Double and Single Bundle in Athletes: A Comparison in Medium and Long-Term Rates to Return to Sport and Re-Injury

Objectives

Compare, retrospectively, the medium- and long-term of return to sport rates and re-injury of the anterior cruciate ligament (ACL) in patients submitted to single-bundle (SB) compared to double-bundle (DB) technique reconstruction.

Methods

Athletes operated by SB or DB ACL reconstruction, with at least five years of follow-up at a single center, were included. The following data were collected: demographic data; competitive sports practice before the injury; previous surgery; injury/surgery to the contralateral knee; return to sports and level of the return; re-injury (time of the re-injury after the first surgery; mechanism of trauma for the re-injury; necessity of operative treatment); signs and complaints related to the knee the last clinical consultation.

Results

Seventy-six athletes (27 SB and 49 DB) were included. The return to sport rate (98%) was the same for both groups, and the return to the previous level rate showed an improvement in the DB group but without statistical significance (63% vs. 79%; P = 0.173). However, other outcomes showed higher results for the DB group: lower re-injury rate throughout the follow-up period (41% vs. 18%; P = 0.034) and during the first year of follow-up (22% vs. 4%; P = 0.021), and less stiffness (0% vs. 22%, P = 0.001). While in primary reconstruction cases, there was not a higher re-injury rate using SB (P = 0.744), in the revision cases, SB was correlated with more re-injuries than DB (P = 0.002).

Conclusion

The overall re-injury in the medium- and long-term and the return to practice sports at the same level as before surgery in athletes submitted to DB reconstruction were slightly better than those submitted to SB reconstruction, especially in the cases that were asecond time lesion ( revisioned knees).

Clinical and Radiological Results after Endoscopic Treatment for Gluteal Tendon Injuries with a Minimum Follow-Up of 12 Months

Objectives

The study aimed to evaluate the clinical and radiological results after endoscopic repair of gluteus medius muscle injuries and proposed an anatomical classification for the different injury classes.

Methods

A retrospective case series, including patients who had undergone endoscopic repair of the hip abductor tendon. The surgical procedure was standardized. Magnetic resonance imaging (MRI) studies were analyzed, and the injuries were classified into three types: nontransfixing partial-extension (nTPE) tear, transfixing partial-extension (TPE) tear, and transfixing full-extension (TFE) tear. TPE and TFE were considered high-grade tears. The postoperative outcomes were as follows: duration of walking aid requirement, duration of physical therapy, time to return to daily activities, modified Harris Hip score (mHHS) and Nonarthritic Hip Score (NAHS) functional scores, pain visual analog scale (VAS), satisfaction, claudication, Trendelenburg test, and reoperation.

Results

Sixteen patients were included (94% women; mean age 65 years), with a mean follow-up of 42 months (12-131, range). Out of the cases with preoperative exams available for analysis, four cases (31%) were nTPE, three (23%) TPE, and six (46%) TFE tears. Thus, 69% of the patients had high-grade injuries. These patients had a higher degree of fat infiltration (P = 0.034), but this was not correlated with inferior postoperative clinical or radiological results. One patient required reoperation due to a recurrent injury.

Conclusion

Isolated extra-articular injuries to the tendons of the gluteus medius and minimus evolved satisfactorily after endoscopic repair. Due to the small number of cases, it was not possible to observe differences in outcomes between high-and low-grade injuries.

Rotational Stability of the Knee in a Comparative Study of Anterior Cruciate Ligament Reconstruction Using the Double-Bundle and Single-Bundle Techniques

BACKGROUND

The purpsose of this study was to evaluate the biomechanical outcomes of patients who underwent ACL reconstruction either with the DB or SB technique. We hypothesized that the DB technique would provide better rotation control of the knee following ACL reconstruction.

