Anterior Translation Research Articles

Dynamic Instability Is Underestimated on Standing Flexion-Extension Films When Compared With Prone CT Imaging.

Single center retrospective cohort study. We performed a retrospective study evaluating the incidence and degree of L4-5 anterior spondylolisthesis in patients with standard supine MRI, standing flexion-extension radiographs, and prone CT. We hypothesize that prone CT imaging will provide greater sensitivity for instability compared with conventional flexion extension or supine positions. Dynamic lumbar instability evaluated by flexion-extension radiographs may underestimate the degree of lumbar spondylolisthesis. Despite efforts to characterize dynamic instability, significant variability remains in current guidelines regarding the most appropriate imaging modalities to adequately evaluate instability. We assessed single-level (L4-5) anterolisthesis between 2014 and 2022 with standing lateral conventional radiographs (CR), flexion-extension images, prone CT images (CT), or supine MRI images (MRI). We identified 102 patients with L4-5 anterolisthesis. The average translation (±SD) measured were 4.9±2.2mm (CR), 2.5±2.6mm (CT), and 3.7±2.6mm (MRI) (P<0.001). The mean difference in anterolisthesis among imaging modalities was 2.7±1.8mm between CR and CT (P<0.001), 1.8±1.4mm between CR and MRI (P<0.001), and 1.6±1.4mm between CT and MRI (P=0.252). Ninety-two of 102 patients (90.2%) showed greater anterolisthesis on CR compared with CT, 72 of 102 (70.6%) comparing CR to MRI, and 27 of 102 (26.5%) comparing CT to MRI. We found that 17.6% of patients exhibited ≥3mm anterior translation comparing CR with MRI, whereas 38.2% of patients were identified comparing CR with CT imaging (χ2 test P=0.0009, post hoc Fisher exact test P=0.0006 between CR and CT). Only 5.9% of patients had comparable degrees of instability between flexion-standing. Prone CT imaging revealed the greatest degree of single L4-5 segmental instability compared with flexion-extension radiographs.

Clinical and radiological comparisons between oblique lumbar interbody fusion combined with percutaneous pedicle screw fixation and transforaminal lumbar interbody fusion for adult isthmic spondylolisthesis: a 2-year follow-up study

Adult isthmic spondylolisthesis(AIS) results in the anterior translation of the vertebral body with neural encroachment. Although oblique lumbar interbody fusion(OLIF) is minimally invasive technique that use a retroperitoneal plane to achieve indirect decompression compared to transforaminal lumbar interbody fusion(TLIF), research on OLIF for AIS remains limited. Therefore, we aimed to compare the clinical and radiological outcomes of these two surgical techniques for AIS. We analyzed the details of 62patients with AIS who were treated with either OLIF(n=26) or TLIF(n=36) between 2019 and 2022, with a minimum 2-year follow-up. The two surgical techniques were compared in terms of perioperative surgical, radiological, and clinical outcomes. The correlation between the severity of foraminal stenosis and clinical outcomes was evaluated. The OLIF group experienced significantly less blood loss, shorter operative times, and shorter hospital stay than the TLIF group. Radiological assessments showed no significant preoperative differences in disc height or slippage ratios, but postoperative slippage correction was significantly greater in the OLIF group than in the TLIF group(13.5±8.0 versus 5.0±8.9; p<0.001). The clinical outcome improvement ratios did not differ significantly between the two groups. The correlation between preoperative severity of foraminal stenosis and clinical outcomes in the OLIF group was not significant. OLIF is more advantageous than TLIF in terms of blood loss, operative time, hospital stay and anterolisthesis correction. In addition, good clinical outcomes were obtained with indirect decompression alone, regardless of the severity of foraminal stenosis. Therefore, OLIF is a good surgical option for the treatment of AIS.

Surgical management of traumatic spondyloptosis: a case series

BackgroundTraumatic spondyloptosis is a rare and severe spinal injury characterized by complete anterior translation of one vertebra over another, often resulting in debilitating neurological deficits.Case presentationWe present two cases of traumatic spondyloptosis and elaborate on the clinical presentation, management, and follow-up improvement. The first case is a 30-year-old Nepalese man who sustained traumatic spondyloptosis following a blunt force injury to his back while engaged in tree-cutting activities. The patient presented with severe back pain, left lower limb paralysis, and neurological deficits (consistent with American Spinal Injury Association grade C). Radiographic evaluation revealed total anterior dislocation of the L4 vertebral body over L5, accompanied by fractures of the superior endplates of both vertebrae. The second case is a 35-year-old Nepalese female who presented with back pain and lower limb paralysis following a fall from a 300-m cliff, exhibiting tenderness and ecchymosis in the mid-back region. Radiological examination revealed D12 vertebra translation over L1 with fracture, categorized as American Spinal Injury Association grade A. Both cases were surgically managed and stabilized.ConclusionThese cases emphasize the importance of a comprehensive approach to trauma management as well as prompt recognition, and early surgical management in optimizing outcomes for patients with traumatic spondyloptosis.

