Surgical approach on combined chronic patellar tendon and bicruciate knee ligament injury.

A combined injury of the patellar tendon and both the anterior and posterior cruciate ligaments is disabling. It directly affects knee kinematics and biomechanics, presenting a considerable surgical challenge. In this complex and uncommon injury, decision-making should take into account the surgeon's experience and consider one- or two-stage surgery, tendon graft, graft fixation, and rehabilitation protocol. This manuscript discusses the surgical approach based on a comprehensive understanding of the patellar tendon and bicruciate biomechanics to guide which structures should be reconstructed first, especially when a two-stage procedure is chosen.

POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: ARE THE RESULTS SIMILAR TO ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION?

Objective: To report and compare the results of posterior cruciate ligament (PCL) and anterior cruciate ligament (ACL) reconstructions. Methods: In total, 42 patients were retrospectively evaluated, 20 with isolated PCL injuries (group 1) and 22 with isolated ACL ones (group 2) who were subjected to arthroscopic ligament reconstruction with autologous grafts and followed up for at least two years. To evaluate the results in group 1, objective IKDC and Lysholm scores, posterior drawer tests, and evaluations by a KT-1000 arthrometer were used, whereas for group 2, subjective IKDC and Lysholm score and the Lachman test were employed. To compare groups, objective IKDC and Lysholm scores and assessment via a KT-1000 arthrometer were considered. Results: Intragroup analysis showed improved results for all variables (p < 0.001) in both groups. Comparisons between groups showed a significant difference in objective IKDC scores (p < 0.001), but no such disparities for Lysholm ones (p = 0.052), clinical tests (p = 0.058) or evaluation by KT-1000 (p = 0.129). Conclusion: Treatment restored knee stability and function in both groups. Comparisons between groups showed that PCL reconstructions had inferior results than ACL ones according to patients' objective IKDC scores. Level of Evidence II, Retrospective Study.

Objetivo: Reportar e comparar os resultados da reconstrução do ligamento cruzado posterior (LCP) e do ligamento cruzado anterior (LCA). Métodos: Foram avaliados retrospectivamente 42 pacientes: 20 com lesão isolada do LCP (grupo 1) e 22 com lesão isolada do LCA (grupo 2), submetidos à reconstrução ligamentar artroscópica com enxertos autólogos e acompanhados por pelo menos dois anos. Para avaliação dos resultados no grupo 1, foram utilizados o escore do International Knee Documentation Committee (IKDC) objetivo, escore de Lysholm, teste da gaveta posterior e avaliação pelo artrômetro KT-1000; e, para o grupo 2, foram utilizados o IKDC subjetivo, escore Lysholm e teste de Lachman. Para comparação entre os grupos, foram considerados o IKDC objetivo, escore Lysholm e avaliação pelo artrômetro KT-1000. Resultados: Ambos os grupos demonstraram melhora dos resultados na análise intragrupo em todas as variáveis (p < 0,001). Na comparação intergrupos, observou-se diferença significativa no IKDC objetivo (p < 0,001), não sendo observada diferença no escore Lysholm (p = 0,052), nos testes clínicos (p = 0,058) ou na avaliação pelo KT-1000 (p = 0,129). Conclusão: A estabilidade e função do joelho foram restauradas em ambos os grupos. Na comparação intergrupos, a reconstrução do LCP apresentou resultados inferiores à reconstrução do LCA no critério IKDC objetivo. Nível de Evidência II, Estudo Retrospectivo.

Relationship of the Cruciate and Meniscofemoral Ligaments with the Knee Osteology. An Anatomical Study / Relação dos ligamentos cruzados e meniscofemorais com a osteologia do joelho: Um estudo anatômico

Abstract Objective To analyze the dimensions of the posterior cruciate ligament (PCL), anterior cruciate ligament (ACL), the presence of meniscus-femoral ligaments MFLs in human knees, and the correlation with the dimensions of the knee skeleton. Methods Anatomical study on 29 specimens of human knees in which we measured the length and width of the cruciate and meniscus-femoral ligaments and the dimensions of femoral and tibia condyles and the femoral notch. The ACL length was calculated with different degrees of knee flexion. The relationship between the ligaments and bone dimensions were analyzed. Results The length of the ACL and the PCL were similar. Posterior MFL was more frequent and longer than the anterior MFL. We found the posterior MFL in the 72.41% of the knees and anterior MFL in 20.69%. The ACL presented 30% of its maximum length up to 60°, approximately half of its length between 90° and 120°, reaching its maximum length at 170°. We found a strong correlation between the length of the ACL and that of the PCL (p= 0.001). However, the lengths of the ACL and PCL were not related with the bone dimensions. Conclusion We have found no correlations between the cruciate and MFLs and the anatomical dimensions of the intercondylar notch and the proximal tibia and distal femur. The presence of the posterior MFL was more frequent and longer than that of the anterior ligament.

