Diss. (sammanfattning) Umeå : University, 2003. / Härtill 5 uppsatser.

Orientador: Alberto Cliquet Junior / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-21T16:15:28Z (GMT). No. of bitstreams: 1 Alves_CarolinaLinsHenrique_M.pdf: 1344793 bytes, checksum: a8898223919974f480976745b55f4b9b (MD5) Previous issue date: 2012 / Resumo: As rupturas crônicas do tendão do calcâneo são desafios cirúrgicos e apresentam consequências na marcha. O propósito deste estudo foi avaliar parâmetros cinéticos e cinemáticos da articulação do tornozelo em treze pacientes diagnosticados com rupturas de tendão do calcâneo e tratados cirurgicamente através da técnica de enxerto livre do tendão do músculo semitendíneo. Os dados foram colhidos seis meses (6M) e doze meses (12M) após o procedimento através de plataforma de força enquanto os movimentos eram gravados por seis câmeras infravermelhas. Dois grupos foram submetidos à análise da marcha: grupo Paciente (subgrupos: pé Normal 6M, pé Normal 12M, pé Operado 6M e pé Operado 12M) e grupo Controle. As variáveis cinemáticas analisadas incluíram velocidade, cadência, comprimento do passo, porcentagem de fase de apoio e amplitude de movimento do tornozelo nos planos frontal e sagital. Os dados cinéticos foram obtidos pelo momento articular em diferentes fases do ciclo da marcha. No questionário de função AOFAS aplicado ao grupo Paciente observou-se aumento significativo de 68,5 pontos para 85,2 pontos (p=0,0215) na escala de 0 a 100 pontos, entre as coletas de seis e doze meses. Velocidade, cadência e comprimento do passo do grupo Paciente foram menores que o grupo Controle. A porcentagem da fase de apoio foi maior no subgrupo pé Normal 6M quando comparado ao grupo Controle. Nos dados cinemáticos a amplitude de movimento do tornozelo na fase de apoio aumentou entre os subgrupos pé Operado 6M e pé Operado 12M (p=0,0255) demonstrando efeito de tempo. Durante a fase de balanço a amplitude de movimento do tornozelo foi menor nos subgrupos pé Operado 6M/12M quando comparados aos subgrupos pé Normal 6M/12M demonstrando efeito de lado (p=0,0255). Os subgrupos pé Operado 6M e pé Operado 12M demonstraram diferença significativa quando comparado com grupo Controle (p=0,0240 e p=0,0414 respectivamente). A amplitude de movimento de inversão e eversão também apresentou efeito de tempo entre os mesmos grupos (p=0, 0059) citados anteriormente. Os dados cinéticos não apresentaram diferença significativa. O presente estudo mostrou grande proximidade entre o grupo Paciente e o grupo Controle, além da melhora entre os subgrupos pé Operado 6M e pé Operado 12M / Abstract: Chronic rupture of the Achilles tendon is a surgical challenge and has consequences in gait. The purpose of this study was to evaluate the kinetic and kinematic parameters of the ankle joint in 13 patients diagnosed with Achilles tendon rupture and operated using a free semitendinosus tendon graft. The data were collected six (6M) and twelve (12M) months after surgery in a force platform while the movements were recorded by six infrared cameras. Two groups were analyzed: group Patient (organized in 4 subgroups: Normal foot 6M, Normal foot 12M, Operated foot 6M, Operated foot 12M) and group Control. The kinematic variables analysed included speed, cadence, step length, percentage of stance phase and range of movement (ROM) of the ankle joint in sagital and frontal plane. Kinetic data were obtained by joint moment in different phases of gait cycle. In the functional questionnaire AOFAS applied to the group Patient it was observed a significant increase from 68,5 (±18,7) to 85,2 (±18,0) (p=0,0215) in a scale ranging from 0 to 100 within six and twelve months . Speed, cadence and step length of the group Patient were lower than Control group. The percentage in stance phase was higher for subgroup Normal foot 6M compared to the Control group. For kinematic data, the range of movement of the ankle in stance phase increased between Operated foot 6M and Operated foot 12M, showing an effect of time. During swing phase, the ankle ROM was lower in subgroups Operated foot 6M/12M when compared to subgroups Normal foot 6M/12M, showing effect of side (p=0,0255). The subgroups Operated foot 6M and Operated foot 12M demonstrated statistical difference when compared to Control group (p=0,0240 and p=0,0414, respectively). ROM of inversion and eversion presented effect of time among the same subgroups (p=0,0059) cited before. There were no statistic differences on kinetic data between groups. This study showed close proximity between group Patient and Control group and better results between subgroups Operated foot 6M and Operated foot 12M / Mestrado / Fisiopatologia Cirúrgica / Mestra em Ciências

