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Focal articular cartilage defects are an important factor that leads to dysfunction of the knee joint. Several different surgical approaches have been tried, most of them showing poor results in the long term. The use of orthobiologics in the context of focal chondral lesion has emerged as a potential tool in the treatment of this condition. In this article, we present a surgical technique for the treatment of focal chondral lesions using a collagen membrane associated with microfragmented adipose tissue graft.

Abstract Objective To evaluate the incidence of symptomatic cyclops lesions requiring surgical treatment after anterior cruciate ligament (ACL) reconstruction and to establish possible intraoperative risk factors related to it. Methods Three hundred and eighty-nine patients aged between 18 and 50 years who underwent primary ACL reconstruction were retrospectively evaluated. Patients were divided into groups according to the presence or absence of symptomatic cyclops lesions, and their characteristics were compared. Patients with associated lesions that required additional surgical procedures (except anterolateral extra-articular procedures) were not included. The rate of symptomatic cyclops lesions was recorded and the following parameters were evaluated: age, gender, time from injury to surgery, graft type and diameter, femoral tunnel perforation technique, fixation type, presence of knee hyperextension, preservation of the ACL remnant, associated anterolateral extra-articular procedure, associated meniscal injury and participation in sports. Results 389 patients were evaluated and 26 (6.7%) patients developed cyclops. The patients with and without cyclops lesions did not differ in age, time from injury to surgery, graft type or diameter, surgical technique, femoral fixation method, presence of knee hyperextension, remnant preservation and associated meniscal injury. The group with cyclops lesion had a higher proportion of females (10 (38.4%) vs 68 (18.7%); OR = 2.7; p= 0.015), higher proportion of extra-articular reconstruction (18 (11.8%) vs 8 (3.4%); OR = 3.8; p= 0.001) and higher proportion of sports practice (23 (8.6%) vs 3 (2.5%); OR = 3.6; p= 0.026). Conclusion In our series, 6.7% of the patients required arthroscopic removal of cyclops lesions. Female gender, associated extra-articular reconstruction and sports practice were factors related to this lesion. Remnant preservation had no relationship with cyclops lesion formation.

The peroneus longus tendon seems a viable graft option for knee ligament reconstructions, with adequate biomechanical properties and low morbidity after harvesting. The objective of this article is to describe a combined anterior cruciate ligament and anterolateral ligament reconstruction technique using a single peroneus longus tendon graft harvested from the infra malleolar region to ensure sufficient length.

Background: Lesions of the medial collateral ligament (MCL) are the most common knee ligament injuries and, when they occur in isolation, they often progress with satisfactory outcomes using conservative treatment. However, MCL lesions associated with anterior cruciate ligament or posterior cruciate ligament (PCL) injuries in knee dislocations should be reconstructed to prevent failure of the central pivot. In knees with combined injuries involving the PCL and the MCL, the confluence of tunnels in the medial femoral condyle can be a potential problem during reconstruction surgery. Indications: The indication of this technique is the combined injury of the PCL and the MCL. Technique Description: The technique consists in the reconstruction of the PCL and the MCL with an Achilles tendon allograft. The bone plug of the graft is fixed on the tibial bed with the inlay technique. The graft passes through a single femoral tunnel drilled in the medial femoral condyle, with entrance point on the footprint of the PCL on the inner wall of the condyle and exit on the origin of the native MCL, near to the medial epicondyle. The graft is fixed in the femoral tunnel with an interference screw and continues to the isometric point of the anatomic insertion of the MCL in the tibia, where an interference screw is used to fix it. Results: Results from our group using this technique have shown good clinical outcomes, with complications and failure rates similar to other series in the literature. Discussion/Conclusion: This technique is an excellent option for surgeons, when an Achilles tendon allograft is available, to avoid confluence of tunnels in the medial femoral condyle. It presents good results and acceptable complication rates, compatible with the severity of this lesion. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Background: Posterolateral knee injuries can occur in 16% of patients with acute ligament injuries, and up to 70% have a combined anterior cruciate ligament (ACL) tear. Studies have shown that, in different populations, the distance between the insertion of the popliteus tendon and the lateral collateral ligament (LCL) may be smaller than the 18.5 mm previously reported in the literature. When we have an associated injury of the ACL and the posterolateral corner (PLC), the confluence of tunnels in the lateral femoral condyle can be a potential problem during reconstruction surgery. Indications: The indication of this technique is the combined injury of the ACL and the PLC. Technique Description: The reconstruction is performed with 2 semitendinosus tendons and 1 gracilis tendon. The technique consists of making a tunnel in the lateral wall of the femur, from the outside-in, at the isometric point between the origin of the LCL and insertion of the popliteus tendon, and emerging in the inner wall of the lateral femoral condyle at the anatomic point of the ACL. The graft is passed from the tibia to the femur with the doubled gracilis tendon and the 2 simple semitendinosus tendons for the ACL graft. The remaining portions of the semitendinosus tendons are left for reconstruction of the PLC structures, with one of them going straight to the posterolateral tibial tunnel (reconstructing the popliteus tendon), and the other passing through the fibular head tunnel (reconstructing the LCL) and continuing from the fibular head to the posterolateral tibial tunnel (reconstructing the popliteofibular ligament). Results: Patients undergoing this technique achieved good functional outcomes and a failure rate similar to that reported in the literature for combined ACL and PLC reconstruction. Discussion/Conclusion: This technique is an excellent option for patients with the combined injury of the ACL and the PLC, avoiding the confluence of tunnels in the lateral femoral condyle. It presents good results and acceptable complication rates, compatible with the severity of this lesion. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Background: This is a case report of a 41-year-old man with torsional knee trauma in 2019 and chondral lesions. Previous microfracture had failed, and the patient presented with a dull pain and knee effusion. Imaging revealed multiple focal lesions including trochlea, patella, medial condyle, and lateral condyle. Fresh osteochondral allograft (OCA) transplantation is a versatile treatment for large defects as it is based on mature, living hyaline cartilage attached to a bone interface. A patient with multiple chondral lesions is rare, and this report presents a case with multiple symptomatic large focal lesions in the knee that underwent a fresh OCA in all 3 knee compartments. Indications: Osteochondral allograft is indicated for patients who present with activity-related pain and recurrent knee effusion. Contraindications are patient clinical conditions that may lead to complications, such as tobacco use, inflammatory arthritis, or septic arthritis. Technique Description: After the chondral defect is exposed, an appropriate allograft Mega-OATS sizer (15-30 mm) is chosen. Cartilage and the subchondral bone are drilled until the desired depth. The donor allograft is drilled in the desired diameter, and excess bone is removed according to the previous measurements of the recipient site. The graft is advanced with firm pressure into the created socket. Postoperative rehabilitation includes a limited range of motion and proprioceptive weightbearing in the first 2 weeks but expected total weightbearing and a full range of motion by the sixth week. Results: Range of motion was full by 6 weeks of surgery. The effusion lasted for 2 months after the surgery. Fresh OCA is a good surgical option for patients with multiple large chondral defects. Discussion/Conclusion: Patient satisfaction is high since the mature cartilage leads to a fast rehabilitation compared with the other surgical procedures for large chondral defects. This technique appears to be effective also for multiple focal lesions as presented in this article. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form.

Graphical Abstract This is a visual representation of the abstract.

