Ligamentous Knee Joint Instability: Association with Chronic Conditions of the Knee and Treatment with Prolotherapy

The medial collateral ligament (MCL) is the most important stabilizer of the medial side of the knee together with the capsuloligamentous complex. As such, it has a distinctive role in joint stability, as far as its biomechanics are concerned, and major joint stability issues onset when it is injured or deficient. One of the main functions of the medial collateral ligament is mechanical as it passively stabilizes the knee and help in guiding it through its normal range of motion when a tensile load is applied. It exhibits nonlinear anisotropic mechanical behaviour, like all ligaments, and under low loading conditions it is relatively compliant, perhaps due to recruitment of “crimped” collagen fibres as well as to viscoelastic behaviours and interactions of collagen and other matrix materials. Continued ligament-loading results in increasing stiffness until a stage is reached where it exhibits nearly linear stiffness and beyond this it continues to absorb energy until it is disrupted. In addition, the function of the MCL has to do with its viscoelasticity which assists the maintainance of joint congruity and homeostasis. The treatment of grade III medial collateral ligament injuries (with gross valgus instability at 0° of flexion) is still controversial. The most severe injuries (especially with severe valgus alignment, intra-articular medial collateral ligament entrapment, large bony avulsions, or multiple ligament involvement) may require acute operative repair or augmentation. In addition, surgical reconstruction is indicated for isolated symptomatic chronic medial collateral ligament laxity. The optimal surgical treatment remains controversial. More studies with evidence of level I and II are required in order to clarify the pros and cons of any solution.

Background: Incidence of osteochondral fractures with osteochondral bone defects without significant anterior cruciate ligament (ACL) injuries is rather uncommon with minimal literature available about the incidence rates of such lesions. Osteochondral injuries of the knee have different mechanisms of injuries like those following ACL rupture and patellar dislocation, which comprise direct and indirect modes of injuries. Various treatment modalities have been described for osteochondral defect depending upon the size of defect, such as debridement, lavage, microfracture technique, and osteochondral autograft transfer system (OATS) therapy. In case of osteochondral fractures, the main mode of management is surgical wherein osteochondral fractures are managed with headless compression screws and bioabsorbable implants. Robust management of the osteochondral fractures and osteochondral defects helps in achieving good prognosis for the patient. Case Report: An 18-year-old young man presented with complaints of pain and inability to move his right knee following alleged history of twisting of right knee while playing football. On examination, the patient had moderate effusion in the knee with tenderness over the medial patellofemoral joint line. Radiological investigation revealed traumatic osteochondral fracture of the patella and incidental finding of osteochondral defect in the lateral femoral condyle which was managed surgically with Herbert headless screw fixation for fracture and debridement with microfracturing for osteochondral defect. Post-operatively, patient had good rehabilitation and regained his normal range of motion (ROM) at the end of 12 weeks. Conclusion: The coincidental existence of both osteochondral fracture and osteochondral defect is a rare entity and warrants the need for surgical management to have better prognosis