Introdução: O alongamento dos músculos isquiotibiais (ISQ) tem sido utilizado com frequência para a correção da contratura em flexão dos joelhos na paralisia cerebral (PC), porém o aumento da anteversão da pelve (AP) e a recidiva da deformidade podem ocorrer a longo prazo. Objetivos: O objetivo deste trabalho foi avaliar se a transferência do semitendíneo para o tubérculo dos adutores (TXST) está relacionada a uma menor taxa de recidiva e a um menor aumento da AP no período pós-operatório, quando comparada ao alongamento deste músculo. Métodos: Foi realizado um estudo tipo coorte retrospectivo. Pacientes com PC diparesia espástica, Gross Motor Function Classification System (GMFCS) I-III, sem cirurgias prévias nos joelhos, submetidos ao alongamento dos ISQ mediais ou à TXST, e com completa documentação no laboratório de marcha foram incluídos no estudo. Foram excluídos aqueles que receberam de forma concomitante a osteotomia extensora do fêmur distal e o encurtamento patelar. Trinta e nove pacientes preencheram os critérios de inclusão e foram divididos em dois grupos de acordo com os procedimentos cirúrgicos realizados: Grupo A (22 pacientes / 44 joelhos), composto por aqueles que receberam o alongamento dos ISQ mediais; Grupo B (17 pacientes / 34 joelhos), formado por aqueles que receberam a TXST ao invés do alongamento do semitendíneo (AST), em conjunto com o alongamento dos demais ISQ mediais. Parâmetros clínicos e de cinemática foram avaliados nos dois grupos antes e após as cirurgias. Resultados: Os grupos não exibiram diferença quanto à distribuição por gênero, idade na cirurgia e tempo de seguimento. A deformidade irredutível em flexão estava presente em 9,1% dos joelhos no Grupo A e em 50% no Grupo B (p < 0,001) antes do tratamento, e em 25% dos joelhos do Grupo A e 20,6% no Grupo B (p=0,647) após os procedimentos cirúrgicos. O número de joelhos com deformidade irredutível em flexão aumentou no Grupo A (p=0,047) e reduziu no Grupo B (p=0,011) após a intervenção. Houve redução significativa da deformidade média em flexão dos joelhos ao exame físico (de 7,3° para 4,4°, p= 0,04) e da flexão dos joelhos durante a fase de apoio da marcha (de 34,2° para 20,2°, p < 0,001) apenas no Grupo B. A AP aumentou nos Grupos A e B após a correção cirúrgica da deformidade em flexão dos joelhos. Conclusão: O aumento da AP foi observado nos dois grupos após o tratamento efetuado. A redução da deformidade em flexão dos joelhos ao exame físico e o aumento da extensão dos joelhos na fase de apoio foram observados apenas nos pacientes submetidos à TXST / Introduction: Hamstrings surgical lengthening has been frequently used for the correction of knee flexion contracture in cerebral palsy (CP), however the increase of anterior pelvic tilt and the recurrence of the deformity can occur in a long-term follow-up. The aim of this study was to evaluate if semitendinosus transfer to distal femur (STTX) is related to less increase of anterior pelvic tilt and less recurrence of knee flexion deformity after treatment than semitendinosus surgical lengthening (STL). Methods: A retrospective cohort study was conducted. Patients with diplegic spastic CP, GMFCS levels I to III, without previous surgical procedures at knee, undergone to bilateral medial hamstrings surgical lengthening or STTX, and with complete documentation at gait laboratory were included in this study. Patients with concomitant distal femur extension osteotomy and patellar tendon shortening were excluded. Thirty-nine patients matched the inclusion criteria and they were divided in two groups according surgical procedures at knees: Group A (22 patients / 44 knees), including patients who received medial hamstrings surgical lengthening as part of multilevel approach; Group B (17 patients / 34 knees), represented by patients who underwent orthopedic surgery including a STTX instead of STL. Clinical and kinematic parameters were evaluated at baseline and at follow-up for all groups. Results: The two groups matched at gender distribution, age at surgery and follow-up time. Fixed knee flexion deformity (FKFD) before surgery was observed at 9.1% of knees in Group A and at 50% in Group B (p < 0.001). At final follow-up, 