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PURPOSE: To evaluate patients who had anterior cruciate ligament (ACL) reconstruction with preoperative hyperextension and compare physical examination (KT-1000 and pivot shift) and patient-reported outcome measures of patients who recovered the entire hyperextension with patients who did not. METHODS: Patients aged 18 to 60 years with more than 5° of knee hyperextension who had anatomic ACL reconstruction with any graft from June 2013 to June 2021 and at least a 24-month follow-up were evaluated retrospectively. Hamstrings and patellar tendon grafts were fixed around 20° to 30° of flexion and in full extension, respectively. Patients who could recover hyperextension were compared with patients who did not. Preoperative, intraoperative, and postoperative data, including physical examination and patient-reported outcome measures, were evaluated. RESULTS: Of the 225 patients evaluated, 48 (21.3%) did not recover hyperextension, and 177 recovered full range of motion. Patients who did not recover hyperextension had a larger graft diameter (8.7 ± 0.7 mm [confidence interval, 8.502-8.898 mm] vs 8.3 ± 0.7 mm [confidence interval, 8.197-8.403 mm]; P = .018). Regarding the postoperative subjective variables, patients who recovered hyperextension showed improvement on all scales (International Knee Documentation Committee, Lysholm, Forgotten Joint Score, and Global Perceived Effect) evaluated compared with patients who did not recover the range of motion. Patients who recovered hyperextension also showed more laxity on physical examination, measured by the KT-1000 (1.8 ± 0.8 vs 1.1 ± 1.0; P = .0006) and the pivot shift (62.1% [grade 0] and 37.9% [grade 1] vs 79.2% [grade 0] and 20.8% [grade 1]; P = .027). CONCLUSIONS: Patients with knee hyperextension who regained range of motion after ACL reconstruction have worse knee laxity than patients who regained full extension but not hyperextension. However, patients who recover full range of motion showed higher scores on subjective function scales, including a greater number of patients who achieved patient acceptable symptom state for the International Knee Documentation Committee score. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic trial.

RESUMO

PURPOSE: To create a cut-off point for hyperextension that best discriminates retear and to verify whether this cut-off point can predict retear regardless of other characteristics after primary anterior cruciate ligament (ACL) reconstruction with hamstrings autograft. METHODS: A cohort of patients submitted to primary isolated ACL reconstruction with hamstrings autografts was retrospectively evaluated. Patients were stratified according to the degree of passive knee hyperextension measured in the normal contralateral knee. The following data were collected: patient age and sex, time from injury to surgery, knee hyperextension, KT-1000 and pivot-shift, associated meniscus injury, intra-articular graft size, follow-up time, graft failure, and postoperative Lysholm and subjective International Knee Documentation Committee scores. RESULTS: Data from 457 patients were evaluated. Median age was 31 years. Thirty-two (7.0%) presented with retear. There was a significant difference in hyperextension between patients with and without retear (P < .001), with the cut-off point established by the receiver operating characteristic curve from 6.5°. Patients with greater hyperextension had a statistically greater frequency of women, longer injury time, greater intra-articular graft diameter, greater postoperative KT-1000, and greater frequency of retear, whereas the subjective International Knee Documentation Committee and Lysholm scores were statistically lower in patients with greater hyperextension. Only hyperextension showed a statistically significant association with re-rupture (P < .001). The odds of retear in patients with hyperextension greater than 6.5 was 14.65 times the odds of patients with hyperextension less than 6.5. CONCLUSIONS: Patients with more than 6.5° of hyperextension are 14.6 times more likely to have a graft rupture than patients with lower hyperextension when submitted to ACL reconstruction with hamstring tendons. Also, they present worse knee stability by the KT-1000 test and worse functional outcomes. Therefore, patients with this degree of hyperextension should not have isolated reconstruction with hamstrings as their first choice. LEVEL OF EVIDENCE: Level III, retrospective comparative prognostic trial.

