Für die Versorgung intraligamentärer vorderer Kreuzbandrupturen wurde bei Patienten im Wachstumsalter, aufgrund der Sorge vor dauerhaften Wachstumsstörungen durch eine Schädigung der Wachstumsfugen, eine Vielzahl verschiedener operativer Techniken entwickelt. Noch hat sich keines der praktizierten Therapieverfahren eindeutig etablieren können. In dieser Arbeit wurden verschiedene aktuell angewandte Operationsverfahren hinsichtlich ihrer klinischen Ergebnisse und Risiken bei Patienten bis zu einem Alter von zwölf Jahren und vergleichend für alle Patienten im Wachstumsalter, untersucht. Hierfür wurden zum einen in einer retrospektiven nationalen Multicenterstudie Patienten im Alter von bis zu zwölf Jahren, die mit einer vorderen Kreuzbandoperation versorgt worden waren, nachuntersucht. Zum anderen wurden im Rahmen einer systematischen Literaturanalyse die Literaturdatenbanken Medline und Embase, die Cochrane Library sowie die Springer- und die Thieme-Verlagsdatenbank durchsucht und operative Versorgungen von Patienten im Wachstumsalter mit einer vorderen Kreuzbandruptur erfasst. In den zehn Kliniken, die in die Multicenterstudie eingeschlossen waren, wurden 25 Patienten nachuntersucht. In der systematischen Literaturanalyse wurden insgesamt 59 Artikel mit 860 operativen Versorgungen von Patienten im Wachstumsalter erfasst. Die Kreuzbandnaht zeigte insgesamt schlechtere klinische Ergebnisse als die Kreuzbandersatzplastik. Fugenkreuzende und fugenschonende Operationstechniken führten zu ähnlich guten klinischen Ergebnissen. Die Rate an Beinlängendifferenzen oder Achsenabweichungen war jedoch bei den fugenschonenden Techniken deutlich höher. Zwischen den verwendeten Transplantaten (Patellasehne, Hamstring, Quadrizepssehne, Fascia lata und Allograft) und auch zwischen gelenknaher und gelenkferner Transplantatfixierung wurden keine wesentlichen Unterschiede in den Ergebnissen festgestellt. Hinsichtlich der Technik zur Bohrung des femoralen Knochenkanals war der anteromediale Zugangsweg nicht mit einer höheren Rate an Beinlängendifferenzen oder Achsenabweichungen assoziiert als der transtibiale Zugang. Insgesamt lassen sich für Patienten im Alter von bis zu zwölf Jahren mit einer Kreuzbandplastik gute bis sehr gute klinische Ergebnisse erzielen. Die Gefahr mit der Operation eine irreversible Beinlängendifferenz oder Achsenabweichung zu verursachen ist jedoch beachtlich und bei Patienten bis zu zwölf Jahren vermutlich größer als bei älteren Patienten, die sich kurz vor Abschluss ihres Wachstums befinden.

Parmi les blessures sportives reliées au genou, 20 % impliquent le ligament croisé antérieur (LCA). Le LCA étant le principal stabilisateur du genou, une lésion à cette structure engendre une importante instabilité articulaire influençant considérablement la fonction du genou. L’évaluation clinique actuelle des patients ayant une atteinte au LCA présente malheureusement des limitations importantes à la fois dans l’investigation de l’impact de la blessure et dans le processus diagnostic. Une évaluation biomécanique tridimensionnelle (3D) du genou pourrait s’avérer une avenue innovante afin de pallier à ces limitations. L’objectif général de la thèse est de démontrer la valeur ajoutée du domaine biomécanique dans (1) l’investigation de l’impact de la blessure sur la fonction articulaire du genou et dans (2) l’aide au diagnostic. Pour répondre aux objectifs de recherche un groupe de 29 patients ayant une rupture du LCA (ACLD) et un groupe contrôle de 15 participants sains ont pris part à une évaluation biomécanique 3D du genou lors de tâches de marche sur tapis roulant. L’évaluation des patrons biomécaniques 3D du genou a permis de démontrer que les patients ACLD adoptent un mécanisme compensatoire que nous avons intitulé pivot-shift avoidance gait. Cette adaptation biomécanique a pour objectif d’éviter de positionner le genou dans une condition susceptible de provoquer une instabilité antérolatérale du genou lors de la marche. Par la suite, une méthode de classification a été développée afin d’associer de manière automatique et objective des patrons biomécaniques 3D du genou soit au groupe ACLD ou au groupe contrôle. Pour cela, des paramètres ont été extraits des patrons biomécaniques en utilisant une décomposition en ondelettes et ont ensuite été classifiés par la méthode du plus proche voisin. Notre méthode de classification a obtenu un excellent niveau précision, de sensibilité et de spécificité atteignant respectivement 88%, 90% et 87%. Cette méthode a donc le potentiel de servir d’outil d’aide à la décision clinique. La présente thèse a démontré l’apport considérable d’une évaluation biomécanique 3D du genou dans la prise en charge orthopédique de patients présentant une rupture du LCA; plus spécifiquement dans l’investigation de l’impact de la blessure et dans l’aide au diagnostic. / The anterior cruciate ligament (ACL) is involved in approximately 20% of all sports-related knee injuries. An injury to the ACL, the primary stabilizer of the knee, will lead to knee joint instability