Marco Antônio Percope de Andrade

Muscle co-contraction after anterior cruciate ligament reconstruction: Influence of functional level

BACKGROUND ACL reconstruction is recommended to improve function in subjects with ligament injuries. However, after surgery, some individuals are not able to return to their pre-injury functional level. The mechanisms related to this incapacity are not well understood. STUDY DESIGN Cross-sectional study. METHODS Co-contraction levels were assessed in individuals who returned to their pre-injury functional level and in 10 individuals who were not able to return to full activity after unilateral ACL reconstruction. Electromyography of the vastus lateralis and biceps femoris muscles before and after sudden perturbations applied during the stance phase of walking was used to calculate co-contraction. RESULTS The involved limb had lower co-contraction pre-perturbation than the non-involved limb in both groups (p=0.049). The co-contraction level post-perturbation was significantly higher in the limited return group than in the full return group (p=0.03). CONCLUSION Decreased co-contraction in the involved limb before perturbation may be caused by sensorial changes resulting from surgery or injury. Increased co-contraction levels observed in the limited return group after perturbation may be a compensatory mechanism to make up for possible decreased intrinsic stability of the knee joint. CLINICAL RELEVANCE Increased co-contraction after perturbation does not contribute to knee stability.

Interprosthetic femoral fractures: proposed new classification system and treatment algorithm

Interprosthetic femoral fracture is a rare and challenging fragility fracture issue. Due to aging of the population, the incidence of this type of fracture is gradually and constantly increasing. There is no complete and specific interprosthetic femoral fracture classification system that indicates treatment and prognosis in the literature. The aim of the present study was to describe a new classification system for interprosthetic femoral fractures, and to present a case series and a treatment algorithm derived from the current evidence in the literature.

The use of a joystick technique facilitates closed reduction and percutaneous fixation of multidirectionally unstable supracondylar humeral fractures in children.

Background: Multidirectionally unstable supracondylar fracture of the distal humerus presents with severe instability in both flexion and extension. Closed reduction and percutaneous fixation is challenging and may not be obtained by the traditional reduction maneuver. Methods: We retrospectively evaluated 8 children (4 boys and 4 girls) with a mean age at presentation of 7.6 years (range, 5.3 to 10.9 y) who underwent closed reduction and percutaneous fixation using a joystick technique for the treatment of multidirectionally unstable supracondylar fractures. Clinical and functional results were assessed by the system described by Flynn. Radiographs at last follow-up were compared with those taken immediate after pinning as well as with normal contralateral elbow radiographs at final follow-up. Results: After an average follow-up of 14.5 months (range, 12 to 24 mo), there was no difference between the injured upper extremity and the contralateral side according to cosmetic, functional, and radiographic evaluation. There was no complication such as pin-site infection, loss of fixation, malunion, cubitus varus, iatrogenic nerve injury, or need for further surgery. Conclusions: The joystick technique is a safe and effective method that can avoid aggressive and frustrating attempts of closed reduction and further open reduction of multidirectionally unstable supracondylar fractures of the humerus in children. Level of Evidence: Level IV—case series.

Complications and outcomes of the transfibular approach for posterolateral fractures of the tibial plateau

OBJECTIVE Evaluate complication rates and functional outcomes of fibular neck osteotomy for posterolateral tibial plateau fractures. DESIGN Retrospective case series. SETTING University hospital. PATIENTS From January 2013 to October 2014, 11 patients underwent transfibular approach for posterolateral fractures of the tibial plateau and were enrolled in the study. All patients who underwent transfibular approach were invited the return to the hospital for another clinical and imaging evaluation. INTERVENTION Transfibular approach (fibular neck osteotomy) with open reduction and internal fixation for posterolateral fractures of the tibial plateau. MAIN OUTCOME MEASUREMENTS Complications exclusively related to the transfibular approach: peroneal nerve palsy; knee instability; loss of reduction; nonunion and malunion of fibular osteotomy; and functional outcomes related to knee function. RESULTS Two patients failed to follow-up and were excluded from the study. Of the 9 patients included in the study, no patients demonstrated evidence of a peroneal nerve palsy. One patient presented loss of fracture reduction and fixation of the fibular neck osteotomy, requiring revision screw fixation. There were no malunions of the fibular osteotomy. None of the patients demonstrated clinically detectable posterolateral instability of the knee following surgery. American Knee Society Score was good in 7 patients (77.8%), fair in 1 (11.1%), and poor in 1 (11.1%). American Knee Society Score/Function showed 80 points average (60-100, S.D:11). CONCLUSION The transfibular approach for posterolateral fractures is safe and useful for visualizing posterolateral articular injury. The surgeon must gently protect the peroneal nerve during the entire procedure and fix the osteotomy with long screws to prevent loss of reduction. LEVEL OF EVIDENCE Therapeutic level IV.