Resumo Objetivo Analisar as dimensões do ligamento cruzado posterior (LCP), do ligamento cruzado anterior (LCA), a presença de ligamentos meniscofemorais (LMFs) em joelhos humanos e a correlação com as dimensões do esqueleto do joelho. Métodos Estudo anatômico em 29 espécimes de joelhos humanos nos quais medimos o comprimento e a largura dos ligamentos cruzado e meniscofemoral e as dimensões dos côndilos femorais e tibiais e do entalhe femoral. O comprimento do LCA foi calculado com diferentes graus de flexão do joelho. Analisou-se a relação entre os ligamentos e as dimensões ósseas. Resultados O comprimento do LCA e do LCP foram semelhantes, LMF posterior foi mais frequente e mais longo do que o LMF anterior. Foram encontradas LMF posterior em 72,41% dos joelhos e LMF anterior em 20,69%. O LCA apresentou 30% de seu comprimento máximo até 60°, aproximadamente metade de seu comprimento entre 90° e 120°, atingindo seu comprimento máximo com flexão de 170°. Encontramos uma forte correlação entre o comprimento do LCA e do LCP (p= 0,001). No entanto, os comprimentos do LCA e do LCP não estavam relacionados com as dimensões ósseas. Conclusão Não encontramos correlações entre os ligamentos cruzado e meniscofemoral e as dimensões anatômicas do entalhe intercondilar e da tíbia proximal e do fêmur distal. A presença do LMF posterior foi mais frequente e maior que a do ligamento anterior.

Posterior cruciate ligament reconstruction using PCL inlay technique with the patient supine in bicruciate ligament injury reconstruction.

BACKGROUND: Surgical reconstruction of the posterior cruciate ligament (PCL) can be technically challenging given the proximity of the popliteal artery to the PCL tibial insertion. This "no-safe zone" makes some knee surgeons less confident and willing to perform this surgical procedure. SURGICAL TECHNIQUE: We present a PCL tibial inlay reconstruction technique using a set of instruments involving three tools (a slot cut, a bone plug positioner, and an impactor). CONCLUSION: This set of instruments allows a more reproducible posteromedial approach and to produce a PCL tibial slot in a posterior cruciate ligament inlay reconstruction with the patient supine in bicruciate ligament injury reconstruction.

Posterior cruciate ligament reconstruction: are the results similar to anterior cruciate ligament reconstruction? / Reconstrução do ligamento cruzado posterior: os resultados são similares à reconstrução do ligamento cruzado anterior?

ABSTRACT Objective: To report and compare the results of posterior cruciate ligament (PCL) and anterior cruciate ligament (ACL) reconstructions. Methods: In total, 42 patients were retrospectively evaluated, 20 with isolated PCL injuries (group 1) and 22 with isolated ACL ones (group 2) who were subjected to arthroscopic ligament reconstruction with autologous grafts and followed up for at least two years. To evaluate the results in group 1, objective IKDC and Lysholm scores, posterior drawer tests, and evaluations by a KT-1000 arthrometer were used, whereas for group 2, subjective IKDC and Lysholm score and the Lachman test were employed. To compare groups, objective IKDC and Lysholm scores and assessment via a KT-1000 arthrometer were considered. Results: Intragroup analysis showed improved results for all variables (p < 0.001) in both groups. Comparisons between groups showed a significant difference in objective IKDC scores (p < 0.001), but no such disparities for Lysholm ones (p = 0.052), clinical tests (p = 0.058) or evaluation by KT-1000 (p = 0.129). Conclusion: Treatment restored knee stability and function in both groups. Comparisons between groups showed that PCL reconstructions had inferior results than ACL ones according to patients' objective IKDC scores. Level of Evidence II, Retrospective Study.

RESUMO Objetivo: Reportar e comparar os resultados da reconstrução do ligamento cruzado posterior (LCP) e do ligamento cruzado anterior (LCA). Métodos: Foram avaliados retrospectivamente 42 pacientes: 20 com lesão isolada do LCP (grupo 1) e 22 com lesão isolada do LCA (grupo 2), submetidos à reconstrução ligamentar artroscópica com enxertos autólogos e acompanhados por pelo menos dois anos. Para avaliação dos resultados no grupo 1, foram utilizados o escore do International Knee Documentation Committee (IKDC) objetivo, escore de Lysholm, teste da gaveta posterior e avaliação pelo artrômetro KT-1000; e, para o grupo 2, foram utilizados o IKDC subjetivo, escore Lysholm e teste de Lachman. Para comparação entre os grupos, foram considerados o IKDC objetivo, escore Lysholm e avaliação pelo artrômetro KT-1000. Resultados: Ambos os grupos demonstraram melhora dos resultados na análise intragrupo em todas as variáveis (p < 0,001). Na comparação intergrupos, observou-se diferença significativa no IKDC objetivo (p < 0,001), não sendo observada diferença no escore Lysholm (p = 0,052), nos testes clínicos (p = 0,058) ou na avaliação pelo KT-1000 (p = 0,129). Conclusão: A estabilidade e função do joelho foram restauradas em ambos os grupos. Na comparação intergrupos, a reconstrução do LCP apresentou resultados inferiores à reconstrução do LCA no critério IKDC objetivo. Nível de Evidência II, Estudo Retrospectivo.

THE OUTCOMES OF POSTERIOR CRUCIATE LIGAMENT TIBIAL AVULSION FIXATION WITH A SCREW USING A DUAL POSTEROMEDIAL PORTAL TECHNIQUE.

Objectives: Our purpose was to evaluate the clinical results of PCL tibial avulsion fracture fixation performed with 4 mm cancellous screws using a dual posteromedial (PM) portal technique. Methods: In a prospective study, we followed 12 patients submitted to PCL tibial insertion avulsion arthroscopic fixation using dual PM portals with cancellous screws from March 2014 to Jan 2020. The proximal higher PM portal served as an instrument portal and provided an optimal trajectory for arthroscopic screw fixation of larger PCL avulsion fractures. The lower PM portal was used as a viewing portal. Results: Significant improvements were found between the preoperative and postoperative mean Lysholm scores at six months. The preoperative IKDC score mean of 10.13 increased to 89.3 at the end of six months. Minor adverse results with this technique were: grade I on posterior sag in five knees (41.6%), temporary stiffness in two cases (16.7 %), delayed union in one patient (8.3 %), and difficulty squatting at the end of six months in one patient (8.3%). Temporary extension lag was present in two individuals (16.7%), and fixed subtle flexion deficit of 3-5 degrees occurred in one individual (8.3 %). Conclusion: The outcomes obtained with the proposed technique were similar to those obtained with open techniques, although mild flexion deficits and discreet posterior sag may be present in a significant number of cases. Level of Evidence II; Prospective Cohort Study .

