Helder de Souza Miyahara

Anatomical study on the anterolateral ligament of the knee

Objective Describe the knee anterolateral ligament (ALL) and establish its anatomical marks of origin and insertion. Methods Dissection of the anterolateral aspect of the knee was performed in six cadavers. After isolation of the ALL, its lenght, width and thickness were measured as its places of origin and insertion. The ALL origin was documented in relation to the lateral collateral ligament (LCL) origin and the insertion was documented in relation to the Gerdy tubercle, fibullar head and lateral meniscus. After the first two dissections, the ligament was removed and sent to histologycal analysis. Results The ALL was clearly identified in all knees. Its origin in the lateral epycondile was on average 0.5 mm distal and 2.5 mm anterior to the LCL. In the tibia, two insertions were observed, one in the lateral meniscus and another in the proximal tibia, about 4.5 mm distal to the articular cartilage, between the Gerdy tubercle and the fibullar head. The average measures obtained were: 35.1 mm lenght, 6.8 mm width and 2.6 mm thickness. In the ligament histological analysis, dense connective tissue was observed. Conclusion The ALL is a constant structure in the knee anterolateral region. Its origin is anterior and distal to the LCL origin. In the tibia, it has two insertions, one in the lateral meniscus and another in the proximal tibia between the Gerdy tubercle and the fibullar head.

Stroke management in a university hospital in the largest South American city

OBJECTIVE To describe characteristics and provision of care for patients admitted with cerebrovascular disorders (CVD), focusing on ischemic stroke (IS), in a large, public, academic hospital in São Paulo, Brazil. METHOD We retrieved information about 357 patients with CVD admitted to the Neurology Emergency Department (NED) and Neurology Ward (NW) of our institution. We described patient characteristics and management of IS in NED and in NW. RESULTS IS was diagnosed in 79.6% of CVD patients admitted to NED; 2.7% were submitted to thrombolysis. Extent of IS investigation and management were significantly different in NED and NW. CONCLUSION IS patients in our center were younger than in developed countries. IS management was significantly influenced by patient characteristics. This information can aid in planning strategies to decrease stroke burden.

Total hip arthroplasty using a posterior minimally invasive approach - results after six years

Objective To evaluate the medium-term clinical–functional results (minimum follow-up of six years) from total uncemented hip arthroplasty performed by means of a posterior minimally invasive access, in comparison with the traditional right lateral access. Methods In a comparative prospective study, 224 adult patients underwent elective total hip arthroplasty due to a diagnosis of primary or secondary osteoarthrosis. A group of 103 patients with posterior minimally invasive access was compared with a group of 121 patients with the traditional right lateral access. The mean length of follow-up among the patients of this sample was 7.2 years. We evaluated the clinical–functional and radiographic results and occurrences of loosening, along with any complications that occurred, with a minimum follow-up of six years. Results The clinical–functional analyses before the surgical procedure and six years afterwards were similar in the two groups (p = 0.88 and p = 0.55). One patient in the minimally invasive group underwent revision of the acetabular component and two patients in the control group underwent the same procedure (p = 0.46). The Trendelenburg clinical test, which showed weakness of the hip abductor musculature, was present in five patients operated using the traditional lateral route and absent in all those who underwent the minimally invasive procedure (p = 0.06). There was no difference regarding the radiographic parameters obtained, either in acetabular or in femoral positioning (p = 0.32 and p = 0.58). Conclusions The medium-term clinical and radiographic results and the complication rates were similar between the patients who underwent total hip arthroplasty by means of the posterior minimally invasive access and those with the traditional lateral access.

Clinical and epidemiological differences between septic arthritis of the knee and hip caused by oxacillin-sensitive and -resistant s. aureus

OBJECTIVE: To establish the risk factors for joint infection by oxacillin-resistant Staphylococcus aureus (MRSA) using clinical and epidemiological data. METHODS: All septic arthritis cases of the knee and hip diagnosed and treated in our institution from 2006 to 2012 were evaluated retrospectively. Only patients with cultures identified as microbial agents were included in the study. The clinical and epidemiological characteristics of the patients were analyzed, seeking the differences between populations affected by MRSA and oxacillin-sensitive Staphylococcus aureus (MSSA). RESULTS: S. aureus was isolated in thirty-five patients (46.0%) in our total sample, 25 in the knee and 10 in the hip. Of these 35 patients, 22 presented with MSSA and 13 presented with MRSA. Provenance from a health service-related environment, as described by the Centers for Disease Control and Prevention, was the only variable associated with oxacillin-resistant strains of this bacterium (p = 0.001). CONCLUSION: Provenance from a health service-related environment was associated with a higher incidence of MRSA-related septic arthritis, suggesting that this agent should be considered in the initial choice of antibiotic treatment. Previous surgeries of the knee or affected limb and the absence of leukocytes might also be related to infection with this agent.

Formation of a pseudotumor in total hip arthroplasty using a tribological metal-polyethylene pair

The aim here was to report a case of a young adult patient who evolved with tumor formation in the left thigh, 14 years after revision surgery on hip arthroplasty. Davies in 2005 made the first description of this disease in patients undergoing metal-on-metal hip arthroplasty. Over the last decade, however, pseudotumors around metal-on-polyethylene surfaces have become more prevalent. Our patient presented with increased volume of the left thigh 8 years after hip arthroplasty revision surgery. Two years before the arising of the tumor in the thigh, a nodule in the inguinal region was investigated to rule out a malignant neoplastic process, but the results were inconclusive. The main preoperative complaints were pain, functional limitation and marked reduction in the range of motion of the left hip. Plain radiographs showed loosening of acetabular and femoral, and a large mass between the muscle planes was revealed through magnetic resonance imaging of the left thigh. The surgical procedure consisted of resection of the lesion and removal of the components through lateral approach. In respect of total hip arthroplasty, pseudotumors are benign neoplasms in which the bearing surface consists of metal-on-metal, but they can also occur in different tribological pairs, as presented in this case.

