INTRODUCÃO: A acurácia da ressonância magnetica (RM) para a detecção de rotura do subescapular apresenta ampla variação na literatura. Existem poucos estudos prospectivos e grande variação metodológica. Acredita-se que estas roturas sejam mais dificilmente diagnosticadas do que as posterossuperiores. O tendão do subescapular apresenta importância na biomecânica no ombro e sua rotura leva a prejuízo funcional. Uma ferramenta diagnóstica de boa acurácia é fundamental na prática clínica, influenciando o prognóstico e o planejamento cirúrgico. O objetivo deste estudo foi avaliar a validade da RM pre-operatória na identificação das roturas do subescapular, comparando os achados de imagem com os dados intra-operatórios de cirurgia artroscó pica. Como objetivo secundário, avaliamos a confiabilidade do método, por meio da concordância interobservador e intraobservador. MÈTODOS: Realizamos um estudo de acurácia diagnóstica comparando os achados da RM (teste índice) com os da artroscopia (teste de referência), em uma coorte prospectiva. Foram incluídos pacientes submetidos a artroscopia para tratamento de roturas do manguito rotador que houvessem realizado RM de alto campo magnético, sem uso de contraste. Foram excluídos casos de manipulacão cirúrgica pregressa no ombro, exames com artefatos de movimentação, indicação cirurgia por via aberta e intervalo entre a RM e procedimento cirúrgico superior a um ano. As imagens foram avaliadas por um cirurgião de ombro e dois radiologistas musculoesqueleticos, de maneira independente e cegos em relacão aos resultados da artroscopia, sendo reavaliadas apos 3 meses pelo cirurgião. Calculamos a validade (sensibilidade, especificidade, valor preditivo positivo, valor preditivo negativo e acurácia) e confiabilidade (concordancia inter e intraobservador) da RM em detectar roturas do subescapular. RESULTADOS: Avaliamos 200 ombros. A incidencia de roturas do subescapular foi de 69,5% (41,5% parciais e 28,0% transfixantes). O cirurgião de ombro apresentou sensibilidade de 51,1 a 59,0% e especificidade de 91,7% a 94,4%. Os radiologistas, 83,5 a 87,1% de sensibilidade e 41 a 45,9% de especificidade. A acura?cia variou de 60,5 a 73,0%. Os valores médios de sensibilidade, especificidade e acurácia foram 70,2%, 61,9% e 67,6%, respectivamente. A concordância interobservador foi moderada para a deteccao de roturas do subescapular (coeficiente kappa 0,463, IC 95% 0,383- 0,534, p < 0,001), assim como a intraobservador (coeficiente kappa 0,546, IC 95% 0,430-0,662, p < 0,001). Os pacientes com rotura do subescapular apresentaram maior incidencia de rotura e instabilidade do bíceps, maior degeneração gordurosa do subescapular e média de idade superior. As demais variáveis nao apresentaram diferenças estatisticamente significantes. CONCLUSAO: A RM de alto campo magneético sem contraste apresentou valores médios de sensibilidade, especificidade e acurácia de 70,2%, 61,9% e 67,6%, respectivamente. A sensibilidade foi superior nos radiologistas enquanto a especificidade no cirurgião de ombro. A concordância interobservador e intraobservador foi moderada / INTRODUCTION: The accuracy of magnetic resonance imaging (MRI) for the detection of subscapularis tear presents wide variation in the literature. There are few prospective studies and great methodological variation. It is believed that these tears are more difficult to diagnose than the posterosuperiores rotator cuff injuries. The subscapularis tendon has importance in the biomechanics in the shoulder and its rupture leads to functional impairment. A diagnostic tool of good accuracy is fundamental in clinical practice, influencing prognosis and surgical planning. The aim of this study was to evaluate the validity of preoperative MRI in the identification of the subscapularis tears, comparing the imaging findings with the intraoperative data of arthroscopic surgery. As a secondary objective, we evaluated the reliability of the method through interobserver and intraobserver agreement. METHODS: We performed a diagnostic accuracy study comparing MRI findings (index test) with those of arthroscopy (reference test), in a prospective cohort. We included patients submitted to arthroscopy for the treatment of rotator cuff tears that had undergone high magnetic field MRI without using contrast. Cases of previous surgical manipulation in the shoulder, exams with moving artifacts, indication for open surgery and interval between MRI and surgical procedure of more than one year were excluded. The images were evaluated by a shoulder surgeon and two musculoskeletal radiologists, independently and blinded to the results of arthroscopy, being reassessed after 3 months by the surgeon. We calculated the validity (sensitivity, specificity, positive predictive value, negative predictive value and accuracy) and reliability (inter- and intraobserver agreement) of MR in detecting subscapularis tears. RESULTS: We evaluated 200 shoulders. The incidence of subscapularis tears was 69.5% (41.5% partial