Combined Reconstruction of the Medial Patellofemoral Ligament and Medial Quadriceps Tendon-Femoral Ligament.

Most patellar dislocations are associated with disruption of the proximal medial patellar restraints (PMPRs). The PMPRs comprise the medial patellofemoral ligament (MPFL) and medial quadriceps tendon-femoral ligament (MQTFL). Although isolated MPFL reconstruction is the most frequently performed procedure for the surgical management of recurrent dislocation, recent studies have shown that the MQTFL has a synergistic role with the MPFL in resisting lateral patellar displacement close to full extension. It has therefore been suggested that surgical techniques that gain the benefits of both proximal and distal PMPR biomechanical behavior may be best. This article describes an established technique for combined MPFL and MQTFL reconstruction using semitendinosus autograft.

Venous Thromboembolism Prevention Protocol: Experience of 2,000 Cases in Total Knee Arthroplasty.

Objective The objective of the present study is to evaluate the impact evaluate the impact of an institutional protocol on a tertiary hospital for the prevention of venous thromboembolism in 2005 patients submitted to primary total knee arthroplasty (TKA). Methods Data from medical records of patients submitted TKA before ( n = 1,115) and after ( n = 890) the implementation of the institutional protocol, totaling 2,005 patients, were retrospectively reported. Demographics, comorbidities, and outcomes were analyzed. Results There was no significant change in the cases of deep venous thrombosis (DVT) (1.6% versus 2.4%; p = 0.211). There was an increase in cases of pulmonary embolism (PE) (0.2% versus 0.8% p = 0.049). Conclusion Despite the implementation of the prevention protocol, no reduction in the studied events was observed. The small global incidence makes further studies with larger series necessary to confirm or rule out these findings.

Venous Thromboembolism Prevention Protocol Experience of 2000 Cases in Total Knee Arthroplasty* / Protocolo de prevenção do tromboembolismo venoso Experiência de 2000 casos em artroplastia total de joelho*

Abstract Objective The objective of the present study is to evaluate the impact evaluate the impact of an institutional protocol on a tertiary hospital for the prevention of venous thromboembolism in 2005 patients submitted to primary total knee arthroplasty (TKA). Methods Data from medical records of patients submitted TKA before (n= 1,115) and after (n= 890) the implementation of the institutional protocol, totaling 2,005 patients, were retrospectively reported. Demographics, comorbidities, and outcomes were analyzed. Results There was no significant change in the cases of deep venous thrombosis (DVT) (1.6% versus 2.4%; p= 0.211). There was an increase in cases of pulmonary embolism (PE) (0.2% versus 0.8% p= 0.049). Conclusion Despite the implementation of the prevention protocol, no reduction in the studied events was observed. The small global incidence makes further studies with larger series necessary to confirm or rule out these findings.

Resumo Objetivo O objetivo do presente estudo é avaliar o impacto de um protocolo institucional em um hospital terciário na prevenção do tromboembolismo venoso em 2.005 pacientes submetidos a artroplastia total primária de joelho. Métodos Os dados dos prontuários de pacientes submetidos a artroplastia total do joelho antes (n= 1.115) e após (n= 890) a implantação do protocolo institucional, totalizando 2.005 pacientes, foram relatados retrospectivamente. Dados demográficos, comorbidades e desfechos foram analisados. Resultados Não houve alteração significativa nos casos de trombose venosa profunda (TVP) (1,6% versus 2,4%; p= 0,211). Houve um aumento nos casos de embolia pulmonar (EP) (0,2% versus 0,8%; p= 0,049). Conclusão Apesar da implementação do protocolo de prevenção, não houve redução nos eventos estudados. A pequena incidência global faz com que novos estudos, com séries maiores, sejam necessários para confirmar ou descartar esses achados.

Effect of porous tantalum on the biological response of human peripheral mononuclear cells exposed to Porphyromonas gingivalis.

AIM: To evaluate biological behavior of human peripheral mononuclear cells (PBMC) in contact with porous tantalum (PT) and Porphyromonas gingivalis (Pg). METHODS: Pg was incubated for 8 hours. The groups formed were: PBMC (control), PBMC + PT, PBMC + Pg and PBMC + PT + Pg. Cell viability was evaluated using MTT assay. The morphology and adhesion of PBMC to PT was evaluated using scanning electron microscopy. Expression of interleukin (IL)-10, transforming growth factor (TGF)-ß, matrix metallopeptidase (MMP)-9 and receptor activator of nuclear factor-κΒ ligand (RANKL) was determined by enzyme-linked immunosorbent assay. RESULTS: MTT assay revealed that PT did not interfere in the mitochondrial activity of PBMC (P > .05). Scanning electron microscopy showed the adherence of PBMC to PT. IL-10 levels in PBMC + PT were similar to PBMC and lower than PBMC + Pg. TGF-ß levels in PBMC + PT were higher than PBMC and PBMC + Pg. MMP-9 levels in PBMC + PT were similar to PBMC and lower than PBMC + Pg and PBMC + PT + Pg. RANKL levels in PBMC + PT were lower than in PBMC. CONCLUSION: PT did not affect PBMC viability, allowed cell adhesion, reduced expression of RANKL and enhanced TGF-ß in comparison with the control group.

Hamstring Tendon Autograft Contamination in Anterior Cruciate Ligament Reconstruction: Comparison between two Harvesting Techniques.

