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.

Influence of type I collagen polymorphisms and risk of anterior cruciate ligament rupture in athletes: a case-control study.

BACKGROUND: Anterior cruciate ligament (ACL) rupture is a common and severe knee injury in sports and occurs mostly due to noncontact injuries. There is an increasing amount of evidence associating ACL rupture to single nucleotide polymorphisms (SNPs), and SNPs in the collagen type I genes can change its expression and tissue mechanical features. This study aimed to investigate the association between SNPs in COL1A1 and COL1A2 with sports-related ACL tears. METHODS: A total of 338 athletes from multiple sports modalities were analyzed: 146 were diagnosed with ACL rupture or underwent an ACL reconstruction surgery and 192 have no musculoskeletal injuries. SNPs were genotyped using validated TaqMan assays. The association of the polymorphisms with ACL rupture was evaluated by a multivariable logistic regression model, using odds ratios (OR) and 95% confidence intervals (CI). RESULTS: The age, sport modality, and training location were associated with an increased risk of a non-contact ACL tear. COL1A2 SNPs (rs42524 CC and rs2621215 GG) were associated with an increased risk of non-contact ACL injury (6 and 4-fold, respectively). However, no significant differences were detected in the distribution of COL1A1 rs1107946 and COL1A2 rs412777 SNPs between cases and controls. There was a protective association with ACL rupture (OR = 0.25; 95% CI = 0.07-0.96) between COL1A1 rs1107946 (GT or TT) and the wildtype genotypes of the three COL1A2 (rs412777, rs42524, rs2621215). COL1A2 rs42524 and rs2621215 SNPs were associated with non-contact ACL risk. CONCLUSION: The combined analysis of COL1A1-COL1A2 genotypes suggests a gene-gene interaction in ACL rupture susceptibility.

Controlled Double Gradual Opening Osteotomy for the Treatment of Severe Varus of the Knee-Blount's Disease.

Varus deformity of the knee can lead to early degeneration of the medial tibiofemoral joint. Pediatric patients can be pathologically affected with this deformity known as Blount disease. The cause of this pathology is still uncertain, but some risk factors are well established, such as obesity and family history. The diagnosis is made through clinical history, physical examination, and the radiographic analysis after the age of 2.5 years. The analysis of the metaphyseal-diaphyseal angle, described by Levine and Drennan, is also commonly used for prognosis. When this angle is greater than 16°, it is considered to be grossly abnormal. Possible options for correcting the generated angular deformity are epiphysiodesis, osteotomy (acute or gradual correction), and gradual correction by distraction of the physis. In this surgical technique, we performed a double tibial osteotomy with controlled gradual opening using monolateral external fixator (Orthofix, Verona, Italy). Our technique proved to be an effective way to correct the adolescent tibia vara and is practical and reproducible. Moreover, the use of gradual opening osteotomy allowed a more accurate outcome.

Continuous Meniscal Suture in Radial Meniscal Tear: The Hourglass Technique.

The key to preventing early knee osteoarthritis is meniscal preservation. The main functions of the meniscus are impact absorption, mechanical load transmission, lubrication, joint stability, and proprioception. Radial lesions that extend to the joint capsule are called complete radial tears. This type of injury compromises 2 of the main meniscal functions, which are impact absorption and load distribution, which is equivalent, from a biomechanical perspective, to a total meniscectomy. In the recent past, the treatment of choice for this type of injury was partial meniscectomy. However, several studies have observed progressive joint degeneration after this type of treatment. Recently, different types of meniscal sutures involving radial lesions of the meniscus have been developed. It is believed that such repairs may bring a decrease in future osteoarthritis in this patient profile. The purpose of this article is to describe the steps of continuous meniscal suture for the treatment of radial tears of the medial and lateral menisci.

How to Create an Arthroscopy Training Laboratory Using a Bovine Knee Model.

