Ligament Pathology Research Articles

Dynamic MR imaging analysis of instability in the injured Lisfranc joint with an MRI-compatible foot stressor device

Purpose: To evaluate the applicability of an MRI-compatible foot stressor device in patients with image-proven or clinically suspected Lisfranc joint injuries. Method: This prospective study evaluated Lisfranc joint injury by utilizing a joint-specific, stress device that was engineered to replicate weightbearing and physical examination maneuvers. Sixteen patients with either clinically suspected or image-proven Lisfranc joint injuries were recruited from September 2018 to November 2019 (9 men, 7 women; mean age, 39.3 years; age range, 14−68 years). Resting and stressed MR sequences of the injured and non-injured feet were obtained. Measured values for Lisfranc interval widths, dorsal tarsometatarsal subluxations, and lambda-angles were subtracted between the stressed and resting images to calculate net stress-induced changes. A graded injury schema was used to measure significance. Results: The foot stressor device reliably generated stress-induced changes in the Lisfranc joint during dynamic MRI examination. All morphologically abnormal ligaments on resting images demonstrated stress-induced changes, whereas all morphologically normal ligaments lacked evidence of instability. More severely injured Lisfranc ligaments allowed greater Lisfranc joint widening (IOL, p < 0.001; PCL, p < 0.001; DCL, p < 0.001). More highly graded DCL injuries allowed greater dorsal TMT subluxation when present (p < 0.001). Angular gain in the midfoot (lambda-angle) correlated with the graded IOL score (p < 0.001). Acute-to-subacute injuries demonstrated greater inducible changes than chronic injuries (p = 0.047). Seven patients underwent surgery and nine patients received physical therapy. Conclusions: Stress-induced changes in the midfoot provided information on the degree of ligament pathology and associated joint instability in Lisfranc joint injuries.

Meniscal and ligament modifications in spontaneous and post-traumatic mouse models of osteoarthritis

BackgroundOsteoarthritis (OA) is a whole joint disease that affects all joint tissues, with changes in the articular cartilage (AC), subchondral bone and synovium. Pathologies in menisci and ligaments, however, are rarely analysed, although both are known to play vital roles in the mechanical stability of the joint. The aim of our study was to describe the pathological changes in menisci and ligament during disease development in murine spontaneous and post-traumatic surgically induced OA and to quantify tissue mineralisation in the joint space using micro-computed tomography (μCT) imaging during OA progression.MethodsKnees of Str/ort mice (spontaneous OA model; 26–40 weeks) and C57CBA F1 mice following destabilisation of medial meniscus (DMM) surgery (post-traumatic OA model; 8 weeks after DMM), were used to assess histological meniscal and ligament pathologies. Joint space mineralised tissue volume was quantified by μCT.ResultsMeniscal pathological changes in Str/ort mouse knees were associated with articular cartilage lesion severity. These meniscal changes included ossification, hyperplasia, cell hypertrophy, collagen type II deposition and Sox9 expression in the fibrous region near the attachment to the knee joint capsule. Anterior cruciate ligaments exhibited extracellular matrix changes and chondrogenesis particularly at the tibial attachment site, and ossification was seen in collateral ligaments. Similar changes were confirmed in the post-traumatic DMM model. μCT analysis showed increased joint space mineralised tissue volume with OA progression in both the post-traumatic and spontaneous OA models.ConclusionsModifications in meniscal and ligament mineralisation and chondrogenesis are seen with overt AC degeneration in murine OA. Although the aetiology and the consequences of such changes remain unknown, they will influence stability and load transmission of the joint and may therefore contribute to OA progression. In addition, these changes may have important roles in movement restriction and pain, which represent major human clinical symptoms of OA. Description of such soft tissue changes, in addition to AC degradation, should be an important aspect of future studies in mouse models in order to furnish a more complete understanding of OA pathogenesis.

