Lateral Femoral Epicondyle Research Articles

Trends in lateral extra-articular augmentation use and surgical technique with anterior cruciate ligament reconstruction from 2016-2023, an ACL Study Group Survey

PurposeTo survey the ACL study group (ACLSG) members to determine the current practice patterns surrounding the use and methodology of lateral extra-articular procedures (LEAPs), including anterolateral ligament reconstruction (ALLR) or lateral extra-articular tenodesis (LET) during ACL reconstruction (ACLR). MethodsA web-based questionnaire was distributed to members of the ACLSG during the 2016, 2018, 2020, and 2023 biennial meetings. Questions explored the indications and techniques when incorporating LEAPs in ACLR. ResultsAnalysis of survey responses found that the reported use of LEAPs in both primary and revision ACLR significantly increased between 2016 and 2023 and that surgeons were using lateral augmentation more frequently over time. Surgical techniques were stable across survey years, with most surgeons using iliotibial band (ITB) autograft attached at Gerdy's tubercle, passed under the lateral collateral ligament (LCL), and anchored proximal/posterior to the lateral femoral epicondyle. ConclusionSurvey responses demonstrate that LEAPs are becoming more common among ACL surgeons in the ACL SG, with the modified Lemaire LET being the predominant technique. This aligns with recent clinical studies showing improved outcomes and reduced risk of failure in ACLR with lateral augmentation compared to ACLR alone. Level of evidenceLevel V, Expert Opinion

Magnetic Resonance Imaging Features of Anterolateral Ligament in Young Adults without Anterior Cruciate Ligament Injury: Preliminary Evaluation.

This study aimed to characterize the Magnetic Resonance Imaging (MRI) features of the Anterolateral Ligament (ALL) in young adults without Anterior Cruciate Ligament (ACL) injury and evaluate its visibility using MRI. In this retrospective analysis, MRI scans of 66 young adults without ACL injuries were assessed by two radiologists. The ALL was examined from its bone-to-bone attachment between the lateral femoral epicondyle and the lateral tibia. The visibility of the ALL was classified as normal, probably normal, abnormal, or non-visualized, based on ligament continuity and thickness relative to the Meniscotibial Ligament (MTL). A continuous structure with thickness equal to or greater than the MTL was considered normal; continuous but wavy and thin features were categorized as probably normal; discontinuity and angulation were deemed abnormal. The proximal attachment of the ALL was categorized as anterior, central, or posterior to the Fibular Collateral Ligament (FCL), while the distal attachment was noted as either at the same location or distal to the MTL. The ALL was identified in 87.9-95.5% of knees and was non-visualized in 4.5-12.1% of cases. Continuous ligamentous structures were observed in 63.7-71.2% of knees (normal in 30.3-37.9%; probably normal in 27.3-40.9%), whereas 19.7-30.3% exhibited abnormal features. Inter-observer agreement was moderate to substantial (κ = 0.66, 0.56), and intra-observer agreement was substantial to excellent (κ = 0.82, 0.66). Among the 58 visible ALLs, proximal attachments were predominantly anterior (63.8%) or central (32.8%) to the FCL, with a minority posterior (1.7%). In total, 4 of the 19 central insertions were incorporated into the FCL mid-substance, and one case was blended into the meniscofemoral ligament. Distal attachments were equally distributed between the same location (50%) and distal to the MTL (50%) (mean 3.7 mm distal). In conclusion, MRI was feasible for detecting the ALL in most young adults without ACL injury, revealing continuous ligament structures in about two-thirds of cases. Approximately 40% of cases exhibited a thickness equal to or greater than the MTL, with the majority of proximal attachments located anterior to the FCL and distal attachments evenly divided between the same insertion and distal to the MTL.

Identifying iliotibial band graft length and incision site may minimise the potential risk of harming adjacent structures: A novel approach for surgeon guidance.

