Comparação entre o dano muscular de flexores do cotovelo e extensores do joelho em idosos= : Muscle damage comparison between elbow flexors and knee extensors in older adults

Universidade Estadual de Campinas . Faculdade de Educação Física

Economic impact of treatment for surgical site infections in cases of total knee arthroplasty in a tertiary public hospital in Brazil

The aim of this study was to estimate the additional cost of treatment of a group of nosocomial infections in a tertiary public hospital. A retrospective observational cohort study was conducted by means of analyzing the medical records of 34 patients with infection after total knee arthroplasty, diagnosed in 2006 and 2007, who met the criteria for nosocomial infection according to the Centers for Disease Control and Prevention. To estimate the direct costs of treatment for these patients, the following data were gathered: length of hospital stay, laboratory tests, imaging examinations, and surgical procedures performed. Their costs were estimated from the minimum values according to the Brazilian Medical Association. The estimated cost of the antibiotics used was also obtained. The total length of stay in the ward was 976 days, at a cost of US$ 18,994.63, and, in the intensive care unit, it was 34 days at a cost of US$ 5,031.37. Forty-two debridement procedures were performed, at a cost of US$ 5,798.06, and 1965 tests (laboratory and imaging) were also performed, at a cost of US$ 15,359.25. US$ 20,845.01 was spent on antibiotics and US$ 1,735.16 on vacuum assisted closure therapy, microsurgical flaps, implant removal, spacer use, and surgical revision. The total additional cost of these cases of hospital infection in 2006 and 2007 was of US$ 91,843.75. Based on that, we demonstrate that the high cost of treatment for hospital infections emphasizes the importance of taking measures to prevent and control hospital infection.

Effects of Laser on the Synovial Fluid in the Inflammatory Process of the Knee Joint of the Rabbit

Objective: The purpose of this study was to evaluate the effects of low-level laser (LLL) energy on the clinical signs of inflammation and the cellular composition of synovial fluid (SF) in the inflamed knee of the rabbit. Background Data: There are few findings related to the effects of LLL on SF in inflammatory processes and there is little knowledge about the optimal parameters for reducing joint inflammation. Materials and Methods: Inflammation in the right knee of 36 rabbits was induced by intracapsular injection (0.2 mL) of Terebinthina commun (Tc). The animals were randomly assigned to three groups: acute experimental group (AEG), chronic experimental group (CEG), and control group (CG), which only received Tc. Each group was divided in two subgroups of six animals each. The AEG and CEG groups began to receive laser treatment 2 and 5 d after the induction of inflammation, respectively. Laser irradiation at a wavelength of 830 nm, power output of 77 mW, and power density of 27.5 W/cm(2) was applied daily for 7 d for either 0.12 sec or 0.32 sec, resulting in doses of 3.4 J/cm(2) and 8 J/cm(2), respectively. Body mass, joint perimeter, joint temperature, and the morphology of the SF were analyzed. Results: There was no statistically significant differences between groups in the body mass, joint perimeter, and SF morphology. Conclusion: Laser irradiation with the selected parameters produced only a few subtle differences in the inflammatory signs and the SF. The lack of effects may have been due to the short irradiation time.

Electrical stimulation and treadmill gait in tetraplegic patients: assessment of its effects on the knee with magnetic resonance imaging

Study design: Evaluation of knees of tetraplegic patients who have been walking for several months with the aid of a system that involves neuromuscular stimulation, treadmill and a harness support device. Objectives: To investigate if the training program could cause knee injury to tetraplegic patients. Setting: Hospital das Clinicas - UNICAMP. Campinas-SP, Brazil. Methods: Nine patients were evaluated. Clinical exam and magnetic resonance images (MRIs) were used for evaluation. MRIs were taken before and after the training program, in a 6-month interval for each patient. There were two sessions of training every week. Each session lasted 20 min. Results: No severe clinical abnormality was observed in any patient. Mild knee injury was observed in four of nine patients studied. Conclusions: Tetraplegic patients undergoing treadmill gait training deserve a close follow-up to prevent knee injury.

