SELF-MANAGEMENT PROGRAM (PARQVE) IMPROVES QUALITY OF LIFE IN SEVERE KNEE OSTEOARTHRITIS.

Objective: To evaluate the effects of the self-management program PARQVE in patients with severe knee osteoarthritis (KOA). Methods: Prospective randomized controlled clinical trial with 65 grade IV Kelgren & Lawrence (K&L) KOA patients who were allocated into groups: Control (CG) and Intervention (IG). Both groups received usual care. IG also participated in two days of multi-professional interventions about OA (causes and treatment) and received the program's DVD and book. Standing X-rays were obtained at inclusion and Ahlback's classification was registered. Western Ontario and McMaster Universities Index (WOMAC), Numerical Rating Scale (NRS), Lequesne, weight, and body mass index (BMI) were obtained at inclusion, and after 6, 12 and 24 months. Results: Groups were similar at baseline, despite higher WOMAC stiffness scores and a greater number of Ahlback's grade 4 and 5 in the IG. Only the IG improved WOMAC and total functions (p<0.001) during the study period above 12%, but did not reach the minimal clinically important difference of 20%. Best results were in one year. Non-significant improvements were observed without changes in body composition (P>0.05). Conclusions: Patients with severe KOA have mild to moderate function and quality of life improvement due to self-management program (PARQVE). Level of Evidence I; Therapeutic Studies; Prospective Randomized Controlled Trial.

Objetivo: Avaliar os efeitos do programa de autocuidado PARQVE em pacientes com osteoartrite grave de joelho (OAJ). Métodos: Ensaio clínico prospectivo randomizado controlado com 65 pacientes Kelgren & Lawrence (K&L) grau IV que foram alocados nos grupos: Controle (GC) e Intervenção (GI). Ambos os grupos receberam cuidados habituais. O IG também participou de dois dias de intervenções multiprofissionais sobre OA (causas e tratamento) e seus membros receberam o DVD e o livro do programa. Raios-X em pé foram obtidos na inclusão e a classificação de Ahlback foi registrada. Western Ontario e McMaster Universities Index (WOMAC), Escala de classificação numérica (ECN), Lequesne, peso e índice de massa corporal (IMC) foram obtidos na inclusão, e aos 6, 12 e 24 meses. Resultados: Os grupos eram semelhantes no início do estudo, apesar de maiores escores de rigidez WOMAC e um número maior de pacientes de Ahlback grau 4 e 5 no GI. Apenas o GI melhorou em WOMAC e função total (p <0,001) acima de 12% durante o período de estudo. Os melhores resultados foram após um ano. Melhorias não significativas foram observadas na composição corporal (P> 0,05). Conclusões: Pacientes com OAJ grave apresentam melhora leve a moderada de função e qualidade de vida pelo programa de autogerenciamento (PARQVE). Nível de Evidência I; Estudos Terapêuticos; Estudo Clínico Prospectivo e Randomizado.

EVALUATION OF MANAGEMENT OF PATIENTS WITH OSTEOPOROTIC FRACTURES BY ORTHOPEDIC RESIDENTS: A CROSS-SECTIONAL OBSERVATIONAL STUDY.

Objective: To assess whether residents (R1, R2, or R3 - according to the year of residency) of a tertiary orthopedic service investigate, treat and/or refer the patient with osteoporotic fracture for osteoporosis (OP) treatment and whether this learning is improved over the years of residency. Methods: Residents answered diagnostic and therapeutic questions related to a clinical case of osteoporotic fracture (OF) in 4 settings, which were initial care in the emergency room, at discharge, during outpatient follow-up at 3 and 6 months. Responses were compared between years of residency. Results: Twenty R1, 21 R2, and 19 R3 raised the questions. One resident treated osteoporosis in R1, two in R2, and four in R3. Seventy-five percent of R1, 90.5% of R2, and 68% of R3 referred patients for OP treatment. Over the years, there has been improved prescribing lab tests for osteoporosis (p = 0.028), with 52.6% of third-year residents prescribing adequate lab tests. In the same period, 100% of R3 correctly prescribed prophylaxis for deep vein thrombosis (p = 0.001). Conclusion: There is learning, but not enough, for secondary prevention of FO. Level of Evidence I; Prospective Comparative Study.

