Ligamentous Complex Injury Research Articles

Anatomic Repair of a Lateral Collateral Ligament and Anterolateral Capsular Complex Injury With Internal Brace Augmentation

Background: Lateral collateral ligament (LCL) injuries are implicated in varus instability of the knee. Often, these accompany other ligamentous injuries including anterior cruciate ligament (ACL), posterior cruciate ligament (PCL) tears, and injury to the anterolateral capsular complex (ALCC). Use of internal brace augmentation with anatomic repair is an alternative to reconstruction to improve patient outcomes and facilitate early range of motion and weight bearing. Indications: We present a case of an anatomic repair of a LCL and an ALCC injury with internal brace augmentation. Technique Description: A curvilinear incision centered over the lateral epicondyle is used. The avulsed LCL and biceps tendon was exposed and a placed #5 FiberWire was placed into the distal LCL, biceps tendon, and the popliteofibular ligament. A split was made in the iliotibial (IT) band and a second #5 FiberWire was placed proximally in the LCL/biceps tendon for additional fixation. A tunnel was made in the fibular head and tibia using a 2.4-mm beath pin and the two #5 FiberWires were passed to the anteromedial tibia. The FiberWires were fixed to the tibia using a 14-mm attachable button system (ABS) manhole cover for suspensory fixation. Repair and internal bracing of the anterolateral capsular complex was accomplished with 2 interlocked TightRopes and a #2 FiberTape. This fixation method achieved repair by compressing the anterolateral capsular complex onto its tibial origin. The suture devices also served to augment the repair and were fixed proximally to the femur using another 14-mm ABS manhole cover. The FiberTape was fixed to the anterolateral tibia distally with a 4.5 mm SwiveLock. The TightRopes were passed through a tunnel to the anterolateral tibia and secured using an ABS Dog Bone. The construct was tensioned in near full extension and gapping was matched fluoroscopically to the contralateral knee. Results: Patient was cleared for full return to sports 9 months postoperatively. At the final follow up visit, the patient had excellent strength, stability, and 135° range of motion on the operative knee. Patient had returned to exercise at home but was unable to return to sports due to COVID-19 restrictions. Conclusion: Anatomic repair of the LCL and the ALCC with internal brace augmentation can serve as an effective alternative to reconstruction and demonstrates excellent patient outcomes regarding restoring stability, ROM, and return to preoperative sports.

Terrible triad injury of the elbow: a historical perspective.

The aims of this study are to summarize (1) the history of terrible triad injury (TTi) treatment and (2) the clinical and biomechanical data that engendered its evolution. A literature search was performed using fiveelectronic databases. Results were discussed as a chronologic review of the relevant literature between 1920 and 2022. In 1962, Osborne was the first to describe a link between elbow dislocation, radial head fracture, and lateral collateral ligament complex injury via a novel mechanism: posterolateral rotatory instability (PLRI). Given that untreated elbow instability leads to post-traumatic osteoarthritis (PTOA), there has been increasing interest in elbow biomechanics since the 1980s. Data from studies in that period revolutionized the approach to elbow instability. The authors demonstrated that TTi could occur via a PLRI mechanism with a disruption of the lateral collateral ulnar ligament and a functionally competent anterior medial collateral ligament (aMCL). Since the 1990s, due to the difficulty in identifying its pathoanatomic features, some began to speculate about a sequence of injuries and mechanisms leading to TTi. However, the clinical literature has largely been unable to reproduce in vitro findings describing the pathomechanics of TTi. Some aspects of treatment remain controversial including systematic coronoid and aMCL repair. Despite a growing body of biomechanics data, there is no widely accepted surgical protocol for the treatment of TTi. Functional outcomes among patients have greatly improved. Better diagnosis and treatment of infra-clinical instability after a TTi may be an important stepping stone to prevent the onset of moderate/severe PTOA.

Risk factors for proximal junctional kyphosis after posterior long-segment internal fixation for chronic symptomatic osteoporotic thoracolumbar fractures with kyphosis

