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.

Diagnostic Contradictions in Carpal Tunnel Syndrome.

Objective Given the divergence of opinions on the need for complementary tests such as ultrasonography (US) and electroneuromyography (ENMG) for the diagnosis of carpal tunnel syndrome (CTS), we aimed to elucidate which of them presents greater accuracy for the confirmation of the presence or not of this condition. Methods A total of 175 patients from a hand surgery outpatient clinic were clinically evaluated, and the results of clinical trials (Tinel, Phalen and Durkan), US (normal or altered), and ENMG (normal, mild, moderate and severe) were noted, crossed, and submitted to a statistical analysis to verify the agreement between them. Results with the sample had a mean age of 53 years, with a prevalence of female patients (159 cases). Of the patients with positive clinical test, 43.7% had normal US and 41.7% had no alterations on the ENMG. Negative results were found on the Tinel in 46.9%, on the Phalen in 47.4%, and on the Durkan in 39.7%. In the crossing between the results of the ENMG and those of the other diagnostic methods, there was little statistical agreement between them. Conclusion There was no agreement between the results of the clinical examinations, the US and the ENMG in the diagnosis of CTS, and there is no clinical or complementary examination for CTS that accurately determines the therapeutic approach. Level of Evidence IV, Case Series.

Diagnostic Contradictions in Carpal Tunnel Syndrome / Contradições diagnósticas na síndrome do túnel do carpo

Abstract Objective Given the divergence of opinions on the need for complementary tests such as ultrasonography (US) and electroneuromyography (ENMG) for the diagnosis of carpal tunnel syndrome (CTS), we aimed to elucidate which of them presents greater accuracy for the confirmation of the presence or not of this condition. Methods A total of 175 patients from a hand surgery outpatient clinic were clinically evaluated, and the results of clinical trials (Tinel, Phalen and Durkan), US (normal or altered), and ENMG (normal, mild, moderate and severe) were noted, crossed, and submitted to a statistical analysis to verify the agreement between them. Results with the sample had a mean age of 53 years, with a prevalence of female patients (159 cases). Of the patients with positive clinical test, 43.7% had normal US and 41.7% had no alterations on the ENMG. Negative results were found on the Tinel in 46.9%, on the Phalen in 47.4%, and on the Durkan in 39.7%. In the crossing between the results of the ENMG and those of the other diagnostic methods, there was little statistical agreement between them. Conclusion There was no agreement between the results of the clinical examinations, the US and the ENMG in the diagnosis of CTS, and there is no clinical or complementary examination for CTS that accurately determines the therapeutic approach. Level of Evidence IV, Case Series.

Resumo Objetivo Diante da divergência sobre a necessidade de exames complementares, como ultrassonografia (US) e eletroneuromiografia (ENMG) para o diagnóstico da síndrome do túnel do carpo (STC), objetivamos elucidar qual deles apresenta maior precisão na confirmação da presença ou não desta afecção. Métodos Um total de 175 pacientes de um ambulatório de cirurgia da mão foram avaliados clinicamente, e os resultados dos testes clínicos (Tinel, Phalen e Durkan), da US (normal ou alterada) e da ENMG (normal, leve, moderada e grave) foram anotados, cruzados, e submetidos a análise estatística para verificar a concordância entre eles. Resultados A idade média da amostra era de 53 anos, sendo prevalente o sexo feminino (159 casos). Dos pacientes com teste clínico positivo, 43,7% apresentavam US normal, e 41,7%, ENMG sem alterações. Foram encontrados resultados negativos no Tinel em 46,9% no Phalen em 47,4%, e no Durkan em 39,7%. No cruzamento entre a ENMG e os demais métodos diagnósticos, houve pouca concordância estatística. Conclusão Não houve concordância entre os resultados dos exames clínicos, da US e da ENMG no diagnóstico da STC, e não há exame clínico ou complementar para STC que determine a conduta terapêutica com precisão. Nível de Evidência IV, Série de Casos.

Importance of computed tomography in posterior malleolar fractures: Added information to preoperative X-ray studies.

