INTRODUÇÃO: A instabilidade multiligamentar do joelho, normalmente, é provocada por um trauma que determina sua luxação, um evento pouco frequente, mas, que pode trazer sequelas devastadoras. Mesmo com o tratamento cirúrgico preconizado é alto o índice de complicações. A mobilização precoce no pósoperatório provoca afrouxamento dos ligamentos reconstruídos, o que leva à instabilidade residual. A imobilização melhora a estabilidade, mas provoca dor e rigidez. Este trabalho tem o objetivo de avaliar se o uso do fixador externo articulado proporciona melhora na mobilidade, estabilidade e na função subjetiva de pacientes submetidos à reconstrução ligamentar. MÉTODOS: Neste ensaio clínico randomizado com grupos paralelos, 33 pacientes do ambulatório do Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Universidade de São Paulo com mais que 3 semanas de lesão dos ligamentos cruzados anterior e posterior associado à lesão de ligamento colateral fibular e/ ou ligamento colateral tibial foram submetidos à cirurgia de reconstrução multiligamentar, após alocação cega aleatória ao grupo 0 - controle (18 pacientes), com órtese rígida ou ao grupo 1 - fixador externo articulado por 6 semanas (15 pacientes), no período entre novembro de 2010 e novembro de 2013. Após seguimento mínimo de um ano de pós-operatório, a estabilidade dos ligamentos reconstruídos foi avaliada ao exame físico, foram mensurados os déficits de extensão e de flexão residual em relação ao joelho contralateral não acometido e foi aplicado o questionário específico para sintomas do joelho de Lysholm. RESULTADOS: Não houve diferença na avaliação da estabilidade articular nem na extensão entre os grupos. No grupo 1, o déficit de flexão passiva foi menor (4,8º +- 5,4º contra 18,2 +- 14,8º, p < 0,05) com mais pacientes, obtendo déficit de flexão considerado normal, de até 5º (64% contra 18%, p < 0,05) e com classificação excelente ou boa no questionário de Lysholm (73% contra 35%, p < 0,05). CONCLUSÕES: Comparado ao protocolo de reabilitação com órtese rígida removível, o uso do fixador externo articulado no tratamento cirúrgico das lesões multiligamentares do joelho proporciona os mesmos resultados de estabilidade ligamentar, aumenta a amplitude de movimento final, com manutenção da extensão e redução do déficit de flexão e proporciona melhores resultados funcionais / INTRODUCTION: Multiligament knee instability is normally caused by a trauma which results in its dislocation, an infrequent event, but one which can have devastating aftereffects. Even with the recommended surgical treatment the rate of complications is high. Early post-operative mobilization provokes loosening of the reconstructed ligaments, which leads to residual instability. Immobilization improves the stability, but causes pain and stiffness. This study aims to assess whether the use of an articulated external fixator provides improvements in the mobility, stability and the subjective function of the patients submitted to ligament reconstruction. METHODS: In this randomized clinical trial with parallel groups, 33 patients of the outpatient clinic of the Institute of Orthopaedics and Traumatology of the Hospital das Clínicas of the University of Sao Paulo with more than 3 weeks of injury to the anterior cruciate ligaments and the posterior cruciate ligaments associated with injury to the fibular collateral ligament and/or medial collateral ligament, were submitted to multiligament reconstruction surgery, after blind random allocation to either: Group 0 - control (18 patients), with rigid bracing, or to Group 1 - articulated external fixator for 6 weeks (15 patients), in the period from November, 2010 to November 2013. The stability of the reconstructed ligaments were assessed after 1 year postoperatively by physical examination, the deficit of residual extension and flexion was measured in relation to the unaffected contralateral knee and the Lysholm knee scoring scale questionnaire was applied. RESULTS: There was no difference in the assessment of joint stability or of the extension between the groups. In group 1 the passive flexion deficit was less (4.8º +- 5.4º versus 18.2 +- 14.8º, p<0.05) with more patients obtaining a flexion deficit considered normal, or up to 5º (64% versus 18%, p<0.05) and with excellent or good classification in the Lysholm knee scoring scale questionnaire (73% versus 35%, p<0.05). CONCLUSIONS: Compared to the rehabilitation protocol with removable rigid bracing, the use of an articulated external fixator in the treatment of multiligament knee injuries provides equal results for ligament stability, increases the amplitude of the Range of Motion, maintains the extension and reduces the flexion deficit, and provides better functional result

INTRODUÇÃO: A localização ideal dos túneis do enxerto para a reconstrução do ligamento cruzado anterior (LCA) está na área da impressão original do ligamento. Entretanto, há pacientes que mesmo após a reconstrução anatômica do LCA se queixam de falseio. O objetivo do presente estudo foi comparar a estabilidade do joelho com túneis em duas posições diferentes da área de impressão original do LCA. MÉTODOS: Trinta reconstruções anatômicas do LCA foram realizadas em 15 joelhos de cadáver, com preservação do quadril até o tornozelo. Não foram criadas lesões para intensificar a instabilidade do joelho. O protocolo possuía quatro grupos: (1) LCA intacto, (2) deficiência completa e isolada do LCA, (3) reconstrução do LCA na posição anteromedial (AM REC) e (4) central (C REC) da impressão original do ligamento (ordem randômica). A estabilidade do joelho foi testada pelo teste de Lachman (68 N) e pelo teste do \"pivot shift\" mecanizado (CPM de 0° a 55° + valgo e rotação interna de 20 Nm) e avaliada por sistema óptico de navegação e tomografia 3D. A descrição da cinemática