10 - aob 646 REVIEW ARTICLE
A SURVEY OF RECENTLY PUBLISHED PAPERS ON ORTHOPEDICS IN THE BRAZILIAN SCIENTIFIC PRESS MAURICIO ROCHA-E-SILVA, ARIANE MARIS GOMES ABSTRACT
This paper is a review of articles published in Brazilian scientific periodicals in recent years. Its main purpose is to bring to the attention of the readership of Acta Ortopedica Brasileira original contributions to the field published in non-specialized journals.
We hope that this will serve as a general scientific update for readers. The review includes works published in six ISI indexed non-orthopedic journals, following a literature search conducted in fourteen such journals. Keywords: Research. Orthopedics. Osteoarthritis.
Citation: Rocha-e-Silva M, Gomes AM. A survey of recently published papers on orthopedics in the Brazilian scientific press. Acta Ortop Bras. [online]. 2012;20(6):367-71. Available from URL: http://www.scielo.br/aob.
INTRODUCTION
GENERAL REVIEW
Brazilian clinical and surgical journals have recently enjoyed a very significant increase both in the quality and the total volume of published original science. No small credit is due here to the enhanced visibility induced by the SciELO collection, which requires all journals indexed therein to be of immediate free open access.1 A second, more recent stimulus has come from the very large increase in Brazilian journals accepted by and indexed in the ISI-THOMSON Journal of Citation Reports (JCR) factor.2 In all categories, the number of Brazilian ISI THOMSON indexed journals rose from 31 in the 2008 JCR edition to 102 in the 2010 version. This review catalogues and summarizes papers that appeared in clinical and surgical journals that are included, or are about to be included in the ISI JCR Impact Factor collection. The present update on recently published papers in ISI indexed Brazilian journals covers contributions to orthopedics. These articles appeared in the following journals: Brazilian Journal of Medical and Biological Research, Clinics, Jornal de Pediatria, Revista da Escola de Enfermagem da USP, Revista Latinoamericana de Enfermagem and São Paulo Medical Journal. Criteria observed for selecting articles were generally based on the new concept of continuously variable rating where articles are evaluated with respect to citations in comparison to other articles cited in the same journal.3 An overwhelming majority of articles cover orthopedic problems of the lower and upper limb in this order.
In the general subject of lower limb orthopedics, knee pathology was dominant. Ciolac and Greve4 analyzed muscle strength and exercise intensity adaptation to resistance training in 23 older women with knee osteoarthritis and total knee arthroplasty divided into the following groups: older, with knee osteoarthritis and total knee arthroplasty in the contralateral limb; older and healthy; young and healthy. Muscle strength and exercise intensity progression were compared before and after 13 weeks of a twice-weekly progressive resistance-training program. At baseline, arthritic women displayed lower muscle strength than both healthy women groups with less muscle strength in the osteoarthritic leg. Strength improved in all groups, more in the osteoarthritic leg vs. the total knee arthroplasty leg reducing interleg difference. Post-training muscle strength was similar between arthritic and healthy older women, suggesting that resistance training is effective to counteract the lower-extremity strength asymmetry reported in osteoarthritic women. Sanghi et al.5 examined the validity of the contention that body mass index and other anthropometric measures have significant relationships with knee osteoarthritis. In total, 180 subjects with a diagnosis of knee osteoarthritis were recruited and classified. Osteoarthritis outcome scores were evaluated. They conclude that this study validates the contention that body mass indexand other anthropometric measures have a significant association with knee osteoarthritis. However, the triceps-skinfold thickness in males and the waist-hip ratio in females were more
$OOWKHDXWKRUVGHFODUHWKDWWKHUHLVQRSRWHQWLDOFRQÁLFWRILQWHUHVWUHIHUULQJWRWKLVDUWLFOH Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo. Mailing address: Rua Dr. Ovídio Pires de Campos 225, 6º andar - 05403-010 - São Paulo/SP – Brazil. Email: [email protected]
Article received on 5/14/2012 and approved on 6/25/2012. Acta Ortop Bras. 2012;20(6): 367-71
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strongly associated with knee osteoarthritis than body mass index. Aliberti et al.6 investigated the influence of Patellofemoral Pain Syndrome on plantar pressure distribution during the foot rollover process (i.e., the initial heel contact, mischance and propulsion phases) of the gait and found that this syndrome is related to a foot rollover pattern that is medially directed at the rear foot during initial heel contact and laterally directed at the forefoot during propulsion. They maintain that detected alterations in the foot rollover process during gait may be used to develop clinical interventions using insoles, taping and therapeutic exercise to rehabilitate this dysfunction. Camanho7 analyzed the incidence, clinical significance, and clinical manifestations of pathological synovial plicae of the knee and claim that the presence of a synovial plica of the knee should be considered as a potential diagnosis in patients with knee pain, especially those who practice sports inappropriately. Angelini et al.8 compared the accuracy of tunnel placement and graft isometry for anterior cruciate ligament reconstruction performed using a computer-assisted navigation system (Orthopilot), and traditional instruments instruments.The anterior cruciate ligament was removed intact from 36 pairs of human cadaver knees. From each pair, one knee was randomized to Group 1 (conventional) and the other to Group 2 (Orthopilot). They found no differences in any other parameters between the groups, and all tunnels were considered to be in satisfactory positions. Because results obtained for anterior cruciate ligament reconstruction depend on precise isometric point positioning, a navigation system might assist surgeons in tunnel positioning. However, no differences in tunnel position were observed between the groups. Nonetheless, better isometry was achieved in the Orthopilot group than with conventional instruments. Lasmar et al.9 evaluated the relative importance of the different static stabilizers of the posterolateral corner of the knee in cadavers by applying varus and external rotation force to the knee in extension at 30 and 60 degrees of flexion. The forces were first applied to intact knees,then repeated after selective sectioning of ligaments. Studied parameters were the angular deformity and stiffness. Findings showed:(a) the lateral collateral ligament was important in varus stability;(b) the popliteofibular complex was the most important structure for external rotation stability but also for varus stability. The posterolateral capsule was important for varus stability and for external