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PURPOSE: To report the arthroscopic treatment results of a degenerative medial meniscus tear with a displaced flap into the meniscotibial recess, tibial peripheral reactive bone edema, and focal knee medial pain. As a secondary objective, we propose to identify possible factors associated with a good or poor prognosis of the surgical treatment of this lesion. METHODS: From 2012 to 2018, patients who had this specific meniscus pathology and underwent arthroscopic surgical treatment were retrospectively evaluated. Patients with Kellgren-Lawrence (KL) classification greater than 2 were excluded. KL classification, the presence of an Outerbridge grade III/V chondral lesion of the medial compartment, limb alignment, body mass index, and smoking were evaluated. The subjective outcomes included the International Knee Documentation Committee score, improvement in the pain reported by patients, and the Global Perceived Effect (GPE) scale score. RESULTS: A total of 69 patients were evaluated. The mean age was 58.6 ± 7.1 years. The follow-up time was 48.7 ± 20.8 months. Fifty-five (79.7%) patients reported pain improvement. The postoperative International Knee Documentation Committee was 62.6 ± 15.4, and the mean GPE was 2.3 ± 2.6. Fourteen patients (20.3%) showed no improvement in pain, and 7 patients (10.2%) presented complications. Groups that improved (GPE > 0) and did not improve (GPE < 0) did not present differences regarding age, sex, follow-up time, chondral lesions, or body mass index. Patients without improvement had a greater incidence of smoking (P = .001), varus alignment (P = .008), and more advanced KL classification (P < .001). In the multivariate analysis based on the GPE score, KL classification (P = .038) and smoking (P = .003) were significant. CONCLUSIONS: Arthroscopic surgical treatment of degenerative medial meniscal tears with a meniscal flap displaced into the meniscotibial recess and adjacent focal bone edema in the tibia shows good results in approximately 80% of cases. Smoking and KL grade 2 were factors associated with poor prognosis of surgical treatment. LEVEL OF EVIDENCE: Level IV (case series).

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.

The purpose of this study was to compare the combined reconstruction of the superficial medial collateral ligament (sMCL) and the posterior oblique ligament (POL) with the reconstruction of the sMCL associated with the advancement of the posteromedial capsule in a complex knee injury scenario. We hypothesized that both techniques would present similar knee stability and failure rates.This is a retrospective case-control study designed to compare the results of the two reported techniques for grade III MCL instability. Patients undergoing MCL reconstruction associated with anterior cruciate ligament, posterior cruciate ligament, or both, from 2010 to 2019, were included. The following parameters were evaluated: demographic data, type of graft, time from injury to surgery, associated meniscus injuries, follow up time, mechanism of trauma, postoperative objective IKDC, subjective IKDC and Lysholm scales, range of motion, reconstruction failure and complications.Seventy-eight patients were evaluated, 37 of whom underwent reconstruction of the sMCL and POL, and 41 of whom underwent reconstruction of the sMCL with advancement of posteromedial structures. There was no difference in any preoperative variable. Patients undergoing reconstruction of the sMCL + advancement had greater loss of flexion (Group 1 3.4 ± 4.6 vs Group 2 8.4 ± 7.9; P = 0.002) and more individuals with flexion loss greater than 10° (Group 1, seven patients (18.9%) vs Group 2, 17 patients (41.5%); P = 0.031). Postoperative knee stability, failures and complications were similar between groups.Both techniques presented good functional results and low rates of complications. However, the advancement technique showed greater flexion loss, which should be considered when choosing the best surgical option.

