Rigidez en cirugía de reconstrucción del ligamento cruzado anterior / Knee stiffness in anterior cruciate ligament reconstruction

La rigidez de rodilla en cirugía de Reconstrucción del Ligamento Cruzado Anterior (R-LCA) es una complicación devastadora, alcanzando una incidencia variable entre el 4% y el 38%. La definición de artrofibrosis es aún poco clara, lo que ha llevado a distintos esquemas terapéuticos. Conocer la etiopatogenia es clave para entender los procesos y las posibles alternativas de tratamiento. Distintas clasificaciones han sido descritas, siendo la de Shelbourne la más usada, debido a su valor pronóstico asociado. El objetivo del tratamiento en una rodilla estable es mejorar la movilidad articular, la satisfacción del paciente, y disminuir el riesgo de artrosis a largo plazo. El tratamiento se puede dividir en quirúrgico y conservador. Ese último, se enfoca principalmente en buscar la causa y lograr una prevención e intervención temprana, siendo el manejo que con mayor frecuencia se realiza. El tratamiento quirúrgico es una opción cuando el tratamiento conservador falla. Se realizó una revisión de la literatura y de 150 pacientes sometidos a R-LCA, de los cuales 4 presentaron artrofibrosis a un seguimiento de 2 años. Además, presentamos nuestro algoritmo de manejo terapéutico.

Knee stiffness in Anterior Cruciate Ligament Reconstruction (ACL-R) is a devastating complication, with a variable incidence of 4% to 38%. The definition of arthrofibrosis is still unclear, which has led to different therapeutic schemes. Knowing the etiopathogenesis is key to understanding the processes and possible treatment alternatives. Different classifications have been described, with Shelbourne being the most used, due to its associated prognostic value. The aim of treatment in a stable knee is to improve joint mobility, patient satisfaction, and decrease the risk of long-term osteoarthritis. The treatment can be divided into operative and non-operative. The latter focuses mainly on finding the cause and achieving prevention and early intervention, being the management that is most frequently performed. Surgical treatment is an option when conservative treatment fails. A review of the literature and of 150 patients undergoing R-LCA was performed, of which 4 presented arthrofibrosis at a 2-year follow-up. In addition, we present our therapeutic management algorithm.

Physical therapists' role in prevention and management of patellar tendinopathy injuries in youth, collegiate, and middle-aged indoor volleyball athletes

ABSTRACTPatellar tendinopathy is highly prevalent in all ages and skill levels of volleyball athletes. To illustrate this, we discuss the clinical, biomechanical, and ultrasound imaging presentation and the intervention strategies of three volleyball athletes at different stages of their athletic career: youth, middle-aged, and collegiate. We present our examination strategies and interpret the data collected, including visual movement analysis and dynamics, relating these findings to the probable causes of their pain and dysfunction. Using the framework of the EdUReP concept, incorporating Education, Unloading, Reloading, and Prevention, we propose intervention strategies that target each athlete's specific issues in terms of education, rehabilitation, training, and return to sport. This framework can be generalized to manage patellar tendinopathy in other sports requiring jumping, from youth to middle age, and from recreational to elite competitive levels.

A conceptual framework for a sports knee injury performance profile (SKIPP) and return to activity criteria (RTAC)

ABSTRACTInjuries to the knee, including intra-articular fractures, ligamentous ruptures, and meniscal and articular cartilage lesions, are commonplace within sports. Despite advancements in surgical techniques and enhanced rehabilitation, athletes returning to cutting, pivoting, and jumping sports after a knee injury are at greater risk of sustaining a second injury. The clinical utility of objective criteria presents a decision-making challenge to ensure athletes are fully rehabilitated and safe to return to sport. A system centered on specific indicators that can be used to develop a comprehensive profile to monitor rehabilitation progression and to establish return to activity criteria is recommended to clear athletes to begin a progressive and systematic approach to activities and sports. Integration of a sports knee injury performance profile with return to activity criteria can guide clinicians in facilitating an athlete's safe return to sport, prevention of subsequent injury, and life-long knee joint health.