BACKGROUND: Ankle fractures are common lesions of the lower limbs. Approximately 40% of ankle fractures affect the posterior malleolus (PM). Historically, PM osteosynthesis was recommended when PM size in X-ray images was greater than 25% of the joint. Currently, computed tomography (CT) has been gaining traction in the preoperative evaluation of ankle fractures. AIM: To elucidate the similarity in dimensions and to correlate PM size in X-ray images with the articular surface of the affected tibial plafond in the axial view on CT (AXCT) of a PM fracture. METHODS: Eighty-one patients (mean age: 39.4 ± 13.5 years) were evaluated (54.3% were male). Two independent examiners measured PM size in profile X-ray images (PMXR) and sagittal CT (SAGCT) slices. The correlation of the measurements between the examiners and the difference in the PM fragment sizes between the two images were compared. Next, the PM size in PMXR was compared with the surface of the tibial plafond involved in the fracture in AXCT according to the Haraguchi classification. RESULTS: The correlation rates between the examiners were 0.93 and 0.94 for PMXR and SAGCT, respectively (P < 0.001). Fragments were 2.12% larger in SAGCT than in PMXR (P = 0.018). In PMXR, there were 56 cases < 25% and 25 cases ≥ 25%. When PMXR was < 25%, AXCT corresponded to 10.13% of the tibial plafond. When PMXR was ≥ 25%, AXCT was 24.52% (P < 0.001). According to the Haraguchi classification, fracture types I and II had similar PMXR measurements that were greater than those of type III. When analyzing AXCT, a significant difference was found between the three types, with II > I > III (P < 0.001). CONCLUSION: PM fractures show different sizes using X-ray or CT images. CT showed a larger PM in the sagittal plane and allowed the visualization of the real dimensions of the tibial plafond surface.

Causes of knee pain evaluated by arthroscopy after knee arthroplasty: a case series.

BACKGROUND: The origin of persistent pain and joint limitation after knee arthroplasty are controversial and difficult to diagnose. Knee arthroscopy is indicated when the results of routine evaluation tests are not clear. The purpose of this study was to determine through arthroscopy the cause of post-knee-arthroplasty pain symptoms in patients without a prior diagnosis of cause of pain. METHODS: This prospective case series study described the outcomes of 34 patients (35 knees) with pain and limited function in the arthroplastic joint, who underwent diagnostic and therapeutic arthroscopy. Patients were clinically evaluated using range-of-motion tests and the Lysholm, Hospital for Special Surgery (HSS) and Knee Society Score (KSS) scales. RESULTS: The procedure found cyclops in 17 knees, synovitis in 9 knees, arthrofibrosis in 6 knees, polyethylene wear with debris in two knees, and polyethylene bouncing in one knee with unicompartmental arthroplasty with a mobile polyethylene platform. It was effective for the relief of pain symptoms, with excellent or good outcomes in 80% of cases; there was a poor outcome in 11.43%, which maintained the presentation of pain and underwent revision arthroplasty, and, in 8.57%, did not undergo another surgery despite symptom persistence. CONCLUSIONS: Post-arthroplasty knee arthroscopy seems beneficial in patients with pain and without a pre-established diagnosis and who had already undergone conservative treatment unsuccessfully.

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

A novel device for greater precision and safety in open-wedge high tibial osteotomy: cadaveric study.

INTRODUCTION: The complications of the open-wedge osteotomy technique (slope, hypo- and hypercorrection and fractures) are related to difficulties in the control of the open-wedge angle during surgery. MATERIALS AND METHODS: In this cadaveric study, we evaluated the safety and precision of a novel system, the Realignment High Control System (RHC), in the correction of knee mechanical axis and slope. The RHC has a fixation plate coupled to a dynamic device that opens the osteotomy continuously, allowing plate fixation before osteotomy wedge opening. RESULTS: All procedures were easily performed, with no fractures. The openings equaled the indicated by the navigation system for 7.5° and 10°, and for 5°, there was a statistically, although not clinically significant, difference of 0.6°. The slope shown by the RHC setting and in the navigation system was significantly different for the 10° setting only, with a mean difference of 0.563°. CONCLUSIONS: RHC facilitates the surgical technique of high tibial osteotomy, with gradual wedge opening, precise correction of the mechanical axis, and appropriate control of the tibial slope, even with larger openings.

Difference in Articular Degeneration Depending on the Type of Sport.

