Ligamentous Tension Research Articles

Retrospective Medical Record Review of an Osteopathic Manipulative Medicine Hospital Consultation Service

In the first half of the 20th century, nearly all osteopathic physicians used osteopathic manipulative medicine (OMM) in the care of hospitalized patients. Over the past few decades, however, inpatient OMM care has declined and is more commonly provided by OMM specialists. To retrospectively evaluate the details of a specialty-level OMM inpatient consultation service. Inpatient OMM consultations that took place at Northeast Regional Medical Center in Kirksville, Missouri, between July 1998 and March 2008 were identified from billing records. Consultations were reviewed for demographic information, admission location, postoperative status, intensive care unit and mechanical ventilation usage, admission and discharge diagnoses, consultation reasons and final diagnoses, areas of somatic dysfunction treated and types of osteopathic manipulative treatment (OMT) techniques used, and hospital length of stay (LOS). A total of 1509 OMM consultations were identified (580 for male patients [38%]; 929 for female patients [62%]; mean [SD] age, 54 [31] years [range, 0-99 years]), representing 11% of all inpatient consultations. Of these, 1372 consultations (91%) were initiated in the inpatient acute care facility, 87 (6%) in the inpatient acute rehabilitation facility, and 50 (3%) in the skilled nursing facility. Further, 265 consultations (18%) were for postoperative patients, 187 (12%) were for patients in the intensive care unit, and 54 (4%) were for patients receiving mechanical ventilation at the time of the consultation. The most common admission diagnoses were hypertension, routine newborn care, lower respiratory infection, chronic obstructive pulmonary disease, and gastrointestinal symptoms. The most common reasons for OMM consultation were chest/rib pain, spinal pain, lower respiratory infection (adjunctive treatment), cranial asymmetry, and infant feeding disorder. The most common types of OMT techniques used were myofascial release, balanced ligamentous tension, muscle energy, soft tissue, and inhibition. The mean (SD) LOS was 5.7 (3.3) days (range, 0-48 days), while the mean (SD) number of days the patient received OMT was 3.1 (2.2) days. Medical records reviewed in the current study revealed that OMM consultations were ordered primarily for musculoskeletal complaints, respiratory problems (adjunctive treatment), and newborn care. A variety of OMT techniques were used. Further retrospective study is warranted to determine if OMM had an effect on LOS.

Influence of a Secondary Downsizing of the Femoral Component on the Extension Gap: A Cadaveric Study

The purpose of this study was to evaluate the effect of a secondary reduction of the femoral component size on flexion and extension gaps intraoperatively in posterior-stabilized total knee arthroplasty (PS-TKA) monitored by computer-assisted surgery. The authors hypothesized that cutting additional bone on the posterior femoral condyle may increase the extension gap due to the posterior capsule and soft tissue loosening. Reduction of the femoral component size was performed by additional 4-in-1 cuts after the PS-TKA on 15 cadaveric knees using a ligamentous tension device with the aid of computer-assisted surgery. Measurements of the medial and lateral flexion gaps, as well as the medial and lateral extension gaps, were recorded before and after reducing the femoral component size. Trial components were used from a mobile-bearing total knee system.After reducing the femoral component size, the medial and lateral flexion and extension gaps measured larger than their initial size. The mean increases of the medial extension and flexion gaps and the lateral extension and flexion gaps were 1.3 ± 0.9, 1.0 ± 1.2, 1.1 ± 1.2, and 1.3 ± 1.3 mm, respectively; all 4 differences were significant (P ≤ .05). Surgeons should be aware of the effect of downsizing components intraoperatively because it might lead to an extension laxity. Thus, a downsizing of the femoral component may compromise the postoperative stability of TKA.

Direct Posterior C1 Lateral Mass Screws Compression Reduction and Osteosynthesis in the Treatment of Unstable Jefferson Fractures

