Remnant preserving ACL reconstruction with a functional remnant is related to improved laxity but not to improved clinical outcomes in comparison to a nonfunctional remnant.

PURPOSE: The Anterior cruciate ligament (ACL) remnant has been pointed out as a ligamentization enhancer. Nonetheless, the remaining tissue can be functional if it still provides some stability or nonfunctional. This study intends to compare the clinical results and knee stability of functional vs. nonfunctional remnant preservation ACL reconstruction (ACLR). METHODS: One hundred and seventy-five patients with ACL injuries were included and underwent remnant preservation ACLR. They were divided into two groups accordingly to remnant tissue functionality: functional (Group F) and nonfunctional (Group NF). Primary outcome was defined as patient reported outcomes measured with Lysholm, IKDC and Tegner continuous scales and improvements. Secondary outcomes comprised of Lachman test, anterior drawer test, pivot shift test, extension and flexion deficit, graft coverage by remnant preserved tissue and failure rate (persistent instability or new ACL lesion). Menisci lesions, cartilage lesions and time to surgery were also recorded for each group. RESULTS: One hundred and forty-four patients were available at a mean of 30.2 ± 10.1 months: 69 Functional and 75 Nonfunctional. Lysholm, IKDC and Tegner functional outcomes demonstrated no difference between the groups, Functional compared to Nonfunctional: 88.4 ± 10.5 vs. 92.2 ± 4.9, n.s. and 83.2 ± 11.3 vs. 87 ± 5.3, n.s. and 6 (5-10) vs. 6 (5-9), n.s., respectively. Lysholm and IKDC functional outcomes improvements demonstrated differences between the groups: Functional compared to Nonfunctional (39.3 ± 9.4 vs. 42.3 ± 7.4, p = 0.014 and 37.7 ± 10 vs. 41.0 ± 6.6, p = 0.032); however, they were not clinically significant. Functional group showed more stability on physical examination pre- and post-operatively (p < 0.001, p < 0.001). There was no difference regarding extension deficit (n.s.); however, functional group had more flexion deficit (p = 0.02). Nonfunctional group had better graft coverage (p = 0.001). There was no difference regarding failure rate: 4% vs. 9%, (n.s.). CONCLUSION: Both remnant preservation ACLR techniques were able to achieve satisfactory functional outcomes. A functional remnant was not related to improved functional outcomes in comparison to a nonfunctional remnant; however, it was related to less laxity pre and postoperatively and inferior graft coverage. LEVEL OF EVIDENCE: II.

Epidemiological analysis of fractures in the previous period and during the quarantine of covid-19 / Análise epidemiológica de fraturas antes e durante a quarentena de covid-19

ABSTRACT Objectives: Our aim was to compare the epidemiology of surgically treated fractures during the pandemic period with previous years without the pandemic. Methods: This was a retrospective study with data collection that included patients hospitalized and operated for fractures between March 24th and June 23rd in 2018, 2019 and 2020. Results: A total of 879 patients were registered, resulting in a total of 965 fractures. During the COVID-19 pandemic, 234 patients were registered, representing 26.62% of the total, and in the period before the pandemic, 645 patients were registered, 73.38% of the total. Conclusion: We observed a proportional increase in high-energy trauma in the social isolation period and patient's average age. The other changes found in the study had no statistical difference. Level of Evidence IV, Case Series.

RESUMO Objetivos: Comparar a epidemiologia das fraturas tratadas cirurgicamente durante o período de contingência causado pela pandemia com os intervalos respectivos de anos anteriores. Métodos: Foram incluídos todos os pacientes com diagnóstico de fratura em qualquer seguimento do corpo, exceto coluna vertebral e face, que foram internados e operados entre 24 de março e 23 de junho de 2018, 2019 e 2020 em dois hospitais referência para tratamento de trauma na grande São Paulo. Os dados foram obtidos a partir da avaliação retrospectiva de prontuários médicos. Levou-se em consideração epidemiologia das fraturas, mecanismo de trauma e dados demográficos dos pacientes tratados no período de contingência em comparação com a média dos três anos anteriores (período controle). Resultados: Foram avaliados 879 pacientes e 965 fraturas. Durante a pandemia pelo coronavírus foram registrados 234 pacientes, enquanto a média do período controle foi de 322,5 pacientes. Em relação ao mecanismo de trauma, houve um significativo aumento do trauma de alta energia em comparação ao período controle. Conclusão: Verificou-se uma diminuição na incidência de fraturas tratadas cirurgicamente nos hospitais avaliados. No entanto, houve uma elevação na taxa de trauma de alta energia no período de isolamento social. Essa alteração demonstra que mudanças no fluxo das cidades podem impactar na demanda hospitalar e que a pandemia influenciou direta e indiretamente os órgãos de saúde. Nível de Evidência IV, Série de Casos.

