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An intramedullary nail is a trauma treatment device used for fracture fixation of long bones. These devices are subject to failure, including lag screw cut-out and failure at the lag screw insertion hole from high stress concentrations in that region. Clinical developments for such devices are frequently based on a trial and error method, which often results in failure before improvement. However, the finite element method can be used for the development of trauma treatment devices, and their interaction with bone, by providing a large data set at a relatively low cost. Also, parameters can be changed to assess the relative benefits of one device to another. A novel finite element model has been developed that can be used for the analysis of intramedullary nails inserted into long bones. A commercially available finite element package, ANSYS, has been used to implement the modelling strategy. The finite element modelling technique has been applied to fractures of the proximal femur, but the model is generic, and can be developed to deal with any form of intramedullary device where contact between the bone and implant is important. The finite element strategy can be used in pre-clinical trials to test a new device, or for the design optimisation of existing devices. The finite element model consists of the device surrounded by a thin layer of bone, which forms a 'base' model component that is re-usable. This 'base' component can be mathematically connected to any long bone model, forming an integrated implant and bone construct. The construct can be used to assess which device is best suited to a particular fracture, for example. Contact elements have been used to allow stresses to develop as contact is achieved within the implant and bone construct. Pre-assignment of contact points is not required. Verification of the finite element model is achieved by comparison to available data from experiments carried out on constructs of bone and device that use intramedullary femoral nails. In this thesis the finite element model has been applied to two areas of proximal femoral nailing. The finite element model is used to analyse the distal end of a Gamma nail, and shows that analyses that do not consider contact may not lead to accurate predictions of stresses. The model has been developed for using configurations with one and two distal locking screws. The most distal locking screw is more critical under axial loading, and the more proximal screw is more important for bending loads. The use of 'softer' screws distributes the load more evenly between them. The finite element model has been used to investigate the mechanical environment of a fracture callus for a femoral neck fracture, and a subtrochanteric fracture. The use of one and two lag screws, fracture gap size and material properties of the nail have been investigated for a stiffening callus. Results show that the use of two lag screws for a neck fracture provides a more rigid support at the early stages of fracture healing, and minimises stress-shielding once the callus has healed. For subtrochanteric fractures there is a critical point at which the fracture callus is able to carry any load. A Titanium nail significantly reduces the peak stress at the lag screw insertion hole, and titanium lag screws share the load more evenly between them. Each two-lag-screw configuration used transfers a similar load into the fracture callus. A configuration using a larger lag screw above a smaller has a significantly higher stress at the upper lag screw insertion hole. Critically, the load shared between two lag screws changes as the fracture callus stiffens and an assessment should be made at different stages of fracture healing to optimise the use of a device.

As fraturas femorais sÃo consideradas um problema de saÃde pÃblica e sÃo responsÃveis por um alto Ãndice de morbidade e mortalidade pela ocorrÃncia de possÃveis complicaÃÃes. Ocorrem nÃo somente em pacientes jovens expostos a grandes traumas como tambÃm na populaÃÃo idosa. A maioria dos pacientes idosos possui determinadas afecÃÃes como, por exemplo, a osteoporose, que aumenta ainda mais o risco dessas fraturas, jà que a tendÃncia à que a idade mÃdia da populaÃÃo aumente, as consequÃncias da osteoporose aumentarÃo na mesma proporÃÃo. Estudos clÃnicos demonstraram que o uso dos bifosfonatos reduzem o risco da ocorrÃncia dessa fraturas em pacientes osteoporÃticos. O Ãcido zoledrÃnico pertence à classe dos bifosfonatos, sendo considerado atualmente o mais potente. Como a dose que esses pacientes utilizam à anual, hà um aumento da aderÃncia e da persistÃncia dos pacientes no tratamento, diminuindo, assim, o risco de fraturas. Este trabalho teve, como objetivo, verificar os efeitos do Ãcido zoledrÃnico no processo de consolidaÃÃo Ãssea nos fÃmures de ratos reduzidos com fio de Kirshner. Foram utilizados 36 