Hip resurfacing is an alternative to total hip arthroplasty for the young and active patient likely to outlive traditional means of hip joint replacement. The acetabular cup is implanted in much the same fashion as an uncemented total hip arthroplasty, however, implantation of the femoral component is unique to hip resurfacing, presenting both distinct benefits and limitations. Hip resurfacing spares much of the proximal femur including the femoral neck and portions of the femoral head. This may be advantageous if the patient requires revision surgery; however, preservation of the femoral neck bears with it the risk of femoral neck fracture. The exact mechanism of neck fracture is not fully understood. Avoiding potential fracture risks is vital to ensuring optimal patient outcomes. The current work investigated mechanical femoral head preparatory factors that may predispose to femoral neck fracture. Intra-operative computer navigation is emerging as the gold-standard in orthopaedic care. In hip resurfacing, navigation may improve the surgeon’s ability to optimally implant the resurfacing prosthesis; however, much of this technology is still in its infancy and requires investigation into the accuracy and repeatability of this peri-operative tool. Pre-operative planning can assist the surgeon in optimally determining the size and position of the resurfacing components, specifically in reference to the patient’s unique anatomy, prior to performing the operation. This may aid in correct implant selection and provide a basis on which to conduct intra-operative navigation. However, the accuracy and repeatability of pre-operative planning for hip resurfacing has not yet been established. Thus, this body of work looked to establish a clear methodology for pre-operative planning, intra-operative computer navigation and surgical technique in order to optimize preparation of the femoral head, ultimately reducing the risk of femoral neck fracture in hip resurfacing.

Hip resurfacing is an alternative to total hip arthroplasty for the young and active patient likely to outlive traditional means of hip joint replacement. The acetabular cup is implanted in much the same fashion as an uncemented total hip arthroplasty, however, implantation of the femoral component is unique to hip resurfacing, presenting both distinct benefits and limitations. Hip resurfacing spares much of the proximal femur including the femoral neck and portions of the femoral head. This may be advantageous if the patient requires revision surgery; however, preservation of the femoral neck bears with it the risk of femoral neck fracture. The exact mechanism of neck fracture is not fully understood. Avoiding potential fracture risks is vital to ensuring optimal patient outcomes. The current work investigated mechanical femoral head preparatory factors that may predispose to femoral neck fracture. Intra-operative computer navigation is emerging as the gold-standard in orthopaedic care. In hip resurfacing, navigation may improve the surgeon’s ability to optimally implant the resurfacing prosthesis; however, much of this technology is still in its infancy and requires investigation into the accuracy and repeatability of this peri-operative tool. Pre-operative planning can assist the surgeon in optimally determining the size and position of the resurfacing components, specifically in reference to the patient’s unique anatomy, prior to performing the operation. This may aid in correct implant selection and provide a basis on which to conduct intra-operative navigation. However, the accuracy and repeatability of pre-operative planning for hip resurfacing has not yet been established. Thus, this body of work looked to establish a clear methodology for pre-operative planning, intra-operative computer navigation and surgical technique in order to optimize preparation of the femoral head, ultimately reducing the risk of femoral neck fracture in hip resurfacing.

Introduction: Hip fractures are very common in Sweden. Keeping reoperation rates as low as possible is critical. One factor correlated to mechanical complications and thereby reoperation rates is the tip-apex distance. In April of 2017 the Orthopedic clinic at Karlstad’s Central Hospital in Sweden implemented new routines for the choice of treatment method of pertrocantheric and subtrocantheric femoral fractures. Aim: The primary aim of this study was to compare reoperation rates of pertrocantheric and subtrocantheric femoral fractures before and after implementation of new routines. Secondly, we wanted to study the association between the tip-apex distance and reoperation rates for pertrocantheric femoral fractures treated at Karlstad’s Central Hospital. Method: This was an internal quality control designed as a retrospective cohort study. Data on patients treated for pertrocantheric or subtrocantheric femoral fractures were retrieved from the Swedish Fracture Registry. Tip-apex distances were measured on patients’ radiographic images. P-values for comparison of the two study periods were created using the chi2 test. Association between the tip-apex distance and reoperation rate was presented as odds ratio. Result: The reoperation rates were the same for both time periods. The reoperation rates of unstable fractures were lower for the study period after implementation of new routines. Neither of these results were statistically significant. There was also no statistically significant association between the tip-apex distance and reoperation rates. Conclusion: No statistically significant decrease in reoperation rates was seen after implementation of new routines. There was no association between the tip-apex distance and reoperation rates.