The Iliotibial band (ITB) is a fibrous thickening of the fascia lata originating at the iliac crest and inserting at Gerdy's tubercle on the lateral tibia. The ITB significantly contributes to lateral knee stabilisation. Due to its size, tensile strength and easy access, it is widely used in orthopaedic surgery as an autograft during reconstruction procedures. Although ITB harvesting may result in complications, such as reduced knee extension or hip flexion, no safety margins or guidelines have been proposed for the procedure. Our aim was to determine the maximal safe length of an ITB graft, that is, that does not harm the lateral collateral ligament (LCL), tensor fasciae latae (TFL), gluteus maximus (GM) or adjacent structures, and reduce the complication rate. The study included 50 lower limbs of 25 human cadavers, previously fixed in 10% formalin solution. The inclusion criterion was the lack of visible signs of surgical interventions in the study region. Forty lower limbs were included in the study: 16 female (mean age 83.1 ± 3.4 years) and 24 male (mean age 84.2 ± 6.8 years). Dissection was performed with a previously established protocol. Morphometric measurements were then obtained twice by two researchers. The mean femur length was 404.8 mm [female (F) = 397.3 mm, male (M) = 409.9 mm, standard deviation (SD): F = 23.8 mm, M = 24.1 mm]. The mean ITB length was 318.9 mm (F = 309.4 mm, M = 325.2 mm, SD: F = 25.7 mm, M = 33.7 mm). Longer femurs were associated with longer ITB (p < 0.05). The mean distance from the insertion of the GM to the myofascial junction of TFL and ITB was 34.6 mm (F = 34.5 mm, M = 34.6 mm, SD: F = 3.2 mm, M = 3.3 mm). The longer femurs or ITBs demonstrated a greater distance from GM insertion to the myofascial junction of the TFL and ITB (p < 0.05). ITB grafts longer than 21 cm may contribute to the greater risk of TFL rupture. Based on simple measurements of the femur length, the surgeon may assess approximate ITB length, and thus assess the length of the maximal graft length. Moreover, to avoid harming the LCL, the incision should be performed 5 cm proximal to the articular surface of the lateral femoral condyle or 13 mm proximal to the lateral femoral epicondyle. Such preparation and preoperative planning may greatly reduce the risk of complications during ITB harvesting, while performing, for instance, the over-the-top technique for anterior cruciate ligament reconstruction in skeletally immature patients. Basic I.

Never undescribed four - headed plantaris muscle.

The plantaris is a small muscle of the superficial posterior compartment of the leg. It originates at the lateral supracondylar line of the femur and the knee joint capsule, from where it continues distally, forming a long and slender tendon distally attached to the calcaneal tuberosity. During standard anatomical dissection four-headed plantaris muscle was found and all of its heads connected to each other as a single muscle belly passing into tendinous structure which was distally attached as a standard plantaris muscle. The first head originated from the popliteal surface of the femur. The second one was originated from distal Kaplan fiber. In turn, the third and fourth heads were proximally attached to the lateral femoral epicondyle. Knowledge about morphological variations is necessary because of its potential clinical significance, which means not only neurovascular compressions, but also surgical procedures.

The PIVOT App: A User Guide

Background: While the pivot shift examination is often regarded as the gold standard test for diagnosis of anterior cruciate ligament (ACL) injury, one of the pitfalls of the pivot shift test is that it lacks standardization among physicians. The PIVOT App is a validated application to quantify the amount of tibial translation during the pivot shift maneuver and improve standardization of clinical measurement. Indications: The PIVOT App can be used in both clinic and operating room settings for patients who sustained injury to the ACL. The PIVOT App may assist in identifying the amount of rotatory knee laxity in patients with ACL deficiency or following ACL reconstruction. Technique Description: The PIVOT App works by quantifying the amount of translation in the lateral tibia relative to a marker on the lateral femoral epicondyle. To use the PIVOT App, 3 yellow circle stickers are placed on the bony prominences of the lateral knee: the lateral epicondyle, Gerdy’s tubercle, and the “pivot point” 3 cm posterior to Gerdy’s tubercle parallel to the joint line. Once placed, the pivot shift flexion maneuver can be recorded in the PIVOT App and analyzed to identify both the distance of spontaneous tibial reduction during the pivot shift maneuver and the time of reduction in seconds. The most common problems encountered while using the application include (1) improper marker placement, (2) interference of marker tracking with yellow color in the background, (3) interference of marker tracking with overhead lighting, and (4) extraneous data collection before and after pivot shift flexion. Results: Previous studies have validated the PIVOT App to accurately distinguish normal, low-grade, and high-grade pivot shifts with resultant increasing tibial translation in the lateral compartment of the knee. The PIVOT App has been used at institutions worldwide to quantify and standardize measurement of the pivot shift. Conclusion: The PIVOT App is a validated application to quantify the amount of lateral tibial translation and reduction during the pivot shift maneuver. Proper use and avoidance of complications while using the application can aid clinicians in accurate diagnosis of rotatory knee laxity in patients following ACL injury. Patient Consent Disclosure Statement: 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.