METHODS

The study included seventy-five participants (26 DB, 22 SB, and 27 healthy volunteers). Only cases with at least one year of postoperative follow-up were included. The participants performed three different demand tasks: walk task, walk and change direction, and stair descent and change direction, which was tracked using a three-dimensional 4-camera optoelectronic system. The following kinematic data were analyzed: tibial rotation amplitude and maximal internal and external rotation. Knees with ACL reconstruction were compared to contralateral knees with intact ACL and healthy knees. Clinical outcomes were determined using the subjective and objective International Knee Documentation Committee (IKDC) questionnaire and a manual arthrometer (KT 1000).

RESULTS

Both surgical groups exhibited similar clinical outcomes (mean subjective IKDC 91 SB vs. 90 DB, P=0.815; KT 1000 difference: 2mm in both groups, P=0.772). The vertical component of the ground force reaction revealed no differences between the surgical and control groups (P>0.05). Tibial rotation amplitude and maximal internal and external rotation were similar between the control, SB, and DB groups in all three different demand tasks (P>0.05).

CONCLUSION

ACL reconstruction using either the SB or DB technique can restore rotational control to the level of a healthy knee. No clinical or functional differences were found between the SB and DB surgical options.

Return to Sport and Re-Injury Rate after Double-Bundle Anterior Cruciate Ligament Reconstruction with at least Five Years of Follow-Up

BACKGROUND

This study retrospectively evaluated the medium- and long-term results of patients submitted to double-bundle (DB) anterior cruciate ligament (ACL) reconstruction.

METHODS

A retrospective study of case series at a single center. Cases submitted to isolated ACL reconstruction with at least five years of follow-up were included. The following data were collected: demographic data; practice of competitive sport before the injury; previous surgery; injury/surgery in the contralateral knee; return to the practices of sports and level; re-injury (postoperative time; mechanism; need for surgery); and symptoms at the last clinical follow-up visit. Descriptive and sub-group analyses were performed.

RESULTS

Sixty-nine patients were included; 52 men (75%), 49 athletes (71%), 47 (68%) with primary injury, mean age of 30 years (SD 10). The patients were followed up for an average of 8.7 years (minimum 5, maximum 11.8) after surgery. After the reconstruction, 67 (97%) returned to the sport; 75% at the same level as before the injury. Ten patients (14%) suffered re-injury after an average of 32 months (between 9 and 50 months). Regarding the outcome of re-injury, no statistically significant differences were found between subgroups of athletes vs non-athletes or primary injury vs revision surgery, despite a significant tendency towards increased re-injury levels in athletes. However, this tendency was not statistically significant.

CONCLUSION

In our series of patients operated on with the double-bundle technique and with a long follow-up time, 14% presented re-injury, with no differences between primary and revision cases, and with a trend towards higher re-injury levels among the athletes in relation to the non-athletes. The rate of return to sport was satisfactory, with 97%, of which 75% were playing at the same level as before the injury.

Arthroscopic Reverse Remplissage in a Bilateral Seizure-related Posterior Shoulder Dislocation: Technique Description and 3-Year Follow-up Case Report

The treatment options for posterior instability associated with epilepsy includes grafts, osteotomies, arthrodesis and arthroplasty. The technique of reverse arthroscopic remplissage was described in 2006 as a method of filling the anterior humeral bone defect, associated with tenodesis of the subscapularis tendon. This case report presents the results of the reverse remplissage technique in relation to a patient who suffered a bilateral posterior glenohumeral dislocation with a reverse Hill-Sachs lesion.

Clinical and functional outcomes of the remplissage technique to repair anterior shoulder dislocation: average 7 years of follow-up

PURPOSE

The purpose of this work is to report mid- to long-term clinical results, recurrence rates and instability following surgery to repair anterior dislocation of the shoulder by the remplissage technique.

METHODS

This was a retrospective case series at a single center with patients with anterior shoulder instability that received surgery using the remplissage technique. Rowe questionnaire, instability complaints, recurrence episodes and return to sport were analyzed.

RESULTS

Of all patients screened, 21 (92.3%) were enrolled and only 2 patients were lost to follow-up. The mean age of the patients at the time of surgery was 27.8y.o., and the mean number of dislocations before surgery was 3.2 episodes. The follow-up average was 83.8 months (range 28-126). No case of postoperative infection was observed. Two patients (9.5%) had recurrent shoulder instability and required reintervention after 18 and 48 months. The average final Rowe score was 92.9 (range 75-100). All patients that played sports before surgery returned to the sport, and 73.7% of them returned to the same activity level.

