Interosseous Ligament Research Articles

MDCT arthrography assessment of the severity of cartilage damage and scapholunate dissociation in regard to specific-component tears of the scapholunate interosseous ligament

PurposeTo evaluate the distribution and severity of cartilage damage and scapholunate dissociation assessed on multi-detector computer tomography (MDCT) arthrography in a sample of patients with scapholunate interosseous ligament (SLIL) injury, in regard to component-specific tears. MethodsWe retrospectively included 37 patients with SLIL tears and 34 patients without SLIL tears who served as controls, all patients had undergone MDCT arthrography. Morphology of SLIL dorsal and volar components was graded as: normal, partial, or complete tear. Cartilage damage was assessed in 14 distinct regions of the wrist using a semiquantitative modified scoring system. Staging of scapholunate advanced collapse (SLAC) for each patient was based on the distribution of cartilage damage seen on MDCT arthrography. Scapholunate dissociation was measured for each patient at the tenth of a millimeter. The Student's t-test (p) and the Wilcoxon Rank-Sum test (P) were used to compare the different groups. ResultsThe cartilage damage scores obtained were greater in patients with complete SLIL dorsal component tear than in other patients (p = 0.0019 and P = 0.0018). Scapholunate dissociation was greater in these patients (p = 0.0003 and P = 0.0013). Scapholunate dissociation was also greater in patients with SLAC wrist (p = 0.0004 and P = 0.0012), with a cut-off value of 3.7 mm for diagnosing SLAC (sensitivity 83.3 % and specificity 89.5 %). ConclusionMDCT arthrography assessment shows that the severity of cartilage damage and scapholunate dissociation is greater when the dorsal component of the SLIL is completely ruptured.

RETRACTED: Surgical Treatment of Subtalar Joint Instability With Reconstruction of the Interosseous Talocalcaneal Ligament: Safety and Accuracy of a New Technique in a Cadaver Model.

New surgical strategies to treat symptomatic subtalar joint (STJ) instability are evolving. Most reconstruction options focus on the interosseous talocalcaneal ligament (ITCL.) We modified a previously described reconstruction strategy and then refined our new surgical technique through simulated surgery and subsequent cadaver dissections. Our purpose was to develop an ITCL reconstruction technique that could easily and safely be performed with commonly available and familiar technology. A percutaneous fluoroscopically guided tunnel for the purpose of ITCL reconstruction was created in 10 cadaveric below-knee specimens. Accuracy of the tunnel with relation to the anatomic boundaries of the ITCL attachment sites as well as damage to relevant structures at risk were recorded. Two sets of 5 surgeries were performed to assess for improvement in technique. Mean distances from the tunnel to ITCL on the calcaneus improved between groups 1 and 2: 4.04 mm and 1.80 mm, respectively (P = .04). Mean distances from the tunnel to ITCL on the talus improved between groups 1 and 2: 6.23 mm and 1.84 mm, respectively (P = .08). With information obtained from this study, an osseous tunnel can be safely placed within 2 mm of the ITCL footprints. Levels of Evidence: Level V: Experimental research, Expert opinion.

Ligamentous Lisfranc injuries: analysis of CT findings under weightbearing.

The aim of this study was to investigate the influence of different ligamentous Lisfranc injuries on computed tomography (CT) findings under weight-bearing and to emphasize the indications for surgical treatment of their various types. Sixteen human cadaveric lower limbs were placed in weight-bearing radiolucent frame for CT scanning. All intact specimens were initially scanned, and then, dorsal approach was used for sequential ligaments cutting of: (1) the dorsal and the interosseous (Lisfranc) ligaments between medical cuneiform (MC) and metatarsal 2 (MT2); (2) the plantar ligament between the MC and MT3; (3) the plantar ligament between MC and MT2. Based on sequential CT scans, the distances MT1-MT2, MC-T2, as well as the alignment and dorsal displacement of MT2 were measured. Slight increase in the distances MT1-MT2 and MC-MT2 was observed after the disruption of the dorsal and the interosseous ligaments. Further increase in MT1-MT2 and MC-MT2 distances was registered after the disruption of the ligament between MC and MT3. The largest distances MT1-MT2 and MC-MT2 were measured after the final plantar ligament cut between MC and MT2. Unequivocal instability is observed with simultaneous transection of the Lisfranc ligament with both plantar ligaments. On CT used as diagnostic tool, plantar injuries at the basis of the second and the third metatarsal are indirect signs of violation of the ligaments and represent an indication for surgical treatment. When using magnetic resonance imaging as diagnostic tool, a ruptured Lisfranc ligament alone without dislocation does not necessarily need surgical intervention.

