Proximal endoscopic repair of the hamstring tendons: a cadaveric anatomical study of posterior hip portals.

Arthroscopy and endoscopic hip surgery have attracted increasing attention in the orthopedic field. In the case of arthroscopy, portals and their relationships with neurovascular bundle structures at risk are well established. However, studies on endoscopic portals used for the repair of hamstring tendon injuries are insufficient. Hamstring injuries are the most common muscle injury in sports medicine, and up to 12% can present as a tendon rupture. Endoscopic surgery is advantageous because it has a lower rate of bleeding and avoids excessive handling of the gluteal muscles. The objective of this study is to perform an anatomical evaluation of endoscopic portals for hamstring repair and measure their distance to neurovascular structures-mainly sciatic nerve and posterior femoral cutaneous nerve (PFCN). Fifteen hips from frozen and formalized cadavers were evaluated. Specimens that showed any modification in their anatomy were excluded. Portals were simulated using Steinmann pins, and anatomical dissection was performed. Distances from neurovascular structures were measured using a digital caliper. Four male cadaver hips (26%) and eleven female cadaver hips (74%) were included. Two dissected hips presented PFCN injury through the posterolateral portal- mean 20.28 mm (±8.14), and one through the distal accessory portal- 21.87 mm (±12.03). The injury rate for PFCN was 3/15 or 20%. None of the portals presented sciatic nerve injury. Conclusion: There is an imminent risk of nerve injury to the PFCN by performing the lateral portals for hamstring repair. To avoid this, we recommend starting the procedure through the most medial (posteromedial) portal, and the other portals must be performed under direct visualization.

ETHICAL AND LEGAL ASPECTS OF TELEMEDICINE APPLIED IN ORTHOPEDICS.

Due to the pandemic of COVID-19, many outpatient services were suspended, affecting hundreds of patients. As a result, several countries were forced to seek strategies to readapt their health systems, one of which was the expansion of telemedicine. Currently, telemedicine is used for several specialties, facilitating the treatment and follow-up of patients who have difficulty accessing it. Tele-orthopedics, telemedicine applied to the orthopedic specialty, allows orthopedic care to be offered to patients regardless of distance. By reducing travel time, waiting time, and costs, tele-orthopedics presents high patient satisfaction, allowing greater rehabilitation effectiveness after surgery and treatment compliance. There is much information in the current literature about telemedicine's legal and ethical aspects, but it is fragmented. This article aims to present a general explanation of these legal and ethical aspects, emphasizing tele-orthopedics. The ethical principles of autonomy, beneficence, non-maleficence and justice must be respected, as well the privacy and confidentiality during a teleconsultation. In this respect, orthopedic surgeons should be governed by traditional moral and ethical precepts. Still, they must also adapt to the new norms and laws regulating telemedicine use. Level of Evidence V: Expert Opinion.

Com a pandemia da COVID-19, muitos atendimentos ambulatoriais foram suspensos, afetando centenas de pacientes. Isso forçou diversos países a buscarem estratégias para readaptar seus sistemas de saúde e, uma delas, foi a expansão da telemedicina. Atualmente, a telemedicina está sendo utilizada para diversas especialidades, facilitando o tratamento e o acompanhamento de pacientes que possuem dificuldade de acesso. A tele-ortopedia, telemedicina aplicada à especialidade ortopédica, permite a oferta dos cuidados ortopédicos a pacientes independente da distância. Por reduzir tempo de viagem, tempo de espera e custos, a tele-ortopedia, apresenta alta satisfação por parte pacientes, o que permite maior efetividade na reabilitação após cirurgias e adesão ao tratamento. Há na literatura atual diversas informações acerca dos aspectos legais e éticos da telemedicina, contudo são informações fragmentadas. Este artigo visa proporcionar uma explanação geral sobre esses aspectos éticos e legais, com ênfase na tele-ortopedia. Os princípios éticos da autonomia, beneficência, não-maleficiência e justiça devem ser respeitados, da mesma forma a privacidade e confidencialidade durante uma teleconsulta. Com isso, os ortopedistas devem ser regidos pelos tradicionais preceitos morais e éticos, mas também, devem se adequar as novas normas e leis que regulamentam o uso da telemedicina. Nível de evidência V: Opinião do especialista.

FEMORAL HEAD DECOMPRESSION AND GRAFT: TECHNIQUE WITH NEW INSTRUMENTS.

Introduction: Osteonecrosis of the femoral head (ONFH) is a pathology that can be treated with many approaches by the hip surgeon. Advanced decompression is a technique that aims to prevent the collapse of the femoral head and the arthrosis process of the joint, a technique already widespread and used by hip surgeons. In this study, we performed the technique with a new retractable blade and a new bone substitute as graft for the femoral head. Objective: To evaluate the technique with new instruments (EasyCore Hip®) and a calcium phosphate bone substitute (Graftys® HBS). Methods: Patients with osteonecrosis of the femoral head without major degenerative changes, such as femoral head collapse, were selected. Femoral head decompression was performed using the EasyCore Hip® retractable blade along with the calcium phosphate bone substitute as graft (Graftys® HBS). Results: The instruments proved to be reliable and reproducible, and the bone substitute presented good mechanical resistance, maintaining its temperature during the surgery. The disposable retractable blade presents variation in size and angle, which is an advantage in the removal of necrotic bone. However, we must take some precautions in order to achieve a better result. Conclusion: using EasyCore Hip® instruments and a calcium phosphate bone substitute (Graftys® HBS) is safe; however, some precautions must be taken during the use of the technique. Level of Evidence IV, Case Series.

