Ligament Reconstruction Procedures Research Articles

Location and Morphology of Acute Lateral Ligament Injury of the Ankle

Category:Ankle, Sports, TraumaIntroduction/Purpose:Acute ankle ligament injuries are usually treated non-operatively, even if the injury is severe. However, when chronic ankle instability is symptomatic, operative treatment is required. When planning local repair, the condition of the remaining ligament is important. We surgically treated acute severe lateral ligament injuries in 103 ankles and investigated the locations of the injuries in the anterior talofibular (ATF) and calcaneofibular (CF) ligaments, subdividing each into three parts. This paper should facilitate more precise planning of the surgical reconstruction procedure.Methods:From 2006 to 2014, 1,042 patients visited our outpatient clinic with a diagnosis of acute lateral ligament injury of the ankle. In total, 103 feet underwent surgical treatment and the locations of the ATF and CF ligament ruptures were investigated. The rupture location in the ATF ligament was subclassified as fibular side, body, or talar side, while for the CF ligament it was classified as fibular side, body, or calcaneal side.Results:The ATF ligament was ruptured on the fibular side in 38 feet (36.9%), body in 30 feet (29.1%), and talar side in 35 feet (34.0%). The CF ligament was ruptured on the fibular side in 15 feet (14.6%), body in 26 feet (25.2%), and calcaneal side in 62 feet (60.2%).Conclusion:Almost all surgical reports on lateral ligament reconstruction procedures (Brostrom et al.) describe ATF ligament repair and advancement on the fibular side, although only one-third of the ligaments were injured on the fibular side in our series. About two-thirds of the CF ligaments had damage to the calcaneal side structure of the entheses. When CF ligament repair is needed, surgeons should be aware of our finding that this ligament was ruptured at the fibular attachment in only 15% of cases, and on the calcaneal side in 60%. This knowledge should lead to better results of surgical reconstruction.

The plantaris muscle: too important to be forgotten. A review of evolution, anatomy, clinical implications and biomechanical properties.

Plantaris muscle (lat. musculus plantaris) is a fusiform muscle of the superficial posterior leg compartment, characterized with a small muscle belly and very long and slender tendon. Many anatomical variations of plantaris muscle have been reported previously, including its inconstancy. Evolutional studies strongly suggest that plantaris muscle is a rudimentary muscle that plays minor role in gait biomechanics. However, plantaris muscle seems to have very important proprioceptive role since it has very high density of muscle spindles. Clinically, plantaris muscle is involved in differential diagnosis of posterior leg pain and several pathological entities such as: plantaris muscle rupture, non-insertional Achilles tendinopathy and popliteal artery compression syndrome. Different surgical specialties have recognized plantaris muscle tendon as a valuable graft. However, literature on plantaris muscle tendon biomechanical properties is rather scant and inconsistent with several limitations for proper data comparison and interpretation. Further comparative studies are needed to properly define biomechanical properties of plantaris muscle tendon grafts for various ligament and tendon reconstructive procedures.

Comparison of Graft Length Changes During Knee Motion Among 5 Different Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction Approaches: A Biomechanical Study.

Background:In several anatomic single-bundle anterior cruciate ligament (ACL) reconstruction (ASB-ACLR) procedures, the femoral and tibial tunnel apertures are created at different locations within the native ACL attachment area.Hypothesis:Graft length changes during knee motion will be different among ASB-ACLR procedures with different femoral and tibial tunnel aperture locations.Study Design:Controlled laboratory study.Methods:A total of 12 cadaveric knees were used in this study. In each knee, 4 and 3 thin tunnels were created within the ACL attachment area on the femur and the tibia, respectively. Using 1 of 5 different combinations of femoral and tibial tunnel aperture location, 5 ASB-ACLRs were performed on each knee. In each reconstruction approach, a strong thread was used in place of the tendon graft, and the tibial graft end was tethered to a custom-made isometric positioner at 0° of knee flexion, with an approximately 12-N load applied to the thread. Then, each specimen underwent 5 cycles of knee flexion-extension motion in a range between 0° and 120°, and graft length changes were determined for each SB-ACLR approach.Results:The length changes of the graft were significantly different among the 5 ASB-ACLRs. The maximum length change values of the 3 grafts that were implanted between the femoral and tibial centers of the posterolateral bundle attachments or implanted into the femoral tunnel created at the center of the fanlike extension fiber attachment were significantly greater than those of the graft implanted between the centers of the anteromedial bundle attachments (P < .0001) and of the graft implanted between the centers of the whole ACL attachments (P < .0001).Conclusion:The length changes of the graft during knee motion were significantly different among the 5 ASB-ACLR approaches, even though all of the tunnel apertures were created within the femoral and tibial attachments of the native ACL.Clinical Relevance:The grafts in the first 3 graft locations may be so relaxed during knee flexion that they cannot resist anterior drawer loads exerted on the tibia.

