Generalized Joint Laxity in Orthopaedic Patients: Clinical Manifestations, Radiographic Correlates, and Management

Scapholunate Ligament Injuries

Injuries to the scapholunate interosseous ligament (SLIL) complex can result in a predictable cascade of incongruous motion in the carpus that leads to radiocarpal degeneration. Both acute traumatic impact and repetitive motion can render the SLIL insufficient. A thorough understanding of SLIL anatomy is required for appropriate diagnosis and treatment. Here, we review scapholunate ligament anatomy, prevention strategies, methods of diagnosis, nonoperative and operative treatments, and outcomes. A myriad of treatment options exist for each stage of the SLIL injury, and management should be an open discussion between the patient and physician.

Clinical Outcomes and Return to Preinjury Sports After Anatomic Reconstruction With a Gracilis Autograft Versus the Modified Broström Procedure in Patients With Generalized Joint Laxity

Background

Generalized joint laxity (GJL) is a risk factor for inferior outcomes after the modified Broström procedure for chronic lateral ankle instability, while anatomic reconstruction with tendons is more inclined to be recommended. However, whether anatomic reconstruction could achieve better results than the modified Broström procedure in patients with GJL is unknown.

Purpose

To compare clinical outcomes and return to sports between anatomic reconstruction and the modified Broström procedure in patients with GJL.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients with GJL (Beighton score ≥4) who underwent either the modified Broström procedure or anatomic reconstruction with gracilis autografts between 2017 and 2020 were reviewed. Included were 19 patients who underwent anatomic reconstruction (reconstruction group) and 49 patients who underwent the modified Broström procedure (MBP group). Clinical outcomes were compared using the Foot and Ankle Outcome Score (FAOS) and the Karlsson score. The rates of return to preinjury level in high-demand sports, sprain recurrence, and range of motion between the 2 groups were also compared.

Results

The mean follow-up duration was 38.3 months in the reconstruction group and 43.7 months in the MBP group. The FAOS and Karlsson scores improved significantly after surgery in both groups (P < .001 for all), with the reconstruction group having significantly higher postoperative FAOS-Sports scores (87.9 ± 8.9 vs 80.5 ± 11.6; P = .015) and Karlsson scores (86.9 ± 6.1 vs 82 ± 8.4; P = .025) than the MBP group. The rate of return to preinjury high-demand sports was higher in the reconstruction group than in the MBP group (73.3% vs 38.9%; P = .034). The MBP group had a significantly higher rate of sprain recurrence (22.4% vs 0%; P = .027). More patients reported dorsiflexion restriction in the reconstruction group (n = 4; 21.1%) than in the MBP group (n = 1; 2%) (P = .019); nonetheless, there was no noticeable effect on daily life and sports.

Conclusion

Better clinical outcomes, less sprain recurrence, and a higher rate of return to preinjury high-demand sports were found after anatomic reconstruction with free tendons compared with the modified Broström procedure in patients with GJL. Anatomic tendon reconstruction can be recommended for such patients, especially those participating in high-demand sports.

Injury Risk in Collegiate Football Players With Generalized Joint Hypermobility: A Prospective Cohort Study Over 2 Years

Background

Generalized joint hypermobility (GJH) has been identified as a risk factor for injury in various athletic patient populations.

Purpose

To evaluate GJH as a predisposing risk factor for injury in a population of National Collegiate Athletic Association (NCAA) Division I football players.

Study Design

Cohort study; Level of evidence, 2.

Methods

The Beighton score was collected for 73 athletes during their preseason physical examinations in 2019. GJH was defined as a Beighton score ≥4. Athlete descriptive characteristics, including age, height, weight, and playing position, were recorded. The cohort was evaluated prospectively for 2 years, and the number of musculoskeletal issues, injuries, treatment episodes, days unavailable, and surgical procedures for each athlete during this period were recorded. These measures were compared between the GJH and no-GJH groups.

Results

The mean Beighton score was 1.4 ± 1.5 for the 73 players; 7 players (9.6%) had a Beighton score indicating GJH. During the 2-year evaluation, there were 438 musculoskeletal issues, including 289 injuries. The mean number of treatment episodes per athlete was 77 ± 71 (range, 0-340), and the mean number of days unavailable was 67 ± 92 days (range, 0-432 days). There were 23 athletes who required 25 operations, the most common procedure being arthroscopic shoulder stabilization (n = 6). The number of injuries per athlete was not significantly different between the GJH and no-GJH groups (3.0 ± 2.1 vs 4.1 ± 3.0; P = .13), nor were there any between-group differences in the number of treatments received (74.6 ± 81.9 vs 77.2 ± 71.5; P = .47), days unavailable (79.6 ± 124.5 vs 65.3 ± 89.3; P = .61), or rates of surgery (43% vs 30%; P = .67).

