Bicruciate Reconstruction with Bilateral Hamstring Autografts: Technique and Functional Results.

Objective The purpose of this study was to evaluate the clinical and functional results of simultaneous reconstruction of the ACL and PCL with bilateral hamstring autografts. We hypothesized that this reconstruction technique results in less morbidity and has similar results to the ones published in the previous literature. Methods Eighteen patients with bicruciate lesions were selected and treated by arthroscopic surgery with autologous hamstring tendons in a single-stage procedure. The thicker semitendinosus tendon (ST) and the two gracilis tendons (G) were used for a 6-strand PCL reconstruction. The thinner ST was used for a 3-strand ACL reconstruction. The average patient age at surgery was 31 years, and the minimum follow-up was 2 years. Function of the operated knee was evaluated according to the Lysholm scale. Anterior knee laxity was examined with a KT-1000 arthrometer. Posterior laxity was evaluated using stress radiographies. Results Statistically significant improvements were found for all three measurements ( p < 0.001). Knee function by the Lysholm score increased from 43.8 ± 4.1 to 89.9 ± 3.8 post-surgery. The average anterior knee laxity improved from 5.2 + -0.8 mm initially to 2.4 + - 0.5 mm post-surgery. The posterior translation of the tibia relative to the femur decreased from 10 ± 3.4 mm to 3 ± 1.6 mm post-surgery. No patient showed loss of motion in extension or knee flexion. Conclusion The simultaneous bicruciate reconstruction with bilateral hamstring autograft is a valuable option to achieve good functional outcomes and ligamentous stability.

Bicruciate Reconstruction with Bilateral Hamstring Autografts: Technique and Functional Results / Reconstrução dos ligamentos cruzados anterior e posterior com autoenxertos bilaterais dos isquiotibiais: Técnica e resultados funcionais

Abstract Objective The purpose of this study was to evaluate the clinical and functional results of simultaneous reconstruction of the ACL and PCL with bilateral hamstring autografts. We hypothesized that this reconstruction technique results in less morbidity and has similar results to the ones published in the previous literature. Methods Eighteen patients with bicruciate lesions were selected and treated by arthroscopic surgery with autologous hamstring tendons in a single-stage procedure. The thicker semitendinosus tendon (ST) and the two gracilis tendons (G) were used for a 6-strand PCL reconstruction. The thinner ST was used for a 3-strand ACL reconstruction. The average patient age at surgery was 31 years, and the minimum follow-up was 2 years. Function of the operated knee was evaluated according to the Lysholm scale. Anterior knee laxity was examined with a KT-1000 arthrometer. Posterior laxity was evaluated using stress radiographies. Results Statistically significant improvements were found for all three measurements (p < 0.001). Knee function by the Lysholm score increased from 43.8 ± 4.1 to 89.9 ± 3.8 post-surgery. The average anterior knee laxity improved from 5.2 + −0.8 mm initially to 2.4 + - 0.5 mm post-surgery. The posterior translation of the tibia relative to the femur decreased from 10 ± 3.4 mm to 3 ± 1.6 mm post-surgery. No patient showed loss of motion in extension or knee flexion. Conclusion The simultaneous bicruciate reconstruction with bilateral hamstring autograft is a valuable option to achieve good functional outcomes and ligamentous stability.

Resumo Objetivo O objetivo deste estudo foi avaliar os resultados clínicos e funcionais da reconstrução simultânea do ligamento cruzado anterior (LCA) e ligamento cruzado posterior (LCP) com autoenxertos bilaterais de isquiotibiais. Nossa hipótese é que esta técnica de reconstrução gera menor morbidade e tem resultados semelhantes aos publicados na literatura anterior. Métodos Dezoito pacientes com lesões em LCA e LCP foram selecionados e tratados por cirurgia artroscópica com tendões isquiotibiais autólogos em procedimento único. O tendão semitendinoso (ST) mais espesso e os dois tendões do músculo grácil (G) foram usados para a reconstrução do LCP com seis fios. O ST mais fino foi usado para reconstrução do LCA com três fios. A média de idade dos pacientes à cirurgia foi de 31 anos e o acompanhamento mínimo foi de 2 anos. A função do joelho operado foi avaliada de acordo com a escala de Lysholm. A lassidão anterior do joelho foi examinada com um artrômetro KT-1000. A lassidão posterior foi determinada por meio de radiografias de estresse. Resultados Melhoras estatisticamente significativas foram observadas nas três medidas (p < 0,001). A função do joelho pelo escore de Lysholm aumentou de 43,8 ± 4,1 para 89,9 ± 3,8 após a cirurgia. A lassidão anterior média do joelho melhorou de 5,2 ± 0,8 mm para 2,4 ± 0,5 mm após a cirurgia. A translação posterior da tíbia em relação ao fêmur diminuiu de 10 ± 3,4 mm para 3 ± 1,6 mm no período pós-operatório. Nenhum paciente apresentou perda de movimento em extensão ou flexão do joelho. Conclusão A reconstrução simultânea do LCA e do LCP com autoenxerto bilateral dos isquiotibiais é uma opção valiosa para obtenção de bons resultados funcionais e estabilidade ligamentar.

Immediate identification and management of an open posterior knee dislocation: Important lessons from a case report.

