1 - Osteoarthritis of the knee

A degenerative knee condition is a disability, both by pain and by functional ch

anges that determine. It installs itself especially after the age of forty and i
s four times more common in females. The gonarthrosis has direct repercussions o
f the socio-professional. One way to remedy this problem is through the total kn
ee arthroplasty. This is an elective surgical procedure designed to reduce pain
and motor impairment. The knee joint is the largest and most complex joint in th
e body. It is a synovial joint - is characterized by a capsule lined with a syno
vial membrane that secretes a lubricant (synovial fluid), synovial joint movemen
ts occur between two sliding surfaces lubricated - ginglymus - a convex surface
fits into a concavity and movement is limited to flexion and extension only in o
ne plane. The knee joint put in contact the distal femur, posterior surface of t
he patella and proximal tibia and stability necessary limitation of motion depen
d on strong thigh muscles and ligaments. The adaptation of bone surfaces is done
by two semilunar cartilage (meniscus) that are connected by the transverse liga
ment. The menisci contribute to the smooth sliding of the tops of bone during fl
exion and knee extension and deaden the action of rotation of the femoral condyl
es on the tibia. The knee joint is designed to provide mobility and stability, i
t lengthens and shortens the functional leg to raise and lower the body, or to m
ove the foot in space. In conjunction with these functions, the knee joint also
serves as a weight-bearing body, a role which carries throughout the ages, a hug
e tear, which may be increased due to certain factors, as are the activity and o
besity, affecting the onset of arthritis. 2
Cartilage is the tissue of the joints noble, and has the following functions:
dampen the mechanical pressures; Ensure the slide from moving parts; Protect
the integrity of joint structures. The cartilage injury causes a change in mech
anical joints, leading to a progressive and degenerative process. Osteoarthritis
is also known as degenerative joint disease, osteoarthritis, hypertrophic arthr
itis, osteoarthritis or arthritis senile. According BOGLIOLO (1982, p.976) arthr
osis this is an eminently chronic degenerative disease of the joints mobile (fro
m diartroses), especially the knee and vertebrae (which support more weight), wh
ich starts at the articular cartilage then extends to all structures ended by de
stroying it completely.
1.1 - ETIOLOGY
Can be several causes of arthritis. Osteoarthritis can start with an anomaly of
the cells that synthesize the components of cartilage. There may be an abnormal
growth of bone at the edges of the joint, forming swellings that might interfere
with the normal functioning of the joint and cause pain. With aging will emerge
in the joint deterioration level of all its components, such as bone, joint cap
sule, synovial membrane, tendons and cartilage. Apart from these it is known tod
ay that also the excess work done by the joint may be a determinant of the onset
of osteoarthritis. According BOGLIOLO (1982, p.976), the genesis of osteoarthri
tis should be considered two factors: (1) the intensity and duration of pressure
force, (2) resistance of cartilage and subchondral bone plate. The intensity an
d duration of pressure force supported by cartilage depend on the intensity of f
orce and the area over which it operates. For this reason, two elements are impo
rtant, if not as factors capable of producing at least as adjuvant arthritis or
aggravating circumstances: the simple increase in body weight and reducing the a
rea over which acts the force of pressure. Examples of osteoarthritis by increas
ing the pressure is 3
overuse of a particular joint (the knee by a football player), congenital or acq
uired diseases of the joints (malformations, deviation of the knee valgus or var
us) modifying the pressure distribution on the articular surface. The pressure i
s not spreading over the entire length of the articular surface, eg due to devia
tion of the knee, is to exercise only on the femoral condyles. The result is ear
ly degeneration of the condyle subject to work load, preservation and on the oth
er. On the other hand, arises when osteoarthritis reduces the resistance of cart
ilage and subchondral bone. Occurs mainly in joint diseases that affect the nutr
ition and vitality of the joint,€that cause early degeneration (arthrosis). This
group includes the cases of idiopathic osteoarthritis. The gonarthrosis appear
in most cases without detectable cause, but in some cases precise causes are:
The genu valgum (deviation from leg to off) - The output shaft thus created caus
es the transfer of weight to the magazine outside of the knee, it follows the pr
emature wear of the cartilage at this level, where external femorotibial arthros
is. The genu varum (deviation of the leg inside) - the difference is reversed
and is complicated by an internal femorotibial arthrosis. The GENU recurvatum
(offset forward) and GENUM FLESSUM (change back) can also be generators of osteo
arthritis of the knee. extensive lesions of the apparatus of the knee - A recu
rrent dislocation of the patella and patellar subluxation external may be respon
sible for osteoarthritis fémororrotuliana in the same way that the fractures of
the patella. Rarer causes - They are the meniscal neglected, articular fractur
es, the consequences of arthritis of the knee, osteochondritis dissecans of the
knee. Classification etiopathogenesis of Gonatroses There are several classifica
tions, however one of the most used is the one adopted by the Committee of diagn
ostic criteria and treatment of the American Rheumatism Association 1983 that th
e etiopathogenic viewpoint considers two major groups: 4
The primitive or primary osteoarthritis of unknown cause, is based on degenerati
ve joint phenomena that begin after the second decade and progresses with advanc
ing age. Osteoarthritis may result from minor trauma, infection, previous fractu
res, another type of arthritis (like rheumatoid arthritis), the stress placed on
the joints of obese, over-load they have to bear, or the erosion of joints foll
owing occupations (the case of coal mining and pugilism). According to the autho
r PHIPPS (2003, pp. 2231), there may also be genetically predisposed to developi
ng osteoarthritis.
