Stress Shielding of Ligaments Using Nonabsorbable Suture Augmentation May Influence the Biology of Ligament Healing

Nonabsorbable suture augmentation of ligament reconstruction has seen an increase in use over the past several years with the goal of protecting the newly reconstructed ligament while allowing early rehabilitation for a potential earlier return to activity and sport. By spanning the joint with a durable nonabsorbable suture, this construct shares the stress and load seen by the reconstructed ligament, thereby protecting it from forces that could result in an early failure during the early ligamentization phase of the tendon graft. However, stress shielding of the ligament via nonabsorbable suture augmentation is also a double-edged sword, as a reduction in the stress and load seen by the ligament during this healing phase may ultimately have an impact on the final strength and composition of the reconstructed ligament. Although the long-term effects of this stress shielding have yet to be studied or reported in human subjects, multiple biomechanical and animal studies have demonstrated overall changes in architecture, tensile strength, and mechanical properties of a stress-shielded autograft ligament reconstruction.

Accuracy of Ultrasound Compared to Magnetic Resonance Imaging in the Diagnosis of Thumb Ulnar Collateral Ligament Injuries: A Prospective Case Series

This prospective case series compared the accuracy of ultrasound (US) to magnetic resonance imaging (MRI) in differentiating complete displaced (CD) thumb ulnar collateral ligament (UCL) tears from nondisplaced injuries in 10 patients with suspected traumatic thumb UCL injuries. Ultrasound identified 100% (2 of 2) of MRI-documented CD tears, both of which were further confirmed during surgical repair. Ultrasound identified the absence of CD tears in the remaining 8 patients. Although MRI is the reference standard imaging modality for characterizing thumb UCL injuries, ultrasound should be considered an accurate, cost-effective, and alternative imaging modality to differentiate surgical versus nonsurgical thumb UCL injuries.

Early functional treatment or trivialization? - current treatment strategies in lateral ligament injuries of the ankle

Introduction: Ankle injuries are common in daily orthopaedic trauma practice, with a high incidence of lateral ligament complex (lat-lig-com) injuries of the ankle joint (AJ). Primarily, these lat-lig-com injuries heal sufficiently, although there is a risk of developing chronic ankle instability. However, there is a lack of knowledge about the clinical application and routine for rehabilitation strategies so as to prevent chronic instability. This study investigates the current rehabilitation concepts in clinical routine after ligament injuries of the AJ. Methods: Rehabilitation protocols, provided by orthopaedic and trauma surgery institutions in German speaking countries, were analysed in terms of weight-bearing, range of motion (ROM), physiotherapy and choice of orthosis. All protocols for operatively and non-operatively (nop) treated ligament ruptures of the AJ were included. Results: 120 of 213 institutions provided protocols of lat-lig-com injuries of the AJ. Regarding the orthosis, the nop-treatment group mainly used ankle braces; in contrast, the operative group preferred the use of an ankle boot. The operative group recommends 6-12 weeks for duration of orthosis in contrast to only 6 weeks in the nop group. Significant differences prevail in ROM, with free ROM in non-operative treatment from the first day after trauma (p<0.001) in contrast to a careful increase in ROM in the first 6 weeks post-operatively. Conclusion: Early functional treatment is clinical standard in rehabilitation after lat-lig-com injuries of the ankle. Regarding current literature the differences of restrictions in ROM and orthosis treatment after lat-lig-com injuries suggest a trivialization of conservative treatment in the first period after trauma compared to post-operative aftercare.

Uncommon hand injury to the batsman in 'gully cricket': report of two cases

Volar plate injuries are typically caused by hyperextension of the proximal interphalangeal joint. These injuries are usually seen in sports where the ball comes in direct contact with the hands. Forceful dorsiflexion of the finger caused by the speeding ball leads to volar plate avulsion. In cricket, such finger injuries predominantly occur in fielders trying to catch or stop the speeding ball with bare hands. We report two unusual cases of volar plate avulsion injury occurring in batsmen that occurred during 'gully cricket' (street-cricket). We propose the possibility of a novel contrecoup-type mechanism causing this type of injury in the two cases. Both were successfully managed with splinting and had excellent recovery without any residual deformity or instability.

