Epidemiological Study on Multiligament Knee Injuries.

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

Posterior-Medial Meniscal Root Repair Through Lateral Tibial Tunnel Combined With Medial Opening Osteotomy and Homologous Graft.

When there is a rupture in the meniscal roots or close to them, the menisci suddenly and considerably reduce their capacity to absorb the axial mechanical load that passes through the knee, quickly leading to the development of a process of chondral degeneration. The varus deformity of the lower limb (when the mechanical axis crosses the medial compartment of the knee) favors this type of injury owing to the overload in the medial compartment. When the patient has both varus deformity and medial meniscal posterior root injury, there is a clear indication for surgical realignment of the affected lower limb. There is still not a consensus regarding combining meniscal root repair with corrective osteotomy, although there is a tendency to perform both procedures aiming at long-term joint preservation. We present a safe alternative technique for simultaneous medial meniscal posterior root repair using a lateral tibial transosseous tunnel associated with a valgus-producing high tibial osteotomy with homologous bone grafting, allowing a full return to daily activities and sports.

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

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

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

Pulsed Radiofrequency Rhizotomy of the Genicular Nerves of the Knee Guided by Radioscopy and Ultrasonography: Step-By-Step Technique.

Osteoarthritis (OA) of the knee is highly prevalent and causes pain, stiffness, and harms the quality of life of millions of patients. Scientific evidence about radiofrequency ablation or rhizotomy of genicular nerves has been presented with increasing frequency in the literature for the treatment of chronic pain related to knee OA as an alternative to total knee arthroplasty. The main indication for this procedure is symptomatic OA unresponsive to conservative treatment, regardless of the disease evolution, although more common indications are in Kellgren-Lawrence grade III or IV, in post-total knee arthroplasty residual pain without an identified cause, in patients with comorbidities and high surgical risk, and those who do not want to undergo surgery. The aim of this study is to describe the step-by-step rhizotomy technique with pulsed radiofrequency of the 3 genicular nerves, guided by radioscopy and ultrasonography.

Impact of the Strategies Adopted to Face the COVID-19 Pandemic in a Brazilian Reference Institute for High Complexity Surgery in Orthopedics and Traumatology.

COVID-19 pandemics required substantial reorganization and adaptation of healthcare services all over the world. This study aims to analyze the effect of operational strategies implemented in Brazil to manage the extra strain placed on healthcare services by the COVID-19 pandemic of 2020. In particular, this investigation examines the strategy to convert an institute specialized in elective orthopedic procedures of high complexity into a trauma unit for all musculoskeletal trauma patients of an entire federative unit. A retrospective study was conducted comparing hospital variables at the peak period of the pandemic (from March 16, 2020 to June 30, 2020) with the same period in 2019 as a comparative baseline. The variables analyzed included number of professionals away from work, surgeries performed, outpatient care, transfers, length of stay, number of patients diagnosed with COVID-19 and patient mortality. During the COVID-19 peak period, there was a 48.5% reduction in surgical productivity and 72.4% reduction in outpatient care compared with the same period in 2019. The number of transfers increased substantially (124.5%), while 94 confirmed cases and 77 suspected cases of COVID-19 were reported. The mortality rate increased by 245%. The present study highlighted the effect of COVID-19 on a tertiary orthopedic hospital. Despite the dramatic changes in hospital operations, due to the implementation of protocols to manage the pandemic, the results demonstrated the feasibility and efficiency of such protocols in prioritizing quality and safety for patients and the healthcare workforce.