Etiology of Cartilage Lesions Does Not Affect Clinical Outcomes of Patellofemoral Autologous Chondrocyte Implantation.

OBJECTIVE: To determine the relationship between cartilage lesion etiology and clinical outcomes after second-generation autologous chondrocyte implantation (ACI) in the patellofemoral joint (PFJ) with a minimum of 2 years' follow-up. METHODS: A retrospective review of all patients that underwent ACI in the PFJ by a single surgeon was performed. Seventy-two patients with a mean follow-up of 4.2 ± 2.0 years were enrolled in this study and were stratified into 3 groups based on the etiology of PFJ cartilage lesions: patellar dislocation (group 1; n = 23); nontraumatic lesions, including chondromalacia, osteochondritis dissecans, and degenerative defects (group 2; n = 28); and other posttraumatic lesions besides patellar dislocations (group 3; n = 21). Patient's mean age was 29.6 ± 8.7 years. Patients in group 1 were significantly younger (25.4 ± 7.9 years) than group 2 (31.7 ± 9.6 years; P = 0.025) and group 3 (31.5 ± 6.6 years; P = 0.05). Body mass index averaged 26.2 ± 4.3 kg/m2, with a significant difference between group 1 (24.4 ± 3.2 kg/m2) and group 3 (28.7 ± 4.5 kg/m2; P = 0.005). A clinical comparison was established between groups based on patient-reported outcome measures (PROMs) and failure rates. RESULTS: Neither pre- nor postoperative PROMs differed between groups (P > 0.05). No difference was seen in survivorship between groups (95.7% vs. 82.2% vs. 90.5%, P > 0.05). CONCLUSION: Cartilage lesion etiology did not influence clinical outcome in this retrospective study after second generation ACI in the PFJ. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Isolated MPTL reconstruction fails to restore lateral patellar stability when compared to MPFL reconstruction.

PURPOSE: To biomechanically evaluate MPTL reconstruction and compare it with two techniques for MPFL reconstruction in regard to changes in patellofemoral contact pressures and restoration of patellar stability. METHODS: This is an experimental laboratory study in eight human cadaveric knees. None had patellofemoral cartilage lesions or trochlear dysplasia as evaluated by conventional radiographs and MRI examinations. The specimens were secured in a testing apparatus, and the quadriceps was tensioned in line with the femoral shaft. Contact pressures were measured using the TekScan sensor at 30°, 60° and 90°. The sensor was placed in the patellofemoral joint through a proximal approach between femoral shaft and quadriceps tendon to not violate the medial and lateral patellofemoral complex. TekScan data were analysed to determine mean contact pressures on the medial and lateral patellar facets. Patellar lateral displacement was evaluated with the knee positioned at 30° of flexion and 9 N of quadriceps load, then a lateral force of 22 N was applied. The same protocol was used for each condition: native, medial patellofemoral complex lesion, medial patellofemoral ligament reconstruction (MPFL-R) using gracilis tendon, MPFL-R using quadriceps tendon transfer, and medial patellotibial ligament reconstruction (MPTL-R) using patellar tendon transfer. RESULTS: No statistical differences were found for mean and peak contact pressures, medial or lateral, among all three techniques. However, while both techniques of MPFL-R were able to restore the medial restraint, MPTL-R failed to restore resistance to lateral patellar translation to the native state (mean lateralization of the patella [mm]: native: 9.4; lesion: 22; gracilis MPFL-R: 8.1; quadriceps MPFL-R: 11.3; MPTL-R: 23.4 (p < 0.001). CONCLUSION: MPTL-R and both techniques for MPFL-R did not increase patellofemoral contact pressures; however, MPTL-R failed to provide a sufficient restraint against lateral patellar translation lateral translation in 30° of flexion. It, therefore, cannot be recommended as an isolated procedure for the treatment of patellar instability.