Conclusion

A preseason diagnosis of GJH did not place NCAA football players at a greater risk for injury during the 2-year study period. Based on the findings of this study, no specific preparticipation risk counseling or intervention is warranted for football players who are diagnosed with GJH as defined by the Beighton score.

Does Generalized Joint Laxity Affect Postoperative Alignment and Clinical Outcomes Following Medial Opening-Wedge High Tibial Osteotomy?

BACKGROUND

The purpose of this study was to investigate whether generalized joint laxity affects the postoperative alignment and clinical outcomes of medial opening-wedge high tibial osteotomy (MOWHTO).

METHODS

A total of 198 patients who underwent MOWHTO was divided into two groups according to absence or presence of generalized joint laxity. Generalized joint laxity was measured using the Beighton and Horan criteria, and a score of 4 or more out of 9 was defined as generalized joint laxity. A weight bearing line (WBL) ratio of 55% to 70% was considered an acceptable postoperative lower limb alignment range; WBL over 70% was defined as overcorrection and less than 55% as undercorrection. The WBL ratio was investigated before and 2 years after surgery, and the Western Ontario McMaster University Osteoarthritis Index scale score (WOMAC) was evaluated for patient-reported outcomes (PRO) of MOWHTO. There were 147 (73.7%) patients in the nongeneralized joint laxity group and 51 (26.3%) in the generalized joint laxity group. Preoperatively, there was no difference between the two groups in hip-knee-ankle (HKA) angle or WBL ratio (all P > .05).

RESULTS

At 2 years postoperatively, the generalized joint laxity group showed significantly higher HKA angle and WBL ratio than the nongeneralized joint laxity group (all P < .05). There was a significant difference in the distribution ratio of undercorrection, normocorrection, and overcorrection patients between the two groups (P < .05). There were no differences between the two groups in preoperative and postoperative WOMAC scores (all, P > .05).

CONCLUSION

The generalized joint laxity significantly affected postoperative over correction of alignment following MOWHTO. However, there was no significant difference in PRO between the patients who did and did not have generalized joint laxity after MOWHTO until 2 years.

Humeral trochlear morphology does not influence coronoid fractures in elbow dislocation

PURPOSE

Traumatic elbow dislocation is the second most frequent joint dislocation, even though the elbow is a congruent and stable joint. Individual variability in anatomical congruence of the elbow and how it relates to simple or complex instability has rarely been studied in the literature; we hypothesized that a greater articular coverage by the humeral trochlea would be more likely to result in complex dislocation. The aim of this study is to analyze trochlear morphology in simple (SED) and complex elbow dislocation (CED), to assess whether the degree of humeroulnar joint congruence influences the incidence of coronoid fractures in elbow dislocation. The secondary goal is to evaluate the association between trochlear morphology and coronoid fracture pattern.

METHODS

All the elbow CT scans of the hospital server were retrospectively analyzed. 62 patients were enrolled and so divided in 2 groups: SED and CED with isolated coronoid fracture. Patients who were skeletally immature, presented with other concomitant elbow fractures, or who previously underwent elbow surgery were excluded. The CT scans were performed after closed reduction and prior to further treatment. Coronoid fracture pattern was classified on CT scan according to Regan-Morrey and O'Driscoll classifications; "grade 0" was assigned to SED. Trochlear coverage was measured and expressed as three angles (anterior, posterior, and distal) and their width/depth ratios. Measurements were taken by four different readers and the assessment was repeated after 15 days.

RESULTS

No statistically significant difference was found between humeral trochlear morphology of SED and CED patients. There was no association between morphometric measurements and coronoid fracture pattern. The results are strengthened by a good intra- and inter-reader reproducibility of the CT analysis protocol.

CONCLUSIONS

Our study is the first to evaluate the impact of trochlear morphology on elbow instability. Considering the results, other variables may have a greater impact on coronoid bone damage, such as trauma energy or ligamentous hyperlaxity: in particular, we believe that the capsuloligamentous structures of the elbow might contribute in a preponderant way to articular stability. The CT analysis protocol gave excellent results: reproducible, accurate and easy to perform.

