Total knee arthroplasty with or without ischemia: the optimal tourniquet use in a comparative, prospective, randomized study

O torniquete (TNQ) pode ser utilizado na artroplastia total do joelho (ATJ) para reduzir o sangramento intraoperatório e proporcionar um campo cirúrgico mais limpo e confortável para o cirurgião. No entanto, seu uso pode estar relacionado ao aumento do sangramento pós-operatório, a uma recuperação funcional pós-operatória prejudicada, além de complicações locais e sistêmicas. Acreditamos que o uso do TNQ de modo otimizado em relação ao tempo de uso e pressão de insuflação poderia minimizar os seus potenciais efeitos adversos. Este estudo teve como objetivo comparar pacientes submetidos a ATJ sem TNQ e com protocolo de uso do TNQ de modo otimizado. Avaliamos prospectivamente 128 pacientes com osteoartrite primária submetidos à ATJ, randomizados em dois grupos: \"sem TNQ\" e \"TNQ otimizado\" (insuflação do TNQ imediatamente antes da incisão na pele e desinsuflação imediatamente após a secagem do cimento que fixa a prótese ao osso, usando pressões apenas 100mmHg acima da pressão arterial sistólica). O tempo médio de duração de cirurgia e de uso do TNQ, perda sanguínea, número de transfusões, elevação do marcador de lesão muscular creatinofosfoquinase (CPK), grau de dor, edema, amplitude de movimento (ADM), escore funcional Knee Society Score (KSS), capacidade de elevação do membro em contração isométrica - straight leg raise (SLR), picos de força de extensão e flexão (subgrupo com 60 pacientes) e complicações pós-operatórias foram comparados. As análises foram realizadas no programa GraphPad Prism (versão 5) e a significância estatística foi considerada quando o valor de p foi menor que 0,05. As diferenças nas variáveis contínuas entre os grupos foram avaliadas pelo teste t de Student ou teste U de Mann-Whitney, dependendo da distribuição característica dos dados. O teste do qui-quadrado ou teste exato de Fisher para diferença em porcentagens foi utilizado para estimar as diferenças entre os grupos nas variáveis categóricas. Quanto as distribuições dos dados de força muscular, foram testadas através do teste de normalidade multivariado de Henze-Zirkler. Tanto o pico de torque de extensão e flexão dos joelhos foram considerados não normais (p<0,05). Para a comparação dos valores de pico de torque entre os momentos (separadamente por membro - operado e contralateral) foi utilizado o teste não-paramétrico Anova de Friedman. Quando necessário o teste de Wilcoxon foi usado como post-hoc para comparação par a par. Por fim, comparações entre os grupos foi realizada par-a-par através do teste de Mann-Whitney. Utilizamos o pacote Pingouin versão 0.5.1. As cirurgias realizadas com TNQ otimizado não apresentaram diferença estatisticamente significativa em relação ao tempo cirúrgico, níveis de perda sanguínea, elevação do CPK, dor, edema, ADM, escore funcional, picos de força, capacidade de realizar o SLR e complicações em relação às cirurgias sem uso de TNQ (p<0,05). Concluímos que os pacientes submetidos à ATJ sob o protocolo TNQ otimizado apresentaram perda sanguínea semelhante e não apresentaram nenhum grau de comprometimento funcional ou complicações em relação à cirurgia sem TNQ.The tourniquet (TNQ) can be used in total knee arthroplasty (TKA) to reduce intraoperative bleeding and provide a cleaner and more comfortable surgical field for the surgeon. However, its use may be related to increased postoperative bleeding, and impaired postoperative functional recovery, in addition to local and systemic complications. We believe that using the TNQ in an optimized way in terms of the time of use and insufflation pressure could minimize its potential adverse effects. This study aimed to compare patients undergoing TKA without TNQ and with an optimized TNQ protocol. We prospectively evaluated 128 patients with primary osteoarthritis undergoing TKA, randomized into two groups: \"without TNQ\" and \"optimized TNQ\" (inflation of the TNQ immediately before the skin incision and deflation immediately after drying of the cement that fixes the prosthesis to the bone, using pressures only 100mmHg above systolic blood pressure). Mean duration of surgery and TNQ use, blood loss, number of transfusions, the elevation of the creatine phosphokinase (CPK) marker of muscle injury, degree of pain, swelling, range of motion (ROM), Knee Society Score functional score (KSS), ability to lift the limb in isometric contraction - straight leg raise (SLR), peak extension and flexion strength (subgroup with 60 patients) and postoperative complications were compared. Analyzes were performed using the GraphPad Prism program (version 5) and statistical significance was considered when the p-value was less than 0.05. Differences in continuous variables between groups were evaluated using Student\'s t-test or Mann-Whitney U test, depending on the characteristic distribution of the data. The chi-square test or Fisher\'s exact test for difference in percentages was used to estimate differences between groups in categorical variables. As for the distributions of muscle strength data, they were tested using the Henze-Zirkler multivariate normality test. Both knee extension and flexion peak torque were considered non-normal (p<0.05). To compare the peak torque values between the moments (separately by limb-operated and contralateral) the Friedman Anova non-parametric test was used. When necessary, the Wilcoxon test was used as a post-hoc pairwise comparison. Finally, comparisons between groups were performed using the Mann-Whitney test. We use the Pingouin package version 0.5.1. Surgeries performed with optimized TNQ showed no statistically significant difference in terms of surgical time, blood loss levels, CPK elevation, pain, edema, ROM, functional score, ability to perform SLR, force peaks and complications in relation to surgeries without using TNQ (p<0.05). We conclude that patients undergoing TKA under the optimized TNQ protocol had similar blood loss and did not experience any degree of functional impairment or complications compared to surgery without TNQ

