Extra-articular Ligament Research Articles

Heredity of pregnancy-related pelvic girdle pain in Sweden.

Pelvic girdle pain during and after pregnancy is a major public health problem with significant daily problems for affected women and their families. There is now accumulating evidence that pregnancy-related pelvic girdle pain originates from the sacroiliac joints and the pubic symphysis as well as their extra-articular ligaments. However, the heritability of the disease remains to be determined. We hypothesized that there is an increased familial risk of pregnancy-related pelvic girdle pain. A population-based national database linkage registry study of approximately 9.3 million individuals within 4.2 million families in Sweden with a recruitment period from 1997 to 2018. The Swedish Multi-generation register was used to find female pairs of twins, full siblings, half-siblings and first cousins where both in the pairs had a completed pregnancy. The outcome measure was diagnosis of pregnancy-related pelvic girdle pain (International Classification of Diseases-10 O26.7 [1997-2018]) in the first pregnancy. Data was obtained from the Swedish Hospital Discharge Register, the Swedish Outpatient Care Register, the Swedish Medical Birth Register, the Primary Healthcare Register, and Medical Treatment Register. Cox regression analysis was used to calculate adjusted estimated effect of the exposure variable familial history of pregnancy-related pelvic girdle pain on the outcome variable pregnancy-related pelvic girdle pain at first birth. From the registers, 1 010 064 women pregnant with their first child within 795 654 families were collected. In total, 109 147 women were diagnosed with pregnancy-related pelvic girdle pain. The adjusted hazard ratio for a familial risk of pregnancy-related pelvic girdle pain was 2.09 (95% CI 1.85-2.37) among twins (monozygotic and dizygotic), 1.78 (95% CI 1.74-1.82) in full siblings, 1.16 (95% CI 1.06-1.28) in half-siblings from the mother, 1.09 (95% CI 1.024-1.16) in half-siblings from the father and 1.09 (95% CI 1.07-1.12) in first cousins. This nationwide observational study showed a familial clustering of pregnancy-related pelvic girdle pain. The hazard ratio for the condition was associated with the degree of relatedness, suggesting that heredity factors contribute to the development of pregnancy-related pelvic girdle pain. There is no causal treatment available for pregnancy-related pelvic girdle pain and further studies are now encouraged to clarify the specific genetic factors that contribute to the disease and for future targeted interventions.

Anatomical Double-Bundle Anterior Cruciate Ligament Reconstruction With Suture Augmentation

Ultra-high molecular weight polyethylene sutures are used for repair and reconstruction of extra-articular ligaments in the knee, elbow, and ankle joints. In recent years, the use of these sutures has become popular in a suture augmentation technique and has been applied for use in the reconstruction of the anterior cruciate ligament, which is an intra-articular ligament. Although several surgical techniques have been described in Technical Notes, all reports have been for single-bundle reconstruction, and none have applied the technique to double-bundle reconstruction. This Technical Note provides a detailed description of an anatomical double-bundle anterior cruciate ligament reconstruction combined with the suture augmentation technique.

Comparative Success of Repair Versus Reconstruction for Knee Extra-articular Ligament Injuries.

Surgical techniques and associated outcomes in treating acute and chronic extra-articular ligament knee injuries are in evolution, and there is question as to whether repair or reconstruction is optimal. The purpose of this study was to compare the subsequent surgery rate between surgical repair versus reconstruction for all extra-articular ligament injuries of the knee utilizing a large database. Our hypothesis was that overall surgical repair of both lateral and medial extra-articular knee injuries would have a higher revision rate than those treated by reconstruction. Cohort study; Level of evidence, 3. The PearlDiver Mariner data set (2010-2019), with 122 million patients, was utilized to generate 2 patient cohorts: those who underwent surgical repair and those who underwent surgical reconstruction of a knee extra-articular ligament injury. All patients had a minimum of 2 years follow-up. Rates of concomitant or subsequent cruciate ligament reconstruction and rates of secondary procedures were assessed and compared between the 2 cohorts. In total, 3563 patients were identified: extra-articular ligament reconstruction was performed for 2405 (67.5%), and repair was performed for 1158 (32.5%). Cruciate ligament reconstruction was performed for 986 (27.7%), of which 888 of 986 (90.1%) were performed on the same day as their extra-articular ligament procedure. At 2-year follow-up, the reconstruction cohort had higher rates of revision surgery compared with the repair cohort (8.2% vs 2.5%; P < .001). Using a large national database, knee extra-articular ligamentous reconstructions (those on both the lateral and the medial side) had a 3.3 times higher rate of revision surgery compared with repair at 2-year follow-up. Further study is needed to investigate the causes leading to revision surgery and to determine the optimal surgical treatment for both medial and lateral extra-articular knee ligament injuries.