Traumatic knee dislocation represents a rare event, contributing to less than 0.02 % of all orthopedic trauma and 0.05 % of joint dislocations, respectively. It is critically important to recognize, identify, and appropriately manage such cases as 'time' is implicated as an outcome-determining factor. Thus, such cases warrant quick consideration and appropriate management to mitigate the possibility of neurovascular damage and long-term sequelae. We report a case of a 59-year-old man struck by a motor vehicle in a remote rural community in northern Mexico managed with external fixation 16 h after the initial trauma, and later resulting in a supracondylar amputation. The authors of this case report underline the importance of timely intervention strategies when faced with such cases of knee dislocation and promote enhanced training of peripheral trauma-care providers to help improve patient outcomes.

Anterolateral ligament MRI of the knee in ACL injuries: MRI abnormalities association with instability.

OBJECTIVE: To evaluate anterolateral ligament abnormalities (ALL) at MRI scans and correlate with data from clinical instability tests (Lachman and pivot shift) performed under anesthesia in patients with acute anterior cruciate ligament (ACL) tears. Furthermore, perform multivariate analysis with other variables to isolate the ALL contribution to instability from other abnormalities. METHODS: Retrospective analysis of MRI and instability tests of 95 patients with ACL tears. The ALL was classified as no abnormality, abnormality without discontinuity, and discontinuity. Injuries in other knee ligament structures and menisci were also assessed. Results of instability tests (pivot shift and Lachman) with the patient anesthetized for arthroscopic ACL reconstruction were obtained from the patient database. Statistical analysis was performed using the IBM SPSS 22. RESULTS: ALL abnormalities and iliotibial band (ITB), lateral (LCL), and medial (MCL) collateral ligament injuries showed a statistically significant correlation with the pivot shift test. The ALL MRI abnormalities were associated with the high-grade pivot shift results (p < 0.0005), with an odds ratio of 55.9 for high degrees of pivot shift in patients with abnormal ALL. The logistic model for all variables analyzed with the results of the pivot shift test demonstrated that the ALL was the only variable with a statistically significant correlation in the model (p < 0.0005). CONCLUSION: MRI ALL abnormalities in patients with ACL injuries have a significant association with pivot shift test results in patients under anesthesia. The logistic model for high - grade pivot shift test results demonstrated that ALL abnormalities were the only variable with significant correlation. KEY POINTS: • Evaluating the anterolateral ligament with MRI in acute anterior cruciate ligament injuries is useful to predict higher grades of pivot shift test in the moment of the arthroscopic reconstruction. • An abnormal anterolateral ligament presented an odds ratio of 55 for high degrees of pivot shift. • ALL MRI abnormalities association with knee instability is independent from other internal knee injuries.

Epidemiological Study on Multiligament Knee Injuries.

Objective The present paper aims to describe multiligament knee injuries and to associate their features with the profile of the patients and trauma mechanisms. Methods This is a cross-sectional study evaluating 82 patients with multiligament knee injuries from September 2016 to September 2018. Evaluated parameters included age, gender, mechanical axis, affected side, range of motion, trauma mechanism, associated injuries, affected ligaments, and absence from work. Results The sample included patients aged between 16 and 58 years old, with an average age of 29.7 years old; most subjects were males, with 92.7% of cases. The most common trauma mechanism was motorcycle accident (45.1%). The most injured ligament was the anterior cruciate ligament (80.5%), followed by the posterior cruciate ligament (77.1%), the posterolateral corner (61.0%), and the tibial collateral ligament (26.8%). The most frequent type of dislocation was KD IIIL (30.4%). Only 1 patient had a vascular injury, and 13 (15.9%) presented with neurological injuries. Most subjects took medical leave from work (52.4%). Conclusion There is a big difference between patients with multiligament lesions in Brazil compared with international studies. Thus, it is advisable to carry out more specific studies on the topic with our population to improve the treatment of these patients.

Epidemiological Study on Multiligament Knee Injuries / Estudo epidemiológico das lesões multiligamentares do joelho

Abstract Objective The present paper aims to describe multiligament knee injuries and to associate their features with the profile of the patients and trauma mechanisms. Methods This is a cross-sectional study evaluating 82 patients with multiligament knee injuries from September 2016 to September 2018. Evaluated parameters included age, gender, mechanical axis, affected side, range of motion, trauma mechanism, associated injuries, affected ligaments, and absence from work. Results The sample included patients aged between 16 and 58 years old, with an average age of 29.7 years old; most subjects were males, with 92.7% of cases. The most common trauma mechanism was motorcycle accident (45.1%). The most injured ligament was the anterior cruciate ligament (80.5%), followed by the posterior cruciate ligament (77.1%), the posterolateral corner (61.0%), and the tibial collateral ligament (26.8%). The most frequent type of dislocation was KD IIIL (30.4%). Only 1 patient had a vascular injury, and 13 (15.9%) presented with neurological injuries. Most subjects took medical leave from work (52.4%). Conclusion There is a big difference between patients with multiligament lesions in Brazil compared with international studies. Thus, it is advisable to carry out more specific studies on the topic with our population to improve the treatment of these patients.

