Epidemiology of Knee Injuries in Baseball Players from the State of São Paulo.

Objective This study aimed to identify the main knee complaints and injuries associated with baseball and their prevalence in the state of São Paulo, Brazil. Methods This epidemiological study analyzed data from an online questionnaire sent to baseball athletes from the state of São Paulo, Brazil, from 2019 to 2022. Results Ninety-eight athletes participated in the study. Their average age was 24.3 years, and 85.72% of the subjects were men. The most prevalent ethnicities were yellow (50%) and white (42.86%). Most athletes had incomplete or complete higher education (75.5%). Most (88.77%) have been training for over 1 year, and 40.82% played in more than 1 position. More than half also practiced another sport. Most (66.32%) athletes present knee complaints or symptoms, and 37.75% had suffered a knee injury playing baseball, with several mechanisms (contact with the ground, contact with another player, or no contact). More than half (59.45%) of the athletes required time away from baseball due to complaints, symptoms, or injuries. Conclusion Among the athletes interviewed, 66.32% had a knee complaint, and 37.75% had already had a knee injury, especially meniscal and ligament injuries. The injury rate was highest in the first year of practice.

Posterolateral Corner Reconstruction: Modification of the LaPrade Technique Using Autologous Hamstring Tendon Grafts: "The Popliteofibular Loop".

Posterolateral corner (PLC) injury is a significant cause of knee instability. In recent years, a better understanding of the anatomy and biomechanics of the PLC structures has led to significant advancements in the surgical treatment of this injury. Anatomical reconstruction techniques, particularly the LaPrade technique, have shown promising results. However, in some settings, the reliance on allografts limits the feasibility of this technique, prompting surgeons to seek reproducible alternatives that use autologous grafts, eliminating the need for tissue banks. The purpose of this Technical Note is to describe a modification of the LaPrade technique for PLC reconstruction using autologous hamstring tendon grafts. The surgical technique is described to ensure reproducibility, with particular emphasis on the proposed modifications: the use of autologous grafts (gracilis and semitendinosus tendons); the configuration in which they are used to increase the thickness of the reconstructed structures; and the exclusive fixation with widely available interference screws.

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

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

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

S. AUREUS IS ASSOCIATED WITH A GREATER NEED FOR REOPERATION IN SEPTIC ARTHRITIS OF THE KNEE.

Objective: To determine the frequency of reoperations in the treatment of adult patients diagnosed with septic arthritis of the knee, the average number of debridements needed to control the infection, the mortality rate, and to assess factors associated with a greater need for reoperation and mortality. Methods: Retrospective cohort study evaluating 38 adult patients diagnosed with septic arthritis who underwent arthrotomy via a medial parapatellar approach for joint cleaning and debridement. Demographic, clinical, surgical, and microbiological variables of the cases were analyzed by review of medical records. Tests for equality of two proportions, chi-square, and multivariate logistic regression analysis were performed, defining a significance level at 0.05, with 95% confidence interval. Results: A total of 50% of the cases underwent reoperation, with an average number of required debridement of 2.02 and a mortality rate of 10.5%. Patients with infection caused by Staphylococcus aureus were more likely to need a reoperation compared to patients with positive cultures for other agents (OR 6.0). Conclusion: In 50% of cases, an average of 2.02 debridements were necessary and the mortality rate was 10.5%. Staphylococcus aureus infection is associated with a 6 times greater chance of additional surgeries. / Level of Evidence IV, Case Series.

Objetivo: Determinar a frequência de reabordagens cirúrgicas no tratamento de pacientes adultos com diagnóstico de artrite séptica do joelho, a média de desbridamentos necessários para o controle da infecção e a taxa de mortalidade, assim como avaliar os fatores associados à maior necessidade de reabordagem e mortalidade. Métodos: Estudo retrospectivo tipo coorte que avaliou 38 pacientes adultos com diagnóstico de artrite séptica submetidos à artrotomia por via parapatelar medial para limpeza e desbridamento da articulação. Foram analisadas variáveis demográficas, clínicas, cirúrgicas e microbiológicas dos casos, por revisão de prontuário médico, e realizados testes de igualdade de duas proporções, qui-quadrado e análise multivariada de regressão logística, sendo definido um nível de significância de 0,05, com 95% de confiança estatística. Resultados: 50% dos casos foram submetidos à reabordagem cirúrgica, sendo a média de desbridamentos necessários de 2,02 e a taxa de mortalidade de 10,5%. Pacientes com infecção causada por Staphylococcus aureus apresentaram mais chances de necessitar de reabordagem quando comparados aos pacientes com culturas positivas para outros agentes (OR 6,0). Conclusão: Em 50% dos casos foram necessários, em média, 2,02 desbridamentos e a taxa de mortalidade foi de 10,5%. A infecção por Staphylococcus aureus está associada com seis vezes mais chances de cirurgias adicionais. Nível de Evidência IV, Série de Casos.