Medial soft tissue release is also related to the anterior stability of cruciate-retaining total knee arthroplasty: a cadaveric study.

Medial soft tissue release is occasionally performed to achieve mediolateral ligament balance in total knee arthroplasty (TKA), whose sequential effect on mediolateral and anteroposterior stability remains unclear. This study aimed to quantitatively evaluate the difference in mediolateral and anteroposterior stability according to a sequential medial soft tissue release in TKA. Cruciate-retaining TKA was performed in six cadaveric knees. Medial and lateral joint gaps, varus-valgus angle, and tibial anterior and posterior translations relative to the femur with pulling and pushing forces, respectively, were measured. All measurements were performed at full extension and 45° and 90° flexion after release of the deep medial collateral ligament (MCL) (stage 1), the posteromedial capsule (stage 2), and the superficial MCL (stage 3). Mediolateral and anteroposterior stability were compared between stages, and correlations between mediolateral and anteroposterior stability were analyzed. Medial joint gap significantly increased from stages 1 to 3 by 3.2mm, 6.8mm, and 7.2mm at extension, 45° flexion, and 90° flexion, respectively, and from stages 2 to 3 by 3.5mm at extension. Varus-valgus angle was varus at stage 2, which turned to valgus at stage 3 (-2.7° to 0.8°, -2.2° to 4.3°, and -5.5° to 2.5° at extension, 45° flexion, and 90° flexion, respectively). Anterior translation at 90° flexion significantly increased from stages 1 and 2 to stage 3 by 11.5mm and 8.2mm, respectively, which was significantly correlated with medial gap (r = 0.681) and varus-valgus angle (r = 0.495). Medial soft tissue release also increased tibial anterior translation as well as medial joint gap, and medial joint gap and tibial anterior translation were significantly correlated. Surgeons should be careful not to create too large medial joint gap and tibial anterior translation in flexion by excessive medial release up to the superficial MCL for achieving an equal mediolateral joint gap in extension.

A Flat Reconstruction of the Medial Collateral Ligament and Anteromedial Structures Restores Native Knee Kinematics: A Biomechanical Robotic Investigation.

Injuries of the superficial medial collateral ligament (sMCL) and anteromedial structures of the knee result in excess valgus rotation and external tibial rotation (ER) as well as tibial translation. To evaluate a flat reconstruction of the sMCL and anteromedial structures in restoring knee kinematics in the combined MCL- and anteromedial-deficient knee. Controlled laboratory study. Eight cadaveric knee specimens were tested in a 6 degrees of freedom robotic test setup. Force-controlled clinical laxity tests were performed with 200 N of axial compression in 0°, 30°, 60°, and 90° of flexion: 8 N·m valgus torque, 5 N·m ER torque, 89 N anterior tibial translation (ATT) force, and an anteromedial drawer test consisting of 89 N ATT force under 5 N·m ER torque. After determining the native knee kinematics, we transected the sMCL, followed by the deep medial collateral ligament (dMCL). Subsequently, a flat reconstruction of the sMCL with anteromedial limb, mimicking the function of the anteromedial corner, was performed. Mixed linear models were used for statistical analysis (P < .05). Cutting of the sMCL led to statistically significant increases in laxity regarding valgus rotation, ER, and anteromedial translation in all tested flexion angles (P < .05). ATT was significantly increased in all flexion angles but not at 60° after cutting of the sMCL. A combined instability of the sMCL and dMCL led to further increased knee laxity in all tested kinematics and flexion angles (P < .05). After reconstruction, the knee kinematics were not significantly different from those of the native state. Insufficiency of the sMCL and dMCL led to excess valgus rotation, ER, ATT, and anteromedial tibial translation. A combined flat reconstruction of the sMCL and the anteromedial aspect restored this excess laxity to values not significantly different from those of the native knee. The presented reconstruction might lead to favorable results for patients with MCL and anteromedial injuries with an anteromedial rotatory knee instability.