Orthopaedic surgeries by video arthroscopy have become increasingly popular, as they allow joint treatment through small incisions and minimal tissue damage. However, their execution requires specific skills from the surgeon, different from open surgery, which can only be achieved through practical training. These skills would be ideally performed on human cadaveric anatomical pieces which, however, can be difficult to access for different reasons. Animal anatomical models for surgical skills training have been used for years in medicine, and we observed that the bovine knee has anatomical characteristics quite similar to that of the human knee. In this study, we explain, step by step, the installation and creation of an arthroscopy laboratory with a bovine model, in an effort to contribute to several training centers in arthroscopic surgery around the world, assisting and guiding such centers to install arthroscopy laboratories and facilitating the improvement of more surgeons.

Posterior Root Repair of Medial Meniscus Combined With Valgus Opening Wedge Tibial Osteotomy.

The medial meniscal root tear, a particular meniscal injury at the level of its posterior bone insertion, leads to a loss of impact absorption and load distribution capacity, similar to total meniscectomy. Therefore, its repair is fundamental for knee joint longevity. This type of injury often occurs in middle-aged patients with lower limbs varus malalignment, which results in mechanical overloading of the medial compartment and induces premature cartilage wear out. The success of meniscal root repair, with meniscal bone reinsertion, depends on the correction and realignment of varus deformities greater than 5° for physiological levels. In this situation, corrective tibial osteotomy combined with meniscal repair is indicated. Our goal is to describe the step-by-step technique of the valgus opening wedge tibial osteotomy combined with the arthroscopic reinsertion of the posterior meniscal root in tibia during the treatment of a patient with varus deformity and medial meniscus root tear.

Stress Radiography for Multiligament Knee Injuries: A Standardized, Step-by-Step Technique.

Physical examination in the presence of a multiligament knee injury can be complex and challenging. Hence, stress radiography is a useful and inexpensive tool that is widely used in the assessment of this type of injury. It guarantees an objective analysis of the magnitude of knee instability, which may reduce the observer's interpretation bias in relation to the physical examination. However, for the radiographic analysis to be reproducible, it is necessary to standardize the technique to evaluate each of the main knee ligaments. This article aims to describe in detail how to perform stress radiography to assess the sufficiency of the posterior cruciate ligament and collateral ligaments in the context of a multiligament injury.

Avaliação do senso da força dos músculos ísquiotibiais em pacientes com lesão do ligamento cruzado anterior / Avaliation of the sense of strength on the hamstrings, in individuals who suffered complete tearing of the anterior cruciate ligament

Since the discovery of sensorial receptors (mechanoreceptors) in the fibers of the anterior cruciate ligament (ACL) in humans, science has been trying to prove and measure its neurosensorial function as well as its correlation with the changes in the neuromuscular activation of the knee extensors (quadriceps) and flexors (hamstrings). The purpose of the study was to investigate the existence of proprioceptive deficits, using a strength reproduction test on the hamstrings, between the injured and uninjured limb (i.e., contralateral normal), in individuals who suffered complete tearing of the anterior cruciate ligament (ACL).Twenty-eight patients with complete tearing of the ACL participated in the study, (2 women e 26 men); age: 28,4 ± 6,2 anos; wheigth: 84,0 ± 12,5 kg; heigth: 169,6 ± 33,0 cm, who were waiting for surgical reconstruction of this ligament at Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad (INTO), Rio de Janeiro, Brazil. A voluntary maximum isometric strength (VMIS) test was performed, followed by the reproduction of the hamstrings muscle strength test in the limb with complete tearing of the ACL and the healthy contralateral limb, with the knee flexed at 60°. The metaintensity used for the procedure was 20% of the VMIS and the proprioceptive performance was determined by means of absolute error, variable error and constant error values. Significant differences were found between the limbs (ACL rupture and contralateral) in the VMIS test (p<0,001). Differences were also found for the variables of constant error (p<0,001) and variable error (p<0,001) in the reproduction muscle strength test. No difference was found in relation to absolut error. Our data corroborate the hypothesis that, there is a proprioceptive deficit in subjects with complete ACL tearing in the injured limb, in comparison with the uninjured limb, using the reproduction of hamstrings muscle strength test. The VMIS was bigger in the uninjured limb.

