Three-dimensional kinematic evaluation of scapulohumeral rhythm after reverse shoulder arthroplasty: a systematic review and meta-analysis.

Background: The movement of the arm relative to the trunk results from 3-dimensional (3D) coordinated movements of the glenohumeral (GH) and scapulothoracic (ST) joints and dictates the scapulohumeral rhythm (SHR). Alterations in SHR increase joint overload and may lead to low functional scores, pain, and failures in patients undergoing reverse total shoulder arthroplasty (RSA). The goal of this systematic review and meta-analysis was to examine 3D SHR kinematics after RSA and compare it to that of asymptomatic shoulders. Methods: A systematic review and meta-analysis of articles in English were performed using PubMed, Embase, Cochrane Library, and SciELO. Additional studies were identified by searching bibliographies. Search terms included "Reverse shoulder arthroplasty", "3D", and "scapula". It was selected cross-sectional studies that reported SHR with 3D motion analysis systems in patients who underwent RSA and asymptomatic controls. Two authors independently performed the extraction of articles using predefined data fields, including study quality indicators. Results: Data from four studies were included in quantitative analysis, totaling 48 shoulders with RSA and 63 asymptomatic shoulders. Pooled analyses were based on random-effects model (DerSimonian-Laird). A statistically smaller SHR ratio was observed in the RSA group than that in the control group (P < .00001), meaning a greater contribution of ST joint in relation to GH joint for arm elevation. The standardized mean difference was -1.16 (95% confidence interval: -1.64, -0.67). A sensitivity analysis with three more studies that had imputed data on control group did not change the direction of the effect. The standardized mean difference on sensitivity analysis was -0.60 (P = .03; 95% confidence interval: -1.13, -0.06). It was detected as "not important heterogeneity" within the comparison (I2: 22%). Chi-square was not statistically significant (Chi2: 3.85), and I2 was 22%. Tau2 was not zero (Tau2: 0.05). Sensitivity analysis showed an I2 of 74%, which might represent substantial heterogeneity, Chi-square was not statistically significant (Chi2: 23.01), and Tau2 was not zero (Tau2: 0.37). Conclusion: This study found that RSA shoulders have an increased contribution of ST joint during arm elevation, compared with asymptomatic shoulders. More movement in ST joint in proportion to GH joint increases GH joint contact forces, which could lead to component loosening or other complications. Further studies should address the clinical implications of this kinematic finding.

Medial Hoffa Fracture: Description of a Novel Classification System and Rationale for Treatment Based on Fragment-Specific Fixation Strategy.

PURPOSE: This study aims to present a novel classification system and a rationale for treatment of medial Hoffa fractures. METHODS: We developed a simple comprehensive classification system for medial Hoffa fractures based on the fragment size and presence of fracture comminution. Furthermore, we propose a treatment algorithm based on two pillars: our case series of nine patients presenting medial Hoffa fractures and the best evidence-based pertinent literature. Fracture healing, range of motion, function, and complications were evaluated after a minimum of 6 months follow-up. RESULTS: All fractures healed with no loss of reduction. Knee flexion ranged from 90 - 130° (mean 110°, standard deviation 15.2). Knee extension ranged from 0 - 10° (mean 1°, standard deviation 3.3). Knee function according to the Lysholm score ranged from 74 - 96 points (mean 85, standard deviation 6.3). There were no complications such as infection, fixation failure, or medial femoral condyle osteonecrosis. One patient required hardware removal due to soft tissue irritation and one patient underwent knee mobilization under anesthesia after 8 weeks of fracture fixation due to knee stiffness. CONCLUSION: The presented rationale for treatment based on the new classification system is a simple and effective strategy on the decision-making process for adequate management of medial Hoffa fractures.

Proposal for a New Fixation Method for Pauwels Type III Femoral Neck Fracture-Metaphyseal Stem: A Finite-Element Analysis.