Objetivo: Avaliar se residentes (R1, R2 ou R3 - de acordo com o ano de residência) de um serviço ortopédico terciário, investigam, tratam e/ou encaminham o paciente com fratura osteoporótica para tratamento de osteoporose (OP) e se esse aprendizado é melhorado ao longo dos anos de residência. Métodos: Os residentes responderam a questões diagnósticas e terapêuticas relacionadas a um caso clínico de fratura osteoporótica (OF) em 4 cenários, que foram o atendimento inicial no pronto-socorro, no momento da alta hospitalar, durante o acompanhamento ambulatorial em 3 e 6 meses. As respostas foram comparadas entre os anos de residência. Resultado: Vinte R1, 21 R2 e 19 R3 levantaram as questões. Um residente tratou osteoporose em R1, dois em R2 e quatro em R3. Setenta e cinco por cento de R1, 90,5% de R2 e 68% de R3 encaminharam pacientes para tratamento com OP. Há melhora na prescrição de exames laboratoriais para investigação de osteoporose ao longo dos anos (p = 0,028) com 52,6% dos residentes do terceiro ano que prescrevem exames laboratoriais adequados. No mesmo período, 100% de R3 prescreveram corretamente a profilaxia para trombose venosa profunda (p = 0,001). Conclusão: Há aprendizado, porém insuficiente, para a prevenção secundária da FO. Nível de Evidência I; Estudo Prospectivo Comparativo.

Pilot study of the effect of therapeutic photobiomodulation on postoperative pain in knee arthroplasty.

Nine participants undergoing primary TKA submitted to spinal anesthesia, sedation, ultrasound-guided obturator and Femoral nerve Block analgesia, and photobiomodulation Therapy (FBMT) were evaluated regarding postoperative pain and morphine consumption. FBMT sessions were performed in the Immediate Postoperative period (IPO) and after 24 hours. Participants received 16.7±15 mg of morphine up to the third postoperative day. At IPO, mean pain score was 4.8±3.2 and 5.6±3.5, at rest and on movement, respectively. Photo biomodulation therapy can be considered an option for mitigating pain for patients undergoing TKA.

BRAZILIAN CONSENSUS STATEMENT ON VISCOSUPPLEMENTATION OF THE KNEE (COBRAVI).

OBJECTIVE: The aim of this consensus statement on viscosupplementation is to serve as a reference document based on relevant literature and clinical experience in the treatment of knee osteoarthritis using an intra-articular injection of hyaluronic acid, covering key aspects such as clinical indications, effectiveness, and tolerability. METHODS: A multidisciplinary panel including two sports medicine physicians, six orthopedists, four physiatrists, and two rheumatologists were selected based on their clinical and academic experience of viscosupplementation. Sixteen statements were prepared and discussed, after which a vote was held. Each member of the panel gave a score between 0 and 10 on a Likert scale, specifying their level of agreement with the statement. RESULTS: The panel reached a consensus on several issues. Specifically, the panel agreed that the best indication is for mild to moderate knee arthrosis; prior or concomitant use of intraarticular triamcinolone hexacetonide may optimize the effect of hyaluronic acid; viscosupplementation should not be performed as an isolated procedure but in conjunction with other rehabilitative and pharmacological measures; viscosupplementation has analgesic, anti-inflammatory, and chondroprotective effects; and viscosupplementation is cost-effective. CONCLUSION: This consensus statement provides clear information and guidance for both individuals and payers. Level of evidence V, Consensus statement.

OBJETIVO: O Consenso Brasileiro de Viscossuplementação visa gerar uma fonte referencial e consensual, a partir de levantamentos bibliográficos relevantes, do conhecimento teórico e da experiência clínica de especialistas de áreas afins para tratamento de viscossuplementação na osteoartrite do joelho, mitigando pontos críticos desse procedimento, como via de aplicação, indicação, eficácia e tolerabilidade. MÉTODOS: Um painel multidisciplinar foi formado com dois médicos do esporte, seis ortopedistas, quatro fisiatras e dois reumatologistas, com base nas experiências clínica e acadêmica no uso da viscossuplementação. Foram elaboradas, discutidas e votadas 16 afirmativas. Cada membro do painel deu um valor entre zero e 10, em uma escala tipo Likert, especificando seu nível de concordância com a afirmação. RESULTADOS: O painel chegou a um consenso sobre diversos aspectos da viscossuplementação, com destaque para as seguintes afirmativas: a melhor indicação é para artrose de joelhos leve a moderada; o uso prévio ou concomitante de hexacetonido de triancinolona intra-articular pode otimizar o efeito do ácido hialurônico; a viscossuplementação não deve ser realizada como procedimento isolado no tratamento da OA, mas em conjunto com outras medidas reabilitadoras e farmacológicas; promove efeito analgésico; anti-inflamatório; condroprotetor; e é custo-efetiva. CONCLUSÃO: Este consenso traz informações claras e servirá, como guia tanto para médicos quanto para as fontes pagadoras. Nível de evidência V, Consenso de especialistas.

