Risk Factors for Symptomatic Cyclops Lesion Formation after Anterior Cruciate Ligament Reconstruction / Fatores de risco para formação de lesão cyclops sintomática após a reconstrução do ligamento cruzado anterior

Abstract Objective To evaluate the incidence of symptomatic cyclops lesions requiring surgical treatment after anterior cruciate ligament (ACL) reconstruction and to establish possible intraoperative risk factors related to it. Methods Three hundred and eighty-nine patients aged between 18 and 50 years who underwent primary ACL reconstruction were retrospectively evaluated. Patients were divided into groups according to the presence or absence of symptomatic cyclops lesions, and their characteristics were compared. Patients with associated lesions that required additional surgical procedures (except anterolateral extra-articular procedures) were not included. The rate of symptomatic cyclops lesions was recorded and the following parameters were evaluated: age, gender, time from injury to surgery, graft type and diameter, femoral tunnel perforation technique, fixation type, presence of knee hyperextension, preservation of the ACL remnant, associated anterolateral extra-articular procedure, associated meniscal injury and participation in sports. Results 389 patients were evaluated and 26 (6.7%) patients developed cyclops. The patients with and without cyclops lesions did not differ in age, time from injury to surgery, graft type or diameter, surgical technique, femoral fixation method, presence of knee hyperextension, remnant preservation and associated meniscal injury. The group with cyclops lesion had a higher proportion of females (10 (38.4%) vs 68 (18.7%); OR = 2.7; p= 0.015), higher proportion of extra-articular reconstruction (18 (11.8%) vs 8 (3.4%); OR = 3.8; p= 0.001) and higher proportion of sports practice (23 (8.6%) vs 3 (2.5%); OR = 3.6; p= 0.026). Conclusion In our series, 6.7% of the patients required arthroscopic removal of cyclops lesions. Female gender, associated extra-articular reconstruction and sports practice were factors related to this lesion. Remnant preservation had no relationship with cyclops lesion formation.

Resumo Objetivo Avaliar a incidência de lesões cyclops sintomáticas que precisam de tratamento cirúrgico após a reconstrução do ligamento cruzado anterior (LCA) e estabelecer os possíveis fatores de risco intraoperatórios relacionados a elas. Métodos Trezentos e oitenta e nove pacientes com idades entre 18 e 50 anos submetidos à reconstrução primária do LCA foram avaliados de forma retrospectiva. Os pacientes foram divididos em grupos de acordo com a presença ou ausência de lesões cyclops sintomáticas e suas características foram comparadas. Não foram incluídos pacientes com lesões associadas que necessitassem de outros procedimentos cirúrgicos (à exceção de procedimentos extra-articulares ântero-laterais). A taxa de lesões cyclops sintomáticas foi registrada e os seguintes parâmetros foram avaliados: idade, sexo, tempo da lesão à cirurgia, tipo e diâmetro do enxerto, técnica de perfuração do túnel femoral, tipo de fixação, presença de hiperextensão do joelho, preservação do LCA remanescente, associação a procedimento extra-articular ântero-lateral, lesão de menisco associada e participação em esportes. Resultados Dos 389 pacientes avaliados, 26 (6,7%) desenvolveram lesão cyclops. Os pacientes com e sem lesão cyclops não diferiram quanto à idade, tempo da lesão à cirurgia, tipo ou diâmetro do enxerto, técnica cirúrgica, método de fixação femoral, presença de hiperextensão do joelho, preservação do LCA remanescente e lesão de menisco associada. O grupo com lesão cyclops apresentou mais mulheres (10 [38,4%] vs. 68 [18,7%]; razão de probabilidades [OR] = 2,7; p= 0,015), maior proporção de reconstrução extra-articular (18 [11,8%] vs. 8 [3,4 %]; OR = 3,8; p= 0,001) e maior proporção de prática esportiva (23 [8,6%] vs. 3 [2,5%]; OR = 3,6; p= 0,026). Conclusão Em nossa série, 6,7% dos pacientes necessitaram de remoção artroscópica das lesões cyclops. O sexo feminino, a reconstrução extra-articular associada e a prática esportiva foram fatores relacionados a essa lesão. A preservação do menisco remanescente não foi associada à formação de lesões cyclops.

Proprioception Analysis following Anterior Cruciate Ligament Reconstruction using Stabilometry: A Prospective, Longitudinal Study / Análise de propriocepção por estabilometria após a reconstrução do ligamento cruzado anterior: Um estudo prospectivo e longitudinal

Abstract Objective Commonly used methods for measuring proprioception have resulted in conflicting reports regarding knee proprioception with anterior cruciate ligament (ACL) rupture and the influence of ACL reconstruction. Methods One hundred subjects (50 patients with radiologically and arthroscopically confirmed unilateral ACL rupture and 50 normal controls) were assessed with regards to proprioception using dynamic single-leg stance postural stabilometry. Instrumented knee ligament laxity and knee outcome scores were also measured. Of the 50 patients in the ACL group, 34 underwent reconstruction and were reassessed postoperatively. Results There was a significant proprioceptive deficiency in the ACL group compared with their contralateral knee ( p < 0.001) and to the control group ( p = 0.01). There was asignificant improvement in knee proprioception following ACL reconstruction compared to preoperative findings ( p = 0.003). There was no correlation between ligament laxity measurements and outcome scores. A significant correlation was found preoperatively between outcome scores and proprioception measurements. This correlation was not found post-operatively. Pre-operative proprioception testing had asignificant correlation (r = 0.46) with post-operative proprioception ( p = 0.006). Conclusion Patients with an ACL rupture had a proprioceptive deficit which improved following ligament reconstruction. Knee outcome scores had a better correlation with proprioception than ligament laxity. Proprioception may be a superior objective measure than ligament laxity in quantifying functional knee deficits and outcomes in patients with ACL ruptures. Level of Evidence III Therapeutic Study; Prospective Longitudinal Case-Control Study.

Resumo Objetivo Os métodos comumente usados para medir a propriocepção resultaram em relatos conflitantes sobre a propriocepção do joelho com ruptura do ligamento cruzado anterior (LCA) e a influência da reconstrução do LCA. Métodos A propriocepção de 100 indivíduos (50 pacientes com ruptura unilateral do LCA confirmada à radiologia e artroscopia e 50 controles normais) foi avaliada por estabilometria postural dinâmica em apoio unipodal. A lassidão ligamentar do joelho instrumentado e suas pontuações de desfechos também foram medidas. Dos 50 pacientes do grupo LCA, 34 foram submetidos à reconstrução e reavaliados no período pós-operatório. Resultados O grupo LCA apresentou deficiência proprioceptiva significativa em relaçãoaojoelho contralateral ( p < 0,001) e ao grupo controle ( p = 0,01). A propriocepção do joelho melhorou de maneira significativa após a reconstrução do LCA em relação aos achados pré-operatórios ( p = 0,003). Não houve correlação entre as medidas de lassidão ligamentar e as pontuações de desfechos. Além disso, observamos uma correlação significativa entre as pontuações de desfechos e as medidas de propriocepção antes da cirurgia. Essa correlação não foi detectada no período pós-operatório. O teste pré-operatório de propriocepção teve correlação significativa ( r = 0,46) com a propriocepção pós-operatória ( p = 0,006). Conclusão Os pacientes com ruptura do LCA apresentaram déficit proprioceptivo que melhorou após a reconstrução ligamentar. As pontuações de desfecho do joelho tiveram melhor correlação à propriocepção do que a lassidão ligamentar. A proprio-cepção pode ser uma medida objetiva superior à lassidão ligamentar na quantificação de déficits funcionais e desfechos do joelho em pacientes com ruptura do LCA. Nível de Evidência III Estudo Terapêutico; Estudo de Caso-Controle Longitudinal Prospectivo.

