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Bhimani R, Lubberts B, DiGiovanni CW, Tanaka MJ. Dynamic Ultrasound Can Accurately Quantify Severity of Medial Knee Injury: A Cadaveric Study. Arthrosc Sports Med Rehabil 2022; 4:e1777-e1787. [PMID: 36312723 PMCID: PMC9596904 DOI: 10.1016/j.asmr.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/02/2022] [Indexed: 12/04/2022] Open
Abstract
Purpose To quantify the severity of medial knee injuries based on medial compartment gapping as measured by stress ultrasonography. Methods In 8 cadaveric knees, the distance between the medial tibial and femoral condyles was measured using ultrasonography. These measurements were obtained in the intact state and repeated after open sequential transection of the superficial medial collateral ligament (sMCL), deep medial collateral ligament (dMCL), posterior oblique ligament (POL), and arthroscopic transection of the anterior cruciate ligament (ACL). Knees were evaluated at 0° and 20° of knee flexion using the Telos device under 0 N and 100 N of valgus force. Receiver operating characteristic curve analysis and the DeLong test were used to determine whether measurements could distinguish between successive severity of MCL injury after identifying the optimal cutoff value for each injury state. Results Of the 8 cadaveric knees included in this study, 3 were male and 5 were female. The mean age was 58 ± 11 years (range 48-82 years). When measured using ultrasonography at 20° knee flexion with valgus load, the medial tibiofemoral distance significantly increased with increasing severity of medial knee injury (P values ranging from .049 to <.001). The optimal cutoff values for distinguishing between an intact knee and sMCL injury were 8.3 mm (area under the curve [AUC] = 0.98), between sMCL and dMCL injury 9.9 mm (AUC = 0.89), dMCL and POL 16.7 mm (AUC = 0.88), and POL and ACL 18.6 mm (AUC = 0.84). When we compared combined intact and sMCL-transected stages with dMCL-transected stage, the optimal cut-off point to differentiate stable from unstable injuries was equal to 13.8 mm of medial tibiofemoral distance (AUC = 0.97; sensitivity = 100%; specificity = 94.1%). Conclusions Dynamic ultrasonographic assessment can accurately quantify the severity of medial knee ligament injury based on medial compartment gapping. In our study, we found medial tibiofemoral distance >13.8 mm at 20° knee flexion under valgus force indicates the presence of dMCL injury with a diagnostic accuracy of 0.97. Clinical Relevance Dynamic ultrasonography can quantify severity of medial knee injury without radiation and at point of care in multiple clinical settings.
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Matava MJ, Koscso J, Melara L, Bogunovic L. Suture Tape Augmentation Improves the Biomechanical Performance of Bone-Patellar Tendon-Bone Grafts Used for Anterior Cruciate Ligament Reconstruction. Arthroscopy 2021; 37:3335-3343. [PMID: 33964381 DOI: 10.1016/j.arthro.2021.04.053] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/14/2021] [Accepted: 04/22/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to investigate the time-zero biomechanical properties (stiffness, displacement, and load at failure) of bone-patellar tendon-bone (BTB) grafts used for anterior cruciate ligament (ACL) reconstruction with and without suture tape augmentation as a means to determine the potential clinical benefit of this technique. METHODS Eight juvenile porcine knees underwent ACL reconstruction with a human cadaveric BTB graft (control). These were compared to 8 juvenile porcine knees that underwent ACL reconstruction with a BTB graft augmented with suture tape. All knees underwent biomechanical testing utilizing a dynamic tensile testing machine. Cyclic loading between 50-250N was performed for 500 cycles at 1 Hz to simulate in vivo ACL loads during the early rehabilitation phase. The grafts were displaced during load-at-failure tensile testing at 20 mm/min. Differences in graft displacement, stiffness, and load at failure for the control and suture tape augmented groups were compared with the Student t-test with a significance level of P < .05. RESULTS There was no difference in graft displacement between the 2 groups. A 104% higher postcyclic stiffness was noted in the augmented group compared to the controls (augmentation: 261 ± 76 N/mm versus control 128 ± 28 N/mm, P = .002). The mean ultimate load at failure was 57% higher in the augmented group compared to controls (744 ± 219 N vs postcyclic 473 ± 169 N, respectively [P = .015]). There was no difference in mode of failure between the control knees and those augmented with suture tape, with approximately half failing from pull off of the tendon from the bone plug and half with pull out of the bone plug from the tunnel. CONCLUSION Independent suture tape augmentation of a BTB ACL reconstruction grafts was associated with a 104% increase in graft stiffness and a 57% increase in load at failure compared to nonaugmented BTB grafts. CLINICAL RELEVANCE In vivo suture tape augmentation of a BTB ACL reconstruction increases graft construct strength and stiffness, which may reduce graft failure in the clinical setting.
