Introdução: A síndrome SPOAN é uma doença neurodegenerativa, de transmissão genética autossômica recessiva, até o momento reconhecida apenas no Brasil, que caracteriza-se por: paraplegia espástica, de início nos primeiros anos de vida e caráter progressivo; atrofia óptica congênita; neuropatia periférica sensitivo-motora axonal, de início a partir da primeira década de vida; sobressaltos à estimulação sonora, disartria, deformidades de coluna e pés e sinais extra piramidais. A sua caracterização foi feita por nosso grupo, que avaliou clinicamente 71 indivíduos, originários do Rio Grande do Norte. Estudo de ligação mapeou o locus responsável pela síndrome SPOAN em uma região de 2 Mb no cromossomo 11q13. O gene responsável pela síndrome SPOAN permanece desconhecido. A síndrome SPOAN é considerada uma forma complicada de paraplegia espástica. A associação entre neuropatia e paraplegia espástica está relacionada à perda progressiva de axônios longos e tem sido relatada em algumas formas complicadas de neuropatias e paraplegias espásticas hereditárias. Casuística e métodos: Foi realizada a avaliação de 27 pacientes, 20 mulheres, com idade variando entre 4 e 58 anos. Todos os indivíduos compartilhavam o mesmo fenótipo (paraplegia espástica, atrofia de nervo óptico e neuropatia periférica) e tinham o mesmo haplótipo 11q13. Pacientes com história de diabetes mellitus ou alcoolismo foram excluídos do estudo. A avaliação neurológica incluiu a pesquisa dos escores modificados de sintomas e comprometimento neuropáticos. A força muscular foi testada e graduada conforme a escala MRC (Medical Research Council). Foi realizada a pesquisa da sensibilidade dolorosa, térmica, tátil, vibratória e artrestésica. O trofismo foi avaliado pela presença de deformidades na coluna e atrofia nos membros inferiores. Os reflexos profundos e o cutâneo plantar também foram analisados. Os estudos da condução nervosa foram realizados em um aparelho portátil Nicolet - Viking Quest, (Viasys, USA). Para os estudos de condução motora foram analisados os nervos axillar, mediano, ulnar, femoral, tibial e fibular direito. A condução sensitiva foi analisada nos nervos mediano, ulnar, radial, sural e fibular direito. O reflexo H e as ondas F foram avaliados com técnicas padrão. Alguns testes não puderam ser realizados devido à intensa atrofia e deformidades esqueléticas. O coeficiente de correlação de Pearson foi calculado entre a idade e os parâmetros, velocidade de condução, latência e amplitude. Valores de P < 0,05 foram considerados estatisticamente significantes. Resultados: Avaliação clínica: Todos os pacientes obtiveram escore de sinais neuropáticos graves e demonstraram déficit de força e atrofia distal. Deformidades dos pés estavam presentes em todos os pacientes e deformidades na coluna, em 58%. Os reflexos profundos dos membros superiores estavam exaltados em 92% dos casos e o reflexo patelar, em 63%. O reflexo Aquileu estava ausente em todos os pacientes. Todas as modalidades de sensibilidade foram afetadas, principalmente nos membros inferiores. Os dados do exame de sensibilidade na paciente de 4 anos foram desconsiderados. Estudo da condução nervosa sensitiva: Os SNAPs dos nervos mediano, sural e fibular estavam ausentes em todos os pacientes. SNAPs do nervo ulnar estavam ausentes em 96% da amostra e do nervo radial, em 80%. Estudo da condução nervosa motora: As latências motoras dos nervos axilar e femoral estavam normais em todos os pacientes. As amplitudes dos CMAPs estavam reduzidas em 15 e 52% da amostra nos nervos mediano e ulnar, respectivamente. Velocidades de condução estavam reduzidas em 50 e 41% desta casuística nos nervos mediano e ulnar, respectivamente. Velocidades de condução estavam acima de 80% do limite inferior da normalidade, em todos os nervos, exceto em 1 paciente que apresentou redução de 27% no nervo ulnar. Entretanto, este mesmo paciente apresentou amplitude menor que 2mV. Ondas F apresentavam aumento da latência, de acordo com a altura, em 100% dos casos. CMAPs estavam ausentes em 93 e 84% da amostra nos nervos fibular e tibial, respectivamente. Reflexo H estava ausente em 88% dos pacientes. Não houve correlação entre idade e a velocidade de condução, latência e amplitude dos nervos mediano e ulnar. Discussão: O estudo da condução nervosa neste grupo preencheu critérios para uma neuropatia primária axonal. Nenhum paciente apresentou bloqueio de condução ou dispersão temporal. As alterações encontradas na velocidade de condução provavelmente se devem à perda de fibras nervosas de condução rápida. Fenótipos SPOAN-like foram descritos em famílias com mutações nos genes C12orf65, TFG e OPA1. No entanto, não existem detalhes sobre a condução nervosa nestes pacientes. Neuropatia axonal de início tardio foi relacionada à SPG55 e DOA (dominant optic atrophy), enquanto neuropatia axonal e desmielinizante com leve comprometimento sensitivo foi descrita na família com mutação no gene TFG. Conclusão: Os pacientes com a síndrome SPOAN apresentam uma acentuada neuropatia axonal, sensitivo motora. As alterações encontradas na condução nervosa dos pacientes com síndrome SPOAN não são específicas, no entanto, resultados normais excluem esta condição em adultos. A paciente mais jovem desta casuística já apresentava alterações ao exame, o que pode sugerir um início precoce da neuropatia. Entretanto, não temos dados suficientes para afirmar que este seja um achado comum a todos os pacientes SPOAN / Introduction: SPOAN syndrome (Spastic Paraplegia, Optic Atrophy and Neuropathy) is a progressive neurodegenerative disorder of autosomal recessive inheritance described by our group in