and 28.0% transfixing). The shoulder surgeon showed sensitivity from 51.1 to 59.0% and specificity from 91.7% to 94.4%. The radiologists, 83.5 to 87.1% of sensitivity and 41 to 45.9% of specificity. Accuracy ranged from 60.5 to 73.0%. The mean values of sensitivity, specificity and accuracy were 70.2%, 61.9% and 67.6%, respectively. Interobserver agreement was moderate for the detection of subscapular tears (kappa coefficient 0.463, 95% CI 0.383-0.534, p < 0.001), as well as intraobserver agreement (kappa coefficient 0.546, 95% CI 0.430-0.662, p < 0.001). Patients with subscapular rupture had a higher incidence of biceps rupture and instability, greater fat subscapular degeneration, and higher mean age. The other variables did not present statistically significant differences. CONCLUSION: MRI of high magnetic field without contrast showed mean values of sensitivity, specificity and accuracy of 70.2%, 61.9% and 67.6%, respectively. Sensitivity was higher in radiologists while specificity in the shoulder surgeon. Interobserver and intraobserver agreement was moderate

Made available in DSpace on 2016-01-26T12:51:43Z (GMT). No. of bitstreams: 1 rassen_dissert.pdf: 1247464 bytes, checksum: 68e143195fe25c1bd50b6681db4d40e7 (MD5) Previous issue date: 2001-09-28 / The aim of the present study is to evaluate the result of the knee pain treatment using The Opposite Side Technique from the Traditional Chinese Medicine. Thirty-six patients with unilateral gonalgia were studied. 44.44% (16) with osteoarthrosis, 30.55% (11) with patella femural osteoarthrosis, 11.11% (4) with severe osteoarthrosis, 11.11% (4) with patella chrondomalacy and 2.77% (1) with synovial plica. The patients were divided in two groups: Group I (Acupuncture) were eighteen, who submitted to 20 acupuncture sessions, where it was used points of counter to lateral acupuncture to the affected knee and acupuncture points to the distance according to the Traditional Chinese Medicine and to the acupuncture neurophisiologic action standard to select these points for the treatment, and Group II (Phisiotherapy) also eighteen, who submitted to 20 physiotherapeutic sessions and antiinflamatory non steroid (AINS) medicines. According to the results from the statistical analysis, non-parametric, of the subjective data (the intensity of the described pain, difficulty in walking, in crouching, in going upstairs and downstairs, in running, in jumping, in claudicant motion, in making use of some walking support) as the objective parameters ( the restriction of the flexional moviment and also the one of the knee extension moviment, and the arc moviment) showed good results in all the studied parameters. The most refractory parameters were the objective ones above mentioned. The Jue Yin (Liver) energetic channel of the foot showed to be the most affected (22.22%), followed by the associations of the Jue Yin (Liver) and the Tae Yang (Bladder) energetic channel of the foot (22.22%), the Jue Yin (Liver) and the Yang Ming (Stomach) of the foot (16.66%), and the Jue Yin (Liver) and the Shao Yang (Gall Bladder) of the foot (11.11%), and another associations (16.66%). The false-Yang (52.77%) characteristics of disorders were the predominant in relation to the energetic ones followed by the Yin (33.33%) and the Yang (13.88%) disorders of the patients. / O presente estudo teve a finalidade de avaliar a eficácia da acunputura no pós-operatório das cirurgias artroscópicas no joelho utilizando - se a técnica "ao oposto" da medicina tradicional chinesa. As 36 gonalgias estudadas foram distribuídas conforme a patologia encontrada nas artroscópicas cirúrgicas: 50,0% tinham lesão do menisco medial isolada, 19,44% tinham lesão meniscal associada à artrose de joelho, 11,11% tinham lesão meniscal lateral associada à artrose de joelho, 8,33% tinham lesão meniscal lateral isolada de joelho, 2,77% apresentavam lesão em ambos os menisco associados à artrose de joelho, 2,77% apresentavam condromalácea de patela e 2,77% eram portador de corpo livre. Os pacientes foram dividos em dois grupos. Todos os pacientes do grupo i (acunputura) 18 foram submetidos a 20 sessões de acunputura, utilizando-se pontos de acunputura, utilizando-se pontos de acunputura contra-lateral ao joelho afetado, e os pacientes do grupo ii (fisioterapia), 18, foram submetidos a 20 sessões de fisioterapia, associadas a anti-inflamatórios não esteroídes (aine). Nota de Resumo A análise estatística não paramétrica dos resultados obtidos nos dados subjetivos (intensidade da dor relatada, dificuldade de andar, de agachar, de subir e descer degraus, de correr, de uso de apoio a marcha), como os parâmetros objetivos (limitação do movimento de flexão, extensão, arco de movimento, edema, derrame e trofismo de joelho) evidenciaram bons resultados na maioria dos parâmetros estudados. Embora os resultados fossem semelhantes, a acunputura apresentou melhores resultados do tratamento mais precocemente, enquanto a fisioterapia mais tardiamente.