Introdução: A osteonecrose da cabeça femoral (ONCF) é uma patologia que pode ser tratada com diversas abordagens pelo cirurgião de quadril. A descompressão avançada é uma técnica que busca evitar o colapso da cabeça femoral e o processo de artrose da articulação, técnica já bastante difundida e utilizada entre os cirurgiões de quadril. Neste estudo, foi realizada a técnica com uma nova lâmina retrátil e um novo substituto ósseo como enxerto para a cabeça femoral. Objetivo: Avaliação da técnica com novo instrumental EasyCore Hip ® e substituto ósseo de fosfato de cálcio (Graftys ® HBS). Métodos: Foram selecionados pacientes com osteonecrose da cabeça femoral sem alterações degenerativas importantes, como o colapso da cabeça femoral. Foi realizada a descompressão da cabeça com a lâmina retrátil EasyCore Hip ® associada à enxertia com o substituto ósseo de fosfato de cálcio (Graftys ® HBS). Resultados: O instrumental mostrou-se confiável e de aplicação reprodutível, e o substituto ósseo apresentou boa resistência mecânica e isotermia durante o procedimento. Conclusão: em nossa série de casos, verificamos segurança na utilização do EasyCore Hip ® e substituto ósseo de fosfato de cálcio (Graftys ® HBS), porém alertamos para cuidados que devem ser tomados durante a realização da técnica. Nível de Evidência IV, Série de Casos.

Osteonecrosis of the Femoral Head: Update Article.

Among the pathologies that affect the hip joint, osteonecrosis of the femoral head (ONFH) is probably the most intriguing and challenging. It consists of a multifactorial disease with a highly-variable spectrum in its clinical presentation. It has a devastating effect, due to disabling painful conditions, both for usual activities and sports. Given the huge range of risk factors, such as prolonged use of corticosteroids (especially in cases of rheumatologic diseases), trauma sequelae, sickle cell anemia, HIV, alcoholism, smoking, blood dyscrasias, and several other diseases that compromise the blood supply to the femoral head, ONFH has a varied clinical presentation and prognosis, which makes it difficult to determine a specific treatment, especially in cases in which chondral involvement has not yet occurred and the hip joint is still preserved. These are the main factors found in the literature that determine the classifications of this pathology. The range of treatments includes several options for cases in which an attempt is made to save the joint: conservative treatment, traditional decompression and/or combined with some type of adjuvant treatment (homologous grafting, synthetic grafting, vascularized grafts, tantalum screws, and bone marrow aspirate injection), and, for cases in which there is already a subchondral fracture and/or collapse of the femoral head and/or a reduction in the joint space, femoral osteotomies or total hip arthroplasty are commonly performed.

Osteonecrosis of the Femoral Head: Update Article / Osteonecrose da cabeça femoral: Artigo de atualização

Abstract Among the pathologies that affect the hip joint, osteonecrosis of the femoral head (ONFH) is probably the most intriguing and challenging. It consists of a multifactorial disease with a highly-variable spectrum in its clinical presentation. It has a devastating effect, due to disabling painful conditions, both for usual activities and sports. Given the huge range of risk factors, such as prolonged use of corticosteroids (especially in cases of rheumatologic diseases), trauma sequelae, sickle cell anemia, HIV, alcoholism, smoking, blood dyscrasias, and several other diseases that compromise the blood supply to the femoral head, ONFH has a varied clinical presentation and prognosis, which makes it difficult to determine a specific treatment, especially in cases in which chondral involvement has not yet occurred and the hip joint is still preserved. These are the main factors found in the literature that determine the classifications of this pathology. The range of treatments includes several options for cases in which an attempt is made to save the joint: conservative treatment, traditional decompression and/or combined with some type of adjuvant treatment (homologous grafting, synthetic grafting, vascularized grafts, tantalum screws, and bone marrow aspirate injection), and, for cases in which there is already a subchondral fracture and/or collapse of the femoral head and/or a reduction in the joint space, femoral osteotomies or total hip arthroplasty are commonly performed.