To compare the failure rate in patients who underwent revision anterior cruciate ligament (ACL) reconstruction alone or associated with an extra-articular procedure. Secondary objectives were to compare ACL laxity, patient-reported outcome measures, and complication rates in these patients and, subsequently, to compare the outcomes of patients who underwent revision ACL reconstruction associated with anatomical anterolateral ligament (ALL) reconstruction or lateral extra-articular tenodesis (LET).This was a retrospective comparative study. Patients were classified into 2 groups, according to whether (group 2) or not (group 1) an extra-articular reconstruction was performed. Patients who underwent an extra-articular procedure were further divided into ALL reconstruction (group 2A) and LET (group 2B). Baseline demographic variables, operative data and postoperative data were evaluated.The groups with (86 patients) and without (88 patients) an associated extra-articular reconstruction had similar preoperative data. Group 2 had a lower failure rate (4.6% vs 14.7%; P = .038), better KT-1000, better pivot-shift, and better Lysholm. There was no difference regarding complications, except more lateral pain in group 2. Regarding the groups who underwent ALL reconstruction (41 patients) and LET (46 patients), group 2A showed better Lysholm scores. Both groups had similar failure rates and complications.Patients who underwent revision ACL reconstruction with a laterally based augmentation procedure had a lower failure rate than patients who underwent isolated revision ACL reconstruction. KT-1000 and pivot-shift examination were also significantly better when a lateral augmentation was performed. Complications were similar except for an increase in lateral pain in the augmented group. No clinically important differences were found when comparing the LET group to the ALL group other than a statistical improvement in the Lysholm functional scale, likely not clinically meaningful, favoring the ALL group and an increased duration of post-operative lateral pain in the LET group.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

INTRODUÇÃO: A reconstrução isolada do ligamento cruzado anterior (LCA) não reestabelece a biomecânica normal do joelho, em casos de lesão associada das estruturas anterolaterais, em estudos biomecânicos in vitro. Estudos avaliando o potencial impacto clínico das lesões do ligamento anterolateral (LAL), no tratamento das lesões do LCA, são necessários para validar ou não os achados dos estudos biomecânicos, principalmente considerando o mau potencial de cicatrização dessa estrutura descrito em trabalhos de ressonância magnética. Dessa forma, o objetivo desta tese é avaliar os resultados clínicos e o índice de falha após reconstrução do LCA, diagnosticada em ressonância magnética em pacientes com e sem lesão do LAL não tratada. MÉTODOS: Uma coorte prospectiva de pacientes com lesão aguda do LCA foram classificados em dois grupos, com base na presença ou ausência da lesão do LAL no exame de ressonância magnética (RM) pré-operatória realizada, na fase aguda da lesão (menos de 3 semanas). O Grupo LAL (1) consistiu em pacientes com lesão do LAL e Grupo LCA isolado (2) sem lesão do LAL associada. Os dois grupos foram submetidos à reconstrução anatômica do LCA com tendões de flexores autólogos com banda simples pela técnica de fora para dentro (outside in). Os escores funcionais subjetivos de Lysholm e International Knee Documentation Committee (IKDC), medidas do KT-1000 pré e pós-operatórias, medidas do pivot shift pré e pós-operatório, taxa de falha da reconstrução, incidência de lesão de LCA contralateral, presença de lesão meniscal associada e seu tratamento e a presença de hiperextensão do joelho foram avaliados com um mínimo de 24 meses de seguimento RESULTADOS: Cento e oitenta e dois pacientes foram avaliados. O seguimento médio foi de 33,6 ± 7,1 meses para o grupo LAL (1) e 36,1 ± 8,1 meses para o grupo LCA isolado (2). Não foram encontradas diferenças significativas entre os grupos em relação à idade, sexo, hiperextensão do joelho, tempo de lesão antes da reconstrução ou lesões meniscais associadas. Na avaliação pré-operatória, o pivot-shift foi semelhante e o grupo LAL apresentou pior KT-1000 (7,9 ± 1,2 mm [grupo LAL] vs 7,2 ± 1,1 mm [grupo LCA isolado]; p < 0,001). Na avaliação pós-operatória, os pacientes do grupo LCA isolado apresentaram menor taxa de falha de reconstrução (10,2% [grupo LAL] vs 1,4% [grupo LCA isolado]; p 0,029) e melhores resultados clínicos das escalas funcionais pós-operatórias para o IKDC (85,5 ± 10,7 [grupo LAL] vs 89,1 ± 6,6 [grupo LCA isolado]; p 0,035) e Lysholm (85,9 ± 10,1 [grupo LAL] vs 92,0 ± 6,3 [grupo LCA isolado]; p < 0,001). Não houve diferença pós-operatória no KT-1000 (P = 0,054) ou pivot-shift (p = 0,116). CONCLUSÃO: Pacientes com lesão do LAL associada ao LCA na RM pré-operatória apresentam maior taxa de rerrotura e piores resultados nos escores funcionais de Lysholm e IKDC subjetivo INTRODUCTION: Isolated anterior cruciate ligament (ACL) reconstruction does not restore normal knee biomechanics in cases of associated injury to anterolateral structures in biomechanical studies. Studies evaluating the potential clinical impact of anterolateral ligament (ALL) injuries in the treatment of ACL tears are necessary to validate or not the findings of biomechanical studies, especially considering the poor healing potential of this structure described in magnetic resonance imaging (MRI) studies. Thus, the objective of this study is to evaluate the clinical outcomes and failure rate after ACL reconstruction, in patients with and without ALL injury diagnosed on MRI. METHODS: A prospective cohort of patients with acute ACL injury was classified into 2 groups based on the presence or absence of the ALL injury in the preoperative magnetic resonance imaging (MRI) performed in the acute phase of the injury (less than 3 weeks). The ALL Group (1) consisted of patients with an ALL injury and an isolated ACL Group (2) without an associated ALL injury. Both groups underwent anatomical reconstruction of the ACL with tendons of autologous hamstrings with a simple bundle through an outside in technique. The functional scores of Lysholm and the subjective International knee Documentation Committee (IKDC), pre- and postoperative KT-1000 measurements, pre- and postoperative pivot shift measurements, reconstruction failure rate, incidence of contralateral ACL injury, presence of associated meniscal injury and its treatment, and the presence of knee hyperextension were assessed with a minimum of 24 months of follow-up. RESULTS: One hundred and eighty-two patients were evaluated. The mean follow-up was 33.6 ± 7.1 months for the ALL group (1) and 36.1 ± 8.1 months for the isolated ACL group (2). No significant differences were found between the groups regarding age, sex, knee hyperextension, time of injury before reconstruction or associated meniscal injuries. In the preoperative evaluation, the pivot shift was similar and the ALL group had the worst KT-1000 (7.9 ± 1.2 mm [ALL group] vs 7.2 ± 1.1 mm [isolated ACL group]; p < 0.001). In the postoperative evaluation, patients in the isolated ACL group had a lower rate of reconstruction failure (10.2% [ALL group] vs 1.4% [isolated ACL group]; p 0.029) and better clinical results of the functional scores for IKDC (85.5 ± 10.7 [group 1] vs 89.1 ± 6.6 [group 2]; p 0.035) and Lysholm (85.9 ± 10.1 [ALL group] vs 92, 0 ± 6.3 [isolated ACL group]; p < 0.001). There was no postoperative difference in the KT-1000 (P = 0.054) or pivot-shift (p = 0.116). CONCLUSION: Patients with ACL tears with an associated ALL injury on preoperative MRI showed a higher re-rupture rate and worse outcomes in Lysholm and subjective IKDC functional scores

