RESUMO
PURPOSE: The aim of this consensus project was to give recommendations regarding surgical treatment of the anterior cruciate ligament (ACL) injured patient. METHODS: For this consensus process, an expert, steering and rating group was formed. In an initial online meeting, the steering group, together with the expert group, formed various key topic complexes for which multiple questions were formulated. For each key topic, a structured literature search was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Sufficient consensus was defined as 80% agreement. RESULTS: During this consensus process, 30 topics regarding the surgical management and technique of ACL reconstruction were identified. The literature search for each key question resulted in 30 final statements. Of these 30 final statements, all achieved consensus. CONCLUSIONS: This consensus process has shown that surgical treatment of ACL injury is a complex process. Various surgical factors influence patient outcomes. The proposed treatment algorithm can be used as a decision aid for the surgeon. LEVEL OF EVIDENCE: Level V.
Assuntos
Lesões do Ligamento Cruzado Anterior , Reconstrução do Ligamento Cruzado Anterior , Humanos , Algoritmos , Ligamento Cruzado Anterior/cirurgia , Lesões do Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior/métodos , ConsensoRESUMO
OBJECTIVES: Implementing evidence-based recommendations with the option of patient-individualised and situation-specific adaptations in telerehabilitation may increase adherence with improved clinical outcome. METHODS: As part of a registry-embedded hybrid design (part 1), digital medical device (DMD)-usage in a home-based setting was analysed in a multinational registry. The DMD combines an inertial motion-sensor system with instructions for exercises and functional tests on smartphones. A prospective, single-blinded, patient-controlled, multicentre intervention study (DRKS00023857) compared implementation capacity of the DMD to standard physiotherapy (part 2). Usage patterns by health care providers (HCP) were assessed (part 3). RESULTS AND CONCLUSION: Registry raw data (10,311 measurements) were analysed from 604 DMD-users, demonstrating clinically expected rehabilitation progression post knee injuries. DMD-users performed tests for range-of-motion, coordination and strength/speed enabling insight to stage-specific rehabilitation (χ2 = 44.9, p<0.001). Intention-to-treat-analysis (part 2) revealed DMD-users to have significantly higher adherence to the rehabilitation intervention compared to the matched patient-control-group (86% [77-91] vs. 74% [68-82], p<0.05). DMD-users performed recommended exercises at home with higher intensity (p<0.05). HCP used DMD for clinical decision making. No adverse events related to the DMD were reported. Adherence to standard therapy recommendations can be increased using novel high quality DMD with high potential to improve clinical rehabilitation outcome, enabling evidence-based telerehabilitation.
RESUMO
PURPOSE: The aim of this consensus project was to create a treatment algorithm for the management of the ACL-injured patient which can serve as an aid in a shared decision-making process. METHODS: For this consensus process, a steering and a rating group were formed. In an initial face-to-face meeting, the steering group, together with the expert group, formed various key topic complexes for which various questions were formulated. For each key topic, a structured literature search was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Sufficient consensus was defined as 80% agreement. RESULTS: During this consensus process, 15 key questions were identified. The literature search for each key question resulted in 24 final statements. Of these 24 final statements, all achieved consensus. CONCLUSIONS: This consensus process has shown that ACL rupture is a complex injury, and the outcome depends to a large extent on the frequently concomitant injuries (meniscus and/or cartilage damage). These additional injuries as well as various patient-specific factors should play a role in the treatment decision. The present treatment algorithm represents a decision aid within the framework of a shared decision-making process for the ACL-injured patient. LEVEL OF EVIDENCE: Level V.
