A ruptura do ligamento cruzado cranial (RLCCr) é a principal causa de claudicação em cães, podendo ocorrer devido à causas traumáticas ou degenerativas. Apesar da ampla variedade de técnicas cirúrgicas disponíveis, o tratamento ideal para esta condição ortopédica permanece indeterminado. Nas últimas décadas, foram desenvolvidas técnicas que evitam a movimentação anormal do joelho por conseguir estabilidade dinâmica através da alteração da geometria óssea e, dentre elas, destacam-se as técnicas de osteotomia para nivelamento do platô tibial (TPLO) e a osteotomia para avanço da tuberosidade tibial (TTA). São poucos os estudos clínicos que avaliam o joelho e sua funcionalidade após as cirurgias de TPLO e TTA. O apoio precoce do membro no pós-operatório é uma das principais vantagens da TPLO e TTA, e este apoio pode ser avaliado de forma subjetiva (tabela com graus de claudicação), mas a análise cinética do movimento em plataforma de pressão destaca-se por proporcionar mensuração objetiva do uso do membro durante a deambulação. O objetivo deste trabalho é comparar as técnicas de osteotomia para avanço da tuberosidade tibial (TTA) e osteotomia para nivelamento do platô tibial (TPLO) na estabilização de joelhos de cães com ruptura de ligamento cruzado cranial, por avaliação subjetiva e objetiva através da análise em plataforma de pressão (baropodometria). Foram avaliados 27 cães adultos acima de 20 quilos e com RLCCr unilateral, submetidos aos procedimentos de TTA (12 cães) ou TPLO (15 cães). Estes pacientes foram avaliados no período pré-operatório e aos 14, 30, 60 e 90 dias de pós-operatório com tabela de graduação da claudicação (dois Médicos Veterinários), escala de análise visual (deambulação pelo proprietário), exames radiográficos mensais (consolidação da osteotomia), tabela de graduação da recuperação do uso do membro (proprietário) e apoio em plataforma de pressão (baropodometria). Os animais foram separados nos grupos de acordo com a angulação do platô tibial (APT) e, baseado na recomendação clínica, foi utilizado TPLO para qualquer APT e TTA para APT de até 27°. Em ambos os grupos foi observada recuperação funcional do membro operado estatisticamente significativa, tanto nas avaliações subjetivas, como na avaliação objetiva em plataforma de pressão. Em decorrência da recomendação clínica para TTA, houve diferença significativa entre os grupos com relação ao ângulo do platô tibial (28,13° para TPLO e 22,33° para TTA), porém este foi corrigido com o teste de covariância. Não houve diferença entre os grupos na recuperação do apoio do membro com RLCCr, tanto na avaliação subjetiva como na avaliação objetiva em plataforma de pressão. Concluise que os procedimentos cirúrgicos de TPLO e TTA foram eficientes em promover melhora do apoio em cães com ruptura do ligamento cruzado cranial unilateral. / Cranial cruciate ligament rupture is the major cause of lameness in dogs and can occur due to degenerative or traumatic causes. Despite the wide variety of surgical techniques available, the ideal treatment for this orthopedic condition remains undetermined. Currently techniques have been developed to prevent abnormal movement of the stifle. Dynamic stability is achieved by changing the bone geometry by techniques like tibial plateau leveling osteotomy (TPLO) and osteotomy to tibial tuberosity advancement (TTA). One of the main advantages of TPLO and TTA is the early weight-bearing in postoperative period, which can be evaluated subjectively. But the locomotion kinetic analysis in pressure platform is a more objective measurement in the use of the limb during walking. The objective of this study is to compare the techniques of tibial tuberosity advancement (TTA) and tibial plateau leveling osteotomy (TPLO) in stabilizing dogs stifles with cranial cruciate ligament deficiency in one limb. Evaluation will be done with subjective and objective assessment via analysis in pressure platform (baropodometry). We evaluated 27 adult dogs over 20 Kg with unilateral or bilateral cranial cruciate ligament rupture. They were underwent to TTA (12 dogs) and TPLO (15 dogs). These patients were evaluated in the preoperative period and at 14, 30, 60 and 90 days postoperatively focus on claudication (two veterinarians - grade scale), visual analysis scale (weightbearing - owner), radiographs (osteotomy healing), recovery degree of the function (owner) and on pressure platform (baropodometry). We evaluated 27 adult dogs with 20 kilos at least and unilateral cranial cruciate ligament deficience. They were subjected to procedures TTA (12 dogs) or TPLO (15 dogs). These patients were evaluated in the preoperative period and at 14, 30, 60 and 90 days after surgery, with postoperative lameness grading system (two veterinarians), scale of visual analysis (owner), radiographic exam (osteotomy healing), recovery grading system (owner) and pressure platform (baropodometry). The animals were divided into groups according to the the tibial plateau angle (TPA) and based on clinical recommendation we used TPLO in all patients and TTA in those patients that had TPA less than 27°. In both groups we observed statistically significant recovery, both in subjective evaluations and objective assessment. Due to the clinical recommendation for TTA, there was significant difference among groups in respect to the tibial plateau slope (28.13 for TPLO and 22.33 for TTA), but It was corrected with the covariance test. There was no difference between groups in recovery of the surgery. We conclude that TPLO and TTA were effective in promoting improved support in dogs with cranial cruciate ligament deficience.

