Diagnosis by Manual Maneuver of Medial Meniscus Ramp Lesions.

The intra-articular injury most often associated with a chronic anterior cruciate ligament tear involves the posterior horn of the medial meniscus. A specific type of medial meniscal injury, called a ramp lesion, has received greater attention for identification and treatment because of its considerable incidence and diagnostic difficulty. Based on their location, these lesions may be arthroscopically "hidden" during traditional anterior visualization. The purpose of the present Technical Note is to describe the Recife maneuver. This maneuver diagnoses injuries to the posterior horn of the medial meniscus using additional arthroscopic management through a standard portal. The Recife maneuver is performed with the patient in the supine position. A 30° arthroscope is inserted through the anterolateral portal, and the posteromedial compartment is accessed according to the transnotch view (modified Gillquist view). In the proposed maneuver, with the knee in 30° of flexion, a valgus stress with internal rotation is performed, followed by palpation of the popliteal region and digital pressure on the joint interline. This maneuver allows a greater visualization of the posterior compartment, allowing the diagnostic evaluation of the integrity between the meniscus and the capsule, in a safer way, being able to identify ramp tears without the need to create a posteromedial portal. We recommend that the addition of the diagnostic visualization step of the posteromedial compartment as described by the Recife maneuver be performed to assess the meniscal status in routine anterior cruciate ligament reconstruction.

The incidence of anterior cruciate ligament injury in youth and male soccer athletes: an evaluation of 17,108 players over two consecutive seasons with an age-based sub-analysis.

PURPOSE: To evaluate the incidence of anterior cruciate ligament (ACL) injuries in male athletes from professional soccer clubs over two consecutive seasons (2018-2019) with a sub-analysis based on age category: under-13 (U-13), under-15 (U-15), under-17 (U-17), and under-20 (U-20) years. METHODS: A total of 17,108 young male soccer players were retrospectively reviewed from sixty-three professional clubs in the four highest Brazilian soccer divisions. Data regarding the number of athletes and the number of ACL injuries confirmed by magnetic resonance imaging (MRI) exams in the 2018 and 2019 seasons were collected. Incidence of ACL injury were compared by season, age category (under-13; under-15; under 17; and under-20), demographic region, and club division. RESULTS: Clubs from all regions of Brazil participated in the study. A total of 336 primary ACL injuries were diagnosed over the two seasons (8,167 athletes during the 2018 season and 8,941 athletes during the 2019 season) among all athletes, which corresponds to 2% of the included athletes. There were 11 cases (0.3%) in the under-13, 53 cases (1.3%) in the under-15, 107 cases (2.5%) in the under-17, and 165 cases (3.8%) in the under-20 age category. There was a higher incidence of ACL injury in the older age groups (p < 0.001). CONCLUSION: A total of 336 ACL injuries were identified in 17,108 youth soccer players from 63 professional clubs with an overall incidence of 2% over 2 seasons of competition. ACL injury rate ranged from 0.3% to 3.8% and was higher in the older and more competitive club divisions. LEVEL OF EVIDENCE: IV.

Preoperative Meniscal Extrusion Predicts Unsatisfactory Clinical Outcomes and Progression of Osteoarthritis after Isolated Partial Medial Meniscectomy: A 5-Year Follow-Up Study.

The objective of this study was to examine the association between preoperative meniscal extrusion of patients undergoing partial medial meniscectomy with clinical outcomes and progression of osteoarthritis and to determine the extent of meniscal extrusion associated with unsatisfactory clinical outcomes and progression of osteoarthritis. Ninety-five patients who underwent partial medial meniscectomy with a minimum follow-up of 5 years were retrospectively reviewed. Preoperative meniscal extrusion was evaluated with magnetic resonance imaging. Patients were assessed preoperatively and postoperatively with Lysholm and International Knee Documentation Committee (IKDC) subjective scores for clinical outcomes and with IKDC radiographic scale for osteoarthritis. An ANOVA (Analysis of Variance) was used to analyze the variations in meniscal extrusion and the clinical and radiological outcomes. A regression analysis was performed to identify factors that affect preoperative medial meniscus extrusion and that influence results after partial meniscectomy. An optimal cutoff value for meniscal extrusion associated with unsatisfactory clinical outcomes and progression of osteoarthritis was established. Significance was set at p < 0.05. The mean ± SD preoperative and postoperative Lysholm scores were 59.6 ± 15.5 versus 83.8 ± 13.1 (p < 0.001) and the mean preoperative and postoperative IKDC subjective scores were 59.4 ± 16.8 versus 82.0 ± 15.8 (p < 0.001). Meniscal extrusion greater than 2.2 mm (sensitivity, 84%; specificity, 81%) and 2.8 mm (sensitivity, 73%; specificity, 85%) was associated with unsatisfactory (poor/fair) Lysholm and IKDC subjective scores, respectively. The progression of osteoarthritis, characterized as a change of at least one category on the IKDC radiographic scale, occurred when meniscal extrusion was greater than 2.2 mm (sensitivity, 63%; specificity, 75%). Patients with higher body mass index (BMI) had significantly greater meniscal extrusion that patients with normal BMI (p < 0.001). The medial meniscus was more extruded in patients with horizontal and root tears. In conclusion, patients with preoperative meniscal extrusion of 2.2 mm or greater had unsatisfactory clinical outcomes and progression of osteoarthritis after partial medial meniscectomy at a minimum of 5 years follow-up. Higher BMI and horizontal and root tears were associated with greater preoperative meniscal extrusion.