and functional impairment. Unfortunately, current clinical assessments of ACL-deficient patients present limitations with respect to the investigation of the impact of the injury on knee function. A 3D knee biomechanical assessment could provide innovative information to overcome these drawbacks. The main objective of the doctoral theses is to demonstrate the role of biomechanics in (1) the investigation of the impact of the injury on knee function and in (2) the diagnostic process. Twenty-nine ACL-deficient patients and a control group of fifteen healthy participants took part in a 3D knee biomechanical assessment during treadmill walking. By assessing the 3D knee biomechanical patterns of each group we observed that ACL-deficient patients adopted a gait compensatory mechanism: the Pivot-shift avoidance gait. The explanation for this adaptative strategy is to avoid placing the knee in a position biomechanically favorable to anterolateral rotatory instability during gait. Furthermore, an automatic classification method capable of distinguishing ACL deficient patients from an asymptomatic population was developed. Features were extracted from the 3D knee biomechanical patterns using a wavelet decomposition method and then classified by the nearest neighbour rule. The proposed classification method obtained a level of accuracy, sensitivity and specificity of 88%, 90% and 87% respectively. This method shows great potential as a diagnostic aid in a clinical setting. This thesis demonstrates that biomechanics plays a substantial role in the management of ACL injuries by improving the understanding of the impact of the injury on knee function and by its capacity to serve as a diagnostic aid.

La luxation du genou, bien que très rare, demeure une blessure dévastatrice car elle entraîne de multiples complications en raison de la nature complexe du traumatisme associé à cette lésion. La luxation peut résulter d'un traumatisme à haute ou basse énergie. Les blessures sévères aux ligaments et aux structures associées donnent à la luxation du genou un potentiel élevé d'atteinte fonctionnelle. Le traitement conservateur, qui était considéré comme acceptable auparavant, est maintenant réservé à un très faible pourcentage de patients. La reconstruction chirurgicale est maintenant préconisée dans la plupart des cas, mais de nombreuses options existent et le traitement chirurgical optimal à préconiser reste controversé. Certains chirurgiens recommandent la reconstruction complète de tous les ligaments endommagés le plus tôt possible, tandis que d'autres, craignant l’établissement d’arthrofibrose, limitent l'intervention chirurgicale immédiate à la reconstruction du ligament croisé postérieur et de l'angle postéro-externe. En raison des multiples structures endommagées lors d’une luxation du genou, les chirurgiens utilisent couramment la combinaison des autogreffes et des allogreffes pour compléter la reconstruction ligamentaire. Les complications associées au prélèvement de la greffe, l'allongement de la greffe, l’affaiblissement précoce du greffon ainsi que les risques de transmission de maladies ont poussé les chirurgiens à rechercher différentes options d’intervention. L'utilisation de matériaux synthétiques pour le remplacement du ligament lésé a été proposée dans les années ´80. Après une première vague d'enthousiasme, les résultats décevants à long terme et les taux élevés d'échec ont diminué sa popularité. Depuis lors, une nouvelle génération de ligaments artificiels a vu le jour et parmi eux, le Ligament Advanced Reinforced System (LARS) a montré des résultats prometteurs. Il a été utilisé récemment dans les reconstructions isolées du ligament croisé antérieur et du ligament croisé postérieur pour lesquelles il a montré de bons résultats à court et moyen termes. Le but de cette étude rétrospective était d'évaluer la fonction et la stabilité du genou après la luxation aiguë suivant la reconstruction des ligaments croisés avec le ligament artificiel de type LARS. Cette étude a évalué 71 patients présentant une luxation du genou et qui ont subi une chirurgie de reconstruction du ligament croisé antérieur et du ligament croisé postérieur à l'aide du ligament LARS. Suite à la chirurgie le même protocole intensif de réadaptation a été suivi pour tous les patients, où la mise en charge progressive était permise après une période d’environ 6 semaines pendant laquelle la force musculaire et la stabilité dynamique se rétablissaient. Les outils d’évaluation utilisés étaient le score Lysholm, le formulaire de «l’International Knee Documentation Committee», le «Short Form-36», les tests cliniques de stabilité du genou, l'amplitude de mouvement articulaire à l’aide d’un goniomètre et la radiographie en stress Telos à 30° et 90° de flexion du genou. Le même protocole d’évaluation a été appliqué au genou controlatéral pour des fins de comparaison. Les résultats subjectifs et objectifs de cette étude sont satisfaisants et suggèrent que la réparation et la reconstruction combinées avec ligaments