The posteromedial corner of the knee: an international expert consensus statement on diagnosis, classification, treatment, and rehabilitation.

PURPOSE: To establish recommendations for diagnosis, classification, treatment, and rehabilitation of posteromedial corner (PMC) knee injuries using a modified Delphi technique. METHODS: A list of statements concerning the diagnosis, classification, treatment and rehabilitation of PMC injuries was created by a working group of four individuals. Using a modified Delphi technique, a group of 35 surgeons with expertise in PMC injuries was surveyed, on three occasions, to establish consensus on the inclusion or exclusion of each statement. Experts were encouraged to propose further suggestions or modifications following each round. Pre-defined criteria were used to refine item lists after each survey. The final document included statements reaching consensus in round three. RESULTS: Thirty-five experts had a 100% response rate for all three rounds. A total of 53 items achieved over 75% consensus. The overall rate of consensus was 82.8%. Statements pertaining to PMC reconstruction and those regarding the treatment of combined cruciate and PMC injuries reached 100% consensus. Consensus was reached for 85.7% of the statements on anatomy of the PMC, 90% for those relating to diagnosis, 70% relating to classification, 64.3% relating to the treatment of isolated PMC injuries, and 83.3% relating to rehabilitation after PMC reconstruction. CONCLUSION: A modified Delphi technique was applied to generate an expert consensus statement concerning the diagnosis, classification, treatment, and rehabilitation practices for PMC injuries of the knee with high levels of expert agreement. Though the majority of statements pertaining to anatomy, diagnosis, and rehabilitation reached consensus, there remains inconsistency as to the optimal approach to treating isolated PMC injuries. Additionally, there is a need for improved PMC injury classification. LEVEL OF EVIDENCE: Level V.

Posterolateral corner of the knee: an expert consensus statement on diagnosis, classification, treatment, and rehabilitation.

PURPOSE: To develop a statement on the diagnosis, classification, treatment, and rehabilitation concepts of posterolateral corner (PLC) injuries of the knee using a modified Delphi technique. METHODS: A working group of three individuals generated a list of statements relating to the diagnosis, classification, treatment, and rehabilitation of PLC injuries to form the basis of an initial survey for rating by an international group of experts. The PLC expert group (composed of 27 experts throughout the world) was surveyed on three occasions to establish consensus on the inclusion/exclusion of each item. In addition to rating agreement, experts were invited to propose further items for inclusion or to suggest modifications of existing items at each round. Pre-defined criteria were used to refine item lists after each survey. Statements reaching consensus in round three were included within the final consensus document. RESULTS: Twenty-seven experts (100% response rate) completed three rounds of surveys. After three rounds, 29 items achieved consensus with over 75% agreement and less than 5% disagreement. Consensus was reached in 92% of the statements relating to diagnosis of PLC injuries, 100% relating to classification, 70% relating to treatment and in 88% of items relating to rehabilitation statements, with an overall consensus of 81%. CONCLUSIONS: This study has established a consensus statement relating to the diagnosis, classification, treatment, and rehabilitation of PLC injuries. Further research is needed to develop updated classification systems, and better understand the role of non-invasive and minimally invasive approaches along with standardized rehabilitation protocols. LEVEL OF EVIDENCE: Consensus of expert opinion, Level V.

Posterior Tibial Labrum Injury in a Professional Soccer Player: A Case Report.

Ankle ligament injuries are one of the most frequent lesions identified in professional soccer players. In most cases, the ligaments involved are the anterior talofibular ligament and the calcaneal fibular ligament. In the present report, we describe a professional soccer player who sustained an ankle sprain that did not respond to initial therapy. The findings from radiographic and magnetic resonance images were inconclusive. Ultimately, rupture of the posterior, transverse ligament with avulsion of the tibial labrum was identified as the cause of his ongoing ankle pain. Confirmation of the pathologic findings and successful treatment were performed arthroscopically.

Propensity for Clinically Meaningful Improvement and Surgical Failure After Anterior Cruciate Ligament Repair.

