A influência da dor no joelho na incapacidade e proprioceção em adultos mais velhos

Introdução: A dor no joelho apresenta uma etiologia multifatorial, sendo a idade um fator de risco importante. A dor no joelho poderá estar relacionada com alterações na propriocetividade do joelho. Objetivo (s): Comparar a influência dor unilateral com bilateral do joelho na incapacidade e proprioceção em adultos mais velhos. Métodos: Estudo transversal com uma amostra de 11 indivíduos com dor no joelho, divididos em grupo com dor unilateral (GDU=6) e grupo com dor bilateral (GDB=5). Utilizou-se, a Knee injury and Osteoarthritis Outcome Score (KOOS) para analisar a dor, rigidez e outros sintomas, atividades de vida diária, desportivas e de lazer e qualidade de vida. Foi medida a sensação de posição articular passiva e ativa, bem como a sensação de discriminação de carga. Foram utilizados os testes de Mann-Whitney e de correlação de Spearman, com um nível de significância de 0,05. Resultados: Nas diferentes dimensões da KOOS apesar de não se ter verificado diferenças significativas entre os grupos, o GDU apresenta scores menores, que traduzem uma maior incapacidade. Na sensação de posição articular e na sensação de discriminação de carga não se verificaram diferenças significativas entre os grupos. Conclusão: A dor no joelho ser unilateral ou bilateral não influencia nem a incapacidade nem a proprioceção nos adultos mais velhos.

Força Muscular Isocinética após Reconstrução do Ligamento Cruzado Anterior – Influência do Tipo de Enxerto (Osso-Tendão-Osso/Isquio-Tibiais)

Introdução: É reconhecida a importância do ligamento cruzado anterior (LCA) no funcionamento normal do joelho. Em caso de rotura ligamentar, nomeadamente em desportos com marcada solicitação dos movimentos de rotação do joelho, é justificada a necessidade de reconstrução do LCA na maioria dos casos. Objetivo (s): Avaliar a influência do tipo de enxerto na reconstrução do ligamento cruzado anterior na força muscular isocinética, assim como na funcionalidade e sintomas após 6 meses. Métodos: Estudo transversal analítico, constituído por 20 indivíduos voluntários do sexo masculino, que haviam sido submetidos a uma ligamentoplastia do cruzado anterior, pelo mesmo cirurgião, seguido de uma intervenção individualizada por um fisioterapeuta. Em 10 indivíduos, o procedimento cirúrgico foi realizado com enxerto do tendão rotuliano (grupo OTO), e nos restantes 10 com enxerto do semitendinoso e gracilis (grupo STG). Como forma de avaliar a Força Muscular Isocinética (Peak Torque, Trabalho Total Muscular, ratio Isquiotibiais/Quadricipite), foi utilizado o Dinamómetro Isocinético Biodex. A avaliação foi efectuada apenas aos 6 meses após o procedimento cirúrgico. Para observação da funcionalidade, amplitude de movimento e sintomas, utilizou-se o questionário International Knee Documentation Committee (IKDC). Resultados: Foi possível observar que entre os grupos apenas se observaram diferenças significativas no peak torque de extensão a 180º no membro não lesado (p=0,019). Contudo, foi observada uma tendência para o grupo OTO apresentar um maior défice no peak torque e trabalho total muscular em extensão. Comparativamente ao membro contra-lateral, o membro lesado apresentou valores significativamente inferiores na maioria das variáveis ( p < 0,05). Conclusão: Após 6 meses de pós-cirúrgico com reabilitação de fisioterapia, não foi possível apontar qual o enxerto que garante uma melhor recuperação da força muscular. Aos 6 meses, ambos os grupos ainda apresentaram limitações musculares, quando comparados com o lado contra-lateral. Relativamente ao rácio isquiotibiais/quadricípite, assim como no IKDC, não se observaram diferenças entre os dois tipos de enxertos.