S. aureus is associated with a greater need for reoperation in septic arthritis of the knee / S. aureus está associada com maior necessidade de reabordagem na artrite séptica do joelho

ABSTRACT Objective: To determine the frequency of reoperations in the treatment of adult patients diagnosed with septic arthritis of the knee, the average number of debridements needed to control the infection, the mortality rate, and to assess factors associated with a greater need for reoperation and mortality. Methods: Retrospective cohort study evaluating 38 adult patients diagnosed with septic arthritis who underwent arthrotomy via a medial parapatellar approach for joint cleaning and debridement. Demographic, clinical, surgical, and microbiological variables of the cases were analyzed by review of medical records. Tests for equality of two proportions, chi-square, and multivariate logistic regression analysis were performed, defining a significance level at 0.05, with 95% confidence interval. Results: A total of 50% of the cases underwent reoperation, with an average number of required debridement of 2.02 and a mortality rate of 10.5%. Patients with infection caused by Staphylococcus aureus were more likely to need a reoperation compared to patients with positive cultures for other agents (OR 6.0). Conclusion: In 50% of cases, an average of 2.02 debridements were necessary and the mortality rate was 10.5%. Staphylococcus aureus infection is associated with a 6 times greater chance of additional surgeries. /Level of Evidence IV, Case Series.

RESUMO Objetivo: Determinar a frequência de reabordagens cirúrgicas no tratamento de pacientes adultos com diagnóstico de artrite séptica do joelho, a média de desbridamentos necessários para o controle da infecção e a taxa de mortalidade, assim como avaliar os fatores associados à maior necessidade de reabordagem e mortalidade. Métodos: Estudo retrospectivo tipo coorte que avaliou 38 pacientes adultos com diagnóstico de artrite séptica submetidos à artrotomia por via parapatelar medial para limpeza e desbridamento da articulação. Foram analisadas variáveis demográficas, clínicas, cirúrgicas e microbiológicas dos casos, por revisão de prontuário médico, e realizados testes de igualdade de duas proporções, qui-quadrado e análise multivariada de regressão logística, sendo definido um nível de significância de 0,05, com 95% de confiança estatística. Resultados: 50% dos casos foram submetidos à reabordagem cirúrgica, sendo a média de desbridamentos necessários de 2,02 e a taxa de mortalidade de 10,5%. Pacientes com infecção causada por Staphylococcus aureus apresentaram mais chances de necessitar de reabordagem quando comparados aos pacientes com culturas positivas para outros agentes (OR 6,0). Conclusão: Em 50% dos casos foram necessários, em média, 2,02 desbridamentos e a taxa de mortalidade foi de 10,5%. A infecção por Staphylococcus aureus está associada com seis vezes mais chances de cirurgias adicionais. Nível de Evidência IV, Série de Casos.

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

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

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

Prospective and Randomized Clinical Evaluation of Hamstring Versus Patellar Tendon Autograft for Anterior Cruciate Ligament Reconstruction in Soccer Players.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction is usually performed with autologous bone-patellar tendon-bone (PT) or hamstring tendon (HT) graft. There has been only 1 randomized clinical trial examining ACL reconstruction with these grafts specifically in soccer players, and more studies comparing these graft types within a homogenous cohort such as soccer athletes may better highlight differences in outcomes. PURPOSE: To compare the results of ACL reconstruction with PT versus HT autograft in soccer players and to evaluate objective and subjective outcomes. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 62 professional or semiprofessional soccer players (mean age, 25.1 years) with ACL injury were randomized to undergo reconstruction with PT or HT autograft by a single orthopaedic surgeon (n = 31 in each group). Outcome measures were recorded preoperatively and at 2 years postoperatively. The primary outcome was the modified Cincinnati Knee Rating System, and secondary outcomes were the objective and subjective International Knee Documentation Committee scores, Lachman test, pivot-shift test, anterior drawer test, and Lysholm score. The following variables were also evaluated postoperatively: return to soccer, level at return, graft rerupture, postoperative complications, anterior knee pain, patellar tendinitis, difficulty sprinting, and loss of kicking power. RESULTS: The PT and HT groups were homogenous in terms of age, sex distribution, injured side, and time from injury to surgery, and there was no difference between them on any preoperative outcome score. At 2 years postoperatively, there were no differences between the groups on any outcome score; however, there were significantly fewer patients with anterior knee pain in the HT group compared with the PT group (7 [22.6%] vs 15 [48.4%], respectively; P = .03). Two patients from each group (2/31; 6.5%) sustained rerupture. CONCLUSION: There were no differences between soccer players who underwent different types of ACL reconstruction with the exception of anterior knee pain, which was more frequent in players who underwent reconstruction with PT graft.Registration: NCT02642692 (ClinicalTrials.gov).

The impact of sonication cultures when the diagnosis of prosthetic joint infection is inconclusive.

