Capsular Ligamentous Complex Research Articles

The Effect of Mechanical Properties of the Capsular-Connected Complex Acetabulum Pedis on Movements in the Two-Segment Foot Model in Normal Foot and Flatfoot

Summary. The flatfoot remains a poorly defined clinical entity.
 Objective: to study the movements that occur in the foot under a single-support load on a two-segment model of the normal foot and flatfoot under different mechanical properties of the capsular-ligamentous complex acetabulum pedis.
 Materials and Methods. A two-segment model of the foot was developed, which consisted of anatomical hindfoot and forefoot. The connection between them was represented by a complex consisting of lig. calcaneonaviculare and the tendon of m. tibialis posterior. A decrease in the mechanical strength of the complex was represented by three types of tendon tissue degeneration according to Z.S. Rosenberg et al.: 0% – the norm, 25% – type І, 50% – type ІІ, and 75% – type ІІІ. The 3D finite element model was created using real foot skeletons from 12 patients with acquired flatfoot, obtained from 3D reconstructions with CT. The model was loaded with a force of 750 N from the plateau of the tibia in the direction of the ground surface. The adequacy of the model was assessed by examining the dependence of the simulation results with the values of the talo-navicular uncovered angle of the same patients.
 Results. The mutual movement of the segments forming the foot model progressively increased with a decrease in the strength of the capsular-ligamentous complex from 4.18 mm in the norm to 8.36 mm in type III degenerative changes. The linear nature of the dependence of total displacements on the decrease in the mechanical strength of the capsular-ligamentous complex is confirmed by the assessment of the adequacy of the model.
 Conclusions. The decrease in the mechanical strength of the capsular-ligamentous complex acetabulum pedis under a single-bearing load causes the mutual movement of segments of the model twice as large compared to the norm; the calculated dependence of movement/decrease in strength is linear.

Optimisation of the ankle sprain recovery process for junior footballers by computerised dynamometers

Abstract. A sprained ankle is one of the most common joint injuries. This traumatic and painful injury is caused by abnormal stress on the capsular ligament complex and occurs secondary to a movement that forces it to stretch beyond its normal range without losing permanent contact between the joint surfaces. In the United States, the incidence of ankle sprain in the general population (between 2002 and 2006) was 2.15 per 1000 person-years, the highest rates being associated with the age of 10 to 19 years. For people aged 15-24, the incidence was considerably higher in men compared to women, while for those over 30, the incidence was higher in women than men. Epidemiological statistics showed that almost half of all ankle sprains occurred during athletic activities. The motivation for choosing this topic is to highlight the benefits of using the Biodex System 4 Pro in the recovery program for junior footballers with grade II ankle sprains. The assessment made by this device provides information on joint mobility and muscle strength; therefore, the programs used in the recovery process can be performed without putting pressure on the joint and within the range and speed parameters set by the physiotherapist (especially passive, isotonic, isometric and isokinetic ones in the eccentric or concentric mode). The study has shown that Biodex is very helpful in the recovery process because it offers the possibility to work in the isokinetic mode, which reduces the functional recovery period and ensures the return to sport in a minimum time.

Optimisation of the ankle sprain recovery process for junior footballers by computerised dynamometers

A sprained ankle is one of the most common joint injuries. This traumatic and painful injury is caused by abnormal stress on the capsular ligament complex and occurs secondary to a movement that forces it to stretch beyond its normal range without losing permanent contact between the joint surfaces. In the United States, the incidence of ankle sprain in the general population (between 2002 and 2006) was 2.15 per 1000 person-years, the highest rates being associated with the age of 10 to 19 years. For people aged 15-24, the incidence was considerably higher in men compared to women, while for those over 30, the incidence was higher in women than men. Epidemiological statistics showed that almost half of all ankle sprains occurred during athletic activities. The motivation for choosing this topic is to highlight the benefits of using the Biodex System 4 Pro in the recovery program for junior footballers with grade II ankle sprains. The assessment made by this device provides information on joint mobility and muscle strength; therefore, the programs used in the recovery process can be performed without putting pressure on the joint and within the range and speed parameters set by the physiotherapist (especially passive, isotonic, isometric and isokinetic ones in the eccentric or concentric mode). The study has shown that the Biodex System 4 Pro is very helpful in optimising the recovery process because it offers the possibility to work in the isokinetic mode, which reduces the functional recovery period and ensures the return to sport in a minimum time

