Orientador: Ibsen Bellini Coimbra / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-12T03:33:19Z (GMT). No. of bitstreams: 1 Mascarin_NaryanaCristina_M.pdf: 2009638 bytes, checksum: 2e824addb63e36ea1e6dc1e178f27f1c (MD5) Previous issue date: 2008 / Resumo: Introdução: Esse estudo envolve o tratamento fisioterapeutico da osteoartrite (OA) de joelho, uma das patologias que mais acometem idosos, embora as pessoas de varias faixas etárias também possam ser acometidas, principalmente mulheres com mais de 45 anos. Osteoartrite (OA) e uma doença da cartilagem articular que envolve as articulacoes sinoviais, como joelho, quadril, coluna, mãos e pés. Os pacientes queixam-se de dor, rigidez articular e edema. O surgimento dessa enfermidade pode ter influencias de varios fatores como raca, genética, hormonais, deformidades, traumas e muitos outros. A fisioterapia dispoe de varias modalidades terapêuticas para diminuir os sintomas da OA de joelho, entre elas a neuroestimulacao eletrica transcutanea, o ultra-som, alongamento e exercícios isométricos, as quais foram utilizadas nesse estudo. O objetivo geral deste estudo foi determinar quais desses tratamentos fisioterapeuticos foram mais eficientes para a dor, rigidez articular e amplitude de movimento na OA de joelhos, em uma amostra de casos. Material e Metodo: Para a pesquisa foram selecionados sessenta pacientes do sexo feminino, com idade acima de 45 anos com diagnostico de OA de joelho, sendo divididos em tres grupos de vinte pessoas para cada modalidade de tratamento: o primeiro grupo foi tratado com exercícios apenas (EX), o segundo com exercícios e neuroestimulacao elétrica transcutanea (TENS) e o terceiro com exercícios e ultrasom (US). Para a coleta de dados foram utilizados a escala visual analogica (EVA), o questionário "WOMAC Osteoarthritis Index" e o teste de resistência "six minutes walking" (caminhada de seis minutos). Resultado: O tratamento mostrou-se eficaz nas pacientes de OA de joelho nos 3 grupos amostrais, que apresentaram uma redução da dor, melhora da rigidez articular, melhora da amplitude de movimento, reducao do peso, melhora da caminhada e melhor qualidade de vida para suas atividades diárias. Discussão: O grupo EX mostrou-se com melhor desempenho no questionário WOMAC, em todos os domínios. / Abstract: Introduction: This study involves the physiotherapeutic treatment of the knee osteoarthritis (OA) one of the most prevalent diseases of the elderly, although it could be present in people of any age, mainly women with more than 45 years. Osteoarthritis is a disease that involves the joint structures, mainly the articular cartilage from the synovial joints, such as knee, hip, column, hands and feet. The patients complain of pain, stiffness and edema. The sprouting of this disease can be influenced by some factors including race, genetics, hormones, deformities, traumas and many others. The physiotherapy has some therapeutic modalities to diminish the symptoms of the OA of knee, among them the transcutaneous electric nerve stimulation, the ultrasound, flexibility and the isometrics exercises, which had been used in this study. The objective of this study was to determine which of these physiotherapeutic treatments was more efficient for pain, articular stiffness and range of movement (ROM) in the treatment of the OA of knees. Material and Methods: Sixty female patients were selected, with age above of 45 years with diagnosis of OA of the knee. They were randomized in three groups of twenty people for each modality of treatment. Pain was assessed using the visual analogical scale (VAS). We also analyzed the resistance test "six minute walking and the questionnaire "Womac Osteoarthritis Index" was used in order to verify the patients quality of life Results: All the treatments used were efficacious and the patients with OA of the knees presented reduction of pain, improvement of the articular stiffness, of the ROM, reduction of the weight, improvement in the six minute walking and better quality of life for their daily activities. Discussion: There was no statistical difference among groups, except that group EX revealed better performance in the WOMAC questionnaire, in the all domain, suggesting that the inclusion of US or TENS in the treatment of OA of the knees was not necessary. / Mestrado / Mestre em Clinica Medica

Orientadores: Sérgio Rocha Piedade, Elinton Adami Chaim / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-22T13:52:26Z (GMT). No. of bitstreams: 1 Tamura_LilianSarli_M.pdf: 8289490 bytes, checksum: b85626f05677462baf9d25b9b1043671 (MD5) Previous issue date: 2013 / Resumo: Introdução: O extremo da condição clínica da obesidade é representado pela obesidade mórbida que ameaça a longevidade e qualidade de vida. No insucesso do tratamento clínico inicial, a cirurgia bariátrica apresenta-se como alternativa terapêutica e é indicada para indivíduos bem informados e motivados com IMC ? 40 kg/m2 ou pacientes com IMC ? 