do joelho com 6 graus de liberdade foi realizada por sistema de coordenadas com eixo no centro geométrico dos côndilos. Estatística: rotação interna (°) e translação anterior (mm) foram avaliados nos testes do \"pivot shift\" e Lachman com 2 e 1- way RM ANOVA, respectivamente (alfa < 0,05). RESULTADOS: O grupo C REC em comparação com o grupo AM REC apresentou menor rotação interna nos testes do \"pivot shift\" (0,6° ± 0,3° vs. 1,8° ± 0,3°, respectivamente, P < 0,05) e de Lachman (2,9° ± 0,4° vs. 3,9° ± 0,4°, respectivamente, P < 0,05) e não apresentou diferença com relação à translação anterior nos mesmos testes do \"pivot shift\" (4,7 mm ± 0,4 mm vs. 4,5 mm ± 0,4 mm, respectivamente, P > 0,05) e de Lachman (1,2 mm ± 0,2 mm vs. 1,1 mm ± 0,2 mm, respectivamente, P > 0,05). Os grupos C REC e AM REC não mostraram diferença quando comparados ao grupo LCA intacto no teste de Lachman para translação anterior (2,1 mm ± 0,5 mm) e rotação interna (3,0° ± 0,5°) (para ambos, P > 0,05) e mostraram diferença no teste do \"pivot shift\" (6,4 mm ± 0,4 mm e 5,6° ± 0,3°, respectivamente, P < 0.05). DISCUSSÃO: Este foi o primeiro estudo a demonstrar alterações da cinemática do joelho em cadáveres com todo o membro preservado e sem lesões associadas para aumentar a instabilidade do joelho, na sequência completa dos experimentos (LCA intacto, lesionado e após as reconstruções anatômicas) com o aparelho de \"pivot shift\" mecanizado. CONCLUSÃO: A reconstrução anatômica do LCA na posição central permitiu uma maior restrição da rotação interna do joelho, em comparação à reconstrução anatômica anteromedial, quando submetida aos testes do \"pivot shift\" mecanizado e de Lachman. Tanto a AM REC quanto a C REC permitiram restabelecer a translação anterior do joelho próximo àquela função do LCA original / INTRODUCTION: The optimal femoral and tibial tunnel locations for grafting in anterior cruciate ligament (ACL) reconstruction are within the original ACL footprint. However, even with anatomic reconstructions, some patients still report giving way. This study aimed to compare knee stability in two different anatomic footprint ACL reconstruction positions. METHODS: Thirty anatomic ACL reconstructions were performed in 15 cadaveric hip-totoe specimens. No associated lesions were created to intensify knee instability. The protocol was conducted in four groups: (1) intact ACL, (2) complete-isolated ACL deficiency, (3) anatomic femoral and tibial anteromedial ACL reconstruction (AM REC); and (4) anatomic femoral and tibial central ACL reconstruction (Central REC). The reconstructions were randomly assigned. The Lachman test (68 N) and mechanized pivot-shift test (CPM from 0° to 55° + valgus and internal torque of 20 Nm) were recorded with optical tracking system and 3D tomography. The 6 degrees of freedom knee kinematics was described with geometric condyle axis based coordinate system. Statistics: internal rotation (°) and anterior displacement (mm) were analyzed in both tests with two- and one-way RM ANOVA (alfa < 0,05). RESULTS: The Central REC group compared to the AM REC group showed a smaller degree of internal rotation in the pivot-shift (0,6° ± 0,3° vs. 1,8° ± 0,3°, respectively, P < 0,05) and Lachman (2,9° ± 0,4° vs. 3,9° ± 0,4°, respectively, P < 0,05) tests and no difference in anterior translation in either the pivot-shift (4,7 mm ± 0,4 mm vs. 4,5 mm ± 0,4 mm, respectively, P > 0,05) or Lachman (1,2 mm ± 0,2 mm vs. 1,1 mm ± 0,2 mm, respectively, P > 0,05) test. Central REC and AM REC groups showed no differences compared to intact ACL group in Lachman test for anterior translation (2,1 mm ± 0,5 mm) and internal rotation (3,0° ± 0,5°) (for both, P > 0,05) but did show significant differences in the pivot-shift test (6,4 mm ± 0,4 mm and 5,6° ± 0,3°, respectively, P < 0.05). DISCUSSION: This was the first study to demonstrate knee kinematic changes in a hip-to-toe cadaver model without associated lesions to amplify knee instability with a mechanized pivot shift in the complete sequence of intact, ACL-deficient and anatomic reconstructions. CONCLUSION: Central anatomic ACL reconstruction permitted greater restriction of internal rotation than did anteromedial anatomic ACL reconstruction based on mechanized pivot shift and Lachman tests. Either AM REC and C REC restored anterior translation close to original ACL function

<p>Osnovni cilj rekonstrukcije prednjeg ukr&scaron;tenog ligamenta kolena je dobijanje pune stabilnosti kolena u celom obimu pokreta. Bez obzira na razvoj operativne tehnike i rehabilitacije i dalje postoji jedan broj pacijenata koji nije u potpunosti zadovoljan rezultatom rekonstrukcije prednjeg ukr&scaron;tenog ligamenta kolena, te je potrebno izvr&scaron;iti ponovnu operaciju. Smatra se da je najče&scaron;ći uzrok rane ponovne nestabilnosti lo&scaron;a pozicija kalema, tj. pozicija tunela koja nije na anatomskom mestu. Većina hirurga koji se bave ovom problematikom procenjuju poziciju kalema u golenjači na osnovu standardnih radiograma: prednje-zadnje i bočne projekcije, &scaron;to svakako nije dovoljno precizno. U ekonomski&nbsp; razvijenim zemljama poziciju kalema određuju analizirajući snimke kompjuterizovane tomografije (CT) ili magnetne rezonance (MRI). Prvenstveno zbog smanjenja doze zračenja kojoj se izlažu pacijenti prilikom kompjuterizovane tomografije, ali i iz ekonomskih razloga bilo bi korisno razvijanje jednog lako dostupnog, jeftinog ali preciznog i jednostavnog metoda određivanja položaja kalema u golenjači. Osnovni cilj ovog istraživanja bio je da se dokaže značaj pozicije kalema u golenjači i mogućnost svakodnevne kliničke primene novorazvijenog kompjuterskog programa u cilju određivanja prostorne pozicije kalema u golenjači iz samo dva standardna radiograma. Studija je bila eksperimentalno-prospektivnog karaktera. Eksperimentalni