LEVEL OF EVIDENCE

III.

Does the contralateral healthy ankle of patient with ipsilateral mechanical lateral ankle laxity show greater lateral ankle laxity? Evaluation of the anterior talofibular ligament by stress ultrasonography

Background

A number of studies have evaluated risk factors for lateral ankle sprain (LAS) or chronic lateral ankle instability (CLAI). However, the definitive risk factors for LAS or CLAI remain controversial. The purpose of this study was to evaluate whether the contralateral healthy ankles of subjects with ipsilateral mechanical lateral ankle laxity (group I) show greater lateral ankle laxity in comparison to the healthy ankles of bilateral healthy controls (group B).

Methods

From March 2020, anterior talofibular ligament (ATFL) lengths of young adult volunteers were cross-sectionally measured in non-stress and stress positions using a previously reported stress ultrasonography (US) procedure. The ATFL ratio (the ratio of stress ATFL/non-stress ATFL length) was calculated as an indicator of lateral ankle laxity. The manual anterior drawer test (ADT) was also performed. The US findings of healthy ankles from groups I and B were compared.

Results

A total of 154 subjects in group B (mean age, 24.5 ± 2.8 years; male/female, 84/70) and 40 subjects in group I (mean age, 24.4 ± 2.3 years; male/female, 26/14) were included in the study. There was no significant difference in the ADT between the groups. There were no significant differences in the non-stress ATFL length (19.4 ± 1.8 vs. 19.3 ± 1.9, p = 0.84), stress ATFL length (20.8 ± 1.8 vs. 20.9 ± 1.9, p = 0.66), length change (1.5 ± 0.6 vs. 1.6 ± 0.6, p = 0.12) and ATFL ratio (1.08 ± 0.03 vs. 1.08 ± 0.03, p = 0.13) between the groups.

Conclusion

No significant difference was detected between the contralateral healthy ankles of subjects with ipsilateral mechanical lateral ankle laxity and those of bilateral healthy controls.

The anterior talofibular ligament ratio was greater in young men with generalized joint laxity than in those without generalized joint laxity

PURPOSE

This study aimed to evaluate the relationship between generalized joint laxity (GJL) and stress ultrasonographic (US) findings of the anterior talofibular ligament (ATFL) of healthy young men.

METHODS

The ATFL lengths of healthy young men were consecutively measured in the stress and nonstress positions. The ATFL ratio was calculated as an indicator of lateral ankle laxity. GJL was evaluated using the Beighton score (BS), and a BS of ≥ 5 was considered GJL. The manual anterior drawer test (ADT) was also performed. The results of stress US and ADT were compared between subjects with and without GJL, and the correlation between GJL and US findings was examined.

RESULTS

A total of 13 subjects with GJL and 95 without GJL were included in the study. The mean BSs in the GJL and no-GJL groups were 5.9 ± 0.9 and 1.1 ± 1.3, respectively (p < 0.0001). The GJL group showed a higher grade of ADT than the no-GJL group (p < 0.0001). Significant differences were found in the stress ATFL length (23.6 ± 1.8 mm vs. 21.7 ± 1.8 mm, p = 0.002) and ATFL ratio (1.15 ± 0.06 vs. 1.07 ± 0.03, p < 0.0001) between the GJL and no-GJL groups. Spearman's correlation coefficients showed a moderate correlation between the BS and ATFL ratio (r = 0.45, p < 0.0001).

CONCLUSION

The present study showed significant differences in the ATFL ratio and stress ATFL length between young men with and without GJL. The BS was moderately correlated with the lateral ankle laxity in this population.

LEVEL OF EVIDENCE

Level IV.

Anatomical Components Associated With Increased Tibial Tuberosity-Trochlear Groove Distance

Background:

Increased tibial tuberosity–trochlear groove (TT-TG) distance is an important indicator of medial tibial tubercle transfer in the surgical management of lateral patellar dislocation (LPD). Changes to TT-TG distance are determined by a combination of several anatomical factors.

Purpose:

To (1) determine the anatomical components related to increased TT-TG distance and (2) quantify the contribution of each to identify the most prominent component.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

Included were 80 patients with recurrent LPD and 80 age- and body mass index–matched controls. The 2 groups were compared in TT-TG distance and its related anatomical components: tibial tubercle lateralization (TTL), trochlear groove medialization, femoral anteversion, tibiofemoral rotation (TFR), tibial torsion, and mechanical axis deviation (MAD). The Pearson correlation coefficient (r) was calculated to evaluate the association between increased TT-TG distance and its anatomical parameters, and factors that met the inclusion criteria of P < .05 and r ≥ 0.30 were analyzed via stepwise multivariable linear regression analysis to predict TT-TG distance.

