Julio Cesar Gali

Importance of anatomically locating the infrapatellar branch of the saphenous nerve in reconstructing the anterior cruciate ligament using flexor tendons

Objective To describe the path of the infrapatellar branch of the saphenous nerve (IBSN) using the medial joint line, anterior tibial tuberosity (ATT), tibial collateral ligament and a horizontal line parallel to the medial joint line that passes over the ATT, as reference points, in order to help surgeons to diminish the likelihood of injuring this nerve branch during reconstruction of the anterior cruciate ligament (ACL) using flexor tendons. Methods Ten frozen knees that originated from amputations were examined. Through anatomical dissection performed with the specimens flexed, we sought to find the IBSN, from its most medial and proximal portion to its most lateral and distal portion. Following this, the anatomical specimens were photographed and, using the ImageJ software, we determined the distance from the IBSN to the medial joint line and to a lower horizontal line going through the ATT and parallel to the first line. We also measured the angle of the direction of the path of the nerve branch in relation to this lower line. Results The mean angle of the path of the nerve branch in relation to the lower horizontal line was 17.50 ± 6.17°. The mean distance from the IBSN to the medial joint line was 2.61 ± 0.59 cm and from the IBSN to the lower horizontal line, 1.44 ± 0.51 cm. Conclusion The IBSN was found in all the knees studied. In three knees, we found a second branch proximal to the first one. The direction of its path was always from proximal and medial to distal and lateral. The IBSN was always proximal and medial to the ATT and distal to the medial joint line. The medial angle between its direction and a horizontal line going through the ATT was 17.50 ± 6.17°.

Radiographic study on the tibial insertion of the posterior cruciate ligament.

Objective To establish the radiographic distances from posterior cruciate ligament (PCL) tibial insertions centers to the lateral and medial tibial cortex in the anteroposterior view, and from these centers to the PCL facet most proximal point on the lateral view, in order to guide anatomical tunnels drilling in PCL reconstruction and for tunnel positioning postoperative analysis. Study design Controlled laboratory study. Methods Twenty cadaver knees were evaluated. The PCLs bundles tibial insertions were identified and marked out using metal tags, and the knees were radiographed. On these radiographs, the bundles insertion sites center location relative to the tibial mediolateral measure, and the distances from the most proximal PCL facet point to the bundles insertion were determined. All measures were calculated using the ImageJ software. Results On the anteroposterior radiographs, the mean distance from the anterolateral (AL) bundle insertion center to the medial tibial edge was 40.68 ± 4.10 mm; the mean distance from the posteromedial (PM) bundle insertion center to the medial tibial edge was 38.74 ± 4.40 mm. On the lateral radiographs, the mean distances from the PCL facet most proximal point to AL and PM bundles insertion centers were 5.49 ± 1.29 mm and 10.53 ± 2.17 mm respectively. Conclusions It was possible to establish a radiographic pattern for PCL tibial bundles insertions, which may be useful for intraoperative tunnels locations control and for postoperative tunnels positions analysis.

O comprimento dos túneis femorais varia com a flexão do joelho na reconstrução anatômica do ligamento cruzado anterior

OBJECTIVE: The objective of our study was to evaluate the effect that knee flexion angle while femoral tunnels are being drilled may have on the length of these tunnels, in anatomical reconstruction of the anterior cruciate ligament. METHODS: We measured the lengths of anteromedial and posterolateral tunnels for the anterior cruciate ligament in 20 unpaired anatomical knee specimens (10 right and 10 left knees), all with the cartilage and cruciate ligaments intact. Tunnels were drilled with the knees flexed at 90o, 110o and 130o, through the accessory anteromedial portal, with a 2.5 mm drill. The statistical analysis was done by means of Friedmans variance analysis and the Mann-Whitney U test. RESULTS: The mean anteromedial femoral tunnel lengths measured with the knees flexed at 90o, 110o and 130o were 33.7 (± 3.72) mm, 37.4 (± 2.93) mm and 38.8 (± 3.31) mm, respectively. For the posterolateral femoral tunnel lengths, the results were 32.1 (± 4.24) mm, 37.3 (± 4.85) mm and 38.4 (± 2.51) mm, respectively. Friedmans variance analysis showed that there was a significant difference between the lengths of the tunnels drilled with 90o and 110o of flexion angle, but showed that there was no significant difference between the tunnels drilled with flexion of 110o and 130o (P < 0.05). CONCLUSIONS: It is possible to drill the femoral tunnels through the accessory anteromedial tunnel with the knee flexed at 110o in such a way as to produce a tunnel of sufficient length for a good bone-graft interface.

Anatomical reconstruction of the anterior cruciate ligament: a logical approach

We describe the surgical approach that we have used over the last years for anterior cruciate ligament (ACL) reconstruction, highlighting the importance of arthroscopic viewing through the anteromedial portal (AMP) and femoral tunnel drilling through an accessory anteromedial portal (AMP). The AMP allows direct view of the ACL femoral insertion site on the medial aspect of the lateral femoral condyle, does not require guides for anatomic femoral tunnel reaming, prevents an additional lateral incision in the distal third of the thigh (as would be unavoidable when the outside-in technique is used) and also can be used for double-bundle ACL reconstruction.

