Avaliação da reprodutibilidade da classificação de Schatzker revisada por Kfuri para as fraturas do planalto tibial

Objective  The Schatzker classification is the most used for tibial plateau fractures. Kfuri et al. 12 reviewed Schatzker's initial classification describing in more detail the involvement of the tibial plateau in the coronal plane, allowing a better understanding of the fracture pattern and a more accurate surgical planning. The objectives of the present study are to evaluate the interobserver agreement of these classifications and to evaluate the influence of the experience of the observer on the reproducibility of the instruments.

Methods  An observational and retrospective study was conducted by evaluating the radiological study of 20 adult individuals with tibial plateau fractures, including radiographs and computed tomography (CT). The fractures were classified once by 34 examiners with varied experience (24 specialists and 10 residents in Orthopedics and Traumatology), according to the Schatzker classification and to the modification proposed by Kfuri. The Fleiss Kappa index was used to verify interobserver agreement.

Results  The interobserver agreement index was considered moderate for the Schatzker classification (κ = 0.46) and mild for the Kfuri modification (κ = 0.30). The Schatzker classification showed moderate agreement, with κ = 0.52 for residents and κ = 0.45 among specialists. The Kfuri classification showed mild agreement, with Kappa values for residents and specialists of 0.39 and 0.28, respectively.

Conclusion  The Schatzker classification and the classification modified by Kfuri presented moderate and mild interobserver agreement, respectively. In addition, the residents presented higher agreement than the specialists for the two systems studied.

The Impact of Computed Tomography on Decision Making in Tibial Plateau Fractures

Schatzker introduced one of the most used classification systems for tibial plateau fractures, based on plain radiographs. Computed tomography brought to attention the importance of coronal plane-oriented fractures. The goal of our study was to determine if the addition of computed tomography would affect the decision making of surgeons who usually use the Schatzker classification to assess tibial plateau fractures. Image studies of 70 patients who sustained tibial plateau fractures were uploaded to a dedicated homepage. Every patient was linked to a folder which contained two radiographic projections (anteroposterior and lateral), three interactive videos of computed tomography (axial, sagittal, and coronal), and eight pictures depicting tridimensional reconstructions of the tibial plateau. Ten attending orthopaedic surgeons, who were blinded to the cases, were granted access to the homepage and assessed each set of images in two different rounds, separated to each other by an interval of 2 weeks. Each case was evaluated in three steps, where surgeons had access, respectively to radiographs, two-dimensional videos of computed tomography, and three-dimensional reconstruction images. After every step, surgeons were asked to present how would they classify the case using the Schatzker system and which surgical approaches would be appropriate. We evaluated the inter- and intraobserver reliability of the Schatzker classification using the Kappa concordance coefficient, as well as the impact of computed tomography in the decision making regarding the surgical approach for each case, by using the chi-square test and likelihood ratio. The interobserver concordance kappa coefficients after each assessment step were, respectively, 0.58, 0.62, and 0.64. For the intraobserver analysis, the coefficients were, respectively, 0.76, 0.75, and 0.78. Computed tomography changed the surgical approach selection for the types II, V, and VI of Schatzker (p < 0.01). The addition of computed tomography scans to plain radiographs improved the interobserver reliability of Schatzker classification. Computed tomography had a statistically significant impact in the selection of surgical approaches for the lateral tibial plateau.

Extended Anterolateral Approach for Complex Lateral Tibial Plateau Fractures

Complex fractures of the lateral tibial plateau may extend to the posterior rim of the knee and to the tibial spines. Displaced fractures of the posterolateral corner of the tibial plateau may result in joint incongruity and instability, especially with the knee in flexion. Anatomical reduction of the joint surface and containment of the tibial rim are the primary goals of the treatment in such cases. Dedicated surgical approaches including dissection of the peroneal nerve, sometimes in association with an osteotomy of the fibular head are typically used to address these injuries. Some techniques require special positioning of the patient on the operative table. Anatomical studies of the knee allowed us to conclude that an osteotomy of the lateral epicondyle of the femur may be a natural extension of the standard anterolateral approach to the tibial plateau. The main advantage of this approach is the broad exposure of the lateral joint surface, allowing its anatomical reduction. It does not violate the proximal tibiofibular joint or pose a risk to the peroneal nerve. The main limitation is the lack of visualization of the posterior metaphysis of the tibia, preventing the application of a buttress plate parallel to the plane of fracture split. To overcome this limitation, we describe a method to support the posterior tibial plateau rim, in cases of bicondylar tibial plateau fractures, combining the extended anterolateral with the posteromedial approach. For selected cases, with a significant compromise of the posterolateral and anterolateral quadrants of the tibial plateau, including the tibial spines, the extended anterolateral approach may be complemented by a planned detachment of the anterior horn of the lateral meniscus. In such variant, a complete exposure of the entire surface of the lateral tibial plateau and tibial spines is achievable, assuring optimal conditions for an anatomical reduction of the articular surface.