ABSTRACT Objective: To analyse the distances between the femoral insertions of the popliteus tendon (PT) and the lateral collateral ligament (LCL) through dissections of cadaveric specimens in a mixed population. Methods: Fresh cadavers were dissected, and the anthropometric data of all specimens were recorded. The distances from the origin of the PT to the LCL in the femoral region and the diameter of each structure were measured using a digital calliper. Results: In total, 11 unpaired knees were dissected, eight men and three women, with an average age of 71.5 ± 15.2 years, weight of 57.2 ± 15.6 kg, and a mean height of 170.5 ± 8.2 cm. The distance from the center of the femoral footprint of the LCL to the PT was 10.0 ± 2.4 mm. The distances between the edges closest to each other and those more distant from each other were 3.1 ± 1.1 mm and 16.3 ± 2.4 mm, respectively. Conclusion: The distance between the midpoints of the PT and the LCL in our mixed population is smaller than the distances often reported in the literature. PLC reconstruction with separate tunnels for the LCL and PT may not be technically possible for individuals of any population. Level of Evidence III, Diagnostic studies.

ABSTRACT Imaging plays a key role in the preoperative diagnosis, surgical planning, and postsurgical assessment of the foot, ankle, and knee pathologies. Interpreting diagnostic imaging accurately is crucial for the clinical practice of orthopedic surgeons. Although among the most used imaging modalities, radiographic assessments are amenable to errors for various technical reasons and superposition of bones. Computed tomography (CT) is a conventional imaging procedure that provides high-resolution images, but fails in considering a truly weight-bearing (WB) condition. In an attempt to overcome this limitation, WB cone beam CT technology has being successfully employed in the clinical practice for the past decade. Besides economically viable and safe, the WB cone beam CT considers WB conditions and provides high-quality scans, thus allowing an equitable and correct interpretation. This review aims to address extensive description and discussion on WBCT, including imaging quality; costs; time consumption; and its applicability in common foot, ankle, and knee, conditions. With this technology increasing popularity, and considering the extensive literature on medical research, radiologists and orthopedic surgeons need to understand its potential applications and use it optimally. Level of Evidence III, Systematic review of level III studies.

ABSTRACT Objective: The synovial fold is an intra-articular structure found in more than 50% of the knees, which can cause symptoms similar to meniscal injuries. These symptoms are mostly related to hypertrophy of the synovial fold resulting from inadequate physical activity. Conservative treatment with readjustment of sports activity and muscle rebalancing solves most cases. Rare cases require surgical treatment, which is indicated due to the persistence of instability, blockage and pain. We present our experience in the treatment of this pathology. Methods: 58 patients (70 knees), with 62 knees treated conservatively and 8 treated surgically exclusively for the pathological synovial fold. Results: Description of the series and treatment results are reported. Conclusion: The non-surgical treatment of the pathological synovial fold of the knee provided good results within 60 days of rehabilitation program in almost 90% of the patients. Arthroscopic resection of the synovial fold is a surgery that has a longer and laborious rehabilitation period, despite good results in most cases. Level of Evidence IV, Case series.

Abstract Background Wound healing complications are causal factors of prosthesis infection and poor postoperative evolution of patients after total knee arthroplasty (TKA). Negative-pressure wound therapy (NPWT) can be an option to minimize these complications. The aim of this study is to compare the complications of patients undergoing TKA who used a portable NPWT device in the immediate postoperative period with those of a control group. Methods A total of 296 patients were evaluated. Patients were divided into two groups: those who used NPWT for seven days in the postoperative period (Group 1 – prospective evaluated) and those who used conventional dressings (Group 2 – historical control group). Epidemiological data, comorbidities, local parameters related to the surgical wound and complications were evaluated. Results The groups did not differ in regard to sex, age and clinical comorbidities. Overall, 153 (51.7%) patients had at least one risk factor for wound complications. Patients who used NPWT had a lower rate of complications (28.5% vs. 45.7%, p = 0.001) and a lower rate of reintervention in the operating room (2% vs. 8.5%, p = 0.001). Patients in group 1 had a lower incidence of hyperaemia (14.7% vs. 40.2%, p = 0.01), skin necrosis (2.1% vs. 8.5%, p = 0.04) and wound dehiscence (3.1% vs 10.1%, p = 0.03). The use of NPWT was a protective factor for the presence of complications, with an odds ratio of 0.36 (95% CI 0.206–0.629). Conclusion The number of complications related to the wound after TKA is high; however, most of them are minor and have no impact on the treatment and clinical evolution of patients. The use of NPWT decreased the number of surgical wound complications, especially hyperaemia, dehiscence and necrosis, and reduced the need for reintervention.

ABSTRACT Objective: To describe the first series of cases of autologous chondrocyte implantation (ACI) in collagen membrane performed in Brazil. Methods: ACI was performed in 12 knees of 11 patients, aged 32.1 ± 10.9 years, with 5.3 ± 2.6 cm2 full-thickness knee cartilage lesions, with a six-month minimum follow-up. Two surgical procedures were performed: arthroscopic cartilage biopsy for isolation and expansion of chondrocytes, which were seeded onto collagen membrane and implanted in the lesion site; the characterization of cultured cells and implant was performed using immunofluorescence for type II collagen (COL2) for cell viability and electron microscopy of the implant. Clinical safety, KOOS and IKDC scores and magnetic resonance imaging were evaluated. We used repeated-measures ANOVA and post-hoc comparisons at α = 5%. Results: COL2 was identified in the cellular cytoplasm, cell viability was higher than 95% and adequate distribution and cell adhesion were found in the membrane. The median follow-up was 10.9 months (7 to 19). We had two cases of arthrofibrosis, one of graft hypertrophy and one of superficial infection as complications, but none compromising clinical improvement. KOOS and IKDC ranged from 71.2 ± 11.44 and 50.72 ± 14.10, in preoperative period, to 85.0 ± 4.4 and 70.5 ± 8.0, at 6 months (p = 0.007 and 0.005). MRI showed regenerated tissue compatible with hyaline cartilage. Conclusion: ACI in collagen membrane was feasible and safe in a short-term follow-up, presenting regenerated formation visualized by magnetic resonance imaging and improved clinical function. Level of evidence IV, Case series.

ABSTRACT Objective: To evaluate the profile of blood loss and blood transfusions after the introduction of Tranexamic acid (TXA) in a tertiary university hospital in Brazil. Methods: 173 patients were retrospectively divided into two groups: the ones who received TXA and the control group. Hemoglobin levels (Hb), drain output, transfusion rates, and thromboembolic events were measured. Results: Among the patients included in this study, 82 cases received TXA. Blood transfusion occurred in 3 cases of the TXA group (3.7%), and in 27 control group cases (29.7%; p < 0.001). The average Hb decrease was 2.7 g/dl (± 1.39) and the median drain output was 270 mL in the TXA group. In the control group, the values were 3.41 g/dl (± 1.34; p < 0.001) and 460 mL (p < 0.001), respectively. Thromboembolic events occurred in 2 TXA group cases (2.4%) and in 3 control group cases (3.3%; p > 0.999). Conclusion: TXA was effective in reducing blood transfusion rates, Hb decrease, and drain output on the 1st postoperative day without increasing thromboembolic events. Level of evidence III, Retrospective comparative study.

ABSTRACT Objective: To retrospectively evaluate the results after applying a protocol for treating acute infections in cases of total knee arthroplasty and to establish factors predictive of success or failure. Methods: Thirty-two patients who were diagnosed with acute infection of the knee following total arthroplasty between 2004 and 2009 were retrospectively evaluated. Infections following arthroplasty were treated in accordance with the protocol for acute infections following arthroscopy recommended at our institution. Results: With application of a treatment protocol for acute infections following total knee arthroplasty, 26 patients (81.2%) had good results and 6 (18.8%) had unsatisfactory results. Statistical analysis showed that the variables correlated with a worse prognosis were age (p = 0.038) and number of surgical debridement procedures performed (p = 0.038). Conclusion: Our treatment routine was effective for infection. Prosthesis revision was performed in 2 cases when the initial surgical debridement failed to control the infection. Nível de Evidência IV, Série de casos.

