Ultrasound-guided hyaluronic acid injection for the treatment of insertional Achilles tendinopathy: A prospective case series.

BACKGROUND: Heel pain is a common condition and often involves the Achilles tendon and is classified as insertional or non-insertional. Several operative and non-operative treatments have been described, but there is no consensus on the most effective therapy. The aim of this study is to evaluate a case series of patients with insertional Achilles tendinopathy refractory to conservative treatment submitted to a single-dose ultrasound-guided injection of hyaluronic acid (40 mg/2.0 mL). METHODS: We prospectively included 25 patients (29 feet) who underwent a single ultrasound-guided injection of hyaluronic acid after conservative treatment failure. Clinical outcomes such as pain (using the Visual Analog Scale - VAS), function (using the American Orthopedic Foot & Ankle Society - AOFAS score), personal satisfaction, and complications were evaluated. Statistical analysis was performed using the R software. RESULTS: Most patients were female (80%) and there was a right-side predominance (55%). The median VAS was 8 points [range 4-10] at baseline, decreasing to 3 points [range 0-8] at the six-month follow-up, with statistical significance (p < .001). The median AOFAS score was 71 points [range 38-87] at baseline, increasing to 90 points [range 48-100] at the six-month follow-up (p < .001). The personal satisfaction level was 69%, and 48% of patients considered the result excellent. There were no Achilles tendon ruptures, infections, or allergic reactions post injection. CONCLUSION: Single-dose injection of hyaluronic acid is a safe treatment option, improving function and reducing pain for six months in patients with insertional Achilles tendinopathy after conservative treatment failure. LEVEL OF EVIDENCE: IV, case series.

Relationship between anterior cruciate ligament rupture and the posterior tibial and meniscal slopes in professional soccer athletes.

OBJECTIVE: Several anatomical parameters have been associated with increased risk of anterior cruciate ligament rupture; however, published studies provide conflicting results. The objectives of this study are to assess whether there is a relationship between anterior cruciate ligament rupture and the lateral and medial posterior tibial slopes, as well as the lateral and medial posterior meniscal slopes and posterior tibial and meniscal delta-slopes. MATERIALS AND METHODS: A retrospective case-control study was conducted in professional soccer athletes, using images from knee magnetic resonance imaging scans in athletes with clinical and radiological diagnosis of anterior cruciate ligament rupture, and control group, with no signs of ligament rupture. RESULTS: The lateral and medial posterior tibial slopes, the lateral and medial posterior meniscal slopes, and the posterior tibial and meniscal delta-slopes showed significant differences between the groups (p < 0.05). Multivariate analysis logistic regression revealed that the lateral and medial posterior meniscal slopes proved to be predictors for increased risk of anterior cruciate ligament rupture in professional soccer players. CONCLUSION: Posterior tibial and meniscal slopes and tibial and meniscal delta-slopes are related to a greater risk of rupture of the anterior cruciate ligament in professional male soccer athletes. The lateral and medial posterior meniscal slopes are predictors for ligament rupture.

Hip apophyseal injuries in soccer players: can MRI findings be useful to define when to return to play?

OBJECTIVE: To describe magnetic resonance imaging (MRI) findings in professional soccer players with acute apophyseal injury of the hip and to assess their relationship with return to sports. MATERIAL AND METHODS: Adolescent soccer players with diagnosis of apophyseal injury in the anterosuperior and anteroinferior iliac spine were retrospectively evaluated between 2008 and 2016. All athletes underwent hip MRI examination within 4 days after onset of clinical complaint. Images were independently analyzed by two radiologists. Medical records were reviewed to obtain clinical data. RESULTS: Mean displacement of the apophysis was 4.8 ± 4.6 mm. Bone edema was present in 82% of athletes and muscular edema in 41%. The mean time to return to sports was 37.3 ± 14.7 days. The difference between the measurements of the two radiologists was close to zero with agreement limits below 1.0 mm (p < 0.001). There was a significant correlation between displacement of the apophysis and return to sports, as well as between both and the presence of muscular edema. A displacement of the apophysis of 3.0 mm might serve as a parameter to predict return to sports/activity before 40 days, with a sensitivity of 92% and specificity of 96%, considering conservative physiotherapy treatment. CONCLUSION: Displacement of the apophysis and presence of muscular edema evaluated by MRI showed a significant correlation with return to sports in athletes with acute apophyseal injuries of the anterosuperior and anteroinferior iliac spines.

Professional soccer is associated with radiographic cam and pincer hip morphology.