LARS est une alternative valable pour le traitement des luxations aiguës du genou. Ces résultats démontrent que ces interventions produisent des effets durables en termes d’amélioration de la fonction et révèlent la durabilité à long terme des ligaments artificiels LARS. Les patients sont à la fois plus autonomes et plus satisfaits avec le temps, même si la luxation du genou est considérée comme une catastrophe au moment où elle se produit. Des études prospectives randomisées sont maintenant nécessaires afin de comparer la sélection de la greffe et le délai de reconstruction chirurgicale. / Knee dislocation, although very rare, remains a devastating injury with many complications because of the complex nature of this trauma. This uncommon injury can result from either a high or low energy trauma. The severe damage to the knee’s ligaments and associated structures render this injury at high potential for functional impairment. Non operative treatment which was once deemed acceptable, is now reserved for very low demand patients. Surgical reconstruction is now the standard of care for most patients, however many options exist but the optimal surgical treatment remains controversial. Some surgeons advocate early complete reconstruction of all damaged ligaments, whereas others who fear arthrofibrosis, limit the immediate surgery to reconstruction of the posterior cruciate ligament and the posterolateral corner. Because of the multiple structures damaged by knee dislocations, surgeons have been successfully using combinations of autografts and allografts for complete knee ligament reconstruction. Complications associated with graft harvesting, graft elongation and early weakness as well as risks for disease transmission has pushed surgeons to look for different options. The use of synthetic material for ligament replacement was proposed in the 1980’s. After an initial wave of enthusiasm, poor long term results and high rates of failure diminished its popularity. Since then, a new generation of artificial ligaments has emerged, the Ligament Advanced Reinforced System (LARS) has shown promising results. It recently has been used in isolated anterior cruciate ligament and posterior cruciate ligament reconstruction and has shown good short to medium term results. The purpose of this retrospective study was to evaluate the knee function and stability after acute knee dislocation reconstructed with LARS artificial ligaments. This study assessed the results of 71 patients with knee dislocations who underwent acute combined repair and reconstruction of anterior cruciate ligament and posterior cruciate ligament using LARS artificial ligaments. After the surgery all patients followed the same intensive rehabilitation protocol. Progressive weight bearing was permitted over 6 weeks as muscle strength and dynamic stability were regained. The outcome measures used were the Lysholm score, the International Knee Documentation Committee form, the Short Form-36, clinical knee stability testing, a goniometer to mesure the range of motion and Telos stress radiography at 30° and 90° of knee flexion. The non-operated knee of the patient was used as a baseline for the operated knee. The subjective and objective findings from this study are satisfactory and suggest that acute combined repair and reconstruction with LARS ligaments is a valid alternative for treating acute knee dislocations. These findings demonstrate sustained results in terms of function and revealed durability of LARS artificial ligaments at long-term. Patients seem to get more autonomous and satisfied with time even though acute knee dislocation is seen as a catastrophe when it happens. Randomised, prospective trials are now needed to compare graft selection and timing of the surgical reconstruction.

Musculoskeletal injuries are commonly associated with muscle atrophy as a function of immobilization or change of normal function. For example, injuries to the anterior cruciate ligament (ACL) which may involve ligament reconstruction, results in the "quadriceps avoidance" gait which leads to atrophy of the knee extensormuscles. In these situations it is not clear whether or not the atrophy is associated with loss of specific muscle fibre types with accompanying functional deficits. Such knowledge would be helpful in implementing exercise regimes designed to compensate for loss of particular fibre types. It is believed that isokinetic exercise performed at speeds below 180° per second strengthens type I muscle fibres, and type II fibres at fast speeds. However, there is no evidence to indicate the specific muscle fibre response to different rates of muscle contraction. Identification of muscle fibre type is most directly determined by biopsy technique but is too invasive for a routine measurement. Electromyography median frequency has been used as a non-invasive measure to infer muscle fibre composition in various studies. However, the reliability and accuracy of this technique has been questioned and improvement is necessary. This