Background: Primary repair of the anterior cruciate ligament (ACL) confers an alternative to ACL reconstruction in appropriately selected patients. Purpose: To prospectively assess survivorship and to define the clinically meaningful outcomes after ACL repair. Study Design: Case series; Level of evidence, 4. Methods: Included were consecutive patients with Sherman grade 1-2 tears who underwent primary ACL repair with or without suture augmentation between 2017 and 2019. Patient-reported outcomes (Lysholm, Tegner, International Knee Documentation Committee, Western Ontario and McMaster Universities Osteoarthritis Index, and Knee injury and Osteoarthritis Outcome Score [KOOS] subscales) were collected preoperatively and at 6 months, 1 year, and 2 years postoperatively. The minimal clinically important difference (MCID) was calculated using a distribution-based method, whereas the Patient Acceptable Symptom State (PASS) and substantial clinical benefit (SCB) were calculated using an anchor-based method. Plain radiographs and magnetic resonance imaging (MRI) were obtained at 6 months, 1 year, and 2 years postoperatively. Results: A total of 120 patients were included. The overall failure rate was 11.3% at 2 years postoperatively. Changes in outcome scores required to achieve the MCID ranged between 5.1 and 14.3 at 6 months, 4.6 and 8.4 at 1 year, and 4.7 and 11.9 at 2 years postoperatively. Thresholds for PASS achievement ranged between 62.5 and 89 at 6 months, 75 and 89 at 1 year, and 78.6 and 93.2 at 2 years postoperatively. Threshold scores (absolute/change based) for achieving the SCB ranged between 82.8 and 96.4/17.7 and 40.1 at 6 months, between 94.7 and 100/23 and 45 at 1 year, and between 95.3 and 100/29.4 and 45 at 2 years. More patients achieved the MCID and PASS at 1 year compared with 6 months and 2 years. For SCB, this trend was also observed for non-KOOS outcomes, while for KOOS subdomains, more patients achieved the SCB at 2 years. High-intensity signal of the ACL repair (odds ratio [OR], 31.7 [95% CI, 1.5-73.4]; P = .030) and bone contusions on MRI (OR, 4.2 [95% CI, 1.7-25.2]; P = .041) at 1 year postoperatively were independently associated with increased risk of ACL repair failure. Conclusion: The rate of clinically meaningful outcome improvement was high early after ACL repair, with the greatest proportion of patients achieving the MCID, PASS, and SCB at 1 year postoperatively. Bone contusions involving the posterolateral tibia and lateral femoral condyle as well as high repair signal intensity at 1 year postoperatively were independent predictors of failure at 2 years postoperatively.

Return to sport soccer after anterior cruciate ligament reconstruction: ISAKOS consensus.

INTRODUCTION: Many factors can affect the return to pivoting sports, after an Anterior Cruciate Ligament Reconstruction. Prehabilitation, rehabilitation, surgical and psychological aspects play an essential role in the decision to return to sports. The purpose of this study is to reach an international consensus about the best conditions for returning to sports in soccer-one of the most demanding level I pivoting sports after anterior cruciate ligament (ACL) reconstruction. METHODS: 34 International experts in the management of ACL injuries, representing all the Continents were convened and participated in a process based on the Delphi method to achieve a consensus. 37 statements related to ACL reconstruction were reviewed by the experts in three rounds of surveys in complete anonymity. The statements were prepared by the working group based on previous literature or systematic reviews. Rating agreement through a Likert Scale: strongly agree, agree, neither agree or disagree, disagree and strongly disagree was used. To define consensus, it was established that the assertions should achieve a 75% of agreement or disagreement. RESULTS: Of the 37 statements, 10 achieved unanimous consensus, 18 non-unanimous consensus and 9 did not achieve consensus. In the preoperative, the correction of the range of motion deficit, the previous high level of participation in sports and a better knowledge of the injury by the patient and compliance to participate in Rehabilitation were the statements that reached unanimous consensus. During the surgery, the treatment of associated injuries, as well as the use of autografts, and the addition of a lateral extra-articular tenodesis in some particular cases (active young athletes, <25 years old, hyperlaxity, high rotatory laxity and revision cases) obtained also 100% consensus. In the postoperative period, psychological readiness and its validation with scales, adequate physical preparation, as well as not basing the RTSS purely on the time of evolution after surgery, were the factors that reached unanimous Consensus. CONCLUSIONS: The consensus statements derived from this international ISAKOS leaders, may assist clinicians in deciding when to return to sports soccer in patients after an ACL reconstruction. Those statements that reached 100% consensus have to be strongly considered in the final decision to RTS soccer.

Arthroscopic anterior cruciate ligament repair with and without suture augmentation: technical note.