PURPOSE: Femoroacetabular impingement (FAI) syndrome is characterized by a triad: symptoms, clinical signs and imaging findings. Some individuals, especially athletes, have only imaging alterations. The objective of this study was to evaluate the prevalence of cam and pincer morphology in professional soccer players compared with a control group of non-athletes and to investigate the association between the age at which players start playing competitive soccer more than three times per week and duration of the soccer career with the prevalence of these radiographic findings. METHODS: The prevalence of cam and pincer morphology in sixty professional adult male soccer players and thirty-two male controls was determined using pelvic anteroposterior radiography. Data were recorded for all hips and correlated with the age at which the players started competitive soccer practice and with the duration of their soccer career. RESULTS: The prevalence of morphological FAI in the soccer players was 92.5% versus 28.1% in the controls (p < 0.001). The duration of the soccer career was positively correlated with the alpha angle (p = 0.033) and negatively correlated with the retroversion index (p = 0.009). The age at which competitive play began was inversely correlated with the alpha angle (p < 0.001). CONCLUSION: The study showed a high prevalence of cam and pincer morphology in Brazilian professional soccer players compared with controls. The duration of the soccer career was associated with an increased alpha angle and a decreased retroversion index, and the age at which competitive soccer participation began was negatively associated with alpha angle values. Finally, this manuscript provides data about the association between greater exposure to soccer and cam and pincer morphological changes in the hip; specifically, cam morphology was more common in patients who began participating in sports at earlier ages. This information serves as an alert for coaches of youth teams to manage the training load in youth athletes. LEVEL OF EVIDENCE: III.

The potential European genetic predisposition for non-contact anterior cruciate ligament injury.

PURPOSE: Previous research has provided evidence of a hereditary predisposition for anterior cruciate ligament (ACL) injury. The purpose of this study was to evaluate the association between ancestral population genetics and risk of non-contact ACL injuries. METHODS: Blood samples were collected from 177 individuals with a history of non-contact ACL injury and 556 non-injured control individuals for analysis of the genetic material through the use of a panel of 48 INDELs ancestry genetic markers from three ancestral origins. RESULTS: Among patients with non-contact ACL injury, 82% were male and 18% were female. In the control group, 78% were male, and 22% were female. The mean age of the non-contact ACL injury group was 31.7 years (± 10.2), and the control group was 33.8 years (± 13.2). The individual genetic contribution from INDELs of each ancestral origin varied considerably: ranging between 1.5-94.8% contribution for INDELs of African origin (mean of 21.4% of INDELs); between 2 and 96.1% contribution for INDELs of European origin (mean of 66.7% of INDELs); and between 1.3-96.4% contribution for INDELs of Amerindian origin (mean of 11.7% of INDELs). When comparing paired subjects from the non-contact ACL and control groups, the genetic analysis showed that the European ancestry score was higher in the non-contact ACL group than control group (0.70 ± 0.21 vs 0.63 ± 0.22 respectively, p < 0.001), whereas African ancestry scores (ACL group 0.18 ± 0.18 vs control group 0.24 ± 0.21, p < 0.001) and Amerindian ancestry scores (ACL group 0.11 ± 0.09 vs control group 0.12 ± 0.10, n.s.) were lower among the non-contact ACL group than in controls. CONCLUSION: European INDELs markers were found to represent a potential genetic predisposition for non-contact ACL injuries when compared to African and Amerindian INDELs. This study has the potential to correlate a measurable and distinct genetic marker with risk of a non-contact ACL injury. Thus, it increases knowledge base and volume of molecular and genetical factors associated with this pathology. Furthermore, this study provides guidance and evidence for the development of genetic risk-screening panels for non-contact ACL injury. LEVEL OF EVIDENCE: Level III Diagnostic Study.

No difference between fixed- and mobile-bearing total knee arthroplasty in activities of daily living and pain: a randomized clinical trial.

PURPOSE: Until now, there are no definitive conclusions regarding functional differences related to middle- and long-term everyday activities and patient pain following implantation of mobile- and fixed-platform tibial prostheses. The aim of this study was to determine whether there are middle-term differences in knee function and pain in patients undergoing fixed- and mobile-bearing total knee arthroplasty (TKA). METHODS: Eligible patients were randomized into two groups: the first group received TKA implantation with a fixed tibial platform (group A); the second group received TKA with a mobile tibial platform (group B). Patients were followed up (2 years), and their symptoms and limitations in daily living activities were evaluated using the Knee Outcome Survey-Activities of Daily Living Scale (ADLS), in addition to pain evaluation assessed using the pain visual analogue scale (VAS). RESULTS: There were no significant differences in function and symptoms in the ADLS and VAS between the study groups. CONCLUSION: The type of platform used in TKA (fixed vs. mobile) does not change the symptoms, function or pain of patients 2 years post-surgery. Although mobile TKAs may have better short-term results, at medium- and long-term follow-up they do not present important clinical differences compared with fixed-platform TKAs. This information is important so that surgeons can choose the most suitable implant for each patient. LEVEL OF EVIDENCE: Randomized clinical trial, Level I.