Resumo Objetivo Descrever e associar as características das lesões multiligamentares de joelho com o perfil do paciente e mecanismo de trauma. Métodos Trata-se de um estudo transversal que avaliou 82 pacientes com lesões multiligamentares do joelho de setembro de 2016 até setembro de 2018. As variáveis coletadas foram idade, gênero, eixo mecânico, lateralidade, arco de movimento, mecanismo do trauma, lesões associadas, ligamentos afetados e afastamento do trabalho. Resultados A amostra incluiu pacientes de 16 a 58 anos, com média de 29,7 anos, e os homens foram os mais afetados, correspondendo a 92,7% dos casos. O mecanismo de trauma mais comum foi acidente motociclístico (45,1%). O ligamento mais lesado foi o ligamento cruzado anterior (80,5%), seguido do ligamento cruzado posterior (77,1%), do canto posterolateral (61,0%) e do ligamento colateral tibial (26,8%). O tipo de luxação mais frequente era o KD IIIL (30,4%). Apenas 1 paciente apresentou lesão vascular, e 13 (15,9%) apresentaram lesões neurológicas. A maioria das vítimas foi afastada do trabalho (52,4%). Conclusão Há grande diferença entre os pacientes que apresentam lesão multiligamentar no Brasil em relação ao encontrado nos estudos internacionais. Desta forma, convém realizar mais estudos específicos sobre o tema com a nossa população, de modo a aperfeiçoar o tratamento destes pacientes.

Bilateral Congenital Knee Dislocation in Colombia: Case Report and Literature Review.

Congenital knee dislocation (CKD) is a rare disease with an estimated incidence of 1 per 100,000 live births, characterized by a rare musculoskeletal malformation in genu recurvatum deformity present at birth, affecting one or both lower limbs. The diagnosis may be suspected during ultrasound when observing that the situation of the extremities is not correct, and is confirmed by physical examination at birth, with plain radiography being helpful to establish the degree of severity. At present there are controversies regarding treatment and there is no definitive protocol. We present a new case of CKD, observed in the city of Manizales, diagnosed immediately after birth.

ANATOMICAL STUDY OF THE POSTEROLATERAL LIGAMENT COMPLEX OF THE KNEE: LCL AND POPLITEUS TENDON.

OBJECTIVE: To analyse the distances between the femoral insertions of the popliteus tendon (PT) and the lateral collateral ligament (LCL) through dissections of cadaveric specimens in a mixed population. METHODS: Fresh cadavers were dissected, and the anthropometric data of all specimens were recorded. The distances from the origin of the PT to the LCL in the femoral region and the diameter of each structure were measured using a digital calliper. RESULTS: In total, 11 unpaired knees were dissected, eight men and three women, with an average age of 71.5 ± 15.2 years, weight of 57.2 ± 15.6 kg, and a mean height of 170.5 ± 8.2 cm. The distance from the center of the femoral footprint of the LCL to the PT was 10.0 ± 2.4 mm. The distances between the edges closest to each other and those more distant from each other were 3.1 ± 1.1 mm and 16.3 ± 2.4 mm, respectively. CONCLUSION: The distance between the midpoints of the PT and the LCL in our mixed population is smaller than the distances often reported in the literature. PLC reconstruction with separate tunnels for the LCL and PT may not be technically possible for individuals of any population. Level of Evidence III, Diagnostic studies.

OBJETIVO: Analisar as distâncias entre as inserções femorais do tendão poplíteo (TP) e o ligamento colateral lateral (LCL) através de dissecções de espécimes cadavéricos em uma população miscigenada. MÉTODOS: Cadáveres frescos foram dissecados. Foram registrados dados antropométricos e foi avaliada a distância da origem do TP e do LCL na região femoral com auxílio de paquímetro digital. Foi também avaliado o diâmetro do footprint femoral do TP e do LCL. RESULTADOS: Foram dissecados 11 joelhos não pareados, 8 homens e 3 mulheres com uma idade média de 71,5 ± 15,2 anos, pesando em média 57,2 ± 15,6 kgs e com altura de 170,5 ± 8,2 cm. A distância do centro do footprint femoral do LCL e do TP foi de 10,0 ± 2,4 mm. As distâncias das bordas mais próximas entre si e das mais distantes entre si foram de 3,1 ± 1,1 mm e 16,3 ± 2,4 mm, respectivamente. CONCLUSÃO: A distância entre o ponto central do TP e do LCL em nossa população mais miscigenada demonstrou um valor absoluto menor do que é, frequentemente, relatado na literatura. Uma reconstrução ligamentar do CPL com túneis separados para o LCL e o TP pode não ser tecnicamente possível para indivíduos de qualquer população. Nível de Evidência III, Estudos diagnósticos.

