Fabricio Fogagnolo

Fraturas do planalto tibial

As fraturas do planalto tibial sao lesoes articulares cujos principios de tratamento envolvem a reducao anatomica da superficie articular e a restauracao funcional do eixo mecânico do membro inferior. Contribuem para a tomada de decisoes no tratamento dessas fraturas o perfil do paciente, as condicoes do envelope de tecidos moles, a existencia de outros traumatismos associados e a infraestrutura disponivel para abordagens cirurgicas. Para as fraturas de alta energia, o tratamento estagiado, seguindo o principio do controle de danos, tem como prioridade a manutencao do alinhamento do membro enquanto se aguarda a resolucao das mas condicoes de tecidos moles. Ja nos traumas de baixa energia, desde que os tecidos moles nao sejam um fator adverso, o tratamento deve ser realizado em tempo unico, com osteossintese definitiva. Fixacao estavel e movimento precoce sao variaveis diretamente relacionadas com os melhores prognosticos. Desenvolvimentos recentes, como os implantes com estabilidade angular, substitutos osseos e imagens tridimensionais para controle intraoperatorio, deverao contribuir para cirurgias menos invasivas e melhores resultados.

Extended Anterolateral Approach for Complex Lateral Tibial Plateau Fractures

Abstract Complex fractures of the lateral tibial plateau may extend to the posterior rim of the knee and to the tibial spines. Displaced fractures of the posterolateral corner of the tibial plateau may result in joint incongruity and instability, especially with the knee in flexion. Anatomical reduction of the joint surface and containment of the tibial rim are the primary goals of the treatment in such cases. Dedicated surgical approaches including dissection of the peroneal nerve, sometimes in association with an osteotomy of the fibular head are typically used to address these injuries. Some techniques require special positioning of the patient on the operative table. Anatomical studies of the knee allowed us to conclude that an osteotomy of the lateral epicondyle of the femur may be a natural extension of the standard anterolateral approach to the tibial plateau. The main advantage of this approach is the broad exposure of the lateral joint surface, allowing its anatomical reduction. It does not violate the proximal tibiofibular joint or pose a risk to the peroneal nerve. The main limitation is the lack of visualization of the posterior metaphysis of the tibia, preventing the application of a buttress plate parallel to the plane of fracture split. To overcome this limitation, we describe a method to support the posterior tibial plateau rim, in cases of bicondylar tibial plateau fractures, combining the extended anterolateral with the posteromedial approach. For selected cases, with a significant compromise of the posterolateral and anterolateral quadrants of the tibial plateau, including the tibial spines, the extended anterolateral approach may be complemented by a planned detachment of the anterior horn of the lateral meniscus. In such variant, a complete exposure of the entire surface of the lateral tibial plateau and tibial spines is achievable, assuring optimal conditions for an anatomical reduction of the articular surface.

Tibial plateau fractures

Tibial plateau fractures are joint lesions that require anatomical reduction of joint surface and functional restoration of mechanical axis of a lower limb. Patient profile, soft tissue conditions, presence of associated injuries and the available infrastructure for the treatment all contribute to the decision making about the best treatment for these fractures. High-energy fractures are usually approached in a staged manner respecting the principle of damage control, and are primarily targeted to maintain limb alignment while the resolution unfavorable soft tissue conditions is pending. Low-energy trauma can be managed on a singlestage basis, provided soft tissues are not an adverse factor, with open reduction and internal fixation. Stable fixation and early painless joint movement are related to a better prognosis. New developments as locked plates, bone replacements, intraoperative 3D imaging are promising and will certainly contribute for less invasive procedures and better outcomes.

A new simplified onlay technique for posterior cruciate ligament reconstruction.

The integrity of posterior cruciate ligament (PCL) is essential for the normal kinematics of the knee. Injury to the PCL has adverse consequences, with worsening of functional performance and an increased risk to develop osteoarthritis. Conservative treatment is sometimes adopted, not only because it is an acceptable option for selected patients but also due to the lack of consensus in the orthopedic literature regarding the best surgical method. Hereby we describe a simplified technique for onlay PCL reconstruction pointing out possible advantages if compared with the traditional transtibial or inlay techniques.

Reconstruçäo do ligamento cruzado anterior com ligamento patelar: análise comparativa do ligamento autólogo versus homólogo

Resumen pt: O ligamento cruzado anterior e um elemento importante na estabilizacao do joelho.1 A ruptura do ligamento cruzado anterior correlacionam-se lesoes meni...

Conventional plate and screws in medial opening-wedge high tibial osteotomy: are they sufficiently stable? A retrospective study

Objective Opening-wedge osteotomy of the proximal tibia is a widely performed procedure for treating medial gonarthrosis in active patients and in the presence of varus malalignment of the lower limb. The fixation method is controversial, and the use of conventional implants has been abandoned in favor of implants with more modern locking screws. The aim of the present clinical study was to assess the maintenance of the correction achieved in cases wherein fixation was performed using conventional implants. Methods This retrospective study included 51 patients who underwent opening-wedge high tibial osteotomy wherein fixation was performed using conventional implants (4.5-mm DCP plate and non-locking screws). Radiological findings regarding patellar height, tibial slope, and varus correction postoperatively and after consolidation were analyzed to assess the maintenance of the correction achieved by osteotomy. Results The mean loss of correction angle, calculated by the difference between the correction angle in the immediate postoperative period and that after consolidation, was 0.92° ± 0.9°. In addition, changes in patellar height determined by the Blackburne–Peel method and in the sagittal slope of the tibial plateau were not significant or clinically relevant. Conclusions The use of conventional plates and screws is viable in the fixation of opening-wedge high tibial osteotomy because they provide enough stability to maintain the achieved correction until consolidation, without significant changes.