Non-surgical management of a tibiofemoral knee dislocation in a patient with sarcoidosis

This case presents a patient who sustained a knee dislocation, and who due to her diagnosis of sarcoidosis, other comorbidities, and prolonged use of corticosteroids, external fixation and physical therapy were implemented versus soft tissue reconstruction/repair. Research indicates worse functional outcomes with non-surgical treatment, and guidelines on optimising outcomes in this population are lacking. Integrated care of the patient-even when complex injuries and comorbid medical conditions are present-can lead to positive functional recovery, despite previous data. Evidence from related injuries can be successfully adapted in non-surgical management of these injuries, providing general treatment guidelines.

Anterior elbow dislocation without fracture in an adult: a rare injury pattern

Anterior elbow dislocation without periarticular fracture (simple dislocation) is an extremely rare injury and is usually caused by distraction or torsional forces. It is important to look for associated ligamentous and musculotendinous injuries in this pattern. We report an elderly patient who sustained simple anterior dislocation of the elbow and in whom successful closed reduction could be achieved. Reduction by closed method is possible if we know the exact mechanism of elbow injury. Despite the presence of medial collateral ligament injury, he was managed non-operatively and had full functional recovery. Checking for joint stability and collateral ligaments after reduction and getting additional radiological investigations help in better treatment planning. Early protected active mobilisation should be initiated to achieve better functional results.

Augmented Ligament Reconstruction Partially Restores Hindfoot and Midfoot Kinematics After Lateral Ligament Ruptures

BACKGROUND

Altered kinematics and persisting ankle instability have been associated with degenerative changes and osteochondral lesions.

PURPOSE

To study the effect of ligament reconstruction surgery with suture tape augmentation (isolated anterior talofibular ligament [ATFL] vs combined ATFL and calcaneofibular ligament [CFL]) after lateral ligament ruptures (combined ATFL and CFL) on foot-ankle kinematics during simulated gait.

STUDY DESIGN

Controlled laboratory study.

METHODS

Five fresh-frozen cadaveric specimens were tested in a custom-built gait simulator in 5 different conditions: intact, ATFL rupture, ATFL-CFL rupture, ATFL-CFL reconstruction, and ATFL reconstruction. For each condition, range of motion (ROM) and the average angle (AA) in the hindfoot and midfoot joints were calculated during the stance phase of normal and inverted gait.

RESULTS

Ligament ruptures mainly changed ROM in the hindfoot and the AA in the hindfoot and midfoot and influenced the kinematics in all 3 movement directions. Combined ligament reconstruction was able to restore ROM in inversion-eversion in 4 of the 5 joints and ROM in internal-external rotation and dorsiflexion-plantarflexion in 3 of the 5 joints. It was also able to restore the AA in inversion-eversion in 2 of the 5 joints, the AA in internal-external rotation in all joints, and the AA in dorsiflexion-plantarflexion in 1 of the joints. Isolated ATFL reconstruction was able to restore ROM in inversion-eversion and internal-external rotation in 3 of the 5 joints and ROM in dorsiflexion-plantarflexion in 2 of the 5 joints. Isolated reconstruction was also able to restore the AA in inversion-eversion and dorsiflexion-plantarflexion in 2 of the joints and the AA in internal-external rotation in 3 of the joints. Both isolated reconstruction and combined reconstruction were most successful in restoring motion in the tibiocalcaneal and talonavicular joints and least successful in restoring motion in the talocalcaneal joint. However, combined reconstruction was still better at restoring motion in the talocalcaneal joint than isolated reconstruction (1/3 for ROM and 1/3 for the AA with isolated reconstruction compared to 1/3 for ROM and 2/3 for the AA with combined reconstruction).

CONCLUSION

Combined ATFL-CFL reconstruction showed better restored motion immediately after surgery than isolated ATFL reconstruction after a combined ATFL-CFL rupture.

CLINICAL RELEVANCE

This study shows that ligament reconstruction with suture tape augmentation is able to partially restore kinematics in the hindfoot and midfoot at the time of surgery. In clinical applications, where the classic Broström-Gould technique is followed by augmentation with suture tape, this procedure may protect the repaired ligament during healing by limiting excessive ROM after a ligament rupture.