Assuntos
Lesões do Ligamento Cruzado Anterior , Traumatismos do Joelho , Menisco , Humanos , Ligamento Cruzado AnteriorRESUMO
PURPOSE: The aim of this consensus project was to validate which endogenous and exogenous factors contribute to the development of post-traumatic osteoarthritis and to what extent ACL (anterior cruciate ligament) reconstruction can prevent secondary damage to the knee joint. Based on these findings, an algorithm for the management after ACL rupture should be established. METHODS: The consensus project was initiated by the Ligament Injuries Committee of the German Knee Society (Deutsche Kniegesellschaft, DKG). A modified Delphi process was used to answer scientific questions. This process was based on key topic complexes previously formed during an initial face-to-face meeting of the steering group with the expert group. For each key topic, a comprehensive review of available literature was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Consensus was defined a-priori as eighty percent agreement. RESULTS: Of the 17 final statements, 15 achieved consensus, and 2 have not reached consensus. Results of the consensus were summarized in an algorithm for the management after ACL rupture (infographic/Fig. 2). CONCLUSION: This consensus process has shown that the development of post-traumatic osteoarthritis is a complex multifactorial process. Exogenous (primary and secondary meniscus lesions) and endogenous factors (varus deformity) play a decisive role. Due to the complex interplay of these factors, an ACL reconstruction cannot always halt post-traumatic osteoarthritis of the knee. However, there is evidence that ACL reconstruction can prevent secondary joint damage such as meniscus lesions and that the success of meniscus repair is higher with simultaneous ACL reconstruction. Therefore, we recommend ACL reconstruction in case of a combined injury of the ACL and a meniscus lesion which is suitable for repair. LEVEL OF EVIDENCE: Level V.
Assuntos
Lesões do Ligamento Cruzado Anterior , Menisco , Osteoartrite , Humanos , Ligamento Cruzado Anterior/cirurgia , Lesões do Ligamento Cruzado Anterior/cirurgia , Articulação do Joelho/cirurgia , Menisco/cirurgia , Osteoartrite/complicações , Ruptura/complicaçõesRESUMO
BACKGROUND: Although anterior cruciate ligament (ACL) tear-prevention programs may be effective in the (secondary) prevention of a subsequent ACL injury, little is known, yet, on their effectiveness and feasibility. This study assesses the effects and implementation capacity of a secondary preventive motor-control training (the Stop-X program) after ACL reconstruction. METHODS AND DESIGN: A multicenter, single-blind, randomized controlled, prospective, superiority, two-arm design is adopted. Subsequent patients (18-35 years) with primary arthroscopic unilateral ACL reconstruction with autologous hamstring graft are enrolled. Postoperative guideline rehabilitation plus Classic follow-up treatment and guideline rehabilitation plus the Stop-X intervention will be compared. The onset of the Stop-X program as part of the postoperative follow-up treatment is individualized and function based. The participants must be released for the training components. The endpoint is the unrestricted return to sport (RTS) decision. Before (where applicable) reconstruction and after the clearance for the intervention (aimed at 4-8 months post surgery) until the unrestricted RTS decision (but at least until 12 months post surgery), all outcomes will be assessed once a month. Each participant is consequently measured at least five times to a maximum of 12 times. Twelve, 18 and 24 months after the surgery, follow-up-measurements and recurrence monitoring will follow. The primary outcome assessement (normalized knee-separation distance at the Drop Jump Screening Test (DJST)) is followed by the functional secondary outcomes assessements. The latter consist of quality assessments during simple (combined) balance side, balance front and single-leg hops for distance. All hop/jump tests are self-administered and filmed from the frontal view (3-m distance). All videos are transferred using safe big content transfer and subsequently (and blinded) expertly video-rated. Secondary outcomes are questionnaires on patient-reported knee function, kinesiophobia, RTS after ACL injury and training/therapy volume (frequency - intensity - type and time). All questionnaires are completed online using the participants' pseudonym only. Group allocation is executed randomly. The training intervention (Stop-X arm) consists of self-administered home-based exercises. The exercises are step-wise graduated and follow wound healing and functional restoration criteria. The training frequency for both arms is scheduled to be three times per week, each time for a 30 min duration. The program follows current (secondary) prevention guidelines. Repeated measurements gain-score analyses using analyses of (co-)variance are performed for all outcomes. TRIAL REGISTRATION: German Clinical Trials Register, identification number DRKS00015313 . Registered on 1 October 2018.