ratos machos, adultos, da linhagem Wistar, com peso que variou de 250 a 300g. Todos os animais foram submetidos à cirurgia em que era realizada a fratura da diÃfise femoral com uma guilhotina romba. Os animais foram divididos em dois grupos: o grupo do Ãcido zoledrÃnico, que recebeu, via intraperitoneal, 0,1 mg/Kg do Ãcido e o grupo controle. Os animais foram sacrificados com 7, 14 e 28 dias de pÃs-operatÃrio. Houve duas mortes por causas desconhecidas. Foram realizados estudos radiogrÃficos com filme de mamÃgrafo para analisar a densidade Ãptica e a Ãrea do calo Ãsseo, medida em mm e estudo histolÃgico, utilizando amostras coradas com picrosirius red sob a luz polarizada do microscÃpio, para quantificar a formaÃÃo de colÃgeno tipo I e tipo III na regiÃo cortical prÃxima a fratura e no calo Ãsseo. Em relaÃÃo à densidade Ãptica, nÃo se observou nenhum resultado estatisticamente relevante em relaÃÃo ao uso do Ãcido zoledrÃnico. Ao se realizar uma anÃlise intergrupos, em relaÃÃo à Ãrea do calo Ãsseo, nÃo houve diferenÃa significante (p<0,05) nos tempos de consolidaÃÃo utilizados nessa pesquisa. Apesar do grupo zoledronato no tempo de 28 dias ter um resultado muito prÃximo em relaÃÃo ao nÃvel de significÃncia (p=0,0532). Jà na anÃlise intragrupos, observa-se um aumento considerado natural na Ãrea do calo Ãsseo. A percentagem de colÃgeno tipo III no calo Ãsseo e nas corticais nÃo revelou diferenÃa significativa tanto na anÃlise intragrupos como na anÃlise intergrupos. Em contrapartida, esse trabalho teve resultados significantes em relaÃÃo ao colÃgeno tipo I, havendo um aumento da percentagem do colÃgeno tipo I no calo Ãsseo no tempo de consolidaÃÃo de 28 dias (p=0,0098). Nas corticais do fÃmur prÃximas à fratura, esse aumento foi verificado nos trÃs tempos de consolidaÃÃo considerados nesta pesquisa. Concluindo que o Ãcido zoledrÃnico promoveu uma maior deposiÃÃo de colÃgeno tipo I, sugerindo aceleraÃÃo no processo de consolidaÃÃo Ãssea, sobretudo na fase final da reparaÃÃo. Em relaÃÃo à percentagem de colÃgeno tipo III (no calo Ãsseo e nas corticais prÃximas ao calo), a Ãrea do calo Ãsseo e a densidade Ãptica do calo Ãsseo, nÃo houve resultados estatisticamente significantes. / Femoral fractures are considered a public health problem and account for a high rate of morbidity and mortality by the occurrence of complications. They occur not only in young patients exposed to major trauma but in the elderly population as well. Most elderly patients have certain conditions, eg, osteoporosis, which further increase the risk of such fractures. Since the trend is that the average age of population increase, the consequences of osteoporosis will increase proportionately. Clinical studies have demonstrated that the use of bisphosphonates reduces the risk of occurrence of fractures in osteoporotic patients. Zoledronic acid belongs to the class of bisphosphonates, currently being considered the most potent. Because the dose that these patients use is an annual basis, there is an increased adherence and persistence of patients in treatment, thereby decreasing the risk of fractures. This study aimed to evaluate the effects of zoledronic acid on bone healing in femurs of rats with reduced Kirshner wire. We used 36 adult male rats, Wistar, weights ranged from 250 to 300g. All animals underwent surgery that was performed on the fracture of the femoral shaft with a blunt guillotine. The animals were divided into two groups: the group of zoledronic acid, which received intraperitoneally 0.1 mg / kg of the acid and the control group. The animals were sacrificed 7, 14 and 28 days postoperatively. There were two deaths from unknown causes. We performed a radiographic study with film mammography to analyze the optical density and area of callus, measured in mm  and histological study, using samples stained with picrosirius red under dense microscopic light to quantify the formation of collagen type I and type III in the cortical region near the fracture and callus. No significant statistical results regarding the optical density were observed with the use of the zoledronic acid. When conducting a comparative inter-group analyses, the callus area showed no significant differences (p <0.05) in a time of consolidation (7, 14 and 28 days) used in this study. Despite the zoledronate group in 28 days time to have a result very close to the level of significance (p <0.05). In the intragroup analysis there is considerable increase in the natural area of the callus. The percentage of type III collagen in the cortical and callus did not possess significant differences in intragroup analysis and the analysis groups. By contrast this study had significant results in relation to collagen type I. Concluding that zoledronic acid significantly increased the percentage of type I collagen in the callus in healing time of 28 days. And in the cortical bone three times considered (7,14,28 days).

