Made available in DSpace on 2016-06-02T20:18:09Z (GMT). No. of bitstreams: 1 TeseFVS.pdf: 3401633 bytes, checksum: b22a99a2e3db18dc60852a024a747b7f (MD5) Previous issue date: 2004-02-05 / Universidade Federal de Minas Gerais / studies about muscle regeneration and injury used invasive methods in animals. Although the muscle regeneration process in many mammals is similar to the one found in humans, it is necessary to improve the application of non-invasive procedures used in the evaluation of the muscle regeneration and injury in humans. Non-invasive techniques such as surface electromyography, isokinetic dynamometry and nuclear magnetic resonance (NMR) for imaging have been used in studies in humans for the evaluation of the skeletal muscle. However, studies in which all these procedures are used together, allowing a more detailed evaluation of the muscle morphology and function, are rare.Thus, the aim of this study was to evaluate the behaviour of the medium maximal isometric torque, the electrical activity and the muscle pain before the injury, during the 7 days after the injury and also between the 21st and 30th days after the injury, when the muscle has already regenerated. For this, a injury was induced in the quadriceps femoris muscle through intense eccentric exercise. To confirm if the model utilized was effective to produce the muscle injury, the plasma activity of the creatine kinase (CK) was also evaluated and the NMR for imaging of the quadriceps femoris muscle was realized. Ten university student volunteers (21,9±1,5), sedentary and without musculoskeletal dysfunction in the lower right limb participated in this study. The extensor medium maximal isometric torque was evaluated through maximal isometric contraction with the knee joint at 90º of flexion, in the isokinetic dynamometer (Biodex Multi-joint System 2 da BIODEX MEDICAL SYSTEM Inc). The electrical activity (Root Mean Square-RMS and Median Frequency) of the vastus medialis oblique (VMO), vastus lateralis (VL) and rectus femoris (RF) muscles was analysed simultaneously to mensuration of the isometric torque, utilizing a Digital Analogue Conversor A/D (LYNX) and single differential active electrodes of surface (LYNX). The quantitative and qualitative analysis of the pain were realized by Visual Analogue Scale (VAS) and by Brazilian Version of Short-Form McGill Pain Questionnaire. The activity of CK was measured utilizing the Kit CK-NAC UV unitest (Wiener lab) and the NMR was realized in the ToRM 0.5 equipment. For the induction of quadriceps femoris muscle injury, the volunteers were submitted to 4 series of 15 maximal eccentric isokinetic contractions, at angle velocity 5º.s-1. The results of this study demonstrated that the medium maximal isometric torque reduced significantly until the 4th day after the eccentric exercise (immediately after and 1st - 4th days after, p<0.01; 4th day after, p<0.05). The RMS of the VMO, VL and RF muscles reduced significantly the 2nd day after (p<0.01, p<0.01 e p<0.05, respectively). However, the RMS of the VL and RF muscles between the 21st and 30th days was significantly greater than before the exercise (p<0.01). There wasn t alteration in the median frequency after tthe eccentric exercise (VMO, p= 0.90; VL, p= 0.55 e RF, p= 0.89). The intensity of pain was greater until the 3rd day, and the peak occurred in the 2nd day after (p<0.01). The McGill Pain Questionnaire demonstrated that the word heavy was the most used to describe the pain after the induced injury by eccentric exercise. The peak of activity of the CK occurred in the 2nd day after the eccentric exercise(p<0.05). The evaluation by NMR demonstrated that the greatest extension of injury occurred in the 2nd and 7th days after, and some voluteers still showed injury sign between the 21st and 30th days. In conclusion, the eccentric exercise reduced the medium maximal isometric torque, increased the activity of the CK, changed the RMS and resulted in pain, which were gradually recovered in one week, despite the presence of muscle injury. / A maioria dos estudos sobre a lesão e regeneração muscular utilizou métodos invasivos em animais. Embora o processo de regeneração muscular em muitos mamíferos seja similar ao encontrado em humanos, é necessário melhorar a aplicação de procedimentos não-invasivos usados na avaliação da lesão e regeneração muscular em humanos. Técnicas não-invasivas tais como a eletromiografia de superfície, a dinamometria isocinética e a ressonância