Efficacy of Biologics for Ligamentous and Tendon Healing

The use of “biologics” has become increasingly popular over the past several decades due to their potential to treat various pathologies by providing supraphysiological doses of anabolic growth factors. Within orthopaedic sports medicine, biologic treatments such as platelet-rich plasma and stem cells/progenitor cells are now widely used to treat soft tissue pathologies despite the lack of evidence for many of these therapies. The effects of orthobiologics on tendon and ligament healing has been investigated in various animal models and clinical trials, yet there is still no clear consensus on which biologic treatments, if any, are efficacious. Among the randomized controlled trials for these different biologics, small sample sizes, heterogenous methodology, and highly variable comparator treatments make comparisons between studies difficult and hinder the understanding of each biologic. The purpose of this review is to provide a concise summary of the best evidence for and against various “biologics” that are being used for orthopaedic tendon and ligament pathologies.

Anterior Midline Incision is a Safe and Effective Approach for High-energy Medial Shear Fractures of the Tibial Plateau

Objective: We present a technical trick for surgical treatment of with (Schatzker IV) medial tibial plateau fractures treated with a standardized operative protocol with early radiographic and clinical outcomes. Methods: Skeletally mature patients with a medial tibial plateau fracture (Schatzker IV) admitted to an academic level 1 trauma center between 2002 and 2017 were identified by institutional database review. Screening of operative reports selected patients treated with a single anteromedial approach following a standard surgical protocol by a single surgeon. Data relevant to initial injury characteristics, patient comorbidities, operative management, and follow-up were extracted by chart review. Preoperative and postoperative clinical documentation and radiographs were examined to measure specific injury and outcome variables. Radiographic and clinical outcomes were validated by one fellowship-trained orthopedic trauma surgeon and 2 orthopedic trauma fellows. Results: Review of 335 patients with tibial plateau fractures during the study period identified a series of 17 high-energy, medial partial articular fractures that met the inclusion criteria. Injury pattern included articular depression in all patients, meniscal injury in 59%, ligamentous injury in 65% and none had compartment syndrome. Immediate radiographic analysis showed restoration of the articular surface, condylar width, and mechanical alignment for all patients. No patient experienced wound healing complications, soft tissue infection or skin necrosis. Median time to radiographic fracture consolidation was 12.9 weeks and ambulation without achieved at 18.9 weeks. Conclusions: The use of a standard anteromedial approach to the knee via medial parapatellar arthrotomy with full-thickness medial skin flap for isolated high-energy medial column tibial plateau fractures offers improved visualization and facilitates reduction and fixation of the lateral and anterior articular impaction while enabling immediate repair or reconstruction of associated meniscal and ligamentous (anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament) pathology. Short-term and mid-term follow-up demonstrates good clinical and radiographic patient outcomes. This approach is a safe and reliable option for treatment of this unique and challenging injury pattern.

Actualización en materia de cirugía ortopédica y traumatología de la repercusión clínica de la utilización de PRGF: plasm rich in growth factors

Objective: Update on plasma rich in growth factors (PRGF) in the field of orthopedic surgery and traumatology. Method: Review of 136 studies on PRGF relevant in the field of orthopedic surgery and traumatology published in the last 10 years. Results: The largest number of studies on PRGF has been performed in the field of osteoarthritis of the knee (25%), followed closely by the comparative studies between PRGF and hyaluronic acid (19%). The studies on ligamentous and tendinous pathology (14%), the joint pathology different from the knee (10%).The remaining studies addressed pseudoarthrosis, osteonecrosis and nerve regeneration among others. The most commonly used platelet products were Plasma Rich in Platelets (73%), Plasma Rich in Growth Factors (15%) and Plasma Rich in Fibrin (12%). Conclusions: To document the preparation of platelet prod-ucts, establish the precise concentration of growth factors and carry out long-term follow-up is es-sential for future studies.

MRI of the Normal Elbow and Common Pathologic Conditions.

