Functional outcomes and rates of return to sport activities in a non-athlete population after the open Brostrom-Gould repair: a seven-year follow-up

INTRODUCTION

After an ankle sprain, up to 20% of patients may develop chronic lateral ankle instability (CLAI) requiring surgical treatment. The objective of this study was to investigate the functional outcomes and rates of return to sport activities in a cohort of non-athlete patients with chronic lateral ankle instability (CLAI) who underwent the opened Brostrom-Gould technique (BGT).

MATERIALS AND METHODS

Seventy-nine patients (seventy-nine feet) from three different centers undergoing BGT were reviewed. For clinical and functional analysis, the AOFAS ankle-hindfoot scale was applied and rates of return to sport activities were assessed. Correlation of Δ-AOFAS and rates of return to sport activities with all variables analyzed was performed.

RESULTS

Mean AOFAS score improved from 64.6 to 97.2 (p < 0.001). Sixty-one (77.2%) returned to preinjury activities and 18 (22.8%) changed to a lower-level modality. Symptoms of instability were related to Δ-AOFAS (p = 0.020). Change in the sport activity was related to pain and symptoms of instability (p = 0.41 and p < 0.001).

CONCLUSION

Recreational athlete patients who underwent the BGT demonstrated excellent functional outcomes after a mean follow-up of 7 years. Residual pain and symptoms of instability after surgery were the main complaints associated with limitations in physical activities.

Levels of 91 circulating inflammatory proteins and risk of lumbar spine and pelvic fractures and peripheral ligament injuries: a two-sample mendelian randomization study

OBJECTIVE

Lumbar spine and pelvic fractures(LPF) are combined with peripheral ligament injuries(PLI), frequently. It has been reported that the site of fracture injury is usually paralleled by the secretion of inflammatory proteins. This study aimed to investigate the causal relationship between 91 circulating inflammatory proteins and LPF and PLI by using a Two-sample Mendelian randomization (MR) analysis.

METHODS

Single nucleotide polymorphisms (SNPs) associated with 91 circulating inflammatory proteins, as exposures were selected from a large genome-wide association study (GWAS). The genetic variant data for LPF and PLI as outcomes from the FinnGen consortium. The inverse-variance-weighted (IVW) method was utilized as the main analysis for exposures and outcomes. In addition, the final results were reinforced by the methods of MR Egger, weighted median, simple mode, and weighted mode. The sensitivity analyses were used to validate the robustness of results and ensure the absence of heterogeneity and horizontal pleiotropy. MR-Steiger was used to assess whether the causal direction was correct to avoid reverse causality.

RESULTS

This study has shown that Beta-nerve growth factor(Beta-NGF) and Interferon gamma(IFN-gamma) are both involved in the occurrence of LPF and PLI, and they are reducing the risk of occurrence(OR:0.800, 95%CI: 0.650-0.983; OR:0.723, 95%CI:0.568-0.920 and OR:0.812, 95%CI:0.703-0.937; OR:0.828, 95%CI:0.700-0.980). Similarly, Axin-1 and Sulfotransferase 1A1 (SULT-1A1) were causally associated with LPF(OR:0.687, 95%CI:0.501-0.942 and OR:1.178,95%CI:1.010-1.373). Furthermore, Interleukin-4(IL-4), Macrophage inflammatory protein 1a(MIP-1a), and STAM binding protein(STAM-BP) were causally associated with PLI(OR:1.236, 95% CI: 1.058-1.443; OR:1.107, 95% CI: 1.008-1.214 and OR:0.759, 95% CI: 0.617-0.933). The influence of heterogeneity and horizontal pleiotropy were further excluded by sensitivity analysis.

CONCLUSION

This study provides new insights into the relationship between circulating inflammatory proteins and LPF and PLI, and may provide new clues for predicting this risk.

[Diagnostic value of 3D fast spin-echo sequence scanning combined with multislice spiral CT in knee cruciate ligament injury]

OBJECTIVE

To explore the potential value of three-dimensional fast spin echo（3D-SPACE） combined with multilayer spiral CT （MSCT） in the diagnosis of knee cruciate ligament injury, to provide a new direction for the optimization of subsequent clinical diagnosis.

METHODS

A total of 120 patients with knee cruciate ligament injury were treated from April 2020 to April 2021, aged from 21 to 68 with an average of（41.52±4.13） years old. For all patients, separate MSCT scanner scans, 3D-SPACE sequence scans alone and 3D-SPACE sequence combined with MSCT scans were used. The injury and classification of the anterior and posterior cruciate ligament of the knee were compared, the length of the anterior-medial bundle and posterolateral bundle and its angle of the knee with the horizontal plane were observed, the diagnostic value of 3 diagnostic methods in knee cruciate ligament injury were determined.

RESULTS

There was no significant difference between the 3D-SPACE sequence scan alone and the MSCT test alone on the total diagnostic rate and grading total diagnostic rate（P>0.05）. The total diagnostic rate and grading total diagnostic rate of 3D-SPACE scan combined with MSCT were significantly higher than those of 3D-SPACE scan or MSCT alone（P<0.05）. The 3D-SPACE sequence scan alone and the MSCT detection alone had no significant difference in the measurement values related to the anterior and posterior cruciate ligaments of the knee joint（P>0.05）. 3D-SPACE sequence scanning combined with MSCT detection on the knee joint anterior and posterior cruciate ligament related measurements were significantly higher than the 3D-SPACE sequence scan or MSCT detection alone（P<0.05）. The area under the ROC curve estimated by 3D-SPACE sequence scanning combined with MSCT was 0.960, which was significantly higher than that of 3D-SPACE sequence scanning and MSCT alone evaluating the area under the ROC curve line of 0.756 and 0.795. The combined 3D-SPACE sequence scanning and 3D-SPACE sequence scanning MSCT analysis and prediction models were statistically different（Z=2.236, P<0.05）, and MSCT alone and 3D-SPACE sequence scanning combined with MSCT analysis and prediction models were statistically different（Z=2.653, P<0.05）.