Introdução: as alças vasculares podem prover o suprimento sanguíneo adequado para um retalho microcirúrgico em um leito desfavorável, como fratura exposta ou área irradiada após a ressecção de tumores. Apesar de realizadas na prática clínica, há falta de estudos demonstrando quais os fatores são responsáveis pelo seu sucesso. Objetivo: avaliar, em coelhos, qual é a influência do desenho da alça de veia femoral com anastomose na artéria femoral, na presença de fluxo (patência) após sete dias. Método: Trinta e nove coelhos foram submetidas à microanastomose arteriovenosa com técnica microcirúrgica. As alças foram acomodadas em dois desenhos, um, chamado \"circular\" e outro, o mais alongado possível sem dobras na alça. Os parâmetros avaliados foram: presença ou não de fluxo, sinais de hemólise, alterações hemodinâmicas sofridas pela veia submetida à pressão arterial. Resultados: Após sete dias, o fluxo estava presente em 68% das alças \"anguladas\" e em 75% das alças \"circulares\" (p > 0,05). Houve, intragrupo, diminuição estatisticamente significante da pCO2 e aumento estatisticamente significante do pH. Não houve diferença estatisticamente significante no restante dos parâmetros avaliados entre os dois modelos de alça. Conclusão: O desenho da alça vascular arteriovenosa na pata do coelho não interfere na sua patência em um período de sete dias / Introduction: the vascular loops can provide adequate blood supply to a microsurgical flap in an unfavorable bed as open fracture or irradiated area after resection of tumors. Although performed in clinical practice, there is a lack of studies showing which factors are responsible for their success. Objective: To evaluate, in rabbits, which is the influence in the presence of flow (patency) of femoral vein loop design in anastomosis of the femoral artery after seven days. Method: Thirty-nine rabbits were subjected to arteriovenous microanastomosis with microsurgical technique. The loops were accommodated in two designs, one named \"circular\" and the other, the more elongated possible without folds. The parameters evaluated were: presence or absence of flow, hemolysis, hemodynamic changes suffered by vein submitted to blood pressure. Results: After seven days, the flow was present in 68% of angled loops and 75% of the \"circular\" loops (p > 0.05). There was intra-group, statistically significant decrease in the pCO2 and statistically significant increase in pH. There was no statistically significant difference in the rest of the parameters evaluated between the two loop models. Conclusion: The design of arteriovenous vascular loops in the rabbit paw does not interfere with its patency over a period of seven days

INTRODUÇÃO: A implantação de stent auto-expansível de nitinol para o tratamento das lesões oclusivas femoro-poplíteas tem sido associado com maus resultados a longo prazo. O everolimus administrado via oral para inibir reestenoses do stent foi investigado recentemente em animais com bons resultados, porém sua segurança e eficácia não têm sido estudada em seres humanos. O propósito deste estudo piloto foi avaliar o impacto da terapia antiproliferativa com everolimus administrado via oral por 28 dias na diminuição de reestenose após implante de stent auto-expansível de nitinol para tratamento de lesões oclusivas da artéria femoral superficial. MÉTODOS E RESULTADOS: Trinta e quatro pacientes foram recrutados para este estudo randomizado, prospectivo. O grupo que recebeu everolimus via oral foi constituído por 15 pacientes e o grupo que não recebeu