Carlos Eduardo da Silveira Franciozi

Background: Anterior cruciate ligament (ACL) reconstruction (ACLR) is one of the most commonly performed procedures in sports medicine. Although international surveys have described global trends in graft selection, extra-articular procedures, and meniscal management, contemporary nationwide data from Brazil remain limited. Hypothesis/Purpose: To characterize current ACLR practices among Brazilian knee surgeons, including graft choice, use of lateral extra-articular procedures, meniscal management, and return-to-sport (RTS) strategies. We hypothesized that Brazilian surgeons would adhere to contemporary evidence regarding meniscal preservation and RTS timing, with distinctive patterns in graft selection and extra-articular augmentation. Study Design: Cross-sectional study. Methods: A nationwide, web-based survey was distributed to board-certified orthopaedic surgeons performing ACLR. The questionnaire included 60 items addressing surgeon characteristics, surgical technique, graft selection, use of lateral extra-articular procedures, meniscal management, and RTS criteria. Responses were analyzed descriptively, with exploratory association analyses evaluating relationships between surgeon characteristics (age, region, and surgical volume) and selected surgical practices. Results: Of 1545 invited surgeons, 382 completed the survey. Hamstring tendon autografts were the primary graft choice for 90.1% of respondents, followed by bone-patellar tendon-bone autografts (5.8%). Lateral extra-articular procedures were used at least occasionally by 94.5% of surgeons in primary ACLR and frequently or always by 74.6% in revision cases. Increased rates of meniscal repair were reported by 82.2% of respondents, and unrestricted RTS was most commonly authorized between 9 and 12 months (74.1%). Higher surgical volume was associated with more frequent use of lateral extra-articular procedures in primary ( P = .001) and revision settings ( P = .046), as well as increased meniscal repair rates ( P = .016). Regional and age-related differences in lateral extra-articular tenodesis/anterolateral ligament use were also observed. Conclusion: Brazilian ACLR practices appear broadly consistent with contemporary international trends, particularly regarding meniscal preservation and RTS timing. Distinctive features include a predominant preference for hamstring autografts and a high rate of lateral extra-articular procedure use. Surgeon characteristics were associated with variation in selected surgical practices.

Introduction: intra-articular injections are widely used for knee osteoarthritis, yet the optimal strategy for sustained symptom relief remains uncertain. Objectives: to compare the clinical outcomes of PRP plasma gel, hyaluronic acid, and corticosteroid intra-articular injections, used alone or in combination, for the treatment of knee osteoarthritis. Methods: this prospective, randomized, single-blind clinical trial included patients with Kellgren–Lawrence grade II–III knee osteoarthritis allocated into 4 treatment groups. Clinical outcomes were assessed using validated patient-reported measures over a 6-month follow-up period. Results: all groups demonstrated early improvement in pain and function. At 6 months, treatments incorporating PRP plasma gel showed more sustained pain and functional benefits compared with corticosteroid alone. The combination of PRP plasma gel, hyaluronic acid, and corticosteroid yielded the most consistent clinical outcomes. Conclusion: the combination of PRP plasma gel, hyaluronic acid, and corticosteroid demonstrated more consistent and sustained clinical improvement at 6 months compared with corticosteroid alone, although no statistically significant differences between groups were observed after adjustment. PRP plasma gel alone showed clinical outcomes comparable to hyaluronic acid.

Purpose: This narrative review synthesises the anatomical, biomechanical, and clinical evidence on the rectus femoris tendon as an autograft for knee ligament reconstruction. Methods: A literature search was conducted in PubMed and Google Scholar up to June 2026 with no language restrictions. A total of 35 articles describing the rectus femoris tendon as a graft for knee ligament reconstruction were included. Results: Cadaveric studies demonstrated consistent morphometric dimensions, with a mean tendon length of approximately 30 cm and graft diameters ranging from 8 to 11 mm. Biomechanical testing across four independent cadaveric studies showed that the doubled rectus femoris provides load‐to‐failure within the range of established anterior cruciate ligament grafts. Multiple harvesting techniques have been described, using the identification of a fat layer between the rectus femoris and the intermediate layer as the primary landmark. The graft has been applied to isolated anterior cruciate ligament reconstruction, combined anterior cruciate ligament and anterolateral or anteromedial ligament reinforcement, posterior cruciate ligament reconstruction, and revision surgery. Early clinical series reported functional outcomes comparable to hamstring tendon autografts, with low donor‐site morbidity. Isokinetic evaluation showed no difference in extensor performance between rectus femoris and hamstring tendon groups at six months. Intraoperative complications included capsular violations and premature graft amputations, concentrated in initial cases and without clinical repercussions. The current clinical evidence is limited to level III and IV studies, with a maximum mean follow‐up of approximately 3.5 years in revision settings and 3 years in primary reconstruction, demonstrating improvement in patient‐reported outcomes and knee stability. Conclusion: The rectus femoris tendon is a viable autograft for knee ligament reconstruction, with consistent anatomy, adequate biomechanical properties, and early clinical results comparable to hamstring tendon autografts. It should be considered in individualised graft selection. Level of Evidence: Level V.

