One-incision versus two-incision techniques for arthroscopically assisted anterior cruciate ligament reconstruction in adults.

BACKGROUND: Anterior cruciate ligament (ACL) tears are serious knee injuries that are frequently treated surgically in the form of arthroscopically assisted reconstruction with grafts from the patella or hamstrings tendons. We reviewed the evidence for the choice of arthroscopically assisted ACL reconstruction technique in terms of whether it should involve one incision (femoral tunnel drilled from inside the knee joint under arthroscopic visualisation) or two incisions (femoral tunnel drilled from outside to inside the knee joint). OBJECTIVES: To assess the effects (benefits and harms) of one-incision versus two-incision techniques for arthroscopically assisted ACL reconstruction in adults. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Latin American and Caribbean Health Sciences (LILACS), the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, reference lists, and conference abstracts. The date of the search was 16 August 2017. SELECTION CRITERIA: Randomised and quasi-randomised controlled clinical trials evaluating one-incision versus two-incision techniques for arthroscopically assisted ACL reconstruction in adults. DATA COLLECTION AND ANALYSIS: Two review authors independently searched and selected studies, and extracted data and assessed the risk of bias of the eligible studies. We undertook limited pooling of data using the fixed-effect model. MAIN RESULTS: We included five trials (four randomised and one quasi-randomised) evaluating a total of 320 participants who were mainly in their 20s. All participants underwent ACL reconstruction with patella tendon grafts. All five included trials were at a high risk of bias, particularly performance bias. Based on these limitations and the insufficiency of the available data resulting in imprecision of effect estimates, we judged the quality of the evidence as very low for all outcomes. This means that we are uncertain of the findings of the review.We found very low-quality evidence of no clinically important differences between the two techniques in self reported knee function, measured using the Lysholm knee score (scale 0 to 100: best outcome), at short-term (3 months) (mean difference (MD) 2.73 favours one-incision technique, 95% confidence interval (CI) -2.70 to 8.15; 79 participants, 2 studies), intermediate-term (12 months) (MD -3.68 favours two-incision technique, 95% CI -6.61 to -0.75; 79 participants, 2 studies), and long-term follow-up. The data available for long-term follow-up (2 to 5 years) was expressed in terms of the numbers of participants with excellent Lysholm scores (90 points or more); we found no difference between the two groups (42/45 versus 36/40; risk ratio (RR) 1.04, 95% CI 0.91 to 1.18; 1 study). There were no data for quality of life measures or for overall numbers of participants incurring an adverse event. We found very low-quality evidence of little between-group differences in individual adverse events such as infection, knee stiffness, reoperation, and graft failure.We found very low-quality evidence from one study (59 participants) of little difference between the two groups in activity levels measured using Tegner scores (scale 0 to 10: highest sport activity) at two years (MD -0.80 favours two-incision technique, 95% CI -1.90 to 0.30). There was very low-quality evidence from four studies of minimal between-group difference in the number of participants with normal or nearly normal objectively measured knee function (International Knee Documentation Committee objective assessment grading) at intermediate follow-up (means 12 to 28 months): 56/78 versus 63/89; RR 1.01, 95% CI 0.85 to 1.21; 167 participants). AUTHORS' CONCLUSIONS: The very low-quality and often absent evidence means that we are uncertain whether one-incision arthroscopically assisted ACL reconstruction techniques yield better, worse, or equivalent results compared with two-incision techniques in terms of short-, intermediate-, or long-term subjective function, quality of life, adverse outcomes, activity levels, and objectively rated knee function. The evidence was available only for single-bundle ACL reconstruction using patella tendon grafts.When considering priorities for high-quality randomised trials on techniques for ACL reconstruction, it is important to note the insufficiency of the evidence available to inform this key comparison.

Increased Femoral Anteversion Influence Over Surgically Treated Recurrent Patellar Instability Patients.

