. In keeping with previous publications of this and other families, there was clear evidence of both variable expression and incomplete penetrance, the latter bearing hallmarks of anticipation. Segregation analysis and multipoint Lod scores calculations (maximum Lod score of 5.03 using the LINKMAP software) using all potentially informative family members, both affected and unaffected, identified the chromosomal region 17p13.1-17p13.3 as the best and only candidate for harboring a novel mutated gene responsible for the syndrome in this family. The candidate gene CRK located within this region was sequenced but no pathogenic mutation was detected.

Exercise loading and cortical bone distribution at the tibial shaft

Cortical bone is not a uniform tissue, and its apparent density [cortical volumetric density (vBMD)] varies around the bone cross-section as well as along the axial length of the bone. It is not yet known, whether the varying vBMD distribution is attributable to modulation in the predominant loads affecting bone. The aim of the present study was to compare the cortical bone mass distribution through the bone cortex (radial distribution) and around the center of mass (polar distribution) among 221 premenopausal women aged 17–40 years representing athletes involved in high impact, odd impact, high magnitude, repetitive low impact, repetitive non-impact sports and leisure time physical activity (referent controls). Bone cross-sections at the tibial mid-diaphysis were assessed with pQCT. Radial and polar vBMD distributions were analyzed in three concentric cortical divisions within the cortical envelope and in four cortical sectors originating from the center of the bone cross-section. MANCOVA, including age as a covariate, revealed no significant group by division/sector interaction in either radial or polar distribution, but the mean vBMD values differed between groups (P < 0.001). The high and odd-impact groups had 1.2 to 2.6% (P < 0.05) lower cortical vBMD than referents, in all analyzed sectors/divisions. The repetitive, low-impact group had 0.4 to 1.0% lower (P < 0.05) vBMD at the mid and outer cortical regions and at the anterior sector of the tibia. The high magnitude group had 1.2% lower BMD at the lateral sector (P < 0.05). The present results generate a hypothesis that the radial and polar cortical bone vBMD distributions within the tibial mid-shaft are not modulated by exercise loading but the mean vBMD level is slightly affected.

Seventy-year-old habitual volleyball players have larger tibial cross-sectional area and may be differentiated from their age-matched peers by the osteogenic index in dynamic performance

The osteogenicity of a given exercise may be estimated by calculating an osteogenic index (OI) consisting of magnitude and rate of strain. Volleyball involves repetitive jumping and requires high power output and thus may be expected to be beneficial to bone and performance. The purpose of the present study was to examine if habitual volleyball playing is reflected in OI. Ten elderly habitual volleyball players [age 69.9 (SD 4.4) years] and ten matched controls volunteered [age 69.7 (4.2) years] as subjects. Distal tibia (d), tibial mid-shaft (50) and femoral neck (F) bone characteristics were measured using pQCT and DXA. To estimate skeletal rigidity, cross-sectional area (ToA50), and compressive (BSId) and bending strength indices (SSImax50) were calculated. Maximal performance was assessed with eccentric ankle plantar flexion, isometric leg press and countermovement jump (CMJ). A fast Fourier transform (FFT) was calculated from the acceleration of the center of mass during the CMJ. Maximal acceleration (MAG) and mean magnitude frequency (MMF) were selected to represent the constituents of OI. OI was calculated as the sum of the products of magnitudes and corresponding frequencies. Volleyball players had 7% larger ToA50 and 37% higher power in CMJ, 15% higher MAG and 36% higher OI (P B 0.047) than the matched controls. No difference was observed in leg press, plantar flexion or the MMF (P C 0.646). In conclusion, habitual volleyball players may be differentiated from their matched peers by their dynamic jumping performance, and the differences are reflected in the magnitude but not rate of loading.

Differential effects of exercise on tibial shaft marrow density in young female athletes

Context:
Increased mechanical loading can promote the preferential differentiation of bone marrow mesenchymal stem cells to osteoblastogenesis, but it is not known whether long-term bone strength-enhancing exercise in humans can reduce marrow adiposity.

Objective:
Our objective was to examine whether bone marrow density (MaD), as an estimate of marrow adiposity 1) differs between young female athletes with contrasting loading histories and bone strengths and 2) is an independent predictor of bone strength at the weight-bearing tibia.

Design:
Mid-tibial MaD, cortical area (CoA), total area, medullary area, strength strain index (SSI), and cortical volumetric bone mineral density (vBMD) (total, endocortical, midcortical, and pericortical) was assessed using peripheral quantitative computed tomography in 179 female athletes involved in both impact and nonimpact loading sports and 41 controls aged 17–40 years.

Results:
As we have previously reported CoA, total area, and SSI were 16% to 24% greater in the impact group compared with the controls (all P < .001) and 12% to 18% greater than in the nonimpact group (all P < .001). The impact group also had 0.5% higher MaD than the nonimpact and control groups (both P < .05). Regression analysis further showed that midtibial MaD was significantly associated with SSI, CoA, endocortical vBMD, and pericortical vBMD (P < .05) in all women combined, after adjusting for age, bone length, loading groups, medullary area, muscle cross-sectional area, and percent fat.

