Rev. bras. ortop. vol.52 número2

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

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Case

Report

Extra-articular

and

transcutaneous

migration

of

the

poly-

l

/

d

-lactide

interference

screw

after

popliteal

tendon

reconstruction

夽

Camilo

Partezani

Helito

∗

_,

_Noel

_O.

_Foni,

_Marcelo

_Batista

_Bonadio,

_José

_Ricardo

_Pécora,

Marco

Kawamura

Demange,

Fabio

Janson

Angelini

UniversidadedeSãoPaulo(USP),HospitaldasClínicas,InstitutodeOrtopediaeTraumatologia,SãoPaulo,SP,Brazil

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Articlehistory: Received27April2016 Accepted30May2016

Availableonline21February2017

Keywords: Tendoninjuries

Anteriorcruciateligament reconstruction

Bonesscrews

Minimallyinvasivesurgical procedures

a

b

s

t

r

a

c

t

Kneeligamentreconstructionsarecommonlyperformedorthopedicprocedures.Graft fixa-tionisgenerallyperformedwithmetallicorabsorbableinterferencescrews.Inarecentstudy, onlytenreportsofscrewmigrationwereretrieved;ofthese,onlyonewasnotrelatedtothe anteriorcruciateligament,andthemajoritywasrelatedtotheuseofpoly-l-lacticacid(PLLA)

screws.Onlyonecaseretrievedintheliteraturereportedscrewmigrationinreconstructions oftheposterolateralcorner,andthatwastotheintra-articularregion.Inthepresentarticle, theauthorsreportacaseofextra-articularandtranscutaneousmigrationofapoly-l/d

-lactide(PDLLA)interferencescrewfollowingpoplitealtendonreconstruction.Besidesbeing thefirstcaseofpoplitealtendonmigrationwithextra-articularscrewmigration,noreports ofPDLLAscrewmigrationwereretrievedintheliterature.

Migrac¸ão

extra-articular

e

transcutânea

de

parafuso

de

interferência

de

poly

L,D-lactide

após

reconstruc¸ão

do

tendão

poplíteo

Palavras-chave:

Traumatismosdostendões Reconstruc¸ãodoligamentocruzado anterior

Parafusosósseos Procedimentoscirúrgicos minimamenteinvasivos

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e

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o

Asreconstruçõesligamentaresdojoelhosãoprocedimentosortopédicos frequentes.As fixaçõesdosenxertossãomaiscomumentefeitascomparafusosdeinterferência, metáli-cosouabsorvíveis.Emestudorecente,somentedezrelatossobremigraçãodeparafusos foramencontrados;somenteumdelesnãoestavarelacionadoaoligamentocruzado ante-rior(LCA)eamaioriaestavarelacionadaaparafusosdepoly-L-lacticacid(PLLA).Apenasum casodaliteraturareportoumigraçãodeparafusoemreconstruçõesdocantoposterolateral, essaparaaregiãointra-articular.Nesteartigo,osautoresrelatamumcasodemigração

夽

StudyconductedattheUniversidadedeSãoPaulo,HospitaldasClínicas,InstitutodeOrtopediaeTraumatologia,DivisãodeCirurgia deJoelho,SãoPaulo,SP,Brazil.

∗ _{Corresponding}_author_.

E-mail:camilohelito@yahoo.com.br(C.P.Helito). http://dx.doi.org/10.1016/j.rboe.2017.02.001

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extra-articularetranscutâneadeumparafusodeinterferênciadepolyL,D-lactide(PDLLA) apósareconstruçãodotendãopoplíteo.Alémdeseroprimeirocasodereconstruçãodo tendãodopoplíteocommigraçãoextra-articulardoparafuso,nãoforamencontradosna literaturarelatosdemigraçãodeparafusosdePDLLA.

Introduction

Ligament reconstructions of the knee are fairly frequent orthopedicprocedures.Amongallreconstructions,surgeryof theanteriorcruciateligament(ACL)isthemostcommon,1_but

16%oftheselesionsalsoinvolvetheposterolateralligament complex.2

Bonefixationsofthegraftsusedcanbemadewith numer-ousdevices,butthe mostcommonlyusedare interference screws,whichmaybemetallicorabsorbable.Recent compar-ativestudies havefoundnofunctionaldifferences between patientsinwhommetallicorabsorbablescrewswereused.3,4

Asdisadvantages,metallicscrewspresenttheriskof dam-agingthegraft,especiallyinthecaseofsofttissuegrafts,and makingthereconstructionmorefragile,aswellasturninginto artifactsonmagneticresonanceimagingandoftenrequiring removalinrevisionligamentreconstructionsurgeries.3,5–7_In

turn,absorbablescrewshaveasdisadvantagesthepossibility ofbreakageandmigration,aswellasinflammatorysynovitis. InarecentstudybyPereiraetal.,8_the_authors_found_only

tencasereportsonmigrationofabsorbablescrews,andonly oneofthemwasnotrelatedtotheACL.Mostcommon migra-tionwastotheintra-articularregion;onlytwocasesmigrated totheextra-articularregion,oneinthefemurandoneinthe tibia.Onlyonecaseintheliteraturereportedthemigrationof partofascrewinreconstructionsoftheposterolateralcorner (PC);thismigrationwasintotheintra-articularregion.

Theauthorsreportacaseofextra-articularand transcu-taneousmigrationofanabsorbableinterferencescrewafter reconstructionofthepopliteustendoninaconditionof pos-terolateralligamentinsufficiency.

