Nilson Roberto Severino

Preoperative surgical planning versus navigation system in valgus tibial osteotomy: a cross-sectional study

PurposeThe objective of this study was to verify whether the correction obtained using a navigation system (NS) corresponds to the wedge calculated by the Dugdale method (DM) in high tibial osteotomy (HTO).MethodsWe included 17 patients with primary varus and HTO indication, consecutively admitted to a public university hospital. All patients underwent panoramic radiography with bipedal load for the wedge calculation by DM. They underwent HTO with an opening wedge, fixed with an HTO plate and monitored by the OrthoPilot NS. Bone grafts were used in every case. The wedge opening obtained by the NS was compared to that calculated in the radiographs.ResultsThe mean opening by DM was 9.53° and by the NS 11.8° (p < 0.045).ConclusionsThere was a significant difference in the calculation of the wedge opening between the DM and NS. HTO without the aid of the NS could theoretically lead to undercorrection of the deformity.

A new fixation material for open-wedge tibial osteotomy for genu varum

Varus deformity of the knee is a determining factor in the development of osteoarthrosis of the medial compartment. Open wedge osteotomy corrects the deformity and has quickly become popular due to the fact that the surgical technique can be easily reproduced, it spares loss of bone tissue in the metaphysiary region, and it does not require muscle dissection, reducing the risk of lesion of the fibular nerve. The objective of this study was to evaluate the characteristics of a new fixation implant (Anthony-K plate - France Bloc S.A, CE n0499, ISO 9001, EN 46001), in terms of its clinical improvement, correction of the deformity, and slope alteration. Twenty adult patients with varus deformity were evaluated, and submitted to open wedge high tibial osteotomy using the Anthony plate, between October 2004 and November 2006. The varus deformity was corrected in all cases, and there was a significant increase in the Lysholm score. Correlation analysis has shown that the greater the preoperative varus deformity, the larger the opening wedge used. Also, the greater the initial posterior tibial slope, the larger the final posterior tibial slope (p=0.0168). There were no complications. The Anthony plate can be considered an alternative in the treatment of medial osteoarthrosis of the varus knee, enabling the correction of the deformity and improvement of the clinical picture. It occurs an increase in posterior tibial slope, similar to that observed with other fixation materials. More studies with the Anthony plate are necessary, after these encouraging results.

Opening wedge high tibial osteotomy: navigation system compared to the conventional technique in a controlled clinical study

PurposeThis study aimed to verify if the navigation system used in high tibial osteotomy (HTO) adds precision to the procedure regarding mechanical axis correction and prevention of tibial slope increases.MethodsIn this historically controlled study, patients with medial osteoarthrosis and genuvarum underwent HTO between 2004 and 2012; the first 20 were operated with the conventional technique, using pre-planning correction by the Dugdale method and 18 further patients were operated with the navigation system introduced in our hospital.ResultsThe two groups were similar for pre-operative mechanical axis (mean 8.10 ± 3.14 for the control and 6.60 ± 2.50 for the navigated group), pre-operative tibial slope (mean 8.95 ± 3.47 versus 8.17 ± 3.11, respectively) and Lyshom score (40.85 ± 15.46 and 44.83 ± 16.86). After surgery, the control group presented mean mechanical axis of 3.35 ± 3.27, tibial slope of 13.75 ± 3.75 and Lyshom score of 87.60 ± 11.12. The navigated group showed a postoperative mechanical axis mean of 3.06 ± 1.70, tibial slope of 10.11 ± 0.18 and Lyshom score of 91.94 ± 11.61.ConclusionsThe navigation system allowed a significantly better control of tibial slope. Patients operated with the navigation system had significantly better Lysholm scores.

Bone tunnel enlargement on anterior cruciate ligament reconstruction

Objective: To assess the presence of tibial bone tunnel enlargement after surgical reconstruction of the anterior cruciate ligament using quadruple graft of the flexor tendons and correlate the functional results in their presence. Methods: The studied lasted six months and included 25 patients, with ages ranging from 18 to 43 years old. Assessment was based on radiographs taken immediately postoperatively and at the third and sixth month of follow up in the anterior cruciate ligament reconstruction. Reconstruction of ligaments was performed with tendon grafts of the semitendinosus and gracilis muscle fixated in the femur with transverse metal screw and in the tibia with interference screws. Patients were evaluated objectively by tests ligament, graded from zero to four crosses and subjectively by the Lysholm method preoperative and after sixth month follow up. Results: Significant increase in the tunnels diameters were observed, 20.56% for radiographs in the anteroposterior view, 26.48% in profile view and 23.22% in computed tomography. Descriptive statistics showed significant improvement in subjective and objective clinical parameters. Conclusions: The bone tunnel enlargement is a phenomenon found in the first months after surgical reconstruction of the anterior cruciate ligament and it has no implications on clinical outcomes in the short term. Level of Evidence II, Prospective Study.