magnética nuclear (RMN) por imagem têm sido utilizadas em estudos em humanos para a avaliação do músculo-esquelético. No entanto, raros são os estudos em que todos esses procedimentos são utilizados conjuntamente, permitindo uma avaliação mais detalhada da função e da morfologia muscular. Assim, o objetivo desse estudo foi avaliar o comportamento do torque isométrico máximo médio, a atividade elétrica e a dor muscular antes da lesão, durante os 7 primeiros dias pós-lesão e também entre o 21º e 30º dias pós-lesão, quando o músculo já se regenerou. Para isso, foi induzida lesão no músculo quadríceps femoral através de exercício excêntrico intenso. Para comprovar se o modelo utilizado foi efetivo para produzir a lesão muscular, foi também avaliada a atividade plasmática da creatina-quinase (CK) e foi realizada a RMN por imagem do músculo quadríceps femoral. Participaram deste estudo 10 universitárias voluntárias (21,9±1,5), sedentárias e sem qualquer patologia osteomioarticular no membro inferior direito. O torque isométrico máximo médio extensor foi avaliado através de contrações isométricas máximas com a articulação do joelho à 90º de flexão, num Dinamômetro Isocinético (Biodex Multi-joint System 2). A atividade elétrica (Root Mean Square-RMS - Raiz Quadrada da Média dos Quadrados e a Freqüência Mediana) dos músculos vasto medial oblíquo (VMO), vasto lateral (VL) e reto femoral (RF) foi analisada simultaneamente à mensuração do torque isométrico, utilizando-se um Conversor Analógico Digital A/D (LYNX) e eletrodos ativos diferenciais simples de superfície (LYNX). As análises quantitativas e qualitativas da dor foram realizadas pela Escala Visual Analógica Visual Analog Scales (VAS) e pela Versão Brasileira Resumida do Questionário McGill de Dor. A atividade da CK foi mensurada utilizando-se o Kit CK-NAC UV unitest e a RMN foi realizada no equipamento ToRM 0.5. Para a indução da lesão no músculo quadríceps femoral, as voluntárias foram submetidas a 4 séries de 15 contrações isocinéticas excêntricas máximas, à velocidade angular de movimento de 5º/s. Os resultados deste estudo demonstraram que o torque isométrico máximo médio diminuiu significativamente até o 4º dia após o exercício excêntrico (imediatamente após e do 1º ao 3º dias após, p<0,01; 4º dia após, p<0,05) . O RMS dos músculos VMO, VL e RF diminuiu no 2º dia após o exercício (p<0,01, p<0,01 e p<0,05, respectivamente). Entretanto, o RMS dos músculos VL e RF entre o 21º e 30 º dias foi maior ao antes do exercício (p<0,01). Não houve alteração na freqüência mediana após o exercício excêntrico (VMO, p= 0,90; VL, p= 0,55 e RF, p= 0,89). A intensidade da dor foi maior até o 3º dia após o exercício excêntrico, com o pico ocorrendo no 2º dia após (p<0,01). O questionário McGill demonstrou que a palavra pesada foi a mais utilizada para caracterizar a dor após a lesão induzida pelo exercício excêntrico. O pico da atividade da CK ocorreu no 2º dia após o exercício excêntrico (p<0,05). A avaliação pela RMN demonstrou que a maior extensão da lesão ocorreu no 2º e 7º dias após, com algumas voluntárias ainda apresentando sinais de lesão entre o 21º e 30º dias. Em conclusão, o exercício excêntrico diminuiu o torque isométrico máximo médio, aumentou a atividade da CK, alterou o RMS e resultou em dor, os quais se recuperaram gradualmente na primeira semana, apesar da presença de lesão muscular.

Orientador: William Dias Belangero / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-19T13:05:04Z (GMT). No. of bitstreams: 1 Sawaia_RogerioNaim_D.pdf: 9806060 bytes, checksum: d75ddfca6472ebb85dbfad46a0daa1a4 (MD5) Previous issue date: 2011 / Resumo: INTRODUÇÃO: O tratamento cirúrgico das fraturas intertrocanterianas do fêmur ainda é motivo de estudo e controvérsias. As vantagens da utilização de técnicas minimamente invasivas para essas fraturas já despontam na literatura. O objetivo deste estudo foi avaliar as complicações da técnica minimamente invasiva que utiliza um implante e um instrumental desenvolvidos especificamente (Sistema Minus) para o tratamento dessas fraturas. CASUÍSTICA E MÉTODO: Foram estudados 172 pacientes com fratura intertrocanteriana do fêmur, tratados com o Sistema Minus, dos quais 52 pacientes foram excluídos do estudo por não terem preenchido os critérios de inclusão. No protocolo inicial foram registrados o gênero, a idade, detalhes operatórios como tempo cirúrgico, tempo de uso da fluoroscopia, qualidade da redução e da fixação da fratura. Como parâmetros clínicos