Эндопротезирование голеностопного сустава

Abstract. Introduction Total ankle replacement is definitely a tough issue for both orthopedic surgeons treating patients with ankle pathology and engineers who develop optimal implant constructs. Extreme short-time kinetic loads, complex motion biomechanics, anatomic features of the ankle result in high demands for ankle joint implants. In general, there is a positive tendency in an annual increase of the number of total ankle replacements. Alongside, a significant lagging in performing this procedure and the tendency for ankle arthrodesis has been observed in Russia. Aim To review the literature data about development and current status of total ankle replacement. To evaluate the use of modern implants for distal tibia replacement. Material and methods The given literature review includes analysis of foreign and domestic publications focused on issues of treatment of osteoarthritis of the ankle joint and tumors of the distal tibia. The information was searched for using GoogleScholar, PubMed, eLIBRARY, PubMedCentral in the Russian and English languages with the following keywords: total ankle replacement, ankle arthrodesis, ankle osteoarthritis, distal tibia replacement. Discussion Currently, there are controversies in selection of biomaterials and constructive parameters for ankle implants. Separately, there is an unsolved issue of selecting the optimal friction pair for bearing surfaces, as well as of operative technique features, such as implant fixation, surgical approach, modeling and restoration of the capsular-ligamentous complex. Conclusion Total ankle replacement is an effective alternative procedure to ankle arthrodesis and limb-sacrificing operations. To improve treatment results, optimal implant construction, fixation methods, selecting appropriate friction pair and capsular-ligamentous complex restoration should be further investigated in complex studies.

Новые подходы к лечению детей с посттравматическими контрактурами локтевого сустава

Abstract. Introduction Post-traumatic elbow contracture is a severe disabling condition of childhood that interferes with both physical and psychic aspects for the child. A high rate of poor results encourages surgeons seek for better surgical treatments. Current diagnostic modalities were practical to get the clinical picture of the contracture mechanogenesis and determine the treatment strategy. The goal of the study was to review long-term results of new surgical techniques developed for post-traumatic elbow contractures in children. Material and methods The inpatient records of 102 pediatric patients with post-traumatic elbow contractures operated on with the technique offered were reviewed. All patients underwent conventional radiological, ultrasound and MSCT examinations. Results Based on the pathobiomechanics of the injured elbow a mobilization technique was developed to ensure complete bone realignment, relieve pain and allow early exercises for the joint. Postoperative lavage of the joint cavity, intra-articular administration of corticosteroids and polyvalent enzymes in the early postoperative period facilitated improved long-term outcomes of elbow contractures. All patients reported good results. Discussion Tenotomies of the lateral ligaments can be added to arthrotomy and reconstruction of articular surfaces for temporary instability of the joint to restore movement in the elbow joint in severe cases. Post-traumatic elbow contractures are accompanied by impaired biomechanics. MSCT and 3D reconstruction of bone structures is the gold standard in the diagnosis of post-traumatic elbow contractures. Conclusion Bone impingements are to be addressed and an extended mobilization of the capsular ligamentous complex be provided for complete movement recovery through partial elbow instability to be temporarily ensured. Prolonged lavage of the elbow joint can be used to prevent adhesions and allow early elbow exercises and provide improved outcomes.

High Valging Tibial Osteotomy in the Complex Treatment of Anterior Cruciate ligament Ruptures in Patients With Varus Gonarthrosis of the Knee

