Total knee arthroplasty with subvastus approach in patient with chronic post-traumatic patellar dislocation

AbstractChronic lateral dislocation of the patella is a rare condition and acquired causes are usually secondary to knee trauma. The neglected chronic dislocation leads to progressive genu valgum and external tibial torsion deformities with subsequent gonarthrosis, which becomes painful and debilitating. There is no consensus regarding treatment of these patients, but total knee arthroplasty (TKA) is a useful therapy in cases of painful symptomatic gonarthrosis. Few reports have shown that subvastus approach and lateral release may be a valid option for TKA, since it allows the correction of valgus deformity and patellar tracking without interrupting vascular blood supply of patella. This article reports a case of TKA and extensor mechanism realignment without patellar resurfacing in a patient with genu valgum and chronic post-traumatic patellar dislocation with satisfactory results after two years of follow-up

Comparison of Floseals and Tranexamic Acid for Bleeding Control after Total Knee Arthroplasty: a Prospective Randomized Study

OBJECTIVE: Tranexamic acid (TXA) and the hemostatic agent Floseals have already been used to minimize bleeding during total knee arthroplasty (TKA). METHODS: We conducted a prospective, randomized study of 90 patients with indications for TKA. Following inclusion, the participants were randomly allocated in blocks to the following 3 groups: control, Floseals and TXA. Bleeding parameters, including decreases in hemoglobin (Hb), drain output, number of blood transfusions and complications, were assessed. ClinicalTrials.gov: NCT02152917. RESULTS: The mean decrease in Hb was highest in the control group (4.81±1.09 g/dL), followed by the Floseals (3.5±1.03 g/dL) and TXA (3.03±1.2 g/dL) groups. The Floseals and TXA groups did not differ, and both performed better than the control group. The mean total drain output was 901.3±695.7 mL in the control group, 546.5±543.5 mL in the TXA group and 331.2±278.7 mL in the Floseals group. Both TXA and Floseals had significantly less output than the control group, and Floseals had significantly less output than TXA. The number of blood transfusions was very small in all 3 groups. CONCLUSION: The use of TXA or Floseals was associated with less blood loss than that of the control group among patients undergoing primary TKA, as measured both directly (intraoperative bleeding + drainage) and on the basis of a decrease in Hb, without differences in the rate of complications. TXA and Floseals showed similar decreases in Hb and total measured blood loss, but the drain output was smaller in the Floseals group

Treatment of bone marrow edema lesions of the knee with subchondroplasty technique