CONCLUSION

The application of 3D-SPACE sequence combined with MSCT scanning for knee cruciate ligament injury can improve the diagnosis rate of patients with knee cruciate ligament injury.It can be used as a diagnostic tool for patients with knee cruciate ligament injury and is worthy of clinical application.

Correlation between vascular endothelial growth factor A gene polymorphisms and tendon and ligament injury risk: a systematic review and meta-analysis

BACKGROUND

Relevant evidence suggests that angiogenic factors contribute significantly to fibril matrix reconstruction following physical injuries to tendon ligaments. Vascular endothelial growth factor A (VEGFA), with its potent angiogenic effect, has been studied extensively, and its functional polymorphisms, including rs699947, rs1570360, and rs2010963, have been the focus of numerous investigations. Some scholars have explored the association between gene polymorphisms in the VEGFA and the risk of tendon ligament injury, but the findings are not entirely consistent.

OBJECTIVES

The purpose of this study was to investigate the association between rs699947, rs1570360, and rs2010963 gene polymorphisms in VEGFA and the risk of tendon and ligament injuries.

METHODS

After including articles about the association of VEGFA rs699947, rs1570360, and rs2010963 polymorphisms with tendon and ligament injuries according to the search strategy, we assessed their quality and conducted meta-analyses to examine the link between these polymorphisms and the risk of tendon and ligament injuries using odds ratios and 95% confidence intervals.

RESULTS

Of 86 related articles, six were included in the meta-analysis. Some of these suggest an association between VEGFA rs2010963 and the risk of tendon and ligament injury in the population, with the specific C allele being one of the adverse factors for knee injury. Some studies suggest that VEGFA rs699947 and VEGFA rs1570360 single-nucleotide polymorphisms are associated with anterior cruciate ligament rupture. The risk of non-contact anterior cruciate ligament rupture is nearly doubled in individuals with the rs699947 CC genotype compared to the control group. Our analysis did not find any significant relationship between VEGFA gene polymorphisms (rs699947, rs1570360, and rs2010963) and the chance of tendon and ligament injury without consideration of race. However, the European population reveals that the CC genotype of VEGFA rs699947 can result in a greater risk of tendon and ligament injury, whereas the AG genotype for rs1570360 provides some protection. Additionally, rs2010963 was significantly associated with tendon and ligament injury; individuals with the C allele and the CC genotype had higher risk. False-positive report probability confirmed the high credibility of our results.

CONCLUSION

Overall, this study found no significant association between VEGFA rs699947, rs1570360, and rs2010963 polymorphisms and the risk of tendon ligament injury. However, in subgroup analysis, some genotypes of VEGFA rs699947, rs1570360, and rs2010963 were found to increase the risk of tendon ligament injury in European populations.

The role of peroneus longus (PL) autograft in the reconstruction of anterior cruciate ligament (ACL): A comprehensive narrative review

Background

Peroneus longus tendon (PLT) is a known graft utilised in the ligamentous reconstructions of knee. The current review was performed to analyze the available evidence regarding PLT in the arthroscopic anterior cruciate ligament (ACL) reconstruction.

Methods

A comprehensive search of literature was performed on March 1, 2023 using 5 databases (for manuscripts published between 2010 and 2023). All studies reporting ACL reconstruction with PL graft in adults ≥18 years were considered; and final studies were shortlisted based on specific exclusion criteria.

Results

The search identified 684 articles, among which 26 manuscripts were finally selected. PLT has been used in primary ACL reconstruction (ACLR), revision ACLR, ACLR in multiligamentous injuries and those at risk for anterior knee pain. The full-thickness PLT graft is variable in its dimensions with the mean size ranging between 7 and 8.8 mm (half-PLT grafts ≤8.1 mm). The ultimate strength of doubled PLT graft is significantly higher than native ACL and comparable to the quadrupled hamstring.There was statistically insignificant difference in the laxity and functional outcome of knee following ACLR with PLT, as compared with other autografts (p > 0.05). PLT harvest is associated with satisfactory clinical foot and ankle outcomes, as well as excellent regenerative ability. Overall, studies have demonstrated lower complications with PLT (p < 0.05).

Conclusion

The dimensions of harvested PLT graft are more consistent than HT. It has similar functional outcome and survival, as compared to other autografts. It also has lower risk for donor-site morbidity and lower complications than HT. PLT is a promising, alternative autograft choice in patients undergoing ACLR.

Management of Complex Hand and Wrist Ligament Injuries

Ligamentous injuries in the hand and wrist are often underdiagnosed and can present with significant functional limitations if there is untimely recognition of injury. Adequate repair or reconstruction is critical in restoring joint stability and mobility. The purpose of this review is to provide an overview of the metacarpophalangeal joint, scapholunate interosseous ligament (SLIL), and non-SLIL carpal ligament anatomy, diagnosis, imaging, treatment consideration and options, as well as surgical techniques encompassing repair, reconstruction, and fusion.

[Radiocarpal dislocations and fracture dislocations]

Radiocarpal dislocations and fracture dislocations are rare but always severe and complex injuries. They occur frequently in young and active patients as a result of high energy accidents. A detailed clinical and imaging examination and an accurate classification leads to a suitable and mostly surgical treatment strategy. The strategy should consider the most important components of the injury, the bony, the ligamentous and the intracarpal lesions. Delayed sequelae, residual pain and functional impairment are frequent after these severe injuries, but with adequate treatment, good, even long-term functional results are possible.