35 kg/m2 que apresentam comorbidades de difícil controle clínico relacionadas à obesidade e que obtiveram fracasso na maioria dos programas de perda de peso. Objetivos: A proposta deste estudo foi avaliar as condições clínica e funcional de pacientes obesos mórbidos, candidatos a cirurgia bariátrica e, paralelamente, investigar se existe perfil clínico específico do candidato. Métodos: Foram avaliados 39 pacientes, sendo 33 (84,6%) mulheres e 6 (15,4%) homens, com idade média de 42,38 anos, que foram classificados em três grupos distintos de acordo com os resultados obtidos no período de adequação pré-operatório. Durante o desenvolvimento da pesquisa, foram identificados três grupos de pacientes, definidos como grupo: desistência, meta e cirúrgico. Nesta avaliação foram aplicados os escores clínicos de KOOS e Lysholm, qualidade de vida SF-36 , assim como a avaliação funcional feita através do teste de caminhada de 6 minutos e escala de Borg. Resultados: A amostra estudada foi caracterizada por indivíduos com prevalência do sexo feminino (84%) e raça branca (64%). O quadro de gonalgia foi predominante (82%), enquanto, a frequência respiratória de repouso foi menor no grupo cirúrgico. Não foi identificado perfil específico para cada grupo estudado nas diversas variáveis estudadas. Conclusão A cirurgia bariátrica é uma intervenção que engloba processo terapêutico complexo, sendo o período de adequação pré-operatória fundamental na seleção natural dos candidatos. A gonalgia foi predominante em 82% dos pacientes (p=0,014), sendo classificada como ruim (Lysholm), fato que interferiu negativamente na qualidade de vida e pode ter contribuído para procura cirúrgica. A análise dos dados clínicos e funcionais (teste de caminhada de 6 minutos e Borg) não permitiu identificar perfil específico para cada grupo estudado. Entretanto, a menor frequência respiratória de repouso apresentada pelo grupo cirúrgico comparada aos demais grupos (p=0,021), pode ser considerada fator preditivo na seleção de indivíduos candidatos a intervenção, pois é um dos parâmetros que reflete status de condições fisiológicas basais / Abstract: Introduction: The extreme of the clinical condition of obesity is represented by morbid obesity that threats the longevity and the quality of life. With the unsuccessful initial clinical treatment, the bariatric surgery presents itself as a therapeutic alternative and is recommended to well-informed and motivated individuals with BMI ? 40 kg/m2 or patients with BMI ? 35 kg/m2 that present comorbidities of hard clinical control related to obesity and have had failures in the most of the weight loss programs. Objectives: The proposition of this study was to evaluate the clinical and functional conditions of morbidly obese patient, candidates to bariatric surgery and, parallelly, investigate if there exists a specific clinical profile of the candidate. Methods: 39 patients were evaluated, from which 33 (84.6%) were females and 6 (15.4%) were male, with an average age of 42.38 years old, that were classified in three distinct groups according with the results obtained in the period of pre-operatory adequation. During the research development, three groups of patients were identified and defined as withdrawal group, surgical group and goal group. In this evaluation, clinical scores of KOOS and LYSHOLM, the SF--?36, as well as functional assessment done by the six--?minute walk test and Borg scale were applied. Results: The sample under study was prevailingly characterized by females (84%) and caucasian (64%) individuals. The diagnosis of knee pain was predominant (82%), while resting respiratory rate was lower in the surgical group. A specific profile was not identified for each group for the several studied variables. Conclusion: Bariatric surgery is an intervention that involves complex therapeutic process, from which the period of preoperative adjustment is fundamental for the natural selection of candidates. The knee pain was prevalent in 82% of patients (p=0,014), being classified as poor (Lysholm), which has interfered negatively on their quality of life and may have contributed to the demand of surgery. The analysis of clinical and functional data (six minute walk test and Borg) haven't led to the identification of a specific profile for each group. However, the lowest resting respiratory rate presented by the surgical group, compared to the other groups (p=0,021), can be considered a predictive factor for the selection of candidates for intervention because it is a parameter that reflects status of basal physiological conditions / Mestrado / Fisiopatologia Cirúrgica / Mestra em Ciências

Orientador: Sérgio Rocha Piedade / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-23T11:33:29Z (GMT). No. of bitstreams: 1 Silveira_PaulaFiquetti_M.pdf: 1610014 bytes, checksum: 31f164837fc5c34e7523e00d420fd4ec (MD5) Previous issue date: 2013 / Resumo: Introdução: o balé clássico é composto por movimentos graciosos e expressivos. A busca pela técnica perfeita e precisa, exige dos bailarinos, que o treinamento seja baseado em inúmeras repetições, associado à força e resistência. Neste contexto, a incidência de lesões musculoesqueléticas nos membros inferiores é alta. As queixas de dor nos joelhos são muito frequentes e, invariavelmente, estão relacionadas à sobrecarga. O turnout refere-se à posição de 180º entre os pés e é realizado nos principais passos do balé clássico. Para desempenhar tal amplitude o quadril atua como elemento articular fundamental. A literatura suporta que a execução inadequada da técnica pode gerar compensações, preferencialmente nos joelhos. A relevância do trabalho é investigar fatores biomecânicos que influenciam na execução do turnout, relacionando-os com as queixas álgicas no joelho de bailarinas clássicas adolescentes. Objetivos: avaliar a amplitude de movimento de rotação lateral do quadril, anteversão do colo femoral, força muscular do quadril e turnout em bailarinas clássicas adolescentes com dor nos joelhos. Metodologia: foram avaliadas bailarinas clássicas, de 12 a 16 anos, com carga horária de treinamento semanal de 15 a 40 horas, com gonalgia. Foram excluídas do estudo, bailarinas com doenças congênitas, adquiridas e cirurgias prévias nos membros inferiores. No grupo controle foram consideradas bailarinas com dados demográficos semelhantes e assintomáticas. Trata-se de um estudo transversal observacional. A avaliação foi realizada por meio de