BACKGROUND: In the absence of a gold standard criterion for diagnosing prosthetic joint infections (PJI), sonication of the removed implant may provide superior microbiological identification to synovial fluid and peri-implant tissue cultures. The aim of this retrospective study was to assess the role of sonication culture compared to tissue cultures for diagnosing PJI, using different consensus and international guidelines for PJI definition. METHODS: Data of 146 patients undergoing removal of hip or knee arthroplasties between 2010 and 2018 were retrospectively reviewed. The International Consensus Meeting (ICM-2018), Musculoskeletal Infection Society (MSIS), Infectious Diseases Society of America (IDSA), the European Bone and Joint Infection Society (EBJIS), and a modified clinical criterion, were used to compare the performance of microbiological tests. McNemar´s test and proportion comparison were employed to calculate p-value. RESULTS: Overall, 56% (82/146) were diagnosed with PJI using the clinical criteria. Out of these cases, 57% (47/82) tested positive on tissue culture and 93% (76/82) on sonication culture. Applying this clinical criterion, the sensitivity of sonication fluid and tissue cultures was 92.7% (95% CI: 87.1%- 98.3%) and 57.3% (95% CI: 46.6%-68.0%) (p<0.001), respectively. When both methods were combined for diagnosis (sonication and tissue cultures) sensitivity reached 96.3% (95% CI: 91.5%-100%). Sonication culture and the combination of sonication with tissue cultures, showed higher sensitivity rates than tissue cultures alone for all diagnostic criteria (ICM-18, MSIS, IDSA and EBJIS) applied. Conversely, tissue culture provided greater specificity than sonication culture for all the criteria assessed, except for the EBJIS criteria, in which sonication and tissue cultures specificity was 100% and 95.3% (95% CI: 87.8-100%), respectively (p = 0.024). CONCLUSIONS: In a context where diagnostic criteria available have shortcomings and tissue cultures remain the gold standard, sonication cultures can aid PJI diagnosis, especially when diagnostic criteria are inconclusive due to some important missing data (joint puncture, histology).

Update on Patellar Instability.

Patellar instability is a multifactorial clinical condition that affects a significant number of patients and occurs due to morphological variations of the joint and patellofemoral alignment. The present literature review study aimed to identify and summarize current concepts on patellar instability, in relation to associated risk factors, diagnostic criteria, and the benefits and risks of conservative and surgical treatments. For this purpose, a search was conducted in the following electronic databases: MEDLINE (via Pubmed), LILACS and Cochrane Library. It is concluded that the accurate diagnosis depends on the detailed clinical evaluation, including the history and possible individual risk factors, as well as imaging exams. The initial treatment of patellar instability is still controversial, and requires the combination of conservative and surgical interventions, taking into consideration both soft tissues and bone structures, the latter being the most common reason for choosing surgical treatment, especially lateral patellar instability.

Update on Patellar Instability / Atualização em instabilidade patelar

Abstract Patellar instability is a multifactorial clinical condition that affects a significant number of patients and occurs due to morphological variations of the joint and patellofemoral alignment. The present literature review study aimed to identify and summarize current concepts on patellar instability, in relation to associated risk factors, diagnostic criteria, and the benefits and risks of conservative and surgical treatments. For this purpose, a search was conducted in the following electronic databases: MEDLINE (via Pubmed), LILACS and Cochrane Library. It is concluded that the accurate diagnosis depends on the detailed clinical evaluation, including the history and possible individual risk factors, as well as imaging exams. The initial treatment of patellar instability is still controversial, and requires the combination of conservative and surgical interventions, taking into consideration both soft tissues and bone structures, the latter being the most common reason for choosing surgical treatment, especially lateral patellar instability.

Resumo A instabilidade patelar é uma condição clínica multifatorial, que acomete um número expressivo de pacientes, ocorrendo devido a variações anatómicas, morfológicas da articulação e do alinhamento patelofemoral. O presente estudo de revisão e atualização da literatura teve como objetivos identificar e sumarizar os conceitos atuais sobre instabilidade patelar em relação aos fatores de risco associados, os critérios diagnósticos e os benefícios e riscos dos tratamentos conservador e cirúrgico. Para tanto, foi realizado um levantamento nas bases de dados eletrónicas MEDLINE (via Pubmed), LILACS e Cochrane Library. Conclui-se que o diagnóstico preciso depende da avaliação clínica detalhada, incluindo o histórico e possíveis fatores de risco individuais, além de exames de imagem. O tratamento inicial da instabilidade patelar é ainda controverso, e requer a combinação de intervenções conservadoras e cirúrgicas, levando em consideração tanto os tecidos moles quanto as estruturas ósseas, sendo estas últimas a razão mais comum para a escolha do tratamento cirúrgico, principalmente instabilidade patelar lateral.

Evaluation of Histological Properties of Human Meniscal Grafts Stored in a Tissue Bank.

Objectives The present paper aims to evaluate and compare the histological features of fresh and frozen menisci stored in a tissue bank for 1 month and for 5 years. Methods The meniscal grafts were subjected to a histological study. A total of 10 menisci were evaluated; 2 were frozen for 5 years, 4 were frozen for 1 month, and 4 were fresh, recently harvested specimens. Histological properties were evaluated in sections stained with hematoxylin and eosin and Masson trichrome methods. Results The menisci frozen for 1 month showed partially preserved collagen fiber structure and no significant hydropic tissue degeneration. The menisci frozen for 5 years presented an evident dissociation of collagen fibers and multiple foci of hydropic degeneration. Discussion Degeneration was much more significant in menisci stored for 5 years, indicating that a long freezing period results in substantial progression of tissue deterioration. This may suggest that the 5-year period, considered the maximum time for graft storage before transplant, is too long. Conclusion Grafts stored for 1 month showed a slight degenerative change in collagen fibers, whereas menisci frozen for 5 years presented significant tissue degeneration.