Avaliação comparativa da altura patelar pós-artroplastias totais do joelho com e sem preservação do ligamento cruzado posterior / Comparative evaluation of patellar height after total knee arthroplasty with and without preservation of the posterior cruciate ligament

OBJETIVO: Avaliar possíveis alterações na altura da patela, pós-artroplastias totais do joelho com e sem preservação do ligamento cruzado posterior (LCP). MÉTODO: Foram analisadas radiografias pré e pós-operatórias, de 120 pacientes submetidos a artroplastias totais do joelho, realizadas no Instituto Nacional de Traumatologia e Ortopedia, no período compreendido entre janeiro de 2003 e janeiro de 2005, com implantes do tipo Johnson de plataforma rotatória. A amostra foi dividida em dois grupos, correspondendo o grupo I a exames radiográficos pré e pós-artroplastias totais do joelho com preservação do LCP (n = 60) e o grupo II, a exames radiográficos pré e pós-artroplastias sem preservação do LCP (n = 60). Para a mensuração dos valores pré e pós-operatórios foi utilizado o método de Blackburne-Peel, cujo valor normal é igual a 0,8 (± 0,2), variando, portanto, entre 0,6 e 1. RESULTADOS: O índice patelar médio pré-operatório do grupo I foi igual a 0,874 e, no grupo II, a média foi igual a 0,857. O índice médio de altura patelar pós-operatório do grupo I foi igual a 0,849, variando entre 0,54 e 1,03. No grupo II, o menor índice foi igual a 0,48, o maior igual a 0,94, sendo o índice médio igual a 0,79. A comparação dos valores pós-operatórios nos dois grupos apresentou diferença estatisticamente significativa (p < 0,05). Conclusões: Foi observada tendência à diminuição da altura patelar em ambos os grupos estudados, sendo esta mais evidente no grupo em que houve sacrifício do LCP.

OBJECTIVE: To evaluate possible changes in patellar height after total knee arthroplasties with and without preservation of the posterior cruciate ligament (PCL). METHOD: Analysis was made of pre- and post-operative X-rays of 120 patients submitted to total knee arthroplasties at the National Institute of Traumatology and Orthopedics between January 2003 and January 2005, with Johnson-type rotary platform implants. The sample was divided into two groups, group I corresponding to radiographic exams before and after total knee arthroplasty with preservation of the PCL (n = 60), and group II corresponding to radiographic exams before and after arthroplasties without preservation of the PCL (n = 60). To measure the values before and after surgery, the authors used the Blackburne Peel method, whose normal value is equal to 0.8 (± 0.2), therefore varying between 0.6 and 1. RESULTS: The mean pre-operative patellar ratio in group I was equal to 0.874, and in group II the mean was equal to 0.857. The mean post-operative patellar height ratio in group I was equal to 0.849, varying between 0.54 and 1.03. In group II, the lower ratio was equal to 0.48, and the highest, equal to 0.94, the mean rate being equal to 0.79. The comparison of post-operative value between the groups presented a statistically significant difference (p < 0.05). CONCLUSIONS: A tendency towards decreased patellar height was seen in both groups studied, but it was more evident in the group in which the PCL was not preserved.

Avaliação comparativa da perda de extensão entre acessos cirúrgicos para revisão de artroplastia total do joelho / Comparative assessment of extension loss among different surgical approaches to the revision of total knee arthroplasty

