Gustavo Gonçalves Arliani

Autologous Osteochondral Transplantation for Treating Patellar Chondral Injuries Evaluation, Treatment, and Outcomes of a Two-Year Follow-up Study

BACKGROUND The patella is the largest human sesamoid bone and often sustains chondral injury. There is no consensus on how to treat a full-thickness, symptomatic articular cartilage injury of the patella. We analyzed the clinical and functional outcomes of patients with symptomatic full-thickness patellar chondral lesions treated with autologous osteochondral transplantation and evaluated osteochondral autograft bone-plug integration through magnetic resonance imaging. METHODS In this prospective study, thirty-three patients with a symptomatic full-thickness patellar chondral injury surgically treated with autologous osteochondral transplantation were evaluated before and after surgical treatment with a minimum two-year follow-up using the Lysholm, Kujala, and Fulkerson questionnaires and the Short Form-36 health survey score. Magnetic resonance images were made at six and twelve months postoperatively and studies were performed to analyze the osteochondral autograft bone-plug integration. RESULTS All thirty-three patients showed a significant improvement in functional scores two years after surgery. The average Lysholm scores were 57.27 points preoperatively and 80.76 points at two years postoperatively, the average Kujala scores were 54.76 points preoperatively and 75.18 points at two years postoperatively, and the Fulkerson average scores were 54.24 points preoperatively and 80.42 points at two years postoperatively. The Short Form-36 life quality score improved significantly. Two years after surgery, all magnetic resonance images showed full bone-plug integration into the patella. CONCLUSIONS Autologous osteochondral transplantation is a successful technique to surgically treat symptomatic full-thickness patellar articular cartilage injuries smaller than 2.5 cm in diameter. Patients had a significant improvement in clinical scores. Bone-plug integration and surface alignment were demonstrated in all patients two years after surgery. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Updates in biological therapies for knee injuries: menisci

The preservation of meniscal tissue is paramount for long-term joint function, especially in younger patients who are athletically active. Many studies have reported encouraging results following the repair of meniscus tears, including both simple longitudinal tears located in the periphery and complex multiplanar tears that extend into the central third avascular region. However, most types of meniscal lesions are managed with a partial meniscectomy. Options to restore the meniscus range from an allograft transplantation to the use of synthetic and biological technologies. Recent studies have demonstrated good long-term outcomes with meniscal allograft transplantation, although the indications and techniques continue to evolve, and the long-term chondroprotective potential of this approach has yet to be determined. Several synthetic implants, most of which are approved in the European market, have shown some promise for replacing part of or the entire meniscus, including collagen meniscal implants, hydrogels, and polymer scaffolds. Currently, there is no ideal implant generated by means of tissue engineering. However, meniscus tissue engineering is a fast developing field that promises to develop an implant that mimics the histologic and biomechanical properties of a native meniscus.

Early osteoarthritis and reduced quality of life after retirement in former professional soccer players

OBJECTIVES: This study aims to compare the prevalence of osteoarthritis in two groups: one comprising former professional soccer players and the other comprising non-professional-athlete participants. METHODS: Twenty-seven male former professional soccer players and 30 male volunteers from different non-sports professional areas participated in the study. All participants underwent bilateral knee radiography and magnetic resonance imaging. In addition, the quality of life, knee pain and joint function were evaluated and compared using questionnaires given to all participants in both groups. Specific knee evaluations, with regard to osteoarthritis and quality of life, were performed in both groups using the Knee Injury and Osteoarthritis Outcome Score subjective questionnaires and the Short-form 36. The chi-squared test, Fishers exact test, the Mann-Whitney U test and Students t-test were used for group comparisons. RESULTS: The between-groups comparison revealed significant differences in the following: pain, symptoms and quality of life related to the knee in the Knee Injury and Osteoarthritis Outcome Score subscales; the physical aspects subscale of the SF-36; total whole-organ magnetic resonance imaging scores with regard to the dominant and non-dominant knees. Former soccer players had worse scores than the controls in all comparisons. CONCLUSIONS: Both the clinical and magnetic resonance evaluations and the group comparisons performed in this study revealed that former soccer players have a worse quality of life than that of a control group with regard to physical aspects related to the knee; these aspects include greater pain, increased symptoms and substantial changes in radiographic and magnetic resonance images of the knee.