INTRODUÇÃO: O edema medular ósseo pode ser encontrado em diversas doenças do joelho e existe ainda grande controvérsia quanto à sua classificação e nomenclatura na literatura, principalmente, em vista dos estudos mais recentes, a partir do ano de 2000, quando a repercussão clínica de tais alterações de imagens de ressonância magnética começaram a ser melhor avaliadas. Estudos demonstraram a correlação do edema ósseo com a dor e a progressão da osteoartrite. Um novo método cirúrgico desenvolvido para o tratamento dessas lesões é denominado subcondroplastia e consiste na injeção de substituto ósseo pastoso no local do edema medular ósseo. O objetivo do presente trabalho é avaliar a técnica de subcondroplastia no Brasil quanto a sua aplicabilidade e os resultados no tratamento do edema medular ósseo. MÉTODOS: Foram incluídos pacientes com idade entre 40 e 85 anos, com dor no joelho há pelo menos 6 meses, associada à ressonância magnética com lesão de hipersinal em ponderação de T2 na tíbia ou fêmur. Os pacientes foram avaliados segundo a escala visual analógica de dor e pela escala de KOOS, IKDC subjetivo e SF36, uma semana antes da cirurgia e com 1, 3, 6, 12, 24 e 48 semanas após. Também foi realizada avaliação por imagem do joelho afetado com radiografia e ressonância magnética, sendo tais exames realizados no pré-operatório e após 48 semanas da cirurgia. A subcondroplastia foi realizada com técnica desenvolvida para o preenchimento da área de lesão óssea medular, guiada por fluoroscopia, com substituto ósseo em pasta à base de fosfato de cálcio. RESULTADOS: O preenchimento foi realizado com sucesso em 20 joelhos, sendo 11 lesões no côndilo femoral medial e 12 no planalto tibial medial. A avaliação pela escala de KOOS apresentou uma melhora significativa durante o seguimento na avaliação de sintomas (p < 0,001), dor (p < 0,001), função diária (p < 0,001), função esportiva (p=0,006) e qualidade de vida (p < 0,001). As avaliações pelas escalas do IKDC subjetivo (p < 0,001) e dor pela EVA (p < 0,001) também apresentaram melhora significativa. Na avaliação da qualidade de vida pela escala SF-36, os critérios de capacidade funcional (p < 0,001), aspectos físicos (p < 0,001), estado geral de saúde (p=0,015), vitalidade (p=0,017), aspectos sociais (p < 0,003), aspectos emocionais (p < 0,001) e saúde mental (p=0,019) apresentaram melhora significativa e apenas o critério de dor (p=0,398) não obteve melhora significativa. A escala radiográfica de Kellgren-Lawrence ao final do seguimento foi significativamente pior que a pontuação pré-operatória (p=0,025). Doze ressonâncias magnéticas realizadas após 48 semanas de seguimento foram avaliadas, com seis pacientes apresentando redução do edema. A impacção estava pior em 5 joelhos, não houve alteração em 6 joelhos e em apenas 1 houve redução da impacção. Todos os pacientes conseguiram deambular, sem apoio adicional, já no primeiro dia após o procedimento. Como complicações, dois pacientes apresentaram extravasamento de enxerto para partes moles. CONCLUSÃO: A técnica de subcondroplastia é segura, apresenta melhora rápida e sustentada de dor e desempenho funcional dos pacientes em um seguimento de 48 semanasINTRODUCTION: Bone marrow edema can be found in several pathologies of the knee and there is still great controversy regarding classification and nomenclature in the literature, especially in view of the most recent studies since the year 2000, when the clinical repercussion of such magnetic resonance imaging began to be better evaluated. Studies have shown the correlation of bone edema with pain and osteoarthritis progression. A new surgical method developed for the treatment of these lesions is called subchondroplasty and consists of the injection of a paste substitute at the site of bone marrow edema. The aim of the present study was the development of the subchondroplasty technique in Brazil to evaluate its applicability and results in the treatment of bone marrow edema. METHODS: We included patients aged 40 to 85 years, with pain in the knee for at least 6 months, associated with increased uptake MRI lesion on T2 weighting in the tibia or femur. The patients were evaluated according to the visual analogue pain scale and the KOOS, subjective IKDC and SF36 scales one week before surgery and at 1, 3, 6, 12, 24 and 48 weeks after surgery. We also performed image evaluation of the affected knee with radiography and MRI, which were performed preoperatively and after 48 weeks of surgery. The subchondroplasty was performed using a technique developed to fill the area of bone marrow lesion, guided by fluoroscopy, with a bone substitute in a paste based on calcium phosphate. RESULTS: The filling was successfully performed on 20 knees, with 11 lesions on the medial femoral condyle and 12 on the medial tibial plateau. The KOOS score showed a significant improvement during the evaluation of symptoms (p < 0.001), pain (p < 0.001), daily function (p < 0.001), sports function (p=0.006) and quality of life (p < 0.001). Evaluations by the subjective IKDC scales (p < 0.001) and pain by the VAS (p < 0.001) also showed significant improvement. In the evaluation of the SF-36 quality of life the criteria of functional capacity (p<0.001), physical aspects (p < 0.001), general health status (p=0.015), vitality (p=0.017), social aspects (p < 0.003), emotional aspects (p < 0.001) and mental health (p=0.019) presented significant improvement, and only the pain criteria (p=0.398) showed no significant improvement. The Kellgren-Lawrence scale at the end of the follow-up was significantly worse than the preoperative score (p=0.025). Twelve magnetic resonances performed after 48 weeks of follow-up were evaluated, with six patients presenting with edema reduction. The impaction was worse in 5 knees, in 6 there was no alteration and in 1 there was reduction of impaction. All patients were able to walk, without additional support, on the first day after the procedure. As complications, two patients presented extravasation of graft to soft parts. CONCLUSION: The subchondroplasty technique is safe and presents rapid and sustained improvement of pain and functional performance of patients at a 48-week follow-u