Anatomical study of the posterolateral ligament complex of the knee: lcl and popliteus tendon / Estudo anatômico do complexo ligamentar posterolateral do joelho: lcl e tendão poplíteo

ABSTRACT Objective: To analyse the distances between the femoral insertions of the popliteus tendon (PT) and the lateral collateral ligament (LCL) through dissections of cadaveric specimens in a mixed population. Methods: Fresh cadavers were dissected, and the anthropometric data of all specimens were recorded. The distances from the origin of the PT to the LCL in the femoral region and the diameter of each structure were measured using a digital calliper. Results: In total, 11 unpaired knees were dissected, eight men and three women, with an average age of 71.5 ± 15.2 years, weight of 57.2 ± 15.6 kg, and a mean height of 170.5 ± 8.2 cm. The distance from the center of the femoral footprint of the LCL to the PT was 10.0 ± 2.4 mm. The distances between the edges closest to each other and those more distant from each other were 3.1 ± 1.1 mm and 16.3 ± 2.4 mm, respectively. Conclusion: The distance between the midpoints of the PT and the LCL in our mixed population is smaller than the distances often reported in the literature. PLC reconstruction with separate tunnels for the LCL and PT may not be technically possible for individuals of any population. Level of Evidence III, Diagnostic studies.

RESUMO Objetivo: Analisar as distâncias entre as inserções femorais do tendão poplíteo (TP) e o ligamento colateral lateral (LCL) através de dissecções de espécimes cadavéricos em uma população miscigenada. Métodos: Cadáveres frescos foram dissecados. Foram registrados dados antropométricos e foi avaliada a distância da origem do TP e do LCL na região femoral com auxílio de paquímetro digital. Foi também avaliado o diâmetro do footprint femoral do TP e do LCL. Resultados: Foram dissecados 11 joelhos não pareados, 8 homens e 3 mulheres com uma idade média de 71,5 ± 15,2 anos, pesando em média 57,2 ± 15,6 kgs e com altura de 170,5 ± 8,2 cm. A distância do centro do footprint femoral do LCL e do TP foi de 10,0 ± 2,4 mm. As distâncias das bordas mais próximas entre si e das mais distantes entre si foram de 3,1 ± 1,1 mm e 16,3 ± 2,4 mm, respectivamente. Conclusão: A distância entre o ponto central do TP e do LCL em nossa população mais miscigenada demonstrou um valor absoluto menor do que é, frequentemente, relatado na literatura. Uma reconstrução ligamentar do CPL com túneis separados para o LCL e o TP pode não ser tecnicamente possível para indivíduos de qualquer população. Nível de Evidência III, Estudos diagnósticos.

Luxación traumática aguda de rodilla. Indicaciones del uso del fijador externo en la urgencia. Revisión bibliográfica sistematizada / Acute knee dislocation. Indications for the use of the external fixator at the emergency room / Deslocamento agudo traumático do joelho. Indicações para o uso do fixador externo na emergência

Resumen: Introducción: la luxación traumática de la rodilla constituye una lesión rara dentro de la patología ortopédica. En muchas ocasiones su diagnóstico pasa desapercibido dado que se dan en el contexto de pacientes politraumatizados, y la falla en el mismo puede derivar en un pronóstico potencialmente letal para el compromiso vital del miembro lesionado. Objetivo: realizar una revisión de la literatura disponible en los últimos veinte años acerca de cuáles son las indicaciones del uso del fijador externo (FFEE) en la luxación traumática aguda de rodilla en la urgencia. Materiales y métodos: se realizó una búsqueda sistematizada a través de los buscadores electrónicos Cochrane, Lilacs, Scielo, Pubmed, Science direct y el portal Timbó. La misma alcanzó un total de 6.495 artículos, y de acuerdo con los criterios de inclusión y exclusión se seleccionaron 14 trabajos para realizarla. Resultados: se destaca que la mayoría de los artículos encontrados son de nivel de evidencia IV. La utilización del uso de la fijación externa en la urgencia como parte de la estabilización temporal y el manejo inicial estaría indicado en los siguientes escenarios clínicos: pacientes politraumatizados, lesión vascular, luxación expuesta, inestabilidad de la articulación, luxación recidivante, luxofracturas, lesiones a nivel del aparato extensor, obesidad mórbida, intolerancia del uso de la férula u ortesis. Conclusión: la sistematización y protocolización a la hora de la toma de decisiones permite disminuir de forma mayoritaria las complicaciones vinculadas a la patología traumática; éstas deben estar dirigidas a la estabilización del paciente en primera instancia, y en segunda instancia a estabilizar la articulación de la rodilla. La fijación externa tiene indicaciones en escenarios clínicos puntuales; sin embargo algunas de estas indicaciones aún son objeto de debate.

Abstract: Introduction: traumatic dislocation of the knee constitutes an unusual lesion in orthopedic pathology, the diagnosis of which is often missed. This is because it occurs in the context of multiple trauma patients, and failure to diagnose it may result in a potentially fatal outcome for the life-threatening compromise of the injured limb. Objective: to perform a literature review of literature on indications for the use of the external fixator in the acute knee dislocation at the emergency room that has been available in the last twenty years. Method: we conducted a systematized search by means of electronic search engines Cochrane, Lilacs, Scielo, Pubmed, Science direct and the Timbó portal. The search included 6495 articles and according to the criteria of inclusion and exclusion 14 studies were selected. Results: the review highlights that most articles found are level of evidence IV. The use of the external fixator in the emergency room as part of the temporary stabilization and initial handling of the condition would be indicated in the following clinical scenarios: multiple trauma patients, vascular lesion, exposed dislocation, joint instability, recurrent dislocation, fracture dislocation, lesions of the extensor apparatus, morbid obesity, splint or orthosis intolerance. Conclusion: systematization and the observation of protocols when it comes to the making of decisions enables the decrease of most complications associated to trauma pathologies. Actions must be geared to stabilizing patients first and to stabilize the knee joint. The external fixator is indicated for specific clinical scenarios. However, some of these indications are still a matter of debate.

