Efectos del autoinjerto hueso-tendón patelar-hueso sobre la posición articular y la fuerza en pacientes con reconstrucción del ligamento cruzado anterior / Effects of bone-patellar tendon-bone autograft on joint position and strength in patients with anterior cruciate ligament reconstruction

RESUMEN: El objetivo del estudio fue comparar el déficit propioceptivo a través del Joint position sense (JPS) y Force steadiness en pacientes con reconstrucción del ligamento cruzado anterior (LCA) injerto hueso-tendón patelar-hueso (HTH) 6 a 12 meses postcirugía. Participaron 15 pacientes (13 hombres y 2 mujeres, 25,5 ± 1,3 años) con reconstrucción de LCA con autoinjerto HTH y 20 personas sin lesión del LCA (19 hombres y 1 mujer, 24,1 ± 0,8 años). Para evaluar la sensación de posición de la articulación de la rodilla se midió la Joint position sense (JPS) en tres rangos: 0°-30°, 31°-60° y 61°-90° y la sensación de fuerza del cuádriceps fue evaluada con la prueba Force steadiness (FS) al 15 % de la contracción voluntaria máxima (CVM), ambas pruebas realizadas 6 a 12 meses post cirugía. Los resultados mostraron que no hubo diferencias estadísticamente significativas en la sensación de la posición articular (JPS 0°-30°) (p=0.564) y 31°-60° (p=0.681), mientras que en el rango 61°-90° (p=0.003) existieron diferencias estadísticamente significativas. En las mediciones de sensación de fuerza del cuádriceps (FS al 15 % CVM) entre los pacientes operados de LCA técnica HTH y el grupo control no hubo diferencias estadísticas (p= 0.987) La sensación de la fuerza del cuádriceps medida con la prueba FS al 15 % CVM no presentaría déficit entre los 6 a 12 meses en pacientes post operados de LCA al ser comparados con sujetos sin lesión ni cirugía de este ligamento. Se concluye que la sensación de la posición articular medida con la prueba JPS en en tres rangos articulares de pacientes con reconstrucción de LCA injerto HTH 6 a 12 meses post cirugía sólo mostró alteraciones en el rango de 61°- 90° al ser comparado con el grupo control, lo cual indica que la sensación de la posición articular presenta un déficit en este rango específico.

SUMMARY: The aim of the study was to compare the proprioceptive deficit through the Joint position sense (JPS) and Force steadiness in patients with anterior cruciate ligament (ACL) bone-patellar tendon-bone graft (PTH) reconstruction 6 to 12 months post-surgery. Fifteen patients (13 men and 2 women, 25.5 ± 1.3 years) with ACL reconstruction with HTH autograft and 20 persons without ACL injury (19 men and 1 woman, 24.1 ± 0.8 years) participated. To assess knee joint position sensation, Joint position sense (JPS) was measured in three ranges: 0°-30°, 31°- 60° and 61°-90° and quadriceps strength sensation was assessed with the Force steadiness (FS) test at 15 % of maximal voluntary contraction (MVC), both tests performed 6 to 12 months post surgery. The results showed that there were no statistically significant differences in joint position sensation (JPS 0°-30°) (p=0.564) and 31°-60° (p=0.681), while in the range 61°-90° (p=0.003) there were statistically significant differences. In the quadriceps strength sensation measurements (FS at 15 % CVM) between the patients operated on ACL HTH technique and the control group there were no statistical differences (p= 0.987). The quadriceps strength sensation measured with the FS test at 15 % CVM would not present a deficit between 6 to 12 months in post- operated ACL patients when compared to subjects without injury or surgery of this ligament. It is concluded that the joint position sensation measured with the JPS test in three joint ranges of patients with ACL reconstruction HTH graft 6 to 12 months post surgery only showed alterations in the range of 61°- 90° when compared to the control group, indicating that the joint position sensation presents a deficit in this specific range.

Retorno deportivo luego de reconstrucción primaria de ligamento cruzado anterior con injerto hueso-tendón patelar-hueso autólogo: análisis de factores relacionados / Return to play after anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft: analysis of related factors

OBJECTIVE: Analyze return to sports and related factors after primary anterior cruciate ligament reconstruction. METHODS: Observational descriptive study. 173 patients operated by the same surgeon and standardized technique (patellar autograft) who answered a questionnaire at least 12 months post procedure were included. Questionnaire included Subjective IKDC, Tegner activity level (Pre and Postoperative) and questions elaborated by the group. RESULTS: Mean age was 30.8 years, 85% were men, 73% practiced soccer and median postoperative IKDC was 71. Follow up until questionnaire response was 28 months. Males had a better return to sports than females (70% vs 48%, p » 0.037). Tegner preinjury level was 5 vs 4.3 postoperative, (p < 0.001). Return to sports was 67% according to Tegner scale and 66% by self-assessment. Return to similar previous activity level was 57% by Tegner scale but 24% by direct questions. Of those patients, 51% have fear of reinjury and 26% by reasons other than knee or surgery. We didn't find association between meniscal injuries and return to sports rate. Patients with chondral injuries had lower rates in return to sports (35% vs 60%, p » 0.002). Subjects that returned to sports had higher IKDC scores (73.5 vs 64.3, p < 0.001). CONCLUSIONS: We found 67% return to sports and 57% to the preinjury level. Positive return to sports factors were male sex, absence of chondral injury and better functional outcome. Psychological factors such as fear of injury is frequent in patients who don't achieve previous levels of activity.