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

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OBJECTIVE: With the aging of the population, more patients have complained of pain due to knee Osteoarthritis (OA), and the number of arthroplasties has also increased. The objective of this study is to evaluate the prevalence of the neuropathic pain component in candidates for Total Knee Replacement and the effects of this component on their quality of life. METHODS: In this cross-sectional study, patients with OA candidates for knee arthroplasty in the present institution were evaluated using the pain detection questionnaire and the Visual Analog Pain (VAS) scale to measure the pain index and the presence of associated neuropathic pain. In addition, evaluation of the quality of life and functionality using the EQ5D and SF12 questionnaires and their relationship with cases of neuropathic pain were performed. RESULTS: One hundred twenty-six patients were evaluated, and 71.4 % were female. The age ranged from 46 to 85 years, and about 70 % of the patients had some associated clinical comorbidity. Neuropathic pain was present in 28.6 % of the patients evaluated. Patients with neuropathic pain presented worse results in the VAS evaluation, in the care, pain, and anxiety domains of the EQ5D, and in the physical and mental scores of the SF12. CONCLUSION: Neuropathic pain was present in 28.6 % of the patients with knee OA who are candidates for arthroplasty. Patients with associated neuropathic pain present a higher level of pain and worse quality of life scores. Recognizing this type of pathology is extremely important in fully monitoring gonarthrosis.

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

Resumo Objetivo Avaliar a incidência de lesões cyclops sintomáticas que precisam de tratamento cirúrgico após a reconstrução do ligamento cruzado anterior (LCA) e estabelecer os possíveis fatores de risco intraoperatórios relacionados a elas. Métodos Trezentos e oitenta e nove pacientes com idades entre 18 e 50 anos submetidos à reconstrução primária do LCA foram avaliados de forma retrospectiva. Os pacientes foram divididos em grupos de acordo com a presença ou ausência de lesões cyclops sintomáticas e suas características foram comparadas. Não foram incluídos pacientes com lesões associadas que necessitassem de outros procedimentos cirúrgicos (à exceção de procedimentos extra-articulares ântero-laterais). A taxa de lesões cyclops sintomáticas foi registrada e os seguintes parâmetros foram avaliados: idade, sexo, tempo da lesão à cirurgia, tipo e diâmetro do enxerto, técnica de perfuração do túnel femoral, tipo de fixação, presença de hiperextensão do joelho, preservação do LCA remanescente, associação a procedimento extra-articular ântero-lateral, lesão de menisco associada e participação em esportes. Resultados Dos 389 pacientes avaliados, 26 (6,7%) desenvolveram lesão cyclops. Os pacientes com e sem lesão cyclops não diferiram quanto à idade, tempo da lesão à cirurgia, tipo ou diâmetro do enxerto, técnica cirúrgica, método de fixação femoral, presença de hiperextensão do joelho, preservação do LCA remanescente e lesão de menisco associada. O grupo com lesão cyclops apresentou mais mulheres (10 [38,4%] vs. 68 [18,7%]; razão de probabilidades [OR] = 2,7; p= 0,015), maior proporção de reconstrução extra-articular (18 [11,8%] vs. 8 [3,4 %]; OR = 3,8; p= 0,001) e maior proporção de prática esportiva (23 [8,6%] vs. 3 [2,5%]; OR = 3,6; p= 0,026). Conclusão Em nossa série, 6,7% dos pacientes necessitaram de remoção artroscópica das lesões cyclops. O sexo feminino, a reconstrução extra-articular associada e a prática esportiva foram fatores relacionados a essa lesão. A preservação do menisco remanescente não foi associada à formação de lesões cyclops.

