Patellar Transskeletal Traction for the Treatment of Chronic Patellar Pseudoarthrosis.

Patellar fractures, which constitute approximately 1% of bone lesions, may lead to severe impairment of the extensor mechanism. When conservative or surgical treatment fails, the patella may develop pseudoarthrosis. Neglect or delayed treatment of this type of injury may lead to significant diastasis between the patellar fragments. There is no consensus regarding the best treatment for such cases. This study is aimed at describing a rare case of patellar pseudoarthrosis in a patient who underwent two-step surgical treatment comprising transskeletal patellar traction followed by osteosynthesis with a tension band. A 17-year-old male patient presented with a left patellar fracture that resulted from a fall from a standing height 8 years ago. He did not undergo any type of surgical treatment during that time, but the fracture was immobilized for only 2 weeks. The two-step surgical treatment with transskeletal patellar traction and patellar osteosynthesis was performed and provided satisfactory functional clinical results in this patient. This two-step surgical treatment can be performed in cases similar to ours with satisfactory results.

Outcome evaluation of staged treatment for bicondylar tibial plateau fractures.

BACKGROUND: The universal accepted strategy for treating high-energy tibial plateau fractures remains a topic of ongoing debate. The challenge for the practicing orthopaedic trauma surgeon is to provide anatomical articular fracture reduction, with successfully managing the complex soft-tissue injury that is commonly present at patient admission. The primary aim of the actual study was to evaluate the results of a staged protocol for the treatment of high-energy bicondylar tibial plateau fractures. The secondary aim was to describe the technique used for the definitive fixation of this complex fracture pattern. METHODS: Thirty patients with unstable high-energy closed bicondylar tibial plateau fractures (17 Schatzker V and 13 Schatzker VI) were managed. There were 24 men (80%) and six women (20%). All of them were skeletally mature with their age ranging from 19 to 67 years (mean of 33.1±3.4 years). Treatment involved a two-stage procedure with appropriate emergency care, preoperative planning, and definitive fixation. Initial treatment, named 'damage control on complex articular fracture elements', consisted on temporary bridging external fixation. Definitive treatment was delayed in a mean of 10 days (ranging from seven to 13 days) and was performed when the soft-tissue conditioning demonstrated either complete or almost complete remission of the inflammatory reaction due to the 'first hit'. Conventional implants were used in the 30 patients. All patients were evaluated clinically and radiographically. RESULTS: Twenty-six (86.7%) patients had a moderate level of activity, three (10%) patients had a very light level of activity, and one (3.3%) patient was unable to have any kind of work activity and is currently supported by the Brazilian Welfare. Using the visual analog scale mean pain score was 30 (ranging from 10 to 60); even the patient with the workers' compensation had no severe pain. All patients except three have no difficulty with stairs, giving way, locking, swelling, and squatting, but were unable to run. Three (10%) patients had problems with stairs and could not bend the operated knee more than 90°. One of them had a varus knee but no instability. Ninety percent of the patients were either very satisfied or somewhat satisfied with their outcome. The three dissatisfied patients suffered postoperative complications, most commonly wound infections. Four (13.4%) patients with former anatomical reduction had a residual articular step-off or diastasis of less than 3mm after fracture healing. All patients had no or mild arthrosis at the time of the last outpatient consultation. CONCLUSIONS: The two-staged procedure presented herein showed to be an effective strategy for managing bycondilar tibial plateau fractures. The protocol used for these complex traumatic injuries follows very well defined steps, which means acute stabilization with a linear bridging external fixation, adequate soft tissue handling, preoperative planning, and definitive surgical fixation after seven to 14 days. The model presents a more biological approach to optimizing functional outcome with an acceptable complication rate and minimal risk of loss of reduction in these high-energy tibial plateau fractures.

Comparative evaluation of patellar height methods in the Brazilian population.