OBJECTIVE: To evaluate the biomechanical behavior of a metaphyseal stem specifically designed for the fixation of Pauwels type-III femoral neck fractures using finite-element analysis. METHODS: Three different constructions were studied: the dynamic hip screw with a superior anti-rotation screw (DHS + ARS), multiple cannulated screws in an inverted triangle configuration (ASNIS), and the Metaphyseal Nailing System (MNS), a new implant developed by the authors. Vertical and total displacement, localized and total maximum and minimum principal, and the Von Mises peak stresses were evaluated. RESULTS: Results are shown for the DHS + ARS, ASNIS, and MNS models, respectively. Vertical displacement (mm) was 1.49, 3.63, and 1.90; total displacement (mm) was: 5.33, 6.02, and 6.30; localized maximum principal (Mpa) was: 2.77, 4.5, and 1.7; Total maximum principal (Mpa) was: 126, 223, and 531; localized minimum principal (Mpa) was: -1.8, -3.15, and -0.39; total minimum (Mpa) was: -121, -449, and -245; and Von Mises peak stress (MPA) was: 315.5, 326.1, and 286.0. CONCLUSION: The present FEM study showed that the MNS device increases general stresses and reduces localized stresses, when compared to the DHS + ARS and ASNIS constructions used to fix Pauwels type-III femoral neck fracture in synthetic models. In this sense, the MNS showed a low fracture focus shift, conducive to the consolidation environment. The significant reduction in the maximum principal stress, allows to affirm that the main deforming force, the shear, in this fracture pattern, was considerably reduced and the low value of Von Mises obtained, consistent with an implant capable of making an effective load sharing.

Energy Required for Fracture in Synthetic Proximal Femoral Models After Synthesis Material Removal: a Biomechanical Study Using Cannulated Screws, Dynamic Hip Screws, and Proximal Femoral Nails.

Objective The present study aims to identify the energy required for synthetic proximal femoral fracture after removal of three implant types: cannulated screws, dynamic hip screws (DHS), and proximal femoral nail (PFN). Methods Twenty-five synthetic proximal femur bones were used: 10 were kept intact as the control group (CG), 5 were submitted to the placement and removal of 3 cannulated screws in an inverted triangle configuration (CSG), 5 were submitted to the placement and removal of a dynamic compression screw (DHSG), and 5 were submitted to the placement and removal of a proximal femur nail (PFNG). All samples were biomechanically analyzed simulating a fall on the greater trochanter using a servo-hydraulic machine to determine the energy (in Joules [J]) required for fracture. Results All samples presented basicervical fractures. The energy required for fracture was 7.1 J, 6.6 J, 6 J, and 6.7 J for the CG, CSG, DHSG and PFNG, respectively. There was no statistically significant difference (considering a 95% confidence interval) in energy among the study groups ( p = 0.34). Conclusion There was no statistically significant difference in the energy required to cause a synthetic proximal femoral fracture after removing all three implant types and simulating a fall over the greater trochanter.

Energy Required for Fracture in Synthetic Proximal Femoral Models After Synthesis Material Removal: a Biomechanical Study Using Cannulated Screws, Dynamic Hip Screws, and Proximal Femoral Nails / Energia necessária para a ocorrência de fratura em modelos sintéticos de fêmur proximal após retirada de material de síntese: Um estudo biomecânico com parafuso canulado, parafuso dinâmico do quadril e haste femoral proximal

Abstract Objective The present study aims to identify the energy required for synthetic proximal femoral fracture after removal of three implant types: cannulated screws, dynamic hip screws (DHS), and proximal femoral nail (PFN). Methods Twenty-five synthetic proximal femur bones were used: 10 were kept intact as the control group (CG), 5 were submitted to the placement and removal of 3 cannulated screws in an inverted triangle configuration (CSG), 5 were submitted to the placement and removal of a dynamic compression screw (DHSG), and 5 were submitted to the placement and removal of a proximal femur nail (PFNG). All samples were biomechanically analyzed simulating a fall on the greater trochanter using a servo-hydraulic machine to determine the energy (in Joules [J]) required for fracture. Results All samples presented basicervical fractures. The energy required for fracture was 7.1 J, 6.6 J, 6 J, and 6.7 J for the CG, CSG, DHSG and PFNG, respectively. There was no statistically significant difference (considering a 95% confidence interval) in energy among the study groups (p = 0.34). Conclusion There was no statistically significant difference in the energy required to cause a synthetic proximal femoral fracture after removing all three implant types and simulating a fall over the greater trochanter.