Kinematic Analysis of Combined Suture-Button and Suture Anchor Augment Constructs for Ankle Syndesmosis Injuries.

Syndesmosis injuries are common, with up to 25% of all ankle injuries being reported to involve an associated syndesmosis injury. These injuries are typically treated with cortical screw fixation or suture-button implants when indicated, but the addition of a suture anchor augment implant has yet to be evaluated. The purpose of this study was to evaluate the ability of a suture anchor augment to add sagittal plane translational and transverse plane rotational constraint to suture-button constructs with syndesmosis injuries. We hypothesized that the suture anchor augment oriented in parallel with the fibers of an injured anterior-inferior tibiofibular ligament (AITFL) in addition to a suture-button construct would achieve physiological motion and stability at the syndesmosis through increased rotational and translational constraint of the fibula. Eleven fresh-frozen cadaver ankles were stressed in external rotation using a custom-made ankle rig. Each ankle had simultaneous recording of ultrasound video, 6 degrees-of-freedom kinematics of the fibula and tibia, and torque as the ankle was stressed by an examiner. The ankles were tested in 6 different states: native uninjured; injured with interosseous ligament and AITFL sectioned; 1× suture button; 2× suture buttons, divergent; 1× suture anchor augment with 2× suture buttons, divergent; and 1× suture anchor augment with 1× suture buttons. Only the suture anchor augment + 2× suture buttons and suture anchor augment + 1× suture-button constructs were found to be significantly different from the injured state (P = .0003, P = .002) with mean external rotation of the fibula. Overall, the most important finding of this study was that the addition of a suture anchor augment to suture-button constructs provided a mechanism to increase external rotational constraint of the fibula. This study provides a mechanistic understanding of how the combined suture-button and suture anchor augment construct provides an anatomically similar reconstruction of constraints found in the native ankle. However, none of the constructs examined in this study were able to fully restore physiologic motion.

Surgical Treatment of Subtalar Joint Instability: Safety and Accuracy of a New Technique in a Cadaver Model

New surgical strategies to treat symptomatic subtalar joint (STJ) instability are evolving. We modified a previously described reconstruction strategy and then refined our new surgical technique through simulated surgery and subsequent cadaver dissections. Our purpose was to show that a tunnel intended to facilitate STJ stabilization surgery could safely be drilled across the footprints of the interosseous talocalcaneal ligament (ITCL). A percutaneous fluoroscopically guided tunnel for the purpose of ITCL reconstruction was created in 10 cadaveric below-knee specimens. Accuracy of the tunnel with relation to the anatomic boundaries of the ITCL attachment sites as well as damage to relevant structures at risk were recorded. Two sets of 5 surgeries were performed to assess for improvement in technique. Mean distances from the tunnel to the ITCL on the calcaneus improved between groups 1 and 2: 4.04 and 1.80 mm, respectively (p = .04). Mean distances from the tunnel to the ITCL on the talus improved between groups 1 and 2: 6.2 and 1.8 mm, respectively (p = .08). With information obtained from this study, an osseous tunnel can be safely placed within 2 mm of the ITCL footprints.

The Relationship Between the Tensile and the Torsional Properties of the Native Scapholunate Ligament and Carpal Kinematics

The purpose of this exploratory study was to examine the relationship between the tensile and the torsional properties of the native scapholunate interosseous ligament (SLIL) and kinematics of the scaphoid and lunate of an intact wrist during passive radioulnar deviation. Eight fresh-frozen cadaveric specimens were transected at the elbow joint and loaded into a custom jig. Kinematic data of the scaphoid and lunate were acquired in a simulated resting condition for 3 wrist positions-neutral, 10° radial deviation, and 30° ulnar deviation-using infrared-emitting rigid body trackers. The SLIL bone-ligament-bone complex was then resected and loaded on a materials testing machine. Specimens underwent cyclic torsional and tensile testing and SLIL tensile and torsional laxity were evaluated. Correlations between scaphoid and lunate rotations and SLIL tensile and torsional properties were determined using Pearson correlation coefficients. Ulnar deviation of both the scaphoid and the lunate were found to decrease as the laxity of SLIL in torsion increased. In addition, the ratio of lunate flexion-extension to radial-ulnar deviation was found to increase with increased SLIL torsional rotation. Our findings support the theory that there is a relationship between scapholunate kinematics and laxity at the level of the interosseous ligaments. Laxity and, specifically, the tensile and torsional properties of an individual's native SLIL should guide reconstruction using a graft material that more closely replicates the individual's native SLIL properties.