OBJECTIVE: The methods most used for patellar height measurement were compared with the plateau-patella angle method. METHODS: A cross-sectional study was conducted, in which lateral-view radiographs of the knee were evaluated using the three methods already established in the literature: Insall-Salvati (IS), Blackburne-Peel (BP) and Caton-Deschamps (CD). These were compared with the plateau-patella angle method. One hundred and ninety-six randomly selected patients were included in the sample. RESULTS: The data were initially evaluated using the chi-square test. This analysis was deemed to be positive with p < 0.0001. We compared the traditional methods with the plateau-patella angle measurement, using Fisher's exact test. In comparing the IS index with the plateau-patella angle, we did not find any statistically significant differences in relation to the proportion of altered cases between the two groups. The traditional methods were compared with the plateau-patella angle with regard to the proportions of cases of high and low patella, by means of Fisher's exact test. This analysis showed that the plateau-patella angle identified fewer cases of high patella than did the IS, BP and CD methods, but more cases of low patella. In comparing pairs, we found that the IS and CD indices were capable of identifying more cases of high patella than was the plateau-patella angle. In relation to the cases of low patella, the plateau-patella angle was capable of identifying more cases than were the other three methods. CONCLUSIONS: The plateau-patella angle found more patients with low patella than did the classical methods and showed results that diverged from those of the other indices studied.

OBJETIVO: Comparar os métodos mais usados de medida da altura patelar, com o método do ângulo platô-patela. MÉTODOS: Foi feito um estudo transversal no qual foram avaliadas radiografias em perfil do joelho, com os três métodos já consagrados pela literatura, o Insall-Salvati (IS), o Blackburne-Peel (BP) e o Caton-Deschamps (CD) e comparando-as com o ângulo platô-patela (APP). Foram incluídos na amostra 196 seis pacientes, aleatoriamente selecionados. RESULTADOS: Inicialmente os dados foram submetidos a uma avaliação pelo teste do qui-quadrado. A análise foi positiva com p < 0,0001. Fizemos comparações entre os métodos tradicionais com a medida do APP com o uso do teste exato de Fisher. Quando comparamos o índice de IS com o APP, não encontramos diferenças estatisticamente significativas em relação à proporção de casos alterados entre os dois grupos. Os métodos tradicionais foram comparados com a medida do APP quanto à proporção de casos de patela alta e baixa pelo teste exato de Fisher. A análise demonstrou que o APP identificou menos casos de patela alta do que os métodos de IS, BP e CD, mas identificou mais casos de patela baixa. Quando comparados os pares, verificamos que os índices de IS e CD foram capazes de identificar mais casos de patela alta que o APP. Em relação aos casos de patela baixa, o APP foi capaz de identificar mais casos que os outros três métodos. CONCLUSÃO: O ângulo platô-patela observou mais pacientes com patela baixa em comparação com os métodos clássicos e resultados discrepantes com os outros índices estudados.

Evaluation of intraoperative radioscopy on the coronal alignment of the tibial component in primary knee arthroplasty.

OBJECTIVES: The present study had the objective of evaluating the effect of the use of intraoperative radioscopy in cases of primary knee arthroplasty, on the final alignment of the tibial component. METHODS: Patients who underwent total knee arthroplasty (TKA) between April 13, 2013, and April 20, 2013, were included in the study. These patients were evaluated retrospectively and two groups were identified: one in which intraoperative radioscopy was used to assess the positioning of the tibial component during the surgery and the other in which this resource was not used. RESULTS: The mean angle of alignment of the tibial component in relation to the tibial diaphysis was greater in the group without use of intraoperative radioscopy (90.82) than in the group with radioscopy (90.63), which was a statistically significant result (p < 0.05). CONCLUSION: Use of intraoperative radioscopy during TKA produced a better mean angle of alignment between the tibial component and the tibial diaphysis, in comparison with nonuse.

OBJETIVOS: Avaliar o efeito do uso da radioscopia intraoperatória em artroplastias primárias de joelho sobre o alinhamento final do componente tibial. MÉTODOS: Foram incluídos no estudo os pacientes submetidos à artroplastia total do joelho (ATJ) entre 13/04/2013 e 20/04/2013. Os pacientes foram avaliados retrospectivamente e dois grupos foram identificados, um com uso de radioscopia intraoperatória para avaliação do posicionamento do componente tibial durante a cirurgia e o segundo sem uso desse recurso. RESULTADOS: A média do ângulo de alinhamento do componente tibial em relação à diáfise da tíbia foi superior no grupo sem uso de radioscopia intraoperatória (90,82) em comparação com o grupo com radioscopia (90,63), com resultado estatisticamente significativo (p < 0,05). CONCLUSÃO: O uso de radioscopia no intraoperatório de ATJ produz melhor média de ângulo de alinhamento entre o componente tibial em relação à diáfise da tíbia quando comparado ao não uso.

