Sérgio Rocha Piedade

Tratamento cirúrgico da fratura-avulsão da inserção tibial do L.C.P. do joelho: experiência de 21 casos

We assessed 21 patients (16 males and 5 females), with mean age of 30 years who underwent surgical treatment for PCL avulsion fracture. In 57% of the cases, injuries were secondary to motorcycle accidents and 19% resulted from car accidents. Injuries on knees anterior surface were detected in 72% of the cases. The surgical procedure involved posterior approach and bone fragment fixation using nut and screw in 18 cases, the trans-bone suture loop fixation in 3 cases with small bone fragments. In 91% of the cases, surgery was performed within the first two weeks following injury. The patients were objectively (posterior drawer test) and subjectively (Lysholm scale) re-evaluated after a minimum follow-up period of 12 postoperative months. The statistical analysis of objective and subjective assessments did not demonstrate any significant difference (p = 0.05). The satisfactory results of the subjective clinical postoperative evaluation may have been due to the absence of peripheral ligament injury. However, the presence of residual tibial posteriorization suggests that the avulsion fracture of the PCL should be treated as bone-ligament injury, and not just as a bone lesion.

Intraoperative fractures and ligament tears during total knee arthroplasty. A 1795 posterostabilized TKA continuous series

INTRODUCTION Intraoperative fractures are a reported complication during the course of primary total knee replacement. Major ligament disruptions can also occur. Clinical data are lacking to tell how much these incidents affect implantation quality and outcome. HYPOTHESIS A thorough knowledge of these occasional incidents helps proper decision making when confronted to such situations at surgery. MATERIALS AND METHODS This report is based on a series of primary, posterostabilized total knee arthroplasties (posterostabilized, mobile bearing TKA with a third median condyle from Tornier Laboratory). We studied all possible mechanical complications that developed during the course of arthroplasty and analyzed their cause. We compared the functional results of patients presenting these complications to those of the total series and to data from the literature. The entire operative reports for the 1795 TKA performed during this study were available and evaluated. A clinical and radiological review was performed for 1624 patients at an average follow-up time of 36.8+/-34 (2-193) months. RESULTS At this last follow-up, the average International Knee Society (IKS) score was 91.2 (19-100) and the function score was 77.76 (0-100). One hundred and thirty-two patients were deceased (unrelated to TKA) at this last follow-up evaluation. A total of 69 mechanical complications were accounted for at the time of surgery (3.8%): 40 definite fractures or fissures around the knee (2.2%), 29 tendon or ligament disruptions or attenuations (1.6%). The risk of tibial cracks was statistically more significant, with the smaller sizes tibial trays (size 1) (p=0.019) or when an anterior tibial tuberosity elevation had been performed (p=0.02). Survival curve analysis (at an average seven and a half-years postoperative follow-up) showed that all prosthetic components were still present in 93.3% of cases in the series of patients with these peroperative complications, and in 93.8% of cases in the series of patients without these intraoperative complications; this survival rate amounted to 91.9% of cases at an average 16-years postoperative follow-up. CONCLUSION This large, homogeneous series of primary, posterostabilized TKA took on 3.8% of intraoperative bone or ligament complications. All these complications could be prevented by a rigorous surgical technique. The improvement of ancillary materials, the saws, and good knowledge of such complications by the surgeon are essential. LEVEL OF EVIDENCE Level IV. Therapeutic Study.

Análise cinemática do joelho ao subir e descer escada na instabilidade patelofemoral

OBJECTIVE: To analyze and to identify possible gait adaptations by individuals with objective patellofemoral instability when climbing up/down stairs. METHODS: A control group (group A) composed by nine women with mean age = 25 years (±1.87), height = 1.62 m (±0.05) and weight = 56.20 kg (±7.34), and; nine women with objective patellofemoral instability (group B) with mean age = 24 years (±6.02), height = 1.62 m (±0.06) and weight = 60.33 kg (±10.31) were analyzed. The groups underwent kinematic analysis while climbing up/down stairs, in a previously determined area. Images were obtained by six cameras (Qualysis) and data analysis utilized the Q gait software program. RESULTS: Group B presented, in the support phase, less knee flexion when climbing up (p = 0.0268), and lower speed (p = 0.0076/ p =0.0243) and pace (p = 0.0027/ p = 0.0165) when climbing up and down stairs, respectively. CONCLUSION: It is suggested that group B used functional changes such as reduced knee flexion, speed and pace when climbing up and down stairs.