Posterior Tibial Tendon and Spring Ligament Lesions in Rheumatoid Arthritis

In rheumatoid arthritis, a significant number of patients have hindfoot pain while they are considered in low disease activity. Then the rheumatoid hindfoot may evolve in valgus flat foot with disability. The aim of our study was to observe the lesions of the main stabilizers of the hindfoot in rheumatoid arthritis to improve the followup and the treatment of the disease. Thirty-three feet (from 21 patients) with rheumatoid arthritis and pain of the hindfoot were consecutively observed. The patients have had no biologic treatment. Every foot had Magnetic Resonance Imaging (MRI) of the hindfoot with gadolinium injection. The tendon of the tibialis posterior muscle, the spring ligament and the inter-osseous talocalcaneal ligament were considered. All the feet presented tenosynovitis of the posterior tibial tendon. Structural lesions of the posterior tibial tendon (23/33 feet, 69.7%) were more frequent than lesions of the spring ligament (12/33 feet, 36.4%). There was no inferior spring ligament lesion without superior spring ligament lesion. No interosseous talocalcaneal ligament lesion was observed. In rheumatoid arthritis, the hindfoot, and particularly the posterior tibial tendon, should be evaluated during patient follow-up to detect a possible lesion. Posterior tibial tendon lesion arises at the same time as the spring ligament lesion, before interosseous talocalcaneal ligament lesion. Imaging, especially MRI, may complete clinical examination. If rheumatoid involvement of the posterior tibial tendon is observed, treatment intensification is required.

Self-identified functional limitations improve in patients with degenerative wrist arthritis after surgery

Study DesignThis is a prospective cohort pilot study. BackgroundDegenerative wrist arthritis leads to pain, loss of strength, mobility, function, and impairments in psychological well-being. Accurate assessment of functional limitations that are unique to the individual is essential for successful treatment that best meets those specific needs. Purpose of the StudyTo identify and determine if self-identified functional limitations improve in patients who underwent surgery for degenerative wrist arthritis. MethodsPatients with degenerative wrist arthritis who were scheduled for surgery were prospectively recruited (n = 14, mean age + SD = 42 + 16, 10 males, 4 females) into a pilot study that measured self-identified functional limitations and outcomes. Inclusion criteria included a diagnosis of scapholunate advanced collapse, scaphoid nonunion advanced collapse, scapholunate interosseous ligament tear, or Kienböck disease. Exclusion criteria included a history of neuromuscular disease or concomitant ipsilateral musculoskeletal injury. Data were collected during two 20-minute sessions, preoperatively and one year postoperatively, utilizing the Patient-Rated Wrist Evaluation and the Canadian Occupational Performance Measure. ResultsAll patients reported significant decreases (P < .001) in total pain (mean change = 17.6, SD = 8.5) and total disability (mean = 17.8, SD = 9.1) on the Patient-Rated Wrist Evaluation from presurgery to postsurgery, with a large effect size of d > 0.8. Patients also reported significant improvements (P < .001) in mean performance (mean = 3.5, SD = 1.5) and mean satisfaction (mean = 4.0, SD = 2.1) with self-identified activities on the Canadian Occupational Performance Measure, with an effect size of d > 0.8. ConclusionPatients with degenerative wrist arthritis reported significant postoperative improvement in both performance and satisfaction in self-identified activities. Consideration of patient-specified goals can inform both patients and clinicians during the surgical decision-making process and allow for more individualized care.

