Medial Ligament Complex Research Articles

Acquired Adult Flatfoot: Pathophysiology, Diagnosis, and Nonoperative Treatment

Acquired adult flatfoot is a deformity characterized by a decreased medial longitudinal arch and a hindfoot valgus with or without forefoot abduction. The etiologies of this deformity include posterior tibial tendon dysfunction, rheumatoid arthritis, trauma, Charcot’s joint, neurologic deficit, and damage to the medial spring ligament complex or plantar fascia. Among these, posterior tibial tendon dysfunction is the most well-known cause. Although posterior tibial tendon dysfunction has been regarded as a synonym of acquired adult acquired flatfoot, failure of the ligaments supporting the arch can also result in progressive deformity even without a posterior tibial tendon problem. The authors describe the pathophysiology, diagnosis, and nonoperative treatment of acquired adult flatfoot, focusing on posterior tibial tendon dysfunction.

Medial and Lateral Collateral Ligament Repair or Reconstruction of the Elbow

The elbow is a complex hinge joint relying on bony and soft tissue restraints for stability. The primary soft tissue stabilizers are the medial and lateral collateral ligament complexes. Injury to these structures may occur because of an elbow dislocation or due to a severe varus or valgus force. Most injuries are treated conservatively, but when associated with more severe soft tissue and bony injuries around the elbow, surgical repair or reconstruction may be required. Repair should be anatomical and should restore stability to the elbow so that early active range of motion can be initiated. Reconstruction may be required in severe cases and where primary repair is not possible. Knowledge of the normal anatomy and understanding the pathoanatomy is crucial to achieving a good result. Depending on the degree of instability, either one or both of the collateral ligament complexes may need to be repaired or reconstructed. When reconstruction is required, usually only the lateral ulnar collateral and the anterior band of the medial collateral ligament need to be reconstructed, but when severely unstable, the posterolateral capsule and the posterior band of the medial collateral ligament may also require reconstruction. This may be accomplished by 2 separate grafts or as a single circumferential graft. Arthroscopy is a valuable tool to assess the stability as well as to identify and treat associated injuries. This article describes the normal and pathoanatomy of the unstable elbow and outlines the surgical techniques for repair and reconstruction of the collateral ligaments.

Peritalar Instability After Tibiotalar Fusion for Valgus Unstable Ankle in Stage IV Adult Acquired Flatfoot Deformity

An unstable valgus ankle with an incompetent medial ligament complex is still treated by many surgeons with isolated tibiotalar (TT) arthrodesis. To date, it is unknown whether rigid fixation of the talus within the ankle mortise sufficiently corrects and stabilizes the hindfoot complex. The purpose of this study was to critically analyze patients with this problem and to assess the underlying causes for their acquired peritalar instability. This series included 4 male patients (ages 55, 70, 72, and 79 years). Preoperatively, all patients presented with an unstable valgus ankle associated with stage IV adult acquired flatfoot deformity (AAFD), with a valgus talar tilt averaging 12 degrees (ranging from 9 to 14 degrees). All patients had a successful TT fusion, with screws and plates used for fixation. The position of the TT fusion was estimated at the intersection of a line drawn defining the talar shoulders and the longitudinal tibial axis on the anteroposterior weight-bearing radiograph. The hindfoot deformity was measured via the calcaneal offset on the Saltzman view. All patients had a healed TT fusion with the talus remaining in valgus averaging 4.8 degrees (ranging from 4 to 6 degrees). At the latest follow-up (1.2-18 years), all patients showed a progressive destabilization of the hindfoot complex that resulted in a valgus pronation deformity with flattening of the arch and a highly unstable foot that was not manageable with corrective shoes and braces. Key findings were a floppy hindfoot that turned into extreme valgus misalignment while loading. Radiographically, the calcaneal offset was in valgus misalignment of 16 to 54 mm related to the tibial axis on the Saltzman alignment view. In 2 cases, there was a complete medial dislocation of the talus. Even with rigid stabilization of the talus in the ankle mortise, peritalar instability may persist and allow calcaneus and navicular subluxation around the talus, which can result in progressive destabilization of the hindfoot complex. In stage IV AAFD, incompetent peritalar ligaments may not be able to withstand the increased mechanical load after TT fusion. Persistent valgus talar tilt after fusion may promote this unfavorable process. Therefore, isolated TT fusion should be performed with caution for treatment of valgus tilted ankles in stage IV AAFD. If this is considered, we recommend that fusion in neutral or even slightly varus talar positions be attempted. Level IV, retrospective case series.