Femoral Trochlear Geometry in Patients with Trochlear Dysplasia Using MRI Oblique Trochlear View.

The objective of this study was to evaluate trochlear morphology in patients with trochlear dysplasia using a new oblique trochlear magnetic resonance imaging (MRI) view (OTV) in comparison with standard axial MRI sequences. MRI exam of 73 patients with patellofemoral instability (PFI) and the same number of controls were retrospectively reviewed. The oblique trochlear sequence was acquired by inclining the axial plane parallel to the intercondylar roof of the sagittal image, showing the anterior cruciate ligament (ACL) in its entire length. Trochlear morphology was assessed on axial and oblique trochlear sequences at three levels: level 1 at 25%, level 2 at 50%, and level 3 at 75% of the length of the trochlear groove. Trochlear sulcus angle and sulcus depth were measured at these three levels and compared between the new trochlear and standard axial sequences. Trochlear sulcus angle and sulcus depth were statistically different between axial and oblique trochlear views at all three levels (p < 0,05). Additionally, OTV displayed more uniform sulcus angle and depth along the trochlea. The oblique trochlear view on the MRI can more accurately evaluate trochlear morphology and also better characterize trochlear dysplasia in patients with PFI. This is Level III, retrospective comparative study.

Trochlear Dysplasia Does Not Affect the Outcomes of Patellofemoral Autologous Chondrocyte Implantation.

PURPOSE: To evaluate the influence of trochlear dysplasia on clinical outcomes after autologous chondrocyte implantation (ACI) for the treatment of large cartilage lesions in the patellofemoral joint (PFJ) with a minimum of 2 years' follow-up. METHODS: We performed a retrospective review of prospectively collected data of all patients submitted to cartilage repair with ACI for focal cartilage defects in the PFJ by a single surgeon. Patient factors, lesion morphology, and preoperative and postoperative patient-reported outcome measures including the Knee Injury and Osteoarthritis Score, Lysholm score, Tegner activity level, and International Knee Documentation Committee Subjective Knee Evaluation Form score were collected. Two independent observers assessed preoperative imaging to determine the presence and grade of trochlear dysplasia. Patients were stratified into 2 groups based on the presence or absence of trochlear dysplasia. Patients without trochlear dysplasia served as controls. Patients were matched 1:1 for sex, age, body mass index, lesion size, and location. RESULTS: Forty-six patients who underwent ACI in the PFJ with a mean follow-up period of 3.7 ± 1.9 years (range, 2-9 years) were enrolled in this study (23 in the trochlear dysplasia group vs 23 in the normal trochlea group). The patients' mean age was 30.1 ± 8.8 years. Patient-reported outcome measures at final follow-up did not differ between the 2 groups (P > .05). No difference in failure rates was seen between the 2 groups (n = 1 [4.3%] vs n = 1 [4.3%], P > .999). Additionally, no difference in clinical outcomes was seen between patients with high-grade dysplasia (19 patients; Dejour types B-D) and patients without dysplasia (19 patients) (P > .05). CONCLUSIONS: ACI in the PFJ provides favorable outcomes even in patients with trochlear dysplasia, which are comparable to those in patients with normal trochlear anatomy. Thus, trochlear dysplasia seems to not influence the clinical outcomes of ACI in the PFJ. LEVEL OF EVIDENCE: Level III, retrospective comparative trial.

Treatment with Human Amniotic Suspension Allograft Improves Tendon Healing in a Rat Model of Collagenase-Induced Tendinopathy.