Impact of the Strategies Adopted to Face the COVID-19 Pandemic in a Brazilian Reference Institute for High Complexity Surgery in Orthopedics and Traumatology / Impacto das estratégias adotadas para enfrentar a pandemia de COVID-19 em um Instituto Brasileiro de referência em cirurgia de alta complexidade em Ortopedia e Traumatologia

Abstract COVID-19 pandemics required substantial reorganization and adaptation of healthcare services all over the world. This study aims to analyze the effect of operational strategies implemented in Brazil to manage the extra strain placed on healthcare services by the COVID-19 pandemic of 2020. In particular, this investigation examines the strategy to convert an institute specialized in elective orthopedic procedures of high complexity into a trauma unit for all musculoskeletal trauma patients of an entire federative unit. A retrospective study was conducted comparing hospital variables at the peak period of the pandemic (from March 16, 2020 to June 30, 2020) with the same period in 2019 as a comparative baseline. The variables analyzed included number of professionals away from work, surgeries performed, outpatient care, transfers, length of stay, number of patients diagnosed with COVID-19 and patient mortality. During the COVID-19 peak period, there was a 48.5% reduction in surgical productivity and 72.4% reduction in outpatient care compared with the same period in 2019. The number of transfers increased substantially (124.5%), while 94 confirmed cases and 77 suspected cases of COVID-19 were reported. The mortality rate increased by 245%. The present study highlighted the effect of COVID-19 on a tertiary orthopedic hospital. Despite the dramatic changes in hospital operations, due to the implementation of protocols to manage the pandemic, the results demonstrated the feasibility and efficiency of such protocols in prioritizing quality and safety for patients and the healthcare workforce.

Resumo A pandemia de COVID-19 exigiu reorganização e adaptação substanciais dos serviços de saúde em todo o mundo. Este estudo tem como objetivo analisar o efeito das estratégias operacionais implementadas no Brasil em resposta à pressão extra imposta aos serviços de saúde pela pandemia de COVID-19 de 2020. Esta pesquisa examina principalmente a estratégia de conversão de um instituto especializado em procedimentos ortopédicos eletivos de alta complexidade em uma unidade de trauma para todos os pacientes com traumatismo musculoesquelético de toda uma unidade federativa. Um estudo retrospectivo comparou as variáveis hospitalares no período de pico da pandemia (de 16 de março de 2020 a 30 de junho de 2020) com o mesmo período de 2019, que representou os valores basais. As variáveis analisadas foram número de profissionais afastados do trabalho, cirurgias realizadas, atendimento ambulatorial, transferências, tempo de internação, número de pacientes com diagnóstico de COVID-19 e mortalidade dos pacientes. Durante o período de pico de COVID-19, houve uma redução de 48,5% na produtividade cirúrgica e de 72,4% no atendimento ambulatorial em comparação ao mesmo período de 2019. O número de transferências aumentou de maneira substancial (124,5%), com relato de 94 casos confirmados e 77 casos suspeitos de COVID-19. A taxa de mortalidade aumentou 245%. Este estudo destacou o efeito da COVID-19 em um hospital ortopédico terciário. Apesar das mudanças dramáticas no funcionamento do hospital devido à instituição de protocolos em resposta à pandemia, os resultados demonstraram a viabilidade e a eficiência de tais protocolos em priorizar a qualidade e a segurança dos pacientes e dos profissionais de saúde.

Viscosupplementation improves pain, function and muscle strength, but not proprioception, in patients with knee osteoarthritis: a prospective randomized trial.

OBJECTIVES: This study aimed to evaluate the clinical outcomes of intra-articular infiltration with hyaluronic acid and dexamethasone alone and in combination in the treatment of knee osteoarthritis (OA). METHOD: This prospective randomized trial evaluated 44 patients undergoing treatment for OA. Patients were selected through clinical and radiological analysis using the American College of Rheumatology criteria. We included patients aged between 50 and 70 years who presented with K-L stage ≤2 knee OA and normal limb alignment. Patients with a previous history of knee injury (ligamentous, meniscal or traumatic), infection, patellofemoral OA or chondroprotective drug use in the previous year were excluded. Participants were randomized into 3 groups and underwent treatment with viscosupplementation (VS, n=16), viscosupplementation plus dexamethasone (VD, n=16) or dexamethasone (DX, n=12). All patients were evaluated before and 6 weeks, 3 months and 6 months after infiltration. Analysis included a physical examination, the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire (total score and domain subscores) and an evaluation of knee extensor and flexor strength and proprioception using an isokinetic dynamometer. RESULTS: VS significantly improved the WOMAC total score and subscores for pain, stiffness and function for up to 6 months after infiltration. It also improved knee extensor and flexor strength during the same period. Proprioception was not affected by any of the treatments. CONCLUSIONS: VS alone improved pain, stiffness and function according to the WOMAC total score and subscores and improved knee extensor and flexor strength, but not proprioception, for up to six months after infiltration. These findings suggest that VS has a positive effect on quadriceps arthrogenic inhibition.