Resumo: No presente estudo, objetivou-se avaliar a utilização do enxerto alógeno de ligamento patelar (OLO) conservado em glicerina 98% e fixado por meio de parafusos de interferência como substituto do ligamento cruzado cranial (LCCr) em cães. Observou-se a exeqüibilidade e eficácia desta técnica cirúrgica e o comportamento do enxerto e dos parafusos durante o período de 120 dias, baseandose na capacidade dos exames clínicos, radiográficos e artroscópicos, em detectar o possível início e a progressão de alterações degenerativas secundárias na articulação do joelho. Para tanto foram utilizados oito animais da espécie canina pesando entre 17,2 e 26,4Kg. O enxerto utilizado correspondeu ao segmento composto pelo terço intermédio da patela, ligamento patelar e porção cranial da tuberosidade da tíbia, coletado de cadáveres de cães e conservado em glicerina 98%. Os oito cães foram separados em dois grupos, A e B e cada um contendo quatro animais para avaliação artroscópica ("segunda observação") aos 60 e 120 dias do pós-operatório. Todos os cães foram submetidos ao procedimento cirúrgico no joelho direito. Clinicamente, avaliou-se o grau de claudicação, o perímetro muscular da coxa e o movimento de gaveta cranial nos oito cães no pré-operatório e semanalmente, até completarem-se 120 dias. Foi observada diminuição da circunferência da coxa significativa (p<0,05) após o período de dez dias em que os cães permaneceram com a bandagem compressiva, sendo recuperada de forma significativa até 13° semana. As pontuações obtidas na avaliação do movimento de gaveta (extensão e flexão) tornaram-se significativamente diferentes da pré-operatória entre a 5° e 15° semanas (p<0,05). Quatro cães apresentaram ao final do experimento ausência de instabilidade articular como na avaliação pré-operatória e os outros... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: The aim of this study was to evaluate the use of patelar ligament allograft (BLB) conserved in 98% glycerin and fixated with interferemce screws as a substitute of the cranial cruciate ligament in dogs (CrCL). It was observed the feasibility and efficiency of this surgical technique and the graft and screws conduct along 120 days, basing on clinical, radiographic and arthroscopic capacity in detect the beginning and progress of secondary degenerative stifle joint changes. For this purpose, eight mongrel dogs weighting from 17,2 e 26,4 Kg were used. The graft consisted of the intermediate third of the pattela, patellar ligament and cranial portion of the tibial crest, harvested from dog cadavers and preserved in 98% glycerin.The eight dogs were randomly allocated in two groups, A and B, each one with four dogs for arthroscopic evaluation ("second-look") at 60 and 120 days postoperative. All the dogs were submitted to the surgical procedure in the right knee. Clinically, lameness degree, thigh girth measurement and cranial-drawer test were evaluated in the eight dogs in preoperative, and weekly, until complete 120 days. A significant decrease in thigh girth (p<0,05) observed after ten days period that the dogs were using compressive bandage was recovered until the 13th week. The cranial-drawer test scores (flexion and extension) became significantly different between the 5th and 15th weeks postoperative (p>0,05). Four dogs presented at the final study period with no articular instability just like the preoperative evaluation, and the other four with just a slight craniocaudal instability. In the lameness evaluation, from the 4th week, all the dogs presented mean score for stands with equal... (Complete abstract click electronic access below) / Orientador: João Guilherme Padilha Filho / Coorientador: Julio Carlos Canola / Banca: Cintia Lúcia Maniscalco / Banca: Márcia Rita Fernandes Machado / Banca: Patricia Popak Giordano / Banca: Gisleine Cristina Eimantas / Doutor

INTRODUCÃO: A acurácia da ressonância magnetica (RM) para a detecção de rotura do subescapular apresenta ampla variação na literatura. Existem poucos estudos prospectivos e grande variação metodológica. Acredita-se que estas roturas sejam mais dificilmente diagnosticadas do que as posterossuperiores. O tendão do subescapular apresenta importância na biomecânica no ombro e sua rotura leva a prejuízo funcional. Uma ferramenta diagnóstica de boa acurácia é fundamental na prática clínica, influenciando o prognóstico e o planejamento cirúrgico. O objetivo deste estudo foi avaliar a validade da RM pre-operatória na identificação das roturas do subescapular, comparando os achados de imagem com os dados intra-operatórios de cirurgia artroscó pica. Como objetivo secundário, avaliamos a confiabilidade do método, por meio da concordância interobservador e intraobservador. MÈTODOS: Realizamos um estudo de acurácia diagnóstica comparando os achados da RM (teste índice) com os da artroscopia (teste de referência), em uma coorte prospectiva. Foram incluídos pacientes submetidos a artroscopia para tratamento de roturas do manguito rotador que houvessem realizado RM de alto campo magnético, sem uso de contraste. Foram excluídos casos de manipulacão cirúrgica pregressa no ombro, exames com artefatos de movimentação, indicação cirurgia por via aberta e intervalo entre a RM e procedimento cirúrgico superior a um ano. As imagens foram avaliadas por um cirurgião de ombro e dois radiologistas musculoesqueleticos, de maneira independente e cegos em relacão aos resultados da artroscopia, sendo reavaliadas apos 