Artroplastia do joelho navegada x mecânica: comparação entre casos iniciais de navegação e convencionais pelo mesmo cirurgião / Navigated versus mechanical knee replacement: comparison between initial navigated and conventional cases performed by the same surgeon

OBJETIVO: Foram avaliados e comparados os eixos mecânicos pós-operatórios de 36 artroplastias totais de joelho pelos sistemas de alinhamento navegado e mecânico feitos no mesmo período pelo mesmo cirurgião e equipe, iniciantes na técnica navegada e com experiência na técnica mecânica. MÉTODOS: Entre 2008 e 2010, 36 próteses totais de joelho foram executadas e comparadas, 25 navegadas e 11 mecânicas. Qualquer desvio de eixo medido no RX panorâmico pós-operatório foi considerado positivo. RESULTADOS: As próteses navegadas obtiveram média de desvio de eixo de 1,32 graus e desvio padrão de 1,57 graus e as mecânicas, respectivamente, 3,18 e 2,99 graus. Houve um melhor alinhamento com tendência à diferença estatística em favor da técnica navegada. CONCLUSÃO: Os casos com desvio de eixo maior que três graus foram significativamente maiores na técnica mecânica. A técnica por navegação foi incorporada por nossa equipe sem complicações adicionais e, mesmo sem experiência em cirurgia navegada, os primeiros casos obtiveram melhor alinhamento em relação à técnica mecânica e número significativamente menor de casos fora da zona de segurança de três graus em relação ao eixo mecânico.

OBJETIVE: The postoperative mechanical axis in 36 cases of total knee arthroplasty using navigated and mechanical alignment systems was evaluated and compared. All the operations were performed over the same period by the same surgeon and team, who were beginners in the navigated technique and experienced in the mechanical technique. METHODS: Between 2008 and 2010, 36 total knee prostheses were performed and compared: 25 navigated and 11 mechanical procedures. Any deviation from the axis measured on the panoramic postoperative X-ray was considered positive. RESULTS: The navigated prostheses produced a mean axis deviation of 1.32 degrees and standard deviation of 1.57 degrees and the mechanical, respectively 3.18 and 2.99 degrees. There was better alignment with a tendency towards a statistical difference favoring the navigated technique. CONCLUSION: There were significantly more cases with axis deviation greater than three degrees using the mechanical technique. The navigated technique was incorporated by this team without additional complications and, even without experience of navigated surgery, the initial cases achieved better alignment than with the mechanical technique, and a significantly smaller number of outliers from the three-degree safety zone.

Positioning of the femoral tunnel for arthroscopic reconstruction of the anterior cruciate ligament: comparative study of 2 techniques

OBJECTIVE: To compare the accuracy of positioning of the femoral tunnel in reconstructing the anterior cruciate ligament by means of 2 techniques: tibial tunnel and anteromedial portal. METHOD: Femoral tunnels were drilled in 20 knees from human cadavers by means of arthroscopy. Group I had the femoral tunnel drilled via a trans-tibial tunnel, and Group II via the anteromedial portal. Four variables were measured: A) posterior wall thickness; B) tunnel positioning at the notch; C) tunnel inclination in relation to the femoral axis; and D) distance between the wire guide exit and the lateral epicondyle. RESULTS: As above, respectively, A) 2.23 mm for group I and 2.36 mm for group II (P =.54); B) 25.5° for group I and 30.0° for group II (P =.23); C) 23.9° for group I and 32.0° for group II (P =.02); D) 7.8 cm for group I and 3.9 cm for group II (P <.001). CONCLUSIONS: Both techniques achieved the desired positioning for the femoral tunnel entrance and satisfactory thickness for the posterior cortex. Drilling via the anteromedial portal may provide greater protection against rupture of the posterior wall.