Resumo Objetivo Identificar a energia necessária para ocorrência de fratura do fêmur proximal em osso sintético após retirada de três modelos de implantes: parafusos canulados, parafuso dinâmico do quadril (dynamic hip screw-DHS) e haste femoral proximal (proximal femoral nail-PFN). Métodos Foram utilizados 25 modelos de ossos sintéticos da extremidade proximal do fêmur: 10 unidades de grupo controle (GC), 5 unidades após colocação e retirada de 3 parafusos canulados colocados em configuração de triângulo invertido (GPC), 5 unidades após colocação e retirada do parafuso de compressão dinâmico (GDHS), e 5 unidades após colocação e retirada da haste de fêmur proximal (GPFN). Uma análise biomecânica foi realizada em todas as amostras simulando uma queda sobre o grande trocânter utilizando uma máquina servo-hidráulica com o objetivo de verificar a energia (em Joules [J]) necessária até a ocorrência de fratura nos diferentes grupos. Resultados Todos os grupos apresentaram fratura basocervical. Os grupos GC, GPC, GDHS e GPFN apresentaram, respectivamente, valores de 7.1J, 6.6J, 6J e 6.7J de energia até ocorrência da fratura. Não houve diferença estatisticamente significativa (intervalo de confiança de 95%) na energia entre os grupos de estudo (p = 0,34). Conclusão Não houve diferença estatisticamente significativa nos valores de energia necessária para ocorrência de fratura da extremidade proximal do fêmur após a retirada de três tipos de implantes utilizando modelos sintéticos simulando queda sobre o grande trocânter.

New fixation method for Pauwels type III femoral neck fracture: a finite element analysis of sliding hip screw, L-shaped, and L-shaped with medial plate.

OBJECTIVE: In this study, we aimed to evaluate the biomechanical behavior of three fixations for Pauwels type III fractures (sliding hip screw (SHS), L-shaped, and L-shaped with medial plate), by finite element analysis (FEM). METHODS: Three internal fixators were developed to treat Pauwels type III fracture by finite elements: SHS; L-shaped; and L-shaped with medial plate. Under the same conditions, localized and total vertical fracture displacement, maximum and minimum principal and von Mises stresses were evaluated. RESULTS: The localized and total vertical displacement evaluated for the SHS, L-shaped, and L-shaped with medial plate were 0.15 mm, 0.17 mm, and 0.07 mm (localized), and 4.52 mm, 6.97 mm, and 6.83 mm (total), respectively. The maximum values obtained in the upper region of the femoral neck for the internal fixations were 1.43 MPa, 1.29 MPa, and 1.24 MPa, and the minimum values obtained in the lower region of the femoral neck were - 0.73 MPa, - 1.09 MPa, and - 1.03 MPa, respectively. The maximum Von Mises peak stress values were 6.35 MPa, 10.7 MPa, and 16.2 MPa for the fixation models using the SHS, L-shaped, and L-shaped with medial plate, respectively. CONCLUSION: The present FEM analysis showed that SHS yields better results in terms of total vertical displacements, maximum distribution, and Von Mises peak stresses reduction. On the other hand, the L-shaped construction plus a medial plate decreases localized vertical displacements and maximum principal distribution when compared to the SHS and L-shaped constructions. These results demonstrate that both constructions, SHS and L-shaped plus a medial plate, are biomechanically efficient for the fixation of Pauwels type III femoral neck fractures.

Anterior minimally invasive plating osteosynthesis technique (MIPO) for humeral shaft fractures: an anatomical study of neuromuscular structures at risk.

OBJECTIVE: The aim of this study was to evaluate the neuromuscular structures at risk during modified anterior minimally invasive plating osteosynthesis technique (Belangero-Livani) for humeral shaft fractures. METHODS: Eight fresh-frozen human specimens ranging from 38 to 82 years old were used. Specimens were positioned supine with the shoulder in 70° abduction and the forearm in full supination. Anterior minimally invasive plating osteosynthesis technique according to Belangero-Livani technique was performed in each specimen. Under radioscopic control, the plate was introduced in retrograde fashion through the subbrachialis path. Anatomical structures were inspected and different anatomical parameters were measured after dissection at the end of the surgical procedures. Measurements were performed using a high digital caliper. Statistical analysis was performed using the Pearson's correlation coefficient test. A p value of < 0.05 was used to define statistical significance. RESULTS: There were no macroscopic lesions of myotendinous or neurovascular structures in any specimen. The mean distance between the radial nerve to the distal lateral end of the plate was 8.63 mm (range 4.14-13.83 mm). The mean total length of the humerus was 328.59 mm. We found a significant direct correlation between the total length of the humerus and both specimen height and weight. CONCLUSION: The modified Belangero-Livani anterior MIPO technique for humeral shaft fractures performed in retrograde fashion is safe and useful, without major risk to the soft tissue of the anterior compartment of the arm, including the radial nerve in the lateral intermuscular septum. Intraoperative dissection, avoiding deep lateral retraction on the distal approach, minimizes the risk of radial nerve damage. Strict surgical planning and appreciation for the anatomic landmarks can reduce the risk of damage to neuromuscular structures. LEVEL OF EVIDENCE: Level IV; Case series with no comparison group; Treatment study.