Improved understanding and treatment of posterior medial and lateral meniscus root tears have attracted increasing interest. These lesions significantly compromise meniscal function, which can result in an outcome resembling total meniscectomy, and are also a potential cause of knee instability. Despite facilitating repair procedures and reducing the operative time for these lesions, all-inside meniscal repair devices are not available in all circumstances or registered for use in all countries worldwide. Furthermore, all-inside arthroscopic devices can be expensive. Therefore, low-cost alternatives for the treatment of these lesions must be identified. We present 2 efficient and safe techniques: an outside-in technique for repairing medial meniscus root tears and a technique using a simple needle inserted through the transtibial tunnel for lateral meniscal root repairs, neither of which requires the use of specific instruments, thus enabling appropriate treatment of posterior medial and lateral meniscus root tears.

ABSTRACT Objective: To compare the plateau-patella angle method to the methods already established for patellar height measurement in patients undergoing high tibial osteotomy. Methods: This is a retrospective study of 13 patients undergoing medial opening tibial osteotomy. The patellar height was measured in pre and post-operative radiographs by the methods from Insall-Salvati, Caton-Deschamps, Blackburne-Peel and patella-plateau angle, as well as the tibial slope and length of the patellar tendon. Measurements were performed by two knee surgeons at two different times. Results: The mean age was 41.33 ± 01.09 years old. The average rates of Caton-Deschamps, Blackburne-Peel, Insall-Salvati and plateau-patella angle were, respectively, 1.00; 0.89; 1.10; and 23.15° preoperatively, and 0.89; 0.78; 1.11; and 20.46°, postoperatively. The correlation of Caton-Deschamps, Blackburne-Pell, and Insall-Salvati indexes and plateau-patellar angle interobserver was 0.72 (p

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.

OBJECTIVE: To analyze occurrences of trochlear dysplasia in patients with Down syndrome in the presence and absence of femoropatellar instability.METHODS: Eleven knees with stable patellae and thirteen with unstable patellae in patients with Down syndrome were compared. Radiographs were produced to evaluate patellar height, trochlear angle and femoropatellar congruence angle.RESULTS: The prevalence ratio for a high patella between the unstable and the stable patients was 1.01 using the Insall-Salvati index and 0.68 using the Caton-Deschamps index. For an abnormal congruence angle, the prevalence ratio was 2.04. An increased congruence angle was only found in four cases, all presenting instability.CONCLUSIONS: Trochlear dysplasia was only found in cases of instability. The trochlear groove angle and the femoropatellar congruence angle correlated with the presence of patellar instability.

Background: Septic arthritis is an infrequent disease although very important due to the possibility of disastrous outcomes if treatment is not adequately established. Adequate information concerning the epidemiology of septic arthritis is still lacking due to the uncommon nature of the disease as well as the struggle to establish a correct case-definition. Objective: To epidemiologically characterize the population seen at Hospital das Clínicas, University of São Paulo with a diagnosis of septic arthritis between 2006 and 2011. Methods: Sixty-one patients diagnosed with septic arthritis of the knee between 2006 and 2011 were retrospectively evaluated. The patients’ clinical and epidemiological characteristics, the microorganisms that caused the infection and the patients’ treatment and evolution were analyzed. Results: Septic arthritis of the knee was more common among men, with distribution across a variety of age ranges. Most diagnoses were made through positive synovial fluid cultures. The most prevalent clinical comorbidities were systemic arterial hypertension and diabetes mellitus, and the most commonly reported joint disease was osteoarthritis. Staphylococcus aureus was the prevailing pathogen. Fever was present in 36% of the cases. All patients presented elevation in inflammatory tests. Gram staining was positive in only 50.8% of the synovial fluid samples analyzed. Six patients presented complications and unfavorable evolution of their condition. Conclusion: S. aureus is still the most common pathogen in acute knee infections in our environment. Gram staining, absence of fever and normal leukocyte count cannot be used to rule out septic arthritis. Keywords: Knee, Infection, Septic arthritis, Epidemiology

With the increase in total knee replacements in Brazil there is also an increase in the number of complications. The authors report a case in which 3 serious complications happened after a total knee replacement and the treatment was based on the literature, but individualized to the patient in some important points. The outcome was considered very good.

OBJETIVO: Avaliar os resultados obtidos com o uso de retalhos miocutâneos de rotação local nos casos de deiscência da ferida operatória após artroplastia total de joelho. MÉTODOS: Os pacientes submetidos a esse procedimentos cirúrgicos foram selecionados no período de 2000 a 2012. Os nove casos selecionados neste período foram submetido a retalhos de cobertura devido a deiscência de pele associada a infecção. Em oito casos utilizamos retalhos de rotação local do gastrocnêmio medial e um caso de avanço de pele. RESULTADOS: Em 89% destes casos houve sucesso quanto à cobertura da prótese e viabilidade dos retalhos. Em quatro casos foi possível manter ou revisar a prótese. Outros quatro casos evoluíram com necessidade de amputação por falha no tratamento infeccioso e um caso permaneceu sem a prótese. A avaliação funcional mostrou um resultado insatisfatório em 89% desses casos. CONCLUSÃO: Os retalhos de cobertura são uma boa opção para o tratamento dos casos de deiscência com exposição da prótese e que o insucesso funcional esteve associado à falha no controle do quadro infeccioso e aos danos causados por este. Nível de Evidência IV, Série de Casos.

OBJECTIVE: Describe the knee anterolateral ligament (ALL) and establish its anatomical marks of origin and insertion. METHODS: Dissection of the anterolateral aspect of the knee was performed in six cadavers. After isolation of the ALL, its lenght, width and thickness were measured as its places of origin and insertion. The ALL origin was documented in relation to the lateral collateral ligament (LCL) origin and the insertion was documented in relation to the Gerdy tubercle, fibullar head and lateral meniscus. After the first two dissections, the ligament was removed and sent to histologycal analysis. RESULTS: The ALL was clearly identified in all knees. Its origin in the lateral epycondile was on average 0.5 mm distal and 2.5 mm anterior to the LCL. In the tibia, two insertions were observed, one in the lateral meniscus and another in the proximal tibia, about 4.5 mm distal to the articular cartilage, between the Gerdy tubercle and the fibullar head. The average measures obtained were: 35.1 mm lenght, 6.8 mm width and 2.6 mm thickness. In the ligament histological analysis, dense connective tissue was observed. CONCLUSION: The ALL is a constant structure in the knee anterolateral region. Its origin is anterior and distal to the LCL origin. In the tibia, it has two insertions, one in the lateral meniscus and another in the proximal tibia between the Gerdy tubercle and the fibullar head.

OBJECTIVE: Profile analysis of articles from scientific journals is rare in our country. The aim of this study was to perform an analysis of publications of the Revista Brasileira de Ortopedia (RBO), to specify the designs of the studies and their level of evidence. METHODS: All articles published in RBO from January 2006 to December 2010 were classified according to the design of the study. The clinical studies were further stratified according to the level of evidence, in agreement with the norm of the journal. The studies classified as randomized and controlled clinical trials (RCTs) had their quality assessed by the system proposed by Jadad. RESULTS: In this period, there were 376 articles published in RBO. Clinical studies represented most of the papers, with 60.64% of the total. Case series represented 61.4% of the clinical studies. Thirteen RCTs were published, accounting for 3.46% of the total, and 5.7% of the clinical studies. The analysis of the quality of the RCTs showed that 5 (38.46%) were considered high quality, while 8 (61.54%) were of low quality. Among the studies in which the level of evidence does not apply (non-clinical), non-systematic reviews (46 articles) and basic research (40 articles) have prevailed, representing 12.23% and 10.64% respectively of the total. CONCLUSIONS: Case series were the most prevalent (37.23%) studies published in RBO between 2006 and 2010, while RCTs accounted for 3.46% of the articles. The majority of RCTs (61.54%) were considered low quality, and only 1.32% of the clinical studies were classified as level I evidence.