Anatomic and biomechanical knowledge of the supporting structures that provide stability to the medial and lateral elbow is essential to correctly interpret pathologic findings.

Medium-Term Results of Arthroscopic Partial Meniscectomy from a Single High-Volume Center

Clinical practice is moving away from treating meniscal tears in patients with osteoarthritis unless there are mechanical symptoms. This study assessed the risk of needing further surgery for osteoarthritis in the 5years following partial meniscectomy in different age groups and different grades of knee osteoarthritis. All partial meniscectomies were performed by the senior author during a 31-month period. Data were collected and analyzed retrospectively using electronic patients' records and imaging database. Patients who had previous arthroscopy, anterior cruciate ligament pathology, discoid meniscus or were less than 34 years old were excluded from the study. Range of follow-up was 3 to 5 years. Osteoarthritis was classified intra-operatively using the Outerbridge classification. Knees that needed further surgical treatment in the form of joint replacement or osteotomy were considered as failures. The population was split into three groups according to their age (35-54, 55-64 and 65+). Survival analysis was calculated using the life table method. 207 knees were included. In the 35-54 age group, patients with no/mild OA had a survival rate of 97.59% and the severe OA group had a survival rate of 73.5%. In the 55-64 age group, these figures were 100% and 73.6%, respectively. In the >65 age group, the survival rates were 100% and 65%, respectively. Our study shows that patients with no/mild OA should be considered for APM. Patient's with meniscal tears and severe OA should be counseled on the outcomes and risks of further surgery after an APM.

Falciform ligament abscess: a report of two cases

Falciform ligament abscess (FLA) is very rare. The rarity and obscure location often cause delay in diagnosis and inadequate treatment. We are here describing two cases of FLA in infants; presentation, hospital course, and outcome of both the children were different. Early consideration of falciform ligament pathology is crucial for timely diagnosis and proper treatment.

Indications and associated outcomes for platelet-rich plasma injections performed in an academic orthopaedic-specific hospital: A patient satisfaction survey

Background: Platelet-rich plasma (PRP) is an autologous biologic product that has become widely used in orthopaedic centers and at so-called “regenerative medicine” or “pain” clinics. Although food Drug Administration (FDA)-approved indications for use of PRP in orthopaedics are for applications in which it is mixed with autograft or allograft bone, attention and clinical research have focused on its off-label uses for treatment of osteoarthritis, musculotendinous disorders, or joint pain. The present study aimed to document indications for PRP used by orthopaedic surgery faculty in an academic orthopaedic-specific hospital between 2011 and 2016, characterize demographics of patients receiving these injections, and assess associated 1-year or greater outcomes for these patients. Methods: With institutional review board approval, this study retrospectively identified 148 patients with osteoarthritis, augmentation surgical treatments, tendon or ligament pathology, and sacroiliac joint pain as indications for PRP treatment. Results: For respondents (n=60), 78.3% (47 of 60) reported PRP-related improvement in symptoms, with mean duration of effect of 800 days and an overall level of satisfaction with their PRP treatment of 67.9% (range, 1-100%). Factors that negatively influenced successful outcomes in the present study included patient age older than 45 yr and use of leukocyte-rich PRP, while degree of improvement and return to full activity positively influenced patient satisfaction with PRP treatment. Conclusions: The results of the present study suggest that PRP can be used to treat a variety of musculoskeletal conditions commonly diagnosed at an academic orthopaedic-specific hospital, with expectations for 78% of patients reporting improvement and an overall patient satisfaction level of 68%. Level of Evidence: Level IV.