Single-cell transcriptome analysis reveals cellular heterogeneity in mouse intra- and extra articular ligaments

Ligaments are collagenous connective tissues that connect bones. Injury of knee ligaments, namely anterior cruciate ligament (ACL) and medial collateral ligament (MCL), is common in athletes. Both ligaments have important functions, but distinct regeneration capacities. The capacity for recovery after injury also diminishes with age. However, cellular heterogeneity in the ligaments remains unclear. Here, we profiled the transcriptional signatures of ACL and MCL cells in mice using single-cell RNA sequencing. These ligaments comprise three fibroblast types expressing Col22a1, Col12a1, or Col14a1, but have distinct localizations in the tissue. We found substantial heterogeneity in Col12a1- and Col14a1-positive cells between ACL and MCL. Gene Ontology analysis revealed that angiogenesis- and collagen regulation-related genes were specifically enriched in MCL cells. Furthermore, we identified age-related changes in cell composition and gene expression in the ligaments. This study delineates cellular heterogeneity in ligaments, serving as a foundation for identifying potential therapeutic targets for ligament injuries.

Knee Multiligament Reconstruction: ACL / PCL / MCL

Background: Multiligament knee injury (MLKI) is a rare, complex injury that requires surgical intervention. However, there is a lack of consensus regarding optimal timing, staging, and graft choice for ligament reconstruction. Indications: Delayed, single-stage reconstruction offers the advantage of attaining improved preoperative range of motion and potential healing of extra-articular ligaments and may be necessary in the setting of multitrauma. Technique Description: A hamstring graft was harvested and diagnostic arthroscopy performed. Three posterior portals were made for posterior cruciate ligament (PCL) reconstruction. Femoral and tibial pins were placed for both PCL and anterior cruciate ligament (ACL) tunnels, positions confirmed with fluoroscopy, and tunnels drilled over the pins. The Achilles allograft was shuttled through the femoral and tibial PCL tunnels in anterograde fashion and fixed with a metal interference screw on the femoral side. The hamstring autograft was passed through the ACL tunnels and suspended on the femoral side. Tibial fixation of both grafts was achieved with biocomposite interference. Medial collateral ligament reconstruction was performed through the medial incision from hamstring harvesting. The semitendinosis allograft was passed and fixed with screws and spiked washers. Fluoroscopy confirmed that screw trajectory did not interfere with the ACL or PCL tunnels. Results: Bagherifard et al reported a study of 41 consecutive patients with MLKI who underwent single-stage reconstruction with autograft and/or allograft. Mean postoperative Lysholm and International Knee Documentation Committee (IKDC) scores were 86.9 and 70, respectively, and only 7 patients experienced restricted range of motion. Billieres et al reported a study of 23 patients with MLKIs who underwent single-stage reconstruction with allograft only. Mean postoperative Lysholm and IKDC scores were 77.3 and 67.2, respectively, and 19 patients returned to sport. Goyal et al reported a study of 27 patients with MLKI who underwent single-stage reconstruction greater than 6 weeks after injury. At 2 years, there were significant improvements in Visual Analog Scale, IKDC, and Lysholm scores, and no patients had residual laxity of the knee joint. Discussion/Conclusion: Single-stage reconstruction of MLKIs is an effective intervention that has been supported in literature; however, further studies are necessary to determine optimal surgical timing and graft type. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

The effect of CT and MRI with and without arthrography on the appearance of the feline carpal ligaments