Is suture-based cerclage biomechanically superior to traditional metallic cerclage for fixation of periprosthetic femoral fractures: A matched pair cadaveric study

BackgroundWhile traditional metallic cerclage remains the primary method in clinical application, non-metallic cerclage systems have recently gained popularity due to low risks of soft tissue irritation and bone intrusion. The objective of this study was to assess the performance of a novel non-metallic suture-based cerclage in comparison to traditional metallic cerclage cables for fixation of periprosthetic femoral fractures. MethodsAn extended trochanteric osteotomy was performed on eight pairs of cadaveric femora, followed by reduction using either metallic cerclages (Group I) or the suture-based cerclage (Group II). A modular tapered fluted stem was then implanted in each specimen. The fragment translation during canal preparation and stem implantation was quantified using laser-scanning. Subsequently, each specimen underwent 500 cycles of multiaxial loading, with fragment translation and stem subsidence measured using a motion capture system. FindingsFollowing stem implantation, specimens in Group II exhibited a significantly greater lateral fragment translation (466 μm vs 754 μm, p = 0.017). However, there were no significant differences in anterior and distal translation between groups (p > 0.05). During multiaxial loading, the average stem subsidence in Group I was 0.36 mm (range, 0.04–1.42 mm), compared to 0.41 mm (range, 0.03–1.29) in Group II (p > 0.05). No significant difference was found in fragment translations between the two groups (p > 0.05). InterpretationThe suture-based cerclage system exhibited comparable biomechanical performance in fixation stability to conventional metallic cerclage cables. Yet, it was associated with a larger residual lateral gap between the fragments following stem implantation. Ultimately, the choice of fixation method should account for multiple factors, including patient characteristics, surgeon preference, and bone quality.

The Influence of Anterior Translation of the Tibia with Patellar Height Measurements in Anterior Cruciate Ligament Insufficient Knee

The Influence of Anterior Translation of the Tibia with Patellar Height Measurements in Anterior Cruciate Ligament Insufficient Knee

Frequency of anterior cruciate ligament injuries and their risk factors in young athletes attended at the Orthopedics and Traumatology Center of the city of Rosario (Argentina) in the year 2023

Introduction: The anterior cruciate ligament (ACL) is one of the most important stabilizers of the knee that prevents anterior translation of the tibia over the femur. ACL injuries commonly occur during sports and are usually caused by sudden stops or changes in direction during running, jumping and landing.Objective: To describe the frequency of anterior cruciate ligament injuries and their risk factors in young athletes attended at the Orthopedics and Traumatology Center of the city of Rosario (Argentina) in the year 2023.Materials and methods: Quantitative, descriptive, observational, cross-sectional and retrospective study, carried out at the Orthopedics and Traumatology Center (COT) from April to September 2023. The population consisted of all patients aged between 18 and 25 years, regardless of sex, who practice high-impact sports on the knee and who consulted for knee injury. The collection instrument was the medical records. The variables were summarized through central position measures (mean) and dispersion measures (range and standard deviation) and expressed in absolute and relative frequency.Results: Thirty medical records were analyzed, of which 100% presented some ACL injury. The mean age was 21.57 ± 2.30 years, 67% were male and 33% female. Regarding the type of injury, 63% presented sprain and 37% tear. Twenty-seven percent played field hockey and rugby respectively, 20% played soccer, 13% basketball, 10% tennis and 3% volleyball. The risk factors associated with ACL injuries found in the studied population were among the intrinsic (50%) the neuromuscular deficit (37%) and genetic risk (13%); while among the extrinsic (23%) were the type of footwear (13%) used and the surface of the field (10%).Conclusions: Patients with ACL injuries evaluated were on average 21.57 ± 2.30 years old with a male: female ratio of 2:1. The most common symptoms were walking instability, edema, swelling, and pain. The most common sports associated with anterior cruciate ligament injuries were field hockey, rugby and soccer. Neuromuscular deficit, genetic risk, improper footwear and unstable field surface were found to be risk factors

Lateral meniscus root tear in anterior cruciate ligament injured patients is not associated with increased rotatory knee laxity: A quantitative pivot shift analysis

ObjectivesBiomechanical investigations conducted in vitro have elucidated the detrimental impact of lateral meniscus posterior root (LMPR) tears on knee contact pressures in the anterior cruciate ligament (ACL)-injured knee. Nevertheless, the influence of LMPR tears on the kinematics of ACL-injured patients remains ambiguous. The purpose of this study was to assess the impact of LMPR tears on anteroposterior and rotatory knee laxity employing a clinically validated quantitative pivot shift (QPS) analysis system. MethodsPatients with ACL injury recruited in a prospective ACL registry spanning from 2012 to 2020 were retrospectively screened for eligibility. Criteria for inclusion encompassed complete primary ACL tears, absence of concurrent ligamentous or osseous injuries requiring operative treatment, and no prior knee surgeries.Patients were assigned to two cohorts based on the presence (LMPR+) or absence (LMPR-) of an LMPR tear concomitant with ACL injury. Each patient underwent a standardized PS test, measurement of anterior tibial translation (ATT) (mm) using the Rolimeter, and QPS (mm) with a tablet-based image analysis system (PIVOT App). Comparative analyses of categorical variables were performed using the Fisher exact and Chi-square tests, while non-normally distributed continuous variables were compared between groups with the Mann–Whitney U test. Alfa was set at 0.05. ResultsA total of 99 patients were included in the study, of which 22 were assigned to the LMPR+ and 77 to the LMPR- group. Tear depth was considered partial in 13 (59%) patients and full in 9 (41%) patients. The prevalence of medial meniscus tears was greater in the LMPR+ (n ​= ​16, 73%) compared with the LMPR- (n ​= ​33, 43%) group (p ​= ​0.01). No difference was observed in ATT measured with the Rolimeter (p ​= ​0.63). Similarly, no difference was found in QPS between the LMPR+ (2.3 ​mm) and the LMPR- (1.9 ​mm) group (p ​= ​0.08). ConclusionUtilizing QPS in this investigation, LMPR tears do not significantly increase ATT or rotatory knee laxity. Consequently, although repairing LMRT associated with ACL injuries may be advisable for minimizing joint stress, their impact on controlling the PS in patients remains uncertain. Level of evidenceIII, retrospective comparative study.