Prevalence of anterolateral complex injury and associated injuries in knees with acute complete and partial anterior cruciate ligament injury

Aim: Kaplan fibers, capsule, ligament (ALL) and Iliotibial band are defined as secondary stabilizers of the internal tibial rotation of the knee. These structures have been summarized as the Anterolateral complex (ALC). We aimed to determine the ALC injury prevalence and the association between Anterior cruciate ligament (ACL) and ALC injury patterns. Materials and Methods: MRI scans of ACL injuries were retrospectively evaluated for the presence of the ACL injury pattern (partial or complete), ALL, iliotibial band, Kaplans fiber, meniscus, bone marrow edema (BME) and collateral ligament pathology. The patients were divided into groups according to the ACL injury pattern. The prevalence of injury of the anatomical structures between groups was examined. Results: MRI scans of 152 patients (152 knees) were evaluated. The mean age of the patients was 28.5±8.6 (range, 18-55). 138 patients were male and 14 were female. Complete ACL injury was detected in 127 (83.6%) patients confirmed by MRI and arthroscopic procedure and partial ACL injury was detected in 25 (16.4%) patients confirmed by MRI. 90 (59.2%) patients had an ALL injury, 87 (57.2%) had an iliotibial band injury, 82 (53.9%) patients had a Kaplans fiber injury, 53 (34.9%) patients had a meniscal injury, 99 (65.1%) patients had BME and 70 (46.1%) patients had a collateral ligament injury. In the complete ACL injury group, the ratio of ALL, iliotibial band, Kaplan fiber, meniscal injury, BME, collateral ligament injury was significantly higher than the partial ACL injury group (p 0.05). Conclusion: The prevalence of injury in at least one anatomic structure of ALC was significantly higher in patients with a complete ACL injury (73.2%) than those with partial ACL injury (32%) at our institution. This study demonstrated that ALC injuries were statistically higher as well as meniscal injuries, BME, collateral ligament injuries after complete ACL injury compared to partial ACL injury.

How to Manage Cartilage Injuries?

Although small cartilage injuries are commonly found in knee arthroscopy procedures, significant chondral and osteochondral injuries are relatively infrequent. Incidence of cartilage injury rises when considering traumatic origin, especially when approaching significant ligamentous or meniscal pathology. Options for restoration span the gamut from benign neglect to open procedures that restore both cartilage and subchondral bone. The best choice of procedure largely depends on lesion size, depth, and location. Smaller lesions isolated to cartilage <2 cm2 can be treated with marrow stimulation techniques such as microfracture with or without biologic options (bone marrow aspirate concentrate or platelet-rich plasma with or without cartilage precursors or scaffolds). Microfracture alone in larger lesions has been reported to be less durable and it is therefore not recommended for larger lesions. Smaller lesions <2 cm2 that include a subchondral injury can be treated with osteochondral autograft implantation, in which a core of cartilage and bone is transferred from a relative non-weightbearing surface to the lesion.Larger osteochondral lesions >2 cm2 are better treated with osteochondral allograft transplantation, where osteochondral cores from a size-matched, fresh cadaver are matched to the patient's lesion. This option may require multiple cores to be placed in a “snowman” pattern; however, recent literature demonstrated that a single plug might produce better outcomes. Alternatively, for large chondral-only lesions, a resurfacing procedure may be chosen that may include biologic options. Autologous chondrocyte implantation (ACI), currently in its third iteration (matrix ACI [MACI]), is an excellent choice with good long-term durability. In addition, MACI may be used for chondral lesions in the patellofemoral joint where matching the native joint topology may be more difficult. If the patient has an underlying bone marrow lesion but an intact cartilage cap that appears healthy on arthroscopic examination, one may consider a core decompression and injection with biologics such as BMAC and bony scaffold with fibrin glue (also known as bioplasty).It is also critical that the surgeon address any concomitant knee pathology that would compromise cartilage restoration. This includes addressing malalignment with distal femoral, proximal tibial, or tibial tubercle osteotomy, significant meniscal deficiency with meniscal transplant, and any instability from lack of cruciate or collateral ligaments with ligament reconstruction.

Concomitant Posterolateral Corner Injuries in Skeletally Immature Patients With Acute Anterior Cruciate Ligament Injuries.