IMPACT Women are more severely by the disease, although incidence rates are the
same in men and women. Men usually develop symptoms before 43 years of age, wome
n generally develop symptoms only after age 55. Women often develop osteoarthrit
is in their hands and knees, while men typically develop osteoarthritis in the h
ips, knees and spine. (Phipps, 2003 pp. 2231) research suggests a genetic compon
ent in the development of osteoarthritis, since there is a mutation of the gene
that directs the formation of collagen type II in families of people with the di
sease. Osteoarthritis is also common among postmenopausal women. Women who take
estrogen replacement appear to have a lower risk of developing the disease, sugg
esting that estrogen may have a protective effect on cartilage. (Phipps, 2003 pp
. 2231)
5
1.2 - PATHOPHYSIOLOGY
In a normal joint, the tops that make up bone are covered by an elastic material
, the cartilage, which absorbs the impact of the bones in motion and allows smoo
th sliding thereof.
Figure n.1 - Articulation normal knee
The gonarthrosis is a disease of the articular cartilage of the knee. Normally,
this cartilage is white, translucent and smooth. When affected by the disease, i
t becomes yellow and opaque. Certain areas of the cartilage degenerates, and the
surface becomes rough, worn and split. It is believed that this occurs by diges
tion of cartilage by enzymes, and alteration of the nutrition of cartilage.
Figure n.2 - Installation progressive gonarthrosis
6
Finally, it is destroyed and the subchondral bone undergoes a remodeling process
. Lips joint and binding sites of support structures, appear a kind of new bone
spurs, called osteophytes. These appear in the margins of the joint and local su
pport structure or connection, they may break in the articular cavity and appear
s as bone nodules.
Figure n.3 - complete deterioration of cartilage, with formation of osteophytes
1.3 - SINTOMATOLOGIA
According to Leal (2001, p.35), the predominant symptom is pain in osteoarthriti
s and may have location varies depending upon the affected joint. It represents,
in general, an early and progressive in its most characteristic form, is caused
primarily or even exclusively by motion or overuse of the joint, ending the hom
e to settle the problem. People seek medical care due to pain, usually described
as deep in the joint. Climate change and increased activity tend to increase th
e pain. The loss of movement in the joint may be caused by loss of articular car
tilage, muscle spasm,€shortening of the ligaments and bone spurs, loss of articu
lar cartilage and subchondral bone can lead to joint subluxation and deformity.
As the joint degenerates, one can refer to decreasing mobility and sensation of
crushing and pressure.
7
Joint pain, leads the patient to avoid using the joint, with resultant weakening
of the muscles that lead to greater instability contributes to the progressive
worsening of the situation (deformation). (Phipps, 2003 pp. 2232) The pain, whic
h is kind of mechanical, relieved by rest and worsens when descending the stairs
. Are still the following clinical features: Joint instability Deviations
axial muscular atrophy syndrome patellar Lock joint stiffness, which progr
esses very slowly and is accompanied by pain; Increase the volume of the joint
, which can be produced by productions bone; Deformation of the knees, knees i
n the so-called "o" forming arc; Pain when pressing certain points of articula
tion; joint noises (clicks) on the drive; slight to moderate limitation of f
lexion and extension which tends to increase with the development of pathology.