a large inbred family from Northeastern Brazil. The clinical picture is characterized by non-progressive congenital optic atrophy, progressive spastic paraplegia, axonal neuropathy, auditory startles, dysarthria, spinal and foot deformities and also extrapyramidal signs. Linkage studies mapped the responsible locus for the syndrome to a 2Mb region on chromosome 11q13. The gene responsible for SPOAN syndrome remains elusive. Materials and Methods: This is a cross sectional study which was conducted from 2009 to 2011. We evaluated 27 patients (20 females), with a0ges ranging from 4 to 58 years. All patients shared the same phenotype (spastic paraplegia, optic atrophy and peripheral neuropathy) and had the same 11q13 haplotype in homozygosis. Patients with history of diabetes mellitus or alcoholism were excluded from this study. All patients were evaluated by the same clinical researcher (SA). Neurological evaluation included determination of modified neuropathy symptoms (NSS) and neuropathy disability (NDS) scores. Motor strength was assessed using MRC scale. Sensibility assessment included small-fiber (pain and temperature) and large-fiber modalities (vibration-128Hz diapason, 10g monofilament and joint position sense). Spine deformities and atrophy in the lower limbs were observed. We also evaluated osteotendineous reflexes and cutaneous plantar reflexes. Nerve conduction studies were performed using a portable Nicolet - Viking Quest, (Viasys,USA). Motor conduction studies included axillary, median, ulnar, femoral, tibial and fibular nerves on the right side. Sensory nerve action potentials of median, ulnar, sural and superficial fibular nerves were recorded using a bar electrode of 3 cm and standard fixed distances. Tibial H-reflex was evaluated with standard technique. Minimal F wave latencies were obtained from ulnar and tibial nerves. A few tests could not be done in every patient due to severe deformities. We calculated Pearson\'s correlation coefficients between age and nerve conduction parameters, including velocities, latencies and amplitudes. P values <0.05 were considered statistically significant. Results: Clinical data: Neuropathic symptoms such as pain and paresthesias were rare. All patients had signs of severe neuropathy. All subjects demonstrated weakness and atrophy that were more significant distally than proximally. Foot deformities were present in all patients and spine deformities were seen in 58%. Upper limb deep tendon reflexes were exalted in 92% and patelar reflex in 63%. Ankle reflex was absent in all patients. In one patient, who was 4 years-old, sensory evaluation was inconsistent and the results were not considered. In all the other ones, sensory modalities were affected and occurred predominantly in the lower limbs. Electrodiagnostic data: Sensory nerve conduction: Median nerve SNAP was absent in all 27 patients. Ulnar nerve SNAPs were absent in 96%, whereas radial nerve SNPAs were absent in 80%. Superficial fibular and sural SNAPs were absent in all patients. Motor nerve conduction: The motor latencies of axillary and femoral nerves were normal in all patients. CMAP amplitudes were reduced in 15% of the median nerves and in 52% of the ulnar nerves. Conduction velocities (CV) were reduced in 50% of the median nerves and in 41% of the ulnar nerves. CV was above 80% of the lower normal limit for all nerves, except for one patient who showed a 27% reduction of ulnar CV, but had also a CMAP amplitude of less than 2 mV. F waves were prolonged according to the height in 100%. Only one patient who presented significant motor CV reduction of the ulnar nerve. CMAPs were absent in 93% of the fibular nerves and in 84% of the tibial nerves. A single fibular nerve showed more than 20% of CV reduction, but also had severely reduced CMAP amplitude. H reflex was absent in 88% of the patients. There was no correlation between age and neurophysiological parameters, such as median or ulnar CV, latencies or CMAP amplitudes. Discussion: Nerve conduction studies in this group fulfill criteria for primary axonal neuropathy. No patient showed conduction block or temporal dispersion. Abnormalities seen in CV and F waves are probably related to loss of fast conduction fiber nerves. We could not demonstrate correlation between age and nerve conduction parameters, including velocities, latencies and amplitudes. SPOAN-like phenotype has been found in families with mutations in C12orf65, TFG and OPA1 genes, however there is no detailed report on nerve conduction studies in these conditions. Axonal neuropathy is also described in SPG55 and DOA plus, but usually with a later onset than on SPOAN syndrome. Peripheral neuropathy is also described in the family with mutation in TFG gene, but this presents a different pattern characterized as a mixed axonal demyelinating neuropathy with mild sensory involvement. Although the nerve conduction abnormalities seen in SPOAN syndrome are not specific, normal results seem to rule out this condition, at least in adult patients. The younger patient in our series was 4-years-old, and her neurophysiological study was severely abnormal, suggesting an early-onset neuropathy. However, we do not have a comprehensive study of several young patients to support that this feature is