Tendon and Ligament Injuries in Elite Rugby: The Potential Genetic Influence

This article reviews tendon and ligament injury incidence and severity within elite rugby union and rugby league. Furthermore, it discusses the biological makeup of tendons and ligaments and how genetic variation may influence this and predisposition to injury. Elite rugby has one of the highest reported injury incidences of any professional sport. This is likely due to a combination of well-established injury surveillance systems and the characteristics of the game, whereby high-impact body contact frequently occurs, in addition to the high intensity, multispeed and multidirectional nature of play. Some of the most severe of all these injuries are tendon and ligament/joint (non-bone), and therefore, potentially the most debilitating to a player and playing squad across a season or World Cup competition. The aetiology of these injuries is highly multi-factorial, with a growing body of evidence suggesting that some of the inter-individual variability in injury susceptibility may be due to genetic variation. However, little effort has been devoted to the study of genetic injury traits within rugby athletes. Due to a growing understanding of the molecular characteristics underpinning the aetiology of injury, investigating genetic variation within elite rugby is a viable and worthy proposition. Therefore, we propose several single nucleotide polymorphisms within candidate genes of interest; COL1A1, COL3A1, COL5A1, MIR608, MMP3, TIMP2, VEGFA, NID1 and COLGALT1 warrant further study within elite rugby and other invasion sports.

Intra-articular dislocation of the patella: a rare variant to an uncommon injury

Horizontal intra-articular dislocation of the patella is a very rare traumatic entity. We present an unusual case of horizontal intra-articular dislocation in which the patellar articular surface was facing upwards besides having an avulsion of the quadriceps tendon from the superior pole. There was associated posterolateral knee subluxation, which has not been described with intra-articular dislocation of the patella. A 20-year-old man presented with open patellar dislocation and locked knee after a roadside accident. The patient was managed successfully by open reduction and repair of the quadriceps tendon. There was buttonholing of the medial femoral condyle through the medial retinaculum leading to irreducible dislocation. A special reduction manoeuvre was employed to bring the knee to its normal alignment. Knowledge of this injury pattern is of utmost importance for proper recognition and appropriate allocation of the surgical technique.

ACL rupture in the immediate build-up to the Olympic Games: return to elite alpine ski competition 5 months after injury and ACL repair

Anterior cruciate ligament (ACL) rupture in the immediate build-up to a major international competition can preclude an athletes' participation due to the prolonged period of rehabilitation that is typically required after ACL reconstruction. ACL repair is an alternative strategy that has been postulated to confer the advantage of rapid rehabilitation and earlier return to sport. A 33-year-old professional alpine skier sustained a right knee ACL rupture in September 2017. The athlete indicated that she wanted to participate in the 2018 Olympics. Arthroscopic ACL repair and reconstruction of the anterolateral ligament was undertaken. At 3 months, Lachman's test revealed a hard end point, a negative pivot shift and no side-to-side laxity difference. MRI at 6 and 12 weeks demonstrated a continuous ACL with no intraligament signal change. At 20 weeks postoperatively, she successfully participated in the slalom at the 2018 Olympic Games.

Reliability, Surgeon Preferences, and Eye-Tracking Assessment of the Stress Examination of the Tarsometatarsal (Lisfranc) Joint Complex

The primary objective of this investigation was to determine the level of agreement and reliability of the stress examination of the Lisfranc tarsometatarsal joint complex. Secondary objectives were to determine surgeon preferences with respect to this testing and to use gaze recognition software to perform an eye-tracking assessment during the performance of the test. Twelve foot and ankle surgeons, 12 residents, and 12 students were shown 2 intraoperative fluoroscopic still images and 1 video of the stress examination of the tarsometatarsal joint complex using stress abduction of the forefoot on the rearfoot. Participants were asked to evaluate the result as being "positive" or "negative" for tarsometatarsal joint stability. The overall reliability of the interpretation of the stress examination was a kappa of 0.281 (surgeons 0.182; residents 0.423; students 0.256) indicating "fair" agreement. Survey results indicated wide variability in the perioperative preferences and protocols of surgeons dealing with the evaluation and treatment of the tarsometatarsal joint. Eye-tracking results also demonstrated variability in the anatomic structures of interest focused on during performance of this testing. The results of this investigation provide evidence of reliability well below what would be expected of a gold standard test during stress examination of the Lisfranc tarsometatarsal joint complex. These results indicate that future scientific endeavors are required to standardize the performance and interpretation of this testing.

