Current Rehabilitation Practices and Return to Sports Criteria After Anterior Cruciate Ligament Reconstruction: A Survey of Physical Therapists in Saudi Arabia.

CONTEXT: With the high prevalence of anterior cruciate ligament rupture among young and active individuals, rehabilitation after the injury and surgery should meet the current evidence-based recommendations to restore knee function and reduce the risk of further injury. This study aimed to investigate the current rehabilitation practices and return to sports (RTS) criteria after anterior cruciate ligament reconstruction (ACLR) among physical therapists in Saudi Arabia. DESIGN: Online cross-sectional survey-based study. METHODS: A total of 177 physical therapists in Saudi Arabia participated in this survey. The survey included questions about the preferred postoperative timing and frequency of rehabilitation, current views on the importance of preoperative and postoperative rehabilitation to the overall outcomes, the timeframe of RTS, and the decision-making process to RTS. RESULTS: Most therapists (96.6%) believed preoperative rehabilitation was essential/important to postoperative outcomes. Two-thirds encouraged patients to start rehabilitation program within 1 to 4 days immediately post-ACLR. RTS was permitted 6 to 9 months post-ACLR by 60% of therapists if satisfied with patient progress and capacity. Factors considered before RTS included knee strength (72.9%), functional capacity (86.4%), lower limb and trunk mechanics (62.7%), and psychological readiness (42.2%). Knee strength was assessed by manual muscle testing (39%), handheld dynamometry (15.3%), and isokinetic dynamometer (13.6%). While 60% of the therapists used single-limbed hop for distance for evaluating functional capacity, only 27.1% used a hop test battery. CONCLUSIONS: The surveyed physical therapists in Saudi Arabia demonstrated variations in the current rehabilitation practices and RTS criteria post-ACLR. Over half of the surveyed therapists considered preoperative rehabilitation essential to postoperative outcomes. However, the therapists should update their perspective with current evidence-based practice regarding the RTS timeframe, psychological readiness assessment for RTS, and knee strength evaluation using objective measurements.

Anteromedial positioning of the femoral tunnel in anterior cruciate ligament reconstruction is the best option to avoid revision: a single surgeon registry.

PURPOSE: The aim of the study is to compare the risk of revision of single-bundle hamstring anterior cruciate ligament (ACL) reconstruction between the anteromedial, transtibial and outside-in techniques. METHODS: This cohort study was based on data from a single surgeon's registry. Patients who underwent primary single-bundle ACL reconstruction with hamstring tendon using the anteromedial portal, transtibial and outside-in technique, operated between 1 November 2003 to 31 December 2016, were eligible for inclusion. A minimum follow-up of 2 years was used, and the end-point of the study was revision surgery. RESULTS: The total number of registered surgeries identified was 665; 109 were excluded, and 556 was the final sample. The overall revision rate was 8.7%. The transtibial technique presented 14/154 [9.9%] of revisions, the transportal 11/96 [11.4%] and the outside-in 22/306 [7.2%]. Separating the outside-in group into central outside-in and anteromedial (AM) outside-in, 18/219 [8.2%] was found for the central outside-in and 4/87 [4.5%] for the AM outside-in technique. Statistical evaluation of the first comparison (transtibial vs. transportal vs. outside-in) obtained p = (n.s.) The second comparison (transtibial vs. central transportal vs. central outside-in vs. AM outside-in, p = (n.s). Placement was also evaluated: high anteromedial placement (transtibial) vs. central (transportal and central outside-in technique) vs. AM placement (AM outside-in). The high AM placement presented 14/154 [9.9%] of revision, the central placement 29/315 [9.2%] and the AM placement 4/87 [4.5%], p = (n.s.) The AM placement was also compared with the other placements (high and central AM), p = (n.s.) CONCLUSION: Based on the registry of a single surgeon during 14 years of ACL reconstruction, the placement of the femoral tunnel in the high anteromedial region was associated with a rupture rate of 9.9%, central placement with 9.2% and anteromedial placement with 4.5%.