OBJETIVO: Avaliar a possibilidade de perda de extensão do joelho, após artroplastias de revisão, realizadas com acessos do tipo quadriceps snip e osteotomia do tubérculo anterior da tíbia (TAT), comparativamente, entre ambos e com um grupo controle, em que foi utilizado o acesso parapatelar medial convencional. MÉTODO: Este estudo foi aprovado pelo Comitê de Ética em Pesquisa do INTO. A perda de extensão do joelho foi avaliada em pacientes submetidos a artroplastias de revisão, unilaterais, realizadas pelo Grupo de Joelho do Instituto Nacional de Traumatologia e Ortopedia - INTO, em que foram utilizados um dos seguintes acessos: convencional - parapatelar medial, snip do quadríceps ou osteotomia do tubérculo anterior da tíbia. A amostra foi composta por 26 indivíduos, cuja idade variou entre 52 e 80 anos, distribuídos em três grupos: grupo I: acesso parapatelar medial convencional (n = 10); grupo II: quadriceps snip (n = 8); e grupo III: osteotomia do TAT (n = 8). O tempo de seguimento médio foi de 18,57 meses. A perda da extensão do joelho foi determinada pela diferença entre o grau de extensão ativa pré e pós-operatória. Na avaliação estatística, foi utilizado o teste de análise de variância ANOVA, de fator único, com o nível de significância a = 0,05 (5 por cento). RESULTADOS: A perda média de extensão da série foi igual a 8,57º, variando entre 2º e 30º. O p-valor obtido foi igual a 0,112, o que permite assumir a hipótese de igualdade entre os grupos. CONCLUSÃO: No presente estudo, não foi observada diferença significativa entre os grupos compostos pelos três tipos de acesso utilizados para as revisões de artroplastias, no que tange ao parâmetro perda de extensão.

OBJECTIVE: To assess the possibility of extension loss of the knee after revision arthroplasties performed with approaches like quadriceps snip and TAT osteotomy, comparing the two methods and using a control group in who the conventional medial parapatellar approach was used. METHOD: This study was approved by the INTO Research Ethics Committee. The loss of extension of the knee was evaluated in patients submitted to unilateral revision arthroplasties of the knee conducted by the Knee Group of the INTO - National Institute of Traumatology and Orthopedics, the following approaches having been used: conventional - medial parapatellar, quadriceps snip, or anterior tibial tubercle osteotomy. The series included 26 individuals, ages ranging from 52 to 80, distributed into three groups: Group I: conventional - medial parapatellar approach (n = 10); Group II: quadriceps snip (n = 8); and Group III: TAT osteotomy (n = 8). Mean follow-up was 18.57 months. Extension loss of the knee was determined by the difference between the range of active extension before and after surgery. In the statistical assessment, the ANOVA variance analysis test was used, with a single factor, with significance level a = 0,05 (5 percent). RESULTS: Mean extension loss in the series was equal to 8.57º, varying between 2º and 30º. The p-value obtained was equal to 0.112, which leads to presume the hypothesis that groups are equal to one another. CONCLUSION: No significant difference was observed among the groups made up by the three types of approach used for arthroplasty revisions in terms of the loss of extension parameter.

Avaliação clínico-funcional de artroplastias totais de joelhos reumatóides com e sem a preservação do ligamento cruzado posterior / Clinical and functional evaluation of total arthroplasties of rheumatoid knee joints with and without preservation of the posterior cruciate ligament

Objetivo: Avaliar retrospectiva e comparativamente, os resultados clínico-funcionais das artroplastias totais do joelho realizadas com e sem a preservação do ligamento cruzado posterior (LCP), em pacientes com artrite reumatóide. Métodos: Foram estudadas 46 artroplastias, realizadas no Instituto Nacional de Traumato-Ortopedia-INTO, em 36 pacientes com artrite reumatóide, no período compreendido entre outubro de 1988 e novembro de 2001. As artroplastias totais do joelho foram divididas em dois grupos, com 23 casos em cada. O grupo I foi composto por artroplastias com preservação do LCP e o grupo II, por artroplastias nas quais o LCP foi ressecado. A média de idade dos pacientes na data da cirurgia foi de 55,5 anos e o tempo médio entre a cirurgia e a avaliação clínico-funcio-nal, de 96,7 meses. O sistema de pontuação do Hospital for Special Surgery (HSS) foi utilizado para a avaliação clíni-co-funcional dos pacientes. Resultados: A pontuação média do grupo I foi de 81,8 pontos e a do grupo II, de 82,5 pontos, sendo ambas classificadas como boas. Dentre os avaliados, apenas um caso foi classificado como insuficiente (grupo II). No grupo I, cinco pacientes apresentaram sinais de instabilidade posterior, o que não resultou em perda funcional. Na análise estatística não foi evidenciada diferença significativa dos valores do HSS nos dois grupos (p = 0,849). Conclusões: Os resultados clínico-funcionais dos dois grupos foram classificados como bons. A instabilidade posterior não interferiu com o resultado funcional dos pacientes