Synovium and blood capillaries at the femoral attachment of anterior cruciate ligament are significantly abundant than those at the tibial attachment / Sinovial y capilares sanguíneos en la inserción femoral del ligamento cruzado anterior son significativamente más abundantes que los de la inserción tibial

SUMMARY: The anterior cruciate ligament (ACL) is a ligament that mainly controls the anterior and rotational mobility of the knee joint, and its surface is covered by a synovial membrane with large number of blood vessels. In general, nutritional supply to the ligament is from many capillaries in the adjacent synovium. However, statistical studies of the capillaries distributed to the ACL are insufficient. In this study, we examined cross-sectional histological images of the femoral attachment (femoral level), middle level of the tendon (middle level), and tibial attachment (tibial level) of the ACL and statistically analyzed blood capillary distribution among the three levels. The ACLs of 10 cadavers were divided into 5 equal sections, and 4mm-thick paraffin sections were made at the femoral level, middle level, and tibial level, and then hematoxylin-eosin (HE) staining were performed. The area of each transverse section was measured using Image-J 1.51n (U. S. National Institutes of Health, Bethesda, MD, USA). Fiber bundles of the ACL were relatively small and sparse in cross-sectional area at the femoral level and became larger and denser toward the tibial level. Many blood levels. The synovium at the attachment of ACL covered the surface of the fiber bundle and also penetrated deeply between the fiber bundles. In particular, the blood capillaries were densely distributed in the synovium at the femoral attachment rather than another two levels. Indeed, the number of capillaries were also most abundant in the femoral level. The cross-sectional ACL area at the femoral level is significantly small, however, the blood capillaries were most abundant. Therefore, when the ACL is injured, its reconstruction with preservation of the femoral ligamentous remnant may be clinically useful for remodeling of the grafted tendon.

El ligamento cruzado anterior (LCA) es un ligamento que controla principalmente la movilidad anterior y rotacional de la articulación de la rodilla, y su superficie está cubierta por una membrana sinovial con gran cantidad de vasos sanguíneos. En general, el suministro de nutrientes al ligamento proviene de muchos capilares en la sinovial adyacente. Sin embargo, los estudios estadísticos de los capilares distribuidos en el LCA son insuficientes. En este estudio, examinamos imágenes histológicas trans- versales de la inserción femoral (nivel femoral), el nivel medio del tendón (nivel medio) y la inserción tibial (nivel tibial) del LCA y analizamos estadísticamente la distribución de los capilares sanguíneos entre los tres niveles. Los LCA de 10 cadáveres se dividieron en 5 secciones iguales y se realizaron cortes en parafina de 4 µm de espesor a nivel femoral, medio y tibial, y luego se realizó tinción con hematoxilina-eosina (HE). El área de cada sección transversal se midió utilizando Image-J 1.51n (Institutos Nacionales de Salud de EE. UU., Bethesda, MD, EE. UU.). Los haces de fibras del LCA eran relativamente pequeños y escasos en el área de la sección transversal a nivel femoral y se hicieron más grandes y más densos hacia el nivel tibial. La membrana sinovial en la unión del LCA cubría la superficie del haz de fibras y también penetraba profundamente entre entre los haces de fibras. En particular, los capilares sanguíneos estaban densamente distribuidos en la unión femoral de la sinovial respecto a los otros dos niveles. De hecho, el número de capilares también fue más abundante a nivel femoral. El área transversal del LCA a nivel femoral era significativamente pequeña, sin embargo, los capilares sanguíneos fueron los más abundantes. Por lo tanto, cuando hay una lesión del LCA su reconstrucción con preservación del ligamento femoral remanente puede ser clínicamente útil para remodelar el tendón injertado.

Relationship of the Cruciate and Meniscofemoral Ligaments with the Knee Osteology. An Anatomical Study / Relação dos ligamentos cruzados e meniscofemorais com a osteologia do joelho: Um estudo anatômico

Abstract Objective To analyze the dimensions of the posterior cruciate ligament (PCL), anterior cruciate ligament (ACL), the presence of meniscus-femoral ligaments MFLs in human knees, and the correlation with the dimensions of the knee skeleton. Methods Anatomical study on 29 specimens of human knees in which we measured the length and width of the cruciate and meniscus-femoral ligaments and the dimensions of femoral and tibia condyles and the femoral notch. The ACL length was calculated with different degrees of knee flexion. The relationship between the ligaments and bone dimensions were analyzed. Results The length of the ACL and the PCL were similar. Posterior MFL was more frequent and longer than the anterior MFL. We found the posterior MFL in the 72.41% of the knees and anterior MFL in 20.69%. The ACL presented 30% of its maximum length up to 60°, approximately half of its length between 90° and 120°, reaching its maximum length at 170°. We found a strong correlation between the length of the ACL and that of the PCL (p= 0.001). However, the lengths of the ACL and PCL were not related with the bone dimensions. Conclusion We have found no correlations between the cruciate and MFLs and the anatomical dimensions of the intercondylar notch and the proximal tibia and distal femur. The presence of the posterior MFL was more frequent and longer than that of the anterior ligament.

Resumo Objetivo Analisar as dimensões do ligamento cruzado posterior (LCP), do ligamento cruzado anterior (LCA), a presença de ligamentos meniscofemorais (LMFs) em joelhos humanos e a correlação com as dimensões do esqueleto do joelho. Métodos Estudo anatômico em 29 espécimes de joelhos humanos nos quais medimos o comprimento e a largura dos ligamentos cruzado e meniscofemoral e as dimensões dos côndilos femorais e tibiais e do entalhe femoral. O comprimento do LCA foi calculado com diferentes graus de flexão do joelho. Analisou-se a relação entre os ligamentos e as dimensões ósseas. Resultados O comprimento do LCA e do LCP foram semelhantes, LMF posterior foi mais frequente e mais longo do que o LMF anterior. Foram encontradas LMF posterior em 72,41% dos joelhos e LMF anterior em 20,69%. O LCA apresentou 30% de seu comprimento máximo até 60°, aproximadamente metade de seu comprimento entre 90° e 120°, atingindo seu comprimento máximo com flexão de 170°. Encontramos uma forte correlação entre o comprimento do LCA e do LCP (p= 0,001). No entanto, os comprimentos do LCA e do LCP não estavam relacionados com as dimensões ósseas. Conclusão Não encontramos correlações entre os ligamentos cruzado e meniscofemoral e as dimensões anatômicas do entalhe intercondilar e da tíbia proximal e do fêmur distal. A presença do LMF posterior foi mais frequente e maior que a do ligamento anterior.