ACL reconstruction demonstrates better stability compared to ACL repair for patients with Schenck III and IV knee dislocations.

This study compared mid-term outcomes of two anterior cruciate ligament (ACL) restoration techniques within an early total surgical care of acute knee dislocation: repair with additional internal bracing (ACLIB) and reconstruction with autograft (ACLR). Initial results at 12 months demonstrated that ACLR offered superior stability compared to ACLIB. Retrospective clinical study of patients with acute type III or IV KD. ACLIB or ACLR procedures were performed accompanied by simultaneous suture and internal bracing of the posterior cruciate ligament (PCL) and repair with lateral augmentation of the medial and lateral complex injuries utilizing Arciero's reconstruction technique. Patient-reported outcome measurements (PROMs), instrumental stability assessment via the Rolimeter-Test, and stress radiographs were analyzed. The study involved 20 patients (5 IIIM, 5 IIIL, and 10 IV injuries) with an average follow-up of 35.2 ± 7.4 months. Notable differences in anterior tibial translation on stress radiography favouring ACLR persisted at 24-month follow-up in side-to-side difference (SSD) (ACLIB 2.8 ± 2.5mm vs. ACLR 0.3 ± 2.6mm; p = 0.0487), but Rolimeter test variance diminished (SSD ACLIB 2.5 ± 0.9mm vs. ACLR 1.8 ± 1.7mm). Both groups showed excellent PROMs (Lysholm Score: ACLIB 84.4 ± 15.8 vs. ACLR 89.9 ± 9.0; IKDC Score: ACLIB 77.1 ± 16.2 vs. ACLR 77.7 ± 8.6). Our results indicate improved anterior stability at 12 months, which persisted at 24 months after ACL reconstruction compared with ACL repair by stress radiography. Both groups showed favourable patient-reported outcomes throughout the follow-up period. Notable rates of postoperative knee stiffness were observed in both groups. These were successfully managed with early, one-time arthroscopic arthrolysis within the first seven months of treatment, resulting in no major range of motion limitations at the 24-month follow-up. Retrospective cohort study, III.

“MCL Repair, Isolated Suture-tape Bracing and No Repair for Grade III MCL Tears During ACL Reconstruction Have Similar Outcome for Combined ACL With MCL Injury: A Randomized Controlled Trial.”

Aim of the study was to compare various MCL management strategies(repair vs isolated suture-tape bracing vs no repair) combined with ACL reconstruction and analyse results of MCL sub-types (femoral/mid-substance/tibial-sided tears) occurring at distinct levels. This study is a double blinded prospective randomised controlled trial. 96 consecutive patients with combined ACL and grade III MCL between 2020 and 2023 with minimum follow up of 24 months were included in the study. Chronic MCL and other ligament injuries were excluded, and computer-generated randomisation was done for allotment into three MCL management groups. ACL reconstruction with hamstring autograft was performed and MCL treated by repair in group 1(n=33), isolated suture-tape bracing -group 2(n=32) and no repair-group 3(n=31). At follow-up, stress radiographs were utilized to analyse anterior and medial laxity. IKDC, Lysholm, KOOS scores, duration of surgery and cost of surgery were compared. Also, subgroup analysis was performed to assess outcomes based on location of MCL injury. Demographic data, duration of injury, mode of injury and level of MCL injury is similar across groups. Over all MCL tears-femoral side, mid-substance and tibial side were 58.3%,18.7%and 23.0% respectively. Post-operatively significant improvement in ROM and functional score was observed in all three groups(P=<0.05); however, there was no statistically significant difference between the three groups at final follow-up in anterior tibial translation(P=0.94), medial opening in 0°(P=0.8) & 30°(P=0.64), ROM(P=0.39), IKDC(P=0.17), Lysholm(P=0.14) & KOOS(P=0.68). Three patients in group 2 had stiffness at 3months; two were treated with CPM and physiotherapy and 1 patient needed arthrolysis. Medial opening(00 and 300) was greater in group 3- mid-substance MCL tear patients(P=0.042,0.043). On Minimal clinically important differences (MCID) analysis more than 80% of patients had improvement in range of motion, functional scores and medial opening less than 5mm, suggestive of successful outcome in all the three groups. The duration of surgery was longer in repair group(P=0.001), whereas cost was higher in the suture-tape bracing group(P=0.003). Repair, isolated suture-tape bracing and no repair treatments of MCL result in good radiological (medial stress laxity) and functional outcomes when combined with ACL reconstruction. MCL Repair or isolated suture-tape bracing restore better medial side stability. Mid-substance MCL tears may need additional procedure(repair/bracing) to restore medial stability.