MATERIALS AND METHODS. We observed 164 patients from 2013 to 2019 (mean age 39.8 ± 5.1 years) who underwent anatomical antegrade ACLR ВТВ autograft . Group 1 (43 people, 31.1%) and Group 2 (48 patients, 29.3%) included patients with isolated medial GA of 2-3 degree and/or varus deformity of at least 5º. Group 3 (73 people or 44.5%) included patients with normal articular cartilage and the correct axis of the limb. In Group 1, ACLR was supplemented with an “open wedge” HVTO. The assessment was carried out according to Lysholm Knee Scoring Scale, 2000 IKDC, KOOS.RESULTS. The simultaneous performance of HVTO and ACLR shows good clinical and radiological results in 93% in the first year, and three years after surgery keeps it in 88.4%. The results of treatment of patients of Group 1 turned out to be significantly better in comparison with Group 2 (p<0.01). In Group 1, the anteroposterior and rotational hypermobility of the knee joint was 16.3%, less commonly we observed pain, synovitis, atrophy of the muscles of the thigh and contracture (p <0.01), some dysfunctions (C according 2000 IKDC scale) were determined in 11.6% (p<0.05), and significant impairment of the knee joint function (D according to 2000 IKDC scale) were not observed (p<0.001). In the first 5 years after surgery, a much larger number of patients of the 1st group were able to fully return to their work, domestic and sports activities, compared with Group 2 (p<0.05).CONCLUSION. The combined ACLR and HVTO allow reliable technology in the treatment of anterior instability in patients with GA (p< 0.05%). This approach is effective in young active middle-aged patients, with anterior instability of the knee joint and varus GA or prerequisites for its development, as well as with revision ACLR, posterior tibial plateau tilt of more than 12º. Performing HVTO simultaneously with ACLR is not practical for patients with valgus deviation of the lower leg, failure of the posterolateral capsular ligamentous complex, or changes in the external joint.

The effects of soft tissue lateral release on the stability of the ligament complex of the knee

PurposeValgus deformity presents a particular challenge in total knee arthroplasty. This condition regularly leads to contractures of the lateral capsular ligament complex and to overstretching of the medial ligamentous complex. Reconstruction of the knee joint kinematics and anatomy often requires lateral release. However, data on how such release weakens the stability of the knee are missing in the literature. This study investigated the effects of sequential lateral release on the collateral stability of the ligament complex of the knee in vitro.MethodsTen knee prostheses were implanted in 10 healthy cadaveric knee joints using a navigation device. Soft tissue lateral release consisted of five release steps, and stiffness and stability were determined at 0, 30, 60 and 90° flexion after each step.ResultsSoft tissue lateral release increasingly weakened the ligament complex of the lateral compartment. Because of the large muscular parts, the release of the iliotibial band and the M. popliteus had little effect on the stability of the lateral and medial compartment, but release of the lateral ligament significantly decreased the stability in the lateral compartment over the entire range of motion. Stability in the medial compartment was hardly affected. Conversely, further release of the posterolateral capsule and the posterior cruciate ligament led to the loss of stability in the lateral compartment only in deep flexion, whereas stability decreased significantly in the medial compartment.ConclusionOur study shows for the first time the association between sequential lateral release and stability of the ligamentous complex of the knee. To maintain the stability, knee surgeons should avoid releasing the entire lateral collateral ligament, which would significantly decrease stability in the lateral compartment.

PO 18238 - Floating metatarsal associated with comminuted calcaneocuboid joint fracture and turf toe

Introduction: The term “floating metatarsal” refers to a rare injury pattern characterized by metatarsal dislocation in both the Lisfranc and metatarsophalangeal joints. The term “turf toe” refers to the rupture of the plantar capsular-ligamentous complex of the first metatarsophalangeal joint. Objective: To report a rare case of floating metatarsal associated with turf toe and comminuted calcaneocuboid joint fracture causing a midfoot abduction deformity. Method: To report the case of a patient who suffered a motorcycle accident and progressed with this rare combination of associated injuries. Results: The patient underwent surgical cleaning, reconstruction of the plantar capsular-ligamentous injury and reduction with Kirschner wire fixation of the first metatarsal and calcaneal fracture, with a local graft for lateral column and calcaneocuboid joint lengthening. The patient progressed well in the 18-month follow-up; fracture union and good joint stability with a slight limitation in range of motion were achieved. Discussion: Floating metatarsal is an injury poorly described in the literature, and its association with turf toe is due to trauma with metatarsophalangeal hyperextension. The patient may postoperatively develop postraumatically acquired hallux rigidus and hallux valgus. Conclusion: The identification of these injuries and a good clinical evaluation are crucial for adequate treatment and the prevention of possible complications.

Research progress of surgical treatment for anterior shoulder dislocation and combined injuries

To summarize the research progress of surgical treatment for anterior shoulder dislocation and combined injuries. The related literature was reviewed, and the surgical treatment options for the anterior shoulder dislocation and its combined injuries were summarized. Anterior shoulder dislocation can combine with anteroinferior capsular ligament complex injury (Bankart injury), bony Bankart defect, and Hill-Sachs lesion. For Bankart and bony Bankart injuries, arthroscopic repair or coracoid osteotomy combined with bony graft reconstruction can be performed. For Hill-Sachs lesion, conservative treatment, soft tissue repair, or bony reconstruction should be selected based on the extent of the bone defect. For bipolar injury, the Bankart repair, Remplissage, or arthroplasty should be selected based on the extent of the glenoid defect. With the development of arthroscopy and the improvement of the surgical concept, there is a complete set of surgical options for various injuries of the anterior shoulder dislocation. When choosing a surgical procedure, the patient's specific injury and age, exercise level, and other relating factors should be comprehensively assessed in order to achieve the best results.