Functional outcomes after patellar autologous osteochondral transplantation.

PURPOSE: The aim of the present study was to assess clinical evaluation of patients who underwent autologous osteochondral transplantation of the patella. METHODS: This prospective study assessed outcomes of 20 patients who underwent patellar autologous osteochondral transplantation at four time-points: preoperatively, 3 days, 6 months, and 2 years after surgery. The following outcomes were assessed at each time-point: pain (VAS), gait, swelling, trophic status, muscle strength, patellar mobility, and range of motion. The Tegner scale was also applied for each time-point. RESULTS: All parameters improved, except for patellar mobility, which did not show any change. Pain score decreased from 7.1 (SD 2.3) to 2.4 (SD 2.6) at the 2-year assessment; limping decreased from 70 % before surgery to 15 % 2 years later; swelling scores decreased from an average of 1.8 (SD 0.8) 3 days after surgery to 0.5 (SD 0.7) at the 2-year assessment; muscle strength increased from 3.9 (SD 0.8) to 4.7 (SD 0.7) points at final follow-up; and the range of motion increased from 84 (SD 16.2) to 132 (SD 10.7) degrees 2 years later. Tegner score before surgery ranged from 0 to 5, and after 2 years, it ranged from 5 to 9. CONCLUSION: Autologous osteochondral transplantation for the treatment of patellar chondral lesion was associated with significant improvement in pain, gait, swelling, and range of motion 2 years after surgery, achieving scores similar to uninjured knees. Most of them were able to return to sports activity after 6 months (recreational level) and 2 years (competitive level). LEVEL OF EVIDENCE: IV.

Intraarticular hamstring graft diameter decreases with continuing knee growth after ACL reconstruction with open physes.

PURPOSE: To evaluate the graft diameter size after one-year follow-up or more of patients Tanner II, III, and IV who were submitted to anterior cruciate ligament reconstruction. METHODS: Ten patients [five males (mean age: 14.4 years) and five females (mean age: 13.6 years)] with open physis and anterior cruciate ligament tear were submitted to transphyseal anterior cruciate ligament reconstruction with quadruple hamstrings graft. During the procedure, graft and tunnel size were recorded. After last clinical follow-up (range 1-11 years), an MRI study was requested and their measurements near the tibial tunnel were compared with the graft diameter measured and used during primary procedure. RESULTS: Four patients had Tanner stage II, four patients Tanner stage III, and two Tanner IV. There were statistically significant decreases in the quadruple hamstrings graft diameter size (average of 25.3%). Mean size at time of surgery was 7.9 mm (±0.87), and mean size measured at different points of follow-up evaluation was 5.9 mm (±0.65). CONCLUSION: Diameter size of hamstring graft in skeletally immature patients is smaller in most cases. If there is a decrease in the diameter of the graft along postoperative time, the risk of a re-rupture is theoretically further increased. Quadruple hamstring graft decreases a mean 25.3% in diameter from time of anterior cruciate ligament reconstruction surgery until reassessment period in skeletally immature patients. LEVEL OF EVIDENCE: IV.

Professional football can be considered a healthy sport?

PURPOSE: This study aimed to compare the results of knee MRIs of former football players with no previous knee surgeries with non-regular practitioners of impact sports, matched by age and sex, and combine these results with other variables such as current quality of life and pain in the knees. METHODS: The study participants were 16 male former professional football players and 21 male volunteers from different non-sports professional areas. All participants underwent bilateral magnetic resonances. Specific knee evaluations with regard to osteoarthritis and quality of life were performed in both groups by applying the Knee Injury and Osteoarthritis Outcome Score (KOOS) subjective questionnaires and SF-36, respectively. RESULTS: The between-group comparison revealed significant differences on: pain, symptoms, and quality of life related to the knee in KOOS subscales; physical aspects and vitality subscale of SF-36; and former soccer players had worst magnetic resonances scores than controls. CONCLUSION: Results of this study indicate probable specific adverse effects associated with participating in professional football. LEVEL OF EVIDENCE: Cross-sectional study, Level III.

