Collateral Ligament Origin Research Articles

A Medial Approach That Provides Ample Exposure of the Coronoid for Fracture Management.

We describe a medial approach to the coronoid where the flexor-pronator mass is released from its humeral origin by creating a proximally based tendinous flap. This technique facilitates access to the coronoid, preservation of the medial collateral ligament origin, and repair of the flexor-pronator mass. This approach has utility for all coronoid fracture variations but especially the O'Driscoll anteromedial subtype 3, which includes fractures of the sublime tubercle, the anteromedial facet, and the coronoid tip.

A Landmark-Based Technique for Determining an Isometric Femoral Attachment Site for Lateral Extraarticular Tenodesis is Inaccurate

To evaluate the reliability and accuracy of a method of placing the femoral fixation location for lateral extra-articular tenodesis (LET) within a safe isometric area using anatomic landmarks. Using a pilot cadaveric specimen, the center of the radiographic safe isometric area for femoral fixation of LET, defined as a 1 cm (proximal-distal) area located proximal to the metaphyseal flare and posterior to the posterior cortical extension line (PCEL), was located using fluoroscopy and found to be 20 mm directly proximal to the center of the fibular collateral ligament (FCL) origin. Using 10 additional specimens, the center of the FCL origin and a location 20 mm directly proximal was identified. K-wires were placed at each location. A lateral radiograph was obtained, and distances of the proximal K-wire relative to the PCEL and metaphyseal flare were measured. The location of the proximal K-wire relative to the radiographic safe isometric area was assessed by 2 independent observers. Intrarater and inter-rater reliability was calculated for all measurements using intraclass coefficients (ICCs). There was excellent intrarater and inter-rater reliability for all radiographic measurements (.908 to .975 and .968 to .988, respectively). In 5/10 specimens, the proximal K-wire was outside of the radiographic safe isometric area, with 4/5 anterior to the PCEL. Overall, the mean distance from the PCEL was 1 mm ± 4 mm (anterior), and the mean distance from the metaphyseal flare was 7.4 mm ± 2.9 mm (proximal). A landmark-based technique referencing the FCL origin was inaccurate in the placement of femoral fixation within a radiographic safe isometric area for LET. Therefore intraoperative imaging should be considered to ensure accurate placement. These findings may help to decrease the likelihood of misplacement of femoral fixation during LET by showing that landmark-based methods without intraoperative image guidance may be unreliable.

Paediatric reference anatomy for ACL reconstruction and secondary anterolateral ligament or lateral extra-articular tenodesis procedures

ObjectivesFor iliotibial band (ITB) lateral extra-articular tenodesis or anterolateral ligamentous/capsular reconstruction with anterior cruciate ligament reconstruction, a clear understanding of the referenced anterolateral knee anatomy is critical—especially given the risk of injury to the physis or key anterolateral structures in the paediatric population, which is at high-risk for primary and secondary anterior cruciate ligament injury. The purpose of this study was to quantitatively assess the anatomy of the knee physes, paediatric lateral collateral ligament (LCL) origin, popliteus origin and ITB tibial insertion. MethodsNine paediatric cadaveric knee specimens with average age 4.2 years (range 2 months–10 years) underwent dissection to identify the LCL's and popliteus’ femoral origins and the ITB's tibial insertion. Metallic marking pins demarcated precise anatomic attachment sites, and subsequent computerised tomography scans enabled quantified measurements among them. ResultsLCL & Popliteus: On the femur, the popliteus origin lay consistently deep to the LCL and inserted both distally and anteriorly to the LCL, a mean distance of 4.6 mm (range 1.9–7.6; standard deviation 2.0). From the joint line, the LCL lay a mean distance of 12.5 mm proximally while the popliteus measured a mean of 8.2 mm. Both were consistently distal to the physis. The LCL was a mean distance of 4.4 mm (range 1.0–9.5) and the popliteus was a mean distance of 8.2 (range 1.7–12.5) from the physis. ITB insertion: The ITB insertion at Gerdy's tubercle had an average footprint measuring 28.2 mm2 (range 10.3–58.4) and the ITB centre lay proximal to the physis in 6 specimens (mean age 4.2 years, median 2.5 years) and distal in 3 specimens (mean age 1.5 years, median 4 months). Mean distance from the footprint centre to the physis was 1.6 mm proximal (range 7.1 proximal – 2.2 distal). ConclusionThis study describes relative and quantitative positions of the femoral LCL and popliteus origins and tibial ITB attachment and their respective physeal relationships. Knowledge of paediatric anterolateral knee anatomy will help guide essential future research and procedures providing extra-articular anterolateral rotatory stabilisation and may help reduce iatrogenic physeal injury risk. Level of evidenceN/A (descriptive anatomic study).