Resumo Entre as patologias que acometem a articulação coxofemoral, a osteonecrose da cabeça femoral (ONCF) é provavelmente a mais intrigante e desafiadora. Consiste em uma doença multifatorial, com um espectro muito variável em sua apresentação clínica. Tem efeito devastador, devido a quadros dolorosos incapacitantes tanto para atividades habituais quanto esportivas. Dada a gama enorme de fatores de risco, tais como uso prolongado de corticoides (principalmente em casos de doenças reumatológicas), sequelas de trauma, anemia falciforme, HIV, etilismo, tabagismo, discrasias sanguíneas, e várias outras doenças que comprometem a irrigação sanguínea da cabeça femoral, a ONCF tem apresentação clínica e prognósticos bem variados, o que dificulta a determinação de um tratamento específico, especialmente em casos nos quais ainda não houve acometimento condral e a articulação do quadril ainda se mantém preservada, sendo estes os principais fatores encontrados na literatura que determinam as classificações desta patologia. No leque de tratamentos, encontramos diversas opções para os casos em que setenta salvar a articulação: tratamento conservador, descompressão simples e/ou associada a algum tipo de tratamento adjuvante (enxertia homóloga, enxertia sintética, enxertos vascularizados, parafusos de tântalo, e injeção de aspirado de medula óssea), e, para casos nos quais já há fratura subcondral e/ou colapso da cabeça femoral e/ou diminuição do espaço articular, reserva-se, comumente, a realização de osteotomias femorais ou artroplastia total do quadril.

Ethical and legal aspects of telemedicine applied in orthopedics / Aspectos éticos e legais da telemedicina aplicada à ortopedia

ABSTRACT Due to the pandemic of COVID-19, many outpatient services were suspended, affecting hundreds of patients. As a result, several countries were forced to seek strategies to readapt their health systems, one of which was the expansion of telemedicine. Currently, telemedicine is used for several specialties, facilitating the treatment and follow-up of patients who have difficulty accessing it. Tele-orthopedics, telemedicine applied to the orthopedic specialty, allows orthopedic care to be offered to patients regardless of distance. By reducing travel time, waiting time, and costs, tele-orthopedics presents high patient satisfaction, allowing greater rehabilitation effectiveness after surgery and treatment compliance. There is much information in the current literature about telemedicine's legal and ethical aspects, but it is fragmented. This article aims to present a general explanation of these legal and ethical aspects, emphasizing tele-orthopedics. The ethical principles of autonomy, beneficence, non-maleficence and justice must be respected, as well the privacy and confidentiality during a teleconsultation. In this respect, orthopedic surgeons should be governed by traditional moral and ethical precepts. Still, they must also adapt to the new norms and laws regulating telemedicine use. Level of Evidence V: Expert Opinion.

RESUMO Com a pandemia da COVID-19, muitos atendimentos ambulatoriais foram suspensos, afetando centenas de pacientes. Isso forçou diversos países a buscarem estratégias para readaptar seus sistemas de saúde e, uma delas, foi a expansão da telemedicina. Atualmente, a telemedicina está sendo utilizada para diversas especialidades, facilitando o tratamento e o acompanhamento de pacientes que possuem dificuldade de acesso. A tele-ortopedia, telemedicina aplicada à especialidade ortopédica, permite a oferta dos cuidados ortopédicos a pacientes independente da distância. Por reduzir tempo de viagem, tempo de espera e custos, a tele-ortopedia, apresenta alta satisfação por parte pacientes, o que permite maior efetividade na reabilitação após cirurgias e adesão ao tratamento. Há na literatura atual diversas informações acerca dos aspectos legais e éticos da telemedicina, contudo são informações fragmentadas. Este artigo visa proporcionar uma explanação geral sobre esses aspectos éticos e legais, com ênfase na tele-ortopedia. Os princípios éticos da autonomia, beneficência, não-maleficiência e justiça devem ser respeitados, da mesma forma a privacidade e confidencialidade durante uma teleconsulta. Com isso, os ortopedistas devem ser regidos pelos tradicionais preceitos morais e éticos, mas também, devem se adequar as novas normas e leis que regulamentam o uso da telemedicina. Nível de evidência V: Opinião do especialista.

Femoral head decompression and graft: technique with new instruments / Descompressão da cabeça femoral e enxertia: técnica com novo instrumental

ABSTRACT Introduction: Osteonecrosis of the femoral head (ONFH) is a pathology that can be treated with many approaches by the hip surgeon. Advanced decompression is a technique that aims to prevent the collapse of the femoral head and the arthrosis process of the joint, a technique already widespread and used by hip surgeons. In this study, we performed the technique with a new retractable blade and a new bone substitute as graft for the femoral head. Objective: To evaluate the technique with new instruments (EasyCore Hip®) and a calcium phosphate bone substitute (Graftys® HBS). Methods: Patients with osteonecrosis of the femoral head without major degenerative changes, such as femoral head collapse, were selected. Femoral head decompression was performed using the EasyCore Hip® retractable blade along with the calcium phosphate bone substitute as graft (Graftys® HBS). Results: The instruments proved to be reliable and reproducible, and the bone substitute presented good mechanical resistance, maintaining its temperature during the surgery. The disposable retractable blade presents variation in size and angle, which is an advantage in the removal of necrotic bone. However, we must take some precautions in order to achieve a better result. Conclusion: using EasyCore Hip® instruments and a calcium phosphate bone substitute (Graftys® HBS) is safe; however, some precautions must be taken during the use of the technique. Level of Evidence IV, Case Series.