Calculation of the Minimal Important Clinical Difference of the Lysholm and IKDC Scores After Anterior Cruciate Ligament Reconstruction / Cálculo da mínima diferença clínica importante dos escores Lysholm e IKDC após reconstrução do ligamento cruzado anterior

Abstract Objective To calculate the minimal important clinical difference (MICD) value for the Lysholm and International Knee Documentation Committee (IKDC) scores in a sample of patients submitted to anterior cruciate ligament reconstruction. Methods Primary, observational, retrospective, analytical study of participants submitted to anterior cruciate ligament reconstruction from March 2019 to December 2020 by the same surgeon, with a minimum follow-up of 6 months, analysis of knee function in the pre- and postoperative period by the Lysholm and IKDC scores, and answer to an anchor question at 6 months postoperatively for the calculation of the MICD of each score. Results A total of 59 patients participated in the study, with a mean age of 27.1 ± 5.7 years old. In the comparison between pre- and postoperative scores of all groups, there was an increase in values with statistical significance after intervention. The MICD was 5.5 for the Lysholm score, and the MICD value for the IKDC score could not be determined. Conclusion For the Lysholm score, the calculation of the MICD value by the anchor question method in the sample evaluated was 5.5. It was not possible to determine the value of the MICD for the IKDC score.

Resumo Objetivo Calcular o valor da mínima diferença clinicamente importante (MDCI) para os escores de Lysholm e International Knee Documentation Commitee (IKDC) na amostra de pacientes submetidos a reconstrução de ligamento cruzado anterior. Métodos Estudo primário, observacional, retrospectivo, analítico, de participantes submetidos a reconstrução do ligamento cruzado anterior no período de março de 2019 a dezembro de 2020, pelo mesmo cirurgião, com seguimento mínimo de 6 meses, análise da função do joelho no período pré e pós-operatório pelos escores de Lysholm e IKDC, e resposta a uma pergunta âncora aos 6 meses de seguimento pós-operatório, para o MDCI de cada escore. Resultados Participaram do estudo 59 pacientes, com média de idade de 27,1 ± 5,7 anos. Na comparação dos escores pré- e pós-operatórios de todos os grupos, observa-se aumento dos valores com significância estatística após a intervenção. A MDCI foi de 5,5 para o escore de Lysholm, não tendo sido possível determinar o valor para o IKDC. Conclusão O cálculo do valor da MDCI pelo método da pergunta âncora, na amostra avaliada, foi de 5,5 para o escore de Lysholm. Não foi possível determinar o valor da MDCI para o IKDC.

Después de una cirugía de ligamento cruzado anterior, ¿cuándo puedo manejar? Evaluación postoperatoria de habilidades de conducción y de reacción de frenado / After anterior cruciate ligament surgery, when can I drive? Postoperative assessment of driving skills and braking reaction

Introducción: La mayoría de las personas que se someten a una reconstrucción del LCA están en edad de conducir, por lo tanto, es importante saber cuándo es seguro para el paciente reanudar la conducción. El objetivo de este trabajo es evaluar de manera prospectiva cuándo los pacientes recuperan las habilidades de manejo y de reacción de frenado después de la reconstrucción primaria de LCA, y compararlos con un grupo control de voluntarios sanos. Materiales y métodos: estudio prospectivo de una serie de pacientes que se sometieron a reconstrucción primaria del LCA utilizando injerto semitendinoso y recto interno. Se excluyeron pacientes en los que se empleó otro tipo de injerto o se les realizó otro gesto quirúrgico y laborales. Se evaluó la capacidad de volver a manejar de manera segura a las 2-3 semanas y a las 4-5 semanas postoperatorias mediante test de reacción simple y de resistencia a la monotonía, y se compararon los resultados con un grupo control de voluntarios sanos. Resultados: en total fueron ciento sesenta y seis pacientes, treinta fueron casos y ciento treinta y seis, controles. Se hallaron diferencias significativas (p = 0.03) entre los casos y controles en las pruebas realizadas tempranamente en cuanto a la aprobación, y no, de los test. Según el promedio en segundos obtenido en cada test realizado, se observan diferencias significativas en el primera prueba de resistencia a la monotonía (p = 0.0001) a favor del grupo control. Discusión: de acuerdo a la prueba de reacción simple y al test a la monotonía evaluados en nuestro trabajo, los pacientes que se someten a reconstrucción del LCA con autoinjertos de ST-RI están en condiciones de manejar un automóvil luego de las 4-5 semanas de la cirugía

Introduction: Most people who undergo ACL reconstruction are of driving age, it is important to know when it is safe for the patient to resume driving. The objective of this work was to prospectively evaluate when patients recover driving skills and brake reaction skills after ACL reconstruction and compare them with a control group of healthy volunteers. Materials and methods: prospective study of a series of patients who underwent primary ACL reconstruction using semitendinosus and medial rectus graft. Patients in whom another type of graft was used, or another surgical and labor gesture was performed, were excluded. The ability to return to driving safely at 2-3 weeks and 4-5 weeks postoperatively was evaluated using the simple reaction and resistance to monotony tests, and the results were compared with a control group of healthy volunteers.Results: a total of 166 patients, 30 are cases and 136 controls. Significant differences (p = 0.03) were found between cases and controls in the tests carried out early in terms of passing and not passing the tests. The relationship according to the average in seconds obtained in each test carried out, significant differences are observed in the first test of resistance to monotony (p = 0.0001) in favor of the control group. Discussion: according to the simple reaction test and the monotony test evaluated in our study, patients who undergo ACL reconstruction with ST-RI autografts are able to drive a car 4-5 weeks after surgery

Comparación cuantitativa de la ejecución de la maniobra de Lachman para su estandarización a través de software para dispositivo móvil / Quantitative comparison of the execution of the Lachman maneuver for its standardization through software for mobile devices

Introducción: la maniobra de Lachman es ampliamente empleada como recurso diagnóstico para detectar lesiones en el ligamento cruzado anterior (LCA) y, por su simplicidad, se tiende a pensar que no existe una variabilidad significativa en su ejecución. El presente estudio comparativo está centrado en utilizar los sensores integrados en un dispositivo móvil para encontrar, a través del índice de correlación intraclase, si las variaciones tanto intraobservador como interobservador son significativas. Materiales y métodos: se efectuaron dos ensayos llamados "Lachmatón", con doce residentes de ortopedia a modo de evaluadores y sujetos de prueba; el primer ensayo ayudó a identificar y describir las diferencias de los gestos de ejecución entre los evaluadores, mientras que el segundo permitió medir el incremento de la similitud de ejecución entre estos al ser instruidos, en contraste con el primer ensayo, donde no habían recibido ninguna instrucción; esto fue posible al medir la similitud características estadísticas y morfológicas de las señales adquiridas a través del índice de correlación intraclase. Resultados: se identificaron dos gestos importantes y que emiten señales con distinta forma al aplicarse, o no, a la ejecución de la maniobra: 1) fijar el pie y, 2) fijar el fémur. Se encontró una diferencia significativa entre ambos ensayos, así como entre los dos estilos más usados por los evaluadores. Conclusión: el uso de los sensores integrados en un dispositivo móvil para medir diferencias en la ejecución de la maniobra de Lachman ayudó a determinar los gestos que permiten una mayor reproducibilidad de esta maniobra. Nivel de Evidencia: III

