Construct Validity and Experience of Using a Low-cost Arthroscopic Shoulder Surgery Simulator.

Objective To validate the low-cost model for arthroscopy training and analyze the acceptance and usefulness of the developed simulator in medical teaching and training. Method Ten medical students, ten third-year orthopedic residents, and ten shoulder surgeons performed predetermined tasks on a shoulder simulator twice. The parameters used were time to complete the tasks, number of looks at the hands, GOALS score (Global Operative Assessment of Laparoscopic Skills) and comparison between groups and within groups. An adapted Likert scale was applied addressing the individuals' impressions about the simulator and its applicability. Results In the intergroup comparison, the shoulder surgeons had better scores and times than the other groups. When the tasks were repeated, the group of surgeons had a 59% improvement in time (p < 0.05), as did the group of medical students. In the GOALS score, shoulder surgeons had consistently better scores than the other groups. And when we evaluated the evolution from the first to the second test, the group of surgeons and the group of academics had a statistically significant improvement (p < 0.05). In terms of lookdowns, there was a decrease in all groups. There was consensus that the simulator is useful in training. Conclusion The simulator developed allowed the differentiation between individuals with different levels of training in arthroscopic surgery. It was accepted by 100% of the participants as a useful tool in arthroscopic shoulder surgical training.

Clinical and quality-of-life outcomes of a combined synthetic scaffold and autogenous tissue graft procedure for articular cartilage repair in the knee.

BACKGROUND: Injuries to the articular cartilage of the knee often fail to heal properly due to the hypocellular and avascular nature of this tissue. Subsequent disability can limit participation in sports and decrease quality of life. Subchondral bone perforations are used for the treatment of small defects. Filling out the central portion in larger lesions becomes difficult, and scaffolds can be used as adjuvants, providing a matrix onto which the defect can be filled in completely. Also, autogenous cartilage grafts can be combined, acting as an inducer and improving healing quality, all in a single procedure. METHODS: This observational study evaluated the clinical and quality-of-life outcomes of patients with articular cartilage lesions of the knee undergoing repair via a microfracture technique combined with a synthetic scaffold and autogenous cartilage graft, with transosseous sutures and fibrin glue fixation, at 12 months of follow-up. Secondarily, it assessed whether combined procedures, previous surgical intervention, traumatic aetiology, lesion location, and age affect outcomes. The sample consisted of adult patients (age 18-66 years) with symptoms consistent with chondral or osteochondral lesions, isolated or multiple, ICRS grade III/IV, 2-12 cm2 in size. Patients with corrected angular deviations or instabilities were included. Those with BMI > 40 kg/m2, prior total or subtotal (> 30%) meniscectomy, second-look procedures, and follow-up < 6 months were excluded. Pain (VAS), physical activity (IKDC), osteoarthritis (WOMAC), and general quality of life (SF-36) were assessed. RESULTS: 64 procedures were included, comprising 60 patients. There was significant improvement (P < 0.05) in VAS score (5.92-2.37), IKDC score (33.44-56.33), and modified WOMAC score (53.26-75.93) after surgery. The SF-36 showed significant improvements in the physical and mental domains (30.49-40.23 and 46.43-49.84 respectively; both P < 0.05). CONCLUSIONS: Combination of microfractures, autogenous crushed cartilage graft, synthetic scaffold, and transosseous sutures with fibrin glue provides secure fixation for treatment of articular cartilage lesions of the knee. At 12-month follow-up, function had improved by 20 points on the IKDC and WOMAC, and quality of life, by 10 points on the SF-36. Age > 45 years had a negative impact on outcomes.

Pseudoaneurysm after arthroscopic procedure in the knee.