Este estudo mostra como o rolamento do pé de pacientes com polineuropatia diabética pode ser melhorado com exercícios para pés e tornozelos, visando a recuperação muscular e articular comprometidos pela doença. Um ensaio clínico randomizado, paralelo, com um braço de crossover, e avaliador cego, foi conduzido. Cinquenta e cinco pacientes com polineuropatia diabética foram randomizados e alocados para o grupo controle (n=29) e grupo intervenção (n=26). A intervenção foi aplicada por 12 semanas, 2 vezes por semana, por 40 a 60 minutos cada sessão. As variáveis primárias foram definidas como as que descrevem o rolamento do pé: pressão plantar em seis regiões plantares de interesse. As variáveis secundárias foram a cinética e cinemática de tornozelo no plano sagital, e as medidas clínicas da função de pés e tornozelo (teste de função muscular manual, testes funcionais), de sinais e sintomas da polineuropatia diabética, exame físico dos pés e teste de confiança e equilíbrio em atividades da marcha. Os efeitos de tempo (baseline e 12 semanas), de grupo (controle e intervenção) e de interação foram calculados por meio de ANOVAs casewise 2 fatores, e para as comparações intragrupo do grupo intervenção (baseline, 12 semanas e 24 semanas) foram usadas ANOVAs para medidas repetidas. As variáveis não paramétricas foram comparadas entre grupos por meio de testes de Mann-Whitney e entre os tempos de intervenção por meio do teste de Wilcoxon. Adotou-se um ? de 5% para diferenças estatísticas e o coeficiente d de Cohen para descrição do tamanho do efeito da intervenção. Após 12 semanas de exercícios, observou-se mudanças positivas no rolamento do pé. Houve uma suavização do contato do calcanhar no apoio inicial, refletido pelo aumento do tempo do pico de pressão e da integral do pico de pressão. O médio-pé aumentou sua participação no rolamento observado pela diminuição da velocidade média do deslocamento do centro de pressão e aumento da integral do pico de pressão. O antepé lateral passou a realizar o apoio no solo antecipadamente em relação ao antepé medial, que previamente à intervenção aconteciam concomitantemente, e esse resultado foi evidenciado pela antecipação do tempo do pico de pressão em antepé lateral após a intervenção. A ação de hálux e dedos também aumentou (aumento de integral do pico de pressão e picos de pressão), em uma patologia marcada pela diminuição do contato do hálux e desenvolvimento de dedos em garra, que diminui o contato dos dedos com o solo. O grupo controle apresentou algumas pioras com relação à função muscular e parâmetros cinéticos e cinemáticos de tornozelo, enquanto que o grupo intervenção mostrou melhora na função de muitos grupos musculares, em testes funcionais e no pico de momento extensor na fase de aplainamento do pé. Apesar do protocolo de intervenção ter sido construído de modo a permitir que o paciente incorpore os exercícios na sua rotina diária, a aderência a este tipo de intervenção deve ser estudada, já que grande parte das variáveis retornaram ao baseline após o período de follow up. Ações preventivas são fundamentais para diminuir as complicações devastadoras da neuropatia diabética / This study shows how the foot rollover process during gait of patients with diabetic polyneuropathy can be improved with exercises for foot and ankle, aiming at the recovery of the muscles and joints affected by the disease. A clinical trial randomized, parallel, one arm of crossover, with blind assessment was conducted. Fifty-five patients with diabetic polineuropathy were randomly allocated to the control group (n = 29) and intervention group (n = 26). The intervention was applied for 12 weeks, twice a week, for 40 to 60 minutes per session. The primary variables were defined as those that describe the foot rollover: plantar pressure in 6 plantar areas of interest. The secondary variables were kinetic and kinematics of the ankle in the sagittal plane were calculated, and the clinical measures of foot and ankle function (manual muscle function testing, functional testing), signs and symptoms of diabetic polyneuropathy, physical examination of the feet and balance and confidence test in gait activities. The time effects (baseline and 12 weeks), group effects (control and intervention groups) and interaction effects were calculated using casewise two factos ANOVAs, and for intragroup comparisons of intervention group (baseline, 12 weeks and 24 weeks) it was used ANOVAs for repeated measures. The nonparametric variables were compared between groups using Mann-Whitney tests and between periods of assessment using Wilcoxon test. We adopted an ? of 5% for statistical differences and the Cohen\'s d coefficient for description of the effect size. After 12 weeks ofexercises, there were positive changes in the foot rollover process. There was a softening of heel contact in initial contact, reflected by the increase in time to peak pressure and the pressure time integral. The midfoot increased its participation observed by the decrease in speed of displacement of the center of pressure and increased pressure time integral. The lateral forefoot contact was earlier relative to the medial forefoot, that occurred at the same time before intervention, observed by the early time to peak pressure of lateral forefoot after the intervention. The participation of the hallux and toes also increased (increase of pressure time integral and peak pressure), in a pathology that is marked by decreased contact of the hallux and development of claw toes, which reduces contact of the toes with the ground. CG showed some worsening in relation to muscle function and kinematic and kinetic parameters of the ankle, while the IG showed improvement in the function of many muscles groups, functional tests and peak extensor moment during the forefoot contact. The intervention protocol was constructed to allow the patient to incorporate exercise into their daily routine, but adherence to treatment should be studied and motivational strategies need to be applied, since most of the variables returned to baseline after the follow up period (12 weeks after the intervention). Preventive actions are critical to reducing the devastating complications of diabetic neuropathy