Objectives To compare the clinical outcomes of isolated anterior cruciate ligament (ACL) reconstruction with combined reconstruction of the ACL and anterolateral ligament (ALL) of the knee. Methods A search was conducted on the PubMed, Medline, Google Scholar, EMBASE, and Cochrane library databases, in line with the PRISMA protocol. The indexation terms used were “anterior cruciate ligament” OR “acl” AND “anterolateral ligament” AND “reconstruction.” Articles that compared patients submitted to combined ACL and ALL reconstruction with those submitted to isolated reconstruction of the ACL, with levels of evidence I, II, and III, were included. Studies with follow-up of less than 2 years and articles that did not use “anatomical” techniques for ALL reconstruction, such as extraarticular tenodesis, were excluded. A meta-analysis with R software was conducted, with a random effects model, presented as risk ratio (RR) or mean difference (MD), with a 95% confidence level (CI) and statistically significant at p Results Ten articles were selected, with a total of 1495 patients, most of whom were men, of whom 674 submitted to ACL and ALL reconstruction and 821 to isolated ACL reconstruction. Combined ACL and ALL reconstruction exhibited a statistically significant advantage in residual pivot shift (RR 0.34, 95% CI 0.24–0.47, I2 = 0%, p I2 = 0%, p I2 = 21%, p I2 = 73%, p Conclusions Combined ACL and ALL reconstruction obtained better postoperative clinical outcomes when compared with isolated ACL reconstruction, especially in reducing residual pivot shift and rerupture rate.