questionário, contendo dados sobre treinamento e características da gonalgia, e pela avaliação física que consistiu na mensuração da amplitude de movimento ativa e passiva da rotação lateral do quadril, anteversão do colo femoral, força muscular dos rotadores laterais, extensores e abdutores do quadril e avaliação dinâmica e estática do turnout. Resultados: foram registrados dados de 23 bailarinas com gonalgia (GD) e 26 controle (GSD). O quadro de gonalgia apresentou caráter atraumático e ocorreu bilateralmente em 74% no GD. O tempo médio foi de 1,4 ± 0,4 anos e a intensidade da dor pela Escala Analógica Visual da Dor foi de 4,9 ± 1,7. Não houve diferenças estatísticas entre os grupos para amplitude de movimento do quadril e força muscular. Os valores angulares médios da anteversão do colo femoral foram semelhantes, no entanto, a anteversão femoral excessiva foi mais prevalente, não estabelecendo associação desta variável com a dor (valor de p= 0,475 e 0,584, direita e esquerda). Somente no turnout dinâmico (p= 0,020) e diferença entre turnouts (p= 0,046) foi observada diferença estatística. Em 74% do GD teve déficits entre 10 a 20% do turnout dinâmico em relação ao estático (p= 0,038). Considerando o turnout dinâmico e força muscular, teve diferença entre os grupos para extensores do quadril bilateral (D1) (p = 0,045 e 0,038, direita e esquerda) e abdutores e extensores direito (D2) (p = 0,035 e 0,047, respectivamente). Conclusão: o quadro de gonalgia apresentou caráter crônico, atraumático e esteve associado ao déficit angular no turnout dinâmico. Na presença do déficit rotacional é fundamental adotar estratégias preventivas de conscientização proximal do gesto esportivo do turnout, na população de bailarinas jovens / Abstract: Introduction: classical ballet is composed of graceful movements and expressive. The search for the perfect technique and precise demands of dancers, the training is based on numerous repetitions, associated with strength and endurance. In this context, the incidence of musculoskeletal injuries in the lower extremities is high. Complaints of pain in the knee are very common and invariably are related to overloading. The turnout refers to the position between 180 feet and is held in the main steps of classical ballet. To play this scale the hip joint acts as the key. The literature supports that the inadequate implementation of the technique can generate offsets, preferably in the knees. The relevance of this work is to investigate biomechanical factors that influence the implementation of the turnout, linking them with complaints of pain in the knee of classical dancer's teens. Objectives: To evaluate the range of motion of rotation of the hip, femoral neck anteversion, hip muscle strength and turnout in ballet dancer's adolescents with sore knees. Methods: was studied classical ballet dancers, 12-16 years old, with a schedule of weekly training 15-40 hours with knee pain. Were excluded from the study, ballet dancers with congenital, acquired and previous surgery of the lower limbs. In the control group were considered dancers with similar demographics and asymptomatic. This is an observational cross-sectional study. The evaluation was conducted through a questionnaire, containing data on characteristics of the training and knee pain, and the physical assessment consisting in measuring range of motion active and passive lateral rotation of the hip, femoral neck anteversion, muscular strength of the external rotators, extensors and hip abductors and evaluation of dynamic and static turnout. Results: data were recorded for 23 dancers with knee pain (GD) and 26 control (GSD). The framework presented character atraumatic knee pain and was bilateral in 74% of GD. The average time was 1.4 ± 0.4 years and the intensity of pain by the EAV of pain was 4.9 ± 1.7. There were no statistical differences between groups for hip range of motion and muscle strength. The average angular values of femoral neck anteversion were similar, however, excessive femoral anteversion was more prevalent, this variable does not establish an association with pain (p = 0.475 and 0.584, right and left). Only turnout dynamic (p = 0.020) and the difference between turnouts (p = 0.046) was observed statistically. 74% of GD had deficits from 10 to 20% of the turnout static dynamic in relation to the (p = 0.038). Considering the turnout and dynamic muscle strength, had difference between groups for bilateral hip extensor (D1) (p = 0.045 and 0.038, right and left) and right hip abductors and extensors (D2) (p = 0.035 and 0.047, respectively). Conclusion: the box gonalgia presented a chronic, atraumatic and was associated with a deficit angle in turnout dynamic. In the presence of rotational deficit is fundamental to adopt preventive strategies for awareness proximal sporting gesture of the turnout in the population of young dancers / Mestrado / Ciências da Cirurgia / Mestra em Ciências da Cirurgia