<p>Kompleksnost visokoenergetskih preloma platoa i pilona tibije i njihova udruženost sa značajnim povredama mekog tkiva oko pripadajućeg zgloba veoma je dobro opisana. Lečenje ima za cilj da multifragmentarni prelomi platoa i pilona tibije postanu stabilni, artikularno poravnani, bezbolni, da koleno i skočni zglob budu pokretni i da se minimizira rizik do nastanka posttraumatskog osteoartritisa. Aparat po Ilizarovu sa nategnutim iglama, koristi opterećenje da stvori jedinstvenu podr&scaron;ku za zglob i stabilnu imobilizacju preloma da se postigne njegovo srastanje. Ovo omogućuje ranu pokretljivost zgloba bez rizika od gubitka redukcije. Cilj istraživanja je procena i poređenje rezultata lečenja unutarzglobnih vi&scaron;ekomadnih preloma kostiju proksimalnog i distalnog okrajka potkolenice tretiranih spoljnjim unilateralnim rigidnim fiksatorom i aparatom po Ilizarovu primenom ASAMI ko&scaron;tanog skoring sistema i funkcionalnog skoring sistema po Karlstrom &ndash; Olerudu.Takođe je jedan od ciljeva istraživanja bio da se uoče faktori koji utiču na različite rezultate lečenja unutarzglobnih vi&scaron;ekomadnih preloma kostiju gornjeg i donjeg okrajka potkolenice tretiranih spoljnim unilateralnim rigidnim fiksatorom i aparatom po Ilizarovu. Istraživanje je dizajnirano kao kontrolisana komparativna klinička studija a podaci su se prikupljali retrospektivno i delom prospektivno na osnovu medicinske dokumentacije od 2008. do 2013. godine. Studija je u potpunosti izvedena na Klinici za ortopediju i traumatologiju Kliničkog centra Vojvodina u Novom Sadu. Studija je obuhvatila ukupno 103 ispitanika kod kojih je u toku 2008 do 2013. godine postavljena dijagnoza unutarzglobnog vi&scaron;ekomadnog preloma gornjeg ili donjeg okrajka tibije. Ispitanici koji su obuhvaćeni ovim kliničkim istraživanjem razvrstani su u tri grupe: Prvu grupu od 53 ispitanika činili su oni sa vi&scaron;ekomadnim unutarzglobnim otvorenim ili zatvorenim prelomima gornjeg ili donjeg okrajka kostiju potkolenice lečenih isključivo spoljnjim unilateralnim rigidnim fiksatorom. Drugu grupu ispitanika, njih 31, činili su oni sa vi&scaron;ekomadnim unutarzglobnim otvorenim ili zatvorenim prelomima gornjeg ili donjeg okrajka kostiju potkolenice lečenih isključivo aparatom po Ilizarovu. Treću grupu činila su 19 ispitanika sa vi&scaron;ekomadnim unutarzglobnim otvorenim ili zatvorenim prelomima gornjeg ili donjeg okrajka kostiju potkolenice koji su lečenje započeli spoljnjim unilateralnim rigidnim fiksatorom, a u kasnijem periodu zbog nastalih komplikacija (lo&scaron;e srastanje, produženo srastanje, nesrastanje, infekcija, pseudoartroza) lečenje nastavili konverzijom spoljnjeg unilateralnog rigidnog fiksatora u aparat po Ilizarovu. Osnovni izvor podataka za prikazano istraživanje bio je protokol formiran za svakog bolesnika pojedinačno, istorije bolesti i poliklinička evidencija. Za potrebe istraživanja dizajniran je protokol istraživanja gde su se prikupljeni podaci analizirali hronolo&scaron;ki : podaci o pacijentu, klinički nalaz na prijemu, postoperativni tok, monitoring aparata, klinički nalaz na otpustu i klinički nalaz na kontrolama od 6, 12 i 18 meseci. Kliničke nalaze na kontrolama na 6, 12 i 18 meseci beležili smo upotrebom skoring sistema ASAMI ( Udruženja za istraživanje i primenu metoda po Ilizarovu) &ndash; za ko&scaron;tane rezultate, i Karlstrom &ndash; Oleruda za procenu funkcionalnih rezultata. Neki do najvažnih rezultata dobijenih prilikom ovog istraživanja jesu da je najbrže vreme srastanja imala grupa Ilizarov, nakon 16&plusmn;2 nedelja. Grupa konverzija zabeležila je prosečno vreme srastanja u 17&plusmn;2 nedelji, dok je kod ispitanika u grupi fiksator zabeženo srastanje u 21&plusmn;4 nedelji. Pojava povr&scaron;nih i dubokih infekcija značajno je veća kod grupe tretiranih spoljnim unilateralnim fiksatorom nego kod grupa tretiranih aparatom po Ilizarovu. Vreme postizanje ranog, punog oslonca na operisani ekstremitet je značajno kraće kod grupe Ilizarov i konverzija nego kod grupe fiksator. Procena ko&scaron;tanih rezultata kori&scaron;ćenjem ASAMI bodovnog sistema ko&scaron;tanog srastanja ukazuje na statistički značajno bolje rezultate kod grupa Ilizarov i konverzija u odnosu na grupu spoljnji fiksator u periodu praćenja i analize na 6,12 i 18 meseci. Funkcionalni rezultati primenom sistema funkcionalne evaluacije po Karlstrom &ndash; Olerudu govore u prilog značajno statistički boljim rezultatima kod grupe Ilizarov i konverzija u odnosu na grupu spoljni fiksator u periodima praćenja i analize na 6,12 i 18 meseci. Na osnovu dobijenih rezultata dolazimo do zaključka da je tretman ispitanika sa multifragmentarnim, intraarikularnim prelomima gornjeg i donjeg okrajka kostiju potkolenice znatno efikasniji aparatom po Ilizarovu &scaron;to sveukupno daje smernice za brži i kvalitetniji oporavak ispitanika i njihov povratak svakodnevnim aktivnostima sa &scaron;to manjim posttraumatskim sekvelama.