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Purpose To compare the functional outcomes, knee stability, failure rate and complication rates of combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction with hamstrings grafts between acute and chronic cases. Methods Consecutive patients who underwent combined ACL and ALL reconstruction with hamstrings grafts were evaluated. Patients operated on less than 8 weeks after injury were allocated to group 1, and the others were allocated to group 2. Demographic data, knee stability, and functional outcomes of the 2 groups were evaluated. Results Thirty-four patients in the acute group and 96 in the chronic group were evaluated. The follow-up time was similar between the groups (28.7 ± 5.2 [24-43] months vs 29.4 ± 7.2 [24-58] months; P = 0.696). No differences were found between the groups in age, sex, trauma mechanism, presence of knee hyperextension, graft diameter, and meniscal injuries. There was no difference between the groups in the postoperative KT-1000 and in the pre- or postoperative pivot shift. The preoperative KT-1000 was higher in group 2 (7.9 ± 1.1 vs 7.4 ± 1.2; P = 0.031). There were no differences in the International Knee Documentation Committee or Lysholm. Three (2.3%) patients developed failure, 1 (2.9%) in group 1 and 2 (2.1%) in group 2. The total complication rate was 10% and did not differ between the groups. Conclusions Combined ACL and ALL reconstruction has similar outcomes in patients undergoing surgery in the acute and chronic phases. Patients with chronic injury have similar knee stability, functional scores, and failure rates as acute-injury patients, and patients with acute injury have no more complications than chronic patients. Level of Evidence Level III, retrospective comparative therapeutic trial.

Background: The degree of knee hyperextension in isolation has not been studied in detail as a risk factor that could lead to increased looseness or graft failure after anterior cruciate ligament (ACL) reconstruction. Purpose: To analyze whether more than 5° of passive knee hyperextension is associated with worse functional outcomes and greater risk of graft failure after primary ACL reconstruction with hamstring tendon autograft. Study Design: Cohort study; Level of evidence, 3. Methods: A cohort of patients who had primary ACL reconstruction with hamstring tendon autografts was divided into 2 groups based on passive contralateral knee hyperextension greater than 5° (hyperextension group) and less than 5° (control group) of hyperextension. Groups were matched by age, sex, and associated meniscal tears. The following data were collected and compared between the groups: patient data (age and sex), time from injury to surgery, passive knee hyperextension, KT-1000 arthrometer laxity, pivot shift, associated meniscal injury and treatment (meniscectomy or repair), contralateral knee ligament injury, intra-articular graft size, follow-up time, occurrence of graft failure, and postoperative Lysholm knee scale and International Knee Documentation Committee subjective form scores. Results: Data from 358 patients initially included in the study were analyzed; 22 were excluded because the time from injury to surgery was greater than 24 months, and 22 were lost to follow-up. From the cohort of 314 patients, 102 had more than 5° of knee hyperextension. A control group of the same size (n = 102) was selected by matching among the other 212 patients. Significant differences in the incidence of graft failure (14.7% vs 2.9%; P = .005) and Lysholm knee scale score (86.4 ± 9.8 vs 89.6 ± 6.1; P = .018) were found between the 2 groups. Conclusion: Patients with more than 5° of contralateral knee hyperextension submitted to single-bundle ACL reconstruction with hamstring tendons have a higher failure rate than patients with less than 5° of knee hyperextension.

The objective of this study is to report the functional outcomes, complications, and reconstruction failure rate of patients undergoing posterolateral complex reconstruction with a single femoral tunnel technique. Patients with posterolateral complex injuries associated with injury of the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), or both undergoing surgical treatment with the single femoral tunnel technique were included in the study. The International Knee Documentation Committee (IKDC) and Lysholm's scales were evaluated, in addition to age, gender, time between trauma and surgery, trauma type, range of motion (ROM) restrictions, peroneal nerve injury, and reconstruction failure. Sixty-six patients were included. Eighteen underwent ACL and posterolateral complex (PLC) reconstruction (group 1), 24 underwent ACL, PCL, and PLC reconstruction (group 2), and 24 underwent PCL and PLC reconstruction (group 3). The mean follow-up was 63 months. The subjective IKDC was 83.7 ± 14.6 for group 1, 74.3 ± 12.6 for group 2, and 66.3 ± 16.0 for group 3 (p

The aim of this study was to evaluate the incidence of knee osteoarthritis, failure rate of reconstruction, and clinical outcomes of patients with chronic multiligament knee injuries subjected to surgical treatment. Sixty-two patients with chronic knee dislocation subjected to multiligament reconstruction between April 2008 and July 2016 were evaluated, with a minimum follow-up of 24 months. Anteroposterior and lateral radiographs were performed in the pre- and last postoperative evaluation; the progression of degenerative changes according to the Kellgren-Lawrence classification (KL) was assessed. The Schenck classification, Knee Injury and Osteoarthritis Outcome Score (KOOS), time between injury and surgery, type of postoperative rehabilitation protocol (brace vs. external fixator), and physical examination for ligament instability were also evaluated. Univariate and multivariate analysis were performed, p

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.

With the increasing number of total knee arthroplasty (TKA) procedures being performed annually, the burden of revision surgery is also expected to increase. Addressing bone loss during revision TKA is a considerable challenge that requires proper preoperative evaluation and surgical planning. In addition to an assessment of femoral and tibial bone loss, a systematic approach to the management of bone loss associated with TKA includes careful implant selection, adherence to the general principles of revision TKA, and an understanding of the available reconstruction options. These options include cement with screws, morcellized allograft, bulk structural allograft, modular wedges, block augments, porous metal cones or sleeves, and megaprostheses.

Resumo Objetivo Avaliar o uso da tecnica de subcondroplastia no tratamento das lesoes medulares osseas em serie inicial de cinco casos. Metodos O estudo incluiu pacientes entre 40 e 75 anos, com dor em joelho com pelo menos seis meses de duracao, associada a ressonância magnetica com lesao hipercaptante em ponderacao de T2 na tibia ou no femur. Os pacientes foram avaliados segundo a escala visual analogica de dor (EVA) e pelo Knee Injury and Osteoarthritis Outcome Score (KOOS), uma semana antes da cirurgia e uma, tres, seis, 12 e 24 semanas apos. A subcondroplastia foi feita com tecnica desenvolvida para o preenchimento, guiado por radioscopia, da area de lesao ossea medular, com o uso de substituto osseo em pasta a base de fosfato de calcio. Resultados O preenchimento foi feito com sucesso em todos os casos, quatro no condilo femoral medial e um no planalto tibial medial. A avaliacao pelo KOOS apresentou uma media pre‐operatoria de 38,44 pontos e 62,7, 58,08, 57,92, 63,34 e 71,26 pontos com uma, tres, seis, 12 e 24 semanas apos a cirurgia, respectivamente. Na avaliacao pela EVA, a media foi de 7,8 pontos no pre‐operatorio e 2,8, 3, 2,8, 1,8 e 0,6 pontos nos mesmos periodos. Todos os pacientes conseguiram deambular, sem apoio adicional, ja no primeiro dia apos o procedimento. Um paciente apresentou minimo extravasamento de enxerto para partes moles, causou dor local que se resolveu completamente apos uma semana. Conclusao A tecnica de subcondroplastia desenvolvida proporcionou melhorias significativas nos parâmetros de dor e capacidade funcional na avaliacao de curto prazo.