Preferential use of nonreversed vein grafts in above-knee femoropopliteal bypasses for critical ischemia: Midterm outcome

We evaluated nonreversed vein grafts in above-knee bypasses for chronic critical limb ischemia in a retrospective study with intention-to-treat analysis in patients who underwent above-knee bypass grafting. During a 4-year period, 51 patients (men, 32; women, 19; mean age 66 years) with 53 critically ischemic lower extremities underwent above-knee femoropopliteal bypass grafting. The follow-up evaluation consisted of clinical examination, assessment of the ankle- brachial systolic blood pressure index, and, whenever necessary, duplex scanning. Three ( 5.7%) deaths occurred within 30 days, two from myocardial infarction and one from an undetermined cause. The 2-year cumulative success rate was 82.5 +/- 9.6% for primary patency, 84.6 +/- 8.9% for secondary patency, 90.1 +/- 7.3% for tertiary patency, 86.9 +/- 7.6% for limb salvage, 77.7 +/- 8.4% for survival, 68.0 +/- 11.1% for composite patency, and 68.4 +/- 9.3% for amputation- free survival; the corresponding estimates for vein grafts alone were 86.6 +/- 9.2%, 88.9 +/- 8.6%, 89.0 +/- 8.5%, 88.1 +/- 8.1%, 81.1 +/- 9.1, 76.8 +/- 11.1%, and 72.6 +/- 10.2%. Three prosthetic grafts failed and were replaced with an arm vein graft. Nonreversed vein bypass grafts in above- knee revascularization of critically ischemic limbs are justified.

Effectiveness of medial-wedge insole treatment for valgus knee osteoarthritis

Objective. To assess the efficacy of medial-wedge insoles in valgus knee osteoarthritis (OA). Methods. Thirty consecutive women with valgus-deformity knee OA a:8 degrees were randomized into 2 groups: medial insole (insoles with B-mm medial elevation at the rearfoot [n = 161) and neutral insole (similar insole without elevation [n = 14]). Both groups also wore ankle supports. A blinded examiner assessed pain on movement, at rest, and at night with a visual analog scale (VAS), the Lequesne index., and Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index. Femorotibial, talocalcaneal, and talar tilt angles were evaluated at baseline and after 8 weeks of insole use. Results. Significant reductions in the medial insole group were observed for pain on movement (mean +/- SD VAS pre- and postintervention 8.1 +/- 1.5 versus 1 4.2 +/- 2.4; P = 0.001), at rest (5.1 +/- 2.3 versus 2.7 +/- 2.4; P = 0.002), and at night (6.1 +/- 2.7 versus 3.1 +/- 2.1; P = 0.001). In addition, a decrease in Lequesne (14.7 +/- 3.4 versus 9.6 +/- 3.8; P = 0.001) and WOMAC scores (74.1 +/- 14.2 versus 56.1 +/- 14.9; P = 0.001) was observed for the medial insole group. In the neutral insole group, a significant reduction was observed only for night pain (mean SD VAS pre- and postintervention 5.8 +/- 2.4 versus 4.6 +/- 2.4; P = 0.019). An increase in femorotibial angle (169.0 +/- 3.4 versus 170.8 +/- 2.4; P = 0.019). An increase in femorotibial angle (169.0 +/- 3.4 versus 170.8 +/- 3.7; P = 0.001) occurred only in the medial 3.7; P = 0.001) occurred only in the medial insole group. Moreover, the difference in measured fernorotibial angles pre- and postintervention was 1.84 +/- 1.42 versus -0.18 +/- 0.67 (P < 0.001) for the medial and neutral insole groups. Conclusion. The use of medial-wedge insoles was highly effective in reducing pain at rest and on movement and promoted a functional improvement of valgus knee OA.