medicação composto por 19 pacientes. As características basais e do procedimento foram similares entre os dois grupos. Todos os pacientes tinham isquemia crônica do membro inferior e oclusão da artéria femoral superficial (média da lesão de 83,14 mm no grupo sem medicação e 105 mm no grupo everolimus). O objetivo primário do estudo foi a redução da porcentagem média do diâmetro da reestenose intra-stent após seis meses da angioplastia avaliada por angiografia quantitativa. A porcentagem média do diâmetro das reestenoses foi 46,9% no grupo tratado com everolimus e 44,5% no grupo que não recebeu a medicação (p=0,81). Não foram observados efeitos colaterais graves nos grupos. No acompanhamento clínico aos 24 meses não houve diferenças significativas entre os grupos em relação a eventos clínicos. A patência primária, primária assistida e secundária em 24 meses, foi 42%, 74% e 79% no grupo sem medicação e 27%, 73% e 73% no grupo tratado com everolimus. CONCLUSÃO: O everolimus via oral por 28 dias em doses altas é seguro e bem tolerado, com baixo índice de efeitos colaterais, porém não é eficaz na redução da porcentagem média do diâmetro da reestenose intra-stent em pacientes com implante de stents auto-expansíveis de nitinol nas lesões oclusivas complexas da artéria femoral superficial. / INTRODUCTION: The implantation of a self-expanding of nitinol stent in the treatment of femoropopliteal occlusive lesions has been associated with a poor outcome in a long term setting. Everolimus administered orally to inhibit restenosis of the stent was investigated recently in animals with good results, but its safety and efficacy has not been studied in humans. The purpose of this pilot study was to evaluate the impact of antiproliferative therapy with everolimus administered orally for 28 days in the reduction of restenosis after implantation of self-expandable nitinol stent for treatment of occlusive lesions of the superficial femoral artery. METHODS AND RESULTS: Thirty-four patients were recruited for this randomized, prospective study. The group that received oral Everolimus was consisted of 15 patients and the group that received no medication was 19 patients. The baseline characteristics and procedure were similar in both groups. All the patients had chronic lower limb ischemia and occlusion of the superficial femoral artery (mean of the lesion of 83.14 mm in the group without medication and 105 mm in the everolimus group). The primary objective of the study was to evaluate the reduction of the average percentage of the diameter of in-stent restenosis six months after angioplasty assessed by quantitative angiography. The in-stent mean percent diameter stenosis was 46.9% in the group treated with everolimus and 44.5% in the group that received no medication (p = 0.81). There were no serious side effects seen in either group in the clinical follow up at 24 months. There was no significant difference between groups in relation to clinical events. The primary patency, assisted primary and secondary in 24 months was 42%, 74% and 79% in the group without medication and 27%, 73% and 73% in the group treated with Everolimus. CONCLUSION: Everolimus administered orally for 28 consecutive days to stent implantation in high doses proves to be safe and well tolerated, with low rate of side effects, but it is not effective in reducing the average percentage of diameter of in-stent restenosis in patients with implantation of self-expandable nitinol stent in complex occlusive lesions of the superficial femoral artery.