Peroneus Longus Graft Harvest: A Technique Note

Multiple graft options are available for knee ligament surgeries, one of the latest being peroneus longus grafts. Despite, an increasing usage of PL for graft harvest there is a scarcity of technique guides for its harvest, finding mention in only a few case studies. The following is a technical note dedicated to peroneous longus graft harvest.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-023-00847-0.

Smaller intercondylar notch size and smaller ACL volume increase posterior cruciate ligament rupture risk

PURPOSE

Little is known about risk factors for sustaining a posterior cruciate ligament (PCL) rupture. Identifying risk factors is the first step in preventing a PCL rupture from occurring. The morphology of the knee in patients who ruptured their PCL may differ from that of control patients. The hypothesis was that the intercondylar notch dimensions, 3-D volumes of the intercondylar notch and, the 3-D volumes of both the ACL and the PCL were correlated to the presence of a PCL rupture.

METHODS

The magnetic resonance imaging (MRI) scans of 30 patients with a proven PCL rupture were compared to 30 matched control patients with proven intact ACL and PCL. Control patients were selected from patients with knee trauma during sports but without cruciate ligament injury. Patients have been matched for age, height, weight, BMI, and sex. The volumes of the intercondylar notch and both the ACL and PCL were measured on 3D reconstructions. Second, the bicondylar width, the notch width, and the notch width index were measured of all subjects. The relationship between our measurements and the presence of a PCL rupture was analysed.

RESULTS

The results show a significant difference in the volumes of the intercondylar notch and the ACL between patients with a ruptured PCL and control patients. Patients with a PCL rupture have smaller intercondylar notch volumes and smaller ACL volumes. There were no significant differences in the bicondylar width, notch width, and notch width index. In the control patients, a significant correlation between the volume of the PCL and the volume of the ACL was found (0.673, p < 0.001).

CONCLUSION

Patients with a PCL rupture have smaller intercondylar volumes and smaller ACL volumes when compared to control patients. Second, patients with smaller ACL volumes have smaller PCL volumes. This study shows, for the first time, that there are significant size and volume differences in the shape of the knee between patients with a PCL rupture and control patients.

LEVEL OF EVIDENCE

IV.

Clinical and Radiological Clues of Traumatic Craniocervical Junction Injuries Requiring Occipitocervical Fusion to Early Diagnosis

Objective

The purpose of this study is to find the clinical and radiographic characteristics of traumatic craniocervical junction (CCJ) injuries requiring occipitocervical fusion (OC fusion) for early diagnosis and surgical intervention.

Methods

We retrospectively reviewed 12 patients with CCJ injuries presenting to St. Michaels Hospital in Toronto who underwent OC fusion and looked into the following variables; (1) initial trauma data on emergency room arrival, (2) associated injuries, (3) imaging characteristics of computed tomography (CT) scan and magnetic resonance imaging (MRI), (4) surgical procedures, surgical complications, and neurological outcome.

Results

All patients were treated as acute spinal injuries and underwent OC fusion on an emergency basis. Patients consisted of 10 males and 2 females with an average age of 47 years (range, 18–82 years). All patients sustained high-energy injuries. Three patients out of 6 patients with normal BAI (basion-axial interval) and BDI (basion-dens interval) values showed visible CCJ injuries on CT scans. However, the remaining 3 patients had no clear evidence of occipitoatlantal instability on CT scans. MRI clearly described several findings indicating occipitoatlantal instability. The 8 patients with normal values of ADI (atlantodens interval interval) demonstrated atlantoaxial instability on CT scan, however, all MRI more clearly and reliably demonstrated C1/2 facet injury and/or cruciate ligament injury.

Conclusion

We advocate measures to help recognize CCJ injury at an early stage in the present study. Occipitoatlantal instability needs to be carefully investigated on MRI in addition to CT scan with special attention to facet joint and ligament integrity.

Overuse-related instability of the elbow: the role of CT-arthrography

The elbow is a complex joint whose biomechanical function is granted by the interplay and synergy of various anatomical structures. Articular stability is achieved by both static and dynamic constraints, which consist of osseous as well as soft-tissue components. Injuries determining instability frequently involve several of these structures. Therefore, accurate knowledge of regional anatomy and imaging findings is fundamental for a precise diagnosis and an appropriate clinical management of elbow instability. This review focuses particularly on the varied appearance of overuse-related elbow injuries at CT-arthrography.

Complications associated with hyperextension bicondylar tibial plateau fractures: a retrospective study

Background

Hyperextension bicondylar tibial plateau fracture (HBTPF) is a particular form of tibial plateau fracture which has gained increasing interest recently but were rarely documented. In this study, we reported the characteristics, clinical intervention, and therapeutic outcomes of HBTPF patients.

Methods

From May 2015 to October 2017, clinical data of consecutive patients with bicondylar tibial plateau fractures (BTPF) who underwent surgical treatment in our hospital were retrospectively studied. The patients were allocated to either the HBTPF group (study group) or the non-HBTPF group (control group) based on the radiological features, and inclusion and exclusion criteria. Demographics, characteristics of knee joint injuries, complications, and outcomes were compared between the two groups.

Results

In total, 59 patients were included in this study. Among them, 17 patients with HBTPF were identified and 42 patients were diagnosed as non-HBTPF. No differences in age, sex, cause of injury, side of injury, site of injury, nerve injury, operation time, and treatment time and incision complication between HBTPF and non-HBTPF group. The incidence rate of popliteal artery injury in HBTPF group was 29.4 %, which was significantly higher than that of non-HBTPF group. Small bone chips on the lateral film were found in 94.1 % of the patients in HBTPF group, which was significantly higher than that of non-HBTPF group. The range of motion (ROM) and hospital for special surgery (HSS) score of HBTPF group were significantly lower than those of non-HBTPF group.

