Lesiones de raíz meniscal posterior: conceptos actuales desde anatomía hasta tratamiento quirúrgico / Posterior meniscal root tears: current concepts

Podemos definir las lesiones de raíz meniscal (LRM) como lesiones radiales ubicadas a 1 cm de la inserción de la raíz meniscal, o las avulsiones de la misma. Dichas lesiones alteran la transmisión de la carga axial de la rodilla debido al fallo del menisco para disiparla lo que lleva a la sobrecarga con el consecuente desgaste acelerado del cartílago articular. La reparación de las lesiones de raíz meniscal está recomendada en pacientes jóvenes sin cambios artrósicos avanzados (Outerbridge 3–4), con el fin de restaurar la congruencia articular, mejorar la distribución de cargas, y así prevenir los cambios degenerativos articulares precoces. Numerosas técnicas quirúrgicas han sido descriptas en la literatura. Se han documentado mejoras en la funcionalidad de los pacientes sometidos a una cirugía de reparación de raíz meniscal, aunque todavía hay controversias sobre si dicho tratamiento puede prevenir o no la artrosis precoz.

Meniscal root tears (MRTs) are defined as radial tears within 1 cm of the meniscal root insertion, or an avulsion of the insertion of the meniscus. These injuries change joint loading due to failure of the meniscus to convert axial loads into hoop stresses, resulting in joint overloading and degenerative changes in the knee joint. Meniscal root repair is recommended in patients without advanced osteoarthritis (Outerbridge 3–4), in order to restore joint congruence, loading and thus avoid the long-term effect of joint overloading. Several techniques have been described in literature. Improved patient function is reported after meniscal root repair, but there are still conflicting reports on whether surgical treatment can prevent osteoarthritis.

Clasificacion de lesiones meniscales de ISAKOS: estudio de reproducibilidad intra e interobservador / Intra and interobserver reliability of ISAKOS classification for meniscal tears

Introducción: El objetivo de este trabajo fue analizar la reproducibilidad intra e interobservador de la clasificación de lesiones meniscales de Sociedad Internacional de Artroscopía, Cirugía de la Rodilla y Medicina Deportiva (ISAKOS). Materiales y Métodos: Se utilizó la clasificación artroscópica de lesiones meniscales creada por la ISAKOS. Se seleccionaron y se analizaron 31 videos artroscópicos de cirugías realizadas en el Hospital Italiano de Buenos Aires. Los mismos fueron evaluados por 3 traumatólogos (2 especialistas en cirugía de rodilla y un becario de postgrado), en dos ocasiones con un intervalo de 30 días. Se utilizó el índice de Kappa de Cohen para evaluar la reproducibilidad intraobservador y el coeficiente de correlación intraclase para la reproducibilidad interobservador. Resultados: La reproductibilidad promedio intraobservador fue para el primero de 51%, para el segundo de 65% y para el tercero de 58%, alcanzando un acuerdo moderado según la categorización del coeficiente de Kappa utilizada por Landis y Koch. Con respecto a la reproductibilidad interobservador, se obtuvo una concordancia buena (ICC=0,71), según el Coeficiente de correlación intraclase. Todos los cálculos fueron estadisticamente significativos. (p<0,05). Conclusión: Si bien esta clasificación permite una detallada descripción de las lesiones meniscales, la reproductibilidad intraobservador no alcanzo los valores óptimos a pesar de haber obtenido en promedio un acuerdo moderado. Por otro lado, la reproductibilidad interobservador demostró en promedio resultados mayores al 70% (concordancia buena), con lo cual podemos afirmar que el acuerdo y reproductibilidad interobservador es aceptable. Tipo de trabajo: Observacional, descriptivo de tipo diagnóstico. Nivel de Evidencia: IV

Objectives: To analyze the intra and interobserver reliability of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) classification for meniscal tears. Methods: The arthroscopic classification for meniscal lesions created by the ISAKOS was used. Thirty-one arthroscopic videos with different meniscal tear characteristics were analyzed by three orthopedic surgeons (two specialists in knee surgery and a fellow), twice at an interval of 30 days. The Kappa Coefficients (k) was used to assess the intraobserver reliability and intraclass correlation coefficient (ICC) for interobserver reliability. Results: The average intraobserver reliability was 51% for the first observer, 65% for the second and 58% for the third, reaching moderate agreement according to the Kappa coefficient used by Landis and Koch. Regarding interobserver reliability, good agreement (ICC = 0.71) was obtained for the intraclass correlation coefficient. The whole results were statistically significant (p <0.05). Conclusion: While this classification provides a detailed description of meniscal lesions, the intraobserver reliability did not reach the optimum values obtained despite having on average a moderate agreement. However interobserver reliability showed on average agreement of 70% (good agreement), which can affirm that the agreement and interobserver reliability is acceptable. Type of Study: Observational, descriptive, a diagnostic study. Level Of Evidence: IV

Resultados de reparaciones meniscales aisladas en asa de balde en deportistas amateurs / Results of isolated bucket handle meniscal repair in amateur athletes