Objetivos: O objetivo foi avaliar os resultados clínicos da fixação da fratura da avulsão tibial PCL realizada com parafusos esponjosos de 4 mm, utilizando uma técnica de portal postero-medial (PM) duplo. Métodos: Em um estudo prospectivo, acompanhamos 12 pacientes submetidos à fixação da avulsão tibial de inserção PCL por via artroscópica utilizando portais duplos PM com parafusos esponjosos de março de 2014 a janeiro de 2020. O portal PM proximal superior serviu como um portal de instrumentos e forneceu uma trajetória ideal para a fixação artroscópica com parafusos de fixação de fraturas avulsas PCL maiores. O portal PM inferior foi usado como um portal de visualização. Resultados: Foram encontradas melhorias significativas entre o pré-operatório e o pós-operatório, com pontuação média de Lysholm aos seis meses. A pontuação média do IKDC pré-operatório de 10,13 aumentou para 89,3 no final dos seis meses. Os resultados adversos menores com esta técnica foram: grau I na flacidez posterior de cinco joelhos (41,6%), rigidez temporária em dois casos (16,7%), união tardia em um paciente (8,3%) e dificuldade de agachamento ao final de seis meses em um paciente (8,3%). O atraso temporário da extensão estava presente em dois indivíduos (16,7%) e o déficit de flexão sutil fixo de 3-5 graus ocorreu em um indivíduo (8,3%). Conclusão: Os resultados obtidos com a técnica proposta foram similares aos obtidos com técnicas abertas, embora déficits leves de flexão e discreta flacidez posterior possam estar presentes em um número significativo de casos. Nível de Evidência II; Estudo de Coorte Prospectivo.

The posterior cruciate ligament inclination angle is higher in anterior cruciate ligament insufficiency.

PURPOSE: Magnetic resonance imaging (MRI) is the gold standard image examination for anterior cruciate ligament (ACL) lesion diagnosis. Our hypothesis was that measuring the posterior cruciate ligament inclination angle (PCLIA) using MRI images may be an auxiliary tool to aid the recognition of ACL insufficiency. The purpose of this study was to compare the PCLIA measurement in MRIs of individuals with and without ACL injury. METHODS: The PCLIA was measured by two radiologists in 65 knee MRIs of patients with intact ACL (control group) and in 65 knee MRIs of people with ACL injury (study group). In both groups, the posterior cruciate ligament was intact. The control group was included 35 men (53.8%) and 30 women (46.1%). The patients' average age was 38.7 years (range 15-75; SD ± 14.8 years). In this group, 31 (47.6%) MRIs were from right knees and 34 (52.3%) were from left knees. The study group consisted of 45 men (69.2%) and 20 women (30.7%). The patients' average age was 36.8 years (range 14-55; SD ± 10.3 years). In this group, 33 (50.7%) were right knees and 32 (49.2%) were left knees. PCLIA was formed by the intersection of two lines drawn in MRI sagittal images. The first passed tangentially to the articular surface of the tibial condyle and the second was drawn over the fraction of the ligament that originated where the first crossed the PCL, outlined proximally. RESULTS: The average PCLIA was 44.2 ± 3.8° in the control group and 78.9 ± 8.6° in the study group. Statistical analyses showed that the PCLIA was higher in the group with ACL injury (p < 0.05). Conclusion The PCLIA was significantly higher in individuals with ACL injuries. The measurement of this angle using MRI images may allow for detection of ACL insufficiency and thus assist in an individualized and precise approach to the treatment of injuries to the ACL. CLINICAL RELEVANCE: PCLIA may be a way to detect ACL insufficiency and thus help surgeons to decide which patient might need ACL reconstruction. LEVEL OF EVIDENCE: III.

The outcomes of posterior cruciate ligament tibial avulsion fixation with a screw using a dual posteromedial portal technique / Desfechos da técnica de portal póstero-medial duplo para fixações de fratura em avulsão tibial do ligamento cruzado posterior

ABSTRACT Objectives Our purpose was to evaluate the clinical results of PCL tibial avulsion fracture fixation performed with 4 mm cancellous screws using a dual posteromedial (PM) portal technique. Methods In a prospective study, we followed 12 patients submitted to PCL tibial insertion avulsion arthroscopic fixation using dual PM portals with cancellous screws from March 2014 to Jan 2020. The proximal higher PM portal served as an instrument portal and provided an optimal trajectory for arthroscopic screw fixation of larger PCL avulsion fractures. The lower PM portal was used as a viewing portal. Results Significant improvements were found between the preoperative and postoperative mean Lysholm scores at six months. The preoperative IKDC score mean of 10.13 increased to 89.3 at the end of six months. Minor adverse results with this technique were: grade I on posterior sag in five knees (41.6%), temporary stiffness in two cases (16.7 %), delayed union in one patient (8.3 %), and difficulty squatting at the end of six months in one patient (8.3%). Temporary extension lag was present in two individuals (16.7%), and fixed subtle flexion deficit of 3-5 degrees occurred in one individual (8.3 %). Conclusion The outcomes obtained with the proposed technique were similar to those obtained with open techniques, although mild flexion deficits and discreet posterior sag may be present in a significant number of cases. Level of Evidence II; Prospective Cohort Study.