foram incluídos a capacidade de marcha, dor, classificação da fratura segundo os critérios de Tronzo e o risco anestésico segundo a classificação de ASA. Dividimos as complicações em dois grupos. As complicações gerais, subdivididas em infecção e mortalidade e as complicações específicas, subdivididas em migração do implante, a perda da redução e a falta de união. Embora a migração do pino deslizante não seja considerada na literatura como uma complicação do DHS (Hrubna e Skotak, 2010)1, no presente estudo ela foi incluída. Cabendo salientar que foi considerada como migração, a impacção lateral da fratura sem a ocorrência de perda de redução. RESULTADOS: O gênero feminino ocorreu em 93 casos e obteve percentual de 77,5%, foi prevalente em relação ao masculino com 27 casos e 22,5%. A idade variou de 52 a 95 anos, com a média de 80,06 anos e desvio padrão de 7,87 anos. A média de idade do gênero masculino foi de 76,19 anos e desvio padrão de 8,321. O gênero feminino obteve a média de 81,18 anos com desvio padrão de 7,407. O tempo cirúrgico médio foi de 39,35 minutos, variando de 25 a 65 minutos. O tempo médio de radioscopia foi 1min7s, variando de 0,6 a 2 minutos e 3s. A redução foi considerada adequada em 92 casos (76,6%), quando obteve-se o alinhamento do eixo de carga, como valgo em 20 casos (16,6%) e como varo em oito casos (6,6%). O somatório médio do TAD (Tip Apex Distance) na incidência Ântero-posterior (AP) foi de 1,19cm, variando de 0,2 a 2,8cm; e no Perfil (P), de 1,14cm, variando de 0,3 a 2,52cm. Dos pacientes, 112 (93,3%) voltaram a andar e a dor pós-operatória em uma escala de 0 a 10, teve a média de 4,44. Dos 120 pacientes, 11 foram classificados como Tronzo I (9,1%), 24 como Tronzo II (20%), 58 como Tronzo III (48,3%), sete Tronzo III variante (5,8%) e 20 Tronzo IV (16,7%). As fraturas instáveis ocorreram em 85 (70,8%) pacientes, os quais 74 (61,6%) tinham idade superior a 75 anos. Já as fraturas estáveis em 35 (29,1%) pacientes, os quais 17 (14,1%) possuíam idade superior a 75 anos. Em relação ao risco anestésico, oito (6,6%) foram classificados como ASA I, 33 (27,5%) ASA II, 74 (61,6%) ASA III e cinco ASA IV (4,16%). Houve um caso de infecção (0,83%). Ocorreram 13 óbitos (10,8%) dentro do primeiro ano de pós-operatório. Desses, um (0,83%) foi classificado como Asa II, cinco (4,16%) como Asa III e sete (5,83%) Asa IV. Dos 85 pacientes com fraturas instáveis, 36 (30%) apresentaram complicações, como perda de redução em 7(5,88%) e migração do pino deslizante em 29 (24,1%). No grupo das 35 fraturas estáveis, as complicações ocorreram em 4 casos (3,33 %), sendo que a perda de redução ocorreu em um caso (0,83%) e a migração em 3 casos (2,5%). No total, a migração ocorreu em 33 casos (27,6%), sendo que desses, todos evoluíram para consolidação. A perda de redução ocorreu em oito (6,7%) e a falta de união, em um caso (0,83%). CONCLUSÃO: Concluímos que a técnica minimamente invasiva, Sistema Minus, é uma técnica segura, que permite a realização da cirurgia com baixa incidência de complicações, quando comparada aos demais métodos existentes / Abstract: INTRODUCTION: The surgical treatment of intertrochanteric fractures is still controversial, resulting in further studies. Many papers have appeared in reference to the advantages of minimal invasive procedures for these fractures. The aim of this study was to evaluate the complications of a minimal invasive procedure using a specific implant and instruments developed for the treatment of intertrochanteric fractures (Minus System). MATERIAL AND METHOD: One hundred and seventy two patients with intertrochanteric fractures of the femur were studied, and submitted to treatment with the Minus System. Fifty two patients were excluded from the study as they did not fulfil all criteria for inclusion. The initial protocol registered gender, age, operative details such as length of operation, length of fluoroscopy use, quality of reduction and fixation of the fracture. The clinical parameters considered included deambulatory ability, pain, Tronzo fracture classification and anesthesia risk according to ASA classification. Complications were divided into two groups: general complications (infection and mortality rate) and specific complications (implant migration, loss of reduction and non-union). Although the migration of a sliding nail has not been considered in the literature as a DHS complication (Hrubna e Skotak, 2010)1 RESULTS: There were 93 feminine cases (77.5%) prevailing on 27 