Evaluar los resultados de reparaciones meniscales aisladas en asa de balde. Material y Métodos: Se analizaron retrospectivamente 46 reparaciones meniscales aisladas en asa de balde, durante los años 2001 y 2010. Se incluyeron lesiones longitudinales en área roja-roja o roja-blanca, en pacientes cuya edad promedio fue de 26.8 años. Durante el preoperatorio y postoperatorio se realizó examen clínico mediante el score de Lysholm y score de Tegner. La evaluación siguiendo los criterios clínicos de Barret e imagenológicos de Heninng por resonancia magnética fue llevada a cabo. El promedio de seguimiento fue de 42 meses (rango 36-88 meses). Un valor p < 0.05 fue considerado estadísticamente significativo. Resultados: De acuerdo a los criterios de Barret, 39 (84.7%) pacientes de 46 casos presentaron curación completa. Treinta y tres (71.7%) de 46 casos curaron completamente en las imágenes por resonancia magnética. Los criterios de curación de Barret y los de Henning en imágenes por resonancia, estuvieron significativamente asociados (P =.006). Siete reparaciones (15.2%) fueron consideradas fallidas. En 39 casos el score de Lysholm resultó significativo (P= 0.0001), de un promedio de 65 puntos en el preoperatorio a 95 en el postoperatorio, mientras que el score de Tegner fue de 3.5 en el preoperatorio a 6.2 en el postoperatorio (P = 0.0001). Conclusión: Las reparaciones meniscales aisladas en asa de balde tratadas en forma aguda presentan un alto porcentaje de curación con un aceptable porcentaje de fracasos. Nivel de evidencia: IV. Tipo de Estudio: Retrospectivo...

Purpose: To evaluate the outcomes of isolated bucket handle meniscal repair. Material and Methods: Between 2001 -2010 forty-six bucket handle meniscal repair were done. Longitudinal lesions in red-red or red-white area were included. The average age was 26.8. Preoperatively and postoperatively subjective outcomes evaluation was performed using the Lysholm score and Tegner score respectively. The clinical Barret criterias and Heninng criterias by MRI was done. Average follow-up was 42 months (range 36-88 months). A p value <0.05 was considered statistically significant. Results: According to the criteria Barrett, 39 (84.7%)of 46 cases showed complete healing. Thirty-three (71.7%) of 46 cases were cured completely in MRI. The criteria healing Barret and Henning resonance images were significantly associated (P = .006). Seven repairs (15.2%) were considered failures. In 39 cases the Lysholm score was significant (P=0.0001), averaging 65 points preoperatively to 95 postoperatively, while the Tegner score was 3.5 preoperatively to 6.2 postoperatively (P = 0.0001). Conclusion: isolated bucket handle meniscal repair have a high healing with an acceptable failure rate. Level of evidence: IV. Study Design: Retrospective...

Bilateral Occurrence and Morphologic Analysis of Complete Discoid Lateral Meniscus

PURPOSE: The aim of the study was to investigate and analyze bilateral incidence and morphology of complete discoid lateral meniscus (DLM) with possible relation to tears and symptoms in knee joints. MATERIALS AND METHODS: Thirty-eight consecutive patients with symptomatic or already-torn complete DLM on magnetic resonance imaging in a unilateral knee underwent diagnostic arthroscopy on both knee joints upon agreement. The presence and shape of complete DLM as well as presence and pattern of tear were recorded accordingly. RESULTS: In total, 89.5% (34 of 38 patients) showed bilateral complete DLM, and 84.2% yielded bilateralism with identical shape. Cape-slab was the most frequent shape, comprising 68.8% of patients with identically-shaped bilateral DLM overall. Tear patterns were more frequent, in the order of longitudinal, simple horizontal, radial, and degenerative; however, the morphological shape of complete DLM was not significantly related to tear incidence or pattern. Meniscus tears and knee symptoms occurred in the contralateral knee with incidences of 32.4% and 26.5% in patients with bilateral complete DLM, respectively. CONCLUSION: Based on these findings, more aggressive warning on the presence of discoid pathology and the need for evaluation on the contralateral knee should be considered during consultation with patients with symptomatic complete DLM in a unilateral knee in the outpatient clinic.

The Results of All-Inside Meniscus Repair Using the Viper Repair System Simultaneously with Anterior Cruciate Ligament Reconstruction

BACKGROUND: Meniscus tears are commonly associated with anterior cruciate ligament (ACL) ruptures. It is essential to repair meniscal tears as much as possible to prevent early osteoarthritis and to gain additional stability in the knee joint. We evaluated the results of arthroscopic all-inside repair using the Meniscal Viper Repair System (Arthrex) on meniscus tears simultaneously with ACL reconstruction. METHODS: Nineteen out of 22 patients who were treated with arthroscopic all-inside repair using the Meniscal Viper Repair System for meniscus tear associated with ACL rupture were evaluated. ACL reconstructions were performed at the same period. The mean follow-up period was 16.5 months (range, 12 to 24 months). The clinical results of the meniscus repair were evaluated by symptoms (such as catching or locking), tenderness, effusion, range of motion limitation, and the McMurray test. Clinical success was defined by negative results in all five categories. The Hospital for Special Surgery (HSS) score was evaluated. Objective results were evaluated with secondary look arthroscopy or magnetic resonance imaging (MRI). The MRI results were categorized as completely repaired, incompletely repaired, and failure by Henning's classification. The results of second-look arthroscopy were evaluated with the criteria of meniscal healing. RESULTS: The clinical success rate was 95.4% and the HSS scores were 93.9 +/- 5.4 at the final follow-up. According to Henning's classification, 15 out of 18 cases showed complete healing (83.3%) and two cases (11.1%) showed incomplete healing. Seventeen out of 18 cases that underwent second-look arthroscopy showed complete healing (94.4%) according to the criteria of meniscal healing. Only one case showed failure and the failure was due to a re-rupture at the sutured area. Complications of ACL reconstruction or meniscus repair were not present. CONCLUSIONS: The results demonstrate that arthroscopic all-inside repair using the Meniscal Viper Repair System is an effective treatment method when it is performed simultaneously with ACL reconstruction.