OBJETIVO: Mostrar nossa experiência com haste não-cimentadas press-fit e fixação metafisária com cimento em série selecionada de pacientes que realizaram revisão de artroplastia total do joelho. MÉTODOS: Trinta e quatro pacientes (35 joelhos) foram submetidos a revisão de artroplastia total do joelho usando técnica "press-fit". Seguimento mínimo foi de um ano (média de 2,2 anos) e máximo de três anos. RESULTADOS: Dos 34 pacientes, 20 foram mulheres e 14 foram homens. Houve um óbito por causa não relacionada a artroplastia e perda de seguimento de um paciente. Não houve nenhum caso em que fosse necessária nova revisão. Os pacientes que foram submetidos à revisão apresentaram melhora clínica e funcional demonstrado pelos resultados do KSS, resultados do questionário de qualidade de vida SF-36, através do ganho de amplitude de movimento e da melhora no alinhamento do membro. CONCLUSÃO: Houve melhora clínica e funcional no pós-operatório em relação ao pré-operatório na revisão de artroplastia total do Joelho com haste não cimentada "press-fit". Nível de Evidência IV, Série de casos.OBJECTIVE: To show our experience with press-fit cementless stem and metaphyseal fixation with cement in a selected series of patients who underwent revision total knee arthroplasty. METHODS: Thirty-four patients (35 knees) underwent revision total knee arthroplasty using the press-fit technique. Minimum follow-up was one year (mean 2.2 years) with a maximum length of three years. RESULTS: Of 34 patients, 20 were women and 14 were men. There was one death due to causes not related to arthroplasty and one patient dropout. There were no cases in which further review was necessary. Patients who underwent revision had clinical and functional improvement demonstrated by the results of the KSS, results of the SF-36 quality of life questionnaire, through gains in range of motion and improved limb alignment. CONCLUSION: There was postoperative clinical and functional improvement in comparison to the preoperative status in revision total knee arthroplasty with press-fit cementless stem. Level of Evidence IV, Case series.

OBJETIVO: Analisar a experiência com transplante homologo do mecanismo extensor nas artroplastias totais do joelho e comparar resultados com experiência internacional. MÉTODOS: Foram avaliados retrospectivamente três casos de transplante homologo do mecanismo extensor após artroplastia total do joelho que foram realizados em nosso serviço com apoio de um dos poucos bancos de tecidos brasileiros e tentamos estabelecer se nossa experiência foi similar à reportada na literatura internacional quanto a indicação do paciente, técnica utilizada e resultados. RESULTADOS: Dois casos evoluíram bem com o procedimento e um caso apresentou resultado insatisfatório evoluindo para amputação. Assim como mostra a literatura, tensão adequada do enxerto, fixação tibial apropriada e principalmente seleção precisa do paciente são os melhores preditores de bom resultado. CONCLUSÃO: O procedimento em questão tem indicação precisa, apesar de incomum, tanto pela raridade da problemática quanto pela baixa demanda de enxertos devido aos poucos bancos de tecidos no Brasil. Nível de Evidência IV, Série de Casos.

OBJETIVO: Analisar a experiência com transplante homologo do mecanismo extensor nas artroplastias totais do joelho e comparar resultados com experiência internacional. MÉTODOS: Foram avaliados retrospectivamente três casos de transplante homologo do mecanismo extensor após artroplastia total do joelho que foram realizados em nosso serviço com apoio de um dos poucos bancos de tecidos brasileiros e tentamos estabelecer se nossa experiência foi similar à reportada na literatura internacional quanto a indicação do paciente, técnica utilizada e resultados. RESULTADOS: Dois casos evoluíram bem com o procedimento e um caso apresentou resultado insatisfatório evoluindo para amputação. Assim como mostra a literatura, tensão adequada do enxerto, fixação tibial apropriada e principalmente seleção precisa do paciente são os melhores preditores de bom resultado. CONCLUSÃO: O procedimento em questão tem indicação precisa, apesar de incomum, tanto pela raridade da problemática quanto pela baixa demanda de enxertos devido aos poucos bancos de tecidos no Brasil. Nível de Evidência IV, Série de Casos.

Although the medial patellotibial ligament (MPTL) has been neglected regarding its function in patellar stability, recently, its importance in terminal extension and during flexion has been recognized. Indications for reconstruction of the medial patellofemoral ligament combined with the MPTL are extension subluxation, flexion instability, children with anatomic risk factors for patellar instability, and knee hyperextension associated with generalized laxity. We describe a combined reconstruction of the medial patellofemoral ligament with quadricipital tendon and reconstruction of the MPTL with patellar tendon autografts.

OBJETIVOS: Avaliar os resultados funcionais iniciais e o índice de complicações precoces das artroplastias totais do quadril cerâmica-cerâmica em pacientes que convivem com o HIV e apresentam osteonecrose da cabeça femoral. MÉTODO: Doze pacientes HIV+ com diagnóstico de osteonecrose da cabeça do fêmur incongruente foram avaliados através de critérios clínicos, laboratoriais, pela escala funcional WOMAC antes e após o tratamento com substituição articular. RESULTADOS: Observamos que 83,3% dos indivíduos faziam uso de inibidores de protease, 75% apresentavam dislipidemia e 66,6% síndrome lipodistrófica, a melhora na evolução no escore WOMAC foi estatisticamente significativa para seis e 12 meses de pós-operatório em comparação com o escore pré-operatório e não observamos complicações secundárias a esse procedimento. CONCLUSÃO: A artroplastia total do quadril com implante de cerâmica-cerâmica para o tratamento da necrose avascular do quadril nessa parcela da população é opção cirúrgica adequada, apresenta melhora funcional inicial significativa e baixo índice de complicação precoce.OBJECTIVES: To evaluate the initial functional results and early complication rate of ceramic-ceramic total hip replacements among patients living with HIV who presented osteonecrosis of the femoral head. METHOD: Twelve HIV-positive patients with a diagnosis of osteonecrosis of the incongruent femoral head were evaluated using clinical and laboratory criteria and the WOMAC functional scale before and after treatment with joint replacement. RESULTS: We observed that 83.3% of the subjects were taking protease inhibitors, 75% had dyslipidemia and 66.6% had lipodystrophy syndrome. The improvement over the evolution of the WOMAC score was statistically significant at six and twelve months after the operation, in comparison with the preoperative score. We did not observe complications secondary to this procedure. CONCLUSION: Total hip arthroplasty with a ceramic-ceramic implant for treating avascular necrosis of the hip is an appropriate surgical option for this portion of the population. It provides a significant initial functional improvement and a low early complication rate.