masculine cases (22.5%). Age span was 52 to 95 years, with an average of 80.06 years (standard deviation of 7.87 years). The average age for men was 76.19 years with a standard deviation of 8.321. The average age for women was 81.18 years with a standard deviation of 7.407. The average operative length of time was 39.35 minutes (25 to 65 minutes). The average time of fluoroscopy was 1min 7sec (0.6 to 2min 3sec). Fracture reduction was considered adequate in 92 cases (76.6%), , in the present study it was taken into account. It is important to mention that migration here is the lateral impaction of the fracture without loss of reduction. when alignment with weight-bearing axis was obtained, valgus in 20 cases (16.6%) and varus in eight cases (6.6%). The average Tip Apex Distance (TAD) on an anteroposterior view was 1.19cm (variation of 0.2 to 2.52 cm) and lateral view was 1.14cm (variaton of 0.3 to 2.52cm). One hundred and twelve patients (93,3%) were able to walk with postoperative pain (average of 4.4 on a pain scale of 0 to 10). The classification of the 120 patients is as follows: 11 patients with Tronzo I (9,1%), 24 cases of Tronzo II (20%), 58 Tronzo III (48.3%), seven Tronzo III variant (5.8%) and 20 Tronzo IV (16.7%). Unstable fractures occured in 85 (70.8%) patients, and 74 (61.6%) were over 75 years of age. There were 35 stable fractures (29.1%), with 17 patients (14.1%) over 75 years of age. As to the anesthesia risk eight (6.6%) were classified as ASA I, 33 (27.5%) ASA II, 74 (61.6%) ASA III and five patients as ASA IV (4.16%). There was one case of infection (0.83%). During the first postoperative year there were 13 deaths (10.8%). Of these, one patient (0.83%) had been classified as ASA II, five (4.16%) as ASA III and seven (5.83%) as ASA IV. There were 36 patients (30%) with complications out of 85 patients with unstable fractures, with loss of reduction in seven (5.88%) and migration of the sliding nail in 29 (24.1%). In the group of 35 stable fractures there were complications in four cases (3.3 %), with loss of reduction in one case (0.83%) and migration in three (2.5%). The total number of migrations was 33 (27.5%), but resulted in union in all patients. The loss in reduction occurred in eight patients (6.7%) and non-union in one case (0.83%). CONCLUSION: The minimal invasive procedure, the Minus System, is a safe procedure, that provides adequate surgery with a low incidence of complications, when compared to other existing techniques / Doutorado / Fisiopatologia Cirúrgica / Doutor em Ciências

Abstract Osteoporosis is a bone disorder that leads to a reduction in bone volume, deterioration of bone microarchitecture and therefore increased fracture risk. Bone disorders such as osteoporosis commonly have both genetic and environmental components. Family and twin studies have shown the importance of genetics in bone formation and health, but most of the genetic factors contributing to bone formation are still largely unknown. The aim of this thesis was to search for and identify genetic factors that predispose to two different bone disorders manifesting in fractures, namely femoral neck stress fractures and childhood primary osteoporosis without features of OI (i.e. non-OI primary osteoporosis). Furthermore, in vitro studies were performed to elucidate the importance and mechanism of action of identified genetic factors in non-OI primary osteoporosis. By using candidate gene analyses we identified predisposing alleles, haplotypes and their interactions that increased the risk for femoral neck stress fractures in young male military conscripts. The conscripts lacking the CTR C allele and/or VDR C-A haplotype had a three-fold increased risk for femoral neck stress fractures compared to the carriers of both. Furthermore, conscripts carrying the LRP5 A-G-G-C haplotype had a three-fold increased risk for femoral neck stress fractures and in combination with VDR C-A haplotype a four-fold increased risk for stress fractures. These associations were mediated by low body weight and BMI. In the search for genetic factors of non-OI primary osteoporosis in children and adolescent, two novel mutations in LRP5 and two more variants in WNT3A and DKK1 were found in patients. The variants were also observed in the affected family members, but not in the control group. The effects of these variants were examined in in vitro studies and the results showed that some LRP5 mutations and the WNT3A variant might reduce bone formation by