Sacroiliac Joint Ligaments and Sacroiliac Pain: A Case–Control Study on Micro- and Ultrastructural Findings on Morphologic Alterations

Background: The sacroiliac joint (SIJ) is a common source of low back pain. SIJ pain has shown to have negative impact on patients’ quality of life. Although clinically there is an increasing interest to treat SIJ-related pain both conservatively and surgically, the underlying mechanisms related to pathology in that region are poorly understood. One hypothesis is that the SIJ ligaments are structurally altered in SIJ pain. Objectives: The given study investigated patient cases with different pain durations undergoing posterior distraction arthrodesis of the SIJ, with subsequent micro- and ultrastructural assessment of the interosseous and posterior SIJ ligaments compared with autopsy controls without known history of low back pain. Study Design: Case–control study. Morphologic-pathological analysis of tissue samples obtained during surgery with controls from legal medicine. Setting: Rural hospital setting in Halberstadt, Germany. Methods: SIJ ligaments were removed from 6 patients undergoing SIJ arthrodesis for histological and ultrastructural assessment in scanning and transmission electron microscopy, and compared with 6 controls without known history of SIJ pathology. Results: A number of alterations were observed in the ligaments of patients with SIJ, namely ligament disruption, collagen loosening and coiling, vascularization, and hemorrhage. In some areas, these changes were observed in proximity to healthy (structurally unaltered and intact tissues), indicative of a potential disease progression. Comparison to controls yielded a significant correlation between SIJ pathology and the level of collagen degeneration (φ ≥ 0.82; P &lt; 0.001). Limitations: Small sample size, method of tissue removal from patients may have influenced tissue integrity. Conclusions: The combined clinical, histological, and ultrastructural analysis provided, to our knowledge, first-time evidence of morphologic SIJ ligament alteration of a nontraumatic and noninflammatory cause. Further research is necessary to elucidate these structural changes and to substantiate pain duration and patient-history-dependent changes at the ligaments of the posterior pelvis

Comparison of MRI & direct MR arthrography with arthroscopy in diagnosing ligament injuries of wrist

IntroductionLigament injuries around the wrist leading to chronic wrist pain are often a diagnostic dilemma.Various imaging modalities like wrist radiographs, CT and MRI have been used to improve the diagnostic accuracy. The objective of this study was to assess the value of MRI & direct magnetic resonance arthrography (MRA) of the wrist for detecting & evaluating tears of the triangular fibrocartilage complex (TFCC) & scapholunate & luno triquetral interosseous ligament (LTIL & SLIL) injuries in comparison with arthroscopy of the wrist. Materials & methodsAll patients presenting with chronic wrist pain of more than 3 months duration with suspected ligament injuries were included. MRI was performed with 8 channel wrist coil on 1.5 T machine. (PHILIPS, Netherlands). MRA was performed after obtaining consent. Retrospective MR findings were then correlated with results in those patients who underwent arthroscopy. Arthroscopic correlation was obtained in 22 (46.8%) cases out of the 45 patients who underwent both MRI & MRA. ResultsThe gold standard arthroscopic procedure diagnosed 15 peripheral & 6 central TFCC tears in 22 patients. 4 scapholunate ligament tears were also identified. MRI diagnosed 16 peripheral & 5 central TFCC tears in these 22 patients. MRA identified 9 central tears and 14 peripheral tears. The sensitivity in diagnosing an overall TFCC tears with MRI as well as MRA was 94.4 & 100%. The specificity of the MRI and MRA in diagnosing an overall TFCC tear was 100% & 75% respectively. Discussion & conclusionsDirect MRA has better sensitivity in detecting TFCC central tears. In view of ‘substantial’ agreement between MRI & MRA with Kappa analysis, conventional MRI can be relied on, in diagnosing TFCC injury. With comparatively low specificity, caution and restraint is advised in interpreting MRA, which may influence decision on surgery.

Caudal vertebrae of titanosaurian sauropod dinosaurs from the Lower Cretaceous Ilek Formation in Western Siberia, Russia

Three sauropod middle caudal vertebrae are described from the three different localities within the Lower Cretaceous (Barremian-Aptian) Ilek Formation in Krasnoyarsk Territory, Western Siberia, Russia. All vertebrae are strongly procoelous and can be referred to Lithostrotia indet. LMCCE 005/40 from Bol'shoi Kemchug 3 locality has a ventral groove on centrum and a very large neural spine that projects posteriorly far beyond the centrum. This specimen also lacks postzygapophyses and bears a heavily sculptured neural spine suggesting high degree of development of the interosseous ligaments. The structure of the neural spine LMCCE 005/40 is similar to that of the saltasaurine Neuquensaurus from the Late Cretaceous of South America. However, the Siberian specimen lacks camellate bone texture characteristic for the caudal vertebrae of Saltasaurinae and its similarity with Neuquensaurus in development of the neural spine likely was independently acquired. These new findings increase the known diversity of sauropod dinosaurs in the Early Cretaceous of Siberia, which includes three taxa of Lithostrotia indet. described herein, lithostrotian Tengrisaurus, and titanosauriform Sibirotitan.