The relationship between performance on the modified star excursion balance test and the knee muscle strength before and after anterior cruciate ligament reconstruction

OBJECTIVES The objective of this study was to evaluate the dynamic balance of the injured and uninjured limb before and after the anterior cruciate ligament (ACL) reconstruction and compare with the control group. STUDY DESIGN Prospective longitudinal. SETTING Biomechanics laboratory. PARTICIPANTS Participants are 24 males (mean age, 27.5 years) with unilateral ACL injury (ACLG) and 24 male healthy volunteers (CG). MAIN OUTCOMES MEASURES The modified star excursion balance test (SEBT) and isokinetic knee extensor and flexor strength were applied in the ACLG preoperatively and after surgery. The dominant limb of CG was evaluated at a single time. RESULTS There was no difference between the injured and the uninjured limb of the ACLG (P > 0.05) before and after surgery. Preoperatively, both ACLG limbs had a significantly lower reach distance in posteromedial (PM) and posterolateral (PL) directions and in composite reach (CR) score compared to the control group (P < 0.001). Postoperatively, no significant differences were found between ACLG and CG (P > 0.05). There was a positive correlation between preoperative PL (0.59) and CR (0.51), postoperative PM (0.36), PL (0.36) and CR (0.46) with flexor strength at 12 months after surgery. CONCLUSION Patients with ACL injury presented a worse performance in the SEBT in the preoperative period compared to the control group. After ligament reconstruction, the performance in the SEBT became equivalent to that of the control group. The strong correlation between flexor strength and posterior directions of the injured limb demonstrates the importance of the knee flexor muscles in the neuromuscular control of patients submitted to ACL reconstruction.

The Impact of Computed Tomography on Decision Making in Tibial Plateau Fractures

&NA; Schatzker introduced one of the most used classification systems for tibial plateau fractures, based on plain radiographs. Computed tomography brought to attention the importance of coronal plane‐oriented fractures. The goal of our study was to determine if the addition of computed tomography would affect the decision making of surgeons who usually use the Schatzker classification to assess tibial plateau fractures. Image studies of 70 patients who sustained tibial plateau fractures were uploaded to a dedicated homepage. Every patient was linked to a folder which contained two radiographic projections (anteroposterior and lateral), three interactive videos of computed tomography (axial, sagittal, and coronal), and eight pictures depicting tridimensional reconstructions of the tibial plateau. Ten attending orthopaedic surgeons, who were blinded to the cases, were granted access to the homepage and assessed each set of images in two different rounds, separated to each other by an interval of 2 weeks. Each case was evaluated in three steps, where surgeons had access, respectively to radiographs, two‐dimensional videos of computed tomography, and three‐dimensional reconstruction images. After every step, surgeons were asked to present how would they classify the case using the Schatzker system and which surgical approaches would be appropriate. We evaluated the inter‐ and intraobserver reliability of the Schatzker classification using the Kappa concordance coefficient, as well as the impact of computed tomography in the decision making regarding the surgical approach for each case, by using the chi‐square test and likelihood ratio. The interobserver concordance kappa coefficients after each assessment step were, respectively, 0.58, 0.62, and 0.64. For the intraobserver analysis, the coefficients were, respectively, 0.76, 0.75, and 0.78. Computed tomography changed the surgical approach selection for the types II, V, and VI of Schatzker (p < 0.01). The addition of computed tomography scans to plain radiographs improved the interobserver reliability of Schatzker classification. Computed tomography had a statistically significant impact in the selection of surgical approaches for the lateral tibial plateau.

Algorithmic treatment of Busch-Hoffa distal femur fractures: A technical note based on a modified Letenneur classification

Treatment of distal femur fractures in the coronal plane can be challenging. Depending on fracture line orientation, topography and associated comminution, decision-making regarding approach and fixation is not straightforward and can result in complications. Therefore, treatment of coronal plane distal femur fractures (Busch-Hoffa fractures) should be approached in a systematic manner, leading to efficient planning and operative execution. Here, we offer a proposed treatment algorithm, guiding treatment, approach and fixation based on the modified Letenneur classification of coronal plane distal femur fractures.

REPLACEMENT VERSUS NON-REPLACEMENT OF THE PATELLAR JOINT SURFACE IN TOTAL KNEE ARTHROPLASTY

ABSTRACT Objective This study addresses functional data, pain, and the reoperation rate in patients undergoing primary total knee arthroplasty (TKA) during which the patella was or was not replaced. Methods Fifty-three knees were included, 18 with the patella replaced and 35 with the patella not replaced. WOMAC and SF-12 scores and knee pain were analyzed preoperatively and 3, 6, and 12 months after TKA. The reoperation rate was also evaluated. Results Both groups presented significant improvement in WOMAC score and pain at all postoperative follow-up appointments. There was no significant difference between the groups in all evaluated variables. Two subjects in the group did not undergo patellar replacement due to complaints of anterior knee pain after arthroplasty. There was no difference between the groups in relation to the reoperation rate. Conclusion Patients receiving patellar replacement during TKA did exhibit significant differences in the rate of reoperation, function, or pain when compared to patients in which the patella was replaced. Level of Evidence III; Cohort study.