Tensile strength comparison between hamstring tendon, patellar tendon, quadriceps tendon and peroneus longus tendon: A cadaver research

Knee ligament injury is a frequent occurrence. Ligament reconstruction using tendon graft is the best therapy recommendation in the case of severe knee ligament injury. Tendon graft that is oftenly used are hamstring tendon, patellar tendon (BPTB), quadriceps tendon and peroneus longus tendon have been proposed as tendon graft donor. Biomechanically, tensile strength from tendon graft is the main factor that greatly contributes to the success of ligament reconstruction procedure. Numerous researches have been done to calculate tensile strengths of hamstring and patellar tendon, but there has not been a research done yet on the comparison of the tensile strengths of peroneus longus tendon, hamstring, patellar tendon and quadriceps tendon. This research will strive to record the tensile strengths of peroneus longus tendon, hamstring, patellar tendon and quadriceps tendon as well as their comparison. Population of this research is 6 cadavers that have met the exclusion and inclusion criterias. From population above, 48 samples are retrieved and further divided into 4 groups. 12 samples for quadriceps tendon group, 12 samples for hamstring group, 12 samples for peroneus longus tendon group and 12 samples for patellar tendon group. Tensile strength measurement will then be done on each tendon by clamping both ends of examined tendon, then pulled on one side until tendon ruptures. Results are then read with a tensile tester. Tensile strength of peroneus longus tendon is not significantly different in comparison to hamstring tendon (p > 0,05). Whereas when compared to patellar and quadriceps tendons, peroneus longus and hamstring tendons have tensile strengths that are significantly higher (p < 0,05). Peroneus longus tendon have the highest tensile strength in comparison to the other three, followed by hamstring, quadriceps, and patellar tendons respectively.

The lateral collateral ligament complex of the elbow: quantitative anatomic analysis of the lateral ulnar collateral, radial collateral, and annular ligaments

Injury to the lateral ulnar collateral ligament (LUCL) complex of the elbow often results in posterolateral rotatory instability. Although surgical reconstruction of the LUCL is often required, gaps in our understanding of the LUCL complex remain. The purpose of this study was to provide a robust and accurate characterization of the lateral elbow ligamentous complex. The LUCLs, radial collateral ligaments, and annular ligaments in 10 cadaveric elbows were 3-dimensionally digitized and reconstructed using computed tomography. Surface areas, origin and insertion footprint areas, distances between perceived footprint centers and geometric footprint centroids, distances to key landmarks, and ligament isometry were measured. The mean surface area of the LUCL was 229.3 mm2. The mean origin and insertion footprint areas were 26.0 mm2 and 22.9 mm2, respectively. The mean distance between the apparent centers and the geometric centroids of the footprints was 1 mm. The center of the LUCL origin was 10.7 mm distal to the lateral epicondyle and 8.2 mm from the capitellar articular margin. The center of the LUCL insertion was 3.3 mm distal to the apex of the supinator crest. The LUCL showed anisometric properties as elbow flexion increased (P < .001). The LUCL origin center was 10.7 mm from the lateral epicondyle, whereas the insertion center was 3.3 mm from the apex of the supinator crest. The visually estimated footprint centers were generally within 1 mm of the geometric centroid. These geometries and distances to key landmarks will be informative for surgeons seeking to perform anatomic ligament reconstruction procedures.

Single- and double-bundle medial patellofemoral ligament reconstruction procedures result in similar recurrent dislocation rates and improvements in knee function: a systematic review.

To evaluate medial patellofemoral ligament (MPFL) reconstruction using hamstring tendon autografts using single-bundle (SB) and double-bundle (DB) techniques, and compare the clinical outcomes including the Kujala score, postoperative apprehension, recurrent subluxation or dislocation, and complications. The PubMed, Embase, and Cochrane Library databases were searched for relevant literature using the terms ''medial patellofemoral ligament'' and ''MPFL''. The pooled mean values of improvement in the Kujala score were calculated by random effects meta-analysis. Unweighted estimates for the rates of postoperative apprehension, recurrent subluxation or dislocation, and complications were determined by dividing the total number of occurrences by the total number of knees. Thirty-one articles were included, involving 1063 patients (1116 knees). Two hundred and forty-four patients (254 knees) underwent SB reconstruction, while 819 patients (862 knees) underwent DB reconstruction. The pooled mean values of Kujala score improvement were similar in the SB group (30.1; 95% CI 26.6-33.6) and DB group (30.7; 95% CI 27.7-33.7). The SB group had a significantly greater rate of postoperative apprehension (7.9%) than the DB group (4.1%; P = 0.014). There were no significant differences between the two groups in the rates of recurrent subluxation or dislocation (1.2 and 1.6%) and complications (10.6 and 7.7%). With variability in patient populations and surgical techniques, the DB procedure for isolated MPFL reconstruction demonstrates similar outcomes to the SB technique regarding improvement of knee function, recurrent subluxation or dislocation, and complications. The SB technique may have a greater risk of postoperative apprehension, whereas the DB technique may cause more stiffness. IV.