Objective: To present an experience with negative-pressure wound therapy (NPWT) in the treatment of surgical wounds in patients treated for infections after total knee arthroplasty (TKA) with or without dehiscence and prophylaxis in wounds considered at risk of healing problems. Methods: We prospectively evaluated patients with TKA infection with or without surgical wound dehiscence and patients with risk factors for infection or surgical wound complications treated with Pico(r) device for NPWT in addition to standard treatment of infection or dehiscence in our institution. We considered as an initial favorable outcome the resolution of the infectious process and the closure of the surgical wound dehiscences in the treated cases and the good progression of the wound without complicating events in the prophylactic cases. Results: We evaluated 10 patients who used Pico(r) in our service. All patients had a favorable outcome according to established criteria. No complications were identified regarding the use of the NPWT device. The mean follow-up of the patients after the use of the device was 10.5 months. Conclusion: The NPWT can be safely used in wound infections and complications following TKA with promising results. Long-term randomized prospective studies should be conducted to prove its effectiveness. Level of Evidence IV, Case Series. RESUMO Objetivo: Apresentar uma experiência com a terapia com pressão negativa (TPN) no tratamento das feridas cirúrgicas de pacientes tratados por infecções em artroplastias totais do joelho (ATJ) associadas ou não à deiscência e como profilaxia nas feridas consideradas em risco de problemas de cicatrização. Métodos: Foram avaliados prospectivamente pacientes que apresentavam infecção de ATJ associada ou não à deiscência de ferida operatória e pacientes com fatores de riscos de infecção ou complicações de ferida cirúrgica tratados com dispositivo PICO(r) para TPN além do tratamento padrão da infecção ou deiscência em nossa instituição. Consideramos como desfecho favorável inicial a resolução do processo de infecção e o fechamento das deiscências de ferida operatória nos casos de tratamento e a boa evolução da ferida operatória, sem eventos complicadores, nos casos profiláticos. Resultados: Foram avaliados 10 pacientes que usaram PICO(r) em nosso serviço. Todos os pacientes apresentaram desfecho favorável de acordo com os critérios estabelecidos. Não foram identificadas quaisquer complicações com relação ao uso do dispositivo de TPN. A média de seguimento dos pacientes após o uso do dispositivo foi de 10 meses e meio. Conclusão: A TPN pode ser usada em complicações de ferida e infecção depois de ATJ de maneira segura e com resultados promissores. Estudos prospectivos randomizados prolongados devem ser realizados para comprovar sua eficácia. Nível de Evidência IV, Série de Casos.

ResumoAs reconstruções ligamentares do joelho são procedimentos ortopédicos frequentes. As fixações dos enxertos são mais comumente feitas com parafusos de interferência, metálicos ou absorvíveis. Em estudo recente, somente dez relatos sobre migração de parafusos foram encontrados; somente um deles não estava relacionado ao ligamento cruzado anterior (LCA) e a maioria estava relacionada a parafusos de poly‐L‐lactic acid (PLLA). Apenas um caso da literatura reportou migração de parafuso em reconstruções do canto posterolateral, essa para a região intra‐articular. Neste artigo, os autores relatam um caso de migração extra‐articular e transcutânea de um parafuso de interferência de poly L,D‐lactide (PDLLA) após a reconstrução do tendão poplíteo. Além de ser o primeiro caso de reconstrução do tendão do poplíteo com migração extra‐articular do parafuso, não foram encontrados na literatura relatos de migração de parafusos de PDLLA.AbstractKnee ligament reconstructions are commonly performed orthopedic procedures. Graft fixation is generally performed with metal or absorbable interference screws. In a recent study, only ten reports of screw migration were retrieved; of these, only one was not related to the anterior cruciate ligament, and the majority was related to the use of poly‐L‐lactic acid (PLLA) screws. Only one case retrieved in the literature reported screw migration in reconstructions of the posterolateral corner, and that was to the intra‐articular region. In the present article, the authors report a case of extra‐articular and transcutaneous migration of a poly‐L/D‐lactide (PDLLA) interference screw following popliteal tendon reconstruction. Besides being the first case of popliteal tendon migration with extra‐articular screw migration, no reports of PDLLA screw migration were retrieved in the literature.

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

ResumoA luxação crônica da patela é uma patologia rara e o trauma sua principal causa adquirida. Quando negligenciada, leva ao geno valgo progressivo, à torção externa da tíbia e à subsequente artrose debilitante. Não existe consenso na literatura com relação ao tratamento desses pacientes, porém a artroplastia total de joelho (ATJ) tem se mostrado um procedimento eficaz em casos de gonartrose sintomática dolorosa. Poucos relatos mostraram que a via subvasto associada à liberação lateral é uma opção válida para ATJ, já que permite a correção de deformidades em valgo e da boa excursão patelar, sem interrupção do suprimento sanguíneo. Relatamos um caso de uma paciente com geno valgo e luxação crônica pós‐traumática de patela submetida a ATJ associada ao realinhamento do mecanismo extensor, com resultados satisfatórios persistentes após seguimento de dois anos.AbstractChronic lateral dislocation of the patella is a rare condition and acquired causes are usually secondary to knee trauma. The neglected chronic dislocation leads to progressive genu valgum and external tibial torsion deformities with subsequent gonarthrosis, which becomes painful and debilitating. There is no consensus regarding treatment of these patients, but total knee arthroplasty (TKA) is a useful therapy in cases of painful symptomatic gonarthrosis. Few reports have shown that subvastus approach and lateral release may be a valid option for TKA, since it allows the correction of valgus deformity and patellar tracking without interrupting vascular blood supply of patella. This article reports a case of TKA and extensor mechanism realignment without patellar resurfacing in a patient with genu valgum and chronic post‐traumatic patellar dislocation with satisfactory results after two years of follow‐up.