research was designed to provide a more accurate and reliable protocol for the determination of EMG median frequency which may be used, after validation against more direct biopsy techniques, as a routine method for inferring muscle fibre composition. The investigation also explored the muscular response as measured by EMG median frequency to varying speeds of muscle contraction, fatiguing exercise and atrophy following ACL reconstruction. The ultimate aim of this research was to improve the reliability of the determination of EMG median frequency to enhance its application as a predictor of muscle fibre composition. This provides information which may improve ACL rehabilitation programs designed to restore and prevent specific muscle fibre types loss that have not previously been targeted by current rehabilitation programs. This research was conducted in three studies. Study one determined the stability of the EMG median frequency bilaterally for the quadriceps and hamstrings muscles and identified the mode of contraction associated with the greatest reliability. The strength and EMG median frequency of the vastus lateralis, medial hamstrings and vastus medialis of 55 subjects was determined across 5 speeds from 0° to 240° per second using a Kin-Com isokinetic dynamometer and an EMG data acquisition system. Isometric contraction was found to have the least bilateral discrepancy (4.01% ±3.06) and between trials standard deviation (4.50) in the vastus lateralis, medial hamstrings and vastus medialis. Study two investigated the EMG median frequency changes in the vastus lateralis which occur immediately following different speeds of isokinetic exercise to the point of fatigue in normal subjects. Thirty-four subjects participated in the study, and performed a 90-second period of isokinetic exercise to activate the knee extensors at either 30° or 300° per second. EMG median frequency of the vastus lateralis was determined before, immediately after and 7 minutes after the fatiguing exercise. The percentage drop in EMG median frequency of the vastus medialis was gnificantly (p<0.05) greater after slow speed (27.9%) than fast speed (20.25%) exercise, while no significant difference was found for the percentage drop in extension torque. Full recovery was found 7 minutes after the fatiguing exercise. By reference to previous research showing a relationship between EMG median frequency and muscle fibre type, an increase in activation of type I muscle fibres with slow speed exercise and an increase in type II muscle fibres with fast speed exercise was observed. Study three identified the changes in EMG median frequency following ACL reconstruction and evaluated the bilateral differences in EMG median frequency of the knee muscles. The relationships between EMG median frequency and the measures of knee functional ability, knee muscle strength, age and time since surgery were also investigated. Twelve subjects who had undergone ACL reconstruction using a semitendinosus and gracilis graft 6 to 12 months earlier, participated in the study. EMG median frequency was determined from an 8-second isometric contraction and knee functional ability was assessed using the Cincinnati Rating Scale. Bilateral EMG median frequency shifts were inconsistent among subjects. On the basis of previous research which indicated a relationship between EMG median frequency and fibre type, no consistent pattern of muscular fibre type atrophy subsequent to ACL reconstruction occurred within 6 to 12 months (ranged from -43 to 57 Hz). Additionally, no significant correlations were found between the EMG median frequency and the knee functional score and knee extension and flexion torques, age, time since operation and the bilateral differences in EMG median frequency. The results of this investigation will serve to improve the reliability of EMG median frequency across a range of conditions in which it has been evaluated. Further research is needed to confirm the relationship between EMG median frequency and direct observations of muscle fibre composition to improve the predictive value of this measure. Following this validation it will be possible to evaluate the bilateral EMG median frequency shift to infer the type of muscle fibre atrophy, and use this measure in determining the efficacy of specific rehabilitation programs. In conclusion * An 8-second isometric contraction is recommended for determining EMG median frequency. * EMG median frequency of a muscle decreases significantly more after slow fatiguing exercise than after fast speed fatiguing exercise. * There was no generalised bilateral EMG median frequency shift found in a group of subjects 6 to 12 months following semitendinosus and gracilis graft ACL reconstruction. * The results of this study will serve to improve the reliability of procedures used to determine EMG median frequency under a range of different contractile conditions. The EMG median frequency changes in response to these conditions require further validations with muscle biopsy in future.