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Affiliation(s)
- Matthew J Matava
- Washington University Department of Orthopedic Surgery, St. Louis, Missouri.
| | - Jonathan Koscso
- Washington University Department of Orthopedic Surgery, St. Louis, Missouri
| | - Lucia Melara
- Arthrex Department of Orthopedic Research, Naples, Florida, U.S.A
| | - Ljiljana Bogunovic
- Washington University Department of Orthopedic Surgery, St. Louis, Missouri
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Bodendorfer BM. Editorial Commentary: The Anterior Cruciate Ligament May Be Safer Wearing a Suture Tape Augmentation Seat Belt: Click It or Ticket. Arthroscopy 2021; 37:3344-3346. [PMID: 34740409 DOI: 10.1016/j.arthro.2021.06.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 06/20/2021] [Indexed: 02/02/2023]
Abstract
Bone-patellar tendon-bone autograft for anterior cruciate ligament (ACL) reconstruction has the most data to support its use. However, there may still be room for improvement, and younger age, insufficient rehabilitation, altered neuromuscular patterns, and precocious return to play can increase risk of graft failure. High strength suture augmentation of soft-tissue repair or reconstruction has gained traction in a variety of applications for the knee, including medial collateral and posteromedial corner, lateral collateral ligament, posterior cruciate ligament, and ACL. For ACL reconstruction, the technique consists of using either suture or suture tape fixed at the femoral and tibial ACL footprints to allow for independent tensioning to back up the separately tensioned ACL reconstruction. The static augment serves as a load-sharing device, allowing the graft to see more strain during earlier levels of graft strain, until graft elongation occurs to a critical level whereby the augment will experience more strain than the graft. Hence, the "seat belt" analogy. This is distinct from static augmentation, where the high strength suture is fixed to the graft. Static augmentation (without tensioning separately from the graft) results in a load-sharing device and increased stiffness, but potential stress shielding compared with the "seat belt." If suture tape augmentation improves patient outcome, it is a worthwhile to "click it."
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Hoit G, Rubacha M, Chahal J, Khan R, Ravi B, Whelan DB. Is There a Disadvantage to Early Physical Therapy After Multiligament Surgery for Knee Dislocation? A Pilot Randomized Clinical Trial. Clin Orthop Relat Res 2021; 479:1725-1736. [PMID: 33729214 PMCID: PMC8277250 DOI: 10.1097/corr.0000000000001729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/15/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Multiligament knee injuries, though rare, can be profoundly disabling. Surgeons disagree about when to initiate rehabilitation after surgical reconstruction due to the conflicting priorities of postoperative stability and motion. QUESTIONS/PURPOSES (1) Does early or late initiation of physical therapy after multiligament knee surgery result in fewer postoperative manipulations? (2) Does early versus late physical therapy compromise stability postoperatively? (3) Does early initiation of physical therapy result in improved patient-reported outcomes, as measured by the Multi-ligament Quality of Life (ML-QOL) score? METHODS Between 2011 and 2016, 36 adults undergoing multiligament repair or reconstruction were prospectively enrolled in a randomized controlled trial and randomized 1:1 to either early rehabilitation or late rehabilitation after surgery. Eligibility included those with an injury to the posterior cruciate ligament (PCL) and at least one other ligament, as well as the ability to participate in early rehabilitation. Patients who were obtunded or unable to adhere to the protocols for other reasons were excluded. Early rehabilitation consisted of initiating a standardized physical therapy protocol on postoperative day 1 involving removal of the extension splint for quadriceps activation and ROM exercises. Late rehabilitation consisted of full-time immobilization in an extension splint for 3 weeks. Following this 3-week period, both groups engaged in the same standardized physical therapy protocol. All surgical reconstructions were performed at a single center by one of two fellowship-trained sports orthopaedic surgeons, and all involved allograft Achilles tendon PCL reconstruction. When possible, hamstring autograft was used for ACL and medial collateral ligament reconstructions, whereas lateral collateral ligament and posterolateral reconstruction was performed primarily with allograft. The primary outcome was the number of patients undergoing manipulation during the first 6 months. Additional outcomes added after trial registration were patient-reported quality of life scores (ML-QOL) at 1 year and an objective assessment of laxity through a physical examination and stress radiographs at 1 year. One patient from each group was not assessed for laxity or ROM at 1 year, and one patient from each group did not complete the ML-QOL questionnaires. No patient crossover was observed. RESULTS With the numbers available, there was no difference in the use of knee manipulation during the first 6 months between the rehabilitation groups: 1 of 18 patients in the early group and 4 of 18 patients in the late group (p = 0.34). Similarly, there were no differences in knee ROM, stability, or patient-reported quality of life (ML-QOL) between the groups at 1 year. CONCLUSION With the numbers available in this study, we were unable to demonstrate a difference between early and late knee rehabilitation with regard to knee stiffness, laxity, or patient-reported quality of life outcomes. The results of this small, randomized pilot study suggest a potential role for early rehabilitation after multiligament reconstruction for knee dislocation, which should be further explored in larger multi-institutional studies. LEVEL OF EVIDENCE Level II, therapeutic study.