POSTERIOR VERSUS ANTERIOR APPROACH TO TOTAL HIP ARTHROPLASTY: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS.

OBJECTIVE: To perform a systematic review and meta-analysis to compare clinical and surgical outcomes of posterior versus anterior approach to primary total hip arthroplasty (THA). METHODS: This study followed the standard methodology established by the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two independent reviewers searched for randomized controlled trials comparing posterior an anterior approach to primary THA with at least one quantifiable functional outcome published in the PubMed, Cochrane, and Virtual Health Library databases. RESULTS: The analysis included ten randomized controlled trials conducted with 774 patients. The posterior approach was associated with shorter operative time (mean of 15.98 minutes shorter, 95% CI 11.21 to 20.76, p < 0.00001) while the anterior approach was associated with shorter length of hospital stay (0.31 days or about eight hours shorter, 95% CI 0.12 to 0.51, p = 0.002) and greater earlier improvement in functional outcomes up to six months from the procedure (mean Harris Hip Score of 4.06 points greater, 95% CI 2.23 to 5.88, p < 0.0001). CONCLUSION: Whereas the posterior approach to primary THA is associated with a shorter operative time, the anterior approach has the potential to decrease the length of stay and provide greater short-term functional restoration. Level of evidence I, Systematic Review and Meta-Analysis.

OBJETIVO: Realizar uma revisão sistemática e metanálise para comparar os resultados clínicos e cirúrgicos entre a via posterior e via anterior para ATQ. MÉTODOS: Este estudo seguiu as diretrizes Cochrane e PRISMA (Principais Itens para Relatar Revisões Sistemáticas e Meta-Análises). Dois investigadores independentes procuraram estudos randomizados controlados nas plataformas de busca PubMed, Cochrane e Biblioteca Virtual em Saúde. Estudos comparando a via posterior com a via anterior para ATQ primária com pelo menos um escore funcional de resultado clínico foram incluídos. RESULTADOS: Dez estudos com 774 pacientes foram incluídos. A via posterior foi associada a um tempo operatório menor (média de 15.98 minutos menor, IC 95% 11.21 a 20.76, p < 0.00001), enquanto a via anterior foi associada a um tempo de internação hospitalar menor (0.31 dia ou cerca de oito horas a menos, IC 95% 0.12 a 0.51, p = 0.002) e melhora superior dos resultados funcionais em até seis meses após a cirurgia (Harris Hip Score médio de 4.06 pontos maior, IC 95% 2.23 a 5.88, p < 0.0001). CONCLUSÃO: A via posterior foi associada a um tempo operatório menor, enquanto a via anterior tem o potencial de diminuir o tempo de hospitalização e fornecer melhor recuperação funcional no curto prazo. Nível de Evidência I, Revisão Sistemática e Metanálise.