RESUMO Introdução: A osteonecrose da cabeça femoral (ONCF) é uma patologia que pode ser tratada com diversas abordagens pelo cirurgião de quadril. A descompressão avançada é uma técnica que busca evitar o colapso da cabeça femoral e o processo de artrose da articulação, técnica já bastante difundida e utilizada entre os cirurgiões de quadril. Neste estudo, foi realizada a técnica com uma nova lâmina retrátil e um novo substituto ósseo como enxerto para a cabeça femoral. Objetivo: Avaliação da técnica com novo instrumental EasyCore Hip ® e substituto ósseo de fosfato de cálcio (Graftys ® HBS). Métodos: Foram selecionados pacientes com osteonecrose da cabeça femoral sem alterações degenerativas importantes, como o colapso da cabeça femoral. Foi realizada a descompressão da cabeça com a lâmina retrátil EasyCore Hip ® associada à enxertia com o substituto ósseo de fosfato de cálcio (Graftys ® HBS). Resultados: O instrumental mostrou-se confiável e de aplicação reprodutível, e o substituto ósseo apresentou boa resistência mecânica e isotermia durante o procedimento. Conclusão: em nossa série de casos, verificamos segurança na utilização do EasyCore Hip ® e substituto ósseo de fosfato de cálcio (Graftys ® HBS), porém alertamos para cuidados que devem ser tomados durante a realização da técnica. Nível de Evidência IV, Série de Casos.

Relationship of the Pelvic-Trochanteric Index with greater trochanteric pain syndrome.

OBJECTIVES: This study aimed to correlate a higher Pelvic-Trochanteric Index (PTI) with an increased varus of the femoral neck with greater trochanteric pain syndrome (GTPS). The secondary objective was to check whether the pelvic width changes with age. METHODS: A prospective study was conducted to compare female patients diagnosed with GTPS (case group) with asymptomatic female participants (control group) from March 2011 to June 2017. On an anteroposterior pelvic radiograph, lines were drawn by two radiologists, and the PTI (ratio of the distance between the greater trochanters and distance between the iliac crests) was defined and the femoral neck-shaft angle was measured. RESULTS: Data collected based on radiographs of 182 female patients (cases) and 150 female participants (controls) showed that the mean PTI was 1.09 (SD=0.01) in the case group and 1.07 (SD=0.01) in the control group (p<0.05), regardless of age. The distance between iliac crests increased with age (p<0.05) in symptomatic and asymptomatic individuals. It was also found that the mean femoral neck-shaft angle was 130.6° (SD=0.59) and progression of the varus angulation occurred with age in both groups, with a significance level of 5%. CONCLUSIONS: The PTI was higher in patients with GTPS. The femoral neck-shaft angle does not differ between individuals with and without GTPS; however, it does decrease with age. The pelvic width tends to increase with aging in symptomatic or asymptomatic individuals; therefore, the increase in the pelvic width and decrease in the femoral neck-shaft angle can be interpreted as normal in aging women, which could alter the biomechanics of the hips and pelvis.

Epidemiology of hip pain in brazilian bodybuilders / Epidemiologia da dor no quadril em fisiculturistas brasileiros

ABSTRACT Objective: To determine the frequency of hip pain in competitive bodybuilders over three different bodybuilding competitions. Methods: This study evaluated bodybuilders recruited from three competitions during the year of 2016. All participants provided their informed consent and the study received IRB approval. Training routine, health condition, level of success on competitions, history of hip pain and physical examination of the hip were evaluated. Results: 113 bodybuilders were evaluated, mean age was 30.5 ± 8.65 years and mean BMI was 25.2 ± 3.65 kg/m2. Mean values for hip flexion, adduction, abduction, internal rotation, external rotation and distance between the knee and the table (FABER distance) were 116 ± 13, 23 ± 8, 71 ± 12, 40 ± 10, 36 ± 9 and 19 ± 4, respectively. Eight (7%) participants presented hip pain within the week prior to examination and only 2 (1,7%) presented with anterior impingement sign. None of the athletes who reported hip pain interrupted their physical training or performance. Conclusion: Symptomatic athletes continued their training program under the presence of hip pain. The frequency of hip pain among bodybuilders is high and may be underestimated in this study. Level of Evidence IV, Case series.

RESUMO Objetivo: Determinar a frequência de dor no quadril em atletas fisiculturistas durante três competições de fisiculturismo. Métodos: Este estudo avaliou fisiculturistas recrutados em três competições de fisiculturismo durante o ano de 2016. Termo de consentimento foi obtido de todos os participantes, e também foi obtido a aprovação do CEP. Rotina de treinos, condição de saúde, nível de sucesso nas competições, antecedente de dor no quadril ao exame físico foram avaliados. Resultados: Um total de 113 fisiculturistas foram avaliados, com idade e IMC médio de 30.5 ± 8.65 anos e 25.2 ± 3.65 kg/m2, respectivamente. O valor médio de flexão, adução, abdução, rotação interna, rotação externa do quadril, e distância entre o joelho e a mesa de exame (distância FABERE) foi de 116 ± 13, 23 ± 8, 71 ± 12, 40 ± 10, 36 ± 9 e 19 ± 4, respectivamente. Oito (7%) participantes apresentavam dor no quadril dentro da última semana antes de serem examinados, e apenas dois (1.7%) apresentavam sinal do impacto anterior do quadril à manobra de flexão adução e rotação interna. A dor no quadril não afetou o treinamento físico e a performance dos atletas que reportaram dor no quadril. Conclusão: Atletas sintomáticos continuaram o programa de treinamento mesmo na presença de dor no quadril. A frequência de dor no quadril de atletas fisiculturistas é alta e pode ter sido subestimada neste estudo. Nível de Evidência IV, Série de casos.