Results:

The LPD and control groups differed significantly in TT-TG distance, TTL, TFR, and MAD (P < .001 for all). Increased TT-TG distance was significantly positively correlated with TTL (r = 0.376; P < .001), femoral anteversion (r = 0.166; P = .036), TFR (r = 0.574; P < .001), and MAD (r = 0.415; P < .001), and it was signficantly negatively correlated with trochlear groove medialization (r = −0.178; P = .024). The stepwise multivariable analysis revealed that higher TTL, excessive knee external rotation, and excessive knee valgus were statistically significant predictors of greater TT-TG distance (P < .001 for all). The standardized estimates that were used for evaluating the predictive values were larger for TFR compared with those for TTL and MAD.

Conclusion:

TTL, TFR, and MAD were the main independent anatomical components associated with increased TT-TG distance, with the most prominent component being TFR. The association of TT-TG distance to each component analyzed in our study may help guide surgical planning.

Association between the Beighton Score and Stress Ultrasonographic Findings of the Anterior Talofibular Ligament in Healthy Young Women: A Cross-Sectional Study

The Beighton score (BS) is widely used to evaluate generalized joint laxity. However, the association between the BS and lateral ankle laxity is unclear. This study compared the ultrasonographic (US) findings of the anterior talofibular ligament (ATFL) between high- (≥6) and low- (≤3) BS groups of healthy young women. The ATFL lengths of healthy young women were measured in the stress and nonstress positions using the previously reported technique from March 2021 to January 2022. The ATFL ratio (ratio of stress to nonstress ATFL length) was used as an indicator of lateral ankle laxity. The anterior drawer test (ADT) was performed. The correlation between the BS and US findings was also examined. A total of 20 (high-BS group) and 61 (low-BS group) subjects with a mean age of 23.8 ± 1.0 years were included. The high-BS group showed a higher grade of ADT than the low-BS group. No significant differences were found in the nonstress and stress ATFL lengths and ATFL ratio (1.10 ± 0.05 vs. 1.09 ± 0.05, p = 0.19) between the groups. No correlation was found between the BS and US findings. In conclusion, this study did not detect significant differences in the US findings of the ATFL between the high- and low-BS groups.

Shoulder and elbow pathology in the female athlete: sex-specific considerations

Unique biologic and biomechanical aspects of the female body make women more prone to certain orthopedic injuries. Sex differences are well understood with regard to certain orthopedic pathologies such as anterior cruciate ligament injury, hallux valgus, carpal tunnel, and carpometacarpal joint arthritis; however, sex differences are less commonly discussed with regard to shoulder and elbow pathology. The purpose of this review is to elucidate sex differences specific to sports-related shoulder and elbow injuries in the female athlete population.

Evaluation of the uninjured anterior talofibular ligament by ultrasound for assessing generalized joint hypermobility

BACKGROUND

Most clinicians use the Beighton score to assess generalized joint hypermobility (GJH) when deciding on the treatment of chronic lateral ankle instability (CLAI). The purpose of the study was to evaluate anterior talofibular ligament (ATFL) status by ultrasound and correlate these values with Beighton scores and the manual anterior drawer test (ADT).

METHODS

The participants were divided into two groups, those without GJH (24 ankles) and with GJH (20 ankles). For the investigation of ATFL, resting and stress ultrasonography was performed to assess the length, height (degree of loosening) and thickness. Beighton scores, manual ADT grades and ultrasound parameters of participants with and without GJH were compared. The correlation coefficients among those values were analyzed.

RESULTS

The mean ATFL length, resting height, stress height and mean difference in height between resting and stress ATFL were all significantly different between the two groups (P < .05). The resting and stress ATFL length, height, and difference in height between resting and stress ATFL showed a positive linear relationship with Beighton scores and manual ADT grades (P < .05).

CONCLUSIONS

The ATFL stress ultrasound parameters showed significant differences between participants with high and low Beighton scores and were correlated with Beighton scores and manual ADT grades.

LEVEL OF EVIDENCE

Cross-sectional cohort study; Level of evidence IV.