OBJECTIVE: To evaluate the contamination rate of hamstring tendon autografts by comparing two different techniques, and to verify whether intraoperative contamination is associated with the development of clinical infection in patients submitted to reconstruction of the anterior cruciate ligament (ACL). METHODS: A total of 110 hamstring tendon autograft ACL reconstructions were performed and divided into two groups: 1-hamstring tendon retraction technique; and 2 - technique maintaining the tibial insertion of the hamstring tendon. During the preparation, two graft fragments were sent for culturing; the harvesting time, the preparation time, and the total surgery time were measured. Twenty-four hours after the surgery, the C-reactive protein was assayed. The clinical outpatient follow-up was performed up to 180 days postoperatively. RESULTS: Although there were two postoperative infections, there was no graft contamination or difference between the groups in relation to the graft preparation time and to the 24-hour postoperative C-reactive protein assessment. The classic technique presented a longer graft harvesting time ( p = 0.038), and there was no statistical difference between the 2 groups regarding the degree of contamination and consequent clinical infection, although 2 patients in group 2 presented with infection, with negative perioperative cultures. CONCLUSION: Based on the results obtained, there was no association between graft contamination and the time or technique of its preparation. In addition, there was also no association between intraoperative contamination and the development of clinical infection, nor was there any sign of an association between the early alteration of C-reactive protein and the onset of infection.

Piriformis Pyomyositis in a Patient with Kikuchi-Fujimoto Disease - A Case Report and Literature Review.

Primary pyomyositis is a deep bacterial infection of the skeletal muscle. If left undiagnosed and untreated, the infection spreads, leading to sepsis, septic shock, and even death. The authors report a 23-year-old female presenting with piriformis pyomyositis during a treatment for Kikuchi-Fujimoto disease. Pyomyositis is a rare but potentially severe infection, which can lead to septic shock. The present case shows the need for a high degree of clinical suspicion for patients with compromised immune systems to begin treatment at an early stage. The literature demonstrates that outcomes of the treatment of piriformis pyomyositis are good.

Piriformis Pyomyositis in a Patient with Kikuchi-Fujimoto Disease - A Case Report and Literature Review / Piomiosite do piriforme em um paciente com doença de Kikuchi-Fujimoto-relato de caso e revisão da literatura

Abstract Primary pyomyositis is a deep bacterial infection of the skeletal muscle. If left undiagnosed and untreated, the infection spreads, leading to sepsis, septic shock, and even death. The authors report a 23-year-old female presenting with piriformis pyomyositis during a treatment for Kikuchi-Fujimoto disease. Pyomyositis is a rare but potentially severe infection, which can lead to septic shock. The present case shows the need for a high degree of clinical suspicion for patients with compromised immune systems to begin treatment at an early stage. The literature demonstrates that outcomes of the treatment of piriformis pyomyositis are good.

Resumo A piomiosite primária é uma infecção bacteriana profunda do músculo esquelético. Quando não diagnosticada ou tratada, a infecção pode evoluir para sepse, choque séptico e até morte. Os autores relatam o caso de uma paciente do sexo feminino, 23 anos, apresentando piomiosite do músculo piriforme durante o tratamento da doença de Kikuchi-Fujimoto. A piomiosite é uma infecção rara, mas potencialmente grave, que pode levar ao choque séptico. Esse caso mostra a necessidade em se elevar o grau de suspeição clínica em pacientes com comprometimento do sistema imunológico, para que o tratamento seja iniciado em estágio precoce. A literatura mostra que os resultados do tratamento da piomiosite do piriforme são bons.

Nonoperative Treatment for Partial Ruptures of the Lateral Collateral Ligament Occurring in Combination With Complete Ruptures of the Anterolateral Ligament: A Common Injury Pattern in Brazilian Jiu-Jitsu Athletes With Acute Knee Injury.

BACKGROUND: Combined partial lateral collateral and complete anterolateral ligament (PLCCALL) injuries are a specific injury pattern seen in Brazilian jiu-jitsu (BJJ) because of the knee varus-flexion mechanism that frequently occurs during grappling. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate the incidence of this injury pattern in a series of BJJ athletes with an acute knee injury and to evaluate clinical and functional outcomes after nonoperative management at a minimum follow-up of 1 year. Our hypotheses were that PLCCALL injuries are common in BJJ and that nonoperative treatment is associated with excellent clinical outcomes and return to the preinjury level of sport. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All BJJ athletes who presented with an acute knee injury between July 2013 and June 2017 and who underwent magnetic resonance imaging (MRI) of the knee were included. A specific emphasis was placed on identifying those whose imaging demonstrated PLCCALL injury. Clinical evaluation included physical examination as well as Lysholm and International Knee Documentation Committee (IKDC) scores. RESULTS: Of the 27 patients analyzed, 7 (25.9%) had MRI-proven PLCCALL injuries. The mean follow-up after nonoperative management was 41.3 months. The mean IKDC and Lysholm scores were 94 and 92 before the injury, 26 and 36 at the initial assessment after the injury, and 83 and 78 at 12-month follow-up, respectively (P < .00001). All 7 patients had returned to their preinjury level of sports by the 12-month follow-up. The mean time between injury and return to competition level was 4.7 months (range, 4-6 months). CONCLUSION: PLCCALL injury is a specific but infrequent injury pattern in BJJ. The prognosis of this injury after nonoperative treatment appears to be excellent. Improved functional scores (IKDC and Lysholm) and changes on MRI demonstrated that the anterolateral ligament has intrinsic healing potential, as the images showed complete healing of the previously documented rupture of the anterolateral ligament from its proximal attachment.