Orientador: Maria José D'Elboux / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-19T12:20:52Z (GMT). No. of bitstreams: 1 Alves_RenataAparecidaEsteves_M.pdf: 2030331 bytes, checksum: f8df67eba67906c4e7e3dd8c06aec955 (MD5) Previous issue date: 2011 / Resumo: Dois artigos elaborados a partir da investigação da qualidade de vida relacionada à saúde (QVRS) de idosos com osteoartrite de joelhos (OA), com objetivos de avaliar a consistência interna e os efeitos teto e chão do instrumento genérico The Medical Study 36 - Item Short - Form Health Survey (SF-36) e o específico Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), e investigar a influência e a comparação dos escores com as variáveis de interesse idade, gênero, IMC (índice de massa corporal), dor (EVA), número de comorbidades, sinais radiográficos e a funcionalidade (algo funcional de Lequesne). Estudo descritivo, correlacional e transversal realizado com 133 idosos com idade igual ou superior a 60 anos, de ambos os gêneros, com o diagnóstico clínico de OA de joelho em acompanhamento ambulatorial num centro de referência na cidade de São Paulo. Os dados foram obtidos por meio da aplicação de quatro instrumentos: 1. Instrumento de caracterização sociodemográfica e clínica; 2. Instrumento genérico de avaliação da QVRS SF-36; 3. Instrumento específico da QVRS WOMAC; e 4. Instrumento de avaliação funcional do joelho - Algo funcional de Lequesne. Os dados foram submetidos á análise estatística descritiva, análise de confiabilidade por meio do alfa de Cronbach, efeito teto e chão, testes estatísticos Qui-Quadrado ou, quando necessário, o teste exato de Fischer, análise de variância univariada (ANOVA) e multivariada (MANOVA), análise de comparação com aplicação dos testes de Mann-Whitney (2 grupos) e de Kruskal-Wallis (? 3 grupos). O nível de significância adotado foi de 5%, ou seja, p<0,05. A amostra estudada teve o predomínio do sexo feminino em 76,6%, a média de idade foi de 69,8 (±6,35) anos. Os escores dos instrumentos de avaliação da QVRS, genérico e específico demonstraram que as questões de natureza física afetaram mais a QV desses idosos. Na avaliação funcional os sujeitos apresentaram em maioria com comprometimento funcional extremamente grave com pontuação ? 14 pontos do Lequesne. A confiabilidade foi satisfatória para a maioria das dimensões do SF-36 e para todas as dimensões do WOMAC, com Alpha de Cronbach >0,70. O efeito teto e chão foi exibido em algumas dimensões do SF-36 e o efeito teto para todas as dimensões do WOMAC. Verificou associação significante (p<0,001) dos efeitos teto e chão com os níveis do Lequesne. De acordo com a MANOVA, a variável número de comorbidades (p=0,024) e função do joelho (p<0,001), foram as que apresentou influência significativa na QVRS avaliada por meio do SF-36. No entanto a variável função do joelho (p<0,001) e dor noturna (p=0,001), apresentou influência significativa na QVRS avaliada por meio do WOMAC. As variáveis: gênero, IMC, número de comorbidades e função do joelho (Lequesne), foram as que apresentaram diferenças significativas relevantes nas dimensões do SF-36 e WOMAC. Os resultados evidenciam que os instrumentos genéricos e específicos são adequados para avaliar a QVRS nesse grupo, porém apresentam algumas limitações. Por fim, sugere-se que ações que aperfeiçoem a avaliação funcional do joelho possam contribuir para melhorar a QVRS desses idosos / Abstract: Two articles elaborated from the investigation of related to quality of life (HRQOL) of elderly patients with knee osteoarthritis (AO) aiming to assess the internal consistency and the ceiling and floor effects of the generic instrument The Medical Study 36 - Item Short - Form Health Survey (SF-36) and specific Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and investigate the influence and comparison of scores with the variables of interest age, gender, BMI (body mass index), pain (VAS), number comorbidities, radiographic and functionality (Index Lequesne). Descriptive study, conducted correlational and cross with 133 elderly aged over 60 years, of both genders with a clinical diagnosis of knee AO as an outpatient at a referral center in São Paulo. Data were obtained through the application of four instruments: 1. Instrument sociodemographics and clinical 2. Generic instrument for assessing HRQOL SF-36, 3. WOMAC specific HRQOL instrument, and 4. Instrument for functional assessment of the knee - Index Lequesne. The data were submitted to descriptive statistics, reliability analysis using Cronbach's alpha, ceiling and floor effect, chi-square statistical tests or, when necessary, Fisher's exact test, analysis of variance (ANOVA) and multivariate ( MANOVA), analysis of application compared with the Mann-Whitney (two groups) and Kruskal-Wallis test (? 3 groups). The level of significance was 5%, (p <0.05). The sample had a predominance of females 76.6%, the mean age was 69.8 (± 6.35) years. The scores of HRQOL assessment instruments, generic and specific questions showed that most affected the physical aspects of the QOL of the elderly. In the functional assessment in most subjects presented with extremely severe functional impairment with a score ? 14 points in Lequesne. Reliability was satisfactory for most of the SF-36 dimensions and all dimensions of the WOMAC, with Cronbach's alpha > 0.70. The floor and ceiling effect was shown in some dimensions of the SF-36 and the ceiling effect for all dimensions of the WOMAC. Found a significant association (p <0.001) of ceiling and floor effects with the levels of Lequesne. According to MANOVA, the variable number of comorbidities (p = 0.024) and knee function (p <0.001), showed the significant influence on HRQL assessed by SF-36. However the variable function of the knee (p <0.001) and nighttime pain (p = 0.001), had significant influence on HRQL assessed using the WOMAC. Variables: gender, BMI, number of comorbidities and knee function (Lequesne), showed the significant differences in the dimensions of the SF-36 and WOMAC. The results show that the generic and specific instruments are suitable to assess HRQOL in this group but have some limitations. Finally, it is suggested that actions that improve the functional evaluation of the knee can help to improve the HRQOL of the elderly / Mestrado / Gerontologia / Mestre em Gerontologia