</p> / <p>The complexity of high-energy fractures of the tibia plateau and pilons and their association with significant violations of the soft tissue around the corresponding joint is well described in the literature. Main aim of the treatment is to multiple fractures of the tibia plateau and pilon become stable, articularly aligned, without pain, and with full motion in the knee and ankle joint with minimum risk for post-traumatic osteoarthritis. Ilizarov apparatus with taut needles is used to create a unique load support for the ankle and create conditions for good healing. This strong stability allows early joint movement, without risk of loss position of fracture parts. The aim of this research is assessment and comparation of the results of treatment, for intraarticular multiple fractures of the proximal and distal part of lower leg tretaed with unilateral external rigid fixator and Ilizarov apparatus, with ASAMI bone scoring system and functional scoring sistem by Karlstrom &ndash; Olerud. One of the goals of the study was to detect factors which affecting different treatment results of the intraarticular multiple fractures of the proximal and distal part of lower leg, tretaed with unilateral external rigid fixator and Ilizarov apparatus. The study was designed as a controlled comparative clinical study and data were collected retrospectively and prospectively form medical records from 2008 to 2013. The study has been fully implemented at the Department for orthopedic surgery and traumatology in the Clinical Center of Vojvodina in Novi Sad and included 103 patients who had intraarticular multiple fractures of the proximal and distal part of tibia. Subjects covered in this clinical study were classified into three groups: The first group of 53 patients were with intraartiulary multifragmentary open or closed fractures of the upper or distal part of lower leg, treated exclusively with unilateral external rigid fixator. The second group included 31 patients with intraarticular open or closed fractures of the upper or distal lower leg, treated exclusively with Ilizarov apparatus. 19 patients made the third group with intraarticulary open or closed fractures of the upper or distal lower leg, which were treated at the begining with unilateral external rigid fixator and later because of the complications (poor or prolonged healing, nonunion, infection and pseudoarthrosis) tretment was continued by Ilizarov apparatus. The main source of data for this study was protocol wich was established for each patient individually. In this protocol collected data analyzed by date: patient data, clinical findings at admission, postoperative course, monitoring apparatus, clinical findings at discharge and clinical findings at the controls which were at 6, 12 and 18 months after surgery. Clinical findings at control examinations (6, 12 and 18 months after surgery), we recorded by scoring system ASAMI (Association for the Study and Application of the Methods of Ilizarov) - that represent the results of the bone healing, and Karlstrom - Olerud for assessment functional outcomes. The most important results were: the fastest time of bone union was in the group of Ilizarov, and it was after 16 &plusmn; 2 weeks and the third group (conversion group) recorded an average time after 17 &plusmn; 2 weeks, while the patients in the first group (external fixator) had average time of union after 21 &plusmn; 4 week. The appearance of superficial and deep infection was significantly higher in the group treated with unilateral external fixator than in the group treated by the Ilizarov apparatus. Fastest full weight bearing on the injured leg, had patients in the group treated with Ilizarov apparatus. Evaluation of results using bone ASAMI fusion scoring system indicating a statistically significantly better results in the conversion and Ilizarov group compared to the group of external fixator in the period of monitoring at 6,12 and 18 months after surgery. Functional results by Karlstrom - Olerud scoring system show statistically significantly better results in the Ilizarov and conversion group contrary to the external fixator group in periods of monitoring at 6,12 and 18 months. Based on these results we conclude that the treatment of subjects with intraarticulary, multifragmentary fractures of the upper and lower part of the lower leg are more efficient after Ilizarov apparatus which provides overall guidance for faster and better recovery of patients and their return to their daily activities with minimal post-traumatic sequelae.</p>

<p>Uvod: magnetno rezonantni imidžing (MR) je u &scaron;irokoj uporebi u dijagnostici patolo&scaron;kih poremećaja ekstremiteta. Postoji interes da se redukuje vreme trajanja snimanja tokom pregleda kako bi se povećao komfor pacijenata i redukovali problemi koji su u vezi sa klaustrofobijom i artefaktima koji nastaju pri pomeranju pacijenta tokom dugih snimanja. Trodimenzionalne (3D) izovoksel sekvence pokazale su značajne mogućnosti u redukciji vremena snimanja MR pregledom zgloba kolena bez smanjenja kvaliteta dijagnostičkih mogućnosti. Cilj: uporediti dijagnostičke mogućnosti rutinskog, 2D MR protokola, na 3.0 Tesla MR aparatu, sa 3D True fast imaging, TrueFISP, izovoksel sekvencom u detekciji hondralnih o&scaron;tećenja, ruptura prednjeg ukr&scaron;tenog ligamenta (LCA), ruptura meniskusa i abnormalnosti subhondralne kosti, u korelaciji sa artroskopijom, kao referentnim standardom. Materijal i metode: Studija je odobrena od institucionalnog etičkog odbora. Pacijenti su informisani o studiji i potpisali pristanak za uče&scaron;će u istraživanju. 