Insatisfação e complicações pós-cirúrgicas caracterizam erro médico?

Nota-se atualmente um crescente número de processos judiciais a médicos, com base em uma suposta quebra de contrato ao direito do consumidor, onde se exige do profissional médico resultados, enquanto este, pelo código de ética médica e bom senso, tem obrigação de meios. O objetivo deste estudo foi discutir os resultados, satisfação e complicações de três das principais cirurgias ortopédicas à nível do joelho (área de atuação dos autores) com o fim de estabelecer diferenças entre erro e insucesso, próprio do ato médico. Concluímos que a imperfeição faz parte da natureza humana e que, por diversos motivos, as cirurgias ortopédicas complicam, falham e pacientes ficam insatisfeitos, independente do grau de recursos que o profissional disponha, o que não caracteriza erro médico.There is currently a growing number of lawsuits against physicians, based on an alleged breach of contract to consumer law, where results are required from the medical professional, while the latter, according to the code of medical ethics and common sense, has an obligation of means. The aim of this study was to discuss the results, satisfaction and complications of three of the main orthopedic surgeries at the level of the knee (the authors' field of work) in order to establish differences between error and failure, which are characteristic of the medical act. We conclude that imperfection is part of human nature and that, for various reasons, orthopedic surgeries complicate, fail and patients are dissatisfied, regardless of the degree of resources available to the professional, which does not characterize medical error

Evaluation of multiple doses of tranexamic acid on blood loss in total knee arthroplasty

Objective: To evaluate the efficacy of multiple doses of tranexamic acid (TXA) in blood loss in patients undergoing total knee arthroplasty (TKA). Methods: Seven patients of both genders over 50 years old undergoingTKA, who received 15 mg/kg intravenous (IV) TXA 30 minutes before the surgical incision and another 3 doses thereafter were included in this report. Blood loss analysis included blood loss at the drain, hemoglobin loss, and estimated blood loss. Statistical analysis was performed. Results: There was a significant hemoglobin drop after 48 hours, compared to preoperative. Mean blood loss assessed by drain was 20.0 ± 25.17 mL after 24 h. Estimated blood loss was higher after 48 hours compared to 24 hours. No complications were reported in this sample, and no patient received transfusions. Conclusion: The use of TXA in multiple doses did not prevent the drop in postoperative hemoglobin levels and did not correlate with increased complications

Modified Lemaire Lateral Tenodesis Associated With an Intra-articular Reconstruction Technique With Bone-Tendon-Bone Graft Using an Adjustable Fixation Mechanism

The goal of this study was to report a surgical technique used in a revision anterior cruciate ligament (ACL) reconstruction case, consisting of an adaptation of the anterolateral iliotibial band tenodesis technique (modified Lemaire technique) combined with ACL reconstruction using an adjustable fixation mechanism. Rotational overload was one of the most likely hypotheses for failure of primary surgery, despite correct positioning and secure fixation. We performed a review of the most pertinent factors related to ACL reconstruction failure, as well as surgical strategies for its treatment. After this, we described, step by step, a combination of the 2 forms of surgical intervention that were already presented isolated with good clinical results, correcting the common anterior and rotational instabilities found in these cases. Knowing new techniques for intra- and extra-articular ligament reconstruction is imperative in the present day, when more patients are seeking a full return to their preinjury recreational, labor, and sports activities. We believe that the combination of these surgical techniques is able to achieve these goals effectively and reproducibly

Vertical Continuous Meniscal Suture Technique

Meniscal injuries are common in the population, representing the major cause of functional impairment in the knee. Vertical longitudinal injuries of the meniscus can be stable or unstable. When extensive, they are commonly unstable and can lead to clinical signs of significant functional disability. Vertical longitudinal injuries have the best prognosis for repair, especially when occurring in the meniscal periphery, called the red-red zone. A recently developed type of meniscal suture device called Meniscus 4 A-II enables the surgeon to perform a meniscal suture from the inside-out continuously, reducing surgical time. Because it allows the surgeon to use a single and inexpensive device to repair the entire injury, costs are significantly reduced. Here, an approach to carry out continuous meniscal repair with vertical sutures is described. This technique warrants excellent stability to the meniscal repair, increasing the chances of a successful outcome. We believe that the popularization of the repair technique from the inside out using the Meniscus 4-All device will help many surgeons around the world save menisci that otherwise would have a great chance of being excised, since it is a cheap, reproducible, and easy-to-handle device