Assuntos
Lesões do Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior , Ligamento Cruzado Anterior/cirurgia , Serviços Hospitalares de Assistência Domiciliar , Atividade Motora , Volta ao Esporte , Prevenção Secundária/métodos , Adolescente , Adulto , Ligamento Cruzado Anterior/diagnóstico por imagem , Ligamento Cruzado Anterior/fisiopatologia , Lesões do Ligamento Cruzado Anterior/diagnóstico por imagem , Lesões do Ligamento Cruzado Anterior/fisiopatologia , Reconstrução do Ligamento Cruzado Anterior/efeitos adversos , Feminino , Alemanha , Humanos , Masculino , Estudos Multicêntricos como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função Fisiológica , Recidiva , Método Simples-Cego , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: The objective of the study was to compare the results of a primary anterior cruciate ligament reconstruction (ACLR) using the press-fit fixation technique for a quadriceps tendon (QT) graft to a standard quadrupled hamstring (HT) graft with interference screw fixation. METHODS: A retrospective cohort study with a 12-month follow up provided data for 92 patients. Exclusion criteria were accompanying ligament injuries and contralateral ACL injury. Patients who suffered a graft failure, which was defined as a side-to-side difference of > 3 mm, or infection were rated 'D' according to the IKDC and excluded from further evaluation. Forty-six patients underwent primary ACLR using the press-fit fixation technique for autologous bone QT graft. These patients were matched in terms of age, gender, accompanying meniscus tear and cartilage injury to 46 patients who underwent standard HT graft with interference screw fixation. Patients were evaluated according to the Lachman test, Pivot-Shift test, IKDC score, Tegner score, Rolimeter measurements, one-leg hop test, thigh circumference and donor side morbidity. RESULTS: No significant differences in Tegner score (p = 0.9), subjective or objective IKDC score (p = 0.9;p = 0.6), knee stability (Lachman Test p = 0.6; Pivot-Shift Test p = 0.4; Side-to-Side Difference p = 0.4), functioning testing (One-Leg Hop Test p = 0.6; Thigh Circumference p = 0.4) or donor side morbidity (p = 0.4) were observed at the follow up. The Lachman test was negative for 85% of the QT group and 83% of the HT group. The Pivot Shift Test was negative for 80% of the QT group and 85% of the HT group. The mean side-to-side difference was 1.6 ± 0 .2mm in both groups. The one-leg hop test revealed a collateral-side jumping distance of 96.2 ± 8.5% for the QT group and 95.5 ± 8.5% for the HT group. The thigh circumference of the injured leg was 98.3 ± 3.0% on the uninjured side in the QT group and 99.7 ± 3.0% in the HT group. A knee walking test resulted in no discomfort for 90% of the QT group and 85% of the HT group. The graft failure rate was 7.3% in the QT group and 9.8% in the HT group. CONCLUSION: QT grafts fixated using the press-fit technique are a reliable alternative for primary ACL surgery.