Reconstrução do ligamento cruzado anterior: impacto do desempenho muscular e funcional no retorno ao mesmo nível de atividade pré-lesão

RESUMO Introducao: A reconstrucao do LCA objetiva restabelecer a biome- cânica e minimizar a instabilidade do joelho. Objetivo: comparar performance muscular, funcional e frouxidao ligamentar, entre voluntarios que retornaram ao mesmo nivel de atividade pre-lesao e aqueles que nao retornaram, apos a reconstrucao ligamentar. Metodos: 25 homens, operados pelo mesmo cirurgiao, com o ligamento patelar, via artroscopia e mais de dois anos de pos- operatorio. Utilizou-se a Cincinnati Knee Rating System para divisao em: grupo adaptado - 15 individuos - retornaram ao mesmo nivel pre-lesao e grupo nao adaptado - 10 individuos - nao retornaram ao mesmo nivel. Todos realizaram o hop test e a corrida em oito para avaliacao do desempenho funcional. A performance muscular foi avaliada pelo dinamometro isocinetico (Biodex System 3 Pro ® ) e a frouxidao ligamentar determinada pelo artrometro KT-1000 (Med- metric ® ). Utilizou-se o teste t independente e ANOVA para analise de associacao. Resultados: nao houve diferenca significativa entre os grupos em nenhuma das variaveis testadas e nao houve diferenca entre os membros - operado e nao operado. Conclusao: O nao retorno ao mesmo nivel funcional pre-lesao nao pode ser explicado pela frouxidao ligamentar residual ou pelas diferencas do desempenho muscular e funcional. Descritores: Reabilitacao; Joelho; Biomecânica. SUMMARY Introduction: ACL reconstruction targets the reestablishment of joint biomechanics and minimization of knee instability. Objective: to compare muscular and functional performances, and passive joint laxity between volunteers who, after ligament reconstruction, returned to the same pre-injury activity level and those who did not, Methods: 25 men who had their ACL ligament arthroscopically reconstructed (patellar ligament) by the same surgeon, at least two years previously were included in the study. The Cincinnati Knee Rat- ing System was used in order to divide the volunteers into: Adapted Group - 15 individuals who returned to the same pre-injury activity level - and Non-adapted Group - 10 individuals who did not return to their pre-injury level. The assessment of functional performance was carried out by means of the hop and the figure-eight ratio tests. Muscular performance was evaluated by an isokinetic dynamometer and passive joint laxity was assessed by the KT-1000 arthrometer. Data analyses were performed by means of t-test and ANOVA. Results: No significant differences were found between the groups for tested variables. There were, also, no differences between legs (operated and not operated). Conclusion: Passive joint laxity or muscular and functional performances cannot explain the return of the individuals to their same pre-injury functional level.

Avaliação prospectiva dos pacientes submetidos à artroplastia total do joelho com e sem colocação de dreno de sucção

OBJECTIVE: Our aim is to prospectively evaluate the standard evolution and post-operative complications related to the use of suction drainage devices when compared to not using these devices in TKA. METHODS: Forty-two patients from a clinic referred to knee surgery were included. Fifteen patients did not receive suction drainage postoperatively and 27 received suction drainage. The parameters evaluated were the range of movement, hematometric indices, knee circumference, and complications for each group. Patients were observed for six months after the surgical procedure. RESULTS: There were no statistically significant differences in knee circumference, hemoglobin, hematocrit, transfusion rate, and infection index. The analysis of the range of movement did not reveal statistically significant differences between the groups preoperatively (p=0.126), during the first postoperative day (p=0.583), fifth to seventh postoperative day (p=0.076) and at six months follow-up (p=0.848). There was a statistically significant difference between groups in the comparison during the 14th and 28th postoperative days (p=0.025). CONCLUSION: In conclusion, there is no benefit to using closed suction drains beyond six months after TKA. However, the range of movement at the end of the first month is superior in patients that received suction drainage.

Prevention of lower-limb lesions and reduction of morbidity in diabetic patients.