Case

report

InJune 2011,a 33-year-oldmale patientwas involvedin a caraccidentthatcauseddislocationofhisrightknee.Hewas initiallytreatedinaregionalemergencyservice,inwhicha closedreductionofthedislocationandimmobilizationwith anextensionbracewasperformed. Patientdidnotpresent neurovascularlesionsorotherassociatedorthopediclesions. Hewasthentransferredtoareferralservicefordefinitive treatmentofthelesions.Theposteriorand anteriordrawer testwerepositive,aswellasposterolateraltibialrotationand varusstress;therefore,posteriorcruciateligament(PCL),PC, andACLlesionswerediagnosed.9,10

InAugust 2011, two monthsafterthe initialinjury and afteragaininrangeofmotion(ROM),patientunderwentinlay PCL reconstruction with Achilles tendon from tissue bank

withboneplug,andPCreconstructionwithtwoposterior tib-ialgraftsfromatissuebank.Thelateralcollateralligament, popliteustendon,andpoplitealfibularligamentwere recon-structed. No ACL reconstruction was performed. After the reconstructions,anarticulatedexternalfixatorwasinstalled forearlyROMgain andprotectionofgrafts.Fixationswere madewithabsorbableinterferencescrewsmadeofpoly-d,l

-lactide(PDLLA)exceptforthetibialinlayPCLfixation.Fixation wasremovedsixweeksaftersurgery.11–14

Fromafunctionalstandpoint,patientisprogressingwell, with areturn topre-injuryactivities aftereightmonthsof rehabilitation.Hedidnotpresentcomplaintsuntil15months postoperatively,whenhenoticedabulgingappearanceinthe anterolateralregionoftheleg.Initially,hedidnotseek med-icalattention,butafterfourweeksofsymptomshenoticed theprotrusionofpartofoneofthescrewsandcametothe hospital(Fig.1).

Patientwastakentotheoperatingroom,whereuponscrew was completelyremoved,associatedwithsurgicalcleaning and closure of the puncture. The screw was intact, with no signs ofdegradation atthe time ofits removal (Fig. 2). Culturescollectedintraoperativelyindicatedthepresenceof Staphylococcusaureus.Patientwastreatedwithoxacillinand rifampicinaccordingtotheprotocoloftheinfection commit-teeofthisinstitution,withsuccess.Atthetimeofsurgeryhe wasexaminedunderanesthesia,demonstratingnoposterior orposterolateralinstability.

Inhislastfollow-upevaluation,fouryearsafterthe recon-struction surgery, hepresented complete clinical improve-ment,withoutcomplaints,withnormalrangeofmotionand noinstability(Figs.3and4).

Discussion

Thecasepresentedisuniquesinceitshowsextra-articular andtranscutaneousmigrationofanabsorbableinterference screwafterPCLreconstruction,morespecificallythetunnel usedforreconstructionofthepopliteustendon.

Migrationofextra-articularandtranscutaneousimplants ofthekneearenotuncommon;therearereportsof migra-tion ranging from prosthetic components to interference screws.8,15,16 _Screw_migrations_are _more_common_after_ACL

reconstruction,albeitstilllowinnumber.

Among the reports retrieved inthe literature,the most common materialtopresentmigrationispoly-l_-lactic _acid

(PLLA).Thispolymerismostoftenusedinorthopedic mate-rialsandpresentedgoodresultsinpublishedstudies,17,18_but

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Fig.1–Anterolateral(A)andlateral(B)imageoftherightkneeofthepatientshowingextra-articularandtranscutaneous migrationofabioabsorbablepolyd,l-lactidescrewusedforgraftfixationofthetendonofthepopliteusmuscle.

toimproveimplantsbyloweringPLLAreactions,but compli-cationsfromtheiruse,suchasformationofpre-tibialcysts, havebeenreported.19_Nonetheless,_to_the_best_of_the_authors’

knowledge,therearenocasesofscrewmigrationwiththeuse ofthismaterialtodate.

The bioabsorbable material passes through the follow-ingstepsafteritsimplantation:hydration,depolymerization, massloss,absorption,andelimination.Duringdegradation, hydrolysismayoccurandparticlesmaybephagocytosedby

Fig.2–Intactpoly-d,l-lactideinterferencescrewremoved

aftertranscutaneousmigration.

macrophages.Suchprocess maybeassociatedwith forma-tionofcysts.19–21_The_authors_postulate_that_screw_migration

canalsoberelatedtosomecomplicationsintheprocess. Duetothesmallnumberofreportsintheliterature,itisnot possibletoestablishacausalrelationshipregardingthe rea-sonforthiscomplication.Itwashypothesizedthatthereisa relationshipbetweentunnelandscrewsizewithitsmigration, whichwasdiscardedinpreviousarticles.8

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Fig.4–Four-yearpostoperativekneerangeofmotion, showingfullextension(A)and120-degreeflexion(B).

Itisalwaysimportanttoconsiderthedifferentialdiagnoses of screw migration, such as meniscal injury, periarticu-lar fracture, and ACL rupture.22 _Typically, _this _diagnosis

is not easily made, since a small migration can be mis-takenwithother pathologies. Thisdifficultyoccurs onlyin cases of intra-articular migration of the implant. As the screw migrationin the present patient was extra-articular and transcutaneous,visible outside the patient’s knee, the diagnosis wasmade withnointercurrences.Imaging stud-ies may be important to differentiate this migration from the formation of pre-tibial cysts in cases of diagnostic doubt.18,19

As the migration occurred 15 months postoperatively, patientdidnotpresentanyproblemsregardingknee instabil-ity,despitethereconstructionshavingbeenmadewithtissue grafts,whichhaveslowerboneintegrationthanautologous grafts.23

Theauthorsreportedacaseofapatientundergoing pos-terolateral reconstruction who evolved with extra-articular and transcutaneous migration of the bioabsorbable screw. Thereare nosimilarstudiesintheliteraturewiththe type ofpolymerusedinthereconstruction.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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