Exposure of Hoffa Fractures Is Improved by Posterolateral and Posteromedial Extensile Approaches: A Qualitative and Quantitative Anatomical Study.

The current literature lacks recommendations regarding surgical approaches to best visualize and reduce Hoffa fractures. The aims of this study were to (1) define surgical corridors to the posterior portions of the lateral and medial femoral condyles and (2) compare the articular surface areas visible with different approaches. Eight fresh-frozen human cadaveric knees (6 male and 2 female donors; mean age, 68.2 ± 10.2 years) underwent dissection simulating 6 surgical approaches to the distal femur. The visible articular surface areas for each approach were marked using an electrocautery device and subsequently analyzed using image-processing software. The labeled areas of each femoral condyle were statistically compared. At 30° of flexion, visualization of the posterior portions of the lateral and medial femoral condyles was not possible by lateral and medial parapatellar approaches, as only the anterior 29.4% ± 2.1% of the lateral femoral condyle and 25.6% ± 2.8% of the medial condyle were exposed. Visualization of the lateral femoral condyle was limited by the posterolateral ligamentous structures, hence a posterolateral approach only exposed its central (13.1% ± 1.3%) and posterior (12.4% ± 1.1%) portions. Posterolateral extension by an osteotomy of the lateral femoral epicondyle significantly improved the exposure to 53.4% ± 2.7% and, when combined with a Gerdy's tubercle osteotomy, to 70.9% ± 4.1% (p < 0.001). For the posteromedial approach, an arthrotomy between the anteromedial retinaculum and the superficial medial collateral ligament, and one between the posterior oblique ligament and the medial gastrocnemius tendon, allowed visualization of the central (13.5% ± 2.2%) and the posterior (14.6% ± 2.3%) portions of the medial femoral condyle, while a medial femoral epicondyle osteotomy significantly improved visualization to 66.1% ± 5.5% (p < 0.001). Visualization of the posterior portions of the femoral condyles is limited by the specific anatomy of each surgical corridor. Extension by osteotomy of the femoral epicondyles and Gerdy's tubercle significantly improved articular surface exposure of the femoral condyles. Knowledge of the surgical approach-specific visualization of the articular surface of the femoral condyles might be helpful to properly reduce small Hoffa fragments.

A Cadaveric Study of the Optimal Isometric Region on the Anterolateral Surface of the Knee in Anterolateral Ligament Reconstruction.

Isolated intra-articular anterior cruciate ligament (ACL) reconstruction is not capable of restoring instability in many cases leading some to recommend concomitant anterolateral ligament (ALL) reconstruction. The satisfactory fixation site and graft length change are crucial in ligament reconstruction to restore the ALL function and avoid some unwanted graft behavior. The purpose of this investigation is to determine the optimal isometric region on the anterolateral aspect of the knee for ALL reconstruction using a three-dimensional optical instrument and a suture similar to an intraoperative isometric test. Six freshly frozen cadaveric human knees were used in this study. Data regarding the anterolateral surface were obtained using an optical measurement system to create a three-dimensional model. Nine points were selected on the femur (F1-F9) and tibia (Ta-Ti) respectively. The three-dimensional length change between each pair of tibial and femoral points was measured during passive knee flexion from 0° to 90° in 15° increments. Subsequently, five femoral points (A-E) were selected from the lateral femur, located in different areas relative to the lateral femoral epicondyle, and three tibial reference points (T1-T3) were selected in the isometric test. The changes in the length between each pair of reference points were measured using sutures. The 95% confidence interval for the rate of length change was estimated using the mean and standard deviation of the maximum rate of length change at different flexion angles, and the data were expressed as the mean (95% confidence interval) and compared with the maximum acceptable rate of change (10%). The maximum acceptable change rate for ligament reconstruction is 10%, and the mean maximum rates and the 95% confidence interval (CI) of length change for the point combinations were calculated. Among all the combined points measured using the optical measurement system and the suture, the qualified point combination for reconstruction was F3 (8mm posterior and 8mm proximal to the lateral femoral epicondyle)-Tb (8mm proximal to the midpoint between the center of Gerdy's tubercle and the fibula head), A (posterior and proximal to the lateral femoral epicondyle)-T2 (10mm below the joint line)and A-T3 (15 mm below the joint line). The position of F3-Tb and A-T2 are close to each other. The most isometric area of the femur for ALL reconstruction was posterior and proximal to the lateral femoral epicondyle. We recommend that the initial location of the femoral point be set at 8 mm posterior and 8 mm proximal to the lateral femoral epicondyle and the tibial point at approximately 10 mm below the joint line, midway between Gerdy's tubercle and fibular head, and subsequently adjusted to the most satisfactory position according to the isometric test.