Treatment of tendon injuries is challenging, with neither conservative nor surgical approaches providing full recovery. Placental-derived tissues represent a promising tool for the treatment of tendon injuries. In this study, human amniotic suspension allograft (ASA) was investigated in a pre-clinical model of Achilles tendinopathy. Collagenase type I was injected in the right hind limb of Sprague Dawley rats to induce disease. Contralateral tendons were either left untreated or injected with saline as controls. Seven days following induction, tendons were injected with saline, ASA, or left untreated. Rats were sacrificed 14 and 28 days post-treatment. Histological and biomechanical analysis of tendons was completed. Fourteen days after ASA injection, improved fiber alignment and reduced cell density demonstrated improvement in degenerated tendons. Twenty-eight days post-treatment, tendons in all treatment groups showed fewer signs of degeneration, which is consistent with normal tendon healing. No statistically significant differences in histological or biomechanical analyses were observed between treatment groups at 28 days independent of the treatment they received. In this study, ASA treatment was safe, well-tolerated, and resulted in a widespread improvement of the tissue. The results of this study provide preliminary insights regarding the potential use of ASA for the treatment of Achilles tendinopathy.

Pulse Lavage Fails to Significantly Reduce Bone Marrow Content in Osteochondral Allografts: A Histological and DNA Quantification Study.

BACKGROUND: Current clinical practice calls for pulse lavage of fresh osteochondral allografts (OCAs) to reduce immunogenicity; however, there is limited evidence of its effectiveness in reducing allogenic bone marrow elements. PURPOSE: To evaluate the effectiveness of pulse lavage in removing marrow elements from trabecular bone in fresh OCA transplantation. STUDY DESIGN: Controlled laboratory study. METHODS: The authors evaluated 48 fresh OCA plugs with 4 different common sizes (14- and 24-mm diameter, 6- and 10-mm thickness). Within each size group, half of the samples underwent pulse lavage (n = 6) with saline solution and half were left untreated (no lavage; control group, n = 6). For each treatment and size group, 3 samples were analyzed for DNA content as an indicator of the number of residual nucleated cells; the other 3 samples were histologically analyzed to assess the presence and distribution of cells within subchondral bone pores in 3 specific locations within the plug: peripheral, intermediate, and core. RESULTS: Osteochondral plugs treated with pulse lavage did not show a significant decrease in DNA content in comparison with untreated plugs. Overall, histological analysis did not show a significant difference between the treated and untreated groups (P = .23). Subgroup analysis by size demonstrated decreased marrow content in treated versus untreated groups in the thinner plug sizes (14 × 6 mm and 24 × 6 mm). Histological evaluation by zone demonstrated a significant difference between groups only in the peripheral zone (P = .04). CONCLUSION: Pulse lavage has limited effectiveness in removing marrow elements, in particular in plugs that are larger in diameter and, more importantly, in thickness. Better techniques for subchondral bone treatment are required for more thorough removal of potentially immunogenic marrow elements. CLINICAL RELEVANCE: OCA transplantation has become an established treatment modality. Unfortunately, OCA is not without limitations, chiefly its mode of failure through inadequate integration of the allograft subchondral bone with subsequent collapse. In an effort to improve integration, current clinical practice calls for pulse lavage to remove allogenic bone marrow from the subchondral bone in hopes of decreasing the immunogenicity of the graft and facilitating revascularization.

Anatomic Risk Factors for Focal Cartilage Lesions in the Patella and Trochlea: A Case-Control Study.