Preliminary analysis of knee stress in Full Extension Landing

OBJECTIVE: This study provides an experimental and finite element analysis of knee-joint structure during extended-knee landing based on the extracted impact force, and it numerically identifies the contact pressure, stress distribution and possibility of bone-to-bone contact when a subject lands from a safe height. METHODS: The impact time and loads were measured via inverse dynamic analysis of free landing without knee flexion from three different heights (25, 50 and 75 cm), using five subjects with an average body mass index of 18.8. Three-dimensional data were developed from computed tomography scans and were reprocessed with modeling software before being imported and analyzed by finite element analysis software. The whole leg was considered to be a fixed middle-hinged structure, while impact loads were applied to the femur in an upward direction. RESULTS: Straight landing exerted an enormous amount of pressure on the knee joint as a result of the body's inability to utilize the lower extremity muscles, thereby maximizing the threat of injury when the load exceeds the height-safety threshold. CONCLUSIONS: The researchers conclude that extended-knee landing results in serious deformation of the meniscus and cartilage and increases the risk of bone-to-bone contact and serious knee injury when the load exceeds the threshold safety height. This risk is considerably greater than the risk of injury associated with walking downhill or flexion landing activities. .

Avaliação da reprodutibilidade das classificações de Outerbridge e da SFA para lesões condrais do joelho / Assessment of the reproducibility of the Outerbridge and SFA classifications for chondral lesions of the knee

OBJETIVO: Avaliar a reprodutibilidade da classificação de Outerbridge e da Sociedade Francesa de Artroscopia entre diferentes observadores e estabelecer uma comparação entre elas. MÉTODO: Foram utilizados 30 vídeos de artroscopia de joelho selecionados aleatoriamente demonstrando lesões condrais que foram classificadas por seis observadores, dois residentes em ortopedia do terceiro ano e quatro ortopedistas, entre os quais dois especialistas em cirurgia de joelho. A avaliação da reprodutibilidade intra e interobservador foi feita através do índice estatístico de Kappa. RESULTADOS: Como resultado da avaliação completa da classificação de Outerbridge com a totalidade dos observadores, encontramos um índice Kappa de 0,434411. Quanto à classificação proposta pela Sociedade Francesa de Artroscopia, encontramos um índice Kappa de 0,45166. CONCLUSÃO: A classificação de Outerbridge e da Sociedade Francesa de Artroscopia para lesões condrais é moderadamente reprodutível entre observadores. Comparando as duas classificações, a proposta pela Sociedade Francesa de Artroscopia se mostrou mais reprodutível, e os autores sugerem o uso dessa classificação como de escolha para a prática clínica da avaliação das lesões condrais do joelho.

OBJECTIVE: To assess the reproducibility of the Outerbridge and the French Society of Arthroscopy classifications between different observers, and to establish a comparison between them. METHOD: Thirty videos on randomly selected knee arthroscopy procedures demonstrating chondral lesions were used. These were classified by six observers: two third-year orthopedics residents and four orthopedic surgeons, of whom two were knee surgery specialists. The intraobserver and interobserver reliability was evaluated by means of the kappa index. RESULTS: The result from the complete evaluation on the Outerbridge classification with all the observers gave a kappa index of 0.434411. For the classification proposed by the French Society of Arthroscopy, the kappa index was 0.45166. CONCLUSION: The Outerbridge and French Society of Arthroscopy classifications for chondral lesions are moderately reproducible between observers. Comparing the two classifications, the proposal from the French Society of Arthroscopy was shown to be more reproducible, and the authors suggest that this classification should be used preferentially in clinical practice for evaluations on chondral lesions of the knee.

