Specific considerations in female patients with patellar instability: current concepts.

Prior literature suggests that patellofemoral instability (PFI) is significantly more prevalent in women than in men. This higher prevalence is commonly attributed to anatomical differences between sexes, particularly with patellofemoral alignment. These differences encompass a higher rate of trochlear dysplasia (TD), patella alta, an increased Q angle, and soft tissue imbalances. In recent years, worse outcomes have been reported in female patients after patellofemoral stabilization surgery using medial patellofemoral ligament reconstruction (MPFLr) alone or in combination with a tibial tubercle osteotomy (TTO), for this reason an "à la carte" plan (addressing the individuals anatomical risk factors) could be more appropriate for female patients.

Early Postoperative Results in Robotic-Arm-Assisted Total Knee Replacement versus Conventional Technique: First Latin American Experience.

Early results with robotic-arm-assisted total knee arthroplasty (TKA) are encouraging; nevertheless, literature might be unrepresentative, as it comes mostly from American, European, and Asian countries. There is limited experience and no comparative clinical reports in Latin America, a region of mainly low- and middle-income countries with limited access to these promising technologies. This study aims to compare the early postoperative results of the first Latin American experience with robotic-arm-assisted TKA versus conventional TKA. A cohort study was performed, including 181 consecutive patients (195 knees) with advanced symptomatic knee osteoarthritis (OA) undergoing primary TKA between March 2016 and October 2019. The cohort included 111 consecutive patients (123 knees) undergoing conventional TKA, followed by 70 consecutive patients (72 knees) undergoing robotic-arm-assisted TKA. The same surgical team (surgeon 1 and surgeon 2) performed all procedures. Patients with previous osteotomy, posttraumatic OA, and revision components were not considered. The same anesthetic and rehabilitation protocol was followed. The investigated clinical outcomes (for the first 60 postoperative days) were: surgical tourniquet time, time to home discharge, time to ambulation, postoperative daily pain (Visual Analog Scale), opioid use, range of motion, blood loss, complications, and postoperative mechanical axis. The early clinical postoperative results of this first Latin American comparative experience of robotic-arm-assisted TKA versus conventional technique showed lower opioids requirements and faster functional recovery of ambulation in those patients operated with the robotic system; nevertheless, surgical times were higher, without differences in total postoperative complications and other clinical outcomes.

Over 50% of self-reported burnout among Latin American orthopaedic surgeons: A cross-sectional survey on prevalence and risk factors.

OBJECTIVE: Assess the prevalence of self-reported burnout and identify risk and protective factors based on demographic and life quality aspects, among Latin American orthopaedic surgeons. METHODS: This study employed a cross-sectional analytical design. An original design survey was developed using multiple-choice and Likert-scale questions to gather self-reported burnout, demographic, work-related, social, personal, and mood-related data. The survey was electronically distributed to the Chilean Orthopaedic Surgery Society and the Latin American Society of Arthroscopy, Knee Surgery, and Sports Medicine members. Statistical analysis included Chi-square and Fisher's exact tests to determine associations between self-reported burnout and other variables. Subsequently, a multivariate logistic regression was carried out to identify key risk and protective factors (p â€‹< â€‹0.05). RESULTS: The survey's response rate was 20 â€‹% (n â€‹= â€‹358) out of the 1779 invitations that were sent. The most representative age range was 41-60 years (50 â€‹%) and 94 â€‹% were men. Of those surveyed, 50 â€‹% reported a burnout episode more than once per year, 60 â€‹% depersonalization when treating patients at least yearly, 13 â€‹% anhedonia, 11 â€‹% a depressive mood more than half of the month or almost every day, and 61 â€‹% weariness at the end of a working day. Burnout was statistically associated with age under 40 years old (p â€‹= â€‹0.012), fewer years as a specialist (p â€‹= â€‹0.037), fear of lawsuits (p â€‹< â€‹0.001), a non-healthy diet (p â€‹= â€‹0.003), non-doing recreational activities (p â€‹= â€‹0.004), depersonalization when treating their patients (p â€‹< â€‹0.001), weariness (p â€‹< â€‹0.001), anhedonia (p â€‹< â€‹0.001), depressive mood (p â€‹< â€‹0.001), and career dissatisfaction (p â€‹< â€‹0.001). The logistic regression demonstrated that fear of lawsuits (p â€‹< â€‹0.001), weariness at the end of a workday (p â€‹= â€‹0.016), and anhedonia (p â€‹= â€‹0.019) were those variables with stronger direct associations with self-reported burnout. A healthy diet was the strongest protective variable (p â€‹< â€‹0.001). CONCLUSION: Over 50 â€‹% of the Latin American orthopaedic surgeons who participated in the survey reported experiencing burnout episodes more than once a year, along with depersonalization when treating their patients at least once a year. Additionally, nearly 10 â€‹% of respondents experienced weekly depressive symptoms. Among the noteworthy risk factors for self-reported burnout were fear of lawsuits, weariness at the end of the workday, and anhedonia. Conversely, maintaining a healthy diet emerged as the most potent protective factor. LEVEL OF EVIDENCE: Level III.