EPIDEMIOLOGY OF HIP PAIN IN BRAZILIAN BODYBUILDERS.

OBJECTIVE: To determine the frequency of hip pain in competitive bodybuilders over three different bodybuilding competitions. METHODS: This study evaluated bodybuilders recruited from three competitions during the year of 2016. All participants provided their informed consent and the study received IRB approval. Training routine, health condition, level of success on competitions, history of hip pain and physical examination of the hip were evaluated. RESULTS: 113 bodybuilders were evaluated, mean age was 30.5 ± 8.65 years and mean BMI was 25.2 ± 3.65 kg/m2. Mean values for hip flexion, adduction, abduction, internal rotation, external rotation and distance between the knee and the table (FABER distance) were 116 ± 13, 23 ± 8, 71 ± 12, 40 ± 10, 36 ± 9 and 19 ± 4, respectively. Eight (7%) participants presented hip pain within the week prior to examination and only 2 (1,7%) presented with anterior impingement sign. None of the athletes who reported hip pain interrupted their physical training or performance. CONCLUSION: Symptomatic athletes continued their training program under the presence of hip pain. The frequency of hip pain among bodybuilders is high and may be underestimated in this study. Level of Evidence IV, Case series.

OBJETIVO: Determinar a frequência de dor no quadril em atletas fisiculturistas durante três competições de fisiculturismo. MÉTODOS: Este estudo avaliou fisiculturistas recrutados em três competições de fisiculturismo durante o ano de 2016. Termo de consentimento foi obtido de todos os participantes, e também foi obtido a aprovação do CEP. Rotina de treinos, condição de saúde, nível de sucesso nas competições, antecedente de dor no quadril ao exame físico foram avaliados. RESULTADOS: Um total de 113 fisiculturistas foram avaliados, com idade e IMC médio de 30.5 ± 8.65 anos e 25.2 ± 3.65 kg/m2, respectivamente. O valor médio de flexão, adução, abdução, rotação interna, rotação externa do quadril, e distância entre o joelho e a mesa de exame (distância FABERE) foi de 116 ± 13, 23 ± 8, 71 ± 12, 40 ± 10, 36 ± 9 e 19 ± 4, respectivamente. Oito (7%) participantes apresentavam dor no quadril dentro da última semana antes de serem examinados, e apenas dois (1.7%) apresentavam sinal do impacto anterior do quadril à manobra de flexão adução e rotação interna. A dor no quadril não afetou o treinamento físico e a performance dos atletas que reportaram dor no quadril. CONCLUSÃO: Atletas sintomáticos continuaram o programa de treinamento mesmo na presença de dor no quadril. A frequência de dor no quadril de atletas fisiculturistas é alta e pode ter sido subestimada neste estudo. Nível de Evidência IV, Série de casos.

Relationship of the Pelvic-Trochanteric Index with greater trochanteric pain syndrome

OBJECTIVES: This study aimed to correlate a higher Pelvic-Trochanteric Index (PTI) with an increased varus of the femoral neck with greater trochanteric pain syndrome (GTPS). The secondary objective was to check whether the pelvic width changes with age. METHODS: A prospective study was conducted to compare female patients diagnosed with GTPS (case group) with asymptomatic female participants (control group) from March 2011 to June 2017. On an anteroposterior pelvic radiograph, lines were drawn by two radiologists, and the PTI (ratio of the distance between the greater trochanters and distance between the iliac crests) was defined and the femoral neck-shaft angle was measured. RESULTS: Data collected based on radiographs of 182 female patients (cases) and 150 female participants (controls) showed that the mean PTI was 1.09 (SD=0.01) in the case group and 1.07 (SD=0.01) in the control group (p<0.05), regardless of age. The distance between iliac crests increased with age (p<0.05) in symptomatic and asymptomatic individuals. It was also found that the mean femoral neck-shaft angle was 130.6° (SD=0.59) and progression of the varus angulation occurred with age in both groups, with a significance level of 5%. CONCLUSIONS: The PTI was higher in patients with GTPS. The femoral neck-shaft angle does not differ between individuals with and without GTPS; however, it does decrease with age. The pelvic width tends to increase with aging in symptomatic or asymptomatic individuals; therefore, the increase in the pelvic width and decrease in the femoral neck-shaft angle can be interpreted as normal in aging women, which could alter the biomechanics of the hips and pelvis.

IMPROVEMENTS IN HIP OSTEOARTHRITIS WITH LAVAGE, TRIAMCINOLONE AND HYLAN G-F20.