Evaluation of Histological Properties of Human Meniscal Grafts Stored in a Tissue Bank / Avaliação das propriedades histológicas de enxertos meniscais humanos armazenados em banco de tecido

Abstract Objectives The present paper aims to evaluate and compare the histological features of fresh and frozen menisci stored in a tissue bank for 1 month and for 5 years. Methods The meniscal grafts were subjected to a histological study. A total of 10 menisci were evaluated; 2 were frozen for 5 years, 4 were frozen for 1 month, and 4 were fresh, recently harvested specimens. Histological properties were evaluated in sections stained with hematoxylin and eosin and Masson trichrome methods. Results The menisci frozen for 1 month showed partially preserved collagen fiber structure and no significant hydropic tissue degeneration. The menisci frozen for 5 years presented an evident dissociation of collagen fibers and multiple foci of hydropic degeneration. Discussion Degeneration was much more significant in menisci stored for 5 years, indicating that a long freezing period results in substantial progression of tissue deterioration. This may suggest that the 5-year period, considered the maximum time for graft storage before transplant, is too long. Conclusion Grafts stored for 1 month showed a slight degenerative change in collagen fibers, whereas menisci frozen for 5 years presented significant tissue degeneration.

Resumo Objetivos Avaliar e comparar as características histológicas de meniscos frescos e meniscos congelados armazenados em banco de tecidos por 1 mês e por 5 anos. Métodos Foi feito um estudo histológico com enxertos meniscais. Avaliamos 10 meniscos, sendo 2 que ficaram armazenados sob congelamento por 5 anos, 4 armazenados congelados por 1 mês, e 4 frescos, recém captados. Foram feitos cortes histológicos corados com hematoxilina e eosina e Tricrômico de Masson, para avaliação das propriedades histológicas. Resultados Os meniscos congelados por 1 mês apresentaram preservação parcial da estrutura das fibras colágenas, sem degeneração hidrópica significativa do tecido. Nos meniscos congelados por 5 anos, observamos dissociação evidente das fibras colágenas, com presença de múltiplos focos de degeneração hidrópica. Discussão Encontramos degeneração bem mais significativa nos meniscos armazenados por 5 anos, o que indica que o longo período de congelamento leva à progressão significativa da degeneração do tecido. Isto pode sugerir que o período de 5 anos, considerado período máximo que o enxerto pode permanecer armazenado antes de ser transplantado, é um período muito longo. Conclusão Nos enxertos armazenados por 1 mês, existiu apenas discreta alteração degenerativa das fibras colágenas, enquanto que nos meniscos com 5 anos de congelamento foi observada degeneração significativa do tecido. Tibiais

Double-bundle posterior cruciate ligament reconstruction: No differences between two types of autografts in isolated or combined lesions.

BACKGROUND: To demonstrate and compare results obtained with the transtibial double-bundle posterior cruciate ligament (PCL) reconstruction technique using two types of autografts in isolated and combined PCL lesions. METHODS: Fifty-two patients with isolated or combined PCL injuries underwent double-bundle PCL reconstruction and were retrospectively evaluated. Among them, 34 were reconstructed using ipsilateral quadriceps and semitendinosus tendon grafts, and 18 were reconstructed using bilateral hamstring tendon grafts. The criteria for outcome evaluation were: objective International Knee Documentation Committee (IKDC) score, Lysholm score, posterior stability (posterior drawer test and KT-1000TM), and rate of complications, comparing the two types of grafts and comparing isolated PCL and combined lesions. The minimum follow-up was two years. RESULTS: Significant improvements were found in all evaluation methods between the pre- and postoperative periods (all P < .05), with no observed differences between the graft type that was used (all P > .05). The whole sample had the following results: objective IKDC score, 96.2% classified as A/B; Lysholm score, 98.1% rated as good or excellent; and KT-1000, 98.1% with a side-to-side difference of up to five millimeters (65.4% with 0 to two millimeters). The complication rate was 9.6%, with no differences between the graft type that was used (P = .585). No significant difference was observed when comparing the results between isolated PCL injuries and combined injuries (all P > .05). CONCLUSIONS: The proposed PCL reconstruction technique presented satisfactory results in both isolated and combined PCL lesions, and there were no differences between different types of autografts used. LEVEL OF EVIDENCE: Level III.

Histological study of the posterior cruciate ligament femoral insertion / Estudo histológico da inserção femoral do ligamento cruzado posterior

ABSTRACT Objectives: To describe the microscopic anatomy of the posterior cruciate ligament femoral insertion in order to identify and establish differences between the direct and indirect insertions of this ligament. Methods: Ten cadaveric knees were used for this study. The posterior cruciate ligament femoral insertion was observed microscopically. Hematoxylin and eosin staining was performed to observe the morphology of the posterior cruciate ligament insertion. Alcian blue staining was performed to determine the location of the cartilage matrix and better assist in the observation and differentiation between direct and indirect insertions. Results: The direct insertion was observed to be a more complex structure than the indirect insertion because it showed four different histological layers (ligament, uncalcified fibrocartilage, calcified fibrocartilage, and bone). Chondrocytes were observed in the uncalcified and calcified fibrocartilage layers. It was observed that the indirect insertion was composed of two layers in which the ligament was anchored directly to the bone by collagen fibers. Indirect insertion was located in the marginal region of the posterior cruciate ligament between the direct insertion and the anterior articular cartilage. Conclusion: Through histological analysis, it was demonstrated that the indirect insertion was adjacent to the anterior articular cartilage and presents a histological pattern where the collagen fibers insert directly into the bone (two-layer insertion). The direct insertion is posterior to the indirect insertion and has four histologically distinct layers.