Repercusión funcional en el rendimiento físico-atlético postoperatorio de pacientes deportistas con lesiones meniscales / Functional repercussions of meniscal injuries on the postoperative physical athletic performance of athletes

La práctica deportiva a la fecha ha tenido un enorme auge en la sociedad mundial. Durante ésta, con frecuencia se generan lesiones de rodilla, específicamente lesiones meniscales que ameritan el tratamiento quirúrgico respectivo pudiendo ser: la remodelación y resección de fragmentos, la reparación meniscal o en casos extremos la práctica de injerto meniscal. En este trabajo prospectivo practicamos la resección fragmentaria y remodelación meniscal en pacientes deportistas y medimos su rendimiento físico-atlético postoperatorio. Métodos: Criterios de inclusión: Pacientes de ambos sexos quienes practicaran algún deporte con nivel amateur o recreativo competitivo y que sufrieran una lesión meniscal. Criterios de exclusión: Pacientes con ruptura total de ligamento cruzado anterior asociada, pacientes con pérdida de seguimiento y pacientes candidatos a reparación de menisco. Cohorte de 23 pacientes, 10 mujeres y 13 hombres captados en nuestro hospital. Se practicó un protocolo diagnóstico a fin de certificar la lesión. Los pacientes fueron intervenidos quirúrgicamente para realizar la resección y remodelación de fragmentos meniscales. Posteriormente fueron rehabilitados por el servicio de fisiatría y finalmente se autorizó regresar a la práctica deportiva. Se aplicó la tabla Tegner Lysholm Knee Scoring Scale para evaluar los resultados postoperatorios. Conclusión: Todos los pacientes fueron capaces de regresar a la práctica deportiva anterior a la lesión aunque con un rendimiento promedio de un 20 a 30% menor al previo. En el sexo femenino se requirió un mayor tiempo de recuperación.

The practice of sports has experienced a huge boom in societies worldwide. It often involves knee injuries, specifically meniscal tears that warrant surgical treatment which may include: fragment remodeling and resection, meniscal repair or, in extreme cases, the use of a meniscal graft. In this prospective study we performed fragment resection and meniscal remodeling in athletes and we measured their postoperative physical-athletic performance. Methods: Inclusion criteria: Patients of both sexes who practice a sport either as amateurs or at a recreational competitive level, who sustained a meniscal injury. Exclusion criteria: Patients with associated total anterior cruciate ligament tear, patients lost to follow-up, and patients eligible for meniscal repair. 23-patient cohort including 10 females and 13 males who presented at our hospital. A diagnostic protocol to certify the injury was applied. Patients underwent surgery to perform meniscal fragment resection and remodeling. They later underwent rehabilitation at the physiatrics service and finally received approval to return to sports. The Tegner Lysholm Knee Scoring Scale was used to assess postoperative results. Conclusion: All patients were able to return to practice their pre-injury sport, but their performance was 20 to 30% lower than before. Recovery took longer in females.

Reconstrucción de ligamento cruzado anterior: resultados funcionales / Reconstruction of the anterior cruciate ligament: functional results

Introducción: Las lesiones del ligamento cruzado anterior (LCA) son muy frecuentes y no tratarlas aumenta el riesgo de osteoartrosis en la rodilla, por lo que hoy se recomienda la reconstrucción quirúrgica sobre todo en gente activa como en el grupo de estudio. Materiales y Métodos: Se realizó un estudio observacional, descriptivo. Se evaluaron 48 pacientes a quienes se les realizó reconstrucción de LCA por abordaje único, con injerto autólogo, heterólogo o híbrido fijados con Sistemas Aperfix Cayenne, entre noviembre 2011 y octubre 2012. Solo se incluyeron pacientes con un mínimo de 6 meses post-operatorio los que fueron evaluados con las Escalas de Lysholm y Tegner. Resultados: La escala de Lysholm mostró resultados excelentes y buenos en un 68.7 por ciento y regulares en un 31 por ciento. El puntaje de la escala de Tegner pasó de 3,1 en el preoperatorio a 5.3 en el posoperatorio. La única complicación observada fue la sinovitis. Discusión: Se puede afirmar que los resultados funcionales de las Reconstrucciones de LCA fueron buenos independientemente del tipo de Injerto utilizado; resultados bastantes similares a los reportados en la literatura mundial.