New Technique of Reconstruction for Medial Elbow Instability

This study reports a new substitution technique as a choice to repair both acute and chronic injuries of the ulnar collateral ligament of the elbow. Different researchers have described different techniques to reconstruct the medial ligament complex with similar results (with the use of grafts). There is a shared variable in the latest reports, the interpretation of the anterior bundle as the most important structure, for medial elbow stability and the only structure to be repaired as well. The approach to the medial structures of the elbow is similar to most of the surgical techniques. It consists of an incision on the medial aspect of the elbow, centered on the epicondyle, of length 4 inches. The reconstruction uses a strip of the aponeurosis of the flexor carpi ulnaris (FCU) reinforced with Kracow stitches. The graft is harvested using the strong aponeurosis of the FCU, a vascularized structure, a viable option and with sufficient resistance to bear the tension of the inner aspect of the elbow. The surgical morbidity is also reduced as the graft is not taken from other zones. As the distal insertion of the neo-ligament, the proximal fixation of the FCU is used in the sublime tubercle, inverting the direction of the fibers of this strip from distal to proximal. The proximal fixation of this ligament is an osseous tunnel in the epitroclea secured with an interference screw. Common complications are those resulting from the approach and the ulnar nerve manipulation. Owing to the satisfactory stability outcome achieved by this technique, early rehabilitation may start without inconveniences.

Novel Reconstruction of a Static Medial Ligamentous Complex in a Flatfoot Model

Little progress has been made addressing reconstruction of the static medial ligamentous structures of the foot. The purpose of this investigation was to reconstruct a flatfoot deformity with a novel static medial ligamentous complex (MLC) and evaluate its ability to correct talar head subluxation and radiographic deformity in a cadaveric model. Eight fresh frozen cadaveric specimens underwent cyclic preconditioning and static axial loading. Loading was applied to the intact foot, the severe flatfoot, and the reconstructed MLC foot. Anteroposterior (AP) and lateral radiographs were taken at each stage. The talo-first metatarsal angle, medial cuneiform height, talocalcaneal angle, and the calcaneal pitch angle were measured on the lateral views and the talo-first metatarsal angle was measured on the anteroposterior views. Compared with the intact foot, the flatfoot showed significant change in the AP talo-first metatarsal angle (p = 0.001), the lateral talo-first metatarsal angle (p = 0.002), the medial cuneiform height (p = 0.007), the talocalcaneal angle (p = 0.03), and the calcaneal pitch angle (p = 0.018). After MLC reconstruction, there was a significant change in the AP talo-first metatarsal angle (p = 0.001), the lateral talo-first metatarsal angle (p = 0.002), and the medial cuneiform height (p = 0.007) and these values were not significantly different than the intact foot. The talocalcaneal angle and the calcaneal pitch angle remained significantly undercorrected after static MLC reconstruction. Static MLC reconstruction was effective in correcting several key radiographic parameters in a cadaveric flatfoot model. The surgical technique evaluated here may be useful as a new soft tissue reconstructive procedure for treating adult flatfoot.

Deltoid Ligament Injuries in Athletes: Techniques of Repair and Reconstruction

Deltoid ligament injuries are a source of valgus and rotational ankle instability and often occur as a result of athletic injury. The anatomy of the medial ankle ligament complex is reviewed and pertinent radiological findings are emphasized. The clinical evaluation of athletes with medial ankle instability as well as methods of repair and reconstruction of the deltoid ligament complex in those patients requiring surgical care are described.