Hamstring Tendon Autograft Contamination in Anterior Cruciate Ligament Reconstruction: Comparison between two Harvesting Techniques / Contaminação de enxertos de tendões flexores na reconstrução do ligamento cruzado anterior: comparação de duas técnicas de retirada

Abstract Objective: To evaluate the contamination rate of hamstring tendon autografts by comparing two different techniques, and to verify whether intraoperative contamination is associated with the development of clinical infection in patients submitted to reconstruction of the anterior cruciate ligament (ACL). Methods: A total of 110 hamstring tendon autograft ACL reconstructions were performed and divided into two groups: 1-hamstring tendon retraction technique; and 2 - technique maintaining the tibial insertion of the hamstring tendon. During the preparation, two graft fragments were sent for culturing; the harvesting time, the preparation time, and the total surgery time were measured. Twenty-four hours after the surgery, the C-reactive protein was assayed. The clinical outpatient follow-up was performed up to 180 days postoperatively. Results: Although there were two postoperative infections, there was no graft contamination or difference between the groups in relation to the graft preparation time and to the 24-hour postoperative C-reactive protein assessment. The classic technique presented a longer graft harvesting time (p = 0.038), and there was no statistical difference between the 2 groups regarding the degree of contamination and consequent clinical infection, although 2 patients in group 2 presented with infection, with negative perioperative cultures. Conclusion: Based on the results obtained, there was no association between graft contamination and the time or technique of its preparation. In addition, there was also no association between intraoperative contamination and the development of clinical infection, nor was there any sign of an association between the early alteration of Creactive protein and the onset of infection.

Resumo Objetivo: Avaliar a taxa de contaminação de autoenxerto de tendões flexores comparando duas técnicas e verificar se a contaminação intraoperatória está associada ao desenvolvimento de infecção clínica em pacientes submetidos a reconstrução do ligamento cruzado anterior. Métodos: Foram feitas 110 reconstruções do ligamento cruzado anterior com tendão dos flexores e divididas em dois grupos: 1) técnica com retirada total dos tendões flexores e 2) técnica que manteve a inserção tibial desses tendões. Durante o preparo, dois fragmentos de cada um desses foram enviados para cultura, sendo mensurado o tempo de retirada dos tendões, do preparo dos tendões e total da cirurgia. Com 24 horas de pós-operatório, foi dosada a proteína C reativa. Seguimento clínico ambulatorial foi realizado de forma protocolada até 180 dias de pós-operatório. Resultados: Apesar de terem sido observadas duas infecções pós-operatórias, não houve contaminação dos enxertos nem diferença entre os grupos emrelação ao tempo de preparo dos enxertos e a proteína C reativa com 24 horas de pós-operatório. A técnica clássica apresentou maior tempo de retirada do enxerto (p = 0,038) e não houve diferença estatística entre os dois grupos no que tange ao grau de contaminação e consequente infecção clínica, embora dois pacientes do grupo 2 tenham tido infecção com culturas perioperatórias negativas. Conclusão: Com base nos resultados obtidos, não houve associação entre contaminação do enxerto com o tempo ou a técnica de sua preparação, tampouco entre a contaminação intraoperatória e o desenvolvimento de infecção clínica ou entre alteração precoce da proteína C reativa e o surgimento de infecção.

The femoral tunnel view test during ACL reconstruction can ensure tunnel integrity / O teste de visualização artroscópica do túnel femoral durante a reconstrução do LCA garante a integridade do túnel

ABSTRACT Objective: Violation of the posterior femoral cortex commonly referred to as posterior wall blowout, can be a devastating intraoperative complication in anterior cruciate ligament reconstruction (ACLR) and can lead to loss of graft fixation or early graft failure. This study describes and analyzes whether the femoral tunnel view test can ensure the integrity of the femoral tunnel during ACLR. Methods: Intraoperative femoral tunnel integrity using the 360º arthroscopic view test was performed in 584 ACLR patients between 2014 and 2016. Posterior wall blowouts were described by their location along the femoral tunnel (i.e., near the aperture or more proximal) and by the depth of the tunnel blowout (<3 mm, 3-5 mm, >5 mm), corresponding to the length of the posterior cortical wall of the violated femoral tunnel. The time spent for the test was measured during ACLR. Complications related to the femoral tunnel view test were also evaluated. Results: The femoral tunnel view test was performed in all 584 patients. In 12 patients (1%), the femoral tunnel presented a posterior cortical blowout that did not extend beyond 3 mm. Only four patients (0.6%) presented posterior wall blowout that extended beyond 5 mm. The time for the test was 40 s (±20 s). No complications related to the test were reported. Conclusion: The femoral tunnel view test is effective for ensuring the integrity of the femoral tunnel during ACL reconstruction, without increasing the surgical time and without an increase in the complications rate. Clinical relevance: The femoral tunnel view test is a quick and straightforward test able to provide an adequate view of the patient's anatomy to ensure tunnel integrity during ACLR.