DETERMINING THE SAFETY AND ACCESSIBILITY OF DIRECT POSTERIOR PORTALS INTO THE KNEE WITH RESPECT TO THE NEUROVASCULAR STRUCTURES: A CADAVERIC STUDY

The posterior compartments of the knee are currently accessed arthroscopically through anterior, posteromedial or posterolateral portals. A direct posterior portal to access the posterior compartments has been overlooked due to a perceived high-risk of injury to the popliteal neurovascular structures. Therefore, this study aimed to investigate the safety and accessibility of a direct posterior portal into the knee.This cross-sectional study comprised a sample of 95 formalin-embalmed cadaveric knees and 9 fresh-frozen knees. Cannulas were inserted into the knees, 16mm from the vertical plane between the medial epicondyle of the femur and medial condyle of the tibia and 8 and 14mm (females and males respectively) from the vertical plane connecting the lateral femoral epicondyle and lateral tibial condyle. Landmarks were identified in full extension and cannula insertion was completed with the formalin-embalmed knees in full extension and the fresh-frozen in 90-degree flexion. Posterior aspects of the knees were dissected from superficial to deep, to assess potential damage caused by cannula insertion. Incidence of neurovascular damage was 9.6% (n=10); 0.96% medial cannula and 8.7% lateral cannula. The medial cannula damaged one small saphenous vein (SSV) in a male specimen. The lateral cannula damaged one SSV, 7 common fibular nerves (CFN) and both CFN and lateral cutaneous sural nerve in one specimen. All incidences of damage occurred in formalin-embalmed knees. The posterior horns of the menisci were accessible in all specimens.A medial-lying direct posterior portal into the knee is safe in 99% of occurrences. The lateral-lying direct posterior portal is of high risk to the CFN.

Lateral Extra-Articular Tenodesis in Skeletally Immature Patients: The Modified Ellison Technique

Background: Anterior cruciate ligament (ACL) rupture is an increasingly common injury in the young population. Unfortunately, reinjury rates in this population following ACL reconstruction (ACLR) are also very high. As such, lateral extra-articular procedures have been proposed to augment ACLR and shown to reduce reinjury rates. Most techniques use a strip of iliotibial band (ITB) fixed proximally on the distal femur in close proximity to the lateral femoral epicondyle, which in the skeletally immature patient may be closely associated with the distal femoral physis. In addition, there is also a risk of convergence with the femoral tunnel for the ACLR. The modified Ellison technique avoids both of these risks given it is a distally based tenodesis with its fixation point on the proximal tibial epiphysis. The purpose of this video is to describe a modified Ellison technique in a skeletally immature patient. Indications: Primary ACLR in skeletally immature patients at high risk of ACL graft rerupture due to their young age, a positive family history of ACL rupture in a first-degree relative, previous contra-lateral ACL rupture, generalized joint hypermobility, high-grade pivot-shift test, and participating in pivoting sports. Technique Description: The modified Ellison technique is a distally based lateral extra-articular procedure. A 1-cm strip of ITB is detached from Gerdy’s tubercle, passed beneath the lateral collateral ligament, and reattached back to from where it was removed. The fixation is within the proximal epiphysis of the tibia. Results: In a high-risk adult population, the modified Ellison technique has been shown to have a low ACL graft reinjury rate at 2 years following an ACLR. Biomechanical studies have demonstrated that a modified Ellison technique closely restores native knee kinematics following simulated anterolateral complex injury. Discussion/Conclusion: The modified Ellison technique is a safe and reproducible lateral extra-articular procedure in skeletally immature patients when performed in combination with an ACLR. Patient Consent Disclosure Statement: 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 effects of alteration in muscle activation on the iliotibial band during an exhaustive run