RESUMO Objetivos O objetivo foi avaliar os resultados clínicos da fixação da fratura da avulsão tibial PCL realizada com parafusos esponjosos de 4 mm, utilizando uma técnica de portal postero-medial (PM) duplo. Métodos Em um estudo prospectivo, acompanhamos 12 pacientes submetidos à fixação da avulsão tibial de inserção PCL por via artroscópica utilizando portais duplos PM com parafusos esponjosos de março de 2014 a janeiro de 2020. O portal PM proximal superior serviu como um portal de instrumentos e forneceu uma trajetória ideal para a fixação artroscópica com parafusos de fixação de fraturas avulsas PCL maiores. O portal PM inferior foi usado como um portal de visualização. Resultados Foram encontradas melhorias significativas entre o pré-operatório e o pós-operatório, com pontuação média de Lysholm aos seis meses. A pontuação média do IKDC pré-operatório de 10,13 aumentou para 89,3 no final dos seis meses. Os resultados adversos menores com esta técnica foram: grau I na flacidez posterior de cinco joelhos (41,6%), rigidez temporária em dois casos (16,7%), união tardia em um paciente (8,3%) e dificuldade de agachamento ao final de seis meses em um paciente (8,3%). O atraso temporário da extensão estava presente em dois indivíduos (16,7%) e o déficit de flexão sutil fixo de 3-5 graus ocorreu em um indivíduo (8,3%). Conclusão Os resultados obtidos com a técnica proposta foram similares aos obtidos com técnicas abertas, embora déficits leves de flexão e discreta flacidez posterior possam estar presentes em um número significativo de casos. Nível de Evidência II; Estudo de Coorte Prospectivo.

QUANTIFICATION OF NEURAL ELEMENTS IN POSTERIOR CRUCIATE LIGAMENT: COMPARISON BETWEEN HEALTHY KNEES AND WITH PRIMARY OSTEOARTHROSIS.

OBJECTIVE: To quantify the neural elements in the posterior cruciate ligament (PCL) in healthy knees and with primary osteoarthrosis (OA). METHODS: In two groups with OA, one of cadavers and another of individuals, the area of neural elements identified in histological sections of PCL with anti-S100 immunohistochemistry was quantified. RESULTS: The overall mean area of the neural elements was 0.96% ± 0.67%, with the value in the cadaver group of 1.02% ± 0.67% and in the OA group of 0.80% ± 0.64%, with a significant statistically difference (p = 0.001). No correlation was observed between neural element quantification and the age of the individuals (p > 0.05). There was no difference in the quantification of neural elements between the sexes in the cadaver group (p = 0.766), but in the OA group there was a statistically significant reduction in males (p = 0.003). Also, in the osteoarthrosis group there was no difference in the quantification of neural elements in the knees with varus or valgus alignment (p = 0.847). CONCLUSION: There was a decrease in neural element quantification in PCL of individuals affected by OA in relation to non-arthritic individuals, with this quantification not related to age or with the axis of the lower limb. However, this quantification is not related to age or the axis of the lower limb. Level of Evidence III, Case control study.

OBJETIVO: Quantificar os elementos neurais no ligamento cruzado posterior (LCP) em joelhos hígidos e com osteoartrose primária (OA). MÉTODOS: Em um grupo de cadáveres e outro de indivíduos com ao, foi realizada a quantificação da área dos elementos neurais identificados em cortes histológicos do LCP com imunohistoquímica anti-S100. RESULTADOS: A média geral da área dos elementos neurais foi 0,96% ± 0,67%, com o valor no grupo cadáver de 1,02% ± 0,67% e no grupo OA de 0,80% ± 0,64%, havendo uma diferença estatisticamente significante (p = 0,001). Não se observou correlação entre a quantificação dos elementos neurais e a idade dos indivíduos (p > 0,05). Não se observou diferença na quantificação dos elementos neurais entre os sexos no grupo cadáver (p = 0,766), mas no grupo OA se observou redução estatisticamente significante no sexo masculino (p = 0,003). No grupo OA não houve diferença na quantificação dos elementos neurais nos joelhos com alinhamento varo ou valgo (p = 0,847). CONCLUSÃO: Foi demonstrada uma redução na quantificação dos elementos neurais no LCP de indivíduos acometidos por OA em relação aos indivíduos não artrósicos, com essa quantificação não tendo relação com idade nem com o eixo do membro inferior. Nível de evidência III, Estudo de caso controle.

Reconstrucción del ligamento cruzado posterior en un paciente adulto mayor con lesión multiligamentaria de rodilla

Las lesiones multiligamentarias de rodilla son traumatismos complejos de alta energía cuyo pronóstico puede ser devastador. Esta lesión es infrecuente en adultos mayores cuyo tratamiento es controversial. El tratamiento quirúrgico en adultos mayores puede presentar resultados funcionales similares que en pacientes jóvenes. Presentamos el caso de una mujer de 75 años, quien presentó ruptura total del ligamento cruzado posterior (LCP), ruptura total del ligamento colateral medial (LCM) y ruptura parcial del ligamento cruzado anterior (LCA) con < 50% de espesor en la rodilla derecha. La cirugía realizada fue una reconstrucción artroscópica del LCP con aloinjerto de tibial posterior y reparación del LCM superficial. El score KOS-ADL preoperatorio fue de 42,9% y el postoperatorio fue de 81,4% a los 18 meses de seguimiento. Por tanto, la cirugía reconstructiva en lesiones multiligamentarias de rodilla es clínicamente factible en pacientes adultos mayores con un resultado clínico aceptable y satisfactorio.

