Maurício Kfuri Júnior

Individualized ACL reconstruction

AbstractThe pivot shift test is the only physical examination test capable of predicting knee function and osteoarthritis development after an ACL injury. However, because interpretation and performance of the pivot shift are subjective in nature, the validity of the pivot shift is criticized for not providing objective information for a complete surgical planning for the treatment of rotatory knee laxity. The aim of ACL reconstruction was eliminating the pivot shift sign. Many structures and anatomical characteristics can influence the grading of the pivot shift test and are involved in the genesis and magnitude of rotatory instability after an ACL injury. The objective quantification of the pivot shift may be able to categorize knee laxity and provide adequate information on which structures are affected besides the ACL. A new algorithm for rotational instability treatment is presented, accounting for patients’ unique anatomical characteristics and objective measurement of the pivot shift sign allowing for an individualized surgical treatment. Level of evidence V.

Fraturas do planalto tibial

As fraturas do planalto tibial sao lesoes articulares cujos principios de tratamento envolvem a reducao anatomica da superficie articular e a restauracao funcional do eixo mecânico do membro inferior. Contribuem para a tomada de decisoes no tratamento dessas fraturas o perfil do paciente, as condicoes do envelope de tecidos moles, a existencia de outros traumatismos associados e a infraestrutura disponivel para abordagens cirurgicas. Para as fraturas de alta energia, o tratamento estagiado, seguindo o principio do controle de danos, tem como prioridade a manutencao do alinhamento do membro enquanto se aguarda a resolucao das mas condicoes de tecidos moles. Ja nos traumas de baixa energia, desde que os tecidos moles nao sejam um fator adverso, o tratamento deve ser realizado em tempo unico, com osteossintese definitiva. Fixacao estavel e movimento precoce sao variaveis diretamente relacionadas com os melhores prognosticos. Desenvolvimentos recentes, como os implantes com estabilidade angular, substitutos osseos e imagens tridimensionais para controle intraoperatorio, deverao contribuir para cirurgias menos invasivas e melhores resultados.

Osteotomia alta da tíbia com cunha de abertura medial: relevância biomecânica da cortical oposta

OBJETIVO: Avaliar o impacto da integridade da cortical lateral osteo-tomia alta de tibia (OAT) com cunha de abertura. METODOS: Modelos experimentais artificiais em poliuretano foram fixados com placa DCP® 4,5mm. Cunhas de abertura foram confeccionadas para simular a distracao da osteotomia alta da tibia. Realizadas falhas na cortical lateral para simular fraturas e fixadas com diferentes tipos de parafusos. Ensaios de torcao e compressao axial foram realizados. 04 diferentes grupos foram constituidos. RESULTADOS: As medidas de torcao registradas no grupo com cortical integra foram superiores aquelas obtidas no grupo com cortical rompida (p 0,05). As medidas de compressao obtidas no grupo com cortical integra foram superiores aos demais grupos (p 0,05). CONCLUSAO: A cortical lateral integra agrega estabilidade as osteotomias com cunha de abertura medial. Modelo com cortical integra evidenciou superioridade biomecânica em rigidez nos ensaios de torcao e compressao. Nos ensaios torcionais, os modelos com falha de continuidade cortical com parafusos de estabilizacao lateral de compressao ou de posicao apresentaram equivalencia aos modelos com cortical integra.

Internal fixators: a safe option for managing distal femur fractures?

OBJECTIVE: Evaluate safety and reliability of internal fixator for the treatment of intra-articular and periarticular distal femur fractures. METHODS: Retrospective data evaluation of 28 patients with 29 fractures fixed with internal fixator was performed. There was a predominance of male patients (53.5%), with 52% of open wound fractures, 76% of AO33C type fractures, and a mean follow up of 21.3 months. Time of fracture healing, mechanical axis deviation, rate of infection and postoperative complications were registered. RESULTS: Healing rate was 93% in this sample, with an average time of 5.5 months. Twenty-seven percent of patients ended up with mechanical axis deviation, mostly resulting from poor primary intra-operative reduction. There were two cases of implant loosening; two implant breakage, and three patients presented stiff knee. No case of infection was observed. Healing rate in this study was comparable with current literature; there was a high degree of angular deviation, especially in the coronal plane. CONCLUSION: Internal fixators are a breakthrough in the treatment of knee fractures, but its use does not preclude application of principles of anatomical articular reduction and mechanical axis restoration. Level of Evidence II, Retrospective Study.