Posterior versus anterior approach to total hip arthroplasty: a systematic review and meta-analysis of randomized controlled trials / Via posterior versus via anterior para artroplastia total do quadril: revisão sistemática e metanálise de estudos clínicos randomizados

ABSTRACT Objective: To perform a systematic review and meta-analysis to compare clinical and surgical outcomes of posterior versus anterior approach to primary total hip arthroplasty (THA). Methods: This study followed the standard methodology established by the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two independent reviewers searched for randomized controlled trials comparing posterior an anterior approach to primary THA with at least one quantifiable functional outcome published in the PubMed, Cochrane, and Virtual Health Library databases. Results: The analysis included ten randomized controlled trials conducted with 774 patients. The posterior approach was associated with shorter operative time (mean of 15.98 minutes shorter, 95% CI 11.21 to 20.76, p < 0.00001) while the anterior approach was associated with shorter length of hospital stay (0.31 days or about eight hours shorter, 95% CI 0.12 to 0.51, p = 0.002) and greater earlier improvement in functional outcomes up to six months from the procedure (mean Harris Hip Score of 4.06 points greater, 95% CI 2.23 to 5.88, p < 0.0001). Conclusion: Whereas the posterior approach to primary THA is associated with a shorter operative time, the anterior approach has the potential to decrease the length of stay and provide greater short-term functional restoration. Level of evidence I, Systematic Review and Meta-Analysis.

RESUMO Objetivo: Realizar uma revisão sistemática e metanálise para comparar os resultados clínicos e cirúrgicos entre a via posterior e via anterior para ATQ. Métodos: Este estudo seguiu as diretrizes Cochrane e PRISMA (Principais Itens para Relatar Revisões Sistemáticas e Meta-Análises). Dois investigadores independentes procuraram estudos randomizados controlados nas plataformas de busca PubMed, Cochrane e Biblioteca Virtual em Saúde. Estudos comparando a via posterior com a via anterior para ATQ primária com pelo menos um escore funcional de resultado clínico foram incluídos. Resultados: Dez estudos com 774 pacientes foram incluídos. A via posterior foi associada a um tempo operatório menor (média de 15.98 minutos menor, IC 95% 11.21 a 20.76, p < 0.00001), enquanto a via anterior foi associada a um tempo de internação hospitalar menor (0.31 dia ou cerca de oito horas a menos, IC 95% 0.12 a 0.51, p = 0.002) e melhora superior dos resultados funcionais em até seis meses após a cirurgia (Harris Hip Score médio de 4.06 pontos maior, IC 95% 2.23 a 5.88, p < 0.0001). Conclusão: A via posterior foi associada a um tempo operatório menor, enquanto a via anterior tem o potencial de diminuir o tempo de hospitalização e fornecer melhor recuperação funcional no curto prazo. Nível de Evidência I, Revisão Sistemática e Metanálise.

Tendon grafts with preserved muscle demonstrate similar biomechanical properties to tendon grafts stripped of muscular attachments: a biomechanical evaluation in a porcine model.

PURPOSE: (1) To evaluate the biomechanical properties of a porcine flexor digitorum superficialis tendon graft with preserved muscle fibers and (2) to compare these results with the biomechanical properties of a porcine tendon graft after removal of associated muscle. METHODS: Eighty-two porcine forelegs were dissected and the flexor digitorum superficialis muscle tendons were harvested. The study comprised of two groups: Group 1 (G1), harvested tendon with preserved muscle tissue; and Group 2 (G2), harvested contralateral tendon with removal of all muscle tissue. Tests in both groups were conducted using an electro-mechanical material testing machine (Instron, model 23-5S, Instron Corp., Canton, MA, USA) with a 500 N force transducer. Yield load, stiffness, and maximum load were evaluated and compared between groups. RESULTS: The behavior of the autografts during the tests followed the same stretching, deformation, and failure patterns as those observed in human autografts subjected to axial strain. There were no significant differences in the comparison between groups for ultimate load to failure (p = 0.105), stiffness (p = 0.097), and energy (p = 0.761). CONCLUSION: In this porcine model biomechanical study, using autograft tendon with preserved muscle showed no statistically significant differences for yield load, stiffness, or maximum load compared to autograft tendon without preserved muscle. The preservation of muscle on the autograft tendon did not compromise the mechanical properties of the autograft. LEVEL OF EVIDENCE: Level III Controlled laboratory study.

Remnant Muscle Preservation on Hamstring Tendon Autograft During ACL Reconstruction Promotes Volumetric Increase With Biological and Regenerative Potential.