Fixation of femoral attachment: anterior cruciate ligament avulsion fracture with arthroscopy suture loop technique

Anterior cruciate ligament (ACL) avulsion fracture is rare and mostly occur in tibial attachment. Avulsion fracture of femoral attachment of ACL was uncommon and mostly reported in skeletally immature patient. This article aims to report an interesting case of femoral attachment-ACL avulsion fracture in skeletally mature patient with arthroscopic suture loop fixation.A 32-year-old man, with no significant medical-surgical history, sustained a right non-contact pivoting knee injury during soccer competition. Plain radiographs of knee joint demonstrated intra-articular bone fragment in the intercondylar notch space. The MRI confirmed femoral attachment-ACL avulsion fracture. Then, we planned to perform fixation of femoral attachment-ACL avulsion fracture with arthroscopy suture loop technique. At 5 months after surgery, patient had no pain and swelling knee. The physical examination demonstrated negative Lachman test, anterior drawer test, pivot shift test and patient can return to preinjury daily activity and sport activities.

Non-operative management of an isolated lateral collateral ligament injury in an adolescent patient and review of the literature

We present a rare case of isolated traumatic pure ligamentous rupture of the lateral collateral ligament of the knee in an adolescent high-level footballer managed non-operatively with a good functional outcome and return to sport in 4 months.

Combined ACL reconstruction and Segond fracture fixation fails to abolish anterolateral rotatory instability

The Segond fracture (SF) is considered pathognomonic of an anterior cruciate ligament (ACL) tear. However, the anatomy of the soft-tissue attachments responsible for the avulsion of SFs has been a cause of controversy. A 31-year-old male patient presented with an injury to his right knee that resulted in ACL tear and a SF. Open SF fixation and arthroscopic ACL reconstruction were performed. The anatomical dissection demonstrated that the avulsion of SFs had occurred because of the tibial attachment of the anterolateral ligament (ALL) with an intact Iliotibial band. At 1-year postoperative follow-up, the ACL graft had restored anterior tibial translation to within normal limits. However, residual rotational knee laxity was observed. This finding highlights that patients with SF may be at increased risk of persistent instability after ACL reconstruction. Consideration should be given to recession of the fixation or augmentation of the ALL when dealing with this injury pattern.

Unique simultaneous avulsion fracture of both the proximal and distal insertion sites of the anterior cruciate ligament

February is a busy month for the ambulance skiing patrol at the skiing resorts in Norway and on this day, a call regarding an 11-year-old boy on one of the hills reached the team. What no one knew at that moment was that this boy had suffered a unique injury and that his X-rays would reveal something that, prior to this, had never been described in the history of mankind. This patient had suffered a simultaneous avulsion fracture of both the femoral and tibial insertion sites of the anterior cruciate ligament without suffering any other injuries to the knee. The injury was treated conservatively and at 1-year follow-up, the patient was completely recovered.

Total patellectomy with extensor mechanism reconstruction following pathological fracture due to patellar Ewing's sarcoma

A young patient presented with a progressive right knee pain and swelling that was worse on ambulation. Following appropriate investigations, he was confirmed having Ewing's sarcoma of the right patella. Two cycles of chemotherapy were initiated before he sustained a fall and a resultant pathological patellar fracture. He finally underwent a total right patellectomy and extensor mechanism reconstruction using Achilles tendon allograft in an attempt to eradicate the disease and salvage his knee extensor mechanism. At 1-year follow-up, no disease recurrence was observed, and the patient had a full range of motion but with slight weakness of the extensor mechanism.

Isolated dorsal dislocation of the lunate

Lunate dislocations are well described in the volar direction as part of the perilunate dislocation, sometimes together with fractures of the other carpal bones or distal radius, as described by the anatomical studies of Mayfield [1]. It is a result of disruption of the complex inter-carpal and radiocarpal ligaments that hold the well conforming carpus in their normal position. Given the strength of these structures a significant trauma is required to cause them to fail.

However, we present a case of a patient who not only presented with relatively trivial trauma that resulted in a lunate dislocation, but it was also in the dorsal direction and not associated with any fracture or neurological compromise. In addition, she presented several days after her injury.

We treated her with closed manipulation and percutaneous K-wire fixation followed by a short period of immobilisation in a Plaster-of-Paris cast, with rapid return to full duties at work.

As many volar lunate dislocations may be missed at presentation, we suggest that in patients with relatively trivial trauma there should also be a suspicion of the lunate dislocating dorsally, which may be treated successfully without the aggressive open surgery usually required in volar perilunate dislocations.