BackgroundThe current diagnosis of feline carpal injuries is based on radiographic examination including stress views and computed tomography; however, these techniques do not allow for direct evaluation of the carpal ligaments. The purpose of this cadaveric study was to assess the ability of CT arthrography (CTA) and MR arthrography (MRA) to provide this information using a single contrast mixture. A protocol for intra-articular injection of the feline carpus was also described. A contrast solution containing gadolinium and iohexol with a 50% gadolinium solution (Magnevist—gadolinium 0.5 mmol/mL diluted to a 0.05 mmol/mL solution) and 50% of iodine (Iohexol—iodine 300mgI/mL) was injected into the antebrachiocarpal and middle carpal joints of feline carpi using fluoroscopic guidance.ResultsCTA allowed for identification of intra-articular ligaments and the silhouette of select extra-articular ligaments when there was adequate joint distension, however it was not considered to be superior to MRI. MRA allowed for improved identification of the dorsal radiocarpal, accessorioulnocarpal, accessorioquartile, short ulnar and short radial collateral ligaments.ConclusionIn this ex-vivo study, combined CTA and MRA enhanced the appearance of the feline carpal ligaments and may provide a foundation for future studies in the diagnosis of carpal injuries.

Acute number one Repair of Extraarticular Ligaments and Staged Surgery in More than One Ligament Knee Injuries

Background: The motive of this observe is to compare the consequences of acute number one repair of extraarticular ligaments with staged surgical treatment for acute knee dislocations (KDs) and multiligament knee injuries (MLKIs). Materials and methods: The atudy has conducted in Department of Orthopedic, UHC sadar, Mymensingh. During the period of January 2013 and May 2021, 67 consecutive patients identified with MLKI or KD have been noted or visited our institution. Of these, 37 sufferers who underwent acute restore of extraarticular ligaments inside three weeks of damage had been included on this observe. These patients were retrospectively categorised into two corporations: people who underwent best primary repair (repair group) and people who underwent staged reconstructive surgical operation (staged group). Follow-up exam protected range of motion (ROM), knee joint balance (Lachman test, posterior drawer take a look at, and varus and valgus stress test), Lysholm knee score, Tegner interest scale, and Knee damage and Osteoarthritis and effect Score (KOOS). Results: Twelve of the 37 sufferers did not want or preference similarly surgical treatment and were protected inside the restore institution. No great distinction becomes determined in demographic facts among the restore and staged businesses. Although staged surgery decreased high-quality posterior drawer check results, no giant difference became located between the 2 businesses concerning ROM, different knee joint balance tests, Lysholm rankings, Tegner scale, or KOOS. Conclusions: all patients lower back to their activities of each day residing and preinjury career ranges. Acute primary restore of extraarticular ligaments gives critical knee stability without varus/valgus instability and may lessen the need for next cruciate ligament reconstruction.

THE DEVELOPMENT OF EXTRA-ARTICULAR LIGAMENTS OF THE HIP JOINT DETERMINE ANGULAR VALUES OF THE PROXIMAL FEMUR

There are practically no data on the quantitative aspects of prenatal morphogenesis and the growth rates of the ligaments of the hip joint in humans, as well as information on the correspondence of the shape and structure of the ligaments to the bones forming the joint. The aim of the study was to reveal the features of the growth of the extra-articular ligaments of the hip joint in the prenatal period and to establish correlations between the structure of the ligaments and the structures of the proximal end of the femur. The material of the study is based on the analysis of 175 cases without pathology of the musculoskeletal system. The dimensions of the ilio-femoral, pubic-femoral, ischio-femoral ligaments and the cervico-diaphyseal angle and angle of rotation of the femoral neck in relation to the distal epiphysis of the bone were studied. As a result of the study, it was found that in the process of prenatal development with increasing age, the distance between the distal fixation points and the angle between the parts of the ilio-femoral ligament increases. Both legs have fibers that are woven into the fibrous membrane of the joint capsule. A correlation was found between the growth of morphometric parameters of the ilio-femoral ligament and the angular values ​​of the proximal femur. In contrast to the ilio-femoral ligament, the pubo-femoral and ischio-femoral ligaments show low signs of differentiation at different stages of prenatal ontogenesis. The pubo-femoral ligament becomes available for macroscopic examination from the beginning of the second half of the prenatal period. It is defined as a thickening of the medial fibrous membrane of the joint capsule, has its origin on the superior branch of the pubic bone and the iliac part of the acetabulum and is attached to the intertrochanteric line in the medial segment. The sciatic-femoral ligament is macroscopically defined as a thickening of the posterior part of the joint capsule. The ligament has a triangular shape, with a base in the region of the ischial part of the acetabulum and the ischial tubercle, its apex facing the trochanteric fossa at the antero-inner edge of the greater trochanter. It was found that the growth rate of morphometric parameters of different parts of the hip joint ligaments at different stages is not the same, which determines the change in the shape of the ligaments. The greatest transformations occur in the ilio-femoral ligament, the smallest in the pubic-femoral and sciatic-femoral ligaments. There is a correlation between the anatomical structure of the extra-articular ligaments of the hip joint and the corresponding angular values ​​of the proximal femur.