Cross-cultural adaptation and validation of the KOOS, JR questionnaire for assessing knee osteoarthritis in Spanish-speaking patients.

PURPOSE: The present study aims to translate, adapt and validate a Spanish version of the Knee Injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS, JR), including a reliability and validity analysis in patients with knee osteoarthritis (OA). METHODS: This study conducted a prospective validation study following the six stages of the "Guidelines for the Process of Cross-Cultural Adaptation of Self-Report Measures". Psychometric testing was conducted in patients with knee osteoarthritis. Subjects answered the Spanish KOOS, JR (S-KOOS, JR) and a validated Spanish Oxford Knee Score (S-OKS). Retest was conducted at 10 days. Acceptability, floor and ceiling effect, internal consistency (Cronbach's α), reproducibility (mixed-effect model coefficient [MEMC]) and construct validity (Spearman's correlation; p = 0.05) were assessed. RESULTS: Forty-one patients (mean age: 65.6 ± 5.39; 48.8% female) participated in the study. All patients (100%) answered both scores during the first assessment and 38 (92.7%) during the second assessment. All patient-reported outcomes measures were answered completely (100%). The S-KOOS, JR resulted in 100% acceptability when answered. There were no ceiling or floor effects detected. The Cronbach's α for the S-KOOS, JR was 0.927 and its MEMC was 0.852 (CI 95% 0.636-1.078). The Spearman's correlation between the S-KOOS, JR and the S-OKS was 0.711 (CI 0.345-0.608; p < 0.001) and 0.870 (CI 0.444-0.651; p < 0.001) for the first and second assessments, respectively. CONCLUSION: The S-KOOS, JR has very high internal consistency and reproducibility, with a high correlation with the S-OKS; it is a reliable and valid instrument for characterising Spanish-speaking patients suffering from knee OA. LEVEL OF EVIDENCE: IV.

Navigation in anterior cruciate ligament reconstruction: State of the art.

Computer navigation (CN) for anterior cruciate ligament (ACL) surgery has been used mainly for two purposes: to enhance the accuracy of tunnel position and to evaluate the kinematics of the ACL reconstruction (ACLR) and the stability achieved by different surgical techniques. Many studies have shown that navigation may improve the accuracy of anatomical tunnel orientation and position during ACL reconstructive surgery compared with normal arthroscopic tunnel placement, especially regarding the femoral side. At the same time, it has become the gold-standard method for intraoperative knee kinematic assessment, as it permits a quantitative multidirectional knee joint laxity evaluation. CN in ACL surgery has been associated with diverse problems. First, in most optic systems additional skin incisions and drill holes in the femoral bone are required for fixation of a reference frame to the femur. Second, additional radiation exposure and extra medical cost to the patient for preoperative planning are usually needed. Third, CN, due to additional steps, has more opportunities for error during preoperative planning, intraoperative registration, and operation. Fourth, soft tissues, including the skin and subcutaneous tissues, are usually not considered during the preoperative planning, which can be a problem for kinematic and stability assessment. Many studies have concluded that ACLR using a CN system is more expensive than conventional surgery, it adds extra time to the surgery and it is not mitigated by better clinical outcomes. This, combined with costs and invasiveness, has limited the use of CN to research-related cases. Future technology should prioritize less invasive intra-operative surgical navigation.

Knee Iliotibial Band Z-Plasty Lengthening and Bursectomy Technique.

Multiple surgical techniques have been described to treat refractory iliotibial band syndrome. However, there is lacking evidence demonstrating superiority of one technique over the other and limited audiovisual resources. Most surgical procedures aim to release the iliotibial band; nevertheless, few focus on reducing concomitant inflammation. The present article illustrates a Z-plasty lengthening technique associated with local bursectomy for treating iliotibial band syndrome refractory to conservative treatment.