deo istraživanja sproveden je na Fakultetu tehničkih nauka (FTN) u Novom Sadu na Departmanu za proizvodno ma&scaron;instvo gde je na osnovu standardnih RTG snimaka (prednje-zadnje i bočne projekcije) razvijen kompjuterski program za određivanje prostornog položaja kalema u golenjači. U cilju verifikacije novorazvijenog programa realizovano je prostorno određivanje položaja kalema u golenjači obradom standardnih RTG snimaka (prednje-zadnje i bočne projekcije) kod 10 pacijenata kod kojih je izvr&scaron;ena primarna rekonstrukcija prednjeg ukr&scaron;tenog ligamenta kolena. Dobijeni rezultati su upoređeni sa položajem kalema na CT snimcima koji su obezbeđeni za sve pacijente. Na taj način je eksperimentalnim putem utvrđena preciznost novorazvijenog softvera u određivanju prostornog položaja kalema u golenjači. Drugi deo istraživanja bilo je prospektivno kliničko ispitivanje koje je sprovedeno na Klinici za ortopedsku hirurgiju i traumatologiju Kliničkog centra Vojvodine u Novom Sadu. Ispitivanu grupu je činilo 120 pacijenata, oba pola, sa prekidom prednjeg ukr&scaron;tenog ligamenta levog ili desnog kolena. Metodom slučajnog izbora pacijenti su podeljeni u četiri grupe od po 30 pacijenata prema veličini sagitalnog ugla (S) bu&scaron;enja kanala u golenjači (S 60&ordm;-69,9&ordm; i S 70&ordm;-80&ordm;) i prema veličini transverzalnog ugla (T) bu&scaron;enja kanala u golenjači (T 60&ordm;-69,9&ordm; i T 70&ordm;-80&ordm;). Grupa I 30 pacijenata (S 60&ordm;-69,9&ordm; i T 60&ordm;-69,9&ordm;), grupa II 30 pacijenata (S 60&ordm;-69,9&ordm; i T 70&ordm;-80&ordm;), grupa III 30 pacijenata (S 70&ordm;-80&ordm; i T 60&ordm;-69,9&ordm;), grupa IV 30 pacijenata (S 70&ordm;-80&ordm; i T 70&ordm;-80&ordm;). Svi pacijenti su godinu dana nakon operacije pro&scaron;li klinička ispitivanja po bodovnim skalama (Tegner bodovna skala, Lysholm bodovna skala i IKDC standard) i artrometrijska merenja. Rezultati dobijeni merenjem položaja kalema u golenjači, kliničkim ispitivanjima i artrometrijskim merenjima poređani su unutar svake grupe posebno, a izvr&scaron;eno je i poređenje dobijenih rezultata između svih grupa. U ispitivanje su uključeni samo oni pacijenti koji su dali potpisani informisani pristanak da učestvuju u ispitivanju nakon detaljnog upoznavanja sa planiranom procedurom. Svaki pacijent je bio informisan o svrsi i načinu sprovođenja istraživanja, kao i o pregledima i merenjima koja će biti vr&scaron;ena. Statističkom analizom rezultata utvrđeno je da veličina gre&scaron;ke prostornog određivanja položaja kalema u golenjači posle rekonstrukcije prednjeg ukr&scaron;tenog ligamenta kolena novorazvijenim kompjuterskim programom nije statistički značajna, a kompjutersko određivanje položaja kalema u golenjači omogućava iste rezultate kao i CT snimci. Sumiranjem zaključaka nakon sveobuhvatne analize dobijenih rezultata istraživanja, može se zaključiti da pozicija kalema u golenjači posle rekonstrukcije prednjeg ukr&scaron;tenog ligamenta kolena utiče na postoperativni funkcionalni rezultat.</p> / <p>The main goal of reconstruction of the anterior cruciate ligament of the knee is to obtain complete knee stability in the full range of movement. Regardless of the development of operational techniques and rehabilitation, there is still a number of patients who are not completely satisfied with the result of reconstruction of the anterior cruciate ligament, and a re-operation is required. It is believed that the most common cause of the instability is the bad position of the graft, i.e. position of the tunnel that is not at the anatomical place insertion. Most surgeons who deal with this problem evaluate the position of the graft in the tibia based on standard radiograms: anterior-posterior and lateral projections, which is not precise enough. In economically developed countries, the position of the graft is determined by analyzing images of computerized tomography (CT) or magnetic resonance (MRI). Primarily due to a decrease in the radiation dose exposed to patients during computerized tomography, but also for economic reasons, it would be useful to develop an easily accessible, inexpensive but precise and simple method for determining the position of the graft in the tibia. The main goal of this examination was to prove the significance of the position of the graft and the possibility of daily clinical use of the newly developed computer program in order to determine in-space position of the graft in only two standard radiograms. The study was experimental-prospective. The experimental part of the research was conducted at the Faculty of Technical Sciences (FTN) in Novi Sad at the Department of Production Engineering, where a computer program for determining in-space position of the graft in the tibia was developed on the basis of standard RTG images (anterior-posterior and lateral projections). In order to verify the newly developed program, in-space determination of the position of the graft in the tibia by processing standard RTG images (anterior-posterior and lateral projections) was performed in 10 patients in which the primary reconstruction of the anterior cruciate ligament was performed. The obtained results were compared with the position of the grafts on CT images provided to all patients. In this way, the accuracy of newly developed software in determining in-space position of the graft in the tibia was determined experimentally. The second part of the study was a prospective clinical trial conducted at the Clinic for Orthopedic Surgery and Traumatology at the Clinical Center of Vojvodina in Novi Sad. The investigated group consisted of 120 patients, both sexes, with a break of the anterior cruciate ligament of the left or right knee. By random selection, patients were divided into four groups of 30 patients according to the size of the sagital