Distributive justice is a bioethical principle concerned with the fair distribution of resources and benefits in society. In the context of orthopaedic surgery management, distributive justice is an important consideration in ensuring that all patients have equal access to the resources and care in the treatment of their injuries. The literature well documents demographic and socioeconomic factors in the allocation of elective orthopaedic surgeries, but unfortunately a similar analysis is lacking when it comes to orthopaedic trauma surgeries. This study examines fundamental philosophical perspectives that underly healthcare delivery specifically pertaining to orthopaedic trauma. In doing so, the influence of race, socioeconomic status, insurance status and other factors on access to care and allocation of resources are described. Findings for various orthopaedic trauma surgery cases suggest decreased allotment to those of black race, lower socioeconomic, educational, and non-insurance status. Although the reason is multifactorial and complex, I suggest a shift in focus to the equity and fair distribution of surgical resources by considering the role of population health, understanding multidisciplinary interactions, improving research methodology, and community partnership. / Urban Bioethics

Background: Cubitus varus is a cosmetically unacceptable complication of supracondylar fractures of the elbow in children. We have performed the lateral closing wedge (French) osteotomy to correct the varus for 27 years. More complex osteotomies have been described to correct the associated hyperextension and internal rotation deformities and to prevent a prominent lateral condyle. Methods: We retrospectively reviewed 90 consecutive patients (1986-2012). The mean age of the patients at surgery was 8.2 years (3 to14 years). The varus angle (mean 21.4°, range 8°- 40°) was assessed pre-operatively with the humero-elbow-wrist (HEW) angle. The postoperative carrying angle (mean 10.4) and the pre- and postoperative range of movement were assessed clinically. The lateral condylar prominence index (LCPI) was retrospectively measured at union. Results: Seventy five (93.3%) of the patients had a good or excellent result. Six (6.7%) had a poor result (residual varus, loss of >20°of pre-operative range of flexion or extension or a complication necessitating repeat surgery). There were no neuro-vascular complications. The mean LCPI was +0.14. Conclusions: The results of the French osteotomy are comparable to the more technically demanding dome, step-cut translation and multi-planar osteotomies, with a lower complication rate. The literature reports adequate remodelling of the hyperextension deformity ( ≤ 10 years) patient. Level of evidence: Level IV: Case series

no / The shear and extensional properties of injection moulding grade hydroxyapatite¿polyethylene composites developed for orthopaedic applications have been studied. The composite was prepared without processing aids owing to concerns over the potential biological responses to such additives. The composite containing 20 vol.-% hydroxyapatite filler showed typical pseudoplastic behaviour. However, that containing 40 vol.-% hydroxyapatite filler tended to exhibit yield. The Maron¿Pierce equation was found to be useful in predicting the viscosities of the composite systems. The activation energy of the composite and the unfilled polymer were equal, indicating that the 20 vol.-% system exhibits the same flow mechanism as the unfilled polymer. A qualitative assessment of extensional properties was made following Cogswell's method. The extensional stress of the unfilled polymer decreases with increasing temperature whereas the composites behave in a complex manner. For all the systems the Trouton ratios tend to increase with apparent shear rates. The Trouton ratio also indicates that at higher temperatures the flow of these composites is dominated by extensional properties.