Introduction: the Lachman maneuver was amplified as a diagnostic resource to detect injuries in the anterior cruciate ligament (ACL) and it tends to be thought, due to its simplicity, that there is no significant accumulation in its execution. This comparative study focuses on using the sensors integrated into a mobile device to find out whether the intraobserver or interobserver variations are significant, through the intraclass correlation coefficient. Materials and methods: two trials called "Lachmatón" will be carried out with twelve orthopedic residents as evaluators and test subjects; the first trial helped to identify and describe the differences in performance gestures between raters, while the second allowed measuring the increase in performance similarity between raters as instructors, in contrast to the first trial, where neither could instruction; This was possible by measuring the similarity of the statistical and morphological characteristics of the signals obtained through the intraclass achievement index.Results: two important gestures were identified, which emit signals in different ways when applied or not to the execution of the maneuver: 1) fix the foot and, 2) fix the femur. You will find that there is a significant difference between you and the evaluators. Conclusion: the use of sensors integrated into a mobile device to measure differences in the execution of the Lachman maneuver helped to determine the gestures that allow a greater reproducibility of this maneuver. Level of Evidence: III

Reconstrucción de ligamento cruzado anterior con isquiotibiales manteniendo su inserción tibial / ACL reconstruction with hamstring autograft maintaining tibial insertion

Introducción: La no desinserción tibial de semitendinoso-recto interno (ST-RI) parece constituir una opción para evitar la necrosis avascular en el proceso de ligamentización. El objetivo de nuestro trabajo es hacer una comparación entre ST-RI desinsertado versus ST-RI no desinsertado. Materiales y métodos: estudio comparativo, prospectivo, randomizado, doble ciego, para el que se formaron dos grupos. El grupo de estudio, conformado por treinta y ocho pacientes con plástica de LCA sin desinserción tibial de ST-RI; el grupo de control, de treinta y nueve pacientes con desinserción tibial. Se realizaron evaluaciones de RM a los seis meses del postoperatorio, se evaluaron el Coeficiente Señal ruido (CS) y la orientación del neoligamento en planos sagital, coronal y axial. La valoración clínica, a través de IKDC, Tegner Lysholm y KT-1000, fue efectuada por médicos en forma ciega.Resultados: el CS valorado por RM a los seis meses mostró diferencias significativas entre el grupo de estudio (14.4) y el de control (24.9) con un valor p <0.001. No existieron diferencias en cuanto a la orientación del injerto entre ambos grupos, ni en el plano sagital, coronal, ni axial. En cuanto al IKDC y Tegner Lysholm, sin diferencias entre grupos a los nueve meses. En el KT-1000 tampoco se encontraron diferencias entre grupos (p = 0.518).Discusión: la no desinserción tibial de ST-RI es una opción válida que podría evitar la fase de necrosis avascular de la ligamentización. Nuestros resultados, sustentados en RM, nos estimulan a utilizarla como una opción con cierta ventaja biológica.

Introduction: Non disinsertion of hamstring autograft tendons may result in avoiding cellular necrosis at the early stage of ligamentization process. The aim of this study was to compare between disinserted vs non disinserted hamstring autograft. Materials and methods: in this prospective, double-blind, randomised controlled trial, two groups were created. In the study group, hamstring tendon retraction (n=39) was performed. In the control group, maintaining tibial insertion (n=38) harvesting technique was used. Patients were evaluated with MRI after six months of follow-up. Graft maturity was evaluated with the signal-to-noise quotient (SNQ) and graft direction and orientation with sagittal, coronal, and axial views. Clinical outcomes were assessment of IKDC, Tegner-Lisholm activity level score and KT-1000 evaluation from a blind ortopaedic surgeon.Results: signal-to-noise quotient (SNQ) was significantly lower in non disinserted hamstring group (study group 14.4 vs control group 24.9-p = 0.001). There were no differences in graft direction between both groups. KT-1000 measurements showed no difference, the same as clinical outcomes assessment of IKDC and Tegner-Lisholm scores.Discussion: non disinserting hamstring tendons autograft is a valid option and may avoid the necrosis phase in ligamentization process. Our results, sustained on MRI imaging encourage us to use it with some biological advantage.

Correlation between spatial inclination of Blumensaat line and anterior cruciate ligament injury based on EOS biplanar 3D imaging system / 中国骨伤

OBJECTIVE@#To explore correlation between femoral mechanical axis and Blumensaat line (FMBL) angle of knee joint (angle between Blumensaat line and femoral mechanical axis), α angle (angle between Blumensaat line and axis of distal femur in sagittal plane) on EOS biplane imaging and non-contact anterior cruciate ligament(ACL) injury, and evaluate angle for its accuracy in predicting the populations prone to non-contact ACL injury.@*METHODS@#From February 2018 to October 2020, EOS imaging and clinical data from 88 patients (176 knees) with unilateral non-contact ACL injury were retrospectively analyzed, including 53 males and 35 females, aged from 18 to 45 years old with an average of (30.3±6.2) years old, 48 patients on the left side and 40 patients on the right side. The patients were divided into ACL-affected group and ACL-health group according to side of ACL injuries, and 51 patients (51 knees) with non-ACL identified from EOS database were included in normal control group, including 28 males and 23 females, aged from 20 to 44 years old with an average of (31.6±5.5) years old, 26 patients on the left side and 25 patients on the right side. Full-length EOS imaging of skeleton extremitatis inferioris among three groups were reconstructed to 3D images of skeletal system with EOS software, and then FMBL angle and α angle were measured on the images. Univariate binary Logistic regression analysis was performed to determine the influence of the univariate(FMBL angle or α angle) on ACL status(normal or torn). And the angle cutoff value for univariate was selected based on receiver operating characteristics curve (ROC) to got the best accuracy.@*RESULTS@#There was no statistically significant difference in age, gender and side distribution between ACL-injured group and normal control group(P>0.05). Statistical analyses (one-way ANOVA) indicated no significant difference in FMBL angle between ACL-injured knee group (32.8±2.3)° and ACL-injured contralateral knee group(32.5±2.3)°(P>0.05), but the values between two groups were significantly lower than that in normal control group (37.0±2.0)°(P<0.001). There was no statistically significant difference in α angle among three groups (P>0.05). Univariate binary Logistic regression analysis demonstrated that FMBL angle was risk factor for non-contact ACL injury[OR=0.433, 95%CI(0.330, 0.569), P<0.001]. The area under ROC curve for FMBL angle was 0.909[95%CI(0.861, 0.958), P<0.001], and the sensitivity and specificity were 70.5% and 98.0% respectively, cut-off value was 33.7°.@*CONCLUSION@#FMBL angle formed by Blumensaat line and femoral mechanical axis is one of the risk factors for non-contact ACL injury and has good predictive accuracy. The general population with FMBL angle below 33.7° may be increased risk for ACL injury.