rotation stability in extension. Using a rabbit animal model, Penteado et al.10 analyzed the effect of high-energy extracorporeal shockwave therapy on tendon angiogenesis in the patellar tendons of rabbits, investigating whether different voltages and number pulses modify the angiogenesis pattern. High-energy extracorporeal shockwave therapy was applied at the tibial insertion of the left patellar ligament in 30 rabbits that were separated into six groups that differed in terms of the voltage and number of applied pulses. Right leg corresponding structures were used as controls. After six weeks, histological analysis showed no differences in the number of blood vessels between the left and right patellar tendons. Vicente et al.11 compared long-term rates of survival and successful osseointegration between two different types of uncemented acetabular components:a porous-coated acetabulum and a Plasmacup® were compared with a focus on long-term prosthesis survival and development of acetabular osseointegration. Among 70 patients implanted with the porous-coated acetabulum, 80%
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achieved osseointegration over a mean follow-up time of 11.9 years versus 75.3% of the 73 patients who received a Plasmacup insert over a mean of 10.7 years. Prosthesis survival rates were not different between the two groups. They conclude that, during the first ten years after surgery, there is no significant difference between these two types of uncemented cups with regard to either prosthesis survival or successful osseointegration. An interesting paper by de Amorim Cabrita et al.12 describes a new technique for removing distal fragments of broken intramedullary femoral nails without disturbing the nonunion site. An AO distractor is applied prior to the removal of the nail fragments, with subsequent removal of the proximal nail fragment in an anterograde fashion and removal of the distal fragment through a medial parapatellar approach. Impaction of the fracture site is then performed with a nail that is broader than the remaining fragmented material. After a mean follow-up period of 61.8 months, none of the 5 patients showed worsened knee osteoarthritis.The technique described in this article allows surgeons to remove the distal fragment of fractured femoral intramedullary nails without opening the nonunion focus or using special surgical instruments. The interaction between exercise and lower limb muscle power was the subject of a study by Ciolac and Greve13, who compared exercise-induced improvements in muscle strength, between normal-weight and overweight/obese postmenopausal sedentary women.Before training, overweight/obese women displayed decreased lower extremity muscle strengths. After training, both groups improved their lower extremity (49.5% and 47.8% in normal-weight and overweight/obese women, respectively) muscle strength. However, only normal-weight women improved their cardiorespiratory fitness (6.6%) and recovery heart rate (5 bpm). These results suggest that exercise-induced improvements muscle strength in overweight women are hampered by cardiorespiratory fitness and heart rate response to exercise. Our last selection in the lower limb category was contributed by Alonso et al.14 evaluated whether lower-limb dominance has an influence on postural balance through a cross-sectional study conducted on 40 healthy sedentary males aged 20 to 40. A single-foot balance test was carried out using the Biodex Balance System equipment, comparing the dominant leg with the nondominant leg of the same individual, concluding that lower-limb dominance did not influence single-foot balance among sedentary males. The upper limb was the subject of Bajuri et al.15 who analyzed the outcomes of clavicle fractures in 70 adults treated non-surgically and to evaluate the clinical effects of displacement, fracture patterns, fracture location, fracture comminution, shortening and fracture union on shoulder function.There were statistically significant functional outcome impairments in non-surgically treated clavicle fractures that correlated with the fracture type (comminution), the fracture displacement (21 mm or more), shortening (15 mm or more) and the fracture union (malunion).They stress the need for surgical intervention to treat clavicle fractures and improve shoulder functional outcomes. Hand arthritis was studied by Bisneto et al.16 who prospectively compared the functional results of carpectomy vs. four-corner fusion surgical procedures for treating osteoarthrosis following carpal trauma in 20 patients who underwent either proximal row carpectomy or four-corner fusion to treat wrist arthritis and their functional results were compared. Both procedures reduced Acta Ortop Bras. 2012;20(6): 367-71
the pain, but all patients had a decreased range of motion after surgery. Functional results of the two procedures were similar as both reduced pain in patients with scapholunate advanced collapse/scaphoid non-union advanced collapse wrist without degenerative changes in the midcarpal joint Orthopedics of the head and neck were the subject of two articles: in a murine model, Mariúba et al.17 investigated in male Wistar rats the effects of thyroid hormones(known to regulate the expression of genes that control bone mass and the oxidative properties of muscles) on the stomatognathic system issue by evaluating: (i) osteoprotegerin (OPG) and osteopontine (OPN) mRNA expression in the maxilla,(ii) myoglobin mRNA and protein expression, (iii) fiber composition of the masseter. Thyroidectomy increased osteoprotegerin and osteopontine mRNA expression, while T3 treatment reduced osteoprotegerin (~40%) and osteopontine. Masseter Mb mRNA expression and fiber type composition remained unchanged, despite the induction of hypo- and hyperthyroidism. However, myoglobin content was decreased in thyroidectomized rats, even after T3 treatment. Authors claim that their data indicate that thyroid hormones interfere with maxilla remodeling and the oxidative properties of the masseter, influencing the function of the stomatognathic system. Pinto et al.18 endeavored to identify factors that may cause complications and influence the final result from reconstructions using pectoralis major myocutaneous flaps (PMMFs) for head and neck defect repair following cancer resection. Data on 58 patients who underwent head and neck defect reconstruction using flaps were reviewed. No total flap losses were registered, with a reconstruction success rate of 93%. Flap-related complications occurred in 43% of the cases, and half of them were considered major. Most of the complications were successfully treated. Since the risk factors for developing major complications and reconstruction failure are known, it is important to heed the technical details and provide careful clinical support for patients in a more critical condition, so that better results can be obtained. Low back pain was the subject of a study by França et al.19 who compared the efficacy of two exercise programs, segmental stabilization and strengthening of