BACKGROUND: The removal of all adherent muscle tissue from the hamstring graft during anterior cruciate ligament reconstruction (ACLR) is common practice. However, there is a paucity of research to justify this removal or evaluate its biological implications. PURPOSE/HYPOTHESIS: The purpose of this study was to (1) evaluate the histological characteristics of the myotendinous muscle tissue harvested from hamstring tendons, (2) compare the final diameter of the prepared graft before and after the removal of the remnant musculature, and (3) evaluate patients who were treated with and without preservation of the graft-adhered muscle. The hypothesis was that the adherent musculature of the graft would have cells that could contribute to graft incorporation and revascularization, assist in the proprioceptive capacity of the neoligament, and increase the graft's diameter. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We divided 84 patients into 2 groups: group 1 underwent ACLR using hamstring tendon autograft with adherent musculature, and group 2 underwent ACLR using hamstring tendon autograft stripped of its remnant muscle. All patients had minimum 2-year follow-up. The muscle harvested from the graft in group 2 was submitted for histological examination, and the graft diameter before and after muscle removal was compared. The Tegner activity scale and Lysholm scores were determined preoperatively and at 12 and 24 months postoperatively. RESULTS: There was a significant difference in graft diameter between groups. The evaluation of the graft diameter in group 2 showed a decrease of 11.52% after removal of muscle tissue from the tendon graft. Patients from group 1 had better Tegner and Lysholm scores (mean ± SD) after 12 months (Tegner, 8.03 vs 7 [P = .004]; Lysholm, 95.48 ± 1.2 vs 87.54 ± 3.21 [P = .002]) and better Lysholm scores after 24 months (95.76 ± 2.1 vs 89.32 ± 2.47; P = .002). The muscle tissue of the analyzed fragments presented a pattern with fibrous tissue beams, invaginating regularly and sequentially from the myotendinous junction into the muscles. CONCLUSION: Preserving the muscle tissue on tendon grafts promoted a volumetric increase in the final autograft diameter and demonstrated biological and regenerative potential. Patients who underwent ACLR using the tendon with the muscle attached had better functional scores at 2-year follow-up as compared with patients treated using the tendon with the muscle removed.

Larger Chondral Lesions Treated with Collagen Membrane - Matrix-Induced Autologous Chondrogenesis - Show Larger Increase in Clinical Scores.

Objective To evaluate clinically and radiologically the results of the treatment of chondral lesions using collagen membrane - autologous matrix-induced chondrogenesis (AMIC). Methods This is a series of observational cases, in which 15 patients undergoing AMIC were analyzed. The clinical evaluation was made by comparing the Lysholm and International Knee Document Commitee (IKDC) scores in the pre- and postoperative period of 12 months, and radiological evaluation using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score in the same postoperative period. Results The mean age of the patients was 39.2 years old, and the mean size of the chondral lesions was 1.55cm 2 . There was a significant improvement in clinical scores, with a mean increase of 24.6 points on Lysholm and of 24.3 on IKDC after 12 months. In the radiological evaluation, MOCART had a mean of 65 points. It was observed that the larger the size of the lesion, the greater the improvement in scores. Conclusion Evaluating subjective clinical scores, the treatment of chondral lesions with the collagen membrane showed good results, as well as the evaluation of MOCART, with greater benefit in larger lesions.

Evaluation of the CTX-II Biomarker in Patients with Anterior Cruciate Ligament Tear: Pilot Study.

Objective The aim of the present study was to quantify the urinary concentration of the C-terminal cross-linked telopeptide of type-II collagen (CTX-II) biomarker in patients who suffered an isolated ACL injury, and to compare the concentrations found in this population with a control group of patients with no metabolic changes in the knee that could lead to cartilage degeneration. Methods A cross-sectional pilot study was performed in two groups: patients with ACL tears and a control group (each group with 10 male subjects, with an age range between 18 and 35 years, and body mass index below 30 kg/m 2 ). In both groups, urine concentrations of a biomarker related to the degradation of type-II collagen (CTX-II) was measured. For the group with ACL tears, a temporal relationship between the time after the injury and the amount of the biomarker was also examined. Results There were significant differences in the concentrations of urinary CTX-II between the ACL group and the control group ( p = 0.009). No significant relationship was observed between the time after the injury and the quantity of the biomarker. Conclusions Patients with ACL injury had higher concentrations of urinary CTX-II biomarker than those with no ACL injury ( p = 0.009). However, there was no correlation between the concentration of this biomarker and the elapsed time after the injury ( p > 0.05).

Higher Meniscal Slope Is a Risk Factor for Anterior Cruciate Ligament Injury in Skeletally Immature Patients.