BACKGROUND: Focal cartilage lesions in the patellofemoral (PF) joint are common. Several studies correlated PF risk factors with PF instability, anterior knee pain, and PF arthritis; however, there is a lack of evidence correlating those factors to PF focal cartilage lesions. PURPOSE: To evaluate the influence of the anatomic PF risk factors in patients with isolated focal PF cartilage lesions. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Patients with isolated PF focal cartilage lesions were included in the cartilage lesion group, and patients with other pathologies and normal PF cartilage were included in the control group. Multiple PF risk factors were accessed on magnetic resonance imaging scans: patellar morphology (patellar width, patellar thickness, and patellar angle), trochlear morphology (trochlear sulcus angle, lateral condyle index, and trochlear sulcus depth), patellar height (Insall-Salvati ratio and Caton-Deschamps index), axial patellar positioning (patellar tilt, angle of Fulkerson), and quadriceps vector (tibial tuberosity-trochlear groove distance). RESULTS: A total of 135 patients were included in the cartilage lesion group and 100 in the control group. As compared with the control group, the cartilage lesion group had a higher sulcus angle (P = .0007), lower trochlear sulcus depth (P < .0001), lower angle of Fulkerson (P < .0001), lower patellar width (P = .0003), and higher Insall-Salvati ratio (P < .0001). From the patients in the cartilage lesion group, 36% had trochlear dysplasia; 27.6%, patella alta; and 24.7%, abnormal patellar tilt. These parameters were more frequent in the cartilage lesion group (P < .0001). Trochlear lesions were more frequent in men, presented at an older age, and had fewer associated anatomic risk factors. Patellar lesions, conversely, were more frequent in women, presented at younger age, and were more closely associated with anatomic risk factors. CONCLUSION: PF anatomic abnormalities are significantly more common in patients with full-thickness PF cartilage lesions. Trochlear dysplasia, patella alta, and excessive lateral patellar tilt are the most common correlated factors, especially in patellar lesions.

Anteromedial Tibial Tubercle Osteotomy Improves Results of Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Instability in Patients With Tibial Tuberosity-Trochlear Groove Distance of 17 to 20 mm.

PURPOSE: To compare the midterm clinical outcomes of anteromedialization tibial tubercle osteotomy combined with medial patellofemoral ligament reconstruction (TTO+MPFLR) with MPFLR alone (MPFLRa) for the treatment of recurrent patellar instability (RPI) in patients with a tibial tuberosity-trochlear groove (TT-TG) of 17 to 20 mm. METHODS: From January 2008 to August 2013, patients with RPI and a TT-TG of 17 to 20 mm were divided into 2 groups: TTO+MPFLR or MPFLRa. Subjects were evaluated for J sign classification (1-4+); patellar glide (1-4+); the apprehension test; increased femoral anteversion; the Caton index; trochlear dysplasia; TT-TG; and Kujala, Lysholm, International Knee Documentation Committee (IKDC), and Tegner scores. Kujala improvement was the primary outcome. RESULTS: Forty-two subjects were evaluated, 18 in the TTO+MPFLR group and 24 in the MPFLRa group. Mean follow-up time was 40.86 months (range, 24-60 months). Demographics between the groups were not different. Preoperatively, there was no statistically significant difference between groups regarding J sign classification; patellar glide; the apprehension test; increased femoral anteversion; the Caton index; trochlear dysplasia; TT-TG; and Kujala, Lysholm, IKDC, and Tegner scores. Postoperative J sign classification mean results comparing TTO+MPFLR and MPFLRa, respectively, were 1 and 1.33 (P = .006). Improvement was significantly higher in the TTO+MPFLR group in all scores except for Tegner. Kujala improvement, 30.27 and 23.95, respectively (P = .003), was also clinically significant, favoring TTO+MPFLR. Lysholm improvement was 40.5 and 36.2, respectively (P = .02), and IKDC improvement was 38.59 and 31.6, respectively (P = .002). There were no reported recurrent subluxations or dislocations in either group. CONCLUSIONS: TTO+MPFLR resulted in better functional outcome scores and patellar kinematics compared with MPFLRa in the surgical treatment of RPI in patients with a TT-TG distance of 17 to 20 mm. LEVEL OF EVIDENCE: Level II, prospective comparative study.

No effect of topical application of tranexamic acid on articular cartilage.