Avaliação clínica da viscossuplementação associada a dexametasona em pacientes com osteoartrite do joelho / Clinical evaluation of viscosupplementation associated with dexamethasona in patients with osteoarthritis in knee

A infiltração visa restaurar as propriedades reológicas do líquido sinovial, diminuir o processo inflamatório e mudar o curso natural da osteoartrite. Estudos comprovaram que o uso isolado de ácido hialurônico apresenta uma ação analgésica mais duradoura quando comparado ao corticoide. O uso associado desses medicamentos diminuiriam a chance de sinovite reacional, que pode acontecer na viscosuplementação isolada. O estudo objetiva avaliar a ação isolada e conjunta da infiltração intra-articular do ácido hialurônico (Orthovisc®) e da dexamethasona no tratamento da osteoartrite do joelho. A citotoxicidade in vitro de diferentes doses de ácido hialurônico e da dexamethasona foi avaliada. Nossos resultados não mostraram alterações na viabilidade celular representativa dos condrócitos que foram tratados. O Ensaio clínico avaliou 43 pacientes em tratamento para osteoartrite no ambulatório do Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad. Os pacientes foram selecionados através de uma análise clínico-radiológica, randomizados de forma homogênea em 3 grupos. Os pacientes receberam injeções intra-articulares no joelho. O grupo A foi infiltrado com 6 ml de ácido hialurônico (15 pacientes), o grupo B foi infiltrado com 1ml Dexamethasona mais 6 ml de ácido hialurônico (16pacientes), e no grupo C foi infiltrado 1ml de Dexamethasona (12 pacientes). Todos os pacientes foram avaliados antes da infiltração e após, na sexta semana, no terceiro e sexto mês, foram também aplicados o questionário de Womac para análise subjetiva da força, dor e rigidez, e analisados de forma objetiva, a força e a propriocepção do membro inferior, através de um dinamômetro isocinético. Houve diferença entre os grupos nas análises objetivas de força e propriocepção nos primeiros 3 meses de tratamento, entretanto no segundo trimestre não foi observado melhora representativa na qualidade de vida, força ou propriocepção dos pacientes

The infiltration aims to restore the rheological properties of synovial fluid, decreasing the inflammatory process and changing the natural course of osteoarthritis. Studies show that the use of hyaluronic acid by itself has a lasting analgesic effect compared to corticosteroids. The combined use of these drugs decrease the chance of reactivity synovitis, which can be seen in isolated viscosupplementation. The study aims to evaluate the action of intra-articular infiltration of hyaluronic acid (Orthovisc®) and dexamethasone, together and isolated to treat osteoarthritis of the knee. The cytotoxicity in vitro of various doses of hyaluronic acid and dexamethasone was evaluated. Our results showed no representative changes in chondrocytes viability that were treated. The clinical trial evaluated 43 patients undergoing treatment for osteoarthritis in the clinic of the National Institute of Traumatology and Orthopedics Jamil Haddad. Patients were selected through a clinical and radiological analysis, randomized evenly into 3 groups. Patients received intra-articular injections into the knee. Group A was infiltrated with 6 ml of hyaluronic acid (15 patients), group B was infiltrated with 1ml Dexamethasona 6 more ml of hyaluronic acid (16 patients), and group C was infiltrated 1ml Dexamethasona (12 patients). All patients were evaluated before and after infiltration, in the sixth week in the third and sixth month, were applied the Womac questionnaire for subjective analysis of strength, stiffness and pain, and also analyzed objectively the strength and proprioception of the lower member, using an isokinetic dynamometer. There were differences between the groups in the objective analysis of strength and proprioception in the first 3 months of treatment, however in the second quarter there was not representative improvement observed in quality of life, strength and proprioception of patients