ORTHOPEDIC INJURIES IN MEN'S PROFESSIONAL SOCCER DURING THE CORONAVIRUS DISEASE PANDEMIC.

Objective: To assess the incidence and characteristics of injuries that occurred in the 2020 season of the Paulista Football Championship during the novel coronavirus disease pandemic. Methods: We conducted a prospective study using an electronic questionnaire developed by the Medical Committee of the Paulista Football Federation. Results were sent to the team doctors of series A1 and A2 after each round of the Paulista Football Championship. Results: Series A1 and A2 presented 12.17 and 15.6 injuries, respectively, per 1000 gaming hours. The strikers were the most affected, with muscle injuries being the most frequent and the lower limbs being the most affected. Most injuries occurred within 31-45 minutes of playing; only 4.5% of injuries required surgery. Conclusion: There was no statistical difference in the comparison between pre- and post-pandemic conditions. In relation to the variables studied, the most injuries occurred in the lower limbs; the most common type of injury was muscle strain, followed by sprain and contusion. The most requested exam was MRI; most injuries were classified as moderate (8-28 days). There was no difference between pre- and post-pandemic conditions. Level of Evidence IV, Case Series.

Objetivo: Avaliar a incidência e as características das lesões ocorridas na temporada 2020 do Campeonato Paulista de Futebol durante a pandemia de covid-19. Métodos: Foi realizado um estudo prospectivo por meio de questionário eletrônico desenvolvido pela Comissão Médica da Federação Paulista de Futebol. Os resultados foram enviados aos médicos das equipes das séries A1 e A2 após cada rodada do Campeonato Paulista de Futebol. Resultados: As Séries A1 e A2 apresentaram 12,17 e 15,6 lesões, respectivamente, por 1.000 horas de jogo. Os atacantes foram os mais acometidos, sendo as lesões musculares as mais frequentes e os membros inferiores os mais afetados. A maioria das lesões ocorreu dentro de 31 a 45 minutos de jogo; apenas 4,5% das lesões necessitaram de cirurgia. Conclusão: Não houve diferença estatística na comparação entre as condições pré e pós-pandemia. Em relação às variáveis estudadas, a maioria das lesões ocorreu nos membros inferiores; o tipo de lesão mais comum foi distensão muscular, seguida de entorse e contusão. O exame mais solicitado foi a ressonância magnética; a maioria das lesões foi classificada como moderada (8-28 dias). Não houve diferença entre as condições pré e pós-pandemia. Nível de Evidência IV, Série de Casos.

ULTRASOUND-GUIDED GENICULAR NERVE BLOCK FOR KNEE OSTEOARTHRITIS: A CASE SERIES.

Objective: Knee genicular nerve blocks have been a topic of discussion among various types of treatment for knee osteoarthritis. This study aims to evaluate the pain and function of patients diagnosed with knee osteoarthritis after undergoing ultrasound-guided genicular nerve blockade using pharmacological agents. Methods: The study included 36 patients diagnosed with knee osteoarthritis, comprising 17 bilateral cases, totaling 53 knees undergoing UGNB using a mixture of triamcinolone, ropivacaine, and lidocaine under ultrasound guidance. Epidemiological data, pain outcomes measured by the Visual Analog Scale (VAS), and function assessed using the Western Ontario and McMaster Universities (WOMAC) score were evaluated before and after 12 weeks of the procedure. Results: The mean age was 75.5 years (standard deviation of 9.4 years), with a predominance of females and right-sided involvement. There was a mean reduction of 3.0 points in VAS (p < 0.001) and 15.4 points in WOMAC (p < 0.001). Two cases reported only minor and transient complications related to the procedure (skin anesthesia and edema). Conclusion: Ultrasound-guided genicular nerve blockade using pharmacological agents demonstrated pain reduction and improved function with a low complication rate after 12 weeks in patients with knee gonarthrosis. Level of Evidence IV, Case Series.