Cimento ósseo com gentamicina no tratamento da infecção óssea: estudo da eluição in vitro

OBJECTIVE: To determine the elution characteristics of the antibiotic (gentamicin) mixed with bone cement. METHODS: 480mg of gentamicin was added to 40g of bone cement. Ten specimens were immersed in buffered saline solution for 28 days. Samples of days 1, 2, 7, 14, 21 and 28 were analyzed by the fluorescence polarization immunoassay method. RESULTS: Most of the gentamicin was eluted from the cement in the first 24 hours. A gradual downslide occurred between days 2 and 14. By the 28th day, there was no trace of the antibiotic. CONCLUSION: The mixture released high amounts of the antibiotic in a predictable (therapeutic) manner during at least fourteen days.

Tibial plateau fractures

Tibial plateau fractures are joint lesions that require anatomical reduction of joint surface and functional restoration of mechanical axis of a lower limb. Patient profile, soft tissue conditions, presence of associated injuries and the available infrastructure for the treatment all contribute to the decision making about the best treatment for these fractures. High-energy fractures are usually approached in a staged manner respecting the principle of damage control, and are primarily targeted to maintain limb alignment while the resolution unfavorable soft tissue conditions is pending. Low-energy trauma can be managed on a singlestage basis, provided soft tissues are not an adverse factor, with open reduction and internal fixation. Stable fixation and early painless joint movement are related to a better prognosis. New developments as locked plates, bone replacements, intraoperative 3D imaging are promising and will certainly contribute for less invasive procedures and better outcomes.

O trauma ortopédico no Brasil

O trauma ortopedico e uma das condicoes mais morbidas exis-tentes na sociedade contemporânea, comprometendo a funcao do individuo, sua participacao economica na sociedade e sua integracao familiar e comunitaria. Inumeras sao as causas pelas quais paises como o Brasil, de baixa renda per capita, apresentam deficiencias na prestacao de servicos ao trauma ortopedico. A maioria das solucoes passa por uma abordagem multisetorial dirigida para os pontos fracos existentes no sistema de saude vigente. Entende-se por sistema de saude o conjunto de todas as ativida-des cujo objetivo primario e o de promover, restaurar ou manter a saude.

Reconstruçäo do ligamento cruzado anterior com ligamento patelar: análise comparativa do ligamento autólogo versus homólogo

Resumen pt: O ligamento cruzado anterior e um elemento importante na estabilizacao do joelho.1 A ruptura do ligamento cruzado anterior correlacionam-se lesoes meni...

Conventional plate and screws in medial opening-wedge high tibial osteotomy: are they sufficiently stable? A retrospective study

Objective Opening-wedge osteotomy of the proximal tibia is a widely performed procedure for treating medial gonarthrosis in active patients and in the presence of varus malalignment of the lower limb. The fixation method is controversial, and the use of conventional implants has been abandoned in favor of implants with more modern locking screws. The aim of the present clinical study was to assess the maintenance of the correction achieved in cases wherein fixation was performed using conventional implants. Methods This retrospective study included 51 patients who underwent opening-wedge high tibial osteotomy wherein fixation was performed using conventional implants (4.5-mm DCP plate and non-locking screws). Radiological findings regarding patellar height, tibial slope, and varus correction postoperatively and after consolidation were analyzed to assess the maintenance of the correction achieved by osteotomy. Results The mean loss of correction angle, calculated by the difference between the correction angle in the immediate postoperative period and that after consolidation, was 0.92° ± 0.9°. In addition, changes in patellar height determined by the Blackburne–Peel method and in the sagittal slope of the tibial plateau were not significant or clinically relevant. Conclusions The use of conventional plates and screws is viable in the fixation of opening-wedge high tibial osteotomy because they provide enough stability to maintain the achieved correction until consolidation, without significant changes.

Efeitos mecânicos causados pela variação da inclinação do parafuso excêntrico no orifício da placa de autocompressão

OBJECTIVE: To evaluate the mechanical effects of sloping the load screw on the axial compression with a dynamic plate. METHODS: Artificial parts simulating shaft fragments were fixated with a 4.5 mm, 7 orifice DCP® plate. A load cell recorded axial compression loads in the space between fragments. Eccentric perforation guides with inclinations to the longitudinal and transversal plan of the plate were made for the experiment. Compression was measured in two different sites of the virtual fracture focus. Eight different groups were formed according to the magnitude of inclination and its direction based on the plate orifice. Mechanical assays recorded maximum load and effective maximum load. RESULTS: Screw inclination contrary to the plate orifice sliding slope was related to decreased mean values of maximum compression load and maximum effective compression load 0o > 10oi (p 20oi (p 25oi (p < 0,001). CONCLUSION: In an experimental model, using non pre-stressed DCP® plates, the inclination upon inserting load screws brought about changes in the mean values of axial compression load. There significant differences (p < 0,05) to lower axial compression obtained in the cortical adjacent to the plate when the screws were inserted in inclination with the longitudinal plane in the opposite direction of the sliding slope of the DCP® orifice.