Beneficial Effect of Creatine Supplementation in Knee Osteoarthritis

NEVES JR., M., B. GUALANO, H. ROSCHEL, R. FULLER, F. B. BENATTI, A. L. DE SA PINTO, F. R. LIMA, R. M. PEREIRA, A. H. LANCHA JR., E. BONFA. Beneficial Effect of Creatine Supplementation in Knee Osteoarthritis. Med. Sci. Sports Exerc., Vol. 43, No. 8, pp. 1538-1543, 2011. Introduction: The aim of this study was to investigate the efficacy of creatine (CR) supplementation combined with strengthening exercises in knee osteoarthritis (OA). Methods: A randomized, double-blind, placebo-controlled trial was performed. Postmenopausal women with knee OA were allocated to receive either CR (20 g.d(-1) for 1 wk and 5 g.d(-1) thereafter) or placebo (PL) and were enrolled in a lower limb resistance training program. They were assessed at baseline (PRE) and after 12 wk (POST). The primary outcome was the physical function as measured by the timed-stands test. Secondary outcomes included lean mass, quality of life, pain, stiffness, and muscle strength. Results: Physical function was significantly improved only in the CR group (P = 0.006). In addition, a significant between-group difference was observed (CR: PRE = 15.7 +/- 1.4, POST = 18.1 +/- 1.8; PL: PRE = 15.0 +/- 1.8, POST = 15.2 +/- 1.2; P = 0.004). The CR group also presented improvements in physical function and stiffness subscales as evaluated by the Western Ontario and McMaster Universities Osteoarthritis Index (P = 0.005 and P = 0.024, respectively), whereas the PL group did not show any significant changes in these parameters (P > 0.05). In addition, only the CR group presented a significant improvement in lower limb lean mass (P = 0.04) as well as in quality of life (P = 0.01). Both CR and PL groups demonstrated significant reductions in pain (P G 0.05). Similarly, a main effect for time revealed an increase in leg-press one-repetition maximum (P = 0.005) with no significant differences between groups (P = 0.81). Conclusions: CR supplementation improves physical function, lower limb lean mass, and quality of life in postmenopausal women with knee OA undergoing strengthening exercises.

FUNCTIONAL COMPARISON BETWEEN SEPTIC AND ASEPTIC KNEE ARTHROPLASTY REVIEW

Introduction: Total knee arthroplasty (TKA) imposes many risks. TKA infection is not the most frequent complication, but is probably the most serious one. Two-step review is the procedure of choice in deep knee prosthesis infection. On the other hand, aseptic prosthesis detachment represents almost half of the primary arthroplasty review indications, Patient`s satisfaction level might diminish after reviews. Objective: The objective of this study was to compare the quality of life and final result of TKA review for septic and aseptic failures. Methods: The patients were assessed using the HSS and SF-36 scores. The patients were divided in two groups: one group submitted to two-step review (septic) and the other to one-step review (aseptic). The analysis of the data obtained shows better scores for the second group in HSS and in 06 of 08 domains of SF-36 classification. Conclusions: The on-step review of total knee arthroplasty leads to better functional outcomes.

USE OF ALLOGRAFT IN LIGAMENTAR RECONSTRUCTION OF KNEE

Introduction: The use of allograft is a matter of huge interest for orthopaedic surgeons, due to the supposed advantages with its use, like decreased surgical time, larger grafts and no donator site morbidity. Objectives: The aim of this article was to review our experience with the use of allografts on ligament reconstruction. We present the technique applied for graft harvest, preparation and storage, as well as the indications for allograft use and the type of procedure in which it was applied. Methods: We revised the records of 46 patients. Results: We used 09 patellar tendons, 09 anterior tibial tendons, 08 calcaneal tendons, 06 quadriceptal tendons and 01 fibular tendon, mainly for multiple ligamentar reconstructions and ACL reviews. Conclusion: The use of allograft seems to be an interesting option for ligamentar reconstruction.

