¿Es segura la cirugía ambulatoria de reconstrucción de ligamento cruzado anterior? experiencia a dos años de seguimiento clínico / Is outpatient reconstruction of the anterior cruciate ligament a safe procedure? experience with two years of follow up

INTRODUCIÓN: La cirugía ambulatoria permite una reducción importante del costo en procedimientos de alta prevalencia; no obstante, siempre debe resguardarse la seguridad del paciente. OBJETIVO: Evaluar las complicaciones operatorias tempranas y resultados funcionales en pacientes sometidos a reconstrucción de ligamento cruzado anterior (R-LCA) en cirugía ambulatoria. Se analiza además una estimación en la reducción de costos por programa ambulatorio. MATERIAL Y MÉTODOS: Estudio retrospectivo de pacientes sometidos a R-LCA con técnica hueso-tendón-hueso (HTH) en pabellón ambulatorio en un mismo centro, entre 2016 y 2018. Se excluyeron pacientes con menos de un año de seguimiento. Se utilizó el mismo protocolo anestésico: anestesia espinal y bloqueo sensitivo único, asociado a analgesia postoperatoria por vía oral. Se entregó a pacientes instructivo de cuidados postoperatorios, síntomas de alarma, y ejercicios de fisioterapia al alta. Se realizó encuesta telefónica al tercer día para evaluar el estado general y las complicaciones, y, al final del seguimiento, para evaluación funcional mediante las escalas de Tegner y Lysholm pre- y postquirúrgicos. Se identificaronó a pacientes no dados de alta el mismo día, consulta precoz no programada, y reintervenciones. Se realizó un análisis de costo para evaluar el ahorro por procedimiento ambulatorio versus hospitalizado. RESULTADOS: Se operaron 36 pacientes de forma ambulatoria. En 4 (11,1%) se asoció a sutura meniscal con técnica dentro-fuera. La encuesta postoperatoria inicial fue respondida por 23 pacientes (63,8%); todos presentaron buen estado general: 43% sin dolor y 57% con molestias tolerables. No hubo sangrados. La encuesta al final del seguimiento (promedio: 22,5 7,9meses) fue respondida por 20 pacientes (55,5%): la puntación en las escalas de Tegner y Lysholm aumentó significativamente, de 3 (rango: 1 a 6) a 6 (rango: 3 a 8) (p » 0,0001) y de 44 (rango: 12 a 81) a 91 (rango: 61 a 100) (p » 0,0001), respectivamente. Todos fueron dados de alta el mismo día de la operación. Hubo 2 (5,5%) consultas precoces, una por caída en domicilio con dehiscencia de herida operatoria, y otra por hematoma no complicado. Se registraron dos reintervenciones: una dehiscencia de herida operatoria y una fractura de patela. La reducción de costos por realizar el procedimiento de forma ambulatoria fue de 203.205 pesos/paciente. CONCLUSIÓN: La cirugía ambulatoria de R-LCA mediante la técnica HTH fue un procedimiento seguro en esta serie, con un manejo adecuado del dolor y resultados funcionales satisfactorios al mediano plazo. Se asoció además a una reducción en estimación de costos.