BackgroundThis study aimed to analyze the risk factors for proximal junctional kyphosis (PJK) for patients with chronic symptomatic osteoporotic thoracolumbar fractures (CSOTLF) and kyphosis who underwent long-segment internal fixation.MethodsWe retrospectively reviewed the records of patients with CSOTLF complicated with kyphosis who underwent posterior multilevel internal fixation in our hospital between January 2013 and January 2020. The patients’ age, sex, body mass index (BMI), bone mineral density (BMD), smoking status, cause of injury, comorbidities, injury segments, and American Spinal Injury Association (ASIA) grading non-surgical data; posterior ligament complex (PLC) injury, upper and lower instrumented vertebral position (UIV and LIV, respectively), number of fixed segments surgical data, proximal junctional angle (PJA), sagittal vertebral axis (SVA), pelvic incidence (PI), lumbar lordosis (LL), pelvic incidence-lumbar lordosis mismatch (PI-LL), pelvic tilt (PT), and sacral slope (SS) surgical indicators were collected. Patients were divided into postoperative PJK and non-PJK groups.ResultsThis study included 90 patients; among them, 30 (31.58%) developed PJK postoperatively. All patients were followed up for > 24 months (mean 32.5 months). Univariate analysis showed significant differences in age, BMI, BMD, PLC injury, UIV, and LIV fixation position, number of fixation stages, and preoperative PJA, SVA, PI-LL, and SS between the two groups (P < 0.05). Additionally, no significant differences were observed in sex, smoking, cause of injury, complications, injury segment ASIA grade, and preoperative PT between the two groups (P > 0.05). Multifactorial logistic regression analysis showed that age > 70 years (OR = 32.279, P < 0.05), BMI > 28 kg/m2 (OR = 7.876, P < 0.05), BMD T value < − 3.5 SD (OR = 20.836, P < 0.05), PLC injury (OR = 13.981, P < 0.05), and preoperative PI-LL > 20° (OR = 13.301, P < 0.05) were risk factors for PJK after posterior long-segment internal fixation in elderly patients with CSOTLF complicated with kyphosis.ConclusionCSOTLF patients undergoing posterior long segment internal fixation are prone to PJK, and age > 70 years, BMI > 28 kg/m2, BMD T value < − 3.5 SD, preoperative PI-LL > 20° and PLC injury may increase their risk.

Soft Tissue Injury in Cervical Spine Is a Risk Factor for Intersegmental Instability: A Finite Element Analysis

Soft tissue cervical spine injury (CSI) has the possibility of causing cervical segmental instability, which can lead to spinal cord injury. There is a lack of certainty in assessing whether soft tissue CSI is unstable or not. This biomechanical study aimed to investigate the risk factors of soft tissue CSI. A 3-dimensional finite element model of the ligamentous cervical spine (C2-C7) was created from medical images. Three soft tissue injury models were simulated at C4-C5: 1) posterior ligament complex (PLC) injury, 2) intervertebral disk (ID) with anterior longitudinal ligament injury (IDI), and 3) anterior longitudinal ligament, PLC, and ID injury (API) model. Pure moment with compressive follower load was applied, and the range of motion, annular stress, nucleus stress, and facet forces were analyzed. For the IDI and API models, the range of motion increased at the injury level in extension (by 101%) and left/right axial rotations (>30%) compared with the intact model. The IDI and API models showed an increase of >50% in annular and nucleus stresses at the injury level in extension and left/right rotations compared with the intact model. The PLC injury showed similar stresses as the intact model except for flexion. The facet contact forces of IDI and API models increased more than 100% compared with other models in all motions. In CSI, all soft tissues have a key role in stabilizing cervical spine, but ID is the most important component of all.

Arthroscopic Medial Compartment Drive-Through Sign for Knee Medial Collateral Ligament Complex Injuries

Acute injuries of the knee medial collateral ligament complex concomitant with anterior cruciate ligament injuries are common. The exact site of the injury may be difficult to diagnose preoperatively on magnetic resonance imaging. This study describes an arthroscopic sign that helps determine the site of the knee medial collateral ligament complex injury. The “medial compartment drive-through sign,” visualized during arthroscopy, is described as an excessive opening of the medial compartment. If this excessive opening is above the meniscus, it corresponds to a femoral-sided injury; conversely, if the excessive opening is below the meniscus, then it is a tibial-sided injury. This allows a precise surgical incision to be made, thereby avoiding extensive approaches and possible wound-related complications.

