Patellar Tilt and Patellar Tendon-Trochlear Groove Angle Present the Optimum Magnetic Resonance Imaging Diagnostic Reliability for Patients With Patellar Instability.

PURPOSE: To describe, in controls and in a population with patellar instability, magnetic resonance imaging values of measurements representing major associated factors for patellar instability (patellar height, trochlear dysplasia, and extensor mechanism alignment), as well as their cutoff values. METHODS: In total, 323 knee magnetic resonance imaging scans, 142 with patellar instability and 181 controls without patellofemoral complaints (anterior cruciate, medial collateral ligament, meniscus ruptures or normal) were evaluated. Means, normality values in the control population, ideal cutoff values through receiver operating characteristic curves analysis, and interobserver reliability (intraclass correlation coefficient) were described for a series of measurements. RESULTS: All measurements were statistically different in control and instability patients, except for the patellotrochlear index and tibial tuberosity to posterior cruciate ligament distance. The interobserver intraclass correlation coefficient was good or excellent (above 0.75) only for the patellotrochlear index, patellar tendon-trochlear groove (PTTG) angle, and patellar tilt. The optimal cutoff value for each measurement was: PTTG angle ≥25.3o with sensitivity (S) of 70% and specificity (E) of 89%, patellar tilt ≥16o (S: 69% and E: 84%), trochlear sulcus angle ≥153o (S: 75% and E: 76%), Carrillon ≤12.8o (S: 62% and E: 87%), PTTG distance ≥11mm (S: 71% and E: 78%), Caton-Deschamps index ≥1.23 (S: 72% and E: 76%) and trochlear bump ≥3.95 mm (S: 76% and E: 65%). CONCLUSIONS: Caton-Deschamps index (≥1.23), trochlear sulcus angle (≥153o), ventral prominence of the trochlea (≥3.95 mm), PTTG distance (≥11 mm), PTTG angle (≥25.3o), Carrillon angle (≤12.8o), and patellar tilt (≥16o) presented better diagnostic performance for patellar instability. Patellotrochlear index and tibial tuberosity to posterior cruciate ligament distance were not related to patellar instability. The interobserver reliability of the factors related to patellar instability was excellent only for the PTTG angle and lateral patellar tilt. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

Blood loss and allogeneic transfusion for surgical treatment of periprosthetic joint infection: a comparison of one- vs. two-stage exchange total hip arthroplasty.

PURPOSE: The purpose of the current study was to compare the blood loss and the need for allogeneic transfusion after one- and two-stage exchange arthroplasty for periprosthetic joint infection (PJI) of THA. METHODS: We performed a retrospective review of all patients undergoing either one-stage or two-stage septic exchange arthroplasty at two high-volume infection referral centres. The study cohort consists of 90 patients undergoing the two-stage and 184 patients the one-stage exchange arthroplasty. The difference between pre- and post-operative haemoglobin (Hb) and total blood loss as well as the allogeneic transfusion rate were compared between both groups. RESULTS: Both procedures together of the two-stage septic exchange arthroplasty had higher intra-operative blood loss and allogeneic blood transfusion rate compared to the one-stage septic exchange arthroplasty group. However, among the patients of the two-stage group, there were more smokers and had worse physical status (ASA) and higher mortality risk (CCI) than patients in the one-stage group. CONCLUSIONS: Two-stage septic revision of total hip arthroplasty has higher rates of blood loss and transfusion rates than one-stage revision. Therefore, the authors believe that blood loss rate, including its complications, should be considered when decision for the type of staged septic exchange is made.

How Reliable Is the Cell Count Analysis in the Diagnosis of Prosthetic Joint Infection?