However, many patients do not mention any of these symptoms despite x-rays show
advanced arthritis of the joints.
1.4 - EVOLUTION
There arthrosis which evolve very slowly and almost without pain, there are othe
rs that worsen quickly. Therefore the development of osteoarthritis is highly va
riable. The development of gonarthrosis is slow, irregular and unpredictable. Di
sability causes a painful, slowly progressive, decreasing the functional capabil
ities of 8
individual, causing changes throughout the joint complex, and may even lead to j
oint destruction. Lesions osteocartilaginous osteoarthritis of the knee worsen s
lowly, but on average, bilateral. The pain initially is often intermittent and u
nilateral, bilateral and permanent thereafter. Sometimes the pain is compounded
by synovial inflammation. In most cases, the state of the clinical activity is c
onsistent with a nearly satisfactory, impotence rarely reaches a state in which
patients require hospitalization.
1.5 - MEDIA DIAGÓSTICO
In the diagnosis of osteoarthritis of the knee are taken into account the sympto
ms reported by the patient, highlighting the characteristics, duration and locat
ion of pain. If the clinical examination of affected joints is not sufficient, c
ertain diagnostic aids such as radiographs (radiographic evidence of decreased j
oint space, osteophytes and bone sclerosis) and the TAC, can reveal changes in t
he bones and joints typical of the disease. Serological examinations and synovia
l fluid are essentially normal. The synovial fluid is clear or pale yellow with
a low count of leukocytes, 500-2000 cells/mm3. Arthroscopy is not necessary for
the diagnosis of osteoarthritis, but is useful because it allows direct visualiz
ation of the articular surface.
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1.6 - TREATMENT
Although there is no cure for gonarthrosis, appropriate treatment can relieve sy
mptoms, improve functional capacity and quality of life and prevent or correct j
oint problems more severe. The patient's knowledge about their disease represent
s, as in almost all forms of arthritis, a major element in determining the outco
mes of treatment. Teaching the disease process and the measures to control himse
lf is the most important aspect in terms of nursing care. Treatment should be ta
ilored to each particular case depending on the severity of the situation, natur
e of symptoms, age, occupation and daily activities. Collaboration informed pati
ent is essential to the success of the therapeutic program.
Treatment methods include: • Therapeutic
There is a wide variety of drugs that can relieve the symptoms of osteoarthritis
, which causes in some cases may have to try several until you identify the most
effective. simple analgesics: there are, in many cases, sufficient to ensure an
effective relief and are generally well tolerated. anti-inflammatory drugs: the
y are sometimes necessary, but entail greater risk than analgesics, especially t
o the stomach. Help to reduce pain, stiffness and joint swelling. Intra-articula
r injection of steroids, in the case of severe malaise.
10
•
Joint protection
Is to prevent the affected joints are subjected to excessive force, capable of i
ncreasing pain or aggravate the disease. The patient can learn to perform curren
t tasks in a more tolerable and appropriate. The use of splints to support or ca
ne may be sometimes€extremely beneficial and is important to use correct posture
at work and at leisure, as well as certain types of chair and mattress, and sho
uld seek to keep the ideal weight.
•
Physical exercise
A program of regular exercise is essential in controlling osteoarthritis. Withou
t it, the joints tend to become more painful and stiff, your muscles weaker and
the patient's condition worsens progressively. The exercise program should be ta
ilored to each particular case. It is suggested that sometimes a physical therap
y, in which patient education is an essential element.
•
Rest
The patient must balance home and work, correctly.
•
Application of heat and cold
Are effective ways to decrease pain and stiffness, even temporarily. A hot bath
in the morning can significantly improve pain and there are many different ways
to apply heat to painful areas. Applying cold helps reduce the tenderness.
•
Weight Management
Is an element of utmost importance, since the excessive weight requires an addit
ional effort of the joints affected.
