Fernando Cury Rezende

Arthroscopic Identification of the Anterolateral Ligament of the Knee

Intense interest has focused on the recent description of the anterolateral ligament of the knee. Advancing knowledge of its anatomy and function is leading to a realization of its importance in the rotatory control of the tibia in anterior cruciate ligament injuries. Reconstruction of this structure will increasingly become an important goal during anterior cruciate ligament reconstruction. However, preoperative assessment of this ligament is difficult. Clinical assessment of rotatory laxity has poor reproducibility, and it is difficult to define using current imaging techniques. This article is the first to describe a safe and reproducible arthroscopic technique to allow identification and examination of the anterolateral ligament of the knee. With the knee at 90° of flexion, the arthroscope is introduced through the anterolateral portal to allow clear visualization of the lateral gutter. Under direct vision, an accessory portal is made over the inferior limit of the lateral gutter. A shaver is then introduced through this portal and used to debride this synovial recess and define the anterolateral ligament. This allows the surgeon to examine the integrity of the anterolateral ligament, in particular its femoral insertion. If required, this additional information can facilitate the performance of a more accurate and effective extra-articular reconstruction.

Anterior cruciate ligament - updating article

This updating article on the anterior cruciate ligament (ACL) has the aim of addressing some of the most interesting current topics in this field. Within this stratified approach, it contains the following sections: ACL remnant; anterolateral ligament and combined intra and extra-articular reconstruction; fixation devices; and ACL femoral tunnel creation techniques.

Is it safe the empirical distal femoral resection angle of 5 to 6 of valgus in the Brazilian geriatric population

Objective The purpose of this study is to determine if there is a safe distal femoral resection angle to restore the normal axial alignment of the limb in total knee arthroplasty (TKA) in the Brazilian geriatric population with knee arthrosis. Method This study analyzed 99 pre-operative hip-knee-ankle radiographs of osteoarthritic knees of 66 patients (54 women, 12 men) with knee osteoarthritis. The distal femoral cut angle was determined based on the femoral mechanical-anatomical angle (FMA). Mean, median and standard deviation measurements of the distal femoral cut angle were calculated, differentiated by gender and side. The mean result of the distal femoral resection angle was compared to 5.7°, the mean average angle of previous and similar study based on European population of patients with knee arthrosis. Results The mean average of the distal femoral resection angle of the study was 6.05 (range 3–9°). The distribution of this angle between genders showed a slight superior average of the male population (6.17°) compared to the female (6.02°), but with no statistically significant difference (p = 0.726). There was no statistically significant difference (p = 0.052) between the mean average of this study (6.05°) compared to the mean average of the literature (5.7°). However, considering 3° as the limit of acceptable error in the coronal plane, this empirical femoral resection angle would not be appropriated for 19.7% of the population. Conclusion The distal femoral resection angle of 5–6° is not completely safe for the Brazilian geriatric population.

Complicações das endopróteses em pacientes com tumores ósseos do joelho

Non-conventional endoprostheses (NCE) are frequently used in orthopedic oncology. The complications associated with this procedure have prompted research, due to the fact that it is commonly performed on young patients, with a higher survival rate. We conducted a systematic review of the literature, searching for the best scientific evidence on the subject. The research was carried out in the following databases: MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of randomized controlled trials (CCTR), seeking to identify studies that report complications, and compare patellar resurfacing versus retention. The studies were selected according to the best methodological quality that exists for the subject. One hundred and forty six (146) studies were evaluated. No randomized clinical trial was found. We conducted a qualitative and quantitative evaluation of the work found (evidence levels IV and V). We used the Mann-Whitney U test for the statistical analysis. The results indicate a need for further studies that will enable us to reach a more solid conclusion. The rate of complications after NCE can be considered high, despite the low quality of the studies, as demonstrated by the studies that exist in the literature.

Anatomic Posterolateral Corner Reconstruction With Autografts

Anatomic posterolateral corner reconstruction reproduces 3 main structures: the lateral collateral ligament, the popliteofibular ligament, and the popliteus tendon. The LaPrade technique reproduces all 3 main stabilizers. However, it requires a long graft, limiting its indication to clinical settings in which allograft tissue is available. We propose a surgical procedure that is a modification of the LaPrade technique using the same tunnel placement, hamstring autografts, and biceps augmentation when necessary. It relies on artificial graft lengthening provided by the loop of the suspensory fixation device fixed at the anterior tibial cortex. The final reconstruction reproduces the popliteus tendon with the bulkiest end of the semitendinosus; the popliteofibular ligament with a strand of the semitendinosus and a strand of the gracilis; and the lateral collateral ligament with a strand of the semitendinosus and a strand of the gracilis, which can also be augmented with a biceps strip.

Reply to the Letter to the Editor: Does Combined Intra- and Extraarticular ACL Reconstruction Improve Function and Stability? A Meta-analysis.

W e would like to thank Dr. Tashman for his interest in our article, and for raising interesting questions concerning the combined ACL reconstruction technique. Regarding the potentially damaging increased forces on cartilage, it is impossible to confirm the association of an additional extraarticular procedure with osteoarthritis (OA) with the present data. There are studies addressing both this correlation and its absence [4, 6]. A long-term study correlated the OA with medial meniscectomy, but not with the additional extraarticular procedure. There was no associated lateral OA, and the medial OA was related to medial meniscectomy in a study including 54 patients with 11 years followup [4]. Nevertheless, studies correlating the extraarticular procedure with OA of the lateral compartment [6] can also be found. Therefore, we agree that this topic requires further clarification regarding biomechanical aspects to elucidate whether the addition of the extraarticular procedure contributes to an overconstrained knee. The assessment of different extraarticular techniques, and their varying degrees of rotation for graft fixation, are needed in order to determine if there is any overtightening in internal rotation. Due to the evolution of these graft procedures, randomized clinical studies examining the current techniques are also needed. However, the present meta-analysis did not find an association of OA with the addition of an extraarticular procedure at 2 to 7 years followup (Fig. 1). Even so, we do agree that longer-term followup studies are needed; confounding factors such as meniscal and chondral lesions should be excluded in order to determine the extent of overconstraining the joint after combined ACL reconstruction. As mentioned, further studies are necessary to determine the possible clinical benefits of extraarticular procedures when performing ACL reconstructions. However, the important finding of reduced laxity added by the combined extraarticular procedure leads to the current question: What are the most-appropriate indications for an (RE: Rezende FC, de Moraes VY, Martimbianco AL, Luzo MV, da Silveira Franciozi CE, Belloti JC. Does Combined Intraand Extraarticular ACL Reconstruction Improve Function and Stability? A Metaanalysis. Clin Orthop Relat Res. 2015; 473:2609–2618). Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/ licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. F. C. Rezende MD (&), V. Y. de Moraes MD, M. V. Luzo PhD, C. E. da Silveira Franciozi MD, J. C. Belloti PhD Department of Orthopedics and Traumatology, Federal University of São Paulo, Borges Lagoa Street 783, Sao Paulo, SP 04038-032, Brazil e-mail: rezendefernando@hotmail.com Reply to the Letter to the Editor Published online: 16 February 2016 The Association of Bone and Joint Surgeons1 2016