BACKGROUND: Synovial analysis of joint aspirates is a key diagnostic tool; all major diagnostic algorithms include cell count (CC) and polymorphonuclear percentage (PMN%) as important criteria to make the diagnosis. In this context, we conducted this study to analyze the overall accuracy of CC and PMN%. METHODS: A single-center retrospective analysis was performed with clinical data of included patients, with a total of 524 preoperative joint aspirations (255 hips, 269 knees). From the aspirated synovial fluid, we tested the leukocyte esterase activity, leukocyte CC, and PMN%, and sent specimens for aerobic and anaerobic bacterial culture. Depending on the clinical results in accordance with the Musculoskeletal Infection Society criteria for prosthetic joint infection (PJI), 203 patients were then admitted for aseptic revision and 134 patients for septic exchange. RESULTS: In 337 cases (64.3% of the study patients), it was possible to measure the CC. The best cutoff level for PJI of all study patients was 2582 leukocytes/µL (sensitivity [SE] 80.6%, specificity [SP] 85.2%) and a PMN% of 66.1% (SE 80.6%, SP 83.3%). The chosen cutoff levels for PJI of total knee and total hip arthroplasty were 1630 leukocytes/µL (SE 83.6%, SP 82.2%) and a PMN% of 60.5% (SE 80.3%, SP 77.1%) and 3063 leukocytes/µL (SE 78.1%, SP 80.0%) and a PMN% of 66.1% (SE 82.2%, SP 82.4%), respectively. CONCLUSIONS: CC and PMN% are sensitive methods for diagnosing PJI of total hip and total knee arthroplasty. However, there are differences in cutoff levels between knees and hips. International guidelines and diagnostic criteria need revisions in terms of these parameters.

Femoral condyle osteochondral fracture treated with bone suture after acute patellar dislocation: a case report.

Osteochondral fracture after acute patellar dislocation in teenagers is relatively common (up to 60% of cases of patellar dislocation), but poorly diagnosed. There are several treatments proposed for this type of injury, but none well defined in the literature. A male patient, 13 years old, with a diagnosis of osteochondral fracture of the lateral femoral condyle after acute dislocation of the right patella. He underwent surgical treatment of the chondral injury, which consisted of suturing of the chondral fragment to the cartilage defect and, in a second approach, reconstruction of the medial patellotibial ligament and medial patellofemoral ligament with autologous flexor graft. Currently, the patient has been followed up for 16 months postoperatively for the suture of the chondral fragment and for 8 months for the ligament reconstruction. He has been evaluated through functional scores and T2 weighted magnetic resonance imaging. Acute fixation through direct bone suturing of a purely chondral fragment can be considered in special situations.

A fratura osteocondral após luxação aguda de patela em adolescentes é relativamente comum (até 60% dos casos de luxação patelar), porém pouco diagnosticada. Existem diversos tratamentos propostos para esse tipo de lesão, mas nenhum está bem definido na literatura. Paciente do sexo masculino, 13 anos, com diagnóstico de fratura osteocondral do côndilo femoral lateral, após luxação aguda da patela direita. Foi submetido a tratamento cirúrgico da lesão condral, que consistiu em sutura do fragmento condral ao defeito da cartilagem e, em um segundo tempo, a reconstrução do ligamento patelotibial medial (LPTM) e reconstrução do ligamento patelofemoral medial (LPFM) com enxerto autólogo de flexores. Atualmente o paciente encontra-se com o seguimento de 16 meses de pós-operatório da sutura do fragmento condral e oito meses da reconstrução ligamentar, foi avaliado através de escores funcionais e ressonância magnética com mapeamento de T2. Em casos especiais, pode-se considerar o uso de fixação aguda por sutura óssea direta de um fragmento puramente condral.

Knee arthroplasty with rotating-hinge implant: an option for complex primary cases and revisions.

OBJECTIVE: To present the indications, technical aspects, and initial results of the first cases using Endo-Model™ implants in Brazil. METHODS: A prospective study was conducted. It included nine patients submitted to a total knee arthroplasty, of which six were primary and three were revisions, using exclusively the Endo-Model™ implant. These patients were followed for an average of 12 months and evaluated with functional scores, such as the Knee injury and Osteoarthritis Outcome Score (KOOS), Knee Society Score (KSS), and visual analog pain scale (VAS). RESULTS: There were statistically significant improvements in all scores evaluated in every patient. Only one complication occurred postoperatively (apraxia of the peroneal nerve) and did not require surgery revision. CONCLUSION: The use of a rotating-hinge implant for knee arthroplasty is a new option for complex cases with severe instability in Brazil; the initial results are satisfactory.

