Diss. (sammanfattning) Stockholm : Karol. inst., 2004. / Härtill 4 uppsatser.

Submitted by Diogo Misoguti (diogo.misoguti@gmail.com) on 2016-06-24T19:52:09Z No. of bitstreams: 1 2015-12-doutorado-pedro-debieux-vargas-silva.pdf: 2344545 bytes, checksum: 1ecd3c6040fb5757f7f2df3ba6314152 (MD5) / Approved for entry into archive by Diogo Misoguti (diogo.misoguti@gmail.com) on 2016-06-24T19:52:38Z (GMT) No. of bitstreams: 1 2015-12-doutorado-pedro-debieux-vargas-silva.pdf: 2344545 bytes, checksum: 1ecd3c6040fb5757f7f2df3ba6314152 (MD5) / Made available in DSpace on 2016-06-24T19:52:38Z (GMT). No. of bitstreams: 1 2015-12-doutorado-pedro-debieux-vargas-silva.pdf: 2344545 bytes, checksum: 1ecd3c6040fb5757f7f2df3ba6314152 (MD5) Previous issue date: 2015 / Introdução: Esta revisão avalia se os parafusos de interferência bioabsorvíveis podem apresentar melhores resultados do que os parafusos de interferência metálicos quando utilizados para a fixação do enxerto na reconstrução do LCA. Objetivo: Comparar a efetividade dos parafusos de interferência bioabsorvíveis e metálicos para a fixação do enxerto na reconstrução do ligamento cruzado anterior, através de meta-análise. Métodos: Foram pesquisadas as bases de dados: Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, The Cochrane Library, MEDLINE, EMBASE, LILACS, Current Controlled Trials e the World Health Organization Clinical Trials Registry Platform. Ensaios clínicos randomizados e quasi-randomizado comparando parafusos de interferência bioabsorvíveis com metálicos foram incluídos na pesquisa. Os desfechos primários foram função, qualidade de vida, falhas de tratamento e nível de atividade. Ao menos dois autores selecionaram estudos elegíveis e avaliaram de forma independente o risco de viés. Os dados relevantes foram agrupados. Resultados: Onze ensaios envolvendo 981 participantes foram incluídos na revisão. Em relação à função (avaliada pelo Lysholm), quatro ensaios clínicos (220 participantes) não mostraram diferenças entre os dois métodos de fixação com 12 ou 24 meses de seguimento: MD -026, IC 95%, -1,63 a 1,11 e MD 1,10, IC 95% -1,44 a 1,64, respectivamente. Quando realizada a análise de subgrupos do Lysholm, entretanto, foi observada diferença estatística favorável ao parafuso metálico, quando o parafuso bioabsorvível era constituído por Ácido-L-Polilático (PLLA): RR -4,00, 95% CI -7,59 a -0,41. Três estudos com 24 meses (RR 1,00, 95% CI 0,81-1,24) e dois estudos com 12 meses de seguimento (RR 1,01, 95% CI 0,94-1,08) não mostraram diferenças no IKDC. Em relação ao nível de atividade (analisado pelo Tegner), dois estudos (117 participantes) com 12 meses, e três estudos com 24 meses de seguimento não evidenciaram diferenças entre o grupo bioabsorvível e o grupo que usou parafuso de metal: MD 0.08, 95% CI -0,39 a 0,55 e MD 0,41, IC 95% -0,23 a 1,05, respectivamente. Na análise de subgrupos, houve diferença estatística favorável ao parafuso de PLLA: RR 1,27, 95% CI 0,49 a 3,30. Apesar da diferença estatística, em nenhum dos desfechos supracitados observou-se relevância clínica. Em relação às falhas de tratamento, foi demonstrada uma diferença significativa entre os dois métodos de fixação, quando considerada a quebra de implante (RR 7,06, 95% CI 1,31-2,75) e quanto ao risco global de falha do tratamento (RR 1,89, 95% CI 1,31-2,75), tendo o parafuso bioabsorvível mais falhas nestes aspectos. Em oposição, não houve diferença significativa para estabilidade, testes funcionais, derrame articular, re-lesões, infecção, reação de corpo estranho, dor ou limitação de movimento. Conclusão: Não há evidência que demonstre diferença de efetividade entre parafusos de interferência metálicos com relação aos bioabsorvíveis para fixação do enxerto na reconstrução do ligamento cruzado anterior quanto a função, qualidade de vida e o nível de atividade; entretanto, há evidências de que parafusos bioabsorvíveis estão associados a mais falhas de tratamento global e quebra do implante. Os ensaios clínicos randomizados presentes na literatura fornecem evidências de moderada/baixa qualidade. / Introduction: This review assesses whether bioabsorbable interference screws may show better results than metal ones when used for fixing the graft in the reconstruction of the anterior cruciate ligament (ACL). Objective: To compare the effects of bioabsorbable and metal interference screws for fixing the graft in the reconstruction of the anterior cruciate ligament, by metaanalysis. Methods: The following databases were searched: Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, The Cochrane Library, MEDLINE, EMBASE, LILACS, Current Controlled Trials and the World Health Organization International Clinical Trials Registry Platform. Randomized controlled trials and quasi-randomized trials comparing bioabsorbable with metal interference screws were included in the survey. Primary outcome measures were function, quality of life, treatment failures and activity level. At least two authors selected eligible studies and independently assessed the risk of bias. The relevant