Establishment of anterior cruciate ligament reconstruction model in cynomolgus monkey with autogenous hamstring tendon transplantation / 中国修复重建外科杂志

OBJECTIVE@#To investigate the feasibility of establishing an anterior cruciate ligament (ACL) reconstruction model using hamstring tendon autograft in cynomolgus monkeys.@*METHODS@#Twelve healthy adult male cynomolgus monkeys, weighing 8-13 kg, were randomly divided into two groups ( n=6). In the experimental group, the ACL reconstruction model of the right lower limb was prepared by using a single bundle of hamstring tendon, and the ACL of the right lower limb was only cut off in the control group. The survival of animals in the two groups was observed after operation. Before operation and at 3, 6, and 12 months after operation, the knee range of motion, thigh circumference, and calf circumference of the two groups were measured; the anterior tibial translation D-value (ATTD) was measured by Ligs joint ligament digital body examination instrument under the loads of 13-20 N, respectively. At the same time, the experimental group underwent MRI examination to observe the graft morphology and the signal/ noise quotient (SNQ) was caculated.@*RESULTS@#All animals survived to the end of the experiment. In the experimental group, the knee range of motion, thigh circumference, and calf circumference decreased first and then gradually increased after operation; the above indexes were significantly lower at 3 and 6 months after operation than before operation ( P<0.05), and no significant difference was found between pre-operation and 12 months after operation ( P>0.05). In the control group, there was no significant change in knee range of motion after operation, showing no significant difference between pre- and post-operation ( P>0.05), but the thigh circumference and calf circumference gradually significantly decreased with time ( P<0.05), and the difference was significant when compared with those before operation ( P<0.05). At 6 and 12 months after operation, the thigh circumference and calf circumference were significantly larger in the experimental group than in the control group ( P<0.05). At 3 and 6 months after operation, the knee range of motion was significantly smaller in the experimental group than in the control group ( P<0.05). Under the loading condition of 13-20 N, the ATTD in the experimental group increased first and then decreased after operation; and the ATTD significantly increased at 3, 6 months after operation when compared with the value before operation ( P<0.05). But there was no significant difference between the pre-operation and 12 months after operation ( P>0.05). There was no significant change in ATTD in the control group at 3, 6, and 12 months after operation ( P>0.05), and which were significantly higher than those before operation ( P<0.05). At each time point after operation, the ATTD was significantly smaller in the experimental group than in the control group under the same load ( P<0.05). The MRI examination of the experimental group showed that the ACL boundary gradually became clear after reconstruction and was covered by the synovial membrane. The SNQ at each time point after operation was significantly higher than that before operation, but gradually decreased with time, and the differences between time points were significant ( P<0.05).@*CONCLUSION@#The ACL reconstruction model in cynomolgus monkey with autogenous hamstring tendon transplantation was successfully established.

Reparación primaria versus reparación y aumentación con cinta de polietileno de alto peso molecular en lesiones del ligamento cruzado anterior: resultados funcionales / Primary repair versus repair and augmentation with high molecular weight polyethylene tape in ACL injuries. Functional results

Introducción: el objetivo del trabajo es evaluar y comparar resultados funcionales en pacientes que fueron sometidos a una reparación primaria del LCA y aquellos en quienes se efectuó reparación asociada con aumentación con cinta de polietileno. Materiales y métodos: se realizó un estudio comparativo en el que se analizaron ochenta y siete pacientes intervenidos quirúrgicamente por lesión proximal del LCA entre 2017 y 2019. El grupo 1, con lesión Sherman I, fue tratado con reparación primaria (cincuenta y seis pacientes). En el grupo 2, con lesiones Sherman II, se efectuó reparación más aumentación (treinta y un pacientes). Se evaluaron el IKDC (Lysholm, Tegner, International Knee Documentation Committee), WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index), y KOOS (Knee Injury and Osteoarthritis Score), preoperatorio y a los seis, doce y veinticuatro meses postoperatorios. Se consideraron significativas aquellas pruebas con p <0.001 (IC 95%). Los análisis estadísticos fueron llevados a cabo en el software estadístico R (R Core Team, 2022).Resultados: el índice de falla fue de 10.4% y 7.6% para los grupos 1 y 2, respectivamente, a los dos años del postoperatorio. Todos los scores mejoraron en el postoperatorio y fue estadísticamente significativa la diferencia con el preoperatorio a los seis y a los veinticuatro meses (p <0.001). El tipo de cirugía no tiene un efecto estadísticamente significativo en los scores clínicos. Conclusión: la reparación en una lesión proximal de LCA (Sherman I o II) es una buena alternativa quirúrgica que permite una mejoría rápida de los scores clínicos, buenos resultados y con bajo índice de complicaciones. Nivel de Evidencia: IV

Introduction: the objective of this study is to compare clinical and functional results in patients who underwent primary ACL repair and primary repair associated with augmentation with polyethylene tape. Materials and methods: eighty-seven patients who underwent surgery for proximal ACL injury between 2017 and 2019 were analyzed. The group 1, with Sherman I injury was treated with primary repair (fifty-six patients). In the group 2, with Sherman II lesions, repair plus augmentation was performed (thirty-one patients). IKDC (Lysholm, Tegner, International Knee Documentation Committee), WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index), and KOOS (Knee Injury and Osteoarthritis Score) were evaluated preoperatively and at six, twelve, and twenty-four months postoperatively. Those tests with p <0.001 (95% CI) were considered significant. Statistical analyzes were carried out in the statistical software R (R Core Team, 2022). Results: the failure rate was 10.4% and 7.6% for groups 1 and 2, respectively, at two years after surgery. All the scores improved in the postoperative period, with significant difference respect to the preoperative period at six and at twenty-four months (p <0.001). Type of surgery does not have a significant effect on clinical scores.Conclusion: repairing a proximal ACL injury (Sherman I or II) is a good surgical alternative, which allows fast improvement of clinical scores, good results and a low rate of complications. Level of Evidence: IV

En la búsqueda de predictores que nos ayuden a obtener un mejor resultado en la cirugía de revisión de ligamento cruzado anterior / In the search for predictors that help us obtain a better result in anterior cruciate ligament revision surgery

Introducción: Los factores de riesgo de re-ruptura de LCA son errores técnicos, características del injerto, lesiones meniscales, condrales o lesiones no tratadas. El objetivo de nuestro trabajo fue reconocer predictores modificables que nos ayuden a obtener un mejor resultado en la cirugía de revisión de LCA. Materiales y métodos: estudio descriptivo transversal. Serie de pacientes tratados en nuestro centro entre 2011 y 2021 a los cuales se les realizó cirugía de revisión de LCA. Se registraron edad, sexo, falla de cirugía primaria traumática, o no, fijación utilizada, ubicación de ambos túneles, injerto utilizado en la cirugía primaria, lesiones articulares condrales y meniscales antiguas y nuevas y tipo de injerto utilizado en cirugía de revisión. Resultados: se analizaron un total de ciento nueve pacientes. Con mayor frecuencia, los pacientes masculinos se sometieron a revisión entre los veinte y los cuarenta años. La principal causa traumática fue la práctica deportiva (40.37%), seguida de accidente de tránsito o en domicilio (7.33%) y en ambiente laboral (24.8%), y sin causa demostrable (27.5%). La mala posición del túnel femoral aislada fue la falla técnica más común en un 41.29%, sin error técnico en 38.53%, y falla de colocación de túnel tibial aislada en 2.75%. En el total de los pacientes evaluados, el 28.44% (treinta y un pacientes) no presentó lesión meniscal previa ni actual; mientras que el 71.56% (setenta y ocho pacientes) evidenció algún tipo de lesión. La elección del injerto fue autoinjerto de H-T-H (30.28%), aloinjerto de tibial posterior (30.28%), aloinjerto de tibial anterior (19.27%), autoinjerto de ST-RI (11.01%), y otros aloinjertos Aquiles, Peroneos y ST (9.17%).Discusión: serán necesarios más estudios para determinar si esta tasa de falla persiste a pesar de nuestro mayor conocimiento de la técnica y diversos aspectos de la cirugía de revisión. Nivel de Evidencia: IV