Alineamiento en prótesis total de rodilla: cuestionando los paradigmas / Alignment in knee prosthesis

La artroplastia total de rodilla (ATR) es un procedimiento altamente exitoso, sin embargo, podemos encontrar pacientes insatisfechos. Aunque la insatisfacción posterior a una ATR es un problema multifactorial, existe un interés creciente en el alineamiento como causa modificable del problema. El alineamiento ideal en ATR aún sigue siendo motivo de controversia y se describen muchas técnicas. La técnica clásica y más utilizada es el alineamiento mecánico, pero existen otros como el anatómico, mecánico ajustado, cinemático, cinemático reverso y el recientemente descripto alineamiento funcional. En esta revisión narrativa se detallan las técnicas de alineamiento más utilizadas, sus beneficios y problemas, y se comentan cuáles podrían ser los nuevos lineamientos que podrían guiar las técnicas de alineamiento en los próximos años

Total knee arthroplasty (TKA) is a highly successful procedure; however, we can find dissatisfied patients. Although post-TKA dissatisfaction is a multifactorial problem, there is growing interest in alignment as a modifiable cause of the problem. The ideal alignment in TKA is still controversial and many techniques are described. The classic and most used technique is mechanical alignment, but there are others such as anatomical, adjusted mechanical, kinematic, reverse kinematic alignment and the recently described functional alignment. This narrative review details the most used alignment techniques, their benefits and problems, and comments on what could be the new guidelines that could guide alignment techniques in the coming years

Posterolateral corner knee injuries: a narrative review.

Limited knowledge of the anatomy and biomechanics of the posterolateral corner (PLC) of the knee, coupled with poor patient outcomes with non-operative management, resulted in the PLC often being labelled as the 'dark side' of the knee. In the last two decades, extensive research has resulted in a better understanding of the anatomy and function of the PLC, and has led to the development of anatomic reconstructions that have resulted in improved patient outcomes.Despite considerable attention in the clinical orthopaedic literature (nearly 400 articles published in the last decade), a standardized algorithm for the diagnosis and treatment of the PLC is still lacking, and much controversy remains.Considering the literature review, there is not a reconstruction technique that clearly prevails over the others. As anatomic, biomechanical, and clinical knowledge of PLC injuries continues to progress, finding the balance between re-creating native anatomy and safely performing PLC reconstruction provides a big challenge. Treatment decisions should be made on a case-by-case basis. Cite this article: EFORT Open Rev 2021;6:676-685. DOI: 10.1302/2058-5241.6.200096.

Participación en investigación durante la formación en traumatología y ortopedia en Chile ¿Con qué frecuencia publican los residentes? / Research involvement during orthopedic surgery training in Chile: how frequently do residents publish?

OBJETIVO: Determinar el promedio de artículos indexados publicados por residentes de traumatología en Chile y, en segundo lugar, establecer si el tiempo protegido para investigación se asociaba con un mayor número de publicaciones. MÉTODOS: Se desarrolló un estudio descriptivo transversal. Se realizó una búsqueda en la base de datos de PubMed para identificar publicaciones escritas por residentes egresados de programas chilenos entre 2012 y 2016. Se incluyeron artículos con fecha de publicación entre 6 meses después del inicio de su residencia y 12 meses después de la graduación. Se excluyeron las cartas al editor, los artículos no relacionados con la cirugía ortopédica, y los proyectos de investigación con una afiliación institucional distinta a sus programas de formación. Cada currículo de los programas de residencia fue revisado para que se identificara la mención de tiempo protegido para investigación. RESULTADOS: Se incluyó a un total de 272 residentes de 10 programas, y 72 artículos cumplieron los criterios de selección. La tasa de publicación promedio fue de 0,26 1,13 artículos (rango: 0 a 13 artículos) por residente durante su formación. En total, 2 programas tuvieron una tasa de publicación promedio superior a 1, y un 89,4% de los residentes chilenos no publicó ningún artículo durante su formación. Ninguno de los programas especificó tiempo protegido para la investigación. CONCLUSIONES: A nuestro entender, este es el primer estudio que describe el estado actual de la participación en la investigación entre los residentes de traumatología chilenos. El número promedio de publicaciones indexadas en PubMed por residente durante la formación en Chile fue de 0.26 1.13 artículos. Sólo el 10% de los residentes publica un artículo durante su residencia. No se pudo establecer una correlación entre el tiempo protegido para la investigación y el número de publicaciones.