Technical case report. To investigate a new concept and surgical technique in the treatment of unstable Jefferson fractures, which preserves the motion of upper cervical spine, avoiding fusion. The management of unstable Jefferson fractures remains controversial. Conservative treatment usually involves a long time of immobilization in halo vest, whereas surgical intervention generally performs fusion, eliminating the range of motion of upper cervical spine. Two patients with unstable Jefferson fractures were surgically treated via direct posterior C1 lateral mass screws compression reduction and osteosynthesis technique, aiming at restoring the C0-C2 height and maintaining the vertical ligamentous tension for C0-C1-C2 complex stability despite the incompetent transverse ligament, achieving physiologic repair instead of traditional fusion. The clinical and radiographic results were documented. The postoperative CT showed that C1 lateral mass screws were well positioned. At 1-year follow-up, plain radiographs, and CT scan revealed no implant failure, good cervical alignment, and bony healing of the fractures; no C1-C2 instability was observed on the flexion-extension radiographs. The patients were completely pain-free, with full range of motion of the cervical spine. The ideal treatment of unstable Jefferson fractures is expected to preserve the function of C0-C1-C2. Unstable Jefferson fractures involve the concomitant failure of the vertical ligamentous tension because of the loss of C0-C2 height. Reduction of the displaced lateral masses to restore the C0-C2 height and maintain the ligamentous tension is the key to the surgery. Direct posterior C1 lateral mass screws compression reduction and osteosynthesis is a valid technique, avoiding fusion of upper cervical spine.

Évaluation de la laxité antérieure du genou en IRM : la laxi-IRM

Purpose Evaluation of the ACL and anterior knee laxity on MR during anterior tibial translation. Patients and methods Three groups were identified based on clinical and arthrometric (KT-1000) data: normal ACL ( n = 12), complete tear ( n = 10) and partial tear ( n = 20). MRI was performed without and with anterior tibial translation (pneumatic device) with morphological and laximetric analysis: drawer tests and dynamic evaluation of ligamentous tension. Results Intra- and inter-observer reproducibility was excellent, correlated to arthrometric data and clinical tests (Lachman, pivot shift). The difference between the drawer signs of normal subjects and patients with ACL tear was significant for a threshold value of 1,1 mm for the anterior drawer (sensitivity: 93,33%, specificity: 91,7%) and 2,8 mm for the posterior drawer (sensitivity: 86,7%, specificity: 100%). Dynamic evaluation of ligamentous tension was also reproducible, statistically correlated to the MR drawer tests and reliable for the diagnosis of ACL lesions. In this preliminary study, the distinction between complete and partial ACL tears could not be detected. Conclusion Anterior cruciate ligament function can be demonstrated on MR. The predictive value of this morphological and functional association should be determined in the management of patients with partial tears.

A biomechanical rationale for C1-ring osteosynthesis as treatment for displaced Jefferson burst fractures with incompetency of the transverse atlantal ligament.

Nonsurgical treatment of Jefferson burst fractures (JBF) confers increased rates of C1-2 malunion with potential for cranial settling and neurologic sequels. Hence, fusion C1-2 was recognized as the superior treatment for displaced JBF, but sacrifies C1-2 motion. Ruf et al. introduced the C1-ring osteosynthesis (C1-RO). First results were favorable, but C1-RO was not without criticism due to the lack of clinical and biomechanical data serving evidence that C1-RO is safe in displaced JBF with proven rupture of the transverse atlantal ligament (TAL). Therefore, our objectives were to perform a biomechanical analysis of C1-RO for the treatment of displaced Jefferson burst fractures (JBF) with incompetency of the TAL. Five specimens C0-2 were subjected to loading with posteroanterior force transmission in an electromechanical testing machine (ETM). With the TAL left intact, loads were applied posteriorly via the C1-RO ramping from 10 to 100 N. Atlantoaxial subluxation was measured radiographically in terms of the anterior antlantodental interval (AADI) with an image intensifier placed surrounding the ETM. Load-displacement data were also recorded by the ETM. After testing the TAL-intact state, the atlas was osteotomized yielding for a JBF, the TAL and left lateral joint capsule were cut and the C1-RO was accomplished. The C1-RO was subjected to cyclic loading, ramping from 20 to 100 N to simulate post-surgery in vivo loading. Afterwards incremental loading (10-100 N) was repeated with subsequent increase in loads until failure occurred. Small differences (1-1.5 mm) existed between the radiographic AADI under incremental loading (10-100 N) with the TAL-intact as compared to the TAL-disrupted state. Significant differences existed for the beginning of loading (10 N, P = 0.02). Under physiological loads, the increase in the AADI within the incremental steps (10-100 N) was not significantly different between TAL-disrupted and TAL-intact state. Analysis of failure load (FL) testing showed no significant differences among the radiologically assessed displacement data (AADI) and that of the ETM (P = 0.5). FL was Ø297.5 +/- 108.5 N (range 158.8-449.0 N). The related displacement assessed by the ETM was Ø5.8 +/- 2.8 mm (range 2.3-7.9). All specimens succeeded a FL >150 N, four of them >250 N and three of them >300 N. In the TAL-disrupted state loads up to 100 N were transferred to C1, but the radiographic AADI did not exceed 5 mm in any specimen. In conclusion, reconstruction after displaced JBF with TAL and one capsule disrupted using a C1-RO involves imparting an axial tensile force to lift C0 into proper alignment to the C1-2 complex. Simultaneous compressive forces on the C1-lateral masses and occipital condyles allow for the recreation of the functional C0-2 ligamentous tension band and height. We demonstrated that under physiological loads, the C1-RO restores sufficient stability at C1-2 preventing significant translation. C1-RO might be a valid alternative for the treatment of displaced JBF in comparison to fusion of C1-2.