PEDIATRIC REFERENCE ANATOMY FOR ANTEROLATERAL LIGAMENT RECONSTRUCTION– A CADAVERIC STUDY

Background:The anatomy of the anterolateral ligament (ALL) has been controversial, with modern studies varying in their description of the precise origin and insertion, as well as relation to surrounding structures on the lateral femur and anterolateral tibia Regardless of such controversy, principles of reconstruction, even non-anatomic, require a clear understanding of the referenced anatomy and surrounding structures. Due to high rates of primary and recurrent ACL tears in pediatric/adolescent patients, the use of ALL reconstruction is increasing in these groups. No pediatric cadaveric study to date has clearly identified the locations of the known surrounding structures of the anterolateral ligamentous complex.Purpose:The purpose of this study was to quantitatively assess the anatomy of the pediatric lateral collateral ligament (LCL) origin, the popliteus origin, and in the tibial insertion of the iliotibioband (ITB).Methods:Nine pediatric cadaveric knee specimens were dissected to identify the ligamentous femoral origin of the LCL, popliteus, and tibial insertion of the ITB.. Marking pins were used to localize the central footprint of these structures, followed by CT Scans.Results: LCL & Popliteus: On the femur, the popliteus was consistently found deep to the LCL and inserted both distally and anteriorly to the LCL a mean distance of 4.6 mm (range 1.9 to 7.6 mm; std dev 2.0). The LCL measured a mean of 12.5 mm to the joint line while the popliteus measured a mean of 8.2 mm from the joint line. Both the LCL and popliteus were consistently distal to the physis. The LCL was a mean distance of 4.4 mm (range 1.0 - 9.5 ) and the popliteus was a mean distance of 8.2 (range 1.7 – 12.5), respectively. ITB insertion: The ITB insertion at Gerdy’s tubercle had an average footprint measuring 28.2 mm2 (range 10.3-58.4), and the ITB center was found proximal to the physis in 6 specimens and distal in 3 specimens. Mean distance from the footprint center to the physis was 1.6 mm proximal (range 7.1 mm proximal to 2.2 mm distal).Conclusion:This study provides quantitative anatomy to structures on the lateral femur and anterolateral tibia, commonly referenced in descriptions of the ALL and lateral extraarticular reconstruction techniques. Knowledge of these structures will define the anterolateral complex and guide extra-articular procedures that provide extraarticular anterolateral rotatory stabilization in the pediatric patients.Figure 1.CT specimen with markers indicating the femoral origin of the LCL and popliteus. Relation to the physis and cartilaginous articular surface are clearly identified.Figure 2.3D CT rendering, recreating an effective true lateral radiograph of the knee. Red dots on markers identify point of penetration into the lateral cortex of the distal femur.

Role of the anconeus in the stability of a lateral ligament and common extensor origin–deficient elbow: an in vitro biomechanical study

The role of the anconeus in elbow stability has been a long-standing debate. Anatomic and electromyographic studies have suggested a potential role as a stabilizer. However, to our knowledge, no clinical or biomechanical studies have investigated its role in improving the stability of a combined lateral collateral ligament and common extensor origin (LCL + CEO)-deficient elbow. Seven cadaveric upper extremities were mounted in an elbow motion simulator in the varus position. An injured model was created by sectioning of the CEO and the LCL. The anconeus tendon and its aponeurosis were sutured in a Krackow fashion and tensioned to 10 N and 20 N using a transosseous tunnel. Varus-valgus angles and ulnohumeral rotations were recorded using an electromagnetic tracking system during simulated active elbow flexion with the forearm pronated and supinated. During active motion, the injured model resulted in a significant increase in varus angulation (P = .0001 for pronation; P = .001 for supination) and external rotation (P = .001 for pronation; P = .003 for supination) of the ulnohumeral articulation compared with the intact state. Tensioning of the anconeus significantly decreased the varus angulation (P = .006 for 10 N pronation; P = .0001 for 20 N pronation; P = .0001 for 10 N supination; P = .0001 for 20 N supination) and external rotation angle (P = .008 for 10 N pronation; P = .0001 for 20 N pronation; P = .0001 for 10 N supination; P = .0001 for 20 N supination) of the injured elbow. In the highly unstable varus elbow orientation, anconeus tensioning restores the in vitro stability of a combined LCL + CEO-deficient elbow during simulated active motion with the forearm in both pronation and supination. These results may have several clinical implications in managing symptomatic lateral elbow instability.