OBJETIVOS: Analizar el retorno deportivo y factores asociados tras la reconstrucción primaria de ligamento cruzado anterior (LCA). MÉTODOS: Estudio observacional descriptivo. Se incluyeron 173 operados entre 2014 y 2017 por el mismo cirujano, los cuales contestaron un cuestionario al menos 12 meses después de la cirugía. El cuestionario incluye IKDC subjetivo, Tegner activity level (pre y post operatorio) y preguntas de elaboración propia. RESULTADOS: La edad promedio es 30,8 años, el 85% son hombres, el 73% practicaba fútbol y la mediana del IKDC fue 71. La media de meses hasta responder el cuestionario fue de 28 meses. Tegner pre-lesión promedio fue de 5 vs 4,3 postoperatorio, p < 0,001. Según la escala Tegner el 57% retorna al mismo nivel previo, sin embargo, de acuerdo con el cuestionario propio solo el 24% lo haría. De ese subgrupo, el 51% tiene temor a lesionarse de nuevo y el 26% reporta razones no relacionadas a la rodilla. No encontramos asociación entre lesiones meniscales y la tasa de retorno. Aquellos que retornan tienen menor prevalencia de lesiones condrales (35% vs 60%, p » 0,002). Los pacientes que retornaron tuvieron un IKDC superior (73,5 vs 64,3, p < 0,001). El sexo masculino tiene una tasa de retorno de 70% vs 48% de su contraparte femenina (p » 0,037). CONCLUSIONES: El 67% retorna al deporte y el 57% lo hace al mismo nivel. Factores positivos relacionados al retorno fueron sexo masculino, ausencia de lesión condral y mejor resultado funcional. Factores psicológicos con el miedo a lesionarse de nuevo son frecuentes en pacientes que no recuperan el nivel previo.

Técnica de figueroa para evitar la discrepancia injerto-túnel en la reconstrucción de ligamento cruzado anterior: acortamiento del injerto del tendón patelar / Figueroa technique to avoid graft-tunnel discrepancy in anterior cruciate ligament reconstruction. shortening of patellar tendon graft

La utilización de autoinjerto hueso–tendón patelar–hueso, para la reconstrucción del ligamento cruzado anterior es considerado por muchos cirujanos como el estándar de oro en pacientes jóvenes con fisis cerrada. Sin embargo, una de las complicaciones técnicas es el riesgo de obtener un injerto de mayor longitud a la deseada, perdiendo la ventaja de mantener el fragmento óseo distal del injerto dentro del túnel tibial. En este trabajo se describe una técnica quirúrgica que permite acortar la longitud del injerto, realizando una migración proximal del fragmento óseo distal (tibial), logrando disminuir la discrepancia entre la longitud del injerto y la longitud de la reconstrucción, sin sacrificar ninguno de los fragmentos óseos, conservando las ventajas del injerto.

The use of autograft bone–patellar tendon–bone, for the reconstruction of the anterior ligament cruciate is considered as a gold standard in procedures in young patients with closed physis. However, one of the technical complications is the risk of obtaining a graft with greater length than expected which leads to a disadvantage of maintaining distal bone fragment of the graft within the tibiae tunnel. This work describes a surgical technique that allows to reduce the length of the graft through a proximal migration of the distal bone fragment (tibia) therefore shortening the discrepancy between the longitude of the graft and the longitude of the reconstruction without sacrificing none of the bone fragments and conserving the benefits of the graft.

Return to sports following anterior cruciate ligament reconstruction - short term follow up

To determine the factors which will help in return to the sports the following anterior cruciate ligament reconstruction and compare the study results to the previous international results. Prospective descriptive case series study. This study was carried out at the Department of Orthopedic Surgery, King AbdulAziz Hospital Jeddah from June 2011 to May 2014. 40 patients were included in this study. These patients were admitted in the Department of Orthopedic Surgery one day before and performed arthroscopic assisted ACL reconstruction at King Abdul AzizHospital Jeddah with anterior cruciate ligaments tear and +/- meniscal injuries. Those patients having associated meniscal injury were included and dealt arthroscopically. The patients were excluded from the study who had associated fracture and also posterior cruciate injuries. The mean age of patients was 22.0 +/- 8.0 years. All the patients were male and soccer players. The mode of injury was sports. The hamstring tendons were taken and applied as grafts in all the cases. Rehabilitations protocol was carried out in the postoperative period in routine rehabilitation clinics. The factors responsible for the determination of the return include age of the patients, how complex injuries, the psychological motivation and delay in surgery. The data was collected and analyzed with the self-generated questionnaire performa taking the help of Lyshlohm Knee Scoring System. The psychologically strong patients with will and wish were excellent in return to their sports activity. Rehabilitation compliance for the young psychologically motivated individuals operated early were having best score with excellent return to sports. So these factors should be considered before the consideration of ACL reconstruction

Estudio de los centros de rotación instantáneos de la rodilla en pacientes con plastia de ligamento cruzado anterior / Study of the instantaneous centers of rotation of the knee in patients with anterior cruciate ligament plasty