Ultrasound-Mediated Gene Delivery Enhances Tendon Allograft Integration in Mini-Pig Ligament Reconstruction.

Ligament injuries occur frequently, substantially hindering routine daily activities and sports participation in patients. Surgical reconstruction using autogenous or allogeneic tissues is the gold standard treatment for ligament injuries. Although surgeons routinely perform ligament reconstructions, the integrity of these reconstructions largely depends on adequate biological healing of the interface between theligament graft and the bone. We hypothesized that localized ultrasound-mediated, microbubble-enhanced therapeutic gene delivery to endogenous stem cells would lead to significantly improved ligament graft integration. To test this hypothesis, an anterior cruciate ligament reconstruction procedure was performed in Yucatan mini-pigs. A collagen scaffold was implanted in the reconstruction sites to facilitate recruitment of endogenous mesenchymal stem cells. Ultrasound-mediated reporter gene delivery successfully transfected 40% of cells recruited to the reconstruction sites. When BMP-6 encoding DNA was delivered, BMP-6 expression in the reconstruction sites was significantly enhanced. Micro-computed tomography and biomechanical analyses showed that ultrasound-mediated BMP-6 gene delivery led to significantly enhanced osteointegration in all animals 8weeks after surgery. Collectively, these findings demonstrate that ultrasound-mediated gene delivery to endogenous mesenchymal progenitor cells can effectively improve ligament reconstruction in large animals, thereby addressing a major unmet orthopedic need and offering new possibilities for translation to the clinical setting.

Predictive Factors of Hamstring Tendon Regeneration and Functional Recovery After Harvesting: A Prospective Follow-up Study

Background: Semitendinosus and gracilis tendons may regenerate after harvesting for ligament reconstruction procedures. However, predictive factors of tendon regeneration and the extent of functional recovery remain unclear. Purpose: To identify predictive factors for hamstring tendon regeneration and to examine the morbidity of nonregenerated hamstring tendons. Study Design: Cohort study; Level of evidence, 3. Methods: Of the 154 patients who were included in a prospective follow-up study, 79 underwent reconstruction of the anterior cruciate ligament entailing the hamstring tendons and met the following inclusion criteria: (1) anterior cruciate ligament rupture diagnosed by physical examination and magnetic resonance imaging (MRI), (2) MRI within 6 months after trauma, (3) age between 18 and 45 years, and (4) 2-year follow-up MRI data available. Hamstring tendon regeneration was assessed as complete if a tendon-like structure could be visualized at the level of the joint line or more cranially. Patient characteristics—such as age, sex, body mass index, alcohol/nicotine use, activity level (Tegner scores), and functional instability (1-legged hop test)—were evaluated preoperatively and at 2 years to determine predictive factors for tendon regeneration or examine functional recovery of hamstring tendon regeneration. Results: At 2 years’ follow-up, 67.1% of the patients showed regeneration of semitendinosus tendons, 81.0% of gracilis tendons, and 59.5% of both tendons. The likelihood of semitendinosus tendon regeneration significantly decreased with aging (odds ratio [OR], 0.92 change per year of age; 95% CI, 0.84-0.99; P = .03) and smoking (OR, 0.20; 95% CI, 0.05-0.77; P = .02). No predictive factor was found for gracilis tendon regeneration. Regeneration of the semitendinosus and gracilis tendons was negatively related with smoking (OR, 0.22; 95% CI, 0.06-0.79; P = .02). Patients without regeneration showed similar postoperative visual analog scale scores during physical activity, similar Tegner scores, and a significant decrease of the upper leg circumference, as compared with their preoperative results. Regardless of the regeneration status, 1-legged hop test results significantly increased at 2-year follow-up. Conclusion: Hamstring tendon regeneration occurs less frequently in older patients and in smokers. However, absence of regenerated tendons does not seem to cause a loss of function.