PURPOSE: The objective of this study was to evaluate potential cytotoxicity of TXA on articular cartilage by assessing chondrocyte viability of osteochondral explants after exposure to different concentrations and durations of TXA. METHODS: Thirty-nine osteochondral plugs (OCPs) were harvested from three adult Yucatan minipigs immediately after their death. OCPs were divided into 13 groups exposed to different concentrations of TXA (1, 2 and 4 mg/ml in saline solution) for 1, 3 and 6 h. Negative controls were exposed to saline solution for 0, 1, 3 and 6 h. Chondrocyte viability was assessed by Live/Dead cell assay and calculated as the ratio of live cells (green fluorescence) to overall cells (green + red cells) for each concentration of TXA and time point in a 50-µm scanned image. RESULTS: No correlation was found between chondrocyte viability, and TXA concentration and time of exposure. Overall, chondrocyte viability ranged from 90 to 99%. There was no statistical difference among control group, 1, 2 and 4 mg/ml TXA solutions at each time point [1 h (n.s.), 3 h (n.s.), 6 h (n.s.)]. Similarly, no statistical difference among groups was observed when comparing cell viability at 1, 3 and 6 h of TXA exposure, (Fig. 2) [1 mg/ml (n.s.), 2 mg/ml (n.s.), and 4 mg/ml (n.s.)]. CONCLUSIONS: In conclusion, doses of TXA approximating the current clinical protocols for topical use did not demonstrate any cytotoxic effects on cartilage explants in a Yucatan mini pig model. Thus, supporting the topical application for procedures with intact cartilage, such as partial knee replacement surgery and cartilage repair procedures.

Cell-Seeded Autologous Chondrocyte Implantation: A Simplified Implantation Technique That Maintains High Clinical Outcomes.

BACKGROUND: The use of autologous chondrocyte implantation (ACI) remains limited, even though multiple studies have demonstrated success rates exceeding 75%. The procedure is perceived as invasive and technically challenging, presenting barriers to more widespread adoption. Purpose/Hypothesis: The objective of this study was to investigate whether outcomes and the failure rate of a simplified ACI technique (cs-ACI) were comparable with those of the more complicated traditional technique of a chondrocyte suspension injected under a collagen membrane (cACI). We hypothesized that the change in technique would not negatively affect outcomes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Thirty-nine patients treated with the cs-ACI technique fulfilled the inclusion requirements. A group of 45 patients treated previously with standard cACI was used as a comparison. The functional outcomes were prospectively collected both preoperatively and postoperatively at the last follow-up. Failure was defined as any graft removal of more than 25% of the original defect size. Magnetic resonance imaging was performed postoperatively, and scans were assessed using a modified MOCART (magnetic resonance observation of cartilage repair tissue) scoring system. RESULTS: Group demographics were not significantly different, except for the defect size and mean follow-up: 4.09 years in the cACI group and 2.46 years in the cs-ACI group. Significant improvements were seen in all outcome measures except the Tegner score from the preoperative baseline to the latest follow-up for both the cACI group (International Knee Documentation Committee [IKDC] score, from 42.0 to 63.4; Knee injury and Osteoarthritis Outcome Score [KOOS]-Pain subscore, from 58.7 to 77.1; Lysholm score, from 57.2 to 69.7; and Tegner score, from 3.5 to 4.2) and the cs-ACI group (IKDC score, from 45.6 to 68.0; KOOS-Pain subscore, from 66.6 to 84.7; Lysholm score, from 53.7 to 75.4; and Tegner score, from 3.2 to 3.8). No significant difference was found between the groups at the latest follow-up. The failure rate at 2 years was not significantly different, while the total failure rate over the entire study period was significantly lower in the cs-ACI group than the cACI group (5% vs 24%, respectively). The overall MOCART score was not significantly different between the groups. CONCLUSION: The treatment of full-thickness articular cartilage defects with a simplified cell-seeded ACI technique demonstrated no significant differences in the failure rate and patient-reported outcomes when compared with a standard technique utilizing interrupted sutures and the injection of a cell suspension under a collagen membrane.

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.

Posteromedial Versus Direct Posterior Approach for Posterior Cruciate Ligament Reinsertion.

Avulsion fractures of the posterior cruciate ligament (PCL) are usually found in pediatric populations. This study investigated which of 2 approaches-posteromedial or direct posterior-enables easier PCL reinsertion. Ten fresh cadavers were studied using direct posterior (10 knees) and posteromedial (10 knees) approaches. In both, a guidewire was inserted into the tibial insertion of the PCL as perpendicular as possible to the coronal knee axis. Then, the angle between the guidewire and the horizontal plane of the table was measured. The mean angle of the guidewire was 8.6° (SD=7.3°) with the direct posterior approach and 36.6° (SD=14.3°) with the posteromedial approach (P=.005). The direct posterior approach allows a greater degree of freedom compared with the posteromedial approach to reach the PCL tibial insertion. [Orthopedics. 2016; 39(5):e1024-e1027.].