The multiligamentary knee injuries are complex high-energy trauma with a devastating prognosis. This injury is rare in older adults whose treatment is controversial. Surgical treatment in older adults may present similar functional results as in younger patients. Present the case of a 75-year-old woman with total posterior cruciate ligament (PCL) rupture, total medial collateral ligament (MCL) rupture and partial anterior cruciate ligament (ACL) rupture with <50% thickness in the right knee. The surgery performed was an arthroscopic reconstruction of the PCL with a posterior tibial allograft and repair of the superficial MCL. The preoperative KOS-ADL score was 42.9% and the postoperative was 81.4% at 18 months of follow-up. The reconstructive surgery in multiligamentary knee injuries is clinically feasible in older adult patients with an acceptable and satisfactory clinical outcome.

Quantification of neural elements in posterior cruciate ligament: comparison between healthy knees and with primary osteoarthrosis / Quantificação dos elementos neurais no ligamento cruzado posterior: comparação entre joelhos hígidos e com osteoartrose primária

ABSTRACT Objective: To quantify the neural elements in the posterior cruciate ligament (PCL) in healthy knees and with primary osteoarthrosis (OA). Methods: In two groups with OA, one of cadavers and another of individuals, the area of neural elements identified in histological sections of PCL with anti-S100 immunohistochemistry was quantified. Results: The overall mean area of the neural elements was 0.96% ± 0.67%, with the value in the cadaver group of 1.02% ± 0.67% and in the OA group of 0.80% ± 0.64%, with a significant statistically difference (p = 0.001). No correlation was observed between neural element quantification and the age of the individuals (p > 0.05). There was no difference in the quantification of neural elements between the sexes in the cadaver group (p = 0.766), but in the OA group there was a statistically significant reduction in males (p = 0.003). Also, in the osteoarthrosis group there was no difference in the quantification of neural elements in the knees with varus or valgus alignment (p = 0.847). Conclusion: There was a decrease in neural element quantification in PCL of individuals affected by OA in relation to non-arthritic individuals, with this quantification not related to age or with the axis of the lower limb. However, this quantification is not related to age or the axis of the lower limb. Level of Evidence III, Case control study.

RESUMO Objetivo: Quantificar os elementos neurais no ligamento cruzado posterior (LCP) em joelhos hígidos e com osteoartrose primária (OA). Métodos: Em um grupo de cadáveres e outro de indivíduos com ao, foi realizada a quantificação da área dos elementos neurais identificados em cortes histológicos do LCP com imunohistoquímica anti-S100. Resultados: A média geral da área dos elementos neurais foi 0,96% ± 0,67%, com o valor no grupo cadáver de 1,02% ± 0,67% e no grupo OA de 0,80% ± 0,64%, havendo uma diferença estatisticamente significante (p = 0,001). Não se observou correlação entre a quantificação dos elementos neurais e a idade dos indivíduos (p > 0,05). Não se observou diferença na quantificação dos elementos neurais entre os sexos no grupo cadáver (p = 0,766), mas no grupo OA se observou redução estatisticamente significante no sexo masculino (p = 0,003). No grupo OA não houve diferença na quantificação dos elementos neurais nos joelhos com alinhamento varo ou valgo (p = 0,847). Conclusão: Foi demonstrada uma redução na quantificação dos elementos neurais no LCP de indivíduos acometidos por OA em relação aos indivíduos não artrósicos, com essa quantificação não tendo relação com idade nem com o eixo do membro inferior. Nível de evidência III, Estudo de caso controle.

[Functional assessment in total knee arthroplasty comparing the posterior cruciate ligament preservation versus postero-stabilization]. / Valoración funcional en artroplastía total de rodilla comparando la preservación del ligamento cruzado posterior versus posteroestabilización.

INTRODUCTION: The two most commonly used types of prostheses are the total knee prosthesis with posterior cruciate ligament preservation and posterior cruciate ligament replacement. OBJECTIVE: To assess whether there is a difference in functionality between the two procedures. MATERIAL AND METHODS: Observational, retrospective and cross-sectional study with 134 patients divided into group A (N = 67) with ligament preservation and group B (N = 67) with posterior substituting. Using the American Association Scale for Knee Prosthetics with Insall modification to assess functionality. Statistical analysis: use of 2 with Yates correction. RESULTS: In group A the results: excellent (31%); good (24%); regular (22%) bad (22%). In group B the results: excellent (34%); good (31%); regular (16%) and bad (19%); without statistical difference between the two groups. CONCLUSIONS: No statistically significant difference was observed between age, gender, laterality of injury, or between number of patients with excellent results, good regular and bad according to the scale used. The high percentage of poor results in both groups of this series for the knee prosthesis is striking.