The Influence of Full-Thickness Chondral Defects on Outcomes Following Meniscal Allograft Transplantation: A Comparative Study

To compare a series of patients who underwent meniscus allograft transplantation (MAT) with full-thickness chondral defects (FTD) with those with no chondral defect (ND) with regard to the following: change in patient-reported outcomes (PROs) from baseline to 2-year follow-up and baseline to the final follow-up (including comparisons to minimal clinically important differences), complications and complication rates, reoperations and reoperation rates/timing, and failures and time to failure (revision MAT or conversion to total knee arthroplasty). Patients who underwent isolated medial or lateral MAT between September 1997 and March 2013 with a minimum of 2years of follow-up were retrospectively identified and split into 2 groups based on the presence or absence of FTD (femoral condyle or tibial plateau) identified intraoperatively after debridement to allow for a better understanding of the lesion characteristics (when applicable): ND (Outerbridge grade 0/I) or FTD (Outerbridge grade IV). Patients with osteochondritis dissecans were eligible for inclusion, as were those with isolated single lesions, multiple lesions, or bipolar lesions. Those with a moderate Outerbridge grade (II and III)-whether treated or neglected-were excluded given the poorer reliability of grading intermediate lesions. Indications for MAT included those patients with subjective complaints (persistent joint-line pain) and objective findings (previous meniscectomy or nonviable meniscus state with pain localized to the affected compartment) of functional meniscal deficiency. All lateral MAT patients used a bridge-in-slot surgical technique, as did most medial MAT patients (few patients with earlier surgical dates received a keyhole technique). All FTD were treated concurrently at the time of index MAT with cartilage restoration procedures (microfracture, autologous chondrocyte implantation, DeNovo particulate cartilage grafting, or osteochondral auto/allografting). Reoperations, failures (revision MAT or conversion to arthroplasty), and PRO deltas were reported comparing baseline to 2-year follow-up and baseline to the final follow-up. Intergroup comparisons were made using Bonferroni-adjusted independent sample t-tests for continuous variables and χ-square for categorical variables. A total of 91 patients (22 ND and 69 FTD) were identified and followed for a mean 4.48 ± 2.63 and 3.84 ± 2.47years, respectively. There were no significant between-group differences in age, body mass index, or number of prior surgeries. The mean chondral lesion size in the FTD group was 4.43 ± 2.5cm2. Concomitant anterior cruciate ligament reconstruction was performed significantly more in ND-group patients than FTD-group patients (8 [38.1%] vs 8 [11.8%], P= .004). There were no differences between ND-group and FTD-group patients in concomitant realignment procedures performed (2 [9.1%] vs 7 [10.1%], P= .986), or prior ligament reconstruction (9 [40.9%] vs 18 [26.1%], P= .111) or realignment procedure (0 [0%] vs 0 [0%]). FTD-group patients underwent concomitant osteochondral allograft (69.6%), autologous chondrocyte implantation (18.8%), microfracture (13.0%), osteochondral autograft (4.3%), or DeNovo juvenile particulate cartilage implantation (1.4%). A comparison of the patient groups found no statistically significant differences in PROs preoperatively (P > .003 for all). Intergroup comparisons of both the 2-year and final follow-up delta PRO scores showed no statistically (P > .003 for all) or clinically (number of PROs meeting minimal clinically important differences) significant differences. One complication occurred (fractured hardware) in the FTD-group patients (1.3%). There were no differences in the number of subsequent surgeries (revision MAT: ND, 2 (10.0%) vs FTD, 8 (12.9%); P= .845) or failures (conversion to total knee arthroplasty: ND, 1 (5.0%) vs FTD, 2 (3.3%); P= .646). When comparing a patient series with FTD who underwent MAT with a patient series with ND, there were no differences in the change in individual PROs from preoperative to the final follow-up. Similarly, there were no differences in complications or failure between those with ND or FTD diagnosed intraoperatively. The results of the current study suggest that chondral damage identified and treated by cartilage restoration means at the time of MAT may not affect the clinical outcomes of MAT. Level III, retrospective comparative study.

Arthroscopic Technique to Reduce Suture Button Migration During Anterior Cruciate Ligament Reconstruction Procedure

Suture button–based femoral cortical suspension constructs of anterior cruciate ligament grafts can facilitate a fast and secure fixation. However, there are several case reports showing button malpositioning resulting from the inability to visualize the “flipped” button. Many current surgical techniques do not allow direct visualization of EndoButtons (Smith & Nephew, Andover, MA) in their final position, making it difficult to ensure that both buttons are fully flipped and that there is no soft-tissue interposition between the button and femur. We describe an arthroscopic technique for making femoral tunnels through the outside-in method that reduces the migration of the EndoButton through a lateral femoral portal. This technique may assist surgeons in understanding how to deal with and potentially avoid EndoButton migration during anterior cruciate ligament reconstruction.

Increased incidence of anterior cruciate ligament revision surgery in paediatric verses adult population.