PurposeLong exhausted running causes pain at the lateral femoral epicondyle for some runners. The pain has been revealed to be related to the behavior of the iliotibial band (ITB) during running. The purpose of this study is to examine the effects of in-series musculature on the behavior of the ITB in healthy participants during an exhaustive run.MethodsTwenty-five healthy participants (15 males, 10 females) were recruited in the current study. All participants performed a 30-minute exhaustive run at a self-selected speed with laboratory-provided footwear. Muscle activities of ITB-related muscles including tensor fascia latae (TFL), gluteus maximus (Gmax), gluteus medius (Gmed), biceps femoris (BF), and vastus lateralis (VL) were recorded using surface electromyography (EMG).ResultsMaximum amplitudes at the initial stage (the first minute), the mid stage (the 15-minute), and the end stage (the 30-minute) were compared during the exhaustive running. Significant decreases (p < 0.05) were observed in the maximum amplitudes of the TFL, Gmax, Gmed, and BF at the mid (decreased by ~ 15%) and end (decreased by ~ 30%) stages compared to the initial stage. The onset and the offset remained unaltered during the running (p ≥ 0.05).ConclusionThe behavior of the healthy ITB might be altered due to the activities of the in-series musculature. Excessive compression forces might be applied to the lateral femoral epicondyle from the ITB to provide stability for the knee joint during an exhaustive run. The findings could provide a basic understanding of the behavior of healthy ITB.

Intrinsic risk factors associated with iliotibial band syndrome: A systematic review

Objectiveː Iliotibial band syndrome (ITBS) is the second most common running injury and the leading cause of lateral knee pain. Despite the numerous investigations on the subject, the intrinsic risk factors that may be involved in the syndrome have still not been highlighted and no consensus has been established in the literature. The objective of this systematic review is to investigate intrinsic risk factors associated with iliotibial band syndrome in order to provide an algorithm for future research and clinical guidance. Material and Methods: A systematic review of the literature was carried out according to the PRISMA guidelines, in the PubMed and ScienceDirect databases in order to identify studies investigating different parameters on patients with the syndrome since 2015; the date of the last systematic review on the subject. Resultsː Ten studies met the inclusion criteria of this review: cohort (n=1), cross-sectional study (n=8), case-control study (n=1). The results show that subjects with iliotibial band syndrome show atypical frontal plane kinematics in the hip and knee joint, a more prominent lateral femoral epicondyle, thickening of the iliotibial band, femoropatellar abnormalities and less resistance to fatigue of the gluteus medius muscle. Conclusionː This review offers opportunities in the management of ITBS. Some morphological, neuromuscular, muscle strength and biomechanical factors have been identified specific to ITBS patients. However, this work has several limitations; a small number of included studies, a lack of high-level studies, and methodological biases. Further studies, including randomized controlled trials and prospective studies are needed to reveal strong relationships between intrinsic risk factors and the onset of the syndrome.

Iliotibial band syndrome - demotion of the lateral femoral epicondyle as a surgical alternative

Objective: Demonstrate an alternative surgery technique for the treatment of Iliotibial band syndrome (ITBS) refractory to conservative treatment, through the lowering of the lateral femoral epicondyle. Methods: From 2005 and 2017, it was analyzed 9 patients diagnosed with ITBS refractory to conservative treatment. They underwent surgery using the main author's own technique (SM), which consists of lowering the lateral femoral epicondyle (LFE), with a mean follow-up time of 13 years, ranging from 5.5 to 16.6 years. They were assessed pre- and postoperatively for pain and return to sports Results: All 9 patients had immediate relief from the pain caused by ITBS. On average, three months after the surgery they were returning to their daily activities and sport Conclusion: The proposal technique of the demotion of the LFE showed excellent and immediate results in post op and long term related to pain and the return to sports We believe that this technique is a great alternative for chronic and refractory cases of ITBS.