RANDOMIZED PROSPECTIVE STUDY ON THE TREATMENT OF FEMORO-PATELLAR OSTEOARTHRITIS USING BRACING.

OBJECTIVE: To compare the effect of a brace designed to stabilize the patellofemoral joint to that of a patella-shaped neoprene sleeve with patella cut out in patients with patellofemoral osteoarthritis. METHODS: Fifty-seven patients with femoro-patellar osteoarthritis were allocated to two groups: patients with femoro-patellar functional brace and those with a neoprene knee with a patellar orifice. Both groups underwent clinical treatment of osteoarthritis and used medications daily 1 month before and up to 3 months after brace placement. They were evaluated with the WOMAC and Lequesne questionnaires and performed five times sit to stand test, Timed Up and Go test, and six minutes walk test immediately before and 1 and 3 months after brace placement. RESULTS: Both groups had improved pain, stiffness, and function with no difference between groups. Drug use decreased in both groups in the first month but increased in the third month. Naproxen use was progressively higher in the control group. CONCLUSION: Both knee orthoses improved pain and function and altered drug use only in the first month. Functional knee brace provided analgesia without increased use of naproxen. Level of Evidence IB, Randomized clinical trial.

OBJETIVO: Comparar o efeito de uma órtese destinada a estabilizar a articulação fêmoro-patelar, em comparação com uma de neoprene com orifício para rótula, em pacientes com artrose fêmoro-patelar. MÉTODOS: Cinquenta e sete pacientes com artrose fêmoro-patelar foram alocados em dois grupos conforme a joelheira que receberam: órtese funcional fêmoro-patelar e joelheira de neoprene com orifício para patela. Ambos os grupos foram orientados sobre o tratamento clínico da osteoartrite e preencherem o consumo diário de medicamentos um mês antes da colocação das órteses e até três meses depois da colocação das mesmas. Foram avaliados com o questionário de WOMAC e Lequesne e realizaram os testes de senta e levanta, Timed-up-and-go e o teste de caminhada de seis minutos, nos momentos imediatamente antes da colocação da órtese e após um e três meses. RESULTADOS: Ambos os grupos melhoram dor, rigidez e função sem diferença entre os grupos. O consumo de medicamentos diminuiu em ambos os grupos no primeiro mês, aumentando no terceiro mês. O consumo de naproxeno foi progressivamente maior no grupo controle. CONCLUSÃO: Ambas as joelheiras melhoraram a dor, a função e alteraram o consumo de medicamentos somente no primeiro mês. A joelheira funcional propiciou analgesia sem consumo aumentado de naproxeno. Nível de evidência IB, Ensaio clínico randomizado.

PROFILE OF PATIENTS WITH OSTEOPOROTIC FRACTURES AND FACTORS THAT DECREASE PREVENTION.

OBJECTIVE: To evaluate the epidemiological profile of patients with osteoporotic fractures compared to patients with osteoarthritis (OA) and identify factors that diminish adherence to secondary prevention. METHODS: A total of 108 patients with osteoporotic fractures (OF) were compared to 86 patients with OA. RESULTS: Patients in the OF group were older (p < 0.001); had a lower body mass index (p < 0.001); were less literate (p = 0.012); were more frequently Caucasian (p = 0.003); were less frequently married (p < 0.001); experienced more falls, cognitive deficiency, previous fractures, old fracture, falls in the last year, and fall fractures; needed more help and took more medicine for osteoporosis (p < 0.05); and showed less pathology in the feet, muscle weakness, less vitamin D intake, and lower Katz & Lawton scores (p < 0.001). Factors that increased the chance of nonadherence included older age (p = 0.020), falls (p = 0.035), cognitive deficiency (p = 0.044), and presence of depression/apathy/confusion (p < 0.001). CONCLUSION: Patient age, ethnicity, marital status, previous falls, foot pathologies, muscle weakness, previous fractures, use of vitamin D, use of osteoporosis drugs, and lower Katz & Lawton scale score defined the OF group. Factors that increased the chance of nonadherence included older age, sedative use, cognitive disorders, and symptoms of depression/apathy/confusion. Level of Evidence III, Case-control.