PURPOSE: To evaluate the relation between the femoral intercondylar index, tibial slope, and meniscal slope between 3 different groups of skeletally immature patients: primary anterior cruciate ligament (ACL) injury (group 1), ACL reconstruction failure (group 2), and control group, without an ACL injury history (group 3). METHODS: This retrospective study evaluated magnetic resonance imaging scans of the knees of 605 skeletally immature patients obtained between 2015 and 2020. The inclusion criteria were as follows: patients younger than 16 years who were skeletally immature and underwent knee magnetic resonance imaging for any reason. RESULTS: A total of 605 skeletally immature patients were included in the study. The ratio of patients with ACL injury (cases) to those without ACL injury (controls) was 1:2.5. Patients with ACL injury had significantly greater medial meniscal slope and lateral meniscal slope values than the control group without ACL injury (P < .001). There was no statistically significant difference between patients with primary ACL injury and those with ACL reconstruction failure for all measured variables. CONCLUSIONS: The medial and lateral meniscal slope values were significantly higher in skeletally immature patients with ACL injury than in the control group of patients without ACL injury. There was no statistically significant difference in measurements of the femoral intercondylar index, lateral meniscal slope, medial meniscal slope, lateral tibial slope, or medial tibial slope between patients with primary injury and those with ACL reconstruction failure. LEVEL OF EVIDENCE: Level III, retrospective comparative trial.

Comparative Study of the Function and Quality of Life of Patients Submitted to Total Knee Arthroplasty with Fixed and Mobile Tibial Platforms.

Objective To compare the function and quality of life of patients undergoing total knee arthroplasty (TKA) with fixed tibial platform and mobile tibial platform. Methods We evaluated 240 patients with knee osteoarthritis, randomized into two groups - Group A consisted of 120 patients who underwent TKA with fixed tibial platform, and the B group, consisting of 120 patients who underwent mobile platform arthroplasty. Patients were accessed according to the function and quality of life by the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and the Short Form Health Survey (SF-36), and pain scores by visual analog scale (VAS) of pain, preoperatively and at 6 months, 1 year, 2 years, 4 years and 8 years of surgery. Results Regarding the various domains of the SF-36, we observed that the average behavior of functional capacity scores, physical aspects, pain and emotional aspects in the patient groups were statistically different during follow-up. The other domains of quality of life showed no mean differences. Regarding the pain assessed by VAS and WOMAC pain scores, we can see that it showed a mean change in follow-up in both patient groups. However, at 2 years of follow-up, they were statistically worse in group A, equaling group B in the other moments. Conclusion After 2 years of follow-up, we observed that pain scores and VAS were lower in the fixed platform group. However, these differences did not remain in the mid-term, suggesting that the mobile tibial platform arthroplasty has a short-term advantage, and may help in the rehabilitation process.

Medial meniscal extrusion greater than 4 mm reduces medial tibiofemoral compartment contact area: a biomechanical analysis of tibiofemoral contact area and pressures with varying amounts of meniscal extrusion.

PURPOSE: The primary objective of this study is to evaluate the contact areas, contact pressures, and peak pressures in the medial compartment of the knee in six sequential testing conditions. The secondary objective is to establish how much the medial meniscus is able to extrude, secondary to soft tissue injury while keeping its roots intact. METHODS: Ten cadaveric knees were dissected and tested in six conditions: (1) intact meniscus, (2) 2 mm extrusion, (3) 3 mm extrusion, (4) 4 mm extrusion, (5) maximum extrusion, (6) capsular based meniscal repair. Knees were loaded with a 1000-N axial compressive force at 0°, 30°, 60°, and 90° for each condition. Medial compartment contact area, average contact pressure, and peak contact pressure data were recorded. RESULTS: When compared to the intact state, there was no statistically significant difference in medial compartment contact area at 2 mm of extrusion or 3 mm of extrusion (n.s.). There was a statistically significant decrease in contact area compared to the intact state at 4 mm (p = 0.015) and maximum extrusion (p < 0.001). The repair state was able to improve medial compartment contact area, and there was no statistically significant difference between the repair and the intact states (n.s.). No significant differences were found in the average contact pressure between the repair, intact, or maximum extrusion conditions at any flexion angle (n.s.). No significant differences were found in the peak contact pressure between the repair, intact, or maximum extrusion conditions at any flexion angle (n.s.). CONCLUSION: In this in vitro model, medial meniscus extrusion greater than 4 mm reduced medial compartment contact area, but meniscal extrusion did not significantly increase pressure in the medial compartment. Additionally, meniscal centralization was effective in restoring the medial tibiofemoral contact area to intact state when the meniscal extrusion was secondary to meniscotibial ligament injury. The diagnosis of meniscal extrusion may not necessarily involve meniscal root injury. Since it is known that meniscal extrusion greater than 3 or 4 mm has a biomechanical impact on tibiofemoral compartment contact area and pressures, specific treatments can be established. Centralization restored medial compartment contact area to the intact state.