Made available in DSpace on 2016-06-02T20:18:16Z (GMT). No. of bitstreams: 1 4184.pdf: 13787055 bytes, checksum: 434e5f6a43d2ae2b1233af9adab7c137 (MD5) Previous issue date: 2012-02-23 / Financiadora de Estudos e Projetos / The aim of Study 1 was to evaluate the effects of using oral contraceptives (OC) on the hip and knee kinematics of healthy women during single-leg squat. Forty two volunteers were divided into two groups: women who had used OC (n= 21) and women who did not use OC (n= 21). The knee abduction/adduction, hip abduction/adduction and medial/lateral rotation excursions (maximum and at 75º of knee flexion) were calculated for the dominant limb during single-leg squat. No significant difference was verified between the groups regarding the maximum excursion of knee abduction (p= 0.26) or hip adduction (p= 0.10) and medial rotation (p= 0.94). When considering the knee flexion at 75º, no significant difference was verified between the groups regarding the excursion of knee abduction (p= 0.31) or hip adduction (p= 0.11) and medial rotation (p= 0.85). These results suggest that the use of OC does not influence the hip and knee kinematics during single-leg squat. As a complement, the aim of Study 2 was to evaluate the effects of using OC on the hip and knee kinematics of healthy women during anterior stair descent. Forty volunteers were divided into two groups: women who had used OC (n= 20) and 2 - women who did not use OC (n= 20). The knee abduction/adduction, hip abduction/adduction and medial/lateral rotation excursions were calculated for the dominant (supporting) limb during anterior stair descent. No significant difference was verified between the groups regarding the maximum excursion of knee abduction (p= 0.58) or hip adduction (p= 0.29) and medial rotation (p= 0.42). When considering the knee flexion at 50º, no significant difference was verified between the groups regarding the excursion of knee abduction (p= 0.92) or hip adduction (p= 0.50) and medial/lateral rotation (p= 0.19). These results suggest that the use of OC does not influence the hip and knee kinematics during anterior stair descent. The aim of Study 3 was to verify the effects of eight-week plyometric training (PT) on hip and knee kinematics and on eccentric hip and knee torques, as well as on lower limb functional performance in healthy women. Thirty-six females were divided into a training group (TG; n= 18), and a control group (CG; n= 18). Kinematic analyses of the hip and knee was carried out during the single-leg squat and the functional performance was evaluated by way of the triple hop (TH) test and the six-meter timed hop (STH) test. The eccentric hip abductor, adductor, lateral rotator and medial rotator as well as the knee flexor and extensor torques/body weight were measured using an isokinetic dynamometer. After 8 weeks, the TG showed a decrease in maximum excursion to knee abduction (p= 0.009) and in maximum excursion to hip adduction (p<0.001), as well as in the excursion to hip adduction at 75º of knee flexion (p=0.002). Moreover, the TG significantly increased the values obtained in the TH test (p=0.05) and significantly decreased those obtained in the STH test (p<0.001) after intervention. However, there was no significant change on hip and knee eccentric torques. Thus, eight weeks of PT were effective to improve hip and knee kinematics and functional performance of women in hop tests. However this was apparently not an effective method to promote strengthening of the hip and knee muscles when used alone / O objetivo do Estudo 1 foi avaliar o efeito do uso dos contraceptivos orais (CO) na cinemática do quadril e do joelho durante o agachamento unipodal em mulheres sadias. Quarenta e duas voluntárias foram divididas em dois grupos: que utilizavam (n=21) ou não (n=21) os CO. As excursões (máximas e no ângulo de 75º de flexão do joelho) em abdução/adução do joelho, em abdução/adução do quadril e em rotação medial/lateral do quadril foram verificadas durante a realização do agachamento unipodal com o membro inferior dominante. Não houve diferença significativa entre os grupos quanto à máxima excursão em abdução do joelho (p=0,26) e em adução (p=0,10) e rotação medial (p=0,94) do quadril. Quando considerado o ângulo de 75º de flexão do joelho, nenhuma diferença significativa foi verificada entre os grupos para os valores de excursão em abdução do joelho (p=0,31) e em adução (p=0,11) e rotação medial (p=0,85) do quadril. Estes achados sugerem que o uso de CO não influencia a cinemática do joelho e do quadril durante a realização do agachamento unipodal. De forma complementar, o Estudo 2 teve por objetivo avaliar os efeitos do uso de CO na cinemática do quadril e do joelho de mulheres sadias durante a descida anterior de degraus. Quarenta voluntárias foram divididas em dois grupos: que utilizavam (n=20) ou não (n=20) os CO. As excursões em abdução/adução do joelho, abdução/adução do quadril e rotação medial/lateral do quadril foram calculadas para o membro dominante durante a descida anterior de degraus. Nenhuma diferença significativa foi verificada entre os grupos para a excursão máxima em abdução do joelho (p=0,58) ou em adução (p=0,29) e rotação medial (p=0,42) do quadril. Quando considerado o ângulo de flexão