INTRODUCTION: Outpatient procedures allow for an important cost reduction in highprevalence procedures; however, patient safety must always be ensured. OBJECTIVE: To evaluate the early complications and functional scores of patients undergoing an anterior cruciate ligament reconstruction (ACLR) as an outpatient procedure. An estimated cost reduction is also analyzed. MATERIALS AND METHODS: A retrospective study of patients undergoing outpatient ACLR with a bone-patellar tendon-bone (BPTB) technique in one center between 2016 and 2018. Patients with less than one year of follow-up were excluded. All patients were submitted to the same anesthetic protocol: spinal anesthesia, a one-shot echo-guided adductor canal nerve block, and outpatient analgesics. Upon discharge, all patients received instructions regarding postoperative care, physical therapy exercises, and red flags. A telephone survey was conducted on the third day to evaluate the general conditions and complications, as well at the final follow-up, to collect pre- and postoperative Tegner and Lysholm functional scores. Patients who were not discharged on the same day, early non-scheduled visits, and re-interventions were recorded. A cost-reduction analysis was performed for the inpatient versus outpatient procedures. RESULTS: In total, 36 patients were submitted to an outpatient procedure, and 4 (11.1%) had an outside-in meniscal suture. The survey was filled out by 23 patients (63.8%); all were in good general condition: 43% reported no pain and 57%, tolerable pain. No bleeding was observed. The survey at the end of the follow-up (average: 22.5 7.9 months) was filled out by 20 patients (55.5%); the scores on the Tegner and Lysholm scales improved significantly, from 3 (range: 1 to 6) to 6 (range: 3 to 8) (p » 0.0001), and from 44 (range: 12 to 81) to 91 (61 to 100) (p » 0.0001) respectively. All patients were discharged on the same day of surgery. There were 2 (5.5%) early visits, one due to a fall at home withdehiscence of the surgical wound, and one due to a non-complicated hematoma. Two re-interventions at the end of the follow-up were recorded: traumatic surgical-wound dehiscence and a patellar fracture. The cost reduction for the outpatient procedure was of 203, 205 pesos per patient CONCLUSION: The outpatient ACLR with the BPTB technique was a safe procedure in the present series, with adequate pain management and satisfactory functional scores at the medium-term follow-up. It was also associated with a reduction in cost estimates.

Fracturas avulsivas tibiales del ligamento cruzado posterior fijadas con tornillos: un estudio clínico y radiológico / Screw fixation of posterior cruciate ligament tibial avulsion fractures: a clinical and radiographic study

OBJETIVO: Realizar la evaluación clínica, imagenológica y funcional de pacientes con fracturas avulsivas tibiales del ligamento cruzado posterior (FTALCPs) fijadas con tornillos canulados con técnica abierta. MÉTODOS: Los pacientes con FTALCP operados entre 2010 y 2017 fueron revisados retrospectivamente. Criterios de inclusión: fracturas agudas, desplazadas, test de cajón posterior grado III, lesiones combinadas de rodilla, seguimiento > 12 meses. Se excluyeron pacientes > 65 años, con FTALCPs bilaterales, lesiones del ligamento cruzado posterior (LCP) intrasustancia, test de cajón posterior grados I-II, fracturas expuestas, lesiones neurovasculares, y seguimientos < 12 meses. Objetivo primario: medir la estabilidad clínica mediante test de cajón posterior y radiografía de estrés arrodillada comparativa. Objetivos secundarios: nvaluar la consolidación en radiografías, complicaciones y funcionalidad con las escalas de Lysholm y Tegner. Resultados Se incluyeron 20 pacientes, con edad media de 41 años (rango: 32 a 61 años). El seguimiento promedio fue de 33,9 meses (rango: 12 a 82 meses). La estabilidad clínica mejoró en 93% (cajón posterior postoperatorio grados 0 y I) de los pacientes. La radiografía de estrés arrodillada mostró una diferencia promedio de 2,6 mm (rango: 0,1 mm a 6,8 mm) de traslación posterior al comparar con el lado sano. Todas las fracturas consolidaron. Siete pacientes presentaron complicaciones. El puntaje promedio de la escala de Lysholm al final del seguimiento fue de 85,17. El promedio preoperatorio del puntaje en la escala de Tegner no varió significativamente en comparación con el postoperatorio. CONCLUSIONES: La fijación de fracturas avulsivas tibiales del LCP con tornillos canulados con técnica abierta es efectiva en restaurar la estabilidad posterior y lograr la consolidación ósea. La funcionalidad clínica a mediano plazo es buena, a pesar del alto número de complicaciones y lesiones concomitantes. NIVEL DE EVIDENCIA: tipo IV.