How Often Would MRI Change the Thoracolumbar Fracture Classification or Decision-Making Compared to CT Alone?

retrospective study of consecutive patients. to analyze the frequency of change in Thoracolumbar fractures (TLFs) classification or decision-making after MRI compared by CT alone. A retrospective review of 244 consecutive patients with acute TLFs (T1-L5) presented to a single level 1 trauma center between 2014 and 2021. Three and 4 reviewers independently classified all fractures according to AOSpine and AOSpine injury severity score (TLAOSIS) by CT then MRI, respectively. Posterior ligamentous complex Injury (PLC) was diagnosed on CT and MRI by ≥ 2 positive CT findings and Black stripe discontinuity. MRI changed AO classification in 25/244 patients (10.2%, P < .0001) due to an 8.2% upgrade from type A to type B and a 2% downgrade from type B to type A. The addition of MRI changed TL AOSIS among the 3 treatment recommendation groups in 35/244 (19.7%, 95% CI [14.9%-25.2%]. The best predictor of upgrade from type A to type B and downgrade from type B to type A was a single positive CT finding and the presence of only 2 CT signs as opposed to ≥3 signs, respectively (P < .0001 P = .03, respectively). Thoracic fractures showed a significantly higher reclassification rate than thoracolumbar and low lumbar (20% vs 10% and 0%, respectively, P = .07). using appropriate CT/MRI criteria for PLC injury, MRI changed the AOSpine classification by 10% and TLAOSIS based treatment by 19.7%. The best predictors of fracture reclassification by MRI were the number of positive CT findings and fracture level.

Essex-Lopresti Lesions and Longitudinal Radioulnar Instability: A Narrative Review.

An Essex-Lopresti injury (ELI) is classically described as a radial head fracture with a concomitant interosseous ligament complex (IOC) injury. However, multiple injury patterns may be present, and an interosseous membrane (IOM) injury should be evaluated for in any axial load injury through the forearm. ELI may result in longitudinal radioulnar instability (LRUI). Diagnosis of an IOC injury can be difficult. Evaluation begins with standard wrist and elbow radiographs and is supplemented with radiographs and intraoperative maneuvers to assess for proximal radial migration. Magnetic resonance imaging and ultrasonography may be useful in the acute setting, although indications and the clinical importance of the findings remain unclear. Surgical management of an acute ELI is focused on restoration of radial length and temporary distal radioulnar joint (DRUJ) stabilization. Radial head excision in the acute setting should be approached with caution because proximal migration may not be present acutely but may develop over time. The indication for acute IOM repair and reconstruction remains unclear. Surgical management of a chronic ELI is focused on restoration of radial length, wrist leveling, and treatment of degenerative changes (either at the radiocapitellar joint or the DRUJ). Reconstruction of the central band can restore forearm load transfer and produce favorable functional outcomes, but its indications continue to be debated.

Isometry of the lateral, posterolateral and anterolateral knee complex: a cadaveric study

Objectives:There is no consensus on the insertion points for reconstruction of lateral ligament complex injuries. The aim of this study is to evaluate the relative isometry between easily identifiable bony ridges in order to recommend adequate reconstruction of the external structures: the lateral collateral ligament, the popliteus complex and the anterolateral ligament.Methods:After dissection of the cutaneous and subcutaneous planes of six lower limbs from 3 anatomical subjects, metal markers were fixed on 7 anatomical edges of interest: no. 1: posteroproximal to the lateral epicondyle, within a bony depression - no. 2: at the tip of the lateral epicondyle - no. 3: 18 mm distal and 0.84 mm anterior to the LCL insertion - no. 4: at Gerdy’s tubercle - no. 5: at the anterior part of the fibular head - no. 6: at the posterior part of the fibular head - no. 7: at the popliteal fossa of the tibia, 10 mm medial to the proximal tibiofibular joint, and 10 mm inferior to the joint space. The distance between these points was measured with a caliper at 0, 30, 60 and 90 degrees of flexion in neutral rotation.Results:We noted a decrease in the distance between anatomic femoral and fibular LCL (pair) insertions 1-5 during flexion (63 mm ± 2.6 to 50 mm ± 4.8). The most isometric positions were identified for the following point pairs: 2-5 (57 mm ± 3.4 to 55 mm ± 3), 3-6 (60 mm ± 3.5 to 59 mm ± 3.2), 2-4 (52 mm ± 4.6 to 55 mm ± 2.7) and 3-7 (53 mm ± 6.4 to 52 mm ± 4.6). We noted no difference between knees.Conclusion:These results show that the anatomical structures are not isometric. However, some easily identifiable point pairs of the lateral aspect of the knee show an isometric feature. Therefore, we recommend using pairs 2-5 for the LCL, 2-4 for the ALL and 3-7 for the PC.

