Prevalence and Classification of Injuries of Anterolateral Complex in Acute Anterior Cruciate Ligament Tears.

PURPOSE: To report on the prevalence of injuries of the lateral compartment occurring in cases of apparently isolated acute anterior cruciate ligament (ACL) tears and to present a classification system of anterolateral complex injuries based on the data obtained. METHODS: Sixty patients operated on for an acute apparently isolated ACL tear, revealed by clinical examination and confirmed by magnetic resonance imaging, were prospectively selected. The lateral compartment was exposed and injuries were detected. Based on the data obtained, lesions of the anterolateral complex were classified as follows: Type I: multilevel rupture with individual layers torn at different levels with macroscopic hemorrhage involving the area of the anterolateral ligament (ALL) and extended to the anterolateral capsule. Type II: multilevel rupture with individual layers torn at different levels with macroscopic hemorrhage extended from the area of the ALL and capsule to the posterolateral capsule. Type III: complete transverse tear involving the area of the ALL near its insertion to the lateral tibial plateau, distal to the lateral meniscus. Type IV: bony avulsion (Segond fracture). The pivot-shift test was repeated intraoperatively after repair of lateral tears before the ACL reconstruction. RESULTS: Although magnetic resonance imaging was able to detect only bony injuries (Segond fracture), macroscopic tears of the lateral capsule were clearly identified at surgery in 54 of 60 patients and classified as follows: Type I: 19/60 Type II: 16/60 Type III: 13/60 Type IV: 6/60 In all cases, repair resulted in a marked reduction or apparent disappearance of the pivot-shift phenomenon. Statistical analysis showed a positive correlation between lesions of the lateral compartment, regardless of the type described, and a pivot shift graded 2 or 3. CONCLUSIONS: Because injuries of secondary restraints often occur in cases of acute ACL tears, recognition and repair of such lesions could be considered to help ACL reconstruction to better control rotational stability. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Clinical and radiological outcomes of postoperative septic arthritis after anterior cruciate ligament reconstruction.

BACKGROUND: Septic arthritis after arthroscopic anterior cruciate ligament (ACL) reconstruction is a rare complication. In the literature, several treatments have been proposed. The aim of the study was to report our results using ambulatory irrigation of the knee and parenteral and oral antibiotics. METHODS: From January 2001 to December 2008, a total of 12 patients were treated for postoperative septic arthritis of the knee after ACL reconstruction in our hospital. The average age at trauma was 24 years (range 16-43 years). The treatment protocol included irrigation of the knee (for 2 days) and parenteral antibiotics and oral antibiotics subsequently. Repetitive irrigation was performed if necessary. The average duration of follow-up for our series was 38 months (range 6-54 months). Follow-up included International Knee Documentation Committee (IKDC) forms, radiography, Tegner and Lysholm scores, and KT-1000 arthrometric evaluation. RESULTS: In all cases treatment of infection was successful. Neither graft nor hardware removal was needed in any of the cases. At final examination, the pivot shift was negative in 10 of 12 patients, and it was 1+ in the other 2 patients; the Lachman was negative in all cases. The mean postoperative Tegner score was 7.2, and the mean Lysholm score was 98.3. In all, 10 of the 12 patients were graded as group A and the other 2 as group B using the IKDC form. The mean postoperative manual maximum KT-1000 side-to-side difference was 2.3. No significant bone tunnel enlargement was found at radiographic evaluation. CONCLUSIONS: The described treatment regimen gives reliable results for this complication. There were no recurrences of septic arthritis or bone infection. No further surgeries were required, and the graft was retained during the treatment of septic arthritis.

Return to sports activity after postoperative septic arthritis in ACL reconstruction.