Resumo: Introdução: a luxação traumática do joelho é uma lesão rara na patologia ortopédica. Em muitas ocasiões, seu diagnóstico passa despercebido, por ocorrer no contexto de pacientes politraumatizados, e que sua falha pode levar a um prognóstico potencialmente letal para o envolvimento vital do membro lesado. Objetivo: realizar uma revisão da literatura disponível nos últimos vinte anos sobre as indicações do uso do fixador externo na luxação traumática aguda do joelho em pronto-socorro. Materiais e métodos: foi realizada uma busca sistemática nas bases LILACS, SciELO, PubMed, Science Direct, na Biblioteca Cochrane e no portal Timbó. Foram obtidas 6.495 referencias dos quais 14 artigos foram selecionados de acordo com os critérios de inclusão e exclusão. Resultados: a maioria dos artigos encontrados apresentam evidência de nível IV. O uso de fixação externa na emergência como parte da estabilização temporária e manejo inicial, seria indicado nos seguintes cenários clínicos: pacientes politraumatizados, lesão vascular, luxação exposta, instabilidade articular, luxação recorrente, luxação, lesões ao nível do aparelho extensor, obesidade mórbida, intolerância ao uso de tala ou órtese. Conclusão: a sistematização e protocolização no momento da tomada de decisão é o que possibilita reduzir, em sua maioria, as complicações relacionadas à patologia traumática. Estas devem ter como objetivo em primeiro lugar estabilizar o paciente e, em segundo lugar, estabilizar a articulação do joelho. A fixação externa tem indicações em contextos clínicos específicos; no entanto, algumas delas ainda geram controvérsia.

Knee Dislocation with Ipsilateral Tibial Fracture Treated with an Intramedullary Locked Nail and Simultaneous Transtibial Tunnel Knee Ligament Reconstruction: A Case Report of Autografts and Limited Resources.

Knee dislocations associated with ipsilateral tibial shaft fracture represent one of the most challenging injuries in trauma surgery. This injury occurs in only 2% of all tibial fractures in several series. With the use of intramedullary nail (IMN) of the tibia, current practice paraments suggest that transtibial tunnels should be avoided and ligamentous knee surgery be delayed until healing of the shaft fracture occurs. We report a novel case which was successfully managed by delayed IMN and multiligamentous transtibial posterior cruciate ligament (PCL) and posterolateral corner (PLC) autograft reconstructions. A 27-year-old male sustained a Gustilo-Anderson grade IIIa tibial shaft fracture and a Schenck IIIL knee dislocation (KD3L) in the ipsilateral knee. At 2 weeks, the patient was then taken back to the operating theater to undergo definitive bone fixation and ipsilateral simultaneous knee ligamentous reconstruction. The knee was stabilized by open reconstruction of the PCL under fluoroscopic control using an ipsilateral quadriceps autograft fixed with metallic interference screws. The PLC was reconstructed with ipsilateral semitendinosus autograft harvested through a separate 1.5-cm standard anteromedial incision using the technique described by Stannard et al. After graft fixation, the 90 degree posterior and posterolateral drawer and 0 and 30 degrees varus stress tests were negative. After 12 months follow-up, the patient had no complaints regarding pain or instability. The tibial fracture had healed and no knee axis deviation could be noted. The patient had returned to recreational low demand activities and motorcycle riding. Treatment of a combined tibial shaft fracture with an ipsilateral knee dislocation may be satisfactorily accomplished with an IMN for the tibia and transtibial tunnel fixation for knee ligament reconstruction allowing for a single rehabilitation course and a shorter recovery without having to use a third stage for knee ligamentous reconstruction.

Controversies in acute multiligamentary knee injuries (MLKI).

Multiligament injuries of the knee (MLKI), remain an infrequent pathology especially in developed countries compared to mono-ligament lesions. In Colombia, MLKI is frequent due to the high accident rate on motorcycles. In the city of Bogota alone, about 160 motorcycle accidents have been estimated daily, being one of the cities that proportionately use this means of transport less compared to small cities. The term MLKI, include all ruptures of two or more major ligaments and therefore it has a broad spectrum of clinical presentation which creates a great challenge for the orthopedists and the surgeons envolved in this topic. The literature is rich in studies level IV but very poor in level I and level II, which generates controversies and little consensus in the diagnosis and treatment of this pathology. However there has been a gradual and better understanding of all factors involved in the treatment of MLKI that has improved the functional results of these knees in our patients, in fact we currently are more precise to achieve accurate diagnosis, evolved from not surgical approach to operate most, applying new anatomical and biomechanical concepts, with specialized and skill surgical techniques with more stable and biocompatible fixation implants, which allow in most cases to initiate an early integral rehabilitation program. Nevertheless due to the complexity and severity of the lesions, in some patients the functional results are poor. The goal of this revision is to identify the most frequent controversies in the diagnosis and treatment of MLKI, defining which of them are agreed according to what is reported in the literature and share some concepts based from the experience of more than 25 years of the senior author (MM) in the management of these injuries. LEVEL OF EVIDENCE: V - Expert Opinion.