Intercarpal Ligament Injuries Associated With Distal Radius Fractures.

Injuries to the scapholunate (SL) and lunotriquetral (LT) interosseous ligaments occur in approximately one third of distal radius fractures. The diagnosis of these injuries is challenging because plain radiographs are not reliably diagnostic. Wrist arthroscopy may be the most accurate way to examine and diagnose soft-tissue injuries of the carpus adjacent to a distal radius fracture. Treatment options for SL and LT ligament injuries include open repair and/or percutaneous pinning. Because the natural history of these injuries is unclear, the necessity of diagnosing and treating these SL and LT interosseous ligament defects remains speculative.

Arthroscopic Assessment of Syndesmotic Instability in the Sagittal Plane in a Cadaveric Model.

Syndesmotic instability is multidirectional, occurring in the coronal, sagittal, and rotational planes. Despite the multitude of studies examining such instability in the coronal plane, other studies have highlighted that syndesmotic instability may instead be more evident in the sagittal plane. The aim of this study was to arthroscopically assess the degree of syndesmotic ligamentous injury necessary to precipitate fibular translation in the sagittal plane. Twenty-one above-knee cadaveric specimens underwent arthroscopic evaluation of the syndesmosis, first with all syndesmotic and ankle ligaments intact and subsequently with sequential sectioning of the anterior inferior tibiofibular ligament (AITFL), the interosseous ligament (IOL), the posterior inferior tibiofibular ligament (PITFL), and deltoid ligament (DL). In all scenarios, an anterior to posterior (AP) and a posterior to anterior (PA) fibular translation test were performed under a 100-N applied force. AP and PA sagittal plane translation of the distal fibula relative to the fixed tibial incisura was arthroscopically measured. Compared with the intact ligamentous state, there was no difference in sagittal fibular translation when only 1 or 2 ligaments were transected. After transection of all the syndesmotic ligaments (AITFL, IOL, and PITFL) or after partial transection of the syndesmotic ligaments (AITFL, IOL) alongside the DL, fibular translation in the sagittal plane significantly increased as compared with the intact state (P values ranging from .041 to <.001). The optimal cutoff point to distinguish stable from unstable injuries was equal to 2 mm of fibular translation for the total sum of AP and PA translation (sensitivity 77.5%; specificity 88.9%). Syndesmotic instability appears in the sagittal plane after injury to all 3 syndesmotic ligaments or after partial syndesmotic injury with concomitant deltoid ligament injury in this cadaveric model. The optimal cutoff point to arthroscopically distinguish stable from unstable injuries was 2 mm of total fibular translation. These data can help surgeons arthroscopically distinguish between stable syndesmotic injuries and unstable ones that require syndesmotic stabilization.

The Interosseous Talocalcaneal Ligament Injury Findings in Lateral Ankle Instability with Sinus Tarsi Pain

Category:Ankle, Arthroscopy, SportsIntroduction/Purpose:Lateral ankle instability (LAI) with concomitant sinus tarsi pain is a quite common finding. However, there has been few studies evaluating the subtalar arthroscopic findings for LAI with sinus tarsi pain. The purpose of the study is to evaluate the ST arthroscopic findings of chronic ankle instability with sinus tarsi syndrome. We hypothesized that chronic ankle instability with sinus tarsi pain is highly associated with interosseous talocalcaneal ligament (ITCL) tear which may be the cause for subtalar instability (STI).Methods:The study is based on 104 LAI with sinus tarsi pain ankles who had performed lateral ankle ligament stabilization. i.e. Modified Brostrum procedure (MBP), lateral ankle reconstruction (LAR) or subtalar ligament reconstruction (STR) with subtalar arthroscopic (STA) examinations from 2007 to 2018. The STA has been mainly focused on the ITCL injury and debridement of the ITCL tears and synovitis were performed when present. VAS pain score, AOFAS, Karlsson-Peterson functional score were evaluated.Results:According to the ST arthrosopic findings, ITCL tears were present in 94% (98/104) of the ankles. Lateral ankle instability (LAI), subtalar instability (STI), and LAI and STI combined were 32%, 30% and 38% respectively. MBP, LAR and STR were performed in 23%, 22% and 56% respectively. VAS pain score was improved from 5.3 to 1.9 (p<0.05). AOFAS score was improved from 67 to 89 (p<0.05), while K-P score improved from 50 to 83 (p<0.05). Sinus tarsi pain was relieved in 65% of the patients.Conclusion:We found the high incidence of the ITCL tears (98%) in LAI with sinus tarsi pain, and also diagnosed the STI in 68% of the ankles. We believe that in case of LAI with sinus tarsi pain, ST arthroscopic evaluation for ITCL tears is necessary and the possibility

