Improved function and strength in patients with knee osteoarthritis as a result of adding a two-day educational program to usual care. Prospective randomized trial.

Objective: The primary aim was to quantify the improvements on function and pain of patients with knee osteoarthritis (KOA), short education and low income by a two-day self-management program. Secondary aims were verifying if the program improves clinically relevant measures of weight and strength. Design: A prospective randomized clinical trial was conducted in a tertiary hospital in Brazil with 191 patients with Kellgren & Lawrence grades II and III KOA who were allocated to two groups: control (usual care- CG) and intervention (usual care and two days of an OA self-management program with a multiprofessional team - IG). Western Ontario and McMaster Universities Index (WOMAC), weight, body mass index (BMI), Timed up and go (TUG) and five Times Sit to Stand Test (FTSST) were assessed at baseline, six, 12 and 24 months. Results: Groups were similar at baseline (p â€‹> â€‹0.05). Both groups exhibited improved WOMAC total and subsets scores throughout the study (p â€‹< â€‹0.001). However, only IG improved WOMAC total and subsets in all follow-ups above 20% (minimally clinically important difference), with differences in WOMAC pain, function and total scores (p â€‹= â€‹0.001, p â€‹< â€‹0.001, and p â€‹< â€‹0.001, respectively) and best effect sizes at 1 year (0.355, 0.651 and 0.770, respectively). IG group lost weight (p â€‹< â€‹0.001) and BMI (p â€‹< â€‹0.01). Both groups exhibited improvements in TUG and FTSST (p â€‹< â€‹0.001) that remained in all evaluations. FTSST results favored the IG, p â€‹= â€‹0.032. Conclusions: An educational program to patients with KOA, short schooling and low income improves clinically important measures of pain and function.

Osteoid osteoma of the glenoid: Arthroscopic treatment.

Osteoid osteoma is a benign tumor that is rarely found in the scapula. We report a clinical case involving a 36-year-old female patient who suffered from progressive pain in her right shoulder for 1 year. This patient was initially diagnosed with impingement syndrome and was treated unsuccessfully with medication and physical therapy for approximately 2 months. Based on imaging exams, a juxta-articular osteoid osteoma of the glenoid was identified. The patient underwent a shoulder arthroscopy that included tumor removal and treatment of the resulting chondral lesion. At 6-, 12- and 36-month assessments, the patient was asymptomatic, with a normal range of motion and experienced a pain intensity corresponding to 0 points on the Visual Analog Scale (VAS) and 35 points on the University of California, Los Angeles (UCLA) Scale. A postoperative MRI indicated the absence of any residual tumor tissue or inflammatory signs. We believe that the approach described in this paper allows juxta-articular osteoid osteomas to be accessed in a minimally invasive manner and permits not only adequate resection but also the treatment of chondral lesions that could remain after tumor resection.

Sequential dose-dense Doxorubicin and Ifosfamide in advanced soft-tissue sarcoma patients in an out-patient-basis schedule.

Aims. This phase II study explored activity/safety of front-line dose-dense chemotherapy in high-grade STS (soft tissue sarcoma) patients and tested ezrin as prognostic factor. Patients and Methods. The protocol consisted of three cycles of doxorubicin (DOXO) 30 mg/m(2) on days 1-3 every 2 weeks, followed by three cycles of ifosfamide (IFO) 2.5 g/m(2) two hours a day on days 1-5 every 3 weeks, with GCSF support. Ezrin was assessed immunohistochemically. Results. Twenty patients, 13 metastatic and 7 locally advanced, were enrolled. Median age was 39 years (25-60). Median dose intensities were 42 mg/m(2)/week and 3.6 g/m(2)/week for DOXO and IFO, respectively. Grade 3/4 toxicities occurred in 18 patients. Response rate was 15% (3 of 20) by RECIST. Patients younger than 45 years with locally advanced disease and synovial histology presented longer survival. A trend towards longer survival was observed among ezrin-positive patients. Conclusions. This dose-dense schedule should not be routinely used due to its high frequency of toxic events; however, a sequential strategy with DOXO and IFO may benefit selected patients and should be further explored with lower doses. The role of ezrin as a prognostic marker should be confirmed in a larger group of patients.

Increased EMG response following electromyographic biofeedback treatment of rectus femoris muscle after spinal cord injury.