MRI appearance of the lateral fibulotalocalcaneal ligament complex injury in the patients with chronic lateral ankle instability

BackgroundThe anterior talofibular ligament (ATFL) comprises the superior and inferior fascicles. The inferior fascicle is connected to the calcaneofibular ligament, and forms “lateral fibulotalocalcaneal ligament (LFTCL) complex”. This study aimed to evaluate the feasibility of diagnosing LFTCL complex injuries in patients with chronic lateral ankle instability (CLAI). MethodsForty-eight ankles (35 with CLAI and 13 without CLAI) underwent arthroscopic surgery, and preoperative magnetic resonance imaging (MRI) was conducted with 0.8 mm- thick axial and oblique slices. The diagnostic accuracy of injuries to the superior fascicle and LFTCL complex was evaluated by two observers. ResultsThe sensitivity and specificity of the LFTCL complex injury were 94.7% and 92.3% for observer 1 and 84.2% and 84.6% for observer 2, respectively. ConclusionsMRI with 0.8 mm slices could detect LFTCL complex injury in patients with CLAI. Diagnosing the LFTCL complex injury on MRI will improve outcomes of an arthroscopic isolated ATFL repair.

Application of high tibial osteotomy for chronic multi-ligament knee injury associated with lower extremity malalignment

To investigate the feasibility and effectiveness of high tibial osteotomy (HTO) in treatment of chronic multi-ligament knee injury (MLKI) associated with lower extremity malalignment. A clinical data of 14 patients (14 knees) of chronic MLKI associated with lower extremity malalignment, who were treated with HTO between January 2016 and September 2020, was retrospectively analyzed. There were 10 males and 4 females, with an average age of 30.5 years (range, 22-48 years). The causes of injury included traffic accident in 8 cases, bruising by a heavy object in 3 cases, falling from height in 2 cases, and twisting in 1 case. According to Schenck classification of knee dislocation (KD), there were 4 cases of KD-Ⅰ [2 cases of anterior cruciate ligament (ACL) and posterolateral complex (PLC) injuries and 2 cases of posterior cruciate ligament (PCL) and PLC injuries], 7 cases of KD-Ⅲ (all of ACL, PCL, and PLC injuries), and 3 cases of KD-Ⅳ. The preoperative hip-knee-ankle angle (HKA) was (167.1±4.7)°, and the posterior tibial slope angle (PTSA) was (16.3±2.7)°. The knee joint was severely unstable and the patients could not stand and walk normally. Among them, 5 cases of medial compartment cartilage were severely worn out (3 cases of Kellgren-Lawrence grading Ⅱ, 2 cases of grading Ⅲ) causing pain. After admission, 2 cases of KD-Ⅰ underwent HTO and ligament reconstruction in the first stage, 1 case of KD-Ⅲ and 1 case of KD-Ⅳ underwent HTO in the first stage and ligament reconstruction in the second stage; the remaining 10 patients only underwent HTO. All patients were followed up 12-50 months, with an average of 30 months. The incisions healed by first intention after operation, and no complications such as infection and deep vein thrombosis of the lower extremities occurred. At 12 months after operation, knee range of extension was -5°-0° (mean, -1.2°) and range of flexion was 110°-140° (mean, 125.5°). The Lachman test was negative in 11 cases and positive in 3 cases. The posterior drawer test was negative in 9 cases and positive in 5 cases. The 0/30° varus stress test was negative in 10 cases and positive in 4 cases. The 0/30° valgus stress test was negative in 13 cases and positive in 1 case. The visual analogue scale (VAS) score was significantly lower than that before operation ( P<0.05), and the International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner score were all significantly higher than those before operation ( P<0.05). The X-ray film reexamination at 12 months after operation showed that the HKA was (178.2±3.8)° and the PTSA was (8.6±2.4)°, which were significantly different from those before operation ( P<0.05). All osteotomies achieved bone union, and the healing time was 3-11 months, with an average of 6.8 months. For chronic MLKI associated with lower extremity malalignment, HTO can restore normal lower extremity alignment and improve knee joint function, which is a feasible salvage operation.

Retrospective Chart Review: Weight Bearing CT Scans and the Measurement of the Lisfranc Ligamentous Complex

