published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

O objetivo desta dissertação foi avaliar biomecanicamente o papel da aplicação de uma técnica cirúrgica utilizando os tendões dos músculos semitendíneo e grácil na reconstrução anatômica de lesão criada no canto póstero-lateral do joelho. Foram estudados 10 joelhos de cadáveres nas situações intacto, lesado, parcialmente reconstruído e reconstruído. As principais estruturas do canto póstero-lateral do joelho foram seccionadas para criar o padrão de lesão. Os momentos de força aplicados foram 2 N.m e 5 N.m, com o joelho a 0º, 30º, 60º ou 90º de flexão. Foi também calculada a rigidez do joelho em cada uma das situações nas diferentes posições testadas. Os ensaios foram realizados em dispositivo criado no Laboratório de Biomecânica LIM-41 da Faculdade de Medicina da USP, e os dados de deformação angular foram obtidos através de programa de fotogoniometria. Os resultados obtidos foram submetidos a análise estatística pela Análise de Variância para Experimento em Blocos Aleatorizados e os tratamentos foram comparados entre si pelo método de Scheffé. Foi possível concluir que: 1) A técnica empregada não corrigiu completamente o aumento da rotação externa. 2)A técnica empregada restaurou a estabilidade em varo. / The purpose of this study was to evaluate the application of a surgical technique for anatomical reconstruction of the structures from the posterolateral corner of the knee. We tested 10 cadaver knees with intact, ruptured, partially reconstructed and reconstructed ligaments. The main posterolatreal structures were cut to produce a lesion pattern. The applied force moments were of 2 N.m and 5 N.m with the knee flexed to 0, 30, 60 and 90 degrees. The stiffness of the knee in each of these situations at the studied angles was also determined. The assays were carried through in a device created at the Laboratory of Biomechanics LIM-41 from of the University of São Paulo School of Medicine. Data from the angular deformation were obtained through a photographic measurement aided by computer software. The results were submitted to ANOVA and the treatments had been compared using statistical method of Scheffé. It was possible to conclude that: 1) The technique employed wasn?t able to restore normal external rotation. 2) The technique employed restored varus stability.

[Truncated abstract] Autologous Chondrocyte Implantation (ACI) has shown early clinical success as a repair procedure to address focal articular cartilage defects in the knee, and involves isolating and culturing a patient's own chondrocytes in vitro and re-implantation of those cells into the cartilage defect. Over time, repair tissue can develop and remodel into hyaline-like cartilage. A progressive partial weight bearing (PWB) program becomes the critical factor in applying protection and progressive stimulation of the implanted cells, to promote best chondrocyte differentiation and development, without overloading the graft. The aim of this thesis was to investigate whether patients could replicate this theoretical load bearing model to possibly render the best quality tissue development. In addition, this proposed external load progression is only a means to loading the articular surface. Several factors, including those that may result from pathology, have the potential to influence gait patterns, and therefore, articular loading. The association between increasing external loads (ground reaction forces - GRF) and knee joint kinetics during partial and full weight bearing gait was, therefore, investigated in the ACI patient group, as was the contribution of other gait variables to these knee joint kinetics which may be modified by the clinician. Finally, current weight bearing (WB) protocols have been based on early ACI surgical techniques. With advancement in the surgical procedure and ongoing clinical experience, we employed a randomised controlled clinical trial to assess the effectiveness of an 'accelerated' load bearing program, compared with the traditionally 'conservative' post-operative protocol. ... Although similar spatio-temporal, knee kinematic and external loading parameters were observed between the traditional and accelerated rehabilitation groups, the accelerated group was 'more comparable' to the controls in their external knee adduction and flexion moments, where the traditional group had lower knee moments. Knee moments greatly affect knee articular loading, and large adduction moments have been related to poor clinical outcomes after surgery. Therefore, the return of normal levels may be ideal for graft stimulation, however, may overload the immature chondrocytes. Acceleration of the intensive rehabilitation program will enable the patient to return to normal activities earlier, whilst reducing time and expenses associated with the rehabilitative process, and may enhance long-term tissue development. However, continued follow-up is required to determine if there are any detrimental effects that may emerge as a result of the accelerated load bearing program, and assess the recovery of normal gait patterns and whether longer term graft outcomes are affected by the recovery time course of normal gait function, and/or abnormal loading mechanics in gait. Furthermore, analysis at all levels of PWB is needed to identify a more complete set of variables attributing to the magnitude of external knee joint kinetics and, therefore, knee articular loading, while the influence muscle activation patterns may have on articular loading needs to be investigated. This becomes critical when you consider loads experienced by the articular surface throughout the early post-operative period following ACI may be important to short- and long-term graft development.