The meniscus plays critical roles in the knee, contributing to load transmission, shock absorption, and joint stability. Little is known about gene expression in meniscal tears, particularly in relation to injury pattern and patient age and sex. The purpose of this study was to test the hypothesis that gene expression in meniscal tears varies depending on patient age and sex and whether the anterior cruciate ligament (ACL) is also torn. Meniscal tissue from twenty-eight patients with an isolated meniscal tear or a meniscal tear with a concomitant ACL tear was collected at the time of clinically indicated partial meniscectomy. Messenger RNA (mRNA) expression was examined by quantitative real-time polymerase chain reaction for molecular markers of osteoarthritis including proinflammatory cytokines (interleukin [IL]-1α, IL-1β, IL-6, and tumor necrosis factor-alpha [TNFα]), chemokines (IL-8, CCL3, CCL3L1, CXCL1, CXCL3, CXCL6, and CCL20), aggrecanases (ADAMTS-4 [a disintegrin and metalloproteinase with thrombospondin type-4 motifs] and ADAMTS-5), matrix metalloproteinases (MMP-1, MMP-3, MMP-9, and MMP-13), transcription factors (NFκB2 [nuclear factor kappa B2], NFκBIA [NF-kappa B inhibitor alpha], and IκBA [inhibitor of kappa B alpha]), and matrix components (bone morphogenetic protein [BMP]-2, type-I collagen alpha 1 [Col1a1], Col2a1, and aggrecan). Expression of IL-1β (p = 0.02), ADAMTS-5 (p = 0.001), MMP-1 (p = 0.007), MMP-9 (p = 0.002), MMP-13 (p = 0.01), and NFκB2 (p = 0.01) was significantly higher in patients with a meniscal tear who were under the age of forty years than it was in those over the age of forty years. Similarly, the expression of ADAMTS-4 (p = 0.002), ADAMTS-5 (p = 0.02), MMP-1 (p = 0.02), and MMP-13 (p = 0.0002) was higher in patients with a meniscal tear and an ACL tear who were under the age of forty years than it was in those over forty years. In patients with a meniscal tear and an ACL tear, the expression of IL-1β (p = 0.01), TNFα (p = 0.02), MMP-13 (p = 0.004), CCL3 (p = 0.03), and CCL3L1 (p = 0.03) was significantly higher, while that of aggrecan (p = 0.03) was lower, than that in patients with a meniscal tear alone. The only sex-based difference in gene expression was higher levels of CCL3L1 in female patients (p < 0.05) of all ages with combined injuries. These findings suggest clinically relevant differences in the response of the knee to meniscal tears on the basis of patient age and sex. Elevated expression levels of arthritis-related markers indicate an increased catabolic response in patients under forty years old. Higher expression of catabolic markers in patients with meniscal and ACL tears suggests this combined injury pattern is more likely to lead to the development of osteoarthritis. Catabolic activity in meniscal tissue may predict patients who are at risk for progression of osteoarthritis following partial meniscectomy.

Meniscal allograft transplantation for symptomatic knee after meniscectomy of torn discoid medial meniscus: Report of three cases

Knee Evaluations

Menisci are well recognized for their key role in load bearing, load transmission, shock absorption, joint stability, joint lubrication and joint congruity. Unfortunately, meniscus tears are the most common type of intra-articular knee injury, involving about 60–70 per 100,000 inhabitants per year. Although the classical treatment for painful meniscal tears is meniscectomy, in recent times the gold standard has shifted from excision to meniscal-repairing surgery. Despite all these considerations, meniscectomy is still frequently performed, and it is often necessary in the case of irreparable meniscal tears or after failure of previous repair. Meniscal allograft transplantation (MAT) has become a powerful treatment option for the patients with pain after meniscectomy, known as the “post-meniscectomy syndrome”, and has been shown to provide predictable relief of pain, improvement in knee function, prevention of osteoarthritis (OA) and a return to sporting activity with good long-term survival. Even if long-term results continue to improve, there still remains significant variability in how MAT is performed, and therefore, there remains the opportunity for optimizing outcome and graft survivorship.

Getting the Dog Moving After Surgery

There are numerous treatment algorithms that have been developed to treat thumb carpometacarpal (CMC) arthritis. A newer treatment option for these patients is CMC stabilization using suture button suspensionplasty. The authors of this case report have extensive experience with the suture-button suspensionplasty using the Mini TightRope CMC technique (Arthrex). We present a novel usage of the suture-button suspensionplasty to reconstruct the dorsal ulnar ligament (in contrast to the usual reconstruction of the volar beak ligament) to treat a patient with persistent thumb metacarpal dislocation at the CMC joint. Two separate patients are presented. One patient demonstrates volar beak ligament instability, and the other demonstrates dorsal ulnar ligament instability. Both patients’ demographics and operative indications are described. The operative technique for the novel usage of the suture-button suspensionplasty is described. Operative results of the dorsal ulnar ligament reconstruction are reviewed. After suture-button suspension of the thumb metacarpal to the trapezium, the dorsal ulnar ligament has been reconstructed. The patient demonstrated stability of the thumb CMC joint without dorsal or radial dislocation. The authors of this case report present a novel usage of the suture-button suspensionplasty to treat a patient with proximal thumb metacarpal dislocation at the trapezial-metacarpal interface. This method, in contrast to the referenced method of volar beak ligament reconstruction, allows reconstruction of the dorsal ulnar ligament. This allows stabilization of the joint by preventing dorsal and radial dislocation of the metacarpal.