Introduction: Anterior cruciate ligament injury (ACL) is one of the most common and not treating it increases the risk of osteoarthrosis in the knee, so nowadays its surgical reconstruction is recommended especially in active people. Methods: A retrospective study was carried out in order to determine the outcome of all patients who underwent an ACL reconstruction surgery using autograft, allograft or Hybrid graft fixed with Aperfix Cayenne System, from November 2011 to October 2012. Only were included patients with a minimum of 6 months post-operative which were evaluated with the Lysholm and Tegner scales. Results: Results were graded good and excellent in 68.7 per cent of the patients and fair in 31 per cent according to Lysholm. Furthermore, an increase in Tegner scale was well documented. The only complication observed in patients was a postoperative synovitis in some of them. Discussion: Our results has shown that the functional results was good, similar to those found up in overall existing medical literature.

Fatores preditivos de resultados desfavoráveis da meniscectomia medial artroscópica em pacientes com mais de 50 anos de idade / Predictors of poor outcomes of arthroscopic medial meniscectomy in patients over 50 years old

A evolução do conhecimento acerca das funções dos meniscos e do tratamento das suas lesões, impulsionada pelo advento da cirurgia artroscópica, consagrou e popularizou a meniscectomia por esta via, por ser uma técnica menos invasiva, com menor morbidade e menores custos hospitalares, a ponto de torná-la, atualmente, a cirurgia ortopédica mais frequentemente realizada no mundo. Embora a maior parte dos pacientes submetidos a esta intervenção cirúrgica tenha resultados favoráveis e resolução rápida dos sintomas, percebe-se que parte considerável dos pacientes, especialmente os mais idosos, não apresenta uma evolução póscirúrgica satisfatória, apresentando piora dos sintomas e, eventualmente, necessitando de nova cirurgia. Partindo da hipótese que em determinados pacientes a meniscectomia, em vez de tratar, precipita e acentua um desequilíbrio biomecânico do joelho, o autor realizou estudo observacional prospectivo não-controlado com 86 pacientes de ambos os gêneros, com idade superior a 50 anos (média de 60,2 ± 7,1 anos), submetidos à meniscectomia artroscópica para tratamento de lesão do menisco medial de natureza degenerativa, com o objetivo de determinar variáveis demográficas, clínicas, anatômicas e cirúrgicas relacionadas aos resultados desfavoráveis. As avaliações funcionais pré e pós-operatórias foram realizadas utilizandose o Índice do KOOS (Knee Injury and Osteoarthritis Outcome Score), aplicado a todos os pacientes antes da cirurgia e 60 meses depois. Após análise estatística dos resultados obtidos, o autor verificou que 10 fatores podem ser considerados preditivos das meniscectomias mediais artroscópicas neste grupo etário, sendo quatro fatores fortemente associados aos resultados desfavoráveis: lesão da raiz posterior do menisco medial, dor pré-operatória intensa, claudicação antes da cirurgia e tempo decorrido entre o início dos sintomas e a cirurgia; dois fatores foram considerados moderadamente associados aos resultados...

The evolution of knowledge concerning meniscal functions and the treatment of their injuries, boosted by the development of arthroscopic surgery, has established and popularized arthroscopic meniscectomy due to its less invasiveness, less post-operative morbidity and lower hospital costs, to the point it has become, nowadays, the most frequently performed orthopedic procedure in the world. Although the majority of patients undergoing this operation is quite pleased with the outcomes and with the prompt resolution of their symptoms, it is noticeable that a considerable amount of patients with meniscal injuries, mainly the older, does not have a satisfactory postoperative outcome, with worsening of symptoms after being operated on and occasionally requiring another surgery. Based on observations of his medical practice and on the assumption that meniscectomy, rather than treat, can hasten and accentuate a biomechanical imbalance of the knee in those patients, the author conducted an observational prospective uncontrolled study with 86 patients of both genders, aged over 50 years old (average 60.2 ± 7.1 years), who underwent arthroscopic meniscectomy for the treatment of degenerative medial meniscal lesions, aiming to determine demographic, anatomical, clinical and surgical variables related to poor outcomes. The functional pre and post-operative evaluations were performed using the KOOS index (Knee Injury and Osteoarthritis Outcome Score) applied to all patients before surgery and 60 months later. After statistical analysis of the results, the author found that 10 factors can be considered predictors of arthroscopic medial meniscectomy in this age group: four factors were strongly associated with unfavorable results - posterior root lesion of the medial meniscus, intense pre-operative pain, claudication before surgery and time elapsed between onset of symptoms and surgery; two factors were moderately associated with unfavorable results - bone marrow...