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.

Total knee arthroplasty with computer-assisted navigation: an analysis of 200 cases / Artroplastia total do joelho auxiliada por navegação: análise de 200 casos

OBJECTIVE: to evaluate the results from surgery with computer-assisted navigation in cases of total knee arthroplasty. METHOD: a total of 196 patients who underwent total knee arthroplasty with computer-assisted navigation were evaluated. The extension and flexion spaces (gaps) were evaluated during the operation and the alignment after the operation was assessed. The Knee Society Score (KSS) questionnaire for assessing patient's function was applied preoperatively and postoperatively after a mean follow-up of 22 months. RESULTS: in all, 86.7% of the patients presented good alignment of the mechanical axis (less than 3◦ of varus or valgus in relation to the mechanical axis) and 96.4% of the patients presented balanced flexion and extension gaps. Before the operation, 97% of the patients presented poor or insufficient KSS, but after the operation, 77.6% presented good or excellent KSS. CONCLUSION: the navigation system made it possible to achieve aligned and balanced implants, with notable functional improvement among the patients. It was found to be useful in assessing, understanding and improving knowledge in relation to performing arthroplasty procedures...

OBJETIVO: avaliar os resultados das cirurgias assistidas por navegação (CAN) nas artroplastias totais de joelho. MÉTODO: foram avaliados 196 pacientes submetidos à artroplastia total de joelho com auxílio da navegação por computador. Avaliados no intraoperatório os espaços (gaps) de extensão e de flexão, o alinhamento pós-operatório e o questionário funcional da Knee Society Score (KSS) pré-operatório e pós-operatório com seguimento médio de 22 meses. RESULTADOS: dos pacientes, 86,7% apresentaram bom alinhamento do eixo mecânico (dentro de 3◦ de varo ou valgo em relação ao eixo mecânico) e 96,4% apresentaram ambos os gaps de flexão e extensão balanceados. No pré-operatório, 97% dos pacientes apresentavam KSS funcional ruim ou insuficiente, no pós-operatório 77,6% apresentavam KSS funcional bom ou excelente. CONCLUSÃO: a navegação proporcionou a obtenção de implantes alinhados e balanceados com importante melhoria da função nos pacientes. Foram evidenciados sua utilidade no estudo, o entendimento e o aperfeiçoamento do conhecimento na execução das artroplastias...

Total knee arthroplasty with computer-assisted navigation: an analysis of 200 cases.

OBJECTIVE: to evaluate the results from surgery with computer-assisted navigation in cases of total knee arthroplasty. METHOD: a total of 196 patients who underwent total knee arthroplasty with computer-assisted navigation were evaluated. The extension and flexion spaces (gaps) were evaluated during the operation and the alignment after the operation was assessed. The Knee Society Score (KSS) questionnaire for assessing patient's function was applied preoperatively and postoperatively after a mean follow-up of 22 months. RESULTS: in all, 86.7% of the patients presented good alignment of the mechanical axis (less than 3° of varus or valgus in relation to the mechanical axis) and 96.4% of the patients presented balanced flexion and extension gaps. Before the operation, 97% of the patients presented poor or insufficient KSS, but after the operation, 77.6% presented good or excellent KSS. CONCLUSION: the navigation system made it possible to achieve aligned and balanced implants, with notable functional improvement among the patients. It was found to be useful in assessing, understanding and improving knowledge in relation to performing arthroplasty procedures.