angle (S) of the tunnel drilling in the tibia (S 60&ordm;-69,9&ordm; and S 70&ordm;-80&ordm;) and according to the transversal angle (T) of the drill tunnel in the tibia ( T 60&ordm;-69.9&ordm; and T 70&ordm;-80&ordm;). Group I 30 patients (S 60&ordm;-69.9&ordm; and T 60&ordm;-69.9&ordm;), group II 30 patients (S 60&ordm;-69.9&ordm; and T 70&ordm;-80&ordm;), group III 30 patients (S 70&ordm;-80&ordm; and T&ordm;60&ordm; -69.9&ordm;), group IV 30 patients (S 70&ordm;-80&ordm; and T 70&ordm;-80&ordm;). All of the patients underwent clinical trials by scales (Tegner score scale, Lysholm score scale and IKDC standard) and arthrometric measurements one year after surgery. The results obtained by measuring the position of the graft in the tibia, clinical trials and arthrometric measurements were classified separately in each group, and obtained results were compared between all groups. The study included only those patients who gave signed informed consent to participate in the study after being thoroughly informed about planned procedure. Each patient was informed about the purpose and method of conducting the research, as well as the examinations and measurements to be performed. Statistical analysis of the results showed that the size of the error in measuring in-space determination of the position of the graft in tibia after reconstruction of the anterior cruciate ligament of the knee by a newly developed computer program was not statistically significant, and the computer determination of the position of the graft in the tibia provides the same results as the CT images. Summarizing the conclusions after a comprehensive analysis of the obtained results of the study, it can be concluded that the position of the graft in tibia after reconstruction of the anterior cruciate ligament affects the postoperative functional result.</p>

La luxation du genou, bien que très rare, demeure une blessure dévastatrice car elle entraîne de multiples complications en raison de la nature complexe du traumatisme associé à cette lésion. La luxation peut résulter d'un traumatisme à haute ou basse énergie. Les blessures sévères aux ligaments et aux structures associées donnent à la luxation du genou un potentiel élevé d'atteinte fonctionnelle. Le traitement conservateur, qui était considéré comme acceptable auparavant, est maintenant réservé à un très faible pourcentage de patients. La reconstruction chirurgicale est maintenant préconisée dans la plupart des cas, mais de nombreuses options existent et le traitement chirurgical optimal à préconiser reste controversé. Certains chirurgiens recommandent la reconstruction complète de tous les ligaments endommagés le plus tôt possible, tandis que d'autres, craignant l’établissement d’arthrofibrose, limitent l'intervention chirurgicale immédiate à la reconstruction du ligament croisé postérieur et de l'angle postéro-externe. En raison des multiples structures endommagées lors d’une luxation du genou, les chirurgiens utilisent couramment la combinaison des autogreffes et des allogreffes pour compléter la reconstruction ligamentaire. Les complications associées au prélèvement de la greffe, l'allongement de la greffe, l’affaiblissement précoce du greffon ainsi que les risques de transmission de maladies ont poussé les chirurgiens à rechercher différentes options d’intervention. L'utilisation de matériaux synthétiques pour le remplacement du ligament lésé a été proposée dans les années ´80. Après une première vague d'enthousiasme, les résultats décevants à long terme et les taux élevés d'échec ont diminué sa popularité. Depuis lors, une nouvelle génération de ligaments artificiels a vu le jour et parmi eux, le Ligament Advanced Reinforced System (LARS) a montré des résultats prometteurs. Il a été utilisé récemment dans les reconstructions isolées du ligament croisé antérieur et du ligament croisé postérieur pour lesquelles il a montré de bons résultats à court et moyen termes. Le but de cette étude rétrospective était d'évaluer la fonction et la stabilité du genou après la luxation aiguë suivant la reconstruction des ligaments croisés avec le ligament artificiel de type LARS. Cette étude a évalué 71 patients présentant une luxation du genou et qui ont subi une chirurgie de reconstruction du ligament croisé antérieur et du ligament croisé postérieur à l'aide du ligament LARS. Suite à la chirurgie le même protocole intensif de réadaptation a été suivi pour tous les patients, où la mise en charge progressive était permise après une période d’environ 6 semaines pendant laquelle la force musculaire et la stabilité dynamique se rétablissaient. Les outils d’évaluation utilisés étaient le score Lysholm, le formulaire de «l’International Knee Documentation Committee», le «Short Form-36», les tests cliniques de stabilité du genou, l'amplitude de mouvement articulaire à l’aide d’un goniomètre et la radiographie en stress Telos à 30° et 90° de flexion du genou. Le même protocole d’évaluation a été appliqué au genou controlatéral pour des fins de comparaison. Les résultats subjectifs et objectifs de cette étude sont satisfaisants et suggèrent que la réparation et la reconstruction combinées avec ligaments LARS est une alternative valable pour le traitement des luxations aiguës du genou. Ces résultats démontrent que ces interventions produisent des effets durables en termes d’amélioration de la fonction et révèlent la durabilité à long terme des ligaments artificiels LARS. Les patients sont à la fois plus autonomes et plus satisfaits avec le temps, même si la luxation du genou est considérée comme une catastrophe au moment où elle se produit. Des études prospectives randomisées sont maintenant nécessaires afin de comparer la sélection de la greffe et le délai de reconstruction chirurgicale. / Knee dislocation, although very rare, remains