Objetivo: Os bloqueios geniculares do joelho têm sido tema de discussão entre os diversos tipos de tratamento da gonartrose. Este estudo tem por objetivo avaliar a dor e a função dos pacientes com diagnóstico de osteoartrose do joelho, após realização do procedimento de bloqueio farmacológico dos nervos geniculares (BFNG) guiado por ultrassom. Métodos: O estudo incluiu 36 pacientes com diagnóstico de gonartrose, sendo 17 casos bilaterais, totalizando 53 joelhos submetidos ao BFNG, com a mistura de triancinolona, ropivacaína e lidocaína guiado por ultrassom. Avaliou-se dados epidemiológicos, desfechos de dor pela Escala Visual Analógica (EVA) e função com escore Western Ontario and Mcmaster Universities (WOMAC) antes e após 12 semanas do procedimento. Resultados: A idade média encontrada foi de 75,5 anos (desvio padrão de 9,4 anos), com predominância do sexo feminino e do lado direito. Houve uma redução média na EVA de 3,0 pontos (p < 0,001) e no WOMAC de 15,4 (p < 0,001). Em dois casos, relataram apenas complicações menores e transitórias relacionadas ao procedimento (anestesia da pele e edema). Conclusão: O bloqueio farmacológico dos nervos geniculares guiado por ultrassom demonstrou redução da dor e melhora na função, com baixa taxa de complicação após 12 semanas nos pacientes com gonartrose. Nível de evidência IV, Série de Casos.

DOPING CONTROL IN MALE SOCCER PLAYERS IN BRAZIL: 10 YEARS OF FOLLOW-UP.

Objective: To understand the Adverse Analytical Finding (AAF) that have occurred in Brazilian soccer in a recent 10-year period, comparing them to international data, to know the Brazilian profile. Methods: A review of the AAR in the Doping Control Commission database of the Brazilian Football Association from 2008 to 2017. The AAR in professional male soccer players between 2008 and 2017 were considered. Results: The sample selected in this research was composed of 40,092 doping tests, with 113 AAR, identified in 18 different competitions (0.28%) in the professional category, in Brazilian national and state competitions between 2008 and 2017, flagged in doping control exams through urine samples. Stimulants were detected most frequently (31.0%), followed by glucocorticoids (21.2%), diuretics, and masking agents (19.5%). The Brazilian Championship series did not show a relationship with any of the World Anti-Doping Agency (WADA) groups of substances. Series A showed 0.07% of AAR, Series B 0.21%, Series C 0.75% and Series D 1.49. Conclusion: The rate of AAR in Brazilian soccer was 0.28%, lower than the average for all soccer worldwide, and shows similar percentages among field positions. Stimulants were the most prevalent drugs. The national elite soccer competitions showed significantly fewer cases than the lower divisions. Level of Evidence II; Retrospective Study.

Objetivo: Compreender os Resultados Analíticos Adversos (RAA) ocorridos no futebol brasileiro nos últimos 10 anos, comparando-os aos dados internacionais, para conhecer o perfil do futebol brasileiro. Métodos: Revisão dos RAA no banco de dados da Comissão de Controle de Doping da Confederação Brasileira de Futebol de 2008 a 2017. Foram consideradas os RAA entre 2008 e 2017. Resultados: A amostra selecionada nesta pesquisa foi composta por 40.092 exames antidoping com 113 RAA, os quais foram identificados em 18 competições diferentes (0,28%) em atletas da categoria professional, entre 2008 e 2017, sinalizadas em exames de controle de doping através de amostras de urina. Estimulantes foram detectados com maior frequencia (31%), seguidos de glicocorticoides (21,2%), diuréticos e agentes mascarantes (19,5%). A série do Campeonato Brasileiro não apresentou relação com nenhum dos grupos de substâncias da World Anti-Doping Agency (WADA). A série A apresentou 0,07% da AAR, Série B 0,21%, Série C 0,75% e Série D 1,49%. Conclusão: A taxa de RAA no futebol brasileiro foi de 0,28%, inferior à media do futebol mundial e apresenta percentuais semelhantes entre as posições do campo. Os estimulantes foram as drogas mais prevalentes. As competições nacionais de futebol das Séries superiores apresentaram significativamente menos casos do que as inferiores. Nível de Evidência II; Estudo Retrospectivo.

Shoulder injuries in Brazilian professional football players: epidemiological analysis of 3828 games.