PURPOSE: To verify the influence that increased femoral anteversion (FA) has on patients with recurrent patellar instability (RPI) treated by anteromedialization tibial tubercle osteotomy (TTO) combined with medial patellofemoral ligament reconstruction (MPFLR) and to present the midterm outcomes of these patients. METHODS: From January 2008 to August 2013, skeletally mature patients with RPI and tibial tubercle (TT)-trochlear groove (TG) ≥ 17 mm who underwent anteromedialization TTO combined with MPFLR were evaluated for J sign, patellar glide, apprehension test, increased FA, Caton index, trochlea dysplasia, TT-TG, Kujala, International Knee Documentation Committee subjective knee evaluation form, and Tegner. Increased FA was determined clinically by a difference of more than 30° between hip internal and external rotation, 70° or more of hip internal rotation, and 30° or more of femoral neck anteversion. A subgroup analysis involving increased FA was made. RESULTS: Forty-eight patients composed the study group. Mean follow-up was 41.5 ± 11.05 months. The J-sign was present in 86% before surgery and none postoperatively (P < .001). All patients had a positive apprehension test or a patellar luxation at the patellar glide test rated as grade 4 before surgery. After surgery, the mean glide was 1.29 ± 0.45 with no apprehension (P < .001). Increased FA was present in 18.7%. Caton index before surgery was 1.11 ± 0.21 and 0.99 ± 0.11 postoperatively (P = .004). Trochlea dysplasia was present in all patients. TT-TG preoperatively was 20.77 ± 2.12 mm and 11.33 ± 1.24 mm postoperatively (P < .001). Functional scores improved preoperatively to postoperatively (P < .001) with Kujala and International Knee Documentation Committee means: 59.08 to 84.37; 52.6 to 85.5, respectively. Tegner preinjury score was 5.4 and postoperatively was 5.2 (P = .01). Increased FA group had worse Kujala compared with the normal FA group and worse Kujala improvement: 77.7 and 85.89 (P = .012), and 21.7 and 26.1, respectively (P < .001). CONCLUSIONS: Increased FA in patients with RPI had a negative effect on the outcome of anteromedialization TTO combined with MPFLR. Combined anteromedialization TTO and MPFLR had good functional midterm outcomes in treating patients with RPI and TT-TG ≥ 17 mm. LEVEL OF EVIDENCE: Level III, comparative study.

Anterior cruciate ligament reconstruction: how do we perform it? Brazilian orthopedic surgeons' preference.

PURPOSE: We evaluated current trends and common practice of Brazilian orthopedic surgeons while selecting approaches for anterior cruciate ligament (ACL) reconstruction surgery. METHODS: Orthopedic surgeons (n = 191) completed a survey consisting of seven questions regarding their profiles and preference for ACL reconstruction techniques. RESULTS: Most surgeons were from Southeast Brazil (56.6%) and had specialized in knee surgery (79.5%); most participants (55.1%) had worked in this field for > five years, and 46.8% had performed >50 ACL reconstructions. Further, 93.1% respondents preferred the hamstring graft. Analysis of preference for the femoral tunnel approach in terms of years of experience showed that surgeons with ten to 15 years' experience preferred the transtibial approach; those with < five years of experience, the transportal technique; those with >15 years' experience, the two-incision technique. CONCLUSIONS: Surgeons' preferences for ACL reconstruction are variable, and are influenced by learning time and availability of tools rather than research evidence.

Does Combined Intra- and Extraarticular ACL Reconstruction Improve Function and Stability? A Meta-analysis.

