Aseptically Processed Allograft Implantation: A Safe Strategy for Knee Ligament Reconstructions.

Postoperative infections after allograft implantation is a major concern in knee ligament reconstructions considering the theoretical risk of disease transmission and its potential severity. Here, we aimed to evaluate the postoperative infection rate after knee ligament reconstructions using aseptically processed allografts, and provide an overview of the allografts use in an academic tertiary hospital. A retrospective study was performed evaluating patients who underwent knee ligament reconstructions using aseptically processed allografts, including primary and revision surgeries, from 2005 to 2018. Demographic data, including the type of knee injury and trauma energy, and postoperative data were collected focusing on postoperative infections. Regarding these infected cases, further analyses were performed considering the presenting signs and symptoms, the isolated microorganism identified in culture, the time between graft implantation and diagnosis of infection (defined as acute, subacute, and late), and the need for graft removal. A total of 180 cases of ligament reconstructions were included. The mean follow-up was 8.2 (range: 2.1-15.6) years and the mean age at surgery was 34.1 (± 11.1) years. A total of 262 allografts were implanted in those 180 cases, 93 (35.5%) as bone plug allografts and 169 (64.5%) as soft tissue allografts. Common surgical indications included multiligament reconstruction (57.2%) and primary anterior cruciate ligament (ACL) reconstruction (15%). Seven cases (3.9%) presented postoperative infections. Knee pain (100%) and swelling (100%) were the most prevalent symptoms. Two cases (28.6%) presented sinus tract. Allografts were removed in two cases, the same cases that presented draining sinus (p = 0.04). High-energy trauma was the only statistically associated factor for infection (p = 0.04). No significant association between infection and the type of allograft (p > 0.99) or sex (p = 0.35) were observed. Four cases (57.1%) had monomicrobial staphylococcal infections. Based on that, the allograft-related infection rate was 1.7% (the remaining three infected cases). Nonirradiated, aseptically processed allografts have a low postoperative infection rate in knee ligament reconstructions, being a safe alternative for surgeries that require additional source, increased variety, and quantity of grafts.

Tibial Tubercle Osteotomy With Distalization Is a Safe and Effective Procedure for Patients With Patella Alta and Patellar Instability.

BACKGROUND: Tibial tubercle osteotomy with concomitant distalization for the treatment of patellar instability remains controversial, as it may cause anterior knee pain and chondral degeneration. PURPOSE: To evaluate radiographic, clinical, and functional outcomes in patients who had patellar instability with patella alta and underwent tibial tubercle osteotomy with distalization (TTO-d) as well as medial patellofemoral ligament reconstruction. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Included in this study were 25 patients (31 cases) (mean age at surgery, 28.7 years; range, 14-33 years) with patellar instability and patella alta who underwent TTO-d with minimum 1-year follow-up. The Caton-Deschamps index (CDI), tibial tubercle-trochlear groove (TT-TG) distance, and amount of distalization were assessed. Clinical and functional variables included J-sign, anterior knee pain, apprehension test, Tegner activity level, and Kujala score. RESULTS: The mean follow-up period was 2.62 years. The mean TT-TG was 16.15 mm (range, 7-24 mm); the mean CDI changed from 1.37 (1.25-1.7) preoperatively to 1.02 (0.9-1.12) postoperatively (P = .001); and the mean amount of tibial tubercle distalization was 8.80 mm (range, 4-16 mm). Lateral release (22 cases; 71.0%), medialization of tibial tubercle (17 cases; 54.8%), and autologous chondrocyte implantation (4 cases; 12.9%) were other associated procedures. The J-sign improved in 30 cases (96.8%; P = .001), and there was a complete resolution of anterior knee pain in 22 cases (71.0%; P = .001). An exploratory analysis showed that patellar cartilage defect severity was correlated with persistent pain (P = .005). The apprehension test became negative in all cases (P = .001). The median Kujala score increased from 52 to 77 (P = .001), and the median Tegner activity level improved from 3 to 4 (P = .001). No cases of osteotomy nonunion were reported. One case (3.2%) of patellar instability recurrence and 3 cases (6.5%) with painful hardware were observed. CONCLUSION: TTO-d resulted in good radiographic, clinical, and functional outcomes providing proper patellar stability to patients with patella alta. TTO-d appears to be a safe and efficient procedure with low complication rates, providing an additional tool for the personalized treatment of patellar instability.

Revision of total knee arthroplasty in a patient with contralateral transfemoral amputation: case report.