¿Es útil fijar las fracturas de Segond para el manejo de la inestabilidad anterolateral de rodilla? A propósito de un caso / Is it worthwhile fixing Segond fractures for the management of anterolateral knee instability? A case report

Introducción El complejo anterolateral de la rodilla es un estabilizador secundario de la rotación tibial interna, su inserción distal esta localizada en el aspecto anterolateral de la tibia proximal y su avulsión es conocida como fractura de Segond, fue descrita hace mas de un siglo por el cirujano francés que le dio su nombre. Es frecuente la asociación de la lesión del ligamento cruzado anterior (LCA) con este complejo, tanto que en la actualidad se considera la fractura de Segond como un signo patognomónico de ruptura del cruzado anterior. Dada la importancia de brindar estabilidad rotacional desde la periferia de la articulación y las propiedades cada vez mas reconocidas de las estructuras anterolaterales, este artículo reporta un caso de fijación directa de la fractura de Segond, en el cual se buscó restituir la anatomía original de la rodilla. Métodos Revisión de la literatura relevante y reporte retrospectivo del caso de un paciente con lesión de LCA y fractura de Segond que fue llevado a reconstrucción de LCA con autoinjerto de HTH y reducción directa y fijación con sutura de anclaje de fractura de Segond por una incisión mínima, con un seguimiento clínico de 4 años. Se aplicaron escalas de valoración subjetiva previo al procedimiento y en el seguimiento postoperatorio. Resultados La inestabilidad anterior y anterolateral posterior al manejo quirúrgico presentó mejoría clínica pasando de tener Lachman IIB a negativo, y Pivot shift grado II a negativo. Las escalas de valoración subjetivas de Lysholm e IKDC mejoraron notablemente de resultados regulares previo al procedimiento a excelentes en el postoperatorio. No presentó complicaciones durante el procedimiento ni requirió reintervenciones. Discusión Aunque la fractura de Segond está descrita desde hace más de un siglo, y su asociación con lesiones de ligamento cruzado anterior se documentó hace mas de 20 años, aun no hay consenso en el manejo de esta fractura. Desde el punto de vista biomecánico, una estructura localizada en el centro de la rodilla como el LCA, de manera aislada, sería insuficiente para controlar la rotación tibial en relación al fémur. Por lo tanto, sería lógico pensar que una estructura localizada lejos del centro de rotación de la rodilla pueda ser más efectiva en controlar la rotación ya que ejerce un mayor control del torque rotacional. Reportamos resultados funcionales satisfactorios y estabilidad postoperatoria adecuada a 4 años de seguimiento, posterior a la fijación de la fractura de Segond asociada a reconstrucción de LCA; consideramos que puede ser una medida exitosa y segura para el manejo de la inestabilidad anterolateral de la rodilla.

Introduction The anterolateral complex of the knee is a secondary stabiliser of the internal tibial rotation. Its distal insertion is located in the anterolateral aspect of the proximal tibia, and its avulsion is known as Segond fracture. This was described more than a century ago by the French surgeon who gave it his name. The combination of anterior cruciate ligament injury (ACL) with the anterolateral complex is so common in as much that Segond fracture is currently considered as a pathognomonic sign of rupture of the anterior cruciate. Given the importance of providing rotational stability from the periphery of the joint and the increasingly recognised properties of the anterolateral structures, this article reports a case of direct fixation of the Segond fracture, in which it was sought to restore the original anatomy of the knee. Methods Review of relevant literature and retrospective case report of a patient with ACL injury and Segond fracture who underwent ACL reconstruction with a host-to-host (HTH) autograft and direct reduction and fixation with Segond fracture anchor suture through a minimal incision. There was a clinical follow-up of 4 years. Subjective assessment scales were applied prior to the procedure and in the postoperative follow-up. Results Anterior and anterolateral instability after surgical management showed a clinical improvement, going from having Lachman IIB to negative, and from Pivot shift grade II to negative. The subjective rating scales of Lysholm and International Knee Documentation Committee (IKDC) improved markedly from regular results prior to the procedure to excellent in the postoperative period. There were no complications during the procedure and no reoperations were required Discussion Although the Segond fracture has been described for more than a century, and its association with anterior cruciate ligament injuries was documented more than 20 years ago, there is still no consensus on the management of this fracture. From the biomechanical point of view, a structure located in the centre of the knee like the ACL, in isolation, would be insufficient to control the tibial rotation in relation to the femur. Therefore, it would be logical to think that a structure located far from the centre of rotation of the knee can be more effective in controlling rotation, since it exerts a greater control of rotational torque. Satisfactory functional results are reported, together with an adequate postoperative stability at 4 years of follow-up, after the fixation of the Segond fracture associated with ACL reconstruction. It is considered that this can be a successful and safe measure for the management of anterolateral instability of the knee.

Knee isokinetic performance following anterior cruciate ligament reconstruction: patellar tendon versus hamstrings graft.