To evaluate the anterior cruciate ligament graft failure rate in a population of 1376 patients submitted to single-bundle anterior cruciate ligament reconstruction procedure. It was hypothesized that the younger the patient, the greater the chance of a new anterior cruciate ligament graft ligament injury. A retrospective chart review was performed on patients who had SB anterior cruciate ligament reconstruction between the years, 2001 and 2016, with a minimum post-operative follow-up period of 6months. The patient population was divided into three groups, according to age: group 1-under 16years old; group 2-between 16 and 18years old; and group 3-older than 18years old. Data collected included sex, laterality and graft choice data. In group 1 (under 16years old), there were 61 primary ACL surgeries performed and 15 (24.6%) revision ACL surgeries. In group 2 (between 16 and 18years old), there was 57 primary ACL procedures, of which 10 (17.5%) were revisions. In the group 3 (older than 18years of age), 1258 surgeries were done with 116 (9.2%) revisions. The rate of ACL revision surgery in patients under 16years of age was significantly higher than that found in patients older than 18years old. When compared to the population between 16 and 18years old, there were a higher number of failure cases, however, statistically non-significant. IV.

Midterm results of combined intra- and extra-articular ACL reconstruction compared to historical ACL reconstruction data. Multicenter study of the French Arthroscopy Society

IntroductionDuring anterior cruciate ligament (ACL) reconstruction procedures, anterolateral reconstruction (ALR) can also be performed to improve the knee's rotational stability. However, the effectiveness of this supplemental technique and its impact on the risk of retears and on the onset of secondary degenerative changesare controversial. HypothesisALR improves control over the pivot shift, reduces the retear risk and delays the appearance of secondary degenerative lesions. Material and methodsClinical examination, knee laxity measurements and X-ray evaluations were done in 478 patients with more than 3years’ follow-up after combined ACL and ALR from 11 participating hospitals. The mean patient age at the time of surgery was 28years. Eighty-eight percent of the patients participated in pivot sports and 45% were competitive athletes. The findings of this study were compared to historical isolated ACL reconstruction data. ResultsThe average follow-up was 6.8years. No detectable pivot shift was found in 83% of patients, while 12.8% of patient had a smooth glide. The side-to-side difference in anteroposterior knee laxity with maximum manual force was less than 3mm in 66% of patients and less than 5mm in 95%. The retear rate was 5.4%, with half of these patients undergoing revision ACL surgery. Secondary meniscus damage requiring surgery occurred in 6.3% of patients; the radiological osteoarthritis rate was 17.5%. DiscussionWhen compared to historical ACL reconstruction data, combined intra- and extra-articular reconstruction does not increase the complication rate. At a mean follow-up of 6.8years, it provides better control over the pivot shift along with a low retear rate and low occurrence of secondary meniscus injuries. Level of evidenceIV, multicenter study.

Is Revision Anatomic Ankle Ligament Repair Augmented with Suture-Tape a Valuable Alternative for Patients with Failed Broström Procedure?

Category: Ankle, Sports Introduction/Purpose: Recurrent instability after previous anatomic ankle ligament repair has been known to be a poor prognostic factor for revision modified Broström procedure, and ligament reconstruction procedures using an allograft or autograft tendon have commonly been recommended. This prospective study was performed to evaluate the intermediate-term outcomes after revision anatomic ankle ligament repair augmented with suture-tape for failed modified Broström procedures. Methods: Thirty patients with failed modified Broström procedures consecutively underwent revision procedures for recurrent ankle instability. Of these patients, 27 patients who could be followed for more than 2 years were analysed in the current study. The clinical evaluation consisted of the Foot and Ankle Outcome Score(FAOS), Foot and Ankle Ability Measure(FAAM) score. Talar tilt angle and anterior talar translation were measured to evaluate radiologically the changes of mechanical ankle stability. Results: FAOS and FAAM scores significantly improved from preoperative averages of 53.6 and 45.6 points to 87.5 and 85.1 points at final follow-up, respectively (p &lt; 0.001). Talar tilt angle and anterior talar translation had significantly improved from preoperative averages of 15.1° and 12.4 mm to 2.8° and 4.1 mm at final follow-up, respectively (p &lt; 0.001). Preoperative side to side comparison in stress radiographs demonstrated statistically significant difference (p &lt; 0.001), but there was not significant side to side difference in these radiographic measures at final follow-up (p &gt; 0.05). Postoperative complications included 2 cases of local wound problems, 2 cases of superficial peroneal nerve injury, and 1 case of recurrent instability. Conclusion: The revision modified Broström procedure augmented with suture-tape appears to be an effective treatment method for recurrent ankle instability in patients with prior failed modified Broström procedure. This combined procedure can provide reliable stability and satisfactory clinical outcomes through supplementation of the anatomic repair of attenuated ligaments using suture-tape.