Knee joint kinematics is the result of a complex roto-translation movementcharacteristic of the tibio-femoral (TF) and patello-femoral (PF) articulations.This movement depends on the shape of the femur, the tibial plateau andthe patella. Moreover, it depends also on the morphological and mechanicalproperties of the soft tissues of the knee joint. In fact, the knee is characterizedby an extrinsic stability due to the active constraints (muscles and tendons)and passive soft tissues (menisci, retinaculum and ligaments) that surround it.As a result, knee kinematics and kinetics are different in each human being, andsometimes, even in the same person, with the right knee behaving differentlycompared to the left one.The ideal total knee arthroplasty TKA, used to correct pathologies that couldaffect the knee joint, should enable the restoration of the patient’s functionalknee kinematics and kinetics, so that the patient does not normally notice theTKA implant.Nowadays, TKA surgery is a well-established procedure and surgeons maychoose from among the broad range of TKA solutions available on the marketto meet the patient’s request. Prostheses may differ because of shape, materials,and mechanical constraints of their components. Consequently, the restorationof the knee joint biomechanics is limited by the degrees of freedom guaranteedby the adopted design solution.Despite the success of TKAs, pain and limited motor skills are reportedto still affect the clinical outcomes and not all patients are shown to be happyafter a TKA.Current complaints regarding post-TKA surgery might be related to the absenceof a proven tool that enables predicting patient-specific outcomes based ondifferent TKA solutions and providing guidelines to surgeons. In fact, surgicalpre-planning is usually based on a patient’s evaluation that the clinician canmake also based on medical images, and clinical experience. Data reported inthe literature can help in guiding the surgeon to a final decision regarding thebest subject-specific solution.Numerical methods, able to simulate knee biomechanics for various configurations,can be fundamental for the development of the appropriate reliableand effective tools to support clinically-tailored responses to a question.In particular, they can be used for subject-specific analyses on the intact kneeand for supporting the surgical pre-planning phase by comparing the effect ofdifferent solutions.When developing a subject-specific knee model, different kinds of datainputsare needed, such as the knee shapes and alignment information, softtissuesbehavior and boundary conditions describing the investigated motortasks. Often, most of this requested data are unlikely to be available (e.g.subject-specific soft-tissues material properties). Consequently, it is a commonoperating procedure to integrate literature data with subject-specific informationin order to develop knee models for collecting personalized outputsthat could be used to address research and clinical questions.However, up to now, the resulting effect of different generalized sources, asa mix of subject-specific and literature data, still needs to be evaluated for itsimpact on personalized outputs concerning knee behaviour.Furthermore, clinical questions are often focused on specific requests thatpartially use features of more complex knee models that could require too muchtime to be efficiently incorporated into daily clinical evaluations.For these reasons, the principal aims of this research have been to assess,first, the impact of differently derived generalized sources on the developmentof an intact subject-specific knee model or after a TKA; second,to provide guidelines to identify efficient clinically-tailored data sourcesused in and for knee modeling.To accomplish these tasks, a numerical knee model of an intact knee wasdeveloped based on both subject-specific and literature data sources. Theinfluence of different approaches to deal with a subject’s information, such asthe reconstruction of the knee geometries from different imaging sources, hasiiibeen evaluated. Moreover, a sensitivity analysis was performed to understandthe potential changes on kinetics and kinematics outcomes due to differentlyderived literature inputs, such as models and the properties that characterizethe joint materials and ligaments description. The outputs collected after finiteelement analyses were analyzed and compared with already published experimentaloutcomes for the same analyzed specimen and replicated boundaryconditions.Additionally, the effects on knee joint contact forces and kinematics afterTKA surgery and due to the mis-alignment of implant components or misidentificationsof ligament insertions were evaluated in another sensitivityanalysis performed with a rigid body analysis for four different TKA designsimplanted in a subject-specific knee model. As for the intact knee model, theanalyzed configurations were compared against already published experimentaloutputs or literature data replicating similar boundary conditions.Moreover, several dedicated knee models were developed to address specificclinical questions, such as the lack of biomechanical explanations for certainbehaviours of TKA designs.Once compared to already published experimental or literature data, the resultsof the developed models agree.The main results from the numerical simulations performed show that, changingthe values of some of the parameters used as inputs, the knee model kinematicsis less influenced than the contact forces and stresses outputs.In particular, in developing an intact knee model, the main effecting parameteris the material properties selection for the knee cartilage layers. Among theconfigurations analyzed using subject-specific knee models with TKAs, theposition of the tibial component and the height of the patellar buttonare the most effecting