INTRODUCCIÓN: Los dos tipos de prótesis que más se utilizan en la actualidad son la prótesis total de rodilla con preservación del ligamento cruzado posterior y con sustitución del ligamento cruzado posterior. OBJETIVO: Valorar si existe diferencia en la funcionalidad entre ambos procedimientos. MATERIAL Y MÉTODOS: Estudio observacional, retrospectivo y transversal con 134 pacientes divididos en grupo A (N = 67) con preservación del ligamento y grupo B (N = 67) con posteroestabilización. Uso de la Escala de la Asociación Americana para Prótesis de Rodilla con la modificación de Insall para valorar funcionalidad. Análisis estadístico: Uso de 2 con corrección de Yates. RESULTADOS: En el grupo A los resultados: excelentes (31%); buenos (24%); regulares (22%) y malos (22%). En el grupo B los resultados: excelentes (34%); buenos (31%); regulares (16%) y malos (19%); sin diferencia estadísticamente entre ambos grupos. CONCLUSIONES: No se observó diferencia estadísticamente significativa entre edad, género, lateralidad de la lesión ni entre número de pacientes, con resultados excelentes, buenos regulares y malos de acuerdo con la escala utilizada. Llama la atención el elevado porcentaje de malos resultados en ambos grupos de esta serie en la prótesis de rodilla.

IS THE "U-SIGN" RADIOLOGIC FEATURE OF A POSTERIOR CRUCIATE LIGAMENT TIBIAL AVULSION FRACTURE?

OBJECTIVE: By analyzing our cases of posterior cruciate ligament (PCL) tibial avulsion fracture, we noted that a U-shaped image was present in the anteroposterior plain radiographs view of the affected knee, even in cases where the profile view of the knee had been inconclusive as to tibial PCL avulsion fracture, a "hidden" fracture. Therefore, we aimed to investigate whether there was an anatomical correlation between this radiological U sign and the tibial insertion of the PCL and to ascertain the intra- and inter-rater reliability of this sign in clinical practice. METHODS: The data of the widths and heights area of the PCL tibial insertion area, and the U sign area were measured and compared to the largest width of the tibia. Two moreover, the reliability and reproducibility of this imaging were analyzed. RESULTS: The areas height of the U-sign area and the anatomical insertion area of the posterior cruciate ligament showed no difference, and both were topographically located in the two central quarters of the proximal end of the tibia. The radiographic assessment showed excellent Kappa agreement rates between interobserver and intraobserver, with high reliability and reproducibility. CONCLUSION: The U sign is a radiographic feature of PCL tibial avulsion fracture seen on the radiograph AP view, there is a high association between the ratios of the U-sign area height in the X-ray and the anatomical height of the PCL tibial insertion site MRI with the largest width of the proximal tibia. The radiographic U sign showed excellent rates of interobserver and intraobserver agreement with Kappa values higher than 0.8. Level of Evidence IV; Dignostic Studies - Investigating a Diagnostic Test.

OBJETIVO: Avaliando nossos casos de fratura-avulsão da inserção tibial do ligamento cruzado posterior, observamos que uma imagem em forma de U estava presente na radiografia plana anteroposterior do joelho afetado, mesmo nos casos em que a visão do perfil do joelho era inconclusiva quanto à fratura por avulsão do ligamento cruzado posterior (LCP) tibial, uma fratura "oculta". Portanto, buscamos investigar se havia uma correlação anatômica entre esse sinal radiológico U e a inserção tibial do LCP, além de verificar a confiabilidade intra e interexaminadores desse sinal na prática clínica. MÉTODOS: Os dados das larguras e alturas da área de inserção tibial do LCP e da área do sinal U foram medidos e comparados com a maior largura da tíbia. Além disso, foram analisadas a confiabilidade e a reprodutibilidade dessa imagem. RESULTADOS: A altura da área do sinal U e da área de inserção anatômica do ligamento cruzado posterior não mostraram diferença, e ambas estavam localizadas topograficamente nos dois quartos centrais da extremidade proximal da tíbia. A avaliação radiográfica mostrou excelentes taxas de concordância Kappa entre interobservador e intraobservador, com alta confiabilidade e reprodutibilidade. CONCLUSÃO: O sinal U é uma característica radiográfica da fratura por avulsão tibial do LCP que pode vista na radiografia AP. Existe uma alta associação entre as proporções da altura da área do sinal U na radiografia e da altura anatômica da inserção tibial do LCP RM local em relação à maior largura da tíbia proximal. O sinal radiográfico U mostrou excelentes taxas de concordância interobservador e intraobservador, com valores de Kappa superiores a 0,8. Nível de Evidência IV, Estudos Diagnósticos - Investigação de um exame para diagnóstico.

Is the "u-sign" radiologic feature of a posterior cruciate ligament tibial avulsion fracture? / A imagem do "u-radiológico" é um sinal da fratura-avulsão tibial ligamento cruzado posterior?

ABSTRACT Objective: By analyzing our cases of posterior cruciate ligament (PCL) tibial avulsion fracture, we noted that a U-shaped image was present in the anteroposterior plain radiographs view of the affected knee, even in cases where the profile view of the knee had been inconclusive as to tibial PCL avulsion fracture, a "hidden" fracture. Therefore, we aimed to investigate whether there was an anatomical correlation between this radiological U sign and the tibial insertion of the PCL and to ascertain the intra- and inter-rater reliability of this sign in clinical practice. Methods: The data of the widths and heights area of the PCL tibial insertion area, and the U sign area were measured and compared to the largest width of the tibia. Two moreover, the reliability and reproducibility of this imaging were analyzed. Results: The areas height of the U-sign area and the anatomical insertion area of the posterior cruciate ligament showed no difference, and both were topographically located in the two central quarters of the proximal end of the tibia. The radiographic assessment showed excellent Kappa agreement rates between interobserver and intraobserver, with high reliability and reproducibility. Conclusion: The U sign is a radiographic feature of PCL tibial avulsion fracture seen on the radiograph AP view, there is a high association between the ratios of the U-sign area height in the X-ray and the anatomical height of the PCL tibial insertion site MRI with the largest width of the proximal tibia. The radiographic U sign showed excellent rates of interobserver and intraobserver agreement with Kappa values higher than 0.8. Level of Evidence IV; Dignostic Studies - Investigating a Diagnostic Test.

