Diego Ariel de Lima

Meniscal preservation is a priority in the treatment of knee injuries because of the fundamental role of the meniscus in load absorption, joint stability, and chondral protection. Several repair techniques have been described, including inside‐out, outside‐in, and all‐inside approaches. More recently, continuous suturing techniques have emerged as a promising alternative, allowing multiple fixation points with shorter operative time and reduced costs. We describe a hybrid continuous meniscal repair technique that combines initial all‐inside fixation with additional outside‐in sutures using the excess suture limb from the implant. The repair begins with meniscal fixation using an all‐inside device, after which the free suture end is redirected percutaneously through successive outside‐in passages, creating a continuous vertical suture construct. This strategy enables multiple fixation points from a single device, potentially enhancing biomechanical stability and reducing the need for additional implants. The integration of all‐inside and outside‐in fixation allows the entire extent of the tear to be addressed in a safe, reproducible, and cost‐effective manner. The described hybrid technique expands the applicability of continuous meniscal suturing and may contribute to improved clinical outcomes in meniscal preservation.

Purpose: To evaluate magnetic resonance imaging (MRI)‐based continuity and signal characteristics of reconstructed anterolateral ligament (ALL) grafts and compare anteroposterior and rotational knee laxity after anterior cruciate ligament (ACL) graft failure with values recorded before the index combined ACL–ALL reconstruction. Methods: This retrospective case series included 15 patients who experienced ACL graft failure after combined ACL–ALL reconstruction; the index combined procedure was primary in 12 patients and a revision in 3. MRI was reviewed to assess ALL graft continuity, intrinsic signal changes and periligamentous edema. Side‐to‐side anterior tibial translation (ATT) measured with the KT‐1000 arthrometer and pivot‐shift grade were compared between the preindex reconstruction assessment and the assessment after ACL graft failure using Wilcoxon signed‐rank tests. Results: ACL graft failure occurred at a mean of 22 ± 1.5 months (range, 18–24 months) after the index reconstruction. The ALL graft showed preserved continuity on MRI in all 15 patients (100%), and mild signal changes were observed in 9 (60%). Median ATT was lower after ACL graft failure than before the index reconstruction (5 vs. 7 mm; median paired reduction, 2 mm [IQR, 1–3]; p = 0.001). Median pivot‐shift grade was also lower (1 vs. 2; median paired reduction, 1 grade [IQR, 1–1.5]; p = 0.001). ATT and pivot‐shift grade improved in 12 of 15 patients (80%), and no patient demonstrated a high‐grade pivot shift after ACL graft failure. Conclusion: Following ACL graft failure after combined ACL–ALL reconstruction, MRI showed preserved ALL graft continuity in all cases, and knee laxity was lower than before the index reconstruction. In this setting, physical examination findings should be interpreted cautiously because anteroposterior and rotational laxity may be lower than expected. The retrospective design and small, heterogeneous sample preclude causal attribution to the ALL graft and any conclusion that anterolateral revision can be omitted. Level of Evidence: Level IV.

Recurrent patellar instability may persist after isolated medial patellofemoral ligament reconstruction, particularly in cases with instability beyond early knee flexion. Recent evidence has emphasized the role of the medial patellotibial ligament as a secondary stabilizer contributing to patellofemoral stability at higher degrees of flexion. As a result, combined reconstruction of the medial patellofemoral ligament and medial patellotibial ligament has emerged as a promising strategy to restore more physiologic patellar kinematics. This technical note describes a reproducible technique for combined medial patellofemoral ligament and medial patellotibial ligament reconstruction using a single rectus femoris tendon autograft harvested from the superficial layer of the quadriceps tendon. The technique is soft‐tissue‐based and physeal‐sparing and avoids bone tunnels, making it particularly suitable for skeletally immature patients. The rectus femoris graft provides sufficient length, favorable biomechanical properties, low donor‐site morbidity, and satisfactory cosmetic results through a minimally invasive approach.

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.

Background: The rectus femoris tendon has recently gained attention as a promising soft tissue autograft for anterior cruciate ligament (ACL) reconstruction. However, there is limited information regarding its graft dimensions, harvesting technique, and safety profile. Purpose: To evaluate the dimensions of the rectus femoris tendon graft in patients undergoing ACL reconstruction, identify anthropometric predictors of graft size, describe key technical steps for safe harvesting, and report intraoperative complications. Study Design: Case series; Level of evidence, 4. Methods: A total of 211 consecutive patients undergoing ACL reconstruction with rectus femoris tendon autograft were prospectively enrolled across multiple centers. Graft dimensions—length and diameter in 2- and 3-strand configurations—were recorded intraoperatively. Correlations between graft size and patient anthropometry were assessed, and a multivariable regression model was developed to predict graft length. Intraoperative complications during graft harvesting were also documented. Results: The mean graft length was 30.8 ± 3.4 cm, with 99.1% measuring ≥24 cm. Mean diameters were 8.1 ± 0.6 mm (2-strand) and 9.3 ± 0.7 mm (3-strand), with only 1.4% of 3-strand grafts measuring <8 mm. Patient height showed the strongest correlation with graft length (r = 0.563). Complications occurred in 11.4% of cases, mostly minor and during the early adoption phase of this technique. Conclusion: The rectus femoris tendon provides consistent and predictable graft dimensions suitable for multistrand ACL reconstruction, including in patients at higher risk of undersized soft tissue grafts. These morphometric findings support its potential as an autograft option and provide a basis for preoperative planning. Clinical outcomes and donor-site morbidity require evaluation in future studies.

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.

Prezado Editor, Dr. Geraldo Rocha Motta Filho, Agradecemos aos autores da carta referente ao nosso artigo publicado na Revista Brasileira de Ortopedia [1] pelas observações apresentadas, que consideramos pertinentes e construtivas. O debate científico, quando conduzido com respeito e embasamento técnico, é essencial para o amadurecimento da ortobiologia como campo de pesquisa e prática clínica. Concordamos plenamente que os resultados devem ser interpretados com cautela, e que a busca por rigor científico e clareza conceitual é fundamental. Valorizamos, portanto, o espírito colaborativo deste debate, que certamente contribuirá para o avanço responsável das terapias ortobiológicas no manejo da osteoartrite de joelho. Os dados serão disponibilizados mediante solicitação ao autor correspondente. Editor-chefe: Geraldo da Rocha Motta Filho. Received: 03 November 2025 Accepted: 18 November 2025 Article published online: 19 March 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit (https://creativecommons.org/licenses/by/4.0/) Thieme Revinter Publicações Ltda. Rua Rego Freitas, 175, loja 1, República, São Paulo, SP, CEP 01220-010, Brazil

Dear Editor, Dr. Geraldo Rocha Motta Filho, We would like to thank the authors of the letter regarding our article published in the Brazilian Journal of Orthopedics [1] for their observations, which we consider relevant and constructive. Scientific debate, when conducted with respect and technical grounding, is essential for the maturation of orthobiology as a field of research and clinical practice. We fully agree that the interpretation of results should be careful and that the pursuit of scientific rigor and conceptual clarity is fundamental. We therefore value the collaborative spirit of this debate, which will certainly contribute to the responsible advancement of orthobiological therapies in the management of knee osteoarthritis. Data will be available upon request to the corresponding author. Editor-in-Chief: Geraldo da Rocha Motta Filho. Received: 03 November 2025 Accepted: 18 November 2025 Article published online: 19 March 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit (https://creativecommons.org/licenses/by/4.0/) Thieme Revinter Publicações Ltda. Rua Rego Freitas, 175, loja 1, República, São Paulo, SP, CEP 01220-010, Brazil