Assessment of motor units recruitment at the knee extensor muscles

Biomechanical conditions of limbs can affect on motor unit recruitment [MUR] markedly. Surface Electromyography [SEMG] is an approach for evaluation of muscle activities and onset time during different fimctions. The purpose of this study is to use SEMG for detection of central motor control in different functions of knee extensor muscles. Ten healthy subjects contributed in this study. They were done five repetitions of knee flexion/extension in open and close chain separately during recording of SEMG simultaneously. Integrated EMG [iEMG] of three middle repeated cycles were detected according to chain [open- close] and kind of contraction [concentric- eccentric].then the Average of three slope of iEMG compared to each other. There were not significant differences in MUR of three extensor muscles for concentric and eccentric contractions in open chain but vastus medialis and lateralis muscles showed significant changes in close chain [P<0.05]. Result showed that there were significant differences of MUR for two kind of muscle contractions between open and close chains [P<0.05]. Recruitment of motor units has not shown difference in open chain between concentric and eccentric contractions. This process indicates representative similarity of control pattern in two kind of contraction in open chain. Concentric contraction at close chain cycle has more MUR in comparison with eccentric contraction. It is equal to more interference of contractible compartment in concentric to eccentric contraction. This happens due to the nature of two kind of contraction particularly in close chain cycle. Comparison between two chains indicated that more motor units contribute in close chain [concentric and eccentric]. It means that motor unit recruitment increased due to effect of increase of load in close chain

Meniscorresis en pacientes con rodilla estable / Meniscal repair in stable knee

Objectives: The objective of the present study is to describe the functional outcome of a group of patients treated with meniscal suture in a stable knee. Materials and Methods: Retrospective study. 21 patients with unstable meniscal lesions and stable knees. A minimum follow up of 6 months. Lysholm and Cincinnati functional scales were applied to all of them. Failure of a meniscal suture was defined as the need of redoing the meniscal suture or the need of a meniscectomy right at the previous meniscal suture. Results: The average age was 29.6 years, 87.5 percent men. The time between lesion and surgery was 43.2 days. In 13 patients the compromised meniscus was the medial. Outside-in technique was used in 13 patients (62 percent); inside-out in 7(33 percent) and all inside in one patient (4.8 percent). 4 patients (20 percent) developed a meniscal suture failure so they were subjected to a partial arthroscopic meniscectomy. The average follow up was 43.5 months with a median of 42.8 months. In terms of the functional evaluation, the average Lysholm score was 92.4 and the EVA was 88.7. Conclusion: In our group of patients, good functional results were achieved for this follow up period The rate of failure was similar to the one described in the literature for meniscal sutures concomitant with LCA reconstruction.

Objetivos: Describir los resultados funcionales de los pacientes sometidos a una meniscorresis en rodillas estables. Materiales y Métodos: Estudio retrospectivo de 21 pacientes sometidos a meniscorresis en lesiones periféricas inestables. Todos los casos en rodillas consideradas estables. Se definió un seguimiento mínimo de 6 meses. Los pacientes fueron evaluados con las escalas de Lysholm y Cincinnati, y evaluación de calidad de vida (EuroQi). Falla de la meniscorresis se definió a la necesidad de nueva meniscorresis y/o a la meniscectomía en el sitio de la meniscorresis realizada inicialmente. Resultados: El promedio de edad fue de 29,6 años, mayoría hombres (87,5 por ciento). El promedio de tiempo entre la lesión y la cirugía fue de 43,2 días (1 a 158). En 13/21 pacientes el menisco comprometido fue el medial. La técnica quirúrgica utilizada fue artroscópica en todos los casos: afuera-dentro en 13 pacientes (62 por ciento), dentro-afuera en 7 (33 por ciento) y dentro-dentro en un paciente (4,8 por ciento). Cuatro pacientes (20 por ciento) presentaron clínica de falla de la meniscorresis por lo que fueron re-operados realizándose una meniscectomla parcial. El seguimiento promedio del grupo estudiado fue de 43,5 meses con una mediana de 42,8 meses. En relación a la evaluación funcional, el promedio de la escala de Lyshoim fue de 92,4 y el promedio de EVA de percepción de bienestar del paciente fue de 88,7. Conclusión: En nuestro grupo de pacientes se lograron buenos resultados funcionales a mediano plazo, con una tasa de falla similar a la descrita previamente para meniscorresis concomitantes con una reconstrucción del LCA.