data were pooled. Results: Eleven trials involving 981 participants were included in the review. Regarding the function (assessed by Lysholm), four trials (220 participants) showed no differences between the two fixation methods with 12 or 24 months of follow-up: MD -026, CI 95% -1.63 - 1.11 and MD 1.10, CI 95% - 1.44 to 1.64, respectively. However, when subgroup analysis using Lysholm score was performed, statistical difference was observed favoring the metal screw when the bioabsorbable screw was comprised of L-polylactic acid (PLLA): RR -4.00, CI 95%, -7.59 - -0.41. Three studies at 24 months (RR 1.00, 95% CI 0.81 to 1.24) and two studies at 12 months follow-up (RR 1.01, 95% CI 0.94 to 1.08) showed no differences the in the IKDC. Regarding the level of activity (analyzed by Tegner activity level scale), two studies (117 participants) at 12 months and three studies at 24 months follow-up showed no differences between the bioabsorbable group and the group using metal screws: MD 0.08, 95 % CI -0.39 to 0.55 and MD 0.41, 95% CI -0,23-1,05 respectively. In the subgroup analysis, a statiscally favorable difference was found for the PLLA screw: RR 1.27, 95% CI 0.49 to 3.30. Despite the statistical differences, none of the above outcomes has presented clinical relevance. With regard to treatment failures, a significant difference was found between the two methods of attachment, when considering the implant breaks (RR 7.06, 95% CI 1.31 to 2.75) and the overall risk of failure (RR 1.89, CI 95% 1.31 to 2.75), with the bioabsorbable screw having more failures in these respects. In contrast, there was no significant difference in stability, functional testing, joint effusion, re-injury, infection, foreign body reaction, pain or limitation of movement. Conclusion: There is no evidence that demonstrates an effective difference between metal and bioabsorbable interference screws for graft fixation in the reconstruction of the anterior cruciate ligament when considering function, quality of life and level of activity. However, there is evidence that bioabsorbable screws are associatewith more failures in the global treatment as well as breaks of the implant. Clinical trials in the literature provide moderate / low quality evidence.

Em uma tentativa de melhor restabelecer a função normal do ligamento cruzado anterior (LCA), foi proposta a técnica de reconstrução do LCA com feixe duplo (FD). Entretanto, a superioridade desta técnica frente à técnica com feixe simples (FS) ainda não está claramente demonstrada no cenário clínico. O propósito do presente estudo foi avaliar e comparar a amplitude de rotação tibial, o máximo de rotação interna e externa, e a força de reação ao solo de joelhos submetidos à reconstrução anatômica com feixe duplo, a joelhos submetidos à reconstrução com feixe simples, durante a realização de tarefas dinâmicas. Para isso, um total de 75 (setenta e cinco) indivíduos foram avaliados (26 reconstruções feixe duplo, 22 reconstruções feixe simples, 27 indivíduos sem lesão do LCA que formaram um grupo controle). Utilizando um sistema de análise do movimento humano, constituído por 4 câmeras para a análise do movimento, os indivíduos foram avaliados em três tarefas de demandas distintas. Utilizou-se a técnica TSACCAST para o cálculo da rotação interna e externa da tíbia. A média da amplitude de rotação tibial, máximo de rotação interna e externa, foi avaliada para cada joelho em cada um dos três grupos. A avaliação clínica destes pacientes foi realizada utilizando-se questionários subjetivo e objetivo (IKDC), assim como artrometria manual. Estas avaliações revelaram que ambos os grupos operados eram semelhantes no que se refere ao resultado clínico pós-operatório. A avaliação da amplitude de rotação tibial, máximo de rotação interna e externa, demonstrou que o joelho operado era semelhante ao joelho não operado e aos joelhos do grupo controle. Também não se verificou diferença significativa nos valores de amplitude de rotação tibial, máximo de rotação interna e externa, quando se comparou o grupo FS ao grupo FD. Desta forma, concluímos que a reconstrução do LCA com a técnica de FS e com a técnica de FD são similares no que se refere ao restabelecimento do controle da rotação da tíbia / In an attempt to better restore the normal function of the two ACL bundles, the ACL reconstruction with two bundles has been proposed. However, the superiority of the double-bundle technique has not been clearly demonstrated in the clinical setting. The purpose of this study was to compare the tibial rotational range, maximal internal and external rotation and ground reaction force of anatomical double-bundle anterior cruciate ligament reconstructed knees with single-bundle anterior cruciate ligament reconstructed knees during three different demanding tasks. A total of 75 subjects, (26 with double-bundle anterior cruciate ligament reconstruction, 22 with single-bundle anterior cruciate ligament reconstruction, and 27 healthy control individuals) were evaluated in this study. Using a 4-camera motion