OBJECTIVES: Football is a globally played sport that poses potential risks for musculoskeletal injuries. Upper-limb injuries have a lower incidence rate than lower-limb injuries but can still cause absenteeism and performance impairment in football players. This descriptive epidemiological study aimed to evaluate and compare the epidemiological data on shoulder injuries among professional football players in two major Brazilian football championships. METHODS: Data were collected throughout the championships, and club physicians medically evaluated each player during official games using two online forms. The collected information included the player's age and position, injury diagnosis, laterality, location on the field where the injury occurred, playing time, imaging examinations performed, need for surgical treatment, time to return to play (TRP), and recurrence of the injury. The incidence of injuries was evaluated using the Federation Internationale de Football Association (FIFA) incidence formula. RESULTS: A total of 107 shoulder injuries were recorded (4.3% of all injuries), with a FIFA incidence of 0.847. Glenohumeral dislocations (GHDs) and acromioclavicular dislocations (ACDs) accounted for 37.38% and 35.51% of all shoulder injuries, respectively. Goalkeepers and defenders presented, respectively, a 2.15 and 1.57 times increased risk of suffering shoulder injuries, while attackers presented a 0.63 times decreased risk. Injury recurrence was observed in 14.95% of cases, with GHDs and ACDs showing recurrence rates of 35.00% and 5.26%, respectively. Surgery was performed in 9.35% of cases, with GHDs representing 50% of all surgeries. The average TRP was 22.37 days, with severe and major injuries accounting for 11.21% and 10.28% of all injuries, respectively. Goalkeepers had the highest average TRP of 36.15 days. Recurring injuries had a higher average TRP of 33.44 days compared to nonrecurring injuries, which had an average TRP of 20.43 days. Surgically treated injuries had the highest average TRP of 112.5 days. CONCLUSION: Shoulder injuries in the professional football scenario are of great concern due to the high recurrence rate and need for surgical treatment, which will lead to a long TRP. These findings emphasize the need to implement prevention protocols and effective treatments to reduce the consequences of such injuries, which are usually underestimated in this sport. LEVEL OF EVIDENCE: III.

Characterization of cruciate ligament impingement: the influence of femoral or tibial tunnel positioning at different degrees of knee flexion.

PURPOSE: We aimed to analyze how different positions of the tibial and femoral tunnels when used for anterior cruciate ligament (ACL) reconstruction affect relations with the posterior cruciate ligament (PCL) at different degrees of knee flexion. Information gained from this study may be helpful in determining optimal placement of the graft in ACL reconstructive surgery. METHODS: We divided 10 cadaveric knees into 2 groups of 5 and had either their femoral or tibial ACL insertion detached. For each specimen, 16 different positions were reproduced during ACL reconstruction based on a combination of 4 different tunnels in the tibia for group A (anterior-medial, anterior-lateral, posterior-medial, and posterior-lateral) and 4 in the femur for group B (anterior-proximal, anterior-distal, posterior-proximal, and posterior-distal) with 4° of knee flexion for each (0°, 45°, 90°, and 135°). We performed a magnetic resonance imaging (MRI) study for each configuration and analyzed the cruciate ligament positioning. RESULTS: We identified 3 different situations: no contact between cruciate ligaments, contact without deformity, and contact with deformity. In group A, the degree of flexion (P = .003) and ligament insertion positioned in the posterior quadrants (P < .05) were statistically significant for the presence of ACL impingement. Ligament contact with deformity was identified in 18 (22.5%) configurations, mostly when the knee was flexed 45° and 90° and the ACL was in the posterior quadrants. For group B, "contact with deformity" was identified in 23 MR images, mostly (12 cases) with the graft position being in the anterior-distal configuration, but it was not significant for the occurrence of cruciate impingement. CONCLUSIONS: Impingement with ligament deformity is greater when the graft is fixed at the posterior quadrants of the tibial footprint, regardless of the degree of knee flexion. Although quite common, the ligament position in the femoral footprint was not a primary cause of ACL impingement with deformity. CLINICAL RELEVANCE: This study helps identify positions of the tibial or femoral tunnels during ACL reconstruction to avoid impingement between cruciate ligaments.

Assessment of Predictors of Infection in Primary Knee and Hip Arthroplasty: A Case-control Study.

Objective This study assesses risk factors for periprosthetic joint infection after elective primary total knee or hip arthroplasty. Methods The study included 706 medical records of patients undergoing elective primary total hip or knee arthroplasty from January to December 2018. We used a multivariate analysis of infection predictors through a logistic regression model. The R software performed all statistical analysis. Results The prevalence of infection in the sample was 2.0% (14 cases). Most patients were women (79.6%), with an afflicted right side (50.6%), and underwent a total knee arthroplasty (61.3%). Significant risk factors ( p < 0.05) for infection included surgical time greater than 120 minutes ( p = 0.009) and a history of diabetes ( p = 0.025). Conclusion The risk of infection after elective primary total knee or hip arthroplasty is higher when the surgical procedure is lengthy (over 120 minutes), or the patient has a history of diabetes mellitus. Level of Evidence IIIB, retrospective, case-control study.

Intra-articular Infiltration of Platelet-Rich Plasma versus Hyaluronic Acid in Patients with Primary Knee Osteoarthritis: Preliminary Results from a Randomized Clinical Trial.