The global burden of injury is severely underappreciated and disproportionately affects low-income countries. With timely, appropriate orthopaedic treatment disability and mortality can be prevented, yet appropriate health resources are seldom available. Without orthopaedic medical devices (OMDs), quality of orthopaedic care suffers and the burden of preventable injury is exacerbated. A qualitative case study of 45 key informant interviews was conducted in Uganda to explore accessibility of OMDs, such as plaster, external fixators and implants. Data analysis elicited four major themes as barriers preventing access to OMDs in Uganda: 1) Poor leadership in government and corruption; 2) inadequate human resources; 3) inefficient and insufficient health care infrastructure; and 4) high costs of OMDs and poverty. Potential solutions for improving access to orthopaedic care were categorized as policies prioritizing orthopaedic services, training more orthopaedic specialists and creating incentives for them to work in underserviced areas, and innovative strategies funding for orthopaedic services.

The global burden of injury is severely underappreciated and disproportionately affects low-income countries. With timely, appropriate orthopaedic treatment disability and mortality can be prevented, yet appropriate health resources are seldom available. Without orthopaedic medical devices (OMDs), quality of orthopaedic care suffers and the burden of preventable injury is exacerbated. A qualitative case study of 45 key informant interviews was conducted in Uganda to explore accessibility of OMDs, such as plaster, external fixators and implants. Data analysis elicited four major themes as barriers preventing access to OMDs in Uganda: 1) Poor leadership in government and corruption; 2) inadequate human resources; 3) inefficient and insufficient health care infrastructure; and 4) high costs of OMDs and poverty. Potential solutions for improving access to orthopaedic care were categorized as policies prioritizing orthopaedic services, training more orthopaedic specialists and creating incentives for them to work in underserviced areas, and innovative strategies funding for orthopaedic services.

Bakgrund: Ren intermittent katetrisering (RIK) är en åtgärd som utförs dagligen på ett flertal patienter inom sjukvården, där sjukvårdspersonal tränger innanför patientens integritetssfär. Patienter har olika personliga gränser för när den personliga integriteten hotas och deras upplevelse vid RIK postoperativt, är sparsamt belyst i tidigare forskning.  Syfte: Att beskriva patienters upplevelse av ren intermittent kateterisering postoperativt. Metod: Datainsamlingen genomfördes med semistrukturerade intervjuer där tretton patienter som kateteriserats postoperativt deltog. Data analyserades med kvalitativ innehållsanalys. Resultat: Resultatet visade att patienterna upplevde vårdpersonalen som kompetenta och de förlitade sig på att vårdpersonalen visste vad som var bäst för patienterna som också kände sig omhändertagna. Det upplevdes vara viktigt att bevara den personliga integriteten och de påtalade vikten av tillräckligt insynsskydd vid kateteriseringen vilket inte alltid varit tillfyllest. Patienterna uttryckte också rädsla dels för smärta i samband med kateteriseringen och dels för att de trodde att det var något fel eftersom de inte kunde urinera. Några beskrev det som en lättnad att få hjälp att tömma blåsan, medan andra kände sig utlämnade och upplevde det som att de inte hade något val. Majoriteten av patienterna hade inte fått/kom inte ihåg att de fått adekvat information om att kateterisering kunde komma att behövas postoperativt och de påtalade vikten av att detta gavs innan operationen. Slutsats: Vårdpersonalens bemötande av patienter som behöver genomgå RIK är av största vikt för patientens upplevelse av vårdsituationen. Vikten av att information ges, som är adekvat och lättförståelig, poängteras. Det är en fördel om patienten görs delaktig i sin vård och att hänsyn även tas till speciella önskemål, som t.ex. kön på den som utför kateteriseringen. / Background: Clean intermittent catheterization is an action that is performed daily on several patients in health care, where health care staff penetrates inside the patients privacy sphere. Patients’ have different personal limits when privacy is threatened and research with focus on the patients experience of clean intermittent catheterization postoperatively is limited. Aim: To describe patients’ experience of clean intermittent catheterization postoperatively. Method: Data collection was conducted by using semi-structured interviews with thirteen patients that had been catheterized postoperatively. Data were analysed using qualitative content analysis. Result: The result showed that patients’ experienced health care staff as competent and they relied on that the medical staff knew what was best for the patients who also felt cared for. It felt to be important to preserve privacy and they stressed the importance of sufficient transparency protection during catheterization which had not always been satisfactory. The patients’ expressed fear partly for pain associated with catheterization and partly because they thought there was something wrong since they were unable to urinate. Some described it as a relief to get help emptying the bladder, while others felt vulnerable and felt that they had no choice. The majority of patients’ had not got or could not remember if they had received adequate information that catheterization could be needed postoperatively and they emphasized importance of that this information was given before surgery. Conclusion: Health care staff treatment of patient’s requiring clean intermittent catheterisation is crucial for the patient's experience of the care situation. The importance that the information given is adequate and understandable was emphasized. It is an advantage if the patient is involved in care and that consideration to special requests, such as that the gender of the person performing catheterisation is considered.