Can Weightbearing CT Scans Be Used to Diagnose Subtalar Joint Instability? A Cadaver Study

Category:Hindfoot, TraumaIntroduction/Purpose:Accurate assessment of subtalar joint stability is difficult. Weightbearing CT (WBCT) scans have increased in popularity among foot and ankle surgeons as it offers an accurate representation of hindfoot joint alignment under weightbearing conditions. However, the clinical utility of this imaging modality to diagnose subtalar joint instability has yet to be investigated. The purpose of this study was to assess the impact of load and torque application on the assessment of subtalar joint instability when using WBCT scans. We hypothesized that load and torque application would improve the ability to identify subtalar joint instability.Methods:Fourteen paired male cadavers (tibial plateau to toe-tip) were included. A radiolucent frame held specimens in a plantigrade position while non-weightbearing and weightbearing CT scans (with and without torque application) were taken. First, intact ankles (Native) were scanned. Second, one specimen from each pair underwent interosseous talo-calcaneal ligament (ITCL) transection (Condition 1A), while the contralateral underwent calcaneo-fibular ligament (CFL) transection (Condition 1B). Third, the lesions were reversed on the same specimens and the remaining intact ITCL or CFL was transected (Condition 2). Finally, the deltoid ligament was transected in all ankles (Condition 3). Two radiographic measurements were performed on the level of the ankle joint (talar tilt [TT], anterior talar translation [ATT]), while the subtalar tilt (STT) was measured at the anterior, middle, and posterior plane of the subtalar joint. Inter- and intra-observer agreement calculations were additionally performed.Results:Weight did not impact most measurements, while the majority of measurements differed significantly within each condition after torque application. Measurements performed at the level of the subtalar joint were more reliable and better predictors for subtalar joint instability compared to measurements performed at the level of the ankle joint. Discrete ITFL, combined ITFL/ CFL, and combined ITFL/ CFL/ deltoid ligament injuries had significantly different STT values than native ankles (Figure 1).Conclusion:Measurements to assess the stability of the subtalar joint should primarily be performed at the level of the subtalar joint rather than at the level of the ankle joint when using WBCT scans. Torque application is crucial for identifying subtalar joint instability, while the application of load should be avoided. Future clinical studies will therefore face substantial technical challenges should they attempt to determine the clinical utility of WBCT scans for assessment of subtalar joint instability.

Surgical Anatomy of the Medial Cuneiform (Cotton) Osteotomy.

Background:The Cotton osteotomy, or dorsal-opening wedge osteotomy of the medial cuneiform (MC), is used to address medial column alignment to restore the static-triangle of support. There are many described techniques regarding the incision and osteotomy. Successful completion of the osteotomy requires knowledge of the anatomy, particularly the location of the medial dorsal cutaneous nerve (MDCN). This study describes the relationship between MDCN, tibialis anterior, extensor-hallucis-longus tendon, and ligamentous attachments to the MC. A technique to determine a safe location for the osteotomy is also described.Methods:Twelve fresh-frozen adult foot specimens were used for this study (7 male and 5 female). The MDCN and its branches were dissected and its relationship with the MC was documented. Osteotomy tilt angle and relationship to structures around the MC were measured.Results:MDCN traveled medially and distally over the dorsum of the MC, and a small branch to the MC was observed. The tilt angle was 80.1 ±1.4 degrees. There was no significant difference between the distance from the distal-articular surface to the midline of the cuneiform and to the interosseous ligament (P = .69), or between the distance from the distal-articular surface to the second tarsometatarsal joint and to the origin of the Lisfranc ligament (P = .12).Conclusions:The dorsal-medial-oblique incision effectively protected MDCN and the MC. We believe the osteotomy should be performed in the safe zone to maintain the stability of the opening wedge.Clinical relevance:The dorsal-medial-oblique incision could reduce the risk of injury to the MDCN and the tibialis-anterior tendon.

Weightbearing CT and MRI findings of Stage II Flatfoot Deformity: Can We Predict Patients at High- Risk for Foot Collapse?