OBJECTIVE: To report mid-term clinical, radiographic, and functional outcomes following open reduction and fixation of posterior cruciate ligament tibial avulsion fractures (PCLTAFs) with cannulated screws. METHODS: This is a retrospective analysis of patients with PCLTAF operated on from August 2010 to April 2017. Patients with acute fractures, with more than 2 mm of displacement and grade III on the posterior drawer test, combined or not to knee injuries, were included. Patients older than 65 years of age, with bilateral avulsion fractures, intrasubstance posterior cruciate ligament (PCL) lesions, stable grade-I to -II on the posterior drawer test, concomitant neurovascular injuries, mid-substance tears, open fractures, and less than 12 months of follow-up were excluded. Primary outcomes: the clinical stability was assessed using the posterior drawer test and a single comparative knee stress radiograph. Secondary outcomes: radiographic consolidation, complications, Lysholm score, and Tegner activity score. RESULTS: In total, 20 patients with a mean age of 41 years (range: 32 to 61 years) were included. The mean follow-up was of 33.9 months (range: 12 to 82 months). Clinical stability (grade 0 or I on the posterior drawer test) was observed in 93% of the patients. The mean difference in contralateral posterior displacement was of 2.6 mm (range: 0.1 mm to 6.8 mm) on a single comparative knee stress radiograph. All fractures presented radiological consolidation. Seven patients developed complications. The mean Lysholm score at the last follow-up visit was of 85.17. The postoperative Tegner activity scores did no vary significantly compared to the preinjury scores. CONCLUSIONS: Cannulated screw fixation of a displaced PCLTAF through a posterior approach restores clinical and radiographic stability and has excellent union rates. The mid-term functional outcomes are good despite the high rates of combined knee lesions and postoperative complications. LEVEL OF EVIDENCE: IV.

Is the Clinician's Eye a Valid and Reproducible Tool for Diagnosing Patella Alta on a Lateral Knee Radiography?

INTRODUCTION: Validity and reproducibility of the clinician's eye (CE) to diagnose patella alta (PA) on a lateral knee radiography (radiograph) is unknown. METHODS: Cross-sectional study of 46 lateral knee x-rays. Three blind observers used CE, Insall-Salvati (IS), modified Insall-Salvati (mIS), and Caton-Deschamps (C-D) to determine patellar height. Sensitivity and specificity of each observer was compared with the musculoskeletal radiologist's C-D measurements. Intraobserver and interobserver agreement were assessed with intraclass correlation coefficient and Fleiss κ, respectively. Time needed to estimate patellar height for every method was recorded in seconds. Statistical differences between observers were calculated with a generalized estimating equation. Analysis of variance and post hoc Bonferroni test compared duration of each method (P < 0.05). Data were analyzed using Stata 15 (StataCorp). RESULTS: CE, IS, mIS, and C-D's sensitivity and specificity values are as follows: 77%, 92%; 94%, 52%; 67%, 58%; and 53%, 89%, respectively. Intraclass correlation coefficient and Fleiss κ of CE, IS, mIS, and C-D values are as follows: 0.66 and 0.43, 0.88 and 0.68, 0.54 and 0.09, and 0.68 and 0.59, respectively. CE was the second most sensitive and most specific method for diagnosis of PA, with moderate intraobserver and interobserver agreement. IS was the most sensitive method with good intraobserver and interobserver agreement. CE was significantly faster (P < 0.05) than all other conventional radiographic ratios. CONCLUSION: CE's sensitivity increases with observer's experience and is highly specific. If normal patellar height is diagnosed, no other ratios are necessary, even in the less experienced clinician. Intraobserver and interobserver reproducibilities were moderate and only inferior to the IS ratio. In case patellar height is uncertain with the CE, the IS ratio is the most sensitive and reproducible method to confirm the diagnosis of PA.

Patellar sleeve avulsion fracture in a patient with Sinding-Larsen-Johansson syndrome: a case report.

BACKGROUND: Patellar sleeve avulsion (PSA) fractures are rare injuries that occur in in skeletally immature patients. Initial diagnosis is key to a successful outcome, as these injuries are easily overlooked on plain radiographs with poor results well documented from delayed management. High index of suspicion from the mechanism of injury, thorough clinical examination and Magnetic Resonance Imaging (MRI) help to avoid misdiagnosis. CASE PRESENTATION: The case of a 12-year-old male athlete with an acute PSA after a conservative treatment of a SLJ syndrome is described. The patient was referred to our clinic due to severe pain and loss of function after performing a high jump. Plain radiographs (X-ray) and MRI confirmed an inferior pole PSA which was fixed with double trans osseous ultra-high strength tapes. At the 3-month follow- up visit the patient was able to ambulate brace free. At 2-years follow up the patient was able to play soccer and ice hockey. To our knowledge, there are no case reports of inferior pole PSA with prior SLJ syndrome described in literature. CONCLUSIONS: Early clinical suspicion and distinguishing this PSA from other enchondral ossification disorders around the knee is critical to avoid misdiagnosis. Whether SLJ syndrome increases the risk of sustaining a PSA is still not clear. Trans osseous fixation with suture tapes leads to good functional results in a young athlete with inferior pole PSA.