BACKGROUND: ACL reconstruction aims to restore knee function and stability; however, rotational stability may not be completely restored by use of standard intraarticular reconstruction alone. Although individual studies have not shown the superiority of combined ACL reconstruction compared with isolated intraarticular reconstruction in terms of function and stability, biomechanical principles suggest a combined approach may be helpful, therefore pooling (meta-analyzing) the available randomized clinical studies may be enlightening. QUESTIONS/PURPOSES: We performed a meta-analysis to determine whether combining extraarticular with intraarticular ACL reconstruction would lead to: (1) similar knee function measured by the IKDC evaluation, return-to-activity, and Tegner Lysholm scores, compared with isolated intraarticular reconstruction; (2) increased stability measured by pivot shift and instrumented Lachman examination; and (3) any differences in complications and adverse events? METHODS: To identify randomized controlled trials (RCTs) comparing combined intra- and extrarticular ACL reconstruction (combined reconstruction) with intraarticular ACL reconstruction only, we searched MEDLINE, EMBASE, SPORTDiscus, Latin American and Caribbean Health Sciences (LILACS), and the Cochrane Central Register of Controlled Trials, and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The main outcomes we sought were patient function and stability and complications after ACL reconstruction. Of 386 identified studies, eight RCTs were included (n=682 participants; followup, 12-84 months; men to women ratio, 2.17:1) in our meta-analysis. Study quality (internal validity) was assessed using the Cochrane risk-of-bias tool; in general, we found a moderate quality of evidence of the included studies. RESULTS: When functional outcomes were compared, we found no difference between patients who underwent intraarticular ACL reconstruction only and those who underwent combined reconstruction (IKDC, return-to-activity, and Tegner Lysholm scores). However, patients who underwent combined reconstruction were more likely to show improved stability based on the pivot shift test (risk ratio [RR], 0.95; 95% CI, 0.91-0.99; p=0.02) and Lachman test (RR, 0.93; 95% CI, 0.88-0.98; p=0.01). In addition, our meta-analysis found no difference between the two treatments in terms of general complications or adverse events (RR, 1.31; 95% CI, 0.70-2.34; p=0.40) and the proportion of patients whose reconstructions failed (RR, 2.88; 95% CI, 0.73-11.47; p=0.13). CONCLUSION: Combined intra- and extraarticular ACL reconstruction provided marginally improved knee stability and comparable failure rates but no difference in patient-reported functional outcomes scores. Complications and adverse events such as knee stiffness may be underreported and technical factors such as graft placement were difficult to evaluate. Future studies are needed to determine whether the small differences in additional stability warrant the potential morbidity of the additional extraarticular procedure and to determine long-term failure rates.

Retinal microvascular abnormalities, cotton wool-like lesions, and macular edema following COVID-19 in a patient previously vaccinated with AstraZeneca and idiopathic myopathy.

In this case study, the authors describe peculiar bilateral cotton wool-like retinal lesions associated with macular edema in a patient with COVID-19 who was vaccinated with a single dose of AstraZeneca one month earlier. This patient had no pulmonary or systemic cardiovascular complications from COVID-19, as reported in other papers that found retinal lesions. However, the patient was diagnosed with idiopathic myopathy when discovering the SARS-CoV-2 infection. The patient was a 22-year-old white female with no previous history of morbidity, complaining of blurred vision in both eyes seven days after testing positive for SARS-CoV-2 by PCR (using nasal and oral swab) and confirmed through ELISA blood test (IgM positive). There was no ancillary test revealing diabetes mellitus. The patient presented with scattered whitish cotton wool-like lesions and a few hemorrhages on the posterior pole in fundus examination. On spectral domain optical coherence tomography (SD-OCT), there were hyperreflective lesions in the nerve fiber layer, ganglion cell layer, inner nuclear layer, and inner and outer plexiform layers at the site corresponding to the whitish cotton wool-like lesions in the posterior fundus photos. Moreover, the macula of both eyes had intraretinal and subretinal fluid, reversible with corticosteroid therapy. In conclusion, COVID-19 has been associated with capillary disorders at different target sites such as retina, lungs, and central nervous system. Similarly, vaccination against SARS-CoV-2 has been linked to retinal complications in the literature; however, cotton wool-like lesions have not yet been reported. There are many questions yet to be answered about the implications of COVID-19 infection and its vaccines.

BRCAness as a Biomarker of Susceptibility to PARP Inhibitors in Glioblastoma Multiforme.