Anterior cruciate ligament (ACL) tears are routinely treated with an ACL reconstruction. This is based on historical literature reporting high failure rates after ACL repairs in addition to the limited healing potential of the ACL. Recently, improved understanding of pathophysiology of ligamentous healing has led to increasing interest in treating proximal avulsions with excellent tissue quality in the acute setting, as this technique allows for ACL healing. Potential advantages of ACL repair include preservation of native proprioceptive and kinematics of the knee, avoidance of graft harvesting morbidity and the possibility to perform a primary ACL reconstruction in case of failure. As a consequence, several techniques for ACL repair have been proposed that can be performed in isolation or with suture augmentation. The primary aim of this technical note is to describe step-by-step the ACL repair technique with and without suture augmentation. The secondary aim of the current study is to review the indications, patient selection and advantages of the technique.

Osteotomía selectiva como tratamiento de la inestabilidad medial de rodilla / Selective osteotomy as a treatment for medial knee instability

Las fracturas de platillos tibiales son lesiones frecuentes. Una de sus complicaciones postoperatorias es la pérdida de reducción con desviación de los ejes en los planos coronal, sagital y axial. La depresión ósea genera incongruencia articular con pérdida de tensión de estructuras ligamentarias indemnes, causando una pseudo-laxitud con inestabilidad. Esto requiere de una corrección ósea para aumentar la tensión de dichas estructuras ligamentarias y lograr así recuperar la congruencia y estabilidad articular en todo el rango de movilidad. El objetivo del presente trabajo es reportar un caso de inestabilidad medial en un paciente joven, quien, tras una fractura de platillo tibial medial mal consolidada, requirió una osteotomía selectiva biplanar e intraarticular para corregir dicha deformidad

Tibial plateau fractures are frequent. Loss of reduction with axis deviation in the coronal, sagittal and axial planes is one of the postoperative complications.Bone depression generates joint incongruity with loss of tension in undamaged ligament structures resulting in pseudo-laxity with instability. This requires a bone correction to increase the tension of ligament structures, hence achieving the recovery of joint congruence and stability throughout the range of mobility.The objective of the current paper is to report a case of medial instability in a young patient, who suffered a medial tibial plateau fracture with poor bone consolidation, with consequent laxity and pain in the medial compartment, which required a selective biplanar and intra-articular osteotomy to correct such deformity.

Avulsión de espina tibial posterior en el adulto. Resolución quirúrgica con técnica de "pull-out". Reporte de un caso / Adult poterior tibial spine avulsion. Pull-out surgical technique. Case report

Introducción: La avulsión de la espina tibial posterior en el adulto representa una forma infrecuente de compromiso del ligamento cruzado posterior (LCP), más común de ver en la población pediátrica. La posibilidad de consolidación de esta lesión, con el tratamiento adecuado en forma temprana, depende de un diagnóstico precoz. Caso: reportamos el caso de una paciente de veintisiete años con una lesión multiligamentaria de rodilla con inestabilidad medial y posterior, por trauma de alta energía tras sufrir un accidente de tránsito en moto. Fue tratada mediante una fijación abierta con técnica de "pull-out". Discusión: en países asiáticos es una lesión frecuente por la alta prevalencia de accidentes en moto, pero menos común en nuestro medio. Si bien el manejo quirúrgico temprano muestra mejores resultados, no existe consenso actual en cuanto a la técnica. Dos tipos de resolución (abierta y artroscópica) muestran resultados similares a largo plazo, con un mayor porcentaje de artrofibrosis en el último grupo. Conclusión: al existir controversia sobre su manejo quirúrgico, creemos que la combinación de las ventajas de ambas técnicas (abierta y artroscópica) constituye una opción reproducible, de bajo costo y con bajo índice de complicaciones.

Introduction: Avulsion of the posterior tibial spine in adults represents an infrequent form of compromise of the posterior cruciate ligament (PCL), more common to see in the pediatric population. The possibility of consolidation of this lesion, with adequate treatment early, depends on an early diagnosis.Case: we report the case of a 27-year-old patient with a multiligamentary knee injury with medial and posterior instability, due to high-energy trauma after suffering a motorcycle traffic accident. Which was treated with an open fixation with a "pull-out" technique. Discussion: in Asian countries it is a frequent injury due to the high prevalence of motorcycle accidents, being less common in our continent. Although early surgical management shows better results, there is no current consensus regarding the optimal technique. Both types of resolution (open and arthroscopic) show similar long-term results, with a higher risk of arthrofibrosis in the last group. Conclusion: as there is controversy over its surgical management, we believe that the combination of the advantages of both techniques (open and arthroscopic) constitutes a reproducible, low-cost option with a low rate of complications.

