Luiz Gabriel Betoni Guglielmetti

Anterior cruciate ligament reconstruction: a new cortical suspension device for femoral fixation with transtibial and transportal techniques

BackgroundIn the field of anterior cruciate ligament (ACL) reconstruction, there is still no consensus regarding the proper fixation method and position of the tunnels. The primary objective of this paper was to describe a new fixation device, the Endo Tunnel Device (ETD®), for both techniques (transtibial and transportal), as well as the associated difficulties and the intraoperative and postoperative intercurrences. The secondary objective was to describe a preliminary clinical evaluation (6 months of follow-up) comparing these techniques.MethodsThis was a prospective, randomized study involving 80 patients with ACL reconstructions using the ETD® for femoral fixation. Forty patients underwent the transtibial technique, and 40 patients underwent the transportal technique. Patients were evaluated by radiography, physical examination, the KT1000 arthrometer, and Lysholm and the International Knee Documentation Committee (IKDC) scores.ResultsThere were more intraoperative intercurrences in the transportal group (soft tissue device fixation, short femoral tunnel, and short graft inside the tunnel). The IKDC scores were significantly better in the transportal group.ConclusionsThe ETD® was demonstrated to be a safe femoral fixation device in this trial; its use in both the transtibial and transportal techniques is technically simple and is associated with few intra- or postoperative complications.

Artroplastia total do joelho com o apoio tibial móvel: avaliação dos resultados a médio prazo

OBJECTIVE: Evaluation of mid-term follow up results of the application of a total knee replacement with a mobile tibial bearing design. METHODS: Ninety six patients (107 knees) were submitted to total knee Arthroplasty, performed with a model of prosthesis with rotating mobility in the tibial component. The patients were evaluated after a mean follow-up of 52.7 months - standard deviation 21.94 (minimum 24 months and maximum 120 months) through the Knee Society Clinical Rating System (KSCRS), with a mean outcome of 78.22 points. RESULTS: The complications that occurred immediately after or during the surgery included: one wound dehiscence with spontaneous healing, two patellar fractures, one fracture of the medial condyle of the femur, three peroneal nerve impairments, and one sympathetic reflex nervous distrophy. Subsequent complications were: one patellar fracture, one distal fracture of the femur, four aseptic loosenings and four deep joint infections, which required arthroplastic revisions. CONCLUSION: With the exception of the cases requiring arthroplastic revision due to septic or aseptic loosening, the authors conclude that the clinical and functional results obtained with Total Knee Replacement with a mobile bearing component, in a mid-term follow-up, were good.

Comparative evaluation of the results of three techniques in the reconstruction of the anterior cruciate ligament, with a minimum follow-up of two years

Objective To compare the clinical results of the reconstruction of the anterior cruciate ligament by transtibial, transportal, and outside-in techniques. Methods This was a retrospective study on 90 patients (ACL reconstruction with autologous flexor tendons) operated between August 2009 and June 2012, by the medial transportal (30), transtibial (30), and “outside-in” (30) techniques. The following parameters were assessed: objective and subjective IKDC, Lysholm, KT1000, Lachman test, Pivot-Shift and anterior drawer test. Results On physical examination, the Lachman test and Pivot-Shift indicated a slight superiority of the outside-in technique, but without statistical significance (p = 0.132 and p = 0.186 respectively). The anterior drawer, KT1000, subjective IKDC, Lysholm, and objective IKDC tests showed similar results in the groups studied. A higher number of complications were observed in the medial transportal technique (p = 0.033). Conclusion There were no statistically significant differences in the clinical results of patients undergoing reconstruction of the anterior cruciate ligament by transtibial, medial transportal, and outside-in techniques.

