Ricardo de Paula Leite Cury

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.

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.

Infected primary knee arthroplasty: Risk factors for surgical treatment failure

Objective To present epidemiological data and risk factors associated with surgical outcomes favorable or unfavorable for the treatment of infection in infected total knee arthroplasty. Methods We reviewed medical records of 48 patients who underwent treatment of primary total knee arthroplasty for infection between January 1994 and December 2008, in the Orthopedics and Traumatology Department of the Santa Casa de Misericórdia de São Paulo. The variables associated with favorable outcome of surgical treatment (debridement and retention or exchange arthroplasty in two days) or unfavorable (arthrodesis or death) infection. Results A total of 39 cases of infection after primary total knee arthroplasty, 22 progressed to 17 for a favorable outcome and unfavorable outcome. Early infections (OR: 14.0, 95% CI 1.5–133.2, p = 0.016) and diabetes (OR: 11.3, 95% CI 1.4–89.3, p = 0.032) were associated with arthrodesis joint and death respectively. Conclusion Patients with early infection had a higher risk of developing surgical procedure with unfavorable outcome (arthrodesis) and diabetics had higher odds of death after infection of primary knee arthroplasties.

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.

Protocolo de reabilitação para as reconstruções isoladas do ligamento cruzado posterior

To create a rehabilitation protocol following reconstruction of the posterior cruciate ligament (PCL), through a literature review. The literature review was conducted in the Medline and Embase databases, to search for data on biomechanical concepts and analyses relating to the posterior cruciate ligament of the knee. The search strategy was set up using the following rules: problem or injury in association with anatomical location terms; or surgical intervention procedure in association with rehabilitation terms. We began the process in this manner and subsequently introduced restrictions on certain terms to improve the search specificity. To design the protocol, a table was created for better data assessment, based on the time that elapsed between surgery and the start of physiotherapy. A rehabilitation protocol was created to improve weight-bearing control in the initial weeks after surgery, with the aid of a knee brace. Our aim was to achieve gains in total range of motion of the knee, which should be attained by the third month, thereby avoiding contractures resulting from the tissue healing process. Strengthening exercises and sensory-motor training were guided accordingly, thus avoiding overload on the graft and respecting the healing phases. The protocol proposed through this review was based on the current evidence relating to this subject.

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.

Concentration of Sonication Fluid through Centrifugation Is Superior to Membrane Filtration for Microbial Diagnosis of Orthopedic Implant-Associated Infection

ABSTRACT Microbial identification of orthopedic implant-associated infections using sonication fluid (SF) submitted to a concentration step by membrane filtration (SMF) was compared with the standard centrifugation (SC) method. Among 33 retrieved infected implants, sonication identified microorganisms in 26 (78.8%). The sensitivity of SC was higher than that of SMF (78.8% versus 30.3%; P < 0.001).

TREATMENT OF INFECTION AFTER TOTAL KNEE ARTHROPLASTY

ABSTRACT Objectives: To identify and compare the rate of success of therapeutic modalities applied in surgeries for the treatment of infections associated with total knee arthroplasty (TKA), and to evaluate the functional outcome and pain in different therapeutic modalities by means of quality of life scores. Methods: We evaluated all patients who developed periprosthetic infection after TKA for primary or secondary osteoarthritis, in the period from January 1st, 2008 to December 31st, 2010. Results: In the study period, 29 patients with TKA had infection, and 12 of these underwent debridement and retention of the prosthesis (D+R), seven received two-stage and six one-stage exchange arthroplasties, and four patients were treated with suppressive antibiotic therapy because they could not undergo another surgical procedure. Conclusion: The D+R, one-stage revision and two-stage revision success rates were 75%, 83.3%, and 100%, respectively. The best results of quality of life (QoL) and function occur in patients undergoing D+R. In contrast, the worst QoL and functional results were obtained in patients treated with two-stage revision arthroplasty. Level of Evidence II, Prognostic Studies - Investigating the Effect of a Patient Characteristic on the Outcome of Disease.