Background: Combined reconstruction of the anterolateral ligament (ALL) and anterior cruciate ligament (ACL) has shown excellent results. It could potentially reduce graft failure and improve outcomes in high-risk patients. There are several surgical techniques described. Hamstrings are the most frequently used graft for ALL reconstruction. The distal portion of the iliotibial band is used for the modified Lemaire procedure. Indications: Anterior cruciate ligament reconstructions associated with the following risk factors: pivoting sports, high-demand athletes, high-grade pivot-shift, chronic ACL injury, lateral femoral condyle notch, Segond fractures, young patients (7 mm. Technique Description: Semitendinosus and gracilis tendons are harvested and their extremities are prepared with continuous suture. The semitendinosus graft is folded in 3 parts leaving the ends of the graft internalized. The triple semitendinosus will be the main component of the ACL and the single gracilis will be used for both ACL and ALL. Anterolateral ligament anatomical landmarks are proximal and posterior to the lateral epicondyle in the femur, and in the mid distance from the fibular head and the Gerdy tubercle in the tibia. The ALL is fixed in knee extension with interference screws. This video also includes a brief demonstration of graft preparation for the modified Lemaire procedure. Results: Results from our group using this technique have shown excellent clinical outcomes, minimal complications, and low failure rates in high-risk populations. This graft preparation shows excellent diameter and length for combined ACL and ALL reconstruction. Conclusion: This technique is easy to perform, with minimal complications, and should be considered in high-risk patients undergoing ACL reconstruction.

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: Isolated reconstruction of the anterior cruciate ligament (ACL) does not reestablish the normal knee biomechanics in cases of associated injuries to the anterolateral structures. Studies evaluating the potential clinical effect of anterolateral ligament (ALL) injury on the treatment of ACL injuries are necessary to validate the findings of biomechanical studies. Purpose: To evaluate the clinical outcomes and failure rate of ACL reconstruction in patients with and without ALL injury diagnosed using magnetic resonance imaging. Study Design: Cohort study; Level of evidence, 2. Methods: A prospective cohort of patients with acute ACL injury was divided into 2 groups based on the presence (ALL group) or absence (no-ALL group) of ALL injury on preoperative magnetic resonance imaging scans. Both groups underwent anatomic reconstruction of the ACL with autologous hamstring tendon grafts. The Lysholm and subjective IKDC scores (International Knee Documentation Committee), KT-1000 arthrometer and pivot-shift test results, reconstruction failure rate, incidence of contralateral ACL injury, presence of associated meniscal injury, and presence of knee hyperextension were evaluated. Results: A total of 182 patients were evaluated. Postoperative mean ± SD follow-up was 33.6 ± 7.1 and 36.1 ± 8.1 months for the ALL and no-ALL groups, respectively. No significant differences were found between the groups in terms of age, sex, knee hyperextension, duration of injury before reconstruction, follow-up time, or associated meniscal injuries. In the preoperative evaluation, the pivot-shift grade was similar, and the ALL group had worse KT-1000 arthrometer values (7.9 ± 1.2 mm vs 7.2 ± 1.1 mm; P < .001). In the postoperative evaluation, patients in the no-ALL group had a lower reconstruction failure rate (10.2% vs 1.4%; P = .029) and better clinical outcomes according to the IKDC subjective (85.5 ± 10.7 vs 89.1 ± 6.6; P = .035) and Lysholm scores (85.9 ± 10.1 vs 92.0 ± 6.3; P < .001). There was no postoperative difference in the KT-1000 or pivot-shift results. Conclusion: Combined ACL and ALL injuries were associated with significantly less favorable outcomes than were isolated ACL injuries at a minimum follow-up of 2 years after ACL reconstruction. Patients with concomitant ALL injury showed a higher rerupture rate and worse functional scores.