OBJETIVO: Avaliar o perfil epidemiológico de pacientes com fraturas osteoporóticas, comparando com pacientes com osteoartrite (OA) e identificar fatores que diminuam aderência à prevenção secundária. MÉTODOS: 108 pacientes com FO foram comparados a 86 pacientes com OA. RESULTADOS: Grupo FO era mais velho (p< 0,001), com menor IMC (p<0,001), menos alfabetizado (p = 0,012), com maior frequência de brancos (p = 0,003), menor frequência de casados (p< 0,001). Apresentaram mais quedas, deficiência cognitiva, fraturas prévias, fratura antiga, queda no último ano, fraturas por queda. Necessitam de mais auxílio e tomam mais medicamento para osteoporose (p< 0,05); apresentaram menos patologia nos pés, fraqueza muscular. Tomam menos vitamina D e menor Katz & Lawton (p<0,001). Tem aumento da chance de não aderência: maior idade (p = 0,020), sedativo (p = 0,020), quedas (p = 0,035), deficiência cognitiva (p = 0,044) e presença de depressão/apatia/confusão (p< 0,001). CONCLUSÃO: Idade do paciente, etnia, estado civil, quedas prévias, patologias nos pés, fraqueza muscular, fraturas prévias, uso de vitamina D, uso de medicamentos para osteoporose e a escala Katz & Lawton definem o grupo FO. Aumentam a chance de não aderência: maior idade, sedativos, distúrbios cognitivos e sintomas de depressão/apatia/confusão. Nível de Evidência III, Estudo de caso controle.

Muscular and Functional Capacity in Subjects Under Treatment for Knee Osteoarthritis: Role of Physical Activity Status.

Background: The purpose of this study was to assess the role of physical activity (PA) in muscular and functional capacity in subjects under treatment for knee osteoarthritis submitted to an interdisciplinary educational program emphasizing the regular practice of PA and exercises. Methods: Subjects under treatment for primary knee osteoarthritis (N = 136; age = 66 [3]) were allocated in sedentary to sedentary (SED-SED, sedentary or insufficiently active at pre and post), active to sedentary (ACT-SED, active or very active at pre and sedentary or insufficiently active at post), sedentary to active (SED-ACT, sedentary or insufficiently active at pre and active or very active at post), and active to active (ACT-ACT, active or very active at pre and post) groups. Muscular capacity (isokinetic test), functional capacity (timed up and down stairs test, timed up and go test, and 5 times sit to stand test), and daily living PA (International PA Questionnaire short version) were assessed before and after (12 mo) the follow-up. Results: There were improvements in performance (P < .05) in the time to up and down stairs: 37% in SED-ACT and 27.5% in ACT-ACT; timed up and go test: 33.5% in SED-ACT, 19% in ACT-SED, and 40% in ACT-ACT; 5 times sit to stand test: 39% in SED-ACT and 51% in ACT-ACT groups after 12 months of follow-up. Conclusions: The present results suggest that high levels of daily living PA may have an important role in the prevention/management of knee osteoarthritis.

Educational program promoting regular physical exercise improves functional capacity and daily living physical activity in subjects with knee osteoarthritis.