How do Orthopedic Surgeons Manage Displaced Femoral Neck Fracture in the Middle-Aged Patient? Brazilian Survey of 78 Orthopaedic Surgeons.

Objective The aim of the present study was to evaluate the practices and preferences of Brazilian orthopedic surgeons for the treatment of femoral neck fractures in middle-aged patients. Methods A survey containing 10 images of femoral neck fractures was sent to a group of 100 orthopedic surgeons, all of them members of the Brazilian Society of Orthopedics and Traumatology. The questionnaire asked the treatment option for cases of nondisplaced and displaced fractures of the femoral neck in middle-aged patients, that is, those between 50 and 69 years old. Descriptive and inferential statistical analyzes were performed using the chi-squared (χ2) and the Fisher exact tests. The level of significance was 5%. Results The survey was answered by 78% of the orthopedic surgeons invited to participate in the study. There was no significant difference in the treatment method distribution between generalists and specialists ( p = 0.16) in the sample of nondisplaced femoral neck fractures. There was a highly significant difference in the treatment method distribution between generalists and specialists ( p < 0.0001) in the sample of displaced fractures of the femoral neck. Conclusion Preservation of the femoral head through multiple cannulated screws fixation is the treatment of choice for nondisplaced femoral neck fractures for both generalists and specialists. Low chronological and/or physiological age are the main factors for this decision-making. In displaced femoral neck fractures, femoral head replacement is preferred for both groups of orthopedists (generalists and specialists). In this situation, specialists prefer total hip arthroplasty (THA), whereas generalists favor partial hip arthroplasty (PHA).

How do Orthopedic Surgeons Manage Displaced Femoral Neck Fracture in the Middle-Aged Patient? Brazilian Survey of 78 Orthopaedic Surgeons / Como os cirurgiões ortopédicos tratam a fratura desviada do colo do fêmur no paciente de meia idade? Pesquisa brasileira com 78 cirurgiões ortopédicos

Abstract Objective The aim of the present study was to evaluate the practices and preferences of Brazilian orthopedic surgeons for the treatment of femoral neck fractures in middleaged patients. Methods A survey containing 10 images of femoral neck fractures was sent to a group of 100 orthopedic surgeons, all of them members of the Brazilian Society of Orthopedics and Traumatology. The questionnaire asked the treatment option for cases of nondisplaced and displaced fractures of the femoral neck in middle-aged patients, that is, those between 50 and 69 years old. Descriptive and inferential statistical analyzes were performed using the chi-squared (χ2) and the Fisher exact tests. The level of significance was 5%. Results The survey was answered by 78% of the orthopedic surgeons invited to participate in the study. There was no significant difference in the treatment method distribution between generalists and specialists (p = 0.16) in the sample of nondisplaced femoral neck fractures. There was a highly significant difference in the treatmentmethod distribution between generalists and specialists (p < 0.0001) in the sample of displaced fractures of the femoral neck. Conclusion Preservation of the femoral head through multiple cannulated screws fixation is the treatment of choice for nondisplaced femoral neck fractures for both