Introduction: Risk factors for ACL rupture are technical errors, graft characteristics, meniscal and chondral injuries, or untreated injuries. The objective of our work was to recognize modifiable predictors that help us obtain a better result in ACL revision surgery. Materials and methods: cross-sectional descriptive study. Series of patients treated at our center between 2011 and 2021 who underwent ACL revision surgery. Age, sex, traumatic or non-traumatic primary surgery failure, fixation used, location of both tunnels, graft used in primary surgery, old and new chondral and meniscal joint injuries and type of graft used in revision surgery were recorded. Results: a total of one hundred and nine patients were analyzed. Most often, male patients underwent revision between the ages of twenty and forty. The main traumatic cause was sports practice (40.37%), followed by traffic accident or at home (7.33%) and in the work environment (24.8%), and without demonstrable cause (27.5%). Isolated femoral tunnel malposition was the most common technical failure at 41.29%, no technical error at 38.53%, and isolated tibial tunnel placement failure at 2.75%. In all the patients evaluated, 28.44% (thirty-one patients) did not present a previous or current meniscal lesion; while 71.56% (seventy-eight patients) showed some type of injury. Graft choice was H-T-H autograft (30.28%), posterior tibial allograft (30.28%), anterior tibial allograft (19.27%), ST-RI autograft (11.01%), and other Achilles, fibular, and ST allografts (9.17%) Discussion: more studies will be necessary to determine if this failure rate persists despite our greater knowledge of the technique and various aspects of revision surgery. Level of Evidence: IV

ACL reconstruction associated with lateral extra-articular tenodesis with shared femoral tunnel

Recently, the anterolateral ligament has gained attention in knee surgery for its ability to improve rotational stability in ACL reconstructions. However, the lateral extra-articular tenodesis (LET) procedure, which involves creating a femoral tunnel using the modified Lemaire technique, presents a risk of overlapping with the femoral tunnel used in the ACL reconstruction. This can lead to complications and limit the success of the surgery. To avoid these issues without needing additional fixation, we describe an easily reproducible surgical technique in which a single femoral tunnel is shared for both ACL reconstruction and LET using the iliotibial tract

Recientemente, el ligamento anterolateral ha ganado atención en la cirugía de rodilla por su capacidad para mejorar la estabilidad rotacional en las reconstrucciones del LCA. Sin embargo, el procedimiento de tenodesis lateral extraarticular (TLE), que implica la creación de un túnel femoral utilizando la técnica modificada de Lemaire, presenta un riesgo de solapamiento con el túnel femoral utilizado en la reconstrucción del LCA. Esto puede provocar complicaciones y limitar el éxito de la cirugía. Para evitar estos problemas, sin necesidad de una fijación adicional, describimos una técnica quirúrgica fácilmente reproducible en la que se comparte un solo túnel femoral tanto para la reconstrucción del LCA como para LET utilizando el tracto iliotibial

Anatomical Study of the Medial Region of the Knee: Qualitative, Quantitative Analysis and Description of the Anterior Oblique Ligament / Estudo anatômico da região medial do joelho: Análise qualitativa, quantitativa e descrição do ligamento oblíquo anterior

Abstract Objective To describe all ligamentous, capsular, tendinous and bone landmarks structures of the medial region of the knee, as well as a new ligamentous structure identified in a series of anatomical dissections of cadaveric specimens. Methods Twenty cadaver knees were dissected to study the medial compartment. The main structures of this region were identified during dissection. The morphology of the structures and their relationship with known anatomical parameters were determined both qualitatively and quantitatively. The collected data were analyzed and interpreted using descriptive statistics. Results In the dissection of all specimens, all ligamentous structures previously described in the anatomical study of the medial part of the knee were identified, and objective measures that can help as parameters for surgical ligament reconstruction were identified. When dissecting the medial collateral ligament, a bony prominence immediately distal to its proximal tibial insertion was observed and described, as well as a bursa below the ligament, in which it was not inserted. We also described a ligamentous structure with extracapsular location, originated anteriorly to the medial epicondyle and following obliquely towards the tibia. These structures were named, respectively, interinsertional tubercle, interinsertional bursa and anterior oblique ligament. Conclusion In addition to the description and measurement of the structures and parameters already existing in the anatomical study of the medial part of the knee, it was possible to describe three new structures not yet described in the literature: the interinsertional tubercle, the interinsertional bursa, and the anterior oblique ligament. These structures were found in all dissections performed.

Resumo Objetivo Descrever todas as estruturas ligamentares, capsulares, tendinosas e marcos ósseos da região medial do joelho, assim como uma nova estrutura ligamentar identificada em uma série de dissecções anatômicas de espécimes cadavéricos. Métodos Vinte joelhos de cadáveres foram dissecados para estudar o compartimento medial. As principais estruturas dessa região foram identificadas durante a dissecção. A morfologia das estruturas e sua relação com parâmetros anatômicos conhecidos foram determinados tanto de forma qualitativa quanto de forma quantitativa. Os dados coletados foram analisados e interpretados por meio de estatística descritiva. Resultados Na dissecção de todos os espécimes, foram identificadas todas as estruturas ligamentares já descritas anteriormente no estudo anatômico da porção medial do joelho, e foram realizadas medidas objetivas que podem auxiliar como parâmetros para a reconstrução ligamentar cirúrgica. Foram observados e descritos, ainda, ao se desprender o ligamento colateral medial superficial, uma proeminência óssea imediatamente distal à sua inserção tibial proximal, uma bursa abaixo do ligamento, na qual o mesmo não se mostrava inserido, assim como uma estrutura ligamentar localizada extracapsularmente e com origem na face anterior do epicôndilo medial, seguindo obliquamente em direção à tíbia, aos quais foram dados os nomes, respectivamente, de tubérculo interinsercional, bursa interinsercional e ligamento oblíquo anterior. Conclusão Além da descrição e medida das estruturas e parâmetros já existentes no estudo anatômico da porção medial do joelho, foi possível a descrição de três novas estruturas: o tubérculo interinsercional a bursa interinsercional e o ligamento oblíquo anterior, ainda não descritos na literatura. Essas estruturas foram encontradas em todas as dissecções realizadas.