OBJETIVO: Apresentar um dispositivo biomecânico para o estudo da reconstrução do ligamento patelofemoral medial (LPFM) e sua isometricidade. MÉTODOS: Foi desenvolvido um sistema biomecânico acessível, que permite a aplicação de forças fisiológicas e não fisiológicas no joelho, através de um braço mecânico e aplicação de pesos e contrapesos, possibilitando a execução de diferentes estudos, além de ter um sistema de medidas bastante preciso de aferição de distâncias entre diferentes estruturas para análise dos experimentos. Este artigo descreve a montagem deste sistema, além de sugerir algumas aplicações práticas. Foram estudados seis joelhos de cadáveres. Os joelhos foram preparados em uma máquina de ensaios desenvolvida no Laboratório de Biomecânica do IOT HC FMUSP, que permitiu a avaliação dinâmica do comportamento patelar, quantificando a sua lateralização entre 0 e 120 graus. A diferença entre as distâncias encontradas, com e sem carga, aplicada na patela foram agrupadas segundo o ângulo de fixação do enxerto (0°, 30°, 60° e 90°) e situação do joelho (íntegro, reconstruído e lesado). RESULTADOS: Houve uma tendência em ocorrer menor desvio lateral em ângulos de fixação acima de 30 graus de flexão, principalmente entre os ângulos entre 45° e 60° graus de flexão, após a reconstrução. Para os demais ângulos não houve significância estatística. CONCLUSÃO: O método desenvolvido é uma ferramenta útil para os estudos da articulação patelofemoral, além de ter um sistema de medidas bastante preciso de aferição de distâncias entre diferentes estruturas e permitir a sua utilização em instituições com menos recursos disponíveis.OBJECTIVE: To present a biomechanical device for evaluating medial patellofemoral ligament (MPFL) reconstruction and its isometricity. METHODS: An accessible biomechanical method that allowed application of physiological and non-physiological forces to the knee using a mechanical arm and application of weights and counterweights was developed, so as to enable many different evaluations and have a very accurate measurement system for distances between different structures, for analysis on experiments. This article describes the assembly of this system, and suggests some practical applications. Six cadaver knees were studied. The knees were prepared in a testing machine developed at the Biomechanics Laboratory of IOT-HCFMUSP, which allowed dynamic evaluation of patellar behavior, with quantification of patellar lateralization between 0° and 120°. The differences between the distances found with and without load applied to the patella were grouped according to the graft fixation angle (0°, 30°, 60° or 90°) and knee position (intact, damaged or reconstructed). RESULTS: There was a tendency for smaller lateral displacement to occur at fixation angles greater than 30 degrees of flexion, especially between the angles of 45° and 60° degrees of flexion, after the reconstruction. For the other angles, there was no statistical significance. CONCLUSION: The method developed is a useful tool for studies on the patellofemoral joint and the MPFL, and has a very accurate measurement system for distances between different structures. It can be used in institutions with fewer resources available.

OBJETIVO: Correlacionar parâmetros dos implantes com incidência de dor. MÉTODOS: 32 joelhos (31 pacientes), operados entre 2006-2008 em uma série de casos de cirurgia de revisão de ATJ, foram acompanhados quanto ao surgimento de dor na ponta da haste. Em todos utilizou-se haste não cimentada Scorpio® TS Total Knee Revision System (Stryker®). Critérios analisados: presença de dor na perna ou coxa sem outras causas; diâmetro e comprimento da haste utilizada; posicionamento da haste no canal medular; e diâmetro do canal intramedular. RESULTADOS: A idade média foi de 66,7 anos e o seguimento médio foi de 2,6 anos. Dos pacientes, 21,87% referiram dores na perna, 9,37% na coxa. O grupo com dor na perna apresentou haste com diâmetro médio de 14,7mm; comprimento de 80mm em 71,42% e de 155mm em 28,58%, relação diâmetro da haste/diâmetro do canal intramedular média de 0,76, 42,8% apresentavam mau alinhamento. O grupo sem dor na perna apresentou haste com diâmetro de 15,2mm; comprimento de 80mm em 68% e de 155mm em 32%, relação dos diâmetros 0,80, 20,8% apresentavam mau alinhamento. O grupo com dor na coxa apresentou haste com diâmetro de 18,3mm; comprimento de 80mm em 66,67% e de 155mm em 33,33%, relação dos diâmetros 0,75, 0% apresentou mau alinhamento. O grupo sem dor na coxa apresentou haste femoral com diâmetro de 16,56mm; comprimento de 80mm em 70,37% e de 155mm em 29,63%, relação dos diâmetro de 0,79, 14,2% apresentavam mau alinhamento. CONCLUSÃO: Não houve associação entre os critérios avaliados e dor na região da ponta da haste.OBJECTIVE: To correlate parameters of implants with incidence of pain. METHODS: 32 knees (31 patients) operated on between 2006 to 2008 in a serie of cases of TKA revision surgery were monitored for evidence of pain at the tip of the stem.In all we used uncemented stem Scorpio TS Total Knee® Revision System (Stryker®). Criteria assessed: pain in the leg or thigh without other causes, diameter and length of the nail; position of the rod in the medullary canal, intramedullary canal diameter. RESULTS: Mean age was 66.7 years and mean follow-up was 2.6 years.21,87% of patients reported leg pain, 9.37% thigh pain. The group of pacients with leg pain presented with shaft diameter 14.7 mm, length 80 mm in 71.42% and 155 mm in 28,58%, stem diameter/ intramedullary canal diameter average relation of 0,76, 42.8% had stem malalignment. The group without leg pain presented with shaft diameter 15.2 mm, length 80 mm in 68% and 155 mm in 32%, diameters average relation of 0.80, 20.8% had stem malalignment. The group with thigh pain presented with shaft diameter 18.3 mm, length 80 mm in 66.67% and 155 mm in 33,33%,diameters average relation of 0.75, 0% had stem malalignment The group without thigh pain presented with shaft diameter 16.56 mm, length 80 mm in 70.37% and 155 mm in 29,63%, diameters average relation of 0.79, 14,2% had stem malalignment. CONCLUSION: There was no association between the assessed criteria and pain in the tip of the stem.

OBJETIVO: Comparar dois métodos de avaliação da estabilidade dos componentes tibial e femoral nas artroplastias de joelho não cimentadas com plataforma rotatória. MÉTODOS: Para isso foram avaliados 20 pacientes (20 joelhos) através de uma análise de radiografias dinâmicas com intensificador de imagem e manobras de estresse em varo e valgo, que foram comparadas com radiografias estáticas em frente e perfil dos joelhos, analisadas por dois cirurgiões experientes, cegos um em relação ao outro. RESULTADOS: Os resultados das análises estáticas e dinâmicas foram comparados e demonstraram forte correlação estatística (pObjetives: Determine the stability of tibial and femoral components of 20 cementless knee arthroplasties with rotating platform. METHODS: The 20 patients (20 knees) underwent an analysis of dynamic radiographs with an image amplifier and maneuvers of varus and valgus which were compared to static frontal and lateral radiographs of the knees and analyzed by two experienced surgeons in a double-blind way. RESULTS: We could observe in this study that both methods showed very similar results for the stability of the tibial and femoral components (p

OBJETIVO: Avaliar o valor da avaliação radiográfica pré-operatória nas revisões de artroplastias totais do joelho. MÉTODOS: Trinta e um joelhos operados no período de 2006 a 2008 em uma série consecutiva de casos de cirurgia de revisão de artroplastia total de joelho foram analisados retrospectivamente. CRITÉRIOS ANALISADOS: número de cunhas ou enxertos ósseos estruturados utilizados para preenchimento dos defeitos ósseos; localização das cunhas e enxertos ósseos utilizados e espessura média do polietileno utilizada. A classificação AORI era estabelecida previamente através de radiografias pré-operatórias segundo critérios preestabelecidos. Após a análise, os joelhos foram divididos em quatro grupos (I, IIA, IIB e III). RESULTADOS: O número médio de cunhas ou enxertos ósseos utilizados em cada joelho variou de maneira crescente entre os grupos (grupo I: 1,33; grupo IIA: 2; grupo IIB: 4,33; grupo III: 4,83) (P = 0,0012). As localizações mais comuns foram: medial na tíbia e posteromedial no fêmur. Não houve diferença estatisticamente significante na espessura do polietileno utilizado. CONCLUSÃO: A classificação AORI para defeitos ósseos no joelho baseada em radiografias pré-operatórias mostrou correlação crescente com a necessidade de utilização de cunhas e/ou enxertos estruturados na revisão de artroplastia total do joelho. Porém, até 46% dos joelhos dos grupos I e IIA apresentaram falhas ósseas de até 5mm não diagnosticadas através das radiografias pré-operatórias.OBJECTIVE: To evaluate the value of preoperative radiographic evaluations for total knee arthroplasty (TKA) revision. METHODS: Thirty-one knees that were operated between 2006 and 2008, in a consecutive series of cases of TKA revision surgery were analyzed retrospectively. THE FOLLOWING CRITERIA WERE EVALUATED: number of wedges or structured bone grafts used for filling the bone defects; locations of the wedges and bone grafts used; and mean thickness of the polyethylene used. The AORI classification was previously established based on preoperative radiographs, using preestablished criteria. After the analysis, the knees were divided into four groups (I, IIA, IIB and III). RESULTS: The mean number of wedges or grafts used in each knee progressively increased among the groups (group I: 1.33; group IIA: 2; group IIB: 4.33; and group III: 4.83) (P = 0.0012). The commonest locations were medial in the tibia and posteromedial in the femur. There were no statistically significant differences in the thickness of the polyethylene used. CONCLUSION: The AORI classification for bone defects in the knee, based on preoperative radiographs, showed a correlation with increasing need to use wedges and/or structured grafts in TKA revisions. However, up to 46% of the knees in groups I and IIA presented bone defects of up to 5 mm that were not diagnosed by means of preoperative radiographs.