OBJECTIVE: To compare knee isokinetic performance six months after reconstruction of the anterior cruciate ligament using grafts from either the patellar tendon or the hamstrings among patients who underwent the same rehabilitation protocol. METHODS: Thirty-four patients were evaluated (17 with grafts from the patellar tendon and 17 with grafts from the hamstrings). Operated and non-operated knees were compared with regards to the variables of peak torque, work and the hamstring/quadriceps relationship at velocities of 60º/s and 180º/s and power of 180º/s after six months of surgery. RESULTS: The patients with ACL reconstruction using the patellar tendon (BPTB) showed quadriceps deficits for all variables, but the flexor musculature was balanced. In the hamstring group, both the extensors and the flexors showed deficits for the variables analyzed, except for hamstring power at 180º/s. CONCLUSION: Patients in the patellar tendon group had a greater quadriceps deficit compared with those in the hamstrings group. Patients in the hamstrings group had a greater muscular deficit in the flexor mechanism compared with the contralateral knee. An unbalanced H/Q ratio was observed regardless of graft type, but this was more evident in the BPTB group.

Tibial fixation in anterior cruciate ligament reconstruction.

OBJECTIVE: To determine whether supplementary tibial graft fixation with a staple is routinely necessary for anterior cruciate ligament (ACL) reconstructions. METHODS: We retrospectively reviewed a series of consecutive patients who underwent ACL reconstruction at our institution from April 2012 to July 2013. Patients who fulfilled the inclusion and exclusion criteria were divided into two groups, of which one with tibial fixation of the graft with a biointerference screw alone (biointerference screw group) and the other with tibial fixation of the graft with a biointerference screw and supplementary extra tunnel staple fixation (biointerference screw and staple group). All the surgeries were performed by a single fellowship-trained sports surgeon, using a standardized transportal technique and rehabilitation protocol. Both well-matched groups were evaluated at 1-year follow-up objectively for ligament laxity using instrumented testing with KT-2000 arthrometer and clinical tests as well as subjectively with the validated International Knee Documentation Committee 2000 (IKDC) and Lysholm knee score. All complications were reported. RESULTS: A total of 64 patients (31 in the only biointerference screw group and 33 in the biointerference screw and staple group) were included in the study. At 1 year, there was no significant difference in the objective and subjective outcome assessments between the two groups. However, four patients from the group with supplementary staple experienced symptomatic hardware on kneeling of which two necessitated removal of hardware. CONCLUSION: Our study showed that supplementary tibial graft fixation with a staple is not routinely necessary for ACL reconstructions. It confers no additional benefits when compared with the use of biointerference screw alone for tibial graft fixation but may increase the risks of symptomatic hardware.

Partial tearing of the anterior cruciate ligament: diagnosis and treatment.

Partial tears of the anterior cruciate ligament (ACL) are common and represent 10-27% of the total. The main reasons for attending to cases of non-torn bundles are biomechanical, vascular and proprioceptive. Continued presence of the bundle also serves as protection during the healing process. There is controversy regarding the definition of these injuries, which is based on anatomy, clinical examination, translation measurements, imaging examinations and arthroscopy. The way in which it is treated will depend on the existing laxity and instability. Conservative treatment is optional for cases without instability, with a focus on motor rehabilitation. Surgical treatment is a challenge, since it requires correct positioning of the bone tunnels and conservation of the remnants of the torn bundle. The pivot shift test under anesthesia, the magnetic resonance findings, the previous level and type of sports activity and the arthroscopic appearance and mechanical properties of the remnants will aid the orthopedist in the decision-making process between conservative treatment, surgical treatment with strengthening of the native ACL (selective reconstruction) and classical (anatomical) reconstruction.

Lesões parciais do ligamento cruzado anterior (LCA) são comuns e representam 10­27% das totais. As principais razões para atenção ao feixe não rompido são biomecânicas, vasculares e proprioceptivas. A permanência do feixe serve ainda de proteção durante o processo cicatricial. A definição dessa lesão é controversa, baseada na anatomia, no exame clínico, na medida da translação, nos exames de imagem e na artroscopia. Seu tratamento vai depender da frouxidão e da instabilidade existentes. O tratamento conservador é opcional para casos sem instabilidade, com enfoque na reabilitação motora. O tratamento cirúrgico é desafiador, pois exige correto posicionamento dos túneis ósseos e conservação dos remanescentes do feixe rompido. O teste do pivot-shift sob anestesia, os achados à ressonância magnética, o nível e o tipo de atividade esportiva prévia e o aspecto artroscópico dos remanescentes e suas propriedades mecânicas auxiliarão o ortopedista no processo decisório entre o tratamento conservador, o tratamento cirúrgico com reforço do LCA nativo (reconstrução seletiva) ou a reconstrução clássica (anatômica).