Assessment of The Addition of Epinephrine to Intra-articular Bupivacaine for the Control of Acute Pain in Patients underwent to Anterior Cruciate Ligament Reconstruction / Avaliação da adição da epinefrina à bupivacaína intra-articular no controle da dor aguda em pacientes submetidos a reconstrução do ligamento cruzado anterior

Abstract Objective To evaluate postoperative pain, using the visual analog scale (VAS), in patients undergoing anterior cruciate ligament reconstruction (ACLR) and receiving intra-articular anesthetic solutions. Methods The present is a randomized clinical trial with a sample of 48 patients divided into 4 groups: Group I (n » 12) - 20 mL of saline solution (control); Group II (n » 12) - 20 mL of 0.5% bupivacaine; Group III (n » 12) - 20 mL of 0.5% bupivacaine þ 0.1 mg of epinephrine; and Group IV (n » 12) - 20 mL of saline solution þ 0.1 mg of epinephrine. These solutions were injected into the knee at the end of the surgery. Pain was assessed using the VAS immediately and 6, 12, 24 and 48 hours after the procedure. Results The VAS scores were highly variable among the groups. A Kruskal-Wallis analysis of variance (ANOVA), considering a level of significance of 5%, revealed that all intra-articular anesthetic solutions influenced the assessment of pain (p » 0.003), and that Group-III subjects presented less postoperative pain. There was no evidence of a higher or lower use of supplemental analgesic agents, or of adverse effects resulting from these anesthetic solutions. Conclusion Bupivacaine combined with epinephrine was the most effective solution for pain control in patients undergoing ACLR, but with no statistically significant differences when compared to Group II (p » 0.547). There was no decrease or increase in the use of supplemental analgesics or in the occurrence of adverse systemic effects (p > 0.05).

Resumo Objetivo Avaliar primariamente a dor pós-operatória, por meio da escala visual analógica (EVA), nos pacientes submetidos a reconstrução do ligamento cruzado anterior (RLCA) que receberam soluções anestésicas intra-articulares (IAs). Métodos Ensaio clínico randomizado com uma amostra de 48 pacientes, divididos em 4 grupos: Grupo I (n » 12) - 20 ml de solução fisiológica (controle); Grupo II (n » 12) - 20 ml de bupivacaína a 0,5%; Grupo III (n » 12) - 20 ml de bupivacaína a 0,5% þ 0,1 mg de epinefrina; e Grupo IV (n » 12) - 20 ml de solução fisiológica þ 0,1 mg de epinefrina, injetados no joelho ao término da cirurgia. A dor foi avaliada pela EVA imediatamente e 6, 12, 24 e 48 horas após o procedimento. Resultados Observou-se grande variabilidade nos resultados da EVA entre os pacientes avaliados em cada grupo. Verificou-se, pela análise de variância (analysis of variance, ANOVA) de Kruskal-Wallis, considerando um nível de 5% de significância, que as soluções anestésicas IAs de cada grupo influenciaram na avaliação da dor desses pacientes (p » 0,003), sendo os do Grupo III os que apresentaram menor dor pósoperatória. Não se evidenciou um maior ou menor consumo de drogas analgésicas suplementares, ou efeitos adversos das decorrentes das soluções empregadas. Conclusão A solução combinada de bupivacaína e epinefrina foi a mais eficaz no controle da dor nos pacientes submetidos a RLCA, mas sem diferenças estatisticamente significativas com relação ao grupo II (p » 0,547). Não se observou diminuição ou aumento no consumo de analgésicos suplementares, ou o aparecimento de efeitos sistêmicos adversos (p > 0,05).

High frequency transcutaneous electrical stimulation in the immediate postoperative period of anterior cruciate ligament reconstruction: a randomized clinical trial / Estimulação elétrica transcutânea de alta frequência no pós operatório imediato de reconstrução do ligamento cruzado anterior: um ensaio clínico randomizado

INTRODUCTION: The anterior cruciate ligament (ACL) is an important structure for knee stability. Transcutaneous electrical nerve stimulation (TENS) is an electrical current applied for significant pain relief. OBJECTIVE: To evaluate the effects of high-frequency TENS on the immediate postoperative period of ACL reconstruction. METHODS: 46 patients in the postoperative period of ACL reconstruction were randomly assigned to a control group (CG=23) and a TENS group (TG=23). Knee range of motion (ROM), pain, muscle strength, and drug intake were assessed before surgery and 24 and 48 hours after surgery. The TENS intervention protocol started in the recovery room, shortly after surgery, and was maintained continuously for the first 48 hours after surgery. RESULTS: The TENS group (TG) significantly controlled the increased level of postoperative pain (p<0.05) and significantly increased flexion ROM (p<0.05). When compared to the Control group (CG), the TENS group had a lower intake of ketoprofen (48.27%), diazepam (256.98%), and dipyrone (121.21%), morphine (320.77%), and tramadol (437.46%). CONCLUSION: Continuous high-frequency TENS significantly reduced pain intensity and significantly improved ROM, muscle strength, and drug intake in the postoperative period of ACL reconstruction.

Avaliação isocinética da força de contração excêntrica dos músculos isquiotibiais no período pré-operatório de pacientes com lesão de ligamento cruzado anterior / Isokinetic assessment of eccentric hamstring strength in the preoperative period of patients with anterior cruciate ligament injury

Introdução: A força de contração excêntrica é uma moderna medida para definir diferentes parâmetros no estudo da Ortopedia moderna, sendo considerada uns dos recentes temas mais discutidos no quesito ganho de força muscular. O objetivo do trabalho foi analisar o estado da musculatura flexora da coxa (isquiotibiais), através da avaliação de sua força de contração excêntrica, por meio do dinamômetro isocinético no período pré-operatório nos pacientes com lesão de ligamento cruzado anterior. Métodos: Estudo retrospectivo observacional entre agosto e dezembro de 2018 de uma clínica especializada em atendimento em Criciúma/SC. Resultados: A média do pico de torque excêntrico da musculatura posterior da coxa em flexão do membro afetado foi de 27,60 ± 10,56 kg, e do membro contralateral atingiu 27,47 ± 6,91 kg. O déficit de força entre os membros teve uma mediana de 9,14 % (0,0 - 61,45), e o tempo médio entre a lesão e o exame isocinético foi de 10,0 (1,0 - 48,0) meses. Observou-se que os maiores déficits de força foram encontrados naqueles indivíduos que tinham maior intervalo de tempo entre a lesão e a realização da avaliação isocinética. Conclusão: Nos indivíduos submetidos ao teste de dinamometria isocinética após lesão do ligamento cruzado anterior, evidenciou-se um déficit na força de contração excêntrica da musculatura isquiotibial entre o membro afetado e contralateral, o que ratifica achados da literatura a respeito da biomecânica articular do joelho. Além disso, maiores déficits foram encontrados naqueles pacientes com maior intervalo de tempo para realização do exame isocinético.