Objective To determine whether type-II collagen degradation is determined by the type of sport. Carboxy-terminal telepoptide of type-II collagen (CTX-II), a serum biomarker of collagen degradation, was measured in athletes who play different sports, and was compared with matched controls. Methods The sample size consisted of 70 female participants aged between 18 and 25 years, 15 of whom were members of a soccer team, 10 of a futsal (a variant of association football played on a hard court) team, 10 of a handball team, 18 of a volleyball team, and 7 of a swimming team. A total of 9 age- and sex-matched individuals with sedentary lifestyles were included in the control group. 3-mL blood samples were collected from each participant, and they were analyzed using an enzyme-linked immunosorbent assay (ELISA). Results A comparison of the CTX-II concentrations of the players of different sports with those of the control group resulted in the following p -values: volleyball ( p = 0.21); soccer ( p = 0.91); handball ( p = 0.13); futsal ( p = 0.02); and swimming ( p = 0.0015). Therefore, in the investigated population, futsal represented the highest risk for type-II collagen degradation and, consequently, for articular cartilage degradation, whereas swimming was a protective factor for the articular cartilage. No statistically significant difference was found in the body mass index among the groups. Conclusion Futsal players are exposed to greater articular degradation, while swimmers exhibited less cartilage degradation compared with the control group in the study population, suggesting that strengthening the periarticular muscles and aerobic exercise in low-load environments has a positive effect on the articular cartilage.

Difference in Articular Degeneration Depending on the Type of Sport / Diferença na degeneração articular de acordo com o tipo de esporte

Abstract Objective To determine whether type-II collagen degradation is determined by the type of sport. Carboxy-terminal telepoptide of type-II collagen (CTX-II), a serum biomarker of collagen degradation, was measured in athletes who play different sports, and was compared with matched controls. Methods The sample size consisted of 70 female participants aged between 18 and 25 years, 15 of whom were members of a soccer team, 10 of a futsal (a variant of association football played on a hard court) team, 10 of a handball team, 18 of a volleyball team, and 7 of a swimming team. A total of 9 age- and sex-matched individuals with sedentary lifestyles were included in the control group. 3-mL blood samples were collected from each participant, and they were analyzed using an enzyme-linked immunosorbent assay (ELISA). Results A comparison of the CTX-II concentrations of the players of different sports with those of the control group resulted in the following p-values: volleyball (p = 0.21); soccer (p = 0.91); handball (p = 0.13); futsal (p = 0.02); and swimming (p = 0.0015). Therefore, in the investigated population, futsal represented the highest risk for type-II collagen degradation and, consequently, for articular cartilage degradation, whereas swimming was a protective factor for the articular cartilage. No statistically significant difference was found in the body mass index among the groups. Conclusion Futsal players are exposed to greater articular degradation, while swimmers exhibited less cartilage degradation compared with the control group in the study population, suggesting that strengthening the periarticular muscles and aerobic exercise in low-load environments has a positive effect on the articular cartilage.

Resumo Objetivo Determinar se a degradação de colágeno tipo II é determinada pelo tipo de esporte. O telopeptídeo carboxiterminal do colágeno tipo II (CTX-II), biomarcador de soro de degradação de colágeno, foi medido em atletas de esportes diferentes e comparado aos controles correspondentes. Métodos A amostra consistiu em 70 participantes do sexo feminino com idade entre 18 a 25 anos, das quais 15 eram membros de uma equipe de futebol, 10 de uma equipe de futebol de salão, 10 de uma equipe de handebol, 18 de uma equipe de voleibol, e 7 de uma equipe de natação. Foram incluídos no grupo de controle 9 indivíduos sedentários, pareados por idade e sexo. Uma amostra de sangue de 3 ml foi coletada de cada participante e analisada usando um ensaio imunossorvente ligado a enzima (ELISA, do inglês enzyme-linked immunosorbent assay). Resultados Uma comparação das concentrações de CTX-II das praticantes de diferentes esportes em comparação com o grupo de controle apresentou os seguintes valores de p: voleibol (p = 0,21); futebol (p = 0,91); handebol (p = 0,13); futebol de salão (p = 0,02) e natação (p = 0,0015). Portanto, na população investigada, o futebol de salão apresentou o maior risco de degradação do colágeno tipo II, e, consequentemente, de degradação da cartilagem articular, enquanto a prática de natação foi um fator protetor para a cartilagem articular. Não foi observada diferença estatisticamente significativa no índice de massa corporal entre os grupos. Conclusão As jogadoras de futebol de salão estão expostas a uma maior degradação articular, enquanto as nadadoras apresentam menor degradação da cartilagem em comparação com o grupo de controle na população estudada, o que sugere que o fortalecimento dos músculos periarticulares e o exercício aeróbico em ambientes de baixa carga têm um efeito positivo na cartilagem articular.