BACKGROUND: Physical exercise and educational programs promote several benefits for patients with knee osteoarthritis (OA). However, little is known about the effects of educational programs promoting the regular practice of physical exercise. The purpose of the present study was to assess the effect of an interdisciplinary educational program, emphasizing the recommendation for regular practice of physical exercise, on functional capacity and daily living physical activity in individuals with knee OA. METHODS: Two hundred and thirty-nine individuals (50 men) with an established diagnosis of knee OA (degree I to IV in the Kelgreen and Lawrence scale) were randomly allocated into a multidisciplinary educational program (EDU; n = 112) or control group (CON; n = 127). Functional capacity (sit and reach, 6-min walking test (6MWT), timed up and down stairs test, timed up and go test (TUGT), and five times sit-to-stand test (FTSST)) and daily living physical activity (IPAQ, short version) were measured before, during (6 months) and after 12 months of follow-up. RESULTS: Body mass index reduced significantly (P < 0.05) after 6 months, and remained reduced after 12-month of follow-up in EDU, but not in CON. EDU group improved (P < 0.05) timed up and down stairs (19%), TUGT (32.5%) and FTSST (30%) performance after 6 months of follow-up, which remained improved after 12 months of follow-up. Functional capacity did not change in CON, excepted for the timed up and down stairs performance that increased after 6 months (12%, P < 0.05), but returned to levels similar to baseline after 12 months of follow-up. There was also an increase (P < 0.05) in the prevalence of active and very active individuals, as well as a reduction (P < 0.05) in the prevalence of sedentary individuals in EDU group during follow-up. There were no significant changes on sit and reach and 6MWT performance during follow-up in both groups. CONCLUSIONS: The results suggest that an educational program emphasizing the recommendation for regular practice of physical exercise may be an effective tool for improving functional capacity and daily physical activity in individuals with knee OA. TRIAL REGISTRATION: NCT 02335034 , December 22, 2014.

Effects of Motor Learning on Clinical Isokinetic Test Performance in Knee Osteoarthritis Patients.

OBJECTIVES:: To analyze the effects of motor learning on knee extension-flexion isokinetic performance in knee osteoarthritis patients. METHODS:: One hundred and thirty-six middle-aged and older sedentary individuals (111 women, 64.3±9.9 years) with knee osteoarthritis (130 patients with bilateral) and who had never performed isokinetic testing underwent two bilateral knee extension-flexion (concentric-concentric) isokinetic evaluations (5 repetitions) at 60°/sec. The tests were first performed on the dominant leg with 2 min of recovery between test, and following a standardized warm-up that included 3 submaximal isokinetic repetitions. The same procedure was repeated on the non-dominant leg. The peak torque, peak torque adjusted for the body weight, total work, coefficient of variation and agonist/antagonist ratio were compared between tests. RESULTS:: Patients showed significant improvements in test 2 compared to test 1, including higher levels of peak torque, peak torque adjusted for body weight and total work, as well as lower coefficients of variation. The agonist/antagonist relationship did not significantly change between tests. No significant differences were found between the right and left legs for all variables. CONCLUSION:: The results suggest that performing two tests with a short recovery (2 min) between them could be used to reduce motor learning effects on clinical isokinetic testing of the knee joint in knee osteoarthritis patients.

Effects of Motor Learning on Clinical Isokinetic Test Performance in Knee Osteoarthritis Patients

OBJECTIVES: To analyze the effects of motor learning on knee extension-flexion isokinetic performance in knee osteoarthritis patients. METHODS: One hundred and thirty-six middle-aged and older sedentary individuals (111 women, 64.3±9.9 years) with knee osteoarthritis (130 patients with bilateral) and who had never performed isokinetic testing underwent two bilateral knee extension-flexion (concentric-concentric) isokinetic evaluations (5 repetitions) at 60°/sec. The tests were first performed on the dominant leg with 2 min of recovery between test, and following a standardized warm-up that included 3 submaximal isokinetic repetitions. The same procedure was repeated on the non-dominant leg. The peak torque, peak torque adjusted for the body weight, total work, coefficient of variation and agonist/antagonist ratio were compared between tests. RESULTS: Patients showed significant improvements in test 2 compared to test 1, including higher levels of peak torque, peak torque adjusted for body weight and total work, as well as lower coefficients of variation. The agonist/antagonist relationship did not significantly change between tests. No significant differences were found between the right and left legs for all variables. CONCLUSION: The results suggest that performing two tests with a short recovery (2 min) between them could be used to reduce motor learning effects on clinical isokinetic testing of the knee joint in knee osteoarthritis patients.

Development of a Fresh Osteochondral Allograft Program Outside North America.