Lateral Extra-Articular Tenodesis via an All-Suture Anchor

Background: In young patients, anterior cruciate ligament (ACL) reconstruction often results in graft failure. This may be due, in part, to concomitant injury to anterolateral complex (ALC) of the knee leading to rotatory laxity. The modified Lemaire lateral extra-articular tenodesis (LET) technique is intended to address the anterolateral rotatory instability due to injury to the ALC and to protect the ACL graft and meniscus. Indications: The International Anterolateral Complex Consensus Group Meeting identified 4 appropriate indications for the modified Lemaire LET procedure: revision ACL, high-grade pivot shift, generalized ligamentous laxity/genu recurvatum, and young patients returning to pivoting activities. Technique Description: The technique consists of harvesting an 8-cm long by 1-cm wide graft from the iliotibial band. The graft is released proximally and remains attached distally to Gerdy’s tubercle. The graft is then passed deep to the lateral collateral ligament (LCL) from distal to proximal. The graft is then affixed to a point proximal and posterior to the lateral femoral epicondyle with an all-suture button. The graft is then tensioned with knee at 30° of flexion and neutral rotation, and then secured in place. Results: With the modified Lemaire LET, there was previously concern for overconstraint and lateral compartment degeneration. However, recent studies have shown that there is no increased risk for these complications with the LET procedure. The STABILITY trial found that the addition of LET to ACL reconstruction significantly reduces re-rupture and residual laxity when compared with ACL reconstruction alone. Moreover, the addition of LET to ACL reconstruction can restore native knee kinematics. Conclusion: The addition of the modified Lemaire LET technique to traditional ACL reconstruction is a safe and effective adjunct that reduces the occurrence of graft rupture, addresses residual rotational laxity, and can restore native knee kinematics in appropriately indicated patient populations. Patient Consent Disclosure Statement: 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.

Anatomical and Biomechanical Characteristics of the Anterolateral Ligament: A Descriptive Korean Cadaveric Study Using a Triaxial Accelerometer.

Background and Objectives: The anterolateral ligament (ALL) could be the potential anatomical structure responsible for rotational instability after anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to investigate the anatomical and biomechanical characteristics of the ALL in Korean cadaveric knee joints. Materials and Methods: Twenty fresh-frozen cadaveric knees were dissected and tested. Femoral and tibial footprints of the ALL were recorded. Pivot shift and Lachman tests were measured with KiRA. Results: The prevalence of ALL was 100%. The average distance of the tibial footprint to the tip of the fibular head was 19.85 ± 3.41 mm; from the tibial footprint to Gerdy's tubercle (GT) was 18.3 ± 4.19 mm; from the femoral footprint to the lateral femoral epicondyle was 10.25 ± 2.97 mm. ALL's footprint distance was the longest at 30° of flexion (47.83 ± 8.05 mm, p < 0.01) in a knee with intact ALL-ACL and neutral rotation. During internal rotation, the footprint distance was the longest at 30° of flexion (50.05 ± 8.88 mm, p < 0.01). Internal rotation produced a significant increase at all three angles after ACL-ALL were transected (p = 0.022), where the footprint distance was the longest at 30° of flexion (52.05 ± 7.60 mm). No significant difference was observed in KiRA measurements between intact ALL-ACL and ALL-transected knees for pivot shift and Lachman tests. However, ACL-ALL-transected knees showed significant differences compared to the intact ALL-ACL and ALL-transected knees (p < 0.01). Conclusions: The ALL was identified as a distinct ligament structure with a 100% prevalence in this cadaveric study. The ALL plays a protective role in internal rotational stability. An isolated ALL transection did not significantly affect the ALL footprint distances or functional stability tests. Therefore, the ALL is thought to act as a secondary supportive stabilizer for rotational stability of the knee joint in conjunction with the ACL.