Se realizó un análisis cinemático bidimensional de la Articulación de la Rodilla (AR) en una población de 6 pacientes con plastia del Ligamento Cruzado Anterior (LCA), con la finalidad de identificar el Centro de Rotación por el Punto de Contacto (CRPC), durante el movimiento de extensión ejecutado en cadena cinemática abierta. Se estudiaron tres situaciones: previamente a la realización de la plastia del LCA, posterior a ésta y en la rodilla contralateral indemne. Se obtuvieron imágenes radiográficas seriadas a lo largo de la extensión de la rodilla por videofluroscopía. Estudiados los métodos descritos en la literatura, se adapta lo que propone Baltzopoulos. Se desarrolló una aplicación informática interactiva para identificar las estructuras anatómicas y para determinar el CRPC. Los resultados obtenidos de los pacientes en las diversas situaciones fueron sometidos a la prueba de Wilcoxon, Nemenyi, McDonald-Thomson`s, con un nivel de significación del 5%. No se encontraron diferencias estadísticamente significativas en la excursión del CRPC entre la rodilla lesionada y la contra lateral saludable. En cambio los datos evidencian una diferencia entre la rodilla lesionada y la reconstruida. Los resultados obtenidos podrían sugerir realizar la plastia en forma temprana, ni bien la situación clínica del paciente lo permita, evitando así la evolución natural del movimiento de la AR saludable hacia un tipo de movimiento de rodilla lesionada.La experiencia lograda y la observación de que no se dispone en la clínica de instrumentos de evaluación dinámica del movimiento relativo de las superficies de la AR sugieren que se especifique y luego se construya un instrumento orientado a una evaluación de mayor especificidad. El trabajo desarrollado en esta tesis integró conocimientos básicos (biomecánica, computación y fisiología) con la actividad clínica, resultando en una profundización del conocimiento de los fenómenos relacionados a la rotura y plastia del LCA.

Preoperative Prediction for Length of Patellar Tendon in Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Autograft / 대한스포츠의학회지

Preoperative prediction of patellar tendon length is important during anterior cruciate ligament (ACL) reconstruction using bone-patellar tendon-bone (BPTB) autograft. Three methods of imaging analysis to predict patellar tendon length were compared in this study. One hundred and twenty-three patients who underwent ACL reconstruction using BPTB autograft by single surgeon during October 2002 through April 2011 were included. We measured the patellar tendon length from true and oblique lateral simple radiographs (classified according to degree of rotation) and magnetic resonance image (MRI). These values were compared with actual length measured during operation and assessed accuracy by calculating the coefficient of determination. The mean length of patellar tendon measured during operation and by true lateral and oblique lateral radiographs and MRI were 42.4+/-0.45 mm (range, 32.0-54.0 mm), 41.7+/-0.61 mm (range, 24.2-55.3 mm), 40.7+/-0.57 mm (range, 24.8-51.5 mm), and 41.7+/-0.52 mm (range, 28.7-56.0 mm), respectively. The correlation of patellar tendon length was the most strong between actual length and value from true lateral radiograph (coefficient of determination, r2=0.660) according to simple linear regression analysis. R2 values were 0.361 and 0.332 for oblique lateral radiograph and MRI compared to actual value, respectively. In conclusion, Patellar tendon length measured on true lateral radiograph was the best method to coincide with actual patellar tendon length among various preoperative prediction methods.

Comparison of two methods of femoral tunnel preparation in single-bundle anterior cruciate ligament reconstruction: a prospective randomized study / Comparação entre dois métodos de preparação de túnel femoral na reconstrução do ligamento cruzado anterior em feixe único: estudo prospectivo randomizado

PURPOSE: To prospectively compare therapeutic effect of femoral tunnel preparation through the tibial tunnel and the anteromedial (AM) portal in single-bundle anterior cruciate ligament (ACL) reconstruction. METHODS: Between June 2008 and October 2010, 76 patients underwent single-bundle ACL reconstruction by autogenous grafting of semitendinosus and gracilis tendon. All cases were randomly divided into two groups according to the method of femoral tunnel preparation: transtibial (TT) group (n=38) and anteromedial (AM) group (n=38). Lysholm knee score and the KT-1000 anterior laxity at 30° of pre-and post-operation were assessed for two groups. RESULTS: Sixty-five patients (TT group, 34; AM group, 31) were followed up for more than 12 months, with a follow-up rate of 86%. The Lysholm knee score and the KT-1000 anterior laxity 12 months after operation were significantly better than before reconstruction. The Lysholm knee score and the KT-1000 anterior laxity were not significantly different between the TT and AM groups after operation. CONCLUSION: Femoral tunnel preparation through tibial tunnel or the anteromedial portal in single-bundle anterior cruciate ligament reconstruction shows same therapeutic effects.

OBJETIVO: Comparar prospectivamente o efeito terapêutico da preparação do túnel femoral através do túnel tibial (TT) ou da porta ântero-medial(AM) na reconstrução do ligamento cruzado anterior(LCA) em feixe único. MÉTODOS: Entre junho de 2008 e outubro de 2010, 76 pacientes foram submetidos à reconstrução do LCA em feixe único pelo enxerto autógeno de tendão semitendíneo egrácil.Todos os casos foram divididos aleatoriamente em dois grupos de acordo como método de preparação do túnel femoral: grupo transtibial (TT) (n=38) e grupo ântero-medial (AM) (n=38). Foi usado o escore Lysholm para joelho. O relaxamento anterior do joelho a 30° sob força tênsil de 133,32N foi determinado com o medidor KT-1000 no pré e no pós-operatório nos dois grupos. RESULTADOS: Sessenta e cinco pacientes (grupo TT, 34; grupo AM,31)foram acompanhados por mais de 12 meses, com uma taxa de follow-up de 86%.A pontuação do Lysholm para joelho e do relaxamento anterior medido pelo KT-1000 aos 12 meses de pós-operatório foi significativamente melhor do que antes da reconstrução.As pontuações de Lysholme do relaxamento KT-1000 não foram significativamente diferentes comparando os grupos TT e AM após a operação. CONCLUSÃO: A preparação do túnel femoral através do túnel tibial ou da porta ântero-medial na reconstrução do ligamento cruzado anterior em feixe único mostrou os mesmos efeitos terapêuticos.