The naked capitellum: a surgeon's guide to intraoperative identification of posterolateral rotatory instability

This study's purpose was to provide a reproducible way for surgeons to intraoperatively assess the elbow's lateral ulnar collateral ligament origin and determine whether there is posterolateral rotatory instability (PLRI) despite an intact common extensor origin (CEO). We hypothesized that we could re-create clinically relevant disruption of lateral supporting structures despite an intact CEO and illustrate progressive elbow PLRI. The relationship of the lateral capsule to the capitellum articular surface was noted in 8 cadaveric upper extremities. The lateral capsule and extensor origin were sequentially sectioned at 4 stages: intact, release to the lateral epicondyle, release of the posterior capsular insertion, and release of the CEO. Posterior and lateral translation of the radial head (RH) relative to the capitellum was measured with the forearm in extension and supination. The average specimen age was 78.9 years. The lateral capsule originated within 1 to 2 mm of the capitellum articular surface. Lateral capsular sectioning to the 6-o'clock position of the lateral epicondyle created an unstable elbow with posterior and lateral RH translation. Sequential sectioning of the posterior capsular insertion created significant additional RH translation posteriorly (P < .05). With release of the capsule and the extensor origin, the elbow was grossly unstable. The elbow's lateral capsuloligamentous complex plays an important role in preventing PLRI. Larger degrees of elbow laxity are associated with further peel back of the capsuloligamentous complex despite an intact CEO. The surgeon must retract the extensor origin intraoperatively to assess for lateral ulnar collateral ligament and/or lateral capsule disruption to prevent a missed case of PLRI.

The Use of Fluoroscopy Leads to Improved Identification of the Femoral Lateral Collateral Ligament Origin Site When Compared With Traditional Tactile Techniques

To determine whether a fluoroscopic technique can be used to improve the accuracy of the determination of the femoral origin of the lateral collateral ligament (LCL). A 1-cm incision was made over the lateral epicondyle in 13 fresh-frozen cadaveric knee specimens, and the LCL origin was determined first by palpation and then with a previously described fluoroscopic method. Both points for the LCL origin were marked with 2-mm Kirschner wires. The distances between the center of the anatomic LCL origin and the LCL origin points determined by palpation and fluoroscopic imaging were calculated. An independent t-test was used to compare the distances between the anatomic LCL origin center and the determined LCL origin points. The LCL origin points determined by fluoroscopic imaging were significantly (P= .005) closer to the anatomic center of the LCL origin point than the ones determined by palpation (3.2mm ± 1.6mm vs 5.0mm ± 1.6mm, respectively). A total of 92.7% fluoroscopically determined LCL origin points were within a 5mm radius surrounding the anatomic LCL origin point. In contrast, only 53.8% LCL origin points determined by palpation were within a 5mm radius surrounding the anatomic LCL origin point. The use of palpation to identify the LCL origin may not be an accurate method for performing an isometric and anatomic LCL reconstruction. The use of fluoroscopic imaging appears to be a feasible method for identifying the LCL origin in clinical practice and may increase the accuracy of LCL origin identification. Fluoroscopic guidance improves accuracy in determining the anatomic LCL origin, which may help avoiding tunnel malplacement during LCL reconstruction. CLINICALRELEVANCE: The use of a previously described radiographic method for identifying the LCL origin may be used to achieve a more anatomic LCL reconstruction.