Frecuencia de lesiones en el compartimiento lateral de la rodilla en jugadores profesionales de básquet / Frequency of lateral knee injuries in professional basketball players

Introducción: El propósito de este trabajo es describir en forma retrospectiva las lesiones en el compartimiento lateral de la rodi Ila en jugadores profesionales de básquet. Materiales y Métodos: Presentamos 6 (seis) casos de jugadores profesionales de básquet del Centro Juventud Sionista (CJS) en seis temporadas de Liga Nacional de Básquet (LNB). Los pacientes fueron evaluados utilizando los siguientes criterios: examen físico, estudios complementarios (Rx y RMN) y artroscopía. Se utilizó la clasificación de Duterbridge para estadificar las lesiones osteocondrales. Resultados: Tres pacientes fueron diagnosticados y tratados con lesiones meniscales puras y regresaron a la competencia a partir de los 40 días de postoperatorio. Aquellos que presentaron lesiones osteocondrales siguieron el mismo protocolo de rehabilitación llevado a cabo por el mismo equipo de kinesiólogos del club (CJS), retornando a la competencia a partir de los 90 días de postoperatorio. Todos los jugadores regresaron a la competencia al mismo nivel y en la misma categoría (LNB-Liga Nacional de Básquet) que antes de operarse. Conclusión: Nuestros hallazgos son coincidentes con la escasa bibliografía internacional respecto a las lesiones meniscales evaluadas en basquetbolistas profesionales que indican una mayor incidencia de lesiones del menisco externo respecto del interno. Creemos que los movimientos específicos desarrollados en este deporte en particular contribuyen al desarrollo de lesiones del compartimiento externo...

Suturas meniscales: evaluación de resultados y análisis de fallas / Meniscal sutures

Objetivo: Evaluar a corto y mediano plazo una población de pacientes a quienes se les practicó sutura meniscal. Se analizaron específicamente las fallas procurando identificar las variables vinculadas. Materiales y métodos: En el periodo comprendido entre Enero de 2003 y Enero de 2011, fueron practicadas por el mismo equipo quirúrgico 1345 artroscopías simples y 785 reconstrucciones de LCA. En forma retrospectiva se seleccionaron los casos en los cuales fueron practicadas suturas meniscales (71 casos) y se identificaron las fallas (18 casos). Se definieron variables potencialmente vinculadas a las fallas como la edad del paciente en el momento de la reparación y al momento de la re-intervención por falla, el lapso transcurrido entre la primera intervención y la primera manisfestación clínica de la falla, el mecanismo traumático asociado, las características del compromiso meniscal, la comparación entre los patrones lesionales original y postsutura y la variedad de sutura realizada. Resultados: El porcentaje total de falla fue 25,35 por ciento, 18 de 71 reparaciones. En 13 casos el procedimiento asociado fue reconstrucción de LCA (porcentaje de falla: 18,30 por ciento) y en 5 pacientes se había realizado la sutura meniscal aislada (porcentaje de falla: 7,04 por ciento). El promedio de edad fue de 27 años (rango: 15-55). En todos se había realizado sutura “afuera-adentro” con Ethibond, PDS y Vicryl 1. En 4 casos se asoció sutura “todo adentro” con RapidLoc NR para los tercios posteriores. 11 pacientes (55,5 por ciento) refirieron un nuevo episodio traumático. El lapso transcurrido entre sutura y aparición de los síntomas fue: promedio 16 meses (3-45). Siendo el patrón lesional de la reruptura: en 9 casos lesiones longitudinal-vertical, en 6 c. lesiones en asas de balde y en 3 c. lesiones complejas. Conclusión: En la serie estudiada los factores más frecuentemente asociados con la re-ruptura fueron: paciente más joven, mecanismo traumático y patrón lesional longitudinal-vertical. La incidencia de fallas fue coincidente con la publicada a nivel internacional. Tipo de Estudio: Serie de casos - Estudio Terapéutico. Nivel de evidencia: IV

Correlation of Histological Examination of Meniscus with MR Images: Focused on High Signal Intensity of the Meniscus Not Caused by Definite Meniscal Tear and Impact on MR Diagnosis of Tears

OBJECTIVE: To document the causes of high signal intensity of the meniscus which is not caused by definite meniscal tears on MR imaging, through correlation with histological examination. MATERIALS AND METHODS: For the correlation between the MR image and histology, we obtained prospectively 31 meniscal specimens from 21 patients. Proton density-weighted turbo spin-echo MR images were used. Minimal tear, thinning of the lamellar layer, degeneration of the central layer, and radial tie fibers were detected upon histological examination, and were correlated with the corresponding MR images. RESULTS: Minimal tear of the lamellar layer was seen in 60 zones out of 100 slides. On MR images, 29 (48.3%) of these 60 zones had high signal intensity. Thinning of the lamellar layer was seen in 24 zones, with 7 (29.2%) having high signal intensity. 57 central zones showed degenerative change in the central layer and high signal intensity on all corresponding MR images. Radial tie fibers in the central layer appeared as high signal intensity areas. CONCLUSION: Minimal tear and thinning of the lamellar layer, degeneration and radial tie fibers of the central layer of the meniscus cause high signal intensity on MR images.