Resumo Objetivo O objetivo do presente estudo foi avaliar as práticas e preferências dos cirurgiões ortopédicos brasileiros para o tratamento da fratura do colo do fêmur no paciente de meia idade. Métodos Foi elaborado um questionário contendo 10 imagens de fraturas do colo do fêmur enviado a um grupo de 100 ortopedistas, todos membros titulares da Sociedade Brasileira de Ortopedia e Traumatologia. No questionário, foi perguntada a opção de tratamento para casos de fratura não desviada e desviada do colo do fêmurempacientes de meia idade, caracterizados como aqueles comidades entre 50 e 69 anos. Foramrealizadas análises estatísticas descritiva e inferencial, pelos testes de qui-quadrado (χ2) e exato de Fisher. O critério de determinação de significância adotado foi o nível de 5%. Resultados O questionário foi respondido por 78% dos ortopedistas convidados a participar do presente estudo. Observou-se que não existe diferença significativa na distribuição do método de tratamento entre as avaliações de generalistas e especialistas (p = 0,16) na amostra de fraturas não desviadas do colo do fêmur. Observou-se que existe diferença altamente significativa na distribuição do método de tratamento entre as avaliações de generalistas e especialistas (p < 0,0001) na amostra de fraturas desviadas do colo do fêmur. Conclusão A preservação da cabeça femoral por meio da fixação com múltiplos parafusos canulados é o tratamento de escolha para as fraturas não desviadas do colo do fêmur, tanto para os generalistas quanto para os especialistas. Idade cronológica e/ ou fisiológica baixas são os principais fatores para esta tomada de decisão. Nos casos em que a fratura do colo do fêmur encontra-se desviada, a substituição da cabeça femoral é a preferência para os dois grupos de ortopedistas (generalistas e especialistas). Nesta situação, os especialistas preferem a artroplastia total do quadril (ATQ) e os generalistas a artroplastia parcial do quadril (APQ).

The role of the medial plate for Pauwels type III femoral neck fracture: a comparative mechanical study using two fixations with cannulated screws.

BACKGROUND: The biomechanical behavior of Pauwels type III fractures should be taken into consideration when performing internal fixation, since this repair should resist the shear force inherent in the vertical fracture line to the greatest extent possible. Recently, the use of a small fragment plate on the medial face of the femoral neck has been proposed by some authors, with satisfactory initial results. In the current study we analyze the mechanical role a medial plate used as a buttress plate for Pauwels type III femoral neck fractures, comparing the resistance of two fixation configurations using three cannulated screws. METHODS: Pauwels type III fractures were simulated in synthetic bones models and two groups were created, one of those using two parallel screws at the bottom of the femoral neck and the third screw crossing the fracture horizontally (G1), and the other fixed in the same arrangement as G1, but with the addition of a medial side plate at the apex of the fracture (G2). The constructs were subjected to axial loading until catastrophic failure. RESULTS: The addition of a medial plate buttressing the femoral neck increased significantly the resistance to maximum loading (p = 0.003). CONCLUSION: Use of a medial buttress plate results in a mechanically superior construction for Pauwels type III fractures fixed with multiple cannulated screws. LEBEL OF EVIDENCE: Level IV. Biomechanical comparative study.

Asymptomatic Dysplasia Epiphysealis Hemimelica of the Shoulder in a Skeletally Mature Patient with Normal Function.

Dysplasia epiphysealis hemimelica is a rare osteocartilaginous overgrowth syndrome of bone epiphysis, mostly encountered in the lower limbs of immature skeleton patients. We report a case of proximal humerus presentation in an adult male, with neither articular involvement nor clinical dysfunction. This case highlights the importance of stratification into intra- and extra-articular lesions, as this distinction ultimately influences both symptoms and treatment outcome. In addition, the case highlights the importance of specific imaging modalities, such as CT and MR images, which provide excellent anatomic location of the lesion, adequate extension of cartilaginous components, exact status of articular cartilage, and accurate assessment of neighboring structures, such as vessels, nerves, ligaments, tendons, and muscles. The imaging features are described, the relevant literature is reviewed, and salient features are discussed.

Metastatic tumor of the hand of unknown primary origin.

Acral metastases in the hand are exceedingly rare. We present the unusual case of a metastatic tumor of the hand of unknown primary site in a 77-year-old man with no known cancer history. The patient presented with pain and swelling in the tip of the left ring finger, which had previously been diagnosed as gout at another clinic. Laboratory tests, including white blood cell count, erythrocyte sedimentation rate/C-reactive protein, and uric acid were all within normal limits. Excisional biopsy was taken by amputation of the distal phalanx of the left ring finger through the distal third of the middle phalanx. Pathology confirmed the presence of a moderately differentiated adenocarcinoma of unknown primary site. Roentgenographic examination of the chest revealed no pathologic findings. The patient refused further investigation and adequate treatment. He died 4 months later. The current description confirms the rarity of metastatic malignancy of the hand and its poor prognosis.

