CLINICAL OUTCOMES AFTER BICRUCIATE KNEE LIGAMENT TWO-STAGE RECONSTRUCTION

Introduction: Bicruciate knee ligament injury has not a well-establish surgical protocol in the literature. Objective: To correlate clinical data and intraoperative findings compared to the postoperative evaluation data from Lysholm scale, Tegner activity score and SF-36 questionnaire after bicruciate knee ligament two-stage reconstruction. Materials and Methods: 25 patients (20 males and 05 females) were evaluated, mean age 32.3 years (17 - 53 years), mean BMI 26.2(18.9 -34.9), mean duration of lesion 18.3 months (chronic lesion). The INLAY technique was applied in PCL reconstruction using the central 1/3 of the patellar tendon. After the 3-months minimum interval, ACL reconstruction was arthroscopically performed using hamstrings. An additional surgical procedure was required for 04 patients (patellar tendon -02 cases, MCL-02 cases). Results: With a 24.8-month mean follow-up, in 60% of cases, the posterior drawer test rated zero or + (0.5 cm), while 40% as + + (1cm) and 60% of patients rated good condition/ excellent (Lysholm). Only one patient achieved the pre-lesion Tegner activity level.  The duration of lesion influenced postoperative clinical results negatively, especially regarding parameters such as physical functioning limitation of physical aspects, vitality and mental health (SF-36). Conclusion: the bicruciate knee ligament two-stage reconstruction improved the knee stability and subjective evaluation, but, 96% of patients did not recover the pre-injury status of physical activity. Moreover, the time of injury had an inverse statistical correlation with the subjective evaluation of physical functioning, limitation of physical aspects, vitality and mental health in the S-36 score.Introdução: A lesão ligamentar bicruciada do joelho não possui um protocolo cirúrgico bem estabelecido na literatura. Objetivo: Correlacionar os dados clínicos e os achados intra-operatórios com os dados da avaliação pós-operatória da escala de Lysholm, escore de atividade de Tegner e questionário SF-36 após reconstrução do ligamento bicruzado do joelho em dois estágios. Materiais e Métodos: Foram avaliados 25 pacientes (20 homens e 05 mulheres), idade média 32,3 anos (17 - 53 anos), IMC médio 26,2 (18,9 -34,9), duração média da lesão 18,3 meses (lesão crônica). A técnica INLAY foi aplicada na reconstrução do LCP utilizando o 1/3 central do tendão patelar. Após o intervalo mínimo de 3 meses, a reconstrução do LCA foi realizada artroscopicamente com isquiotibiais. Um procedimento cirúrgico adicional foi necessário para 04 pacientes (tendão patelar -02 casos, casos MCL-02). Resultados: Com seguimento médio de 24,8 meses, em 60% dos casos, o teste da gaveta posterior foi avaliado como zero ou + (0,5 cm), enquanto 40% como + + (1cm) e 60% dos pacientes avaliaram bom estado / excelente (Lysholm). Apenas um paciente atingiu o nível de atividade de Tegner pré-lesão. O tempo de lesão influenciou negativamente os resultados clínicos pós-operatórios, principalmente em relação a parâmetros como limitação do funcionamento físico dos aspectos físicos, vitalidade e saúde mental (SF-36). Conclusão: a reconstrução do ligamento bicruzado do joelho em dois estágios melhorou a estabilidade do joelho e a avaliação subjetiva, mas 96% dos pacientes não recuperaram o estado pré-lesão da atividade física. Além disso, o tempo da lesão apresentou correlação estatística inversa com a avaliação subjetiva da capacidade funcional, limitação dos aspectos físicos, vitalidade e saúde mental no escore S-36

Estudo da perda da tensao do enxerto de tendão calcâneo bovino

A lesão do ligamento cruzado anterior do joelho (LCA) é um problema que afeta tanto os animais como os seres humanos, e pode evoluir com instabilidade articular, muitas vezes, sintomática e incapacitante para o paciente. Os enxertos de tendões autólogos são a principal opção como substitutos ligamentares. Durante a reconstrução cirúrgica do LCA, o enxerto é submetido a tensionamento com o objetivo de restabelecer a lassidão normal do joelho LCA-deficiente. Embora o tensionamento do enxerto exerça papel fundamental na evolução clínica pós-operatória, a literatura ainda não estabeleceu os níveis ideais de tensionamento a serem aplicados. Assim, o estiramento ou elongamento do enxerto que pode ocorrer com o passar do tempo permanece como uma das principais causas da falha da reconstrução ligamentar.Neste trabalho, dez tendões de calcâneo bovino foram submetidos a dois ensaios sucessivos de tensionamento fisiológico a deformação relativa máxima de 2.5% do comprimento inicial do tendão ensaiado, mantida durante 600s, sendo registrados os valores de força (N) no tempo zero (inicial), 300s e 600s. Ao término do primeiro ensaio, o tendão retornava ao seu comprimento inicial, sendo mantido em repouso durante 300s, seguido de novo ensaio de tensionamento repetindo-se os mesmos procedimentos anteriores. A análise estatística permitiu concluir que o elongamento do tendão é mais pronunciado nos 300s iniciais, refletindo uma queda mais acentuada nos valores da tensão do enxerto. Portanto, 300s após o tensionamento e fixação do enxerto, o cirurgião pode avaliar mais adequadamente se o nível de tensionamento foi suficiente.Lesion of the anterior cruciate ligament (ACL) in the knee is a problem that affects animals as well as humans and may evolve with joint instability that is often symptomatic and incapacitating. The main option for ligament substitution is the autologous tendon graft. The graft undergoes tensioning during ACL reconstructive surgery to reestablish the normal laxity of the ACL- deficient knee. Although graft tensioning plays a fundamental role in postoperative clinical evolution, ideal tensioning levels have not been established in the literature. Therefore, graft elongation that may occur over time is still one of the main reasons for ligament reconstruction failure. In this study, ten bovine calcaneus tendons underwent two successive assays of physiological tensioning for a maximum deformation of 2.5% of the initial tendon length, maintained for 600s with force (N) values recorded at zero time (initial), 300s and 600s. At the end of the first assay, the tendon returned to its initial length and was maintained at rest for 300s and then the next tensioning assay was initiated, repeating the previous procedure. Statistical analysis revealed that tendon elongation is more pronounced during the initial 300s, reflecting a more accentuated decline in the tension values of the graft. Therefore, 300s after tensioning and fixing the graft, the surgeon can assess with more precision if the tensioning level was adequate