Purpose To compare functional outcomes, residual instability, and rupture rates in patients with ligamentous hyperlaxity undergoing isolated anterior cruciate ligament (ACL) reconstruction or combined ACL and anterolateral ligament (ALL) reconstruction. Methods Two groups of patients were evaluated and compared retrospectively. Both groups consisted of patients with ACL injuries and associated ligamentous hyperlaxity, defined based on the modified Beighton scale with a minimum score of 5. Group 1 patients underwent anatomical ACL reconstruction, and group 2 patients underwent anatomical ACL reconstruction combined with ALL reconstruction. Group 1 consisted of historical controls. The presence of associated meniscal injury, subjective International Knee Documentation Committee and Lysholm functional scores, KT-1000 measurements, the presence of a residual pivot-shift, and the graft rupture rate were evaluated. The study was performed at University of Sao Paulo in Brazil. Results Ninety patients undergoing ACL reconstruction with ligamentous hyperlaxity were evaluated. The mean follow up was 29.6 ± 6.2 months for group 1 and 28.1 ± 4.2 months for group 2 (P = .51). No significant differences were found between the groups regarding Beighton scale, gender, the duration of injury before reconstruction, follow-up time, preoperative instability, or associated meniscal injuries. The mean age was 29.9 ± 8.1 years in group 1 and 27.0 ± 9.1 years in group 2 (P = .017). In the final evaluation, group 2 patients showed better anteroposterior clinical stability as evaluated by KT-1000 arthrometry (P = .02), better rotational stability as evaluated by the pivot-shift test (P = .03) and a lower reconstruction failure rate (21.7% [group 1] vs 3.3% [group 2]; P = .03). Clinical evaluations of postoperative functional scales showed no differences between the 2 groups (P = .27 for International Knee Documentation Committee; P = .41 for Lysholm). Conclusions Combined ACL and ALL reconstruction in patients with ligamentous hyperlaxity resulted in a lower failure rate and improved knee stability parameters compared to isolated ACL reconstruction. No differences were found in the functional scales. Level of evidence Level III, case control study.

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. RESUMO OBJETIVO: Descrever técnica cirúrgica de reconstrução anatômica do LPFM com tendão quadricipital combinada com a reconstrução do LPTM com tendão patelar e apresentar os resultados iniciais em uma série de casos. MÉTODO: Foi aplicada a técnica proposta em uma série de casos de pacientes do Grupo de Joelho do HC-IOT diagnosticados com instabilidade patelofemoral e com indicação de tratamento cirúrgico. No pré e pós-operatório foram avaliados: amplitude de movimento (ADM), teste da apreensão, teste da translação lateral, teste da inclinação patelar, sinal do J invertido, subluxação em extensão, dor a compressão da patela e dor a contração do quadríceps. No pós-operatório também foi perguntado aos pacientes se houve novo episódio de luxação, qual o grau de satisfação com a cirurgia (escala de zero a 10) e se passariam pela cirurgia novamente. RESULTADOS: Foram operados sete joelhos em sete pacientes e a média de seguimento foi de 5,46 meses (±2,07). Tivemos quatro pacientes com apreensão no pré-operatório que não tinham apreensão no pós-operatório. O teste de translação lateral foi normalizado em todos os pacientes enquanto o teste da inclinação patelar permaneceu positivo em dois pacientes. Os pacientes com J invertido permaneceram com o sinal positivo. A subluxação em extensão, presente no pré-operatório em cinco pacientes, foi negativa em todos no pós-operatório. Nenhum paciente apresentou novo episódio de luxação da patela. Todos responderam estar satisfeitos. Cinco pacientes referiram satisfação 9 e dois referiram 10. Todas passariam novamente pela cirurgia. Apenas uma paciente apresentou complicação pós-operatória, deiscência de ferida. CONCLUSÃO: A reconstrução combinada do LPFM com tendão quadricipital com a reconstrução do LPTM com tendão patelar é tecnicamente segura e apresentou bons resultados clínicos objetivos e subjetivos nesta série de caso de curto seguimento.

To assess whether the use of an articulated external fixator provides improvements in the mobility, stability and subjective function of patients undergoing ligament reconstruction. Thirty-three patients with sub-acute and chronic knee dislocation were subjected to multi-ligament reconstruction surgery. These patients were randomly allocated to two groups for immobilization after reconstruction: group 0—control (18 patients), with rigid knee bracing, and group 1—articulated external fixator (15 patients). The stability of the reconstructed ligaments was assessed after at least 14 months (26.6-month average) postoperatively by physical examination. Deficit of extension and flexion was measured in relation to the unaffected contralateral knee, and the Lysholm knee scoring scale questionnaire was applied. There was no difference in the assessment of joint stability between the groups. In group 1, patients showed less flexion deficit (4.8° ± 5.4° vs. 18.2° ± 14.8°, p

The aim of this study is to characterize in detail the meniscal insertion of the anterolateral ligament (ALL) of the knee, establishing parameters regarding the circumference of the lateral meniscus and the popliteal muscle tendon (PMT) groove in addition to its histological analysis. A total of 33 knees of cadavers were dissected. The ALL and the lateral meniscus were removed en bloc. After removal of the anatomical specimen, the meniscus circumference, the ALL insertion points on the external surface of the lateral meniscus, and the PMT groove were measured. Eight menisci were subjected to histological analysis. The ALL was found in all dissections performed. The ALL insertion occurred macroscopically in the transition between the anterior horn and the lateral meniscus body, specifically beginning at 36.0 % and ending at 41.9 % of the meniscal circumference, occupying a mean area of 5.6 mm. The distance between the end of the ALL meniscal insertion and the beginning of the PMT groove averaged 12.9 mm. In the histological evaluation, in longitudinal sections, we observed dense collagen fibers of the ligament inserting on the external surface of the meniscus. It is possible to observe a spreading of collagen fibers at the moment of meniscal insertion. The ALL meniscal insertion was found in all dissected specimens, beginning with approximately 36 % of the meniscal outer diameter, 12.9 mm anterior to the beginning of the PMT groove. The histological analysis confirmed the presence of true ligamentous tissue in the dissected specimens.

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.