A via de acesso arterial é um importante sítio de complicações após a realização de procedimentos coronários invasivos. Dentre as estratégias para a redução de complicações vasculares, encontra-se estabelecida a eficácia da técnica radial. Os dispositivos de oclusão vascular propiciam maior conforto ao paciente, reduzindo o tempo de hemostasia e repouso no leito. Entretanto, a inconsistência de dados comprovando sua segurança limita sua adoção rotineira como estratégia para redução de complicações vasculares, requerendo evidências de estudos randomizados com metodologia adequada. O objetivo deste estudo foi comparar a incidência de complicações no sítio de punção arterial entre a técnica radial e a técnica femoral com utilização de Angio-Seal em pacientes com síndrome coronariana aguda sem supradesnível do segmento ST submetidos à estratégia invasiva precoce. Trata-se de um ensaio clínico unicêntrico, de não inferioridade, no qual duzentos e quarenta pacientes foram randomizados para a técnica radial ou técnica femoral com utilização de Angio-Seal. O objetivo primário foi a ocorrência de complicações no sítio de punção arterial até 30 dias após o procedimento, incluindo sangramento grave, hematoma >= 5 cm, hematoma retroperitoneal, síndrome compartimental, pseudoaneurisma, fístula arteriovenosa, infecção, isquemia de membro, oclusão arterial, lesão de nervo adjacente ou necessidade de reparo vascular cirúrgico. Em relação às características demográficas e clínicas, houve diferença apenas quanto ao gênero, com presença maior de pacientes do sexo feminino no grupo radial (33,3% versus 20,0%, p=0,020). Não se observaram diferenças entre os grupos quanto ao diagnóstico de admissão, alterações isquêmicas presentes no eletrocardiograma, elevação de marcadores de necrose miocárdica ou escores de risco, bem como quanto à farmacoterapia antitrombótica adjunta e características da intervenção coronária percutânea. A hemostasia foi obtida na totalidade dos procedimentos do grupo radial com a utilização da pulseira compressora seletiva TR Band e em 95% dos procedimentos realizados pela técnica femoral com o Angio-Seal (p=0,029). Exceto pela maior incidência de oclusão arterial no grupo radial comparado ao femoral, não houve diferenças entre os demais desfechos analisados. Segundo o teste de não inferioridade para complicações na via de acesso arterial aos 30 dias, verificou-se que a utilização do Angio-Seal não produziu resultados inferiores ao acesso radial, considerando-se a margem de 15% (12,5% versus 13,3%, diferença -0,83%, IC 95% -9,31 - 7,65, p para não inferioridade <0,001). Os resultados principais deste estudo demonstram que, em uma população de pacientes com diagnóstico de síndrome coronariana aguda sem supradesnível do segmento ST, submetida à estratificação de risco invasiva, a utilização do dispositivo de oclusão vascular Angio-Seal confere ao procedimento efetivado pelo acesso femoral inferioridade na incidência de complicações no sítio de punção arterial aos 30 dias quando comparado ao acesso radial. / Arterial access is a major site of complications after invasive coronary procedures. Among strategies to decrease vascular complications, the radial approach is an established one. Vascular closure devices provide more comfort to patients decreasing hemostasis and need for bed rest. However, the inconsistency of data proving their safety limits their routine adoption as a strategy to prevent vascular complications, requiring evidence through adequately designed randomized trials. The aim of this study is to compare the radial versus femoral approach using Angio-Seal for the incidence of arterial puncture site complications among non-ST-segment elevation acute coronary syndrome patients submitted to an early invasive strategy. This study is a unicentric, non-inferiority clinical trial where two hundred and forty patients with non-ST-segment elevation acute coronary syndrome were randomized to either radial or femoral access using Angio-Seal. The primary outcome was the occurrence of complications at the arterial puncture site until 30 days after the procedure, including major bleeding, hematoma >= 5 cm, retroperitoneal hematoma, compartment syndrome, pseudoaneurysm, arteriovenous fistula, infection, limb ischemia, arterial occlusion, adjacent nerve injury or the need for vascular surgery repair. With respect to demographic and clinical characteristics, there were differences only in terms of gender, with greater presence of female patients in the radial group (33.3% versus 20.0%, p = 0.020). There were no differences between the groups regarding the diagnosis of admission, ischemic changes present in the electrocardiogram, elevation of myocardial necrosis markers or risk scores, as well as the adjunct antithrombotic pharmacotherapy and features of the percutaneous coronary intervention. Hemostasis was achieved in the entire radial group with the use of selective radial compressor TR Band and in 95% of the procedures performed by femoral technique with Angio-Seal (p = 0.029). Except for a higher incidence of arterial occlusion in the radial group compared to the femoral, there were no differences among the other outcomes analyzed. According to the non-inferiority test for arterial access site complications in 30 days, it was found that the use of Angio-Seal not produced results inferior to the radial approach, considering the margin of 15% (12.5% vs. 13.3%, difference -0.83%, 95% CI -9.31 - 7.65, p for noninferiority <0.001). The main results of this study demonstrated that in a population of patients diagnosed with non-ST segment elevation acute coronary syndrome, who underwent invasive risk stratification, the use of the Angio-Seal vascular closure device confers to the femoral approach noninferiority in the incidence of arterial puncture site complications at 30 days when compared to the radial approach.