abdominal and trunk muscles, on pain, functional disability, and activation of the transversus abdominis muscle (TrA), in individuals with chronic low back pain.Thirty individuals were randomly assigned to one of two treatment groups: segmental stabilization, and superficial strengthening, as compared to baseline, both treatments were effective in relieving pain and improving disability. Segmental stabilization induced significant gains for all variables when compared to the superficial strengthening. Both techniques lessened pain and reduced disability. Segmental stabilization is superior to superficial strengthening for all variables. General orthopedic problems were covered in 17 articles. Ren et al.20 explored the signal transduction pathways of chondrocyte proliferation and matrix synthesis under periodic mechanical stress endeavoring to identify the role of the MEK1/2-ERK1/2 signaling pathway in chondrocyte proliferation and matrix synthesis following cyclic physiologic mechanical compression. Their findings suggest that periodic mechanical stress promotes chondrocyte proliferation and matrix synthesis in part through the Src-PLCȖ1-MEK1/2-ERK1/2 signaling pathway, which links these three important signaling molecules into a mitogenic Acta Ortop Bras. 2012;20(6): 367-71
cascade. Rodrigues et al.21 studied molecules involved in extracellular matrix remodeling in order to identify and quantify heparanase isoforms present in herniated and degenerative discs.They find that the overexpression of heparanase isoforms in the degenerative intervertebral discs and the herniated discs suggests a potential role of both proteins in the mediation of inflammatory processes and in extracellular matrix remodeling. The heparanase-2 isoform may be involved in normal metabolic processes, as evidenced by its higher expression in the control intervertebral discs relative to the expression of heparanase-1. Mara et al.22 investigated chondrogenesis employing periosteal mesenchymal cells harvested from patients who underwent orthopedic surgeries. Mesenchymal stem cells were characterized through flow cytometry using specific antibodies and were divided into four groups, two stimulated with transforming growth factor ȕ3 (TGF-ȕ3), one cultivated in a monolayer culture one in a micromass culture. Two groups were cultivated in monolayer or micromass in the absence of TGF-ȕ3. TGF-ȕ3-stimulated monolayer and micromass groups expressed type II collagen that was significantly greater in the micromass system. These results show that the interactions between the cells in the micromass culture system can regulate the proliferation and differentiation of periosteal mesenchymal cells during chondrogenesis and that this effect is enhanced by TGF-ȕ3. Qing et al.23 determined whether the co-culture of rabbit articular chondrocytes and BMSCs in vitro promotes the expression of cartilaginous extracellular matrix and, if so, what is the optimal ratio of the two cell types. Results demonstrate that the co-culture of rabbit chondrocytes and rabbit BMSCs at defined ratios can promote the expression of cartilaginous extracellular matrix. The optimal cell ratio appears to be 2:1 (chondrocytes:BMSCs). It appears that this approach has potential applications in cartilage tissue engineering since it provides a protocol for maintaining and promoting seed-cell differentiation and function. Reis et al.24 describe the response of human osteoblast-like MG63 cells after 6 days of culture in contact with artificially generated particles from both UHMWPE polymer and multiwalled carbon nanotubes (MWCNT)/UHMWPE nanocomposites. This novel composite has superior wear behavior, having thus the potential to reduce the number of revision hip arthroplasty surgeries required by wear failure of acetabular cups and diminish particle-induced osteolysis. The results of this in vitro study of viability and proliferation and interleukin-6 (IL-6) production, especially the absence of significant elevation in the osteolysis inductor IL-6 values, reinforce the potential of this superior wear-resistant composite for future orthopedic applications, when compared to traditional UHMWPE. Monteiro and Faro25 evaluated the functional independence of 34 aged individuals with fractures, at admission, discharge and more than one month after their return home. They also checked on the relation ship between functional independence and demographic and health variables. The motor and total functional independence scores increased at discharge, but decreased one month after their returning home. Functional impairment increased with age and also with longer length of stay. Hypothyroidism was related to cognitive impairment, while dementia and depression were related to motor impairment. The critical problem of infections related to orthopedic surgery
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was covered in two articles. Ercole et al. 26 evaluated the applicability of the National Nosocomial Infection Surveillance index for prediction of surgical site infection in orthopedic surgeries and to propose an alternative index. The study involved a historical cohort of 8,236 patients who had been submitted to orthopedic surgery. The incidence of infection was 1.41%. Prediction models were evaluated and compared to the National Nosocomial Infection Surveillance index. The proposed model was not considered a good predictor of infection, despite moderately stratified orthopedic surgical patients in at least three of the four scores. The alternative model scored higher than the National Nosocomial Infection Surveillance index in the prediction of infection. Ercole et al.27 endeavored to identify risk factors associated with surgical site infections in orthopedic surgical patients at a public hospital in Minas Gerais, Brazil, between 2005 and 2007. A historical cohort of 3,543 patients was submitted to orthopedic surgical procedures. A descriptive analysis was conducted and surgical site infection incidence rates were estimated. The incidence of surgical site infection was 1.8%. Potential surgical wound contamination, clinical conditions, time and type of surgical procedure were statistically associated with infection. Identifying the association between surgical site infection and these risk factors is important and contributes to nurses’ clinical practice. Bitar et al.28 conducted a study to histologically analyze allografts from cadaveric semitendinous muscle after cryopreservation at -80 degrees C in comparison to a control group kept at only -4 degrees C to test the hypothesis that the histological characteristics of the tissue are maintained when the tendons are kept at lower temperatures. No histological differences between the fresh and frozen samples were found in relation to seven variables.They conclude that semitendinous muscle tendon allografts can be submitted to cryopreservation at -80 degrees C without suffering histological modifications. Dogan et al.29 investigated the effectiveness of 850-nm gallium arsenide aluminum (Ga-As-Al) laser therapy on pain, range of motion