a devastating injury with many complications because of the complex nature of this trauma. This uncommon injury can result from either a high or low energy trauma. The severe damage to the knee’s ligaments and associated structures render this injury at high potential for functional impairment. Non operative treatment which was once deemed acceptable, is now reserved for very low demand patients. Surgical reconstruction is now the standard of care for most patients, however many options exist but the optimal surgical treatment remains controversial. Some surgeons advocate early complete reconstruction of all damaged ligaments, whereas others who fear arthrofibrosis, limit the immediate surgery to reconstruction of the posterior cruciate ligament and the posterolateral corner. Because of the multiple structures damaged by knee dislocations, surgeons have been successfully using combinations of autografts and allografts for complete knee ligament reconstruction. Complications associated with graft harvesting, graft elongation and early weakness as well as risks for disease transmission has pushed surgeons to look for different options. The use of synthetic material for ligament replacement was proposed in the 1980’s. After an initial wave of enthusiasm, poor long term results and high rates of failure diminished its popularity. Since then, a new generation of artificial ligaments has emerged, the Ligament Advanced Reinforced System (LARS) has shown promising results. It recently has been used in isolated anterior cruciate ligament and posterior cruciate ligament reconstruction and has shown good short to medium term results. The purpose of this retrospective study was to evaluate the knee function and stability after acute knee dislocation reconstructed with LARS artificial ligaments. This study assessed the results of 71 patients with knee dislocations who underwent acute combined repair and reconstruction of anterior cruciate ligament and posterior cruciate ligament using LARS artificial ligaments. After the surgery all patients followed the same intensive rehabilitation protocol. Progressive weight bearing was permitted over 6 weeks as muscle strength and dynamic stability were regained. The outcome measures used were the Lysholm score, the International Knee Documentation Committee form, the Short Form-36, clinical knee stability testing, a goniometer to mesure the range of motion and Telos stress radiography at 30° and 90° of knee flexion. The non-operated knee of the patient was used as a baseline for the operated knee. The subjective and objective findings from this study are satisfactory and suggest that acute combined repair and reconstruction with LARS ligaments is a valid alternative for treating acute knee dislocations. These findings demonstrate sustained results in terms of function and revealed durability of LARS artificial ligaments at long-term. Patients seem to get more autonomous and satisfied with time even though acute knee dislocation is seen as a catastrophe when it happens. Randomised, prospective trials are now needed to compare graft selection and timing of the surgical reconstruction.

INTRODUÇÃO: A instabilidade multiligamentar do joelho, normalmente, é provocada por um trauma que determina sua luxação, um evento pouco frequente, mas, que pode trazer sequelas devastadoras. Mesmo com o tratamento cirúrgico preconizado é alto o índice de complicações. A mobilização precoce no pósoperatório provoca afrouxamento dos ligamentos reconstruídos, o que leva à instabilidade residual. A imobilização melhora a estabilidade, mas provoca dor e rigidez. Este trabalho tem o objetivo de avaliar se o uso do fixador externo articulado proporciona melhora na mobilidade, estabilidade e na função subjetiva de pacientes submetidos à reconstrução ligamentar. MÉTODOS: Neste ensaio clínico randomizado com grupos paralelos, 33 pacientes do ambulatório do Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Universidade de São Paulo com mais que 3 semanas de lesão dos ligamentos cruzados anterior e posterior associado à lesão de ligamento colateral fibular e/ ou ligamento colateral tibial foram submetidos à cirurgia de reconstrução multiligamentar, após alocação cega aleatória ao grupo 0 - controle (18 pacientes), com órtese rígida ou ao grupo 1 - fixador externo articulado por 6 semanas (15 pacientes), no período entre novembro de 2010 e novembro de 2013. Após seguimento mínimo de um ano de pós-operatório, a estabilidade dos ligamentos reconstruídos foi avaliada ao exame físico, foram mensurados os déficits de extensão e de flexão residual em relação ao joelho contralateral não acometido e foi aplicado o questionário específico para sintomas do joelho de Lysholm. RESULTADOS: Não houve diferença na avaliação da estabilidade articular nem na extensão entre os grupos. No grupo 1, o déficit de flexão passiva foi menor (4,8º +- 5,4º contra 18,2 +- 14,8º, p < 0,05) com mais pacientes, obtendo déficit de flexão considerado normal, de até 5º (64% contra 18%, p < 0,05) e com classificação excelente ou boa no questionário de Lysholm (73% contra 35%, p < 0,05). CONCLUSÕES: Comparado ao protocolo de reabilitação com órtese rígida removível, o uso do fixador externo articulado no tratamento cirúrgico das lesões multiligamentares do joelho proporciona os mesmos resultados de estabilidade ligamentar, aumenta a amplitude de movimento final, com manutenção da extensão e redução do déficit de flexão e proporciona melhores resultados funcionais / INTRODUCTION: Multiligament knee instability is normally caused by a trauma which results in its dislocation, an infrequent event, but one which can have devastating aftereffects. Even with the recommended surgical treatment the rate of complications is high. Early post-operative mobilization provokes loosening of the