OBJECTIVE: To verify whether the use of Hylan G-F20 improves saline lavage and triamcinolone injection results in the treatment of hip osteoarthritis (HOA). METHODS: 82 patients with HOA categorized as grades II and III severity, according to Kellgren and Lawrence criteria, were randomized into the groups: lavage and triamcinolone (G0); lavage, triamcinolone, and 2 mL of hylan G-F20 (G1); lavage, triamcinolone, and 4mL of hylan G-F20 (G2); lavage, triamcinolone, and 6mL of hylan G-F20 (G3). The VAS, range of motion (ROM), WOMAC, and Lequesne questionnaires were administered at baseline, one, three, six, and twelve months post-injection. RESULTS: All groups showed clinically relevant improvements (> 20%) between baseline and first month post-injection, maintaining subjective results throughout the study period (p < 0.001). We found no differences between groups in any subjective evaluations (p > 0.05, for all). G2 and G3 obtained improved flexion results up to a year (p = 0.028). Hylan groups presented an improved external rotation since the first postoperative month and maintained the results up to a year (G1, p = 0.041; G2, p = 0.007), whereas G0 showed no improvement (p = 0.336). CONCLUSION: Hip lavage and triamcinolone injection, with or without the use of hylan, improves pain, function, and quality of life up to a year in HOA. Hylan may improve ROM up to one year. Level of Evidence IB, Randomized clinical trial.

OBJETIVO: Verificar se o Hylan G-F20 melhora os resultados da lavagem e injeção de triancinolona na osteoartrite do quadril (OAQ). MÉTODOS: 82 pacientes com HOA Kellgren e Lawrence graus II e III foram randomizados: lavagem e triamcinolona (G0); lavagem, triancinolona e 2 mL de Hylan G-F20 (G1); lavagem, triamcinolona e 4 mL de Hylan G-F20 (G2); lavagem, triancinolona e 6 mL de Hylan G-F20 (G3). A escala visual analógica (EVA), amplitude de movimento (ADM), questionários Womac e Lequesne foram obtidos no início, um, três, seis e doze meses após a injeção. RESULTADOS: Todos os grupos apresentaram melhora clinicamente relevante (> 20%) entre o início e o primeiro mês, mantendo resultados subjetivos durante o estudo (p <0,001). Não foram encontradas diferenças entre os grupos nas avaliações subjetivas (p > 0,05). A flexão aumentou no G2 e G3 até um ano (p = 0,028). A rotação externa melhorou nos grupos Hylan no primeiro mês, mantendo os resultados até um ano (G1, p = 0,041; G2, p = 0,007), enquanto G0 nunca melhorou (p = 0,336). CONCLUSÃO: Lavagem do quadril e injeção de triancinolona, com ou sem Hylan, melhoram a dor, função e qualidade de vida até um ano na OAQ. Hylan pode melhorar a ADM até um ano. Nível de evidência IB, Ensaio clínico randomizado.

Femoroacetabular Impingement and Acetabular Labral Tears - Part 3: Surgical Treatment.

In the last 15 years, the diagnosis of femoroacetabular impingement has become more frequent; with the advance of surgical indications, different techniques have been developed. Surgical treatment includes a wide variety of options, namely: periacetabular osteotomy, surgical hip dislocation, arthroscopy with osteochondroplasty via a small incision, modified anterior approach technique, and exclusively arthroscopic technique. The type of approach should be chosen according to the complexity of the morphology of the femoroacetabular impingement and to the surgeon's training. The techniques most used today are arthroscopy, surgical dislocation of the hip, and periacetabular osteotomy. The present article aims to describe the current main surgical techniques used to treat femoroacetabular impingement, their indications, advantages and disadvantages, complications and clinical results.

Femoroacetabular Impingement and Acetabular Labral Tears - Part 3: Surgical Treatment / Impacto femoroacetabular e lesão do lábio acetabular - Parte 3: Tratamento cirúrgico

Abstract In the last 15 years, the diagnosis of femoroacetabular impingement has become more frequent; with the advance of surgical indications, different techniques have been developed. Surgical treatment includes a wide variety of options, namely: periacetabular osteotomy, surgical hip dislocation, arthroscopy with osteochondroplasty via a small incision, modified anterior approach technique, and exclusively arthroscopic technique. The type of approach should be chosen according to the complexity of the morphology of the femoroacetabular impingement and to the surgeon's training. The techniques most used today are arthroscopy, surgical dislocation of the hip, and periacetabular osteotomy. The present article aims to describe the current main surgical techniques used to treat femoroacetabular impingement, their indications, advantages and disadvantages, complications and clinical results.

Resumo Nos últimos 15 anos, o diagnóstico do impacto femoroacetabular tem se tornado cada vez mais frequente; com o avanço do entendimento de quais pacientes potencialmente se beneficiariam do tratamento cirúrgico, diferentes técnicas foram desenvolvidas. O tratamento cirúrgico inclui grande variedade de opções, sendo elas: osteotomia periacetabular, técnica de luxação cirúrgica do quadril, artroscopia com osteocondroplastia via pequena incisão, técnica via anterior modificada, e técnica exclusivamente artroscópica. O tipo de abordagem deve ser escolhido de acordo com a complexidade da morfologia do impacto femoroacetabular e com o treinamento do cirurgião. As técnicas mais utilizadas atualmente são a artroscopia, a luxação cirúrgica do quadril e a osteotomia periacetabular. O presente artigo busca descrever as principais técnicas cirúrgicas utilizadas para o tratamento do impacto femoroacetabular, suas indicações, vantagens e desvantagens, complicações e resultados clínicos.