OBJECTIVE: To determine the average number of indexed articles published per orthopedic resident in Chile, and, secondarily, to establish if protected research time for residents was associated with a higher number of publications. METHODS: A transverse descriptive study was developed. A search for publications authored by orthopedic residents who graduated from Chilean programs between 2012 and 2016 was performed on the PubMed database. Articles with a publication date between 6 months after the beginning of the residency and 12 months postgraduation were included. Letters to the editor, articles not related to orthopedic surgery, and research projects with an institutional affiliation other than their training programs were excluded. Each residency curriculum was reviewed for protected time for research. RESULTS: A total of 272 residents from 10 programs were included, and 72 articles fulfilled the selection criteria. The average rate of publication was of 0.26 1.13 articles (range: 0 to 13 articles) per resident during training. In total, 2 programs had an average publication rate higher than 1, and 89.4% of the Chilean residents did not publish an article during their training. None of the programs specified protected time for research. CONCLUSIONS: To our understanding, the present is the first study to describe the current state of research involvement among Chilean orthopedic residents. The average number of publications indexed on PubMed per orthopedic resident during training was of 0.26 1.13 articles. Only 10% of the residents publish an article during their residency. No correlation between protected time for research and the number of publications could be established.

¿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.

There is direct relationship between bone bridge length and coracoclavicular fixation resistance to failure: Biomechanical study in a porcine model.

BACKGROUND: This study aims to evaluate the relation between coracoclavicular resistance to failure and the distance between clavicular tunnels. The hypothesis is that a greater clavicular bone bridge between tunnels achieves a stronger coracoclavicular fixation. METHODS: Descriptive Laboratory Study. Thirty-six (36) coracoclavicular models were constructed utilizing porcine metatarsals. Coracoclavicular stabilizations were performed using a subcoracoid loop fixation configuration through two clavicular tunnels, tied at the clavicle's superior cortex using a locking knot. Models were randomly assigned to 1 of 3 experimental groups of variable bone bridge length between clavicular tunnels: 5 mm, 10 mm, and 15 mm. Each group had 12 models. Fixation resistance was assessed through the ultimate failure point under an axial load to failure trial. Failure patterns were documented. A one-way ANOVA test was used, and a Tukey post hoc as needed (P < 0.05). FINDINGS: Mean strength per bone bridge length: 5 mm = 312 N (Range: 182-442 N); 10 mm = 430 N (Range: 368-595 N); 15 mm = 595 N (Range: 441-978 N). The 15 mm group had a significantly higher ultimate failure point than the other two groups: 5 mm (P < 0.001) and 10 mm (P < 0.001). All fixations systematically failed by a superior cortex clavicle fracture at the midpoint between tunnels. INTERPRETATION: A direct relationship between bone bridge length and coracoclavicular resistance to failure was demonstrated, being the 15 mm length a significantly higher strength construct in a tied loop model.

Abordaje anterolateral extendido y fijación con placa rim en fragmentos posterolaterales en fracturas de platillo tibial / Extended anterolateral approach and rim plate fixation for posterolateral fragments in tibial plateau fractures

Los fragmentos posterolaterales (FPLs) en fracturas de platillo tibial son frecuentes, pero difíciles de reducir y estabilizar. Actualmente existe controversia sobre cómo deben ser abordados; si bien un abordaje anterolateral es más seguro, este puede ser insuficiente para lograr una correcta reducción. Los abordajes posterolaterales y posteriores ofrecen una visión directa y permiten una fijación con ventaja biomecánica; sin embargo, son más demandantes y exponen al paciente a una mayor morbilidad. A continuación, se presenta una nota técnica sobre la reducción y fijación de FPLs con una placa rim por medio de un abordaje anterolateral extendido a través del espacio paraligamento colateral lateral.

Posterolateral fragments (PLFs) are commonly seen in tibial plateau fractures, but their reduction and fixation are challenging. There is no consensus about the ideal approach to fix this particular fragment. Even though an anterolateral approach is a safe option, it may impair a correct reduction. The posterolateral and posterior approaches offer direct visualization of the fragment, and enable a fixation with a biomechanical advantage; however, they are more demanding and expose the patient to a higher risk if morbidity. The following technical note describes the reduction and fixation of PLFs with a rim plate through an extended anterolateral approach using the paralateral collateral ligament space.