do joelho de 50º, nenhuma diferença foi verificada entre os grupos para a excursão em abdução do joelho (p=0,92) ou em adução (p=0,50) e rotação medial/lateral (p=0,19) do quadril. Estes resultados sugerem que o uso de CO não influencia a cinemática do quadril e do joelho durante a descida anterior de degraus. A proposta do Estudo 3 foi verificar os efeitos do treinamento pliométrico (TP) de 8 semanas na cinemática e no torque excêntrico do quadril e do joelho, bem como sobre o desempenho funcional do membro inferior de mulheres sadias. Trinta e seis mulheres foram divididas em dois grupos: 1) grupo treinamento (GT; n=18) e 2) grupo controle (GC; n=18). A análise cinemática do quadril e do joelho foi realizada durante o agachamento unipodal e o desempenho funcional foi avaliado por meio do salto triplo unipodal (STU) e pelo salto unipodal em 6 metros cronometrado (SUC). A relação torque excêntrico abdutor, adutor, rotador lateral e rotador medial do quadril/massa corporal e o torque excêntrico flexor e extensor do joelho/massa corporal foram mensurados por meio de um dinamômetro isocinético. Após 8 semanas, o GT apresentou diminuição da excursão máxima em abdução do joelho (p=0,009) e em adução do quadril (p<0,001), bem como da excursão em adução do quadril a 75º de flexão do joelho (p=0,002). Além disso, o GT apresentou melhora no desempenho funcional para o STU (p=0,05) e para o SUC (p<0,001). Entretanto, não houve modificação significativa nos torques excêntricos do quadril e do joelho. Deste modo, o TP oito semanas foi eficiente para induzir alterações positivas de ordem cinemática e funcional nas mulheres avaliadas. Contudo, não apresentou eficiência para promover o fortalecimento dos músculos do quadril o joelho

Made available in DSpace on 2016-06-02T20:18:20Z (GMT). No. of bitstreams: 1 TeseJSB.pdf: 1248166 bytes, checksum: 2327b08724c3471ad628a8f9fb5ff44d (MD5) Previous issue date: 2004-12-10 / Financiadora de Estudos e Projetos / The anterior cruciate ligament (ACL) is the most commonly injured ligament in the knee and its rupture results in pain, instability, muscle atrophy and weakness. The quadriceps femoris muscle dysfunction is common before and after ACL reconstruction and can persist over years. A detailed understanding of neuromuscular function after ACL reconstruction is critical to the development of optimal rehabilitation strategies. The purpose of this study was to investigate the contributions of functional and morphological factors, in the muscle recovery, after ACL reconstruction. The effects of two therapeutic methods, usually utilized to recover muscle strength were also evaluated: Neuromuscular Electrical Stimulation (NMES) and eccentric exercise. Eight subjects (age = 31.3 ± 5.8 years) who had undergone ACL ligament reconstruction (mean 9.4 ± 0.7 months after the surgery) were randomly assigned to either an eccentric exercise associated with NMES (russian current) or only an eccentric exercise group. Only the involved limb was trained 2 days a week, for 12 weeks. The uninvolved one was also evaluated as reference. The quadriceps muscle function was evaluated by the measurement of the knee extensor torque during isometric and eccentric isokinetic contractions (30 and 120º/s) and by surface electromyography (EMG) of the Vastus Medialis Obliquos (VMO), Vastus Lateralis (VL) and Rectus Femoris (RF) muscles. The quadriceps cross-sectional area (CSA) was measured in six regions using Nuclear Magnetic Resonance Imaging (MRI-I). The initial evaluation showed significant extensor torque deficit both in isometric and eccentric conditions of the involved limb, compared to the contralateral one. There was significant muscle atrophy along the quadriceps extension, mainly in the distal thigh region. The EMG activity was lower for the VMO in all tested situations. NMES did not interfere in the gain of muscular strength, in any of the evaluated functions. The eccentric training increased significantly the isometric (from 198 ± 37 to 228 ± 48 Nm, p<0.05) and eccentric torque at 30 and 120º/s (from 227 ± 56 to 291 ± 65, p< 0.01 and from 199 ± 51 to 240 ± 63, p< 0.05, respectively). Quadriceps cross-sectional area also increased at all the evaluated regions for the involved limb, and the highest hypertrophy was at the thigh proximal region (from 169 ± 27 to 189 ± 25,8 cm2, p< 0.01 ), when compared to the distal region (form 31,5 ± 5,9 to 35,1 ± 6,1 cm2, p< 0.01). The EMG activity of VMO was recovered after the first six weeks of eccentric training. In the same period, the increased extensor torque showed correlation with the increased quadriceps cross-sectional area (r=0,81) and with the recovery of motor unit activation (r=0.69). After twelve weeks of training, there was correlation only between increased torque and cross-sectional area (r=0.78). In conclusion: 1) eccentric training showed to be a potent resource in the recovery of both morphological and functional factors of quadriceps, after ACL reconstruction; 2) NEMS did not interfere in the rehabilitation of these individuals. / O Ligamento Cruzado Anterior (LCA) é o mais freqüentemente ligamento lesado do joelho e a sua ruptura resulta em dor, instabilidade, atrofia e fraqueza muscular. A disfunção do músculo quadríceps é comum antes e