RESUMO Objetivos: A violação da cortical femoral posterior pode ser complicação intraoperatória devastadora na reconstrução do ligamento cruzado anterior (RLCA), pode levar à perda de fixação ou à falha precoce do enxerto. Este estudo descreve e analisa a capacidade do teste de visualização artroscópica do túnel femoral em evidenciar a integridade de suas paredes durante a RLCA. Métodos: Foram prospectivamente avaliados 584 pacientes elegíveis à RLCA entre 2014 e 2016 quanto à integridade do túnel femoral com o uso do teste de visualização artroscópica. A localização ao longo do túnel femoral e a profundidade da violação no túnel (< 3 mm, 3-5 mm, > 5 mm) foram avaliadas. O tempo para o teste foi medido e a ocorrência de complicações relacionadas ao mesmo também foi analisada. Resultados: Todos os 584 pacientes elegíveis foram submetidos ao teste de visualização do túnel femoral durante a cirurgia artroscópica para RLCA. Em 12 (1%) pacientes, o túnel femoral apresentou perda de integridade da cortical posterior, que não ultrapassou 3 mm. Apenas quatro (0,6%) pacientes apresentaram violação da cortical posterior, que se estendeu para além de 5 mm. O tempo médio dispendido no teste foi de 40 segundos (± 20). Nenhuma complicação realização foi relatada. Conclusão: O teste de visualização do túnel femoral é eficaz para avaliar a integridade desse túnel durante a RLCA, sem aumentar o tempo cirúrgico e sem provocar aumento na taxa de complicações relativas ao procedimento. Relevância Clínica: O teste de visualização artroscópica do túnel femoral é uma técnica simples e rápida, capaz de obter visão adequada da anatomia do paciente, garante a integridade do túnel durante a RLCA.

The femoral tunnel view test during ACL reconstruction can ensure tunnel integrity.

OBJECTIVE: Violation of the posterior femoral cortex commonly referred to as posterior wall blowout, can be a devastating intraoperative complication in anterior cruciate ligament reconstruction (ACLR) and can lead to loss of graft fixation or early graft failure. This study describes and analyzes whether the femoral tunnel view test can ensure the integrity of the femoral tunnel during ACLR. METHODS: Intraoperative femoral tunnel integrity using the 360° arthroscopic view test was performed in 584 ACLR patients between 2014 and 2016. Posterior wall blowouts were described by their location along the femoral tunnel (i.e., near the aperture or more proximal) and by the depth of the tunnel blowout (<3 mm, 3-5 mm, >5 mm), corresponding to the length of the posterior cortical wall of the violated femoral tunnel. The time spent for the test was measured during ACLR. Complications related to the femoral tunnel view test were also evaluated. RESULTS: The femoral tunnel view test was performed in all 584 patients. In 12 patients (1%), the femoral tunnel presented a posterior cortical blowout that did not extend beyond 3 mm. Only four patients (0.6%) presented posterior wall blowout that extended beyond 5 mm. The time for the test was 40 s (±20 s). No complications related to the test were reported. CONCLUSION: The femoral tunnel view test is effective for ensuring the integrity of the femoral tunnel during ACL reconstruction, without increasing the surgical time and without an increase in the complications rate. CLINICAL RELEVANCE: The femoral tunnel view test is a quick and straightforward test able to provide an adequate view of the patient's anatomy to ensure tunnel integrity during ACLR.

OBJETIVOS: A violação da cortical femoral posterior pode ser complicação intraoperatória devastadora na reconstrução do ligamento cruzado anterior (RLCA), pode levar à perda de fixação ou à falha precoce do enxerto. Este estudo descreve e analisa a capacidade do teste de visualização artroscópica do túnel femoral em evidenciar a integridade de suas paredes durante a RLCA. MÉTODOS: Foram prospectivamente avaliados 584 pacientes elegíveis à RLCA entre 2014 e 2016 quanto à integridade do túnel femoral com o uso do teste de visualização artroscópica. A localização ao longo do túnel femoral e a profundidade da violação no túnel (<3 mm, 3-5 mm, >5 mm) foram avaliadas. O tempo para o teste foi medido e a ocorrência de complicações relacionadas ao mesmo também foi analisada. RESULTADOS: Todos os 584 pacientes elegíveis foram submetidos ao teste de visualização do túnel femoral durante a cirurgia artroscópica para RLCA. Em 12 (1%) pacientes, o túnel femoral apresentou perda de integridade da cortical posterior, que não ultrapassou 3 mm. Apenas quatro (0,6%) pacientes apresentaram violação da cortical posterior, que se estendeu para além de 5 mm. O tempo médio dispendido no teste foi de 40 segundos (± 20). Nenhuma complicação realização foi relatada. CONCLUSÃO: O teste de visualização do túnel femoral é eficaz para avaliar a integridade desse túnel durante a RLCA, sem aumentar o tempo cirúrgico e sem provocar aumento na taxa de complicações relativas ao procedimento. RELEVÂNCIA CLÍNICA: O teste de visualização artroscópica do túnel femoral é uma técnica simples e rápida, capaz de obter visão adequada da anatomia do paciente, garante a integridade do túnel durante a RLCA.

Clinical Outcomes of Single Anteromedial Bundle Biologic Augmentation Technique for Anterior Cruciate Ligament Reconstruction With Consideration of Tibial Remnant Size.