Category:Midfoot/ForefootIntroduction/Purpose:Lisfranc Ligamentous Complex injuries are commonly misdiagnosed due to their unreliable projection on plain films. Many studies have striven to establish baseline measurements of the frequently injured articulations. While cadaver, MRI, ultrasound, and non-weight bearing computer tomography (CT) have been utilized, weight bearing CT (WBCT) scans are a relatively new imaging modality that has not yet been utilized to establish reproducible and widely-referenced baseline anatomic positions. The hyoptheses of this study are: 1. Standing, weight bearing CT scan will allow for evaluation and measurement of the Lisfranc joint complex. 2. There will be no side to side variation or sex-based differences in the Lisfranc joint complex.Methods:A retrospective chart review was conducted using the electronic medical record. Inclusion criteria was applied as follows: patients who have undergone weight bearing CT of the bilateral lower extremities from 2018 to 2020. One hundred twelve foot CT scans were acquired for measurements. Measurements were collected by two independent reviewers twice in order to achieve inter- and intra-reliability. The measurements were then analyzed in order to establish a baseline for normal anatomy, compare injured to non-injured side, and observe any sex-based differences.Results:Measurements of uninjured legs were utilized to define normal parameters for Lisfranc ligamentous complex (LLC) injuries. Averages were found for measurements of base 1 to 2 MT 2.7mm (SD=0.7mm), medial cuneiform to 2nd MT [M2-C1] 3.7mm (SD=0.7mm), intercuneiform distance 1.2mm (SD=0.3mm), sagittal descent 12.2mm (SD=5.4mm).Patient's with injury to LLC had a larger base of M1-M2, distance from base of first metatarsal to base of second metatarsal (Δ=.5903, p <.0001) and M2- C1 interval (Δ=1.8008, p<0.0001). Males had significantly higher M2-C1 (p=0.0031), intercuneiform distance (p=0.0039), and sagittal descent (p=0.0008) compared to female patients.No significant differences were found with regard to left vs right side in any of the measurements. Intercuneiform distance (p=0.0039) was found to significantly decrease as age increased, while sagittal descent significantly increased with increased age (p=0.0066).Conclusion:This study is one of the first investigations aims to assist in defining baseline anatomic measurements for Lisfranc ligamentous complex parameters on WBCT. The values and comparisons obtained were able to reinforce that weight bearing CT is valuable in identifying subtle injuries to the LLC while also demonstrating that there is male-to-female and age-related differences that should be kept in mind when radiographically evaluating imaging studies of injured patients.

Flexible Fixation Technique for Subtle Lisfranc Injuries

Background: Subtle Lisfranc injuries represent a primarily ligamentous Lisfranc complex injury involving the Lisfranc ligament and the medial and middle cuneiform ligaments. Static radiographic displacement or dynamic instability of the medial cuneiform and 2nd metatarsal typically warrants operative intervention to prevent chronic functional pain, allow for timely return-to-sport, and mitigate posttraumatic osteoarthritis. Flexible fixation techniques offer a unique solution to the issues seen with transarticular screws, plates, and arthrodesis for ligamentous Lisfranc injuries. Indications: We present the case of a 16-year-old female basketball player with a subtle Lisfranc injury sustained during practice. X-rays show isolated widening of the 1st and 2nd metatarsal bases and dynamic diastasis between the medial and middle cuneiforms. Magnetic resonance imaging (MRI) confirmed a rupture of the plantar Lisfranc ligament. After extensive discussion regarding treatment options, the patient and her family decided to proceed with surgical intervention using a suture anchor and button technique to restore stability to the Lisfranc ligament and intercuneiform complexes. Technique Description: A standardized dynamic examination under anesthesia identifies the extent of the injury. Exposure of the base of the 2nd metatarsal and medial cuneiform is performed. Reduction clamps are applied to restore the intercuneiform relationship and interval between the medial cuneiform and base of 2nd metatarsal. The suture anchor and button construct is placed using fluoroscopic guidance. A final dynamic examination is performed to confirm stability of the construct. Results: Biomechanical studies have shown that flexible fixation maintains physiologic motion about the Lisfranc articulations and has comparable stability to transarticular screws in cadaveric models of isolated Lisfranc ligament insufficiency. Clinical results are limited but demonstrate excellent postoperative functional outcome scores with very few fixation-related complications at 1 to 3 years. Discussion: Flexible fixation techniques for subtle Lisfranc injuries offer unique benefits to transarticular screws, plates, and arthrodesis. We highlight the appropriate evaluation of patients with a suspected subtle ligamentous Lisfranc injury, the surgical technique using a suture button and anchor construct, and review postoperative management and expected outcomes based on the present literature.