Missed posterolateral corner (PLC) injuries are a known cause of anterior cruciate ligament reconstruction (ACL) failure in the adult population. Failed ACL reconstruction causes significant morbidity in the skeletally immature pediatric population. There is little literature on the character and potential significance of PLC injuries in skeletally immature patients. Magnetic resonance imaging studies of the knee at a tertiary care children's hospital for patients who underwent an ACL reconstruction without PLC surgery were retrospectively reviewed. Demographic variables were obtained through chart review, and magnetic resonance imaging studies were evaluated for PLC (popliteus, fibular collateral ligament, popliteofibular ligament, and arcuate ligament) injury, and ACL, medial collateral ligament (MCL), bone bruise, fracture, and meniscal pathology by an experienced pediatric musculoskeletal radiologist. A total of 50 patients with a mean age at 13.3 years at injury were analyzed. PLC injuries were found in 26 patients (52%), with 7 patients (14%) having a complete tear of a component of the PLC. There was no association between sex (P=0.35), Segond fracture (P=0.09), meniscus injury (P=0.92), or MCL injury (P=0.24) with the risk of PLC injury. There was an association between patient age and PLC injury (P=0.02). For each additional year of age, the odds of PLC injury increased by 1.8 times (odds ratio, 1.8; 95% confidence interval, 1.4-2.2). There was no association between PLC injury and ACL graft failure (P=0.19). Missed PLC injuries are a significant source of morbidity and poor clinical outcomes in the management of concomitant ACL injuries in adults. This study demonstrates the prevalence of PLC injuries in the setting of concomitant ACL injuries in the unique skeletally immature patient population. Incomplete PLC injuries are relatively common. Complete PLC injuries are relatively uncommon. PLC injury was more common in older patients. No other concomitant injury predicted the likelihood of PLC injury. Further research is needed regarding the risk of ACL reconstruction failure from associated PLC injury and the indications for PLC reconstruction in skeletally immature patients. Level IV-diagnostic study.

Beyond the bones and joints: a review of ligamentous injuries of the foot and ankle on 99mTc-MDP-SPECT/CT.

99mTc-MDP-single photon emission computed tomography (SPECT)/CT has established itself as a useful modality in the assessment of the painful foot and ankle, owing to its ability to depict anatomical and functional information simultaneously. Despite its growing popularity, much of the literature describing the utility of 99mTc-MDP-SPECT/CT of the foot and ankle is limited to osseous and articular pathology, with descriptions of ligamentous pathology limited to just a handful of cases. Though assessment of soft tissues using a combination of bone tracer and CT is limited, with a sound understanding of the regional anatomy, it is certainly within the scope of 99mTc-MDP-SPECT/CT to accurately identify ligamentous injuries based on focal tracer uptake patterns and suspected ligamentous injuries should be reported as such. This article provides a case-based pictorial review of the 99mTc-MDP-SPECT/CT appearances of the various ligamentous injuries of the foot and ankle with case examples and MRI correlation where available, most of which have yet to be described. The typical patterns of bone tracer uptake and associated CT abnormalities that may be observed are discussed.

Coracohumeral Ligament Reconstruction for Patients With Multidirectional Shoulder Instability

Coracohumeral ligament pathology arises from acute trauma, capsular thickening, or congenital connective tissue disorders within the glenohumeral joint. Recent studies have highlighted the significance of this pathology in multidirectional shoulder instability because insufficiency of the rotator interval has become increasingly recognized and attributed to failed shoulder stabilization procedures. The diagnosis and subsequent treatment of coracohumeral ligament pathology can be challenging, however, because patients usually present with a history of failed surgical stabilization and persistent laxity. At the time of presentation, most patients have undergone failed nonoperative treatments and are indicated for surgical intervention. One of the options for the treatment of coracohumeral ligament pathology is reconstruction. The purpose of this Technical Note is to describe our preferred surgical technique for the reconstruction of the coracohumeral ligament. Research was performed at the Steadman Philippon Research Institute.