Conclusion:
In young female athletes, tibial bone MaD was associated with loading history and was an independent predictor of tibial bone strength. These findings suggest that an exercise-induced increase in bone strength may be mediated via reduced bone marrow adiposity and consequently increased osteoblastogenesis.

Mid-femoral and mid-tibial muscle cross-sectional area as predictors of tibial bone strength in middle-aged and older men

While it is widely acknowledged that bones adapt to the site-specific prevalent loading environment, reasonable ways to estimate skeletal loads are not necessarily available. For long bone shafts, muscles acting to bend the bone may provide a more appropriate surrogate of the loading than muscles expected to cause compressive loads. Thus, the aim of this study was to investigate whether mid-thigh muscle cross-sectional area (CSA) was a better predictor of tibial mid-shaft bone strength than mid-tibia muscle CSA in middle aged and older men. 181 Caucasian men aged 50–79 years (mean±SD; 61±7 years) participated in this study. Mid-femoral and mid-tibial bone traits cortical area , density weighted polar moment of area and muscle CSA [cm²] were assessed with computed tomography. Tibial bone traits were positively associated with both the mid-femur (r=0.44 to 0.46, P<0.001) and the mid-tibia muscle CSA (r=0.35 to 0.37, P<0.001). Multivariate regression analysis, adjusting for age, weight, physical activity and femoral length, indicated that mid-femur muscle CSA predicted tibial mid-shaft bone strength indices better thn mid-tibia muscle CSA. In conclusion, the association between a given skeletal site and functionally adjacent muscles may provide a meaningful probe of the site-specific effect of loading on bone.

Effects of bone-specific physical activity, gender and maturity on tibial cross-sectional bone material distribution; a cross-sectional pQCT comparison of children and young adults aged 5-29 years

Growth is the opportune time to modify bone accrual. While bone adaptation is known to be dependent on local loading and consequent deformations (strain) of bone, little is known about the effects of sex, and bone-specific physical activity on location-specific cross-sectional bone geometry during growth. To provide more insight we examined bone traits at different locations around tibial cross sections, and along the tibia between individuals who vary in terms of physical activity exposure, sex, and pubertal status. Data from 304 individuals aged 5-29 years (172 male, 132 female) were examined. Peripheral quantitative computed tomography (pQCT) was applied at 4%, 14%, 38%, and 66% of tibial length. Maturity was established by estimating age at peak height velocity (APHV). Loading history was quantified with the bone-specific physical activity questionnaire (BPAQ). Comparisons, adjusted for height, weight and age were made between sex, maturity, and BPAQ tertile groups. Few to no differences were observed between sexes or BPAQ tertiles prior to APHV, whereas marked sexual dimorphism and differences between BPAQ tertiles were observed after APHV. Cross-sectional location-specific differences between BPAQ tertiles were not evident prior to APHV, whereas clear location-specificity was observed after APHV. In conclusion, the skeletal benefits of physical activity are location-specific in the tibia. The present results indicate that the peri- or post-pubertal period is likely a more favourable window of opportunity for enhancing cross-sectional bone geometry than pre puberty. Increased loading during the peri-pubertal period may enhance the bone of both sexes.

Estudo do desempenho em fadiga do componente tibial metálico de um modelo de prótese total de joelho

A substituição total de uma articulação de joelho é uma técnica amplamente usada para corrigir os danos irreversíveis na juntas originais, causadas por patologias como osteoartrite e artrite reumatóide. Com o aumento número de pacientes jovens e mais ativos, a evolução na técnica da substituição da articulação total de joelho visando desempenho de longo prazo passa a ser uma demanda crítica. Portanto, na tentativa de evitar as falhas prematuras e prolongar a vida em serviço como um todo, as modificações na bandeja tibial podem produzir erros fundamentais. O design da bandeja tibial é um importante fator, porque a sua fratura pode ocorrer em função de elementos geométricos da mesma, como raios de concordância e cantos vivos. A escolha do material e do processo de fabricação também são importantes. No tocante a rota de fabricação, pode ser visto que as ligas forjadas tem o maior limite de fadiga, se comparado com as obtidas pelo processo de fundição. Entretanto, a combinação das técnicas de desenho assistido por computador (CAD), engenharia assistida por computador (CAE) e manufatura assistida por computador (CAM) podem ser uma solução rápida e barata para alcançar melhores características das bandejas tibiais. Contudo, testes pré-clínicos devem ser executados para garantir que as bandejas tibiais não falharão prematuramente devido à fadiga. As técnicas de metalografia, microdureza e espectrometria foram empregadas neste trabalho com o objetivo de caracterizar metalurgicamente a liga de aço inoxidável atualmente empregada. A rugosidade superficial foi avaliada, assim como o número de ciclos para a iniciação das trincas. Com a utilização do método de elementos finitos, verificou-se o ponto de maior tensão e, aliado ao estudo de fractografia, foi determinado o modo de falha Os resultados indicaram que o material atualmente empregado não está em conformidade com todos os requisitos das normas vigentes, de forma que um material alternativo é sugerido. Com o objetivo de melhorar a resistência à fadiga sem apresentar problemas de ordem clínica, cinco geometrias foram propostas e os resultados da análise de tensões pelo método de elementos finitos indicaram um grande potencial de aumento da vida em fadiga.