decreasing the canonical Wnt signalling activity. / Tiivistelmä Osteoporoosi on luustosairaus, joka alentaa luuntiheyttä ja heikentää luun rakennetta ja siten lisää murtumien riskiä. Osteoporoosin kaltaiset luusairaudet ovat usein monitekijäisiä tauteja, joiden syntyyn vaikuttavat sekä perinnölliset että ympäristölliset tekijät. Perhe- ja kaksostutkimukset ovat osoittaneet perinnöllisten tekijöiden olevan tärkeitä luun muodostuksessa ja terveydessä, mutta nämä tekijät ovat kuitenkin vielä suurelta osin tuntemattomia. Tutkimustyön tavoitteena oli etsiä ja tunnistaa perinnöllisiä tekijöitä, jotka altistavat kahdelle luunmurtumina ilmenevälle sairaudelle: reisiluunkaulan rasitusmurtumille ja lasten primaariselle osteoporoosille. Lisäksi primaariselle osteoporoosille altistavien perinnöllisten tekijöiden merkitystä ja vaikutusmekanismeja tutkittiin in vitro- kokeilla. Reisiluunkaulan rasitusmurtumille altistavien alleelien, haplotyyppien ja näiden vuorovaikutusten tunnistamiseen käytettiin ehdokasgeenianalyysiä nuorten alokkaiden aineistossa. Potilailla, joilta CTR-geenin C-alleeli ja/tai VDR-geenin C-A haplotyyppi puuttuivat, oli kolminkertainen riski rasitusmurtumien syntyyn molempien geenimuotojen kantajiin verrattuna. Myös LRP5-geenin A-G-G-C haplotyypin kantajilla oli kolminkertainen riski rasitusmurtumiin ja VDR-geenin C-A haplotyyppi ja A-G-G-C yhdessä lähes nelinkertaistivat rasitusmurtumien riskin alokkailla. Näiden assosiaatioiden todettiin välittyvän alhaisen painon ja painoindeksin välityksellä. Lapsuudessa tai varhaisnuoruudessa puhkeavan primaarisen osteoporoosin perinnöllisten tekijöiden etsinnässä löydettiin kaksi uutta mutaatiota LRP5-geenistä ja yhteensä kaksi uutta muutosta WNT3A- ja DKK1-geeneistä. Uusien ehdokasgeenilöydösten osuutta primaarisen osteoporoosin syntyyn tukee se, että muutokset löydettiin potilaiden lisäksi heidän sairailta sukulaisiltaan eikä muutoksia havaittu kontrolliaineistoissa. Uusien mutaatioiden mahdollisia vaikutuksia tutkittiin in vitro-kokein, jotka osoittivat, että eräät LRP5-geenin mutaatiot ja WNT3A-geenin muutos alentavat kanonisen Wnt-signalointireitin aktiivisuutta ja voivat siten vähentää luunmuodostusta.

Hip fracture has increased in the last decades and has been considered one of the major causes of mortality and morbidity in elderly people. In most cases is an event with catastrophic consequences to elderly life with impairment in your physical, psychical and social welfare. Is often responsible for the permanent institutionalization of the elderly. Epidemiologic studies contribute to specify certain orthopedic and traumatologic injuries and it helps in the treatment and prevention of these injuries. These actions are essential to health promotion. In Latin America, there are few epidemiological studies on mortality associated with hip fracture in elderly. Aims to assess mortality one year after hip fracture and in-hospital mortality in elderly subjects who were treated at the Orthopaedics and Traumatology division of University Hospital of Santa Maria. Identifying risk factors for one year mortality in-hospital mortality in these subjects and determinate one year subjects survival. This is a prospective cohort study that evaluates one year mortality by Cox s Regression and in-hospital mortality by Logistic Regression. The survival time was evaluate by Kaplan Meier analyze. The mean age was 80.6±7.5(SD) years, 76.4% were female gender, 57.8% were transtrochanteric fracture and 44.9% had ASA grade I or II. One year mortality was 25.2% and in-hospital mortality was 12.5%. One year mortality predictor s were ASA (HR 1.922, 95% CI 1.150 3.211) and time to surgery (HR 1.049, 95% CI 1.012 1.087). Only ASA grade were risk factor for in-hospital mortality (OR 6.373, 95% CI 2.954 13.747). The survival time was 297.7±11.3 days. The mean time to surgery was 7.8±5.4 days. In our study for every day that the surgery was delayed the one year survival was shortened by 9 days. Improvements in public health that would decrease time to surgery could have an impact at the survival of these subjects. The ASA grade is a useful tool to evaluate the patient clinical status. / A fratura do terço proximal do fêmur tem aumentado significativamente nas últimas décadas e tem sido uma das maiores causas de morbimortalidade em idosos. Constitui-se muitas vezes em um evento com consequências catastróficas para a vida do paciente, com grandes implicações no seu bem-estar físico, psíquico e social. É uma causa