Steep lateral tibial slope and lateral-to-medial slope asymmetry are risk factors for concomitant posterolateral meniscus root tears in anterior cruciate ligament injuries.

PURPOSE: To compare sagittal and coronal tibial slopes between anterior cruciate ligament (ACL) injured subjects with and without posterolateral meniscus root tear (PLRT). METHODS: A chart review was conducted to identify patients with isolated ACL tears and patients with an associated PLRT. Patients with other concomitant injuries and patients who underwent surgery > 6 months after the injury were excluded. Magnetic resonance image data were used to compare the medial and lateral sagittal tibial slope (MTS and LTS), lateral-to-medial slope asymmetry (LTS-MTS), and coronal slope of the tibial plateau between both groups. Mean LTS and standard deviation (SD) of the control group were calculated, and a value of > mean + 1 SD was considered an abnormal LTS. Interobserver reproducibility was assessed by calculating interclass correlation coefficients (ICCs) of measurements independently obtained by two reviewers. RESULTS: Fifty-nine patients met the in- and exclusion criteria. Thirty nine (66%) had an isolated ACL tear and 20 (34%) had an associated PLRT. Interrater ICCs for LTS, MTS, and coronal slope were 0.930, 0.884 and 0.825, respectively, representing good to excellent interobserver reproducibility. Patients with a PLRT had significantly steeper LTS (8.0 ± 3.2 vs. 4.0 ± 2.0; p < 0.001) and significantly greater difference of LTS-MTS (3.7 ± 2.9 vs. - 0.6 ± 2.0; p < 0.001). Furthermore, patients with abnormal LTS were significantly overrepresented among patients with PLRT (70% vs. 18%; p < 0.001). No significant difference between both groups was found for MTS and coronal slope. CONCLUSION: A steep lateral tibial slope and lateral-to-medial slope asymmetry are risk factors for concomitant PLRT in ACL-injured subjects. LEVEL OF EVIDENCE: IV, retrospective cohort study.

No association between positive intraoperative allograft cultures and infection rates after reconstructive knee ligament surgery.

BACKGROUND: Several reports of severe infections associated with allograft tissue in knee reconstructive surgery have led many surgeons to consider routine intraoperative culture of allograft tissue before implantation. Thus, the purpose of this study was to determine the prevalence of positive soft tissue allograft cultures in reconstructive knee surgery, and evaluate its association with surgical site infection. METHODS: Retrospective study of 202 patients who underwent knee reconstructive ligament surgeries, including revisions, between January 2013 and July 2017. Intraoperative culture results were obtained and the report of a surgical site infection during follow-up was recorded. Patients without cultures were excluded. A priori power analysis was performed. The association between positive culture results and development of surgical site infection was evaluated using Fisher's Exact test (P < 0.05). RESULTS: A total of 300 allografts were implanted in 202 patients. Mean average follow-up was 32.9 ±â€¯12.5 (range 13 to 57.9) months. Sixteen patients had positive intraoperative allograft cultures (7.9%). The most frequently isolated organism was Bacillus species (six cultures); none of these patients presented with clinical signs of infection. Nine patients developed surgical site infections and were treated with oral antibiotics, and one patient developed septic arthritis that required surgical debridement of the implanted graft; all of these patients had a negative soft tissue allograft culture. No significant association was found between a positive culture and surgical site infection (P = 0.43). CONCLUSION: There was no apparent association between positive intraoperative irradiated soft tissue allograft cultures and surgical site infection in reconstructive knee surgery.

