Revisão de Classificações em Joelho

Classificacao Anatomica para Luxacoes Joelho (SCHENCK, 1992; modificada
por Wascher, 1997)
I – Cruzado único + colateral
II – LCA / LCP (colaterais intactos)
IIIM – LCA / PCL / LCM (LCL + CPL intactos)
IIIL – LCA / PCL / LCL + CPL (MCL intacto)
IV – LCA / LP / LCM / LCL + CPL
V – Fratura-Luxacao
C – Lesao arterial
N – Lesao nervosa
Schenck RC et al. South Med J 1992; 85(3S): 61.
Wascher DC, Dvirnak PC, DeCoster TA. Knee dislocation: initial assessment and implications for treatment. J
Orthop Trauma 1997; 11 (7): 525–529.
_________________________________________________________
Classificação quanto ao deslocamento tibial
Spontaneous reduction of knee dislocation occurs in 20‐50%
Kennedy classification (JBJS Am 1963;45:889–904 and JBJS Am 1976;58:350)
• Anterior – hyperextension (40%)
• Posterior – AP force (33%)
• Lateral – Valgus (18%)
• Medial – Varus (4%)
• Rotatory (AM,PM,AL,PL)
Kennedy JC. Complete dislocation of the knee joint. J Bone Joint Surg Am. 1963; (45):889-904.
_________________________________________________________________________
Classificacao de Iwano et al. (1990), para OA Fêmoro-patelar
Estágio I – leve: espaço articular tem pelo mais do que 3mm
Estágio II – moderada: espaço articular mede menos do que 3mm, sem contato ósseo
Estágio III – severa: contato ósseo é menor que ¼ da superfície articular
Estágio VI – muito severa: superfícies articulares se tocam inteiramente
Iwano T, Kurosawa H, Tokuyama H, Hoshikawa Y. Roentgenographic and clinical findings of
patellofemoral osteoarthrosis. With special reference to its relationship to femorotibial
osteoarthrosis and etiologic factors. Clin Orthop Relat Res. 1990;(252):190–197.
Classificação de Ahlbäck modificada
por Keyes e Goodfellow
Grau I Redução do espaço articular
Grau II Obliteração do espaço articular
Grau III AP – desgaste do platô tibial < 5mm
perfil – parte posterior do platô intacta
Grau IV AP – desgaste de 5 a 10mm do platô tibial
perfil – extenso desgaste da margem posterior
do platô tibial
Grau V AP – grave subluxação da tíbia
perfil – subluxação anterior da tíbia > 10mm
Ahlbäck S. Osteoarthrosis of the knee. A radiographic investigation. Acta Radiol Diagn.
1968;(Suppl 277):7-72.
Keyes GW, Carr AJ, Miller RK, Goodfellow JW. The radiographic classification of medial
gonarthrosis - Correlation with operation methods in 200 knees. Acta Orthop Scand.
1992;63(5):497-501.
______________________________________________________
Classificação de Kellgreen e Lawrence
Grau 0 Normal
Grau I Estreitamento do espaço articular duvidoso e
possível osteófitos na borda
Grau II Possível estreitamento do espaço articular e osteófito
definido
Grau III Definido estreitamento do espaço articular, múltiplos
osteófitos moderados, alguma esclerose
subcondral e possível deformidade do contorno
ósseo
Grau IV Notável estreitamento do espaço articular, severa
esclerose subcondral, definida deformidade
do contorno ósseo e presença de grandes
osteófitos
Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Ann Rheum Dis.
1957;16(4):494-502.