Selecting the optimal autograft for knee ligament reconstruction is a critical factor influencing graft strength, surgical strategy, and postoperative outcomes. Although patellar and hamstring tendons are traditionally preferred, emerging options-including quadriceps, rectus femoris, peroneus longus, braided hamstrings, and iliotibial band (ITB)-have gained attention. However, direct biomechanical comparison under standardized conditions remains limited. It was hypothesized that the four emerging grafts (rectus femoris, peroneus longus, braided hamstrings, and ITB) would demonstrate ultimate load to failure comparable to the three traditional autografts, with potential mechanical advantages for the rectus femoris and peroneus longus tendons. Controlled laboratory biomechanical study. Fifty-eight grafts were harvested from adult cadaveric donors (all male; mean age, 35 ± 5 years). Seven autograft types were evaluated: full thickness quadriceps, double strand rectus femoris, double strand peroneus longus, patellar (soft-tissue portion of the bone-patellar-tendon-bone), quadruple strand hamstring (parallel and braided configurations), and iliotibial band. Each graft was fixed in polyurethane foam blocks with titanium interference screws and tested to failure in a universal testing machine (EMIC DL 10000) at 10 mm/min. Ultimate load to failure (N) was analyzed using a linear mixed-effects model with donor as a random effect to account for within-donor clustering. Significant differences in ultimate load to failure were observed among graft types in the linear mixed-effects model (overall p < 0.001). The full-thickness quadriceps tendon demonstrated the highest ultimate load (2302.9 ± 79.7 N), significantly greater than all other graft configurations (all adjusted p < 0.05). The double-strand peroneus longus tendon also demonstrated high resistance (1991.3 ± 160.3 N), with significantly greater ultimate load values than the patellar tendon, double-strand rectus femoris tendon, quadruple-strand hamstring (parallel configuration), and iliotibial band (all adjusted p < 0.05). The patellar tendon (1734.7 ± 136.2 N), double-strand rectus femoris tendon (1713.9 ± 56.1 N), and quadruple-strand hamstring (parallel configuration) grafts (1683.8 ± 80.5 N) demonstrated comparable biomechanical performance (all adjusted p > 0.05). The braided hamstring configuration demonstrated an 8.2% greater ultimate load than the parallel configuration (1821.8 ± 11.7 N vs 1683.8 ± 80.5 N), although this difference was not statistically significant (adjusted p > 0.05). The iliotibial band demonstrated the lowest resistance (749.1 ± 155.4 N), significantly lower than all other graft groups (all adjusted p < 0.05). The full-thickness quadriceps and double-strand peroneus longus grafts demonstrated the highest absolute ultimate loads to failure under standardized static testing conditions. The rectus femoris, patellar tendon, and hamstring graft configurations showed comparable biomechanical performance, whereas the iliotibial band demonstrated lower resistance. These findings represent time-zero biomechanical data and should not be interpreted as evidence of clinical superiority of any graft option.

Knee osteoarthritis (OA) remains a leading cause of pain and disability worldwide, and current injectable options such as corticosteroids and hyaluronic acid often provide limited or short‐term benefits. Orthobiologic therapies, particularly platelet‐rich plasma (PRP), have gained attention for their regenerative and anti‐inflammatory potential. PRP plasma gel is a autologous formulation obtained through controlled thermal denaturation of plasma proteins, producing an albumin‐based semisolid matrix subsequently mixed with fresh PRP. This process results in a homogeneous gel capable of sustained release of bioactive growth factors, potentially prolonging intra‐articular residence time and clinical effect compared with conventional PRP. We describe a step‐by‐step technique for preparing PRP plasma gel using standard laboratory equipment, without the need for commercial kits. The method is reproducible, low cost, and suitable for outpatient settings, including resource‐limited environments. Clinical application is shown in knee osteoarthritis, where the formulation can be injected intra‐articularly as an accessible and versatile orthobiologic option. The technique offers technical and economic advantages, with the potential to broaden the use of orthobiologic therapies in daily practice.