A generally accepted goal in orthopaedic surgery today is to maximize conservation of tissue and reduce tissue damage. Bone-conserving implants have bone-mating surfaces that reproduce the natural curvature of bone structures, requiring less bone removal. No small, reliable, inexpensive and universal bone sculpting technique currently exists, however, that can both create and accurately align such complex surfaces. The goal of this thesis was to develop a haptic hard surface emulation mechanism that could be applied to curvilinear bone sculpting using a surgical robot. A novel dynamic physical constraint concept was developed that is able to emulate realistic hard constraints, smooth surface following, and realistic surface rigidity, while allowing complete freedom of motion away from the constraints. The concept was verified through the construction of a two-link manipulator prototype. Tests were run on nine users that involved each user tracing out five different virtual surfaces on a drawing surface using the prototype. The primary purposes of prototype testing were to obtain subjective data on how effectively the dynamic physical constraint concept simulates simple surfaces, to assess how it reacts to typical user interactions and to identify any unexpected behaviour. Users were 100% satisfied with the prototype’s ability to emulate realistic and stiff hard surfaces and with its ease of manipulation. The amount of incursion into each of the virtual surfaces by all the users was measured to assess the precision of the system with the goal of deciding whether this new haptic concept should be further developed specifically for precision applications such as surgery. For curvilinear surfaces, 90% of the cumulative distribution of the measured data was less than 2mm, while for linear surfaces it was less than 6mm. Four behavioural effects were noticed: lateral deflection, reverse ‘stickiness’, hysteresis and instability in certain areas. These effects were studied in detail to determine how to either eliminate them or to minimize them through system design optimization. A computer simulation was also used to model the behaviour of the prototype and to gain further understanding of these effects. These analyses showed that the concept can be successfully used in curvilinear bone sculpting.

The purpose of this study was to determine the effectiveness of the Augmented Soft Tissue Mobilization (A.S.T.M.) Rehabilitation Technique on total knee replacement patients. The specific measurements assessed were stride length (SL), stride frequency (SF), walking velocity, support time (ST), total time (TT), static and walking range of motion (ROM) of the hip, knee, and ankle, ground reaction forces (GRF), and torques. Fourteen subjects (Female = 7, Male = 7) completed the study. Subjects were randomly assigned to two experimental groups, the Traditional Therapy treatment or the A.S.T.M. treatment. There were five testing sessions: pre operation, 8 weeks, 12 weeks, 16 weeks, and 24 weeks post operation. On the 12 week test, the subject had completed their assigned of treatment protocol. Static ROM was derived from gonimetric measurements before each testing session. Stride length, stride frequency, velocity, time, and walking ROM were derived from accelerometer data. Statistical analysis using ANOVA revealed a significant change in all static ROM, SL, and ST. The data indicated that both groups of the Total Knee Replacement patients did improve their functional status from their status prior to surgery. In addition, the data indicated that the Augmented Soft Tissue Mobilization program and the Traditional Therapy program are equally acceptable rehabilitation techniques. / School of Physical Education