and disability in subacromial impingement syndrome in 52 patients randomly assigned into a laser therapy or a placebo group, which received sham laser therapy. Initially cold pack (10 minutes) was applied to all of the patients. An exercise program including range of motion, stretching and progressive resistive exercises was also prescribed. No significant differences were recorded between the groups, indicating that the low-level laser therapy seems to have no superiority over sham laser therapy in reducing pain severity, range of motion and functional disability. Jannini et al.30 determined the prevalence of pain, musculoskeletal syndromes and orthopedic disorders as related to using computers and playing videogames among 100 obese adolescents matched to 100 healthy-weight controls using a confidential, self-report questionnaire covering demographic data, sports participation, painful musculoskeletal system symptoms and using computers and playing videogames. Pain and musculoskeletal syndromes were equally prevalent in both groups, but orthopedic disorders, tight quadriceps and genu valgum were more prevalent in obese adolescents. Median computer time was lower among the obese subjects who were less likely to play handheld videogames. Pain was more frequent among females and was associated with more time spent playing on Sundays.Programs developed specifically for obese female
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adolescents with musculoskeletal pain are needed. Burke et al.31 evaluated posture and postural control among 66 elderly women with and without osteoporosis, according to their bone mineral density. Osteoporosis patients swayed at higher velocity on a stable surface with open eyes and fell more than controls. The postural control in elderly women with osteoporosis differed from that of the controls, with higher sway velocity and maximum displacement of COP. Despite postural abnormalities such as hyperkyphosis and forward head, the COP position was posteriorized. Finally, orthopedic nursing was the subject of four articles. Almeida et al.32 endeavored to validate four nursing outcomes’ indicators of the Nursing Outcomes Classification presented by patients in postoperative of orthopedic surgery. An instrument containing the outcome indicators Self-care Activities of Daily Living, Bathing, Hygiene and Oral Hygiene was built, along with a Likert scale ranging from 1 to 5 (1 = not important, 5 = extremely important). Out of the 34 indicators studied, 2 were considered as main temporary indicators, 22 as secondary temporary indicators and 10 were discarded. The main and secondary temporary indicators will be used during the bathing observation of patients in postoperative of Total Hip Replacement, and their development will be monitored. Cameron et al.33 identified some undergraduate nursing students’ imaginary manifestations concerning themselves and care delivered to patients with orthopedic and/or trauma disorders. The Sociopoetic method was used and 15 undergraduate students were tested. Data revealed that care provided by orthopedic nursing students is the result of a care relationship that emerges from their sensitivity toward patients and their own knowledge, skills and attitudes. The orthopedic treatment, equipment and procedures to which patients are submitted cause important emotional distress, empathic behavior and encourage students to search for ways to minimize their patients’ pain. Cameron et al.34 examines the role that vision plays as an instrument for holistic and quality nursing care. This is a qualitative, exploratory study, using the Sociopoetic method. The data was categorized as follows: (1) Vision as an instrument and (2) Outer body changes. In trauma and orthopedics, nurses should be able to provide patients with care in complex conditions and in an environment, which changes fast. Results show that vision is a powerful health care instrument in trauma and orthopedic nursing, promoting professional practice that is truly appropriate to the patients’ needs. De Abreu Almeida et al.35 mapped the 52 nursing care actions prescribed for orthopedic patients onto Self-care Deficit: bathing and/or hygiene, Impaired Physical Mobility and Risk for Infection, according to the Nursing Interventions Classification (NIC). The study used the Delphi Technique as the content validation method, considering a level of 70% of agreement among experts. Data were analyzed through descriptive statistics. Twenty-two experts validated the mapping of 51 nursing care actions onto 56 NIC interventions in two rounds. The objective was achieved because only one mapped care action did not reach the established level of agreement. None of the mapped care actions reached 100% consensus, which evidences the various possibilities of comparison and the importance of validation studies. Acta Ortop Bras. 2012;20(6): 367-71
REFERENCES 1. SciELO - Scientific Electronic Library Online. FAPESP, CNPq, FapUnifesp, BIREME. [cited 2011 Aug 20]. Available from: http://www.scielo.org. 2. The Journal of Citation Report. [cited 2011 Aug 20]. Available from: http:// www.isi.knowledge.com. 3. Rocha e Silva M. Continuously variable rating: a new, simple and logical procedure to evaluate original scientific publications. Clinics (São Paulo). 2011;66(12):2099-104. 4. Ciolac EG, Greve JM. Muscle strength and exercise intensity adaptation to resistance training in older women with knee osteoarthritis and total knee arthroplasty. Clinics (Sao Paulo). 2011;66(12):2079-84. 5. Sanghi D, Srivastava RN, Singh A, Kumari R, Mishra R, Mishra A. The association of anthropometric measures and osteoarthritis knee in non-obese subjects: a cross sectional study. Clinics (Sao Paulo). 2011;66(2):275-9. 6. Aliberti S, Costa MeS, Passaro AeC, Arnone AC, Hirata R, Sacco IC. Influence of patellofemoral pain syndrome on plantar pressure in the foot rollover process during gait. Clinics (Sao Paulo). 2011;66(3):367-72. 7. Camanho GL. Treatment of pathological synovial plicae of the knee. Clinics (Sao Paulo). 2010;65(3):247-50. 8. Angelini FJ, Albuquerque RF, Sasaki SU, Camanho GL, Hernandez AJ. Comparative study on anterior cruciate ligament reconstruction: determination of isometric points with and without navigation. Clinics (Sao Paulo). 2010;65(7):683-8. 9. Lasmar RC, Marques de Almeida A, Serbino JW, Mota Albuquerque RF, Hernandez AJ. Importance of the different posterolateral knee static stabilizers: biomechanical study. Clinics (Sao Paulo). 2010;65(4):433-40. 10. Penteado FT, Faloppa F, Giusti G, Moraes VY, Belloti JC, Santos JB. High-energy extracorporeal shockwave therapy in a patellar tendon animal model: a vascularizationfocused study. Clinics (Sao Paulo). 2011;66(9):1611-4. 11. Vicente JR, Ulhoa CA, Katz M, Addeo RD, Croci AT. A comparative study of plasmacup and porous-coated acetabular components: survival after 10 to 12 years of follow-up. Clinics (Sao Paulo). 2010;65(11):1111-4. 12. de Amorim Cabrita HA, Malavolta EA, Teixeira OV, Montenegro NB, Duarte FA, Mattar R. Anterograde removal of broken femoral nails without opening the nonunion site: a new technique. Clinics (Sao Paulo). 