Forty-one of fifty patients (fifty knees) who had had a repair of an acute tear of the medial ligaments, a procedure in which repair of the posterior oblique ligament and the semimembranosus complex was emphasized, were re-evaluated after an average duration of follow-up of twenty-two years (range, eighteen to thirty years). The ages of the patients at the time of the injury had ranged from fifteen to twenty-one years. In twenty-four of the forty-one knees, the anterior cruciate ligament had been torn. In seventeen of these knees, the torn ligament had been debrided; in six others, which had had avulsion of a bone fragment or a terminal tear, the ligament had been repaired with absorbable sutures; and in the remaining knee, the repaired anterior cruciate ligament had been augmented. Four patients had had a pes anserinus transfer to supplement the medial repair. The medial meniscus had been intact or repaired in twenty-five of the forty-one knees and had been removed from the remaining sixteen. The lateral meniscus had been retained in thirty-nine knees and removed from two. Postoperatively, all knees had been immobilized for six weeks in 60 degrees of flexion by means of a plaster cast. This had not caused lasting loss of motion, persistent muscle atrophy, or clinically demonstrable deterioration of the articular cartilage. In the twenty-four knees that had had a tear of the anterior cruciate ligament, the rates of instability, meniscal injury, and deterioration of the joint had not increased since the time of treatment, compared with those in the knees with an intact ligament, even though repair and augmentation of this ligament had not been performed (except in one patient, in whom it was unsuccessful). Thirty-eight patients had good stability and a normal range of motion, as well as little or no muscle atrophy. Radiographic changes were slight or absent in all but four knees. Most patients had maintained a high level of physical fitness and recreational athletic activity. There were three failures of treatment (7 per cent). This previously described treatment of acute tears of the medial ligaments, with or without an associated tear of the anterior cruciate ligament, provides good long-term results and is still recommended.

Anterior cruciate ligament and meniscal injuries are associated with secondary osteoarthrosis which may lead to functional impairment and economic burden. The prevalence of knee injury has not been studied in depth. Our purpose was to report the prevalence of knee ligament and meniscal injuries and their associations with gender, body mass index (BMI), and height in young adults and to characterize individuals with meniscal injuries who gained full recovery. A cross-sectional, population-based study was conducted. Information on the disability codes of knee ligament and meniscal injury according to the Regulations of Medical Fitness Determination was retrieved from a medical database containing records of young prerecruits into mandatory service. Logistic regression assessed the association between genders, BMI, and body height to knee injuries. A total of 825,187 subjects were included. Prevalence of knee injuries was 0.35%. Males had 2.2-fold more knee injuries than females. Increased BMI was associated with increased prevalence of knee injury in both genders, more significantly in females (overweight and obese females had an odds ratio of 1.406 and 1.519, respectively, to suffer from concomitant meniscal and ligamentous knee injury). Being underweight was associated with a lower prevalence of knee injury. An above normal BMI was more significantly associated with meniscal and/or ligament injuries that did not fully recover (females > males). Body height was associated with isolated meniscal injury in both genders. We found an association between BMI, body height, and knee injury in both males and females. Higher body height and higher BMI might be risk factors for knee injuries. Higher BMI was associated with greater probability of disability coding. Meniscal and ligament injuries are more common among males.

Meniscal tears can cause considerable symptoms (pain, catching or locking, and effusions) and may subject the knee to premature degeneration of the joint. They also are one of the most common indications for an orthopaedic surgical procedure [3]. As such, although a tear of the meniscus is never life- or limb-threatening, its importance in orthopaedic surgery is undoubted.