Tesis por compendio de publicaciones / El presente estudio fue llevado a cabo para describir la apariencia ecográfica y desarrollar los abordajes ecoguiados para el bloqueo de los nervios ciático y femoral, así como evaluar la eficacia clínica del bloqueo ecoguiado del nervio ciático en el gato. Se realizaron disecciones anatómicas y criosecciones para determinar las marcas anatómicas para localizar los nervios de interés. La apariencia ecográfica de los nervios ciático y femoral fue estudiada tanto en cadáveres como en gatos vivos, utilizando un transductor linear de 4-13 MHz. EL bloqueo ecoguiado del nervio ciático se realizó insertando una aguja para bloqueo de nervios periféricos cerca del nervio ciático y se infiltró lidocaína alrededor del mismo. El abordaje medio-femoral y el abordaje dorsal permitieron la evaluación ecográfica y aproximación ecoguiada de los nervios ciático y femoral respectivamente. El abordaje medio-femoral permitió el bloqueo clínicamente efectivo del nervio ciático en el gato. Palabras clave: ecografía, anestesia, anestesia regional, bloqueo de nervios periféricos, nervio ciático, nervio femoral, gato. / Use of ultrasound for the blockade of the peripheral nerves of the pelvic limb in the cat (Felis catus L.) This study was carried out to describe the ultrasonographic appearance and to develop the ultrasound (US)-guided approaches to block the sciatic (SCN) and femoral (FN) nerves, and to evaluate the clinical efficacy of the US-guided blockade of the ScN in the cat. Anatomical dissections and transversal cryosections were performed to determine the anatomical landmarks to localise the ScN and FN nerves. The ultrasonographic appearance of the ScN and FN were determined on cadavers and alive cats using a 4-13MHz linear transducer. The US-guided blockade of the ScN was performed inserting a peripheral nerve block needle close to the ScN and lidocaine was infiltrated around it. The midfemoral approach for the ScN and the dorsal approach for the FN, allowed an optimal US-guided location to evaluate and block these nerves. The midfemoral allowed an accurate US-guided blockade of the ScN in felines.

Femoral neck fracture (FNF) is a great challenge for today´s health care and is associated with high mortality and morbidity in the elderly.  In the short term several studies in the literature have demonstrated improved hip function, quality of life and fewer re-operations in elderly patients treated with total hip arthroplasty (THA) instead of internal fixation (IF). There are few reports on the long-term outcome comparing IF and THA. The vast majority of orthopaedic departments in Sweden use the direct lateral (DL) or posteriolateral (PL) approaches for hip arthroplasty. The PL approach has been linked to an increased risk of dislocation of the prosthesis and a higher rate of revision surgery in comparison to the DL approach. There are few reports focusing on radiological risk factors for prosthetic dislocation and patient reported hip function comparing the two surgical approaches for hip arthroplasty in FNF. The randomized controlled trial (RCT) is the gold standard for evaluating medical or surgical interventions. An RCT of high quality has to be internally and externally valid. Internal validity refers to a correct study design to avoid bias skewing the results. External validity (EV) refers to whether the results will be clinically relevant to a definable group of patients and can be extrapolated to the general health care situation. There are only a few reports in the orthopaedic literature focusing on the EV of published studies and none in the field of hip fractures. Study I: This is a RCT of 100 patients with a displaced FNF comparing THA and IF. Follow-up evaluations were performed at three months and 1, 2, 4, 11 and 17 years. It was found that the Harris hip score (HHS) was higher and the rate of reoperations lower for patients treated with THA. Study II: This is a prospective cohort study of 185 hips, comparing the DL and the PL approaches in patients treated with a hemiarthroplasty (HA) for a displaced FNF. Follow-up was after 1 year. There was no difference in