Luis Eduardo Passarelli Tirico

Anatomy and Histology of the Knee Anterolateral Ligament

Background: Reconstruction of the anterior cruciate ligament (ACL) is one of the most common procedures in orthopaedic surgery. However, even with advances in surgical techniques and implants, some patients still have residual anterolateral rotatory laxity after reconstruction. A thorough study of the anatomy of the anterolateral region of the knee is needed. Purpose: To study the anterolateral region and determine the measurements and points of attachments of the anterolateral ligament (ALL). Study Design: Descriptive laboratory study. Methods: Dissections of the anterolateral structures of the knee were performed in 20 human cadavers. After isolating the ALL, its length, thickness, width, and points of attachments were determined. The femoral attachment of the ALL was based on the anterior-posterior and proximal-distal distances from the attachment of the lateral collateral ligament (LCL). The tibial attachment point was based on the distance from the Gerdy tubercle to the fibular head and the distance from the lateral tibial plateau. The ligaments from the first 10 dissections were sent for histological analysis. Results: The ALL was found in all 20 knees. The femoral attachment of the ALL at the lateral epicondyle averaged 3.5 mm distal and 2.2 mm anterior to the attachment of the LCL. Two distal attachments were observed: one inserts into the lateral meniscus, the other between the Gerdy tubercle and the fibular head, approximately 4.4 mm distal to the tibial articular cartilage. The mean measurements for the ligament were 37.3 mm (length), 7.4 mm (width), and 2.7 mm (thickness). The histological analysis of the ligaments revealed dense connective tissue. Conclusion: The ALL is consistently present in the anterolateral region of the knee. Its attachment to the femur is anterior and distal to the attachment of the LCL. Moving distally, it bifurcates at close to half of its length. The ALL features 2 distal attachments, one at the lateral meniscus and the other between the Gerdy tubercle and the fibular head. Clinical Relevance: The ALL may be important in maintaining normal rotatory limits of knee motion; ALL rupture could be responsible for rotatory laxity after isolated intra-articular reconstruction of the ACL.

Simultaneous anterior cruciate ligament reconstruction and computer-assisted open-wedge high tibial osteotomy: a report of eight cases.

Eight patients, aged 37-50 years, with chronic anterior cruciate ligament (ACL) deficiency, medial compartment osteoarthritis and varus deformity underwent simultaneous arthroscopic ACL reconstruction and open-wedge high tibial osteotomy controlled by a computer navigation system. Despite preoperative planning, the surgeon may need to choose a different osteotomy site during the procedure, invalidating the previous plans. The intraoperative wire control for osteotomies is not precise. The navigation system can help obtain precise alignment during high tibial osteotomy. The average preoperative mechanical axis was 7.5 of varum (sd±1.17°), the average postoperative axis was 1.2° of valgus (sd±1.04°) (p<0.01), and the average correction of the mechanical axis was 8.7° (sd±0.76°). The site of the osteotomy was 3.9 cm (3.5-4.8 cm, sd±0.35 mm) from the articular line, with an inclination of 27.9° (24-35, sd±4.8). The simultaneous use of these procedures allowed proper correction of the knee axis during the surgery. The surgery can be performed concomitantly with ACL reconstruction.

Judet Quadricepsplasty in the Treatment of Posttraumatic Knee Rigidity: Long-Term Outcomes of 45 Cases.

Background: Posttraumatic knee stiffness is a very debilitating condition. Judets quadricepsplasty technique has been used for more than 50 years. However, few reports of quadricepsplasty results exist in the literature. Methods: We report the results of 45 cases of posttraumatic arthrofibrosis of the knee treated with Judets quadricepsplasty. The results of the procedure were analyzed by measuring the degrees of flexion of the operated knees at different time points (before, immediately after, and late postoperatively). Results: The degree of flexion increased from 33.6 degrees (range, 5–80 degrees) preoperatively to 105 degrees (range, 45–160 degrees) immediately after surgery, followed by a slight fall in the range of motion (ROM) in the late postoperative period, which reached an average of 84.8 degrees. There was no significant correlation between knee strength and the patients gender, but there was a slight trend of lower strength with age. Although Judets quadricepsplasty technique dates from more than 50 years ago, it still provides good outcomes in the treatment of rigid knees of various etiologies. In general, all cases showed the same pattern of a small decrease in the ROM in the late postoperative period. Conclusion: Judets quadricepsplasty can increase the ROM of rigid knees. The ROM obtained with the surgery persists long term.