Objective To investigate the effect of meniscus on the stability of knee joint after anterior cruciate ligament rupture and reconstruction. Methods From January 2017 to October 2018, patients undergone anterior cruciate ligament reconstruction were included in the research prospectively. Partial anterior cruciate ligament rupture and multiple ligaments injury cases were excluded. Unstable meniscus tears diagnosed by arthroscopy were recorded and treated with partial meniscus resection. All the cases were divided into several groups according to the position and degree of the injury meniscus. KT-1000 test was used to quantify the anterior translation of the tibia (ATT) before surgery and at three and six months postoperatively. Independent t test was used to compare quantitative data between groups. Results A total of 158 patients with anterior cruciate ligament reconstruction were included in the research in which including 61 patients with a normal meniscus, 49 patients with a posterior horn of the medial meniscus (PHMM) tear (19 cases of avulsion 40% of the total width) group was significantly different from those of patients with normal meniscus (t=12.141; P 0.05). Conclusion Tear of posterior horn of medial meniscus and rupture of anterior cruciate ligament can increase the instability of knee joint, and partial meniscectomy has no effect on the stability of knee joint after anterior cruciate ligament reconstruction. Key words: Meniscus, tibial; Anterior cruciate ligament; Arthroscopy; Knee joint; Biomechanics