The purpose of this study is to describe cases of traumatic exposure during the early postoperative period in patients with a total knee replacement (TKR) and to report the treatments instituted and complications of this adverse event.A retrospective review of postoperative patients with TKR performed at the Universidade de São Paulo from 2001 to 2017 who subsequently were treated at the emergency room due to trauma to the TKR region accompanied by surgical wound dehiscence in deep planes and implant exposure was conducted. The initial treatment, evolution, and complications of each patient were reported.In 16 years, there were 3224 TKRs performed at the study institution. Among this population, 4 (0.1%) patients had trauma dehiscence of the surgical wound during the immediate postoperative period. All patients were women between the ages of 64 and 88 years with comorbidities (eg, diabetes mellitus and/or hypertension). The mean time between the surgery and trauma was 6.7 ± 6.2 days. All patients underwent surgical cleaning, debridement with polyethylene exchange, and primary closure of the surgical wound and received adjuvant treatment with broad-spectrum antibiotic therapy. Of the 4 patients affected, 3 developed an infection, 3 required new surgery after initial cleaning, 2 lost their prostheses, and 1 lost a limb, requiring a transfemoral amputation.Traumatic dehiscence with implant exposure during the initial postoperative period of TKR is an infrequent event (0.1%) with a high potential for complications (75%), which may lead to loss of the prosthesis and even the limb. Measures should be taken to prevent falls and gather reports from several centers to broaden the knowledge of this rare event, identify prognostic factors, and define the best treatment algorithm.

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.

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.

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

Patients with multiligament knee injuries represent a heterogeneous group of complex lesions. The challenge starts with performing an accurate diagnosis in the acute phase and selecting the appropriate treatment. Surgical techniques are diverse and there are no standard rehabilitation protocols for all cases. Unfortunately, due to the complexity and the uniqueness of each case, treatment should be patient oriented and there is no simple algorithm to follow.

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.

Background To report the functional outcomes and complications from reconstructing the knee posterolateral complex (PLC), associated with one-stage opening-wedge tibial valgus osteotomy, and discuss the technical feasibility of this procedure. Methods Five patients with chronic PLC injuries and varus deviation of the mechanical axis, associated with central pivot injuries or not, underwent medial opening-wedge high tibial osteotomy combined with PLC reconstruction. The lateral collateral ligament, popliteal tendon, and popliteofibular ligament were reconstructed using a single femoral tunnel. Patients were assessed on physical examination, range-of-motion and functional scales, and radiographs. The International Knee Documentation Committee (IKDC) score, Lysholm score, and Knee Injury and Osteoarthritis Outcome score (KOOS) were determined. Results Five patients were evaluated: four presented with central pivot injury, and one had an isolated PLC injury. The mean time between injury and surgery was 40 ± 6.5 months (± is indicating standard deviation value). Four patients had minimal residual instability on physical examination, with a lateral opening at varus stress of ± 3 + at 30° flexion. The means of the IKDC score, Lysholm score, and KOOS were 67.8 ± 9.2, 83.0 ± 9.3, and 79.2 ± 5.9, respectively. All patients showed satisfactory consolidation of osteotomy in 2.6 ± 0.9 months. Conclusions The results of this series indicate that one-stage PLC ligament reconstruction associated with medial opening-wedge valgus osteotomy is feasible and shows satisfactory functional results with a low rate of complications. A one-stage procedure might be indicated for young patients with high functionality and more pronounced posterolateral instabilities.

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 analyze the characteristics of patients with Lisfranc injuries and their associated fractures . Methods: This is a retrospective analysis on 42 patients with Lisfranc injuries hospitalized at Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, between 2006 and 2010. Parameters on patient profile, risk factors, fracture characteristics, data on treatment and acute complications were analyzed . Results: Analysis of 42 cases showed that in our sample, men were more affected than women, with a ratio of 4.25:1. The most frequent trauma mechanism was car accident, followed by motorcycle accident. The most frequent type of injury was isolated lesion type B of Quenu and Kuss classification, representing 50% of cases. The most common fracture on the sample was the second metatarsal bone, with 16 cases, followed by cuboid bone fracture. Among the 42 cases, 17% had exposed fractures and 33 patients presented other associated fractures. The mean time elapsed between the trauma and definitive treatment was 6.7 days, while the mean length of hospital stay was 13.8 days. Six patients presented acute postoperative complications . Conclusion: Lisfranc injuries are more common in men undergoing automobile trauma. The prevalence of associated fractures is a frequent finding and the hospital stay may be longstanding. Level of Evidence IV, Case Series. RESUMO Objetivo: Analisar o perfil de pacientes com lesões de Lisfranc, as características das lesões e fraturas associadas. Métodos: Trata-se de uma análise retrospectiva com 42 pacientes com lesões de Lisfranc internados no Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo entre 2006 e 2010. O perfil dos pacientes, características das lesões, fraturas associadas, dados sobre o tratamento e complicações agudas foram analisados. Resultados: Nesta amostra, os homens foram mais afetados do que as mulheres, com uma proporção de 4,25:1. O mecanismo de trauma mais frequente foi acidente de carro, seguido por acidente com moto. O tipo de lesão mais frequente foi a lesão isolada tipo B de Quenu e Kuss, representando 50% dos casos. A fratura mais comumente encontrada foi a do segundo metatarso, com 16 casos, seguido pela fratura do osso cubóide. Entre os 42 casos estudados, sete foram fraturas expostas e 33 pacientes apresentaram fraturas associadas. O tempo médio entre o trauma e o tratamento definitivo foi de 6,7 dias. O tempo médio de permanência hospitalar foi de 13,8. Seis pacientes apresentaram complicações pós-operatórias agudas. Conclusão: As lesões de Lisfranc são mais comuns em homens submetidos a trauma automobilístico. A prevalência de fraturas associadas é um achado frequente e o tempo de permanência hospitalar pode ser prolongado. Nível de Evidência IV, Série de Casos