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Affiliation(s)
- Graeme Hoit
- Department of Surgery, Division of Orthopaedics, University of Toronto, Toronto, ON, Canada
| | | | - Jaskarndip Chahal
- Department of Surgery, Division of Orthopaedics, University of Toronto, Toronto, ON, Canada
- Division of Orthopaedic Surgery, Women’s College Hospital, Toronto, ON, Canada
| | - Ryan Khan
- Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Bheeshma Ravi
- Department of Surgery, Division of Orthopaedics, University of Toronto, Toronto, ON, Canada
| | - Daniel B. Whelan
- Department of Surgery, Division of Orthopaedics, University of Toronto, Toronto, ON, Canada
- Division of Orthopaedic Surgery, St. Michael’s Hospital, Unity Health, Toronto ON, Canada
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Lutz PM, Feucht MJ, Wechselberger J, Rasper M, Petersen W, Wörtler K, Imhoff AB, Achtnich A. Ultrasound-based examination of the medial ligament complex shows gender- and age-related differences in laxity. Knee Surg Sports Traumatol Arthrosc 2021; 29:1960-1967. [PMID: 32965547 PMCID: PMC8126541 DOI: 10.1007/s00167-020-06293-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/14/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Ultrasound (US) examination of the medial joint space of the knee has played a subordinate diagnostic role up till now. The purpose of the present study was to describe mean values of medial joint width and to investigate the impact of gender, age, and body mass index (BMI) on medial joint laxity in healthy knees using modern, dynamic US in a standardized fashion in unloaded and standardized loaded conditions. METHODS A total of 65 subjects with 79 healthy knees were enrolled in this study. All volunteers underwent clinical examination of the knee. The medial knee joint width was determined using US in a supine position at 0° and 30° of knee flexion in unloaded and standardized loaded (= 15 Dekanewton, daN) conditions using a specific device. Mean values were described and correlations between medial knee joint width and gender, age, and BMI were assessed. RESULTS Thirty-two females and 33 males were enrolled in this study. The mean medial joint width in 0° unloaded was 5.7 ± 1.2 mm and 7.4 ± 1.4 mm loaded. In 30° of knee flexion, the mean medial joint width was 6.1 ± 1.1 mm unloaded and 7.8 ± 1.2 mm loaded. The average change between unloaded and loaded conditions in 0° was 1.7 ± 1.0 mm and in 30° 1.7 ± 0.9 mm. A significant difference between genders was evident for medial joint width in 0° and 30° of flexion in unloaded and loaded conditions (p < 0.05). With rising age, a significant increased change of medial joint space width between unloaded and loaded conditions could be demonstrated in 0° (p = 0.032). No significant correlation between BMI and medial joint width in US could be found. CONCLUSION Mean values of medial joint width in unloaded and standardized loaded conditions using a fixation device could be demonstrated. Based on the results of this study, medial knee joint width in US is gender- and age-related in healthy knees. These present data may be useful for evaluating patients with acute or chronic pathologies to the medial side of the knee. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Patricia M Lutz
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Matthias J Feucht
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
- Department of Orthopedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Judith Wechselberger
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Munich, Germany
| | - Michael Rasper
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Munich, Germany
| | | | - Klaus Wörtler
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Munich, Germany
| | - Andreas B Imhoff
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Andrea Achtnich
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
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Boutin RD, Fritz RC, Walker REA, Pathria MN, Marder RA, Yao L. Tears in the distal superficial medial collateral ligament: the wave sign and other associated MRI findings. Skeletal Radiol 2020; 49:747-756. [PMID: 31820044 DOI: 10.1007/s00256-019-03352-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 11/13/2019] [Accepted: 11/14/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To analyze the MRI characteristics of distal superficial medial collateral ligament (sMCL) tears and to identify features of tears displaced superficial to the pes anserinus (Stener-like lesion (SLL)). MATERIALS AND METHODS Knee MRI examinations at four institutions were selected which showed tears of the sMCL located distal to the