General principles for treatment of femoral head fractures.

Femoral head fractures occur almost exclusively as a result of a traumatic hip dislocation. Treatment is typically an emergency and includes the reduction of the dislocated hip under anesthesia. As a rule, the earlier the reduction, the better the outcome. Open reduction and internal fixation of the fracture of the femoral head is the treatment of choice for most young patients. In some selected cases when there is a very small fragment located in the region below the fovea, removal should be indicated. In elderly patients and those who experience severe femoral head impaction, it is preferable to perform a total hip replacement. Despite optimal management, the rate of complications after femoral head fractures may reach as high as 50%. In the present study, the authors review the general principles of management of patients with femoral head fractures.

A Survey of Current Practices and Preferences for Internal Fixation of Trochanteric Fractures of the Femur in Brazil.

Objective The primary aim of this study was to survey current practices and preferences behind internal fixation of trochanteric femoral fractures among Brazilian orthopedic surgeons. The secondary aim was to identify the main reason for these preferences. Methods A survey containing 20 images of trochanteric fractures of the femur was presented to a group of 62 orthopedists, all members of the Brazilian Society of Orthopedics and Traumatology (SBOT). The first part of the questionnaire was created to identify the surgeons' degree of professional experience, type of practice, and areas of greatest interest and performance within the specialty. The second part of the questionnaire contained options for fixating different trochanteric fracture patterns in the femur for participants to choose, along with the main reason for their decision. Statistical analysis was descriptive and profiled the surgeons' major area of interest, treatment option, and the main reason for their therapeutic decision. Results Of the 62 orthopedists who participated in the study, 10 (16.0%) stated that their area of greatest interest was orthopedic trauma and 52 (83.9%) reported greater interest in another area of the specialty; these two groups were classified as the Trauma Group and Orthopedics Group, respectively. To treat AO 31A1 type fractures, the trauma group selected the sliding hip screw (SHS) in 66.7% of cases, while the orthopedics group chose the SHS in 65.8% of cases. For 31A2 type fractures, the trauma group chose the intramedullary (IM) nail in 64.0% of the cases, while the orthopedics group chose the IM nail in 76.7% of the cases. For 31A3 type fractures, the trauma group opted for the IM nail in 70.0% of the cases, while the orthopedics group selected the IM nail in 88.0% of the cases. The two most important factors in implant selection for the three types of fracture were fracture pattern and implant availability. Conclusion The sliding hip screw is preferred by most Brazilian orthopedic surgeons for fixation of 31A1 type trochanteric femoral fractures. For 31A2 and 31A3 type fractures, the IM nail is preferred.

Stability of L-shaped and inverted triangle fixation assemblies in treating Pauwels type II femoral neck fracture: a comparative mechanical study.

PURPOSE: The aim of our study is to compare the mechanical resistance of two screw configurations in fixating type II Pauwels femoral neck fractures. METHODS: Fifteen synthetic models of femur bones in young adults were divided into three equal groups: intact (G1), models with fixation of a 5.0-mm failure zone created in the posterior cortex of the femoral neck using an L-shaped screw arrangement (G2, n = 5), and models with an identical failure zone fixated using an inverted triangle assembly (G3, n = 5). Model strength (axial loading) and rotational deviation of the fragments were load-tested until a 5.0-mm displacement was reached (step 1) and then until failure, here considered as 10.0 mm displacement in G2 and G3 or femoral neck fracture in G1 (step 2). RESULTS: In step 1, the mean resistance in G1 was 1593 N (standard deviation [SD] of 62 N); this value in G2 was 1261 N (SD 49 N) and in G3 was 1074 N (SD 153 N). During step 2, the value for G1 was 2247 N (SD 84 N), for G2 was 1895 N (SD 69 N), and for G3 was 1523 N (SD 280 N). G3 (the inverted triangle assembly) showed a significantly lower maximum load than the group using the L-shaped assembly (G2) and the control group (G1), which was significant using Kruskal-Wallis analysis of variance (p = 0.002). CONCLUSION: Under test conditions in synthetic bone, fixation using a L-shaped screw assembly provides greater mechanical resistance than an inverted triangle assembly.

Comparative radiographic analysis on the anatomical axis in knee osteoarthritis cases: inter and intraobserver evaluation.