Reconstrucción de ligamento cruzado anterior de rodilla en mujeres deportistas / Anterior cruciate ligament reconstruction in female athletes

Actualmente ha habido un aumento en la práctica deportiva de la población femenina, fundamentalmente en deportes de contacto. Si comparamos con los hombres que practican el mismo deporte, las mujeres tienen hasta 8 veces mayor riesgo de rotura del LCA. Aún hay disparidad en los estudios de incidencia y las aproximaciones en relación a la etiología de esta diferencia necesitan más nivel de evidencia. Sin embargo la consolidación de la resolución quirúrgica de esta patología en todo tipo de atletas, permitiéndole el retorno precoz a la actividad competitiva, no está en discusión.Varias técnicas reconstructivas así como la elección del injerto son sujeto actual de investigación. Consideramos que una aproximación interesante en esta población es el énfasis en la prevención, fundamentalmente en la de tipo neuro muscular propioceptiva, que ha demostrado bajar la incidencia de lesiones del LCA en atletas mujeres.

Currently has increased the practice sports of the female population, especially in contact sports. If compared with men who practice the same sport, women have up to 8 times greater risk of ACL rupture. There are still disparities in incidence studies and approaches related to the etiology of this difference needed more level of evidence. However the consolidation of the surgical resolution of this pathology in all types of athletes, allowing early return to competitive activity, isn't under discussion. Several reconstructive techniques aswell as the choice of graft are actually a research subject. We believe that an interesting approximation in this population is the emphasis on prevention, mainly in neuromuscular and proprioceptive, which has shown to lower the incidence of ACL injuries in female athletes.

Estudo biomecânico da fixação transcortical ou transesponjosa do enxerto de tendão patelar com pinos bioabsorvíveis na reconstrução do LCA em ovinos / Biomechanical study of transcortical or transtrabecular bone fixation of patellar tendon graft with bioabsorbable pins in ACL reconstruction in sheep

OBJETIVO: Determinar a resistência inicial de fixação do sistema RigidFix® e comparar com o método tradicional de fixação que utiliza parafusos de interferência metálicos. Avaliar a resistência da fixação com o sistema RigidFix® ao se modificar o posicionamento rotacional do bloco ósseo no interior do túnel femoral. MÉTODOS: 40 espécimes de joelhos (soldras) de ovinos, foram submetidos à reconstrução do ligamento cruzado anterior (LCA)utilizando enxerto osso-tendão-osso. Em 20 espécimes utilizou-se o método RigidFix®, este grupo foi subdividido em dois, 10 joelhos foram utilizados para fixação através da esponjosa e 10 para fixação cruzando a tábua óssea cortical. Nos 20 espécimes restantes fixou-se o enxerto com parafusos de interferência metálico de 9mm. RESULTADOS: A comparação do método RigidFix® com o método de fixação com parafuso de interferência metálico não mostrou diferenças estatisticamente significativas ao se considerar carga máxima e rigidez, também não houve diferenças estatisticamente significativas ao se modificar o posicionamento rotacional do bloco ósseo no interior do túnel femoral. Para estas avaliações considerou-se o p < 0,017. CONCLUSÃO: A fixação do enxerto osso-tendão-osso com dois pinos bioabsorvíveis, independente do posicionamento rotacional no túnel femoral, permite uma fixação comparável em termos de resistência inicial ao parafuso de interferência metálico neste modelo experimental.

OBJECTIVE: to determine the initial resistance of fixation using the Rigid Fix® system, and compare it with traditional fixation methods using metal interference screws; and to evaluate the resistance of the fixation with the rigid fix system when the rotational position of the bone block is altered in the interior of the femoral tunnel. METHODS: forty ovine knee specimens (stifle joints) were submitted to anterior cruciate ligament reconstruction (ACL) using a bone-tendon-bone graft. In twenty specimens, the RigidFix® method was used; this group was subdivided into two groups: ten knees used for fixation with trabecular bone screw, and ten for fixation passing through the layer of cortical bone. In the twenty remaining specimens, the graft was fixed with 9mm metal interference screws. RESULTS: comparison of the Rigidfix® method with the metal interference screw fixation method did not show any statistically significant differences in terms of maximum load and rigidity; also, there were no statistically significant differences when the rotational position of the bone block was altered inside the femoral tunnel. For these evaluations, a level of significance of p < 0.017 was considered. CONCLUSION: fixation of the bone-tendon-bone graft with 2 bioabsorbable pines, regardless of the rotational position inside the femoral tunnel, gave a comparable fixation in terms of initial resistance to the metal interference screw, in this experimental model.

Clinics in diagnostic imaging. 141. Complete anterior cruciate ligament tear

A 38-year-old man presented with right knee pain and swelling following a football injury. Magnetic resonance (MR) imaging showed a complete anterior cruciate ligament (ACL) tear and lateral meniscal tears. The torn ACL was repaired with a graft obtained from the semitendinosus muscle, and the menisci were debrided. The mechanisms of injury to the ACL are varied and may be due to direct or indirect contact with the knee as well as with twisting injuries. Knowledge of the ACL's normal anatomy, together with MR imaging technique and understanding of the appearance of the lesion on MR examination, is crucial to aid in the identification of an ACL tear. Diagnosis of an ACL tear should be based on direct MR imaging signs, although indirect signs may be helpful, particularly in chronic tears. Other associated injuries to be aware of include meniscal and other ligamentous injuries. Normal ACL graft and post-ACL graft reconstruction complications are also briefly discussed.