Palmer Midcarpal Instability: An Algorithm of Diagnosis and Surgical Management

Background Palmar midcarpal instability (PMCI) is an uncommon form of nondissociative carpal instability. However, it is an important cause of chronic ulnar wrist pain. Diagnosis can be difficult and high index of suspicion is mandatory. Pathomechanics and optimal treatment of PMCI remain uncertain. We propose an algorithm of clinical diagnosis and evaluate the outcome of our management. Materials and Methods Between 2000 and 2011, 16 patients, including 7 males and 9 females, of a mean age of 33.9 diagnosed with PMCI were reviewed for their clinical, radiologic, and arthroscopic features. All patients presented with ulnar wrist pain in their dominant hands except in one. Initial management included a disease-specific anticarpal supination splint. Refractory cases were evaluated by arthroscopy and treated by arthroscopic thermal shrinkage using radiofrequency appliance as an interim or definite surgical intervention. Shrinkage was targeted at the ulnocarpal ligament at the radiocarpal joint and triquetrohamate ligament at the midcarpal joint. Nonresponsive or recurrent cases were managed by a novel technique of dorsal radiocarpal ligament reconstruction procedure using a pisiform-based split flexor carpi ulnaris (FCU) tendon graft. Results In all cases, the midcarpal clunk test was positive with pain. Other common clinical features included lax ulnar column, carpal supination, volar sagging of the wrist, increased pisostyloid distance, wrist pain aggravated by passive hand supination and not by passive forearm supination, and increased wrist pain upon resisted pronation, which could be partially alleviated by manually supporting the pisostyloid interval. Common arthroscopic findings were excessive joint space at triquetrohamate interval and reactive synovitis over the ulnar compartments. Nine patients (56.3%) responded well to splinting alone at an average follow-up of 3.3 years. Arthroscopic thermal shrinkage was performed in five patients with recurrence in two patients. Five patients received split FCU tendon graft for ligament reconstruction. All patients showed improvement in the wrist performance score (preop 21.0, postop 36.6 out of 40) and pain score (preop 10.0, postop 2.2 out of 20) at the final follow-up of average 86 months (range: 19-155 months). Grip strength improved from 66.9 to 82.0% of the contralateral side. Wrist motion slightly decreased from a flexion/extension arc of 132 to 125 degrees. Three patients were totally pain free, one had mild pain, and one had moderate fluctuating pain. All patients returned to their original works. X-ray showed no arthrosis. Conclusion PMCI is an uncommon but significant cause of chronic ulnar wrist pain. We have developed a clinical algorithm for diagnosis of the condition. The natural history seems to favor a benign course. Conservative treatment with an anticarpal supination splint is recommended as the initial management. Surgical options for resistant cases include arthroscopic thermal shrinkage or soft tissue reconstruction. The reconstruction of the dorsal radiocarpal ligament using a pisiform-based split FCU tendon graft provides reliable restoration of the carpal stability with good long-term outcome and few complications. This should be considered a viable alternative to limited carpal fusion.

Autogenous Hamstring-Bone Graft Preparation for Anterior Cruciate Ligament Reconstruction

Despite the popularity of anterior cruciate ligament (ACL) reconstruction procedures, the ideal graft for reconstruction remains a matter of controversy. The ideal graft for ACL reconstruction should have histologic and biomechanical characteristics similar to those of the native ACL; should be quickly and fully incorporated within the bony tunnels; should maintain its viscoelastic properties for a long time; should have minimal donor-site morbidity; should be of sufficient length and diameter; should have minimal adverse effects on the extensor mechanism; should have no risk of rejection or disease transmission; and should be cost-effective and readily available. Synthetic grafts are not widely accepted because of their dangerous complications. The main sources of grafts for ACL reconstruction are allografts and autografts. Each type of graft has its own relative advantages and disadvantages. Allografts are not available in every country, besides being expensive, and there are many concerns regarding disease transmission. Autografts, particularly bone–patellar tendon–bone (BPTB), and hamstring tendon grafts have been the standard for ACL reconstruction. The main advantage of autogenous BPTB grafts is the direct bone-to-bone healing in the tunnel, whereas the main disadvantages of such grafts are related to donor-site morbidity, anterior knee pain, and extensor mechanism dysfunction. The popularity of autogenous hamstring tendon grafts for ACL reconstruction is increasing, but there are still concerns regarding the slow soft tissue–to–bone healing, with delayed healing and incorporation of the graft. We describe a technique for ACL reconstruction with autogenous hamstring-bone graft, aiming to produce a type of graft that combines the main advantages of BPTB and hamstring grafts, with avoidance of the main disadvantages of these 2 most commonly used graft types in ACL reconstruction.

Clinical Outcome Reporting in Youth ACL Literature Is Widely Variable.