Scheuermann's kyphosis

Purpose of review Scheuermann’s kyphosis is a condition characterized by increased posterior rounding of the thoracic spine in association with structural deformity of the vertebral elements. Currently, there is debate over whether anterior procedures are necessary in the surgical treatment of Scheuermann’s kyphosis. Recent findings Nonoperative treatment is reserved for skeletal immature patients (Risser 2 or less) with a progressive deformity that is cosmetically or functionally unacceptable. Surgical indications for Scheuermann’s kyphosis should be assessed on a case-by-case basis, but in general patients with pain, a rigid deformity, a curve of more than 70–758, progressive deformity and an unacceptable cosmetic appearance are surgical candidates. Newer technologies, such as third generation segmental instrumentation, in combination with compression rod techniques have nearly eliminated the need for combined anterior–posterior procedures. When an anterior procedure is deemed to be necessary, prone video-assisted thoracic surgery anterior release and fusion is an attractive alternative to formal open anterior release to provide the anterior release, followed by posterior correction and then placement of structural graft. Summary Combined anterior–posterior procedures are rarely necessary with current spine instrumentation and techniques. Proper fusion level selection, avoidance of adjacent posterior ligamentous tension band resection, and preventing overcorrection will limit junctional kyphosis.

Effect of knee laxity on in vivo kinematics of meniscal-bearing knee prostheses

Introduction This study determined the relationship between the in vivo kinematics and joint laxity of mobile-bearing knees. Materials and methods Ten subjects who were judged clinically successful after a posterior-cruciate-ligament-retaining mobile-bearing total knee arthroplasty were analyzed under dynamic conditions using fluoroscopy, following a quantitative evaluation of coronal and sagittal laxity using Telos and KT-2000 arthrometers under static conditions. Results Under static conditions, the anteroposterior laxity averaged 10.3 mm at 30° of flexion, and 8.3 mm at 75°. Abduction and adduction at full extension averaged 3.7 and 4.4 mm, respectively. Under dynamic conditions, 7/10 subjects demonstrated posterior femoral rollback of their lateral condyle moving from full extension to maximum knee flexion, and 8/10 experienced normal axial rotation patterns during deep knee bend activity. Furthermore, 7/10 subjects exhibited screw-home motion. 4/10 subjects experienced greater than 1.0 mm of condylar liftoff. Conclusion We could not predict a consistent relationship between the laxity and kinematics. The activity of the muscles and ligamentous tension under dynamic conditions might have a much greater effect on the kinematics with currently used prosthetic designs than the laxity of ligamentous structures under static conditions.

Elbow joint laxity after experimental radial head excision and lateral collateral ligament rupture: Efficacy of prosthetic replacement and ligament repair