The aim of this study was to review all cases of pseudoaneurysm in the literature, in predominantly arthroscopic procedures on the knee, and to report on a case of pseudoaneurysm that we treated. A bibliographic search was conducted for scientific articles published in Brazilian and foreign periodicals over the last 23 years. Forty-seven cases were found, in 40 articles. In addition to these 47 cases, there was the case that we treated, which was also included in the data. Among the operations that progressed with formation of a pseudoaneurysm, 60% were cases of meniscal injuries and 23%, anterior cruciate ligament injuries. In 46% of the cases, the artery affected with the popliteal, and in 21%, the inferomedial genicular artery. The commonest clinical symptom was pain (37%), followed by pulsating tumor (31%), edema of the calf (12%) and hemarthrosis (11%). The median time taken to make the diagnosis was 11 days, but it ranged from one day to 10 weeks after the procedure. Although rare, pseudoaneurysms are a risk that is inherent to arthroscopic surgery. All patients should be made aware of the vascular risks, even in small-scale procedures.

O objetivo deste estudo é revisar na literatura todos os casos de pseudoaneurisma em procedimentos predominantemente artroscópicos do joelho e relatar um caso de pseudoaneurisma tratado pelos autores. Foi feita uma pesquisa bibliográfica por meio de artigos científicos publicados em periódicos nacionais e internacionais nos últimos 23 anos. Foram levantados 47 casos, em 40 artigos. Somou-se aos 47 um caso dos autores deste estudo que foi incluído nos dados. Das cirurgias que cursaram com pseudoaneurisma, 60% se tratavam de lesões meniscais e 23% de lesões do ligamento cruzado anterior. Em 46% dos casos a artéria acometida foi poplítea e em 21% a artéria genicular inferomedial. O sintoma clínico mais comum foi dor (37%), seguido de tumor pulsátil (31%), edema de panturrilha (12%) e hemartrose (11%). A mediana do tempo para diagnóstico foi de 11 dias, mas variou de um dia até 10 semanas após o procedimento. Apesar de raro, o pseudoaneurisma é um risco inerente à cirurgia artroscópica. Todo paciente deve ser notificado dos riscos vasculares, mesmo em procedimentos de pequeno porte.

Biomechanical analysis on transverse tibial fixation in anterior cruciate ligament reconstructions.

OBJECTIVE: To verify whether the combination of tibial cross pin fixation and femoral screw fixation presents biomechanical advantages when compared to femoral cross pin fixation and tibial screw fixation for the reconstruction of the anterior cruciate ligament (ACL). METHODS: Thirty-eight porcine knees and bovine extensor digitorum tendons were used as the graft materials. The tests were performed in three groups: (1) standard, used fourteen knees, and the grafts were fixated with the combination of femoral cross pin and a tibial screw; (2) inverted, used fourteen knees with an inverted combination of tibial cross pin and a femoral screw; (3) control, ten control tests performed with intact ACL. After the grafts fixation, all the knees were subjected to tensile testing to determine yield strength and ultimate strength. RESULTS: There was no statistically significant difference in survival techniques in regard to strength, yield load and tension. There was a higher survival compared in the standard curves of yield stress (p < 0.05). CONCLUSION: There is no biomechanical advantage, observed in animal models testing, in the combination of tibial cross pin fixation and femoral screw when compared to femoral cross pin fixation and tibial screw.

OBJETIVO: Investigar se a fixação transversa tibial com parafuso femoral apresenta vantagens biomecânicas sobre a fixação transversa femoral com parafuso tibial na reconstrução do ligamento cruzado anterior (LCA). MÉTODO: Foram usados como modelos de testes joelhos suínos e tendões extensores digitais bovinos. Foram submetidos à reconstrução do LCA 28 joelhos: 14 foram fixados com parafuso na tíbia e implante transverso no fêmur (grupo padrão) e 14 com parafuso no fêmur e fixação transversa na tíbia (grupo invertido). Os modelos foram submetidos aos testes de tração. RESULTADOS: Não houve diferença estatisticamente significante na sobrevivência das técnicas no que tange a força, força máxima sem falha e tensão. Houve uma sobrevivência maior no grupo padrão na comparação das curvas de tensão de limite elástico (p < 0,05). CONCLUSÃO: Não há vantagem biomecânica da fixação transversa tibial com parafuso femoral em relação à fixação transversa femoral com parafuso tibial, observada em testes com modelos animais.