Impact of Nervous System Hyperalgesia on Pain, Disability, and Quality of Life in Patients With Knee Osteoarthritis: A Controlled Analysis

Objective. Refractory, disabling pain associated with knee osteoarthritis (OA) is usually treated with total knee replacement. However, pain in these patients might be associated with central nervous sensitization rather than peripheral inflammation and injury. We evaluated the presence of hyperalgesia in patients scheduled for a total knee replacement due to knee osteoarthritis with refractory pain, and we assessed the impact of pressure pain threshold measurements (PPT) on pain, disability, and quality of life of these patients. Methods. Sixty-two female patients were compared with 22 age-matched healthy controls without reported pain for the last year. PPT was measured at the lower extremities subcutaneous dermatomes, over the vastus medialis, adductor longus, rectus femoris, vastus lateralis, tibialis anterior, peroneus longus, iliacus, quadratus lumborum and popliteus muscles and at the supraspinous ligaments from L1-L5, over the L5-S1 and S1-S2 sacral areas and at the pes anserinus bursae and patellar tendon. Results. Patients with knee OA had significantly lower PPT over all evaluated structures versus healthy control subjects (P < 0.001). Lower PPT values were correlated with higher pain intensity, higher disability scores, and with poorer quality of life, except for the role-emotional and general health status. Combined PPT values over the patellar tendon, at the S2 subcutaneous dermatome and at the adductor longus muscle were the best predictors for visual analog scale and Western Ontario and McMaster Universities Osteoarthritis Index pain scores. Conclusion. Patients with pain due to osteoarthritis who were scheduled for total knee replacement showed hyperalgesia of nervous system origin that negatively impacted pain, knee functional capacity, and most aspects of quality of life.

Translation and Cross-Cultural Adaptation of the Brazilian Version of the International Knee Documentation Committee Subjective Knee Form Validity and Reproducibility

Background: The perception of improvement by a patient has assumed a central role in functional evaluation after a variety of knee problems. One of the instruments most used in clinical research is the International Knee Documentation Committee (IKDC) Subjective Knee Form because its psychometric properties are considered to be excellent. Nonetheless, this questionnaire was originally developed for use in the English language. Therefore, to use this questionnaire in the Brazilian population, it is essential to translate and validate it. Purpose: The aim of this study was to translate the IKDC Subjective Knee Form into a Brazilian version and to test its validity and reproducibility. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The translation of the original IKDC Subjective Knee Form into a Brazilian version was accomplished in accordance with the American Orthopaedic Society for Sports Medicine guidelines and was tested in 32 patients with knee pathologic conditions to develop the first Brazilian version. To test validity and reproducibility, 117 patients with several knee complaints completed the Brazilian IKDC Subjective Knee Form, the Short Form 36 (SF-36), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Lysholm score. From these patients, 85 were retested within a week to achieve reproducibility. The validation was addressed by correlating the Brazilian IKDC Subjective Knee Form to the other outcome measures. The reproducibility was tested by measuring internal consistency, test-retest reliability, and agreement. Results: The Brazilian IKDC Subjective Knee Form was highly related to the physical component summary of the SF-36, the Lysholm score, and the WOMAC, and weakly related to the mental component summary of SF-36 (r=.79, .89, .85, and .51, respectively). The internal consistency was strong, with a Cronbach a value of .928 and .935 in the test and retest assessment, respectively. The test-retest reliability proved to be excellent, with a high value of the intraclass correlation coefficient (.988), as well as the agreement, demonstrated by the low differences between the means of the test and retest, and the short limit of agreement, observed in the Altman-Bland and survival-agreement plots. Conclusion: The results of this study provide evidence that the Brazilian IKDC Subjective Knee Form has psychometric properties similar to the original version. In addition, it was a reliable evaluation instrument for patients with knee-related problems.