Factores determinantes del rango de movimiento postoperatorio en artroplastia total de rodilla primaria / Identify determinants for postoperative range of motion after primary total knee arthroplasty

Introducción: El objetivo de este trabajo es describir e identificar variables determinantes de la progresión del rango de movilidad articular (RMA) postoperatorio en artroplastia total de rodilla primaria (ATRp). Materiales y métodos: estudio prospectivo de pacientes con gonartrosis, operados de ATRp por un mismo equipo quirúrgico, implante y protocolo de rehabilitación. Se excluyeron pacientes con seguimiento menor a seis meses. Se midió el RMA (extensión-flexión) preoperatorio, durante la hospitalización y al primer, tercer y sexto mes postoperatorio. Se definió RMA funcional y satisfactorio como 5-95º y 0-120º, respectivamente. El análisis estadístico incluyó modelos mixtos, buscando relación entre la progresión del RMA postoperatorio y variables demográficas, pre, intra y postoperatorias externas a la técnica quirúrgica (p < 0.05).Resultados: cincuenta pacientes (53 ATRp), edad mediana 68 (49-91), 75.5% mujeres. Al sexto mes, el 100% presentó un RMA funcional y un 72.2% un RMA satisfactorio. Un umbral de 105º de flexión al tercer mes fue significativo para discriminar aquellos pacientes que alcanzaron un RMA favorable al sexto mes (sensibilidad = 97.1%; especificidad = 75%). Conclusión: la progresión del RMA postoperatorio de ATRp fue determinante del RMA satisfactorio (0-120º) a los seis meses. Un umbral de 105º de flexión al tercer mes postoperatorio posee una excelente capacidad de identificar aquellos pacientes que no lograrán el RMA apropiado. Nivel de Evidencia: Estudio pronóstico Nivel I

Introduction: This study aims to describe and identify determinants for the postoperative RMA progression after a primary total knee arthroplasty (pTKA).Materials and methods: prospective study in patients with knee osteoarthritis who underwent pTKA. Patients were operated by the same surgical team, implant, and followed the same rehabilitation protocol. Exclusion criteria included a follow-up of less than six months. The RMA (extension-flexion) was evaluated preoperatively, during the hospital stay, and postoperatively (first, third and sixth months). Functional and satisfactory RMA were established as 5-95º and 0-120º, respectively. Statistical analysis included mixed models for association between postoperative RMA and demographic, pre, intra, and postoperative non-related surgical technique variables (p < 0.05).Results: fifty patients (53 pTKA), median age 68 (49-91), 75.5% females. At six months, 100% of patients presented with functional RMA, and 72.2% with satisfactory RMA. A threshold of 105º of flexion at the third postoperative month, was statistically significant for identifying patients who achieved an acceptable RMA at six months (sensitivity = 97.1%; specificity = 75%).Conclusions: the postoperative RMA progression was determinant for a satisfactory RMA at six months after pTKA. A threshold of 105º of flexion at the third postoperative month has an excellent accuracy to identify patients who will not achieve an acceptable RMA. Level of Evidence: Prognostic study Level I

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.

Medial side knee injuries: simplifying the controversies: current concepts.

Injuries to the medial side of the knee (MSK) are the most common knee ligament lesions. Historically, these injuries have been treated conservatively; however, a better understanding of the anatomy and biomechanics of the different structures of the MSK have resulted in diverse and controversial opinions about the ideal management of these lesions. A cautious analysis should be done in nomenclature because the same surgical technique principles have been differently named in the literature. The diagnostic process of MSK injuries must involve a critical thinking process to precise those lesions that imply an imminent risk of healing failure. This review article provides an evidence and clinical-based clarification of the controversies regarding injuries to the MSK and proposes an evidence-based algorithm for their management.