joint line. MRIs were evaluated for a SLL, a wavy contour to the sMCL, and the location of the proximal sMCL stump. Additional coexistent knee injuries were recorded. RESULTS The study included 51 patients (mean age, 28 years [sd, 12]). A SLL was identified in 20 of 51 cases. The proximal stump margin was located significantly (p < 0.01) more distal and more medial with a SLL (mean = 33 mm [sd = 11 mm] and mean = 6.5 mm [sd = 2.5 mm], respectively), than without a SLL (mean = 19 mm [sd = 16 mm] and mean = 4.8 mm [sd = 2.4 mm], respectively). Medial compartment osseous injury was significantly (p < 0.05) more common with a SLL (75%) than without a SLL (42%). The frequency of concomitant injuries in the group (ACL tear, 82%; PCL tear, 22%; deep MCL tear, 61%; lateral compartment osseous injury, 94%) did not differ significantly between patients with and without a SLL. CONCLUSION A distal sMCL tear should be considered when MRI depicts a wavy appearance of the sMCL. Distal sMCL tears have a frequent association with concomitant knee injuries, especially ACL tears and lateral femorotibial osseous injuries. A SLL is particularly important to recognize because of implications for treatment.
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Affiliation(s)
- Robert D Boutin
- Department of Radiology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305-5105, USA.
| | - Russell C Fritz
- Musculoskeletal Radiologist, National Orthopedic Imaging Associates, 1260 South Eliseo Drive, Greenbrae, Greenbrae, CA, 94904, USA
| | - Richard E A Walker
- Department of Radiology, Cumming School of Medicine, McCaig Institute for Bone & Joint Health, University of Calgary, Room 812, North Tower, Foothills Medical Centre, 1403-29th Street NW, Calgary, AB, T2N 2T9, Canada
| | - Mini N Pathria
- Department of Radiology, University of California San Diego Health System, 200 West Arbor Drive, San Diego, CA, 92103-8756, USA
| | - Richard A Marder
- Department of Orthopaedic Surgery, UC Davis School of Medicine, Sacramento, CA, 95817, USA
| | - Lawrence Yao
- Radiology and Imaging Sciences, CC-NIH, 10 Center Drive, Bethesda, MD, 20892, USA
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Bodendorfer BM, Michaelson EM, Shu HT, Apseloff NA, Spratt JD, Nolton EC, Argintar EH. Suture Augmented Versus Standard Anterior Cruciate Ligament Reconstruction: A Matched Comparative Analysis. Arthroscopy 2019; 35:2114-2122. [PMID: 31167738 DOI: 10.1016/j.arthro.2019.01.054] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 01/29/2019] [Accepted: 01/29/2019] [Indexed: 02/08/2023]
Abstract
PURPOSE To compare outcomes between standard anterior cruciate ligament reconstruction (ACLR) using hamstring grafts with and without suture augmentation (SA). METHODS Patients who underwent ACLR with hamstring autografts or allografts with minimum 2-year follow-up were retrospectively reviewed. Patients undergoing ACLR with SA were matched 1:1 by age, gender, body mass index, graft type, and revision status to standard ACLR. Range of motion, pain, postoperative activity, patient-reported outcome measures (PROMs), and complications were collected. Paired 2-tailed Student's t-tests and Pearson's χ2-tests were used for continuous and categorical variables, respectively. A multivariate analysis of variance was conducted. Return to preinjury activity level was assessed using Spearman's rho and Pearson's χ2-tests. RESULTS Sixty patients at a mean age of 29.50 ± 6.60 years, 43.4% male, body mass index 26.27 ± 3.37, and follow-up of 29.54 ± 5.37 months were included. Preoperative PROMs were not significantly different (P >. 05). Postoperative range of motion was similar between groups (P = .457). Postoperative average daily (0.60 ± 1.25 vs 1.66 ± 1.90) and maximum daily pain (1.57 ± 1.83 vs 3.35 ± 2.28) were significantly lower for SA (P < .014). SA predicted improvement in PROMs (P < .05) and maximum pain scores (P = .001). SA was significantly correlated with improved time to return to preinjury activity level (9.17 ± 2.06 vs 12.88 ± 3.94 months; P = .002) and percentage of preinjury activity level (93.33% ± 13.22% vs 83.17% ± 17.69%; P = .010). There was a trend toward improved rate of return to preinjury activity level for SA (76.7% vs 56.7%; P = .100). CONCLUSIONS Our study demonstrates that SA hamstring ACLRs were associated with improved PROMs, less pain, and a higher percentage of and earlier return to preinjury activity level when compared with standard hamstring ACLRs without evidence of overconstraint. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Blake M Bodendorfer
- Department of Orthopaedic Surgery, Georgetown University Medical Center, Washington, DC, U.S.A..