Lesiones de menisco en pacientes con osteoartritis de la rodilla / Meniscus lesions in patients with osteoarthritis of knee

Las lesiones de los meniscos de rodilla en pacientes con osteoartritis son muy frecuentes, se manifiesta por la triada de Henderson, lo que limita aún más el movimiento de la articulación de la rodilla. Desarrollo: se realizó una revisión bibliográfica con relación a los siguientes aspectos: composición bioquímica normal de los meniscos, alteraciones que sufren durante el proceso degenerativo articular de la rodilla, relación causa-efecto entre menisco y presencia de osteoartritis. Por último se hace mención al tratamiento mediante vía artroscópica y los resultados propios del los autores con referencia a citas de autores internacionales. Conclusiones: las lesiones de los meniscos tienen un comportamiento divergente en pacientes con osteoartritis de rodilla. El resultado del tratamiento quirúrgico vía artroscópica constituye una fuente de buen pronóstico y la ausencia o disminución del tejido meniscal aumenta el progreso de la enfermedad degenerativa articular de la rodilla

Meniscus lesions of knee in patients with osteoarthritis are very common, showed by Henderson´s triad, thereby further limiting the movement of knee joint. Development: a literature review was conducted with regard to the following aspects: normal biochemical composition of meniscus, alterations that suffer during the degenerative joint process of knee, cause-effect relationship between meniscus and presence of osteoarthritis. Finally it is mentioned the treatment via arthroscopy and authors´ own outcomes with reference to citations from international authors.Conclusions: meniscus lesions have different behavior in patients with osteoarthritis of knee. The result of surgical treatment via arthroscopy constitutes a source of good prognosis and the absence or decrease of meniscal tissue increases the progression of degenerative joint disease of knee

[ comparison between the role of MRI and arthroscopy in the diagnosis of traumatic knee lesions]

The knee is one of the most frequently injured joints. Clinical tests in the diagnosis of meniscus and ligament injuries have limitations and it may not be possible to elicit objective signs repeatedly. MRI, has been shown to improve diagnostic accuracy in many knee disorders. Its principal attractiveness over arthroscopy is that, it is noninvasive. To determine the effectiveness of magnetic resonance imaging in the appropriate identification of traumatic intra articular knee lesions, we compared its findings with clinical examination and arthroscopy as a gold standard technique in a descriptive cross sectional study. Overall 100 patients with knee trauma were entered and completed the study. All patients had thorough clinical examination by experienced physicians. An MRI of the affected knee was requested in all patients. Arthroscopies were performed for all of them. Overall 55 knees were reported to have ACL tear arthroscopically, Meniscal injuries were found in 75 cases. We found correlation between posterior drawer test, MRI report of PCL tear and arthroscopic PCL tear. The sensitivity of MRI for detecting Meniscal tear: represented high, for bucket handle tear of medial meniscus, and high specificity for lateral meniscal tear. It is concluded that arthroscopy still remains the gold standard technique. More powerful MRI scan equipments with better soft wares will be needed in order to have much better diagnosis

Intra-articular Patterns of Bucket Handle Meniscal Tears and Its Relation to Reducibility

BACKGROUND: The purpose of this study was to assess the intra-articular patterns in the rotational deformities of bucket handle meniscal tears (BHMTs) based on arthroscopic findings and their clinical relevance. METHODS: From 2004 to 2009, 42 patients with a BHMT diagnosed by magnetic resonance imaging underwent arthroscopic surgery. The arthroscopic data (all procedures were recorded) were evaluated retrospectively, and BHMTs were classified according to the rotational directions of centrally displaced fragments. To assess the reliability of the agreement in this classification, 2 orthopedic surgeons re-classified BHMTs, 1 week after first trial. Intra- and interobserver reliabilities were assessed using kappa statistics. In addition, we address specific tear patterns, associated anterior cruciate ligament injury, medio-lateral difference, reducibility, chronicity, and reparability. RESULTS: Most of the tears could be categorized into one of 3 morphologic patterns. Of the tears, 4.8% could not be categorized. BHMTs were classified, based on the rotational directions of centrally displaced fragments, as follows; the upward rotation group (type 1), the downward rotation group (type 2) and the reverse group (type 3). The most common intra-articular pattern was type 1 (29 patients, 69%). The occurrence of the other patterns was: type 2 in 7 patients (16.7%), type 3 in 4 patients (9.5%); we were not able to make a classification of type in 2 patients (4.8%). Intra-observer reliability was 0.86 in terms of kappa statistics, which implies almost perfect agreement. Mean interobserver reliability (0.73) showed substantial agreement. Type 1 and 2 tears were easily reduced, whereas all type 3 tears (4/4) needed additional procedures to achieve reduction. CONCLUSIONS: Based on arthroscopic findings, we describe a comprehensive BHMT classification scheme that encompasses 95.2% of all tears. Tear type was correlated with reducibility.