The intra-articular use of an hemostatic and non-adherent bicomponent for pain control, hemarthrosis, and knee range of motion after anterior cruciate ligament reconstruction

Introduction: Complications in the recent postoperative period of anterior cruciate ligament reconstruction are common. Among them, pain, hemarthrosis, and difficulty of complete range of motion. The purpose of this study is to evaluate the use of the intra-articular carboxymethylcellulose ­ polysaccharide B bicomponent shortly after anterior cruciate ligament reconstruction, and to compare the results obtained for pain control, hemarthrosis, and knee range of motion with a control group. Materials and methods: randomized, and prospective clinical trial of thirty-two patients divided into two groups: reconstruction of the anterior cruciate ligament with an intra-articular injection of a bicomponent carboxymethylcellulose-polysaccharide B (n = 16) and without the bicomponent (n = 16). Pain, hemarthrosis and knee range of motion were evaluated in the first postoperative week. Results: the group with bicomponent presented less pain on the third (p = 0.017) and fifth (p = 0.029) postoperative day when compared to the control group. Hemarthrosis was significantly lower on the first postoperative day (p = 0.001), and there was a significant improvement in the range of motion on the seventh day of surgery (p = 0.008) in this same group. Conclusions: the use of intra-articular carboxymethylcellulose-polysaccharide B showed superior results for pain control, hemarthrosis, and gain in the knee range of motion in the recent postoperative period (up to seven days) after anterior cruciate ligament reconstruction, when compared to patients from the control group

EVALUATION BY THE FELLOW IN KNEE SURGERY IN BRAZIL.

OBJECTIVE: To evaluate the fellow in knee surgery and the training offered by accredited programs in Brazil. METHODS: This cross-sectional study administered a questionnaire to fellows in knee surgery. RESULTS: Most fellows reported being assisted by the preceptor in theoretical, practical, and scientific activities. CONCLUSION: The training offered by accredited programs to fellows in knee surgery presented good results for their education. This study may propose educational measures for the Brazilian Society for Surgery of the Knee (SBCJ). Level of Evidence IIC, Cross-sectional study.

OBJETIVO: Avaliar o especializando em cirurgia de joelho e o treinamento oferecido pelos serviços credenciados no Brasil. MÉTODOS: Estudo transversal por meio de um questionário enviado para os especializados em cirurgia de joelho responderem. RESULTADOS: A maioria dos especializandos relataram assistência por parte da preceptoria nas atividades teórica, prática e científica. CONCLUSÃO: O treinamento dos serviços credenciados oferecido para os especializandos em cirurgia de joelho apresentou bons resultados para a formação deles. O estudo pode promover medidas educacionais para a Sociedade Brasileira de Cirurgia de Joelho (SBCJ). Nível de Evidência IIC, Estudo transversal.

Medial Opening Wedge High Tibial Osteotomy Decreases Medial Meniscal Extrusion and Improves Clinical Outcomes and Return to Activity.

BACKGROUND: Medial meniscal extrusion (MME) is defined as displacement of the meniscus that extends beyond the tibial margin. Knee varus malalignment increases MME. PURPOSE/HYPOTHESIS: The purpose of this study was to quantify MME before and after medial opening wedge high tibial osteotomy (HTO) and to correlate the reduction of MME with clinical outcomes and return to activity. It was hypothesized that MME would decrease after HTO and that patients with lower MME after surgery would have improved clinical outcomes and return to activity at short-term follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This study included 66 patients who underwent HTO to correct the anatomic axis with a minimum follow-up of 2 years. MME was measured using magnetic resonance imaging preoperatively and 6 weeks after surgery (study protocol). Patients were assessed preoperatively and postoperatively with the Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog scale (VAS) score for pain, and Tegner score. RESULTS: The mean ± SD preoperative and postoperative MME values were 3.9 ± 0.6 mm and 0.9 ± 0.5 mm, respectively. At 2 years after surgery, KOOS, pain VAS, and Tegner scores were higher than those found preoperatively (P < .001). Patients with less than 1.5 mm of MME after surgery had better clinical outcomes and return to activity compared with patients who had MME of 1.5 mm or more (P < .05). CONCLUSION: Medial opening wedge HTO decreased MME after 6 weeks and improved clinical outcomes and return to activity at a minimum 2-year follow-up. Additionally, patients with postoperative MME of less than 1.5 mm had better clinical outcomes and return to activity compared with patients who had postoperative MME of 1.5 mm or more.