Avulsión de la tuberosidad tibial anterior combinada con desinserción del tendón rotuliano en paciente con fisis abierta. Resolución quirúrgica. Reporte de un caso / Anterior tibial tuberosity avulsion combined extensor mechanism injuries in open physis patient. Surgical resolution. Case report

Introducción: La avulsión de la tuberosidad anterior de la tibia representa <1% de las lesiones fisarias en la población pediátrica, mientras que las rupturas del tendón patelar son aun más infrecuentes. A su vez, la combinación de ambas es una lesión rara con escasos reportes en la bibliografía. Caso: se reporta el caso de un paciente de quince años con fisis abiertas, con una lesión combinada del aparato extensor. Se detalla su resolución quirúrgica y manejo postoperatorio sobre la base de la bibliografía actual. Discusión: existe escasa información precisa sobre la incidencia, diagnóstico y pronóstico de esta lesión. En trabajos recientes se describe un aumento en su incidencia y se propone una nueva clasificación que permita un mejor manejo de esta grave lesión en forma temprana. Conclusión: Las lesiones combinadas del aparato extensor están en aumento en la población esqueléticamente inmadura por la mayor participación en deportes competitivos a edades cada vez más tempranas. Actualmente no existe consenso en su diagnóstico. Se propone la resonancia nuclear magnética como método de elección por detectar lesiones asociadas y permitir planificar la estrategia quirúrgica.

Introduction: Avulsion of the anterior tuberosity of the tibia represents <1% of physeal injuries in the pediatric population, while patellar tendon ruptures are even more infrequent. In turn, the combination of both is a rare lesion with few reports in the bibliography. Case: the case of a 15-year-old patient with open physis, with a combined lesion of the extensor mechanism is reported. Its surgical resolution and postoperative management are detailed based on the current bibliography. Discussion: there is little precise information on the incidence, diagnosis and prognosis of this lesion. Recent works describe an increase in its incidence and propose a new classification that allows better management of this serious injury early. Conclusion: combined extensor mechanism injuries are increasing in the skeletally immature population due to greater participation in competitive sports at increasingly younger ages. Currently there is no consensus on its diagnosis. Magnetic resonance imaging is proposed as the method of choice because it detects associated lesions and allows planning the surgical strategy

Resolución quirúrgica de inestabilidad anterior de rodilla en pacientes con fisis abiertas. Técnicas quirúrgicas / Surgical treatment of anterior knee instability in children with open physis. Surgical techniques

Introducción: La lesión de LCA en niños con fisis abierta va en aumento debido a una mayor participación en deportes de contacto y al diagnóstico precoz. El tratamiento conservador de este tipo de lesiones está asociado al desarrollo de lesiones secundarias condrales y meniscales por lo que, sobre la base de la bibliografía actual, su tratamiento en pacientes esqueléticamente inmaduros con inestabilidad anterior de rodilla objetiva y sintomática es quirúrgico. Materiales y métodos: en el siguiente trabajo se presenta una revisión de dieciocho pacientes esqueléticamente inmaduros con reconstrucción de LCA y un seguimiento promedio de veintiséis meses (entre doce y cincuenta y seis) evaluados con los scores Lysholm, Tegner e IKDC, y telemetrías postoperatorias con mejoría de los scores funcionales permitiendo el retorno al mismo nivel de actividad deportiva en la mayoría de los casos. Conclusión: en esta población, no se han observado cambios en la angulación del miembro intervenido en las telemetrías postoperatorias de control, ni en el desarrollo de alteraciones del crecimiento. Tipo de estudio: Serie de Casos. Nivel de evidencia: IV

Introduction: ACL injury in children with open physis is increasing due to greater participation in contact sports and early diagnosis. Conservative treatment of this type of injury is associated with the development of secondary chondral and meniscal injuries, so based on current literature the treatment of this type of injury in skeletally immature patients with objective and symptomatic anterior knee instability is surgical. Materials and methods: the following work presents a review of eighteen skeletally immature patients with ACL reconstruction and an average follow-up of twenty-six months (between twelve and fifty-six months) evaluated with the Lysholm, Tegner and IKDC scores and postoperative telemetries with improvement in functional scores allowing return at the same level of sports activity in most cases. Conclusion: in this population, no changes in the angulation of the operated limb have been observed in the postoperative control telemetries or the development of growth alterations in any case. Type of study: Case series. Level of evidence: IV

