Moisés Cohen

Arthroscopic-Assisted Broström-Gould for Chronic Ankle Instability A Long-Term Follow-up

Background: Lateral ankle sprains account for 85% of ankle lesions. Hypothesis: Combined open and arthroscopic procedures could improve the diagnosis and management of intra-articular lesions and allow surgeons to perform minimally invasive anatomic reconstruction of the lateral ligament complex. Study Design: Case series; Level of evidence, 4. Methods: Forty consecutive patients underwent ankle arthroscopy for recurrent (2 or more episodes) lateral ankle instability unresponsive to nonoperative measures. The clinical diagnosis of mechanical instability was confirmed at imaging (plain radiographs and magnetic resonance imaging [MRI]) and arthroscopic assessment. All patients underwent arthroscopic Broström-Gould repair for management of lateral ankle instability; secondary lesions were also managed. Postoperatively, the American Orthopaedic Foot & Ankle Society (AOFAS) score was administered to assess the functional status; clinical examination and conventional radiographs were performed in all patients. Results: Thirty-eight patients were reviewed at an average postoperative follow-up of 9.8 years. The mean AOFAS score was 90 (range, 44-100) at the last follow-up. No significantly different outcomes were found in patients who had undergone microfractures for management of grade III to IV cartilage lesions compared with patients with no cartilage lesions. Postoperative AOFAS scores were graded as excellent and good in almost all patients (94.7%). Concerning failure rate, 2 patients (5.3%) reported a low AOFAS score: one patient underwent soft tissue removal for anterior impingement, and one received simultaneous medial ankle instability repair. Conclusion: The arthroscopic Broström-Gould–assisted technique could be a viable alternative to the gold-standard Broström-Gould procedure for anatomic repair of chronic lateral ankle instability and management of intra-articular lesions. Prospective randomized controlled trials are needed.

Questionário específico para sintomas do joelho "Lysholm Knee Scoring Scale": tradução e validação para a língua portuguesa

inTRoDUcTion Knee joint internal disturbances are uncountable, presenting variable consequences for an individual’s function and quality of life. The increasing search for physical activities associated to a complex and so vulnerable anatomy of knee joint led to an increase of the number of ligament injuries on this joint, especially on anterior cruciate ligament. Joint instability is reported by patients complaining about missing steps and lack of confidence upon certain movements. Chronic anterior instability evolves with a large incidence of X-ray degenerative changes, as well as meniscal and chondral injuries. Current trend for patients intending to resume sports practice is the indication of knee ligament reconstruction. Knee surgery advancement has been assessed by means of the development of new surgical techniques, new instruments, as well as of surgeons’ specialization. Previously, empirical assessments were made for checking the effectiveness of an established treatment. Many times, those assessments provided wrong conclusions regarding the evolution and quality of the employed techniques. The complexity of knee joint and the number of criteria for evaluating its function and symptoms make measurements and quantification of employed treatments difficult. In 1955, O’Donoghue(1) was the first to develop a system for assessing outcomes. An objective examination and a questionnaire totaling 100 score points was used for assessing outcomes on knee ligament repairs. The answers to each question were “yes” (10 points) or “no” (0 point) kind. Assessment was supplemented by adding subjective criteria, such as stroke, disability, and functional evaluation. Slocum and Larson(2) recognized the need to assess rotational instability and comparative values preand postoperatively. Larson(3) developed a scale of 100 score points based on subjective, objective and functional criteria. At functional aspect, it was concerned to assess an individual’s conditions to walk, run, jump, and squat. Marshall et al.(4), emphasized that the adequate method of assessment should allow a surgeon to determine anatomical injuries and correspondent functional damages. On this ground, they developed, in 1977, the scale “Hospital for Special Surgery Knee Score (HSSKS)”(5), the first specific method used for assessing knee ligament injuries. The HSSKS includes subjective symptoms, subjective function, and SpEciFic QUESTionnaiRE FoR KnEE SYMpToMS THE “LYSHoLM KnEE ScoRinG ScaLE” – TRanSLaTion anD VaLiDaTion inTo poRTUGUESE

Transphyseal Anterior Cruciate Ligament Reconstruction in Patients With Open Physes

