Joicemar Tarouco Amaro

Transphyseal Anterior Cruciate Ligament Reconstruction in Patients With Open Physes

PURPOSE The purpose of this study was to evaluate the clinical outcomes of transphyseal anterior cruciate ligament (ACL) reconstruction in patients with open physes. METHODS Transphyseal ACL reconstruction was performed in 26 patients with open tibial and femoral physes (physis >2 mm) by use of autogenous quadrupled hamstrings as grafts. Meniscal tearing was found in 65.3% of the patients. Partial chondral defect injury on the medial femoral condyle was found 6 months after injury in only 2 patients (7.69% of all patients). The mean follow-up period was 45 +/- 18.3 months. Clinical outcomes were evaluated by use of the International Knee Documentation Committee score and Lysholm Knee Scoring Scale, and the anteroposterior stability was objectively measured by use of KT-1000 arthrometer (MEDmetric, San Diego, CA). Possible length and angular discrepancies were observed by conventional radiography in a long film and scanograms of the lower limbs. RESULTS The mean length discrepancy between the operated lower limb and the contralateral limb was 1.2 +/- 3.2 mm (range, -7 to 7 mm). The mean angular deviation difference between the lower limbs was 0.46 degrees +/- 1.1 degrees . New traumatic injuries developed in 3 patients, in whom surgical revision was performed; 1 patient underwent a late meniscectomy. The mean difference in KT-1000 measurement was 2.0 +/- 1.0 mm. The mean subjective International Knee Documentation Committee score was 91.5 +/- 5.7, and the mean score on the modified Lysholm scale was 93.5 +/- 4. Of the patients, 3 (11.2% of all patients) could not return to the same level of physical activity as before injury. CONCLUSIONS ACL reconstruction by use of the transphyseal technique in an immature skeleton with a hamstring autograft, with careful attention being paid to the technique, resulted in good clinical outcomes and no growth abnormalities. LEVEL OF EVIDENCE Level IV, therapeutic case series.

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.

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.

Transplante osteocondral autólogo no tratamento de lesões osteocondrais em atletas

OBJECTIVE: To evaluate clinical outcomes of the osteochondral autologous transplantation technique for treatment of osteochondral defects of the knee in athletes. METHODS: For an average follow-up period of 52 months (30 to 82 months), 19 patients were evaluated pre and post-operatively by using subjective IKDC scores, modified Cincinnati Scores, and rate of return to sports activities. Prognosis according to age, duration of symptoms and location of the lesion was also evaluated. RESULTS: Subjective IKDC scores were 64.6 + 6.8 pre-operatively and 81.8 + 20.1 post-operatively. Modified Cincinnati score was 5.3 + 0.8 pre-operatively and 7.5 + 1.7 post-operatively. Fifty-three percent of the patients returned to pre-operative level of sports activity, 29% returned to a lower level, and 17% did not return to sports. Better results were observed in patients younger than 35 years, with less than one year of symptoms, in patients with femoral condyle defects and without concomitant meniscus or ACL tear. Throclear lesions had inferior results to condylar defects. CONCLUSION: Osteochondral autologous transplantation promoted a subjective improvement of the knee in athletes. Return to sports activity occurred in a specific group of patients

Transplante osteocondral autólogo no tratamento de lesões condrais na patela

1 – Professor Adjunto e Chefe do Departamento de Ortopedia e Traumatologia da Universidade Federal de Sao Paulo – Sao Paulo, SP, Brasil. 2 – Medico Assistente do Instituto Cohen de Ortopedia, Reabilitacao e Medicina do Esporte – Sao Paulo, SP, Brasil. 3 – Estagiario do Instituto Cohen de Ortopedia, Reabilitacao e Medicina do Esporte – Sao Paulo, SP, Brasil. 4 – Membro do Centro de Traumatologia do Esporte (CETE) do Departamento de Ortopedia e Traumatologia da Universidade Federal de Sao Paulo – Sao Paulo, SP, Brasil. 5 – Medica do Grupo do Joelho da Faculdade de Ciencias Medicas da Santa Casa de Sao Paulo – Sao Paulo, SP, Brasil. 6 – Radiologista da Clinica de Diagnostico por Imagem do Hospital do Coracao – Sao Paulo, SP, Brasil.

Surgical treatment of chondral knee defects using a collagen membrane – autologus matrix-induced chondrogenesis

Objectives To evaluate the clinical and functional results of patients diagnosed with full-thickness chondral defects on symptomatic knees who underwent a biological repair technique using autologous matrix-induced chondrogenesis. Methods Seven patients who underwent surgical treatment due to chondral lesions in the knee by autologous matrix-induced chondrogenesis were evaluated. The Lysholm, Kujala and visual analog scale of pain questionnaires were applied before and 12 months after the surgery. Nuclear magnetic resonance images were evaluated 12 months after surgery according to MOCART (magnetic resonance observation of cartilage repair tissue) cartilage repair tissue score. Results Of the seven patients evaluated, three presented defects classified as grade III and four as grade IV according to the International Cartilage Repair Society classification. Chondral defects were located in the medial femoral condyle (n = 2), patella (n = 2), and trochlea (n = 3). The mean age of the patients (six men and one woman) was 37.2 years (24–54 years). The mean chondral defect size was 2.11 cm2 (1.0–4.6 cm2). After 12 months, post-operative nuclear magnetic resonance showed resurfacing of the lesion site with scar tissue less thick than normal cartilage in all patients. The mean MOCART score was 66.42 points. A significant decrease in pain and an improvement in the Lysholm and Kujala scores were observed. Conclusion The use of the collagen I/III porcine membrane was favorable for the treatment of chondral and osteochondral lesions of the knee when assessing the results using the VAS, Lysholm, and Kujala scores 1 year after surgery, as well as when assessing the magnetic resonance image of the lesion 6 months after surgery.

OSTEOCHONDRAL AUTOLOGOUS TRANSPLANTATION FOR TREATING CHONDRAL LESIONS IN THE PATELLA.

Objective: The primary aim of this study was to assess the clinical and functional evolution of patients with total-thickness symptomatic cartilaginous injury of the patellar joint surface, treated by means of osteochondral autologous transplantation. Methods: This prospective study was conducted from June 2008 to March 2011 and involved 17 patients. The specific questionnaires of Lysholm, Kujala and Fulkerson were completed preoperatively and one year postoperatively in order to assess the affected knee, and SF-36 was used to assess these patients’ general quality of life. The nonparametric paired Wilcoxon test was used for statistical analysis on the pre and postoperative questionnaires. The data were analyzed using the SPSS for Windows software, version 16.0, and a significance level of 5% was used. Results: The Lysholm preoperative and postoperative average scores were 54.59 and 75.76 points (p < 0.05). The Fulkerson pre and postoperative average scores were 52.53 and 78.41 points (p < 0.05). Conclusions: We believe that autologous osteochondral transplantation is a good treatment method for total-thickness symptomatic chondral lesions of the joint surface of the patella.