Indicaciones y complicaciones en la reconstrucción del ligamento patelofemoral medial / Medial patellofemoral ligament reconstruction. Indications and complications

Introducción: La reconstrucción del ligamento patelofemoral medial por inestabilidad rotuliana es un procedimiento reproducible con indicaciones precisas. El objetivo del presente trabajo fue evaluar las indicaciones, las complicaciones y la satisfacción postoperatoria en un grupo de pacientes, tratados con la misma técnica de reconstrucción. Material y método: Se evaluaron en forma retrospectiva 53 rodillas de 49 pacientes intervenidos entre el año 2009 al 2018, por inestabilidad rotuliana, con la misma técnica de reconstrucción de partes blandas asociada o no a otros procedimientos sobre estructuras óseas. Registrando edad, sexo, lado afectado, fecha, número de intervenciones y actividad física. Se evaluaron las indicaciones, las complicaciones y satisfacción postoperatoria con el score de Kujala. Resultados: La indicación de la cirugía fue la luxación recidivante de rotula. Nuestra complicación menor más frecuente fue el dolor, asociado en un bajo porcentaje a inestabilidad subjetiva. Dentro de las complicaciones mayores presentamos un caso de rigidez postoperatoria que requirió movilización bajo anestesia, un caso de reluxación que requirió una reintervención y un caso de retiro de material por dolor. Conclusión: La reconstrucción del ligamento patelofemoral medial es un procedimiento efectivo, con un bajo índice de recidiva, permitiendo el retorno a la actividad física previa. Es fundamental una indicación precisa. Se hallo un porcentaje reducido de complicaciones mayores, pero con un número considerable de complicaciones menores. Tipo de estudio: Serie de casos. Nivel de evidencia: IV

Introduction: The medial patella-femoral ligament reconstruction due to patellar instability is a reproducible procedure which has accurate indications. The objective of the present paper was to evaluate the indications, the complications and postop satisfaction in a group of patients, treated with the same reconstruction technique. Material and method: Fifty-six knees from 52 patients operated between 2009 and 2018, due to patellar instability, were evaluated retrospectively, with the same soft tissue reconstruction technique, whether or not associated with other procedures on bone structures. Age, gender, affected site, date and number of surgeries and physical activity were registered. Indications, complications and postop satisfaction were evaluated with Kujala score. Results: The patellar recurrent luxation was the indication for surgery. Pain was the most frequent minor complication, associated to subjective instability in a low percentage. Within the major complications two cases of postop stiffness that required mobilization under anesthesia were presented, and also was one recurrent luxation case that needed a new surgery. Conclusion: The medial patello-femoral ligament reconstruction is an effective procedure, which has a low recurrent rate, and which allows the return to previous physical activity. An accurate indication is fundamental. A lower rate of major complications was found, but with a non-negligible number of minor complications. Type study: Case series. Level of evidence: IV

Indicaciones y complicaciones de la osteotomía de la tuberosidad anterior de la tibia en el tratamiento de la inestabilidad patelofemoral / Tibial anterior tuberosity osteotomy for the treatment of patellofemoral instability. Indications and complications

Introducción: La osteotomía de la tuberosidad anterior de la tibia es un procedimiento efectivo y seguro para el tratamiento de la inestabilidad patelofemoral. El objetivo del presente trabajo es desarrollar las indicaciones y evaluar las complicaciones de dicho procedimiento realizado en un grupo de pacientes intervenidos por nuestro equipo. Material y método: Se analizaron en forma retrospectiva las historias clínicas de 77 pacientes intervenidos quirúrgicamente por inestabilidad patelofemoral a quienes se les realizó una osteotomía de la TAT, y en quienes se utilizó la misma técnica quirúrgica. Se registró edad, sexo, actividad deportiva y número de intervenciones, y se analizaron las indicaciones quirúrgicas de cada caso. Por último, se cuantifico el número de complicaciones (menores y mayores) y se evaluó el grado de satisfacción postquirúrgica de los pacientes con el score de kujala. Resultados: En la mayoría de los casos los pacientes presentaban un aumento de la distancia ST-TAT de más de 20 mm con un ángulo Q aumentado, asociado a episodios de luxación recidivante de rotula y dolor anterior de rodilla. La complicación más frecuente fue la recidiva del dolor (de menor intensidad y frecuencia que el presentado previo a la cirugía). Registramos dos casos de aflojamiento de material que requirió una segunda cirugía y un caso de secreción persistente de herida quirúrgica que no requirió re intervención. Conclusión: La osteotomía de la TAT es una procedimiento eficaz y con bajo índice de complicaciones postoperatorias para tratar la luxación recidivante de rotula, permitiendo al paciente retornar a sus actividades deportivas con un bajo porcentaje de morbilidad postoperatoria. Tipo de estudio: Serie de casos. Nivel de evidencia: IV