reconstructed ligaments, which leads to residual instability. Immobilization improves the stability, but causes pain and stiffness. This study aims to assess whether the use of an articulated external fixator provides improvements in the mobility, stability and the subjective function of the patients submitted to ligament reconstruction. METHODS: In this randomized clinical trial with parallel groups, 33 patients of the outpatient clinic of the Institute of Orthopaedics and Traumatology of the Hospital das Clínicas of the University of Sao Paulo with more than 3 weeks of injury to the anterior cruciate ligaments and the posterior cruciate ligaments associated with injury to the fibular collateral ligament and/or medial collateral ligament, were submitted to multiligament reconstruction surgery, after blind random allocation to either: Group 0 - control (18 patients), with rigid bracing, or to Group 1 - articulated external fixator for 6 weeks (15 patients), in the period from November, 2010 to November 2013. The stability of the reconstructed ligaments were assessed after 1 year postoperatively by physical examination, the deficit of residual extension and flexion was measured in relation to the unaffected contralateral knee and the Lysholm knee scoring scale questionnaire was applied. RESULTS: There was no difference in the assessment of joint stability or of the extension between the groups. In group 1 the passive flexion deficit was less (4.8º +- 5.4º versus 18.2 +- 14.8º, p<0.05) with more patients obtaining a flexion deficit considered normal, or up to 5º (64% versus 18%, p<0.05) and with excellent or good classification in the Lysholm knee scoring scale questionnaire (73% versus 35%, p<0.05). CONCLUSIONS: Compared to the rehabilitation protocol with removable rigid bracing, the use of an articulated external fixator in the treatment of multiligament knee injuries provides equal results for ligament stability, increases the amplitude of the Range of Motion, maintains the extension and reduces the flexion deficit, and provides better functional result

OBJETIVO: Avaliar o padrão de degeneração histológica do ligamento cruzado posterior (LCP) em pacientes com artrose submetidos à artroplastia total de joelho com prótese com substituição do ligamento cruzado posterior (LCP). A degeneração histológica foi classificada em leve, moderada e grave. Os achados histológicos foram correlacionados com dados clínicos, radiográficos e do transoperatório (presença ou ausência do ligamento cruzado anterior) com a finalidade de aferir se estes parâmetros seriam capazes de predizer o grau de degeneração histológica do LCP em pacientes com gonartrose. MÉTODOS: foram avaliados 89 ligamentos cruzados posterior de 85 pacientes com idade média de 69,79 anos, sendo 69 do sexo feminino, 16 do masculino. O LCP foi corado em hematoxilina-eosina e Tricrômio de Gomori e classificado quanto ao comprometimento histológico em leve, moderado e grave. A degeneração histológica foi correlacionada aos parâmetros idade, artrose radiográfica classificada por Ahlbäck (grau I ao V), eixo radiográfico tíbio-femoral (varo, neutro e valgo), e estado do ligamento cruzado anterior (LCA), presença ou ausência.Os achados histológicos de hipercelularidade, infiltração linfocitária crônica, proliferação vascular; presença de cistos; clones de condrócitos; degenerações colágena, fibrinóide, cartilaginosa ,gordurosa e mucoide foram correlacionados com o grau de degeneração do LCP e ao estado de conservação do LCA. RESULTADO: Não foram identificadas relações entre o grau de degeneração histológica do LCP e faixa etária (abaixo ou acima de 70 anos), sexo, classificação radiográfica de Ahlbäck e presença ou ausência do LCA. Os achados histológicos de degeneração fibrinóide, proliferação vascular e presença de cistos estiveram estatisticamente relacionados à degeneração histológica grave do LCP. CONCLUSÃO: Os parâmetros clínicos e radiográficos não foram capazes de predizer o grau de degeneração histológica do LCP .Os achados histológicos de degeneração fibrinóide, proliferação vascular e presença de cistos caracterizaram a degeneração histológica grave do LCP / OBJECTIVE: Evaluate the histologic degeneration pattern of the posterior cruciate ligament (PCL) in osteoarthrosis patients submitted to total knee replacement with a cruciate substituting prosthesis. The histologic degeneration was classified in mild, moderate and severe. The histologic pattern was related to clinical, per-operatory (presence or absence of anterior cruciate ligament) and radiographic parameters with the aim to settle if these parameters would be reliable to predict the PCL degeneration grade. METHODS: 89 PCLs from 85 patients, 16 men, 69 women, mean age 69, 79 years old. PCL was stained with hematoxylin and eosin and trichromium of Gomori. The PCL histologic degeneration was graded from normal-minimum to severe. The histologic PCL degeneration pattern was related to age, radiographic arthrosis classification (Ahlbäck - grades I to V), knee radiographic axis (varus, neutral, valgus) and to the ACL status (presence or absence).The histologic findings of hipercellularity, chronic lymphocit infiltration, neoangiogenesis, cysts, collagen degeneration (deg), fibrinoid deg, mucoid deg., cartilaginous, deg., fat deg. and condrocyte clones were related to the grade of PCL degeneration and to ACL status. RESULTS: There was no correlation of histologic degeneration to sex or age (above or below 70 years), arthrosis radiographic classification (Ahlbäck) and presence or absence of ACL. The histological findings of fibrinoid degeneration, vascular proliferation and cysts were statistically related to severe histologic LCP degeneration. CONCLUSION: The parameters studied were not capable of predicting the grade of LCP degeneration. The histological findings of fibrinoid degeneration, vascular proliferation and cysts were characteristic of severe PCL histologic degeneration