ResumoObjetivoAvaliar a presença do ligamento anterolateral (LAL) do joelho em exames de ressonância magnética (RM).MétodosForam avaliadas 33 RM de joelho de pacientes feitas por indicações não relacionadas a instabilidade ligamentar ou trauma. Foram obtidas imagens no plano sagital ponderadas em T1 e imagens nos planos axial, sagital e coronal ponderadas em T2 com saturação de gordura. As imagens foram avaliadas por dois radiologistas experientes em patologias musculoesqueléticas. Na avaliação da visualização, dividimos a análise do ligamento em três porções: origem femoral até o seu ponto de bifurcação, da bifurcação até a inserção meniscal e da bifurcação até a inserção tibial. Considerou‐se com variável categórica dicotômica (sim ou não) a capacidade de visualizar o ligamento em cada uma das porções e no seu todo.ResultadosO LAL foi visualizado com característica de sinal semelhante às demais estruturas ligamentares do joelho, com hipossinal em T2 com saturação de gordura. O principal plano em que o ligamento foi identificado foi o coronal. Alguma porção do ligamento foi visualizada com clareza em 27 (81,8%) joelhos. A porção meniscal ficou evidente em 25 (75,7%) dos joelhos, a porção femoral em 23 (69,6%) e a tibial em 13 (39,3%). As três porções foram visualizadas em conjunto em 11 (33,3%) joelhos.ConclusãoO ligamento anterolateral do joelho é mais bem visualizado em sequências no plano coronal. O ligamento foi caracterizado por completo em 33,3% dos casos. A porção meniscal foi a mais facilmente identificada e a tibial a menos encontrada.AbstractObjectiveTo evaluated the presence of the anterolateral ligament (ALL) of the knee in magnetic resonance imaging (MRI) examinations.MethodsThirty‐three MRI examinations on patients’ knees that were done because of indications unrelated to ligament instability or trauma were evaluated. T1‐weighted images in the sagittal plane and T2‐weighted images with fat saturation in the axial, sagittal and coronal planes were obtained. The images were evaluated by two radiologists with experience of musculoskeletal pathological conditions. In assessing ligament visibility, we divided the analysis into three portions of the ligament: from its origin in the femur to its point of bifurcation; from the bifurcation to the meniscal insertion; and from the bifurcation to the tibial insertion. The capacity to view the ligament in each of its portions and overall was taken to be a dichotomous categorical variable (yes or no).ResultsThe ALL was viewed with signal characteristics similar to those of the other ligament structures of the knee, with T2 hyposignal with fat saturation. The main plane in which the ligament was viewed was the coronal plane. Some portion of the ligament was viewed clearly in 27 knees (81.8%). The meniscal portion was evident in 25 knees (75.7%), the femoral portion in 23 (69.6%) and the tibial portion in 13 (39.3%). The three portions were viewed together in 11 knees (33.3%).ConclusionThe anterolateral ligament of the knee is best viewed in sequences in the coronal plane. The ligament was completely characterized in 33.3% of the cases. The meniscal portion was the part most easily identified and the tibial portion was the part least encountered.

To evaluate the results of combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction in patients with chronic ACL injury. It was hypothesized that patients who underwent combined ACL and ALL reconstruction would exhibit less residual laxity and better clinical outcomes. Two groups of patients were evaluated and compared retrospectively. Both groups consisted only of patients with chronic (more than 12 months) ACL injuries. Patients in group 1 underwent anatomical intra-articular reconstruction of the ACL and patients in group 2 underwent anatomic intra-articular ACL reconstruction combined with ALL reconstruction. The presence of associated meniscal injury, the subjective International Knee Documentation Committee (IKDC) and Lysholm functional outcome scores in the postoperative period, KT-1000 evaluation, the presence of residual pivot shift and graft rupture rate were evaluated. One hundred and one patients who underwent reconstruction of chronic ACL injuries were evaluated. The median follow-up was 26 (24–29) months for group 1 and 25 (24–28) months for group 2. There were no significant differences between groups regarding gender, age, duration of injury until reconstruction, follow-up time or presence of associated meniscal injuries in the preoperative period. Regarding functional outcome scores, patients in group 2 presented better results on both the IKDC (p = 0.0013) and the Lysholm (p

Objective To test different fixation methods of a 3-dimensionally woven poly(ϵ-caprolactone) (PCL) scaffold within chondral defects of a weightbearing large animal model. Methods Full thickness chondral defects were made in the femoral condyles of 15 adult male Yucatan mini-pigs. Two surgical approaches were compared including total arthrotomy (traditional) and a retinaculum-sparing, minimally invasive surgery (MIS) approach. Following microfracture (MFX), scaffolds were placed without fixation or were fixed with fibrin glue, suture, or subchondral anchor. Experimental endpoints were between 1 and 6 weeks. Micro–computed tomography and histology were used to assess samples. Results The MIS approach was superior as the traditional approach caused medial condyle cartilage wear. One of 13 (7.7%) of scaffolds without fixation, 4 of 11 (36.3%) fibrin scaffolds, 1 of 4 (25%) of sutured scaffolds, and 9 of 9 (100%) of anchor-fixed scaffolds remained in place. Histology demonstrated tissue filling with some overgrowth of PCL scaffolds. Conclusions Of the methods tested, the MIS approach coupled with subchondral anchor fixation provided the best scaffold retention in a mini-pig chondral defect model. This finding has implications for fixation strategies in future animal studies and potential future human use.

Combined injuries involving the anterior cruciate ligament (ACL) and posterolateral corner (PLC) occur in approximately 10% of complex knee injuries. The current tendency is to reconstruct both the ACL and the structures of the PLC. In injuries involving multiple ligaments, a potential problem in the reconstruction is the convergence of tunnels in the lateral walls of the femur. As a solution to this problem, we propose a combined technique for reconstruction of the ACL and PLC with a single tunnel in the lateral femoral wall. Combined ACL/PLC 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, for reconstruction of the collateral ligament and popliteus tendon, and emerging in the joint region at the anatomic point of the ACL reconstruction. The graft is passed from the tibia to the femur with the double gracilis tendon and the simple semitendinosus tendon; the remaining portions are left for reconstruction of the structures of the PLC. This technique is very effective in terms of minimizing the number of tunnels, but it does rely on having grafts of adequate size.

Background This study compares a traditional parapatellar retinaculum-sacrificing arthrotomy to a retinaculum-sparing arthrotomy in a porcine stifle joint as a cartilage repair model. Findings Surgical exposure of the femoral trochlea of ten Yucatan pigs stifle joint was performed using either a traditional medial parapatellar approach with retinaculum incision and luxation of the patella (n = 5) or a minimally invasive (MIS) approach which spared the patellar retinaculum (n = 5). Both classical and MIS approaches provided adequate access to the trochlea, enabling the creation of cartilage defects without difficulties. Four full thickness, 4 mm circular full-thickness cartilage defects were created in each trochlea. There were no intraoperative complications observed in either surgical approach. All pigs were allowed full weight-bearing and full range of motion immediately postoperatively and were euthanized between 2 and 3 weeks. The traditional approach was associated with increased cartilage wear compared to the MIS approach. Two blinded raters performed gross evaluation of the trochlea cartilage surrounding the defects according to the modified ICRS cartilage injury classification. The traditional approach cartilage received a significantly worse score than the MIS approach group from both scorers (3.2 vs 0.8, p = 0.01 and 2.8 vs 0, p = 0.005 respectively). Conclusion The MIS approach results in less damage to the trochlear cartilage and faster return to load bearing activities. As an arthrotomy approach in the porcine model, MIS is superior to the traditional approach.