OBJETIVO: Apresentar as indicações, os aspectos técnicos e os resultados iniciais dos primeiros casos do uso do implante constrito Endo-Model® no Brasil. MÉTODOS: Foi conduzido um estudo prospectivo que incluiu nove pacientes submetidos a artroplastia total de joelho, seis primárias e três revisões, exclusivamente com o implante Endo-Model®. Esses pacientes foram acompanhados por uma média de 12 meses e avaliados com os escores funcionais do Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Society Score (KSS) e escala visual analógica de dor (EVA). RESULTADOS: Todos os escores avaliados apresentaram melhorias estatisticamente significantes em todos os pacientes. Somente uma complicação pós-operatória foi observada (apraxia do nervo fibular), sem necessidade de revisão da cirurgia. CONCLUSÃO: O uso de implante em dobradiça rotatória em artroplastia de joelho é uma nova opção para casos complexos com instabilidade grave no Brasil, com resultados iniciais satisfatórios.

Variants in endothelial nitric oxide synthase (eNOS) gene in idiopathic infertile Brazilian men.

PURPOSE: In recent years, considerable concern has been expressed about the deleterious effects of reactive oxygen species (ROS) on sperm function, because ROS at high levels is potentially detrimental to sperm function and quality. Nitric oxide (NO) is a powerful anti-oxidant present in seminal plasma. The aim of the study was to analyze the distribution of the of endothelial nitric oxide synthase (eNOS) gene (T-786C, G894T, e 4a/b) polymorphisms in idiopathic infertile Brazilian men and evaluate the possible role of these polymorphisms in sperm count. METHODS: A case-control study was performed comprising 208 infertile men [n=74 with non-obstructive azoospermia and n=134 with severe oligozoospermia] and 201 fertile men as controls. Genotyping of eNOS polymorphisms was performed by real time (T-786C and G894T) and conventional PCR (4a/b). The results were analyzed statistically and a p-value<0.05 was considered significant. RESULTS: According to the sperm count, relatively similar eNOS polymorphism genotypes and allele frequencies were found among the groups. Combined genotypes of the eNOS polymorphisms did not identify a haplotype associated with idiopathic infertility, even when the patients were separated in non-obstructive azoospermia or severe oligozoospermia. CONCLUSION: In conclusion, the findings demonstrate that, in Brazilian population studied, genetic variations, T-786C, G894T, and e 4a/b, of the eNOS gene are not associated with male infertility.

Femoral condyle osteochondral fracture treated with bone suture after acute patellar dislocation: a case report / Lesão condral do fêmur tratada com sutura óssea após luxação aguda de patela: um relato de caso

ABSTRACT Osteochondral fracture after acute patellar dislocation in teenagers is relatively common (up to 60% of cases of patellar dislocation), but poorly diagnosed. There are several treatments proposed for this type of injury, but none well defined in the literature.A male patient, 13 years old, with a diagnosis of osteochondral fracture of the lateral femoral condyle after acute dislocation of the right patella. He underwent surgical treatment of the chondral injury, which consisted of suturing of the chondral fragment to the cartilage defect and, in a second approach, reconstruction of the medial patellotibial ligament and medial patellofemoral ligament with autologous flexor graft. Currently, the patient has been followed up for 16 months postoperatively for the suture of the chondral fragment and for 8 months for the ligament reconstruction. He has been evaluated through functional scores and T2 weighted magnetic resonance imaging. Acute fixation through direct bone suturing of a purely chondral fragment can be considered in special situations.