Arthroscopic Anterior Talofibular Ligament Repair Combined With All-Inside Suture Tape Augmentation for Treatment of Chronic Lateral Ankle Instability With Generalized Joint Laxity.

To analyze the feasibility and clinical results of the modified Broström operation (MBO) combined with suture tape augmentation under arthroscopy for chronic lateral ankle instability (CLAI) in patients with generalized joint laxity (GJL). From October 2019 to October 2021, a total of 111 patients (111 ankles) treated with MBO combined with suture tape augmentation under arthroscope were retrospectively divided into a GJL group (29 patients) and a control group (82 patients). Mechanical stability of the affected ankle joint was evaluated radiographically preoperatively, at 6 months postoperatively, and the last follow-up. Complications and surgical failures, as well as visual analog scale (VAS) score, the Foot and Ankle Ability Measure (FAAM), and the Karlsson score were also recorded. All statistical analyses were completed using SPSS 20.0. The average follow-up time was 21.7 ± 5.2 months for the GJL group, and 20.9 ± 5.3 months for the control group. Pain and symptoms in both groups were effectively relieved by the procedure reflected by decreased VAS scores, improved FAAM and Karlsson scores at 6 months postoperatively, and the final follow-up (P < .05). Preoperative talar tilt angle and anterior talar translation were significantly greater in the GJL group than those in the control group (P < .05). Postoperatively, both talar tilt angle and anterior talar translation were reduced in both groups at 6 months postoperatively and the last follow-up (P < .05), and we found no significant difference between the two groups (P > .05). Furthermore, we found no significant difference in VAS, FAAM, and Karlsson scores between the 2 groups 6 months postoperatively and at the last follow-up. Arthroscopic MBO combined with suture tape augmentation is a reliable procedure for treating CLAI with GJL. At short-term follow-up, we found that the GJL group achieved an equivalent level of stability compared with the control group.

Causes, effects and treatment of forward head posture. Systematic literature review

The human cervical spine, with its complex structure, is designed to serve unique biomechanical functions. In addition to providing support and protection for the skull, the cervical spine also acts as a shock absorber for brain structures. Mechanically, it transfers weight and facilitates head flexion movements. To effectively carry out its function, proper alignment of the head’s posture with the body’s vertical center of gravity is necessary to minimize pressure and tension on spinal muscles. When continuous activities involving head restraint or forward bending cause an anterior translation of the head over extended periods of time, it can lead to a condition known as forward head posture (FHP). Prolonged FHP can result in injuries to muscles, tendons, and ligaments within both the cervical and lumbar regions of the spine, resulting in various health issues such as neck pain, shoulder pain or discomfort in the upper thoracic scapular segment. The aim of this study was to determine the impact, causes, and management strategies that can be implemented when forward posture occurs in individuals. The data used for this research were obtained from accredited journals such as Mendeley and PubMed. Articles were searched based on keywords related to forward head posture and then filtered according to inclusion and exclusion criteria. Ten out of 140 articles were selected as primary sources for this study. The results indicate that one significant impact of forward head posture is acute neck pain, which primarily affects an individual’s balance negatively. Known causes of forward head posture include engaging in work that involves repetitive bending or maintaining a static position where one leans their neck forwards continuously over prolonged periods. Finally, the recommended management approach when dealing with forward head posture is treatment through exercise therapy, such as Chin tuck exercise, McKenzie Neck Exercise, and Forward Head Posture Exercise.

Anterior Cruciate Ligament Tear Detection Based on T-Distribution Slice Attention Framework with Penalty Weight Loss Optimisation.

Anterior cruciate ligament (ACL) plays an important role in stabilising the knee joint, prevents excessive anterior translation of the tibia, and provides rotational stability. ACL injuries commonly occur as a result of rapid deceleration, sudden change in direction, or direct impact to the knee during sports activities. Although several deep learning techniques have recently been applied in the detection of ACL tears, challenges such as effective slice filtering and the nuanced relationship between varying tear grades still remain underexplored. This study used an advanced deep learning model that integrated a T-distribution-based slice attention filtering mechanism with a penalty weight loss function to improve the performance for detection of ACL tears. A T-distribution slice attention module was effectively utilised to develop a robust slice filtering system of the deep learning model. By incorporating class relationships and substituting the conventional cross-entropy loss with a penalty weight loss function, the classification accuracy of our model is markedly increased. The combination of slice filtering and penalty weight loss shows significant improvements in diagnostic performance across six different backbone networks. In particular, the VGG-Slice-Weight model provided an area score of 0.9590 under the receiver operating characteristic curve (AUC). The deep learning framework used in this study offers an effective diagnostic tool that supports better ACL injury detection in clinical diagnosis practice.