INTRODUÇÃO: A lesão do ligamento cruzado anterior (LCA) é considerada uma lesão grave e pode afetar a carreira de um jogador de futebol profissional. O tratamento cirúrgico é frequentemente necessário para o tratamento da instabilidade. Embora a reconstrução do LCA seja considerada um procedimento eficaz em restaurar a estabilidade articular, a literatura mostra que apenas 55% dos atletas retornam à prática de esportes competitivos após a cirurgia. Jogadores de futebol profissional dependem de habilidades técnicas, táticas e físicas, como boa função do joelho e capacidade aeróbia. O objetivo deste trabalho é avaliar a capacidade aeróbia em jogadores profissionais de futebol de campo com lesão do LCA e após seis meses de reabilitação pós-operatória. MÉTODOS: Vinte jogadores profissionais de futebol de campo com lesão do LCA foram submetidos a reconstrução do LCA com tendões flexores autólogos e foram comparados com 20 jogadores profissionais de futebol de campo em atividade, sem histórico de lesão no joelho. Avaliamos a capacidade aeróbia máxima pelo consumo máximo de oxigênio (VO2max) e submáxima pelos limiares ventilatórios (LV1 e LV2), avaliados por ergoespirometria em esteira utilizando o protocolo de Heck modificado. Os testes foram realizados no pré-operatório e aos seis meses de pós-operatório e os resultados comparados ao grupo controle de jogadores profissionais em plena atividade. Também realizamos questionários de função subjetiva do joelho (Lysholm e IKDC), dinamometria isocinética computadorizada e avaliação da composição corporal por bioimpedância. RESULTADOS: No grupo com lesão do LCA a média da idade foi de 21,7 anos, enquanto no grupo controle foi de 22,1 anos (p=0,99). O intervalo de tempo a lesão e a cirurgia foi, em média, cinco meses. No pré-operatório, o VO2max, em mL/kg/min, foi em média ? desvio padrão de 45,2 +- 4,3, aos seis meses de pós-operatório 48,9 +- 3,8 (p < 0,001) e no grupo controle 56,9 +- 4,2 (p < 0,001 comparado ao pré-operatório e pós-operatório). A porcentagem de gordura corporal, em média +- desvio padrão, no pré-operatório foi de 14,7+- 3,7, no pós-operatório 14,9 +- 5,4 e no grupo controle 12,8 +- 4, sem diferença estatisticamente significativa entre os grupos. Os resultados do questionário Lysholm no pré-operatório, pós-operatório e no grupo controle foram, em média, 77,25, 94,12 e 97,5 (p < 0,05 em todas as comparações) e do questionário IKDC subjetivo foram 59,46, 87,75 e 97,28 (p < 0,001 em todas as comparações). O déficit de pico de torque de extensão do joelho a 60 O/s, foi de 21,5% no pré-operatório, 15,7% no pós-operatório (p=0,63) e 3,1% no grupo controle (p < 0,001 com relação ao pré-operatório e pós-operatório). CONCLUSÃO: Os jogadores profissionais de futebol de campo avaliados seis meses após a reconstrução do LCA apresentaram VO2max significativamente inferior aos resultados do grupo controle, embora os resultados pós-operatórios tenham sido significativamente superiores aos observados no pré-operatório. Houve uma melhora significativa nos scores de função do joelho no pós-operatório com relação ao pré-operatório e a composição corporal dos indivíduos não apresentou diferenças estatisticamente significativas / INTRODUCTION: Anterior cruciate ligament (ACL) injury is a severe injury and may impact a professional football player\'s career. Surgical treatment is often indicated due to knee instability. Although ACL reconstruction (ACLR) is considered a successful procedure in restoring knee stability in athletes, it has been shown that only 55% return to competitive sports after surgery. Professional football players need technical, tactical and physical skills to succeed, including adequate knee function and aerobic capacity. Our purpose is to evaluate aerobic capacity in professional football players with ACL injury and six months after ACL reconstruction. METHODS: Twenty professional football players underwent ACL reconstruction with autologous hamstring grafts and were compared to 20 active, uninjured professional football players. We assessed maximal aerobic capacity with maximal oxygen consumption (VO2max) and submaximal with ventilatory thresholds, measured by ergoespirometric test performed in a treadmill with a modified Heck protocol. The tests were performed pre-operatively and six months after ACLR, and compared to the control group. We also performed knee function questionnaires (Lysholm and IKDC), isokinetic strength test and body composition evaluation with electric bioimpedance. RESULTS: ACL group average age was 21.7 y.o., and control group 22.1 y.o.(p=.99). Time span between injury and surgery was 5 months, in average. Pre-operative VO2max was 45.2 +- 4.3 mL/kg/min, post-operative was 48.9 +- 3.8 (p > .001) and control group was 56.9 +- 4.2 (p < 001 in both comparisons). Pre-op body fat percentage was 14.7+-3.7, post-op was 14.9 +- 5.4 and control 12.8 +- 4 (n.s.). Lysholm questionnaire results were 77.25, 94.12, and 97.5 (pre-op, post-op and control, respectively, p <. 05 in all comparisons). IKDC results were 59.46, 87.75 and 97.28 (pre-op, post-op and control, respectively, p < .001 in all comparisons). Preop peak torque isokinetic knee extension deficit at 60°/s was 21.5%, postop 15.7% (p=.63) and control 3.1% (p <. 001). CONCLUSION: Professional football players had significantly lower VO2max six months after ACLR compared to controls, although their results were significantly higher than observed pre-operatively. There was a significant improvement in knee function scores after ACLR. Body composition evaluation was not significant different among the groups evaluated

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.