patient reported outcome between the groups measured with the HHS and WOMAC index. The PL approach resulted in a higher re-operation rate while the DL approach in a higher incidence of limping. Study III: This is a retrospective cohort study of 373 patients with a cemented bipolar HA using a PL approach for a FNF with a follow-up ranging from 6 months to 7 years. Radiographs and all surgical records were reviewed regarding femoral offset (FO), leg length discrepancy (LLD) and Wiberg angle. Patients with recurrent dislocations had a decreased postoperative FO, LLD and shallower acetabulum on the operated side compared with their controls. Study IV: This is a prospective cohort study of 840 hips comparing patients included in a RCT with those that did not give their informed consent (NC) or did not fulfill the criteria for participating in the trial (MS). Patients in the NC and MS groups had an increased mortality rate in comparison to those included in the study. We did not find any differences in hip function between these groups. The main conclusions of this thesis are: Healthy and lucid elderly patients with good hip function preoperatively, should be treated with THA for a displaced FNF. The DL approach is favourable in treating displaced FNF with HA due to its decreased risk of reoperation but with an identical hip function outcome as the PL approach. Care should be taken to restore the LLD and FO otherwise this may increase the risk of recurrent dislocation of a HA. Our findings suggest that trial participants had a lower mortality rate than non-participants but the functional outcome of non-participants appeared to be satisfactory. This is important to take into consideration when extrapolating study results to a health care system. / Lårbenshalsfrakturer (FNF) är en utmaning för dagens sjukvård och förknippad med hög mortalitet i den äldre befolkningen. FNF orsakas främst av lågenergitrauma efter fall i samma plan hos patienter med benskörhet. Total höftledsprotes (THA) har visat sig ge en bättre höftfunktion, livskvalitet med färre omoperationer hos äldre patienter än sluten reposition samt fixering med skruvar (IF) under de första två-fyra åren efter operation. Få studier har publicerats med långtidsuppföljning av THA jämfört med IF. Vid behandling av felställd FNF med halv höftledsplastik (HA) eller THA finns olika kirurgiska metoder (snittföring) för implantation av protesen. Majoriteten av ortopedkliniker i Sverige använder direkt lateral (DL) eller posteriolateral (PL) snittföring. PL har kopplats till en ökad risk för luxation av protesen (urledsvridning), vilket i sin tur genererat en högre risk för omoperation jämfört med DL. Få studier har utvärderat höftfunktion med avseende på snittföring. Detsamma gäller vilka radiologiska faktorer som påverkar risken förprotesluxation. Det finns olika typer av studiedesigner för utvärdering av medicinska och kirurgiska behandlingsmetoder. Studiedesignen med högst bevisvärde anses vara den randomiserade kontrollerade studien (RCT). För att en RCT skall hålla hög kvalitet krävs intern och extern validitet. Intern validitet syftar på ett korrekt studieupplägg som mäter det som avses och undviker påverkan av icke önskvärda faktorer. Extern validitet (EV) innebär att erhållna resultat från studien är generaliserbara och kan extrapoleras till andra grupper än den studerade. Det inga rapporter i ortopediska litteraturen med fokus på EV med patienter som drabbats av FNF. Studie I: Prospektiv randomiserad studie av 100 patienter med en felställd FNF jämförs THA med IF med avseende på höftfunktion och reoperationer. Uppföljning gjordes efter tre månader samt 1, 2, 4, 11 och 17 år. HHS som mått på höftfunktion var högre och andelen reoperationer lägre för patienter som behandlades med THA. Studie II: Prospektiv kohortstudie med 183 patienter med felställd FNF behandlade med HA och antingen DL eller PL. Vi fann ingen skillnad i patientrapporterad höftfunktion utvärderat med HHS och WOMAC efter 1 år men en ökad förekomst av hälta vid DL. Studie III: Retrospektiv kohortstudie av 373 patienter opererade med en cementerad bipolär HA och PL. Postoperativa