analysis system, motion subjects were recorded performing during three different tasks. Using the CAST technique, the internal-external tibial rotation of both knees was calculated. The mean tibial rotational range, maximum internal and external rotation, for each knee, was evaluated for the 3 groups (double-bundle group, single-bundle group, and control group). Clinical assessment, including objective and subjective IKDC scores, and knee arthrometric measurement, revealed restoration of the reconstructed knee stability with no differences between the two anterior cruciate ligament reconstruction groups. The results demonstrated that both groups resulted in tibial rotation range values that were similar to those in the non-injured knees and those in the healthy controls. There were also no significant differences in tibial rotational range, maximal internal and external rotation and ground reaction force between the DB group and the SB group. Therefore, anatomical double-bundle and single-bundle reconstruction are able to restore normal tibial rotation

Orientador: Sérgio Rocha Piedade / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-24T17:24:46Z (GMT). No. of bitstreams: 1 Inada_MauroMitsuo_M.pdf: 1830767 bytes, checksum: 4b553d2b930c1c4c78288e15aa3c117e (MD5) Previous issue date: 2014 / Resumo: Introdução: A lesão bicruzado do joelho é rara e está frequentemente associada a traumas de alta energia, sendo o procedimento cirúrgico o tratamento instituído devido a sua complexidade. Objetivo: Avaliar os resultados clínicos e funcionais de pacientes submetidos a reconstrução bicruzado do joelho, realizada em dois tempos cirúrgicos, utilizando os Escores de Lysholm, Tegner, KOOS e SF-36. Materiais e Métodos: 25 pacientes (20 homens e 5 mulheres) foram avaliados, idade média de 32,3 anos (17 a 53 anos), IMC médio de 26,2(18,9 a 34,9 Kg/m²), tempo de lesão de 18,3 meses (lesões crônicas). Quanto ao mecanismo de lesão, os acidentes auto-moto-ciclístico responsáveis por 72% dos casos, a prática esportiva por 16% e queda ou entorse por 12%. Inicialmente, foi utilizada a técnica Inlay para a reconstrução do LCP, utilizando o terço central do tendão patelar. Após um intervalo mínimo de 3 meses realizou-se a reconstrução do ligamento cruzado anterior via artroscópica, utilizando tendões flexores. Foram observadas as seguintes lesões associadas: condral em 7 pacientes (28%), meniscal em 16 pacientes (64%), lesões ligamentares associadas em 12 pacientes (48%). Procedimento cirúrgico adicional foram necessários em 4 pacientes (tendão patelar em 2 casos e ligamento colateral medial em 2 pacientes). Resultados: Com seguimento pós-operatório médio de 24,8 meses, em 60% dos casos a gaveta posterior foi classificada como zero e + (0,5 cm), enquanto 40% foram classificados como ++ (até 1cm). 60% dos pacientes obtiveram Escore de Lysholm bom/excelente. O Escore de atividade Tegner apresentou queda no nível de atividade física pós-reconstrução bicruzado, em comparação com o nível de atividade física pré-lesão, com relevância estatística. Entretanto, apenas 1 paciente retornou ao mesmo nível de atividade pré-lesão. A análise estatística revelou que o tempo de lesão influenciou negativamente os resultados clínicos pós-operatórios, em particular os parâmetros atividades esportivas/recreativas, do questionário KOOS, além dos domínios capacidade funcional, limitação dos aspectos físicos, vitalidade e saúde mental, do questionário SF-36. Por outro lado, variáveis como idade, IMC, presença de lesões condrais, meniscais e ligamentares associadas, assim como gaveta posterior residual não afetaram o resultado final. Conclusão: neste estudo o tempo de lesão teve um impacto negativo no prognóstico pós-operatório da reconstrução bicruzado, realizado em dois tempos cirúrgicos. Entretanto, é importante ressaltar que outras variáveis estudadas devem ser consideradas. Palavras-chave: ligamento cruzado posterior, ligamento cruzado anterior, joelho, traumatismos do joelho / Abstract: Introduction: Bicruciate lesions of the knee are rare and often related to high-energy traumas. A surgical procedure is used because of their complexity. Objective: to assess the clinical and the functional outcomes after two-stages bicruciate knee reconstruction using the Lysholm, Tegner, KOOS and SF-36 scores. Materials and methods: 25 patients (20 males and 5 females) were evaluated, mean age 32,3 years (17-53 years), mean BMI 26,2 (18,9-34,9), mean duration of lesion 18,3 months (chronic lesions). Regarding the mechanism of injury, car, motorcycle and bicycle accidents were responsible for 72%, while sports practices 16% and falls or sprains 12%. The Inlay technique was applied in PCL reconstruction using the central 1/3 of the patellar tendon. After 3 months minimum interval, ACL reconstruction was arthroscopically performed using flexor tendons. The following intraoperative lesions were detected: chondral ¿ 07 patients (28%); meniscal ¿ 16 patients (64%); associated ligament lesions ¿ 12 (48%). An additional surgical procedure was required