Dupla banda x banda simples x banda simples associado a lemaire: estudo comparativo em dois anos de acompanhamento / Double band x single band x single band associated to lemaire comparative study in two years of monitoring / Doble banda x banda simple x banda simple asociado a lemaire estudio comparativo en dos años de acompañamiento

Os procedimentos convencionais de plastia do LCA reconstroem apenas o feixe anteromedial por considerá-lo o mais isocinético. Esta reconstrução apresenta resultados clínicos satisfatórios, porém com uma taxa de instabilidade rotatória residual Pivot Shift em torno de 15 porcento a 30 porcento. Como solução para este problema, tem-se proposto reconstrução da dupla banda, reconstrução da banda simples com maior horizontalização do túnel femoral ou reconstrução da banda simples associada com uma plastia extra-articular. Objetivo Comparar os resultados clínicos destas três técnicas em dois anos de acompanhamento. Método No ano de 2007, um mesmo cirurgião sênior operou 196 plastias do LCA, dentre estas 109 banda simples BS, 53 dupla banda DB e 34 banda simples associada a Lemaire BSL. Foram reconvocados de forma aleatória 25 pacientes de cada grupo, todos avaliados por um examinador independente. Os pacientes foram submetidos a um exame clínico, radiográfico, escore IKDC e teste de translação anterior pós-operatório TELOS. Ao TELOS foram aferidas a translação anterior do compartimento medial e lateral em perfil absoluto a 15 kg em pré e pós-operatório. Foram ainda analisados e comparados com o tipo de plastia o nível de retorno a atividade esportiva, Pivot-Shift pós-operatório e complicações. Resultados O nível de satisfação aferido pelo IKDC subjetivo apresentou 86 porcento, 85 porcento e 78 pocento de pacientes muito satisfeitos ou satisfeitos para as técnicas de DB, BS e BSL, respectivamente p igual 0,04. Ao exame físico, os pacientes BSL apresentaram maiores índices de alterações em relação aos outros dois grupos, com 45 pocento de inchaço e 30 pocento de déficit de amplitude articular. No retorno ao esporte, 30 porcento dos BSL tiveram um retorno em um nível inferior, contra os pacientes de DB e BS que, em sua maioria, retornaram ao esporte num mesmo nível antes do trauma. Ao ser analisado o Pivot Shift pós-operatório 25 pocento dos BS apresentaram um ressalto pós-operatório contra 12 pocento dos DB e 10 pocento dos BSL p igual0,01. Ao TELOS, o índice de correção do compartimento medial foi de 71 pocento, 77 pocento e 79 pocento para DB, BS e BSL, respectivamente; para o compartimento lateral, estes índices foram 75 pocento, 51 pocento e 82 pocento, mostrando melhor controle de ambos os compartimentos para os pacientes submetidos à banda simples associado a Lemaire BSL. A única complicação registrada envolveu apenas 1 caso de ciclope para cada grupo. Não houve diferença significante para os três grupos quando analisados os escores IKDC objetivo e subjetivo, assim como quanto ao número de complicações. Conclusão Não existe diferença estatisticamente significante dos escores IKDC objetivo e subjetivo quando comparadas as três técnicas cirúrgicas. A reconstrução da banda simples associada a Lemaire apresenta melhor correção da translação anterior de ambos os compartimentos, porém com maior repercussão clínica desfavorável e o retorno ao esporte num nível inferior.

Introduction: Conventional procedures for repair of the ACL reconstruct only the anteromedial bundle, considering it as isokinetic. This reconstruction provides satisfactory clinical results, but with a residual rate of rotational instability Pivot Shift around 15 percent to 30 percent. As a solution to this problem, it has been proposed: rebuilding the dual-band, rebuilding the single band with more flattening of the femoral tunnel or reconstruction of the single band associated with an extra-articular plasty. Objective: To compare the clinical outcomes of these three techniques in two years of monitoring. Method In 2007, the same senior surgeon operated on 196 ACL plasties, among these 109 single band SB, 53 dual band DB and 34 single-band associated with Lemaire BSL. Were re-recruited at random 25 patients in each group, all evaluated by an independent examiner. The patients underwent a clinical examination, radiographic examination, IKDC score and anterior translation test postoperatively TELOS. In TELOS were measured the anterior translation of the medial and lateral compartment in absolute profile to 15 kg pre-and postoperatively. We also analyzed and compared with the type of repair the level of return to sports activities, Pivot Shift, postoperative and complications. Results The level of satisfaction as measured by subjective IKDC showed 86 percent, 85 percent and 78 percent of patients very satisfied or satisfied for techniques of DB, BS and BSL, respectively p equals 0.04. On physical examination, BSL patients had higher changes compared to the other two groups, with 45 percent of swelling and 30 percent deficit of articulation range. On returning to sports, 30 percent of BSL have returned at a lower level against the DB and BS patients that, in most cases, returned to sports at the same level before the trauma. Upon analyzing the postoperative Pivot Shift 25 per cent of BS showed a rebound after surgery compared with 12 percent of DB and 10 percent of BSL p equals 0.01. In TELOS, the correction index of the medial compartment was 71 percent, 77 percent and 79 percent for DB, BS and BSL, respectively, for the lateral compartment, these rates were 75 percent, 51 percent and 82 percent, showing better control of both compartments for patients undergoing single-band associated with Lemaire BSL. The only complication involved only one recorded case of Cyclops for each group. There was no significant difference for the three groups when analyzing the objective and subjective IKDC scores, as well as on the number of complications. Conclusion No statistically significant difference in objective and subjective IKDC scores when comparing the three surgical techniques. The reconstruction of the single-band associated with Lemaire has a better correction of anterior translation of both compartments, but with greater clinical adverse repercussion and return to sports at a lower level.

