César Janovsky

Return to sport after surgical treatment for pubalgia among professional soccer players.

Objective to evaluate the return to sport after surgical treatment for pubalgia among 30 professional soccer players and describe the surgical technique used. Method this case series was evaluated by means of a questionnaire and physical examination on 30 male professional soccer players of mean age 24.4 years (range: 18–30). The mean duration of the symptoms was 18.6 months (range: 13–28). The diagnosis was made through clinical investigation, special maneuvers and complementary examinations, by the same examiner. All the patients underwent surgical treatment after conservative treatment failed; all procedures were performed by the same surgeon using the same technique. Nonparametric comparisons were made to investigate the time taken to recover after the surgery, for the patients to return to their sport. Results five patients evolved with hematoma, with the need to remove the stitches three weeks after the operation because of a small dehiscence at the site of the operative wound. The wound healed completely in all these cases by five weeks after the surgery. Four patients presented dysuria in the first week, but improved in the second postoperative week. The mean time taken to return to training was around eight weeks (range: seven–nine). All the players returned to competitive soccer practice within 16 weeks. When asked about their degree of satisfaction after the operation (satisfied or dissatisfied), taking into consideration their return to the sport, there was 100% satisfaction, and they returned to professional practice at the same competitive level as before the injury. This degree of satisfaction continued to the last assessment, which was made after 36 months of postoperative follow-up. Conclusion the surgical technique presented in this case series, with trapezoidal resection of the pubic symphysis in association with bilateral partial tenotomy of the long adductor, was a fast and effective procedure with a low rate of postoperative complications. It was shown to be an excellent treatment option for refractory cases, with a return to sports activity among professional soccer players.

Posterior cruciate ligament reconstruction by means of tibial tunnel: anatomical study on cadavers for tunnel positioning

Objective to determine the reference points for the exit of the tibial guidewire in relation to the posterior cortical bone of the tibia. Methods sixteen knees from fresh cadavers were used for this study. Using a viewing device and a guide marked out in millimeters, three guidewires were passed through the tibia at 0, 10 and 15 mm distally in relation to the posterior crest of the tibia. Dissections were performed and the region of the center of the tibial insertion of the posterior cruciate ligament (PCL) was determined in each knee. The distances between the center of the tibial insertion of the PCL and the posterior tibial border (CB) and between the center of the tibial insertion of the PCL and wires 1, 2 and 3 (CW1, CW2 and CW3) were measured. Results in the dissected knees, we found the center of the tibial insertion of the PCL at 1.09 ± 0.06 cm from the posterior tibial border. The distances between the wires 1, 2 and 3 and the center of the tibial insertion of the PCL were respectively 1.01 ± 0.08, 0.09 ± 0.05 and 0.5 ± 0.05 cm. Conclusion the guidewire exit point 10 mm distal in relation to the posterior crest of the tibia was the best position for attempting to reproduce the anatomical center of the PCL.

Avaliação funcional da reconstrução do ligamento patelofemoral medial em atletas

Objective  The aim of the present study was to evaluate the clinical results, functional outcomes, and risk factors after anatomic reconstructions using knee flexor grafts in athletes. Methods  The authors followed-up 32 patients and 34 knees for 1 year in a prospective design case series evaluating pre- and postoperative functional scores (Kujala and Lysholm) and associated risk factors. Results  All of the 32 patients had a significant increase of the Lysholm and Kujala scores. Patients with < 5 preoperative dislocations had a better score on the Lysholm and Kujala scales. The mean preoperative Lysholm score was 62.8, and the mean postoperative score was 94.3. The mean preoperative Kujala score was 63.0, and the mean postoperative score was 94.0. Conclusion  Medial patellofemoral ligament reconstruction with hamstring graft in athletes with patellar instability improved clinical and functional scores. The bone drilling through the patella and the positioning of the femoral tunnel should be judiciously performed.

Ultrasonography for evaluation of hamstring tendon diameter: is it possible to predict the size of the graft?

Objective Perform the preoperative measurement of the hamstring tendons using ultrasound imaging, validating and correlating the measured value with that found during surgical reconstruction of the ligament. Methods A cross-sectional study was carried out with 24 patients who underwent ultrasonographic measurement of the semitendinosus and gracilis muscle tendons and were subsequently submitted to surgical reconstruction of the ACL, with ipsilateral semitendinosus and gracilis tendon grafting. Results The patients’ ages ranged from 16 to 43 years, with a mean of 24.8 years (SD = 8.4 years), 79.2% were men, and the distribution by side was 41.7% right knees and 58.3% left knees. A non-significant correlation coefficient was found between the area calculated by ultrasound (2 × semitendinosus area + 2 × gracilis area) and the intraoperative measurement (r = 0.16; p = 0.443). No evidence of a difference between intraoperative measurements <8 mm and ≥8 mm was found for the area calculated by the ultrasound (p = 0.746). The difference observed between the groups was −0.01 (95% CI: −0.09 to 0.07). Conclusion Preoperative ultrasound imaging of the semitendinosus and gracilis tendons does not present a statistically significant correlation with the intraoperative measurement of the quadruple hamstring graft for ligament reconstruction.