ARTHROSCOPIC REPAIR OF SMALL AND MEDIUM TEARS OF THE SUPRASPINATUS MUSCLE TENDON: EVALUATION OF THE CLINICAL AND FUNCTIONAL OUTCOMES AFTER TWO YEARS OF FOLLOW-UP

Objective: To evaluate the clinical and functional outcomes from arthroscopic repairs on small and medium-sized tears of the supraspinatus muscle tendon. Methods: 129 cases of isolated small and medium tears of the supraspinatus muscle tendon were evaluated retrospectively. The average duration of pain was 29 months. The average joint range of motion comprised active elevation of 136°, lateral rotation of 58° and medial rotation at T12 level; and the preoperative functional UCLA score averaged 17 points. In all the cases, complete repair could be achieved. Results: The average score on the UCLA functional scale in the postoperative period was 32 points. The average length of follow-up was 39 months. Seventy-five cases (58%) had excellent results and 42 (32%) had good results. The average final active elevation was 156° with an average gain of 20°, and the average final lateral rotation was 57° with an average gain of 9°. Both of these were statistically significant (P < 0.05). The patients who underwent tenotomy of the long head of the biceps (LHB), with or without tenodesis, did not present statistically inferior functional outcomes, in comparison with the patients who only underwent decompression and lesion repair (P = 1.00). Fourteen cases (10.8%) presented complications during the postoperative period. Six (4.6%) developed adhesive capsulitis and four (3.1%) presented re-rupture of the tendon, proven by means of magnetic resonance imaging. Conclusions: Arthroscopic repair of small and medium tears of the supraspinatus muscle tendon provided a functional clinical improvement, with good and excellent results in 90% of the cases.

Updates in biological therapies for knee injuries: bone

Bone is a unique tissue because of its mechanical properties, ability for self-repair, and enrollment in different metabolic processes such as calcium homeostasis and hematopoietic cell production. Bone barely tolerates deformation and tends to fail when overloaded. Fracture healing is a complex process that in particular cases is impaired. Osteoprogenitor cells proliferation, growth factors, and a sound tridimensional scaffold at fracture site are key elements for new bone formation and deposition. Mechanical stability and ample vascularity are also of great importance on providing a proper environment for bone healing. From mesenchymal stem cells delivery to custom-made synthetic scaffolds, many are the biological attempts to enhance bone healing. Impaired fracture healing represents a real burden to contemporary society. Sound basic science knowledge has contributed to newer approaches aimed to accelerate and improve the quality of bone healing.

USE OF AUTOLOGOUS BONE GRAFT ASSOCIATED WITH SUPPORT OSTEOSYNTHESIS FOR TIBIAL EDGE BONE LOSSES IN TOTAL KNEE PROSTHESES

Objective: To report the initial results from the use of a new technique for fixation of bone grafts in uncontained tibial bone defects in patients undergoing total knee prosthesis implantation. Methods: Six patients with severe varus deformity of the knee who, after cuts and ligament balancing had been performed, still presented bone deficiencies that reached the edge of the tibial cut and compromised the implant stability, underwent a new fixation technique. Results: Five of the patients had good-clinical results, with integration of the graft within 12 weeks. One patient presented clinical complications with wound dehiscence and implant exposure, which evolved to the need for implant removal and knee arthrodesis. Conclusion: Support osteosynthesis as a graft fixation method is a viable option for treating tibial bone deficiencies. The proposed technique certainly needs further studies for its validation.

EFFECTS OF CHEMICAL PROCESSING AND OXIDE ETHYLENE STERILIZATION ON CORTICAL AND CANCELLOUS RAT BONE: A LIGHT AND ELECTRON SCANNING MICROSCOPY STUDY

To evaluate, under microscopic examination, the structural changes displayed by the trabecular and cortical bones after being processed chemically and sterilized by ethylene oxide. Methods: Samples of cancellous and cortical bones obtained from young female albinus rats (Wistar) were assigned to four groups according to the type of treatment: Group I- drying; Group II- drying and ethylene oxide sterilization; III- chemical treatment; IV- chemical treatment and ethylene oxide sterilization. Half of this material was analyzed under ordinary light microscope and the other half using scanning electron microscopy. Results: In all the samples, regardless the group, there was good preservation of the general morphology. For samples submitted to the chemical processing there was better preservation of the cellular content, whereas there was amalgamation of the fibres when ethylene oxide was used. Conclusion: Treatment with ethylene oxide caused amalgamation of the fibers, possibly because of heating and the chemical treatment contributed to a better cellular preservation of the osseous structure.