Total knee arthroplasty with subvastus approach in patient with chronic post-traumatic patellar dislocation

ABSTRACT Chronic lateral dislocation of the patella is a rare condition and acquired causes are usually secondary to knee trauma. The neglected chronic dislocation leads to progressive genu valgum and external tibial torsion deformities with subsequent gonarthrosis, which becomes painful and debilitating. There is no consensus regarding treatment of these patients, but total knee arthroplasty (TKA) is a useful therapy in cases of painful symptomatic gonarthrosis. Few reports have shown that subvastus approach and lateral release may be a valid option for TKA, since it allows the correction of valgus deformity and patellar tracking without interrupting vascular blood supply of patella. This article reports a case of TKA and extensor mechanism realignment without patellar resurfacing in a patient with genu valgum and chronic post-traumatic patellar dislocation with satisfactory results after two years of follow-up

Reconstruction of medial patellofemoral ligament using quadriceps tendon combined with reconstruction of medial patellotibial ligament using patellar tendon: initial experience

ABSTRACT OBJECTIVE: To describe a surgical technique for anatomical reconstruction of the medial patellofemoral ligament using the quadriceps tendon, combined with reconstruction of the medial patellotibial ligament using the patellar tendon; and to present the initial results from a case series. METHOD: The proposed technique was used on a series of cases of patients with diagnoses of patellofemoral instability and indications for surgical treatment, who were attended by the Knee Group of HC-IOT, University of São Paulo. The following were evaluated before and after the operation: range of motion (ROM), apprehension test, lateral translation test, patellar inclination test, inverted J sign, subluxation upon extension, pain from compression of the patella and pain from contraction of the quadriceps. After the operation, the patients were asked whether any new episode of dislocation had occurred, what their degree of satisfaction with the surgery was (on a scale from 0 to 10) and whether they would be prepared to go through this operation again. RESULTS: Seven knees were operated, in seven patients, with a mean follow-up of 5.46 months (±2.07). Four patients who presented apprehension before the operation did not show this after the operation. The lateral translation test became normal for all the patients, while the patellar inclination test remained positive for two patients. The patients with an inverted J sign continued to be positive for this sign. Five patients were positive for subluxation upon extension before the operation, but all patients were negative for this after the operation. None of the patients presented any new episode of dislocation of the patella. All of them stated that they were satisfied: five gave a satisfaction score of 9 and two, a score of 10. All of them said that they would undergo the operation again. Only one patient presented a postoperative complication: dehiscence of the wound. CONCLUSION: Reconstruction of the medial patellofemoral ligament using the quadriceps tendon, combined with reconstruction of the medial patellotibial ligament using the patellar tendon, was technically safe and presented good objective and subjective clinical results in this case series with a short follow-up

Reconstrução do ligamento patelofemoral medial com tendão quadricipital combinada com patelotibial medial com tendão patelar: experiência inicial