Orthopedic Injury Profiles in Adolescent Elite Athletes: A Retrospective Analysis From a Sports Medicine Department.

Aim: The aim of the study was to identify common orthopedic sports injury profiles in adolescent elite athletes with respect to age, sex, and anthropometrics.Methods: A retrospective data analysis of 718 orthopedic presentations among 381 adolescent elite athletes from 16 different sports to a sports medical department was performed. Recorded data of history and clinical examination included area, cause and structure of acute and overuse injuries. Injury-events were analyzed in the whole cohort and stratified by age (11–14/15–17 years) and sex. Group differences were tested by chi-squared-tests. Logistic regression analysis was applied examining the influence of factors age, sex, and body mass index (BMI) on the outcome variables area and structure (α = 0.05).Results: Higher proportions of injury-events were reported for females (60%) and athletes of the older age group (66%) than males and younger athletes. The most frequently injured area was the lower extremity (47%) followed by the spine (30.5%) and the upper extremity (12.5%). Acute injuries were mainly located at the lower extremity (74.5%), while overuse injuries were predominantly observed at the lower extremity (41%) as well as the spine (36.5%). Joints (34%), muscles (22%), and tendons (21.5%) were found to be the most often affected structures. The injured structures were different between the age groups (p = 0.022), with the older age group presenting three times more frequent with ligament pathology events (5.5%/2%) and less frequent with bony problems (11%/20.5%) than athletes of the younger age group. The injured area differed between the sexes (p = 0.005), with males having fewer spine injury-events (25.5%/34%) but more upper extremity injuries (18%/9%) than females. Regression analysis showed statistically significant influence for BMI (p = 0.002) and age (p = 0.015) on structure, whereas the area was significantly influenced by sex (p = 0.005).Conclusion: Events of soft-tissue overuse injuries are the most common reasons resulting in orthopedic presentations of adolescent elite athletes. Mostly, the lower extremity and the spine are affected, while sex and age characteristics on affected area and structure must be considered. Therefore, prevention strategies addressing the injury-event profiles should already be implemented in early adolescence taking age, sex as well as injury entity into account.

Age-Related Variances in Patients with Tibial Plateau Fractures.

Tibial plateau fractures account for approximately 8% of fractures in the elderly population. Treatment strategies in the elderly are similar to those for younger patients; however, practitioners must account for the elevated comorbidity burden in this population. To date, few studies have analyzed age-based outcomes in patients with tibial plateau fractures. Therefore, the purpose of this study was to determine age-related variances in demographics, fracture characteristics, mechanism of injury, and complications. A 10-year retrospective review was conducted to identify patients who received treatment for a tibial plateau fracture. There were 351 patients (360 tibial plateau fractures) who were identified and subsequently stratified according to their age at the time of injury. Patients were classified as elderly if they were 65 years of age or older at the time of injury; all other patients were included in the control cohort. These two cohorts were analyzed using bivariate analysis to isolate for age-related variations with respect to risk factors, mechanism of injury, and complications. There were 351 patients (360 tibial plateau fractures) with a median follow-up of 1.84 ± 2.44 years who met inclusion criteria. There were a greater proportion of women in the elderly cohort as compared with the younger cohort (60.0 vs. 43.4%, p = 0.06). Elderly patients were significantly more likely to present with diabetes (33.3 vs. 16.1%, p = 0.01) or osteoporosis (14.3 vs. 1.6%, p = 0.001). Younger patients were significantly more likely to require further surgery to address ligament (12.6 vs. 0%, p = 0.008), meniscus (20.9 vs. 7.1%, p = 0.036), or cartilage pathology (13.6 vs. 0%, p = 0.005). There was no difference in the arthroplasty conversion rate (4.8% elderly vs. 7.9% control, p = 0.755). While elderly patients presented with a greater comorbidity burden, they had equivalent or better short-term outcomes when compared with their younger peers when treated with open reduction and internal fixation (ORIF). Despite the recent interest in primary total knee arthroplasty for elderly patients with tibial plateau fractures, the results of this study suggest that elderly patients may respond well when treated with ORIF following a tibial plateau fracture.