11
•
Surgery
In the treatment of advanced arthrosis, surgery is arguably one of the most rewa
rding advances in modern orthopedics. Cleaning articular (removal of foreign bod
ies in the meniscus, the osteocytes, the synovium, patella) can give good result
s. The artrósede (joint locking) rarely practiced. The total prosthesis (joint r
eplacement) is a recent intervention, yet rarely practiced due to lack of kickba
ck that is available. In secondary osteoarthritis of the deviations of the leg i
s necessary to correct the misalignment of a corrective osteotomy. The results o
n pain are very good but the mobility remains more or less stable in the same wa
y that the radiological signs. Arthrosis in the so-called primitive (without a d
etectable cause), medical treatment has a preponderant place: associates a knee
savings by deleting the long marches and standing positions for prolonged bed re
st and many times a day and a drug treatment based on aspirin and glafenina or,
sometimes, in indomethacin or phenylbutazone. The infiltrations intra - articula
r cortisone should used with caution because they aggravate the wear of the cart
ilage and extreme aseptic precautions to avoid infection.
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2 - KNEE ARTHROPLASTY
For MOLITOR (1989, p.7), arthroplasty is "a term that applies to any type of sur
gery, resulting in an artificial joint." It is a surgery that aims to restore th
e maximum integrity and functionality of the joint and restore the function of m
uscles and ligaments. The knee arthroplasty implant is a procedure in which the
tibial and femoral joint are replaced, because the knee joint is severely destro
yed. This type of surgery is indicated in patients with severe destruction of th
e knee resulting from traumatic arthritis or degenerative arthritis, or destruct
ion of only the medial or lateral compartments of the knee resulting from deform
ity. The objectives of arthroplasty are:

Restore movement and stability of the knee; Retrieve the function of muscles and
ligaments; Correcting deformities; Relieve pain.
2.1 - TYPES OF ARTHROPLASTY
The knee arthroplasty can be classified into partial or total arthroplasty. Part
ial arthroplasty is commonly used in patients with changes only in one half of t
he knee, internal or external. These cases is indicated at 13
unicondiliana knee arthroplasty, which consists of a metal femoral condyle that
articulates with a tibial component. This technique is a compromise between the
tibial osteotomy (corrective intervention knee) and total knee replacement. In t
he case of younger patients, active adult or the elderly are not sedentary, is i
ndicated for a knee reconstruction process called osteotomy. A hip replacement i
s the total knee replacement as their joint surfaces are worn. It is a type of s
urgery is indicated in patients with a painful and disabling joint, and usually
with a relatively inactive lifestyle.
Figure n.4 - Total knee arthroplasty
As regards MEEKER (1997, p.772), "the majority of authors believe that the moder
n era of total knee replacement date of 1971, with the development of a prosthes
is minimally restraining re biomechanical considerations."
Types of hip replacement
A hip replacement can be divided into: excision arthroplasty - is the removal
of the damaged joint surfaces and immobilized in order to reduce pain and increa
se range of
14
movements because it reduces the tension of joint movements. The very nature rec
onstructs the capsule and the articular surfaces from the fibrous tissue. This m
ethod has some disadvantages such as prolonged immobilization after surgery, the
joint instability and limb shortening.
Arthroplasty grafts - involves the redevelopment of both the articular surface
s and are used grafts of various types of materials. The most commonly used are:
metal (stainless steel and alloys), high molecular weight polyethylene, ceramic
s and polymers elastic flexible. The joint replacements can be fixed with cement
(polymethyl crilato) or fixed with a special porous coating that promotes bone
growth for fixation within the implant surface. The choice of method of fixation
and the type of implant depends on the willingness of the bone, age and activit
y level of the patient and the surgeon's familiarity with the specific technique
. Arthroplasty graft is designed to prevent instability and limb shortening resu
lting from excisions. Its main disadvantage is related to sepsis, since the pres
ence of foreign bodies in the body hinders the control of infection. According M
EEKER (1997, p.773), the total knee implant can be classified into three differe
nt categories, according to portions of the knee to be replaced - unicompartment
al implants, and biocompartimentais tricompartimentais. Unicompartmental implant
s are used to replace only one opposite the articular surface (medial or lateral
) of the femur and tibia. However, these implants have lost popularity in recent
years due to trapping and biomechanical techniques. Represent less than 10% of
all total knee replacements performed in the United States. Projects biocomparti
mentais mentioned only to demonstrate the progression of the project total knee
replaced the medial and lateral surfaces of the femur and tibia. This implant de
sign is almost completely rejected as a technique for knee replacement.
15
Implants tricompartimentais replace not only the opposite femorotibial joint, bu
t also the patellofemoral joint. Most total knee replacements performed today is
of this type. Knees tricompartimentais divided into three categories: unicompar
tmental knee, knee and total knee pleading.