Post-Traumatic Hallux Valgus: A Modified Surgical Technique

Post-traumatic hallux valgus, a turf toe variant, is a rare, yet limiting injury. According to the literature, the deformity has been associated with acute medial collateral ligament tears, turf toe variant injuries, Lisfranc injury patterns, and first metatarsal fractures. There have been few documented cases of post-traumatic hallux valgus secondary to medial collateral ligament tears, and the treatment has been variable. Some authors have described direct end-to-end repair of the ligament to address the deformity, while others have described a modified McBride bunionectomy involving a Silver bunionectomy, lateral soft tissue release, and medial capsular and ligamentous repair. We propose a modified technique similar to the modified McBride bunionectomy, however, with the use of an all-suture anchor in the medial capsular and ligamentous repair. Our belief is that the all-suture anchor will allow for a stronger repair that will meet the physical demands of everyday ambulation and athletic participation. We used this technique in an individual who had evidence of a medial ligamentous complex injury of the hallux on MRI and failed conservative management. Postoperatively, the patient is immobilized until they can begin working on range of motion, strengthening, and finally to achieve return to full activity and sports.

Use of Computed Tomography Compression Ratio in Diagnosis of Disc Injuries and Posterior Ligamentous Complex Injuries in Osteoporotic Thoracolumbar Compression Fractures

Background: Osteoporotic compression fractures are common among the elderly. It is important to predict the posterior ligamentous complex (PLC) and disc injuries in computed tomography (CT) scans of patients with magnetic resonance imaging (MRI) contraindications. Objectives: To determine the role of the CT compression ratio (CTCR) in diagnosing PLC and disc injuries and to compare it with the loss of vertebral body height (LOVBH) in osteoporotic thoracolumbar compression fractures. Patients and Methods: A total of 91 consecutive patients with vertebral fractures were included as the study population. The PLC and disc injuries were assessed using MRI, and the following radiological parameters were determined based on CT scans for further MRI examinations: CTCR, LOVBH, local kyphosis (LK), interspinous widening (ISW), vertebral translation (VBT), and posterior structures fractures (PSF). Statistical analysis was performed to identify the diagnostic value of CT features in PLC and disc injuries. Results: The PLC injuries were detected in 9/91 cases, and the number of disc injuries was 47/91. Neither CTCR nor LOVBH was associated with PLC injuries (P &gt; 0.05). However, the CTCR was associated with disc injuries (P &lt; 0.05), with an optimal threshold of 1.755 (sensitivity, 68.1%; specificity, 79.5%), while the LOVBH was not significantly associated with disc injuries. Based on the results, VBT was significantly related to PLC and disc injuries (P &lt; 0.05). Conclusion: The injured vertebral CTCR was associated with disc injuries rather than PLC injuries, suggesting that compression fractures are relatively stable with less PLC injury. Overall, CTCR is a useful indicator reflecting the compression degree of the injured vertebrae; it is also a valid predictor of disc injuries.

How Often MRI Would Change the Fracture Classification or Decision-making in Thoracolumbar Fractures Compared to CT Alone?

Introduction: This study aimed at analyzing the frequency and predictor of the change in classification of TLFs after performing MRI compared with CT alone.&#x0D; Methodology: This retrospective review included 235 consecutive patients with acute TLFs (T1-L5) who presented at a single level-1 trauma center between 2014 and 2021 and underwent both CT and MRI. Patients with translation injury, neurologic deficit, or osteoporotic fracture were excluded. Three reviewers independently classified all fractures according to AOSpine and Thoracolumbar Injury classification (TLISS) by CT and then MRI. A fourth reviewer only looked at the MRI images. Posterior ligamentous complex Injury was diagnosed on CT and MRI by two positive CT findings and black stripe discontinuity. Mc-Nemar test was used to evaluate the difference in the proportions of AO type A and B.&#x0D; Result: The AO classification by CT was type A in 181 patients (77%) and type B in 54 patients (23%). The addition of MRI after CT changed AO classification in 25/235 patients (10.6%, P &lt; 0.0001) due to an 8.5% (20/235) upgrade from type A to type B and 2.1% (5/235) downgrade from type B to type A. When PLC injury in CT was defined by one positive CT finding and in MRI by high signal intensity, it significantly increased the rate of fracture reclassification by MRI compared to default analysis (22% and 33% vs 11%, respectively; P &lt; 0.0001). The best predictor of upgrade from type A to type B and downgrade from type B to type A was a single positive CT finding, and the presence of only two CT signs as opposed to three signs, respectively (reclassification rate 26% vs 4.6%, P &lt; 0.0001 and 17% vs 0%, P = 0.03, respectively). Thoracic and thoracolumbar fractures showed a significantly higher reclassification rate than low lumbar (20% and 10% vs 0%, respectively, P = 0.07).&#x0D; Conclusion: Using appropriate CT/MRI criteria of PLC injury, the rate of fracture reclassification by MRI can be as low as 10%. The use of alternative CT/MRI criteria or inaccurate image interpretation could significantly increase the rate of fracture reclassification up to 20–30%. The rate of change of fracture classification by MRI could be predicted by the number of positive CT findings on CT or fracture level.