Varus mechanism is associated with high incidence of popliteal artery lesions in multiligament knee injuries.

PURPOSE: This study aims to identify multiple ligament knee injury patterns that possess a high-risk of vascular lesion. METHODS: We retrospectively compared torn ligament patterns and the presence of vascular lesions confirmed by magnetic resonance imaging and computed tomography angiography from 122 consecutive patients with diagnoses of multiple ligament knee injury made at the emergency department between January 2012 and December 2017. Patients were not eligible if they had an ipsilateral lower extremity lesion (dislocations or fractures at another level), initial evaluation at another hospital, or follow-up for less than 12 months. The primary outcomes were the comparison between the imaging findings of torn structures patterns and the presence of a vascular lesion. RESULTS: We identified 48 eligible patients (50 knees) with multiligamentary knee lesions, of whom eight had popliteal artery damage, yielding an incidence of 16%. Our clinical examination detected six of these patients that were classified, according to the Schenck system, as KD-IIIL (6 knees) and KD-IIIM (2 knees). The odds of having a popliteal artery injury is 4.69 to 1 with a KD-IIIL injury that with any other type of injury on that classification (95% CI 0.960-22.98). CONCLUSIONS: This data suggests that varus forces causing enough energy to produce a KD-IIIL lesion possess a higher popliteal artery injury risk, making recommendable a thorough examination of the vascular integrity when diagnosing a KD-IIIL lesion.

Posterolateral reconstruction combined with one-stage tibial valgus osteotomy: Technical considerations and functional results.

BACKGROUND: To report the functional outcomes and complications from reconstructing the knee posterolateral complex (PLC), associated with one-stage opening-wedge tibial valgus osteotomy, and discuss the technical feasibility of this procedure. METHODS: Five patients with chronic PLC injuries and varus deviation of the mechanical axis, associated with central pivot injuries or not, underwent medial opening-wedge high tibial osteotomy combined with PLC reconstruction. The lateral collateral ligament, popliteal tendon, and popliteofibular ligament were reconstructed using a single femoral tunnel. Patients were assessed on physical examination, range-of-motion and functional scales, and radiographs. The International Knee Documentation Committee (IKDC) score, Lysholm score, and Knee Injury and Osteoarthritis Outcome score (KOOS) were determined. RESULTS: Five patients were evaluated: four presented with central pivot injury, and one had an isolated PLC injury. The mean time between injury and surgery was 40 ±â€¯6.5 months (± is indicating standard deviation value). Four patients had minimal residual instability on physical examination, with a lateral opening at varus stress of ±3+ at 30° flexion. The means of the IKDC score, Lysholm score, and KOOS were 67.8 ±â€¯9.2, 83.0 ±â€¯9.3, and 79.2 ±â€¯5.9, respectively. All patients showed satisfactory consolidation of osteotomy in 2.6 ±â€¯0.9 months. CONCLUSIONS: The results of this series indicate that one-stage PLC ligament reconstruction associated with medial opening-wedge valgus osteotomy is feasible and shows satisfactory functional results with a low rate of complications. A one-stage procedure might be indicated for young patients with high functionality and more pronounced posterolateral instabilities.

Bicruciate lesion biomechanics, Part 1-Diagnosis: translations over 15 mm at 90° of knee flexion are indicative of a complete tear.

PURPOSE: Understanding the pathomechanics of a bicruciate injury (BI) is critical for its correct diagnosis and treatment. The purpose of this biomechanical study aims to quantify the effects of sequential sectioning of the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) bundles on knee laxity. METHODS: Twelve cadaveric knees (six matched pairs) were used. Knee laxity measurements consisted of neutral tibial position, anterior-posterior translation, internal-external rotation, and varus-valgus angulation in different conditions: intact, ACL cut, incomplete BI (divided into two groups: anterolateral (AL) bundle intact or posteromedial (PM) bundle intact) and complete bicruciate tear. Data were collected using a Microscribe system at 0°, 30°, 60°, and 90° of knee flexion. RESULTS: In comparison to the intact knees, incomplete BI and complete BI showed a significant increase of total antero-posterior tibial translation. The largest significant increase was observed at 90° of flexion after a complete bicruciate resection (p < 0.001). A threshold difference greater than 15 mm from the intact could be used to identify a complete BI from an incomplete BI evaluating the total antero-posterior translation at 90°. All sectioned states had significant increases compared with the intact condition in internal-external rotation and varus-valgus stability at all tested flexion angles. CONCLUSION: Both incomplete and complete BI led to an important AP translation instability at all angles; however, full extension was the most stable position at all injured models. Total antero-posterior translation at 90° of knee flexion over 15 mm, in comparison to the intact condition, was indicative of a complete BI. Since the appropriate assessment of a combined ACL and PCL lesion remains a challenge, this study intends to assist its diagnosis. As BI's main antero-posterior instability occurred at 90°, a total antero-posterior drawer test is proposed to evaluate BI in the clinical setting. Total antero-posterior translation at 90° > 15 mm, in comparison to the intact condition or the contra-lateral non-injured knee, can be used to identify a complete from an incomplete BI.