OBJECTIVE: To standardize and to develop a fresh osteochondral allograft protocol of procurement, processing and surgical utilization in Brazil. This study describes the steps recommended to make fresh osteochondral allografts a viable treatment option in a country without previous fresh allograft availability. DESIGN: The process involves regulatory process modification, developing and establishing procurement, and processing and surgical protocols. RESULTS: Legislation: Fresh osteochondral allografts were not feasible in Brazil until 2009 because the law prohibited preservation of fresh grafts at tissue banks. We approved an amendment that made it legal to preserve fresh grafts for 30 days from 2°C to 6°C in tissue banks. Procurement: We changed the protocol of procurement to decrease tissue contamination. All tissues were procured in an operating room. Processing: Processing of the grafts took place within 12 hours of tissue recovery. A serum-free culture media with antibiotics was developed to store the grafts. Surgeries: We have performed 8 fresh osteochondral allografts on 8 knees obtaining grafts from 5 donors. Mean preoperative International Knee Documentation Committee (IKDC) score was 31.99 ± 13.4, improving to 81.26 ± 14.7 at an average of 24 months' follow-up. Preoperative Knee Injury and Oseoarthritis Outcome Score (KOOS) score was 46.8 ± 20.9 and rose to 85.24 ± 13.9 after 24 months. Mean preoperative Merle D'Aubigne-Postel score was 8.75 ± 2.25 rising to 16.1 ± 2.59 at 24 months' follow-up. CONCLUSION: To our knowledge, this is the first report of fresh osteochondral allograft transplantation in South America. We believe that this experience may be of value for physicians in countries that are trying to establish an osteochondral allograft transplant program.

One-Year Results of an Educational Program on Osteoarthritis: A Prospective Randomized Controlled Trial in Brazil.

INTRODUCTION: Knee osteoarthritis (KOA) is the most prevalent form of osteoarthritis. Low socioeconomic level, age, and obesity are directly correlated with the incidence of the disease. Education, exercise, and diet are the core recommendations of all KOA treatment guidelines. OBJECTIVE: To evaluate the impact of a multiprofessional educational program on patients with KOA. METHODS: Of a total of 198 participants, 150 patients with KOA attended 2 days of lectures (at 1- to 3-month intervals) and received educational material on osteoarthritis, and a control group (48 patients) received educational materials only. Body mass index (BMI), frequency, and intensity of physical activity, pain, function, and quality-of-life scores were assessed at baseline and at 4 and 12 months after the educational program. Bimonthly telephone calls were made to half of the participants. Correlations between BMI, level of education, coping skills, functional, and pain results was procured. RESULTS: The groups were similar in terms of race, gender, affected side, and osteoarthritis severity. The results were not affected by the telephone calls or the patients' level of education. At baseline, 25 performed physical activity, whereas 123 performed at 1 year. Seventy-two (36.36%) patients decreased BMI (45 by 1 point and 27 by more than 2 points). There were some weak correlations such as BMI reduction with pain and functional improvements and with coping results. Significant improvements in function and quality of life were found at 4 months. Quality of life remained improved at 1 year. CONCLUSION: The effect of this educational program in function and quality of life of patients with KOA is very subtle. Interval between classes (1, 2, or 3 months) is not an important issue.

Objective functional results in patients with knee osteoarthritis submitted to a 2-day educational programme: a prospective randomised clinical trial.

BACKGROUND: Although education is recommended for the treatment of knee osteoarthritis (KOA), its effectiveness in osteoarthritis (OA) remains low according to subjective questionnaires. The timed-up-and-go (TUG) and five-times-sit-to-stand tests (FTSST) reflect muscle strength and balance and could be used as objective measures of effectiveness. AIM: To measure the effect of an educational programme in patients with KOA by TUG and FTSST and correlate these results to those of subjective questionnaires. METHODS: Prospective randomised controlled trial of patients with KOA. Participants (n=198) were allocated into four groups. Three groups participated in 2 days of lectures with 1 (group 1), 2 (group 2) and 3-month (group 3) intervals between classes. Group 4 had no classes. Participants were asked to exercise at least three times a week. Half of the patients from all groups received bimonthly telephone calls reinforcing diet and exercise instructions. All four groups received the printed and video material presented in the classes. At baseline and at 1 year after initial assessment, patients performed the FTSST and TUG and answered WOMAC, Lequesne, SF-36 and Visual Analogue Scale questionnaires. RESULTS: The TUG results did not change at 1 year follow-up, whereas FTSST improved (average difference of 4.66, p<0.001) irrespective of the implementation of classes or telephone calls. Both baseline and 1 year TUG and FTSST results correlated weakly (r<0.3) to the subjective functional, pain and quality of life results (p<0.001). CONCLUSIONS: This educational programme improved function as determined by lower limb muscle strength (FTSST) irrespective of the patients' subjective non-improvement. TRIAL REGISTRATION NUMBER: Clinical trials registration number: NCT01572051. LEVEL OF EVIDENCE: Level 1A.