RESUMO Objetivos: Descrever a anatomia microscópica da inserção femoral do ligamento cruzado posterior a fim de identificar e estabelecer diferenças entre as inserções direta e indireta desse ligamento. Métodos: Foram usados dez joelhos procedentes de amputações transfemorais. A inserção femoral do ligamento cruzado posterior foi observada microscopicamente. A coloração hematoxilina e eosina foi feita para observar a morfologia da inserção do ligamento cruzado posterior. A coloração azul de Alcian foi feita para determinar a localização da matriz de cartilagem e melhor ajudar na observação e diferenciação entre a inserção direta e indireta. Resultados: Observou-se que a inserção direta do ligamento cruzado posterior é uma estrutura mais complexa do que a inserção indireta, por apresentar quatro camadas histológicas distintas (ligamento, fibrocartilagem não calcificada, fibrocartilagem calcificada e osso). Os condrócitos foram observados nas camadas não calcificadas e calcificadas de fibrocartilagem. Foi observado que a inserção indireta, composta de duas camadas nas quais o ligamento está inserido diretamente ao osso por fibras de colágeno, está localizada na região marginal do ligamento cruzado posterior entre a inserção direta e a borda da cartilagem anterior do côndilo. Conclusão: Através de análise histológica, o presente estudo demonstrou que a inserção indireta do ligamento cruzado posterior situa-se adjacente à borda da cartilagem anterior do côndilo femoral e apresenta um padrão histológico no qual as fibras de colágeno se inserem diretamente no osso. A inserção direta encontra-se posterior à inserção indireta e apresenta quatro camadas histológicas distintas.

Histological study of the posterior cruciate ligament femoral insertion.

OBJECTIVES: To describe the microscopic anatomy of the posterior cruciate ligament femoral insertion in order to identify and establish differences between the direct and indirect insertions of this ligament. METHODS: Ten cadaveric knees were used for this study. The posterior cruciate ligament femoral insertion was observed microscopically. Hematoxylin and eosin staining was performed to observe the morphology of the posterior cruciate ligament insertion. Alcian blue staining was performed to determine the location of the cartilage matrix and better assist in the observation and differentiation between direct and indirect insertions. RESULTS: The direct insertion was observed to be a more complex structure than the indirect insertion because it showed four different histological layers (ligament, uncalcified fibrocartilage, calcified fibrocartilage, and bone). Chondrocytes were observed in the uncalcified and calcified fibrocartilage layers. It was observed that the indirect insertion was composed of two layers in which the ligament was anchored directly to the bone by collagen fibers. Indirect insertion was located in the marginal region of the posterior cruciate ligament between the direct insertion and the anterior articular cartilage. CONCLUSION: Through histological analysis, it was demonstrated that the indirect insertion was adjacent to the anterior articular cartilage and presents a histological pattern where the collagen fibers insert directly into the bone (two-layer insertion). The direct insertion is posterior to the indirect insertion and has four histologically distinct layers.

OBJETIVOS: Descrever a anatomia microscópica da inserção femoral do ligamento cruzado posterior a fim de identificar e estabelecer diferenças entre as inserções direta e indireta desse ligamento. MÉTODOS: Foram usados dez joelhos procedentes de amputações transfemorais. A inserção femoral do ligamento cruzado posterior foi observada microscopicamente. A coloração hematoxilina e eosina foi feita para observar a morfologia da inserção do ligamento cruzado posterior. A coloração azul de Alcian foi feita para determinar a localização da matriz de cartilagem e melhor ajudar na observação e diferenciação entre a inserção direta e indireta. RESULTADOS: Observou-se que a inserção direta do ligamento cruzado posterior é uma estrutura mais complexa do que a inserção indireta, por apresentar quatro camadas histológicas distintas (ligamento, fibrocartilagem não calcificada, fibrocartilagem calcificada e osso). Os condrócitos foram observados nas camadas não calcificadas e calcificadas de fibrocartilagem. Foi observado que a inserção indireta, composta de duas camadas nas quais o ligamento está inserido diretamente ao osso por fibras de colágeno, está localizada na região marginal do ligamento cruzado posterior entre a inserção direta e a borda da cartilagem anterior do côndilo. CONCLUSÃO: Através de análise histológica, o presente estudo demonstrou que a inserção indireta do ligamento cruzado posterior situa-se adjacente à borda da cartilagem anterior do côndilo femoral e apresenta um padrão histológico no qual as fibras de colágeno se inserem diretamente no osso. A inserção direta encontra-se posterior à inserção indireta e apresenta quatro camadas histológicas distintas.