OBJETIVO: Traduzir, adaptar culturalmente e validar o "Knee Society Score" (KSS) para a língua portuguesa e verificar suas propriedades de medida, reprodutibilidade e validade. MÉTODO: Avaliados 70 pacientes de ambos os sexos, em estudo clínico transversal, idade entre 55 e 85 anos, osteoartrose primária submetidos a artroplastia total de joelho, com o questionário KSS pelo avaliador 1 (inglês) e após 30 minutos pelo avaliador 2 (português) no pré- operatório e após três e seis meses de pós-operatório. RESULTADOS: O índice alfa de Cronbach e a diagramação de Bland-Altman não detectaram diferença entre as médias das duas avaliações no pré-operatório (p=1,000), com três meses (p=0,991) e seis meses de pós-operatório (p=0,985) na pontuação do joelho e na nota da função do joelho, p=1,000 nos três períodos. CONCLUSÃO: A versão brasileira do Knee Society Score, o Escore da Sociedade do Joelho, mostrou ser um instrumento de fácil compreensão e aplicação; válido e confiável para medir a pontuação e função do joelho de pacientes brasileiros submetidos a ATJ. Nível de Evidências: Estudos diagnósticos - Nivel de Evidência I, Teste de critérios diagnósticos desenvolvidos anteriormente em pacientes consecutivos (com padrão de referência "ouro" aplicado).OBJECTIVE: To translate, culturally adapt and validate the "Knee Society Score" (KSS) for the Portuguese language and determine its measurement properties, reproducibility and validity. METHOD: We analyzed 70 patients of both sexes, aged ages between 55 and 85 years, in a cross-sectional clinical trial, with diagnosis of primary osteoarthritis, undergoing total knee arthroplasty surgery. We assessed the patients with the English version of the KSS questionnaire and after 30 minutes with the Portuguese version of the KSS questionnaire, done by a different evaluator. All the patients were assessed preoperatively, and again at three, and six months postoperatively. RESULTS: There was no statistical difference, using Cronbach's alpha index and the Bland-Altman graphical analysis, for the knee score during the preoperative period (p = 1), and at three months (p = 0.991) and six months postoperatively (p = 0.985). There was no statistical difference for knee function score for all three periods (p = 1.0). CONCLUSION The Brazilian version of the Knee Society Score is easy to apply, as well providing as a valid and reliable instrument for measuring the knee score and function of Brazilian patients undergoing TKA. Level of Evidence: Level I - Diagnostic Studies- Investigating a Diagnostic Test - Testing of previously developed diagnostic criteria on consecutive patients (with universally applied 'gold' reference standard).

Os ensaios clínicos controlados e randomizados (ECCR) são considerados o padrão ouro da medicina baseada em evidências na atualidade, sendo importantes para direcionar a conduta médica através de observações científicas consistentes. Passos como seleção dos pacientes, randomização e cegamento são fundamentais na realização de um ECCR e apresentam algumas dificuldades extras nos ensaios que envolvem procedimentos cirúrgicos, como é comum na Ortopedia. O objetivo deste artigo é destacar e discutir algumas dificuldades e eventuais limitações dos ECCR na área cirúrgica.Randomized controlled clinical trials (RCTs) are considered to be the gold standard for evidence-based medicine nowadays, and are important for directing medical practice through consistent scientific observations. Steps such as patient selection, randomization and blinding are fundamental for conducting an RCT, but some additional difficulties are presented in trials that involve surgical procedures, as in common in orthopedics. The aim of this article was to highlight and discuss some difficulties and possible limitations on RCTs within the field of surgery.

OBJETIVO: Considerando a dificuldade para classificar os defeitos ósseos foi feito estudo para avaliar se a classificação de falha óssea da AORI baseada na radiografia pré-operatória é fidedigna e reprodutível entre diferentes médicos. MÉTODOS: Seis ortopedistas com subespecialização em cirurgia do joelho foram treinados para o uso da classificação radiográfica. Esses cirurgiões avaliaram e classificaram isoladamente as falhas ósseas de 26 radiografias de próteses de joelho pré revisão. RESULTADOS: Constatou-se que houve coincidência de >50% (correlação moderada) da classificação em 24 dos 26 casos no fêmur e em 22 dos 26 casos na tíbia; e correlação de >80% (boa correlação) em 12 dos 26 casos no fêmur e em sete dos 26 casos na tíbia. CONCLUSÃO: Em relação à concordância da classificação, observamos que a classificação AORI apresenta moderada correlação inter-observadores. Nível de evidência III, Estudo de pacientes não consecutivos; sem padrão de referencia "ouro" aplicado uniformemente.OBJECTIVE: Considering the difficulty for classifying bone losses the present study was designed to analyse if the AORI classification based on pre-operative radiographies is consistent and reproductible between different orthopaedic surgeons. METHODS: Six orthopedists specialized in knee surgery were trained for the use of the classification based on radiographic evaluation. All the surgeons individually classified 26 pre operative knee radiographs. RESULTS: There was a moderate (> 50%) matching of the classification in 24 of 26 cases in the femur and 22 of 26 in the tibia. A good matching (> 80%) was present in 12 of 26 cases in the femur and in 7 of 26 cases in the tibia. CONCLUSION: We observed that the AORI classification presented a moderate radiographic correlation between surgeons. Evidence of level III, Study of nonconsecutive patients; without consistently applied reference ''gold'' standard.

Esta revisão da literatura descreve o processo do transplante autólogo de condrócitos em todas as suas etapas, indicações clínicas, técnica operatória, técnica laboratorial, reabilitação e resultados clínicos. Desde 1994, quando a técnica de ACI foi descrita pela primeira vez, este procedimento foi aprimorado e tornou-se uma das mais importantes alternativas cirúrgicas para o tratamento das lesões condrais do joelho. Nivel de Evidência II, Prospectivo Comparativo.This literature review article describes the autologous chondrocyte implantation (ACI) process - its stages, clinical indications, surgical technique, laboratory protocol, rehabilitation and clinical outcomes. Since 1994, when the ACI was described for the first time, the procedure has improved to become one of the most important surgical alternatives for the treatment of chondral lesions of the knee.