OBJETIVO: Comparar a acurácia do posicionamento do túnel femoral na reconstrução do ligamento cruzado anterior através de duas vias: túnel tibial e portal ântero - medial. MÉTODO: Foram perfurados túneis femorais em vinte joelhos de cadáveres humanos por via artroscópica. Grupo I: túnel femoral por acesso trans túnel tibial. Grupo II: via portal ântero-medial. Quatro variáveis foram estudadas: A) espessura da parede posterior; B) posicionamento do túnel no intercôndilo; C) angulação do túnel em relação ao eixo do fêmur; D) distância entre a saída do fio guia e o epicôndilo lateral. RESULTADO: A) grupo I: 2,23 mm, grupo II: 2,36 mm (p=0,543); B) grupo I: 25,5°, grupo II: 30° (p=0,226); C) grupo I: 23,9°, grupo II: 32° (p= 0,014); D) grupo I: 7,8 cm, grupo II 3,9 cm (p<0,001). CONCLUSÃO: As duas técnicas obteveram o posicionamento desejado da entrada do túnel femoral e espessura adequada da cortical posterior. A perfuração via portal ântero-medial pode propiciar maior proteção contra rotura da parede posterior.

Estudo biomecânico de resistência à tração de âncoras metálicas de sutura em diferentes ângulos de inserção / Traction endurance biomechanical study of metallic suture anchors at differente insertion angles

The suture anchors' insertion angle and its traction resistance are the main subjects of this study. Twenty trials were realized using threaded suture anchors in four diferents angulations (30º /45º /60º /90º) in human bone (distal femur) and another twenty trials in artificial bone (SawboneTM). The anchors were pulled out being tractioned uprightly from its bone surface by a Kratos Universal test machine. The human bone results found no relation between the main subjects of this study, so whithout statistical value. On the other hand at the artificial bone the insertion angle of 90º beared more traction, being statistically significant compared to the other angles.

Osteotomia valgizante de tíbia com placa calço de Puddu combinada com a reconstrução do ligamento cruzado anterior do joelho / Valgus osteotomy of the tibia with a Puddu plate combined with anterior cruciate ligament reconstruction

Anterior knee instability associated with a varus deformity is a complex condition with several treatment possibilities. Among these, anterior cruciate ligament (ACL) associated to a simultaneous valgus tibial osteotomy is a increasing indication. This simultaneous procedure adds technical issues to those related to the isolated surgeries. Thus, the osteotomy plane and location of fixation hardware shouldnÆt conflict with tibial tunnel and ACL graft fixation. Authors analyze the relations between a opening tibial valgus osteotomy stabilized with a Puddu plate and ACL reconstruction with a patellar tendon graft fixated with interference screws in 10 human cadaver knees. A straight oblique tibial osteotomy starting on the medial tibial cortex and oriented laterally and proximally was performed on all knees with a 10mm opening medially and stabilized with a Puddu plate on the most posterior aspect of the medial tibia, and a tibial tunnel drilled 50° to tibial plateau. With this technique there was no intersection between tibial tunnel or interference screw and the osteotomy or the plate fixation screws.

Appraisal of surgical treatment of 47 cases of patellofemoral instability

INTRODUCTION: Patellofemoral instability is a common knee disease. Its etiology is complex and variable, with many components making different contributions in each individual, resulting in several distinct clinical presentations. Our goal was to analyze the results of surgical treatment in our hospital over a period of 10 years. PATIENTS AND METHODS: We analyzed 55 knees of 47 patients who underwent surgery for patellofemoral instability and were classified into 2 main groups: proximal realignment and combined proximal and distal realignment. Three other groups were analyzed according to the duration of preoperative symptoms: less than 1 year (group I); 1 to 10 years (group II); and more than 10 years (group III). RESULTS: There were 62 percent good results overall, with 78 percent good results in groups I and II. Group III had 81 percent bad results, showing that a late diagnosis of advanced disease results in a poor prognosis. In addition to late diagnosis, bad results were usually associated with incorrect diagnosis or choice of surgical technique. There was no significant difference between isolated proximal realignment and combined proximal and distal realignment in groups I or II, but in group III, the combined technique yielded better results. DISCUSSION: Our results indicate that patellofemoral instability should be addressed in its early stages. Patients with long-lasting symptoms or more severe disease seem to achieve better results with combined techniques. CONCLUSION: Proximal and distal realignments produce better results than isolated proximal realignment in patients with joint degeneration or with greater duration of disease. The realignment surgery does not produce good results in patients with advanced disease