Should the meniscal height be considered for preoperative sizing in meniscal transplantation?

PURPOSE AND HYPOTHESIS: In preoperative sizing for meniscal transplantation, most authors take into consideration the length and width of the original meniscus, but not its height. This study aimed at evaluating (1) whether the meniscal height is associated with the meniscal length and width, (2) whether the heights of the meniscal segments are associated with the individual's anthropometric data, (3) whether the heights of the meniscal segments are associated with each other in the same meniscus, and (4) the degree of symmetry of the meniscal dimensions between the right and left knees. METHODS: In this cross-sectional, observational study, two independent radiologists measured the meniscal length, width and height in knee magnetic resonance imaging scans obtained from 25 patients with patello-femoral pain syndrome. Reproducibility of measurements was calculated with intraclass correlation coefficients. Associations between the anthropometric data and the meniscal measurements, the meniscal length and width versus height, and the heights of the meniscal segments in the same meniscus were examined with Pearson's correlation. RESULTS: Inter-observer reliability was excellent (>0.8) for length and height and good (0.6-0.8) for width measurements. There was also excellent agreement (>0.8) for the length and width of the menisci in the right and left knees. The heights of the horns of the lateral meniscus showed good agreement (0.6-0.8), while the heights of the other meniscal segments had excellent agreement between the sides (>0.8). There were significant associations with generally low (r < 0.5) correlation between the heights of the meniscal segments and the lengths and widths of the menisci, between the meniscal height and anthropometric data, and between the heights of the meniscal segments in the same meniscus. Correlations between anthropometric data and meniscal length and width were generally high (r > 0.7). CONCLUSIONS: There was excellent agreement between the meniscal dimensions of the right and left knees, and a weak association between the meniscal height with the meniscal width and length, between the height of the menisci with anthropometric data and between the heights of the segments in the same meniscus. The height of the meniscal segments may be a new variable in preoperative meniscal measurement.

Comparative evaluation of the results of three techniques in the reconstruction of the anterior cruciate ligament, with a minimum follow-up of two years.

OBJECTIVE: To compare the clinical results of the reconstruction of the anterior cruciate ligament by transtibial, transportal, and outside-in techniques. METHODS: This was a retrospective study on 90 patients (ACL reconstruction with autologous flexor tendons) operated between August 2009 and June 2012, by the medial transportal (30), transtibial (30), and "outside-in" (30) techniques. The following parameters were assessed: objective and subjective IKDC, Lysholm, KT1000, Lachman test, Pivot-Shift and anterior drawer test. RESULTS: On physical examination, the Lachman test and Pivot-Shift indicated a slight superiority of the outside-in technique, but without statistical significance (p = 0.132 and p = 0.186 respectively). The anterior drawer, KT1000, subjective IKDC, Lysholm, and objective IKDC tests showed similar results in the groups studied. A higher number of complications were observed in the medial transportal technique (p = 0.033). CONCLUSION: There were no statistically significant differences in the clinical results of patients undergoing reconstruction of the anterior cruciate ligament by transtibial, medial transportal, and outside-in techniques.

OBJETIVO: Comparar os resultados clínicos objetivos e subjetivos da reconstrução do ligamento cruzado anterior (LCA) pelas técnicas transtibial, transportal e "de fora para dentro". MÉTODOS: Estudo retrospectivo de 90 pacientes operados entre agosto de 2009 e junho de 2012, para reconstrução do LCA pelas técnicas transportal medial (30), transtibial (30) e "de fora para dentro" (30). Os pacientes foram avaliados por meio do International Knee Documentation Committee (IKDC) objetivo e subjetivo, escore Lysholm e testes KT1000, de Lachman, Pivot-Shift e gaveta anterior. RESULTADOS: Em relação ao exame físico, nos testes de Lachman e Pivot-Shift encontrou-se uma discreta superioridade da técnica "de fora para dentro", porém sem significância estatística (p = 0,132 e p = 0,186 respectivamente). Gaveta anterior, KT1000, IKDC subjetivo, Lysholm e IKDC objetivo apresentaram resultados semelhantes nos grupos avaliados. Um maior número de complicações foi relatado na técnica transportal (p = 0,033). CONCLUSÃO: Resultados clínicos objetivos e subjetivos sem significância estatística na comparação das três técnicas de reconstrução do LCA.

Comparative evaluation of the results of three techniques in the reconstruction of the anterior cruciate ligament, with a minimum follow-up of two years / Avaliação comparativa dos resultados de três técnicas na reconstrução do ligamento cruzado anterior com seguimento mínimo de dois anos

ABSTRACT OBJECTIVE: To compare the clinical results of the reconstruction of the anterior cruciate ligament by transtibial, transportal, and outside-in techniques. METHODS: This was a retrospective study on 90 patients (ACL reconstruction with autologous flexor tendons) operated between August 2009 and June 2012, by the medial transportal (30), transtibial (30), and "outside-in" (30) techniques. The following parameters were assessed: objective and subjective IKDC, Lysholm, KT1000, Lachman test, Pivot-Shift and anterior drawer test. RESULTS: On physical examination, the Lachman test and Pivot-Shift indicated a slight superiority of the outside-in technique, but without statistical significance (p = 0.132 and p = 0.186 respectively). The anterior drawer, KT1000, subjective IKDC, Lysholm, and objective IKDC tests showed similar results in the groups studied. A higher number of complications were observed in the medial transportal technique (p = 0.033). CONCLUSION: There were no statistically significant differences in the clinical results of patients undergoing reconstruction of the anterior cruciate ligament by transtibial, medial transportal, and outside-in techniques.