PURPOSE: The primary aim of this study was to evaluate the functional outcomes, knee stability, complications, and reoperations associated with anatomic anterior cruciate ligament (ACL) reconstruction using the single anteromedial bundle biological augmentation (SAMBBA) technique in a consecutive series of 128 patients with a minimum follow-up of 24 months. A secondary aim was to compare larger preserved ACL remnants with smaller preserved remnants. METHODS: Patients who underwent primary anatomic ACL reconstruction using the SAMBBA technique from July 2013 to October 2014 were analyzed. Exclusion criteria were (1) age <16 years, (2) revision cases, (3) multiple ligament injuries, (4) chondral lesions greater than grade 2 according to the Outerbridge classification, (5) additional injuries to the collateral ligaments greater than grade 2, or (6) a history of a contralateral ACL injury. Clinical assessment including evaluation of side-to-side difference and functional outcome measures with the International Knee Documentation Committee (IKDC) subjective score and the Tegner Activity Scale were used to evaluate outcomes before surgery and at the last follow-up. Any subsequent surgical procedures were systematically recorded during the study period. The patients were also divided in 2 groups according to their ACL remnant size, ≥50% or <50%, and compared. RESULTS: Of the 135 patients who underwent primary SAMBBA technique, 128 patients returned to final follow-up, with a mean follow-up of 31.7 months (range, 24-44.3). At last follow-up, the IKDC score significantly improved from 54.1 ± 15.1 to 92.5 ± 11.4 (P < .001); the Tegner activity score (6.4 ± 1.2) was similar (P = .3) to the preinjury score (6.5 ± 1.2). Side-to-side laxity significantly improved from 6.7 ± 1.2 mm to 0.7 ± 1 mm (P < .001). Twenty-four subsequent surgeries (18.7%) were performed including 10 meniscal procedures, 7 ACL revisions, 5 arthroscopies for cyclops lesions, one microfracture, and one manipulation under anaesthesia. The side-to-side laxity (P = .30) and rates of reoperation (P = .65), graft failure (P = .45), and cyclops lesions (P = .67) were not significantly different between ≥50% or <50% ACL remnant groups. CONCLUSIONS: The results of this study demonstrate that primary anatomic ACL reconstruction using the SAMBBA technique significantly improved clinical and functional outcomes between baseline and follow-up at a minimum of 24 months. A low rate of complications was observed with this technique. No significant differences between large and moderate size ACL remnants were detected for all outcome measures. LEVEL OF EVIDENCE: Level IV case series with subgroup analysis.

Efficacy evaluation of a protocol for safe hip surgery (total hip arthroplasty).

OBJECTIVE: To propose a multidisciplinary protocol to standardize the care of patients undergoing total hip arthroplasty (THA) and evaluate it effectiveness after implementation. METHODS: Retrospective evaluation of 95 consecutive patients undergoing THA divided into two groups, one group of 47 patients operated before the protocol implementation and 48 after. RESULTS: Assessing the re-admission rate, among 47 patients evaluated prior to implementation of the protocol, seven (14.9%) were re-admitted, and when observing the 48 patients evaluated after implementation, one (2.1%) was re-admitted, showing statistical significance (p < 0.05). The chance of re-admission before the protocol was eight times the chance of hospitalization after implementation (95% CI: 1.01 to 377.7). By comparing the clinical complications among the groups, it was observed that there was a lower rate of complications following implementation of the protocol (p = 0.006). CONCLUSION: The introduction of a multidisciplinary protocol to standardize the management of patients undergoing THA decreased the rates of rehospitalization and clinical complications after the procedure.

OBJETIVO: Propor um protocolo multidisciplinar para padronização do cuidado dos pacientes que serão submetidos a artroplastia total do quadril (ATQ) e avaliar sua eficácia após a implantação. MÉTODOS: Avaliação retrospectiva dos resultados de 95 pacientes consecutivos submetidos a ATQ divididos em dois grupos, um com 47 operados antes da implantação do protocolo e 48 após. RESULTADOS: Na avaliação da taxa de reinternação, tem-se que entre os 47 pacientes avaliados antes da implantação do protocolo, sete (14,9%) foram reinternados e dos 48 avaliados depois da implantação, um (2,1%) foi reinternado, mostrou-se significância estatística (p < 0,05). A chance de reinternação antes da implantação foi oito vezes maior do que a chance de internação após a implantação (IC 95%: 1,01 a 377,7). Ao comparar as complicações clínicas entre os grupos observou-se que houve menor taxa de complicações após a implantação do protocolo (p = 0,006). CONCLUSÃO: A introdução de um protocolo multidisciplinar para padronização do manejo do paciente submetido a ATQ diminuiu as taxas de reinternação e de complicações clínicas após o procedimento.

Diffuse pigmented villonodular synovitis in knee joint: diagnosis and treatment.

Pigmented villonodular synovitis is a rare proliferative condition of the synovium. Although the condition can present in any joint, the knee is the most commonly affected site. Despite being a benign condition, pigmented villonodular synovitis is often aggressive, with marked extra-articular extension in some cases. Monoarticular involvement occurs in two forms: localized and diffuse. The latter is more common, with a high recurrence rate. There is no standard method of management of this lesion. Open surgery is a classical and effective method for treatment. Arthroscopic synovectomy, however, has gained popularity, and has several advantages over the open technique particularly in exclusively articular cases. The combined approach is suggested in cases with extra-articular involvement. Synovectomy through any approach may prevent secondary osteoarthritis and subsequent joint arthroplasty. Internal irradiation or external beam radiation as an adjuvant treatment to surgical synovectomy appears to decrease the rate of local recurrence in diffuse cases. The authors observed a great heterogeneity in reporting of functional results, and specific conclusions should not be drawn. Each patient should be managed in accordance with his/her particular condition.