Category:HindfootIntroduction/Purpose:Adult acquired flatfoot deformity (AAFD) is characterized by concurrent bony deformities, tendinous and ligamentous insufficiencies. Weightbearing CT (WBCT) allows excellent dynamic evaluation of the relative three-dimensional positioning of the tarsal bones. MRI provides accurate evaluation of soft tissue integrity in the unloaded foot. Study’s objective was to evaluate the correlation between bone deformity and soft tissue insufficiency in patients with stage II AAFD, using WBCT and MR images. We hypothesized that significant correlation would be found between WBCT measurements of increased longitudinal arch collapse, hindfoot valgus, peritalar subluxation and forefoot abduction, with MRI findings demonstrating degree of soft tissue involvement.Methods:This retrospective comparative study included 55 patients (56 feet) with stage II AAFD, 20 men and 35 women, mean age of 52.5 (range, 20 to 78) years. Multiple WBCT and MRI variables related to the severity of the deformity were evaluated by four blinded and independent readers (two radiologists and two foot and ankle surgeons), including: arch collapse (navicular-floor distance and forefoot arch angle), hindfoot alignment angle (HAA), forefoot abduction (talonavicular uncoverage angle), subtalar joint subluxation, sinus tarsi and subfibular impingement, and soft tissue insufficiency (posterior tibial tendon, spring and talocalcaneal ligaments). Tendinous and ligamentous involvement on MRI were graded from zero (normal) to four (complete tear). Intra- and interobserver reliabilities were assessed by Pearson/Spearman’s and intraclass correlation coefficient, respectively. A multiple regression analysis was used to evaluate the relationship between bone alignment (WBCT variables) and soft tissue injury (MRI variables). P-values of less than 0.05 were considered significant.Results:We found overall good to excellent intra (range, 0.83-0.99) and interobserver reliability (range, 0.71-0.97) for WBCT measurements and MRI readings. Spring ligament superomedial component involvement was the only finding to correlate with medial column collapse and decreased navicular-floor distance (p=0.03). Superomedial spring ligament and PTT degeneration were also significantly correlated with increased HAA (p<0.01). Involvement of the talocalcaneal interosseous ligament significantly correlated with increased forefoot abduction as measured by the talonavicular uncoverage angle. Spring ligament degeneration, of both superomedial and inferior components, and talocalcaneal interosseous ligaments significantly correlated to subtalar joint subluxation (p<0.001). Involvement of the talocalcaneal interosseous ligament was the only one to significantly correlate to the presence of subfibular impingement (p=0.02). Degeneration of the PTT was significantly associated with sinus tarsi impingement (p=0.04).Conclusion:This study is the first to evaluate correlation between bone, tendinous and ligamentous involvement in AAFD patients, using WBCT and MR images. Our results demonstrated that progressive bone deformity in WBCT is significantly correlated to MRI involvement of the PTT and other important restraints such as the spring and talocalcaneal ligaments. The implications are that WBCT can predict ligamentous injuries and that MRI can predict dynamic bone deformity in AAFD patients. Furthermore, the correlation of bone and soft tissue involvement could impact surgical planning of flatfoot patients, decreasing thresholds for additional soft tissue procedures such as a spring ligament reconstruction.

The Effects of Capitate Height Alteration on Dorsal Intercalated Segment Instability.

Question/Purpose Carpal kinematics may be influenced by the manipulation of carpal dimensions. This may provide a surgical alternative to unpredictable soft tissue reconstruction for scapholunate dissociation. The purpose of this study was to determine if altering capitate height can correct dorsal intercalated segment instability (DISI). Materials and Methods Five cadaveric wrists had baseline radiolunate (RL) angles and scapholunate (SL) intervals measured fluoroscopically, confirming no baseline DISI. We simulated open- and clenched-fist testing via a constant load of the wrist extensors and sequential loading of the digital flexors. We confirmed no baseline static/dynamic DISI. The SL ligament and secondary stabilizers (scapho-trapezio-trapezoid [STT] and dorsal intercarpal ligaments) were transected. Repeat loading and fluoroscopic measurements confirmed creation of static DISI. Capitate height was altered in three interventions: 2 mm shortening osteotomy of capitate waist, 7 mm shortening osteotomy of capitate waist, and 2 mm lengthening of original capitate height by insertion of a spacer at capitate waist. The osteotomized capitate was stabilized with a Kirschner wire; RL angles and SL intervals were measured via fluoroscopy during open- and clenched-fist testing. Primary and secondary outcomes were change in RL angle and SL interval, from the DISI stage to each capitate shortening and lengthening stage. Results SL ligament and secondary stabilizers sectioning created a DISI pattern, with abnormal RL angles (>15°) and widened SL intervals. Neither capitate shortening nor overexpansion corrected RL angles or SL intervals in any DISI-induced wrists. Conclusions Under the conditions studied, isolated capitate shortening or lengthening did not correct radiographic DISI posturing of the lunate following sectioning of the SL and STT interosseous ligaments. Further study of carpal kinematics with more substantial bone changes and loading of adjacent joints may be beneficial. Clinical relevance Surgeons performing capitate shortening osteotomy in isolation should not expect to improve DISI.