Comparative radiographic analysis on the anatomical axis in knee osteoarthritis cases: inter and intraobserver evaluation.

OBJECTIVE: To make a comparative inter and intraobserver analysis on measurements of the anatomical axis between panoramic radiographs of the lower limbs in anteroposterior (AP) view with bipedal weight-bearing, on short film. METHODS: An accuracy study comparing radiographic measurements on 47 knees of patients attending the knee surgery outpatient clinic due to osteoarthritis. The radiographic evaluation used was as standardized for the total knee arthroplasty program, including panoramic AP views of the lower limbs and short radiographs of the knees in AP and lateral views, all with bipedal weight-bearing. Following this, the anatomical axis of the lower limbs or the femorotibial angle was measured by five independent examiners on the panoramic and short AP radiographs; three of the examiners were considered to be more experienced and two, less experienced. All the measurements were made again by the same examiners after an interval of not less than 15 days. The statistical analysis was performed using the intraclass correlation coefficient, in order to evaluate the inter and intraobserver concordance of the anatomical axis measurements. RESULTS: From the statistical analysis, it was observed that there was strongly significant concordance between the anatomical axis measurements on the panoramic and short radiographs, for all the five examiners and for both measurements. CONCLUSIONS: Under the conditions studied, short radiographs were equivalent to panoramic radiographs for evaluating the anatomical axis of the lower limbs in patients with advanced osteoarthritis. The measurements used also showed high rates of inter and intraobserver concordance and reproducibility.

OBJETIVO: Fazer a análise comparativa inter e intraobservador da medida do eixo anatômico entre as radiografias panorâmica, dos membros inferiores (MMII) com raio anteroposterior (AP) e apoio bipodálico e AP com carga bipodal em filme curto. MÉTODOS: Foi feito estudo de acurácia que comparou medidas radiográficas em 47 joelhos de pacientes do ambulatório de cirurgia do joelho, por osteoartrite (OA). A avaliação radiográfica usada foi a padronizada para a programação de ATJ, incluindo as incidências panorâmica dos MMII em AP e as radiografias curtas dos joelhos em AP e perfil, todas com apoio bipodálico. Em seguida, as radiografias panorâmicas e curtas em AP tiveram os eixos anatômicos dos MMII ou ângulo femorotibial (AFT) medidos por cinco examinadores independentes, dos quais três eram considerados mais experientes e dois menos experientes. Todas as medidas foram refeitas pelos mesmos examinadores em um intervalo não menor do que 15 dias. A análise estatística foi feita com o uso do coeficiente de correlação intraclasses (ICC) para avaliar a concordância na medida do eixo anatômico inter e intraobservadores. RESULTADOS: Após análise estatística observou-se forte concordância significativa entre o eixo anatômico medido nas radiografias panorâmica e curta para todos os cinco examinadores e para ambas as medidas. CONCLUSÕES: Nas condições estudadas a radiografia curta equipara-se à panorâmica na avaliação do eixo anatômico dos MMII em pacientes com OA avançada. A mensuração usada também mostra alta taxa de concordância e reprodutibilidade inter e intraobsevadores.

Avulsion fracture of the posterior cruciate ligament in an uncommon location associated with distal injury to the patellar ligament.

Avulsion fractures of the posterior cruciate ligament in unusual locations are rare injuries. We report the first case in the literature of an avulsion fracture of the posterior cruciate ligament associated with distal injury to the patellar ligament. The aim of this study was to present a novel case, the therapy used and the clinical follow-up.

A fratura avulsão do ligamento cruzado posterior em localização não usual é uma lesão rara. Relatamos o primeiro caso da literatura de uma fratura avulsão do ligamento cruzado posterior associada a lesão distal do ligamento patelar. O objetivo deste estudo foi apresentar um caso inédito, a terapêutica adotada e o seguimento clínico.

Proximal humeral fractures: an understanding of the ideal plate positioning.