Ensaio uniaxial de tração dos tendões dos músculos grácil e semitendinoso humanos

The use of isolated human tendons as well as in associated forms on knee reconstrution has become na usual practice. The literature reveals that the use of implants of patellar tendon as well as the double semitendinous tendon associated to the double gracilis tendon exhibits different post surgical evolution related to the minimal extension loss, anterior-posterior displacement (KT-1000 artrometer), as well as to the sport activities. This research work aim to analyze the mechanical behavior of human tendons (gracilis and semitendinous) subject to uniaxial traction to failure. The mechanical parameters considered includes: stress at failure (MPa), strain energy at failure (N.mm) and strain rate (mm/mm). Results induced to the following conclusions: - tendon of semitendinous muscle is more resistent than the tendon gracilis muscle; exhibits lower strain, stores higher level of strain energy at failure. - as they present distinct mechanical behavior, it would be necessary to acomplish a more detaield analysis to face the time and history dependence wich are the basic characteristics of viscoelastic materials.

Isokinetic evaluation after two-stage bicruciate reconstruction

Objective: To assess the functional balance of the knee after bicruciate reconstruction and its correlation with clinical score. Methods: 14 patients (11 men and three women), mean age 29.9±7.65 years, mean BMI 26.2±2.51 kg/m2 underwent surgical reconstruction of the Posterior Cruciate Ligament (PCL) and Anterior Cruciate Ligament (ACL) in two stages, with a mean interval of 3 months between procedures. With a mean follow-up period of 27.33 months, the isokinetic knee analysis was performed at 60°/s and 180°/s and the Lysholm and Tegner scores were applied. Results: The Lysholm score was 86.8±11.1 points and the Tegner score showed a deficit of 30% compared to pre-injury level. In isokinetic evaluation, the deficit of the operated quadriceps average torque was 17.05% at 60°/s and 12.16% at 180°/s, while the average flexor torque deficit was 3.43% at 60°/s and 5.82% at 180°/s. Although it was observed torque deficit between members, there were no statistical differences regarding the functional balance between hamstrings and quadriceps. Conclusion: Although the results of isokinetic evaluation has shown a functional balance of the knee (flexor-extensor), which may have contributed to the good subjective Lysholm score in the bicruciate two-stage reconstruction, two-stage reconstruction did not restore the pre-injury functional level. Level of Evidence IV, Case Series.

Influence of morbid obesity on physical capacity, knee-related symptoms and overall quality of life: A cross-sectional study

Objective: To evaluate the impact of morbid obesity on physical capacity, joint-related symptoms, and on the overall quality of life. Method: Cross-sectional study carried out at a university hospital, enrolling 39 individuals admitted to a bariatric surgery service. Physical capacity was assessed by Six-Minute Walk Test (SMWT) and the Borg rating of perceived exertion (RPE). Knee-related symptoms were evaluated by Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Lysholm Score. Quality of life was evaluated by Short Form 36 Health Questionnaire (SF-36). Results: On SMWT, the mean distance walked was 374.1±107.5 m. The mean Borg score was 12.9±2.4. KOOS questionnaire found the following scores: pain (64.3±24), other symptoms (67.2±25.5), function in daily living (60.4±26.8), function in sport and recreation (28.5±32.2), knee-related quality of life (35.9±33.5), mean Lysholm scale score (55.3±25.4). SF-36 provided the following scores: physical functioning (41±27.4), physical role functioning (34.6±39.2), bodily pain (45.7±23.6), general health perceptions (63.1±26.2), vitality (53.5±12.1), social role functioning (52.6±29.3), emotional role functioning (41±44.9), mental health (55±27.7). Conclusion: Obesity led to significant loss of physical capacity, gait impairment, knee-related symptoms, and a negative impact on the overall quality of life.