Conclusions

HBTPF is a severe injury with a higher incidence rate of popliteal artery injury and worse outcomes than non-HBTPF. Small bone chips at the anterior margin of the proximal tibia on the lateral plain film might be a characteristic of HBTPF.

[Characteristics and related factors of plantar pressure in the chronic ankle instability individuals]

OBJECTIVE

To analyze characteristics and related factors of the plantar pressure during the level walking and single leg standing in the chronic ankle instability (CAI) individuals.

METHODS

From April 2019, 75 CAI individuals and 40 healthy individuals were enrolled in this study. Both of the static and dynamic plantar pressure were measured during six times level walking and three times single leg standing testing. The data including peak force, time to peak force in various foot contact areas and the time to boundary (TTB) and velocity of center of pressure (COP) were measured and compared between the affected side and the unaffected side and between the CAI cases and the healthy individuals. The correlations between the plantar pressure and the gender, Beighton score, affected side and body mass index (BMI) were analyzed.

RESULTS

The characteristics of plantar pressure distribution in the CAI individuals included: (1) During the level walking, the affected side showed the similar pressure contribution as the unaffected side (P>0.05). While compared with healthy individuals, there was a significantly higher peak force in the 5th metatarsal area (t=-3.86, P=0.03) of the affected side, lower peak force in the 1st (t=2.99, P=0.02), 2nd metatarsal head areas (t=2.09, P=0.01) of the affected side, medial hindfoot areas of both sides (affected, t=2.33, P=0.01; unaffected, t=3.74, P=0.02) and toes areass of both sides (affected, t=2.23, P=0.01; unaffected, t=3.28, P=0.02) and a delay to peak force in the 4th metatarsal head area (t=3.33, P=0.01) of the affected side. (2) During the single leg standing, the CAI individuals showed significantly worse balance control in the anterior/posterior direction (P < 0.05) and lateral/medial direction (P < 0.05) compared with the healthy controls, and the affected side had more severe balance control deficit in the lateral/medial direction (P < 0.05). (3) The women (P < 0.05) and the individuals with higher Beighton scores (P < 0.05) showed worse balance control deficit in the lateral/medial direction.

CONCLUSION

CAI individuals showed significantly a more lateral shifted plantar distribution during the level walking compared with the healthy individuals and the tendency was worse on the affected sides, and showed worse balance control in the anterior/posterior direction and lateral/medial direction during the single leg standing. The women and those with generalized ligament laxity showed significantly worse balance control.

A biomechanics study on ligamentous injury in anterior-posterior compression type II pelvic injury

Background

Anterior-posterior compression (APC) type II pelvis fracture is caused by the destruction of pelvic ligaments. This study aims to explore ligaments injury in APC type II pelvic injury.

Method

Fourteen human cadaveric pelvis samples with sacrospinous ligament (SPL), sacrotuberous ligament (SBL), anterior sacroiliac ligament (ASL), and partial bone retaining unilaterally were acquired for this study. They were randomly divided into hemipelvis restricted and unrestricted groups. We recorded the separation distance of the pubic symphysis and anterior sacroiliac joint, external rotation angle, and force when ASL ruptured. We observed the external rotation damage to the pelvic bone and ligaments.

Result

When ASL failed, there was no significant difference in pubic symphysis separation (28.6 ± 8.4 mm to 23.6 ± 8.2 mm, P = 0.11) and anterior sacroiliac joint separation (11.4 ± 3.8 mm to 9.7 ± 3.9 mm, P = 0.30) between restricted and unrestricted groups. The external rotation angle (33.9 ± 5.5° to 48.9 ± 5.2°, P < 0.01) and force (553.9 ± 82.6 N to 756.6 ± 41.4 N, P < 0.01) were significantly different. Pubic symphysis separation between two groups ranged from 14 to 40 mm. In the restricted group, both SBL and SPL were injured. SPL ruptured first, and then SBL and the interosseous sacroiliac ligament were damaged while the posterior ligament remained unharmed. In the unrestricted group, interosseous sacroiliac ligament and posterior sacroiliac ligaments were damaged, while SBL and SPL were not. When the ASL, SBL, and SPL all failed, pubic symphysis and anterior sacroiliac joint separation between two groups increased significantly (from 28.6 ± 8.4 to 42.0 ± 7.6 mm, 11.4 ± 3.8 to 16.7 ± 4.2 mm respectively, all P < 0.05).

Conclusion

Pelvic external rotation injury is either hemipelvic restricted or unrestricted, which can result in different outcomes. When the ASL ruptures, the unrestricted group needs greater external rotation angle and force, without SBL or SPL injury, while both SBL and SPL were injured in another group. When ASL fails in two groups, pubic symphysis separation fluctuates considerably. Finally, when the ASL ruptures, SBL and SPL may be undamaged.

Magnetic resonance imaging of midtarsal sprain: Prevalence and impact on the time of return to play in professional soccer players

BACKGROUND

Ankle sprain is a common injury in professional soccer, but to date midtarsal sprain has not been investigated in this context. The purpose of this study was to determine the prevalence of midtarsal sprain by MRI and to assess its impact on the time of return to play in professional soccer players.

METHODS

We included 52 professional soccer players who underwent 59 MRI examinations after acute ankle trauma between January 2012 and September 2019. Images were retrospectively reviewed in consensus by two radiologists for assessment of midtarsal sprain and ankle sprain. Ligaments were graded as i) normal, ii) partial tear, or iii) complete tear. Time to return to play (RTP) for each athlete was retrieved from team medical records. A Kruskal-Wallis test and Dunn's pairwise tests were used to calculate differences in RTP time between groups with i) isolated midtarsal sprain, ii) isolated lateral ankle sprain, and iii) combined midtarsal and lateral ankle sprain.