Estudio comparativo de reconstrucción de ligamento cruzado anterior con y sin lesiones condrales; resultados funcionales a largo plazo / Anterior cruciate ligament reconstruction with and without chondral lesions; long term functional results

INTRODUCCIÓN: La lesión del ligamento cruzado anterior (LCA), es una patología frecuente, y el éxito de la reconstrucción depende de diversos factores, tales como la técnica quirúrgica empleada, la edad del paciente, índice masa corporal, nivel de actividad y lesiones asociadas. El objetivo de este estudio es comparar los resultados funcionales a largo plazo de pacientes con lesiones condrales tratadas y sin lesiones condrales sometidos a la reconstrucción de LCA (RLCA), con autoinjerto semitendinoso-gracilis (ST-G). MATERIALES Y MÉTODOS: Estudio analítico retrospectivo. Cuarenta y nueve pacientes (34 hombres y 15 mujeres), fueron sometidos a la RLCA con autoinjerto ST-G. Se compararon dos grupos. Grupo RLCA + LC: 24 pacientes con lesiones condrales ICRS grado III y IV tratadas en el mismo acto quirúrgico y grupo RLCA: 25 pacientes sin lesiones condrales concomitantes. Las edades promedio fueron de 32 y 28 años en cada grupo respectivamente. La funcionalidad de los pacientes a largo plazo fue evaluada con el test de Lysholm, IKDC y retorno deportivo. Se compararon los promedios de los scores funcionales según cada grupo con Test de Mann-Whitney. La asociación entre ambos grupos y el retorno deportivo se analizó con Test de Chi2. Los análisis estadísticos se realizaron con Stata IC 13. RESULTADOS: El seguimiento promedio fue de 106,8 meses (rango: 86­125). Los resultados funcionales obtenidos al comparar el grupo RLCA + LC vs grupo RLCA fueron significativamente peores en el primero, con un promedio del score de Lysholm de 84,87 vs 94,52 (p = 0.0001) e IKDC de 84,43 vs 92,08 (p = 0,004), respectivamente. El retorno deportivo de cada grupo fue de 70,8% y 88% (p = 0,136). CONCLUSIÓN: La funcionalidad a largo plazo de los pacientes con una RLCA y que tengan alguna LC profunda tratada concomitante, es significativamente inferior que aquellos pacientes con RLCA aislada. No existen diferencias significativas en el porcentaje de retorno deportivo entre ambos grupos.

INTRODUCTION: Anterior cruciate ligament injury is a frequent sports injury, and successful reconstruction depends on diverse factors, such as surgical technique, age, body mass index, level of activity and other concomitant cartilage and meniscal lesions. The objective of this study is to retrospectively compare the long term clinical outcomes of ACL hamstring tendon autograft reconstruction with and without concomitant cartilage injuries. MATERIALS AND METHODS: Forty nine patients (34 men and 15 women) underwent single bundle transtibial ACL reconstruction and were divided in two groups (Group 1: 24 patients with chondral lesions grade III and IV of the ICRS, and Group 2: 25 patients without chondral lesions). Mean age of both groups was 32 and 28 years, respectively. Clinical outcome was evaluated with Lysholm test, IKDC and return to previous level of sport activities. Mean values of of funcional outcome scores between both groups were compared with Mann-Whitney test. Return to previous level of activity in both groups was analyzed with Chi-2 test. The statistical analysis was performed with Stata IC 13. RESULTS: The mean follow-up period was 106.8 months (range: 86­125). Mean Lysholm test for group 1 vs group 2 was 84.87 and 94.52 (p < 0.001), mean IKDC was 84.43 and 92.08 (p < 0.001), and return to previous sports was 70.8% vs 88% (p = 0.136) for each group. CONCLUSION: Long term clinical outcomes in patients with chondral lesions that underwent ACL reconstruction were significantly lower than patient with isolated ACL injuries. No statistical differences were found in the return to previous sport activities.

Five-Strand Hamstring Autograft Versus Quadruple Hamstring Autograft With Graft Diameters 8.0 Millimeters or More in Anterior Cruciate Ligament Reconstruction: Clinical Outcomes With a Minimum 2-Year Follow-Up.