Reconstrução do L.C.P. do joelho: técnica de fixação no leito tibial ("INLAY"). Avaliação objetiva e subjetiva de 30 casos

SUMMARY Surgical reconstruction of the knee posterior cruciate ligament (P.C.L.) still remains as a major therapeutic challenge. In this paper, we assessed 30 patients submitted to surgical reconstruction of the P.C.L. with a technique of tendinous graft fixation on tibial bed by direct approach (“INLAY”). Twenty-eight male patients and 2 female patients, with mean age of 31.10 years, participated on the study. The average injury time was 34.24 months. In 67% of the cases, injury was secondary to motorcycle accidents. Chondral injuries and knee anterior cruciate ligament (ACL) injuries were present in 67% and 33% of the cases, respectively. Patients were assessed objectively (posterior drawer test) and subjectively (Lysholm’s Scale). Mean post-operative follow-up time was 21.7 months. About 66% of the cases were rated as good and excellent at the subjective and objective evaluation. The statistical analysis showed a similar behavior for both evaluations. Post-operative clinical outcomes achieved in this study have encouraged us to keep using this surgical technique.

Classification of Meniscal Tears

The classification systems of meniscal tears strengthen the importance of the anatomical and biomechanical particularities of meniscus tissue, regarding the pattern and configuration of a meniscal tear. Each system of classification approaches a particular aspect of the meniscal structure according to its morphology, proximity to the blood supply, anatomical site, and injury pattern. Meniscal traumatic lesions are characterized arthroscopically, as a lesion produced by a specific, well-known trauma on normal meniscal tissue, while degenerative meniscal tears are often related to a decompensation after minor trauma or even no known traumatic event. Moreover, in the degenerative condition, the meniscus substance exhibits macroscopic and microscopic alterations called myxoid degeneration. Classifying meniscal tears offers the knee surgeon the opportunity to identify and define an adequate treatment approach based on the literature for each specific meniscal tear. Moreover, it allows the surgeon to group meniscal tears, analyze their outcomes, and share their personal experience on different meniscal tears with other knee surgeons.

Erratum to: All-Inside Meniscal Repair: Updates on Technique

Necrosis in burns has a major impact on dermal regeneration, functional, and esthetic results. Thus patient’s satisfaction and quality of life is determined by the timely regeneration process of all dermal layers. Pathophysiological changes after burn trauma lead to different perfusion patterns (“zones”). Inflammation has been described having a key role in maintaining reduced subdermal perfusion with increased risk of burn necrosis. In addition, various key regulators of inflammation have been identified to play a critical role in activating burn necrosis. This chapter analyzes the impact of necrosis in acute burns and gives an overview of the currently available literature of pathophysiology, apoptosis, and inflammation in burns resulting in primary, secondary, or tertiary burn necrosis. Local therapeutic options are discussed, but it is not intended to be exhaustive with regard to systemic reactions and systemic therapy in case of burn necrosis. In summary, there is increasing evidence of pathophysiology of necrosis in burns in animal models, but there is still a lack of transfer to clinical application.

All-Inside Meniscal Repair: Updates on Technique

Most of the increasing popularity of the all-inside meniscal repair is related to the possibility to perform a meniscal repair with no additional skin incision. Moreover, the all-inside techniques allow the possibility of placing sutures in the different meniscal tear patterns such as horizontal, vertical, oblique, or longitudinal. In this situation, it can be more attractive to a knee surgeon, because they could offer potential benefits that include a shorter operative time and a lower risk of neurovascular injury. However, as well as any other surgical procedure, the anatomy and the biomechanical concepts are points that the surgeon should keep in mind when performing an all-inside meniscal repair. Some factors have a direct influence on the decision of repairing a meniscal tear, such as the tear location, tear type, the size of a meniscal tear, the quality of meniscal tissue, and the configuration and the stability of the meniscal tear.