Mutilations Due to Medical Disorders in Children

Soft-tissue and bone necrosis, although rare in childhood, occasionally occur in the course of infectious diseases, either viral or bacterial, and seem to be the result of hypoperfusion on a background of disseminated intravascular coagulation. Treatment consists in correction of septic shock and control of necrosis. Necrosis, once started, shows extraordinarily rapid evolution, leading to soft-tissue and bone destruction and resulting in anatomic, functional, psychological, and social handicaps. Ten mutilated children were treated from January 1986 to January 1999 in Hospital de Dona Estefaˆ nia, Lisbon, Portugal. One was recovering from hemolytic-uremic syndrome with a severe combined immunodeficiency, another malnourished, anemic child had malaria, and three had chicken pox (in one case complicated by meningococcal septicemia). There were three cases of meningococcal and two of pyocyanic septicemia (one in a burned child and one in a patient with infectious mononucleosis). The lower limbs (knee,leg, foot) were involved in five cases, the face (ear, nose, lip) in four, the perineum in three, the pelvis (inguinal region, iliac crest) in two, the axilla in one, and the upper limb (radius, hand) in two. Primary prevention is based on early recognition of risk factors and timely correction. Secondary prevention consists of immediate etiologic and thrombolytic treatment to restrict the area of necrosis. Tertiary prevention relies on adequate rehabilitation with physiotherapy and secondary operations to obtain the best possible functional and esthetic result.

Iron Overload in a Murine Model of Hereditary Hemochromatosis Is Associated with Accelerated Progression of Osteoarthritis Under Mechanical Stress

OBJECTIVE: Hereditary hemochromatosis (HH) is a disease caused by mutations in the Hfe gene characterised by systemic iron overload and associated with an increased prevalence of osteoarthritis (OA) but the role of iron overload in the development of OA is still undefined. To further understand the molecular mechanisms involved we have used a murine model of HH and studied the progression of experimental OA under mechanical stress. DESIGN: OA was surgically induced in the knee joints of 10-week-old C57BL6 (wild-type) mice and Hfe-KO mice. OA progression was assessed using histology, micro CT, gene expression and immunohistochemistry at 8 weeks after surgery. RESULTS: Hfe-KO mice showed a systemic iron overload and an increased iron accumulation in the knee synovial membrane following surgery. The histological OA score was significantly higher in the Hfe-KO mice at 8 weeks after surgery. Micro CT study of the proximal tibia revealed increased subchondral bone volume and increased trabecular thickness. Gene expression and immunohistochemical analysis showed a significant increase in the expression of matrix metallopeptidase 3 (MMP-3) in the joints of Hfe-KO mice compared with control mice at 8 weeks after surgery. CONCLUSIONS: HH was associated with an accelerated development of OA in mice. Our findings suggest that synovial iron overload has a definite role in the progression of HH-related OA

Healthcare- Associated infections: An analysis of costs in a Portuguese Hospital

Hospital-acquired infections (HAIs) delay healing, prolong Hospital stay, and increase both Hospital costs and risk of death. This study aims to estimate the extra length of stay and mortality rate attributable to each of the following HAIs: wound infection (WI); bloodstream infection (BSI); urinary infections (UI); and Hospital-acquired pneumonia (HAP). The study population consisted of patients discharged in CHLC in 2014. Data was collected to identify demographic information, surgical operations, development of HAIs and its outputs. The study used regressions and a matched strategy to compare cases (infected) and controls (uninfected). The matching criteria were: age, sex, week and type of admission, number of admissions, major diagnostic category and type of discharge. When compared to matched controls, cases with HAI had a higher mortality rate and greater length of stay. WI related to hip or knee surgery, increased mortality rate by 27.27% and the length of stay by 74.97 days. WI due to colorectal surgery caused an extra mortality rate of 10.69% and an excess length of stay of 20.23 days. BSI increased Hospital stay by 28.80 days and mortality rate by 32.27%. UI caused an average additional length of stay of 19.66 days and risk of death of 12.85%. HAP resulted in an extra Hospital stay of 25.06 days and mortality rate of 24.71%. This study confirms the results of the previous literature that patients experiencing HAIs incur in an excess of mortality rates and Hospital stay, and, overall, it presents worse results comparing with other countries.