Acute primary repair of extraarticular ligaments and staged surgery in multiple ligament knee injuries

BackgroundThe purpose of this study is to compare the outcomes of acute primary repair of extraarticular ligaments with staged surgery for acute knee dislocations (KDs) and multiligament knee injuries (MLKIs).Materials and methodsBetween January 2005 and May 2018, 61 consecutive patients diagnosed with MLKI or KD were referred to or visited our institution. Of these, 31 patients who underwent acute repair of extraarticular ligaments within 3 weeks of injury were included in this study. These patients were retrospectively classified into two groups: those who underwent only primary repair (repair group) and those who underwent staged reconstructive surgery (staged group). Follow-up examination included range of motion (ROM), knee joint stability (Lachman test, posterior drawer test, and varus and valgus stress test), Lysholm knee score, Tegner activity scale, and Knee Injury and Osteoarthritis and Outcome Score (KOOS).ResultsTwelve of the 31 patients did not need or desire further surgery and were included in the repair group. No significant difference was observed in demographic data between the repair and staged groups. Although staged surgery decreased positive posterior drawer test results, no significant difference was observed between the two groups regarding ROM, other knee joint stability tests, Lysholm scores, Tegner scale, or KOOS.ConclusionsIn this series, all patients returned to their activities of daily living and preinjury occupation levels. Acute primary repair of extraarticular ligaments provides essential knee stability without varus/valgus instability and may reduce the need for subsequent cruciate ligament reconstruction.Level of evidenceLevel IV, retrospective observational study.

Result of single stage early surgical treatment of high-grade multiligamentous knee injuries (Schenck Type III, IV and V)

Introduction:The Multiligament Knee Injury is a complex knee problem and mostly associated with subluxation or dislocation of knee joint. Failure to diagnose and treat them appropriately can leads to devastating outcome particularly high-grade injury (Schenck Type 3,4 and 5). We favor single stage early surgical treatment of high grade Multiligament knee injury which leads to good functional outcome and return to work.Hypotheses:Single stage early surgical treatment of high grade Multiligament knee injury will leads to good functional outcome with higher IKDC and Lysholm score and helps the patients to in return early to work with higher satisfaction rate.Methods:From June 2013 to January 2020, 42 patients with age from 18 years to 56 years with acute (< 6 weeks) Multiligament knee injury included in surgical treatment. Patients with neurovascular injury were not included in study. From 42 patients, 28 patients was type 3,8 patients was type 4 and 6 patients was type 5 in this study. In all 42 patients, single stage treatment first Intraarticular ligament (anterior cruciate ligament ACL, posterior cruciate ligament PCL or both) reconstruction done by arthroscopic method then Extraarticular ligament (medial collateral ligament MCL, lateral collateral ligament LCL, Posterolateral corner PLC) treated with repair/augmentation/reconstruction depending upon status of ligaments by open method. We used only autograft (hamstring and peroneal longus tendon) of same limb or contralateral limb. Patient evaluation done with IKDC and Lyshlom score both in preoperative and postoperative period. Patient limb was kept in full extention in brace and started with aggressive physiotherapy with passive ROM at 2 weeks in post operative period . Follow up done at 2 weeks then every 6 weeks interval till 6 months then every 3 months interval. Partial weight bearing started at 6 weeks and full weight bearing usually between 10 weeks to 12 weeks.Results:Road traffic accident was the most common cause of Multiligament knee injury. Average follow up was 4 years (range 2 to 6.5 years) .40 % has excellent ,40% has good and 20% has average result. There was a significant improvement in both outcome scores as compared with the preoperative scores. Postoperatively average IKDC was 78 and Lyshlom was 86. Terminal restriction of knee movement was in 19% patients particularly those associated with medial side injury was the major complication in our study. Manipulation under anaesthesia was done in 4 cases and implant removal in 1 case and arthroscopic synovectomy and long term antibiotic in 1 case who develop early infection. Gade 1 posterior laxity and grade 1 varus stress was observed in 10 patints.Recovery after surgery takes 9 to 12 months of rehabilitation prior to returning to full activities.Conclusion:Proper evaluation and full diagnosis is key in Multiligament injury of knee. Failure to treat all injured structure can lead to change in knee kinematics and poorer outcome and increased risk for graft failure.Operative treatment with proper rehabilitation yields good functional and clinical outcome with early return to work and sports activity.