ResumoObjetivoDescrever técnica cirúrgica de reconstrução anatômica do LPFM com tendão quadricipital combinada com a reconstrução do LPTM com tendão patelar e apresentar os resultados iniciais em uma série de casos.MétodoFoi aplicada a técnica proposta em uma série de casos de pacientes do Grupo de Joelho do HC‐IOT diagnosticados com instabilidade patelofemoral e com indicação de tratamento cirúrgico. No pré e pós‐operatório foram avaliados: amplitude de movimento (ADM), teste da apreensão, teste da translação lateral, teste da inclinação patelar, sinal do J invertido, subluxação em extensão, dor a compressão da patela e dor a contração do quadríceps. No pós‐operatório também foi perguntado aos pacientes se houve novo episódio de luxação, qual o grau de satisfação com a cirurgia (escala de zero a 10) e se passariam pela cirurgia novamente.ResultadosForam operados sete joelhos em sete pacientes e a média de seguimento foi de 5,46 meses (±2,07). Tivemos quatro pacientes com apreensão no pré‐operatório que não tinham apreensão no pós‐operatório. O teste de translação lateral foi normalizado em todos os pacientes enquanto o teste da inclinação patelar permaneceu positivo em dois pacientes. Os pacientes com J invertido permaneceram com o sinal positivo. A subluxação em extensão, presente no pré‐operatório em cinco pacientes, foi negativa em todos no pós‐operatório. Nenhum paciente apresentou novo episódio de luxação da patela. Todos responderam estar satisfeitos. Cinco pacientes referiram satisfação 9 e dois referiram 10. Todas passariam novamente pela cirurgia. Apenas uma paciente apresentou complicação pós‐operatória, deiscência de ferida.ConclusãoA reconstrução combinada do LPFM com tendão quadricipital com a reconstrução do LPTM com tendão patelar é tecnicamente segura e apresentou bons resultados clínicos objetivos e subjetivos nesta série de caso de curto seguimento.AbstractObjectiveTo describe a surgical technique for anatomical reconstruction of the medial patellofemoral ligament using the quadriceps tendon, combined with reconstruction of the medial patellotibial ligament using the patellar tendon; and to present the initial results from a case series.MethodThe proposed technique was used on a series of cases of patients with diagnoses of patellofemoral instability and indications for surgical treatment, who were attended by the Knee Group of HC‐IOT, University of São Paulo. The following were evaluated before and after the operation: range of motion (ROM), apprehension test, lateral translation test, patellar inclination test, inverted J sign, subluxation upon extension, pain from compression of the patella and pain from contraction of the quadriceps. After the operation, the patients were asked whether any new episode of dislocation had occurred, what their degree of satisfaction with the surgery was (on a scale from zero to 10) and whether they would be prepared to go through this operation again.ResultsSeven knees were operated, in seven patients, with a mean follow‐up of 5.46 months (±2.07). Four patients who presented apprehension before the operation did not show this after the operation. The lateral translation test became normal for all the patients, while the patellar inclination test remained positive for two patients. The patients with an inverted J sign continued to be positive for this sign. Five patients were positive for subluxation upon extension before the operation, but all patients were negative for this after the operation. None of the patients presented any new episode of dislocation of the patella. All of them stated that they were satisfied: five gave a satisfaction score of 9 and two, a score of 10. All of them said that they would undergo the operation again. Only one patient presented a postoperative complication: dehiscence of the wound.ConclusionReconstruction of the medial patellofemoral ligament using the quadriceps tendon, combined with reconstruction of the medial patellotibial ligament using the patellar tendon, was technically safe and presented good objective and subjective clinical results in this case series with a short follow‐up

Extra-articular and transcutaneous migration of the poly-l/D-lactide interference screw after popliteal tendon reconstruction

ABSTRACT Knee ligament reconstructions are commonly performed orthopedic procedures. Graft fixation is generally performed with metallic or absorbable interference screws. In a recent study, only ten reports of screw migration were retrieved; of these, only one was not related to the anterior cruciate ligament, and the majority was related to the use of poly-l-lactic acid (PLLA) screws. Only one case retrieved in the literature reported screw migration in reconstructions of the posterolateral corner, and that was to the intra-articular region. In the present article, the authors report a case of extra-articular and transcutaneous migration of a poly-l/D-lactide (PDLLA) interference screw following popliteal tendon reconstruction. Besides being the first case of popliteal tendon migration with extra-articular screw migration, no reports of PDLLA screw migration were retrieved in the literature