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

Patellar instability is a debilitating disease. An important factor related to recurrent dislocation is patellar height. A new method of patellar height measurement, the plateau-patella angle (PPA), was proposed in 2011. However, to date, there is no study evaluating the use of this method in patients with patellar instability. The aim of this study was to evaluate the PPA in patients with recurrent patellar dislocation.This was a retrospective evaluation of the radiographs of 78 knees with patellar instability. Patellar height was measured using the Insall-Salvati (I/S), Caton-Deschamps (C/D) and Blackburne-Peel (B/P) indices and the PPA. The qualitative and quantitative correlations between the various methods and between observers were calculated.The PPA had a Pearson correlation of 0.76 (P0.001) with the I/S index, 0.78 (P0.001) with the C/D index and 0.90 (P0.001) with the B/P index. In the qualitative correlation using the Spearman coefficient, the PPA had a correlation of 0.52 (P0.001) with the I/S index, 0.72 (P0.001) with the C/D index and 0.70 (P0.001) with the B/P index. The correlations between the conventional methods were as follows: 0.57 (P0.001) between the I/S and C/D indices; 0.61 (P0.001) between the I/S and B/P indices; and 0.73 (P0.001) between the C/D and B/P indices.The determination of the PPA is a reproducible method that is consistent with the methods currently used to measure patellar height in patients with recurrent patellar dislocation.

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.

Dear Editor, Quadriceps tendon rupture is an uncommon injury in orthopedic traumatology and is usually associated with chronic diseases, or the use of systemic or local corticosteroids (1,2). Simultaneous bilateral lesions are even more uncommon, with few cases described in the literature since 1949, when the first description was made by Steiner and Palmer (3). Although bilateral lesions have been described in patients without predisposing factors, the most common scenario is patients with pathologies such as diabetes, renal failure, and autoimmune diseases. One of the problems of bilateral lesions is their delayed diagnosis. Neubauer et al. showed that diagnoses are performed on average more than two months after the injury, which hinders patient recovery, as functional recovery is correlated with the time elapsed between the injury and the surgical procedure (4). Due to the high rate of functional losses after isolated repairs of quadriceps tendon lesions, particularly in chronic lesions, some alternatives have been created with the intention of obtaining a functional improvement in these patients. Alternatives include the Codivilla technique, reinforcement using steel wires and allografts, and even the use of platelet-rich plasma with the goal of achieving better healing of the tendon (4-6). The use of fascia lata allografts is becoming increasingly common in reconstructions around the shoulder and knee due to their material, structural, and biomechanical properties that resemble the original tendon tissue (7). In this letter we present a report on a patient with chronic bilateral quadriceps tendon tear treated surgically with repair of the tendon using transosseous sutures associated with reinforcement using two flexor tendons and coverage of the repair using fascia lata graft, simulating the retinaculum in the anterior region of the knee. A 56-year-old male patient who smoked, suffered from hypertension, diabetes, and had been undergoing dialysis treatment for chronic kidney failure for 9 years, felt both knees snap when descending a ladder. He denied a history of falls or trauma in the knee during the episode. After the incident he presented functional impotence of the lower limbs and was unable to walk. He sought medical attention at a secondary hospital where he was examined, had frontal and lateral radiographs taken of both knees and was released with referral to a basic health care unit for physiotherapy with a diagnosis of arthralgia of the knees. The patient maintained functional impotence, pain, and edema in the anterior region of the knee even after physiotherapy treatment. The patient was unable to work after the episode and was restricted to a wheelchair. Eight months after the onset of the condition, he once again visited the medical service at our hospital where he presented with a gap in the suprapatellar region and functional impotence of the extensor mechanism of both knees. The patient had an ultrasound scan which showed complete rupture of the bilateral quadriceps tendon with retraction of 7.3 cm between the stumps on the right side and 7.4 cm on the left side. The patient also had an MRI scan after diagnostic confirmation. At the time of diagnosis, the patient exhibited decompensated diabetes and poor clinical control of his other systemic pathologies which ruled out an immediate surgical procedure. Perfect control of the co-morbidities, necessary for a safe surgical procedure with a lower risk of healing complications, only occurred after three months, totaling 11 months after the initial injury. Immediately before the surgery the patient presented a score of 32 on the KSS scale. The chosen surgical treatment was the simultaneous repair of the bilateral quadriceps tendon with extensive anterior approach, transosseous sutures through the patella, and reinforcement with flexor tendons from a tissue bank associated with coverage of the repair using a fascia lata graft with the intention of imitating the anterior retinaculum of the knee. The reinforcement with flexor tendons was performed in a circumferential shape, or ‘O’ shape, splicing the tendons in the remaining portion of the quadriceps tendon and passing it under the patella, without making tunnels in the patella so as to preserve it (Figure 1A). The graft was tensioned with the knee in full extension. The fascia lata graft then had its ends sutured on the anterior tuberosity of the tibia and on the quadriceps tendon (Figure 1B). Figure 1. A) Clinical photo showing circumferential reinforcement of the left quadriceps tendon repair with allograft tendons. The asterisk shows the patella. B) Clinical photo showing the final aspect of the coverage of the repair with fascia lata graft from a ... The patient used a long orthosis in extension for 6 weeks. During the first six weeks activity was limited to isometric exercise for the quadriceps, glutei, adducers, and abductors. Gain in passive range of motion (ROM) started at three weeks from 0–45°, developing to 60° in the fourth week, and then in the sixth week the active gain of ROM was released, reaching 0–130° in the tenth week. Sutures were removed three weeks after surgery, and the patient did not have any healing problems. Prophylactic anticoagulant medication was maintained until the knee orthosis was removed. In week eight the patient started orthostatism exercises and gait training with the assistance of parallel bars, subsequently a walking frame, a cane, and later on without support. As the patient was having dialysis on alternate days, he found it hard to cope with the physiotherapy follow-up treatment, only managing to perform exercises no more than twice a week. Six months after surgery the patient is very satisfied with his level of activity and function, presenting a KSS of 80. Fascia lata grafts have recently been used to reconstruct the anterior cruciate ligament, the patellar tendon, and for other procedures with good results (7). Aurora et al. (8) showed that the material, biomechanical, and structural properties of fascia lata grafts are similar to tendon tissue, which acts as an incentive for their use on a larger scale in these types of reconstruction. Even in the absence of any healing complication, which would be quite possible on account of the patient’s clinical co-morbidities, we decided to exercise great caution when starting rehabilitation, avoiding forcing the repair at first. Even if it takes 6 months to restore pre-injury function, we believe that recovery of the total range of motion, without extension lag and with normal strength of the quadriceps, was an excellent result due to the patient’s age and co-morbidities and the time elapsed between the injury and the surgical treatment, which prevented the patient from walking for 11 months. Neubauer et al. showed total recovery in just 3 of 14 patients operated more than 14 days after lesion (4). In short, we believe that surgical treatment of chronic lesions can present good results provided that the rehabilitation is performed carefully and additional methods of reinforcement are used besides simple surgical repair. To our knowledge, the fascia lata graft has not yet been used for that purpose and may be yet another option for health care services that have a tissue bank available.