frequente de institucionalização permanente. Estudos epidemiológicos contribuem para especificar características de determinadas lesões traumato-ortopédicas, bem como, a partir daí, auxiliar na sua prevenção e tratamento. Estas ações são essenciais para a promoção da saúde. Na América Latina, existem poucos estudos epidemiológicos sobre a mortalidade associada a fraturas da extremidade proximal do fêmur em idosos. Este estudo tem como objetivos: avaliar a mortalidade um ano após fratura do fêmur proximal (FFP) e mortalidade intra-hospitalar nos pacientes com 65 anos ou mais, que foram atendidos no Serviço de Ortopedia e Traumatologia do Hospital Universitário de Santa Maria (SOT - HUSM); Identificar os fatores de risco para mortalidade um ano após FFP e mortalidade intra-hospitalar nestes pacientes; Determinar a sobrevida dos pacientes um ano após o evento trauma. Trata-se de um estudo de coorte prospectivo que avaliou através de Regressão de Cox os fatores de risco para mortalidade um ano após FFP e por meio de Regressão Logística, os preditores para mortalidade intra-hospitalar. A análise de sobrevida foi feita pelo método de Kaplan Meier. A idade média dos pacientes foi de 80,6±7,5(DP) anos, 76,4% eram do sexo feminino, 57,8% tiveram fratura transtrocantérica e 44,9% tinham escore ASA I ou ASA II. Ao final de um ano morreram 25,2% dos pacientes e 12,5% morreram durante a internação hospitalar. Foram fatores preditores de aumento de mortalidade em um ano o escore ASA (American Society of Anesthesiologists) (HR 1,922, 95% IC 1,150 3,211) e o tempo porta-cirurgia (HR 1,049, 95% IC 1,012 1,087). Apenas o escore ASA (OR 6,373, 95% IC 2,954 13,747) foi preditor de aumento da mortalidade intra-hospitalar. O tempo de sobrevida médio foi de 297,7±11,3 dias. O tempo médio entre a internação e a realização da cirurgia foi 7,8±5,4 dias. Em nosso estudo, para cada dia de espera, a sobrevida no primeiro ano foi encurtada em 9 dias. A tomada de medidas de saúde pública que venham a diminuir o tempo de espera para a cirurgia pode vir a apresentar um impacto positivo na diminuição dessa mortalidade. O escore ASA é uma importante ferramenta para avaliar o estado clínico do paciente.

The intact development of postural functions is the condition for the posture. The muscles are automatically integrated into the posture by maturing of the central nervous system. Together with the postural function of the phasic muscles the morphology of the skeleton matures too. The target of this work is to prove the influence of the muscles onto the morphology of the hip joint - femoral neck anteversion. Point to the cohesion of clinical symptoms of the bigger femoral neck anteversion. The results of the clinical survey compare with the ultrasound of the hip joint. Powered by TCPDF (www.tcpdf.org)

Background: To ensure adequate function after orthopedic tumor reconstruction, it is important to reattach the remaining soft tissue to the implant. This study aimed at obtaining mechanical properties of textile muscle-implant and muscle-bone connections in a preliminary test. Methods: Two groups of soft-tissue attachment were mechanically tested and compared: Native bone-muscle samples obtained from human femora and muscles attached to a prosthetic implant by means of Trevira® attachment tubes. Additionally, muscle samples were tested with muscle fibers aligned parallel and perpendicular to the tension load. A uniaxial load was exerted upon all samples. Results: Failure loads of 26.7 ± 8.8 N were observed for the native bone-muscle group and of 18.1 ± 9.9 N for the Trevira® group. Elongations of 94.8 ± 36.2 % were observed for the native bone-muscle group and 79.3 ± 51.8 % for the Trevira® group. The location of failure was mainly observed in the central area of the muscle fibers. Muscle fibers with parallel fiber orientation (47.6 ± 11.5 N) yielded higher tensile strength than those with perpendicular fiber orientation (14.8 ± 4.1 N). Conclusions: Our experiments showed that higher forces were transmitted in the origin and insertion areas than in areas of flat soft tissue reconstruction using attachment tubes. The data indicate that the tested material allows reattaching muscles, but without reinforcing the insertion site. Therefore, attachment tubes with region-dependent and potentially anisotropic material behavior might be advantageous to optimize muscle-bone load transmission after surgery, which may allow lower complication rates and shorter physical recovery.