3 meses pelo cirurgião. Calculamos a validade (sensibilidade, especificidade, valor preditivo positivo, valor preditivo negativo e acurácia) e confiabilidade (concordancia inter e intraobservador) da RM em detectar roturas do subescapular. RESULTADOS: Avaliamos 200 ombros. A incidencia de roturas do subescapular foi de 69,5% (41,5% parciais e 28,0% transfixantes). O cirurgião de ombro apresentou sensibilidade de 51,1 a 59,0% e especificidade de 91,7% a 94,4%. Os radiologistas, 83,5 a 87,1% de sensibilidade e 41 a 45,9% de especificidade. A acura?cia variou de 60,5 a 73,0%. Os valores médios de sensibilidade, especificidade e acurácia foram 70,2%, 61,9% e 67,6%, respectivamente. A concordância interobservador foi moderada para a deteccao de roturas do subescapular (coeficiente kappa 0,463, IC 95% 0,383- 0,534, p < 0,001), assim como a intraobservador (coeficiente kappa 0,546, IC 95% 0,430-0,662, p < 0,001). Os pacientes com rotura do subescapular apresentaram maior incidencia de rotura e instabilidade do bíceps, maior degeneração gordurosa do subescapular e média de idade superior. As demais variáveis nao apresentaram diferenças estatisticamente significantes. CONCLUSAO: A RM de alto campo magneético sem contraste apresentou valores médios de sensibilidade, especificidade e acurácia de 70,2%, 61,9% e 67,6%, respectivamente. A sensibilidade foi superior nos radiologistas enquanto a especificidade no cirurgião de ombro. A concordância interobservador e intraobservador foi moderada / INTRODUCTION: The accuracy of magnetic resonance imaging (MRI) for the detection of subscapularis tear presents wide variation in the literature. There are few prospective studies and great methodological variation. It is believed that these tears are more difficult to diagnose than the posterosuperiores rotator cuff injuries. The subscapularis tendon has importance in the biomechanics in the shoulder and its rupture leads to functional impairment. A diagnostic tool of good accuracy is fundamental in clinical practice, influencing prognosis and surgical planning. The aim of this study was to evaluate the validity of preoperative MRI in the identification of the subscapularis tears, comparing the imaging findings with the intraoperative data of arthroscopic surgery. As a secondary objective, we evaluated the reliability of the method through interobserver and intraobserver agreement. METHODS: We performed a diagnostic accuracy study comparing MRI findings (index test) with those of arthroscopy (reference test), in a prospective cohort. We included patients submitted to arthroscopy for the treatment of rotator cuff tears that had undergone high magnetic field MRI without using contrast. Cases of previous surgical manipulation in the shoulder, exams with moving artifacts, indication for open surgery and interval between MRI and surgical procedure of more than one year were excluded. The images were evaluated by a shoulder surgeon and two musculoskeletal radiologists, independently and blinded to the results of arthroscopy, being reassessed after 3 months by the surgeon. We calculated the validity (sensitivity, specificity, positive predictive value, negative predictive value and accuracy) and reliability (inter- and intraobserver agreement) of MR in detecting subscapularis tears. RESULTS: We evaluated 200 shoulders. The incidence of subscapularis tears was 69.5% (41.5% partial and 28.0% transfixing). The shoulder surgeon showed sensitivity from 51.1 to 59.0% and specificity from 91.7% to 94.4%. The radiologists, 83.5 to 87.1% of sensitivity and 41 to 45.9% of specificity. Accuracy ranged from 60.5 to 73.0%. The mean values of sensitivity, specificity and accuracy were 70.2%, 61.9% and 67.6%, respectively. Interobserver agreement was moderate for the detection of subscapular tears (kappa coefficient 0.463, 95% CI 0.383-0.534, p < 0.001), as well as intraobserver agreement (kappa coefficient 0.546, 95% CI 0.430-0.662, p < 0.001). Patients with subscapular rupture had a higher incidence of biceps rupture and instability, greater fat subscapular degeneration, and higher mean age. The other variables did not present statistically significant differences. CONCLUSION: MRI of high magnetic field without contrast showed mean values of sensitivity, specificity and accuracy of 70.2%, 61.9% and 67.6%, respectively. Sensitivity was higher in radiologists while specificity in the shoulder surgeon. Interobserver and intraobserver agreement was moderate

[Truncated abstract] Articular cartilage (AC) covers the surface of synovial joints providing a nearly frictionless bearing surface and distributing mechanical load. Joint trauma can damage the articular surface causing pain, loss of mobility and deformation. Currently there is no uniform treatment protocol for managing focal cartilage defects, with most treatment options targeted towards symptomatic relief but not limiting the progression into osteoarthritis (OA). Autologous chondrocyte implantation (ACI) and more recently matrix-induced autologous chondrocyte implantation (MACI), have emerged as promising methods for producing hyaline or hyaline-like repair tissue, however there remains some controversy regarding the exact histological nature of the tissue formed. Histological characterisation of AC repairs requires destructive tissue biopsy potentially inducing further joint pathology thereby negating the treatment effect. OA is recognised as a major cause of pain, loss of function