Posterior Ligamentous Complex Injuries of the Thoracolumbar Spine: Importance and Surgical Implications.

The soft tissues surrounding the spine play a primordial role in its stability, the most important of which are located posteriorly and are deemed the posterior ligamentous complex (PLC). Injuries to the PLC in the setting of thoracolumbar trauma are often dreaded and little attention has been given to them in the management protocols of thoracolumbar trauma. This review aims to summarize and contextualize current concepts in PLC injuries of the thoracolumbar spine with the aim to provide a clear guide for clinical management.Injuries to the PLC may be suspected on the clinical exam but are often missed, leading to serious complications, including instability and neurological compromise. The diagnosis is often made indirectly by spinal radiographs and CT-scanning or by direct visualization of soft tissues via magnetic resonance imaging. The latter remains the standard imaging modality and is mandatory for patients with a high suspicion of PLC injury. PLC injuries are associated with vertebral fractures and follow a progressive pattern of severity, depending on the mechanism of injury and extent of trauma. Surgical management is warranted, as PLC damage renders the spine unstable. Although fusion was once the standard of care and remains applicable for certain patients, recent endeavors of temporary spinal fixation without fusion are increasingly gaining traction in patients with PLC injuries.In conclusion, PLC injuries are challenging as they are often missed, poorly understood, and are not easily managed. Proper diagnosis and management are crucial to avoid long-standing complications such as spinal instability. Considering the paucity of available data on such an important topic in thoracolumbar trauma, this review article aims to contextualize current concepts in PLC injuries in order to demystify this sparsely covered subject.

Traumatic low lumbar fractures: How often MRI changes the fracture classification or clinical decision-making compared to CT alone?

To determine the impact of magnetic resonance imaging (MRI) on fracture classification for low lumbar fractures (LLFs) compared to CT alone. This study was a retrospective review of 41 consecutive patients with LLFs who underwent CT and MRI within 10 days of injury. Three reviewers classified all fractures according to AOSpine Classification and the Thoracolumbar Injury Classification (TLISS). Posterior ligamentous complex (PLC) injury in MRI was defined by black stripe discontinuity and in CT by the presence of: vertebral body translation, facet joint malalignment, horizontal laminar or spinous process fracture, and interspinous widening. The proportion of patients with AO type A/B/C and with TLISS < 5 and≥5 was compared between CT and MRI. We examined the overall accuracy and individual CT findings for PLC injury. AO classification using CT was: AO type A in 26 patients (61%), type B in 7 patients (17%), and type C in 8 patients (22%). Seventeen patients (41%) had a TLISS≥5 while 24 (59%) had TLISS < 5. The addition of MRI after CT changed the AO classification in only 2 patients (4.9%, 95% CI (0.6-16.5%) due to upgrade of type A to type B or vice versa, but did not change TLISS from < 5 to≥5 [p< 0.0001; 95% CI (0.59, 0.77)]. CT was highly accurate (95%) for diagnosis of PLC injury in LLFs. Addition of MRI after CT did not change the AO classification or TLISS, compared to CT alone, thus suggesting limited additional value of MRI for PLC assessment or fracture classification.

Diagnostic Value of Various Morphological Features of Horizontal and Vertical Laminar Fractures for Posterior Ligamentous Complex Injury of the Thoracolumbar Spine as Defined by Magnetic Resonance Imaging

To determine diagnostic value of morphological features of horizontal laminar fracture (HLF) and vertical laminar fracture (VLF) for diagnosis of posterior ligamentous complex (PLC) injury. This retrospective review comprised 271 consecutive patients with acute thoracolumbar fractures presenting to a Level 1 trauma center between January 2014 and January 2021. Two reviewers evaluated computed tomography and magnetic resonance imaging. VLFs were subclassified based on length and depth of lamina involved, as follows: type 1, full-length complete; type 2, full-length incomplete; type 3, partial-length complete or incomplete. HLFs were subclassified as follows: bilateral versus unilateral, displaced >2 mm versus nondisplaced, and lamina-only versus laminar and pedicle. We examined the diagnostic accuracy and the univariate and multivariate associations of laminar fracture subtypes with PLC injury as defined by black stripe discontinuity. Bilateral HLFs, laminar and pedicle fractures, displaced HLFs, and type 1 VLFs yielded a high positive predictive value for PLC injury (95%, 91%, 100%, and 86%, respectively). Type 2 and 3 VLFs did not show significant univariate associations with PLC injury. Bilateral HLFs, laminar and pedicle fractures, and displaced HLFs showed independent associations with PLC injury (adjusted odds ratio= 13.6, 8.4, 6, and 10.3, respectively; P < 0.002). Type 1 VLFs did not show a significant association with PLC (adjusted odds ratio= 10.3; P= 0.06). Bilateral HLFs, laminar and pedicle fractures, and displaced HLFs, but not any VLF subtypes, were independently associated with PLC injury. These findings may improve the reliability of PLC assessment by computed tomography.