CONCLUSION

The remplissage technique applied to repair anterior shoulder dislocation with humeral bone loss presents good results regarding clinical scores, shoulder stability and acceptable rates of return to sports, even in a mid- to long-term follow-up.

LEVEL OF EVIDENCE

IV.

RANDOMIZED PROSPECTIVE STUDY ON TRAUMATIC PATELLAR DISLOCATION: CONSERVATIVE TREATMENT VERSUS RECONSTRUCTION OF THE MEDIAL PATELLOFEMORAL LIGAMENT USING THE PATELLAR TENDON, WITH A MINIMUM OF TWO YEARS OF FOLLOW-UP

Objective: The aim of this study was to compare the surgical results from reconstruction of the medial patellofemoral ligament (MPFL) with non-operative treatment of primary patellar dislocation. Methods: Thirty-nine patients (41 knees) with patellar dislocation were randomized into two groups. One group was treated conservatively (immobilization and physiotherapy) and other was treated surgically with reconstruction of the MPFL, and the results were evaluated with a minimum follow-up of two years. The Kujala questionnaire was applied to assess pain and quality of life, and recurrences were evaluated. Pearson's chi-square test and Fisher's exact test were used in the statistical evaluation. Results: The statistical analysis showed that the mean Kujala score was significantly lower in the conservative group (70.8), compared with the mean value in the surgical group (88.9), with p = 0.001. The surgical group presented a higher percentage of “good/excellent” Kujala score results (71.43%) than in the conservative group (25.0%), with p = 0.003. The conservative group presented a greater number of recurrences (35% of the cases), while in the surgical group there were no reports of recurrences and/or subluxation. Conclusions: Treatment with reconstruction of the medial patellofemoral ligament using the patellar tendon produced better results, based on the analysis of post-treatment recurrences and the better final results from the Kujala questionnaire after a minimum follow-up period of two years.

Traumatic patellar dislocation: nonoperative treatment compared with MPFL reconstruction using patellar tendon

BACKGROUND

Over the long term, acute patellar dislocations can result in patellar instability, with high recurrence rates after nonoperative treatment.

PURPOSE

To compare the results of operative (reconstruction of the medial patellofemoral ligament [MPFL]) versus nonoperative treatment of primary patellar dislocation.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Thirty-nine patients (41 knees) (mean age, 24.2 years; range, 12-38 years) with acute patellar dislocation were randomized into 2 groups. One group was treated nonoperatively with immobilization and physiotherapy, the other was treated surgically with MPFL reconstruction; both groups were evaluated with minimum follow-up of 2 years. The Kujala questionnaire was applied to assess pain and quality of life, and recurrence was evaluated. Pearson χ(2) or Fisher exact test was used in the statistical evaluation.

RESULTS

The statistical analysis showed that the mean Kujala score was significantly lower in the nonoperative group (70.8), when compared with the mean value of the surgical group (88.9; P = .001). The surgical group presented a higher percentage of "good/excellent" results (71.43%) on the Kujala score when compared with the nonoperative group (25.0%; P = .003). The nonoperative group presented a large number of recurrences and subluxations (7 patients; 35% of cases), whereas there were no reports of recurrences or subluxations in the surgical group.

CONCLUSION

Treatment with MPFL reconstruction using the patellar tendon produced better results, based on the analyses of posttreatment recurrences and the better final results of the Kujala questionnaire after a minimum follow-up period of 2 years.

ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION USING THE DOUBLE-BUNDLE TECHNIQUE – EVALUATION IN THE BIOMECHANICS LABORATORY

Objective: The objective of this study was to describe the methodology of knee rotation analysis using biomechanics laboratory instruments and to present the preliminary results from a comparative study on patients who underwent anterior cruciate ligament (ACL) reconstruction using the double-bundle technique. Methods: The protocol currently used in our laboratory was described. Three-dimensional kinematic analysis was performed and knee rotation amplitude was measured on eight normal patients (control group) and 12 patients who were operated using the double-bundle technique, by means of three tasks in the biomechanics laboratory. Results: No significant differences between operated and non-operated sides were shown in relation to the mean amplitudes of gait, gait with change in direction or gait with change in direction when going down stairs (p > 0.13). Conclusion: The preliminary results did not show any difference in the double-bundle ACL reconstruction technique in relation to the contralateral side and the control group.

Tratamento artroscópico da instabilidade anterior do ombro: estudo retrospectivo de 159 casos

OBJETIVO: Análise dos resultados de 159 pacientes com instabilidade anterior do ombro submetidos ao tratamento artroscópico de janeiro de 2001 a dezembro de 2005. MÉTODOS: Estudo retrospectivo de prontuários com dados completos. RESULTADOS: Em 108 pacientes notou-se a lesão de Bankart e em 62 pacientes a lesão do tipo SLAP estava presente. Utilizou-se em média 2,7 âncoras. Apresentaram complicações 42 casos; 14 tinham dor aos esforços, 12 tinham algum grau de diminuição da rotação externa, 16 apresentaram recidiva. Os pacientes que evoluíram com complicações utilizaram em média 2,5 âncoras, enquanto naqueles sem complicações a média foi de 2,8 (p<0,05). De 35 pacientes com lesão óssea da borda anterior da glenóide 8 tiveram recidiva e de 124 casos sem fratura 8 recidivaram (p<0,05). De 113 pacientes com primo-luxação traumática 12 evoluíram com limitação da rotação externa enquanto em 46 casos atraumáticos nenhum apresentou limitação (p<0,05). Dos casos que apresentavam lesão SLAP 11 evoluíram com dor, enquanto que nos casos sem esta lesão três apresentaram dor (p<0,05). CONCLUSÃO: Houve maior índice de recidiva na presença da lesão óssea da borda anterior da glenóide. Dor pós-operatória foi mais frequente quando presente a lesão SLAP. Limitação da rotação externa está relacionada com instabilidade traumática.

Comparison between Platelet-Rich Plasma and Autologous Iliac Grafts for Tibial Osteotomy

OBJECTIVE

Platelet-rich plasma (PRP) has the capacity to improve the bone-healing process. The aim of this pilot study was to investigate the occurrence of bone healing and the time taken to achieve this in patients submitted to medial opening wedge high tibial osteotomy (MOWHTO), comparing platelet-rich plasma with bone marrow aspirate to autologous iliac graft.

DESIGN

Twenty-five patients who underwent tibial osteotomy were randomly divided into 2 groups: a control group, which received autologous iliac grafts (14 patients), and a study group, which received a compound of PRP and bone marrow aspirate (11 patients).

RESULTS

The bone-healing rates achieved were 100% in the control group and 91% in the study group. There was no difference in the time taken to achieve bone healing between the groups.

CONCLUSIONS

The use of a combination of PRP and bone marrow aspirate, as a bone substitute, did not demonstrate any advantage over the use of an autologous iliac graft in MOWHTO.

ARTHROSCOPIC TREATMENT OF CALCIFYING TENDINITIS OF THE ROTATOR CUFF

To evaluate the clinical and radiographic results from arthroscopic surgical treatment of the rotator cuff in patients with calcifying tendinitis.

METHOD

A retrospective study was conducted on twenty patients who underwent arthroscopic treatment for calcifying tendinitis of the shoulder between March 1999 and November 2005. Six patients were excluded due to loss of follow-up. The average follow-up period was 41.4 months. Eight patients (57%) were female and six (43%) were male. The right side was affected in 10 cases (71%) and the left in four cases (29%). Nine cases (64%) had calcification in the supraspinatus tendon, two (14%) in the infraspinatus tendon, and three (21%) in both tendons.