RESULTS

MRI revealed isolated ankle sprain in 24 of 59 MRI examinations (40.6 %). Acute midtarsal ligament injury was present in 15 examinations (25.4 %). Four of the 15 examinations (26.7 %) had isolated midtarsal injuries and eleven of the 15 examinations (73.3 %) had concomitant ankle sprain. RTP time was 39 days (range 9-70 days) for isolated midtarsal sprain. RTP time was significantly higher for athletes with combined ankle and midtarsal sprain (47 days, range 15-74 days) when compared to athletes with isolated ankle sprain (24 days, range 2-59 days) (p = .019).

CONCLUSION

Our MRI study reveals that midtarsal sprain is a frequent injury in professional soccer players with ankle sprain. Midtarsal ligament findings on MRI combined with evidence of lateral ankle sprain is associated with a longer time of return to play compared to isolated lateral ligament injuries.

LEVEL OF EVIDENCE

Retrospective study, observational study.

Clinical features and treatment of "Non-dislocated hyperextension tibial plateau fracture"

Background

To explore the epidemiological characteristics, clinical characteristics, treatment strategies, and clinical results of non-dislocated hyperextension tibial plateau fracture.

Method

A total of 25 cases of non-dislocated hyperextension tibial plateau fracture patients were collected (12 males and 13 females), aged 27–79 years. Preoperative tibial plateau posterior slope angle was − 10~0° (average − 5.2°). Preoperative MRI showed 5 cases of MCL injury, 3 cases of PLC complex injury, and 2 cases of PLC + PCL injury. The change of tibial plateau posterior slope angle was more than 10° in patients with ligament injury, and the patients with a tibial plateau posterior slope angle change less than 10° had no ligament injury; 6 patients with simple column fracture had a ligament injury, 2 patients with bilateral column fracture had a ligament injury, and 2 patients with three column fracture had a ligament injury.

Results

Patients were followed up for 12–24 months (average 16.4 months). The operative time was 65–180 min (average 124 min), and the blood loss was 20–200 ml (average 106 ml). The plate was placed on the anterior part of tibial plateau. Evaluation of postoperative fracture reduction was as follows: 20 cases reached anatomic reduction, 5 cases reached good reduction (between 2 and 5 mm articular surface collapse), and the excellent rate of fracture reduction was 100%. The fracture healing time was 3–6 months (average 3.3 months). The postoperative knee Rasmussen score was 18–29 (average 24.9), and the postoperative knee joint mobility was 90–130° (average 118°). Two patients suffered superficial infection.

Conclusions

The main imaging characteristic of “non-dislocated hyperextension tibial plateau fracture” is the change of tibial plateau posterior slope angle. The injury of single anteromedial column/anterolateral column fracture is easy to combine with “diagonal” injury, and when the tPSA changes more than 10°, it is easy to be combined with ligament injury. By reducing the joint articular surface and lower limb force line, repairing the soft tissue structure, and reconstructing the knee joint stability, we can get satisfactory results.

Trial registration

It was a retrospective study. This study was consistent with the ethical standards of the Second Affiliated Hospital of Zhejiang University Medical College and was approved by the hospital ethics committee and the trial registration number of our hospital was 20180145.

Does subtalar instability really exist? A systematic review

BACKGROUND

Subtalar joint instability (STI) is considered as a potential source of chronic lateral hindfoot instability. However, clinical diagnosis of STI is still challenging. This systematic review was conducted to assess the consistency of the clinical entity "subtalar instability", to investigate the reliability of available diagnostic tools and to provide a critical overview of related studies.

METHODS

A systematic review of the Medline, Web of Sciences and EMBASE databases was performed for studies reporting on tests to investigate subtalar instability or lesions of the subtalar ligaments. To investigate the relation with chronic STI, studies focusing on sinus tarsi syndrome (STS) or acute lesions of the subtalar ligaments were also included in the search strategy and were assessed separately.

RESULTS

This review identified 25 studies focusing on different topics: chronic STI (16), acute lesions of the subtalar ligaments (5) and STS (4). Twelve studies, assessing STI, demonstrated the existence of a subgroup with instability complaints related to abnormal increased subtalar motion (7) or abnormalities of the subtalar ligaments (6). We found insufficient evidence for measuring subtalar tilting using stress radiographs. MRI was able to assess abnormalities of the ligaments and stress-MRI detected abnormally increased motion.

CONCLUSION

Complaints of instability can be related to subtalar ligaments injuries and an abnormally increased motion of the subtalar joint. Stress radiographs should be interpreted with caution and should not have the status of a reference test. Clinical diagnosis should rely on several parameters including MRI.

Ultrasound Imaging of Orthopedic Injuries

With the high cost and limited availability of gold standard imaging modalities, ultrasound has become an alternative in many musculoskeletal (MSK) injuries. Ultrasound has become increasingly portable and readily available in many acute care settings. Its ability to diagnose MSK injuries and help guide management has the potential to improve patient safety and flow. Ultrasound has been shown to diagnose fractures, dislocations, and tendon and ligament injuries. It helps guide fracture and dislocation reductions and aids in regional anesthesia for pain management. This article reviews the common MSK injuries that can be diagnosed with ultrasound with a focus on point-of-care ultrasound.