Background:Advances in anterior cruciate ligament (ACL) reconstruction procedures in pediatric and adolescent patients have resulted in an increase in recent clinical studies on this topic. However, the consistency with which outcome measures are reported in this demographic is unknown.Purpose:To document outcome reporting patterns of youth ACL reconstruction studies in high-impact journals.Study Design:Systematic review; Level of evidence, 4.Methods:All articles published in 5 high-impact orthopaedic journals from 2010 to 2016 were reviewed to identify those reporting clinical outcomes of young patients who underwent ACL reconstruction. Studies that were nonclinical, reported on patients older than 18 years, or included fewer than 10 patients were excluded. Outcome measures used in all included studies were recorded.Results:Seventeen studies encompassing 772 subjects (mean age, 14.3 years; range, 6.3-18.0 years) were analyzed. Eight studies (47%) reported on Tanner stage of subjects, while 1 study reported skeletal age. Ten studies (59%) clearly documented the presence or absence of surgical complications. Range of motion was reported in 65% of studies. Leg-length discrepancy and angular deformity were each reported in 76% of studies, with 12% quantifying results through radiographic measurements. Ligament testing was variably defined by inclusion of instrumented testing (65%), Lachman test (53%), and pivot-shift test (53%). Fourteen studies (82%) explicitly reported on the rate of ACL rerupture, while 71% reported on the rate of revision surgery. Rate of return to preinjury activity was reported in 8 studies (47%), of which 2 defined criteria for return to sport and 3 defined the level of competitive sport. Patient-reported outcome measures (PROMs) were used variably. For the 3 most commonly reported PROMs (Lysholm, International Knee Documentation Committee, and Tegner), 24% of studies reported all 3 PROMs, 35% of studies reported 2 PROMs, and 6% of studies reported 1 PROM in isolation. A pediatric-specific PROM was reported in 1 of the 17 studies.Conclusion:Studies on pediatric ACL reconstruction published in high-impact journals unreliably defined subjects’ skeletal maturity, inconsistently reported on objective outcome measures, and used disparate adult-validated PROMs to assess subjective outcomes. These findings highlight the need for standardized, pediatric-specific outcome measures to be applied in future studies evaluating ACL reconstruction in children and adolescents.

Enhanced ACL Graft Incorporation by Novel Minimally Invasive Activation of Endogenous Stem Cells

Objectives:The ultimate healing of a ligament graft to bone is a lengthy process that results in reparative tissue that is distinctly different from a native ligament insertion. This known structural aberration results in inferior biomechanical properties and can contribute significantly to recurrent injury as well as compromised function. Thus, technology allowing for accelerated biologic incorporation as well as the recapitulation of a native insertion would be of great benefit to patients. We hypothesized that the treatment of anterior cruciate ligament (ACL) reconstruction bone tunnels with bone morphogenetic protein (BMP) DNA combined with a pulse of ultrasound (US) energy would lead to activation of endogenous stem cells and result in enhanced graft incorporation.Methods:Soft tissue allograft ACL reconstruction was performed in nine mini-pigs using cortical screw post fixation. A collagen scaffold was added to the terminus of each tendon graft limb contained within the corresponding bone tunnel. On post-operative day 14, a lipid microsphere solution containing DNA encoding either green fluorescence protein (GFP, n=3 pigs) or BMP-6 (n=6 pigs) was delivered into the bone tunnels percutaneously under fluoroscopic guidance. The bone tunnels in the US treated group were then immediately treated with a transcutaneous US energy pulse at the site of the bone tunnels, whereas the control group did not receive US delivery. At five days post-treatment the cells occupying the bone tunnels of the GFP treated pigs (n=3) were harvested and subjected to fluorescence-activated cell sorting (FACS) analysis to assess for expression of GFP as well as known mesenchymal stem cell (MSC) markers (CD29, CD44, CD90). Six weeks post-treatment the BMP/US treated pigs (n=3) and control pigs (n=3) were sacrificed and their knee joints were scanned using microCT. Biomechanical testing of anterior-posterior (AP) knee laxity was performed via application of sinusoidal AP-directed shear loads for 12 cycles. Load to failure was assessed by removal of the joint capsule, menisci, collateral ligaments, and the PCL leaving only the ACL graft intact. The tibia and femur were then mounted on a universal material testing machine with a 5kN load cell and distracted until failure of the ACL graft or graft-bone interface.Results:FACS analysis done 5 days after GFP gene delivery showed that 40-50% of the cells occupying the US treated bone tunnels expressed GFP and this was significantly more than the cells in untreated bone tunnels (p< 0.05). In addition, 12-22% of the cells in the bone tunnels expressed MSC markers. Quantification of bone volume in ACL reconstruction tunnels showed significantly higher values in BMP-6/US treated animals (fig 1A,B,C; *p<0.05, t-test). AP laxities at ±20N of BMP-6/US treated pigs were lower than untreated pigs (fig 1D). The linear stiffness (fig 1E) and maximum load to failure (fig 1F) were both significantly higher than untreated pigs, demonstrating stronger graft-bone integration among the treated animals. (*p<0.05, t-test).Conclusion:Endogenous stem cell gene expression can be altered in a large animal model via novel minimally invasive techniques and this can result in enhanced ligament biomechanical properties. Minimally invasive biologic technology such as this would likely be of significant benefit to the treatment of patients undergoing ligament reconstruction procedures and more research regarding these technologies is certainly warranted.