What is the Prognosis of Triple Arthrodesis in the Treatment of Adult Acquired Flatfoot Deformity (AAFD)?

Objective The present study aims to evaluate the ability of triple arthrodesis in eliminating the main complaints presented by patients with adult acquired flatfoot deformity (AAFD): 1) disabling hindfoot pain; 2) major deformities, such as medial arch collapse, valgus, abduction, and supination. Methods A total of 17 patients (20 feet) with advanced AAFD who underwent surgical correction by triple arthrodesis were evaluated after a mean follow-up period of 43 months (range: 18-84 months). The average age of the patients at surgery was 62 years old (range: 38-79 years old). The visual analogue scale (VAS) for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score were used to assess the final results. Results According to the VAS, the average residual pain was 3 points; the AOFAS hindfoot score points increased 23% after the surgery; and the correction of deformities was considered satisfactory in 10 out of 20 feet; partially satisfactory in 4 out of 20 feet; partially unsatisfactory in 5 out of 20 feet; and unsatisfactory in 1 out of 20 feet. Conclusion Despite the high index of bone fusion after triple arthrodesis, which is the gold standard treatment in advanced AAFD, the incomplete correction of major deformities and the persistence of residual pain contributed to a high disappointment rate of the patients with the surgical results.

What is the Prognosis of Triple Arthrodesis in the Treatment of Adult Acquired Flatfoot Deformity (AAFD)? / Qual o prognóstico da artrodese tríplice quando utilizada no tratamento do pé plano adquirido do adulto (PPAA)?

Abstract Objective The present study aims to evaluate the ability of triple arthrodesis in eliminating the main complaints presented by patients with adult acquired flatfoot deformity (AAFD): 1) disabling hindfoot pain; 2) major deformities, such asmedial arch collapse, valgus, abduction, and supination. Methods A total of 17 patients (20 feet) with advanced AAFD who underwent surgical correction by triple arthrodesis were evaluated after a mean follow-up period of 43 months (range: 18-84 months). The average age of the patients at surgery was 62 years old (range: 38-79 years old). The visual analogue scale (VAS) for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score were used to assess the final results. Results According to the VAS, the average residual pain was 3 points; the AOFAS hindfoot score points increased 23% after the surgery; and the correction of deformities was considered satisfactory in 10 out of 20 feet; partially satisfactory in 4 out of 20 feet; partially unsatisfactory in 5 out of 20 feet; and unsatisfactory in 1 out of 20 feet. Conclusion Despite the high index of bone fusion after triple arthrodesis, which is the gold standard treatment in advanced AAFD, the incomplete correction of major deformities and the persistence of residual pain contributed to a high disappointment rate of the patients with the surgical results.

Resumo Objetivo Avaliar a capacidade da artrodese tríplice de aliviar as principais queixas dos pacientes que apresentam pé plano adquirido do adulto (PPAA): 1) dor incapacitante localizada no médio e retropé; 2) deformidades marcadas pelo colapso do arco medial, valgo, abdução e supinação. Método Avaliamos 17 pacientes (20 pés) portadores de PPAA em estado avançado que foram submetidos à correção cirúrgica pela artrodese tríplice modelante. A média de idade dos pacientes no momento da cirurgia foi de 62 anos (variação de 38 a 79 anos), e o tempo médio de seguimento foi de 43 meses (variação de 18 a 84 meses). Utilizamos critérios clínicos empregando a escala visual analógica da dor (EVAD) e a escala funcional da American Orthopaedic Foot and Ankle Society (AOFAS, na sigla em inglês) do retropé para avaliar a eficácia da cirurgia. Resultados A dor residual mensurada pela EVAD foi de três pontos, em média. Observamos incremento médio de 23% nos valores da escala AOFAS do retropé após o tratamento cirúrgico. A correção das deformidades foi satisfatória em 10 de 20 pés; parcialmente satisfatória em 4 de 20 pés; parcialmente insatisfatória em 5 de 20 pés; e insatisfatória em 1 de 20 pés. Conclusão Apesar da artrodese tríplice modelante indicada no tratamento do PPAA em estágio avançado apresentar alto índice de consolidação óssea, a correção incompleta das deformidades pré-existentes e a persistência de dor residual contribuíram para a elevada taxa de decepção dos pacientes com o resultado da cirurgia.