Assuntos
Reconstrução do Ligamento Cruzado Anterior/métodos , Parafusos Ósseos , Músculos Isquiossurais/transplante , Fixadores Internos , Músculo Quadríceps/transplante , Tendões/transplante , Adulto , Lesões do Ligamento Cruzado Anterior/diagnóstico , Lesões do Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior/instrumentação , Reconstrução do Ligamento Cruzado Anterior/tendências , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Análise por Pareamento , Estudos Retrospectivos , Fatores de Tempo , Doadores de Tecidos , Transplante de Tecidos/métodos , Adulto JovemRESUMO
PURPOSE: To investigate whether pre-soaking the graft in vancomycin during anterior cruciate ligament reconstruction (ACLR) reduces the postoperative infection rate and if this technique is associated with an increased rate of complications, including graft failure or arthrofibrosis. METHODS: A retrospective review of a prospective database was performed in 1779 patients who underwent ACLR over a period of 5 years, analysing the rate of postoperative deep knee infection. Group 1 and 2 both received perioperative IV antibiotics, while only group 2 underwent ACLR with grafts pre-soaked in a 5 mg/ml vancomycin solution. To analyse possible side effects associated with vancomycin use, 500 patients out of the overall study population (100 patients per year) were randomly selected and retrospectively interviewed for further postoperative complications including graft failure and arthrofibrosis as well as subjective evaluation of their knee by completing the IKDC form with a minimum mean follow-up of 37 months. RESULTS: In group 1, 22 out of 926 (2%) patients suffered a postoperative deep knee infection. In contrast, there were no postoperative infections in the second group of 853 patients (0%). 16 of 22 infections (73%) were caused by coagulase-negative Staphylococcus. Statistical analysis revealed a significantly reduced postoperative infection rate when bathing the autograft in vancomycin (p < 0.01). Analysis of the random sample revealed a significant decrease of graft failure with 8 reruptures in 257 patients (3%) in the vancomycin group compared to 16 cases of graft failure in 167 patients (10%) in the control group (p < 0.05). No differences were found in the rate of postoperative arthrofibrosis, Tegner or subjective outcome scores. CONCLUSION: Prophylactic vancomycin pre-soaking of autografts during ACLR appears to be a viable, cost-effective and safe option to reduce the rate of deep infection compared to systemic antibiotics alone. LEVEL OF EVIDENCE: III.
Assuntos
Lesões do Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior/métodos , Articulação do Joelho/cirurgia , Infecção da Ferida Cirúrgica/prevenção & controle , Vancomicina/uso terapêutico , Adulto , Antibacterianos/uso terapêutico , Autoenxertos , Feminino , Rejeição de Enxerto , Humanos , Artropatias/cirurgia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/cirurgia , Estudos Prospectivos , Estudos Retrospectivos , Transplante Autólogo , Transplantes/cirurgia , Adulto JovemRESUMO
PURPOSE: The quantification of posterior knee laxity is crucial in the evaluation of injuries to the posterior cruciate ligament (PCL) as it has important implications to the treatment for these injuries. The objective of this study was to compare the test results of stress radiography and instrumented drawer testing (Rolimeter) for the assessment of posterior knee laxity in patients with PCL injury. METHODS: In 45 patients with an injury to the PCL, lateral radiographs of both knees were obtained under anterior and posterior tibial load (150 N) using a standardized approach. Patients with injury of the ACL to either knee were excluded from the study. During the same clinic visit, an instrumented measurement of anterior-posterior knee laxity was performed at 90° of knee flexion by an experienced examiner using the Rolimeter device. The mean side-to-side differences (SSD) of both (radiographic and instrumented) measurements were compared to each other, and the correlation was calculated using the Pearson coefficient. RESULTS: The SSD (affected/healthy side) of posterior translation determined from the radiographs was 8.2 ± 3.2 mm, and the SSD of the instrumented measurement testing was 7.6 ± 3.2 mm. The mean difference between radiographic and Rolimeter test results was 1.8 ± 1.5 mm. The Pearson's correlation coefficient revealed a good correlation between both measurements of 0.74. CONCLUSIONS: It may be suggested by the results of this study that under the absence of an ACL injury and a fixed posterior drawer sign, the Rolimeter is a suitable tool to assess the posterior laxity of the knee in the clinical setting. Its advantages are the absence of radiation to the patient, its availability, and the low cost. Therefore, the Rolimeter device may serve as a valuable alternative to stress radiography in the evaluation of PCL-injured patients. LEVEL OF EVIDENCE: II.