______________________________________________________________________________________________
Dejour
Grau I RX normal (pré-artrose)
Grau II Artrose inicial
> AFTI:
# AP – pinçamento parcial
# perfil – pinçamento efetivo na parte central do
platô tibial
> AFTE:
# AP – interlinha articular normal, com condensação
subcondral e osteófitos
# perfil – pinçamento pouco significativo
Grau III Artrose com desequilíbrio
> AFTI:
# AP – pinçamento total da interlinha articular,
com báscula do côndilo femoral medial dentro
da cúpula interna, sendo a incidência mais eloqüente
(varo com rotação interna)
> AFTE:
# AP – valgo com cúpula externa bem condensada
e decoaptação do compartimento medial
(valgo com rotação externa da tíbia)
Grau IV Artrose grave
> AFTI:
# AP – grande varo, com côndilo femoral lateral
em conflito com as espinhas tibiais
# perfil – lesões importantes na patela
> AFTE:
# AP – grande valgo
# perfil – lesões importantes na patela
AFTI – Art. Femorotibial Interna; AFTE – Art. Femorotibial Externa.
Dejour H, Carret JP, Walch G, et al. Les Gonarthroses. 7émes Journées Lyonnaises de Chirurgie
de Genou. Lyon: 1991.
Displasia Troclear
Retirado de: Insall and Scott. Surgery of the Knee 5th ed. , pag. 598.
Rémy, F., Gougeon, F., Ala Eddine, T., Migaud, H., Fontaine, C., and Duquennoy,
A.: Reproducibility of the new classification of femoral trochlea dysplasia proposed by dejour:
predictive value for severity of femoropatellar instability in 47 knees. J Bone Joint Surg Br, Vol
84-B(Issue SUPP): 43, 2002.
_____________________________________________________________________________
Retirado de: Insall and Scott. Surgery of the Knee 5th ed. , pag. 597.
Rémy, F., Gougeon, F., Ala Eddine, T., Migaud, H., Fontaine, C., and Duquennoy,
A.: Reproducibility of the new classification of femoral trochlea dysplasia proposed by dejour:
predictive value for severity of femoropatellar instability in 47 knees. J Bone Joint Surg Br, Vol
84-B(Issue SUPP): 43, 2002.
____________________________________________________________________________
Medida radiográfica do tunel femoral na reconstrução do LFPM (Schottle, 2007).
Schottle PB, Hensler D, Imhoff AB, Anatomical Double-Bundle MPFL Reconstruction with an Aperture Fixation,
Knee Surg Sports Traumatol Arthroscopy (epub ahead of print), 2009.
_________________________________________________________
Classificação de Insall para as patologias da articulação fêmoropatelar.
Insall JN: Disorders of the patella. In Insall JN (ed): Surgery of the knee, New York, 1984, Churchill
Livingstone, p 191.
_____________________________________________________________________
Classificação de Merchant para as Patologias da Articulação Fêmoropatelar
Merchant AC: Classification of patellofemoral disorders. Arthroscopy 4:235, 1988.
Classificação de Outerbridge modificada (apresentada no sistema métrico), comparada
a classificação da sociedade internacional de cartilagem) o ICRS (ICRS, International
Cartilage Repair Society) para as Lesões Condrais
Retirado de: Insall and Scott. Surgery of the Knee 5th ed. pag. 119.
Classificação de Outerbridge do trabalho original (Medida em polegadas pelo Sistema
Inglês)
Outerbridge RE. The etiology of chondromalacia patellae. J Bone Joint Surg Br. 1961;43:752–
757.
Quanto ao tratamento das lesões condrais:
Lesion Size
≤1 cm
1 cm-2 cm
2 cm-3.5 cm
3.5 cm-10 cm
Multiple (2 or 3)
Operative Treatment
Observation
Abrasion chondroplasty
Microfracture
Osteochondral autograft transfer
Abrasion chondroplasty
Microfracture
Osteochondral autograft transfer
Fresh osteochondral allograft
Autologous chondrocyte implantation
Autologous chondrocyte implantation
Autologous chondrocyte implantation
Garrick JG, ed: Orthopaedic knowledge update: sports medicine, 3rd ed,
Rosemont, Ill, 2004, American Academy of Orthopaedic Surgeons.
Classificação das Lesões da Cartilagem Articular quanto a
severidade da Lesão
Retirado de Campbell’s Operative Orthopaedics. 11 ed.