Effectiveness of electrical stimulation on rehabilitation after ligament and meniscal injuries: a systematic review / Efetividade da estimulação elétrica na reabilitação pós-lesões ligamentares e meniscais: uma revisão sistemática

CONTEXT AND OBJECTIVE: Electrical stimulation (ES) is widely used to strengthen muscles following ligament and meniscal injuries. The aim of this study was to evaluate the effectiveness of ES for rehabilitation after soft tissue injuries of the knee treated surgically or conservatively. DESIGN AND SETTING: Systematic review at the Brazilian Cochrane Center. METHODS: We searched the Cochrane Central Register of Controlled Trials (2010, Issue 12), Medline (Medical Analysis and Retrieval System Online) via PubMed (1966 to December 2010), Embase (Excerpta Medica database, 1980 to December 2010), Lilacs (Literatura Latino-Americana e do Caribe em Ciências da Saúde, 1982 to December 2010), and PEDro (Physiotherapy Evidence Database, 1929 to December 2010). The studies included were randomized controlled trials using ES to increase muscle strength for rehabilitation of patients with soft tissue injuries of the knee. Two authors independently evaluated studies for inclusion and performed data extraction and methodological quality assessment. RESULTS: Seventeen studies evaluating ES after anterior cruciate ligament reconstruction and two studies evaluating ES after meniscectomy were included. There was a statistically significant improvement in quadriceps strength through ES (mean difference, MD: -32.7; 95 percent confidence interval, CI: -39.92 to -25.48; n = 56) and in functional outcomes (MD -7; -12.78 to -1.22; n = 43) six to eight weeks after surgical reconstruction of the anterior cruciate ligament. CONCLUSION: There is evidence that ES coupled with conventional rehabilitation exercises may be effective in improving muscle strength and function two months after surgery.

CONTEXTO E OBJETIVO: A estimulação elétrica (ES) é amplamente utilizada para fortalecimento muscular após lesões ligamentares ou meniscais do joelho. O objetivo deste estudo foi avaliar a efetividade da ES na reabilitação de lesões de tecidos moles do joelho tratadas de forma cirúrgica ou conservadora. TIPO DE ESTUDO E LOCAL: Revisão sistemática no Centro Cochrane do Brasil. MÉTODOS: Realizamos uma busca no Cochrane Central Register of Controlled Trials (2010, Issue 12), Medline (Medical Analysis and Retrieval System Online) via PubMed (1966 até dezembro 2010), Embase (Excerpta Medica Database, de 1980 até dezembro 2010), Lilacs (Literatura Latino-Americana e do Caribe em Ciências da Saúde, de 1982 até dezembro de 2010), and PEDro (Physiotherapy Evidence Database, de 1929 até dezembro de 2010). Os estudos incluídos foram ensaios clínicos randomizados que utilizaram a ES com o objetivo de aumento de força muscular na reabilitação de pacientes com lesões de tecidos moles. Dois autores avaliaram os estudos para inclusão de forma independente e realizaram a extração de dados e avaliação da qualidade metodológica. RESULTADOS: Dezessete estudos incluídos utilizaram a ES após a reconstrução do ligamento cruzado anterior e dois estudos após meniscectomia. Houve melhora estatisticamente significante na força do quadríceps através da ES (diferença média, MD -32.7; 95 por cento intervalo de confiança, IC -39.92 to -25.48; n = 56) e nos desfechos funcionais (MD -7; -12.78 to -1.22; n = 43), seis a oito semanas após cirurgia de reconstrução do ligamento cruzado anterior. CONCLUSÃO: Há evidências de que a ES combinada a exercícios de reabilitação convencional pode ser efetiva na melhora da força muscular e função dois meses após cirurgia.

Rupturas del ligamento cruzado anterior: incidencia de lesiones secundarias relacionadas con el tiempo de reconstrucción / Anterior cruciate ligament rupture: incidence of secondary lesions

Objetivos: el propósito de este trabajo fue evaluar las rupturas del ligamento cruzado anterior, intervenidas en nuestra institución, y determinar la incidencia y severidad de lesiones condrales y meniscales asociadas, comparando estos resultados con el tiempo de evolución. Material y métodos: Evaluamos 207 pacientes con ruptura del ligamento cruzado anterior. Los pacientes fueron divididos en cinco grupos según el tiempo de evolución desde la lesión: O a 2 meses, 2 a 6 meses, 6 a 12 meses, 12 a 24 meses y más de 24 meses de evolución. Las lesiones meniscales y condrales fueron determinadas artroscópicamente y clasificadas según la escala de Outbridge. Realizamos un estudio retrospectivo tipo caso-controles comparativo (Nivel de evidencia III), utilizando estadística cuantitativa por análisis mediante test chi cuadrado para lesiones condrales y meniscales. Consideramos como significativo una P menor de 0,05. Resultados: en todos los tipos de lesión evaluados (menisco interno, menisco externo y cartílago articular) notamos un aumento significativo en el número y severidad de estas a medida que la reconstrucción se realizaba a mayor distancia en el tiempo con respecto al momento de la lesión. Conclusión: Para evitar daños a mediano y largo plazo en pacientes jóvenes, se recomienda realizar la reconstrucción del LCA dentro de los primeros 12 meses desde la lesión inicial. Diseño del estudio: Retrospectivo, comparativo, caso-control. Nivel de evidencia: III.