PURPOSE: To compare the outcomes of 2 groups of patients undergoing anterior cruciate ligament (ACL) reconstruction: the first with a quadrupled semitendinosus gracilis (ST-G) autograft larger than 8 mm diameter and the second with a 5-strand ST-G autograft larger than 8 mm due to an insufficient diameter graft harvesting. METHODS: This was a retrospective study with 70 patients divided into 2 groups. Inclusion criteria included ACL ruptures of less than 3 months, ST-G ACL reconstructions, and final (4-strand or 5-strand) graft size larger than 8 mm. Exclusion criteria included multiligament knee injuries, meniscal or chondral pathology, ACL re-ruptures, inflammatory joint disease, or other procedures in the knee. RESULTS: Group A comprised 33 patients with a quadruple ST-G graft, and group B comprised 37 patients with an insufficient graft diameter (<8 mm) in which a 5-strand graft was used. Mean age in group A was 29.7 (range 17-52) years and in group B was 30.6 (range 13-53) years (P = .78). Average follow-up in group A was 32.2 (range 24-48) months and in group B was 30.35 (range 24-48) months (P = .75). Average graft diameter in group A was 8.5 mm (range 8-10) and in group B when the graft was measured as quadruple was 7.2 mm (range 6.5-7.5) and 9.2 mm (range 8-10) when it was converted to 5-strand (P = .00596). Group A had 3 (9%) re-ruptures, and group B had 2 (5.4%) (P = .55). The average postoperative Lysholm score in group A was 93.3 (range 71-100) and in group B was 97.1 (range 80-100) (P = .79). Mean postoperative International Knee Documentation Committee in group A was 91 (range 75.9-100) and in group B was 96.8 (range 82-100) (P = .18). CONCLUSIONS: In our study, the 5-strand hamstring autograft in ACL reconstruction was clinically comparable with the quadruple autograft larger than 8 mm. The differences in re-rupture and clinical outcomes were not statistically significant between the 2 groups, suggesting that it is a valid option when we have a graft of insufficient diameter. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Reconstrucción mínimamente invasiva del ligamento anterolateral / Minimally invasive anterolateral ligament reconstruction following anterior cruciate ligament revision surgery: technical note

INTRODUCCIÓN: La inestabilidad anteroposterior y la laxitud rotatoria demostrada mediante test de pivot-shift severo podría estar causada por la combinación de lesión de ligamento cruzado anterior (LCA) y de estructuras laterales de la rodilla, particularmente del ligamento anterolateral (LAL). Este último actúa como estabilizador secundario, restringiendo la rotación interna y complementando el rol primario de estabilización del LCA. MATERIAL Y MÉTODOS: Describir la técnica de reconstrucción mínimamente invasiva del LAL tras realizar una cirugía de revisión del LCA. Además, se ofrece una breve descripción de las indicaciones quirúrgicas, resultados y complicaciones. DISCUSIÓN: La inestabilidad rotatoria persistente tras la reconstrucción de LCA indica que la reconstrucción intraarticular podría no ser suficiente para restaurar la estabilidad rotacional en un subgrupo específico de pacientes. Se han descrito numerosas técnicas de reconstrucción extraarticulares (mencionadas previamente), algunas de ellas con incisiones de gran tamaño, con los consiguientes problemas estéticos. Esta nota describe una técnica simple y mínimamente invasiva de reconstrucción de LAL, realizada tras una revisión del LCA con técnica anatómica, todo en el mismo procedimiento quirúrgico. Esta técnica está indicada en roturas agudas o exploraciones/revisiones del LCA que presenten pivot-shift severo, así como también en pacientes con roturas crónicas del LCA o en pacientes que sean hiperlaxos. A pesar de que esta técnica no ha demostrado ser superior a otras reconstrucciones extraarticulares del LAL, se presenta como una cirugía simple, confiable y rápida, con buenos resultados estéticos.

INTRODUCTION: Anteroposterior instability and rotatory laxity demonstrated by severe pivot-shift test may be caused by combined lesions of the anterior cruciate ligament (ACL) and lateral structures of the knee, particularly the anterolateral ligament (ALL). This ligament acts as a secondary stabiliser that restrains internal rotation and supplements the primary stabilising role of the ACL. MATERIAL AND METHODS: To describe a minimally invasive ALL reconstruction technique following anterior cruciate ligament revision surgery. Brief description of surgical indications, outcomes, and complications. DISCUSSION: Persistent rotatory instability after ACL reconstruction suggests that intra-articular reconstruction may not be sufficient to restore rotational stability in a subgroup of patients. Numerous extra-articular reconstruction techniques have been described with long incisions and cosmetic issues. A description is presented of a simple, minimally invasive ALL reconstruction technique performed after anatomical ACL revision in a single procedure. This technique is indicated in patients with acute ACL injuries and revision ACL associated with a severe pivot-shift, chronic ACL injuries, and joint hyper-laxity. Although this technique has not proven to be superior to any other extra-articular anterolateral ligament reconstructions, it uses simple, reliable and cosmetic surgery, with good early results in a small series of patients.