PURPOSE The purpose of this study was to evaluate the clinical outcomes of transphyseal anterior cruciate ligament (ACL) reconstruction in patients with open physes. METHODS Transphyseal ACL reconstruction was performed in 26 patients with open tibial and femoral physes (physis >2 mm) by use of autogenous quadrupled hamstrings as grafts. Meniscal tearing was found in 65.3% of the patients. Partial chondral defect injury on the medial femoral condyle was found 6 months after injury in only 2 patients (7.69% of all patients). The mean follow-up period was 45 +/- 18.3 months. Clinical outcomes were evaluated by use of the International Knee Documentation Committee score and Lysholm Knee Scoring Scale, and the anteroposterior stability was objectively measured by use of KT-1000 arthrometer (MEDmetric, San Diego, CA). Possible length and angular discrepancies were observed by conventional radiography in a long film and scanograms of the lower limbs. RESULTS The mean length discrepancy between the operated lower limb and the contralateral limb was 1.2 +/- 3.2 mm (range, -7 to 7 mm). The mean angular deviation difference between the lower limbs was 0.46 degrees +/- 1.1 degrees . New traumatic injuries developed in 3 patients, in whom surgical revision was performed; 1 patient underwent a late meniscectomy. The mean difference in KT-1000 measurement was 2.0 +/- 1.0 mm. The mean subjective International Knee Documentation Committee score was 91.5 +/- 5.7, and the mean score on the modified Lysholm scale was 93.5 +/- 4. Of the patients, 3 (11.2% of all patients) could not return to the same level of physical activity as before injury. CONCLUSIONS ACL reconstruction by use of the transphyseal technique in an immature skeleton with a hamstring autograft, with careful attention being paid to the technique, resulted in good clinical outcomes and no growth abnormalities. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Interobserver reliability of the international society of arthroscopy, knee surgery and orthopaedic sports medicine (ISAKOS) classification of meniscal tears

Background: Consistency of arthroscopic evaluation and documentation in meniscal tears between investigators is essential to the validity of multicenter studies. A group of experts developed a classification of meniscal tears that may be used internationally. Hypothesis: The International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) classification of meniscal tears provides sufficient interobserver reliability for pooling of data from international clinical trials designed to evaluate the outcomes of treatment for meniscal tears. Study Design: Cohort study (diagnosis); Level of evidence, 1. Methods: A pilot study was performed by having 8 members of the committee grade 10 arthroscopic videos for classification of tear depth, rim width, location, tear pattern, and quality of the tissue. The results of the pilot study were used to change the instruction sheet and evaluation form. International interobserver reliability was determined by having 8 orthopaedic surgeons who practice in different countries evaluate 37 arthroscopic videos selected to represent different meniscal tear characteristics. The Spearman ρ correlation coefficient was used to compare the area of the meniscus excised, as drawn on the diagram, with the numeric percentage of meniscus excised. Results: There was an 87% agreement for anterior-posterior location of the tear (κ = .65); 79% agreement for tear pattern (κ = .72); 88% agreement for tear depth (κ = .52); 68% agreement for anterior, middle, and posterior location of the tear (κ = .46); and 72% agreement for tissue quality (κ = .47). There was 54% agreement for the rim width (κ = .25) and 67% agreement if the tear was central to the popliteal hiatus (κ = .36). Based on the Landis and Koch criteria for κ coefficients, there was substantial agreement for anterior-posterior location of the tear and tear pattern; moderate agreement for tear depth, anterior, middle, and posterior location of the tear, and tissue quality; and fair agreement for rim width and if the tear was central to the popliteal tear. Interobserver reliability based on the intraclass correlation coefficient (ICC) was good for tear length (ICC = .83) and moderate for percentage of meniscus that was excised (ICC = .65). The mean ρ for all raters was .92 (95% confidence interval [CI], .89-.94) comparing the values for percentage of meniscus excised with the area on the diagrams. Conclusion: The ISAKOS classification of meniscal tears provides sufficient interobserver reliability for pooling of data from international clinical trials designed to evaluate the outcomes of treatment for meniscal tears.