Darbo objektas: kineziterapijos poveikis. Darbo tikslas: Nustatyti šlaunies raumenų jėgos, apimties ir judesių amplitudės pokyčius, taikant kineziterapiją, patyrus šlaunikaulio lūžį su poslinkiu ir be jo. Darbo uždaviniai: 1. Nustatyti ir palyginti šlaunies raumenų jėgą, patyrus šlaunikaulio lūžį su poslinkiu ir be jo, po 24 dienų kineziterapijos. 2. Nustatyti ir palyginti klubo sąnario judesių amplitudę, patyrus šlaunikaulio lūžį su poslinkiu ir be jo, prieš kineziterapiją, po 12 ir 24 dienų kineziterapijos. 3. Nustatyti ir palyginti šlaunies raumenų apimtį ir skausmą, patyrus šlaunikaulio lūžį su poslinkiu ir be jo, prieš kineziterapiją, po 12 ir 24 dienų kineziterapijos. 4. Įvertinti judėjimo funkciją ir savarankiškumą, patyrus šlaunikaulio lūžį su poslinkiu ir be jo, prieš kineziterapiją, po 12 ir 24 dienų kineziterapijos. Išvados: 1. 24 dienų kineziterapija turėjo teigiamą poveikį šlaunies raumenų jėgai patyrus šlaunikaulio lūžį su poslinkiu ir be jo. 2. 24 dienų kineziterapija turėjo teigiamą poveikį šlaunies lenkimo amplitudei patyrus šlaunikaulio lūžį su poslinkiu ir be jo. Patyrus šlaunikaulio lūžį be poslinkio, po kineziterapijos šlaunies lenkimo amplitudė buvo didesnė. 3. 24 dienų kineziterapija neturėjo reikšmingo poveikio šlaunies apimčiai ir skausmui patyrus šlaunikaulio lūžį su poslinkiu ir be jo. 4. 24 dienų kineziterapija neturėjo reikšmingo poveikio funkciniui mobilumui ir savarankiškumui patyrus šlaunikaulio lūžį su poslinkiu ir be jo. / The Object: effects of physiotherapy. Aim of study: To determine thigh muscle strength and circumferences, hip amplitude of the movements changes in patients after femur fractures with and without displacement using physiotherapy. Goals of study: 1. To determine and compare thigh muscle strenght after femur fracture with and without displacement after 24 days of physiotherapy. 2. To determine and compare hip amplitude of the movements after femur fracture with and without displacement before physiotherapy, after 12 and 24 days of physiotherapy. 3. To determine and compare thigh circumferences and pain after femur fracture with and without displacement before physiotherapy, after 12 and 24 days of physiotherapy. 4. To assess movement mobility and independence after femur fracture with and without displacement before physiotherapy, after 12 and 24 days of physiotherapy. Conclusions: 1. 24 days of physiotherapy had a positive effect on thigh muscle strength suffered femur fracture with and without displacement. 2. 24 days of physiotherapy had a positive effect on thigh flexion amplitude suffered femur fracture with and without displacement. Suffered femur fracture without displacement, the thigh flexion amplitude was higher after physiotherapy. 3. 24 days of physiotherapy hadn’t significant effect on thigh circumferences and pain suffered femur fracture with and without displacement. 4. 24 days of physiotherapy hadn‘t significant effect on movement mobility and... [to full text]

A otimização do nível máximo de massa óssea alcançada durante a maturação esquelética pode reduzir o risco de fraturas ósseas e a incidência de osteoporose na vida adulta. Sabe-se que uma ingesta nutricional adequada desempenha um papel importante na maximização da aquisição esquelética. Por outro lado, a desnutrição e a má qualidade óssea são duas condições relacionadas, bem documentadas na literatura. No entanto, pouco se sabe sobre os efeitos da restrição alimentar na consolidação de fraturas ósseas. Desta forma, objetivamos avaliar a influência da restrição alimentar na reparação da fratura e na qualidade do calo ósseo. Foram utilizados 68 ratos machos Wistar, com massa corporal inicial de 70 gramas, divididos em dois grupos experimentais: (1) CON: ratos controle submetidos à fratura óssea e; (2) RA: ratos submetidos à restrição alimentar e fratura óssea. Cada grupo experimental foi subdividido em dois, totalizando quatro subgrupos. Os subgrupos se diferenciaram de acordo como período de observação pós-fratura; 14 e 28 dias, correspondentes às fases de calo mole e calo duro, respectivamente. Durante o experimento, os animais permaneceram em gaiola individual, a restrição alimentar foi de 50% em relação à ingesta dos controles, realizada por seis semanas a partir do desmame (três semanas de vida). A fratura foi realizada na diáfise femoral pelo método fechado e fixada com implante intramedular. Ao término do período experimental, os ossos foram submetidos às análises macroscópica, microtomográfica (avaliação qualitativa e quantitativa da microarquitetura do calo ósseo), densitométrica (DXA), histomorfométrica (quantificação de tecido neoformado e colágeno), de expressão gênica e resistência mecânica. O nível de significância estatística foi de 5%. A restrição alimentar diminuiu significativamente a massa corporal dos animais, os parâmetros macroscópicos dos fêmures e ocasionou várias alterações fenotípicas no calo ósseo (atraso na proliferação e diferenciação celular, menor deposição de colágeno e