röntgenbilder granskades avseende femoral offset (FO), postoperativ benlägdsskillnad (LLD) samt acetabulär Wibergvinkel och relaterades till återkommande protesluxationer. Detta relaterades till återkommande luxationer. Uppföljningstiden varierade mellan 6 månader och 7 år. Patienter med återkommande luxationer hade en minskad postoperativ global FO, förkortad LLD och grundare acetabulum på den opererade sidan jämfört med kontroller. Studie IV: Prospektiv kohortstudie av 840 patienter med felställd FNF där patienter som ingick i en RCT jämförs med de som inte gav sitt samtycke för deltagande eller ej inkluderats i screeningprocessen. De patienterna som inte gav sitt samtycke hade ökad dödlighet, men ingen skillnad i höftfunktion jämfört med deltagare. Slutsatser • Friska och kognitivt vitala äldre patienter med god höftfunktion innan en felställd lårbenshalsfraktur bör behandlas med total höftledsprotes. • DLsnittföring ger ett lika bra patientrapporterad höftfunktion men en ökad förekomst av hälta jämfört med PL snitt vid behandling med halvprotes på grund av en felställd lårbenshalsfraktur. • Ansträngning bör göras för att återställa benlängdsskillnad samtfemoral offset och därigenom minska risken för återkommande luxation. • Våra resultat tyder på att patienter som deltar i en randomiserad studie har lägre dödlighet än patienter som avböjt att delta samt de som missats i screeningprocessen. Det är viktigt att ta hänsyn till när extrapolerar studieresultat till ett hälso-och sjukvårdssystem. Detta bör vägas in i värderingen av studieresultatens externa validitet.

BACKGROUND: Osteoarthritis is a leading cause of disability in people of 65 and older. Researches have shown several possible factors leading to knee osteoarthritis development. Patellofemoral joint maltracking has been thought to be associated with or caused edema in the knee; which is thought to be the early signs of osteoarthritis. Hoffa's fat pad is an intra-articular component of knee located under the kneecap. It has also been suggested as one marker for osteoarthritis, when MRI shows a presence of edema in it. Recently, edema in the superolateral region of Hoffa's fat pad has been hypothesized as a distinct signal than the edema on other regions. There is an interest in finding the relation of this superolateral edema with other factors of osteoarthritis development. OBJECTIVE: This thesis research project is aimed to assess the relation of kneecap-thighbone (patellofemoral) joint alignment, femoral trochlea morphology, and patellar height to edema in the superolateral region of Hoffa’s fat pad especially in the population with average age above 65 years old. The hypothesis is that the flatter trochlear morphology and abnormal patella alignment will have higher risk of superolateral edema. METHODS: This is a cross-sectional study using a subset data from Multicenter Osteoarthritis (MOST) study, specifically at 60-month visit. This study measured the patellofemoral measurements (sulcus angle, lateral and medial trochlear inclination angle, trochlear angle, Insall-Salvati ratio, patellar tilt angle, and bisect offset) as the predictor variables, and semiquantitative scoring of MRI edema in superolateral Hoffa’s fat pad as the outcome variable. Logistic regression analyses were performed to find the strongly associated patellofemoral measurements to superolateral Hoffa’s fat pad edema. RESULTS: From the logistic regression analysis, trochlear angle, Insall-Salvati ratio, and bisect offset were highly associated with the superolateral edema. A further analysis, by categorizing the measurements to quartiles, was found that only the highest quartiles of both bisect offset and trochlear angle are associated with superolateral Hoffa’s fat pad edema when compared to the reference quartile. All quartiles of Insall-Salvati ratio are strongly associated with superolateral edema when compared to the reference quartile. CONCLUSION: Current study presents that people above 65 years old with high trochlear angle, extreme lateral patellar translation or bisect offset, and high patella riding have high risk of having superolateral Hoffa’s fat pad edema.