Auto-referência de sintomas de lesões músculo-esqueléticas ligadas ao trabalho LMELT numa grande empresa em Portugal

RESUMO - A dor, incómodo ou desconforto ao nível músculo-esquelético, sobretudo devido a situações e/ou postos de trabalho com elevadas exigências ao nível postural, de aplicação de força, de repetitividade ou por incorrecta distribuição das pausas, é aceite como um indicador de situações de risco passíveis de se encontrarem na génese de lesões músculo- -esqueléticas ligadas ao trabalho (LMELT) (Stuart-Buttle, 1994). No sentido de avaliar a prevalência de sintomas de LME, efectuou-se um estudo numa grande empresa da indústria de componentes para automóveis na região de Lisboa durante o ano de 2001. Utilizou-se um instrumento de recolha de informação construído a partir de uma adaptação do questionário nórdico músculo-esquelético (QNM) (Kuorinka et al., 1987). Com o apoio do serviço de saúde ocupacional da referida empresa, o questionário foi entregue a todos os trabalhadores, obtendo-se uma taxa de respondentes de 63,2% (n = 574). A população em estudo é maioritariamente do sexo feminino (83,9%), tem idades compreendidas entre os 18 e os 65 anos e a classe modal situa-se entre os 26 e os 33 anos (23,3%). Os resultados evidenciam uma alta prevalência de sintomatologia de LME e diferenças significativas de sintomas entre as categorias profissionais (1) operadores de máquina de costura, (2) trabalhadores dos armazéns e de transporte de mercadorias e (3) trabalhadores da logística, qualidade e escritórios. Os operadores apresentam índices superiores e diferentes (p < 0,05) de sintomatologia nos últimos doze meses ao nível da região cervical, ombros, cotovelos, ancas/coxas, pernas/joelhos e tornozelos/pés e nos punhos nos últimos sete dias. No presente estudo, a análise dos dados obtidos parece indicar que a natureza e as características da actividade de trabalho do grupo profissional operadores de máquina de costura (flexão cervical > 20°, trabalho muscular predominantemente estático ao nível da articulação dos ombros, elevação dos membros superiores > 45°, ortostatismo e exigências elevadas ao nível dos punhos/mãos) estão implicadas no desencadear da sintomatologia auto- -referida.

Safe dissection of the distally based anterolateral thigh flap.

Background The distally based anterolateral thigh (ALT) flap is an interesting reconstructive solution for complex soft tissue defects of the knee. In spite of a low donor site morbidity and wide covering surface as well as arch of rotation, it has never gained popularity among reconstructive surgeons. Venous congestion and difficult flap dissection in the presence of a variable anatomy of the vascular pedicle are the possible reasons.Methods An anatomical study of 15 cadaver legs was performed to further clarify the blood supply of the distally based ALT. Our early experience with the use of preoperative angiography and a safe flap design modification that avoids distal intramuscular skeletonization of the vascular pedicle and includes a subcutaneous strip ranging from the distal end of the flap to the pivot point is presented.Results The distally based ALT presents a constant and reliable retrograde vascular contribution from the superior genicular artery. Preoperative angiography reliably identified and avoided critical Shieh Type II pedicled flaps. The preservation of a subcutaneous strip ranging from the distal flap end to the upper knee was associated with the absence of venous congestion in a short case series.Conclusions Preoperative angiography and a flap design modification are proposed to allow the safe transfer of the distally based ALT to reconstruct soft tissue defects of the knee.

Minimal invasive surgery for coronoid fracture: technical note.