<p>There is no common understanding on what constitutes good sick-listing, a frequent and problematic task for many physicians, especially general practitioners (GPs) and orthopaedic surgeons. Aiming to achieve a deeper understanding of sick-listing practices, 19 GPs (I, III) and 18 orthopaedic surgeons (II) in four counties were interviewed, and data analysed qualitatively for views on good sickness certification and barriers to desired practice. Data from a survey of all 7665 physicians in two counties on emotionally straining problems in sickness certification (IV) was analysed quantitatively. </p><p>Some GPs exposed narrow views of sick-listing, where their responsibility was limited to issuing a certificate, while GPs with the most inclusive view had a perspective of the patient’s total life-situation and aimed to help patients shoulder their own responsibility (I). The orthopaedic surgeons´ perceptions of good sick-listing were mainly related to their views on their role in the health-care system. Some perceived their responsibility as confined to the orthopaedic clinic only, while others had the ultimate goal of helping the patient to become well functioning in life with regained work capacity – by means of surgery <i>and</i> proper management of sick-listing (II). </p><p>Difficulty handling conflicting opinions was a barrier to good sickness certification for GPs (III), and problematic for about 50% of all physicians and about 80% of GPs (IV). Orthopaedic surgeons’ handling of such situations varied from being directed by the patient, via compromising, to being directed by professional judgement (II). Other barriers included poor stakeholder collaboration (III). GPs with a workplace-policy on sickness certification reported fewer conflicts and less worry of getting reported to the disciplinary board in relation to sick-listing (IV).</p><p>Understanding physicians’ underlying views on and barriers to practicing “good sick-listing” can inform efforts to change physician practice. Communications skills training in handling sick-listing situations with conflicting opinions is recommended.</p>