INTRODUÇÃO: A implantação de stent auto-expansível de nitinol para o tratamento das lesões oclusivas femoro-poplíteas tem sido associado com maus resultados a longo prazo. O everolimus administrado via oral para inibir reestenoses do stent foi investigado recentemente em animais com bons resultados, porém sua segurança e eficácia não têm sido estudada em seres humanos. O propósito deste estudo piloto foi avaliar o impacto da terapia antiproliferativa com everolimus administrado via oral por 28 dias na diminuição de reestenose após implante de stent auto-expansível de nitinol para tratamento de lesões oclusivas da artéria femoral superficial. MÉTODOS E RESULTADOS: Trinta e quatro pacientes foram recrutados para este estudo randomizado, prospectivo. O grupo que recebeu everolimus via oral foi constituído por 15 pacientes e o grupo que não recebeu medicação composto por 19 pacientes. As características basais e do procedimento foram similares entre os dois grupos. Todos os pacientes tinham isquemia crônica do membro inferior e oclusão da artéria femoral superficial (média da lesão de 83,14 mm no grupo sem medicação e 105 mm no grupo everolimus). O objetivo primário do estudo foi a redução da porcentagem média do diâmetro da reestenose intra-stent após seis meses da angioplastia avaliada por angiografia quantitativa. A porcentagem média do diâmetro das reestenoses foi 46,9% no grupo tratado com everolimus e 44,5% no grupo que não recebeu a medicação (p=0,81). Não foram observados efeitos colaterais graves nos grupos. No acompanhamento clínico aos 24 meses não houve diferenças significativas entre os grupos em relação a eventos clínicos. A patência primária, primária assistida e secundária em 24 meses, foi 42%, 74% e 79% no grupo sem medicação e 27%, 73% e 73% no grupo tratado com everolimus. CONCLUSÃO: O everolimus via oral por 28 dias em doses altas é seguro e bem tolerado, com baixo índice de efeitos colaterais, porém não é eficaz na redução da porcentagem média do diâmetro da reestenose intra-stent em pacientes com implante de stents auto-expansíveis de nitinol nas lesões oclusivas complexas da artéria femoral superficial. / INTRODUCTION: The implantation of a self-expanding of nitinol stent in the treatment of femoropopliteal occlusive lesions has been associated with a poor outcome in a long term setting. Everolimus administered orally to inhibit restenosis of the stent was investigated recently in animals with good results, but its safety and efficacy has not been studied in humans. The purpose of this pilot study was to evaluate the impact of antiproliferative therapy with everolimus administered orally for 28 days in the reduction of restenosis after implantation of self-expandable nitinol stent for treatment of occlusive lesions of the superficial femoral artery. METHODS AND RESULTS: Thirty-four patients were recruited for this randomized, prospective study. The group that received oral Everolimus was consisted of 15 patients and the group that received no medication was 19 patients. The baseline characteristics and procedure were similar in both groups. All the patients had chronic lower limb ischemia and occlusion of the superficial femoral artery (mean of the lesion of 83.14 mm in the group without medication and 105 mm in the everolimus group). The primary objective of the study was to evaluate the reduction of the average percentage of the diameter of in-stent restenosis six months after angioplasty assessed by quantitative angiography. The in-stent mean percent diameter stenosis was 46.9% in the group treated with everolimus and 44.5% in the group that received no medication (p = 0.81). There were no serious side effects seen in either group in the clinical follow up at 24 months. There was no significant difference between groups in relation to clinical events. The primary patency, assisted primary and secondary in 24 months was 42%, 74% and 79% in the group without medication and 27%, 73% and 73% in the group treated with Everolimus. CONCLUSION: Everolimus administered orally for 28 consecutive days to stent implantation in high doses proves to be safe and well tolerated, with low rate of side effects, but it is not effective in reducing the average percentage of diameter of in-stent restenosis in patients with implantation of self-expandable nitinol stent in complex occlusive lesions of the superficial femoral artery.