Short Oblique Patellar Tunnels for Patellar Fixation Do Not Increase Fracture Risk in MPFL Reconstruction: A Retrospective Cohort Study

Objectives:The current standard of care for recurrent patellar instability is reconstruction of the medial patellofemoral ligament (MPFL), the primary soft tissue constraint to lateral subluxation of the patella. Historically, transpatellar bone tunnels have been associated with increased rates of patella fracture. To avoid this dreaded outcome, many surgeons now employ suture anchors to affix the MPFL graft to the patella. This study aims to evaluate the costs and outcomes associated with short oblique patella tunnels as compared to suture anchor fixation in MPFL reconstruction.Methods:A total of 467 knees in 419 patients undergoing MPFL reconstruction between 2011 and 2018 were included in the study. A single institution electronic medical record queried for all patients undergoing extra-articular ligament reconstruction using Current Procedural Technology codes 27422 and 27427. Chart review of operative reports was utilized to identify those who had undergone MPLF reconstruction. Patients undergoing revision MPFL reconstruction were excluded, as were patients for whom fully transpatellar bone tunnels were employed for patellar fixation. This left two groups: those for whom small, oblique tunnels (n = 277) and suture anchors (n = 190) for patellar fixation were compared. Implant pricing for the 3.2 mm drill bit, suture anchors, and allograft were obtained through publicly available databases and prior published research.Results:Short oblique tunnels showed no significant increase in risk of patellar fracture compared to suture anchors for patellar fixation (P = 1.00). Use of suture anchors was associated with an increased risk of subluxation or dislocation compared to small, oblique tunnels (OR = 3.34, P = 0.021). No significant difference in the need for revision MPFL reconstruction surgery was found (OR = 1.964, P = 0.45) [Table 1]. The cost difference between allo- and autograft in ligament reconstruction has been analyzed in multiple prior studies and found to be $1100. The 3.2mm drill bit used to create the tunnels cost $84 but is reusable, while the average cost of two suture anchors was $500, leading to a material cost savings of $1600 per case in which transpatellar tunnels were used for MPFL autograft fixation when compared to a suture anchor and allograft combination. Regardless of the graft choice, material cost savings exceeds $400 per case simply by conversion to short oblique tunnels rather than suture anchors.Conclusion:The use of small, oblique tunnels with hamstring autograft is a safe and cost effective method for patellar fixation in MPFL reconstruction. Value in healthcare is defined as quality divided by cost. As surgeons and institutions are increasingly judged not only by the quality of the care they provide, but also in its cost, employment of this high-value technique should be considered by surgeons performing MPFL reconstruction.

Advanced Anterior Cruciate Ligament Repair and Reconstruction Techniques for Different Rupture Types

Literature concerning anterior cruciate ligament (ACL) reconstruction has increased in both scope and sophistication during the last decades. Heretofore, the principle focus has been on graft choice comparisons, the appropriate handling of co-injuries such as meniscal tears, cartilage lesions, as well as extra-articular ligament injuries. Despite the accumulated knowledge, there is still a lack of clarity concerning a therapy algorithm for different rupture types. With different consequences in therapy strategy, rupture types were differentiated as (1) subsynovial ACL tears/stretch injury and proximal avulsion tears, (2) single-bundle tear (anteromedial/posterolateral), and (3) total ACL rupture. The article presented here provides an overview of recommended operative therapy strategies for different rupture types of the ACL. Within the past decade, advances in arthroscopic technology coupled with rigorous scientific inquiry have resulted in significantly improved treatment options. With these developments in mind, ACL surgery and postoperative therapy can and should be performed in a manner befitting the patient's individual circumstances. Furthermore, intra- and postoperative suggestions including vancomycin graft-coating, as well as an accelerated “Early Active Rehabilitation” program, including early active physiotherapy without postoperative bracing, as well as additional postoperative extracorporeal shock-wave therapy are recommended.