inputs.Exploring the different chapters of this research thesis, several specific resultsare shown regarding each main step followed in developing a knee numericalmodel. For example, new approaches based on MRIs have been suggested andtested proving that they are suitable for collecting subject-specific informationregarding geometrical shapes and landmark definitions. Moreover, a newgraphical method was proposed resulting more effective and immediate thanconventional representations in reporting huge amount of data. In particular,the method is the favourite to show complex biomechanical analyses especiallyfor the clinical audience that replied to a survey. Furthermore, the differentmodels tailored to address specific clinical questions collected useful biomechanicalresults, to provide clinical advice or industrial guidelines, and can beconsidered as examples of what should be included in a knee model for similarscenarios.The results of this thesis offer several contributions. Generally, these findingscould provide useful guidelines for knee-model developers to achievea more balanced approach to subject-specific intact knee models based upongeneral sources in order to improve the understanding of personalized kneebiomechanics.To address a general comment to the title of this thesis, there is no singleanswer. In fact, the selection of data sources is case-dependent using, forexample, the subject’s or literature available data to describe material’s behavioror the boundary conditions of a specific motor task. Moreover, differentclinical questions can be addressed with different numerical approaches, e.g.finite element analysis is necessary especially in the case that stress outputs arerequested, but can be too time-consuming for addressing complex sensitivityanalyses.Once the knee model developer has identified the necessary data sources andthe approaches to be implemented, the question-tailored knee models can thusbe used for several applications such as predicting subject-specific abnormalknee kinematics and kinetics for different TKA designs, polyethylene wear,patellofemoral dislocation and bone remodeling, choosing the best fitting TKAdesign for a specific patient, and developing a procedure to optimize TKAimplant designs. / Doctorat en Sciences de l'ingénieur et technologie / info:eu-repo/semantics/nonPublished

Abstract High tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) are performed for the treatment of isolated medial osteoarthritis (OA) of the knee. In the treatment of knee OA, the incidence of osteotomies has decreased with the popularisation of knee arthroplasties, but it is still indicated in young and active patients. Results of HTO tend to deteriorate over the time and patients may need to undergo subsequent total knee arthroplasty (TKA). TKA after HTO is a demanding procedure, and the influence of previous osteotomy on the results of TKA is not defined. Results of UKAs are controversial. Single centre studies have shown good results, but arthroplasty registers report consistently inferior survivorships compared with TKAs. However, comparison of register survivals may be inadequate because differences in the demographics of the patients have not been taken into account. The aims of the current nationwide register-based study were to assess incidence of osteotomies and survivorship of HTO in the treatment of knee OA, and to compare survivorship of TKAs performed after HTO with primary TKAs between 1987 and 2008 in Finland. In addition, this study reports survivorship of UKAs over a 25 year period and compare it with the survival of cemented TKAs. Based on this study, the overall incidence of osteotomies has decreased, especially in females, in the treatment of knee OA during the last two decades. In the patients less than 50 years of age, the incidence of osteotomies has been stable or slightly increased. Register-based survivorship of HTO was inferior compared with smaller cohort studies and females and patients aged &#62;50 years had the poorest results. The survivorship of TKA after osteotomy was slightly inferior compared with primary operations in general, but any clinical significance was minor. In this study UKA had inferior survivorship compared with TKA, even after adjusting for the age and gender of the patients. The reported survivorship of UKA was similar to those from available unadjusted arthroplasty register data. Surgeons should be made aware of this, but the reasons for incoherence with single-centre studies are not yet established and need further study. / Tiivistelmä Sääriluun katkaisu- ja kääntöleikkauksia (osteotomia) ja osatekonivelleikkauksia tehdään polven sisäsyrjän nivelrikon hoitamiseksi. Tekonivelleikkausten yleistyttyä osteotomioiden määrä on vähentynyt polven nivelrikon hoidossa, mutta niitä tehdään edelleen nuorille ja aktiivisille potilaille. Osteotomian jälkeen polveen voidaan joutua asentamaan kokotekonivel. Tämä leikkaus on vaativa, ja edeltävällä osteotomialla voi olla vaikutusta kokotekonivelleikkauksen tuloksiin. Polven sisäsyrjän nivelrikkoa voidaan hoitaa osteotomian ja kokotekonivelleikkauksen lisäksi osatekonivelellä. Polven sisäsyrjän osatekonivelleikkauksen tulokset ovat kuitenkin ristiriitaisia. Yksittäisissä tutkimuksissa on raportoitu hyvistä tuloksista, mutta tekonivelrekisterien raporteissa osatekonivelleikkauksen uusintaleikkausriski on kokotekonivelleikkausta selvästi suurempi. Tämän rekisteritutkimuksen tarkoituksena oli selvittää polven nivelrikon vuoksi tehtyjen osteotomialeikkausten määrän kehitystä ja polven nivelrikon vuoksi tehtyjen säären osteotomialeikkausten tuloksia Suomessa vuosina 1987–2008. Lisäksi tutkimuksessa selvitettiin samalla ajanjaksolla