PURPOSE: The present study aims to evaluate if the bicipital groove can be used as a parameter for ideal plate positioning in proximal humeral fixation applying locking compression plate. METHOD: The authors questioned whether the bicipital groove can be used as a parameter for ideal plate positioning applying locking compression plate for proximal humeral fractures. A method using the bicipital groove as the main parameter was developed using computed tomography scan (CT-scan). Seventy shoulders presenting fracture absence were used to calculate proper plate positioning, allowing the largest area for locked screw placement into the humeral head. Intraclass correlation coefficient and Bland and Altman graphics calculated intra-observer reliability for CT-scan evaluation. RESULTS: All observers presented satisfactory plate positioning using this method. The mean differences for observers were close to zero, suggesting high interobserver reproducibility. A significant (p <0.0001) intra-observer agreement existed for the three evaluators. Observer 2 agreement was the strongest (ICC = 0.98), showing almost perfect reproducibility measurement, followed by observer 3 (ICC = 0.84) with good reproducibility, and lastly observer 1 demonstrated moderate degree agreement (ICC = 0.47). CONCLUSION: Considering the CT-scan analysis, the bicipital groove can be used as a parameter for ideal plate positioning in proximal humeral fractures. This method demonstrated satisfactory intra-observer reproducibility. Adopting this method, longer and better distributed screw placement provides more stable fixation for proximal humeral fractures.

SIMULTANEOUS BILATERAL AVULSION FRACTURE OF THE TIBIAL TUBEROSITY IN A TEENAGER: CASE REPORT AND THERAPY USED.

Simultaneous bilateral avulsion fracture of the tibial tuberosity in teenagers is a rare lesion. We describe the first case in the literature, in a teenage girl who sustained a fall while jumping during a volleyball match. No predisposing factors were iden tified. The lesions were treated with open surgical reduction and internal fixation. The aim of the present study was to present a case of simultaneous bilateral avulsion fracture of the tibial tuberosity in a teenage girl and the therapy used.

MEDIUM-TERM ASSESSMENT OF TOTAL KNEE ARTHROPLASTY WITH IMPLANT MADE IN BRAZIL.

OBJECTIVE: This study assessed 47 patients who underwent total knee arthroplasty (TKA) with implants manufactured in Brazil, with a mean follow-up of five years. METHODS: This was a retrospective study at Santa Casa de Misericordia Hospital in Rio de Janeiro, from January 1993 to December 2002. The sample comprised 47 patients (44 females and three males) who underwent TKA, totaling 58 knees. The patients' ages ranged from 46 to 83 years. A diagnosis of osteoarthritis or rheumatic disease was confirmed in all the patients. RESULTS: In this investigation, all the patients underwent cemented TKA with preservation of the posterior cruciate ligament. The length of follow-up ranged from 5 to 17 years. The functional assessment criterion used was the one of the Hospital for Special Surgery (HSS), and this yielded an average of 87 points after the operation. The radiographic criterion used was the Knee Society Total Knee Arthroplasty Roentgenographic Evaluation and Scoring System. We had three cases with a radiolucent line without implant loosening, which were asymptomatic from a clinical standpoint. CONCLUSION: The total knee arthroplasty procedures using an implant made in Brazil were performed by a trained and experienced team. To date, over the clinical follow-up on these patients with knee osteoarthritis or rheumatoid arthritis, the results have been seen to be satisfactory.

ANALYSIS ON THE MODIFIED LYSHOLM FUNCTIONAL PROTOCOL AMONG PATIENTS WITH NORMAL KNEES.

OBJECTIVE: To evaluate the modified Lysholm protocol among patients with knees that were considered to be normal (without previous complaints or pathological conditions in this region). METHOD: Between January 2010 and March 2010, a prospective study was conducted on 300 patients with orthopedic complaints in other regions of the body who came to the emergency service of our hospital. The inclusion criterion among these patients was the absence of complaints or previous surgery in the knee that was considered to be dominant. The age range was from 16 to 40 years, with an average of 28.8 years. Our study group consisted of 153 males and 147 females. In the modified Lysholm system, the maximum score is 100 points and this includes functional and objective criteria. Altogether, 50% of the total score is based on symptoms of pain and instability. RESULTS: The average score using the Lysholm protocol was 95 points in the knees that were considered normal. Males had higher scores than females. CONCLUSION: These patients with knees that were considered normal did not achieve the maximum score when evaluated using the modified Lysholm protocol. This study suggests that this line of research on functional evaluation systems for the knee is open for further evaluations. Moreover, creation and development of new forms of functional assessment for the knee should be investigated in order to achieve a worldwide consensus.