Lesions of the medial collateral ligament (MCL) are the most common knee ligament injuries, and lesions associated with the anterior cruciate ligament or the posterior cruciate ligament (PCL) in knee dislocations should be reconstructed to prevent failure of the central pivot reconstruction. The purpose of this study was to evaluate the outcomes of combined PCL/MCL reconstruction using a single femoral tunnel with a minimum 2-year follow-up. A retrospective study of thirteen patients with combined PCL/MCL injuries was conducted. The patients underwent PCL and MCL reconstruction using an Achilles tendon allograft with a single tunnel in the medial femoral condyle, thereby avoiding tunnel conversion. All patients achieved a range of motion of at least 100°. The mean loss of extension and flexion values compared to the contralateral side was 1° ± 2° and 9° ± 10°, respectively. Our results included 26 reconstructions with three (11.5 %) failures, two in the PCL (15.3 %) and one in the MCL (7.6 %), in three different patients. In the final evaluation, the mean IKDC subjective score was 71.63 ± 16.23, the mean Lysholm score was 80.08 ± 13.87, and the median Tegner score was 6 (range = 2–7). The PCL/MCL reconstruction technique using a single femoral tunnel and an Achilles tendon allograft is safe, avoids the convergence of tunnels in the medial femoral condyle, has excellent results, and is reproducible. IV.

This study sought to determine the safety limits for performing a femoral bone tunnel to reconstruct the knee anterolateral ligament (ALL) by establishing its distance from the lateral collateral ligament (LCL) and the popliteus muscle tendon (PT) on the lateral femoral condyle.Anatomic study on 48 knee cadaveric specimens. The femoral attachments of the studied structures were isolated, and the distance between them was measured. For each cadaver, the percentage of cases in which at least 50 % of the LCL and PT would be injured when using 4- to 12-mm-diameter drills in an ALL reconstruction procedure was evaluated.The LCL and PT were 3.8 mm and 10.2 mm distant from the ALL, respectively. A 4-mm tunnel would cause LCL injury in 8.3 % of cases, with increasing incidence of injury up to 87.5 % with a 12-mm drill. Injury to the PT would start with the 10-mm drill, causing injury in 2.0 % of cases.Performing a tunnel in the center of the ALL may cause an iatrogenic injury to the LCL origin. No cases of PT injury are expected to occur with drills smaller than 10 mm.

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.

Osteonecrosis of the knee is a disease that generates important limitations to the patient, but is still poorly understood. More recently, with the increasing number of arthroscopies, a new category of osteonecrosis was identified after meniscectomies. The purpose of this article is to review the concepts of the possible causes, clinical and radiological presentation of post-meniscectomy osteonecrosis.

Background: Recent anatomical studies have identified the anterolateral ligament (ALL). Injury to this structure may lead to the presence of residual pivot shift in some reconstructions of the anterior cruciate ligament. The behavior of the length of this structure and its tension during range of motion has not been established and is essential when planning reconstruction. Purpose: To establish differences in the ALL length during range of knee motion. Study Design: Descriptive laboratory study. Methods: Ten unpaired cadavers were dissected. The attachments of the ALL were isolated. Its origin and insertion were marked with a 2 mm–diameter metallic sphere. Computed tomography scans were performed on the dissected parts under extension and 30°, 60°, and 90° of flexion; measurements of the distance between the 2 markers were taken at all mentioned degrees of flexion. The distances between the points were compared. Results: The mean ALL length increased with knee flexion. Its mean length at full extension and at 30°, 60°, and 90° of flexion was 37.9 ± 5.3, 39.3 ± 5.4, 40.9 ± 5.4, and 44.1 ± 6.4 mm, respectively. The mean increase in length from 0° to 30° was 3.99% ± 4.7%, from 30° to 60° was 4.20% ± 3.2%, and from 60° to 90° was 7.45% ± 4.8%. From full extension to 90° of flexion, the ligament length increased on average 16.7% ± 12.1%. From 60° to 90° of flexion, there was a significantly higher increase in the mean distance between the points compared with the flexion from 0° to 30° and from 30° to 60°. Conclusion: The ALL shows no isometric behavior during the range of motion of the knee. The ALL increases in length from full extension to 90° of flexion by 16.7%, on average. The increase in length was greater from 60° to 90° than from 0° to 30° and from 30° to 60°. The increase in length at higher degrees of flexion suggests greater tension with increasing flexion. Clinical Relevance: Knowledge of ALL behavior during the range of motion of the knee will allow for fixation (during its reconstruction) to be performed with a higher or lower tension, depending on the chosen degree of flexion.

A technique for combined reconstruction of the anterior cruciate ligament (ACL) and posterolateral corner (PLC) with a single femoral tunnel was recently described. This technique aims to avoid tunnel confluence in the lateral femoral condyle. Because there have been no studies on the functional outcomes and possible complications of this technique, our goal is to demonstrate a two-year minimum follow-up of patients who underwent this type of reconstruction. Nine patients were prospectively evaluated. The ACL was reconstructed with an anatomic single bundle, and the PLC structures reconstructed were the lateral collateral ligament, the popliteus tendon, and the popliteofibular ligament. Patients were evaluated using the objective and subjective International Knee Documentation Committee (IKDC) and the Lysholm and Tegner scales before and after the surgical procedure. The mean follow-up period of the studied patients was 27.3 months. The mean subjective IKDC score rose from 43.6 to 84.0, and the Lysholm score rose from 62.1 to 90.8. In the final assessment, six patients were classified as IKDC A and three as IKDC B. According to the Tegner scale, five patients were able to return to their level of activity prior to the injury. There were no reconstruction failures. One patient experienced postoperative infection and pain in the lateral scar. The results of the reconstruction of ACL injuries associated with PLC with a single femoral tunnel produced a good functional outcome and a low incidence of complications.