Conservative Versus Surgical Management of Elbow Medial Ulnar Collateral Ligament Injury: A Systematic Review

Objective

Several studies have been published regarding the treatment of medial ulnar collateral ligament (MUCL) injuries for professional overhead athletes. However, there is a paucity of data regarding non‐professional athletes. The aim of this systematic review was to compare the rate of outcome scores and complications of conservative versus operative treatments both in non‐professional athletes and in non‐sport‐related trauma patients with MUCL lesions.

Methods

A systematic review of the published literature was performed by applying the PRISMA guidelines. A search was conducted using three databases: Medline, Science Direct, and Web of Science. The keywords used were “ulnar collateral ligament injury,” “elbow,” “surgery,” and “conservative treatment”. Patients were divided into three groups: patients who underwent conservative treatment (C‐group), surgical treatment (S‐group), and surgery after a failed conservative treatment (C&S‐group). Clinical outcomes were analyzed: Disability of Arm, Shoulder and Hand (DASH), Conway scale, Carson score, and Kerlan–Jobe Orthopaedic Clinic score (KJOC).

Results

A total of 15 studies were included, evaluating 513 patients. Although good and excellent outcomes were found for most patients during daily and/or sport activities, independently of the type of treatment, the C‐group had better results. Excellent results were found in 98.8% of the C‐group, in 88.1% of the S‐group, and in 87.7% of the C&S‐group. The complication rate in the C‐group was statistically higher compared to the S and C&S groups (P < 0.001). However, its complication rate was higher with lower patient satisfaction.

Conclusions

There is insufficient evidence to establish statistically significant differences in the effects of conservative versus surgical treatments on the functional outcomes of patients with MUCL lesions. However, a period of rehabilitation therapy and the functional request of the single injured subject are useful to discern which patients genuinely require MUCL surgical repair.

In vivo assessment of high-molecular-weight polyethylene core suture tape for intra-articular ligament reconstruction: an animal study

AIMS

Options for the treatment of intra-articular ligament injuries are limited, and insufficient ligament reconstruction can cause painful joint instability, loss of function, and progressive development of degenerative arthritis. This study aimed to assess the capability of a biologically enhanced matrix material for ligament reconstruction to withstand tensile forces within the joint and enhance ligament regeneration needed to regain joint function.

MATERIALS AND METHODS

A total of 18 New Zealand rabbits underwent bilateral anterior cruciate ligament reconstruction by autograft, FiberTape, or FiberTape-augmented autograft. Primary outcomes were biomechanical assessment (n = 17), microCT (µCT) assessment (n = 12), histological evaluation (n = 12), and quantitative polymerase chain reaction (qPCR) analysis (n = 6).

RESULTS

At eight weeks, FiberTape alone or FiberTape-augmented autograft demonstrated increased biomechanical stability compared with autograft regarding ultimate load to failure (p = 0.035), elongation (p = 0.006), and energy absorption (p = 0.022). FiberTape-grafted samples also demonstrated increased bone mineral density in the bone tunnel (p = 0.039). Histological evaluation showed integration of all grafts in the bone tunnels by new bone formation, and limited signs of inflammation overall. A lack of prolonged inflammation in all samples was confirmed by quantification of inflammation biomarkers. However, no regeneration of ligament-like tissue was observed along the suture tape materials. Except for one autograft failure, no adverse events were detected.

CONCLUSION

Our results indicate that FiberTape increases the biomechanical performance of intra-articular ligament reconstructions in a verified rabbit model at eight weeks. Within this period, FiberTape did not adversely affect bone tunnel healing or invoke a prolonged elevation in inflammation. Cite this article: Bone Joint J 2019;101-B:1238-1247.

Efficacy of Primary Repair in Professional Athletes with Chronic Radial Collateral Ligament Injuries of Thumb Metacarpophalangeal Joint

Background: Management of grade III injuries of the radial collateral ligament (RCL) of the thumb is controversial. These injuries are often treated with early surgery. However, early surgery may not be practical for the professional athlete. We report on the outcome of delayed primary repair of chronic RCL injuries without the use of tendon grafts or tendon transfers. Methods: Twelve elite professional athletes with 15 soft tissue RCL injuries who underwent delayed surgery (greater than 6 weeks) were included in this study. Athletes were managed with splinting and ongoing play during the sporting season, and underwent surgery at the conclusion of the season. Mean duration from injury to surgery was 5 months. Mean follow-up was 4.2 years after surgery. Patient-report outcome measures including pain, satisfaction rating, and disability of the arm, shoulder and hand (DASH) scores were collected. Examination findings including range of motion, laxity, and grip and pinch strength were also measured. Return-to-play data were collected for all athletes. Results: The RCL was able to be primarily repaired with suture anchors in all cases. All twelve patients were able to return to competitive play at the same pre-injury professional level. Post-operative joint function such as range of motion and laxity were comparable to the unaffected contralateral side, as were grip and lateral pinch strengths. Tip-pinch strength is lower compared to the unaffected side, but is comparable to age and sex-matched reference group. Conclusions: Delayed primary repair of the RCL is a viable option and results in satisfactory long-term outcomes. This option may be more preferable to the professional athlete who wishes to avoid surgery during the sporting season.

Effect of simulated joint instability and bracing on ankle and subtalar joint flexibility

It is clinically challenging to distinguish between ankle and subtalar joints instability in vivo. Understanding the changes in load-displacement at the ankle and subtalar joints after ligament injuries may detect specific changes in joint characteristics that cannot be detected by investigating changes in range of motion alone. The effect of restricting joints end range of motion with ankle braces was already established, but little is known about the effect of an ankle brace on the flexibility of the injured ankle and subtalar joints. Therefore, the purposes of this study were to (1) understand how flexibility is affected at the ankle and subtalar joints after sectioning lateral and intrinsic ligaments during combined sagittal foot position and inversion and during internal rotation and (2) investigate the effect of a semi-rigid ankle brace on the ankle and subtalar joint flexibility. Kinematics and kinetics were collected from nine cadaver feet during inversion through the range of ankle flexion and during internal rotation. Motion was applied with and without a brace on an intact foot and after sequentially sectioning the calcaneofibular ligament (CFL) and the intrinsic ligaments. Segmental flexibility was defined as the slope of the angle-moment curve for each 1 Nm interval. Early flexibility significantly increased at the ankle and subtalar joint after CFL sectioning during inversion. The semi-rigid ankle brace significantly decreased early flexibility at the subtalar joint during inversion and internal rotation for all ligament conditions and at the ankle joint after all ligaments were cut.