for 4 patients (patellar tendon ¿ 2 cases, CML ¿ 2 cases). Results: With a 24,8 month mean postoperative follow-up of the cases, the posterior drawer test rated zero or + (0,5 cm) were observed in 60% of the patients, while 40% as ++ ( 1cm) and 60% of patients rated good/excellent condition (Lysholm). The Tegner activity score revealed that postoperative physical activity was less than physical activity level before the lesion and and the reduction was statistically significant. Moreover, only one patient achieved the pre-lesion activity level. The statistical analysis revealed that duration of lesion negatively influenced postoperative clinical results, especially regarding parameters such as sports/recreative activities (KOOS) and physical functioning, limitation of physical aspects, vitality and mental health (SF-36). However, in this study, the variables such as age, BMI, presence of chondral, meniscal, ligament lesions and residual posterior drawer did not affect the final result. Conclusion: The results obtained by this study concluded that duration of lesion had a negative impact on postoperative prognosis. However, it is important that other analyzed variables should also be considered. Keywords: posterior cruciate ligament, anterior cruciate ligament, knee, knee injury / Mestrado / Fisiopatologia Cirúrgica / Mestre em Ciências

Introduction: The Anterior Cruciate ligament (ACL) is one of the most important ligaments in the knee providing joint stability. Rupture of ACL is the most common sports injury. About half of the patients undergo surgical reconstruction. The Orthopaedic clinic in Region Örebro county underwent a reorganization in 2016. Aim: The aim of this study was to evaluate the two-year risk of re-arthroscopy in the same knee after primary ACL-reconstruction. Material and Methods: A retrospective cohort study. All patients from 1st January 2005 until 31st December 2017 with primary ACL reconstruction in Region Örebro county were included. Data was collected from medical records and The Swedish National Anterior Cruciate Ligament Register. Results: 431 patients were included. The total risk of re-arthroscopy was 13.0%. Meniscal surgeries and age did not affect the outcome. Fixation method in femur and tibia affected the outcome, as did choice of graft. There was a small numerical difference before (13.4%) vs after (12.1%) the reorganization, but it was not statistically significant either unadjusted or adjusted for age and meniscal surgeries (p=0.721). Conclusions: Our study indicates that choice of graft and fixation method in femur and tibia affect the re-arthroscopy rate. Regarding graft, the semitendinosus tendon alone was the better option, and for fixation both for femur and tibia it seems like Tightrope was the best option and screw the worst. The reorganization did not affect the outcome but might have other benefits.

Osteoarthritis (OA) of the knee, a musculoskeletal disease characterized by degenerations in multiple joint tissues including the articular cartilage and subchondral bone, is a major clinical challenge worldwide that currently has no cure. Traumatic knee injuries such as anterior cruciate ligament (ACL) tear predispose subjects to early onset of post-traumatic OA (PTOA), necessitating the development of effective disease modifying therapies as total knee replacement surgeries have a limited lifetime. Significant knowledge gap remains in the pathogenesis of OA, while recent evidence suggests the important role of subchondral bone microstructure and mechanics in OA development. Subchondral bone is composed of the subchondral bone plate, a thin layer of cortical lamella, and the subchondral trabecular bone, composed of individual plate-like and rod-like trabeculae. These trabecular plates and rods determine the microstructure and mechanics of trabecular bone entirely and can be quantitatively analyzed using individual trabecula segmentation (ITS). Recent application of ITS showed that changes in the plate-and-rod microstructure of subchondral trabecular bone precede cartilage damage and are implicated to play a role in disease pathogenesis. Studies presented in this thesis aim to provide a deeper understanding of subchondral bone in knee OA scientifically and clinically, which may ultimately be used to improve diagnosis, prevention and treatment of this prevalent and disabling disease. In the first study, we comprehensively quantified microstructural and tissue biomechanical properties of the subchondral bone and articular cartilage in human knee specimens with advanced OA and control knees without OA. We found reduced tissue modulus in trabecular plates and rods in regions with moderate OA, where cartilage is still intact, that persisted in severe OA regions, where cartilage is severely damaged. These observations suggest that tissue biomechanical changes in the subchondral trabecular bone may precede cartilage damage in OA development. Furthermore, we found strong correlations between structural and mechanical parameters of the cartilage and