RESUMO OBJETIVO: Comparar os resultados clínicos objetivos e subjetivos da reconstrução do ligamento cruzado anterior (LCA) pelas técnicas transtibial, transportal e "de fora para dentro". MÉTODOS: Estudo retrospectivo de 90 pacientes operados entre agosto de 2009 e junho de 2012, para reconstrução do LCA pelas técnicas transportal medial (30), transtibial (30) e "de fora para dentro" (30). Os pacientes foram avaliados por meio do International Knee Documentation Committee (IKDC) objetivo e subjetivo, escore Lysholm e testes KT1000, de Lachman, Pivot-Shift e gaveta anterior. RESULTADOS: Em relação ao exame físico, nos testes de Lachman e Pivot-Shift encontrou-se uma discreta superioridade da técnica "de fora para dentro", porém sem significância estatística (p = 0,132 e p = 0,186 respectivamente). Gaveta anterior, KT1000, IKDC subjetivo, Lysholm e IKDC objetivo apresentaram resultados semelhantes nos grupos avaliados. Um maior número de complicações foi relatado na técnica transportal (p = 0,033). CONCLUSÃO: Resultados clínicos objetivos e subjetivos sem significância estatística na comparação das três técnicas de reconstrução do LCA.

Double-bundle PCL reconstruction using autologous hamstring tendons: outcome with a minimum 2-year follow-up.

OBJECTIVE: To present the outcomes of posterior cruciate ligament (PCL) double-bundle reconstruction using autologous hamstring tendons, with a minimum follow-up of two years. METHODS: Evaluation of 16 cases of PCL injury that underwent double-bundle reconstruction with autogenous hamstring tendons, between 2011 and 2013. The final sample consisted of 16 patients, 15 men and one woman, with a mean age of 31 years (21-49). The predominant mechanism was motorcycle accident in half of the cases. There was a mean interval of 15 months between the time of lesion and the surgery (three to 52 months). Five lesions were isolated and 11, associated. Clinical evaluation, application of validated scores, and measurements with use of the KT-1000 were performed. RESULTS: The analysis showed a mean preoperative Lysholm score of 50 points (28-87), progressing to 94 points (85-100) postoperatively. The IKDC score also demonstrated improvement. In the preoperative evaluation, four and 12 patients were respectively classified as C (abnormal) and D (very unusual), and in the postoperative evaluation six as A (normal) and ten as B (close to normal). In the post-operative evaluation by KT1000 arthrometer, 13 patients showed difference between 0-2 mm and 3 between 3 and 5 mm, when compared with the contralateral side. CONCLUSION: Autologous hamstring tendons are a viable option in double-bundle reconstruction of the PCL, with good clinical results in a minimum follow-up of two years.

OBJETIVO: Apresentar os resultados de uma série de casos de reconstrução do ligamento cruzado posterior (LCP) em dupla banda com o uso dos tendões flexores autólogos, com seguimento mínimo de dois anos. MÉTODOS: Avaliação de 16 casos de lesão do LCP submetidos a reconstrução em dupla banda com tendões flexores autólogos entre 2011 e 2013. A amostra final foi composta por 16 pacientes, 15 homens e uma mulher, com média de 31 anos (21-49). O mecanismo predominante foi acidente motociclístico em metade dos casos. Houve um intervalo médio de 15 meses entre a lesão e a cirurgia (três a 52 meses). Cinco lesões eram isoladas e 11, associadas. Foram feitas avaliação clínica, aplicação de escores validados e mensuração com uso do artrômetro KT-1000. RESULTADOS: A avaliação pela escala de Lysholm pré-operatória teve média de 55 pontos (28-87), evoluiu para uma média pós-operatória de 94 pontos (85-100). O IKDC também demonstrou melhoria. Na avaliação pré-operatória, quatro e 12 pacientes foram respectivamente classificados como C (anormal) e D (muito anormal); na avaliação pós-operatória, seis foram classificados como A (normal) e dez como B (próximo ao normal). Na avaliação pós-operatória pelo artrômetro KT1000, 13 pacientes apresentaram diferença entre 0-2 mm e três, entre 3-5 mm, na comparação com o lado contralateral. CONCLUSÃO: O uso dos tendões flexores autólogos é uma opção viável na reconstrução do LCP em dupla banda, apresenta bons resultados clínicos em seguimento mínimo de dois anos.