RESULTS

In all cases, resection of the calcium deposits was performed by means of a needle (Jelco® No. 14) in combination with curettage (mini-curette). Two shoulders (14%) underwent subacromial decompression, and one (7%) underwent excision of the distal clavicle. A tendon-tendon suture was performed in three shoulders (21%). None of the patients underwent tendon-bone reinsertion. The mean score obtained on the UCLA scale was 33 points (26-35), thus indicating that a majority of patients had good results. In the final radiographic evaluation, none of the patients showed signs of calcification.

CONCLUSION

Arthroscopic treatment of calcifying tendinitis of the shoulder safely allows excision of the calcification, leading to good results in relation to shoulder pain and function.

Acute calcaneus tendon rupture associated with ipsilateral malleolar fracture: case report and literature review

Malleolar fractures are rarely associated with lesions of the adjacent tendons or neurovascular structures. The association of ankle fractures with Achilles tendon rupture is even more infrequent, although both of these injuries are very common in and of themselves. To our knowledge, fracture of the lateral malleolus in association with an acute rupture of the ipsilateral calcaneus tendon has not been previously described. In this article, we describe a female patient who sustained an acute rupture of the Achilles tendon in conjunction with fracture of the ipsilateral lateral malleolus.

Histological study of fresh versus frozen semitendinous muscle tendon allografts

OBJECTIVE

The purpose of this study was to histologically analyze allografts from cadaveric semitendinous muscle after cryopreservation at -80 degrees C in comparison to a control group kept at only -4 degrees C to test the hypothesis that the histological characteristics of the tissue are maintained when the tendons are kept at lower temperatures.

METHODS

In a tissue bank, 10 semitendinous tendons from 10 cadavers were frozen at -80 degress C as a storage method for tissue preservation. They were kept frozen for 40 days, and then a histological study was carried out. Another 10 tendon samples were analyzed while still "fresh".

RESULTS

There was no histological difference between the fresh and frozen samples in relation to seven variables.

CONCLUSIONS

Semitendinous muscle tendon allografts can be submitted to cryopreservation at -80 degrees C without suffering histological modifications.

Conservative versus surgical treatment for repair of the medial patellofemoral ligament in acute dislocations of the patella

PURPOSE

The objective of this study was to analyze and compare the results obtained after 2 types of treatment, surgical and conservative, for acute patellar dislocations.

METHODS

We divided 33 patients with acute patellar dislocations into 2 groups. One group with 16 patients underwent conservative treatment (immobilization and subsequent physiotherapy), and the other group with 17 patients underwent surgical treatment. A radiographic examination was performed in the evaluation of the patients to verify predisposing factors for patellofemoral instability, and the Kujala questionnaire was applied with the intention of analyzing the improvement of pain and quality of life. The chi(2) test, t test, and Fisher test were used in the statistical evaluation. A significance level of P < .05 was adopted.

RESULTS

The groups were considered parametric in relation to age and sex. The conservative treatment group exhibited a higher number of recurrent dislocations (8 patients) than the surgical treatment group, which did not have any relapses. In addition, the surgical treatment group obtained a better mean score on the Kujala test (92) than the conservative treatment group (69).

CONCLUSIONS

We conclude that surgical treatment afforded better results. There were no recurrences in the surgical treatment group, but there were 8 recurrences in the conservative treatment group. The mean Kujala score was 92 in the surgical treatment group and 69 in the conservative treatment group.

LEVEL OF EVIDENCE

Level II, lesser-quality therapeutic randomized controlled trial.

THE USE OF PLATELET RICH PLASMA WITH BONE MARROW ASPIRATE IN PUDDU TIBIAL OSTEOTOMY

Objective: The present study was performed in order to evaluate the use of platelet rich plasma associated to bone marrow aspirate, substituting autologous iliac bone graft in medial opening wedge osteotomy (OWHTO). Methods: Twenty-five patients were submitted to tibial opening wedge osteotomy, being divided into two groups. Iliac group: 14 patients submitted to OWHTO, using autologous iliac bone graft to fill the gap. PRP group: 11 patients using platelet rich plasma associated to bone marrow aspirate to fill the gap. We evaluated bleeding (hemoglobin and hematocrit levels) and pain (visual analogic scale-VAS), then we compared the groups regarding these variables. Results: Differences between the groups were not found regarding hemoglobin levels (p=0.820) and hematocrit levels (p=0.323). The groups were not different regarding pain measured with VAS (p=0.538). Conclusion: The use of platelet rich plasma associated to bone marrow aspirate in medial opening wedge osteotomy did not offer advantages over autologous iliac bone graft regarding bleeding and pain.