| | - Evan M Michaelson
- Department of Orthopaedic Surgery, Georgetown University Medical Center, Washington, DC, U.S.A
| | - Henry T Shu
- Department of Orthopaedic Surgery, MedStar Washington Hospital Center, Washington, DC, U.S.A
| | - Nicholas A Apseloff
- Department of Orthopaedic Surgery, Georgetown University Medical Center, Washington, DC, U.S.A
| | - James D Spratt
- Department of Orthopaedic Surgery, Georgetown University Medical Center, Washington, DC, U.S.A
| | - Esther C Nolton
- Department of Orthopaedic Surgery, Inova Fairfax Hospital, Falls Church, Virginia, U.S.A
| | - Evan H Argintar
- Department of Orthopaedic Surgery, MedStar Washington Hospital Center, Washington, DC, U.S.A
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Slane LC, Slane JA, Scheys L. The measurement of medial knee gap width using ultrasound. Arch Orthop Trauma Surg 2017; 137:1121-1128. [PMID: 28677074 PMCID: PMC5551498 DOI: 10.1007/s00402-017-2740-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Medial knee instability is a key clinical parameter for assessing ligament injury and arthroplasty success, but current methods for measuring stability are typically either qualitative or involve ionizing radiation. The purpose of this study was to perform a preliminary analysis of whether ultrasound (US) could be used as an alternate approach for quantifying medial instability by comparing an US method with an approach mimicking the current gold standard fluoroscopy method. MATERIALS AND METHODS US data from the medial knee were collected, while cadaveric lower limbs (n = 8) were loaded in valgus (10 Nm). During post-processing, the US gap width was measured by identifying the medial edges of the femur and tibia and computing the gap width between these points. For comparison, mimicked fluoroscopy (mFluoro) images were created from specimen-specific bone models, developed from segmented CT scans, and from kinematic data collected during testing. Then, gap width was measured in the mFluoro images based on two different published approaches with gap width measured either at the most medial or at the most distal aspect of the femur. RESULTS Gap width increased significantly with loading (p < 0.001), and there were no significant differences between the US method (unloaded: 8.7 ± 2.4 mm, loaded: 10.7 ± 2.2 mm) and the mFluoro method that measured gap width at the medial femur. In terms of the change in gap width with load, no correlation with the change in abduction angle was observed, with no correlation between the various methods. Inter-rater reliability for the US method was high (0.899-0.952). CONCLUSIONS Ultrasound shows promise as a suitable alternative for quantifying medial instability without radiation exposure. However, the outstanding limitations of existing approaches and lack of true ground-truth data require that further validation work is necessary to better understand the clinical viability of an US approach for measuring medial knee gap width.
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Affiliation(s)
- Laura C Slane
- Institute for Orthopaedic Research and Training, KU Leuven, Oude Markt 13, 3000, Louvain, Belgium.
- Institute for Orthopaedic Research and Training (IORT), KU Leuven, UZ Pellenberg, Weligerveld 1/Blok 1, 3212, Pellenberg, Belgium.
| | - Josh A Slane
- Institute for Orthopaedic Research and Training, KU Leuven, Oude Markt 13, 3000, Louvain, Belgium
| | - Lennart Scheys
- Institute for Orthopaedic Research and Training, KU Leuven, Oude Markt 13, 3000, Louvain, Belgium
- University Hospitals Leuven, Campus Pellenberg, Weligerveld 1/Blok 1, 3212, Pellenberg, Belgium
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