Positioning of the femoral tunnel in anterior cruciate ligament reconstruction: functional anatomical reconstruction.

The aim of this study was to review and update the literature in regard to the anatomy of the femoral origin of the ACL, the concept of the double band and its respective mechanical functions, and the concept of direct and indirect fibres in the ACL insertion. These topics will be used to help determine which might be the best place to position the femoral tunnel and how this should be achieved, based on the idea of functional positioning, that is, where the most important ACL fibres in terms of knee stability are positioned. Low positioning of the femoral tunnel, reproducing more of the posterolateral band, and positioning the tunnel away from the lateral intercondylar ridge, that is, in the indirect fibres, would theoretically rebuild a ligament that is less effective in relation to knee stability. The techniques described to determine the femoral tunnel's centre point all involve some degree of subjectivity; the point is defined manually and depends on the surgeon's expertise. The centre of the ACL insertion in the femur should be used as a parameter. Once the centre of the ligament in its footprint is marked, the centre of the tunnel must be defined, drawing the marking toward the intercondylar ridge and anteromedial band. This will allow the femoral tunnel to occupy the region containing the most important original ACL fibres in terms of this ligament's function.

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 study of topical vs. intravenous tranexamic acid regarding blood loss in total knee arthroplasty.

OBJECTIVE: To compare topical vs. intravenous tranexamic acid (TA) in total knee arthroplasty regarding blood loss and transfusion. METHODS: Ninety patients were randomized to receive TA intravenously (20 mg/kg in 100 mL of saline; group IV), topically (1.5 g in 50 mL of saline, sprayed over the operated site, before release of the tourniquet; topical group), or intravenous saline (100 mL with anesthesia; control group). The volume of drained blood in 48 h, the amount of transfused blood, and the serum levels of hemoglobin and hematocrit before and after surgery were evaluated. RESULTS: The groups were similar for gender, age, weight, laterality, and preoperative hemoglobin and hematocrit levels (p > 0.2). The hemoglobin level dropped in all groups when comparing the preoperative and the 48-h evaluations: the control group decreased 3.8 mg/dL on average, while the IV group had a decrease of 3.0, and the topical group, of 3.2 (p = 0.019). The difference between the control and IV groups was confirmed by Bonferroni test (p = 0.020). The difference between the control group and the topical group was not significant (p = 0.130), although there was less reduction in hemoglobin in the topical group; the comparison between the IV group and the topical group was also not significant (p = 1.000). CONCLUSION: Using topic and IV tranexamic acid decreased blood loss and the need for transfusion in total knee arthroplasty. Topical application showed results similar to IV use regarding the need for blood transfusion, but without the possible side effects of IV administration.

OBJETIVO: Comparar o uso de ácido tranexâmico (AT) tópico e intravenoso na artroplastia total de joelho com relação à perda de sangue e necessidade de transfusão. MÉTODOS: Foram randomizados 90 pacientes para receber AT por via intravenosa (20 mg/kg em 100 mL de solução salina; grupo IV), tópico (1,5 g em 50 mL de solução salina, antes de soltar o torniquete; grupo tópico) ou solução salina intravenosa (100 mL com anestesia; grupo controle). O volume de sangue drenado em 48 horas, a quantidade de sangue transfundido e as concentrações sérias de hemoglobina e hematócrito foram avaliados antes e depois da cirurgia. RESULTADOS: Os grupos eram semelhantes quanto a sexo, idade, lateralidade e concentrações pré-operatórias de hemoglobina e hematócrito (p > 0,2). A concentração de hemoglobina diminuiu em todos os grupos quando as avaliações pré-operatória e em 48 horas foram comparadas: o grupo controle teve redução média de 3,8 mg/dL, enquanto o grupo IV teve diminuição de 3,0 e o grupo tópico, de 3,2 (p = 0,019). A diferença entre os grupos controle e IV foi confirmada pelo teste de Bonferroni (p = 0,020). A diferença entre os grupos controle e tópico não foi significativa (p = 0,130), apesar de haver uma menor diminuição da hemoglobina no grupo tópico; a comparação entre os grupos IV e tópico também não foi significativa (p = 1,000). CONCLUSÃO: O uso de AT tópico e IV reduziu as perdas sanguíneas e a necessidade de transfusão na artroplastia total do joelho. O uso tópico mostrou resultado semelhante ao uso IV em relação à necessidade de transfusão sanguínea, porém sem os possíveis efeitos colaterais da administração IV.

