Q-angle static or dynamic measurements, which is the best choice for patellofemoral pain?

The elevated Q-angle seems to be one of the most suggested factors contributing to patellofemoral pain. Females with patellofemoral pain are often evaluated through static clinical tests in clinical practice. However, the adaptations seem to appear more frequently in dynamic conditions. Performing static vs. dynamic evaluations of widely used measures would add to the knowledge in this area. Therefore, the aim of this study was to determine the reliability and discriminatory capability of three Q-angle measurements: a static clinical test, peak dynamic knee valgus during stair ascent and a static measurement using a three-dimensional system. Twenty-nine females with patellofemoral pain and twenty-five pain-free females underwent clinical Q-angle measurement and static and dynamic knee valgus measurements during stair ascent, using a three-dimensional system. All measurements were obtained and comparisons between groups, reliability and discriminatory capability were calculated. Peak dynamic knee valgus was found to be greater in the patellofemoral pain group. On the other hand, no significant effects were found for static knee valgus or clinical Q-angle measurements between groups. The dynamic variable demonstrated the best discriminatory capability. Low values of reliability were found for clinical Q-angle, in contrast to the high values found for the three-dimensional system measurements. Based on our findings, avoiding or correcting dynamic knee valgus during stair ascent may be an important component of rehabilitation programs in females with patellofemoral pain who demonstrate excessive dynamic knee valgus. Q-angle static measurements were not different between groups and presented poor values of discriminatory capability.

Análise do ângulo de rotação da coxa em indivíduos com síndrome da dor patelofemoral durante a subida de degraus

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Onset of quadriceps and torque variation in individuals with patellofemoral pain during stair ascent

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Papiloma de plexo coroide em um cão

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Translation and Cross-cultural Adaptation of the Lower Extremity Functional Scale Into a Brazilian Portuguese Version and Validation on Patients With Knee Injuries

STUDY DESIGN: Clinical measurement. OBJECTIVE: To translate and culturally adapt the Lower Extremity Functional Scale (LEFS) into a Brazilian Portuguese version, and to test the construct and content validity and reliability of this version in patients with knee injuries. BACKGROUND: There is no Brazilian Portuguese version of an instrument to assess the function of the lower extremity after orthopaedic injury. METHODS: The translation of the original English version of the LEFS into a Brazilian Portuguese version was accomplished using standard guidelines and tested in 31 patients with knee injuries. Subsequently, 87 patients with a variety of knee disorders completed the Brazilian Portuguese LEES, the Medical Outcomes Study 36-Item Short-Form Health Survey, the Western Ontario and McMaster Universities Osteoarthritis Index, and the International Knee Documentation Committee Subjective Knee Evaluation Form and a visual analog scale for pain. All patients were retested within 2 days to determine reliability of these measures. Validation was assessed by determining the level of association between the Brazilian Portuguese LEFS and the other outcome measures. Reliability was documented by calculating internal consistency, test-retest reliability, and standard error of measurement. RESULTS: The Brazilian Portuguese LEES had a high level of association with the physical component of the Medical Outcomes Study 36-Item Short-Form Health Survey (r = 0.82), the Western Ontario and McMaster Universities Osteoarthritis Index (r = 0.87), the International Knee Documentation Committee Subjective Knee Evaluation Form (r = 0.82), and the pain visual analog scale (r = -0.60) (all, P<.05). The Brazilian Portuguese LEES had a low level of association with the mental component of the Medical Outcomes Study 36-Item Short-Form Health Survey (r = 0.38, P<.05). The internal consistency (Cronbach alpha = .952) and test-retest reliability (intraclass correlation coefficient = 0.957) of the Brazilian Portuguese version of the LEES were high. The standard error of measurement was low (3.6) and the agreement was considered high, demonstrated by the small differences between test and retest and the narrow limit of agreement, as observed in Bland-Altman and survival-agreement plots. CONCLUSION: The translation of the LEFS into a Brazilian Portuguese version was successful in preserving the semantic and measurement properties of the original version and was shown to be valid and reliable in a Brazilian population with knee injuries. J Ort hop Sports Phys Ther 2012;42(11):932-939, Epub 9 October 2012. doi:10.2519/jospt.2012.4101

Isokinetic muscle strength and knee function associated with double femoral pin fixation and fixation with interference screw in anterior cruciate ligament reconstruction