and disability in Western populations, however the exact aetiology is yet to be elucidated. The assessment of both OA and cartilage repair has been limited to macroscopic observation, radiography, magnetic resonance imaging (MRI) or destructive biopsy. The development of non-destructive AC assessment modalities will facilitate further development of AC repair techniques and enable early monitoring of OA changes in both experimental animal models and clinical subjects. Confocal laser scanning microscopy (CLSM) is a type of fluorescence microscopy that generates high-resolution three-dimensional images from relatively thick sections of tissue. ... Biomechanical analysis suggested that the mechanical properties of MACI tissue remain inferior for at least three months. This study showed the potential of a multi-site sheep model of articular cartilage defect repair and validated its assessment via LSCA. Finally, the LSCA was used to arthroscopically image the cartilage of an intact fresh frozen cadaveric knee from a patient with clinically diagnosed OA. Images were correlated to ICRS (Outerbridge) Grades I-IV and histology. The LSCA gave excellent visualization of cell morphology and cell density to a depth of up to 200'm. Classical OA changes including clustering chondrocytes, surface fibrillation and fissure formation were imaged. Fair to moderate agreement was demonstrated with statistically significant correlations between all modalities. This study confirmed the viability of the LSCA for non-destructive imaging of the microstructure of the OA cartilage. In conclusion, the LSCA identified histological features of orthopaedic tissues, accurately quantified chondrocyte morphology and demonstrated classical OA changes. While the development and investigation of an ovine model of cartilage repair showed the treatment benefit of MACI, some biomechanical issues remain. Ultimately, the LSCA has been demonstrated as a reliable nondestructive imaging modality capable of providing optical histology without the need for mechanical biopsy. Medical Subject Headings (MESH): articular cartilage; autologous chondrocyte implantation; matrix-induced autologous chondrocyte implantation; biomechanics; cartilage; confocal microscopy; diagnosis; histology; image analysis; immunohistochemistry; magnetic resonance imaging; microscopy; osteoarthritis

Zielstellung: Bei der Frage, ob die Durchführung von Korrekturosteotomien zur Ent-lastung betroffener Areale bei Hunden mit ED sinnvoll ist, erscheint es uns von zentraler Bedeutung, auch eine geringgradig ausgeprägte RUI präzise zu bestim-men. In der vorliegenden Arbeit wurden deshalb folgende Ziele verfolgt: (1) Evaluie-rung der Sensitivität und Spezifität der Bestimmung von radioulnaren Gelenks-formationen anhand von dreidimensionalen CT-Modellen und der Arthroskopie. (2) Erweiterung des Untersuchungsgutes, da im Gegensatz zu vorangegangenen Stu-dien sowohl Inkongruenzen mit verkürztem Radius (positive RUI) als auch mit ver-kürzter Ulna (negative RUI) einbezogen wurden. Material und Methode: In das Untersuchungsgut gingen Vordergliedmaßen gesun-der Hunde mittelgroßer und großer Rassen ein. Mit Hilfe eines etablierten Modells wurde experimentell der Radius stufenweise um 1 und 2 mm verkürzt, bzw. verlän-gert. In der ersten Studie wurden 64 radioulnare Gelenksformationen anhand von dreidimensional rekonstruierter CT-Modelle untersucht. In der zweiten Studie wurden 72 radioulnare Gelenksformationen arthroskopisch beurteilt. Die Art der Stufe und ih-re Reihenfolge waren jeweils randomisiert und geblindet. Die Gelenksformationen wurden als -2, -1, 0, 1 und 2 mm Stufe klassifiziert. Ergebnisse: Für die Bestimmung der radioulnaren Gelenksformation anhand von dreidimensional rekonstruierter CT-Modelle konnte ein Interklassen-Korrelations-koeffizient von 0,87 und ein Intraklassen-Korrelationskoeffizient von 0,96 ermittelt werden. Die mediane Sensitivität im Hinblick auf das Erkennen eines inkongruenten Gelenkes lag bei 0,86 (0,82 - 0,98). Die mediane Spezifität bei 0,77 (0,62 - 0,92). Bei der Arthroskopie konnte ein kongruentes Gelenk mit einer Sensitivität von 0,98 (95% KI: 0,90 - 0,99) bestimmt werden. Die Spezifität ein kongruentes Gelenke richtig zu diagnostizieren, lag bei 0,89 (95% KI: 0,65 – 0,98). Schlussfolgerungen: Die Abweichungen zwischen den drei Untersuchern in der ersten Studie legen nahe, dass die Genauigkeit der Bestimmung von radioulnaren Inkongruenzen durch entsprechendes Training deutlich verbessert werden können. Die besten Ergebnisse konnte der Untersucher erzielen, der sich am längsten mit der beschriebenen Technik befasst hatte. Wir postulieren daher, dass die Genauigkeit der semiquantitativen Beurteilung der RUI anhand dreidimensional rekonstruierter CT-Modelle bei regelmäßiger Schulung zunimmt. Dieses Diagnostikum ist in-vitro präzise, wiederholbar und ermöglicht eine nicht invasive Beurteilung der subchondra-len Gelenkflächen. Die Arthroskopie erlaubt eine direkte Visualisierung und Palpation der intraartiku-lären Strukturen und eine präzise Bestimmung sowohl einer positiven als auch negativen RUI. Festzuhalten bleibt, dass es eine minimal invasive Technik ist und sich somit als Standard- beziehungsweise Vorsorgeuntersuchung zur Diagnostik der ED beim Hund kaum eignet. Im Vergleich zu Röntgen- und CT-Untersuchungen kön-nen mittels Arthroskopie jedoch die besten Ergebnisse zur Bestimmung der radio-ulnaren Gelenksformation in-vitro erzielt werden.