osteotomian jälkeisten kokotekonivelleikkausten uusintaleikkausriskiä verrattuna primaareihin tekonivelleikkauksiin ja polven osatekonivelleikkausten uusintaleikkausriskiä verrattuna polven kokotekonivelleikkauksiin. Tutkimuksessa todettiin seuraavaa: polven nivelrikon vuoksi tehtyjen osteotomialeikkausten määrä on kahden viimeksi kuluneen vuosikymmenen aikana vähentynyt, etenkin naispotilailla. Osteotomialeikkausten määrä on kuitenkin pysynyt samana tai hiukan noussut alle 50-vuotiailla. Tässä rekisteritutkimuksessa säären osteotomian jälkeisen tekonivelleikkauksen uusintaleikkausriski oli suurempi kuin pienemmissä tutkimussarjoissa keskimäärin. Lisäksi tutkimuksessa todettiin, että säären osteotomian jälkeisten kokotekonivelleikkausten uusintaleikkausriski on suurempi kuin primäärien kokotekonivelleikkausten, mutta eron kliininen merkitys on vähäinen. Osatekonivelten osalta todettiin, että iän ja sukupuolen mukaan vakioitujen osatekonivelleikkausten uusintaleikkausriski on suurempi kuin kokotekonivelleikkausten. Tulosten ero yksittäisten tutkimusten ja rekisterien välillä on kuitenkin suuri, mikä vaatii lisätutkimuksia.

Abstract The number of ambulatory surgical procedures is increasing throughout the world. This is partly due to the development of a number of new anaesthetic, analgesic and adjuvant drugs, each with more rapid onset and shorter duration of action, over the past two decades. An interest in the issues discussed in this thesis arose out a desire to improve the quality of anaesthesia for patients who undergo day-case surgery. A second aim was to compare the different anaesthetic methods in terms of recovery from anaesthesia and costs. A total of 233 patients undergoing day-case knee arthroscopy under either 2% or 5% lidocaine spinal anaesthesia or general anaesthesia with desflurane, isoflurane, propofol or sevoflurane were investigated in two prospective, randomised clinical trials. The overall aims were to find the most suitable, satisfactory and economically feasible method for adult ambulatory knee arthroscopy and to assess the factors that affect the immediate postoperative period and the one-week recovery profile at home. The patients were highly satisfied with all the methods of anaesthesia. There was a slight tendency in favour of general anaesthesia compared to spinal anaesthesia. The general level of pain after ambulatory knee surgery was low after the first few hours postoperatively and continued to be low during the first postoperative week. After short-acting general anaesthesia with desflurane, isoflurane and propofol, home readiness was achieved over two hours earlier than after 5% lidocaine spinal anaesthesia. Home readiness was significantly delayed after 2% lidocaine spinal anaesthesia compared to sevoflurane inhalation anaesthesia. General anaesthesia with isoflurane was cheaper than the other general anaesthetics, i.e. desflurane, sevoflurane, propofol, or 2% and 5% lidocaine spinal anaesthesias. Propofol anaesthesia was the most expensive. The spinal anaesthesia patients had a higher incidence of headache, backache and lower leg pain during the first postoperative week than the patients who had had general anaesthesia. In busy ambulatory surgery units, remarkable savings may be achieved by using short-acting general anaesthetics, i.e. desflurane and isoflurane, instead of propofol or sevoflurane general anaesthesias or lidocaine spinal anaesthesia. This is due to the lower costs of desflurane and isoflurane compared to sevoflurane and propofol and the shorter time needed for postoperative care compared to spinal anaesthesia.

INTRODUCTION: The knee joint is one of the most frequently injured structures in the game of golf. The loads experienced by the knee during the golf swing are typically greater than those experienced during walking. In particular, a heightened lead limb peak external knee adduction moment has been linked to the progression of medial compartment knee osteoarthritis (OA). Altering movement patterns is a common strategy that can be used to reduce loading on the knee joint but has received little attention during the golf swing. Also, while such manipulations may be beneficial from an injury prevention perspective, they may have implications on golf performance. The purpose of this study was to analyze the effects altering stance has on the peak knee adduction moment and swing speed during the golf swing. METHODS: Twenty healthy subjects were recruited for a 3-dimensional biomechanical analysis wherein participants hit three golf shots using different stance positions in which either foot angle or stance width was altered. The following stance conditions were used: self-selected, 0º foot angle (perpendicular to target line), 30º foot angle (externally rotated), wide stance width, and narrow stance width RESULTS: Both the 30º foot angle and the wide stance width significantly decreased (p < 0.001) the lead limb peak external knee adduction moment compared to the self-selected golf stance. In contrast, the narrow stance width significantly increased (p = 0.023) the peak knee adduction moment when compared to the self-selected stance. No significant differences were found in the peak knee adduction moment between the 0º foot angle and self-selected stance. Lastly, no significant differences (p = 0.109) were found in swing speed between any of the stance conditions. CONCLUSION: The externally rotated foot position and wider stance width decreased the lead limb peak knee adduction moment without hindering performance. Considering the prevalence of injury to the lead limb knee joint, modifying a golfer’s stance could potentially be used to increase the longevity of their playing career.