Operative treatment of coronoid fracture often requires a large dissection of soft tissue, resulting in elbow stiffness and functional limitation. The authors present a minimal invasive, safe technique, useful in the case of isolated coronoid fracture associated with elbow dislocation. This technique does not require soft tissue dissection and allows an early unlimited resumption of sports activities.

Le genou peut-il représenter un problème sur le lieu de travail ?

Résumé Avec 8% des accidents en Suisse, le genou est une articulation fréquemment blessée. Si la majorité des traumatismes surviennent lors de la pratique du sport, les conséquences sur la reprise de l'activite professionnelle sont relativement méconnues. Pourtant, en 2002, un quart des patients hospitalises dans le service de rééducation de l'appareil locomoteur de la CRR, présentait une lésion du genou responsable d'une limitation fonctionnelle significative. Les diagnostics principaux sont les entorses graves et les lésions dégénératives. Une majorité de patients est issue du secteur secondaire et exerce souvent une profession exigeante d'un point de vue physique. Le but de cet article est d'une part de présenter aux praticiens des repères utiles à la compréhension de cette problématique particulière; d'autre part d'initier une reflexion pratique sur la réadaptation professionnelle de ces patients, par la discussion d'un cas clinique. From approximately 8% of the accidents in Switzerland, the knee is a frequently wounded articulation. If the majority of the traumas occur whilst playing sport, the effects on the resumption of professional activity are relatively ignored. However, in 2002, a quarter of the patients hospitalized in the locomotor service of rehabilitation at the CRR, presented a lesion of the knee as factor most commonly responsible for their functional limitations. The principal diagnoses consisted of serious distorsions and degenerative lesions. A majority of patients come from industry which, from a physical point of view, is generally a demanding occupation. The goals of this article are to present information concerning the comprehension of these particular problems as well as to initiate practises for the vocational rehabilitation of these patients, by the discussion of a clinical case.

Importance of a three-dimensional measure of humeral head subluxation in osteoarthritic shoulders.

HYPOTHESIS: During total shoulder arthroplasty (TSA), humeral head subluxation may be difficult to manage. Furthermore, there is a risk for postoperative recurrence of subluxation, affecting the outcome of TSA. An accurate evaluation of the subluxation is necessary to evaluate this risk. Currently, subluxation is measured in 2 dimensions (2D), usually relative to the glenoid face. The goal of this study was to extend this measure to 3 dimensions (3D) to compare glenohumeral and scapulohumeral subluxation and to evaluate the association of subluxation with the glenoid version. MATERIALS AND METHODS: The study analyzed 112 computed tomography scans of osteoarthritic shoulders. We extended the usual 2D definition of glenohumeral subluxation, scapulohumeral subluxation, and glenoid version by measuring their orientation in 3D relative to the scapular plane and the scapular axis. We evaluated statistical associations between subluxation and version in 2D and 3D. RESULTS: Orientation of subluxation and version covered all sectors of the glenoid surface. Scapulohumeral subluxation and glenoid version were highly correlated in amplitude (R(2) = 0.71; P < .01) and in orientation (R(2) = 0.86; P < .01). Approximately every degree of glenoid version induced 1% of scapulohumeral subluxation in the same orientation of the version. Conversely, glenohumeral subluxation was not correlated to glenoid version in 2D or in 3D. CONCLUSIONS: Orientation of the humeral subluxation is rarely within the arbitrary computed tomography plane and should therefore be measured in 3D to detect out-of-plane subluxation. Scapulohumeral subluxation and glenoid version measured in 3D could bring valuable information for decision making during TSA.

Fractures périprothétiques [Periprosthetic fractures]

A periprosthetic fracture is a fracture around or in proximity of a prosthetic implant. As more and more prostheses are implanted, the incidence of periprosthetic fractures also increases. Several risk factors have been outlined, some due to the patient, and some due to the implant itself. Key points in diagnosis are the case history and the imaging, as they allow the distinction between a well-fixed and a loose prosthesis. Correct classification is crucial for the treatment choice, which can be non-operative or consist in an osteosynthesis or in a revision arthroplasty, depending on the patient's general medical condition and the local status.