Weakening of the knee ligament complex due to sequential medial release in total knee arthroplasty.

The purpose of this study was to investigate the effects of sequential medial release on the stiffness and collateral stability of the ligament complex of the knee. Irrespective of the implantation technique used, varus deformity frequently requires release of the capsular ligament complex. Yet, no data are available on how stiffness and stability of the knee ligament complex are weakened by such release. After total knee arthroplasty, ten healthy Thiel-fixed knee joints were subjected to sequential medial release consisting of six release steps. After each step, stiffness and stability were determined at 0°, 30°, 60°, and 90°. Sequential medial release increasingly weakened the ligament complex. In extension, release of the anteromedial tibial sleeve 4cm below the joint line already weakened the ligament complex by approximately 13%. Release 6cm below the joint line reduced stiffness and stability by 15-20% over the entire range of motion. After detachment of the medial collateral ligament, stability was only about 60% of its initial value. Our study showed for the first time the association between medial release and stiffness and stability of the knee ligament complex. To maintain stability, vigorous detachment of the knee ligament complex should be avoided. Release of the anteromedial tibial sleeve already initiates loss of stability. The main stabiliser is the medial ligament, which should never be completely detached. IV.

A simple method for determining ligament stiffness during total knee arthroplasty in vivo

A key requirement in both native knee joints and total knee arthroplasty is a stable capsular ligament complex. However, knee stability is highly individual and ranges from clinically loose to tight. So far, hardly any in vivo data on the intrinsic mechanical of the knee are available. This study investigated if stiffness of the native ligament complex may be determined in vivo using a standard knee balancer. Measurements were obtained with a commercially available knee balancer, which was initially calibrated in vitro. 5 patients underwent reconstruction of the force-displacement curves of the ligament complex. Stiffness of the medial and lateral compartments were calculated to measure the stability of the capsular ligament complex. All force-displacement curves consisted of a non-linear section at the beginning and of a linear section from about 80 N onwards. The medial compartment showed values of 28.4 ± 1.2 N/mm for minimum stiffness and of 39.9 ± 1.1 N/mm for maximum stiffness; the respective values for the lateral compartment were 19.9 ± 0.9 N/mm and 46.6 ± 0.8 N/mm. A commercially available knee balancer may be calibrated for measuring stiffness of knee ligament complex in vivo, which may contribute to a better understanding of the intrinsic mechanical behaviour of knee joints.

The Posterior Capsular Ligamentous Complex Contributes to Hip Joint Stability in Distraction

BackgroundLaxity of soft tissues after total hip arthroplasty is considered to be a cause of accelerated wear of bearing surfaces and dislocation. The purpose of this study is to assess the contribution of the anterior and posterior capsular ligamentous complexes and the short external rotators, except the quadratus femoris, on the stability of the hip against axial traction. MethodsThe study subjects comprised 7 fresh cadavers with 12 normal hip joints. In 6 hips, soft tissues surrounding the hip joint were resected in the following order to simulate the anterior approach: anterior capsule, posterior capsule, piriformis, conjoined tendon, and external obturator. In the remaining 6 hips, soft tissues were resected in the following order to simulate the posterior approach: piriformis, conjoined tendon, external obturator, posterior capsule, and anterior capsule. Soft tissue tension was measured by applying traction amounting to 250 N with joints in the neutral position. ResultsThe separation distance between the femoral head and acetabulum during axial leg traction significantly increased from 4.0 to 14.5 mm on average after circumferential resection of the capsule via the anterior approach. Subsequent resection of the short external rotators increased the separation distance up to 19.0 mm, but the differences did not reach statistical significance. Resection of the short external rotators via the posterior approach did not significantly increase the separation distance; it significantly increased from 6.0 to 11.4 mm after the resection of the anterior capsule and further to 20.5 mm after the resection of the posterior capsule. ConclusionThe posterior capsule, in addition to the anterior capsule, significantly contributes to hip joint stability in distraction regardless of whether the short external rotators, except the quadratus femoris, were preserved or resected.