Depression fractures of the posterolateral tibial plateau: Treatment by lateral femoral epicondyle osteotomy approach

ObjectiveThe best surgical exposure and fixation method for fractures affecting the posterolateral corner of the tibial plateau remain debatable. This study describes a surgical approach to treat lateral depressions of the posterolateral tibial plateau with or without rim involvement by osteotomy of the lateral femoral epicondyle associated with osteosynthesis with a one-third tubular horizontal belt plate to stabilize the fracture fragment. MethodWe evaluated 13 patients with fractures of the tibial plateau affecting the posterolateral region. Assessments included the degree of the depression (in millimeters), quality of the reduction, complications, and function. ResultsAll fractures and osteotomies consolidated. The patients had a mean age of 48 years and were mostly men (n=8). Regarding the quality of the reduction, the mean reduction obtained was 15.8 mm, and 8 patients achieved anatomical reduction. The mean (± standard deviation) Knee Society Score was 92±13 (range 65–100), and the mean Function Score was 95±9.6 (range 70–100). The mean Lysholm Knee Score was 92±11.7 (range 66–100), and the mean International Knee Documentation Committee Score was 85±12.6 (range 63–100). All these scores reflect good results. None of the patients developed superficial or deep infection or presented healing disorders. Sensitive or motor complications of the fibular nerve were not observed. ConclusionsIn this series of patients with depression fractures of the posterolateral tibial plateau, a surgical approach through osteotomy of the lateral femoral epicondyle allowed direct reduction and stable osteosynthesis of the fractures without functional impairment.

Development of diagnosis and treatment in the iliotibial band syndrome

Introduction and objective: The iliotibial band (ITB) is a complex structure located in the lateral part of the thigh and consists of longitudinally arranged fascial connective tissue. The aim of this study is to analyze the current literature regarding etiology, epidemiology, diagnosis, and conservative treatment of iliotibial band syndrome (ITBS). Materials and methods: PubMed database were searched. The criteria for qualifying the article for the review were the following keywords: running, iliotibial band syndrome, knee injuries, conservative treatment, physical therapy modalities. 11 articles from 2017 to 2022 were analyzed. The searches included systematic reviews, meta-analyses, randomized controlled trials, and review articles. Description of the state of knowledge: Iliotibial band syndrome is the most common cause of lateral knee pain in runners and cyclists. It is presumably caused by excessive tension in the iliotibial band. Excessive tension is the result of overuse disorder of the lateral knee. Key symptom of ITBS is sharp or burning pain in the region of the lateral femoral epicondyle.. Pain typically occurs during physical activity, after a reproducible time or distance of running. The diagnosis is achieved through taking clinical history and physical assessment. Summary: Treatment of ITBS is based on therapeutic exercise, manual therapy, neuromuscular re-education, modalities and anti-inflammatory medications. Eliminating modifiable risk factors helps prevent ITBS from recurring.

Artículo traducido] Ligamento anterolateral de la rodilla. Estudio en cadáver en una población caucásica

IntroductionDespite the recognized importance of the anterolateral ligament (ALL) in rotational stability of the knee, some studies still deny its role and even its existence. We studied the prevalence of the ALL in a Caucasian population, as well as its characteristics and anatomical relationships. Materials and methodsThe study was performed on 20 knees from 10 embalmed cadavers. A lateral approach, as described by Steven Claes, was used and the relations of the ALL with the lateral epicondyle, lateral inferior genicular artery, lateral meniscus, Gerdy's tubercle and fibular head were recorded. Its length and its width were also measured. ResultsThe ALL was identified in 16 knees. Its origin was at a distance inferior to 1mm posterior and proximal to the lateral femoral epicondyle and insertion within a mean distance of 2.1±0.6mm from the tibial articular surface, 20.6±1.3mm from the Gerdy's tubercle and 20.3±1.2mm from the fibular head. In all cases ALL presented mutual fibers with the lateral meniscus. The length was 35.8±4.6mm and the width was 4.2±1.3/4.9±1.0/6.5±1.5mm at its proximal, middle and distal third, respectively. No difference was found between gender and the dimensions of the ligament. ConclusionsThe ALL was found in 80% of the knees. Its origin is closely related to the lateral collateral ligament and its insertion is halfway between the fibular head and the Gerdy's tubercle. In all cases, we verified the connection between ALL and the lateral meniscus.