Glioblastoma multiforme (GBM) is the most common primary brain cancer. GBMs commonly acquire resistance to standard-of-care therapies. Among the novel means to sensitize GBM to DNA-damaging therapies, a promising strategy is to combine them with inhibitors of the DNA damage repair (DDR) machinery, such as inhibitors for poly(ADP-ribose) polymerase (PARP). PARP inhibitors (PARPis) have already shown efficacy and have received regulatory approval for breast, ovarian, prostate, and pancreatic cancer treatment. In these cancer types, after PARPi administration, patients carrying specific mutations in the breast cancer 1 (BRCA1) and 2 (BRCA2) suppressor genes have shown better response when compared to wild-type carriers. Mutated BRCA genes are infrequent in GBM tumors, but their cells can carry other genetic alterations that lead to the same phenotype collectively referred to as 'BRCAness'. The most promising biomarkers of BRCAness in GBM are related to isocitrate dehydrogenases 1 and 2 (IDH1/2), epidermal growth factor receptor (EGFR), phosphatase and tensin homolog (PTEN), MYC proto-oncogene, and estrogen receptors beta (ERß). BRCAness status identified by accurate biomarkers can ultimately predict responsiveness to PARPi therapy, thereby allowing patient selection for personalized treatment. This review discusses potential biomarkers of BRCAness for a 'precision medicine' of GBM patients.

Electroporation of vascular endothelial growth factor gene in a unipedicle transverse rectus abdominis myocutaneous flap reduces necrosis.

Necrosis in TRAM (transverse rectus abdominis myocutaneous) still occurs in flap breast reconstruction. Blood flow may be improved by vascular endothelial growth factor (VEGF), an endogenous protein that stimulates neovascularization. Experimental studies of gene therapy with plasmid vector expressing human VEGF (hVEGF) presented inadequate results. Low level of gene expression could be the cause. To prove that high level of VEGF gene expression can minimize necrosis of TRAM flap, electroporation of VEGF plasmid was tested.Forty-two adult, male, Wistar-EPM rats were randomly distributed in 6 groups of 7 animals and 50 microg of vectors were injected in the intradermal layer of TRAM flap donor region, by electroporation: LacZ (beta-galactosidase gene); CG (no substance injected and flap elevated); P2G (empty gT plasmid in area 2); PV2G (gT-VEGF165 in area 2); P4G (empty gT plasmid in area 4); PV4G (gT-VEGF165 in area 4). Five days after flap elevation, the animals were euthanized and the degree of necrosis was analyzed by histology and paper template method.Dermal X-gal staining after electroporation with pSV2lacZ proved high rate of gene transfer. Mean values of necrosis by the paper template method were: CG (74.5%), P2G (62.2%), PV2G (41.1%), P4G (76.6%), and PV4G (59%). Degree of necrosis, preservation of muscle layer, and degree of infiltrates seen by histology were in accordance with mean values of necrosis.Intradermal injection of gT-VEGF165 in area 2, by electroporation, was effective in reducing unipedicle TRAM flap necrosis, in rats.

Return to Sports after ACL Reconstruction with Resection or Remnant-Preserving Technique.

Objectives To analyze the results of anterior cruciate ligament (ACL) reconstruction with remnant-preserving versus remnant-resecting technique, concerning the return to pre-lesion activity level. Methods The present retrospective cohort study has assessed adults > 18 years old who underwent ACL anatomical reconstruction between 2010 and 2014. The main outcomes assessed were: level of physical activity (4-point scale), sports participation rate, ACL rerupture defined as documented lesion requiring revision surgery and the numeric pain scale rate (NPSR). Results A total of 83 individuals were included in the study, with a mean age of 31.8 years old and follow-up mean time of 4.2 years after the surgery. A total of 34 patients underwent ACL reconstruction with remnant-preserving technique, and 49 without remnant preservation. No statistically significant difference was found between groups in all outcomes assessed: level of physical activity before the lesion and after the surgery, ACL rerupture rates and postoperative pain level. Subgroup analysis has shown a statistically significant decrease in the activity level in both groups. The most practiced sport was football; 72% of patients in the remnant group have resumed football activity versus 52.6% of the control group. Conclusion Based in these findings, the comparison between ACL reconstruction with remnant preserving technique and remnant resecting technique has shown no differences concerning the return to prelesion activity level.