Figure No. 5 - Implants knees tricompartimentais
2.1.1. Types of prostheses
The prosthesis is a mechanical piece of metal alloy designed to replace a bone a
nd / or a joint. The level of the knee is used after appropriate preparation of
the distal femur and proximal tibia and patella, is fixed by fitting, as precise
ly that there is complete restoration of the joint. The prostheses of the knee a
re the "hinge". These can be classified according to the degree of rotation, thu
s:

Prostheses constricting - knee stability is entrusted to the prosthesis. This ha

s the disadvantage of only allowing movement in one plane, 16
there is therefore no rotation, and allowing the metal to metal contact on the a
rticular surfaces. Eg Stanmore prosthesis this is a simple hinge with rods for s
pinal fixation.
Figure No. 5 - example of a prosthesis constrictive

Prostheses semi-constricting - only a part is by metallic, being filed with a fl

exible substance.
Eg Prosthesis Freeman - have a metal femoral component that articulates with a p
olyethylene tibial component. These are indicated in patients few assets (+ 70 y
ears) due to the forces of pressure they are subjected. These allow a bending un
til 90th.

Prostheses not constricting - stability is entirely dependent on the knee ligame

nts allowing a greater degree of rotation.
According to Olivier and Guire (1994), knee implants can be further classified i
nto three different categories according to the portions of the knee to be repla
ced: unicompartmental prostheses - are used to replace only one opposite the a
rticular surface of the femur and tibia; bicompartimental prosthetics - are us
ed for total knee replacement, however this type of prosthesis has been rejected
lately.
17
tricompartimentais-Prostheses are also used to replace the joint femorotibial
opposite the patellofemoral joint. Currently the total knee replacements are of
this type. In view of Cabot et. al. 1996 may be considered four types of prosthe
ses for replacement of damaged articular surface of the knee: uni prosthesis; to
tal condylar replacement prosthesis;€posterior stabilized prosthesis, prosthetic
replacement of collateral ligaments.
2.2 - COMPLICATIONS OF ARTHROPLASTY
This surgery, although a success of 97% at 10 years and improve the comfort and
quality of life of patients, is not free of complications beyond the advantages
it presents. The complications that may arise from an arthroplasty or intraopera
tive or postoperative surveillance of nurses require in order to evade early com
plications. Possible complications can be divided into clinical complications, m
echanical complications and infections. Clinical complications include cardiac a
rrhythmias, myocardial infarction, hematoma that occurs due to malfunction of th
e suction drains and due to anticoagulant therapy, nerve damage - are uncommon c
omplications in which the patient has paresthesias, deep vein thrombosis - the f
ormation is of a thrombus in the vein due to anticoagulant therapy and venous st
asis, pain occurs when walking, cyanosis of the extremity, swelling and local he
at;
18
pulmonary embolism, which causes chest pain, tachycardia, dyspnea, cyanosis, and
hyperventilation; fat embolism; Reaction to cement because the cement can sprea
d into the bloodstream during cementation of the prosthesis, leading to a transi
ent hypotension, or you can lead to an embolism, which can become serious if not
treated.
Mechanical complications include: fractures (fracture of the acetabulum, which i
s a technical complication that can occur during preparation of the acetabular c
avity); loosening and wear of the joints; dislocation of the prosthesis, which c
an occur due to poor placement of the prosthesis.
The infection is a catastrophic complication that often requires additional surg
ery to remove the prosthesis, a prolonged hospitalization and higher financial e
xpenses.
2.3 - CARE NURSING
The nursing care provided to patients undergoing knee replacement surgery can be
divided into nursing: preoperative ; postoperative; preparation for discha
rge.
19
Nursing Care in Preoperative Objectives: • • Preparation physical and psycholo
gical; Teach the patient developing activities postoperatively.