A novel MIS technique for posterior cruciate ligament avulsion fractures

OBJECTIVE

Open surgical approaches to treat tibial avulsion fractures of the posterior cruciate ligament (PCL) often use large incisions involving extensive muscle dissection and retraction. The objective of this study was to describe a new mini-invasive approach targeting the fractured zone, to minimize surgical dissection and improve recovery and rehabilitation.

METHODS

The new approach was used in 15 males and seven females with isolated PCL avulsions. The length of the surgical incision, surgical time, need for conversion to open technique, visual analog scores (VAS) and duration of hospital stay were studied to assess the efficacy, learning curve and advantages of the new technique. Neurovascular complications were recorded. At the two-year follow-up, International Knee Documentation Committee (IKDC) scores were recorded to assess function.

RESULTS

Patients were followed up for a mean of 29months (range: 34-41). The mean length of the incision was 4.1cm (range: 3.4 to five) measured at the end of the procedure. None of the patients required conversion to an open technique and no neurovascular complications were recorded. The mean surgical time was 40min (range: 25-50). The mean VAS on discharge was 2.2 (range: one to four) and patients stayed at the hospital for a mean of 2.2days (range: one to three). The mean IKDC score at one-year post surgery was 86.4 (range: 83.9-90.8).

CONCLUSIONS

The new mini-invasive targeted approach provides adequate exposure for performing internal fixation of PCL avulsion fractures without the surgical morbidity associated with conventional open surgical approaches. The procedure is safe, fast and does not require a long learning curve.

Management of acute injuries of the tibiofibular syndesmosis

The syndesmosis is important for ankle stability and load transmission and is commonly injured in association with ankle sprains and fractures. Syndesmotic disruption is associated with between 5 and 10% of ankle sprains and 11-20% of operative ankle fractures. Failure to recognize and appropriately treat syndesmotic disruption can portend poor functional outcomes for patients; therefore, early recognition and appropriate treatment are critical. Syndesmotic injuries are difficult to diagnose, and even when identified and treated, a slightly malreduced syndesmosis can lead to joint destruction and poor functional outcomes. This review will discuss the relevant anatomy, biomechanics, mechanism of injury, clinical evaluation, and treatment of acute injuries to the ankle syndesmosis.

Assessment of knee laxity using a robotic testing device: a comparison to the manual clinical knee examination

PURPOSE

The purpose of this study was to collect knee laxity data using a robotic testing device. The data collected were then compared to the results obtained from manual clinical examination.

METHODS

Two human cadavers were studied. A medial collateral ligament (MCL) tear was simulated in the left knee of cadaver 1, and a posterolateral corner (PLC) injury was simulated in the right knee of cadaver 2. Contralateral knees were left intact. Five blinded examiners carried out manual clinical examination on the knees. Laxity grades and a diagnosis were recorded. Using a robotic knee device which can measure knee laxity in three planes of motion: anterior-posterior, internal-external tibia rotation, and varus-valgus, quantitative data were obtained to document tibial motion relative to the femur.

RESULTS

One of the five examiners correctly diagnosed the MCL injury. Robotic testing showed a 1.7° larger valgus angle, 3° greater tibial internal rotation, and lower endpoint stiffness (11.1 vs. 24.6 Nm/°) in the MCL-injured knee during varus-valgus testing when compared to the intact knee and 4.9 mm greater medial tibial translation during rotational testing. Two of the five examiners correctly diagnosed the PLC injury, while the other examiners diagnosed an MCL tear. The PLC-injured knee demonstrated 4.1 mm more lateral tibial translation and 2.2 mm more posterior tibial translation during varus-valgus testing when compared to the intact knee.

CONCLUSIONS

The robotic testing device was able to provide objective numerical data that reflected differences between the injured knees and the uninjured knees in both cadavers. The examiners that performed the manual clinical examination on the cadaver knees proved to be poor at diagnosing the injuries. Robotic testing could act as an adjunct to the manual clinical examination by supplying numbers that could improve diagnosis of knee injury.

LEVEL OF EVIDENCE

Level II.

[ADVANCES IN ANATOMICAL REPAIR OF CHRONIC LATERAL ANKLE INSTABILITY]

OBJECTIVE

To summarize the current status and progress of the treatment of chronic lateral ankle instability (CLAI).

METHODS

The literature about the anatomical repair of CLAI at home and abroad was reviewed and summarized.

RESULTS

Broström and its modified operations are the most common surgical treatment of CLAI. The operations showed satisfactory clinical outcomes in the short-, medium-, and long-term follow-up and low complication rate. Suture anchor technique and arthroscopic techniques are gradually used in Broström and its modified operations with satisfactory short-term effectiveness, but long-term effectiveness needs further observation because of the limitation of the short clinical application time.

CONCLUSIONS

Broström and its modified operations are effective, convenient, and safe to treat CLAI. Based on the researches of biomechanics and dynamic anatomy, the more personalized design of the rehabilitation program is the further research direction.