Blood cardiac biomarkers responses are associated with 24 h ultramarathon performance.

PURPOSE: Clinical significance of cardiac biomarkers response in ultra-endurance runners are not completely elucidated because events vary in distance/duration and competitors modulate running intensity according to individual running capacity. The aim of this study was to examine the relationship between self-selected exercise intensity with cardiac biomarkers comparing experienced (EXP, N = 11) and novice (NOV, N = 14) runners able to finish a 24h ultramarathon (24UM) with significant differences in performance. METHODS: Cardiac biomarkers (i.e. CKMB/totalCK, cTnT and NT-proBNP), inflammatory markers (i.e. leukocytes and CRP) and cortisol were analyzed before and after a 24UM. RESULTS: EXP finished the race with significant (p < 0.05) longer distance than NOV (158.8 ± 15.8 vs 116.8 ± 10.3 Km). Two-way mixed ANOVA showed significant time × performance level interaction with greater increase of cTnT (F(1,23) = 6.18, p = 0.021), NT-proBNP (F(1,23) = 9.27, p = 0.006) and cortisol (F(1, 23) = 5.13, p = 0.03) in the EXP group. CKMB/totalCK (F(1, 23) = 71.90, p < 0.0001) decreased while leukocytes (F(1, 23) = 100.06, p < 0.0001) and CRP (F(1, 23) = 93.37, p < 0.0001) increased in both groups (main effect of time). Correlations were found between 24UM distance and cortisol (r = 0.58; p = 0.002), CKMB (r = 0.47; p = 0.017), cTnT (r = 0.44; p = 0.027) or NT-proBNP (r = 0.56; p = 0.003). Cortisol and NT-proBNP were also significantly correlated (r = 0.51; p = 0.01). CONCLUSIONS: Although there is no clear evidence of cardiac risk when comparing cardiac biomarkers levels with clinical cut-off values, cardiac biomarkers are associated with running performance and pituitary-adrenocortical system response. In EXP runners, higher levels of cardiac biomarkers and cortisol suggest a more hemodynamically challenged heart during prolonged endurance exercise.

Osteochondritis dissecans of the trochlea: case report.

The authors report a rare case of osteochondritis dissecans of the trochlea. The treatment of these lesions, in which the osteochondral fragment is not viable, is difficult and often limited in Brazil. A clinical case is presented with functional and radiological outcomes after treatment with microfracture technique, bone graft, and collagen membrane coverage.

Os autores relatam um caso raro de osteocondrite dissecante de tróclea. O tratamento dessas lesões com inviabilidade do fragmento osteocondral é difícil e muitas vezes limitado no nosso meio. Os autores apresentam resultados clínicos e radiológicos após o tratamento com a técnica de microfratura, enxertia óssea e cobertura com membrana de colágeno.

Anatomic Posterolateral Corner Reconstruction With Autografts.

Anatomic posterolateral corner reconstruction reproduces 3 main structures: the lateral collateral ligament, the popliteofibular ligament, and the popliteus tendon. The LaPrade technique reproduces all 3 main stabilizers. However, it requires a long graft, limiting its indication to clinical settings in which allograft tissue is available. We propose a surgical procedure that is a modification of the LaPrade technique using the same tunnel placement, hamstring autografts, and biceps augmentation when necessary. It relies on artificial graft lengthening provided by the loop of the suspensory fixation device fixed at the anterior tibial cortex. The final reconstruction reproduces the popliteus tendon with the bulkiest end of the semitendinosus; the popliteofibular ligament with a strand of the semitendinosus and a strand of the gracilis; and the lateral collateral ligament with a strand of the semitendinosus and a strand of the gracilis, which can also be augmented with a biceps strip.

Anterior cruciate ligament - updating article.