2010;65(3):279-83. 13. Ciolac EG, Greve JM. Exercise-induced improvements in cardiorespiratory fitness and heart rate response to exercise are impaired in overweight/obese postmenopausal women. Clinics (Sao Paulo). 2011;66(4):583-9. 14. Alonso AC, Brech GC, Bourquin AM, Greve JM. The influence of lower-limb dominance on postural balance. Sao Paulo Med J. 2011;129(6):410-3. 15. Bajuri MY, Maidin S, Rauf A, Baharuddin M, Harjeet S. Functional outcomes of conservatively treated clavicle fractures. Clinics (Sao Paulo). 2011;66(4):635-9. 16. Bisneto EN, Freitas MC, Paula EJ, Mattar R, Zumiotti AV. Comparison between proximal row carpectomy and four-corner fusion for treating osteoarthrosis following carpal trauma: a prospective randomized study. Clinics (Sao Paulo). 2011;66(1):51-5. 17. Mariúba MV, Goulart-Silva F, Bordin S, Nunes MT. Effect of triiodothyronine on the maxilla and masseter muscles of the rat stomatognathic system. Braz J Med Biol Res. 2011;44(7):694-9. 18. Pinto FR, Malena CR, Vanni CM, Capelli Fde A, Matos LL, Kanda JL. Pectoralis major myocutaneous flaps for head and neck reconstruction: factors
Acta Ortop Bras. 2012;20(6): 367-71
influencing occurrences of complications and the final outcome. Sao Paulo medical journal = Revista paulista de medicina. 2010;128(6):336-41. 19. França FR, Burke TN, Hanada ES, Marques AP. Segmental stabilization and muscular strengthening in chronic low back pain: a comparative study. Clinics (Sao Paulo). 2010;65(10):1013-7. 20. Ren K, Ma Y, Huang Y, Liang W, Liu F, Wang Q, et al. Periodic mechanical stress activates MEK1/2-ERK1/2 mitogenic signals in rat chondrocytes through Src and PLCȖ1. Braz J Med Biol Res. 2011;44(12):1231-42. 21. Rodrigues LM, Theodoro TR, Matos LL, Mader AM, Milani C, Pinhal MA. Heparanase isoform expression and extracellular matrix remodeling in intervertebral disc degenerative disease. Clinics (Sao Paulo). 2011;66(5):903-9. 22. Mara CS, Sartori AR, Duarte AS, Andrade AL, Pedro MA, Coimbra IB. Periosteum as a source of mesenchymal stem cells: the effects of TGF-ȕ3 on chondrogenesis. Clinics (Sao Paulo). 2011;66(3):487-92. 23. Qing C, Wei-ding C, Wei-min F. Co-culture of chondrocytes and bone marrow mesenchymal stem cells in vitro enhances the expression of cartilaginous extracellular matrix components. Braz J Med Biol Res. 2011;44(4):303-10. 24. Reis J, Kanagaraj S, Fonseca A, Mathew MT, Capela-Silva F, Potes J, et al. In vitro studies of multiwalled carbon nanotube/ultrahigh molecular weight polyethylene nanocomposites with osteoblast-like MG63 cells. Braz J Med Biol Res. 2010;43(5):476-82. 25. Monteiro CR, e Faro AC. [Functional evaluation of aged with fractures at hospitalization and at home]. Rev Esc Enferm USP. 2010;44(3):719-24. 26. Ercole FF, Chianca TC, Duarte D, Starling CE, Carneiro M. Surgical site infection in patients submitted to orthopedic surgery: the NNIS risk index and risk prediction. Rev Lat Am Enfermagem. 2011;19(2):269-76. 27. Ercole FF, Franco LM, Macieira TG, Wenceslau LC, Resende HI, Chianca TC. Risk of surgical site infection in patients undergoing orthopedic surgery. Rev Lat Am Enfermagem. 2011;19(6):1362-8. 28. Bitar AC, Santos LA, Croci AT, Pereira JA, França Bisneto EN, Giovani AM, et al. Histological study of fresh versus frozen semitendinous muscle tendon allografts. Clinics (Sao Paulo). 2010;65(3):297-303. 29. Dogan SK, Ay S, Evcik D. The effectiveness of low laser therapy in subacromial impingement syndrome: a randomized placebo controlled double-blind prospective study. Clinics (Sao Paulo). 2010;65(10):1019-22. 30. Jannini SN, Dória-Filho U, Damiani D, Silva CA. Musculoskeletal pain in obese adolescents. J Pediatr (Rio J). 2011;87(4):329-35. 31. Burke TN, Franca FJ, Meneses SR, Cardoso VI, Pereira RM, Danilevicius CF, et al. Postural control among elderly women with and without osteoporosis: is there a difference? Sao Paulo Med J. 2010;128(4):219-24. 32. Almeida MeA, Seganfredo DH, Unicovsky MR. [Nursing outcome indicator validation for patients with orthopedic problems]. Rev Esc Enferm USP. 2010;44(4):1059-64. 33. Cameron LE, Araújo ST. Undergraduate students in orthopedic nursing care. Rev Lat Am Enfermagem. 2011;19(6):1391-7. 34. Cameron LE, de Araújo ST. [Vision as an instrument of perception in trauma and orthopedic nursing care]. Rev Esc Enferm USP. 2011;45(1):95-9. 35. de Abreu Almeida M, Pergher AK, do Canto DF. Validation of mapping of care actions prescribed for orthopedic patients onto the nursing interventions classification. Rev Lat Am Enfermagem. 2010;18(1):116-23.
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A SURVEY OF RECENTLY PUBLISHED PAPERS ON ORTHOPEDICS IN THE BRAZILIAN SCIENTIFIC PRESS MAURICIO ROCHA-E-SILVA, ARIANE MARIS GOMES ABSTRACT
This paper is a review of articles published in Brazilian scientific periodicals in recent years. Its main purpose is to bring to the attention of the readership of Acta Ortopedica Brasileira original contributions to the field published in non-specialized journals.
We hope that this will serve as a general scientific update for readers. The review includes works published in six ISI indexed non-orthopedic journals, following a literature search conducted in fourteen such journals. Keywords: Research. Orthopedics. Osteoarthritis.
Citation: Rocha-e-Silva M, Gomes AM. A survey of recently published papers on orthopedics in the Brazilian scientific press. Acta Ortop Bras. [online]. 2012;20(6):367-71. Available from URL: http://www.scielo.br/aob.
INTRODUCTION
GENERAL REVIEW
Brazilian clinical and surgical journals have recently enjoyed a very significant increase both in the quality and the total volume of published original science. No small credit is due here to the enhanced visibility induced by the SciELO collection, which requires all journals indexed therein to be of immediate free open access.1 A second, more recent stimulus has come from the very large increase in Brazilian journals accepted by and indexed in the ISI-THOMSON Journal of Citation Reports (JCR) factor.2 In all categories, the number of Brazilian ISI THOMSON indexed journals rose from 31 in the 2008 JCR edition to 102 in the 2010 version. This review catalogues and summarizes papers that appeared in clinical and surgical journals that are included, or are about to be included in the ISI JCR Impact Factor collection. The present update on recently published papers in ISI indexed Brazilian journals covers contributions to orthopedics. These articles appeared in the following journals: Brazilian Journal of Medical and Biological Research, Clinics, Jornal de Pediatria, Revista da Escola de Enfermagem da USP, Revista Latinoamericana de Enfermagem and São Paulo Medical Journal. Criteria observed for selecting articles were generally based on the new concept of continuously variable rating where articles are evaluated with respect to citations in comparison to other articles cited in the same journal.3 An overwhelming majority of articles cover orthopedic problems of the lower and upper limb in this order.