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The performance of genicular nerve block requires an imaging method to guide the procedure. Radioscopy has the disadvantage of being radiation dependent. Objective: To assess whether the use of adhesive radiopaque grids reduce radiation exposure in these cases. Methods: This is a cross-sectional study conducted with 23 orthopedists in which needles were positioned in a model with and without the use of adhesive radiopaque grids. The number of fluoroscopy shots necessary for proper positioning in three points (superior lateral, superior medial, and inferior medial) were registered. Results: A statistical difference was observed in the three blocking points studied. The number of radioscopies required for these three points were 12.1 ± 2.5 in the group without grid and 5.0 ± 1.8 in the group with grid. The superior medial point presented the greatest numerical difference and the inferior medial point the smallest. Conclusion: The use of adhesive radiopaque grids led to a statistically significant reduction in the number of radioscopies/fluoroscopies required to perform the genicular block. The use of this device increases the safety of the physician and patient by reducing radiation exposure in this procedure. Level of Evidence III, Level of Evidence II, Random Clinical Trial.

Para a realização do bloqueio de nervos geniculares é necessário guiar o procedimento por um método de imagem. A radioscopia possui a desvantagem de ser dependente de radiação. Objetivo: Avaliar se o uso de máscaras localizadoras diminui a exposição à radiação nesses casos. Métodos: Estudo transversal realizado com 23 ortopedistas, que realizaram o posicionamento de agulhas em um modelo com e sem o uso da máscara localizadora. Foi registrado o número de escopias necessárias para o posicionamento adequado em três pontos: superior lateral, superior medial e inferior medial. Resultados: Foi observada diferença estatística nos três pontos de bloqueio analisados. O número de radioscopias necessárias nos três pontos somados foi de 12,1 ± 2,5, no grupo sem máscara, e 5,0 ± 1,8, no grupo com máscara. O ponto superior medial foi o que apresentou a maior diferença numérica, e o inferior medial a menor. Conclusão: O uso da máscara localizadora reduziu de forma estatisticamente significativa o número de escopias necessárias para a realização do bloqueio genicular. O uso desse dispositivo aumenta a segurança do médico e do paciente por diminuir a exposição à radioscopia nesse procediment. Nível de Evidência III, Ensaio clínico randomizado aberto - Nível de recomendação B - nível de evidência 2b.

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Objective: To evaluate the clinical and radiographic results of the surgical treatment of fractures of the middle third of the clavicle, using the technique of minimally invasive plate osteosynthesis (MIPO) with locking. Methods: Prospective case series, evaluating displaced fractures of the middle third of the clavicle submitted to MIPO with locking, with procedures performed by a single surgeon. Patients were evaluated at 12 months using the University of Los Angeles (UCLA) scale and anteroposterior radiographs of the clavicles with 45° cranial and caudal inclination, as well as reporting complications. Results: In total, 15 patients were evaluated. The median of surgical time was 50 minutes (IQR 35). The UCLA scale had a median of 35 (IQR 2) at 12 months. All patients presented fracture healing. Minor complications occurred in three cases (20%), with two (13.3%) evolving with plate prominence and one (6.7%) with local paresthesia, while major complications occurred in only one case (6.7%), with suture dehiscence requiring surgical re-approach. Conclusion: MIPO with locking is a viable option for the treatment of displaced fractures of the middle third of the clavicle, with excellent results according to the UCLA scale, fracture healing in all cases, and a low rate of complications. Level of Evidence IV, Case Series.