Positioning of the femoral tunnel in anterior cruciate ligament reconstruction: functional anatomical reconstruction

The aim of this study was to review and update the literature in regard to the anatomy of the femoral origin of the ACL, the concept of the double band and its respective mechanical functions, and the concept of direct and indirect fibres in the ACL insertion. These topics will be used to help determine which might be the best place to position the femoral tunnel and how this should be achieved, based on the idea of functional positioning, that is, where the most important ACL fibres in terms of knee stability are positioned. Low positioning of the femoral tunnel, reproducing more of the posterolateral band, and positioning the tunnel away from the lateral intercondylar ridge, that is, in the indirect fibres, would theoretically rebuild a ligament that is less effective in relation to knee stability. The techniques described to determine the femoral tunnel’s centre point all involve some degree of subjectivity; the point is defined manually and depends on the surgeon’s expertise. The centre of the ACL insertion in the femur should be used as a parameter. Once the centre of the ligament in its footprint is marked, the centre of the tunnel must be defined, drawing the marking toward the intercondylar ridge and anteromedial band. This will allow the femoral tunnel to occupy the region containing the most important original ACL fibres in terms of this ligament’s function.

RETORNO AO ESPORTE APÓS ARTROPLASTIA TOTAL DO JOELHO: REVISÃO SISTEMÁTICA

Esta revision sistematica tuvo como objetivo analizar las variables que intervienen en el retorno a las actividades deportivas en los pacientes sometidos a artroplastia total de rodilla (ATR), comprobar el tipo recomendado de deporte, el tiempo para volver al deporte, la satisfaccion del paciente y el nivel la actividad fisica despues de la cirugia. Estudios relacionados con la practica de la actividad fisica y deportiva despues de la ATR fueron seleccionados por dos revisores independientes. Once estudios (10 transversales retrospectivos y 1 caso control) fueron incluidos. La mayoria de los pacientes que participaron en alguna actividad fisica regular antes de la ATR regreso al deporte despues de la cirugia, siendo mas comunes los deportes de bajo impacto, como la caminata, deportes acuaticos, golf, bicicleta estatica, entre otros. Fue posible observar que el nivel de actividad fisica no depende del dolor ni de los sintomas postoperatorios, sino de la satisfaccion con la cirugia, motivacion y capacidad funcional de los individuos. El tiempo para volver al deporte vario de seis a 18 meses despues de la ATR. Aunque algunos estudios muestran que los cirujanos no recomiendan la practica de deportes de alto impacto despues de la cirugia, algunos estudios mostraron buenos resultados, desde que sean considerados el nivel de actividad previo a la cirugia, la poblacion adecuada y la expectativa del paciente en el postoperatorio. Por lo tanto, se concluye que el retorno al deporte despues de la ATR no solo es posible, como se recomienda en los niveles de recreo, y un paciente colaborador, bien informado y adecuadamente entrenado puede mejorar la aptitud tanto a nivel funcional y cardiovascular como psicologico, con aumento de la autoestima y calidad de vida. Tambien existe la necesidad de mas estudios de buena calidad metodologica como ensayos clinicos aleatorios sobre los efectos (beneficios y danos) de deportes de alto impacto para los pacientes sometidos a ATR.