Introduction: Injuries from the athlete’s hand are frequent. We present 2 clinical cases: Stener injury and traumatic dislocation of the metacarpophalangeal joint of the thumb. The “skier’s thumb” is an injury to the ulnar collateral ligament of the metacarpophalangeal joint of the thumb produced by abduction and hyperextension of the thumb. Dorsal dislocation of the thumb metacarpophalangeal joint (MCP) in children is a rare entity. There are three types of dislocation: incomplete, simple and complete complete complex. Methods: Presentation of 2 clinical cases of injuries of the athlete’s hand: Stener injury and traumatic dislocation of the metacarpophalangeal joint of the thumb. Retrospective descriptive method with reports of clinical cases based on patients’ electronic clinical processes. Results: CASE 1: Male 11 years old, put into service urgency by hand trauma during football match. He had pain and swelling at the ulnar rim of the joint of the first metacarpal-phalangeal joint. Radiogram unchanged. Coping with clinical suspicion was carried out ray under stress (radial deviation) showed that this instability of the joint. Ultrasonography confirmed complete rupture of the ulnar side of the attachment with the aponeurosis interposition of the adductor - stener lesion. Surgery decided. Focus through internal and distal reinsertion. 4 weeks immobilization period, followed by a return to activities of daily living. At the last visit, at 6 months after the operation there was no residual instability. CASE 2: Seven-year-old boy put into service urgency for thumb injury in hyperextension during football match. The objective examination shows hyperextension deformity of MCF. The radiological study confirmed complete MCF dorsal joint dislocation diagnosis of the thumb joint. A closed reduction procedure under sedation, by McLaughlin corset technique. Immobilization was performed for two weeks. At six weeks he was asymptomatic, with normal mobilities, symmetrical grip and clamp strength without instability or radiographic changes. Discussion/Conclusion: Lesion of the ulnar side ligament is a possible diagnosis of the pediatric age, even without associated withdrawal. Proper clinical observation and x-rays provide supplemented by ultrasound, often all the information necessary for diagnosis and therapeutic decision. The low frequency relevance of pediatric Stener injuries can damage your diagnosis of the emergency situation. In this clinical case, it is possible to detect this damage. The dislocations dorsal joint MCP thumb are more frequent than flying, lesional mechanism involving the traumatic hyperextension of it. The diagnosis is based on clinical information supplemented by radiography, which allows the differentiation between complete and incomplete dislocations. A complete dislocation can not be reduced by maneuvering bloodless injury is complex and requires surgical treatment. The reduction technique involves MCF hyperextension and replacement of the base of the phalanx. Other gestures should be avoided, and axial traction, risk of joint injury structures, cartilage growth or conversion of a simple dislocation into complex, to determine the need for surgical intervention. After reducing the stability of the collateral ligaments should be evaluated, often directly damaged by trauma or inappropriate gestures reducing the reduction of multiple attempts. Lateral instability may benefit from surgical correction. References STENER, B.: “Displacement of the ruptured ulnar collateral ligament of the metacarpo-phalangeal joint of the thumb”. A clinical and anatomical study. J. Bone Jt. Surg. 44-B: 869, 1962. STENER, B.: “Hyperextension injuries to the metacarpophalangeal joint of the thumb. Rupture of ligaments, fracture of sesamoid bones, rupture of flexor pollicis brevis. An anatomical and clinic study”. Acta Chir. Scand. 125: 275, 1963. COONRAD, R.W., GOLDNER, J.L.: “A study of the pathological findings and treatment in soft-tissue injury of the thumb metacarpophalangeal joint”. J. Bone Jt Surg. 59- A: 439, 1968. PARIKH, M., NAHIGIAN, S., FROIMSON, A.: “Gamekeeper’s thumb”. Plast. Reconstr, Surg. 58:24, 1976. STENER, B.: “Entorses récents de la métacarpophalangienne du pource”, en Traité de chirurgie de la main de Tubiana R. Tomo II, pág. 779. París, Masson, 1984. KAPLAN, E.B.: “The pathology and treatment of radial subluxation of the thumb with ulnar displacement of the head of the first metacarpal”. J. Bone Jt Surg. 43-A: 541, 1961. YAMANAKA, K., YOSHIDA, K., INOVE, A., MIYAGI, T.: “Locking of the metacarpophalangeal joint of the thurnb”. J. Bone Jt Surg. 67-A: 782, 1985. NAVES, J., SALVADOR, A., PUIG, M.: “Traumatología del deporte”. Pág. 251. Salvat, Barcelona, 1986, SMITH, R.J.: “Post-traumatic instability of the metacarpophalangeal joint of the thumb”. J. bone Jt Surg. 59-A: 14-21, 1977. Kasuaki M. Dorsal dislocations of the second to fifth carpometacarpal joints: a case report. Hand Surg 2008; 13(2): 129-132. Laforgia R, Specchiulli F, Mariani A. Dorsal dislocation of the fifth carpometacarpal joint. Hand Surg Am 1990; 15: 463-465. Gangloff D, Mansat P, Gaston A, Apredoaei C, Rongières M. Carpometacarpal dislocation of the fifth finger: descriptive study of 31 cases. Chir Main 2007; 26(4-5): 206-213. Epub 2007 Jul 16. Eichhorn-Sens J, Katzer A, Meenen NM, Rueger JM. Carpometacarpal dislocation injuries. Handchir, Mikrochir, Plast Chir 2001; 33(3): 189. Yoshida R, Shah MA, Patterson RM, Buford WL Jr, Knighten J, Viegas SF. Anatomy and pathomechanics of ring and small finger carpometacarpal joint injuries. J Hand Surg Am 2003; 28(6): 1035-1043.

