Revisão de artroplastia unicompartimental de joelho: implantes usados e causas de falha

ResumoObjetivoDeterminar as causas de falha da artroplastia Unicondilar, assim como identificar os implantes utilizados e a possível necessidade de enxertia óssea nos pacientes submetidos à cirurgia de revisão de AUJ no Centro de Cirurgia do Joelho do Instituto Nacional de Traumatologia e Ortopedia ‐ INTO, no período entre janeiro de 1990 a janeiro de 2013 foram analisados.MétodosAnálise retrospectiva da documentação médica e exames de imagem, determinando‐se a causa da falha da AUJ e o momento de sua ocorrência, assim como os componentes protéticos implantados durante a revisão e a necessidade de enxertia óssea.ResultadosForam incluídos nesta série 27 falhas de revisão de AUJ (26 pacientes). Colapso (afundamento) de um ou mais componentes representou a principal causa de falha, ocorrendo em 33% dos pacientes, soltura asséptica foi identificado em 30% dos casos, por progressão da osteoartrose em 15%, infecção e dor em 7% cada, desgaste do polietileno e osteólise em 4% cada. Falha precoce ocorreu em 41% de todas as indicações de revisões e falha tardia em 59%. A cirurgia de revisão da artroplastia unicompartimental foi realizada em 23 pacientes.ConclusõesEm 35% das cirurgias de revisão foi necessária enxertia óssea no lado tibial, sendo três casos necessário enxerto homólogo de Banco de Tecidos Músculo Esquelético. Não utilizamos aumento metálico em nenhum caso. Em um caso foi implantado prótese semiconstrita por instabilidade.AbstractObjectiveDetermine the causes of unicondylar knee arthroplasty failures, as well as identify the implants used and the need of bone grafting in patients undergoing revision UKA in Center of Knee Surgery at the Instituto Nacional de Traumatologia e Ortopedia (INTO) in the period between January 1990 and January 2013.MethodsA retrospective analysis of the medical documentation and imaging, determining the cause of failure of UKA and the time of its occurrence, as well as prosthetic components implanted during the review and the need for bone grafting.ResultsIn this study, were included 27 UKA failures in 26 patients. Colapse of one or more components was the main cause of failure, occurring in 33% of patients. Aseptic failure was identified in 30% of cases, progression of osteoarthrosis in 15%, infection and pain 7% each, and osteolisis and poliethilene failure in 4% each. Early failure occurred in 41% of all revisions of UKA and late failure in 59%. 23 patients have undergone revision of UK.ConclusionIn 35% of revisions was needed the use of bone grafting in tibial area; in 3 cases we needed allograft from Tissue Bank. We didn’t use metal increase in any of the revision. In one patient we used implant constraint for instability

Effect of the Combined Intervention with Passive Whole-Body Vibration and Auriculotherapy on the Quality of Life of Individuals with Knee Osteoarthritis Assessed by the WHOQOL-Bref: A Multi-Arm Clinical Trial

The aim of this study was to determine the effect on the quality of life of two non-pharmacological interventions isolated or in combination: (i) passive whole-body vibration exercise (WBVE), and (ii) auriculotherapy (AT). One hundred three participants with knee osteoarthritis (KOA) were allocated to: (a) a vibration group (WBVEG; n = 17) that performed WBVE (peak-to-peak displacement: 2.5 to 7.5 mm, frequency: 5 to 14 Hz, Peak acceleration: 0.12 to 2.95 g), two days/weekly for five weeks, (b) an AT group (ATG; n = 21), stimulation of three specific auriculotherapy points (Kidney, Knee and Shenmen) in each ear pavilion, (c) WBVE + AT (WBVE + AT; n = 20) and (d) respective control groups (WBVE_CG, n = 15; AT_CG, n = 12; WBVE + AT_CG, n = 18). The participants filled out the WHOQOL-bref Questionnaire before the first and after the last sessions. Statistical differences in the various domains of the WHOQOL-bref were not found. In conclusion, WBVE or AT alone or combined did not contribute in altering the quality of life of individuals exposed to these interventions

Acute Effects of Whole-Body Vibration Exercise on Pain Level, Functionality, and Rating of Exertion of Elderly Obese Knee Osteoarthritis Individuals: A Randomized Study