Background: Cryotherapy is commonly used during physiotherapeutic rehabilitation of patients following total knee replacement (TKR). Evidence for treatment effectiveness within the current literature is contradictory and there are no clinical guidelines to inform cryotherapy treatment within this particular patient group. This study surveys current cryotherapy treatment efficacy in the acute post-operative management of TKR patients. Methods: In total 263 senior physiotherapists completed and returned a postal questionnaire, which, using open and closed questions investigated the use of cryotherapy following TKR. Survey results were used to inform a pragmatic randomized clinical trial (RCT) involving 133 consecutive TKR patients. The RCT investigated cryotherapy treatment efficacy in the acute post-operative management of TKR patients. Patients were randomized into three groups; no cryotherapy (NC), delayed cryotherapy (DC) and immediate cryotherapy (IC). The primary outcome measure was post-operative pain with knee swelling, active range of motion (AROM), function and levels of physiotherapy input assessed as secondary outcome measures. Observations were taken pre-operatively and at 3, 7 and 42 days post-operatively. Results: The survey reported that 33% of respondents used some form of cryotherapy routinely following TKR surgery. The two main methods of cryotherapy application were Cryocuff (59%) and crushed ice (30%). Treatments were most frequently applied between 24 hrs and 48 hrs post-surgery for 20 minutes, twice a day. Chi square analysis indicated significant differences (p<0.01) in between NHS and private sites relating to a lack of cryotherapy resources and treatment time for cryotherapy in the NHS. A lack of proven efficacy was the most cited reason for not applying cryotherapy treatment, and swelling the most common treatment indicator. There was particular uncertainty regarding the cleaning and sterilization of the Cryocuff device. The RCT indicated that patients in IC group had significantly less post-operative pain than the NC and DC groups at 3 days. Mean difference (p <0.05, 95% CI) in post-operative analogue scores (VAS, scale 0-10) was -1.6 (p <0.01, CI -2.49- to -0.707) for IC and NC; and -0.922 (p= 0.044, CI -0.183 to -0.009) for IC and DC groups. At 7 and 42 days there were significant reductions in VAS scores for both cryotherapy groups compared to the NC group. There was significant improvement in knee swelling, AROM, ability to transfer and need for additional physiotherapy in both cryotherapy treatment groups although no significant reduction in opiate requirement was found. Conclusions: In current clinical practice there was little consensus regarding treatment indicators, method of application and management of cryotherapy following TKR. However, in a RCT the use of cryotherapy combined with compression, as compared to a no cryotherapy control, led to significant reductions in patient reported pain, less post-operative swelling, greater recovery of AROM, faster return of function and less reliance on OPD physiotherapy treatment. It is concluded that cryotherapy combined with compression has an important role to play in the acute rehabilitation of TKR and should be considered as part of routine management.

A generally accepted goal in orthopaedic surgery today is to maximize conservation of tissue and reduce tissue damage. Bone-conserving implants have bone-mating surfaces that reproduce the natural curvature of bone structures, requiring less bone removal. No small, reliable, inexpensive and universal bone sculpting technique currently exists, however, that can both create and accurately align such complex surfaces. The goal of this thesis was to develop a haptic hard surface emulation mechanism that could be applied to curvilinear bone sculpting using a surgical robot. A novel dynamic physical constraint concept was developed that is able to emulate realistic hard constraints, smooth surface following, and realistic surface rigidity, while allowing complete freedom of motion away from the constraints. The concept was verified through the construction of a two-link manipulator prototype. Tests were run on nine users that involved each user tracing out five different virtual surfaces on a drawing surface using the prototype. The primary purposes of prototype testing were to obtain subjective data on how effectively the dynamic physical constraint concept simulates simple surfaces, to assess how it reacts to typical user interactions and to identify any unexpected behaviour. Users were 100% satisfied with the prototype’s ability to emulate realistic and stiff hard surfaces and with its ease of manipulation. The amount of incursion into each of the virtual surfaces by all the users was measured to assess the precision of the system with the goal of deciding whether this new haptic concept should be further developed specifically for precision applications such as surgery. For curvilinear surfaces, 90% of the cumulative distribution of the measured data was less than 2mm, while for linear surfaces it was less than 6mm. Four behavioural effects were noticed: lateral deflection, reverse ‘stickiness’, hysteresis and instability in certain areas. These effects were studied in detail to determine how to either eliminate them or to minimize them through system design optimization. A computer simulation was also used to model the behaviour of the prototype and to gain further understanding of these effects. These analyses showed that the concept can be successfully used in curvilinear bone sculpting.

[Truncated abstract] Unicondylar knee arthroplasty (UKA) has re-emerged as a successful treatment option for isolated single compartment tibio-femoral joint osteoarthritis. However despite its increasing use, controversy still remains over fixed or mobile bearing tibial components, as there is a lack to prospective randomised studies reported in the literature. In addition, the theoretical advantages of the mobile bearing for knee kinematics, kinetics and clinical outcome have not been evaluated in vivo. The aim of this research study was to explore the clinical and biomechanical outcomes of the fixed and mobile bearing UKA. . . . When the results for the both studies were combined, utilising the Preservation and MG fixed bearing prostheses, there was a significant relationship between knee adduction moment, and a poor prognosis predicted from RSA. Those patients with translation or rotation of the tibial component in any direction above 1mm and 1.5 degrees respectively were considered to have a poor prognosis for long term fixation. Of the 28 patients, the 8 patients considered to have a poor prognosis, had increased knee adduction moments post-surgery (mean difference = 1.66Nm.kg-1, p = 0.007). There was no difference between the groups for knee flexion moment (mean difference 0.16Nm.kg-1, p = 0.844). Pre-surgery gait was unable to predict the post-surgery outcome, due to the significant changes in gait from pre- to post-surgery. Care must taken when implanting the Preservation mobile bearing prosthesis, as long term outcome is questionable. The mobile bearing prosthesis also produced the worst clinical outcome, however the theoretical advantages of the mobile bearing does not affect gait. Gait analysis is a useful tool to identify patient who are overloading their prosthesis, leading to potential early failure. Identification of these gait patterns can allow for early intervention to reduce joint load, and possible extend the longevity of the prosthesis.