RESUMO Objetivo: Avaliando nossos casos de fratura-avulsão da inserção tibial do ligamento cruzado posterior, observamos que uma imagem em forma de U estava presente na radiografia plana anteroposterior do joelho afetado, mesmo nos casos em que a visão do perfil do joelho era inconclusiva quanto à fratura por avulsão do ligamento cruzado posterior (LCP) tibial, uma fratura "oculta". Portanto, buscamos investigar se havia uma correlação anatômica entre esse sinal radiológico U e a inserção tibial do LCP, além de verificar a confiabilidade intra e interexaminadores desse sinal na prática clínica. Métodos: Os dados das larguras e alturas da área de inserção tibial do LCP e da área do sinal U foram medidos e comparados com a maior largura da tíbia. Além disso, foram analisadas a confiabilidade e a reprodutibilidade dessa imagem. Resultados: A altura da área do sinal U e da área de inserção anatômica do ligamento cruzado posterior não mostraram diferença, e ambas estavam localizadas topograficamente nos dois quartos centrais da extremidade proximal da tíbia. A avaliação radiográfica mostrou excelentes taxas de concordância Kappa entre interobservador e intraobservador, com alta confiabilidade e reprodutibilidade. Conclusão: O sinal U é uma característica radiográfica da fratura por avulsão tibial do LCP que pode vista na radiografia AP. Existe uma alta associação entre as proporções da altura da área do sinal U na radiografia e da altura anatômica da inserção tibial do LCP RM local em relação à maior largura da tíbia proximal. O sinal radiográfico U mostrou excelentes taxas de concordância interobservador e intraobservador, com valores de Kappa superiores a 0,8. Nível de Evidência IV, Estudos Diagnósticos - Investigação de um exame para diagnóstico.

CLINICAL OUTCOMES AFTER TWO-STAGE BICRUCIATE KNEE LIGAMENT RECONSTRUCTION.

OBJECTIVE: To correlate clinical and intraoperative findings with the postoperative evaluation of two-stage bicruciate knee ligament reconstruction. METHODS: The study was conducted with 25 patients (20 men and 05 women) with mean age of 32.3 years, mean body mass index (BMI) of 26.2, and mean lesion duration of 18.3 months. The treatment consisted of an Inlay reconstruction of the posterior cruciate ligament (PCL) followed by the anterior cruciate ligament (ACL) reconstruction, at least 3 months after the first surgical procedure. Four patients required additional procedures: patellar tendon (02), medial collateral ligament (MCL) (02). RESULTS: With an average follow-up of 24.8 months, 60% of the patients scored zero or + at the posterior drawer test, while 40% scored ++; 60% of patients were evaluated as good/excellent according to the Lysholm scale. Only one patient reached the pre-injury Tegner activity level. Injury duration had a negative influence on functional limitation, vitality, and mental health (SF-36). CONCLUSION: Although two-stage bicruciate knee ligament reconstruction improved knee stability and self-assessment, 96% of patients did not recover their pre-injury state. In the 36-item short form survey (SF-36), injury duration was inversely correlated with self-assessment of functional capacity, physical limitation, vitality, and mental health. Level of Evidence II, retrospective study.

OBJETIVO: Correlacionar os achados clínicos e intraoperatórios com a avaliação pós-operatória da reconstrução ligamentar bicruzada do joelho em dois tempos. MÉTODOS: 25 pacientes (20 homens e 05 mulheres), média de idade de 32,3 anos, IMC médio de 26,2, tempo médio da lesão de 18,3 meses. O tratamento foi iniciado com a reconstrução INLAY do LCP e, após o intervalo mínimo de 3 meses, foi realizada a reconstrução do LCA. Procedimentos adicionais em 04 pacientes - tendão patelar (02), LCM (02). RESULTADOS: com seguimento médio de 24,8 meses, o teste de gaveta posterior foi classificado como zero ou + em 60% dos pacientes avaliados e 40% como ++. 60% dos pacientes avaliados como bons / excelentes (Lysholm). Apenas um paciente atingiu o nível de atividade Tegner pré-lesão. A tempo da lesão influenciou negativamente os parâmetros de limitação do funcionamento físico dos aspectos físicos, vitalidade e saúde mental (SF-36). CONCLUSÃO: a reconstrução bicruzado do joelho, em dois tempos, melhorou a estabilidade do joelho e a avaliação subjetiva, mas 96% dos pacientes não recuperaram o estado pré-lesão. O tempo de lesão apresentou correlação estatística inversa com a avaliação subjetiva da capacidade funcional, limitação dos aspectos físicos, vitalidade e saúde mental no escore S-36. Nível de Evidência II, Estudo retrospective.

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.