Analysis of the Combined Computed Tomography Findings Improves the Accuracy of Computed Tomography for Detecting Posterior Ligamentous Complex Injury of the Thoracolumbar Spine as Defined by Magnetic Resonance Imaging

To determine the diagnostic accuracy of combined computed tomography (CT) findings for detecting posterior ligamentous complex (PLC) injury in thoracolumbar fractures using magnetic resonance imaging as a reference. A retrospective review of 263 consecutive patients with thoracolumbar fractures who underwent CT and magnetic resonance imaging within 10 days of injury. Two reviewers evaluated CT for the following findings: facet joint malalignment, facet joint widening, horizontal laminar fracture, spinous process fracture, and interspinous widening. We examined the independent association of CT findings with PLC injury before combining the CT findings to calculate the diagnostic accuracy: sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), and positive and negative likelihood ratios. PLC injury was defined by black stripe discontinuity caused by supraspinous or ligamentum flavum rupture. Facet joint malalignment, spinous process fracture, horizontal laminar fracture, and interspinous widening were independently associated with PLC injury (adjusted odds ratio range, 4.4e17.4). A single positive CT finding yielded a PPV of 31% and NPV of 66% for PLC injury. Two or more CT findings yielded a PPV of 91% for PLC injury. A negative CT for all the 4 CT sings had a 94% NPV for PLC injury. Two or more CT findings provided the best combination to confirm PLC injury; thus, this combination could be used as a criterion for injured PLC. A single CT finding lacks sufficient predictive value to confirm or rule out PLC injury. A negative CT for the 4 CT findings provided the highest sensitivity for PLC injuries.

Epidemiology of Foot and Ankle Injuries in NCAA Jumping Athletes in the United States During 2009-2014

Background:Foot and ankle injuries comprise a significant proportion of all injuries sustained by National Collegiate Athletic Association (NCAA) athletes. In particular, sports that combine jumping and rapid changes in direction are associated with increased lower extremity injuries.Purpose:To describe the epidemiology of foot and ankle injuries in men’s and women’s jumping sports, including NCAA men’s and women’s basketball, women’s volleyball, and women’s gymnastics, during the 2009-2010 through 2013-2014 seasons.Study Design:Descriptive epidemiology study.Methods:Injury-surveillance data were obtained from the NCAA Injury Surveillance Program for the 2009-2010 through 2013-2014 seasons. Injuries were examined by mechanism, activity during injury, and participation restriction time. Injury rates per 1000 athlete-exposures (AEs), injury rate ratios, and risk ratios with 95% CIs were calculated. Reported sex differences were calculated for men’s and women’s basketball. All 95% CIs not containing 1.0 were considered statistically significant.Results:A total of 1136 players sustained foot and ankle injuries (483 male and 653 female) over 612,680 AEs. These injuries resulted in a combined rate of 1.85 per 1000 AEs (95% CI, 1.75-1.97). Ankle sprains were the most common injury (63.7%), with lateral ligamentous complex injuries making up 77.1% of all ankle sprains. The most common foot injury varied based on sport and sex. Ankle injury rates were higher in male versus female basketball players (injury rate ratio, 1.33 [95% CI, 1.13-1.57]), but foot injury rates did not differ. Among basketball and volleyball players, player contact during jumping was the most common injury mechanism. Female gymnasts had higher overuse injury rates than other athletes (0.49/1000 AEs [95% CI, 0.30-0.74]; P < .002). Overall, female basketball players were 1.81 times more likely to sustain an overuse injury than male basketball players (95% CI, 1.02-3.20; P = .02).Conclusion:The most common foot and ankle injury sustained in collegiate jumping sports was a lateral ligamentous complex ankle sprain. Injury-prevention programs focusing on ankle flexibility, strength, and proprioception may help to alleviate the injury burden and lessen severity. Improving the anticipation of contact during jumping and landing may reduce injury rates and increase player safety. The increased prevalence of overuse injuries in female collegiate athletes competing in jumping sports necessitates further investigation to reduce injury rates through prevention and training programs.