Expectativas y aprensiones de los pacientes sometidos a cirugía de reconstrucción de ligamento cruzado anterior de rodilla / Expectations and concerns of patients undergoing anterior cruciate ligament reconstruction surgery

INTRODUCCIÓN: La lesión del ligamento cruzado anterior (LCA) es una afección frecuente cuyo manejo quirúrgico genera incertidumbre en el paciente sobre su retorno a la actividad. Las expectativas previas al procedimiento influyen en su percepción del éxito del tratamiento, la aparición de complicaciones y en el resultado final, comprometiendo la satisfacción en el postoperatorio. OBJETIVO: Determinar las preocupaciones y expectativas de los pacientes sometidos a cirugía de reconstrucción de LCA. MÉTODO: Estudio prospectivo observacional realizado a través de encuestas a pacientes con lesión del LCA que serían sometidos a una cirugía de reconstrucción. Las variables evaluadas fueron edad, mecanismo de lesión, práctica de actividad deportiva, información previa acerca de la intervención quirúrgica y las preocupaciones y expectativas sobre el procedimiento. RESULTADOS: Cincuenta pacientes fueron encuestados, 38 hombres y 12 mujeres, con edad promedio de 30 años. Los mecanismos de lesión más frecuentes correspondieron a accidentes deportivos de fútbol y esquí. El 96% de los encuestados practicaba algún deporte de forma regular (promedio 5h semanales) previo a la intervención quirúrgica. El 90% de los pacientes investigaron sobre la cirugía de reconstrucción de LCA. Las principales preocupaciones preoperatorias correspondieron al tiempo de recuperación (40%) y a la posibilidad de reintegrarse en la práctica deportiva (38%). Las expectativas se concentraron en lograr un reintegro deportivo precoz (54%) y la presencia de dolor postoperatorio (40%). CONCLUSIÓN: Los pacientes sometidos a reconstrucción de LCA presentan preocupaciones principalmente respecto al tiempo de recuperación postoperatorio y sus expectativas se centran en el logro de un reintegro deportivo precoz.

INTRODUCTION: Anterior cruciate ligament (ACL) injury is a common condition and its surgical treatment causes uncertainty in patients about their return to activity. The expectations prior to the procedure influence their perception of treatment success, development of complications, and final results, and can have an impact on post-surgical patient satisfaction. OBJETIVE: To determine the concerns and expectations of patients undergoing ACL reconstruction surgery. METHOD: Prospective observational study, in which questionnaires were completed by patients with ACL injury that would undergo reconstructive surgery. The evaluated variables were age, mechanism of injury, sports practice, prior information about the surgery and concerns and expectations about the procedure. RESULTS: A total of 50 patients completed the questionnaire, of whom 38 were men and 12 women with a mean age of 30 years. The most common injury mechanisms were when practicing football and skiing. Almost all (96%) of respondents played sports regularly (average 5hours a week) before the surgery. A total of 90% of patients had enquired about ACL reconstruction surgery. The main pre-operative concerns were recovery time (40%) and the possibility of reinstatement of sports (38%). Expectations are focused on achieving an early sports recovery (54%) and the presence of postoperative pain (40%). CONCLUSION: Patients undergoing ACL reconstruction have concerns primarily as regards post-surgical recovery time and expectations are focused on achieving an early reinstatement of sports.