Prevalence of osteoporosis in patients awaiting total hip arthroplasty.

OBJECTIVE: To evaluate the prevalence of osteoporosis in patients awaiting total hip arthroplasty. METHOD: Twenty-nine patients diagnosed with hip osteoarthritis awaiting primary total arthroplasty of the hip answered WOMAC questionnaire, VAS and questions about habits, osteoporosis and related diseases. Bone mineral densitometry of the lumbar spine and hips and laboratory tests (complete blood count and examination of calcium metabolism) were performed. Weight and height were measured to calculate body mass index (BMI). The evaluated quantitative characteristics were compared between patients with and without osteoporosis using the Mann-Whitney tests. RESULTS: Thirteen men and 16 women with a mean age of 61.5 years old, WOMAC 51.4; EVA 6.4 and BMI 27.6 were evaluated. The prevalence of osteoporosis was 20.7%, and 37.9% had osteopenia. Patients with osteoporosis were older than patients without osteoporosis (p=0.006). The mean bone mineral density of the femoral neck without hip osteoarthritis was lower than the affected side (p=0.007). Thirty-five percent of patients did not know what osteoporosis is. Of these, 30% had osteopenia or osteoporosis. CONCLUSION: osteoarthritis and osteoporosis may coexist and the population waiting for total hip arthroplasty should be considered at risk for the presence of osteoporosis. Level of Evidence III, Observational Study.

Subjective results of joint lavage and viscosupplementation in hemophilic arthropathy.

OBJECTIVE: To assess whether joint lavage, viscosupplementation and triamcinolone improve joint pain, function and quality of life in patients with severe hemophilic arthropathy. METHODS: Fourteen patients with knee and/or ankle hemophilic arthritis with and without involvement of other joints underwent joint lavage and subsequent injection of hylan G-F20 and triamcinolone in all affected joints. The patients answered algo-functional questionnaires (Lequesne and WOMAC), visual analog scale for pain (VAS) and SF-36 preoperatively, and at one, three, six and twelve months postoperatively. RESULTS: Sixteen knees, 15 ankles, 8 elbows and one shoulder were treated in 14 patients. Six patients had musculoskeletal bleeding [ankle (1), leg muscle (2) and knees (4)] at 3 months affecting the results. Pain did not improve significantly. Function improved (WOMAC p=0.02 and Lequesne p=0.01). The physical component of SF-36 improved at all time points except at 3 months, with best results at one-year follow-up (baseline = 33.4; 1 month = 39.6; 3 months= 37.6; 6 months 39.6 and 1 year = 44.6; p < 0.001). CONCLUSION: Joint lavage followed by injection of triamcinolone and hylan G-F20 improves function and quality of life progressively up to a year, even in severe hemophilic arthropathy. Level of Evidence IV, Case Series.

Arthroscopic partial anterior synovectomy of the knee on patients with haemophilia.

PURPOSE: This study assessed the results of two-portal knee arthroscopic synovectomy in terms of bleeding recurrence, knee function, quality of life (QOL), and radiographic staging in a prospective case series of patients with haemophilia. METHODS: Nine knees from eight patients (median age 16.1 years; range 9.6-25 years) with haemophilia and recurrent knee haemarthrosis were prospectively evaluated. Yearly recurrence of bleeding was evaluated once a year for 5 years postoperatively. Range of motion (ROM) and radiographic staging, as well as results of the short form (SF)-36 and subjective knee form of the International Knee Documentation Committee (IKDC) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaires, were evaluated before surgery and at the end of follow-up. RESULTS: Mean bleeding recurrence was significantly reduced during the 5-year follow-up period. Questionnaire results showed significant improvements (IKDC P = 0.015, WOMAC P = 0.011, and SF-36 P = 0.023), whereas ROM was not significantly affected. Arthropathy progressed from Arnold-Hilgartner radiographic stage III to stage IV (P = 0.0082). CONCLUSIONS: Two-portal knee arthroscopic synovectomy was effective at reducing bleeding recurrence and improving knee function and QOL in patients with haemophilia, but did not interrupt the progression of radiographic changes.

Posterolateral anatomical reconstruction restored varus but not rotational stability: A biomechanical study with cadavers.