Case Report - Infection of Total Knee Arthroplasty Treated with One-Stage Surgery and Linezolid

Staphylococcus spp meticillin resistant infection can be treated with Linezolid. This is a case report of an orthopaedic implant infection in a 60 year-old male treated orally with Linezolid and Rifampicin for three months after one-stage arthroplasty. This is possible provided that platelet count is closely monitored throughout the course of treatment.

Synovial C-Shaped Tibial Footprint of the Anterior Cruciate Ligament

Background: Although numerous anatomic studies about the anterior cruciate ligament (ACL) structure and attachments have been performed, these studies have not reached consensus on the ACL footprint. Purpose: To investigate the existing controversy regarding the morphology of the tibial ACL insertion (footprint) and confirm histologically that the tibial ACL footprint is not completely filled with ligament tissue. Study Design: Descriptive laboratory study. Methods: The tibial ACL footprint was dissected from 20 different fresh-frozen cadaveric knees (all males; mean age, 68.8 ± 5.4 years [range, 55-80 years]; mean weight, 78 ± 6.6 kg [range, 45-93 kg]). Two knees, 1 with severe osteoarthritis and 1 with previous knee surgery, were excluded. The tibial ACL insertion was observed, and this area was longitudinally divided into 4 parallel slices (0%-25%, 25-50%, 50%-75%, and 75%-100%), embedded in paraffin wax, and stained with hematoxylin-eosin, alcian blue, and picrosirius-polarization. The specimens were measured using a microscope to determine the distances from the anterior to the posterior border of the ACL ligament tibial insertion and the distance from the posterior border to the end of the ligament fibers of the ACL ligament tibial insertions. Results: The 18 evaluated knee specimens confirmed the finding of a C-shaped tibial insertion of the ACL. The measurements showed that the ligament (vertical parallel collagen fibers) occupied only 30.8% of the complete insertion. The remaining area was filled with synovial tissue, demonstrating histologically the “C” shape. Conclusion: This study confirms macroscopically the C-shaped tibial insertion of the ACL and shows histologically that synovial tissue is an indirect insertion filling the major part of the footprint. Clinical Relevance: This anatomic study suggests a different shape of the ACL tibial footprint, which may be useful for new perspectives regarding ACL reconstruction surgery research.

Fixação intramedular das fraturas do fêmur na infância e na adolescência com hastes flexíveis

Objetivos: Avaliar o resultado do tratamento cirurgico da fratura diafisaria isolada do femur pela fixacao intramedular retrograda com hastes de Ender. Metodos: Os autores realizam um estudo retrospectivo de 31 pacientes (32 femures), sendo 22 (71%) do sexo masculino e nove (29%), do feminino. As idades variaram entre oito e 16 anos com media de 11,3 anos. Quanto ao mecanismo de trauma, observamos: 13 (42%) foram vitimas de acidente automobilistico; cinco (16%), de acidente motociclistico; quatro (13%), de atropelamento; seis (19%), de queda de altura; e tres (10%), de queda de bicicleta. Quanto ao lado acometido, ocorreram 14 (44%) fraturas femorais direitas e 18 (56%) esquerdas com um paciente fraturado bilateralmente. O tempo de seguimento variou de 1,6 anos a 6,3 anos com media de 2,7 anos. O periodo de internacao foi, em media, de 6,81 dias, variando entre tres e 19 dias. Apos um ano, realizaram avaliacao funcional (dor, movimento, claudicacao) e escanometria para avaliar possiveis discrepâncias. Resultados: 28 (90,3%) pacientes com resultado satisfatorio e tres (9,6%), insatisfatorio. Como complicacoes, observamos anisomelia em oito (25,8%), dor em dois (6,4%) e limitacao do arco de movimento de flexao joelho em um (3,2,%) paciente. Conclusoes: Os autores ainda consideram a populacao estudada pequena, mas os resultados demonstram ser promissores. O tratamento com haste intramedular de Ender foi efetivo, seguro e economico, podendo ser indicado para as fraturas femorais isoladas estaveis.