subchondral bone in CT knees, suggesting cross-talk at the tissue level. This coupling persisted in moderate OA regions but disappeared in severe OA regions, suggesting that loss of tissue crosstalk may be an additional indicator of disease progression. In the second study, we quantified subchondral bone microstructural changes after ACL tear in vivo in human subjects using the second-generation high resolution peripheral quantitative computed tomography (HR-pQCT). We examined short-term longitudinal changes during the acute phase (~18 days to ~141 days) after injury, as well as long-term adaptations (~5 years post injury) in the injured knee relative to the contralateral knee in a cross-sectional cohort. We found subchondral bone loss within 1 month from injury that primarily targeted trabecular rods, especially at the distal femur. We also found increased spatial heterogeneity in subchondral trabecular microstructure within the injured knees compared to the contralateral knees in the long-term after injury. These findings indicate that ACL tear results in both short-term and long-term microstructural adaptations in the subchondral bone. ITS based on HR-pQCT knee scans may be a valuable tool to monitor disease progression in vivo. Finally, we quantified subchondral bone microstructural changes after ACL-transection in a canine model of PTOA and investigated the effects of bisphosphonate and NSAID treatment on subchondral bone changes and OA progression. Studies were conducted in skeletally-mature and juvenile animals to investigate the effect of injury age. We found that subchondral bone adaptations after surgery and treatment effects depended on skeletal maturity of animals. In mature animals, changes in the microstructure of trabecular plates and rods occurred 1-month post-op and persisted until 8-months post-op. Bisphosphonate treatment attenuated these microstructural changes and cartilage degeneration while NSAID treatment did not. In juvenile animals that have not reached skeletal maturity, transient changes in trabecular plate and rod microstructure occurred at 3-months post-op but disappeared by 9-months post-op. Neither bisphosphonate nor NSAID treatment attenuated bone microstructural changes or cartilage damages. These findings suggest that age and skeletal maturity at time of injury may need to be considered as additional factors in studying PTOA progression and developing preventative treatments. Taken together, these studies highlight the importance of microstructural and tissue biomechanical changes of subchondral bone in the development of OA. In vivo quantification of subchondral bone using advanced imaging modalities enable longitudinal monitoring of disease progression. Therapeutic agents targeting subchondral bone changes after traumatic injury may be effective preventative strategies for PTOA.

No description available.

Zielstellung: Die Ruptur des vorderen Kreuzbandes (VkB) ist die häufigste Ursache einer Lahmheit beim Hund. Im Gegensatz zu der Humanmedizin, wo die anatomische intraartikuläre Rekonstruktion des vorderen Kreuzbandes als Therapie der Wahl gilt, wird die intraartikuläre Rekonstruktion beim Hund nur selten durchgeführt und hat bis jetzt nicht dauerhaften Erfolg. Die anatomische Platzierung der Bohrkanäle ist bei Menschen für den Erfolg der Operation bei Menschen entscheidend. Erstes Ziel der Studie war die Bestimmung der radiologischen Lage des Zentrums des femoralen vorderen Kreuzbandursprungs beim Hund. Zweites Ziel war die Entwicklung und Erprobung eines Zielgerätes für die arthroskopisch-assistierte, anatomische vordere Kreuzbandrekonstruktion beim Hund. Material und Methode: A. Radiologische Studie: Die kraniale Begrenzung des femoralen Ursprungs des vorderen Kreuzbandes (VK) wurde mit einem röntgendichten Draht bei 49 Femora orthopädisch gesunder Hunde (KM > 20 kg) markiert. Anschließend wurde eine Computertomographie und 3D- Rekonstruktion jedes Femurs angerfertigt, anhand derer der Ursprung manuell segmentiert und das Zentrum berechnet wurde. Schließlich wurden, basierend auf den 3D-Modellen, virtuelle Röntgenbilder in zwei Ebenen berechnet. An diesen wurde die Position des berechneten Zentrums mit drei unterschiedlichen Methoden bestimmt (4x4-Gitterbox-Methode und prozentuale Position für die medio-laterale Projektion; Ziffernblattmethode für die disto-proximale Projektion). B. Zielgerät: Hintergliedmaßen (n = 12) von 6 Hundekadavern (KM ≥20 kg) wurden verwendet. Eine Gliedmaße jedes Kadavers wurde zufällig ausgewählt und die kaudo-kraniale Lage des Zentrums des vorderen Kreuzbandansatzes (vKBA) in medio-lateralen Röntgenbildern berechnet und anschließend auf ein justierbares Zielgerät übertragen. Unter arthroskopischer Kontrolle wurde das Zielgerät hinter der lateralen Kondyle eingehakt und ein Steinmann Pin von extra nach intraartikulär platziert. Die Position der resultierenden Bohrkanäle wurde sowohl röntgenologisch bestimmt als auch dreidimensional mit dem anatomischen Zentrum des vKBA der kontralateralen Hintergliedmaßen verglichen. Ergebnisse: A. Radiologische Studie: In der medio-lateralen Projektion befand sich das Zentrum des femoralen Kreuzbandursprungs im zweiten Rechteck von proximal in der kaudalen Spalte. Die mittlere prozentuale kaudo-kraniale und proximo-distale Position war 20,2 % (± 2,2), beziehungsweise 33,8% (± 3,7). Im disto-proximalen Röntgenbild lag in 97,6 % der Femora das Zentrum des femoralen Kreuzbandursprungs zwischen 14:00 und 15:00 Uhr. B. Zielgerät: In allen postoperativen Röntgenaufnahmen lagen die sechs Bohrkanäle im bzw. nahe dem Zentrum des vKBA. Die 3D- Messungen ergaben eine mediane Abweichung der Bohrkanalposition im Vergleich zum anatomischen Zentrum der kontralateralen Seite von 0,6 mm (Bereich:0,2– 0,9 mm). Schlussfolgerung: Die erarbeiteten Referenzwerte können für die Planung sowie die intra- und postoperative Kontrolle der femoralen Bohrung verwendet werden. Die Verwendung eines justierbaren Zielgerätes ermöglicht die präzise anatomische Platzierung des femoralen Bohrkanals für die intraartikuläre Rekonstruktion des vorderen Kreuzbandes. Die beschriebene Methode wird helfen, eine Fehlplatzierung des femoralen Bohrkanals im Zuge der intraartikulären vorderen Kreuzbandplastik zu reduzieren. In Kombination mit dem bereits beschriebenen tibialen Zielgerät sind nun die technischen Voraussetzungen für die arthroskopisch-assistierte anatomische vordere Kreuzbandplastik in der Tiermedizin gegeben. / Objective: Cranial cruciate ligament (CrCL) pathology is the most frequent cause of lameness in dogs. In contrast to human medicine, where anatomic reconstruction of the ACL is considered the treatment of choice, intra-articular repair in dogs is not commonly performed and until now has not met with enduring success. Accurate tunnel placement has been shown to be crucial in obtaining a successful outcome after anterior cruciate ligament reconstruction in humans. The first aim of our study was to define the radiographic location of the center of the femoral attachment of the CrCL in dogs, for the pre- operative planning as well as post-operative control of anatomical placement of the femoral tunnel. Second aim of the study was to develop and validate an aiming device for arthroscopic femoral tunnel placement. Materials and Methods: A. Radiographic study: Using femora from 49 adult, orthopedically sound dogs (BW ≥ 20 kg), a radiopaque marker was placed on the cranial border of the femoral footprint of the CrCL. Computed tomography and 3D reconstruction of each femur was performed subsequently, followed by manual segmentation of the footprint on the 3D models and calculation of its center. Finally, virtual digital radiographs in two planes were produced and the location of the calculated center of the CrCL was expressed using three different methods (4x4 box grid method and percentage position for the medio-lateral projection; o’clock position for the disto-proximal projection). B. Aiming device: Hindlimbs (n=12) of 6 cadaveric dogs weighing ≥20 kg were used. One hindlimb from each cadaver was randomly chosen and the caudo- cranial position of the CrCL center was calculated, on standard medio-lateral stifle radiographs, and transferred onto to an adjustable aiming device. During stifle arthroscopy the aiming device was inserted and guide pin placed from extra-to-intra-articular. The position of the resulting bone tunnel was evaluated on stifle radiographs and also compared with the anatomic center of each contralateral hindlimb, in the three dimensional (3D) space. Results: A. Radiographic study: In the medio-lateral radiographs the center of the femoral footprint was consistently located in the second rectangle from the top of the most caudal column of the 4x4 grid. The mean percentage caudo- cranial and proximo-distal location was 20.2% (± 2.2) and 33.8% (± 3.7), respectively. In the disto-proximal radiograph, the o’clock position of the CrCL center was between 2 and 3 o’clock in 97.6% of the femora. B. Aiming device: According to the postoperative radiographs, the location of all 6 intra-articular tunnel openings was consistent with the results of the radiographic study. In 3D space, arthroscopic femoral drilling resulted in a median deviation of the drill tunnels of 0.6 mm around the CrCL center. All tunnel openings were located within the CrCL insertion. Conclusions: The reported data can be used to plan and verify the placement of the femoral tunnel opening during intra-articular anatomic CrCL repair. The use of the aiming device suggests that arthroscopic femoral tunnel placement can be achieved with high precision. The measurement for the device can be derived from a standard medio-lateral radiograph of the stifle, which is part of the diagnostic work up of every dog with lameness localized in the stifle. The proposed technique may reduce femoral tunnel misplacement when performing intra-articular CrCL repair in dogs. In combination with the described technique for arthroscopic tibial tunnel drilling, arthroscopic assisted anatomic reconstruction of the CrCL in dogs can be achieved.