Intensive scheduling in sports requires athletes to resume physical activity shortly after injury. The purpose of this study was to investigate early isokinetic muscle strength and knee function on bone-patellar tendon-bone (BPTB) ACL reconstruction with double femoral pin fixation or interference screw technique. A prospective study was conducted from 2008 to 2009, with 48 athletes who received femoral BPTB fixation with interference screw (n = 26) or double pin (n = 22). Clinical (IKDC objective score and hop test) and isokinetic muscle strength (peak torque (PT), PT/body weight and flexion/extension rate (F/E) in 60 and 240A degrees/s) were analyzed at 6 months of follow-up. Analysis at baseline showed no differences between groups before surgery related to age, gender, associated injury, Tegner or Lysholm score; thus showing that groups were similar. During follow-up, however, there were significant differences between the two groups in some of the isokinetic muscle strength: PT/BW 60A degrees/s (Double Pin = 200% +/- A 13% vs. Interference Screw = 253% +/- A 16%*, *P = 0.01); F/E 60A degrees/s (Double Pin = 89% +/- A 29%* vs. Interference Screw = 74% +/- A 12%, *P = 0.04). No statistical differences between groups were observed on IKDC objective score, hop test and complications. The significant muscle strength outcome of the interference screw group found in this study gives initial evidence that this fixation technique is useful for athletes that may need accelerated rehabilitation. Early return to sports ability signaled by isokinetic muscle strength is of clinical relevance as it is one of the main goals for athletes' rehabilitation. III.

Experimental diabetes modulates collagen remodelling of joints in rats

The aim of this study was to evaluate extracellular matrix components in articular cartilage, ligaments and synovia in an experimental model of diabetes. Young Wistar rats were divided into a streptozotocin-induced (STZ; 35 mg/kg) diabetic group (DG; n=15) and a control group (CG; n=15). Weight, blood glucose and plasma anti-carboxymethyllysine were measured 70 days after STZ infusions. Knee joints, patellar ligaments, and lateral and medial collateral ligaments were isolated and stained with hematoxylineosin and Picrosirius. The total collagen content was determined by morphometry. Immunofluorescence was employed to evaluate types I, III, and V collagen in ligaments and synovial tissues and types II and XI collagen in cartilage. Results: Higher blood glucose levels and plasma anti-carboxymethyllysine were observed in DG rats when compared to those in CG rats. The final weight was significantly lower in the DG rats than in the CG rats. Histomorphometric evaluation depicted a small quantity of collagen fibers in ligaments and articular cartilage in DG rats, as well as increased collagen in synovial tissue. There was a decrease in cartilage proteoglycans in DG rats when compared with CG rats. Immunofluorescence staining revealed an increase of collagen III and V in ligaments, collagen XI in cartilage, and collagen I in synovial tissue of DG rats compared with CG rats. Conclusion: The ligaments, cartilage and synovia are highly affected following STZ-induced diabetes in rats, due the remodeling of collagen types in these tissues. This process may promote the degradation of the extracellular matrix, thus compromising joint function. Our data may help to better understand the pathogenesis of joint involvement related to diabetes.

Método de ensaio biomecânico para análise da isometricidade na reconstrução do ligamento patelofemoral medial

OBJETIVO: Apresentar um dispositivo biomecânico para o estudo da reconstrução do ligamento patelofemoral medial (LPFM) e sua isometricidade. MÉTODOS: Foi desenvolvido um sistema biomecânico acessível, que permite a aplicação de forças fisiológicas e não fisiológicas no joelho, através de um braço mecânico e aplicação de pesos e contrapesos, possibilitando a execução de diferentes estudos, além de ter um sistema de medidas bastante preciso de aferição de distâncias entre diferentes estruturas para análise dos experimentos. Este artigo descreve a montagem deste sistema, além de sugerir algumas aplicações práticas. Foram estudados seis joelhos de cadáveres. Os joelhos foram preparados em uma máquina de ensaios desenvolvida no Laboratório de Biomecânica do IOT HC FMUSP, que permitiu a avaliação dinâmica do comportamento patelar, quantificando a sua lateralização entre 0 e 120 graus. A diferença entre as distâncias encontradas, com e sem carga, aplicada na patela foram agrupadas segundo o ângulo de fixação do enxerto (0°, 30°, 60° e 90°) e situação do joelho (íntegro, reconstruído e lesado). RESULTADOS: Houve uma tendência em ocorrer menor desvio lateral em ângulos de fixação acima de 30 graus de flexão, principalmente entre os ângulos entre 45° e 60° graus de flexão, após a reconstrução. Para os demais ângulos não houve significância estatística. CONCLUSÃO: O método desenvolvido é uma ferramenta útil para os estudos da articulação patelofemoral, além de ter um sistema de medidas bastante preciso de aferição de distâncias entre diferentes estruturas e permitir a sua utilização em instituições com menos recursos disponíveis.