OBJECTIVE: To make a comparative inter and intraobserver analysis on measurements of the anatomical axis between panoramic radiographs of the lower limbs in anteroposterior (AP) view with bipedal weight-bearing, on short film. METHODS: An accuracy study comparing radiographic measurements on 47 knees of patients attending the knee surgery outpatient clinic due to osteoarthritis. The radiographic evaluation used was as standardized for the total knee arthroplasty program, including panoramic AP views of the lower limbs and short radiographs of the knees in AP and lateral views, all with bipedal weight-bearing. Following this, the anatomical axis of the lower limbs or the femorotibial angle was measured by five independent examiners on the panoramic and short AP radiographs; three of the examiners were considered to be more experienced and two, less experienced. All the measurements were made again by the same examiners after an interval of not less than 15 days. The statistical analysis was performed using the intraclass correlation coefficient, in order to evaluate the inter and intraobserver concordance of the anatomical axis measurements. RESULTS: From the statistical analysis, it was observed that there was strongly significant concordance between the anatomical axis measurements on the panoramic and short radiographs, for all the five examiners and for both measurements. CONCLUSIONS: Under the conditions studied, short radiographs were equivalent to panoramic radiographs for evaluating the anatomical axis of the lower limbs in patients with advanced osteoarthritis. The measurements used also showed high rates of inter and intraobserver concordance and reproducibility.

OBJETIVO: Fazer a análise comparativa inter e intraobservador da medida do eixo anatômico entre as radiografias panorâmica, dos membros inferiores (MMII) com raio anteroposterior (AP) e apoio bipodálico e AP com carga bipodal em filme curto. MÉTODOS: Foi feito estudo de acurácia que comparou medidas radiográficas em 47 joelhos de pacientes do ambulatório de cirurgia do joelho, por osteoartrite (OA). A avaliação radiográfica usada foi a padronizada para a programação de ATJ, incluindo as incidências panorâmica dos MMII em AP e as radiografias curtas dos joelhos em AP e perfil, todas com apoio bipodálico. Em seguida, as radiografias panorâmicas e curtas em AP tiveram os eixos anatômicos dos MMII ou ângulo femorotibial (AFT) medidos por cinco examinadores independentes, dos quais três eram considerados mais experientes e dois menos experientes. Todas as medidas foram refeitas pelos mesmos examinadores em um intervalo não menor do que 15 dias. A análise estatística foi feita com o uso do coeficiente de correlação intraclasses (ICC) para avaliar a concordância na medida do eixo anatômico inter e intraobservadores. RESULTADOS: Após análise estatística observou-se forte concordância significativa entre o eixo anatômico medido nas radiografias panorâmica e curta para todos os cinco examinadores e para ambas as medidas. CONCLUSÕES: Nas condições estudadas a radiografia curta equipara-se à panorâmica na avaliação do eixo anatômico dos MMII em pacientes com OA avançada. A mensuração usada também mostra alta taxa de concordância e reprodutibilidade inter e intraobsevadores.

Análise radiográfica comparativa do eixo anatômico na osteoartrite do joelho: Avaliação inter e intraobservadores / Comparative radiographic analysis on the anatomical axis in knee osteoarthritis cases: inter and intraobserver evaluation

OBJETIVO:fazer a análise comparativa inter e intraobservador da medida do eixo anatômico entre as radiografias panorâmica, dos membros inferiores (MMII) com raio anteroposterior (AP) e apoio bipodálico e AP com carga bipodal em filme curto.MÉTODOS:foi feito estudo de acurácia que comparou medidas radiográficas em 47 joelhos de pacientes do ambulatório de cirurgia do joelho, por osteoartrite (OA). A avaliação radiográfica usada foi a padronizada para a programação de ATJ, incluindo as incidências panorâmica dos MMII em AP e as radiografias curtas dos joelhos em AP e perfil, todas com apoio bipodálico. Em seguida, as radiografias panorâmicas e curtas em AP tiveram os eixos anatômicos dos MMII ou ângulo femorotibial (AFT) medidos por cinco examinadores independentes, dos quais três eram considerados mais experientes e dois menos experientes. Todas as medidas foram refeitas pelos mesmos examinadores em um intervalo não menor do que 15 dias. A análise estatística foi feita com o uso do coeficiente de correlação intraclasses (ICC) para avaliar a concordância na medida do eixo anatômico inter e intraobservadores.RESULTADOS:após análise estatística observou-se forte concordância significativa entre o eixo anatômico medido nas radiografias panorâmica e curta para todos os cinco examinadores e para ambas as medidas.CONCLUSÕES:nas condições estudadas a radiografia curta equipara-se à panorâmica na avaliação do eixo anatômico dos MMII em pacientes com OA avançada. A mensuração usada também mostra alta taxa de concordância e reprodutibilidade inter e intraobservadores.