Introduction: Tibial anterior tuberosity osteotomy is an effective and safe procedure for the treatment of patello-femoral instability. The objective of the present paper is to talk about the indications and to evaluate the complications of the mentioned procedure performed in a group of patients who underwent surgery with our team. Material and method: The clinical histories of 77 patients operated due to patello-femoral instability, who underwent TT osteotomy and in whom the same surgical technique was performed, were analyzed retrospectively. Age, gender, sports activity and number of surgeries were registered and surgery indications in each case were analyzed. Lastly, the number of (minor and major) complications was quantified and patients postop satisfaction was evaluated with the Kujala score. Results: In most of cases patients presented a ST-TT distance increase of over 20 mm with an augmented Q angle associated to patellar recurrent luxation episodes and to anterior knee pain. The most frequent complication was pain recurrence (of lower intensity and frequency than that presented prior to surgery). Two cases of loosening material which required a second surgery and one case of persistent secretion from the surgical wound which did not require a new surgery were registered. Conclusion: The TT osteotomy is an effective procedure and with a low postop complications rate to treat patellar recurrent luxation, which allows the patient to resume sports activities with a low rate of postop morbidity. Type study: Case series. Level of evidence: IV

Osteotomía de deflexión tibial en cirugía de revisión de ligamento cruzado anterior / Tibial deflexion osteotomy in ACL revision

En la reconstrucción primaria del LCA existen variantes como injertos, túneles, fijaciones y rehabilitación, que actúan como factores determinantes del éxito de la cirugía. Las principales causas de fracaso son errores técnicos, inestabilidades asociadas, sexo, edad, hiperlaxitud y aumento del slop tibial (inclinación platillo tibial). Este último es un factor importante a tener en cuenta ante el fracaso de una cirugía de revisión de LCA. En pacientes con antecedente de 2 fallas previas de LCA se recomienda la corrección del slope tibial cuando este excede los 12°, sobre todo en presencia de lesiones meniscales asociadas para disminuir el riesgo de re-ruptura. Se describe la técnica quirúrgica de deflexión anterior de tibia. La reconstrucción de LCA es una de las cirugías más frecuentes en lesiones deportivas. Hay una constante evolución en todos los aspectos del tratamiento de estas lesiones. Estos cambios van desde la técnica quirúrgica hasta el proceso de rehabilitación, pasando por el mejoramiento de los implantes, la implementación de terapias biológicas, etc. A pesar de esta constante evolución, aún existe un porcentaje alto de re rupturas. Creemos que en aquellos pacientes con dos o más rupturas de la plástica de LCA y en donde se han descartado fallas técnicas, o inestabilidades asociada no diagnosticadas previamente, el slope tibial aumentado (más de 12 grados) es un factor a corregir. La técnica quirúrgica descripta, si bien requiere una curva de aprendizaje y es de cierta complejidad, es un procedimiento reproducible. Los trabajos hasta ahora publicados presentan buenos resultados. Tipo de estudio: Nota técnica. Nivel de evidencia: V