Die Oberschenkelhalsfraktur ist eine der häufigsten Frakturen des älteren Menschen. Die Tücke dieser Verletzung liegt in einer nahezu obligaten Immobilisierung der Betroffenen und den sich daraus ergebenden Folgen mit drohender vitaler Gefährdung. Während die Behandlung noch vor wenigen Jahrzehnten zumeist in einer längerfristigen konservativen Therapie mittels Streckverbänden bestand, stehen dem Chirurgen heute standardisierte operative Versorgungsmöglichkeiten zur Verfügung, welche eine zeitnahe Belastung der verletzten Extremität und somit eine rasche Mobilisierung der Patienten erlauben. Diese chirurgischen Behandlungsmethoden lassen sich im Wesentlichen in die Stabilisierung der Fraktur durch eine geeignete Osteosynthese und dadurch Erhalt des nativen Gelenks einerseits und den künstlichen Ersatz des Oberschenkelkopfes oder des gesamten Hüftgelenkes andererseits unterteilen. Das Ziel der vorliegenden Arbeit war es, möglicherweise bestehende Einflüsse der Wahl des Therapieverfahrens auf die kurz- und mittelfristigen Ergebnisse nach operativer Versorgung zu identifizieren. Hierbei wurde der Entwicklung der Mobilität, Pflegestufe und Institutionalisierung der Patienten besondere Beachtung geschenkt. In einem 2-Jahreszeitraum zwischen den Jahren 2010 und 2012 wurden alle mindestens 60 Jahre alten Patienten eingeschlossen, welche am Universitätsklinikum Leipzig aufgrund einer traumatischen Schenkelhalsfraktur behandelt werden mussten. Es erfolgte die Auswertung der im elektronischen Patientenverwaltungsprogramm der Klinik hinterlegten Daten sowie der Dokumentation der 6 und 12 Monate nach dem jeweiligen Unfallereignis erfolgten Nachuntersuchungen. Die Ergebnisse wurden anonymisiert und statistisch ausgewertet. 172 Patienten mit einem mittleren Alter von 80,4 Jahren wurden operativ versorgt. In 28,5% (n=49) der Fälle wurde kopferhaltend und in 71,5% (n=123) der Fälle endoprothetisch operiert. 8,7% der Patienten verstarben während des initialen Krankenhausaufenthaltes. Nach einem Jahr waren 27,4% der Patienten mit nachvollziehbarem Verlauf verstorben. Bezüglich der Mortalität bestanden keine statistisch signifikanten Unterschiede zwischen den Therapieverfahren. Bei jenen Patienten, welche auch ein Jahr nach Fraktur noch untersucht werden konnten, zeigte sich eine prozentual nahezu gleiche Verteilung chirurgischer Komplikationen von ca. 20% bei Osteosynthesen und Endoprothesen. Jedoch war die Revisionsrate mittels Osteosynthese versorgter Patienten signifikant höher. Während sich keine statistisch relevanten Einflüsse der Therapieverfahren auf die Pflegestufe und die Institutionalisierung zeigten, fielen klare Unterschiede bei der Mobilität auf. Obwohl die mittels Osteosynthese operierten Patienten vor dem Trauma insgesamt jünger, gesünder und mobiler waren, verloren sie mehr an Mobilität und berichteten über stärkere Schmerzen als die Patienten der Endoprothesengruppe. Schlussfolgernd wird festgestellt, dass - insbesondere unter dem Aspekt der geringeren Revisionsraten, des geringeren Verlustes an Mobilität sowie der offenbar geringeren Schmerzhaftigkeit - bei älteren Patienten mit dislozierten Schenkelhalsfrakturen die endoprothetische Versorgung der Osteosynthese gegenüber zu bevorzugen ist. Dennoch sollte der Therapieentscheid individuell und unter Einbezug weiterer Parameter (Paresen, Demenz, vorbestehende Immobilität, etc.) erfolgen.:I. Abkürzungsverzeichnis 5 1 Einleitung: 6 1.1 Ätiologie und Epidemiologie 7 1.2 Anatomie 8 1.3 Therapie 9 1.3.1 Konservative Therapie 9 1.3.2 Chirurgische Versorgung 10 2 Aufgabenstellung: 13 3 Patienten und Methoden: 13 3.1 Datenerfassung und -auswertung 13 3.1.1 Patientenkollektiv 13 3.1.2 Auswertung 14 3.2 Patientendaten 14 3.2.1 Allgemeine Daten 14 3.2.2 Wohn- und Pflegesituation (Institutionalisierung) 15 3.2.3 Unfallmechanismen 15 3.2.4 Mobilitätsscore nach Merle d'Aubigné und Postel 16 3.2.5 Dauer bis zur operativen Versorgung 17 3.2.6 Präoperativer Gesundheitszustand 18 3.3 Klassifikation 18 3.3.1 Klassifikation nach GARDEN 18 3.3.2 Klassifikation nach PAUWELS 19 3.3.3 AO-Klassifikation 20 3.4 Komplikationen, Revisionsoperationen und Todesereignisse 21 3.5 Entlassungsort 23 3.6 Nachuntersuchungen nach 6 und 12 Monaten 23 4 Ergebnisse: 25 4.1 Allgemeine Patientendaten 25 4.2 Unfallmechanismen 26 4.3 Präoperative Wohn- und Pflegesituation 27 4.4 Merle d'Aubigné Score vor Trauma 29 4.5 ASA-Einteilung 29 4.6 Präoperative Liegedauer 30 4.7 Frakturklassifikation nach GARDEN 30 4.8 Operative Versorgungsart der Frakturen 31 4.9 Schnitt-Naht-Zeiten 33 4.10 Komplikationen im stationären Verlauf 34 4.10.1 Allgemeine Komplikationen 34 4.10.2 Chirurgische Komplikationen 35 4.10.3 Todesereignisse im stationären Verlauf 36 4.11 Entlassungsort 38 4.12 Follow-Up nach 6 und 12 Monaten 39 4.12.1 Wohn- und Pflegesituation nach 6 und 12 Monaten 40 4.12.2 Mobilität nach 12 Monaten 42 4.12.3 Komplikationen und Revisionsoperationen im Nachuntersuchungszeitraum 43 4.12.4 Überlebensrate nach 12 Monaten 44 5 Diskussion: 46 6 Zusammenfassung der Arbeit: 70 7 Literaturverzeichnis 73 8 Abbildungsverzeichnis 81 9 Erklärung über die eigenständige Abfassung der Arbeit 82 10 Lebenslauf und wissenschaftlicher Werdegang: 83 11 Danksagung: 85