Assuntos
Instabilidade Articular/diagnóstico por imagem , Traumatismos do Joelho/diagnóstico por imagem , Articulação do Joelho/diagnóstico por imagem , Ligamento Cruzado Posterior/lesões , Amplitude de Movimento Articular/fisiologia , Estresse Mecânico , Adulto , Feminino , Humanos , Instabilidade Articular/etiologia , Instabilidade Articular/fisiopatologia , Traumatismos do Joelho/complicações , Traumatismos do Joelho/fisiopatologia , Articulação do Joelho/fisiopatologia , Masculino , RadiografiaRESUMO
BACKGROUND: Patients with a history of anterior cruciate ligament rupture are at elevated risk of developing knee osteoarthritis. Altered knee kinematics and kinetics during functional activities have been viewed as risk factors for cartilage breakdown and, therefore, one of the primary goals of anterior cruciate ligament reconstruction is to restore knee joint function. METHODS: Patients' (n=18) knee mechanics while performing a single leg hop for distance were calculated for both legs using a soft-tissue artifact optimized rigid lower-body model at the pre-reconstruction state and six and twelve months after anterior cruciate ligament reconstruction. FINDINGS: Independent of the analyzed time point the involved leg showed a lower external flexion and adduction moment at the knee, and an increased anterior translation and external rotational offset of the shank with respect to the thigh compared to the uninvolved leg. There were no differences for any of the analyzed knee kinematic and kinetic parameters within the control subject group. INTERPRETATION: The identified kinematic changes can cause a shift in the normal load-bearing regions of the knee and may support the view that the risk of developing knee osteoarthritis in an anterior cruciate ligament ruptured joint while performing activities involving frequent landing and stopping actions is less likely to be associated with the knee adduction moment and is rather due to kinematic changes. Anterior cruciate ligament reconstruction surgery failed to restore normal knee kinematics during landing, potentially explaining the persistent risk for the development of knee osteoarthritis in patients who have returned to sports following reconstruction surgery.
Assuntos
Reconstrução do Ligamento Cruzado Anterior/reabilitação , Ligamento Cruzado Anterior/fisiopatologia , Articulação do Joelho/fisiopatologia , Adulto , Fenômenos Biomecânicos/fisiologia , Estudos de Casos e Controles , Feminino , Humanos , Joelho/fisiopatologia , Traumatismos do Joelho/fisiopatologia , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Movimento , Amplitude de Movimento Articular , Rotação , Ruptura/fisiopatologia , Coxa da Perna/fisiopatologia , Suporte de CargaRESUMO
BACKGROUND: The purpose of this article was to evaluate the risks and benefits of non-operative treatment versus surgical excision of a fabella causing posterolateral knee pain. We performed a systematic review of literature and also present two case reports.Twelve publications were found in a PubMed literature review searching the word "fabella syndrome". Non-operative treatment and surgical excision of the fabella has been described. CASE PRESENTATION: Two patients presented to our outpatient clinic with persisting posterolateral knee pain. In both cases the presence of a fabella was identified, located in close proximity to the posterolateral femoral condyle. All other common causes of intra- and extra articular pathologies possibly causing the posterolateral knee pain were excluded.Following failure to respond to physiotherapy both patients underwent arthroscopy which excluded other possible causes for posterolateral knee pain. The decision was made to undertake surgical excision of the fabella in both cases without complication.Both patients were examined 6 month and one year after surgery with the Tegner activity score, the Visual Analogue Scale (VAS), and International Knee Documentation Committee Score (IKDC). CONCLUSION: Consistent posterolateral pain during exercise might indicate the presence of a fabella syndrome. Resecting the fabella can be indicated and is a minor surgical procedure with minimal risk. Despite good results in the literature posterolateral knee pain can persist and prevent return to a high level of sports. LEVEL OF EVIDENCE: IV, case reports and analysis of literature.