McDonald et al . (1), identified patients treated for anterior cruciate ligament (ACL) injury from their institutional registry. Measurements to determine anterior tibial translation were performed, as described and validated by Iwaki et al . (2,3), determining the subluxation in the medial and lateral compartments.

Objectives - Anemia is the most common hematological alteration in patients with Crohn's disease, and is frequently related to intestinal inflammatory activity. Its cause is multifactorial and mostly associated with absolute iron deficiency (iron deficiency anemia) and/or functional iron deficiency (inflammation anemia or anemia of chronic disease). It may also be identified through other causes, such as folic acid or vitamin B12 deficiency and secondary to adverse effects from medications (salicylic derivatives and immunosuppressive drugs). In the present study, patients with active Crohn's disease and anemia were evaluated and treated with intravenous ferric carboxymaltose. We discuss the therapeutic schemes (doses), safety, results and improvement of quality of life. Methods - In the present prospective study, 10 consecutive patients with Crohn's disease, with moderate to severe activity, with anemia (Hb: 6.7 to 10 g/dL), who were attended between March 2014 and March 2015, were evaluated. Six (60%) were men and four were women, all with moderate or severe anemia (hemoglobin

Background: The patellar tendon has limited ability to heal after harvesting its central third. Platelet-rich plasma (PRP) could improve patellar tendon healing.Hypothesis: Adding PRP to the patellar tendon harvest site would improve donor site healing and improve clinical outcome at 6 months after anterior cruciate ligament (ACL) reconstruction with a patellar tendon graft.Study Design: Randomized controlled trial; Level of evidence, 1.Methods: Twenty-seven patients were randomly divided to receive (n = 12) or not receive (n = 15) PRP in the patellar tendon harvest site during ACL reconstruction. The primary outcome was magnetic resonance imaging (MRI) assessment of patellar tendon healing (gap area) after 6 months. Secondary outcomes were questionnaires and isokinetic testing of ACL reconstruction with a patellar tendon graft comparing both groups.Results: Patellar tendon gap area was significantly smaller in the PRP group (4.9 ± 5.3 mm2; 95% confidence interval [CI], 1.1-8.8) than in the control group (9.4 ± 4.4 mm2; 95% CI, 6.6-12.2; P = .046). Visual analog scale score for pain was lower in the PRP group immediately postoperatively (3.8 ± 1.0; 95% CI, 3.18-4.49) than in the control group (5.1 ± 1.4; 95% CI, 4.24-5.90; P = .02). There were no differences after 6 months in questionnaire and isokinetic testing results comparing both groups.Conclusion: We showed that PRP had a positive effect on patellar tendon harvest site healing on MRI after 6 months and also reduced pain in the immediate postoperative period. Questionnaire and isokinetic testing results were not different between the groups at 6 months.