Reconstruction of the anterior cruciate ligament: comparison of analgesia using intrathecal morphine, intra-articular morphine and intra-articular levobupivacaine.

OBJECTIVE: To compare the analgesic effect of intra-articular administration of morphine and levobupivacaine (separately or in combination) with intrathecal administration of morphine in patients undergoing anterior cruciate ligament (ACL) reconstruction using autologous grafts from the patellar tendon. METHODS: This was a retrospective analysis on data gathered from the medical files of 60 patients aged 20 to 50 years who underwent knee video arthroscopy for ACL reconstruction. The patients were divided into four groups of 15 individuals (A, B, C and D) according to the agent administered into the joint and around the incision: 20 mL of saline solution with 5 mg of morphine in A; 20 mL of 0.5% levobupivacaine solution in B; 10 mL of solution with 2.5 mg of morphine plus 10 mL of 0.5% levobupivacaine solution in C; and morphine administered intrathecally in D. RESULTS: All the groups presented low pain scores during the first 12 h after the surgery. Groups B and C presented significantly greater pain scores than shown by group D (control), 24 h after the surgery. There was no statistical difference in pain scores between group A and group D. CONCLUSION: The patients in group A presented analgesia comparable to that of the patients in group D, whereas the procedure of group C was no capable of reproducing the analgesic effect observed in group D, as observed 24 h after the surgery. Further studies are needed in order to show the exact mechanism of action, along with the ideal dose and concentration for applying opioids to joints.

OBJETIVO: Comparar o efeito analgésico da administração intra-articular de morfina e levobupivacaína (isoladas ou associadas) com a administração intratecal de morfina em pacientes submetidos à reconstrução do LCA com enxerto autólogo de tendão patelar. MÉTODOS: Análise retrospectiva dos dados coletados nos prontuários de 60 pacientes entre 20 e 50 anos, submetidos à vídeoartroscopia de joelho para reconstrução do LCA. Os pacientes encontravam-se separados em quatro grupos de 15 pessoas (A, B, C e D) de acordo com a administração intra-articular e peri-incisional de 20 mL de solução salina com 5 mg de morfina em A, 20 mL de solução a 0.5% levobupivacaína em B, 10 mL de solução com 2.5 mg de morfina e 10 mL de solução a 0.5% de levobupivacaína em C e morfina intratecalmente em D. RESULTADOS: Todos os grupos apresentaram baixos escores de dor nas primeiras 12 horas após a cirurgia. Os grupos B e C apresentaram escores de dor significativamente maiores do que o grupo D (controle) 24 horas após a cirurgia. Não houve diferença estatística entre os escores de dor do grupo A e do grupo D. CONCLUSÃO: Nos pacientes do grupo A houve analgesia comparável à dos pacientes do D, ao passo que o procedimento em C não foi capaz de reproduzir o efeito analgésico observado em D quando os indivíduos foram estudados após 24 horas da cirurgia. Novos estudos são necessários para evidenciar o exato mecanismo de ação, bem como a dose e concentração ideais para aplicação articular de opioides.

Partial tearing of the anterior cruciate ligament: diagnosis and treatment / Lesão parcial do ligamento cruzado anterior: diagnóstico e tratamento

Partial tears of the anterior cruciate ligament (ACL) are common and represent 10-27% of the total. The main reasons for attending to cases of non-torn bundles are biomechanical, vascular and proprioceptive. Continued presence of the bundle also serves as protection during the healing process. There is controversy regarding the definition of these injuries, which is based on anatomy, clinical examination, translation measurements, imaging examinations and arthroscopy. The way in which it is treated will depend on the existing laxity and instability. Conservative treatment is optional for cases without instability, with a focus on motor rehabilitation. Surgical treatment is a challenge, since it requires correct positioning of the bone tunnels and conservation of the remnants of the torn bundle. The pivot shift test under anesthesia, the magnetic resonance findings, the previous level and type of sports activity and the arthroscopic appearance and mechanical properties of the remnants will aid the orthopedist in the decision-making process between conservative treatment, surgical treatment with strengthening of the native ACL (selective reconstruction) and classical (anatomical) reconstruction...