Bloqueo de nervio femoral único vs. continuo en reconstrucción de ligamento cruzado anterior; un estudio clínico aleatorizado / Femoral nerve block in anterior cruciate ligament surgery; a prospective randomised trial

En cirugía de reconstrucción del ligamento cruzado anterior (LCA) es fundamental la rehabilitación precoz y, para ello, la analgesia. El bloqueo de nervio femoral (BNF) es un procedimiento frecuentemente utilizado en cirugía artroscópica y protésica de rodilla, sin embargo, se debate aún cómo debe ser aplicado para mejorar la analgesia sin afectar una rehabilitación precoz. Objetivo: Comparar analgesia mediante BNF con punción única versus infusión continua en las primeras 48h de reconstrucción del LCA. Metodología:Cuarenta y tres pacientes >18 años, ASA 1-2, sometidos a cirugía artroscópica de LCA (autoinjerto) con mismo equipo quirúrgico. Se crearon aleatoriamente 2 grupos: grupo 1 (G1) bloqueo femoral único con bupivacaína más solución fisiológica; grupo 2 (G2) bloqueo femoral+catéter femoral con infusión continua de bupivacaína con adrenalina 1:300.000 por 48h. Se evaluó dolor de reposo y al mover la extremidad, hipoestesia de muslo y necesidad de analgesia adicional a las 6, 12, 24 y 48h. Resultados: El BNF fue exitoso en todos los pacientes, logrando hipoestesia en la totalidad del G2 vs solo 17 por ciento del G1 a las 24h y 74 por ciento vs 0 por ciento a las 48h, respectivamente. El dolor postoperatorio fue bajo y sin diferencias entre los grupos, con requerimiento de analgesia extra de 33 por ciento G1 vs 0 por ciento G2. Conclusión: El BNF es una técnica analgésica eficaz para controlar el dolor postoperatorio en cirugía de LCA. No se observaron diferencias significativas entre las técnicas investigadas. Nivel de evidencia tipo ii...

Early rehabilitation is essential after anterior cruciate ligament (ACL) surgery. Femoral nerve block (FNB) is a frequently used method to control post-operative pain in arthroscopic and reconstructive knee surgery; however, it is still unknown how to apply this procedure to improve analgesia without affecting early rehabilitation. Objective:To compare the effectiveness of pain management after a single dose of FNB vs a continuous FNB infusion during the first 48hours after ACL surgery. Methodology: Forty-three patients older than 18 years, ASA I-II, underwent ACL reconstruction with an autograft. Patients were prospectively randomised into two separate groups: Group 1 (G1) received a single dose of FNB with bupivacaine diluted in 10mL saline solution. Group 2 (G2) received continuous FNB infusion with bupivacaine and epinephrine (1:300.000) for 48hours. Pain was assessed at rest and with controlled passive motion of the knee. Thigh hypo-aesthesia and the need for additional analgesia were evaluated at 6, 12, 24, and 48hours. Statistical analysis was performed with Fisher's exact test (percent) and Mann-Whitney's test (VAS). Statistical significance with P<.05. Results: FNB was successful in all patients, and thigh hypo-aesthesia was present in 100 percent of G2 vs. 17 percent in G1 at 24hours, declining to 74 percent vs. 0 percent at 48hours, respectively. Post-operative pain scores were low, and did not differ between the two groups. Additional analgesia was required in 33 percent of patients in G1 vs. 0 percent in G2. Conclusion: FNB is a successful method for controlling pain after ACL reconstruction. No statistical significance differences were found in pain control between techniques investigated. Level of Evidence type II...

Single time angular deformity correction and treatment of knee instability in congenital fibular hemimelia. A case report.

BACKGROUND: Fibular hemimelia is the most frequently occurring congenital anomaly of long bones. These patients, among other deficiencies, have a poor development of the anterior cruciate ligament (ACL). Unless it causes clinically assessed instability of the knee, nonsurgical treatment is given. When surgical treatment is required, correction of angular limb deformity must be realized prior to ACL reconstruction. METHODS: We present the case of a 16-year old patient with congenital fibular hemimelia. Physical examination showed genu valgum, anteromedial rotatory instability and recurvatum of the right knee. We decided to perform surgical correction of the angular deformities and ACL reconstruction in the same surgical time. RESULTS: Twelve months after surgery, the patient had no evidence of clinical instability, with a range of motion from -5°-110° of the right knee. No claudication or gait instability was found. The KT-1000 arthrometer showed a difference of 2mm between both knees. CONCLUSION: The ACL reconstruction and corrective osteotomies of angular deformities performed in a single surgical procedure had a good clinical result in a 12 month follow up-period, restoring stability of the knee and allowing a normal gait cycle.