[Truncated abstract] An important field of research in orthopaedic biomechanics is the elucidation and mathematical modelling of the mechanical response of cartilaginous tissues. Such research has applications in the understanding of joint function and degenerative processes, as well as in surgical planning and simulation, and engineering of tissue replacements. In the case of surgical and tissue engineering applications especially, patient-specific mechanical properties are highly desirable. Unfortunately, obtaining such information would generally involve destructive mechanical testing of patient tissue, thus rendering the tissue functionally unusable. Development of a laser scanning confocal arthroscope (LSCA) within our School will soon allow non-invasive extraction of 3D microstructural images of cartilaginous tissues in vivo. It is also envisaged that, linked to a suitably formulated constitutive formulation, such information could allow estimation of tissue mechanical response without physical biopsy. This thesis describes the development of techniques to potentially allow non-invasive patient-specific estimation of tissue mechanical response based on confocal arthroscopy data. A microstructural constitutive model is developed which is capable of directly incorporating LSCA-derived patient-specific structural information. A fibre composite type homogenisation approach is used as the basis for the model. ... The result is a series of orientation tensors describing the 3D orientation of linear features in the image stack. The developed analysis techniques are used to estimate fibre volume fraction and orientation distribution for each of the meniscal specimens. The developed constitutive model and image-derived structural parameters are finally used to estimate the reaction force history of two meniscal cartilage specimens subjected to partially confined compression. The predictions are made on the basis of the specimens? individual structural condition as assessed by confocal microscopy and involve no tuning of material parameters. Although the model does not reproduce all features of the experimental curves, as an unfitted estimate of mechanical response the prediction is quite accurate. In light of the obtained results it is judged that more general non-invasive estimation of tissue mechanical properties is possible using the developed framework. The likely limitations and potential areas of improvement are discussed.

A evolução do conhecimento acerca das funções dos meniscos e do tratamento das suas lesões, impulsionada pelo advento da cirurgia artroscópica, consagrou e popularizou a meniscectomia por esta via, por ser uma técnica menos invasiva, com menor morbidade e menores custos hospitalares, a ponto de torná-la, atualmente, a cirurgia ortopédica mais frequentemente realizada no mundo. Embora a maior parte dos pacientes submetidos a esta intervenção cirúrgica tenha resultados favoráveis e resolução rápida dos sintomas, percebe-se que parte considerável dos pacientes, especialmente os mais idosos, não apresenta uma evolução póscirúrgica satisfatória, apresentando piora dos sintomas e, eventualmente, necessitando de nova cirurgia. Partindo da hipótese que em determinados pacientes a meniscectomia, em vez de tratar, precipita e acentua um desequilíbrio biomecânico do joelho, o autor realizou estudo observacional prospectivo não-controlado com 86 pacientes de ambos os gêneros, com idade superior a 50 anos (média de 60,2 ± 7,1 anos), submetidos à meniscectomia artroscópica para tratamento de lesão do menisco medial de natureza degenerativa, com o objetivo de determinar variáveis demográficas, clínicas, anatômicas e cirúrgicas relacionadas aos resultados desfavoráveis. As avaliações funcionais pré e pós-operatórias foram realizadas utilizandose o Índice do KOOS (Knee Injury and Osteoarthritis Outcome Score), aplicado a todos os pacientes antes da cirurgia e 60 meses depois. Após análise estatística dos resultados obtidos, o autor verificou que 10 fatores podem ser considerados preditivos das meniscectomias mediais artroscópicas neste grupo etário, sendo quatro fatores fortemente associados aos resultados desfavoráveis: lesão da raiz posterior do menisco medial, dor pré-operatória intensa, claudicação antes da cirurgia e tempo decorrido entre o início dos sintomas e a cirurgia; dois fatores foram considerados moderadamente associados aos resultados desfavoráveis: presença de edema de medula óssea na ressonância magnética (RM) préoperatória e duração da cirurgia; quatro fatores foram considerados associados de modo fraco aos resultados desfavoráveis: Índice de Massa Corporal (IMC) >= 30 kg/m2 , varismo do joelho, presença de cisto poplíteo na RM pré-operatória e extensão da ressecção do menisco medial / The evolution of knowledge concerning meniscal functions and the treatment of their injuries, boosted by the development of arthroscopic surgery, has established and popularized arthroscopic meniscectomy due to its less invasiveness, less post-operative morbidity and lower hospital costs, to the point it has become, nowadays, the most frequently performed orthopedic procedure in the world. Although the majority of patients undergoing this operation is quite pleased with the