BACKGROUND: Knee arthroplasty is an efficient solution for osteoarthrosis in amputees. However, because of overload on the implant, it is apparently more subject to failure than in the non-amputated population. The aim of this case report is to show a failure of primary total knee arthroplasty contralateral to transfemoral amputation that required revision involving a tissue bank because of severely compromised knee bone. Surgical strategies, rehabilitation, and postoperative care for the operated limb and the contralateral prosthesis were demonstrated. CASE DESCRIPTION AND METHODS: A 60-year-old patient with early failure of total knee arthroplasty contralateral to transfemoral amputation underwent arthroplasty revision in which a graft from a tissue bank was used. After the revision, prosthesis length adjustment and exercise therapy were fundamental to the rehabilitation. FINDINGS AND OUTCOMES: The patient progressed well after the revision of the arthroplasty, with increases on the Knee Society Score and 36-Item Short Form Health Survey scales. CONCLUSION: Knee arthroplasty in amputees should be planned differently to that of the general population. For the procedure to be successful, there should be greater attention to implant stability, equalization of leg length, and a postoperative regimen including muscle strengthening and range of motion exercises to achieve the required knee flexion. CLINICAL RELEVANCE: This case report is important because it presents a challenging case of a unilateral transfemoral amputee with failed arthroplasty over the years in the contralateral limb. To our knowledge, such a case has not been described in the scientific literature. It would be helpful for surgeons and rehabilitation professionals to chart out a treatment protocol and also to prevent premature failure of the joint.

Combined reconstruction of the anterior cruciate ligament and posterolateral corner with a single femoral tunnel.

Combined injuries involving the anterior cruciate ligament (ACL) and posterolateral corner (PLC) occur in approximately 10% of complex knee injuries. The current tendency is to reconstruct both the ACL and the structures of the PLC. In injuries involving multiple ligaments, a potential problem in the reconstruction is the convergence of tunnels in the lateral walls of the femur. As a solution to this problem, we propose a combined technique for reconstruction of the ACL and PLC with a single tunnel in the lateral femoral wall. Combined ACL/PLC reconstruction is performed with 2 semitendinosus tendons and 1 gracilis tendon. The technique consists of making a tunnel in the lateral wall of the femur, from the outside in, at the isometric point, for reconstruction of the collateral ligament and popliteus tendon, and emerging in the joint region at the anatomic point of the ACL reconstruction. The graft is passed from the tibia to the femur with the double gracilis tendon and the simple semitendinosus tendon; the remaining portions are left for reconstruction of the structures of the PLC. This technique is very effective in terms of minimizing the number of tunnels, but it does rely on having grafts of adequate size.

Judet quadricepsplasty in the treatment of posttraumatic knee rigidity: long-term outcomes of 45 cases.

BACKGROUND: Posttraumatic knee stiffness is a very debilitating condition. Judet's quadricepsplasty technique has been used for more than 50 years. However, few reports of quadricepsplasty results exist in the literature. METHODS: We report the results of 45 cases of posttraumatic arthrofibrosis of the knee treated with Judet's quadricepsplasty. The results of the procedure were analyzed by measuring the degrees of flexion of the operated knees at different time points (before, immediately after, and late postoperatively). RESULTS: The degree of flexion increased from 33.6 degrees (range, 5­80 degrees) preoperatively to 105 degrees (range, 45­160 degrees)immediately after surgery, followed by a slight fall in the range of motion (ROM) in the late postoperative period, which reached an average of 84.8 degrees. There was no significant correlation between knee strength and the patient's gender, but there was a slight trend of lower strength with age. Although Judet's quadricepsplasty technique dates from more than 50 years ago, it still provides good outcomes in the treatment of rigid knees of various etiologies. In general, all cases showed the same pattern of a small decrease in the ROM in the late postoperative period. CONCLUSION: Judet's quadricepsplasty can increase the ROM of rigid knees. The ROM obtained with the surgery persists long term.

Comparative study on anterior cruciate ligament reconstruction: determination of isometric points with and without navigation.

OBJECTIVES: To compare the accuracy of tunnel placement and graft isometry for anterior cruciate ligament reconstruction performed using a computer-assisted navigation system (Orthopilot) and using traditional instruments. METHODS: The anterior cruciate ligament was removed intact from 36 pairs of human cadaver knees. From each pair, one knee was randomized to Group 1 (conventional) and the other to Group 2 (Orthopilot). An inelastic suture was then passed through the central points of the tibial and femoral tunnels. Neither of the tunnels was drilled. All knees were then dissected, and six parameters were obtained: distances from the tibial tunnel center to the 1) posterior cruciate ligament, 2) anterior horn of the lateral meniscus and 3) medial tibial spine; 4) distance from the femoral tunnel center to the posterior femoral cortex; 5) femoral tunnel coronal angle; and 6) variation of the distance from the femoral to the tibial tunnel with the knee extended and at 90 degrees of flexion. RESULTS: The variation of the distance from the femoral to the tibial tunnel during flexion and extension was smaller in the Orthopilot group (better isometry) compared to the conventional group. There were no statistical differences in any other parameters between the groups, and all tunnels were considered to be in satisfactory positions. DISCUSSION: The results obtained for anterior cruciate ligament reconstruction depend on precise isometric point positioning, and a navigation system is a precision tool that can assist surgeons in tunnel positioning. CONCLUSION: No differences in tunnel position were observed between the groups. Nonetheless, better isometry was achieved in the Orthopilot group than with conventional instruments.