A cartilagem hialina recobre as superfícies articulares e tem um papel importante na redução da fricção e da carga mecânica das articulações sinoviais, como o joelho. Este tecido não é suprido de vasos, nervos ou circulação linfática, o que pode ser uma das razões pela qual a cartilagem articular tem uma péssima capacidade de cicatrização. As lesões condrais, quando atingem o osso subcondral (lesão osteocondral), não cicatrizam e podem progredir para artrose com o passar do tempo. Em pacientes jovens, o tratamento dos defeitos condrais do joelho ainda é um desafio, principalmente as lesões maiores de 4cm. Uma das opções de tratamento nesses pacientes é o transplante autólogo de condrócitos, que por não violar o osso subcondral e por reparar o defeito com tecido semelhante à cartilagem hialina, teria a vantagem teórica de ser mais biológico e mecanicamente superior, quando comparado a outras técnicas. Descreveremos nesse artigo a experiência do Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Universidade de São Paulo (IOT-HCFMUSP) com o transplante autólogo de condrócitos (ACI), através do relato de três casos.Hyaline cartilage in the surface of synovial joints plays an important role in lowering stress and attrition in joints such as the knee. This tissue has no blood vessels, nerves, nor lymphatic drainage, which in part explains why articular cartilage has such poor capacity for healing. Chondral lesions reaching the subchondral bone (osteochondral lesions) do not heal and may progress to osteoarthritis as time passes. In young patients, treatment of such defects is challenging, especially in lesions larger than 4 cm. One option in young adults is the autologous chondrocyte implantation, capable of filling the defect with tissue similar to hyaline cartilage without violating the subchondral bone. Theoretically, it has biological and mechanical advantages over other surgical options. In this paper, we describe the experience with this procedure in a series of 3 cases at the Institute of Orthopedics and Traumatology, University of São Paulo.

O tratamento clínico da osteoartrite/artrose (OA) está sempre indicado e baseia-se no autocuidado feito pelo paciente e orientado pelo médico. O uso de medicamentos é complementar às medidas de emagrecimento, ganho de força, de propriocepção, de flexibilidade e de amplitude de movimento. Entre os medicamentos disponíveis para o tratamento da OA há os que são essencialmente analgésicos e que não interferem no curso da doença; bem como os anti-inflamatórios, controversos por seus efeitos colaterais e pelo seu papel na OA, porém, com propriedades analgésicas e anti-inflamatórias indiscutíveis; e, por fim, as drogas modificadoras de estrutura, que retardam a evolução da OA. As medicações ainda podem ser de uso tópico, intra-articular, oral e injetável (sistêmico). As várias apresentações de ácido hialurônico (AH) mostram o poder analgésico da droga e há indícios de poder modificador de estrutura da cartilagem pela medicação. Há nível de evidência IA, para diacereína e para a glucosamina, de que retardam a evolução da OA. Mais tecnologia para diagnóstico e controle de tratamento da OA, bem como mais estudos multicêntricos são necessários para consolidar o poder do tratamento medicamentoso de outras drogas.Clinical treatment for osteoarthritis (OA) is very important and is based on patient's self care and guided by the physician. Drug therapy is additional to losing weight, improving muscular strength, proprioception, flexibility and range of motion. Between the available drugs for osteoarthritis' treatment, some are basically analgesics and do not interfere on disease's progression; some are anti-inflammatory with good analgesic power but with side effects that compromise their prolonged usage; and the structure modifying drugs that slow down the progression of OA. The medications are presented in topic, oral, intra-muscular, intra-venous and intra-articular forms. The hyaluronic acid has various presentations with good analgesic effect and some evidence of structure modifying property. There is IA evidence level for the use of diacerhein and of glucosamine to slow down the disease. Still, more technology for diagnosis and therapy control of OA is necessary to define the efficacy of other drugs.

OBJETIVO: O cimento acrílico é utilizado há anos nas cirurgias ortopédicas, especialmente nas artroplastias do joelho, merecendo atenção também quando utilizado com o acréscimo de antibióticos (para tratamento de infecções) ou corantes (para facilitação de uma possível retirada). Neste estudo procurou-se avaliar diferenças mecânicas entre o cimento ortopédico puro e quando misturado com antibiótico e/ou corante. MÉTODOS: Foram utilizados cimento acrílico ortopédico Surgical Simplex®P Stryker, vancomicina em pó e azul de metileno e as misturas submetidas a testes físicos e mecânicos de acordo com a norma ABNT NBR ISO 5833. Avaliou-se: tempo para a formação de massa, capacidade de intrusão, resistência à compressão, resistência ao dobramento (tensão) e temperatura máxima atingida pelas misturas. RESULTADOS: As misturas avaliadas foram aprovadas quanto ao tempo de preparação da mistura, temperatura máxima alcançada, profundidade da intrusão e resistência à compressão. Somente aquela contendo apenas cimento puro foi aprovada no ensaio de flexão. CONCLUSÃO: O acréscimo de vancomicina e/ou azul de metileno ao cimento ortopédico Surgical Simplex®P Stryker reduz a resistência da mistura à flexão, sendo reprovada pela norma ABNT NBR ISO 5833.OBJECTIVE: Acrylic cement has been used for years on orthopaedic surgeries, especially on knee arthroplasties, deserving special attention when added to antibiotics (for treatment of deep bone infections) or stains (to facilitate its removal). The present study was conducted in order to evaluate potential mechanical differences between the orthopaedic cement itself and when this is added to antibiotic and/or stains. METHODS: Surgical bone cement Simplex®P Stryker, vancomycin and methylene blue were used, and the mixtures were submitted to physical and mechanical tests according the ABNT NBR ISO 5833 rule. The parameters studied here were: time for mass formation, intrusion capability, resistance to compression, resistance to flexion and maximum temperature reached by the mixtures. RESULTS: The evaluated mixtures were approved as to mass formation, maximum temperature, intrusion capability and resistance to compression. Only the one containing pure cement was approved on the flexion essay. CONCLUSION: The addition of vancomycin and/or methylene blue to Surgical Simplex®P Stryker bone cement reduces its resistance to flexion, being unacceptable by the ABNT NBR ISO 5833 rule.

Distal femoral varus osteotomy is a well-established procedure for the treatment of lateral compartment cartilage lesions and degenerative disease, correcting limb alignment and decreasing the progression of the pathology. Surgical techniques can be performed with a lateral opening-wedge or medial closing-wedge correction of the deformity. Fixation methods for lateral opening-wedge osteotomies are widely available, and there are various types of implants that can be used for fixation. However, there are currently only a few options of implants for fixation of a medial closing-wedge osteotomy on the market. This report describes a medial, supracondylar, V-shaped, closing-wedge distal femoral osteotomy using a locked anterolateral proximal tibial locking plate that fits anatomically to the medial side of the distal femur. This is a great option as a stable implant for a medial closing-wedge distal femoral osteotomy.

We present a new technique for the combined intra- and extra-articular reconstruction of the anterior cruciate ligament. Intra-articular reconstruction is performed in an outside-in manner according to the precepts of the anatomic femoral tunnel technique. Extra-articular reconstruction is performed with the gracilis tendon while respecting the anatomic parameters of the origin and insertion points and the path described for the knee anterolateral ligament.

OBJETIVO: Avaliar se a hemostasia com eletrocauterização em comparação ao uso do Floseal® durante artroplastias totais primárias de joelho, leva a diferentes taxas de sangramento peri-operatório. MÉTODOS: Foi realizado um estudo comparativo entre dois grupos: grupo de estudo com 10 casos de próteses primárias consecutivas com o uso do Floseal® como método hemostático, e grupo controle com 10 casos de próteses primárias consecutivas com uso de eletrocauterização como método hemostático. Foram avaliados parâmetros de sangramento como debito do dreno, infusão de líquidos, queda dos valores de hemoglobina e índice de transfusões sanguíneas. RESULTADOS: O grupo que fez uso de Floseal® apresentou em números absolutos menores valores de sangramento em relação ao grupo que fez hemostasia com eletrocautério tanto no débito do dreno pós-operatório quanto na infusão de líquidos e quantidade de transfusões sanguíneas. Nenhum parâmetro, porém, foi estatisticamente significativamente. CONCLUSÃO: A hemostasia com uso do Floseal® se mostrou semelhante à hemostasia com uso do eletrocautério, tornando-o uma alternativa aos pacientes que tenham contraindicação ao uso do bisturi elétrico. Nível de Evidência II, Estudo Prospectivo Comparativo.