The Brazilian Football Association (CBF) model for epidemiological studies on professional soccer player injuries

OBJECTIVE: This study aims to establish a national methodological model for epidemiological studies on professional soccer player injuries and to describe the numerous relevant studies previously published on this topic. INTRODUCTION: The risk of injury in professional soccer is high. However, previous studies of injury risk in Brazil and other countries have been characterized by large variations in study design and data collection methods as well as definitions of injury, standardized diagnostic criteria, and recovery times. METHODS: A system developed by the Union of European Football for epidemiological studies on professional soccer players is being used as a starting point to create a methodological model for the Brazilian Football Association. To describe the existing studies on professional soccer player injuries, we developed a search strategy to identify relevant epidemiological studies. We included the Latin American and Caribbean Center on Health Sciences and Medline databases in our study. RESULTS: We considered 60 studies from Medline and 16 studies from the Latin American and Caribbean Center on Health Sciences in the final analysis. Twelve studies were selected for final inclusion in this review: seven from the Latin American and Caribbean Center on Health Sciences and five from Medline. We identified a lack of uniformity in the study design, data collection methods, injury definitions, standardized diagnostic criteria, and the definition of recovery time. Based on the information contained within these articles, we developed a model for epidemiological studies for the Brazilian Football Association. CONCLUSIONS: There is no uniform model for epidemiological studies of professional soccer injuries. Here, we propose a novel model to be applied for epidemiological studies of professional soccer player injuries in Brazil and throughout the world.

Identification of Suitable Reference Genes for Investigating Gene Expression in Anterior Cruciate Ligament Injury by Using Reverse Transcription-Quantitative PCR.

The anterior cruciate ligament (ACL) is one of the most frequently injured structures during high-impact sporting activities. Gene expression analysis may be a useful tool for understanding ACL tears and healing failure. Reverse transcription-quantitative polymerase chain reaction (RT-qPCR) has emerged as an effective method for such studies. However, this technique requires the use of suitable reference genes for data normalization. Here, we evaluated the suitability of six reference genes (18S, ACTB, B2M, GAPDH, HPRT1, and TBP) by using ACL samples of 39 individuals with ACL tears (20 with isolated ACL tears and 19 with ACL tear and combined meniscal injury) and of 13 controls. The stability of the candidate reference genes was determined by using the NormFinder, geNorm, BestKeeper DataAssist, and RefFinder software packages and the comparative ΔCt method. ACTB was the best single reference gene and ACTB+TBP was the best gene pair. The GenEx software showed that the accumulated standard deviation is reduced when a larger number of reference genes is used for gene expression normalization. However, the use of a single reference gene may not be suitable. To identify the optimal combination of reference genes, we evaluated the expression of FN1 and PLOD1. We observed that at least 3 reference genes should be used. ACTB+HPRT1+18S is the best trio for the analyses involving isolated ACL tears and controls. Conversely, ACTB+TBP+18S is the best trio for the analyses involving (1) injured ACL tears and controls, and (2) ACL tears of patients with meniscal tears and controls. Therefore, if the gene expression study aims to compare non-injured ACL, isolated ACL tears and ACL tears from patients with meniscal tear as three independent groups ACTB+TBP+18S+HPRT1 should be used. In conclusion, 3 or more genes should be used as reference genes for analysis of ACL samples of individuals with and without ACL tears.

A prospective double blinded randomized study of anterior cruciate ligament reconstruction with hamstrings tendon and spinal anesthesia with or without femoral nerve block

BACKGROUND Current literature supports the thought that anesthesia and analgesia administered perioperatively for an anterior cruciate ligament (ACL) reconstruction have a great influence on time to effective rehabilitation during the first week after hospital discharge. PURPOSE The aim of this study is to answer the research question is there a difference in clinical outcomes between the use of a femoral nerve block with spinal anesthesia versus spinal analgesia alone for people undergoing ACL reconstruction? METHODS ACL reconstruction with spinal anesthesia and patient sedation (Group one); and spinal anesthesia with patient sedation and an additional femoral nerve block (Group two). Patients were re-evaluated for pain, range of motion (ROM), active contraction of the quadriceps, and a Functional Independence Measure (FIM) scoring scale. RESULTS Spinal anesthesia with a femoral nerve block demonstrates pain relief 6h after surgery (VAS 0.37; p=0.007). From the third (VAS=4.56; p=0.028) to the seventh (VAS=2.87; p=0.05) days after surgery, this same nerve blockage delivered higher pain scores. Patients had a similar progressive improvement on knee joint range of motion with or without femoral nerve block (p<0.002). Group one and two had 23.75 and 24.29° 6h after surgery and 87.81 and 85.36° of knee flexion after 48h post op. CONCLUSION Spinal anesthesia associated with a femoral nerve block had no additional benefits on pain control after the third postoperative day. There were no differences between groups concerning ability for knee flexion and to complete daily activities during postoperative period. LEVEL OF EVIDENCE Randomized Clinical Trial Level I.