Development of a Fresh Osteochondral Allograft Program Outside North America

Objective To standardize and to develop a fresh osteochondral allograft protocol of procurement, processing and surgical utilization in Brazil. This study describes the steps recommended to make fresh osteochondral allografts a viable treatment option in a country without previous fresh allograft availability. Design The process involves regulatory process modification, developing and establishing procurement, and processing and surgical protocols. Results Legislation: Fresh osteochondral allografts were not feasible in Brazil until 2009 because the law prohibited preservation of fresh grafts at tissue banks. We approved an amendment that made it legal to preserve fresh grafts for 30 days from 2°C to 6°C in tissue banks. Procurement: We changed the protocol of procurement to decrease tissue contamination. All tissues were procured in an operating room. Processing: Processing of the grafts took place within 12 hours of tissue recovery. A serum-free culture media with antibiotics was developed to store the grafts. Surgeries: We have performed 8 fresh osteochondral allografts on 8 knees obtaining grafts from 5 donors. Mean preoperative International Knee Documentation Committee (IKDC) score was 31.99 ± 13.4, improving to 81.26 ± 14.7 at an average of 24 months’ follow-up. Preoperative Knee Injury and Oseoarthritis Outcome Score (KOOS) score was 46.8 ± 20.9 and rose to 85.24 ± 13.9 after 24 months. Mean preoperative Merle D’Aubigne-Postel score was 8.75 ± 2.25 rising to 16.1 ± 2.59 at 24 months’ follow-up. Conclusion To our knowledge, this is the first report of fresh osteochondral allograft transplantation in South America. We believe that this experience may be of value for physicians in countries that are trying to establish an osteochondral allograft transplant program.

Fresh Osteochondral Allograft Transplantation for Fractures of the Knee

Objective The purpose of this study was to evaluate functional outcomes and allograft survivorship among patients with knee fracture who underwent fresh osteochondral allograft (OCA) transplantation as a salvage treatment option. Design Retrospective analysis of prospectively collected data. Setting Department of Orthopaedic Surgery at one hospital. Patients Fresh OCAs were implanted for osteochondral lesions after knee fracture in 24 males and 15 females with an average age of 34 years. Twenty-nine lesions (74%) were tibial plateau fractures, 6 (15%) were femoral condyle fractures, and 4 (10%) were patella fractures. Main Outcome Measurements Clinical evaluation included modified Merle d’Aubigné-Postel (18-point), International Knee Documentation Committee, and Knee Society function scores, and patient satisfaction. Failure of OCA was defined as revision OCA or conversion to total knee arthroplasty (TKA). Results Nineteen of 39 knees (49%) had further surgery. Ten knees (26%) were considered OCA failures (3 OCA revisions, 6 TKA, and 1 patellectomy). Survivorship of the OCA was 82.6% at 5 years and 69.6% at 10 years. Among the 29 knees (74%) that had the OCA still in situ, median follow-up was 6.6 years. Pain and function improved from preoperative to latest follow-up; 83% of patients reported satisfaction with OCA results. Conclusion OCA transplantation is a useful salvage treatment option for osteochondral lesions caused by knee fracture. Although the reoperation rate was high, successful outcome was associated with significant clinical improvement.

Loosening of the Patellar Component and Extra-articular and Transcutaneous Migration After TKA

Replacement of the patella during total knee arthroplasty (TKA) remains controversial. Despite some attempts to establish guidelines for this procedure, there is still no consensus in the literature. When the patella is replaced, the patient is subjected to certain complications, including loosening of the component. The loosened patellar component most commonly migrates to the intra-articular region of the knee. However, there have been a few reports of migration of the component to the extra-articular region, particularly when release of the lateral retinaculum and osteonecrosis of the patella are involved. The authors report a case of patellar component loosening and extra-articular and transcutaneous migration of the component 9 years after TKA. This report is unique because, during the primary procedure, no lateral release was performed and no patellar necrosis was evident on radiographs. The component was removed in the operating room and the wound cleaned and closed. Because of the probable slow migration of the component, there was no communication between the external environment and the joint at the time of surgery. There were no further complications after the wound healed. This case emphasizes the need for periodic radiographic follow-up after TKA.

O uso do transplante osteocondral a fresco no tratamento das lesões osteocondrais do joelho

Treatment of chondral and osteochondral knee lesions in young patients remains a challenge for orthopedic surgeons. The repair techniques currently available in Brazil, such as debridement, microfracture and autologous osteochondral transplantation are insufficient for treating large chondral and osteochondral lesions. Fresh homologous osteochondral transplants have been used in the knee joint in the United States with excellent results. This article had the aims of reviewing the basic science, indi cations, surgical techniques and possible complications and describing the technique of fresh homologous osteochondral transplantation in the knee joint, performed in the Institute of Orthopedics and Traumatology, Hospital das Clinicas, Univer sity of Sao Paulo.