Soft tissue artifact distribution on lower limbs during treadmill gait: Influence of skin markers' location on cluster design.

Segment poses and joint kinematics estimated from skin markers are highly affected by soft tissue artifact (STA) and its rigid motion component (STARM). While four marker-clusters could decrease the STA non-rigid motion during gait activity, other data, such as marker location or STARM patterns, would be crucial to compensate for STA in clinical gait analysis. The present study proposed 1) to devise a comprehensive average map illustrating the spatial distribution of STA for the lower limb during treadmill gait and 2) to analyze STARM from four marker-clusters assigned to areas extracted from spatial distribution. All experiments were realized using a stereophotogrammetric system to track the skin markers and a bi-plane fluoroscopic system to track the knee prosthesis. Computation of the spatial distribution of STA was realized on 19 subjects using 80 markers apposed on the lower limb. Three different areas were extracted from the distribution map of the thigh. The marker displacement reached a maximum of 24.9mm and 15.3mm in the proximal areas of thigh and shank, respectively. STARM was larger on thigh than the shank with RMS error in cluster orientations between 1.2° and 8.1°. The translation RMS errors were also large (3.0mm to 16.2mm). No marker-cluster correctly compensated for STARM. However, the coefficient of multiple correlations exhibited excellent scores between skin and bone kinematics, as well as for STARM between subjects. These correlations highlight dependencies between STARM and the kinematic components. This study provides new insights for modeling STARM for gait activity.

The effect of a weighted-vest strength and balance training program on obstructed walking in postmenopausal women

SUMMARY Background: Age related declines in lower extremity strength have been associated with impaired mobility and changes in gait patterns, which increase the likelihood of falls. Since community dwelling adults encounter a wide range of locomotor challenges including uneven and obstmcted walking surfaces, we examined the effect of a strength 11 and balance exercise program on obstructed walking in postmenopausal women. Objectives: This study examined the effect of a weighted-vest strength and balance exercise program on adaptations of the stance leg during obstacle walking in postmenopausal women. Methods: Eighteen women aged 44-62 years who had not engaged in regular resistance training for the past year were recruited from the St. Catharines community to participate in this study. Eleven women volunteered for an aerobic (walking), strength, and balance training program 3 times per week for 12 weeks while 7 women volunteered as controls. Measurements included: force platform dynamic balance measure of the center of pressure (COP) and ground reaction forces (GRFs) in the stance leg while going over obstacles of different heights (0,5, 10,25 and 30 cm); and isokinetic strength measures of knee and ankle extension and flexion. Results: Of the 18 women, who began the trial, 16 completed it. The EX group showed a significant increase of 40% in ankle plantar flexion strength (P < 0.05). However, no improvements in measures of COP or GRFs were observed for either group. Failure to detect any changes in measures of dynamic balance may be due to small sample size. Conclusions: Postmenopausal women experience significant improvements in ankle strength with 12 weeks of a weighted-vest balance and strength training program, however, these changes do not seem to be associated with any improvement in measures of dynamic balance.