OBJECTIVE: To study increases in electromyographic (EMG) response from the right and left rectus femoris muscles of individuals with long-term cervical spinal cord injuries after EMG biofeedback treatment. DESIGN: Repeated measure trials compared EMG responses before and after biofeedback treatment in patients with spinal cord injuries. MAIN OUTCOME MEASURES: The Neuroeducator was used to analyse and provide feedback of the EMG signal and to measure EMG response. SETTING: Department of Traumatic Orthopaedics, School of Medicine, University of São Paulo, Brazil. PARTICIPANTS: Twenty subjects (three men and 17 women), between 21 and 49 years of age, with incomplete spinal cord injury at level C6 or higher (range C2 to C6). Of these subjects, 10 received their spinal cord injuries from motor vehicle accidents, one from a gunshot, five from diving, three from falls and one from spinal disc herniation. RESULTS: Significant differences were found in the EMG response of the right rectus femoris muscle between pre-initial (T1), post-initial (T2) and additional (T3) biofeedback treatment with the subjects in a sitting position [mean (standard deviation) T1: 26µV (29); T2: 67µV (50); T3: 77µV (62)]. The mean differences and 95% confidence intervals for these comparisons were as follows: T1 to T2, -40.7 (-53.1 to -29.4); T2 to T3, -9.6 (-26.1 to 2.3). Similar differences were found for the left leg in a sitting position and for both legs in the sit-to-stand condition. CONCLUSIONS: The EMG responses obtained in this study showed that treatment involving EMG biofeedback significantly increased voluntary EMG responses from right and left rectus femoris muscles in individuals with spinal cord injuries.

The use of a modular titanium endoprosthesis in skeletal reconstructions after bone tumor resections: method presentation and analysis of 37 cases.

We analyzed 37 patients who underwent segmental wide resection of bone tumors and reconstruction with a modular titanium endoprosthesis at the Orthopaedic Oncology Group, between 1992 and 1998. Twelve patients were male and 25 were female, with a mean age of 30 years (9 - 81). The mean follow-up was 14 months (2 - 48). The diagnoses were: osteosarcoma (14 cases), metastatic carcinoma (10), Ewing's sarcoma (4), giant cell tumor (4), malignant fibrous histiocytoma (3), chondrosarcoma (1), and aneurysmal bone cyst (1). Eleven articulated total knee, 8 partial proximal femur with bipolar acetabulum, 8 partial proximal humerus, 3 total femur, 2 partial proximal tibia, 2 diaphyseal femur, 2 diaphyseal humerus, and 1 total proximal femur with cementless acetabulum endoprosthesis implant procedures were done. The complications related to the procedure included: infection (5 cases), dislocation (3), module loosening (1), and ulnar nerve paresthesia (1). We used the following criteria for the clinical evaluation: presence of pain, range of motion, reconstruction stability, surgical and oncologic complications, and patient acceptance. The results were good in 56.8% of the cases, regular in 32.4% and poor in 10.8%.

Influence of disease activity and chronicity on ankylosing spondylitis bone mass loss.

We investigated 30 consecutive Brazilian patients with definite ankylosing spondylitis (AS) fulfilling the New York and the European spondyloarthropathy study group classification criteria. The mean age at study was 37 years old and the mean disease duration was 17 years. Bone densitometry employed the dual-energy X-ray absorptiometry (DEXA) technique, using a Hologic QDR-1000/W densitometer. Axial bone mineral density (BMD) was measured in the lumbar spine (L1-L4) and appendicular BMD was measured in the total proximal femur and sub-regions (neck, greater trochanter, intertrochanter and Ward's triangle). Based on World Health Organisation criteria, the lumbar spine showed osteopenia or osteoporosis in 50% of the patients, while 86% had osteopenia or osteoporosis in the total proximal femur. When compared with the normal population, the patients showed a significant BMD decrease in the lumbar spine and total proximal femur with sub-regions, except for the femoral neck. A comparison of BMD between patients with active and inactive disease did not reveal a significant effect of clinical disease activity on the lumbar spine and total proximal femur with sub-regions, except for Ward's triangle. Concerning disease chronicity, there were significant positive correlations between disease duration and lumbar spine, total proximal femur, greater trochanter and intertrochanteric regional BMD. This false increase in lumbar spine BMD found mostly in patients with long standing AS was due to the presence of paravertebral calcification and ossification. We conclude that the bone mass loss in AS is better evaluated in the proximal femur, because of the greater sensitivity of bone densitometry in this region, which is almost free of artefacts.

Activity of intraarterial carboplatin as a single agent in the treatment of newly diagnosed extremity osteosarcoma.

BACKGROUND: Chemotherapy has dramatically improved the rates of cure and survival of patients with localized and metastatic osteosarcoma. Nonetheless, the number of chemotherapeutic agents active against osteosarcoma is limited to doxorubicin, cisplatin, high-dose methotrexate, and ifosfamide. Carboplatin, a cisplatin analogue, has been tested as a single agent in patients with recurrent osteosarcoma or as part of multiagent chemotherapy in newly diagnosed patients. PROCEDURE: We tested the activity and toxicity of two cycles of intraarterial carboplatin as a "window therapy" (600 mg/m2 per cycle) in 33 consecutive patients with extremity osteosarcoma before the start of multiagent chemotherapy. Response was based on clinical (tumor diameter, local inflammatory signs, and range of motion) and radiological parameters (plain local films and arteriographic studies prior to drug administration). RESULTS: Patients' age ranged between 8 and 18 years (median age 13 years). Primary tumor originated from the femur (15 patients), tibia (10 patients), fibula (4 patients), humerus (3 patients), and calcaneus (1 patient). Only 7 patients (21%) had metastatic disease at diagnosis (5 in the lung and 2 in other bones). A favorable clinical and radiological response was documented in 81% and 73% of the patients, respectively. Clinical and radiological progression occurred in 12% and 9% of the patients, respectively. Seventeen of the patients remain alive and disease-free. Survival and event-free survival at 3 years for nonmetastatic patients are 71% (SE = 9%) and 65% (SE = 9%), respectively; for metastatic patients, the figures are 17% (SE = 15%) and 14% (SE = 13%), respectively. CONCLUSIONS: We conclude that carboplatin is an active agent in the treatment of newly diagnosed extremity osteosarcoma.