Simultaneous Reconstruction of the Medial and Lateral Ligament Complexes of the Ankle Joint with Semitendinosus Tendon Allograft

Ankle ligament injuries occur frequently during recreational activities as well as competitive sports1. Although most heal with little medical intervention, recurrent instability can occur in 15% to 48% of patients2-6 and long-term sequelae can occur in up to 50% of patients7. Even following nonoperative treatment such as physiotherapy, bracing, or medication, continued problems may require surgical intervention, and the normal stability and biomechanics of the ankle joint should be reestablished to prevent the development of arthritis8,9. Several procedures for the reconstruction of the lateral ankle ligaments have been proposed, and the overall success rates of these operations have been reported to be >80%6,9-15. However, reconstruction of the deltoid ligament has received relatively little attention16-20. Moreover, operative management of chronic global ankle instability, including an incompetent deep deltoid ligament, has rarely been described, to the best of our knowledge18,21. We present a case of combined insufficiency of the medial and lateral ankle ligaments that was treated successfully with simultaneous reconstruction of those ligaments with a semitendinosus tendon allograft. The patient was informed that data concerning the case would be submitted for publication, and he consented. A thirty-six-year-old man presented with discomfort in the left ankle. He had sustained an ankle injury seven years earlier during a soccer game, after which recurrent sprains had often occurred with only minor exertion. He did not participate in sports activity as much as he wanted to because of a feeling of the ankle giving way. He was seen at our clinic with symptoms of instability and a clunking sensation in the ankle joint two months after sustaining another, severe ankle injury. On physical examination, there was no effusion or swelling …

Knee: Ligamentous Injuries of the Knee

Injuries of the knee causing ligament failure are common, especially in amateur and professional athletes. These injuries affect the anterior and posterior cruciate ligaments, the medial collateral ligamentous complex, or the lateral supporting structures, or combinations of these ligaments. The presence of marrow edema on MR images obtained shortly after the injury provide an important clue to accurate diagnosis and to the mechanism of the traumatic event. In this presentation, the effects of external and internal forces applied to the knee will be studied. The modifications in the distribution of the marrow edema caused by such factors as impaction/distraction, flexion, rotation, hyperextension, and translation will be illustrated. Stages of ligament injury during specific traumatic mechanisms will be discussed, and examples of some of the 010 most important mechanisms of knee injury will be shown.

New thoughts on the origin of Pellegrini-Stieda: the association of PCL injury and medial femoral epicondylar periosteal stripping

For the past 100 years, Pellegrini-Stieda disease has been described as calcification and ossification within the tibial collateral ligament, although these typical radiographic findings are often located more superior than the most proximal extent of the ligament. In this article, we demonstrate four magnetic resonance imaging cases of knee trauma with complete posterior cruciate ligament tear or avulsion, each demonstrating that injury to the medial collateral ligamentous complex can involve significant stripping of the tissue proximal to the medial epicondyle. Classic radiographic findings of Pellegrini-Stieda calcifications can be caused by stripping of the femoral periosteum proximal to the femoral attachment of the tibial collateral ligament, which appears to be associated with a complete posterior cruciate ligament injury.

Medial Patellofemoral Ligament: Cadaveric Investigation of Anatomy with MRI, MR Arthrography, and Histologic Correlation

The purpose of this study was to use MRI with gross anatomic and histologic correlation in cadavers to define the anatomic details of the medial patellofemoral ligament. MRI of seven cadaveric knees was performed before and after intraarticular administration of a gadolinium solution. T1-weighted spin-echo MR images with and without fat suppression were acquired in three planes. Correlation was made between findings derived from MRI and cadaveric sections. Histologic analysis was performed on five specimens. The bilaminar and trilaminar appearance of the medial patellar ligamentous complex was defined on axial images. The medial patellofemoral ligament and the medial patellotibial ligament were best visualized on axial images. In three of five knees, the superficial fibers of the medial patellofemoral ligament were attached to the epicondyle in a position posterior to the attachment point of the tibial collateral ligament. In all three knees, the deep fibers of the medial patellofemoral ligament merged with and attached to the tibial collateral ligament. In two of these five knees, all fibers of the medial patellofemoral ligament were attached to the tibial collateral ligament. These findings were confirmed at histologic examination. The medial patellofemoral ligament can attach only to the tibial collateral ligament or to both the tibial collateral ligament and the femoral epicondyle. The bilaminar and trilaminar appearances of the medial patellar ligamentous complex and the course of the medial patellofemoral, medial patellomeniscal, and medial patellotibial ligaments were best defined on axial images.