CONCOMITANT POSTEROLATERAL CORNER INJURIES IN SKELETALLY IMMATURE PATIENTS WITH ACUTE ANTERIOR CRUCIATE LIGAMENT INJURIES

Background: Missed and/or untreated posterolateral corner (PLC) injuries are a known cause of anterior cruciate ligament (ACL) reconstruction failure in the adult population. Failed ACL reconstruction causes significant morbidity in the skeletally immature pediatric population. There is little literature on the character and potential significance of posterolateral corner injuries in skeletally immature patients. Methods: Magnetic resonance imaging (MRI) studies of the knee performed at a single tertiary care pediatric hospital between 01/01/2010 and 12/31/2015 for patients who underwent an ACL reconstruction were retrospectively reviewed. Demographic variables were obtained via medical record review, and MRI studies were evaluated for PLC (popliteus, fibular collateral ligament (FCL), popliteofibular ligament (PFL), arcuate ligament) injury, as well as ACL, medial collateral ligament (MCL), bone bruise, fracture, and meniscal pathology by an experienced pediatric musculoskeletal radiologist. Results: Fifty-two patients, 65% of whom were male, with a mean age of 13.8 years at injury were analyzed. PLC injuries were found in 28 patients (54%), with 7 patients (14%) having a complete tear of a component of the PLC. MCL injuries were found in 13 patients (25%). Meniscus tears were found in 25 patients (48%); 17 were of the medial meniscus (33%), and 10 were of the lateral meniscus (19%). A Segond fracture was seen in four patients (8%). The most common injury pattern involved the PFL only (9, 32% of patients with PLC injuries). There was no association between sex (p=0.29), Segond fracture (p=0.09), meniscus injury (p=0.93), or MCL injury (p=0.32) with the risk of PLC injury. There was an association between patient age and PLC injury (p=0.02). For each additional year of age, the odds of PLC injury increased by 1.7 times (OR=1.7 (1.1, 2.8)). Patients were an average age of 14.0 years at ACL reconstruction, and 9 patients went on to re-tear. There was no association between PLC injury and ACL graft failure (p=0.72). Conclusions: This study demonstrates the prevalence of PLC injuries in the setting of concomitant ACL injuries in the skeletally immature patient population. Age was found to predict the odds of PLC injury, which was significantly higher in older skeletally immature patients. No other concomitant injury predicted likelihood of PLC injury.

Clinical experience with two-point mDixon turbo spin echo as an alternative to conventional turbo spin echo for magnetic resonance imaging of the pediatric knee.

Two-point modified Dixon (mDixon) turbo spin-echo (TSE) sequence provides an efficient, robust method of fat suppression. In one mDixon acquisition, four image types can be generated: water-only, fat-only, in-phase and opposed-phase images. To determine whether PD mDixon TSE water-only and, by proxy, PD in-phase images generated by one acquisition can replace two conventional PD TSE sequences with and without fat suppression in routine clinical MR examination of the knee. This is a retrospective study of 50 consecutive pediatric knee MR examinations. PD mDixon TSE water-only and PD fat-saturated TSE sequences (acquired in the sagittal plane with identical spatial resolution) were reviewed independently by two pediatric radiologists for homogeneity of fat suppression and detection of intra-articular pathology. Thirteen of the 50 patients underwent arthroscopy, and we used the arthroscopic results as a reference standard for the proton-density fat-saturated and proton-density mDixon results. We used the Kruskal-Wallis rank test to assess difference in fat suppression between the proton-density mDixon and proton-density fat-saturated techniques. We used kappa statistics to compare the agreement of detection of intra-articular pathology between readers and techniques. We also calculated sensitivity, specificity and accuracy between arthroscopy and MR interpretations. Proton-density mDixon water-only imaging showed significant improvement with the fat suppression compared with proton-density fat-saturated sequence (P=0.02). Each observer demonstrated near-perfect agreement between both techniques for detecting meniscal and ligamentous pathology and fair to substantial agreement for bone contusions, and chondral and osteochondral lesions. Two-point mDixon water-only imaging can replace conventional proton-density fat-saturated sequence. When same-plane proton-density fat-saturated and non-fat-saturated sequences are required, proton-density water-only and proton-density in-phase image types acquired in the same acquisition shorten the overall examination time while maintaining excellent intra-articular lesion conspicuity.