The purpose of this master thesis was to investigate if using both X-ray images and patient's register data could increase the performance of a neural network in discrimination of two types of fractures in the thigh bone, called atypical femoral fractures (AFF) and normal femoral fractures (NFF). We also examined and evaluated how the fusion of the two data types could be done and how different types of fusion affect the performance. Finally, we evaluated how the number of variables in the register data affect a network's performance. Our image dataset consisted of 1,442 unique images from 580 patients (16.85% of the images were labelled AFF corresponding to 15.86% of the patients). Since the dataset is very imbalanced, sensitivity is a prioritized evaluation metric. The register data network was evaluated using five different versions of register data parameters: two (age and sex), seven (binary and non-binary) and 44 (binary and non-binary). Having only age and sex as input resulted in a classifier predicting all samples to class 0 (NFF), for all tested network architectures. Using a certain network structure (celled register data model 2), in combination with the seven non-binary parameters outperforms using both two and 44 (both binary and non-binary) parameters regarding mean AUC and sensitivity. Highest mean accuracy is obtained by using 44 non-binary parameters. The seven register data parameters have a known connection to AFF and includes age and sex. The network with X-ray images as input uses a transfer learning approach with a pre-trained ResNet50-base. This model performed better than all the register data models, regarding all considered evaluation metrics.        Three fusion architectures were implemented and evaluated: probability fusion (PF), feature fusion (FF) and learned feature fusion (LFF). PF concatenates the prediction provided from the two separate baseline models. The combined vector is fed into a shallow neural network, which are the only trainable part in this architecture. FF fuses a feature vector provided from the image baseline model, with the raw register data parameters. Prior to the concatenation both vectors were normalized and the fused vector is then fed into a shallow trainable network. The final architecture, LFF, does not have completely frozen baseline models but instead learns two separate feature vectors. These feature vectors are then concatenated and fed into a shallow neural network to obtain a final prediction. The three fusion architectures were evaluated twice: using seven non-binary register data parameters, or only age and sex. When evaluated patient-wise, all three fusion architectures using the seven non-binary parameters obtain higher mean AUC and sensitivity than the single modality baseline models. All fusion architectures with only age and sex as register data parameters results in higher mean sensitivity than the baseline models. Overall, probability fusion with the seven non-binary parameters results in the highest mean AUC and sensitivity, and learned feature fusion with the seven non-binary parameters results in the highest mean accuracy.

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Introduction: Congenital short femur, or proximal femoral focal deficiency (PFFD), is a rare complex deformity of the lower extremity with femoral dominance. The clinical findings cover wide range of variety, from femoral absence till inconspicuous shortening of the femur. Aim of the study: 1. Molecular analysis of pseudoarthrosis tissue in congenital short femur with focusing on osteogenic and angiogenic gene expression in comparison with physiological bone. The differences in gene expression were expected. 2. Retrospective analysis of femoral healing after prolongation calculating the severity of affection, age, distance of elongation and complication. The extended healing according to severity type and age was expected compared to control group. Material and methods: The RNA from piece of one was isolated and transcription profile of possible 113 genes of osteogenesis and angiogenesis was detected by biochip technology (SuperArray Bioscience Corporation). 10 samples analyses were performed (7 of PFFD, 3 controls). The data of 57 PFFD patients indicated for elongation of the femur with the types Pappas III, IV, VII, VIII and IX and 12 patients in control group were evaluated retrospectively and statistically by GLS method. Results: The expected differences in gene expression in PFFD tissue...