Introduction: Among chronic diseases, knee osteoarthritis (KOA) is a joint disease that causes important progressive alterations in the articular and periarticular structures, including synovial inflammation. Exercise has been suggested as an intervention to KOA individuals, and studies suggest that whole-body vibration (WBV) exercise decreases pain levels and favours the functionality of KOA individuals. Objective: The aim of the present study is to analyze the acute effects of WBV exercise on pain levels, functionality (Timed Up and Go (TUG test), anterior trunk flexion (ATF)), and rating of exertion of elderly obese KOA individuals. Methods: Thirty-seven individuals with KOA were allocated to a WBV exercise group (WBVEG), n = 19 (15 females/4 males), and a control group (CG), n = 18 (15 females/3 males). WBVEG performed one session of WBV exercise (11 min, using 5 Hz, 2.5, 5.0, and 7.5 mm, 0.12, 0.25, and 0.37 g). Three bouts were performed (working time of 3 min and rest time of 1 min) using a side-alternating vibrating platform (VP). The same position was used in CG; however, the VP was turned off and there was equipment coupled to the VP that emitted a sound like the vibrations. The pain level was evaluated using a visual analog scale (VAS). Functionality was evaluated with a TUG test and ATF. The rating of subjectively perceived exertion was measured with the category ratio CR-10 (BORG Scale CR-10), Results: A reduction of pain levels in WBVEG after the intervention (p = 0.001) and intergroups (p = 0.041) was found. A decrease of TUG test time in both groups (p = 0.001) and intergroups (p = 0.045) was found, while no statistical changes were observed in the Borg Scale score. Significant improvements of flexibility in both groups (p = 0.001) and intergroups (p = 0.043) were found. Conclusion: One session of WBV exercise can lead to important improvements in individuals with KOA, possibly triggered by physiological responses. However, more studies are needed, in this clinical context, to confirm these results

Study of the metabolic profile of the synovial fluid of patients with periprosthetic infection of the knee

A infecção articular periprotética (IAP) é uma das mais desafiadoras e graves complicações da artroplastia total do joelho (ATJ). Apesar de sua importância, há uma escassez de estudos sobre sua patogênese, impactando na identificação assertiva de biomarcadores que auxiliem no seu diagnóstico. Recentemente, diversos estudos têm demonstrado que a reprogramação metabólica celular desempenha um papel importante na progressão e desfecho das doenças infecciosas. Uma visão geral dos aspectos metabólicos dos sistemas biológicos pode ser realizada através da Metabolômica, entretanto, tal abordagem ainda não foi aplicada no contexto da IAP. Portanto, o objetivo deste estudo foi avaliar a composição de metabólitos no líquido sinovial (LS) de pacientes com IAP ou falha asséptica de ATJ. Para isso, os LS de 21 pacientes submetidos a cirurgia de revisão da artroplastia total do joelho (11 com diagnóstico IAP e 10 com falha asséptica) foram analisados usando espectroscopia por ressonância magnética nuclear. Foram realizadas análises estatísticas uni e multivariadas para identificar os metabólitos diferencialmente abundantes entre esses grupos. Após a aquisição e análise dos espectros, foram identificados e anotados 28 metabólitos no LS de pacientes com falha da artroplastia. Cinco destes metabólitos se encontravam diferencialmente abundantes entre LS infectado e não infectado. Lactato, acetato e 3-hidroxibutirato estavam em maior concentração, e glicose e creatina foram encontradas reduzidas no LS de pacientes com IAP. Nossos resultados revelaram ainda a presença de dois perfis metabólicos distintos nos pacientes com IAP, caracterizados por diferenças nos níveis de lactato. Dentre os pacientes com IAP, não foram encontradas diferenças no perfil metabólico em relação às infecções agudas vs crônicas e nas diferentes classificações de Tsukayama. Entretanto, pacientes com infecções causadas por Staphylococcus aureus apresentavam níveis mais elevados de lactato e acetato no LS. A performance diagnóstica dos metabólitos diferencialmente abundantes foi avaliada e o lactato, a glicose e a creatina apresentaram-se como potenciais biomarcadores, por apresentaram AUC ROC >0,8. Além disso, o acetato se apresentou como um potencial biomarcador para discriminar entre as infecções causadas por S. aureus em relação às causadas por outros tipos de bactérias. Nossos resultados evidenciam que o LS de pacientes com IAP exibe um perfil metabólico distinto, possivelmente refletindo as adaptações metabólicas que ocorrem no microambiente periprotético. Através da metabolômica foi possível a identificação de três potenciais biomarcadores da IAP (lactato, glicose e creatina). Mais estudos são necessários para obter uma visão mais ampla das vias metabólicas ativadas por patógenos e células imunes no contexto da IAP, assim como para uma avaliação mais específica dos potenciais biomarcadores identificados neste estudo.Periprosthetic joint infection (PJI) is one of the most challenging and serious complications of total knee arthroplasty. Despite its importance, there is a lack of studies in the literature on its pathogenesis, impacting the assertive identification of biomarkers to aid in its diagnosis. Recently, several studies have shown that cellular metabolic reprogramming plays an important role in the progression and outcome of infectious diseases. A broader view of the metabolic aspects of biological systems can be achieved through Metabolomics, however, such an approach has not yet been applied in the context of PJI. Therefore, the aim of this study was to evaluate the synovial fluid (SF) metabolite composition of patients with PJI or aseptic failure of total knee arthroplasties. For this, synovial fluid from 21 patients undergoing total knee arthroplasty revision surgery (11 with a diagnosis of PJI and 10 with aseptic failure) were analyzed using nuclear magnetic resonance spectroscopy. Univariate and multivariate statistical analyzes were performed to identify differentially abundant metabolites between these groups. After the acquisition and analysis of the spectra obtained, 28 metabolites were identified and anotated in the SF of patients with arthroplasty failure. Five of these metabolites were differentially abundant between infected and non-infected cohorts. Lactate, acetate and 3-hydroxybutyrate were in higher concentration, and glucose and creatine were found to be reduced in the synovial fluid of patients with PJI. Our results also revealed the presence of two distinct metabolic profiles in patients with PJI, characterized by differences in lactate levels. Among patients with PJI, no differences were found in the metabolic profile in relation to acute vs. chronic infections and in the different Tsukayama classifications. However, infections caused by Staphylococcus aureus had higher levels of lactate and acetate in the SL. The diagnostic performance of the differentially abundant metabolites was evaluated, and lactate, glucose and creatine were presented as potential biomarkers, as they presented AUC ROC >0.8. In addition, acetate presented itself as a potential biomarker to discriminate between infections caused by S. aureus in relation to those caused by other types of bacteria. Our results show that the synovial fluid of patients with PJI exhibits a distinct metabolic profile, possibly reflecting metabolic adaptations that occur in the periprosthetic microenvironment. Through metabolomics, it was possible to identify four potential PJI biomarkers (lactate, glucose, and creatine). More research and studies are needed to obtain a broader view of the metabolic pathways involved by pathogens and immune cells in the context of PJI, as well as for a more specific assessment of the potential biomarkers identified in the present study