Role of Ligament Stabilizers of the Proximal Carpal Row in Preventing Dorsal Intercalated Segment Instability: A Cadaveric Study.

Isolated injuries of the scapholunate interosseous ligament (SLIL) are insufficient to produce dorsal intercalated segment instability. There is no consensus about which additional ligamentous stabilizers are critical determinants of dorsal intercalated segment instability. The aim of this study was to evaluate the role of the long radiolunate (LRL), scaphotrapeziotrapezoid (STT), and dorsal intercarpal (DIC) ligaments in preventing dorsal intercalated segment instability. Thirty fresh-frozen forearms were randomized to 5 ligament section sequences to study the SLIL, LRL, STT, and DIC ligaments. The DIC-lunate insertion (DIC) and scaphoid insertion (DIC) were studied separately; the DIC insertions on the trapezium and triquetrum were left intact. Loaded posteroanterior and lateral fluoroscopic images were obtained at baseline and repeated after each ligament was sectioned. After each sequence, the wrists were loaded cyclically (71 N). The radiolunate angle was measured with load. Dorsal intercalated segment instability was defined as an increase of >15° in the radiolunate angle compared with baseline. Division of the SLIL did not increase the radiolunate angle. Section of the SLIL+LRL or SLIL+DIC significantly increased the radiolunate angle but did not produce dorsal intercalated segment instability. Section of the SLIL+STT or SLIL+DIC+DIC produced dorsal intercalated segment instability. In order to produce dorsal intercalated segment instability, complete scapholunate injuries require the disruption of at least 1 critical ligament stabilizer of the scaphoid or lunate (the STT or DIC+DIC). When treating SLIL tears with dorsal intercalated segment instability, techniques to evaluate the volar and dorsal critical stabilizers of the proximal carpal row should be considered.

Long-Term Outcomes for Arthroscopic Thermal Treatment for Scapholunate Ligament Injuries.

Background Arthroscopic electrothermal treatment of low-grade Geissler's scapholunate interosseous ligament (SLIL) tears has shown clinical benefit at short-term follow-up. Questions/Purpose This study aims to evaluate the long-term functional outcomes in patients undergoing this treatment. Patients and Methods A retrospective review of all patients treated between 2005 and 2013 was performed. Patients were excluded with less than 5 years of follow-up, the presence of static SLIL injuries, prior wrist surgery, and concomitant denervation. Symptom resolution, return to activity, postoperative complications, range of motion, grip strength, and subsequent treatment were recorded. Each patient completed Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Modified Mayo Wrist (MMW), and Patient-Rated Wrist Evaluation (PRWE) questionnaires. Results Nine patients underwent treatment for Geissler's grade I, II, and III SLIL injuries with a mean 7 years (range: 5-11 years) of follow-up. Mean grip strength was 99% of the nonsurgical extremity. Wrist motion was near symmetric with a mean of 76 (±14), 74 (±8), 21 (±13), and 40 degrees (±13) for wrist flexion, extension, radial deviation, and ulnar deviation. QuickDASH improved significantly by a mean 39 points (50 (preoperative)-11 [postoperative], p = 0.009). Postoperative MMW and PRWE scores were 83 and 14, respectively. Visual analog scale (VAS) score was 1.4. A total of 90% was returned to their preinjury level of function or higher. Conclusions Arthroscopic electrothermal treatment of low-grade Geissler's SLIL tears demonstrates excellent objective and subjective outcomes at a minimum 5-year follow-up, providing evidence that this is an effective, safe, and, most importantly, durable-therapeutic modality. Level of Evidence This is a Level IV, case series study.