Grade
Outerbridge
Modified Outerbridge
ICRS
0
Normal cartilage
Intact cartilage
Intact cartilage
I
Softening and swelling
Chondral softening or
Superficial (soft indentation or superficial fissures and cracks)
blistering with intact
surface
II
Fragmentation and fissures in
Superficial ulceration,
area less than 0.5 inch in
fibrillation, or fissuring less
diameter
than 50% of depth of
Lesion less than half the thickness of articular cartilage
cartilage
III
Fragmentation and fissures in
Deep ulceration, fibrillation,
area larger than 0.5 inch in
fissuring, or chondral flap
diameter
more than 50% of cartilage
Lesion more than half the thickness of articular cartilage
without exposed bone
IV
Exposed subchondral bone
Full-thickness wear with
exposed subchondral bone
ICRS, International Cartilage Repair Society.
Retirado de Campbell’s Operative Orthopaedics. 11 ed.
Lesion extending to subchondral bone
ICRS, International Cartilage Repair Society.
Classificação das Instabilidades do Joelho
(melhor utilizada para as instabilidades crônicas)
Demonstration of shift in vertical axis away from center of tibia as tibia shifts excessively and abnormally in relation to femur. Position of femur is
designated by shaded area. (Redrawn from Nicholas JA: The five-one reconstruction for anteromedial instability of the knee. Indications, technique,
and the results in fifty-two patients, J Bone Joint Surg 55A:899, 1973.
Retirado de Campbell’s Operative Orthopaedics. 11 ed.
Classificação proposta pelo Committee on Research and Education of the
American Orthopaedic Society for Sports Medicine.
Retirado de Campbell’s Operative Orthopaedics. 11 ed.
______________________________________________________________________________________________
Sítios mais comuns na Osteocondrite Dissecante (OCD), de acordo com Heffi
et al. (A) e Aichroth (B).
Classification of Osteochondritis Dissecans Based on Bone Scan (Scintigraphy)
Stag
e
Bone Scan Finding
0
Normal radiographic and scintigraphic appearance
I
Lesion visible on plain radiographs, bone scan normal
II
Increased uptake in area of lesion on bone scan
III
Increased isotopic uptake in entire femoral condyle
IV
Uptake in tibial plateau opposite lesion
Cahill BR: Osteochondritis dissecans of the knee: treatment of juvenile and adult forms, J Am Acad Orthop Surg
3:237, 1995.
Staging Systems for Osteochondritis Dissecans
Stage
Arthroscopy
MRI
I
Irregularity and softening of articular cartilage; no definable fragment
Thickening of articular cartilage; low signal changes
II
Articular cartilage breached; definable fragment, not displaceable
Articular cartilage breached; low signal rim behind fragment
indicating fibrous attachment
III
Articular cartilage breached; definable fragment, displaceable, but
Articular cartilage breached; high signal changes behind
attached by some overlying cartilage
fragment indicating synovial fluid between fragment
and underlying subchondral bone
IV
Loose body
Loose body
Dipaola JD, Nelson DW, Colville MR: Characterizing osteochondral lesions by magnetic resonance imaging,
Arthroscopy 7:101, 1991.
___________________________________________________________________________________
Osteonecrose Idiopática do Joelho
Koshino T: The treatment of spontaneous osteonecrosis of the knee by high tibial osteotomy with and without bonegrafting or drilling of the lesion. J Bone Joint Surg Am. 1982;64:47.
Agietti et al., modificaram a classificação de Koshino, conforme tabela 2, apresentada abaixo.
Aglietti P, Insall JN, Buzzi R, et al: Idiopathic osteonecrosis of the knee: aetiology, prognosis and treatment. J Bone Joint
Surg Br. 1983;65:588.
Mont et al. (1997), adaptaram a classificação de Ficat e Arlet (1980), que é uma classificação básica utilizando RX.
Ficat P: [Vascular pathology of femoral head necrosis (author’s transl)]. Orthopade. 1980;9:238.
Mont MA, Tomek IM, Hungerford DS: Core decompression for avascular necrosis of the distal femur: long-term followup. Clin Orthop. 1997;334:124.