Objective The present study aimed to compare the effects of intraarticular infiltration of platelet-rich plasma with those of hyaluronic acid infiltration in the treatment of patients with primary knee osteoarthritis. Methods A randomized clinical trial was conducted with 29 patients who received an intraarticular infiltration with hyaluronic acid (control group) or platelet-rich plasma. Clinical outcomes were assessed using the visual analog scale for pain and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire before and after the intervention. In addition, the posttreatment adverse effects were recorded. Categorical variables were analyzed using the chi-square and Fisher exact tests, whereas continuous variables were analyzed using the Student t test, analysis of variance, and the Wilcoxon test; all calculations were performed with the Stats package of the R software. Results An independent analysis of each group revealed a statistical difference within the first months, with improvement in the pain and function scores, but worsening on the 6 th month after the procedure. There was no difference in the outcomes between the groups receiving hyaluronic acid or platelet-rich plasma. There was no serious adverse effect or allergic reaction during the entire follow-up period. Conclusion Intraarticular infiltration with hyaluronic acid or platelet-rich plasma in patients with primary knee gonarthrosis resulted in temporary improvement of functional symptoms and pain. There was no difference between interventions.

Protocol for the Request of Knee Magnetic Resonance Imaging in Elderly Patients with Suspected Osteoarthritis: Reduction in Test Requests and Impact on Management and Diagnosis.

Objective To develop an evidence-based protocol to guide magnetic resonance imaging (MRI) requests in elderly patients with suspected knee osteoarthrosis and to evaluate its effectiveness after implementation. Methods The institutional protocol was developed after reviewing the literature during the first semester of 2018. The control group was defined as patients cared for in the first semester of 2018, before the implementation/dissemination of the institutional protocol, and the study group was composed by patients cared for during the second semester of 2018 after the standardization of MRI requests for suspected knee osteoarthrosis. Results Our sample included 826 patients undergoing knee MRI, with a mean age of 69.3 years. Protocol implementation decreased MRI requests and increased radiograph requests ( p < 0.001). After the implementation of the protocol, the MRI changed the diagnosis or treatment in only 11.2% of the cases. Conclusion Protocol implementation resulted in a 47.5% reduction in the number of requests for knee MRI, with most (89%) patients with alteration in diagnosis or treatment. Level of evidence: case-control study (IIIB).

ORTHOPAEDIC TELEMEDICINE SERVICES DURING THE CURRENT NOVEL CORONAVIRUS PANDEMIC.

Introduction: To evaluate the use of telemedicine by physicians specializing in orthopaedics and traumatology at the authors' institution, and to assess the rates of satisfaction and resolution for this type of care. The current global coronavirus disease 2019 (COVID-19) pandemic has resulted in the expansion of telemedicine services. However, quality measures and barriers for physicians dealing with the rapid increase in patients have not been well described. Materials and Methods: This study included 255 patients with orthopaedic complaints. Between 24 and 48 hours after the appointment, independent physicians, who did not participate in the initial appointment, contacted one another to assess the degree of satisfaction with the appointment, and whether there was a solution to the orthopaedic complaint. Results: There was a need for referral for face-to-face consultation in only 13.8% of cases. When asked about the probability of recommending telemedicine to a friend/family member, the answer was 90.3%. The satisfaction rate with the service was 91.1% and 93.69% of patients would return for a telemedicine consultation. Telemedicine consultations solved the problem in 82.74% of cases. Conclusions: Telemedicine care in orthopaedics proved to be a service modality with a high rate of satisfaction among the patients evaluated. Level of evidence III, Retrospective cohort study.

Introdução: O estudo avaliou o uso da telemedicina por especialistas em ortopedia e traumatologia da instituição dos autores e avaliou os índices de satisfação e resolução desse tipo de atendimento. A atual pandemia causada pelo coronavírus 2019 (COVID-19) resultou na expansão dos serviços de telemedicina. Contudo, as medidas de qualidade e barreiras para médicos que lidam com o rápido aumento não foram bem descritas. Material e Método: Este estudo incluiu 255 pacientes com queixas ortopédicas. Entre 24 e 48 horas depois da consulta, médicos independentes, que não participaram da primeira consulta, entraram em contato para avaliar o grau de satisfação com o atendimento e se houve solução da queixa ortopédica. Resultados: Houve necessidade de encaminhamento para consultas presenciais em apenas 13,8% dos casos. Quando questionados sobre a probabilidade de recomendar a telemedicina para um amigo/familiar, a resposta dos participantes foi 90,3%. A taxa de satisfação com o serviço foi de 91,1% e 93,6% de pacientes que retornariam para consulta por telemedicina. As consultas de telemedicina resolveram o problema em 82,74% dos casos. Conclusões: O atendimento por telemedicina em ortopedia mostrou ser uma modalidade de serviço com alto índice de satisfação entre os pacientes avaliados. Nível de evidência III, Estudo de coorte retrospectivo.