As lesões do ligamento cruzado posterior (LCP) geralmente estão associadas a traumas de alta energia. Ainda existem muitas controvérsias sobre a técnica cirúrgica ideal para o tratamento dessas lesões, no que diz respeito aos métodos de seleção e fixação do enxerto. A técnica onlay, recentemente descrita, permite a fixação direta de um autoenxerto de tendões flexores ao aspecto posterior da tíbia com parafuso esponjoso e arruela dentada plástica, com proteção às estruturas neurovasculares e evitando a chamada \"curva assassina\". O objetivo deste estudo foi realizar uma avaliação biomecânica da técnica onlay, comparando entre si as fixações tibiais unicortical e bicortical de enxertos, imediatamente após o implante (tempo zero). O ensaio biomecânico e a coleta de dados foram realizados no Thompson Laboratory for Regenerative Orthopaedic da Universidade de Missouri (Columbia, Missouri, EUA). Para isso, oito joelhos de espécimes cadavéricos foram distribuídos aleatoriamente em uma das duas técnicas de fixação do LCP (n = 4 joelhos/técnica), que foram realizadas por cirurgiões experientes no procedimento. O teste biomecânico consistiu em uma força com direção posterior aplicada a região proximal da tíbia, em quatro ângulos de flexão do joelho, 10o, 30o, 60o e 90o. O teste foi realizado com uma taxa de deslocamento de 1 mm/s, em uma máquina servo-hidráulica (8821s, Instron, Norwood, MA). As variáveis medidas foram: carga para 5 mm de deslocamento posterior, deslocamento máximo (com carga de 100 N) e rigidez. Para a análise estatística, os dados de cada joelho foram normalizados para o joelho com LCP nativo intacto e depois agrupados nas categorias unicortical ou bicortical, de acordo com a fixação realizada. Dados obtidos, nas variáveis mencionadas, para os grupos joelho intacto, joelho desbridado, unicortical e bicortical, foram comparados por meio da análise de variância simples (one-way ANOVA) para avaliar diferenças estatisticamente significativas (p < 0,05). Quando comparadas aos joelhos com LCP desbridado, as técnicas de fixação unicortical e bicortical apresentaram menor frouxidão a uma carga máxima de 100N. Quando comparados com os joelhos intactos, o grupo unicortical apresentou maior frouxidão em todos os ângulos e o grupo bicortical apresentou maior frouxidão apenas a 90o de flexão (p < 0,001). Na avaliação da força relativa do enxerto, ou seja, a carga necessária para atingir 5 mm de deslocamento na gaveta posterior, as técnicas unicortical e bicortical exigiram menos carga que os joelhos com LCP intacto. O grupo com fixação bicortical, no entanto, foi superior ao unicortical em todos os ângulos (p < 0,001), na avaliação da força relativa. Em relação à rigidez, não houve diferenças significativas entre os grupos unicortical e bicortical e ambos foram superiores aos joelhos desbridados e inferiores aos joelhos com LCP intacto. Com base nos testes biomecânicos de cadáveres, nenhuma das técnicas de reconstrução do LCP foi capaz de reproduzir os resultados do joelho com LCP intacto, mas ambas as técnicas foram superiores aos joelhos com deficiência de LCP. Ao se optar pela técnica onlay de reconstrução do LCP, a técnica de fixação tibial bicortical parece ter vantagens biomecânicas em relação à técnica de fixação unicortical. / Posterior cruciate ligament (PCL) injuries are generally associated with high energy trauma. There are many controversies regarding optimal surgical technique in regard to graft selection and fixation methods. The recently described onlay technique allows for direct fixation of a hamstring autograft to the posterior aspect of the tibia, protecting the neurovascular structures and avoiding the so-called \"killer turn\". The onlay technique requires a cancellous screw and spiked washer to secure the graft to the tibia. The objective of this study was to compare immediate post-implantation biomechanics of unicortical versus bicortical tibial fixation of onlay PCL grafts. Biomechanical testing and data collection were performed at the Thompson Laboratory for Regenerative Orthopedics at the University of Missouri (Columbia-Missouri-USA). For that, eight knees were randomly assigned to one of two onlay PCL techniques (n= 4 knees/technique), performed by surgeons experienced with the procedure. Testing consisted of a posterior-directed force at four knee flexion angles, 10, 30, 60, and 90 degrees, at a displacement rate of 1 mm/s, performed in a servo-hydraulic machine (8821s, Instron, Norwood, MA). Measured variables were: load to 5 mm of posterior displacement, maximum displacement (at 100 N load) and stiffness. For statistical analyses, data for each knee were normalized to the native PCL-intact knee and then grouped into unicortical or bicortical groups accordingly. Data for load to 5 mm (strength), displacement at 100 N, and stiffness were compared among PCL-intact, PCL-deficient, unicortical fixation, and bicortical fixation categories using one-way analysis of variance (ANOVA) to assess for statistically significant (p < 0.05) differences. When compared to PCL-deficient knees, both unicortical and bicortical fixation techniques had less laxity at a maximum load of 100N. When compared with PCL-intact knees, unicortical had more laxity at all angles and bicortical had more laxity only at 90 degrees (p < 0.001). For relative graft strength, namely the load required to reach 5mm of displacement in posterior drawer, unicortical and bicortical techniques required less load to 5 mm of posterior drawer than for PCL-intact knees. Bicortical, however, outperformed unicortical at all angles (p < 0.001) for relative strength. Regarding stiffness of each construct, there were no significant differences between unicortical and bicortical and both were superior to PCL-deficient and inferior to PCL-intact knees. Based on cadaveric biomechanical testing, none of the reconstructed PCL knees was able to replicate the intact native PCL, but both techniques were superior to PCLdeficient knees. The bicortical tibial fixation technique appears to have biomechanical advantages when opting for onlay PCL reconstruction.