Lesões parciais do ligamento cruzado anterior (LCA) são comuns e representam 10%-27% das totais. As principais razões para atenção ao feixe não rompido são biomecânicas, vasculares e proprioceptivas. A permanência do feixe serve ainda de proteção durante o processo cicatricial. A definição dessa lesão é controversa, baseada na anatomia, no exame clínico, na medida da translação, nos exames de imagem e na artroscopia. Seu tratamento vai depender da frouxidão e da instabilidade existentes. O tratamento conservador é opcional para casos sem instabilidade, com enfoque na reabilitação motora. O tratamento cirúrgico é desafiador, pois exige correto posicionamento dos túneis ósseos e conservação dos remanescentes do feixe rompido. O teste do pivot-shift sob anestesia, os achados à ressonância magnética, o nível e o tipo de atividade esportiva prévia e o aspecto artroscópico dos remanescentes e suas propriedades mecânicas auxiliarão o ortopedista no processo decisório entre o tratamento conservador, o tratamento cirúrgico com reforço do LCA nativo (reconstrução seletiva) ou a reconstrução clássica (anatômica)...

Bone tunnel enlargement on anterior cruciate ligament reconstruction.

OBJECTIVE: To assess the presence of tibial bone tunnel enlargement after surgical reconstruction of the anterior cruciate ligament using quadruple graft of the flexor tendons and correlate the functional results in their presence. METHODS: The studied lasted six months and included 25 patients, with ages ranging from 18 to 43 years old. Assessment was based on radiographs taken immediately postoperatively and at the third and sixth month of follow up in the anterior cruciate ligament reconstruction. Reconstruction of ligaments was performed with tendon grafts of the semitendinosus and gracilis muscle fixated in the femur with transverse metal screw and in the tibia with interference screws. Patients were evaluated objectively by tests ligament, graded from zero to four crosses and subjectively by the Lysholm method preoperative and after sixth month follow up. RESULTS: Significant increase in the tunnels diameters were observed, 20.56% for radiographs in the anteroposterior view, 26.48% in profile view and 23.22% in computed tomography. Descriptive statistics showed significant improvement in subjective and objective clinical parameters. CONCLUSIONS: The bone tunnel enlargement is a phenomenon found in the first months after surgical reconstruction of the anterior cruciate ligament and it has no implications on clinical outcomes in the short term. Level of Evidence II, Prospective Study.

Bone tunnel enlargement on anterior cruciate ligament reconstruction

Verificar a presença de alargamento do túnel ósseo tibialapós cirurgia de reconstrução do ligamento cruzado anterior usandoenxerto quádruplo de tendões flexores e correlacionar resultados funcionaisna sua presença. Métodos: O estudou teve a duração de 6meses e contou com 25 pacientes, com idades variando de 18 a 43anos. A avaliação baseou-se em radiografias realizadas no período pós--operatório imediato, terceiro e sexto mês de evolução das operaçõesde reconstrução dos ligamentos cruzados anteriores. Os ligamentosforam reconstruídos com os enxertos do tendão do músculo semitendíneoe do músculo grácil, fixados no fêmur com parafuso transversometálico, e na tíbia, com parafuso de interferência. Os pacientes foramavaliados objetivamente por testes ligamentares graduados de zero aquatro cruzes e subjetivamente pelo método de Lysholm no períodopré-operatório e no sexto mês de evolução. Resultados: Observou-seum aumento significativo dos diâmetros dos túneis, de 20,56% pararadiografias na incidência anteroposterior, 26,48% na incidência de perfile 23,22% nas tomografias computadorizadas. A estatística descritivamostrou melhoria significativa dos parâmetros clínicos objetivos e subjetivos.Conclusões: O alargamento dos túneis ósseos é um fenômenopresente nos primeiros meses após a cirurgia de reconstrução do ligamentocruzado anterior e não tem implicação nos resultados clínicosem curto prazo. Nível de Evidência II, Estudo prospectivo...

To assess the presence of tibial bone tunnel enlargementafter surgical reconstruction of the anterior cruciate ligamentusing quadruple graft of the flexor tendons and correlate the functionalresults in their presence. Methods: The studied lasted sixmonths and included 25 patients, with ages ranging from 18 to43 years old. Assessment was based on radiographs taken immediatelypostoperatively and at the third and sixth month of followup in the anterior cruciate ligament reconstruction. Reconstructionof ligaments was performed with tendon grafts of the semitendinosusand gracilis muscle fixated in the femur with transversemetal screw and in the tibia with interference screws. Patientswere evaluated objectively by tests ligament, graded from zero tofour crosses and subjectively by the Lysholm method preoperativeand after sixth month follow up. Results: Significant increasein the tunnels diameters were observed, 20.56% for radiographsin the anteroposterior view, 26.48% in profile view and 23.22% incomputed tomography. Descriptive statistics showed significantimprovement in subjective and objective clinical parameters. Conclusions:The bone tunnel enlargement is a phenomenon found inthe first months after surgical reconstruction of the anterior cruciateligament and it has no implications on clinical outcomes in theshort term. Level of Evidence II, Prospective Study...