BACKGROUND: Septic arthritis after arthroscopic anterior cruciate ligament (ACL) reconstruction is a rare but potentially serious complication. Several different options have been proposed to treat this condition. Our study aims to report the clinical, radiological, and sports activity results using our original protocol based on outpatient irrigation of the knee as well as parenteral and oral antibiotics. METHODS: From January 2001 to January 2009, 14 patients (all active in sports) were treated for postoperative septic arthritis of the knee after ACL reconstruction in our institute. The treatment protocol included outpatient irrigation of the knee and parenteral antibiotics, followed by oral antibiotics. Repetitive irrigation was performed if necessary. The average follow-up period for our series was 38 months (range, 8-54 months). Follow-up included International Knee Documentation Committee (IKDC) forms, radiographs, Tegner and Lysholm scores, and KT-1000™ arthrometric evaluation. RESULTS: Treatment of infection was successful in all cases. At final examination, pivot shift score was negative in 12 of 14 patients, and was > 1 in 2 of 14 patients, whereas the Lachman item score was negative in all cases. The mean postoperative Tegner score was 7, and 12 of 14 patients returned to the same sport at the same level after surgery. The mean Lysholm score was 96. Using the IKDC score, 12 of 14 patients were graded as group A, and 2 of 14 patients were graded as group B. The mean postoperative manual maximum KT-1000™ side-to-side difference was 2.5 mm. No significant bone tunnel enlargement was found when evaluating the patients' radiographs. CONCLUSION: The treatment regimen previously described provides reliable results for this complication. There were no recurrences of septic arthritis or bone infection, and no further surgeries were required. The graft could be retained during treatment of septic arthritis. Almost all patients returned to the preoperative and preinfection sport at the same level.

Instrumented measurements of knee laxity: KT-1000 versus navigation.

The KT-1000 is widely accepted as a tool for the instrumented measurement of the antero-posterior (AP) tibial translation. The aim of this study is to compare the data obtained with the KT-1000 in ACL deficient knees with the data obtained using a navigation system during "in vivo" ACL reconstruction procedures and to validate the accuracy of the KT-1000. An ACL reconstruction was performed using computer aided surgical navigation (Orthopilot, B-Braun, Aesculap, Tuttlingen, Germany) in 30 patients. AP laxity measurements were obtained for all patients using KT-1000 arthrometer (in a conscious state and under general anaesthesia) and during surgery using the navigation system, always at 30 degrees of knee flexion. The mean AP translation was 14 +/- 4 and 15.6 +/- 3.8 mm using the KT-1000 in conscious and under general anaesthesia, respectively (P = 0.02) and 16.1 +/- 3.7 mm using navigation. Measurements obtained with the KT-1000 under general anaesthesia were no different from those obtained "in vivo" with the navigation system (P = 0.37). In conclusion this study validates the accuracy of the KT-1000 to exactly calculate AP translation of the tibia, in comparison with the more accurate measurements obtained using a navigation system.

Extra-articular ACL Reconstruction and Pivot Shift: In Vivo Dynamic Evaluation With Navigation.

BACKGROUND: The pivot-shift test is considered a reliable examination to evaluate the results of anterior cruciate ligament (ACL) reconstruction, as it strongly correlates with patient satisfaction, giving-way episodes, and activity level. The addition of lateral tenodesis (LT) to current techniques of intra-articular reconstruction with a hamstring graft could potentially improve knee laxity in cases of severe rotational instability. PURPOSE: To biomechanically investigate the effect of intra- and extra-articular ACL reconstructions on knee laxity and the pivot-shift phenomenon. STUDY DESIGN: Controlled laboratory study. METHODS: Twenty patients underwent anatomic single-bundle ACL reconstruction with doubled semitendinosus and gracilis tendons with the addition of extra-articular reconstruction. In patients in group A, intra-articular reconstruction was performed first and LT thereafter; in patients in group B, LT was performed first and intra-articular reconstruction thereafter. A navigator equipped with software designed for both static and dynamic evaluations was used to measure maximum anterior tibial translation (ATT) and axial tibial rotation (ATR) at 30° of flexion (static evaluation) and during the pivot-shift test (dynamic evaluation). Measurements were performed before reconstruction, after the first procedure, and after the second procedure. RESULTS: For the static evaluation, in group A, the mean ATT significantly decreased from 14.1 ± 3.7 mm in the preoperative (ACL-deficient) condition to 6.0 ± 1.9 mm after ACL reconstruction and to 5.3 ± 1.6 mm after LT. The mean ATR at 30° of knee flexion significantly decreased from 35.7° ± 4.8° to 28.9° ± 4.1° and to 20.9° ± 4.8°, respectively. In group B, the mean ATT significantly decreased from 13.5 ± 6.5 mm in the preoperative (ACL-deficient) condition to 10.2 ± 3.2 mm after LT and to 4.0 ± 1.6 mm after ACL reconstruction. The mean ATR at 30° of knee flexion significantly decreased from 36.7° ± 4.8° to 26.2° ± 6.2° and to 23.5° ± 4.9°, respectively. For the dynamic evaluation (pivot-shift test), in group A, the mean ATT significantly decreased from 15.0 ± 6.8 mm in the preoperative (ACL-deficient) condition to 9.4 ± 6.4 mm after ACL reconstruction and to 8.5 ± 5.4 mm after LT. The mean ATR significantly decreased from 16.9° ± 4.7° to 11.6° ± 4.1° and to 6.1° ± 2.2°, respectively. In group B, the mean ATT significantly decreased from 12.5 ± 3.3 mm in the preoperative (ACL-deficient) condition to 9.1 ± 5.9 mm after LT and to 8.1 ± 5.4 mm after ACL reconstruction. The mean ATR significantly decreased from 16.0° ± 4.5° to 9.2° ± 4.3° and to 7.5° ± 4.0°, respectively. CONCLUSION/CLINICAL RELEVANCE: Extra-articular reconstruction had little effect in reducing the anterior displacement of the tibia at 30° of flexion, but it was more effective than intra-articular reconstruction in reducing ATR. Anatomic ACL reconstruction and LT were synergic in controlling the pivot-shift phenomenon.