The objectives of this experimental study were to investigate the effect of radial head excision and lateral collateral ligament (LCL) division on elbow joint laxity and to determine the efficacy of radial head prosthetic replacement and LCL repair. Valgus, varus, internal rotation, and external rotation of the ulna were measured during passive flexion-extension and application of a 0.75-Nm torque in 6 intact cadaveric elbows and after (1) either excision of the radial head or division of the LCL, (2) removal of both constraints, (3) isolated radial head prosthetic replacement, (4) isolated LCL repair, and (5) radial head replacement combined with LCL repair. Isolated radial head excision increased varus (mean, 4.8 degrees) and external rotatory laxity (mean, 7.1 degrees), as did isolated LCL division (mean, 14.1 degrees for varus; mean, 14.7 degrees for external rotation). After removal of both constraints, varus and external rotatory laxities were increased by 19.0 degrees and 20.1 degrees, respectively, compared with the intact specimens. Isolated radial head replacement reduced mean varus laxity to 14.6 degrees and mean external rotatory laxity to 14.8 degrees. Isolated LCL repair normalized varus laxity but resulted in a 2.9 degrees increase in external rotatory laxity. The combined procedures restored laxity completely. The radial head is a constraint to varus and external rotation in the elbow joint, functioning by maintaining tension in the LCL. Still, removal of both constraints induces severe laxity, and in this case, prosthetic replacement may substitute for the constraining capacity of the native radial head. The combination of LCL repair and radial head replacement restores laxity completely, but an isolated LCL repair performs almost as well, probably by compensating for the ligamentous tension lost from radial head excision.

A determination of ankle kinematics using fluoroscopy.

In vivo weight-bearing studies utilizing dynamic video fluoroscopy have been shown to offer an accurate and reproducible method for determining the kinematics of a joint. The purpose of this study was to evaluate translational and rotational motions of the distal tibia relative to the talus in the sagittal and frontal planes. Ten subjects, each having a normal ankle and a total ankle arthroplasty on the opposite side (Buechel-Pappas Total Ankle, Endotec, South Orange, NJ), were studied under in vivo, weight-bearing conditions using video fluoroscopy. All ten subjects were judged to have a successful arthroplasty without demonstrable pain or ligament instability. Under weight-bearing conditions, each subject performed successive motions moving from maximum dorsiflexion to plantarflexion. At maximum dorsiflexion, both the normal and implanted ankles had similar sagittal midline talar contact positions but with plantar flexion, implanted ankles had increased posterior talar contact. Contact points on the distal tibia revealed that the lateral surface contacted at the midline or posterior throughout range-of-motion with minimal translation. The medial distal tibia contacted the talus posterior on plantarflexion and often moved anteriorly with dorsiflexion. This translation described relative external rotation of the distal tibia on plantar flexion and internal rotation on dorsiflexion. The measured distances were larger for the implanted ankles with higher variability. The average range-of-motion was 37.4 degrees for normal ankles and 32.3 degrees for implanted ankles. This study defines the normal kinematic rotational and translational motions of the ankle joint by accurately describing the three dimensional joint orientations. The implanted ankles experienced rotational and translational motions but had contacts more posterior, possibly related to surgical technique or alterations of ligamentous tension.

Critical Analysis of the Sequence and Extent of the Result of the Pathological Failure Of Self-Bracing of the Sacroiliac Joint

AbstractWhen the sacrum is loaded with superincumbent weight, the sacroiliac joint functions as a self-compensating force couple. This couple creates and tends to rotate around an axis perpendicular to itself. The location of this axis may vary and depends upon the forces applied to the couple. As ligamentous tension increases in the couple, the sacroiliac joints are drawn tightly together through a mechanism of self-bracing. Self-bracing and its normal release or diminution provides for the storage and release of energy, which enhances the efficiency of normal ambulation and which modifies external forces. Failure of the force couple causes failure of the transverse axis of rotation of the sacroiliac joint and failure of the self-bracing mechanism. Because of the decrease in friction and stability, the innominate bones rotate anteriorly on the sacrum on an acetabular axis with the onset of pain and an alteration in apparent leg length. The resultant dysfunction may range from slight to severe, from minor...

Critical Analysis of the Sequence and Extent of the Result of the Pathological Failure of Self-Bracing of the Sacroiliac Joint

When the sacrum is loaded with superincumbent weight, the sacroiliac joint functions as a self-compensating force couple. This couple creates and tends to rotate around an axis perpendicular to itself. The location of this axis may vary and depends upon the forces applied to the couple. As ligamentous tension increases in the couple, the sacroiliac joints are drawn tightly together through a mechanism of self-bracing. Self-bracing and its normal release or diminution provides for the storage and release of energy, which enhances the efficiency of normal ambulation and which modifies external forces. Failure of the force couple causes failure of the transverse axis of rotation of the sacroiliac joint and failure of the self-bracing mechanism. Because of the decrease in friction and stability, the innominate bones rotate anteriorly on the sacrum on an acetabular axis with the onset of pain and an alteration in apparent leg length. The resultant dysfunction may range from slight to severe, from minor ligamentous sprains to major sprains, muscle separations, and rents in the joint capsule. These rents may leak synovial fluid to the fifth lumbar nerve root, the lumbosacral plexus, and other tissues; and the resulting lesion may mimic disc dysfunction or create the impression of a multifactorial etiology. However it is seldom included in assessment of low back pain. A critical analysis of the biomechanics demonstrates the sequence and extent of involvement of adjacent tissues and structures, and it provides some direction for the restoration of normal function.