Introducción Los procedimientos convencionales de plastia del LCA reconstruyen apenas el haz anteromedial por considerarlo el más isocinético. Esta reconstrucción presenta resultados clínicos satisfactorios, pero con una tasa de inestabilidad rotatoria residual Pivot Shift en torno de 15 por ciento a 30 por ciento. Como solución para este problema, se há propuesto: reconstrucción de la doble banda, reconstrucción de la banda simple con mayor horizontalización del túnel femoral o reconstrucción de la banda simple asociada a una plastia extra-articular. Objetivo Comparar los resultados clínicos de estas tres técnicas en dos años de acompañamiento. Método El año de 2007, un mismo cirujano experiente operó 196 plastias del LCA, entre éstas 109 banda simple BS, 53 doble banda DB y 34 banda simple asociada a Lemaire BSL . Fueron reconvocados de forma aleatória 25 pacientes de cada grupo, todos evaluados por un examinador independiente. Los pacientes fueron sometidos a un exámen clínico, radiográfico, registro IKDC y test de traslación anterior post-operatório TELOS. Al TELOS le compararon la traslación anterior del compartimiento medial y lateral en perfil absoluto a 15 kg en pre y post-operatório. Fueron analizados y comparados, aún, con el tipo de plastia el nivel de retorno a la actividad deportiva, Pivot-Shift post-operatório y sus complicaciones. Resultados El nivel de satisfacción registrado por el IKDC subjetivo presentó 86 por ciento, 85 por ciento y 78 por ciento de pacientes muy satisfechos o satisfechos para las técnicas de DB, BS y BSL, respectivamente p gual 0,04. Al exámen físico, los pacientes BSL presentaron mayores índices de alteraciones en relación a los otros dos grupos, con 45 por ciento de inchazo y 30 por ciento de déficit de amplitud articular. Al retorno al deporte, 30 por ciento de los BSL tuvieron un retorno en un nivel inferior, contra los pacientes de DB y BS que, en su mayoría, retornaron al deporte en un mismo nivel antes del trauma. Al analizar el Pivot Shift post-operatório 25 por ciento de los BS presentaron un resalto post-operatório contra 12 por ciento de los DB y 10 por ciento de los BSL p igual 0,01. Al TELOS, el índice de corrección del compartimiento medial fue de 71 por ciento, 77 por ciento y 79 por ciento para DB, BS y BSL, respectivamente; para el compartimiento lateral, estos índices fueron 75 por ciento, 51 por ciento y 82 por ciento, mostrando mejor control de ambos compartimientos para los pacientes sometidos a la banda simple asociada a Lemaire BSL. La única complicación registrada envolvió apenas 1 caso de ciclope para cada grupo. No hubo diferencia significante para los tres grupos cuando se analizaron los registros IKDC objetivo y subjetivo, así como cuanto al número de complicaciones. Conclusión No existe diferencia estadísticamente significante de los registros IKDC objetivo y subjetivo cuando se comparan las tres técnicas quirúrgicas. La reconstrucción de la banda simple asociada a Lemaire presenta mejor corrección de la traslación anterior de ambos compartimientos, pero, con mayor repercusión clínica desfavorable y el retorno al deporte en un nivel inferior.

Anterior Cruciate Ligament Reconstruction in Patients with Generalized Joint Laxity

Generalized joint laxity is a genetically determined component of overall joint flexibility. The incidence of joint laxity in the overall population is approximately 5% to 20%, and its prevalence is higher in females. Recently it was noticed that individuals with generalized joint laxity are not only prone to anterior cruciate ligament injuries but also have inferior results after a reconstruction. Therefore, an anterior cruciate ligament reconstruction in patients with generalized laxity should be undertaken with caution due to the higher expected failure rate from the complexity of problems associated with this condition. It is also necessary to identify the risk factors for the injury as well as for the post operative outcome in this population. A criterion that includes all the associated components is necessary for the proper screening of individuals for generalized joint laxity. Graft selection for an anterior cruciate reconstruction in patients with ligament laxity is a challenge. According to the senior author, a hamstring autograft is an inferior choice and a double bundle reconstruction with a quadriceps tendon-bone autograft yields better results than a single bundle bone-patella tendon-bone autograft. Future studies comparing the different grafts available might be needed to determine the preferred graft for this subset of patients. Improved results after an anterior cruciate ligament reconstruction can be achieved by proper planning and careful attention to each step beginning from the clinical examination to the postoperative rehabilitation.