Management of Athletic Turf Toe Using Biologics

Turf toe is a common injury in a variety of different athletes, especially those involved in contact sports played on rigid surfaces. It is caused by a hyperextension injury to the hallux metatarsophalangeal joint resulting in attenuation or tearing of the plantar capsular ligamentous complex. Treatment generally consists of nonoperative measures such as rest, ice, nonsteroidal anti-inflammatory drugs, taping, a stiff-sole shoe, walking boot, or casting. There has been a recent increase in the use of biologics, such as platelet-rich plasma and autologous conditioned plasma for the treatment of a variety of orthopaedic conditions. This study reports on 2 cases of turf toe treated with a combination of Toradol and autologous conditioned plasma. These case presentations are followed by a literature review on the use of biologics in the treatment of sports injuries.

Results of restoration of complex injuries in ligamentous apparatus of the knee joint

Injuries of multiple ligaments of the knee joint usually occur as a result of high energy trauma. The greatest difficulties one has in choice of tactics in treatment of patients with combined injuries of capsular and ligamentous apparatus of the knee joint. Objective : To determine the most appropriate treatment strategy for patients with complex injuries of the ligaments of the knee joint. Methods : We studied 37 patients (31 men, and 6 women aged 24 to 44 years) with two or more ligaments injuries of the knee joint of varying severity as a result of sport (12) and road traffic (25) injuries. We discovered combined injuries of ligaments: anterior crucial ligament (ACL) and medial collateral — 12; posterior crucial ligament (PCL) and medial collateral — 3; ACL, PCL and both collateral — 15; PCL and lateral collateral — 7. All patients were treated surgically. The outcomes were evaluated in 4 and 6 months after the operation according to scale IKDC and MRI parameters. Results : The most severe injuries are luxations of the shin accompanied by injuries of two crucial ligaments and one or two collateral ligaments. In this case restorative surgical treatment of all damaged structures can be made in the first day after trauma. But due to technical difficulties conservative waiting tactics with staged restoration of ligaments is justified. In the case of fresh or inveterate injury of ACL and PCL it is possible to perform their simultaneous and staged recovery when firstly they restore PCL, and after 3–4 months — ACL. The best results of PCL reconstruction are obtained in case surgical treat­ment immediately after the injury. Along with the reconstruction of PCL it is necessary to restore posterolateral capsular-ligamentous complex. The combined damages of the medial collateral ligament and one of the crucial ligaments rarely need to restore medial capsular-ligamentous structures. Under condition of restoration of fresh ACL injury almost always they eliminate instability caused by medial collateral ligament injury. In another case after fresh injury it is necessary to perform suturing of disruption place and after inveterate — plasthy of medial part of the knee joint.

Behavior of the anterolateral structures of the knee during internal rotation

IntroductionSince the recent descriptions of the anterolateral ligament (ALL), the role played by the anterolateral peripheral structures in the rotational control of the knee is again being debated. The objective of this study was to identify the structures during internal tibial rotation and then to define their anatomical characteristics. We hypothesized that internal rotation would tighten several anatomical formations, both superficial and deep, with the ALL one part of these structures. Material and methodsNine fresh-frozen cadaver knee specimens were studied. The anterolateral structures tightened were identified from superficial to deep at 30° of flexion. Each was selectively dissected, identifying its insertions and orientations, and measuring its size. The length variations of the ALL during internal tibial rotation were measured by applying a 30-N force using a dynamometric torque wrench at the tibiofibular mortise. ResultsThe superficial structures tightened were the iliotibial tract and the Kaplan fibers. In internal tibial rotation, the Kaplan fibers held the iliotibial tract against the lateral epicondyle, allowing it to play the role of a stabilizing ligament. The Kaplan fibers were 73.11±19.09mm long (range, 63–82mm) and at their femoral insertion they were 12.1±1.61mm wide (range, 10–15mm). The deep structures tightened covered a triangular area including the ALL and the anterolateral capsule. The ALL was 39.11±3.4mm long (range, 35–46mm) in neutral rotation and 49.88±5.3mm long (range, 42–58mm) in internal rotation (p<0.005). Its femoral insertion area was narrow at 5.27±1.06mm (range, 3.5–7mm) and was mainly proximal and posterior at the lateral epicondyle. Its tibial insertion zone was wide, with a clearly differentiated anterior limit but a posterior limit confused with the joint capsule. In the vertical plane, this insertion was located 6.44±2.37mm (range, 2–9) below the joint space. DiscussionThis study demonstrates two distinct anterolateral tissue planes tightened during internal rotation of the tibia: a superficial plane represented by the iliotibial tract and the Kaplan fibers, which acts as a ligament structure, and a deep plane represented by a triangular capsular ligament complex within which the ALL and the anterolateral capsule are recruited. Level of evidenceDescriptive cadaver study IV.