Hypermobile Disorders and Their Effects on the Hip Joint

Hypermobility, or joint hyperlaxity, can result from inherited connective tissue disorders or from micro- or macrotrauma to a joint. The supraphysiologic motion of the hip joint results in capsuloligamentous damage, and these patients have a propensity to develop femoroacetabular impingement syndrome (FAIS) and labral injury. In this review, the recent literature evaluating the definitions, history, incidence, genetics, and histology of hypermobile disorders is investigated. We then review the clinical evaluation, natural history, and resulting instability for patients presenting with a hypermobile hip. Lastly, treatment options and outcomes will be highlighted.

Interrater and Intrarater Reliability of the Beighton Score: A Systematic Review

Background:

The Beighton score is commonly used to assess the degree of hypermobility in patients with hypermobility spectrum disorder. Since proper diagnosis and treatment in this challenging patient population require valid, reliable, and responsive clinical assessments such as the Beighton score, studies must properly evaluate efficacy and effectiveness.

Purpose:

To succinctly present a systematic review to determine the inter- and intrarater reliability of the Beighton score and the methodological quality of all analyzed studies for use in clinical applications.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

A systematic review of the MEDLINE, Embase, CINAHL, and SPORTDiscus databases was performed. Studies that measured inter- or intrarater reliability of the Beighton score in humans with and without hypermobility were included. Non-English, animal, cadaveric, level 5 evidence, and studies utilizing the Beighton score self-assessment version were excluded. Data were extracted to compare scoring methods, population characteristics, and measurements of inter- and intrarater reliability. Risk of bias was assessed with the COSMIN (Consensus-Based Standards for the Selection of Health Measurement Instruments) 2017 checklist.

Results:

Twenty-four studies were analyzed (1333 patients; mean ± SD age, 28.19 ± 17.34 years [range, 4-71 years]; 640 females, 594 males, 273 unknown sex). Of the 24 studies, 18 reported raters were health care professionals or health care professional students. For interrater reliability, 5 of 8 (62.5%) intraclass correlation coefficients and 12 of 19 (63.2%) kappa values were substantial to almost perfect. Intrarater reliability was reported as excellent in all studies utilizing intraclass correlation coefficients, and 3 of the 7 articles using kappa values reported almost perfect values. Utilizing the COSMIN criteria, we determined that 1 study met “very good” criteria, 7 met “adequate,” 15 met “doubtful,” and 1 met “inadequate” for overall risk of bias in the reliability domain.

Conclusion:

The Beighton score is a highly reliable clinical tool that shows substantial to excellent inter- and intrarater reliability when used by raters of variable backgrounds and experience levels. While individual components of risk of bias among studies demonstrated large discrepancy, most of the items were adequate to very good.

Arthroscopic thermal stabilization for distal radioulnar joint instability: 3 to 19 years follow-up

This retrospective study investigated the clinical outcomes of patients treated for chronic distal radioulnar joint instability with arthroscopic thermal annealing of the superficial radioulnar ligaments, ulnar palmar wrist ligaments, and dorsoulnar wrist capsule using a radiofrequency probe. Sixty patients (62 wrists) were treated over an 18-year period. At mean follow-up of 10 years (range 3 to 19), 30 of 33 patients were satisfied with their surgical outcomes. There were statistically significant improvements in ulnar-sided wrist pain on a visual analogue scale and in distal radioulnar joint stability on the dorsopalmar stress test after surgery compared with preoperative status. The modified Mayo Wrist Score and Quick Disabilities of the Arm, Shoulder, and Hand score of the patients were favourable. Early failure occurred in 11 of 62 wrists. Nine of these 11 wrists needed a secondary procedure. We conclude that arthroscopic thermal shrinkage is effective for the majority of the patients with mild to moderate chronic distal radioulnar joint instability in long-term follow-up. Secondary open ligament reconstruction is an option in the case of early failure.Level of evidence: IV.

The Original Anatomic Reconstruction of Palmar and Dorsal Radioulnar Ligaments for Distal Radioulnar Joint Instability

Thirty years ago, the first anatomic reconstruction of the palmar and dorsal radioulnar ligaments for chronic distal radioulnar joint (DRUJ) instability was proposed by Sanders. In this surgical technique, the midpoint of a free tendon autograft is firmly secured in a bony tunnel at the ulnar fovea. The 2 graft limbs anchored at the fovea traverse the DRUJ and are securely woven into the periarticular soft tissues radially, reproducing the ligamentous anatomy while not overconstraining the joint. This report documents the original anatomic DRUJ reconstruction technique described by Sanders and our procedure modifications.