Avaliação Clinicofuncional de Artroplastias Totais de Joelhos Reumatóides com e Sem a Preservação do Ligamento Cruzado Posterior

Existe controvérsia na literatura sobre se a preservação ou não do ligamento cruzado posterior(LCP)nas atroplastias totais de joelho em pacientes reumatóides afetaria a estabilidade do implante nos seguimentos mais longos

Artroplastia total do joelho não cimentada, sem substituição da patela: avaliação clínico-funcional / Cementless total knee arthroplasties without patellar resurfacing: a clinical and functional evaluation

Objetivo: Avaliar os resultados clínico-funcionais de uma série de artroplastias totais do joelho, não cimentadas e sem substituição da patela, nas quais foram utilizados implantes LCs®. Material e método: Entre abril de 1995 e novembro de 2001, foram realizadas 61 artroplastias totais do joelho, primárias, não cimentadas, com e sem substituição patelar, com implantes LCS® do tipo platform e meniscal bearing, pelo Grupo de Joelho do Hospital de Tráumato-Ortopedia do Rio de Janeiro. Desse universo, foram incluídas neste estudo apenas aquelas em que não foi realizada a substituição patelar, perfazendo, assim, um total de 46 artroplastias em 41 pacientes, portadores exclusivamente de osteoartrose. A idade dos pacientes variou entre 45 e 90 anos. O tempo médio decorrido entre a cirurgia e a avaliação clínico-funcional foi de 65,76 meses. Resultados: A pontuação média dessa série foi de 89 pontos. Foram classificados como excelentes e bons 45 casos (97,82 por cento). A pontuação média, pelo protocolo New Jersey, das artroplastias realizadas com implante do tipo platform foi de 91,65 pontos, enquanto a média das artroplastias do tipo meniscal bearing foi igual a 86,88 pontos, sendo ambas consideradas excelentes. Não foram encontradas diferenças estatísticas entre as artroplastias com implantes meniscal

Avaliação da Reprodutibilidade da Classificação de Schatzker para as Fraturas do Planalto Tibial

O objetivo do presente estudo é avaliar a reprodutibilidade da classificação de Schatzker entre diferentes observadores, subdividindo os resultados conforme a experiência e área de especialização dos mesmos

Aplicação do Dispositivo de Avaliação Pressórica na Avaliação da Transferência de Carga Entre os Membros Inferiores Após a Reconstrução do Ligamento Cruzado Anterior

A lesão do ligamento cruzado anterior (LCA) é frequente em pacientes jovens, relacionada à prática esportiva profissional e recreacional. Quando lesado, a instabilidade anterior provocada pode levar a torções repetitivas do joelho, lesões da cartilagem articular, artrose da articulação, alterações do equílibrio postural, da cinestesia articular e da força muscular, levando a limitação funcional nas atividades cotidianas e no rendimento esportivo dos atletas

Preservação do Ligamento Cruzado Posterior nas Artroplastias Totais de Joelhos Reumatóides: Análise Clínico-Funcional

Nas artroplastias totais de joelho, em pacientes reumatóides, existe controvérsia na literatura, se a preservação ou não do ligamento cruzado posterior(LCP) afetaria a estabilidade do implante nos seguimentos mais longos

Avaliação Comparativa da Altura Patelar Pós Artroplastias Totais do Joelho com Preservação ou Não do Ligamento Cruzado Posterior

Avaliar possíveis alterações na altura da patela, pós-artroplastias totais do joelho com e sem preservação do ligamento cruzado posterior(LCP)