Diagnostic value of US, MR and MR arthrography in shoulder instability

IntroductionThe aim of our study was to compare US, conventional MRI and MR arthrography findings in patients with anterior shoulder instability and with a clinical diagnosis of labral capsular ligamentous complex lesion. At the same time we evaluated the accuracy of MR arthrography in the diagnosis of this lesion. MethodsAfter approval of the local Ethics Committee, our department's Trauma Registry from July 2008 up to February 2012 was retrospectively reviewed to identify all eligible patients. Eligibility criteria included: 1)history of acute or chronic shoulder instability (more than three dislocations over a period of more than two months); 2) diagnosis of labroligamentous lesion.All patients were investigated with plain radiographs, Ultrasound Scans (US), Magnetic Resonance Imaging (MRI) and MR arthrography. Finally, all patients underwent an arthroscopy that confirmed the diagnosis. ResultsA total of 200 consecutive patients who met the inclusion criteria were included in this study. The mean age was 39 years (range 15 to 83); 147 were male and 133 involved the right shoulder. Chronic instability was documented in 133 patients, whereas acute instability was documented in 67 patients. We detected a statistically significant difference between US and MR arthrography in SLAP (Superior Labrum Anterior to Posterior) lesions (TypeII, III and IV), in Bankart lesions, in glenohumeral ligament lesions (superior, middle, anterior-inferior and anterior inferior glenohumeral ligament) in Hill-Sachs lesions, in diagnosing internal subacromial impingement and in normal findings. MR arthrography was superior to the US.A statistically significant difference was evident between MRI and MR arthrography findings in SLAP lesions (III and IV Type lesions), in glenohumeral ligament lesions (anterior inferior and posterior inferior glenohumeral ligament), in partial rotator cuff ruptures and in normal findings. MR arthrography diagnosed this lesion better than MRI without contrast.We also found a statistically significant difference between US and MRI findings in SLAP Type II lesions, in partial rotator cuff ruptures, in Hill-Sachs lesions and in diagnosing internal subacromial impingement. ConclusionThe US scan is a valuable diagnostic technique for rotator cuff complete or incomplete ruptures. For evaluating Hill-Sachs lesions or bony Bankart lesions, MRI is more accurate. In the case of labral capsular ligamentous complex lesions, MR arthrography is superior.

The Latarjet Procedure for Recurrent Anterior Shoulder Instability: Rationale and Technique

The Latarjet coracoid transfer procedure provides a triple blocking effect in the treatment of anterior shoulder instability. First, the coracoid bone block increases the anterior posterior diameter of the inferior portion of the glenoid fossa, making it more difficult for the humeral head to subluxate or dislocate. Second, the conjoined tendon acts as a sling reinforcing the inferior capsular ligamentous complex and the inferior portion of the subscapularis. Finally, repair of the inferior capsular ligamentous complex to the stump of the coracoacromial ligament reconstructs the capsulolabral anatomy. We describe our preferred technique for this procedure. With proper patient selection and systematic surgical technique, instability can be eliminated without loss of external rotation in more than 98% of cases.