Bacteria drug resistance profile affects knee and hip periprosthetic joint infection outcome with debridement, antibiotics and implant retention.

BACKGROUND: Evaluate the effect of bacteria drug resistance profile on the success rates of debridement, antibiotics and implant retention. METHODS: All early acute periprosthetic infections in hip and knee arthroplasties treated with DAIR at our institution over the period from 2011 to 2015 were retrospectively analyzed. The success rate was evaluated according to the type of organism identified in culture: multidrug-sensitive (MSB), methicillin-resistant Staphylococcus aureus (MRSA), multidrug-resistant Gram-negative bacteria (MRB) and according to other risk factors for treatment failure. The data were analyzed using univariate and multivariate statistics. RESULTS: Fifty-seven patients were analyzed; there were 37 in the multidrug-sensitive bacteria (MSB) group, 11 in the methicillin-resistant Staphylococcus aureus (MRSA) group and 9 in the other multidrug-resistant Gram-negative bacteria (MRB) group. There was a statistically significant difference (p < 0.05) in the treatment failure rate among the three groups: 8.3% for the MSB group, 18.2% for the MRSA group and 55.6% for the MRB group (p = 0.005). Among the other risk factors for treatment failure, the presence of inflammatory arthritis presented a failure rate of 45.1 (p < 0.05). CONCLUSION: DAIR showed a good success rate in cases of early acute infection by multidrug-sensitive bacteria. In the presence of infection by multidrug-resistant bacteria or association with rheumatic diseases the treatment failure rate was higher and other surgical options should be considered in this specific population. The MRSA group showed intermediate results between MSB and MRB and should be carefully evaluated.

A modified iliofemoral approach to intrapelvic acetabular revision - technical note / Acesso iliofemoral modificado para revisão de componente acetabular intrapélvico - nota técnica

ABSTRACT Among the patterns of acetabular osteolysis associated with acetabular loosening, the authors emphasize the severity of pelvic dissociation and medial segmental losses in which the quadrilateral lamina is severely affected. Such lesions are potentially lethal in cases of large vascular injury. This note aimed to describe a modified iliofemoral approach in cases of massive intrapelvic migration of the acetabular component in patients with total proximity of the iliac vascular bundle and absence of an anatomical demarcation plane between the migrated contents and the iliac bundle. This approach was performed in 12 of 21 patients who had these criteria.

RESUMO Entre os padrões de osteólise acetabular associados às solturas acetabulares, os autores destacam como de maior gravidade a dissociação pélvica e as perdas segmentares mediais nas quais a lâmina quadrilátera está gravemente acometida. Tais lesões são potencialmente letais em casos de lesão vascular de grande porte. O objetivo desta nota foi descrever um acesso iliofemoral modificado quando há migração intrapélvica maciça do componente acetabular em pacientes com proximidade total do feixe vascular ilíaco e ausência de plano demarcatório anatômico entre o conteúdo migrado e o feixe ilíaco. Esse acesso foi feito em 12 pacientes de 21 que apresentavam tais critérios.

A modified iliofemoral approach to intrapelvic acetabular revision - technical note.

Among the patterns of acetabular osteolysis associated with acetabular loosening, the authors emphasize the severity of pelvic dissociation and medial segmental losses in which the quadrilateral lamina is severely affected. Such lesions are potentially lethal in cases of large vascular injury. This note aimed to describe a modified iliofemoral approach in cases of massive intrapelvic migration of the acetabular component in patients with total proximity of the iliac vascular bundle and absence of an anatomical demarcation plane between the migrated contents and the iliac bundle. This approach was performed in 12 of 21 patients who had these criteria.

Entre os padrões de osteólise acetabular associados às solturas acetabulares, os autores destacam como de maior gravidade a dissociação pélvica e as perdas segmentares mediais nas quais a lâmina quadrilátera está gravemente acometida. Tais lesões são potencialmente letais em casos de lesão vascular de grande porte. O objetivo desta nota foi descrever um acesso iliofemoral modificado quando há migração intrapélvica maciça do componente acetabular em pacientes com proximidade total do feixe vascular ilíaco e ausência de plano demarcatório anatômico entre o conteúdo migrado e o feixe ilíaco. Esse acesso foi feito em 12 pacientes de 21 que apresentavam tais critérios.

Total hip arthroplasty using a posterior minimally invasive approach - results after six years.

OBJECTIVE: To evaluate the medium-term clinical-functional results (minimum follow-up of six years) from total uncemented hip arthroplasty performed by means of a posterior minimally invasive access, in comparison with the traditional right lateral access. METHODS: In a comparative prospective study, 224 adult patients underwent elective total hip arthroplasty due to a diagnosis of primary or secondary osteoarthrosis. A group of 103 patients with posterior minimally invasive access was compared with a group of 121 patients with the traditional right lateral access. The mean length of follow-up among the patients of this sample was 7.2 years. We evaluated the clinical-functional and radiographic results and occurrences of loosening, along with any complications that occurred, with a minimum follow-up of six years. RESULTS: The clinical-functional analyses before the surgical procedure and six years afterwards were similar in the two groups (p = 0.88 and p = 0.55). One patient in the minimally invasive group underwent revision of the acetabular component and two patients in the control group underwent the same procedure (p = 0.46). The Trendelenburg clinical test, which showed weakness of the hip abductor musculature, was present in five patients operated using the traditional lateral route and absent in all those who underwent the minimally invasive procedure (p = 0.06). There was no difference regarding the radiographic parameters obtained, either in acetabular or in femoral positioning (p = 0.32 and p = 0.58). CONCLUSIONS: The medium-term clinical and radiographic results and the complication rates were similar between the patients who underwent total hip arthroplasty by means of the posterior minimally invasive access and those with the traditional lateral access.