The influence of femoral tunnel length on graft rupture after anterior cruciate ligament reconstruction.

BACKGROUND: For ACL reconstruction, the minimum length of the femoral tunnel and the flexor tendon graft length needed within the tunnel for proper integration have not been defined. The aim of this study was to assess whether a short tunnel is a risk factor for poor prognosis and re-rupture by comparing the outcomes of patients with short femoral tunnels to those of patients with longer tunnels. MATERIALS AND METHODS: A retrospective observational study of 80 patients who underwent ACL reconstruction using flexor tendons via the medial transportal or transtibial technique was performed. Patients were categorized according to the amount of graft within the tunnel: ≤1.5 versus >1.5 cm; ≤2 versus >2 cm; ≤2.5 versus >2.5 cm; and ≤1.5 versus >2.5 cm. Patients were evaluated 2 years after surgery by performing a physical examination (Lachman, pivot shift and anterior drawer tests), using a KT1000 arthrometer, calculating objective and subjective International Knee Documentation Committee scores, conducting the Lysholm score, and recording re-ruptures. RESULTS: Of the 80 operated patients, nine were lost to follow-up. Comparative assessment of the patients with different amounts of graft within the tunnel indicated no significant differences in the evaluated outcomes, except for positive Lachman test results, which were more frequent in patients with tunnels with ≤2 cm of graft than in those with tunnels with >2 cm of graft. CONCLUSION: The amount of graft within the femoral tunnel does not appear to be a risk factor for clinical instability of the knee or re-rupture of the graft. LEVEL OF EVIDENCE: case series, level IV. LEVEL OF EVIDENCE: Case series, level IV.

Comparative study of topical vs. intravenous tranexamic acid regarding blood loss in total knee arthroplasty / Estudo comparativo com uso do ácido tranexâmico tópico e intravenoso em relação à perda sanguínea na artroplastia total do joelho

ABSTRACT Objective: To compare topical vs. intravenous tranexamic acid (TA) in total knee arthroplasty regarding blood loss and transfusion., Methods: Ninety patients were randomized to receive TA intravenously (20 mg/kg in 100 mL of saline; group IV), topically (1.5 g in 50 mL of saline, sprayed over the operated site, before release of the tourniquet; topical group), or intravenous saline (100 mL with anesthesia; control group). The volume of drained blood in 48, h, the amount of transfused blood, and the serum levels of hemoglobin and hematocrit before and after surgery were evaluated., Results: The groups were similar for gender, age, weight, laterality, and preoperative hemoglobin and hematocrit levels (p> 0.2). The hemoglobin level dropped in all groups when comparing the preoperative and the 48-h evaluations: the control group decreased 3.8 mg/dL on average, while the IV, group had a decrease of 3.0, and the topical group, of 3.2 (p= 0.019). The difference between the control and IV, groups was confirmed by Bonferroni test (p= 0.020). The difference between the control group and the topical group was not significant (p= 0.130), although there was less reduction in hemoglobin in the topical group; the comparison between the IV, group and the topical group was also not significant (p= 1.000). Conclusion: Using topic and IV, tranexamic acid decreased blood loss and the need for transfusion in total knee arthroplasty. Topical application showed results similar to IV use regarding the need for blood transfusion, but without the possible side effects of IV, administration.