This updating article on the anterior cruciate ligament (ACL) has the aim of addressing some of the most interesting current topics in this field. Within this stratified approach, it contains the following sections: ACL remnant; anterolateral ligament and combined intra and extra-articular reconstruction; fixation devices; and ACL femoral tunnel creation techniques.

Este artigo de atualização sobre ligamento cruzado anterior (LCA) visa abordar alguns dos tópicos mais interessantes e atuais sobre o tema. Dentro dessa abordagem estratificada incluem-se as seguintes seções: remanescente do LCA; ligamento anterolateral e reconstruções extra-articulares combinadas a intra-articulares; dispositivos de fixação; técnicas de confecção do túnel femoral.

Return to Sports after ACL Reconstruction with Resection or Remnant-Preserving Technique / Retorno ao esporte após reconstrução do LCA com ressecção ou preservação do remanescente

Abstract Objectives To analyze the results of anterior cruciate ligament (ACL) reconstruction with remnant-preserving versus remnant-resecting technique, concerning the return to pre-lesion activity level. Methods The present retrospective cohort study has assessed adults > 18 years old who underwent ACL anatomical reconstruction between 2010 and 2014. The main outcomes assessed were: level of physical activity (4-point scale), sports participation rate, ACL rerupture defined as documented lesion requiring revision surgery and the numeric pain scale rate (NPSR). Results A total of 83 individuals were included in the study, with a mean age of 31.8 years old and follow-up mean time of 4.2 years after the surgery. A total of 34 patients underwent ACL reconstruction with remnant-preserving technique, and 49 without remnant preservation. No statistically significant difference was found between groups in all outcomes assessed: level of physical activity before the lesion and after the surgery, ACL rerupture rates and postoperative pain level. Subgroup analysis has shown a statistically significant decrease in the activity level in both groups. The most practiced sport was football; 72% of patients in the remnant group have resumed football activity versus 52.6% of the control group. Conclusion Based in these findings, the comparison between ACL reconstruction with remnant preserving technique and remnant resecting technique has shown no differences concerning the return to prelesion activity level.

Resumo Objetivo Analisar os resultados da reconstrução do ligamento cruzado anterior (LCA) com preservação do remanescente, comparada à técnica convencional, no retorno do paciente ao nível de atividade física pré-lesão. Métodos Estudo transversal retrospectivo, que avaliou indivíduos adultos submetidos à reconstrução anatômica do LCA no período de 2010 a 2014. Os desfechos analisados foram: nível de atividade física, taxa retorno ao esporte, relesão do LCA definida como lesão documentada que necessite de nova reconstrução ligamentar, e dor pela escala numérica de dor (EVN). Resultados Foram incluídos 83 indivíduos com média de 31,8 anos de idade e seguimento médio de 4,2 anos após a cirurgia, 34 submetidos à reconstrução do LCA com preservação do remanescente, e 49 à convencional. Não houve diferença estatisticamente significativa entre os grupos na frequência de atividade física pré-lesão e pós-operatória, na taxa de relesão do LCA reconstruído e na intensidade da dor no pós-operatório. Na análise intragrupos, houve uma queda estatisticamente significativa na frequência da prática de atividade física pós-operatória para ambos os grupos em comparação ao nível pré-lesão. O tipo de esporte mais praticado foi o futebol, onde 72% pacientes do grupo remanescente retornaram ao esporte comparado a 52,6% do grupo controle; porém, essa diferença não foi estatisticamente significante. Conclusão Não foi possível observar diferenças entre os pacientes submetidos às técnicas cirúrgicas de reconstrução LCA com e sem a preservação do remanescente em relação ao retorno ao esporte, frequência de atividade física e intensidade da dor. Estudos futuros prospectivos são necessários.

Arthroscopic Identification of the Anterolateral Ligament of the Knee.