New functional and biomechanical assessments for the improvement of the surgical navigation systems for joint replacement in the human lower limb

In case of severe osteoarthritis at the knee causing pain, deformity, and loss of stability and mobility, the clinicians consider that the substitution of these surfaces by means of joint prostheses. The objectives to be pursued by this surgery are: complete pain elimination, restoration of the normal physiological mobility and joint stability, correction of all deformities and, thus, of limping. The knee surgical navigation systems have bee developed in computer-aided surgery in order to improve the surgical final outcome in total knee arthroplasty. These systems provide the surgeon with quantitative and real-time information about each surgical action, like bone cut executions and prosthesis component alignment, by mean of tracking tools rigidly fixed onto the femur and the tibia. Nevertheless, there is still a margin of error due to the incorrect surgical procedures and to the still limited number of kinematic information provided by the current systems. Particularly, patello-femoral joint kinematics is not considered in knee surgical navigation. It is also unclear and, thus, a source of misunderstanding, what the most appropriate methodology is to study the patellar motion. In addition, also the knee ligamentous apparatus is superficially considered in navigated total knee arthroplasty, without taking into account how their physiological behavior is altered by this surgery. The aim of the present research work was to provide new functional and biomechanical assessments for the improvement of the surgical navigation systems for joint replacement in the human lower limb. This was mainly realized by means of the identification and development of new techniques that allow a thorough comprehension of the functioning of the knee joint, with particular attention to the patello-femoral joint and to the main knee soft tissues. A knee surgical navigation system with active markers was used in all research activities presented in this research work. Particularly, preliminary test were performed in order to assess the system accuracy and the robustness of a number of navigation procedures. Four studies were performed in-vivo on patients requiring total knee arthroplasty and randomly implanted by means of traditional and navigated procedures in order to check for the real efficacy of the latter with respect to the former. In order to cope with assessment of patello-femoral joint kinematics in the intact and replaced knees, twenty in-vitro tests were performed by using a prototypal tracking tool also for the patella. In addition to standard anatomical and articular recommendations, original proposals for defining the patellar anatomical-based reference frame and for studying the patello-femoral joint kinematics were reported and used in these tests. These definitions were applied to two further in-vitro tests in which, for the first time, also the implant of patellar component insert was fully navigated. In addition, an original technique to analyze the main knee soft tissues by means of anatomical-based fiber mappings was also reported and used in the same tests. The preliminary instrumental tests revealed a system accuracy within the millimeter and a good inter- and intra-observer repeatability in defining all anatomical reference frames. In in-vivo studies, the general alignments of femoral and tibial prosthesis components and of the lower limb mechanical axis, as measured on radiographs, was more satisfactory, i.e. within ±3°, in those patient in which total knee arthroplasty was performed by navigated procedures. As for in-vitro tests, consistent patello-femoral joint kinematic patterns were observed over specimens throughout the knee flexion arc. Generally, the physiological intact knee patellar motion was not restored after the implant. This restoration was successfully achieved in the two further tests where all component implants, included the patellar insert, were fully navigated, i.e. by means of intra-operative assessment of also patellar component positioning and general tibio-femoral and patello-femoral joint assessment. The tests for assessing the behavior of the main knee ligaments revealed the complexity of the latter and the different functional roles played by the several sub-bundles compounding each ligament. Also in this case, total knee arthroplasty altered the physiological behavior of these knee soft tissues. These results reveal in-vitro the relevance and the feasibility of the applications of new techniques for accurate knee soft tissues monitoring, patellar tracking assessment and navigated patellar resurfacing intra-operatively in the contest of the most modern operative techniques. This present research work gives a contribution to the much controversial knowledge on the normal and replaced of knee kinematics by testing the reported new methodologies. The consistence of these results provides fundamental information for the comprehension and improvements of knee orthopedic treatments. In the future, the reported new techniques can be safely applied in-vivo and also adopted in other joint replacements.