OBJETIVO: Avaliar o resultado clínico-funcional em médio prazo (seguimento mínimo de seis anos) da artroplastia total do quadril não cimentada feita por acesso minimamente invasivo (MIS) posterior comparado ao acesso lateral direto (LD) tradicional. MÉTODOS: Em um estudo comparativo prospectivo, 224 pacientes adultos foram submetidos à artroplastia total do quadril em caráter eletivo, por diagnóstico de osteoartrose primária ou secundária, e se comparou o grupo MIS posterior (103 pacientes) com o grupo acesso LD tradicional (121). A média de tempo de seguimento dos pacientes da amostra foi 7,2 anos. Avaliamos os resultados clínico-funcionais e radiográficos e a ocorrência de solturas, assim como complicações ocorridas com um seguimento mínimo de seis anos. RESULTADOS: A análise clínico-funcional antes e seis anos após o procedimento cirúrgico foi semelhante nos dois grupos (p = 0,88 e p = 0,55). Um paciente do grupo MIS foi submetido à revisão do componente acetabular e dois do grupo controle foram submetidos ao mesmo procedimento, p = 0,46. O teste clínico de Trendelenburg, que evidenciou uma fraqueza da musculatura abdutora do quadril, estava presente em cinco pacientes operados pela via lateral tradicional e ausente em todos os submetidos ao MIS (p = 0,06). Não houve diferença quanto aos parâmetros radiográficos obtidos tanto do posicionamento acetabular quanto do femoral (p = 0,32, p = 0,58). CONCLUSÕES: Os resultados em médio prazo, clínicos e radiográficos, e a taxa de complicações foram semelhantes entre os pacientes submetidos à artroplastia total do quadril pelo acesso posterior minimamente invasivo e pela via lateral tradicional.

Hip arthroscopy.

Hip arthroscopy is a safe method for treating a variety of pathological conditions that were unknown until a decade ago. Femoroacetabular impingement is the commonest of these pathological conditions and the one with the best results when treated early on. The instruments and surgical technique for hip arthroscopy continue to evolve. New indications for hip arthroscopy has been studied as the ligamentum teres injuries, capsular repair in instabilities, dissection of the sciatic nerve and repair of gluteal muscles tears (injuries to the hip rotator cuff), although still with debatable reproducibility. The complication rate is low, and ever-better results with fewer complications should be expected with the progression of the learning curve.

A artroscopia de quadril é um método seguro para o tratamento de diversas patologias desconhecidas até a última década. O impacto femoroacetabular é a patologia mais comum e com melhores resultados quando tratada precocemente. O instrumental e a técnica cirúrgica da artroscopia de quadril continuam em evolução. Novas indicações de artroscopia de quadril vem sendo estudadas, como o tratamento das lesões do ligamento redondo, capsulorrafia nas instabilidades, dissecação do nervo ciático e reparo de lesões dos músculos glúteos (lesões do manguito rotador do quadril), porém ainda com reprodutibilidade discutível. A taxa de complicações é baixa e resultados cada vez melhores e com menor número de complicações devem ser esperados com a progressão da curva de aprendizado.

Artroscopia de quadril / Hip arthroscopy

A artroscopia de quadril é um método seguro para o tratamento de diversas patologias desconhecidas até a última década. O impacto femoroacetabular é a patologia mais comum e com melhores resultados quando tratada precocemente. O instrumental e a técnica cirúrgica da artroscopia de quadril continuam em evolução. Novas indicações de artroscopia de quadril vem sendo estudadas, como o tratamento das lesões do ligamento redondo, capsulorrafia nas instabilidades, dissecação do nervo ciático e reparo de lesões dos músculos glúteos (lesões do manguito rotador do quadril), porém ainda com reprodutibilidade discutível. A taxa de complicações é baixa e resultados cada vez melhores e com menor número de complicações devem ser esperados com a progressão da curva de aprendizado.

Hip arthroscopy is a safe method for treating a variety of pathological conditions that were unknown until a decade ago. Femoroacetabular impingement is the commonest of these pathological conditions and the one with the best results when treated early on. The instruments and surgical technique for hip arthroscopy continue to evolve. New indications for hip arthroscopy has been studied as the ligamentum teres injuries, capsular repair in instabilities, dissection of the sciatic nerve and repair of gluteal muscles tears (injuries to the hip rotator cuff), although still with debatable reproducibility. The complication rate is low, and ever-better results with fewer complications should be expected with the progression of the learning curve.