RETORNO AO ESPORTE APÓS ARTROPLASTIA TOTAL DO JOELHO: REVISÃO SISTEMÁTICA / RETURN TO SPORTS AFTER TOTAL KNEE ARTHROPLASTY: A SYSTEMATIC REVIEW / RETORNO AL DEPORTE DESPUÉS DE LA ARTROPLASTIA TOTAL DE LA RODILLA: UNA REVISIÓN SISTEMÁTICA

RESUMO Esta revisão sistemática da literatura teve como objetivo analisar as variáveis envolvidas no retorno às atividades esportivas em pacientes submetidos à artroplastia total do joelho (ATJ), verificar o tipo de esporte recomendado, o tempo de retorno ao esporte, a satisfação do paciente e o nível de atividade física após a cirurgia. Os estudos relacionados com a prática de atividade física e desportiva depois da ATJ foram selecionados por dois revisores independentes. Foram incluídos 11 estudos (10 transversais retrospectivos e um caso-controle). A maioria dos pacientes que participou de alguma atividade física regular antes da ATJ retornou à prática esportiva após a cirurgia, sendo mais comuns os esportes de baixo impacto como caminhada, esportes aquáticos, golfe, bicicleta estacionária, entre outros. Foi possível observar que o nível de atividade física não depende da dor e dos sintomas pós-operatórios, mas da satisfação com a cirurgia, motivação e capacidade funcional dos indivíduos. O tempo de retorno ao esporte variou de seis a 18 meses depois da ATJ. Apesar de alguns estudos mostrarem que os cirurgiões não recomendam a prática de esportes de alto impacto após a cirurgia, alguns estudos mostraram bons resultados, desde que o nível de atividade prévio à cirurgia, a população adequada e a expectativa do paciente no pós-operatório sejam considerados. Assim, conclui-se que o retorno ao esporte após ATJ não só é possível, como é recomendado em níveis recreativos, e um paciente colaborativo, instruído e com preparo adequado de condicionamento físico pode melhorar tanto no nível funcional e cardiovascular quanto no psicológico, com aumento da autoestima e da qualidade de vida. Há ainda a necessidade de estudos futuros, de boa qualidade metodológica como os ensaios clínicos randomizados, sobre os efeitos (benefícios e prejuízos) dos esportes de alto impacto para os pacientes submetidos à ATJ.

ABSTRACT This systematic review of the literature aimed to analyze the variables involved in the return to sports activities in patients who underwent total knee arthroplasty (TKA), to verify the recommended type of sport, the time to return to sport, patient satisfaction and the level of physical activity after surgery. Studies related to the practice of physical and sports activity after TKA were selected by two independent reviewers. Eleven studies (10 retrospective cross-sectional and 1 case-control) were included. Most patients who participated in any regular physical activity before TKA returned to sports after surgery with low impact sports such as walking, water sports, golf, and stationary bicycle, among others. It was observed that the level of physical activity does not depend on pain and the postoperative symptoms, but on the satisfaction with the surgery, motivation, and functional capacity of individuals. The time take to return to sports ranged from six to 18 months after TKA. Although some studies show that surgeons do not recommend high-impact sports after surgery, some studies have shown good results, provided that the level of activity prior to surgery, the appropriate population and the patient's expectation in the postoperative period are all considered. Thus, it is concluded that the return to sports after TKA is not only possible, as it is recommended at recreational levels, and a collaborative, knowledgeable and well-trained patient can improve both the functional and cardiovascular level, as well as the psychological, with increased self-esteem and quality of life. There is also a need for further studies of good methodological quality as randomized clinical trials on the effects (benefits and damages) of high impact sports for patients who underwent TKA.

RESUMEN Esta revisión sistemática tuvo como objetivo analizar las variables que intervienen en el retorno a las actividades deportivas en los pacientes sometidos a artroplastia total de rodilla (ATR), comprobar el tipo recomendado de deporte, el tiempo para volver al deporte, la satisfacción del paciente y el nivel la actividad física después de la cirugía. Estudios relacionados con la práctica de la actividad física y deportiva después de la ATR fueron seleccionados por dos revisores independientes. Once estudios (10 transversales retrospectivos y 1 caso control) fueron incluidos. La mayoría de los pacientes que participaron en alguna actividad física regular antes de la ATR regresó al deporte después de la cirugía, siendo más comunes los deportes de bajo impacto, como la caminata, deportes acuáticos, golf, bicicleta estática, entre otros. Fue posible observar que el nivel de actividad física no depende del dolor ni de los síntomas postoperatorios, sino de la satisfacción con la cirugía, motivación y capacidad funcional de los individuos. El tiempo para volver al deporte varió de seis a 18 meses después de la ATR. Aunque algunos estudios muestran que los cirujanos no recomiendan la práctica de deportes de alto impacto después de la cirugía, algunos estudios mostraron buenos resultados, desde que sean considerados el nivel de actividad previo a la cirugía, la población adecuada y la expectativa del paciente en el postoperatorio. Por lo tanto, se concluye que el retorno al deporte después de la ATR no sólo es posible, como se recomienda en los niveles de recreo, y un paciente colaborador, bien informado y adecuadamente entrenado puede mejorar la aptitud tanto a nivel funcional y cardiovascular como psicológico, con aumento de la autoestima y calidad de vida. También existe la necesidad de más estudios de buena calidad metodológica como ensayos clínicos aleatorios sobre los efectos (beneficios y daños) de deportes de alto impacto para los pacientes sometidos a ATR.