Graft Site Morbidity in Elbow Ligament Reconstruction Procedures: A Systematic Review

Background: It is unclear which tendon harvest for ulnar or lateral collateral ligament reconstruction has the lowest graft site morbidity rate. Purposes: To obtain graft site morbidity rates after tendon harvest for ulnar and lateral collateral ligament reconstruction procedures. Study Design: Systematic review/Meta-analysis. Methods: Studies were eligible if (1) patients had undergone elbow ligament reconstruction procedures; (2) original data for at least 5 patients were available; (3) the article was written in English, German, or Dutch; (4) a full-text article was available; and (5) information about graft site morbidity was available. The review excluded studies about complicated elbow ligament reconstruction procedures due to initial fractures, revision procedures, or circumferential graft techniques; animal studies; (systematic) reviews; and expert opinions. Because the majority of studies were case reports, no selection form or overall scoring system to evaluate methodological quality was used. Results: The review included 619 patients with an ulnar or lateral collateral ligament reconstruction procedure. The autograft types used included palmaris longus tendon (58%), gracilis tendon (24%), semitendinosus tendon (8%), triceps tendon (7%), toe extensor tendon (<2%), plantaris tendon (<2%), extensor carpi radialis longus tendon (<1%), and Achilles tendon (<1%). Conclusion: Graft site morbidity occurred in 1% of the patients after an ulnar or lateral collateral ligament reconstruction procedure. This study did not have enough samples of all the autograft types to conclude that autograft type and graft site morbidity are unrelated.

Treatment of dynamic scapholunate instability dissociation: Contribution of arthroscopy

Scapholunate (SL) ligament injuries generally result from trauma to an extended, supinated wrist, leading to chronic instability that progresses toward osteoarthritis. They can occur together with distal radius fracture. These injuries can be difficult to diagnose, especially early on. Treating chronic SL ligament injuries before the onset of osteoarthritis is still a challenge for surgeons. Until recently, the recommended treatments consisted of open SL ligament reconstruction or repair procedures that reduce pain and improve pinch strength but also lead to wrist stiffness. The introduction of arthroscopy has completely changed our understanding of these injuries and how to treat them. We review here the treatment approach through the eyes of three specific groups of surgeons: the “pioneers” who first analyzed these injuries; the “specialists” who explored various stabilization techniques to compensate for the torn SL ligament; and the most recent group, the “anatomists” who, based on recent arthroscopy findings, sought to reconstruct the anatomical structures as accurately as possible and who developed the concept of the SL complex.

Mid-Term Follow-Up of the Result of Periarticular Osteotomy in Treating Asymmetrical Ankle Arthritis

Category: Ankle Arthritis Introduction/Purpose: A retrospective control study to evaluate periarticular osteotomy in treating asymmetrical ankle arthritis. Methods: Fifty-two consecutive patients with asymmetrical ankle arthritis were collected between 2009 and 2012. Forty-two of them were followed up. All the cases were performed the surgery of periarticular osteotomy including supramalleolar tibial osteotomy in 14 cases, supramalleolar tibial and fibular osteotomy in 5 cases, supramalleolar osteotomy combined with calcaneal osteotomy in 23 cases. Thirty cases got ligament reconstruction procedures. The age of surgery ranged from 31 to 70 years old (mean, 55.5). According to the Takakura classification of ankle arthritis, there were 16 cases in grade Ⅲa, and 26 cases in grade Ⅲb. The AOFAS-HA score and radiographic examinations including TAS and TLS were recorded and compared before and after surgery. Magnetic resonance imaging of the ankles were obtained before and after surgery (midterm result) in fifteen patients to evaluated the condition of the cartilage. Results: The average follow-up time was 44.5 months (36 to 75 months). All the patients got complete bone healing with an average healing time of 8 weeks. Average postoperative AOFAS -HA score by the last followup was 76.6±4.4 (compare with 35.7±5.6 preoperatively). Delayed wound healing occurred in 5 cases and was solved by wound care. All the cases had improvements in Takakura ankle arthritis classification by the last follow-up after surgery. Twenty-two patients felt the result of excellent, 20 felt good. The radiological assessment by the last followup showed no worsening of the ankle arthritis grade. None of these patients received or want to receive further surgeries such as ankle arthrodesis or ankle replacement. Conclusion: Periarticular osteotomy is a sound method in treating asymmetrical arthritis of the ankle in the midterm followup. This procedure can alter or decrease the contact pressures on the degenerated cartilage with mechanical realignment and can prolong the life span of the ankle itself.