BACKGROUND AND AIM: Lesions to the posterolateral corner (PLC) of the knee are rarely isolated injuries, and they are potentially devastating, leading to progressive chondral injury, with important functional impairment. The objectives of this biomechanical study were to evaluate angular deformation with two loads and considering four flexion angles of the knee, varus and external rotation and in three situations of integrity, reconstruction and injury of posterolateral knee structures. METHODS: The posterolateral structures of 10 cadaveric knees were submitted to three biomechanical assays: in the "intact condition", "injured", and "reconstructed". The technique used for the reconstruction was the one proposed by LaPrade et al., but with autografts of hamstring tendons instead. A device was designed to apply loads of 2 and 5Nm, with zero, 30°, 60° and 90° of knee flexion, in varus or in external rotation, measuring angular deformation with photogoniometry. RESULTS: The anatomical reconstruction of the PLC proposed here did restore varus stability in all flexion angles (p<0.005), but not rotational stability. External rotation deformation at 90° was similar in all test conditions. In knee extension, external rotation was stabilized only at 2Nm. At 60°, external rotation was partially stabilized (p<0.05). CONCLUSIONS: The anatomical PLC reconstruction using hamstring tendons restored varus but not external rotational stability. CLINICAL RELEVANCE: The reconstruction of posterolateral corner injuries with autologous allografts is very important for regions were tissue banks are not available. This technique may be a first step to achieve this goal.

Effect of hyaluronic acid on chondrocyte apoptosis.

OBJECTIVE: To determine the percentage of apoptotic cells in a contusion model of osteoarthritis (OA) and to assess whether intra-articular injection of high doses of hyaluronic acid (HA) immediately after trauma reduces chondrocyte apoptosis. METHODS: Forty knees from adult rabbits were impacted thrice with a 1 kg block released through a 1 meter tall cylinder (29.4 Joules). Subsequently, 2 mL of HA was injected in one knee and 2 mL saline in the contra-lateral knee. Medication were administered twice a week for 30 days, when animals were sacrificed. Specimens were prepared for optical microscopy exam and terminal deoxynucleotidyl transferase end labeling assay (TUNEL). RESULTS: The apoptosis rate in the contusion model was 68.01% (± 19.73%), a higher rate than previously described. HA significantly reduced the rate of apoptosis to 53.52% (± 18.09) (p <0.001). CONCLUSION: Intra-articular HA administration started immediately after trauma reduces impact-induced chondrocyte apoptosis rates in rabbits.

The natural history of the anterior knee instability by stress radiography.

OBJECTIVE: To analyze the anteroposterior displacement of the knee by means of stress radiography in individuals with unilateral anterior knee instability and relate to time of instability. METHODS: Sixty individuals with intact knees (control group) and 125 patients with unilateral anterior instability (AI group) agreed to participate in the study. Gender, age, weight, height, age at injury, time between injury and testing, and surgical findings are studied. Both groups are submitted to anterior and posterior stress radiographies of both knees. Anterior (ADD) and posterior displacement difference (PDD) were calculated between sides. RESULTS: In the control group ADD and PDD are in average, zero, whereas in the AI group ADD averaged 9.8mm and PDD, 1.92mm. Gender, age, weight, height, age at trauma and presence of menisci's lesions do not intervene in the values of ADD and PDD. Meniscal injuries increase with time. ADD and PDD do not relate with the presence or absence of associated menisci's lesions. The ADD and the PDD are related to each other and increase with time. CONCLUSION: There is a permanent anterior subluxation of the injured knee that is related to the amount of anterior displacement that increases with time. Level of Evidence III, Study Types Case-control study.

Obesity, ostearthritis and clinical treatment.

OBJECTIVE: To evaluate the relationship between BMI and pain and function in patients with OA undergoing medical treatment following OARSI recommendations. METHODS: Thirty-eight patients were classified according to their arthritis degree by X-ray and body mass index (BMI). All patients completed the WOMAC, Lequesne, and visual analogue pain scale (VAS) questionnaires at baseline and after six months treatment. All patients were treated with diacerhein and analgesics (according to pain), orthotics (when indicated), and an educational program on osteoarthritis. They were instructed on balanced diet and exercise at least three times a week. RESULTS: There was no significant BMI variation in this study. The higher the initial BMI, the lower the improvement in pain (p = 0.03). Pain did not improve significantly (p = 0.2). Function improved (p <0.001) in inverse ratio to the initial BMI. CONCLUSION: BMI determines how patients will improve pain and function.