Viscosupplementation during rehabilitation.

CONTEXT: Viscosupplementation (VS) and physical therapy are both used to treat pain associated with knee osteoarthritis (OA). EVIDENCE ACQUISITION: PubMed and EMBASE searches were performed to July 2013. Search terms included hyaluronic acid OR hylan, physical therapy OR exercise, AND osteoarthritis. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 4. RESULTS: The efficacy and safety of VS in painful knee OA is well documented, as are the appropriate candidates for this intervention. Studies suggest that adding VS to physical therapy and therapeutic exercise may lead to improved pain reduction and increased functionality compared with physical therapy alone. CONCLUSION: Appropriately selected patients undergoing physical therapy for knee OA may benefit from VS.

Intra-articular bupivacaine or bupivacaine and morphine after ACL reconstruction.

OBJECTIVE: Reconstructive surgery of the ACL is one of the most commonly performed surgeries today and the control of postoperative pain is part of the priorities of the surgeon. Within the arsenal of analgesia we have the intra-articular application of drugs, and the most studied one is bupivacaine with or without morphine. This study compared the application of bupivacaine with or without morphine with a control group after ACL reconstruction with flexor tendon graft. METHODS: Forty-five patients were randomized into three groups: in group I, 20 ml of saline were applied intra-articularly at the end of the surgery; in group II, 20 ml of bupivacaine 0.25%; and in group III, bupivacaine 0.25% associated with 1 mg of morphine. The groups were assessed for degree of pain by the Visual Analog Scale at 6, 24 and 48 hours postoperatively. RESULTS: Group III had less pain at all times, but the pain was not as intense in all groups to the point of needing extra medications beyond the established protocol. CONCLUSION: The intra-articular application of these medications after ACL reconstruction with flexor tendon graft when performed under spinal anesthesia is not useful enough to use regularly. Level of Evidence II, Lesser quality RCT.

PERI-INCISIONAL DYSESTHESIA FOLLOWING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION USING CENTRAL THIRD OF PATELLAR TENDON.

OBJECTIVE: To evaluate the prevalence and type of dysesthesia around the incision used to obtain the patellar tendon for anterior cruciate ligament (ACL) reconstruction surgery. METHODS: Out of a population of 1368 ACL reconstructions using the central third of the patellar tendon, 102 patients (111 knees) were evaluated by means of telephone interview. RESULTS: The mean follow-up was 52 months (ranging from 12 to 88 months). The patients' ages ranged from 16 to 58 years (mean: 34.7 years). There was some degree of peri-incisional dysesthesia in 66 knees (59.46%). In 40.54% of the knees, this condition was not found. In all the cases of dysesthesia, the type encountered was Highet's type II. CONCLUSION: Peri-incisional dysesthesia following ACL reconstruction using the central third of the patellar tendon is highly prevalent. It affected more than half of the cases in this series.

RADIOLOGICAL ANALYSIS OF BONE TUNNEL POSITION IN ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION SURGERY: COMPARISON BETWEEN THE OPEN TECHNIQUE AND ARTHROSCOPY VIA AN ANTEROMEDIAL PORTAL.

OBJECTIVES: To evaluate and compare bone tunnel positioning in anterior cruciate ligament (ACL) reconstruction surgery using the arthroscopic technique and the open technique consisting of arthrotomy. METHOD: A comparative retrospective study on 70 patients with ACL lesions was conducted. Thirty-five patients underwent ACL reconstruction by means of the open technique and 35 by means of the arthroscopic technique using an anteromedial portal. All the patients underwent ACL reconstruction using an autologous graft from the middle third of the patellar tendon, fixed using interference screws. The postoperative radiographs were reviewed and the positioning of the femoral tunnel was evaluated using the methods proposed by Harner et al. and Aglietti et al., while the tibial tunnel was assessed using the method proposed by Rauschning and Stäubli. RESULTS: Fifty-four of the patients were male and 16 were female. Their mean age at the time of the procedure was 34 years and 3 months, with a range from 17 to 58 years. The arthroscopic technique was shown to be more accurate than the open technique for positioning both the femoral and the tibial bone tunnels. CONCLUSIONS: Radiological analysis on the knees subjected to ACL reconstruction showed that the positioning of both the femoral and the tibial bone tunnels presented less variation when the surgery was performed arthroscopically.

ANATOMICAL ACL RECONSTRUCTION WITH DOUBLE BUNDLE: FIRST 40 CASES.