OBJECTIVE: To make a comparative inter and intraobserver analysis on measurements of the anatomical axis between panoramic radiographs of the lower limbs in anteroposterior (AP) view with bipedal weight-bearing, on short film. METHODS: An accuracy study comparing radiographic measurements on 47 knees of patients attending the knee surgery outpatient clinic due to osteoarthritis. The radiographic evaluation used was as standardized for the total knee arthroplasty program, including panoramic AP views of the lower limbs and short radiographs of the knees in AP and lateral views, all with bipedal weight-bearing. Following this, the anatomical axis of the lower limbs or the femorotibial angle was measured by five independent examiners on the panoramic and short AP radiographs; three of the examiners were considered to be more experienced and two, less experienced. All the measurements were made again by the same examiners after an interval of not less than 15 days. The statistical analysis was performed using the intraclass correlation coefficient, in order to evaluate the inter and intraobserver concordance of the anatomical axis measurements. RESULTS: From the statistical analysis, it was observed that there was strongly significant concordance between the anatomical axis measurements on the panoramic and short radiographs, for all the five examiners and for both measurements. CONCLUSIONS: Under the conditions studied, short radiographs were equivalent to panoramic radiographs for evaluating the anatomical axis of the lower limbs in patients with advanced osteoarthritis. The measurements used also showed high rates of inter and intraobserver concordance and reproducibility.

Positioning of the acetabular component in cemented prostheses - radiographic calculation / Posicionamento do componente acetabular em próteses cimentadas - cálculo radiográfico

OBJECTIVE: to assess the reliability of the inclination angle and anteversion of acetabular cup component in patients with idiopatic osteoarthritis of the hip, aseptic necrosis and hip neck fracture using trigonometric formula and plain radiographs. METHODS: 66 patients underwent cemented total arthroplasty of 72 hips. The inclination of acetabular component was measured using plain radiograph. The acetabular component anteversion was measured using trigonometric formula. RESULTS: it was observed that, in the osteoarthritic hips, hip neck fracture and aseptic necrosis, the degree of agreement was highly significant (p < 0.0001), in the measurements of anteversion and inclination angles, among the three assessments, from intra as well as inter-observers. All the agreement pairs were of excellent degree (ICC > 0.80). CONCLUSION: using plain radiographs and trigonometric formula, the method resulted to be highly accurate and reliable. Besides being easy to be calculated. No significant variation was found in the anteversion and inclination angles when compared with osteoarthritis of the hip, aseptic necrosis and hip neck fracture.

OBJETIVO: Medir a confiabilidade do ângulo de inclinação e a anteversão do componente acetabular em pacientes com osteoartrose idiopática do quadril, necrose asséptica e na fratura do colo do fêmur por meio de uma fórmula trigonométrica e radiografias convencionais. MÉTODOS: Foram tratados 66 pacientes com artroplastia total cimentada em 72 quadris. A inclinação do componente acetabular foi medida por radiografias panorâmicas de bacia em incidência anteroposterior. A anteversão do componente acetabular foi medida com o uso de fórmula trigonométrica. RESULTADOS: Observou-se que, tanto nos quadris com artrose, na fratura do colo do fêmur e na necrose asséptica, o grau de concordância foi altamente significativo (p < 0,0001), nas medidas dos ângulos de anteversão e inclinação, entre os três avaliadores, tanto intra como interobservador. Todos os pares de concordância foram de grau ótimo (ICC > 0,80). CONCLUSÃO: Usando radiografias convencionais e uma fórmula trigonométrica, o método mostrou ser altamente preciso, fácil de ser calculado e com grande confiabilidade. Não foi encontrada variação significativa no ângulo de anteversão e no ângulo de inclinação quando comparado com a artrose do quadril, a necrose asséptica e a fratura do colo do fêmur.