Objetivo: Avaliar os resultados clínicos e radiográficos do tratamento cirúrgico de fraturas do terço médio da clavícula pela técnica de osteossíntese minimamente invasiva com placa (OMIP) bloqueada. Métodos: Série de casos prospectiva que avaliou fraturas desviadas do terço médio da clavícula submetidas à OMIP bloqueada, com procedimentos realizados por um único cirurgião. Os pacientes foram avaliados aos 12 meses por meio da escala da Universidade da Califórnia em Los Angeles (UCLA) e por radiografias das clavículas em anteroposterior (AP) com inclinação cranial e caudal de 45°, além de relatos de complicações. Resultados: Foram avaliados 15 pacientes. A mediana do tempo cirúrgico foi de 50 minutos (IIQ 35). A escala da UCLA aos 12 meses teve mediana de 35 (IIQ 2). Todos os pacientes apresentaram consolidação da fratura. Complicações menores ocorreram em três casos (20%): dois (13,3%) com proeminência da placa e um (6,7%) com parestesia local. Maiores complicações ocorreram em apenas um caso (6,7%), com deiscência de sutura, necessitando de reabordagem cirúrgica. Conclusão: A OMIP bloqueada se mostrou uma opção viável ao tratamento das fraturas desviadas do terço médio da clavícula, com resultados excelentes de acordo com a escala UCLA, consolidação em todos os casos e baixo índice de complicações. Nível de Evidência IV, Série de Casos.

RESUMO

PURPOSE: To compare patients undergoing anterior cruciate ligament (ACL) reconstruction with hamstring grafts 7 mm or less in diameter combined with anterolateral ligament (ALL) reconstruction versus isolated ACL reconstruction with grafts greater than 7 mm in diameter. METHODS: We retrospectively evaluated the descriptive data and clinical outcomes of patients who underwent primary ACL reconstruction with hamstring grafts from June 2013 to January 2020 and had a minimum follow-up period of 2 years. Patients with quadrupled or quintupled semitendinosus and gracilis autograft 7 mm or less in diameter combined with single-strand ALL reconstruction (ACL-ALL group) were matched in a 1:2 propensity ratio to patients who underwent isolated single-bundle ACL reconstruction with hamstring grafts greater than 7 mm (ACL group). RESULTS: We identified 30 patients in our database who met the criteria for the ACL-ALL group. The patients in this group were matched to 60 patients comprising the ACL group. Both groups were similar regarding all preoperative matched and unmatched variables. The mean ACL graft diameter was 6.8 ± 0.4 mm in the ACL-ALL group and 8.6 ± 0.6 mm in the ACL group (P < .001). The ACL-ALL group presented 1 failure (3.3%), and the ACL group presented 3 failures (5%) (P = .717). Postoperative KT-1000 measurements were similar between the groups (2.1 ± 1.1 mm vs 1.9 ± 1.2 mm, P = .114), as were postoperative pivot-shift grades (P = .652). Subjective International Knee Documentation Committee scores and Lysholm scores did not present any differences between the groups (P = .058 and P = .280, respectively). CONCLUSIONS: Patients who undergo combined ACL-ALL reconstruction with an ACL graft diameter of 7 mm or less can achieve similar results to patients who undergo isolated ACL reconstruction with a graft diameter greater than 7 mm. An associated ALL reconstruction can be performed to increase knee stability in patients with small-diameter hamstring grafts. LEVEL OF EVIDENCE: Level III, retrospective, comparative therapeutic trial.

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ABSTRACT Objective: To evaluate the clinical and radiographic results of the surgical treatment of fractures of the middle third of the clavicle, using the technique of minimally invasive plate osteosynthesis (MIPO) with locking. Methods: Prospective case series, evaluating displaced fractures of the middle third of the clavicle submitted to MIPO with locking, with procedures performed by a single surgeon. Patients were evaluated at 12 months using the University of Los Angeles (UCLA) scale and anteroposterior radiographs of the clavicles with 45° cranial and caudal inclination, as well as reporting complications. Results: In total, 15 patients were evaluated. The median of surgical time was 50 minutes (IQR 35). The UCLA scale had a median of 35 (IQR 2) at 12 months. All patients presented fracture healing. Minor complications occurred in three cases (20%), with two (13.3%) evolving with plate prominence and one (6.7%) with local paresthesia, while major complications occurred in only one case (6.7%), with suture dehiscence requiring surgical re-approach. Conclusion: MIPO with locking is a viable option for the treatment of displaced fractures of the middle third of the clavicle, with excellent results according to the UCLA scale, fracture healing in all cases, and a low rate of complications. Level of Evidence IV, Case Series.