We developed a novel approach that requires subjects to produce and finely tune ground reaction forces (GRFs) while standing. Using this method we were able to identify specific contributions of individual muscles and how these contributions change with the effects of age. One of the aims of this investigation was to determine whether electromyographic data in our findings was due to random muscle activation or representative of a neuromuscular control strategy. Ten healthy young adults (5 male, 5 female) with their dominant foot fixed within a boot mounted to a force platform participated twice in a target matching protocol, requiring subjects to control both the direction and magnitude of GRF along the horizontal plane while maintaining constant inferior-superior loads of 50% body-weight. Subjects were asked to manoeuvre a cursor with their dominant leg to match a series of targets projected on a screen. Targets appeared at random one at-a-time, separated by 30o around a circular trajectory. Subjects applied loads to the force platform in various horizontal directions to move the cursor while also controlling body weight. A successful target match required subjects to maintain 50% body weight and 30% of their peak horizontal load for one second. Electromyography (EMG) of eight muscles that cross the knee joint, ground reaction forces, and kinematic data were recorded for each successful match. EMG was normalized to percent maximum voluntary isometric contractions collected on an isokinetic dynamometer. Each target matching session was separated by two-three days. A random model, single measures intra-class correlation analysed the reliability for both test-retest and intra-day results, in addition to intersubject reliability. We observed moderate to high ICC values (0.60 – 0.993) for most muscles in most directions, indicating low within-subject variance. In addition, moderate to high between-subject reliability was observed in all eight muscle activation profiles, indicating subjects used similar neuromuscular control strategies to achieve the desired GRFs. Our findings support that groups who have undergone the same number of testing sessions can be compared, and that a single testing session is all that is required to compare neuromuscular control strategies used by a group to achieve target locations. The second aim of this investigation was to evaluate age related differences in neuromuscular control about the knee joint using our target match protocol. Thirty-three healthy adults (17 younger 24 years ±2, 16 older 59 years ±5), completed the same protocol evaluated above. The mean magnitude of muscle activity, specificity index, and mean direction of muscle activity were calculated in each target direction. Older adults presented with significantly lower strength in knee flexion and extension, hip abduction, and ankle plantar flexion. Significantly (p<0.25) higher mean activation magnitudes in the rectus femoris, vastus lateralis, vastus medialis, biceps femoris, semitendinosus, medial gastrocnemius, and tensor facia lata were also observed. Intraclass correlations (ICC) magnitudes indicate the percentage of global variance that can be explained by within subject and between trial variability. Muscle activation patterns were found to be similar in all muscles (ICC≤0.82). Similar patterns are supported by non-significant differences in mean direction of activation and muscle activation specificity. These results indicated that healthy older adults utilise different activation magnitudes for stabilising the knee while maintain similar muscle activation synergies in all muscles to younger adults.

Muscular stabilisation strategies during activities of daily living alter in the presence of knee osteoarthritis (OA). By examining neuromuscular adaptations using our weight-bearing target match protocol, the main objective of this research is to establish sex differences in adaptations of neuromuscular control that are associated with older males and females with and without OA. 66 participants completed the protocol while EMG, ground reaction forces (GRF), and kinematics were recorded. Muscle activation patterns were presented in polar plots with an EMG vector representing normalised muscle activation in twelve directions, each representing a GRF vector scaled to 30% maximal effort. Asymmetry about the polar plot (activation occurring in one direction more than another) was determined and specificity index (SI) and mean direction of activation were calculated when appropriate. Healthy females demonstrated greater rectus femoris (RF) mean muscle magnitude (XEMG) (p=0.067) and less biceps femoris (BF) XEMG than healthy males (p=0.084) and females with OA (p=0.041), and males and females with OA demonstrated greater RF XEMG than healthy controls of the same sex (p=0.016, 0.072, respectively). Females with OA had significantly greater medial gastrocnemius XEMG than healthy females (p=0.031) and males with OA (p=0.020). Females with OA have less specificity in all muscles compared to males with OA and OA participants generally had less specificity compared to healthy controls of the same sex. Healthy males had the largest SI for lateral gastrocnemius with an asymmetrical activation pattern contrasting the more symmetrical activation pattern of all other groups. In conclusion, we suggest OA-affected adults and healthy females use a quadriceps dominant strategy to stabilise the joint, and that this strategy may be a compensatory mechanism for reduced quadriceps function. We suggest RF, BF, MG, and LG should be targeted for prophylactic intervention as they displayed altered activation strategies in participants with OA and healthy females.