Actualización en trasplante meniscal. Resultados clínicos y funcionales de una serie de casos retrospectiva / Actualization in meniscal transplantation

El trasplante meniscal autólogo (TMA) es el tratamiento de elección en el síndrome postmeniscectomía, sin embargo, sigue siendo un procedimiento limitado, existiendo controversias en la literatura. No se encontraron reportes de TMA en pacientes y centros latinoamericanos, lo que imposibilita sustentar una conducta en base a literatura local. El objetivo de este estudio es revisar los aspectos más importantes del TMA, detallar una de las técnicas quirúrgicas más utilizadas y describir y discutir los resultados de una serie de casos consecutivos de pacientes tratados con TMA en un país latinoamericano. Se describe la técnica quirúrgica para un TMA lateral con fijación ósea a través de canal trapezoidal ("Keyhole") que ofrece ventajas para los TMA laterales, pues las raíces son muy cercanas entre ellas y el canal tiene una fijación "pressfit" disminuyendo el stress en las suturas sin la necesidad de realizar túneles óseos, que podrían interferir con procedimientos asociados.Se incluyen los resultados demográficos, clínicos, funcionales y de satisfacción de una serie retrospectiva de 16 pacientes [18 trasplantes (12 laterales y 6 mediales)] consecutivos [mediana de edad 20,5 (15-37)], operados de TMA por un mismo cirujano, entre 2004-2019, con mediana de seguimiento de 3,3 (0,5-14,8) años. No se excluyeron pacientes. Los datos fueron obtenidos a través de revisión de fichas clínicas y encuestas telefónicas. Se realizó un análisis estadístico que incluyó un test multivariado buscando asociaciones entre las variables, Wilcoxon para resultados funcionales y Kaplan-Meier para sobrevida del trasplante (reintervenciones) (p<0,05). Los resultados de esta primera serie de TMA en Latinoamérica son discutidos y se comparan con la literatura, encontrándose resultados similares a lo reportado en otras regiones y concuerdan con lo esperado para un procedimiento de salvataje

Meniscal allograft transplantation (MAT) is the gold standard treatment for post meniscectomy syndrome. However, it is still considered a limited procedure, existing controversies in the reported literature. No reports in Latin American centers and patients were found, hindering the generalization of results with this treatment. This study aims to review the critical aspects of MAT, describe a technical note for a commonly used MAT procedure, and report and discuss the results of a consecutive series of patients treated with MAT in a Latin American country.The technical note for a lateral MAT with the Keyhole bone fixation is described. This technique offers advantages in lateral MAT, where meniscal roots are close together. The keyhole is press-fit fixed into the tibial plateau, decreasing the stress of the holding sutures, and without interfering with associated procedures.The review includes the demographic, clinical, functional, and satisfaction results of a consecutive retrospective series of 16 patients [18 MAT (12 lateral and 6 medial)] with a median age of 20.5 (15-37) years. All patients were operated by the same surgeon between 2004-2019, and the median follow-up was 3.3 (0.5-14.8) years. The data was obtained through the revision of clinical files and telephonic surveys. The statistical analysis included a multivariate analysis for the association between variables, Wilcoxon for functional tests, and Kaplan-Meier for survival rate (reinterventions) (p<0.05).The results of the first Latin American MAT series are discussed and compared to the reported literature, finding similar results and are consistent with a salvage procedure

Artroplastía total de rodilla con asistencia de brazo-robótico: resultados clínicos postoperatorios tempranos / Robotic arm-assisted total knee arthroplasty: early postoperative results