76 zgloba kolena kod 76 pacijenata (34 ženskog pola; prosečne starosti 36 godina) uključeno je u prospektivnu studiju, snimljeno je standardnim 2D MR protokolom snimanja i 3D TrueFISP sekvencom u sagitalnoj ravni. Svim pacijentima je urađena artroskopija u periodu od maksimum 30 dana nakon snimanja. Dva radiologa, nezavisno jedan od drugog, su evaluirala dobijene snimke. Preciznost u detekciji hondralnih o&scaron;tećenja, ruptura LCA i meniskusa, i abnormalnosti subhondralne kostne srži je određena podudarno&scaron;ću radiolo&scaron;kih i artroskopskih nalaza kao i proverom podudaranja ove dve metode snimanja. Rezultati: prosečna senzitivnost i specifičnost 3DTrueFISP sekvence je bila 75%, 94% respektivno, u dijagnostici o&scaron;tećenja hrskavice, 97%, 97% u detekciji ruptura LCA, 65%, 89% u postavljanju dijagnoze ruptura meniskusa, a dobra podudarnost radiolo&scaron;kih nalaza je dobijena u interpretaciji o&scaron;tećenja subhondralne kosti. Standardnim 2D MR protokolom prosečna senzitivnost i specifičnost je bila 70%, 93%, respektivno, u postavljanju dijagnoze hondralnih o&scaron;tećenja, 94% i 100% u postavljanju dijagnoze rupture LCA, 65%, 88% u detekciji ruptura meniskusa. Zaključak: dijagnostičke mogućnosti upotrebom 3DTrueFISP sekvence su uporedive sa standardnim, 2D, MR protokolom u snimanju zgloba kolena.</p> / <p>Introduction: Magnetic resonance imaging (MR) is widely used to assess internal derangements of the extremities. There is an interest in decreasing examination times to improve patient comfort and reduce the problems related to claustrophobia and motion artifacts, which occur more commonly with long examinations. The three-dimensional (3D) isovoxel true FISP sequence facilitates a noticeable reduction in acquisition time for MR imaging of the knee without reducing diagnostic performance. Objective: To compare the diagnostic performance of conventional, 2D, MR protocol, at 3.0 Tesla MR, with 3D water-excitation true fast imaging with steady-state precession, TrueFISP, an isotropic resolution sequence for detecting articular cartilage defects, anterior crucial ligament tears, meniscal tears and subhondral bone changes of the knee joint, with arthroscopy as reference standard. Materials and methods: The study was institutional review board approved. Written informed consent was obtained from all patients. 76 knees of 76 patients (34 females; mean age 36 years) were prospectively examined by using a conventional 2D MR protocol and sagittal 3D TrueFISP sequence. All patients underwent arthroscopy within a maximum period of 30 days after imaging. Two blinded readers evaluated the MR images. Accuracy for detection of cartilage defects, anterior cruciate ligament and meniscal tears, and subchondral bone abnormalities interobserver agreement, and intermethod agreement were calculated. Results: Overall sensitivity and specificity of 3DTrueFISP sequence were, respectively, 75%, 94% for diagnosis cartilage defects, 97%, 97%, for a diagnosis ACL tears, 65%, 89% for diagnosis of meniscal tears and with good interobserver agreement in interpretation of subhondral bone abnormalities. The standard MR protocol had overall sensitivities and specificities 70%, 93%, respectively, for diagnosis of cartilage defects, 94% and 100% for diagnosis ACL tears and 65%, 88% for diagnosis meniscal tears. Conclusion: The diagnostic perfomance of knee MR imaging performed by using a 3DTrueFISP sequence is comparable to the diagnostic performance of the conventional, 2D, MR protocol.</p>

The mevalonate pathway is an important biosynthetic pathway, found in all cells of virtually all known pro- as well as eukaryotic organisms. This thesis is an investigation into the use of two drugs, originally developed for different applications, but both affecting the mevalonate pathway, in to models of fracture repair. Using two different rodent models of fracture repair, a commonly used cholesterol lowering drug (statin) and two drugs used to treat osteoporosis (bisphosphonate) were applied both systemically as well as locally in order to enhance fracture repair. Papers I and II investigate the potential of simvastatin to improve the healing of femoral fractures in mice. Papers III and IV explore the use of two bisphosphonates to improve early fixation of stainless steel screws into rat bone. The statin simvastatin lead to an increased strength of the healing cellus. The application of bisphosphonates increased early screw fixation. It seems clear that both drugs have uses in orthopaedic applications. One interesting avenue of further research would be to combine the two classes of drugs and see if we can get the benefits while at the same time diminishing the drawbacks.

Previous studies have used accelerometers with various operating ranges (ORs) when measuring biomechanical parameters. However, it is still unclear whether ORs influence the accuracy of running parameters, and whether the different stiffnesses of footwear midsoles influence this accuracy. The purpose of the present study was to systematically investigate the influence of OR on the accuracy of stride length, running velocity, and on peak tibial acceleration. Twenty-one recreational heel strike runners ran on a 15-m indoor track at self-selected running speeds in three footwear conditions (low to high midsole stiffness). Runners were equipped with an inertial measurement unit (IMU) affixed to the heel cup of the right shoe and with a uniaxial accelerometer at the right tibia. Accelerometers (at the tibia and included in the IMU) with a high OR of ±70 g were used as the reference and the data were cut at ±32, ±16, and at ±8 g in post-processing, before calculating parameters. The results show that the OR influenced the outcomes of all investigated parameters, which were not influenced by tested footwear conditions. The lower ORs were associated with an underestimation error for all biomechanical parameters, which increased noticeably with a decreasing OR. It can be concluded that accelerometers with a minimum OR of ±32 g should be used to avoid inaccurate measurements.