In the general subject of lower limb orthopedics, knee pathology was dominant. Ciolac and Greve4 analyzed muscle strength and exercise intensity adaptation to resistance training in 23 older women with knee osteoarthritis and total knee arthroplasty divided into the following groups: older, with knee osteoarthritis and total knee arthroplasty in the contralateral limb; older and healthy; young and healthy. Muscle strength and exercise intensity progression were compared before and after 13 weeks of a twice-weekly progressive resistance-training program. At baseline, arthritic women displayed lower muscle strength than both healthy women groups with less muscle strength in the osteoarthritic leg. Strength improved in all groups, more in the osteoarthritic leg vs. the total knee arthroplasty leg reducing interleg difference. Post-training muscle strength was similar between arthritic and healthy older women, suggesting that resistance training is effective to counteract the lower-extremity strength asymmetry reported in osteoarthritic women. Sanghi et al.5 examined the validity of the contention that body mass index and other anthropometric measures have significant relationships with knee osteoarthritis. In total, 180 subjects with a diagnosis of knee osteoarthritis were recruited and classified. Osteoarthritis outcome scores were evaluated. They conclude that this study validates the contention that body mass indexand other anthropometric measures have a significant association with knee osteoarthritis. However, the triceps-skinfold thickness in males and the waist-hip ratio in females were more
$OOWKHDXWKRUVGHFODUHWKDWWKHUHLVQRSRWHQWLDOFRQÁLFWRILQWHUHVWUHIHUULQJWRWKLVDUWLFOH Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo. Mailing address: Rua Dr. Ovídio Pires de Campos 225, 6º andar - 05403-010 - São Paulo/SP – Brazil. Email: [email protected]
Article received on 5/14/2012 and approved on 6/25/2012. Acta Ortop Bras. 2012;20(6): 367-71
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strongly associated with knee osteoarthritis than body mass index. Aliberti et al.6 investigated the influence of Patellofemoral Pain Syndrome on plantar pressure distribution during the foot rollover process (i.e., the initial heel contact, mischance and propulsion phases) of the gait and found that this syndrome is related to a foot rollover pattern that is medially directed at the rear foot during initial heel contact and laterally directed at the forefoot during propulsion. They maintain that detected alterations in the foot rollover process during gait may be used to develop clinical interventions using insoles, taping and therapeutic exercise to rehabilitate this dysfunction. Camanho7 analyzed the incidence, clinical significance, and clinical manifestations of pathological synovial plicae of the knee and claim that the presence of a synovial plica of the knee should be considered as a potential diagnosis in patients with knee pain, especially those who practice sports inappropriately. Angelini et al.8 compared the accuracy of tunnel placement and graft isometry for anterior cruciate ligament reconstruction performed using a computer-assisted navigation system (Orthopilot), and traditional instruments instruments.The anterior cruciate ligament was removed intact from 36 pairs of human cadaver knees. From each pair, one knee was randomized to Group 1 (conventional) and the other to Group 2 (Orthopilot). They found no differences in any other parameters between the groups, and all tunnels were considered to be in satisfactory positions. Because results obtained for anterior cruciate ligament reconstruction depend on precise isometric point positioning, a navigation system might assist surgeons in tunnel positioning. However, no differences in tunnel position were observed between the groups. Nonetheless, better isometry was achieved in the Orthopilot group than with conventional instruments. Lasmar et al.9 evaluated the relative importance of the different static stabilizers of the posterolateral corner of the knee in cadavers by applying varus and external rotation force to the knee in extension at 30 and 60 degrees of flexion. The forces were first applied to intact knees,then repeated after selective sectioning of ligaments. Studied parameters were the angular deformity and stiffness. Findings showed:(a) the lateral collateral ligament was important in varus stability;(b) the popliteofibular complex was the most important structure for external rotation stability but also for varus stability. The posterolateral capsule was important for varus stability and for external rotation stability in extension. Using a rabbit animal model, Penteado et al.10 analyzed the effect of high-energy extracorporeal shockwave therapy on tendon angiogenesis in the patellar tendons of rabbits, investigating whether different voltages and number pulses modify the angiogenesis pattern. High-energy extracorporeal shockwave therapy was applied at the tibial insertion of the left patellar ligament in 30 rabbits that were separated into six groups that differed in terms of the voltage and number of applied pulses. Right leg corresponding structures were used as controls. After six weeks, histological analysis showed no differences in the number of blood vessels between the left and right patellar tendons. Vicente et al.11 compared long-term rates of survival and successful osseointegration between two different types of uncemented acetabular components:a porous-coated acetabulum and a Plasmacup® were compared with a focus on long-term prosthesis survival and development of acetabular osseointegration. Among 70 patients implanted with the porous-coated acetabulum, 80%
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achieved osseointegration over a mean follow-up time of 11.9 years versus 75.3% of the 73 patients who received a Plasmacup insert over a mean of 10.7 years. Prosthesis survival rates were not different between the two groups. They conclude that, during the first ten years after surgery, there is no significant difference between these two types of uncemented cups with regard to either prosthesis survival or successful osseointegration. An interesting paper by de Amorim Cabrita et al.12 describes a new technique for removing distal fragments of broken intramedullary femoral nails without disturbing the nonunion site. An AO distractor is applied prior to the removal of the nail fragments, with subsequent removal of the proximal nail fragment in an anterograde fashion and removal of the distal fragment through a medial parapatellar approach. Impaction of the fracture site is then performed with a nail that is broader than the remaining fragmented material. After a mean follow-up period of 61.8 months, none of the 5 patients showed worsened knee osteoarthritis.The technique described in this article allows surgeons to remove the distal fragment of fractured femoral intramedullary nails without opening the nonunion focus or using special surgical instruments. The interaction between exercise and lower limb muscle power was the subject of a study by Ciolac and Greve13, who compared exercise-induced improvements in muscle strength, between normal-weight and overweight/obese postmenopausal sedentary women.Before training, overweight/obese women displayed decreased lower extremity muscle strengths. After training, both groups improved their lower extremity (49.5% and 47.8% in normal-weight and overweight/obese women, respectively) muscle strength. However, only normal-weight women improved their cardiorespiratory fitness (6.6%) and recovery heart rate (5 bpm). These results suggest that exercise-induced improvements muscle strength in overweight women are hampered by cardiorespiratory fitness and heart rate response to exercise. Our last selection in the lower limb category was contributed by Alonso et al.14 evaluated whether lower-limb