RESUMO Objetivo: Comparar o uso de ácido tranexâmico (AT) tópico e intravenoso na artroplastia total de joelho com relação à perda de sangue e necessidade de transfusão. Métodos: Foram randomizados 90 pacientes para receber AT por via intravenosa (20 mg/kg em 100 mL de solução salina; grupo IV, ), tópico (1,5 g em 50 mL de solução salina, antes de soltar o torniquete; grupo tópico) ou solução salina intravenosa (100 mL com anestesia; grupo controle). O volume de sangue drenado em 48 horas, a quantidade de sangue transfundido e as concentrações sérias de hemoglobina e hematócrito foram avaliados antes e depois da cirurgia. Resultados: Os grupos eram semelhantes quanto a sexo, idade, lateralidade e concentrações pré-operatórias de hemoglobina e hematócrito (p > 0,2). A concentração de hemoglobina diminuiu em todos os grupos quando as avaliações pré-operatória e em 48 horas foram comparadas: o grupo controle teve redução média de 3,8 mg/dL, enquanto o grupo IV, teve diminuição de 3,0 e o grupo tópico, de 3,2 (p = 0,019). A diferença entre os grupos controle e IV, foi confirmada pelo teste de Bonferroni (p = 0,020). A diferença entre os grupos controle e tópico não foi significativa (p = 0,130), apesar de haver uma menor diminuição da hemoglobina no grupo tópico; a comparação entre os grupos IV, e tópico também não foi significativa (p = 1,000). Conclusão: O uso de AT tópico e IV, reduziu as perdas sanguíneas e a necessidade de transfusão na artroplastia total do joelho. O uso tópico mostrou resultado semelhante ao uso IV, em relação à necessidade de transfusão sanguínea, porém sem os possíveis efeitos colaterais da administração IV.

TRANSTIBIAL VERSUS ANTEROMEDIAL PORTAL TECHNIQUES IN ACL RECONSTRUCTION / TÉCNICA TRANSTIBIAL VERSUS TRANSPORTAL MEDIAL NA RECONSTRUÇÃO DO LCA / TÉCNICA TRANSTIBIAL VERSUS TRANSPORTAL EN RECONSTRUCCIÓN DEL LCA

Abstract Introduction: Although the results of anterior cruciate ligament (ACL) reconstruction are well documented in many studies, with good to excellent outcomes in most cases, some issues like tunnel positioning are still discussed and studied. Objective: To compare the objective and subjective clinical outcomes of ACL reconstruction using the transtibial and anteromedial portal techniques. Methods: Prospective randomized study of 80 patients undergoing anterior cruciate ligament reconstruction by the same surgeon, with 40 patients operated by the transtibial technique and 40 by anteromedial portal technique. The patients, 34 in the transtibial group and 37 in the anteromedial portal group (nine dropouts), were reassessed during a 2-year follow-up period. The clinical assessment consisted of physical examination, KT-1000TM evaluation, Lysholm score, and objective and subjective International Knee Documentation Committee - IKDC scores. Results: Regarding the Lachman and pivot shift tests, we observed more cases of instability in the transtibial group, but with no statistical significance (p=0.300 and p=0.634, respectively). Regarding the anterior drawer test, the groups presented similar results (p=0.977). Regarding KT-1000TM evaluation, the mean results were 1.44 for the transtibial group and 1.23 for the anteromedial portal group, with no statistical significance (p=0.548). We separated the objective IKDC scores into two groups: Group 1, IKDC A, and Group 2, IKDC B, C, or D, with no statistical significance (p=0.208). Concerning the Lysholm score, the transtibial group had a mean score of 91.32, and the anteromedial portal group had a mean score of 92.81. The mean subjective IKDC scores were 90.65 for the transtibial group and 92.65 for the anteromedial portal group. Three re-ruptures were encountered in the transtibial group and three in the anteromedial portal group. Conclusions: There were no significant differences in the subjective and objective clinical assessments among patients submitted to anterior cruciate ligament reconstruction using the transtibial or anteromedial portal techniques.