All-Epiphyseal Anterior Cruciate Ligament Femoral Tunnel Drilling: Avoiding Injury to the Physis, Lateral Collateral Ligament, Anterolateral Ligament, and Popliteus—A 3-Dimensional Computed Tomography Study

To investigate the relation of the at-risk structures (distal femoral physis, lateral collateral ligament, anterolateral ligament, popliteus, and articular cartilage) during all-epiphyseal femoral tunnel drilling. A second purpose was 2-fold: (1) to develop recommendations for tunnel placement and orientation that anatomically reconstruct the anterior cruciate ligament (ACL) while minimizing the risk of injury to these at-risk structures, and (2) to allow for maximal tunnel length to increase the amount of graft in the socket to facilitate healing. Three-dimensional models of 6 skeletally immature knees (aged 7-11years) were reconstructed from computed tomography and used to simulate all-epiphyseal femoral tunnels. Tunnels began within the ACL footprint and were directed laterally or anterolaterally, with the goal of avoiding injury to at-risk structures. The spatial relation between the ideal tunnel and these structures was evaluated. Full-length tunnels and partial length condyle sockets were simulated in the models using the same trajectories. An anterolateral tunnel could be placed to avoid direct injury to lateral structures. The safe zone on the anterolateral aspect of the femur was larger than that of a tunnel with a direct lateral trajectory (median 127mm2 vs 83mm2, P= .028). Anterolateral tunnels were longer than direct lateral tunnels (median 30mm vs 24mm, P= .041). Safe angles for anterolateral tunnels were 34° to 40° from the posterior condylar axis; direct lateral tunnels were drilled 4° to 9° from the posterior condylar axis. Sockets could be placed without direct injury to structures at risk with either orientation. An all-epiphyseal ACL femoral tunnel can be placed without causing direct injury to at-risk structures. Atunnel angled anterolaterally from the ACL origin is longer and has a larger safe zone compared with the direct lateraltunnel. The largest safe zone for femoral all-epiphyseal ACL drilling was (1) anterior to the lateral collateral ligament origin, (2) distal to the femoral physis, and (3) proximal to the popliteus tendon origin. A direct lateral tunnel may also be used, but has a smaller safe zone. Sockets or partial length tunnels may have a lower risk of injury to at-risk structures.

Bare medial epicondyle physeal fracture of the humerus: A case report

We identified an unusual case of the medial epiondyle physeal fracture, which has been caused by a direct blow, accompanied with complete stripping of soft tissue. Surgery was performed for open reduction and internal fixation of the medial epicondyle and reattachment of the anterior oblique bundle of medial collateral ligament and flexor muscle origin. Six months after the surgery, strength of wrist flexion and forearm pronation, range of motion and valgus stability of the left elbow had recovered. One year after the injury, radiographs showed atrophy and sclerosis of the medial epicondylar apophysis. In this type of injury, revascularization of medial epicondyle fracture is not essential for recovery of elbow function when reattachment of the medial collateral ligament and flexor-pronator muscle origin to the distal medial humerus successfully restores stability of the elbow joint.

Anterolateral Ligament of the Knee Shows Variable Anatomy in Pediatric Specimens.

Anterior cruciate ligament (ACL) reconstruction failure rates are highest in youth athletes. The role of the anterolateral ligament in rotational knee stability is of increasing interest, and several centers are exploring combined ACL and anterolateral ligament reconstruction for these young patients. Literature on the anterolateral ligament of the knee is sparse in regard to the pediatric population. A single study on specimens younger than age 5 years demonstrated the presence of the anterolateral ligament in only one of eight specimens; therefore, much about the prevalence and anatomy of the anterolateral ligament in pediatric specimens remains unknown. We sought to (1) investigate the presence or absence of the anterolateral ligament in prepubescent anatomic specimens; (2) describe the anatomic relationship of the anterolateral ligament to the lateral collateral ligament; and (3) describe the anatomic relationship between the anterolateral ligament and the physis. Fourteen skeletally immature knee specimens (median age, 8 years; range, 7-11 years) were dissected (12 male, two female specimens). The posterolateral structures were identified in all specimens, including the lateral collateral ligament and popliteus tendon. The presence or absence of the anterolateral ligament was documented in each specimen, along with origin, insertion, and dimensions, when applicable. The relationship of the anterolateral ligament origin to the lateral collateral ligament origin was recorded. The anterolateral ligament was identified in nine of 14 specimens. The tibial attachment point was consistently located in the same region on the proximal tibia, between the fibular head and Gerdy's tubercle; however, the femoral origin of the anterolateral ligament showed considerable variation with respect to the lateral collateral ligament origin. The median femoral origin of the anterolateral ligament was 10 mm (first interquartile 6 mm, third interquartile 13) distal to the distal femoral physis, whereas its median insertion was 9 mm (first interquartile 5 mm, third interquartile 11 mm) proximal to the proximal tibial physis. The frequency of the anterolateral ligament in pediatric specimens we observed was much lower than other studies on adult specimens; future studies might further investigate the prevalence, development, and functional role of the anterolateral ligament of the knee. This study expands our understanding of the anterolateral ligament and provides important anatomic information to surgeons considering anterolateral ligament reconstruction concomitantly with primary or revision ACL reconstruction in pediatric athletes.