OBJETIVO: avaliar os resultados das cirurgias assistidas por navegação (CAN) nas artroplastias totais de joelho. MÉTODO: foram avaliados 196 pacientes submetidos à artroplastia total de joelho com auxílio da navegação por computador. Avaliados no intraoperatório os espaços (gaps) de extensão e de flexão, o alinhamento pós-operatório e o questionário funcional da Knee Society Score (KSS) pré-operatório e pós-operatório com seguimento médio de 22 meses. RESULTADOS: dos pacientes, 86,7% apresentaram bom alinhamento do eixo mecânico (dentro de 3° de varo ou valgo em relação ao eixo mecânico) e 96,4% apresentaram ambos os gaps de flexão e extensão balanceados. No pré-operatório, 97% dos pacientes apresentavam KSS funcional ruim ou insuficiente, no pós-operatório 77,6% apresentavam KSS funcional bom ou excelente. CONCLUSÃO: a navegação proporcionou a obtenção de implantes alinhados e balanceados com importante melhoria da função nos pacientes. Foram evidenciados sua utilidade no estudo, o entendimento e o aperfeiçoamento do conhecimento na execução das artroplastias.

PREVALENCE OF LESIONS ASSOCIATED WITH TRAUMATIC RECURRENT SHOULDER DISLOCATION.

OBJECTIVE: To evaluate the prevalence of lesions associated with traumatic anterior shoulder instability and the relationships between the prevalence of these lesions and the number of episodes and time since symptoms started. METHOD: Fifty-seven patients aged 18 to 40 years, with traumatic anterior shoulder instability, more than one episode of shoulder dislocation and at least six months since the first dislocation, who required surgery to treat the instability, were selected. Arthroscopic inspection was performed on all the patients to assess any associated lesions. RESULTS: The prevalence of lesions was assessed, and Bankart lesions were the most prevalent, followed by Hill-Sachs lesions, while rotator cuff injuries were the least prevalent. There was no correlation from comparison between the number of episodes of dislocation and the prevalence of associated lesions. On the other hand, in relation to the time since symptoms started, the patients who had had symptoms for longer times had fewer Hill-Sachs lesions. CONCLUSION: It was not possible to affirm that, in patients with chronic shoulder instability, the numbers of associated lesions increased with the time since symptoms started, or with the number of episodes of dislocation.

Prevalência das lesões associadas na luxação recidivante traumática do ombro / Prevalence of lesions associated with traumatic recurrent shoulder dislocation

OBJETIVO: Avaliar a prevalência das lesões associadas à instabilidade anterior traumática do ombro e a relação entre o número de episódios e o tempo do início dos sintomas com a prevalência destas lesões. MÉTODO: Foram selecionados 57 pacientes com instabilidade anterior traumática do ombro, entre 18 e 40 anos, com mais de um episódio de luxação do ombro e com no mínimo, seis meses da primeira luxação, que necessitaram de cirurgia para tratamento da instabilidade. Foi realizada inspeção artroscópica em todos os pacientes para avaliação das lesões associadas. RESULTADOS: Foi avaliada a prevalência das lesões, sendo a lesão de Bankart a mais prevalente seguida pela lesão de Hill-Sachs e as lesões do manguito rotador as menos prevalentes. Não houve correlação comparando o número de episódios de luxação com a prevalência de lesões associadas. Já em relação ao tempo de sintomas, os pacientes com maior tempo de sintomas tiveram menos lesão de Hill-Sachs. CONCLUSÃO: Não foi possível afirmar que, em pacientes com instabilidade crônica do ombro, as lesões associadas aumentam com o tempo de sintomas ou com o número de episódios de luxação.

OBJECTIVE: To evaluate the prevalence of lesions associated with traumatic anterior shoulder instability and the relationships between the prevalence of these lesions and the number of episodes and time since symptoms started. METHOD: Fifty-seven patients aged 18 to 40 years, with traumatic anterior shoulder instability, more than one episode of shoulder dislocation and at least six months since the first dislocation, who required surgery to treat the instability, were selected. Arthroscopic inspection was performed on all the patients to assess any associated lesions. RESULTS: The prevalence of lesions was assessed, and Bankert lesions were the most prevalent, followed by Hill-Sachs lesions, while rotator cuff injuries were the least prevalent. There was no correlation from comparison between the number of episodes of dislocation and the prevalence of associated lesions. On the other hand, in relation to the time since symptoms started, the patients who had had symptoms for longer times had fewer Hill-Sachs lesions. CONCLUSION: It was not possible to affirm that, in patients with chronic shoulder instability, the numbers of associated lesions increased with the time since symptoms started, or with the number of episodes of dislocation.