osso neoformado, redução na área e densidade do calo, diminuição do volume tridimensional, deterioração da microestrutura, menor resistência ao esforço mecânico de torção), além de reduzir a expressão gênica relacionada à osteoblastogênese (Runx2 e Col1a1). Concluiu-se que a restrição alimentar afetou negativamente a consolidação óssea, com atraso na formação do calo ósseo pósfratura e calo de pior qualidade. / Optimizing the peak level of bone mass achieved during skeletal maturation may reduce bone fracture risk and osteoporosis incidence later in life. An adequate nutritional intake is known to play an important role at maximizing the skeletal acquisition. On the other hand, undernutrition and poor bone quality are two related conditions well documented in literature. However, little is known about the effects of food restriction on bone fracture healing. Therefore, we aimed to evaluate the effects of food restriction on fracture healing and bone callus quality. A total of 68 male Wistar rats weighing 70g were randomly assigned into two groups: (1) CON: Control rats sustaining a bone fracture and; (2) RA: food restricted rats with bone fracture. Each group was subdivided into two subgroups, according to the post-operative follow-up period: 14 and 28 days, which represent soft and hard callus formation, respectively. All rats were individually housed during the course of experiment. After weaning, food restricted rats were fed 50% of the ad libitum food intake. Forty-two days after food restriction, animals underwent bone fracture at the right mid-femur by the closed method, followed by surgical stabilization of bone fragments. On days 14 and 28 post-fracture, the rats were euthanized and the fractured femurs were dissected, weighed, measured and analyzed by micro-computed tomography (qualitative and quantitative analysis of bone callus michoarchitecture), densitometry (DXA), histomorphometry (quantity of newly formed bone and collagen deposition), gene expression assessment and mechanical test. Statistical significance was set at 5%. Food restriction decreased body mass gain, morphological measurements and resulted in several phenotypic changes at the bone callus (a delay in cell proliferation and differentiation; lower rate of newly formed bone and collagen deposition; reductions in bone callus density and size; decrease in tridimensional callus volume, deterioration in bone callus microstructure and reduction in callus strength), together with the downregulated expression of osteoblast-related genes (i.e. Runx2, Col1a1). We concluded that food restriction had detrimental effects on osseous healing, with a delay in bone callus formation and lower quality.

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Métodos: Estratégia de busca: abrangeu CENTRAL, MEDLINE, EMBASE e LILACS. Não houve restrições de idioma ou meios de publicações. A última estratégia de busca foi realizada em julho de 2009. Critério de seleção: foram incluídos ensaios clínicos randomizados e quase-randomizados que avaliaram o tratamento de fratura aguda e pseudartrose do terço médio da clavícula em adultos e adolescentes. Os desfechos primários foram: dor, qualidade de vida/função do ombro e falha do tratamento. Coleta e análise dos dados: dois autores, independentemente, selecionaram os estudos elegíveis, avaliaram a qualidade metodológica e extraíram os dados. Calculou-se o risco relativo com 95% de intervalo de confiança para as variáveis dicotômicas; para variáveis contínuas, a diferença entre as médias foi calculada com 95% de intervalo de confiança. Quando possível, os estudos foram agrupados. Resultados: Intervenções não cirúrgicas: dois estudos compararam imobilização em oito versus tipoia. Ambos possuíam baixo poder estatístico e alto risco de viés. Houve maiores níveis de dor e desconforto durante o tratamento nos pacientes submetidos à imobilização em oito. Um terceiro estudo, com baixo risco de viés, mas baixo poder estatístico, avaliou o ultrassom terapêutico. Não houve diferenças significantes entre o ultrassom de baixa intensidade e placebo nos desfechos avaliados. Intervenções não cirúrgicas versus cirúrgicas: Quatro estudos, dois com moderado e dois com alto risco de viés foram incluídos. Dois estudos compararam fixação com placa versus tipoia, com resultados favoráveis ao tratamento cirúrgico ao avaliar falha do tratamento e qualidade de vida/função do ombro. Outros dois estudos compararam fixação intramedular versus tratamento não cirúrgico; a cirurgia foi superior para os desfechos dor e qualidade de vida/função do ombro. Intervenções cirúrgicas: quatro estudos com baixo poder estatístico, cada qual avaliando diferentes comparações, foram incluídos; três possuíam alto risco de viés. Um estudo comparou placa de compressão de baixo contato com placa de compressão dinâmica em pseudartrose da clavícula; os pacientes tratados com placa de baixo contato apresentaram evolução melhor para: função do ombro, consolidação, retorno ao trabalho e