Injury to the posterolateral corner (PLC) is difficult to diagnose; most lesions of this type are included within the context of complex knee injuries. Study of the posterolateral complex is growing in importance because of the complex instability generated by these injuries. Although various physical examination tests are described for the diagnosis of PLC lesions, in 72% of cases these lesions are not identified at their initial presentation, which shows the difficulty in both performing these tests and interpreting the results. The maneuver described in this report is performed by executing external rotation of the leg. With the thumb of the proximally positioned hand, the examiner evaluates the positioning of the lateral tibial plateau in relation to the femoral condyle. With this maneuver, in lesions of the PLC and particularly lesions of its external rotation–restricting structures, we observe external rotation of the tibia and posterior subluxation of the lateral tibial plateau that cause the anterior edge of the tibial plateau to be posteriorized in relation to the anterior edge of the lateral femoral condyle. The idea behind this maneuver is not to eliminate the use of other tests but, rather, to add it to a diagnostic arsenal that still has interpretation flaws.

Background Many reconstruction techniques have already been developed for treating posterolateral corner (PLC) injuries, with still no consensus regarding what would be the best option. Some techniques use non-bone tunnel fixation, attaching the graft to the femur using a cortical screw with toothed washer. The main objective of the present study is to evaluate complications related to fixation performed by a screw and toothed washer technique. Methods A prospective study with surgical reconstruction of the PLC structures of the knee between January 2008 and December 2009 was performed. PLC reconstruction included reconstruction of the lateral collateral ligament, popliteofibular ligament and popliteal muscle tendon. Fixation of the grafts in the femur was achieved by means of a 4.5 mm screw with a toothed washer. The assessments were done using the following methods: objective IKDC, subjective IKDC, Lysholm and Tegner. Radiographic evaluations were performed immediately after the operation, at 3, 6 and 12 months after surgery, and yearly thereafter. Complications were documented. Results The mean subjective IKDC score after the operation was 69.2; Lysholm scale was 80.7. Two patients presented failure of reconstructions of the PLC. In the radiographic evaluations, signs of loosening of the screw with toothed washer in the femur were observed in eight cases (66.6%). Six patients (50%) complained of lateral pain after the operation. Conclusion The technique of femoral fixation was shown to be efficient in restoration of stability. However there was a high rate of complications secondary to implant, such as loosening of the screws and iliotibial tract friction. Level of evidence Case series, Leve IV.

Background: Reconstruction of the anterior cruciate ligament (ACL) is one of the most common procedures in orthopaedic surgery. However, even with advances in surgical techniques and implants, some patients still have residual anterolateral rotatory laxity after reconstruction. A thorough study of the anatomy of the anterolateral region of the knee is needed. Purpose: To study the anterolateral region and determine the measurements and points of attachments of the anterolateral ligament (ALL). Study Design: Descriptive laboratory study. Methods: Dissections of the anterolateral structures of the knee were performed in 20 human cadavers. After isolating the ALL, its length, thickness, width, and points of attachments were determined. The femoral attachment of the ALL was based on the anterior-posterior and proximal-distal distances from the attachment of the lateral collateral ligament (LCL). The tibial attachment point was based on the distance from the Gerdy tubercle to the fibular head and the distance from the lateral tibial plateau. The ligaments from the first 10 dissections were sent for histological analysis. Results: The ALL was found in all 20 knees. The femoral attachment of the ALL at the lateral epicondyle averaged 3.5 mm distal and 2.2 mm anterior to the attachment of the LCL. Two distal attachments were observed: one inserts into the lateral meniscus, the other between the Gerdy tubercle and the fibular head, approximately 4.4 mm distal to the tibial articular cartilage. The mean measurements for the ligament were 37.3 mm (length), 7.4 mm (width), and 2.7 mm (thickness). The histological analysis of the ligaments revealed dense connective tissue. Conclusion: The ALL is consistently present in the anterolateral region of the knee. Its attachment to the femur is anterior and distal to the attachment of the LCL. Moving distally, it bifurcates at close to half of its length. The ALL features 2 distal attachments, one at the lateral meniscus and the other between the Gerdy tubercle and the fibular head. Clinical Relevance: The ALL may be important in maintaining normal rotatory limits of knee motion; ALL rupture could be responsible for rotatory laxity after isolated intra-articular reconstruction of the ACL.

We read with great interest the article by Young et al. [1] entitled “Management of the exposed total knee prosthesis, a six-year review” regarding the outcomes of complex infection cases after total knee arthroplasty. We agree with the authors in relation to the fact that it is very difficult to treat these types of patients. We performed a similar case series [2] a few years ago and found a rate of amputation of 44.4%, higher than the rate found by Young et al. and by other small case series published [1,3–5]. All of our patients were infected by multi-resistant bacteria and had comorbidities with rheumatoid arthritis diagnosed in 66.6%. In this scenario, we feel that the treatment success is not only based on the institution protocol but also on the initial patient condition and on the bacteria causing the infection. Regarding patients that undergo amputation following infection, another study performed in our institution showed that only one patient was able to walk after this procedure, a result much worse than the patients that retained a spacer [6]. We feel that patients that proceed to amputation following a knee infection are very weakened and have been through a significant number of surgical procedures, making it difficult for them to return to regular activities.

Introduction Knee dislocations are defined as ligament injuries involving at least two of the four most important knee ligaments. Results from recent studies have shown a tendency towards improvement of the functional outcomes with use of an articulated external fixator during the postoperative period following multiligament reconstruction. Our hypothesis was that good knee stability and early gain of range of motion could be achieved with the use of the external fixator after ligament reconstructions. Methods Fourteen patients with knee dislocations were evaluated after multiligament reconstruction in association with use of a lateral monoplanar external fixator for six weeks. Reconstructions were performed using grafts from a tissue bank. Range of motion was measured after one, two, three, six, twelve months and at the final evaluation at a mean time of 49 months. The assessments were made using objective and subjective IKDC, Lysholm and Tegner scales. Results The mean scores were 71.7 for the subjective IKDC score, 81.5 for the Lysholm score. No patient was able to return to previous Tegner score. Out of the 45 ligament reconstructions performed, only four failed during the follow-up time. The mean range of motion of the knee presented a progressive increase from the first to the twelfth month, from 67.8° to 115.7°. Two cases of superficial infection on the site of the external fixator pins were observed. Conclusion The use of an external fixator enabled early rehabilitation with range-of-motion gains starting from the first postoperative month, a low rate of reconstruction failure and minimal complications. Nevertheless, none of the patients returned to the level of activity prevailing prior to the injury. Level of evidence Level IV, retrospective therapeutic case series.