Ultrasonographic visualization and assessment of the anterolateral ligament.

Injury to the anterolateral ligament (ALL) of the knee has recently received attention as a potential risk factor for failure of anterior cruciate ligament reconstruction. However, evaluation of the anterolateral ligament is currently difficult, and radiologic data are sparse with regard to the normal appearance of this ligament. The purpose of the present study was to determine whether the ALL could be identified and visualized using ultrasonography. Ten non-paired, fresh-frozen cadaveric knees underwent ultrasound by an experienced musculoskeletal radiologist using a Siemens S2000 Acuson Ultrasound machine with a 14-MHz linear transducer. After first identifying anatomical landmarks by palpation, a thin band of tissue originating in the vicinity of the fibular collateral ligament (FCL) origin was identified and followed up distally. The tibia was held at 30° of flexion and internally rotated to verify tightening of the structure. Under ultrasound guidance, 25-gauge hypodermic needles were placed at what were sonographically determined to be the origin and insertion points of the ligament. One-tenth of a CC of aniline blue dye was injected. The specimens were then dissected to confirm the presence and location of the ALL. If an ALL was found, distances between the epicentre of the injected dye and the actual origin and insertion points were calculated. Additionally, ligament length based on dissection images and ultrasound images was calculated. Eight of ten specimens had an anterolateral structure that originated from the lateral femoral epicondyle just posterior and superior to the origin of the FCL and inserted on the lateral plateau approximately halfway between Gerdy's tubercle and the fibular head. The average length based on ultrasound was 3.8cm (±.7; range 3.1-4.7) and 4.1cm (±1.1; range 2.6-6.1) based on dissection. Length based on dissection and ultrasound had minimal agreement (ICC=.308; 95% confidence interval .257-.382, p=.265). The average width of the structure on dissection was .8cm (±.24; range .5-1.2). The mean distance from ultrasound-determined origin and insertion points to anatomical origin and insertion based on dissection was 10.9mm (±2.9, range 7.0-15.8) and 12.5mm (±5.7 range 3.2-19.3), respectively. Inter-observer reliability was excellent for all measurements based on dissection and ultrasound. Ultrasound was unable to reliably identify the anterolateral structure from its femoral to tibial attachment sites. Distinguishing it from the posterior IT band and anterolateral capsule was challenging, and it is possible that the structure is a thickened band of fascia rather than a true ligament. As a clinical diagnostic tool, ultrasound likely offers little utility in the evaluation of the ALL for injury. IV.

The Sagittal Plane Angle and Tunnel-Related Complications in Double-Bundle Anterior Cruciate Ligament Reconstruction Using the Transportal Technique: An In Vivo Imaging Study