OBJETIVO: Describir los resultados clínicos postoperatorios tempranos de la primera serie de pacientes operados de artroplastía total de rodilla (ATR) con asistencia de brazo-robótico en Latinoamérica. MATERIALES Y MÉTODOS: Estudio prospectivo de 52 pacientes (53 rodillas) con gonartoris tricompartimental sintomática operados de ATR primaria con asistencia de brazo-robótico (RIO-MAKO) de manera consecutiva, con seguimiento a 2 meses postoperados. No se excluyeron pacientes. Se utilizó el mismo protocolo anestésico y de rehabilitación. Se realizó revisión de fichas clínicas para recolectar los siguientes resultados: tiempo de isquemia quirúrgica, estadía hospitalaria, tiempo a marcha, dolor postoperatorio diario [Escala visual análoga (EVA)], uso de opioides, rangos de movilidad articular (ROM), pérdida sanguínea, complicaciones y eje mecánico postoperatorio. RESULTADOS: Tiempos de Isquemia: 82 minutos (60­120). Estadía Hospitalaria: 4 días (2­12). Dolor postoperatorio: EVA el mismo día operatorio de 0 (0­10) y previa al alta de 0 (rango 0­4), con 0,3 purgas (0­6,5) de opioides por paciente. Tiempo a marcha (día logrado): 1 día (1­3), cuarenta y cinco pacientes (84,9%) iniciaron la marcha el primer día postoperatorio. ROM (Extensión-Flexión): Aumento progresivo durante el seguimiento. En el control ambulatorio de los dos primeros meses [23 días (13­50)], veintiún pacientes (40%) alcanzaron un ROM mayor o igual a 0­90° y once (20%) presentaron un ROM funcional máximo (0­120°). Pérdida sanguínea: Siete pacientes (13,2%) requirieron transfusión. Complicaciones: un paciente (1,89%) presentó una dehiscencia del cierre de la artrotomía. No hubo otras complicaciones. Eje mecánico postoperatorio: 179,1° (178,2­180). DISCUSIÓN: Los resultados concuerdan con la evidencia descrita en otras regiones, sugiriendo que la asistencia de brazo-robótico permite resultados postquirúrgicos reproducibles. CONCLUSIÓN: Los resultados clínicos postoperatorios tempranos de esta serie de pacientes operados de ATR con asistencia de brazo-robótico, muestran una baja percepción del dolor, con bajo consumo de opioides, una rápida recuperación funcional de la marcha y ROM, y excelentes resultados desde el punto de vista del eje mecánico postoperatorio. NIVEL DE EVIDENCIA: IV.

OBJECTIVE: Describe the early clinical postoperative outcomes, of the first series of patients operated on Robotic Arm-Assisted Total Knee Arthroplasty (TKA) in Latin America. MATERIAL AND METHOD: Retrospective study including 52 patients (53 knees) with advanced symptomatic knee osteoarthritis, consecutively operated on Robotic ArmAssisted TKA (RIO-MAKO) during October 2018 and May 2019 with two months of follow-up. No patients were excluded from the study. The same anesthetic and rehabilitation protocol was followed for all patients. Data were obtained from the clinical files for the following outcomes: Surgical tourniquet time, hospital stay, time to walk, postoperative daily pain [Visual Analog Scale (VAS)], opioid consumption, range of motion (ROM), blood loss, complications, and the attained postoperative mechanical axis. RESULTS: Tourniquet Time: 82 minutes (60­120). Hospital Stay: 4 days (2­12). Postoperative Pain: VAS of 0 (0­10) the same day of surgery, and 0 (0­4) before discharge. The opioid consumption was 0,3 purge (0­6,5) per patient. Time to Walk (Day achieved): 1st day (1­3), forty-five patients (84,9%) walked on their first postoperative day. ROM (Extension-Flexion): progressively increases during the follow up. On the first two-month visits [23 days (13­50)], twenty-one patients (40%) reached a ROM equal or superior to 0­90°, and eleven (20%) presented a maximal functional ROM (0­120°). Blood Loss: Seven patients (13.2%) required a blood transfusion. Complications: one patient (1.89%) presented dehiscence of the arthrotomy closure. No other complications were registered. Postoperative Mechanical Axis: 179.1° (178.2­180). DISCUSSION: The results coincide with the reported evidence from other regions. Robotic-arm assistance may generate reproducible postoperative results. CONCLUSIONS: The early postoperative clinical results of this series of patients operated on Robotic Arm-Assisted TKA show a low pain perception and opioid use, a rapid functional rehabilitation in terms of gait and ROM, and excellent postoperative mechanical alignment. LEVEL OF EVIDENCE: IV.

Evaluación biomecánica de reparación de roturas del tendón patelar: ¿es mejor doble Bunnell paralelo o perpendicular? / Biomechanical comparison of two patellar tendon repair techniques: is double Bunnell better parallel or perpendicular?