Emergency Magnetic Resonance Imaging of Musculoskeletal Trauma

Musculoskeletal (MSK) trauma is commonly encountered in the emergency department. Computed tomography and radiography are the main forms of imaging assessment, but the use of magnetic resonance (MR) imaging has become more common in the emergency room (ER) setting for evaluation of low-velocity/sports-related injury and high-velocity injury. The superior soft tissue contrast and detail provided by MR imaging gives clinicians a powerful tool in the management of acute MSK injury in the ER. This article provides an overview of techniques and considerations when using MR imaging in the evaluation of some of the common injuries seen in the ER setting.

Safety assessment characteristics of pedestrian legform impactors in vehicle-front impact tests

This study investigated the characteristics of safety assessment results of front-area vehicle impact tests carried out using the Transport Research Laboratory (TRL) legform impactor and a flexible legform impactor (FLEX legform impactor). Different types of vehicles (sedan, sport utility vehicle, high-roof K-car, and light cargo van) were examined. The impact locations in the study were the center of the bumper and an extremely stiff structure of the bumper (i.e., in front of the side member) of each tested vehicle. The measured injury criteria were normalized by injury assessment reference values of each legform impactor. The test results for center and side-member impacts indicated that there were no significant differences in ligament injury assessments derived from the normalized knee ligament injury measures between the TRL legform impactor and the FLEX legform impactor. Evaluations made using the TRL legform impactor and the FLEX legform impactor are thus similar in the vehicle safety investigation for knee ligament injury. Vehicle-center impact test results revealed that the tibia fracture assessments derived from the normalized tibia fracture measures did not significantly differ between the TRL legform impactor and the FLEX legform impactor. However, for an impact against an extremely stiff structure, there was a difference in the tibia fracture assessment between the FLEX legform impactor and the TRL legform impactor owing to their different sensor types.

Surgical management of the multiple-ligament injured knee: a case series from Chongqing, China and review of published reports

OBJECTIVE

The correct management of multiple-ligament injured knees (MLIKs) remains controversial. This study aimed to summarize the epidemiological features and short-term results of patients treated in our department.

METHODS

Sixty-six patients diagnosed with MLIKs from 2009 to 2011 were enrolled. Relevant patient characteristics and clinical variables were analyzed to characterize the epidemiology. A surgical algorithm based on a knee dislocation classification system and postoperative rating scales, including Lysholm and Tegner rating, as well as joint mobility, stability and radiography were collected for functional evaluation at 2.5-year follow-up.

RESULTS

The epidemiological profile demonstrated that 30- to 50-year-old men were at the highest risk. The primary causes were vehicle accidents and falls and most common injury type cruciate combined collateral ligament injuries. Final follow-up analysis comparing operative versus conservative management and surgically treated mild versus severe MLIKs showed significant differences in Lysholm and Tegner scale scores, as well as knee mobility and stability.

CONCLUSION

The therapeutic outcome of MLIKs depends on various clinical variables and a surgical algorithm. Satisfactory restoration of function was acquired in the majority of our surgically treated MLIK cases; however, most patients had not achieved their pre-injury activity levels by the follow-up endpoint.

Anterior cruciate ligament rupture: Delay to diagnosis

INTRODUCTION AND AIM

Anterior cruciate ligament (ACL) tears are common injuries. Despite the diagnosis being in essence a clinical one, this has often proved unreliable. The objective of this study was to ascertain the delay to diagnosis of ACL injury from initial presentation and subsequent delay to review by a knee specialist.

METHODS

The study involved a retrospective review of 130 patient case notes in a consecutive series of patients undergoing primary ACL reconstruction. Details regarding mechanism of injury, dates of initial and subsequent clinic attendances and the treating health-care professional were recorded. Other information included dates of magnetic resonance imaging (MRI) scans and when a patient first saw a knee specialist. From this, delays to clinical or radiological diagnosis were calculated.

RESULTS

There were 82 acute and 48 chronic ACL injuries. Overall, the initial treating practitioner made the diagnosis in only 25 patients, yielding a diagnostic rate of 19.2%. Diagnoses made on MRI scan accounted for 38.5% of cases, the remainder being diagnosed clinically. The mean delay to diagnosis of ACL rupture was 65 days, and only 53 patients were diagnosed within 30 days of initial presentation. A total of 15 patients had undergone arthroscopy, eight of which were diagnostic. The mean delay to consulting a soft-tissue knee surgeon was 165 days. In the acute group, the initial diagnostic rate was only 7.3% and the mean delay to diagnosis was 82 days, with 29 patients diagnosed within 30 days.

CONCLUSIONS

Despite 78% of the patients having a typical mechanism of ACL injury, and most attending acutely via the Emergency Department (ED), diagnosis of this common injury remains tardy. There has been at best only minor improvement in the diagnostic rate and delays, certainly of acute ACL injury, since a study in 1996. The overall clinical diagnostic rate remains disconcertingly low as does the delay to consulting a soft-tissue knee specialist.

Volar dislocation of the triquetrum - case report and review of literature

In contrast to triquetral fractures, dislocations of the triquetrum are very uncommon because of the very strong ligamentous support. They occasionally occur in association with complex wrist injuries, isolated dislocations however are extremely rare. We report a case of a male athlete who sustained an isolated volar dislocation of the triquetrum. The injury was treated by open reduction, fixation with Kirschner-wires and direct repair of torn ligaments. Kirschner-wires were removed after 6 weeks and physiotherapy was started. At 3 years follow-up he reported to be free of pain and showed only slightly restricted grip strength and range of motion when compared to his uninjured hand. A review of the literature indicates that final outcomes are usually satisfactory if prompt diagnosis and treatment occurs. However persistent pain and impaired hand function may result because of delayed diagnosis or insufficient repair of associated ligament injuries.