Posterior Meniscal Root Repair Using a Meniscal Suture Device

A greater understanding of the deleterious consequences that a meniscal root tear brings to the knee joint and how its surgical repair can be advantageous over the previously used treatment strategies brings the need for the development of surgical techniques that make the procedure less complex and more reproducible. When meniscal root rupture occurs, a mechanical overload occurs in the affected compartment similar to a total meniscectomy. Several authors have concluded that meniscal root reinsertion significantly improves postoperative outcomes and patient satisfaction, regardless of age or laterality of the meniscal injury. The Meniscus 4 A-II device (Rio de Janeiro, Brazil) allows stitching at the root of the medial and lateral menisci. In this article, we describe the surgical repair technique for posterior-medial and -lateral meniscal root tears using this meniscal suture device. This technique is fast and effective

Stress Radiography for Multiligament Knee Injuries: A Standardized, Step-by-Step Technique

Physical examination in the presence of a multiligament knee injury can be complex and challenging. Hence, stress radiography is a useful and inexpensive tool that is widely used in the assessment of this type of injury. It guarantees an objective analysis of the magnitude of knee instability, which may reduce the observer's interpretation bias in relation to the physical examination. However, for the radiographic analysis to be reproducible, it is necessary to standardize the technique to evaluate each of the main knee ligaments. This article aims to describe in detail how to perform stress radiography to assess the sufficiency of the posterior cruciate ligament and collateral ligaments in the context of a multiligament injury

Outside-in Continuous Meniscal Suture Technique of the Knee

The meniscus is largely responsible for the health and longevity of the knee. It has diverse functions, being fundamental in load absorption and distribution and even in joint stability. To preserve meniscal functions and prevent the occurrence of osteoarthritis after meniscectomy, several meniscal repair techniques have been developed. To perform meniscal repair in anterior horn, the outside-in technique is the most used. There are few devices for performing them, with most of the surgical techniques described using needles. Our group uses a device capable of performing meniscal repair in different ways. Our objective is to describe a continuous outside-in meniscal repair technique, especially indicated for anterior horn and meniscus body tears, with the “Meniscus 4-All suture device.” The continuous outside-in meniscal suture technique using this device is easy to perform, inexpensive, fast, and reproducible, minimizing the risk of soft-tissue entrapment. In addition, it allows the surgeon to perform meniscal repair in the posterior horn in extensive injuries with the same repair device, just switching to inside-out technique

Continuous Meniscal Suture Technique of the Knee

The menisci are fibroelastic structures interposed between the articular surfaces of the femur and tibia. They absorb impact and transmit load. Meniscal injury may compromise function and cause rapid joint degeneration, leading to the development of secondary osteoarthritis. Surgical treatment of meniscal injury is usually performed by arthroscopy, and meniscectomy or meniscal suture may be associated with such treatment. Meniscal suture should be considered when the injury compromises the proper functioning of the meniscus to recover its anatomy and function. Different meniscal suture techniques exist; the most widely used are the inside-out, outside-in, and all-inside techniques. The gold-standard repair technique is the inside-out technique. A drawback of this technique is the need to alternate between intra- and extra-articular structures for every stitch, which makes it even more laborious. We describe the continuous meniscal suture technique, also called “meniscal stitching,” for a medial meniscal bucket-handle injury. This technique is performed from the inside out and allows the surgeon to perform multiple stitches with the same thread quickly and effectively. This surgical technique is performed using a single meniscal suture device that was developed by our group, called the “Meniscus 4 A-II” device

Posterior Root Repair of Medial Meniscus Combined With Valgus Opening Wedge Tibial Osteotomy

The medial meniscal root tear, a particular meniscal injury at the level of its posterior bone insertion, leads to a loss of impact absorption and load distribution capacity, similar to total meniscectomy. Therefore, its repair is fundamental for knee joint longevity. This type of injury often occurs in middle-aged patients with lower limbs varus malalignment, which results in mechanical overloading of the medial compartment and induces premature cartilage wear out. The success of meniscal root repair, with meniscal bone reinsertion, depends on the correction and realignment of varus deformities greater than 5° for physiological levels. In this situation, corrective tibial osteotomy combined with meniscal repair is indicated. Our goal is to describe the step-by-step technique of the valgus opening wedge tibial osteotomy combined with the arthroscopic reinsertion of the posterior meniscal root in tibia during the treatment of a patient with varus deformity and medial meniscus root tear