Evaluation of quality of life and walking ability among amputated patients and those who refused to undergo amputation following infection of total knee arthroplasty: Small case series

Background: Patients who undergo transfemoral amputation after infection of a total knee arthroplasty do not have good functional outcomes and have major difficulty walking. Objectives: To evaluate the quality of life and walking ability among patients who underwent amputation and among those who refused to undergo amputation following infection of a total knee arthroplasty. Study design: Retrospective case series. Methods: Patients who received an indication for amputation following an infection of a total knee arthroplasty were evaluated retrospectively. The patients were divided between those who accepted the amputation procedure and those who refused amputation (four amputee vs four non-amputees). Walking ability and quality of life were evaluated using the Short Form–36 questionnaire. Results: The average physical health was 27.4 for the amputees and 31.3 for the non-amputees. The average mental health was 49.9 for the amputees and 47.1 for the non-amputees. In relation to walking ability, only one (25%) of the amputees was able to walk, as opposed to 100% in the non-amputee groups. Conclusion: Twenty-five percent of the amputee patients continued to be able to walk. The functional outcome of non-amputee patients was better, with 100% being able to walk, though with limitations. Clinical relevance This is the first study evaluating patients who refused the amputation procedure and remained with the spacer. Despite the fact that this option is not recommended by the medical community, we believe that these data are useful when discussing, with a patient, quality of life after amputation.

Fresh Osteochondral Allograft Transplantation: Is Graft Storage Time Associated With Clinical Outcomes and Graft Survivorship?:

Background: Regulatory concerns and the popularity of fresh osteochondral allograft (OCA) transplantation have led to a need for prolonged viable storage of osteochondral grafts. Tissue culture media allow a longer storage time but lead to chondrocyte death within the tissue. The long-term clinical consequence of prolonged storage is unknown. Hypothesis: Patients transplanted with OCAs with a shorter storage time would have lower failure rates and better clinical outcomes than those transplanted with OCAs with prolonged storage. Study Design: Cohort study; Level of evidence, 3. Methods: A matched-pair study was performed of 75 patients who received early release grafts (mean storage, 6.3 days [range, 1-14 days]) between 1997 and 2002, matched 1:1 by age, diagnosis, and graft size, with 75 patients who received late release grafts (mean storage time, 20.0 days [range, 16-28 days]) from 2002 to 2008. The mean age was 33.5 years, and the median graft size was 6.3 cm2. All patients had a minimum 2-year follow-up. Evaluations included pain, satisfaction, function, failures, and reoperations. Outcome measures included the modified Merle d’Aubigné-Postel (18-point) scale, International Knee Documentation Committee (IKDC) form, and Knee Society function (KS-F) scale. Clinical failure was defined as revision OCA transplantation or conversion to arthroplasty. Results: Among patients with grafts remaining in situ, the mean follow-up was 11.9 years (range, 2.0-16.8 years) and 7.8 years (range, 2.3-11.1 years) for the early and late release groups, respectively. OCA failure occurred in 25.3% (19/75) of patients in the early release group and 12.0% (9/75) of patients in the late release group (P = .036). The median time to failure was 3.5 years (range, 1.7-13.8 years) and 2.7 years (range, 0.3-11.1 years) for the early and late release groups, respectively. The 5-year survivorship of OCAs was 85% for the early release group and 90% for the late release group (P = .321). No differences in postoperative pain and function were noted between the groups. Ninety-one percent of the early release group and 93% of the late release group reported satisfaction with OCA results. Conclusion: The transplantation of OCA tissue with prolonged storage is safe and effective for large osteochondral lesions of the knee and has similar clinical outcomes and satisfaction to the transplantation of early release grafts.

Evaluation of the isometry of different points of the patella and femur for medial patellofemoral ligament reconstruction

BACKGROUND The location of patellar and femoral fixation of the graft in medial patellofemoral ligament reconstructions has been widely discussed. This study aimed to assess the distances between different patellar and femoral fixation points to identify the least anisometric pairs of points. METHODS Ten cadaver knees were attached to an apparatus that simulated an active range of motion of 120°, with three metallic markers fixed onto the medial side of the patella, and seven markings onto the medial epicondyle. The examined points included the proximal patella pole (1), the patellar center (3), the midpoint between points 1 and 3 (2), a point directly on the epicondyle (6), points 5mm anterior (5) and posterior (7) to the epicondyle, points 5mm anterior to point 5 (4) and 5mm posterior to point 7 (8), and points 5mm proximal (9) and distal (10) to the epicondyle. The distances between patella and femur points were measured by a photogrammetry system at 15° intervals. FINDINGS The pair of points that exhibited the lowest average variability in distance, and hence was the most isometric, was the patella center combined with the anterior to the medial femoral epicondyle. The pairs of points that exhibited the highest average variability in distance, and hence were the least isometric, were the ones located distal or posterior to the medial femoral epicondyle, with less influence by the patellar location. INTERPRETATION Surgeons should avoid positioning the graft distally or posterior to the epicondyle due to the increase in anisometry.