Correlação entre tempo para o tratamento cirúrgico e mortalidade em pacientes idosos com fratura da extremidade proximal do fêmur

OBJETIVO: O objetivo primario do estudo e analisar a possivel associacao entre o atraso para a realizacao do tratamento cirurgico e mortalidade em pacientes idosos com fratura da extremidade proximal do femur. METODOS: Foram estudados 269 pacientes com fraturas da extremidade proximal do femur (fraturas do colo do femur e fraturas intertrocanterianas), tratadas cirurgicamente no Hospital Sao Paulo - Unifesp-SP, no periodo de janeiro de 2003 a dezembro de 2007. Foram analisados e comparados com a literatura referente ao assunto os seguintes atributos: sexo, idade, tipo de fratura, classificacao da mesma, lado acometido, sintese utilizada, mecanismo de trauma, tempo de internacao, tempo para cirurgia, comorbidades associadas, hemograma de entrada, tipo de anestesia, necessidade de transfusao sanguinea, dia da semana e estacao do ano da fratura. RESULTADOS: O estudo apresentou correlacao entre maior numero de comorbidades clinicas, maior tempo de internacao e utilizacao de anestesia geral na cirurgia com maior mortalidade dos pacientes. CONCLUSAO: Nao houve associacao entre tempo para realizacao da cirurgia e mortalidade.

Introducing 3-Dimensional Stereoscopic Imaging to the Study of Musculoskeletal Anatomy

The stereoscopic imaging technique is an option for a more realistic understanding of what we normally see in 2 dimensions on paper or on a screen. To produce a 3-dimensional image of an object, it is necessary to register 2 different images of the same object at the same distance and height with the use of cameras that focus on one particular point. A convergence between the left and right images is required for human vision. The distance between the camera and the images necessary to create the stereo pair should be proportional to the normal distance between the pupils. Stereoscopic or polarization techniques are used to create the images, and special glasses are required to view them. In medicine, 3-dimensional images are an extremely effective resource in the study and teaching of anatomy at both the macroscopic and microscopic levels. With advancements in technology and the emergence of new diagnostic imaging techniques and innovative therapeutic modalities, 3-dimensional images can be an excellent educational tool.

Medial Patellofemoral Ligament Reconstruction: A Longitudinal Study Comparison of 2 Techniques with 2 and 5-Years Follow-Up

Background : The purpose of this study was to compare the results of two popular surgical techniques for medial patellofemoral ligament MPFL reconstruction with a minimum of two-year follow-up. Methods : Fifty-eight patients with traumatic tear of the medial patellofemoral ligament were included in one of the two surgical groups. Group 1 MPFLs were reconstructed through graft endobutton fixation and Group 2 through graft anchor fixation into the patella. After two to five-year follow-up, patients were asked to answer knee function questionnaires (Fulkerson and Kujala) as well as the SF-36 life quality score. Results : There were no statistical difference among postoperative Kujala, Fulkerson, and SF-36 questionnaires scores between Groups 1 and 2. There were statistical significant differences favorable to patients in Group 1 with a shorter follow-up length (2-5 years) compared to those with a longer period of 5-10 years for both Kujala and Fulkerson scores and no difference for group 2. Conclusion : Both medial patellofemoral ligament reconstruction techniques had similar results in a two to ten-year follow-up according to functions and life quality questionnaires. Furthermore, endobutton fixation for the patellar edge of the graft had better results in patients with 2 years of follow-up than those with 5 years. Gender was not significant for surgical results. Moreover, group 1 patients had higher number of complications.

Lesão do ligamento cruzado anterior: tratamento e reabilitação. Perspectivas e tendências atuais

Universidade Federal de Sao Paulo (UNIFESP) Departamento de Ortopedia e Traumatologia Centro de Traumatologia do Esporte