Neuromuscular adaptations in endurance-trained boys and men

Competitive sports participation in youth is becoming increasingly more common in the Western world. It is widely accepted that sports participation, specifically endurance training, is beneficial for physical, psychomotor, and social development of children. The research on the effect of endurance training in children has focused mainly on healthrelated benefits and physiological adaptations, particularly on maximal oxygen uptake. However, corresponding research on neuromuscular adaptations to endurance training and the latter's possible effects on muscle strength in youth is lacking. In children and adults, resistance training can enhance strength and mcrease muscle activation. However, data on the effect of endurance training on strength and neuromuscular adaptations are limited. While some evidence exists demonstrating increased muscle activation and possibly increased strength in endurance athletes compared with untrained adults, the neuromuscular adaptations to endurance training in children have not been examined. Thus, the purpose of this study was to examine maximal isometric torque and rate of torque development (RID), along with the pattern of muscle activation during elbow and knee flexion and extension in muscle-endurancetrained and untrained men and boys. Subjects included 65 males: untrained boys (n=18), endurance-trained boys (n=12), untrained men (n=20) and endurance-trained men (n=15). Maximal isometric torque and rate of torque development were measured using an isokinetic dynamometer (Biodex III), and neuromuscular activation was assessed using surface electromyography (SEMG). Muscle strength and activation were assessed in the dominant arm and leg, in a cross-balanced fashion during elbow and knee flexion and extension. The main variables included peak torque (T), RTD, rate of muscle activation (Q30), Electro-mechanical delay (EMD), time to peak RTD and co-activation index. Age differences in T, RTD, electro-mechanical delay (EMD) and rate of muscle activation (Q30) were consistently observed in the four contractions tested. Additionally, Q30, nonnalized for peak EMG amplitude, was consistently higher in the endurancetrained men compared with untrained men. Co-activation index was generally low in all contractions. For example, during maximal voluntary isometric knee extension, men were stronger, had higher RTD and Q30, whether absolute or nonnalized values were used. Moreover, boys exhibited longer EMD (64.8 ± 18.5 ms vs. 56.6 ± 15.3 ms, for boys and men respectively) and time to peak RTD (112.4 ± 33.4 ms vs. 100.8 ± 39.1 ms for boys and men, respectively). In addition, endurance-trained men had lower T compared with untrained men, yet they also exhibited significantly higher nonnalized Q30 (1.9 ± 1.2 vs. 1.1 ± 0.7 for endurance-trained men and untrained men, respectively). No training effect was apparent in the boys. In conclusion, the findings demonstrate muscle strength and activation to be lower in children compared with adults, regardless of training status. The higher Q30 of the endurance-trained men suggests neural adaptations, similar to those expected in response to resistance training. The lower peak torque may su9gest a higher relative involvement oftype I muscle fibres in the endurance-trained athletes. Future research is required to better understand the effect of growth and development on muscle strength and activation patterns during dynamic and sub-maximal isometric contractions. Furthennore, training intervention studies could reveal the effects of endurance training during different developmental stages, as well as in different muscle groups.

Active isolated stretching : an investigation of the mechanical mechanisms

The Active Isolated Stretching (AIS) technique proposes that by contracting a muscle (agonist) the opposite muscle (antagonist) will relax through reciprocal inhibition and lengthen without increasing muscle tension (Mattes, 2000). The clinical effectiveness of AIS has been reported but its mechanism of action has not been investigated at the tissue level. Proposed mechanisms for increased range of motion (ROM) include mechanical or neural changes, or an increased stretch tolerance. The purpose of the study was to investigate changes in mechanical properties, i.e. stiffness, of skeletal muscle in response to acute and long-term AIS stretching for the hamstring muscle group. Recreationally active university-aged students (female n=8, male n=2) classified as having tight hamstrings, by a knee extension test, volunteered for the study. All stretch procedures were performed on the right leg, with the left leg serving as a control. Each subject was assessed twice: at an initial session and after completing a 6-week AIS hamstring stretch training program. For both test sessions active knee extension (ROM) to a position of "light irritation", passive resisted torque and stiffness were determined before and after completion of the AIS technique (2x10 reps). Data were collected using a Biodex System 3 Pro (Biodex Medical Systems, NY, USA) isokinetic dynamometer. Surface electromyography (EMG) was used to monitor vastus lateralis (VL) and hamstring muscle activity during the stretching movements. Between test sessions, 2x10 reps of the AIS bent knee hamstring stretch were performed daily for 6-weeks.