Modified Lemaire Lateral Tenodesis Associated With an Intra-articular Reconstruction Technique With Bone-Tendon-Bone Graft Using an Adjustable Fixation Mechanism

The goal of this study was to report a surgical technique used in a revision anterior cruciate ligament (ACL) reconstruction case, consisting of an adaptation of the anterolateral iliotibial band tenodesis technique (modified Lemaire technique) combined with ACL reconstruction using an adjustable fixation mechanism. Rotational overload was one of the most likely hypotheses for failure of primary surgery, despite correct positioning and secure fixation. We performed a review of the most pertinent factors related to ACL reconstruction failure, as well as surgical strategies for its treatment. After this, we described, step by step, a combination of the 2 forms of surgical intervention that were already presented isolated with good clinical results, correcting the common anterior and rotational instabilities found in these cases. Knowing new techniques for intra- and extra-articular ligament reconstruction is imperative in the present day, when more patients are seeking a full return to their preinjury recreational, labor, and sports activities. We believe that the combination of these surgical techniques is able to achieve these goals effectively and reproducibly.

Decreased Posterior Tibial Slope Does Not Impact Postoperative Posterior Knee Laxity after Double-Bundle Posterior Cruciate Ligament Reconstruction

Objectives: Recent clinical studies have identified sagittal plane posterior tibial slope as a risk factor for increased postoperative laxity after single-bundle (SB) posterior cruciate ligament reconstruction (PCLR). However, the effect of tibial slope and its role in graft laxity following double-bundle (DB) PCLR has not been investigated clinically. Therefore, the purpose of this study was to retrospectively compare the degree of posterior tibial slope and its impact on posterior tibial translation (PTT) after DB PCLR. It was hypothesized that preoperative tibial slope would not be associated with graft laxity following DB PCLR. Methods: Patients who underwent primary DB PCLR without ACL injury between 2010 and 2017 by a single surgeon were retrospectively analyzed. Measurements of posterior tibial slope were performed using the lateral radiograph and PTT was measured using kneeling PCL stress radiographs, preoperatively and at a minimum of 1-year postoperatively. Linear regression was used to assess the relationship between native posterior tibial slope and postoperative graft laxity, determined by PCL stress radiographs. Results: One hundred three patients with PCL tears and subsequent DB PCL reconstructions were included. Ninety (87.4%) patients reported a contact mechanism at time of injury, while 13 (12.6%) patients reported a noncontact injury mechanism. Sixty-four (62.1%) patients had combined extra-articular ligament injuries that were concurrently reconstructed with the PCL tear, while isolated PCL tears were identified in 39 (37.9%) patients. Forty-nine (47.6%) patients had an acute (less than 6 weeks) injury, 54 (52.4%) patients had a chronic (greater than 6 weeks) injury at time of imaging and evaluation. Four (4%) patients demonstrated failed PCLRs, as defined by SSD in PTT greater than 8 mm on PCL stress radiographs. The mean posterior tibial slope for all PCL injured patients was 5.9 degrees &amp;#177; 2.2 degrees. There was a significant reduction in the amount of mean SSD in PTT between preoperative (10.6 &amp;#177; .7 mm) and postoperative (1.5 &amp;#177; 2.6 mm) PCL stress radiographs following DB PCLR (95% CI [8.4, 9.8], p &lt; 0.001). Linear regression analysis revealed no significant correlation between preoperative posterior tibial slope and the amount of SSD in PTT on postoperative stress radiographs obtained at a mean 18.5 months postoperatively (R = -0.115, p = 0.249). Similarly, when adjusting for combined ligamentous injury, injury chronicity, mechanism of injury, BMI, and age at surgery via multiple linear regression, preoperative tibial slope was not a significant independent predictor of postoperative SSD in PTT (beta = -0.079, 95% CI [-0.308, 0.150], p = 0.496). Combined injury (beta = -1.01, 95% CI [-2.00, -0.01], p = 0.047) was a significant independent predictor of decreased postoperative SSD in PTT on posterior stress radiographs. Conclusion: Graft laxity, determined by PTT in posterior kneeling stress radiographs, was not influenced by decreased posterior tibial slope in patients following DB PCLRs. Combined PCL injury was a significant independent predictor of decreased postoperative SSD in PTT on posterior stress radiographs. Additionally, the majority of patients (96%) demonstrated improved objective posterior knee stability following DB PCLR. Thus, DB PCLR can be recommended as a surgical treatment option for patients with grade III isolated and combined PCL injuries, irrespective of native posterior tibial slope. [Table: see text]