To evaluate the relation between the tunnel angle in the 3 orthogonal planes, especially the sagittal plane, which can be influenced by knee flexion during drilling, and the incidence of complications from the transportal technique using in vivo imaging data. Fifty-one patients who underwent anatomic double-bundle anterior cruciate ligament reconstruction by the transportal technique were evaluated retrospectively. A 3-dimensional surface model was made using an axial computed tomography scan obtained after anterior cruciate ligament reconstruction. The tunnel length, posterior cortical damage, proximity between the outer orifice of the tunnel and lateral collateral ligament (LCL) origin, and medial femoral condyle cartilage damage were evaluated on a 3-dimensional computed tomography scan and 3-T magnetic resonance imaging. Correlations between those parameters and the tunnel angle in the coronal, axial, and sagittal planes were analyzed. A tunnel length of less than 30 mm developed in 4 cases (8%) in the anteromedial tunnel and in 1 case (2%) in the posterolateral (PL) tunnel. Posterior cortical damage developed in 12 cases (23%). A distance from the outer orifice of the tunnel to the LCL origin of less than 3 mm occurred in 18 cases (35.2%) in the PL tunnel. Medial femoral condyle cartilage damage was detected in 3 cases (6%). A positive correlation was observed between the sagittal angle and anteromedial tunnel length (P = .002, r = 0.547). The sagittal angle in the group with posterior cortical damage was lower than that in the group with no posterior cortical damage (P = .002). A negative correlation was observed between the distance from the outer orifice of the PL tunnel to the LCL origin and the sagittal angle (P = .002, r = -0.55). Drilling at a higher angle in the sagittal plane decreased the incidence of posterior cortical damage and a short anteromedial tunnel. However, drilling at a higher angle shortened the distance to the LCL origin for the PL tunnel. Level IV, therapeutic case series.

Double-loop locking cross-stitch suture and suspension fixation for medial collateral ligament origin reconstruction.

The purpose of this study was to summarize the clinical application and results of the double-loop locking cross-stitch suture and suspension fixation method for medial collateral ligament origin reconstruction. Thirty-six patients (21 males, 15 females) with an average age of 40 years (range = 17-58 years), who underwent treatment for acute fracture of the medial collateral ligament at our hospital from February 2008 to May 2009, were included in this study. All patients presented unilateral injuries (17 right-sided, 19 left-sided) and underwent repair with the double-loop locking cross-stitch suture and suspension fixation method. All incisions in this group of patients healed by first intention. Thirty-two patients were followed up for 6-20 months (average = 12 months). There were no reports of wound infection, ligament re-fracture or other complications in the follow-up period. Based on the Lysholm knee-scoring scale, the patients received a 100% excellent and good rating (20 patients - excellent score, 12 patients - good score) postoperatively. The advantages of the double-loop locking cross-stitch suture and suspension fixation method are a smaller incision, reliable fixation, and early restoration of knee joint stability. It is, therefore, an effective and low-risk method for the reconstruction of medial collateral ligament origin.

Medial Ulnar Collateral Ligament Origin in Children and Adolescents

The medial ulnar collateral ligament (MUCL) is the primary stabilizer against valgus stress on the elbow. The anatomy of the 3 bundles of the MUCL has been well studied in adults, but our review of the English literature found no study evaluating the origin of the MUCL in a large group of asymptomatic, skeletally immature elbows as it relates to the medial epicondylar physis. Magnetic resonance T1-coronal images of 44 skeletally immature elbows (ages 5 to 17 y) with no history of fracture were evaluated by 2 independent musculoskeletal radiologists, a board-certified orthopaedic surgeon with fellowship training in pediatric orthopaedics, and an orthopaedic surgery resident. The location of the origin of the anterior bundle of the MUCL (aMUCL) was identified and its distance from the medial epicondylar physis was measured. All 44 images showed that the aMUCL attached either on or medial to the medial epicondylar physis. The average distance from the origin of the aMUCL to the medial epicondylar physis was 3.1 mm. There was no statistically significant relationship between age and location of the aMUCL insertion relative to the physis (P=0.183). In the skeletally immature elbow, the aMUCL originates medial to the medial epicondylar physis. Although treatment of medial epicondylar humeral fractures remains controversial, understanding the relationship between the aMUCL and the medial epicondylar physis may be helpful in making decisions regarding fracture management.

Estudo anatômico do ligamento anterolateral do joelho

ObjectiveDescribe the knee anterolateral ligament (ALL) and establish its anatomical marks of origin and insertion. MethodsDissection of the anterolateral aspect of the knee was performed in six cadavers. After isolation of the ALL, its lenght, width and thickness were measured as its places of origin and insertion. The ALL origin was documented in relation to the lateral collateral ligament (LCL) origin and the insertion was documented in relation to the Gerdy tubercle, fibullar head and lateral meniscus. After the first two dissections, the ligament was removed and sent to histologycal analysis. ResultsThe ALL was clearly identified in all knees. Its origin in the lateral epycondile was on average 0.5mm distal and 2.5mm anterior to the LCL. In the tibia, two insertions were observed, one in the lateral meniscus and another in the proximal tibia, about 4.5mm distal to the articular cartilage, between the Gerdy tubercle and the fibullar head. The average measures obtained were: 35.1mm lenght, 6.8mm width and 2.6mm thickness. In the ligament histological analysis, dense connective tissue was observed. ConclusionThe ALL is a constant structure in the knee anterolateral region. Its origin is anterior and distal to the LCL origin. In the tibia, it has two insertions, one in the lateral meniscus and another in the proximal tibia between the Gerdy tubercle and the fibullar head.