Assuntos
Artralgia/etiologia , Joelho/patologia , Músculo Esquelético/patologia , Ossos Sesamoides/patologia , Adolescente , Adulto , Idoso , Artralgia/cirurgia , Artroscopia , Exercício Físico , Humanos , Joelho/diagnóstico por imagem , Masculino , Músculo Esquelético/cirurgia , Manejo da Dor , Neuropatias Fibulares/etiologia , Radiografia , Recuperação de Função Fisiológica , Ossos Sesamoides/diagnóstico por imagem , Ossos Sesamoides/cirurgia , Esportes , SíndromeRESUMO
INTRODUCTION: Interference screw fixation of soft tissue grafts has been a widely used fixation technique for cruciate ligament reconstruction. Suturing of the graft construct prior to graft fixation has been proposed to increase fixation strength; however, the effect on mechanical properties has not been well characterized. The goal of this study was to determine whether uniform suturing of the tendon graft affects (1) ultimate fixation strength of the hamstring tendon graft and (2) motion of the tendon in the bone tunnel during cyclic loading when comparing sutured grafts vs. unsutured grafts. METHOD: Eight pairs of matched mature porcine tibias (age <2 years) and eight paired fresh-frozen human quadrupled hamstring tendon grafts were used. One quadrupled graft from each pair was placed into one of two groups. In the group A a single cerclage suture 3 cm from the doubled end of the graft was placed to join the four tendon strands. In group B a heavy suture was used to tightly unite the four strands of tendon graft to provide a better grip for the interference screw during fixation. The grafts were placed in tibial bone tunnels that matched the graft's diameter and fixed with an interference screw. The looped end of the graft and the attached tibia were rigidly fixed in a material testing machine. The graft constructs were subjected to 100 cycles of 20-250 N load, followed by a load-to-failure test. In addition, a motion analysis system was used during cyclic testing to better determine the amount of elongation at the graft-tunnel interface. Statistical analysis of the failure load and stiffness and the overall elongation following cyclical loading was performed using the Wilcoxon rank sum test. Level of significance was set at p < 0.05. RESULTS: Elongation at the tendon-bone interface during sub-maximal cyclic loading was 2.4 ± 1.4 mm (unsutured) vs. 2.0 ± 0.7 mm (sutured) (p > 0.05). Failure load of the grafts without sutures (634 ± 86 N) was significantly lower than with the sutures (837 ± 183 N). Ultimate stiffness of group A (283 ± 34 N/mm) was lower than that of group B (331 ± 51 N/mm); however, this was not statistically significant (p = 0.051). CONCLUSION: This study confirms that suturing of the graft construct before interference screw fixation may increase ultimate failure load. However, an improvement of structural properties in response to cyclic loading with sub-maximal loads could not be confirmed. Clinicians using interference screw fixation may suture the graft to improve fixation strength; however, suturing does not appear to allow a more aggressive rehabilitation after surgery.
Assuntos
Suturas , Tendões/transplante , Animais , Fenômenos Biomecânicos , Humanos , Técnicas In Vitro , Suínos , Tendões/cirurgia , TíbiaRESUMO
PURPOSE: This longitudinal study aimed to examine whether patients with anterior cruciate ligament (ACL) reconstruction show a similar landing strategy during the single-leg hop test (SLHT) postsurgery analog to that previously identified when ACL deficient. It is hypothesized that ACL-reconstructed patients demonstrate greater trunk flexion to reduce knee joint moments at the cost of postural dynamic stability at their involved leg compared to their uninvolved leg. METHODS: Ten ACL-reconstructed patients performed a bilateral SLHT 6 and 12 months after surgery. Landing mechanics were determined by means of a soft tissue artifact optimized, rigid, full-body model, and the margin of stability was quantified using an inverted pendulum approach. Knee extensor muscular strength (KS) was assessed during isometric maximal voluntary knee extension contractions. RESULTS: ACL-reconstructed patients showed similar landing strategies as previously reported in their ACL-deficient state. By flexing their trunk, patients repositioned the ground reaction force vector more anteriorly in relation to the joints of the lower extremity (P < 0.05) and, in doing so, were able to transfer joint moments from the knee to the adjacent joints (P < 0.05). This upper body strategy reduced the margin of stability in the ACL-reconstructed leg during landing (P < 0.05). Twelve months after surgery, the ACL-reconstructed leg showed lower KS compared to the uninvolved leg (P < 0.05), and knee joint moment output during landing was significantly correlated to KS. CONCLUSIONS: The results highlight the important role of KS on the interaction between trunk angle, joint kinetics, and postural dynamic stability during landing and show that ACL-reconstructed patients use an analogous feedforward strategy (e.g., more flexed trunk) to that used in their ACL-deficient state, aiming to compensate for KS deficits and thereby sacrificing postural dynamic stability and increasing the risk of loss of balance during landing maneuvers.