Neurophysiological analysis of the functional state of neuromotor apparatus in the children with cerebral palsy during treatment with Botulotoxin-A

Background A number of key clinical manifestations of infantile cerebral paralysis significantly affecting the diseases outcome can be specified. First of all, this is the time of formation of static locomotor habits reflecting “maturation” of antigravitation functional system that should be mentioned. Then the spasticity follows, significantly limiting development of voluntary motility, decreasing not only the patients’ locomotor capacity but also their vital activity and resulting in transformation of reflex contractures into the non-reflex ones, due to secondary fibro-trophic changes in muscles and capsular ligamentous complex. Spasticity triggers development of contractures. Pareses and palsies in ICP patients are less pronounced than the muscular tonicity pathology. These are contractures that serve as a leading mechanism limiting further evolution of motor sphere and significantly reducing quality of life in this category of patients (Bronnikov and Kravtsov, 2007). Though not an end in itself, muscular hypertonicity reduction in patients with spastic ICP forms is important since elimination and considerable reduction of its effect as a key factor of development of contractures would allow achieving functional improvement in the patients (Kojevnikova, 2005; Doris Valencia Valencia, 2009). Despite sufficient number of methods for the muscular tonicity reduction in ICP, they all have disadvantages, side and adverse effects and contraindications. Most modalities require prolonged management, the effect being short. Search for novel, more efficient non-invasive methods for the muscular tonicity correction with long-lasting effect, minimum side effects and contraindications is under way. In this respect local injections of botulotoxin-A seem attractive (Carla Rito et al., 2009; Doris Valencia Vlencia, 2009; Isolda Ferreira de Arajio et al., 2009). Our experience in the field, high efficiency and, ultimately, good promises of the method for rehabilitation and subsequent social adaptation of the incapacitated children were among the motives to study the aspect in detail and more profoundly. The work was initiated to study effect of botulotoxin-A injections on parameters of neuromotor apparatus’s functional condition in patients with ICP spastic forms by means of global and stimulation electromyography. Materials and methods

Turf Toe

Context:Despite an increasing awareness of turf toe injury, confusion still exists regarding the anatomy, mechanism, diagnosis, and treatment of this hyperextension injury to the hallux metatarsophalangeal (MTP) joint.Evidence Acquisition:This article reviews the anatomy, diagnosis, and treatment algorithm for turf toe injury by reviewing relevant studies and presenting information useful to clinicians, therapists, and athletic trainers. A literature search was performed by a review of PubMed and OVID articles published from 1976 to July 2010.Results:Grade I injury is a sprain or attenuation of the plantar capsular ligamentous complex of the hallux MTP joint; athletes are typically able to return to play as tolerated. Grade II injury is a partial rupture of the plantar soft tissue structures of the hallux MTP joint, typically requiring about 2 weeks to recover. Grade III injury is a complete rupture of the plantar structures of the hallux MTP joint, requiring at least 10 to 16 weeks to recover. Some complete ruptures require surgical repair.Conclusion:With accurate diagnosis, athletes can have an appropriate treatment plan, and their expectations can be tempered to the degree of injury. Careful management may allow successful return to play at a preinjury level of participation.

Chronic lateral ankle instability surgical repairs: The long term prospective

The present study sought to assess the clinical and radiological results and long-term joint impact of different techniques of lateral ankle ligament reconstruction. A multicenter retrospective review was performed on 310 lateral ankle ligament reconstructions, with a mean 13-year-follow-up (minimum FU: 5 years). Male subjects (53%) and sports trauma (78%) predominated. Mean duration of instability was 92 months; mean age at surgery was 28 years. Twenty-eight percent of cases showed subtalar joint involvement. Four classes of surgical technique were distinguished: C1, direct capsular ligamentous complex reattachment; C2, augmented repair; C3, ligamentoplasty using part of the peroneus brevis tendon and C4, ligamentoplasty using the whole peroneus brevis tendon. Clinical and functional assessment used Karlsson and Good-Jones-Livingstone scores; radiologic assessment combined centered AP and lateral views, hindfoot weight-bearing Méary views and dynamic views (manual technique, Telos or self-imposed varus). The majority of results (92%) were satisfactory. The mean Karlsson score of 90 [19-100] (i.e., 87% good and very good results) correlated with the subjective assessment, and did not evolve over time. Postoperative complications (20%), particularly when neurologic, were associated with poorer results. Control X-ray confirmed the very minor progression in degenerative changes, with improved stability; there was, however, no correlation between functional result and residual laxity on X-ray. Unstable and painful ankles showed poorer clinical results and more secondary osteoarthritis. Analysis by class of technique found poorer results in C4-type plasties and poorer control of laxity on X-ray in C1-type tension restoration. The present results confirm the interest of lateral ankle ligamentoplasty in the management of instability and protection against secondary osteoarthritis, and of precise lesion assessment (CT-scan/MRI) to adapt surgery to the ligamentary and associated lesions. Level IV. Retrospective therapeutic study.