Anatomical study on the anterolateral ligament of the knee

ObjectiveDescribe the knee anterolateral ligament (ALL) and establish its anatomical marks of origin and insertion. MethodsDissection of the anterolateral aspect of the knee was performed in six cadavers. After isolation of the ALL, its lenght, width and thickness were measured as its places of origin and insertion. The ALL origin was documented in relation to the lateral collateral ligament (LCL) origin and the insertion was documented in relation to the Gerdy tubercle, fibullar head and lateral meniscus. After the first two dissections, the ligament was removed and sent to histologycal analysis. ResultsThe ALL was clearly identified in all knees. Its origin in the lateral epycondile was on average 0.5mm distal and 2.5mm anterior to the LCL. In the tibia, two insertions were observed, one in the lateral meniscus and another in the proximal tibia, about 4.5mm distal to the articular cartilage, between the Gerdy tubercle and the fibullar head. The average measures obtained were: 35.1mm lenght, 6.8mm width and 2.6mm thickness. In the ligament histological analysis, dense connective tissue was observed. ConclusionThe ALL is a constant structure in the knee anterolateral region. Its origin is anterior and distal to the LCL origin. In the tibia, it has two insertions, one in the lateral meniscus and another in the proximal tibia between the Gerdy tubercle and the fibullar head.

Combined surgical treatment for missed rupture of triceps tendon associated with avulsion of the ulnar collateral ligament and flexor-pronator muscle mass

Triceps tendon ruptures are rare injuries. Coexistence of ipsilateral ulnar collateral ligament injury is even rarer. Here, we describe an unusual combination injury to elbow of a 39-year-old male construction worker consisting of triceps tendon rupture, avulsion of elbow ulnar collateral ligament and flexor pronator muscle origin ipsilaterally. A simultaneous repair and reconstruction of all damaged structures was proposed with individualized postoperative rehabilitation. Return to pre-injury level of activities obtained with this treatment protocol. High degree of suspicion and careful examination were needed to prevent missed diagnosis and prolonged instability which may be inevitable after inappropriate treatment of such injury.

Biomechanical Comparison of Medial Collateral Ligament Reconstructions Using Computer-Assisted Navigation

Background The medial collateral ligament is a broad ligament that functions as the primary stabilizer against valgus knee stress, particularly at 30° of flexion. Hypothesis A double-bundle reconstruction technique that better restores the native medial collateral ligament anatomy will restore valgus and external rotation stability to a medial collateral ligament–deficient knee. Study Design Controlled laboratory study. Methods Seven fresh-frozen cadaveric knees were studied. A surgical navigation system was used to determine valgus opening and external rotation at 0° and 30° with a 9.8-N·m valgus stress applied to the tibia graft isometry at multiple points on the tibia and femur. Intact and disrupted medial collateral ligament knees were used as controls. Four repair techniques were tested: Bosworth, modified Bosworth, anatomical single bundle, and anatomical double bundle. Results Complete sectioning of the medial collateral ligament resulted in an increase in valgus opening of 5° at 0° and 7.7° at 30°. External rotation increased 4.6° at 0° and 9.7° at 30°. Single-bundle techniques (Bosworth, anatomical single bundle) did not restore valgus laxity at 0° or 30°; the anatomical single bundle did not restore external rotation at 0°. Double-bundle techniques (modified Bosworth, anatomical double bundle) restored valgus laxity and external rotation to the native knee conditions at 0° and 30°. At 30°, the modified Bosworth was 0.3° tighter and the anatomical double bundle 0.2° tighter than was the intact knee. The center of the medial collateral ligament origin on the femur to the proximal insertion of the superficial medial collateral ligament resulted in the most isometric graft position. Conclusion Medial collateral ligament reconstruction configurations that use a double-bundle reconstruction better resist valgus and external rotations in response to valgus stress than do single-bundle techniques. Clinical Relevance Although the medial collateral ligament often heals without surgical intervention, surgical reconstruction is occasionally necessary in grade III medial collateral ligament and combined ligamentous injuries to the knee. Double-bundle reconstruction of the medial collateral ligament better resists valgus forces across the knee and may allow for better surgical outcome after medial collateral ligament reconstruction.