Estudo da perda da tensao do enxerto de tendão calcâneo bovino

Lesion of the anterior cruciate ligament (ACL) in the knee is a problem that affects animals as well as humans and may evolve with joint instability that is often symptomatic and incapacitating. The main option for ligament substitution is the autologous tendon graft. The graft undergoes tensioning during ACL reconstructive surgery to reestablish the normal laxity of the ACL- deficient knee. Although graft tensioning plays a fundamental role in postoperative clinical evolution, ideal tensioning levels have not been established in the literature. Therefore, graft elongation that may occur over time is still one of the main reasons for ligament reconstruction failure. In this study, ten bovine calcaneus tendons underwent two successive assays of physiological tensioning for a maximum deformation of 2.5% of the initial tendon length, maintained for 600s with force (N) values recorded at zero time (initial), 300s and 600s. At the end of the first assay, the tendon returned to its initial length and was maintained at rest for 300s and then the next tensioning assay was initiated, repeating the previous procedure. Statistical analysis revealed that tendon elongation is more pronounced during the initial 300s, reflecting a more accentuated decline in the tension values of the graft. Therefore, 300s after tensioning and fixing the graft, the surgeon can assess with more precision if the tensioning level was adequate

Tibial tubercle osteotomy in primary total knee arthroplasty: A safe procedure or not?

The objective of this study was to investigate the influence of tibial tubercle osteotomy on postoperative outcome, intra- and postoperative complications, as well as postoperative clinical results and failures in primary total knee arthroplasty (TKA). In a continuous, consecutive series of 1474 primary TKA, we analysed 126 cases where a tibial tubercle osteotomy approach was performed and 1348 cases without tibial tubercle osteotomy. Before surgery, all patients underwent a systematic assessment that included a clinical examination, radiographs (stress hip–knee– ankle film [pangonogram], weight bearing, anteroposterior knee view, schuss view, profile and patellar axial view at 30°, stress valgus and varus view) and International Knee Society scores. When analysing intraoperative complications, tibial plateau fissures or fractures and tibial tubercle fracture were considered as complications relating to the tibial tubercle osteotomy group (pb0.001, p=0.007). With a 2-year minimum follow-up, there was no statistical difference in the number of revisions carried out in the two study groups (p=0.084). However, postoperative tibial tubercle fracture and skin necrosis were significantly related to the osteotomy (p=0.001 and p≤0.001, respectively). Tibial tubercle osteotomy cannot be considered an entirely safe procedure in primary TKA as it is associated with local complications, particularly skin necrosis and fracture of the tibial tubercle. Therefore, tibial tubercle osteotomy should be performed only when necessary, i.e. in cases where there are difficulties gaining adequate surgical exposure, ligament balance and correct implant positioning. The procedure also demands considerable surgical experience to achieve a good outcome

Static tensioning promotes hamstring tendons force relaxation more reliably than cycling tensioning

Graft elongation might be a major reason for increased anterior laxity after anterior cruciate ligament (ACL) reconstruction. This study analyzed the force relaxation values and their stabilization when single strands of the gracilis and semitendinosus tendons underwent cyclic and static tensioning at 2.5% strain level, and compared the efficiency of static and cyclic tensioning in promoting force relaxation. Methods: Eighteen gracilis tendons and 18 semitendinosus tendons from nine male cadavers (mean age: 22.44 years) were subjected to 10 in vitro cyclic loads at 2.5% strain level, or to a static load at 2.5% strain level. Results: During cyclic loading, the reduction in force values tended to stabilize after the sixth cyclic load, while, in the case of static loading, this stabilization occurred by the second minute. Comparing static and cyclic loading, the gracilis tendon had similar mechanical responses in both conditions, while the semitendinosus tendon showed greater force relaxation in static compared with cyclic loading. Conclusions: Considering that the semitendinosus tendon is the main component of the hamstring graft, its biomechanical response to loading should guide the tensioning protocol. Therefore, static tensioning seems more effective for promoting force relaxation of the semitendinosus tendon than cyclic tensioning. The gracilis tendon showed a similar mechanical response to either tensioning protocols.24477578