após a reconstrução do LCA, podendo persistir por anos. Um detalhado conhecimento da função neuromuscular após reconstrução do LCA é crítico para a otimização das estratégias de reabilitação. O propósito deste estudo foi avaliar as contribuições dos fatores funcionais e morfológicos na recuperação da força muscular, após reconstrução do LCA. Os efeitos de dois métodos terapêuticos usualmente utilizados na reabilitação também foram avaliados: a Estimulação Elétrica Neuromuscular (EENM) e o exercício excêntrico. Oito indivíduos (31.3 ± 5.8 anos) os quais foram submetidos a reconstrução do LCA (média de 9.4 ± 0.7 meses de pós-operatório) foram aleatoriamente designados para o grupo exercício excêntrico com EENM (utilizando a corrente russa) ou apenas exercício excêntrico. Apenas o membro envolvido foi treinado, 2 vezes por semana, durante 12 semanas. O membro não envolvido foi avaliado como referência. A função do músculo quadríceps foi avaliada por medidas do torque extensor do joelho durante contrações isométricas e isocinéticas excêntricas (30 e 120º/s) e por meio da eletromiografia (EMG) de superfície dos músculos Vasto Medial Oblíquo (VMO), Vasto Lateral (VL) e Reto Femoral. A Área de Secção Transversa (AST) do quadríceps foi mensurada em seis regiões, por meio de imagens de Ressonância Nuclear Magnética (RNM). A avaliação inicial demonstrou significativo déficit no torque extensor do membro acometido, quando comparado ao não acometido, tanto nas avaliações isométricas como nas excêntricas. Houve significativa atrofia muscular ao longo do quadríceps, sobretudo na região distal. A atividade EMG mostrou-se reduzida no VMO, em todas as situações avaliadas. A EENM não interferiu no ganho de força muscular, em nenhuma das funções mensuradas. O treinamento excêntrico aumentou significativamente o torque isométrico (de 198 ± 37 para 228 ± 48 Nm, p<0.05) e excêntrico em 30 e 120º/s (de 227 ± 56 para 291 ± 65, p< 0.01 e de 199 ± 51 para 240 ± 63, p< 0.05, respectivamente). A área de secção transversa também aumentou em todas as regiões avaliadas do membro acometido, sendo que a maior hipertrofia ocorreu na região proximal da coxa (de 169 ± 27 para 189 ± 25,8 cm2, p< 0.01), quando comparada a região distal (de 31,5 ± 5,9 para 35,1 ± 6,1 cm2, p< 0.01). A atividade EMG do VMO foi recuperada após as primeiras seis semanas de treinamento excêntrico. No mesmo período, o aumento no torque extensor demonstrou correlação direta com o aumento na área de secção transversa (r=0.81) e com a recuperação na ativação das unidades motoras (r=0.69). Após doze semanas de treinamento, houve correlação apenas entre o aumento do torque e a área de secção transversa (r=0.78). Em conclusão: 1) o treinamento excêntrico mostrou-se um potente recurso tanto na recuperação dos fatores morfológicos como funcionais do músculo quadríceps, após reconstrução do LCA; 2) a EENM não interferiu na reabilitação desses indivíduos.

O autor estudou as propriedades biomecânicas dos tendões dos músculos tibial anterior e tibial posterior congelados a -20°C e a -86°C extraídos de cadáveres humanos frescos. Foram realizados ensaios mecânicos de tração até a ruptura e determinadas as seguintes propriedades: resistência máxima, coeficiente de rigidez, módulo de elasticidade e alongamento máximo relativo. Os dados obtidos foram comparados aos existentes na literatura relativos ao ligamento cruzado anterior, ligamento da patela e aos tendões dos músculos grácil e semitendíneo / The author studied the mechanical properties of the anterior and posterior tibialis muscle tendons frozen at -20°C and -86°C obtained from fresh-frozen human cadavers. The tendons were submitted to axial traction until failure and the following properties were determined: ultimate load, stiffness, modulus of elasticity and relative strain. Data obtained were compared to those from the literature related to the anterior cruciate ligament, patellar tendon, gracilis and semitendinous tendons

The aim of this diploma thesis was to summarize the topic of the anterior cruciate ligament (LCA) injury dependency on the menstrual cycle phase of young women with regular sport activity. The general part describes basic knowledge about connective tissue, LCA, issues of LCA injury and related risk situations. Large chapter is dedicated to sex hormones and menstrual and ovarian cycle, which is crucial for understanding the whole topic. The main part is focused on impact of sex hormones and hormonal contraception on connective tissue, but also on muscle and nervous tissues, which might be as well important for LCA injury incidence. Next part of the thesis consists of a questionnaire survey. 52 respondents aged 15-35 with rupture or partial rupture of LCA answered the non-standardized questionnaire compiled specially for this thesis and the results were statistically processed. 14 respondents were using hormonal contraception, remaining 38 had physiological menstrual cycle. Based on the theoretical findings we expected highest incidence of LCA injuries among women without contraception in phases of menstrual cycle with highest levels of oestrogen (10th -15th day). That was confirmed (P-value: 0,0218) as well as overall lower incidence among women using contraception (P-value: 0,0006). Expected higher...