Hamstring tendons insertion - an anatomical study.

OBJECTIVE: To study the anatomy of the hamstring tendons insertion and anatomical relationships. METHODS: Ten cadaver knees with medial and anterior intact structures were selected. The dissection was performed from anteromedial access to exposure of the insertion of the flexor tendons (FT), tibial plateau (TP) and tibial tuberosity (TT). A needle of 40 × 12 and a caliper were used to measure the distance of the tibial plateau of the knee flexor tendons insertion at 15 mm from the medial border of the patellar tendon and tibial tuberosity to the insertion of the flexor tendons of the knee. The angle between tibial plateau and the insertion of the flexor tendons of the knee (A-TP-FT) was calculated using Image Pro Plus software. RESULTS: The mean distance TP-FT was 41 ± 4.6 mm. The distance between the TT-FT was 6.88 ± 1 mm. The (A-TP-FT) was 20.3 ± 4.9°. CONCLUSION: In the anterior tibial flexor tendons are about 40 mm from the plateau with an average of 20°.

OBJETIVO: Determinar parâmetros anatômicos para localizar a inserção dos tendões flexores do joelho na tíbia. MÉTODOS: Foram selecionados 10 joelhos de cadáveres com estruturas mediais e anteriores íntegras. A dissecção foi feita por acesso ântero-medial até a exposição adequada da inserção dos tendões flexores (TF), do planalto tibial (PT) e da tuberosidade anterior da tíbia (TAT). Uma agulha 40×12 e um paquímetro digital foram usados para aferir a distância do planalto tibial da inserção dos tendões flexores do joelho a 15 mm da borda medial ao tendão patelar e da tuberosidade anterior da tíbia à inserção dos tendões flexores do joelho. O ângulo formado entre o planalto tibial e a inserção dos tendões flexores do joelho (Â PT-TF) foi calculado com o auxílio do software ImagePro Plus®. RESULTADOS: A distância PT-TF foi de 41 ± 4,6 mm em média. A distância entre a TAT-TF foi de 6,88 ± 1 mm. A angulação (Â PT-TF) foi de 20,3 ± 4,9 graus. CONCLUSÃO: Na região anterior da tíbia os tendões flexores estão a cerca de 40 mm do planalto com um ângulo médio de 20 graus.

Oblique popliteal ligament - an anatomical study.

OBJECTIVE: To study the anatomy of the oblique popliteal ligament, as regards its dimensions, expansion and anatomical relationships. METHODS: Eleven cadaver knees were dissected in order to study the anatomy and take measurements of anatomical structures and relationships of the oblique popliteal ligament. The dissection was for posterior access to the proper exposure of the oblique popliteal ligament, the semimembranosus muscle and its expansions. For measurement of dimensions, 40 × 12 needles were used for marking the specific points and a caliper. The angles were calculated using the software ImagePro Plus®. RESULTS: The distance from the origin of the oblique popliteal ligament to the tibial plateau was 7.4 mm, the thickness at its origin was 7.3 mm, length was 33.6 mm and the tibial plateau angle 34.8°. The length of the expansion of the proximal oblique popliteal ligament was 39.2 mm, thickness 7.8 mm and angle of the oblique popliteal ligament with its expansion 32.2°. CONCLUSION: The oblique popliteal ligament is thick, rises in the semimembranosus and protrudes proximally forming an acute angle with the joint interline, crossing the popliteal fossa. In some cases it has a proximal expansion.