Static Knee Alignment Measurements among Caucasians and African Americans: The Johnston County Osteoarthritis Project

Objective. To determine if knee alignment measures differ between African Americans and Caucasians without radiographic knee osteoarthritis (rOA). Methods. A single knee was randomly selected from 175 participants in the Johnston County Osteoarthritis Project without rOA in either knee. Anatomic axis, condylar, tibia] plateau, and condylar plateau angles were measured by I radiologist; means were compared and adjusted for age and body mass index (BMI). Results. There were no significant differences in knee alignment measurements between Caucasians and African Americans among men or women. Conclusion. Observed differences in knee rOA occurrence between African Americans and Caucasians are not explained by differences in static knee alignment. (First Release July 15 2009; J Rheumatol 2009;36:1987-90; doi: 10.3899/jrheum.081294)

USE OF ANTIBIOTIC SPACERS FOR KNEE ENDOPROSTHESIS INFECTIONS TREATMENT

Objective: The aim of this study is to evaluate the use of cement spacers impregnated with antibiotics for the treatment of infections in the nonconventional endoprostheses of the knee. Methodology: We have treated seven patients since 2004 (of which six were submitted to surgery in our service and one patient had been submitted to a primary tumor surgery in another removal service) with deep infection in knee tumor prosthesis. All patients were submitted to endoprosthesis removal and reconstructed with antibiotic cement spacer All patients were monitored both clinically and by lab tests as for monitoring the evolution, being considered able for reviews after 6 (six) months without infections signs. Results: We have noted a small predominance of infectious processes on the prosthesis inserted on proximal tibia as compared with distal femur (57.1% x 42.9%). The mean follow-up time of patients was 68.2 months. During the follow up, one patient died as a result of the root disease. Six patients out of seven were regarded as cured and one persisted with infection signs and symptoms. Conclusion: The results obtained up to date have motivated us to continue using this method of treatment.

ISOKINETIC EVALUATION OF PATIENTS SUBMITTED TO TOTAL KNEE ARTHROPLASTY

Objective: In total knee arthroplasty, the minimally-invasive approach has been claimed to enable earlier rehabilitation because it spares the femoral quadriceps muscle. To check the influence of preserving the extensor apparatus during surgery, the strength of knee extension and flexion muscles was evaluated in patients submitted to total knee arthroplasty with different approaches. Materials and Methods: The values of maximum torque and total work obtained by isokinetic dynamometry six months after surgery were compared for the Minimally invasive surgery group constituted of 12 individuals submitted to total knee arthroplasty by the minimally invasive surgical approach and the Control group, constituted of eight patients submitted to total knee arthroplasty by the transquadricipital approach, between January 2005 and July 2006. Results: Statistical analysis of the absolute values for maximum torque and total work adjusted for body weights did not show differences between both groups. Conclusion: There was no difference in the extension and flexion strength of the knee muscles six months after surgery.

Analysis of patellar stabilizers muscles and patellar kinematics in anterior knee pain subjects

Patella stabilizer muscle response and patellar kinematics were evaluated in 19 women with anterior knee pain (AKP) and 20 healthy women during maximum voluntary isometric contraction (MVIC) with the knee positioned at 15 degrees, 30 degrees and 45 degrees flexion during open (OKC) and closed (CKC) kinetic chain exercises. Patellar kinematics was evaluated through patellar tilt and displacement, and the electrical activity of patellar stabilizers through the root mean square normalized during MVIC and OKC with the knee at 90 degrees flexion. Data revealed that the vastus medialis oblique muscle (VMO) was more active in the control group compared to the AKP group during OKC exercises with the knee at 45 degrees flexion. However, no difference in the patellar kinematics was observed between these groups; nevertheless, the correlation between these parameters also showed, with the knee at 45 degrees flexion, that lateral patellar tilt increase was associated with a reduction in the activity of lateral patellar stabilizers in the control group and with an increase in the VMO activity in the AKP group. In conclusion, electrical activity is an important factor in evaluating AKP and in AKP treatment evolution. (C) 2010 Elsevier Ltd. All rights reserved.