RESUMO A fratura osteocondral após luxação aguda de patela em adolescentes é relativamente comum (até 60% dos casos de luxação patelar), porém pouco diagnosticada. Existem diversos tratamentos propostos para esse tipo de lesão, mas nenhum está bem definido na literatura. Paciente do sexo masculino, 13 anos, com diagnóstico de fratura osteocondral do côndilo femoral lateral, após luxação aguda da patela direita. Foi submetido a tratamento cirúrgico da lesão condral, que consistiu em sutura do fragmento condral ao defeito da cartilagem e, em um segundo tempo, a reconstrução do ligamento patelotibial medial (LPTM) e reconstrução do ligamento patelofemoral medial (LPFM) com enxerto autólogo de flexores. Atualmente o paciente encontra-se com o seguimento de 16 meses de pós-operatório da sutura do fragmento condral e oito meses da reconstrução ligamentar, foi avaliado através de escores funcionais e ressonância magnética com mapeamento de T2. Em casos especiais, pode-se considerar o uso de fixação aguda por sutura óssea direta de um fragmento puramente condral.

Knee arthroplasty with rotating-hinge implant: an option for complex primary cases and revisions / Artroplastia de joelho com implante constrito e rotatório: uma opção para casos complexos primários e de revisão

ABSTRACT Objective: To present the indications, technical aspects, and initial results of the first cases using Endo-Model™ implants in Brazil. Methods: A prospective study was conducted. It included nine patients submitted to a total knee arthroplasty, of which six were primary and three were revisions, using exclusively the Endo-Model™ implant. These patients were followed for an average of 12 months and evaluated with functional scores, such as the Knee injury and Osteoarthritis Outcome Score (KOOS), Knee Society Score (KSS), and visual analog pain scale (VAS). Results: There were statistically significant improvements in all scores evaluated in every patient. Only one complication occurred postoperatively (apraxia of the peroneal nerve) and did not require surgery revision. Conclusion: The use of a rotating-hinge implant for knee arthroplasty is a new option for complex cases with severe instability in Brazil; the initial results are satisfactory.

RESUMO Objetivo: Apresentar as indicações, os aspectos técnicos e os resultados iniciais dos primeiros casos do uso do implante constrito Endo-Model® no Brasil. Métodos: Foi conduzido um estudo prospectivo que incluiu nove pacientes submetidos a artroplastia total de joelho, seis primárias e três revisões, exclusivamente com o implante Endo-Model®. Esses pacientes foram acompanhados por uma média de 12 meses e avaliados com os escores funcionais do Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Society Score (KSS) e escala visual analógica de dor (EVA). Resultados: Todos os escores avaliados apresentaram melhorias estatisticamente significantes em todos os pacientes. Somente uma complicação pós-operatória foi observada (apraxia do nervo fibular), sem necessidade de revisão da cirurgia. Conclusão: O uso de implante em dobradiça rotatória em artroplastia de joelho é uma nova opção para casos complexos com instabilidade grave no Brasil, com resultados iniciais satisfatórios.

Genetic variants in fibrinolytic system-related genes in infertile women with and without endometriosis.

AIMS: The aim of this study was to evaluate urokinase-type plasminogen activator gene (uPA) and thrombin-activatable fibrinolysis inhibitor gene (TAFI) genotypes in a group of infertile women with and/or without endometriosis and controls. METHODS: A case-control study comprising 180 infertile women with endometriosis, 68 women with idiopathic infertility, and 152 fertile women as controls was carried out. Detection of uPA (C422T/rs2227564) and TAFI (G438A/rs2146881) polymorphisms was performed by TaqMan polymerase chain reaction. The results were statistically analyzed and a p-value of <0.05 was considered significant. RESULTS: We found no association among both uPA or TAFI polymorphisms and endometriosis-related infertility (p=0.920 and p=0.356, respectively) or idiopathic infertility (p=0.502 and p=0.392, respectively) comparing to controls, even considering minimal/mild and moderate/severe endometriosis separately. Both uPA and TAFI polymorphisms were in Hardy-Weinberg equilibrium for all studied groups. The combinatory analysis of both uPA and TAFI polymorphisms to endometriosis-related infertility, idiopathic infertility, and control group showed no statistical difference to any combination. CONCLUSION: The data suggest that, in the Brazilian population, genetic variations in both uPA and TAFI were not relevant to endometriosis and/or infertility.