Resultado de la reconstrucción del ligamento cruzado anterior con el ligamento patelar bajo control artroscópico con un seguimiento superior a 15 años / Arthroscopic reconstruction of the ACL using the patellar tendon follow-up more than 15 years

Los resultados a largo plazo de las reconstrucciones del LCA por artroscopia son raros. Nosotros presentamos los resultados de un estudio de 57 pacientes con un seguimiento superior a 15 años. La reconstrucción es realizada bajo control artroscópico. Nosotros utilizamos un injerto hueso ligamento rotuliano hueso. El túnel femoral es realizado de afuera hacia adentro. La fijación femoral obtenida por "pressfit" y la fijación tibial es realizada con un tornillo de interferencia metálico. 240 pacientes fueron operados con esta técnica en 1992. Nosotros pudimos ver 57 de estos pacientes con un seguimiento promedio de 182 meses. Todos los pacientes fueron evaluados con el formulario IKDC. La laxitud diferencial fue medida con el Rolimeter (aircast). Un examen radiológico completo fue realizado a todos los pacientes. A 15 años de seguimiento 43 por ciento de pacientes fueron clasificados como A, 40 por ciento B, 10 por ciento C 5 por ciento y D según el formulario IKDC objetivo. El IKDC subjetivo promedio fue de 85,8/100. La laxitud diferencial instrumental promedio fue de 1,8 mm. 86 por ciento de los pacientes presentaron radiografías normales y solamente 5 por ciento de artrosis. Este estudio demuestra que esta técnica permite obtener buenos resultados en cuanto a la laxitud y la artrosis.

The results of the ACL by arthroscopy in the long term are rare. The following are the results of a study we made of 57 patients with a folloe-up of more than 15 years. The reconstruction was carried out by arthroscopy. We used a patellar ligament bone graft. The femoral tunnel procedure is outside-inside. The femoral attachment was by "pressfit", and the tibial attachment using a metalic interference screw. 240 patients were operated on in 1992 using this technique. We reviewed 57 of these patient with a mean follow-up time of 182 months. All the patients were evaluated using the IKDC formula. The laxity differential was measured using the Rolimeter (aircast). A complete radiological examination was carried out on all the patients. After 15 years follow-up 43 percent of the patients were classified A 40 percent, B 10 percent, C 5 percent and D using the IKDC formula objective. The mean IKDC subjective score was 85,8/100. The mean instrumental laxity diferrential was 1,8 mm. 86 percent of the patients had normal X-rays and only 5 percent had arthritis. This study demonstrates that using this technique good resultd can be obtained with regard to laxity and arthritis.

Arthroscopic reconstruction of the posterior cruciate ligament using single-bundle bone-patella tendon-bone graft with moderate to long term follow-up / 中华外科杂志

<p><b>OBJECTIVES</b>To evaluate the 4- to 10-year results of arthroscopic reconstruction of the posterior cruciate ligament (PCL) using single-bundle bone-patella tendon-bone graft, and to find out the principle and influential factor of the isolated PCL reconstruction.</p><p><b>METHODS</b>From May 1998 to July 2004 the data of 29 patients with isolated PCL reconstruction retrospectively investigated, using single-bundle bone-patella tendon-bone graft. Twenty-two cases were followed up with average 7.1 years (5 - 10 years). Follow-up included the subjective knee function evaluation, KT2000, Biodex and the radiographic assessment.</p><p><b>RESULTS</b>The mean final follow-up IKDC score, Lysholm score, and Tegner score of the 22 cases were 89.4 +/- 8.1, 94.5 +/- 9.2, and 6.9 +/- 2.6 respectively. There were statistically significant improvements in them when compared with preoperative data respectively (P < 0.01). The average posterior displacement measured with KT2000 was (4.9 +/- 1.1) mm (90 degrees flexion) and (4.3 +/- 1.2) mm (30 degrees flexion) respectively. At the final follow-up, KT2000 examination revealed >or= 6 mm of posterior laxity in 6 patients (group A), and <or= 5 mm posterior laxity in 16 patients (group A). A statistically significant improvement was noted in comparing the mean final follow-up IKDC score, Lysholm score, and Tegner score between the group A and B (P < 0.01). The average time from injury to surgery of group A and B was (17.6 +/- 3.9) months and (2.9 +/- 2.1) months respectively, the difference was statistically significant (P < 0.01). The data was received from the Biodex dynamometer for the 22 patients who were followed up in clinic service. Patients achieved (90 +/- 22)% (60 degrees /s) and (87 +/- 19)% (120 degrees /s) recovery of the extensor peak torque respectively, for the flexor peak torque patients achieved (93 +/- 16)% (60 degrees /s) and (92 +/- 20)% (120 degrees /s) respectively, the difference between the peak torque of extensor and flexor in the same condition was statistically significant (P < 0.01). X-ray findings: 8 of the 22 patients (36.4%) were assessed as mild grade change (3 case in medial compartment isolated, 1 case in patellofemoral joint isolated, and 4 case in both compartments) and 2 patients (9.1%) as moderate grading in final follow-up radiographs (in both anterior and medial compartments), and 12 of the 22 patients (54.5%) revealed normal X-ray findings. The average time from injury to surgery of patients who revealed joint degeneration and patients who revealed normal X-ray findings was (16.6 +/- 2.7) months and (3.3 +/- 1.7) months respectively, the difference was statistically significant (P < 0.01).</p><p><b>CONCLUSIONS</b>Arthroscopic reconstruction of the posterior cruciate ligament using single-bundle bone-patella tendon-bone graft produces well results with moderate to long term follow-up. For the patients with III or IV PCL injury, PCL reconstruction should be done as soon as possible.</p>

[Early complication of anterior cruciat ligament reconstruction with bone-patellar tendon- bone graft]