In primary ACL reconstruction there are variables such as grafts, tunnels, fixations and rehabilitation which play a determinant role in the success of the surgery. The main causes of failure are: technical errors, associated instabilities, gender, age, hyper laxity and an increase in the tibial slope (a inclination in the tibial plateau). The latter is an important factor to take into account when there is failure of an ACL revision surgery. In patients with a background of two previous ACL failures, correction of the tibial plateau is recommended when it exceeds 12°, mainly in the presence of associated meniscal lesions to lower the risk of a re-rupture. The anterior tibial deflexion surgical technique will be described. LCA reconstruction is one of the most frequent surgeries in sports lesions. There is a constant evolution in all aspects of the treatment of these lesions. These changes range from the surgical technique to the rehab process, going through the improvement of implants, the implementation of biologic therapies, etc. Despite this constant evolution, there is still a high percentage of re ruptures. We believe that, in those patients with two or more ruptures of ACL reconstruction, and in whom technical failure or associated instabilities, which were not previously diagnosed, have been ruled out, the increased tibial slope (over 12°) is a factor to be corrected. The surgical technique described, even though it requires a learning curve and is of a certain complexity, is a reproducible procedure. And papers published so far present good results. Type of study: Technical note. Level of evidence: V

Biotenodesis con tensor de fascia lata. técnica extraarticular / Biotenodesis with fascia lata tensor

Las biotenodesis con tensor de fascia lata para el tratamiento de las inestabilidades por insuficiencia del ligamento cruzado anterior han sido utilizadas con muy buenos resultados durante muchísimos años. Tuvieron su máximo apogeo entre los años 1975 y 1985, siendo prácticamente olvidadas por la mayoría de los cirujanos con la llegada de las técnicas de reconstrucción intraarticulares artroscópicas. En los últimos años luego de la descripción de un “viejo-nuevo” ligamento anterolateral de la rodilla, han tenido un nuevo auge si bien debe mencionarse claramente que la técnica de Lemaire no reconstruye este ligamento. Esta técnica resulta sumamente útil cuando se la asocia con plásticas intraarticulares en revisiones o insuficiencias luego de una plástica primaria del LCA, o como procedimiento único en pacientes de más de 50 años con bajo nivel de exigencia física, en virtud que presentan una muy baja morbilidad y una rehabilitación más rápida en relación a las plásticas intraarticulares. Tipo de estudio: Técnica Quirúrgica. Nivel de evidencia: V.

The biotenodesis with fascia lata tensor for the treatment of instabilities due to insufficiency of the anterior cruciate ligament have been used with very good results for many years. In recent years after the description of an “old-new” anterolateral ligament of the knee have had a new boom although it should be clearly stated that the technique of Lemaire does not reconstruct this ligament. Anatomical repairs and details of surgical technique are described. This technique is extremely useful when it is associated with intraarticular plastics in revisions or insufficiencies after primary plastic surgery of the ACL or as a single procedure in patients over 50 years of age with a low level of physical requirement because they present a very low morbidity and one Rehabilitation in relation to intra-articular plastic. Type of study: Surgical Technique. Level of Evidence: V.

Reparacion endoscopica del ligamento lateral a través de dos portales en inestabilidad cronica del tobillo / Endoscopic repair of the lateral ligament for chronic ankle instability

Objetivos: La lesión del complejo ligamentario lateral del tobillo es una de las lesiones más frecuentes relacionada al deporte.Generalmente, la lesión del ligamento lateral evoluciona favorablemente con el tratamiento médico y kinésico, sin embargo, lainestabilidad lateral crónica se desarrolla como secuela en casi el 30% de los pacientes.Numerosas técnicas de cirugía abierta y artroscópica han sido descriptas para tratar esta patología.Materiales y Métodos: Se trataron 22 pacientes; 18 varones y 4 mujeres, edad 17 a 42 años (media 28 años). Todos lospacientes presentaban una historia de inestabilidad funcional con más de tres esguinces de tobillo en los últimos dos años. Serealizó una artroscopía anterior del tobillo e todos los pacientes con el fin de tratar la enfermedad asociada y posteriormente serealizó una reparación “todo adentro” del ligamento lateral a través de dos portales (anteromedial y anterolateral) utilizando unasutura de anclaje sin nudos.Resultados: Las evaluaciones de los resultados clínicos se realizaron con un seguimiento promedio de 25 meses (R: 17-31).Los resultados globales se objetivaron por medio del score de la Asociación Americana de Pie y Tobilllo (AOFAS). La puntuaciónAOFAS mejoró de 63 puntos (rango 52-77) antes de la operación a 90 puntos (rango 73-100) al final del follow up.Ningún caso de recurrencia de la inestabilidad del tobillo se encontró en los casos presentados...