No description available.

La rupture du ligament croisé antérieur du genou est très fréquente, notamment dans les activités qui impliquent des contraintes en rotation. Une dégénérescence du cartilage articulaire du genou peut par la suite engendrer une arthrose. Le but de cette étude était d’une part dans les pathologies traumatiques et d’autre part dans les pathologies dégénératives, atteignant cette articulation, d’analyser les facteurs prédictifs du contrôle postural et de la récupération fonctionnelle. Les effets d’une rééducation innovante combinant une rééducation conventionnelle réduite avec une rééducation en milieu aquatique ont été comparés à ceux d’une rééducation conventionnelle définie par la Haute Autorité de Santé, sur la cinétique de récupération des compétences proprioceptives et sur l’amélioration fonctionnelle. Le contrôle postural par posturographie et la motricité au moyen de tests cliniques ont été quantifiés chez 67 patients ayant présenté une rupture du ligament croisé antérieur, avant intervention et jusqu’à six mois après intervention chirurgicale. Les effets des paramètres météorologiques sur le contrôle postural et la douleur dans la gonarthrose ont été évalués chez 113 patients, par posturographie et échelle de douleur. Pour une même qualité globale du contrôle postural six mois après ligamentoplastie du genou, les patients ayant suivi le protocole de rééducation innovant utilisaient davantage la somesthésie que ceux ayant suivi une rééducation conventionnelle, qui devaient recourir plus à un mécanisme de compensation. La proprioception était améliorée deux mois après l’intervention chirurgicale par rapport à l’évaluation pré-opératoire chez les patients ayant suivi le protocole innovant. La force musculaire était plus importante chez les patients ayant suivi le protocole de rééducation innovant un mois, deux mois et six mois après intervention. Un mois après l’intervention, la distance de marche parcourue était plus importante chez les patients ayant suivi la rééducation innovante que chez les patients ayant suivi la rééducation conventionnelle. Chez les patients présentant une gonarthrose, une dégradation du contrôle postural était observée lorsque la pression atmosphérique et l’humidité maximale diminuaient au cours de la matinée et lorsque la pression atmosphérique diminuait au cours de la journée. L’augmentation de la douleur était corrélée avec l’augmentation de la température sur la matinée et avec l’augmentation de la température et de l’humidité sur la journée. L’environnement dans lequel évolue le sujet (ex : milieu aquatique, ambiance climatique) a donc une influence sur la performance du contrôle postural. Une meilleure prise en charge en rééducation post-ligamentoplastie du genou permettrait de limiter la nécessité de compensation sur le membre contralatéral par une meilleure utilisation de la somesthésie et ainsi prévenir la survenue de l’arthrose et d’une rupture ligamentaire contralatérale. Ceci permettrait de limiter les coûts socio-professionnels / The knee can suffer damage from either traumatic or degenerative pathology. Anterior cruciate ligament (ACL) injuries frequently occur, especially in activities that including rotational stresses. Degeneration of the articular cartilage of the knee can subsequently result in osteoarthritis. The aim of this study was to analyze the predictive factors of postural control and recovery in traumatic injuries and also in degenerative pathologies of the knee. The effects of an innovative rehabilitation protocol combining reduced conventional rehabilitation with aquatic rehabilitation were compared with conventional rehabilitation defined by the National French Health Authority on the kinetics of recovery of proprioceptive skills and functional improvement. Postural control and motor control using clinical tests were quantified in 67 patients with ACL surgery before and up to six months after surgery. The effects of meteorological parameters on postural control and pain in knee osteoarthritis were evaluated in 113 patients, using posturography and also a pain scale. Six months after knee ligament surgery, both groups attained the same quality of postural control. However, patients who followed the innovative protocol made more used of proprioceptive inputs compared to the group who underwent conventional rehabilitation who made more use of a compensation mechanism. In patients following the innovative protocol proprioception was improved two months after surgery compared to before surgery. Muscle strength was higher in patients who followed the innovative rehabilitation protocol at one, two and six months after surgery. One month after surgery, the walking distance traveled was higher in patients who underwent innovative rehabilitation than in patients who had undergone conventional rehabilitation. In patients with knee osteoarthritis, degradation of postural control was observed when atmospheric pressure and maximum humidity decreased during the morning and when atmospheric pressure decreased during the entire day. Increased pain was correlated with increased temperature in the morning and with increased temperature and humidity during the entire day. The environment in which evolves the subject (aquatic, climatic) thus has an influence on postural control performance. A better management in post-ligamentoplasty rehabilitation of the knee would reduce the need for compensation using the contralateral limb, by better use of somesthesia. This could prevent the occurrence of osteoarthritis and a contralateral ACL injury, which would also reduce costs to the society and health care