Efficacia del trattamento con concentrati piastrinici (P.R.P.) nelle lesioni condrali e tendinopatie

Purpose: Recent knowledge regarding tissue biology highlights a complex regulation of growth factors in reaction to tissue damage. Platelet Rich Plasma (P.R.P.), containing a natural pool of growth factors, can be obtained in a simple and minimally invasive way and be applied to the lesion site. The aim of this study is to explore this novel approach to treat cartilage degenerative lesions of the knee and tendon chronic lesions( patellar tendon, and achilles tendon). In this study we evaluated if the treatment with PRP injections can reduce pain and increase function in cases of patellar tendinosis (Jumper’s Knee), in chronic achilles tendinopathy and in patients with cartilage injuries of the knee. Materials and Methods: 40 patients with cartilage lesion of the knee, 28 male and 12 female with mean age 47 y. (min 18- max 52 years), were treated and prospectively evaluated at a minimum 6 months follow-up; in the same way, 12 patients with achilles tendon lesion (8 male and 4 female) with mean age 44,5 y. (min 32-max 58 years) and 10 patients with “Jumper’s Knee” (8 male and 2 female) with mean age 23,2 y. (min 18-max 37 years), were evaluated at 6 months follow up. The procedure involved 3 multiple injections , performed every two weeks. All patients were clinically evaluated at the end of the treatment and at 6 months follow up. IKDC, SF36, EQ-VAS, scores were used for clinical evaluation and patient satisfaction and functional status were also recorded. Results: Statistical analysis showed a significant improvement in the SF36 questionnaire in all parameters evaluated at the end of the therapy and 6 months follow-up in both group(tendinopathies and chondral lesions), and in the EQ VAS and IKDC score (paired T-test, p<0.0005) from basal evaluation to the end of the therapy, and a further improvement was present at 6 months follow-up. Whereas a higher improvement of the sport activity level was achieved in the “Jumper’s Knee” group. No complications related to the injections or severe adverse events were observed during the treatment and follow up period. Conclusion: PRP inhibits excess inflammation, apoptosis, and metalloproteinase activity. These interactive pathways may result in the restoration of tendon or cartilage, which can with stand loading with work or sports activity, thereby diminishing pain. PRP may also modulate the microvascular environment or alter efferent or afferent neural receptors. The clinical results are encouraging, indicating that PRP injections may have the potential to increase the tendon and cartilage healing capacity in cases with chronic tendinosis and chondropathy of the knee.

Impiego di cellule staminali in terapia veterinaria

Over the past few years, in veterinary medicine there has been an increased interest in understanding the biology of mesenchymal stem cells (MSCs). This interest comes from their potential clinical use especially in wound repair, tissue engineering and application in therapeutics fields, including regenerative surgery. MSCs can be isolated directly from bone marrow aspirates, adipose tissue, umbilical cord and various foetal tissues. In this study, mesenchymal stem cells were isolated from equine bone marrow, adipose tissue, cord blood, Wharton’s Jelly and, for the first time, amniotic fluid. All these cell lines underwent in vitro differentiation in chondrocytes, osteocytes and adipocytes. After molecular characterization, cells resulted positive for mesenchymal markers such as CD90, CD105, CD44 and negative for CD45, CD14, CD34 and CD73. Adipose tissue and bone marrow mesenchymal stem cells were successfully applied in the treatment of tendinitis in race horses. Furthermore, for the first time in the horse, skin wounds of septicemic foal, were treated applying amniotic stem cells. Finally, results never reported have been obtained in the present study, isolating mesenchymal stem cells from domestic cat foetal fluid and membranes. All cell lines underwent in vitro differentiation and expressed mesenchymal molecular markers.

Valutazione dell'efficacia di iniezioni peritendinee di acido ialuronico nel tendine rotuleo di ratto disallenato