Intense interest has focused on the recent description of the anterolateral ligament of the knee. Advancing knowledge of its anatomy and function is leading to a realization of its importance in the rotatory control of the tibia in anterior cruciate ligament injuries. Reconstruction of this structure will increasingly become an important goal during anterior cruciate ligament reconstruction. However, preoperative assessment of this ligament is difficult. Clinical assessment of rotatory laxity has poor reproducibility, and it is difficult to define using current imaging techniques. This article is the first to describe a safe and reproducible arthroscopic technique to allow identification and examination of the anterolateral ligament of the knee. With the knee at 90° of flexion, the arthroscope is introduced through the anterolateral portal to allow clear visualization of the lateral gutter. Under direct vision, an accessory portal is made over the inferior limit of the lateral gutter. A shaver is then introduced through this portal and used to debride this synovial recess and define the anterolateral ligament. This allows the surgeon to examine the integrity of the anterolateral ligament, in particular its femoral insertion. If required, this additional information can facilitate the performance of a more accurate and effective extra-articular reconstruction.

Arthroscopically confirmed femoral button deployment.

The anterior cruciate ligament TightRope RT (Arthrex, Naples, FL) is a graft suspension device for cruciate ligament reconstruction. It is an adjustable-length graft loop cortical fixation device designed to eliminate the requirement for loop length calculation and to facilitate complete graft fill of short femoral sockets that are common with anatomic anterior cruciate ligament placement. The adjustable loop length means "one size fits all," thus removing the need for multiple implant sizes and allowing graft tensioning even after fixation. However, the device has been associated with the same complications that have been described with EndoButton (Smith & Nephew Endoscopy, Andover, MA) fixation. The button of the TightRope RT may remain in the femoral tunnel rather than flipping outside of the tunnel to rest on the lateral femoral cortex, or it may become jammed inside the femoral canal. Conversely, the button may be pulled too far off the femoral cortex into the overlying soft tissue and flip in the substance of the vastus lateralis. We describe a new and simple arthroscopic technique to directly visualize the deployment and seating of the TightRope button on the lateral cortex of the femur to avoid all the aforementioned complications.

Is it safe the empirical distal femoral resection angle of 5° to 6° of valgus in the Brazilian geriatric population?

OBJECTIVE: The purpose of this study is to determine if there is a safe distal femoral resection angle to restore the normal axial alignment of the limb in total knee arthroplasty (TKA) in the Brazilian geriatric population with knee arthrosis. METHOD: This study analyzed 99 pre-operative hip-knee-ankle radiographs of osteoarthritic knees of 66 patients (54 women, 12 men) with knee osteoarthritis. The distal femoral cut angle was determined based on the femoral mechanical-anatomical angle (FMA). Mean, median and standard deviation measurements of the distal femoral cut angle were calculated, differentiated by gender and side. The mean result of the distal femoral resection angle was compared to 5.7°, the mean average angle of previous and similar study based on European population of patients with knee arthrosis. RESULTS: The mean average of the distal femoral resection angle of the study was 6.05 (range 3-9°). The distribution of this angle between genders showed a slight superior average of the male population (6.17°) compared to the female (6.02°), but with no statistically significant difference (p = 0.726). There was no statistically significant difference (p = 0.052) between the mean average of this study (6.05°) compared to the mean average of the literature (5.7°). However, considering 3° as the limit of acceptable error in the coronal plane, this empirical femoral resection angle would not be appropriated for 19.7% of the population. CONCLUSION: The distal femoral resection angle of 5-6° is not completely safe for the Brazilian geriatric population.