RESUMO Objetivo: Avaliar os resultados clínicos e radiográficos do tratamento cirúrgico de fraturas do terço médio da clavícula pela técnica de osteossíntese minimamente invasiva com placa (OMIP) bloqueada. Métodos: Série de casos prospectiva que avaliou fraturas desviadas do terço médio da clavícula submetidas à OMIP bloqueada, com procedimentos realizados por um único cirurgião. Os pacientes foram avaliados aos 12 meses por meio da escala da Universidade da Califórnia em Los Angeles (UCLA) e por radiografias das clavículas em anteroposterior (AP) com inclinação cranial e caudal de 45°, além de relatos de complicações. Resultados: Foram avaliados 15 pacientes. A mediana do tempo cirúrgico foi de 50 minutos (IIQ 35). A escala da UCLA aos 12 meses teve mediana de 35 (IIQ 2). Todos os pacientes apresentaram consolidação da fratura. Complicações menores ocorreram em três casos (20%): dois (13,3%) com proeminência da placa e um (6,7%) com parestesia local. Maiores complicações ocorreram em apenas um caso (6,7%), com deiscência de sutura, necessitando de reabordagem cirúrgica. Conclusão: A OMIP bloqueada se mostrou uma opção viável ao tratamento das fraturas desviadas do terço médio da clavícula, com resultados excelentes de acordo com a escala UCLA, consolidação em todos os casos e baixo índice de complicações. Nível de Evidência IV, Série de Casos.

RESUMO

ABSTRACT The performance of genicular nerve block requires an imaging method to guide the procedure. Radioscopy has the disadvantage of being radiation dependent. Objective: To assess whether the use of adhesive radiopaque grids reduce radiation exposure in these cases. Methods: This is a cross-sectional study conducted with 23 orthopedists in which needles were positioned in a model with and without the use of adhesive radiopaque grids. The number of fluoroscopy shots necessary for proper positioning in three points (superior lateral, superior medial, and inferior medial) were registered. Results: A statistical difference was observed in the three blocking points studied. The number of radioscopies required for these three points were 12.1 ± 2.5 in the group without grid and 5.0 ± 1.8 in the group with grid. The superior medial point presented the greatest numerical difference and the inferior medial point the smallest. Conclusion: The use of adhesive radiopaque grids led to a statistically significant reduction in the number of radioscopies/fluoroscopies required to perform the genicular block. The use of this device increases the safety of the physician and patient by reducing radiation exposure in this procedure. Level of Evidence III, Level of Evidence II, Random Clinical Trial.

RESUMO Para a realização do bloqueio de nervos geniculares é necessário guiar o procedimento por um método de imagem. A radioscopia possui a desvantagem de ser dependente de radiação. Objetivo: Avaliar se o uso de máscaras localizadoras diminui a exposição à radiação nesses casos. Métodos: Estudo transversal realizado com 23 ortopedistas, que realizaram o posicionamento de agulhas em um modelo com e sem o uso da máscara localizadora. Foi registrado o número de escopias necessárias para o posicionamento adequado em três pontos: superior lateral, superior medial e inferior medial. Resultados: Foi observada diferença estatística nos três pontos de bloqueio analisados. O número de radioscopias necessárias nos três pontos somados foi de 12,1 ± 2,5, no grupo sem máscara, e 5,0 ± 1,8, no grupo com máscara. O ponto superior medial foi o que apresentou a maior diferença numérica, e o inferior medial a menor. Conclusão: O uso da máscara localizadora reduziu de forma estatisticamente significativa o número de escopias necessárias para a realização do bloqueio genicular. O uso desse dispositivo aumenta a segurança do médico e do paciente por diminuir a exposição à radioscopia nesse procediment. Nível de Evidência III, Ensaio clínico randomizado aberto - Nível de recomendação B - nível de evidência 2b.