MORTALITY IN PATIENTS > 90 YEARS OLD WITH PROXIMAL FEMORAL FRACTURES SUBJECTED TO SURGERY.

Introduction: Proximal femoral fractures have a high mortality rate among older adults, especially those aged > 80 years. Objective: To analyze predictive factors for hospital or late mortality of patients > 90 years old who showed proximal femoral fracture and subjected to surgery. Methods: The study included data from 230 patients aged > 90 years diagnosed with proximal femoral fracture and who underwent surgery between January and December 2017. The statistical evaluation was performed by multivariate analysis by a logistic regression. The associations were estimated by the odds ratio (OD) and confidence interval (95%). Statistical significance was determined with p < 0.05. Results: Late death occurred in 51.3% (118 patients) of the sample and hospital death in 3.5% (8 patients). Most patients were women (83.5%) and the most common fracture was transtrochanteric (57.0%). There was association between late death and the surgery duration (p < 0.05), and between hospital death and the presence of heart diseases (p < 0.05) or endocrinopathies (p < 0.05). Conclusion: Most patients aged > 90 years with proximal femoral fracture subjected to surgery died in less than one year. Late death was associated with the surgery duration and hospital death was associated with the presence of previous endocrinopathies or heart diseases, and the female gender was a protective factor from this outcome. Level of Evidence III, Retrospective Case-Control Study.

Introdução: As fraturas do fêmur proximal têm alta taxa de mortalidade entre os idosos, especialmente entre os considerados superidosos (> 80 anos). Objetivo: Analisar fatores preditivos para mortalidade hospitalar ou tardia de pacientes com idade superior a 90 anos que apresentaram fratura do fêmur proximal e foram submetidos ao tratamento cirúrgico. Métodos: O estudo incluiu dados de 230 pacientes com idade superior a 90 anos que apresentaram diagnóstico de fratura do fêmur proximal e foram submetidos ao tratamento cirúrgico entre janeiro e dezembro de 2017. A avaliação estatística foi realizada pela análise multivariada por meio da regressão logística. As associações foram estimadas pelo valor de odds ratio (OD) e intervalo de confiança (95%). A significância estatística foi determinada com p < 0,05. Resultados: O óbito tardio ocorreu em 51,3% (118 pacientes) da amostra e o hospitalar em 3,5% (8 pacientes). A maioria dos pacientes foram do sexo feminino (83,5%) e a fratura mais comum foi a transtrocanteriana (57,0%). Houve associação do óbito tardio com a duração do procedimento cirúrgico (p < 0,05), e do óbito hospitalar com a presença de cardiopatias (p < 0,05) ou endocrinopatias (p < 0,05). Conclusão: A maioria dos pacientes com idade superior a 90 anos com fratura do fêmur proximal submetida ao tratamento cirúrgico evoluiu para óbito em menos de um ano. O óbito tardio foi associado à duração do procedimento cirúrgico e o óbito hospitalar à presença de endocrinopatias ou cardiopatias prévias, sendo o sexo feminino fator de proteção para tal desfecho. Nível de Evidência III, Estudo Caso-Controle Retrospectivo.

Atypical femur fractures associated with chronic bisphosphonates use: A case series with 66 patients.

Objective The present study aims to describe outcomes from a series of surgically treated patients with atypical femoral fracture due to bisphosphonates use, in addition to correlate the time of previous medication use with fracture consolidation time, and to compare the consolidation time of complete and incomplete fractures. Methods This is an observational, retrospective study with 66 patients diagnosed with atypical femur fractures associated with chronic bisphosphonates use. The patients underwent orthopedic surgical treatment at a referral hospital from January 2018 to March 2020. Results All patients were females, with two bilateral cases. Fracture consolidation occurred in all cases, with an average time of 2.3 months and a follow-up time of 5.8 months. The average time of bisphosphonates use was 7.8 years. There was no correlation between the time of previous bisphosphonates use and the time for fracture consolidation. Consolidation time differed in complete and incomplete fractures. Conclusion Surgical treatment with a long cephalomedullary nail resulted in consolidation in all patients. The consolidation time was longer in complete fractures when compared with incomplete lesions, and there was no correlation between the time of previous bisphosphonates use and the consolidation time . Level of evidence Level IV, case series.