Análise da capacidade funcional de indivíduos submetidos a tratamento cirúrgico após fratura do planalto tibial / Assessment of the functional capacity of individuals submitted to surgical treatment after tibial plateau fracture

As fraturas articulares são consideradas graves e ocasionam incapacidade, principalmente quando atingem uma articulação de carga, como o joelho. É necessário tratamento imediato a fim de obter estabilização dos fragmentos, evitando complicações secundárias. O objetivo do presente estudo foi analisar a capacidade funcional, durante as atividades de vida diária, de indivíduos que sofreram fraturas do planalto tibial e foram submetidos a tratamento cirúrgico entre os anos de 2002 a 2005. Foram analisados 20 pacientes com a aplicação do questionário ADLS (Activities of Daily Living Scale). Concluímos que 85 por cento dos indivíduos apresentaram capacidade funcional próximo ao normal, de acordo com a pontuação estabelecida pela escala utilizada.

Joint fractures are regarded as serious, causing disability, especially when involving a load joint, as the knee. Early treatment is required in order to get stabilization of fragments, preventing the occurrence of secondary complications. The present study was aimed at assessing functional capacity during daily life activities, on individuals who experienced tibial plateau fractures and submitted to surgical treatment between the years 2002 to 2005. Twenty patients were assessed by using the ADLS questionnaire (Activities of Daily Living Scale). We concluded that 85 percent of the individuals presented close-to-normal functional capacity, according to the scale's scoring system.

A ressonância magnética para o diagnóstico das lesões condrais, meniscais e dos ligamentos cruzados do joelho / Magnetic resonance imaging for diagnosis of the chondral, meniscal and cruciate ligaments injuries of the knee

OBJETIVO: Avaliar o valor diagnóstico da ressonância magnética (RM) do joelho. MATERIAIS E MÉTODOS: Setenta e dois pacientes foram submetidos a RM previamente à artroscopia do joelho realizada por um único cirurgião e considerada como método padrão. Verificou-se a sensibilidade, a especificidade, os valores de verossimilhança e a concordância entre o radiologista e o ortopedista em classificar as lesões. RESULTADOS: O coeficiente de concordância kappa entre a RM e a artroscopia, em classificar as lesões, foi muito bom para lesões de ligamento cruzado anterior (0,84), bom para o menisco lateral (0,75), razoável para o menisco medial (0,50) e baixo para lesões condrais (menor que 0,50). A RM mostrou ter alta sensibilidade para rupturas de ligamento cruzado anterior (94 por cento) e menisco medial (92 por cento), boa sensibilidade para lesões de menisco lateral (80 por cento) e baixa sensibilidade para lesões em todas as zonas condrais (menor que 50 por cento), enquanto a especificidade foi excelente para todas as estruturas condrais, ligamentares e para o menisco lateral estudadas (maior que 97 por cento) e razoável para o menisco medial (65 por cento). CONCLUSÃO: A RM é uma ferramenta útil para subsidiar o diagnóstico clínico de lesões intra-articulares do joelho, como já foi mostrado em resultados semelhantes encontrados na literatura produzida no Brasil e no exterior.

OBJECTIVE: To evaluate the diagnostic accuracy of magnetic resonance imaging (MRI) of the knee. MATERIALS AND METHODS: Seventy-two patients have been submitted to MRI previously to arthroscopy of the knee performed by a single surgeon and utilized as a comparative standard method. Sensitivity, specificity, values of likelihood and rate of interobserver agreement have been evaluated. RESULTS: The kappa agreement coefficient between MRI and arthroscopy was very good for lesions in the anterior cruciate ligament (0.84), good for lateral meniscus (0.75), reasonable for medial meniscus (0.50) and poor for chondral lesions (< 0.50). MRI has demonstrated high sensitivity for tears in the anterior cruciate ligament (94 percent) and in the medial meniscus (92 percent), good sensitivity for lesions in the lateral meniscus (80 percent), and low sensitivity for lesions in all of the chondral zones (< 50 percent), while the specificity has been excellent for all the chondral, and ligamentous structures, besides the lateral menisci analyzed (more than 97 percent), and reasonable (65 percent) for the medial meniscus. CONCLUSION: MRI is a useful tool in the clinical diagnosis of intra-articular knee lesions, as already demonstrated by similar results reported both in the Brazilian and international literature.