Efecto de los factores de crecimiento autólogos en las lesiones radiales del cuerno posterior del menisco externo en la rodilla del conejo: un modelo experimental / Effects of autologous growth factors on repairing lateral meniscal posterior horn tears: experimental model

Introducción: en la actualidad, la reparación de las lesiones de menisco en el hiato del poplíteo tienen mal pronóstico y su recuperación es lenta. El objetivo de este estudio es determinar el efecto que tienen los factores de crecimiento autólogos en la reparación de las lesiones radiales del cuerno posterior del menisco externo en la rodilla del conejo. Materiales y métodos: se diseñó un estudio experimental doble ciego y autocontrolado de conejos a los cuales se les realizan lesiones radiales en el cuerno posterior del menisco lateral a la altura del hiato poplíteo y se aplican factores de crecimiento autólogos a una de las rodillas (grupo experimental) y plasma pobre en plaquetas a la otra rodilla (grupo control) del mismo conejo. Los meniscos se estudiaron a las 3 y 6 semanas tanto macroscópicamente como bajo visión microscópica. Resultados: se encontraron diferencias entre los meniscos intervenidos con factores de crecimiento y los meniscos de control a favor del grupo experimental. La aplicación de factores de crecimiento autólogos en lesiones de menisco en el conejo mejoró tanto el número de resoluciones como el tiempo de cicatrización de las lesiones. Discusión: es necesario el diseño de nuevos trabajos en humanos utilizando los factores de crecimiento en lesiones meniscales complejas para obtener resultados más objetivos que permitan dar recomendaciones acerca de su uso y poder en un futuro cambiar el protocolo de rehabilitación, en especial en deportistas de alto rendimiento.

A importância da ressonância magnética pré-operatória nas fraturas do planalto tibial / The importance of pre-operative magnetic resonance image in tibial plateau fractures

OBJETIVO: Caracterizar a importância da Ressonância Nuclear Magnética (RNM) como método de investigação pré-operatória nas fraturas do planalto tibial, tratando de correlacionar o padrão de lesão óssea, classificado de acordo com os critérios de Schatzker, com a ocorrência de lesões ligamentares e meniscais. MÉTODOS: Foram avaliados as imagens de 25 pacientes com fraturas do planalto tibial, estudando a correlação entre lesões ósseas e de partes moles. Estabeleceu-se uma correlação entre a classificação de Schatzker e os achados de RNM. RESULTADOS: As lesões meniscais foram diagnosticadas em 96 por cento dos casos e as lesões ligamentares foram encontradas em 44 por cento dos pacientes. Houve correlação entre o tipo de fratura, segundo a classificação de Schatzker, e as lesões meniscais e/ ou ligamentares encontradas na RNM. As fraturas do tipo I e do tipo II de Schatzker apresentaram lesão do menisco lateral em 71,4 por cento e 83,3 por cento dos casos, respectivamente. Nas fraturas clas- sificadas como Schatzker tipo IV encontramos lesões de um ou mais ligamentos na RNM pré-operatória em 75 por cento dos pacientes. CONCLUSÃO: A RNM é um exame que agrega informações importantes para o entendimento da magnitude do dano em fraturas do planalto tibial, auxiliando no planejamento e tomada de decisões no tratamento destas lesões. Os autores recomendam, portanto, a incorporação da RNM no protocolo de avaliação pré-operatória das fraturas do planalto tibial.

OBJECTIVE: The aim of this study was to emphasize the role of Magnetic Resonance Image (MRI) as an adjuvant diagnostic tool for tibial plateau fractures, concerning the establishment of a relationship between bone fracture patterns and ligament and/ or menisci injuries. METHODS: Evaluation of image database of 25 patients victims of tibial plateau fractures. A correlation between bone and soft tissues has been established, based on Schatzker classification for tibial plateal fractures. RESULTS: 96 percent of these patients presented with associated menisci in- juries and 44 percent of them were diagnosed with associated liga- ment injuries. A correlation was established between fracture pattern, according to Schatzker classification, and soft tissue lesions detected by MRI. Fractures types I and II of Schatzker had association with lateral meniscus injury in 71,4 percent and 83,3 percent, respectively. Fractures of medial tibial plateau (Schatzker IV) were associated with ligament injuries in 75 percent of the cases. CONCLUSIONS: The authors conclude that MRI is a valuable and recommendable diagnostic method, enhancing the understanding of the injury and supporting preoperative planning and decision-making.

Characteristics of Radial Tears in the Posterior Horn of the Medial Meniscus Compared to Horizontal Tears

BACKGROUND: The clinical and radiologic features of radial tears of the medial meniscus posterior horn were compared with those of horizontal tears. METHODS: From January 2007 to December 2008, 387 consecutive cases of medial meniscal tears were treated arthroscopically. Among these, 91 were radial tears in the medial meniscus posterior horn, and 95 were horizontal tears in the posterior segment of the medial meniscus. The patients' data (age, gender, duration of symptom, body mass index, and injury history), radiographic findings (Kellgren and Lawrence score, posterior tibial slope, and femorotibial angle), and chondral lesions were recorded. RESULTS: The patient factors of age, gender, and body mass index were related to radial tears of the medial meniscus posterior horn. Radial tears were significantly correlated with Kellgren and Lawrence score, varus alignment, posterior tibial slope, and severity of the chondral lesion. CONCLUSIONS: Radial tears of the medial meniscus posterior horn are a unique clinical entity that are associated with older age, females and obesity, and are strongly associated with an increased incidence and severity of cartilage degeneration compared to horizontal tears.