A sinovite vilonodular pigmentada é uma rara condição proliferativa da membrana sinovial. Apesar de a doença poder estar presente em qualquer articulação, o joelho é o local mais frequentemente afetado. Ainda que doença benigna, geralmente tem comportamento agressivo, pode ter extensão extra-articular em alguns casos. O acometimento monoarticular ocorre em duas formas: localizada ou difusa. A forma difusa é mais comum e tem alta taxa de recorrência. Não há método padronizado para o manejo dessa lesão. O tratamento cirúrgico aberto é o método clássico e efetivo. A sinovectomia artroscópica, entretanto, tem ganhado popularidade e tem diversas vantagens sobre a técnica aberta, principalmente em casos exclusivamente articulares. A abordagem combinada é sugerida em casos com envolvimento extra-articular. A sinovectomia pode prevenir a osteoartrose secundária e o subsequente tratamento reconstrutivo. A radioterapia usada como tratamento adjuvante à sinovectomia parece diminuir a taxa de recorrência local na forma difusa da doença. Os autores encontraram grande heterogeneidade na forma como os resultados funcionais foram reportados e não se deve chegar a conclusões específicas. Cada paciente deve ser manejado de acordo com suas particularidades.

Diffuse pigmented villonodular synovitis in knee joint: diagnosis and treatment / Sinovite vilonodular pigmentada difusa no joelho: diagnóstico e tratamento

ABSTRACT Pigmented villonodular synovitis is a rare proliferative condition of the synovium. Although the condition can present in any joint, the knee is the most commonly affected site. Despite being a benign condition, pigmented villonodular synovitis is often aggressive, with marked extra-articular extension in some cases. Monoarticular involvement occurs in two forms: localized and diffuse. The latter is more common, with a high recurrence rate. There is no standard method of management of this lesion. Open surgery is a classical and effective method for treatment. Arthroscopic synovectomy, however, has gained popularity, and has several advantages over the open technique particularly in exclusively articular cases. The combined approach is suggested in cases with extra-articular involvement. Synovectomy through any approach may prevent secondary osteoarthritis and subsequent joint arthroplasty. Internal irradiation or external beam radiation as an adjuvant treatment to surgical synovectomy appears to decrease the rate of local recurrence in diffuse cases. The authors observed a great heterogeneity in reporting of functional results, and specific conclusions should not be drawn. Each patient should be managed in accordance with his/her particular condition.

RESUMO A sinovite vilonodular pigmentada é uma rara condição proliferativa da membrana sinovial. Apesar de a doença poder estar presente em qualquer articulação, o joelho é o local mais frequentemente afetado. Ainda que doença benigna, geralmente tem comportamento agressivo, pode ter extensão extra-articular em alguns casos. O acometimento monoarticular ocorre em duas formas: localizada ou difusa. A forma difusa é mais comum e tem alta taxa de recorrência. Não há método padronizado para o manejo dessa lesão. O tratamento cirúrgico aberto é o método clássico e efetivo. A sinovectomia artroscópica, entretanto, tem ganhado popularidade e tem diversas vantagens sobre a técnica aberta, principalmente em casos exclusivamente articulares. A abordagem combinada é sugerida em casos com envolvimento extra-articular. A sinovectomia pode prevenir a osteoartrose secundária e o subsequente tratamento reconstrutivo. A radioterapia usada como tratamento adjuvante à sinovectomia parece diminuir a taxa de recorrência local na forma difusa da doença. Os autores encontraram grande heterogeneidade na forma como os resultados funcionais foram reportados e não se deve chegar a conclusões específicas. Cada paciente deve ser manejado de acordo com suas particularidades.

Three-Dimensional CT Evaluation of Tunnel Positioning in ACL Reconstruction Using the Single Anteromedial Bundle Biological Augmentation (SAMBBA) Technique.

BACKGROUND: Remnant preservation may confer important advantages in the anterior cruciate ligament (ACL)-reconstructed knee. However, the presence of a large remnant may obscure visualization and impair the ability to correctly place tunnels during surgery. PURPOSE: To determine whether tunnel placement during anatomic ACL reconstruction using the single anteromedial bundle biological augmentation (SAMBBA) technique is consistent and precise when a large native remnant is preserved. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Included in this study were 99 patients undergoing an ACL reconstruction during which at least 50% of the native ACL was preserved. The femoral tunnel was created using an outside-in specific guide. The tibial tunnel was positioned in the anteromedial region of the ACL footprint, and the remnant was carefully preserved while drilling and passing the semitendinosus graft through it. Postoperatively, 3-dimensional computed tomography (3D CT) was used to evaluate tunnel placement. The mean tunnel locations were calculated and the standard deviation was used to evaluate precision of positioning. Inter- and intrareader agreement were determined to assess reliability of evaluation of tunnel position. RESULTS: The center of the femoral tunnel was positioned at a mean 19.4% (SD, 2%) of the depth of the notch and a mean 23.1% (SD, 3.5%) of the lateral wall height. The center of the tibial tunnel was positioned at a mean 36.3% (SD, 3.8%) of the anteroposterior length of the tibial plateau and at a mean 47.0% (SD, 2.7%) of the mediolateral width. The small standard deviations demonstrate that this technique allows precise tunnel placement. The tunnel positions achieved were consistent with previous anatomic studies of femoral and tibial anteromedial bundle insertion. Intra- and interobserver reliability were high. CONCLUSION: Three-dimensional CT evaluation demonstrated that despite the presence of a large remnant, placement of femoral and tibial tunnels for anatomic ACL reconstruction using the SAMBBA technique is consistent and precise.

Range of motion predictability after total knee arthroplasty with medial pivot prosthesis.