menor incidência de sintomas relacionados ao implante. Outro estudo comparou fixação intramedular com pinos de Knowles versus fixação com placa para o tratamento de fratura aguda e pseudartrose da clavícula; a fixação intramedular acarretou em menor consumo de analgésicos após a cirurgia, menor número de complicações associadas ao implante e menor tempo cirúrgico e de internação. Um terceiro estudo, com baixo risco de viés, concluiu que a técnica de fixação tridimensional com placa ocasionou menor incidência de retardo de consolidação em relação à fixação na face superior das fraturas agudas da clavícula. Um último estudo avaliou a fixação intramedular das fraturas agudas da clavícula comparando redução fechada versus redução aberta. Houve diferenças significativas em favor da redução fechada quando avaliados os desfechos primários. Conclusão: os ensaios clínicos disponíveis na literatura não apresentam qualidade metodológica adequada e/ou poder estatístico apropriado, portanto, não há evidência suficiente para determinar quais os mais apropriados métodos de tratamento para a fratura e pseudartrose do terço médio da clavícula. Há uma tendência de melhores resultados funcionais e radiográficos a favor das intervenções cirúrgicas quando comparadas às intervenções não cirúrgicas. / Objectives: To evaluate the effectiveness of different methods of treatment for acute fracture or non-union of the middle third of the clavicle in adults and adolescents. Methods: Search strategy: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, trial registries and reference lists of articles. No language or publication restrictions were applied. Selection criteria: Randomised and quasi-randomised controlled trials evaluating any intervention for treating fractures or non-union of the middle third of the clavicle were considered. The primary outcomes were pain, treatment failure and health-related quality of life or shoulder function. Data collection and analysis: Two authors independently selected eligible trials and three authors assessed methodological quality and cross-checked data extraction. Results: Conservative interventions: Three trials were included in this comparison. Two trials compared the figure-of-eight bandage with sling in a total of 234 participants. Both trials were underpowered and compromised by poor methodology. One trial found slightly higher pain levels in the bandage group at 15 days, and the other trial reported greater discomfort during bandage wear. There were no significant differences in functional or other outcomes reported for either trial. The third trial, which evaluated therapeutic ultrasound in 120 participants, was also underpowered but had a low risk of bias. The trial found no statistically significant difference between low-intensity pulsed ultrasound and placebo in the time to clinical fracture healing or in any of the other reported outcomes. Surgical versus conservative interventions: Four studies, two with moderate and two with high risk of bias were included. Two compared plate fixation versus sling; plate fixation showed better patient-based upper extremity outcome scores and less treatment failure. Other two trials comparing intramedullary fixation versus conservative interventions presented better upper limb function to the surgery treatment. Surgical interventions: Data from four small trials, each testing a different comparison, were included. Three trials had design features that carry a high risk of bias, limiting the strength of their findings. Low-contact dynamic compression plates appeared to be associated with significantly better upper-limb function throughout the year following surgery, earlier fracture union and return to work, and a reduced incidence of implant-associated symptoms when compared with a standard dynamic compression plate in 36 adults with symptomatic non-union of the middle third of the clavicle. One study (69 participants) compared the Knowles pin versus plate for treating middle third clavicle fractures or non-union. Knowles pins appeared to be associated with lower pain levels and use of post-operative analgesics, reduced incidence of implant-associated symptoms, and shorter operation time and hospital stay. One study (133 participants) found that a three-dimensional technique for fixation with a reconstruction plate was associated with a significantly lower incidence of symptomatic delayed union than a standard superior position surgical approach. One study (201 participants) assessed the intramedullary fixation for treating acute clavicle fractures comparing closed and opened reduction; there were statistical significant differences in favour of closed reduction with percutaneous fixation for the primary outcomes. Conclusion: There is limited evidence, from single trials only, regarding the effectiveness of different methods for treating fracture and non-union of the middle third of the clavicle. Further research is warranted. / TEDE / BV UNIFESP: Teses e dissertações