Introdução: Na reconstrução anatômica do ligamento cruzado anterior (LCA) com banda simples, o diâmetro dos túneis não preenche totalmente sua área de origem e inserção. Estudos recentes sugerem que a banda anteromedial teria um papel dominante na função estabilizadora do LCA em qualquer grau de flexão, o que favoreceria o posicionamento dos túneis nessa região. No entanto, ao se buscar reproduzir a função das duas bandas com um enxerto simples, a escolha mais intuitiva é posicioná-lo na região central. O posicionamento inadequado do enxerto poderá resultar em uma instabilidade residual, mais evidente em indivíduos com alta demanda funcional, como é o caso de esportistas. Retomar a prática esportiva no mesmo nível não depende somente da estabilidade isolada do joelho, é preciso que o equilíbrio postural seja reestabelecido. O objetivo deste estudo foi comparar o posicionamento do enxerto na região anteromedial ou central na origem e inserção do LCA. Métodos: Trata-se de um estudo clínico prospectivo e randomizado, incluindo 42 esportistas (Tegner > 5) com lesão do LCA alocados para serem submetidos àreconstrução anatômica na posição anteromedial (22 pacientes - Grupo AM) ou central (20 pacientes - Grupo C). O desfecho primário foi obtido pelo valor médio da oscilação do centro de pressão (CP) de cada indivíudo no plano mediolateral (Xavg) avaliado na plataforma de força com apoio monopodálico simulando a posição de chute aos 6 meses de pós-operatório, enquanto os demais parâmetros de posturografia, escalas de Tegner, Lysholm, IKDC subjetivo, hop test e avaliação isocinética foram considerados desfechos secundários. Todos os resultados foram avaliados aos 6 e 12 meses, com exceção da escala de Tegner, avaliada somente aos 12 meses. Resultados: Na avaliação dos dados de posturografia fornecidos pela plataforma de força, o grupo C apresentou melhores resultados quando comparados ao grupo AM em três parâmetros de oscilação mediolateral do CP: valor médio (Xavg) na posição de chute aos 6 meses (-0,43 ± 0,15cm vs. -0,87 ± 0,18cm respectivamente, p < 0,05), deslocamento máximo (Xmax) na posição de apoio monopodálico simples aos 12 meses (1,05 ± 0,18cm vs. 1,28 ± 0,31 cm respectivamente, p < 0,05) e valor médio na posição de flexão do joelho aos 6 meses (0,31 + 1,35cm vs. -1,03 + 1,18cm respectivamente, p < 0,05). O grupo C também apresentou melhores resultados quando comparado ao grupo AM nas seguintes avaliações: índice de simetria do hop test aos 6 meses (93 ± 7% vs. 84 ± 17% respectivamente, p < 0,05) e aos 12 meses (100 ± 7% vs. 92 ± 7% respectivamente, p < 0,05) e deficit do pico de torque na velocidade angular de 60o/s aos 6 meses (12,55 ± 9,77 Nm vs. 22,9 ± 17,89 Nm respectivamente, p < 0,05). Conclusões: A reconstrução anatômica do LCA na posição central apresentou melhores resultados em três parâmetro de posturografia relacionados a oscilação no plano mediolateral (incluindo o desfecho primário), melhor índice de simetria no hop test e menor deficit do pico de torque na velocidade angular de 60o/s aos 6 meses, quando comparados à reconstrução na posição anteromedial. Não houve diferença significante quanto ao número de complicações / Introduction: Bone tunnel diameters in anatomical single-bundle anterior cruciate reconstruction cannot fulfill the footprint area. The latest studies have suggested that the anteromedial bundle might play a dominant role in ACL function at any flexion degree. This fact could support placing the bone tunnel on the anteromedial bundle footprint. However, positioning the graft at the center of the footprint could be a more efficient way to mimic part of the two-bundle function. Improper graft positioning may result in residual instability, particularly in individuals with higher functional demand, such as sport practitioners. Returning to their sport at the same level as before their injury could not be defined by knee stability alone; a global evaluation provided by more comprehensive parameters, such as postural balance, should also be included. The main purpose of this study is to compare grafts on anteromedial or central area positions in an ACL footprint. Methods: A prospective, randomized clinical study included 42 sports practitioners (Tegner > 5) with ACL injury undergoing anatomic ACL reconstruction on the anteromedial footprint (22 patients - AM group) or at the central footprint area (20 patients - Group C). The primary outcome was based on a mean center pressure (CP) mediolateral oscillation parameter analysis of each individual simulating a kicking motion on a force plate. Other posturography parameters, Tegner, Lysholm and IKDC subjective scales, a hop test and an isokinetic evaluation were considered as secondary outcomes. All results were evaluated at 6 and 12 months, with the exception of the Tegner scale, which was evaluated only at 12 months. Results; Group C presented better results in three posturography parameters when compared with Group AM: mean mediolateral plane oscillation with kicking position at 6 months (-0,43 ± 0,15cm vs. -0,87 ± 0,18cm respectively, p < 0.05), maximum CP lateral displacement