L'objectif de ce travail était de rendre compte d'une revue complète de la littérature comparant les différentes méthodes et techniques de mesure de la pente tibiale par la radiographie conventionnelle, le scanner et l'IRM pour aider les chirurgiens orthopédistes à établir une méthode de mesure standardisée et fiable. Le travail inclut aussi deux études rétrospectives mesurant la pente tibiale en utilisant des modalités différentes. Il a été rapporté que la pente tibiale postérieure (PTS) a une influence sur la cinématique du genou notamment le ligament croisé antérieur (LCA). Une meilleure compréhension de la signification de la PTS pourrait améliorer le développement du dépistage des lésions du LCA, et les programmes de prévention, et pourrait servir de base pour des programmes de réadaptation individuels adaptés après la reconstruction du LCA. De plus, dans plusieurs interventions orthopédiques telle que l'ostéotomie tibiale haute, la pente tibiale peut modifier la mécanique du genou. Dès lors, une mesure préopératoire exacte de la pente tibiale postérieure est obligatoire. Plusieurs méthodes sont utilisées sur des radiographies conventionnelles, des scanners et l’IRM, mais jusqu'à présent il n'y a aucune méthode standard validée. La première partie de ce travail consiste en une introduction générale des structures anatomiques d'intérêt impliquées dans cette étude, à savoir l'articulation du genou, les ligaments croisés antérieurs, les ménisques et le tibia. Cette partie d'introduction inclut une description de l'anatomie brute, de la structure microscopique, de la fonction et quelques considérations cliniques. La deuxième partie du travail est consacrée à une revue systématique des modalités et techniques disponibles dans la littérature. Les informations quant aux méthodes de mesure de la pente tibiale chez des sujets normaux et avec LCA-lésé ont été extraites de toutes les études incluses de manière systématique, et ont été classifiées selon la technique de mesure et les modalités utilisées. L'axe le plus utilisé était l'axe tibial anatomique proximal (PTAA), et la méthode Midpoint est la plus fréquemment utilisée pour calculer le PTAA. Les valeurs les plus grandes de la pente tibiale médiale (MTS) et de la pente tibiale latérale (LTS) ont été obtenues en utilisant l'axe du cortex tibial antérieur, tandis que les valeurs les plus faibles ont été obtenues avec l'axe tibial diaphysaire. En comparaison directe, la plus grande valeur de la MTS pour le genou pathologique a été trouvée par les études radiologiques, tandis que les études IRM ont présenté les plus petites valeurs. Par conséquent, pour la LTS, les valeurs IRM étaient plus petites que celles des études par CT. La troisième partie du travail était une étude de cas-contrôle, en utilisant l'IRM; les LTS, MTS et pentes des ménisque interne et externe (LMS, MMS) ont été comparés chez 100 patients avec un LCA-déchiré isolé et chez un groupe témoin de 100 patients avec une douleur patello-fémorale et un LCA intact. La découverte la plus importante de cette étude consiste en ce que les pentes tibiales augmentées, aussi bien osseuse que méniscales, sont des facteurs de risque pour la blessure du LCA. Comme le ménisque a tendance à corriger la pente observée vers l'horizontale, la perte du ménisque postérieur peut potentialiser cet effet en augmentant la pente fonctionnelle. La quatrième partie du travail visait à évaluer les effets des caractéristiques des patients, du délai entre la blessure et l’intervention (TFI) et de la pente tibiale postérieure sur les formes de lésions des ménisques. Chez les 362 patients ayant un LCA-déchiré, le site de la lésion méniscale le plus commun était la corne postérieure (PH) du ménisque médial (MM), suivi par la lésion impliquant le MM entier. L'âge du patient, le BMI (Body Mass Index) et le TFI ont été significativement associés à l'incidence de la lésion du MM... [etc] / The aim of this work was to report a comprehensive literature review comparing the different methods and techniques of measurement of the posterior tibial slope (PTS) among the conventional radiograph, computed tomography (CT), and magnetic resonance imaging (MRI) in order to help the orthopedic surgeons to establish a standard and reliable measurement method. The work also includes two retrospective studies measuring the tibial slope using different modalities. It has been reported that the PTS has an influence on the kinematics of the knee notably the anterior cruciate ligament (ACL). A better understanding of the significance of the PTS could improve the development of ACL injury screening and prevention programmes, and might serve as a basis for individual adapted rehabilitation programmes after ACL reconstruction. Additionally, in several orthopedic interventions such as high tibial osteotomy, the tibial slope can result in altered knee mechanics. Therefore, an exact preoperative measurement of the posterior tibial slope is mandatory. Several methods are used on conventional radiographs, CT and MRI, but until now there is no standard validated method. The first part of this work was a general introduction about the anatomical structures of interest involved in this study, namely the knee joint, the anterior cruciate ligaments, the menisci, and the tibia, this introduction part included the gross anatomy, the microscopic structure, function, and some clinical considerations. The second part of the work is dedicated to a systematic review of the available modalities and techniques in the literature. Information regarding methods of measurement of the tibial slope in normal and ACL-injury subjects was extracted from all the studies in a systematic fashion and classified according to the measurement technique and used modalities. The most common used axis was the proximal tibial anatomical axis (PTAA), and the midpoint method is the most frequently used method for calculating the PTAA. By direct comparison, the greatest value of the medial tibial slope (MTS) for the pathological knee was achieved by the