[Osteoblastoma: analysis of the treatment of 24 cases]. / Osteoblastoma: análise do tratamento de 24 casos.

The authors study 24 patients with the histologic diagnosis of osteoblastoma treated from 1953 to 1996, with a mean follow-up of 33.4 months. Two were considered as a malignant osteoblastoma. Twenty-two cases were operated, and in 2 of these was performed only a selective embolization to pelvic and spine localization. It was discussed clinical and radiographic aspects and the response to treatment. It was obtained 20 good and 4 poor results.

[Current status of the treatment of high grade bone sarcomas]. / Momento atual do tratamento dos sarcomas ósseos de alta malignidade.

The authors present a review of the changes occurred in the treatment of high grade bone sarcomas in the last 20 years. It was discussed the multidisciplinary approach for the local and systemic control of these tumors particularly the neoadjuvant chemotherapy that leads to an increase in the overall survival not only for the osteosarcoma but also for the Ewing sarcoma. They showed the possibilities for limb reconstruction after wide resection of the lesion that includes non conventional endoprosthesis and allografts.

[Surgical approach to giant cell tumors of the distal radius]. / Abordagem cirúrgica do tumor de células gigantes da extremidade distal do rádio.

The authors review 15 patients with giant cell tumor of the distal part of the radius in the period from 1980 to 1993. Pain was always present. The treatment of stage 2 with marginal resection and methylmethacrylate yielded excellent result. In the treatment of stage 3 the authors emphasize the need of wide resection. In these patients the best functional results were obtained with the use of vascularized proximal epiphyseal fibular graft, preserving some painless mobility of the wrist and forearm.

[The use of hydroxyapatite in the surgical treatment of benign non aggressive bone lesions]. / O emprego da hidroxiapatita no tratamento cirúrgico das lesões ósseas benignas não agressivas.

The authors studied, in the period 1990-1993, 31 patients with benign non aggressive bone lesions, surgically treated with intralesional resection followed by the introduction of hydroxyapatite. Their follow-up was two years and one month. The authors discussed the surgical indications, the operative technique employed, and the post-operative results which were considered to be good in 29 of the patients studied. Occurred complications in three patients: local infections in two and sterile fistula in one. It is concluded that the use of hydroxyapatite is a good option as substitute of the autologous bone graft.

Chondromyxoid fibroma: a study based on 18 cases.

The authors report on 18 cases of chondromyxoid fibroma seen at the Institute of Orthopedics and Traumatology, University of São Paulo, from 1953 to 1990. A survey of the literature on chondromyxoid fibromas was conducted and radiographic analysis of all cases is presented, with a mean follow-up of 64 months. The surgical treatment employed in each case is discussed, with emphasis on the use of cement as an adjuvant. This procedure was used in 10 patients, who have been free of recurrence up to the present time.

[Surgical treatment of malignant bone neoplasms at level of the knee with wide resection and reconstitution with non-conventional endoprosthesis]. / Tratamento cirúrgico dos tumores ósseos malignos ao nível do joelho através da ressecção ampla e reconstituição com endoprótese não convencional.

Forty-five patients with malignant bone tumors of the knee were submitted to wide resection and reconstitution of the joint with a custom made endoprosthesis. The mean follow-up was seven years and seven months. There were observed nine complications: in four cases the tumor recurred locally and in one case an artery was injured. The end result was considered good in 36 patients and poor in nine patients. The better results achieved in recent years were due to modifications introduced in chemotherapy for the osteosarcoma, the new system of staging of the bone tumors and new oncological and compartmental surgical techniques.

Intrauterine diagnosis of congenital dislocation of the knee.

The authors present a case of congenital dislocation of the knee diagnosed in utero, when an abdominal radiograph was performed on a woman in the eighth month of pregnancy.

Consideracoes sobre osteocondrite dissecante do joelho. / Dissecating osteochondritis of the knee

Os autores analisam 16 casos de osteocondrite dissecante, fazendo comentarios sobre fatores etiologicos, achados clinicos, radiologicos, artroscopicos e cirurgicos.Sua opiniao a respeito do tratamento e cirurgica, sendo realizados os seguintes procedimentos: 1) exerese isolada do fragmento livre; 2) exerese do fragmento livre associada a tecnica de esponjizacao; 3) fixacao do fragmento desprendido com cavilhas osseas. Finalmente, descrevem a tecnica cirurgica e suas indicacoes e os resultados a curto prazo