Introduction: Eccentric strength is a modern measurement for defining different parameters in the study of modern orthopaedics, being considered one of the most widely discussed topics in recent times within the subject of muscle strength gain. The aim of this work was to analyze the state of flexor muscles in the thigh (hamstring muscles) by evaluating their eccentric strength with an isokinetic dynamometer during the preoperative period of patients with anterior cruciate ligament injury. Methods: This is a retrospective observational study performed between August and December 2018 at a specialized clinic in Criciúma/SC. Results: The mean eccentric peak torque of the hamstring muscles during flexion of the affected limb was 27.60 ± 10.56 kg and that for the contralateral limb was 27.47 ± 6.91 kg. The strength deficit between limbs had a median value of 9.14% (0.0­61.45) and the mean time between the injury and isokinetic testing was 10.0 (1.0­48.0) months. Higher strength deficits were observed in individuals who had longer periods between the injury and isokinetic testing. Conclusion: In individuals who underwent isokinetic testing after an anterior cruciate ligament injury, there was a deficit between the eccentric hamstring strength of the affected limb and that of the contralateral limb, which corroborates findings in the literature regarding the biomechanics of the knee joint. Moreover, larger deficits were found in patients with longer periods between the injury and isokinetic testing.

Quadricipital Tendon: Option in Knee Ligament Reconstruction / Tendão quadricipital: Opção na reconstrução ligamentar do joelho

Abstract Although it is a versatile tendon, only 1% of surgeons choose to use the quadricipital tendon as a graft in anterior cruciate ligament (ACL) reconstruction. The present article aims to describe a quadricipital graft removal technique in which its deepest part is maintained. The technique consists of an approach in which the first incision is made in the medial part of the quadricipital tendon to prevent it from getting too short. This is due to its triangular design. The technique also addresses the depth and identification of the three layers of the quadricipital tendon so that it is possible to preserve its deepest part. This approach aims to preserve the extensor apparatus and to not communicate it with the joint environment, avoiding fluid extravasation both in the trans and postoperative periods.

Resumo Ainda que seja um tendão versátil, apenas 1% dos cirurgiões optam por utilizar o tendão quadricipital como enxerto na reconstrução do ligamento cruzado anterior (LCA). O presente artigo tem o objetivo de descrever uma técnica de retirada do enxerto quadricipital na qual a sua porção mais profunda é mantida. A técnica consiste em uma abordagem na qual a primeira incisão é feita na porção medial do tendão quadricipital para evitar que ele fique muito curto. Isso acontece devido ao seu desenho triangular. A técnica também aborda a profundidade e a identificação das três camadas do tendão quadricipital para que seja possível preservar sua porção mais profunda. Esta conduta tem o objetivo de uma maior preservação do aparelho extensor e de não haver comunicação com o meio articular, evitando extravasamento de líquido tanto no trans- quanto no pós-operatório.

Eleccion de injertos en la cirugía de reconstrucción del ligamento cruzado anterior: revisión de conceptos actuales / Anterior cruciate ligament reconstruction. Graft selection. Current Concepts

La ruptura del ligamento cruzado anterior (LCA) es una lesión frecuente en la población general, con una incidencia de hasta 75/100.000 personas por año. Hombres y mujeres jóvenes, involucrados en deportes de contacto y colisión, suelen ser los más afectados. La reconstrucción artroscópica se ha convertido en el estándar de tratamiento, con cerca de doscientos mil procedimientos por año en EEUU. Los injertos se clasifican según sus elementos constituyentes (hueso-tendón-hueso, hueso-tendón o tendón), o el origen del dador (autoinjerto o aloinjerto). A pesar de su alta prevalencia, el injerto ideal sigue siendo motivo de debate en la bibliografía. Consideramos que su elección debe basarse en la experiencia del cirujano con los diferentes injertos y en las características individuales de cada paciente

Anterior cruciate ligament (ACL) tear is a common injury in the general population, with an incidence of up to 75/100,000 annually, affecting mainly men and women involved in contact and collision sports. With nearly 200,000 procedures performed annually in the US, arthroscopic reconstruction has become the standard treatment. Grafts can be classified according to their constituent elements (bone-tendon-bone, bone-tendon or tendon) or the origin of the donor (autograft or allograft). Despite its high prevalence, today the bibliographic debate continues regarding which is the ideal graft. We consider that graft selection should be based on the experience and comfort of the surgeon and the individual patient characteristics

Estudio anatómico de las porciones tendinosas de los músculos semitendinoso y grácil, aplicado a la reconstrucción del ligamento cruzado anterior / Anatomical study of gracilis and semitendinosus muscles tendons applied to ACL reconstruction

Introducción: La reconstrucción del ligamento cruzado anterior (LCA) con injerto autólogo con la porción tendinosa de los músculos grácil y semitendinoso ha ganado popularidad. El emplazamiento de la incisión para cosechar dicho injerto y la cantidad de tejido disponible son claves a la hora de su utilización. El estudio cadavérico y ecográfico permite evaluar mejor sus propiedades con aplicación quirúrgica.Materiales y métodos: estudio descriptivo transversal. Se disecaron veinticuatro miembros inferiores de adultos, formolados. Se realizó ecografía de partes blandas en dieciocho miembros inferiores de adultos de ambos sexos. Se midieron los tendones de los músculos grácil y semitendinoso en longitud y diámetro. Se topografió su inserción en relación al borde anterior de la tibia (BAT) y a la interlínea articular (IA). Resultados: en el estudio cadavérico, la inserción promedio del grácil fue a 2.7 cm del BAT y 4.6 cm de la IA, y del semitendinoso fue a 2.7 cm del BAT y 5.7 cm de la IA. El diámetro y longitud de los tendones fue de 0.55 cm y 13.29 cm, respectivamente, para el grácil y de 0.68 cm y 16.42 cm para el semitendinoso. La ecografía mostró valores estadísticamente distintos en todas las variables. Se establecieron regresiones lineales significativas entre el largo de la pierna y la longitudes de los tendones, así como la distancia a la IA.Conclusiones: el presente estudio aporta información precisa sobre el punto de inserción de los dos músculos. Las propiedades morfológicas de ambos tendones se prestan para su utilización como injerto. La ecografía no mostró resultados comparables con los cadavéricos

Introduction: Anterior cruciate ligament (ACL) using autologous hamstring graft, with gracilis and semitendinosus muscles tendons, has gained popularity. Incision emplacement for harvesting the aforementioned graft, and tissue availability are key points when considering its utilization. Cadaveric and ultrasonography study allows a better evaluation of its properties, with surgical application.Materials and methods: descriptive cross-sectional study. Twenty-four adult formaldehyde-fixed lower limbs were dissected, there were limbs of both sexes. Soft tissue ultrasonography was performed in eighteen lower limbs of adults of both sexes. The tendons of the gracilis and semitendinosus muscles were measured in length and diameter. Their insertion was surveyed in relation to tibial anterior border (TAB) and joint line (JL). The results obtained were compared, with a p value <0.05 considered significant.Results: in cadaveric study, mean insertion site for gracilis was 2.7 cm medial to TAB and 4.6 distal to JI, and for semitendinosus it was 2.7 cm medial to TAB and 5.7 cm distal to JI. Diameter and length of tendon was 0.55 cm and 13.29 cm respectively for gracilis, and 0.68 cm and 16.42 for semitendinosus. Ultrasonography showed statistically different results for all variables. Significant lineal regressions were established between leg length and tendon length or distance of insertion to JI.Conclusions: the present study provides precise information on the insertion point of both muscles, applied to ACL reconstruction. Morphological properties of both tendons allow their use as grafts. Ultrasound did not show comparable results with cadaveric study