OBJETIVO: Avaliar se a hemostasia com eletrocauterização em comparação ao uso do Floseal® durante artroplastias totais primárias de joelho, leva a diferentes taxas de sangramento peri-operatório. MÉTODOS: Foi realizado um estudo comparativo entre dois grupos: grupo de estudo com 10 casos de próteses primárias consecutivas com o uso do Floseal® como método hemostático, e grupo controle com 10 casos de próteses primárias consecutivas com uso de eletrocauterização como método hemostático. Foram avaliados parâmetros de sangramento como debito do dreno, infusão de líquidos, queda dos valores de hemoglobina e índice de transfusões sanguíneas. RESULTADOS: O grupo que fez uso de Floseal® apresentou em números absolutos menores valores de sangramento em relação ao grupo que fez hemostasia com eletrocautério tanto no débito do dreno pós-operatório quanto na infusão de líquidos e quantidade de transfusões sanguíneas. Nenhum parâmetro, porém, foi estatisticamente significativamente. CONCLUSÃO: A hemostasia com uso do Floseal® se mostrou semelhante à hemostasia com uso do eletrocautério, tornando-o uma alternativa aos pacientes que tenham contraindicação ao uso do bisturi elétrico. Nível de Evidência II, Estudo Prospectivo Comparativo.

OBJETIVO: Avaliar as taxas de publicação do Congresso Brasileiro de Ortopedia (CBOT) de 2007. MÉTODOS: Avaliação do número de trabalhos enviados pelas diferentes sub-especialidades ortopédicas e pelos estados brasileiros. Em seguida, realização de uma busca nas bases de dados Lilacs e Pubmed com o intuito de encontrar quais trabalhos geraram artigos publicados na literatura nacional e internacional. RESULTADOS: São Paulo e a região Sudeste foram os responsáveis pelo maior número de apresentações no Congresso (54,1% e 68,3% respectivamente). A sub-especialidade com maior número de trabalhos foi Ombro e Cotovelo (13,8%). Do total de 653 trabalhos no congresso, 174 (26,6%) foram publicados. Apresentações orais obtiveram uma taxa de publicação 3,58 vezes maior que pôsteres. CONCLUSÕES: A taxa de publicação do CBOT encontra-se abaixo dos 30%. Muitos dos trabalhos apresentados no CBOT não passam pelo crivo de revistas científicas e as apresentações deste congresso não devem ser a única forma de atualização científica dos congressistas. Epidemiológico Descritivo.

This case report describes a patient presenting with anterior knee pain (extensor mechanism pain), a poorly studied complaint in the HIV population. The final diagnosis was malignant fibrohistiocytoma, a rare condition among knee pathologies, successfully treated with endoprosthesis after tumor resection. This article focuses on what the authors learned after treating this patient, particularly on the difficulty in making a correct diagnosis of this group of patients due to lack of adequate epidemiological characterization. By assuming that the pathology was related to long-term infection and treatment of HIV (knee hoffitis), the authors underestimated the gravity of the case, almost compromising the result of treatment.

ABSTRACT OBJECTIVE: To evaluate the effect of complete absence of muscle contractions on normal human cartilage in the presence of joint motion. METHODS: Patients with complete acute spinal cord injuries were enrolled. All patients underwent magnetic resonance imaging (MRI) on both knees as soon as their medical condition was stable and at six months after the primary lesion. All patients received rehabilitation treatment that included lower-limb passive motion exercises twice a day. The MRIs were analyzed by two radiologists with expertise in musculoskeletal disorders. A region of interest was established at the patellar facets and trochlea, and T2 relaxation times were calculated. The area under the cartilage T2 relaxation time curve was calculated and standardized. RESULTS: Fourteen patients with complete spinal cord injuries were enrolled, but only eight patients agreed to participate in the study and signed the informed consent statement. Two patients could not undergo knee MRI due to their clinical conditions. Initial knee MRIs were performed on six patients. After six months, only two patients underwent the second bilateral knee MRI. Both patients were neurologically classified as Frankel A. An increase in T2 values on the six-month MRI was observed for both knees, especially in the patellofemoral joint. CONCLUSION: The absence of muscle contractions seems to be deleterious to normal human knee cartilage even in the presence of a normal range of motion. Further studies with a larger number of patients, despite their high logistical complexity, must be performed to confirm this hypothesis.

ABSTRACT Objective: To present the indications, technical aspects, and initial results of the first cases using Endo-Model™ implants in Brazil. Methods: A prospective study was conducted. It included nine patients submitted to a total knee arthroplasty, of which six were primary and three were revisions, using exclusively the Endo-Model™ implant. These patients were followed for an average of 12 months and evaluated with functional scores, such as the Knee injury and Osteoarthritis Outcome Score (KOOS), Knee Society Score (KSS), and visual analog pain scale (VAS). Results: There were statistically significant improvements in all scores evaluated in every patient. Only one complication occurred postoperatively (apraxia of the peroneal nerve) and did not require surgery revision. Conclusion: The use of a rotating-hinge implant for knee arthroplasty is a new option for complex cases with severe instability in Brazil; the initial results are satisfactory.

ABSTRACT Osteochondral fracture after acute patellar dislocation in teenagers is relatively common (up to 60% of cases of patellar dislocation), but poorly diagnosed. There are several treatments proposed for this type of injury, but none well defined in the literature.A male patient, 13 years old, with a diagnosis of osteochondral fracture of the lateral femoral condyle after acute dislocation of the right patella. He underwent surgical treatment of the chondral injury, which consisted of suturing of the chondral fragment to the cartilage defect and, in a second approach, reconstruction of the medial patellotibial ligament and medial patellofemoral ligament with autologous flexor graft. Currently, the patient has been followed up for 16 months postoperatively for the suture of the chondral fragment and for 8 months for the ligament reconstruction. He has been evaluated through functional scores and T2 weighted magnetic resonance imaging. Acute fixation through direct bone suturing of a purely chondral fragment can be considered in special situations.

ABSTRACT OBJECTIVE: Translation, cultural adaptation, and validation of the new version of the Knee Society Score - The 2011 KS Score - into Brazilian Portuguese and verification of its measurement properties, reproducibility, and validity. In 2012, the new version of the Knee Society Score was developed and validated. This scale comprises four separate subscales: (a) objective knee score (seven items: 100 points); (b) patient satisfaction score (five items: 40 points); (c) patient expectations score (three items: 15 points); and (d) functional activity score (19 items: 100 points). METHOD: A total of 90 patients aged 55-85 years were evaluated in a clinical cross-sectional study. The pre-operative translated version was applied to patients with TKA referral, and the post-operative translated version was applied to patients who underwent TKA. Each patient answered the same questionnaire twice and was evaluated by two experts in orthopedic knee surgery. Evaluations were performed pre-operatively and three, six, or 12 months post-operatively. The reliability of the questionnaire was evaluated using the intraclass correlation coefficient (ICC) between the two applications. Internal consistency was evaluated using Cronbach's alpha. RESULTS: The ICC found no difference between the means of the pre-operative, three-month, and six-month post-operative evaluations between sub-scale items. CONCLUSION: The Brazilian Portuguese version of The 2011 KS Score is a valid and reliable instrument for objective and subjective evaluation of the functionality of Brazilian patients who undergo TKA and revision TKA.