Surgical Outcome of 2-Stage Management of Multiple Knee Ligament Injuries After Knee Dislocation

The purpose of this study was to determine the effectiveness of a new 2-stage surgical treatment for acute traumatic knee dislocation. The study involved 15 knees in 14 patients treated between October 1997 and November 2001. The mean follow-up was 88.9 months (range, 35 to 110 months). In the first surgical stage, medial or lateral ligament complexes were repaired or reconstructed within 2 weeks of injury. In the second surgical stage, once full range of motion was obtained 3 to 6 months later, the anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) was reconstructed if significant laxity was present. The final outcomes were assessed based on stress radiographs, range of motion, Lysholm score, Tegner activity stage, and International Knee Documentation Committee rating. There were 10 cases of medial collateral ligament (MCL) tear and 8 cases of lateral collateral ligament (LCL) tear. All MCL and LCL injuries were either repaired or reconstructed. All cases had both ACL and PCL tears. After the first stage of MCL/LCL complex surgery, the second-stage surgery involving ACL and PCL reconstruction was deemed necessary in 3 and 7 cases, respectively. Five cases did not require ACL or PCL reconstruction. On stress radiography at the last follow-up, MCL, LCL, ACL, and PCL instability was graded as 0 to 1 in 15, 14, 15, and 11 cases, respectively. PCL instability was graded as 2 in 4 cases. The mean postoperative Lysholm score was 87.6 points. The 2-stage surgical approach described resulted in good outcomes for acute knee dislocation patients in terms of range of motion and stability. Level IV, therapeutic case series.

Non-union of Weber B fractures: A case series

Non-union of the distal fibula is considered rare. The fibula may serve as a model for successful fracture healing due to its endosteal blood supply and its reduced exposure to biomechanical stress. Fractures of the fibula that begin at the joint line and extend proximally, with or without the anterior syndesmosis intact (Weber B) are the commonest ankle fractures. They are generally considered to be stable if damage to the medial complex is excluded. In the absence of medial ligament injury conservative treatment is considered to provide excellent results. We report three cases of fractures through the fibula at the level of the syndesmosis, with intact medial ligament complexes, in which fracture nonunion developed despite adequate management. The purpose of this case series is to demonstrate the clinical and radiographic features of fibular nonunion and to discuss its effect on management.

THREE DIMENSIONAL ANALYSES OF CLUB MOVEMENT AND CLUBHEAD ORIENTATION AT IMPACT DURING THE GOLF SWING

Failure by fatigue is one mechanism by which ligaments can rupture, with the accumulation of damage gradually degrading the ligament strength. Baseball pitchers who perform repeated high-level throwing continuously subject the medial ligament complex of the elbow to extreme levels of loading, which can lead to fatigue and eventual rupture. This study sought to investigate this behavior and quantify the fatigue properties of the anterior bundle of the medial collateral ligament (AMCL) with respect to valgus elbow torque. Eleven pairs of cadaveric elbow specimens were used for this study. One side of each pair was tested in vertical elongation at four flexion angles and then tested to failure at 90° of flexion. The contralateral specimens were tested in valgus fatigue at 90° of flexion using a specialized apparatus with application of known moments based on the elongation failure load. The average tensile failure load for the AMCL was 595.3 ± 201.9 N. During cycling, the average increase in the maximum valgus rotation angle was 4.77° ± 2.82°. The average maximum stretch of the AMCL middle band increased from 1.066 ± 0.017 to 1.076 ± 0.018 near the time of fatigue failure. The average cycles to failure for specimens tested at 90% and 80% of the estimated failure torque were 3211 ± 4721.33 and 25063 ± 30487.58, respectively. The nonlinear non-dimensional fatigue life and damage accretion results work in conjunction to predict the fatigue properties for a valgus elbow motion of arbitrary torque magnitude at 90° of elbow flexion.