Effect of trunk flexion speed on flexion relaxation of erector spinae

Flexion relaxation of erector spinae (ES) has mainly been studied during slow trunk movements. Due to the viscoelastic properties of spinal ligaments, the ES activity may change at different movement speeds. Twenty-one normal females (20-25 years) were examined during slow, intermediate and natural speeds of trunk flexion. The movements and simultaneous ES surface EMG recordings were recorded by two synchronised video cameras. The ES relaxed at approximately 80 per cent of vertebral flexion at each speed, and no difference was found among the three speeds. This implies that either ES activity is independent of speed in the slow to natural functional speed range, or the flexion relaxation phenomenon is not related to changes in spinal ligamentous tension.

Clinical Results of the Oxford Knee

The Oxford method of knee arthroplasty replaces the femoral condyles with convex spherical metal components and relines the tibial plateaus with flat metal components. Free meniscal bearings of polyethylene, spherically concave above and flat below, lie between the fixed metal components, held in place by their geometry and ligamentous tension. Advantages of the design include: congruity of the articulating surfaces; unconstrained tibiofemoral movement; preservation of all the ligaments with facility to tension them accurately from a range of bearing thicknesses; minimal bone excision; applicability to unicondylar use. Laboratory studies showed that combined rolling and sliding at meniscofemoral and meniscotibial interfaces mimic normal joint kinematics and mechanics. One hundred twenty-five bicompartmental implants were followed for two to six years. Pain was relieved in 90%; mean flexion limit was 99 degrees and mean flexion deformity 7 degrees. Stability and alignment were recovered in nearly all joints. Six knees failed and were successfully arthrodesed (two) or converted to another prosthesis (four). Eight knees required revision to replace a dislocated bearing (five) or to recement a loose component (three). In knees with an intact anterior cruciate ligament, there were no failures and a low revision rate (4.8%). The prosthesis is proposed as a reliable and safe alternative to more invasive prostheses in rheumatoid and osteoarthritic joints in which the disease is still limited to the articular surfaces.

Documentation of Medial Rotation Accompanying Shoulder Flexion

We dissected a fresh cadaver to determine which glenohumeral structures causes medial rotation of the humerus during flexion in the sagittal plane. All structures associated with both shoulders were dissected thoroughly. Both elbows were disarticulated to expose the distal end of each humerus to be used as measurement landmarks. We used a universal goniometer for measurements of shoulder flexion. To determine which structures cause passive medial rotation, the associated shoulder muscles, ligaments, and the capsule were individually reflected from the humerus. Passive shoulder flexion to the point where medial rotation started was measured after each structure was resected. The end passive glenohumeral flexion without rotation was 60 degrees after reflection of all musculature and other periarticular shoulder structures. Our results support Steindler's conclusion that during flexion of the humerus beyond the horizontal there is forced rotation caused by ligamentous tension. We also found that the bony configuration of the glenohumeral joints also plays an important role in medial rotation accompanying shoulder flexion.

ORTHOPEDIC CAUSES OF PELVIC PAIN

This paper presents the problem of pelvic pain in a deliberately simplified form. My purpose is to show that measurements of pelvic mobility are essential to an accurate diagnosis. The fundamental structure of the pelvis consists of bones, muscles and joints. The massive ring formed by the two innominate bones and the sacrum gives origin and insertion to the most powerful muscles in the body; muscles that go far afield for attachment to other bones. The intrapelvic sacroiliac joints and symphysis pubis allow the bony ring to change its shape. The extrapelvic hip joints, sacrolumbar and sacrococcygeal joints allow motion of other bones on the pelvic ring. The ligaments of the pelvic joints are tremendously strong and are elaborately arranged in all planes, so that the slightest change in the position or shape of the pelvic ring alters the total ligamentous tension. Flexion and extension are the normal motions of