25% of knees in Group A and 20.6% in Group B shown FKFD (p=0.647). FKFD increased in Group A (p=0.047) and decreased in Group B (p=0.011) after treatment. The reduction of mean FKFD (from 7.3° to 4.4°, p= 0.04) and of knee flexion during gait stance phase (from 34.2° to 20.2°, p< 0.001) were observed only in Group B after surgical procedures. The anterior pelvic tilt increased at both groups after treatment. Conclusion: The increase of anterior pelvic tilt occurred at both groups after correction of knee flexion deformity. Patients who received STTX exhibited less fixed knee flexion deformity and better knee extension during stance phase after surgical treatment than those whom undergone to STL

Introdução: O alongamento dos músculos isquiotibiais (ISQ) tem sido utilizado com frequência para a correção da contratura em flexão dos joelhos na paralisia cerebral (PC), porém o aumento da anteversão da pelve (AP) e a recidiva da deformidade podem ocorrer a longo prazo. Objetivos: O objetivo deste trabalho foi avaliar se a transferência do semitendíneo para o tubérculo dos adutores (TXST) está relacionada a uma menor taxa de recidiva e a um menor aumento da AP no período pós-operatório, quando comparada ao alongamento deste músculo. Métodos: Foi realizado um estudo tipo coorte retrospectivo. Pacientes com PC diparesia espástica, Gross Motor Function Classification System (GMFCS) I-III, sem cirurgias prévias nos joelhos, submetidos ao alongamento dos ISQ mediais ou à TXST, e com completa documentação no laboratório de marcha foram incluídos no estudo. Foram excluídos aqueles que receberam de forma concomitante a osteotomia extensora do fêmur distal e o encurtamento patelar. Trinta e nove pacientes preencheram os critérios de inclusão e foram divididos em dois grupos de acordo com os procedimentos cirúrgicos realizados: Grupo A (22 pacientes / 44 joelhos), composto por aqueles que receberam o alongamento dos ISQ mediais; Grupo B (17 pacientes / 34 joelhos), formado por aqueles que receberam a TXST ao invés do alongamento do semitendíneo (AST), em conjunto com o alongamento dos demais ISQ mediais. Parâmetros clínicos e de cinemática foram avaliados nos dois grupos antes e após as cirurgias. Resultados: Os grupos não exibiram diferença quanto à distribuição por gênero, idade na cirurgia e tempo de seguimento. A deformidade irredutível em flexão estava presente em 9,1% dos joelhos no Grupo A e em 50% no Grupo B (p < 0,001) antes do tratamento, e em 25% dos joelhos do Grupo A e 20,6% no Grupo B (p=0,647) após os procedimentos cirúrgicos. O número de joelhos com deformidade irredutível em flexão aumentou no Grupo A (p=0,047) e reduziu no Grupo B (p=0,011) após a intervenção. Houve redução significativa da deformidade média em flexão dos joelhos ao exame físico (de 7,3° para 4,4°, p= 0,04) e da flexão dos joelhos durante a fase de apoio da marcha (de 34,2° para 20,2°, p < 0,001) apenas no Grupo B. A AP aumentou nos Grupos A e B após a correção cirúrgica da deformidade em flexão dos joelhos. Conclusão: O aumento da AP foi observado nos dois grupos após o tratamento efetuado. A redução da deformidade em flexão dos joelhos ao exame físico e o aumento da extensão dos joelhos na fase de apoio foram observados apenas nos pacientes submetidos à TXST / Introduction: Hamstrings surgical lengthening has been frequently used for the correction of knee flexion contracture in cerebral palsy (CP), however the increase of anterior pelvic tilt and the recurrence of the deformity can occur in a long-term follow-up. The aim of this study was to evaluate if semitendinosus transfer to distal femur (STTX) is related to less increase of anterior pelvic tilt and less recurrence of knee flexion deformity after treatment than semitendinosus surgical lengthening (STL). Methods: A retrospective cohort study was conducted. Patients with diplegic spastic CP, GMFCS levels I to III, without previous surgical procedures at knee, undergone to bilateral medial hamstrings surgical lengthening or STTX, and with complete documentation at gait laboratory were included in this study. Patients with concomitant distal femur extension osteotomy and patellar tendon shortening were excluded. Thirty-nine patients matched the inclusion criteria and they were divided in two groups according surgical procedures at knees: Group A (22 patients / 44 knees), including patients who received medial hamstrings surgical lengthening as part of multilevel approach; Group B (17 patients / 34 knees), represented by patients who underwent orthopedic surgery including a STTX instead of STL. Clinical and kinematic parameters were evaluated at baseline and at follow-up for all groups. Results: The two groups matched at gender distribution, age at surgery and follow-up time. Fixed knee flexion deformity (FKFD) before surgery was observed at 9.1% of knees in Group A and at 50% in Group B (p < 0.001). At final follow-up, 25% of knees in Group A and 20.6% in Group B shown FKFD (p=0.647). FKFD increased in Group A (p=0.047) and decreased in Group B (p=0.011) after treatment. The reduction of mean FKFD (from 7.3° to 4.4°, p= 0.04) and of knee flexion during gait stance phase (from 34.2° to 20.2°, p< 0.001) were observed only in Group B after surgical procedures. The anterior pelvic tilt increased at both groups after treatment. Conclusion: The increase of anterior pelvic tilt occurred at both groups after correction of knee flexion deformity. Patients who received STTX exhibited less fixed knee flexion deformity and better knee extension during stance phase after surgical treatment than those whom undergone to STL

Tendon transfer surgery is used to improve the hand function of patients with nerve injuries, spinal cord lesions, cerebral palsy (CP), stroke, or muscle injuries. The tendon of a muscle, usually with function opposite that of the lost muscle function, is transferred to the tendon of the deficient muscle. The aim is to balance the wrist and fingers to achieve better hand function. The position, function, and length at which the donor muscle is sutured is essential for the outcome for the procedure. In these studies the significance of the transferred muscle’s morphology, length and apillarization was investigated using both animal and human models. Immunohistochemical, biochemical, and laser diffraction techniques were used to examine muscle structure. In animal studies (rabbit), the effects of immobilization and of tendon transfers at different muscle lengths were analyzed. Immobilization of highly stretched muscles resulted in fibrosis and aberrant regeneration. A greater pull on the tendon while suturing a tendon transfer resulted in larger sarcomere lengths as measured in vivo. On examination of the number of sarcomeres per muscle fiber and the sarcomere lengths after 3 weeks of immobilization and healing time, we found a cut-off point up to which the sarcomerogenesis was optimal. Transfer at too long sarcomere lengths inhibited adaptation of the muscle to its new length, probably resulting in diminished function. In human studies we defined the sarcomere lengths of a normal human flexor carpi ulnaris muscle through the range of motion, and then again after a routinely performed tendon transfer to the finger extensor. A calculated model illustrated that after a transfer the largest force was predicted to occur with the wrist in extension. Morphological studies of spastic biceps brachii muscle showed, compared with control muscle, smaller fiber areas and higher variability in fiber size. Similar changes were also found in the more spastic wrist flexors comparing with wrist extensors in children with CP. In flexors, more type 2B fibers were found. These observations could all be due to the decreased use in the spastic limb, but might also represent a specific effect of the spasticity. In children and adults with spasticity very small fibers containing developmental myosin were present in all specimens, while none were found in controls. These fibers probably represent newly formed fibers originating from activated satellite cells. Impaired supraspinal control of active motion as well as of spinal reflexes, both typical of upper motor syndrome, could result in minor eccentric injuries of the muscle, causing activation of satellite cells. Spastic biceps muscles had fewer capillaries per cross-sectional area compared to age-matched controls, and also a smaller number of capillaries around each fiber. Nevertheless, the number of capillaries related to the specific fiber area was normal, and hence the spastic fibers are sufficiently supplied with capillaries. This study shows that the length of the muscle during tendon transfer is crucial for optimization of force output. Laser diffraction can be used for accurate measurement of sarcomere length during tendon transfer surgery. Wrist flexor muscles have more morphological alterations typical of spasticity compared to extensors.