Back pain is a massive global public health problem with multiple contributing factors including obesity. Obesity is thought to be linked to back pain through mechanical factors. However, obesity also causes a systemic low-grade inflammatory milieu. This would suggest a possible biochemical link between obesity, intervertebral disc degeneration, and back pain. Furthermore, the relationship between obesity and the clinical presentation of spine patients is unclear. This thesis aims to examine the effect of and relationship between obesity, the intervertebral discs, and back pain from biochemical, clinical, and epidemiological perspectives. In this thesis, an in vitro study assessed the effect of leptin, a fat-specific cytokine, upon the intervertebral disc. The bovine intervertebral disc was used as a model in a cell culture system. An ex vivo study examined leptin and pro-inflammatory cytokines produced by paraspinal adipose tissue taken during routine surgical procedures from spinal patients. Plasma taken from patients presenting with low back pain was analysed by mass spectrometry and multiplex immunoassay to identify possible protein biomarkers. At an epidemiological level, statistical modelling of the Genodisc patient population was conducted. This was a pan-European study of 2636 patients presenting to tertiary spinal units. Analyses were performed to examine relationships between obesity, quantified by body mass index (BMI), and pain, clinical diagnosis, and spinal degeneration identified on magnetic resonance imaging (MRI). Leptin was shown to increase the production of and expression of degradative and pain-generating molecules by disc cells. A pro-inflammatory environment, especially IL-6, potentiated this response. Leptin and pro-inflammatory cytokines produced by paraspinal fat were unrelated to clinical symptoms. However, levels of the pro-inflammatory cytokines, TNF-&alpha; and IL-6, were raised in the plasma of patients with greater pain or those with spinal stenosis. Furthermore, clusterin and complement were identified, by mass spectrometry, as potential biomarkers for spine patients. Epidemiological analyses revealed that obesity was associated with greater back pain, although the magnitude of this association was small. Similarly, obesity was associated with a diagnosis of spinal stenosis. Finally, increased BMI was found to be an independent predictor of disc degeneration, spinal stenosis, and disc herniation on MRI. In summary, this thesis has furthered the clinical understanding of lumbar spine pathology and back pain. It will provide clinicians with a better framework to assess spine patients. These results show that obesity is associated with lumbar spine degeneration and pain. Leptin could be a factor mediating this relationship. Further studies should concentrate on clarifying the mechanism of action of leptin upon the intervertebral disc and assessing the longitudinal effect of obesity upon the lumbar spine. In this thesis, an in vitro study assessed the effect of leptin, a fat-specific cytokine, upon the intervertebral disc. The bovine intervertebral disc was used as a model in a cell culture system. An ex vivo study examined leptin and pro-inflammatory cytokines produced by paraspinal adipose tissue taken during routine surgical procedures from spinal patients. Plasma taken from patients presenting with low back pain was analysed by mass spectrometry and multiplex immunoassay to identify possible protein biomarkers. At an epidemiological level, statistical modelling of the Genodisc patient population was conducted. This was a pan-European study of 2636 patients presenting to tertiary spinal units. Analyses were performed to examine relationships between obesity, quantified by body mass index (BMI), and pain, clinical diagnosis, and spinal degeneration identified on magnetic resonance imaging (MRI). Leptin was shown to increase the production of and expression of degradative and pain-generating molecules by disc cells. A pro-inflammatory environment, especially IL-6, potentiated this response. Leptin and pro-inflammatory cytokines produced by paraspinal fat were unrelated to clinical symptoms. However, levels of the pro-inflammatory cytokines, TNF-α and IL-6, were raised in the plasma of patients with greater pain or those with spinal stenosis. Furthermore, clusterin and complement were identified, by mass spectrometry, as potential biomarkers for spine patients. Epidemiological analyses revealed that obesity was associated with greater back pain, although the magnitude of this association was small. Similarly, obesity was associated with a diagnosis of spinal stenosis. Finally, increased BMI was found to be an independent predictor of disc degeneration, spinal stenosis, and disc herniation on MRI. In summary, this thesis has furthered the clinical understanding of lumbar spine pathology and back pain. It will provide clinicians with a better framework to assess spine patients. These results show that obesity is associated with lumbar spine degeneration and pain. Leptin could be a factor mediating this relationship. Further studies should concentrate on clarifying the mechanism of action of leptin upon the intervertebral disc and assessing the longitudinal effect of obesity upon the lumbar spine.

The use of computational modeling is an increasingly commonplace technique for the investigation of biomechanics in intact and pathological musculoskeletal systems. Moreover, given the robust and repeatable nature of computer simulation and the prevalence of software techniques for accurate 3-D reconstructions of tissues, the predictive power of these models has increased dramatically. However, there are no patient-specific kinematic models whose function is dictated solely by physiologic soft-tissue constraints, articular shape and contact, and without idealized joint approximations. Moreover, very few models have attempted to predict surgical effects combined with postoperative validation of those predictions. Given this, it is not surprising that the area of foot/ankle modeling has been especially underserved. Thus, we chose to investigate the pre- and postoperative kinematics of Adult Acquired Flatfoot Deformity (AAFD) across a cohort of clinically diagnosed sufferers. AAFD was chosen as it is a chronic and degenerative disease wherein degradation of soft-tissue supporters of the medial arch eventually cause gross malalignment in the mid- and hindfoot, along with significant pain and dysfunction. Also, while planar radiographs are still used to diagnose and stage the disease, it is widely acknowledged that these 2-D measures fail to fully describe the 3-D nature of AAFD. Thus, a population of six patient-specific rigid-body computational models was developed using the commercially available software packages Mimics® and SolidWorks® in order to investigate foot function in patients with diagnosed Stage IIb AAFD. Each model was created from patient-specific sub-millimeter MRI scans, loaded with body weight, individualized muscle forces, and ligament forces, in single leg stance. The predicted model kinematics were validated pre- and postoperatively using clinically utilized radiographic angle distance measures as well as plantar force distributions. The models were then further exploited to predict additional biomechanical parameters such as articular contact force and soft-tissue strain, as well as the effect of hypothetical surgical interventions. Subsequently, kinematic simulations demonstrated that the models were able to accurately predict foot/ankle motion in agreement with their respective patients. Additionally, changes in joint contact force and ligament strain observed across surgical states further elucidate the complex biomechanical underpinnings of foot and ankle function.