Which Are the Most Reliable Methods of Predicting the Meniscal Size for Transplantation

Background: Although the size of the meniscal allograft is crucial during meniscal transplantation, the accuracy of meniscal measurement methods is still under debate. A number of methods based on radiographic and magnetic resonance imaging (MRI) data as well as on anthropometric data have been proposed, but their reproducibility and reliability are still unclear. Purpose: To compare meniscal length and width as measured by different techniques (anthropometric and plain radiographic) to establish which of these 2 methods is more reliable and cost-effective for determining the meniscal size in comparison to MRI. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The MRI scans and plain radiographic films of 22 patients (44 knees) from a single institution were studied. The width and length of the medial and lateral menisci were measured using specific techniques. Data on sex, age, body weight, and height were used to develop a regression formula for meniscal measurements (comparing both imaging methods) to establish meniscal dimensions. Data validation was achieved using the Pearson correlation, the intraclass correlation coefficient, and the Wilcoxon nonparametric test for all variables, with a significance level established at 95%. Accuracy was established as a 10% measure discrepancy from the gold standard (MRI) and was considered an average between the right and left knees. Results: No statistically significant difference was observed between the right and left knees on radiographic and MRI measurements. The Pollard technique of radiographic measurement overestimated the width of the lateral meniscus when compared with anthropometric measurements (P < .001), considering MRI as the gold standard. The same was observed for MRI measurements of the length of the lateral meniscus in which not only anthropometric but also plain radiographic measurements using the Yoon technique were significantly smaller than those values found with the Pollard technique (P < .001). The anthropometric method underestimated the width and length of the medial meniscus with an accuracy of 68.2% and 63.6%, respectively. The radiographic method was comparable with MRI in establishing all medial meniscal measurements with an accuracy of 93.2% for length and 77.3% for width. Conclusion: Some viable alternatives to MRI have been suggested. For the lateral meniscus, anthropometric data are an alternative for width, and the Yoon method can be used to assess length. For the medial meniscus, the Pollard method is considered a satisfactory alternative. This study emphasized the importance of measuring the width and length of the meniscus independently during preoperative sizing for a meniscal allograft transplantation procedure. Using MRI as a gold standard, the study also proposed other less costly and satisfactory methods of obtaining such measurements.

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.

Reconstrução do ligamento cruzado posterior com enxerto autólogo do tendão do músculo semitendinoso duplo e do terço médio do tendão do quadríceps em duplo túnel no fêmur e único na tíbia: resultados clínicos em dois anos de seguimento

OBJECTIVE: To evaluate the surgical aspects that may offer good anatomic and functional results in posterior cruciate ligament (PCL) reconstruction using an autologous graft of the quadriceps tendon and double semitendinosus through a double femoral tunnel. METHODS: Fourteen patients with isolated PCL lesions, instability and pain were operated on by arthroscopy and evaluated according to the International Knee Documentation Committee (IKDC) and Lysholm scales. Posterior knee laxity was examined with a KT 1000 arthrometer. RESULTS: The mean postoperative posterior side-to-side difference was between 0-2 mm in 57.1% of patients and between 3 and 5 mm in 35.7% of cases. The average Lysholm score was 93 points in the final follow-up. In the IKDC evaluation, 3 patients were graded A, 10 were graded B, and 1 patient was graded C. Conclusions: Double bundle arthroscopic PCL reconstruction based on the anatomical positioning of the tunnels, with double semitendinosus tendon and single quadriceps, provides a clinically evident reduction in symptoms and restores satisfactory stability, although no statistically significant difference was found due to the small sample.

Estudo anatômico da inserção femoral do ligamento cruzado posterior

OBJETIVO: Identificar parâmetros objetivos para guiar a correta localizacao do LCP no femur. METODOS: Os LCP de 20 cadaveres humanos foram ressecados. As seguintes porcoes foram medidas: da porcao mais distal do ligamento, proximo ao teto, ate a borda da cartilagem mais anterior (AB); distância da porcao mais proximal do ligamento, proximo ao teto, ate a cartilagem mais anterior (AC); distância entre as duas porcoes do ligamento proximo ao teto (BC); distância da borda distal do ligamento na sua porcao posterior ate a borda articular mais posterior (D-E); distância da borda distal do ligamento na sua porcao posterior ate o teto intercondilar (DF); e, finalmente, o formato da insercao ligamentar e area de abrangencia no condilo femoral. RESULTADOS: O LCP tem a forma de um quarto de elipse, com area de, em media, 153,5mm2. As distâncias medias encontradas foram: AB de 2,1mm; AC de 10,7mm, BC de 8,6mm, D-E de 12.4mm e DF de 16,8mm. CONCLUSOES: A borda proxima ao teto do feixe anterolateral e mais proxima da cartilagem articular (2,1mm) comparada com o feixe posteromedial, que mede 12,4mm a partir de sua borda proximal da cartilagem. Estas referencias devem ajudar em um posicionamento melhor e mais acurado dos tuneis femorais na reconstrucao do LCP.

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.

Estudo da articulação patelofemoral por ressonância magnética: a variação da morfologia do ligamento patelofemoral medial

OBJETIVO: Estudar as medidas e relacoes anatomicas da articulacao patelofemoral por ressonância magnetica, avaliando a variacao da morfologia do ligamento patelofemoral medial (LPFM) de acordo com a altura e a idade do paciente, bem como com as variacoes das medidas das outras estruturas reconhecidamente envolvidas na predisposicao a instabilidade patelar. METODO: Foram submetidos ao exame de ressonância magnetica 23 joelhos (18 pacientes), sendo aferidas as medidas da distância interepicondilar, altura da patela, profundidade da troclea, proeminencia troclear ventral, ângulo do sulco da troclea, inclinacao da faceta lateral, inclinacao lateral da patela, tamanho da faceta lateral e medial e sua razao, e as medidas de comprimento e espessura do LPFM, sendo essas comparadas com as demais medidas. RESULTADOS: O comprimento do LPFM foi de, em media, 46,4mm, enquanto as espessuras medidas na insercao patelar, terco medio e insercao femoral foram de, respectivamente, 1,7mm, 1,4mm e 1,2mm. A espessura do LPFM correlacionou-se positivamente com a medida do condilo lateral e a distância interepicondilar, e negativamente com a idade do paciente. CONCLUSAO: A morfologia do LPFM varia em funcao da distância interepicondilar e do condilo lateral e da idade do paciente.