Simultaneous Reconstruction of Medial and Lateral Elbow Ligaments for Instability Using a Circumferential Graft

Reconstructing elbow instability remains a challenging problem. Techniques described have included techniques for the lateral ligamentous complex, including the lateral ulnar collateral ligament, and techniques to reconstruct the medial collateral ligament. We describe a new circumferential technique to reconstruct both the lateral and medial ligament complexes, using 1 circular graft. A hole is drilled through the center of rotation of the distal humerus and through the insertion sites of the medial and lateral ligament complexes. A hamstring tendon graft is passed through the humerus twice to reconstruct the anterior and posterior bands of the medial collateral ligament and sutured onto itself. Endobutton fixation is used to fix the graft on either side of the ulna. The graft is tightened on the lateral and medial sides and fixed into the humerus using interference fit screws. Advantages of the technique described include stabilization of both the medial and lateral ligament complexes with 1 graft. The strength of fixation allows for individual tensioning in all limbs of the reconstruction and the multiple passes of the graft through a single humeral tunnel increasing the strength of the reconstruction. Potential complications could include ulnar nerve damage, recurrent instability, elbow stiffness, and wound breakdown. Complications related to the potential use of a hinged external fixator are not specific to this procedure but can be associated. Early active mobilization can be initiated because of the strong stability provided by the circumferential graft and good fixation.

Arthroscopic Patellar “Bankart” Repair After Acute Dislocation

Abstract We present a case of acute patellar dislocation in a skeletally immature patient treated with arthroscopic medial patellofemoral ligamentous complex repair using suture anchors with a horizontal mattress suture technique. Patellar dislocation is a common problem in the skeletally immature. Treatment is controversial for first-time dislocators because of the high rate of recurrent instability and functional disability in these patients. Surgical repair of the medial restraints may decrease recurrent instability, although anterior knee pain and crepitus is a common finding after open surgical techniques. Arthroscopic medial retinacular imbrication has been described for patients with persistent instability with good short-term results. Acute dislocations may cause avulsion of the medial patellofemoral ligamentous complex from the patella; this is amenable to direct primary repair to prevent recurrent instability and avoid the morbidity of open surgery. This technique recreates normal anatomy and function with minimally invasive surgery.

Two Stage Surgical Treatment of Acute Traumatic Knee Dislocation

Purpose: The purpose of this study was to determine the effectiveness of a new two stage surgical treatment for acute traumatic knee dislocation. Materials and Methods: The study involved 15 knees in 14 patients treated between October 1997 and November 2001. The mean follow-up period was 24 months. In the first surgical stage, medial and/or lateral ligament complexes were repaired or reconstructed within two weeks of the injury. In the second surgical stage, once full range of motion was obtained 3-6 months later, anterior or posterior cruciate ligaments (ACL or PCL) were reconstructed if significant laxity was present. The final outcomes were assessed using stress X-rays, range of motion and Lysholm score. Results: There were ten cases of MCL tear and eight cases of LCL tear. All MCL and LCL injuries were either repaired or reconstructed. All cases had both ACL and PCL tears. Following the first stage of MCL/LCL surgery, the second stage surgery of ACL or PCL reconstructions was deemed to be necessary in three and seven cases, respectively. Five cases did not require ACL or PCL reconstruction. In stress X-rays at the last follow up examination, MCL, LCL, ACL and PCL instability was graded as 0 or 1 in 15, 14, 15 and 11 cases, respectively. PCL instability was graded as 2 in four cases. The mean postoperative Lysholm score was 87.6 points. Conclusion: The two stage surgical approach described here resulted in good outcomes for patients suffering from acute knee dislocation patients in terms of range of motion and stability.