Avaliação do ângulo de inclinação tibial e altura patelar após osteotomia tibial de abertura medial

OBJETIVO: Mensurar a variação do ângulo de inclinação tibial posterior e da altura patelar em pacientes submetidos à osteotomia valgizante tibial proximal com técnica de cunha de abertura medial. MÉTODOS: Foram analisadas radiografias panorâmicas de membros inferiores em anteroposterior e perfil do joelho pré e pós-operatórias de 46 pacientes com artrose unicompartimental do joelho, em que se realizou osteotomia tibial. RESULTADOS: Em 23 casos, utilizou-se fixador externo para confecção de cunha de abertura medial gradual e nos outros 23, foi utilizada placa bloqueada com batente como método de fixação. Foram excluídos deste estudo aqueles pacientes com doença tricompartimental do joelho e aqueles submetidos à osteotomias para tratamento de sequelas de fraturas. Após a cirurgia, a inclinação tibial proximal aumentou, em média, 1,7 graus (p OBJECTIVE: To measure the variation in posterior tibial slope angle and patellar height in patients who underwent proximal tibial valgus-producing osteotomy using the medial-opening wedge technique. METHODS: Anteroposterior panoramic radiographs of the lower limbs and lateral radiographs of the knee obtained before and after tibial valgus-producing osteotomy on 46 patients with unicompartmental arthrosis of the knee were analyzed. RESULTS: In 23 patients, an external fixator was used to gradually apply a medial-opening wedge; and in the other 23, a blocked plate with a stop bar was applied as a fixation method. Patients with tricompartmental knee disease and those who underwent osteotomy to treat fracture sequelae were excluded from this study. After surgery, the mean increase in the tibial slope was 1.7 degrees (p < 0.01) in the group in which the blocked plate with a stop bar was used; and 2.7 degrees (p < 0.05) in the group in which the external fixator was used. There was no statistical difference between the groups regarding the increase in the posterior tibial slope. CONCLUSION: The patellar height did not present any change in the cases in which the plate was used, when measured using the Insall-Salvati method, but it presented a decrease in 11 cases (47.8%) when the Caton-Dechamps method was applied. The same tendency was observed regarding change in the patellar height in the cases in which the external fixator was used, such that a decrease was observed in eight cases (34.7%) only when measured using the Caton-Dechamps method

Use of a trabecular metal cone made of tantalum, to treat bone defects during revision knee arthroplasty,

OBJECTIVES: the aim of this study was to evaluate the surgical technique and determine the initial results, with a minimum follow-up of two years, from total knee arthroplasty revisions in which trabecular metal cones made of tantalum were used at the Knee Surgery Center of the National Institute of Traumatology and Orthopedics (INTO) or at the authors' private clinic between July 2008 and December 2010.METHODS: ten patients were included in the study prospectively, through clinical and radiographic evaluations.RESULTS: seven patients presented evolution without complications relating to the tantalum cones used. Five of these patients said that they did not have any pain and all of them were able to walk without needing crutches. In all the cases, we observed that osseointegration of the tantalum cones had occurred. No migration or loosening of the implants was observed, nor was osteolysis.CONCLUSION: use of trabecular metal cones made of tantalum for treating AORI type II or II bone defects was capable of providing efficient structural support to the prosthetic revision implants, in evaluations with a short follow-up