INTRODUÇÃO: Anualmente nos E.U. A, estima-se mais de 250.000 mil casos de lesão do ligamento cruzado anterior, o que torna a reconstrução cirúrgica um procedimento comum na pratica da medicina esportiva. Ainda não existe consenso sobre o quanto de atividade promove uma reabilitação adequada sem prejudicar o enxerto ou produzir uma frouxidão anterior anormal, com consequente dano ao menisco e a cartilagem articular. OBJETIVO: Analisar e comparar o efeito de um protocolo de fisioterapia acelerado na estabilidade anterior e evolução clínica dos indivíduos submetidos à reconstrução do ligamento cruzado anterior. MÉTODOS: Foram incluídos 29 indivíduos no estudo que apresentaram ruptura total do LCA confirmada por RM e submetidos à reconstrução ligamentar com Tendão patelar. Aleatoriamente foram alocados em dois grupos com intervalos de reabilitação diferentes: Grupo Acelerado (4 meses) ou Grupo Convencional (6 meses). No pré-operatório, sexto e no quarto mês de pós-operatório um avaliador cego registrou: a lassidão anterior através do KT1000, Força muscular (CYBEX) e a função do joelho acometido através do IKDC (2000) e o Hop Test. RESULTADOS: os grupos foram semelhantes em relação aos dados demográficos. Não foi encontrada diferença estatística na lassidão anterior no quarto mês 0,92mm versus 1,33mm e no sexto mês 0,50mm versus 1,67mm sendo Grupo Convencional versus Grupo Acelerado respectivamente. No quarto mês o Grupo Acelerado apresentou uma melhora significativa (P< 0,001) na evolução clínica do IKDC (2000) 79,50 versus 60,61 do Grupo Convencional, essa diferença não se repetiu no sexto mês. A força muscular e o Hop Test, o Grupo Acelerado apresentou maiores valores, mas não de forma significativa nos dois momentos de avaliação (P> 0.05). CONCLUSÃO: Com base nos resultados obtidos, o protocolo acelerado quando comparado ao Convencional, não se diferiu quanto à estabilidade anterior do joelho e foi suficiente para demonstrar uma melhora significativa precoce na evolução clínica do joelho / BACKGROUND: Each year in the US, it is estimated more than 250 million cases of anterior cruciate ligament injury, which makes surgical reconstruction a common procedure in the practice of sports medicine. There is still no consensus on how much activity to promote adequate rehabilitation without damaging the graft or produce an abnormal anterior laxity, with consequent damage to the meniscus and articular cartilage. PURPOSE: To analyze and compare the effect of an accelerated physiotherapy protocol in the anterior-stability and clinical outcome of patients undergoing reconstruction of the anterior cruciate ligament. METHODS: We included 29 subjects in the study who had total ACL rupture confirmed by MRI and underwent ligament reconstruction with patellar tendon. Patients were randomly allocated in two groups with different rehabilitation intervals: Accelerated Group (4 months) or Conventional Group (6 months). Preoperatively, six and four months postoperatively a blind evaluator recorded: anterior laxity by KT1000, Brawn (CYBEX) and knee function affected by IKDC (2000) and the Hop Test. RESULTS: the groups were similar relative to demographic data. There was no statistical difference in anterior laxity in the fourth month 0,92mm versus 1.33mm and 0.50mm in the sixth month versus 1,67mm being conventional group versus accelerated group respectively. In the fourth month the accelerated group showed a significant improvement (P <0.001) in the clinical evolution of the IKDC (2000) 79.50 versus 60.61 in the conventional group, this difference was not repeated in the sixth month. Muscle strength and the Hop Test, the fast group had higher values, but not significantly in both time points (P> 0.05). CONCLUSION: Based on these results, the Accelerated protocol when compared to conventional, do not differ as the anterior knee stability and was sufficient to establish an early significant improvement in the clinical outcome of the knee