Bicruciate lesion biomechanics, Part 2-treatment using a simultaneous tensioning protocol: ACL fixation first is better than PCL fixation first to restore tibiofemoral orientation.

PURPOSE: An uncommon technique for bicruciate ligament reconstruction involving simultaneous tensioning of the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) grafts with ACL graft fixation first has been pointed out as superior to the "gold-standard" PCL graft fixation first. The purpose of this study was to compare tibiofemoral biomechanics between ACL fixation first and PCL fixation first in a simultaneous tensioning protocol for bicruciate ligament reconstruction. METHODS: 12 fresh-frozen cadaveric knees (six matched pairs) were tested using a custom testing system. Neutral tibial position representing tibiofemoral orientation, anterior-posterior (AP) tibial translation, varus-valgus laxity, and internal-external rotation were measured using a Microscribe 3DLX at 0°, 30°, 60°, and 90° of knee flexion. The following knee conditions were evaluated: intact, bicruciate deficient and following bicruciate reconstruction. A simultaneous tensioning protocol was used for bicruciate reconstruction and PCL fixation first was compared to ACL fixation first. PCL graft fixation was always performed at 90° of flexion and ACL graft fixation was always performed at full extension. RESULTS: ACL fixation first achieved a tibiofemoral orientation closer to the intact knee than PCL fixation first at 90° flexion (1.8 ± 1.6 mm versus 6.1 ± 3.2 mm, p = 0.016). PCL fixation first had a larger decrease in AP translation than ACL fixation first at 30° flexion (64.6 ± 3.5% vs. 58.3 ± 2.4%, p = 0.01). No significant differences were found for varus/valgus, external-internal rotation decrements after bicruciate reconstruction nor for AP translation, varus/valgus and internal/external rotation increase after bicruciate lesion comparing ACL fixation first to PCL fixation first. CONCLUSION: Bicruciate ligament reconstruction using a simultaneous tensioning protocol with ACL fixation first resulted in a closer to normal tibiofemoral orientation. This study will help guide surgeons in decision making for the graft tensioning protocol and fixation sequence in a bicruciate ligament reconstruction. LEVEL OF EVIDENCE: V therapeutic study.

Tratamiento conservador en luxación congénita de rodilla: reporte de un caso y revisión de la literatura / Conservative treatment in congenital knee dislocation: report of a case and review of the literature

Introducción: la luxación congénita de rodilla es una de las alteraciones anatómicas muy poco frecuente, que su diagnóstico se basa en los hallazgos clínicos obtenidos al nacimiento y corroborados con exámenes radiológicos. La evolución y complicaciones que puede acarrear esta patología dependerá del grado de severidad y del momento de la instauración del tratamiento, ya que un tratamiento oportuno conducirá a una movilidad adecuada y un desarrollo sicomotor apropiado. Presentación del caso: presentamos un caso observado en nuestro hospital con seguimiento por cinco meses, en donde se le realizo un cambio paulatino de inmovilizaciones cruropédica y controles radiológicos sucesivos. Se realiza una revisión de caso clínico y revisión bibliográfica. Resultado: el presente caso muestra un manejo conservador en un recién nacido con Luxación Congénita de Rodilla, con el que se obtuvo una adecuada reducción mediante un manejo conservador oportuno. Conclusiones: un diagnóstico apropiado acompañado de un tratamiento oportuno otorgó una recuperación eficaz llevando a una movilidad adecuada, evitando complicaciones serias tanto musculo esqueléticas y sicosociales(AU)

Introduction: congenital knee dislocation is one of the very rare anatomical alterations, whose diagnosis is based on the clinical findings obtained at birth and corroborated with radiological examinations. The evolution and complications that this pathology can bring will depend on the degree of severity and on the time of the initiation of the treatment, since an opportune treatment will lead to an adequate mobility and an appropriate psychomotor development. Case: we present a case observed in our hospital with follow-up for five months, in which a gradual change of cruropic immobilizations and successive radiological controls was made. A clinical case review and bibliographic review is carried out. Result: the present case shows a conservative management in a newborn with Congenital Knee Dislocation, with which an adequate reduction was obtained through opportune conservative management. Conclusions: an appropriate diagnosis accompanied by an opportune treatment granted an effective recovery leading to an adequate mobility, avoiding serious musculoskeletal and psychosocial complications(AU)

External fixator for treatment of the sub-acute and chronic multi-ligament-injured knee.

PURPOSE: To assess whether the use of an articulated external fixator provides improvements in the mobility, stability and subjective function of patients undergoing ligament reconstruction. METHODS: Thirty-three patients with sub-acute and chronic knee dislocation were subjected to multi-ligament reconstruction surgery. These patients were randomly allocated to two groups for immobilization after reconstruction: group 0-control (18 patients), with rigid knee bracing, and group 1-articulated external fixator (15 patients). The stability of the reconstructed ligaments was assessed after at least 14 months (26.6-month average) postoperatively by physical examination. Deficit of extension and flexion was measured in relation to the unaffected contralateral knee, and the Lysholm knee scoring scale questionnaire was applied. RESULTS: There was no difference in the assessment of joint stability between the groups. In group 1, patients showed less flexion deficit (4.8° ± 5.4° vs. 18.2° ± 14.8°, p < 0.05), and the percentage of patients with a flexion deficit of 5° or less were higher compared with group 0 (64 vs. 18 %, p < 0.05). There was no difference between groups in relation to extension loss. Group 1 also presented better Lysholm scores, with 73 % of patients rated as excellent or good compared with 35 % in group 0 (p < 0.05). CONCLUSIONS: Compared with the control rehabilitation protocol with rigid knee bracing in extension, the use of an articulated external fixator in the treatment of chronic multi-ligament-injured knees provided the same ligament stability, better final range of motion and improved Lysholm score. Patients presenting with chronic multi-ligament instability should be considered for articulated external fixation to supplement reconstruction procedures. LEVEL OF EVIDENCE: Randomized controlled trial, Level I.