with the one leg standing position at 12 months (1,05 ± 0,18cm vs. 1,28 ± 0,31 cm respectively, p < 0.05) and mean mediolateral plane oscillation with knee flexed position (0.31 ± 1.35 cm vs. -1.03 ± 1.18 cm respectively, p < 0.05) and). Group C also presented better results in the following evaluations: symmetry index in the hop test at 6 months (93 ± 7% vs. 84 ± 17% respectively, p < 0.05) and at 12 months (100 ± 7% vs. 92 ± 7%, respectively, p < 0.05) and torque peak deficit on angular velocity of 60 o/s at 6 months (12.55 ± 9.77 Nm vs. 22.9 ± 17, 89 Nm respectively, p < 0.05). CONCLUSION: Anatomic single bundle ACL reconstruction in the center of the ACL footprint shows better results compared with the anteromedial ACL footprint area in three posturography parameters related to coronal plane balance, index of symmetry in the hop test and the peak of torque deficit on an angular velocity of 60 o/s at 6 months. Surgical complications were similar in both groups

Atualmente, os bons resultados na lesão do ligamento cruzado posterior por avulsão óssea na tíbia associam-se ao tratamento cirúrgico e precoce. A técnica convencional é a fixação com parafuso pela via de acesso posterior do joelho, com abordagem direta das estruturas vasculares e nervosas da região. Neste estudo experimental em 20 joelhos de cadáveres, buscamos apresentar uma alternativa com amarrilho por via artroscópica, comparando-o com a técnica convencional, através da inspeção direta e de testes biomecânicos. Houve falha na fixação de apenas um exemplar de cada método e medidas de deslocamento tibial posterior (p=0,23) e rigidez média (p=0,28) sem diferenças significativas entre as duas técnicas. Concluímos ser o amarrilho artroscópico viável e uma alternativa no tratamento desta lesão. / Nowadays, good results on the management of posterior cruciate ligament bony avulsion of the tibia are associated with early surgical repair. The usual method of treatment is the open posterior approach with screw fixation, wich requires popliteal neurovascular bundle direct manipulation. This study presents a new arthroscopic suture and compares it with the conventional technique, using biomechanical tests and direct inspection in cadaveric specimens (20 knees). On both methods there was a fixation fail in one knee. The analisys of tibial posterior displacement (p=0,23) and stiffness (p=0,20) were similar for the two methods. The Arthroscopic suture presented is an effective reattachment method for this fracture pattern.

<p>Ispitivanu grupu činilo je 1247 ispitanika sa povredama prednje ukr&scaron;tene veze kolena koji su operativno lečeni u periodu 2012.-2017. godina na Klinici za ortopedsku hirurgiju i traumatologiju Kliničkog centra Vojvodine. Ciljevi istraživanja bili su utvrđivanje uticaja nivoa sportske aktivnosti i mehanizama povređivanja na nastanak povreda prednje ukr&scaron;tene veze kolena, zatim uticaj spolja&scaron;njih faktora rizika (vrsta sporta, rang takmičenja, vrsta podloge, trening ili utakmica, period treninga) na nastanak povreda prednje ukr&scaron;tene veze kolena, odnosno uticaj unutra&scaron;njih faktora rizika (pol, starost, BMI) na nastanak povreda ove strukture kolena. Od ukupnog broja ispitanika njih 517 (41,5%) su činili aktivni sportisti, a 730 (58,5%) rekreativci. Značajnu većinu u posmatranom uzorku su činili mu&scaron;karci (82,6%), osobe starosti od 16 do 25 godina (62,6%) i normalno uhranjenje osobe (62%). Do povrede prednje ukr&scaron;tene veze do&scaron;lo je kod njih 504 (40,5%) prilikom aktivnog bavljenja sportom, dok su se povrede prilikom rekreativnog bavljenja sportom dogodile kod 741 ispitanika (59,5%). Među aktivnim sportistima, vi&scaron;e od dve trećine se takmičilo na internacionalnom ili republičkom nivou, odnosno u najvi&scaron;im rangovima takmičenja. Kontaktnim kolektivnim sportovima (fudbal, ko&scaron;arka i rukomet) bavilo se 77,9% ispitanika. Nekontaktnim sportovima kao &scaron;to su odbojka, borilački sportovi i skijanje bavilo se 22,1% ispitanika, pri čemu je najveći broj povreda nastao prilikom igranja fudbala (51,3%). Statistički značajno vi&scaron;e povreda (i prilikom aktivnog i prilikom rekreativnog bavljenja sportom) je nastalo bez direktnog kontakta (nekontaktne povrede koje su činile 78,7% povreda), pri čemu je najveći broj povreda nastao usled promene pravca i ritma kretanja. Kod aktivnih sportista najvi&scaron;e povreda dogodilo se na utakmicama (73,8%), slede povrede na treningu (24,1%), dok se na rekreaciji povredilo svega 2,1% ispitanika. Značajno vi&scaron;e povreda dogodilo se na sredini bavljenja sportskom aktivno&scaron;ću (47,4%) u odnosu na povrede na zagrevanju, početku, odnosno kraju sportske aktivnosti. Povrede su značajno če&scaron;će nastajale na travi (42%) i parketu (28%), nego na drugim vrstama podloge. Najveći broj ispitanika povredio se noseći patike prilikom bavljenja sportskom aktivno&scaron;ću. Postoje značajne razlike u kontekstu povređivanja u zavisnosti od pola ispitanika. Žene su u značajno većem procentu povređivane prikom aktivnog bavljenja sportom, dok su se mu&scaron;karci če&scaron;će povređivali na