OBJECTIVE: To discuss the technique of anatomical reconstruction of the anterior cruciate ligament (ACL) with a double bundle, the learning curve and the preliminary results. METHODS: Forty patients with ACL injury underwent reconstruction with an anatomical double bundle, using the semitendinosus tendon to remake the anteromedial (AM) band and the gracilis to remake the posterolateral (PL) band of the knee. RESULTS: We had two cases of limitation of extension, and in one of them, arthroscopic arthrolysis had to be performed; and there was one case of deep vein thrombosis. CONCLUSION: ACL reconstruction with double bundle proved feasible, despite having a longer learning curve, and the advantages of the proposed technique still must be proven compared to the single-bundle technique.

HOW CAN BONE TUNNEL ENLARGEMENT IN ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION SURGERY BE MEASURED? DESCRIPTION OF A TECHNIQUE.

UNLABELLED: To assess the presence of tibial bone tunnel enlargement after surgery to reconstruct the anterior cruciate ligament using quadruple flexor tendon grafts, and to propose a new technique for its measurement. METHODS: The study involved 25 patients aged 18-43 years over a six-month period. The assessment was based on radiographs taken immediately postoperatively and in the third and sixth months of evolution after operations to reconstruct the anterior cruciate ligament using grafts from the tendons of the semitendinosus and gracilis muscles, fixed in the femur with a transverse metal screw and in the tibia with an interference screw. The radiographs were evaluated in terms of the relative value between the diameter of the tunnel and the bone, both at 2 cm below the medial tibial condyle. RESULTS: There were significant increases in tunnel diameters: 20.56% for radiographs in anteroposterior view and 26.48% in lateral view. Enlargement was present in 48% of anteroposterior and lateral radiographs, but was present in both views in only 16% of the cases. CONCLUSIONS: Bone tunnel enlargement is a phenomenon found in the first months after surgery to reconstruct the anterior cruciate ligament. The measurement technique proposed in this study was sufficient to detect it.

Reconstrução anatômica do LCA com duplo feixe: primeiros 40 casos / Anatomical ACL reconstruction with double bundle: first 40 cases

OBJETIVO: Discutir a técnica de reconstrução anatômica do ligamento cruzado anterior (LCA) com duplo feixe, a curva de aprendizado e os resultados preliminares. MÉTODOS: Quarenta pacientes com lesão do LCA foram submetidos à reconstrução anatômica com duplo feixe, utilizando-se do tendão semitendinoso para refazer a banda anteromedial (AM) e gracilis para refazer a banda posterolateral (PL) do joelho. RESULTADOS: Tivemos dois casos de limitação de extensão, sendo que em um deles foi necessária a realização de artrólise artroscópica, e um caso de trombose venosa profunda. CONCLUSÃO: A reconstrução do LCA com duplo feixe se mostrou factível, apesar de apresentar uma maior curva de aprendizado; e as vantagens da técnica proposta ainda deverão ser comprovadas se comparada com a técnica de feixe único.

OBJECTIVE: To discuss the technique of anatomical reconstruction of the anterior cruciate ligament (ACL) with double beam, the learning curve and preliminary results. METHODS: Forty patients with ACL injury underwent reconstruction with anatomical double-bundle, using the semitendinosus tendon to remake the band anterior medial (AM) and gracile to remake the band posterior lateral (PL) of the knee. RESULTS: We had two cases of limitation of extension, and in one of them were necessary to perform arthroscopic artrolise, and one case of deep vein thrombosis. CONCLUSION: ACL reconstruction with double bundle proved feasible, despite having a higher learning curve, and the advantages of the proposed technique still must be proven compared to the single-beam technique.

Estudo biomecânico comparativo, em cadáveres, da reconstrução do ligamento cruzado anterior do joelho com técnica convencional e com túneis duplos tibiais e femorais / An in vitro biomechanical comparison study of anterior cruciate ligament reconstruction: single bundle versus anatomical double bundle techniques