OBJECTIVE: To assess whether there the final range of motion (ROM) results achieved by patients undergoing total knee arthroplasty (TKA) with prosthesis using Medial Pivot design are predictable. METHODS: Between January and August of 2014, 155 patients with primary osteoarthritis of knee who underwent TKA using the prosthesis ADVANCE® Medial Pivot were prospectively assessed. All ROM measures were made and recorded before, during, and after surgery. All patients were clinically assessed preoperatively and postoperatively (15, 45 days, three months, six months, one year, and annually thereafter after surgery); their functional status was assessed using the WOMAC questionnaire. RESULTS: Significant differences (p < 0.001) were observed between the means and medians of ROM in the preoperative when compared with those during the perioperative; the perioperative values, when compared with those after six months postoperative, were also different (p < 0.001). No significant differences were found between the means and medians ROM between the intraoperative period and at the 45-day assessment (ns) and between the means and medians ROM between the preoperative period and at the six-month evaluation (ns). CONCLUSION: The final ROM achieved by patients that underwent TKA with medial pivot prosthesis can be predicted. The perioperative ROM correlates with that at 45 days after surgery. The final ROM is correlated with that of the pre-operative period.

OBJETIVO: Avaliar se há previsibilidade da amplitude de movimentos alcançada por pacientes submetidos a artroplastia total do joelho com prótese que usa desenho medial pivot. MÉTODOS: Entre janeiro e agosto de 2014 foi feita avaliação prospectiva de 155 pacientes com osteoartrose primária do joelho submetidos a artroplastia total do joelho com o uso da prótese Advance® Medial Pivot. Todas as medidas da amplitude de movimentos foram feitas antes, durante e após a cirurgia. Todos os pacientes foram avaliados clinicamente no pré- e pós-operatório (15, 45 dias, três meses, seis meses, um ano e depois anualmente após a cirurgia) para a análise de seu estado funcional. O questionário Western Ontario and McMaster Universities Osteoarthritis Index (Womac) foi usado. RESULTADOS: Diferenças significativas (p < 0,001) foram relatadas entre as médias e medianas da amplitude de movimentos no pré-operatório em comparação com as medidas obtidas no período intraoperatório. As medidas do pré-operatório também se mostraram diferentes quando comparadas com aquelas após seis meses de pós-operatório (p < 0,001). Não foram encontradas diferenças significativas entre as médias e medianas da amplitude de movimento na comparação do intraoperatório e as medidas feitas aos 45 dias (ns) e entre as médias e medianas das medidas pré-operatórias e aquelas observadas aos seis meses (ns). CONCLUSÃO: Há previsibilidade da amplitude de movimentos obtida por pacientes submetidos a artroplastia total do joelho com prótese medial pivot. A amplitude aos 45 dias é semelhante àquela observada nas medidas intraoperatórias. A amplitude final está relacionada à amplitude pré-operatória.

Incidence and MRI characterization of the spectrum of posterolateral corner injuries occurring in association with ACL rupture.

OBJECTIVE: To determine the incidence and MRI characteristics of the spectrum of posterolateral corner (PLC) injuries occurring in association with anterior cruciate ligament (ACL) rupture. MATERIALS AND METHODS: We carried out a level IV, retrospective case series study. All patients clinically diagnosed with an ACL rupture between July 2015 and June 2016 who underwent MRI of the knee were included in the study. In addition to standard MRI knee reporting, emphasis was placed on identifying injury to the PLC and a description of involvement of these structures by two musculoskeletal radiologists. Association with PLC involvement was sought with concomitant injuries using correlation analysis and logistic regression. RESULTS: One hundred sixty-two patients with MRI following ACL rupture were evaluated. Thirty-two patients (19.7%) had an injury to at least one structure of the PLC, including the inferior popliteomeniscal fascicle (n = 28), arcuate ligament (n = 20), popliteus tendon (n = 20), superior popliteomeniscal fascicle (n = 18), lateral collateral ligament (n = 8), popliteofibular ligament (n = 7), biceps tendon (n = 4), iliotibial band (n = 3), and fabellofibular ligament (n = 1). Seventy-five percent of all patients with combined ACL and PLC injuries had bone contusions involving the lateral compartment of the knee. The presence of these contusions strongly correlated with superior popliteomeniscal fascicle lesions (p < 0.05). There was no correlation between injuries to other structures of the PLC and other intra-articular lesions. CONCLUSION: Missed injuries of the PLC lead to considerable morbidity. The relevance of this study is to highlight that these injuries occur more frequently than previously described and that an appropriate index of suspicion, clinical examination, and MRI are all required to reduce the risk of missed diagnoses. The results of this study support previous suggestions that the rate of concomitant PLC injury in the ACL-deficient knee is under-reported. The rate of combined injuries in this series was 19.7%. The key message of this paper is that PLC injury is common in the presence of ACL injury and should be sought both clinically and radiologically.

Range of motion predictability after total knee arthroplasty with medial pivot prosthesis / Previsibilidade da amplitude de movimento após artroplastia total do joelho com prótese medial pivot

ABSTRACT OBJECTIVE: To assess whether there the final range of motion (ROM) results achieved by patients undergoing total knee arthroplasty (TKA) with prosthesis using Medial Pivot design are predictable. METHODS: Between January and August of 2014, 155 patients with primary osteoarthritis of knee who underwent TKA using the prosthesis ADVANCE(r) Medial Pivot were prospectively assessed. All ROM measures were made and recorded before, during, and after surgery. All patients were clinically assessed preoperatively and postoperatively (15, 45 days, three months, six months, one year, and annually thereafter after surgery); their functional status was assessed using the WOMAC questionnaire. RESULTS: Significant differences (p < 0.001) were observed between the means and medians of ROM in the preoperative when compared with those during the perioperative; the perioperative values, when compared with those after six months postoperative, were also different (p < 0.001). No significant differences were found between the means and medians ROM between the intraoperative period and at the 45-day assessment (ns) and between the means and medians ROM between the preoperative period and at the six-month evaluation (ns) . CONCLUSION: The final ROM achieved by patients that underwent TKA with medial pivot prosthesis can be predicted. The perioperative ROM correlates with that at 45 days after surgery. The final ROM is correlated with that of the pre-operative period.