Descriptive anatomy of the anterior cruciate ligament femoral insertion

Objective To evaluate the morphology of the anterior cruciate ligament (ACL) femoral insertion in order to describe its anatomical features and insertion site location, with the aim of verifying if the ACL femoral insertion has individual characteristics and to provide information for appropriate femoral tunnel placement on anatomic ACL reconstruction. Methods Sixteen knees obtained from amputations were studied. The ACL femoral bundles and insertion shape were observed macroscopically, and the ligaments insertion length and thickness were measured with a digital caliper. The distances between the limits of the ligament to the articular cartilage, and the measurement of the area of insertion were checked using ImageJ software. Results The ACL femoral insertion site was eccentric, closer to the deep condyle cartilage. In ten knees (62.5%), the ACL femoral insertion was oval; the mean length of the insertion was 16.4 mm, varying from 11.3 to 19.3 mm, the mean thickness varied from 7.85 to 11.23 mm, and the mean area of the insertion was 99.7 mm2, varying from 80.9 a 117.2 mm2. The mean distances between the limits of the ligament to the superficial, deep, and inferior articular cartilage were 9.77 ± 1.21, 2.60 ± 1.20, and 1.86 ± 1.15 mm, respectively. Conclusion There was a 30% to 40% difference between the minimum and maximum results of measurements of ACL femoral insertion length, thickness, and area demonstrating an important individual variation. The insertion site was eccentric, closer to the deep cartilage of the lateral femoral condyle.

Comorbidities, clinical intercurrences, and factors associated with mortality in elderly patients admitted for a hip fracture

Objective To analyze comorbidities and clinical complications, and to determine the factors associated with mortality rates of elderly patients admitted with a hip fracture in a tertiary public hospital. Methods Sixty-seven medical records were reviewed in a retrospective cohort study, including patients equal to or older than 65 years admitted to this institution for hip fracture between January 2014 and December 2014. The evaluated items constituted were the following: interval of time between fracture and hospital admission, time between admission and surgical procedure, comorbidities, clinical complications, type of orthopedic procedure, surgical risk, cardiac risk, and patient outcome. Results The average patients’ age in the sample was 77.6 years, with a predominance of the female gender. Most patients (50.7%) had two or more comorbidities. The main clinical complications during hospitalization included cognitive behavioral disorders, respiratory infection and of the urinary tract. The times between fracture and admission and between admission and surgery were more than seven days in most of cases. The mortality rate during hospitalization was 11.9%, and was directly connected to the presence of infections during hospital stay (p = 0.006), to time between admission and surgery longer than seven days (p = 0.005), to the Goldman Cardiac Risk Index class III (p = 0.008), and to age equal to or greater than 85 years (p = 0.031). Conclusion Patients with hip fractures generally present comorbidities, are susceptible to clinical complications, and have an 11.9% mortality rate.

Tromboprofilaxia na artroplastia total do joelho

The authors report an update of the main methods for preventing deep vein thrombosis after total knee replacement, which are divided into mechanical and pharmacological methods. The current principal used drugs, their dosages, and the comparative risks and benefits are also reported.

Tibial Insertions of the Posterior Cruciate Ligament: Topographic Anatomy and Morphometric Study

Objective To provide anatomical and morphometric basis of the posterior cruciate ligaments tibial insertions in order to assist the creation of anatomical tibial tunnels, in the ligament surgical reconstruction. Material and methods The topographic anatomy and morphometry of the posterior cruciate ligaments anterolateral and posteromedial bundles’ tibial insertions were analyzed in 24 anatomical knee pieces. The pieces were photographed by a digital camera and the images obtained were studied by the software ImageJ, where the bundles’ insertion areas were measured in square millimeters, and the length of structures and the distances between significant points were measured in millimeters. Results In 54.2% of the knees the insertion’ shape was concave; in most pieces (41.6%) the form of insertion was oval. The average posterior cruciate ligaments tibial insertion total area was 88.33 ± 21.66 mm2; the average anterolateral bundles tibial insertion area was 46.79 ± 14.10 mm2 and it was 41.54 ± 9.75 mm2 for the posteromedial bundle. Conclusions The anterolateral bundle has a tibial insertion area larger than the posteromedial bundle; the insertion areas of those bundles in our study, were smaller than the ones found in the literature. The variations in the posterior cruciate ligaments tibial insertion area suggest that there should be an indication for anatomical reconstructions of this ligament using single or double tibial tunnels according to individual characteristics.

Anatomical relationships between Wrisberg meniscofemoral and posterior cruciate ligament's femoral insertions

Objective To evaluate the frequency and morphometry of the Wrisbergs ligament and its relationships with the posterior cruciate ligaments femoral insertion. Study design Controlled laboratory study. Methods 24 unpaired knee pieces, 12 right and 12 left were submitted to a deep dissection of the Wrisberg and posterior cruciate ligaments. The pieces were photographed with a digital camera and ruler; the Image J software was used to measure the ligaments’ insertion areas, in square millimeters. Results The Wrisberg ligament was present in 91.6% of the studied pieces. In those its shape was elliptical in 12 pieces (54.54%). In 68% of the knees, the WL insertion was proximal to the medial intercondilar ridge, close to the PCL posteromedial bundle. The average area for the WL was 20.46 ± 6.12 mm2. This number corresponded to 23.3% of the PCLs average area. Conclusions WL ligament is a common structure in knees. There is a wide variation of its insertion area. Proportionally to the PCLs insertion area the WL ones suggests that it may contribute to the posterior stability of the knee joint.