rekreaciji. Žene su se najče&scaron;će povređivale na rukometu, mu&scaron;karci na fudbalu. U odnosu na mu&scaron;karce, kod žena su povrede znatno ređe nastajale prilikom direktnog kontakta, a kad je u pitanju mesto povređivanja, žene su se če&scaron;će nego mu&scaron;karci povređivale na treningu. Preko 50% žena je povređeno na parketu, dok se najveći broj mu&scaron;karaca povredio na travi. Ispitanici sa prekomernom telesnom masom značajno če&scaron;će su se povređivali prilikom rekreacije, dok su se normalno uhranjeni če&scaron;će povređivali prilikom aktivnog bavljenja sportom. Faktori rizika za nastanak povreda prednje ukr&scaron;tene veze su brojni i specifični, odnosno da za svaku populacionu kategoriju postoje rizici, ali se uočava da su u svim sportovima, na svim podlogama i kod svih ispitanika povrede najče&scaron;će nastajale nekontaknim mehanizmom povređivanja. Formiranjem registra povređenih omogućilo bi se bolje razumevanje faktora rizika i njihovog međusobnog uticaja, kao i definisanje profila osoba pod najvećim rizikom za nastanak povrede prednje ukr&scaron;ene veze kolena. Na taj način obezbedile bi se potrebne informacije za planiranje preventivnih programa usmerenih na smanjenje rizika od povređivanja i omogućilo bi se sprovođenje odgovarajućih mera selektivne prevencije.</p> / <p>The study group consisted of 1247 respondents with anterior cruciate ligament injuries who were surgically treated in the period 2012-2017. at the Clinic for Orthopedic Surgery and Traumatology of the Clinical Center of Vojvodina. The objectives of the study were to determine the impact of sports activity levels and injury mechanisms on the occurrence of anterior cruciate ligament injuries, then the impact of external risk factors (type of sport, competition rank, type of surface, training or match, training period) on the occurrence of anterior cruciate ligament injuries and the influence of internal risk factors (gender, age, BMI) on the occurrence of injuries of this knee structure. Out of the total number of respondents 517 (41.5%) were active athletes, and 730 (58.5%) were recreational athletes. A significant majority in the observed group were men (82.6%), persons aged 16 to 25 years (62.6%) and normal BMI respondents (62%). Anterior cruciate ligament injury occurred in 504 of them (40.5%) during active sports, while injuries during recreational sports occurred in 741 respondents (59.5%). Among active athletes, more than two thirds competed at the international or national level- in the highest ranks of the competition. Contact collective sports (football, basketball and handball) were practiced by 77.9% of respondents. 22.1% of respondents practiced non-contact sports such as volleyball, martial arts sports and skiing. The largest number of injuries occurring while playing football (51.3%). Statistically significantly more injuries (both during active and recreational sports) occurred without direct contact (noncontact injuries-78,7% of total injuries number), with the largest number of injuries caused by changes in the direction and rhythm of movement. Among active athletes, most injuries occurred in matches (73.8%), followed by injuries in training (24.1%), while only 2.1% of respondents were injured in recreation. Significantly more injuries occurred in the middle of engaging in sports activity (47.4%) compared to injuries during the warm-up, beginning and end of sports activity. Injuries occurred significantly more often on grass (42%) and floor (28%) than on other types of surfaces. Most of the respondents were injured wearing sneakers while doing sports. There are significant differences in the context of injury depending on the gender of the respondents. A significantly higher percentage of women were injured during active sports, while men were more often injured during recreational sport activities. Women were most often injured in handball, men in football. Compared to men, injuries were much less common in women during direct contact, and when it comes to the place of injury, women were injured more often than men during training acitivities. Over 50% of women were injured on the floor, while the largest number of men were injured on the grass. Subjects with overweight were significantly more likely to be injured during recreational sport acitivites, while those with normal BMI were more likely to be injured during active sports. Risk factors for anterior cruciate ligament injuries are numerous and specific and there are risks for each population category, but it is noticed that in all sports, on all surfaces and in all subjects, injuries were most often caused by a noncontact injury mechanism. The formation of a Register of injuries would enable a better understanding of risk factors and their mutual influence, as well as the definition of the profile of persons at greatest risk for the occurrence of an anterior cruciate ligament injury. This would provide the necessary information for planning prevention programs aimed at reducing the risk of injury and would enable the implementation of appropriate selective prevention measures.</p>