INTRODUCCIÓN: En tendón patelar, se ha probado que agregar un segundo punto Bunnell dispuesto perpendicular al punto clásico, es más resistente, sin embargo, esa técnica dispuesta paralelamente no ha sido evaluada. PROPÓSITO: Comparar la resistencia entre la técnica doble Bunnell dispuesta en perpendicular y en paralela. MÉTODO: 28 muestras frescas de tendones patelares porcinos, asignadas aleatoriamente a 2 grupos. Grupo 1: 14 muestras reparadas con doble Bunnell perpendicular. Grupo 2: 14 muestras reparadas con doble Bunnell paralelo. Todas realizadas con la misma sutura ultrarresistente. Con una máquina computarizada de tracción, se aplicó tracción axial continua hasta el fallo. Se registró el punto máximo de fallo (PMF) y el modelo de falla mecánica. Análisis estadístico con t-student (p < 0,05). RESULTADOS: Grupo 1: PMF = 342 ± 50,7 Newton. Todas las muestras sufrieron avulsión central, preservando fibras perimetrales. Grupo 2: PMF = 358 ± 34,1 Newton. Todas las muestras sufrieron un split longitudinal del tendón. Sin diferencia significativa entre los grupos (p = 0,340). CONCLUSIÓN: Este estudio no demostró diferencias significativas en la resistencia de una técnica de doble Bunnell paralelo versus perpendicular, aplicada en un modelo experimental de tendón patelar. RELEVANCIA CLÍNICA: Ambas técnicas tienen propiedades biomecánicas similares y dejan un remanente de tejido tendinoso luego del fallo que permitiría una segunda reparación directa, potencialmente sin necesidad de requerir el uso de injertos.

INTRODUCTION: In the patellar tendon, a second Bunnell stitch arranged perpendicular to the classic configuration has increased the resistance of the repair, however, the effect of a double parallel technique has not been evaluated. PURPOSE: To compare the resistance between a patellar tendon repair with Double Bunnell technique arranged in parallel or perpendicular. METHOD: 28 fresh porcine patellar tendon samples were randomly assigned to 2 groups. Group 1: 14 samples repaired with a perpendicular Double Bunnell technique. Group 2: 14 samples repaired with a parallel Double Bunnell technique. All performed with the same ultraresistant suture. The samples were fixed to a computerized traction machine, applying continuous axial traction, until failure. The ultimate failure point (UFP) and the mechanical failure model were recorded. Statistical analysis included student́s t-test (p < 0.05). RESULTS: Group 1: UFP = 342 ± 50.7 Newton. All samples suffered a central avulsion, preserving the perimetral tendon fibers. Group 2: UFP = 358 ± 34.1 Newton. All samples suffered a longitudinal split of the tendon. No significant difference was found among groups (p = 0.340). CONCLUSION: This biomechanical study showed no significant differences in the strength of a tendon repair using a parallel versus a perpendicular double Bunnell technique. CLINICAL RELEVANCE: Both techniques have similar biomechanical properties and leave a remnant of tendon tissue after the failure that would allow a second direct repair, potentially without requiring the use of grafts.

Lower Limb Symmetry: Comparison of Muscular Power Between Dominant and Nondominant Legs in Healthy Young Adults Associated With Single-Leg-Dominant Sports.

BACKGROUND: Achieving a symmetrical power performance (difference <15%) between lower limbs is generally recommended during sports rehabilitation. However, athletes in single-leg-dominant sports, such as professional soccer players, could develop significant asymmetry between their dominant and nondominant legs, such that symmetry does not act as a viable comparison. PURPOSE: To (1) compare maximal muscular power between the dominant and nondominant legs in healthy young adults, (2) evaluate the effect of a single-leg-dominant sport activity performed at the professional level, and (3) propose a parameter of normality for maximal power difference in the lower limbs of this young adult population. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 78 healthy, male, young adults were divided into 2 groups according to sport activity level. Group 1 consisted of 51 nonathletes (mean ± SD age, 20.8 ± 1.5 years; weight, 71.9 ± 10.5 kg) who participated in less than 8 hours a week of recreational physical activity with nonspecific training; group 2 consisted of 27 single-leg-dominant professional soccer players (age, 18.4 ± 0.6 years; weight, 70.1 ± 7.5 kg) who specifically trained and competed at their particular activity 8 hours or more a week. For assessment of maximal leg power, both groups completed the single-leg squat jump test. Dominance was determined when participants completed 2 of 3 specific tests with the same extremity. Statistical analysis included the Student t test. RESULTS: No statistical difference was found for maximal power between dominant and nondominant legs for nonathletes (t = -1.01, P = .316) or single-leg-dominant professional soccer players (t = -1.10, P = .281). A majority (95%) of participants studied showed a power difference of less than 15% between their lower extremities. CONCLUSION: Among young healthy adults, symmetrical power performance is expected between lower extremities independent of the existence of dominance and difference in sport activity level. A less than 15% difference in power seems to be a proper parameter to define symmetrical power performance assessed by vertical single-leg jump tests.