FasT-Fix versus Inside-Out Suture Meniscal Repair in the Goat Model

Background Recent all-inside meniscal repair devices are available, but in vivo studies with these devices are sparse. Hypothesis The FasT-Fix has inferior meniscal healing compared with the inside-out suture technique in the goat model. Study Design Controlled laboratory study. Methods After Institutional Review Board approval, 73 male castrated goats (Capra hircus) underwent a 2-cm meniscal incision and subsequent repair with the FasT-Fix device on one knee and inside-out meniscal repair on the contralateral knee. Both repairs used a vertical mattress suture technique. Access to the menisci was via an open technique with an extra-articular osteotomy of the medial collateral ligament origin on the femur. The animals were then allowed to ambulate unrestricted in a pasture after a 7-day stay in cages. Necropsy was carried out 6 months postoperatively, and the menisci and articular cartilage were studied with gross and microscopic inspection. Results Nine of the 73 animals were excluded before necropsy. A total of 64 animals underwent necropsy, gross measurement of residual lesions, gross evaluation for chondral damage, histologic evaluation of meniscal repair, histologic evaluation of any adjacent inflammatory reaction to implants, and data analysis. Compared with the inside-out group, the FasT-Fix group had longer residual full-thickness defects (1.2 ± 2.9 mm vs 0.2 ± 1.1 mm; P =. 011) and longer residual partial-thickness defects (8.4 ± 6.3 mm vs 3.6 ± 5.5 mm; P <. 001). A total of 148 FasT-Fix devices were placed for 73 knees. Two devices were replaced for improper deployment. The device deployed and attached correctly 146 of 148 times for a success rate of 98.6%. There was no gross chondral damage and no histologic findings of inflammatory reaction to the implants with either technique. Conclusions The FasT-Fix meniscal repair had inferior meniscal healing results in this animal model. Previous studies using this animal model have paralleled clinical outcomes. Implantation of the FasT-Fix device does not damage adjacent femoral or tibial cartilage. The deployment of the FasT-Fix implant was simple and reproducible. There was no inflammatory reaction to the FasTFix implant. Clinical Relevance The FasT-Fix meniscal repair has inferior meniscal healing results compared with the inside-out meniscal repair technique in the goat model. The clinical significance of this finding is not known. Further clinical study of the FasT-Fix implant is warranted.

Proximity of Collateral Ligament Origin to the Axis of Rotation of the Proximal Interphalangeal Joint of the Finger

Descriptive anatomical study. To determine the proximity of proximal interphalangeal (PIP) joint collateral ligament origin to the axis of rotation (AOR) of the joint. Normal function of the PIP joints of the hands requires competent collateral ligaments. Studies of the collateral ligaments of the PIP joint have led to a hypothesis that the collateral ligaments of the PIP joints originate at the joint AOR. However, no studies have yet provided quantitative evidence to support this assertion. A total of 30 collateral ligament specimens were prepared from the radial and ulnar halves of 16 fingers (digits 2 through 5) from the right hands of 5 formalin-embalmed cadavers. A geometric method was employed to estimate the PIP joint AOR. The proximity of collateral ligament origins to the estimated AOR of the PIP joint was determined. Collateral ligaments were found to have their proximal attachment an average of 0.02 mm distal and 0.24 mm palmar to the PIP joint AOR. For 90% of specimens the center of the collateral ligament origin was within 1.00 mm of the joint AOR. These results support the hypothesis that PIP joint collateral ligaments originate at the joint AOR. This finding predicts that the linear distance between the attachments should remain constant as the PIP joint moves through its range of motion. The modest changes in PIP collateral ligament length described in other studies can be attributed primarily to travel of the ligament across a small condylar tubercle at approximately 15 degrees to 20degrees of PIP joint flexion. The practice of immobilizing the PIP joint in 15degreesto 20" egreesof flexion is supported by these findings. J O rthop