OBJETIVO: Determinar se existe um ângulo seguro para o corte femoral distal, para que o membro resulte alinhado após uma artroplastia total de joelho (ATJ), na população geriátrica brasileira com gonartrose. MÉTODO: Foram feitas radiografias panorâmicas de 99 membros inferiores em 66 pacientes consecutivos (54 mulheres e 12 homens) portadores de gonartrose do joelho. O ângulo do corte femoral distal foi determinado pelo encontro entre o eixo mecânico femoral (EMF) e o eixo anatômico femoral (EAF). Foram calculados os valores da média, o desvio padrão e a mediana do ângulo do corte femoral distal desses pacientes diferenciados por sexo e lado. O valor médio do ângulo de corte do fêmur distal ideal aqui obtido foi comparado com o valor médio de 5,7 obtido em estudo prévio semelhante a esse feito com populações europeias de pacientes osteoartríticos submetidos a ATJ. RESULTADOS: A média do ângulo formado pelos EAF × EMF, considerado o ângulo do corte femoral distal em uma ATJ, do grupo estudado foi de 6,05 (variação de 3o a 9o). A distribuição desse ângulo entre os sexos evidenciou uma média discretamente superior entre os homens (6,17o) em comparação com as mulheres (6,02o), porém sem significância estatística (p = 0,726). Não houve diferença estatística (p = 0,052) entre o valor médio obtido na amostra atual (6,05 - DP 1,27) com o valor médio obtido na literatura (5,7°). Entretanto, se considerarmos aceitável um erro de 3° no plano coronal, 19,7% da população operada se encontrariam fora dessa faixa aceitável se optarmos pelo corte femoral empírico de acordo com o instrumental. CONCLUSÃO: O corte femoral distal na ATJ em 5° ou 6° de valgo não é completamente seguro para a população geriátrica brasileira.

Osteochondritis dissecans of the trochlea: case report / Osteocondrite dissecante da tróclea: relato de caso

ABSTRACT The authors report a rare case of osteochondritis dissecans of the trochlea. The treatment of these lesions, in which the osteochondral fragment is not viable, is difficult and often limited in Brazil. A clinical case is presented with functional and radiological outcomes after treatment with microfracture technique, bone graft, and collagen membrane coverage.

RESUMO Os autores relatam um caso raro de osteocondrite dissecante de tróclea. O tratamento dessas lesões com inviabilidade do fragmento osteocondral é difícil e muitas vezes limitado no nosso meio. Os autores apresentam resultados clínicos e radiológicos após o tratamento com a técnica de microfratura, enxertia óssea e cobertura com membrana de colágeno.

Anterior cruciate ligament - updating article / Ligamento cruzado anterior - Artigo de atualização

ABSTRACT This updating article on the anterior cruciate ligament (ACL) has the aim of addressing some of the most interesting current topics in this field. Within this stratified approach, it contains the following sections: ACL remnant; anterolateral ligament and combined intra and extra-articular reconstruction; fixation devices; and ACL femoral tunnel creation techniques.

RESUMO Este artigo de atualização sobre ligamento cruzado anterior (LCA) visa abordar alguns dos tópicos mais interessantes e atuais sobre o tema. Dentro dessa abordagem estratificada incluem-se as seguintes seções: remanescente do LCA; ligamento anterolateral e reconstruções extra-articulares combinadas a intra-articulares; dispositivos de fixação; técnicas de confecção do túnel femoral.

Specific warm-up exercise is the best for vertical countermovement jump in young volleyball players

Abstract We evaluated the effect of performing various distinct warm-up exercises on vertical countermovement jump (VCMJ) performance. Eight volleyball players (age 15.4 ± 0.5 yrs) performed five different warm-up activities (in a counterbalanced, randomized crossover study) over five days, at 24-h intervals: stretching (4 × 30 s, 30 s between sets), cycloergometer (5 min at 50 W + 5 min at 100 W), resistance exercise (leg press 45°, 3 × 5 repetitions maximum, 3-min pause between sets), specific vertical jumping (4 × 10 VCMJ, 2-min pause between sets), and no warm-up at all (control condition). Beginning 3 min after their warm-up, the players performed 3 attempts (at intervals of 3 min) of VCMJ (on a contact carpet), and each player's best jump was considered in the analysis. All warm-up activities presented higher VCMJ performance (p< 0.05) than the control condition, with the exception of stretching. Vertical jumping revealed a large effect size(0.8) than other interventions. We conclude that in practical terms, vertical jumps are the best warm-up exercise (when applied by itself) to acutely improve VCMJ performance in volleyball players, but that other exercises can make a complementary contribution.