Sternoclavicular dislocation--reconstruction with semitendinosus tendon autograft: a case report

Traumatic sternoclavicular dislocation is a rare injury corresponding to less than 5% of all injuries of the scapular belt. It is preferentially treated through reduction of the sternoclavicular joint, symptom relief, a brief period of immobilization and rehabilitation, with the aim of gaining strength and range of motion. In some patients, however, this type of injury may progress with instability and pain, thus causing discomfort and pain. On such occasions, surgical treatment is chosen. The objective of this study was to report the clinical case of a sports player who progressed with chronic traumatic anterior instability of the sternoclavicular joint and underwent reconstruction using the ipsilateral semitendinosus tendon. This was a 16-year-old male patient who was a state-level judo player. Following a fall during a fight, he presented pain, slight deformity and edema in the right sternoclavicular joint, and he underwent conservative treatment for 12 months, without success. In the end, reconstruction of the sternoclavicular joint was carried out using the ipsilateral autologous semitendinosus, with resection of the intra-articular disc and suturing of the costoclavicular ligaments. We have presented a case of dislocation of the sternoclavicular joint in a high-performance judo player who underwent reconstruction using the semitendinosus, with excellent functional results after 1 year of follow-up.

Results of meniscectomy for treatment of isolated meniscal injuries: correlation between results and etiology of injury

PURPOSE

To evaluate the results of the treatment of patients with isolated meniscal injuries of different etiologies.

MATERIALS AND METHODS

435 patients of both sexes and different age groups underwent meniscectomy after their isolated meniscal injuries were clinically diagnosed and confirmed by nuclear magnetic resonance imaging.

RESULTS

Most patients achieved good results and were able to return to the activities they had practiced prior to surgery without major limitations.

CONCLUSIONS

Meniscectomy for the treatment of traumatic meniscal injury provides better results than meniscectomy for the treatment of degenerative meniscal injury. The results of meniscectomy for the treatment of meniscal injury due to fatigue are similar to those of meniscectomy for the treatment of traumatic meniscal injury, although the risk of osteonecrosis development is higher.

Estudo prospectivo e comparativo entre o tratamento conservador e o cirúrgico (reparo do ligamento femoropatelar medial) nas luxações agudas de patela

Foram avaliados dois grupos de pacientes com o primeiro episódio de luxação aguda femoropatelar traumática e acompanhados prospectivamente em relação às recidivas e aos fatores predisponentes à luxação. No Grupo I, 17 pacientes com média de idade de 24,6 anos, sendo 11 do sexo feminino, foram submetidos ao reparo do ligamento femoropatelar medial com menos de um mês de trauma. O tempo médio de seguimento foi de 40,4 meses e o mínimo de 18 meses. Como resultados, não houve nenhuma recidiva da luxação,houve dois episódios de subluxação . Nove pacientes apresentavam fatores predisponentes à luxação. No Grupo II, 15 pacientes com média de idade de 26,8 anos, sendo oito do sexo feminino, foram submetidos ao tratamento conservador com média de 18,5 dias de imobilização. O tempo de seguimento médio foi de 35,7 meses e o mínimo de 11 meses. Oito joelhos tiveram recidiva da luxação, apenas dois joelhos foram considerados estáveis . Neste grupo, 14 pacientes apresentavam fatores predisponentes. Concluímos que o tratamento cirúrgico das luxações agudas femoropatelares traumáticas apresenta resultados superiores quanto à recidiva em relação ao tratamento conservador no período estudado. A presença de fatores predisponentes em nossa série de pacientes não influenciou as recidivas das luxações femoropatelares.