OBJETIVO: Avaliar o padrão de degeneração histológica do ligamento cruzado posterior (LCP) em pacientes com artrose submetidos à artroplastia total de joelho com prótese com substituição do ligamento cruzado posterior (LCP). A degeneração histológica foi classificada em leve, moderada e grave. Os achados histológicos foram correlacionados com dados clínicos, radiográficos e do transoperatório (presença ou ausência do ligamento cruzado anterior) com a finalidade de aferir se estes parâmetros seriam capazes de predizer o grau de degeneração histológica do LCP em pacientes com gonartrose. MÉTODOS: foram avaliados 89 ligamentos cruzados posterior de 85 pacientes com idade média de 69,79 anos, sendo 69 do sexo feminino, 16 do masculino. O LCP foi corado em hematoxilina-eosina e Tricrômio de Gomori e classificado quanto ao comprometimento histológico em leve, moderado e grave. A degeneração histológica foi correlacionada aos parâmetros idade, artrose radiográfica classificada por Ahlbäck (grau I ao V), eixo radiográfico tíbio-femoral (varo, neutro e valgo), e estado do ligamento cruzado anterior (LCA), presença ou ausência.Os achados histológicos de hipercelularidade, infiltração linfocitária crônica, proliferação vascular; presença de cistos; clones de condrócitos; degenerações colágena, fibrinóide, cartilaginosa ,gordurosa e mucoide foram correlacionados com o grau de degeneração do LCP e ao estado de conservação do LCA. RESULTADO: Não foram identificadas relações entre o grau de degeneração histológica do LCP e faixa etária (abaixo ou acima de 70 anos), sexo, classificação radiográfica de Ahlbäck e presença ou ausência do LCA. Os achados histológicos de degeneração fibrinóide, proliferação vascular e presença de cistos estiveram estatisticamente relacionados à degeneração histológica grave do LCP. CONCLUSÃO: Os parâmetros clínicos e radiográficos não foram capazes de predizer o grau de degeneração histológica do LCP .Os achados histológicos de degeneração fibrinóide, proliferação vascular e presença de cistos caracterizaram a degeneração histológica grave do LCP / OBJECTIVE: Evaluate the histologic degeneration pattern of the posterior cruciate ligament (PCL) in osteoarthrosis patients submitted to total knee replacement with a cruciate substituting prosthesis. The histologic degeneration was classified in mild, moderate and severe. The histologic pattern was related to clinical, per-operatory (presence or absence of anterior cruciate ligament) and radiographic parameters with the aim to settle if these parameters would be reliable to predict the PCL degeneration grade. METHODS: 89 PCLs from 85 patients, 16 men, 69 women, mean age 69, 79 years old. PCL was stained with hematoxylin and eosin and trichromium of Gomori. The PCL histologic degeneration was graded from normal-minimum to severe. The histologic PCL degeneration pattern was related to age, radiographic arthrosis classification (Ahlbäck - grades I to V), knee radiographic axis (varus, neutral, valgus) and to the ACL status (presence or absence).The histologic findings of hipercellularity, chronic lymphocit infiltration, neoangiogenesis, cysts, collagen degeneration (deg), fibrinoid deg, mucoid deg., cartilaginous, deg., fat deg. and condrocyte clones were related to the grade of PCL degeneration and to ACL status. RESULTS: There was no correlation of histologic degeneration to sex or age (above or below 70 years), arthrosis radiographic classification (Ahlbäck) and presence or absence of ACL. The histological findings of fibrinoid degeneration, vascular proliferation and cysts were statistically related to severe histologic LCP degeneration. CONCLUSION: The parameters studied were not capable of predicting the grade of LCP degeneration. The histological findings of fibrinoid degeneration, vascular proliferation and cysts were characteristic of severe PCL histologic degeneration

This study explored the impact of three psychological interventions over seven weeks - goal setting (GS), GS and imagery (IM), and GS and mindful self-compassion (MSC) - on 20 athletes' (Mage = 16.75 years) pain, cognitive appraisal, depression reinjury anxiety, psychological readiness to return to sport, and range of motion (ROM). IM and GS interventions have demonstrated initial effectiveness; however, no study has examined MSC in relation to post-ACL recovery. All athletes experienced significant decrease in pain (F(2) = 97.30, p = .000) from Week 1 to Week 7 and a significant increase in ROM from Week 2 to Week 7 (F(1) = 77.93, p = .000). All athletes experienced significantly higher depression at Week 1 compared to both Week 2 and Week 7 (F(2) = 9.01, p = .001), and significantly higher difficulty coping with their injury at Weeks 1 and 2 compared to Week 7 (F(2) = 6.32, p = .005). There were no statistically significant effects found between the intervention groups at Weeks 1, 2, and 7. However there were moderate effect sizes between interventions which suggest MSC and IM could help athletes cope with their injury during the first few weeks after surgery, and GS may contribute towards less depression at seven weeks post-surgery. Limitations include small sample size, low power, and use of self-report measures. Results have implications for orthopedic surgeons, physical therapists, and health professionals working with athletes recovering from serious sport injury.