ResumoObjetivo: Descrever o ligamento anterolateral (LAL) do joelho e estabelecer seus pontos anatômicos de origem e inserção e suas medidas.Métodos: Foram feitas dissecções da região anterolateral do joelho em seis cadáveres. Após isolamento do LAL, medidas de comprimento, espessura e largura foram feitas, assim como seus locais de origem e inserção. A origem do LAL foi documentada com base na sua distância ântero-posterior e proximal- distal em relação à origem do ligamento colateral lateral. A inserção foi documentada com base no tubérculo de Gerdy, a cartilagem do planalto tibial lateral e o menisco lateral. Nas duas primeiras dissecções, o ligamento foi removido e enviado para análise histológica.Resultados: O LAL foi observado com clareza nas dissecções de todos os seis joelhos. Sua origem no epicôndilo lateral apresentou uma média 0,5mm distal e 2,5mm anterior à origem do LCL. Na tíbia foram observadas duas inserções, uma mais proximal no menisco lateral e outra mais distal entre o tubérculo de Gerdy e a cabeça da fíbula, cerca de 4,5mm distal à cartilagem articular da tíbia. As medidas encontradas do ligamento foram: comprimento médio de 35,1mm, largura média de 6,8mm e espessura média de 2,6mm. Na análise histológica dos ligamentos foi observada presença de tecido conectivo denso.Conclusão: O LAL do joelho é uma estrutura constante na região anterolateral. Sua origem no fêmur é anterior e distal à origem do LCL. Na tíbia, apresenta duas inserções, no menisco lateral e entre o tubérculo de Gerdy e a cabeça da fíbula.AbstractObjectiveDescribe the knee anterolateral ligament (ALL) and establish its anatomical marks of origin and insertion.MethodsDissection 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.ResultsThe ALL was clearly identified in all knees. Its origin in the lateral epycondile was on average 0.5mm distal and 2.5mm anterior to the LCL. In the tibia, two insertions were observed, one in the lateral meniscus and another in the proximal tibia, about 4.5mm distal to the articular cartilage, between the Gerdy tubercle and the fibullar head. The average measures obtained were: 35.1mm lenght, 6.8mm width and 2.6mm thickness. In the ligament histological analysis, dense connective tissue was observed.ConclusionThe 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.

Introduction Knee dislocations are defined as ligament injuries involving at least two of the four most important knee ligaments. Results from recent studies have shown a tendency towards improvement of the functional outcomes with use of an articulated external fixator during the postoperative period following multiligament reconstruction. Our hypothesis was that good knee stability and early gain of range of motion could be achieved with the use of the external fixator after ligament reconstructions. Methods Fourteen patients with knee dislocations were evaluated after multiligament reconstruction in association with use of a lateral monoplanar external fixator for six weeks. Reconstructions were performed using grafts from a tissue bank. Range of motion was measured after one, two, three, six, twelve months and at the final evaluation at a mean time of 49 months. The assessments were made using objective and subjective IKDC, Lysholm and Tegner scales. Results The mean scores were 71.7 for the subjective IKDC score, 81.5 for the Lysholm score. No patient was able to return to previous Tegner score. Out of the 45 ligament reconstructions performed, only four failed during the follow-up time. The mean range of motion of the knee presented a progressive increase from the first to the twelfth month, from 67.8° to 115.7°. Two cases of superficial infection on the site of the external fixator pins were observed. Conclusion The use of an external fixator enabled early rehabilitation with range of motion gains starting from the first postoperative month, a low rate of reconstruction failure and minimal complications. Nevertheless, none of the patients returned to the level of activity prevailing prior to the injury. Level of evidence Level IV, retrospective therapeutic case series.

OBJECTIVE: To evaluate the use of subchondroplasty in the treatment of bone marrow lesions in an initial series of five cases. METHODS: The study included patients aged between 40 and 75 years old, with pain in the knee for at least six months, associated with high-signal MRI lesion on T2 sequences, on the tibia or femur. Patients were assessed using the visual analog pain scale and the KOOS score, one week before surgery and one, three, six, 12, and 24 weeks after the procedure. Subchondroplasty was performed with a technique developed for filling the area of the bone marrow lesion with a calcium phosphate bone substitute. RESULTS: The filling was performed on the medial femoral condyle in four patients and medial tibial plateau in one case. The assessment by the KOOS score presented a preoperative average of 38.44 points and 62.7, 58.08, 57.92, 63.34, and 71.26 points with one, three, six, 12, and 24 weeks after surgery, respectively. In the evaluation by the VAS, the average was 7.8 points preoperatively and 2.8, 3, 2.8, 1.8, and 0.6 points over the same periods. All patients were able to ambulate without additional support, on the first day after the procedure. One patient had a minimal graft dislocation to the soft tissue, with local pain, which resolved completely after a week. CONCLUSION: The subchondroplasty technique provided significant improvements in the parameters of pain and functional capacity in the short-term assessment. RESUMO OBJETIVO: Avaliar o uso da técnica de subcondroplastia no tratamento das lesões medulares ósseas em série inicial de cinco casos. MÉTODOS: O estudo incluiu pacientes entre 40 e 75 anos, com dor em joelho com pelo menos seis meses de duração, associada à ressonância magnética com lesão hipercaptante em ponderação de T2 na tíbia ou no fêmur. Os pacientes foram avaliados segundo a escala visual analógica de dor (EVA) e pelo Knee Injury and Osteoarthritis Outcome Score (KOOS), uma semana antes da cirurgia e uma, três, seis, 12 e 24 semanas após. A subcondroplastia foi feita com técnica desenvolvida para o preenchimento, guiado por radioscopia, da área de lesão óssea medular, com o uso de substituto ósseo em pasta à base de fosfato de cálcio. RESULTADOS: O preenchimento foi feito com sucesso em todos os casos, quatro no côndilo femoral medial e um no planalto tibial medial. A avaliação pelo KOOS apresentou uma média pré-operatória de 38,44 pontos e 62,7, 58,08, 57,92, 63,34 e 71,26 pontos com uma, três, seis, 12 e 24 semanas após a cirurgia, respectivamente. Na avaliação pela EVA, a média foi de 7,8 pontos no pré-operatório e 2,8, 3, 2,8, 1,8 e 0,6 pontos nos mesmos períodos. Todos os pacientes conseguiram deambular, sem apoio adicional, já no primeiro dia após o procedimento. Um paciente apresentou mínimo extravasamento de enxerto para partes moles, causou dor local que se resolveu completamente após uma semana. CONCLUSÃO: A técnica de subcondroplastia desenvolvida proporcionou melhorias significativas nos parâmetros de dor e capacidade funcional na avaliação de curto prazo.