O objetivo desta dissertação foi avaliar biomecanicamente o papel da aplicação de uma técnica cirúrgica utilizando os tendões dos músculos semitendíneo e grácil na reconstrução anatômica de lesão criada no canto póstero-lateral do joelho. Foram estudados 10 joelhos de cadáveres nas situações intacto, lesado, parcialmente reconstruído e reconstruído. As principais estruturas do canto póstero-lateral do joelho foram seccionadas para criar o padrão de lesão. Os momentos de força aplicados foram 2 N.m e 5 N.m, com o joelho a 0º, 30º, 60º ou 90º de flexão. Foi também calculada a rigidez do joelho em cada uma das situações nas diferentes posições testadas. Os ensaios foram realizados em dispositivo criado no Laboratório de Biomecânica LIM-41 da Faculdade de Medicina da USP, e os dados de deformação angular foram obtidos através de programa de fotogoniometria. Os resultados obtidos foram submetidos a análise estatística pela Análise de Variância para Experimento em Blocos Aleatorizados e os tratamentos foram comparados entre si pelo método de Scheffé. Foi possível concluir que: 1) A técnica empregada não corrigiu completamente o aumento da rotação externa. 2)A técnica empregada restaurou a estabilidade em varo. / The purpose of this study was to evaluate the application of a surgical technique for anatomical reconstruction of the structures from the posterolateral corner of the knee. We tested 10 cadaver knees with intact, ruptured, partially reconstructed and reconstructed ligaments. The main posterolatreal structures were cut to produce a lesion pattern. The applied force moments were of 2 N.m and 5 N.m with the knee flexed to 0, 30, 60 and 90 degrees. The stiffness of the knee in each of these situations at the studied angles was also determined. The assays were carried through in a device created at the Laboratory of Biomechanics LIM-41 from of the University of São Paulo School of Medicine. Data from the angular deformation were obtained through a photographic measurement aided by computer software. The results were submitted to ANOVA and the treatments had been compared using statistical method of Scheffé. It was possible to conclude that: 1) The technique employed wasn?t able to restore normal external rotation. 2) The technique employed restored varus stability.

A generally accepted goal in orthopaedic surgery today is to maximize conservation of tissue and reduce tissue damage. Bone-conserving implants have bone-mating surfaces that reproduce the natural curvature of bone structures, requiring less bone removal. No small, reliable, inexpensive and universal bone sculpting technique currently exists, however, that can both create and accurately align such complex surfaces. The goal of this thesis was to develop a haptic hard surface emulation mechanism that could be applied to curvilinear bone sculpting using a surgical robot. A novel dynamic physical constraint concept was developed that is able to emulate realistic hard constraints, smooth surface following, and realistic surface rigidity, while allowing complete freedom of motion away from the constraints. The concept was verified through the construction of a two-link manipulator prototype. Tests were run on nine users that involved each user tracing out five different virtual surfaces on a drawing surface using the prototype. The primary purposes of prototype testing were to obtain subjective data on how effectively the dynamic physical constraint concept simulates simple surfaces, to assess how it reacts to typical user interactions and to identify any unexpected behaviour. Users were 100% satisfied with the prototype’s ability to emulate realistic and stiff hard surfaces and with its ease of manipulation. The amount of incursion into each of the virtual surfaces by all the users was measured to assess the precision of the system with the goal of deciding whether this new haptic concept should be further developed specifically for precision applications such as surgery. For curvilinear surfaces, 90% of the cumulative distribution of the measured data was less than 2mm, while for linear surfaces it was less than 6mm. Four behavioural effects were noticed: lateral deflection, reverse ‘stickiness’, hysteresis and instability in certain areas. These effects were studied in detail to determine how to either eliminate them or to minimize them through system design optimization. A computer simulation was also used to model the behaviour of the prototype and to gain further understanding of these effects. These analyses showed that the concept can be successfully used in curvilinear bone sculpting. / Applied Science, Faculty of / Mechanical Engineering, Department of / Graduate