The effect of exercise on the protein profile of rat knee joint intra- and extra-articular ligaments

Abstract Injuries to the intra-articular knee joint ligament (anterior cruciate ligament (ACL)) together with the extra-articular medial collateral ligament (MCL) result in significant joint instability, pain and immobility for the affected individual. Moderate endurance type exercise has been shown to increase ligament strength, however little is known on the effect of short-term high intensity exercise regimes such as treadmill training on the ACL and MCL and whether they may be beneficial to the extracellular matrix (ECM) structure of these ligaments. This study aimed to identify the effect of short-term high intensity exercise on the proteome of the rat ACL and MCL using mass spectrometry. Sprague Dawley male rats (n=12) were split into equal groups of control and exercise animals, which were subjected to high intensity training and followed by proteomic analysis of the ACL and MCL. Knee joint and ligament health was assessed using OARSI scoring or using a validated histological scoring system. Histopathological analyses demonstrated no significant changes in the ACL, MCL or cartilage of the knee joint, indicating that the exercise regime used in this study did not have substantial impact on tissue structure and health of several tissues within the rat knee joint. Some proteins were found to be significantly more abundant in the ACL in the exercised group than the control group. However, no proteins with a significantly different expression were identified between MCL control and MCL exercised groups. The majority of proteins expressed at higher levels in the ACL exercise group were cytoskeletal proteins, ribosomal proteins and enzymes. Several matrisomal proteins were also more abundant such as collagen proteins and proteoglycans in ACL exercise group. In conclusion, our results indicate that short-term high intensity exercise has an impact on ACL ECM protein expression, with the majority of differential expressed proteins being cellular proteins such as actins, ribosomal and heat shock proteins, indicative of metabolic and molecular responses. Further study is necessary to determine the impact of these short-term changes on ligament structure and function.

Anterior Cruciate Ligament Reconstruction With Suture Tape Augmentation

The advent of suture tape augmentation has led to increased use in knee, elbow, and ankle ligament repairs and reconstructions. Recent biomechanical analysis of the use of suture tape augmentation have shown superior strength characteristics compared with repair or reconstruction alone. Despite its increased use in extra-articular ligament procedures, its use as an augment to anterior cruciate ligament reconstruction has not been widely described. This article details a simple technique to incorporate the use of suture tape augmentation during concurrent anterior cruciate ligament reconstruction using hamstring autograft.

Do Tibial Plateau Fractures Worsen Outcomes of Knee Ligament Injuries? A Matched Cohort Analysis.

Background:Tibial plateau fractures account for a small portion of all fractures; however, these fractures can pose a surgical challenge when occurring concomitantly with ligament injuries.Purpose/Hypothesis:The purpose of this study was to compare 2-year outcomes of soft tissue reconstruction with or without a concomitant tibial plateau fracture and open reduction internal fixation. We hypothesized that patients with a concomitant tibial plateau fracture at the time of soft tissue surgery would have inferior outcomes compared with patients without an associated tibial plateau fracture.Study Design:Cohort study; Level of evidence, 3.Methods:Forty patients were included in this study: 8 in the fracture group and 32 in the matched control group. Inclusion criteria for the fracture group included patients who were at least 18 years old at the time of surgery and sustained a tibial plateau fracture and a concomitant injury of the anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament, or fibular collateral ligament in isolation or any combination of cruciate or collateral ligaments and who subsequently underwent isolated or combined ligament reconstruction. Patients were excluded if they underwent prior ipsilateral knee surgery, sustained additional bony injuries, or sustained an isolated extra-articular ligament injury at the time of injury. Each patient with a fracture was matched with 4 patients from a control group who had no evidence of a tibial plateau fracture but underwent the same soft tissue reconstruction procedure.Results:Patients in the fracture group improved significantly from preoperatively to postoperatively with respect to Short Form–12 (P < .05) and Western Ontario and McMaster Universities Osteoarthritis Index total scores (P < .05). The Lysholm (P = .075) and Tegner scores (P = .086) also improved, although this was not statistically significant. Patients in the control group improved significantly from preoperatively to postoperatively across all measured scores. A comparison of the postoperative results between the 2 groups showed no statistically significant difference.Conclusion:The presence of a tibial plateau fracture in conjunction with a ligamentous knee injury did not have a negative effect on postoperative patient-reported outcomes. Patient-reported outcome scores after surgery in both the fracture and control groups improved beyond the minimally clinically important difference, indicating that the presence of a fracture did not detract from the outcomes observed in patients without fractures undergoing concomitant ligament reconstruction.