RESUMO OBJETIVO: Avaliar se há previsibilidade da amplitude de movimentos alcançada por pacientes submetidos a artroplastia total do joelho com prótese que usa desenho medial pivot. MÉTODOS: Entre janeiro e agosto de 2014 foi feita avaliação prospectiva de 155 pacientes com osteoartrose primária do joelho submetidos a artroplastia total do joelho com o uso da prótese Advance(r) Medial Pivot. Todas as medidas da amplitude de movimentos foram feitas antes, durante e após a cirurgia. Todos os pacientes foram avaliados clinicamente no pré- e pós-operatório (15, 45 dias, três meses, seis meses, um ano e depois anualmente após a cirurgia) para a análise de seu estado funcional. O questionário Western Ontario and McMaster Universities Osteoarthritis Index (Womac) foi usado. RESULTADOS: Diferenças significativas (p < 0,001) foram relatadas entre as médias e medianas da amplitude de movimentos no pré-operatório em comparação com as medidas obtidas no período intraoperatório. As medidas do pré-operatório também se mostraram diferentes quando comparadas com aquelas após seis meses de pós-operatório (p < 0,001). Não foram encontradas diferenças significativas entre as médias e medianas da amplitude de movimento na comparação do intraoperatório e as medidas feitas aos 45 dias (ns) e entre as médias e medianas das medidas pré-operatórias e aquelas observadas aos seis meses (ns). CONCLUSÃO: Há previsibilidade da amplitude de movimentos obtida por pacientes submetidos a artroplastia total do joelho com prótese medial pivot. A amplitude aos 45 dias é semelhante àquela observada nas medidas intraoperatórias. A amplitude final está relacionada à amplitude pré-operatória.

Anterolateral Ligament Reconstruction Is Associated With Significantly Reduced ACL Graft Rupture Rates at a Minimum Follow-up of 2 Years: A Prospective Comparative Study of 502 Patients From the SANTI Study Group.

BACKGROUND: Graft failure and low rates of return to sport are major concerns after anterior cruciate ligament (ACL) reconstruction, particularly in a population at risk. PURPOSE: To evaluate the association between reconstruction techniques and subsequent graft rupture and return-to-sport rates in patients aged 16 to 30 years participating in pivoting sports. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A prospective study of patients undergoing primary ACL reconstruction with a bone-patellar tendon-bone (B-PT-B) graft, quadrupled hamstring tendon (4HT) graft, or hamstring tendon graft combined with anterolateral ligament reconstruction (HT+ALL) was conducted by the Scientific ACL NeTwork International (SANTI) Study Group. Survivorship data from Kaplan-Meier analysis were analyzed in multivariate Cox regression models to identify the prognosticators of graft ruptures and return to sport. RESULTS: Five hundred two patients (mean age, 22.4 ± 4.0 years) with a mean follow-up of 38.4 ± 8.5 months (range, 24-54 months) were included. There were 105 B-PT-B, 176 4HT, and 221 HT+ALL grafts. The mean postoperative scores at latest follow-up were the following: Lysholm: 92.4 ± 8.6, Tegner: 7.4 ± 2.1, and subjective International Knee Documentation Committee (IKDC): 86.8 ± 10.5 for B-PT-B grafts; Lysholm: 91.3 ± 9.9, Tegner: 6.6 ± 1.8, and subjective IKDC: 85.4 ± 10.4 for 4HT grafts; and Lysholm: 91.9 ± 10.2, Tegner: 7.0 ± 2.0, and subjective IKDC: 81.8 ± 13.1 for HT+ALL grafts. The mean side-to-side laxity was 0.6 ± 0.9 mm for B-PT-B grafts, 0.6 ± 1.0 mm for 4HT grafts, and 0.5 ± 0.8 mm for HT+ALL grafts. At a mean follow-up of 38.4 months, the graft rupture rates were 10.77% (range, 6.60%-17.32%) for 4HT grafts, 16.77% (range, 9.99%-27.40%) for B-PT-B grafts, and 4.13% (range, 2.17%-7.80%) for HT+ALL grafts. The rate of graft failure with HT+ALL grafts was 2.5 times less than with B-PT-B grafts (hazard ratio [HR], 0.393; 95% CI, 0.153-0.953) and 3.1 times less than with 4HT grafts (HR, 0.327; 95% CI, 0.130-0.758). There was no significant difference in the graft failure rate between 4HT and B-PT-B grafts (HR, 1.204; 95% CI, 0.555-2.663). Other prognosticators of graft failure included age ≤25 years ( P = .012) and a preoperative side-to-side laxity >7 mm ( P = .018). The HT+ALL graft was associated with higher odds of returning to preinjury levels of sport than the 4HT graft (odds ratio [OR], 1.938; 95% CI, 1.174-3.224) but not compared with the B-PT-B graft (OR, 1.460; 95% CI, 0.813-2.613). CONCLUSION: In a high-risk population of young patients participating in pivoting sports, the rate of graft failure with HT+ALL grafts was 2.5 times less than with B-PT-B grafts and 3.1 times less than with 4HT grafts. The HT+ALL graft is also associated with greater odds of returning to preinjury levels of sport when compared with the 4HT graft.