Comparative study on anterior cruciate ligament reconstruction: determination of isometric points with and without navigation

OBJECTIVES: To compare the accuracy of tunnel placement and graft isometry for anterior cruciate ligament reconstruction performed using a computer-assisted navigation system (Orthopilot) and using traditional instruments. METHODS: The anterior cruciate ligament was removed intact from 36 pairs of human cadaver knees. From each pair, one knee was randomized to Group 1 (conventional) and the other to Group 2 (Orthopilot). An inelastic suture was then passed through the central points of the tibial and femoral tunnels. Neither of the tunnels was drilled. All knees were then dissected, and six parameters were obtained: distances from the tibial tunnel center to the 1) posterior cruciate ligament, 2) anterior horn of the lateral meniscus and 3) medial tibial spine; 4) distance from the femoral tunnel center to the posterior femoral cortex; 5) femoral tunnel coronal angle; and 6) variation of the distance from the femoral to the tibial tunnel with the knee extended and at 90 degrees of flexion. RESULTS: The variation of the distance from the femoral to the tibial tunnel during flexion and extension was smaller in the Orthopilot group (better isometry) compared to the conventional group. There were no statistical differences in any other parameters between the groups, and all tunnels were considered to be in satisfactory positions. DISCUSSION: The results obtained for anterior cruciate ligament reconstruction depend on precise isometric point positioning, and a navigation system is a precision tool that can assist surgeons in tunnel positioning. CONCLUSION: No differences in tunnel position were observed between the groups. Nonetheless, better isometry was achieved in the Orthopilot group than with conventional instruments.

Aseptic loosening of total hip arthroplasty: preliminary genetic investigation.

Femoral and acetabular loosening can be attributed different factors, but the causes and mechanism of early failure are still obscure. The objective of this study was to investigate the relationship between gene polymorphisms and early implant failure. Fifty-eight patients older than 50 years was recruited for analysis of MMP-1 promoter polymorphisms in early osseointegrated implant failure. The results showed in control group a frequency of 20.97% of 2G allele and 67.74% the genotype 1G/1G whereas, in the test group, a frequency of 83.33% of 2G allele and 66.66% the genotype 2G/2G. These results indicate that the polymorphism in the promoter of the MMP-1 gene could be a risk factor for early implant failure of total hip arthroplasty.

A isometricidade do ligamento cruzado posterior / Isometry of the posterior cruciate ligament

Trabalho de revisão bibliográfica referente à isometricidade do ligamento cruzado posterior. São avaliados doze artigos que estudam a isometricidade do ligamento, constatando que a maioria destes é concorde com a maior importância da inserção femoral na isometricidade e que existe uma linha ou área mais isométrica na inserção femoral, aproximadamente perpendicular ao teto da fossa intercondilar, localizada de 10 a 14mm da abertura anterior desta fossa.

Importância da ressonância magnética na avaliaçäo das lesöes traumáticas da placa de crescimento epifisária / Magnetic ressonance imaging importance in evaluation of the traumatic lesions of the epiphyseal growth plate

Estudo retrospectivo de nove pacientes que sofreram lesao traumática da placa de crescimento foi realizado através da análise de seus prontuários, com o objetivo de determinar o valor da ressonância magnética no diagnóstico precoce das lesoes pós-traumáticas da placa de crescimento e também na capacidade de identificar o tipo, localizaçao e extensao da lesao, para melhor planejar o tratamento. As ressonâncias magnéticas foram realizadas com séries pesadas em T1, T2 e T2* (gradiente eco), nos planos coronais e sagitais. Em dois casos de lesao traumática aguda sem desvio da placa de crescimento, foi possível sua identificaçao. Nos casos em que havia ponte através da placa de crescimento, foi possível identificar sua localizaçao, sua extensao e ainda diferenciar entre ponte óssea ou fibrosa, com exceçao de um caso. Os resultados mostraram que a RM é um eficiente método na detecçao precoce das alteraçoes pós-traumáticas da placa de crescimento, assim como na determinaçao da localizaçao e extensao dessas, contribuindo muito para o planejamento terapêutico.

Estudo mecänico dos complexos colaterais do joelho / Mechanical study of collateral complexes of the knee

Os autores realizaram estudo biomecânico dos complexos colaterais medial e lateral de 40 joelho de cadáveres frescos, com o objetivo de compara-los entre si e estabelecer relaçöes com a idade, peso e a altura dos espécimes. Após a análise dos dados, constatam que näo existe diferença entre os lados e nem entre os complexos colaterais mediais e laterais, sendo que o limite de resistência varia inversamente com peso para ambos os complexos colaterais e a idade relaciona-se inversamente com o complexo colateral lateral

Tratamento cirúrgico da pseudoartrose do rádio: relato de um caso / Surgical treatment of pseudoarthrosis of the radius: report of a case

Os autores relatam a experiência do Serviço de Ortopedia e Traumatologia do Hospital da Polícia Militar do Estado de Säo Paulo no tratamento da pseudoartrose de rádio em uma paciente do sexo feminino de sete anos de idade empregando a técnica de Sofield. Conseguiram a reparaçäo da pseudartrose após 4,5 meses de pós-operatório e tecem consideraçöes sobre a etiologia