The Conventional Gait Model’s sensitivity to lower-limb marker placement

Clinical gait analysis supports treatment decisions for patients with motor disorders. Measurement reproducibility is affected by extrinsic errors such as marker misplacement—considered the main factor in gait analysis variability. However, how marker placement affects output kinematics is not completely understood. The present study aimed to evaluate the Conventional Gait Model’s sensitivity to marker placement. Using a dataset of kinematics for 20 children, eight lower-limb markers were virtually displaced by 10 mm in all four planes, and all the displacement combinations were recalculated. Root-mean-square deviation angles were calculated for each simulation with respect to the original kinematics. The marker movements with the greatest impact were for the femoral and tibial wands together with the lateral femoral epicondyle marker when displaced in the anterior–posterior axis. When displaced alone, the femoral wand was responsible for a deviation of 7.3° (± 1.8°) in hip rotation. Transversal plane measurements were affected most, with around 40% of simulations resulting in an effect greater than the acceptable limit of 5°. This study also provided insight into which markers need to be placed very carefully to obtain more reliable gait data.

Variation in Kaplan fiber insertion to the distal femur and surgical implications: A cadaveric anatomical study comparing Asian and Caucasian knees

BackgroundThe iliotibial band together with its attachment to the distal femur, known eponymously as the Kaplan fibers, has been shown to contribute to anterolateral rotatory stability of the knee. However, there remains paucity of data regarding the detailed anatomy of the Kaplan fibers to aid us in anatomical-based surgical reconstruction of these structures. The aim of our study was to identify and compare the presence and quantitative anatomy of the Kaplan fibers in Caucasian and Asian cadavers. MethodsTwenty paired fresh-frozen Asian and 20 unpaired embalmed Caucasian cadaveric knees were dissected using a standard outside–in technique. The presence, qualitative and quantitative measurements of any distal femoral attachments of the iliotibial band were recorded. Mean values of its dimensions were calculated and compared between the Caucasian and Asian groups. ResultsA consistent supracondylar attachment of the iliotibial band was found in all Caucasian knees and in 19 of 20 Asian knees. The fibers were noted to have two variations with regard to their insertion to the distal femur, either as a single limb or as a double limb attachment, averaging between 30 mm and 40 mm from the lateral femoral epicondyle. No statistically significant difference was noted in dimensions of the fibers between the Caucasian and Asian groups. ConclusionsThe Kaplan fibers are a consistent attachment of the iliotibial band at the distal femur in both Caucasian and Asian knees with two different patterns of insertion. Surgical reconstructions should aim to recreate these attachments to be as anatomically based as possible.

Imaging Findings of Complications After Lateral Extra-Articular Tenodesis of the Knee: A Current Concepts Review.

Background:Despite successful anterior cruciate ligament (ACL) reconstruction, many patients continue to experience persistent anterolateral rotatory instability. Lateral extra-articular tenodesis (LET) is used to address this instability by harvesting a portion of the iliotibial band, passing it underneath the fibular collateral ligament, and attaching it just proximal and posterior to the lateral femoral epicondyle. Based on the most recent clinical evidence, the addition of LET to ACL reconstruction improves clinical outcomes, which has led to an increase in the use of this technique.Purpose:To provide an overview of the postoperative complications of the LET procedure and their associated imaging findings, with a focus on magnetic resonance imaging (MRI).Study Design:Narrative review.Methods:In this scoping review, the authors reviewed available radiographic, computed tomography, and MRI scans of patients who experienced postoperative complications after ACL reconstruction with LET, in which the complication was determined to be from the LET procedure. Images were reviewed and subsequently described by an on-staff musculoskeletal radiologist.Results:The authors found 9 different complications associated with LET: graft failure, hematoma, infection, chronic pain, tunnel convergence, fixation device migration, muscular hernia, peroneal nerve palsy, and knee stiffness. They supplemented these findings with radiographic evidence from 6 patients.Conclusion:As extra-articular reconstruction techniques including LET become more popular among orthopaedic surgeons, it is important that radiologists and surgeons be adept at recognizing the normal imaging findings of LET and associated complications.