Anterior-Posterior Laxity in Midflexion After Posterior-Stabilized TKA Is Sensitive to MCL Tension in Passive Flexion: An in Vitro Biomechanical Study.

Knee instability in midflexion may contribute to patient dissatisfaction following total knee arthroplasty (TKA). Midflexion instability involves abnormal motions and tissue loading in multiple planes. Therefore, we quantified and compared the tensions carried by the medial and lateral collateral ligaments (MCL and LCL) following posterior-stabilized (PS) TKA through knee flexion, and then compared these tensions with those carried by the native knee. Finally, we examined the relationships between collateral ligament tensions and anterior tibial translation (ATT). Eight cadaveric knees (from 5 male and 3 female donors with a mean age of 62.6 years and standard deviation of 10.9 years) underwent PS TKA. Each specimen was mounted to a robotic manipulator and flexed to 90°. ATT was quantified by applying 30 N of anterior force to the tibia. Tensions carried by the collateral ligaments were determined via serial sectioning. Robotic testing was also conducted on a cohort of 15 healthy native cadaveric knees (from 9 male and 6 female donors with a mean age of 36 years and standard deviation of 11 years). Relationships between collateral ligament tensions during passive flexion and ATT were assessed via linear and nonlinear regressions. MCL tensions were greater following PS TKA than in the native knee at 15° and 30° of passive flexion, by a median of ≥27 N (p = 0.002), while the LCL tensions did not differ. Median tensions following PS TKA were greater in the MCL than in the LCL at 15°, 30°, and 90° of flexion, by ≥4 N (p ≤ 0.02). Median tensions in the MCL of the native knee were small (≤11 N) and did not exceed those in the LCL (p ≥ 0.25). A logarithmic relationship was identified between MCL tension and ATT following TKA. MCL tensions were greater following PS TKA with this typical nonconforming PS implant than in the native knee. Anterior laxity at 30° of flexion was highly sensitive to MCL tension during passive flexion following PS TKA but not in the native knee. Surgeons face competing objectives when performing PS TKA: they can either impart supraphysiological MCL tension to reduce anterior-posterior laxity or maintain native MCL tensions that lead to heightened anterior-posterior laxity, as shown in this study.

Anterior cruciate ligament repair using dynamic intraligamentary stabilization grants 88.5% survival at minimum follow-up of 5 years.

The aim of this study was to report on the revision rates and clinical outcomes following dynamic intraligamentary stabilization (DIS) at a minimum follow-up of 5 years and to investigate which preoperative or intraoperative characteristics could influence revision rates or clinical scores. The authors retrospectively assessed all 609 knees that underwent ACL repair using DIS at a single centre. At a minimum follow-up of 5 years, patients were assessed using the Lysholm, International Knee Documentation Committee (IKDC) and Tegner scores, as well as passive flexion and extension. At a follow-up of 5.1 ± 0.3 years (range, 5-10), of the 609 patients, 428 patients were available for clinical assessment. Anterior tibial translation decreased from 9.7 ± 2.1 to 7.8 ± 1.9 mm, and side-to-side difference decreased from 4.3 ± 2.3 to 1.5 ± 1.8 mm. The postoperative Lysholm score was 96.9 ± 5.6, subjective IKDC was 95.6 ± 6.1 and Tegner scores ranged from 4 to 11, of which 51% of patients had a score of 7 or more. The estimated survival rate was 86% for the first half of the cohort and increased to 91% for the second half of the cohort. At a minimum follow-up of 5 years following ACL repair using DIS, it was found that it grants satisfactory clinical outcomes and that surgeons should inform patients who have predispositions about the higher risk of revision. Level IV retrospective study.