Introduzione L’attività fisica moderata seguita da improvvisa interruzione può influenzare le caratteristiche biologiche del tendine. Lo scopo del lavoro è stato quello di valutare l’attività cellulare, le caratteristiche istologiche, istomorfometriche e microstrutturali del tendine patellare e della sua entesi in condizioni di non allenamento (sedentarietà), allenamento ed improvviso arresto dell’attività fisica. E’ stato ipotizzato che un’iniezione peri-tendinea di acido ialuronico nelle settimane successive all’improvviso arresto dell’attività fisica potesse mantenere l’integrità strutturale e biologica del tendine patellare. Materiali e Metodi 24 ratti Sprague Dawley maschi di 8 settimane sono stati suddivisi in tre gruppi, allenati per 10 settimane, fino a 60-80% VO2max. I ratti sono stati suddivisi in tre gruppi: Non Allenati (6), Allenati (6), Disallenati (12). A 6 dei 12 ratti del gruppo Detrained, è stata praticata un’infiltrazione peri-tendinea a nel tendine patellare destro di 300 μl di acido ialuronico, mentre nei rimanenti 6, è stata praticata l’infiltrazione con soluzione fisiologica. I tendini rotulei espiantati sono stati valutati con coltura cellulare, valutazione biologica molecolare, valutazioni morfologiche microstrutturali, proliferazione, conta ed attività cellulare. Risultati I risultati in vitro hanno evidenziato vitalità e conta cellulare simili fra i Gruppi Trained e Detrained-HA con un incremento significativo del metabolismo cellulare rispetto agli altri Gruppi. La cellularità ha mostrato valori maggiori nei Gruppi Non Allenati e Detrained-NaCl ove si è osservata una biosintesi del collagene III superiore ai Gruppi Trained e Detrained-HA. Contrariamente, la produzione di collagene I e II presentava valori maggiori nei Gruppi Trained e Detrained-HA suggerendo una superiore efficienza tessutale e metabolica di questi ultimi. Conclusioni Questi risultati confermano che l’allenamento ed il suo improvviso arresto hanno effetti sulla struttura tendinea patellare di ratto e che l’iniezione peritendinea di acido ialuronico nel periodo di inattività ha effetti significativi su metabolismo cellulare e sul tendine rispetto al trattamento con soluzione fisiologica.

Intraoperative kinematic evaluation with navigation system and postoperative kinematic evaluation with dynamic RSA of total knee arthroplasty

Restoring a correct implant kinematics and providing a good ligament balance and patellar tracking is mandatory to improve clinical and functional outcome after a Total Knee Replacement. Surgical navigation systems are a reliable and accurate tool to help the surgeon in achieving these goals. The aim of the present study was to use navigation system with an intra-operative surgical protocol to evaluate and determine an optimal implant kinematics during a Total Knee Replacement.

Quantitative mapping of T2 using partial spoiling

Fast quantitative MRI has become an important tool for biochemical characterization of tissue beyond conventional T1, T2, and T2*-weighted imaging. As a result, steady-state free precession (SSFP) techniques have attracted increased interest, and several methods have been developed for rapid quantification of relaxation times using steady-state free precession. In this work, a new and fast approach for T2 mapping is introduced based on partial RF spoiling of nonbalanced steady-state free precession. The new T2 mapping technique is evaluated and optimized from simulations, and in vivo results are presented for human brain at 1.5 T and for human articular cartilage at 3.0 T. The range of T2 for gray and white matter was from 60 msec (for the corpus callosum) to 100 msec (for cortical gray matter). For cartilage, spatial variation in T2 was observed between deep (34 msec) and superficial (48 msec) layers, as well as between tibial (33 msec), femoral, (54 msec) and patellar (43 msec) cartilage. Excellent correspondence between T2 values derived from partially spoiled SSFP scans and the ones found with a reference multicontrast spin-echo technique is observed, corroborating the accuracy of the new method for proper T2 mapping. Finally, the feasibility of a fast high-resolution quantitative partially spoiled SSFP T2 scan is demonstrated at 7.0 T for human patellar cartilage.

Bioabsorbable pins for treatment of osteochondral fractures of the knee after acute patella dislocation in children and young adolescents

A retrospective study was performed on the use of bioabsorbable pins in the fixation of osteochondral fractures (OCFs) after traumatic patellar dislocation in children. Eighteen children (13 females, 5 males) aged 11 to 15 years (mean age 13.1 years) with osteochondral fracture (OCF) of the knee joint were treated at the authors' institution. Followup ranged from 22 months to 5 years. Diagnosis was verified by X-ray and magnetic resonance imaging (MRI) of the knee and patella. In seven patients the osteochondral fragment was detached from the patella and in 11 it was detached from the lateral femoral condyle. All patients were subjected to open reduction and fixation of the lesion with bioabsorbable pins. Postoperatively, the knee was immobilized in a cast and all patients were mobilized applying a standardized protocol. Bone consolidation was successful in 17 of the 18 patients. Bioabsorbable pins reliably fix OCF in children and adolescents, demonstrating a high incidence of consolidation of the detached osteochondral fragment in short- and middle-term followup without requiring further operative procedures.