THE 50 MOST CITED ARTICLES IN THE BRAZILIAN MEDICAL LITERATURE ON KNEE SURGERY.

OBJECTIVE: To provide an analysis of the 50 most cited articles on knee surgery in the Brazilian medical literature. METHODS: This is a study of systematic review and meta-analysis, level of evidence 3. It was carried out through search in the SCOPUS database to identify scientific articles published in the Brazilian medical literature. Eighty-six Brazilian journals were analyzed, and articles with ten or more citations and which had the word "joelho" or "knee" in the title, abstract or keywords were selected. RESULTS: All articles were published as of the year 2000 in 14 journals. The Journal Clinics presented the largest number of publications, followed by Acta Ortopédica Brasileira. The main focus of the studies was on anatomy and biomechanics, mainly from Brazilian authors. Most of the authors were Brazilian, from Brazilian and public research institutions. CONCLUSION: Biometric analysis has been gaining ground in recent years, but its interpretation must consider various aspects related to the paramount analytical importance.

OBJETIVO: Fornecer uma análise dos cinquenta artigos mais citados sobre cirurgia do joelho na literatura médica brasileira. MÉTODOS: Foi utilizada a base de dados da SCOPUS para identificar artigos científicos publicados na literatura médica brasileira de 1945 a junho de 2008 com o tema referente ao joelho. Foram analisados 86 periódicos brasileiros e selecionados os artigos com número de citações igual ou superior a dez que possuíam a palavra "joelho" ou knee no título, resumo ou palavras-chave. Foram selecionados aqueles que possuíam a articulação do joelho como foco principal do estudo, chegando ao resultado final de cinquenta artigos mais citados. RESULTADOS: Todos os artigos foram publicados a partir do ano 2000, em quatorze revistas. A Revista Clinics apresentou maior número de publicações, seguida da Acta Ortopédica Brasileira. A maior parte foi sobre estudos sobre anatomia e biomecânica, preponderamente de autores brasileiros. Instituições de pesquisa brasileiras e públicas foram as responsáveis pela maior parte das pesquisas. CONCLUSÃO: Análise biométrica vem ganhando espaço nos últimos anos, contudo sua interpretação deve considerar variados aspectos relacionados a importância analítica.

The 50 most cited articles in the brazilian medical literature on knee surgery / Os 50 artigos mais citados da literatura médica brasileira sobre cirurgia do joelho

ABSTRACT Objective: To provide an analysis of the 50 most cited articles on knee surgery in the Brazilian medical literature. Methods: This is a study of systematic review and meta-analysis, level of evidence 3. It was carried out through search in the SCOPUS database to identify scientific articles published in the Brazilian medical literature. Eighty-six Brazilian journals were analyzed, and articles with ten or more citations and which had the word "joelho" or "knee" in the title, abstract or keywords were selected. Results: All articles were published as of the year 2000 in 14 journals. The Journal Clinics presented the largest number of publications, followed by Acta Ortopédica Brasileira. The main focus of the studies was on anatomy and biomechanics, mainly from Brazilian authors. Most of the authors were Brazilian, from Brazilian and public research institutions. Conclusion: Biometric analysis has been gaining ground in recent years, but its interpretation must consider various aspects related to the paramount analytical importance.

RESUMO Objetivo: Fornecer uma análise dos cinquenta artigos mais citados sobre cirurgia do joelho na literatura médica brasileira. Métodos: Foi utilizada a base de dados da SCOPUS para identificar artigos científicos publicados na literatura médica brasileira de 1945 a junho de 2008 com o tema referente ao joelho. Foram analisados 86 periódicos brasileiros e selecionados os artigos com número de citações igual ou superior a dez que possuíam a palavra "joelho" ou knee no título, resumo ou palavras-chave. Foram selecionados aqueles que possuíam a articulação do joelho como foco principal do estudo, chegando ao resultado final de cinquenta artigos mais citados. Resultados: Todos os artigos foram publicados a partir do ano 2000, em quatorze revistas. A Revista Clinics apresentou maior número de publicações, seguida da Acta Ortopédica Brasileira. A maior parte foi sobre estudos sobre anatomia e biomecânica, preponderamente de autores brasileiros. Instituições de pesquisa brasileiras e públicas foram as responsáveis pela maior parte das pesquisas. Conclusão: Análise biométrica vem ganhando espaço nos últimos anos, contudo sua interpretação deve considerar variados aspectos relacionados a importância analítica.