Zur Zeit gibt es keinen optimalen Sehnentransfer zur Behandlung von irreparablen Ruptur der Subscapularissehne. Obwohl der Pectoralis major Transfer als Therapie der Wahl gilt, bleibt der Kraftvektor der verlagerten Sehne-Muskeleinheit sehr unterschiedlich zum Kraftvektor des Subscapularismuskels. Das Ziel dieser Arbeit war, ein neues Konzept zur Behandlung von irreparablen Subscapularisrupturen zu definieren, bei dem die Subscapulariseinheit selektiv mittels Teres major(TM) und Pectoralis major (PM) wiederhergestellt wird. In den Kadaverstudien dieser Arbeit konnte gezeigt werden, dass sich der M. Teres major anatomisch-chirurgisch als Sehnentransfer zur Rekonstruktion der unteren Hälfte des M. Subscapularis eignet. Darüberhinaus wurde in einer dreidimensionalen Vektoranalyse gezeigt, dass der Kraftvektoren vom verlagerten Teres major sich nicht signifikant vom Kraftvektoir des unteren Anteils des Musculus subscapularis unterscheidet. Es wurde weiterhin gezeigt, dass Modifikationen des Pectoralis major transfer durch Reroutingmassnahmen zu einer deutlichen Verbesserung seines Kraftvektors im Vergleich zum oberen Amteil des Musculussubscapularis führt. Basierend auf den neuen anatomischen und biomechanischen Erkenntnissen wurde im letzten Teil dieser Schrift das neue Konzept klinisch angewandt. Dabei wurde bei 7 Patienten mit einer irreparablen Subscapularisruptur nach multiplen Voreingriffen eine selektive Rekonstruktion mittels kombinierten TM-PM Transfer durchgeführt. Es traten keine Komplikationen auf und alle Patienten hatten eine deutliche Linderung Ihrer Schmerzen und eine Verbesserung der Funktion. Somit erscheint diese neue Transferoperation eine sichere und effiziente Option zur Behandlung irreparabler Subscapularisrupturen darzustellen. / Currently there is no optimal tendon transfer procedure for the management of irreparable subscapularis lesions. Although the pectoralis major transfer is considered as the gold standard in the treatment of irreparable subscapularis tears, the force vector orientation of this transfer may not be optimal in comparision to the situation at the subscapularis muscle. Objective of this monograph was to establish the anatomical and biomechanical basis for a new concept of selective subscapularis reconstruction combining a teres major transfer to the pectoralis major transfer. In the cadaveric part of this work, it could be demonstrated that the teres major is a safe and biomechanically logical transfer for reconstruction of the lower part of the subscapularis. The analysis was carried on to define the optimal transfer for reconstruction of the upper part of the subscapularis. It was possible to determine the biomechanical effect of rerouting procedures of the pectoralis major transfer. Passing the tendon underneath the conjoined tendon appeared to be the most effective way to improve the direction of the pectoralis major transfer for subscapularis reconstruction. However this technique is demanding when the plane underneath the conjoined tendon is scarred and the pectoralis major is bulky. In such cases there is a risk to injure the musculocutaneous nerve. Therefore, rerouting the sternal part of the pectoralis major underneath its clavicular part (sPM tansfer) may be a safer option. Finally, based on the acquired anatomical and biomechanical data, early clinical experience in a series of 7 patients was reported. Although the clinical series was small, the combined TM-sPM transfer appeared to be a valuable and a safe alternative to treat irreparable subscapularis tears. An interesting observation in this study was that the transfer was able to recenter the statically subluxed humeral head in two cases. This could be attributed to the dynamic hammock built by the transferred teres major. The early promising subjective and objective results presented here encourage for further investigation.