Distal femoral cut in total knee arthroplasty in a Brazilian population

OBJECTIVE: To determine the ideal angle for making the distal femoral cut in total knee arthroplasty in a Brazilian population.METHODS: Panoramic radiographs of the lower limbs bearing weight from 79 patients (57 women and 22 men) were studied, totaling 107 knees with an indication for total knee arthroplasty. The femoral anatomical axis, femoral mechanical axis and cervical-diaphyseal angle were traced out. The angle of the femoral cut was determined from the meeting point between the femoral anatomical and mechanical axes. The ideal degree of femoral valgus was compared between men and women and between knees presenting varus and valgus alignment of the lower limb. The ideal distal femoral cut was also correlated with the cervical-diaphyseal angle.RESULTS: The ideal femoral valgus angle ranged from 4.2 to 8.6 degrees, with a mean of 6.3 degrees. There was no statistically significant difference in the distal femoral cut between patients with coronal varus and valgus alignment (p = 0.180). Comparing men and women, there was no statistically significant difference regarding the ideal femoral valgus between the groups (p = 0.057). The cervical-diaphyseal angle presented an inverse relationship with the distal femoral cut.CONCLUSIONS: The mean angle between the femoral mechanical and anatomical axes was 6.3 degree. Neither preoperative coronal alignment nor sex had any influence on the distal femoral cut. The cervical-diaphyseal angle presented an inverse relationship with the distal femoral cut

Avaliação do ângulo de inclinação tibial e altura patelar após osteotomia tibial de abertura medial

OBJETIVO: Mensurar a variação do ângulo de inclinação tibial posterior e da altura patelar em pacientes submetidos à osteotomia valgizante tibial proximal com técnica de cunha de abertura medial. MÉTODOS: Foram analisadas radiografias panorâmicas de membros inferiores em anteroposterior e perfil do joelho pré e pós-operatórias de 46 pacientes com artrose unicompartimental do joelho, em que se realizou osteotomia tibial. RESULTADOS: Em 23 casos, utilizou-se fixador externo para confecção de cunha de abertura medial gradual e nos outros 23, foi utilizada placa bloqueada com batente como método de fixação. Foram excluídos deste estudo aqueles pacientes com doença tricompartimental do joelho e aqueles submetidos à osteotomias para tratamento de sequelas de fraturas. Após a cirurgia, a inclinação tibial proximal aumentou, em média, 1,7 graus (p < 0,01) no grupo em que foi utilizada placa bloqueada com batente e 2,7 graus (p < 0,05) no grupo que utilizou fixador externo. Não houve diferença estatística entre os grupos quanto ao aumento da inclinação tibial posterior. CONCLUSÃO: A altura patelar não apresentou variação com o uso de placa, quando mensurada pelo método de Insall-Salvati, mas em 11 casos (47,8%) evoluiu com patela baixa quando aferida pelo método de Caton-Deschamps. A mesma tendência foi observada na variação da altura patelar com o uso do fixador externo, sendo constatada patela baixa em oito casos (34,7%) apenas quando aferida pelo método de Caton-Deschamps

Homologous structural graft for treatment of bone defect during knee revision arthroplasty

OBJECTIVE: Obtaining stable bone-implant interface, correct alignment of the components, proper balance of soft tissues' tension, maintenance of proper joint interline are fundamental principles for success in surgical revision total knee arthroplasty, which are only obtained with management bone deficiency. However, proper treatment of large defects remains unclear. The aim of this study was to evaluate the clinical and radiographic results of patients that had underwent revision surgery for total knee arthroplasty with use of structural grafts of musculoskeletal tissue bank in the period between January 2002 to December 2010 by the Knee Surgery Center of National Institute of Traumatology and Orthopaedics (INTO). The study included 26 revision arthroplasties with homologous structural bone grafting in 25 patients. Thirty-four structural bone grafts were used during the 26 revision total knee arthroplasty surgeries studied. The proximal tibia and distal femur were the grafts most frequently used. Six patients developed deep infection and in one of them with damage to the extensor mechanism associated. The average score on the WOMAC was 24,9. In the assessment of functional capacity in the SF-36, the average was 52.5. In radiographic evaluation, resorption of the graft occurred in three patients and no cases were observed of osteolysis, fracture of the graft, migration or subsidence of the components. Bone grafting of a musculoskeletal tissue bank is a satisfactory option to the handling of the bone defect in the setting of revision surgery for total knee arthroplasty