outcomes and with the prompt resolution of their symptoms, it is noticeable that a considerable amount of patients with meniscal injuries, mainly the older, does not have a satisfactory postoperative outcome, with worsening of symptoms after being operated on and occasionally requiring another surgery. Based on observations of his medical practice and on the assumption that meniscectomy, rather than treat, can hasten and accentuate a biomechanical imbalance of the knee in those patients, the author conducted an observational prospective uncontrolled study with 86 patients of both genders, aged over 50 years old (average 60.2 ± 7.1 years), who underwent arthroscopic meniscectomy for the treatment of degenerative medial meniscal lesions, aiming to determine demographic, anatomical, clinical and surgical variables related to poor outcomes. The functional pre and post-operative evaluations were performed using the KOOS index (Knee Injury and Osteoarthritis Outcome Score) applied to all patients before surgery and 60 months later. After statistical analysis of the results, the author found that 10 factors can be considered predictors of arthroscopic medial meniscectomy in this age group: four factors were strongly associated with unfavorable results - posterior root lesion of the medial meniscus, intense pre-operative pain, claudication before surgery and time elapsed between onset of symptoms and surgery; two factors were moderately associated with unfavorable results - bone marrow edema in preoperative magnetic resonance imaging (MRI) and surgery time length; four factors that were weakly associated with poor results - bone mass index (BMI) >= 30 kg/m2, varus knee, poplyteal cyst in pre-operative MRI and extension of meniscal ressection

INTRODUÇÃO: A precisão no posicionamento dos túneis ósseos na reconstrução do ligamento cruzado anterior do joelho (LCA) é considerado um dos fatores fundamentais para o bom resultado dessa cirurgia. A cirurgia ortopédica auxiliada por computador (computer aided orthopedic surgery CAOS) é um avanço tecnológico que tem como um dos principais objetivos exatamente o aumento da precisão. OBJETIVO: comparar o posicionamento do centro dos túneis e a isometria do enxerto obtidos com o uso de um sistema de navegação computadorizada (Orthopilot) e com o uso de guias cirúrgicos convencionais. MÉTODOS: 36 joelhos pareados de cadáveres tiveram o LCA ressecado por artroscopia no Laboratório de Artroscopia do Departamento de Ortopedia e Traumatologia da Faculdade de Medicina da Universidade de São Paulo. Um joelho de cada par foi ramdomizado para o grupo 1 (guias cirúrgicos convencionais) e o outro para o grupo 2 (Orthopilot). Um fio de sutura inelástico foi passado pelo centro dos túneis tibial e femoral confeccionados para a reconstrução do LCA, sem que os túneis fossem finalmente brocados. Todos os joelhos foram então analisados quanto ao posicionamento do centro do túnel tibial (distância do LCP, distância da tubérculo intercondilar medial da tíbia e distância do corno anterior do menisco lateral), do centro do túnel femoral (distância da cortical posterior e angulação coronal na fossa intercondilar do fêmur) e a variação da distância entre os pontos centrais do túnel femoral para o túnel tibial em flexão de 90º e em extensão (isometria). Os dados foram analisados segundo o teste de Wilcoxon para comparação de duas amostras pareadas. RESULTADOS: A variação da distância entre o tunel femoral e tibial em flexão e extensão (isometria) foi maior no grupo 1 convencional, do que no grupo 2 Orthopilot (grupo 1: média 4,2mm com intervalo de 1,1mm a 9,4mm versus grupo 2: média 2,8mm com intervalo de 0,3mm a 6,7mm; p<0,05). Os outros parâmetros analisados não tiveram diferença estatística entre os grupos e demonstraram que todos os túneis dos dois grupos estavam bem posicionados de acordo com os critérios adotados. CONCLUSÕES: O emprego de instrumental cirúrgico navegado pelo sistema Orhtopilot permitiu o posicionamento dos túneis ósseos da reconstrução do LCA de maneira tão precisa quanto os guias cirúrgicos convencionais utilizados. Mais do que isso, proporcionou um posicionamento significativamente mais isométrico nessa série / INTRODUCTION: Precise tunnel location has been considered to be very important to achieve good results in anterior cruciate ligament (ACL) reconstruction surgery. Computer Aided Orthopedic Surgery (CAOS) is a technology improvement whose main objective is to enhance precision. PURPOSE: To compare the accuracy of tunnel placement and graft isometry for ACL reconstruction performed with the use of a computer-assisted navigation system (Orthopilot) and with traditional instruments. METHODS: 36 matched-paired cadaveric knees had their intact ACL removed by arthroscopy at the Arthroscopy Laboratory Orthopedic Department of University of São Paulo Medical School. One knee of each pair was randomized to group 1 (traditional instruments) or group 2 (Orthopilot). An inelastic suture was then passed through the center of where would be the tibial tunnel and then through the center of where would be the femoral tunnel. None of the tunnels were actually drilled. All knees were then dissected and 6 parameters were obtained: The distance from the tibial tunnel center to: 1) the PCL; 2) the lateral meniscus anterior horn; 3) the medial tibial spine. 