What is the role of core decompression in the early stages of osteonecrosis of the femoral head? Evaluation of the surgical result by functional score and radiological follow-up

Objectives This study is aimed at evaluating whether core decompression of the femoral head in the early stages of femoral head osteonecrosis improves patients’ subjective perception of pain and avoids the progression of the disease to a femoral head collapse and a final indication of total hip arthroplasty. Methods Eighteen patients (30 hips) in the early stages of the disease (Ficat and Arlet 1 and 2A) were evaluated through clinical, radiological, risk factor maintenance, and by the functional Merle D’Aubigné, and Postel score before and after core decompression of the femoral head. Results There was an improvement of symptoms up to the sixth month in 83.3% of the hips evaluated through the Merle D’Aubigné and Postel score. However, 73.3% of the cases evolved with femoral head collapse, and in 50%, total hip arthroplasty was indicated regardless of whether or not the risk factors were maintained. Conclusions Core decompression of the femoral head improves patients’ pain early in the initial stages of the pathology. However, it does not alter the prognosis and the ultimate indication of total hip arthroplasty in the final stages of the disease.

Clinical and radiographic outcomes of hip resurfacing arthroplasty after eight years – a retrospective study

Objective To assess the clinical and radiographic outcomes of hip resurfacing arthroplasty for the treatment of hip osteoarthritis. Methods This study retrospectively assessed 30 patients with hip osteoarthritis who underwent hip resurfacing arthroplasty between 2005 and 2014. Patients of both genders suffering from advanced primary and secondary hip osteoarthritis were included in the study. Data were collected about postoperative complications and the need for revision of the arthroplasty. Antero-posterior pelvis and lateral hip x-rays were performed in order to classify osteolysis according to the Amstutz criteria; the Lequèsne index of severity for osteoarthritis of the hip and the UCLA activity level questionnaires were answered pre- and postoperatively. Results After a mean follow-up of eight years, a statistically significant improvement was observed between the mean of the outcomes of both scores, when compared pre- and postoperatively (p < 0.001). Nevertheless, there was a high incidence of arthroplasty revision (20%), related to the size of the femoral stem and errors in surgical technique. Conclusion Using the appropriate technique, hip resurfacing arthroplasty can present good results in well-selected patients.

Use of closed suction drainage after primary total hip arthroplasty: a prospective randomized controlled trial

Objective This study aimed to investigate drain use in a controlled population of patients with hip osteoarthritis undergoing primary total hip arthroplasty. Methods This prospective controlled trial evaluated 93 patients randomized into two groups: a group that received drains and a group that did not. The patients who were randomized to the drain group used a 3.2 mm drain placed under the fascia that was kept in place for 24 h. Postoperative evaluations were performed after 24 h and then three, six, and 12 weeks after total hip arthroplasty. The primary outcome was perioperative blood loss in both groups 24 h after total hip arthroplasty. The other parameters that were evaluated included mid-thigh circumference, the rate of blood transfusion, hematocrit, inflammatory serum levels, and the Harris Hip Score. Results The clinical and laboratory data revealed no differences between the study groups with respect to blood loss and need for blood transfusion, duration of hospital stay, reoperation rate, complications, inflammatory serum markers, and the Harris Hip Score. Patients without closed suction drainage reported higher pain levels after 24 h (VAS score 1 vs. 2, p < 0.01). Conclusion Similar clinical and laboratory outcomes were found in both cohorts.

A modified iliofemoral approach to intrapelvic acetabular revision – technical note

Among the patterns of acetabular osteolysis associated with acetabular loosening, the authors emphasize the severity of pelvic dissociation and medial segmental losses in which the quadrilateral lamina is severely affected. Such lesions are potentially lethal in cases of large vascular injury. This note aimed to describe a modified iliofemoral approach in cases of massive intrapelvic migration of the acetabular component in patients with total proximity of the iliac vascular bundle and absence of an anatomical demarcation plane between the migrated contents and the iliac bundle. This approach was performed in 12 of 21 patients who had these criteria.

TWO CLASSIFICATIONS FOR SURGICAL WOUND HEMATOMA AFTER TOTAL HIP REPLACEMENT

ABSTRACT Objective: To determine the reliability of two classification methods for wound hematoma after total hip replacement. Methods: This prospective cohort study was conducted on patients who underwent total hip replacement for hip osteoarthritis between May 2014 and April 2015. Epidemiological, surgical, and functional data were assessed. Two experienced hip surgeons evaluated 75 pictures of wounds taken 24 hours after surgery. Both evaluators performed the analysis twice, with a 6-week interval between the two analyses. The subjective classification was divided into four different categories describing the hematoma: absent, mild, moderate, and severe. The objective classification was derived from mathematical calculation of the area of the hematoma using a grid superimposed on a picture of the wound. Results: The subjective classification demonstrated an intra-rater agreement of more than 70%, while kappa values showed poor to moderate inter-rater reliability. The objective classification based on mathematical measurements of the hematoma area was more reliable, with good to excellent intra- and inter-rater reliability. Conclusion: The objective classification demonstrated higher intra- and inter-rater reliability. The classification methods used in this study could serve as a useful instrument for orthopedic surgeons, researchers, and health care providers when assessing wound hematomas after total hip replacement. Level of Evidence II; Development of diagnostic criteria on consecutive patients (with universally applied reference ‘‘gold’’ standard).