Key Determinants of Anterior Cruciate Ligament Spontaneous Healing

Anterior cruciate ligament (ACL) injuries are known to have very low rates of spontaneous healing. There have been several studies since the mid-1960s concerning the approaches to accelerate spontaneous healing of ACL injuries. Recent studies have identified similarities in the healing response of ACL and other extra-articular ligaments, in terms of their cellular response and vascularity. Research has demonstrated that mechanical stress has an important influence on the biological response of tissue healing. Novel treatment approaches may exploit the role of mechanical loads on the regulation of gene expression in achieving spontaneous healing of injured ACL. This article reviews the determinants of the ACL healing response and their relationship to mechanical stress and spontaneous healing, and explores novel concepts that are emerging in the management of ACL injuries.

Salvage of dislocated hip and knee during limb lengthening for congenital femoral deficiency

Background The articular and soft tissue deficiencies associated with congenital femoral deficiency are reported to predispose to joint dislocation during limb lengthening, which would negate the value of limb lengthening. Patients and methods The cases of 17 children who suffered hip and/or knee dislocation as a result of femoral lengthening for congenital femoral deficiency of Paley’s classification type 1 and 2a were included. Their ages ranged from 4.5 to 13 years (average: 6.8 years). The average lengthening achieved at the time of diagnosis of the dislocation was 5.7±1.048 cm (range: 4.5–8 cm). Hip dislocation only was present in seven (41%) cases, knee dislocation only in six (35%) cases, and combined dislocation in four (24%) cases. Results A center-edge angle of Wiberg less than 22° had a highly significant effect on hip dislocation (P=0.001), and all knee dislocations were associated with a hypoplastic lateral femoral condyle. Both joint dislocations were common when the child had a center-edge angle of 15–20° together with a hypoplastic lateral femoral condyle. Discussion and conclusion Hip dislocations were managed with soft tissue release and pericapsular acetabuloplasty with satisfactory Mckay’s hip scores in all cases. Knee dislocations were reduced and stabilized by means of extra-articular ligament reconstruction with satisfactory Judet’s knee criteria in 82% of cases.

Results of multiple ligament injured knees operated by three different strategies.

Background:Multiple ligament injured knee is generally described for a scenario when at least 2 of the 4 major ligaments are ruptured. The most effective treatment for these injuries remains controversial. This study presents the clinical outcome of 3 surgical strategies based on personalized treatment.Materials and Methods:Thirty two patients with multiple ligament injured knee were treated by 3 surgical strategies in the acute phase. (1) One-stage: Twelve patients treated by repair and reconstruction of all ruptured ligaments in a single operation. (2) Staged: Eleven patients treated by repair or reconstruction of the extraarticular (EA) ligaments and then intraarticular ligaments in 2nd stage. (3) EA ligament repair: Nine patients underwent only EA ligaments repair.Results:The patients were followed up for an average of 34.7 ± 12.1 months. Significant improvements in knee stabilities (P < 0.01), Lysholm score (P < 0.01) and International Knee Documentation Committee grade (P < 0.01) were noticed in all groups. Of the 32 patients, none had gross mal alignment or gait abnormalities at the latest followup. Comparing the 3 groups, a significant difference in Lysholm score was shown between the one stage group and the EA repair group (P = 0.040); additionally, significant differences were found in 2 subscales of knee injury and osteoarthritis outcome score (P < 0.05).Conclusion:Satisfactory clinical and functional outcomes could be achieved adopting the 3 surgical strategies based on personalized treatment. However, a combination of EA repair and intraarticular repair or reconstruction might be more reasonable options for the young and active patients.