4) The distance from the femoral tunnel center to the posterior femoral cortex. 5) The femoral tunnel coronal angle. 6) The variation of the distance from the femoral to the tibial tunnels with the knee extended and in 90 degree flexion. The data were submitted to statistical analysis and compared with the Wilcoxon Matched Pairs Test. RESULTS: The variation of the distance from the femoral to the tibial tunnels in flexion and extension was smaller in the Orthopilot group (better isometry): group 1: mean 4.2 mm (1.1-9.4 mm); group 2: mean 2.8 mm (0.3-6.7 mm) p<0,05. All other parameters showed no statistical difference between the groups and all tunnels were considered to be in satisfactory positions. DISCUSSION: There was no difference in tunnel position between the groups. Better isometry was achieved in the Orthopilot group compared to conventional instruments

Akute Sprengungen des Acromioclaviculargelenks sind eine häufige Verletzungsentität des jungen Erwachsenen. Für höhergradige Verletzungen wird eine operative Versorgung empfohlen, hierbei gibt es eine überwältigende Vielzahl an therapeutischen Möglichkeiten. Durch die wachsende Beliebtheit minimalinvasiver Behandlungsmöglichkeiten etablierten sich in den letzten Jahren arthroskopische Techniken zunehmend in der operativen Versorgung von ACG-Verletzungen. Die arthroskopischen Therapieempfehlungen unterlagen aufgrund einer häufig beobachteten Instabilität in der Horizontalebene des Acromioclaviculargelenks in den letzten Jahren einem Paradigmenwechsel. Für akute Acromioclaviculargelenkssprengungen empfiehlt die Mehrzahl der aktuellen Publikationen eine arthroskopische Versorgung mittels einer doppelten Implantation künstlicher Bandstrukturen zur Rekonstruktion der coracoclaviculären Ligamente in anatomischer Positionierung sowie eine zusätzliche operative Reparatur der acromioclaviculären Kapsel. Ein Konsens zu optimalen Versorgung höhergradiger Verletzungen besteht aktuell nicht. Ziel der vorliegenden Arbeit war es, die aktuellen Empfehlungen auf Grundlage der biomechanischen Eigenschaften des Acromioclaviculargelenks in der Horizontalebene nach arthroskopischer Rekonstruktion zu reevaluieren. Dafür sollte überprüfen werden, inwieweit die Positionierung und Anordnung der Rekonstruktionsimplantate der coracoclaviculären Ligamente sowie eine zusätzliche Stabilisierung der Acromioclavicularkapsel mittels Fadencerclage einen Einfluss auf die Stabilität im AC-Gelenk haben. Als Untersuchungsgegenstand dienten folgende Rekonstruktionsarten: • Single-Coracoclavicular-Tunnel (SCT) Technik als Rekonstruktion mittels eines coracoclaviculär eingebrachten TightRope™-Implantates (Arthrex Inc.; Naples, FL, USA) mit zusätzlicher acromioclaviculärer Fadencerclage • Double-Coracovlavicular-Tunnel (DCT) Technik als Rekonstruktion mittels zweier coracoclaviculär eingebrachter TightRope™-Implantate (Arthrex, USA) in anatomischer Positionierung ohne additive Stabilisierung • Double-Coracovlavicular-Tunnel (DCT) Technik als Rekonstruktion mittels zweier coracoclaviculär eingebrachter TightRope™-Implantate (Arthrex, USA) in anatomischer Positionierung mit zusätzlicher acromioclaviculärer Fadencerclage • Double-Coracovlavicular-Tunnel (DCT) Technik als Rekonstruktion mittels zweier coracoclaviculär eingebrachter TightRope™-Implantate (Arthrex, USA) in nicht-anatomischer (spiegelbildlicher) Positionierung mit zusätzlicher acromioclaviculärer Fadencerclage Die biomechanische Untersuchung erfolgte an Ethanol-Glycerin-fixierten menschlichen Schulterpräparaten. Die Auswertung erfolgte mit einem optischen 3D-Messsystem. In dieser Arbeit konnte nachgewiesen werden, dass eine Rekonstruktion der coracoclaviculären Bänder mit zwei eingebrachten TightRope™-Implantaten (Arthrex, USA) in anatomischer Positionierung mit und ohne zusätzliche acromioclaviculäre Cerclage in einer signifikant höheren Stabilität in der Horizontalebene des Acromioclaviculargelenks resultiert als eine Rekonstruktion mit nur einem TightRope™-Implantat (Arthrex, USA), auch mit zusätzlicher acromioclaviculärer Cerclage. Zwischen den Rekonstruktionstechniken der coracoclaviculären Bänder mit zwei Implantaten gab es keinen signifikanten Unterschied in der Stabilität durch eine zusätzliche acromioclaviculäre Cerclage. Die Rekonstruktion der coracoclaviculären Ligamente mit zwei eingebrachten TightRope™-Implantaten (Arthrex, USA) in anatomischer Positionierung resultierte in einer signifikant höheren Stabilität in der Horizontalebene als bei spiegelbildlicher Positionierung der eingebrachten Implantate. Im Gegensatz zu dem aktuell populären Ansatz, eine hinreichende Stabilisierung in der Horizontalebene des Acromioclaviculargelenks durch eine arthroskopische Rekonstruktion mittel künstlicher Ligament-Implantate sei nur mit einer zusätzlichen Rekonstruktion der acromioclaviculären Kapsel zu erreichen, konnte in dieser Arbeit demonstriert werden, dass eine Rekonstruktion der AC-Kapsel nicht generell die Stabilität in der Horizontalebene im AC-Gelenk beeinflusst. Die Stabilisierung hängt maßgeblich von einer suffizienten Rekonstruktion der coracoclaviculären Ligamente in anatomischer Positionierung ab.