Sutura meniscal artroscópica con agujas: técnica fuera-dentro / Arthroscopic meniscal suture by two needles: qutside in technique

Se presenta una cohorte descriptiva (observacional, prospectiva y longitudinal) de 8 pacientes con lesión meniscal, que se trataron con reparación artroscópica con 2 agujas, mediante nylon 000. La lesión fue de menos de 3 meses de evolución y como mínimo de 10 mm de longitud, en el cuerno anterior, en zona roja-roja o roja-blanca. Cuando hubo lesión ligamentosa se hizo la reconstrucción respectiva. Se colocó un vendaje de Jones por 2 semanas y se difirió la carga de peso hasta después de 6 semanas. Después de un seguimiento de 7 a 14 meses, se encontró desprendimiento de la sutura en dos casos, confirmados por artroscopía, en quienes se resecó el fragmento suelto y se remodeló el fragmento parietal. El resultado general fue bueno en 4 casos (50 por ciento), regular en 2 (25 por ciento) y malo en 2 (25 por ciento).

Evaluación artroscópica de los signos meniscales / Arthroscopic evaluation of meniscal signs

De una serie de 153 pacientes con patología de la rodilla, se realizó en 51 pacientes el diagnóstico de lesión meniscal. Se obtuvo una certeza diagnóstica en el 92.1 por ciento de los pacientes, la cual se evaluó artroscopicamente encontrándose una sensibilidad del 91.8 por ciento para el menisco interno y una sensibilidad del 92.8 por ciento para el menisco externo

Examen instrumentado de la rodilla: utilización del aparato KT-1000 en lesiones de ligamento cruzado anterior / Instrumental examination of the knee. The use of KT-100 in anterior cruciate ligament injuries

Los aparatos para el examen instrumentado de rodilla han sido descritos, especialmente aquellos que miden la inestabilidad antero-posterior, concluyendo que son aparatos útiles, pero sólo como complemento de un buen examen clínico. Se reportan los resultados de un estudio con el aparato KT-1000, con los objetivos de evaluar si existían resultados similares entre diferentes examinadores, en múltiples periódos de tiempo y valorar el efecto de la presión aplicada a la rótula durante el examen. Siete investigadores examinaron a siete voluntarios en tres diferentes periódos. Se colocó un transductor de presión en la porción rotuliana del aparato. En el tercer periódo de prueba se estandarizó la presión por todos los examinadores. Se evaluó la prueba de cajón manual máximo y de carga de 20 lbs. Se concluye que el aparato es reproducible para el mismo examinador con diferentes voluntarios, pero que los resultados de un investigador no pueden ser comparados a los de otro examinador por la gran variabilidad de respuesta que existe entre los mismos. La presión aplicada en la rótula es muy variable, pero no es necesario estandarizarla para obtener resultados confiables con el aparato

Comparación del cuadro clínico con el diagnóstico artroscópico en las lesiones meniscales y del ligamento cruzado anterior de la rodilla / Comparison between clinical and arthroscopic findings in meniscal injuries and anterior cruciate ligament tears of the knee

Se revisó una serie retrospectiva de 68 pacientes con patología de la rodilla, en los que se comparó la eficacia del diagnóstico clínico con la comprobación diagnóstica artroscópica en nuestro departamento, habiendo encontrado que hubo coincidencia de los diagnósticos clínico y artroscópico con porcentaes variables para los distintos aspectos de la patología en la forma siguiente: meniscopatía lateral en el 57 por ciento; meniscopatía medial en el 37 por ciento; ruptura del ligamento cruzado anterior en el 33 por ciento y condromalacia patelar en el 70 por ciento de los casos