Shares nursing Establish presentation of the health team, as well as their ser
vice to the patient; Establish an empathic relationship with the patient so th
at he can express their fears, doubts and fears; Communicate effectively at or
der to achieve understanding and cooperation of the patient; Explain to patien
t intervention that you will be subject, informing him about the type of prosthe
sis that will be applied; Prepare patient for the effects of anesthesia can ex
pect that will be subject, as well as arthroplasty; inform the patient about t
he care that should have after surgery, particularly in relation to the position
taken in the postoperative period; Prepare patient for rehabilitation; teac
h breathing exercises the patient as well as, to cough effectively, to prevent p
ulmonary stasis after surgery; Explain to the patient relaxation exercises, wh
ich will allow for better control of pain; teach some useful exercises such as
isometric contractions quadricípide and hamstrings; education of gait with
crutches since early in the postoperative period the march will be held in unloa
ding; 20
muscle stimulation in order to minimize muscle atrophy from disuse, which will
inevitably arise in the postoperative period; People with underlying illnesse
s such as diabetes mellitus or respiratory failure should be hospitalized a few
days before the intervention to be evaluated ; Assess and record vital signs;
Explain to patient the importance of complementary exams; Perform urine test
to screen for outbreaks of infection according to prescription; Perform blood
collection according to the prescription; Weigh the patient and if necessary
provide dietary information; Perform bowel preparation the patient; Inform t
he patient that should keep fasting for at least 8 hours before surgery; Make
trichotomy enlarged and make the skin preparation zone to be interventional
Nursing in Postoperative The postoperative hospital usually lasts two weeks, v
arying however with the evolution of the patient and to the release from hospita
l. Watch closely the patient after surgery in order to early detect any compli
cation; Perform monitoring of vital signs from 15 to 15 minutes in the first h
ours€evaluate the pattern and respiratory airways, as well as detecting early si
gns of shock; Using other measures of pain relief, such as placing ice on the
knee, 30 minutes before and 30 minutes after the exercise of active flexion; d
o surveillance of the intestinal patient, if the second or third day after surge
ry this still does not work you should report this to the doctor;
21
Before mobilization, the nurse should direct the patient in some exercises, in
cluding lifting the leg in extension and flexion when the knee is about 50 and 7
0 degrees, the patient should try to start the march, the march should be init
iated between 2 and 5 days after the intervention (according to the surgeon);
Teach the patient to move initially with the stroller and then with crutches, re
lying as much as possible in the joint; If the patient is unable good flexion
with active exercise should be used ropes and pulleys or an exercise machine con
tinuous passive if still there is a good progression may then be required mobili
zation under anesthesia; Points must be removed between the 14th and 16th days
, as wound healing; The patient should return to the query within about 4-6 we
eks;
Preparation for High Inform the patient that must not impose excessive burde
n on the State; Advise the patient to keep the limb elevated operated upon to
prevent swelling; Inform the patient that should continue to make joint mobili
zation active knee flexion to gain. It will be ideal to obtain a bending of abou
t 90 ° before the three weeks; highlight the importance of exercise through ph
ysical therapy, swimming, stationary bicycle to increase range of motion and str
engthen muscles; advise the patient to correct gait in front of the mirror, as
well as the posture correction; barring certain activities, including avoidin
g kneel or make sudden movements, to observe at least two months; Tell the pat
ient that must be made to training difficulties and obstacles of the day to day
is like, travel on slopes, sitting and standing; The nurse should also give so
me useful advice to the patient: 22
use crutches for long journeys; avoid wearing high heels;
3 - REFERENCES
•
ADAMS, John Crawford. Manual of Orthopaedics, Medical Arts, 8th edition, 1978.
• •
BOGLIOLO, Luigi, Handbook of Pathology, 3rd ed., Guanabara Koogan, 1982.
CARVALHO, Fernando, et. al, nursing care for patients undergoing total knee arth
roplasty, vital signs, Coimbra, No. 47, March, 2003.
•
LEAL, Manuel LM Studies of Levels of Functional Independence of patients with Go
narthrosis After Total Knee Arthroplasty. Vital Signs, Coimbra, No. 39, November
, 2001.
•
Luckman, SORENSEN, Medical-Surgical Nursing, 4th ed., Rio de Janeiro: Guanabara
Koogan, vol.2, 1996.
•
MEEKER, Margaret Huth et al, Nursing the Surgical Patient, Rio de Janeiro: Guana
bara Koogan, 10th edition, 1997.
23
• •
MOLITOR, Peter (1989). Arthroplasty. Nursing, Oct., 21.
PHIPPS, Wilma, et. al. Medical-surgical nursing - concepts and clinical practice
, 6th ed., Lisbon: Lusociência, 2003.
•
RYCKEWANT, A. et al Huesos y Articulación, Barcelona: Editorial Espaxs, 1973, IS
BN - 84 - 7179-049 - 1.
•
RABOURDIN, Jean - Pierre et al. Great Medical Encyclopedia. Lisboa / São Paulo:
Editorial Verbo, 1974, Vol IV.
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