Funktionelle Anatomie des Ellenbogengelenkes - Welche intrinsischen und extrinsischen Stabilisatoren sind wichtig?

Die Stabilität im Ellenbogengelenk hängt von mehreren Strukturen ab. Neben intrinsischen Stabilisatoren, wie der knöchernen Gelenkführung, der Gelenkkapsel, der Morphologie von Knorpel und synovialen Veränderungen, spielen die extrinsischen Stabilisatoren, wie der laterale und mediale Bandapparat sowie die Muskulatur eine wesentliche Rolle. Anhand der aktuell verfügbaren Literatur wird die funktionelle Anatomie des Ellenbogengelenkes beschrieben. Gleichzeitig wird das pathomorphologische klinische Korrelat bei Verletzungen dieser Strukturen betrachtet. Bei den multifaktoriellen Ursachen für Störungen im Gleichgewicht der Stabilisatoren müssen insbesondere auch intrinsische Stabilisatoren wie die Kapsel hervorgehoben werden.

Structural properties of the medial collateral ligament complex of the human knee

The anatomy of the medial collateral ligament (MCL) complex consists of three identifiable passive restraining structures: the longitudinal fibres of the superficial medial collateral ligament (sMCL), the deep medial collateral ligament (dMCL), and the posteromedial capsule (PMC). The purpose of this study was to measure and compare the structural properties of these three individual structures. Eight human cadaveric knees (age 72–89 years, mean=77 years, S.D. 5.3) were harvested and bone–ligament–bone tensile testing specimens prepared. After preconditioning, the specimens were extended to failure at 1000mm/min in an Instron tensile testing machine. Ligament bundles failed either mid-substance or at their bony attachments. The ligament bundles had maximum loads of 534N (sMCL), 194N (dMCL), 425N (PMC) and failed at 10.2, 7.1, and 12.0mm mean extension, respectively. The maximum load and linear stiffness of the sMCL were significantly higher than those of the dMCL but not the PMC. The maximum load of the PMC was significantly higher than that of the dMCL; the linear stiffness of the PMC was higher than that of the dMCL but this did not reach statistical significance. The dMCL failed at a significantly lower extension than the other structures. The sMCL bundles that failed at their bony attachment were remounted using a freezing clamp fixture and again extended to failure, resulting in mid-substance failure at 884N (74% higher). This study has shown that the PMC of the knee has comparable structural properties to the long superficial MCL and the short, deep MCL. In summary, the structural properties of the different component structures of the medial ligament complex indicate possible functional significance.

The “Terrible Triad” of the Elbow

The “Terrible Triad” of the Elbow

Functional anatomy of the medial ligamentous complex of the elbow. Its role in anterior posterior instability.

The question remains unanswered regarding the role of repair of medial ligament injuries associated with subluxation of the elbow and non-reconstructable radial head fracture and whether or not this will decrease the risk of chronic instability and cubitus valgus. The goal of this study was to define the role of the medial ligamentous complex of the elbow in elbow instability and to describe the anatomy of the complex in 35 fresh-frozen cadaver elbows. We documented medial ligamentous complex anatomy and compared our results to those in the literature. 25 elbows were dissected in order to describe the different bundles of the medial ligament complex and to precise the positions of the elbow that placed each in tension; section of the different ligamentous bundles was done to study the role of each in elbow stability. 10 other elbows were dissected and used for the ligamentous section studies which were performed subcutaneously. We found two bundles at the level of the anterior portion and termed them superficial and deep. Section of the anterior bundle lead to posterior subluxation of the elbow at 30-100 degrees flexion in both supination and pronation. Posterior subluxation was obtained after an anterior capsulotomy; medial epicondylectomy did not compromise the stability of the elbow after a complete section of the insertion of the deep fibers of the anterior bundle. Elements thus required for stability of the elbow are integrity of the articular surface of the humerus and the ulna, and the anterior bundle of the medial ligamentous complex.