RESUMO Introdução: Embora a reconstrução do ligamento cruzado anterior (LCA) proporcione resultados clínicos bons e excelentes na maioria dos estudos, algumas questões ainda são discutidas e estudadas, como o posicionamento dos túneis. Objetivo: Comparar os resultados clínicos objetivos e subjetivos da reconstrução do LCA entre duas técnicas, a transtibial e a transportal medial. Métodos: Estudo prospectivo e randomizado de 80 pacientes submetidos à reconstrução do LCA pelo mesmo cirurgião, com 40 pacientes operados pela técnica transtibial e 40 pela técnica transportal medial. Ocorreram nove desistências, sendo 34 pacientes do grupo transtibial e 37 do grupo transportal medial, reavaliados durante dois anos de seguimento. A avaliação utilizou exame físico, avaliação com KT-1000TM, escores de Lysholm e (International Knee Documentation Committee) - IKDC (objetivo e subjetivo). Resultados: Nos testes de Lachman e pivot shift, foram observados mais casos de instabilidade no grupo transtibial, porém sem significância estatística (p = 0,300 e p = 0,634, respectivamente). Em relação ao teste de "gaveta anterior", os resultados foram semelhantes (p = 0,977). A avaliação com KT-1000TM apresentou resultado médio de 1,44 no grupo transtibial e 1,23 no grupo transportal medial, sem diferença estatística (p = 0,548). Os resultados do IKDC objetivo foram separados em 2 grupos: Grupo 1, pacientes com IKDC A e grupo 2, pacientes com IKDC B, C ou D, sem diferença estatisticamente significante (p = 0,208). Em relação ao escore de Lysholm, o grupo transtibial teve uma pontuação média de 91,32 e o grupo transportal medial teve 92,81. O escore médio do IKDC subjetivo foi de 90,65 no grupo transtibial e de 92,65 no grupo transportal medial. Três rerrupturas foram encontradas no grupo transtibial e três no grupo transportal medial. Conclusões: Não foram encontradas diferenças com significância estatística nas avaliações objetivas e subjetivas, ao comparar pacientes submetidos à reconstrução do LCA pelas técnicas transtibial e transportal medial.

RESUMEN Introducción: Aunque los resultados del ligamento cruzado anterior (LCA) están bien documentados en numerosos estudios, con buenos a excelentes resultados en la mayoría de los casos, algunos temas como el posicionamiento del túnel todavía son discutidos y estudiados. Objetivo: Comparar los resultados clínicos objetivos y subjetivos de la reconstrucción del LCA utilizando la técnica transtibial y la técnica transportal. Métodos: Estudio prospectivo aleatorizado de 80 pacientes sometidos a reconstrucción del ligamento cruzado anterior por el mismo cirujano, con 40 pacientes operados mediante la técnica transtibial y 40 mediante técnica transportal. Hubo nueve pérdidas y 34 pacientes del grupo transtibial y 37 en del grupo transportal fueron re-evaluados durante un período de seguimiento de 2 años. La evaluación clínica consistió en examen físico, evaluación KT-1000TM, puntuaciones de Lysholm e (International Knee Documentation Committee) - IKDC objetiva y subjetiva. Resultados: En cuanto a la prueba de Lachman y la prueba de pivot shift, hemos observado más casos de inestabilidad en el grupo transtibial, pero sin significación estadística (p = 0,300 y p = 0,634, respectivamente). En cuanto a la prueba del cajón anterior, los grupos presentaron resultados similares (p = 0,977). En cuanto a la evaluación con KT-1000TM, los resultados promedio fueron de 1,44 para el grupo transtibial y 1,23 para el grupo transportal, sin significación estadística (p = 0,548). Separamos las puntuaciones IKDC objetivo en dos grupos: Grupo 1, pacientes con IKDC Ay Grupo 2, pacientes con IKDC B, C o D, sin significación estadística (p = 0,208). En lo que respecta a la puntuación de Lysholm, el grupo transtibial tenía puntuación media de 91,32 y el grupo transportal tuvo puntuación media de 92,81. Las puntuaciones medias de IKDC subjetivo fueron 90,65 para el grupo transtibial y 92,65 para el grupo transportal. Tres re-roturas fueron encontradas en el grupo transtibial y tres en el grupo transportal. Conclusiones: No hubo diferencias significativas en las evaluaciones clínicas subjetivas y objetivas entre los pacientes sometidos a la reconstrucción del ligamento cruzado anterior utilizando las técnicas transtibial y transportal.