Purpose: To evaluate bilateral isokinetic performance symmetry of knee extensors and flexors 6 months after anterior cruciate ligament reconstruction using a rectus femoris tendon autograft. Methods: This retrospective case series included patients consecutively recruited at a single tertiary sports medicine center between January 2023 and July 2024. Inclusion required primary anterior cruciate ligament reconstruction with a rectus femoris autograft, no prior knee surgeries, and a minimum 6‐month follow‐up; patients with revision or multiligamentous procedures were excluded. Isokinetic testing was performed at 6 months using a computerized dynamometer. The nonoperative limb was tested first, followed by the operative limb. Patients performed 5 maximal effort trials at 60°/s for both extension and flexion. Measured outcomes included peak torque (PT), PT normalized to body weight, angle at PT, total work (TT), and mean power (PM) for both knee extension and flexion. Paired t‐tests compared operated and nonoperated limbs. Statistical significance was set at P ≤ .05. Results: Thirty‐one male patients (mean age, 26.3 ± 4.7 years) were included, with a mean follow‐up of 6.2 ± 0.4 months. At 6 months, the operated limb achieved 71% of contralateral PT and 75% of contralateral PM, with significant deficits in extension PT ( P < .001), PT normalized to body weight ( P < .001), TT ( P < .001), and PM ( P = .002), while no significant difference was found for angle at PT ( P = .457). Flexor performance showed near‐complete recovery, with the operated limb reaching 93% of contralateral peak torque and 90% of TT, with P = .355, .340, .902, .153, and .316 for PT, PT normalized to body weight, angle at PT, TT, and PM, respectively. Conclusions: At 6 months, anterior cruciate ligament reconstruction with a rectus femoris autograft was associated with complete recovery of knee flexor performance but persistent deficits in knee extensor performance. Level of Evidence: Level IV, retrospective case series.

Purpose: To compare isokinetic quadriceps performance 6 months after anterior cruciate ligament reconstruction (ACLR) using rectus femoris (RF) versus hamstring tendon (HT) autografts. Methods: In this cross‐sectional study, 75 male patients who underwent primary ACLR with RF ( n = 31) or HT ( n = 44) autografts were evaluated ~6 months postoperatively. Bilateral isokinetic testing at single angular velocity 60°/s (Biodex Multi‐Joint System 4) measured peak torque (PT), PT normalized to body weight (PT/BW), angle at peak torque (aPT), total work (TW), and mean power (PM). Between‐group comparisons used independent t‐tests; paired comparisons were conducted within the RF group. Results: No between‐group differences were detected for PT, PT/BW, aPT, TW, or PM ( p > 0.05 for all—primary contrast PT: mean diff. 5.3 Nm; 95% CI –20.4 to 30.9; p = 0.689). Within the RF group, the operated limb showed lower PT, PT/BW, TW, and PM than the contralateral limb (all p ≤ 0.002), with no difference in aPT. Conclusions: At 6 months after ACLR, quadriceps performance did not differ between RF and HT autografts. These early data do not address return‐to‐sport timing or graft healing and should not be interpreted as evidence of equivalence (it is not powered for equivalence/non‐inferiority); rather, they support RF as a potential option warranting longer‐term studies incorporating functional tests and patient‐reported outcomes. Level of Evidence: Level III, cross‐sectional comparative study.

Knee dislocations are rare but severe injuries, often resulting from high-energy trauma and commonly associated with vascular and neurologic damage. In low-income settings, the evaluation and management of these injuries are especially challenging because of limited access to advanced imaging, surgical implants, and structured rehabilitation services. This review aims to provide a practical, evidence-based framework for managing knee dislocations in resource-constrained environments. A focused literature review was conducted on studies published in the past decade that address diagnosis, treatment strategies, and system-level barriers in underserved regions. Key topics include simplified diagnostic approaches using clinical evaluation and basic imaging, early detection of vascular and nerve injuries without advanced tools, and cost-effective surgical techniques. These include the use of autografts, external fixators, and implantless fixation methods such as press-fit and bone bridges, as well as the use of the same tunnels and fixation devices for more than one ligament. Rehabilitation strategies are also adapted, with emphasis on simplified protocols that consider social and logistical barriers to follow-up. Despite notable limitations, appropriate prioritization, creative use of available materials, and staged reconstructions can ensure acceptable outcomes. This article offers orthopaedic surgeons working in low-resource environments practical guidance to maintain standards of care through adaptable, cost-conscious decision-making.