Assuntos
Lesões do Ligamento Cruzado Anterior , Traumatismos do Joelho/fisiopatologia , Joelho/fisiopatologia , Movimento , Força Muscular , Adulto , Reconstrução do Ligamento Cruzado Anterior , Fenômenos Biomecânicos , Humanos , Traumatismos do Joelho/cirurgia , Estudos Longitudinais , Músculo Esquelético/fisiologia , Tronco/fisiologia , Suporte de Carga , Adulto JovemRESUMO
OBJECTIVE: Application of an arthroscopic suture system to restore the form and function of the meniscus by adaptation of a longitudinal tear close to the base. INDICATIONS: Unstable longitudinal tears near the base of the meniscus, mainly in the posterior horn of the medial or lateral of the meniscus. Dislocated bucket-handle tears of the medial and lateral meniscus close to the base. CONTRAINDICATIONS: Poor tissue quality with fibrillated meniscal tissue. Meniscal tears in the avascular zone (zone I). Insufficient blood supply from the joint capsule and the base of the meniscus. Degenerative meniscal lesions. Anterior or posterior knee joint instability. Allergic reactions to nonresorbable suture material. SURGICAL TECHNIQUE: Standard anterior arthroscopic portals. Arthroscopic assessment of the meniscal tear using the probe. Revitalization of the tear margins and perforation of the meniscal base to induce bleeding. Adaptation of the tear margins and fixation with a suture-anchor system using an ipsilateral standard portal for tears in the posterior horn or by way of a contralateral standard portal for tears in the lateral horn. POSTOPERATIVE MANAGEMENT: Full weight bearing with the knee in extension in a knee immobilizer, relative to the pain threshold in the 1st postoperative week. Range of motion exercises without weight bearing from full extension to 90 degrees knee flexion (0/0/90). If simultaneous reconstruction of the anterior cruciate ligament (ACL) is being performed, rehabilitation protocols follow the principles for ACL reconstruction. RESULTS: Since the year 2000, meniscal tears in more than 300 patients have been repaired with the all-inside suture system. In the context of a multicenter study by ESSKA (European Society for Sports Medicine, Surgery and Arthroscopy) involving 20 patients, the result was evaluated by direct MRI arthrography (gadolinium). The suture bar anchors were generally not detectable, the incision channels produced a hypodense signal in the meniscus tissue. If re-rupture occurred, it was because the meniscus had pulled out of the suture loop. Cartilaginous lesions were not found. There were no complications related to the nonresorbable suture bar anchors.
Assuntos
Artroscópios , Traumatismos do Joelho/cirurgia , Meniscos Tibiais/cirurgia , Técnicas de Sutura/instrumentação , Lesões do Menisco Tibial , Artrografia , Europa (Continente) , Humanos , Imageamento por Ressonância Magnética , Estudos Multicêntricos como Assunto , Cuidados Pós-Operatórios , Complicações Pós-Operatórias/diagnóstico por imagem , Instrumentos CirúrgicosRESUMO
We report about the case of a 4(1/2)-year delayed screw fixation of a tibial posterior cruciate ligament (PCL) avulsion fracture in combination with a posterolateral stabilization. After open reduction and rigid screw fixation, combined with a posterolateral stabilization using a semitendinosus tendon autograft, the patient returned to full activity in sports and daily life. If the PCL substance is sufficient, a delayed refixation in an old PCL avulsion injury seems to be a viable alternative to PCL reconstruction.