Higher Axial Tibiofemoral Rotation and Functional Outcomes with Mobile-Bearing Compared with Fixed-Bearing Total Knee Arthroplasty at 1- but Not at 2-Year Follow-Up-A Randomized Clinical Trial.

The objective of this study was to determine in vivo knee kinematics and clinical outcomes of patients who underwent fixed- and mobile-bearing total knee arthroplasty (TKA) at 1- and 2-year follow-up. This prospective double-blinded randomized controlled trial was performed from November 2011 to December 2012. A total of 64 patients were randomized to fixed- and mobile-bearing TKA groups (32 patients in each group). All patients were evaluated with the following: three-dimensional in vivo knee kinematics analysis during gait, stepping up and stepping down stair steps, and getting up from and sitting on a chair; and knee range of motion and patient-reported outcome measures (Knee Outcome Survey Activities of Daily Living Scale [KOS-ADLS] and pain visual analog scale [VAS]) at 1- and 2-year follow-up. Descriptive statistics (means, standard deviations, and percentages) were calculated for all variables. The Kolmogorov-Smirnov test was used to test if variables were normally distributed. A Student's t-test was used to compare continuous variables between patients in the two groups. The chi-square test was used to compare the groups with respect to categorical variables. The α level for statistical significance was set at p < 0.05. The mean axial tibiofemoral rotation in patients who underwent mobile-bearing TKA was significantly higher during gait (13.3 vs. 10.7), stepping up (12.8 vs. 10) stair steps, and getting up (16.1 vs. 12.1) from a chair compared with fixed-bearing TKA patients at 1-year follow-up (p < 0.05). KOS-ADLS function score was significantly higher in the mobile-bearing compared with the fixed-bearing TKA group (32 vs. 27.7) at 1-year follow-up (p < 0.05). No significant difference in kinematics and clinical outcomes between fixed- and mobile-bearing TKA groups was observed at 2-year follow-up (p > 0.05). Based on the results of this study, mobile-bearing TKA allowed a higher degree of rotation when walking, stepping up stair steps, and standing up from a chair, and had higher functional outcomes compared with fixed-bearing TKA at 1-year follow-up. However, no difference in in vivo kinematics or in clinical outcomes was observed between fixed- and mobile-bearing prostheses at 2-year follow-up.

Arthroscopic assessment of meniscal injuries using an anatomical zone classification system

The present study aimed to evaluate the inter- and intra-observer reproducibility of the arthroscopic meniscus tear classification system in patients treated with meniscal suture, as well as to correlate these anatomical zones, according to the injury characteristics and the suture technique employed.Forty-six knee arthroscopies were analyzed for meniscal sutures. The evaluators recorded data of the zones described by Smigielski, types of injuries, meniscal vascularity, suture techniques, and types of suture knots applied to sutures. Data were analyzed with respect to inter and intra-observer agreement. All clinical and anatomical outcomes as well as the characterization of the injury and meniscal treatment were correlated.The intra- and inter-observer reproducibility (Kappa coefficient) for the arthroscopic classification system of meniscus injury proposed by Smigielski ranged from slight to moderate.The zone classification defines the menisci and their relationship with the surrounding anatomic landmarks of the knee; however, it has limited arthroscopic application. The practical knowledge of the classification system described in this study can help specifically guide treatment for various types of meniscal injury

El propósito del presente estudio es evaluar la reproducibilidad inter e intraobservador de la clasificación artroscópica de lesiones meniscales propuesta por Smigielski en pacientes tratados con suturas meniscales, así como correlacionar las zonas anatómicas con las características lesionales y el tipo de técnica de sutura empleada.Se analizaron cuarenta y seis artroscopías de rodilla con sutura meniscal de la lesión. Se examinó la zona descripta según Smigielski, el tipo de lesión meniscal, la vascularidad, la técnica de sutura meniscal y el tipo de nudo empleados. Los datos fueron evaluados para considerar la reproducibilidad intra e interobservador. Todos los resultados clínicos, anatómicos, características de la lesión, así como el tratamiento meniscal utilizado, se correlacionaron.La correlación intra e interobservador (coeficiente Kappa) para la clasificación artroscópica de lesiones meniscales propuesta por Smigielski fue leve o moderada. La clasificación por zonas que define la lesión meniscal y su relación con las estructuras anatómicas de la rodilla tiene aplicación limitada en la cirugía artroscópica. El conocimiento práctico de la clasificación podría servir como guía para la toma de conducta ante las lesiones meniscales reparables