TRANSTIBIAL VERSUS ANTEROMEDIAL PORTAL TECHNIQUES IN ACL RECONSTRUCTION

Introduccion: Aunque los resultados del ligamento cruzado anterior (LCA) estan bien documentados en numerosos estudios, con buenos a excelentes resultados en la mayoria de los casos, algunos temas como el posicionamiento del tunel todavia son discutidos y estudiados. Objetivo: Comparar los resultados clinicos objetivos y subjetivos de la reconstruccion del LCA utilizando la tecnica transtibial y la tecnica transportal. Metodos: Estudio prospectivo aleatorizado de 80 pacientes sometidos a reconstruccion del ligamento cruzado anterior por el mismo cirujano, con 40 pacientes operados mediante la tecnica transtibial y 40 mediante tecnica transportal. Hubo nueve perdidas y 34 pacientes del grupo transtibial y 37 en del grupo transportal fueron re-evaluados durante un periodo de seguimiento de 2 anos. La evaluacion clinica consistio en examen fisico, evaluacion KT-1000TM, puntuaciones de Lysholm e (International Knee Documentation Committee) - IKDC objetiva y subjetiva. Resultados: En cuanto a la prueba de Lachman y la prueba de pivot shift, hemos observado mas casos de inestabilidad en el grupo transtibial, pero sin significacion estadistica (p = 0,300 y p = 0,634, respectivamente). En cuanto a la prueba del cajon anterior, los grupos presentaron resultados similares (p = 0,977). En cuanto a la evaluacion con KT-1000TM, los resultados promedio fueron de 1,44 para el grupo transtibial y 1,23 para el grupo transportal, sin significacion estadistica (p = 0,548). Separamos las puntuaciones IKDC objetivo en dos grupos: Grupo 1, pacientes con IKDC Ay Grupo 2, pacientes con IKDC B, C o D, sin significacion estadistica (p = 0,208). En lo que respecta a la puntuacion de Lysholm, el grupo transtibial tenia puntuacion media de 91,32 y el grupo transportal tuvo puntuacion media de 92,81. Las puntuaciones medias de IKDC subjetivo fueron 90,65 para el grupo transtibial y 92,65 para el grupo transportal. Tres re-roturas fueron encontradas en el grupo transtibial y tres en el grupo transportal. Conclusiones: No hubo diferencias significativas en las evaluaciones clinicas subjetivas y objetivas entre los pacientes sometidos a la reconstruccion del ligamento cruzado anterior utilizando las tecnicas transtibial y transportal.

Total knee arthroplasty with mobile tibial weight-bearing: clinical evaluation after a minimum of five years of postoperative follow-up.

Objective To evaluate the medium and long term results from total knee arthroplasty with rotating tibial weight-bearing. Methods Between January 2000 and July 2007, 162 patients underwent total knee arthroplasty with mobile tibial weight-bearing. Among these, 96 were evaluated in a previous study with a mean follow-up of 4 years. In the present study, the same group was invited back for reassessment and the results were analyzed. Sixty-nine patients responded to this call (79 knees), and they were evaluated in accordance with the Knee Society Rating System (KSRS), after a mean follow-up of 8 years and 8 months (ranging from 5.5 and 13 years). Results A mean KSRS score of 74.41 points was obtained, with good or excellent results. Conclusion The medium and long-term results from total knee arthroplasty with mobile tibial weight-bearing were good, and a mean score of 74.41 points in the Knee Society Clinical Rating System was attained.

Resultados da tenotomia dos músculos adutores do quadril na paralisia cerebral espástica

OBJETIVO: Avaliacao radiografica da evolucao dos quadris submetidos a liberacao de partes moles. METODOS: Avaliacao retrospectiva de 101 pacientes com paralisia cerebral submetidos a liberacao de partes moles, no periodo entre 1991 e 2006. Destes, 44 pacientes com criterios de inclusao, 23 do sexo masculino e 21 do feminino, 34 dipareticos e 10 tetrapareticos. Funcionalmente, 29 nao andadores, cinco andadores domiciliares e 10 andadores comunitarios. Foram mensurados o indice acetabular (IA) e indice de Reimers (IR) nas radiografias pre e pos-operatoria, com tempo minimo de seguimento de tres anos. A idade media na cirurgia foi 6,4 anos. RESULTADOS: Considerou-se bom resultado os quadris com diminuicao ou aumento menor que 10% do IR (52% deste estudo). Observou-se melhora evidente do IR, alem de apresentar piores resultados nos pacientes maiores de cinco anos de seguimento pos-operatorio. CONCLUSAO: Deve-se realizar a liberacao de partes moles, o mais precocemente possivel, independentemente da idade, condicao deambulatoria, tipo clinico, IR, IA e sexo, assim que apresentar abducao menor que 30 graus clinicamente, devido aos beneficios quanto a marcha, prevencao e tratamento da subluxacao, higienizacao e alivio da dor.