Saúde bucal na infância: o conhecimento de estudantes de enfermagem e de medicina de uma Universidade do sul do Brasil / Oral health in childhood: the knowledge of students of nursing and medicine at a university of the south of Brazil

Objetivo: Analisar o conhecimento de acadêmicos de Enfer-magem e de Medicina de uma universidade da Região Sul do Brasil, em relação ao tema saúde bucal na infância. Materiais e Métodos: Estudo do tipo exploratório, mediante coleta de dados primários. Participaram da pesquisa 129 acadêmicos sendo 55 de Enfermagem e 74 de Medicina. O instrumento de coleta foi um questionário anônimo e autoaplicável. Os dados foram organizados mediante procedimentos da estatística descritiva. O nível de conhecimento foi classificado em: bom, intermediário e insuficiente. Resultados: Um total de 60,5% dos acadêmicos informou não ter recebido informações sobre saúde bucal, ao longo da matriz curricular. Acadêmicos de enfermagem foram os que mais receberam estas informações, tendo sido identificada uma diferença altamente significativa entre os cursos (p˂0,001). A frequência do bom nível de conhecimento foi a mais alta nos dois cursos (47,3% para Enfermagem; 48,3% para Medicina). Não houve diferença significativa no nível de conhecimento em função do curso (p=0,862). Os tópicos em que houve melhor desempenho foram: função do flúor (Enfermagem), importância da dentição decídua (Enfermagem e Medicina) e uso de chupeta e desenvolvimento orofacial (Medicina). O pior desempenho foi em relação a: conceito de cárie (Enfermagem), procedimentos básicos em casos de avulsão dentária (Enfermagem e Medici-na), amamentação e saúde bucal (Enfermagem e Medicina). Conclusão: Os conhecimentos sobre saúde bucal na infância dos estudantes de Enfermagem e de Medicina participantes da pesquisa em alguns aspectos apresentam-se satisfatórios. No entanto, é fundamental que se dê especial atenção às lacunas identificadas. (AU)

Objective: To analyze the knowledge of Nursing and Medi-cine students of a university in the southern region of Brazil, regarding the topic of oral health in childhood. Material and Methods: Exploratory study, through the collection of primary data. A total of 129 students participated in the study, 55 of Nursing and 74 of Medicine. The instrument of data collection was an anonymous self-administered questionnaire. Data was organized using descriptive statistical procedures. The level of knowledge was classified as: good, intermediate and insufficient. Results: A total of 60.5% of the students reported not having received information about oral health, throughout the curricular matrix. Nursing students were the ones who received the most information, and a significant difference between the courses was identified (p = 0.000). The frequency of the good level of knowledge was the highest in both courses (47.3% for Nurs-ing, 48.3% for Medicine). There was no significant difference in knowledge level due to the course (p = 0.862). The topics in which they performed best were: fluoride function (Nursing); importance of the deciduous dentition (Nursing and Medicine); pacifier use and orofacial development (Medicine). The worst performance was in relation to: concept of caries (Nursing); basic procedures in cases of dental avulsion (Nursing and Med-icine); breastfeeding and oral health (Nursing and Medicine). Conclusion: The knowledge about oral health in childhood of Nursing and Medicine students participating in the research in some aspects are satisfactory. However, it is fundamental that particular attention be paid to the gaps identified. (AU)

Navigated knee kinematics after tear of the ACL and its secondary restraints: preliminary results.