Introdução: O ligamento cruzado anterior (LCA) é o ligamento mais frequentemente lesionado do joelho. O resultado de uma cirurgia de reconstrução do LCA depende de muitos fatores. O grau de hiperextensão passiva do joelho não foi estudado em detalhes e isoladamente como um fator de risco para o aumento da frouxidão ou falha do enxerto após uma reconstrução do LCA. Objetivo: Analisar se mais de 5 graus de hiperextensão passiva do joelho foi associada a piores resultados funcionais e maior risco de falha do enxerto após reconstruções primárias do LCA com enxerto autólogo de tendões flexores. Desenho do estudo: Estudo de Coorte Retrospectivo; Nível de evidência, 3. Métodos: Uma coorte de pacientes submetidos à reconstrução primária do LCA com enxerto autólogo de tendões flexores foi dividida em dois grupos com base na hiperextensão passiva do joelho maior que 5 graus (grupo hiperextensão) e inferior a 5 graus (grupo controle). Os grupos foram pareados por idade, sexo e lesões meniscais associadas. Os seguintes dados foram coletados e comparados entre os grupos: dados demográficos dos pacientes (idade e sexo), tempo da lesão até a cirurgia, hiperextensão passiva do joelho, KT-1000 e pivot-shift, lesão meniscal associada e tratamento (meniscectomia ou reparo), lesão ligamentar do joelho contra lateral, tamanho do enxerto intra-articular, tempo de acompanhamento, ocorrência de falha do enxerto, escala de Lysholm pós-operatória do joelho e formulário subjetivo do International Knee Documentation Committee (IKDC). Resultados: Os dados de 358 pacientes inicialmente incluídos no estudo foram analisados; 22 foram excluídos devido ao tempo de lesão até cirurgia superior a 24 meses e 22 foram excluídos devido a perda do seguimento ou perda de dados. Da coorte de 314 pacientes, 102 tinham mais de 5 graus de hiperextensão passiva do joelho. Um grupo controle do mesmo tamanho (102) foi selecionado entre os demais 212 pacientes por pareamento. Foi encontrada uma diferença significativa entre os grupos na incidência de falha do enxerto (14,7% vs. 2,9% ; p=0.005) e na escala de Lysholm (86.4 +/- 9.8 vs. 89.6 +/- 6.1 ; p=0.018). Conclusão: Pacientes com mais de 5 graus de hiperextensão do joelho submetidos à reconstrução do LCA com banda única com enxerto autólogo de tendões flexores apresentaram maior taxa de falha e piores resultados funcionais do que pacientes com menos de 5 graus de hiperextensão passiva do joelho Background: The anterior cruciate ligament (ACL) is the most frequently injured ligament of the knee. The outcome of an ACL reconstruction surgery depends on many factors. The degree of knee hyperextension in isolation has not been studied in detail as a risk factor that may lead to increased looseness or graft failure after an ACL reconstruction. Purpose: To analyze whether more than 5 degrees of passive knee hyperextension was associated with worse functional outcomes and greater risk of graft failure after primary ACL reconstructions with hamstrings tendon autografts. Study Design: Retrospective Cohort Study; Level of Evidence, 3. Methods: A cohort of patients submitted to primary ACL reconstruction with hamstrings tendon autografts was divided in two groups based on passive knee hyperextension greater than 5 degrees (hyperextension group) and inferior to 5 degrees hyperextension (control group). Groups were matched by age, gender and associated meniscal tears. The following data were collected and compared between the groups: patient demographic data (age and gender), time from injury to surgery, passive knee hyperextension, KT-1000 and pivot-shift, associated meniscus injury and treatment (meniscectomy or repair), contra-lateral knee ligament injury, intra-articular graft size, follow-up time, occurrence of graft failure and postoperative Lysholm knee scale and International Knee Documentation Committee (IKDC) subjective form. Results: Data from 358 patients initially included in the study were analyzed; 22 were excluded due to time from injury to surgery greater than 24 months and 22 were excluded due to lost follow up. From the cohort of 314 patients, 102 had more than 5 degrees of knee hyperextension. A control group of the same size (102) was selected by matching among the other 212 patients. A significant difference in the incidence of graft failure (14.7% vs. 2.9% ; p=0.005) and Lysholm knee scale (86.4 +/- 9.8 vs. 89.6 +/- 6.1 ; p=0.018) between the two groups was found. Conclusion: Patients with more than 5 degrees of knee hyperextension submitted to single bundle ACL reconstruction with hamstring tendons had a higher failure rate and worst functional outcome than patients with less than 5 degrees of knee hyperextension