dominance has an influence on postural balance through a cross-sectional study conducted on 40 healthy sedentary males aged 20 to 40. A single-foot balance test was carried out using the Biodex Balance System equipment, comparing the dominant leg with the nondominant leg of the same individual, concluding that lower-limb dominance did not influence single-foot balance among sedentary males. The upper limb was the subject of Bajuri et al.15 who analyzed the outcomes of clavicle fractures in 70 adults treated non-surgically and to evaluate the clinical effects of displacement, fracture patterns, fracture location, fracture comminution, shortening and fracture union on shoulder function.There were statistically significant functional outcome impairments in non-surgically treated clavicle fractures that correlated with the fracture type (comminution), the fracture displacement (21 mm or more), shortening (15 mm or more) and the fracture union (malunion).They stress the need for surgical intervention to treat clavicle fractures and improve shoulder functional outcomes. Hand arthritis was studied by Bisneto et al.16 who prospectively compared the functional results of carpectomy vs. four-corner fusion surgical procedures for treating osteoarthrosis following carpal trauma in 20 patients who underwent either proximal row carpectomy or four-corner fusion to treat wrist arthritis and their functional results were compared. Both procedures reduced Acta Ortop Bras. 2012;20(6): 367-71
the pain, but all patients had a decreased range of motion after surgery. Functional results of the two procedures were similar as both reduced pain in patients with scapholunate advanced collapse/scaphoid non-union advanced collapse wrist without degenerative changes in the midcarpal joint Orthopedics of the head and neck were the subject of two articles: in a murine model, Mariúba et al.17 investigated in male Wistar rats the effects of thyroid hormones(known to regulate the expression of genes that control bone mass and the oxidative properties of muscles) on the stomatognathic system issue by evaluating: (i) osteoprotegerin (OPG) and osteopontine (OPN) mRNA expression in the maxilla,(ii) myoglobin mRNA and protein expression, (iii) fiber composition of the masseter. Thyroidectomy increased osteoprotegerin and osteopontine mRNA expression, while T3 treatment reduced osteoprotegerin (~40%) and osteopontine. Masseter Mb mRNA expression and fiber type composition remained unchanged, despite the induction of hypo- and hyperthyroidism. However, myoglobin content was decreased in thyroidectomized rats, even after T3 treatment. Authors claim that their data indicate that thyroid hormones interfere with maxilla remodeling and the oxidative properties of the masseter, influencing the function of the stomatognathic system. Pinto et al.18 endeavored to identify factors that may cause complications and influence the final result from reconstructions using pectoralis major myocutaneous flaps (PMMFs) for head and neck defect repair following cancer resection. Data on 58 patients who underwent head and neck defect reconstruction using flaps were reviewed. No total flap losses were registered, with a reconstruction success rate of 93%. Flap-related complications occurred in 43% of the cases, and half of them were considered major. Most of the complications were successfully treated. Since the risk factors for developing major complications and reconstruction failure are known, it is important to heed the technical details and provide careful clinical support for patients in a more critical condition, so that better results can be obtained. Low back pain was the subject of a study by França et al.19 who compared the efficacy of two exercise programs, segmental stabilization and strengthening of abdominal and trunk muscles, on pain, functional disability, and activation of the transversus abdominis muscle (TrA), in individuals with chronic low back pain.Thirty individuals were randomly assigned to one of two treatment groups: segmental stabilization, and superficial strengthening, as compared to baseline, both treatments were effective in relieving pain and improving disability. Segmental stabilization induced significant gains for all variables when compared to the superficial strengthening. Both techniques lessened pain and reduced disability. Segmental stabilization is superior to superficial strengthening for all variables. General orthopedic problems were covered in 17 articles. Ren et al.20 explored the signal transduction pathways of chondrocyte proliferation and matrix synthesis under periodic mechanical stress endeavoring to identify the role of the MEK1/2-ERK1/2 signaling pathway in chondrocyte proliferation and matrix synthesis following cyclic physiologic mechanical compression. Their findings suggest that periodic mechanical stress promotes chondrocyte proliferation and matrix synthesis in part through the Src-PLCȖ1-MEK1/2-ERK1/2 signaling pathway, which links these three important signaling molecules into a mitogenic Acta Ortop Bras. 2012;20(6): 367-71
cascade. Rodrigues et al.21 studied molecules involved in extracellular matrix remodeling in order to identify and quantify heparanase isoforms present in herniated and degenerative discs.They find that the overexpression of heparanase isoforms in the degenerative intervertebral discs and the herniated discs suggests a potential role of both proteins in the mediation of inflammatory processes and in extracellular matrix remodeling. The heparanase-2 isoform may be involved in normal metabolic processes, as evidenced by its higher expression in the control intervertebral discs relative to the expression of heparanase-1. Mara et al.22 investigated chondrogenesis employing periosteal mesenchymal cells harvested from patients who underwent orthopedic surgeries. Mesenchymal stem cells were characterized through flow cytometry using specific antibodies and were divided into four groups, two stimulated with transforming growth factor ȕ3 (TGF-ȕ3), one cultivated in a monolayer culture one in a micromass culture. Two groups were cultivated in monolayer or micromass in the absence of TGF-ȕ3. TGF-ȕ3-stimulated monolayer and micromass groups expressed type II collagen that was significantly greater in the micromass system. These results show that the interactions between the cells in the micromass culture system can regulate the proliferation and differentiation of periosteal mesenchymal cells during chondrogenesis and that this effect is enhanced by TGF-ȕ3. Qing et al.23 determined whether the co-culture of rabbit articular chondrocytes and BMSCs in vitro promotes the expression of cartilaginous extracellular matrix and, if so, what is the optimal ratio of the two cell types. Results demonstrate that the co-culture of rabbit chondrocytes and rabbit BMSCs at defined ratios can promote the expression of cartilaginous extracellular matrix. The optimal cell ratio appears to be 2:1 (chondrocytes:BMSCs). It appears that this approach has potential applications in cartilage tissue engineering since it provides a protocol for maintaining and promoting seed-cell differentiation and function. Reis et al.24 describe the response of human osteoblast-like MG63 cells after 6 days of culture in contact with artificially generated particles from both UHMWPE polymer and multiwalled carbon nanotubes (MWCNT)/UHMWPE nanocomposites. This novel composite has superior wear behavior, having thus the potential to reduce the number of revision hip arthroplasty surgeries required by wear failure of acetabular cups and diminish particle-induced osteolysis. The results of this in vitro study of viability and proliferation and interleukin-6 (IL-6) production, especially the absence of significant elevation in the osteolysis inductor IL-6 values, reinforce the potential of this superior wear-resistant composite for future orthopedic applications, when compared to traditional UHMWPE. Monteiro and Faro25 evaluated the functional independence of 34 aged individuals with fractures, at admission, discharge and more than one month after their return home. They also checked on the relation ship between functional independence and demographic and health variables. The motor and total functional independence scores increased at discharge, but decreased one month after their returning home. Functional impairment increased with age and also with longer length of stay. Hypothyroidism was related to cognitive impairment, while dementia and depression were related to motor impairment. The critical problem of infections related to orthopedic surgery