Objective To assess the impact of a diabetic foot outpatient clinic on reducing the morbidity of this disease, with emphasis on lower-limb lesions. Methods This was a prospective observational study with a target population of 30 cases out of a total of 77 patients in the diabetic foot outpatient clinic. The inclusion criterion was that data relating to laboratory tests, clinical examinations, neuropathic and vascular tests and the elbow-arm index needed to be available from all the patients, with repetition after 18 months of follow-up, so as to analyze their evolution. The statistical analysis was done using the McNemar chi-square test for dependent samples. Results The patients’ mean age was 61 years. All of them had type 2 diabetes mellitus (DM), which had started 14.5 years previously, on average, and 20% had neuropathies. After 18 months, there was no change in the frequency of lesions in diabetes target organs (p = 1.000) or in the neuropathy rate (p = 1.000). However, there were significant improvements in neuropathic symptoms, from 70% to 36.7% (p = 0.035), and in peripheral arterial disease, from 73.3% to 46.7% (p = 0.021). There was also a decrease in ulcers from 13.3% to 10% (p = 1.000). Conclusions Creation of specialized outpatient clinics for prevention of diabetic foot is a viable investment, which has low cost compared with the high costs generated through the complications from this disease. This approach noticeably improves the patients’ quality of life, with reduction of morbidity.

Clinical and three-dimensional computed tomographic comparison between ACL transportal versus ACL transtibial single-bundle reconstructions with hamstrings

BACKGROUND Anterior cruciate ligament (ACL) reconstruction using a single-bundle transtibial technique can achieve good or excellent results in more than 90% of patients, but anatomical and biomechanical studies have questioned its ability to restore knee function. The purpose of this study was to evaluate clinical and tomographic results (patient satisfaction, knee function, and tunnel location) of patients who underwent transportal or transtibial single-bundle ACL reconstruction. METHODS Seventy-one patients with ACL tears were included. Forty-one patients were treated by the single-bundle transportal technique and 30 patients were treated by the single-bundle transtibial technique. Clinical and tomographic data were analyzed in both groups. RESULTS After a minimum of 2-year period, the transportal group showed more patients with normal clinical tests than the transtibial group (Lachman [p=0.037], pivot shift [0.00], anterior drawer [0.002]; and arthrometer [0.002] tests). Regarding CT evaluation, transportal and transtibial groups obtained the following femoral central tunnel location (mean [SD]), as percentage: 30 (6.5) and 4.2 (6.4) in high-low axis; and 30.9 (5.9) and 33.2 (4.6) in the deep-shallow axis. Values in the tibial side were, respectively: 38 (6.5) and 46.0 (6.8) in the anterior-posterior axis; and 47.2 (2.5) and 46.9 (2.1) in the medial-lateral axis. CONCLUSION CT findings showed that the transportal single-bundle technique positions the ACL tunnel closer to the native ACL footprint in both femur and tibia compared with the transtibial single-bundle technique. Moreover, mild asymptomatic instability and extension deficit were observed more often in the transtibial group.

Lesser Metatarsal Phalangeal Joint Arthroscopy: Anatomic Description and Comparative Dissection

PURPOSE The aim of this article is to describe the normal arthroscopic anatomy of the lesser metatarsophalangeal (MTP) joints and compare it with that seen in open dissection in cadaveric models. METHODS We performed arthroscopic examination of 18 MTP joints of 6 normal fresh frozen feet. The second, third, and fourth MTP joints were studied because of the higher incidence of pathologic conditions found in these joints. During arthroscopy, each anatomic structure identified was named and marked with different colored sutures using straight suture needles. After the arthroscopic procedure of identification and marking, each MTP joint was dissected, and all the anatomic structures were grossly identified. With these data, the correlation between the arthroscopic and the direct visualization of a normal MTP joint was established. RESULTS Considering the joint regions, we found that the examination accuracy of the medial gutter was 91%, whereas the central joint accuracy reached 100% and the accuracy of the lateral gutter was 98%. The overall arthroscopic accuracy for the lesser MTP joints was 96%. CONCLUSIONS There is a high level of anatomic accuracy at the lesser MTP joint with arthroscopy. CLINICAL RELEVANCE The high overall level of anatomic accuracy of lesser MTP joint arthroscopy (96%) allows us to consider this resource as a valuable tool in the diagnosis and treatment of these joints, expanding the spectrum of indications using this method.

Expanding indications of the horizontal belt plate: A technical note

BACKGROUND Although the standard treatment for articular fractures usually involves open anatomic reduction and internal fixation with the concept of absolute stability, achieving adequate fracture stabilisation in multifragmentary patterns is always challenging. Several anatomical implants were developed to increase stabilisation and improve clinical outcomes in articular fractures. However modern implants, especially in developing countries, are expensive and not always available for routine use. Horizontal rafting plate has recently emerged as an alternative technique to treat complex tibial plateau fractures using simple implants that function as a large washer. OBJECTIVE This technical note aims to describe horizontal belt plate use for treatment of periarticular fractures including the tibial plateau, thereby expanding its initial indication. CONCLUSION Horizontal belt plate is an effective, safe, and inexpensive treatment alternative for complex articular fractures. However, the surgeon must carefully analyse the fracture pattern to verify if the horizontal belt plate can be used alone or with traditional techniques.