In this study we evaluated the role of the anterior cruciate ligament (ACL) and its secondary restraint in controlling knee stability using a navigation system. The purpose of this study was to evaluate the kinematics of the knee in different conditions of instability: ACL intact, after transection of the posterolateral (PL) bundle, after transection of the anteromedial (AM) bundle, and after lesion of the anterolateral femorotibial ligament (ALFTL). Anterior tibial translation and rotation were measured with a computer navigation system in 6 knees in whole fresh-frozen human cadavers by use of a manual maximum load. Anterior translation was evaluated at 30°, 60°, and 90° of flexion; rotation at 0°, 15°, 30°, 45°, 60°, and 90° of flexion. Cutting the PL bundle does not increase anterior translation and rotation of the knee. Cutting the AM bundle significantly increased the anteroposterior (AP) translation at 30° and 60° of flexion (P=.01), but does not increase rotation of the knee. Cutting the ALFTL increased anterior translation at 60° of flexion (P=.04) and rotation at 30°, 45°, and 60° of flexion (P=.03). The PL bundle does not affect anterior translation and rotation of the knee. The AM bundle is the primary restraint of the anterior translation but does not affect rotation of the knee. The lateral compartment becomes the primary restraint of rotation after ACL cut. The primary kinematic effect of an ACL injury is an increase in anterior tibial translation, but there is no significant change in maximum internal or external rotation. The lesion of the ALFTL increases tibial rotation and could be correlated to the pivot shift phenomenon.

Double-bundle anterior cruciate ligament reconstruction: a comprehensive kinematic study using navigation.

BACKGROUND: Single-bundle anterior cruciate ligament reconstruction seems to be insufficient to control a combined rotatory load of internal and valgus torque, whereas anatomical double-bundle reconstruction might produce a better biomechanical outcome, especially during rotatory loads. HYPOTHESIS: The addition of the posterolateral bundle to the anteromedial bundle, in an in vivo double-bundle computer-assisted anterior cruciate ligament reconstruction, is able to reduce the internal rotation of the tibia at different degrees of flexion. STUDY DESIGN: Controlled laboratory study. METHODS: Ten consecutive anterior cruciate ligament reconstruction procedures were performed in male patients using double-bundle gracilis and semitendinosus tendon graft with the 2.0 OrthoPilot anterior cruciate ligament navigation system. Anteroposterior displacement at 30 degrees , 60 degrees , and 90 degrees as well as internal and external rotation at 0 degrees , 15 degrees , 30 degrees , 45 degrees , 60 degrees , and 90 degrees of knee flexion were evaluated before reconstruction, after fixation of the anteromedial bundle, and then after fixation of the posterolateral bundle. RESULTS: Fixation of the anteromedial bundle significantly (P < .05) reduced the anteroposterior displacement at 30 degrees , 60 degrees , and 90 degrees of knee flexion; the internal rotation at 15 degrees , 30 degrees , 45 degrees , and 60 degrees ; and the external rotation at 0 degrees , 30 degrees , 60 degrees , and 90 degrees . The addition of the posterolateral bundle to the anteromedial bundle did not significantly reduce internal and external rotation of the tibia at degrees of flexion measured (P > .05). CONCLUSION: The hypothesis that the addition of the posterolateral bundle to the anteromedial bundle is able to reduce internal rotation of the tibia, minimizing the pivot-shift phenomenon, was not confirmed. CLINICAL RELEVANCE: The effective role of the anatomical double-bundle procedure in better restoring knee kinematics and allowing better clinical outcomes should be questioned in an in vivo model of anterior cruciate ligament reconstruction using doubled semitendinosus and gracilis graft.