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was covered in two articles. Ercole et al. 26 evaluated the applicability of the National Nosocomial Infection Surveillance index for prediction of surgical site infection in orthopedic surgeries and to propose an alternative index. The study involved a historical cohort of 8,236 patients who had been submitted to orthopedic surgery. The incidence of infection was 1.41%. Prediction models were evaluated and compared to the National Nosocomial Infection Surveillance index. The proposed model was not considered a good predictor of infection, despite moderately stratified orthopedic surgical patients in at least three of the four scores. The alternative model scored higher than the National Nosocomial Infection Surveillance index in the prediction of infection. Ercole et al.27 endeavored to identify risk factors associated with surgical site infections in orthopedic surgical patients at a public hospital in Minas Gerais, Brazil, between 2005 and 2007. A historical cohort of 3,543 patients was submitted to orthopedic surgical procedures. A descriptive analysis was conducted and surgical site infection incidence rates were estimated. The incidence of surgical site infection was 1.8%. Potential surgical wound contamination, clinical conditions, time and type of surgical procedure were statistically associated with infection. Identifying the association between surgical site infection and these risk factors is important and contributes to nurses’ clinical practice. Bitar et al.28 conducted a study to histologically analyze allografts from cadaveric semitendinous muscle after cryopreservation at -80 degrees C in comparison to a control group kept at only -4 degrees C to test the hypothesis that the histological characteristics of the tissue are maintained when the tendons are kept at lower temperatures. No histological differences between the fresh and frozen samples were found in relation to seven variables.They conclude that semitendinous muscle tendon allografts can be submitted to cryopreservation at -80 degrees C without suffering histological modifications. Dogan et al.29 investigated the effectiveness of 850-nm gallium arsenide aluminum (Ga-As-Al) laser therapy on pain, range of motion and disability in subacromial impingement syndrome in 52 patients randomly assigned into a laser therapy or a placebo group, which received sham laser therapy. Initially cold pack (10 minutes) was applied to all of the patients. An exercise program including range of motion, stretching and progressive resistive exercises was also prescribed. No significant differences were recorded between the groups, indicating that the low-level laser therapy seems to have no superiority over sham laser therapy in reducing pain severity, range of motion and functional disability. Jannini et al.30 determined the prevalence of pain, musculoskeletal syndromes and orthopedic disorders as related to using computers and playing videogames among 100 obese adolescents matched to 100 healthy-weight controls using a confidential, self-report questionnaire covering demographic data, sports participation, painful musculoskeletal system symptoms and using computers and playing videogames. Pain and musculoskeletal syndromes were equally prevalent in both groups, but orthopedic disorders, tight quadriceps and genu valgum were more prevalent in obese adolescents. Median computer time was lower among the obese subjects who were less likely to play handheld videogames. Pain was more frequent among females and was associated with more time spent playing on Sundays.Programs developed specifically for obese female
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adolescents with musculoskeletal pain are needed. Burke et al.31 evaluated posture and postural control among 66 elderly women with and without osteoporosis, according to their bone mineral density. Osteoporosis patients swayed at higher velocity on a stable surface with open eyes and fell more than controls. The postural control in elderly women with osteoporosis differed from that of the controls, with higher sway velocity and maximum displacement of COP. Despite postural abnormalities such as hyperkyphosis and forward head, the COP position was posteriorized. Finally, orthopedic nursing was the subject of four articles. Almeida et al.32 endeavored to validate four nursing outcomes’ indicators of the Nursing Outcomes Classification presented by patients in postoperative of orthopedic surgery. An instrument containing the outcome indicators Self-care Activities of Daily Living, Bathing, Hygiene and Oral Hygiene was built, along with a Likert scale ranging from 1 to 5 (1 = not important, 5 = extremely important). Out of the 34 indicators studied, 2 were considered as main temporary indicators, 22 as secondary temporary indicators and 10 were discarded. The main and secondary temporary indicators will be used during the bathing observation of patients in postoperative of Total Hip Replacement, and their development will be monitored. Cameron et al.33 identified some undergraduate nursing students’ imaginary manifestations concerning themselves and care delivered to patients with orthopedic and/or trauma disorders. The Sociopoetic method was used and 15 undergraduate students were tested. Data revealed that care provided by orthopedic nursing students is the result of a care relationship that emerges from their sensitivity toward patients and their own knowledge, skills and attitudes. The orthopedic treatment, equipment and procedures to which patients are submitted cause important emotional distress, empathic behavior and encourage students to search for ways to minimize their patients’ pain. Cameron et al.34 examines the role that vision plays as an instrument for holistic and quality nursing care. This is a qualitative, exploratory study, using the Sociopoetic method. The data was categorized as follows: (1) Vision as an instrument and (2) Outer body changes. In trauma and orthopedics, nurses should be able to provide patients with care in complex conditions and in an environment, which changes fast. Results show that vision is a powerful health care instrument in trauma and orthopedic nursing, promoting professional practice that is truly appropriate to the patients’ needs. De Abreu Almeida et al.35 mapped the 52 nursing care actions prescribed for orthopedic patients onto Self-care Deficit: bathing and/or hygiene, Impaired Physical Mobility and Risk for Infection, according to the Nursing Interventions Classification (NIC). The study used the Delphi Technique as the content validation method, considering a level of 70% of agreement among experts. Data were analyzed through descriptive statistics. Twenty-two experts validated the mapping of 51 nursing care actions onto 56 NIC interventions in two rounds. The objective was achieved because only one mapped care action did not reach the established level of agreement. None of the mapped care actions reached 100% consensus, which evidences the various possibilities of comparison and the importance of validation studies. Acta Ortop Bras. 2012;20(6): 367-71
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