OBJETIVO: Estudar a anatomia do ligamento poplíteo oblíquo no que se refere às suas dimensões, expansões e relações anatômicas. MÉTODOS: Onze joelhos de cadáveres foram dissecados com o intuito de se estudar a anatomia e fazer medições das estruturas e das relações anatômicas do ligamento poplíteo oblíquo. A dissecção foi por acesso posterior até a exposição adequada do ligamento poplíteo oblíquo, do músculo semimembranoso e de suas expansões. Para aferição das medidas, foram usados agulhas 40 × 12 na marcação dos pontos específicos e um paquímetro. Os ângulos foram calculados com o auxílio do software ImagePro Plus®. RESULTADOS: A distância da origem do ligamento poplíteo oblíquo ao platô tibial foi de 7,4 mm, a espessura na sua origem foi de 7,3 mm, o comprimento foi de 33,6 mm e o ângulo com o platô tibial foi de 34,8°. O comprimento da expansão proximal do ligamento poplíteo oblíquo foi de 39,2 mm, a espessura foi de 7,8 mm e o ângulo do ligamento poplíteo oblíquo com sua expansão foi de 32,2°. CONCLUSÃO: O ligamento poplíteo oblíquo é espesso, nasce no músculo semimembranoso, projeta-se proximalmente, forma um ângulo agudo com a interlinha articular e cruza a fossa poplítea. Em alguns casos apresenta uma expansão proximal.

BIOMECHANICAL STUDY OF TRANSCORTICAL OR TRANSTRABECULAR BONE FIXATION OF PATELLAR TENDON GRAFT WITH BIOABSORBABLE PINS IN ACL RECONSTRUCTION IN SHEEP.

OBJECTIVE: To determine the initial resistance of fixation using the Rigid Fix(®) system, and compare it with traditional fixation methods using metal interference screws; and to evaluate the resistance of the fixation with the rigid fix system when the rotational position of the bone block is altered in the interior of the femoral tunnel. METHODS: forty ovine knee specimens (stifle joints) were submitted to anterior cruciate ligament reconstruction (ACL) using a bone-tendon-bone graft. In twenty specimens, the Rigid Fix method was used; this group was subdivided into two groups: ten knees the pins transfixed only the spongious area of the bone block, and ten for fixation passing through the layer of cortical bone. In the twenty remaining specimens, the graft was fixed with 9mm metal interference screws. RESULTS: comparison of the RIGIDFIX(®) method with the metal interference screw fixation method did not show any statistically significant differences in terms of maximum load and rigidity; also, there were no statistically significant differences when the rotational position of the bone block was altered inside the femoral tunnel. For these evaluations, a level of significance of p < 0.017 was considered. CONCLUSION: fixation of the bone-tendon-bone graft with 2 bioabsorbable pines, regardless of the rotational position inside the femoral tunnel, gave a comparable fixation in terms of initial resistance to the metal interference screw, in this experimental model.

[Is it possible to predict the length of knee flexor tendons by anthropometry?]. / É possível prever o comprimento de tendões flexores do joelho por antropometria?

OBJECTIVE: To compare the anthropometric data and the sportive way of life with the hamstring tendons dimensions, prospectively, in order to create a rule to predetermine its dimensions. METHODS: General and anthropometric data were collected from 30 patients that were submitted to anterior cruciate ligament reconstruction. These data were correlated to the diameter and length of the hamstring tendons. The data collected were: height, weight, age, knee lesion side, body mass, sportive training level, femoral length, tibia length, thigh circumference, and knee circumference. The correlation was made by Pearson coefficient. RESULTS: Statistic significant correlation occurred only with height and tibia length versus the gracilis and semitendinous tendon length. Using linear regression the relations found could be expressed with the following formulas: semitendinous length = -2.276 + 0.177 x height; semitendinous length = 13.048 + 0.46 x tibia height; gracilis length = -9.413 + 0.207 x height; gracilis length = 7.036 + 0.583 x tibia height. CONCLUSION: It is possible to predetermine hamstring tendons length through linear regression formulas before surgical intervention.