Surgical management of knee dislocations with ligament reconstruction associated with a hinged external fixator.

INTRODUCTION: Knee dislocations are defined as ligament injuries involving at least two of the four most important knee ligaments. Results from recent studies have shown a tendency towards improvement of the functional outcomes with use of an articulated external fixator during the postoperative period following multiligament reconstruction. Our hypothesis was that good knee stability and early gain of range of motion could be achieved with the use of the external fixator after ligament reconstructions. METHODS: Fourteen patients with knee dislocations were evaluated after multiligament reconstruction in association with use of a lateral monoplanar external fixator for six weeks. Reconstructions were performed using grafts from a tissue bank. Range of motion was measured after one, two, three, six, twelve months and at the final evaluation at a mean time of 49 months. The assessments were made using objective and subjective IKDC, Lysholm and Tegner scales. RESULTS: The mean scores were 71.7 for the subjective IKDC score, 81.5 for the Lysholm score. No patient was able to return to previous Tegner score. Out of the 45 ligament reconstructions performed, only four failed during the follow-up time. The mean range of motion of the knee presented a progressive increase from the first to the twelfth month, from 67.8° to 115.7°. Two cases of superficial infection on the site of the external fixator pins were observed. CONCLUSION: The use of an external fixator enabled early rehabilitation with range of motion gains starting from the first postoperative month, a low rate of reconstruction failure and minimal complications. Nevertheless, none of the patients returned to the level of activity prevailing prior to the injury. LEVEL OF EVIDENCE: Level IV, retrospective therapeutic case series.

Uso do fixador externo articulado no tratamento cirúrgico da instabilidade multiligamentar crônica do joelho

INTRODUÇÃO: A instabilidade multiligamentar do joelho, normalmente, é provocada por um trauma que determina sua luxação, um evento pouco frequente, mas, que pode trazer sequelas devastadoras. Mesmo com o tratamento cirúrgico preconizado é alto o índice de complicações. A mobilização precoce no pósoperatório provoca afrouxamento dos ligamentos reconstruídos, o que leva à instabilidade residual. A imobilização melhora a estabilidade, mas provoca dor e rigidez. Este trabalho tem o objetivo de avaliar se o uso do fixador externo articulado proporciona melhora na mobilidade, estabilidade e na função subjetiva de pacientes submetidos à reconstrução ligamentar. MÉTODOS: Neste ensaio clínico randomizado com grupos paralelos, 33 pacientes do ambulatório do Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Universidade de São Paulo com mais que 3 semanas de lesão dos ligamentos cruzados anterior e posterior associado à lesão de ligamento colateral fibular e/ ou ligamento colateral tibial foram submetidos à cirurgia de reconstrução multiligamentar, após alocação cega aleatória ao grupo 0 - controle (18 pacientes), com órtese rígida ou ao grupo 1 - fixador externo articulado por 6 semanas (15 pacientes), no período entre novembro de 2010 e novembro de 2013. Após seguimento mínimo de um ano de pós-operatório, a estabilidade dos ligamentos reconstruídos foi avaliada ao exame físico, foram mensurados os déficits de extensão e de flexão residual em relação ao joelho contralateral não acometido e foi aplicado o questionário específico para sintomas do joelho de Lysholm...

NTRODUCTION: Multiligament knee instability is normally caused by a trauma which results in its dislocation, an infrequent event, but one which can have devastating aftereffects. Even with the recommended surgical treatment the rate of complications is high. Early post-operative mobilization provokes loosening of the reconstructed ligaments, which leads to residual instability. Immobilization improves the stability, but causes pain and stiffness. This study aims to assess whether the use of an articulated external fixator provides improvements in the mobility, stability and the subjective function of the patients submitted to ligament reconstruction. METHODS: In this randomized clinical trial with parallel groups, 33 patients of the outpatient clinic of the Institute of Orthopaedics and Traumatology of the Hospital das Clínicas of the University of Sao Paulo with more than 3 weeks of injury to the anterior cruciate ligaments and the posterior cruciate ligaments associated with injury to the fibular collateral ligament and/or medial collateral ligament, were submitted to multiligament reconstruction surgery, after blind random allocation to either: Group 0 - control (18 patients), with rigid bracing, or to Group 1 - articulated external fixator for 6 weeks (15 patients), in the period from November, 2010 to November 2013. The stability of the reconstructed ligaments were assessed after 1 year postoperatively by physical examination, the deficit of residual extension and flexion was measured in relation to the unaffected contralateral knee and the Lysholm knee scoring scale questionnaire was applied...