Clinical outcomes after two-stage bicruciate knee ligament reconstruction / Resultado clínico após reconstrução ligamentar bicruzado do joelho, em dois tempos

ABSTRACT Objective: To correlate clinical and intraoperative findings with the postoperative evaluation of two-stage bicruciate knee ligament reconstruction. Methods: The study was conducted with 25 patients (20 men and 05 women) with mean age of 32.3 years, mean body mass index (BMI) of 26.2, and mean lesion duration of 18.3 months. The treatment consisted of an Inlay reconstruction of the posterior cruciate ligament (PCL) followed by the anterior cruciate ligament (ACL) reconstruction, at least 3 months after the first surgical procedure. Four patients required additional procedures: patellar tendon (02), medial collateral ligament (MCL) (02). Results: With an average follow-up of 24.8 months, 60% of the patients scored zero or + at the posterior drawer test, while 40% scored ++; 60% of patients were evaluated as good/excellent according to the Lysholm scale. Only one patient reached the pre-injury Tegner activity level. Injury duration had a negative influence on functional limitation, vitality, and mental health (SF-36). Conclusion: Although two-stage bicruciate knee ligament reconstruction improved knee stability and self-assessment, 96% of patients did not recover their pre-injury state. In the 36-item short form survey (SF-36), injury duration was inversely correlated with self-assessment of functional capacity, physical limitation, vitality, and mental health. Level of Evidence II, retrospective study.

RESUMO Objetivo: Correlacionar os achados clínicos e intraoperatórios com a avaliação pós-operatória da reconstrução ligamentar bicruzada do joelho em dois tempos. Métodos: 25 pacientes (20 homens e 05 mulheres), média de idade de 32,3 anos, IMC médio de 26,2, tempo médio da lesão de 18,3 meses. O tratamento foi iniciado com a reconstrução INLAY do LCP e, após o intervalo mínimo de 3 meses, foi realizada a reconstrução do LCA. Procedimentos adicionais em 04 pacientes - tendão patelar (02), LCM (02). Resultados: com seguimento médio de 24,8 meses, o teste de gaveta posterior foi classificado como zero ou + em 60% dos pacientes avaliados e 40% como ++. 60% dos pacientes avaliados como bons / excelentes (Lysholm). Apenas um paciente atingiu o nível de atividade Tegner pré-lesão. A tempo da lesão influenciou negativamente os parâmetros de limitação do funcionamento físico dos aspectos físicos, vitalidade e saúde mental (SF-36). Conclusão: a reconstrução bicruzado do joelho, em dois tempos, melhorou a estabilidade do joelho e a avaliação subjetiva, mas 96% dos pacientes não recuperaram o estado pré-lesão. O tempo de lesão apresentou correlação estatística inversa com a avaliação subjetiva da capacidade funcional, limitação dos aspectos físicos, vitalidade e saúde mental no escore S-36. Nível de Evidência II, Estudo retrospective.

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.

Thick Graft Versus Double-Bundle Technique on Posterior Cruciate Ligament Reconstruction: Experimental Biomechanical Study with Cadavers.

Objective To evaluate the biomechanical effect of graft thickness compared with the double-bundle technique on posterior cruciate ligament (PCL) reconstruction in human cadaveric knees. Methods A total of 9 human cadaveric knees were tested in 5 conditions: intact knee (INT); single-bundle reconstruction with a 10-mm quadriceps tendon (SB); double-bundle reconstruction with a 10 mm-quadriceps tendon for the anterolateral bundle and a 7-mm doubled semitendinosus tendon for the posteromedial bundle (DB); single-bundle reconstruction with a 10-mm quadriceps tendon plus a 7-mm doubled semitendinosus tendon (SBT); and PCL-deficient (NoPCL). The posterior tibial translation (PTT) was measured in response to a 134-N posterior tibial load at 0 ∘ , 30 ∘ , 60 ∘ e 90 ∘ of knee flexion. Results The PTT values of the DB and SBT techniques were always significantly lower (better stability) than those of the SB technique. The PTT values of the SBT technique were significantly lower than those of the DB technique at 60 ∘ ( p = 0.005) and 90 ∘ ( p = 0.001). Conclusions Graft enlargement improves knee stability in isolated PCL reconstructions, whereas the graft division in the two-bundle technique worsens this stability at 60 ∘ and 90 ∘ of knee flexion. The findings of the present study suggest that knee stability in PCL reconstructions may be improved with the use of thicker grafts in the SB technique rather than performing the DB technique.

Treatment and outcomes of lateral collateral ligament injury associated with anterior and posterior cruciate ligament injury at 2-year follow-up.

BACKGROUND: Injuries to the lateral collateral ligament (LCL) are most commonly associated with anterior cruciate ligament (ACL) injury than with posterior cruciate ligament (PCL) injury. There is currently a paucity in the literature in regards to treatment and outcomes of such lesions. METHODS: 30 patients underwent surgical treatment of concomitant LCL and ACL injury or concomitant LCL and PCL injury with follow-up postoperative period of two years. The Lysholm score and varus stress radiographs was calculated and analysed before and at 6, 12, and 24 months postoperatively. RESULTS: There was a significant increase in scores between two timepoints over the follow-up period for both groups: before surgery and after 6 months, and between 6 and 12 months (p < 0.05). The lateral joint opening measured on the varus stress radiographs was greater in group 2 than in group 1 before surgery (p = 0.04). When assessing each group separately, the lateral joint opening decreased at each timepoint in the first year for both groups (p < 0.05). CONCLUSION: Patients diagnosed with combined LCL and PCL injuries were shown to have a higher degree of lateral opening at the time of injury when compared to patients with combined LCL and ACL injuries. However, there was no difference in lateral joint opening on stress radiography after 12 months postoperatively in either group. Finally Lysholm scores for both groups significantly increased between the preoperative period and 6 months postoperatively, as well as between 6 months and 12 months postoperatively. LEVEL OF EVIDENCE: III.