Assuntos
Traumatismos do Joelho/cirurgia , Ligamento Cruzado Posterior/lesões , Ligamento Cruzado Posterior/cirurgia , Tendões/transplante , Fraturas da Tíbia/cirurgia , Adulto , Parafusos Ósseos , Fixação Interna de Fraturas/instrumentação , Humanos , Masculino , Fraturas da Tíbia/complicações , Fatores de Tempo , Transplante AutólogoRESUMO
After replacement of the anterior cruciate ligament with a free tendon graft, the substitute initially is avascular and without a synovial surface. To ensure long-term survival, the graft must become revascularized. Despite numerous studies on the topic, there still is discussion regarding revascularization. The goal of the current study was to investigate the endoligamentous microcapillary revascularization of the free tendon graft after anterior cruciate ligament replacement with time. Thirty-six mature sheep had an anterior cruciate ligament reconstruction with an ipsilateral flexor tendon split graft. Midsubstance tissue samples were immunostained for von Willebrand factor (Factor VIII) at 6, 9, 12, 24, 52, and 104 weeks to detect the endothelial cells of capillaries. Cross sections of vessels were determined in three zones (subsynovial, intermediate, and center of the graft) and were evaluated by means of histomorphometry using a digital imaging analysis system. The observations showed that capillary vessels, which originate from the synovial envelope, invaded the avascular graft tissue from the surface toward the center zone. The highest level of vascular density was found after 6 weeks, reaching the vascular status of the native anterior cruciate ligament after 24 weeks. These findings are in contrast to the findings of previous studies in animals. The current study showed, for the first time, the kinetics of an endoligamentous revascularization of a free tendon graft at the capillary level. In the current model, the process of revascularization terminated earlier than previously described.
Assuntos
Lesões do Ligamento Cruzado Anterior , Tendões/irrigação sanguínea , Tendões/transplante , Animais , Feminino , Membro Posterior , Imuno-Histoquímica , Modelos Animais , Procedimentos de Cirurgia Plástica , Ovinos , Fatores de TempoRESUMO
Several grafts and several fixation techniques have been introduced for PCL reconstruction over the past years. To date, autograft and allograft tissues are recommended for PCL reconstruction, whilst synthetic grafts should be avoided. Autograft tissues include the bone-patellar tendon-bone graft, the hamstrings and the quadriceps tendon. Allograft tissues are increasingly being used for primary PCL reconstruction. The use of allograft tissues requires a number of formal prerequisites to be fulfilled. Besides the previous mentioned graft types allograft tissues include Achilles and tibialis anterior/posterior tendons. To date no superior graft type has been identified. Several techniques and devices have been used for fixation of a PCL replacement graft. Most of these were originally developed for ACL reconstruction and then adapted to PCL reconstruction. However, biomechanical requirements of the PCL differ substantially from those of the ACL. To date, requirements for PCL graft fixations are not known. From a systematic approach femoral graft fixation can either be achieved within the bone tunnel (nearly anatomic) with an interference screw or outside the bone tunnel on the medial femoral condyle using a staple, an endobutton or a screw. Tibial graft fixation can be achieved either with an interference screw in the bone tunnel or with a staple, screw/washer or sutures tied over a bone bridge outside the bone tunnel (extra-anatomic). An alternative fixation on the tibial side is the inlay technique that reduces the acute angulation of the graft at the posterior aspect of the tibia. Further research is necessary to identify the differences between the various fixation techniques.
Assuntos
Procedimentos Ortopédicos/métodos , Ligamento Cruzado Posterior/lesões , Ligamento Cruzado Posterior/cirurgia , Tendões/transplante , Fenômenos Biomecânicos , Fêmur/cirurgia , Humanos , Articulação do Joelho/cirurgia , Patela/cirurgia , Resistência à Tração/fisiologia , Tíbia/cirurgia , Transplante Autólogo , Transplante HomólogoRESUMO
A new method is presented to quantify the extent of posterolateral knee laxity. Stress computed tomography (CT) is performed to determine external rotation of the tibia on both knees. Manual maximum external torque is applied to the tibia from both feet by an examiner while both femurs are stabilized by a tape at approximately 30 degree of knee flexion. CT images are acquired at this position and side-to-side differences of external rotation are determined from the images by standard computer software. The technique is simple and helps to quantify posterolateral knee laxity before and after surgical procedures of posterolateral knee reconstruction.