Comparative study of I.D.E.A.L. technique and transtibial technique in anterior cruciate ligament reconstruction

To compare the effectiveness of I.D.E.A.L technique and transtibial (TT) technique in anterior cruciate ligament (ACL) reconstruction. A clinical data of 60 patients with ACL injury, who were admitted and met the selection criteria between January 2020 and September 2022, was retrospectively analyzed. All patients underwent arthroscopic ACL reconstruction with autologous tendon. During operation, the femoral tunnel was prepared by using I.D.E.A.L technique in 30 cases (I.D.E.A.L group) and using TT technique in 30 cases (TT group). There was no significant difference in baseline data such as age, gender, body mass index, cause of injury, injured side, interval from injury to operation, constituent ratio of combined cartilage and meniscus injury, and preoperative Lysholm score, International Knee Documentation Committee (IKDC) score, visual analogue scale (VAS) score, anterior tibial translation difference, and Blumensaat angle between the two groups ( P>0.05). The length of hospital stay and the occurrence of early and late complications were recorded. During follow-up, the Lysholm score, IKDC score, and VAS score were used to evaluate knee joint function and pain degree, and the anterior tibial translation difference was measured. MRI reexamination was performed to observe the healing of the graft, and the signal to noise quotient (SNQ) values of the femoral end, middle section, and tibial end of the graft, as well as the Blumensaat angle of the knee joint were measured. The differences in tibial anterior translation difference and Blumensaat angle before and after operation (change values) were calculated and compared between the two groups. The incisions in both groups healed by first intention after operation, and there was no significant difference in the length of hospital stay between the two groups ( P>0.05). All patients were followed up 12-18 months, with an average of 14.9 months. The Lysholm score and IKDC score of the knee joint in both groups after operation increased when compared with those before operation, and the VAS score decreased. Compared to preoperative scores, except for the VAS score of the TT group at 1 week after operation ( P>0.05), there were significant differences in all scores at different time points postoperatively in the two groups ( P<0.05). The above scores in both groups showed a further improvement trend with the prolongation of time after operation. There were significant differences in Lysholm score and VAS score among 1 week, 1 month, 3 months, 6 months, and 12 months after operation in the two groups ( P<0.05). The IKDC score of both groups at 1 month after operation was significantly different from that at 1 week after operation ( P<0.05). At 1 week after operation, the Lysholm score and IKDC score in the I.D.E.A.L group were significantly higher than those in the TT group ( P<0.05), and the VAS score was significantly lower ( P<0.05); there was no significant difference between the two groups at 1, 3, 6, and 12 months after operation ( P>0.05). At 12 months after operation, the anterior tibial translation differences in both groups were significantly lower than those before operation ( P<0.05); and the change value in the I.D.E.A.L group was significantly higher than that in the TT group ( P<0.05). The incidences of early and late complications in the I.D.E.A.L group were significantly lower than those in the TT group ( P<0.05). At 12 months after operation, MRI examination showed that the grafts of the knee joint in both groups survived well, and the Blumensaat angles of both groups were significantly smaller than those before operation ( P<0.05). The change value of the Blumensaat angle in the I.D.E.A.L group was significantly higher than that in the TT group ( P<0.05). The SNQ values of the femoral end, middle section, and tibial end of the graft in the I.D.E.A.L group were significantly higher than those in the TT group ( P<0.05). The early effectiveness of ACL reconstruction by using the I.D.E.A.L technique is better, the knee joint is more stable, and the incidence of postoperative complication is lower. However, the maturity of the graft after reconstruction using the TT technique is higher.

Oblique Dorsiflexion Osteotomy of the Distal Tibia for Fixed Ankle Equinus: Surgical Technique.

There are significant challenges in the treatment of a severe rigid ankle equinus caused by a flat-topped talus, arthrogryposis, burn sequelae, or extensive scarring. Conventional approaches, such as soft tissue releases, often fail due to joint incongruence or compromised soft tissues, thereby necessitating supramalleolar osteotomies. The classic transverse supramalleolar osteotomy (TSO) of the distal tibia can lead to secondary anterior translation of the centre of rotation of the ankle and alters mechanical and anatomical axes. An alternative technique involves an oblique closing wedge osteotomy of the distal tibia, with a fulcrum near the ankle joint. This technical note delineates the planning parameters and procedural steps for the oblique dorsiflexion osteotomy of the distal tibia (ODODT). Using an anterior approach to the distal tibia, the "alpha angle," which determines the size of the closing wedge required for the foot to be plantigrade, is resected with a fulcrum at the most posterior part of the ankle joint, ensuring that the posterior cortex remains intact. The inclination of this resected wedge is planned preoperatively and is referred to as the "beta angle." This aims to equalise the lengths on both sides of the osteotomy. For osteotomy fixation, 2 or 3 cannulated screws in lag mode are employed. Postoperatively, a short cast boot is used for 6 weeks. The ODODT is a salvage solution for severe rigid ankle equinus when first-line foot and ankle procedures are impractical due to tibiotalar incongruence or poor soft tissues. Advantages include minimal translation of the centre of rotation of the ankle, excellent stability when the posterior cortex remains intact, avoidance of large internal fixation devices, and cost-effectiveness, making it suitable for low-resource settings. Olleac R, Farfan F, Acosta L, et al. Oblique Dorsiflexion Osteotomy of the Distal Tibia for Fixed Ankle Equinus: Surgical Technique. Strategies Trauma Limb Reconstr 2024;19(2):104-110.