Objectives: One of the most frequent lesions related to the sports activity is the ankle lateral ligament complex lesion. Generally,this lesion resolves favorably with medical and kinesiologic treatment; however, chronic lateral instability develops as a sequela innearly 30% of patients. Several open and arthroscopic surgery techniques have been described to treat this pathology.Materials and methods: Twenty-two patients were treated, 18 males and four females, aged between 17 to 42 years (meanage 28). All patients presented a history of functional instability with over three ankle sprains in the last two years. An anteriorarthroscopy of the ankle was performed in all patients with the aim to treat the associated lesions, and following that, an “all –inside” repair of the lateral ligament was also performed through two portals (anteromedial and anterolateral) using a knotlesssuture anchor.Results: Assessment of clinical results was carried out with an average follow-up of 25 months (Range: 17-31).Global results were established by means of the AOFAS score (The Ankle and Foot American Association). The AOFAS scoreimproved from 63 points before surgery (range 52-77) to 90 points (range 73-100) at the end of follow-up.No case of recurrence of ankle instability was found in the cases presented...

Comparación de protocolos de rehabilitación en cirugía del ligamento cruzado anterior con tendón patelar en jugadores profesionales de fútbol / Rehabilitation protocols comparison after ACL reconstruction using patellar tendon in professional soccer players

Objetivo: El presente estudio investigó la influencia entre 2 protocolos de rehabilitación (agresivo y no agresivo) en los resultados después de la reconstrucción del LCA utilizando autoinjertos de tendón patelar en futbolistas profesionales. Métodos: Se efectuó un estudio prospectivo ramdomizado incluyendo 84 pacientes divididos en dos grupos iguales tratados con 2 protocolos de rehabilitación diferentes: Agresivo y No Agresivo, en el postoperatorio. A los 3 años de seguimiento, se realizó una evaluación compuesta por el score IKDC, la medición KT 1000 y las imágenes de RM. Se utilizó la prueba t para muestras independientes y pareadas y la prueba de Chi-cuadrado de Pearson para el análisis estadístico (p / 0,05). Resultados: Sólo 69,04% (N = 58) de los pacientes fueron examinados a los 3 años después de la operación. Los resultados del score IKDC del grupo de rehabilitación NO agresiva (A 55%, B 35%, C 10%; del grupo de rehabilitación Agresiva A 52%, B 35%, C 13%) y la medición instrumental de la laxitud anteroposterior con artrómetro KT1000 (no agresivo 0.5 ± 2,1 mm, agresivo 0,9 ± 3,2 mm) no mostraron diferencias significativas. Se encontraron diferencias en las imágenes de RM entre ambos grupos obtenidas durante el postoperatorio inmediato y a 3 años de seguimiento. Con el protocolo Agresivo de rehabilitación se observó un aumento en la densidad y pérdida de nitidez del neoligamento, además de una diferencia significativa en el ensanchamiento de los túneles óseos y mayor sinovitis en relación al grupo que recibió un protocolo No Agresivo de rehabilitación. Conclusión: La rehabilitación postoperatoria con un protocolo agresivo de rehabilitación después de la reconstrucción del LCA presenta buenos resultados funcionales con imágenes alteradas de RM a 3 años después de la reconstrucción del LCA con tendón patelar en jugadores profesionales de fútbol.

Purpose: The current study investigated the influence of two-rehabilitation protocol (aggressive and no aggressive) in the results after ACL reconstruction using patellar tendon autografts in professional soccer players. Methods: A prospective randomized study was initiated including 84 patients divided into two equal groups treated with or without an aggressive rehabilitation protocol Post-operatively. A 3 years follow-up examination comprised the IKDC score, KT1000 measurement and MR images. The t test for independent and paired samples and the Pearson’s Chi-square test was used for statistical analysis (p/0.05). Results: Only 69,04% (N=58) of the patients were examined 3 years post-operatively. IKDC, non-aggressive rehabilitation protocol group results (A 55 %, B 35 %, C 10 %; aggressive rehabilitation protocol group A 52 %, B 35 %, C 13%) and instrumental measurement of anteroposterior laxity with KT1000 (non aggressive 0.5 ± 2.1 mm, aggressive 0.9± 3.2 mm) showed no significant differences. There were MRI differences between the groups concerning heterogeneous images signal, continuity, and tunnel widening and synovitis findings in the aggressive rehabilitation protocol group. Conclusion: Post-operative rehabilitation with an aggressive protocol after ACL reconstruction present good functional results with poor images of MR 3 years post reconstruction of ACL with patellar tendon in professional soccer players.