A Comparison of Hip Strength Between Sedentary Females With and Without Patellofemoral Pain Syndrome

STUDY DESIGN Cross-sectional study. OBJECTIVE To compare the hip strength of sedentary females with either unilateral or bilateral patellofemoral pain syndrome (PFPS) to a control group of sedentary females of similar demographics without PFPS. BACKGROUND It has been suggested that hip muscle weakness may be an important factor in the etiology of young female athletes with PFPS. This syndrome is also common in sedentary females and it is unclear if similar findings of hip weakness would be present in this population. METHODS Females between 15 and 40 years of age (control group, n = 50; unilateral PFPS, n = 21; bilateral PFPS, n = 29) participated in the study. Strength for all 6 hip muscle groups was measured bilaterally on all subjects using a handheld dynamometer. RESULTS The hip musculature of sedentary females with bilateral PFPS was statistically weaker (range, 12%-36%; P<.05) than that of the control group for all muscle groups. The hip abductors, lateral rotators, flexors, and extensors of the injured side of those with unilateral PFPS group were statistically weaker (range, 15%-20%; P<.05)than that of the control group, but only the hip abductors were significantly weaker when compared to their uninjured side (20%; P<.05). CONCLUSION This study demonstrates that hip weakness is a common finding in sedentary females with PFPS.

Pectoralis Major Muscle Rupture in Athletes A Prospective Study

Background In the past 20 years, there has been an increase in the incidence of upper extremity tendinous injuries, especially in sports including strong physical activity, such as in weight lifting, as well as with the concurrent use of anabolic steroids. Today, there are more than 200 cases describing rupture of the pectoralis major muscle in athletes. Hypothesis Surgical treatment will have a better outcome than nonsurgical treatment in total rupture of the pectoralis major muscle in athletes. Study Design Cohort study; Level of evidence, 2. Methods Twenty athletes with pectoralis major muscle (PMM) rupture were studied; 10 had surgical treatment, and the other 10 were treated nonoperatively. The mean age was 32.27 years (range, 27-47 years); all of them were men. The average follow-up was 36 months (range, 48-72 months). Injuries were diagnosed by history, physical examination, and subsidiary tests. Functional evaluation and isokinetic evaluation were performed on all 20 patients. Results The clinical evaluation revealed 70% (n = 7) excellent, 20% good (n = 2), and 10% poor (n = 1) outcomes for the cases treated with surgery and 20% good (n = 2), 50% fair (n = 5), and 40% poor (n = 4) outcomes for the cases treated nonsurgically. The isokinetic evaluation at 60-deg/s speed showed a decrease in strength of 53.8% in the nonsurgical group and 13.7% for the surgical group. Conclusion Total PMM rupture in athletes showed a better functional result after surgical treatment than after nonsurgical treatment.

Clinical Considerations for the Surgical Treatment of Pectoralis Major Muscle Ruptures Based on 60 Cases A Prospective Study and Literature Review

Background: Early recognition of the clinical signs of ruptures of the pectoralis major muscle (PMM) in athletes by orthopaedic surgeons, physical therapists, and physical trainers may prove to be critical for patient access to surgical treatment while the injury is still in the acute phase. Hypothesis: Total ruptures of the PMM may yield a better outcome with surgical treatment than with nonoperative treatment in athletes. Study Design: Cohort study; Level of evidence, 2. Methods: A prospective study was performed on 60 patients with total ruptures of the PMM. The patients were followed from 1997 to 2012, with a physical examination every 6 months for the first 2 years and every 12 months thereafter. The patients’ mean age was 31.21 years, and the mean length of follow-up was 48.25 months. The surgical treatment methods included reinsertion of the tendon in 51% of the patients and nonoperative treatment in 49% of the patients. All of the patients were evaluated using the Bak criteria. Results: The bench-press exercise was associated with 80% of the PMM ruptures (48 patients). Forty-one of the patients with chronic ruptures were seen after 3 months (80%). The outcomes were poor in 9 patients from the nonoperative group (31%) and in 3 patients from the surgical group (9.7%); the outcomes were fair in 12 patients from the nonoperative group and in no patients from the surgical group. Excellent results were not observed in any patient from the nonoperative group and were observed in 21 patients from the surgical group (67.7%). The isokinetic evaluation at 60 deg/s showed a decrease in strength of 41.7% in the nonsurgical group and 14.3% for the surgical group, which was significant at P < .05. Conclusion: Total ruptures of the PMM exhibit better outcomes with surgical treatment than with nonoperative treatment based on the Bak criteria in athletes.