Single-bundle ACL combined with ALL reconstruction yields comparable outcomes in patients with varied anatomical risk factors for ACL graft failure

BackgroundAnterior cruciate ligament (ACL) graft failure is influenced by factors such as meniscal tears and tibial plateau slope. Combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction has reduced failure rates; however, its efficacy in high-risk patients remains unclear. This study hypothesized that combined ACL and ALL reconstruction would yield similar clinical outcomes in patients with varying risks of ACL failure.Patients and methodsA total of 76 patients who underwent primary single-bundle ACL reconstruction combined with ALL reconstruction between June 2018 and June 2021 were included. The medial tibial slope (MTS), lateral tibial slope (LTS), and anterior tibial translation (ATT) were measured using magnetic resonance imaging and plain radiography of the knee joint. The meniscal lesions were assessed during surgery. Preoperative clinical assessments and final follow-up were conducted using patient-reported outcome measurements (PROMs), including the International Knee Documentation Committee (IKDC) evaluation, Lysholm knee scoring scale, and Tegner Activity scale. PROMs were collected at least two years postoperatively.ResultsThe average follow-up was 32.5 ± 7.4 months. There were no significant differences in postoperative IKDC score, Lysholm score, or Tegner activity score between patients with or without medial meniscus injury (p = 0.155, 0.914, and 0.042, respectively), with or without lateral meniscus injury (p = 0.737, 0.569, and 0.942, respectively), medial tibial slope > 12° or ≤ 12° (p = 0.290, 0.496, and 0.988, respectively), or lateral tibial slope > 7.4° or ≤ 7.4° (p = 0.213, 0.625, and 0.922, respectively). No significant correlations were found between anterior tibial translation and postoperative IKDC (R = -0.058, p = 0.365), Lysholm (R = -0.017, p = 0.459), or Tegner activity scores (R = -0.147, p = 0.189).ConclusionOur study demonstrates that single-bundle ACL reconstruction combined with ALL reconstruction provides reliable and comparable clinical outcomes in patients with high-risk factors for ACL graft failure, such as increased tibial slope or meniscal injury. Our results suggest that the indications for ALL reconstruction may be expanded to include patients with a high tibial slope or meniscal injury, because these factors have been shown to contribute to increased rotational instability and high rates of ACL graft failure. Future prospective randomized controlled trials with large patient cohorts and long follow-up periods are needed to validate these findings and establish clear guidelines for patient selection and surgical decision-making.Level of evidenceLevel 3.

In vivo analysis of ankle joint kinematics and ligament deformation of chronic ankle instability patients during level walking.

Introduction: Chronic ankle instability (CAI) carries a high risk of progression to talar osteochondral lesions and post-traumatic osteoarthritis. It has been clinically hypothesized the progression is associated with abnormal joint motion and ligament elongation, but there is a lack of scientific evidence. Methods: A total of 12 patients with CAI were assessed during level walking with the use of dynamic biplane radiography (DBR) which can reproduce the in vivo positions of each bone. We evaluated the uninjured and CAI side of the tibiotalar and subtalar joint for three-dimensional kinematics differences. Elongation of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL) were also calculated bilaterally. Results: For patients with CAI, the dorsiflexion of the tibiotalar joint had reduced (21.73° ± 3.90° to 17.21° ± 4.35°), displacement of the talus increased (2.54 ± 0.64mm to 3.12 ± 0.55mm), and the inversion of subtalar joint increased (8.09° ± 2.21° to 11.80° ± 3.41°). Mean ATFL elongation was inversely related to mean dorsiflexion angle (CAI: rho = -0.82, P < 0.001; Control: rho = -0.92, P < 0.001), mean ATFL elongation was related to mean anterior translation (CAI: rho = 0.82, P < 0.001; Control: rho = 0.92, P < 0.001), mean CFL elongation was related to mean dorsiflexion angle (CAI: rho = 0.84, P < 0.001; Control: rho = 0.70, P < 0.001), and mean CFL elongation was inversely related to mean anterior translation (CAI: rho = -0.83, P < 0.001; Control: rho = -0.71, P < 0.001). Furthermore, ATFL elongation was significantly (CAI: rho = -0.82, P < 0.001; Control: rho = -0.78, P < 0.001) inversely correlated with CFL elongation. Discussion: Patients with CAI have significant changes in joint kinematics relative to the contralateral side. Throughout the stance phase of walking, ATFL increases in length during plantarflexion and talar anterior translation whereas the elongation trend of CFL was the opposite. This understanding can inform the development of targeted therapeutic exercises aimed at balancing ligament tension during different phases of gait. The interrelationship between two ligaments is that when one ligament shortens, the other lengthens. The occurrence of CAI didn't change this trend. Surgeons might consider positioning the ankle in a neutral sagittal plane to ensure optimal outcomes during ATFL and CFL repair.