radiological studies, while the MRI studies presented the smallest values. Consequently, for the pathological lateral tibial slope (LTS), the MRI values were smaller than that of the CT studies. The greatest values of the MTS and LTS were obtained by the anterior tibial cortex axis, while the minimum values were achieved by the tibial diaphyseal axis.This third part of the work was a case-control study, by using MRI, the bony slopes as well as the lateral and medial meniscal slopes (LMS, MMS) were compared in 100 patients with isolated ACL injury and a control group of 100 patients with patello-femoral pain and an intact ACL. The most important finding of this study is that the increased tibial slopes, both bony and meniscal, are risk factors for ACL injury. As the meniscus tends to correct the observed slope towards the horizontal, loss of the posterior meniscus may potentiate this effect by increasing the functional slope. The fourth part of the work is aimed to evaluate the effects of the patient characteristics, time from injury (TFI), and PTS on meniscal tear patterns. In the 362 ACL-injured analyzed patients; the most common tear location was the posterior horn (PH) of the medial meniscus (MM), followed by tear involving the whole MM. Patient age, BMI, and TFI were significantly associated with the incidence of MM tear. An increase in the tibial slope, especially of the lateral plateau, seems to increase the risk of tear of the lateral meniscus (LM), and of both menisci

L’Ostéotomie Tibiale de Valgisation (OTV) par ouverture médiale est un traitement conservatif efficace dans le traitement de la gonarthrose médiale chez le patient jeune et actif présentant un défaut d’alignement du membre inférieur. Ce défaut entraine un déséquilibre dans la répartition des charges transitant dans le genou et est un facteur de risque la gonarthrose. L’objectif est de corriger l’alignement en corrigeant une déformation osseuse du tibia proximal. Une coupe osseuse médiolatérale incomplète partant du bord médial de la métaphyse tibiale et orientée vers l’articulation tibio-fibulaire permet de créer une ouverture sur le bord médial par rotation autour de la charnière latérale, épaisseur d’os non-coupée sur le bord latéral. L’importance de l’ouverture dépend de la déformation osseuse et du stade d’arthrose. La réussite de l’OTV par ouverture médiale est conditionnée par une correction précise, un montage d’ostéosynthèse stable et une charnière latérale préservée pendant l’ouverture. L’objectif de cette thèse était de proposer une méthodologie de planification préopératoire à associer à une instrumentation patient-spécifique réalisée en impression 3D. Cette instrumentation devait permettre d’appliquer la correction souhaitée dans les plans frontal et sagittal mais aussi de préserver la charnière latérale pendant la chirurgie. Nos résultats ont montré, grâce aux études in-vitro et in-vivo réalisées au cours de la thèse, que le guide de coupe patient-spécifique développé permet de reproduire avec précision la planification préopératoire en apportant de la sécurité au geste opératoire tant au niveau de la précision que de la préservation de la charnière latérale. / Medial Opening Wedge High Tibial Osteotomy (MOWHTO) is an efficient conservative surgical treatment for young and active patients with moderate medial gonarthrosis and varus lower limb malalignment. Varus malalignment unbalances load distribution in the knee, which is a gonarthrosis risk factor. MOWHTO aims to correct the lower limb alignment by correcting the proximal tibia bony deformity. Incomplete mediolateral cut is performed in the proximal tibia from the medial side of the tibial metaphysis towards the tibiofibular joint, and then opened by rotation around the lateral hinge which is the remaining uncut bone thickness on the lateral side. Amount of the opening depends on the importance of the proximal tibial deformity and on the medial gonarthrosis stage. MOWHTO success remains on precise correction, stable osteosynthesis system and lateral hinge preservation during the opening. Objective of this thesis was to propose a preoperative planning methodology to be associated with 3D printed patientspecific instrumentation. This instrumentation was intended to apply the correction chosen by the surgeon in the frontal and sagittal planes, but also to preserve the lateral hinge during the surgery. Our in-vitro and in-vivo results have shown that the developed patient-specific cutting guide make it possible to accurately reproduce the preoperative planning with security to the surgical gesture by bringing accuracy and lateral hinge preservation.

Previous studies have used accelerometers with various operating ranges (ORs) when measuring biomechanical parameters. However, it is still unclear whether ORs influence the accuracy of running parameters, and whether the different stiffnesses of footwear midsoles influence this accuracy. The purpose of the present study was to systematically investigate the influence of OR on the accuracy of stride length, running velocity, and on peak tibial acceleration. Twenty-one recreational heel strike runners ran on a 15-m indoor track at self-selected running speeds in three footwear conditions (low to high midsole stiffness). Runners were equipped with an inertial measurement unit (IMU) affixed to the heel cup of the right shoe and with a uniaxial accelerometer at the right tibia. Accelerometers (at the tibia and included in the IMU) with a high OR of ±70 g were used as the reference and the data were cut at ±32, ±16, and at ±8 g in post-processing, before calculating parameters. The results show that the OR influenced the outcomes of all investigated parameters, which were not influenced by tested footwear conditions. The lower ORs were associated with an underestimation error for all biomechanical parameters, which increased noticeably with a decreasing OR. It can be concluded that accelerometers with a minimum OR of ±32 g should be used to avoid inaccurate measurements.

No description available.