Scanning the wrist for ligament injuries

To understand the pathology which may occur following an injury to the wrist, this presentation will review the anatomy and biomechanics of this joint. The biomechanics of wrist injuries are as follows Weightbearing injuries which may be sustained weightlifting or in gymnastics where there is increased axial loading or where the wrist is extended and radially deviated, may result in volar carpal ligament injuries. Twisting injuries during wrestling and again gymnastics where there is excessive pronation or supination of the wrist may affect the TFCC. Impact injuries such as a fall onto the outstretched hand - FOOSH - can result in scapho-lunate, lunotriquetral and or palmar radiocarpal ligament rupture, a TFCC tear or a strain of the dorsal radiocarpal ligament. (Anderson, Read, 2008) All these ligaments which have been listed are easily seen with ultrasound. A detailed history is imperative prior to scanning the wrist. Specific tests can also be useful determining which ligaments may be injured prior to scanning such as Watsons test. Injuries to intrinsic ligaments such as the scapholunate ligament can be classified into 3 different grades. Grade 1 is a stable injury with only mild stretching of the joint from radial to ulnar deviation. Grade 2 is a tear of the central and dorsal components of the ligament leading to widening of the joint from radial to ulnar deviation. Grade 3 is a tear of all 3 regions of the ligament leading to not only widening of the joint but malalignment of the joint. A partial tear or strain of an extrinsic ligament will appear as a thickened, hypoechoic, but in tact ligament. A full thickness tear will appear as an anechoic defect in the ligament. The ultrasound appearances and technique for scanning these ligaments as well as ligamentous pathology will be reviewed in this presentation.

Wrist arthroscopy and MRI for the evaluation of scapholunate and lunotriquetral ligaments tear in Kienbock’s disease

Purpose The principal intrinsic wrist interosseous ligaments of the wrist are the scapholunate ligament (SLL) and the lunotriquetral ligament (LTL). Injuries to the wrist ligaments are common and can lead to chronic wrist pain. To our knowledge, the incidence of associated intrinsic wrist ligament pathology in Kienbock’s disease has not been previously described. Herein, we used wrist arthroscopy and MRI for the evaluation of SLL and LTL injury in 40 patients with Kienbock’s disease. Patient and methods The study was based on 40 patients with Kienbock’s disease (stages II, IIIa, and IIIb), 17 women and 23 men. Their age ranged from 13 to 46 years (mean, 31 years and 6 months). All patients underwent MRI followed by wrist arthroscopy for the diagnosis of SLL and/or LTL tear. Results The incidence of isolated SLL tear and combined SLL and LTL tear of the 40 patients with Kienbock’s disease included in this study was 27.5 and 7.5% as evaluated with MRI, respectively, and 35 and 15% as evaluated with wrist arthroscopy, respectively. According to Geissler arthroscopic classification, 75% of SLL injury were of grade I, while 25% were of grade III. Moreover, 50% of the patients with ligamentous injury reported a history of trauma with a mean of 4.4 months interval between the trauma and first presentation. Conclusion This study had proved that Kienbock’s disease is associated with tear of SLL and/or LTL in a significant number of patients among the study group. However, it was difficult to distinguish between the degenerative and traumatic ligament tears.