OBJETIVO: comparar a técnica de reconstrução convencional do LCA com enxerto patelar e feixe único com a técnica com enxerto patelar bipartido e quatro túneis ósseos, através de um estudo experimental biomecânico em joelhos de cadáveres com testes pareados, sem variação na quantidade de enxerto utilizada em ambas as técnicas. INTRODUÇÃO: As lesões do ligamento cruzado anterior (LCA) do joelho são comuns principalmente na prática esportiva, e o tratamento cirúrgico de reconstrução com o uso de enxertos autólogos, pelos bons resultados alcançados, um consenso na literatura mundial. As controvérsias ficam por conta das variações que podem apresentar a técnica deste procedimento, na busca constante pelo aperfeiçoamento da mesma. Uma delas encontra-se na troca da tradicional reconstrução de feixe único do LCA pela reconstrução dos dois feixes, visando uma maior semelhança com a anatomia do LCA original. Recentemente a tendência nesta técnica é pela passagem dos enxertos por dois túneis femorais e dois túneis tibiais. MÉTODOS: Nosso estudo foi realizado em joelhos de cadáveres (18 joelhos de 9 cadáveres), todos do sexo masculino, com idade variando entre 44 e 63 anos. Estas peças foram divididas aleatoriamente, sempre em pares, nos grupos A, de joelhos operados com a técnica de reconstrução do LCA com único feixe, e grupo B, de joelhos operados com a técnica de reconstrução com duplo feixe e quatro túneis ósseos. Cada espécime foi submetido a testes biomecânicos nas condições LCA íntegro, lesado e operado, com registro de dados de Deslocamento Anterior Máximo (DTAM), Rigidez Média (R) e Rotação Tibial Interna Passiva (RIT), sob força de 100N de deslocamento tibial horizontal, a 30°,60° e 90° de flexão dos joelhos. RESULTADOS: Não houve diferenças significativas, pelo método de Análise de Variância de grupos, entre as duas técnicas tanto para medidas de DTAM em 30°(p=0,47), 60°(p=0,59), 90°(p=0,27); como para R em 30° (p=0,93), 60° (p=0,97), 90° (p=0,45)...

PURPOSES: Test an anatomical double bundle reconstruction technique with a longitudinally split bone-patellar tendon-bone graft through double femoral and tibial tunnels and biomechanically compare it to conventional single bundle reconstruction with the same total amount of bone-patelar tendon-bone graft in a paired experimental cadaver study. INTRODUCTION: Anterior Cruciate Ligament ruptures are frequent especially in sports practice. Surgical reconstruction with autologous grafts widely employed in international literature. Controversies remain in respect to technique variations as continuous research for improvement takes place. One these are the anatomical double bundle techniques instead of conventional single bundle (antero-medial bundle) technique. More recently there is a tendency of positioning of the two bundles through double tunnel technique in the femur and the tibia. METHODS: Nine pairs of male cadaver knees, age ranging from 44 to 63 years were randomized into 2 groups, (A) single bundle reconstruction and (B) anatomical double bundle reconstruction through double femoral and double tibial tunnels. Each knee was biomechanically tested in 3 conditions: intact ACL, sectioned ACL and reconstructed ACL. Maximum anterior dislocation, rigidity and passive internal tibia rotation were recorded with the knee submitted to a 100N horizontal anterior dislocation force applied to the tibia with the knee in 30º, 60º and 90º of flexion. RESULTS: There were no differences between the two techniques for any of the measurements. CONCLUSIONS: The technique of anatomical double bundle reconstruction of the anterior cruciate ligament with bone-patellar tendon-bone graft has a similar biomechanical behavior in regard to anterior tibial dislocation, rigidity and passive internal tibial rotation.

[[Systemic genotoxic effect caused by ischemia-/reperfusion-/surgical trauma of the lower extremity--detection of DNA chain breaks in leukocytes with the Comet Assay]]. / Systemisch genotoxischer Effekt durch das Ischämie-/Reperfusions-/Operations-Trauma der unteren Extremität--Nachweis von DNA-Kettenbrüchen in Leukozyten mittels Comet-Assay.

Ischemia-reperfusion-injury (IRI) represents a fundamental common pathway of tissue damage in a wide variety of disease processes, i.e. myocardial infarction, septic or hemorrhagic shock, multiple organ failure, trauma and organ transplantation. IRI is said to be initiated by leukocyte accumulation and adhesion to vascular endothelium as well as oxygen free radicals (OFR) playing a pivotal role in the pathogenesis of ischemia-reperfusion-injury. However, only few data exist for measuring influence of toxic OFR on DNA in humans. To assess the potential genotoxicity the single-cell gel electrophoresis (COMET assay) of white blood cells was used in BTB-operated humans before and after 0, 5, 15, 30 and 120 min of tourniquet-ischemia of the lower limb (n = 20). We show that tourniquet-ischemia (60-170 min) significantly increased the tailmoment measuring the DNA-damage in the operated limb to 173.4% (median in % baseline (bl); Q0.35: 149.9%; Q0.75: 214.5%; p < 0.01 vs bl) and in the systemic circulation to 157.8% (Median in % bl; Q0.25: 136.8%; Q0.75: 174.8%; p < 0.01 vs bl). These results indicate that the IRI induces a local and systemic oxidative damage in white blood cells resulting in DNA strand breaks indicating an overwhelming of the antioxidative barrier of circulating human leucocytes.