Influence of knee position on the postural stability index registered by the Biodex Stability System

The importance of knee position for bodily stability is described by some authors, however Biodex Stability System (BSS) trials have not been used to assess the reliability and effects of different knee positions. The purposes of this study were to test the reliability of BSS indices using two knee positions in the measurement protocol (either permitting slight knee flexion or maintaining them locked in total extension) and to compare the BSS indices between these two knee positions. The measurements were taken of the Overall Stability Index (OSI), Anterior-Posterior Stability Index (APSI) and Medial-Lateral Stability Index (MLSI) during a 30s protocol which gradually and automatically increased in difficulty among 21 healthy female subjects (22.8+/-1.0 years old). The subjects performed four trials which, without visual feedback, permitted knee flexion as well as four trials which did not, in a randomized order. The first two trials in each set were used for familiarization only. Permitting slight flexion yielded better reliability results (OSI Intra-class Correlation Coefficient [ICC]=0.93, APSI ICC=0.90, MLSI ICC=0.89) than maintaining the knee in total extension (OSI ICC=0.88, APSI ICC=0.87, MLSI ICC=0.79), with good agreement in the Bland and Altman test. Moreover, permitted knee flexion in BSS presented better balance stability values for OSI (P=0.001) and APSI (P=0.024), however the MLSI did not present significant difference between positions (P=0.345).

Absorbable Versus Nonabsorbable Sutures for the Arthroscopic Treatment of Anterior Shoulder Instability in Athletes: A Prospective Randomized Study

PURPOSE The purpose of this study was to compare the functional results of arthroscopic treatment for traumatic anterior shoulder instability in 2 groups of athletes. METHODS Fifty patients were randomly assigned to 2 different groups with comparable patient demographics. Group A was treated with anchors loaded with absorbable sutures, and group B was treated with the same type of anchors loaded with nonabsorbable sutures. The same type of absorbable anchor, surgical technique, and rehabilitation protocol was used in both groups. The outcomes were evaluated after a minimum postoperative period of 24 months. The Rowe score and the Athletic Shoulder Outcome Scoring System were applied, and statistical analysis was performed. RESULTS The mean Rowe score was 83.8 in group A and 79.5 in group B. The mean values for the Athletic Shoulder Outcome Scoring System were 84 and 79.2, respectively. Good or excellent results were found in 90.5% of patients in group A and 87.5% in group B. We had 2 failures (9.5%) in group A and 3 (12.5%) in group B. No statistically significant difference was found in the comparison of the outcomes (P > .05). CONCLUSIONS The type of suture used, absorbable or nonabsorbable, did not influence the functional results of arthroscopic treatment for traumatic anterior shoulder instability in this series.

Anatomic Relation Between the Posterior Cruciate Ligament and the Joint Capsule

PURPOSE The aim of this anatomic study on cadavers was to determine the anatomic relation between the posterior cruciate ligament (PCL) and the posterior joint capsule attachment. METHODS Thirty knees were dissected by means of a posterior approach to the knee. The presence of the posterior popliteal ligament and Wrisberg meniscofemoral ligament was observed and a U-shaped capsulotomy was performed while preserving the distal insertion of the ligament. After detaching the PCL and determining its area on the tibia, we determined its geometric center and posterior margin and measured the distances between the tibial insertion of the capsule and these points. RESULTS The distance between the center of the PCL and the posterior capsule was 10.3 mm, and the distance between the posterior margin of the PCL and the capsule was 1.7 mm. The posterior popliteal ligament was easy to see in all the specimens, measuring around 42 mm in length. The Wrisberg meniscofemoral ligament was seen in 12 specimens. CONCLUSIONS We can conclude that the distances from the center of the tibial insertion and the margin of the PCL to the joint capsule were 10.3 mm and 1.7 mm, respectively, thus enabling greater knowledge of the anatomy of the posterior compartment of the knee. CLINICAL RELEVANCE Our findings provide anatomic data that increase the safety and knowledge regarding the surgical procedures related to the PCL, because we have supplied information that can contribute to obtaining the best arthroscopic view of this area, thus decreasing the risk of vascular and nerve damage.