Anterior cruciate ligament [ACL] tear is one of the most common knee injuries among young adults and sportman. They need reconstruction when they are accompanying with other knee internal derangements to prevent knee osteoarthritis. This study was designed to explore early complication of anterior cruciat ligament reconstruction with bone-patellar tendon- bone graft. This prospective and cross-sectional study was done on 13 patients which refered to Qaern hospital in Mashhad-lran during 2008. The first 3 months complications and problems of anterior cruciate ligament reconstructions, with bone-patellar tendon, bone graft technique, was recorded on regular basis, symptoms and signs were documented. Anterior knee pain and knee stiffness were common as 70% and 38% respectively. We did not observe any infection but in 15% of patients a minor instability [ADT+] was detected. Patients cooperation was low and even 54% of them did not implement, post-operative advices. This study showed that minor instability and subsequent pain are the early problems during the first three month after anterior cruciate ligament constraction

Anterior cruciate ligament reconstruction with hamstring tendons preserved tibial insertion and an implant fixation technique of hamstring tendon knot and bone bolt press-fit / 中国骨伤

<p><b>OBJECTIVE</b>To evaluate the feasibility of hamstring autograft anterior cruciate ligament reconstruction with hamstring tendons insertion on tibia preserved and an implant fixation technique of hamstring tendons knot and bone bolt press-fit.</p><p><b>METHODS</b>Twenty cases of injured anterior cruciate ligament were reconstructed. There were 15 males and 5 females with the average age of 22 years old. Ten left knees and 10 right knees were involved. Hamstring tendons were taken, and pretension was performed. Tibial tunnel and femoral tunnel were prepared,and the femoral tunnel was a frame of narrow inside and wide outside. The hamstring tendons knot and bone bolt were pulled inside of femoral tunnel. The tendons distal of tendons knot were brought to pass the femoral tunnel, joint capsule and another tibial tunnel. Then, the tendons distal of tendons knot were tightened together with the part of hamstring tendons of which the insertion were on tibia. After the operation, the knee was fixed at a flexion of 45 degrees by brace.</p><p><b>RESULTS</b>The patients were followed up for 8 to 24 months. The function of troubled knees was evaluated by Lysholm knee functional scale. The average knee score were 61.5 +/- 4.6 and 92.5 +/- 3.7 respectively before and after operation, and the difference was statistically significant (P < 0.05).</p><p><b>CONCLUSION</b>Hamstring tendons insertion on tibia preserved and an implant fixation technique of hamstring tendons knot and bone bolt press-fit was biological fixation for anterior cruciate ligament reconstruction with hamstring. The advantage of this method was avoidance of using high cost material for fixation,which lessened spending for the patients. And it was also benefit for tendon-bone healing.</p>

Diagnosis and management of septic arthritis after arthroscopic anterior cruciate ligament (ACL) reconstruction / 中华外科杂志

<p><b>OBJECTIVE</b>To summary the experience in the diagnosis and management of septic arthritis after anterior cruciate ligament (ACL) reconstruction.</p><p><b>METHODS</b>The knee joint infections after arthroscopic anterior cruciate ligament reconstruction were retrospectively studied. From January 1997 to July 2007, 16 of 3638 patients undergoing anterior cruciate ligament reconstructions experienced postoperative septic arthritis. The incidence, cause, presentation, laboratory results, treatment, and outcome of all infected patients were analyzed. The experiences of diagnosis and management of septic arthritis after anterior cruciate ligament reconstruction were summarized.</p><p><b>RESULTS</b>The incidence of septic arthritis after ACL reconstruction was 0.44%. The most common symptoms of the infected patients were fever, swelling, severe pain, tenderness, restricted motion. Eleven (68.8%) patients were positive for bacteria cultures, and Staphylococcus epidermidis was the most common bacteria. Nine of the 16 patients were performed arthroscopic debridement, and the other 7 patients were conservatively treated. All patients regained full range of motion and normal stability at the 19.7 months follow-up.</p><p><b>CONCLUSIONS</b>Septic arthritis, which could bring the dysfunction of the joint, is subsequent with cartilage injury and the failure of the ACL grafts. Early diagnosis and treatment of arthroscopic debridement in time are essential to the ultimate clinical outcome.</p>

Bone-patellar tendon-bone graft in anterior cruciate ligament reconstruction: allograft versus autograft / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the clinical result of arthroscopic anterior cruciate ligament (ACL) reconstruction with either allo- or auto- bone-patellar tendon-bone (B-PT-B) grafts.</p><p><b>METHODS</b>From February 2002 to January 2006, 142 of 187 cases of ACL ruptures who received ACL reconstruction with B-PT-B grafts were studied retrospectively. There were 93 male and 49 female whose age was from 15 to 57 years (mean 26 years). Patients were divided into 2 groups by graft selection: 38 patients with autograft and 104 with allograft. Clinical results were evaluated according to IKDC, Lysholm, Irgang and Larson scales. Sub-items of scales such as pain, swelling and laxity were specifically evaluated.</p><p><b>RESULTS</b>All of the patients were followed up with an average of 24 months (range from 6 to 43 months). All grafts were radiographically in good position at the time of follow-up. KT-1000 examination of affected knee showed less than 3 mm anterior translation difference compared with contralateral one's. Allograft group: 85 patients got normal IKDC score (81.7%). Lysholm score 82.8 +/- 8.5, Irgang score 79.2 +/- 7.3, Larson score 86.7 +/- 3.1. Autograft group: 29 patients got normal IKDC score (76.3%). Lysholm score 84.6 +/- 9.5, Irgang score 79.5 +/- 7.6, Larson score 88.9 +/- 6.8. No significant statistical difference was found between the 2 groups in the comprehend scale (P>0.05).</p><p><b>CONCLUSIONS</b>Both autograft and allograft group achieve good results, and the allograft B-PT-B could provide the similar clinical result as autograft, the preliminary result of allograft reconstruction might indicate predictable result in the future.</p>