To prospectively compare magnetic resonance (MR) imaging-defined abnormalities of osteoarthritis (OA) of the knee with radiographic severity measurements of OA of the knee and self-reported pain. This study was approved by the institutional review board of University of Michigan. Informed consent was obtained for this HIPAA-compliant study. Knee MR imaging was performed in 117 women (mean age, 46 years; range, 32-56 years) from a community-based arthritis study (n = 1053) with 30 women in each of four categories: (a) no pain and no OA of the knee, (b) no pain and OA of the knee, (c) pain and no OA of the knee, and (d) pain and OA of the knee. OA of the knee was defined from radiographs. Two hundred thirty-two eligible knees had Kellgren-Lawrence scores for OA of the knee as follows: grade 0, 115 (49.6%); grade 1, 33 (14.2%); grade 2, 66 (28.4%); grade 3, 17 (7.3%); and grade 4, one (0.4%). MR images were assessed for location and severity of defects of cartilage, bone marrow edema (BME), osteophytes, subchondral cysts, sclerosis, meniscal and/or ligamentous tears, joint effusion, synovial cysts, and synovitis. MR imaging findings were compared with radiographic severity of OA of the knee (Kellgren-Lawrence scale) and self-reported pain with analysis of variance, t tests, and contingency table analyses. Defects of cartilage (higher than grade IIA) were found in 75% of knees; BME was found in 57% of knees (<1 cm, 41%; >1 cm, 16%). Large BME lesions were common in the pain and OA of the knee group (P = .001); this group was significantly more likely to have defects of cartilage (P = .001); meniscal tears (P = .001); and osteophytes, subchondral cysts, sclerosis, joint effusion, and synovitis (P < .001). Defects of cartilage, osteophytes, sclerosis, meniscal or ligamentous tears, joint effusion, and synovitis were strongly related to increasing Kellgren-Lawrence grade (P < .001). In middle-aged women, there were significant associations between pain, radiographic severity of OA of the knee, and seven MR imaging-identified parameters.

Background:Prevention of knee osteoarthritis (OA) following anterior cruciate ligament (ACL) rupture and reconstruction is vital. Risk of postreconstruction knee OA is markedly increased by concurrent meniscal injury. It is unclear whether reconstruction results in normal relationships between tibiofemoral contact forces and cartilage morphology and whether meniscal injury modulates these relationships.Hypotheses:Since patients with isolated reconstructions (ie, without meniscal injury) are at lower risk for knee OA, we predicted that relationships between tibiofemoral contact forces and cartilage morphology would be similar to those of normal, healthy knees 2 to 3 years postreconstruction. In knees with meniscal injuries, these relationships would be similar to those reported in patients with knee OA, reflecting early degenerative changes.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Three groups were examined: (1) 62 patients who received single-bundle hamstring reconstruction with an intact, uninjured meniscus (mean age, 29.8 ± 6.4 years; mean weight, 74.9 ± 13.3 kg); (2) 38 patients with similar reconstruction with additional meniscal injury (ie, tear, repair) or partial resection (mean age, 30.6 ± 6.6 years; mean weight, 83.3 ± 14.3 kg); and (3) 30 ligament-normal, healthy individuals (mean age, 28.3 ± 5.2 years; mean weight, 74.9 ± 14.9 kg) serving as controls. All patients underwent magnetic resonance imaging to measure the medial and lateral tibial articular cartilage morphology (volumes and thicknesses). An electromyography-driven neuromusculoskeletal model determined medial and lateral tibiofemoral contact forces during walking. General linear models were used to assess relationships between tibiofemoral contact forces and cartilage morphology.Results:In control knees, cartilage was thicker compared with that of isolated and meniscal-injured ACL-reconstructed knees, while greater contact forces were related to both greater tibial cartilage volumes (medial: R2 = 0.43, β = 0.62, P = .000; lateral: R2 = 0.19, β = 0.46, P = .03) and medial thicknesses (R2 = 0.24, β = 0.48, P = .01). In the overall group of ACL-reconstructed knees, greater contact forces were related to greater lateral cartilage volumes (R2 = 0.08, β = 0.28, P = .01). In ACL-reconstructed knees with lateral meniscal injury, greater lateral contact forces were related to greater lateral cartilage volumes (R2 = 0.41, β = 0.64, P = .001) and thicknesses (R2 = 0.20, β = 0.46, P = .04).Conclusion:At 2 to 3 years postsurgery, ACL-reconstructed knees had thinner cartilage compared with healthy knees, and there were no positive relationships between medial contact forces and cartilage morphology. In lateral meniscal-injured reconstructed knees, greater contact forces were related to greater lateral cartilage volumes and thicknesses, although it was unclear whether this was an adaptive response or associated with degeneration. Future clinical studies may seek to establish whether cartilage morphology can be modified through rehabilitation programs targeting contact forces directly in addition to the current rehabilitation foci of restoring passive and dynamic knee range of motion, knee strength, and functional performance.